Every finding on record at Whitehall Rehab & Nursing

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 4 of 12 residents (Resident's #35, #17, #65, and #66) reviewed for quality of care.The facility failed to remove worn and damaged mechanical lift slings from service for Resident's #35, #17, #65 ,and #66.This failure could result in a loss of quality of life due to injuries. Findings included:1.Record review of Resident # 35's face sheet, dated 2/24/2026, indicated Resident # 35 was a [AGE] year-old female, admitted [DATE], with diagnoses of cerebral infarction (stroke), hypertension (high or raised blood pressure) and peripheral vascular disease (decreased circulation in the lower extremities).Record review of Resident # 35's annual MDS assessment, dated 02/06/2026, indicated Resident #35 had a BIMS score of 15 indicating intact cognition, was dependent on staff for assistance with all ADLs, used a motorized wheelchair, and section GG indicated dependent for mobility and does not walk.Record review of Resident # 35's comprehensive care plan, revision date 02/16/2026, indicated Resident 35's care plan indicated transfers: partial and moderate assistance. The care plan did not reflect the current transfer status of requiring a mechanical lift.Record review on 02/24/2026 of Resident # 35's order summary report dated 02/24/2026 revealed Resident #35 indicated there was no order related to Resident # 35's transfer status or use of mechanical lift.During an observation and interview on 02/24/2026 at 11:00 am, Resident # 35 in bed in her room. Resident # 35 had a lift sling with straps faded in color, light pink for red, strap green or blue is white with light green stitching. Resident #35 said they use the mechanical lift everyday to transfer her to the wheelchair.2. Record review of Resident #17's face sheet, dated 2/24/2026, indicated Resident #17 was an [AGE] year-old female, admitted [DATE], with diagnoses of Alzheimer's disease (a neurodegenerative disease that usually starts slowly and progressively worsens), chronic obstructive pulmonary disease (a condition that limits airflow into and out of the lungs), and hypertension (high blood pressure).Record review of Resident's 17's quarterly MDS assessment, dated 2/6/2026, indicated Resident #17 had a BIMS scocre of 00 indicating severe cognitive impairment, was dependent on staff for assistance with ADLs, used a wheelchair, and section GG indicated resident was dependent for transfers and mobility.Record review of Resident # 17's comprehensive care plan, revision date 08/22/2025, Resident 17's care plan indicated transfers: dependent. Record review on 02/24/2026 of Resident # 17's order summary report dated 02/24/2026, revealed there was no order related to Resident # 17's transfer status or use of mechanical lift.During an observation on 02/24/2026 at 1:00 pm, Resident # 17 was sitting in a wheelchair in the lobby watching television. Resident # 17 had a lift sling located under her with straps faded in color, light pink for red, strap green or blue is white with light green stitching.Unable to interview Resident # 17 due to severe cognitive impairment. 3. Record review of Resident #65's face sheet, dated 2/24/2026, indicated Resident #65 was an [AGE] year-old male, admitted [DATE], with diagnosis of displaced intertrochanteric fracture of the left femur (broken bone of upper left leg).Record review of Resident's 65's admission MDS assessment, dated 2/19/2026, indicated Resident #65 had a BIMS score of 15 indicating he was cognitively intact, he required assistance of 1 for transfers.Record review of Resident # 65's comprehensive care plan, revision date 02/23/2026, indicated Resident 65's care plan indicated transfers: maximum assist of 1 person.Record review on 02/24/2026 of Resident # 65's order summary report dated 02/24/2026, revealed there was no order related to Resident # 65's transfer status.During an observation on 02/23/2026 at 9:30 am and 3:00 PM, and on 02/24/2026 at 8:30 AM, Resident # 65 had a wheelchair in his room with a mechanical lift sling located in the chair. The lift sling located in the wheelchair had straps faded in color, light pink for red, strap green or blue is white with light green stitching. The labels on the lift sling were faded and the print on the label was faded and illegible. During an interview with Resident # 65 on 2/24/2026 at 8:30 AM he stated that he stands and transfers with the assistance of staff. He denies ever transferring with the assistance of a mechanical lift. He stated he believed that the lift sling was a chair cover and was not aware that it was used for transfers. He stated he has been transferred from his bed to his chair with the assistance of 1 CNA since he was admitted from the hospital.4. Record review of Resident #66's face sheet, dated 2/24/2026, indicated Resident #66 was an [AGE] year-old female, admitted [DATE], with diagnoses of unspecified dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and senile degeneration of the brain (the gradual deterioration of brain cells and their connections, leading to a progressive loss of cognitive and motor functions).Record review of Resident's 66's quarterly MDS assessment, dated 01/31/2026, indicated Resident #66 had a BIMS score of 07 indicating severe cognitive impairment, used a wheelchair, and section GG indicated resident was dependent for transfers and mobility.Record review of Resident # 66's comprehensive care plan, revision date 03/27/2024, indicated Resident 66's care plan indicated transfers: dependent. The care plan did reflect the current transfer status of requiring a mechanical lift.Record review on 02/24/2026 of Resident # 66's order summary report dated 02/24/2026, revealed there was no order related to Resident # 66's transfer status or use of mechanical lift.During an observation on 02/24/2026 at 1:00 pm, Resident # 66 was sitting in a wheelchair in the lobby watching television. Resident # 66 had a lift sling located under her with straps faded in color, light pink for red, strap green or blue is white with light green stitching and the print on the label was faded and illegible.Unable to interview Resident # 66 due to severe cognitive impairment.During an interview on 2/24/2026 at 8:15 am CNA A she said she had training on mechanical lift transfers and watching for fading, rips and tears, threads coming unsewn on the slings used for transfers. CNA A said faded slings should be removed from service. CNA A said using a mechanical lift sling that was faded could cause injury if the straps broke.During an interview on 2/24/2026 at 8:50 AM with CNA B, she stated that Resident #65 was a one person assist with transfers. She stated that the resident was able to stand and pivot to chair and that a mechanical lift was not used on the resident. She stated that a mechanical lift has not ever been used on Resident #65. When asked about the lift sling that was in the wheelchair of Resident #65 she stated she was not sure why the item was in his room. She said that any lift slings for resident use should be free of wear and tear, no holes or fraying and that there should not be any faded material. She stated the sling located in Resident #65 room should be taken out of service and not available for use. She stated staff could take the lift sling to another resident's room for use and it would be a risk for injury to the resident if the sling was in poor condition. She stated any torn or faded slings should be disposed of and not available to staff for use. During an interview on 2/24/2026 at 9:00 AM with CNA C, she stated that Resident #65 was a one person assist with transfers. She stated a mechanical lift was not used on Resident #65. When asked about the lift sling that was in the wheelchair of Resident #65 she stated she was not sure why the item was in his room or who placed it in there. She said that any lift slings for resident use should be free of wear and tear, no holes or fraying and that there should not be any faded material. She stated the sling located in Resident #65 room should not be available for use. She stated staff could take the lift sling to another resident's room for use and it would be a risk for injury to the resident if the sling was in poor condition. She stated any torn or faded slings should be disposed of and not available to staff for use.During an interview on 2/24/2026 at 1:30 PM, LVN J said that slings should be monitored for any holes or tears. When asked about fading of the loops or fabric she stated she was not aware that faded loops would be a reason to take lift slings out of service. She said that a damaged lift sling could lead to injury to a resident during transfer. During an interview on 02/25/2026 at 9:00 AM, the DON said the staff are in-serviced on signs of wear and tear and to remove mechanical lift slings from service if they have rips, tears and coming unsewn. She said the lift slings used for Residents #17, # 35, #65 and #66 were removed from service due to their fading and new lift slings were distributed. She said that using the faded lift sling could cause injury if it broke. DON said that they had obtained physician orders on all the residents needing a mechanical lift to transfer and had updated all care plans to include interventions for correct transfer status including mechanical lifts if applicable.During an interview on 02/25/2026 at 9:15 AM, the Administrator said the lift sling used for Resident's #17, #35, #65 and #66 were removed from service. She said they would have an in-service with staff. She said that using the faded lift sling could cause injury if it broke.During an interview on 02/25/2026 at 9:30 AM, the Laundry Aide said she washes the mechanical lift slings without bleach and she hangs them to air dry.Record Review of Facility policy dated 09/13/2024 Hydraulic Lift (Hoyer Lift) .Policy: To enable one individual to lift and move a resident safely, with as little effort as possible.Procedure.Record Review of Manufacturer's recommendations accessed www.medline.com 02/11/2026Indicated: Always inspect slings prior to each use Signs of rips. tears. or frays indicate sling wear which is unsafe and could result in injury Signs of fading. bleached areas. or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury Any slings with signs of wear or improper laundering should be immediately removed from use.Always confirm compatibility between the connection style of the patient sling and the patient lift before use.Do not remove sling labels. If sling labels are removed or no longer legible. sling must be immediately removed from use.Frequency of laundering should follow facility guidelines, or when the sling is soiled. Refer to the sling's tag for laundering instructions and follow all wash instructions.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 residents (Resident #1 and Resident #53) and 3 of 7 staff (CNA A, CNA D and CNA G) reviewed for infection control. 1. The facility failed to ensure CNA D changed her gloves and did not touch clean items with dirty gloves when incontinent care was provided to Resident #1 on 02/24/2026. 2. The facility failed to ensure CNA A and CNA G followed EBP when completing direct resident care and CNA G changed her gloves and performed hand hygiene when incontinent care was given to Resident #53 on 02/23/2026. 3. The facility failed to ensure CNA G transported soiled linens and completed hand hygiene to prevent the spread of infections on 02/24/2026. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included: 1. Record review of an admission Record for Resident #1 dated 2/25/2026 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of critical illness myopathy (muscle weakness from prolonged immobilization), pressure ulcer of sacral region (bed sore on the tailbone), and depression. Record review of an admission MDS Assessment for Resident #1 dated 2/9/2026 indicated she did not have any impairment in thinking with a BIMS score of 15. She was dependent on staff for toileting hygiene. She was always incontinent of urine/bowel. Record review of a care plan for Resident #1 dated 2/3/2026 indicated she was incontinent of bowel/bladder related to critical illness myopathy. Interventions included to check frequently for wetness and soiling and change as needed. During an observation on 2/24/2026 at 3:15 pm, CNA D was in the room of Resident #1 to perform incontinent care. CNA D donned (put on) a gown and gloves but did not perform hand hygiene prior to applying gloves. She removed the resident's pants because they were wet and opened the brief and pulled it down between her thighs. She removed wipes from the package and wiped both inner thighs and down the middle of her vagina from front to back and placed the wipes in the trash. The resident was rolled onto her right side and CNA D removed wipes from the package and wiped her rectal area from front to back and placed the wipes in the trash. She removed the brief and rolled it into a ball and left it sitting on the bed. She did not remove her gloves after touching the dirty brief. She placed a clean brief under the resident's buttocks and secured it. She put clean pants on the resident, touched the bed control and lowered the bed. She placed the brief in the trash bag and doffed (removed) her gown and gloves. She went into the bathroom and washed her hands. She exited the room and placed the bag of trash in the bin in the hallway. She entered another room on hall 100 and left the package of wipes in the room and exited. During an interview on 2/24/2026 at 3:25 pm, CNA D said she had been employed at the facility for 2 years and worked 6 am -6 pm on hall 100 where Resident #1 resided. When questioned about the incontinent care provided to Resident #1, she said she would not have done anything differently. When she was questioned about the use of gloves, she said she would only change gloves if they were contaminated, visibly dirty or if she had to pick something up from the floor. She said she forgot to wash or sanitize her hands before care was started and did not change her gloves and should have changed them before she placed a clean brief on the resident. She said it had been a long time since she had a skills check off. She said they did not have enough packages of wipes to leave wipes in every resident room but thought that placing wipes in bag before going into the resident's room would make sense. She said there was a risk of cross contamination and infection if they touched clean items with dirty gloves or did not change gloves when care was provided. Record review of a long-term care CNA skills/competency checklist for CNA D dated 6/30/2025 by the DON indicated she met the requirements for perineal care for a female resident and hand hygiene with infection control. Record review of an individual employee in-service record for CNA D dated 12/1/2025 indicated the ADON provided a verbal review of training on infection control with the use of gloves. 2. Record review of Resident 53's facility face sheet, dated 2/24/2026, indicated Resident #53 was an [AGE] year-old female, admitted [DATE], with diagnosis of dementia. Record review of Resident #53's significant change MDS assessment, dated 01/26/2026, revealed a BIMS was not completed, and facility completed a SAMS that indicated Resident #53 had severely impaired cognition for decision making. She was dependent on staff for all ADLs, required a feeding tube and was always incontinent of bowel and bladder. Record review of Resident #53's comprehensive care plan, revision date 10/13/2025, indicated Resident #53 required the use of a feeding tube but did not address EBP requirement related to feeding tube. She was incontinent of bowel and bladder and to monitor for signs of urinary tract infections. Record review of Resident #53's order summary report, dated 2/24/2026, indicated Resident #53 had an order dated 6/09/2025 for EBP related to her feeding tube. During an observation on 02/23/2026 at 3:05 pm, Resident #53 had an EBP sign posted outside her door indicating a gown and gloves were required for care. During an observation on 02/23/2026 at 3:11 pm, CNA A and CNA G enter Resident #53's room to perform incontinent care. Neither CNA A nor CNA G applied a gown per the EBP standard prior to performing care. Both CNAs adjusted the linen and resident's gown. CNA G opened Resident #53's brief and cleaned her with wipes from front to back. CNA A rolled Resident #53 to her left side and CNA G cleaned the back area with wipes and removed her soiled brief and placed it in a bag. She then proceeded to apply a new brief and skin barrier without changing her soiled gloves. Both CNAs then adjusted the resident's linens. CNA G removed her soiled glove from her left hand and adjusted the bed position using the bed remote control. Both CNAs removed their soiled gloves and placed them in a bag. CNA A sanitized her hands and left Resident #53's room, however CNA G left Resident #53's room without hand hygiene. CNA G then placed a pack of wipes from Resident #53's room back on the clean linen cart, the soiled bag in the trash receptacle and never performed hand hygiene. During an interview on 02/23/2026 at 3:16 pm, CNA A said Resident #53 had a feeding tube and she should have applied a gown before performing care. She said the PPE was to protect the residents from transmission of germs. She said she had been properly trained and just forgot to pay attention. During an interview on 02/23/2026 at 3:17 pm, CNA G said that she should have applied a gown before performing care for Resident #53 but was nervous. She said she should have removed her soiled gloves, performed hand hygiene and put on new gloves before proceeding after removing Resident #53's soiled brief. She said she should have performed hand hygiene before leaving the resident's room. She said should have removed needed wipes from the package, not brought the package in the room and put the package back on the clean linen cart. She said all these failures could cause the spread of infections and she had been trained on infection control measures. 3. During an observation on 02/24/2026 at 2:28 pm, CNA G exited from room [ROOM NUMBER] with unbagged soiled linen in her gloved hands. She walked down the hallway approximately 20 feet and placed the soiled linen in the soiled linen receptacle and then removed her gloves and placed them in the trash. She returned to room [ROOM NUMBER] and washed her hands. During an interview on 02/24/2026 at 2:35 pm, CNA G said she knew not to bring unbagged soiled linen in the hall and wear soiled gloves, but she was in a hurry. She said she should place all soiled linen in a bag, remove her gloves and perform hand hygiene before leaving any resident room. She said by not following infection control measures she could spread germs in the facility. During an interview on 02/24/2026 at 3:50 pm, the DON said that she and other nurse managers were responsible for training staff on the infection control program. She said she was also the Infection Preventionist for the facility. She said regarding the CNAs taking the wipe packages in the resident's room that was something the nurse aides had been doing but they should have only been taking the wipes needed for the care and place them in a plastic bag. She said the CNAs should always perform hand hygiene before care, before applying gloves, after gloves changes, and before leaving the resident's room. She said gloves should be changed during incontinent care when going from soiled to clean. She said soiled linens should be bagged for transport. She said residents with EBP staff should have a gown and gloves for care and the sign on the door was their aid for staff to know when EBP was required. She said that staff not following the infection control program could spread infections and she would begin retraining. During an interview on 02/25/2026 at 1:16 pm, the Administrator said the DON and ADON were responsible for ensuring all staff were following the infection control program. She said that infection control should be always followed by all staff. She said if the resident was on EBP, EBP should be followed. Hand hygiene should occur before entering resident rooms, before leaving a resident room and any other required time. She said linens should always be bagged and not carried freely in the hallway. She said not following the infection control program could lead to the spread of infections. Record review of a facility policy titled Infection Prevention and Control Program dated 11/2024 indicated, .This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.6. Enhanced Barrier Precautions EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.EBP are indicated for residents with any of the following: a. Infection or colonization with an MDRO when Contact Precautions do not otherwise applyb. Wounds and/or indwelling medical devices (e.g., central lines, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status During high-contact resident care activities:12. e. Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom . Record review of a facility policy titled Hand Hygiene revised 2/11/2022 indicated, .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 6 a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .

Based on observation, interview, and record review, the facility failed to provide a resident who is unable to carry out activities of daily living receive the necessary services to maintain good personal hygiene for 1 of 12 residents (Resident #31) reviewed for ADLs. The facility failed to provide ADL care to Resident #31 from 2/14/2026 to 2/25/2026. This failure could cause all residents not to receive daily personal hygiene needs and cause the residents to have health, social, and emotional issues. Findings included: Record review of Resident 31's facility face sheet, dated 02/24/2026, indicated Resident #31 was an [AGE] year-old male, admitted [DATE], with diagnosis of dementia. Record review of Resident #31's quarterly MDS assessment, dated 12/29/2025, revealed a BIMS was not completed, and facility completed a SAMS that indicated Resident #31 had severely impaired cognition for decision making. He was dependent on staff for all ADLs. Record review of Resident #31's comprehensive care plan, revision date 7/31/2024, indicated Resident #31 had an ADL self-care performance deficit, was at risk for not having their needs met in a timely manner and to provide shower, shave, oral care, hair care, and nail care per schedule and when needed. Record review of a shower schedule, dated 2/24/2026, indicated Resident #31 was to receive a shower on Monday, Wednesday and Friday on the night shift. Record review of Resident #31's ADL response in his medical recorded, dated from 01/26/2026 to 02/24/2026, indicated Resident had not received a bath or shower since 02/14/2026. There was a response on 02/18/2026 and 02/24/2026 stating not applicable. This indicated he had missed 4 showers. Record review of Resident #31's skin observation worksheet, dated for January 2026 and February 2026, indicated Resident #31 had not had a skin observation worksheet completed since 02/13/2026. During an observation on 02/23/2026 at 10:59 am, Resident #31 had facial hair, a white substance built up on his lips and nails on both hands had a thick black substance under them. During an observation and interview on 02/24/2026 at 8:30 am, Resident #31 was lying in bed with his eyes closed. He had fascial hair, white buildup on his lips and under his nails on both hands had a thick black substance. He could not answer regarding when he last received a bath and said do what you got to do. During an observation on 02/25/2026 at 8:30 am, Resident #31 was up in a wheelchair at the nurses' station. He was awake and his fascial hair remained as well as the buildup on his lips and black substance under his nails. During an interview on 02/25/2026 at 8:35 am, CNA H said that the CNA's used the shower schedule at the nurse's station to know who was scheduled for what day and shift. She said Resident #31 was on night shift for showers. She said that when a shower was given, all care should include skin, nails, shave and mouth care. She said then the CNA completed a skin observation sheet and gave the skin sheet to the nurse. She said when a resident refused the nurse was notified. She said the CNA charted in the computer the shower was given or refused but never not applicable unless they were out of the facility. She said Resident #31 would sometimes hit at staff and say inappropriate things to staff but did not refuse care. She said dependent residents that did not get ADL care could have skin breakdown or infections. During an interview on 02/25/2026 at 8:41 am, LVN E said the charge nurses were responsible for oversight of the CNAs. She said the nurses should ensure that resident care was performed. She said the CNAs had a schedule to follow and could not speak to the night shift, but the day CNAs turned in a skin observation sheet with each shower for her to review and if the resident refused it was charted in the medical record. She said ADLs for dependent residents should be completed to prevent infections and skin breakdown. During an interview on 02/25/2026 at 9:46 am, the DON said the CNAs were responsible for completing ADL care for all residents and the charge nurses were to oversee that the care was completed. She said the CNAs were to complete a skin observation sheet after a bath and record the bath in the resident record. She said she was not sure why not applicable would be checked. She said if a resident were to refuse the nurse was to be notified. She said dependent residents should have mouth care daily, baths as scheduled with shaving, skin and nail care. She said that failing to provide ADL care to residents could result in infections and skin breakdown. During an interview on 02/25/2026 at 1:16 pm, the Administrator said that the CNAs were responsible for the residents ADL care, and the nurses should be providing oversight that the care was completed. She said their process had been for the CNA to complete a skin observation sheet with each bath or shower, the nurse reviewed them, and she would see that that process was completed. She said she expected all residents to receive personal hygiene per the schedule to prevent skin breakdown and infections. Record review of a facility policy titled Clinical Practice Guideline Activities of Daily Living dated 1/23/2016 indicated, .Residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, personal and oral hygiene .

Based on observations, interviews, and record review, the facility failed ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 6 residents (Resident #53) reviewed for accommodation of needs.The facility failed to ensure Resident #53's call light in the room was left within reach when she was in bed on 02/23/2026 and 02/24/2026.This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.Findings: Record review of Resident 53's facility face sheet, dated 02/24/2026, indicated Resident #53 was an [AGE] year-old female, admitted [DATE], with diagnosis of dementia. Record review of Resident #53's significant change MDS assessment, dated 01/26/2026, revealed a BIMS was not completed, and facility completed a SAMS that indicated Resident #53 had severely impaired cognition for decision making. She was dependent on staff for all ADLs. Record review of Resident #53's comprehensive care plan, revision date 10/13/2025, indicated Resident #53's had a potential for falls and to place call light in reach to use for assistance. During an observation on 02/23/2026 at 11:06 am, Resident #53 was lying in bed, and her call light was attached to itself at the wall out of reach. During an observation on 02/23/2026 at 3:53 pm, Resident #53 was lying in bed and her call light remained attached to itself at the wall out of reach. Resident #53 was unable to communicate or answer questions regarding call light. During an observation on 02/24/2026 at 11:05 am, Resident #53 was lying in bed and her call light was on the wall plug out of reach. Resident #53 had trouble communicating but was able to demonstrate pushing the call light when it was handed to her. During an interview on 02/24/2026 at 11:10 am, CNA A said that Resident #53 could use her call light but never did. She said they kept her door open so they could visibly see her when making rounds and checked her every 2 hours to ensure she was good. She said all residents should have access to their call lights and could have negative outcomes if they couldn't call for help. During an interview on 02/25/2026 at 8:40 am LVN E said that all staff should ensure each resident could reach their call light so they could call for help if they need to. She said Resident #53 did not use her call light that she was aware of but should still have it near in case she wanted to use the light. She said a call light out of reach could result in resident injuries. During an interview on 02/25/2026 at 9:46 am, the DON said that all staff should ensure resident call lights were in reach. She said each time rounds were made the call light should be placed back in reach for the residents to use if they desired before leaving the room. She said the staff were trained verbally on call light placement on hire and annually. She said she expected each resident to have access to their call light to prevent injuries. During an interview on 02/25/2026 at 1:16 pm, the Administrator said that residents call lights should always be within reach and was the responsibility of everyone that rounds. She said all staff were trained on call light placement on hire, annually and as needed and discussed through resident rights. She said if call lights were not in place resident injuries could occur. Record review of a facility policy titled Call Light Response, dated 8/11/13, indicated, Place call light/bell within patient's reach regardless of patient location such as:in bed, on commode, unaccompanied in sitting area .

Based on observation, interview, and record review the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 of 12 residents (Residents #35 and #53) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #35's comprehensive care plan was revised to reflect current transfer status of requiring a mechanical lift. 2. The facility failed to ensure Resident #53's comprehensive care plan was revised to reflect requiring EBP related to feeding tube. These failures could place residents at increased risk of falls, injuries, delay in care and/or a decreased quality of life.Findings included: 1. Record review of Resident # 35's face sheet, dated 2/24/2026, indicated Resident # 35 was a [AGE] year-old female, admitted [DATE], with diagnoses of cerebral infarction (stroke), hypertension (high or raised blood pressure) and peripheral vascular disease (decreased circulation in the lower extremities). Record review of Resident # 35's annual MDS assessment, dated 02/06/2026, indicated Resident #35 had a BIMS score of 15 indicating intact cognition, was dependent on staff for assistance with all ADLs, used a motorized wheelchair, and section GG indicated dependent for mobility and does not walk. Record review of Resident # 35's comprehensive care plan, revision date 02/16/2026, indicated Resident 35's care plan indicated transfers: partial and moderate assistance. The care plan did not reflect the current transfer status of requiring a mechanical lift.Record review on 02/24/2026 of Resident # 35's order summary report dated 02/24/2026 revealed Resident #35 indicated there was no order related to Resident # 35's transfer status or use of mechanical lift. During an interview and observation on 02/24/2026 at 12:16 pm of a Kardex (electronic plan of care) for Resident #35, CNA A said the Kardex had no interventions listed for transfers using a mechanical lift. CNA A said that when Resident #35 came back from the hospital she was unable to stand for transfers and the staff started using a mechanical lift for her transfers. She said a new staff member would not be aware of the correct transfer status if the Kardex was not correct. CNA A said using the incorrect transfer could result in injuries. During an interview on 02/24/2026 at 4:20 pm the Regional Reimbursement Consultant said the facility has had turnover in the MDS and care plan position and she does her best to oversee the care plans are correct and included the required elements per policy. She said the facility has put a new employee in that position as of last week and she will be training her. She said that the transfer status was missed when Resident #35 reentered the facility in May of 2025 after hospitalization and she had corrected it to reflect two-person transfer with mechanical lift today. She said not having the correct status on the care plan could cause injuries if the incorrect transfer procedure for the residents was not followed. During an interview on 02/24/2026 at 9:15 AM, the DON said not having the correct transfer status on the care plan could cause injury if the staff were not aware of what was required for safety. The DON said the care plan was updated yesterday and orders obtained for use of the mechanical lift for transfers for Resident #35. During an interview on 02/24/2026 at 9:30 AM, the Administrator said the care plan interdisciplinary team was responsible for making changes in the resident's care and updating the care plans. She said not having the correct transfer status on the care plan could possibly cause injury to a resident if the staff was not aware of what transfer status was required. 2. Record review of Resident 53's facility face sheet, dated 2/24/2026, indicated Resident #53 was an [AGE] year-old female, admitted [DATE], with diagnosis of dementia. Record review of Resident #53's significant change MDS assessment, dated 01/26/2026, revealed a BIMS was not completed, and facility completed a SAMS that indicated Resident #53 had severely impaired cognition for decision making. She required a feeding tube. Record review of Resident #53's comprehensive care plan, revision date 10/13/2025, indicated Resident #53 had required the use of a feeding tube but did not address EBP requirement related to feeding tube. Record review of Resident #53's readmission progress note, dated 6/06/2025, indicated Resident #53 returned to the facility from the hospital with a feeding tube. Record review of Resident #53's order summary report, dated 02/24/2026, indicated Resident #53 had an order dated 6/09/2025 for EBP related to her feeding tube. During an observation on 02/23/2026 at 11:06 am, Resident #53 had an EBP sign outside her door and had a feeding tube with continuous feeding in place. During an interview on 02/24/2026 at 4:00 pm LVN F said that Resident #53 had a feeding tube since last year and had EBP in place. She said the MDS nurse completed the care plans, and she did not have a part in the revision or review of care plans. She said that the nurses did use the care plan at times but mainly followed the orders. She said incomplete care plans could cause a delay in care or inaccurate care. During an interview on 02/24/2026 at 4:20 pm, the Regional Reimbursement Consultant said that she was responsible for the MDS assessment oversight at the facility. She said the facility had not had a consistent MDS nurse for several months and she did not micromanage the department. She said she came to the facility 1-2 times a week but completed most of her work offsite. She said that she had been reviewing and revising care plans as they came due but had not completed them all. She said that Resident #53 should have had a care plan to reflect her feeding tube and need for EBP. She said the care plan should have been reviewed and revised with her comprehensive care plans and somehow it was missed. She said inaccurate care plans could result in residents not receiving care. During an interview on 02/25/2026 at 9:46 am, the DON said that the interdisciplinary team met to discuss resident care on admission, quarterly and with significant changes. She said during those meetings the team completed the team meeting note and the MDS nurse was responsible for reviewing and revising the care plan accordingly. She said the corporate MDS nurse that had been covering was not participating in the meetings and could not speak to why. She said inaccurate care plans could result in resident care delays and injuries. During an interview on 02/25/2026 at 1:16 pm, the Administrator said that the MDS nurse was responsible for reviewing and revising the resident's care plan. She said they had a lot of turnover with the MDS nurse position and the regional reimbursement consultant had been helping. She said the comprehensive care plan should be revised quarterly and as needed and should reflect all care the residents required. She said she expected the care plans to be revised per the regulations to prevent resident care issues. Record review of a facility policy titled Comprehensive Care Plans dated 9/04/2024 indicated, .Comprehensive Care Plans Policy: 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 assessment. 3. 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. 5. the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment .

Based on interview and record review, the facility failed to ensure the drug regimen review recommendations from the pharmacy consultant were acted upon for 1 of 4 residents reviewed for drug regimen review. (Residents #34)The facility did not follow up on the pharmacy consultant's recommendations dated 1/24/2025 to 2/12/2026 with the physician for Resident #34.These failures could place residents at risk for medication errors, unnecessary medications, and incorrect administration.Findings included: Record review of an admission Record dated 2/24/2026 for Resident #34 indicated he admitted to the facility 10/7/2024 and was [AGE] years old with diagnoses of cerebral infarction (stroke), dementia with anxiety, peripheral vascular disease (impaired circulation to the legs) and atrial fibrillation (irregular heartbeat). Record review of active physician orders dated 2/24/2026 for Resident #34 indicated an order for Seroquel 25 mg give 12.5 mg by mouth one time a day for dementia with behaviors with a start date of 1/9/2025. An order for Seroquel 50 mg give one tabled by mouth every morning and at bedtime for behaviors and anxiety with a start date of 3/14/2025. An order for trazodone 50 mg give one tablet by mouth at bedtime for sleep insomnia with a start date of 1/22/2026. Record review of pharmacy recommendations of 2/12/2026 indicated Seroquel 50 mg every morning needed a CMS approved diagnosis to be continued. Record review of a Quarterly MDS Assessment for Resident #34 dated 12/20/2025 indicated he had severe impairment in thinking with a BIMS score of 0. There were not any behaviors noted during the look back period. He did not have any psychiatric/mood disorders. During the 7 day look back period he received antipsychotic medications. Drug regimen review did not indicate physician contact for prescribed/recommended actions. Record review of a care plan for Resident #34 revised 6/3/2025 indicated he required psychotropic drug use related to dementia with targeted/disruptive behaviors. Interventions included for medication regimen to be routinely reviewed by the pharmacist with all recommendations, including suggested reductions, to be forwarded on to the physician. Record review of pharmacy recommendation dated 2/20/2025 for Resident #34 indicated Seroquel needed a CMS approved diagnosis to be continued. Record review of pharmacy recommendations of 1/24/2025 indicated Seroquel needed a CMS approved diagnosis to be continued. During an interview on 2/25/2026 at 10:39 am, the DON said she along with the ADON were responsible for completing the pharmacy recommendations. She said the pharmacy consultant visited the facility monthly. She said the day after the consultant's visit they would review the pharmacy recommendations. She said Resident #34 was admitted to the facility with an order for Seroquel. She said the NP was contacted last week about a reduction in Resident #34's Seroquel and the NP told her the resident needed to be referred to psychiatric services. She said she asked the NP if the resident could have something else ordered due to him sleeping all day. She said she also talked to the Pharmacy Consultant as well to see if there was something else, they could try. She said she failed to review his recommendations from the Pharmacy Consultant and did not get an appropriate diagnosis for the use of Seroquel. She said she had been overwhelmed and it was missed. She said there was a safety risk if they did not review the pharmacy recommendations and ensure appropriate measures were put in place to protect the residents. During a phone interview on 2/25/2026 at 10:52 am, the NP said she had been going to the facility weekly for about 4-5 weeks. She said she had been contacted about Resident #34 with the biggest issue with him being up all night and sleeping all day. She said the MD was his physician and he wanted Resident #34 to refer to psychiatric services. She said she recently added trazadone to be given at night to help with his sleeping. She said Seroquel would be better managed by psychiatric services. She said she believed behaviors were an appropriate diagnosis for the use of Seroquel but did not prescribe antipsychotics. She said his physician did not allow her to prescribe antipsychotics. During a phone interview on 2/25/2026 at 11:01 am, the MD said Resident #34 was on Seroquel and it was prescribed to try and regulate his behaviors, outbursts, and agitation. He said the resident had dementia and worsening agitation. He said he did not recall if the facility sent him a recommendation from the Pharmacy Consultant requesting an appropriate diagnosis for the use of Seroquel. He said he was going to the facility that day to address a possible GDR for Seroquel. He said the facility was very diligent with contacting him. He said the Seroquel diagnosis was appropriate and they could use it. During a phone interview on 2/25/2026 at 11:11 am, the Pharmacy Consultant said she had been going to the facility since August 2024 and visited monthly. She said her last visit was 2/10/2026 and she reviewed Resident #34's medications. She said the use of psychotropic medications must have an appropriate diagnosis with the use of Seroquel and dementia was not an appropriate diagnosis for its use according to CMS regulations. She said she had been reminding the facility monthly since January 2025 that an appropriate diagnosis was needed. She said the facility had not responded to her in person and would tell her they were working on it. She said the purpose of the Pharmacy Consultant was to make sure things were in order and help the facility get in compliance. She said she had sent the MD messages before requesting a new diagnosis with no response. She said the last time she contacted him was in August 2025 and he told her he reminded the nurses to complete it but did not change the diagnosis. During an interview on 2/25/2026 at 11:25 am, the ADON said she had been employed at the facility since [DATE]. She said she was still in training. She said she would be responsible for helping the DON with pharmacy recommendations. She said she was not aware Resident #34 did not have an appropriate dx for the use of Seroquel. She said the resident had behaviors and was not sure if he was on psych services. She said the pharmacy consultant helped to keep the facility in compliance with state regulations and making sure the appropriate diagnosis were being used. She said consent for psychotropic medications should be completed before the initial dose was given to the resident, either written or verbal. She said there was a risk of not knowing what medications would be given and they should be made aware of the side effects of the medications. She said she did not see the pharmacy recommendation for Resident #34 that indicated he needed an appropriate diagnosis for the use of Seroquel after the pharmacy consultant visited the facility last week. During an interview on 2/25/2026 at 1:20 pm, the Administrator said the Pharmacy Consultant visited the facility monthly which included reviewing medications, and they would give recommendations. She said the DON was responsible for ensuring the recommendations were completed and sent them to the physicians usually in a day or two after the consultant's visit. She said she was not aware that Resident #34 did not have an appropriate diagnosis for the use of Seroquel and the Pharmacy Consultant had been telling the facility for over a year that one was needed for its continued use. She said going forward she would be involved in ensuring the pharmacy recommendations were completed. She said there could be a negative impact for the residents if they were not done. Record review of a facility policy titled Drug Regimen Review Process revised 10/3/2018 indicated, .It is the policy of this facility to conduct a drug regimen review upon a resident's SNF Prospective Payment System (PPS) admission and as indicated throughout the resident's stay. Medication irregularities identified and reported by the consultant pharmacist are maintained in an orderly, organized manner to trach physician or nursing response. Monthly Drug Regimen Review: The Consultant pharmacist reviews the medication of each resident at least monthly and more frequently if deemed necessary. Recommendations that require Physician response are sent to Physician timely for follow up or the Physician is contacted by phone as indicated. The DON will validate that all recommendations sent to Physician, once returned are acted upon timely .

Based on observation, interview, and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 1 of 4 residents (Residents #34) reviewed for medical records.The facility failed to ensure Resident #34's medical records were accurate when LVN J documented meal intake for breakfast and lunch on 2/23/2026.This deficient practice could place residents at risk of improper care and monitoring due to inaccurate medical records. Findings include:Record review of an admission Record dated 3/24/2026 for Resident #34 indicated he admitted to the facility 10/7/2024 and was [AGE] years old with diagnoses of cerebral infarction (stroke), dementia with anxiety (restlessness, worry, agitation with a decline in thinking), PVD (decreased blood flow to the lower legs) and atrial fibrillation (irregular heartbeat).Record review of a MAR for Resident #34 dated 2/24/2026 indicated an order for the nurse to monitor his meals, document amount consumed and if less than 50% document substitute given with a start date of 1/19/2026.Record review of a MAR for Resident #34 dated 2/23/2026, LVN J documented he ate 100% at breakfast and 75 % at lunch. Record review of a meal intake sheet dated 2/23/2026 indicated Resident #34 did not have any documentation for breakfast, lunch, or dinner for his meal intake.Record review of a care plan for Resident #34 revised 1/15/2026 indicated he received a mechanical soft diet and was at risk for malnutrition/dehydration with unintended weight loss. Interventions included helping the resident to form a wake and sleep cycle to allow him to be up for meals as appropriate.Record review of a Quarterly MDS Assessment for Resident #34 dated 12/20/2025 indicated he had severe impairment in cognition with a BIMS score of 0. There were not any behaviors noted during the look back period. He required substantial/maximal assistance with eating. During an observation on 2/23/2026 at 2:15 pm, Resident #34 was in bed resting with his eyes closed and his lunch tray sitting on the over bed table that had been untouched.During an observation and interview on 2/23/2026 at 2:40 pm, CNA D was in the room of Resident #34 to provide incontinent care. She said he would sleep all day until about 3 pm. She asked him if he was hungry and he said he was and his lunch tray was still sitting on the over bed table. She said he slept most of the day and was up at night.During an observation and interview on 2/23/2026 at 3:32 pm, Resident #34 was asleep in bed. His lunch tray was still untouched on his overbed table. CNA D said he had not eaten anything today, breakfast nor lunch.During an observation and interview on 2/24/2026 at 2:02 pm, Resident #34 was sitting up in a wheelchair looking out the window in the hallway leading to the kitchen. He was alert to person only with confusion noted. CNA D was present and said he had been up since around 12 pm and he ate 100% of his lunch. During an interview on 2/24/2026 at 2:12 pm, LVN J said she had been employed at the facility for a year and worked 6 am -6 pm shift. She said the nurses were responsible for monitoring and documenting the meal intake of Resident #34 daily. She said when he was fully awake, he would eat about 100% of his meals, but when he was not fully awake, he would holler out, and it would be hard for him to focus on eating his meals. She said that day at breakfast, he had a supplement shake and lunch he ate 100%. She said she could not remember his intake for breakfast and lunch yesterday 2/23/2026, so she looked at her documentation and said she charted he ate 100% at breakfast and lunch 75%. She said at lunch yesterday she gave him cookies and a health shake. She could not remember anything about his breakfast intake. When asked about his lunch tray that sat in his room for hours yesterday, she said she did not offer him the lunch meal because it was cold. She said there was a sheet at the nurse station where the staff would document the percentage of each resident's meal intake. She said the sheet for 2/23/2026 did not have any documentation on it for Resident #34. She said she did not follow up after meals to ensure the documentation was correct for each resident with the percentage of meals eaten. She said the documentation for his meal intake yesterday (2/23/2026) was incorrect and false documentation. She said there could be a risk for weight loss if the information was not accurate for a resident who was on weekly weight monitoring. She said he had a lot of behaviors and had periods of time when he did not want to eat so he was placed on weekly weights. During an interview on 2/25/2026 at 11:25 am, the ADON said she had been employed at the facility since February 10, 2026. She was responsible for monitoring the POC documentation in the resident records that included documentation of meal intakes. She said she had an in-service with the staff on documenting meal intakes and the nurse aides were responsible for the documentation. She said if a resident did not eat, staff should let the charge nurse know so interventions could be put in place. If documentation were not correct, they should complete an addendum and if not then it could lead someone to believe the information was correct.During an interview on 2/25/2026 at 1:20 pm, the Administrator said meal intakes should be recorded by the charge nurses daily. She said Resident #34 liked to snack and stayed up at night. She said she was made aware of the documentation that LVN J made on Resident #34. She said staff should have better documentation and it varied with the intake Resident #34 received. She said at night they would give him snacks if he was up. She said if the documentation was entered into the system in error, the staff should create an addendum to correct the incorrect information. She said if the information were not corrected, it would be inaccurate and could impact care. She said they started conducting in-services with the staff and have changed their system for a better recording of meal intakes for the residents. Record review of an in-service training report dated 2/25/2026 by the Administrator titled meal service and documentation of intake was conducted. Record review of a facility policy titled Clinical Document Guidelines revised 3/25/2025 indicated, .The patient's clinical record provides a record of the health status, including observations, measurements, history and prognosis and serves as the primary document describing healthcare services provided to the patient. The clinical record is used by the healthcare team to record, preserve and communicate the patient's progress and current treatment .

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 6 residents (Resident #42) reviewed for accidents. The facility failed to provide adequate supervision to prevent Resident #42 from eloping from the facility and being located in an empty lot with multiple fall and environment hazards approximately 550 feet behind facility and approximately 300 feet from highway on 10/13/24 at 1:30 am. The facility failed to keep Resident #42 in a safe environment to prevent an elopement on 10/13/24 at 1:30 am. The noncompliance was identified as PNC (past non-compliance). The IJ (immediate jeopardy) began on 10/13/24 and ended 10/14/24. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for serious injury, accidents, and death. Findings included: Record review of a facility face sheet dated 11/11/24 for Resident #42 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke), dementia, and hyperlipidemia (high cholesterol). Record review of a comprehensive MDS assessment dated [DATE] for Resident #42 indicated that she had a BIMS score of 9, which indicated that she had moderately impaired cognition. She had hallucinations and delusions. Wandering behavior was not present during 7-day lookback period. She was independent with most all ADLs and was able to independently ambulate at least 150 feet. She was always continent to bowel and bladder. She had a wander/elopement alarm device. Record review of a comprehensive care plan initiated on 9/1/22 and most recently revised on 10/18/24 for Resident #42 indicated that she was a high risk for elopement related to progressing dementia and signs of sundowning with interventions that read: .check for placement of wanderguard Q shift . dated 4/15/24 and .Use audible monitoring system to alert staff of exit seeking behaviors as appropriate . dated 9/22/23. Care plan also indicated that she exhibited wandering/exit seeking and had an intervention that read: .Check for proper functioning of the audible alarm system every shift and PRN as ordered . dated 9/21/22. Interventions added after incident included: .Monitor resident for tailgating when visitors are in the building or on the unit . dated 10/13/24 and .Electronic monitoring as needed with family consent . dated 10/18/24. Record review of a physician's order summary report dated 11/11/24 for Resident #42 indicated that she had the following order dated 10/13/24: .Check function of wanderguard every shift for wandering .; and the following order dated 4/14/24: .Wanderguard - check placement every shift for safety . Record review of a facility form titled AHS - Elopement/Wandering Risk assessment dated [DATE] for Resident #42 indicated that she was at risk for elopement or unsafe wandering. Record review of a facility form titled AHS - Elopement/Wandering Risk assessment dated [DATE] for Resident #42 indicated that she was at risk for elopement or unsafe wandering. Record review of a facility incident report dated 10/13/24 for Resident #42 indicated that she eloped from the facility and was located outside the facility and redirected back to building without issues. Administrator, DON, physician, and responsible party all appropriately notified. Record review of a witness statement dated 10/13/24 and completed by RN H read .I heard alarm sounding on 100 hall - station 1. I went outside the door and looked at area around exit door area not seeing anyone I went back inside and checked resident [Resident #42] room to ensure that she was in there. She had just stated that she was going to bed per her norm. Not seeing resident in bed or [bathroom] in her room, I went back outside and looked around exit area and toward road. I then went to notify the other staff members. As I was walking down to unit 2 I approached [LVN F] and [CNA E] and informed them of [Resident #42] was not in her room and asked if they had seen her. The stated they had not. The other aides from unit 2 were also coming up the hall. I went outside the therapy room exit door and walked toward [facility name] to circle the back side of the building. The other staff members went outside the short hall door and [LVN F] remained in the building. When I rounded the side of the building where aides were searching, I heard [CNA G] ask if that was a person over there. I looked and saw her too. [CNA E] and myself [CNA E] ran toward her and were able to redirect resident back inside building without incident. Resident stated that she was looking at the stars. Resident showed no signs of distress or injury . Record review of a witness statement dated 10/13/24 and completed by LVN F read .I heard an alarm going off and discovered it was the exit door in short hallway next to DON office. Nurse proceeded to door and looked outside door and did not see any one. Sent [CNA M], Aide to inform [RN H]. As she walked down hall toward front, [RN H] was coming towards us. He asked if we had seen [Resident #42] because she was not in her room. [CNA G] and [CNA E] the at door with us. The 4 staff members then went outside building, going in different directions searching for resident. I stayed inside building monitoring doors and other facility residents. Shortly after, resident was found outside and safely returned . Record review of a witness statement dated 10/13/24 and completed by CNA G read .I heard alarm going off and it was the door by DON office in that short hall. [RN H] let us know that he could not find [Resident #42]. He said they had just seen her but she is not in her room and they can't find her. We went outside to look for her. [LVN F] the nurse stayed inside. We saw someone moving ahead of us and [RN H] and [CNA E] took off towards her. I went back in and went to unit one to monitor. [CNA M] monitored station 2 with [LVN F] until they got her and came back inside . Record review of a witness statement dated 10/13/24 and completed by CNA M read .I heard an alarm going off. I went down to the door that was alarming - the door on hall next to DON office. I was with [CNA G]. We did not see a resident near by the door or in hall. [LVN F] said go get [RN H] but I turned and he was walking toward me and asked us if we had seen [Resident #42]. We had not seen her so then we went outside and all walked toward the smoke shack. We looked in different directions for her. It was almost right away that we saw her walking toward the Texas Burger. [CNA E] and [RN H] ran after her. Me and [CNA G] went back in the building to check on the other residents . Record review of a witness statement dated 10/13/24 and completed by CNA E read .I was in the break room eating and heard alarm going off at smoking door exit. Went to door - no residents around and looked out window and didn't see anyone there. I went to look for [RN H] to tell him. Walking down 200 hall I seen the nurse from station 2 walking down hall. She said the door was alarming on the short hall by DON office. [RN H] come around from 100 hall asking if we seen [Resident #42]. He told us she wasn't in her room. I had just seen [Resident #42] because she was up front she turned back around to go towards her room. We all went toward the short hall door. Me, [CNA G], and [CNA M] immediately go outside to look for her. [RN H] went out the therapy exit door. [CNA M], [CNA G], and I looked in all different directions. Just as [CNA M] said is that a person over there [RN H] was coming back around the building and met us there and said yes it is so we take off. I run and [RN H] was running/speed walking and we caught up to her towards the [business name]. We came back to the facility and went back inside . During an interview and observation on 11/11/24 at 12:40 pm the DON said Resident #42 was found in an empty lot between facility and [business name]. The empty lot where Resident #42 was located was observed to be approximately 550 feet behind facility and approximately 300 feet from highway. Multiple hazards were observed in the empty lot such as fall/trip hazards, ant beds, holes, rusty pipes, broken glass, and uneven ground. During a telephone interview on 11/11/24 at 2:25 pm CNA G said that the door on unit 1 alarmed first. She said she immediately headed to respond to the alarm, and that is when she saw RN H coming down the hall and he told her that Resident #42 was not in her room. She said they then went outside the door on the short hall. She said she was standing next to the smoke shack when she was outside looking for her and saw Resident #42's figure moving in the distance. She said she was unsure how long Resident #42 was outside but thought that it was about 3 to 4 minutes from the first alarm going off until they found her. During an observation on 11/11/24 at 2:38 pm, the exit door on 100-hall that Resident #42 eloped from was set off with wanderguard by this surveyor. Nursing staff immediately responded to the alarm. The exit door on the short hall by the DON's office was also set off from the outside with the same wanderguard. The exit door to the smoking area was also set off with wanderguard from outside. Each door was observed to alarm separately. During an interview on 11/11/24 at 3:25 pm the Administrator said she felt like the resident took the shorter path around the back of the building instead of going completely around because it would have taken her longer. She said she felt like the staff did a good job of retrieving Resident #42 and bringing her back inside the facility. She said Resident #42 now has a sitter at night and staff check on her every 15 minutes throughout the day. During an observation and interview on 11/11/24 at 4:20 pm Resident #42 was observed at the nurse's station. She ambulated without difficulty and without assistive devices. She was unable to recall incident or appropriately answer questions. She had impaired cognition and verbalized that she worked at facility doing shorthand. Wanderguard was observed in place to right wrist. During a telephone interview on 11/12/24 at 9:28 pm LVN F said she stayed inside the facility with other residents while the rest of the staff went outside to look for Resident #42. She was able to verbalize training regarding elopements and appropriate actions to take in the event of an elopement. During a telephone interview on 11/12/24 at 9:35 pm CNA E said she had been at the nurse's station and Resident #42 had been walking around at the nurse's station and then Resident #42 turned and walked back towards her room. She said RN H was rounding, checking on the residents and was in a resident's room. She said she then walked to the break room to eat lunch. She said she heard the door alarm going out to the smoking area start going off while she was eating lunch, so she got up and went to check it. She said she looked around outside and did not see anyone. She said she was not sure if it was a malfunction or what it was, she had never dealt with an elopement before. She said that she put the code in to turn the alarm off and immediately went to look for RN H. She said she couldn't find him, so she headed to the unit 2 nurses' station and the alarm for the door on the short hall next to the DON office was going off and the nurse did not know the code. She said they then saw RN H coming up the hallway saying that Resident #42 was not in her room, and he could not find her. They immediately went outside to look for her while LVN F stayed inside the facility. She said RN H had already made a perimeter around the building and when he was coming back around from the side, CNA G said is that a person over there? and that was when they saw her walking towards [Texas Burger]. She said she started running towards Resident and RN H was right behind her walking really fast. She said they got up to her almost to [Texas Burger] in the empty lot. They were able to bring her back inside and RN H took over after that. She was able to appropriately answer questions related to elopement training. During an interview on 11/13/24 at 10:05 am the Maintenance man said that he used a wanderguard to set off each door weekly to ensure they functioned correctly. He said residents that eloped could be at risk for all kinds of injuries such as being hit by a car and killed. During an interview on 11/13/24 at 10:20 am the Administrator said if residents eloped, they could be harmed, a lot of things could happen, they could fall, or maybe get lost. She said Resident #42 now has a sitter at night and was more closely supervised during the day, that staff were documenting her location every 15 minutes. She said they have placed checking of the wanderguard on the MAR, checked all residents in facility for elopement risk, tightened up on the door codes to prevent resident's from using codes to exit. During an interview on 11/13/24 at 10:40 am the DON said if a resident eloped, they could be at risk for falls, getting in the road, being ran over, getting injured, hunger, thirst, and low blood sugar. She said she expects her staff to immediately respond to door alarms to help prevent elopements. During a telephone interview on 11/13/24 at 10:30 am RN H said he checked on residents every hour and a half or so, and that Resident #42 must have just slipped by him. He said she did wander the facility and wore a wanderguard. He said she could have been seriously injured or harmed or she could have run out into the street. He said he was in a resident's room when he initially heard the door alarm going off, he said staff should immediately respond to the alarms, but he was tied up with a resident and it took him a minute or so to respond. Record review of a facility policy titled Missing Resident Policy dated 10/24/22 and revised 8/15/23 read: .This facility ensures that resident who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk The facility took the following action to correct the non-compliance on 10/14/24: Record review of Elopement/Wandering Risk assessment history indicated all residents were reassessed for elopement risk by 10/13/24. The facility identified seven residents to be at risk and to require additional supervision. Record review of 15-minute check documentation forms dated 10/13/24 through 11/11/24 indicated that staff document Resident #42's location every 15 minutes throughout the day. Record review of invoices from [business name], a private sitting company indicate that facility paid for a private sitter for Resident #42 from the night of 10/14/24 through 11/11/24. Record review of facility form for elopement drill indicated that facility held elopement drills on 10/13/24 for day shift attended by 8 staff members; 10/13/24 for night shift attended by 5 staff members; 10/14/24 day shift attended by 10 staff members; and 10/14/24 night shift attended by 7 staff members. Record review of facility log sheets dated 10/13/24 through 10/19/24 indicated that documentation of daily door checks were done for front door, dining room door, 100-hall exit door, exit door by DON office, therapy exit door, 400-hall exit door and 500-hall exit door. Record review of Resident #42's physician orders indicated that a new order was put into place to check function of wanderguard every shift for wandering dated 10/13/24. During interviews on 11/12/24 between 1:10 pm and 1:40 pm LVN B, MA L, Medical Records, LVN K, CNA C, and CNA G were able to verbalize training regarding elopements and appropriate actions to take in the event of an elopement. The noncompliance was identified as PNC. The IJ began on 10/13/24 and ended 10/14/24. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen. The facility failed to discard molded food including tomatoes, honeydew melons, and a bag of shredded mozzarella cheese. The facility failed to store food safely including cookie dough, sliced cheese, french fries, whipped topping, and prepared pudding. These failures could place residents at risk for food-borne illnesses. Findings included: During an observation on [DATE] at 9:04 AM in the kitchen, the walk-in refrigerator contained the following items: a cardboard box containing molded tomatoes a cardboard box containing molded honeydew melons a bag of molded shredded mozzarella cheese a cardboard box containing sealed bags of whipped topping that had a brown and sticky liquid on approximately half of the top of the box and several of the bags inside the box a container of prepared pudding that was uncovered, and two cardboard boxes of unsealed raw cookie dough. During an observation on [DATE] at 9:09 AM in the kitchen, the refrigerator contained the following items: a bag of unsealed sliced cheese that was unlabeled and undated. a bag of unsealed french fries that was unlabeled and undated. During an interview on [DATE] at 9:10 AM, [NAME] Q said all kitchen staff were responsible for checking the freezers and refrigerators daily to ensure that moldy or expired food were discarded and not served to residents. She said the risks to residents if they consume expired food would be food-borne illness and residents could get sick. During an interview on [DATE] at 9:15 AM, Dietary Aide R said that he does not check food in the freezers or refrigerators. He said the cooks and dietary manager were responsible for making sure expired or molded food is discarded. During an interview on [DATE] at 9:30 AM, the DM said she regularly checks for expired food in the morning when she gets to work, but she had an emergency today and was late to work. She said the cooks were responsible for checking for expired food if she was not at the facility. She said the risks to residents if they were served expired food was food poisoning. During an interview on [DATE] at 2:16 PM, the Administrator said she and the DM were responsible for making sure all kitchen staff received appropriate training. She said the expectation was that kitchen staff were checking food quality daily and cleaning the kitchen as scheduled. She said that she does not like to answer questions about the risks to residents, but that it wouldn't be good to serve them expired food. Record review of a facility policy revised [DATE], titled Frozen and Refrigerated Foods Storage indicated, .Packaged frozen items that are opened and not used in their entirety must be properly sealed, labeled and dated for continued storage . and .All refrigerated and frozen items in storage will contain a minimum label of common name of product and dated .

Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 3 of 12 (Residents #18, #25, and #59) residents observed for care. CNA C and CNA D failed to provide Resident #25 with full privacy while providing incontinent care on 11/11/24. RN A and LVN B failed to sit while feeding Resident's #18 and #59 on 11/11/24. These failures could place residents at risk of not being treated with dignity and respect. Findings: 1. Record review of a facility face sheet dated 11/13/24 indicated Resident #25 was a [AGE] year-old female that was admitted to the facility on [DATE]. She was admitted with diagnosis of dementia. Record review of a comprehensive care plan dated 6/24/24 indicated Resident #25 was incontinent of bowel and bladder and to check and change as needed. Record review of a Significant Change MDS assessment dated [DATE] indicated Resident #25 had a BIMS score of 15 which indicated intact cognition and was dependent of staff for toileting hygiene. During an observation on 11/11/24 at 10:36 AM Resident # 25 was provided incontinent care by CNA C. CNA C did not pull the privacy curtain between the room or at the door and Resident # 25's roommate was present in the room. At 10:44 am CNA D knocked on Resident # 25's door and walked in room while resident was receiving care exposing her to the hallway. Both CNA's proceeded to dress Resident # 25 with no privacy curtain pulled. During an interview on 11/11/24 at 10:59 AM Resident # 25 said the staff often don't pull her privacy curtain and she felt exposed and embarrassed. Said she would like it if the curtain was pulled so everyone would not see her getting care if her door opened. During an interview on 11/11/24 at 10:54 AM CNA D said she had been at the facility since August and was a newly certified nurse aide. She said she had been trained on resident privacy and dignity. She said she should have knocked louder and waited to enter. She said the privacy curtain should have been pulled to keep resident from being exposed to the hallway. She said the resident could be upset being exposed and privacy not maintained. During an interview on 11/11/24 at 10:57 AM CNA C said she had worked at the facility for 6 years. She said she should have pulled the privacy curtain before starting resident care and she had been trained on privacy. She said residents could be embarrassed if they were exposed. 2. Record review of a facility face sheet dated 11/13/24 indicated Resident #18 was [AGE] year old female that admitted on [DATE] for diagnosis of dementia. Record review of a comprehensive care plan dated 7/11/24 indicated Resident #18 was at risk for nutrition and hydration deficit related to progressing dementia; she required frequent cuing and monitoring to complete her meals and drink fluids; she was fed by staff at times to assist with meal intake. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #18 had a BIMS score of 02 indicating severe cognitive impairment and required supervision with eating. Record review of a facility face sheet dated 11/13/24 indicated Resident #59 was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of metabolic encephalopathy (change in how your brain works). Record review of a comprehensive care plan dated 8/19/24 indicated Resident #59 had an ADL (activity of daily living) deficit and required supervision and setup with meals. Record review of a Quarterly MDS assessment dated [DATE] indicated Resident #59 had a BIMS score of 07 indicating moderately impaired cognition and required supervision with eating. During an observation on 11/11/24 at 12:45 PM RN A and LVN B were both observed standing while feeding residents in the dining room. RN A was standing over Resident # 18 and LVN B was standing over Resident # 59. During an interview on 11/11/24 at 12:50 PM LVN B said that she had worked at the facility for 4 years and Resident #59 needed assistance with meals. She said the staff should be seated when assisting with meals. She said she did not sit because there was not a chair and by standing it could make the resident feel intimidated or rushed. During an interview on 11/11/24 at 4:17 PM RN A said she had worked at the facility 2 years and Resident #18 could sometimes feed herself but does need some assistance at times. She said when assisting residents staff should be seated. She said she should have gotten a chair and sat to assist Resident #18. She said by standing over a resident it could be presumed as being authoritative and make them uncomfortable. Attempted interview on 11/11/24 at 12:55 PM with Resident's #18 and #59 and neither could answer questions. During an interview on 11/13/24 at 10:53 AM the DON said she had been at the facility 3 years and was responsible for oversight of all nursing staff and education on resident rights. She said all staff should pull the privacy curtain during care and sit when assisting with meals. She said by not doing so it could make a resident feel exposed, embarrassed, or rushed. She said she expected all staff to maintain resident rights and dignity. During an interview on 11/13/24 at 3:16 PM the Administrator said all employees were responsible for following resident rights and ensuring resident privacy and dignity were maintained. She said the situations were not ideal and would not speak on the risk to the residents. She said she expected all staff to always respect resident privacy and dignity. Record review of training transcript for RN A indicated she completed resident rights training 6/24/24. Record review of training transcript for LVN B indicated she completed resident rights training 7/28/24. Record review of training transcript for CNA C indicated she completed resident rights training 6/04/24. Record review of training transcript for CNA D indicated she completed resident rights training 8/24/24. Record review of a facility policy dated 2/20/2021 titled Resident Rights indicated, .the facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents .

Based observation and interview, the facility failed to ensure no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span for residents eating meals in their rooms. The facility failed to ensure that no more than 14 hours lapsed between a substantial evening meal and breakfast the following day and provide a nourishing snack for residents that ate in their rooms. This failure placed residents at risk of their nutritional needs, preferences, and requests being met. Findings include: During an observation on 11/11/2024 at 9:30 AM breakfast trays were being served by staff to rooms on hall 100. During observation on 11/12/2024 between 9:00 am and 9:30 AM breakfast trays were being served by to staff to residents on Hall 100. During an interview on 11/12/2024 at 2:00 PM with 10 members of the facility resident council , the residents stated that the facility served breakfast late and that for the residents that had their meals in their rooms it was often after 9:00 am before they were served breakfast. The residents stated supper was served around 6:00 PM. Residents stated snacks were available at the nurse's station in the evening and that the snacks consisted of crackers or cookies. Residents said they had to go to the nurse's station if they wanted a snack, that staff did not bring them to their rooms. There were 3 residents present in the meeting that were diabetic and they stated that they did not receive snacks at night. The residents said if they wanted a sandwich in the evening that they had to tell the kitchen before supper. The residents said the mealtime between supper and breakfast was long, and that the supper menu was a lighter meal. Posted mealtimes in the dining room are breakfast 7:30 AM; lunch 12:00 PM; Supper 5:30PM. During an interview on 11/13/24 at 10:15 AM with the Dietary Manager she said breakfast was served in the dining room at 7:30 AM and that the last trays for the hall were out for serving by 8:50 AM every morning. She said supper was served at 5:30 PM and that the hall trays were out by 5:45 PM every day. She said the nursing staff were responsible for getting the hall trays from the kitchen and passing them out on the hall. She stated snack times were 10:00 AM, 2:00 PM and 8:00PM. She said the evening kitchen staff were responsible for stocking and preparing the snacks. She said the snacks were prepared and taken to the nurse's station for the nursing staff to pass out. She said all residents with diabetes had a label printed out and those residents get sandwiches every evening. She said she had complaints in the past that sandwiches were not being made and left for the evening snacks, she could not recall when the complaint was. She said she had a meeting with the evening shift staff, and they were instructed to make sandwiches for the evening snacks. She said she has not had any other complaints about snacks, so she did not know that it was a problem. The Dietary Manager stated she did not have a policy on frequency of meals and snacks. She stated she knew that the time limit was 14 hours between supper and breakfast. During an interview on 11/13/24 at 11:25 AM with the DON, she stated she was aware that there were inconsistencies in mealtimes. She stated dietary normally brings the trays to station 1 and then they announce that trays were ready for station 2 and the dietary staff meets that nursing staff halfway with the trays. She said she was not aware that the sandwiches were not being passed out to residents during the evening. She said her expectations are that dietary staff were consistent with mealtimes and that nursing staff serves trays promptly to the residents. She said possible effects of extended or inconsistent mealtimes would be that residents that need to take medications with meals or receive insulin before meals could have unwanted side effects related to taking medication prior to meals and meals were late. During an interview on 11/13/24 at 01:20 PM with Dietary Aide N, he said he worked at the facility for 3 months. He stated that he was responsible for preparing evening snacks for the facility. He stated tthe snacks were prepared and sent to the nurse's station with supper trays. He stated snack cakes and crackers were placed on the cart. He stated that he prepares 10 sandwiches and cuts them in half to send them to each nurse's stations. He stated that he does not put the residents name/label on the sandwiches, but he does put a label with the date on it. He said he does not know how the snacks were passed out once they were at the nurse's station. During an interview on 11/13/24 at 01:30 PM with [NAME] P he said he has worked at the facility for 5 months. He said he helps with preparing the snacks for the evening shift. He said snack cakes, cookies and chips were placed on the snack cart. He said that half sandwiches were made every night. He said he would make sandwiches for all the residents that have evening snacks ordered. He said extra sandwiches were made for residents that request the sandwiches. He stated the snacks were sent with the evening meal trays. During an interview on 11/13/24 at 01:41 PM with the Administrator she stated she has worked in the facility for 2 years. She stated she was made aware of the residents complaining about breakfast being served late. She said she did not believe that the residents on the hall received their meals after 9:00 AM. She then stated there has been some staffing challenges in the dietary department and that they have had some challenges in that department. She stated they did back up the serving time and that breakfast was out timely this morning. She said she has been working with the dietary manager on solutions to make meal service more consistent. She said she has received complaints from residents in the past on how late the breakfast trays were being served. She stated by not providing a consistent mealtime and following the time frame allowed between meals that residents could get hungry, and that consistency was needed to assist in maintaining weights. She said she would work with the director of nurses on ensuring that snacks were being given to the residents. During an interview on 11/13/2024 at 10:15 AM with the Dietary Manager she said the facility did not have a policy regarding mealtimes and snacks.

Based on observations, interviews and record reviews, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice and their care plans for 1 of 4 residents (Resident #19) observed for respiratory care and services. The facility failed to ensure Resident #19's nebulizer mask, humidifier bottle and tubing for the oxygen concentrator were changed per the physician's orders. These failures could place residents who require respiratory care at risk for respiratory infections, breathing in dust and allergens, decreased effectiveness of oxygen concentrators, and exacerbation of respiratory distress. Findings included: Record review of a facility face sheet dated 11/13/2024 for Resident #19 indicated that she was a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (a condition that limits airflow into and out of the lungs), generalized anxiety disorder (fear characterized by behavioral disturbances), Type 2 diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel), and Chronic Kidney Disease, Stage 2 (involves a gradual loss of kidney function). Record review of a quarterly MDS dated [DATE] for Resident #19 indicated that she had a BIMS score of 15, which indicated that she was cognitively intact. Section O indicated that she had received nebulizer treatments for at least 15 minutes for 2 of the previous 7 days of the assessment reference date (9/6/2024). Record review of medication administration records for Resident #19 for November 2024 indicated that she received nebulizer medication three times daily and oxygen at 4 liters via nasal cannula continuous daily. Record review of a consolidated physician's order list for Resident #19 indicated an order date of 7/11/24 to change oxygen set up and nebulizer tubing every Sunday. Record review of comprehensive care plan with a revision date of 6/15/2024 indicated the Resident #19 used oxygen therapy routinely related to chronic obstructive pulmonary disease. During an observation and interview on 11/11/24 at 10:36 am, Resident # 19 was observed lying in bed. Resident #19 had oxygen on 4 liters via nasal cannula. The humidified water bottle attached to the oxygen concentrator was dated 10/27/24 and had a small amount of water at the bottom of the bottle. A nebulizer mask was observed on her bedside table in a bag which was dated 11/27/24. Resident #19 stated that she wore her oxygen all the time and that she received nebulizer treatments daily. She said that the nurse changed the oxygen tubing and the nebulizer mask but that she could not recall the last time it was changed. During an observation 11/11/24 at 3:05 PM the humidifier bottle had a small amount of water and dated 10/27/24. The nebulizer mask on the bedside table was in a bag and dated 11/27/2024. During an observation on 11/12/24 at 8:30 AM the humidifier bottle was full of water and bubbling. The bottle was dated 11/12/2024. The nebulizer mask was in a bag on the bedside table and dated 11/12/2024. During an interview on 11/13/24 at 11:00 AM with the DON, she stated that the charge nurses on night shift were responsible to replacing the oxygen set up every Sunday and that it was on the resident's medication administration record. She said that the nurse was responsible for putting the correct date on the oxygen set up. She said that she expected the charge nurse to change the oxygen set up as ordered and as needed if the oxygen mask or tubing was visibly soiled and if the water on the concentrator was low or empty. She said that not changing the oxygen set up can lead to possible infection control risk due to soiled mask. She said that the water was necessary to humidify the oxygen for the resident's comfort and to avoid drying out the resident's nasal passages. During an interview on 11/13/24 at 01:36 PM with the Administrator, she stated that the director of nurses would be following up with the night shift nurses to ensure that orders were being followed and that anything that needed to be dated would be dated correctly. Record review of a facility policy titled Following Physician Orders implemented 9/28/2021 read .the nurse will . carry out and implement physician's orders. Record review of a facility policy titled Oxygen Administration reviewed on 1/5/2020 read Change disposable parts once a week and label with date.

Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment that did not result in bodily injury within 24 were reported within 24 hours for 1 of 6 residents (Resident #42) reviewed for abuse and neglect. The Administrator failed to report an allegation of neglect on 4/14/24 when Resident #42 eloped from the facility and was found in the emergency room parking lot next door to the facility. This failure could place residents at risk for harm and injury. Findings included: Record review of a facility face sheet dated 11/11/24 for Resident #42 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke), dementia, and hyperlipidemia (high cholesterol). Record review of a comprehensive MDS assessment dated [DATE] for Resident #42 indicated that she had a BIMS score of 9, which indicated that she had moderately impaired cognition. She had hallucinations and delusions. Wandering behavior was not present during 7-day lookback period. She was independent with most all ADLs and was able to independently ambulate at least 150 feet. She was always continent to bowel and bladder. She had a wander/elopement alarm device. Record review of a comprehensive care plan initiated on 9/1/22 and most recently revised on 10/18/24 for Resident #42 indicated that she was a high risk for elopement related to progressing dementia and signs of sundowning with interventions that read: .check for placement of wanderguard Q shift . and .Use audible monitoring system to alert staff of exit seeking behaviors as appropriate . Care plan also indicated that she exhibited wandering/exit seeking and read: .[Resident #42 ] wanders through the facility at times and is at risk for elopement and injury . She had an intervention that read: .Check for proper functioning of the audible alarm system every shift and PRN as ordered . Record review of a physician's order summary report dated 11/11/24 for Resident #42 indicated that she had the following order dated 10/13/24: .Check function of wanderguard every shift for wandering .; and the following order dated 4/14/24: .Wanderguard - check placement every shift for safety . Record review of a facility incident report dated 4/14/24 at 3:10 pm for Resident #42 indicated that resident had eloped from the facility and was found in the emergency room parking lot next door. Report read .heard 100 hall alarm sound when in assisting another resident. Went to check at door and outside for elopement. No one immediately outside. Went to search for [Resident #42], she was not in her room, facility searched, resident not in building, sent staff outside, found resident within 10 minutes in the ER (emergency room ) parking lot at hospital next door . Record review of TULIP (Texas Unified Licensing Information Portal) website accessed on 11/12/24 indicated that elopement incident on 4/14/24 was not reported to HHSC (Health and Human Services Commission). During an observation and interview on 11/11/24 at 4:20 pm Resident #42 was observed at nurse's station. She ambulated without difficulty and without assistive devices. She was unable to recall incident or appropriately answer questions. She had impaired cognition and verbalized that she worked at facility doing shorthand. Wanderguard was observed in place to right wrist. During an interview on 11/13/24 at 10:05 am the Maintenance man said he checked each door alarm weekly. He said if a resident eloped, they could be at risk of all kinds of injuries and they could be hit by a car. During an interview on 11/13/24 at 10:40 am the DON said Administrator was responsible for reporting incidents. She said she did not consider this incident an elopement because she thought staff had had Resident #42 within their sight at all times. She said staff should respond to alarms immediately. During an interview on 11/13/24 at 10:20 am the Administrator said she was responsible for reporting incidents and said that staff never actually lost Resident #42. She said a staff member had gone outside and saw Resident #42. She said she believed staff had eyes on Resident #42 the entire time. She said she was the abuse coordinator and she used HHSC guidance to determine reporting criteria. She said she would have reported it if she thought the incident had been a reportable incident, but since she thought staff had eyes on her the entire time, she did not report it. She said if incidents were not reported then possibly a thorough enough investigation might not occur and residents could be harmed. She said after this incident, they put an order in place to ensure wanderguard was in place on the medication administration record. Record review of a facility policy titled Missing Resident Policy dated 10/24/22 and revised on 8/15/23 read .Appropriate reporting requirements to the State Survey agency shall be conducted . Record review of a facility policy titled Abuse/Neglect Policy and Procedure dated 1/8/24 read .Definitions: .Neglect: failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . and .Reporting: Administrator or designee will then notify the appropriate State agency(s) when required, after identification of alleged incident. Initiate process according to State- specific regulations . Record review of a Long-Term Care Regulatory Provider Letter titled Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility (NF) Must Report to the Health and Human Services Commission (HHSC) dated August 29, 2024 read: .2.1 Incident that a NF Must Report to HHSC. A NF must report to HHSC the following types of incidents, in accordance with applicable state and federal requirements: a missing resident . and .An incident that does not result in serious bodily injury and involves: a missing resident-Immediately, but not later than 24 hours after the incident occurs or is suspected .

Based on observation, interview and record review, the facility failed to ensure 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 pressure ulcers from developing for 1 of 2 residents (Resident #21) reviewed for pressure ulcers. The facility failed to provide wound care for pressure ulcer for Resident #21 on Left Heel for 3 of 27 days and failed to provide wound care for pressure ulcer on Right Buttocks for 4 of 27 days in October 2024 which could have caused pressure ulcers to deteriorate. This failure could place residents with pressure ulcers at risk for wound deterioration and decline in existing pressure ulcers. Findings included: Record review of an Admission Record dated 10/04/24 indicated Resident #21 was admitted on [DATE], was [AGE] years old, and was diagnosed with senile degeneration of brain, fracture of left femur, unstageable pressure ulcer of left heel, and stage 3 pressure ulcer of right buttock. Record review of an MDS dated [DATE] indicated Resident #21 had severe cognitive impairment, required substantial to total assistance for all ADLs, was at risk for developing pressure ulcers, had one stage 3 and one unstageable pressure ulcer at the time of admission. Record review of a VOHRA Wound Physicians Evaluation and Management summary dated 10/18/24 specified Resident #21 had a pressure injury to her buttocks and to her left heel. Physician treatment plan reflected the following orders: STAGE 3 PRESSURE WOUND OF THE RIGHT BUTTOCK FULL THICKNESS DRESSING TREATMENT PLAN Primary Dressing(s) Alginate rope apply once daily for 21 days Secondary Dressing(s) Gauze island w/ bdr apply once daily for 21 days UNSTAGEABLE (DUE TO NECROSIS) OF THE LEFT HEEL FULL THICKNESS DRESSING TREATMENT PLAN Primary Dressing(s) Betadine apply three times per week for 21 days; Alginate calcium w/silver apply three times per week for 30 days Secondary Dressing(s) Gauze island w/ bdr apply three times per week for 30 days Record review of a treatment record for October 2024 for Resident #21 reflected that wound care for pressure ulcer of left heel had not been documented 3 of 27 days, and wound care for pressure ulcer of buttocks was not documented for 4 of 27 days. During an interview with an employee at the facility who wished to remain anonymous said that wound care was not always done for Resident #21 when the treatment nurse was off work. Employee said it was the responsibility of the RN on the floor to perform wound care as ordered when the treatment nurse was off work. During an interview on 11/12/24 at 10:38AM the Treatment Nurse said she performs wound care for Resident #21 on weekdays. She said on weekends or any other day when she is off, an RN working performs wound care. During an interview on 11/13/24 at 2:20 PM the DON said the treatment nurse was responsible for wound care when she was at the facility, and the charge RN or RN supervisor was responsible for performing wound care when the treatment nurse was not working. She said the expectation of staff was to always perform wound care as it was ordered. She said going forward she would more closely monitor treatment reports to ensure orders were being followed. She said risks to residents if physician wound care orders were not followed would be worsening wounds. Record review of a wound care policy dated 3/11/2024 reflected that .Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present .

Based on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 7 residents (Resident #1) reviewed for accidents and supervision. 1. The facility failed to properly secure Resident #1 in the facility van on [DATE] and Resident #1 fell forward while in transport striking his head on the side of the van causing a laceration and emergency room care. An IJ (Immediate Jeopardy) was identified on [DATE] at 4:30 pm. The IJ template was provided to the facility on [DATE] at 5:05 pm. While the IJ was removed on [DATE] at 12:07 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 is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective systems. This failure placed all residents that used the facility van at risk of injury and death. Findings: Record review of a facility face sheet dated [DATE] indicated Resident #1 was an [AGE] year-old male that admitted to the facility on [DATE] with diagnosis of myocardial infarction (heart attack). Record review of a significant change MDS assessment dated [DATE] indicated Resident #1 had a BIMS of 9 indicating moderately impaired cognition and had impairment to both upper and lower extremities, was an amputee and was dependent for all ADLs. Record review of a comprehensive care plan dated [DATE] indicated Resident #1 had an ADL Self Care Performance Deficit and was at risk for not having their needs met in a timely manner and had the potential for falls with new intervention dated [DATE] to ensure prosthesis was in place for added safety and stability. Record review of an incident report dated [DATE] at 8:20 am during transport with two facility staff Resident #1 was witnessed leaning forward and hitting the inside wall of the van. Staff jumped up to catch wheelchair and Resident #1 but Resident #1 bumped his head on the inside of the van resulting in a small gash on his forehead. Resident #1 was assessed, and emergency medical services were notified to send to the emergency room (ER) . The doctor and family were notified of the incident. During an interview on [DATE] at 10:15 am Resident #1's family member said Resident #1 had gone to see his heart doctor in another city by the facility van. She and another family member met the van at the doctor's appointment. She said after the appointment the aide and driver loaded Resident #1 in the van and she and the other family member left. She said shortly after, her phone rang, and the van driver told her there was an incident when she came down a steep hill and applied the brakes, Resident #1 fell from his chair forward and hit his head. She said she and the other family member arrived and 911 had been called. She said she was in such a panic she did not pay attention to his wheelchair and if there was a restraint or not. She said she does not know if the facility could have done anything else because she did not know if they failed to secure him or not. During an interview on [DATE] at 1:00 pm CNA A said she had worked at the facility since 1980 and currently was in medical records but was also an aide. She said she was the aide on transport the day Resident #1 fell in the van. She said the driver had loaded Resident #1 and secured him with the lap belt, but she could not recall there being a shoulder harness in the van. She said she did not routinely ride as the attendant but did that day. She said they left the doctor's office and headed home. She said the driver was going slowly down a hill and she saw out of the corner of her eye Resident #1 falling forward but she could not reach him. She said the driver stopped and they assisted Resident #1 to the floor while they called the nursing home and 911. She said the ambulance picked him up and took him to the ER to be evaluated. She said a shoulder harness would be safer for the residents and could prevent falls or injuries. During an interview on [DATE] at 1:26 pm the van driver said she had been employed since [DATE]. She said on hire she was trained by the previous driver and the maintenance director. She said she was trained on how to properly secure the wheelchair wheels and place the seatbelt across the resident's lap. She said the day of the incident with Resident #1, Resident #1 was in a high back wheelchair that reclined, and she had leaned him slightly backwards for his comfort, secured the wheels and placed the seatbelt across his lap. She said when she was going down a hill and applied the brakes, Resident #1 fell over the front right side of his wheelchair and struck the side of the van. She said CNA A was sitting in the seat in front of him and tried to reach him but could not. She said Resident #1 did not fall out of the wheelchair onto the floor, but she and CNA A had assisted him to the floor. She said they tried to reposition Resident #1 in his wheelchair but could not because of his size and felt it was safer to lower him to the floor. She said they called his family and 911. She said by not having a shoulder harness in the van residents could become injured during transport. During an observation and interview on [DATE] at 1:35 pm the facility van was parked behind the facility. The van driver demonstrated how she loaded and secured residents for transport. The wheelchair was loaded, and wheels locked and secured using 4 straps. She then applied a lap belt under the armrest and over the lap and secured. No shoulder harness was applied, and the van driver said there had not been a shoulder harness and she was not trained on needing to apply one. She said a shoulder harness should be in place to secure the resident and keep them from going forward and getting hurt. During an interview on [DATE] at 2:09 pm the maintenance director said he had worked at the facility for 1 ,d+[DATE] years and he did a weekly check on the facility van. He said the checks included checking the fluids, lights, wheelchair lift, straps to secure the wheelchair and the seat belts. He said the van only had a lap belt and there was not a shoulder harness in the van that was used. He said he was trained on the van on hire by the previous van driver and by just having common knowledge on vehicles. He said he and the previous van driver trained the current van driver and training included verbal and demonstration of properly securing and transporting residents. He said he and the previous van driver did a few transports with the current van driver to ensure she was ready before her first trip. He said there was no literature of manufacturer information for the seatbelts in the van. He said there was not a vehicle operating manual to follow that he has seen but would try to locate one online. He said the van was a 2008 Ford Econoline van and was purchased before his hire date. He said the van driver was not trained on applying a shoulder harness because there was not one to apply. He said by not having a shoulder harness it could result in injury of a resident during transport. During an interview on [DATE] at 2:40 pm the Administrator said she had been the administrator since 2022 and had participated in the training of the van driver when she was hired along with the previous van driver. She said the maintenance director retrained the van driver after the incident with Resident #1. She said securing the resident properly was part of the initial training. She said that she thought the lap and shoulder harness were in use and was not aware there was no shoulder harness being used. She said the maintenance director was responsible for checking the securement devices in the van weekly and as needed. She said the training was to check the lap belt or the shoulder harness and at least one device had to be in place. She said by not having a shoulder harness it could cause falls and injuries. She said there were no other staff that drove the van and if the current van driver was not available, she used a private transport service. She said she would take the van out of service until a shoulder harness could be installed. Record review of an orientation checklist for community Driver-Van-Bus dated [DATE] indicated the van driver had received proper training on hire for transporting residents including applying lap and shoulder belts. Record review of a facility policy titled Transportation Policy and Procedure for Facility Based Vehicle dated ,d+[DATE] indicated assure that the vehicle is in good repair and in full compliance with all recommended maintenance as per vehicle operating manual. The authorized driver must complete a competency-based training to include but not limited to b. application of seat belt . Record review of Code of Federal Regulations website https://www.ecfr.gov/current/title-49/subtitle-A/part-38/subpart-B/section-38.23 at Title 49 Subtitle A Part 38 Subpart B S 38.23 Mobility aid accessibility last amended [DATE] indicated, .(d) Securement devices (7) Seat belt and shoulder harness. For each wheelchair or mobility aid securement device provided, a passenger seat belt and shoulder harness, complying with all applicable provisions of part 571 of this title, shall also be provided for use by wheelchair or mobility aid users. Such seat belts and shoulder harnesses shall not be used in lieu of a device which secures the wheelchair or mobility aid itself. Record review of weekly center-based vehicle maintenance logs dated from [DATE] to present date indicated the seatbelts operable including all straps, for wheelchair tie down, shoulder strap and floor wheelchair tie down straps were ok. Unable to review vehicle operating manual due to no manual found at the facility. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 4:30 pm. The facility's Administrator was notified. The Administrator was provided the IJ template on [DATE] at 5:05 pm. The following Plan of Removal (POR) submitted by the facility was accepted on [DATE] at 9:20 am. Plan of Removal - F 689 Free of Accidents and Hazards/supervision/devices Tag Cited: F-689 Issue Cited: Free of Accidents/Hazards/Supervision Tag Cited: F-689 Issue Cited: Free of Accidents and Hazards Failure to ensure the facility van had proper securement devices (shoulder harness and lap belt) and resulted in a resident falling forward out of wheelchair striking his head. 1. Immediate Action Taken A. Resident # 1 expired in the facility on [DATE] . B. The facility's van immediately stopped all van transport on [DATE] at 4:30 pm C. The facility's van is scheduled for replacement / installation of shoulder harness this Thursday [DATE]. D. The Administrator or designee completed the following with the one facility designated van driver: o In-service education on the Transportation Policy which provides direction on duties and responsibilities of driver, van safety, and forms required was completed on [DATE] at 7:00pm. Skills check off on driving of the van, how to operate the wheelchair lift and the wheelchair securement system, use of seat and shoulder harness, and how to transport more than 1 wheelchair was completed on [DATE] at 8:00am at neighboring facility with a similar van. Van driver performed return demonstration on noted skills. This process will be redone once our van has the shoulder harness installed. o In-service education provided to van driver by administrator/designee on weekly maintenance log which includes checking Operable seatbelt straps, wheelchair tie down, shoulder strap, floor W/C tie down straps that van driver will complete and provide to administrator/designee weekly. This was completed on [DATE] at 7:00 pm. o The Administrator reviewed with van driver, a new signed job description. This was completed on [DATE] at 7:00 pm. 2. Identification of Residents Affected or Likely to be Affected: A. No other residents identified, all scheduled van transports for the remainder of the week will be transported by an outside vendor and will continue if needed until repairs are made to the facility van. 3. Actions to Prevent Occurrence/Recurrence: A. As of [DATE], any staff member hired for van transports will be provided the following by the facility maintenance supervisor. o In-service education on the Transportation Policy which provides direction on duties of driver, driving of the van, how to operate the wheelchair lift and the wheelchair securement system, use of seat and shoulder harness, and how to transport more than 1 wheelchair prior to driving the van. o In-service education on weekly maintenance log which includes checking Operable seatbelt straps, W/C/ tie down, shoulder strap, floor W/C tie down straps that van driver will complete and provides to administrator/designee weekly o Completed a skills validation check list on van driver to acknowledge skills competence on how to operate the wheelchair lift and the wheelchair securement system, seatbelts including shoulder harness, and will complete a return demonstration. o Have van driver sign job description duties Immediate Jeopardy Removal Plan F-689 - (Free of Accidents and Hazards) B. The weekly maintenance log will be reviewed in the morning meeting by the Administrator or designee on [DATE] the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to Accidents/Hazards/Supervision and reviewed plan to sustain compliance. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: _____[DATE]____________ Plan of removal was monitored as follows: During an interview on [DATE] at 9:40 am the van driver was able to verbalize the proper technique for loading and securing a resident in a wheelchair, weekly completing the check of operable seatbelt straps, understanding of transportation policy, job description, and new skills checkoff with maintenance director using another facility van. The van driver verbalized the facility van was no longer in operation and all appointments had been rescheduled with a private transportation service. During an observation on [DATE] at 11:45 am the van driver was able to properly demonstrate using a different facility van how to place both the lap belt and shoulder harness to secure a resident during transport. During an interview on [DATE] at 12:00 pm the maintenance director said he went through the checklist with the van driver 3 times, then observed her secure a wheelchair in the van, and verbalized the inservice training to include the van was not to be used until it was repaired, weekly maintenance log and checkoff with each transport once transports resume and a lap and shoulder belt must be in place. Record review of inservice training titled Van safety ( review weekly maintenance log, checkoff form prior to transport, van to have lap belt and shoulder belt, and new training to occur after shoulder harness was installed) dated [DATE] indicated Administrator, Maintenance director and van driver signed and understood the information. Record review of a Transportation Policy dated [DATE] indicated the van driver signed on [DATE]. Record review of an Orientation checklist Community Driver-Van-Bus dated [DATE] indicated the van driver had received new skills validation by the maintenance director. Record review of a job description for the van driver indicated had been resigned on [DATE]. Record review of an email dated [DATE] indicated an appointment had been made with a wheelchair van company to evaluate and repair restraint system. Record review of facility form titled appointments for remainder of week indicated 3 residents had appointments and transportation had been arranged with a private transport company. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 12:07 pm.; however, 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 is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations , interviews, and record reviews the facility failed to ensure 4 of 6 (NA B, NA C, NA D, and NA E) staff were not working in the facility longer than four months without having completed a nurse aide competency evaluation program. The facility failed to ensure NA B, NA C, NA D, and NA E became certified within four months of hire as full-time staff. This deficient practice could place residents at risk for receiving care from an individual whose skill level was not known. Findings include: Record review of the facility staff roster dated 8/19/24 indicated the following staff were listed as nurse aides with hire dates: *Nurse Aide B hire date of 12/13/2023. *Nurse Aide C hire date of 1/30/2024. *Nurse Aide D hire date of 5/10/2021. *Nurse Aide E hire date of 12/28/2023. Record review of employee personnel files indicated the following staff had not completed a training and competency evaluation program, or a competency evaluation program approved by the State: *Nurse Aide B *Nurse Aide C *Nurse Aide D *Nurse Aide E Record review of competency evaluations for NA B, NA C, NA D and NA E indicated they had received skills checkoff training by the facility staff on hire and annually for resident care. Record review of working schedules dated 8/19/24 to 8/23/24 indicated NA B, NA C, NA D, and NA E were on the schedule to work. During an observation and interview on 8/19/24 at 10:08 am NA D was on 100 hall and said she was assigned 100 hall with another certified nurse aide. She said she was non-certified and had been employed with the facility for 3 years. She said she had attempted the CNA course 2 previous times and did not pass her written test and she began the program again 3 weeks ago. She said during her employment she had performed nurse aide tasks such as bathing, dressing and transfers with assist of another aide and had been trained and checked off on skills. She said she will retest orally this time and was not aware she had to complete the course in 4 months. She said when she hired it was after Covid and everything was different. She said she was knowledgeable on providing care and felt the residents were safe. She said she could see where resident care could be affected if nurse aides were not trained accordingly. Attempted phone interview on 8/20/24 at 8:15 am with NA E but there was no answer, voicemail left, and no return call received. During an interview on 8/20/2024 at 1:28 pm the ADON said she was responsible for staffing in the facility. She said when a nurse aide was hired, the administrator enrolled them into the NATCEP (Nurse Aide Training and Competency Evaluation Program), but she was not sure on how long the nurse aide had to complete the program. She said the administrator kept up with that information. She said the nurse aide was not to perform hands on resident care until they were enrolled in the program and had completed the skills competency. She said she and the DON completed the inhouse competency checkoffs and once they completed, they were placed with a CNA for further training. She said there was no system in place to ensure the nurse aides were completing the course assignments and getting their certificates. She said she scheduled the nurse aides and oversaw that they did not provide care alone until they were certified. She said if nurse aides did not receive proper training a resident could have negative outcome. During an interview on 8/20/2024 at 1:52 pm the DON said she had been the DON for 3 years and the administrator took care of the nurse aides being hired and enrolled in the NATCEP program. She said originally the facility would assist the nurse aide with enrolling in the in-person class but now utilize the online course because there have been instances that the nurse aide did not attend the in-person classes. She said she was not aware of the 4-month timeframe until yesterday but had met with the administrator to discuss the nurse aides currently on the schedule that have not completed the program within 4 months of hire. She said the facility did their own training for the nurse aides and each one was checked off for skill competency before being scheduled. She said the nurse aide was scheduled with a CNA for supervision and training as well as overseen by the charge nurses. She said if a nurse aide does not complete the program per the regulation, it could cause a safety issue. During an interview on 8/20/24 at 3:31 pm the Administrator said she had been at the facility for 2 years and was responsible for the oversight of the nurse aides and enrolled them in the NATCEP program. She said after the Covid waiver ended they were enrolling the NAs in the in-person hybrid courses but some like NA B, NA C and NA E were having trouble getting to the classes. She said they completed skills training and competencies and assisted with transport if they needed it. She said she was not aware the 4-month timeframe had started since the Covid waiver lifted. She said they were now using the online NATCEP program and that had helped, and she had been able to enroll the NAs in the program as of July 2024. She said she did not have a tracking system for ensuring the NAs completed their training but had developed a new form to track their progress in the program. She said the NAs were competent and felt there was no risk for not completing the program in the required timeframe because they had been training NAs in house since Covid. Record review of a Long-Term Regulatory Provider Letter 2023-05 revised 5/8/2023 indicated, .if the nurse aide hire date begins on or after 5/11/2023; certification date should be 4 months from date of hire, if the nurse aide began employment before 5/11/23, and has worked 4 months or more certification date should be no later than 9/10/23 . Record review of a facility policy titled Nursing Services and Sufficient Staff dated 4/10/2022 indicated, .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. 6. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for the residents' needs . Record review of Nurse Aide job description, undated, reflected: nurse aides were to complete all required on-line education as deemed necessary by the state and facility.

Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from physical abuse for one of four residents (Resident #1) reviewed for abuse. 1. The facility failed to prevent physical abuse for Resident #1 witnessed by HA to have been hit on the head by CNA A on 02/27/2024 at approximately 3:00 a.m. during incontinence care. The noncompliance was identified as PNC. The IJ began on 02/27/2024 and ended on 03/05/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for physical harm, psychosocial harm, unsafe environment, and further abuse. Findings included: Review of facility policy, titled Abuse/Neglect Policy & Procedure, with no date, revealed the following: PREVENTION AND REPORTING: 1. The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. 2. The facility has designed and implemented processes, which strives to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. 3. The facility has implemented the following processes in an effort to provide residents/patients and staff a safe and comfortable environment. 4. Administrator is the Abuse Coordinator. The Administrator considers the Director of Nursing a designee for reporting and investigation of alleged abuse. In their absence, Admin and DON can appoint appropriate supervisory personnel to initiate investigation. 5. The Administrator and Director of Nursing are responsible for investigation and reporting. They are also ultimately responsible for the following as they relate to abuse, neglect, and/or misappropriation of property standards and procedures: Ongoing monitoring Reporting Investigation Tracking and trending 6. Implementation and ongoing monitoring consist of the following: Screening Training Prevention Identification Protection Investigation Reporting DEFINITIONS: Abuse Willful infliction of injury Unreasonable confinement Intimidation with resulting physical harm or mental anguish Punishment with resulting physical harm or pain or mental health Deprivation by the individual, including a caretaker, of good or service that is necessary to attain or maintain physical, mental, and psychosocial well being . Physical Abuse Includes hitting, slapping, pinching, scratching, spitting, holding, roughly, etc. It also includes controlling behavior through corporal punishment . Training 1. Provide training for new employees through orientation and with ongoing training programs. Training will include, but not limited to: Definitions of abuse, neglect, mistreatment, and misappropriation of property. Identification of abuse . Utilization of appropriate interventions to deal with aggressive and/or catastrophic (detrimental) reactions of residents/patients. How to provide protection for residents/patients How to investigate and report incidents of abuse, neglect, mistreatment, and misappropriation of property. Prevention of abuse, neglect, mistreatment, and misappropriation of property including, but not limited to, recognizing signs of burnout, frustration and stress . Prevention Ensure that prevention techniques are implemented in the facility including, but not limited to, ongoing supervision of employees through visual observation of care delivery and recognition of signs of burnout, frustration, and stress. 1. Identify, correct, and intervene in situations where abuse, neglect, and/or mistreatment are more likely to occur. This includes, but is not limited to, identification/analysis of: Secluded areas of the facility Sufficient staffing on each shift to meet the needs of the residents/patients Assigned staff demonstrating knowledge of individual resident/patient needs Sufficient and appropriate supervisory staff to identify inappropriate behaviors Residents with needs and behaviors which might lead to conflict or neglect 2. Encourage residents/patients and families to report concerns, incident, and grievances without fear of retribution. Provide feedback regarding the concerns that have been expressed. 3. Instruct staff that they are required to report resident concerns, incidents, and grievances. Identification 1. Identify events, such as suspicious bruising of residents/ patients, occurrences, patterns, and trends that mat constitute abuse, neglect, and/or mistreatment and investigate . 3. instruct staff, resident/patient, family call my visitor, etc. to report immediately, without fear of reprisal, any knowledge or suspicion of suspected abuse, neglect, mistreatment, and/or misappropriation of property. Protection 1. provide for the immediate safety of the resident patient upon identification of suspected abuse, neglect, mistreatment, and/or this appropriation of property. Means of providing protection include, but are not limited to: Moving resident/patient to another room or unit Provide 1:1 monitoring as appropriate Immediate suspension of suspected employee(s) pending outcome of the investigation . 2. Initiate behavior crisis management interventions, as applicable . 2. Administrator and/or designee will initiate the Investigation. The investigation should be thorough with witness statements from staff, resident, family members who are interview-able and have information regarding the allegation . Employee Suspension from Duty 1. Any time an allegation is made involving abuse, neglect, or mistreatment of a resident/patient which names a specific employee, laws and regulations are specific about protecting all residents/patients from harm / potential harm farmer which means suspending the employee until the completion of the investigation. 2. The employee is not to remain on duty, and is not to be assigned to any other area of the facility. 3. The administrator, or in his/her absence the Director of Nursing, Assistant Director of Nursing, or Charge nurse, in that order, must relieve the employee of his/her duty without pay until the investigation is complete. If the allegation is substantiated, the employee will be terminated immediately. 4. if the result of the investigation is in favor of the employee or is inconclusive, the employee will be paid regular wages during the time he/she was relieved from duty. Reporting 1. Notify the Administrator, DON, or Shift Supervisor/Charge Nurse immediately if suspected abuse, neglect, mistreatment, or misappropriation of property occurs. 2. Notify the appropriate State agency(s) after identification of alleged incident. initiate process according to State-specific regulations. 3. Person(s) initially identifying potential abuse, neglect, mistreatment, and/or misappropriation of property are accountable to report to proper chain of command. 4. Notify the legal guardian, spouse, or responsible family members/ significant other of the alleged or suspected abuse, neglect, mistreatment, and/or misappropriation of property. 5. Notify the physician of allegation and investigation. 6. Initiate contact with local law enforcement, immediately, when warranted, as required by state law. 7. Report results of investigation to the proper authorities as required by State law. 8. Follow up with resident/patient results and outcome of investigation and ensure their feelings of safety and security. Review of facility policy, titled Reporting Abuse, Neglect, and Mistreatment, with no date, revealed the following: Alleged, suspected or observed abuse, neglect or mistreatment of a resident or patient or his/her belongings are thoroughly investigated by the Administrator and/or the Director of Nursing. Alleged, suspected or observed violations are reported immediately to the Administrator, Regional [NAME] President, Medical Director, VP Quality & Compliance, Ombudsman, State Health and Environmental Departments, and all other officials required by state law. In all cases, the Administrator or Director of Nursing will immediately notify the resident or patient's legal guardian, family member, responsible party or significant other of the alleged, suspected or observed abuse, neglect or mistreatment. If a direct caregiver is observed, suspected or alleged to have engaed in abuse, neglect or mistreatment of resident/patient belongings, the caregiver will be relieved of duty and placed under investigative suspension by the Administrator, Director of Nursing or Nursing Supervisor, until the investigation is completed . Review of a facesheet for Resident #1, dated 03/27/2024, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses including: altered mental status, chronic pain, speech disturbances, muscle weakness, contracture of muscle (multiple sites), and dysphagia (difficulty swallowing). Review of Resident #1's Quarterly MDS, dated [DATE], revealed he had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate impairment. Resident #1's behavior and functional status revealed he had no physical or verbal behavioral symptoms directed towards others exhibited, he had impairment to both sides of upper and lower extremities and required substantial/maximal assistance with toileting hygiene. Review of Resident #1's care plan, revised 03/05/2024, revealed he had interventions in place for history of aggression with staff and dementia with behaviors to include: stopping and returning if resident becomes agitated, approach resident in a calm manner, talk while providing care, when resident becomes agitated intervene before agitation escalates by guiding away from source of distress, engaging calmly in conversation, approach at a later time if response is aggressive, and encourage resident to express feelings appropriately. Review of incident statement, dated 02/28/2024, signed by Administrator, revealed the following: Informed by [CNA C] that another [HA] had informed her that she had witnessed abuse by another staff member [CNA A]. Called [HA] to confirm statement. [HA] stated she was in the resident's room [Resident #1], with [CNA A] during incontinent care the resident punched her [HA] in the stomach, and she stepped back away from him. Then [CNA A] rolled resident over to his back and hollered motherfucker, do not do that again while slapping him in the forehead several times. The resident then swung at [CNA A]. When asked why [HA] did not report to supervisor immediately, she stated because she was scared of [CNA A] and that she had a look when she turned to look at her and she was upset about everything. Did not tell anyone until the next day when she told the other CNA, who reported to me. Review of witness statement, dated 02/28/2024 at 3:00 p.m., signed by CNA C, revealed the following: On 2-27-24 at approx. 6:30 pm, staff member [HA] told me that on Monday night while doing incontinent care, [Resident #1] had punched her in the stomach. HA said she stepped back and [CNA A] rolled [Resident #1] over and slapped him in the face and grabbed his hand. She said this scared her and she didn't know what to do. I told her she needed to go and report this to DON or Admin. She said she felt that she could come to me and that she didn't want to get anyone in trouble. [HA] said she had called her family member to talk about the situation. Review of witness statement, dated 02/28/2028, signed by HA, revealed the following: [HA] interviewed about incident that occurred with (Resident #1). She stated that on Tuesday morn (morning) at 3am (3:00 a.m.) during incontinent rounds, she and co-worker [CNA A] went into [Resident #1's] room. When they first went in the room he drew is fist back. [HA] stated she tried to talk him down because usually this will work. They began performing care and rolled him over toward her (she was between the bed and the wall) but he started hitting her in the stomach. [CNA A] then rolled him back over and slapped him more than once on the forehead. [HA] stated [CNA A] said I'll beat the f--- out of you. You know you laying in the bed and can't move. They finished the care and put a brief on him and left the room. After this [HA] said she went outside because she was upset. She stated she thought about leaving but didn't, she came back inside to complete shift. She didn't go to charge nurse at that time. Stated she was afraid she would be in trouble as well. This was the last round of the evening so nothing else occurred with other residents and [CNA A]. [HA] stated she went back into [Resident #1's] room and gave him a hug. He was fine and didn't seem upset. Stated she knows she should have said something but that she had never seen anything like this and it just scared her. Tuesday 2-27-24 at 6:30pm [HA] told [CNA C] what had occurred with [Resident #1] that morning during her shift. Review of witness statement, dated 02/28/2024, signed by LVN D, revealed the following: DON interviewed [LVN D] regarding alleged abuse incident that occurred with Resident #1. [LVN D] stated aides did not tell her that [Resident #1] hit [HA] or anything else that occurred after that point. She stated they told her that [Resident #1] was being difficult during incontinent care. The time reported to her was between 3am (3:00 a.m.) and 4am (4:00 a.m.) so it would have been their last round with him that night. Review of Associate Disciplinary Memorandums, dated 02/28/2024, revealed CNA A, HA, and CNA C were suspended pending investigation. CNA C and HA were reinstated and received training on abuse. CNA C received formal written disciplinary action for failing to report abuse. Supervisors Comments revealed CNA C was aware of reporting guidelines, understands not to wait if she believed anything has occurred, and stated she told employee to report to DON or Admin. CNA A was discharged effective 03/05/2024 due to employee confirming allegation of incident that warrants termination. Review of witness statement, dated 02/29/2024, signed by CNA A, revealed the following: [CNA A] interviewed in person by DON and Administrator on 2-29-24 at 10:15am. She was off on 2-28-24 when the investigation initiated and we were unable to reach her until late that evening. The meeting was set up for Thursday 2-29-24 to obtain statement and her version of events that occurred on 2-27-24 at 3am with [Resident #1]. STATEMENT: We went in to do incontinent care on [Resident #1]. He punched [HA] in the stomach. I tried to hold him down with his hands on his chest so he couldn't hit her anymore. When she was cleaning between his legs he tried to punch me. I told him: stop this, this is not how things go. We don't hit women, it does not work that way. [HA] said my doesn't even hit me. He continued to try to hit us. I did not hit him, it wouldn't do any good anyway. So I just held him down. I did not tell the nurse at that time, she wouldn't do anything anyway. I thought [HA] was going to tell her. No one should have to go into a room and wonder if they are going to get hit. It was self defense. Follow up: Admin asked about the curse words that were alleged. Asked her if she used the f-word. stated that she did not curse . maybe the worst she said was damn don't do this. Admin asked about the allegation that she slapped on the forehead several times and she said well yes she did do that just to get him to stop hitting. I asked her to demonstrate and she slapped her forehead several times with her fingers, palm down in front of nose. Admin asked about why she didn't just back away when he was combative as this could be one approach - she stated they just had to get the job done. Review of personnel record for CNA A revealed she was hired on 12/06/2018 and signed and dated policy for reporting abuse, responsibility for reporting abuse, and Senate [NAME] 9 employee acknowledgement that mistreatment or abuse will not be tolerated and will be subject to immediate discharge. Review of personnel record for HA revealed she was hired on 12/28/2023 and signed and dated policy for reporting abuse and responsibility for reporting abuse. Review of audit, titled Staff Awareness on What Constitutes Abuse, dated 01/25/2024, revealed CNA A and HA met criteria for knowing when and who to report allegations of abuse. Audit revealed met criteria for knowledge of reporting physical abuse immediately to the Administrator. Review of training records, dated 3/5/2024, completed by CNA A, revealed the following education was provided: Preventing, Recognizing, and Reporting Abuse, and Managing Anger completed on 08/13/2023 and Communication and People with Dementia completed on 02/05/2024. Review of training records, dated 3/1/2024, completed by CNA C, reveled the following education was provided: Communication and People with Dementia completed on 1/31/2024, Managing Anger on 08/09/2023, and Preventing, Recognizing, and Reporting Abuse on 03/03/2024. Review of Provider Investigation Report, dated 03/06/2024, revealed the following: .Description of the Allegation: Employee (HA) alleged that resident (Resident #1) had hit her in the stomach while they were performing incontinent care. (CNA A) had cursed at the resident telling him not to do that and slapped him on the forehead several times . Description of assessment . Resident had no physical injuries. His forehead had no discoloration or bruising noted. No redness or complaints of pain. Resident was interviewed as to the allegation and denied anything had occurred. His behavior was normal for his baseline. He has been doing his normal routine with no concerns from staff. DON checked daily for three days and assessed his mood and behaviors with no changes noted . Provider Response: . Upon receipt of allegations, employees involved were suspended immediately, including the individual making the allegation, pending outcome of investigation. Resident was assessed for injuries and evaluated for his feeling of safety, and any need for intervention as a result of the alleged incident. Resident had no physical injuries and denied the occurrence of the incident, stating he had no complaints about the staff. Residents responsible party, position and investment were notified. Police were called to report the allegation . Investigation Summary: . Resident #1 was the first with no injuries noted. He also denied that anything had occurred regarding an employee slapping him and cursing at him. His roommate, who was alert and oriented, was interviewed about if he witnessed or heard anything at the time this was alleged to occur, he stated that he didn't know of anything out of the ordinary but that (Resident #1) was all the time fighting the girls. Resident's roommate, (Resident #2), was asked about his feeling of safety and if anything had ever happened to him, as far as staff mistreating him, during his stay here and he stated no everything was fine. Responsible party of (Resident #1) was notified of allegation and to determine if he had shared anything related to allegation or any other time regarding his feeling of safety and well-being. She was not aware of anything abnormal or anything with him. Staff working the night of the alleged abuse were interviewed and were not aware of anything out of the ordinary occurring (with exception of the witness who reported the incident). (CNA A), alleged perpetrator, was interviewed. (CNA A) Stated that after (Resident #1) punched (HA) in this stomach, she (CNA A) had held him down so he could not hit her anymore. (CNA A) Stated that he had also tried to hit her. She denied cursing at him but said she told him this was unacceptable-that you cannot hit women. initially she denied slapping him but when asked by administrator if she had hit him on the forehead she stated she only did it to get him to stop hitting them. She demonstrated the same motion that was displayed by (HA) during her interview. Fingertips slapping forehead, palm down in front of face. Residents cared for by (CNA A) were interviewed to determine if they felt safe and if there were any other issues to report regarding staff treatment of residence. (Resident #1) continues to display no negative effects related to the incident. (CNA A) confirmed the allegation and was terminated from employment .Physician, family, police, and Ombudsman were notified of the incident. Investigation Findings: Confirmed. Provider Action Taken Post Investigation: Employee (CNA A) was terminated post investigation. (CNA C) and (HA) were suspended but reinstated after receiving additional training on abuse/neglect, reporting guidelines, and how to handle dementia and combative residence. Facility staff received in service training on abuse neglect, handling them into residence, and how they handle combative residents. Post test given and follow up on any staff lacking proper knowledge during testing related to abuse/neglect. training upon hire, at minimum annually and as needed. Review of Resident #1's progress notes by ADON, dated 02/29/2024, revealed Resident #1 head to toe skin assessment was performed with no skin alterations noted. Review of Provider Investigation Report, dated 3/6/2024, revealed monitoring statements signed by the Administrator for Resident #1, dated between 02/28/2024 and 03/01/2024 The monitoring statements signed by the Administrator revealed Resident #1 had exhibited no physical or psychosocial harm, had no indication of stress, no behaviors, he was socializing normally, and had no concerns. Review of statement, dated 03/06/2024, signed by Administrator, revealed Ombudsman spoke with Resident #1 that told her They fired her and slapped his head a few times when asked what happened and he denied that it hurt and had no further concerns. Review of inservices and employee roster provided by Administrator and DON, dated between 02/28/2024 and 03/01/2024 revealed all nursing staff received education on abuse and reporting. During an interview with the Administrator and DON on 03/26/2024 at 1:42 p.m., the Administrator said she was the abuse coordinator and was aware of a self-reported incident of abuse concerning Resident #1. The Administrator said the aide admitted that she did pat his head lightly to try to keep him from hitting her and they terminated her. She said the resident showed no signs of psychosocial or physical harm when the Administrator monitored him for three days following report of incident documented in her monitoring statements in provider investigation report. During an interview on 03/26/2024 at 3:05 p.m., the Ombudsman said Resident #1 was physically abused with two staff in the room and the Ombudsman had spoken with his RP and she was okay with how the facility was handling it. The Ombudsman said he has a speech impediment and was not aware of any skin changes or bruising. During an interview on 03/26/2024 at 3:26 p.m., PTA said he did not suspect abuse at this facility and had received training on abuse and handling dementia residents via in-services. PTA said if he suspected abuse he would report it to the ADM immediately. PTA said Resident #1 was doing good and has known him for 6 or 7 years and has had no change in condition. PTA said he can have behaviors but that he has known him for a long time but that they had a good relationship and he knew how to talk and approach him to maintain his trust. PTA said Resident #1 liked coming to therapy and doing his legs and had never had any concerns with staff being abusive or rough with him. During an interview and observation on 03/26/2024 at 4:20 p.m., Resident #1 said he was doing good and that everyone was nice to him at the facility. Resident #1 said he had no concerns. The Resident appeared well groomed, free from apparent injury, pleasant, and in no distress sitting up in wheelchair in his room watching television. During an interview on 03/27/2024 at 11:41 a.m., HA L said she did not suspect abuse, had been trained on abuse, reporting, and dementia residents via in-services, and had been employed at the facility for 2 years. HA L said it was important for resident's care plan to be followed to prevent harm and make sure all residents receive proper care. During an interview on 03/27/2024 at 11:56 a.m., CNA T said she had been employed at the facility for 5 years and did not suspect abuse. CNA T said she had received training on abuse, reporting, and caring for dementia residents. CNA T said if there is a resident that is showing signs or aggression she would try again later after the resident had calmed down and that if she ever witnessed any abuse she would report to the ADM or DON immediately. During an interview via phone on 03/27/2024 at 12:45 p.m., CNA C said The hospitality aide that worked at night came in and said I need to talk to you. She said I don't know what to do [CNA A] slapped the resident in the face twice. I said you should have reported it to the charge nurse. CNA C said HA told her she was scared, and afraid CNA A would retaliate on her if she reported the incident. CNA C said she knew should have reported it then, but she did not report it until the next day to her DON because she had told HA to report it. CNA C said Resident #1 had no injuries or behavior changes and the facility had provided training on abuse and when to report. CNA C said she would report to the DON or ADM any suspected abuse immediately and the abuse coordinator was the Administrator. CNA C felt the facility took care of that situation. CNA C said she had no previous concerns with the care provided by CNA A and believed it was an isolated incident. CNA C said it was important to report abuse immediately to ensure resident safety. During an interview on 03/27/2024 at 1:45 p.m., the Administrator said staff expectation was to report alleged abuse immediately. The Administrator said it was important to report immediately so that residents could be prevented from further harm and to allow the facility to respond to the situation. The Administrator said all staff received education on abuse and reporting. The Administrator said she has conducted a verbal audit check monthly to ensure staff knowledge on abuse, neglect, and reporting. The Administrator said she was the abuse coordinator and was responsible for training on abuse. During an interview via phone on 03/27/2024 at 2:11 p.m., HA said she had been at the facility for 5 months and works on the night shift. HA said she did witness the incident with Resident #1 and said she saw CNA A hit the resident on the face with her fingers on his forehead multiple times, roll him around and heard her tell the resident she could have someone come in to whoop his ass whenever she wanted to with him being in this bed. HA said after that happened CNA A left the room and HA stepped out of the room due to being upset and scared. HA said she returned to the room to finish his care and gave him a hug. HA said he had no injuries and never had any social isolation following the incident. HA said she has taken care of him since then and that he seems to be doing better with no combative behavior and appears happy. HA said the incident happened early in the morning between midnight and 4:00 a.m. HA said she did not know if CNA A worked the next day and that she does not remember working with her. HA said that she knew she should have reported the incident immediately to the abuse coordinator but that it was late and did not have her phone number. HA said she notified another CNA, CNA C, around 6:30 p.m. on 2/27/2024 and that CNA C notified the Administrator immediately. HA said that she had received training on abuse briefly in orientation and that she did receive training following the incident. HA said the abuse coordinator was the Administrator and that it was important for alleged abuse to be reported immediately to her to prevent abuse from occurring and further protect residents from harm. HA said she believed the incident was isolated and had no concerns with CNA A prior to this incident. HA said that CNA A was fired and that she felt the facility handled the situation appropriately. During an interview and record review on 03/27/2024 at 5:28 p.m., the Administrator said her expectations of staff was to report abuse immediately and that if she was notified of the abuse allegation promptly she would have responded the same way by suspending the perpetrator once notified, ensure residents were safe, and assess the resident/victim involved in the incident. The Administrator confirmed via timesheet the perpetrator continued to work the remainder of her shift following the abuse incident as well as the following shift the next day. The Administrator said the perpetrator was showing signs of different behavior and believe she had personal things going on at home that may have contributed to this isolated incident and that the employee had no concerns with her background check and had been working at the facility for 5 years. The Administrator and DON said they were responsible for training staff on abuse, reporting, and their expectations of staff when caring for aggressive residents included to approach in a calm manner, to stop what they are doing and come back later once the resident has calmed down. The Administrator said she had conducted an audit check of nursing staff to ensure knowledge of abuse, reporting, and handling residents with dementia and she would continue to conduct verbal audit checks monthly to verify knowledge of training. During an interview via phone on 03/28/2024 at 11:23 a.m., Detective K said there have been no warrants issued at this time for CNA A and that she had no criminal history or background indicating history of abusive behavior. Detective K said she was aware Resident #1's family was looking to drop the charges but that ultimately it was up to the district attorney's office. Detective K said the police report has not been completed because they were waiting on medical records to determine Resident #1's mental and physical capabilities. During state office call on 03/27/2024 at 4:35 p.m., an Immediate Jeopardy (IJ) Past Non-Compliance (PNC) was determined. The administrator was notified of IJ PNC on 03/27/2024 at 5:28 p.m. due to the above failures. The administrator was provided with the IJ template on 03/27/2024 at 5:28 p.m. The surveyor confirmed PNC had been implemented sufficiently to remove the Immediate Jeopardy by: - Facility implementation of monitoring resident daily for three days for psychosocial harm. - Facility notification of abuse incident to responsible parties, MD, police, Ombudsman, and HHSC. - Completion of head-to-toe skin assessment on resident/victim. - Completion of in-services on abuse, reporting, dementia and approaching combative residents. - Completion of safe surveys on residents. - Suspension of involved staff pending outcome. - Completion of formal disciplinary actions for involved staff. - Termination of confirmed perpetrator. The noncompliance was identified as PNC. The IJ began on 02/27/2024 and ended on 03/05/2024. The facility had corrected the noncompliance before the survey began.

Based on observations, interviews, and record reviews, the facility failed to implement policies and procedures that prohibit and prevent abuse, neglect, and exploitation of resident to ensure residents were free from physical abuse for one of four residents (Resident #1) reviewed for abuse. 1. The facility failed to prevent physical abuse of Resident #1 who was hit on the head by CNA A on 02/27/2024. 2. The facility failed to ensure CNA A was not allowed to work after the allegation of abuse had been reported The noncompliance was identified as PNC. The IJ began on 02/27/2024 and ended on 03/05/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for physical harm, psychosocial harm, unsafe environment, and further abuse. Findings included: Review of facility policy, titled Abuse/Neglect Policy & Procedure, with no date, revealed the following: PREVENTION AND REPORTING: 1. The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. 2. The facility has designed and implemented processes, which strives to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. 3. The facility has implemented the following processes in an effort to provide residents/patients and staff a safe and comfortable environment. 4. Administrator is the Abuse Coordinator. The Administrator considers the Director of Nursing a designee for reporting and investigation of alleged abuse. In their absence, Admin and DON can appoint appropriate supervisory personnel to initiate investigation. 5. The Administrator and Director of Nursing are responsible for investigation and reporting. They are also ultimately responsible for the following as they relate to abuse, neglect, and/or misappropriation of property standards and procedures: Ongoing monitoring Reporting Investigation Tracking and trending 6. Implementation and ongoing monitoring consist of the following: Screening Training Prevention Identification Protection Investigation Reporting DEFINITIONS: Abuse Willful infliction of injury Unreasonable confinement Intimidation with resulting physical harm or mental anguish Punishment with resulting physical harm or pain or mental health Deprivation by the individual, including a caretaker, of good or service that is necessary to attain or maintain physical, mental, and psychosocial well being . Physical Abuse Includes hitting, slapping, pinching, scratching, spitting, holding, roughly, etc. It also includes controlling behavior through corporal punishment . Training 1. Provide training for new employees through orientation and with ongoing training programs. Training will include, but not limited to: Definitions of abuse, neglect, mistreatment, and misappropriation of property. Identification of abuse . Utilization of appropriate interventions to deal with aggressive and/or catastrophic (detrimental) reactions of residents/patients. How to provide protection for residents/patients How to investigate and report incidents of abuse, neglect, mistreatment, and misappropriation of property. Prevention of abuse, neglect, mistreatment, and misappropriation of property including, but not limited to, recognizing signs of burnout, frustration and stress . Prevention Ensure that prevention techniques are implemented in the facility including, but not limited to, ongoing supervision of employees through visual observation of care delivery and recognition of signs of burnout, frustration, and stress. 1. Identify, correct, and intervene in situations where abuse, neglect, and/or mistreatment are more likely to occur. This includes, but is not limited to, identification/analysis of: Secluded areas of the facility Sufficient staffing on each shift to meet the needs of the residents/patients Assigned staff demonstrating knowledge of individual resident/patient needs Sufficient and appropriate supervisory staff to identify inappropriate behaviors Residents with needs and behaviors which might lead to conflict or neglect 2. Encourage residents/patients and families to report concerns, incident, and grievances without fear of retribution. Provide feedback regarding the concerns that have been expressed. 3. Instruct staff that they are required to report resident concerns, incidents, and grievances. Identification 1. Identify events, such as suspicious bruising of residents/ patients, occurrences, patterns, and trends that mat constitute abuse, neglect, and/or mistreatment and investigate . 3. instruct staff, resident/patient, family call my visitor, etc. to report immediately, without fear of reprisal, any knowledge or suspicion of suspected abuse, neglect, mistreatment, and/or misappropriation of property. Protection 1. provide for the immediate safety of the resident patient upon identification of suspected abuse, neglect, mistreatment, and/or this appropriation of property. Means of providing protection include, but are not limited to: Moving resident/patient to another room or unit Provide 1:1 monitoring as appropriate Immediate suspension of suspected employee(s) pending outcome of the investigation . 2. Initiate behavior crisis management interventions, as applicable . 2. Administrator and/or designee will initiate the Investigation. The investigation should be thorough with witness statements from staff, resident, family members who are interview-able and have information regarding the allegation . Employee Suspension from Duty 1. Any time an allegation is made involving abuse, neglect, or mistreatment of a resident/patient which names a specific employee, laws and regulations are specific about protecting all residents/patients from harm / potential harm farmer which means suspending the employee until the completion of the investigation. 2. The employee is not to remain on duty, and is not to be assigned to any other area of the facility. 3. The administrator, or in his/her absence the Director of Nursing, Assistant Director of Nursing, or Charge nurse, in that order, must relieve the employee of his/her duty without pay until the investigation is complete. If the allegation is substantiated, the employee will be terminated immediately. 4. if the result of the investigation is in favor of the employee or is inconclusive, the employee will be paid regular wages during the time he/she was relieved from duty. Reporting 1. Notify the Administrator, DON, or Shift Supervisor/Charge Nurse immediately if suspected abuse, neglect, mistreatment, or misappropriation of property occurs. 2. Notify the appropriate State agency(s) after identification of alleged incident. initiate process according to State-specific regulations. 3. Person(s) initially identifying potential abuse, neglect, mistreatment, and/or misappropriation of property are accountable to report to proper chain of command. 4. Notify the legal guardian, spouse, or responsible family members/ significant other of the alleged or suspected abuse, neglect, mistreatment, and/or misappropriation of property. 5. Notify the physician of allegation and investigation. 6. Initiate contact with local law enforcement, immediately, when warranted, as required by state law. 7. Report results of investigation to the proper authorities as required by State law. 8. Follow up with resident/patient results and outcome of investigation and ensure their feelings of safety and security. Review of facility policy, titled Reporting Abuse, Neglect, and Mistreatment, with no date, revealed the following: Alleged, suspected or observed abuse, neglect or mistreatment of a resident or patient or his/her belongings are thoroughly investigated by the Administrator and/or the Director of Nursing. Alleged, suspected or observed violations are reported immediately to the Administrator, Regional [NAME] President, Medical Director, VP Quality & Compliance, Ombudsman, State Health and Environmental Departments, and all other officials required by state law. In all cases, the Administrator or Director of Nursing will immediately notify the resident or patient's legal guardian, family member, responsible party or significant other of the alleged, suspected or observed abuse, neglect or mistreatment. If a direct caregiver is observed, suspected or alleged to have engaed in abuse, neglect or mistreatment of resident/patient belongings, the caregiver will be relieved of duty and placed under investigative suspension by the Administrator, Director of Nursing or Nursing Supervisor, until the investigation is completed . Review of a facesheet for Resident #1, dated 03/27/2024, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses including: altered mental status, chronic pain, speech disturbances, muscle weakness, contracture of muscle (multiple sites), and dysphagia (difficulty swallowing). Review of Resident #1's Quarterly MDS, dated [DATE], revealed he had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate impairment. Resident #1's behavior and functional status revealed he had no physical or verbal behavioral symptoms directed towards others exhibited, he had impairment to both sides of upper and lower extremities and required substantial/maximal assistance with toileting hygiene. Review of Resident #1's care plan, revised 03/05/2024, revealed he had interventions in place for history of aggression with staff and dementia with behaviors to include: stopping and returning if resident becomes agitated, approach resident in a calm manner, talk while providing care, when resident becomes agitated intervene before agitation escalates by guiding away from source of distress, engaging calmly in conversation, approach at a later time if response is aggressive, and encourage resident to express feelings appropriately. Review of incident statement, dated 02/28/2024, signed by Administrator, revealed the following: Informed by [CNA C] that another [HA] had informed her that she had witnessed abuse by another staff member [CNA A]. Called [HA] to confirm statement. [HA] stated she was in the resident's room [Resident #1], with [CNA A] during incontinent care the resident punched her [HA] in the stomach, and she stepped back away from him. Then [CNA A] rolled resident over to his back and hollered motherfucker, do not do that again while slapping him in the forehead several times. The resident then swung at [CNA A]. When asked why [HA] did not report to supervisor immediately, she stated because she was scared of [CNA A] and that she had a look when she turned to look at her and she was upset about everything. Did not tell anyone until the next day when she told the other CNA, who reported to me. Review of witness statement, dated 02/28/2024 at 3:00 p.m., signed by CNA C, revealed the following: On 2-27-24 at approx. 6:30 pm, staff member [HA] told me that on Monday night while doing incontinent care, [Resident #1] had punched her in the stomach. HA said she stepped back and [CNA A] rolled [Resident #1] over and slapped him in the face and grabbed his hand. She said this scared her and she didn't know what to do. I told her she needed to go and report this to DON or Admin. She said she felt that she could come to me and that she didn't want to get anyone in trouble. [HA] said she had called her family member to talk about the situation. Review of witness statement, dated 02/28/2028, signed by HA, revealed the following: [HA] interviewed about incident that occurred with (Resident #1). She stated that on Tuesday morn (morning) at 3am (3:00 a.m.) during incontinent rounds, she and co-worker [CNA A] went into [Resident #1's] room. When they first went in the room he drew is fist back. [HA] stated she tried to talk him down because usually this will work. They began performing care and rolled him over toward her (she was between the bed and the wall) but he started hitting her in the stomach. [CNA A] then rolled him back over and slapped him more than once on the forehead. [HA] stated [CNA A] said I'll beat the f--- out of you. You know you laying in the bed and can't move. They finished the care and put a brief on him and left the room. After this [HA] said she went outside because she was upset. She stated she thought about leaving but didn't, she came back inside to complete shift. She didn't go to charge nurse at that time. Stated she was afraid she would be in trouble as well. This was the last round of the evening so nothing else occurred with other residents and [CNA A]. [HA] stated she went back into [Resident #1's] room and gave him a hug. He was fine and didn't seem upset. Stated she knows she should have said something but that she had never seen anything like this and it just scared her. Tuesday 2-27-24 at 6:30pm [HA] told [CNA C] what had occurred with [Resident #1] that morning during her shift. Review of witness statement, dated 02/28/2024, signed by LVN D, revealed the following: DON interviewed [LVN D] regarding alleged abuse incident that occurred with Resident #1. [LVN D] stated aides did not tell her that [Resident #1] hit [HA] or anything else that occurred after that point. She stated they told her that [Resident #1] was being difficult during incontinent care. The time reported to her was between 3am (3:00 a.m.) and 4am (4:00 a.m.) so it would have been their last round with him that night. Review of Associate Disciplinary Memorandums, dated 02/28/2024, revealed CNA A, HA, and CNA C were suspended pending investigation. CNA C and HA were reinstated and received training on abuse. CNA C received formal written disciplinary action for failing to report abuse. Supervisors Comments revealed CNA C was aware of reporting guidelines, understands not to wait if she believed anything has occurred, and stated she told employee to report to DON or Admin. CNA A was discharged effective 03/05/2024 due to employee confirming allegation of incident that warrants termination. Review of witness statement, dated 02/29/2024, signed by CNA A, revealed the following: [CNA A] interviewed in person by DON and Administrator on 2-29-24 at 10:15am. She was off on 2-28-24 when the investigation initiated and we were unable to reach her until late that evening. The meeting was set up for Thursday 2-29-24 to obtain statement and her version of events that occurred on 2-27-24 at 3am with [Resident #1]. STATEMENT: We went in to do incontinent care on [Resident #1]. He punched [HA] in the stomach. I tried to hold him down with his hands on his chest so he couldn't hit her anymore. When she was cleaning between his legs he tried to punch me. I told him: stop this, this is not how things go. We don't hit women, it does not work that way. [HA] said my doesn't even hit me. He continued to try to hit us. I did not hit him, it wouldn't do any good anyway. So I just held him down. I did not tell the nurse at that time, she wouldn't do anything anyway. I thought [HA] was going to tell her. No one should have to go into a room and wonder if they are going to get hit. It was self defense. Follow up: Admin asked about the curse words that were alleged. Asked her if she used the f-word. stated that she did not curse . maybe the worst she said was damn don't do this. Admin asked about the allegation that she slapped on the forehead several times and she said well yes she did do that just to get him to stop hitting. I asked her to demonstrate and she slapped her forehead several times with her fingers, palm down in front of nose. Admin asked about why she didn't just back away when he was combative as this could be one approach - she stated they just had to get the job done. Review of personnel record for CNA A revealed she was hired on 12/06/2018 and signed and dated policy for reporting abuse, responsibility for reporting abuse, and Senate [NAME] 9 employee acknowledgement that mistreatment or abuse will not be tolerated and will be subject to immediate discharge. Review of personnel record for HA revealed she was hired on 12/28/2023 and signed and dated policy for reporting abuse and responsibility for reporting abuse. Review of audit, titled Staff Awareness on What Constitutes Abuse, dated 01/25/2024, revealed CNA A and HA met criteria for knowing when and who to report allegations of abuse. Audit revealed met criteria for knowledge of reporting physical abuse immediately to the Administrator. Review of training records, dated 3/5/2024, completed by CNA A, revealed the following education was provided: Preventing, Recognizing, and Reporting Abuse, and Managing Anger completed on 08/13/2023 and Communication and People with Dementia completed on 02/05/2024. Review of training records, dated 3/1/2024, completed by CNA C, reveled the following education was provided: Communication and People with Dementia completed on 1/31/2024, Managing Anger on 08/09/2023, and Preventing, Recognizing, and Reporting Abuse on 03/03/2024. Review of Provider Investigation Report, dated 03/06/2024, revealed the following: .Description of the Allegation: Employee (HA) alleged that resident (Resident #1) had hit her in the stomach while they were performing incontinent care. (CNA A) had cursed at the resident telling him not to do that and slapped him on the forehead several times . Description of assessment . Resident had no physical injuries. His forehead had no discoloration or bruising noted. No redness or complaints of pain. Resident was interviewed as to the allegation and denied anything had occurred. His behavior was normal for his baseline. He has been doing his normal routine with no concerns from staff. DON checked daily for three days and assessed his mood and behaviors with no changes noted . Provider Response: . Upon receipt of allegations, employees involved were suspended immediately, including the individual making the allegation, pending outcome of investigation. Resident was assessed for injuries and evaluated for his feeling of safety, and any need for intervention as a result of the alleged incident. Resident had no physical injuries and denied the occurrence of the incident, stating he had no complaints about the staff. Residents responsible party, position and investment were notified. Police were called to report the allegation . Investigation Summary: . Resident #1 was the first with no injuries noted. He also denied that anything had occurred regarding an employee slapping him and cursing at him. His roommate, who was alert and oriented, was interviewed about if he witnessed or heard anything at the time this was alleged to occur, he stated that he didn't know of anything out of the ordinary but that (Resident #1) was all the time fighting the girls. Resident's roommate, (Resident #2), was asked about his feeling of safety and if anything had ever happened to him, as far as staff mistreating him, during his stay here and he stated no everything was fine. Responsible party of (Resident #1) was notified of allegation and to determine if he had shared anything related to allegation or any other time regarding his feeling of safety and well-being. She was not aware of anything abnormal or anything with him. Staff working the night of the alleged abuse were interviewed and were not aware of anything out of the ordinary occurring (with exception of the witness who reported the incident). (CNA A), alleged perpetrator, was interviewed. (CNA A) Stated that after (Resident #1) punched (HA) in this stomach, she (CNA A) had held him down so he could not hit her anymore. (CNA A) Stated that he had also tried to hit her. She denied cursing at him but said she told him this was unacceptable-that you cannot hit women. initially she denied slapping him but when asked by administrator if she had hit him on the forehead she stated she only did it to get him to stop hitting them. She demonstrated the same motion that was displayed by (HA) during her interview. Fingertips slapping forehead, palm down in front of face. Residents cared for by (CNA A) were interviewed to determine if they felt safe and if there were any other issues to report regarding staff treatment of residence. (Resident #1) continues to display no negative effects related to the incident. (CNA A) confirmed the allegation and was terminated from employment .Physician, family, police, and Ombudsman were notified of the incident. Investigation Findings: Confirmed. Provider Action Taken Post Investigation: Employee (CNA A) was terminated post investigation. (CNA C) and (HA) were suspended but reinstated after receiving additional training on abuse/neglect, reporting guidelines, and how to handle dementia and combative residence. Facility staff received in service training on abuse neglect, handling them into residence, and how they handle combative residents. Post test given and follow up on any staff lacking proper knowledge during testing related to abuse/neglect. training upon hire, at minimum annually and as needed. Review of Resident #1's progress notes by ADON, dated 02/29/2024, revealed Resident #1 head to toe skin assessment was performed with no skin alterations noted. Review of Provider Investigation Report, dated 3/6/2024, revealed monitoring statements signed by the Administrator for Resident #1, dated between 02/28/2024 and 03/01/2024 The monitoring statements signed by the Administrator revealed Resident #1 had exhibited no physical or psychosocial harm, had no indication of stress, no behaviors, he was socializing normally, and had no concerns. Review of statement, dated 03/06/2024, signed by Administrator, revealed Ombudsman spoke with Resident #1 that told her They fired her and slapped his head a few times when asked what happened and he denied that it hurt and had no further concerns. Review of inservices and employee roster provided by Administrator and DON, dated between 02/28/2024 and 03/01/2024 revealed all nursing staff received education on abuse and reporting. During an interview with the Administrator and DON on 03/26/2024 at 1:42 p.m., the Administrator said she was the abuse coordinator and was aware of a self-reported incident of abuse concerning Resident #1. The Administrator said the aide admitted that she did pat his head lightly to try to keep him from hitting her and they terminated her. She said the resident showed no signs of psychosocial or physical harm when the Administrator monitored him for three days following report of incident documented in her monitoring statements in provider investigation report. During an interview on 03/26/2024 at 3:05 p.m., the Ombudsman said Resident #1 was physically abused with two staff in the room and the Ombudsman had spoken with his RP and she was okay with how the facility was handling it. The Ombudsman said he has a speech impediment and was not aware of any skin changes or bruising. During an interview on 03/26/2024 at 3:26 p.m., PTA said he did not suspect abuse at this facility and had received training on abuse and handling dementia residents via in-services. PTA said if he suspected abuse he would report it to the ADM immediately. PTA said Resident #1 was doing good and has known him for 6 or 7 years and has had no change in condition. PTA said he can have behaviors but that he has known him for a long time but that they had a good relationship and he knew how to talk and approach him to maintain his trust. PTA said Resident #1 liked coming to therapy and doing his legs and had never had any concerns with staff being abusive or rough with him. During an interview and observation on 03/26/2024 at 4:20 p.m., Resident #1 said he was doing good and that everyone was nice to him at the facility. Resident #1 said he had no concerns. The Resident appeared well groomed, free from apparent injury, pleasant, and in no distress sitting up in wheelchair in his room watching television. During an interview on 03/27/2024 at 11:41 a.m., HA L said she did not suspect abuse, had been trained on abuse, reporting, and dementia residents via in-services, and had been employed at the facility for 2 years. HA L said it was important for resident's care plan to be followed to prevent harm and make sure all residents receive proper care. During an interview on 03/27/2024 at 11:56 a.m., CNA T said she had been employed at the facility for 5 years and did not suspect abuse. CNA T said she had received training on abuse, reporting, and caring for dementia residents. CNA T said if there is a resident that is showing signs or aggression she would try again later after the resident had calmed down and that if she ever witnessed any abuse she would report to the ADM or DON immediately. During an interview via phone on 03/27/2024 at 12:45 p.m., CNA C said The hospitality aide that worked at night came in and said I need to talk to you. She said I don't know what to do [CNA A] slapped the resident in the face twice. I said you should have reported it to the charge nurse. CNA C said HA told her she was scared, and afraid CNA A would retaliate on her if she reported the incident. CNA C said she knew should have reported it then, but she did not report it until the next day to her DON because she had told HA to report it. CNA C said Resident #1 had no injuries or behavior changes and the facility had provided training on abuse and when to report. CNA C said she would report to the DON or ADM any suspected abuse immediately and the abuse coordinator was the Administrator. CNA C felt the facility took care of that situation. CNA C said she had no previous concerns with the care provided by CNA A and believed it was an isolated incident. CNA C said it was important to report abuse immediately to ensure resident safety. During an interview on 03/27/2024 at 1:45 p.m., the Administrator said staff expectation was to report alleged abuse immediately. The Administrator said it was important to report immediately so that residents could be prevented from further harm and to allow the facility to respond to the situation. The Administrator said all staff received education on abuse and reporting. The Administrator said she has conducted a verbal audit check monthly to ensure staff knowledge on abuse, neglect, and reporting. The Administrator said she was the abuse coordinator and was responsible for training on abuse. During an interview via phone on 03/27/2024 at 2:11 p.m., HA said she had been at the facility for 5 months and works on the night shift. HA said she did witness the incident with Resident #1 and said she saw CNA A hit the resident on the face with her fingers on his forehead multiple times, roll him around and heard her tell the resident she could have someone come in to whoop his ass whenever she wanted to with him being in this bed. HA said after that happened CNA A left the room and HA stepped out of the room due to being upset and scared. HA said she returned to the room to finish his care and gave him a hug. HA said he had no injuries and never had any social isolation following the incident. HA said she has taken care of him since then and that he seems to be doing better with no combative behavior and appears happy. HA said the incident happened early in the morning between midnight and 4:00 a.m. HA said she did not know if CNA A worked the next day and that she does not remember working with her. HA said that she knew she should have reported the incident immediately to the abuse coordinator but that it was late and did not have her phone number. HA said she notified another CNA, CNA C, around 6:30 p.m. on 2/27/2024 and that CNA C notified the Administrator immediately. HA said that she had received training on abuse briefly in orientation and that she did receive training following the incident. HA said the abuse coordinator was the Administrator and that it was important for alleged abuse to be reported immediately to her to prevent abuse from occurring and further protect residents from harm. HA said she believed the incident was isolated and had no concerns with CNA A prior to this incident. HA said that CNA A was fired and that she felt the facility handled the situation appropriately. During an interview and record review on 03/27/2024 at 5:28 p.m., the Administrator said her expectations of staff was to report abuse immediately and that if she was notified of the abuse allegation promptly she would have responded the same way by suspending the perpetrator once notified, ensure residents were safe, and assess the resident/victim involved in the incident. The Administrator confirmed via timesheet the perpetrator continued to work the remainder of her shift following the abuse incident as well as the following shift the next day. The Administrator said the perpetrator was showing signs of different behavior and believe she had personal things going on at home that may have contributed to this isolated incident and that the employee had no concerns with her background check and had been working at the facility for 5 years. The Administrator and DON said they were responsible for training staff on abuse, reporting, and their expectations of staff when caring for aggressive residents included to approach in a calm manner, to stop what they are doing and come back later once the resident has calmed down. The Administrator said she had conducted an audit check of nursing staff to ensure knowledge of abuse, reporting, and handling residents with dementia and she would continue to conduct verbal audit checks monthly to verify knowledge of training. During an interview via phone on 03/28/2024 at 11:23 a.m., Detective K said there have been no warrants issued at this time for CNA A and that she had no criminal history or background indicating history of abusive behavior. Detective K said she was aware Resident #1's family was looking to drop the charges but that ultimately it was up to the district attorney's office. Detective K said the police report has not been completed because they were waiting on medical records to determine Resident #1's mental and physical capabilities. During state office call on 03/27/2024 at 4:35 p.m., an Immediate Jeopardy (IJ) Past Non-Compliance (PNC) was determined. The administrator was notified of IJ PNC on 03/27/2024 at 5:28 p.m. due to the above failures. The administrator was provided with the IJ template on 03/27/2024 at 5:28 p.m. The surveyor confirmed PNC had been implemented sufficiently to remove the Immediate Jeopardy by: - Facility implementation of monitoring resident daily for three days for psychosocial harm. - Facility notification of abuse incident to responsible parties, MD, police, Ombudsman, and HHSC. - Completion of head-to-toe skin assessment on resident/victim. - Completion of in-services on abuse, reporting, dementia and approaching combative residents. - Completion of safe surveys on residents. - Suspension of involved staff pending outcome. - Completion of formal disciplinary actions for involved staff. - Termination of confirmed perpetrator. The noncompliance was identified as PNC. The IJ began on 02/27/2024 and ended on 03/05/2024. The facility had corrected the noncompliance before the survey began.

Based on observations, interviews, and record reviews, the facility failed to ensure that all alleged violations involving abuse or mistreatment were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, to the administrator of the facility and to other officials (including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one of four residents (Resident #1) reviewed for abuse. 1. The facility failed to report physical abuse of Resident #1 to the Administrator immediately following HA witnessing CNA A hit Resident #1 on the head on 02/27/2024 at approximately 3:00 a.m. during incontinent care. 2. HA notified CNA C of a witnessed abuse incident on 02/27/2024 at 6:30 p.m. and CNA C did not report the allegation of abuse to the administrator/abuse prohibition coordinator until 02/28/2024 at approximately 3:00 p.m. The noncompliance was identified as PNC. The IJ began on 02/27/2024 and ended on 03/05/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for physical harm, psychosocial harm, unsafe environment, and further abuse. Findings included: Review of facility policy, titled Abuse/Neglect Policy & Procedure, with no date, revealed the following: PREVENTION AND REPORTING: 1. The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. 2. The facility has designed and implemented processes, which strives to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. 3. The facility has implemented the following processes in an effort to provide residents/patients and staff a safe and comfortable environment. 4. Administrator is the Abuse Coordinator. The Administrator considers the Director of Nursing a designee for reporting and investigation of alleged abuse. In their absence, Admin and DON can appoint appropriate supervisory personnel to initiate investigation. 5. The Administrator and Director of Nursing are responsible for investigation and reporting. They are also ultimately responsible for the following as they relate to abuse, neglect, and/or misappropriation of property standards and procedures: Ongoing monitoring Reporting Investigation Tracking and trending 6. Implementation and ongoing monitoring consist of the following: Screening Training Prevention Identification Protection Investigation Reporting DEFINITIONS: Abuse Willful infliction of injury Unreasonable confinement Intimidation with resulting physical harm or mental anguish Punishment with resulting physical harm or pain or mental health Deprivation by the individual, including a caretaker, of good or service that is necessary to attain or maintain physical, mental, and psychosocial well being . Physical Abuse Includes hitting, slapping, pinching, scratching, spitting, holding, roughly, etc. It also includes controlling behavior through corporal punishment . Training 1. Provide training for new employees through orientation and with ongoing training programs. Training will include, but not limited to: Definitions of abuse, neglect, mistreatment, and misappropriation of property. Identification of abuse . Utilization of appropriate interventions to deal with aggressive and/or catastrophic (detrimental) reactions of residents/patients. How to provide protection for residents/patients How to investigate and report incidents of abuse, neglect, mistreatment, and misappropriation of property. Prevention of abuse, neglect, mistreatment, and misappropriation of property including, but not limited to, recognizing signs of burnout, frustration and stress . Prevention Ensure that prevention techniques are implemented in the facility including, but not limited to, ongoing supervision of employees through visual observation of care delivery and recognition of signs of burnout, frustration, and stress. 1. Identify, correct, and intervene in situations where abuse, neglect, and/or mistreatment are more likely to occur. This includes, but is not limited to, identification/analysis of: Secluded areas of the facility Sufficient staffing on each shift to meet the needs of the residents/patients Assigned staff demonstrating knowledge of individual resident/patient needs Sufficient and appropriate supervisory staff to identify inappropriate behaviors Residents with needs and behaviors which might lead to conflict or neglect 2. Encourage residents/patients and families to report concerns, incident, and grievances without fear of retribution. Provide feedback regarding the concerns that have been expressed. 3. Instruct staff that they are required to report resident concerns, incidents, and grievances. Identification 1. Identify events, such as suspicious bruising of residents/ patients, occurrences, patterns, and trends that mat constitute abuse, neglect, and/or mistreatment and investigate . 3. instruct staff, resident/patient, family call my visitor, etc. to report immediately, without fear of reprisal, any knowledge or suspicion of suspected abuse, neglect, mistreatment, and/or misappropriation of property. Protection 1. provide for the immediate safety of the resident patient upon identification of suspected abuse, neglect, mistreatment, and/or this appropriation of property. Means of providing protection include, but are not limited to: Moving resident/patient to another room or unit Provide 1:1 monitoring as appropriate Immediate suspension of suspected employee(s) pending outcome of the investigation . 2. Initiate behavior crisis management interventions, as applicable . 2. Administrator and/or designee will initiate the Investigation. The investigation should be thorough with witness statements from staff, resident, family members who are interview-able and have information regarding the allegation . Employee Suspension from Duty 1. Any time an allegation is made involving abuse, neglect, or mistreatment of a resident/patient which names a specific employee, laws and regulations are specific about protecting all residents/patients from harm / potential harm farmer which means suspending the employee until the completion of the investigation. 2. The employee is not to remain on duty, and is not to be assigned to any other area of the facility. 3. The administrator, or in his/her absence the Director of Nursing, Assistant Director of Nursing, or Charge nurse, in that order, must relieve the employee of his/her duty without pay until the investigation is complete. If the allegation is substantiated, the employee will be terminated immediately. 4. if the result of the investigation is in favor of the employee or is inconclusive, the employee will be paid regular wages during the time he/she was relieved from duty. Reporting 1. Notify the Administrator, DON, or Shift Supervisor/Charge Nurse immediately if suspected abuse, neglect, mistreatment, or misappropriation of property occurs. 2. Notify the appropriate State agency(s) after identification of alleged incident. initiate process according to State-specific regulations. 3. Person(s) initially identifying potential abuse, neglect, mistreatment, and/or misappropriation of property are accountable to report to proper chain of command. 4. Notify the legal guardian, spouse, or responsible family members/ significant other of the alleged or suspected abuse, neglect, mistreatment, and/or misappropriation of property. 5. Notify the physician of allegation and investigation. 6. Initiate contact with local law enforcement, immediately, when warranted, as required by state law. 7. Report results of investigation to the proper authorities as required by State law. 8. Follow up with resident/patient results and outcome of investigation and ensure their feelings of safety and security. Review of facility policy, titled Reporting Abuse, Neglect, and Mistreatment, with no date, revealed the following: Alleged, suspected or observed abuse, neglect or mistreatment of a resident or patient or his/her belongings are thoroughly investigated by the Administrator and/or the Director of Nursing. Alleged, suspected or observed violations are reported immediately to the Administrator, Regional [NAME] President, Medical Director, VP Quality & Compliance, Ombudsman, State Health and Environmental Departments, and all other officials required by state law. In all cases, the Administrator or Director of Nursing will immediately notify the resident or patient's legal guardian, family member, responsible party or significant other of the alleged, suspected or observed abuse, neglect or mistreatment. If a direct caregiver is observed, suspected or alleged to have engaed in abuse, neglect or mistreatment of resident/patient belongings, the caregiver will be relieved of duty and placed under investigative suspension by the Administrator, Director of Nursing or Nursing Supervisor, until the investigation is completed . Review of a facesheet for Resident #1, dated 03/27/2024, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses including: altered mental status, chronic pain, speech disturbances, muscle weakness, contracture of muscle (multiple sites), and dysphagia (difficulty swallowing). Review of Resident #1's Quarterly MDS, dated [DATE], revealed he had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate impairment. Resident #1's behavior and functional status revealed he had no physical or verbal behavioral symptoms directed towards others exhibited, he had impairment to both sides of upper and lower extremities and required substantial/maximal assistance with toileting hygiene. Review of Resident #1's care plan, revised 03/05/2024, revealed he had interventions in place for history of aggression with staff and dementia with behaviors to include: stopping and returning if resident becomes agitated, approach resident in a calm manner, talk while providing care, when resident becomes agitated intervene before agitation escalates by guiding away from source of distress, engaging calmly in conversation, approach at a later time if response is aggressive, and encourage resident to express feelings appropriately. Review of incident statement, dated 02/28/2024, signed by Administrator, revealed the following: Informed by [CNA C] that another [HA] had informed her that she had witnessed abuse by another staff member [CNA A]. Called [HA] to confirm statement. [HA] stated she was in the resident's room [Resident #1], with [CNA A] during incontinent care the resident punched her [HA] in the stomach, and she stepped back away from him. Then [CNA A] rolled resident over to his back and hollered motherfucker, do not do that again while slapping him in the forehead several times. The resident then swung at [CNA A]. When asked why [HA] did not report to supervisor immediately, she stated because she was scared of [CNA A] and that she had a look when she turned to look at her and she was upset about everything. Did not tell anyone until the next day when she told the other CNA, who reported to me. Review of witness statement, dated 02/28/2024 at 3:00 p.m., signed by CNA C, revealed the following: On 2-27-24 at approx. 6:30 pm, staff member [HA] told me that on Monday night while doing incontinent care, [Resident #1] had punched her in the stomach. HA said she stepped back and [CNA A] rolled [Resident #1] over and slapped him in the face and grabbed his hand. She said this scared her and she didn't know what to do. I told her she needed to go and report this to DON or Admin. She said she felt that she could come to me and that she didn't want to get anyone in trouble. [HA] said she had called her family member to talk about the situation. Review of witness statement, dated 02/28/2028, signed by HA, revealed the following: [HA] interviewed about incident that occurred with (Resident #1). She stated that on Tuesday morn (morning) at 3am (3:00 a.m.) during incontinent rounds, she and co-worker [CNA A] went into [Resident #1's] room. When they first went in the room he drew is fist back. [HA] stated she tried to talk him down because usually this will work. They began performing care and rolled him over toward her (she was between the bed and the wall) but he started hitting her in the stomach. [CNA A] then rolled him back over and slapped him more than once on the forehead. [HA] stated [CNA A] said I'll beat the f--- out of you. You know you laying in the bed and can't move. They finished the care and put a brief on him and left the room. After this [HA] said she went outside because she was upset. She stated she thought about leaving but didn't, she came back inside to complete shift. She didn't go to charge nurse at that time. Stated she was afraid she would be in trouble as well. This was the last round of the evening so nothing else occurred with other residents and [CNA A]. [HA] stated she went back into [Resident #1's] room and gave him a hug. He was fine and didn't seem upset. Stated she knows she should have said something but that she had never seen anything like this and it just scared her. Tuesday 2-27-24 at 6:30pm [HA] told [CNA C] what had occurred with [Resident #1] that morning during her shift. Review of witness statement, dated 02/28/2024, signed by LVN D, revealed the following: DON interviewed [LVN D] regarding alleged abuse incident that occurred with Resident #1. [LVN D] stated aides did not tell her that [Resident #1] hit [HA] or anything else that occurred after that point. She stated they told her that [Resident #1] was being difficult during incontinent care. The time reported to her was between 3am (3:00 a.m.) and 4am (4:00 a.m.) so it would have been their last round with him that night. Review of Associate Disciplinary Memorandums, dated 02/28/2024, revealed CNA A, HA, and CNA C were suspended pending investigation. CNA C and HA were reinstated and received training on abuse. CNA C received formal written disciplinary action for failing to report abuse. Supervisors Comments revealed CNA C was aware of reporting guidelines, understands not to wait if she believed anything has occurred, and stated she told employee to report to DON or Admin. CNA A was discharged effective 03/05/2024 due to employee confirming allegation of incident that warrants termination. Review of witness statement, dated 02/29/2024, signed by CNA A, revealed the following: [CNA A] interviewed in person by DON and Administrator on 2-29-24 at 10:15am. She was off on 2-28-24 when the investigation initiated and we were unable to reach her until late that evening. The meeting was set up for Thursday 2-29-24 to obtain statement and her version of events that occurred on 2-27-24 at 3am with [Resident #1]. STATEMENT: We went in to do incontinent care on [Resident #1]. He punched [HA] in the stomach. I tried to hold him down with his hands on his chest so he couldn't hit her anymore. When she was cleaning between his legs he tried to punch me. I told him: stop this, this is not how things go. We don't hit women, it does not work that way. [HA] said my doesn't even hit me. He continued to try to hit us. I did not hit him, it wouldn't do any good anyway. So I just held him down. I did not tell the nurse at that time, she wouldn't do anything anyway. I thought [HA] was going to tell her. No one should have to go into a room and wonder if they are going to get hit. It was self defense. Follow up: Admin asked about the curse words that were alleged. Asked her if she used the f-word. stated that she did not curse . maybe the worst she said was damn don't do this. Admin asked about the allegation that she slapped on the forehead several times and she said well yes she did do that just to get him to stop hitting. I asked her to demonstrate and she slapped her forehead several times with her fingers, palm down in front of nose. Admin asked about why she didn't just back away when he was combative as this could be one approach - she stated they just had to get the job done. Review of personnel record for CNA A revealed she was hired on 12/06/2018 and signed and dated policy for reporting abuse, responsibility for reporting abuse, and Senate [NAME] 9 employee acknowledgement that mistreatment or abuse will not be tolerated and will be subject to immediate discharge. Review of personnel record for HA revealed she was hired on 12/28/2023 and signed and dated policy for reporting abuse and responsibility for reporting abuse. Review of audit, titled Staff Awareness on What Constitutes Abuse, dated 01/25/2024, revealed CNA A and HA met criteria for knowing when and who to report allegations of abuse. Audit revealed met criteria for knowledge of reporting physical abuse immediately to the Administrator. Review of training records, dated 3/5/2024, completed by CNA A, revealed the following education was provided: Preventing, Recognizing, and Reporting Abuse, and Managing Anger completed on 08/13/2023 and Communication and People with Dementia completed on 02/05/2024. Review of training records, dated 3/1/2024, completed by CNA C, reveled the following education was provided: Communication and People with Dementia completed on 1/31/2024, Managing Anger on 08/09/2023, and Preventing, Recognizing, and Reporting Abuse on 03/03/2024. Review of Provider Investigation Report, dated 03/06/2024, revealed the following: .Description of the Allegation: Employee (HA) alleged that resident (Resident #1) had hit her in the stomach while they were performing incontinent care. (CNA A) had cursed at the resident telling him not to do that and slapped him on the forehead several times . Description of assessment . Resident had no physical injuries. His forehead had no discoloration or bruising noted. No redness or complaints of pain. Resident was interviewed as to the allegation and denied anything had occurred. His behavior was normal for his baseline. He has been doing his normal routine with no concerns from staff. DON checked daily for three days and assessed his mood and behaviors with no changes noted . Provider Response: . Upon receipt of allegations, employees involved were suspended immediately, including the individual making the allegation, pending outcome of investigation. Resident was assessed for injuries and evaluated for his feeling of safety, and any need for intervention as a result of the alleged incident. Resident had no physical injuries and denied the occurrence of the incident, stating he had no complaints about the staff. Residents responsible party, position and investment were notified. Police were called to report the allegation . Investigation Summary: . Resident #1 was the first with no injuries noted. He also denied that anything had occurred regarding an employee slapping him and cursing at him. His roommate, who was alert and oriented, was interviewed about if he witnessed or heard anything at the time this was alleged to occur, he stated that he didn't know of anything out of the ordinary but that (Resident #1) was all the time fighting the girls. Resident's roommate, (Resident #2), was asked about his feeling of safety and if anything had ever happened to him, as far as staff mistreating him, during his stay here and he stated no everything was fine. Responsible party of (Resident #1) was notified of allegation and to determine if he had shared anything related to allegation or any other time regarding his feeling of safety and well-being. She was not aware of anything abnormal or anything with him. Staff working the night of the alleged abuse were interviewed and were not aware of anything out of the ordinary occurring (with exception of the witness who reported the incident). (CNA A), alleged perpetrator, was interviewed. (CNA A) Stated that after (Resident #1) punched (HA) in this stomach, she (CNA A) had held him down so he could not hit her anymore. (CNA A) Stated that he had also tried to hit her. She denied cursing at him but said she told him this was unacceptable-that you cannot hit women. initially she denied slapping him but when asked by administrator if she had hit him on the forehead she stated she only did it to get him to stop hitting them. She demonstrated the same motion that was displayed by (HA) during her interview. Fingertips slapping forehead, palm down in front of face. Residents cared for by (CNA A) were interviewed to determine if they felt safe and if there were any other issues to report regarding staff treatment of residence. (Resident #1) continues to display no negative effects related to the incident. (CNA A) confirmed the allegation and was terminated from employment .Physician, family, police, and Ombudsman were notified of the incident. Investigation Findings: Confirmed. Provider Action Taken Post Investigation: Employee (CNA A) was terminated post investigation. (CNA C) and (HA) were suspended but reinstated after receiving additional training on abuse/neglect, reporting guidelines, and how to handle dementia and combative residence. Facility staff received in service training on abuse neglect, handling them into residence, and how they handle combative residents. Post test given and follow up on any staff lacking proper knowledge during testing related to abuse/neglect. training upon hire, at minimum annually and as needed. Review of Resident #1's progress notes by ADON, dated 02/29/2024, revealed Resident #1 head to toe skin assessment was performed with no skin alterations noted. Review of Provider Investigation Report, dated 3/6/2024, revealed monitoring statements signed by the Administrator for Resident #1, dated between 02/28/2024 and 03/01/2024 The monitoring statements signed by the Administrator revealed Resident #1 had exhibited no physical or psychosocial harm, had no indication of stress, no behaviors, he was socializing normally, and had no concerns. Review of statement, dated 03/06/2024, signed by Administrator, revealed Ombudsman spoke with Resident #1 that told her They fired her and slapped his head a few times when asked what happened and he denied that it hurt and had no further concerns. Review of inservices and employee roster provided by Administrator and DON, dated between 02/28/2024 and 03/01/2024 revealed all nursing staff received education on abuse and reporting. During an interview with the Administrator and DON on 03/26/2024 at 1:42 p.m., the Administrator said she was the abuse coordinator and was aware of a self-reported incident of abuse concerning Resident #1. The Administrator said the aide admitted that she did pat his head lightly to try to keep him from hitting her and they terminated her. She said the resident showed no signs of psychosocial or physical harm when the Administrator monitored him for three days following report of incident documented in her monitoring statements in provider investigation report. During an interview on 03/26/2024 at 3:05 p.m., the Ombudsman said Resident #1 was physically abused with two staff in the room and the Ombudsman had spoken with his RP and she was okay with how the facility was handling it. The Ombudsman said he has a speech impediment and was not aware of any skin changes or bruising. During an interview on 03/26/2024 at 3:26 p.m., PTA said he did not suspect abuse at this facility and had received training on abuse and handling dementia residents via in-services. PTA said if he suspected abuse he would report it to the ADM immediately. PTA said Resident #1 was doing good and has known him for 6 or 7 years and has had no change in condition. PTA said he can have behaviors but that he has known him for a long time but that they had a good relationship and he knew how to talk and approach him to maintain his trust. PTA said Resident #1 liked coming to therapy and doing his legs and had never had any concerns with staff being abusive or rough with him. During an interview and observation on 03/26/2024 at 4:20 p.m., Resident #1 said he was doing good and that everyone was nice to him at the facility. Resident #1 said he had no concerns. The Resident appeared well groomed, free from apparent injury, pleasant, and in no distress sitting up in wheelchair in his room watching television. During an interview on 03/27/2024 at 11:41 a.m., HA L said she did not suspect abuse, had been trained on abuse, reporting, and dementia residents via in-services, and had been employed at the facility for 2 years. HA L said it was important for resident's care plan to be followed to prevent harm and make sure all residents receive proper care. During an interview on 03/27/2024 at 11:56 a.m., CNA T said she had been employed at the facility for 5 years and did not suspect abuse. CNA T said she had received training on abuse, reporting, and caring for dementia residents. CNA T said if there is a resident that is showing signs or aggression she would try again later after the resident had calmed down and that if she ever witnessed any abuse she would report to the ADM or DON immediately. During an interview via phone on 03/27/2024 at 12:45 p.m., CNA C said The hospitality aide that worked at night came in and said I need to talk to you. She said I don't know what to do [CNA A] slapped the resident in the face twice. I said you should have reported it to the charge nurse. CNA C said HA told her she was scared, and afraid CNA A would retaliate on her if she reported the incident. CNA C said she knew should have reported it then, but she did not report it until the next day to her DON because she had told HA to report it. CNA C said Resident #1 had no injuries or behavior changes and the facility had provided training on abuse and when to report. CNA C said she would report to the DON or ADM any suspected abuse immediately and the abuse coordinator was the Administrator. CNA C felt the facility took care of that situation. CNA C said she had no previous concerns with the care provided by CNA A and believed it was an isolated incident. CNA C said it was important to report abuse immediately to ensure resident safety. During an interview on 03/27/2024 at 1:45 p.m., the Administrator said staff expectation was to report alleged abuse immediately. The Administrator said it was important to report immediately so that residents could be prevented from further harm and to allow the facility to respond to the situation. The Administrator said all staff received education on abuse and reporting. The Administrator said she has conducted a verbal audit check monthly to ensure staff knowledge on abuse, neglect, and reporting. The Administrator said she was the abuse coordinator and was responsible for training on abuse. During an interview via phone on 03/27/2024 at 2:11 p.m., HA said she had been at the facility for 5 months and works on the night shift. HA said she did witness the incident with Resident #1 and said she saw CNA A hit the resident on the face with her fingers on his forehead multiple times, roll him around and heard her tell the resident she could have someone come in to whoop his ass whenever she wanted to with him being in this bed. HA said after that happened CNA A left the room and HA stepped out of the room due to being upset and scared. HA said she returned to the room to finish his care and gave him a hug. HA said he had no injuries and never had any social isolation following the incident. HA said she has taken care of him since then and that he seems to be doing better with no combative behavior and appears happy. HA said the incident happened early in the morning between midnight and 4:00 a.m. HA said she did not know if CNA A worked the next day and that she does not remember working with her. HA said that she knew she should have reported the incident immediately to the abuse coordinator but that it was late and did not have her phone number. HA said she notified another CNA, CNA C, around 6:30 p.m. on 2/27/2024 and that CNA C notified the Administrator immediately. HA said that she had received training on abuse briefly in orientation and that she did receive training following the incident. HA said the abuse coordinator was the Administrator and that it was important for alleged abuse to be reported immediately to her to prevent abuse from occurring and further protect residents from harm. HA said she believed the incident was isolated and had no concerns with CNA A prior to this incident. HA said that CNA A was fired and that she felt the facility handled the situation appropriately. During an interview and record review on 03/27/2024 at 5:28 p.m., the Administrator said her expectations of staff was to report abuse immediately and that if she was notified of the abuse allegation promptly she would have responded the same way by suspending the perpetrator once notified, ensure residents were safe, and assess the resident/victim involved in the incident. The Administrator confirmed via timesheet the perpetrator continued to work the remainder of her shift following the abuse incident as well as the following shift the next day. The Administrator said the perpetrator was showing signs of different behavior and believe she had personal things going on at home that may have contributed to this isolated incident and that the employee had no concerns with her background check and had been working at the facility for 5 years. The Administrator and DON said they were responsible for training staff on abuse, reporting, and their expectations of staff when caring for aggressive residents included to approach in a calm manner, to stop what they are doing and come back later once the resident has calmed down. The Administrator said she had conducted an audit check of nursing staff to ensure knowledge of abuse, reporting, and handling residents with dementia and she would continue to conduct verbal audit checks monthly to verify knowledge of training. During an interview via phone on 03/28/2024 at 11:23 a.m., Detective K said there have been no warrants issued at this time for CNA A and that she had no criminal history or background indicating history of abusive behavior. Detective K said she was aware Resident #1's family was looking to drop the charges but that ultimately it was up to the district attorney's office. Detective K said the police report has not been completed because they were waiting on medical records to determine Resident #1's mental and physical capabilities. During state office call on 03/27/2024 at 4:35 p.m., an Immediate Jeopardy (IJ) Past Non-Compliance (PNC) was determined. The administrator was notified of IJ PNC on 03/27/2024 at 5:28 p.m. due to the above failures. The administrator was provided with the IJ template on 03/27/2024 at 5:28 p.m. The surveyor confirmed PNC had been implemented sufficiently to remove the Immediate Jeopardy by: - Facility implementation of monitoring resident daily for three days for psychosocial harm. - Facility notification of abuse incident to responsible parties, MD, police, Ombudsman, and HHSC. - Completion of head-to-toe skin assessment on resident/victim. - Completion of in-services on abuse, reporting, dementia and approaching combative residents. - Completion of safe surveys on residents. - Suspension of involved staff pending outcome. - Completion of formal disciplinary actions for involved staff. - Termination of confirmed perpetrator. The noncompliance was identified as PNC. The IJ began on 02/27/2024 and ended on 03/05/2024. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 1 medication storage room and 1 of 3 medication carts (Unit Two Cart) reviewed for pharmacy services. The facility failed to remove 1 vial of Insulin from the medication cart that had expired on 09/16/2023. The facility failed to monitor and log the temperatures of the medication storage refrigerator twice daily as indicated by policy. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings included: Record review of an Admission Record dated 9/26/2023 for Resident #27 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of diabetes (high blood glucose) hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (paralyzed on left side following a stroke), chronic diastolic congestive heart failure (inability of the heart to pump efficiently), type 2 diabetes, and hypertension. Record review of an active medication order dated 9/26/23 for Resident #27 indicated a prescription filled 09/03/23 #86312803 Lantus (Glargine Insulin) 100unit per millimeter solution inject 13 units subcutaneously at bedtime for diabetes. During an observation on 09/26/23 at 2:00 PM with LVN C the medication cart for Unit 2 had 1 opened vial of Lantus Insulin labeled with date filled 08/09/23 for Resident #27 with an open date of 08/16/23 and instructions to dispose of 28 days after opening. LVN C discarded the expired vial and retrieved a new vial of Lantus Insulin for Resident #27 from the medication refrigerator for Unit Two. During an observation on 09/26/23 at 2:10 PM with LVN C the medication refrigerator on Unit 2 contained Insulin for resident #27 and 10 vials of insulin for other residents. The freezer had no medications stored inside. During an observation and record review on 09/26/23 at 2:15 PM of the medication refrigerator log posted on the medication room refrigerator for September 2023 indicated, instructions to check the medication refrigerator and freezer at least once each day and log temperatures for the refrigerator and freezer daily. The log indicated no temperatures were recorded for the freezer on 09/08/23, 09/09/23, 9/22/23, 09/23/23, 09/24/23 and 09/26/23. The log indicated no temperatures were recorded for the refrigerator on 09/08/23, 09/09/23, 09/22/23, 09/23/23, 09/24/23 and 09/26/23. During an interview on 09/26/2023 at 2:15 PM LVN C stated that the insulin for Resident #27 was given at night before bedtime. LVN C said sge did not give the nighttime insulin, so she did not check it for expiration . She stated multi-use vials of insulin were to be dated when opened and they were usually only good for 28 days. She stated she had received training on multi use vials use by dates. She stated the risk could be ineffective medication. She stated the temperature of the refrigerator and freezer should be logged at least once each day and recorded. During an interview on 09/26/2023 at 3:20 PM the DON stated the nurses were responsible for monitoring the medication refrigerator, removing expired medications, and dating all multiuse vials when opened. She stated the nurses had training and they had started in-servicing on expired medications and logging the temperature of the refrigerator. She stated it was her responsibility to provide oversight. She stated the risk could be ineffective medication. During an interview on 09/26/2023 at 4:30 PM the Administrator stated the DON and ADON were responsible for medication storage and removing expired medications for destruction. She stated she was not sure how long multiuse vials were good for but if a resident were to receive expired medications it could not work or make them sick. Record review of a manufacturer for Lantus Insulin expiration dates indicated, Lantus Insulin discard 28 days after opening. Record Review of policy for Storage of Medications dated 2018 Pharm script Indicated, . II. Temperature 1. All medications are maintained within the temperature ranges . c. Refrigerated: 36-46 degrees [Fahrenheit] with a thermometer to allow temperature monitoring. d. Frozen: In the freezer at -13 to 14 degrees [Fahrenheit] 4. Medications requiring refrigeration are kept in a refrigerator at temperatures between 36 and 46 degrees [Fahrenheit] with a thermometer monitoring . 6. The facility should maintain a temperature log in the storage area to record temperatures at least once a day or in accordance with facility policy. 7. The facility should check the Refrigerator or Freezer in which vaccines are stored at least two times a day, per CDC guidelines 14. Outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy, if a current order exists, . III. Expiration Dating (beyond use dating) 3. Certain medications or package types, such as IV solutions, multi dose injectable vials require an open date and expires as indicated by manufacturer use by date.