Every finding on record at White Settlement Nursing Center

Based on observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of his or her personal and medical records for 1 of 5 residents (Resident #1) reviewed for residents' rights. The facility failed to ensure LVN A locked the medication cart computer screen and left Resident #1's information exposed. This failure could place residents at risk of resident-identifiable information being accessed by unauthorized persons. The findings included: Observation on 08/11/26 from 11:58 AM to 12:05 PM revealed a medication cart was left unattended facing the hallway in Station 1. The computer screen on top of the medication cart counter was left opened with Resident #1's information exposed. Computer screen was showing a picture of Resident #1, resident information and medications. Observed staff and visitors walking by the medication cart while the computer screen was opened. LVN A was observed at the nurses' station assisting a visitor, she then walked the visitor to Station 1 hall and then locked her computer screen. Interview on 08/11/26 at 1:24 PM, LVN A stated the medication cart with the computer screen open on Station 1 was her medication cart. She stated she was on the hallway when x-ray tech came in and asked for documentation. She stated she stepped away from her medication cart to assist the x-ray tech and forgot to lock the computer screen. She stated she was only away for about 3 minutes. She stated when stepping away from the computers, they should always lock the computer screen for resident privacy. Interview on 08/11/26 at 3:24PM, the ADON stated it was her expectation that staff locked the computer screens when stepping away from the medication cart. She stated they must protect residents' information. ADON stated the potential risk of leaving computer screen open would be an unauthorized person obtaining the resident's condition and medications information, and it was a violation of their rights. Interview on 08/11/26 at 4:19PM the Administrator stated the expectation was for the staff to lock the computer screens when stepping away from the medication cart. He stated the potential risk would be HIPAA violation. Record review of the facility Resident Rights policy, revised February 2021, revealed the following: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . t. privacy and confidentiality

Based on observation, interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 1 residents (Resident #6) reviewed for treatment of pressure ulcers.1. The facility failed to implement interventions for Resident #6's right arm contracture which led to the development of a stage 3 pressure ulcer (wound developed from pressure that extends through the skin into the fatty layer but not into the muscle, tendon or bone) to the right palm identified on 06/03/2026.2. The facility failed to ensure Resident #6's dressing to the left hip was dated and initialed.The failures could place residents at risk of developing new or worsening pressure ulcers. Findings include:Findings include:Record review of Resident #6's Significant Change MDS, dated [DATE], reflected he was a [AGE] year-old male with an original admission date of 05/22/24 and readmission date of 04/29/26. Resident #6's diagnoses included stroke, Hemiplegia (partial paralysis of one side of the body) or Hemiparesis (weakness on one side of the body) and Encephalopathy (any disease, damage, or malfunction of the brain that causes altered mental function). Resident #6's BIMS score was blank, and cognitive skills were severely impaired. Resident #6 had upper and lower extremity impairment on both sides and was dependent for all ADLs. Record review of Resident #6's care plan, revealed the following:-Resident #6 had an ADL self-care performance deficit and was dependent on staff for all ADLs, Date initiated 05/23/24.-Resident #6 has the potential for the development of a pressure ulcer, Date initiated 07/20/25 with interventions that included pressure reliving/reducing devices on bed/chair.reposition frequently.-Resident #6 at risk for impaired skin integrity r/t contractures in all extremities, Date initiated 09/12/25 with interventions that included use circular limb off loader to keep hand from resting against other body parts. utilized pillows or foam wedges to avoid direct contract with bony prominences.utilize pressure relieving devices on appropriate surfaces.-Resident #6 had alteration in musculoskeletal status r/t contractures of all moveable joints, Date Initiated 12/01/25 with interventions that included Range of Motion weekly by therapy dated 02/18/26, and wash cloth right thumb and index finger Wash cloth against shoulder and hand on right; Change wash clothes daily dated 02/18/26. Record review of Resident #6's order summary reflected the following:- Cleanse stage 3 right palm wound with wound cleanser. Dry with gauze. Apply gentell blue. Coverwith bordered gauze Wednesday and Saturday and PRN if soiled or malfunction start date 07/03/26- Cleanse Pressure unstageable DTI left lateral (away from the middle of the body) hip with wound cleanser. Dry with gauze. Cover with honey hydrogel. Cover with gauze island dressing MWF and PRN start date 07/29/26.- Skilled Occupational Therapy services for PASSR services 1xs for 90 days for self-care, ADL retraining,therapeutic activities, therapeutic exercises, neuromuscular re-education, and manual therapy, and safety education order date 6/09/26- Skilled Physical therapy for 1X/WK FOR 90 days for PASRR services order date 06/09/26Record review of Resident #6's skin note dated 06/03/26, written by LVN I reflected in part: 0Skin Issue: #003: New skin Issue. Location: Right palm. Laterality / Orientation: Lateral. Issue type: Other skin issue. Other skin issue description: unstageable DTI Progress: New: new wound. Wound acquired in-house. Exact date: 06/03/2026 Signs and symptoms of infection: None. Painful: No. Staged by: In-house nursing. Length (cm): 2 Width (cm): 2.2 Depth (cm): 0.1 Undermining: No. Tunneling: No. Granulation (new temporary connective tissue that fills a wound): 80%. Slough (dead tissue usually yellow, white or tan): 20%. Exudate (wound drainage or fluid) amount: Moderate. Exudate type: None. Odor after cleansing: None. Periwound (tissue surrounding the wound): Attached. Surrounding tissue: Intact. Induration: None present. Edema (swelling): No swelling or edema. Periwound temperature: Normal. Dressing saturation: None 0%. Cleansing solution: Generic wound cleanser. Debridement: Autolytic (using the body's own enzymes and moisture to break down dead tissue). Primary dressing: Calcium alginate. Secondary dressing: Composite dressing. Modalities: None. frequency of treatment: q day.Record review of Resident #6's wound physician's notes, dated 06/10/26, reflected Stage 3 pressure wound of the right hand full thickness.Duration >7 days Wound Size (L x W x D): 1.3 x 1.8 x 0.1 cmSurface Area: 2.34 cm^2Exudate: Moderate SerousGranulation tissue: 100 %Pain Assessment: NoneInfection Assessment: No sign(s) of infection. ADDITIONAL WOUND DETAILSevere contracture limiting ability to debride this woundDRESSING TREATMENT PLANPrimary Dressing(s)Methylene blue foam apply twice a week and as needed: if saturated, soiled, or dislodged. For 30 daysSecondary Dressing(s)Gauze island with border apply once weekly and as needed: if saturated, soiled, or dislodged. For 30 days.Record review of Resident #6's wound physician's notes, dated 06/17/26, reflected Stage 3 pressure wound of the right hand full thickness. Wound Size (L x W x D): 1.3 x 1.5 x 0.1 cmSurface Area: 1.95 cm^2Exudate: Moderate SerousGranulation tissue: 100 %Wound progress: Improved evidenced by decreased surface areaPain Assessment: NoneInfection Assessment: No sign(s) of infection.Record review of Resident #6's wound physician's notes, dated 07/15/26, reflected Stage 3 pressure wound of the right hand full thickness. Wound Size (L x W x D): 1.4 x 1.3 x 0.1 cmSurface Area: 1.82 cm^2Exudate: Moderate SerousGranulation tissue: 100 %Hypergranulation (excessive granulation tissue that extends above the surround skin) tissue present within the wound margins.Wound progress: Not at goal due to contracturesPain Assessment: NoneInfection Assessment: No sign(s) of infection.Record review of Resident #6's wound physician's notes, dated 07/22/26, reflected Stage 3 pressure wound of the right hand full thickness. Wound Size (L x W x D): 0.8 x 0.7 x Not Measurable cmDepth is unmeasurable due to presence of tissue overgrowth.Surface Area: 0.56 cm^2Exudate: Moderate SerousGranulation tissue: 100 %Wound progress: Improved evidenced by decreased surface areaPain Assessment: NoneInfection Assessment: No sign(s) of infection.Observation on 07/28/2026 at 3:00 PM, revealed Resident #6 was lying in bed. The resident was not able to answer questions. Resident #6's left hand appeared contracted. No offloading device was observed on Resident #6 wrist or hand.Observation on 07/29/26 at 9:24 AM, revealed Resident #6 was lying in bed, bordered gauze was on the right palm, no wash clothes or offloading device was observed in or around the hands or wrists. CNA K was in the room to check if Resident #6 needed to be changed. Interview on 07/29/26 at 9:55 AM, LVN I stated Resident #6 was severely contracted. She stated he had wedges and repositioning devices and a device that was round that fit around the arms to help lift it. She stated the CNAs were responsible for putting them on and Resident #6 was supposed to wear them all the time. Observation on 07/29/26 at 10:07 AM, revealed Resident #6 was lying in bed, no wash clothes or offloading device was observed in or around the hands or wrists. A blue round offloading device was observed in the wheelchair.Interview on 07/29/26 at 10:08 AM, CNA L stated he usually worked nights and stated Resident #6 was contracted and had not seen the blue offloading device before. He stated when he cleaned Resident #6's hands sometimes he would fold a towel and place it in his hands and he would grip it. He stated therapy and the Wound Care Nurse checked on him. He stated he placed pillows under his legs to relieve pressure and if he noticed any issues he would report to the nurse. Interview on 07/29/26 at 10:15 AM, LVN F stated Resident #6 did not have an order for an offloading device but he saw therapy go in and apply it to Resident #6's wrists. He stated he did not get instructions Resident #6 was supposed to wear it all the times. He stated nurses and CNAs were responsible for turning and repositioning Resident # 6 every two hours and they would put a pillow in between his chest and arms to relieve pressure. He stated the Wound Care Nurse provided treatment to the wound on the right palm. He stated no CNAs had reported any changes to skin to him. Interview on 07/29/26 at 11:06 AM, the DOR stated Resident #6 was currently receiving PT, OT and ST through PASARR one time a week for each. She stated Resident #6 did not stretch enough to use a splint and they tried to stretch out the contractures, but Resident #6 could not tolerate a splint. Observation and interview on 07/29/2026 at 11:33 AM, LVN F stated the nurse was responsible for cutting Resident #6's nails and said he cut them a couple of weeks ago. He stated CNAs were to clean Resident #6's hands and if they were not cleaned, he could develop skin issues or wounds. LVN F put on gloves and turned Resident #6's right hand which revealed long nails on all fingers except the ring finger. LVN F stated they were about an inch and a half long and needed to be trimmed. LVN F attempted to open Resident #6's right hand and stated the nails needed to be cut. Observation and interview on 07/29/26 at 11:45 AM in Resident #6's room, revealed OT N and PTA R provided therapy to Resident #6, with the DOR present. OT N was working on moving Resident #6's arms and stated he had been more contracted since he had been back from the hospital [in April 2026] and they were trying to maintain his ROM. OT N stated as far as splinting, it would rest against his thumb and could cause a wound. The OT stated if she noticed any skin issues she would tell the Wound Care Nurse. The OT stretched and moved Resident #6's right arm to show the offloading device would fit onto his wrist. The DOR stated she in-serviced nursing on where to place positioning devices and to use a pillowcase in the hands or between his arm and chest. The DOR stated the aides would be responsible to place the pillowcases or devices and she did not think an order was needed for offloading devices since it would be the same as a wedge. Interview on 07/29/26 at 12:10 PM, CNA K stated she had worked with Resident #6 for about a week. She stated she used towels in his hands and in between his arms or the blue offloading device. She stated there were boots for his feet. Interview by phone on 07/29/26 at 12:34 PM with CNA S was unsuccessful, a voicemail was left. In a follow-up interview on 07/29/26 at 1:10 PM, LVN I stated staff reported to her if they found any new skin issues. She stated she would then assess the resident and call the wound doctor, get a new order for treatment. She stated usually carrots were used for contracture management, but Resident #6's hands were so tight a carrot would not fit so they were to use foam or a washcloth to relieve pressure. She stated she did not realize his [right] hand was pushing up against his chest as much as it was before he developed the wound to the right palm. She stated the risk of not using the washcloths or something to decrease the pressure was first, the contracture could get worse and second the pressure from his own body could cause an opening. Interview on 07/29/26 at 1:29 PM, via phone, with CNA O revealed she had only worked with Resident #6 for the past week or two. She stated she put washcloths in his hands and an offloading device on his wrists to keep his hand from touching his skin. She stated CNAs were responsible for cleaning Resident #6's hands and reporting any skin issues to the nurse or the wound care nurse. Interview on 07/29/26 at 1:37 PM, the Wound Care Physician stated Resident #6 was very contracted, moved in a ball, and was contracted in his hands. She stated clipping his nails was difficult and he had developed a wound [that had since healed]. She stated developing wounds was unavoidable because he was rigid, and it would be impossible to offload, however she could not deny that there could have been more done to prevent the wound on the right palm. She stated when residents were that contracted, she would let therapy decide on how to offload. Interview on 07/29/26 at 3:02 PM, CNA P stated she has worked at the facility for 4 years and 7 months. CNA P stated she worked with Resident #6 and was his aide yesterday and gave him a shower yesterday. She stated he had been very contracted for a long time and would try to clean under his fingers when he showered, but she could not open his hands up, so she cleaned mostly the outside of the hands. CNA P stated she did not put anything in his hands but sometimes the nurse would do that. She stated sometimes she would put a pillow between one hand because he would bleed. She stated he would have the blue brace sometimes when therapy put it on and she would put it back on after a shower, but would not put it on if he was not wearing it. She stated he did not have anything on yesterday, not the brace or washcloths. Interview on 07/30/26 at 3:00 PM, RN Q stated Resident #6 had contractures and nurses and aides were responsible for putting washcloths in the palm and underneath his hand to prevent friction. She stated aides were supposed to clean his hands daily and ensure that there was no skin breakdown. Observation and interview on 07/30/26 at 3:14 PM in Resident #6's room, revealed LVN I and RN J were performing wound care treatment to the right palm. Resident #6 was turned on his right side so RN J could hold his arms while LVN I provided the wound care. The wound bed was pink, measured approximately 1x1 inch with skin intact and no signs of infection noted. The dressing on Resident #6's left hip was not dated. LVN I stated she had put the dressing on yesterday with the Wound Care Physician and did not date it because she forgot her marker. She stated she was supposed to date and initial the dressing and the risk of not doing that was the dressing could be left on there too long. She stated she documented on the TAR when the dressing was changed. Interview on 07/30/26 at 4:42 PM, ADON A stated CNAs were responsible for applying washcloths and offloading devices and the nurses were to make sure they were in place for Resident #6. She stated if not done the risk to the resident would be further wounds could develop. ADON A stated wound dressings should be dated by whoever provided the treatment. She stated it was important to date the dressings so it could show when it was done, and if not the resident could be at risk of infection and the wound getting worse. Interview on 07/30/26 at 6:00 PM, the DON stated they were managing Resident #6's contractures the best they could by putting pillowcases, and towels in his hands and the round foam device on his wrists. She stated CNAs, and nurses could attempt and if they had trouble getting them in his hands, they could go to therapy to try to get them in. She stated the washcloth was to soak up moisture, so yeast did not develop and try to keep his skin integrity. The DON stated Resident #6's hands should be cleaned daily and the washcloths should be changed daily. She stated if staff noticed any odor or change it should be reported to the nurse by the aides. The DON stated her expectation was that all wound dressings and bandages should be dated and initialed so they would know when they were done. The DON did not answer when asked what the risk to the resident was. Interview on 07/30/26 at 6:57 PM, the Interim Administrator stated nursing staff was responsible for applying offloading devices. He stated the risk of not managing Resident #6's contractures was he could develop wounds and have a decline in his well-being. Review of facility Skin Prevention and Management Guidelines revised 04/13/2023, reflected in part: Management.therapeutic exercises: incorporate therapeutic exercise into the resident's daily routine, including both passive and active range-of-motion exercises to maintain or improve joint mobility.orthopedic devices: utilize orthopedic devices such as splints or braces, to support proper joint alignment and prevent further contracture development.

Based on observations, interviews, and record reviews, the facility failed to provide a clean, safe, and functional environment for 1 of 8 rooms (room [ROOM NUMBER]) and 2 of 2 halls (Station 1 and Station 2) reviewed for environment. 1. The facility failed to repair the blinds in Resident #27's room.2. The facility failed to ensure there was not a foul odor that lingered into the hall from the soiled utility room in Station 1 hall.3. The facility failed to ensure there was not a strong urine odor in Station 2 hall near Resident #28, Resident #16 and Resident #85's rooms.These failures could place residents at risk of living in an unsanitary, unsafe environment and a diminished quality of life. Findings included:Observation and interview on 07/28/2026 at 11:34 AM, in Resident #27's room, revealed a red and green blanket hanging up covering the left side of the window. Vertical blinds were missing behind the blanket. Resident #27 stated the blanket hanging up and broken blinds did not bother him.Observation on 07/28/2026 at 3:00 PM revealed a staff member opened the door to the soiled utility room on Station 1 to put away soiled linen and trash. A foul odor was noted once the door opened and lingered in the hallway. Observation on 07/28/2026 at 2:41 PM, on Station 2 hallway, revealed a strong urine odor in the hallway between Resident #28, Resident #16 and Resident #85's rooms.Interview on 07/30/26 at 3:38 PM, the Maintenance Director stated he had worked at the facility for 6 weeks. He stated he expected staff to tell him if repairs were needed or to put needed repairs in the [name of building management software].Interview on 07/30/26 at 5:15 PM, ADON B stated she noticed an odor on Station 2 hallway. She stated a resident would change herself and throw wet briefs and linens on the floor. She stated nursing staff would pick up the linens and trash and get housekeeping to clean the room. She said if it happened during the night shift, nursing staff would mop the floor. She stated if urine was spilled on the floor in the bathroom, it could cause the odor. She stated the smell could make some residents nauseas and it would be nasty.Interview on 07/30/26 5:35 PM, the Housekeeping Supervisor stated resident rooms, soiled utility rooms and hallways were cleaned by housekeeping staff. She stated if any BM or urine was in the rooms the CNA would clean it first, then the housekeeping staff would go in and sanitize. She stated she noticed the urine odor in Station 2 hallway and said one of the residents did not like to wear briefs and went to the bathroom and did not allow housekeeping to clean the room. She stated another room on the same hall had a resident who would urinate and put the urine in the trash can. She stated some residents urinated on the floor in the bathroom which caused the odor near Resident #48's room. She stated they were not allowed to use bleach or air fresheners and used the chemicals they were provided. She stated the risk to residents was it could be a hazard because it was urine and it stinks. The Housekeeping Supervisor stated she expected her staff to report to her and to Maintenance if any repairs were needed in resident rooms. She stated Resident #27's blinds needed to be replaced, they had been broken for three to four months and new ones were ordered. She stated if repairs were not done residents could feel like they were not taken care of. Interview on 07/30/26 at 6:00 PM, the DON stated she noticed the urine odor on Station 2 hallway some days. She stated housekeeping was supposed to clean, but if something had feces or urine on it the nursing staff was to clean it first and then they would get housekeeping to sanitize. She stated housekeeping mopped frequently and they were not allowed to use aerosols. The DON stated she did not know if the urine odors would pose a risk to residents, but it could make them unhappy. She stated her expectation was for staff to report to Maintenance if repairs were needed in resident rooms. She stated the risk could be making Resident #27 unhappy. Interview on 07/30/26 at 6:57 PM, the Interim Administrator stated blinds were ordered for Resident #27's room. He stated staff should report needed repairs or cleaning to Maintenance or Housekeeping. He stated the odors and broken blinds could affect residents by not creating a nice environment to live in and could be unsanitary. Record review of facility Resident Rights policy, dated 2/20/2021, reflected the following: .8. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observations, interviews, and record review the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal care for 2 of 16 residents (Residents #26 and #6) reviewed for ADL care. The facility failed to ensure nail care, to include trimming, was provided to Residents #26 and #6, observed on 7/28/26, 7/29/26, and 7/30/26. The failure placed the residents at risk of hygiene and safety risks such as nail tearing, injury, and functional difficulties. Findings included: 1. Record review of Resident #26's Face Sheet, dated 07/30/26, reflected a [AGE] year-old male who admitted on [DATE]. Record review of Resident #26's Quarterly MDS, dated [DATE], reflected the resident had diagnoses that included: Cerebral Infarction (stroke caused by blocked blood flow), Vascular Dementia (cognitive impairment caused by lack of blood flow), Aphasia (brain disorder that affects how you speak, understand, read, and write), and Diabetes Mellitus (chronic condition in which the body does not regulate blood sugar levels). The MDS reflected that Resident #26 was dependent (requires full assistance of staff) for all ADLs and had severe cognitive impairment. Record review of Resident #26's Care Plan, undated, reflected the resident had an ADL self-care performance deficit with interventions that he required extensive assistance with ADLs and to, Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. The care plan also reflected he had a diagnosis of Diabetes. Record review of Resident #26's July 2026 progress notes revealed no documentation of refusal of fingernail care. Observation on 07/28/2026 at 2:37 PM reflected Resident #26 was sitting in a recliner chair watching TV. His fingernails were observed to be approximately 1/2 inch long with jagged, sharp edges. Resident #26 could not answer any questions about his fingernails or preferences when interviewing. Observation on 07/29/2026 at 10:49 AM reflected Resident #26 was sitting in the dining room in his chair. His fingernails were observed to be 1/2 inch long with jagged edges. The resident was clean with damp hair and appeared to have received a shower. Resident #26 was not interviewable and did not answer any questions about his fingernails. Observation on 07/30/2026 at 12:46 PM revealed Resident #26 sitting in the dining room after lunch. His fingernails were observed to be approximately 1/2 inch long with sharp corners and edges. Interview and observation on 07/30/2026 at 12:48 PM with CNA G revealed she worked regularly with Resident #26. During the interview, CNA G observed Resident #26's nails and stated his nails were very long and needed to be trimmed. CNA G stated Resident #26 was a diabetic, so she did not cut his nails. She stated LVN H knew his nails were long because she made a comment the previous day, 07/29/26, during his blood sugar check that she was going to trim them. CNA G stated LVN H was busy and must not have had time to trim them. CNA G stated she did not notify any nurses about Resident #26's long nails and that he did not refuse any nail trims that she was aware of. CNA G stated the risk of long nails was the resident scratching himself. Interview on 07/30/2026 at 12:52 PM with LVN H revealed that she had worked at the facility for 2 years and was Resident #26's nurse. LVN H stated Resident #26's nails were long and that she noticed how long they were this morning, but that no one had notified her previously. LVN H stated she was responsible for cutting his nails since he was a diabetic resident, but she had not got to it yet. LVN H stated his nails were cut last month but was unable to recall the date. She stated the risk of Resident #26 having long nails was he could scratch himself and cause harm. 2. Record review of Resident #6's Significant Change MDS, dated [DATE], reflected he was a [AGE] year-old male with an original admission date of 05/22/24 and readmission date of 04/29/26. Resident #6's diagnoses included stroke, Hemiplegia (partial paralysis of one side of the body) or Hemiparesis (weakness on one side of the body) and Encephalopathy (any disease, damage, or malfunction of the brain that causes altered mental function). Resident #6's BIMS score was blank and cognitive skills were severely impaired. Record review of Resident #6's care plan, dated 05/23/24 reflected Resident #6 had an ADL self-care performance deficit and was dependent on staff for all ADLs. Record review of Resident #6's progress notes from 05/25/26 to 07/29/26 revealed no entries that nail care was provided or attempted. Observation on 07/28/2026 at 3:00 PM, revealed Resident #6 was lying in bed. The , resident was not able to answer questions. Resident #6's left hand appeared contracted, and the thumb nail was long. Observation and interview on 07/29/2026 at 11:33 AM, LVN F stated the nurse was responsible for cutting Resident #6's nails and said he cut them a couple of weeks ago. He stated CNAs were to clean Resident #6's hands and if they were not cleaned, he could develop skin issues or wounds. LVN F put on gloves and turned Resident #6's right hand which revealed long nails on all nails except the ring finger. LVN F stated they were about an inch and a half long and needed to be trimmed. LVN F attempted to open Resident #6's right hand and stated the nails needed to be cut. Interview on 07/30/2026 at 4:19 PM with ADON A revealed she had been an ADON at the facility for 1 year. She stated she expected the CNAs to observe the residents' nails every shower day and trim and clean them when needed. ADON A stated if they were a diabetic resident, the nurses were responsible for trimming their nails. ADON A stated the nurse should cut Resident #6's nails. ADON A stated if the residents had long nails, the risk was self-injury and infection control issues. Interview on 07/30/2026 at 5:00 PM with ADON B revealed she had been an ADON for 3-4 years. She stated she was the ADON over Resident #26. ADON B stated she expected the residents to have short and clean nails if that was what they wanted. ADON B stated the nurses were responsible for ensuring the nails were trimmed if the resident was a diabetic. She stated she had seen Resident #26's nails when he was eating and that they were long. ADON B stated the long nails could cause skin tears and infections. Interview on 07/30/2026 at 5:43 PM with the DON revealed she expected the staff to complete nail care when the residents needed it. She stated the aides were supposed to check on shower days and daily as needed. The DON stated the nurses were responsible for completing diabetic resident nail trims. She stated she was familiar with Resident #26 but had not seen his long nails. The DON stated the risk of long nails was the residents scratching themselves and causing an infection. The DON stated the nurse should cut Resident #6's nails, and CNAs should inform the nurse if his nails were long. She said if they were left long they could injure his skin. Interview on 07/20/26 at 6:58 PM with the Interim Administrator revealed that he expected the residents' nails to be cut when they were needed. He stated the nursing team was responsible for ensuring nail care was completed. The Interim Administrator stated the risk of long nails was the residents cutting themselves and injury. Record review of facility Activities of Daily Living Care Guidelines policy, dated 01/23/16, reflected the following: A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 of 1 resident (Resident #6) reviewed for range of motion. The facility failed to implement interventions to prevent further decline of Resident #6's contractures to right and left hands and arms. The failure could place residents at risk for decline in range of motion, decreased mobility, pain, and worsening of contractures. Findings included:Record review of Resident #6's Significant Change MDS, dated [DATE], reflected he was a [AGE] year-old male with an original admission date of 05/22/24 and readmission date of 04/29/26. Resident #6's diagnoses included stroke, Hemiplegia (partial paralysis of one side of the body) or Hemiparesis (weakness on one side of the body) and Encephalopathy (any disease, damage, or malfunction of the brain that causes altered mental function). Resident #6's BIMS score was blank, and cognitive skills were severely impaired. Resident #6 had upper and lower extremity impairment on both sides and was dependent for all ADLs.Record review of Resident #6's care plan, revealed the following:-Resident #6 had an ADL self-care performance deficit and was dependent on staff for all ADLs, Date initiated 05/23/24.-Resident #6 had the potential for the development of a pressure ulcer, Date initiated 07/20/25 with interventions that included pressure reliving/reducing devices on bed/chair.reposition frequently.-Resident #6 at risk for impaired skin integrity r/t contractures in all extremities, Date initiated 09/12/25 with interventions that included use circular limb off loader to keep hand from resting against other body parts. utilized pillows or foam wedges to avoid direct contract with bony prominences.utilize pressure relieving devices on appropriate surfaces.-Resident #6 had alteration in musculoskeletal status r/t contractures of all moveable joints, Date Initiated 12/01/25 with interventions that included Range of Motion weekly by therapy dated 02/18/26, and Wash cloth right thumb and index finger. Wash cloth against shoulder and hand on right. Change wash clothes daily dated 02/18/26. Record review of Resident #6's order summary reflected the following:- Skilled Occupational Therapy services for PASSR services 1xs for 90 days for self-care, ADL retraining,therapeutic activities, therapeutic exercises, neuromuscular re-education, and manual therapy, and safety education order date 6/09/26- Skilled Physical therapy for 1X/WK FOR 90 days for PASRR services order date 06/09/26- Speech therapy: Skilled Speech/Language treatment 1x/wk x 90 days for PASRR services order date 06/08/26Observation on 07/28/2026 at 3:00 PM, revealed Resident #6 lying in bed, resident was not able to answer questions. Resident #6's left hand appeared contracted and thumb nail was long. No offloading device was observed on Resident #6's arm or wrist.Observation on 07/29/26 at 9:24 AM, revealed Resident #6 lying in bed, bordered gauze was on the right palm, no wash clothes or offloading device was observed in or around the hands or wrists. CNA K was in the room to check if Resident #6 needed to be changed. Interview on 07/29/26 at 9:55 AM, LVN I stated Resident #6 was severely contracted. She stated he had wedges and repositioning devices and a device that was round that fit around the arm to help lift it. She stated the CNAs were responsible for putting them on and Resident #6 was supposed to wear them all the time. Observation on 07/29/26 at 10:07 AM, revealed Resident #6 lying in bed, no wash clothes or offloading device was observed in or around the hands or wrists. A blue round offloading device was observed in the wheelchair.Interview on 07/29/26 at 10:08 AM, CNA L stated he usually worked nights and stated Resident #6 was contracted and had not seen the blue offloading device before. He stated when he cleaned Resident #6's hands sometimes he would fold a towel and place it in his hands and he would grip it. He stated therapy and the wound care nurse checks on him. Interview on 07/29/26 at 10:15 AM, LVN F stated Resident #6 did not have an order for an offloading device but he saw therapy go in and apply it to Resident #6's wrists. He stated he did not get instructions Resident #6 was supposed to wear it all the time. Interview on 07/29/26 at 11:06 AM, the DOR stated Resident #6 was currently receiving PT, OT and ST through PASARR one time a week for each. She stated Resident #6 does not stretch enough to use a splint and they try to stretch out the contractures, but Resident #6 could not tolerate a splint. Observation and interview on 07/29/26 at 11:45 AM in Resident #6's room, OT N and PTA R provided therapy to Resident #6, with DOR present. OT N was working on moving Resident #6's arms and stated he had been more contracted since he had been back from the hospital [in April 2026] and they were trying to maintain his ROM. OT N stated as far as splinting, it would rest against his thumb and could cause a wound. The OT stated if she noticed any skin issues she would tell the wound care nurse. The OT stretched and moved Resident #6's right arm to show the offloading device would fit onto his wrist. The DOR stated she in- serviced nursing on where to place positioning devices and to use a pillowcase in the hands or between his arm and chest. The DOR stated the aides would be responsible to place the pillowcases or devices and she did not think an order was needed for offloading devices since it would be the same as a wedge. Interview on 07/29/26 at 12:10 PM, CNA K stated she had worked with Resident #6 for about a week. She stated she used towels in his hands and in between his arms or the blue offloading device. She stated there were boots for his feet. Interview on 07/29/26 at 12:34 PM with CNA S was unsuccessful, a voicemail was left. In a follow-up interview on 07/29/26 at 1:10 PM, LVN I stated usually carrots were used for contracture management, but Resident #6's hands were so tight a carrot would not fit so they were to use foam or a washcloth to relieve pressure. She stated the risk of not using the washcloths or something to decrease the pressure was first, the contracture could get worse and second, the pressure from his own body could cause an opening. Interview on 07/29/26 at 1:29 PM, via phone, with CNA O revealed she had only worked with Resident #6 for the past week or two. She stated she put washcloths in his hands and an offloading device on his wrists to keep his hand from touching his skin. Interview on 07/29/26 at 3:02 PM, CNA P stated she has worked at the facility for 4 years and 7 months. CNA P stated she worked with Resident #6 and was his aide yesterday and gave him a shower yesterday. She stated he had been very contracted for a long time and would try to clean under his fingers when he showered, but she could not open his hands up, so she cleaned mostly the outside of the hands. CNA P stated she did not put anything in his hands but sometimes the nurse would do that. She stated sometimes she would put a pillow between one hand because he would bleed. She stated he would have the blue brace sometimes when therapy put it on and she would put it back on after a shower, but would not put it on if he was not wearing it. She stated he did not have anything on yesterday, not the brace or washcloths. Interview on 07/30/26 at 3:00 PM, RN Q stated Resident #6 had contractures and nurses and aides were responsible for putting washcloths in the palm and underneath his hand to prevent friction. Interview on 07/30/26 at 4:42 PM, ADON A stated CNAs were responsible for putting washcloths and offloading devices on Resident #6 and the nurses were to make sure they were in place for Resident #6. She stated if not done the risk to the resident would be the worsening of contractures. Interview on 07/30/26 at 6:00 PM, the DON stated they were managing Resident #6's contractures the best they could by putting pillowcases, and towels in his hands and the round foam device on his wrists. She stated CNAs, and nurses can attempt and if they had trouble getting them in his hands, they could go to therapy to try to get them in. She stated the washcloth was to soak up moisture, so yeast did not develop and try to keep his skin integrity. The DON stated Resident #6's hands should be cleaned daily and the washcloths should be changed daily. She stated if staff noticed any odor or change it should be reported to the nurse by the aides. The DON did not answer when asked what the risk was.Interview on 07/30/26 at 6:57 PM, the Interim Administrator stated nursing staff was responsible for applying offloading devices. He stated the risk of not managing Resident #6's contractures was he could develop wounds and have a decline in his well-being. Review of Inservice dated 02/18/26 presented by OT N and PTA R reflected Resident #6 Wedge laterally and rotate every 2 hours. Contracture management for BUE/LEs.[sic]Review of facility Contracture Management dated 02/01/25, reflected in part: This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries.'Avoidable' means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following:. implement interventions that are consistent with resident needs, resident goals, and professional standards of practice.3. Interventions for Prevention and to Promote Healing c.i. Redistribute pressure.ii. Minimize exposure to moisture and keep skin clean.skin care intervention such as showers.repositioning devices/schedule and adaptive devices, etc,. are used to reduce the risk of pressure injury development.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 3 of 6 residents (Residents #7, #10, 6#2) reviewed for accidents and supervision. 1.The facility failed to ensure Residents #10 was covered with a smoking apron while being supervised during smoking breaks. 2.The facility failed to ensure Residents #7, #10, and #62 received quarterly smoking assessments. These deficient practices could place residents at risk for burns causing injury or harm. Findings included: Review of Resident #7's MDS dated [DATE] indicated Resident #7 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #7 had a BIMS of 06 indicating severe cognitive impairment. Resident #7 had a diagnoses that included Anxiety Disorder (excessive, uncontrollable worry about everyday issues, affecting daily function and quality of life), Bipolar Disorder (elevated mood, increased energy, and decreased need for sleep, while depressive episodes can lead to feelings of sadness, hopelessness, and loss of interest in activities), Schizophrenia (a severe, chronic brain disorder that affects how a person thinks, feels, and acts), Respiratory Failure (when your respiratory system cannot bring enough oxygen into your blood or get rid of enough carbon dioxide), lack of coordination.Record review of Resident #7's undated care plan revealed: [Resident #7] is a smoker and is at risk for injury. Resident is dependent on staff for smoking. Goal: [Resident #7] will abide by facility's smoking policy and remain safe during times. Interventions included Dependent Smoker: This resident is a dependent smoker and required staff supervision to reduce the risk for smoking related injuries. Independent Smoker: Resident is an independent smoker and does not require the use of a smoking apron or direct staff supervision during smoking breaks. Perform smoking assessment according to facility policy. Safety tubed ashtray device for safety of burn prevention.Resident #7 did not have a smoking assessment[BR51.1] in his clinical chart. Observation and interview on 07/29/26 at 3:40 PM with Resident #7 revealed him outside during a smoking break with a tubing device, with one end of a tube in his hand to administer to his mouth and the other end connected to a lit cigarette. The cigarette was observed to drop ashes to an ashtray that was connected to her wheelchair. Resident #7 indicated he was required to use the tube (smoking apparatus) by pointing to the aide during smoke break waiting on her to provide the tube. Review of Resident #10's MDS dated [DATE] indicated Resident #10 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #10 had a diagnoses that included stroke (sudden interruption of blood flow to the brain), Non-Alzheimer's Dementia (conditions that impair memory, cognition, and daily functioning), Parkinson's Disease (affects movement, balance, tremors), Anxiety Disorder (excessive, uncontrollable worry about everyday issues, affecting daily function and quality of life), Bipolar Disorder (elevated mood, increased energy, and decreased need for sleep, while depressive episodes can lead to feelings of sadness, hopelessness, and loss of interest in activities), Psychotic Disorder (state of having difficulty distinguishing what is real from what is not), Post Traumatic Stress Disorder (intrusive thoughts, avoidance behaviors, negative changes in mood and cognition), and Chronic Obstructive Pulmonary Disease (progressive lung disease that makes it difficult to breathe, primarily caused by long-term exposure to irritants like cigarettes smoke and air pollution), muscle weakness Review of Resident #10's undated care plan revealed: [Resident #10] is a smoker and is at risk for injury. Dependent Smoker. [Resident #10] is a dependent smoker and required staff supervision to reduce the risk for smoking related injuries. Goal: [Resident #10] will abide by facility's smoking policy and remain safe during times. Interventions included assist resident to and from smoking area as needed. Perform smoking assessment according to facility policy. Remind family of need for smoking apron for unsafe smoker and that they must remain with the resident when smoking to prevent injury. Residents use a smoking apron during smoke breaks. Staff to provide direct supervision to unsafe smokers. Resident #10's care plan did not express the use or requirement of a smoking apparatus. Resident #10 did not have a smoking assessment [BR52.1]in her clinical chart. Observation and interview on 07/29/26 at 3:40 PM with Resident #10 revealed her outside during a smoking break with an apron across the front of her body. Resident #10 had a tubing device, with one end of a tube in her hand to administer to her mouth and the other end connected to a lit cigarette. The cigarette was observed to drop ashes to an ashtray that is connected to her wheelchair. According to Resident #10 she was required to use the apron and tube (smoking apparatus) if she wanted to smoke. Resident #10 expressed staff assisted her to the smoking patio, provided an apron and the smoking apparatus during each smoking break. Review of Resident #62's MDS dated [DATE] indicated Resident #62 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #62 had a diagnosis that included high blood pressure, high blood sugar, Anxiety Disorder (excessive, uncontrollable worry about everyday issues, affecting daily function and quality of life), Bipolar Disorder (elevated mood, increased energy, and decreased need for sleep, while depressive episodes can lead to feelings of sadness, hopelessness, and loss of interest in activities), Psychotic Disorder (state of having difficulty distinguishing what is real from what is not), Schizophrenia (a severe, chronic brain disorder that affects how a person thinks, feels, and acts), Respiratory Failure (when your respiratory system cannot bring enough oxygen into your blood or get rid of enough carbon dioxide), nicotine dependence (chronic, relapsing condition where the body and brain become reliant on nicotine). Review of Resident #62's undated care plan revealed: [Resident #62] is a smoker and is at risk for injury. [Resident #62] will have behaviors when she is out of cigarettes. Goal: Resident will abide by facility's smoking policy and remain safe during times. Interventions included Independent Smoker: Resident is an independent smoker and does not require the use of a smoking apron or direct staff supervision during smoking breaks. Perform smoking assessment according to facility policy.Resident #62 did not have a smoking assessment [BR53.1]in her clinical chart. Observation and interview on 07/29/26 at 3:40 PM with Resident #62 revealed her outside during a smoking break with a cigarette. Resident #62 appeared to be a safe smoker with cigarettes. Resident #62 was able to maintain her cigarette after the CNA C lit it and was able to properly use an ashtray to prevent any dropped ashes or burns. Resident #62 expressed staff held cigarettes in a box and issued two cigarettes during each smoke break. According to Resident #62 she was able to smoke without an apron or smoking tube, she was not sure if she had ever completed a smoking assessment. Observation and interview on 07/30/26 at 3:44 PM with CNA C revealed 7-8 residents on the patio during a smoking break. Resident #7 was on the patio observed with a smoking tube (smoking apparatus) in his hand waiting to have a cigarette administered to the end of the tube. Resident #10 on the patio holding a smoking apparatus in her hand, administering it to her mouth for smoking. Resident #10 was not wearing an apron as it was on the ground underneath the table where CNA C was standing. [BR54.1][JT54.2]Resident #62 was sitting in her rollator smoking on a cigarette, another cigarette in her hand, and asking for her vape. Resident #62 indicated her vape was not working and would like to have it charged for the next smoke break. According to CNA C, all residents required supervision however, both Resident #7 and Resident #10 required a smoking tube which connected the tube to the cigarette, the cigarette was mounted to the ashtray, which was attached to their wheelchair. According to CNA C the apparatus prevented any ashes dropping on their body or clothing. CNA C stated Resident #62 did not require a smoking tube because she was an independent smoker. When CNA C was asked about Resident #10's smoking apron, she stated Resident #10 did not have to use the apron as long as she used the smoking tube. CNA C further stated smoking assessments for residents, she stated nurses were responsible for completing the smoking assessments. CNA C stated she had training to supervise residents during smoking breaks which included which residents required supervision. CNA C stated staff who took residents out to smoke were responsible for supervising residents and administering any protective equipment. CNA C stated not properly supervising residents placed them at risk of burn injuries. Interview on 07/30/26 at 6:00 PM with Social Worker revealed she completed smoking contracts and educated residents on the facility policy for smoking. The Social Worker stated she had not completed any smoking assessments with residents, she had only completed the smoking contracts. The Social Worker stated the smoking contracts were completed in March or April 2026 before the new company took over. The Social Worker stated she was not aware of who was responsible for completing the smoking assessments for residents that smoked. The Social Worker stated all contracts were uploaded in the old system to be transferred into the new system. The Social Worker stated she had not reviewed resident charts to ensure the smoking contracts were there and could not provide copies at this time. According to the Social Worker, not providing smoking assessments placed residents at risk of injury if was not aware of the required safety measures. Interview on 07/30/2026 at 6:35 PM the DON stated all staff that assisted residents with smoking were aware that Resident #7 required a smoking apparatus, Resident #10 required protective equipment that included a smoking apron or smoking apparatus. The DON stated Resident #10 now used a smoking apparatus, which did not require the use of an apron[BR55.1][JT55.2]. The DON expressed that Resident #62 was an independent smoker and did not require either. The DON further expressed all staff were responsible for ensuring residents were supervised during smoking breaks with appropriate protective equipment. The DON stated smoking assessments were to be completed quarterly, which were every 3 months. The DON stated when the facility was acquired by a new company, new smoking contracts and new smoking assessments were completed, however they may not have been transferred into the new system. The DON stated she could not locate the assessments as they were all uploaded to the system with the expectation of the documents transferring properly with the new company in April 2026. [BR56.1]The DON stated the Social Worker was responsible for ensuring smoking assessments were completed quarterly, not doing so placed residents as risks of smoking injuries. Record review of the facility Smoking Policy - Residents policy, revised 07/14/23, reflected: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees as related to smoking. To evaluate a patient's ability to participate and exercise the privilege to smoke/Use smokeless Tobacco products while residing within the facility.Evaluate patients that smoke/use smokeless tobacco, utilizing the Smoking Evaluation/Smokeless Tobacco Tool: (a) upon admission; (b) quarterly (c) when a previous non-smoking patient takes up smoking or when a patient takes up the use of smokeless tobacco (d) if unsafe smoking practices are observed in a current smoker; or a smokeless Tobacco user can no longer manage the use of, or cleaning/storage abilities (e) when a patient that smokes or uses smokeless Tobacco products has a significant change in medical condition. Request therapy screen as indicated. Education will be provided to the resident on the assessment and the facility's expectation of compliance with the smoking program. Residents who smoke/use smokeless tobacco, will sign a smoke agreement upon admission and will be required to follow rules and regulations.

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 the facility's only kitchen. 1. The facility failed to ensure a large piece of meat stored in the refrigerator was properly sealed and stored to prevent liquid from spilling over other food items that were not properly sealed, labeled or dated.2. The facility failed to ensure staff that worked or entered the kitchen wore and maintained proper use of hair nets.This failure could place all residents at risk for food contamination and food borne illness. Findings included: Observation and interview on 07/28/26 at 9:00 AM with [NAME] D of the refrigerator revealed a sheet pan with a large piece of meat wrapped in plastic, lightly covered by a piece of foil. The sheet pan was observed to be tilted on food item that [NAME] D revealed to be unsealed, unlabeled, or undated bacon wrapped in white parchment paper. The parchment paper had red ring stains indicating that liquid from the sheet pan had leaked creating a puddle at the bottom of the refrigerator. According to [NAME] D she did not know how long the meat had been in the refrigerator. [NAME] D stated the Dietary Manager was responsible for completing daily walks throughout the refrigerator to ensure food was properly sealed, labeled and dated. [NAME] D further stated the Dietary Manager was responsible for cleaning out the refrigerator when spills happened. [NAME] D stated when food was not properly stored it placed residents at risk of getting sick. Observation and interview on 07/29/26 at 11:30 AM in the kitchen revealed the Maintenance Assistant entered the kitchen without providing any hand hygiene. The Dietary Manager advised the hair nets were behind him. The Maintenance Assistant turned around to administer a beard net to his head, which included a long ponytail. According to the Maintenance Assistant, he was not aware of how to administer the hair net. The Maintenance Assistant was advised the hair net was for his beard, he then stepped outside the kitchen to administer the proper hair net. Observation revealed he did not cover his entire head of hair while in the kitchen, leaving out his ponytail that measured at least 12 inches long from the back of his neck. The Maintenance Assistant returned to the kitchen without any hand hygiene and stood near staff preparing resident's dessert [VT74.1]for the lunch trays. Interview with the Maintenance Assistant revealed he did not think the beard net was the right hair net, so he went outside the door to get a proper hair net. The Maintenance Director stated he was aware to use the hair nets while in the kitchen. According to the Maintenance Assistant, he just forgot to use hand hygiene after entering the kitchen, not doing so placed residents at risk of contamination and food illnesses. Interview on 07/29/26 at 12 PM with the Dietary Manager revealed she noticed the leaking in the refrigerator when she entered the facility on 07/28/26. The Dietary Manager revealed she had been trying to rearrange the refrigerator, to have one side for thawing to prevent situations like leakages. According to the Dietary Manager, the cooks were in charge when she was not working and she expected all staff and the cooks to complete daily walk-throughs to ensure food was properly sealed, labeled and dated. The Dietary Manager stated [NAME] D should have observed the spill and open food upon the start of her shift and removed the open bacon and discarded it; the leakage at the bottom of the refrigerator should have been cleaned. The Dietary Manager stated these conditions placed residents at risk of contamination and illness. The Dietary Manager further expressed that she did advise the Maintenance Assistant to administer a hair net but did not see that he tried to use the beard net for his head. The Dietary Manager stated the Maintenance Assistant entered the kitchen during lunch rush, so she did not notice he did not wash his hands and administered the hair net incorrectly. The Dietary Manager stated she expected all staff entering the kitchen to use proper hygiene, which included hair nets and washing their hands, not doing so placed residents at risk of food born illnesses due to food contamination. Food Storage Policy was requested, however, it was not provided by exit date. Review of the facility's Personal Hygiene policy, revised 10/24/22, reflected: Dietary employees will maintain proper food safety practices through proper personal hygiene. Proper hand washing techniques and exclusion of infectious individuals from handling food are critical for prevention of foodborne illness.Dietary employees shall wear, hair covering, beard restraint, and clothing that covers body hair. Staff that work serving in the dining room do not need to wear hair restraints. Any staff entering the kitchen must comply with hair restraints and hand washing.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests and rodents for 1 of 2 halls (Station 1), Resident #6's room, and 1 of 1 kitchen reviewed[VT69.1] for pest control. The facility failed to ensure Station 1 hall and the kitchen were free from pests.This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life.Findings included:Observation on 07/29/26 at 9:20 AM on Station 1 hallway, revealed 2 flies flying and landed on wall near the soiled utility room. Interview and observation on 07/29/26 at 11:40 AM in the kitchen revealed 3-5 flies on the snack box and another 4-5 flies flying around the kitchen. According to the Dietary Manager, she was aware of the fly problem in the kitchen, she stated it was due to the back door not having a proper seal to close off the door properly. The Dietary Manager stated the Administrator was aware and in the process of purchasing a blower over the door to keep flies from entering the back door to the kitchen. According to the Dietary Manager all staff were responsible for ensuring the door is closed at all times to prevent flies from entering the kitchen. The Dietary Manager stated not doing so will place residents at risk of food contamination.Observation and interview on 07/29/26 at 3:14 PM, in Resident #6's room during wound care, revealed a fly flying around in the room around Resident #6, who was in bed. Resident #6 was not able to answer questions. RN J said she noticed the fly in the room and said if they saw pests they were to write it down for the exterminator. She stated she had noticed flies in common areas and they would shoo them away from residents. Interview on 07/28/26 at 3:38 PM, the Maintenance Director stated he had been there 6 weeks. He stated he had noticed flies and they were working on the door curtains and new doors for the kitchen. He stated staff were to write any sightings in the pest control book and when pest control did come out, they would treat those areas. Interview on 07/28/26 at 4:16 PM, the Interim Administrator stated they were trying to address the pest control issue and a new frame and door were approved to be replaced in the kitchen. He stated there was an air curtain outside the kitchen door and they had ordered two new ones but had some issues getting them up due to electrical problems. The new air curtains were for the kitchen and the smoking area. He stated the flies were coming in when staff took people to smoke.Interview on 07/28/26 at 6:00 PM, the DON stated flies could irritate the residents and they had pest control come out to treat some resident rooms for flies. She stated her expectation was for staff to write down any pest sightings or alert Maintenance. She stated the risk to residents would be infection control. Interview on 07/28/26 at 6:57 PM, the Interim Administrator stated the risks to residents were flies and pests could potentially carry disease and it could be unclean and undignified for the residents. [Vendor Name] pest services inspection reports reflected the following:- Report dated 06/09/26 reflected, in part, Recommendations: Repair or replace the kitchen rear exit door to ensure proper closure.Replace the recommended fly light bulbs and starters - Report dated 07/09/26 reflected, in part, [Vendor Name] completed a specialized fly control service targeting house flies, drain flies.fly wipe-down treatments were performed on common resting areas.bulbs were replaced in the kitchen light unit.Record review of the facility's Pest Control Program policy, dated 1/10/2020, reflected .It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.4. Facility will utilize a variety of methods in controlling certain seasonal pests, i.e. flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations.

Based on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #10) of 5 residents reviewed for comprehensive care plans. The facility failed to update Resident #10's care plan to address the use of a smoking apparatus.The facility failed to ensure Resident #10 was wearing an apron as it was on the ground underneath table where CNA C was standing. This failure could result in the resident not receiving appropriate supervision, protection and care during smoking breaks.Findings included:Review of Resident #10's MDS dated [DATE] indicated Resident #10 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #10 had a diagnoses that included stroke (sudden interruption of blood flow to the brain), Non-Alzheimer's Dementia (conditions that impair memory, cognition, and daily functioning), Parkinson's Disease (affects movement, balance, tremors), Anxiety Disorder (excessive, uncontrollable worry about everyday issues, affecting daily function and quality of life), Bipolar Disorder (elevated mood, increased energy, and decreased need for sleep, while depressive episodes can lead to feelings of sadness, hopelessness, and loss of interest in activities), Psychotic Disorder (state of having difficulty distinguishing what is real from what is not), Post Traumatic Stress Disorder (intrusive thoughts, avoidance behaviors, negative changes in mood and cognition), and Chronic Obstructive Pulmonary Disease (progressive lung disease that makes it difficult to breathe, primarily caused by long-term exposure to irritants like cigarettes smoke and air pollution), and muscle weakness. Review of Resident #10's undated care plan revealed: [Resident #10] is a smoker and is at risk for injury. Dependent Smoker. [Resident #10] is a dependent smoker and required staff supervision to reduce the risk for smoking related injuries. Goal: [Resident #10] will abide by facility's smoking policy and remain safe during times. Interventions included assist resident to and from smoking area as needed. Perform smoking assessment according to facility policy. Remind family of need for smoking apron for unsafe smoker and that they must remain with the resident when smoking to prevent injury. Residents use a smoking apron during smoke breaks. Staff to provide direct supervision to unsafe smokers. Resident #10's care plan did not express the use or requirement of a smoking apparatus. Resident #10 did not have a smoking assessment in her clinical records.Observation and interview on 07/29/26 at 3:40 PM with Resident #10 revealed her outside during a smoking break with an apron across the front of her body. Resident #10 had a tubing device, with one end of the tube in her hand to administer to her mouth and the other end connected to a lit cigarette. The cigarette was observed to drop ashes to an ashtray that was connected to her wheelchair. According to Resident #10 she was required to use the apron and tube (smoking apparatus) if she wanted to smoke. Resident #10 expressed staff assisted her to the smoking patio, provided an apron and the smoking apparatus during each smoking break. Observation and interview on 07/30/26 at 3:44 PM with CNA C revealed Resident #10 on the patio holding a smoking apparatus in her hand, administering it to her mouth for smoking. Resident #10 was not wearing an apron as it was on the ground underneath table where CNA C was standing. According to CNA C, Resident #10 was a smoker, she required supervision, which included the smoking tube and ashtray that was connected to her wheelchair. CNA C stated Resident #10 did not have to use the apron because she used the smoking apparatus. CNA C explained both the smoking apparatus and the apron were used to provide protection against Resident #10 burning herself or clothing if she was to drop her cigarette. CNA C stated she had training to supervise residents during smoking breaks which included which residents required supervision. CNA C stated staff who took residents out to smoke were responsible for supervising residents and administering any protective equipment. CNA C stated not properly supervising residents placed them at risk of burn injuries. Interview on 07/30/2026 at 6:35 PM with the DON revealed all staff that assisted residents with smoking were aware that Resident #10 required protective equipment. The DON stated Resident #10 now used a smoking apparatus, which did not require the use of an apron. The DON did not indicate when Resident #10 started using the smoking apparatus. The DON further expressed all staff were responsible for ensuring resident care plans were updated. The DON stated Resident #10's use of the smoking apparatus should have been included in her care plan so that all staff knew how to properly assist her during smoking breaks. Review of facility policy Comprehensive Care Plans dated: 02/10/21 reflected the following: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessments. The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 of 3 residents (Resident #6) reviewed for enteral feeding. The facility failed to ensure LVN F checked G-tube (tube placed into the stomach to deliver food, liquids, and medicine) placement prior to administering Resident #6's medications on 07/29/26 per facility policy and physician's order.These failures could place residents at increased risk of aspiration, bloating discomfort, and not receiving the full benefit of the medications administered. Findings included:Record review of Resident #6's Face Sheet, dated 07/30/26, reflected a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #6's Significant Change MDS, dated [DATE], reflected that he had the following diagnoses: Encephalopathy (any disease, damage, or malfunction of the brain that causes altered mental function), Dysphagia (difficulty swallowing), and Malnutrition. The MDS also reflected Resident #6's cognitive skills were severely impaired, and he required a feeding tube for nutrition. Record review of Resident #6's Care Plan, undated, reflected that he required the use of a feeding tube for all nutrition with an intervention to check for tube placement per facility protocol. Record[BR57.1] review of Resident #6's order summary reflected the following: Enteral Feed Order every shift for monitor check G/T placement before administration of meds and enteral feedings.Enteral Feed Order every shift.Flush enteral tube with 30ml water pre/post medication administrationand 5-10 ml water between each medicationObservation on 07/29/26 at 7:34 AM reflected LVN F performed hand hygiene, and prepared the following medications into one medication cup: Vitamin D3 1000-unit 1 capsule Acetaminophen 500 mg 1 tabletAscorbic Acid 250 mg (Vitamin C) 2 tabletsZinc Sulfate 220 mg 1 tablet Thiamine 100 mg 1 tablet Eliquis 5 mg (blood thinner) 1 tabletTizanidine 4 mg (muscle relaxer) 1 tablet Atorvastatin 40 mg 1 tablet LVN F also prepared medication multivitamin with minerals 5 ml of liquid and Prostat 30 ml (wound healing supplement) in separate medication cups. LVN F crushed the medication tablets together and poured the crushed medications into a new cup. LVN F then mixed the medications with water. After preparing the medications, LVN F performed hand hygiene, applied PPE, and entered Resident #6's room. The medications were set on a clean table with a barrier. LVN F paused and disconnected Resident #6's tube feeding. LVN F connected the syringe to the G-tube and flushed[BR58.1] with 30 ml of water via gravity, poured the crushed medications into the syringe[BR59.1], flushed with 10 ml of water, administered the Prostat, flushed with 10 ml of water, administered the multivitamin, and then flushed with 30 ml of water all via gravity. LVN F then restarted the tube feeding, discarded the supplies, removed the PPE and washed his hands before exiting the room. LVN F did not check G-tube placement before administering the medications and did not administer the medication tablets separately. Interview on 07/29/26 at 8:05 AM with LVN F revealed he had worked at the facility for 2 years. He stated he had been trained on G-tube administration, but he was nervous. LVN F stated he forgot to check the tube placement and pointed to his stethoscope on the medication cart. He stated the risk of not checking the placement was administering the medication in the wrong place if the tube was dislodged. Interview on 07/30/26 at 4:21 PM with ADON A revealed that she expected the nurses to crush each medication separately, check placement with auscultation (listening with a stethoscope while pushing a small amount of air into the g-tube), and follow the physician's orders with flushing in-between the medications. ADON A stated the nurses were responsible for ensuring the proper administration of medication. ADON A stated checking the tube placement was important to ensure it was in the proper position. She stated the risk of not checking G-tube placement was administering in the incorrect placement and causing harm to the resident. Interview on 07/30/26 at 5:46 PM with the DON revealed that she expected the nurses to check placement before administering any medications. She stated that was important to ensure it was in the proper place. The DON stated the risk of not checking placement was administering medications in the wrong area. The DON stated the risk of mixing medications was drug interactions. Record review of the facility policy, titled Enteral Tube Feeding revised 02/22/25, reflected the following: .7. Each medication is prepared individually so that it can be administered separately.9. Enteral tube placement must be checked via auscultation and/or aspiration (attach a syringe and draw out a small amount of stomach fluid] before any fluids or medication is administered.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 2 of 6 residents (Resident #60 & #76) and 1 of 3 medication carts (Station 2 Nurse cart) reviewed for pharmaceutical services. 1. MA E failed to supervise Resident #60 after she left the resident's medications in his room during morning medication administration on 07/28/26. 2. The facility failed to ensure that one bottle of OTC Famotidine 10 mg, with an expiration date of January 2026, and a bubble pack of Ondansetron 8 mg tablets prescribed to Resident #76, with an expiration date of 06/20/26, had been removed from the Station 2 nurse cart. This failure could place the residents at risk of not receiving medications as ordered by the physician or receiving medications that were ineffective.Findings included: 1. Record review of Resident #60's Face Sheet, dated 07/29/26, reflected a [AGE] year-old male who admitted on [DATE]. Record review of Resident #60's Quarterly MDS, dated [DATE], reflected he had the following diagnoses: Diffuse Traumatic brain Injury with loss of consciousness (Widespread damage to brain's nerve fibers), Hypertension (high blood pressure), and need for assistance with personal care. The MDS also reflected Resident #60 had a BIMS score of 15, indicating he was cognitively intact. Record review of Resident #60's Care Plan, undated, reflected the resident was taking a black box medication (high-risk medication) and had cognitive impairment with an intervention to administer mediations per physician's orders and monitor for effectiveness or adverse reactions. Record review of Resident #60's Self Administration Evaluation Assessment, dated 07/21/21, reflected he was unable to safely administer medications.Record review of Resident #60's July MAR and physician orders reflected the following medications were administered the morning of 07/28/26 by MA E: Amiodarone 200 mg tablet (medication used to treat and prevent life-threatening heart rhythm problems)Aspirin 81 mg tablet Cholecalciferol 50 mcg tablet (Vitamin D)Cranberry 450 mg tablet Folic Acid 1 mg tablet Multivitamin tablet Thiamine 100 mg tablet Tylenol 325 mg 2 tablets Zoloft 50 mg tablet for depressionGabapentin 300 mg capsule for neuropathy Interview and observation on 07/28/26 at 10:59 AM with Resident #60 reflected he was lying in bed. Medications in cup observed on bedside table in front of him. Resident #60 stated he was going to take his medications right now, that he just needed to open his coca cola first. No staff member was present in the room. Observation reflected at least 6 medications in the cup, with 1 red tablet. Resident #60 decline to allow the medications to be counted. He stated he did not want[VT70.1] anything written down about the medications or for the staff to get in trouble. Resident #60 stated the staff member just dropped off his medications a couple minutes ago and would not say the staff's name. Resident #60 stated he had a lot of medications and preferred to take them by himself, so he asked the staff member to leave them. He stated the staff would not always leave the medications on his table, but he preferred when they did. During the interview, Resident #60 took his medications. Interview on 07/28/26 at 11:23 AM, LVN H stated MA E gave Resident #60 his medications that morning.Interview on 07/28/26 at 12:23 PM with MA E reflected that she gave morning medications to Resident #60. She stated she did leave the medications on his table and did not observe him taking the medications. MA E stated that Resident #60 told her to leave the medications and leave the room. She stated Resident #60 would not take the medications if she watched him and that she would wait all day. MA E stated the nurses were aware that Resident #60 had that behavior. She stated she was not supposed to leave medications at the bedside because there was a risk another resident could take them instead. MA E stated she would go back to ensure that he took his medications by seeing the empty medication cup. MA E stated she had been trained to not leave the medications at the bedside. Interview on 07/30/26 at 1:07 PM with LVN H reflected that she was the nurse for Resident #60. LVN H stated the MAs should always watch Resident #60 take the medications and not leave them unattended. She stated it was protocol to ensure that the residents took the medications. LVN H stated the MAs were responsible for ensuring that they were administering the medications. LVN H stated the risk of leaving medications unattended was the resident may not take them and it could harm the resident. Interview on 07/30/26 at 5:02 PM with ADON B reflected that she expected the staff to watch all the residents take the medications. ADON B stated the nurses and MAs were responsible for ensuring the residents were taking the medications. ADON B stated she was not aware of medications being left in Resident #60's room unattended. She stated Resident #60 could be difficult, but that medications should not be left unattended. ADON B stated the risk of leaving medications unattended was another resident could take the medications or the resident may not take them and cause side effects. Interview on 07/30/26 at 5:46 PM with the DON reflected that she expected her staff to observe the residents taking their medications. She stated if the resident does not want to take the medications, then the medications should be taken out of the room. The DON stated the nurses were responsible for ensuring that the medications were administered. The DON stated Resident #60 could not self-administer medications. The DON stated the risk of leaving medications unattended was another resident could potentially take the medications. 2. Record review of Resident #76's Face Sheet, dated 07/30/26, reflected a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE].Record review of Resident #76's Quarterly MDS, dated [DATE], reflected he had the following diagnoses: Dementia (decline in brain function that interferes with daily life) and Nausea with vomiting. The MDS also reflected Resident #76's cognitive skills were moderately impaired. Record review of Resident #76's Care Plan, undated, reflected that he had cognitive impairment related to his Dementia and to administer medications per physician's order. The care plan also reflected that the resident received medications and to monitor for any nausea or vomiting. Record review of Resident #76's order summary, dated 07/30/26, reflected: Ondansetron (Zofran) 8 mg tablet give 1 tablet every 12 hours as needed for nausea and vomiting.Record review of Resident #76's MAR from 06/20/2026-07/29/26 reflected that he did not receive any as needed doses of Ondansetron.Observation on 07/29/26 at 12:02 PM of the Station 2 Nurse hallway medication cart with LVN H reflected a bubble pack of Ondansetron 8 mg prescribed to Resident #76 with 2 tablets remaining that had expired on 06/20/26. Observation also revealed OTC Famotidine (medication to reduce stomach acid) 10 mg with an expiration date of 01/2026. Interview on 07/29/26 at 12:05 PM with LVN H, she stated the Famotidine expired in January 2026 and the Ondansetron expired on 06/20/26. She stated she had not given the Ondansetron to Resident #76 in a while and was not able to recall the last dose given. LVN H stated she checked her medication cart for expired medications when she had time and before administering the medications. LVN H stated the nurses were responsible for ensuring there were no expired medications on the carts. She stated the risk of having expired medications was they could be administered and cause an adverse reaction. Interview on 07/30/26 at 5:02 PM with ADON B, she stated that she expected the nurses to check the expiration date before administering medications. She stated she would check the medication carts quarterly and as needed to ensure there were no expired medications. ADON B was unable to recall the last time she reviewed the medication carts. ADON B stated the nurses were responsible for ensuring there were no expired medications in their carts. She stated the risk of having expired mediations in the cart was they could be given and cause side effects or be ineffective.Interview on 07/30/26 at 5:52 PM with the DON reflected that she expected her staff to check for expired medications when administering any medications. She stated they had pharmacy that came once a month and the ADONs did random audits to ensure there were no expired medications. The DON stated the nurses were responsible for ensuring there were no expired medications. She stated the risk of having expired medications was they could be administered to the residents and not be effective. Record review of the facility's Medication Administration: Medication Pass policy, revised 02/10/20 reflected the following: .Remain with patient until administration of medications is complete.Record review of the facility's Medication Storage Policy, dated 01/20/21 reflected the following: .8. Medication Carts are routinely inspected for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are removed and destroyed in accordance with the facility policy[VT.

Based on observation, interview and record review the facility failed to ensure the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 27.59%, based on 8 errors out of 29 opportunities, which involved 1 of 5 residents (Resident #6) and 1 of 3 staff (LVN F) observed during medication administration reviewed for medication error.The facility failed to ensure LVN F mixed each crushed medication with water and administered one medication at a time through Resident #6's g-tube.This failure could place residents at risk of medication interactions leading to an altered therapeutic response. Findings include:Record review of Resident #6's Face Sheet, dated 07/30/26, reflected a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #6's Significant Change MDS, dated [DATE], reflected that he had the following diagnoses: Encephalopathy (any disease, damage, or malfunction of the brain that causes altered mental function), Dysphagia (difficulty swallowing), and Malnutrition. The MDS also reflected Resident #6's cognitive skills were severely impaired, and he required a feeding tube for nutrition. Record review of Resident #6's Care Plan, undated, reflected that he required the use of a feeding tube for all nutrition with an intervention to check for tube placement per facility protocol. Record review of Resident #6's order summary reflected no physician order to combine medication tablets or cocktail medications. Observation on 07/29/26 at 7:34 AM reflected LVN F performed hand hygiene, and prepared the following medications into one medication cup: Vitamin D3 1000-unit 1 capsule Acetaminophen 500 mg 1 tabletAscorbic Acid 250 mg (Vitamin C) 2 tabletsZinc Sulfate 220 mg 1 tablet Thiamine 100 mg 1 tablet Eliquis 5 mg (blood thinner) 1 tabletTizanidine 4 mg (muscle relaxer) 1 tablet Atorvastatin 40 mg 1 tablet LVN F also prepared multivitamin with minerals 5 ml of liquid and Prostat 30 ml (wound healing supplement) in separate medication cups. LVN F crushed the medication tablets together and poured the crushed medications into a new cup. LVN F then mixed the medications with water. After preparing the medications, LVN F performed hand hygiene, applied PPE, and entered Resident #6's room. The medications were set on a clean table with a barrier. LVN F paused and disconnected Resident #6's tube feeding. LVN F flushed with 30 ml of water via gravity, poured crushed medications into syringe, flushed with 10 ml of water, administered the prostat, flushed with 10 ml of water, administered the multivitamin, and then flushed with 30 ml of water all via gravity. LVN F then restarted the tube feeding, discarded supplies, removed PPE and washed his hands before exiting the room. LVN F did not administer the medication tablets separately. Interview on 07/29/26 at 8:05 AM with LVN F reflected he had worked at the facility for 2 years. LVN F stated he typically crushed the medication tablets together if they were not enteric coated (outer layer on pills and capsules that stops them from dissolving in the stomach). He stated he was aware that he was not supposed to mix the liquids but thought if the tablets were not enteric coated, they could be given together. LVN F stated administering the medications together could put a risk of medication interaction and cause an adverse reaction to the resident. He stated he had been trained on G-tube administration, but he was nervous. Interview on 07/30/26 at 4:21 PM with ADON A reflected that she expected the nurses to crush each medication separately, check placement with auscultation, and follow the physician orders with flushing in-between the medications. ADON A stated the medications should not be crushed together. She stated there was a risk of potential interactions and side effects of the medications if they were crushed and administered together. ADON A stated the nurses were responsible for ensuring the proper administration of medication. Interview on 07/30/26 at 5:46 PM with the DON reflected that she expected her staff to crush and administer medications for G-tube administration separately. She stated the medications should not be cocktailed. The DON stated the risk of mixing medications was drug interactions. The DON stated it was a medication error to mix the medications together. The DON stated it was the nursing team's responsibility to ensure proper medication administration. Record review of the facility policy, titled Enteral Tube Feeding revised 02/22/25, reflected the following: .7. Each medication is prepared individually so that it can be administered separately.9. Enteral tube placement must be checked via auscultation and/or aspiration before any fluids or medication is administered. Record review of the facility policy, titled Prevention of Medication Errors revised 02/10/22, reflected the following: Medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specification or accepted professional standards and principals.25. Crushed meds are combined only as indicated based on person centered.

Based on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in 1 of 1 kitchen. The facility failed to ensure water in the compartment sink had an appropriate ppm of sanitizer.This failure could place residents at risk for food contamination and food borne illness. Findings included:Observation and interview on 04/01/26 at 10:10 AM with the Dishwasher Aide revealed he returned to work on 04/01/26 to the dishwasher area being inoperable due to ongoing repairs, which required the kitchen to serve meal with paper products. Observation of the Dishwater Aide using the compartment sink to wash cups from the morning breakfast, The Dishwasher Aide revealed he had not tested the level of sanitation and when asked to complete he responded that he had only been working at the facility for 4 weeks, never been trained to ensure he was properly sanitizing dishes. Interview on 04/01/26 at 10:13 AM with the [NAME] stated, there are strips over there to check the sanitation, but I am just the Cook, The [NAME] was asked to demonstrate how she performed sanitation level checks when washing her own cooking utensils, she then stated she did not test sanitation levels for her dishes. The [NAME] further explained she did not have a log sanitation log to show the history of sanitation levels. During an interview and observation on 04/01/26 at 11:20 AM, the Administrator revealed the facility had purchased paper goods on 03/27/26 to begin immediately once repairs in the dishwashing area in the kitchen began. The Administrator stated she was unaware that residents were using anything other than paper goods. The Administrator stated the Dietary Manager was out due to being ill. The Administrator went to the kitchen to see how much sanitizer was required when using the compartment sink. Record review revealed the kitchen logbook sheet dated 04/07/26 did not indicate ppm of sanitizer needed when using at the compartment sink. During an interview on 04/01/26 at 11:25 AM, the [NAME] revealed she received a text on 04/01/26 indicating the facility was to use paper goods for meals due to kitchen repairs in the dishwashing area. The [NAME] stated the evening shift prepared the drinks for the morning meal with regular cups, and the Dishwasher Aide was using the compartment sink to clean them. The [NAME] stated the Dishwasher Aide was responsible for logging sanitation levels, however he had never been trained, and had never tested sanitation levels. During an interview on 04/01/26 at 11:40 AM, the Administrator revealed the kitchen staff should have been serving resident meals on paper goods. The Administrator stated education will be provided, all dishes washed on 04/01/26 will be rewashed using the high temperature dishwasher machine. The Administrator stated it was the responsibility of all kitchen staff to ensure the proper sanitation levels are being tested while using the compartment sinks, not doing so placed residents at risk of illnesses. Observation and interview on 04/01/26 at 1:20 PM with the Dishwasher Aide revealed him running water in the compartmental sink explaining the sanitation rinse water was to be used after the dishes had been cleaned . Observation of the Dishwasher Aide pulled testing strip and identified the sanitation level to read between 200- 400 ppm. According to the Dishwasher Aide he had completed education to ensure all dishes were properly sanitized after each use. The Dishwasher Aide stated he was responsible for testing the sanitizer levels while doing the dishes. The Dishwasher Aide stated it was important to ensure proper levels of sanitation to create cleanliness, prevent illness and if there was an issue it should be reported to the Dietary Manager. Record review of the facility's Food Safety and Sanitation Plan policy, revised November 2017, reflected the following: It is the policy of this facility to follow an effective, proactive food safety program that is based on preventing food safety hazards before they occur. Sanitizing solution must be maintained at appropriate strength per manufacturer's instructions. The sanitizing solution shall be used for no other purpose. The solution must be changed routinely to ensure proper strength.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility's only kitchen free of pest when reviewed for pest control. The facility failed to ensure the facility's kitchen was free of gnats and roaches.This failure could affect residents by placing them at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life. Findings included: Observation and interview on 04/01/26 at 10:00 AM with the Dishwasher Aide revealed there were gnats and roaches in the kitchen, in the dishwasher area. The was water on the floor, gnats flying, and roaches crawling in the dishwashing area. The Dishwasher Aide stated there had been pests in the dishwashing area since he started about 4 weeks ago, due to the standing water. The Dishwasher Aide stated the Dietary Manager was notified and knew about the issues in the dishwasher area.Observation and interview on 04/01/26 at 10:09 AM with the Maintenance Supervisor revealed there had been ongoing attempts to correct the standing water issue in the dishwashing area. The Maintenance Supervisor stated there was an issue with water leaking which resulted in several attempts to find the source. The Maintenance Supervisor stated he was aware of the pest in the dishwashing area; the gnats appeared with the standing water and the roaches appeared when the floor was dug up in repair to a busted pipe. The Maintenance Supervisor stated pest control vendor has been out to get rid of the pest. He was responsible for addressing the pest by contacting the Administrator and the pest control vendors, not doing so placed residents at risk of malnutrition and decreased quality of food. Record review of the pest control vendor logbook reflected that the last visits to the facility were on 03/02/26, 02/27/26 and 01/06/26.Interview on 04/01/26 at 10:35 AM with the Administrator revealed there had been an ongoing issue with pests in the dishwashing area of the kitchen. The Administrator stated the pest control vendors came to the facility monthly. The Administrator stated pest control vendors had been called to the facility additional times to address the gnats during the repairing phases. The Administrator stated she was not aware of roaches. The Administrator stated that not providing proper pest control placed residents at risk of contamination and illness.Record review of the facility's Pest Control Program policy, dated 01/10/20, reflected the following: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.Facility will obtain services as indicated related to issues that may arise in between scheduled visits with the outside pest service and treat as indicated.Facility will utilize a variety of methods in controlling certain seasonal pests, i.e., flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations.

Based on observation, interview, and record review, the facility failed to provide a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 5 residents (Resident #1) reviewed for ADL care. The facility failed to ensure staff consistently performed resident rounds every two hours as required by facility policy and Resident #1's care plan. This failure could place residents at risk for complications associated with delayed care which could negatively affect the resident's safety, comfort, and skin integrity.Record review of Resident #1's admission Record, dated 10/18/25, reflected the resident was a [AGE] year-old male initially admitted [DATE] with diagnoses to include Cerebral Infarction (disruption of blood supply that could result to tissue death), Epilepsy (seizures), Cognitive Communication Deficit (trouble participating in conversations), Dysphagia Oropharyngeal Phase (difficulty swallowing in mouth and throat), Dysarthria and Anarthria (complete loss of speech), Amyotrophic Lateral Sclerosis (loss of muscle control), Muscle Weakness, Unsteadiness on Feet, Lack of Coordination, and Repeated Falls. Record review of Resident #1's Quarterly MDS, dated [DATE], reflected the resident had a BIMS score of 6 out of 15, which indicated severe cognitive impairment. In MDS Assessment Section GG-Functional Abilities revealed resident was dependent or required substantial assistance for ADL care. Record review of Resident #1's care plan, revised date 10/21/24, reflected: Focus: ADLs: [Resident #1] an ADL Self Care Performance Deficit related to: Limited ROM, Limited Mobility, Confusion. Requires 2 staff members to assist [Resident #1] due to size, extensive assistance, and high fall risk. Goal: [Resident #1] will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through next review date. Interventions: Hoyer lift x2 staff. Resident educated to use call light prior to attempting activities and wait for assistance. Remind/educated resident on physical limitations and inability to walk without assistance. Staff will frequently round to anticipate needs. Resident is Max assist. Bed Mobility: Extensive assistance. Transfers: Total Dependence assistance x2 staff using a Hoyer Lift. Eating: SUPERVISION-LIMITED ASSIST X 1-2 STAFF. Toileting: Total Dependence assistance. Ambulation: n/a. Wheelchair: Extensive assistance. Dressing: Extensive assistance. Person Hygiene: Extensive assistance. Bathing: TOTAL ASSIST X 1-2. Focus: Incontinence: [Resident #1] is incontinent of bowel/bladder related to Alzheimer, confusion, impaired mobility, physical limitations. Goal: [Resident] will be clean and odor free throughout next review date. Interventions: INCONTINENT: Check frequently for wetness and soiling, every two hours, and change as needed. In an interview on 10/18/25 at 2:24 PM, Resident #1 stated staff did not round every 2 hours. Resident #1 also stated staff did not ensure his call light was always within his reach. Resident #1 revealed there were times that staff did not respond when he pressed his call light. Resident #1 also revealed at times, staff had come into his room, turned off his call light, and left without addressing his needs. Resident #1 stated numerous times staff on the 2:00PM-10:00PM shift had ignored aiding. Resident #1 stated his roommate had to use his call light to assist him. He stated he witnessed evening staff sitting in the halls talking on the phone instead of assisting with his needs. In an interview on 10/18/25 at 2:28 PM, Resident #1's roommate revealed he did not need much assistance but Resident #1 did. He revealed staff did not round Resident #1 every two hours. He also stated at times the CNAs did rounds and did not return to their room. He stated staff did not always ensure Resident #1 call light was within his reach. Resident #1's roommate also revealed staff did not always answer his roommate's call light. He stated he used his call light to get Resident #1 assistance. Resident #1's roommate revealed staff would leave Resident #1 in his brief for hours after the call light had been pressed. He also stated when staff took long to answer the call light, he would go into the hall to get staff. Observation on 10/18/2025 at 2:48 PM, two CNAs seated in the hall on their cell phones. At the time, Resident #1 stated he needed assistance due to dry throat but was unable to reach his call light from the floor. In an interview on 10/18/25 at 2:50 PM, CNA A stated she had finished her first rounds for rooms 21, 22, 23, 24. 25, and 26. CNA A also stated she was sitting while she waited for ice to be passed to residents on the opposite end of the hall. CNA A stated Resident #1's room was worked by CNA B, so CNA B would assist. She stated there was only one ice chest for the entire hall. She also stated while she waited, she was on her phone taking care of her kids. In an interview 10/18/25 at 3:01 PM, the DON stated expectations once staff arrived for shift was to complete their rounds. She stated when staff came in for their shift, she expected them to check on residents, check to ensure call lights were within reach, provide showers, and get residents' water. She stated staff were to assist residents with whatever was needed at that time. In an interview on 10/18/25 at 5:39 PM, CNA A stated she did not work with Resident #1. She stated she worked in the same hall where Resident #1 was located but different rooms. CNA A stated she when she completed her rounds, she would check to ensure call lights were within reach. She stated she did rounds at 2:00 PM, 4:00 PM, 6 PM, 8:00 PM, and 9:00 PM. She also stated she gave her residents 30 minutes after finishing dinner to do repositioning and turning. CNA A stated not answering call lights could be a life-or-death situation with the resident. She stated if a call light was not in reach, the resident would not be able to ask for help. In an interview on 10/18/25 at 6:06 PM, CNA B stated she worked 2:00PM-10:00PM. CNA B stated she had worked with Resident #1. CNA B also stated on 10/18/25 she worked with residents in Rooms 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, and 26. CNA B revealed she had completed her first rounds approximately 20 minutes after she arrived. She stated her first rounds consisted of checking bed linens, ensuring call lights were pinned on sheets or within reach, ensure residents had water, and anything else resident may need. CNA B stated her second rounds were done shortly after which consisted of giving residents ice water. CNA B stated she was not aware of Resident #1 call light on the floor. She stated after she was told to give Investigator a moment to leave, she went and sat down in the hall. She stated she had not had a chance to pick Resident #1's call light off the floor. CNA B stated the expectations were for staff to answer call lights timely and ensure they were in reach. Record review of the facility's in service, dated 9/24/25, on the topic Rounding, linen, attendance, POC charting, revealed in part the following: Rounds: Every resident is to be rounded on every 2 hours Even your continent residents BSC must be checked hourly for continent residents-residents should not be emptying their own BSC. Record review of the facility's in service, dated 01/14/25, on the topic In-Service, revealed in part the following: 1. First and foremost, every resident is your resident the minute you clock in. Whether or not you are assigned to them. Please when you are asked by someone to help or answer questions about a resident whether you are assigned to them that shift or not, you need to help them or find someone who can help them and don't just walk away, stay there until they get the help they need.2. Incontinent care is to be performed every 2 hours.3. Residents must be repositioned every 2 hours in the bed or in their chair.4. Residents should not be left up all day without getting incontinent care.5. Call lights are to always be within reach of the residents.

Based on observation, interview, and record review, the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or a centralized staff work area for 1 of 5 resident rooms (Resident #1) reviewed for call lights. The facility failed to ensure a call light in Resident #1 room was accessible. Resident #1's call light was observed on the floor out of his reach while he was in bed on 10/18/25. This failure could place residents who rely on the call light system to have delayed response or no way to contact staff to meet their needs. Findings included: Record review of Resident #1's admission Record, dated 10/18/25, reflected the resident was a [AGE] year-old male initially admitted [DATE] with diagnoses to include Cerebral Infarction (disruption of blood supply that could result to tissue death), Epilepsy (seizures), Cognitive Communication Deficit (trouble participating in conversations), Dysphagia Oropharyngeal Phase (difficulty swallowing in mouth and throat), Dysarthria and Anarthria (complete loss of speech), Amyotrophic Lateral Sclerosis (loss of muscle control), Muscle Weakness, Unsteadiness on Feet, Lack of Coordination, and Repeated Falls. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 6 out of 15, which indicated severe cognitive impairment. In MDS Assessment Section GG-Functional Abilities revealed resident was dependent or required substantial assistance for ADL care. Record review of Resident #1's care plan, revised date 10/21/24, revealed Focus: Visual Function (Impaired): [Resident #1] has impaired visual function and is at risk for falls, injury. Goal: [Resident #1] will maintain optimal quality of life and not experience a decline in ADL functional abilities, or an injury related to vision loss in the next 90 days. Interventions: Anticipate needs and meet them as able. Keep call light in reach when in room or bathroom. Focus: Communication (Impaired): [Resident #1] has a communication problem related to Alz and he may miss part of simple directions given. History of CVA, causing speech to be slurred/muffled at times. Goal: [Resident #1] will have needs met in a timely manner, dignity will be maintained, and current level of functioning will be maintained over the next 90 days. Interventions: Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, Avoid isolation. Focus: ADL's: [Resident #1] an ADL Self Care Performance Deficit related to: Limited ROM, Limited Mobility, Confusion. Requires 2 staff members to assist [Resident #1] due to size, extensive assistance, and high fall risk. Goal: [Resident #1 will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. Interventions: Resident educated to use call light prior to attempting activities and wait for assistance. Remind/educated on physical limitations and inability to walk without assistance. Staff will frequently round to anticipate needs. Resident is Max assist. Focus: Falls: [Resident #1] the potential for further falls related to cognitive impairment, incontinence, Gait/balance problems. [Resident #1] has an actual hx of falls related to confusion with no injuries and unable to balance my own body weight for positioning. Goal: [Resident #1] will be free of falls through the next review date. Interventions: anticipate and meet need of resident. Place frequently used items within reach. CALL LIGHT WITH IN REACH, CALL [DON'T] FALL SIGNAGE. Observation on 10/18/25 at 2:23 PM, Resident #1 was lying in bed watching television. Resident #1's call light was observed on the floor approximately 2 feet away. In an interview on 10/18/25 at 2:24 PM, Resident #1 stated staff did not round every 2 hours. Resident #1 also stated staff did not ensure his call light was always within his reach. Resident #1 revealed there were times that staff did not respond when he pressed his call light. Resident #1 also revealed at times, staff had come into his room, turned off his call light, and left without addressing his needs. Resident #1 stated numerous times staff on the 2:00PM-10:00PM shift had ignored aiding. Resident #1 stated his roommate had to use his call light to request assistance for him. He stated he witnessed evening staff sitting in the halls talking on the phone instead of assisting with his needs. In an interview on 10/18/25 at 2:28 PM, Resident #1's roommate revealed he did not need much assistance but Resident #1 did. He revealed staff did not round Resident #1 every two hours. He also stated at times the CNAs did rounds and did not return to their room. He stated staff did not always ensure Resident #1 call light was within his reach. Resident #1's roommate also revealed staff did not always answer his roommate's call light. He stated he used his call light to get Resident #1 assistance. Resident #1's roommate revealed staff would leave Resident #1 in his brief for hours after the call light had been pressed. He also stated when staff took long to answer the call light, he would go into the hall to get staff. Observation on 10/18/2025 at 2:48 PM, two CNAs seated in the hall on their cell phones. At the time, Resident #1 stated he needed assistance due to dry throat but was unable to reach his call light from the floor. In an interview on 10/18/25 at 2:50 PM, CNA A stated she had finished her first rounds for rooms 21, 22, 23, 24. 25, and 26. CNA A also stated she was sitting while she waited for ice to be passed to residents on the opposite end of the hall. CNA A stated Resident #1's room was worked by CNA B, so CNA B would assist. She stated there was only one ice chest for the entire hall. She also stated while she waited, she was on her phone taking care of her kids. In an interview 10/18/25 at 3:01 PM, the DON stated expectations once staff arrived for shift was to complete their rounds. She stated when staff came in for their shift, she expected them to check on residents, check to ensure call lights were within reach, provide showers, and get residents' water. She stated staff were to assist residents with whatever was needed at that time. In an interview on 10/18/25 at 5:39 PM, CNA A stated she did not work with Resident #1. She stated she worked in the same hall where Resident #1 was located but different rooms. CNA A stated the expectations when a resident pressed the call light was to answer within a timely manner. She stated when she responded to call lights, she knocked, introduced herself, and found out what was needed. CNA A stated she when she completed her rounds, she would check to ensure call lights were within reach. She stated she did rounds at 2:00 PM, 4:00 PM, 6 PM, 8:00 PM, and 9:00 PM. She also stated she gave her residents 30 minutes after finishing dinner to do repositioning and turning. CNA A stated not answering call lights could be a life-or-death situation with the resident. She stated if a call light was not in reach, the resident would not be able to ask for help. In an interview on 10/18/25 at 6:06 PM, CNA B stated she worked 2:00PM-10:00PM. CNA B stated she had worked with Resident #1. CNA B also stated on 10/18/25 she worked with residents in rooms 16, 17, 18,19, 20, 21, 22, 23, 24, 25, and 26. CNA B revealed she had completed her first rounds approximately 20 minutes after she arrived. She stated her first rounds consisted of checking bed linens, ensuring call lights were pinned on sheets or within reach, ensure residents had water, and anything else resident may need. CNA B stated her second rounds were done shortly after which consisted of giving residents ice water. CNA B stated she was not aware of Resident #1 call light on the floor. She stated when she went to check on Resident #1, the Investigator informed her she was in the room and to hold on. She stated after she was told to give Investigator a moment to leave, she went and sat down in the hall. She stated she had not had a chance to pick Resident #1's call light off the floor. CNA B stated the expectations were for staff to answer call lights timely and ensure they were in reach. In an interview on 10/18/25 at 6:50 PM, ADON revealed her expectations were that all residents have a call light within reach. She stated her expectation was for staff to answer call lights within 10 minutes. She also stated her expectations when staff arrived for their shift was to complete rounds. She stated when staff did rounds, they should ensure residents were in the facility, residents were clean and dry, call lights within reach, and provide residents with ice water. She also revealed she received a complaint last week from a resident stating the call light was not being answered. She stated no in-service was completed for the one staff on the day she received the complaint, but she did more of a talk directive to the one specific staff member. She revealed she stayed on top of staff. The ADON stated the risk of not having a call light or an unanswered call light would be residents not receiving help. The ADON stated the resident may risk injuries such as falls or choking hazard. Interview on 10/18/25 at 7:51 PM, DON stated she expected CNAs to ensure call lights were within reach whenever rounds were done. The DON stated her expectations were that staff answered call lights as quickly as possible. She stated rounds were expected to be done every two hours. In an interview on 10/18/25 at 7:52 PM, the Administrator revealed her expectations were for each resident's call light to be within reach and answered as soon as possible. She stated she was not aware Resident #1 call light was on the floor but when the staff went to check on Resident #1, Investigator was in the room and told staff to hold on. Record review of the facility's policy and procedure, revised on 01/01/24, subject Call Light-Use of, reflected in part the following: Policy:It is the policy of this home to ensure residents have a call light within reach that they are physically able to access and that they have been instructed to use. Equipment:1. Beside call light in functioning order.2. Emergency call light in functioning order Procedure:1. All nursing personnel must be aware of call lights at all times.8. When providing care to residents, be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light.12. Be sure call lights are placed near the resident, never on the floor or bedside stand.

Based on observation, interview and record review the facility failed to ensure a resident had the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely and allowed the resident to use his or her belongings to the extent possible for 1 of 5 residents (Resident #1) reviewed for sanitary and comfortable environment.1. The facility failed to maintain Resident #1's wheelchair in a sanitary and safe operating condition leaving food, liquid, dirt, and debris to collect down both sides of the wheelchair. 2. The facility failed to ensure Resident #1's wheelchair padding on both arm rests were not torn and didn't expose padding on 08/11/25. These failures could place residents at risk of contamination, infections, skin tears and bruising. Findings include:Record review of Resident #1's Quarterly MDS, dated [DATE], reflected a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's had diagnoses which included contracture of right and left hands (a fixed tightening of muscles, tendons, ligaments, or skin that prevents normal movement of the hands), abnormalities of gait ad mobility (a walking abnormality), lack of coordination, speech disturbances (any condition that affects a person's ability to produce sounds that create words) and muscle wasting and atrophy (wasting or thinning of muscle mass). The MDS reflected a BIMS of 0, which indicated she was not able to complete the assessment. Resident #1 required use of a manual wheelchair, and she required set up or clean-up assistance with eating and required substantial/maximal assistance and dependent on staff for all other ADLs. Record review of Resident #1's current, undated, Care Plan reflected the following plans of care:- Resident #1 had an ADL self-care performance deficit related to musculoskeletal impairment, limited mobility, impaired balance. The care plan goals included the resident participating to the best of the resident's ability and maintaining the resident's current level of function. The care plan interventions included monitoring the resident after each meal to ensure the resident's clothes were clean and dry. - Resident #1 required supervision during meals, had fragile skin related to the aging process, and was at risk for bruising easily and skin tears. The care plan goals included the resident's risk for the development of skin tears and bruising being minimized. The care plan interventions included using a clothing protector to protect the resident's skin and notifying the physician and responsible party when there was a change in the resident's status. Keep skin clean and dry. Interview on 08/11/25 at 9:33 AM with Resident #1's Family Member revealed Resident #1's wheelchair was filthy and nasty. The Family Member stated the wheelchair looked like it had never been cleaned, and it should be cleaned. The Family Member stated the facility refused to clean and sanitize the wheelchair. The Family Member stated the arm rests on Resident #1's wheelchair were worn down and could potentially cause bruises on the underside of the resident's forearms. The Family Member further stated, Any normal person would not want to sit in a dirty wheelchair, so why does the facility think its ok for [Resident #1] to sit in a dirty wheelchair. Observation and interview on 08/11/25 at 10:41 AM revealed Resident #1 used her wheelchair for mobility throughout the facility. The arm pad covers on her wheelchair's armrests were torn and exposed the padding. The wheelchair had caked on food, dirt, and debris on both sides. Observation of Resident #1's arms revealed no findings of wounds, skin tears, or bruising. Resident #1 indicated she was mobile throughout the facility a lot, and she did not like her wheelchair to look dirty, Resident #1 did not indicate how having a dirty wheelchair made her feel. Resident #1 did not indicate if she ever asked for the wheelchair to be cleaned or if staff ever attempted to clean it. Interview on 08/11/25 at 11:26 AM with the DOR revealed Resident #1 was seen today (08/11/25) by a contracted vendor to get moldings for a new wheelchair. The DOR stated she noticed the need for a new wheelchair, so she placed a referral on 06/11/25. The DOR stated the reason for the new wheelchair was to assist Resident #1 with balancing and stability while sitting and propelling in the wheelchair. The DOR stated she was aware of how dirty Resident #1's wheelchair was with food and debris; however, she had not reported this to anyone. The DOR indicated she did not have a reason for not reporting the condition of the wheelchair The DOR stated there were times the therapy department would wipe down wheelchairs, but the CNAs on the overnight shift (10:00 PM - 6:00 AM) were responsible for cleaning resident wheelchairs. The DOR stated she noticed the padding on the wheelchair was worn; however, she had not noticed any injury to the resident's forearms. The DOR stated Resident #1 was provided with sleeve protectors, but the resident would remove them. The DOR stated having a dirty wheelchair could place residents at risk of contamination and infections. Interview on 08/11/25 at 11:44 AM with CNA A revealed she had not worked with Resident #1 lately; however, she had previously observed Resident #1's wheelchair had dried food on the sides. CNA A stated aides on the overnight shift were responsible for cleaning resident wheelchairs. CNA A stated if she was currently working with Resident #1 and observed residents with dirty wheelchairs, she would just clean it herself. CNA A further stated she would not want to sit in a dirty chair, so she could imagine residents did not want to sit in a dirty chair as well. CNA A stated when residents were in a dirty environment it placed them at risk of germs which would make them sick. Interview on 08/11/25 at 12:15 PM with the Physical Therapy Technician revealed CNAs on the overnight shift would be the first to notice when resident wheelchairs were dirty and needed to be cleaned, the 10:00 PM - 6:00 AM shift was responsible for cleaning wheelchairs. The Physical Therapy Technician stated when staff came in on the 6:00 AM - 2:00 PM shift and noticed chairs were dirty, they should be reporting to the DON, nurse, physical therapy, or the Maintenance Department. The Physical Therapy Technician revealed she noticed Resident #1's wheelchair needed to be cleaned, but she had never reported it, thinking the overnight shift would clean the wheelchairs. She stated not doing so placed Resident #1 at risk of infection. Observation and interview on 08/11/25 at 1:35 PM with CNA B revealed she worked with Resident #1, and she noticed Resident #1's wheelchair was dirty. CNA B stated it was the responsibility of the overnight shift to clean wheelchairs. CNA B stated Resident #1 fed herself, but she had difficulty due to the way she sat in her wheelchair. She stated it caused the resident to drop and spill a lot of her food and drink during meals, which landed on the wheelchair. CNA B could not recall the last time she attempted to clean Resident #1's wheelchair and could not recall the last time the chair was cleaned. Resident #1 was observed in the dining room drinking a cup of coffee, and there was a light brown thickened substance that appeared to have dripped down the entire right side of the resident's wheelchair. CNA B was asked if Resident #1 ate in the dining room and if she was monitored during lunch. CNA B stated Resident #1 was required to eat in the dining room where she could be monitored. CNA B further stated she did not see food spilled on the wheelchair. CNA B described Resident #1's wheelchair had wasted, caked on food that had dried along with food from today's lunch. CNA B stated not taking the time to ensure Resident #1's wheelchair was clean placed her at risk of infections. Attempts to contact CNA C, CNA D, CNA E, LVN F on the overnight (10:00 PM - 6:00AM) shift were unsuccessful. Interview on 08/11/25 at 2:58 PM with the DON revealed the facility had ordered a new wheelchair for Resident #1; however, it was a custom wheelchair, so it was unknown how long it would take to deliver. The DON stated she had scrubbed the resident's wheelchair the first couple of weeks of her employment at the facility, but she could not find anything who would clean it. She stated it was hard to get into the smaller spaces. The DON stated the overnight shift had a wheelchair cleaning schedule they were supposed to go by. The DON stated aides would check-off when the task was completed; however, they did not indicate which resident chairs were cleaned. The DON stated she knew the arm pads on Resident #1's wheelchair were torn, but there were no injuries on the resident's arms. She stated although it was torn the padding was still intact. The DON stated not ensuring resident's wheelchairs were cleaned and safe placed residents at risk of a build-up of debris and created a dignity issue for residents. Interview on 08/11/25 at 3:24 PM with the Administrator revealed CNAs on the overnight shift were responsible for ensuring all wheelchairs were cleaned according to the schedule. The Administrator stated obviously the CNAs were not doing so, and the overnight nurses were responsible to ensure all the overnight tasks were being completed. The Administrator revealed when residents wheelchairs were not properly cleaned and maintained it placed them at risk of having an issue with dignity and safety. Record review of the facility's Homelike Environment policy, dated 04/24/25, reflected: This policy aims to provide a comprehensive framework for creating and maintaining a homelike environment in long-term care facilities. A homelike environment is essential for promoting the comfort, dignity, and quality of life of residents.Privacy and Dignity: Ensure that residents have privacy and that their dignity is maintained at all times.Creating a homelike environment in long-term care facilities is essential for promoting the well-being and quality of life of residents. By implementing the principles and guidelines outlined in this policy, facilities can create a supportive and nurturing environment that respects residents' individuality, fosters social connections, and enhances their overall experience of care.The facility policy provided did not include anything about resident equipment.

Based on observations, interviews, and record reviews, the facility failed to ensure residents were provided comfortable and safe temperature levels maintained at a range of 71 to 81 degrees Fahrenheit for 16 of 26 residents (Residents #1, #2, #3, #4, #5, #6,#7, #8, #9, #10, #11, #12, #13, #14, #15, and #16) of 26 residents reviewed for environment. The facility failed to ensure Residents #1, #2, #3, #4, #5, #6,#7, #8, #9, #10, #11, #12, #13, #14, #15, and #16 had adequate cooling. This failure could place residents at risk of heat related illnesses and dehydration. Findings included: Observation on 06/17/25 at 10:00 AM of the front hallway of the facility revealed two large fans were in use in the hallway. Observation on 06/17/25 at 10:38 AM of Residents #9 and #10's room revealed there were 6 fans in use to cool the room down. The ambient temperature was 78 degrees Fahrenheit. In an interview on 06/17/25 at 10:40 AM, Resident #9 stated the air conditioning in their section of the facility had not been working for several weeks. He stated he and his roommate purchased the fans to try to keep the room cool enough to be comfortable, but it was not enough for the afternoons. Resident #9 stated after about 11:00 AM they had to stay in the common area where the air conditioning was working. The Administrator was aware and provided fans for residents. Observation and interview on 06/17/25 at 10:44 AM of Residents #5 and #6's room revealed they had two fans in use. The ambient temperature was 80 degrees Fahrenheit. Resident #6 stated the facility provided the two fans to help with the heat of the room. She stated the fans helped until around noon when the temperature was too warm to stay in the room and they had to sit in the dining area to keep cool. Observation on 06/17/25 at 10:48 AM of Residents #1 and #2's room revealed an ambient temperature was 75 degrees Fahrenheit. Both residents were not in their room. Observation and interview on 06/17/25 at 10:52 AM of Resident's #3 and #4's room revealed two fans were in use. The ambient temperature was 75 degrees Fahrenheit. Resident #3 stated the room was comfortable as long as she had her fans on. Her family purchased the two fans in use. Observation on 06/17/25 at 11:00 AM of Residents #7 and #8's room revealed two fans were in use. Both residents were not in their room. The ambient temperature was 76 degrees Fahrenheit. Observation and interview on 06/17/25 at 11:04 AM of Residents #11 and #12's room revealed two fans were in use. Resident #12 stated she purchased the fans for the heat. She spent the afternoons in the dining area where it was cooler. The ambient temperature was 77 degrees Fahrenheit. Observation and interview on 06/17/25 at 11:10 AM of Residents #13 and #14's room revealed two fans in use. The ambient temperature was 75 degrees Fahrenheit. Resident #13 stated the room was still too uncomfortable to spend much time in. Resident #13 had sweat on his forehead. Observation and interview on 06/17/25 at 11:20 AM of Residents #15 and #16's room revealed three fans were in use. Resident #15 stated the room was still too hot even with the fans. Her roommate spent all day in the dining area where it was cool, and she herself would go out there when it got to be too much. She stated her hair was wet from sweat, and her hair appeared damp at the nape of the neck. The ambient temperature was 76 degrees Fahrenheit. In an interview on 06/17/25 at 11:40 AM, the Maintenance Director stated Unit #3 covered rooms 15-22 and it was serviced by their HVAC company two weeks prior when the elevated temperature was noticed in that area. He stated the company got the unit working again by bypassing something but it was still not cooling enough. The company was supposed to be back with an ordered part to complete the process. He stated the temperature should be between 72 and 74 degrees for the comfort of the residents. He stated if it was too hot the residents could be at risk of heat related illnesses. Follow up observations on 06/17/25 from 12:30 PM-12:50 PM of Rooms 15-22 revealed the temperatures had risen even higher. room [ROOM NUMBER] was measured at 79 degrees, room [ROOM NUMBER] was measured at 77 degrees, room [ROOM NUMBER] was measured at 82 degrees, room [ROOM NUMBER] was measured at 81 degrees, room [ROOM NUMBER] was measured at 80 degrees,, room [ROOM NUMBER] was measured at 79 degrees, room [ROOM NUMBER] was measured at 79 degrees, and room [ROOM NUMBER] was measured at 80 degrees. The ambient temperature in the hallway was 80 degrees Fahrenheit as measured with ambient thermometer by the Surveyor. In a phone interview on 06/17/25 at 3:10 PM the Administrator stated HVAC unit #3 had been struggling to keep up. The HVAC company advised there was not enough return air for the unit to function properly. They recommended placing portable units in the dining area next to the affected area, blocking off the vents in the dining area to attempt to divert enough flow to the affected rooms. She stated she was waiting to hear from corporate on what they were going to do. She stated the biggest risk to the residents was dehydration. She was still waiting to hear back from the corporate office on how they were going to proceed. The Administrator stated staff were keeping the affected residents supplied with ice and water. Record review of the facility's policy Homelike Environment, dated 4/24/25, reflected: 1. Living spaces . Ensure that living spaces are comfortable, safe, and accessible, with appropriate lighting, temperature control and furniture.

Based on interviews and record reviews, the facility failed to ensure residents had the right to be free from abuse , neglect, misappropriation of resident property, and exploitation for 2 of 4 residents (Residents #17 and #18) reviewed for abuse. The facility failed to ensure Resident #17 was not abused by Resident #18 who hit her in the face. The noncompliance was identified as PNC. The noncompliance began on 05/22/25 and ended on 05/22/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of injury and loss of dignity. Findings included: Record review of Resident #17's undated admission Record reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, bipolar disorder, and schizoaffective disorder. Record review of Resident #17's quarterly MDS, dated [DATE], reflected a BIMS score of 8, which indicated moderate cognitive impairment. Record review of Resident #17's care plan, dated 03/31/25, reflected she had impaired judgement related to her cognitive decline, and she had behavioral problems of going into other resident's closets and taking items that did not belong to her. Record review of Resident #17's assessment on 05/22/25 by RN A reflected: This nurse got notified that there was yelling between two residents about purse. The two residents [Resident #18] and [Resident #17] pulling purse from one another, physical therapy staff and nurse got separated them. Upon head to toe assessment, no pain/injury noted at this time. Resident walking with walker, alert and oriented. MD, Administrator, DON made aware. Unable to reach RP .voice message left. Record review of Resident #18's undated admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included kidney failure, diabetes, and cognitive communication deficit. Record review of Resident #18's quarterly MDS reflected a BIMS score of 14, indicating she was cognitively intact. Record review of Resident #18's care plan, dated 05/15/25, reflected she had behavioral problems related to her schizophrenia, and impaired visual function related to her vision decline. The resident's care plan had also been updated for her aggressive behavior on 05/22/25. Record review of the facility's investigation report reflected on 05/22/25 around 11:15 AM the PT witnessed Residents #17 and #18 tugging on a purse, each arguing about whose purse it was. The PT stated he stepped between the two residents to break up the dispute, and as he did so Resident #18 struck out at Resident #17 with a closed fist, hitting Resident #17 in the face. The PT and other staff separated the residents and reported the incident to the DON. In an interview on 06/17/25 at 2:25 PM, the PT stated Resident #18 was working in the gym when Resident #17 entered in her wheelchair. Resident #17 had a purse and Resident #18 yelled it was her purse. Resident #18 tried to grab it from Resident #17 and a tug of war over the purse began. The PT stated he stepped between them and told Resident #17 to give the purse back. Resident #18 managed to reach around him and strike Resident #17. The PT stated it was a closed fist and she hit Resident #17 somewhere on the face. He stated there was not a lot of force to the strike. He stated he and the DOR separated the two residents. The PT took Resident #17 to the nurse station and the DOR took Resident #18 to her room with the purse. When Resident #18 looked in the purse she told the DOR it was not her purse after all. The PT reported the incident to the nurse and the DON. He did not see any redness to the resident's face. Interview attempted on 06/17/25 at 2:50 PM with Resident #17 was unsuccessful due to the resident having no recollection of the event. In an interview on 06/17/25 at 2:55 PM, Resident #18 stated she thought Resident #17 had her purse because it was the same color as hers. She stated Resident #17 had a history of taking things from her room. She said she accidentally hit Resident #17 on the head. She has had no issues since then. In a phone interview on 06/17/25 at 3:00 PM with Resident #17's Responsible Party, he stated he was told about the event. When he checked on her the next day she did not remember what happened. She had no redness or bruising to her face. He had no concerns about her care. In a phone interview on 06/17/25 at 3:05 PM with Resident #18's Responsible Party, she stated she was told about the event. She stated she was surprised Resident #18 had lashed out like that because she was usually pretty calm. She stated there did not seem to be any affects from the event, and the resident was quite happy. In an interview on 06/17/25 at 3:08 PM, the DON stated the residents resided on different halls at the time of the event, and they rarely interacted with each other. She stated Resident #17 had no recollection of the event. Staff were in-serviced on resident-to-resident altercations that day and the next day. She stated there had never been any issues between the two residents in the past, and no history of Resident #18 being aggressive towards anyone. She stated Resident #18 was very even keeled and got along with everyone, this was very abnormal for her. She stated Resident #18 stated she knew Resident #17 liked to go into other resident's rooms and take things and when she saw her with a purse that looked like hers she just got mad. She did not mean to hit the resident, she was just frustrated. The DON stated she began to in-service staff on abuse, resident altercations and how to handle aggressive residents. Record review of the facility's training records reflected an Inservice Attendance Record, dated 05/22/25, which covered: Topic: When there is are [sic] resident to resident altercation. Resdients [sic] are to be seperated [sic] immediately, assessed for any injuries, s/s of distress. Resident to resident altercations must [be] reported to the abuse coordiantor [sic] / administrator immediatly [sic]. Resident to resident altercations are considered a form of abuse and must be reported immediatly [sic] to t he abuse coordiantor [sic] / administrator. In an interview on 06/17/25 at 3:15 PM, RN A stated she was in-serviced on resident-to-resident altercations. She stated she was supposed to separate the residents, assess for injuries, and report it to the Administrator. She would then monitor the residents for continued behaviors. In an interview on 06/17/25 at 3:18 PM, LVN B stated she was in-serviced on resident-to-resident altercations. She was supposed to separate them, assess for injuries, and notify the Administrator and DON. She would then monitor the residents for continued behaviors. In an interview on 06/17/25 at 3:22 PM, MA C stated she was in-serviced on resident-to-resident altercations. She was supposed to separate the residents and report it to her nurse or the DON. She would then monitor the residents for continued behaviors. In an interview on 06/17/25 at 3:30 PM, CNA D stated she was in-serviced on resident-to-resident altercations. She stated she was to separate the residents and notify the nurse and the Administrator. She would then monitor the residents for continued behaviors. In an interview on 06/17/25 at 3:35 PM, CNA E stated she was in-serviced on altercations between residents. She stated she would separate them and notify the nurse and the Administrator. She would then monitor the residents for continued behaviors. In an interview on 06/17/25 at 3:38 PM, CNA F stated there was an in-service on resident-to-resident altercations. She was supposed to separate them and report it to the Administrator and the nurse. She would then monitor the residents for continued behaviors. Record review of the facility's Abuse, Neglect, and Exploitation policy, dated 10/24/22, reflected: .1. The facility provides resident protection that includes: a) Prevention/Prohibition resident abuse, neglect, and exploitation and misappropriation of property. .III. The facility will make every effort to prevent and prohibit all types of abuse, neglect, misappropriation of property, and exploitation The noncompliance was identified as PNC. The noncompliance began on 05/22/25 and ended on 05/22/25. The facility had corrected the noncompliance before the survey began .

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for one of one meal (lunch on 05/07/25) reviewed for food and nutrition services. The facility failed to ensure the menu was followed for the lunch meal by: - leaving out the dinner roll for the pureed diets on 05/07/25, and - substituting greens for broccoli florets This failure could place residents at risk of weight loss, altered nutritional status and diminished quality of life. Findings included: Observation on 05/07/25 at 11:30 AM revealed the [NAME] pureed pork roast, greens, and boiled potatoes. No dinner rolls were pureed or served to residents who should have received pureed meals. Observation and Interview on 05/07/25 at 1:10 PM with Dietary Manager J revealed there was no pureed dinner roll on the pureed test tray. Dietary Manager J revealed the [NAME] forgot to prepare the pureed dinner roll. Dietary Manager J revealed the facility policy stated everyone should receive the same meal. Dietary Manager J stated the importance of following the menu was so that residents could receive sufficient calories. Dietary Manager J said that if residents did not receive enough calories, it could lead to possible weight loss and a decline in health. There was no posting observed in the facility of a substitution of the greens for the broccoli florets in the facility on 05/07/25. Dietary Manager J was observed in-servicing her staff on following the menu for special diets on 05/08/25. Observation and interview on 05/07/25 at 1:15 PM with Dietary Manager K revealed she was a dietary manager from a sister facility who was there to oversee the kitchen operations that day. The test tray for the lunch meal was present during this interview, and Dietary Manager K stated she saw there was no pureed dinner roll on the puree test tray. Dietary Manager K said the facility policy was to follow the menu and post substitutions if they occurred. Dietary Manager K revealed the importance of following the menu is so that residents receive all their nutritional value of the day. Dietary Manager K revealed also the cook should notify the facility's manager if there was no pureed bread so that a substitution could be made. Record review of resident council minutes for February, March, and April 2025 reflected there were no complaints for the dietary department regarding substitutions. Record review of the facility's menu, dated 03/14/25, reflected for Wednesday (05/07/25) the following: Lunch - Pork Roast Loin Garlic Herb, Buttered Broccoli Florets, Boiled Potato, Dinner Roll, Chocolate Pudding. Record review of the facility's Menu Changes and Substitutions policy, revised 08/02/17, reflected: Policy: Any variation from the planned menu will be properly documented by the Dietary Services Manager (DSM) and reviewed and signed by the Dietician. Menu changes and substitutions, when necessary, will be made with foods of equivalent nutritive value .

Based on interview, observation, and record review, the facility failed to immediately consult with the resident's physician and notify the resident representative when there was a significant change in the resident's physical or mental status or need to alter treatment significantly for one (Resident #1) of eight residents reviewed for change of condition. The facility failed to notify Resident #1's physician and responsible party when the resident's blood pressure was 216/114 on 01/24/25. An Immediate Jeopardy (IJ) was identified on 02/14/25. The Administrator was notified of the Immediate Jeopardy and provided with the IJ Template on 2/14/25 at 05:04 PM. While the Administrator and DON were notified that the IJ was removed on 02/15/25 at 02:34 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place all residents at risk of not receiving immediate medical attention when there is a change in their condition, which could lead to worsening of conditions and serious injury or harm. Findings included: Record review of Resident #1's face sheet, dated, 02/04/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: pneumonia (infection of lungs), hypertension (high blood pressure), type II diabetes (body's inability to regulate blood sugar), muscle weakness, chronic kidney disease, morbidly obese, mild dementia (brain disorder that affects memory, thinking, and behavior). Record review of Resident #1's Quarterly MDS assessment, dated 02/03/25, revealed the resident had a BIMS score of 12 which suggested he was moderately cognitively impaired. The Quarterly MDS assessment reflected Resident #1 could usually make himself understood and could usually understand others. Further review reflected Resident #1 was dependent on staff for most ADLs. Review of Resident #1's care plan initiated on 07/12/24 reflected the resident was diagnosed with hypertension and was at risk for fluctuations in blood pressure. Interventions included administer antihypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (sudden drop in blood pressure when standing from a seated or prone position), headache, vertigo, chest pain, and decreased heart rate. Avoid taking blood pressure readings after physical activity or emotional distress. Monitor for edema (swelling caused by excess fluid buildup in the body's tissue) and document when present. Notify physician of changes in severity of edema as needed. Weigh at least monthly Diet as ordered. Record review of Resident #1's order summary report, dated 02/04/25, reflected the following: -Furosemide oral tablet 40 mg- give one tablet by mouth two times a day related to hypertension (active) -hydrALAZINE HCL oral tablet 25 mg-give one tablet by mouth three times a day related to hypertension. (active) - hydrALAZINE HCL oral tablet 50 mg-give one tablet by mouth three times a day related to hypertension. (active) -Lisinopril oral tablet 40 mg-give one tablet by mouth in the morning related to hypertension. (active) -Toprol XL oral tablet extended release 24-hour 25 mg-give one tablet by mouth in the morning for hypertension. Hold for SBP<110, DBP<50, pulse<50. (active) -Obtain a complete set of vitals every shift. (active) Record review of Resident #1's vitals revealed the following: 01/24/25 at 04:16 PM Blood Pressure- 216/114 taken by MA C Temperature- not documented. Further review reflected there was no blood pressure re-check documented by MA C or LVN B. Record review of Resident #1's progress notes reflected there was no documentation on 1/24/25 regarding notifying the MD or RP about the resident's elevated blood pressure. There was also no documentation by MA C that LVN B was notified of Resident #1's elevated blood pressure. Further record review of Resident #1's progress note, dated 01/25/25 at 04:37 PM by RN D, reflected the following: [Resident #1] called 911 by himself that he is not feeling well, and he wants to go to hospital. Paramedics here and the writer tried to talk [Resident #1] out, to allow the facility nurse to reach the physician for orders and treatment. [Resident #1] insisted of [sic] going to the hospital. Action: [Resident #1] transported to the hospital on a stretcher by the paramedics. DON/ADON and responsible party notified. Record review of Resident #1's hospital records, dated 01/25/25, reflected the following: Chief complaint: [Resident #1] presents with fatigue from [Nursing Facility] with c/o cough and malaise (discomfort) x 3 days. Glucose 360, baseline GCS 14. Bed bound from previous CVA. . Laboratory Results: Chest X-ray - 01/25/25 -Lungs and pleura- low lung volumes. Left mid and basilar interstitial opacities (disorder that causes scarring in lung). No pleural effusion. No pneumothorax. Impression: 1. Low lung volumes. Left mid and basilar atelectasis (condition where the lower lobes of the lungs collapse) or atypical infiltrate (pneumonia). . Differential Diagnosis: Pneumonia, viral upper respiratory infection, acute on chronic CHF exacerbation. In an interview on 02/04/25 at 01:08 PM, the DON stated Resident #1 reported not feeling well on 01/25/25, and RN D was working on contacting the MD through telehealth to get orders, but the EMTs were already entering the facility after Resident #1 called 911 himself. She stated Resident #1 was transported to the hospital where he was admitted and diagnosed with pneumonia. The DON stated Resident #1's O2 level was at 92%, taken on 01/25/25 at 4:33 PM, and he likely could have been treated at the nursing facility, but he insisted on going to the hospital. The DON stated Resident #1 had a history of calling 911 if staff did not get to him quick enough, and he recently called 911 for them to come change his brief. The DON checked Resident #1's chart and stated his blood pressure was 216/114 on 01/24/25, which was considered extremely high. She stated she had not been previously made aware that Resident #1's blood pressure was elevated on 01/24/25. The DON stated with a blood pressure that high, the expectation would have been for a nurse to recheck it manually and if was still high to notify the RP and MD immediately for further instructions. She stated all blood pressures were recorded in the EHR. The DON stated Resident #1's blood pressure ran high on multiple days, and he was on routine blood pressure medication. The DON stated there were no other reports or signs indicative of Resident #1 having an infection. The DON stated not notifying the MD of an extremely high blood pressure could place the resident at risk of a stroke and any change of condition that was not assessed could lead to harm or even death. An attempted interview on 02/04/25 at 01:30 PM with RN D by phone was unsuccessful due to no response to call. In an interview on 02/04/25 at 02:03 PM, LVN A stated she worked 1st shift, Monday-Friday. She stated she worked with Resident #1 the week leading up to him going to the hospital on 01/25/25 and he did not exhibit any symptoms of respiratory distress and did not complain of being sick. LVN A stated she was surprised to find that Resident #1 was at the hospital when she returned to work on 01/27/25. In an interview on 02/04/25 at 02:25 PM, LVN B stated she worked 2nd shift, Monday-Friday. LVN B stated she worked with Resident #1 on 01/24/25 and there were no reports that he felt unwell. She stated Resident #1 was not coughing and did not have any other symptoms or complaints that day. LVN B stated Resident #1 did not have an order for daily vital checks by the nurse, so the medication aides were the only ones who checked his vitals before administering blood pressure medication. LVN B stated the medication aides were supposed to report any abnormal blood pressure readings to the nurse for them to assess and recheck. LVN B stated on 01/24/25, MA C did not report to her that Resident #1's blood pressure was higher than usual. She stated if it had been reported that Resident #1's blood pressure was 216/114, she would have rechecked it manually and notified the MD. In an interview on 02/04/25 at 02:57 PM, MA C stated she worked 2nd shift, Monday-Friday. She stated she worked with Resident #1 on 01/24/25 and checked his vitals at 04:00 PM before administering his blood pressure medication. She stated Resident #1's blood pressure was normally high when she checked it, and she would always tell the nurse. MA C stated Resident #1's blood pressure was high so often she asked the nurse about getting him a PRN blood medication to supplement his routine medication. MA C could not recall what Resident #1's blood pressure was when she checked it on 01/24/25; however, she stated if it was high, she certainly reported it to the nurse because she took her job seriously and would not forget to report something like high blood pressure, especially an extremely high blood pressure. MA C stated all blood pressure checks were supposed to be documented in the residents' EHR. MA C stated she did not normally document her communication with the nurse in the residents' EHR but moving forward she would document it in the progress notes. In an interview and observation on 02/04/25 at 03:45 PM, Resident #1 was dressed and well-groomed with no odors or visible marks or bruises. Resident #1 also did not show any signs of distress. Resident #1 stated he was feeling better but not completely healed since returning to the facility on [DATE] from the hospital. He stated he still had a slight cough. Resident #1 stated he called 911 himself on 01/25/25 because he had been coughing for weeks and was feeling bad on that day. Resident #1 stated he did not tell staff that he was feeling bad because he would have had to wait too long for them to call the MD so he figured it would be quicker for him to call 911 and go to the hospital. Resident #1 stated he always had a cough due to ongoing lung issues, so it was not a big deal until he started feeling worse about a day before he went to the hospital. Resident #1 stated he only told his family member that he did not feel well. Resident #1 stated he had high blood pressure and took medication for it. He stated he was unsure if his blood pressure was high on 01/24/25 or 01/25/25 but it was possible because he did not feel well in general on those days. In an interview on 02/04/25 at 03:56 PM, Resident #1's RP revealed she spoke with the resident on 01/24/25 and he told her that he did not feel well and had a cough. The RP stated the facility did not notify her of a change of condition in Resident #1 on 01/24/25; however, they called her on 01/25/25 after Resident #1 called 911 for himself and she told them to go ahead and transport him to the hospital. In an interview on 02/14/25 at 01:40 PM, the MD stated the expectation was for the nurses to notify him of any blood pressures outside of the parameters. The MD stated he was not notified on 01/24/25 that Resident #1's blood pressure was 216/114. He stated a systolic blood pressure over 180 should have been reported to him. The MD stated if it had been reported, he would have had the nurse to do a manual blood pressure re-check because the wrist cuffs were not always accurate. He stated if the blood pressure was still elevated, he would have asked for a clinical assessment of Resident #1's physical condition as the blood pressure numbers alone would not have been indicative of a hypertensive emergency. The MD stated he would have likely ordered an adjustment of the medication and monitoring unless there were concerns for Resident #1's physical condition, which he would have then ordered for the resident to be sent out to the hospital. The MD stated Resident #1 ended up going to the hospital on 01/25/25 and was diagnosed with pneumonia; however, he could not state that the elevated blood pressure the previous day was related. The MD stated the nurses usually notified him of abnormal vitals. Review of the facility's policy titled Notification of Changes, dated 07/13/2015, revealed in part the following: Policy: To provide guidance on when to communicate acute changes in status to MD, NP, and responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following: . 3. A significant change in the physical, mental or psychosocial status of the resident. Review of an article in the American Heart Association, updated 2025, reflected in part the following: In most cases damage from high blood pressure happens over time. If not detected and controlled, high blood pressure can lead to: -Heart attack -Stroke -Heart Failure -Kidney disease or failure . If your blood pressure reading is higher than 180/120 mm Hg, you could be having a hypertensive crisis. Wait at least 1-2 minutes and then take your blood pressure again. Contact your health care professional right away if your readings are still above 180/120 mm Hg and you aren't having any other symptoms . An Immediate Jeopardy (IJ) was identified on 02/14/25 at 03:25 PM. The Administrator and DON were notified of an Immediate Jeopardy (IJ) on 02/14/25 at 04:45 PM, due to the above failures and the IJ Template was provided at 05:04 PM. The facility's Plan of Removal (POR) was accepted on 02/15/25 at 12:46 PM and included: [Nursing Facility] 2/14/25 at 5:04pm Immediate Jeopardy called F580 Failure to Notify physician of change of condition. I. Resident Specific Staff nurse completed a clinical assessment of Resident # 1 on 2/4/25 at 5:00pm including blood pressure. Physician was immediately notified of previous high blood pressures on 2/4/25 at 5:06pm. On 2/4/25 all residents with a diagnosis of Hypertension had a clinical assessment completed by the DON and ADON including blood pressure. There were no residents identified requiring physician notification. On 2/15/25 all residents with a diagnosis of Hypertension will have a clinical assessment completed by the DON and Designee including blood pressure. Any resident identified with any abnormal findings the DON and designee will notify the physician immediately. Staff nurses will continue to monitor and report any changes to the physician. II. System Changes Each nurse will review vital signs prior to the end of their shift to ensure all abnormalities are addressed and will be ongoing. DON/ADON will review the previous days vital signs in morning meeting to ensure all abnormalities are addressed and will be ongoing. The weekend Supervisor will review previous days vital signs at the beginning of her shift to ensure all abnormalities are addressed and will be ongoing. III. Education On 2/4/25 medication aides were in-serviced by the ADON on reporting all abnormal vital signs to the nurse immediately and then documenting who they notified. On 2/15/25 DON completed education with all medication aides on reporting all abnormal vital signs to the nurse immediately and then documenting who they notified. This education will be ongoing to include any new staff and staff not yet trained. Identified medication aide received disciplinary action for failure to notify nurse of abnormal blood pressure. On 2/4/25 all nurses were in-serviced by DON on notifying the physician of all vital signs out of the documented parameters and documenting who they notified and what new orders were given. On 2/15/25 DON completed education with all nurses on notifying the physician of all vital signs out of the documented parameters and documenting who they notified and what new orders were given. This education is ongoing to include any new staff and staff not yet trained. IV. Monitoring DON/ADON will randomly pull 3 residents with hypertension weekly x 4 weeks and review their blood pressure for appropriate follow-up and interventions if required. Results of the random audits will be reviewed in QAPI meeting monthly x 3 months. On 02/15/25 the investigator began monitoring (01:02 PM-02:40 PM) to determine if the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Observations, interviews, and records reviews on 02/15/25, 01:02 PM-01:45 PM, of Residents #1, #2, #3, #4, #5, #6, #7, and #8 revealed no further concerns for a violation of resident rights. Record review of residents' EHR reflected no concerns for changes in physical, mental, or psychosocial status. Observations and interviews with residents and/or RPs revealed no concerns for change of condition or quality of care received. Record review of Resident #1's nursing notes, dated 02/04/25, reflected the resident received a complete clinical assessment including a blood pressure check with no notable changes. Further review reflected the NP was notified of Resident #1's high blood pressures on 02/04/25, with no new orders given. Record review of a document provided by the DON titled Resident Responses Analyzer, dated 02/04/25, reflected all residents diagnosed with hypertension received a clinical assessment including blood pressure checks by the DON or ADON with no concerns requiring physician notification. Record review of a document provided by the DON titled Resident Responses Analyzer, dated 02/15/25, reflected all residents diagnosed with hypertension received a clinical assessment including blood pressure checks by the DON with no concerns requiring physician notification. Record review of an in-service titled Abnormal vital signs and med not given, dated 02/04/25, reflected all medication aides and nurses were educated on parameters for vital signs, and when to notify the physician. Record review of an in-service titled Notification of Physician Protocol, dated 02/15/25, reflected all medication aides and nurses were educated on parameters for vital signs, and when to notify the physician. Record review of a document provided by the Administrator titled Associate Disciplinary Memorandum, dated 02/05/25, reflected MA C was disciplined for failure to notify the nurse of an abnormal blood pressure. Interviews on 02/15/25, 01:45 PM-02:40 PM, conducted with the DON, medication aides and nurses from various shifts: RN E (3rd shift/weekdays), RN D (1st shift/weekends), MA F (2nd shift/weekends), MA C (2nd shift/weekdays), LVN G (1st shift/weekends), LVN H (3rd shift/weekdays), LVN B (2nd shift/weekdays), MA I (1st shift/weekdays), and LVN J (2nd shift/weekdays). indicated they all participated in in-service trainings. The medication aides were able to describe in their own words the protocol for abnormal vital signs. They were able to state the parameters for vitals, when to notify the nurse, and to document all incidents. The nurses were able to describe in their own words the protocol for abnormal vital signs. They were able to state the parameters for vitals, to manually re-check and notify the physician as necessary, and to document all incidents. The DON stated the expectation that all vitals from the previous day would be reviewed, and any abnormal vitals would be addressed accordingly. An Immediate Jeopardy (IJ) was identified on 02/14/25. The Administrator was notified of the Immediate Jeopardy and provided with the IJ Template on 2/14/25 at 05:04 PM. While the Administrator and DON were notified that the IJ was removed on 02/15/25 at 02:34 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure the residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of eight residents reviewed for quality of care. The facility failed to follow protocols for abnormal vital signs when MA C did not notify the nurse after Resident #1's blood pressure was 216/114 and there was no re-check to ensure accuracy to determine if further treatment was needed. An Immediate Jeopardy (IJ) was identified on 02/14/25. The Administrator was notified of the Immediate Jeopardy and provided with the IJ Template on 2/14/25 at 05:04 PM. While the Administrator and DON were notified that the IJ was removed on 02/15/25 at 02:34 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed all residents at risk of a delay in medical evaluation and treatment. Findings included: Record review of Resident #1's face sheet, dated, 02/04/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: pneumonia (infection of lungs), hypertension (high blood pressure), type II diabetes (body's inability to regulate blood sugar), muscle weakness, chronic kidney disease, morbidly obese, mild dementia (brain disorder that affects memory, thinking, and behavior). Record review of Resident #1's Quarterly MDS assessment, dated 02/03/25, revealed the resident had a BIMS score of 12 which suggested he was moderately cognitively impaired. The Quarterly MDS assessment reflected Resident #1 could usually make himself understood and could usually understand others. Further review reflected Resident #1 was dependent on staff for most ADLs. Record review of Resident #1's care plan initiated on 07/12/24 reflected the resident was diagnosed with hypertension and was at risk for fluctuations in blood pressure. Interventions included administer antihypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (sudden drop in blood pressure when standing from a seated or prone position), headache, vertigo, chest pain, and decreased heart rate. Avoid taking blood pressure readings after physical activity or emotional distress. Monitor for edema (swelling caused by excess fluid buildup in the body's tissue) and document when present. Notify physician of changes in severity of edema as needed. Weigh at least monthly Diet as ordered. Record review of Resident #1's order summary report, dated 02/04/25, reflected the following: -Furosemide oral tablet 40 mg- give one tablet by mouth two times a day related to hypertension (active) -hydrALAZINE HCL oral tablet 25 mg-give one tablet by mouth three times a day related to hypertension. (active) - hydrALAZINE HCL oral tablet 50 mg-give one tablet by mouth three times a day related to hypertension. (active) -Lisinopril oral tablet 40 mg-give one tablet by mouth in the morning related to hypertension. (active) -Toprol XL oral tablet extended release 24-hour 25 mg-give one tablet by mouth in the morning for hypertension. Hold for SBP<110, DBP<50, pulse<50. (active) - Obtain a complete set of vitals every shift. (active) Record review of Resident #1's vitals revealed the following: 01/24/25 at 04:16 PM Blood Pressure - 216/114 taken by MA C Temperature - not documented. Further review reflected there was no blood pressure re-check documented by MA C or LVN B. Record review of Resident #1's progress notes reflected there was no documentation on 01/24/25 regarding notifying the MD or RP about the resident's elevated blood pressure. There was also no documentation by MA C that LVN B was notified of Resident #1's elevated blood pressure. Further record review of Resident #1's progress note, dated 01/25/25 at 04:37 PM by RN D, reflected the following: [Resident #1] called 911 by himself that he is not feeling well, and he wants to go to hospital. Paramedics here and the writer tried to talk [Resident #1] out, to allow the facility nurse to reach the physician for orders and treatment. [Resident #1] insisted of [sic] going to the hospital. Action: [Resident #1] transported to the hospital on a stretcher by the paramedics. DON/ADON and responsible party notified. Record review of Resident #1's hospital records, dated 01/25/25, reflected the following: Chief complaint: [Resident #1] presents with fatigue from [Nursing Facility] with c/o cough and malaise (discomfort) x 3 days. Glucose 360, baseline GCS 14. Bed bound from previous CVA. .Laboratory Results: Chest X-ray - 01/25/25 -Lungs and pleura- low lung volumes. Left mid and basilar interstitial opacities (disorder that causes scarring in lung). No pleural effusion. No pneumothorax. Impression: 1. Low lung volumes. Left mid and basilar atelectasis (condition where the lower lobes of the lungs collapse) or atypical infiltrate (pneumonia). . Differential Diagnosis: Pneumonia, viral upper respiratory infection, acute on chronic CHF exacerbation. In an interview on 02/04/25 at 01:08 PM, the DON stated Resident #1 reported not feeling well on 01/25/25, and RN D was working on contacting the MD through telehealth to get orders, but the EMTs were already entering the facility after Resident #1 called 911 himself. She stated Resident #1 was transported to the hospital where he was admitted and diagnosed with pneumonia. The DON stated Resident #1's O2 level was at 92%, taken on 01/25/25 at 4:33 PM, and he likely could have been treated at the nursing facility, but he insisted on going to the hospital. The DON stated Resident #1 had a history of calling 911 if staff did not get to him quick enough, and he recently called 911 for them to come change his brief. The DON checked Resident #1's chart and stated his blood pressure was 216/114 on 01/24/25, which was considered extremely high. She stated she had not been previously made aware that Resident #1's blood pressure was elevated on 01/24/25. The DON stated with a blood pressure that high, the expectation would have been for a nurse to recheck it manually and if was still high to notify the RP and MD immediately for further instructions. She stated all blood pressures were recorded in the EHR. The DON stated Resident #1's blood pressure ran high on multiple days, and he was on routine blood pressure medication. The DON stated there were no other reports or signs indicative of Resident #1 having an infection. The DON stated not notifying the MD of an extremely high blood pressure could place the resident at risk of a stroke and any change of condition that was not assessed could lead to harm or even death. An attempted interview on 02/04/25 at 01:30 PM with RN D by phone was unsuccessful due to no response to call. In an interview on 02/04/25 at 02:25 PM, LVN B stated she worked 2nd shift, Monday-Friday. LVN B stated she worked with Resident #1 on 01/24/25 and there were no reports that he felt unwell. She stated Resident #1 was not coughing and did not have any other symptoms or complaints that day. LVN B stated Resident #1 did not have an order for daily vital checks by the nurse, so the medication aides were the only ones who checked his vitals before administering blood pressure medication. LVN B stated the medication aides were supposed to report any abnormal blood pressure readings to the nurse for them to assess and recheck. LVN B stated on 01/24/25, MA C did not report to her that Resident #1's blood pressure was higher than usual. She stated if it had been reported that Resident #1's blood pressure was 216/114, she would have rechecked it manually and notified the MD. In an interview on 02/04/25 at 02:57 PM, MA C stated she worked 2nd shift, Monday-Friday. She stated she worked with Resident #1 on 01/24/25 and checked his vitals at 04:00 PM before administering his blood pressure medication. She stated Resident #1's blood pressure was normally high when she checked it, and she would always tell the nurse. MA C stated Resident #1's blood pressure was high so often she asked the nurse about getting him a PRN blood medication to supplement his routine medication. MA C could not recall what Resident #1's blood pressure was when she checked it on 01/24/25; however, she stated if it was high, she certainly reported it to the nurse because she took her job seriously and would not forget to report something like high blood pressure, especially an extremely high blood pressure. MA C stated all blood pressure checks were supposed to be documented in the residents' EHR. MA C stated she did not normally document her communication with the nurse in the residents' EHR but moving forward she would document it in the progress notes. In an interview and observation on 02/04/25 at 03:45 PM, Resident #1 was dressed and well-groomed with no odors or visible marks or bruises. Resident #1 also did not show any signs of distress. Resident #1 stated he was feeling better but not completely healed since returning to the facility on [DATE] from the hospital. He stated he still had a slight cough. Resident #1 stated he called 911 himself on 01/25/25 because he had been coughing for weeks and was feeling bad on that day. Resident #1 stated he did not tell staff that he was feeling bad because he would have had to wait too long for them to call the MD so he figured it would be quicker for him to call 911 and go to the hospital. Resident #1 stated he always had a cough due to ongoing lung issues, so it was not a big deal until he started feeling worse about a day before he went to the hospital. Resident #1 stated he only told his family member that he did not feel well. Resident #1 stated he had high blood pressure and took medication for it. He stated he was unsure if his blood pressure was high on 01/24/25 or 01/25/25 but it was possible because he did not feel well in general on those days. In an interview on 02/14/25 at 01:40 PM, the MD stated the expectation was for the nurses to notify him of any blood pressures outside of the parameters. The MD stated he was not notified on 01/24/25 that Resident #1's blood pressure was 216/114. He stated a systolic blood pressure over 180 should have been reported to him. The MD stated if it had been reported, he would have had the nurse to do a manual blood pressure re-check because the wrist cuffs were not always accurate. He stated if the blood pressure was still elevated, he would have asked for a clinical assessment of Resident #1's physical condition as the blood pressure numbers alone would not have been indicative of a hypertensive emergency. The MD stated he would have likely ordered an adjusted of the medication and monitoring unless there were concerns for Resident #1's physical condition, which he would have then ordered for the resident to be sent out to the hospital. The MD stated Resident #1 ended up going to the hospital on 01/25/25 and diagnosed with pneumonia; however, he could not state that the elevated blood pressure the previous day was related. The MD stated the nurses usually notified him of abnormal vitals. Record review of the facility's policy titled Nursing Policy and Procedure (Blood Pressure-Obtaining), dated October 2020, reflected in part the following: It is the policy of this home that blood pressure readings will be obtained using correct technique to ensure accuracy. Precautions: 1. Report to charge nurse if blood pressure equipment is not in good working order or if cuff is not available in correct size for accurate reading. The cuff is the proper size when the length of the inflatable bladder is at least 80% of the circumference of the resident's arm. 2. Recheck a blood pressure no more than 3 times and wait at least 1 to 2 minutes before repeating the B/P measurement on the same arm. 3. Report to the charge nurse for assistance if you cannot hear the B/P or are unsure of what you are hearing after 3 tries. Do not guess at the B/P reading Record review of the facility's policy titled Notification of Changes, dated 07/13/2015, revealed in part the following: Policy: To provide guidance on when to communicate acute changes in status to MD, NP, and responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following: .3. A significant change in the physical, mental or psychosocial status of the resident. Record review of an article in the American Heart Association, updated 2025, reflected in part the following: In most cases damage from high blood pressure happens over time. If not detected and controlled, high blood pressure can lead to: -Heart attack -Stroke -Heart Failure -Kidney disease or failure . If your blood pressure reading is higher than 180/120 mm Hg, you could be having a hypertensive crisis. Wait at least 1-2 minutes and then take your blood pressure again. Contact your health care professional right away if your readings are still above 180/120 mm Hg and you aren't having any other symptoms . An Immediate Jeopardy (IJ) was identified on 02/14/25 at 03:25 PM. The Administrator and DON were notified of an Immediate Jeopardy (IJ) on 02/14/25 at 04:45 PM, due to the above failures and the IJ Template was provided at 05:04 PM. The facility's Plan of Removal (POR) was accepted on 02/15/25 at 12:46 PM and included: [Nursing Facility] 2/14/25 at 5:04pm Immediate Jeopardy called I. Resident Specific Staff nurse completed a clinical assessment of Resident # 1 on 2/4/25 at 5:00pm including blood pressure. Physician was immediately notified of previous high blood pressures on 2/4/25 at 5:06pm. On 2/4/25 all residents with a diagnosis of Hypertension had a clinical assessment completed by the DON and ADON including blood pressure. There were no residents identified requiring physician notification. On 2/15/25 all residents with a diagnosis of Hypertension will have a clinical assessment completed by the DON and Designee including blood pressure. Any resident identified with any abnormal findings the DON and designee will notify the physician immediately. Staff nurses will continue to monitor and report any changes to the physician. II. System Changes Each nurse will review vital signs prior to the end of their shift to ensure all abnormalities are addressed and will be ongoing. DON/ADON will review the previous days vital signs in morning meeting to ensure all abnormalities are addressed and will be ongoing. The weekend Supervisor will review previous days vital signs at the beginning of her shift to ensure all abnormalities are addressed and will be ongoing. III. Education On 2/4/25 medication aides were in-serviced by the ADON on reporting all abnormal vital signs to the nurse immediately and then documenting who they notified. On 2/15/25 DON completed education with all medication aides on reporting all abnormal vital signs to the nurse immediately and then documenting who they notified. This education will be ongoing to include any new staff and staff not yet trained. Identified medication aide received disciplinary action for failure to notify nurse of abnormal blood pressure. On 2/4/25 all nurses were in-serviced by DON on notifying the physician of all vital signs out of the documented parameters and documenting who they notified and what new orders were given. On 2/15/25 DON completed education with all nurses on notifying the physician of all vital signs out of the documented parameters and documenting who they notified and what new orders were given. This education is ongoing to include any new staff and staff not yet trained. IV. Monitoring DON/ADON will randomly pull 3 residents with hypertension weekly x 4 weeks and review their blood pressure for appropriate follow-up and interventions if required. Results of the random audits will be reviewed in QAPI meeting monthly x 3 months. On 02/15/25 the investigator began monitoring (01:02 PM-02:40 PM) to determine if the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Observations, interviews, and records reviews on 02/15/25, 01:02 PM-01:45 PM, of Residents #1, #2, #3, #4, #5, #6, #7, and #8 revealed no further concerns for a violation of resident rights. Record review of residents' EHR reflected no concerns for changes in physical, mental, or psychosocial status. Observations and interviews with residents and/or RPs revealed no concerns for change of condition or quality of care received. Record review of Resident #1's nursing notes, dated 02/04/25, reflected the resident received a complete clinical assessment including a blood pressure check with no notable changes. Further review reflected the NP was notified of Resident #1's high blood pressures on 02/04/25, with no new orders given. Record review of a document provided by the DON titled Resident Responses Analyzer, dated 02/04/25, reflected all residents diagnosed with hypertension received a clinical assessment including blood pressure checks by the DON or ADON with no concerns requiring physician notification. Record review of a document provided by the DON titled Resident Responses Analyzer, dated 02/15/25, reflected all residents diagnosed with hypertension received a clinical assessment including blood pressure checks by the DON with no concerns requiring physician notification. Record review of an in-service titled Abnormal vital signs and med not given, dated 02/04/25, reflected all medication aides and nurses were educated on parameters for vital signs, and when to notify the physician. Record review of an in-service titled Notification of Physician Protocol, dated 02/15/25, reflected all medication aides and nurses were educated on parameters for vital signs, and when to notify the physician. Record review of a document provided by the Administrator titled Associate Disciplinary Memorandum, dated 02/05/25, reflected MA C was disciplined for failure to notify the nurse of an abnormal blood pressure. Interviews on 02/15/25, 01:45 PM-02:40 PM, conducted with the DON, medication aides and nurses from various shifts: RN E (3rd shift/weekdays), RN D (1st shift/weekends), MA F (2nd shift/weekends), MA C (2nd shift/weekdays), LVN G (1st shift/weekends), LVN H (3rd shift/weekdays), LVN B (2nd shift/weekdays), MA I (1st shift/weekdays), and LVN J (2nd shift/weekdays). indicated they all participated in in-service trainings. The medication aides were able to describe in their own words the protocol for abnormal vital signs. They were able to state the parameters for vitals, when to notify the nurse, and to document all incidents. The nurses were able to describe in their own words the protocol for abnormal vital signs. They were able to state the parameters for vitals, to manually re-check and notify the physician as necessary, and to document all incidents. The DON stated the expectation that all vitals from the previous day would be reviewed, and any abnormal vitals would be addressed accordingly. An Immediate Jeopardy (IJ) was identified on 02/14/25. The Administrator was notified of the Immediate Jeopardy and provided with the IJ Template on 2/14/25 at 05:04 PM. While the Administrator and DON were notified that the IJ was removed on 02/15/25 at 02:34 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 21 residents (Resident #47) reviewed for abuse. The facility failed to ensure Resident #47 was free from abuse when LVN F sent the resident a mentally/emotionally abusive text message, which caused the resident to experience fear for her personal safety. The noncompliance was identified as PNC. The IJ began on 01/16/24 and ended on 01/17/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Record review of Resident #47's quarterly MDS Assessment, dated 11/07/23, reflected she had a BIMS score of 12, which indicated mild cognitive impairment. Record review of the facility's Provider Investigation Report, signed and dated by the Administrator on 01/19/24, reflected on 01/16/24 at 7:17 PM, LVN F sent Resident #47 a verbally abusive text message that was traced back to the nurse's phone. The Provider Investigation Report reflected the provider response to the incident included notifying the police department and the physician, LVN F was terminated, a complaint was filed with the Board of Nursing, and the resident was assessed. Additionally, the Administrator provided staff with in-service training regarding reporting abuse, verbal and mental abuse, forms of abuse, and the Abuse Coordinator. Further review of the Provider Investigation Report revealed the following investigation summary: Resident has a dx of schizophrenia, bipolar, anxiety, vascular dementia. Resident has a history of verbal and physical abuse towards staff, verbal abuse towards past roommates. Resident has a history of refusing care from staff and only demanding certain staff in room, kicking staff out of room. Resident has history of repeatedly calling the facility. Resident has a history of refusing to see the physician. Resident has refused all psych services. On 01/17/24 at approximately 11:45AM charge nurse LVN G reported to the abuse coordinator that resident [Resident #47] showed her a text message on her phone in which someone had sent the resident a hateful text. At about 11:55 AM, Administrator and business office manager .spoke with resident [Resident #47] about the text message she had received. Resident was able to show the message on her phone to Administrator and business office manager. Resident allowed Administrator to take a picture of the text message sent to her showing the text message, date sent, time and number from which it was sent. Resident stated this is why she contacted the police on 01/16/24 and the police have a copy of the text message as well. Resident stated this is not the first text message she had received. The administrator and business office manager reassured the resident that an investigation would be done, and that [the] resident would be safe at the facility. The administrator compared the number to staff phone numbers to rule out any staff. The phone number was found to belong to [LVN F]. The administrator notified the local police department of the allegations of abuse. The administrator was told by dispatch that an office had been out to the resident the night before and would combine complaints as they were similar in nature. The police department provided the contact email for [Officer X] that came to the facility on [DATE]. The administrator contacted [Office X] via email (per police department request) with the information discovered in the facility investigation. On 01/17/24 at about 12:34 PM, the Administrator contacted [LVN F] about the information discovered on [the] resident's phone. [LVN F] denied sending the text message to [Resident #47]. The administrator explained to [LVN F] that her number is seen on the text message and the police have been notified. [LVN F] said it was not her who sent the text and that someone must have taken her phone and sent the message. At approximately 1:15 PM Administrator and Social Worker .checked in on [Resident #47]. The Administrator informed the resident that she has been in contact with [Officer X] and has provided the officer with the information that the facility has regarding the text message that was sent to the resident. The administrator reassured the resident that she is safe, and the person who sent the text message would not be back in the facility and that she was safe Actions Taken by Facility: [LVN F] immediately suspended pending investigation and terminated from employment. Police notified. Texas Board of Nursing notified. Safe surveys were completed on station 2 with all residents that nurse had contact with. Immediate education began with staff over verbal and mental abuse, how residents can receive verbal and mental abuse (via text message). Staff questions regarding messages on residents' personal devices were addressed. Immediate monitoring of resident for any s/s of distress began. Resident asked social worker and other staff to stop checking on her. Observation of the text Resident #47 received revealed the following: You are an ignorant bitch. You are a dope addict. You're just fucking nasty!!!! All you ever do is scream and bitch. You need to just die. Make the world a better place and go to hell where u came from you witch! Observation and interview on 04/02/24 at 11:07 AM with Resident #47 revealed the resident was lying in bed. Resident #47 stated that she was scared and frightened since she received the text message. She stated that she did not who sent the text message. Resident #47 also expressed that she felt that there was no one to protect her and that she was in extreme fear since the incident. Interview with LVN G on 04/02/24 at 2:42 PM revealed on 01/17/24 Resident #47 showed her a text she had received on her personal cell phone the evening of 01/16/24. LVN G stated she went and called the administrator, who was the abuse coordinator, immediately to report the incident. LVN G stated she was unaware who sent the text to Resident #47. Interview on 04/04/24 at 2:41 PM with former employee, LVN F, revealed she was unaware of the incident. LVN F stated that she was called by the Administrator and told that texts that were verbally abusive to Resident #47 were sent from her phone. LVN F said that she did not send the texts and often left her personal cell phone lying on the nurse's station desk in addition to loaning her phone to two separate staff. LVN F stated she was terminated on the phone by the Administrator. Interview on 04/04/24 at 5:43 PM with Administrator revealed LVN G called her after seeing the text on Resident #47's personal cell phone. The Administrator stated that she entered the number in her phone and LVN F's name came up matching the phone number. She then called LVN F and terminated her on the phone. The Administrator stated that she referred LVN F to the board of nursing including all supporting documentation. Record review of the facility's policy dated 10/24/22, and titled Abuse, Neglect, and Exploitation reflected: .III. Prevention of Abuse, Neglect and Exploitation; The facility will make every effort to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is suspected or identified by: 1. Taking immediate action to correct any issues that can reduce the risk of further harm continuing or occurring to resident or other residents

Based on interview and record review, it was determined the facility failed to implement written policies and procedures that prohibit resident neglect. 1. LVN H failed to protect Resident #1 from Resident #2 when she did not notify other staff and address Resident #2's inappropriate behavior toward Resident #1, which started on 05/13/12. 2. ADON F failed to protect Resident #1 from Resident #2 when she was aware at 10:00 AM on 05/15/12 that Resident #2 open mouthed kissed Resident #1, which upset Resident #1. 3. LVN A and LVN I failed to protect Resident #1 from Resident #2 by not notifying other staff and addressing Resident #2's inappropriate behaviors toward Resident #1. These failures resulted in Resident #1 being touched inappropriately by Resident #2 which caused Resident #1 to have feelings of embarrassment, guilt, not being safe, and feeling that the sanctity of his room had been violated. These failures could affect the other 92 residents who were dependent or needed staff assistance with transfers by placing them at risk for mistreatment by other residents and unwanted attention from other residents. Findings included: Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 did not have memory problems and he was able to express his ideas and wants and had the ability to understand others. Resident #1 required extensive assistance of two people with bed mobility, transferring, dressing, and toileting. Resident #2 was a [AGE] year-old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's Admission Nursing Assessment 03/13/12 reflected a [DIAGNOSES REDACTED]. Resident #2's Nurse's Notes dated 05/11/12 reflected Resident #2 was able to walk up and hug staff and residents. Review of Resident #2's MDS assessment dated [DATE] revealed Resident #2 was admitted from a psychiatric hospital. The MDS assessment reflected Resident #2 was usually able to understand others and was usually able to make his ideas and wants known. The MDS assessment also reflected Resident #2 was able to walk within his room and in the corridors with supervision only and he did not have any behaviors during the assessment period except for rejecting care one to three days. Resident #2's MDS assessment reflected active [DIAGNOSES REDACTED]. On 05/31/12 at 1:22 p.m. an interview with LVN H revealed Resident #2 was on the back, where he lived, and she took care of Resident #1 who lived on the front hall. LVN H stated she watched Resident #2 because he started to become quite fond of Resident #1. She stated on 05/13/12, she redirected Resident #2 as a preventative measure. LVN H stated she was at the medication cart, when Resident #2 headed toward Resident #1's room. She stated Resident #2 would tell Resident #1 he loved him. She stated she monitored him because she knew Resident #1 was heterosexual. She stated in the main dining room she observed Resident #2 telling Resident #1 he loved him (Resident #1) and then would attempt to approach him. There was a couple of times LVN H observed Resident #2 attempting to go to Resident #1's room, but she would redirect him and stated she did not want him to become too familiar with Resident #1. LVN H stated Resident #2 would lean over and attempt to kiss Resident #1, not on his cheek but on his mouth. LVN H stated she did not remember when, but the DON told her to keep an eye on Resident #2. She stated she thought it was the next day when she was feeding a resident in the main dining room. She stated she was directly across from Resident #1. LVN H stated Resident #2 was observed going to the coffee pot and then back, and then he got up again and went straight for Resident #1. LVN H stated she saw Resident #2's lips puckered up and she stepped in the way and he kissed her shirt. LVN H stated she had Resident #2 then sit back down. (LVN H documented the incident in the Daily Skilled Notes on 05/15/12 at 8:00 a.m.) LVN H stated Resident #2 always told people he loved them and would kiss people on the cheek, but his mannerisms were different with Resident #1. LVN H did not report her concerns to anyone. Resident #1's Nurse's Notes dated 05/14/12 as a late entry for 10:15 a.m., at 4:00 p.m., reflected, "Male resident on Station came to this resident, kissed him and said he wanted a big bed for them. (Resident #1) then told CNAs, then told this nurse...Pt (patient) was subdued and anxious, calmed down. Nurse on Sta. 2 aware, DON aware...." On 05/31/12 at 10:15 a.m. an interview with ADON F revealed she heard from the DON Resident #2 had inappropriate behavior and tried to kiss Resident #1. She stated Resident #1 said Resident #2 came in his room, kissed him, and put his tongue in Resident #1's mouth. ADON F described Resident #1 as "with it" and educated. She stated she felt Resident #1 understood what happened and Resident #2 had psychiatric problems. Review of Daily Skilled Nurse's Notes for Resident #2 revealed on 05/14/12" ...advised that this Res. Has kissed another male Resident on the mouth. DON and ADM aware. Notified son. Social Services aware & stated 'he said he's been dreaming about (Resident #1) & is going to buy them a big bed'...." On 05/31/12 at 1:36 p.m. an interview with LVN I revealed when Resident #2 was admitted to the facility he was impulsive and had difficulty expressing his needs. She stated his impulsive behavior changed from food to being sexually inappropriate and he became attracted to men specifically Resident #1. LVN I stated she saw Resident #2 blowing kisses toward Resident #1 and trying to kiss Resident #1. LVN I stated she never saw him actually kiss Resident #1. She stated he did the same things toward another resident but did not go any further with it. LVN I stated the behavior went on for a few days. She stated Resident #2 told her he had been having dreams about Resident #1 and wanted to buy a big bed for them to sleep in. She stated Resident #2 told her this suddenly. She stated she attempted to redirect him by telling him to please stop and to leave Resident #1 alone. She stated Resident #1 was taken out of the dining room, and he made it clear he was not "ok" with Resident #2's advances. LVN I stated she notified the next shift but did not know who she informed. LVN I stated the DON was in the facility, so she notified the DON that Resident #2 actually kissed Resident #1 on 05/14/12. Review of the Provider Investigation Report dated 05/15/12 at 2:15 p.m. revealed Incident Dated 05/15/12 at 2:00 a.m. in Resident #1's room. "Description of the Allegation: Resident, (Resident #1), stated that Resident, (Resident #2) came into his room at night, and kissed him and touched his penis ...Provider Response: (Resident #2) was removed from the room, and placed on 15 minute checks, Families, Physician, and Psychiatrist were notified ...Provider Action Taken Post-Investigation ...4). (Resident #2) was transferred to (psychiatric hospital) on 5/17/12 for psychiatric eval and treat...." On 05/31/12 at 2:03 a.m. an interview with CNA D revealed Resident #1 was alert and oriented and had episodes of agitation. She stated Resident #1 was unable to get out of bed and required a Hoyer lift for transfers. CNA D also stated Resident #1 could move his arms with difficulty. When queried about Resident #2, CNA D revealed she had only worked with Resident #2 a couple of times. She stated Resident #2 was loud when he talked and he was up in the middle of the night. CNA D stated Resident #2 was very happy and always smiling, but he was hard to understand. She stated Resident #2 did not always comprehend what staff told him, and they had to write things down for him to be able to read and understand. CNA D stated she did not see Resident #2 go into any other resident's room, but did see Resident #2 on the hall on the night in question. On that night, CNA D stated Resident #1's call light was on. When she entered the room to answer the call light, Resident #1 had a bottle of mouthwash in his hand and was attempting to open it. Resident #1 had a worried look on his face. CNA D stated she asked what he was doing and why he was attempting to open the mouthwash because it was unusually late. Resident #1 responded to her to not let that man come back in his room. CNA D stated Resident #1 did not know Resident #2's name but was able to describe him by his voice and the way he talked. CNA D stated she had previously seen Resident #2 on the hall so "it made sense." CNA D asked Resident #1 why he did not want Resident #2 in his room and Resident #1 explained he had come into his room and was kissing on him. When queried about the kisses, Resident #1 revealed Resident #2 had kissed him on the mouth, which was why he wanted to use the mouthwash. CNA D helped Resident #1 use the mouthwash. She stated she told Resident #1 she had to report the information to the nurse, and she asked him if there was anything else and if it was only the one time. Resident #1 stated, "No." He revealed Resident #2 came in and kissed him then left, but Resident #2 came back and tried to pull down his (Resident #1's) brief. CNA D stated she reported the information to LVN B. She stated LVN A was with LVN B when she reported it. CNA D stated LVN B left to talk with Resident #1. She stated she moved the linen cart to prevent Resident #2 from entering the hall from the "Coca Cola Room," and she positioned herself in front of the Nurse's Station to monitor the hallway. CNA D stated she did not see Resident #2 come back over on the hallway, but she heard from the other employees he tried to and was wanting to take Resident #1 some cookies. CNA D stated Resident #2 was watched all night and he was either in the dining room watching television or he was going in and out of the "Coca Cola Room." On 05/31/12 at 10:00 a.m. an interview with Resident #1 revealed the Resident #2 went around kissing everyone in the dining room, especially the men. Resident #1 explained one night he was in his room, he had already taken his [MEDICATION NAME] and sleeping pill, and after every smoke break Resident #2 came in his room and kissed him. Resident #1 stated he got worse and worse over a two day period to the point Resident #2 would lick his nose and lips. Resident #1 stated the last time Resident #2 came in his room, he put his hands in his (Resident #1's) brief and touched him. Resident #1 stated he told the CNAs to try to keep him out of his room, but Resident #2 would "sneak past" and come in his room. Resident #1 stated Resident #2 kissed him during the day and he told the staff, and then he repeatedly came back in during the night. Resident #1 stated it made him feel bad and he could not get away from Resident #2 because he was in bed. Resident #1 stated he could not holler, but he did turn on his call light and told the CNA. Resident #1 stated he tried to tell Resident #2 to "stop please stop" more than once. Resident #1 stated after that night, he did not see Resident #2 again. Resident #1 stated it upset him because he could not do anything to fight Resident #2 off and was under medications. Resident #1 stated he reported to CNA D and then the next day he spoke with the Administrator. He also stated he had been meeting with a psychiatrist about the incident. Resident #1 stated he felt safe living at the facility now that Resident #2 was not there. On 05/31/12 at 1:52 a.m. LVN B, Resident #1's charge nurse who worked on the front hall, revealed she was not real familiar with Resident #2, but she had noticed him going into another resident's room. She identified the other room as belonging to Resident #1. LVN B revealed a CNA informed her Resident #1 voiced fear in staying in his room. She stated Resident #1 alleged Resident #2 had touched him inappropriately. LVN B stated she spoke with Resident #1 and told him it would be alright, and they (staff) would stay right outside his room. LVN B stated she then posted herself outside of the Nurse's Station and monitored the room. She stated Resident #2 did not return to Resident #1's room, but continued to walk around in the hallway. LVN B revealed the CNAs helped her monitor the hallway the night of the incident 05/15/12 Further interview with LVN B on 05/31/12 at 2:14 a.m. revealed she did not report the incident on 05/15/12 to anyone. She stated she did not report it to the Administrator or the DON. LVN B stated she thought LVN A would report it, and her only thought was to protect Resident #1. The night of the incident On 05/31/12 at 1:57 a.m. an interview with CNA C revealed Resident #1 was unable to get out of his bed by himself. CNA C stated she was doing rounds, and he told her Resident #2 had come into his room and was bothering him by hugging and kissing on him. She stated Resident #1 was bed-bound and "with it." CNA C stated she did not see Resident #2 in Resident #1's room. CNA C stated she reported this information to the nurse. CNA C stated she then made sure Resident #2 stayed in the dining room by keeping a closer watch of him. CNA C stated Resident #2 walked to the Nurses' Station but did not go any further. CNA C was only aware of the one incident. CNA C stated Resident #1 was not afraid but stated that it did bother him and something had to be done with Resident #2. Resident #2 was later "sent out somewhere" (discharged ). Resident #1's Social Services Progress Note dated 05/25/12 reflected "he does not sleep as well but had a good night's sleep last night and slept all night." The Notes reflected Resident #1 "He said talking to counselor...Resident reported feeling that the sanctity of his room had been violated 'like Superman's fortress of solitude was broken into.' He said he still hasn't told his brother or sister what had happened. He said 'I still feel embarrassed, that it is my fault I let it go so far.' SW reassured him it was not his fault and even if his family did know they would not think any differently about him. SW said that no one here at the facility things anything bad or differently about him either. SW spoke with counselor about this and counselor believes most of the feelings dealt with have to do with his helplessness the resident feels by being in his physical condition not being able to fight back or prevent. SW told resident that he is very strong. Resident feels much better since other resident (perpetrator) has left the building. Counselor believes resident is experiencing normal feelings after such an incident and it is better to not over-do addressing this topic with resident. Counselor believes resident would like to get back to normal & not have anyone make a big deal out of incident. Counselor will address possible issues of shame next counseling session. SW will cont. to follow for behavior/mood changes in resident with relation to this incident." On 05/31/12 at 10:44 a.m. an interview with LMSW (Licensed Masters Social Worker) revealed Resident #2 always spoke loudly and always critiqued the food but nothing alarming. The LMSW stated the behavior started with the Dietary Manager because he would try to kiss her and she felt uncomfortable. The LMSW stated she talked to him about this and he said he would not do again. She stated Resident #2 was always agreeable with her and said thank you and I love you a lot. The LMSW stated then it progressed to more people. She stated the change happened pretty quickly. The LMSW stated one day he was blowing kisses, and then the next day an incident happened with Resident #1. The LMSW stated the Incident Report reflected Resident #2 went into Resident #1's room and was kissing him and trying to put his tongue in his mouth. The LMSW state she thought Resident #2 left and came back in the room and then talked about Resident #1's penis and then touched his penis under his brief. She stated Resident #1 turned on his call light and told the CNA to keep the man away from him and described Resident #2. The LMSW stated she learned about the incident the next day from nursing in the morning meeting. The LMSW stated she was aware that during the day Resident #2 kissed Resident #1 on 05/14/12. She stated she spoke with Resident #2 about him kissing other people and he denied doing anything. The LMSW stated even after the incident that happened at night, Resident #2 said he was completely innocent. She stated Resident #2 had memory problems and was delusional. The LMSW also stated Resident #1 was usually very aware and able to tell what happened. She stated Resident #1 did not have memory problems but did have outbursts of anger and mood regulating problems. She stated that had zero bearing on what happened to him (Resident #1). The LMSW stated she spoke with him later and he said he was embarrassed by what happened and as his own responsible party, he was not sure he wanted his family to know what happened. The LMSW stated a counselor had been meeting with Resident #1. She stated during the assessment, the counselor felt Resident #1 was dealing and there was nothing out of the ordinary. The LMSW stated Resident #1 just wanted everything done and over with and did not want to be treated differently because of the incident. On 05/31/12 at 1:45 a.m. an interview with LVN A, Resident #2's charge nurse who worked on the back hall, revealed Resident #2 was sent to the psychiatric hospital because of sexual gestures towards other male residents. LVN A stated she never saw Resident #2 become physical with a resident, but Resident #2 would verbalize affection by saying he "love him." LVN A stated she did not know who or what Resident #2 was referring too when he expressed his love. LVN A stated before Resident #2 left the facility he would stay up late at night and watch the television in the dining room. LVN A stated she saw Resident #2 trying to go into another resident's (Resident #1's) room on the front hall. She stated she redirected him and took him back to the dining room. LVN A stated Resident #2 had only been living at the facility for a couple of months and there had not been any issues with him until the last couple of days before he was transferred out. LVN A stated she documented in the Nurse's Notes a couple of times when he was up wandering around at night. LVN A stated the staff members did not have to come to her about Resident #2 . She stated she was able to keep track of him for the most part. LVN A also stated Resident #2, at one time (05/15/12), was placed on 15 minute checks for going into another resident's room. On 05/31/12 at 2:18 a.m. an interview with LVN A revealed nothing happened while she was there and she redirected Resident #2. LVN A could not remember which CNA but a CNA reported Resident #1 was upset. She stated when she went to talk with Resident #1, he reported a man kept coming in his room. LVN A stated Resident #1 described Resident #2 and she told him she would keep an eye on him. She stated Resident #1 did not report any specific thing Resident #2 did. LVN A stated the rest of the night she did not see Resident #2 go back to Resident #1's hall. LVN A stated when she came to work, during report she was told Resident #2 needed to be watched because he had been trying to kiss Resident #1. LVN A stated she did communicate with the other nurse on the front hall. LVN A stated an incident report was completed, but she did not write a witness statement because nothing had happened. LVN A stated she thought Resident #2 was discharged to a psychiatric hospital. On 05/31/12 at 11:18 a.m. an interview with the Dietary Manager revealed she noticed Resident #2's behavior when he first was admitted to the facility. She stated he would always tell her how good the food was and wanted to kiss her on the check. The Dietary Manager stated as time went on, it started to bother her because she felt "targeted." The Dietary Manager told the LMSW, once he started getting more forceful. She stated Resident #2 would grab her face and kiss her cheek. The Dietary Manager stated she asked him to shake her hand, but he would not do this. The LMSW talked to him and wrote it down on the board for him to read and after that he did. The Dietary Manager stated it was to the point she would turn and leave rather than deal with Resident #2. On 05/31/12 at 10:28 a.m. an interview with ADON G revealed Resident #2 was not at the facility long. She stated when he first moved in the facility, he was having difficulty because he was unable to process what was said. ADON G stated he spoke very loudly and his voice was very irritating. She stated it appeared he screamed to speak but he was not trying to. ADON G stated Resident #2 started out ambulating with a wheelchair and by the time he discharged he was able to walk. She stated then the behaviors started. ADON G stated she did not hear Resident #2 was ever inappropriate with any of the staff members. But she did observe Resident #2 in the dining room, and a family member was visiting another resident when Resident #2 started making comments about beautiful women in a repetitive nature. She stated then Resident #2 got up from his table and walked over and kissed her. ADON G stated Resident #2 kissed the family member on the cheek because she turned her head, and then he went and sat back down. ADON G stated she did not document the incident in his chart but should have. ADON G stated Resident #2 was aggressive and impulsive. ADON G was unable to remember when she first learned about Resident #2 and Resident #1. ADON G stated Resident #2 was placed on 15 minute checks with LVN A on 05/15/12 at 2:15 a.m. ADON G reviewed the chart and stated she did not document but reviewed the notes. ADON G stated if there was an incident at 2:00 a.m. then the nurse should have reported it to the Administrator at that time. She stated there were times when they did not learn things until the next day. On 05/31/12 at 11:21 a.m. an interview with the Administrator revealed he originally found out about the incident involving Resident #1 and Resident #2 on 05/15/12 around 8:00 a.m. when he arrived at work. The Administrator stated he was not notified immediately. The Administrator stated he was notified the day before of Resident #2 trying to kiss Resident #1. The Administrator stated it was common for Resident #2 to hug and kiss on the cheek. The Administrator stated he was told by the nurse there was no actual kiss. The Administrator stated he was not aware Resident #2 kissed a family member or had been aggressive with the Dietary Manager. On 05/31/12 at 11:40 a.m., further interview with the Administrator revealed an inservice was conducted on 05/29/12 and was included in the investigation. He stated immediately after the incident, the nurse started 15 minute checks on Resident #2. He stated the psychiatrist was called and after being evaluated, he was sent to the hospital because they had to follow their procedures. The Administrator stated inservicing on abuse and neglect was started on 05/18/12 and was completed on an on-going basis. On 05/31/12 at 3:21 p.m. an interview with the Administrator revealed the reason the incident occurred at the facility was because Resident #2 had [MEDICAL CONDITION], was extremely friendly and very thankful and then he "twisted in his mind" causing him to have a behavior involving Resident #1. The Administrator stated because a new nurse was not comfortable enough to call him in the middle of the night was the reason the alleged abuse was not reported to him immediately. Review of the inservices for the past five months revealed there was an inservice about abuse and neglect and reporting on 01/13/12, 02/24/12 and 05/29/12. And on 04/03/12 an inservice was done on patients with Dementia and dealing with combative or aggressive residents. On 05/31/12 at 10:57 a.m. an interview with the DON revealed the Administrator took care of the investigation. She stated she did not know about the incident and when it initially started. The DON stated on 05/14/12 ADON F reported to her. The DON stated Resident #2 was blowing kisses at Resident #1 last she heard and then the next night the incident occurred. She stated 15 minute checks were initiated and the residents were separated. The DON stated she was not notified until she came in the next morning. The DON stated she was not aware Resident #2 actually kissed Resident #1. The DON stated Resident #1 did not seem to be affected and no harm was done. Resident #2 was not noted to have behaviors, according to the DON. She stated Resident #2 was a loving man, he favored men and he hugged the Administrator daily. The DON stated prior to the incident, nothing happened but then after the night when the incident occurred, she was notified the next morning but did not remember who reported it to her. The DON stated she should have been contacted when the incident occurred. The DON stated the initial kiss was not a big deal. The DON reviewed Resident #1's chart and said LVN H documented at 8:00 a.m. Resident #2 attempted to kiss Resident #1 and 10:00 a.m. someone came in and told. She stated the residents were then separated and then they did not think anything of it. The DON read where the ADON F documented a late entry that indicated Resident #1 reported he was kissed. The DON stated Resident #1 was noted to be very alert and oriented and he did occasionally get things distorted, but when he told ADON F something then it was the truth because he talked to her about everything. She stated Resident #1 was "ok" afterward but anxious. The DON stated the investigation started the next day when she came to work. The DON stated the Administrator should have been notified after the actual kiss happened on 05/14/12. She stated the 15 minute checks were initiated after the incident. The DON stated she did not realize Resident #1 had been kissed and she was not aware Resident #2 had kissed a family member or was making the Dietary Manager uncomfortable. On 05/31/12 at 4:00 p.m. an interview with the DON revealed the reason the incident happened was because LVN B did not call the Abuse Coordinator. The DON stated she did understand she was new at working at the facility but she was a "seasoned nurse." The DON stated she thought there needed to be inservices conducted and the nurses and staff responsibilities in cases such as this needed to be addressed. The DON stated she originally thought everything was under control but realized it was not. Corporate employees informed her that inservicing needed to be started immediately on addressing resident behaviors. An interview on 05/31/12 at 9:25 a.m. with the Administrator revealed he had spoken with the psychiatric hospital and with Resident #2's family member and the facility had decided they would not be accepting Resident #1 back. The Administrator stated they had to keep all the other residents safe. He also stated he was also concerned about the high number of psychiatric residents in the facility and feared for Resident #2's safety as well. On 05/31/12 at 2:03 p.m. an interview with ADON F and the DON revealed prior to talking with Resident #1, they were told Resident #2 had gone into Resident #1's room. They stated then Resident #1 told ADON F that Resident #2 touched his penis. ADON F and the DON stated it was unknown when for sure the incident report was started. The DON stated the staff were supposed to be watching Resident #2 because of the attempted kiss. The charts were reviewed and it was noted LVN B did not document anything about the incident on 05/15/12. When asked if Resident #1 had a roommate ADON F stated yes he did, but he was not able to give any additional information. On 05/31/12 at 3:07 p.m. in a Resident Group Interview with eight residents, who were alert and interviewable according to the facility, a resident stated there was a problem with one resident (Resident #2) going in and out of people's rooms and he yelled and hollered. The residents stated Resident #2 was no longer in the facility. Review of the Psychiatric Progress Notes dated 05/16/12 revealed Resident #2 was seen by a psychiatrist due to his behaviors. His [MEDICATION NAME] was discontinued and he was started on [MEDICATION NAME] 10 mg. Resident #2 was originally referred to the psychiatrist on 03/13/12. The psychiatrist was contacted after the incident. Review of the facility's Abuse Prohibition Policy and Procedure dated February 2012 revealed "Policy: Residents have the right to be free from abuse, corporal punishment, and involuntary seclusion. The following procedures will be operationalized in order that residents will not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility ensure all alleged violations are reported immediately to the administrator or the administrative designee. Local law enforcement, the state survey agency and the Department of Family and Protective Services (if appropriate) will be notified in accordance with federal and state law... II. Training Employees: Prevention, Intervention, Detection, Reporting, and Employee Rights...5. If resident abuse or neglect is witnessed, the person witnessing the abuse or neglect must immediately intervene for the protection and safety of the resident. 6. Discuss behavioral interventions that can be used for inappropriate resident behaviors ... III. Prevention of Abuse: A. The facility will provide residents, families, staff, and volunteers, staff of other agencies serving the residents, and consultants; information of how and to whom they may report concerns, incidents and grievances without fear of retribution. B. The Administrator or designee will be responsible to provide feedback regarding concerns expressed by the resident, families, volunteers, staff of other agencies serving the residents, and consultants... VII. Reporting and Response to Alleged Incidents: ...B. All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property shall be reported immediately (not to exceed 2 hours after discovery) to the Administrator or the DON... C. If neither is in the facility when such incidents occur or are discover after hours, the report will be given to the Charge Nurse or Supervisor in charge. D. The Charge Nurse or Supervisor must immediately contact the Administrator or the DON of the incident. E. The nurse must document all incidents of alleged abuse/neglect on the Incident Report and on the 24-hour report...G. The Administrator or designated representative will immediately begin an investigation and follow the State Guidelines for reporting incidents and accidents. Investigation guidelines include: 1. Resident(s) and responsible party interview, as applicable... 3. Staff interviews and written statements, as applicable... 5. Methods to support the individual and detect and prevent further victimization...." Review of the CMS Form 672 Resident Census and Conditions of Residents Form dated 05/31/12 revealed there was a census of 99. There were 8 residents who where dependent for transferring and 85 required the assistance of one or two staff members to transfer.

Based on interview and record review, it was determined the facility failed to ensure one (Confidential Interviewee) of six residents reviewed for abuse was free from verbal/mental abuse. A Confidential Interviewee said he/she was verbally abused by MA A. He/she was very scared of MA A and thought if MA A knew he/she was reporting the abuse he/she would be harmed. The interviewee also stated a nurse heard the verbal abuse, but did not report it. These failures could affect the other 48 residents on the back hall where MA A administered medication and could expose the residents to further abuse. Findings included: On 03/31/11 at 9:00 AM, during the entrance conference with the Administrator and the DON, the Administrator stated a complaint had been worked several weeks ago concerning MA A abusing the residents. The Administrator stated the complaint was unsubstantiated. The Administrator further stated, "___ (MA A) had worked in the facility for several years, and had a very good work record." The Administrator stated, "___ (MA A) has a very heavy voice and talked to residents loudly." The Administrator stated, "___ (MA A's) behavior had never been reported to him." The Administrator further stated when MA A worked the front hall, no resident reported her attitude. He also stated no employee reported MA A. The DON stated, "The CNAs did not like ___ (MA A), because ___ (MA A) was in charge of the scheduling and was unpopular." The Administrator stated LVN B was the charge nurse for MA A on the 2:00 PM to 10:00 PM shift. The Administrator stated both MA A and LVN B were provided an in-service on 03/16/11 at 5:00 PM concerning verbal abuse, reporting staff suspected of verbal abuse, and how to address residents. On 03/31/11 an interview was conducted at 9:45 AM with Resident #2. The resident was asked if he had overheard or had ever been verbally abused by MA A. Resident #2 stated, "Yes. Last week I overheard MA A yell at a resident in the hall." On 03/31/11 at 10:36 AM, the surveyor interviewed Resident #3. Resident #3 stated, "I do not remember ___ (MA A) well. She might have been in my room. My roommate told me to report ___ (MA A) to the charge nurse when she talked mean to me." Resident #3 further stated, "Is it someone else I can report to if someone does something to me?" The surveyor told Resident #3 to call the Administrator. On 03/31/11 at 10:45 AM, an interview was conducted with Resident #4 concerning MA A's verbal abuse toward residents. Resident #4 stated, "Yes. ___ (MA A) is very loud and intimidating. She is very talkative, and her demeanor is less desiring." Resident #4 told the surveyor, "Someone from the state department was here the other week investigating ___ (MA A), because of her attitude, and the way she verbally abused the residents." Resident #4 further stated LVN B and MA A had the same attitudes. Resident #4 stated if you reported abuse to LVN B about MA A, she would not report it to the Administrator. Therefore, any resident reporting to the charge nurse does not get their complaint heard. Resident #4 stated LVN B did not get up to give PRN medications when medication was requested. Resident #4 stated she (LVN B)sat at the desk and allowed the residents to wait. A confidential interviewee revealed, "I am afraid of ___ (MA A). She can hurt me. I cannot say anything about her, because she will get me. Please do not let her know I talked with you." The interviewee then stated, "The nurse heard ___ (MA A) talk to me very rudely and did not report it." On 03/31/11 at 11:48 AM, an interview was conducted with the DON concerning MA A verbally abusing a resident. The DON stated she had not had any reports on MA A. The DON stated she was on vacation when a surveyor was in the facility before investigating a complaint about MA A abusing residents. The DON further stated she did not talk with MA A. The Administrator told her the State had come in while she was on vacation. The DON stated the Administrator was the Abuse Coordinator, and residents were told to report abuse to the charge nurse or to the Abuse Coordinator. The DON further stated the staff had several in-services and knew what abuse was and knew who to report abuse to if abuse occurred. The DON stated, "I will need to look into the issue. ___ (MA A) worked one day on the front hall." On 03/31/11 at 12:25 PM, an interview was conducted with Resident #5 concerning MA A's verbal abuse. Resident #5 stated MA A worked one day on the hall and was very verbally abusive to the residents. Resident #5 further stated MA A did not need to work in the facility. She was loud and intimidating with her voice. Resident #5 stated, "___ (MA A ) thought her voice made her in charge." Resident #5 stated, "I hope you can do something about ___ (MA A's) attitude toward the residents." Resident #5 stated the residents, who attended the Resident Council meetings, talked about how MA A treated residents and how she was verbally abusive, but they never put it in their minutes, because they were frightened of what MA A would do if she found out. On 03/31/11 at 1:55 PM, an interview was conducted with LVN B. LVN B stated, "I do not see ___ (MA A) mistreating the residents. She talks too loud to residents." LVN B stated, "I have asked her to lower her voice before, and she continued to talk loud to residents. The DON and Administrator are aware of the problem." On 03/31/11 at 2:10 PM, the surveyor interviewed CNA C concerning MA A's verbal abuse to the residents. CNA C stated she worked with MA A on the back hall, and MA A always told residents to "Shut up and be quiet." CNA C stated she overheard MA A tell residents to go to their room and shut up. She further stated, "___ (MA A) had an attitude with me, because I called in." CNA C further stated, " ___ (MA A) was very rude to residents and some staff." An interview was conducted on 03/31/11 at 2:15 PM with CNA D concerning MA A's verbal abuse toward residents. CNA D stated, "___ (MA A) is very rude and loud. She yells at the staff. She does the scheduling/staffing, but we stopped calling her when we were absent, because she yells." CNA D further stated, "If we report to the Administrator and the DON, they tell us to settle down and do nothing about the problem." CNA D further stated, "I used to tell MA A when I was going to be off duty, but I don't tell her anymore. I tell the DON." CNA D stated MA A came down the hall and asked her what day she was going to be off. She stated, "The residents stated they did not want me to take off, because they did not want MA A working their hall." CNA D stated MA A did yell at a resident. CNA D stated she left station two because of MA A. CNA D stated, "___ (MA A) kept me in tears, and I had to get away." An interview was conducted on 03/31/11 at 2:25 PM with MA A. MA A stated she had worked in the facility since 2003. She stated, "My voice is loud. I have to tone my voice down. I never heard residents say they were afraid of me or if I'm talking too loud. I have never been told about being abusive to residents, but I have been told that I was loud with residents." MA A further stated, "I do not talk loud to all residents. I raise my voice to residents that can't hear well. It is not my job to scream and yell at residents." MA A further stated, "Some people may feel my voice is too high tone." MA A further stated a resident may come and ask for Tylenol for her knee or leg, but she had not yelled at the resident. The surveyor asked CMA A why she thought the residents were afraid of her. MA A stated, "I truly do not know. Residents feel intimidated. I do not know why." MA A further stated, "I have to get along with the employees. Some employees I do not get along with, others I do." At the end of the interview, the surveyor asked MA A, "We have interviewed from 2:25 PM to 2:45 PM. During the interview, you have spoken in a very normal voice; why do you not speak to the residents in the same voice?" The surveyor asked the question, but MA A could not give the surveyor an answer. On 03/31/11 at 4:00 PM, an interview was conducted with the Administrator concerning MA A. The surveyor asked the Administrator how many residents MA A administered medications to on the evening shift. The Administrator stated MA A was responsible for medications on the back hall. The surveyor asked the Administrator, "Do you know the residents are afraid of MA A?" The Administrator stated, "No." The surveyor asked the Administrator why he did not complete an investigation on MA A, when the surveyor was in the building previously investigating the MA on an allegation of abuse towards residents. The Administrator stated he should have investigated the incident. The Administrator stated he suspended MA A and LVN B that afternoon, and he would conduct his own investigation. An interview was conducted on 03/31/11 at 2:50 PM with CNA E. CNA E stated she worked on the back hall for about a month with MA A. CNA E stated a resident told her, she was going to call the "state department" and report MA A. CNA E further stated a resident told her (CNA E) he/she heard MA A yelling and screaming at another resident. CNA E further stated, "I have heard ___ (MA A) talk to residents and staff rudely. ___ (MA A) is in charge of staffing, and she yells at the staff." CNA E stated the Administrator and DON will not set her straight. CNA E further stated, "The staff stopped calling ___ (MA A) when they were absent, because she is too rude." A confidential interview revealed, "In Resident Council Meetings, the residents talked about how mean ___ (MA A) was to all the residents. ___ (MA A) was rude and loud and very mean." The interviewee stated MA A did the scheduling for the facility, and administration did not want to reprimand her or discharge her. He/she also stated, the day before the state surveyor came two weeks ago to investigate MA A, she was really rude to a resident. The interviewee said they told MA A she did not have to talk to the resident so rudely. He/she stated, "When the residents came to her cart for medication, ___ (MA A) yelled at the residents and puts them 'in their place.' " The interviewee stated the Administrator and DON only slapped MA A on her hands and just told her to talk softly. A review of the New Hire Employee Information form, dated 08/26/03, located in the personnel file of MA A, revealed she was hired by the facility on 08/26/03. MA A signed an abuse/neglect acknowledgement. A review of the summary report dated 03/16/11 at 5:00 PM, regarding MA A and completed by the facility's only ADON, revealed a one-on-one in-service meeting. The meeting notes dated 03/16/11 reflected, "Your voice and words must be kind and soft when addressing Residents, family members, and other staff members while on the clock in the facility. Inappropriate conduct will result in disciplinary action." The report was signed by MA A. MA A did not complete the employee comment section or write any additional comments. A review of the summary report dated 03/16/11 at 5:00 PM, regarding LVN B as the charge nurse for MA A and completed by the ADON, revealed a one-on-one in-service meeting. The meeting notes dated 03/16/11 reflected, "As a charge nurse you are responsible for the conduct (behavior) of the CNAs that work with you. Failure to take charge and oversee the interaction between staff and residents - report and writing up as needed or disciplinary action will follow." The report was signed by LVN B, no comments were documented by LVN B in the comment section or any additional comments. A review of the facility's Abuse Prohibition Policy and Procedure dated January 2007 revealed the following: "...Residents have the right to be free from abuse, corporal punishment, and involuntary seclusion. The following procedures will be operationalized in order that Residents will not be subjected to abuse by anyone including but not limited to facility staff, other Residents, consultants, volunteers, staff of other agencies servicing the Residents, family members or legal guardians, friends or other individuals. The facility shall ensure that all alleged violations are reported immediately to the Administrator or the administrative designee. The Administrator designee shall ensure that the violations are investigated and reported to the appropriate regulatory agency in accordance with federal and state law... The facility shall be proactive in identifying events and occurrences that may contribute to abuse or neglect through: A. Through Resident council, care plan conferences, family conferences, staff meetings. Residents, families, and staff will be educated and encouraged to report concerns, incidents, and grievances without fear of retaliation. #5...(A) The facility must have evidence that all violations including allegations are thoroughly investigated, utilize attachment D, (facility investigation procedures), to facilitate the investigation process." The review of the grievance log revealed no concerns were reported regarding MA A or verbal abuse. A review of the Resident council meetings, dated December 2010 through March 2011 revealed nothing in regard to MA A verbally/mentally abusing the residents, yelling at them or being rude. On 03/31/11, an in-service was provided to the surveyor, which was conducted by the Administrator. The subject covered abuse/neglect and had a sign-in sheet with staff signatures. The CMS form 672, Resident Census and Conditions of Residents, dated 03/31/11 and signed by the corporate LVN reflected a census of 99 residents. A review of the Patient List Report dated 03/31/11 reflected 48 residents resided on the back hall.

Based on interview and record review, the facility failed to ensure all alleged violations of mistreatment and abuse were reported immediately to the Administrator of the facility, the facility failed to investigate allegations of verbal abuse for one (Confidential Interviewee) of six residents reviewed for abuse. 1. A Confidential Interviewee said he/she was verbally abused by MA A. He/she was very scared of MA A and thought if MA A knew he/she was reporting the abuse he/she would be harmed. The interviewee also stated a nurse heard the verbal abuse, but did not report it. 2. LVN B said MA A will not lower her voice when she spoke to the residents, as LVN B had requested. LVN B stated the Administrator and the DON were aware of the problem. 3. CNA C said MA A frequently told residents to "shut up and be quiet." 4. CNA D said MA A yelled at a resident. 5. The Administrator said he did not know the residents were afraid of MA A. He also said he did not start an investigation when the previous surveyor was in the facility investigating MA A. He said he should have initiated an investigation. 6. CNA E said she heard MA A talking rudely to a resident. CNA E also said she was told by a resident that MA A was yelling and screaming at a resident. 7. Confidential interviewee said MA A was loud, rude, and mean. The interviewee said the Administrator and DON were aware, but only told MA A to speak softly. 8. Resident #4 said MA A was "loud and intimidating" and if residents reported the treatment to LVN B, she would not report it to the Administrator. These failures could affect the 48 residents who resided on the back hall where MA A worked by placing them at risk of verbal abuse. Findings included: 1. On 03/31/11 at 9:00 AM, during the entrance conference with the Administrator and the DON, the Administrator stated a complaint had been worked several weeks ago concerning MA A abusing the residents. The Administrator stated the complaint was unsubstantiated. The Administrator further stated, "___ (MA A) had worked in the facility for several years, and had a very good work record." The Administrator stated, "___ (MA A) has a very heavy voice and talked to residents loudly." The Administrator stated, "____ (MA A's) behavior had never been reported to him." The Administrator further stated when MA A worked the front hall, no resident reported her attitude. He also stated no employee reported MA A. The DON stated, "The CNAs did not like ______ (MA A) because _____ (MA A) was in charge of the scheduling and was unpopular." The Administrator stated LVN B was the charge nurse for MA A on the 2:00 PM to 10:00 PM shift. The Administrator stated both MA A and LVN B were provided an in-service on 03/16/11 at 5:00 PM concerning verbal abuse, reporting staff suspected of verbal abuse, and how to address residents. 2. On 03/31/11 at 10:45 AM, an interview was conducted with Resident #4 concerning MA A's verbal abuse toward residents. Resident #4 stated, "Yes, ___ (MA A) is very loud and intimidating, she is very talkative and her demeanor is less desiring." Resident #4 told the surveyor, "Someone from the state department was here the other week investigating ___ (MA A) because of her attitude and the way she verbally abused the residents." Resident #4 further stated LVN B and MA A had the same attitudes. Resident #4 stated if you reported abuse to LVN B about MA A, she would not report it to the Administrator. Therefore, any resident reporting to the charge nurse does not get their complaint heard. Resident #4 stated LVN B did not get up to give PRN medications when medication was requested. Resident #4 stated she sat at the desk and allowed the residents to wait. 3. On 03/31/11 at 11:48 AM, an interview was conducted with the DON concerning MA A verbally abusing a resident. The DON stated she had not had any reports on MA A. The DON stated she was on vacation when a surveyor was in the facility investigating a complaint about MA A abusing residents. The DON further stated she did not talk with MA A, the Administrator told her the state had come in while she was on vacation. The DON stated the Administrator was the Abuse Coordinator and residents were told to report abuse to the charge nurse or to the Abuse Coordinator. The DON further stated the staff had several in-services and knew what abuse was and knew who to report abuse to if abuse occurred. The DON stated, "I will need to look into the issue, ____ (MA A) worked one day on the front hall." 4. A Confidential Interview revealed, "I am afraid of ___ (MA A). She can hurt me. I cannot say anything about her, because she will get me. Please do not let her know I talked with you." The Confidential Interviewee stated, "The nurse heard ______ (MA A) talk to me very rudely and did not report it." 5. On 03/31/11 at 1:55 PM, an interview was conducted with LVN B. LVN B stated, "I do not see __ (MA A) mistreating the residents. She talks too loud to residents." LVN B stated, "I have asked her to lower her voice before, and she continued to talk loud to residents, the DON and Administrator are aware of the problem." On 03/31/11 at 2:10 PM the surveyor interviewed CNA C concerning MA A's verbal abuse to the residents. CNA C stated she worked with MA A on the back hall, and MA A always told residents to "shut up and be quiet." CNA C stated she overheard MA A tell residents to go to their room and shut up. She further stated, "_____ (MA A) had an attitude with me, because I called in." CNA C further stated, " ____ (MA A) was very rude to residents and some staff." An interview was conducted on 03/31/11 at 2:15 PM with CNA D concerning MA A's verbal abuse toward residents. CNA D stated, "____ (MA A) is very rude and loud. She yells at the staff. She does the scheduling/staffing, but we stopped calling her when we were absent, because she yells." CNA D further stated, "If we report to the Administrator and the DON, they tell us to settle down and does nothing about the problem." CNA D further stated, "I used to tell ___ (MA A) when I was going to be off duty, but I don't tell her anymore. I tell the DON." CNA D stated MA A came down the hall and asked her what day she was going to be off. She stated, "The residents stated they did not want me to take off, because they did not want ___ (MA A) working their hall." CNA D stated MA A did yell at a resident. CNA D stated she left station two, because of MA A. CNA D stated, "_____ (MA A) kept me in tears, and I had to get away." An interview was conducted on 03/3/11 at 2:25 PM, with MA A. MA A stated she had worked in the facility since 2003. She stated, "My voice is loud. I have to tone my voice down. I never heard residents say they were afraid of me or if I'm talking too loud. I have never been told about being abusive to residents, but I have been told that I was loud with residents." MA A further stated, "I do not talk loud to all residents. I raise my voice to residents that can't hear well, it is not my job to scream and yell at residents." MA A further stated, "Some people may feel my voice is too high tone." MA A further stated a resident may come and ask for Tylenol for her knee or leg, but she had not yelled at the resident. The surveyor asked MA A why she thought the residents were afraid of her. MA A stated, "I truly do not know. Residents feel intimidated. I do not know why." MA A further stated, "I have to get along with the employees, some employees I do not get along with, others I do." At the end of the interview, the surveyor asked MA A, "We have interviewed from 2:25 PM to 2:45 PM during the interview, you have spoken in a very normal voice; why do you not speak to the residents in the same voice?" The surveyor asked the question, but MA A could not give the surveyor an answer. On 03/31/11 at 4:00 PM, a second interview was conducted with the Administrator concerning MA A. The surveyor asked the Administrator how many residents MA A administered medications to on the evening shift. The Administrator stated MA A was responsible for medications on the back hall. The surveyor asked the Administrator, "Do you know the residents are afraid of MA A?" The Administrator stated, "No." The surveyor asked the Administrator why he did not complete an investigation on MA A when the surveyor was in the building previously investigating MA A on abuse to residents. The Administrator stated he should have investigated the incident The Administrator stated he suspended MA A and LVN B that afternoon and he would conduct his own investigation. An interview was conducted on 03/31/11 at 2:50 PM with CNA E. CNA E stated she worked on the back hall for about a month with MA A. CNA E stated a resident told her, she was going to call the "state department" and report MA A. CNA E further stated a resident told her (CNA E) he/she heard MA A yelling and screaming at another resident. CNA E further stated, "I have heard ___ (MA A) talk to residents and staff rudely. ____ (MA A) is in charge of staffing and she yells at the staff." CNA E stated the Administrator and DON will not set her straight. CNA E further stated, "The staff stopped calling ____ (MA A) when they were absent because she is too rude." 6. A confidential interview revealed, "In resident council meetings, the residents talked about how mean ___ (MA A) was to all the residents. ___ (MA A) was rude and loud and very mean." The interviewee stated MA A did the scheduling for the facility, and administration did not want to reprimand her or discharge her. He/she also stated, the day before the state surveyor came two weeks ago to investigate MA A, she was really rude to a resident. The interviewee said they told MA A she did not have to talk to the residents so rudely. He/she stated, "When the residents came to her cart for medication, ____ (MA A) yelled at the residents and puts them 'in their place.'" The interviewee stated the Administrator and DON only slapped MA A on her hands and just told her to talk softly. 7. A review of the facility's Abuse Prohibition Policy and Procedure dated 01/07 revealed the following: "...Residents have the right to be free from abuse, corporal punishment, and involuntary seclusion. The following procedures will be operationalized in order that Residents will not be subjected to abuse by anyone including but not limited to facility staff, other Residents, consultants, volunteers, staff of other agencies servicing the Residents, family members or legal guardians, friends or other individuals. The facility shall ensure that all alleged violations are reported immediately to the Administrator or the administrative designee. The Administrator designee shall ensure that the violations are investigated and reported to the appropriate regulatory agency in accordance with federal and state law... The facility shall be proactive in identifying events and occurrences that may contribute to abuse or neglect through: A. Through Resident council, care plan conferences, family conferences, staff meetings. Residents, families, and staff will be educated and encouraged to report concerns, incidents, and grievances without fear of retaliation. #5...(A) The facility must have evidence that all violations including allegations are thoroughly investigated, utilize attachment D, (facility investigation procedures), to facilitate the investigation process." A review of the New Hire Employee Information form, dated 08/26/03, located in the personnel file of MA A revealed she was hired by the facility on 08/26/03. MA A signed an abuse/neglect acknowledgement. A review of the summary report dated 03/16/11 at 5:00 PM, regarding MA A and completed by the ADON, revealed a one on one in-service meeting. The meeting notes dated 03/16/11 reflected, "Your voice and words must be kind and soft when addressing Residents, family members, and other staff members while on the clock in the facility. Inappropriate conduct will result in disciplinary action." The report was signed by MA A. MA A did not complete the employee comment section or write any additional comments. A review of the summary report dated 03/16/11 at 5:00 PM, regarding LVN B as the charge nurse for MA A and completed by the ADON, revealed a one-on-one in-service meeting. The meeting notes dated 03/16/11 reflected, "As a charge nurse you are responsible for the conduct (behavior) of the CNAs that work with you. Failure to take charge and oversee the interaction between staff and residents - report and writing up as needed or disciplinary action will follow." The report was signed by LVN B, no comments were documented by LVN B in the comment section or any additional comments. The review of the grievance log revealed no concerns were reported regarding MA A and verbal abuse against any resident. A review of the Resident council meetings, dated 12/2010 through 03/2011, did not reveal MA A verbal abusing the residents. On 03/31/11, an in-service was presented to the surveyor, which was conducted by the Administrator. The subject covered abuse/neglect and had a sign-in sheet with staff signatures. 8. The CMS form 672, Resident Census and Conditions of Residents, dated 03/31/11 and signed by the corporate LVN reflected a census of 99 residents. A review of the Patient List Report dated 03/31/11 reflected 48 residents residing on the back hall.

Based on interview and record review, the facility failed to implement the facility's written policies and procedures that prohibit mistreatment and abuse of residents for one (Confidential Interviewee) of six residents reviewed for abuse. 1. A Confidential Interviewee said he/she was verbally abused by MA A. He/she was very scared of MA A and thought if MA A knew he/she was reporting the abuse he/she would be harmed. The Confidential Interviewee also stated a nurse heard the verbal abuse, but did not report it. 2. LVN B said MA A will not lower her voice when she spoke to the residents, as LVN B had requested. LVN B stated the Administrator and the DON were aware of the problem. 3. CNA C said MA A frequently told residents to "shut up and be quiet." 4. CNA D said MA A yelled at a resident. 5. The Administrator said he did not know the residents were afraid of MA A. He also said he did not start an investigation when the previous surveyor was in the facility investigating MA A. He said he should have initiated an investigation. 6. CNA E said she heard MA A talking rudely to a resident. CNA E also said she was told by a resident that MA A was yelling and screaming at a resident. 7. Confidential interview said MA A was loud, rude, and mean. The interviewee said the Administrator and DON were aware, but only told MA A to speak softly. These failures could affect the other 48 Residents on the back hall where MA A worked by placing them at risk of verbal abuse. Findings included: 1. A review of the facility's Abuse Prohibition Policy and Procedure dated January 2007 revealed the following: "...Residents have the right to be free from abuse, corporal punishment, and involuntary seclusion. The following procedures will be operationalized in order that Residents will not be subjected to abuse by anyone including but not limited to facility staff, other Residents, consultants, volunteers, staff of other agencies servicing the Residents, family members or legal guardians, friends or other individuals. The facility shall ensure that all alleged violations are reported immediately to the Administrator or the administrative designee. The Administrator designee shall ensure that the violations are investigated and reported to the appropriate regulatory agency in accordance with federal and state law... The facility shall be proactive in identifying events and occurrences that may contribute to abuse or neglect through: A. Through Resident council, care plan conferences, family conferences, staff meetings. Residents, families, and staff will be educated and encouraged to report concerns, incidents, and grievances without fear of retaliation. #5...(A) The facility must have evidence that all violations including allegations are thoroughly investigated, utilize attachment D, (facility investigation procedures), to facilitate the investigation process." 2. On 03/31/11 at 9:00 AM, during the entrance conference with the Administrator and the DON, the Administrator stated a complaint had been worked several weeks ago concerning MA A abusing the residents. The Administrator stated the complaint was unsubstantiated. The Administrator further stated, "___ (MA A) had worked in the facility for several years, and had a very good work record." The Administrator stated, "___ (MA A) has a very heavy voice and talked to residents loudly." The Administrator stated, "____ (MA A's) behavior had never been reported to him." The Administrator further stated when MA A worked the front hall, no resident reported her attitude. He also stated no employee reported MA A. The DON stated, "The CNAs did not like ______ (MA A) because _____ (MA A) was in charge of the scheduling and was unpopular." The Administrator stated LVN B was the charge nurse for MA A on the 2:00 PM to 10:00 PM shift. The Administrator stated both MA A and LVN B were provided an in-service on 03/16/11 at 5:00 PM concerning verbal abuse, reporting staff suspected of verbal abuse, and how to address residents. 3. On 03/31/11 at 10:36 AM, the surveyor interviewed Resident #3. Resident #3 stated, "I do not remember ____ (MA A) well. She might have been in my room. My roommate told me to report ___ (MA A) to the charge nurse when she talked mean to me." Resident #3 further stated, "Is it someone else I can report to if someone does something to me?" The surveyor told Resident #3 to call the Administrator. On 03/31/11 at 10:45 AM, an interview was conducted with Resident #4 concerning MA A's verbal abuse toward residents. Resident #4 stated, "Yes, ___ (MA A) is very loud and intimidating, she is very talkative and her demeanor is less desiring." Resident #4 told the surveyor, "Someone from the state department was here the other week investigating ___ (MA A) because of her attitude and the way she verbally abused the residents." Resident #4 further stated LVN B and MA A had the same attitudes. Resident #4 stated if you reported abuse to LVN B about MA A, she would not report it to the Administrator. Therefore, any resident reporting to the charge nurse does not get their complaint heard. Resident #4 stated LVN B did not get up to give PRN medications when medication was requested. Resident #4 stated she sat at the desk and allowed the residents to wait. 4. On 03/31/11 at 11:48 AM, an interview was conducted with the DON concerning MA A verbally abusing a resident. The DON stated she had not had any reports on MA A. The DON stated she was on vacation when a surveyor was in the facility investigating a complaint about MA A abusing residents. The DON further stated she did not talk with MA A, the Administrator told her the state had come in while she was on vacation. The DON stated the Administrator was the Abuse Coordinator and residents were told to report abuse to the charge nurse or to the Abuse Coordinator. The DON further stated the staff had several in-services and knew what abuse was and knew who to report abuse to if abuse occurred. The DON stated, "I will need to look into the issue, ____ (MA A) worked one day on the front hall." 5. A Confidential Interview revealed, "I am afraid of ___ (MA A). She can hurt me. I cannot say anything about her, because she will get me. Please do not let her know I talked with you." The Confidential Interviewee stated, "The nurse heard ______ (MA A) talk to me very rudely and did not report it." 6. On 03/31/11 at 1:55 PM, an interview was conducted with LVN B. LVN B stated, "I do not see __ (MA A) mistreating the residents. She talks too loud to residents." LVN B stated, "I have asked her to lower her voice before, and she continued to talk loud to residents, the DON and Administrator are aware of the problem." On 03/31/11 at 2:10 PM the surveyor interviewed CNA C concerning MA A's verbal abuse to the residents. CNA C stated she worked with MA A on the back hall, and MA A always told residents to "shut up and be quiet." CNA C stated she overheard MA A tell residents to go to their room and shut up. She further stated, "_____ (MA A) had an attitude with me, because I called in." CNA C further stated, " ____ (MA A) was very rude to residents and some staff." An interview was conducted on 03/31/11 at 2:15 PM with CNA D concerning MA A's verbal abuse toward residents. CNA D stated, "____ (MA A) is very rude and loud. She yells at the staff. She does the scheduling/staffing, but we stopped calling her when we were absent, because she yells." CNA D further stated, "If we report to the Administrator and the DON, they tell us to settle down and does nothing about the problem." CNA D further stated, "I used to tell ___ (MA A) when I was going to be off duty, but I don't tell her anymore. I tell the DON." CNA D stated MA A came down the hall and asked her what day she was going to be off. She stated, "The residents stated they did not want me to take off, because they did not want ___ (MA A) working their hall." CNA D stated MA A did yell at a resident. CNA D stated she left station two, because of MA A. CNA D stated, "___ (MA A) kept me in tears, and I had to get away." An interview was conducted on 03/3/11 at 2:25 PM, with MA A. MA A stated she had worked in the facility since 2003. She stated, "My voice is loud. I have to tone my voice down. I never heard residents say they were afraid of me or if I'm talking too loud. I have never been told about being abusive to residents, but I have been told that I was loud with residents." MA A further stated, "I do not talk loud to all residents. I raise my voice to residents that can't hear well, it is not my job to scream and yell at residents." MA A further stated, "Some people may feel my voice is too high tone." MA A further stated a resident may come and ask for Tylenol for her knee or leg, but she had not yelled at the resident. The surveyor asked MA A why she thought the residents were afraid of her. MA A stated, "I truly do not know. Residents feel intimidated. I do not know why." MA A further stated, "I have to get along with the employees, some employees I do not get along with, others I do." At the end of the interview, the surveyor asked MA A, "We have interviewed from 2:25 PM to 2:45 PM during the interview, you have spoken in a very normal voice; why do you not speak to the residents in the same voice?" The surveyor asked the question, but MA A could not give the surveyor an answer. On 03/31/11 at 4:00 PM, a second interview was conducted with the Administrator concerning MA A. The surveyor asked the Administrator how many residents MA A administered medications to on the evening shift. The Administrator stated MA A was responsible for medications on the back hall. The surveyor asked the Administrator, "Do you know the residents are afraid of MA A?" The Administrator stated, "No." The surveyor asked the Administrator why he did not complete an investigation on MA A when the surveyor was in the building previously investigating the MA on abuse to residents. The Administrator stated he should have investigated the incident The Administrator stated he suspended MA A and LVN B that afternoon and he would conduct his own investigation. An interview was conducted on 03/31/11 at 2:50 PM with CNA E. CNA E stated she worked on the back hall for about a month with MA A. CNA E stated a resident told her, she was going to call the "state department" and report MA A. CNA E further stated a resident told her (CNA E) he/she heard MA A yelling and screaming at another resident. CNA E further stated, "I have heard ___ (MA A) talk to residents and staff rudely. ____ (MA A) is in charge of staffing and she yells at the staff." CNA E stated the Administrator and DON will not set her straight. CNA E further stated, "The staff stopped calling ____ (MA A) when they were absent because she is too rude." 7. A confidential interview revealed, "In resident council meetings, the residents talked about how mean ____ (MA A) was to all the residents. ____ (MA A) was rude and loud and very mean." The interviewee stated MA A did the scheduling for the facility, and administration did not want to reprimand her or discharge her. He/she also stated, the day before the state surveyor came two weeks ago to investigate MA A, she was really rude to a resident. The interviewee said they told MA A she did not have to talk to the resident so rudely. He/she stated, "When the residents came to her cart for medication, MA A yelled at the residents and puts them 'in their place.'" The interviewee stated the Administrator and DON only slapped MA A on her hands and just told her to talk softly. 8. A review of the New Hire Employee Information form, dated 08/26/03, located in the personnel file of MA A revealed she was hired by the facility on 08/26/03. MA A signed an abuse/neglect acknowledgement. A review of the summary report dated 03/16/11 at 5:00 PM, regarding MA A and completed by the ADON, revealed a one on one in-service meeting. The meeting notes dated 03/16/11 reflected, "Your voice and words must be kind and soft when addressing Residents, family members, and other staff members while on the clock in the facility. Inappropriate conduct will result in disciplinary action." The report was signed by MA A. MA A did not complete the employee comment section or write any additional comments. A review of the summary report dated 03/16/11 at 5:00 PM, regarding LVN B as the charge nurse for MA A and completed by the ADON, revealed a one-on-one in-service meeting. The meeting notes dated 03/16/11 reflected, "As a charge nurse you are responsible for the conduct (behavior) of the CNAs that work with you. Failure to take charge and oversee the interaction between staff and residents - report and writing up as needed or disciplinary action will follow." The report was signed by LVN B, no comments were documented by LVN B in the comment section or any additional comments. 9. The CMS form 672, Resident Census and Conditions of Residents, dated 03/31/11 and signed by the corporate LVN reflected a census of 99 residents. A review of the Patient List Report dated 03/31/11 reflected 48 residents residing on the back hall.