Every finding on record at Whisperwood Nursing & Rehabilitation Center

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to develop an accurate, consistent, and completed care plan for Resident #1, specific to Resident #1's dietary needs ordered by the physician. This failure could place residents at risk of not receiving the care required to meet their individualized needs.Findings include: Record review of Resident #1's face sheet, dated 04/21/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Dementia in other diseases classified elsewhere, moderate without agitation (a decline in cognitive abilities that affects a person's daily functioning), age related cognitive decline, dysphagia (difficulty swallowing), Parkinson's disease with dyskinesia and fluctuations (progressive neurological disorder that affects movement), malignant neoplasm of the tonsillar pillar (type of throat cancer), and cognitive communication deficit. Record review of Resident #1's admission MDS assessment, dated10/7/2025, revealed in Section C - Cognitive Patterns, Resident #1 had a BIMS score of 01, which indicated severe cognition impairment. Record review of the current care plan for Resident #1, undated, revealed the following Focus areas: The resident has a swallowing problem r/t throat cancer. Date Initiated: 09/25/2025, with a Goal that stated, (Resident) will not have injury related to aspiration. The Interventions/Tasks included the following, All staff to be informed of resident's special dietary and safety needs. Date Initiated: 09/25/2025; Alternate small bites and sips. Use a teaspoon for eating. Do not use straws. Date Initiated: 09/25/2025.Check mouth after meal for pocketed food and debris. Report to nurse. Provide oral care to remove debris. Date Initiated: 09/25/2025.Diet to be followed as prescribed. Date Initiated: 09/25/2025.Instruct resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly. Date Initiated: 09/25/2025.Monitor for shortness of breath, choking, labored respirations, lung congestion. Date Initiated: 09/25/2025.Monitor/document/report to nurse/dietitian and MD PRN for difficulty swallowing, holding food in mouth, prolonged swallowing time, repeated swallows per bite, coughing, throat clearing, drooling, pocketing food in mouth. Date Initiated: 09/25/2025.Refer to Speech therapist for Swallowing Evaluation. Date Initiated: 09/25/2025.Resident has a diet order other than Regular and is at risk for unplanned weight loss or gain. Large Portions, Mechanical Soft texture, Regular consistency. Date Initiated: 09/25/2025. Revision on: 01/15/2026, with a Goal that stated, Resident will maintain ideal weight and receive proper nutrition daily x 90 days. Date Initiated: 09/25/2025. The Interventions/Tasks included: Determine food preferences and provide within dietary limitations. Date Initiated: 09/25/2025.Encourage meal completion and document amount consumed. Date Initiated: 09/25/2025.House shakes TID. Date Initiated: 01/15/2026.Monitor weight per facility protocol. Date Initiated: 09/25/2025.Offer sub if resident eats less than 50% or dislikes meal and offer supplement if resident continues to eat less than 50%. Date Initiated: 09/25/2025.Place a Red Glass on the resident's meal tray to identify the resident to staff as possibly needing assistance, encouragement, and substitutes. Date Initiated: 01/15/2026. Praise resident for eating well. Date Initiated: 09/25/2025.RD assess per facility protocol Date Initiated: 09/25/2025.Serve diet and snacks as ordered. Date Initiated: 09/25/2025. ST eval and Tx per Physicians orders as condition warrants. Date Initiated: 09/25/2025. Record review of Resident #1's active physician's order, dated 4/21/2026, revealed an order that stated the following: Fortified/Enhanced Diet: diet Pureed texture, Nectar consistency, shakes with all meals/large portions for Weight Gain related to dementia in other diseases classified elsewhere, moderate, with agitation. Order start date: 03/05/2026. Record review of Resident #1's Vitals/Weights Report, dated 04/21/2026, revealed the following weights for the resident: 2/20/2026 - 128.003/13/2026 - 128.004/17/2026 - 130.0 Record review of Resident #1's lunch meal ticket, dated 04/21/2026, indicated Resident #1 received a Regular/Pureed diet. During an observation and interview on 04/22/2026 at 1:00 PM revealed Resident #1 was in the dining room eating lunch. Resident #1 was assisted with his meal by staff. Resident #1 received a pureed meal, and Resident #1 finished all food on his plate. An interview was attempted with Resident #1; however, Resident #1 was unable to be interviewed due to impaired cognitive functioning. CNA A stated Resident #1 received a pureed diet at every meal. During an interview on 04/22/2026 at 9:50 AM, the ADM stated the DON was responsible for ensuring care plans were updated when a resident's physician's orders were changed. The ADM stated, according to Resident #1's active physician order, he should have received a pureed diet. The ADM stated this should have been reflected on Resident #1's care plan as well. The ADM stated when Resident #1's dietary change was ordered by the physician, the care plan should have been updated as soon as possible. The ADM stated care plan reviews were completed at least quarterly. The ADM stated she was not aware Resident #1's care plan reflected a mechanical soft diet. The ADM stated nursing staff received training on care plans upon hire and received regular in-service trainings. The ADM stated it was her expectation that care plans were updated as soon as any changes or updates were received. The ADM stated if a care plan was not accurate, it could affect a resident's daily care and could cause inconsistencies. The ADM stated she would ensure the care plan was reviewed and updated as soon as possible. During an interview on 04/22/2026 at 10:45 AM, the DON stated the Interdisciplinary Team worked together to ensure care plans were updated with any necessary changes, but it was her responsibility to ensure care plans were updated. The DON stated when a resident received an updated dietary order, it was her responsibility to ensure the care plan was updated as well. The DON stated she was not aware Resident #1's care plan indicated he received a mechanical soft diet. The DON stated the care plan should have reflected a pureed diet as indicated in the resident's physician's order. The DON stated she received training on care plans, and all nursing staff received this training upon hire. The DON stated care plans were reviewed regularly and during quarterly reviews. The DON stated it was her expectation the facility staff worked collectively, as a team, to ensure care plans were updated and accurate. The DON stated if a care plan was not updated or accurate, all staff may not be updated on a resident's current needs. The DON stated she would do a full review of the resident's care plan as soon as possible to ensure it was updated and accurate. The DON stated that a resident not receiving the correct diet could impact the resident's nutrition. Record review of the facility's, undated, policy titled, Comprehensive Care Planning reflected the following: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and time limits to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following -The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and.Comprehensive Care PlansA comprehensive care plan will be- The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences, and needs of the resident and in response to current interventions.

Based on observation, interview and record review the facility failed to ensure the resident was offered a therapeutic diet when there was a nutritional problem and the health care provider ordered a therapeutic diet for 1 of 5 residents (Resident #1) reviewed for therapeutic diets.The facility failed to ensure Resident #1 was given supplemental shakes at every meal (three times a day) as ordered by the physician. This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity.Findings include: Record review of Resident #1's face sheet, dated 04/21/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included the following: Dementia in other diseases classified elsewhere, moderate without agitation (c a decline in cognitive abilities that affects a person's daily functioning), age related cognitive decline, dysphagia (difficulty swallowing), Parkinson's disease with dyskinesia and fluctuations (progressive neurological disorder that affects movement), malignant neoplasm of the tonsillar pillar (type of throat cancer), and cognitive communication deficit. Record review of Resident #1's admission MDS assessment, dated10/7/2025, revealed in Section C - Cognitive Patterns, Resident #1 had a BIMS score of 01, which indicated severe cognition impairment. Record review of the current care plan for Resident #1, undated, revealed the following Focus areas: The resident has a swallowing problem r/t throat cancer. Date Initiated: 09/25/2025, with a Goal that stated, (Resident) will not have injury related to aspiration. The Interventions/Tasks included the following, All staff to be informed of resident's special dietary and safety needs. Date Initiated: 09/25/2025; Alternate small bites and sips. Use a teaspoon for eating. Do not use straws. Date Initiated: 09/25/2025.; Check mouth after meal for pocketed food and debris. Report to nurse. Provide oral care to remove debris. Date Initiated: 09/25/2025.; Diet to be followed as prescribed. Date Initiated: 09/25/2025.; Instruct resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly. Date Initiated: 09/25/2025.; Monitor for shortness of breath, choking, labored respirations, lung congestion. Date Initiated: 09/25/2025.; Monitor/document/report to nurse/dietitian and MD PRN for difficulty swallowing, holding food in mouth, prolonged swallowing time, repeated swallows per bite, coughing, throat clearing, drooling, pocketing food in mouth. Date Initiated: 09/25/2025. ; Refer to Speech therapist for Swallowing Evaluation. Date Initiated: 09/25/2025. Resident has a diet order other than Regular and is at risk for unplanned weight loss or gain. Large Portions, Mechanical Soft texture, Regular consistency. Date Initiated: 09/25/2025. Revision on: 01/15/2026, with a Goal that stated, Resident will maintain ideal weight and receive proper nutrition daily x 90 days. Date Initiated: 09/25/2025. The Interventions/Tasks included: Determine food preferences and provide within dietary limitations. Date Initiated: 09/25/2025.; Encourage meal completion and document amount consumed. Date Initiated: 09/25/2025.; House shakes TID. Date Initiated: 01/15/2026.; Monitor weight per facility protocol. Date Initiated: 09/25/2025.; Offer sub, if resident eats less than 50% or dislikes meal and offer supplement if resident continues to eat less than 50%. Date Initiated: 09/25/2025.:, Place a Red Glass on the resident's meal tray to identify the resident to staff as possibly needing assistance, encouragement, and substitutes. Date Initiated: 01/15/2026.; Praise resident for eating well. Date Initiated: 09/25/2025.; RD assess per facility protocol Date Initiated: 09/25/2025; Serve diet and snacks as ordered. Date Initiated: 09/25/2025.; ST eval and Tx per Physicians orders as condition warrants. Date Initiated: 09/25/2025. Record Review of Resident #1's lunch meal ticket dated 04/21/2026 indicated Resident #1 received a Regular/Pureed diet. There was no supplemental shake listed on the meal ticket. Record review of Resident #1's Vitals/Weights Report, dated 04/21/2026 revealed the following weights for the resident: 2/20/2026 - 128.003/13/2026 - 128.004/17/2026 - 130.0 Record review of Resident #1's active physician's order, dated 4/21/2026, revealed an order that stated the following: Fortified/Enhanced Diet: diet Pureed texture, Nectar consistency, shakes with all meals/large portions for Weight Gain related to dementia in other diseases classified elsewhere, moderate with agitation. Order start date: 03/05/2026. During an observation and interview on 04/22/2026 at 1:00 PM revealed Resident #1 in the dining room eating lunch. Resident #1 was assisted with his meal by staff. Resident #1 was had a pureed diet. There was no shake observed with Resident #1's meal. CNA A stated there was no supplemental shake served for Resident #1 during the meal. CNA A stated she did not know why the supplemental shake was not listed on Resident #1's meal ticket. CNA A stated the supplemental shake should have been listed on Resident #1's meal ticket. CNA A stated a supplemental shake was always provided by CNA A if Resident #1 did not finish his meal. CNA A stated Resident #1 usually had a good appetite and ate all of his food. Resident #1 received a pureed meal, and Resident #1 finished all food on his plate. An interview was attempted with Resident #1; however, Resident #1 was unable to be interviewed due to impaired cognitive functioning. During an interview on 04/22/2026 at 9:50 AM, the ADM stated she was not aware Resident #1 was not receiving supplemental shakes at every meal. The ADM stated Resident #1's physician order for supplemental shakes at every meal should have been reflected on the resident's meal ticket. The ADM stated dietary staff relied on the meal ticket to ensure therapeutic diets were followed for each resident. The ADM stated the DON was responsible for ensuring dietary orders were communicated to the Dietary Manager. The ADM stated the facility's current Dietary manager began working at the facility on 04/20/2026 and would not have been aware of Resident #1's current dietary order. The ADM stated she did not know why the meal ticket did not reflect the physician's order for supplemental shakes at every meal. The ADM stated a review would be completed to ensure the meal ticket was updated and Resident #1 was receiving his accurate therapeutic diet needs. The ADM stated Resident #1 did not have any significant weight loss over the last 90 days. The ADM stated Resident #1 was documented to have a good appetite and usually ate well. The ADM stated staff received regular training on following physician orders. The ADM stated if the resident's diet was a physician order, the DON was responsible for ensuring this was communicated to the dietary staff. The ADM stated it was her expectation that all physician orders were followed and diet orders were complied with. The ADM stated if a resident was not receiving their physician ordered diet, it may impact the resident's nutritional status and could contribute to weight loss or inconsistencies. During an interview on 04/22/2026 at 10:45 AM, the DON stated she was responsible for communicating therapeutic diets ordered by the physician to the Dietary Manager. The DON stated there was not a Dietary Manager for the facility when Resident #1 received the physician order for supplemental shakes at every meal. The DON stated she was not aware Resident #1 was not receiving the supplemental shakes with each meal or that the dietary order was not reflected on the resident's meal ticket. The DON stated the dietary staff relied on the meal ticket to ensure diets were followed as ordered by the resident's physician. The DON stated she did not know why Resident #1's meal ticket was not updated to include supplemental shakes at each meal as ordered by his physician. The DON stated Resident #1 did not have significant weight loss in the past 90 days. The DON stated she did audit meal tickets frequently, and she would complete a full audit on all meal tickets to ensure they were all accurate. The DON stated Resident #1's meal ticket had been updated on this date, 04/22/2026, to now include his dietary order for supplemental shakes at each meal. The DON stated if a resident's dietary orders were not communicated accurately to the dietary staff, the resident's nutrition could be impacted. Record review of the facility's policy related to following physical orders for therapeutic diets was requested. The facility did not provide a policy related to therapeutic diets or following physician orders.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure the dishwasher was working properly with the hot water temperature and the facility failed to allow the food processor for puree to air-dry completely before using. These failures could place residents at risk for food contamination and foodborne illness. The findings include: Observations during the puree process on 01/21/26 at 11:36 AM revealed [NAME] A pureed hamburger patties in the food processor. After the hamburger patties were pureed, [NAME] A transferred the food to a smaller container and then [NAME] A washed the food processor in a 3-compartment sink and then placed the food processor on a tray to go through a wash cycle in the low temperature/chemical dishwasher. The food processor was removed from the tray when the wash cycle was completed, and the food processor was then picked up and placed back on the machine with liquid dripping from the food processor. [NAME] beans were added to the food processor to puree. The green beans were pureed and transferred to a smaller container and then [NAME] A washed the food processor in a 3-compartment sink and then placed the food processor on a tray to go through a wash cycle in the low temperature/chemical dishwasher. It was noted at this time that the dishwasher temperature in the wash cycle did not go above 88 degrees F. The data plate on the dishwasher stated the wash cycle minimum temperature should be 120 degrees F. During an interview on 01/21/26 at 11:45 AM, [NAME] A stated she had checked the dishwasher temperature earlier that morning and it was reaching 120 degrees F. [NAME] A stated she did not know what changed but she would get the DM to help. During an interview on 01/21/26 at 11:50 AM, the DM stated she did not know what was wrong with the dishwasher, but the facility would not use it until it could be serviced, and the facility would use a 3-compartment sink for this time. During an interview on 01/21/26 at 12:14 PM, the DM stated a switch had been turned off to the water booster and that was why the dishwasher was not reaching up to temperature. The DM stated she was not sure who switched off the water booster. During an interview on 01/23/26 at 9:17 AM, [NAME] A stated she had been trained to let the food processor air-dry completely before using again. [NAME] A stated she was trying to get the puree food done on time for the meal and that was why she did not let it air-dry before using it. [NAME] A stated it had been a while since she had been trained and could not remember exactly. [NAME] A stated a potential negative outcome to the residents was it could cause the food to taste different. [NAME] A stated she did not know what happened to the dishwasher not getting up to 120 degrees F. [NAME] A stated she had been trained to check the dishwasher temperatures when using but had forgotten to check during the puree process. [NAME] A stated a potential negative outcome to the residents was it could make them sick if the dishes were not cleaned properly. During an interview on 01/21/26 at 9:25 AM, the DM stated the dietary staff were trained on allowing the food processor to air-dry and checking the temperature of the dishwasher. The DM stated she had only worked at the facility for about a month, so she was not sure the last time the dietary staff were trained in these areas. The DM stated she expected the dietary staff to check the dishwasher temperature every time it gets used. The DM stated a potential negative outcome to the residents with not allowing the food processor to air dry was it could have some sanitizer or chemicals still in there. The DM stated a potential negative outcome to the residents with the dishwasher not reaching a minimum temperature of 120 degrees F was it could not be hot enough for the chemicals to work on the dishes. During an interview on 01/23/26 at 9:45 AM, the ADM stated she would need to look at the facility policy regarding the puree process and air-drying the food processor before using. The ADM stated she did not know when the cooks were last trained on the puree process and stated they were trained on hire and orientation for new cooks. The ADM stated not allowing the food processor to air-dry could contaminate the food. The ADM stated the kitchen staff were trained on checking the dishwasher temperatures. The ADM stated she expected the dishwasher temperature to be checked before washing dishes with it. The ADM stated she expected a 3-compartment sink to be used if the dishwasher could not be used. The ADM stated a potential negative outcome to the residents was that the dishes could be contaminated and spread infection. Record review of the facility policy titled, Dishwashing Preparation and Dishwashing, undated, reflected the following: The facility will complete the dishwashing process in a sanitary manner to provide clean and sanitary dishes and utensils.Procedure:.2. Automatic dishwasher: Low temperature machinec. The wash period shall be at least 40 seconds with a temperature of 120 degrees F in dish machine. The sanitizing rinse period shall be at least 20 seconds with minimum temperature of 120 degrees F. Record review of the facility's policy titled, Equipment Sanitation, undated, reflected the following: We will provide clean and sanitized equipment for food preparation. The facility will clean all food service equipment in a sanitary manner.Procedure:.8. Blenders and food processors bowls should be inverted after cleaning to drain dry on shelves or trays with vented slots or bar netting. Record review of the chemical label for the dishwasher titled, Sani 3000 Liquid Dish Machine Sanitizer, undated, reflected the following: Keep out of reach of Children. Danger.First Aid: Ingestion: DO NOT induce vomiting. DO NOT give carbonate of any kind. Give large amounts of water. Consult physician immediately.

Based on observations, interviews, and record reviews, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 1 Resident's personal refrigerators reviewed for food safety (Resident #66) in that: The facility did not have a system in place to assist residents in cleaning and maintaining their personal refrigerators to ensure safe food handling and prevent consumption of spoiled and/or expired foods. The personal refrigerator in Resident #66's room did not contain a thermometer. The refrigerator contained an unknown substance that was unlabeled and undated. Resident #66 was unable to identify an unlabeled and undated unknown substance in the personal refrigerator. These failures could place residents at risk for food borne illnesses.Findings include: Record review of Resident #66's electronic face sheet dated 01/23/2026 revealed a [AGE] year-old female admitted to the facility on [DATE]. The face sheet included the following diagnoses: Schizoaffective disorder, bipolar type (a chronic mental illness combining symptoms of schizophrenia (hallucinations, delusions, disorganized thinking) with symptoms of bipolar disorder (manic episodes with high energy, irritability, impulsivity, and sometimes depressive episodes); bipolar disorder; and Alzheimer's Disease, unspecified, (progressive, irreversible neurodegenerative brain disorder and the most common cause of dementia (loss of cognitive functioning, thinking, memory, mood, and behavior)). Record review of Resident #66's Annual MDS dated [DATE], under Section C Cognitive Patterns, revealed a BIMS of 10, indicating the resident was moderately cognitively impaired. During an observation and interview on 01/22/2026 at 9:15 AM, Resident #66's room contained a personal refrigerator. There was not a thermometer present indicating the refrigerator's temperature. The refrigerator contained perishable items such as cans of soda and an unknown brown substance in an undated, unlabeled zip lock bag. Resident #66 stated she did not know who cleaned her refrigerator. Resident #66 stated she was not aware of a zip lock bag of food in her refrigerator and could not state what was in the bag. Resident #66 stated she did not know how often her refrigerator was supposed to be clean. Resident #66 did not respond when asked if anyone had ever cleaned it out for her. During an interview on 01/23/2026 at 11:00 AM, the ADM stated residents, and their families were responsible for maintaining their personal refrigerators. The ADM stated this included cleaning the refrigerator, storing food properly, and discarding spoiled food items. The ADM stated facility staff could assist, if needed, but there was no specific staff assigned to this duty. The ADM stated the facility relied on family and residents to ensure the refrigerators were maintained. The ADM stated she believed all personal refrigerators contained a thermometer, purchased by the family. The ADM stated there was no task assigned to facility staff to check personal refrigerators to ensure they were maintaining a safe temperature. The ADM stated if a resident were not cognitively capable of maintaining their refrigerator themselves, the family would be responsible for maintaining it. The ADM stated if a resident's family did not visit frequently and the resident was not cognitively or physically capable of maintaining their personal refrigerator, a facility staff could assist the resident, but there was no current system in place to ensure this was done. The ADM stated the facility administration staff make rounds to resident rooms and could assist residents with checking their personal refrigerators, but there was no current system in place to ensure this was done. The ADM stated a cognitively impaired resident that had no frequent visitors was permitted to have a personal refrigerator in their room. The ADM stated there was no system in place to ensure resident's personal refrigerators were consistently maintained. The ADM stated if a resident or resident's family were unable to maintain the personal refrigerator in the resident's room, it was possible expired or spoiled food could be left in the refrigerator and there was a risk of residents consuming the food. Record review of the facility's policy titled Personal Refrigerators Policy, Environmental Services Policy and Procedure 2026, revealed: Residents of the facility may place a personal or dormitory size refrigerator in their room if space permits and under Life Safety Code regulations, that the resident room has an adequate electrical system, such as proper outlets, to allow the connection of a refrigerator without overloading the electrical system. The care and maintenance of any refrigerator is the responsibility of the resident and/or responsible party. It is also the responsibility of the resident and/or resident representative to properly store non-facility supplied foods that require refrigeration in their personal refrigerator. If food is expired or appears spoiled or moldy, the facility reserves the right to discard it. Housekeeping can assist the residents and/or family member by inspecting the refrigerators at least weekly and assist with removal of outdated food items and cleanliness.Care and MaintenanceThe resident and/or resident representative should clean and maintain the refrigerators according to the manufacturer's user manual. If needed you can ask facility housekeeping or maintenance staff for assistance. Temperature ControlThe refrigerator compartment should be maintained at temperature of 35-41 degreesThe freezer compartment should be maintained at zero degrees or less, or food frozen to a solid state Temperatures can be monitored by the use of a thermometer designed for a refrigerator/freezer that can be purchased from a department store.Cold Food StorageFood should be stored in the refrigerator/freezer as determined by the food item. Commonly Used DatesSell by date - indicates that a product should not be sold after that date if the buyer is to have it at its best qualityBest by or Use by date -the maker's estimate of how long a product will keep at its best quality. They are quality dates only, not safety dates. If stored properly, a food product should be safe. wholesome and of good quality after its Use by or Best by date. Expired date - the food items should not be consumed and should be discarded if not eaten by the expiration dateFruits and Vegetables - should not be consumed and should be discarded if there are signs of spoilage. Signs of spoilage on fruits and vegetables are mold, a soft and mushy consistency, and a bad smell.Regardless of dates, if any food that shows signs of spoilage should not be consumed and should be discarded.DietsIt is recommended that food stored in the refrigerator that is to be consumed by the resident should be according to the resident's diet ordered by the physician. Risks associated with non-compliance with diet (this is not an all-inclusive list); hyperglycemia (high blood sugar), aspiration, pneumonia, choking, and up to and including death. If you have any questions related to the resident's diet, please refer to the nurse.

Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 3 Residents (Resident #6) reviewed for hospice care: The facility failed to ensure Resident #6 had a physician's order for hospice care. This failure could result in residents not receiving care without a physician's order.The findings included: Record review of the admission record for Resident #6, dated 01/21/26 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: dementia (a decline in mental ability), dysphagia (difficulty swallowing), and age-related cognitive decline. The admission record revealed Resident #6 used Hospice Company A. Record review of the annual MDS for Resident #6, dated 10/07/25, Section O revealed Resident #6 was receiving hospice services. Record review of the care plan for Resident #6, last reviewed on 12/10/25, revealed a focus area for: [Resident #6] has a terminal prognosis and/or is receiving hospice services, initiated on 09/25/25. Record review of the physician orders for Resident #6, dated 01/23/26, revealed no physician order for hospice care services. Record review of a facility document titled, MDS Resident Matrix, dated 01/21/26 revealed Residents #6 was checked off for Hospice. During an interview on 01/22/26 at 3:17 PM with LVN and the ADON, LVN A stated she did not see a physician order for hospice for Resident #6. LVN A stated she knew Resident #6 was on hospice services because it stated what hospice was used in the banner in his chart. The ADON stated it was nursing in general who were responsible for ensuring a resident had physician orders for hospice services. The ADON stated she did not think he needed a physician order for hospice services because the hospice physician writes orders for Resident #6. LVN A stated she did not know why Resident #6 did not have a physician order for hospice. The ADON stated a potential negative outcome for the residents was not contacting the correct provider or they [the facility] could do something not on hospice orders. During an interview on 01/22/26 at 3:30 PM with the DON and the Corporate Nurse, the DON stated it was unknown why Resident #6 did not have a physician order for hospice. The DON stated she knew Resident #6 was on hospice because it stated on the banner in his chart. The DON stated the nurse or the MDS nurse usually put in hospice orders on admission. The Corporate Nurse stated a potential negative outcome to the residents was there would be an unknown diagnosis for why hospice was treating the residents. During an interview on 01/23/26 at 9:45 AM, the ADM stated she expected there to be a physician order for hospice services and the diagnosis. The ADM stated the nurse who was responsible for receiving the order for hospice from the physician was the nurse responsible for ensuring the order was put in. The ADM stated all the nurses had been trained. The ADM stated a potential negative outcome to the residents was she was unsure if the physician was aware there was not an order for hospice. Record review of the facility policy and procedure titled, Hospice Services, undated, reflected the following: As an end of life measure, the resident or responsible family member may choose to use hospice services within the facility.Procedures:11. The DON or designee will be responsible for ensuring that documentation is a part of the current clinical record. At a minimum, the documentation will include: Physician Certification of Terminal Illness.

Based on interview, and record review, the facility failed to ensure the residents had the right to be free from verbal abuse and neglect for 2 (Resident #1 and #2) of 7 residents reviewed for abuse. The facility staff failed to protect Resident #1 from verbal abuse from Resident #2 on 7/11/25 between 7:00 PM and 7:30 PM.The noncompliance was identified as PNC. The IJ began on 07/11/25 and ended on 7/25/25. The facility had corrected the noncompliance before the survey began.This failure could place residents at risk of abuse, neglect, trauma, injury and psychosocial harm. Findings included: Resident #1 Record review of Resident #1's face sheet, 8/14/25, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), schizoaffective disorder (mental disorder), anxiety (increased worry), insomnia (difficulty sleeping), major depressive disorder (increase sadness) and UTI (infection in the urinary system). Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was severely impaired. Record review of Resident #1's care plan, dated 7/14/25, revealed the following:Resident #1 had a focus for elopement and wandering specifically that she wandered aimlessly (date initiated 8/14/25). The goal was for Resident #1 to remain safe within the facility unless accompanied by a staff or authorized person. Interventions included distracting resident from wandering by offering pleasant diversions and supervising closely and make regular compliance rounds. Resident #1 had a focus for coping, specifically Resident #1 had a tough time coping with a roommate as roommate might have been verbally aggressive towards Resident #1 (date initiated 7/14/25). The goal was for Resident #1 to feel comfortable in a safe living environment. Interventions included staff would listen to Resident #1's concerns. Staff would monitor if Resident #1 were unable to cope with roommate and the social worker would find a new roommate if applicable. Record review of Resident #1's progress notes, dated 5/13/25-8/14/25, revealed: No incidents documented involving Resident #1 and any other residents on 7/11/25.07/13/25 at 9:11 PM LVN B documented: family report a CNA reported to them Resident #1's roommate was cursing at her and telling her to clean up after herself in the bathroom. Initial treatment included skin assessment; roommate placed on 1:1 monitoring supervision. Medical doctor and nurse practitioner notified. Responsible party was notified. 07/13/25 at 10:37 PM LVN B documented skin assessment conducted with no negative findings. 07/14/25 at 2:58 AM LVN B documented trauma assessment conducted. There were no negative findings or experiences documented or found. Resident #1 did not express fear or anger. 7/14/25 at 9:36 PM the DON documented a late entry indicating Resident #1's family reported to administration that the CNA (unidentified in the progress note) told them Resident #1's roommate was cursing at Resident #1 and telling her to clean up after herself in the bathroom. Resident #1's roommate was placed on one-to-one monitoring. Skin Assessment performed on Resident #1. A room swap was made. Family was aware and notified. FNP was notified. 7/15/25 at 8:36 AM LVN EE documented that Resident #1 appeared to be in no pain and monitoring was conducted. 7/15/25 at 8:37 AM LVN EE documented that Resident #1 had no signs or symptoms of distress noted, resident in good spirits.7/15/25 at 10:13 PM LVN BB documented that Resident #1 had no signs or symptoms of distress and did not complain of any pain.During an interview on 8/14/25 at 12:31 PM, Resident #1 could not recall the incident that occurred between she and Resident #2. She could not identify her last roommate by name. She stated she could not remember if she was afraid on 7/11/25. She could not remember how long she had been in the room that she was and why she had moved. She reported that she felt safe at the facility. Resident #2 Record review of Resident #2's face sheet, dated 8/14/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include intermittent explosive disorder (mental disorder characterized by outburst of anger or violence), anxiety (increased worry) and dementia (memory loss). Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 08, which indicated the resident's cognition was moderately impaired. Section E did not reveal any coded behaviors.Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: Section E Behavior Resident #2 had other behavioral symptoms not directed towards others.Resident #2's care plan, dated 7/14/25 revealed the following:Resident #2 had a focus for behavioral symptoms specifically that Resident #2 had potential to demonstrate physical behaviors. (initiated 7/4/25) The goal was for Resident #2 to demonstrate effective coping skills. Interventions included staff analyzing key times, places, circumstances, triggers, and what de-escalates behavior and document. Staff should assess and address sensory deficits and notify the charge nurse of any physically abusive behaviors. When Resident #2 becomes agitated staff should intervene before agitation escalates. Resident #2 had a focus for behavioral symptoms specifically that Resident #2 had a behavior problem related to being verbally aggressive to staff and other residents. (initiated 7/14/25) The goal was for Resident #2 to not have episodes of being verbally aggressive. Interventions included anticipate the needs of Resident #2. Staff should provide opportunity for positive interaction. Consultation with psychiatry will be made if needed. Staff should also intervene as necessary to protect the rights and safety of others. Staff will also monitor behavior episode of Resident #2. Record review of Resident #2's progress notes, dated 5/13/25-8/14/25, revealed: No incidents documented involving Resident #2 and any other residents on 7/11/25.7/13/25 at 9:11 PM the DON documented Resident #2 had a behavior (verbal, resident to resident alleged behavior). Resident #2 scolded her roommate (Resident #1) with curse words to clean up her mess in the bathroom. 1:1 mentoring supervision implemented. Consulted FNP for new orders of hydroxyzine 50 mg PO Q4 hours prn. Recommended to conduct room swap. Resident #2 stated we get along good. Resident #2 stated she worried about her roommate because she sleeps all day and does not sleep much. Attempted to contact Resident #2's family. 7/14/25 at 8:20 AM the DON documented late entry: Informed by administrator the resident's (unspecified in this progress note) roommate's family informed her the CNA (unspecified in this progress note) told them Resident #2 was cursing at her roommate and telling her to clean up after herself in the bathroom. Resident #2 was immediately place on one-on-one observation. Consulted psych provider for any new orders/recommendations. New order to start hydroxyzine 50 mg prn Q4 hours for anxiety/agitation. Performed a roommate swap and may d/c one-on-one monitoring but ensure frequent monitoring as the resident was not physically aggressive. Attempted to notify Family Member FF multiple times. D/c one-on-one supervision. Resident #2 currently does not have a roommate currently.07/15/25 at 10:18 AM the SW documented that she received notification from the administration that a referral to the behavioral center was needed. The SW notified Family Member FF, and he agreed to the referral and the referral was completed. 07/15/25 at 10:24 AM LVN EE documented no verbal behaviors noted, and Resident #2 was in good spirits. 07/15/25 at 10:29 PM LVN BB documented Resident #2 was quiet without negative behaviors, toward resident or staff. 07/16/25 at 8:57 AM LVN EE documented Resident #2 had no behaviors. 07/16/25 at 8:57 PM LVN B documented no behaviors reported during her shift. 07/17/25 at 2:57 PM The SW documented that the referral for Resident #2 was denied due to Resident #2's insurance being out of network. During an interview on 8/14/25 at 12:33 PM, Resident #2 stated she does not remember why her last roommate moved. She stated she got along well with her last roommate. She could not identify her last roommate by name. She could not report if she had an incident with Resident #1 on 7/11/25. During an interview on 8/14/25 at 9:31 AM, CNA A stated she did not have a calendar in front of her but believed the incident occurred on 7/11/25. She stated she worked the night shift (6:00 PM- 6:00 AM). She stated on that day (7/11/25) her partner that she worked with that day called in late. She stated she and LVN B were the only ones on the locked female unit. She stated around 7:00 PM or 7:30 PM while LVN B was attending to another resident next door to Resident #1 and Resident #2 they (CNA A and LVN B) heard Resident #2 yell a loud and clear Get your mother fucking ass in that God Damn bathroom and clean that shit up! CNA A stated she and LVN B looked at each other. CNA A stated LVN B asked her Who is she (Resident #2) hollering at? CNA A stated LVN B instructed her (CNA A) to go and look. CNA A stated when she stepped into Resident #1 and Resident #2's room she observed Resident #1 standing in front of Resident #2 and the look on Resident #1's face gave her (CNA A) the impression that she was scared. CNA A stated she motioned for Resident #1 to come with her. CNA A stated she took Resident #1 to where LVN B was and during this time LVN B then goes to Resident #2. CNA A stated she and Resident #1 stood outside the room where Resident #2 and LVN B were. CNA A stated LVN B asked Resident #2 what was going on and Resident #2 voiced her complaint about Resident #1 pissing on the bathroom floor. She stated LVN B instructed Resident #2 that if it happened again, she needed to call staff for help. CNA A stated she went to get a towel to clean up the urine in the bathroom and while she was doing this Resident #1 followed LVN B. CNA A stated Resident #2 yelled at her Don't clean up that shit! This is why she (Resident #1) don't learn because y'all baby her (Resident #1)! CNA A stated Resident #1 was afraid and did not go back to the room with Resident #2 for majority of the night. CNA A stated Resident #1 did not go to bed until Resident #2 was asleep. CNA A stated she was under the impression that since LVN B witnessed the incident along with her that she would report it to the abuse coordinator, document and notify the family. CNA A stated a couple of days later (unsure of the exact date), Resident #1's family came to the facility and in passing the family asked why is it that when they have come in Resident #1 is not in her bed and sometimes is found in other resident's bed. CNA A stated she told them that it was most likely because she (Resident #1) was afraid of her roommate (Resident #2). She stated that immediately once she mentioned the incident to Family Member CC, he became upset and exclaimed no one told him about the incident. She stated that LVN B was upset with her and told her at that time to complete a report. She stated unsure of the date the following Monday she was suspended because she failed to report the incident. CNA A stated she did not feel it was right that she was suspended for failure to report when LVN B also heard the incident and was present. CNA A stated that the ADM told her that LVN B may have misheard what happened. CNA A stated this was not the case because Resident #2 said what she said very loud, and they were next door to their room. CNA A stated Resident #1 slept in the same room with Resident #2 the night of the incident. CNA A stated she was told that Resident #1 was moved out of the room only after Resident #1's family complained. CNA A stated Resident #2 had a history of aggression and that she had expressed concern in the past. CNA A stated Resident #2 had broken the facility door before and was an exceptionally large lady in comparison to Resident #1. She stated although she did not believe Resident #2 physically hit Resident #1, she believed that Resident #1 was afraid because she would not go back in her room the night of the incident. She stated she and other staff reported to LVN B that even they (staff) were afraid of Resident #2. CNA A stated no other incidents had occurred between Resident #1 and Resident #2 since 7/11/25 but she could not attest for any time after she was suspended. She stated she was trained that if she suspects or witness abuse, she was to report abuse to her chain of command, and this would have been LVN B. She stated that being a CNA for over 25 years this was the way it has always been. She stated that the ADM stated at the time of her suspension that she was supposed to report the incident to her (the ADM). CNA A stated the nurses were responsible for reporting incidents to the family. CNA A stated the night of the incident Resident #1 did not have any injuries that she could visibly see. During an interview on 8/14/25 at 10:32 AM, CNA C stated she had never worked the female locked unit. She stated she had guarded the door once when the doors were not working. She stated she had not worked directly with Resident #1 and Resident #2. During an interview on 8/14/25 at 10:43 AM, CNA D stated she did not have any information regarding the verbal incident between Resident #1 and Resident #2 that occurred on 07/11/25. She stated she is unaware if any incidents had occurred since 7/11/25. During an interview on 8/14/25 at 11:09 AM, CNA E stated she did not have any firsthand information about the verbal incident that occurred on 7/11/25 between Resident #1 and Resident #2. She stated Resident #1 and Resident #2 had never had issues before 7/11/25 or since 7/11/25. She stated Resident #2 rarely has behaviors. She stated Resident #1 has no behaviors but will ask questions over and over. During an interview on 8/14/25 at 11:24 AM, CNA F stated she did not have any firsthand information about Resident #1's and Resident #2's verbal altercation that occurred on 7/11/25. She stated there had been no additional altercations between Resident #1 and Resident #2. She stated Resident #1 had an issue where she wanted to leave the unit but never had any altercations with residents in the unit. During an interview on 8/14/25 at 11:35 AM, CNA G stated she does not work the female unit and did not have any information regarding the incident that occurred on 7/11/25 between Resident #1 and Resident #2. During an interview on 8/14/25 at 11:45 AM, CNA H stated although she works the female locked unit at times, she did not have any information regarding the verbal altercation that occurred between Resident #1 and Resident #2. She stated she did not have any information about Resident #1 and Resident #2's behaviors as she had not worked the female locked unit in a while. During an interview on 8/14/25 at 11:55 AM, LVN I stated he did not have any firsthand information about the verbal altercation that occurred on 7/11/25 between Resident #1 and Resident #2. He stated Resident #1 and Resident #2 did not have a history of verbal altercations and there had been no incidents since 7/11/25. He stated Resident #1 was pleasantly confused. He stated she would wander but no other behaviors. He stated in the past Resident #2 had behaviors that included hoarding briefs. He stated in the past on an unknown date she (Resident #2) broke the female locked unit door but was sent to a behavior unit because of that behavior. He stated the facility manages Resident #2's behavior well through close monitoring. During an interview on 8/14/25 at 12:11 PM, LVN J stated she did not have any firsthand information about Resident #1 and Resident #2's verbal altercation that occurred on 7/11/25 as she did not work the female locked unit on that date. She stated she did not have any additional information regarding Resident #2 or Resident #1 behaviors. During an interview on 8/14/25 at 1:04 PM, CNA K stated she did not have firsthand information regarding Resident #1 and Resident #2 verbal altercation that occurred on 7/11/25. She stated she had worked with both residents before and after 7/11/25. She stated the two had never had any issues before or after. She stated Resident #2 never comes out of her room. She stated Resident #1 can be active at times. She stated neither resident has ever had significant behaviors in her presence. Interviews conducted on 8/14/25 between 10:32 AM-1:04 PM, revealed that daytime staff (CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, LVN I, LVN J and CNA K) had been trained on the facility's abuse policy. The staff were able to identify the abuse coordinator, and stated if they suspected or witnessed abuse, they would report directly to the abuse coordinator. During their interviews, staff was able to report that apart of the suspicion or witnessing abuse they would protect the resident. During an interview on 8/14/25 at 2:33 PM, the ADM stated that she was unsure of the date and time but while at home one-night LVN B called her and explained that Resident #1's family was upset. She stated LVN B told her about the initial complaint from the family involved cleaning supplies and them (Family Member CC) having to clean the restroom. The ADM stated that she received a call from Family Member DD 30 minutes later who stated that the real reason that they (family) were upset was because Resident #1 had been abused and her roommate (Resident #2) was screaming at her (Resident #1). The ADM stated at the time Family Member DD notified her of Resident #2 screaming at Resident #1 she was unaware of the incident. She stated once Family Member DD notified her, she notified the DON, and the DON instructed for 1:1 to be started for Resident #2 to LVN B. The ADM stated that LVN B stated she was unaware of any incidents of abuse that involved Resident #1 and Resident #2. She (the ADM) stated that she started her abuse process. The ADM stated LVN B reported to her that she (LVN B) heard yelling one night (date was not specified) and LVN B instructed CNA A to see what happened. The ADM stated LVN B reported to her that CNA A never reported to her that Resident #2 was yelling at Resident #1. The ADM stated Resident #2 had a history of yelling at staff. The ADM stated she immediately suspended CNA A for not reporting directly to her. She stated she interviewed CNA A and CNA stated she did tell Family Member CC about the incident between Resident #1 and Resident #2. The ADM stated she asked CNA A why she did not report the incident directly to her as the abuse coordinator as she had been trained and CNA A response was my bad. During an interview on 8/15/25 at 12:15 PM, the ADM stated that she was unsure of the exact date of the incident between Resident #1 and Resident #2, but voiced that she was notified of the incident on 7/13/25 by Family Member DD. The ADM stated she reported the incident to HHSC on 7/13/25 at 11:05 PM. She stated Resident #2 was placed on 1:1 supervision as soon as she was notified of the incident on 7/13/25. She stated Resident #1 was not moved out of the room with Resident #2 because of bed availability. She stated room moves had to be made before she could move Resident #1 out of the room with Resident #2. The ADM stated Resident #1 shared the same bedroom with Resident #2 after the incident up until she was notified on 7/13/25. The ADM said no additional incidents had occurred between Resident #1 and Resident #2. She stated she suspended CNA A on 7/14/25 and the last date CNA A had been in the facility was on the morning of her shift ended on 7/14/25. She started safe surveys were conducted on the female locked unit and there were no findings. She stated after consulting with the corporate office and gaining approval she terminated CNA A for failure to report ANE. She stated they started re-education on the facility's abuse policy and by 7/14/25 100 percent of her staff had been trained on the facility's abuse policy. The ADM stated she was sure all staff had been trained because the day they started re-education it was the facility's pay day and each staff that came in had to pick up their check. They re-educated and quizzed the staff verbally on the expectations. She stated staff had always been trained to report to her as the abuse coordinator. She stated Resident #2 was referred to psychiatric services for the incident.During an interview on 8/15/25 at 12:20 PM, the DON stated that on 07/09/25 Resident #2 had a recent change in medication where she had started Depakote. She stated because of the incident between Resident #1 and Resident #2 it was decided to continue to monitor the newly change medication and they added a PRN medication (Hydroxyzine). The ADM, DON, regional Nurse Consultant and Director of Operations were notified on 8/15/25 at 4:08 PM that a PNC IJ situation was identified due to the above failures and the IJ template and 3-strike letter was provided.Interviews conducted on 8/15/25 between 4:31 PM-6:16 PM, revealed that administration, daytime and nighttime staff (the DM, MDS Coordinator, ADON, HR, the Maintenance Supervisor, DS L, [NAME] M, LVN N, LVN O, CNA P, MA Q, CNA R, CNA S, RN T, CNA U, MA V, CNA W, CNA X, CNA Y, CNA Z, CNA AA, and LVN BB) had been trained on the facility's abuse policy recently (within the past 30-60 days). The staff voiced they had been trained by the ADM, DON and or the ADON. They stated that they were given the opportunity to ask questions if they needed to. They were all able to identify the abuse coordinator as the ADM and that they needed to report all suspected or witnessed abuse to the ADM. They all were able to voice that they would not assume that an incident had been reported but would report the incident as it was their responsibility. They all were able to report that protection of the resident(s) involved was a part of following the abuse protocol for the facility. They all were able to report that if they did not see any protection interventions put in place that they would follow up with management and or the abuse coordinator. All nurses interviewed were able to report that it was their responsibility to notify family and or responsible party of any significant events involving the residents that resided at the facility. All staff interviewed voiced that they were comfortable, confident in their role carrying out the facility's expectation regarding the facility's abuse policy and requirements. During an interview on 8/15/25 at 6:18 PM, Family Member CC stated they were not notified of the incident that occurred with Resident #1 and Resident #2 at the time of the incident. Family Member CC stated CNA A notified them that Resident #1 was afraid of her roommate (Resident #2). Family Member CC stated he had not observed any incidents between Resident #1 and Resident #2. He stated that they (he and his family) were incredibly pleased with how the facility responded to them reporting their concerns about Resident #1. Family Member CC stated as soon as they reported the incident the facility staff moved Resident #1. Family Member CC stated there had been no incidents since the incident. Family member CC stated that he was unsure if Resident #1 was afraid, but they (he and the family) had concerns that Resident #1 was sleeping in other resident's beds because she had a UTI. He stated when he asked CNA A about what she thought regarding Resident #1 sleeping in other's beds CNA disclosed the incident. He stated he honestly believed CNA was trying to console them because they had other concerns within the same night. He stated since the incident between Resident #1 and Resident #2 the facility staff have done so well notifying them (he and family). During an interview on 8/15/25 at 5:15 PM, the ADM stated regarding the failure to prevent abuse she had been trained on the facility's policy. She stated they review the abuse policy routinely. She stated the purpose of the policy was to protect the residents and ensure they investigate all allegations of abuse. The ADM stated when the allegation was reported to her on 7/13/25 she did investigate and found that CNA A failed to report timely. The ADM stated when she interviewed CNA A, she stated CNA A stated she thought LVN B had reported it. The ADM stated she reminded CNA A at that time it was her responsibility and CNA A's response was my bad. The ADM stated the potential negative outcome for not preventing abuse was residents could endure harm. The ADM stated she could not confirm if Resident #1 was abused. The ADM stated she had no indication that Resident #1 was harmed or was withdrawn. She stated after the incident no staff reported any changes. The ADM stated she was unaware that Resident #2 had yelled at Resident #1. She stated she became aware of the incident on 7/13/25 when the family called her. The ADM stated the system to monitor residents and ensuring they are not abused was re-educating staff, making rounds, and talking to residents and family about abuse. She stated staff are trained upon hire, annually and when there is an incident. The ADM stated she had never observed Resident #2 be aggressive to Resident #1 or any other residents. The ADM stated she expected facility staff to prevent abuse for all residents. The ADM stated all staff are responsible for preventing abuse. The ADM stated the reason abuse was not prevented in the incident involving Resident #1 and Resident #2 was because she was unaware of the incident as it was not reported to her by CNA A. The ADM stated she was unaware that Resident #2 was treating Resident #1 in any way that was negative. During an interview on 8/15/25 at 5:42 PM, the DON stated regarding the failure to prevent abuse that she was familiar with the facility's ANE policy. The DON stated the purpose of preventing abuse was to prevent harm to the residents. The DON stated they did not want to harm the residents. The DON stated Resident #1 has always had the behavior of wandering as she (Resident #1) was pleasantly confused. The DON stated Resident #1 may have been in other resident's room during the time the family noticed not because she was afraid of Resident #2 but because of her dementia diagnoses. The DON stated residents with dementia do not remember. The DON stated she did not feel that Resident #2 abused Resident #1. The DON stated she interviewed Resident #2 and Resident #2 expressed that she and Resident #1 were good. She stated Resident #2 expressed that she (Resident #2) had concern regarding Resident #1's eating and sleeping habits. The DON stated she was unaware of the incident and was made aware of the incident on 7/13/25 when the ADM notified her. The DON stated their system to monitor and ensure residents do not experience abuse was through education to staff. The DON stated the staff were repeatedly trained on the policy and should have known what to do. She stated they also investigate all allegations, speak to staff and residents. The DON stated CNA A failed to report to the abuse coordinator, the ADM, and if CNA A had reported the incident, then the facility could protect the residents. The DON stated she had been trained on the abuse policy and all staff had all been trained. The DON stated she had never observed Resident #2 be verbally abusive to Resident #1. The DON stated she expected staff to prevent abuse from happening. The DON stated all staff are responsible for preventing abuse. The DON stated she does not feel abuse occurred but that regarding the incident between Resident #1 and Resident #2 CNA A did fail to report the incident to the abuse coordinator. During an interview on 8/15/25 at 8:45 PM, LVN B stated she was unsure of the exact date of the incident that occurred between Resident #1 and Resident #2. LVN B stated that she was in the last room at the end of the hallway assisting another resident. She stated CNA A heard one of the residents raise their voice. She stated she asked CNA A which resident raised their voice and was told by CNA A that it was Resident #2 and Resident #1. LVN B stated CNA A told her that Resident #2 was raising her voice at Resident #1. LVN B stated she voiced to Resident #2 that she does not need to raise her voice. LVN B stated that was it and she left Resident #2 in her room. LVN B stated 5 minutes later both residents could not remember the incident. LVN B stated she does not know what specifically Resident #2 said to Resident #1. She stated CNA A did not specify what was said but only stated Resident #2 was yelling at Resident #1 because there was piss on the floor. LVN B stated she did not suspect abuse because normally Resident #2 was loud resident and that was the way she talked. She stated working on the locked unit residents have behaviors and she considered Resident #2 yelling as one of her behaviors and she needed redirection. LVN B stated Resident #1 did not appear afraid to her. LVN B stated Resident #1 went back to her room within an hour of the incident. LVN B stated that CNA A did not report to her or indicate that Resident #1 was afraid. LVN B stated after the incident between Resident #1 and Resident #2 she never had a discussion with Resident #1's family nor did she discuss the incident any further with CNA A. LVN B stated that had not been any other incidents since the verbal incident between Resident #1 and Resident #2 nor had there been any incidents before. LVN B stated CNA A reported to the Resident #1's family that Resident #1 felt threatened by Resident #2 and that is what caused them to call the ADM. She stated when they called the ADM, she was instructed to place Resident #2 on 1:1 supervision. LVN B stated she did not report the incident to the abuse coordinator because she felt it was a nursing judgement call to redirect Resident #2. LVN B stated she had been trained on the facility's abuse policy recently (within the past 30-60 days) by the ADM, DON and ADON. She stated that protection of the resident(s) involved was a part of following the abuse protocol for the facility. She stated if she did not see any protection interventions put in place that she would follow up with management and or the abuse coordinator. LVN B stated Resident #1 and Resident #2 shared the same room after the incident up until she was instructed to place Resident #2 on 1:1 supervision. LVN B stated no other incidents occurred with Resident #1 and Resident #2 after the verbal incident on the unknown date that she was aware of. She stated before the incident that occurred with Resident #1 and Resident #2, she had received training on the facility's ANE policy.During the investigation held on 8/14/25-8/15/25 there were no observation of any interactions between Resident #1 and Resident #2. Resident #1 and Resident #2 were observed in their separate rooms during the visit. Record review of the facility's Form 3614 (Provider Investigation Report), dated 7/17/25, revealed:Incident Date: 7/11/25Person(s) or Resident(s) involved:Resident #1 Alleged Perpetrator: None listed.Witnesses:CNA ADescription of the Allegation: Resident #1's roommate cusses at her and tries to make her clean up the bathroom. Assessment:7/13/25: Resident has no injuries. Provider Response: Resident #2 was placed on one-to-one monitoring immediately upon receiving report from Resident #1's family. Resident #1 was assessed for any injuries-none noted. Physician notified. Family, physician and psychiatry notified for Resident #2.Investigation Summary: Resident #1's family reported to LVN B, that they had been finding Resident #1 bathroom with bowel and urine on the floor and they had been bringing toilet paper because she had not had toilet paper and sometimes paper towels. LVN B notified the ADM via phone of the concern. The ADM later received a call from Family Member B stating what family had reported and added that Resident #2 had been yelling and cussing at Resident #1. LVN B was aware that one evening she heard raised voices and sent CNA A to see what was going on but nothing was ever reported to LVN B about cussing or demanding residents to het on her knees and clean up the bathroom. CNA A was suspended pending investigation and will be terminated for failure to report. Both residents lack capacity to m[TRUNCATED]

Based on interviews and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for 2 of 7 residents (Resident #1, and #2) reviewed for abuse. CNA A failed to follow the facility's abuse policy by not reporting the incident (verbal abuse) to the facility's Abuse Coordinator involving Resident #1and Resident #2 that occurred on 7/11/25 between 7:00 PM and 7:30 PM.LVN B failed to follow the facility's abuse policy by not reporting the incident (verbal abuse) to the facility's Abuse Coordinator involving Resident #1and Resident #2 that occurred on 7/11/25 between 7:00 PM and 7:30 PM.The ADM failed to follow the facility's abuse policy by not reporting the incident (verbal abuse) to HHSC involving Resident #1 and Resident #2 that occurred on 7/11/25 between 7:00 PM and 7:30 PM.The facility failed to notify Resident #1's family of the verbal abuse incident that occurred on 7/11/25 between 7:00 PM and 7:30 PM.The facility failed to put protective measures to protect Resident #1 from Resident #2 after a verbal abuse incident occurred on 7/11/25.The noncompliance was identified as PNC. The IJ began on 07/11/25 and ended on 7/14/25. The facility had corrected the noncompliance before the survey began.These failures could place residents as risk for abuse and injury. Findings included: Record review of the facility's abuse policy, dated 3/29/18, revealed the following: The resident has the right to be free from abuse,.Residents should not be subjected to abuse by anyone, including, but notlimited to, facility staff, other residents,.PreventionThe facility will provide the residents, families, and staff an environment free from abuse and neglect.The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect.The facility has in place a method to identify events such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse.ReportingAny person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse,neglect or exploitation must report this to the DON, administrator, state and/or adult protective services.State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation ofthe elderly and incapacitated persons.When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation ofproperty comes to the attention of any employee, that employee will make an immediate verbal report tothe Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, theAbuse Preventionist and/or designee will be called.Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC.If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegationIf the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation.Protection (Resident to Resident)The above policy will apply to potential resident-to-resident abuse. Provider letter 19-17 will be reviewed to determine if resident-to-resident abuse occurred.Resident #1 Record review of Resident #1's face sheet, 8/14/25, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), schizoaffective disorder (mental disorder), anxiety (increased worry), insomnia (difficulty sleeping), major depressive disorder (increase sadness) and UTI (infection in the urinary system). Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was severely impaired. Record review of Resident #1's care plan, dated 7/14/25, revealed the following:Resident #1 had a focus for elopement and wandering specifically that she wandered aimlessly (date initiated 8/14/25). The goal was for Resident #1 to remain safe within the facility unless accompanied by a staff or authorized person. Interventions included distracting resident from wandering by offering pleasant diversions and supervising closely and make regular compliance rounds. Resident #1 had a focus for coping, specifically Resident #1 had a tough time coping with a roommate as roommate might have been verbally aggressive towards Resident #1 (date initiated 7/14/25). The goal was for Resident #1 to feel comfortable in a safe living environment. Interventions included staff would listen to Resident #1's concerns. Staff would monitor if Resident #1 were unable to cope with roommate and the social worker would find a new roommate if applicable. Record review of Resident #1's progress notes, dated 5/13/25-8/14/25, revealed: No incidents documented involving Resident #1 and any other residents on 7/11/25.07/13/25 at 9:11 PM LVN B documented: family report a CNA reported to them Resident #1's roommate was cursing at her and telling her to clean up after herself in the bathroom. Initial treatment included skin assessment; roommate placed on 1:1 monitoring supervision. Medical doctor and nurse practitioner notified. Responsible party was notified. 07/13/25 at 10:37 PM LVN B documented skin assessment conducted with no negative findings. 07/14/25 at 2:58 AM LVN B documented trauma assessment conducted. There were no negative findings or experiences documented or found. Resident #1 did not express fear or anger. 7/14/25 at 9:36 PM the DON documented a late entry indicating Resident #1's family reported to administration that the CNA (unidentified in the progress note) told them Resident #1's roommate was cursing at Resident #1 and telling her to clean up after herself in the bathroom. Resident #1's roommate was placed on one-to-one monitoring. Skin Assessment performed on Resident #1. A room swap was made. Family was aware and notified. FNP was notified. 7/15/25 at 8:36 AM LVN EE documented that Resident #1 appeared to be in no pain and monitoring was conducted. 7/15/25 at 8:37 AM LVN EE documented that Resident #1 had no signs or symptoms of distress noted, resident in good spirits.7/15/25 at 10:13 PM LVN BB documented that Resident #1 had no signs or symptoms of distress and did not complain of any pain.During an interview on 8/14/25 at 12:31 PM, Resident #1 could not recall the incident that occurred between she and Resident #2. She could not identify her last roommate by name. She stated she could not remember if she was afraid on 7/11/25. She could not remember how long she had been in the room that she was and why she had moved. She reported that she felt safe at the facility. Resident #2 Record review of Resident #2's face sheet, dated 8/14/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include intermittent explosive disorder (mental disorder characterized by outburst of anger or violence), anxiety (increased worry) and dementia (memory loss). Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 08, which indicated the resident's cognition was moderately impaired. Section E did not reveal any coded behaviors.Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: Section E Behavior Resident #2 had other behavioral symptoms not directed towards others.Resident #2's care plan, dated 7/14/25 revealed the following:Resident #2 had a focus for behavioral symptoms specifically that Resident #2 had potential to demonstrate physical behaviors. (initiated 7/4/25) The goal was for Resident #2 to demonstrate effective coping skills. Interventions included staff analyzing key times, places, circumstances, triggers, and what de-escalates behavior and document. Staff should assess and address sensory deficits and notify the charge nurse of any physically abusive behaviors. When Resident #2 becomes agitated staff should intervene before agitation escalates. Resident #2 had a focus for behavioral symptoms specifically that Resident #2 had a behavior problem related to being verbally aggressive to staff and other residents. (initiated 7/14/25) The goal was for Resident #2 to not have episodes of being verbally aggressive. Interventions included anticipate the needs of Resident #2. Staff should provide opportunity for positive interaction. Consultation with psychiatry will be made if needed. Staff should also intervene as necessary to protect the rights and safety of others. Staff will also monitor behavior episode of Resident #2. Record review of Resident #2's progress notes, dated 5/13/25-8/14/25, revealed: No incidents documented involving Resident #2 and any other residents on 7/11/25.7/13/25 at 9:11 PM the DON documented Resident #2 had a behavior (verbal, resident to resident alleged behavior). Resident #2 scolded her roommate (Resident #1) with curse words to clean up her mess in the bathroom. 1:1 mentoring supervision implemented. Consulted FNP for new orders of hydroxyzine 50 mg PO Q4 hours prn. Recommended to conduct room swap. Resident #2 stated we get along good. Resident #2 stated she worried about her roommate because she sleeps all day and does not sleep much. Attempted to contact Resident #2's family. 7/14/25 at 8:20 AM the DON documented late entry: Informed by administrator the resident's (unspecified in this progress note) roommate's family informed her the CNA (unspecified in this progress note) told them Resident #2 was cursing at her roommate and telling her to clean up after herself in the bathroom. Resident #2 was immediately place on one-on-one observation. Consulted psych provider for any new orders/recommendations. New order to start hydroxyzine 50 mg prn Q4 hours for anxiety/agitation. Performed a roommate swap and may d/c one-on-one monitoring but ensure frequent monitoring as the resident was not physically aggressive. Attempted to notify Family Member FF multiple times. D/c one-on-one supervision. Resident #2 currently does not have a roommate currently.07/15/25 at 10:18 AM the SW documented that she received notification from the administration that a referral to the behavioral center was needed. The SW notified Family Member FF, and he agreed to the referral and the referral was completed. 07/15/25 at 10:24 AM LVN EE documented no verbal behaviors noted, and Resident #2 was in good spirits. 07/15/25 at 10:29 PM LVN BB documented Resident #2 was quiet without negative behaviors, toward resident or staff. 07/16/25 at 8:57 AM LVN EE documented Resident #2 had no behaviors. 07/16/25 at 8:57 PM LVN B documented no behaviors reported during her shift. 07/17/25 at 2:57 PM The SW documented that the referral for Resident #2 was denied due to Resident #2's insurance being out of network. During an interview on 8/14/25 at 12:33 PM, Resident #2 stated she does not remember why her last roommate moved. She stated she got along well with her last roommate. She could not identify her last roommate by name. She could not report if she had an incident with Resident #1 on 7/11/25. During an interview on 8/14/25 at 9:31 AM, CNA A stated she did not have a calendar in front of her but believed the incident occurred on 7/11/25. She stated she worked the night shift (6:00 PM- 6:00 AM). She stated on that day (7/11/25) her partner that she worked with that day called in late. She stated she and LVN B were the only ones on the locked female unit. She stated around 7:00 PM or 7:30 PM while LVN B was attending to another resident next door to Resident #1 and Resident #2 they (CNA A and LVN B) heard Resident #2 yell a loud and clear Get your mother fucking ass in that God Damn bathroom and clean that shit up! CNA A stated she and LVN B looked at each other. CNA A stated LVN B asked her Who is she (Resident #2) hollering at? CNA A stated LVN B instructed her (CNA A) to go and look. CNA A stated when she stepped into Resident #1 and Resident #2's room she observed Resident #1 standing in front of Resident #2 and the look on Resident #1's face gave her (CNA A) the impression that she was scared. CNA A stated she motioned for Resident #1 to come with her. CNA A stated she took Resident #1 to where LVN B was and during this time LVN B then goes to Resident #2. CNA A stated she and Resident #1 stood outside the room where Resident #2 and LVN B were. CNA A stated LVN B asked Resident #2 what was going on and Resident #2 voiced her complaint about Resident #1 pissing on the bathroom floor. She stated LVN B instructed Resident #2 that if it happened again, she needed to call staff for help. CNA A stated she went to get a towel to clean up the urine in the bathroom and while she was doing this Resident #1 followed LVN B. CNA A stated Resident #2 yelled at her Don't clean up that shit! This is why she (Resident #1) don't learn because y'all baby her (Resident #1)! CNA A stated Resident #1 was afraid and did not go back to the room with Resident #2 for majority of the night. CNA A stated Resident #1 did not go to bed until Resident #2 was asleep. CNA A stated she was under the impression that since LVN B witnessed the incident along with her that she would report it to the abuse coordinator, document and notify the family. CNA A stated a couple of days later (unsure of the exact date), Resident #1's family came to the facility and in passing the family asked why is it that when they have come in Resident #1 is not in her bed and sometimes is found in other resident's bed. CNA A stated she told them that it was most likely because she (Resident #1) was afraid of her roommate (Resident #2). She stated that immediately once she mentioned the incident to Family Member CC, he became upset and exclaimed no one told him about the incident. She stated that LVN B was upset with her and told her at that time to complete a report. She stated unsure of the date the following Monday she was suspended because she failed to report the incident. CNA A stated she did not feel it was right that she was suspended for failure to report when LVN B also heard the incident and was present. CNA A stated that the ADM told her that LVN B may have misheard what happened. CNA A stated this was not the case because Resident #2 said what she said very loud, and they were next door to their room. CNA A stated Resident #1 slept in the same room with Resident #2 the night of the incident. CNA A stated she was told that Resident #1 was moved out of the room only after Resident #1's family complained. CNA A stated Resident #2 had a history of aggression and that she had expressed concern in the past. CNA A stated Resident #2 had broken the facility door before and was an exceptionally large lady in comparison to Resident #1. She stated although she did not believe Resident #2 physically hit Resident #1, she believed that Resident #1 was afraid because she would not go back in her room the night of the incident. She stated she and other staff reported to LVN B that even they (staff) were afraid of Resident #2. CNA A stated no other incidents had occurred between Resident #1 and Resident #2 since 7/11/25 but she could not attest for any time after she was suspended. She stated she was trained that if she suspects or witness abuse, she was to report abuse to her chain of command, and this would have been LVN B. She stated that being a CNA for over 25 years this was the way it has always been. She stated that the ADM stated at the time of her suspension that she was supposed to report the incident to her (the ADM). CNA A stated the nurses were responsible for reporting incidents to the family. CNA A stated the night of the incident Resident #1 did not have any injuries that she could visibly see. During an interview on 8/14/25 at 10:32 AM, CNA C stated she had never worked the female locked unit. She stated she had guarded the door once when the doors were not working. She stated she had not worked directly with Resident #1 and Resident #2. During an interview on 8/14/25 at 10:43 AM, CNA D stated she did not have any information regarding the verbal incident between Resident #1 and Resident #2 that occurred on 07/11/25. She stated she is unaware if any incidents had occurred since 7/11/25. During an interview on 8/14/25 at 11:09 AM, CNA E stated she did not have any firsthand information about the verbal incident that occurred on 7/11/25 between Resident #1 and Resident #2. She stated Resident #1 and Resident #2 had never had issues before 7/11/25 or since 7/11/25. She stated Resident #2 rarely has behaviors. She stated Resident #1 has no behaviors but will ask questions over and over. During an interview on 8/14/25 at 11:24 AM, CNA F stated she did not have any firsthand information about Resident #1's and Resident #2's verbal altercation that occurred on 7/11/25. She stated there had been no additional altercations between Resident #1 and Resident #2. She stated Resident #1 had an issue where she wanted to leave the unit but never had any altercations with residents in the unit. During an interview on 8/14/25 at 11:35 AM, CNA G stated she does not work the female unit and did not have any information regarding the incident that occurred on 7/11/25 between Resident #1 and Resident #2. During an interview on 8/14/25 at 11:45 AM, CNA H stated although she works the female locked unit at times, she did not have any information regarding the verbal altercation that occurred between Resident #1 and Resident #2. She stated she did not have any information about Resident #1 and Resident #2's behaviors as she had not worked the female locked unit in a while. During an interview on 8/14/25 at 11:55 AM, LVN I stated he did not have any firsthand information about the verbal altercation that occurred on 7/11/25 between Resident #1 and Resident #2. He stated Resident #1 and Resident #2 did not have a history of verbal altercations and there had been no incidents since 7/11/25. He stated Resident #1 was pleasantly confused. He stated she would wander but no other behaviors. He stated in the past Resident #2 had behaviors that included hoarding briefs. He stated in the past on an unknown date she (Resident #2) broke the female locked unit door but was sent to a behavior unit because of that behavior. He stated the facility manages Resident #2's behavior well through close monitoring. During an interview on 8/14/25 at 12:11 PM, LVN J stated she did not have any firsthand information about Resident #1 and Resident #2's verbal altercation that occurred on 7/11/25 as she did not work the female locked unit on that date. She stated she did not have any additional information regarding Resident #2 or Resident #1 behaviors. During an interview on 8/14/25 at 1:04 PM, CNA K stated she did not have firsthand information regarding Resident #1 and Resident #2 verbal altercation that occurred on 7/11/25. She stated she had worked with both residents before and after 7/11/25. She stated the two had never had any issues before or after. She stated Resident #2 never comes out of her room. She stated Resident #1 can be active at times. She stated neither resident has ever had significant behaviors in her presence. Interviews conducted on 8/14/25 between 10:32 AM-1:04 PM, revealed that daytime staff (CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, LVN I, LVN J and CNA K) had been trained on the facility's abuse policy. The staff were able to identify the abuse coordinator, and stated if they suspected or witnessed abuse, they would report directly to the abuse coordinator. During their interview staff was able to report that apart of the suspicion or witnessing abuse they would protect the resident. During an interview on 8/14/25 at 2:33 PM, the ADM stated that she was unsure of the date and time but while at home one-night LVN B called her and explained that Resident #1's family was upset. She stated LVN B told her about the initial complaint from the family involved cleaning supplies and them (Family Member CC) having to clean the restroom. The ADM stated that she received a call from Family Member DD 30 minutes later who stated that the real reason that they (family) were upset was because Resident #1 had been abused and her roommate (Resident #2) was screaming at her (Resident #1). The ADM stated at the time Family Member DD notified her of Resident #2 screaming at Resident #1 she was unaware of the incident. She stated once Family Member DD notified her, she notified the DON, and the DON instructed for 1:1 to be started for Resident #2 to LVN B. The ADM stated that LVN B stated she was unaware of any incidents of abuse that involved Resident #1 and Resident #2. She (the ADM) stated that she started her abuse process. The ADM stated LVN B reported that she (LVN B) heard yelling one night (date was not specified) and LVN B instructed CNA A to see what happened. The ADM stated LVN B reported to her that CNA A never reported to her that Resident #2 was yelling at Resident #1. The ADM stated Resident #2 had a history of yelling at staff. The ADM stated she immediately suspended CNA A for not reporting directly to her. She stated she interviewed CNA A and CNA stated she did tell Family Member CC about the incident between Resident #1 and Resident #2. The ADM stated she asked CNA A why she did not report the incident directly to her as the abuse coordinator as she had been trained and CNA A response was my bad. During an interview on 8/15/25 at 12:15 PM, the ADM stated that she was unsure of the exact date of the incident between Resident #1 and Resident #2, but voiced that she was notified of the incident on 7/13/25 by Family Member DD. The ADM stated she reported the incident to HHSC on 7/13/25 at 11:05 PM. She stated Resident #2 was placed on 1:1 supervision as soon as she was notified of the incident on 7/13/25. She stated Resident #1 was not moved out of the room with Resident #2 because of bed availability. She stated room moves had to be made before she could move Resident #1 out of the room with Resident #2. The ADM stated Resident #1 shared the same bedroom with Resident #2 after the incident up until she was notified on 7/13/25. The ADM no additional incidents had occurred between Resident #1 and Resident #2. She stated she suspended CNA A on 7/14/25 and the last date CNA A had been in the facility was on the morning of her shift ended on 7/14/25. She started safe surveys were conducted on the female locked unit and there were no findings. She stated after consulting with the corporate office and gaining approval she terminated CNA A for failure to report ANE. She stated they started re-education on the facility's abuse policy and by 7/14/25 100 percent of her staff had been trained on the facility's abuse policy. The ADM stated she was sure all staff had been trained because the day they started re-education it was the facility's pay day and each staff that came in had to pick up their check. They re-educated and quizzed the staff verbally on the expectations. She stated staff had always been trained to report to her as the abuse coordinator. She stated Resident #2 was referred to psychiatric services for the incident.During an interview on 8/15/25 at 12:20 PM, the DON stated that on 07/09/25 Resident #2 had a recent change in medication where she had started Depakote. She stated because of the incident between Resident #1 and Resident #2 it was decided to continue to monitor the newly change medication and they added a PRN medication (Hydroxyzine). The ADM, DON, regional Nurse Consultant and Director of Operations were notified on 7/15/25 at 4:08 PM and a PNC IJ situation was identified due to the above failures and the IJ template and 3-strike letter was provided.Interviews conducted on 8/15/25 between 4:31 PM-6:16 PM, revealed that administration, daytime and nighttime staff (the DM, MDS Coordinator, ADON, HR, the Maintenance Supervisor, DS L, [NAME] M, LVN N, LVN O, CNA P, MA Q, CNA R, CNA S, RN T, CNA U, MA V, CNA W, CNA X, CNA Y, CNA Z, CNA AA, and LVN BB) had been trained on the facility's abuse policy recently (within the past 30-60 days). The staff voiced they had been trained by the ADM, DON and or the ADON. They stated that they were given the opportunity to ask questions if they needed to. They were all able to identify the abuse coordinator as the ADM and that they needed to report all suspected or witnessed abuse to the ADM. They all were able to voice that they would not assume that an incident had been reported but would report the incident as it was their responsibility. They all were able to report that protection of the resident(s) involved was a part of following the abuse protocol for the facility. They all were able to report that if they did not see any protection interventions put in place that they would follow up with management and or the abuse coordinator. All nurses interviewed were able to report that it was their responsibility to notify family and or responsible party of any significant events involving the residents that resided at the facility. During an interview on 8/15/25 at 6:18 PM, Family Member CC stated they were not notified of the incident that occurred with Resident #1 and Resident #2 at the time of the incident. Family Member CC stated CNA A notified them that Resident #1 was afraid of her roommate (Resident #2). Family Member CC stated he had not observed any incidents between Resident #1 and Resident #2. He stated that they (he and his family) were incredibly pleased with how the facility responded to them reporting their concerns about Resident #1. Family Member CC stated as soon as they reported the incident the facility staff moved Resident #1. Family Member CC stated there had been no incidents since the incident. Family member CC stated that he was unsure if Resident #1 was afraid, but they (he and the family) had concerns that Resident #1 was sleeping in other resident's beds because she had a UTI. He stated when he asked CNA A about what she thought regarding Resident #1 sleeping in other's beds CNA disclosed the incident. He stated he honestly believed CNA was trying to console them because they had other concerns within the same night. He stated since the incident between Resident #1 and Resident #2 the facility staff have done so well notifying them (he and family). During an interview on 8/15/25 at 5:15 PM, the ADM stated regarding the failure to prevent abuse she had been trained on the facility's policy. She stated they review the abuse policy routinely. She stated the purpose of the policy was to protect the residents and ensure they investigate all allegations of abuse. The ADM stated when the allegation was reported to her on 7/13/25 she did investigate and found that CNA A failed to report timely. The ADM stated when she interviewed CNA A, she stated CNA A stated she thought LVN B had reported it. The ADM stated she reminded CNA A at that time it was her responsibility and CNA A's response was my bad. The ADM stated the potential negative outcome for not preventing abuse was residents could endure harm. The ADM stated she could not confirm if Resident #1 was abused. The ADM stated she had no indication that Resident #1 was harmed or was withdrawn. She stated after the incident no staff reported any changes. The ADM stated she was unaware that Resident #2 had yelled at Resident #1. She stated she became aware of the incident on 7/13/25 when the family called her. The ADM stated the system to monitor residents and ensuring they are not abused was re-educating staff, making rounds, and talking to residents and family about abuse. She stated staff are trained upon hire, annually and when there is an incident. The ADM stated she had never observed Resident #2 be aggressive to Resident #1 or any other residents. The ADM stated she expected facility staff to prevent abuse for all residents. The ADM stated all staff are responsible for preventing abuse. The ADM stated the reason abuse was not prevented in the incident involving Resident #1 and Resident #2 was because she was unaware of the incident as it was not reported to her by CNA A. The ADM stated she was unaware that Resident #2 was treating Resident #1 in any way that was negative. The ADM stated regarding the failure to follow the facility's abuse policy that she had been trained on the facility policy and it is routine that they go over the abuse policy. She stated the overall potential negative outcome for not following the facility's abuse policy was the residents would not be free from abuse in their own home. The ADM stated she was unaware that the facility's ANE policy was not being followed. She stated she became aware on 7/13/25 when Resident #1's family called her. The ADM stated the facility's system to ensure that the facility ANE policy (specifically ANE was reported to the appropriate parties (HHSC and abuse coordinator), protection measures were put in place and family was notified) was being followed was through staff education, re-education, routine rounds and talking to staff. The ADM stated she and all her staff had been trained on the facility's ANE policy (specifically ANE was reported to the appropriate parties (HHSC and abuse coordinator), protection measures were put in place and family was notified) and their specific roles as it related to the policy. The ADM stated she expected all staff to follow the abuse policy. Specifically, the ADM stated she expected family to be notified of incidents of ANE, the abuse coordinator to be notified immediately if they suspect or witness abuse, incidents of ANE to be reported to HHSC and protective measures to protect residents should be implemented. The ADM stated everyone was responsible for following the abuse policy. The ADM stated more specifically the nursing staff, DON or the ADM was responsible for family notifications. The ADM stated all staff was responsible for reporting to the abuse coordinator immediately. The ADM stated she and the DON was responsible for reporting incidents to HHSC. The ADM stated once they were notified, they were responsible for implementing protective measures, but all staff had been trained to ensure resident safety. The ADM stated the reason the facility ANE policy was not followed was because CNA A did not report the details of the incident between Resident #1 and Resident #2 to LVN B. The ADM stated the potential negative outcome for not notifying family was the family would not be aware of issues and they are supposed to be aware of issues concerning their resident. The ADM stated if CNA A would have notified the LVN B then LVN B could have notified Resident #1's family. The ADM stated the reason Resident #1's family was not notified was because CNA A did not report the details of the incident to LVN B. The ADM stated the potential negative outcome for not reporting to the abuse coordinator was the abuse coordinator would not know. The ADM stated with the abuse coordinator not knowing of an incident then they would not be able to report to HHSC timely to HHSC. The ADM stated the reason the incident was not reported to HHSC timely was because CNA A did not report to the incident to LVN B or to her timely. The ADM stated the potential negative outcome for not reporting to HHSC would be a thorough investigation may not be conducted. The ADM stated the reason that the incident was not reported to HHSC timely was because CNA A did not report the details to LVN B or to her as the abuse coordinator. The ADM stated the potential negative outcome for not implementing protective measures for a resident after an incident would be resident safety could be affected. The ADM stated protective measures are put in place to ensure that the resident is safe. The ADM additionally stated that she also ensures that protective measures were put in place by initiating 1:1 supervision until other protective measures can be put in place. The ADM stated protective measures were not put in place for Resident #1 because CNA A did not report the incident details to LVN B. During an interview on 8/15/25 at 5:42 PM, the DON stated regarding the failure to prevent abuse that she was familiar with the facility's ANE policy. The DON stated the purpose of pr[TRUN

Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) and the Abuse Coordinator for 2 of 7 residents (Resident #1, and #2) reviewed for abuse. CNA A failed to report the allegation of abuse involving Resident #1 and Resident #2, to the abuse Coordinator (ADM) on 7/11/25 when she heard Resident #2 verbally assault Resident #1 between 7:00 PM and 7:30 PM.LVN B failed to report the allegation of abuse involving Resident #1 and Resident #2, to the abuse Coordinator (ADM) on 7/11/25 when she heard Resident #2 verbally assault Resident #1 between 7:00 PM and 7:30 PM.The Abuse Coordinator (ADM) failed to follow the facility's abuse policy by not reporting to HHSC verbal abuse involving Resident #1 and Resident #2 that occurred on 7/11/25 between 7:00 PM and 7:30 PM.The noncompliance was identified as PNC. The IJ began on 07/11/25 and ended on 7/14/25. The facility had corrected the noncompliance before the survey began.These failures could place residents as risk for abuse and neglect. Findings included: Resident #1 Record review of Resident #1's face sheet, 8/14/25, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), schizoaffective disorder (mental disorder), anxiety (increased worry), insomnia (difficulty sleeping), major depressive disorder (increase sadness) and UTI (infection in the urinary system). Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was severely impaired. Record review of Resident #1's care plan, dated 7/14/25, revealed the following:Resident #1 had a focus for elopement and wandering specifically that she wandered aimlessly (date initiated 8/14/25). The goal was for Resident #1 to remain safe within the facility unless accompanied by a staff or authorized person. Interventions included distracting resident from wandering by offering pleasant diversions and supervising closely and make regular compliance rounds. Resident #1 had a focus for coping, specifically Resident #1 had a tough time coping with a roommate as roommate might have been verbally aggressive towards Resident #1 (date initiated 7/14/25). The goal was for Resident #1 to feel comfortable in a safe living environment. Interventions included staff would listen to Resident #1's concerns. Staff would monitor if Resident #1 were unable to cope with roommate and the social worker would find a new roommate if applicable. Record review of Resident #1's progress notes, dated 5/13/25-8/14/25, revealed: No incidents documented involving Resident #1 and any other residents on 7/11/25.07/13/25 at 9:11 PM LVN B documented: family report a CNA reported to them Resident #1's roommate was cursing at her and telling her to clean up after herself in the bathroom. Initial treatment included skin assessment; roommate placed on 1:1 monitoring supervision. Medical doctor and nurse practitioner notified. Responsible party was notified. 07/13/25 at 10:37 PM LVN B documented skin assessment conducted with no negative findings. 07/14/25 at 2:58 AM LVN B documented trauma assessment conducted. There were no negative findings or experiences documented or found. Resident #1 did not express fear or anger. 7/14/25 at 9:36 PM the DON documented a late entry indicating Resident #1's family reported to administration that the CNA (unidentified in the progress note) told them Resident #1's roommate was cursing at Resident #1 and telling her to clean up after herself in the bathroom. Resident #1's roommate was placed on one-to-one monitoring. Skin Assessment performed on Resident #1. A room swap was made. Family was aware and notified. FNP was notified. 7/15/25 at 8:36 AM LVN EE documented that Resident #1 appeared to be in no pain and monitoring was conducted. 7/15/25 at 8:37 AM LVN EE documented that Resident #1 had no signs or symptoms of distress noted, resident in good spirits.7/15/25 at 10:13 PM LVN BB documented that Resident #1 had no signs or symptoms of distress and did not complain of any pain.During an interview on 8/14/25 at 12:31 PM, Resident #1 could not recall the incident that occurred between she and Resident #2. She could not identify her last roommate by name. She stated she could not remember if she was afraid on 7/11/25. She could not remember how long she had been in the room that she was and why she had moved. She reported that she felt safe at the facility. Resident #2 Record review of Resident #2's face sheet, dated 8/14/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include intermittent explosive disorder (mental disorder characterized by outburst of anger or violence), anxiety (increased worry) and dementia (memory loss). Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 08, which indicated the resident's cognition was moderately impaired. Section E did not reveal any coded behaviors.Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: Section E Behavior Resident #2 had other behavioral symptoms not directed towards others.Resident #2's care plan, dated 7/14/25 revealed the following:Resident #2 had a focus for behavioral symptoms specifically that Resident #2 had potential to demonstrate physical behaviors. (initiated 7/4/25) The goal was for Resident #2 to demonstrate effective coping skills. Interventions included staff analyzing key times, places, circumstances, triggers, and what de-escalates behavior and document. Staff should assess and address sensory deficits and notify the charge nurse of any physically abusive behaviors. When Resident #2 becomes agitated staff should intervene before agitation escalates. Resident #2 had a focus for behavioral symptoms specifically that Resident #2 had a behavior problem related to being verbally aggressive to staff and other residents. (initiated 7/14/25) The goal was for Resident #2 to not have episodes of being verbally aggressive. Interventions included anticipate the needs of Resident #2. Staff should provide opportunity for positive interaction. Consultation with psychiatry will be made if needed. Staff should also intervene as necessary to protect the rights and safety of others. Staff will also monitor behavior episode of Resident #2. Record review of Resident #2's progress notes, dated 5/13/25-8/14/25, revealed: No incidents documented involving Resident #2 and any other residents on 7/11/25.7/13/25 at 9:11 PM the DON documented Resident #2 had a behavior (verbal, resident to resident alleged behavior). Resident #2 scolded her roommate (Resident #1) with curse words to clean up her mess in the bathroom. 1:1 mentoring supervision implemented. Consulted FNP for new orders of hydroxyzine 50 mg PO Q4 hours prn. Recommended to conduct room swap. Resident #2 stated we get along good. Resident #2 stated she worried about her roommate because she sleeps all day and does not sleep much. Attempted to contact Resident #2's family. 7/14/25 at 8:20 AM the DON documented late entry: Informed by administrator the resident's (unspecified in this progress note) roommate's family informed her the CNA (unspecified in this progress note) told them Resident #2 was cursing at her roommate and telling her to clean up after herself in the bathroom. Resident #2 was immediately place on one-on-one observation. Consulted psych provider for any new orders/recommendations. New order to start hydroxyzine 50 mg prn Q4 hours for anxiety/agitation. Performed a roommate swap and may d/c one-on-one monitoring but ensure frequent monitoring as the resident was not physically aggressive. Attempted to notify Family Member FF multiple times. D/c one-on-one supervision. Resident #2 currently does not have a roommate currently.07/15/25 at 10:18 AM the SW documented that she received notification from the administration that a referral to the behavioral center was needed. The SW notified Family Member FF, and he agreed to the referral and the referral was completed. 07/15/25 at 10:24 AM LVN EE documented no verbal behaviors noted, and Resident #2 was in good spirits. 07/15/25 at 10:29 PM LVN BB documented Resident #2 was quiet without negative behaviors, toward resident or staff. 07/16/25 at 8:57 AM LVN EE documented Resident #2 had no behaviors. 07/16/25 at 8:57 PM LVN B documented no behaviors reported during her shift. 07/17/25 at 2:57 PM The SW documented that the referral for Resident #2 was denied due to Resident #2's insurance being out of network. During an interview on 8/14/25 at 12:33 PM, Resident #2 stated she does not remember why her last roommate moved. She stated she got along well with her last roommate. She could not identify her last roommate by name. She could not report if she had an incident with Resident #1 on 7/11/25. During an interview on 8/14/25 at 9:31 AM, CNA A stated she did not have a calendar in front of her but believed the incident occurred on 7/11/25. She stated she worked the night shift (6:00 PM- 6:00 AM). She stated on that day (7/11/25) her partner that she worked with that day called in late. She stated she and LVN B were the only ones on the locked female unit. She stated around 7:00 PM or 7:30 PM while LVN B was attending to another resident next door to Resident #1 and Resident #2 they (CNA A and LVN B) heard Resident #2 yell a loud and clear Get your mother fucking ass in that God Damn bathroom and clean that shit up! CNA A stated she and LVN B looked at each other. CNA A stated LVN B asked her Who is she (Resident #2) hollering at? CNA A stated LVN B instructed her (CNA A) to go and look. CNA A stated when she stepped into Resident #1 and Resident #2's room she observed Resident #1 standing in front of Resident #2 and the look on Resident #1's face gave her (CNA A) the impression that she was scared. CNA A stated she motioned for Resident #1 to come with her. CNA A stated she took Resident #1 to where LVN B was and during this time LVN B then goes to Resident #2. CNA A stated she and Resident #1 stood outside the room where Resident #2 and LVN B were. CNA A stated LVN B asked Resident #2 what was going on and Resident #2 voiced her complaint about Resident #1 pissing on the bathroom floor. She stated LVN B instructed Resident #2 that if it happened again, she needed to call staff for help. CNA A stated she went to get a towel to clean up the urine in the bathroom and while she was doing this Resident #1 followed LVN B. CNA A stated Resident #2 yelled at her Don't clean up that shit! This is why she (Resident #1) don't learn because y'all baby her (Resident #1)! CNA A stated Resident #1 was afraid and did not go back to the room with Resident #2 for majority of the night. CNA A stated Resident #1 did not go to bed until Resident #2 was asleep. CNA A stated she was under the impression that since LVN B witnessed the incident along with her that she would report it to the abuse coordinator, document and notify the family. CNA A stated a couple of days later (unsure of the exact date), Resident #1's family came to the facility and in passing the family asked why is it that when they have come in Resident #1 is not in her bed and sometimes is found in other resident's bed. CNA A stated she told them that it was most likely because she (Resident #1) was afraid of her roommate (Resident #2). She stated that immediately once she mentioned the incident to Family Member CC, he became upset and exclaimed no one told him about the incident. She stated that LVN B was upset with her and told her at that time to complete a report. She stated unsure of the date the following Monday she was suspended because she failed to report the incident. CNA A stated she did not feel it was right that she was suspended for failure to report when LVN B also heard the incident and was present. CNA A stated that the ADM told her that LVN B may have misheard what happened. CNA A stated this was not the case because Resident #2 said what she said very loud, and they were next door to their room. CNA A stated Resident #1 slept in the same room with Resident #2 the night of the incident. CNA A stated she was told that Resident #1 was moved out of the room only after Resident #1's family complained. CNA A stated Resident #2 had a history of aggression and that she had expressed concern in the past. CNA A stated Resident #2 had broken the facility door before and was an exceptionally large lady in comparison to Resident #1. She stated although she did not believe Resident #2 physically hit Resident #1, she believed that Resident #1 was afraid because she would not go back in her room the night of the incident. She stated she and other staff reported to LVN B that even they (staff) were afraid of Resident #2. CNA A stated no other incidents had occurred between Resident #1 and Resident #2 since 7/11/25 but she could not attest for any time after she was suspended. She stated she was trained that if she suspects or witness abuse, she was to report abuse to her chain of command, and this would have been LVN B. She stated that being a CNA for over 25 years this was the way it has always been. She stated that the ADM stated at the time of her suspension that she was supposed to report the incident to her (the ADM). CNA A stated the nurses were responsible for reporting incidents to the family. CNA A stated the night of the incident Resident #1 did not have any injuries that she could visibly see. Interviews conducted on 8/14/25 between 10:32 AM-1:04 PM, revealed that day time staff (CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, LVN I, LVN J and CNA K) had been trained on the facility's abuse policy. The staff were able to identify the abuse coordinator, and stated if they suspected or witnessed abuse, they would report directly to the abuse coordinator. During their interview staff was able to report that apart of the suspicion or witnessing abuse they would protect the resident. During an interview on 8/14/25 at 2:33 PM, the ADM stated that she was unsure of the date and time but while at home one-night LVN B called her and explained that Resident #1's family was upset. She stated LVN B told her about the initial complaint from the family involved cleaning supplies and them (Family Member CC) having to clean the restroom. The ADM stated that she received a call from Family Member DD 30 minutes later who stated that the real reason that they (family) were upset was because Resident #1 had been abused and her roommate (Resident #2) was screaming at her (Resident #1). The ADM stated at the time Family Member DD notified her of Resident #2 screaming at Resident #1 she was unaware of the incident. She stated once Family Member DD notified her, she notified the DON, and the DON instructed for 1:1 to be started for Resident #2 to LVN B. The ADM stated that LVN B stated she was unaware of any incidents of abuse that involved Resident #1 and Resident #2. She stated that she started her abuse process and notified HHSC the same day the family notified her. The ADM, DON, regional Nurse Consultant and Director of Operations were notified on 7/15/25 at 4:08 PM and a PNC IJ situation was identified due to the above failures and the IJ template and 3-strike letter was provided.Interviews conducted on 8/15/25 between 4:31 PM-6:16 PM, revealed that administration, daytime and nighttime staff (the DM, MDS Coordinator, ADON, HR, the Maintenance Supervisor, DS L, [NAME] M, LVN N, LVN O, CNA P, MA Q, CNA R, CNA S, RN T, CNA U, MA V, CNA W, CNA X, CNA Y, CNA Z, CNA AA, and LVN BB) had been trained on the facility's abuse policy recently (within the past 30-60 days). The staff voiced they had been trained by the ADM, DON and or the ADON. They stated that they were given the opportunity to ask questions if they needed to. They were all able to identify the abuse coordinator as the ADM and that they needed to report all suspected or witnessed abuse to the ADM. They all were able to voice that they would not assume that an incident had been reported but would report the incident as it was their responsibility. All staff interviewed voiced that they were comfortable, confident in their role carrying out the facility's expectation regarding the facility's abuse policy and requirements. During an interview on 8/15/25 at 12:15 PM, the ADM stated that she was unsure of the exact date of the incident between Resident #1 and Resident #2, but voiced that she was notified of the incident on 7/13/25 by Family Member DD. The ADM stated she reported the incident to HHSC on 7/13/25 at 11:05 PM. The ADM stated she was sure all staff had been trained because the day they started re-education it was the facility's pay day and each staff that came in had to pick up their check. They re-educated and quizzed the staff verbally on the expectations. She stated staff had always been trained to report to her as the abuse coordinator. She stated Resident #2 was referred to psychiatric services for the incident.During an interview on 8/15/25 at 6:18 PM, Family Member CC stated they were not notified of the incident that occurred with Resident #1 and Resident #2 at the time of the incident. Family Member CC stated CNA A notified them that Resident #1 was afraid of her roommate (Resident #2). Family Member CC stated he had not observed any incidents between Resident #1 and Resident #2. He stated that they (he and his family) were incredibly pleased with how the facility responded to them reporting their concerns about Resident #1. Family Member CC stated as soon as they reported the incident the facility staff moved Resident #1. Family Member CC stated there had been no incidents since the incident. Family member CC stated that he was unsure if Resident #1 was afraid, but they (he and the family) had concerns that Resident #1 was sleeping in other resident's beds because she had a UTI. He stated when he asked CNA A about what she thought regarding Resident #1 sleeping in other's beds CNA disclosed the incident. He stated he honestly believed CNA was trying to console them because they had other concerns within the same night. He stated since the incident between Resident #1 and Resident #2 the facility staff have done so well notifying them (he and family). During an interview on 8/15/25 at 5:15 PM, the ADM stated the facility's system to ensure that the facility ANE policy (specifically ANE was reported to the appropriate parties (HHSC and abuse coordinator) and family was notified) was being followed was through staff education, re-education, routine rounds and talking to staff. The ADM stated she and all her staff had been trained on the facility's ANE policy (specifically ANE was reported to the appropriate parties (HHSC and abuse coordinator), and family was notified) and their specific roles as it related to the policy. The ADM stated she expected all staff to follow the abuse policy. Specifically, the ADM stated she expected family to be notified of incidents of ANE, the abuse coordinator to be notified immediately if they suspect or witness abuse and incidents of ANE to be reported to HHSC. The ADM stated more specifically the nursing staff, DON or the ADM was responsible for family notifications. The ADM stated all staff was responsible for reporting to the abuse coordinator immediately. The ADM stated she and the DON was responsible for reporting incidents to HHSC. The ADM stated the potential negative outcome for not notifying family was the family would not be aware of issues and they are supposed to be aware of issues concerning their resident. The ADM stated if CNA A would have notified the LVN B then LVN B could have notified Resident #1's family. The ADM stated the reason Resident #1's family was not notified was because CNA A did not report the details of the incident to LVN B. The ADM stated the potential negative outcome for not reporting to the abuse coordinator was the abuse coordinator would not know. The ADM stated with the abuse coordinator not knowing of an incident then they would not be able to report to HHSC timely to HHSC. The ADM stated the reason the incident was not reported to HHSC timely was because CNA A did not report to the incident to LVN B or to her timely. The ADM stated the potential negative outcome for not reporting to HHSC would be a thorough investigation may not be conducted. The ADM stated the reason that the incident was not reported to HHSC timely was because CNA A did not report the details to LVN B or to her as the abuse coordinator. During an interview on 8/15/25 at 5:42 PM, the DON stated the system to monitor ANE was reported to the appropriate parties (HHSC and abuse coordinator), and family was notifications was inservicing and educating staff on the policy. The DON stated they teach the staff over and over to follow the abuse policy which included reporting and family notifications. The DON stated she reviews documentation to also ensure that the policy was being followed. The DON stated that she had been trained on the facility's expectation that ANE was reported to the appropriate parties (HHSC and abuse coordinator), and family notifications as well as all her staff. The DON stated she expected that all staff to follow the expectation that ANE was reported to the appropriate parties (HHSC and abuse coordinator), and family notifications were made. The DON stated specifically for family notifications she expected family to be notified of all things that had to do with the residents. The DON stated that she expected for family to be notified of all incidents and any changes. The DON stated expected that the abuse coordinator should be notified immediately of any suspicions of ANE so that the proper steps are taken and followed. The DON stated that she expected HHSC to notified timely according to their policy so the proper investigations can be initiated. The DON stated whichever staff witnessed the incident was responsible for reporting to the abuse coordinator. The DON stated the nurse involved in the incident was responsible for notifying the family, but this could only be done after the person reported the incident to the nurse. The DON stated the abuse coordinator was responsible for notifying HHSC. The DON stated that the reason ANE was not reported to the appropriate parties (HHSC and abuse coordinator) was because CNA A did not report the incident between Resident #1 and Resident #2 to LVN B and the abuse coordinator. The DON stated that the potential negative outcome for not notifying family was the family would not bee aware of what was going on with the resident. The DON stated it was improper for notifications not to be done. The DON stated the reason the family was not notified was because CNA A did not notify LVN B or the abuse coordinator. The DON stated the potential negative outcome of not reporting to the abuse coordinator immediately was the situation with the resident would not be addressed and the residents would be at risk for harm. The DON was unaware that Resident #1's family had not been notified. The DON stated the reason the abuse coordinator was not notified was because CNA A did not notify LVN B or her. The DON stated the potential negative outcome of not reporting to HHSC timely was the facility would not be following the proper procedures. The DON stated that potentially the incident would not be investigated, and safety could not be ensured. The DON stated she was unaware that HHSC had not been notified because she was unaware of the incident until it was reported on 7/13/25. The DON stated the reason HHSC was not notified was because CNA A did not notify LVN B or the abuse coordinator. During an interview on 8/15/25 at 8:45 PM, LVN B stated she was unsure of the exact date of the incident that occurred between Resident #1 and Resident #2. LVN B stated that she was in the last room at the end of the hallway assisting another resident. She stated CNA A heard one of the residents raise their voice. She stated she asked CNA A which resident raised their voice and was told by CNA A that it was Resident #2 and Resident #1. LVN B stated CNA A told her that Resident #2 was raising her voice at Resident #1. LVN B stated she voiced to Resident #2 that she does not need to raise her voice. LVN B stated that was it and she left Resident #2 in her room. LVN B stated 5 minutes later both residents could not remember the incident. LVN B stated she does not know what specifically Resident #2 said to Resident #1. She stated CNA A did not specify what was said but only stated Resident #2 was yelling at Resident #1 because there was piss on the floor. LVN B stated she did not suspect abuse because normally Resident #2 was loud resident and that was the way she talked. She stated working on the locked unit residents have behaviors and she considered Resident #2 yelling as one of her behaviors and she needed redirection. LVN B stated Resident #1 did not appear afraid to her. LVN B stated Resident #1 went back to her room within an hour of the incident. LVN B stated that CNA A did not report to her or indicate that Resident #1 was afraid. LVN B stated after the incident between Resident #1 and Resident #2 she never had a discussion with Resident #1's family nor did she discuss the incident any further with CNA A. LVN B stated that had not been any other incidents since the verbal incident between Resident #1 and Resident #2 nor had there been any incidents before. LVN B stated CNA A reported to the Resident #1's family that Resident #1 felt threatened by Resident #2 and that is what caused them to call the ADM. She stated when they called the ADM, she was instructed to place Resident #2 on 1:1 supervision. LVN B stated she did not report the incident to the abuse coordinator because she felt it was a nursing judgement call to redirect Resident #2. LVN B stated she did not notify the family of the incident but could not give a reason as to why because she could not remember what was going on that day to be able to give the investigator accurate information. LVN B stated an incident of the same nature involving Resident #1 and Resident #2 would have been an incident that she would notify family of. She stated she did not document the incident in either resident's progress notes. LVN B stated she could not give the investigator a reason because she could not recall specifically what went on that day that would potentially hinder her in documenting. LVN B stated she had been trained on the facility's abuse policy recently (within the past 30-60 days) by the ADM, DON and ADON. LVN B was able to identify the abuse coordinator as the ADM and that she needed to report all suspected or witnessed abuse to the ADM. She stated that she would not assume that an incident had been reported but would report the incident as it was her responsibility. She stated that protection of the resident(s) involved was a part of following the abuse protocol for the facility. She stated if she did not see any protection interventions put in place that she would follow up with management and or the abuse coordinator. LVN B stated Resident #1 and Resident #2 shared the same room after the incident up until she was instructed to place Resident #2 on 1:1 supervision. LVN B stated no other incidents occurred with Resident #1 and Resident #2 after the verbal incident on the unknown date that she was aware of. LVN B stated it was her responsibility to notify family and or responsible party of any significant events involving the residents that resided at the facility. She stated before the incident that occurred with Resident #1 and Resident #2, she had received training on the facility's ANE policy.During the investigation held on 8/14/25-8/15/25 there were no observation of any interactions between Resident #1 and Resident #2. Resident #1 and Resident #2 were observed in their separate rooms during the visit. Record review of the facility's Form 3614 (Provider Investigation Report), dated 7/17/25, revealed:Incident Date: 7/11/25Person(s) or Resident(s) involved:Resident #1 Alleged Perpetrator: None listed.Witnesses:CNA ADescription of the Allegation: Resident #1's roommate cusses at her and tries to make her clean up the bathroom. Assessment:7/13/25: Resident has no injuries. Provider Response: Resident #2 was placed on one-to-one monitoring immediately upon receiving report from Resident #1's family. Resident #1 was assessed for any injuries-none noted. Physician notified. Family, physician and psychiatry notified for Resident #2.Investigation Summary: Resident #1's family reported to LVN B, that they had been finding Resident #1 bathroom with bowel and urine on the floor and they had been bringing toilet paper because she had not had toilet paper and sometimes paper towels. LVN B notified the ADM via phone of the concern. The ADM later received a call from Family Member B stating what family had reported and added that Resident #2 had been yelling and cussing at Resident #1. LVN B was aware that one evening she heard raised voices and sent CNA A to see what was going on but nothing was ever reported to LVN B about cussing or demanding residents to het on her knees and clean up the bathroom. CNA A was suspended pending investigation and will be terminated for failure to report. Both residents lack capacity to make informed decisions. Room changes were done, and Resident #2 remained one to one until the room changes were done. Referral was made to the behavior center for Resident #2. No issues since Resident #2 does not have a roommate. Facility Investigation Findings: UnconfirmedProvider Action Taken Post-Investigation: Continue to monitor resident and re-education with staff on abuse, neglect and reporting procedures.Record review of CNA A's witness statement, dated 7/14/25, revealed: I was in the room talking to my nurse, LVN B, when I heard Resident #2 yelling and cussing, saying Get your fucking ass in that goddamn bathroom and clean up that mess right now. I'm sick of this shit. LVN B had asked me to go see who she was talking to. I walked to the door and saw Resident #1 standing in front of Resident #2. I motioned for Resident #1 to come out in the hall. I then told LVN B she was talking to Resident #1. LVN B then asked Resident #2 what was going on and Resident #2 stated Resident #1 had peed on the bathroom floor and had done it before, and she wanted her to clean it up. LVN B told Resident #2 that Resident #1 could not do that because she could fall. I had went to get a towel to clean up the urine and Resident #2 stated to me that Resident #1 needed to get on her hands and knees and clean that shit up because she was tired of her doing that. I had advised Resident #2 that Resident #1 was not able to do so. I told Resident #2 if it happened again for her to let me or any aide that is on the hall and we would clean it up. Resident #2 then told me as long as we keep babying her and not making her clean up her mess then she would never stop. I walked out of the room and nothing more was said. Record review of Resident #2's 1:1 monitoring supervision sheet, dated 7/13/25-, revealed:Resident #2 was on 1:1 monitoring from 7/13/25 at 9:49 PM until 7/14/25 at 4:45 AM.Record review of CNA Record review of staff (LVN BB), undated, witness statements that revealed they had never observed Resident #2 being mean or rude to Resident #1.Record review of staff (CNA Z) written statement, undated, revealed she was not sure of the date, but she heard Resident #2 tell Resident #1 tell Resident #1 to clean up the bathroom, or she would make her and then she would kick her butt. The statement stated Resident #2 told Resident #1 she knew what she was doing. Record review of staff (CNA HH), dated 7/14/25, witness statements that revealed they had never observed Resident #2 being mean or rude to Resident #1.Record review of LVN B's written statement, dated, 7/16/25, revealed she (LVN B) was in the room assisting another resident in the restroom

Based on interviews and record reviews the facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment for 2 of 7 residents (Resident #1, #2) reviewed for abuse.The facility failed to immediately implement protective measures to protect Resident #1 from Resident #2 after a verbal abuse incident occurred on 7/11/25 between 7:00 PM and 7:30 PM.The noncompliance was identified as PNC. The IJ began on 07/11/25 and ended on 7/14/25. The facility had corrected the noncompliance before the survey began.These failures could place residents as risk for further abuse to include emotional and physical.Findings Included: Resident #1 Record review of Resident #1's face sheet, 8/14/25, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), schizoaffective disorder (mental disorder), anxiety (increased worry), insomnia (difficulty sleeping), major depressive disorder (increase sadness) and UTI (infection in the urinary system). Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was severely impaired. Record review of Resident #1's care plan, dated 7/14/25, revealed the following:Resident #1 had a focus for elopement and wandering specifically that she wandered aimlessly (date initiated 8/14/25). The goal was for Resident #1 to remain safe within the facility unless accompanied by a staff or authorized person. Interventions included distracting resident from wandering by offering pleasant diversions and supervising closely and make regular compliance rounds. Resident #1 had a focus for coping, specifically Resident #1 had a tough time coping with a roommate as roommate might have been verbally aggressive towards Resident #1 (date initiated 7/14/25). The goal was for Resident #1 to feel comfortable in a safe living environment. Interventions included staff would listen to Resident #1's concerns. Staff would monitor if Resident #1 were unable to cope with roommate and the social worker would find a new roommate if applicable. Record review of Resident #1's progress notes, dated 5/13/25-8/14/25, revealed: No incidents documented involving Resident #1 and any other residents on 7/11/25.07/13/25 at 9:11 PM LVN B documented: family report a CNA reported to them Resident #1's roommate was cursing at her and telling her to clean up after herself in the bathroom. Initial treatment included skin assessment; roommate placed on 1:1 monitoring supervision. Medical doctor and nurse practitioner notified. Responsible party was notified. 07/13/25 at 10:37 PM LVN B documented skin assessment conducted with no negative findings. 07/14/25 at 2:58 AM LVN B documented trauma assessment conducted. There were no negative findings or experiences documented or found. Resident #1 did not express fear or anger. 7/14/25 at 9:36 PM the DON documented a late entry indicating Resident #1's family reported to administration that the CNA (unidentified in the progress note) told them Resident #1's roommate was cursing at Resident #1 and telling her to clean up after herself in the bathroom. Resident #1's roommate was placed on one-to-one monitoring. Skin Assessment performed on Resident #1. A room swap was made. Family was aware and notified. FNP was notified. 7/15/25 at 8:36 AM LVN EE documented that Resident #1 appeared to be in no pain and monitoring was conducted. 7/15/25 at 8:37 AM LVN EE documented that Resident #1 had no signs or symptoms of distress noted, resident in good spirits.7/15/25 at 10:13 PM LVN BB documented that Resident #1 had no signs or symptoms of distress and did not complain of any pain.During an interview on 8/14/25 at 12:31 PM, Resident #1 could not recall the incident that occurred between she and Resident #2. She could not identify her last roommate by name. She stated she could not remember if she was afraid on 7/11/25. She could not remember how long she had been in the room that she was and why she had moved. She reported that she felt safe at the facility. Resident #2 Record review of Resident #2's face sheet, dated 8/14/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include intermittent explosive disorder (mental disorder characterized by outburst of anger or violence), anxiety (increased worry) and dementia (memory loss). Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 08, which indicated the resident's cognition was moderately impaired. Section E did not reveal any coded behaviors.Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: Section E Behavior Resident #2 had other behavioral symptoms not directed towards others.Resident #2's care plan, dated 7/14/25 revealed the following:Resident #2 had a focus for behavioral symptoms specifically that Resident #2 had potential to demonstrate physical behaviors. (initiated 7/4/25) The goal was for Resident #2 to demonstrate effective coping skills. Interventions included staff analyzing key times, places, circumstances, triggers, and what de-escalates behavior and document. Staff should assess and address sensory deficits and notify the charge nurse of any physically abusive behaviors. When Resident #2 becomes agitated staff should intervene before agitation escalates. Resident #2 had a focus for behavioral symptoms specifically that Resident #2 had a behavior problem related to being verbally aggressive to staff and other residents. (initiated 7/14/25) The goal was for Resident #2 to not have episodes of being verbally aggressive. Interventions included anticipate the needs of Resident #2. Staff should provide opportunity for positive interaction. Consultation with psychiatry will be made if needed. Staff should also intervene as necessary to protect the rights and safety of others. Staff will also monitor behavior episode of Resident #2. Record review of Resident #2's progress notes, dated 5/13/25-8/14/25, revealed: No incidents documented involving Resident #2 and any other residents on 7/11/25.7/13/25 at 9:11 PM the DON documented Resident #2 had a behavior (verbal, resident to resident alleged behavior). Resident #2 scolded her roommate (Resident #1) with curse words to clean up her mess in the bathroom. 1:1 mentoring supervision implemented. Consulted FNP for new orders of hydroxyzine 50 mg PO Q4 hours prn. Recommended to conduct room swap. Resident #2 stated we get along good. Resident #2 stated she worried about her roommate because she sleeps all day and does not sleep much. Attempted to contact Resident #2's family. 7/14/25 at 8:20 AM the DON documented late entry: Informed by administrator the resident's (unspecified in this progress note) roommate's family informed her the CNA (unspecified in this progress note) told them Resident #2 was cursing at her roommate and telling her to clean up after herself in the bathroom. Resident #2 was immediately place on one-on-one observation. Consulted psych provider for any new orders/recommendations. New order to start hydroxyzine 50 mg prn Q4 hours for anxiety/agitation. Performed a roommate swap and may d/c one-on-one monitoring but ensure frequent monitoring as the resident was not physically aggressive. Attempted to notify Family Member FF multiple times. D/c one-on-one supervision. Resident #2 currently does not have a roommate currently.07/15/25 at 10:18 AM the SW documented that she received notification from the administration that a referral to the behavioral center was needed. The SW notified Family Member FF, and he agreed to the referral and the referral was completed. 07/15/25 at 10:24 AM LVN EE documented no verbal behaviors noted, and Resident #2 was in good spirits. 07/15/25 at 10:29 PM LVN BB documented Resident #2 was quiet without negative behaviors, toward resident or staff. 07/16/25 at 8:57 AM LVN EE documented Resident #2 had no behaviors. 07/16/25 at 8:57 PM LVN B documented no behaviors reported during her shift. 07/17/25 at 2:57 PM The SW documented that the referral for Resident #2 was denied due to Resident #2's insurance being out of network. During an interview on 8/14/25 at 12:33 PM, Resident #2 stated she does not remember why her last roommate moved. She stated she got along well with her last roommate. She could not identify her last roommate by name. She could not report if she had an incident with Resident #1 on 7/11/25. During an interview on 8/14/25 at 9:31 AM, CNA A stated she did not have a calendar in front of her but believed the incident occurred on 7/11/25. She stated she worked the night shift (6:00 PM- 6:00 AM). She stated on that day (7/11/25) her partner that she worked with that day called in late. She stated she and LVN B were the only ones on the locked female unit. She stated around 7:00 PM or 7:30 PM while LVN B was attending to another resident next door to Resident #1 and Resident #2 they (CNA A and LVN B) heard Resident #2 yell a loud and clear Get your mother fucking ass in that God Damn bathroom and clean that shit up! CNA A stated she and LVN B looked at each other. CNA A stated LVN B asked her Who is she (Resident #2) hollering at? CNA A stated LVN B instructed her (CNA A) to go and look. CNA A stated when she stepped into Resident #1 and Resident #2's room she observed Resident #1 standing in front of Resident #2 and the look on Resident #1's face gave her (CNA A) the impression that she was scared. CNA A stated she motioned for Resident #1 to come with her. CNA A stated she took Resident #1 to where LVN B was and during this time LVN B then goes to Resident #2. CNA A stated she and Resident #1 stood outside the room where Resident #2 and LVN B were. CNA A stated LVN B asked Resident #2 what was going on and Resident #2 voiced her complaint about Resident #1 pissing on the bathroom floor. She stated LVN B instructed Resident #2 that if it happened again, she needed to call staff for help. CNA A stated she went to get a towel to clean up the urine in the bathroom and while she was doing this Resident #1 followed LVN B. CNA A stated Resident #2 yelled at her Don't clean up that shit! This is why she (Resident #1) don't learn because y'all baby her (Resident #1)! CNA A stated Resident #1 was afraid and did not go back to the room with Resident #2 for majority of the night. CNA A stated Resident #1 did not go to bed until Resident #2 was asleep. CNA A stated she was under the impression that since LVN B witnessed the incident along with her that she would report it to the abuse coordinator, document and notify the family. CNA A stated a couple of days later (unsure of the exact date), Resident #1's family came to the facility and in passing the family asked why is it that when they have come in Resident #1 is not in her bed and sometimes is found in other resident's bed. CNA A stated she told them that it was most likely because she (Resident #1) was afraid of her roommate (Resident #2). She stated that immediately once she mentioned the incident to Family Member CC, he became upset and exclaimed no one told him about the incident. She stated that LVN B was upset with her and told her at that time to complete a report. She stated unsure of the date the following Monday she was suspended because she failed to report the incident. CNA A stated she did not feel it was right that she was suspended for failure to report when LVN B also heard the incident and was present. CNA A stated that the ADM told her that LVN B may have misheard what happened. CNA A stated this was not the case because Resident #2 said what she said very loud, and they were next door to their room. CNA A stated Resident #1 slept in the same room with Resident #2 the night of the incident. CNA A stated she was told that Resident #1 was moved out of the room only after Resident #1's family complained. CNA A stated Resident #2 had a history of aggression and that she had expressed concern in the past. CNA A stated Resident #2 had broken the facility door before and was an exceptionally large lady in comparison to Resident #1. She stated although she did not believe Resident #2 physically hit Resident #1, she believed that Resident #1 was afraid because she would not go back in her room the night of the incident. She stated she and other staff reported to LVN B that even they (staff) were afraid of Resident #2. CNA A stated no other incidents had occurred between Resident #1 and Resident #2 since 7/11/25 but she could not attest for any time after she was suspended. She stated she was trained that if she suspects or witness abuse, she was to report abuse to her chain of command, and this would have been LVN B. She stated that being a CNA for over 25 years this was the way it has always been. She stated that the ADM stated at the time of her suspension that she was supposed to report the incident to her (the ADM). CNA A stated the nurses were responsible for reporting incidents to the family. CNA A stated the night of the incident Resident #1 did not have any injuries that she could visibly see. During an interview on 8/14/25 at 10:32 AM, CNA C stated she had never worked the female locked unit. She stated she had guarded the door once when the doors were not working. She stated she had not worked directly with Resident #1 and Resident #2. During an interview on 8/14/25 at 10:43 AM, CNA D stated she did not have any information regarding the verbal incident between Resident #1 and Resident #2 that occurred on 07/11/25. She stated she is unaware if any incidents had occurred since 7/11/25. During an interview on 8/14/25 at 11:09 AM, CNA E stated she did not have any firsthand information about the verbal incident that occurred on 7/11/25 between Resident #1 and Resident #2. She stated Resident #1 and Resident #2 had never had issues before 7/11/25 or since 7/11/25. She stated Resident #2 rarely has behaviors. She stated Resident #1 has no behaviors but will ask questions over and over. During an interview on 8/14/25 at 11:24 AM, CNA F stated she did not have any firsthand information about Resident #1's and Resident #2's verbal altercation that occurred on 7/11/25. She stated there had been no additional altercations between Resident #1 and Resident #2. She stated Resident #1 had an issue where she wanted to leave the unit but never had any altercations with residents in the unit. During an interview on 8/14/25 at 11:35 AM, CNA G stated she does not work the female unit and did not have any information regarding the incident that occurred on 7/11/25 between Resident #1 and Resident #2. During an interview on 8/14/25 at 11:45 AM, CNA H stated although she works the female locked unit at times, she did not have any information regarding the verbal altercation that occurred between Resident #1 and Resident #2. She stated she did not have any information about Resident #1 and Resident #2's behaviors as she had not worked the female locked unit in a while. During an interview on 8/14/25 at 11:55 AM, LVN I stated he did not have any firsthand information about the verbal altercation that occurred on 7/11/25 between Resident #1 and Resident #2. He stated Resident #1 and Resident #2 did not have a history of verbal altercations and there had been no incidents since 7/11/25. He stated Resident #1 was pleasantly confused. He stated she would wander but no other behaviors. He stated in the past Resident #2 had behaviors that included hoarding briefs. He stated in the past on an unknown date she (Resident #2) broke the female locked unit door but was sent to a behavior unit because of that behavior. He stated the facility manages Resident #2's behavior well through close monitoring. During an interview on 8/14/25 at 12:11 PM, LVN J stated she did not have any firsthand information about Resident #1 and Resident #2's verbal altercation that occurred on 7/11/25 as she did not work the female locked unit on that date. She stated she did not have any additional information regarding Resident #2 or Resident #1 behaviors. During an interview on 8/14/25 at 1:04 PM, CNA K stated she did not have firsthand information regarding Resident #1 and Resident #2 verbal altercation that occurred on 7/11/25. She stated she had worked with both residents before and after 7/11/25. She stated the two had never had any issues before or after. She stated Resident #2 never comes out of her room. She stated Resident #1 can be active at times. She stated neither resident has ever had significant behaviors in her presence. Interviews conducted on 8/14/25 between 10:32 AM-1:04 PM, revealed that daytime staff (CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, LVN I, LVN J and CNA K) had been trained on the facility's abuse policy. The staff were able to identify the abuse coordinator, and stated if they suspected or witnessed abuse, they would report directly to the abuse coordinator. During their interview staff was able to report that apart of the suspicion or witnessing abuse they would protect the resident. During an interview on 8/14/25 at 2:33 PM, the ADM stated that she was unsure of the date and time but while at home one-night LVN B called her and explained that Resident #1's family was upset. She stated LVN B told her about the initial complaint from the family involved cleaning supplies and them (Family Member CC) having to clean the restroom. The ADM stated that she received a call from Family Member DD 30 minutes later who stated that the real reason that they (family) were upset was because Resident #1 had been abused and her roommate (Resident #2) was screaming at her (Resident #1). The ADM stated at the time Family Member DD notified her of Resident #2 screaming at Resident #1 she was unaware of the incident. She stated once Family Member DD notified her, she notified the DON, and the DON instructed for 1:1 to be started for Resident #2 to LVN B. The ADM stated that LVN B stated she was unaware of any incidents of abuse that involved Resident #1 and Resident #2. She (the ADM) stated that she started her abuse process. The ADM stated LVN B reported to her that she (LVN B) heard yelling one night (date was not specified) and LVN B instructed CNA A to see what happened. The ADM stated LVN B reported to her that CNA A never reported to her that Resident #2 was yelling at Resident #1. The ADM stated Resident #2 had a history of yelling at staff. The ADM stated she move Resident #1 away from Resident #2 on 7/14/25. The ADM could not specifically state when the incident between the two residents happened but that she became aware of the incident on 7/13/25. During an interview on 8/15/25 at 12:15 PM, the ADM stated that she was unsure of the exact date of the incident between Resident #1 and Resident #2, but voiced that she was notified of the incident on 7/13/25 by Family Member DD. She stated Resident #2 was placed on 1:1 supervision as soon as she was notified of the incident on 7/13/25. She stated Resident #1 was not moved out of the room with Resident #2 because of bed availability. She stated room moves had to be made before she could move Resident #1 out of the room with Resident #2. The ADM stated Resident #1 shared the same bedroom with Resident #2 after the incident up until she was notified on 7/13/25. The ADM no additional incidents had occurred between Resident #1 and Resident #2. She started safe surveys were conducted on the female locked unit and there were no findings. She stated they started re-education on the facility's abuse policy and by 7/14/25 100 percent of her staff had been trained on the facility's abuse policy. The ADM stated she was sure all staff had been trained because the day they started re-education it was the facility's pay day and each staff that came in had to pick up their check. They re-educated and quizzed the staff verbally on the expectations. She stated Resident #2 was referred to psychiatric services for the incident.During an interview on 8/15/25 at 12:20 PM, the DON stated that on 07/09/25 Resident #2 had a recent change in medication where she had started Depakote. She stated because of the incident between Resident #1 and Resident #2 it was decided to continue to monitor the newly change medication and they added a PRN medication (Hydroxyzine). The ADM, DON, regional Nurse Consultant and Director of Operations were notified on 7/15/25 at 4:08 PM and a PNC IJ situation was identified due to the above failures and the IJ template and 3-strike letter was provided.Interviews conducted on 8/15/25 between 4:31 PM-6:16 PM, revealed that administration, daytime and nighttime staff (the DM, MDS Coordinator, ADON, HR, the Maintenance Supervisor, DS L, [NAME] M, LVN N, LVN O, CNA P, MA Q, CNA R, CNA S, RN T, CNA U, MA V, CNA W, CNA X, CNA Y, CNA Z, CNA AA, and LVN BB) had been trained on the facility's abuse policy recently (within the past 30-60 days). The staff voiced they had been trained by the ADM, DON and or the ADON. They stated that they were given the opportunity to ask questions if they needed to. They all were able to report that protection of the resident(s) involved was a part of following the abuse protocol for the facility. They all were able to report that if they did not see any protection interventions put in place that they would follow up with management and or the abuse coordinator. All nurses interviewed were able to report that it was their responsibility to notify family and or responsible party of any significant events involving the residents that resided at the facility. During an interview on 8/15/25 at 6:18 PM, Family Member CC stated they were not notified of the incident that occurred with Resident #1 and Resident #2 at the time of the incident. Family Member CC stated CNA A notified them that Resident #1 was afraid of her roommate (Resident #2). Family Member CC stated he had not observed any incidents between Resident #1 and Resident #2. He stated that they (he and his family) were incredibly pleased with how the facility responded to them reporting their concerns about Resident #1. Family Member CC stated as soon as they reported the incident the facility staff moved Resident #1. Family Member CC stated there had been no incidents since the incident. Family member CC stated that he was unsure if Resident #1 was afraid, but they (he and the family) had concerns that Resident #1 was sleeping in other resident's beds because she had a UTI. He stated when he asked CNA A about what she thought regarding Resident #1 sleeping in other's beds CNA disclosed the incident. He stated he honestly believed CNA was trying to console them because they had other concerns within the same night. He stated since the incident between Resident #1 and Resident #2 the facility staff have done so well notifying them (he and family). During an interview on 8/15/25 at 5:15 PM, the ADM stated the facility's system to ensure that protection measures were put in place was through staff education, re-education, routine rounds and talking to staff. The ADM stated she and all her staff had been trained on implementing protection measures for residents and their specific roles as it related to the facility's abuse policy. Specifically, the ADM stated she expected the abuse coordinator to be notified immediately if they suspect or witness abuse, and protective measures to protect residents should be implemented. The ADM stated once they were notified, they were responsible for implementing protective measures, but all staff had been trained to ensure resident safety. The ADM stated the potential negative outcome for not implementing protective measures for a resident after an incident would be resident safety could be affected. The ADM stated protective measures are put in place to ensure that the resident is safe. The ADM additionally stated that she also ensures that protective measures were put in place by initiating 1:1 supervision until other protective measures can be put in place. The ADM stated protective measures were not put in place for Resident #1 because CNA A did not report the incident details to LVN B. During an interview on 8/15/25 at 5:42 PM, the DON stated the system to monitor implementation of protection measures were through inservicing and educating staff on the abuse policy. The DON stated they teach the staff over and over to follow the abuse policy which included protecting the residents from abuse. The DON stated she reviews documentation to also ensure that the policy was being followed and that protection measures were put in place. The DON stated that she had been trained to implement protection measures for residents when there is a suspicion or witnessed abuse as well as all her staff. The DON stated she expected that all staff to implement protection measures for all residents that experienced abuse or potentially could experience abuse. The DON stated expected that the abuse coordinator should be notified immediately of any suspicions of ANE so that the proper steps are taken and followed. The DON stated she expected for protective measures to be put in place to protect residents so that the residents are always safe, and the proper additional interventions can be put in place and implemented. The DON stated all staff were responsible for implementing protective measures, but this could only be done if the incident was reported correctly. The DON stated the potential negative outcome of not implementing protective measures for residents was harm to the residents involved could occur. The DON stated she was unaware that protective measures were not implemented immediately because she was unaware of the incident. The DON stated the reason protective measures were not implemented at the time of the incident was because CNA A did not notify LVN B or the abuse coordinator. During an interview on 8/15/25 at 8:45 PM, LVN B stated she was unsure of the exact date of the incident that occurred between Resident #1 and Resident #2. LVN B stated that she was in the last room at the end of the hallway assisting another resident. She stated CNA A heard one of the residents raise their voice. She stated she asked CNA A which resident raised their voice and was told by CNA A that it was Resident #2 and Resident #1. LVN B stated CNA A told her that Resident #2 was raising her voice at Resident #1. LVN B stated she voiced to Resident #2 that she does not need to raise her voice. LVN B stated that was it and she left Resident #2 in her room. LVN B stated 5 minutes later both residents could not remember the incident. LVN B stated she does not know what specifically Resident #2 said to Resident #1. She stated CNA A did not specify what was said but only stated Resident #2 was yelling at Resident #1 because there was piss on the floor. LVN B stated she did not suspect abuse because normally Resident #2 was loud resident and that was the way she talked. She stated working on the locked unit residents have behaviors and she considered Resident #2 yelling as one of her behaviors and she needed redirection. LVN B stated Resident #1 did not appear afraid to her. LVN B stated Resident #1 went back to her room within an hour of the incident. LVN B stated that CNA A did not report to her or indicate that Resident #1 was afraid. LVN B stated after the incident between Resident #1 and Resident #2 she never had a discussion with Resident #1's family nor did she discuss the incident any further with CNA A. LVN B stated that had not been any other incidents since the verbal incident between Resident #1 and Resident #2 nor had there been any incidents before. LVN B stated CNA A reported to the Resident #1's family that Resident #1 felt threatened by Resident #2 and that is what caused them to call the ADM. She stated when they called the ADM, she was instructed to place Resident #2 on 1:1 supervision. LVN B stated she did not report the incident to the abuse coordinator because she felt it was a nursing judgement call to redirect Resident #2. LVN B stated she had been trained on the facility's abuse policy recently (within the past 30-60 days) by the ADM, DON and ADON. LVN B was able to identify the abuse coordinator as the ADM and that she needed to report all suspected or witnessed abuse to the ADM. She stated if she did not see any protection interventions put in place that she would follow up with management and or the abuse coordinator. LVN B stated Resident #1 and Resident #2 shared the same room after the incident up until she was instructed to place Resident #2 on 1:1 supervision. LVN B stated no other incidents occurred with Resident #1 and Resident #2 after the verbal incident on the unknown date that she was aware of. She stated before the incident that occurred with Resident #1 and Resident #2, she had received training on the facility's ANE policy.During the investigation held on 8/14/25-8/15/25 there were no observation of any interactions between Resident #1 and Resident #2. Resident #1 and Resident #2 were observed in their separate rooms during the visit. Record review of the facility's Form 3614 (Provider Investigation Report), dated 7/17/25, revealed:Incident Date: 7/11/25Person(s) or Resident(s) involved:Resident #1 Alleged Perpetrator: None listed.Witnesses:CNA ADescription of the Allegation: Resident #1's roommate cusses at her and tries to make her clean up the bathroom. Assessment:7/13/25: Resident has no injuries. Provider Response: Resident #2 was placed on one-to-one monitoring immediately upon receiving report from Resident #1's family. Resident #1 was assessed for any injuries-none noted. Physician notified. Family, physician and psychiatry notified for Resident #2.Investigation Summary: Resident #1's family reported to LVN B, that they had been finding Resident #1 bathroom with bowel and urine on the floor and they had been bringing toilet paper because she had not had toilet paper and sometimes paper towels. LVN B notified the ADM via phone of the concern. The ADM later received a call from Family Member B stating what family had reported and added that Resident #2 had been yelling and cussing at Resident #1. LVN B was aware that one evening she heard raised voices and sent CNA A to see what was going on but nothing was ever reported to LVN B about cussing or demanding residents to het on her knees and clean up the bathroom. CNA A was suspended pending investigation and will be terminated for failure to report. Both residents lack capacity to make informed decisions. Room changes were done, and Resident #2 remained one to one until the room changes were done. Referral was made to the behavior center for Resident #2. No issues since Resident #2 does not have a roommate. Facility Investigation Findings: UnconfirmedProvider Action Taken Post-Investigation: Continue to monitor resident and re-education with staff on abuse, neglect and reporting procedures.Record review of CNA A's witness statement, dated 7/14/25, revealed: I was in the room talking to my nurse, LVN B, when I heard Resident #2 yelling and cussing, saying Get your fucking ass in that goddamn bathroom and clean up that mess right now. I'm sick of this shit. LVN B had asked me to go see who she was talking to. I walked to the door and saw Resident #1 standing in front of Resident #2. I motioned for Resident #1 to come out in the hall. I then told LVN B she was talking to Resident #1. LVN B then asked Resident #2 what was going on and Resident #2 stated Resident #1 had peed on the bathroom floor and had done it before, and she wanted her to clean it up. LVN B told Resident #2 that Resident #1 could not do that because she could fall. I had went to get a towel to clean up the urine and Resident #2 stated to me that Resident #1 needed to get on her hands and knees and clean that shit up because she was tired of her doing that. I had advised Resident #2 that Resident #1 was not able to do so. I told Resident #2 if it happened again for her to let me or any aide that is on the hall and we would clean it up. Resident #2 then told me as long as we keep babying her and not making her clean up her mess then she would never stop. I walked out of the room and nothing more was said. Record review of Resident #2's 1:1 monitoring supervision sheet, dated 7/13/25-, revealed:Resident #2 was on 1:1 monitoring from 7/13/25 at 9:49 PM until 7/14/25 [TRUNCATED]

Based on interview and record review, the facility failed to immediately notify with the responsible party of an incident involving the resident which had the potential for requiring physician intervention for 2 (Resident #1 & Resident #2) of 7 residents reviewed for notification of change.The facility failed to immediately notify Resident #1's responsible party when Resident #2 verbally abused Resident #1 on 7/11/25 between 7:00 PM and 7:30 PM. This failure could place residents responsible party at the risk of not being aware/informed of residents' conditions. Findings included:Resident #1 Record review of Resident #1's face sheet, 8/14/25, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), schizoaffective disorder (mental disorder), anxiety (increased worry), insomnia (difficulty sleeping), major depressive disorder (increase sadness) and UTI (infection in the urinary system). Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was severely impaired. Record review of Resident #1's care plan, dated 7/14/25, revealed the following:Resident #1 had a focus for elopement and wandering specifically that she wandered aimlessly (date initiated 8/14/25). The goal was for Resident #1 to remain safe within the facility unless accompanied by a staff or authorized person. Interventions included distracting resident from wandering by offering pleasant diversions and supervising closely and make regular compliance rounds. Resident #1 had a focus for coping, specifically Resident #1 had a tough time coping with a roommate as roommate might have been verbally aggressive towards Resident #1 (date initiated 7/14/25). The goal was for Resident #1 to feel comfortable in a safe living environment. Interventions included staff would listen to Resident #1's concerns. Staff would monitor if Resident #1 were unable to cope with roommate and the social worker would find a new roommate if applicable. Record review of Resident #1's progress notes, dated 5/13/25-8/14/25, revealed: No incidents documented involving Resident #1 and any other residents on 7/11/25.07/13/25 at 9:11 PM LVN B documented: family report a CNA reported to them Resident #1's roommate was cursing at her and telling her to clean up after herself in the bathroom. Initial treatment included skin assessment; roommate placed on 1:1 monitoring supervision. Medical doctor and nurse practitioner notified. Responsible party was notified. 07/13/25 at 10:37 PM LVN B documented skin assessment conducted with no negative findings. 07/14/25 at 2:58 AM LVN B documented trauma assessment conducted. There were no negative findings or experiences documented or found. Resident #1 did not express fear or anger. 7/14/25 at 9:36 PM the DON documented a late entry indicating Resident #1's family reported to administration that the CNA (unidentified in the progress note) told them Resident #1's roommate was cursing at Resident #1 and telling her to clean up after herself in the bathroom. Resident #1's roommate was placed on one-to-one monitoring. Skin Assessment performed on Resident #1. A room swap was made. Family was aware and notified. FNP was notified. 7/15/25 at 8:36 AM LVN EE documented that Resident #1 appeared to be in no pain and monitoring was conducted. 7/15/25 at 8:37 AM LVN EE documented that Resident #1 had no signs or symptoms of distress noted, resident in good spirits.7/15/25 at 10:13 PM LVN BB documented that Resident #1 had no signs or symptoms of distress and did not complain of any pain.During an interview on 8/14/25 at 12:31 PM, Resident #1 could not recall the incident that occurred between she and Resident #2. She could not identify her last roommate by name. She stated she could not remember if she was afraid on 7/11/25. She could not remember how long she had been in the room that she was and why she had moved. She reported that she felt safe at the facility.Resident #2 Record review of Resident #2's face sheet, dated 8/14/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include intermittent explosive disorder (mental disorder characterized by outburst of anger or violence), anxiety (increased worry) and dementia (memory loss). Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 08, which indicated the resident's cognition was moderately impaired. Section E did not reveal any coded behaviors.Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: Section E Behavior Resident #2 had other behavioral symptoms not directed towards others.Resident #2's care plan, dated 7/14/25 revealed the following:Resident #2 had a focus for behavioral symptoms specifically that Resident #2 had potential to demonstrate physical behaviors. (initiated 7/4/25) The goal was for Resident #2 to demonstrate effective coping skills. Interventions included staff analyzing key times, places, circumstances, triggers, and what de-escalates behavior and document. Staff should assess and address sensory deficits and notify the charge nurse of any physically abusive behaviors. When Resident #2 becomes agitated staff should intervene before agitation escalates. Resident #2 had a focus for behavioral symptoms specifically that Resident #2 had a behavior problem related to being verbally aggressive to staff and other residents. (initiated 7/14/25) The goal was for Resident #2 to not have episodes of being verbally aggressive. Interventions included anticipate the needs of Resident #2. Staff should provide opportunity for positive interaction. Consultation with psychiatry will be made if needed. Staff should also intervene as necessary to protect the rights and safety of others. Staff will also monitor behavior episode of Resident #2. Record review of Resident #2's progress notes, dated 5/13/25-8/14/25, revealed: No incidents documented involving Resident #2 and any other residents on 7/11/25.7/13/25 at 9:11 PM the DON documented Resident #2 had a behavior (verbal, resident to resident alleged behavior). Resident #2 scolded her roommate (Resident #1) with curse words to clean up her mess in the bathroom. 1:1 mentoring supervision implemented. Consulted FNP for new orders of hydroxyzine 50 mg PO Q4 hours prn. Recommended to conduct room swap. Resident #2 stated we get along good. Resident #2 stated she worried about her roommate because she sleeps all day and does not sleep much. Attempted to contact Resident #2's family. 7/14/25 at 8:20 AM the DON documented late entry: Informed by administrator the resident's (unspecified in this progress note) roommate's family informed her the CNA (unspecified in this progress note) told them Resident #2 was cursing at her roommate and telling her to clean up after herself in the bathroom. Resident #2 was immediately place on one-on-one observation. Consulted psych provider for any new orders/recommendations. New order to start hydroxyzine 50 mg prn Q4 hours for anxiety/agitation. Performed a roommate swap and may d/c one-on-one monitoring but ensure frequent monitoring as the resident was not physically aggressive. Attempted to notify Family Member FF multiple times. D/c one-on-one supervision. Resident #2 currently does not have a roommate currently.07/15/25 at 10:18 AM the SW documented that she received notification from the administration that a referral to the behavioral center was needed. The SW notified Family Member FF, and he agreed to the referral and the referral was completed. 07/15/25 at 10:24 AM LVN EE documented no verbal behaviors noted, and Resident #2 was in good spirits. 07/15/25 at 10:29 PM LVN BB documented Resident #2 was quiet without negative behaviors, toward resident or staff. 07/16/25 at 8:57 AM LVN EE documented Resident #2 had no behaviors. 07/16/25 at 8:57 PM LVN B documented no behaviors reported during her shift. 07/17/25 at 2:57 PM The SW documented that the referral for Resident #2 was denied due to Resident #2's insurance being out of network. During an interview on 8/14/25 at 12:33 PM, Resident #2 stated she does not remember why her last roommate moved. She stated she got along well with her last roommate. She could not identify her last roommate by name. She could not report if she had an incident with Resident #1 on 7/11/25. During an interview on 8/14/25 at 9:31 AM, CNA A stated she did not have a calendar in front of her but believed the incident occurred on 7/11/25. She stated she worked the night shift (6:00 PM- 6:00 AM). She stated on that day (7/11/25) her partner that she worked with that day called in late. She stated she and LVN B were the only ones on the locked female unit. She stated around 7:00 PM or 7:30 PM while LVN B was attending to another resident next door to Resident #1 and Resident #2 they (CNA A and LVN B) heard Resident #2 yell a loud and clear Get your mother fucking ass in that God Damn bathroom and clean that shit up! CNA A stated she and LVN B looked at each other. CNA A stated LVN B asked her Who is she (Resident #2) hollering at? CNA A stated LVN B instructed her (CNA A) to go and look. CNA A stated when she stepped into Resident #1 and Resident #2's room she observed Resident #1 standing in front of Resident #2 and the look on Resident #1's face gave her (CNA A) the impression that she was scared. CNA A stated she motioned for Resident #1 to come with her. CNA A stated she took Resident #1 to where LVN B was and during this time LVN B then goes to Resident #2. CNA A stated she and Resident #1 stood outside the room where Resident #2 and LVN B were. CNA A stated LVN B asked Resident #2 what was going on and Resident #2 voiced her complaint about Resident #1 pissing on the bathroom floor. She stated LVN B instructed Resident #2 that if it happened again, she needed to call staff for help. CNA A stated she went to get a towel to clean up the urine in the bathroom and while she was doing this Resident #1 followed LVN B. CNA A stated Resident #2 yelled at her Don't clean up that shit! This is why she (Resident #1) don't learn because y'all baby her (Resident #1)! CNA A stated Resident #1 was afraid and did not go back to the room with Resident #2 for majority of the night. CNA A stated Resident #1 did not go to bed until Resident #2 was asleep. CNA A stated she was under the impression that since LVN B witnessed the incident along with her that she would report it to the abuse coordinator, document and notify the family. CNA A stated a couple of days later (unsure of the exact date), Resident #1's family came to the facility and in passing the family asked why is it that when they have come in Resident #1 is not in her bed and sometimes is found in other resident's bed. CNA A stated she told them that it was most likely because she (Resident #1) was afraid of her roommate (Resident #2). She stated that immediately once she mentioned the incident to Family Member CC, he became upset and exclaimed no one told him about the incident. She stated that LVN B was upset with her and told her at that time to complete a report. She stated unsure of the date the following Monday she was suspended because she failed to report the incident. CNA A stated she did not feel it was right that she was suspended for failure to report when LVN B also heard the incident and was present. CNA A stated that the ADM told her that LVN B may have misheard what happened. CNA A stated this was not the case because Resident #2 said what she said very loud, and they were next door to their room. CNA A stated Resident #1 slept in the same room with Resident #2 the night of the incident. CNA A stated she was told that Resident #1 was moved out of the room only after Resident #1's family complained. CNA A stated Resident #2 had a history of aggression and that she had expressed concern in the past. CNA A stated Resident #2 had broken the facility door before and was an exceptionally large lady in comparison to Resident #1. She stated although she did not believe Resident #2 physically hit Resident #1, she believed that Resident #1 was afraid because she would not go back in her room the night of the incident. She stated she and other staff reported to LVN B that even they (staff) were afraid of Resident #2. CNA A stated no other incidents had occurred between Resident #1 and Resident #2 since 7/11/25 but she could not attest for any time after she was suspended. She stated she was trained that if she suspects or witness abuse, she was to report abuse to her chain of command, and this would have been LVN B. She stated that being a CNA for over 25 years this was the way it has always been. She stated that the ADM stated at the time of her suspension that she was supposed to report the incident to her (the ADM). CNA A stated the nurses were responsible for reporting incidents to the family. CNA A stated the night of the incident Resident #1 did not have any injuries that she could visibly see. During an interview on 8/14/25 at 2:33 PM, the ADM stated that she was unsure of the date and time but while at home one-night LVN B called her and explained that Resident #1's family was upset. She stated LVN B told her about the initial complaint from the family involved cleaning supplies and them (Family Member CC) having to clean the restroom. The ADM stated that she received a call from Family Member DD 30 minutes later who stated that the real reason that they (family) were upset was because Resident #1 had been abused and her roommate (Resident #2) was screaming at her (Resident #1). The ADM stated at the time Family Member DD notified her of Resident #2 screaming at Resident #1 she was unaware of the incident. She stated once Family Member DD notified her, she notified the DON. She stated she interviewed CNA A and CNA stated she did tell Family Member CC about the incident between Resident #1 and Resident #2. The ADM stated she asked CNA A why she did not report the incident directly to her as the abuse coordinator as she had been trained and CNA A response was my bad. During an interview on 8/15/25 at 12:15 PM, the ADM stated that she was unsure of the exact date of the incident between Resident #1 and Resident #2, but voiced that she was notified of the incident on 7/13/25 by Family Member DD. The ADM stated she reported the incident to HHSC on 7/13/25 at 11:05 PM. The ADM stated she suspended CNA A on 7/14/25 and the last date CNA A had been in the facility was on the morning of her shift ended on 7/14/25. She stated after consulting with the corporate office and gaining approval she terminated CNA A for failure to report ANE. She stated they started re-education on the facility's abuse policy and by 7/14/25 100 percent of her staff had been trained on the facility's abuse policy. The ADM stated she was sure all staff had been trained because the day they started re-education it was the facility's pay day and each staff that came in had to pick up their check. During an interview on 8/15/25 at 6:18 PM, Family Member CC stated they were not notified of the incident that occurred with Resident #1 and Resident #2 at the time of the incident. Family Member CC stated CNA A notified them that Resident #1 was afraid of her roommate (Resident #2). Family Member CC stated he had not observed any incidents between Resident #1 and Resident #2. He stated that they (he and his family) were incredibly pleased with how the facility responded to them reporting their concerns about Resident #1. Family Member CC stated as soon as they reported the incident the facility staff moved Resident #1. Family Member CC stated there had been no incidents since the incident. Family member CC stated that he was unsure if Resident #1 was afraid, but they (he and the family) had concerns that Resident #1 was sleeping in other resident's beds because she had a UTI. He stated when he asked CNA A about what she thought regarding Resident #1 sleeping in other's beds CNA disclosed the incident. He stated he honestly believed CNA was trying to console them because they had other concerns within the same night. He stated since the incident between Resident #1 and Resident #2 the facility staff have done so well notifying them (he and family). During an interview on 8/15/25 at 5:15 PM, the ADM stated the facility's system to ensure that the facility ANE policy (specifically family was notified) was being followed was through staff education, re-education, routine rounds and talking to staff. The ADM stated she and all her staff had been trained on the facility's ANE policy (specifically family was notified) and their specific roles as it related to the policy. The ADM stated she expected all staff to follow the abuse policy. Specifically, the ADM stated she expected family to be notified of incidents of ANE. The ADM stated more specifically the nursing staff, DON or the ADM was responsible for family notifications. The ADM stated the potential negative outcome for not notifying family was the family would not be aware of issues and they are supposed to be aware of issues concerning their resident. The ADM stated if CNA A would have notified the LVN B then LVN B could have notified Resident #1's family. The ADM stated the reason Resident #1's family was not notified was because CNA A did not report the details of the incident to LVN B. During an interview on 8/15/25 at 5:42 PM, the DON stated that she had been trained on the facility's abuse policy (specifically family was notified) as well as all her staff. The DON stated she expected that all staff follow the abuse policy (specifically was notified). The DON stated specifically for family notifications she expected family to be notified of all things that had to do with the residents. The DON stated that she expected for family to be notified of all incidents and any changes. The DON stated the nurse involved in the incident was responsible for notifying the family, but this could only be done after the person reported the incident to the nurse. The DON stated that the reason the family was not notified of the incident between Resident #1 and Resident #2 was because CNA A did not report the incident between Resident #1 and Resident #2 to LVN B and the abuse coordinator. The DON stated that the potential negative outcome for not notifying family was the family would not be aware of what was going on with the resident. The DON stated it was improper for notifications not to be done. The DON stated the reason the family was not notified was because CNA A did not notify LVN B or the abuse coordinator. During an interview on 8/15/25 at 8:45 PM, LVN B stated she was unsure of the exact date of the incident that occurred between Resident #1 and Resident #2. LVN B stated that she was in the last room at the end of the hallway assisting another resident. She stated CNA A heard one of the residents raise their voice. She stated she asked CNA A which resident raised their voice and was told by CNA A that it was Resident #2 and Resident #1. LVN B stated CNA A told her that Resident #2 was raising her voice at Resident #1. LVN B stated she voiced to Resident #2 that she does not need to raise her voice. LVN B stated that was it and she left Resident #2 in her room. LVN B stated 5 minutes later both residents could not remember the incident. LVN B stated she does not know what specifically Resident #2 said to Resident #1. She stated CNA A did not specify what was said but only stated Resident #2 was yelling at Resident #1 because there was piss on the floor. LVN B stated she did not suspect abuse because normally Resident #2 was loud resident and that was the way she talked. She stated working on the locked unit residents have behaviors and she considered Resident #2 yelling as one of her behaviors and she needed redirection. LVN B stated Resident #1 did not appear afraid to her. LVN B stated Resident #1 went back to her room within an hour of the incident. LVN B stated that CNA A did not report to her or indicate that Resident #1 was afraid. LVN B stated after the incident between Resident #1 and Resident #2 she never had a discussion with Resident #1's family nor did she discuss the incident any further with CNA A. LVN B stated that there had not been any other incidents since the verbal incident between Resident #1 and Resident #2 nor had there been any incidents before. LVN B stated CNA A reported to the Resident #1's family that Resident #1 felt threatened by Resident #2 and that is what caused them to call the ADM. LVN B stated she did not notify the family of the incident but could not give a reason as to why because she could not remember what was going on that day to be able to give the investigator accurate information. LVN B stated an incident of the same nature involving Resident #1 and Resident #2 would have been an incident that she would notify family of. LVN B stated she had been trained on the facility's abuse policy recently (within the past 30-60 days) by the ADM, DON and ADON. LVN B stated it was her responsibility to notify family and or responsible party of any significant events involving the residents that resided at the facility.The facility staff (The ADM and Regional Nurse Consultant) did not provide a policy regarding notification to responsible parties. The facility did provide a policy regarding notification to the physician on 08/22/25 at 12:16 PM. A request for notification to the family was requested on 08/22/25 at 2:16 PM. As of 8/29/25 the policy for notification to the family was not provided.

Based on observations, interviews, and record review, the facility failed to ensure that 1 of 8 residents (Resident #1) reviewed for quality of care was offered a therapeutic diet when there is a nutritional problem, and the health care provider ordered a therapeutic diet.On 6/27/25 the facility did not ensure Resident #1 received her physician ordered NPO diet Enteral Feed diet (a method of providing nutrition directly into the gastrointestinal tract) when CNA provided Resident #1 with a plate of puree food (chili dog on a bun, sauerkraut, tater tots, diced onions, assorted gelatin; pureed). An IJ was identified on 07/02/25 at 2:50 PM. The IJ template was provided to the facility on [DATE] at 2:50 PM. While the IJ was removed on 7/03/25 at 9:23 AM, the facility remained out of compliance at a scope of no harm and a severity level of isolated because all staff had not been trained on 7/03/25.This failure put residents at risk for health complications related to nonadherence to diet order. Findings included:Record review of Resident #1's face sheet, undated, revealed a [AGE] year-old-female was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include cerebral palsy, Aphagia (inability or refusal to swallow), unspecified severe protein malnutrition, major depressive disorder, diaphragmatic hernia without obstruction and partial intestinal obstruction (abdominal organs moved through a hole in the diaphragm and are experiencing partial blockage in the digestive tract), dysphasia (difficulty swallowing food or liquids), dysarthria (weaken muscles of neck), moderate intellectual disability, and GERD (gastro esophageal reflux disease).Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C - Brief Interview for Mental Status score revealed a score of 06, which indicated the resident's cognition was severely impaired. Section K - Swallowing/Nutritional Status revealed while a resident, she utilized a feeding tube and she received 51% or more of her total calories through tube feeding at a rate of 501 cc/daily. Section V - Care Area Assessment (CAA) Summary:CAA Results: 13. Feeding Tube Record review of Resident #1's Care plan dated 5/23/25, revealed:Nutritional StatusFOCUS: Resident #1 was NPO had a peg tube and received her nutrition per physician orders via peg tube. (initiated 9/23/24 revised on 5/16/25)GOAL: Resident #1 would maintain ideal weight and receive proper nutrition daily. (initiated 9/23/24 revised on 5/16/25)INTERVENTIONS: Follow orders for PEG Feedings. (initiated 5/16/25) Record review of Resident #1's Care plan dated,5/26/25, revealed:Nutritional StatusFOCUS: Resident #1 had a peg tube and received her nutrition orally (Regular diet, pureed texture, and nectar consistency fluids). (initiated 9/23/25 revised on 7/01/25)GOAL: Resident #1 will maintain ideal weight and receive proper nutrition daily. (initiated 9/23/25 revised on 7/01/25)INTERVENTIONS: Follow PEG Orders for feedings (initiated 6/16/25) Record review of Resident #1's physician orders, dated 6/27/25, revealed NPO diet, NPO texture, NPO consistency. order date 4/28/2025 and Enteral Feed every 12 hours IsoSource 1.5 50 ml/hr x (over) 22 hours off from 1900-2100 (7pm-9pm) .order date 6/15/2025. Record review of Resident #1's Progress Notes dated, 3/30/25-7/01/25, revealed:RN W documented on 6/27/25 at 1:24 PM The chest x-ray of [Resident #1] came in and [Resident #]1 has pulmonary edema, and pneumonia. Notified the results to RR, FNP who ordered IV Rocephin 1 g daily for 5 days. RN W documented on 6/28/25 at 1:30 AM [Resident #1] was given food by the day CNA (cannot specified) and chest x-ray taken due to that although it came negative but showed Resident #1 has pneumonia and is on Rocephin. RN W administered Resident #1's first dose.Record Review of Resident #1's hospital records dated 4/26/2025 revealed Resident #1 Peg evaluation, Aspiration pneumonia (a lung infection that develops when food, liquids, or other foreign materials are inhaled into the lungs, causing inflammation and infection), dysphagia, has failed swallow evaluations.Record Review of Resident #1's hospital records dated 4/27/2025 revealed Resident #1 underwent EGD (procedure that uses a camera to examine the esophagus) with PEG placement on 4/23.20 French PEG placement (a feeding tube that is 20 inch in diameter) was successfully completed. Record review of Resident #1 hospital discharge orders revealed Diet: NPO.hydration/water.125ml/q4hrs.continuous tube feeding.Jevity 1.2.rate 60. Record Review of Resident #1's Xray report, dated 6/19/25, revealed Subtle patchy opacity (a faint or indistinct area of increased density) is seen in the right upper lung and left lower lung. This could be due to pulmonary edema (a condition where fluid builds up in the lungs, making it difficult to breathe), atelectasis (Complete or partial collapse of a lung or a section (lobe) of a lung) and/or pneumonia (an infection that inflames the air sacs in one or both lungs).Record Review of Resident #1's Xray report, dated 6/27/25 revealed Subtle patchy opacity (a faint or indistinct area of increased density) is seen in the right upper lung and left lower lung. This could be due to pulmonary edema (a condition where fluid builds up in the lungs, making it difficult to breathe), atelectasis (Complete or partial collapse of a lung or a section (lobe) of a lung) and/or pneumonia (an infection that inflames the air sacs in one or both lungs).Record review of Resident #1's dietary ticket, dated 6/27/25, revealed: NPO/PureeBeverage texture: NectarDuring an interview on 7/1/25 at 3:41 PM, Resident #1 only answered yes and no questions. She answered yes to receiving a tray on 6/27/25, consuming the food on the tray in its entirety, to the food being good and being able to consume the food without complication. She answered no to being in any pain and she stated no when asked was she to receive a tray on 6/27/25. During interviews conducted on 07/01/25 at 9:00 AM, the ADM stated CNA A gave Resident #1 a tray that contained pureed food. She stated CNA C reported the incident to RN W on 6/27/25. The ADM stated after investigating the incident, she found that the vendor that was used for dietary needs was implementing a system update which made it impossible to print the dietary tickets for the facility. She stated the system to print the tickets had never been down before. She stated the vendor had to print the dietary tickets for the facility and when the tickets were printed, Resident #1's, who was actively in NPO status, because she received her nutrition via PEG tube, ticket was printed and included with the remainder of the facility resident dietary tickets. She stated initially CNA C assumed Resident #1 received regular textured food because CNA C knew other residents received regular textured food. The ADM stated that she spoke with CNA A who stated that the food that she served Resident #1 was pureed and described it as that slurpee stuff. The ADM stated when she interviewed CNA A, she inquired what happened and she was told by CNA A that she read the ticket and was surprised because Resident #1 did not usually get a tray. The ADM stated CNA A stated she consulted with CNA B and CNA B told CNA A to leave the tray for Resident #1. The ADM stated Resident #1 received her PEG tube at the end of the April 2025, and since then, Resident #1 had been crying because she wanted to eat. The ADM stated she reported the incident to state because CNA C stated it was negligent and Resident #1 should not have received a tray of food because she was NPO. During an interview conducted on 07/01/25 at 9:10 AM, the DON stated Resident #1 had a PEG tube in place on 6/27/25. The DON stated Resident #1 had the PEG placed in April 2025 due to ongoing stomach issues and she was experiencing pain. The DON stated Resident #1 also had a history of pneumonia. The DON stated ever since the PEG placement, Resident #1 had been crying because she wanted to eat. The DON stated when Resident #1 received a tray on 6/27/25 and RN W was notified, he (RN W) notified facility management, RR, the MD and ordered an x-ray. She stated RN W reported to her that the x-ray did not have any significant findings. The DON stated that she was told by RN W that there were signs of pneumonia, but it was lingering pneumonia from a previous diagnosis. The DON stated Rocephin was ordered, and the first dose was given that night. The DON stated there were no signs of aspiration. The DON stated since 6/27/25, the orders for Resident #1 were changed and Resident #1 was actively able to consume food orally. She stated when Resident #1 consumed her meal, a staff sat with her and a nurse was present during the meal. During an interview conducted on 07/01/25 at 11:25 AM, CNA A stated on 6/27/25 they (she and CNA B) were passing out trays. She stated she received the tray for Resident #1. She stated it was not whole food. She described the food as food that you slurped up and it looked like baby food. CNA A stated that she did not believe a nurse checked the trays before the resident trays were brought to the hall. CNA A stated she looked at the dietary ticket for Resident #1 and remember seeing her name on the ticket, but did not remember seeing anything else. She stated after she saw that Resident #1 had a tray, she consulted with CNA B, and she was told by CNA B to leave the tray with Resident #1. CNA A stated she left the tray, but did not see her consume the food on the tray. She stated she did not know if Resident #1 consumed the entire tray of food or not because their shift did not pick up the trays. She stated the potential negative outcome was Resident #1 could have choked or died. She stated her nurse would have been LVN L, but LVN L did not bring the resident trays to the hall. CNA A stated that the dietary staff (did not know which one) brought the trays on 6/27/25. CNA A stated she was a newer staff and had been employed at the facility for about three weeks. She stated she had only been a CNA for a brief time. She stated she did not realize Resident #1 receiving the tray of food was an issue until the ADM called her the following day (6/28/25) and asked her about the incident. CNA A stated she was told that when she returned, she was instructed to give a statement. CNA A stated she gave Resident #1 the food because she did not know Resident #1 could not have food. She was unaware that she had a PEG tube for her nutrition. She stated she later found out Resident #1 had a PEG tube when the ADM called her. She stated there were no other residents with PEG tube placements. She stated she did not contact or consult a nurse. She stated after consulting CNA B, she thought it was ok. She stated CNA B had been with the facility longer than her. CNA A stated she did not have access to the facility's EMR/PCC at the time of the incident (6/27/25). She stated she just received access not to long before the interview but did not remember the exact date. She stated the facility process of checking the trays was the nurse would check the trays in the dining room. She stated dietary staff brought the trays to the hall normally. She stated they (CNAs) checked the dietary ticket for the name and served the tray. She stated on 6/27/25, she was floating between halls and not assigned to any hall. She stated she had been trained that NPO meant nothing by mouth, and she would know if someone was NPO if the resident had a feeding tube.During interviews conducted on 07/01/25 at 12:18 PM, CNA B stated NPO meant the resident could not be fed by mouth. CNA B stated she was never officially told that Resident #1 was NPO, but she assumed she was because Resident #1 never received a tray since she had worked at the facility. She stated she had worked at the facility for at least a month. CNA B stated there were no other residents in the facility that were NPO status. CNA B stated she was unaware that Resident #1 received a tray on 6/27/25. She stated she found out about the incident on 6/28/25 when she was asked who gave Resident #1 a tray. She stated the night/evening staff picked up the tray and that was how they (nighttime staff) found it. CNA B stated she worked with CNA A on 6/27/25. She stated CNA A did not consult her (CNA B) about giving Resident #1 the tray. CNA B stated she could not recall telling CNA A anything about leaving the tray for Resident #1. She stated at the time of the incident she did not receive any additional training or instruction about Resident #1 or about any residents that could not eat. She stated they (staff that worked 6/28/25) were told that Resident #1 was not to receive a tray on 6/27/25. CNA B stated she was unsure if the tray was checked by a nurse on 6/26/25. She stated she could not remember who the nurse was on 6/26/25. She stated the facility process for administering the trays to the resident during mealtimes was the nurse should check the trays in the dining room but not the trays on the hall. CNA B stated she had never had any issues with the trays being wrong on the halls. She stated the staff from dietary brought the resident trays from dining room to the halls to serve to the residents that eat in their rooms. She stated it was different staff each time, but always dietary staff. During interviews conducted on 07/01/25 at 1:23 PM, DA P stated he had been trained that NPO was nothing by mouth. He stated he knew a resident was NPO based off the dietary ticket. He stated if a resident was NPO, they (residents) should not have a dietary ticket. He stated if the saw on a ticket conflicting information he was unsure what to do. He stated he was not present on 6/27/25 when Resident #1 received a tray. He stated the facility process for distributing resident trays was the nurse checked the tray. He stated they (dietary staff) was not to serve until a nurse was in the dining room. He stated the nurse was to take the trays to the hall for the residents that eat in their room. He stated in the dining room, the nurse checked the tray and handed it to the CAN and the CNA would then distribute to the residents. He stated he was unsure if the CNAs were checking in addition to the nurse checking. During interviews conducted on 07/01/25 at 12:18 PM, DA Q stated NPO was nothing by mouth. He stated they (dietary staff) knew when a resident was NPO because it should say it on the resident's dietary ticket. He stated if he saw a diet texture and NPO on a ticket he would contact a charge nurse so that they (dietary and clinical staff) could figure it out together. DA Q stated he was not working on 6/27/25 and was unaware that Resident #1 had a PEG tube. He stated the facility process for distributing trays to residents was the nurse would sometimes check the tray before. He stated the nurses sometimes were busy. He stated there were times when the CNA would grab the tray and go. He stated, the majority of the time, the nurse checked the tray before distribution. He stated the trays that went to the halls were checked half the time. He stated he was unsure what the nurses checked for on residents' trays. During interviews conducted on 07/01/25 at 1:51 PM, the DM stated NPO meant nothing by mouth and the dietary staff know because if there was a change, then the nurse would send the dietary department a communication form so that the dietary cards were updated. The DM stated whether they (residents) eat their food or not each resident should have a dietary card. She stated if the resident was NPO then they (residents) should not have a dietary card. She stated when they (dietary staff) print out the dietary cards Resident #1's card did not normally print out when they (dietary staff) printed them out. She stated she was unsure why when the vendor printed the dietary tickets for them (dietary staff) Resident #1 had a dietary card to print out. She stated on 6/27/25, during breakfast and lunch, she assisted the dietary staff with ensuring that all residents received the appropriate diet. She stated the vendor printed the tickets out for supper, she handed the dietary tickets to the dietary staff, and did not check the tickets for accuracy. She did not have a reason she did not check the tickets. She stated she did not think about checking the tickets for accuracy. She stated she left at 5:00 PM on 6/27/25 and was not present when the dietary staff prepared Resident #1 tray. She stated [NAME] T would have been the only staff that she would have thought that did not know that Resident #1 did not consume food orally. She stated DA R, and DA S would have known Resident #1 did not consume food orally because they had worked at the facility for a while. She stated once they (dietary staff) saw the ticket they (dietary staff) should have questioned the ticket. She stated the ticket first went to the cook who would place the entre on the plate. The DM stated that the cook was looking for the texture and should be checking the dietary ticket in its entirety. The DM stated then the plate goes to the first dietary aide who was added things such as vegetables and any other sides. The DM stated the first dietary aide was continuing the correct texture that was listed on the ticket and should also be checking the dietary ticket in its entirety. She stated each dietary staff would have had the opportunity to identify on Resident #1's ticket that she was NPO. The DM stated the dietary staff should have consulted with the charge nurse on 6/27/25 when they (dietary staff) observed a diet texture and the status of NPO listed. The DM stated then the last part of the plating process was the last/second dietary aide would add things such as drinks, bread, and desserts. They (dietary staff) would hand the tray to the nurse or place it on the cart for the tray to go to the hall. She stated the second dietary aide should also be checking the dietary ticket in its entirety. The DM stated Resident #1 had never received a tray while on NPO status. The DM stated they (the facility) had never had issues with their system before. She stated when she gave the dietary workers the dietary tickets, she was unaware Resident #1 had a ticket. The DM stated the potential negative outcome for serving Resident #1 a tray, when she was not supposed to, was that she could have choked, aspirated, and possibly died. The DM stated she was unsure if Resident #1's tray was checked on 6/27/25. The DM stated she expected the residents to receive the correct meal on their ticket and if they (residents) were not to have a meal, then they (residents) should not receive one. The DM stated she was never at the facility for dinner because she left at 5:00 PM daily. She stated she was present during breakfast and lunch, and she normally observed dietary staff checking the dietary tickets and nurses checking the trays before distribution to the residents. During interviews conducted on 07/01/25 at 2:37 PM, [NAME] T stated he worked on 6/27/25, but he did not know specifically who Resident #1 was until after she was served and management addressed them (dietary staff). He stated he was new and was at the beginning of the plating process. He stated after him the plate would go through, two other workers and then a CNA would check it. [NAME] T stated he did not remember reading Resident #1's ticket. He stated he normally looks at the texture but did not remember seeing NPO on Resident #1's ticket. [NAME] T stated he was told/trained by the DM that NPO meant that the resident could not receive anything by mouth and received their nutrition by tube. [NAME] T stated even if he had seen NPO he may not have done anything different because he was not made aware of the NPO status until after the incident. He stated he was trained on NPO and the incident the day after the incident before his shift started. He stated he recently learned that he was to look at the entire dietary ticket. [NAME] T stated he knew to ask questions if he needed to, and would, moving forward. [NAME] T stated he was still new and stated he honestly could not tell the difference between the CNAs or the nurses as he was a newer employee. [NAME] T stated he had only worked at the nursing facility for 2-3 weeks. During interviews conducted on 07/01/25 at 2:39 PM, LVN L stated she knew what NPO was and that it meant nothing by mouth. She stated she knew that a resident had the status of NPO when it was listed in the residents' chart. She stated they (facility staff) were also told during shift change if a person received a new order of NPO. She stated the staff would have access to NPO information in the EMR. LVN L stated she was unaware that Resident #1 had been given a tray by CNA A because she did not remember which CNAs worked on 6/27/25, and she was not told that Resident #1 received a tray. She stated on 6/28/25 she received the information during shift change in report from RN W. She stated RN W stated that Resident #1 received a tray. LVN L stated she did not monitor the dining room on 6/27/25 during dinner time. She stated she monitored breakfast, and Resident #1 did not receive a tray during breakfast on 6/27/25. She stated LVN O would have been the other nurse on duty. She stated she was unaware if he was in the dining room, or if the dining room trays were checked before the resident trays went to the hallway. She stated that there were only two nurses on duty, and they (LVN L and LVN O) were training other nurses that day. LVN L stated she had never seen Resident #1 consume food or receive a tray. LVN L stated she did not receive any specialized training because of the incident. She stated the facility process for distributing resident trays was once the tray came off the line, the nurse checked the ticket against the tray for accuracy. She stated the nurse was checking to make sure the resident had the correct diet texture. She stated then they (nurses) gave the tray to a CNA to distribute. LVN L stated the cook for that day was new and she remembered the system that dietary used was down, but she did not have much information about it. LVN L stated she was aware that Resident #1 had a PEG and was NPO. She stated Resident #1 had a PEG tube because she had stomach issues, but she was unsure of the details and specifics. She stated when she checked the ticket, she checked the dietary ticket in its entirety for the correct resident and diet details. During interviews conducted on 07/01/25 at 3:16 PM, DA R stated NPO meant the resident could not have anything by mouth. He stated they (dietary staff) knew when a resident was NPO because the nurses told them (dietary staff), and it would indicate the information on the dietary ticket. He stated he knew Resident #1 did not eat and knew who she was. DA R stated he was aware that Resident #1 was NPO. He stated he observed her ticket on 6/27/25 and saw she was to receive a pureed tray and that was why he was served one. DA R stated their cook (Cook T) was new but since he made the plate for Resident #1, he assumed that it was ok. DA R stated he was unsure if the trays were checked by a nurse but did not remember seeing a nurse. DA R stated the facility process in distributing trays was the nurse was to check the tray before it was served to the resident. He stated on 6/27/25, he took the tray to the Hall were Resident #1 resided and this was because they (dietary staff) did not see a nurse. He stated once he took the cart to the hall, it would have been the nurse's aides to serve the trays to the residents. He stated that when it was time to serve meals, the dietary staff announced the mealtime over the loudspeaker. He stated he had not received any additional training regarding the incident. He stated when he checked the dietary ticket, he looked at the ticket in its entirety. He stated he did not see the word NPO on the ticket on 6/27/25. During interviews conducted on 07/01/25 at 4:50 PM, RN W stated NPO meant nothing by mouth and the resident was not allowed to have anything by mouth. He stated that he knew a resident was NPO because of the MAR, EMR, or PCC. He stated he was aware that Resident #1 was NPO. RN W stated he worked the night shift on 6/27/25. He stated he was notified by CNA C that Resident #1 hit her call light for her tray to be picked up. RN W stated CNA C reported that the tray was empty when she picked up Resident #1's tray. RN W stated when he went to see Resident #1, he observed red Kool-Aid on her face. He stated he notified management, the MD, and the RR. He stated the MD ordered an x-ray. He stated the x-ray was completed and it showed that she had lingering pneumonia but no signs of aspiration. RN W stated Resident #1 had pneumonia in the past and had received treatment, so the MD ordered IV Rocephin and he administered the medication the night of 6/27/25. He stated when he started his shift on 6/27/25 at 6:00 PM, LVN L gave him report and it did not include any information about Resident #1 receiving a tray of food. RN W stated he would not have been responsible for any meal monitoring because when he arrived at the facility, dinner would have already started as it started at 5:00 PM. He stated the evening/night shift were only responsible for passing out snacks and picking up dinner trays if there were any left. He stated when he reported the incident to the DON, the DON told him she would educate the staff. RN W stated he immediately verbally educated his staff on what NPO was and the importance. During an interview on 7/01/2025 at 10:24am with Resident #1's Guardian, she stated she had received a call during the weekend and was told Resident #1 had been served a tray of food although she was NPO. She stated Resident #1 had been placed on NPO after a PEG placement due to recurrent GI issues and recurrent aspiration pneumonia. She stated Resident #1 had not had any food since she had the PEG tube placed and had a decrease in quality of life, but as of 6/30/2025, Resident #1 had the PEG tube removed by hospice and was allowed pleasure feedings. During an interview on 7/01/2025 at 4:51 pm with the MD, he stated he had been made aware of the incident that occurred on 6/27/2025 with Resident #1, and from his understanding, there had been no complications from the incident. He stated he expected the staff at the facility to follow the diet orders for each resident. He stated the potential negative outcome of Resident #1 receiving the incorrect diet could have been aspiration pneumonia). The MD stated Resident #1 had a diaphragmatic hernia and the PEG tube had been placed because Resident #1 was having reflux (referred to the backward flow of stomach contents into the esophagus), and there were concerns about possible aspiration. The MD stated he had spoken to the ADM (unknown date) and the ADM would be ensuring all the diet orders were reviewed for accuracy with the kitchen staff and with the floor staff. The MD stated after speaking with Resident #1's guardian, they decided Resident #1 would have the PEG tube removed.During interviews conducted on 07/02/25 at 12:55 PM, the DON stated if the vendor's system was to stop working again, the facility intended to address the issue by ensuring the dietary staff knew to report the issue to the DM, DON, and ADM. She stated once they (management staff) were notified, they (DON/ADM) would work with the DM and dietary staff comparing the diet orders in the EMR/PCC to what the dietary staff had. She stated on 6/27/25, there were two nurses on duty, and they (LVN L and LVN O) were training two new nurses. She stated if there were three nurses then they (nurses on duty) would have split the mealtimes equally (1 nurse per mealtime). She stated if there would have been two nurses then they (nurses on duty) should have had one meal monitoring per nurse and split the dinner meal to monitor. She stated the nurses should have communicated to ensure monitoring for dinner was conducted by a nurse on 6/27/25. She stated on 6/27/25, there was no specific nurse assigned to dinner mealtime monitoring. She stated the nurses that were on duty (not the nurses that were being trained) would have been responsible. She stated it would have been between LVN L and LVN O who would have been responsible for monitoring the dinner mealtime. She stated the facility process was that nurses assigned to certain halls had specific meals that they (nurses on duty) were responsible for. The DON stated on 6/27/25, Resident #1 should not have received a tray of food, and should not have had a dietary ticket. She stated at the time, the dietary or clinical staff noticed that Resident #1 received a dietary ticket or there was a discrepancy on her dietary ticket they (the dietary and clinical staff) should have notified the DM and or a charge nurse. The DON stated the DM should have checked the dietary tickets for accuracy before giving the dietary tickets to the dietary staff. The DON stated that she did not see Resident #1's dietary ticket, but was told by the DM that the ticket indicated Resident #1 was NPO and could receive a pureed diet texture. The DON stated when there was conflicting information, the staff had been trained to verify with a charge nurse. The DON stated Resident #1 was NPO on 6/27/25. The DON stated Resident #1 had her PEG tube placed in April 2025 because she had aspiration pneumonia in the past. It was determined that it was safest if she had the PEG placed. The DON stated Resident #1 had dysphasia. She stated Resident #1 was once on mechanical soft and because she was having difficulty swallowing, she was moved to pureed. The DON stated when Resident #1 would consume the mechanical soft, she would have increased coughing. The DON stated Resident #1 even vomited a few times. The DON stated all the staff had been trained by her, the ADM, and the DM except for some of the nighttime shift. She stated the nighttime shift would be trained before they (nighttime shift) were allowed to work their shift. The DON stated she was familiar with the facility's policies related to dietary services and residents receiving the correct prescribed therapeutic diet. She stated the purpose of having the correct diet and having a policy for therapeutic diet was for resident safety and to prevent choking. She stated the potential negative outcome for not following the policies, or ensuring the residents have the correct diet, was the resident could choke or aspirate. She stated that residents could potentially not receive the nutrition they (residents at the facility) needed and could experience weight loss. The DON stated, on 6/27/25, she was unaware that Resident #1 had received a tray of food while she was ordered to be NPO. She stated she was unaware that CNA A was not following the physician order for Resident #1. She stated the system to monitor or ensure that staff were following the physicians order for diets, was once the MD ordered the diet, then it was entered in the EMR/PCC. The nursing staff then reported the change to dietary via communication form. She stated the CNAs were informed because the information was accessible in the EMR/PCC. She stated she and her staff had been trained regarding residents receiving the correct diet per physicians' orders. She stated she expected for all staff to follow the physician orders and for all residents to receive their meal as ordered by the physician. The DON stated the reason Resident #1 received the tray when she was not supposed to was because the vendor generated a dietary ticket, and the tray was not checked. She stated the dietary staff, and clinical staff should have asked the nurse about any discrepancies. The DON confirmed that CNA A had access to the facility EMR/PCC as of 6/24/25. During interviews conducted on 07/02/25 at 2:50 PM, the ADM stated if the system that dietary used to print dietary tickets goes down again, they (the ADM, DON, and DM) would ensure to check all tickets printed from the vendor for accuracy. The ADM stated on 6/27/25 one of the charge nurses on duty would have been responsible for monitoring the dinner mealtime. She stated it would have been between LVN L and LVN O. The ADM stated that the nurses would have known who was responsible for the meal monitoring based off the scheduling system created by the DON and ADON. The ADM stated, on 6/27/25, what should have happened was at the moment the staff observed Resident #1 had a dietary ticket and that it had a diet texture and listed as NPO, they (the clinical and

Based on interviews and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for 2 of 10 residents (Resident #1, and #2) reviewed for abuse. The ADM (Abuse Preventionist) and the DON failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC regarding the Resident-to-Resident inappropriate sexual activity between residents (Resident #1 kissed Resident #2) that occurred on an unknown date. The ADM (Abuse Preventionist) and the DON failed to follow the facility's abuse policy by not notifying the family representative regarding the Resident-to-Resident inappropriate sexual activity between residents (Resident #1 kissed Resident #2) that occurred on an unknown date. The ADM (Abuse Preventionist) and the DON failed to follow the facility's abuse policy by not conducting a thorough investigation and documenting regarding the Resident-to-Resident inappropriate sexual activity between residents (Resident #1 kissed Resident #2) that occurred on an unknown date. These failures could place residents as risk for abuse and neglect. Findings included: Record review of Resident #1's face sheet, dated 03/19/25, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), major depressive disorder, and anxiety. Record review of Resident #1's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 08, which indicated the resident's cognition was moderately impaired. Section B Hearing, Speech and Vision revealed that Resident #1 had clear speech, had the ability to make himself understood and had the ability to understand others. Record review of Resident #5's care plan, dated 10/01/24, revealed the following: Focus Sexually inappropriate AEB: was witnessed kissing a female resident on the lips in the dining room initiated 1/21/25. Goal Resident will have no episodes of sexually inappropriate behavior in the next 90 days initiated 1/21/25. Interventions Evaluate the resident ability to understand behavior and the consequences of that behavior initiated 1/21/25. Explain to the resident the acceptable expressions of sexuality based on the cognitive evaluation initiated 1/21/25. Listen/talk to the resident-see if they will tell you why they do the behavior initiated 1/21/25. Psychiatric Services consult as needed initiated 1/21/25. Reinforce with staff that clear, firm limits are healthy and required when resident makes inappropriate gestures or statements initiated 1/21/25. Report incidents of inappropriate sexual behavior to charge nurse and if other resident are involved, immediately intervene to protect the safety of all residents involved initiated 01/21/25 Record review of Resident #1's progress notes dated 01/18/25-01/19/25 revealed: There was no progress note related to Resident #1 kissing Resident #2. An interview was not conducted with Resident #1 because he was not actively in the facility on 03/19/25. Record review of Resident #2's face sheet, dated 03/19/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), and chronic hepatitis C. Record review of Resident #2's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section B Hearing, Speech and Vision revealed that Resident #2 had clear speech, usually made herself understood and usually had the ability to understand others. Record review of Resident #5's care plan, dated 02/10/25, revealed the following: Focus Cognitive Function: Resident #2 has impaired cognitive function/dementia or impaired thought processes Dementia, impaired decision making initiated 2/13/23. Goal The resident will maintain current level of cognitive function initiated 02/13/23. Interventions/Task Discuss concerns about confusion, disease process, nursing home placement with the resident/family and care givers initiated 02/13/23. Record review of Resident #2's care plan, 2/10/25, did not address a desire to be in a relationship or incidents of inappropriate sexual behavior. Record review of Resident #2's progress notes dated 01/18/25-01/19/25 revealed there was no progress note related to Resident #2 being kissed by Resident #1. During an interview on 03/19/25 at 2:09 PM, Resident #2 stated she had a boyfriend. She said she did not know his name but that he was at the facility on 03/19/25. She said she did not remember if she kissed anyone. After asking why she was being questioned, she said she could kiss if she wanted to and felt safe in the facility. During an interview on 03/19/25 at 11:59 AM, the DON said that the Activity Director reported to her a few days after the incident (Resident #1 and Resident #2 kissed) occurred. She was unable to report the date the incident occurred. She stated it was reported to her that it was a peck on the lips. She said she was told that the residents were separated. She said Resident #2 had a BIMS of 3. The DON said she was unsure if anything else was done regarding the incident. She said the only person she spoke with was the Activity Director about the incident, and she would have more information. During an interview on 03/19/25 at 12:02 PM, the Activity Director stated that approximately 2 months ago, Resident #1 and Resident #2 kissed. The Activity Director stated that Resident #1 resided in the male-locked unit, and he would come out and assist her with activities. She stated that Resident #1 would shake hands and hug other residents, and Resident #1 was friendly. She said that because he was out of the male-locked unit, he was with her and helped her gather supplies, gather residents, and deliver items. The Activity Director stated they were near the nurse's station when he kissed Resident #2. Before she knew it, she observed Resident #1 and Resident #2 pecking each other on the lips. The Activity Director stated she separated both residents and explained to Resident #1 that he could not do that because of illnesses he could be exposed to. She stated Resident #1 joked and said, They were both grown. The Activity Director stated she spoke with Resident #2, but she did not understand at that moment and did not recall the incident. The Activity Director stated she believed Resident #2 had dementia. The Activity Director stated she did not think any other staff observed the incident. The Activity Director stated she reported the incident to the ADM and DON the same day the incident occurred. She said it was discussed the next morning in the morning meeting but did not remember the details of the meeting. She said that neither of the residents had a history of inappropriate sexual behaviors. The Activity Director stated she did not document the incident in either of the resident's progress notes. She stated she did not have a reason for not documenting the incident. She stated moving forward, she had just reminded Resident #1 of the best way to greet people. She stated the incident did not happen again. She stated she did not pass the information about the incident to the male-locked unit staff. During an interview on 03/19/25 at 1:15 PM, Family Member E stated she was not notified by facility staff about Resident #1 kissing another resident, but that Resident #1 told her about it. She said he told her he was told not to do it anymore. She could not remember if the kiss was on the lips or cheeks. She referred to the incident by saying, It was just a kiss! The interview ended abruptly because she said she was out with her grandchildren and would call back. During an interview on 03/19/25 at 1:30 PM, the Assistant Activity Director stated she had no first-hand information about Resident #1 kissing Resident #2. She stated that she heard about it but was not given specific instructions related to Resident #1 regarding the matter. She said that Resident #1 had never displayed behavior like that before. She said neither resident had the cognitive ability to make decisions independently. An attempt to interview Family Member F was unsuccessful on 03/19/25 at 1:18 PM. During an interview on 03/19/25 from 12:13 PM to 2:22 PM with LVN A, LVN B, C, and D revealed that they had provided care for Resident #1. They were all unaware of Resident #1 kissing Resident #2. They had not been given specific instructions regarding Resident #1's inappropriate behavior. They had never witnessed him having inappropriate behavior. They all expressed that Residents #1 and #2 could not make decisions cognitively. During an interview on 03/19/25 at 2:34 PM, the ADM stated that HR had told her that Resident #1 had kissed Resident #2. The ADM stated Resident #1 greets everyone and the ladies at the facility and swoons over him. ADM stated that she once was told by Family Member E that while in the community, he (Resident #1) oversaw completing shopping for the ladies in his apartment complex. She said that after HR told her she went and spoke with the Activity Director, she (the Activity Director) told her (The ADM) both residents (Resident #1 and #2) greeted each other and pecked each other on the lips. She said The Activity Director pulled both Residents apart. The ADM stated it was unusual but not an issue. She said she (The ADM) did not see it as inappropriate. She said they discussed the incident in the morning meeting and lightly mentioned that they should plan it because it could be inappropriate. She said she assumed that was why the DON care planned it as inappropriate behavior. The ADM stated Resident #2 was not cognitively able to make her own decisions, and neither was Resident #1. She said she had spoken with Resident #2, and she did not remember. She said she did not talk with Resident #1. She said Resident #1 greets people in this manner. She showed the investigator that he would give a side hug, press his face to other residents, and made a kissing sound. She said he was not asking permission of the residents to greet them in that manner. The ADM stated she did not think there was anything to it. She said she did have a surveillance system, but where the incident occurred, it would not have been an unobstructed view for the cameras. She said she did not even think to look at the camera because she did not think Resident #1 meant to do it. The ADM stated she did not report it to Resident #1's family, and Resident #1 does not have family. The ADM stated Resident #2's family representative was her boyfriend, who did not answer phone calls. She stated when she spoke with Resident #2, she (Resident #2) was not upset. She said she was not sure if an incident like this would necessarily be reported to the family, depending on the resident. She said it was something that they needed to watch but did not consider it an issue because Resident #2 was not upset and could not remember. She said it was reported to her that Resident #2 was pecking him back. She said Resident #2 could let her feelings be known. She said HR was not in the facility today because she was out attending a funeral. During an interview on 03/19/25 at 3:04 PM, the DON stated she was familiar with the facility's abuse policy, specifically reporting to HHSC , notifying the family representative, and conducting a thorough investigation. She said the purpose of reporting to HHSC was so that HHSC could come and investigate. She said the purpose of notifying the family representative was because that was the policy. She said the purpose of conducting a thorough investigation and documenting it was to determine if they needed to substantiate, figure out what happened, and what could have been done to prevent it. She stated they usually get witness statements from all the people who were involved. She stated they typically would try to interview the staff and residents as soon as it happens so that the information was fresh on their minds. She said the longer they wait, the more the residents could forget. She said the PNO of not following the facility's abuse policy was that the facility would be cited for deficiencies. She said the PNO of not notifying the family representative was the family may have further questions and would not know what was going on with the resident's care. She said she did not notify the families of the residents who were involved. She said the PNO of not conducting a thorough investigation and documenting it was then they could not prevent it from happening again and the lack of documenting would make it difficult for others to know about the incident. She said the incident should have been documented in the resident progress notes. She said she did not know it was not documented in the progress notes. She said she was aware that the facility did not report the incident to HHSC, investigate, or contact the family members of both residents involved. She said she was unaware that the incident between Resident #1 and #2 should have been investigated, but in hindsight, she could see where they should have been investigated. She said the system for monitoring that the facility's abuse policy was being followed was using the provider letter and policies to determine if the incident needed to be reported to HHSC. She said her system to monitor family notifications was she would review risk management. She said the system to monitor investigations was if they had a self-report, they would follow the self-report protocol based on what occurred. She said that this was generated in their computer system. She said she would review all documentation. She said she had been trained to report all reportable incidents to HHSC. She said she had been trained to notify family representatives of any significant incidents that involve residents. She said she had been trained to conduct a thorough investigation regarding allegations of abuse. She said she had been trained to conduct a thorough investigation and document regarding ANE. She said she expected all reportable incidents to be reported to HHSC. She said she expected all family representatives to be notified if there was an incident that involved any resident. She said she expected all allegations of ANE reported to be documented and thoroughly investigated. She said she and the ADM were responsible for reporting reportable incidents to HHSC. She said the charge nurse was typically responsible for notifying the resident's family when they were involved in an incident. She said she and the ADM were responsible for investigating and the documentation of the investigation. She said the incident was not reported to HHSC because it was a peck, and she was not troubled by it. She said he was supervised every time Resident #1 was out of the male-locked unit. She said he greeted a lot of people but did not kiss them on the lips. She said she had never seen him make contact with any other resident on the lips. She said the family was not notified because they did not perceive it as concerning or find out about the incident until several days later. She said Resident #2 was not troubled. She said that the reason the incident was not thoroughly investigated or documented was because they did not perceive the incident as ANE. She said she did not customize the care plan but used a template. She stated all staff were trained to notify if there was an allegation of ANE. During an interview on 03/19/25 at 3:36 PM, the ADM stated she was familiar with the facility's abuse policy, specifically reporting to HHSC, notifying the family representative, and conducting a thorough investigation. She said the purpose of reporting ANE to HHSC was to protect the resident and to have a second set of eyes. It ensured that nothing was not missed. She said the purpose of notifying the family representative was to let the family know what was going on with their care. She said conducting a thorough investigation and documenting was to ensure they did not miss anything and get the whole story. She said an investigation would involve interviewing other residents to see if it was a pattern. She said she would also interview the residents involved. She said they would interview any witnesses. She only interviewed Resident #2, HR, and the Activity Director. She said she did not document the interviews because she did not think about it. She said she did not perceive the incident between Resident #1 and Resident #2 as an incident. She said that the PNO of not reporting to HHSC was when the incidents that should have been reported may not have been investigated. She said the PNO of not notifying family representatives was the family needed to know what was going on, and if they did not notify the family, they could fail to do something they (the family) wanted them to do regarding the residents. She said she was aware that the incident where Resident #1 kissed Resident #2 was not reported to HHSC. She said she was aware that the family was not notified and did not notify the family of Residents #1 and #2. She said she does not believe that anyone would have done a notification because an incident report was not completed. She said she was aware an investigation was not completed because they did not feel it was a reportable incident, and she failed to report it. She said the system to monitor reportable incidents to HHSC was they always reviewed incidents. She said they typically reported incidents to the corporate office, and they all came to an agreement. She said if one person agreed that the incident should be reported, they should report it to HHSC. She said they did not report the incident between Resident #1 and #2 to the corporate nurse and operation manager. She said she did not consider it a reportable incident when it was reported to her. She said she heard it from HR, and she told her they (Resident #1 and Resident #2) were kissing. She said the system to monitor family notifications was to ensure that the DON would complete the notification if it were a reportable incident. If it was the charge nurse, she should also be checking behind the incident reports. She said the system they used to monitor investigations was that she and the DON drive the process and get interviews. She said she was unsure if she would have expected the incident to be documented in the resident progress notes. She said she had been trained to report reportable incidents to HHSC. She said she had been trained to notify family members if the resident was involved in a reportable incident. She said she had been trained to conduct a thorough investigation and document that investigation. She said she had been trained to report reportable incidents to HHSC. She said she expected family representatives to be notified if there were any incidents, new orders, or behaviors. She said she expected all reportable incidents to be thoroughly investigated and documented. She said she typically reported incidents to HHSC but that the DON could do it in her absence. She said the DON typically would report incidents to the corporate office. She said that depending on the incident would determine who was responsible for notifying the family representative. She said it would be the charge nurse or nurse present during the incident. She said she, as the ADM, was responsible for conducting a thorough investigation and documenting the investigation. She said she did not report the incident to HHSC because she felt it was accidental. She said there was no harm or intent. She said the family was notified because they did not feel it was an incident or harmful behavior between the two. She said the incident (Resident #1 and Resident #2 kissing) was not investigated and documented because they genuinely did not feel it was reportable. She said she mentioned in the morning meeting on an unknown date that the incident needed to be care planned with the DON being new care planned the incident as inappropriate sexual behavior, but she did not feel that the behavior was sexually inappropriate. During an interview on 03/24/25 at 2:58 PM, she said she did not witness Resident #1 and Resident #2 kiss, but she was told about the incident on an unknown date by the Activity Director while they were doing work for Meals on Wheels. She said although she did not remember the day she was told, she knew she was not told about the incident the same day the incident occurred because the Activity Director just casually mentioned the incident. She said the Activity Director told her that while they (The Activity Director and Resident #1) were bringing other residents to have an appetizer, Resident #1 and Resident #2 kissed. She said it was like a greeting and that the Activity Director joked about the incident. HR stated she did not get the impression as if it was a bad thing. She said she had never seen Resident #1 do this (kiss or greet other residents) before. She said Resident #1 was friendly and felt like he worked at the facility. She said she reported the incident to the ADM in casual conversation. She said she and the ADM were talking about Resident #2's boyfriend dumping her at the facility and being difficult to contact. HR stated she joked with the ADM and said, Oh, he better behave because Resident #2 was kissing boys. She said the ADM stopped and said, Oh God, what? We should probably get that care planned. HR said the ADM spoke about it in the morning meeting the following day. She said they should care plan it just in case it came up or happened again, and they would have a reference. She said both residents have memory issues where they cannot remember very well, but Resident #2 was verbal enough to express if she did not want something, she would let it be known. She said Resident #2 would wink and flirt a little. Record review of the facility policy, Abuse/Neglect, date revised 03/29/18, revealed: The resident has the right to be free from abuse . Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents . The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, and situations that may constitute abuse or neglect to any resident in the facility. Prevention The facility will provide the residents, families, and staff an environment free from abuse and neglect. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or Abuse Preventionist within 24 hours of complaint. Appropriate notification to state and home office will be the responsibility of the administrator and per policy. Reporting Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. Investigation Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated. The administrator in consultation with the Risk Management Department will be responsible for investigating and reporting cases to the HHSC. After receipt of the allegation the Abuse Preventionist and administrator in conjunction with Risk Management will immediately evaluate the resident's situation using the criteria as stated in this policy. Determination will be made for required reporting to HHSC per reporting guidelines found in Provider letter 19-17. A report to the appropriate agency will include the following: The name and address of the suspected victim. The name and address of the suspected victim's care giver, if known. Resident to Resident The above policy will apply to potential resident-to-resident abuse. Provider letter 19-17 will be reviewed to determine if resident-to-resident abuse occurred.

Based on interviews and record reviews the facility failed to have evidence all allegations of abuse, neglect or mistreatment were thoroughly investigated for 2 of 10 residents (Resident #1, and #2) reviewed for abuse. The ADM (Abuse Preventionist) and the DON failed to follow the facility's abuse policy by not conducting a thorough investigation and documenting regarding the Resident-to-Resident inappropriate sexual activity between residents (Resident #1 kissed Resident #2) that occurred on an unknown date. These failures could place residents as risk for abuse and neglect by not investigating allegations of abuse, neglect, exploitation, or mistreatment. Findings included: Record review of Resident #1's face sheet, dated 03/19/25, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), major depressive disorder, and anxiety. Record review of Resident #1's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 08, which indicated the resident's cognition was moderately impaired. Section B Hearing, Speech and Vision revealed that Resident #1 had clear speech, had the ability to make himself understood and had the ability to understand others. Record review of Resident #5's care plan, dated 10/01/24, revealed the following: Focus Sexually inappropriate AEB: was witnessed kissing a female resident on the lips in the dining room initiated 1/21/25. Goal Resident will have no episodes of sexually inappropriate behavior in the next 90 days initiated 1/21/25. Interventions Evaluate the resident ability to understand behavior and the consequences of that behavior initiated 1/21/25. Explain to the resident the acceptable expressions of sexuality based on the cognitive evaluation initiated 1/21/25. Listen/talk to the resident-see if they will tell you why they do the behavior initiated 1/21/25. Psychiatric Services consult as needed initiated 1/21/25. Reinforce with staff that clear, firm limits are healthy and required when resident makes inappropriate gestures or statements initiated 1/21/25. Report incidents of inappropriate sexual behavior to charge nurse and if other resident are involved, immediately intervene to protect the safety of all residents involved initiated 01/21/25 Record review of Resident #1's progress notes dated 01/18/25-01/19/25 revealed: There was no progress note related to Resident #1 kissing Resident #2. An interview was not conducted with Resident #1 because he was not actively in the facility on 03/19/25. Record review of Resident #2's face sheet, dated 03/19/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), and chronic hepatitis C. Record review of Resident #2's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section B Hearing, Speech and Vision revealed that Resident #2 had clear speech, usually made herself understood and usually had the ability to understand others. Record review of Resident #5's care plan, dated 02/10/25, revealed the following: Focus Cognitive Function: Resident #2 has impaired cognitive function/dementia or impaired thought processes Dementia, impaired decision making initiated 2/13/23. Goal The resident will maintain current level of cognitive function initiated 02/13/23. Interventions/Task Discuss concerns about confusion, disease process, nursing home placement with the resident/family and care givers initiated 02/13/23. Record review of Resident #2's care plan, 2/10/25, did not address a desire to be in a relationship or incidents of inappropriate sexual behavior. Record review of Resident #2's progress notes dated 01/18/25-01/19/25 revealed there was no progress note related to Resident #2 being kissed by Resident #1. During an interview on 03/19/25 at 2:09 PM, Resident #2 stated she had a boyfriend. She said she did not know his name but that he was at the facility on 03/19/25. She said she did not remember if she kissed anyone. After asking why she was being questioned, she said she could kiss if she wanted to and felt safe in the facility. During an interview on 03/19/25 at 11:59 AM, the DON said that the Activity Director reported to her a few days after the incident (Resident #1 and Resident #2 kissed) occurred. She was unable to report the date the incident occurred. She stated it was reported to her that it was a peck on the lips. She said she was told that the residents were separated. She said Resident #2 had a BIMS of 3. The DON said she was unsure if anything else was done regarding the incident. She said the only person she spoke with was the Activity Director about the incident, and she would have more information. During an interview on 03/19/25 at 12:02 PM, the Activity Director stated that approximately 2 months ago, Resident #1 and Resident #2 kissed. The Activity Director stated that Resident #1 resided in the male-locked unit, and he would come out and assist her with activities. She stated that Resident #1 would shake hands and hug other residents, and Resident #1 was friendly. She said that because he was out of the male-locked unit, he was with her and helped her gather supplies, gather residents, and deliver items. The Activity Director stated they were near the nurse's station when he kissed Resident #2. Before she knew it, she observed Resident #1 and Resident #2 pecking each other on the lips. The Activity Director stated she separated both residents and explained to Resident #1 that he could not do that because of illnesses he could be exposed to. She stated Resident #1 joked and said, They were both grown. The Activity Director stated she spoke with Resident #2, but she did not understand at that moment and did not recall the incident. The Activity Director stated she believed Resident #2 had dementia. The Activity Director stated she did not think any other staff observed the incident. The Activity Director stated she reported the incident to the ADM and DON the same day the incident occurred. She said it was discussed the next morning in the morning meeting but did not remember the details of the meeting. She said that neither of the residents had a history of inappropriate sexual behaviors. The Activity Director stated she did not document the incident in either of the resident's progress notes. She stated she did not have a reason for not documenting the incident. She stated moving forward, she had just reminded Resident #1 of the best way to greet people. She stated the incident did not happen again. She stated she did not pass the information about the incident to the male-locked unit staff. During an interview on 03/19/25 at 1:15 PM, Family Member E stated she was not notified by facility staff about Resident #1 kissing another resident, but that Resident #1 told her about it. She said he told her he was told not to do it anymore. She could not remember if the kiss was on the lips or cheeks. She referred to the incident by saying, It was just a kiss! The interview ended abruptly because she said she was out with her grandchildren and would call back. During an interview on 03/19/25 at 1:30 PM, the Assistant Activity Director stated she had no first-hand information about Resident #1 kissing Resident #2. She stated that she heard about it but was not given specific instructions related to Resident #1 regarding the matter. She said that Resident #1 had never displayed behavior like that before. She said neither resident had the cognitive ability to make decisions independently. An attempt to interview Family Member F was unsuccessful on 03/19/25 at 1:18 PM. During an interview on 03/19/25 at 2:34 PM, the ADM stated that HR had told her that Resident #1 had kissed Resident #2. The ADM stated Resident #1 greets everyone and the ladies at the facility and swoons over him. ADM stated that she once was told by Family Member E that while in the community, he (Resident #1) oversaw completing shopping for the ladies in his apartment complex. She said that after HR told her she went and spoke with the Activity Director, she (the Activity Director) told her (The ADM) both residents (Resident #1 and #2) greeted each other and pecked each other on the lips. She said The Activity Director pulled both Residents apart. The ADM stated it was unusual but not an issue. She said she (The ADM) did not see it as inappropriate. She said they discussed the incident in the morning meeting and lightly mentioned that they should plan it because it could be inappropriate. She said she assumed that was why the DON care planned it as inappropriate behavior. The ADM stated Resident #2 was not cognitively able to make her own decisions, and neither was Resident #1. She said she had spoken with Resident #2, and she did not remember. She said she did not talk with Resident #1. She said Resident #1 greets people in this manner. She showed the investigator that he would give a side hug, press his face to other residents, and made a kissing sound. She said he was not asking permission of the residents to greet them in that manner. The ADM stated she did not think there was anything to it. She said she did have a surveillance system, but where the incident occurred, it would not have been an unobstructed view for the cameras. She said she did not even think to look at the camera because she did not think Resident #1 meant to do it. She stated when she spoke with Resident #2, she (Resident #2) was not upset. She said it was reported to her that Resident #2 was pecking him back. She said Resident #2 could let her feelings be known. During an interview on 03/19/25 at 3:04 PM, the DON stated she was familiar with the facility's abuse policy, specifically conducting a thorough investigation. She said the purpose of conducting a thorough investigation and documenting it was to determine if they needed to substantiate, figure out what happened, and what could have been done to prevent it. She stated they usually get witness statements from all the people who were involved. She stated they typically would try to interview the staff and residents as soon as it happens so that the information was fresh on their minds. She said the longer they wait, the more the residents could forget. She said the PNO of not conducting a thorough investigation and documenting it was then they could not prevent it from happening again and the lack of documenting would make it difficult for others to know about the incident. She said the incident should have been documented in the resident progress notes. She said she did not know it was not documented in the progress notes. She said she was unaware that the incident between Resident #1 and #2 should have been investigated, but in hindsight, she could see where they should have been investigated. She said the system to monitor investigations was if they had a self-report, they would follow the self-report protocol based on what occurred. She said that this was generated in their computer system. She said she would review all documentation. She said she had been trained to conduct a thorough investigation regarding allegations of abuse. She said she had been trained to conduct a thorough investigation and document regarding ANE. She said she expected all allegations of ANE reported to be documented and thoroughly investigated. She said she and the ADM were responsible for investigating and the documentation of the investigation. She said that the reason the incident was not thoroughly investigated or documented was because they did not perceive the incident as ANE. During an interview on 03/19/25 at 3:36 PM, the ADM stated she was familiar with the facility's abuse policy, specifically conducting a thorough investigation. She said conducting a thorough investigation and documenting was to ensure they did not miss anything and get the whole story. She said an investigation would involve interviewing other residents to see if it was a pattern. She said she would also interview the residents involved. She said they would interview any witnesses. She only interviewed Resident #2, HR, and the Activity Director. She said she did not document the interviews because she did not think about it. She said she did not perceive the incident between Resident #1 and Resident #2 as an incident. She said she was aware an investigation was not completed because they did not feel it was a reportable incident, and she failed to report it. She said she did not consider it a reportable incident when it was reported to her. She said she heard it from HR, and she told her they (Resident #1 and Resident #2) were kissing. She said the system they used to monitor investigations was that she and the DON drive the process and get interviews. She said she was unsure if she would have expected the incident to be documented in the resident progress notes. She said she had been trained to conduct a thorough investigation and document that investigation. She said she expected all reportable incidents to be thoroughly investigated and documented. She said she, as the ADM, was responsible for conducting a thorough investigation and documenting the investigation. She said the incident (Resident #1 and Resident #2 kissing) was not investigated and documented because they genuinely did not feel it was reportable. She said she mentioned in the morning meeting on an unknown date that the incident needed to be care planned with the DON being new care planned the incident as inappropriate sexual behavior, but she did not feel that the behavior was sexually inappropriate. Record review of the facility policy, Abuse/Neglect, date revised 03/29/18, revealed: The resident has the right to be free from abuse . Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents . The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, and situations that may constitute abuse or neglect to any resident in the facility. Investigation Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated. The administrator in consultation with the Risk Management Department will be responsible for investigating and reporting cases to the HHSC. Resident to Resident The above policy will apply to potential resident-to-resident abuse. Provider letter 19-17 will be reviewed to determine if resident-to-resident abuse occurred.

Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) and the administrator of the facility for 2 of 10 residents (Resident #1 and #2) reviewed for reporting abuse, in that: The ADM (Abuse Preventionist) and the DON failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC regarding the Resident-to-Resident inappropriate sexual activity between residents (Resident #1 kissed Resident #2) that occurred on an unknown date. These failures could place residents as risk for abuse and neglect. Findings included: Record review of Resident #1's face sheet, dated 03/19/25, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), major depressive disorder, and anxiety. Record review of Resident #1's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 08, which indicated the resident's cognition was moderately impaired. Section B Hearing, Speech and Vision revealed that Resident #1 had clear speech, had the ability to make himself understood and had the ability to understand others. Record review of Resident #5's care plan, dated 10/01/24, revealed the following: Focus Sexually inappropriate AEB: was witnessed kissing a female resident on the lips in the dining room initiated 1/21/25. Goal Resident will have no episodes of sexually inappropriate behavior in the next 90 days initiated 1/21/25. Interventions Evaluate the resident ability to understand behavior and the consequences of that behavior initiated 1/21/25. Explain to the resident the acceptable expressions of sexuality based on the cognitive evaluation initiated 1/21/25. Listen/talk to the resident-see if they will tell you why they do the behavior initiated 1/21/25. Psychiatric Services consult as needed initiated 1/21/25. Reinforce with staff that clear, firm limits are healthy and required when resident makes inappropriate gestures or statements initiated 1/21/25. Report incidents of inappropriate sexual behavior to charge nurse and if other resident are involved, immediately intervene to protect the safety of all residents involved initiated 01/21/25 Record review of Resident #1's progress notes dated 01/18/25-01/19/25 revealed: There was no progress note related to Resident #1 kissing Resident #2. An interview was not conducted with Resident #1 because he was not actively in the facility on 03/19/25. Record review of Resident #2's face sheet, dated 03/19/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), and chronic hepatitis C. Record review of Resident #2's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section B Hearing, Speech and Vision revealed that Resident #2 had clear speech, usually made herself understood and usually had the ability to understand others. Record review of Resident #5's care plan, dated 02/10/25, revealed the following: Focus Cognitive Function: Resident #2 has impaired cognitive function/dementia or impaired thought processes Dementia, impaired decision making initiated 2/13/23. Goal The resident will maintain current level of cognitive function initiated 02/13/23. Interventions/Task Discuss concerns about confusion, disease process, nursing home placement with the resident/family and care givers initiated 02/13/23. Record review of Resident #2's care plan, 2/10/25, did not address a desire to be in a relationship or incidents of inappropriate sexual behavior. Record review of Resident #2's progress notes dated 01/18/25-01/19/25 revealed there was no progress note related to Resident #2 being kissed by Resident #1. During an interview on 03/19/25 at 2:09 PM, Resident #2 stated she had a boyfriend. She said she did not know his name but that he was at the facility on 03/19/25. She said she did not remember if she kissed anyone. After asking why she was being questioned, she said she could kiss if she wanted to and felt safe in the facility. During an interview on 03/19/25 at 11:59 AM, the DON said that the Activity Director reported to her a few days after the incident (Resident #1 and Resident #2 kissed) occurred. She was unable to report the date the incident occurred. She stated it was reported to her that it was a peck on the lips. She said she was told that the residents were separated. She said Resident #2 had a BIMS of 3. The DON said she was unsure if anything else was done regarding the incident. She said the only person she spoke with was the Activity Director about the incident, and she would have more information. During an interview on 03/19/25 at 12:02 PM, the Activity Director stated that approximately 2 months ago, Resident #1 and Resident #2 kissed. The Activity Director stated that Resident #1 resided in the male-locked unit, and he would come out and assist her with activities. She stated that Resident #1 would shake hands and hug other residents, and Resident #1 was friendly. She said that because he was out of the male-locked unit, he was with her and helped her gather supplies, gather residents, and deliver items. The Activity Director stated they were near the nurse's station when he kissed Resident #2. Before she knew it, she observed Resident #1 and Resident #2 pecking each other on the lips. The Activity Director stated she separated both residents and explained to Resident #1 that he could not do that because of illnesses he could be exposed to. She stated Resident #1 joked and said, They were both grown. The Activity Director stated she spoke with Resident #2, but she did not understand at that moment and did not recall the incident. The Activity Director stated she believed Resident #2 had dementia. The Activity Director stated she did not think any other staff observed the incident. The Activity Director stated she reported the incident to the ADM and DON the same day the incident occurred. She said it was discussed the next morning in the morning meeting but did not remember the details of the meeting. She said that neither of the residents had a history of inappropriate sexual behaviors. The Activity Director stated she did not document the incident in either of the resident's progress notes. She stated she did not have a reason for not documenting the incident. She stated moving forward, she had just reminded Resident #1 of the best way to greet people. She stated the incident did not happen again. She stated she did not pass the information about the incident to the male-locked unit staff. During an interview on 03/19/25 at 1:15 PM, Family Member E stated she was not notified by facility staff about Resident #1 kissing another resident, but that Resident #1 told her about it. She said he told her he was told not to do it anymore. She could not remember if the kiss was on the lips or cheeks. She referred to the incident by saying, It was just a kiss! The interview ended abruptly because she said she was out with her grandchildren and would call back. During an interview on 03/19/25 at 1:30 PM, the Assistant Activity Director stated she had no first-hand information about Resident #1 kissing Resident #2. She stated that she heard about it but was not given specific instructions related to Resident #1 regarding the matter. She said that Resident #1 had never displayed behavior like that before. She said neither resident had the cognitive ability to make decisions independently. An attempt to interview Family Member F was unsuccessful on 03/19/25 at 1:18 PM. During an interview on 03/19/25 at 2:34 PM, the ADM stated that HR had told her that Resident #1 had kissed Resident #2. The ADM stated Resident #1 greets everyone and the ladies at the facility and swoons over him. ADM stated that she once was told by Family Member E that while in the community, he (Resident #1) oversaw completing shopping for the ladies in his apartment complex. She said that after HR told her she went and spoke with the Activity Director, she (the Activity Director) told her (The ADM) both residents (Resident #1 and #2) greeted each other and pecked each other on the lips. She said The Activity Director pulled both Residents apart. The ADM stated it was unusual but not an issue. She said she (The ADM) did not see it as inappropriate. She said they discussed the incident in the morning meeting and lightly mentioned that they should plan it because it could be inappropriate. She said she assumed that was why the DON care planned it as inappropriate behavior. The ADM stated Resident #2 was not cognitively able to make her own decisions, and neither was Resident #1. She said she had spoken with Resident #2, and she did not remember. She said she did not talk with Resident #1. She said Resident #1 greets people in this manner. She showed the investigator that he would give a side hug, press his face to other residents, and made a kissing sound. She said he was not asking permission of the residents to greet them in that manner. The ADM stated she did not think there was anything to it. She said she did have a surveillance system, but where the incident occurred, it would not have been an unobstructed view for the cameras. She said she did not even think to look at the camera because she did not think Resident #1 meant to do it. She said she was not sure if an incident like this would necessarily be reported to the family, depending on the resident. She said it was something that they needed to watch but did not consider it an issue because Resident #2 was not upset and could not remember. She said it was reported to her that Resident #2 was pecking him back. She said Resident #2 could let her feelings be known. During an interview on 03/19/25 at 3:04 PM, the DON stated she was familiar with the facility's abuse policy, specifically reporting to HHSC. She said the purpose of reporting to HHSC was so that HHSC could come and investigate. She said the PNO of not following the facility's abuse policy (reporting to HHSC) was that the facility would be cited for deficiencies. She said she was aware that the facility did not report the incident to HHSC. She said the system for monitoring that the facility's abuse policy was being followed was using the provider letter and policies to determine if the incident needed to be reported to HHSC. She said she had been trained to report all reportable incidents to HHSC. She said she expected all reportable incidents to be reported to HHSC. She said she and the ADM were responsible for reporting reportable incidents to HHSC. She said the incident was not reported to HHSC because it was a peck, and she was not troubled by it. She said he was supervised every time Resident #1 was out of the male-locked unit. She said he greeted a lot of people but did not kiss them on the lips. She said she had never seen him make contact with any other resident on the lips. She stated all staff were trained to notify if there was an allegation of ANE. During an interview on 03/19/25 at 3:36 PM, the ADM stated she was familiar with the facility's abuse policy, specifically reporting to HHSC. She said the purpose of reporting ANE to HHSC was to protect the resident and to have a second set of eyes. It ensured that nothing was not missed. She said she did not perceive the incident between Resident #1 and Resident #2 as an incident. She said that the PNO of not reporting to HHSC was when the incidents that should have been reported may not have been investigated. She said she was aware that the incident where Resident #1 kissed Resident #2 was not reported to HHSC. She said the system to monitor reportable incidents to HHSC was they always reviewed incidents. She said they typically reported incidents to the corporate office, and they all came to an agreement. She said if one person agreed that the incident should be reported, they should report it to HHSC. She said they did not report the incident between Resident #1 and #2 to the corporate nurse and operation manager. She said she did not consider it a reportable incident when it was reported to her. She said she heard it from HR, and she told her they (Resident #1 and Resident #2) were kissing. She said she had been trained to report reportable incidents to HHSC. She said she typically reported incidents to HHSC but that the DON could do it in her absence. She said she did not report the incident to HHSC because she felt it was accidental. She said there was no harm or intent. She said she mentioned in the morning meeting on an unknown date that the incident needed to be care planned with the DON being new care planned the incident as inappropriate sexual behavior, but she did not feel that the behavior was sexually inappropriate. During an interview on 03/24/25 at 2:58 PM, she said she did not witness Resident #1 and Resident #2 kiss, but she was told about the incident on an unknown date by the Activity Director while they were doing work for Meals on Wheels. She said although she did not remember the day she was told, she knew she was not told about the incident the same day the incident occurred because the Activity Director just casually mentioned the incident. She said the Activity Director told her that while they (The Activity Director and Resident #1) were bringing other residents to have an appetizer, Resident #1 and Resident #2 kissed. She said it was like a greeting and that the Activity Director joked about the incident. HR stated she did not get the impression as if it was a bad thing. She said she had never seen Resident #1 do this (kiss or greet other residents) before. She said Resident #1 was friendly and felt like he worked at the facility. She said she reported the incident to the ADM in casual conversation. She said she and the ADM were talking about Resident #2's boyfriend dumping her at the facility and being difficult to contact. HR stated she joked with the ADM and said, Oh, he better behave because Resident #2 was kissing boys. She said the ADM stopped and said, Oh God, what? We should probably get that care planned. HR said the ADM spoke about it in the morning meeting the following day. She said they should care plan it just in case it came up or happened again, and they would have a reference. She said both residents have memory issues where they cannot remember very well, but Resident #2 was verbal enough to express if she did not want something, she would let it be known. She said Resident #2 would wink and flirt a little. Record review of the facility policy, Abuse/Neglect, date revised 03/29/18, revealed: The resident has the right to be free from abuse . Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents . The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, and situations that may constitute abuse or neglect to any resident in the facility. Reporting Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. After receipt of the allegation the Abuse Preventionist and administrator in conjunction with Risk Management will immediately evaluate the resident's situation using the criteria as stated in this policy. Determination will be made for required reporting to HHSC per reporting guidelines found in Provider letter 19-17. A report to the appropriate agency will include the following: The name and address of the suspected victim. The name and address of the suspected victim's care giver, if known. Resident to Resident The above policy will apply to potential resident-to-resident abuse. Provider letter 19-17 will be reviewed to determine if resident-to-resident abuse occurred.

Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #4) reviewed for elopement. The facility failed to supervise Resident #4 while he was outside smoking. When the gate opened on 12/05/2024, Resident #4 was able to exit through the gate and leave the grounds. An Immediate Jeopardy situation was determined to have existed on 12/05/2024. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance on 12/05/2024 before the beginning of the survey. This failure could place residents at risk for serious injury, harm, impairment, or death. Findings included: Record Review of Resident #4's facesheet dated 12/10/2024 revealed that Resident #4 was initially admitted to the facility on [DATE] with a readmission on 07/20/2022. Resident #4 had a medical history of neuroleptic induced parkinsonism (condition that occurs when antipsychotic drugs cause parkinsonism like symptoms such as tremors and rigidity ), dementia with behavioral disturbance (loss of thinking, remembering, and reasoning with behavioral changes including agitation, aggression, wandering, delusions, hallucinations, depression often impacting their quality of life), schizoaffective disorder bipolar type (is a rare mental illness that combines schizophrenia symptoms with bipolar disorder symptoms of highs and lows), amnestic disorder (memory loss), schizophrenia (mental health condition that affects everything from how you think to how you feel and behave), anxiety disorder (feeling of fear, dread, and uneasiness), mild intellectual disability (deficits in intellectual functions pertaining to abstract/theoretical thinking), extrapyramidal and movement disorder (a group of movement disorders that CNA occur as a side effect of certain drugs particularly antipsychotics ), ataxia (impaired coordination, CNA be due to damage to brain, nerves, or muscles), borderline intellectual functioning (difficulty adapting to changes or learning new skills), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #4's MDS dated [DATE] revealed, Section C- Cognitive patterns revealed a BIMS score of 00 which indicated Resident #4 had a severe cognitive impairment. Record review of Resident #4's care plan dated 07/22/2019 revealed focus: **MENS SECURE UNIT** Resident #4 is at risk for wandering due to cognitive loss and has exit seeking behavior related to parkinson's and dementia. He currently resides on the secured unit related to high risk of elopement. Revision on 07/13/2023. Goals: Resident #4 will not leave facility unattended through the review date. Date initiated 07/22/2019, revision on 10/31/2019, target date 12/29/2024. Interventions/Tasks: Assess for fall risk 11/14/2019. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Date initiated 11/14/2019, revision on 11/14/2019. Identify pattern of wandering: is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it include the need for exercise? Intervene as appropriate. Date initiated, 07/22/2019. If Resident #4 is exit seeking, stay with him, and notify the charge nurse by calling out, sending another staff member, call system, etc. Date initiated 07/22/2019, revision 08/08/2019. Monitor for fatigue and weight loss. Date initiated 07/22/2019. Monitor for resident messing with his window in his room. Date initiated 10/10/2020. Resident #4 resides on the male secure unit. Date initiated 01/02/2020. Resident #4 will reside in the secure unit. Date initiated 12/06/2024. Focus: **Smoker Alert** Resident #4 is a smoker. Safe smoking assessment completed; Resident #4 able to safely smoke supervised. Smoking materials to be kept at the nurses station. Date initiated 7/22/2019, revision 12/06/2024. Goal: Will smoke in designated areas without occurrence of injury of the next 90 days. Date initiated 07/22/2019, revision on 10/31/2029. Target Date 12/29/2024. Interventions/Tasks: 1. Perform smoking assessment according to facility policy. Date initiated 08/06/2019. 2. Explain/Show where designated smoking areas are, and smoking times-repeat as needed. Date initiated 08/06/2019. 3. Monitor when smoking to assure resident safety. Date initiated 08/06/2019, revision on 12/06/2024. 4. Keep all smoking materials at nurses station. Date initiated 08/06/2019. 5. Gather all smoking supplies after smoking time is completed, he saves his cigarette butts to take to his room, assist him in disposing of them properly. Date initiated 10/23/202, revision 12/06/2024. Focus: Actual elopement or elopement attempt. Resident #4 was confused and wandered outside the facility unattended. Dated initiated 12/05/2024, revision on 12/06/2024. Goal: Will remain safe in the facility with no further elopements or elopement attempts, unless accompanied by staff or other authorized person through review date. Date initiated 12/06/2024. Target date 12/292024. Interventions/Tasks: Directly supervise resident while smoking. Date initiated 12/06/2024. Provide structural activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Date initiated 12/05/2024. Distract Resident #4 from elopement attempts by offering pleasant diversions, structured activities, food, conversation, television, books. Date initiated, 12/05/2024. If Resident #4 is exit seeking, stay with the resident, and notify the charge nurse by calling out, sending another staff member, call system, etc. Date initiated 12/05/2024. Record review of Resident #4's elopement risk assessment dated [DATE] reveals Resident #4 is an elopement risk with a score of 25 out of 28. Elopement risk assessment dated [DATE] revealed a score of 27 out of 28 which reveals elopement risk. Record review of Resident #4's safe smoking assessment dated [DATE] revealed: A. Evaluation: 6. Resident #4 is unable to enter door code to get to designated smoke area. B. Summary: 2. This resident requires direct supervision while smoking. 5. Care Plan up to date or updated. Safe smoking assessment dated [DATE] revealed: A. Evaluation: 6. Resident #4 resides on the secure unit and is unable to access it independently. 12. Trouble using fine motor skills. B. Summary: 2. This resident requires direct supervision while smoking. 4. All smoking materials will be kept at the nurses station. 5. Care plan up to date or updated. 6. The evaluation has been discussed with the resident. Record review of progress notes for Resident #4 dated 12/05/2024 revealed: Event- Elopement/Attempted: Blood pressure 146/74, Temperature 97.8, Pulse 81, Respirations 22. Door exited: smoke door on D Hall. How long missing: unknown. Where was the resident discovered: off campus. Code Orange was initiated. Injuries: No. Cognition/Behavior at time of event: Cognitive impairment, paces, wanders. CNA's alerted nurse that resident was outside smoking and is now missing. Initial Treatment/New Orders: No. Resident Statement: I went for a walk. Physician and family notified. Interventions: Resident #4 placed back on the secure unit. During an interview on 12/11/2024 at 8:55 AM, the ADM stated that on Tuesday 12/03/2024, the facility became aware that the secured door on Hall A was not locked. The ADM reported that she called the repair company at that time, and they arrived that evening. ADM stated that the repair company was able to remotely tell them what to do to get the door back locked and secure. The repair company came back on Wednesday 12/04/2024 to continue to work and troubleshoot the problem. On Thursday 12/05/2024, ADM stated that the repairman was in her office at the time of the event. ADM stated that the worker was telling her that everything was secure at this time, but they would have to make arrangements for staff to monitor the Chapel door and two gates that evening because he was going to have to leave that circuit disengaged, due to him having to wait on a part that was being shipped. The worker reported that the Chapel Door circuit was losing voltage and affected two gates. During their conversation, RN called a Code Orange and reported that Resident #4 was missing. ADM reported that there were three staff on the unit when the incident happened. Resident #4 is the only resident that smokes on Hall D secured unit. The CNA A reported that the gate was closed when she let Resident #4 go out. ADM reported that she went to check the gate and reported that when it was disengaged it swung open. ADM stated that the Code Orange was called at 3:40 PM and the resident was located at 3:54 PM. ADM reported that HR located the resident in an alley, approximately a half a mile from the facility. ADM reported that the repair company basically replaced the whole system. ADM stated they had staff at the facility all weekend monitoring the doors and gates, and that she still had staff checking the doors, stating that she was no longer just going to rely on the system. ADM stated that the facility completed elopement assessments on every resident. ADM stated they had also changed their smoking policy to all residents have to have direct supervision when smoking. During an interview on 12/11/2024 at 10:00 AM, RN stated that on 12/05/2024 that she entered Hall D Secure Unit to check on the residents and to see if the CNA's needed anything. RN stated that when she got back there she sat down by CNA B, and then CNA A and HA came in from outside. RN stated that when HA was leaving she asked her to check on a resident that she thought was sick, and CNA A was checking on another resident that was up without assistance. RN stated she left the unit at that time, then a few minutes later, RN went back to the unit to tell CNA A and CNA C to get some clothes ready for a resident they were going to send out. RN stated around 3:40 PM that CNA C notified her that while she was on break, that one of the CNA' let Resident #4 go out and smoke, and now they cannot find him. RN stated she immediately called a Code Orange and made assignments. RN stated that she had not seen Resident #4 outside, and the staff did not report to her that he was outside. RN stated she thought CNA A and HA had just gone out to vape on their own. RN stated when they got Resident #4 back to the facility, that she completed a full head-to-toe assessment with no injuries noted. RN stated that Resident #4 reported he had just gone for a walk. RN stated she notified the family and reported that they were happy he was able to go for a walk and hoped he had enjoyed it. RN stated that they had immediate in-services, and now all smokers have to be directly supervised, and the care plans have been updated. During an interview on 12/11/2024 at 10:53 AM, HR stated that when she heard the Code Orange, she left her office to see who it was. HR stated after checking around the facility that she got in her car. HR stated that she knew Resident #4 did not like commotion or being around a lot of people and did not think he would stay around the main roads. HR stated that she drove around the back of the facility, where there is an open field that leads to a remote residential/business area. HR stated that she located Resident #4 shuffling down an alley. HR asked Resident #4 if he wanted to get in the car and go for a ride. HR stated that Resident #4 stated no and then swung a hand in a downward motion, indicating for her to go away. HR stated that she called the ADM who came to the area. HR stated that ADM got out and went to talk to Resident #4, asking him if he wanted to get a hamburger and a milkshake, Resident #4 stated he did. HR stated they were able to get him in the car, and they went to the drive through at a fast food establishment. HR stated that Resident #4 just wanted a coke. HR stated that Resident #4 indicated he was tired when they asked him how he was. HR stated that she googled the location, and it was 1.2 miles driving, but Resident #4 was probably only about half a mile the way he went. HR stated the staff have a secure app on their phones for communication, and notifications started coming in immediately. HR revealed that she had been in-serviced on the Code Orange, Elopement Protocol, and Supervised Smoking. Observation on 12/11/2024 at 11:20 AM, HR accompanied me to the main smoking area that is off of the main dining room. The Chapel is in the back left corner of the main dining room. HR had to put in the code to the side door for us to enter the smoking area. From the back of the fence, the gate to Unit D secured smoking area was able to be visualized and was closed. There is a large vacant field behind the facility, which leads to a residential/business section. HR verbalized and pointed out the road she was on while looking for Resident #4. During an interview on 12/11/2024 at 12:20 PM, the ADON stated the facility has been doing a lot of education and follow-up. ADON stated that CNA A is a brand new CNA. The ADON reported that CNA A got called away to assist with another resident. ADON stated that the department heads were at the facility all weekend checking doors and the gates. ADON also reported that facility staff are continuing to check the doors to be sure they are secured. During an interview on 12/11/2024 at 12:51 PM, CNA A stated that she has been certified for about a month and a half. CNA A stated that her residents are like her family, and that she was so glad that Resident #4 was not hurt. CNA A stated that she had just returned from her break, and that her partner, CNA C then left the unit for her break. CNA A stated Resident #4 was wanting to go smoke, but stated she did not have a lighter, then HA came on the unit and CNA A asked her if she had a lighter. CNA A stated that HA left the unit to find a lighter, and when she got back, CNA A asked HA if she wanted to hit her vape before she left. CNA A stated they went outside, and she lit Resident #4's cigarette. CNA A stated that Resident #4 likes to walk over and stand at the turtle sanctuary that is in the back corner of the secured smoking area. CNA A stated that she and the HA were standing by the door, then HA stated she needed to leave. CNA A asked Resident #4 if he was ready to come in, and he said he was not ready. CNA A stated that she told Resident #4 to come to the door when he was ready to come in, and that she would be watching for him. CNA A stated she knows the gate was closed when they were outside. CNA A stated that when they went back in, that HA was leaving and hollered at her to come help with a resident that was up without assistance. CNA A stated that when she heard that, it was just instinct to run to go assist so that resident did not fall. She also reported that HA had notified RN that she was concerned that another resident needed to be checked because HA thought he was sick. CNA A stated that after they got that resident in bed, she heard another resident holler out. CNA A stated she had to go assist him or he will go to the bathroom in the floor. CNA A stated by that time CNA C had returned from her break, and that the RN asked them to get some clothes packed for a resident they were going to send out. CNA A stated that when they were in that resident's room getting clothes packed, she looked out the window and did not see Resident #4. CNA A stated that she figured Resident #4 was at the door ready to come in, but when she got to the door, he was not there, and the gate was open. CNA stated she went out and looked out the gate and did not see him. CNA A went inside and told CNA C that she could not locate Resident #4. CNA A stated they looked in all the rooms and closets and could not find him. CNA C notified RN who then called the Code Orange and protocol started. CNA A stated that no one had told her they were working on the gates, otherwise, I would not have let him go outside. CNA A stated that when she was being trained and she was working on her hours, that staff would just let Resident #4 go out and smoke, stating that he will be ok, the gate is locked. CNA A stated that Resident #4 will never be outside alone again. CNA A revealed that she had been in-serviced on the Orange Code, Elopement Protocol, and Supervised Smoking. During an interview on 12/11/2024 at 3:21 PM, CNA B stated that she was told to go cover Unit D while CNA C went on her lunch break. CNA B stated that when she got back to the unit, she asked CNA A what she needed to do, and CNA A reported that she had just completed her rounds. CNA B stated that at that point she sat down in a chair just outside the common area. CNA B stated that Resident #4 was wanting a light. CNA B stated that HA came on the unit and was talking to CNA A, and then the RN came in the unit and CNA B stated she was talking to her. CNA B stated that she did not see Resident #4, CNA A, and HA go outside. CNA B stated that while she was talking to the RN, that the other two girls came in and they were all four talking. CNA B stated that when HA was leaving, that HA hollered for CNA A to come assist with a resident, and that HA also notified RN about a resident that she thought might be sick. CNA B stated she was walking off the unit because she saw that CNA C was back on the unit. CNA B stated she went to the nursing station to work on some documentation, and she had four residents to document on. CNA B stated that when the Code Orange was called she had one more resident to chart on. CNA B stated that she cleared her halls she was assigned to, then went outside. Stated she saw CNA A and CNA C outside by a fence, stating that CNA A looked really upset. Stated that the ADON came out and told them someone needed to go back to the unit. CNA C stated she did not want to leave CNA A alone. CNA B stated that she would stay with her, and then CNA A took off running. CNA B stated that she was following her, then she fell and did not CNA A any longer. CNA C stated at that point she went back into the facility, and when she got to the nursing station she heard that they had located Resident #4. CNA B stated that she has been in-serviced on elopement and resident supervision of residents while smoking. During observation on 12/11/2024 at 5:00 PM, Investigator left facility and drove the route that HR had reported she had taken to locate Resident #4. Observed a large vacant field behind the facility. The area contains a residential area, including an apartment complex, with a couple of places of business. Area was remote with no traffic during drive through. During an interview on 12/12/24 at 9:10 AM, ADM stated that Resident #4's care plan stated supervision, which meant that the resident was just to be visually seen, and they were observing from the windows. ADM stated staff have been in-serviced and all residents that smoke have to be directly supervised, meaning the staff have to be outside with the residents. If it is found out that a resident is not being directly supervised, it is automatic termination. ADM stated they have been making observations to make sure staff is complying. ADM stated that she guessed if she would have had someone at the doors and gates while the repair company was here, that this probably would not have happened. ADM stated that CNA C clocked back in on 12/05/2024 at 3:00 PM, and that HA had clocked out at 3:03 PM on 12/05/2024. ADM stated their policy for notifying the police is 30 minutes. ADM stated she was in the process of getting information on what Resident #4 was wearing so she could call them, but Resident #4 had been located prior to her making that call. During an interview on 12/12/2024 at 9:35 AM, the DON came into the Conference Room and had CNA C on the phone. Phone interview with CNA C revealed that on 12/05/2024, she had returned from her lunch break around 3:00 PM. CNA C stated she entered Unit D and she saw RN, CNA A, CNA B, and HA on the other end of the hall. CNA C stated that she had gotten about halfway down the hall when HA hollered for CNA A that a resident was walking without assistance. CNA C stated that CNA A came down the hall to assist with that resident, then another resident was hollering out and CNA A went to check on him. CNA C stated that the RN had instructed them to get some clothes ready for a resident they were sending out. CNA C stated as she and CNA A were getting clothes packed, that is when CNA A stated that Resident #4 was outside smoking, so CNA A went to go check on him. CNA C stated that she heard CNA A yelling he was not out there, stating CNA A was hysterical. CNA C stated she was trying to calm her down and voiced for them to check the closets in all the rooms, because Resident #4 likes to hide sometimes. CNA C stated that they could not locate Resident #4, so she notified RN. CNA C stated that CNA A was being pulled in all directions, and she was just trying to do the right thing. CNA C reported that when she was being trained on the unit, that the staff would let Resident #4 go out to smoke and was told to just keep an eye on him. CNA C stated that now all residents are direct supervision for smoking, and if staff fails to do that, it is automatic termination. CNA C voiced that Resident #4 paces often and he will shadowbox, stating he will swing at you. During an interview on 12/12/2024 at 2:40 PM, the DON stated that they were monitoring smoking times to make sure staff is directly supervising. If staff is found not to be directly supervising, that employee will be immediately terminated. DON reported that the ADM had sent surveys to all of the employees earlier regarding elopement protocol and supervision, stating they all answered correctly. During a phone interview on 12/12/2024 at 2:45 PM, HA stated that on 12/5/2024 that she was getting ready to leave the facility for the day. HA stated that CNA A and her are good friends, so she went back to Hall D secure unit to let her know that she was leaving. HA stated when she got to the unit that CNA A asked her if she had a lighter. HA stated she did not, so she went out of the unit to find a lighter. When she got back, CNA A asked her if she wanted to go out and hit her vape before she left. HA stated that she, CNA A, and Resident #4 stepped outside. CNA A lit Resident #4's cigarette and then he walked to where the turtles are. HA stated after a few minutes she told CNA A that she needed to go, so she stepped inside, and CNA A was asking Resident #4 if he was ready to go in, and he was not ready. HA stated her and CNA A went in, and she saw RN and CNA B sitting in chairs just outside the common area. HA stated when she was leaving she saw a resident who was walking without assistance and yelled for CNA A to come help. HA stated that she saw another resident that she thought might be sick, so she told the RN who went in to check on him. HA stated when they got the other resident settled back in bed, she left the unit. HA stated she was suspended, has been in-serviced on elopement, and direct supervision of residents when they are outside smoking. Observation on 12/12/2024 at 4:35 PM, Resident #4 ambulated out of his room. Investigator introduced self and asked how he was doing. Resident #4 made eye contact but did not engage in conversation. His stance appeared as if he was ready to bolt. Staff walked up and talked with Resident #4. Resident #4 pointed to medication cart and stated he wanted some water. Resident #4 with steady gait followed staff to get water. Observation on 12/11/24 at 8:45 AM front entrance door was locked. Investigator rang doorbell and staff member approached door to enter code. During an interview on 12/11/2024 at 9:50 AM, MDS Nurse revealed that she had been in-serviced on Code Orange drills, Elopement Protocol, and Supervised Smoking. MDS Nurse stated that she helped with the door watches. During an observation on 12/11/2024 at 11:47 AM, Investigator put in the code to Secure Hall D. The alarm sounded upon entering unit and stopped when the door was closed. The alarm goes off when entering and exiting the unit. Resident #4 was resting in bed with eyes closed. The door that goes out to the smoking area also requires a code, and it was working. During an observation on 12/11/2024 at 11:55 AM, Investigator put in the code to Secure Hall C. The alarm sounded upon entering unit and stopped when the door was closed. The alarm goes off when entering and exiting the unit. The same thing occurred when leaving the Secure Hall C unit. The door was working. Record review on 12/11/2024 reviewed the Plan of Correction: Interventions put into place to prevent reoccurrence dated 12/05/2024, the document Self-Reporting Protocol/ Ad Hoc QAPI- Missing Resident or Elopement, Elopement Prevention QA Check List dated 12/05/2024 at 4:30 PM, 6:30 PM, 9:30 PM. 12/06/24 at 1:00 PM and 5:45 PM. 12/7/2024 at 1:00 AM, 3:30 PM, 7:30 PM. 12/08/2024 2:30 PM. Record review of in-service: Smoking Policy: If resident is unsupervised while smoking it will be an automatic termination, dated 12/05/2024 with 57 staff member signatures. Record review of in-service: Elopement Response: Codes are on the back of name badge. If it is not, notify HR for a new name tag. Code Orange is called if an employee discover a resident is missing from the facility. Undated with 59 staff member signatures. The following policy reviewed: Smoking Policy, Resident Admission Packet, revised 11/01/2017. Smoking policies must be formulated and adopted by the facility. The policies must comply with all applicable codes, regulations, and standards, including local ordinances. The facility is responsible for enforcement of smoking policies which must include at least the following provisions: 2. A safe smoking assessment will be done regularly for each resident who smokes. Smoking by resident classified as unsafe will be prohibited except when the resident will be directly supervised by facility personnel or visitors who are aware of the resident's limitations with smoking. 3. If the facility identifies the resident needs assistance/supervision and/or additional protective devices for smoking, the facility includes this information in the resident's care plan, and reviews and revises the plan periodically as needed. The following policy reviewed: Elopement prevention dated 2003, revised 10/27/2010. Policy Statement: Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1. Physical Plant: All facility exits that residents have access to will have a device in place to alert staff of possible elopement attempts. The following policy reviewed: Elopement Response dated 2003, revised 10/27/2010. Policy statement: 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. Policy Interpretation and Implementation: 2. C. A resident must demonstrate a free willful intent to leave the facility without prior notification of staff or is a wandering, confused resident who leaves the facility unattended. 7. Post return resident evaluation and care: C. The facility will evaluate its elopement prevention program and all residents will be reassessed for elopement. The ADM was notified on 12/12/2024 at 11:45 AM, that a past non-compliance IJ situation had been identified to the above failures. It was determined these failures placed Resident #4, in an IJ situation on 12/05/2024. These failures have the potential to affect all residents residing in the Secure Unit. The facility implemented the following interventions to prevent reoccurrence: Medical Director was notified of the elopement on 12/05/2024 at 4:30 PM. All exit doors and gates were checked by the Administrator on 12/05/2024 at 4:45 PM for proper alarming and functioning. No issues were identified. Repair company was in the facility on 12/05/2024 to assess power voltage. Repair company returned to the facility on [DATE] to continue assessment and repairs around 8:00 AM and repairs were completed around 12:30 PM. On 12/05/2024 staff were posted at the exit doors and gates until repair company completed all repairs. Elopement risk assessments were completed on all residents. Staff were in-serviced on 12/05/2024 on elopement response protocol and smoking policy by DON/Designee. All staff not present will be in-serviced prior to their next scheduled shift by DON/Designee. On 12/05/2024 an AD Hoc QAPI meeting was held with the medical director, facility Administrator, Director of Nurses, and Social Services Director to review the plan of correction. Monitoring: On 12/06/2024 the facility will monitor exit and gates for functioning 5x per week for 4 weeks, and prn thereafter to identify any potential future failures. On 12/06/2024 the DON/Designee will monitor resident smoke breaks for staff supervision 5x a week for 4 weeks and, then prn thereafter. On 12/06/2024 the DON/Designee will monitor elopement risk assessments to ensure completion 5x per week for 4 weeks, then prn thereafter. Interviews, observations, and record reviews confirmed that staff have been in-serviced on direct supervision of residents who smoke and elopement protocol.

Based on observations, interviews, and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality and the facility failed to protect and promote the rights of the resident for 4 of 21 residents (Resident #9, Resident #26, Resident #41, and Resident #231) reviewed for resident rights in that: 1. CNA H failed to knock on the door prior to entering Resident #41's room during wound care. 2. CNA I failed to provide full privacy while providing peri care for Resident #9 3. CNA E and CNA F failed to provide full privacy while providing peri care for Resident #231. 4. Resident #26 was observed with no clothes on, just a brief and right sock on while in his room with the door open on 11/05/2024 and 11/06/2024. These failures could place residents at risk for diminished quality of life and loss of dignity and self-worth. The findings included: Resident #9: Record Review of Resident #9's face sheet revealed an [AGE] year-old female, admitted on [DATE] with diagnoses of: acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood causing an absence of enough oxygen in the tissues to sustain bodily functions), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), dementia, high blood pressure, heart failure, acid reflux. Record review of Resident #9's Quarterly MDS assessment dated [DATE], revealed Resident #9 had a BIMS Score of 03, meaning Resident #9 had severe cognitive impairment. Under section for Bowel & Bladder listed Resident #9 as always being incontinent for urinary and bowel. During an observation of CNA I providing peri care for Resident #9 on 11/6/2024 at 11:20 am. CNA I failed to pull the privacy curtain all the way before proceeding with providing peri care for Resident #9. CNA I did close the door but did not close the privacy curtain all the way, just half way, dividing the resident from roommate. During an interview with CNA I on 11/06/2024 at 11:37 am. CNA I stated that she should have closed the privacy curtain all of the way providing full privacy. CNA I stated that she had been trained in providing privacy for resident by in-services, approximately every couple of weeks. CNA I stated that the negative potential outcome of not providing full privacy is that someone could walk in and it may make the resident feel embarrassed and invaded of privacy. Resident#26: Record Review of Resident #26's face sheet revealed a [AGE] year-old male, admitted on [DATE] with an initial admitted [DATE] with diagnoses of: dementia, constipation, muscle weakness, insomnia, acid reflux, schizoaffective disorder (a chronic mental illness), high blood pressure, hypothyroidism (low thyroid hormone levels), type 2 diabetes, congestive heart failure, hyperlipidemia (high lipids/fats in blood), depression. Record review of Resident #26's Quarterly MDS assessment, dated 08/12/2024, revealed Resident #26 had a BIMS Score of 00, meaning Resident #26 had severe cognitive impairment. Under section for Bowel & Bladder listed Resident #26 as always incontinent with urinary continence. During an observation of Resident #26 on 11/5/2024 at 12:57 pm. Observed Resident #26 laying in his bed with no sheet, no clothes on, with a brief and one sock on the right foot. Observed the resident's door open with other residents walking by. Resident #26's room is located next to the dining room. During an observation of Resident #26 on 11/5/2024 at 4:11 pm. Observed Resident #26 laying in his bed with no sheet, no clothes on, with a brief and one sock on the right foot. Observed the resident's door open with other residents walking by. Resident #26's room is located next to the dining room. During an observation of Resident #26 on 11/6/2024 at 7:29 am. Observed Resident #26 in his room, laying in his bed with no sheet, no clothes on, with a brief and one sock on the right foot. Observed the resident's door open with other residents walking by. Resident #41 Record review of Resident #41's face sheet, dated 11/7/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: cerebral infarction (stroke), projectile vomiting (forceful vomiting), and peripheral vascular disease (poor blood circulation). Record review of Resident #41's comprehensive MDS assessment, dated 04/17/24, revealed Resident #41 has a BIMS score of 13, which indicates intact cognition. Resident #41 was checked off on having a diabetic foot ulcer. During an observation on 11/06/24 at 10:35 AM of wound care performed by the WCN, CNA H was heard talking outside Resident #41's room and the door opened as she continued talking with her head turned towards the hallway. CNA H turned her head and saw the surveyor in the room, then 3 small knocks were heard on the door. CNA H did not knock prior to entering Resident #41's room. Interview on 11/06/24 at 10:55 AM, Resident #41 stated staff rarely knocks on his door before entering. Resident #41 stated sometimes it bothers him when the staff don't knock before entering his room. Interview on 11/07/24 at 12:59 PM, CNA H stated sometimes the residents get mad at them for knocking too hard when entering their rooms. CNA H stated she has been trained on knocking on the resident's door prior to entering. CNA H stated there are not many potential negative outcomes to the residents by not knocking on their door prior to entering as the residents can usually hear the staff talking in the hallways before going in their rooms. Resident #231 Record Review of Resident #231's face sheet revealed a [AGE] year-old male, admitted on [DATE] with diagnoses of: dementia, depression, anxiety, high blood pressure, acid reflux, muscle weakness, amnesia. Record review of Resident #231's Admission MDS assessment, dated 09/27/2024, revealed Resident #231 had a BIMS Score of 14, meaning Resident #231 was cognitively intact. Under section for Bowel & Bladder listed Resident #231 as occasionally being incontinent for urinary and bowel. During an observation of CNA E and CNA F providing peri care for Resident #231 on 11/6/2024 at 10:25 am. CNA E and CNA F failed to pull the privacy curtain all the way before proceeding with providing peri care for Resident #231. CNA F opened the door and left it completely open in the middle of peri care to go get some more wipes, leaving Resident #231 uncovered and completely exposed. CNA E failed to cover Resident #231. CNA E stood next to the bed while Resident #231 was exposed, waiting for CNA F to get back with wipes while the door was open the entire time. When CNA F returned to Resident #231's room with the wipes she then closed the door. During an interview with CNA E on 11/6/2024 at 4:54 pm. CNA E stated that she had been trained in privacy and dignity by in-services, monthly. CNA E stated that it is usually a verbal in-service provided by the DON. CNA E stated that she knows that she should provide privacy by pulling the privacy curtain completely. CNA E stated that she did not think to do that. CNA E stated that she does not know why Resident #26 was left in his room with only a brief and one sock on with no sheet, with the door open. CNA E stated that the negative potential outcome of not providing privacy to a resident is that it could leave them feeling anxious and embarrassed and may put them in an awkward position by being seen by others. During an interview with CNA F on 11/07/2024 at 3:04 pm. CNA F stated that she does not know why Resident 26 was left in nothing with a brief and one sock on with the door open for two days. CNA F stated that she does not really like going around Resident #26 because he shows sexual behaviors. CNA F stated that she is not sure why she did not pull the privacy curtain while assisting with peri care for Resident #231. CNA F stated, My mind went blank. CNA F stated that she had been trained in dignity by in-services, approximately every few weeks. CNA F stated that the negative potential outcome of not providing dignity is that the resident would be embarrassed or be worried if someone may see them undressed or it may even embarrass them if their roommate were to see them like that. During an interview with the admin on 11/07/24 at 2:27 PM, the admin stated she expects the staff to always provide privacy to everyone with any type of care being provided. The admin stated she expects staff to shut the doors when providing care, and knock and introduce themselves. The admin stated this is their house [the residents], not ours [the staff]. The admin stated the staff have been trained on privacy and dignity. The admin stated a potential negative outcome to the residents was it could cause mental anguish or embarrassment for them. Record review of the facility policy titled, Resident Rights undated, reflected the following: .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. The facility must protect and promote the rights of the residents 43150

Based on observation, interview, and record review, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 5 of 12 residents (Resident # 26, Resident #49, Resident #53, Resident #67, Resident #231) reviewed for hydration. The facility failed to ensure Resident #26, Resident #49, Resident #53, Resident #67, and Resident #231 received adequate fluid intake on 11/5/24, 11/6/24, and 11/7/24. This failure could place residents at risk for dehydration, decline in health, organ problems, seizures, and failure to thrive. Findings included: Resident #26: Record Review of Resident #26's face sheet revealed a [AGE] year-old male, admitted on [DATE] with diagnoses of: dementia, constipation, muscle weakness, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), insomnia, acid reflux, schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), high blood pressure, type 2 diabetes, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), heart failure, inflammation, depression. Record review of Resident #26's Quarterly MDS assessment dated [DATE], revealed Resident #26 had a BIMS Score of 00, meaning Resident #49 was unable to recall. Record review of Resident #26's care plan dated 08/7/2023 revealed that Resident #26 had potential fluid deficit due to oral intake, diuretic use, and poor oral intake with the interventions of: Monitor/document/report to MD PRN s/sx of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. Notify Physician if: Persistent symptoms of diarrhea, nausea/vomiting unresolved past 48 hours; persistent output exceeding intake past 48 hours; abnormal lab. Record Review of Resident #26's active physician orders as of 11/07/2024 revealed no fluid restrictions. During an observation of Resident #26 in the dining room on 11/06/2024 at 9:55 am. Observed Resident #26 sitting in his wheelchair in the dining room, stating he is thirsty. Made CNA E aware that Resident #26 was thirsty. Resident #49: Record Review of Resident #49's face sheet revealed a [AGE] year-old male, admitted on [DATE] with diagnoses of: high blood pressure, acid reflux, psychotic disorder (a mental disorder characterized by a disconnection from reality), anxiety, edema, dysphagia (difficulty swallowing foods or liquids), aphasia (a language disorder that affects a person's ability to communicate), urinary tract infection. Record review of Resident #49's Quarterly MDS assessment dated [DATE], revealed Resident #49 had a BIMS Score of 03, meaning Resident #49 was severely cognitively impaired. Record review of Resident #49's care plan dated 11/08/2022 revealed that Resident #49 had potential fluid deficit due to oral intake and diuretic use with the interventions of: encourage the resident to drink fluids of choice, invite the resident to activities that promote additional fluid intake, offer drinks during one-on-one visits, ensure that all beverages offered comply with diet/fluid restrictions and consistency requirements, Monitor/document/report to MD PRN s/sx of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. Record Review of Resident #49's active physician orders as of 11/07/2024 revealed no fluid restrictions. During an observation of hydration for Resident #49 on 11/06/2024 at 9:48 am. Observed Resident #49 with an empty pitcher sitting on his bedside table with no liquid in the pitcher. Resident #49 stated he would like some water when asked. Surveyor made CNA F aware that Resident #49 would like some water. During an observation of Resident #49 on 11/7/2024 at 7:29 am. Observed Resident #49 laying in his bed awake. Observed Resident #49 smacking his lips, stating he needs water. Observed no water in Resident #49's pitcher. Made CNA E aware that Resident #49 needed water. Resident #53: Record Review of Resident #53's face sheet revealed an [AGE] year-old male, admitted on [DATE] with diagnoses of: chronic kidney disease, dehydration, depression, gout (a form of arthritis that causes severe pain, swelling, redness and tenderness in the joints), retention of urine, hypothyroidism, type 1 diabetes, hyperlipidemia, dementia, high blood pressure. Record review of Resident #53's Quarterly MDS assessment dated [DATE], revealed Resident #53 had a BIMS Score of 11, meaning Resident #53 was moderately cognitively impaired. Record review of Resident #53's care plan dated 07/14/2023 revealed that Resident #53 had potential for fluid deficit due to dementia, diuretic use, and poor oral intake with the interventions of: encourage the resident to drink fluids of choice, ensure the resident has fluids in reach, inform the nurse if the resident is refusing to drink fluids, invite the resident to activities that promote additional fluid intake, offer drinks during one on one visits, ensure that all beverages offered comply with diet/fluid restrictions and consistency requirements, monitor/document/report to MD PRN s/sx of dehydration decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. Record Review of Resident #53's active physician orders as of 11/07/2024 revealed no fluid restrictions. During an observation of hydration for Resident #53 on 11/06/2024 at 9:50 am. Observed Resident #53 with an empty pitcher sitting on his bedside table with no liquid in the pitcher. During an observation of Resident #53 on 11/7/2024 at 7:32 am. Observed Resident #53 lying in bed, awake. Resident #53 stated he would like something to drink. Made CNA F aware that Resident #53 would like some water. Observed Resident #53 with an empty pitcher with no water. Resident #67: Record Review of Resident #67's face sheet revealed a [AGE] year-old male, admitted on [DATE] with diagnoses of: depression, schizophrenia, anxiety, bipolar disorder. Record review of Resident #67's Annual MDS assessment dated [DATE], revealed Resident #67 had a BIMS Score of 9, meaning Resident #67 was moderately cognitively impaired. Record review of Resident #67's care plan dated 09/12/2024 revealed that Resident #67 had potential for fluid deficit due to dementia and poor oral intake with the interventions of: monitor and document intake and output as per facility policy, monitor/document/report to MD PRN s/sx of dehydration decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. Record Review of Resident #67's active physician orders as of 11/07/2024 revealed no fluid restrictions. During an initial tour on 11/5/2024 at 10:32 am, Resident #67 stated he would like some water. Observed an empty pitcher on his bedside table. Made CNA D aware that Resident #67 would like some water. During an observation of hydration for Resident #67 on 11/6/2024 at 9:46 am. Observed Resident #67 with an empty pitcher with no water. Observed the empty pitcher sitting on top of the refrigerator across the room. Resident #67 stated that he was thirsty and wanted water. Surveyor had to get CNA E to get some water. During an observation of Resident #67 on 11/7/2024 at 7:42 am. Observed Resident #67 laying in bed and his empty pitcher sitting in the same place as the day before, empty. Observed the empty water pitcher sitting on top of the refrigerator in the room, under the tv, across the room. Resident #231: Record Review of Resident #231's face sheet revealed a [AGE] year-old male, admitted on [DATE] with diagnoses of: dementia, depression, anxiety, high blood pressure, acid reflux, muscle weakness, amnesia. Record review of Resident #231's Admission MDS assessment dated [DATE], revealed Resident #231 had a BIMS Score of 14, meaning Resident #231 was cognitively intact. Record Review of Resident #231's active physician orders as of 11/07/2024 revealed no fluid restrictions. During an observation of hydration for Resident #231 on 11/06/2024 at 9:52 am. Observed Resident #231 with an empty pitcher sitting on his bedside table with no liquid in the pitcher. During an observation of the hydration station in the dining room on 11/06/2024 at 9:56 am. Observed no pitcher of water available in the dining room for residents. During an interview with CNA E about the hydration station on 11/06/2024 at 9:59 am. CNA E stated that they have no water right now because the DON came to get the jug to take to the kitchen to get cleaned and filled with water. CNA E stated that the DON came to get the water container earlier that morning. During an observation of the hydration station in the dining room on 11/7/2024 at 8:00 am. Observed a large container of water full of ice and water with cups. During an interview with CNA D on 11/5/2024 at 11:49 am. CNA D stated that there was no water or hydration set up at this time. CNA D stated that she is not sure why. CNA D stated that she had been having to run to the kitchen to get water for the residents. CNA D stated that she had fallen behind is why it had not been done. CNA D stated that the negative outcome for not keeping residents hydrated is they could become dehydrated. During an interview with the Administrator on 11/7/2024 at 4:18 PM. The Administrator stated that she expects staff to offer hydration rounds frequently. The Administrator stated that the staff have been trained to make hydration rounds by in-services every couple of weeks. The Administrator stated that the negative potential outcome of not providing hydration rounds is that it could cause multiple issues for the resident, and it affects all systems including skin integrity. During an interview with CNA F on 11/7/2024 at 2:58 PM. CNA F stated that normally hydrations rounds are to be made every couple of hours. CNA F stated that they usually have a hydrations station completely set up. CNA F stated that she does not know why it had not been set up and what was taking the kitchen staff so long to clean the water container and get it filled and returned. CNA F stated that the DON came to get the water container earlier that morning of 11/6/2024 to get it cleaned and filled. CNA F stated that if there is no water on D hall then she will have to go to the kitchen to get the resident something to drink. CNA F stated that she had not done that because she was busy. CNA F stated that if the resident is wanting something to drink, they can come ask her and she will go to the kitchen to get them something. CNA F stated that the negative potential outcome of a resident not having access to water is that they can become dehydrated and have a decline in health. During an interview with DON on 11/7/2024 at 3:12 PM. The DON stated that she expects staff to make hydration rounds hourly. The DON stated that the staff have been in-serviced on hydration rounds. The DON stated that training is approximately monthly. The DON stated that the negative potential outcome of not providing hydration rounds is that it could affect the health of the resident. During an interview with CNA E on 11/7/2024 at 3:58 pm. CNA E stated that the DON came and got the water container and took it to the kitchen to get cleaned and filled and she had not seen it since then. CNA E stated that it had been taking too long to get the water container back from the kitchen. CNA E stated that she checked with the kitchen, and they told her that they were busy and that is why it was taking so long but that they would get her the water container. CNA E stated that eventually a guy from the kitchen brought the water container full of water and ice. CNA E stated that she would go to the kitchen to get residents water if they needed it. CNA E stated that she had gotten busy and that is why it had not been done. CNA E stated that the negative potential outcome of not providing hydration rounds frequently could cause the resident to become dehydrated. Record review of a facility Policy, labeled, Hydration,, dated 2023, revealed: The facility provides each resident with sufficient fluid intake to maintain proper hydration and health. The resident will receive sufficient amounts of fluid based on assessed need to prevent dehydration and promote optimum psychological functions daily. Goals: 1. The resident will maintain adequate hydration. 4. Fluid intake is monitored routinely. 5. The resident will not demonstrate signs or symptoms of dehydration. Procedure: 2. Staff should offer hydration, unless contraindicated, at the following intervals. 1. Direct care interaction with the resident in the resident's room. 2. Prior to, during, and following meals. 3. During medication pass. 4. During activities. 3. The facility may utilize fine dining programs to encourage fluids prior to, during, and following meals. The facility may use education and encouragement to increase fluid intake with intermittent direct care duties. Fresh water will be maintained at bedside when not contraindicated. The facility may implement a dehydration cart system designed to offer appropriate fluids every shift to residents except where contraindicated. Alternative treatment approaches may include use of popsicles, gelatin, and other similar non-fluid foods as recommended by the Dietician. 4. Residents who demonstrate a risk for dehydration will be care planned and treated accordingly. 6. Residents will also be frequently monitored for indications of dehydration.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. 1) The facility failed to keep food properly sealed in the refrigerator. 2) The facility failed to properly store bowls, plates and pans in the kitchen area. 3) The facility failed to keep the microwave handles and buttons and the deep fryer clean and ready for use. 4) The facility failed to store Liquid Steel [NAME] (cleaning solution) separately from where food is stored. These failures could place residents at risk for food contamination and foodborne illness. The findings included: Observation during a kitchen tour on 11/05/24 at 9:46 AM revealed 1 pack of King Hawaiian Rolls 24 count not properly sealed in the small refrigerator. 1 bottle of Liquid Steel [NAME] was noted to be sitting on top of the small refrigerator. 6 silver preparation bowls and 3 silver pots were noted to be sitting right side up on the bottom shelf of food preparation tables in the kitchen. The microwave handle was noted to have dry substances stuck on the inside of the handle. The microwave buttons were noted to have dry sticky substances stuck on them. The deep fryer was noted to have dried substances on the fryer basket and on the back and sides where the oil is stored. Observation on 11/05/24 at 12:04 PM of the food temperature checks on the food line revealed 7 small bowls sitting right side up and 14 small plates sitting right side up where dishes are stored outside of the kitchen behind the steam table. Observation of the kitchen on 11/06/24 at 11:04 AM, 3 silver pots were noted to be sitting right side up on a bottom shelf. Interview on 11/06/24 at 4:20 PM, the DM stated the FSS was out for the day and would not be available for interview. Interview on 11/07/24 at 9:52 AM, the DM stated the FSS was out for the day and would not be available for interview. Interview on 11/07/24 at 2:11 PM, the DM stated that he is mainly responsible for ensuring kitchen foods and items are stored properly and chemicals are not stored in food areas, but all the kitchen staff should be more mindful. The DM stated the Liquid Steel [NAME] was probably left over from the night cleaning and was not properly stored. The DM stated the King Hawaiian Rolls should have been sealed all the way when stored. The DM stated the microwave handle and buttons probably got dirty as he made breakfast and lunch that day. The DM stated the deep fryer should be cleaned after each use so it is ready to use the next time it is needed. The DM stated he does not know why the deep fryer was not cleaned after it was last used. The DM stated he was not trained on storing bowls, pots or plates upside down. The DM stated a potential negative outcome for storing the Liquid Steel [NAME] in the food area was the bottle could leak and cause issues if it gets into food. The DM stated microscopic bacteria, dust or allergens could get onto plates and bowls not stored properly and the resident could get sick, cause an allergic reaction or cause fatality. The DM stated cleaning and sanitizing in the kitchen was his top priority. Interview on 11/07/24 at 2:27 PM, the admin stated chemicals should not be stored in food preparation or food storage areas. The admin stated she did not know why the Liquid Steel [NAME] was stored in a food storage area. The admin stated the deep fryer and the microwave should be kept clean and the bowls, plates and pots should be stored properly. The admin stated she expects the kitchen staff to follow their cleaning schedules and keep the kitchen clean. The admin stated all the kitchen staff have been trained on storing items and kitchen cleanliness. The admin stated a potential negative outcome to the residents was a risk for unsanitary conditions. Record review of the facility's policy and procedure title, Food Storage and Supplies dated 2012, reflected the following: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. Procedure: 2. Insecticides, sprays, and cleaning supplies are stored separately from food products and disposable supplies. 4. Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened Record review of the facility's policy and procedure titled, Equipment Sanitation dated 2012, reflected the following: We will provide clean and sanitized equipment for food preparation. The facility will clean all food service equipment in a sanitary manner

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 2 Residents observed for infection control practices (Resident #9, and Resident #231) in that: 1. CNA I failed to use proper hand washing techniques before and after assisting with resident during peri care for Resident #9. CNA I washed her hands for 15 seconds and 17 seconds with soap and friction before rinsing. CNA I used the same paper towel to dry hands to turn off faucet. 2. CNA E and CNA I failed to wash hands prior to gathering peri care supplies. 3. CNA F and CNA E failed to use proper hand washing techniques before, during, and after assisting with Resident #231's peri care. 4. CNA I failed to wash hands or use hand sanitizer prior to gathering peri care supplies 5. CNA E put on a new pair of gloves without washing hands or using hand sanitizer These failures could place residents at risk for infection through cross contamination of pathogens. The findings included: Resident #9: Record Review of Resident #9's face sheet revealed an [AGE] year-old female, admitted on [DATE] with diagnoses of: acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood causing an absence of enough oxygen in the tissues to sustain bodily functions), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), dementia, high blood pressure, heart failure, acid reflux. Record review of Resident #9's Quarterly MDS assessment dated [DATE], revealed Resident #9 had a BIMS Score of 03, meaning Resident #9 had severe cognitive impairment. Under section for Bowel & Bladder listed Resident #9 as always being incontinent for urinary and bowel. Under Skin Conditions listed Resident #9 as being at risk for pressure ulcers but does not currently have pressure ulcers. Record Review of Resident #9's Care Plan dated 08/28/2024 revealed Resident #9 had bowel and urinary incontinence with the interventions of: apply barrier cream after every incontinent episode, provide peri care after each incontinent episode, report any skin change to the nurse immediately, monitor and document intake and output as per facility policy, monitor/document for s/sx of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating habits. During an observation of CNA I providing peri care for Resident #9 on 11/06/2024 at 11:20 am. CNA I failed to wash hands or use hand sanitizer prior to gathering peri care supplies. CNA I washed hands prior to proceeding with peri care. CNA I turned on faucet, and wet hands. CNA I rubbed hands together for 15 seconds and rinsed hands. CNA I used three clean paper towels to dry hands and then used the same paper towel to turn off faucet. CNA I proceeded in providing complete peri care for Resident #9. After CNA provided peri care she discarded used gloves in the trash. CNA washed hands after providing peri care for Resident #9. CNA I turned on water and wet hands. CNA I used two squirts of soap and rubbed hands together for 17 seconds. CNA I used three clean paper towels to dry her hands and then used the same paper towel to turn off faucet. CNA I discarded the used paper towels in the trash. CNA I gathered used laundry and trash and removed from Resident #9's room. During an interview with CNA I on 11/06/2024 at 11:39 AM. CNA I stated that she realized that she should have washed her hands for 20 to 25 seconds and used a clean paper towel to turn off the water faucet. CNA I stated that she had been trained in infection control practices/ hand washing by in-services monthly and proficiency checks every few months. CNA I stated that the DON is responsible for providing training. CNA I stated that the negative potential outcome for not providing adequate hand washing techniques would be the spread of bacteria. Resident #231: Record Review of Resident #231's face sheet revealed a [AGE] year-old male, admitted on [DATE] with diagnoses of: dementia, depression, anxiety, high blood pressure, acid reflux, muscle weakness, amnesia. Record review of Resident #231's Admission MDS assessment dated [DATE], revealed Resident #231 had a BIMS Score of 14, meaning Resident #231 was cognitively intact. Under section for Bowel & Bladder listed Resident #231 as occasionally being incontinent for urinary and bowel. Under Skin Conditions listed Resident #231 as being at risk for pressure ulcers but does not currently have pressure ulcers. Record Review of Resident #231's Care Plan dated 08/28/2024 revealed Resident #231 had urinary incontinence with the interventions of: apply barrier cream after each incontinent episode, monitor/document for s/sx of UTI: pain burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Monitor/document/report to MD as needed medical causing incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, stroke, medication side effects. During an observation on 11/6/2024 at 10:44 am CNA E failed to wash her hands prior to gathering peri care supplies. CNA E and CNA F were providing peri care for Resident #231. CNA F turned on water faucet and wet her hands, used two squirts of soap and used friction for nine seconds and rinsed. CNA F grabbed a clean paper towel to dry her hands and then used the same paper towel to dry hands to turn off the faucet and then discarded the paper towel. CNA E washed hands correctly before beginning peri care. CNA E and CNA F put on clean gloves. CNA E unfastened Resident #231's brief from the front and tucked it up under the resident between the legs. CNA E provided peri care to the front side of Resident #231 by using one swipe per wipe beginning at the top groin, the left groin, and groin area, and then the penis. CNA E discarded each wipe after use. CNA E and CNA F rolled Resident #231 to the right side and removed the remainder of the backside of the brief and discarded in the trash. CNA E removed gloves and discarded in the trash, while CNA F kept the same gloves on. CNA E put on a new pair of gloves without washing hands or using hand sanitizer. CNA E provided peri care to the backside buttocks for Resident #231. CNA E used one wipe per swipe to the buttocks area beginning at the center buttock, right buttock, left buttock. CNA F had to stop and get more wipes during the procedure because Resident #231 was having a bowel movement. CNA F removed gloves and discarded them in the trash. CNA F left the room and came back a few minutes later with more wipes. CNA went to the resident's restroom to wash hands. CNA F turned on faucet and wet hands. CNA F used two squirts of soap to wash hands. CNA F rubbed her hands together for six seconds and then rinsed hands. CNA F used three paper towels to dry hands and used the same paper towel to turn off faucet, then discarded the used paper towels in the trash. CNA F put on clean gloves and proceeded with peri care. CNA E proceeded in using clean wipes to continue wiping the center buttocks. CNA E discarded each wipe in the trash after use. CNA F placed a clean brief underneath Resident #231 and then rolled him on his back and then pulled the remainder of the brief through the front between the legs and then fastened the brief. CNA E and CNA F removed gloves and discarded in the trash. CNA E washed hands correctly after peri care. CNA F turned on the water faucet and wet hands. CNA F used two squirts of soap, rubbed hands together for 5 seconds, and then rinsed hands. CNA F used four clean paper towels to dry hands and then used the same paper towels to turn off faucet. CNA F discarded in the trash. CNA E gathered all trash and used laundry and removed from Resident #231's room. During an interview with CNA E on 11/6/2024 at 4:54 pm. CNA E stated that she had been trained in infection control practices/ hand washing by in-services through verbal communication and the training is monthly. CNA E stated that proficiency checks had been provided every few months. CNA E stated that the negative potential outcome of not washing hands is the spread of bacteria and contamination. During an interview with CNA F on 11/06/2024 at 5:11 PM. CNA F stated that she had been trained in infection control practices/ hand washing approximately every two to three weeks. CNA F stated that she had been trained by proficiency checks monthly. CNA F stated that the policy states to wet hands, scrub, use clean napkins to dry hands, dispose, and grab a new napkin to turn off the faucet. CNA F stated that the policy stated to wash hands for 45 to 60 seconds. CNA F stated that the negative potential outcome of not washing hands correctly is spreading germs and you could spread germs to everyone. During an interview with the DON on 11/07/2024 at 3:09 PM. The DON stated that staff had been trained in infection control practices by in-services monthly and proficiency checks quarterly. The DON stated that she expects staff to provide complete and correct hand washing techniques. The DON stated that the negative potential outcome of not providing hand washing is the spread of infections and germs. During an interview with the Administrator on 11/07/2024 at 4:10 pm revealed that the Administrator expected staff to wash their hands. The Administrator stated that all staff had been trained in hand washing and infection control practices by proficiency checks and in-services and all training is ongoing and regularly quarterly. The Administrator stated that the negative potential outcome is the spread of infection. Record review of the facility policy titled; Hand Washing undated, revealed: We will ensure proper hand washing procedures are utilized. Employees are to frequently perform hand washing as outlined below. Procedure: 2. The hand washing technique is as follows: a. Remove ring and watch if they cannot be sanitized during the hand washing process. b. Turn on water, adjusting to warm temperature and forceful flow. d. Deliver soap in palm. e. Lather up soap. f. Cup fingertips within the palms of the hands and rub vigorously. g. Interlock fingers and work them back and forth and side to side. h. Scrub back of hands, wrists, and lower arms. i. Rinse hands, wrists, and lower arms thoroughly. 3. Dry hands and arms with paper towel, then turn off the faucets with a new paper towel. 4. Discard used paper towels in trash receptacle. Record Review of website for handwashing revealed: US Centers for Disease Control and Prevention. (2024, February 16). About Handwashing. Clean Hands. https://www.cdc.gov/clean-hands/about/index.html Why it's important: Washing hands can keep you healthy and prevent the spread of respiratory and diarrheal infections. Germs can spread from person to person or from surfaces to people. How it works: Washing your hands is easy, and it's one of the most effective ways to prevent the spread of germs. Follow these five steps every time. 1. Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap. 2. Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails. 3. Scrub your hands for at least 20 seconds. Need a timer? Hum the Happy Birthday song from beginning to end twice. 4. Rinse your hands well under clean, running water. 5. Dry your hands using a clean towel or an air dryer

Based on observation, interview and record review, the facility failed to assist the resident in making appointments to ensure residents receive proper treatment and assistive devices to maintain hearing abilities for one of one resident (Resident #47) reviewed for hearing devices. The facility failed to assist Resident #47 in locating missing hearing aids, and did not make an appointment to replace them, leaving Resident #47 to struggle to hear causing Resident #47 to become frustrated and depressed. Staff did not know that Resident #47 had hearing aids and were not assisting him with aids to hear. This failure could place residents at risk for limited social interactions and a decline in hearing. The findings included: Record review of Resident # 47's Face sheet reflected a [AGE] year-old male readmitted to the facility on [DATE] with an initial admitted [DATE]. Diagnoses included dementia, hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone), stroke, depression, vitamin D deficiency, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), high blood pressure, acid reflux. Review of Resident #47's care plan dated 08/10/2023 revealed that Resident #47 was listed as having a communication/hearing deficit and stated that Resident #47 had a hearing deficit due to sensorineural hearing loss. The care plan stated that Resident #47 throws hearing aids away. Interventions listed as: do not cut off or interject when the resident is speaking, if resident has a device to assist them with hearing, encourage them to use it, maintain eye contact while speaking to resident, monitor hearing ability and report any changes to the physician, notify MD/family of any changes, speak in a clear voice and face them when speaking to the resident, the resident uses a hearing aid. Record Review of Resident #47's MDS assessment dated [DATE] revealed that Resident #47 had a BIMS of 3 meaning that Resident #47 had severe cognitive impairment. Under section O of the MDS labeled, Special treatments, Procedures, and Programs, for Speech-Language Pathology and Audiology Services were left blank and incomplete. Under the section titled, Hearing, revealed that Resident #47 was listed as highly impaired for hearing. Under the section titled, Hearing Aid, revealed that Resident #47 was listed as not having a hearing aid. Record Review of Resident #47's Physician Orders dated 11/07/2024 obtained by verbal consent, revealed: assist resident with putting hearing aides on in the am one time a day, assist resident with taking out hearing aids at bedtime. Record Review of Resident #47's Physician Orders as of 11/07/2024 did not indicate an order for hearing aids. During an interview with Resident #47 on 11/05/2024 at 4:12 PM. Resident #47 stated that he could not hear anything. Observed Resident #47 struggling to hear questions from Surveyor by Resident #47 saying, What, I can't hear you. Resident #47 stated that someone took his hearing aids and he had not had his hearing aids since right after coming to the facility. Resident #47 stated that he keeps asking staff about the hearing aids and no one will help. Resident #47 stated that it does not matter what anyone says because Resident #47 can't hear them anyway. During an interview with Resident #47 on 11/06/2024 at 9:39 AM. Resident #47 voiced frustration of not being able to hear and stated that he needs help to get some hearing aids. Resident #47 stated he can not hear what people are saying. Resident #47 stated that he can hear that people are saying something, but he cannot hear the words. Resident #47 stated it makes it hard to do anything. During an attempted interview call with RP for Resident #47 on 11/06/2024 at 10:30 AM. Attempted to make contact with RP to verify if Resident #47 had a hearing aid device. No answer. Left return contact information. No return call. During an observation of Resident #47 on 11/06/2024 at 11:50 AM. Observed CNA E trying to get Resident #47 to the dining room for lunch and CNA E had to talk loudly and Resident #47 struggled to hear what CNA E was saying. Observed CNA E had to repeat herself a couple of times before Resident #47 was able to hear her. During an interview with Social Worker on 11/07/2024 at 9:50 AM. The Social Worker stated that she believes that Resident #47's hearing aids went missing right after Resident #47 got to the facility. The Social Worker stated that Resident #47 came into the facility with hearing aids. The Social Worker stated that Resident #47 will have to wait until the ENT doctor orders the hearing aids at the six-month re-evaluation appointment in order for Medicaid to pay for them. The Social Worker stated that the next appointment for Resident #47 is in February 2025. The Social Worker stated that there is nothing else that they can do until then. During an observation of Resident #47 in activity group in the dining room on 11/07/2024 at 10:52 AM. Observed Resident #47 sitting in activities against the wall and Social Worker assisting with putting hearing aids in Resident #47's ears. During a resident council meeting on 11/07/2024 at 11:00 AM, Resident #47 stated several times that he could not hear. The State Surveyor positioned herself in front of him and spoke louder, however Resident #47 stated several times he could not hear and asked if the service was over. Resident #47 stated he was leaving the meeting because he could not hear and then exited the meeting. Observed that Resident #47 was not wearing hearing aids. During an interview with CNA E on 11/07/2024 at 11:08 AM. CNA E stated that she had not known Resident #47 to ever have hearing aids. CNA E stated that she had worked on D hall for three months and was trained by a former CNA to just raise her voice to talk to Resident #47. CNA E stated that no one in the facility had told her that Resident #47 had to have hearing aids. CNA E observed the new hearing aids that the speech therapist stated she found in Resident #47's room and CNA E stated that she had never seen the hearing aids before. CNA E stated that she knew that Resident #47 could not hear hardly at all but thought that was how it was. During an interview with CNA F on 11/07/2024 at 11:12 AM. CNA F stated that she had worked on D hall for several weeks and was not aware that Resident #47 needed to wear hearing aids. CNA F stated that no one told her that Resident #47 wore hearing aids. CNA F stated that Resident #47 would state that someone took his hearing aids but stated that she had never seen any hearing aids. CNA F stated she had never assisted Resident #47 with hearing aids. CNA F stated that she would have to talk louder and sometimes Resident #47 would still not hear what she said. During an interview with Social Worker on 11/07/2024 at 11:19 AM. The Social Worker stated that she had went and talked to SLP with speech therapy and she had brought those hearing aids to her, stating that she had found them in Resident #47's room. The Social Worker stated that the SLP stated that she had found the hearing aids on top of Resident #47's nightstand. The Social Worker stated that she had helped Resident #47 put them in his ears in the dining room during activities because she believed that he was struggling to hear anything, which would make it difficult to participate in activities. The Social Worker stated that she understands how this could be frustrating for Resident #47. During an attempted interview with RP on 11/07/2024 at 11:27 AM. Attempted to contact RP for Resident #47 with no answer. Left message with return contact information. No return call. During an interview with SLP on 11/07/2024 at 11:40 AM. The SLP stated that the Social Worker came to her and stated that Surveyor was asking questions about Resident #47's hearing aids and no one could find them. The SLP stated that she went to Resident #47's room and found them on his nightstand. The SLP stated that she was not sure why none of the other staff could find them to assist Resident #47 with the devices. The SLP stated that these are the hearing aids that she had known Resident #47 to always have. The SLP stated that she does not see Resident #47 on a day-to-day basis and only evaluated Resident #47 on a quarterly basis. The SLP stated that she had not seen Resident #47 since April 2024. During an interview with CNA D on 11/07/2024 at 11:50 AM. CNA D stated that she had worked on D hall for several months and she had never known Resident #47 to wear hearing aids. CNA D observed the hearing aids that were brought to Resident #47's room and stated that she had never seen the hearing aids before. CNA D stated that she had always known that Resident #47 could not hear hardly at all because he would get really frustrated by it. CNA D stated that she would always just have to talk louder with Resident #47. CNA D stated that she does think that by Resident #47 not having hearing aids would affect the quality of life and cause the resident to become depressed and not want to socialize. During an interview with ADON B on 11/07/2024 at 12:00 PM. ADON B stated that she was not seeing an initial inventory list in Resident #47's medical history file. ADON B stated that she is not sure why this had not been completed but could verify that there was not one. During an interview with ADON C on 11/07/2024 at 12:03 PM. ADON C stated that she was not seeing an initial inventory list in Resident #47's PCC file. ADON C stated that she could also verify that there had not been one completed for Resident #47. During an interview with Resident #47 on 11/07/2024 at 2:12 PM. Resident #47 stated, I got some new hearing aids, Do you see, I can hear now. Resident #47 showed excitement that he could hear by smiling and talking cheerfully. Resident #47 stated that he had not seen these hearing aids before but guessed the facility bought them. Resident #47 stated that it took a long time to get some hearing aids but Resident #47 was glad to be able to hear. During an interview with the DON on 11/07/2024 at 3:09 PM. The DON stated that she did not think that an initial inventory list was ever completed for Resident #47's items upon admission. The DON stated that she was not sure why this had not been done. The DON stated that she had now completed an inventory list of Resident #47's belongings, as of 11/07/2024. The DON stated that she would make sure that the inventory lists are completed from now on. The DON stated that she had just completed an in-service for assisting with hearing aids. The DON stated that she would expect staff to notify someone if they noticed that Resident #47 was struggling to hear. The DON stated that the negative outcome for the resident not being able to hear is that it could be frustrating for him, causing behaviors due to the frustration and that struggling to hear could potentially cause the hearing to get worse. During an interview with the Administrator on 11/07/2024 at 4:09 PM. The Administrator stated that she would expect that staff would assist the resident with putting in the hearing aids, replacing batteries, or cleaning them. The Administrator stated that she would expect that if Resident #47 was struggling with hearing that they would report to the DON, herself, or social services. The Administrator stated that the negative outcome of the resident not being able to hear would be that it could affect all areas of quality of life and communication. Record review of the facility's policy titled, Sensory or Perceptual Alteration (auditory), Revised July 1, 2005, reflected, Change in the characteristics of auditory stimuli to altered sensory reception, transmission, or integration. Assessment may include history of ear disorders, trauma, surgery, and age. Access to basic health care services is the right of every resident and access to information regarding basic services is one essential element of that right. Facility will make provisions to optimize all aspects of resident rights and quality of life issues. Goals: 4. The resident compensates for auditory loss by use of signing, gestures, lip-reading, hearing aid, and other measures. Procedure: 1. Assess the resident upon admission and in conjunction with IDT meetings thereafter. Document any auditory deficits and plan for care accordingly. 3. Determine how to communicate effectively with the resident. You may use gestures, written words, signing, lip-reading, etc. If the resident has a hearing aid, encourage its use. Planned communication with resident improves care delivery. 4. Refer resident to appropriate ancillary services (speech therapy) for evaluation and treatment. Ancillary services have specialty training to facilitate communication with residents experiencing sensory deficits. 5. Ancillary services will facilitate education of staff as necessary with communication techniques and specialty equipment. 6. The physician may refer the resident for evaluation and treatment for sensory deficits. The facility will assist the resident with transfer and treatment compliance issues. 8. Provide sensory stimulation by using tactile and visual stimuli to help compensate for hearing loss. Encourage family to bring familiar objects from home. Sensory stimulation of resident's other senses helps compensate for hearing loss. 10. Make sure other staff members are aware of residents hearing deficit. Record information on resident's medical record and chart cover. This ensures effective nursing care delivery by staff. 12. Educate resident in alternative ways of coping with hearing loss, care of hearing aid, if prescribed, and safety and protective measures to avoid harm or injury (use amplifier or signal devices on telephone, visual cues in environment). Knowledgeable residents will be better able to cope with hearing loss. 15. The facility will provide the resident with a picture communication device and/or communication boards as needed.

Based on the interview and record review, the facility failed to immediately inform the physician and/or Resident/Responsible Party (RP) when there was a need to alter treatment for 1 of 5 residents reviewed for notification of changes. (Residents #1) - The facility failed to notify the physician that Resident #1 had an elevated blood sugar of 501. An IJ was identified on 02/25/23 at 5:02 PM. The IJ template was provided to the facility on [DATE] at 5:05 PM. While the IJ was removed on 02/26/23 at 1:24 PM, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of not having notifications made for health-related issues and could hinder resident treatment. Findings included: Review of Resident #1's face sheet revealed he was an [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of dementia and a secondary diagnosis of type 1 diabetes. Review of Resident #1's admission MDS, dated [DATE], revealed his BIMS was 09, suggesting that the resident's cognitive was moderately impaired. Review of Resident #1's 48-hour baseline care plan, dated 02/20/23, revealed that diabetes management had not been care planned. Review of Resident #1's physician's orders dated 02/27/23 revealed the following order was written on 02/17/23: HumaLOG Subcutaneous Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 59 Give OJ ; 60 - 150 = 0 units; 151 - 200 = 2 units; 201 -250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units; 451+ Call physician, subcutaneously four times a day for diabetes-related to Type 2 Diabetes Mellitus with unspecified diabetic retinopathy . Record Review of Resident #1's Admission Medical Records, dated 02/15/22, listed diabetes mellitus and diabetic retinopathy as active problems and past medical problems. Record review of Resident #1's Admission note, dated 02/18/23, revealed the resident had the a diagnosis of diabetes. Record Review of the Investigative worksheet for intake # 408693 revealed the following: On 2/23/23 [Resident #1] was eating feces and throwing up what appeared to be feces. [LVN H] got orders for a KUB, but the family requested he go out to be evaluated. [LVN H] canceled the KUB and called Non-Emergency transport resident to ER. After calling non-emergency transport,[ LVN H] got a blood sugar of 501 and did not administer insulin per sliding scale orders. [LVN H] reports she reported to EMS that he had a blood sugar of 501 and she had not administered insulin. It was reported that when he arrived to the ER his blood sugar was in the 700s but EMS reported 400s. Record review of Resident #1's progress notes dated 02/23/23, entered by LVN H, revealed the following: LVN H at 11:00 AM spoke with Resident #1's family about sending him out to the ER. LVN H checked Resident #1 blood sugar, and it was 501. The note reflected she reported to the transportation staff his blood sugar and that she had not given him insulin. The progress note reflected the MD Representative was notified that Resident #1 was going to the ER because the family wanted him to and that the KUB would be canceled. The progress note did not specifically indicate the MD Representative was notified of the blood sugar level of 501. Record review of Resident #1 Medication Administration Record, dated 02/25/23, revealed the Resident #1's blood sugar was documented as 149 on 02/23/23 at 07:00 AM which did not require any units of the sliding scale insulin to be given according to the physician's orders. Resident #1's blood sugar was documented as 501 on 02/23/23 at 11:00 AM. The record reflected no documented evidence Humalog subcutaneous solution 100 unit/ML was as administered. Record review of the MD standing order, dated 01/29/21, revealed the following documentation: 10. Sliding Scale insulin greater than 451 10 units , recheck in 30 minutes, if no significant improvement call the physician. On 02/25/23 at 2:31 PM an observation of 5 Humalog insulin injection 100/ml dated 02/21/23 for Resident #1 located in the medication storage room refrigerator. Attempted to obtain hospital records on the following dates and times: 03/01/23 at 4:15 PM and on 03/03/23 at 11:28 PM. An Interview was conducted on 02/25/23 at 10:39 AM LVN J said Resident #1 had not been at the facility for a long time. He said he came in the morning of the incident (02/23/23) to help with coverage. He said his blood sugar was 149 that morning when he checked it. He said Resident #1 did have behaviors where he was smearing feces between 6 AM and 7 AM that morning. He said he addressed the behavior by contacting the MD Representative and getting an order for a medication to calm him. LVN J said that his shift ended and that he left the facility at 8:45 AM. He said he completed all treatments for all of the resident's assigned to him. He said he gave report to the oncoming nurse. He said he specifically reported to LVN H about Reisdent #1's behaviors. He stated Resident #1 was calm and resting in bed when he left. He said Resident #1's blood sugar ran high 300 to 400 regularly. He said they normally had to give him his coverage (sliding scale insulin). He said it was important to always follow the sliding scale. He said there were times when they did not give insulin, but it was because they were following the sliding scales or an actual order from the physician. He said a potential negative outcome was a resident could go into a diabetic coma. He stated during that, the resident was at risk of organ failure and also at risk of becoming septic (the body's extreme response to infection). He said blood sugar was fragile because it could quickly transition either way. An Interview was conducted on 02/25/23 at 10:58 AM LVN I said she did not have any specific information regarding the incident with Resident #1 but that as a nurse the sliding scale is always followed. She said the MD is notified if a resident's blood sugar is above the parameters or below what is listed in the orders. She said when notifying the MD she should receive additional instructions to treat the information she reported. An Interview was conducted on 02/25/23 at 11:09 AM, the Administrator stated LVN H is new. She said she was told by LVN H on 02/24/23 that she did not give the insulin because Resident #1 had not eaten and was throwing up. When asked why she reported the incident as neglect, she said when the MD Representative called and reported that she had not been notified that Resident #1 blood sugar was 501 and the insulin should have been given, she took it that the MD representative was alleging that the resident had not been adequately taken care of. She said after interviewing LVN H, the nurse did well with notifying the family, the MD Representative, and the transport staff. She said she expected the nursing staff to follow all physician orders. An Interview was conducted on 02/25/23 at 11:57 AM the MD Representative said she was the MD's nurse and was the equivalent of notifying the doctor. She said LVN J called first on 02/23/23 (time not disclosed) and wanted an order for Ativan to settle him down because he was exhibiting behaviors. She said she was told he was digging in his brief and painting the walls with his feces. She said LVN H called her later on 02/23/23 (time not disclosed) and told her she thought he was vomiting feces, which sounded like a bowel obstruction . The MD Representative said LVN H never mentioned that Resident #1 had an elevated blood sugar. The MD Representative said she was concerned that LVN H called an ambulance agency and not EMS or 911. The MD Representative said if notified, she would have told LVN H to go by the sliding scale and notified the doctor about the elevated blood sugar. She said the facility had standing orders that instructed the staff to notify the MD if the blood sugar was outside the sliding scale parameters. She said Resident #1 would have continued to be confused without insulin administration. She said if a blood sugar exceeded 451, they were to give 10 units of short-acting insulin but was not for sure because she did not have the orders in front of her at the time of the interview. She stated there is a standing order at the facility. She stated none of that was done that she was aware of. When asked what the potential negative outcome would be for not administering the insulin to a resident with an elevated blood sugar, she said it was hard to answer because it can be different individually. She said some people lose consciousness or can experience metabolic acidosis due to diabetes. She said acidosis could affect several body parts, such as the kidneys and mental status. She said it could build up toxins in the body. She said the elevated blood sugar could have caused the vomiting. She said LVN H should have known to treat the blood sugar. She said the lack of insulin contributes to the admitting diagnosis. She said if they had given his insulin, that would have started the blood sugar coming down but doing nothing did not help the resident. The MD representative said that she was not notified about Resodent #1 blood sugar level until after his admission in the hospital. She said that she had limited access to the hospital medical recor and this is how she was aware that the resident's blood sugar was at 749 when he arrived at the hospital. An Interview was conducted on 02/25/23 at 1:57 PM, LVN H stated she had been a nurse since 1990 and had been trained in dealing with residents with diabetes. She said she took over Resident #1 from LVN J around 10:15 AM or 10:30 AM on 02/23/23 She stated she was told by LVN J that Resident #1 had been throwing up and had not had breakfast. She said LVN J reported Resident #1's blood sugar was 147 at 7:00 AM that day. LVN H said it was reported to her that Resident #1 vomit appeared like poop. She stated she observed Resident #1's vomit. She stated it was dark and resembled coffee grounds. She stated she notified Resident #1's family. She said the family wanted Resident #1 to go the ER. She said she checked Resident #1 insulin between 11:15 AM and 11:20 AM. She stated his blood sugar was 501. She stated she notified the MD Representative shortly after she checked the blood sugar. She stated she was still determining the exact time but believed it was 7 to 8 minutes after she took the resident blood sugar is when she called and notified the MD representative of Resident #1 blood sugar level. When asked what the representative said when she told her about the elevated blood sugar, she said the representative said, Oh, okay. She said she had already called the non-emergency transportation before she checked Resident #1 blood sugar. She said she is unsure why she called the non-emergency transportation vs. the emergency transportation. She said at that time she did not think it was an emergency. She said Resident #1 family was okay with her not giving the insulin. She said it seemed like the non-emergency transportation was taking a long time, so she called them twice. She said the resident waited 40- 45 minutes. She said she checked his blood sugar because the family had requested it, but because it would have been the scheduled time to check it. She said it was her decision not to administer the insulin. She said she was afraid that he would bottom out. She said Resident #1 had not had any food that day and that it concerned her. When asked to explain bottom out, she said that happens when a resident's blood sugar exceeds 60. She said the physician must be the one to determine whether insulin should be held if the resident's blood sugar is outside of the parameters of the sliding scale. She said she further told the MD Representative she was holding the insulin and canceling the KUB . She said she told the MD Representative she was sending Resident #1 out because of his vomiting and she had concerns about bowel obstruction. She stated when Resident #1 was picked up by the non-emergency transportation she told them he had a blood sugar level of 500 and that she had not given him the sliding scale insulin. She stated in hindsight that she should have given the insulin and at blood sugar levels of 501 and that was a dangerous level and should have been an emergent situation but that she did not call 911 because the non emergency transport said they were near the facility. Record review of the facility's policy, Glucometer, revised 02/13/2007, revealed the following documentation: Abnormal Results 1. Notify the physician if the blood glucose is outside of any physician-specific parameters and implement any new orders prescribed. Record review of the facility's policy, Guidelines for notifying Physicians of Clinical Problems , dated 02/2014, revealed the following: Overview These guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record. When contacting the practitioner, especially at night and on weekends the nurse should have the following information available: 1. Detailed description of current issues or problems, including a chronological story story of symptoms and treatment to date, On 02/25/23 at 5:02 PM, the Administrator was notified that the facility would be placed in immediate jeopardy status due to failure to administer Resident #`1 sliding scale insulin when the resident blood sugar was outside the parameters . Record Review of the POR submitted by the Administrator revealed the following: 02/25/2023 Plan of Removal- Quality of Care Interventions: 100% blood sugar audit in progress Physician will be notified of all blood sugars outside the parameters The following in-services were initiated 02/24/2023 by Admin: Any nurse not present or in-serviced on 2/25/23 will not be allowed to assume their duties until in-serviced: o Following facility policy for hypoglycemia located in the Glucometer policy: o Following facility policy for hyperglycemia located in the Glucometer policy: o Staff in-service on utilization of SBARs and E-transfers (SBAR includes change of condition, notification to physician/family, and new orders if applicable) o Staff in-service on following physician orders and not deviating from orders unless directed by physician. Notify the physician if the blood glucose is outside of any physician specific parameters and implement any new orders as prescribed. o In-Service nursing staff that any transport going to the emergency room will be 911. There will be no non emergent transports when going to the emergency room . Abnormal Results-see glucometer policy If the resident is unresponsive, notify emergency medical services. Notified Medical Director of IJ situation on 2/25/23 at 6:06 PM. Monitoring: ADMIN/ADON/Regional Compliance/Designee will review 5-8 residents sliding scale results for proper notification to MD if outside parameters weekly x 4 weeks. ADMIN/ADON/Regional Compliance/Designee will monitor all blood sugars outside parameters of sliding scale for notification to MD weekly x 4 weeks. Regional Compliance Nurse will review ADMIN/DON/Designee for monitoring compliance weekly x 4 weeks. The QA Committee will review findings and Physician Notification Policy and will make changes as needed monthly. On 03/26/23, the surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Record review of Resident #2 electronic medical record conducted and revealed there were no discrepancies for sliding scale insulin orders. Record review of Resident #3 electronic medical record conducted and revealed there were no discrepancies for sliding scale insulin orders. Record review of LVN H's Certificate of Completion , dated 02/24/23, reflected she had a satisfactory completion of Preparing and Administering insulin. Record review of LVN H Certificate of Completion , dated 02/24/23, reflected she had a satisfactory completion of Insulin Administration. Record review of the facility's signature sheet and in-service, High and Low Blood Sugars CNA Protocol, dated 02/26/23, reflected the in-service instructed CNAs were instructed to monitor the resident's baseline and notify nurses of any change in symptoms. Record review of the facility's signature sheet and in-service, Emergency vs. Non-Emergency Transportation, dated 02/26/23, reflected the in-service instructed facility staff that if any resident was being sent to the emergency room for any reason, then 911 emergency transport should be used. Record review of the facility's signature sheet and in-service on hyperglycemia, dated 02/25/23 reflected the several factors that could contribute to hyperglycemia in people with diabetes. It listed early symptoms and unrelated symptoms such as headache, blurred vision, frequent urination, and fatigue. It listed the negative outcomes if hyperglycemia was untreated. The outcomes included abdominal pain, shortness of breath, fruity-smelling breath, coma, nausea and vomiting, dry mouth, weakness, and confusion. An Interview was conducted on 02/26/23 at 3:39 PM, LVN F said she had received additional training before she was allowed to work. She reported if a resident's blood sugar were outside of the sliding scale parameters, she was trained to contact the physician and follow the physician's orders. She said she was trained to stay within the physician's orders. She said if she reports concerns regarding a resident, she has been trained to document the response of the MD. She stated if the resident's elevated blood sugar is not addressed, it can result in a coma. She said she feels competent in the facility's expectations regarding blood sugars, MD notification, following physician orders, and deciphering between emergency vs. non-emergency situations. An Interview was conducted on 02/26/23 at 3:23 PM the MD said he was not notified about the elevated blood sugar until after the resident was already admitted to the hospital. He said he was told that he was not notified because transportation was already there to pick up the resident. He stated he could not remember who notified him and when they notified him but that he was notified after the resident was admitted into the hospital. He said if he had been notified he would have instructed the staff to follow the sliding scale . He said without giving insulin, there is increased confusion. In addition, he said it places the resident at risk for dehydration, infection, and renal failure. He said even if the resident has not eaten, he would have instructed the sliding scale insulin to be given because, with elevated blood sugar at 500, there is no concern that it will go too low. An Interview was conducted on 02/26/23 at 3:39 PM LVN F said she was not allowed to work until she was in-serviced. She said she was never trained to go outside the physician's orders. She said she was trained to report the information to the MD and wait for additional instructions if blood sugar levels were outside the sliding scale parameters. She said she was competent in the facility's expectations regarding blood sugars, MD notification, following physician's orders, and deciphering between emergency vs. non-emergency situations. An Interview was conducted on 02/26/23 at 3:58 PM, RN C said she had received additional training before being allowed to work. She said she would never deviate outside of physician's orders. She said emergency transportation should be used if a resident needed to go to the emergency room . She said elevated blood sugars outside of the sliding scale ranges should be reported to the physician for additional instructions. She said she feels competent in the facility's expectations regarding blood sugars, MD notification, following physician orders, and deciphering between emergency vs. non-emergency situations. An Interview was conducted on 02/27/23 at 9:31 AM LVN D said she had been trained prior to work about blood sugar expectations. She said she were supposed to notify the MD if there are concerns with blood sugar levels. She said she was to never deviate outside the physician's orders for any reason. She said if physician's orders are not followed, the worst that could happen would be the resident could go into a coma and die. She said she feels competent in the facility's expectations regarding blood sugars, MD notification, following physician orders, and deciphering between emergency vs. non-emergency situations. An Interview was conducted on 02/27/23 at 9:39 AM LVN C She said she was trained before working her shift. She said she was instructed but already knew to stay within the physician's orders. She said blood sugar levels outside the sliding scale parameters should be reported to the physician. She said if the physician did not respond appropriately with clear, concise instructions, she would clarify to ensure she was heard. She said she feels competent in the facility's expectations regarding blood sugars, MD notification, following physician orders, and deciphering between emergency vs. non-emergency situations. An Interview was conducted on 02/27/23 at 9:50 AM, LVN B said she was trained before her shift about the importance of blood sugar levels. She said they were trained to notify the MD if the blood sugar level was too high or too low. She said if a resident has to go to the ER, non-emergency transport should not be used. She said she is required to document the response of the MD when they notify them of a change in the resident's condition. She said she feels competent in the facility's expectations regarding blood sugars, MD notification, following physician orders, and deciphering between emergency vs. non-emergency situations. An interview was conducted on 03/09/23 at 11:19 AM with LVN H. When asked why she did not document her conversation in detail with the MD representative specifically about notification of the blood sugar, she said: Things were happing so fast, and at the moment I was like, oh ok She said at that time she did not think to ask further information or clarification on what to do When asked had she been trained before the incident to document detailed notifications of MD instructions she said as a nurse she had been trained but not specifically by the facility. She said she was unaware of their process at that time for documentation. When asked about her experience as a nurse, what has she been taught about information that was not documented, and what does that mean? She said it would mean it was not done. A negative outcome could be not following the doctor's orders or knowing what was said. She said she was trained to contact the MD representative Monday-Friday 8-5, and then the MD Representative would contact the MD or the MD assistant. She said she was trained not to contact the MD directly. She said she was unaware that standing orders were available at the facility. She said at the previous facility, she was trained not to use the standing orders and to still notify the physician. An interview was conducted on 03/09/23 at 11:28 with the Administrator. When asked what her expectation of documentation of notifications was, she said they would document if there were any new orders and follow up with the orders. When asked about her experience as an administrator and what she was taught regarding information that is not documented and she said if it was not documented, it was not done. She said she did send the phone records of LVN H to HHSC but clarified that those records would not indicate the content of the calls. She said that based on the progress note entered in the electronic medical chart provided to the surveyor, she would not be able to tell if the MD was notified of the elevated blood sugar. She said that the MD was notified that day but not before leaving. She said that she expected the MD to be notified before the resident went to the ER. An interview was conducted on 03/09/23 at 11:47 AM with the MD representative. She said on 02/23/23, LVN H did not give her a detailed description of Resident #1 current issue with elevated blood sugar. She said the facility has standing orders is what the facility has on hand and what they have on anyone so that the MD does not have to call for everything. She said in the previous interview when she said she would have instructed LVN H to give the 10 units; she knew this exact amount because the facility has a standing order for sliding scale insulin, and that is what should have been followed on 02/23/23 when Resident #1 blood sugar was elevated to 501. When asked which order should be followed if the standing order differs from what is in the resident's electronic medical record, she said that the orders shouldn't have been different. She said the sliding scale order had been the same for a long time. She said she was not sure who entered the information on the facility. She said she does not review the orders once given to the facility. An interview was conducted on 03/09/23 at 6:08 PM with the MD, and when asked for clarification about the sliding scale order for Resident #1, he said that the sliding scale order should have been the same as the standing order. He said he did not know why the order on the computer would be different. He said the only reason the standing order would not match what was in the electronic medical record would be if the resident was under a different doctor and then came to the doctor. He said he was the attending doctor, and the orders should have matched. He said his standing order for sliding scale insulin was any blood sugar level over 451, 10 units would have been given, and after 30 minutes, if there were no changes, he should have been notified. On 02/25/23 at 5:06 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/26/23 at 4:14 PM, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on records reviews, and interviews, the facility failed to ensure that its residents are free of any significant medication errors for one (Resident #1) of five residents reviewed for medication review. 1.LVN H failed to give Resident #1 sliding scale insulin when his blood sugar levels were noted at 501, greater than the 451 listed in the physician's orders. As a result, resident #1 blood sugar level continued to increase from 501 to 749, contributing to his emergency admission diagnosis of DKA. An IJ was identified on 02/25/23 at 5:02 PM. The IJ template was provided to the facility on [DATE] at 5:05 PM. While the IJ was removed on 02/26/23 at 1:24 PM, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The failure placed the resident at risk of elevated blood sugars and potential risk for worsening conditions, including metabolic acidosis (production of too much acid in the body) and or death. Findings include: Review of Resident #1's face sheet revealed he was an [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of dementia and a secondary diagnosis of type 1 diabetes. Review of Resident #1's admission MDS, dated [DATE], revealed his BIMS was 09, suggesting that the resident's cognitive was moderately impaired. Review of Resident #1's 48-hour baseline care plan, dated 02/20/23, revealed that diabetes management had not been care planned. Review of Resident #1's physician's orders dated 02/27/23 revealed the following order was written on 02/17/23: HumaLOG Subcutaneous Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 59 Give OJ ; 60 - 150 = 0 units; 151 - 200 = 2 units; 201 -250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units; 451+ Call physician, subcutaneously four times a day for diabetes-related to Type 2 Diabetes Mellitus with unspecified diabetic retinopathy . Record Review of Resident #1's Admission Medical Records, dated 02/15/22, listed diabetes mellitus and diabetic retinopathy as active problems and past medical problems. Record review of Resident #1's Admission note, dated 02/18/23, revealed the resident had the a diagnosis of diabetes. Record Review of the Investigative worksheet for intake # 408693 revealed the following: On 2/23/23 [Resident #1] was eating feces and throwing up what appeared to be feces. [LVN H] got orders for a KUB, but the family requested he go out to be evaluated. [LVN H] canceled the KUB and called Non-Emergency transport resident to ER. After calling non-emergency transport,[ LVN H] got a blood sugar of 501 and did not administer insulin per sliding scale orders. [LVN H] reports she reported to EMS that he had a blood sugar of 501 and she had not administered insulin. It was reported that when he arrived to the ER his blood sugar was in the 700s but EMS reported 400s. Record review of Resident #1's progress notes dated 02/23/23, entered by LVN H, revealed the following: LVN H at 11:00 AM spoke with Resident #1's family about sending him out to the ER. LVN H checked Resident #1 blood sugar, and it was 501. The note reflected she reported to the transportation staff his blood sugar and that she had not given him insulin. The progress note reflected the MD Representative was notified that Resident #1 was going to the ER because the family wanted him to and that the KUB would be canceled. The progress note did not specifically indicate the MD Representative was notified of the blood sugar level of 501. Record review of Resident #1 Medication Administration Record, dated 02/25/23, revealed the Resident #1's blood sugar was documented as 149 on 02/23/23 at 07:00 AM which did not require any units of the sliding scale insulin to be given according to the physician's orders. Resident #1's blood sugar was documented as 501 on 02/23/23 at 11:00 AM. The record reflected no documented evidence Humalog subcutaneous solution 100 unit/ML was as administered. Record review of the MD standing order, dated 01/29/21, revealed the following documentation: 10. Sliding Scale insulin greater than 451 10 units , recheck in 30 minutes, if no significant improvement call the physician. On 02/25/23 at 2:31 PM an observation of 5 Humalog insulin injection 100/ml dated 02/21/23 for Resident #1 located in the medication storage room refrigerator. Attempted to obtain hospital records on the following dates and times: 03/01/23 at 4:15 PM and on 03/03/23 at 11:28 PM. An Interview was conducted on 02/25/23 at 10:39 AM LVN J said Resident #1 had not been at the facility for a long time. He said he came in the morning of the incident (02/23/23) to help with coverage. He said his blood sugar was 149 that morning when he checked it. He said Resident #1 did have behaviors where he was smearing feces between 6 AM and 7 AM that morning. He said he addressed the behavior by contacting the MD Representative and getting an order for a medication to calm him. LVN J said that his shift ended and that he left the facility at 8:45 AM. He said he completed all treatments for all of the resident's assigned to him. He said he gave report to the oncoming nurse. He said he specifically reported to LVN H about Reisdent #1's behaviors. He stated Resident #1 was calm and resting in bed when he left. He said Resident #1's blood sugar ran high 300 to 400 regularly. He said they normally had to give him his coverage (sliding scale insulin). He said it was important to always follow the sliding scale. He said there were times when they did not give insulin, but it was because they were following the sliding scales or an actual order from the physician. He said a potential negative outcome was a resident could go into a diabetic coma. He stated during that, the resident was at risk of organ failure and also at risk of becoming septic (the body's extreme response to infection). He said blood sugar was fragile because it could quickly transition either way. An Interview was conducted on 02/25/23 at 10:58 AM LVN I said she did not have any specific information regarding the incident with Resident #1 but that as a nurse the sliding scale is always followed. She said the MD is notified if a resident's blood sugar is above the parameters or below what is listed in the orders. She said when notifying the MD she should receive additional instructions to treat the information she reported. An Interview was conducted on 02/25/23 at 11:04 AM RN B said she did not have any specific information regarding Resident #1 but blood sugar levels are very serious, and nursing staff must make sure they are giving insulin orders as prescribed because it could affect the resident to the point of placing them in a coma. However, she said there is no reason not to give the insulin if it is prescribed. An Interview was conducted on 02/25/23 at 11:09 AM, the Administrator stated LVN H is new. She said she was told by LVN H on 02/24/23 that she did not give the insulin because Resident #1 had not eaten and was throwing up. When asked why she reported the incident as neglect, she said when the MD Representative called and reported that she had not been notified that Resident #1 blood sugar was 501 and the insulin should have been given, she took it that the MD representative was alleging that the resident had not been adequately taken care of. She said after interviewing LVN H, the nurse did well with notifying the family, the MD Representative, and the transport staff. She said she expected the nursing staff to follow all physician orders. An Interview was conducted on 02/25/23 at 11:35 AM, RN A said he did not have any information regarding Resident #1. She stated however, when asked if there is any instance where an elevated blood sugar would not be treated if the blood sugar is showing to be 500 or more, he said he would have given the prescribed sliding scale insulin because the blood sugar is at 500, and at that level, the resident could go into DKA. He said that is risky for the resident and could result in death. An Interview was conducted on 02/25/23 at 11:57 AM the MD Representative said she was the MD's nurse and was the equivalent of notifying the doctor. She said LVN J called first on 02/23/23 (time not disclosed) and wanted an order for Ativan to settle him down because he was exhibiting behaviors. She said she was told he was digging in his brief and painting the walls with his feces. She said LVN H called her later on 02/23/23 (time not disclosed) and told her she thought he was vomiting feces, which sounded like a bowel obstruction . The MD Representative said LVN H never mentioned that Resident #1 had an elevated blood sugar. The MD Representative said she was concerned that LVN H called an ambulance agency and not EMS or 911. The MD Representative said if notified, she would have told LVN H to go by the sliding scale and notified the doctor about the elevated blood sugar. She said the facility had standing orders that instructed the staff to notify the MD if the blood sugar was outside the sliding scale parameters. She said Resident #1 would have continued to be confused without insulin administration. She said if a blood sugar exceeded 451, they were to give 10 units of short-acting insulin but was not for sure because she did not have the orders in front of her at the time of the interview. She stated there is a standing order at the facility. She stated none of that was done that she was aware of. When asked what the potential negative outcome would be for not administering the insulin to a resident with an elevated blood sugar, she said it was hard to answer because it can be different individually. She said some people lose consciousness or can experience metabolic acidosis due to diabetes. She said acidosis could affect several body parts, such as the kidneys and mental status. She said it could build up toxins in the body. She said the elevated blood sugar could have caused the vomiting. She said LVN H should have known to treat the blood sugar. She said the lack of insulin contributes to the admitting diagnosis. She said if they had given his insulin, that would have started the blood sugar coming down but doing nothing did not help the resident. The MD representative said that she was not notified about Resodent #1 blood sugar level until after his admission in the hospital. She said that she had limited access to the hospital medical recor and this is how she was aware that the resident's blood sugar was at 749 when he arrived at the hospital. An Interview was conducted on 02/25/23 at 12:36 PM, the Hospital RN said Resident #1's admitting diagnosis was DKA. He said the lack of insulin could contribute to the diagnosis. He said the failure to give the resident insulin would allow his blood sugar to rise, which can become very dangerous for the resident. He said he was not clear on the surrounding events that led Resident #1 to be admitted , but it was his understanding that there was no insulin available at the facility that he resided at. He said the resident blood sugar level was noted as 749 when he was admitted . He said the sliding scale insulin is vital to prescribed residents because it means the long-lasting insulin is not enough, and they need the sliding scale insulin to maintain. He said with a blood sugar as high as 500 there should have been no concerns with his blood sugar going too low. He stated when a resident reaches the level of DKA it becomes complex to treat. He said DKA is treated with an IV drip and requires constant insulin and hourly monitoring because during the process the resident is at high risk of going either way regarding blood sugar levels. He said in his experience, even if a resident has not eaten when blood sugars reach that level, then the sliding scale insulin should be given, and the physician notified. He said to have high blood sugar it is odd that the resident's blood sugar was elevated. He said failure to give the sliding scale insulin at such elevated blood sugar levels could cause at the very worst DKA, coma, or death, but that it can also cause vomiting. An Interview was conducted on 02/25/23 at 12:46 PM, the Hospital MD said she was not the admitting MD but had treated Resident #1 since he had been at the hospital. She said it is her understanding that Resident #1 was given long-acting insulin but not his sliding-scale insulin and when he arrived his blood sugar level was 749. She said his admitting diagnosis (DKA) was the only issue they found since he was hospitalized . She said there were no signs of infection. However, she said with his diagnosis of dementia and the medications he is on could cause constipation and that may have explained the vomiting. She stated in her experience she would have encouraged giving the sliding scale insulin even if he had not eaten because the high blood sugar needed to be addressed. When asked about the potential negative outcome of not giving insulin, she said, He could end up in a condition the way he is now and how he came to us. She said he came in with elevated blood sugar which required him to be admittted to medical ICU and on an insulin drip that focused on lowering his blood sugar to safer levels. An Interview was conducted on 02/25/23 at 12:53 PM Family Member A said she was aware that Resident #1 did not have insulin given to him and that his blood sugar tested high. She said she was told by Family Member B the reason the insulin was not given was that the nurse ( LVN H) did not want to interfere with the treatment that the ER would give. An Interview was conducted on 02/25/23 at 12:56 PM, Resident #1 said he did not know why he was at the hospital. He was unable to answer any questions that were asked accurately. He was not oriented to time and place. An Interview was conducted on 02/25/23 at 1:33 PM Family Member B said she was aware Resident #1 was admitted to the hospital with the diagnosis of DKA, and she knew Resident #1 was not given his sliding scale insulin. She said she was told by LVN H that she did not administer any insulin because she did not want to interfere with the treatment the EMS workers would give. She said the facility knew Resident #1 was a brittle diabetic . She said during admission she explained he needed his blood sugar checked at least 4 times a day. She said he never became acclimated to the nursing facility, which was traumatic for him. She said Resident #1, waited 45 minutes for transportation to the ER from the time his blood sugar was tested until he was picked up from the facility. An Interview was conducted on 02/25/23 at 1:57 PM, LVN H stated she had been a nurse since 1990 and had been trained in dealing with residents with diabetes. She said she took over Resident #1 from LVN J around 10:15 AM or 10:30 AM on 02/23/23 She stated she was told by LVN J that Resident #1 had been throwing up and had not had breakfast. She said LVN J reported Resident #1's blood sugar was 147 at 7:00 AM that day. LVN H said it was reported to her that Resident #1 vomit appeared like poop. She stated she observed Resident #1's vomit. She stated it was dark and resembled coffee grounds. She stated she notified Resident #1's family. She said the family wanted Resident #1 to go the ER. She said she checked Resident #1 insulin between 11:15 AM and 11:20 AM. She stated his blood sugar was 501. She stated she notified the MD Representative shortly after she checked the blood sugar. She stated she was still determining the exact time but believed it was 7 to 8 minutes after she took the resident blood sugar is when she called and notified the MD representative of Resident #1 blood sugar level. When asked what the representative said when she told her about the elevated blood sugar, she said the representative said, Oh, okay. She said she had already called the non-emergency transportation before she checked Resident #1 blood sugar. She said she is unsure why she called the non-emergency transportation vs. the emergency transportation. She said at that time she did not think it was an emergency. She said Resident #1 family was okay with her not giving the insulin. She said it seemed like the non-emergency transportation was taking a long time, so she called them twice. She said the resident waited 40- 45 minutes. She said she checked his blood sugar because the family had requested it, but because it would have been the scheduled time to check it. She said it was her decision not to administer the insulin. She said she was afraid that he would bottom out. She said Resident #1 had not had any food that day and that it concerned her. When asked to explain bottom out, she said that happens when a resident's blood sugar exceeds 60. She said the physician must be the one to determine whether insulin should be held if the resident's blood sugar is outside of the parameters of the sliding scale. She said she further told the MD Representative she was holding the insulin and canceling the KUB . She said she told the MD Representative she was sending Resident #1 out because of his vomiting and she had concerns about bowel obstruction. She stated when Resident #1 was picked up by the non-emergency transportation she told them he had a blood sugar level of 500 and that she had not given him the sliding scale insulin. She stated in hindsight that she should have given the insulin and at blood sugar levels of 501 and that was a dangerous level and should have been an emergent situation but that she did not call 911 because the non emergency transport said they were near the facility. Record review of the facility's policy, Glucometer, revised 02/13/2007, revealed the following documentation: Abnormal Results 1. Notify the physician if the blood glucose is outside of any physician-specific parameters and implement any new orders prescribed. Record review of the facility's policy, Guidelines for notifying Physicians of Clinical Problems , dated 02/2014, revealed the following: Overview These guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record. When contacting the practitioner, especially at night and on weekends the nurse should have the following information available: 1. Detailed description of current issues or problems, including a chronological story story of symptoms and treatment to date, Record Review of the facility's policy, Nursing Care of the Resident with Diabetes Mellitus, dated 05/07/23 revealed: Glucose Monitoring (1) The management of individuals with diabetes mellitus should follow physician's orders. .(5) Approximate reference ranges for hypoglycemia (high blood sugar) are: 1. Mild hypoglycemia 55-70 mg/dl 2. Moderate hypoglycemia 40-55 mg/dl 3. Severe hypoglycemia <40 mg/dl. On 02/25/23 at 5:02 PM, the Administrator was notified that the facility would be placed in immediate jeopardy status due to failure to administer Resident #`1 sliding scale insulin when the resident blood sugar was outside the parameters . Record Review of the POR submitted by the Administrator revealed the following: 02/25/2023 Plan of Removal- Quality of Care Interventions: 100% blood sugar audit in progress Physician will be notified of all blood sugars outside the parameters The following in-services were initiated 02/24/2023 by Admin: Any nurse not present or in-serviced on 2/25/23 will not be allowed to assume their duties until in-serviced: o Following facility policy for hypoglycemia located in the Glucometer policy: o Following facility policy for hyperglycemia located in the Glucometer policy: o Staff in-service on utilization of SBARs and E-transfers (SBAR includes change of condition, notification to physician/family, and new orders if applicable) o Staff in-service on following physician orders and not deviating from orders unless directed by physician. Notify the physician if the blood glucose is outside of any physician specific parameters and implement any new orders as prescribed. o In-Service nursing staff that any transport going to the emergency room will be 911. There will be no non emergent transports when going to the emergency room . Abnormal Results-see glucometer policy If the resident is unresponsive, notify emergency medical services. Notified Medical Director of IJ situation on 2/25/23 at 6:06 PM. Monitoring: ADMIN/ADON/Regional Compliance/Designee will review 5-8 residents sliding scale results for proper notification to MD if outside parameters weekly x 4 weeks. ADMIN/ADON/Regional Compliance/Designee will monitor all blood sugars outside parameters of sliding scale for notification to MD weekly x 4 weeks. Regional Compliance Nurse will review ADMIN/DON/Designee for monitoring compliance weekly x 4 weeks. The QA Committee will review findings and Physician Notification Policy and will make changes as needed monthly. On 03/26/23, the surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Record review of Resident #2 electronic medical record conducted and revealed there were no discrepancies for sliding scale insulin orders. Record review of Resident #3 electronic medical record conducted and revealed there were no discrepancies for sliding scale insulin orders. Record review of LVN H's Certificate of Completion , dated 02/24/23, reflected she had a satisfactory completion of Preparing and Administering insulin. Record review of LVN H Certificate of Completion , dated 02/24/23, reflected she had a satisfactory completion of Insulin Administration. Record review of the facility's signature sheet and in-service, High and Low Blood Sugars CNA Protocol, dated 02/26/23, reflected the in-service instructed CNAs were instructed to monitor the resident's baseline and notify nurses of any change in symptoms. Record review of the facility's signature sheet and in-service, Emergency vs. Non-Emergency Transportation, dated 02/26/23, reflected the in-service instructed facility staff that if any resident was being sent to the emergency room for any reason, then 911 emergency transport should be used. Record review of the facility's signature sheet and in-service on hyperglycemia, dated 02/25/23 reflected the several factors that could contribute to hyperglycemia in people with diabetes. It listed early symptoms and unrelated symptoms such as headache, blurred vision, frequent urination, and fatigue. It listed the negative outcomes if hyperglycemia was untreated. The outcomes included abdominal pain, shortness of breath, fruity-smelling breath, coma, nausea and vomiting, dry mouth, weakness, and confusion. An Interview was conducted on 02/26/23 at 3:39 PM, LVN F said she had received additional training before she was allowed to work. She reported if a resident's blood sugar were outside of the sliding scale parameters, she was trained to contact the physician and follow the physician's orders. She said she was trained to stay within the physician's orders. She said if she reports concerns regarding a resident, she has been trained to document the response of the MD. She stated if the resident's elevated blood sugar is not addressed, it can result in a coma. She said she feels competent in the facility's expectations regarding blood sugars, MD notification, following physician orders, and deciphering between emergency vs. non-emergency situations. An Interview was conducted on 02/26/23 at 3:23 PM the MD said he was not notified about the elevated blood sugar until after the resident was already admitted to the hospital. He said he was told that he was not notified because transportation was already there to pick up the resident. He stated he could not remember who notified him and when they notified him but that he was notified after the resident was admitted into the hospital. He said if he had been notified he would have instructed the staff to follow the sliding scale . He said without giving insulin, there is increased confusion. In addition, he said it places the resident at risk for dehydration, infection, and renal failure. He said even if the resident has not eaten, he would have instructed the sliding scale insulin to be given because, with elevated blood sugar at 500, there is no concern that it will go too low. An Interview was conducted on 02/26/23 at 3:39 PM LVN F said she was not allowed to work until she was in-serviced. She said she was never trained to go outside the physician's orders. She said she was trained to report the information to the MD and wait for additional instructions if blood sugar levels were outside the sliding scale parameters. She said she was competent in the facility's expectations regarding blood sugars, MD notification, following physician's orders, and deciphering between emergency vs. non-emergency situations. An Interview was conducted on 02/26/23 at 3:58 PM, RN C said she had received additional training before being allowed to work. She said she would never deviate outside of physician's orders. She said emergency transportation should be used if a resident needed to go to the emergency room . She said elevated blood sugars outside of the sliding scale ranges should be reported to the physician for additional instructions. She said she feels competent in the facility's expectations regarding blood sugars, MD notification, following physician orders, and deciphering between emergency vs. non-emergency situations. An Interview was conducted on 02/27/23 at 9:31 AM LVN D said she had been trained prior to work about blood sugar expectations. She said she were supposed to notify the MD if there are concerns with blood sugar levels. She said she was to never deviate outside the physician's orders for any reason. She said if physician's orders are not followed, the worst that could happen would be the resident could go into a coma and die. She said she feels competent in the facility's expectations regarding blood sugars, MD notification, following physician orders, and deciphering between emergency vs. non-emergency situations. An Interview was conducted on 02/27/23 at 9:39 AM LVN C She said she was trained before working her shift. She said she was instructed but already knew to stay within the physician's orders. She said blood sugar levels outside the sliding scale parameters should be reported to the physician. She said if the physician did not respond appropriately with clear, concise instructions, she would clarify to ensure she was heard. She said she feels competent in the facility's expectations regarding blood sugars, MD notification, following physician orders, and deciphering between emergency vs. non-emergency situations. An Interview was conducted on 02/27/23 at 9:50 AM, LVN B said she was trained before her shift about the importance of blood sugar levels. She said they were trained to notify the MD if the blood sugar level was too high or too low. She said if a resident has to go to the ER, non-emergency transport should not be used. She said she is required to document the response of the MD when they notify them of a change in the resident's condition. She said she feels competent in the facility's expectations regarding blood sugars, MD notification, following physician orders, and deciphering between emergency vs. non-emergency situations. An interview was conducted on 03/09/23 at 11:19 AM with LVN H. When asked why she did not document her conversation in detail with the MD representative specifically about notification of the blood sugar, she said: Things were happing so fast, and at the moment I was like, oh ok She said at that time she did not think to ask further information or clarification on what to do When asked had she been trained before the incident to document detailed notifications of MD instructions she said as a nurse she had been trained but not specifically by the facility. She said she was unaware of their process at that time for documentation. When asked about her experience as a nurse, what has she been taught about information that was not documented, and what does that mean? She said it would mean it was not done. A negative outcome could be not following the doctor's orders or knowing what was said. She said she was trained to contact the MD representative Monday-Friday 8-5, and then the MD Representative would contact the MD or the MD assistant. She said she was trained not to contact the MD directly. She said she was unaware that standing orders were available at the facility. She said at the previous facility, she was trained not to use the standing orders and to still notify the physician. An interview was conducted on 03/09/23 at 11:28 with the Administrator. When asked what her expectation of documentation of notifications was, she said they would document if there were any new orders and follow up with the orders. When asked about her experience as an administrator and what she was taught regarding information that is not documented and she said if it was not documented, it was not done. She said she did send the phone records of LVN H to HHSC but clarified that those records would not indicate the content of the calls. She said that based on the progress note entered in the electronic medical chart provided to the surveyor, she would not be able to tell if the MD was notified of the elevated blood sugar. She said that the MD was notified that day but not before leaving. She said that she expected the MD to be notified before the resident went to the ER. An interview was conducted on 03/09/23 at 11:47 AM with the MD representative. She said on 02/23/23, LVN H did not give her a detailed description of Resident #1 current issue with elevated blood sugar. She said the facility has standing orders is what the facility has on hand and what they have on anyone so that the MD does not have to call for everything. She said in the previous interview when she said she would have instructed LVN H to give the 10 units; she knew this exact amount because the facility has a standing order for sliding scale insulin, and that is what should have been followed on 02/23/23 when Resident #1 blood sugar was elevated to 501. When asked which order should be followed if the standing order differs from what is in the resident's electronic medical record, she said that the orders shouldn't have been different. She said the sliding scale order had been the same for a long time. She said she was not sure who entered the information on the facility. She said she does not review the orders once given to the facility. An interview was conducted on 03/09/23 at 6:08 PM with the MD, and when asked for clarification about the sliding scale order for Resident #1, he said that the sliding scale order should have been the same as the standing order. He said he did not know why the order on the computer would be different. He said the only reason the standing order would not match what was in the electronic medical record would be if the resident was under a different doctor and then came to the doctor. He said he was the attending doctor, and the orders should have matched. He said his standing order for sliding scale insulin was any blood sugar level over 451, 10 units would have been given, and after 30 minutes, if there were no changes, he should have been notified. On 02/25/23 at 5:06 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/26/23 at 4:14 PM, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the impleme [TRUNCATED]

Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and help prevent the development and transmission of communicable diseases and infections for 3 of 91 residents reviewed. This deficient practice affected 3 of 91 residents reviewed for infection control (resident's #1. #2, #3) as evidence by: The facility failed to ensure appropriate social distancing was practice with staff and residents. The Facility failed to ensure staff wore PPE appropriately. This failure to follow infection control had the potential to place all residents at harm, or even death. A total of 87 residents testing positive for COVID -19, resulting in 27 resident deceased after being diagnosed with [REDACTED]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as pattern. The administrator was notified on [DATE] of the acceptance of plan of removal and the Immediate Jeopardy was lowered. The evidence is as follows: A review of the facility report intake 9 dated [DATE] documented the facility administrator notified the local health department they had a staff member test positive for COVID - 19. The administrator reported the facility is following recommendations that all staff wear a protective masks , and additional staff and residents would be tested to determine if any exposure had occurred. During initial phone interview on [DATE] at 9:15 AM with Administrator regarding the intake that was called in, he stated that CMA #1 (Certified Medication Assistant) had tested positive for COVID-19 and he (administrator) was notified of the test results on [DATE]. He reported her last worked days in the facility were on [DATE], [DATE], and [DATE]. CMA #1 was screened at the entrance each day and was negative for any temperature or signs and symptoms. Administrator reported that CMA #1 had heard that loss of smell and taste were a symptom, so she went through a drive through screening on [DATE]. Administrator said CMA #1 called the facility on Monday [DATE] to report that she had been tested because of her loss of smell, and then got a positive result on [DATE]. Administrator also reported that there was another employee that had tested positive for COVID -19 the Corporate Clinical Liaison. Corporate Clinical Liaison was in the facility on [DATE] and [DATE] she was screened prior to entering the building and did not have a temperature and was not showing any signs or symptoms. Administrator stated that she was in contact with staff, but no residents. He also reported the facility was on lock down from visitors, all employees and vendors are screened prior to entering facility. The residents are encouraged to eat in their rooms. Administrator voiced there were some residents that were adamant about eating in the dining room, so they are sitting one at a table to maintain social distance. Staff are all wearing masks. Administrator reported that the Health Department had dropped off some boxes of PPE earlier today. He stated they have the PPE locked up, due to missing items over the weekend. He stated that DON (Director of Nursing), Central Supply, Maintenance Supervisor, and himself are the only ones that have access to the PPE. Administrator reported that before they leave they make sure the night shift has enough supplies to get through the shift. Observation made on [DATE] at 4:00 PM, entrance to the facility noticed resident #1 was sitting in his wheelchair near the screening table. Staff RN #2 was present at the screening table. Resident #1 did not have on a mask, resident #1 was not social distancing from the screening table, RN #2 did not redirect resident to his room or redirect resident #1 to place any PPE on, RN #2 did not redirect resident on social distancing. Resident #1, DOB [DATE], [AGE] year-old male admitted to the facility on [DATE], with a readmission on [DATE] with the following Diagnoses: [REDACTED]. Confirmed positive for COVID-19 on [DATE]. deceased in the facility on [DATE]. Observation made on [DATE] at 4:02 PM, in front lobby at the screening table a small trash can was placed at the end of the table with a clear bag in the trash can. The trash can was full with discarded exam gloves and discarded masks. Observation made on [DATE] at 4:25 PM, three staff members present in the nurse's station area, not social distancing. Staff is sitting in chairs at the nurse's station approximately two to three feet apart from each other. Observation made on [DATE] at 4:28 PM, resident #3 sitting in the dining room without use of a mask. Two other residents were out in the smoking area without any masks observed and sitting ,[DATE] feet apart, not social distancing. Resident #3, DOB [DATE], [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. She was transferred to the hospital on [DATE] for low oxygen saturations related to pneumonia. She was confirmed positive for COVID-19 on [DATE] at the hospital. Transferred to hospital on [DATE] for decreased oxygen saturation. deceased at hospital. Observation made on [DATE] at 4:29 PM, two staff members in the hall at the medication cart, not social distancing. Staff were standing side by side approximately one to two feet apart. Observation made on [DATE] at 4:50 PM, while in the kitchen checking the dishwasher Dietary Staff #1 had on a mask with two straps on the mask, staff was wearing the mask improperly only using one strap to secure the mask. During an interview on [DATE] at 4:40 PM with Dietary staff #1 when asked about wearing the PPE mask provided with one strap and not both straps on the mask Dietary staff #1 stated she was trained on how to wear the mask properly with both straps to secure it and she was not wearing it the way she was trained. Observation made on [DATE] at 5:59 PM, Resident #2 came down the hallway to the nurse station not wearing a mask. Staff redirected her to go back to her room or put a mask on. Resident #2 continued to stand at the desk and staff walked off. Staff did not offer resident #2 a mask before staff walked off. Resident #2, DOB [DATE], [AGE] year-old female admitted to the facility on [DATE], with a readmission on [DATE] with the following Diagnoses: [REDACTED]. Confirmed positive for COVID-19 on [DATE] has remained at the facility. During a phone interview on [DATE] at 5:45 PM, Administrator called to report he had just gotten off the phone with the Health Department, and a third employee had tested positive for COVID -19. CMA #2 was screened because she had been in contact with CMA #1. Her last days worked in the facility were [DATE], [DATE], [DATE], and [DATE]. Record review of an email from the Health Department Director dated [DATE] to facility Administrator documented the following as recommendations made to the facility on ce it was determined COVID - 19 was active in the building. Below are the measures that should be initiated immediately. If you need assistance implementing this let us know. We are able to request supplies including PPE and resources through the emergency operations center. I also need the names of all providers that have entered the facility such as physicians, nurse practitioners, occupational therapists and respiratory therapists since [DATE]. I also need the date when you closed the facility to visitors. Implement universal use of facemask for HCP while in the facility. Employees should practice social distancing (remain 6 feet apart as much as possible) Restrict residents (to the extent possible) to their rooms except for medically necessary purposes. If a resident leaves their room they should wear a facemask, perform hand hygiene, limit movement in facility and perform (stay at least 6 feet away from others). Record review of recommendations made by the Center for Disease Control on social distance documented the following: Stay at least 6 feet (about 2 arms' length) from other people Do not gather in groups Stay out of crowded places and avoid mass gatherings https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html Record review of an email dated [DATE] from Health Department Director to Health and Human Services staff, documented that when health department staff entered the facility on [DATE] observations were made of lack of PPE and facility staff had homemade masks. Record review of the facility Infection Control Policy & Procedure Manual 2018 RO ,[DATE].0, documented the following. Contact Precautions Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient's environment. The specific agents and circumstance for which Contact Precautions are indicated are found in the policy, Type and Duration. Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission. A single-patient room is preferred for patients who require Contact Precautions. In multi-patient rooms, ?3 feet spatial separation between beds is advised to reduce the opportunities for inadvertent sharing of items between the infected/colonized patient and other patients. Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination Droplet Precautions Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Because these pathogens do not remain infectious over long distances in a healthcare facility, special air handling and ventilation are not required to prevent droplet transmission. A single patient room is preferred for patients who require Droplet Precautions. When a single-patient room is not available, consultation Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) Last update: [DATE] Page 71 of 203 with infection control personnel is recommended to assess the various risks associated with other patient placement options (e.g., cohorting, keeping the patient with an existing roommate). Spatial separation of ?3 feet and drawing the curtain between patient beds is especially important for patients in multi-bed rooms with infections transmitted by the droplet route. Healthcare personnel wear a mask (a respirator is not necessary) for close contact (within 3 feet) with infectious patient; the mask is generally donned upon room entry. Patients on Droplet Precautions who must be transported outside of the room should wear a mask if tolerated and follow Respiratory Hygiene/Cough Etiquette. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination During a phone interview on [DATE] at 1:00 PM, the facility administrator, RN #1, and RN #2 were notified that an Immediate Jeopardy situation had been identified due to infection control concerns. During an interview on [DATE] at 4:26 PM with RN #1 when asked about staff being at the nurse's station together not social distancing RN #1 replied, she would remind staff to social distance while at the nurse station and would post a sign to remind them. RN #1 stated she would see about setting up a laptop to provide another area for staff to work. During an interview on [DATE] at 5:30 PM, LVN #1 (Licensed Vocational Nurse) stated she saw two staff members wearing homemade mask while in the building working prior to them knowing there was anyone with COVID -19 in the building, and this was prior to the health department coming in the building. LVN #1 am not sure of their names, but they were CNA's (Certified Nurse Aide). The administrator put a stop to them wearing homemade mask after the Health Department came in. During an interview on [DATE] at 5:59 PM, with the Administrator it was discussed of an allegation brought forth by the Local Health Department Director, that staff were seen wearing homemade masks on [DATE]. Administrator stated, yes we were wearing homemade masks at that time. We had a limited supply of surgical masks and we were using the surgical masks for the residents that were on isolation and the staff providing care to those residents. At the time our corporate office approved the homemade masks. Once the Health Department came in on [DATE] we switched to the surgical masks, and then the day after the Local Health Department came in [DATE] we received a shipment of N95 masks and started using the N95 masks. During an interview on [DATE] at 3:00 PM, CNA #2 stated she had been tested twice because the people she was working around tested positive. She had worked with CMA #1 on [DATE], [DATE] and [DATE]. Then CNA #2 was told that CMA #1 had called the facility and told the Administrator she was going to get tested for COVID-19 . CNA#2 was later told that CMA #1 was positive for COVID-19 and on [DATE] CNA #2 was tested the first time and those results were negative. CNA #2 stated she was tested a second time on [DATE] and received those results back as positive for COVID -19. When asked about mask in the building for staff to wear CNA #2 stated we did have mask in the build and the supply was running low. CNA #2 stated corporate was contacted and she was told to send a staff member to another one of their facility's and they could get five boxes of mask with 50 masks in each box. CNA 2 stated that the staff was using homemade mask before the Health Department came in the facility. Once the Health Department came in they switched to surgical mask then they received a shipment of the N95 mask and they switched to wearing those masks. CNA #2 stated the facility staff was making the homemade mask. That staff was wearing these as precaution before finding out about anyone having tested positive for COVID-19. On [DATE] the facility provided a plan of removal and it was accepted. The plan of removal included continuing to screen all employees with Center for Disease Control (CDC) guidelines. The facility will continue to isolate confirmed or suspected residents with COVID -19. Nursing staff was in-serviced beginning on [DATE] that residents who are in a common area or leave their room will be required to have a mask while out of their room. All staff in the facility as of [DATE] are wearing a n95 mask as a precautionary measure, (day after survey started). All staff will be in-serviced beginning on [DATE] regarding how to properly wear an n95 mask according to the manufacturer's recommendations. Nurses were in-serviced that they are to maintain at least ,[DATE] feet from one another while working at the nurse's station. As of [DATE] only 2 nurses will be allowed to work on each side of the nurse's station. Any additional nursing staff will be provided another area to perform documentation utilizing a laptop computer. Signage was placed on the nursing station on [DATE] reminding staff of social distancing and not to congregate or lean on nursing station. Observations made on [DATE] at 2:30 PM, staff present inside the entrance door at the facility screening all persons entering the building. Staff and visitor logs are present where staff is documenting all employees and visitor's temperature and asking screening questions about travel, exposure and health questions. A cart is present by the front door with PPE. Bio-hazard boxes are at the front entrance and exit door and a red bio-hazard bags are in the boxes. The facility has placed signs at the nurse's desk to remind staff to social distance while at the nurse's station working. Staff observed wearing PPE correctly. Residents were wearing masks. Immediate Jeopardy (IJ) was removed on [DATE] at 3:30 PM the facility remained out of compliance at a potential for actual harm with a scope identified as pattern. The administrator was notified on [DATE] of the acceptance of plan of removal and the Immediate Jeopardy was lowered.

Based on interview, record review and observation, the facility failed to ensure that the resident receives adequate supervision and assistive devices to prevent avoidable accidents for 1 of 5 residents (resident #1) reviewed for accidents and hazards. The facility failed to provide adequate supervision and assistive devices to prevent accidents when staff attempted to transfer resident #1, on her own, and failed to use the prescribed mechanical lift, resulting in resident #1 obtaining an acute proximal tibial and fibular fractures with posterior angulation extending to tibial plateau. The facility's failure to provide adequate supervision and assistive devices, placed residents at risk for serious injury. The evidence is as follows: Record review of resident #1's MDS, dated [DATE], documented that she is a [AGE] year old woman who has the following Diagnoses: [REDACTED]. Resident #1 also has a BIMS score of 15 which is very good cognitive function. Resident #1's functional status requires extensive assistance in bed mobility with two plus person physical assist. She is total dependence with two plus persons- physical assist for transfers. Interview with CNA #1 on 8/08/19 at 10:45am, revealed that she went to change resident #1 on 7/26/19 at approximately 1:30pm, and when she finished changing resident #1, CNA attempted to transfer resident #1 from bed to wheelchair. CNA #1 said she put her gait belt around resident #1 and when she tried to lift resident #1 in her wheelchair, the wheelchair moved and resident #1 started to slide down and CNA #1 said she didn't have enough strength to lift her up onto her wheelchair, so she guided her down to the floor. CNA #1 said that resident #1's foot got caught under her bed and that is how she thinks it got broken because resident #1 didn't fall. She said she didn't ask for help and did not see the sign on resident #1's wall close to her bed that read to please use a (mechanical) lift per resident's request. CNA #1 said that she had been gone for a long time, since (MONTH) (YEAR) and/or (MONTH) 2019 and that she didn't remember, resident #1 using a mechanical lift at that time, and that she had no problems in transferring her before. She had just been rehired and this had been her first day at work. She also said that she could have looked at resident #1's care plan to see what type of transfer resident was, but she just didn't. CNA #1 said that she called the nurse immediately and that the resident was sent to emergency room that day. CNA #1 said Trust me, I feel really bad about it and it was just an accident. CNA #1 said she was retrained and had someone follow her when she came back for one day and then she went on her own the second day. Interview with resident #1 on 8/08/19 at 8:45am, revealed that she said that the day CNA #1 lifted her on her own, resident #1 said she didn't tell her anything because that day, she was out of it and next thing she knew she was on the floor in pain. Resident #1 said that she was in pain. Furthermore, resident #1 said that CNA #1 did not neglect her but that it was an accident. She said she was a sweet girl. Observation of resident #1 revealed she was a left leg [MEDICAL CONDITION] and that her right leg had what appeared to be an immobilizer. Record review of resident #1's x-ray, dated 7/26/2019, documented findings were acute proximal tibial and fibular fractures with posterior angulation. Suspect tibial fracture extends to tibial plateau. Small joint effusion noted. Moderate [MEDICAL CONDITION]. [MEDICAL CONDITION] and moderate [MEDICAL CONDITION]. There is no evidence of dislocation or osseous lesion. The femorotibial joint space is preserved. Record review of Witness Statement dated 8:08am signed at 11:00am by CNA #1 documented that CNA #1 answered resident #1's call light and she wanted to be changed. She said that she had previously worked with resident #1, in the past. CNA #1 wrote that she was in mid=transfer when the locked wheelchair moved. It was at that point that resident #1 fell but that she gently guided her (resident #1) to the ground and went to (get) charge nurse. She wrote that her leg had gotten caught under the bed as she guided her to the ground. She wrote that she had also not seen a sling in her room and didn't have problems before (lifting her). After getting resident #1 in her bed, an x-ray was ordered, and she was immediately suspended. Record review of Provider Investigation Report, dated 8/02/2019, documented that on (MONTH) 26, 2019, CNA #1 entered resident #1's room to assist her to the wheelchair. Resident #1 is a [AGE] year-old female admitted on [DATE] [DIAGNOSES REDACTED]. Resident #1 called for a CNA so she could get up from the bed. CNA #1 entered the room to help residents #1 to the wheelchair. The bed was in the lowest position. CNA attempted to lift resident to the wheelchair when the chair moved. CNA slid resident to the floor twisting her foot and ankle. The charge nurse was notified of the fall. An assessment revealed pain to the right leg. The resident was transported to emergency department. An x-ray showed [MEDICAL CONDITION] tibial and fibular. The physician ordered a wrap and 6 week follow up with ortho. Resident #1 is a two-person and mechanical lift. The findings were confirmed. Record review of physician's orders [REDACTED].#1: Age: 63, weighs 221 lbs. on 7/03/19. Doctor's order: 9/27/2018 may use Hoyer (mechanical) lift with each transfer, Record review of the facility's Hydraulic Lift Policy, undated, but presented as current, documented that the lift is reserved for those who are paralyzed, obese, or too weak to transfer without complete assistance. Interview with DON on 8/08/19 at 10:25am stated that CNA #1 had worked for the facility before and it was CNA #1's first day of work when the incident happened. She did confirm that resident #1 was a mechanical lift with two-person physical assist and that CNA #1 should have asked for help but she also told DON that she didn't have a sling in the room for the mechanical lift. Interview with CNA #2 on 8/08/19 at 10:45am stated that resident #1 is a two person-physical assist with a mechanical lift. She said that she was not going to try to lift her because she was not going to break her back. CNA #2 said that resident #1 has that on her care plan (2-person, mechanical lift), as well. Record review of Coaching/Re-Education of Employee, dated 7/26/19, at 1:00pm, documented that employee transferred resident who required mechanical lift by herself. Resident obtained injury at time of incident. Redirection: Employee will use Hoyer lift to transfer patients who require mechanical lift. Employee will ask for assistance when needed. Record review of in-services on 7/26/2019, regarding Moving a Resident, Bed to Chair/Bed to Chair, documented that the purpose of this procedure was to provide safe transferring of the resident. Steps in Procedure: Note: This procedure may require two (2) persons. Interview with Regional Nurse, for the facility, on 8/08/19 on 2:25pm revealed that CNA #1 was supposed to be terminated, and apparently, she was not. Regional Nurse also confirmed that resident was a two (2) person mechanical lift. She also said that CNA #1 was not supposed to return to facility but the Administrator #1 (Interim) felt she was trainable, so they decided to terminate CNA #1 and Administrator #1 will not be returning to the facility.