Every finding on record at William R Courtney Texas State Veterans Home

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of 1 of 6 (Resident #1) residents reviewed for significant medication errors.The facility failed to ensure the nurses administered Resident #1's PRN hydralazine on 8/08/2026, 8/09/2026, 8/11/2026, and on 8/17/2026 for a systolic blood pressure over 180 as ordered by the MD.The facility failed to ensure a system was in place to prevent significant medication errors.These failures could place Resident #1 at risk of symptoms of high blood pressure including chest pain, headache, heart attack, and stroke.Findings included:A record review of Resident #1's face sheet dated 8/19/2026 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of hypertension (high blood pressure), type 2 diabetes (uncontrolled blood sugar), depression, hyperlipidemia (high cholesterol), hypothyroidism (underactive thyroid), anemia, and presence of cardiac pacemaker.A record review of Resident #1's MDS assessment dated 5//07/2026 reflected a BIMS score of 15, which indicated no cognitive impairment.A record review of Resident #1's care plan last revised on 5/14/2026 reflected that he was on diuretic therapy related to hypertension (high blood pressure) and congestive heart failure. Interventions included to monitor, document, and report PRN adverse reactions to diuretic therapy such as dizziness, postural hypotension (low blood pressure), fatigue, and an increased risk for falls.A record review of Resident #1's order dated 6/22/2026 reflected an order written by the MD for hydralazine HCl oral table 10 mg PRN every 8 hours If needed when systolic blood pressure was over 180 or diastolic blood pressure was over 100.A record review of Resident #1's blood pressure readings reflected the following:On 8/08/2026 at 17:01, MA A documented a reading of 187/90 mmHg.On 8/08/2026 at 20:59, MA A documented a reading of 190/85 mmHg.On 8/09/2026 at 16:35, MA A documented a reading of 185/92 mmHg.On 8/09/2026 at 20:37, MA A documented a reading of 188/93 mmHg.On 8/11/2026 at 15:52, MA B documented a reading 183/90 mmHg.On 8/17/2026 at 21:05, MA A documented a reading of 182/70 mmHg.On 8/18/2026 at 20:35, MA A documented a reading of 189/97 mmHg.A record review of Resident #1's progress notes reflected that PRN hydralazine HCl was administered on 8/18/2026. There were no notes reflecting that hydralazine was administered on other days in August of 2026.During an observation and interview on 8/19/2026 at 12:53 PM, Resident #1 was observed sitting in his room. Resident #1 stated that there was sometimes an issue with medications being given on time. Resident #1 stated that he was supposed to receive PRN hydralazine when his systolic blood pressure was above 180 mmHg.During an interview on 8/19/2026 at 1:21 PM, the MD stated that the facility had orders to check Resident #1's vitals and if his systolic blood pressure reading was over 180, staff were to administer hydralazine. The MD stated that if hydralazine were not administered and Resident #1 had symptoms including headache and chest pain, it could cause stroke or heart attack.During an interview on 8/19/2026 at 2:45 PM, MA A stated that it was the nurse's responsibility to administer PRN hydralazine to Resident #1. MA A said that PRN orders did not show up on her MAR. MA A stated the only time she reported Resident #1's blood pressure to the nurse was when his systolic reading was in the 190s or 200s. MA A said she did not notify the nurse if Resident #1's systolic blood pressure was in the 180s because it's in the 180s all the time. MA A stated that she had not been advised to report a systolic reading over 180 and she had been going by a judgement call.During an interview on 8/19/2026 at 3:21 PM, the MD stated that Resident #1 should receive hydralazine any time his systolic blood pressure reading was over 180 unless they receive direction from myself of another medical provider. The MD stated that hydralazine should have been administered to Resident #1 on 8/08/2026 and on 8/09/2026. The MD said that in the absence of giving hydralazine or talking to her, they weren't following the order as written.During an interview on 8/19/2026 at 4:22 PM, when asked how medication aides would know what the parameters were for Resident #1's hydralazine if they could not see the PRN MAR, the DON stated they don't give it. The DON stated that medication aides could not see parameters for PRN orders and that medication aides were responsible for communicating blood pressure readings to the nurse. When asked if medication aides were supposed to communicate all blood pressure readings to the nurse, the DON stated it depended on what they're giving. When asked when nurses checked blood pressure for PRN medications, the DON stated, it depends. The DON stated that she did not know why Resident #1 had not received PRN hydralazine when his systolic blood pressure was over 180. The DON stated, we have to have an order for med aides to see. The DON stated that the MD normally entered all of her orders into the electronic health records system. When asked what a potential negative outcome was if PRN blood pressure medication was not administered when needed, the DON stated, that's on [the MD]. The DON stated, there's nothing that nursing can do because we don't have a separate order to check blood pressure.During an interview on 8/19/2026 at 4:47 PM, the Administrator stated that he expected orders to be followed and that staff followed parameters. The Administrator stated that the nursing team should monitor staff as well as the ADON and DON. The Administrator stated that the adverse effects of not receiving medication for blood pressure depended on if it was too high or too low.A record review of the facility's policy titled Administering Medications revised in April of 2019 reflected the following: Policy StatementMedications are administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation.4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of 1 of 6 (Resident #1) residents reviewed for pharmaceutical services.The facility failed to ensure the nurses administered Resident #1's PRN hydralazine on 8/08/2026, 8/09/2026, 8/11/2026, and on 8/17/2026 for a systolic blood pressure over 180 as ordered by the MD.The facility failed to ensure a system was in place to ensure that PRN orders were administered according to the physician's order.These failures could place Resident #1 at risk of symptoms of high blood pressure including chest pain, headache, heart attack, and stroke.Findings included:A record review of Resident #1's face sheet dated 8/19/2026 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of hypertension (high blood pressure), type 2 diabetes (uncontrolled blood sugar), depression, hyperlipidemia (high cholesterol), hypothyroidism (underactive thyroid), anemia, and presence of cardiac pacemaker.A record review of Resident #1's MDS assessment dated 5//07/2026 reflected a BIMS score of 15, which indicated no cognitive impairment.A record review of Resident #1's care plan last revised on 5/14/2026 reflected that he was on diuretic therapy related to hypertension (high blood pressure) and congestive heart failure. Interventions included to monitor, document, and report PRN adverse reactions to diuretic therapy such as dizziness, postural hypotension (low blood pressure), fatigue, and an increased risk for falls.A record review of Resident #1's order dated 6/22/2026 reflected an order written by the MD for hydralazine HCl oral table 10 mg PRN every 8 hours If needed when systolic blood pressure was over 180 or diastolic blood pressure was over 100.A record review of Resident #1's blood pressure readings reflected the following:On 8/08/2026 at 17:01, MA A documented a reading of 187/90 mmHg.On 8/08/2026 at 20:59, MA A documented a reading of 190/85 mmHg.On 8/09/2026 at 16:35, MA A documented a reading of 185/92 mmHg.On 8/09/2026 at 20:37, MA A documented a reading of 188/93 mmHg.On 8/11/2026 at 15:52, MA B documented a reading 183/90 mmHg.On 8/17/2026 at 21:05, MA A documented a reading of 182/70 mmHg.On 8/18/2026 at 20:35, MA A documented a reading of 189/97 mmHg.A record review of Resident #1's progress notes reflected that PRN hydralazine HCl was administered on 8/18/2026. There were no notes reflecting that hydralazine was administered on other days in August of 2026.During an observation and interview on 8/19/2026 at 12:53 PM, Resident #1 was observed sitting in his room. Resident #1 stated that there was sometimes an issue with medications being given on time. Resident #1 stated that he was supposed to receive PRN hydralazine when his systolic blood pressure was above 180 mmHg.During an interview on 8/19/2026 at 1:21 PM, the MD stated that the facility had orders to check Resident #1's vitals and if his systolic blood pressure reading was over 180, staff were to administer hydralazine. The MD stated that if hydralazine were not administered and Resident #1 had symptoms including headache and chest pain, it could cause stroke or heart attack.During an interview on 8/19/2026 at 2:45 PM, MA A stated that it was the nurse's responsibility to administer PRN hydralazine to Resident #1. MA A said that PRN orders did not show up on her MAR. MA A stated the only time she reported Resident #1's blood pressure to the nurse was when his systolic reading was in the 190s or 200s. MA A said she did not notify the nurse if Resident #1's systolic blood pressure was in the 180s because it's in the 180s all the time. MA A stated that she had not been advised to report a systolic reading over 180 and she had been going by a judgement call.During an interview on 8/19/2026 at 3:21 PM, the MD stated that Resident #1 should receive hydralazine any time his systolic blood pressure reading was over 180 unless they receive direction from myself of another medical provider. The MD stated that hydralazine should have been administered to Resident #1 on 8/08/2026 and on 8/09/2026. The MD said that in the absence of giving hydralazine or talking to her, they weren't following the order as written.During an interview on 8/19/2026 at 4:22 PM, when asked how medication aides would know what the parameters were for Resident #1's hydralazine if they could not see the PRN MAR, the DON stated they don't give it. The DON stated that medication aides could not see parameters for PRN orders and that medication aides were responsible for communicating blood pressure readings to the nurse. When asked if medication aides were supposed to communicate all blood pressure readings to the nurse, the DON stated it depended on what they're giving. When asked when nurses checked blood pressure for PRN medications, the DON stated, it depends. The DON stated that she did not know why Resident #1 had not received PRN hydralazine when his systolic blood pressure was over 180. The DON stated, we have to have an order for med aides to see. The DON stated that the MD normally entered all of her orders into the electronic health records system. When asked what a potential negative outcome was if PRN blood pressure medication was not administered when needed, the DON stated, that's on [the MD]. The DON stated, there's nothing that nursing can do because we don't have a separate order to check blood pressure.During an interview on 8/19/2026 at 4:47 PM, the Administrator stated that he expected orders to be followed and that staff followed parameters. The Administrator stated that the nursing team should monitor staff as well as the ADON and DON. The Administrator stated that the adverse effects of not receiving medication for blood pressure depended on if it was too high or too low.A record review of the facility's policy titled Administering Medications revised in April of 2019 reflected the following: Policy StatementMedications are administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation.4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on interview and record review, the facility failed to protect one resident (Resident #1) out of 11 residents reviewed for abuse and neglect in that:CNA B observed CNA A tapping Resident # 1's mouth, several times, during care, while she was when she went to ask CNA A if she needed assistance with getting Resident #1 to bed on 05/21/2026.This failure could place residents at risk of physical and mental or emotional harm, fear, and anxiety. Findings included:Record review of Resident #1's admission recorded dated 06/15/2026 documented an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses included: Alzheimer's Disease(progressive, irreversible brain disorder that slowly destroys memory and thinking skills), dementia(decline in mental ability-such as memory, thinking, and reasoning severe enough to interfere with daily life), and chronic kidney disease(long-term condition where the kidneys are damaged and lose their ability to properly filter waste and excess fluid from the blood).Record review of Resident #1's Quarterly MDS assessment, dated 03/09/2026 , revealed the resident had a BIMS score of 8 indicating the resident had moderate cognitive impairment.Record review of Resident #1's care plan, dated 06/14/2026, revealed Resident #1 was care planned for memory problems. Resident #1 was at risk for further decline in cognition that may affect the ability to communicate needs and wants r/t cognitive deficit.Review of facility's investigation of physical abuse dated 05/29/2026 reflected a thorough investigation was completed, and the allegation of physical abuse was confirmed and training was conducted over abuse. CNA A was suspended immediately after the incident was reported and was terminated.An interview with Resident #1 on 06/14/2026 at 4:05 pm, he stated he was safe but could not recall an incident of abuse. Resident # 1 started talking back in time.An interview with Resident #1's RP on 06/15/2026 at 3:01 pm revealed it was not appropriate for CNA A to have tapped the resident on the mouth with her hand. Resident #1's RP stated that Resident # 1 did not recall the incident and there were no injuries. Resident # 1's RP stated she was pleased that the facility had suspended CNA A immediately after the incident and terminated her once the investigation was completed.An interview with CNA B on 06/15/2026 at 2:09 pm revealed that she could not recall the date of the incident back in May around 10:00 pm or 11:00 pm where she witnessed the incident with Resident # 1 and CNA A. CNA B stated she was in the hallway and overheard CNA A tell Resident # 1 to get in bed. CNA B stated she went to Resident #1's room to ask CNA B if she needed help getting Resident # 1 in bed. CNA B stated she had observed CNA A tapping Resident #1's lips with her hand because Resident # 1 was cursing and being combative. CNA B stated CNA A kept tapping Resident #1's lips until he was put in the bed and Resident #1 had told CNA A to stop. CNA B stated CNA A said she had done that so Resident # 1 would calm down. CNA B stated she immediately left the room and reported the incident to the charge nurse. CNA B stated Resident # 1 did not have any injuries and that was not right what CNA had done. CNA B stated she had worked for agency that night and she could not recall the name of the charge nurse she reported the incident to.An interview with the Social Worker on 06/15/2026 at 1:00 pm, she stated that she was made aware of the incident on 05/22/2026 at 9:00 am in the morning huddle. The Social Worker stated Resident # 1 had pretty advanced dementia and could not remember what happened due to a very low BIMS score. The Social Worker stated Resident # 1 was at his normal baseline with no observed changes or distress. An attempted interview with CNA A was made on 06/15/2026 at 1:59 pm, 3:04 pm, and 5:15 pm. Voice messages were left with no returned call back by exit.An interview with the DON on 06/15/2026 at 2:20 pm revealed that CNA B had witnessed the incident on 05/21/2026 with CNA A and Resident # 1. The DON stated CNA A was immediately suspended and removed from the facility when CNA B reported the incident immediately after witnessing it. The DON stated that after the investigation was fully completed, it was confirmed the incident had occurred and CNA A was terminated. The DON stated it was expected for Resident # 1 to have been touched inappropriately by CNA A. The DON stated that the incident was unacceptable and could have led to injuriesAn interview with the ADM on 06/15/2026 at 5:58 pm revealed CNA A should never have placed her hands on Resident #1's mouth. The ADM stated it was not expected for CNA A to have done that, and it could have caused injuries. The ADM stated it was expected for CNA A to have been professional with Resident #1.Review of CNA A's personnel file reflected that she was hired on 09/01/2025 and was terminated on 05/28/2026.Review of facility's Policy dated 02/01/2017 and revised 01/27/2020 titled Abuse, Neglect, Misappropriation Prevention Program reflected: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure DA H wore a hair net when standing over the food prep table and portioning salads on plates. The facility failed to ensure DA H washed her hands between food preparation tasks.The facility failed to ensure the [NAME] used proper hand sanitation between puree preparation.The facility failed to and LVN A used proper hand sanitation during food plate distribution for the lunch meal.The facility failed to ensure CNA C and LVN B used proper hand sanitation during food plate distribution for breakfast meal.The facility failed to ensure that designated hand-washing station 2 had hand soap, paper towels, or designated trash bin available for staff to use between kitchen tasks. These failures could place residents at risk of foodborne illness and food contamination.Findings included:During an observation on 05/19/2026 at 8:56 am revealed DA H stood over the food prep table, and she was portioning salads onto individual plates, and she did not wear a hair net. During an Interview on 05/20/2026 at 1:37 p.m., DA H said she has worked at this facility for 1 month and she had been trained in food safety and proper hand sanitation. She stated the reason for hand sanitation was to prevent cross contamination. When asked why DA H failed to wear a hair net and why she did not wash her hands between tasks, she said, Yesterday I forgot to wash my hands after I removed of my gloves. And she said, Yesterday I forgot to use a hair net when I was preparing food in the kitchen. During an observation and interview on 05/19/2026 at 12:42 p.m., it was revealed that LVN A had reviewed a meal ticket for accuracy while she was at the tray distribution cart. After distributing a tray to another staff member, she then walked across the dining room to observe a resident's meal ticket. She returned to the distribution cart, and she resumed distributing meal trays. LVN A failed to use hand sanitizer between tray service. LVN A stated she had been trained in resident rights and on proper hand sanitization. She stated residents had a right to live in sanitary conditions. She stated she had not had any in-service on sanitary practices for food distribution. During an observation and interview on 05/20/2026 at 7:10 a.m., it was revealed that CNA C entered the dining room. He shook bare hands with LVN B. He failed to wash his hands or use hand sanitizer prior to serving a tray of food to a resident. CNA C stated that he has worked PRN as a CNA for 2 months at this facility and he has been trained in hand hygiene. He stated, staff were to hand sanitize after each tray served to a resident. CNA C stated, I don't remember not using hand sanitizer when I was serving meals. During an observation on 05/20/2026 at 7:15 a.m., it revealed that LVN B had hand-to-hand contact with CNA C while greeting each other in the dining room. LVN B failed to use proper hand sanitation after contact with CNA C, and she failed to use hand sanitizer prior to verifying meal tickets for accuracy. Per interview on 05/21/2026 at 11:01 a.m., LVN B said she has worked for this facility for 3 years as an LVN and she has been trained in proper hand sanitation. She stated that she expects that staff are to perform hand sanitation every third tray. She stated, the reason for hand sanitization is for infection control purposed. She stated, if hand sanitizer is not used, there is a possibility of cross contamination. During an observation and interview on 05/20/2026 at 7:33 a.m., revealed that designated hand hygiene station # 2 did not have hand soap, paper towels or a designated trash can present. The DM stated his staff have been trained in proper hand sanitation. The DM said that he placed a request for a hand soap dispenser, paper towel dispenser and a designated trash can to be located at hand hygiene station # 2. The DM stated, if they don't have paper towels, they will likely use their clothes to dry their hands after washing. He said the improper hand sanitation can cause transmission of germs to the residents who were consuming the food. During an observation and interview on 05/20/2026 at 10:38 a.m., revealed [NAME] prepared puree spinach. She removed her gloves then she brought a pan of rice to the prep area, and she failed to wash her hands before putting on a new pair of gloves. The [NAME] stated she has worked at this facility for one and 1/2 weeks and she has been trained on hand sanitation. The [NAME] stated, the purpose of hand sanitation was to prevent cross contamination. She stated, I am to wash my hands for 20 seconds anytime I leave the food line. During an Interview on 05/20/2026 at 3:09 p.m., the RD said she has worked for this facility for 2 years and she was responsible for residents' clinical reviews of dietary needs and audits involving kitchen sanitation, food tray distribution, and food preparation. She stated she was not aware of the staff failure to follow the hand sanitation procedures. She stated it was her expectation that staff use proper hand sanitation guidelines every day. She stated she will be addressing the hand sanitation requirements on her next visit to the facility. D During an interview on 05/21/2026 at 3:05 p.m., the ADM revealed that two months ago, Healthcare Services Group was contracted to manage the kitchen. He stated that the contract company have their own policies regarding kitchen sanitation, hand hygiene, and food preparation practices. He stated it was his understanding that the Nursing staff were responsible for the training and holding Nursing staff accountable for hand sanitation during food distribution. ADM stated she was not aware that DA H failed to use a hair net and to properly perform hand sanitation while preparing food in the kitchen. ADM stated that the DM is responsible for making sure the cook uses proper hand sanitation in the kitchen while performing food preparation tasks. Per record review of in-services provided to surveyor by DM on 05/21/2026 at 3:45 p.m., it was revealed that on 04/14/2026 in-services were conducted on topic: Infection control- hand hygiene. Record review revealed that thirteen kitchen staff had completed training in hand sanitation between 4/26/2026 and 4/30/2026. The course offered essential training in hand hygiene, a vital practice in preventing the spread of germs and healthcare associated infections. Objectives were: Understanding the importance of hand hygieneDifferentiated between hand hygiene methodsDemonstrate propre handwashing techniques.Demonstrate effective use of Alcohol - based hand Sanitizers andRecognize situations requiring hand hygiene. And record review confirmed that 13 kitchen staff and DM have been certified in food handler safety. Record review of the facility's policy of Employee Staff Attire dated 05/2024, revised 01/2025, reflected Procedures:1. All staff members will have their hair off their shoulders, confined in a hair net or cap, and facial hair properly restrained.2. All staff will exhibit appropriate personal hygiene.3. All staff members will wear clean approved attire, including appropriate footwearRecord Review of facility policy of Environment dated 05/2025, revised 06/2025. Policy Statement: All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition.The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation.All trash will be contained in covered, leak-proof containers that prevent cross contamination.Record Review of policy of Food: Preparation dated 5/2014, revised 02/2026. Policy Statement: All foods are prepared in accordance with the FDA Food Code.Procedures1. All staff will practice proper hand-washing techniques and glove use.2. Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination Record review of the facility's policy of Employee Sanitation, dated 12/01/2011, reflected hair restraints, such as hats, hair coverings or nets, caps and beard/moustache restraints or other effective hair restraints are worn to keep hair from contacting food and food -contact surfaces.

Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information for the first quarter (October 1, 2025, to December 31, 2025). The facility failed to submit complete PBJ staffing information to CMS for October 1, 2025, to December 31, 2025. This failure could place all residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.Findings Included: Record review of the CASPER3 PBJ report reflected the facility failed to submit data for the FY quarter 1 (October 1, 2025- December 31, 2025). No other quarter was triggered. An interview was conducted on 05/21/2026 at 3:35PM with the DON, who reported that she was not aware that quarter 1 PBJ was not submitted. The DON stated that she was responsible for reporting the data and stated the failure was an oversight. An interview was conducted on 05/21/2026 at 4:54PM with the ADM, who reported that the PBJ staffing data was not submitted when it was due, because they forgot to submit the data. The ADM stated the facility missed the submission deadline due to an oversight. RR of policy provided by the facility titled Reporting Direct Care Staffing Information (Payroll-Based Journal) dated August 2022 revealed the following: Direct care staffing information is submitted on the schedule specified by CMS, but no less frequently than quarterly.Staffing information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter.Quarter 1 dates October 1-December 31 must be reported by February 14Quarter 2 dates January 1-March 31 must be reported by May 15Quarter 3 dates April 1 - June 30 must be reported by August 14Quarter 4 dates July 1-September 30 must be reported by November 14

Based on observation, interview and record review the facility failed to ensure residents received and were provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 3 of 3 residents (Residents # 51 # 65 and #135) reviewed for dietary services. The facility failed to provide palatable food served at an appetizing temperature and taste to Residents #51, #65 and #135. The facility failed to provide palatable food served at an appetizing temperature and taste for 3 test trays provided to the survey team. This failure could place residents at risk of weight loss, altered nutritional, status, and diminished quality of life. Findings include: Record review of Resident #51's admission Record dated 05/21/2026 revealed an [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #51 had a diagnosis which included Alzheimer's Disease with late onset, (A type of brain disorder that causes problems with memory, thinking, and behavior. This is gradually progressive condition.), Dementia, (A group of symptoms that affects memory, thinking and interferes with daily life. and Major depressive disorder, (A mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts.) Record review of Resident #51's Care Plan, dated 04/14/2026, revealed; Resident was on a regular diet with thin liquids, and he was at risk for nutritional deficits and/or dehydration risks related to cognitive deficit and self-care deficit. Resident sometimes take food from other residents during meals, mistaking it for his own food. Interventions are to Provide diet and fluids including supplements and snacks as ordered. Record review of MDS assessment, dated 03/13/2026, revealed; Resident #51 had a BIMS score of 1, which indicates he has a severe problem with thinking and memory. MDS Section Functional Status indicates Resident # 51 required Supervision or touching assistance and Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Record review of Resident #65's, admission report dated 05/21/2026, revealed a [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #65 had a primary diagnosis which included Type 2 Diabetes, (a chronic condition characterized by insulin resistance and high blood sugar levels), Anemia in chronic kidney disease,(Anemia is a common complication of chronic kidney disease, primarily caused by reduced erythropoietin production, iron deficiency, and other metabolic disturbances) and Chronic diastolic (congestive Heart failure), (cardiac failure including breathing difficulty, fluid retention, and circulatory changes). Record review of Resident #65's Care Plan, dated 02/21/2026, revealed Resident #65 was on a regular texture with liquids, diet. Interventions were for RD to evaluate and make diet change recommendations PRN and Provide diet and fluids including supplements and snacks as ordered. Record review of resident # 65's MDS report revealed he had a BIMS score of 12 indicating he had Moderate problems with thinking and memory. Resident # 65's functional abilities indicated he needs assistance with eating for set up and clean up, resident can complete this activity. Resident #65 residents were dependent on assistance for transfer from chair to chair. Record review of Resident # 135's admission record report dated 05/21/2026 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident # 135 had a primary diagnosis which included Dementia, (A group of symptoms that affects memory, thinking and interferes with daily life.) Depression (feeling uneasiness or worry) and prediabetes, (a higher-than-normal blood sugar level. It's not high enough to be considered type 2 diabetes yet). Record review of Resident # 135's Care Plan, dated 02/21/2026 revealed Resident # 135 was on a Regular diet, regular texture with thin liquids. Interventions were to provide diet and fluids including supplements and snacks as ordered. Record review of Resident # 135's MDS revealed he had a BIMS score of 12 indicating he had Moderate problems with thinking and memory. Resident # 135's MDS report revealed that he requires assistance with eating for set up and clean up, resident can complete this activity. Resident # 135 is dependent on assistance for transfer from chair to chair. During an observation and food temperature readings on 05/20/2026 at 7:48 a.m., in the facility's secure units dining room, it was revealed that Resident 51's breakfast meal was served to him at 97.5 F. Resident # 65's meal was served at 108.6F. and Resident # 135's meal was served at 112F. Per interview on 05/20/2026 at 10:09 a.m., it was revealed that Resident # 50's only complaint was that his food was cold by the time it reaches him. Per observation and interview on 05/20/2026 at 1:29 p.m., it was revealed that test tray #1 included Mechanical soft texture diet and it was served at 108.6F. Test tray # 2 included regular texture diet and it was served at 112.6F. Test tray #3 included puree texture diet and it was served at 104F. The DM stated that cooked food temperatures should be no lower than 120F at the time it is served to a resident. The DM stated the reason the test trays were so cold was because they were sitting in the kitchen for a long time before they were served to the Survey staff. The DM stated food temperatures had been an issue with some residents, he was not able to identify a specific complainant. The DM stated that he has been working with ADM to address the issue of food temperatures. He said, we are getting the food out quicker and he said that will resolve the issue of cold food. Interview on 05/21/2026 at 11:01 a.m., with LVN B revealed she was in the dining room during breakfast on 05/20/2026 and she observed the food did not appear hot when she was checking the meals for the meal ticket for accuracy. She stated she believes residents have a right to be served warm food. Interview on 05/21/2026 at 3:05 p.m., The ADM revealed the facility wanted the residents to enjoy their meals; hot foods should be served hot and cold foods should be served cold. He stated the facility kitchen was responsible for getting the temperatures correct and the nursing staff were responsible for getting the food to the residents in a timely manner, so the food was still hot. Record Review of Food Preparation dated 05/2014, revised 02/2026.Policy Statement All foods are prepared in accordance with the Federal Dietary Food Code.Procedures 12. When hot pureed, ground, or diced food drop in the danger zone (below 135 F), the mechanically altered food must be reheated to 165F for 15 seconds if held for hot service. 14. All foods will be held at appropriate temperatures, greater than 135F (or as state regulations) for hot hold, and less than 41F for cold food holding. 15. Temperatures for foods will be recorded at time of service and monitored periodically during meal service periods.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) Level I assessment accurately reflected the resident's status for 1 of 3 residents (Resident # 68) reviewed for PASARR Level I screenings. The facility failed to ensure the accuracy of the PASARR Level 1 screening for Resident #68. The PASARR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis major depressive disorder and bipolar disorder was present upon admission. The facility did not complete a 1012 form to update Resident #68 PASARR Level 1 with the diagnosis. These failures could place residents who had a mental illness at risk of not receiving a needed assessment (PASARR Evaluation), individualized care, or specialized services to meet their needs.Findings included: Record review of Resident #68's undated face sheet reflected an [AGE] year-old male who admitted to the facility on [DATE]. Resident #68 had diagnoses of Neurocognitive disorder with Lewy bodies (a progressive brain disorder caused by abnormal protein deposits called Lewy bodies), dementia in other diseases classified elsewhere, moderate mood disturbance (cognitive decline and significant affective symptoms (like depression or apathy) caused by an underlying medical condition), major depressive disorder (serious, common mental health condition characterized by persistent, severe low mood, loss of interest in activities, and low energy lasting at least two weeks), and post-traumatic stress disorder, unspecified (a diagnosis given when a patient exhibits trauma-related symptoms causing significant distress, but the clinical presentation or timeline (like exact onset or duration) lacks the specific details needed to meet the full diagnostic criteria for standard). Record review of Resident #68's MDS record dated 02/14/2026 reflected a BIMS score of 00, indicating severe impairment. Resident # 68 had a diagnosis of depression and post traumatic stress disorder (PTSD) which was labeled under psychiatric/mood disorders. Record review of Resident #68's care plan reflected a diagnosis of being at risk for psychosocial or emotional distress r/t PTSD. The care plan stated resident will not experience any distress or discomfort that will affect his functional well-being throughout his next review date. Record review of Resident #68's level 1 PASARR dated 02/06/2024 reflected that Resident #68 did not have evidence of a mental illness. An interview on 5/21/2026 at 1:20 PM was conducted with DON stated the facility's process for identifying residents with a possible MD, ID, or a related condition prior to admission to the facility was they process a PASSAR and they get the information from the health records, the information was entered into SIMPLE and the PASSAR people will come to the facility or wherever the resident was located, and based on the information provided will determine if they can have admission into the facility. The DON stated if the resident was identified as having a mental, intellectual disability or related conditions, once they entered the facility, they would have been referred to Psychic Services. She stated the social service coordinator was responsible for making the referral to the appropriate state designated authority. The DON stated if the resident had a change in condition after admission to the facility, they would get an order from the physician to consult Psych services. She stated the reason the referral was not made to the appropriate state authority was because they person was not familiar with the resident having the diagnosis or they did not think that was mental illness. The DON stated the negative affect that could have was that the resident would not get the services they need. An interview on 5/21/2026 at 1:47 PM was conducted with the MDS Coordinator she stated the facility's process for identifying residents with a possible MD, ID, or a related condition prior to admission to the facility was once they received the form from another facility, they will input the information into SIMPLE, and they will come and evaluate the resident. The MDS Coordinator stated if the resident was identified as having a mental, intellectual disability or related conditions after admission, they will resubmit the PASSAR and then LIDDA will come in and do the evaluation. She stated she was responsible for making the PASSAR referral by inputting the information into SIMPLE. The MDS Coordinator stated if a resident had a change in condition, a PL1 was the first assessment and if the diagnosis was incorrect, she will put correct numbers in and submit it to LIDDA. Record review of the facility's admission Criteria Policy revised March 2019 reflected: Policy Statement: Our facility admits only residents whose medical and nursing care needs can be met. 9. All new admissions and readmissions are screened for mental disorders (MD). Intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payor source, to determine if the individual meets the criteria for an MD, ID, RD. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process.

Abbreviations: Based on interview and record review, the facility failed to immediately notify the resident's representative when the resident experienced a change in condition for 1 of 3 residents (Resident #1) reviewed for a change of condition. The facility failed to notify Resident #1's Responsible Party (RP) when she was put on contact isolation precautions for E coli. This failure could place residents at risk delayed coordination when they experience a change in condition. Findings include: Record review of Resident #1's face sheet, dated 05/01/2026, reflected [AGE] year-old female admitted on [DATE] with diagnosis of personal history of urinary tract infection (a bacterial infection affecting the bladder, urethra, or kidneys). Record review of Resident #1's quarterly MDS assessment, dated 04/04/2026, reflected BIMS level of 15, intact cognition, and always incontinent for bladder and bowel (no episodes of continent voiding) Record review of Resident #1's nursing note, dated 04.18.2026, revealed Resident #1 continue to be on antibiotic therapy for a urinary tract infection, resident on contact isolation for e coli, isolation precaution in place, staff and resident reminders to handwash and wear proper personal protective equipment, fluids encouraged and consumed, no noted adverse effects. Record review of Resident #1's nursing progress notes written by LVN A, dated 04/16/2026 at 11:29, reflected a note Family came in this morning very upset that they were not notified by staff that Resident #1 was put on enhanced barrier precautions related to E. coli (E. coli infections are highly contagious, typically spreading via the fecal-oral route through contaminated food, water, or direct contact with infected people/animals) in her urine. I apologized to them for the inconvenience and mistake on our part. RP then stated that she would not be taking resident's laundry home per usual and she would like for facility to wash her laundry until treatment of Resident #1 was completed and then she would resume taking it home again. RP then came to nurse's station upset and verbally complaining about upset she was to not have received a phone call. She also spoke to nurse on 500 hall about it and then told me that she would be contacting our administrator regarding this incident. I apologized to the family once again and let he know it wound not happen again.[sic] Resident #1 remains on contact precautions for UTI: 3/10 days. During an interview on 05/01/2026 at 1:15 p.m., Resident #1 stated that she was told that she had E. coli in her urine and she was put on isolation when her roommate moved out to a different room. She stated that her RP was not notified when it happened. During an interview on 05/01/2026 at 3:21 p.m., Resident #1's RP stated that she was not notified regarding Resident #1 having E. coli infection in her urine and being put on contact isolation. She stated that she found out about this information when she came to the facility and spoke to Resident #1. She stated that not receiving the information about change of condition made her very upset and felt like she could not trust the facility, giving her truthful information about Resident #1's condition. During an interview on 05/01/2026 at 2:26 p.m., DON stated that per facility's policy they should notify Medical Director, nurse practitioner and RP immediately of resident's change of condition. She stated that charge nurse on Resident #1's unit was responsible to notify Resident #1's RP as soon as she received information about E. coli in urine and putting her on contact isolation. She stated that RP was notified about UTI status but not about E. coli in the urine and Resident #1's contact isolation status. She stated that not updating residents' RPs on change of condition including new infection could violate the resident's right regarding the notification of changes. During an interview on 05/01/2026 at 4:26 p.m., LVN A stated she spoke to Resident #1 RP on 04/16/2026 when she was upset about not being notified regarding Resident #1 being on contact isolation for E.coli in her urine. She stated that charge nurses were responsible for notification of physician, MD and RPs regarding change of condition. She stated that RP was notified by other charge nurses before her shift started regarding UTI status of Resident #1, but not regarding E. coli and implementation of contact isolation precautions. She stated that she was trained on notification of change of condition at hire and if RP was not informed immediately, it could cause delayed communication and violation of residents' rights. During an interview on 05/01/2026 at 4:36 p.m., MD stated that she was informed regarding Resident #1's change of condition including E. coli and contact isolation precautions. She stated that Resident #1's RP should be notified immediately regarding residents' status change including isolation precautions and new infection. Record review of Facility's policy Charting and Documentation dated July 2017 indicated: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in resident's medical record. 7. Documentation of procedures and treatments will include care-specific details, including f. Notification of family, physician of other staff, if indicated.

Based on interview and record review, the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 15 (Resident #1) residents reviewed for care plan revisions.The facility failed to revise Resident #1's care plan to reflect interventions for physical aggression r/t anger due to dementia on 02//15/2026.This failure could place residents at risk of not receiving appropriate interventions to meet their current needs. Findings included:Record review of Resident #1's admission record, dated 02/23/2026, revealed an [AGE] year-old male was admitted on [DATE]. Resident #1 had diagnoses which included: vascular dementia (progressive decline in thinking and memory skills caused by reduced blood flow to the brain), Alzheimer's disease (memory loss, cognitive decline, and behavioral changes due to brain cell death), and major depressive disorders (sad).Record review of Resident #1's Quarterly MDS assessment, dated 02/18/2026, revealed the resident had a BIMS score that was blank, which indicated Resident #1 was unable to complete the interview. Resident #1's behavioral symptoms on the Quarterly MDS revealed presence of physical aggression.Record review of Resident #1's care plan, dated 02/22/2026, revealed Resident #1was care planned on 05/10/2024 for cognitive function/dementia or impaired thought process r/t dementia with interventions to keep my routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion.Record review of Resident #1's care plan, dated 02/22/2026, revealed Resident #1 was care planned on 02/07/2026 and did not include interventions for physical aggression r/t anger due to dementia on 02/15/2026.During an interview on 02/22/2026 at 11:15 p.m., the DON stated it was expected for the care plans to reflect the current intervention for the behavior on 02/15/2026. The DON stated the MDS Coordinator was responsible for updating the care plans. The DON stated without the intervention updated it would not show what was put in place for Resident #1.During an interview on 02/22/2026 at 2:04 p.m., the MDS Coordinator stated she was responsible for updating the care plan interventions for 02/15/2026. The MDS Coordinator stated it was expected for her to update the care plan with the interventions of 1 to 1 so staff would know how to assist the residents. The MDS Coordinator stated he failed to update the most recent intervention date of 02/15/2026 for Resident #1.During an interview on 02/23/2026 at 4:11 p.m., Resident #1 stated he was safe but could not recall any incidents with any other residents that he may had.During an interview on 02/23/2026 at 4:20 p.m., the ADM stated it was expected for the MDS Coordinator to have updated Resident #1 behavior interventions on the care plan 02/15/2026. The ADM stated the MDS Coordinator was responsible for making sure the intervention was updated on 02/15/2026 to ensure Resident #1's individual needs would be met.Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 2001, revised March 2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.

Based on interview and record review, the facility failed to provide pharmaceutical services which includes the accurate acquiring and administering of medications to meet the needs for 1 (Resident #1) of 5 residents reviewed for pharmacy services, in that:The facility failed to administer Resident #1's Lorazepam medication according to physicians' orders on 12/16/2025, 12/17/2025, and 12/18/2025 resulting in Resident #1 getting double the amount of his scheduled medication.This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, could result in worsening or exacerbation of chronic medical conditions, and hospitalization.Review of Resident #1's face sheet dated 2/3/2026 reflected an [AGE] year-old male admitted on [DATE] with diagnoses that included vascular dementia (decline in cognitive function caused by impaired blood flow to the brain), Alzheimer's disease (progressive neurological brain disorder leading to cognitive decline), type 2 diabetes (blood sugar disorder), atrial fibrillation (heart rhythm disorder), chronic kidney disease and repeated falls.Review of Resident #1's quarterly MDS assessment reflected a BIMS score of 6 suggesting severe cognitive impairment.Review of Resident #1's care plan dated last review completed 12/10/2025, reflected the following problem: the resident is on pain medication therapy (opioid) [related to] pain or shortness of breath/pain or distress with intervention administer analgesic medications as ordered by the physician. Monitor/document side effects and effectiveness Q-Shift.Review of Resident # 1 orders in the EMR reflected a current physician order dated 10/19/2025 for: Lorazepam Tablet 0.5 MG Give 1 tablet by mouth every morning and at bedtime for Anxiety/Agitation related to DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, MODERATE, WITH OTHER BEHAVIORAL DISTURBANCE. And another physician order dated 10/23/2025 for Ativan Oral Tablet 1 MG (Lorazepam) Give 1 tablet by [sic] mouth every 4 hours as needed for Anxiety for 90 Days, discontinued on 1/21/2026.Review of Resident #1's December 2025 MAR reflected it had been signed off for his schedule Lorazepam tablet, 0.5 mg on: 12/16/2025 at AM12/16/2025 at Bedtime12/17/2025 at AM12/17/2025 at Bedtime12/18/2025 at AMReview of Resident #1's December 2025 narcotic count sheet reflected his Lorazepam 1.0 mg had been signed off as being given on 12/16/2025 at 6:50 am12/16/2025 at 8:00 pm12/17/2025 at 8:00 am12/17/2025 at 8:00 pm12/18/2025 at 8:00 amDuring an interview on 2/3/2026 at 2:40 pm, the DON stated the issues with Resident #1 medications were not a med error - it was a documentation error. The DON stated Resident #1 had two orders for Lorazepam, one scheduled at 0.5 mg and one prn at 1.0.mg. The nurses were using the 1 mg tablet and halving it - giving the resident half and wasting the other part. It was just a documentation error from the nurses wasting the other part of the tablet.During an interview on 2/3/2026 at 3:18 pm, the medical director stated she was aware of the narcotic med errors with Resident #1 and that nurses were wasting medications. She stated her concerns with Resident #1 getting more than his scheduled dose of Lorazepam was that he could have been more fatigued, tired, somnolent which could have translated to less activity and less eating. It may have made him unsteady on his feet, but he was already a high fall risk with a long history of falls and behaviors. During an interview on 2/3/2026 at 3:24 pm, LVN A stated she had worked on 12/17/2025 and gave Resident #1 his Lorazepam at 8pm. She stated she gave him a 1 mg tablet and signed off on the narcotic sheet that she gave a 1 mg tablet. LVN A denied wasting any part of the medication. She stated she signed off in the MAR that she gave Resident #1 0.5 mg, but she gave him 1.0 mg of Lorazepam. She stated she did not follow the order for the 0.5 mg tablet of Lorazepam. During an interview on 2/3/2026 at 4:04 pm, LVN B stated he had worked 12/18/2025 and gave Resident #1 his Lorazepam at 8:00 am. He stated Resident #1 ran out of his scheduled 0.5 mg tablet of Lorazepam, so he came him the 1 mg tablet of Lorazepam and signed it off in the MAR under his 0.5 mg tablet. LVN B denied wasting any part of the medication. LVN B stated he did not follow the order for the scheduled 0.5 mg tablet of Lorazepam. During an intervie w on 2/3/2026 at 4:18 pm, LVN C stated she had worked on 12/16/2025 and gave Resident #1 his AM dose of Lorazepam. She stated if she signed out on the narcotic sheet that she gave a 1 mg tablet, then that's what she gave the resident. She denied wasting any medication and stated if she had wasted any part of the medication she would have noted it in the narcotic count sheet and had another nurse witness the wasting. She stated she did not follow the order for the 0.5 mg Lorazepam that was scheduled.During an interview on 2/3/2026 at 4:36 pm, LVN D stated she had worked on 12/17/2025 and gave Resident #1 his AM dose of Lorazepam. She stated if I signed it [narcotic count sheet] , I'm assuming I gave it. She stated the 0.5 mg tablet was not there, so she gave the 1 mg tablet instead. She wanted resident #1 to have something for his anxiety. She stated later I realized I had signed off the MAR on the 0.5 mg order, and it was wrong, but I didn't get a chance to go back and check and fix it. LVN D denied wasting any medication and stated she gave Resident #1 the 1 mg tablet.An attempt was made to contact LVN E on 2/3/2026, but the call was not returned.During an interview on 2/4/2026 at 11:46 am, the pharmacy nurse stated she was aware of the issue with Resident #1's Lorazepam. She stated she had talked to the nurses (LVN A, B, C, D, E) and they said they were taking the 1 mg PRN tablet and administering half of it and the nurses just hadn't put that they had wasted half of the tablet on the narcotic count sheet. She stated, no one gave her a sufficient answer as to why they didn't document the wasting and she did not ask any of the nurses if they had had a witness when they wasted the medication. She stated Resident #1 was out of his scheduled 0.5 mg Lorazepam due to a lack of communication, so the nurses were using the PRN 1 mg dose instead.During an interview on 2/4/2026 at 3:06 pm, the ADM stated he was aware of the issues with Resident #1's Lorazepam medication. He stated his expectation was that staff will followed physician orders and they should not be signing them out on the narc sheet and not documenting appropriately in the MAR. He stated his concerns would be that we don't know if the patient actually got them - possible diversion.During an interview on 2/4/2026 at 3:14 pm, the DON stated her expectations are that staff will administer medications as ordered and they are supposed to document that way. She stated if staff was wasting medications, they should be doing that with another nurse as a witness and documenting this on the narcotic count sheet including the date and signature of the person that witnessed and the nurse giving the medication. She stated if medications were not documented correctly in the MAR, we don't know if residents got the medication as ordered - medication is not therapeutic as it's supposed to be.Review of the facility's policy Administering Medications, revision April 2019, reflected the following: Policy Statement Medications are administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation4. Medications are administered in accordance with prescriber orders, including any required time frame.22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record:a. the date and time the medication was administered;b. the dosage;c. the route of administration;d. the injection site (if applicable);e. any complaints or symptoms for which the drug was administered;f. any results achieved and when those results were observed; andg. the signature and title of the person administering the drug.Review of Facility Policy Controlled Substances, revision November 2022 reflected the following: Policy Statement The facility complies with all laws, regulations, and other requirements related to handling. storage, disposal. and documentation of controlled medications (listed as Schedule 11-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976). Policy Interpretation and ImplementationDispensing and Reconciling Controlled Substances2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following:a. Records of personnel access and usage;b. Medication administration records;c. Declining inventory records; and d. Destruction, waste and return to pharmacy records.

Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and establish policies and procedures to investigate any such allegations for two out of eight residents (Resident #1 and Resident #2). 1.The facility staff did not report Resident #1 and Resident #2's resident-to-resident altercation to the administrator immediately after the incident on 05/27/25. 2. The facility failed to report to Health and Human Services alleged abuse that occurred in the facility's secured unit on 05/27/25 involving Resident #1 and Resident #2. This failure resulted in the identification of Immediate Jeopardy (IJ) on 07/02/25 at 5:00pm. While the immediacy was removed on 07/03/25 at 12:58pm the facility remained out of compliance at scope of isolated and severity no actual harm due to the facility's need to monitor the implementation of the plan of removal. This failure could place residents at risk of ongoing abuse, neglect, pain, and diminished quality of life.Findings included: Review of Resident #1's face sheet, dated 06/07/25, reflected a [AGE] year-old male admitted on [DATE] with diagnoses of basal cell carcinoma of skin (skin cancer), iron deficiency anemia, vitamin D deficiency, chronic kidney disease, Alzheimer's disease, psychotic disturbance, mood disturbance and anxiety. Review of Resident #1's MDS assessment, dated 04/25/25, reflected a BIMS score of 04 reflecting severe cognitive impairment. The MDS did not indicate any behavior concerns. Review of Resident #1's care plan, dated 05/28/25, reflected Resident #1 can become aggressive when he perceived that others are invading his space. The relevant intervention was to monitor/document/report to MD PRN of any unexpected side effects to anti-anxiety therapy like mania, hostility, rage, aggressive or impulsive behavior and hallucinations. Review of Resident #1's progress notes on electronic medical record (EMR), dated 05/27/25 at 11:46 am authored by LVN A, reflected: While taking BS [a resident] before lunch, I heard screaming. Found resident [Resident #1] in the doorway standing up with his Foley dragging on the ground. His peer was lying on the floor. Resident punch his peer [Resident #2] who tried to enter his room in the face. His peer was punched to the ground, resident needed to be held back by staff to keep him from hitting his peer again. Resident was screaming I ain't done with him. Was able to talk resident down and keep him in his room to avoid further altercation. MD made aware. Will continue with plan of care. Progress notes of Resident #1 by LVN A on 05/27/25 at 14:40pm reflected: CNA notified this nurse that resident had bruising to the corner of left eye. When assessing resident eye noted pupil is enlarged and covering part of iris. Reached out to on-call MD, for sending out for CT of head. Also notified MD, who states to reach out to RP and if they prefer to be sent out or monitored in-house. RP- states to monitor in-house and if eye worsens to be sent out. MD made aware. Will continue with plan of care. Review of Resident #2's face sheet, dated 06/07/25, reflected an [AGE] year-old male admitted on [DATE] with diagnoses of Alzheimer's disease, mood disorder due to known physiological condition, type 2 diabetes, chronic kidney disease and unsteadiness on feet. Review of Resident #2's MDS, dated [DATE], reflected a BIMS score 8 reflecting moderate cognitive impairment. The MDS indicated physical and verbal behavioral symptoms directed towards others. Review of Resident #2's care plan, dated 05/28/25, reflected Resident #1 was at risk for elopement and/or wandering, r/t: cognitive impairment/judgement and enter other residents' rooms uninvited and do not want to leave as it happened on 05/27/25 . The relevant interventions were, assessing his continued need for residing on the memory care/secure unit and putting pictures on the wall beside the door of Resident #1's room to identify which room was his. Review of progress notes, dated 05/27/25 at 11:30 am, of Resident # 2 authored by LVN A reflected : While taking BS [a resident at the facility] heard resident scream. He (Resident #2) was found on the floor in the hallway, he had been punched in the face d/t entering another resident (Resident #1) room without permission. No injuries noted. Record review of Resident #1 and Resident #2's Q15 minute Behavior related time observation 72-hour hot box revealed 15 minutes check on Resident #1 and Resident #2 were commenced on 05/27/25 at 11:30 am and ended on 05/29/25 at 6:00 pm. Record review of safe surveys among the residents residing in memory care dated 05/27/25 revealed there were no negative remarks from any of the residents in the safe survey. During a telephone interview on 06/07/25 at 2:30pm, LVN A stated during her rounds on 05/27/25 at about 11:00 am, she saw Resident #1 in his bed sleeping. At about 11:30 am, while she was attending another resident, she heard a screaming from Resident #1's room. She stated she rushed to Resident #1's room to see Resident #2 was on the ground and Resident #1 was standing against him with [NAME]. LVN A said the staff intervened and separated them without further incidents. She said she had conducted a head-to-toe assessment on both and found no injuries, pain, or deformation. She stated both the residents spent the rest of the days with their normal activities. LVN A stated ,at about 2:30 pm, CNA B reported a hematoma at the left orbit of the left eye of Resident #1 . She stated during observation she noticed dilated pupils of the left eye as well. LVN A stated she immediately contacted the RP and NP for further instructions for care. LVN A said she was not sure if the injury occurred from the incident between Resident #1 and Resident #2 or an injury of unknown origin as there was no injuries observed during the initial assessment immediately after the incident . LVN A stated she reported the incident to UM. During a phone interview on 06/07/25 at 3:40 pm, CNA B stated she had witnessed the incident as she was in the 800 Hallway when the incident was occurred. She stated both Resident #1 and Resident #2 resided in Hall-800. CNA B stated at about 11:30 am, while she was doing the bed of Resident #2, she heard a loud argument between Resident #1 and Resident #2 . She stated Resident #2, who was shorter than Resident #1, was standing at the door of Resident #1 facing towards Resident #1. His right arm was up towards Resident #1's face, and in a fraction of a second, Resident #1 punched both of Resident #2's shoulders, and knocked him down. She stated she believed during the fall, Resident #2's right hand might have brushed Resident #1's left side of the face. She stated staff immediately intervened and deescalated the situation. She said she explained the incident to the charge nurse, LVN A, who was present to separate the residents. During an interview on 06/07/25 at 1:25 pm, the NP stated she visited and assessed Resident #1 on 05/28/25 . She stated she observed a hematoma at the left periphery of his left eye. The NP said there was no swelling or discomfort noticed at that time. She stated, during her assessment, Resident #1 asked her why everybody was inquiring if his eyes were hurting though he did not have any issue with his eyes. During an interview on 06/07/25 at 1:10 pm, the UM stated she was the manager for the memory care unit where Resident #1 and Resident #2 resided. She said the staff reported to her, that on 05/27/25 at about 11:30 am, Resident #1 knocked Resident #2 down to the floor when Resident #2 wandered into Resident #1's room. She stated Resident #2 was a wanderer whereas Resident #1 preferred to be in his room, and was protective of his personal space. The UM stated Resident #1 shared his room with another resident and he never had any issue with him, however, Resident #1 did not like if anyone else intruded into his space without his permission. The UM said Resident #1 and Resident #2 had no injuries from the incident, however, a few hours after the incident, Resident #1 developed a hematoma to the left side of his left eye. She added, it was unclear if the injury was from the incident between him and Resident #2. During another interview on 06/20/25 at 11:20 am, the UM stated she reported the incident on 05/27/25, immediately after the incident, to the DON. She stated she did not report the incident directly to the ADM, who was the abuse coordinator, since she had reported it to the DON so that he would report the incident to the ADM. During a phone interview on 06/07/25 at 1:10 pm, the DON stated he had not witnessed the incident, however, he saw the resident when the staff reported of the hematoma at the left eye area, and conducted a neuro assessment . He stated the facility informed the RP about the plan to send Resident #1 to the hospital, however the RP stated it would be okay to put him under observation at the facility if the injury was not serious. The DON stated, per his assessment, the resident had a discoloration at the periphery of the left eye with a dilated pupil. He stated no swelling , pain, or other issues were noticed . He stated the NP at the facility did an assessment on him later, and recommended to keep him under close observation at the facility. During an interview on 06/20/25 at 12:20 pm, the DON stated the UM phoned him and let him know about the incident, and he thought she had informed the ADM as well. He said per facility policy, any abuse or neglect were reported to the ADM, the abuse coordinator, directly instead of following the chain of command. He stated in-services conducted on abuse and neglect that covered reporting . He stated he was under the impression that all staff were aware of it. The DON stated he did not conduct any knowledge check on staff in this regard. The DON stated in-services were conducted by the clinical management team that included peoples like the DON, the Physical therapy manager and the wound care nurse. The DON stated, after the incident, the nurse conducted a head-to-toe assessment on Resident #1 and Resident #2, mental status assessments were completed on all residents to ensure emotional safety, safe surveys were conducted by the social worker, and the family and physician were contacted. The DON stated both the residents involved were under close monitoring every 15 minutes for 72 hours, and there were no incidents after the incident occurred on 05/27/25, between Resident #1 and Resident #2. During an interview on 06/20/25 at 10:30 am, CNA C stated she worked at the facility for about 3 years. She said she received in-services often on abuse and neglect. CNA C stated she would follow the chain of command and would report abuse and neglect to the nurse in charge. She stated she believed the abuse coordinator was the ADM though she was not very sure. During an interview on 06/20/25 at 10:20 am, the HK D stated he worked at the facility for two months. He stated he received abuse and neglect training during orientation. HK D stated if he witnessed any abuse or neglect, he would report it to the nurse in charge. He stated he did not know who the facility abuse coordinator was. During an interview on 06/20/25 at 11:55 am, MA E stated she would follow the chain of command and report any abuse or neglect to the nurse in charge so that she would be able to report it to the ADM who was the abuse coordinator. During an interview on 06/20/25 at 12:00 pm, CNA F stated she has been working at the facility since October 2024 . She said if she was in suspicion of any abuse or neglect at the facility, she would report that to the ADM and nurse in charge. CNA F stated she did not know who the abuse coordinator was. During an interview on 06/20/25 at 12:05 pm, CNA G stated she would report abuse or neglect to the nurse in charge of the unit on that day. She stated she did not know who the abuse coordinator was. An observation on 06/20/25 in Hall A, B, C and D revealed the abuse coordinator's name (ADM) and phone number was displayed in the nursing stations, instructing to contact him to report abuse and neglect. During an interview on 06/07/25 at 12:30 pm, the ADM stated he had no idea about any reportable incidents that occurred at the facility recently. He stated he was not aware of the altercation between Resident #1 and Resident #2 that occurred on 05/27/25. He stated he was not aware of it as no one reported to him. The ADM stated there was no specific system of reporting in writing, however, staff members generally met him at the office to report incidents or phoned him if he was away from facility. During an interview on 06/20/25 at 1:30 pm, the ADM stated he was the abuse coordinator, and it was his responsibility to report any reportable incidents reported to state agency. He stated, in his absence, it was delegated to other responsible team members and ensured that the incidents were reported by them in a timely manner in his absence. He stated the staff required further training in reporting abuse and neglect directly to him instead of following the chain of command. He stated he monitored if reportable incidents were reported to him, by reviewing the progress notes and reports in EMR, daily rounding in the facility by administrative staff, talking to residents about any concerns or incidents, discussing in the daily morning staff meeting, and reviewing 24 hours reporting forms. Record review on 06/20/25 of the in-services since 03/01/25 reflected revealed in-services on abuse and neglect and reporting were conducted on 6/18/25, 6/12/25,5/28/25, 5/12/25, 4/17/25, and 3/23/25. These in-services indicated: You should report ANE incidents immediately or no later than two hours after the incident occurs or suspected to Administrator /Abuse coordinator. It is the responsibility of everyone to stop any instances of ANE and then report it to the proper authorities. Immediately report abuse/neglect to the abuse and neglect coordinator [ADM] ph. xxxx. Record review on 06/07/255 of Texas Unified Licensure Information Portal (TULIP- the online portal used by healthcare providers in Texas to report various incidents, including those related to abuse and neglect) reflected no initial self-report by the facility for an incident occurred on 05/27/25 involving Resident #1 and Resident #2. Record review of the facility's policy Abuse Guidance: Preventing, Identifying and Reporting implemented in February 2017 reflected: . Seven Elements of ANE:Screening - All team members are to report any signs and symptoms or suspicions of abuse/neglect to the Administrator/Abuse Coordinator, their supervisor or to the Director of Nursing immediately.Training- All new and existing team members receive periodic in-service training relative to resident rights and abuse neglect and exploitation ANE prevention, identification, protecting and reporting.Prevention- The Administrator/Abuse Coordinator has the overall responsibility for the coordination and implementation of the ANE prevention and reporting program.Identification- It is the responsibility of our team members, consultants, attending physicians, family members, visitors, etc. to promptly report any incident of suspected neglect or resident abuse, including injuries of an unknown source, and theft or misappropriation of resident property to the Abuse Coordinator/Administrator and/or community's management.Protection- Our community will protect residents from harm during investigations of abuse allegations.Reporting/Response- All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities are individuals as may be required by law and per the current state/federal reporting requirements.Investigation- All phases of the investigation will be kept confidential in accordance with the Community's policies concerning the confidentiality of medical records.Reporting Allegations or Suspicions of Abuse :Allegations of, incidents of or suspicions of abuse or neglect are reportable to state authorities in accordance with HHSC's PL 19-17. A community owner, operator or team member who has knowledge of an allegation of or cause to believe that abuse, neglect, or exploitation has been allegedly occurred should report the suspicion or allegation of abuse, neglect, or exploitation to state authorities and may also be reported to local authorities as indicated.Report alleged or suspicions of abuse to HHSC by email reporting or via TULIP reporting within the designated time frames in accordance with HHSC's PL 19-17 (Replaces PL 17-18).Resident-to-resident altercation should be reviewed as a potential situation of abuse, as per HHSC's PL 19-17 (Replaces PL 17-18). On 07/02/25 at 5:00pm an Immediate Jeopardy (IJ) was identified. The ADM was notified. The ADM was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. The following Plan of Removal, submitted by the facility and accepted on 07/03/2025 at 12:58 pm, indicated the following: Plan of Removal Community's Name: [facility]Immediate Plan of Removal for: Abuse and Neglect/Resident to resident Failure to report. Immediate Response:All residents were immediately assessed by the nurse to ensure physical and emotional well-being. Date Completed: 7/2/2025.Outcome: No s/s of physical or emotional distressRisk Response:Risk: All residents and those who reside on the memory care unit may potentially be affected. Administrator/Social Worker/Director of Nursing/Designee will conduct team members and resident interviews to identify any concerns. If any are identified nursing and social service will assess, notify the physician, local authorities and the IDT and will review the plan of care as indicated. Date completed: 7/2/2025.Outcome: No negative outcomes were identified.Interviews with staff and residents and record review of inservice files on 07/03/25 revealed this was accomplished on 07/02/25. [NAME] President of Operations conducted re-education to the Director of Nursing and Administrator regarding the Abuse and Neglect, Identifying and Preventing; thus, having the identified risk identified on the plan of care and to ensure appropriate monitoring and supportive interventions are in place and an investigation is conducted. Date completed: 7/2/2025.Record review of the in-service folder on 07/03/25 revealed vice president of operations conducted an in service on 07/02/25. Review of the sign in sheet revealed Director on Nursing Services and Administrator had attended. During an interview on 07/03/25 the DON and ADM stated they attended the reeducation program. [NAME] President of Operations conducted a re-education of Abuse and Neglect reporting guideline to the Director on Nursing Services and Administrator. Date completed: 7/2/2025.Record review of the in-service folder on 07/03/25 revealed vice president of operations conducted an in service on 07/02/25. Review of the sign in sheet revealed Director on Nursing Services and Administrator had attended. During an interview on 07/03/25 the DON and ADM stated they attended the reeducation program. The Director of Nursing Services conducted education to the Assisted Director of Nursing Services, Memory Care Director, and Health Information Coordinator on Abuse and Neglect reporting guidelines and regarding the Abuse and Neglect, Identifying and Preventing; thus, having the identified risk identified on the plan of care and to ensure appropriate monitoring and supportive interventions are in place and an investigation is conducted. Date Completed: 7/2/2025. Record review of the in-service folder and interviews with various staff members on 07/03/25 revealed this was accomplished on 07/02/25. System Response: Director of Nursing / Assistant Director of Nursing, Health Information Coordinator and Memory Care Director conducted re-educated to the team members regarding the Abuse and Neglect, Identifying and Preventing; thus, having the identified risk identified on the plan of care and to ensure appropriate monitoring and supportive interventions are in place. Date completed: 7/2/2025.Record review of the in-service folder and interviews with various staff members on 07/03/25 revealed this was accomplished on 07/02/25. Director of Nursing / Administrator / Designee provided education to all team members regarding the process for monitoring, observing, and reporting all concerns, involving resident to resident altercations or s/s ANE, by anyone, including family, visitors or staff immediately to their immediate supervisor and administrator/abuse coordinator in order to protect the safety and well-being of all residents and to ensure appropriate interventions are in place and the care plan/ Kardex are adhered to as per facility's expected practices. Date completed: 7/2/2025.Record review of the in-service folder and interviews with various staff members on 07/03/25 revealed this was accomplished on 07/02/25. Director of Nursing / Designee to conduct re-education for all team members on Abuse and Neglect and reporting of Abuse and Neglect to all new team members and if when using agency staff. Date completed: 7/2/2025. Record review of the in-service folder and interviews with various staff members on 07/03/25 revealed this was accomplished on 07/02/25. Ad Hoc QAPI held with Administrator, Director of Nursing and Medical Director to review abuse and neglect policy, reporting abuse and neglect and review the plan of removal.Date Completed: 7/2/2025.Record review on 07/03/25 of the facility document Ad Hoc quality and performance improvement meeting revealed the meeting was conducted on 07/02/2025 to discuss Observations and monitoring regarding a resident-to-resident Altercation that occurred on the memory care unit. The review of the sign in sheet revealed 10 attendees including Administrator, Director of Nursing and Medical Director were participated. Monitoring Response: Director of Nursing / Administrator / Social Worker / Designee will conduct random daily rounds 3-7 days a week, on various shifts to validate the safety and well-being of our residents by conducting safe surveys. Director of Nursing/Designee will utilize an audit monitoring tool to review progress notes, changes in conditions, risk management reports and the nursing 24 hr report daily 5-7 days per week during the morning clinical meeting in order to validate appropriate follow up and necessary interventions are in place accordingly. The Administrator will provide oversight by monitoring and validating this task to confirm completions. The regional nurse assigned to the community will review this system during her visits to validate completed. This plan will remain in place for the next 2 months and findings will be reported to the QAPI committee during monthly meeting for the next 2 months. The QAPI committee will then determine compliance or identify a need for additional training. The Administrator was informed the Immediate Jeopardy was removed on 07/03/25 at 1:40 pm. The facility remained out of compliance at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

Based on interviews and record reviews, the facility failed to ensure that each resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 (Residents #1 and #2) of 12 residents reviewed for resident to resident altercations. The facility failed to prevent Resident #2 from being abused when Resident #1 punched him and knocked him on the floor, resulting in pain. Staff failed to notify the ADM, who was the abuse coordinator of the incident. This failure resulted in an IJ being identified on 07/22/25. The IJ template was provided to the facility on [DATE] at 6:05 p.m. While the IJ was removed on 07/23/25, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk of abuse, neglect, change in condition, and receiving untimely care and services. Review of Resident #1's admission Record, dated 07/22/25, reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] and had an RP. Resident #1 had medical diagnoses including late onset Alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior), dementia (a general term for a decline in mental ability, severe enough to interfere with daily life), and unsteadiness on feet. Review of Resident #1's Quarterly MDS, dated [DATE], reflected he had a BIMS score of 4/15, which indicated he had severe cognitive impairment. Resident #1 also had a fluctuated presence of inattention and disorganized thinking behaviors. Resident #1 had no other noted behavior symptoms. Resident #1 also had no wandering behaviors noted. Review of Resident #1's Care Plan, dated 05/05/25, reflected no notes related to aggression and other behaviors. Resident #1 had impaired cognitive function/dementia or impaired thought process related to Alzheimer's dementia. All staff was required to keep his routine and caregivers consistent to decrease confusion, administer medications as ordered, ask yes/no questions to determine his needs, and break tasks one step at a time. There was no other interventions noted. Resident #1 was also at risk for elopement and/or wandering with unsafe boundaries related to his dementia. Nursing staff and the SW was required to assess his continued need for residing in the memory care/secure unit and identify exit seeking patterns and intervene as appropriate to minimize behavior. There was no other interventions noted. Resident #1 also had a communication problem related to his Alzheimer's dementia. Nursing staff was required to anticipate and meet his needs, notify the MD PRN for changes in communication, and encourage him to continue stating thoughts even if he was having difficulty. There was no other interventions noted. Review of Resident #1's Progress Notes reflected:-A nursing progress note by LVN A on 05/27/25 at 11:38 a.m., While taking BS before lunch, I heard screaming. Found [Resident #1] in the door way standing up with his Foley dragging on the ground. [Resident #2] was lying on the floor. [Resident #1] punch [Resident #2] who tried to enter is room in the face. [Resident #2] was punched to the ground, [Resident #1] needed to be held back by staff to keep him from hitting [Resident #2] again. [Resident #1] was screaming, ‘I ain't done with him.' Was able to talk [Resident #1] down and keep him in his room to avoid further altercation. MD made aware. Will continue with plan of care. Review of Resident #2's admission Record, dated 07/22/25, reflected he was an [AGE] year-old male who was admitted to the facility on [DATE] and had an RP. Resident #2 had medical diagnoses including dementia, late onset Alzheimer's disease, repeated falls, mood disorder, unsteadiness on feet, and cognitive communication deficit. Review of Resident #2's admission MDS, dated [DATE], reflected he had a BIMS score of 8/15, which indicated he had moderate cognitive impairment. Resident #2 did not have any acute onset mental status change in behaviors noted. Resident #2 had physical and verbal behaviors directed towards others and other behavioral symptoms not directed toward others that occurred every 1-3 days noted. Resident #2 also had wandering behaviors that occurred every 1-3 days. Review of Resident #2's Care Plan, dated 04/08/25, reflected no notes related to aggressive behaviors. Resident #2 was also at risk for wandering with unsafe boundaries related to his cognitive impairment/judgement and safety awareness. Nursing staff and the SW were required to assess Resident #2's need for residing in the memory care unit and wander guard use as interventions for his wandering risk. There were no other interventions noted. Resident #2 also chose not to follow recommendations made by his physician and clinical team related to his care and services. Nursing staff were required to ensure his safety and health by attempting several times to provide care even if he initially refuses and to redirect and approach again when he was no longer agitated. There were no other interventions noted. Resident #2 also had a communication problem related to his Alzheimer's dementia. Nursing staff were required to anticipate and meet his needs and notify the MD PRN and nurse for changes in his communication. There were no other interventions noted. Resident #2 also had impaired cognitive function/dementia or impaired thought process related Alzheimer's dementia. All staff were required to keep his routine and caregivers consistent, administer medications as ordered, ask yes/no questions in order to determine his needs, and break tasks one step at a time. There were no other interventions noted. Review of Resident #2's Progress Notes reflected:-A nursing progress note by LVN C on 05/27/25 at 5:31 a.m., This morning, staff attempted to change [Resident #2] brief per routine care. However, [Resident #2] refused stating, ‘leave me alone.' Reattempt made later, but [Resident #2] became verbally aggressive, yelling ‘Get out.' No physical aggression observed. Will reattempt at a later time.-A nursing progress note by LVN A on 05/27/25 at 11:30 a.m., While taking BS heard [Resident #2] scream. [Resident #2] was found on the floor in the hall way, he had been punched in the face d/t entering another [Resident #1] room without permission. No injuries noted. VSS. 160/78, 64HR, 97%02 RA, 97.7, 18RR. Neuro checks in progress.-A nursing progress note by LVN A on 05/27/25 at 6:07 p.m., [Resident #2] continue to wander w/o walker and into peers room despite several reminders. Review of Resident #2's Pain Level Summary reflected his pain level was assessed using a PAINAD scale (a tool used to assess pain in individuals with advanced dementia who may not be able to verbally communicate their pain) on 05/27/25 at 9:12 p.m. and he exhibited 2/10 pain. During an interview on 06/07/25 at 10:00 a.m., Resident #1 stated he was fine and could not remember the incident with Resident #2 on 05/27/25. An attempt to interview Resident #2 was made on 06/07/25 at 10:30 a.m., but Resident #2 was unable to answer any questions about the incident with Resident #1 on 05/27/25 and deemed not interviewable. During an interview on 06/07/25 at 11:45 a.m., MA D stated she was working on 05/27/25. MA D stated on 05/27/25, she heard someone scream, turned around, and observed Resident #2 on the floor and Resident #1 was furious. MA D stated more staff came in and deescalated the incident. During an interview on 06/07/25 at 11:55 a.m., RN E stated Resident #1 was territorial and will not let other people enter his space. RN E stated Resident #2 was a wanderer with dementia. RN E stated she did not witness Resident #1 and #2's incident on 05/27/25. RN E stated she was informed that on 05/27/25, Resident #2 entered Resident #1's room, Resident #1 was standing at the doorway of his room, and Resident #1 punched Resident #2 down. RN E stated staff then intervened and deescalated the incident. During an interview on 06/07/25 at 12:30 p.m., the ADM stated he was not aware, and no one reported to him about Resident #1 and #2's incident on 05/27/25. During an interview on 06/07/25 at 1:10 p.m., the MCD stated Resident #1 preferred to be in his room, was protective of his personal space, and did not like if anyone intruded into his space without his permission. The MCD stated Resident #2 was a wanderer. The MCD stated staff reported to her that on 05/27/25 at about 11:30 a.m., Resident #2 wandered and invaded into Resident #1's room, Resident #1 knocked Resident #2 down to the floor, and Resident #2's hand went on Resident #1's face. During an interview on 06/07/25 at 2:30 p.m., LVN A stated she was working on 05/27/25. LVN A stated during her rounds on 05/27/25 at about 11:00 a.m., she observed Resident #1 sleeping in his bed. LVN A stated on 05/27/25 at about 11:30 a.m., she was attending to another resident, heard a scream coming from Resident #1's room, rushed to Resident #1's room, and observed Resident #2 on the ground and Resident #1 standing against him with [NAME]. LVN A stated staff intervened and separated Resident #1 and #2 without further incident. LVN A stated staff reported to her that Resident #2 wandered into Resident #1's room and Resident #1 knocked Resident #2 down. LVN A stated staff also reported that Resident #2's hand met Resident #1's face. LVN A stated she reported Resident #1's and #2's incident to the MCD. During an interview on 06/07/25 at 3:40 p.m., CNA B stated she was working on 05/27/25 and witnessed Resident #1 and #2's incident. CNA B stated on 05/27/25 at about 11:30 a.m., she was making Resident #2's bed when she heard a loud argument between Resident #1 and #2. CNA B stated she observed Resident #2 standing in front of Resident #1 in the doorway of Resident #1's room, Resident #2's right arm was up and towards Resident #1's face, and Resident #1 punched Resident #2's both shoulders and knocked him down. CNA B stated Resident #2's right hand might have brushed the left side of Resident #1's face. CNA B stated staff immediately intervened and deescalated the incident. CNA B stated her and LVN A separated Resident #1 and #2. CNA B stated she explained the incident to LVN A. During an interview on 06/20/25 at 11:20 a.m., the MCD stated she immediately notified the DON about Resident #1 and #2's incident on 05/27/25. The MCD stated she thought the DON reported the incident to the ADM, who was the abuse and neglect coordinator. During an interview on 06/20/25 at 11:30 a.m., the DON stated he was not present when Resident #1 and #2's incident occurred. The DON stated the MCD called and reported the incident to him. The DON stated the MCD was supposed to report the incident to the ADM. During an interview on 06/20/25 at 12:20 p.m., the DON stated the MCD notified him about Resident #1 and #2's incident on 05/27/25. The DON stated he thought the MCD also notified the ADM about the incident. During an interview on 07/22/25 at 1:55 p.m., MA D stated Resident #1 had a history of wanting his door shut and not wanting other residents and staff coming into his room. MA D stated Resident #1 would yell, Get out! if anyone came into his room and his door was left open. MA D stated nursing staff were taught to redirect other residents away from Resident #1's room whenever they wandered towards his room. MA D stated Resident #1 never been physically aggressive with other residents before the 05/27/25 incident. MA D stated Resident #2 had a history of getting up on his own and wandering into other residents' rooms. MA D stated Resident #2 also had a history of verbal aggression towards staff and other residents and telling other residents to, Shut up. MA D stated Resident #2 also had a history of pushing staff away in self-defense. MA D stated Resident #2 never been physically aggressive with other residents before the 05/27/25 incident. MA D stated sometime in the afternoon on 05/27/25, she was administering medications to residents in the memory care unit when she heard yelling. MA D stated she could not identify who was yelling. MA D stated she came to the area where she heard the yelling and observed Resident #2 on the ground screaming and yelling. MA D stated she also observed CNA B trying to help Resident #2 off the ground and asking him if he was okay. MA D stated she also observed Resident #1 standing in the doorway of his room. MA D stated Resident #1 told her that he did not want Resident #2 in his room. MA D stated CNA B told her that she was trying to get Resident #2 out of Resident #1's room. MA D stated she notified LVN A. MA D stated she was trained and in-serviced on abuse and resident to resident altercations by the MCD and DON before the incident on 05/27/25. MA D stated she learned to immediately notify a nurse, the DON, and ADM whenever there was a resident to resident altercation. MA D stated she did not know a resident to resident altercation could be resident abuse. MA D stated she defined resident abuse as hitting, verbal, sexual, and neglecting residents. During an interview on 07/22/25 at 3:31 p.m., LVN A stated Resident #1 had a history of not wanting other residents and staff in his room and would yell, Get out! of anyone came into his room and left his door open. LVN A stated nursing staff were taught to redirect other residents aware from Resident #1's room whenever they wandered towards his room. LVN A stated Resident #1 never been physically aggressive with other residents before the 05/27/25 incident. LVN A stated Resident #2 had a history of getting up on his own and wandering into other residents' rooms, falling, and unsteadiness on his feet. LVN A Stated Resident #2 also had a history of verbal and physical aggression towards staff and others. LVN A did not clarify who she meant by others. LVN A stated Resident #2 also told other residents to, Shut up, whenever he was yelled at by another resident. LVN A stated Resident #2 never been physically aggressive with other residents before the05/27/25 incident. LVN A stated on 05/27/25, she walked into the memory care unit, heard a loud noise, and heard someone yell, Ow! LVN A stated she believed Resident #2 yelled, Ow! LVN A stated she came to the area she where she heard the yelling and observed Resident #1 standing in the doorway of his room, both his fists were balled up, he was in a fighting stance, and he yelled, Get him the fuck out my room! LVN A stated she tried to hold back Resident #1, but he kept trying to push her out the way and said, I ain't done with him. LVN A stated she eventually was able to redirect Resident #1 back into his room and had to stand in front of the doorway of his room. LVN A stated she also observed Resident #2 on the floor and CNA B trying to help Resident #2 off the floor. LVN A stated CNA B told her that she witnessed Resident #1 reach out and punch Resident #2, Resident #2 fell to the ground, and that Resident #2 did not even have a chance to defend himself. LVN A stated she notified the MCD, MD, and both residents' families after the incident. LVN A stated she believed the MCD notified the DON after the incident. LVN A stated she believed Resident #1 deliberately hit Resident #2 and the incident was resident abuse. LVN A stated she was trained on abuse and resident to resident altercations before the incident on 05/27/25. LVN A stated she learned to immediately notify the ADM, who was the abuse and neglect coordinator, and the DON whenever there was a resident to resident altercation and resident abuse. During an interview on 07/22/25 at 5:01 p.m., CNA B stated Resident #1 had a history of not wanting other residents and staff in his room. CNA B stated Resident #1 would yell, Get out! if anyone came into his room and his door was left open. CNA B stated nursing staff were taught to redirect other residents away from Resident #1's room whenever they wandered towards his room. CNA B stated Resident #1 never been physically aggressive with other residents before the 05/27/25 incident. CNA B stated Resident #2 had a history of getting up on his own and wandering into other residents' rooms, falling, and unsteadiness on his feet. CNA B stated Resident #2 also had a history of verbal and physical aggression towards staff and yelling back, Shut up! whenever he got yelled at by another resident. CNA B stated Resident #2 never been physically aggressive with other residents before the 05/27/25 incident. CNA B stated on 05/27/25, she was in Resident #2's room changing his bed sheets and Resident #2 was standing next to his bed with his walker. CNA B stated Resident #2 walked out of his room while she was changing his bed sheets. CNA B stated she heard an argument ensue back and forth and remarks, such as, You don't belong here. This ain't your room. CNA B stated she could not identify who was making these comments. CNA B stated she came to the area where she heard the comments and observed Resident #1 standing in the doorway of his room, Resident #2 standing in front of Resident #1, Resident #1 leaned forward and towards Resident #2, Resident #1 punched Resident #2, Resident #2's right arm was up and made contact with one of Resident #1's cheeks, Resident #2 fell backwards onto the floor, and Resident #1's fists were balled up and he was in a fighting stance. CNA B stated she came next to Resident #2 and yelled for help. CNA B stated MA D and LVN A came to the area. CNA B stated MA D helped her get Resident #2 off the floor. CNA B stated Resident #1 was angry and said, This isn't his room. CNA B stated she told LVN A that she was changing Resident #2's bed sheets and she observed Resident #2 in the doorway of Resident #1's room, and she did not know if Resident #1 hit or pushed Resident #2 back. CNA B stated she believed LVN A notified the MCD and DON after the incident. CNA B stated she believed Resident #1 deliberately punched or pushed Resident #2 to the floor and the incident was resident abuse. CNA B stated she was trained on abuse and resident to resident altercations by the MCD and DON before the incident on 05/27/25. CNA B stated she learned to immediately notify the ADM, who was the abuse and neglect coordinator, and the DON whenever there was a resident to resident altercation and resident abuse. During an observation of the memory care unit on 07/23/25 at 11:50 a.m., there was a video camera mounted at the entrance of Resident #1's hall. During an interview on 07/23/25 at 12:02 p.m., the MS stated the video cameras do not work. Review of the facility's abuse and neglect in-services, dated 05/12/25, reflected, You should report ANE incidents immediately or no later than two hours after the incident occurs or suspected. ADM/Abuse Coordinator.It is the responsibility of everyone to stop any instances of ANE and then report it to the proper authorities. Immediately report abuse/neglect to the abuse and neglect coordinator [ADM]. Review of the facility's Abuse Guidance: Preventing, Identifying, and Reporting policy, revised January 2024, reflected, Compliance Guidelines: Every resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents should not be subjected to abuse by anyone, including, but not limited to, community team members, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. It is the responsibility of our team members, Community consultants, attending physicians, family members, visitors, etc. to promptly report any incident of suspected neglect or resident abuse, including injuries of an unknown source, and theft or misappropriation of resident property to Community management. Types of abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation of goods or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing.Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. This failure resulted in the identified of an IJ on 07/22/25. The ADM was notified and provided with the IJ template on 07/22/25 at 6:05 p.m. The following Plan of Removal was submitted by the facility and accepted on 07/23/25 at 4:20 p.m.: Community's Name: [Facility] Immediate Plan of Removal for: On 7/22/2025, an abbreviated survey was initiated at the community. On 7/22/25, the surveyor provided an IJ Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of the Immediate Jeopardy states as follows: The facility must ensure each resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitations. Immediate Response: All residents on MCU were immediately assessed by the nurse and social workers to ensure physical and emotional well-being documented on safe survey. Date Completed: 7/22/2025. Outcome: No s/s of physical or emotional distress Risk Response[PH1] : Risk: All residents and those who reside on the memory care unit may potentially be affected. [NAME] President of Operations conducted re-education on 7/22/2023, to the Director of Nursing and Administrator regarding Abuse and Neglect, Identifying and Preventing, to ensure appropriate monitoring and supportive interventions are in place, and an investigation is conducted. Education on Residents' Rights was provided to the Administrator and Director of Nursing Services. [NAME] President of Operations conducted a re-education of Abuse and Neglect reporting guidelines to the Director of Nursing Services and Administrator.Date completed: 7/22/2025 The Director of Nursing Services conducted education to the Assisted Director of Nursing Services, Memory Care Director, and Health Information Coordinator on Abuse and Neglect reporting guidelines and regarding the Abuse and Neglect, Identifying and Preventing; thus, having the identified risk identified on the plan of care and to ensure appropriate monitoring and supportive interventions are in place and an investigation is conducted.Date Completed: 7/22/2025 System Response: Director of Nursing / Assistant Director of Nursing, Health Information Coordinator, and designee conducted re-education to the team members regarding Abuse and Neglect and Resident Rights.Date Completed: 7/22/2025 Monitoring Response: Director of Nursing / Administrator / Social Worker I Designee will conduct random daily rounds 3-7 days a week, on various shifts to validate the safety and well-being of our residents by conducting safe surveys. If signs of agitation or indicators of aggression are displayed. The medical director and resident responsible party will be notified of the incident. There were no changes in the plan of care, but resident was referred to Psych. Services. Team members will report incidents to the Administrator, Director of Nursing Services, or Immediate Supervisor, and the community will follow best practices by redirecting and separating the residents. Policy will be followed to keep residents safe. Director of Nursing/Designee will utilize an audit monitoring tool to review progress notes, changes in conditions, risk management reports, and the nursing 24-hour report daily, 1-7 days per week during the morning clinical meeting to validate appropriate follow-up and necessary interventions are in place accordingly. The Administrator will provide oversight by monitoring and validating these tasks to confirm completions. Interventions will be updated in the careplan/Kardex. The regional nurse assigned to the community will review this system during her visits to validate completed. This plan will remain in place for the next 30 days, and findings will be reported to the QAPI committee during monthly meetings for the next 2 months. The QAPI committee will then determine compliance or identify a need for additional training. The Survey Team monitored the POR on 07/23/25 as followed: During interviews from 07/23/25 at 4:54 p.m. through 07/23/25 at 8:14 p.m., MA D, CNA F, CNA G, CNA H, LVN I, LA J, the HKM, LVN K, MSA, LVN L, DA M, DA N, CNA O, RN E, MA P, CNA Q, LVN R, LVN S, RN T,CNA U, LVN V, CNA W, CNA X, LVN Y, CNA Z, and CNA AA stated they were in-serviced before they began their shifts. They were in-serviced on resident to resident abuse and neglect, abuse, neglect, and resident rights. They were able to give examples, factors, and interventions of resident to resident abuse and neglect and resident rights. They were also in-serviced on immediately reporting ANE to the ADM, was the abuse and neglect coordinator, and immediate supervisor as soon as an incident occurred. During an interview on 07/23/25 at 6:28 p.m., the ADON stated she was in-serviced before she began her shift. She was in-serviced on resident to resident abuse and neglect, abuse, neglect, and resident rights. She was able to give examples, factors, and interventions of resident to resident abuse and neglect and resident rights. She was also in-serviced on immediately reporting ANE to the ADM, was the abuse and neglect coordinator, and immediate supervisor as soon as an incident occurred by the DON. During an interview on 07/23/25 at 6:36 p.m., the DON stated the VPO in-serviced him on 07/22/25 regarding resident rights, abuse, neglect, reporting, identifying and preventing ANE, ensuring appropriate monitoring and supportive interventions are in place, ensuring investigation was conducted, and immediately reporting ANE to the ADM, who was the abuse and neglect coordinator. The DON stated he in-serviced the staff on ANE, resident rights, and resident to resident ANE. During an interview on 07/23/25 at 6:44 p.m., the MCD stated the DON in-serviced her on abuse and neglect reporting guidelines, abuse and neglect, identifying and prevention, updating the plan of care after a resident to resident altercation to ensure appropriate monitoring and supportive interventions are in place, conducting proper ANE investigation, and immediately reporting ANE to the ADM, who was the abuse and neglect coordinator. During an interview on 07/23/25 at 6:48 p.m., the ADM stated the VPO in-serviced him on 07/22/25 regarding abuse, neglect, identifying and preventing ANE, ensuring appropriate monitoring and supportive interventions are in place to alleviate ANE, if resident to resident altercations have occurred they are care planned, confirm an investigation was conducted, and residents' rights and abuse and neglect reporting guidelines. The ADM stated he then in-serviced the nurses, CNAs, CMA, and ancillary staff on the above information. During an interview on 07/23/25 at 6:58 p.m., the VPO stated she in-serviced the ADM on 07/22/25 regarding abuse and neglect, identifying and preventing ANE, ensuring appropriate monitoring and supportive interventions were in place, and confirming a proper and thorough investigation was conducted. The VPO stated she also in-serviced the DON and ADM on residents' rights and abuse and neglect reporting guidelines. Review of the facility's resident safety surveys, dated 07/22/25, reflected all residents on MCU were immediately assessed to ensure physical and emotional well-being was documented. There were no signs or symptoms of physical or emotional distress. Residents from outside the MCU were also assessed and believed they were well taken care of, felt safe in the facility, staff followed procedures when caring for them, needs were being met, no one took anything from them without their permission, staff was not rough with them when providing care, no other residents threatened them, and no current concerns needed to be addressed. Review of the VPO's in-services, initiated and completed 07/22/25, reflected the VPO conducted a re-education to the DON and ADM regarding Abuse, Guidance: Preventing, Identifying, and Reporting, Abuse, Neglect, Exploitation, Misappropriation of Resident Property and other incidents that a nursing facility must report to the health and human services commission provider letter, resident rights, and statement of resident rights. Review of the DON's in-services, initiated and completed on unknown date, reflected the DON conducted a re-education to all staff on abuse/neglect/exploitation, resident to resident altercations, factors contributing to resident to resident altercations, consequences of resident to resident altercations, prevention and intervention techniques. Review of the DON's audit monitoring tool, July 2025, reflected progress notes, changes in conditions, risk management reports, and the daily nursing 24-hour report were reviewed on 07/23/25 and validated appropriate follow-up and necessary interventions are in place accordingly. Review of QAPI meeting attendees sheet, dated 07/22/25, reflected all QAPI members attended the meeting to determine compliance or identify a need for additional training The ADM was notified on 07/23/25 at 8:36 p.m. that the IJ was removed. While the IJ was removed on 07/23/25, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and establish policies and procedures to investigate any such allegations for two out of eight residents (Resident #1 and Resident #2) 1.The facility staff did not report Resident #1 and Resident #2's resident-to-resident altercation to the administrator immediately after the incident on 05/27/25. 2. The facility failed to report to Health and Human Services alleged abuse that occurred in the facility's secured unit on 05/27/25 involving Resident #1 and Resident #2. This failure resulted in the identification of Immediate Jeopardy (IJ) on 07/02/25 at 5:00pm. While the immediacy was removed on 07/03/25 at 12:58pm the facility remained out of compliance at scope of isolated and severity no actual harm due to the facility's need to monitor the implementation of the plan of removal. This failure could place residents at risk of ongoing abuse, neglect, pain, and diminished quality of life. Findings included: Review of Resident #1's face sheet dated 06/07/25, reflected a [AGE] year-old male admitted on [DATE] with diagnoses of basal cell carcinoma of skin (skin cancer), iron deficiency anemia, vitamin D deficiency, chronic kidney disease, Alzheimer's disease, psychotic disturbance, mood disturbance and anxiety. Review of Resident #1's MDS assessment, dated 04/25/25, reflected a BIMS score of 04 reflecting severe cognitive impairment. The MDS did not indicate any behavior concerns. Review of Resident #1's care plan dated 05/28/25 reflected Resident #1 can become aggressive when he perceived that others are invading his space. The relevant intervention was to monitor/document/report to MD PRN of any unexpected side effects to anti-anxiety therapy like mania, hostility, rage, aggressive or impulsive behavior and hallucinations. Review of Resident #1’s progress notes on electronic medical record (EMR) dated 05/27/25 at 11:46 am authored by LVN A reflected : “While taking BS [a resident] before lunch, I heard screaming. Found resident [Resident #1] in the doorway standing up with his Foley dragging on the ground. His peer was lying on the floor. Resident punch his peer [Resident #2] who tried to enter his room in the face. His peer was punched to the ground, resident needed to be held back by staff to keep him from hitting his peer again. Resident was screaming I ain’t done with him. Was able to talk resident down and keep him in his room to avoid further altercation. MD made aware. Will continue with plan of care.” Progress notes of Resident #1 by LVN A on 05/27/25 at 14:40pm reflected: “ CNA notified this nurse that resident had bruising to the corner of left eye. When assessing resident eye noted pupil is enlarged and covering part of iris. Reached out to on-call MD, for sending out for CT of head. Also notified MD, who states to reach out to RP and if they prefer to be sent out or monitored in-house. RP- states to monitor in-house and if eye worsens to be sent out. MD made aware. Will continue with plan of care.” Review of Resident #2's face sheet dated 06/07/25, reflected an [AGE] year-old male admitted on [DATE] with diagnoses of Alzheimer’s disease, mood disorder due to known physiological condition, type 2 diabetes, chronic kidney disease and unsteadiness on feet. Review of Resident #2's MDS, dated [DATE], reflected a BIMS score 8 reflecting moderate cognitive impairment. The MDS indicated physical and verbal behavioral symptoms directed towards others. Review of Resident #2's care plan dated 05/28/25 reflected Resident #1 was at risk for elopement and/or wandering, r/t: cognitive impairment/judgement and enter other residents' rooms uninvited and do not want to leave as it happened on 05/27/25 . The relevant interventions were, assessing his continued need for residing on the memory care/secure unit and putting pictures on the wall beside the door of Resident #1’s room to identify which room was his. Review of progress notes dated 05/27/25 at 11:30 am of Resident # 2 authored by LVN A reflected : “While taking BS [a resident at the facility] heard resident scream. He (Resident #2) was found on the floor in the hallway, he had been punched in the face d/t entering another resident (Resident #1) room without permission. No injuries noted….” Record review of Resident #1 and Resident #2’s “Q15 minute Behavior related time observation 72-hour hot box” revealed 15 minutes check on Resident #1 and Resident #2 were commenced on 05/27/25 at 11:30 am and ended on 05/29/25 at 6:00 pm. Record review of safe surveys among the residents residing in memory care dated 05/27/25 revealed there were no negative remarks from any of the residents in the safe survey. During a telephone interview on 06/07/25 at 2:30pm, LVN A stated during her rounds on 05/27/25 at about 11:00 am, she saw Resident #1 in his bed sleeping. At about 11:30 am, while she was attending another resident, she heard a screaming from Resident #1’s room. She stated she rushed to Resident #1’s room to see Resident #2 was on the ground and Resident #1 was standing against him with [NAME]. LVN A said the staff intervened and separated them without further incidents. She said she had conducted a head-to-toe assessment on both and found no injuries, pain, or deformation. She stated both the residents spent the rest of the days with their normal activities. LVN A stated ,at about 2:30 pm, CNA B reported a hematoma at the left orbit of the left eye of Resident #1 . She stated during observation she noticed dilated pupils of the left eye as well. LVN A stated she immediately contacted the RP and NP for further instructions for care. LVN A said she was not sure if the injury occurred from the incident between Resident #1 and Resident #2 or an injury of unknown origin as there was no injuries observed during the initial assessment immediately after the incident . LVN A stated she reported the incident to UM. During a phone interview on 06/07/25 at 3:40 pm, CNA B stated she had witnessed the incident as she was in the 800 Hallway when the incident was occurred. She stated both Resident #1 and Resident #2 resided in Hall-800. CNA B stated at about 11:30 am, while she was doing the bed of Resident #2, she heard a loud argument between Resident #1 and Resident #2 . She stated Resident #2, who was shorter than Resident #1, was standing at the door of Resident #1 facing towards Resident #1. His right arm was up towards Resident #1’s face, and in a fraction of a second, Resident #1 punched both of Resident #2’s shoulders, and knocked him down. She stated she believed during the fall, Resident #2’s right hand might have brushed Resident #1’s left side of the face. She stated staff immediately intervened and deescalated the situation. She said she explained the incident to the charge nurse, LVN A, who was present to separate the residents. During an interview on 06/07/25 at 1:25 pm, the NP stated she visited and assessed Resident #1 on 05/28/25 . She stated she observed a hematoma at the left periphery of his left eye. The NP said there was no swelling or discomfort noticed at that time. She stated, during her assessment, Resident #1 asked her why everybody was inquiring if his eyes were hurting though he did not have any issue with his eyes. During an interview on 06/07/25 at 1:10 pm, the UM stated she was the manager for the memory care unit where Resident #1 and Resident #2 resided. She said the staff reported to her, that on 05/27/25 at about 11:30 am, Resident #1 knocked Resident #2 down to the floor when Resident #2 wandered into Resident #1’s room. She stated Resident #2 was a wanderer whereas Resident #1 preferred to be in his room, and was protective of his personal space. The UM stated Resident #1 shared his room with another resident and he never had any issue with him, however, Resident #1 did not like if anyone else intruded into his space without his permission. The UM said Resident #1 and Resident #2 had no injuries from the incident, however, a few hours after the incident, Resident #1 developed a hematoma to the left side of his left eye. She added, it was unclear if the injury was from the incident between him and Resident #2. During another interview on 06/20/25 at 11:20 am, the UM stated she reported the incident on 05/27/25, immediately after the incident, to the DON. She stated she did not report the incident directly to the ADM, who was the abuse coordinator, since she had reported it to the DON so that he would report the incident to the ADM. During a phone interview on 06/07/25 at 1:10 pm, the DON stated he had not witnessed the incident, however, he saw the resident when the staff reported of the hematoma at the left eye area, and conducted a neuro assessment . He stated the facility informed the RP about the plan to send Resident #1 to the hospital, however theRP stated it would be okay to put him under observation at the facility if the injury was not serious. The DON stated, per his assessment, the resident had a discoloration at the periphery of the left eye with a dilated pupil. He stated no swelling , pain, or other issues were noticed . He stated the NP at the facility did an assessment on him later, and recommended to keep him under close observation at the facility. During an interview on 06/20/25 at 12:20 pm, the DON stated the UM phoned him and let him know about the incident, and he thought she had informed the ADM as well. He said per facility policy, any abuse or neglect were reported to the ADM, the abuse coordinator, directly instead of following the chain of command. He stated in-services conducted on abuse and neglect that covered reporting. He stated he was under the impression that all staff were aware of it. The DON stated he did not conduct any knowledge check on staff in this regard. The DON stated in-services were conducted by the clinical management team that included peoples like the DON, the Physical therapy manager and the wound care nurse. The DON stated, after the incident, the nurse conducted a head-to-toe assessment on Resident #1 and Resident #2, mental status assessments were completed on all residents to ensure emotional safety, safe surveys were conducted by the social worker, and the family and physician were contacted. The DON stated both the residents involved were under close monitoring every 15 minutes for 72 hours, and there were no incidents after the incident occurred on 05/27/25, between Resident #1 and Resident #2. During an interview on 06/20/25 at 10:30 am, CNA C stated she worked at the facility for about 3 years. She said she received in-services often on abuse and neglect. CNA C stated she would follow the chain of command and would report abuse and neglect to the nurse in charge. She stated she believed the abuse coordinator was the ADM though she was not very sure. During an interview on 06/20/25 at 10:20 am, the HK D stated he worked at the facility for two months. He stated he received abuse and neglect training during orientation. HK D stated if he witnessed any abuse or neglect, he would report it to the nurse in charge. He stated he did not know who the facility abuse coordinator was. During an interview on 06/20/25 at 11:55 am, MA E stated she would follow the chain of command and report any abuse or neglect to the nurse in charge so that she would be able to report it to the ADM who was the abuse coordinator. During an interview on 06/20/25 at 12:00 pm, CNA F stated she has been working at the facility since October 2024 . She said if she was in suspicion of any abuse or neglect at the facility, she would report that to the ADM and nurse in charge. CNA F stated she did not know who the abuse coordinator was. During an interview on 06/20/25 at 12:05 pm, CNA G stated she would report abuse or neglect to the nurse in charge of the unit on that day. She stated she did not know who the abuse coordinator was. An observation on 06/20/25 in Hall A, B, C and D revealed the abuse coordinator’s name (ADM) and phone number was displayed in the nursing stations, instructing to contact him to report abuse and neglect. During an interview on 06/07/25 at 12:30 pm, the ADM stated he had no idea about any reportable incidents that occurred at the facility recently. He stated he was not aware of the altercation between Resident #1 and Resident #2 that occurred on 05/27/25. He stated he was not aware of it as no one reported to him. The ADM stated there was no specific system of reporting in writing, however, staff members generally met him at the office to report incidents or phoned him if he was away from facility. During an interview on 06/20/25 at 1:30 pm, the ADM stated he was the abuse coordinator, and it was his responsibility to report any reportable incidents reported to state agency. He stated, in his absence, it was delegated to other responsible team members and ensured that the incidents were reported by them in a timely manner in his absence. He stated the staff required further training in reporting abuse and neglect directly to him instead of following the chain of command. He stated he monitored if reportable incidents were reported to him, by reviewing the progress notes and reports in EMR, daily rounding in the facility by administrative staff, talking to residents about any concerns or incidents, discussing in the daily morning staff meeting, and reviewing 24 hours reporting forms. Record review on 06/20/25 of the in-services since 03/01/25 reflected revealed in-services on abuse and neglect and reporting were conducted on 6/18/25, 6/12/25,5/28/25, 5/12/25, 4/17/25, and 3/23/25. These in-services indicated: “You should report ANE incidents immediately or no later than two hours after the incident occurs or suspected to Administrator /Abuse coordinator.” “It is the responsibility of everyone to stop any instances of ANE and then report it to the proper authorities. Immediately report abuse/neglect to the abuse and neglect coordinator [ADM] ph. xxxx.” Record review on 06/07/255 of Texas Unified Licensure Information Portal (TULIP- the online portal used by healthcare providers in Texas to report various incidents, including those related to abuse and neglect) reflected no initial self-report by the facility for an incident occurred on 05/27/25 involving Resident #1 and Resident #2. Record review of the facility’s policy “Abuse Guidance: Preventing, Identifying and Reporting” implemented in February 2017 reflected: “…… Seven Elements of ANE: Screening - All team members are to report any signs and symptoms or suspicions of abuse/neglect to the Administrator/Abuse Coordinator, their supervisor or to the Director of Nursing immediately. Training- All new and existing team members receive periodic in-service training relative to resident rights and abuse neglect and exploitation ANE prevention, identification, protecting and reporting. Prevention- The Administrator/Abuse Coordinator has the overall responsibility for the coordination and implementation of the ANE prevention and reporting program. Identification- It is the responsibility of our team members, consultants, attending physicians, family members, visitors, etc. to promptly report any incident of suspected neglect or resident abuse, including injuries of an unknown source, and theft or misappropriation of resident property to the Abuse Coordinator/Administrator and/or community’s management. Protection- Our community will protect residents from harm during investigations of abuse allegations. Reporting/Response- All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities are individuals as may be required by law and per the current state/federal reporting requirements. Investigation- All phases of the investigation will be kept confidential in accordance with the Community’s policies concerning the confidentiality of medical records. …Reporting Allegations or Suspicions of Abuse : Allegations of, incidents of or suspicions of abuse or neglect are reportable to state authorities in accordance with HHSC’s PL 19-17. A community owner, operator or team member who has knowledge of an allegation of or cause to believe that abuse, neglect, or exploitation has been allegedly occurred should report the suspicion or allegation of abuse, neglect, or exploitation to state authorities and may also be reported to local authorities as indicated… ….Report alleged or suspicions of abuse to HHSC by email reporting or via TULIP reporting within the designated time frames in accordance with HHSC’s PL 19-17 (Replaces PL 17-18)…. ….Resident-to-resident altercation should be reviewed as a potential situation of abuse, as per HHSC’s PL 19-17 (Replaces PL 17-18)…” On 07/02/25 at 5:00pm an Immediate Jeopardy (IJ) was identified. The ADM was notified. The ADM was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. The following Plan of Removal, submitted by the facility and accepted on 07/03/2025 at 12:58 pm, indicated the following: Plan of Removal Community’s Name: [facility] Immediate Plan of Removal for: Abuse and Neglect/Resident to resident Failure to report. Immediate Response: All residents were immediately assessed by the nurse to ensure physical and emotional well-being. Date Completed: 7/2/2025. Outcome: No s/s of physical or emotional distress Risk Response: Risk: All residents and those who reside on the memory care unit may potentially be affected. · “Administrator/Social Worker/Director of Nursing/Designee will conduct team members and resident interviews to identify any concerns. If any are identified nursing and social service will assess, notify the physician, local authorities and the IDT and will review the plan of care as indicated. Date completed: 7/2/2025.Outcome: No negative outcomes were identified.” Interviews with staff and residents and record review of inservice files on 07/03/25 revealed this was accomplished on 07/02/25. · “Vice President of Operations conducted re-education to the Director of Nursing and Administrator regarding the Abuse and Neglect, Identifying and Preventing; thus, having the identified risk identified on the plan of care and to ensure appropriate monitoring and supportive interventions are in place and an investigation is conducted.” Date completed: 7/2/2025. Record review of the in-service folder on 07/03/25 revealed vice president of operations conducted an in service on 07/02/25. Review of the sign in sheet revealed Director on Nursing Services and Administrator had attended. During an interview on 07/03/25 the DON and ADM stated they attended the reeducation program. · “Vice President of Operations conducted a re-education of Abuse and Neglect reporting guideline to the Director on Nursing Services and Administrator. Date completed: 7/2/2025.” Record review of the in-service folder on 07/03/25 revealed vice president of operations conducted an in service on 07/02/25. Review of the sign in sheet revealed Director on Nursing Services and Administrator had attended. During an interview on 07/03/25 the DON and ADM stated they attended the reeducation program. · “The Director of Nursing Services conducted education to the Assisted Director of Nursing Services, Memory Care Director, and Health Information Coordinator on Abuse and Neglect reporting guidelines and regarding the Abuse and Neglect, Identifying and Preventing; thus, having the identified risk identified on the plan of care and to ensure appropriate monitoring and supportive interventions are in place and an investigation is conducted. Date Completed: 7/2/2025.” Record review of the in-service folder and interviews with various staff members on 07/03/25 revealed this was accomplished on 07/02/25. System Response: · “Director of Nursing / Assistant Director of Nursing, Health Information Coordinator and Memory Care Director conducted re-educated to the team members regarding the Abuse and Neglect, Identifying and Preventing; thus, having the identified risk identified on the plan of care and to ensure appropriate monitoring and supportive interventions are in place. Date completed: 7/2/2025.” Record review of the in-service folder and interviews with various staff members on 07/03/25 revealed this was accomplished on 07/02/25. “Director of Nursing / Administrator / Designee provided education to all team members regarding the process for monitoring, observing, and reporting all concerns, involving resident to resident altercations or s/s ANE, by anyone, including family, visitors or staff immediately to their immediate supervisor and administrator/abuse coordinator in order to protect the safety and well-being of all residents and to ensure appropriate interventions are in place and the care plan/ Kardex are adhered to as per facility’s expected practices. Date completed: 7/2/2025.” Record review of the in-service folder and interviews with various staff members on 07/03/25 revealed this was accomplished on 07/02/25. · “Director of Nursing / Designee to conduct re-education for all team members on Abuse and Neglect and reporting of Abuse and Neglect to all new team members and if when using agency staff. Date completed: 7/2/2025.” Record review of the in-service folder and interviews with various staff members on 07/03/25 revealed this was accomplished on 07/02/25. · “Ad Hoc QAPI held with Administrator, Director of Nursing and Medical Director to review abuse and neglect policy, reporting abuse and neglect and review the plan of removal. Date Completed: 7/2/2025.” Record review on 07/03/25 of the facility document “Ad Hoc quality and performance improvement meeting” revealed the meeting was conducted on 07/02/2025 to discuss “Observations and monitoring regarding a resident-to-resident Altercation that occurred on the memory care unit”. The review of the sign in sheet revealed 10 attendees including Administrator, Director of Nursing and Medical Director were participated. Monitoring Response: · Director of Nursing / Administrator / Social Worker / Designee will conduct random daily rounds 3-7 days a week, on various shifts to validate the safety and well-being of our residents by conducting safe surveys. · Director of Nursing/Designee will utilize an audit monitoring tool to review progress notes, changes in conditions, risk management reports and the nursing 24 hr report daily 5-7 days per week during the morning clinical meeting in order to validate appropriate follow up and necessary interventions are in place accordingly. The Administrator will provide oversight by monitoring and validating this task to confirm completions. The regional nurse assigned to the community will review this system during her visits to validate completed. · This plan will remain in place for the next 2 months and findings will be reported to the QAPI committee during monthly meeting for the next 2 months. The QAPI committee will then determine compliance or identify a need for additional training. The Administrator was informed the Immediate Jeopardy was removed on 07/03/25 at 1:40 pm. The facility remained out of compliance at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

Based on observation and interview, the facility failed to ensure all drugs and biologicals were in locked compartments and inaccessible to unauthorized staff, visitors, and residents for 1 of 2 medication carts (Med Cart #1) reviewed for medication storage in that: The facility failed to prevent Med Cart #1 from being unattended and unlocked against the wall across from the nurses' station on the 300/400 Hall on 6/24/2025. This failure could allow residents, visitors, staff, and unauthorized individuals unsupervised access to prescription and over-the-counter medications. Findings Include: Observation on 6/24/2025 at 4:10 am revealed, Med Cart #1 sitting against the wall across from the nurses' station on the 300/400 Hall was unsupervised and unlocked. A review of the contents of Med Cart #1 revealed prescription and over-the counter medications and ointments, glucometer supplies, insulin pens, and insulin syringes. MA-A was not in visible sight and there were no staff in the nurses' station. Multiple staff members were escorting residents to the dining room for dinner and walked past the cart. Two residents in wheelchairs, wheeled by the med cart when no staff were present. The DON approached the nurses' station and was informed by the surveyor that the medication cart was unlocked. During an interview on 6/25/2025 at 1:50 PM MA-A revealed she had been in her position for thirteen months, she stated the DON informed her Med Cart #1 had been left unlocked. She stated it should have been locked when she was assisting with dinner. She said, If anything goes missing, it falls on us. We have controlled drugs, and we do not want anyone to go into our cart. She identified adverse outcomes as unauthorized persons could take the drugs and distribute them. During an interview on 6/25/2025 at 2:05 PM the DON revealed he had been employed at the facility for three years. He stated it was everyone's responsibility to lock the med cart. He said his expectation was the medication carts should have been locked. He said he had started in-servicing staff on the importance of locking the medication carts. During an interview on 6/25/2025 at 2:20 PM the ADM revealed his expectation was the medication cart should have been locked.

Based on interviews and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 (Resident #1) of 12 residents reviewed for elopement. 1. The facility failed to ensure Resident #1's wander guard bracelet was secured on his wrist so he could not remove it before he eloped from the facility on 03/15/25. 2. The facility failed to ensure staff noticed Resident #1 was missing until approximately 11 hours after he left the faciity on [DATE]. An IJ was identified on 03/21/25. The IJ template was provided to the facility on [DATE] at 4:57 p.m. While the IJ was removed on 03/22/25, the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm because of the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving adequate supervision, injury, and death. Findings included: Review of Resident #1's Admission Record, dated 03/21/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, unspecified dementia, depression, and unsteadiness on feet. Resident #1 had an MPOA and FPOA, which were his responsible parties. Review of Resident #1's Admission and Modified MDS Assessments, dated 12/25/24, reflected he had a BIMS score of 12, which indicated he had moderate cognitive impairment. Resident #1 used a wander/elopement alarm daily. Resident #1 required supervision with toileting, bathing, dressing, and transferring, set-up assistance with personal and oral hygiene, and was independent with eating and repositioning. Review of Resident #1's Admission Assessment, dated 03/21/25, reflected he was a high risk for elopement and had on one or more occasions attempted to exit or had exited the facility. Review of Resident #1's Care Plan, dated 01/01/25, reflected he was exit-seeking and at risk for elopement and/or wandering with unsafe boundaries related to his dementia. Resident #1 was also at risk for falls related to his unsteady gait, poor balance, history of falls, osteoarthritis, and dementia. Review of Resident #1's Order Summary Report, dated 03/21/25, reflected he had the following active orders: -Check Functionality of the Wander Guard/Alert Device: may use system check wand or use door alarm to confirm functionality every shift for Wandering/Exit Seeking related to Alzheimer's disease ordered and started on 12/19/24 -Check placement of wander guard/roam alert on (left wrist). Document N = Not present/Not in place - replace and document in progress notes. Y - Yes, Present/in place (Add N/Y to supplementary documentation) every shift for Wandering/Exit Seeking related to Alzheimer's disease ordered and started on 12/19/24 Review of Resident #1's Psychological Services Progress Note, dated 02/28/25, reflected, Patient reported some increase in depression. He stated that he has been rethinking his feelings about nursing home placement because he is realizing that he is not going to be able to do some of the things he wants to do .Patient continues to appear impulsive and somewhat grandiose and unrealistic in his thinking. Another Psychological Services Progress Note also reflected he could travel outside the home only when accompanied and supervised. Review of Resident #1's Hotel Registration, printed on 03/15/25 at 2:14 p.m., reflected Resident #1's arrived at the hotel on 03/15/25 and signed his check in registration in-person. Review of Resident #1's Progress Notes reflected there were no notes from 02/21/25 through 03/15/25. The progress notes also reflected: -A note by LVN A on 03/16/25 at 6:01 a.m., This nurse was notified by CNA's at approx. 2130 (9:30 p.m.) that resident had not been seen since the beginning of the shift. We began searching his regular spots, like the library and dining room. When we couldn't locate him, RN supervisor was informed and she notified DON and administrator. Family was notified and Police and PD were also informed and responded to the incident. Every hall was instructed to check every room, bathroom, closet and office. The perimeter of the building was searched and Police searched the entire property by their patrol vehicles. DON and administrator were informed and administrator arrived to the facility to aid in the investigation. PD was informed and also arrived on scene to obtain more information about resident's appearance and other pertinent information. Family was informed and kept updated throughout the shift. -A note by the DON on 03/16/25 at 8:26 a.m., Notified by CNAs on duty that resident was not located in room upon rounds. Staff immediately initiated room search which then extended to entire community and campus without identifying resident's location. Said nurse immediately called Administrator, Police and PD to inform of possible missing person. PD onsite and additional details were provided. Family reported that resident has previously done this before and to notify them if resident's whereabouts are identified. Resident confirmed that he left the community yesterday evening with the intention of not returning. Resident is A&O x 4 and verbalized his plans of moving from the area to Oklahoma where he has friends. Resident was asked why he failed to alert the staff of his intentions and resident replied that he chose not to alert staff because he thought that the staff would not allow him to leave the facility. Resident reports that he is not happy with his family and does not want his family making his decisions. Resident has communicated that he is capable of making his own decisions and intends on doing so. Resident is in a local hotel room and reports that his plan continues to be to go to a friend's home and ultimately plans to move to Oklahoma. He stated that may consider a community in Oklahoma or wants his own apartment. He also reported that he is going to store tomorrow to get a phone, but for now he will remain at his hotel. Resident was informed that his PCP has provided orders that he is discharged from community AMA and that his medications will be released to him and that a nurse will review the medications with him as recommended and that Home Health will be referred if he is agreeable. Resident was informed that out of an abundance of caution community will refer to APS for wellness checks as well as possible assistance that he may need for relocating since resident is not agreeable to remain in the facility. Resident was informed that any additional belongings he may have in the community will also be brought to him at the hotel along with his medications and that in good faith the community is going to have a nurse review his medications with him to ensure he is able to properly administer and that we strongly recommend that he allow home health services. Despite education and resident has been discharged AMA at his request. Community will adhere to MD's recommendations for home health referral and out of an abundance of caution SW will notify APS for a wellness check and any additional support that resident may need. -A Late Entry note by the SW on 03/16/25 10:00 a.m., SW was notified that resident expressed a desire to no longer reside at facility. SW was asked to bring the AMA waiver to resident's location. The waiver was signed by resident, with a nurse serving as the witness. SW conducted a Brief Interview for Mental Status exam with resident, scoring 9. Additionally, SW provided information regarding a nursing home in Oklahoma, which resident expressed interest in. Upon returning to facility, SW immediately called APS to report resident leaving AMA. Review of Resident #1's BIMS Evaluation, dated 03/16/25 at 1:46 p.m. by SW, reflected he had a BIMS of 9, which indicated his cognitive status declined since his admission. Review of Resident #1's AMA Waiver, dated 03/16/25 12:25 p.m., reflected Resident #1 reviewed and signed the waiver with LVN B. Review of the facility's Provider Investigation Report reflected the RN Supervisor notified the facility on 03/16/25 that on 03/16/25 at 12:30 a.m., Resident #1 was not present in his room. There were no witnesses. Investigation Summary reflected, At approximately 9:45 p.m., CNAs reported to their charge nurse that they last recalled seeing Resident #1 on 03/15/25 around 6:30 p.m. The charge nurse promptly informed the RN Supervisor, who prompted the team to initiate an initial search. The facility conducted a search of the entire community and immediate area outside the community and could not locate Resident #1. On 03/16/25 at approximately 12:30 a.m., the RN Supervisor notified the ADM, DON, and police. During this process, the RN Supervisor discovered an itinerary in the copy room containing various pertinent details, including information regarding a train company, cab company, hotel, and bank. This information was communicated to the ADM and responding police officer upon their arrival on-site. The search efforts were then expanded within the community by reaching out to the contacts and businesses listed on the itinerary. The ADM first contacted the hotel at approximately 2:00 a.m., only to be informed that Resident #1 was not present there. However, later that morning, the memory care director contacted the hotel again and was informed that Resident #1 was indeed at the hotel. In response, the memory care director, accompanied by another team member and a social worker, proceeded to the hotel to retrieve Resident #1. An assessment was conducted, and attempts were made to persuade Resident #1 to return to the community; however, Resident #1 declined. Resident #1 who has a BIMS of 12 and when assessed by the charge nurse on site shared, he is alert and oriented x4, explained that he had intentionally departed from the community without signing out or notifying his nurse, as he believed the nurse would not support his desire to visit a friend. He expressed plans to continue to a friend's home in Oklahoma, where he preferred to be. Resident #1 was subsequently informed that should he choose not to return, he would need to sign out of the community AMA, which he proceeded to do. One of the team members then returned to the community to collect all of his medications and APS was notified. Additionally, his family was informed that he had been located and was safe. The following morning, the community dispatched a charge nurse back to Resident #1's hotel room to conduct a health and welfare check, ensuring that he remained safe, alert, and oriented. Upon this visit, it was confirmed that he was indeed safe, alert, and oriented, and his family had arrived at the hotel. The facility's investigation findings were unfounded. Staff were in-serviced on elopement response on unknown date by unknown person, abuse and neglect reporting on unknown date by the DON, and medication administration documentation on unknown date by the DON. There were no in-services related to checking residents' wander guard devices to ensure functionality and placement. During facility's immediate response, staff identified Resident #1's exit seeking device was removed and left within the community. There were no immediate, risk, system, and monitoring response interventions related to checking and ensuring all other residents' wander guard devices and wander guard alarm system were functional and in place. Staff statements reflected CNA C observed Resident #1 on 03/15/25 in the early afternoon, CNA D observed Resident #1 around 3:00 p.m., CNA F observed Resident #1 lying in his bed around 5:45 p.m., CNA E observed Resident #1 lying in his bed around 6:00 p.m., LVN A observed Resident #1 lying in his bed at approximately 6:20 p.m., the RN Supervisor was notified by LVN A that Resident #1 was missing at approximately 10:00 p.m., and the Memory Care Director called and found Resident #1 at a hotel on unknown date. During an interview on 03/21/25 at 11:40 a.m., the ADM stated Resident #1 was discharged from the facility. The ADM stated he could not recall the exact discharge date . During an interview on 03/21/25 at 11:49 a.m., Resident #1's FAM stated Resident #1 wore a wander guard device at the facility. FAM stated LVN G called and told them on 03/15/25 at 10:30 p.m. the facility staff were unable to locate and were searching for Resident #1. The FAM stated LVN G called and told them on 03/16/25 at 12:00 a.m. that Resident #1 was last seen lying in his bed in his room on 03/15/25 at 6:30 p.m. The FAM stated on 03/16/25 at 12:46 p.m., the ADM called and told them Resident #1 was found at a hotel, did not want to return to the facility, staff conducted a BIMS evaluation, and allowed Resident #1 to sign himself out AMA. The FAM stated Resident #1 told them he was able to take off the wander guard device on his own, had taken off his wander guard device, and placed it in his dresser one month ago (February 2025). The FAM stated Resident #1 told them he left the facility through the front door, and they did not know if anyone observed Resident #1 leave the facility. The FAM stated Resident #1 told them he got a ride to the hotel by giving his walker to some strangers. The FAM stated Resident #1 told them he fell in the hotel shower and scraped his knee. The FAM stated Resident #1 was in denial about his dementia, limitations, and was a high fall risk. The FAM stated they took Resident #1 to the hospital on 03/17/25 to be evaluated because they believed the facility did not evaluate him. During an interview on 03/21/25 at 2:16 p.m., Resident #1 stated he took off his wander guard device one month ago and staff did not notice him not wearing it since he took it off. Resident #1 stated staff last checked on him on 03/15/25 around 7:00 a.m., he ate breakfast in his room around 8:00 a.m., walked out the facility's front door around 11:00 a.m., and did not return. Resident #1 stated no one observed him walk out the facility's front door because the receptionist and staff were all on a break and not present. Resident #1 stated he did not tell anyone that he left the facility because it was nobody's business, and he did not want to return to the facility. Resident #1 stated he left the facility because the facility ran out of tissue paper. Resident #1 stated he walked for two hours to a store (approximately 2.8 miles from the facility), got a ride at some point to the store, got another ride to the hotel, and arrived at the hotel (approximately 10 miles from the store) around 3:00 p.m.-4:00 p.m. Resident #1 stated he lost his balance, fell , and hit his shin while taking a shower at the hotel on the morning of 03/16/25. Resident #1 stated he often fell before his admission to the facility. Resident #1 stated the facility staff found him at the hotel on 03/16/25 around 11:00 a.m. Resident #1 stated the SW had him sign an AMA after he told the facility staff he did not want to return to the facility. Resident #1 stated his FAM were his POAs and the facility typically notified his FAM for decisions about his care. Resident #1 stated he went to the hospital from 03/17/25 through 03/21/25 and did not know why he was kept at the hospital. An attempt to call and interview the MD was made on 03/21/25 at 3:08 p.m. The phone number provided was a general phone number. During an interview on 03/21/25 at 3:09 p.m., the NP stated she expected CNAs and nurses to make hourly rounds on the residents. The NP defined elopement as someone attempting to leave and was deemed as not being safe to be on their own. The NP stated she did not know Resident #1 was an elopement risk. The NP stated Resident #1 had dementia, history of elopement, and wore a wander guard device. The NP stated she did not know if it was safe for Resident #1 to be out alone without supervision because he had mild dementia and took medications to slow down his dementia progression. The NP stated the wander guard alarm rang if a resident tried to leave the facility. The NP stated she did not know how often the wander guard was required to be checked. The NP stated she expected the nurses to check residents' wander guard devices daily, notify her if a resident took off the wander guard device and said, Because it's for safety. The NP stated she knew the importance of checking residents' wander guard devices and said, It was a device used to determine if a resident left the facility unsupervised. It's a safety issue. It's not supposed to be easy to take off a wander guard. The wander guards were supposed to be placed securely around residents' ankles or wrists. During an interview on 03/22/25 at 9:34 a.m., RN F stated CNAs and nurses were responsible for checking on residents every two hours. RN F stated she defined elopement as when a resident left the facility or locked unit. RN F stated residents' wander guards were to be checked daily and placed on a resident's right arm. RN F stated she never observed a resident take of their wander guard and believed residents could find a way of taking off their wander guard. RN F stated she knew the importance of checking residents' wander guard devices and said, To ensure safety and make sure the resident was able to use it and make sure the alarm worked. I'm sure there were some that would try and take it off. Residents could go any number of places, walk out in the street, and be injured or taken any numbers of ways and unimaginable things. During an interview on 03/22/25 at 10:04 a.m., CNA G stated she checked on residents every hour. CNA G stated she knew the importance of checking on residents and said, To know where resident was and to prevent falls. CNA G stated she defined elopement as a resident getting out of the facility. CNA G stated she would search for the resident if a resident was missing and notify the nurse if she could not find the resident. CNA G stated CNAs and nurses checked residents' wander guards and ensured the wander guards were functioning and in place daily. During an interview on 03/22/25 at 10:14 a.m., LVN H stated CNAs and nurses were required to check on residents every two hours. LVN H stated she defined elopement as a resident leaving the facility and was unable to be found without anyone knowing. LVN H stated nurses were responsible for checking residents' wander guard devices and ensuring they were functioning and in place. LVN H stated she knew the importance of checking residents' wander guard devices and said, Residents could go missing, and staff could just not know that residents were outside. During an interview on 03/22/25 at 10:31 a.m., CNA I stated CNAs and nurses were responsible for checking on residents every 15 or 20 minutes. CNA I stated she could not define elopement because she did not know what it meant. CNA I stated she would immediately notify a nurse and search for the resident if a resident was missing and she was unable to locate the resident. CNA I stated she was unsure who was responsible for checking residents' wander guard devices to ensure they were functioning and in place. CNA I stated she knew the importance of checking residents' wander guard devices and said, Just in case a resident took off, to make sure the wander guard alarm goes off, residents don't walk out the building and get lost, and so we wouldn't know they were gone because it could be devastating. During an interview on 03/22/25 at 10:51 a.m., the Memory Care Director stated CNAs and nurses checked on residents every two hours. The Memory Care Director stated she defined elopement as someone leaving the facility. The Memory Care Director stated she would look for the resident if a resident was not in their room and notify the DON and the ADM if the resident was still missing. The Memory Care Director stated nurses checked residents' wander guard devices to make sure they were functioning and in place. The Memory Care Director stated she knew the importance of checking the wander guard devices and said, So you know if a resident left and could locate the resident. The resident could disappear, and no one could know where they were at. During an interview on 03/22/25 at 11:02 a.m., CNA J stated CNAs and nurses checked on residents every 30 minutes. CNA J stated she knew the importance of checking on residents and said, Because a resident could go missing or fall. CNA J stated she would locate a resident and notify the nurse if she could not find a resident. CNA J stated CNAs and nurses were responsible for checking residents' wander guard devices. CNA J stated she knew the importance of checking residents' wander guard devices and said, If we don't, residents will wander out the doors. Very important. During an interview on 03/22/25 at 11:14 a.m., the MS stated the RN Supervisor called and notified him on 03/16/25 around 12:45 a.m.-12:50 a.m. that Resident #1 eloped from the facility and there was damage to an exit door on Resident #1's hall. The MS stated the ADM called and notified him on 03/16/25 at 12:52 a.m. that Resident #1 broke off the facility's back door wander guard alarm plate and removed the battery. The MS stated he visited the facility on 03/16/25 and observed a paperclip, screw, and wander guard alarm system cover stored in a fire extinguisher box near the exit door on Resident #1's hall. The MS stated he checked the wander guard alarm system daily and did not document the daily inspections before Resident #1's incident. The MS stated he repaired the exit door, verified the wander guard alarm system on the door was operable, and provided a wander guard tester to staff after Resident #1's incident. The MS stated he and the nurses checked residents' wander guard devices to ensure they were functioning. The MS stated the nurses checked residents' wander guard devices to ensure they were in place. The MS stated he checked the facility's exit doors and computers to ensure residents' wander guard devices were functioning and notified the DON whenever they were inoperable. The MS stated residents required assistance with taking off their wander guard devices. The MS stated he never observed a resident take off their wander guard device by themself. The MS stated he knew the importance of checking residents' wander guard devices and said, Because it's for the safety of the resident. Residents could get out, get hurt, get struck, and could pass away. During an interview on 03/22/25 at 1:15 p.m., CNA K stated she frequently checked on residents and could not clarify on what she meant by frequent. CNA K stated CNAs and nurses checked on residents every two hours. CNA K stated she knew the importance of checking on residents and said, To make sure everyone was alive, and wellbeing was okay, and care was provided. CNA K stated she defined elopement as when a resident was not in the facility. CNA K stated she would notify a nurse if a resident was missing. CNA K stated CNAs monitored residents' wander guard devices and management installed the wander guard alarms. CNA K stated she knew the importance of checking residents' wander guard devices and said, You don't want anything to happen to them. Some people have dementia. They could get hurt out there. During an interview on 03/22/25 at 1:45 p.m., CNA D stated she last saw Resident #1 in his room on 03/15/25 around 3:00 p.m. CNA D stated she was the only CNA working on Resident #1's hall on 03/15/25. CNA D stated the RN Supervisor notified her on 03/16/25 that Resident #1 was missing. CNA D stated she checked on residents every two hours. CNA D stated she knew the importance of checking on residents and said, Because residents who were ADL dependent were bed bound and needed to be repositioned and some residents were incontinent and needed to be changed and some residents had wander guard so to make sure they were in the facility. CNA D stated she defined elopement as a resident who escaped from the facility and wandered into the facility, and no one was aware of it. CNA D stated she would search for the resident and notify the nurse or another supervisor if a resident was missing. CNA D stated she did not know who was responsible for checking residents' wander guard devices and ensuring they were functional and in place. CNA D stated she knew the importance of checking residents' wander guard devices and said, Residents could leave the facility and get harmed easily. If a resident had Alzheimer's disease, they could slip out of the wander guard and leave the facility and wander out into street and no one would know. During an interview on 03/22/25 at 2:05 p.m., the RN Supervisor stated LVN A notified her on 03/15/25 around 10:00 p.m. that Resident #1 was not in his room and missing. The RN Supervisor searched inside and outside the facility, did a head count, and could not find Resident #1. The RN Supervisor stated LVN A notified the police, and she notified the ADM, the DON, and the Pharmacy Coordinator, who told her that she noticed Resident #1's itinerary and suspected Resident #1 left sometime during the day. The RN Supervisor stated CNA L told her that he noticed Resident #1's lunch tray was untouched around 5:30 p.m.-6:00 p.m. and told CNA D, who told him to replace Resident #1's lunch tray with a dinner tray. The RN Supervisor stated she observed Resident #1's dinner tray in Resident #1's room and found his wander guard device in his drawer. The RN Supervisor stated the Memory Care Director and LVN B found Resident #1 at a hotel on 03/16/25. The RN Supervisor stated she defined elopement as when a person wandered off from the facility without a caregiver being aware of him or her leaving the facility. The RN Supervisor stated CNAs and nurses checked on residents every two hours or more frequently on residents who were an elopement risk and had a history of wandering. The RN Supervisor stated she knew the importance of checking on residents and said, To be there to prevent a fall. Residents could fall and be on the floor for a while. The RN Supervisor stated charge nurses were responsible for checking residents' wander guards to ensure they were functioning and in place. The RN Supervisor stated she knew the importance of checking residents' wander guard devices and said, Sometimes wander guards could be loose or not working and sometimes residents could take them off like what happened that night . Residents could elope from the facility and end up somewhere. During an interview on 03/22/25 at 2:35 p.m., LVN A stated she defined elopement as when a resident got out of the building, expressed desire or a need to leave the facility, and not wanting to come back to the facility or be at the facility. LVN A stated she would ask a CNA, look for the resident, and notify the RN Supervisor if a resident was missing. LVN A stated CNA E notified her on 03/15/25 between 9:00 p.m. and 9:30 p.m. that she did not observe Resident #1 in his room since the beginning of their shift, which was from 6:00 p.m. through 6:00 a.m. LVN A stated she observed Resident #1 walking from his room towards what she believed was the facility library around 6:15 p.m. and 6:20 p.m. and did not observe him after that observation because she was conducting medication pass for 48 other residents. LVN A stated she told CNA E to search for Resident #1 in the facility and around the facility's perimeter. LVN A stated she found Resident #1's wander guard device in his drawer. LVN A stated nurses checked residents' wander guard devices every shift to ensure functionality and they were in place. LVN A stated she checked Resident #1's wander guard device at the beginning of her shift on 03/15/25. LVN A stated she observed the exit door at the end of Resident #1's hall did not have an outside wander guard alarm system panel on it during her search for Resident #1. LVN A stated the MS was responsible for checking the wander guard alarm system panel and did not know how often the MS completed that task. LVN A stated she found Resident #1's itinerary, called the hotel, and the hotel staff told her that he was not there. LVN A stated the Memory Care Director called the hotel again and found out Resident #1 was at the hotel on 03/16/25. During an interview on 03/22/25 at 3:09 p.m., CNA E stated CNAs and nurses checked on residents every two hours. CNA E stated she knew the importance of checking on residents and said, Because residents could wander around and get lost and so residents are clean and well-positioned. CNA E stated she defined elopement as when a resident wanders without a trace. CNA E stated she did not observe Resident #1 when she started her shift on 03/15/25 around 6:10 p.m. and 6:15 p.m. CNA E stated she thought she observed Resident #1 underneath his bed sheet in his bed. CNA E stated she noticed Resident #1's dinner tray was untouched and realized Resident #1 was not in his bed. CNA E stated she notified LVN A around 8:00 p.m. CNA E stated her and LVN A searched in the facility and around the facility's premises to look for Resident #1 and notified the RN Supervisor and the police. CNA E stated she observed Resident #1's wander guard device was in his drawer. Resident #1 had a phone on his bed in which he made calls to a cab company on 03/15/25 around 12:13 p.m. Resident #1 had an itinerary listing hotel information and notified LVN A. CNA E stated everyone who cared for the resident was responsible for checking wander guard devices to ensure functionality and they were in place. CNA E stated she knew the importance of checking residents' wander guard devices and said, For resident safety. Residents could leave the building, and no one would know because the alarm would not turn on. During an interview on 03/22/25 at 3:32 p.m., CNA C stated she defined elopement as a resident not being on the premises or in the facility. CNA C stated she would notify the nurse if she could not locate a resident. CNA C stated she last observed Resident #1 walking up the hall towards the nursing station on 03/15/25 around 4:00 p.m. CNA C stated nurses were responsible for checking residents' wander guard devices. CNA C stated she knew the importance of checking residents' wander guard devices and said, Residents could go out the door and get away if a resident's wander guard was not checked. During an interview on 03/22/25 at 3:46 p.m., CNA L stated he defined elopement as when a resident left the facility. CNA L stated he would notify a nurse if a resident was missing. CNA L stated he did not observe Resident #1 in his room during his shift on 03/15/25 from 2:00 p.m. through 10:00 p.m. CNA L stated on 03/15/25 around 5:15 p.m., he was passing out dinner trays and observed Resident #1 was not in his room and his lunch tray was still in his room. CNA L stated he notified an unknown name CNA (CNA D) that he did not observe Resident #1 in his room, observed Resident #1's lunch tray was in his room on his bedside table, and that Resident #1 did not eat his lunch. CNA L stated the CNA (CNA D) told him to take Resident #1's lunch tray and replace it with Resident #1's dinner tray. CNA L stated he did not notify a nurse because he did not know the facility's system because it was his third day of training on 03/15/25. During an interview on 03/22/25 at 4:20 p.m., CNA M stated she defined elopement as a resident who ran away from the facility. CNA M stated she would notify the nurse and the ADM if a resident was missing. CNA M stated CNAs and nurses checked on residents every two hours. CNA O stated she knew the importance of checking on residents and said, To make sure they received care and not trying to leave or on the side of their bed. CNA O stated anyone can check the residents' wander guard devices. CNA O stated she knew the importance of checking residents' wander guard devices and said, Resident could walk out the door and no one would know or be alerted. During an interview on 03/22/25 at 4:33 p.m., LVN G stated CNAs and nurses checked on residents every two hours. LVN G stated she knew the importance of checking on residents and said, To ensure safety and to make sure residents were at the facility. Residents could fall and elope. LVN G stated she defined elopement as a resident who left the facility and did not have the capacity to leave on their own. LVN G stated she knew to notify

Based on interviews and record review, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 (Resident #1) of 12 residents reviewed for elopement. The facility failed to ensure staff's statements were accurately documented when they last observed and checked on Resident #1 before he eloped on 03/15/25. This failure could place residents at risk of not being checked on, eloping, falls, and changes in condition. Findings included: Review of Resident #1's Admission Record, dated 03/21/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, unspecified dementia, depression, and unsteadiness on feet. Resident #1 had an MPOA and FPOA, which were his responsible parties. Review of Resident #1's Admission and Modified MDS Assessments, dated 12/25/24, reflected he had a BIMS score of 12, which indicated he had moderate cognitive impairment. Resident #1 used a wander/elopement alarm daily. Resident #1 required supervision with toileting, bathing, dressing, and transferring, set-up assistance with personal and oral hygiene, and was independent with eating and repositioning. Review of Resident #1's BIMS Evaluation, dated 03/16/25 at 1:46 p.m. by SW, reflected he had a BIMS of 9, which indicated his cognitive status declined since his admission. Review of Resident #1's Admission Assessment, dated 03/21/25, reflected he was a high risk for elopement and had on one or more occasions attempt to exit or had exited the facility. Review of Resident #1's Care Plan, dated 01/01/25, reflected he was exit-seeking and at risk for elopement and/or wandering with unsafe boundaries related to his dementia. Resident #1 was also at risk for falls related to his unsteady gait, poor balance, history of falls, osteoarthritis, and dementia. Review of Resident #1's Progress Notes reflected there were no notes from 02/21/25 through 03/15/25. The progress notes also reflected: -A note by LVN A on 03/16/25 at 6:01 a.m., This nurse was notified by CNA's at approx. 2130 (9:30 p.m.) that resident had not been seen since the beginning of the shift. We began searching his regular spots, like the library and dining room. When we couldn't locate him, RN supervisor was informed and she notified DON and administrator. Family was notified and Police and PD were also informed and responded to the incident. Every hall was instructed to check every room, bathroom, closet and office. The perimeter of the building was searched and Police searched the entire property by their patrol vehicles. DON and administrator were informed and administrator arrived to the facility to aid in the investigation. PD was informed and also arrived on scene to obtain more information about resident's appearance and other pertinent information. Family was informed and kept updated throughout the shift. -A note by the DON on 03/16/25 at 8:26 a.m., Notified by CNAs on duty that resident was not located in room upon rounds. Staff immediately initiated room search which then extended to entire community and campus without identifying resident's location. Said nurse immediately called Administrator, Police and PD to inform of possible missing person. PD onsite and additional details were provided. Family reported that resident has previously done this before and to notify them if resident's whereabouts are identified. Resident confirmed that he left the community yesterday evening with the intention of not returning. Resident is A&O x 4 and verbalized his plans of moving from the area to Oklahoma where he has friends. Resident was asked why he failed to alert the staff of his intentions and resident replied that he chose not to alert staff because he thought that the staff would not allow him to leave the facility. Resident reports that he is not happy with his family and does not want his family making his decisions. Resident has communicated that he is capable of making his own decisions and intends on doing so. Resident is in a local hotel room and reports that his plan continues to be to go to a friend's home and ultimately plans to move to Oklahoma. He stated that may consider a community in Oklahoma or wants his own apartment. He also reported that he is going to store tomorrow to get a phone, but for now he will remain at his hotel. Resident was informed that his PCP has provided orders that he is discharged from community AMA and that his medications will be released to him and that a nurse will review the medications with him as recommended and that Home Health will be referred if he is agreeable. Resident was informed that out of an abundance of caution community will refer to APS for wellness checks as well as possible assistance that he may need for relocating since resident is not agreeable to remain in the facility. Resident was informed that any additional belongings he may have in the community will also be brought to him at the hotel along with his medications and that in good faith the community is going to have a nurse review his medications with him to ensure he is able to properly administer and that we strongly recommend that he allow home health services. Despite education and resident has been discharged AMA at his request. Community will adhere to MD's recommendations for home health referral and out of an abundance of caution SW will notify APS for a wellness check and any additional support that resident may need. -A Late Entry note by the SW on 03/16/25 10:00 a.m., SW was notified that resident expressed a desire to no longer reside at facility. SW was asked to bring the AMA waiver to resident's location. The waiver was signed by resident, with a nurse serving as the witness. SW conducted a Brief Interview for Mental Status exam with resident, scoring 9. Additionally, SW provided information regarding a nursing home in Oklahoma, which resident expressed interest in. Upon returning to facility, SW immediately called APS to report resident leaving AMA. Review of Resident #1's Hotel Registration, printed on 03/15/25 at 2:14 p.m., reflected Resident #1 arrived at the hotel on 03/15/25 and signed his checked in registration in-person. Review of Resident #1's MAR/TAR , dated 03/21/25, reflected CNA C documented administering Resident #1's order of 1 drop of Carboxymethylcellulose Sod PF Ophthalmic Solution 0.5 % in both Resident #1's eyes on 03/15/25 at 11:00 a.m. and 4:00 p.m. and the DON documented he was out of the community at 9:00 p.m. Review of Resident #1's Pain Level Summary, dated 03/21/25, reflected staff conducted and documented a numerical pain assessment on Resident #1 in which they indicated he had 0/10 pain on 03/15/25 at 4:48 p.m. Review of Resident #1's POC, dated 03/21/25, reflected CNA D documented Resident #1 ate 76-100% of his meal on 03/15/25 at 1:22 p.m. CNA E documented and signed that she set up Resident #1's meal and supervised Resident #1 eating on 03/15/25 at 9:01 p.m. Review of the facility's Provider Investigation Report reflected the RN Supervisor notified the facility on 03/16/25 that on 03/16/25 at 12:30 a.m., Resident #1 was not present in his room. There were no witnesses. Investigation Summary reflected, At approximately 9:45 p.m., CNAs reported to their charge nurse that they last recalled seeing Resident #1 on 03/15/25 around 6:30 p.m. The charge nurse promptly informed the RN Supervisor, who prompted the team to initiate an initial search. The facility conducted a search of the entire community and immediate area outside the community and could not locate Resident #1. On 03/16/25 at approximately 12:30 a.m., the RN Supervisor notified the ADM, DON, and police. During this process, the RN Supervisor discovered an itinerary in the copy room containing various pertinent details, including information regarding a train company, cab company, hotel, and bank. This information was communicated to the ADM and responding police officer upon their arrival on-site. The search efforts were then expanded within the community by reaching out to the contacts and businesses listed on the itinerary. The ADM first contacted the hotel at approximately 2:00 a.m., only to be informed that Resident #1 was not present there. However, later that morning, the memory care director contacted the hotel again and was informed that Resident #1 was indeed at the hotel. In response, the memory care director, accompanied by another team member and a social worker, proceeded to the hotel to retrieve Resident #1. An assessment was conducted, and attempts were made to persuade Resident #1 to return to the community; however, Resident #1 declined. Resident #1 who has a BIMS of 12 and when assessed by the charge nurse on site shared, he is alert and oriented x4, explained that he had intentionally departed from the community without signing out or notifying his nurse, as he believed the nurse would not support his desire to visit a friend. He expressed plans to continue to a friend's home in Oklahoma, where he preferred to be. Resident #1 was subsequently informed that should he choose not to return, he would need to sign out of the community AMA, which he proceeded to do. One of the team members then returned to the community to collect all of his medications and APS was notified. Additionally, his family was informed that he had been located and was safe. The following morning, the community dispatched a charge nurse back to Resident #1's hotel room to conduct a health and welfare check, ensuring that he remained safe, alert, and oriented. Upon this visit, it was confirmed that he was indeed safe, alert, and oriented, and his family had arrived at the hotel. The facility's investigation findings were unfounded. Staff statements reflected CNA C stated she observed Resident #1 on 03/15/25 in the early afternoon, CNA D stated she observed Resident #1 on 03/15/25 around 3:00 p.m., CNA F stated she observed Resident #1 lying in his bed on 03/15/25 around 5:45 p.m., CNA E stated she observed Resident #1 lying in his bed on 03/15/25 around 6:00 p.m., LVN A stated she observed Resident #1 lying in his bed on 03/15/25 at approximately 6:20 p.m., the RN Supervisor stated she was notified by LVN A that Resident #1 was missing at approximately 10:00 p.m., and the Memory Care Director stated she called and found Resident #1 at a hotel on unknown date. During an interview on 03/21/25 at 11:40 a.m., the ADM stated Resident #1 discharged from the facility and could not recall the discharge date . During an interview on 03/21/25 at 11:49 a.m., Resident #1's FAM stated LVN G called and notified them on 03/15/25 at 10:30 p.m. that the facility staff were unable to locate Resident #1 and were searching for him. The FAM stated LVN G called and notified them on 03/16/25 at 12:00 a.m. that Resident #1 was last observed lying in his bed in his room on 03/15/25 at 6:30 p.m. The FAM stated the ADM called and notified them on 03/16/25 at 12:46 p.m. Resident #1 was found at a hotel. The FAM stated they believed the facility staff were lying about last observing Resident #1 on 03/15/25 at 6:30 p.m. because the hotel staff told them that Resident #1 checked into the hotel on 03/15/25 at 2:13 p.m. The surveyor emailed the ADM a list of records, including requesting to review the facility's in-services from 03/01/25 through 03/21/25, on 03/21/25 at 12:20 p.m. During an interview on 03/21/25 at 2:16 p.m., Resident #1 stated staff last checked on him on 03/15/25 around 6:00 a.m. when they checked his blood sugar. Resident #1 stated he ate breakfast in his room on 03/15/25 around 7:00 a.m. Resident #1 stated he left the facility around 11:00 a.m. and did not return to the facility. Resident #1 stated he walked for two hours to a store (approximately 2.8 miles from the facility), got a ride at some point to the store, got another ride to the hotel, and arrived at the hotel (approximately 10 miles from the store) around 3:00 p.m. and 4:00 p.m. Resident #1 stated the facility staff found him at the hotel on 03/16/25 around 11:00 a.m. During an interview on 03/22/25 at 10:14 a.m., LVN H stated she documented care provided to a resident in residents' progress notes and medications administered to a resident in the residents' MAR. LVN H stated the CNAs documented ADL care provided to a resident in the residents' POC. LVN H stated she knew the importance of accurately documenting care and said, For everyone's knowledge, so there was a reference point and so everyone on the team was involved. Residents could go missing and be lost if there was incorrect documentation. During an interview on 03/22/25 at 10:31 a.m., CNA I stated she documented ADL care provided to a resident in the residents' POC as soon as possible, when she can and in between rounds. CNA I stated she knew the importance of accurately documenting ADL care in the residents' POC and said, Just in case if a fall occurred, a resident felt bad or needed to be changed, to make sure everything was okay with resident and to catch everything quickly. We are all held accountable for documentation. Residents could be missing in action or not be at the facility. During an interview on 03/22/25 at 1:45 p.m., CNA D stated she last observed Resident #1 in his room on 03/15/25 around 3:00 p.m. when he refused his shower that she offered. CNA D stated she was the only CNA working on Resident #1's hall and another hall on 03/15/25. CNA D stated a CNA Trainee (CNA L) was working in the shower room on 03/15/25 around 4:00 p.m. and was working with her on Resident #1's hall. CNA D stated she documented ADL care provided to a resident in the residents' POC after ADL care was performed, refused or before 2:00 p.m. per the facility policy. CNA D stated she knew the importance of accurately and timely documenting ADL care in the residents' POC and said, If you did not document, then it did not happen. To make sure you did not forget anything and make sure the time of the completed task is accurate. Residents could slip out the facility or not receive the ADL care . During an interview on 03/22/25 at 2:05 p.m., the RN Supervisor stated LVN A notified her on 03/15/25 around 10:00 p.m. that Resident #1 was not in his room and missing. The RN Supervisor stated CNA L told her that he noticed Resident #1's lunch tray was untouched around 5:30 p.m. and 6:00 p.m., told CNA D, and CNA told him to replace the lunch tray with a dinner tray. The RN Supervisor stated she documented medications administered and treatments given to a resident in the residents' progress notes . During an interview on 03/22/25 at 2:35 p.m., LVN A stated CNA E notified her on 03/15/25 around 9:00 p.m. and 9:30 p.m. that she had not observed Resident #1 in his room since the beginning of their 6:00 p.m. through 6:00 a.m. shift. LVN A stated she last observed Resident #1 walking from his room towards what she assumed to be the facility's library on 03/15/25 around 6:15 p.m. and 6:20 p.m. LVN A stated she did not observe Resident #1 after the previously mentioned observation of him because she was busy conducting medication pass for 48 other residents. LVN A stated she documented medications administered to a resident in the residents' MAR. LVN A stated she knew the importance of accurately documenting medications administered to residents in the residents' MAR and said, Because to know if resident had a habit of refusing medication. Residents could start having side effects or overdose. LVN A stated she found Resident #1's itinerary that illustrated hotel information, she called the hotel on 03/15/25, and was told he was not there. LVN A stated she was unsure if she documented her call to the hotel in a progress note . During an interview on 03/22/25 at 3:09 p.m., CNA E stated she did not observe Resident #1 during her 6:00 p.m. through 6:00 a.m. shift. CNA E stated she thought she observed Resident #1 underneath his bed sheet in bed. CNA E stated around 8:00 p.m., she noticed Resident #1's dinner tray was untouched, observed and realized Resident #1 was not in his bed, and notified LVN A. CNA E stated during her search for Resident #1, she observed Resident #1 had a phone on his bed that had calls made to the yellow cab on 03/15/25 around 12:13 p.m. and notified LVN A and found Resident #1 had an itinerary that included hotel information that she started making calls to. CNA E stated she documented ADL care provided to a resident in the residents' POC after each round. CNA E stated she knew the importance of accurately and timely documenting ADL care in residents' POC and said, So nurses could give attention to a resident and so changes in condition were found. Residents could have something bad happen to them if ADL care was not accurately and timely documented in POC . During an interview on 03/22/25 at 3:32 p.m., CNA C stated she also worked as an MA. CNA C stated she last observed Resident #1 walking up the hall towards the nursing station on 03/15/25 around 4:00 p.m. CNA C stated she documented medications administered to a resident in the residents' MAR. CNA C stated she knew the importance of accurately documenting medications administered in residents' MAR and said, To make sure the resident received medications on time, resident was visibly seen and taken the medication and for the safety of the resident. Residents could die and anything could happen to them if the MAR was falsified. During an interview on 03/22/25 at 3:46 p.m., CNA L stated he was passing out dinner trays when he observed Resident #1 was not in his room and Resident #1's lunch tray was in his room on 03/15/25 around 5:15 p.m. CNA L stated he notified an unknown CNA (CNA D) he did not observe Resident #1, and observed Resident #1's lunch tray was untouched and still in his room on his bedside table. CNA L stated the unknown CNA (CNA D) told him to take Resident #1's lunch tray and replace it with Resident #1's dinner tray. CNA L stated he did not notify a nurse because he did not know the facility's system because it was his third day of training orientation. CNA L stated he did not observe Resident #1 in his room during his 2:00 p.m. through 10:00 p.m. shift on 03/15/25 . During an interview on 03/22/25 at 7:36 p.m., the Pharmacy Coordinator stated she last observed Resident #1 lying in his bed in his room before dinner on 03/15/25 around 4:40 p.m . During an interview on 03/22/25 at 7:57 p.m., the ADM stated the RN Supervisor notified him on 03/16/25 around 12:10 a.m. and 12:15 a.m. that the CNAs last observed Resident #1 on 03/15/25 around 6:30 p.m. The ADM stated the RN Supervisor also told him the CNAs observed Resident #1's lunch tray was still in his room when conducting a check at 9:00 p.m. The ADM stated he expected the CNAs to document ADL care provided to residents in residents' POC before leaving their shift and nurses to document care provided to residents before leaving their shift. The ADM stated he knew the importance of accurately and timely documenting and said, If we don't document accurately and timely, we could have a negative outcome. During an interview on 03/22/25 at 8:34 p.m., the DON stated the ADM notified him on 03/15/25 around 11:00 p.m. that Resident #1 was missing. The DON stated he expected the nurses to enter medication administrations in residents' MAR within one hour of administering the medication to the resident. The DON stated he expected CNAs to document ADL care in residents' POC within one hour of the ADL care provided to the resident. The DON stated when he reviewed Resident #1's MAR after Resident #1's incident, he found the timeliness and accuracy of documentation was off and in-serviced the staff on MAR documentation. The DON stated he knew the importance of timely and accurately documenting and said, Because it could cause a discrepancy and delay. The ADM did not provide the state surveyor with the facility's in-services from 03/01/25 through 03/21/25. Review of the facility's Medication Administration policy, revised January 2023, reflected: Responsible Disciplines: Licensed Nurses, C.M.A.'s .10. Record the results of medications administered as necessary. Documentation: Initial the electronic administration record after the medication is administered to the resident.

Based on interviews and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 12 residents reviewed for elopement. The facility failed to ensure staff assessed Resident #1 after finding him at a hotel on 03/16/25 after he eloped from the facility on 03/15/25. This failure could place residents at risk of changes in condition not being treated. Findings included: Review of Resident #1's Admission Record, dated 03/21/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, unspecified dementia, depression, and unsteadiness on feet. Review of Resident #1's Admission and Modified MDS Assessments, dated 12/25/24, reflected he had a BIMS score of 12, which indicated he had moderate cognitive impairment. Resident #1 required supervision with toileting, bathing, dressing, and transferring, set-up assistance with personal and oral hygiene, and was independent with eating and repositioning. Review of Resident #1's Care Plan, dated 01/01/25, reflected he was exit-seeking and at risk for elopement and/or wandering with unsafe boundaries related to his dementia. Resident #1 was also at risk for falls related to his unsteady gait, poor balance, history of falls, osteoarthritis, and dementia. Review of Resident #1's Progress Notes reflected there were no notes from 02/21/25 through 03/15/25. The progress notes also reflected: -A note by LVN A on 03/16/25 at 6:01 a.m., This nurse was notified by CNA's at approx. 2130 (9:30 p.m.) that resident had not been seen since the beginning of the shift. We began searching his regular spots, like the library and dining room. When we couldn't locate him, RN supervisor was informed and she notified DON and administrator. Family was notified and Police and PD were also informed and responded to the incident. Every hall was instructed to check every room, bathroom, closet and office. The perimeter of the building was searched and Police searched the entire property by their patrol vehicles. DON and administrator were informed and administrator arrived to the facility to aid in the investigation. PD was informed and also arrived on scene to obtain more information about resident's appearance and other pertinent information. Family was informed and kept updated throughout the shift. -A note by the DON on 03/16/25 at 8:26 a.m., Notified by CNAs on duty that resident was not located in room upon rounds. Staff immediately initiated room search which then extended to entire community and campus without identifying resident's location. Said nurse immediately called Administrator, Police and PD to inform of possible missing person. PD onsite and additional details were provided. Family reported that resident has previously done this before and to notify them if resident's whereabouts are identified. Resident confirmed that he left the community yesterday evening with the intention of not returning. Resident is A&O x 4 and verbalized his plans of moving from the area to Oklahoma where he has friends. Resident was asked why he failed to alert the staff of his intentions and resident replied that he chose not to alert staff because he thought that the staff would not allow him to leave the facility. Resident reports that he is not happy with his family and does not want his family making his decisions. Resident has communicated that he is capable of making his own decisions and intends on doing so. Resident is in a local hotel room and reports that his plan continues to be to go to a friend's home and ultimately plans to move to Oklahoma. He stated that may consider a community in Oklahoma or wants his own apartment. He also reported that he is going to store tomorrow to get a phone, but for now he will remain at his hotel. Resident was informed that his PCP has provided orders that he is discharged from community AMA and that his medications will be released to him and that a nurse will review the medications with him as recommended and that Home Health will be referred if he is agreeable. Resident was informed that out of an abundance of caution community will refer to APS for wellness checks as well as possible assistance that he may need for relocating since resident is not agreeable to remain in the facility. Resident was informed that any additional belongings he may have in the community will also be brought to him at the hotel along with his medications and that in good faith the community is going to have a nurse review his medications with him to ensure he is able to properly administer and that we strongly recommend that he allow home health services. Despite education and resident has been discharged AMA at his request. Community will adhere to MD's recommendations for home health referral and out of an abundance of caution SW will notify APS for a wellness check and any additional support that resident may need. -A Late Entry note by the SW on 03/16/25 10:00 a.m., SW was notified that resident expressed a desire to no longer reside at facility. SW was asked to bring the AMA waiver to resident's location. The waiver was signed by resident, with a nurse serving as the witness. SW conducted a Brief Interview for Mental Status exam with resident, scoring 9. Additionally, SW provided information regarding a nursing home in Oklahoma, which resident expressed interest in. Upon returning to facility, SW immediately called APS to report resident leaving AMA. There were no notes related to assessing Resident #1 post-elopement. Review of Resident #1's Hotel Registration, printed on 03/15/25 at 2:14 p.m., reflected Resident #1's arrived at the hotel on 03/15/25 and signed his checked in in-person. Review of the facility's Provider Investigation Report reflected the RN Supervisor notified the facility on 03/16/25 that on 03/16/25 at 12:30 a.m., Resident #1 was not present in his room. There were no witnesses. Investigation Summary reflected, At approximately 9:45 p.m., CNAs reported to their charge nurse that they last recalled seeing Resident #1 on 03/15/25 around 6:30 p.m. The charge nurse promptly informed the RN Supervisor, who prompted the team to initiate an initial search. The facility conducted a search of the entire community and immediate area outside the community and could not locate Resident #1. On 03/16/25 at approximately 12:30 a.m., the RN Supervisor notified the ADM, DON, and police. During this process, the RN Supervisor discovered an itinerary in the copy room containing various pertinent details, including information regarding a train company, cab company, hotel, and bank. This information was communicated to the ADM and responding police officer upon their arrival on-site. The search efforts were then expanded within the community by reaching out to the contacts and businesses listed on the itinerary. The ADM first contacted the hotel at approximately 2:00 a.m., only to be informed that Resident #1 was not present there. However, later that morning, the memory care director contacted the hotel again and was informed that Resident #1 was indeed at the hotel. In response, the memory care director, accompanied by another team member and a social worker, proceeded to the hotel to retrieve Resident #1. An assessment was conducted, and attempts were made to persuade Resident #1 to return to the community; however, Resident #1 declined. Resident #1 who has a BIMS of 12 and when assessed by the charge nurse on site shared, he is alert and oriented x4, explained that he had intentionally departed from the community without signing out or notifying his nurse, as he believed the nurse would not support his desire to visit a friend. He expressed plans to continue to a friend's home in Oklahoma, where he preferred to be. Resident #1 was subsequently informed that should he choose not to return, he would need to sign out of the community AMA, which he proceeded to do. One of the team members then returned to the community to collect all of his medications and APS was notified. Additionally, his family was informed that he had been located and was safe. The following morning, the community dispatched a charge nurse back to Resident #1's hotel room to conduct a health and welfare check, ensuring that he remained safe, alert, and oriented. Upon this visit, it was confirmed that he was indeed safe, alert, and oriented, and his family had arrived at the hotel. The facility's investigation findings were unfounded. The elopement response in-service given to staff by unknown on unknown date did not reflect assessing residents after locating them. The facility's response plan did not reflect assessing residents after locating them. There were no assessments on Resident #1 included with the report. Review of Resident #1's BIMS Evaluation, dated 03/16/25 at 1:46 p.m. by SW, reflected he had a BIMS of 9, which indicated his cognitive status declined since his admission. Review of Resident #1's Assessments, dated 03/21/25, reflected there were no other assessments on 03/16/25 other than the SW's BIMS discharge evaluation on 03/16/25. Review of Resident #1's vitals, dated 03/21/25, reflected there were no vitals taken on 03/16/25. During an interview on 03/21/25 at 11:40 a.m., the ADM stated Resident #1 discharged from the facility and could not recall the exact date. During an interview on 03/21/25 at 11:49 a.m., Resident #1's FAM stated LVN G called and notified them on 03/15/25 around 10:30 p.m. that they could not locate Resident #1 and Resident #1 was last observed lying in his bed in his room on 03/15/25 around 6:30 p.m. The FAM stated the ADM called and notified them on 03/16/25 at 12:46 p.m. Resident #1 was found at a hotel, did not want to return to the facility, they conducted a BIMS exam, and allowed him to sign himself out AMA. The FAM stated Resident #1 told them that he fell in the shower at the hotel and scraped his knee on 03/16/25. The FAM stated Resident #1 was a high fall risk, diagnosed with dementia in 2023, and was in denial about his dementia and limitations. The FAM stated they took Resident #1 to the hospital because they believed he was not evaluated. During an interview on 03/21/25 at 2:16 p.m., Resident #1 stated staff last checked on him on 03/15/25 around 7:00 a.m., he ate breakfast in his room around 8:00 a.m., walked out the facility's front door around 11:00 a.m., and did not return. Resident #1 stated he left the facility because the facility ran out of tissue paper. Resident #1 stated he walked for two hours to a store (approximately 2.8 miles from the facility), got a ride at some point to the store, got another ride to the hotel, and arrived at the hotel (approximately 10 miles from the store) around 3:00 p.m.-4:00 p.m. Resident #1 stated he lost his balance, fell , and hit his shin while taking a shower at the hotel on the morning of 03/16/25. Resident #1 stated he often fell before his admission to the facility and never fell during his admission at the facility. Resident #1 stated the facility staff found him at the hotel on 03/16/25 around 11:00 a.m. Resident #1 stated staff did not assess him. Resident #1 stated the SW had him sign an AMA form after he told the facility staff that he did not want to return to the facility. Resident #1 stated his FAM were his POAs and the facility typically notified his FAM for decisions about his care. Resident #1 stated he went to the hospital from 03/17/25 through 03/21/25 and did not know why he was kept at the hospital. During an interview on 03/21/25 at 2:38 p.m., Resident #1's FAM stated Resident #1 stayed at the hospital from 03/17/25 through 03/21/25 because he was being transferred to another facility with a wander guard system. During an interview on 03/21/25 at 3:09 p.m., the NP stated Resident #1 had dementia, history of elopement, and wore a wander guard. The NP stated she did not know if Resident #1 had a history of falls, if he had the capacity to make informed decisions for himself, and if it was safe for him to be out alone without supervision because he had mild dementia and was taking medications to slow down dementia progression. The NP stated she expected staff to assess resident's post-elopement for any changes in condition. During an interview on 03/22/25 at 9:34 a.m., RN F stated she knew to assess a resident after an elopement. RN F stated she knew the importance of assessing resident's post-elopement and said, Because residents could have had a change in condition or a fall when they were missing. During an interview on 03/22/25 at 10:14 a.m., LVN H stated nurses assessed residents after an elopement to ensure nothing occurred while they were missing. LVN H stated she knew the importance of assessing resident's post-elopement and said, Because how do we know what happened to the resident if we don't assess and follow-up to make sure resident was okay. During an interview on 03/22/25 at 2:05 p.m., the RN Supervisor stated nurses performed a head-to-toe assessment on a resident after an elopement. The RN Supervisor stated she knew the importance of assessing resident's post-elopement and said, Residents could have fallen and sustained a fracture or bruises or different things or could have been sexually or physically assaulted, which was why we assess them. During an interview on 03/22/25 at 2:35 p.m., LVN A stated nurses were required to conduct an elopement risk assessment and basic head to toe assessment to make sure a resident did not fall or get injured after an elopement. LVN A stated she knew the importance of assessing resident's post-elopement and said, Because they could have fallen or hurt themselves while they were missing. Residents could have repercussions from any injuries they sustained while missing. During an interview on 03/22/25 at 4:33 p.m., LVN G stated nurses were required to conduct a head-to-toe assessment on a missing resident after an elopement. LVN G stated she knew the importance of assessing resident's post-elopement and said, Because a resident might not know if they were injured and because staff did not know what they ate and drank and they need to know if the resident was still at baseline. During an interview on 03/22/25 at 6:48 p.m. the Memory Care Director stated she reviewed Resident #1's itinerary, called the hotel listed on his itinerary, learned he was at the hotel, and her and the SW went to the hotel on 03/16/25. The Memory Care Director stated she conducted a head-to-toe assessment on Resident #1 to determine if he had any changes in condition on 03/16/25. The Memory Care Director stated Resident #1 did not have any bruises or changes in condition. The Memory Care Director stated she did not know Resident #1 fell in the hotel shower while he was missing. The Memory Care Director stated she did not document the assessment in Resident #1's electronic health records and documented the assessment in her statement included in the facility's Provider Investigation Report. The Memory Care Director stated she knew the importance of assessing resident's post-elopement and said, Because residents could have been in danger, and we don't know what happened to the resident when they were missing. During an interview on 03/22/25 at 7:57 p.m., the ADM stated the RN Supervisor notified him on 03/16/25 around 12:10 a.m. and 12:15 a.m. that the unknown name CNAs last observed Resident #1 on 03/15/25 around 6:30 p.m. and observed Resident #1's lunch tray was still in his room around 9:00 p.m. The ADM stated the Memory Care Director reviewed an itinerary Resident #1 made at the facility and found out Resident #1 was at a hotel on 03/16/25. The ADM stated the Memory Care Director, and the SW went to the hotel and found Resident #1. The ADM stated the Memory Care Director conducted a head-to-toe assessment on Resident #1 and believed she documented the assessment, and the DON could confirm. The ADM stated Resident #1 did not have any injuries. The ADM stated he expected residents to be immediately assessed following an incident. The ADM stated he knew the importance of assessing residents after an incident and said, Because it could be a negative outcome and residents could die. During an interview on 03/22/25 at 8:34 p.m., the DON stated the ADM called and notified him on 03/15/25 around 11:00 p.m. that Resident #1 was missing. The DON stated the Memory Care Director notified him on 03/16/25 that Resident #1 was at a hotel. The DON stated the Memory Care Director, and the police went to the hotel. The Memory Care Director conducted a visual nurse assessment on Resident #1 and ensured he was alert and oriented. The DON stated he was unsure if the Memory Care Director conducted a head-to-toe assessment on Resident #1. The DON stated he expected the Memory Care Director to conduct the assessment on Resident #1, if Resident #1 allowed her, and knew at the time that Resident #1 was agitated. The DON stated he was not aware that Resident #1 had a fall while he was missing. The DON stated nurses would typically assess a resident upon finding them . Review of the facility's Missing Resident/Elopement policy, revised 05/23/22, reflected: When an elopement occurs: After the resident has been found, complete a thorough evaluation of resident's physical condition and psychosocial wellbeing. Provide medical intervention as needed. Review of the facility's Elopement Response and Exit Seeking Management policy, revised January 2023, reflected: B. Response following the location of the resident: Once located and safety confirmed, conduct an assessment.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #120) observed for infection prevention. The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when LVN-D provided wound care for Resident #120 without wearing a gown. This deficient practice could place residents at-risk for spread of infection. Findings included: Record review of Resident #120's face sheet dated 06/08/2023 reflected he was an [AGE] year-old man, with an initial admitted [DATE] with diagnoses which included: Chronic Diastolic (Congestive) Heart Failure (a condition where the heart muscle is weakened and cannot pump blood effectively), Chronic Kidney Disease (a long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood), Chronic Pain Syndrome (a condition characterized by persistent pain that lasts for at least 3 months and significantly impacts a person's life), Hyperkalemia (a condition where the potassium level in the blood is too high), Long Tern (Current) use of Anticoagulants, Gastro-esophageal Reflux Disease (a condition that occurs when stomach contents flow into the esophagus), without Esophagitis (an inflammation of the esophagus, the tube that carries food from the mouth to the stomach), Benign Prostatic Hyperplasia (a noncancerous enlargement of the prostate gland that can cause urinary symptoms) with lower Urinary Tract Symptoms, Essential (Primary) Hypertension (a condition characterized by persistently high blood pressure without an identifiable underlying cause), and Atherosclerosis of Coronary Artery Bypass Graft(s) (a buildup of fatty plaque in the graft that can limit blood flow), and Unspecified with Unstable Angina Pectoris (a type of chest pain where the exact cause is unknown). Record review of Resident #120's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 10, indicating moderate cognitive impairment. Further review reflected Resident #120 was assessed as having an unstageable pressure ulcer present upon reentry to the facility. Record review of Resident #120's Active Orders dated 02/14/2025 reflected orders which included: - Enhanced Barrier Precautions start date 02/19/2025. - WC: Clean area to right heel with normal saline. Apply Leptospermum honey and calcium alginate daily to the area and cover with a bordered gauze. Apply pressure relieving boot to right foot as indicated. start date 02/18/2025. Record review of Resident #120's Care Plan dated last reviewed 01/19/2025 reflected a Problem which included My skin is fragile, and I am at risk for skin injury-new or worsening skin condition. Thin, fragile, loose skin. Actual skin impairment Deep Tissue Injury-Unstageable to right heel, initiated 08/23/2023 and revised 01/24/2025. This problem area included the following interventions: - Apply treatment as ordered; initiated 08/23/2023 and - Keep clean & dry and apply skin barrier cream as indicated.; Initiated 08/23/2023 - Follow community's practice for assessing skin, reporting skin concerns to charge nurse doctor, resident or representative and follow skin protocol in place as indicated; Initiated 10/04/2023 - Give dietary supplements to promote healing/resolving as indicated/ordered; Initiated 08/23/2023 - I use therapeutic off-loading boots/Right heel protectors as indicated; Initiated 02/05/2025 Observation on 02/19/2025 at 09:16 a.m., reflected there was a sign indicating Enhanced Barrier Precautions above the head of the bed in Resident #120's room, and there was no supply of PPE available outside the door/room. Further observation revealed LVN D put on gloves but did not put on or wear a gown while performing wound care for Resident #120. During an interview with LVN D on 02/19/2025 at 01:30 p.m., LVN D stated that the wound care doctor considered open wounds to require gown and gloves during wound care. During an interview with the DON on 02/19/2025 at 01:56 p.m., the DON stated the resident should have been on EBPs. The DON stated a negative outcome of failure to abide by EBPs would be the spread of infection. Record review of facility policy titled Infection Prevention and Control revised 4/1/2024 reflected In addition to isolation practices, Enhanced Barrier Precautions (EBP) may be implemented as an infection control intervention designed to reduce transmission of resistant organisms. The use of PPE, such as gown and glove use during high contact resident care activities. EBP may be indicated as a recommendation by the CDC (when contact Precautions do not otherwise apply) for residents with the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. Infection or colonization with an MDRO. EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Residents/Patient with the following clinical indication should be under EBP: Significant wounds such as chronic wounds, ulcers, open Pressure Ulcers or complicated/non-healing surgical incisions or wounds, and/or open wounds require a dressing.

Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 6 residents (Resident #3 Resident #14) reviewed for comprehensive care plans. The facility failed to ensure Resident #3's comprehensive care plan was updated to reflect Resident #3's refusal of physician order for daily weights. The facility failed to ensure Resident #14's care plan was updated to reflect the resident's recent falls on 02/15/2025. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans. Findings included: Review of Resident #3's undated face sheet reflected an [AGE] year-old female who was readmitted to the facility on [DATE] with diagnoses including congenital stenosis of aortic valve (a person born with a narrowed aortic valve in their heart), chronic obstructive pulmonary disease (a lung disease that makes it hard to breathe), cerebrovascular disease (a condition that affects the brain's blood supply and blood vessels), and essential primary hypertension (high blood pressure with no clear, identifiable cause). Review of Resident #3's annual MDS, dated [DATE], reflected a BIMS score of 15, indicating she was cognitively intact. Resident #3's annual MDS section I reflected Resident #3 had diagnoses of heart failure and hypertension. Resident #3's annual MDS reflected that Resident #3 required partial/ moderate assistance in the areas of toileting hygiene, upper body dressing, and lower body dressing. Resident #3's annual MDS reflected that Resident #3 was dependent in shower/bathe self and putting on/taking off footwear. Review of Resident #3's care plan, dated 02/19/25, reflected Resident #3 was care planed for I have heart disease. I am at risk for associated cardiac complications such as chest pain, SOB, fatigue, dizziness, poor endurance/activity intolerance and edema (swelling cause by fluid building up in body tissues), CHF/Heart Failure, Hyperlipidemia/ High Cholesterol, Hypertension. Resident #3 had an intervention of daily weight in the morning for CHF, give PRN torsemide if greater than 3 lb weight gain in 1 day. Review of Resident #3's physician order, dated 02/19/25, reflected Daily weights with a start dated of 10/19/24. Review of Resident #3's Weight Summary in her EMR, dated 02/19/25, reflected Resident #3's daily weight was not taken on the following dates: 02/02/25, 02/05/25, 02/06/25, 02/10/25, 02/11/25, 02/12/25, 02/15/2025, 02/16/2025, & 02/17/25. Record review of a facility face sheet for Resident #14 dated 02/19/2025, reflected an [AGE] year-old female who was admitted to the facility 03/06/2024 Resident #14's diagnoses included: chronic fatigue (serious condition that causes extreme tiredness that doesn't improve with rest), history of falling (has a history of falling, which can indicate a higher risk of future falls), delusional disorder (someone firmly believes things that aren't true, even when presented with evidence that contradicts their beliefs) and essential primary hypertension (high blood pressure with no clear, identifiable cause). Record review of Resident #14's Quarterly MDS assessment dated [DATE], reflected the resident had a BIMS score of 00, which indicated severe cognitive impairment. Resident #14's Quarterly MDS reflected she required substantial/maximal assistance in the areas of shower/bathe self, upper body dressing, lower body dressing, and putting on/taking off footwear. Resident #14's Quarterly MDS reflected she was dependent in the areas of toileting hygiene and personal hygiene. Resident #14's MDS Section J1800 reflected that Resident #14 has had falls since admission/entry or reentry or the prior assessment with no injuries. Record review of Resident #14's Care Plan dated 02/19/2025 reflected Resident #14 was care planned for I am at risk for falls r/t: Hx, of falls, use of psychotropic meds, and heart disease, actual falls: 11/27/2024, 12/16/2024, & 12/21/2024. Resident #14's care plan did not reflect she had falls on 02/15/2025. Review of the facility's Fall incidents, dated 02/18/25, reflected Resident #14 had a fall on 02/15/25. During an interview with Resident #3 on 02/20/2025 at 9:15 am, Resident #3 stated that sometimes she did not feel like being weighed. Resident #3 stated being weighed daily was a hassle. Attempted to interview Resident #14 on 02/19/2025 at 10:45 am but was not successful due to her severe cognitive impairment. During an interview with LVN C on 02/20/2025 at 11:25 am, LVN C stated that Resident #3 had an order for daily weights. LVN C stated that Resident #3 refused to be weighed. LVN C stated that Resident #3 refused her daily weights usually once or twice a week. LVN C stated Resident #3 had an order for daily weighs due to her diagnosis of CHF. LVN C stated that the resident was often weighed during her physical therapy appointment due to her liking to be weighed in her wheelchair. During an interview with the MDS Coordinator on 02/20/2025 at 12:10pm, the MDS Coordinator stated she was responsible for updating resident's care plans. The MDS coordinator stated she was not aware of Resident #3's refusals. MDS coordinator stated if a resident has refused care frequently that should be care planned. The MDS coordinator stated that Resident #3's refusals of care should have been discussed in the morning meeting and care planned. The MDS Coordinator stated she was responsible for updating Resident #14's care plan to reflect her most recent fall on 02/15/25. The MDS coordinator stated she was not present during the morning meeting when the fall was discussed and forgot to update the resident's care plan. The MDS coordinator stated that a resident may not receive the appropriate care if the resident's care plan was not accurate or up to date. During an interview with the DON on 02/20/2025 at 12:15pm, the DON stated that Resident #3 was not weighed on the following dates: 02/02/25, 02/05/25, 02/06/25, 02/10/25, 02/11/25, 02/12/25, 02/15/2025, 02/16/2025, & 02/17/25 due to Resident #3 refusing. The DON stated that Resident #3's nurse was responsible for her being weighed daily per physician orders. The DON stated that Resident #3 was not care planned for refusal. The DON stated there would not be any negative outcome from Resident #3 not being care planned for refusals due to staff documenting her refusal. The DON stated that Resident #14's fall on 02/15/2025 should have been reflected on her care plan. The DON stated that MDS coordinator is responsible for updating care plans. The DON stated a negative outcome would be the resident's most recent fall would not be reflected on the care plan. During an interview with the ADM on 02/20/2025 at 1:10pm, the ADM stated the DON was responsible for ensuring residents who required daily weights are weighed. The ADM stated that a negative outcome of Resident #3 not being weighed daily was the resident could have an increase or decrease in weight. The ADM stated that his expectations were for all residents' physician orders to be followed as ordered. The ADM stated that his expectation was for all refusals of care to be documented and care planned. The ADM stated that if a resident was not care planned for refusals, they may not receive the proper care and the appropriate intervention would not be put in place to assist the resident. The ADM stated it was the MDS coordinator's responsibility for updating care plans with prior or new concerns. The ADM stated it was his expectation for care plan to be updated within 24 hours to reflect Resident #14's most recent fall. The ADM stated if a resident's care plan was not updated to reflect their most recent fall, the appropriate intervention may not be put in place for the resident to receive the highest quality of care. The ADM stated the facility used the RAI manual for care planning. Review of the Resident Assessment Instrument Manual dated October 2024, reflected the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and any services that would otherwise be required but are not provided due to the resident's exercise of rights including the right to refuse treatment.

Based on interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Residents #3 and #100) of nine residents reviewed for quality of care. The facility failed weigh Residents #3 and #100 daily according to physician orders. This failure could place residents at risk of not receiving necessary medical care and hospitalization . Findings included: Review of Resident #3's undated face sheet reflected an [AGE] year-old female who was readmitted to the facility on [DATE] with diagnoses including congenital stenosis of aortic valve (a person born with a narrowed aortic valve in their heart), chronic obstructive pulmonary disease (a lung disease that makes it hard to breathe), cerebrovascular disease (a condition that affects the brain's blood supply and blood vessels), and essential primary hypertension (high blood pressure with no clear, identifiable cause). Review of Resident #3's annual MDS, dated [DATE], reflected a BIMS score of 15, indicating she was cognitively intact. Resident #3's annual MDS section I reflected Resident #3 had diagnoses of heart failure and hypertension. Resident #3's annual MDS reflected that Resident #3 required partial/ moderate assistance in the areas of toileting hygiene, upper body dressing, and lower body dressing. Resident #3's annual MDS reflected that Resident #3 was dependent in shower/bathe self and putting on/taking off footwear. Review of Resident #3's care plan, dated 02/19/25, reflected Resident #3 was care planed for I have heart disease. I am at risk for associated cardiac complications such as chest pain, SOB, fatigue, dizziness, poor endurance/activity intolerance and edema (swelling cause by fluid building up in body tissues), CHF/Heart Failure, Hyperlipidemia/ High Cholesterol, Hypertension. Resident #3 had an intervention of daily weight in the morning for CHF, give PRN torsemide if greater than 3 lb weight gain in 1 day. Review of Resident #3's physician order, dated 02/19/25, reflected Daily weights with a start date of 10/19/24. Review of Resident #3's Weight Summary in her EMR, dated 02/19/25, reflected Resident #3's daily weight was not taken on the following dates: 02/02/25, 02/05/25, 02/26/25, 02/10/25, 02/11/25, 02/12/25, 02/15/2025, 02/16/2025, 02/17/25. Review of Resident #100's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene (a condition where a person has type 2 diabetes and narrowed arteries due to diabetes), type 2 diabetes mellitus with hyperglycemia (condition where a person with type 2 diabetes has high blood sugar levels), hypertensive chronic kidney disease with stage 1 through 4 chronic kidney disease or unspecified chronic disease (a condition where chronic kidney disease (CKD) is caused by high blood pressure (hypertension) and is classified as being in stages 1 to 4 of CKD progression, or where the specific stage of CKD is not clearly stated, indicating a general chronic kidney disease due to hypertension), chronic kidney disease, stage 4 (severe) (indicates a significant decline in kidney function where the kidneys are moderately to severely damaged, resulting in a reduced ability to filter waste from the blood, with an estimated glomerular filtration rate (eGFR) (a measurement of how well your kidneys are filtering waste products form your blood) between 15-29 ml/min, often accompanied by noticeable symptoms like swelling, fatigue, and potential complications like anemia and high blood pressure), anemia in chronic kidney disease (a condition where the blood has fewer red blood cells than normal), moderate protein-calorie malnutrition (state where a person has a significant but not severe deficiency in both protein and calories, typically characterized by a weight that is between 75-85% of their ideal body weight, noticeable muscle wasting, and potential signs of nutritional deficiencies, but not as extreme as in severe malnutrition). Review of Resident #100's admission MDS, dated [DATE], reflected a BIMS score of 14, indicating he was cognitively intact. Resident #100's admission MDS also reflected he was dependent in the following areas: shower/bathe and putting on/taking off footwear. Resident #100 required substantial/maximal assistance in the following areas: oral hygiene, toileting hygiene, upper /lower body dressing, and personal hygiene. Resident #100 needed setup or cleanup assistance with eating. Review of Resident #100's care plan, dated 02/19/25, did not reflected Resident #100 is to be weighed three times a week. Record review of the Care plan on 03/07/2025 at 12:40PM reveal no interventions for weight gain. Review of Resident #100's physician order, dated 12/8/2024 and revised on 2/16/2025, reflected Resident #100 should be weighed every day on Mondays, Thursdays, and Sundays. Resident #100 had a previous physician order start dated 9/1/24 with a revision date 8/2/2024 of vitals should be taken one time a day ending on the first of every month. Record review of the Medical Record conducted 03/07/2025 at 11:57AM reveals diet orders changed from Renal diet, Minced and Moist texture, Thin/Regular consistency written on 08/07/2024 was changed to Regular diet, Regular Texture, thin/regular consistency on 12/06/2024 to meet resident preference. Face sheet reads Waiver signed by RP for Regular Diet, No fluid Restrictions. Review of Resident #100's Weights Summary in his EMR, dated 02/20/25, reflected Resident #100's weights had not been documented as ordered beginning from 9/1/2024 to current. Here are the dates and times, weights, and how the resident was weighed: Dates & Times Weights (pounds) Scale 8/2/2024 at 7:48 AM 120.6 Wheelchair 10/7/2024 at 13:23 PM 112.8 Standing 11/8/2024 at 9:56 AM 114.0 Sitting 12/5/2024 at 17:38 PM 113.0 Sitting 1/9/2025 at 13:22 PM 113.0 Wheelchair 1/19/2025 at 11:27 AM 114.0 Sitting 2/6/2025 at 10:37 AM 134.0 Sitting 2/16/2025 at 13:44 PM 140.0 Sitting 2/17/2025 at 8:38 AM 141.0 Sitting During an interview with Resident #3 on 02/18/25 at 2:05 PM, Resident #3 stated she was not weighed daily. Resident #3 stated that sometimes she refused to be weighed and other times the nurse forgot to weigh her. Resident #3 stated that staff were not consisted with taking her weight so now she does not want to be weighed. During an interview with LVN A on 02/20/25 at 11:15 AM, LVN A stated she did not know Resident #100 was supposed to have his weight taken 3 times a week until it popped up in the computer system. LVN A stated she has fixed it that it that a symbol pops up in the MAR which indicates the resident needs to be weighed. LVN A stated Resident #100 must be weighed for edema in reference to CKD stage 4. She stated the nurse is responsible for taking the residents vitals, but the CNAs can take vitals also. During an interview with LVN B on 02/20/25 at 11:35 AM, LVN B stated sometimes Resident #100 refused to have his weight taken. LVN B had no answer for why he did not get weighed 3 times a week as ordered by the physician, and she stated she would get back to the surveyor with the results. LVN B never returned. During an interview with LVN C on 02/20/2025 at 11:25 am, LVN C stated that Resident #3 had an order for daily weights. LVN C stated that Resident #3 does refuse to be weighed. LVN C stated that Resident #3 refused her daily weights usually once or twice a week. LVN C stated that Resident #3 has an order for daily weights due to her diagnosis of CHF. LVN C stated that the resident was often weighed during her physical therapy appointment due to her liking to be weighed in her wheelchair. During an interview with the DON on 02/20/2025 at 12:15pm, the DON stated that Resident #3 was not weighed on the following dates 02/02/25, 02/05/25, 02/26/25, 02/10/25, 02/11/25, 02/12/25, 02/15/2025, 02/16/2025, 02/17/25 due to her refusing. The DON stated that Resident #3's nurse was responsible for her being weighed daily per physician orders. During an interview with DON on 02/20/25 at 11:43 AM, DON stated Resident #100 had cardiac issues and if he is gaining too weight, it can cause shortness of breath. The DON stated the floor nurses are responsible to make sure the weights are done. DON stated he expects the nurses to follow doctor orders. During an interview with the ADM on 02/20/2025 at1:10pm, the ADM stated the DON was responsible for ensuring residents who required daily weights are weighed. The ADM stated that a negative outcome of Resident #3 not being weighed daily was the resident could have an increase or decrease in weight. The ADM stated that his expectations were for all residents' physician orders to be followed as ordered. During an interview with the NP on 03/07/2025 12:02PM she stated she was aware of the weight gain Ressident #100 had and had discussed with the MD. She also stated the weights were ordered so that she could monitor the resident's heart failure and be able to treat the swelling of his left leg. Furthermore, she stated residents have the right to refuse weights and consume foods of their choice. She stated the weight gain of the resident was not a concern. During a second interview with the NP conducted on 03/07/2025 at 4:14PM, she stated she had tried to educate the Resident #100 and his representative regarding his excessive intake of sugar and sodas. She also acknowledged the resident's excessive consumption of sugary snacks. During an interview with NP on 03/07/2025 at 12:02PM she stated the weight gain was not a risk of imminent harm to Resident #100. This was confirmed in an interview with the MD during an interview on 03/07/2025 at 3:11PM. Review of the facility policy Quality of Care dated January 2023 reflected The comprehensive assessment of a resident, the community will ensure resident receive the treatment and care in accordance with professionals standards of practice, the comprehensive person-centered care plan, and the resident's choices.

44317 Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 9 (Resident #11, Resident #51, Resident #54, Resident #62, Resident #77, Residents #105, Resident #116, Resident #135, and Resident #137) out of 148 residents reviewed for infection control. The facility failed to: 1. Isolate a resident with confirmed scabies (Resident #105) and five other residents (Residents #11, #51, #54, #62, #116, and #137) presented with rashes. On 01/10/24 at7:20 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 01/12/24 at 9:27 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. 2. Ensure CMA M administered Resident #135's eye drops in a sanitary condition. 3. Ensure Resident # 77's oxygen tubing was stored in a sanitary manner. These failures placed residents at risk of transmission and/or spread of infection or contagious disease which could lead to infections and hospitalization . Findings included: 1.) Review of Resident #105's face sheet printed 01/11/24, reflected a [AGE] year-old male admitted on [DATE]. His diagnoses included dementia, chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs), hypertension (high blood pressure), and major depressive disorder. Review of Resident #105's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 8 indicating moderately impaired cognition. Section GG (Functional Abilities) reflected he was able to ambulate with supervision. Section M (Skin Conditions) reflected no ulcers, wounds, or other skin problems. Review of Resident #105's Patient Handout (The summary and physician orders) from the dermatology clinic, dated 01/09/24, reflected in part, Scabies Located on the right proximal dorsal middle finger and right proximal dorsal index finger. Review of Resident #105's physician's order dated 01/09/24 at 2:30 PM reflected, Permethrin External Cream 5% apply to neck down to feet topically at bedtime every 7 day(s) for scabies Leave on for 8 hours/wash off in AM. Repeat in one week. Review of Resident #105's physician's order dated 01/09/24 at 3:41 PM reflected, Ivermectin oral tablet 3 MG, give 6 tablet [sic] by mouth one time only for Scabies for 1 day Start when in house. The medication was ordered by the Med Dir. Review of Resident #105's Medication and Treatment Administration Records for December 2024, reflected permethrin cream was applied on 01/09/21 at 11:18 PM, Ivermectin tablets were given 01/10/24 at 3:28 AM by the MSU Mgr, and the resident was placed on contact isolation on 01/10/24 during the 6:00 PM to 6:00 AM shift. Review of Resident #105's nursing progress note dated 01/10/24 at 9:07 PM reflected in part, Resident continues follow up Permethrin External Cream 5% due to skin rash for prophylaxis. Medication applied from neck down, scabbed over red rash present to bilateral arms, legs, abdomen, buttocks . Review of Resident #105's nursing progress note dated 01/10/24 at 3:36 PM, written by the Director of Nurses, reflected, Reconfirmed with physician the need for isolation for veteran . Physician states that that veteran was treated with PERMETHRIN 5% CREAM(GM)on 01/09/24 @ 2218, linen was removed, unit was deep cleaned, and veteran is in a private room. No need for isolation at this time. Skin to be assessed daily for 5 days, notify physician of any changes in condition. Review of Resident #11's face sheet printed 01/11/24, reflected an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included dementia, type 2 diabetes, essential hypertension, and chronic kidney disease stage 4. Review of Resident #11's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 5 indicating severely impaired cognition. Section M (Skin Conditions) reflected no ulcers, wounds, or other skin problems. Review of Resident #11's physician's order, dated 01/10/24, reflected Permethrin External Cream 5% (Permethrin) Apply to neck down to feet topically at bedtime every 7 days for prophylactically apply overnight for 8 hours and wash off in the AM. Review of Resident #11's Total Body Skin assessment dated [DATE] reflected turgor - good elasticity, skin color - normal for ethnic group, temperature - warm (normal), moisture - normal, and condition - normal. The assessment reflected no new wounds. Review of Resident #51's face sheet printed 01/11/24, reflected a [AGE] year-old male admitted to the facility 03/15/17 and readmitted [DATE]. His diagnoses included neurocognitive disorder with Lewy Bodies (a dementia where protein deposits develop in nerve cells in the brain), Alzheimer's disease, cerebral infarction (stroke), and osteoarthritis. Review of Resident #51's quarterly MDS assessment dated [DATE], Section B (Hearing, Speech, and Vision) reflected the resident had clear speech, was usually understood, and he usually understands. Section C (Cognitive Patterns) reflected no BIMS score. Section GG (Functional Abilities) reflected he used a wheelchair for mobility with supervision or touching assistance. Section M (Skin Conditions) reflected no ulcers, wounds, or other skin problems. Review of Resident #51's care plan, printed 1/11/24, reflected an Upper chest rash - NEW 1/5/24 with no new interventions documented. Review of Resident #62's face sheet printed 01/11/24, reflected an [AGE] year-old male admitted on [DATE]. His diagnoses included Alzheimer's disease, post-traumatic stress disorder, atherosclerotic heart disease, hypertension, and chronic kidney disease stage 3. Review of Resident #62's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 9 indicating moderately impaired cognition. Section GG (Functional Abilities) reflected he was able to ambulate with only supervision. Section M (Skin Conditions) reflected no ulcers, wounds, or other skin problems. Review of Resident #62's physician's order, dated 01/10/24, reflected Permethrin External Cream 5% (Permethrin) Apply to neck down to feet topically at bedtime every 7 days for prophylactically apply overnight for 8 hours and wash off in the AM. Review of Resident #62's nursing progress note dated 01/10/24 at 11:26 PM reflected, Resident continues follow up Permithrin External Cream 5 % for prophylaxis day 1/7, red patches noted from neck down to feet, resident has not complained of pain or discomfort so far during this shift. Resident currently resting in bed, with call light within reach. Plan of care continued. Review of Resident #116's face sheet printed 01/11/24, reflected an [AGE] year-old male admitted on [DATE]. His diagnoses included chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs) , major depressive disorder, essential hypertension, dementia, and benign prostatic hyperplasia (the flow of urine is blocked due to an enlarged prostate gland). Review of Resident #116's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 3 indicating severely impaired cognition. Section M (Skin Conditions) reflected the resident did not have any ulcers, wounds, or any skin problems . Review of Resident #137's face sheet printed 01/10/24, reflected an [AGE] year-old male admitted to the facility 03/17/23. His diagnoses included unspecified dementia, post-traumatic stress disorder, and adult failure to thrive. Review of Resident #137's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 8 indicating moderately impaired cognition. Section GG (Functional Abilities) reflected he was able to ambulate with only supervision. Section M (Skin Conditions) reflected no ulcers, wounds or other skin problems were present. Review of Resident #137's physician's order, dated 01/10/24, reflected, Permethrin external Cream 5% (Permethrin) Apply to neck down to feet topically at bedtime every 7 days for prophylactically apply overnight for 8 hours and wash off in the AM. Review of Resident #137's progress note written 01/10/24 at 4:43 PM by MSU Mgr reflected, This writer, DON, DCO assessed skin. Resident has itchy, dry skin. Resident schedule hydrocortisone cream. Will continue plan of care. All parties notified about skin condition. Observation on 01/09/24 at 11:40 PM revealed Resident #105 standing by the nurse's station with two other residents standing nearby. Observation on 01/09/24 at 12:28 PM revealed Resident #137, Resident #62, and Resident #11 eating lunch in the dining room/dayroom. Observation on 01/10/24 at 2:15 PM revealed Resident #105 lying in bed in his room. There was no sign on or near the door to indicate if transmission-based precautions were used. There was no PPE outside of the room. During an observation and interview on 01/10/24 at 2:17 PM with LVN A, she stated, Resident #105 had his rash for a while, maybe it had started last week. She stated the resident had gone to the doctor on 01/09/24 and was tested for scabies but she did not have the results. She stated if the results were back, she would have received that information in the morning report. She stated staff wear gloves in the room but no other PPE. She stated they were treating all the residents on the unit prophylactically. She stated she had just received more medication from the pharmacy. Observation revealed seven tubes of Permethrin cream (a medication used to treat scabies) for seven residents on the unit. Observation on 01/10/24 at 2:47 PM revealed Resident #105 lying in bed. There was no sign on the door indicating transmission-based precautions. There was no PPE near the room. Observation on 01/10/24 from 2:45 PM to 3:05 PM revealed nursing staff and housekeeping personnel enter Resident #105's room without gloves or other PPE. Observation on 01/11/24 at 8:32 AM revealed a Contact Isolation sign on the door of Resident #105's room. A cart containing PPE was observed next to the room. Resident #105 was lying in his bed. Observation on 01/11/24 at 9:56 AM revealed Resident #51 as he sat in a wheelchair and wheeled himself up and down the hall. His arms and chest had multiple red dots. He was not able to say how long he had the rash or if it was itching. During an observation and interview on 01/11/24 at 10:10 AM with Resident #105, he stated he had a rash all over his body. LVN A assisted resident to turn and adjusted his clothes to reveal red dots on the resident's neck, torso, both arms, back, and both legs. The resident stated they put some cream on him and he recently showered to wash off the medication. He stated he did not remember taking the six pills that the dermatologist had ordered. LVN A stated she gave him the pills during morning med pass. Observation on 01/11/24 at 3:04 PM revealed Resident #137 in the day room with other residents. MSU Mgr asked resident to go to his room for a skin check. The check revealed a rash, red dots, on the left side of his trunk from the hip up to the ribs. Observation on 01/11/24 at 3:09 PM revealed Resident #62 had red spots on both legs, both arms, and his trunk. MSU Mgr stated the rash is throughout his whole body except for his face. Observation on 01/11/24 at 3:15 PM revealed Resident #11 in the day room with other residents. MSU Mgr asked resident to go to his room for a skin check. Resident #11 had a rash covering his right arm. Observation on 01/11/24 at 3:16 PM revealed Resident #116 had a rash of red dots on left side ribs to hip. He declined any further skin check. Observation on 01/11/24 at 4:40 PM revealed an isolation sign on resident #105's room door. During an interview on 01/10/24 at 2:25 with the Director of Nurses, he stated, he had been in his current position for a few days and prior to becoming the Director of Nurses he was the Infection Preventionist. He stated only one resident (Resident #105) had been tested for scabies and the results were still pending. He stated isolation or transmission-based precautions were not necessary because scabies was not confirmed. He stated they were treating the whole unit prophylactically and were in the process of notifying all the responsible parties . During an interview on 01/10/24 at 2:40 PM with the DCE, she stated she knew Resident #105 went out for an appointment on 01/09/24. She stated she brought up her concerns that the resident was to be placed on transmission-based precautions but was told by the Director of Nurses that it was not necessary because the residents on the unit were being treated and the diagnosis of scabies was not confirmed. She stated if it was any other suspected contagious disease, the resident would be on isolation or transmission-based precautions while they waited for test results. She stated not placing someone on transmission-based precautions could cause spread of infection. During an interview on 01/10/24 at 2:53 PM with CNA A, she stated, she was the aide assigned to work on the hall with Resident #105. She stated the resident goes out to the dining room or sometimes he just sat with other residents and watched television. She stated she was aware that the resident may have scabies, she heard he was tested , but did not know for sure. She stated she was afraid of taking something home to her family, so she had been putting on two pairs of gloves to protect herself. She stated she had not been instructed to wear any other PPE. During an interview on 01/11/24 at 8:25 AM with the MSU Mgr, she stated, Resident #105 had been placed on contact precautions some time before her shift started. She stated PPE should be worn because you didn't want to get people sick or spread something. She stated by not using TBP, everyone could get sick. During an attempted telephone interview on 01/11/24 at 11:20 AM, a message that requested a return call was left at the dermatology clinic visited by Resident #105. During a telephone interview 01/11/24 at 2:39 PM with a certified dermatology technician at the dermatology clinic, she was told the purpose of the call. She placed the call on hold and talked with the provider. She came back to the call and after some discussion, stated she would have the provider call back. The call was not returned prior to exit of the survey. During an interview on 01/11/24 at 3:18 PM with MSU Mgr, she stated all rashes should have been documented in the electronic medical records. During an interview on 01/11/24 at 3:24 PM with the Director of Nurses, he stated he had verified with the doctor that no isolation was needed. He stated Resident #105 was never on transmission-based precautions just standard precautions and gloves were a part of standard precautions. He stated all residents on the unit were treated prophylactically. He stated he read the dermatologists' report this morning. He stated he talked with the doctor both before and after reading the dermatologist report and isolation was not indicated. When asked the protocol for notifying staff or visitors that PPE is needed, he stated, By putting up a sign, we missed that. He stated the facility policy was followed . During a telephone interview on 01/11/24 at 4:15 PM with Resident #105's family member, they stated they took the resident to a dermatologist on 01/09/24. They stated while they were at the office, the dermatologist took the scraping from his hand and looked at it under the microscope and confirmed it was scabies. When they returned to the facility around 1:30 or 2:00 PM, shortly after lunch, they signed him back in at the book at the nurse's station. They stated they gave the Patient Handout including the two prescriptions (permethrin cream and Ivermectin tablets) for treating scabies to the MSU Mgr. During an interview on 01/11/24 at 4:30 PM with MSU Mgr, she stated when Resident #105 and his family member returned from the dermatology appointment on 01/09/24, sometime just after lunch, the family member pulled her aside and told her what the dermatologist said. The family member told her the dermatologist did a scrape and talked about scabies. The family member gave her the paperwork from the dermatologist, she read it and saw that it talked about scabies. She stated she called the Director of Nurses. She stated he read the paperwork form the dermatologist, said he was going to call the doctor, and get right back to her. She stated the paperwork had the order for the two scabies medications. She stated the pharmacy nurse made sure the facility had the medication order. She stated there was an isolation sign on the room door now but it was not there the previous day. During an interview on 01/11/24 at 4:32 PM with the Med Dir, she stated, in general a real infection was confirmed and the resident was treated empirically. She stated it depended on the disease but something like C-diff or scabies, if we suspect it is highly likely, contact precautions would be implemented immediately. She stated she reviewed the facility policies and the policies are all current. Regarding Resident #105, she stated they suspected scabies, but the resident was in a private room and staff used contact precautions right away. She stated, Contact precautions means a gown and gloves are worn for every contact with the resident. If staff did not follow contact precautions, there was the risk of transmission to staff and residents. She stated a resident suspected of scabies should be put on isolation immediately with gloves and gowns. She stated the on-call doctor was notified late in the evening of 01/09/24 and the facility was told to isolate the resident. The Med Dir stated at no point in time did they tell the Director of Nurses not to isolate the resident. She stated scabies is infectious and should be treated like any contagious disease. She stated, The instant they come back with the paperwork is when it all starts. She stated she did not see the paperwork from the dermatologist until this morning. They suspected scabies and initiated precautions right away. She stated the resident started treatment that night. She stated his rash was diffuse but not on his feet or the palms of his hands. During a telephone interview on 01/11/24 at 5:16 PM with Resident #105's family member, they stated the resident was scheduled for a follow up visit with the dermatologist at the end of January. They stated the Med Dir saw Resident #105's rash and thought the resident should be seen before the end of January. The family member made multiple calls and they were able to secure the appointment on 01/09/24. During an interview on 01/11/24 at 7:05 PM with the Administrator, she stated they follow guidance to keep everyone safe. She stated the policies are based on CDC and CMS guidelines and doctors' recommendations. She stated she was aware Resident #105 was going to the dermatologist for a follow up visit. She stated she was aware he had a scraping done and received prescriptions. She stated, I left it to the medical team. She stated she did not know when he got his treatment. She stated she saw the paperwork from the dermatologist on 01/10/24 . She stated if an infection was not contained it could spread to other residents or staff. Review of the Scabies Identification, Treatment and Environmental Cleaning policy revised 08/16 reflected in part, 8. Affected residents should remain on Contact Precautions until twenty-four (24) hours after treatment. 12. Individuals who come into contact with the infected resident or with potentially contaminated bedding or clothing should wear a gown and gloves or other protective clothing . Review of the CDC's website https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/type-duration-precautions.html#S accessed 01/11/24, contact precautions in addition to standard precautions should be used until 24 hours after initiation of effective therapy to prevent the spread of scabies. Review of the CDC's website https://www.cdc.gov/parasites/scabies/gen_info/faqs.html accessed on 01/11/24 reflected The most common symptoms of scabies are intense itching and a pimple-like skin rash. The scabies mite usually is spread by direct, prolonged, skin-to-skin contact with a person who has scabies. Review of the World Health Organization website https://www.who.int/news-room/fact-sheets/detail/scabies accessed 01/11/24 reflected Scabies can lead to skin sores and serious complications like septicaemia (a bloodstream infection), heart disease and kidney problems. This was determined to be an Immediate Jeopardy (IJ) on 01/10/24 at 7:20 PM the Administrator, Director of Nurses, and Regional Nurse Coordinator were notified. The Administrator was provided with the IJ template on 01/10/24 at 7:20 PM. The following POR submitted by the facility was accepted on 01/12/24 at 12:33 PM: F880 - Infection Control The facility failed to follow CMS and CDC guidance addressing infection control in that 7 residents are being treated for a contagious infection without isolation precautions. All residents were at risk of being exposed to scabies, which likely could result in severe itching, rash, sores, thick crusts on skin, and secondary bacterial infections. 1. Action: Immediate The Charge Nurse notified resident #105's MD/NP. The MCU Charge Nurse on duty assessed resident #105. Rash isolated to top of hands, with no other skin irritations present. Date Completed: 1/10/24 Director of Nurses immediately placed resident#105 on contact precautions. Date Completed: 1/10/24 2. Action: The MDS nurse and IDT initiated a review of resident #105's care plan on 1/10/24, and has revised and updated to include the rash area to the bilateral hands. Date initiated: 1/10/24 Date completed: 1/11/24 3. Action: The IDT initiated a review of all residents' care plans who reside on the MCU (secured memory care unit). The MDS nurse updated all care plans for risk for infection. Date Completed: 1/11/24 4. Action: Resident #105's room was cleaned by direct care staff members. Resident #105's clothes, and linens were removed and washed, all no washable items were place on plastic bags as indicated. The Director of Nurses validated that the resident was treated as per physician's orders, and that the room, clothing, and linens were appropriately bagged and laundered. 1. Wash linens in hot water and dry on hot temperature before any use. Follow the isolation practice for contact isolation when handling the contaminated linens or clothing. Bag belongings that cannot be disinfected or laundered in a plastic bag, tied/sealed for up to 3 days. Clean clothing may be returned to the resident's room after the first dose of treatment. 2. Consider washing at least 3-4 changes of clothing in hot water and dry on hot temp prior to providing to resident to be worn while being treated. Completion Date: 1/10/24 5. Action: Risk--All residents who actively reside on the MSU (secured memory care unit) may have been at risk; Therefore, facility implemented prophylactic treatment as recommended by the facility's medical director. The facility's medical director recommended prophylactic treatment for all 30 residents who reside on the MSU. The Director of Nurses will validate that all residents on the MCU received the prophylactic treatment as per physician's orders. Additional measures that were in place to minimize the risk of spreading was keeping resident 105 in a private room on the secured unit, isolated and separated form others, continued consistent staffing to the unit, which minimizes the spread throughout the community, access to supplies, provide PPE ( gloves and gowns) supplies to isolation room, gloves, hand hygiene supplies throughout the secured unit, as well as the deep cleaning and laundering interventions for resident #105 and all others residing in memory care unit. On 1/10/24, following the IJ concern being cited the Director of Nurses implemented contact precautions for resident #105. Date Completed: 1/11/24 6. Action: Nurses conducted a resident skin sweep on residents who reside on the MCU (secured care unit): There were no findings or indication of infectious outbreak. All residents on the MCU have the skin results documented in each of the resident's electronic health record progress. Date Completed: 1/10/24 7. Action: The Regional Nurse conduct re-education to the Director of Nurses, Assistant Director of Nurses, and Infection Preventionist prior to them proceeding with in-service training. In-service provided: Scabies Information, Scabies response guide, Infection Control and Prevention- Isolation Practices, Preventing the Spread of Infection of Communicable Disease/Conditions, Utilizing Isolation Precautions to include PPE(gown and gloves) and Hand Hygiene Practices. Date Completed: 1/11/24 8. Action: The Director of Nurses, Assistant Director of Nurses, and Infection Preventionist conducted in-service education to all staff prior to assuming their next shift. The Director of Nurses, Assistant Director of Nurses, and Infection Preventionist will conduct in-service education to all newly hired staff during orientation. The Director of Nurses, Assistant Director of Nurses, and Infection Preventionist will conduct in-service education to all agency staffers upon entrance to facility prior to assuming their assignment. Inservice training provided: o Scabies Information o Scabies response guide o Infection Control and Prevention- Isolation Practices, Preventing the Spread of Infection of Communicable Disease/Conditions, Utilizing Isolation Precautions to include PPE (gloves and gown) and Hand Hygiene Practices Date Completed: 1/11/24 and on-going 9. Action: The Director of Nursing and Infection Preventionist conducted staff education consisting of the identification and reporting of s/s scabies, infection control practices and hand hygiene practices. All staff assigned to that designated area have received the education and the in-servicing was also extended to all staff and no staff will work their next shift unless the staff member has received the scabies related in-service. regarding infection prevention and control measures to include but not limited to: o Scabies Information o Scabies response guide o Infection Control and Prevention- Isolation Practices, Preventing the Spread of Infection of Communicable Disease/Conditions, Utilizing Isolation Precautions to include PPE (gown and gloves) and Hand Hygiene Practices Completion Date: 1/11/24 10. Action: The Administrator, Director or Nurses conducted and Ad Hoc QAPI review of this situation and IJ Plan of Removal with the facility's Medical Director. Completion Date: 1/11/24 The Survey team monitored the Plan of Removal on 01/12/24 as followed: Record review of Resident #105's progress notes revealed a note, documented by MSU Mgr on 1/10/24 at 5:24 PM, stated, This writer, DON, DCO assessed skin. Resident has itchy rash and scaly. Resident recieves schedule clobetasol propionate cream, ketoconazole shampoo, fluocinonide external cream. Resident denies itching at this time. Will continue plan of care. All parties notified about skin condition. Note, documented by Pharmacy Nurse on 1/9/24 at 3:53 PM, stated, Resident seen by dermatology, new order for permethrin 5% topical cream and Ivermectin 3mg x 6 tablets for one time dose. MSU Mgr was attempted to be contacted on 01/12/24 at 5:41 PM. A voicemail was left with call back number. Med Dir and Attending Physician were attempted to be contact on 01/12/24 at 5:42 PM but the office was closed. Record review of Resident #105's skin and wound assessment, documented by RN N on 1/10/24, revealed he had good elasticity turgor, normal skin color, warm temperature, normal moisture, normal condition, and no new wounds. Record review of Resident #105's skin and wound evaluation, documented by RN N on 1/11/24, revealed he had a rash on left upper abdomen, acquired in-house, wound been present since 12/14/23, wound bed epithelial, 100% of wound covered with surface intact, no evidence of infection, pink or red color and scab, exudate none, periwound attached: edge appears flush with wound bed or as a sloping edge, intact with unbroken skin, no induration present, no swelling or edema present, normal periwound temperature, no pain frequency, healable for goals for care, no dressing appearance, cleaning solution or debridement, no dressing applied, topicals for care, stable progress, practitioner and RP notified. Record review of Resident #105's Dermatology consult, dated 1/9/24, revealed orders and instructions for applying permethrin 5% topic cream on neck down to feet, ivermectin 3mg tablet 6 by mouth at once, expectations, contaminated clothing, contacting office if scabies fails to resolve, and skin education. Record review of Resident #105's care plan revealed staff reviewed the care plan and included a revision, documented by Regional Nurse Coordinator on 1/11/24, that noted Resident #105's had rash to hand. Goal was to assess redness, blisters, or discoloration through review date and skin injury will resolve without associated complications through review date. Interventions included apply treatment as ordered and follow community's practice for assessing skin, reporting skin concerns to charge nurse, doctor, resident, or RP, and follow skin protocol in place as indicated. Record review of Resident #105's order summary report, dated 1/12/24, revealed the following orders: Contact Isolation Precautions: Strict Isolation required in which all care, therapy and other services are provided in private room r/t an active infection. Every shift for 7 days. Permethrin External Cream 5% apply to neck down to feet topically at bedtime every 7 day(s) for scabies leave on for 8 hours/wash off in AM. Repeat in one week. Record review of all residents' care plans who resided on MCU (secure memory unit) revealed staff updated all care plans to include risk for infection. Record review of all MCU residents' progress notes and order summary report revealed they were ordered and received prophylactic treatment as recommended by MD. Record review of all MCU residents' progress notes and skin assessment results revealed they were assessed by nurses for skin issues and had findings documented on assessments in EHR. Record review of in-services revealed the DON, the ADON, and the IP were re-educated on contact precautions by the regional nurse and Abuse and neglect by the ADM on 1/10/24. Visual aids for contact precautions and washing hands were included. The DON, the ADON, and the IP were also re-educated on scabies, scabies response guide, infection control and prevention isolation practices, preventing the spread of infection of communicable disease/conditions, utilizing isolation precautions, which included PPE and hand hygiene practices on 1/10/24 by the regional nurse. Record review of in-services revealed the ADON, the DON, and the ADM re-educated staff prior to assuming their next shift, newly hired staff during orientation, agency staff upon entrance to facility prior to assuming their assignment, and staff designated to area on non-crusted and crusted scabies, scabies, scabies response, infection prevention and control isolation practices, preventing the spread of infection of communicable disease/conditions, utilizing isolation precautions including PPE and hand hygiene, contact precautions, and abuse and neglect on 1/10/24. Guides on non-crusted scabies, crusted scabies, contact precautions, and hand hygiene were included. Record review of Ad Hoc QAPI review revealed the MD, the ADM, the DCO, and the [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 30 residents (Residents #69 and #244) reviewed for pain management. 1. The facility failed to ensure Resident #69 was assessed, monitored and received pain medication after Resident #69 suffered a displaced transverse femur fracture on 10/12/2022 with the fracture not being identified by the facility until 10/13/2022. 2.The facility failed to ensure Resident #69, who was determined to not be a surgical candidate after his femur fracture, was assessed, monitored and received pain medication upon his return to the facility from the hospital on 10/17/2022 until 10/18/2022. 3. The facility failed to assess, provide effective pain treatment, and address pain promptly for Resident #244 with terminal cancer, who was assumed to be wearing a fentanyl patch upon readmission to facility, but was not and did not receive a new fentanyl patch for 17 hours. An immediate Jeopardy (IJ) situation was identified on 10/19/2022. While the IJ was removed on 10/22/2022 at 10:45 AM, the facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of experiencing significant pain and discomfort. Findings include: 1. Review of Resident #69's face sheet dated 10/18/2022 reflected he was admitted on [DATE] with the following diagnoses Malignant neoplasm of prostate (prostate cancer), Transient Ischemic Attack and cerebral infarction (a brief episode of neurological dysfunction caused by loss of blood flow; Infarction refers to death of tissue) and Hemiplegia affecting left side (paralysis of one side of the body.) Review of Resident #69's quarterly MDS assessment dated [DATE] reflected Resident #69 was assessed to have a BIMS score of 15 indicating he was cognitively intact. Resident #69 was assessed to require extensive assist with two person assist with transfers and ADLs. Resident #69 was assessed to have scheduled pain medication regimen. Review of Resident #69's comprehensive care plan reflected a focus area self-care deficit related to hemiparesis left side with contractures causing limited physical functioning related to stiff or limited joint range of motion. Review of Resident #69's interventions did not reflect how the resident was to be transferred. Review of Resident #69's nursing progress notes reflected an entry dated 10/13/2022 Resident had complaints of pain in his left hip, Resident stated that when he got back from his appointment his leg got stuck in between the machine and he heard a crack. Nurse called in an order of the x-ray at 12:00 PM on 10/13/2022 the results came back and found a transverse fracture through the proximal left femoral diaphysis with superior displacement of the distal fracture fragment of approximately 3.5 cm MD was notified and EMS is on their way to transfer the resident to the hospital. Review of Resident #69's incident report dated 10/13/2022 reflected Nursing Description: Resident had complaints of pain in his left hip. Nurse called in an order for the x-ray at 12:00 PM on 10/13/2022. Results came back and found a transverse fracture through the proximal left femoral diaphysis with superior displacement of the distal fracture with fragment of approximately 3.5 cm. The MD was notified, and EMS was on their way to transfer the resident to the hospital. Resident Description: Veteran stated that when he got back from his appointment his leg got stuck between the Hoyer and he heard a crack. Review of Resident #69's X-ray report dated 10/13/2022 at 3:25 PM reflected a transverse fracture through the proximal left femoral diaphysis with associated superior displacement of the distal fracture fragment of approximately 3.5 cm and apex lateral angulation . Review of Resident #69's consolidated physician orders dated 10/18/2022 reflected an order dated 06/16/2022 to assess the residents' level of pain every shift, on a 0-10 scale, every day and night shift. Further review of the consolidated physician orders reflected an order dated 03/01/2022 for Acetaminophen 325 mg two tablets by mouth every 4 hours as needed for pain, an order for Acetaminophen 500 mg two tablets by mouth every 8 hours for 14 days related to displaced transverse fracture of shaft of left femur with a start date of 10/19/2022, and an order for oxycodone HCL 10 mg tablet by mouth every 8 hours as needed for pain related to displaced transverse fracture of shaft of left femur with a start date of 10/18/2022. Review of Resident #69's MAR dated October 2022 reflected no pain medication was administered on 10/12/2022 or 10/13/2022. Review of Resident #69's Re-admission assessment dated [DATE] at 7:43 PM reflected under the pain section that resident was able to verbalize pain and had no history of or current signs of pain. The assessment further stated Resident #69's location of pain was left hip dislocation (non-surgical) with the type of pain being acute. The pain assessment did not rate Resident #69's pain only described it hot/ burning and his acceptable or tolerable level of pain was a 2 out of 10. Review of Resident #69's nursing progress note dated 10/17/2022 at 8:21 PM Facility supervisor was informed unable to input narcotic oxycodone 10 mg, they took care of order, the on call that verified orders stated to let facility MD know to obtain triplicate and contact pharmacy to order medication . In an interview on 10/18/2022 at 1:23 PM, LVN A stated she sent Resident #69 to the hospital on 10/13/2022 after an x-ray confirmed he had a broken hip. She stated Resident #69 told her it happened the day before on 10/12/2022 when he was being transferred with the Hoyer lift. LVN A stated he told her his leg got caught on the mechanical lift and as they turned him, he heard a pop. LVN A stated he was in pain when she checked on him and she looked at left hip and saw swelling. She stated the MD requested an x-ray then confirmed the fracture. She stated the doctor was notified and said send him to hospital. LVN A stated Resident #69 returned last night 10/17/2022. LVN A stated she notified the DON immediately upon Resident #69's reporting injury and pain. LVN A stated the staff nurses did not do incidents that the DON would have done the incident report and subsequent investigation. LVN A stated she was not sure if Resident #69 had surgery on his hip while hospitalized . LVN A stated she was the nurse in charge of Resident #69 on 10/12/2022 and CNAs (CNA B & CNA C) did not report any incident or injury regarding Resident #69 to her on 10/12/2022 or 10/13/2022. LVN A stated Resident #69 was out of bed on 10/12/2022 due to MD appointment and they would have been transferring him back to bed when it happened. She said staff are supposed to report to charge nurse and/or DON immediately of a resident injury. LVN A stated Resident #69 normally doesn't require treatment for pain and had only had PRN Tylenol ordered for pain. LVN A stated Resident #69 had to be treated with something stronger for pain when he returned to the facility on [DATE] at 5:34 PM but his pain medicine was not in the building last night when he arrived. LVN A stated they were having trouble filling the medication because they did not have triplicate for the prescription which was a controlled medication. LVN A stated she had not administered any pain medication to him that morning because he had not asked for any. LVN A stated she was unaware of any change in his care plan. She said in response to his hip being broken, the facility did an in-service on abuse/neglect reporting and mechanical lifts on Thursday 10/13/2022. LVN A stated she was not aware of any other staff education done regarding Resident #69 and his broken hip or care and pain needs. Observation and interview on 10/18/2022 at 10:35 AM revealed Resident #69 was in bed, Resident #69 was observed to have a contracture of his left arm. Resident #69 was also observed to have bruises on his arm. Resident #69 stated they were from his transfer to the hospital a week ago. Resident #69 stated he was still in pain and stated the staff went to the nurse but had not come back. He stated he has been in pain all morning. Resident #69 stated he didn't know when he could take his medication and stated nobody has advised him on his medication. He stated the doctor at the hospital said he could take it every 4 hours, but the doctor here said every 8 hours. Review of Resident #69's MAR dated October 2022 reflected Resident #69 was assessed to not have pain on the night of 10/17/2022. Further review of Resident #69's MAR reflected he was medicated for pain for the first time on 10/18/2022 at 1:30 PM with oxycodone HCL 10 mg and was medicated with Tylenol 325 mg two tabs at 3:55 PM for continued pain rated at a 4/10. In an interview on 10/18/2022 at 2:16 PM, Resident #69 stated the nurse finally did give him some pain medication . In an interview on 10/18/2022 at 3:39 PM, the DON stated they should have made sure the resident had pain medication in house when Resident #69 returned from the hospital. An interview and observation on 10/19/2022 at 8:40 AM revealed CNA E was outside of Resident #69's room preparing to perform incontinent care for the resident. CNA E stated she was not sure what leg was broken on resident and went up and down the hall multiple times to find someone to help her. CNA H arrived to assist CNA E. The CNAs began incontinent care, Resident #69 grimaced while the CNAs were preforming front peri care was done. The CNAs rolled Resident #69 to his left side to do care his left leg was shaking CNA E asked Resident #69 if he was in pain and he stated yes. The CNAs then turned Resident #69 to his back and his leg and left side was shaking and Resident #69's facial expressions indicated he was in pain. In an interview on 10/19/2022 at 11:45 AM, CNA F stated she worked the 2:00 PM to 10:00 PM shift on 10/17/2022. She stated she was aware of his accident. She stated she answered Resident #69's call light and he stated he needed a pain pill that he was in pain. CNA F stated she communicated to the nurse, the resident was in pain and she stated she did not know her name she was an agency staff . CNA F stated she did not see if the nurse medicated him and stated the resident was sleepy, so she didn't check on him frequently and stated CNA G took care of him. In an interview on 10/19/2022 at 1:15 PM, CNA G stated she went to Resident #69's room to get him water and he asked her if she could let the nurse know that he needed pain medication . CNA G stated she told the nurse, who was agency, that Resident #69 need pain medication. She stated she did not know if he got the medication. CNA G stated around 9:30 PM 10/17/2022, the agency nurse was making her way down the hall, but she did not see what room she went into or if she gave Resident #69 any medication . In an interview on 10/20/2022 at 8:50 AM, LVN I stated she worked the night of 10/17/2022 and her shift ended at 6:00 AM. LVN I stated Resident #69's pain medication was not available on her shift and was not given to resident. She stated she did not do the re-admission assessment another nurse (she did not know the name of) did the assessment. When asked why her name was on the assessment, she stated she did not know. LVN I, stated she did not get the report from the hospital when Resident #69 was readmitted from the other nurse. She further stated she was not told if he had been medicated for pain prior to discharge from the hospital . She stated she did go and check on the resident and took his vital signs but was not able to say at what time the assessment occurred. She stated it was documented in the progress notes (review of notes reflected no assessment or vital signs, review of MAR revealed no vital signs). She stated no one reported to her about the resident having pain and was not able to say when she performed a pain assessment on Resident #69. 44174 2. Review of Resident #244's face sheet revealed Resident #244 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses of cancer of the esophagus, atrial fibrillation (irregular heartbeat), history of lower leg amputation, high blood pressure, depression, chronic kidney disease. Review of Resident #244's quarterly MDS assessment dated [DATE] revealed Resident #244 had a BIMS score of 15 to indicate intact cognition. Resident #244 did not require a pain assessment. Review of Resident #244's discharge MDS assessment dated [DATE] revealed Resident #244 received a scheduled pain medication regimen and the pain assessment interview was not completed. Review of Resident #244's Readmission Assessment completed 10/19/2022 revealed Resident #244's pain assessment portion of the assessment was blank. Resident #244 was noted to have a terminal condition related to cancer and required end of life/hospice/pallative plan of care. Under vital signs it was noted Resident #244 had a pain level of 0 on 10/19/2022 at 3:10 AM. Review of Resident #244's MAR dated 10/19/2022 revealed on 10/22/2022 Resident #244 had a pain level of 9 when the fentanyl patch was administered. Review Resident #244's nursing progress note dated 10/19/2022 at 10:03 PM revealed Resident #244 returned from the hospital, VSS. Resident #244 had a new order for 15 mg morphine every four hours as needed for pain. Review of Resident #244's nursing progress note dated 10/20/2022 at 9:15 AM revealed Resident #244 refused hydrocodone and morphine was administered. Review of Resident #244's nursing progress dated 10/20/2022 at 9:28 AM revealed a new order was entered for Fentanyl patches ordered every 72 hours 75 mcg/hr with instructions to apply one patch transdermally one time a day every three days. In an observation on 10/19/2022 at 3:00 PM, Resident #244's RP notified LVN J that Resident #244's pain medications including morphine and fentanyl patches had been sitting on his bed side for over an hour, unsecured, and that someone should probably lock them up before they went missing. LVN J took the medications and exited the room. In an interview on 10/19/2022 at 3:05 PM, Resident #244's RP stated he wanted Resident #244 to be comfortable and as pain free as possible due to his terminal cancer diagnosis. He stated Resident #244 required strong pain medication due to the cancer spreading all over his body and into his bones. He stated Resident #244 had a fentanyl patch on and it was due to be changed tonight at midnight. He stated he spoke with LVN J and notified him of the need for the patch change and that Resident #244's RP did not want it missed because Resident #244 would be in pain. He stated prior to Resident #244's recent hospitalization , it was not uncommon for the nursing staff to run late with Resident #244's pain medication. He stated he was in the process of setting up hospice care at his home for Resident #244, so they could ensure he received the pain medications as ordered and so Resident #244 would be more comfortable. In an interview on 10/20/2022 at 9:35 AM, Resident #244 stated his new fentanyl patch was not put on until 9:00 AM that morning and his pain level had reached a 9; at that time, it was at a 7. He stated he asked for his morphine pill and LVN D brought him hydrocodone. He said she told him the facility did not have his morphine filled. He said he told her he returned from the hospital with it filled and then LVN D left to find it. He stated he told her he needed the morphine because his pain was so bad. He said she returned and gave him the morphine. He said the whole thing was screwed up. He said MD Q saw him yesterday and assured him all of his pain medications would be ready at his request. He said his pain medication was not ready and they could not apply the new fentanyl patch because there was no physician order. In an interview on 10/20/2022 at 10:55 AM, LVN D stated she gave Resident #244 his morphine pill at 9:11 AM and his previous dose was at 4:45 AM. She stated the fentanyl patch was replaced at 9:20 AM as there was no order for the patch until then. She stated she did not know why the order was not in yesterday. In an interview on 10/22/2022 at 10:20 AM, the DON stated there was confusion over Resident #244's fentanyl patch. She stated Resident #244's RP told the admitting nurse he had the patch on and it needed to be replaced that night (10/19/2022) at midnight. She stated the fentanyl patch was removed by the hospital staff prior to his discharge and when Resident #244 returned to the facility, he was not wearing a fentanyl patch. She said no one checked for the patch sooner. They clarified the order with the physician the morning of 10/20/2022 and the charge nurse placed the patch on 10/20/2022 at 9:11 AM. Review of the facility's policy Pain Management dated 03/14/2019 reflected Compliance Guidelines: to assess the resident pain control and management needs at admission/ readmission, quarterly, annual and when a change of condition indicates a need for initiating or modifying a pain management program for the residents. Pain screening is conducted upon admission using the UDA: Nursing: admit/ Re-admit nursing review .Residents who experience a change in condition or have a suspected new onset of pain are evaluated for pain. Residents are also evaluated for pain regularly by team members inquiring if they have pain and observation of the resident for non-verbal signs and symptoms of pain . An Immediate Jeopardy (IJ) was identified on 10/19/2022 at 3:55 PM, due to the above failures. The Administrator was notified of the IJ and the IJ template was provided. The Administrator verbalized understanding of the IJ and a Plan of Removal was requested. The Plan of Removal was accepted on 10/21/2022 at 8:43 PM and is as follows: Plan of Removal Immediate Jeopardy On 10/18/2022 an annual survey was initiated at facility. On the evening of 10/19/2022 the surveyor provided an Immediate Jeopardy Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to a resident's health and safety. F697 Pain Management r/t the resident stated to surveyor on 10/18/2022 that he was in pain at the time of the interview and had not received pain medication for five hours. The notification of Immediate Jeopardy states as follows: On 10/18/2022 The surveyor indicated that the resident reported during an interview on 10/18/2022 that he had returned to the community on the night before (10/17/2022) and was currently in pain and had reported his pain to the nurse but had not received any pain medication and has been in pain all morning for about 5 hours. All residents who currently reside at the facility (152 active residents) may have the potential to be affected. 1. Action: At approximately 5:30 pm, on 10/19/2022 Administrator and Registered Nurse rounded to confirm resident was comfortable and without distress. There were no negative outcomes identified at that time, as in no pain or discomfort noted. Nurse re-assessed resident on 10/19/2022 at 19:21, noted a pain score of 8 out of 10 and the nurse medicated resident with oxycodone as ordered. Nursing will continue to monitor for s/s of pain. 10/19/2022 Director of Nurses confirmed that the Oxycodone 10mg Q8 hrs. was available to be administered as ordered. Start Date: 10/19/2022 Completion Date: 10/19/2022 and on-going monitoring continues every shift and as needed until fracture resolved. Pain monitoring will be continued every shift throughout duration of stay. Responsible: Director of Nursing Services / Licensed Nurses The electronic health record has a pain monitoring order scheduled for Q-shift (every shift) on the LNAR (licensed nurses administration record) to indicate the pain assessment is scheduled to be completed and the nurse will document the pain assessment findings. 2. Action: Administrator/Director of Nursing Services conducted rounds and interviewed resident and team members who provided direct care to resident, which included a licensed vocational nurse on duty at time of resident's admission, the licensed vocational nurse taking over at shift change at 6pm 10/17/2022, and two certified nurse's aides to identify additional pain concerns noted. Outcome: There were no associated negative findings noted. As indicated in action # 7, the Administrator / Director of Nursing Service /Director of Clinical Education/Register Nurse Supervisor will conduct random, at least weekly rounds on all residents to ensure the comfort and well-being of our residents is maintained and if pain present, it is managed and being addressed. This has commenced 10/19/2022 and will be an ongoing activity added to weekly tasks. Start Date: 10-19-2022 Completion Date: 10-19-2022 Responsible Administrator/Director of Nursing Services 3. Action: The Director of Nursing Services was immediately re-educated by the Regional Registered Nurse following the IJ being cited. The Director of Nursing Services then re-educated the Director of Clinical Education and RN supervisor so that they may assist with educating licensed nurses, medication aids and nurses aids alike. All licensed nurses and aids, full time and part time, on duty and off, were re-educated by Director of Nursing Service /Director of Clinical Education/Register Nurse Supervisor on Prevention of Abuse & Neglect identifying and anticipating and meeting pain management as well as the care to include monitoring and provide care in a gentle manner to prevent pain and discomfort during care related to care of a patient with a known fracture without surgical intervention, as well as communicating patient needs to ensure staff (licensed nurses, medication aids and aids) are aware of patient care needs upon return from the hospital. Additionally, all nursing staff to include licensed nurses, medication aids and aids have been re-educated as indicated in action #4 as indicated below. The education provided regarding assessing pain needs, addressing pain needs and providing gentle and appropriate care to prevent discomfort and pain, was regarding the issue identified as well as other residents who have injuries such as fractures and any resident experiencing pain. Start Date: 10-19-2022 Completion Date: 10-20 -2022 Responsible Administrator/Director of Nursing Services 4. Action: Director of Nursing Services/Director of Clinical Education/RN Supervisor initiated Inservice training & re-education will be provided to all nursing team members ( (licensed nurses, medication aids and aids) and those team members who were identified as assigned to the resident during the time in question as indicated above in action #3, regarding topics: (this education was extended to other nursing team members (licensed nurses, medication aids and aids) in order to ensure that the team is aware of how to assess pain, address pain management needs and to provide care in a gentle and careful manner in order minimize pain and discomfort especially for those with fractures). Prevention of Abuse & Neglect identifying and anticipating and meeting pain management as well as the care to include monitoring and provide care in a gentle manner to prevent pain and discomfort during care related to care of a patient with a known fracture without surgical intervention, as well as communicating patient needs to ensure staff is aware of patient care needs upon return from the hospital. Current full time and PRN nursing team members will be re-educated prior to assuming next shift. Nursing team members (LVNs/RNs/Certified Med Aids and Certified nurse aids and non-certified nurse aids in training), both full time and PRN and those (LVNs/RNs/Certified Med Aids and Certified nurse aids and non-certified nurse aids in training), who are absent have been re-educated via telephone communication. The in-service attendance page with signatures indicates in person re-education received and the team member names, and role listed indicates the telephone communication provided. The team members re-educated consists of LVNs/RNs/Certified Med Aids and Certified nurse aids and non-certified nurse aids in training, future team members will be educated during on boarding prior to working their assignment. This education has been provided through current date, upon new hire on-boarding, annually and as needed. Start Date: 10/19/2022 Completion Date: 10/20/2022 Responsible Director of Nursing Services/Director of Clinical Education/RN Supervisor 5. Action: Director of Nursing Services requested that physician assess resident to ensure condition stable and pain needs are being managed appropriately. Physician's assessment and review of plan of care was conducted on 10/19/2022 The plan of care was reviewed on 10/19/2022 and will be updated as clinically indicated. Start Date: 10-19-2022 Completion Date: 10-19 -2022 Responsible Director of Nursing Services & Dr. [NAME] 6. Action: Administrator conducted an AdHoc QAPI meeting (additional, specific quality assurance meeting) with the MD and Director of Nursing Services to review identified concern and response plan. (Plan of removal) Start Date: 10-19-2022 Completion Date: 10-19 -2022 Responsible Administrator, Director of Nursing Services & MD 7. Action: The Administrator / Director of Nursing Service /Director of Clinical Education/Register Nurse Supervisor will conduct random, at least weekly rounds to ensure the comfort and well-being of our residents This has commenced 10/19/2022 and will be an ongoing activity added to weekly tasks. Director of Nursing Services/Director of Clinical Education/RN Supervisor have reviewed the 24-hour report, progress notes, risk management reports and changes in condition, to identify any new onset or worsening pain and validated interventions are in place. Date Completed: 10-19-2022 Start Date: 10-19-2022 Responsible: Director of Nursing Services The Survey team monitored the plan of removal as follows: In an interview on 10/21/2022 at 12:30 PM CNA M stated she was educated on notifying the charge nurse immediately if a resident had new onset of pain or worsening pain. She stated she was to notify the charge nurse immediately of any change in condition or injury to a resident for assessment by the charge nurse. She stated if a resident's pain was not relieved she would speak with the charge nurse again or notify the DON. In an interivew 10/21/2022 at 9:30 AM CNA E stated she was inserviced on notifying the charge of a resident change in condition or increased pain. She stated sh was educated regarding reading the shift report log for updated information regarding a resident's condition or change in condition. She stated she was to notify the charge nurse of any new or worsening pain in a resident. In an interview on 10/22/2022 at 9:25 AM, LVN K stated she received education/in-servicing regarding pain management, comprehensive pain assessment under assessments tab and reporting any incident to DON. She stated CNA's should report any incident to charge nurse and then she would report to DON. She stated if a resident was injured in any way, staff were to assess the injury and assess for pain immediately and frequently to ensure resident was not in pain. She stated she was to notify the doctor if needed if current pain management medication was not effective. She stated she was not aware of any resident currently in pain and continuing to do pain assessments on Resident #244 who required morphine as needed every 4 hours. In an interview on 10/22/2022 at 9:40 MA N stated she received in-service regarding pain management for residents with acute or chronic pain. She stated she was to notify the nurse immediately if a resident complained of pain and required PRN pain medication. She stated if a resident was injured during care or a fall, notify the nurse immediately. She stated she was instructed to check in with residents regularly to ensure pain did not continue to be an issue. She stated there were no residents currently complaining of pain to her this morning. In an interview on 10/22/2022 at 9:47 AM, Resident #244 stated he was not currently in bad pain. He stated his pain level was a 9 that morning but now it was down to a 3. He stated the staff were bringing his pain medication as requested. In an interview on 10/22/2022 at 9:55 AM, LVN A stated she was in-serviced on pain management and conducting comprehensive pain assessments upon readmission. She stated she was educated on follow up for effectiveness of pain medication. She stated she was educated on the use of the pain assessment under assessment tab each time assessing for acute pain or new onset of pain. She stated if a resident experienced any changes or if pain medication was not effective, she was to notify the doctor for further instructions. She stated she was to notify the DON if a pain medication was not available. She stated they were to notify the DON of any changes or incidents with residents. She stated they were to give any new or changed information on shift report regarding pain or new injury or issue with a resident and ensure the aides knew as well. In an interview on 10/22/2022 at 10:00 AM, LVN L stated she was educated on addressing resident pain needs as soon as possible and if pain medication was not effective with current medication, they were to notify the physician. She stated they were to notify the physician of new onset of pain. She stated they were to notify oncoming charge nurse and aides of any changes or new incidents with a resident so all were aware of changes in care needs for residents. She stated in addition to medication they were re-educated regarding other forms of pain relief like repositioning residents to more comfortable or offer heat/cold pack as requested. She stated they were instructed to complete the comprehensive pain assessment under the assessment tab. In an interview on 10/22/2022 at 10:05 AM, Resident #69 stated his pain was at baseline and he received medication as requested. He stated he felt his pain needs were adequately addressed and he would report to the DON or the Administrator, if not. In an interview on 10/22/2022 at 10:20 AM, the DON stated in addition to the education provided regarding pain management they implemented the procedure that aides would also review the shift report log. So they were familiar with new resident issues or changes. She stated the staff were not communicating well and having agency staff was the reason for lack of knowledge for new patient issues. Review of Record of Inservice dated 10/19/2022 at 6:00 PM revealed staff were educated regarding handling veterans with care, pain management, pain assessments, documentation, abuse and neglect. Permanent staff, agency staff and PRN staff currently on the schedule were noted to have completed the in-service as required by the POR. Review of Resident #69's Progress noted dated 10/19/2022 revealed Resident #69 completed an assessment of Resident #69 and confirmed Resident #69 was stable and pain management needs were met. Review of Resident #69's MAR dated 10/22/2022 revealed Resident #69 was assessed for pain each shift as required. On 10/22/2022 at 10:45 AM, the administrator was notified that the Immediate Jeopardy (IJ) was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated, due to the facility needed to evaluate the effectiveness of the corrective systems.

Based on observation, interviews and record reviews the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents and hazards for one (Resident #69) of 30 residents reviewed for accidents and hazards The facility failed to ensure staff properly transferred Resident #69 from his wheelchair to bed resulting in Resident #69's left leg getting caught on the mechanical lift bar and resulting in a displaced transverse femur fracture. This failure could result in residents experiencing accident, injuries, unrelieved pain and diminished quality of life. Findings Include: Review of Resident #69's face sheet dated 10/18/2022 reflected he was admitted on [DATE] with the following diagnoses Malignant neoplasm of prostate (prostate cancer), Transient Ischemic Attack and cerebral infarction (a brief episode of neurological dysfunction caused by loss of blood flow; Infarction refers to death of tissue) and Hemiplegia affecting left side (paralysis of one side of the body.) Review of Resident #69's quarterly MDS assessment dated [DATE] reflected Resident #69 was assessed to have a BIMS score of 15 indicating he was cognitively intact. Resident #69 was assessed to require extensive assist with two person assist with transfers and ADLs. Resident #69 was assessed to have scheduled pain medication regimen. Resident #69 was further assessed to not have pain. Review of Resident #69 comprehensive care plan reflected a focus area self-care deficit related to hemiparesis left side with contractures causing limited physical functioning related to stiff or limited joint range of motion. Review of Resident #69's interventions did not reflected how resident was to be transferred. Further review of Resident #69's care plan did not reflect a plan of care for pain. Review of Resident #69's nursing progress notes reflected an entry dated 10/13/2022 Resident had complaints of pain in his left hip, Resident stated that when he got back from his appointment his leg got stuck in between the machine and he heard a crack. Nurse called in an order of the x-ray at 12:00 PM on 10/13/2022 the results came back and found a transverse fracture through the proximal left femoral diaphysis with superior displacement of the distal fracture fragment of approximately 3.5 cm MD was notified and EMS is on their way to transfer the resident to the hospital. Review of Resident #69's incident report dated 10/13/2022 reflected Nursing Description: Resident had complaints of pain in his left hip. Nurse called in an order for the x-ray at 12:00 PM on 10/13/2022. Results came back and found a transverse fracture through the proximal left femoral diaphysis with superior displacement of the distal fracture with fragment of approximately 3.5 cm. MD was notified and EMS is on their way to transfer the resident to the hospital. Resident Description: Veteran states that when he got back from his appointment his leg got stuck between the Hoyer and he heard a crack. Review of Resident #69's X-ray report dated 10/13/2022 at 3:25 PM reflected a transverse fracture through the proximal left femoral diaphysis with associated superior displacement of the distal fracture fragment of approximately 3.5 cm and apex lateral angulation .(The term 'displacement' is often used as a specific term to describe loss of bone alignment along its long axis. Loss of alignment, or displacement, is usually accompanied by some degree of angulation, rotation or change in bone length . To describe fracture angulation the direction of the distal bone and degree of angulation in relation to the proximal bone.) Review of Resident #69's Hospital records dated 10/17/2022 reflected an entry dated 10/14/2022 Resident is a pleasant [AGE] year-old male who was admitted last night for intractable left hip pain after the injury at the nursing home on Tuesday. He was being transferred via Hoyer lift when his left lower extremity hit pole of lift during turning while in the sling. He has had persistent pain since incident which warranted emergency department visit. Per radiology patient has impacted and displaced fracture of the proximal left femoral shaft in a varus configuration. (A varus alignment causes the load-bearing axis of the leg to shift to the inside, causing more stress and force on the medial (or inner) compartment of the knee.) Patient is a not surgical candidate per orthopedics who recommended pain management and nursing care . In an interview on 10/18/2022 at 1:23 PM LVN A stated she sent Resident #69 to the hospital on 10/13/2022 after an x-ray confirmed he had a broken hip. She stated Resident #69 told her it had happened the day before on 10/12/2022 when he was being transferred with themechanical lift. LVN A stated he told her his leg got caught on the mechanical lift and as they turned him, he heard a pop. LVN A stated he was in pain when she checked on him and she looked at left hip and saw swelling. She stated the MD requested an x-ray then confirmed fracture. She stated the doctor notified and said send him to hospital. LVN A stated Resident #69 returned last night 10/17/2022. LVN A stated she notified DON immediately upon Resident #69's reporting injury and pain. LVN A stated the staff nurses do not do incidents that the DON would have done the incident report and subsequent investigation. LVN A stated she was not sure if Resident #69 had surgery on hip while hospitalized . LVN A stated she was the nurse in charge of Resident #69 on 10/12/2022 CNAs (CNA B & CNA C) did not report any incident or injury regarding Resident #69 to her on 10/12/2022 or 10/13/2022. LVN A stated Resident #69 was out of bed on 10/12/2022 due to MD appointment and they would have been transferring him back to bed when it happened. She said staff are supposed to report to charge nurse and/or DON immediately of a resident injury. She said in response to hip being broken the facility did an in-service on abuse/neglect reporting and Hoyer lifts on Thursday 10/13/2022. LVN A stated she was not aware of any other staff education done regarding Resident #69 and his broken hip or care and pain needs. In an interview on 10/18/2022 at 1:44 PM CNA B stated her, and CNA C were assisting Resident #69 this morning for resident care and using two aides because that is what he said he needed. CNA B stated she heard Resident #69 was blaming them for his broken hip, but they didn't do it. She said they did move him using the mechanical lift one day last week maybe Thursday. She stated as they moved him from bed to wheelchair to go to his MD appointment, his foot got caught on the wheelchair pedal and she had to physically lift his foot and set it on the pedal. CNA B stated no other incident occurred during Resident #69's care or when he returned from the appointment. CNA B stated she did not notify anyone of the incident because nothing happened. She stated Resident #69 was not in pain and she did not hear a pop during the transfer. CNA B stated Resident #69 returned from MD and they transferred him back to his bed without incident. She did not know how his hip was broken. She said he slides down in his chair a lot and needs a bigger wheelchair. CNA B stated she just heard today he had a broken hip/femur. Said she used to be able to change him by herself with his assistance by holding onto the bar on bed but now he always needed two people. CNA B stated no one at facility told her anything had changed regarding his care. CNA B stated Resident #69 told her this morning. CNA B stated she was in serviced on Thursday 10/13/2022 related to Hoyer lift transfers and abuse/neglect reporting. Attempts to interview CNA C via phone calls during survey on 10/19/2022 and 10/20/2022 were unsuccessful. Review of CNA B's caregiver competency checklist dated 06/20/2022 reflected she was checked off as competent in mechanical lift devices. Review of CNA C's caregiver competency checklist dated 07/04/2022 reflected she was checked off as competent in mechanical lift devices. In an interview and observation on 10/18/2022 at 2:16 PM, Resident #69 was in his room in bed. He stated the nurse finally did give him some pain medication about an hour ago. When asked what happened to his leg, he stated when he was transferred last week, he told the CNAs to watch his leg and his leg got caught on the bar of the lift and when they went to turn in to put him in bed, he heard his leg snap. He stated they had to hear it too. He stated he told them that it was hurt. In an interview on 10/18/2022 at 3:39 PM the DON stated she did not complete an investigation into the injury of Resident #69's leg and did not report the incident to HHSC because the Resident could state what happened. The DON agreed the incident should have been investigated for neglect and staff should have been monitored to ensure they were component to preform mechanical lift transfers and she stated she did not do that. The DON stated they should have made sure the resident had pain medication in house when he returned from the hospital. In an interview on 10/18/2022 at 4:00 PM the Administrator stated they did not follow the facility's abuse and neglect policy to complete an investigation, suspend the employee's pending investigation or report the injury to HHSC. When asked if she felt like it was neglect, and the incident should have been investigated as such since the two aides were transferring a dependent resident which caused a serious injury she stated when you put it like that yes it should have been investigated. Review of the facility's Record of In-service dated 10/13/2022 reflected an in-service titled Nursing in-service: Hoyer transfers, abuse and neglect .Hoyer left transfers require at a minimum 2 staff members to operate. No Exceptions . Physical Abuse: unexplained injuries, broken bones, medication issues .Neglect is the failure to meet a Resident's basic needs .It occurs when a resident in nursing homes do not get proper care and suffer physical or mental health problems as a result . Review of the facility's policy How to safely lift a patient into a patient lift/ Hoyer lift (not dated) reflected Lifting and moving patients either in a healthcare institution or at home can be dangerous task, as doing so improperly can injure the patient or damage the lift .Hoyer transfers require 2 or more staff members to safely operate lift and handle patient .use gentle hands-on pressure to guide patient as you slowly move lift toward receiving surface. Slowly lower patient toward receiving surface. Move patient's body into correct position on receiving surface before releasing patient's weight .

Based on observation, interview, and record review the facility failed to ensure that the resident environment remains as free of accident hazards as possible, and each resident receives adaquate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 1 residents reviewed for accidents during transport. Resident #1 sustained a bruise under her left breast due to an incident. Resident #1 was placed in the facility van in an unrestrained scooter. The scooter tipped over, resulting in Resident #1 falling out onto another wheelchair and injuring her breast area. This failure resulted in an avoidable accident, causing Resident #1 pain, discomfort with injury and bruising. Findings include: Observation on 5/2/12 at 9:10 AM revealed the inside of the facility van equipped with devices to securely strap in 2 wheelchairs. The seats of the van were equipped with seatbelts. Review of Resident #1 Admission Record reflected a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] reflected the following: BIMS (brief interview for mental status) score of 15. (cognitively intact) - no mood or behavior concerns.- extensive assist with most ADLs. (activities of daily living) Pain-occasional, moderate pain. Review of Resident #1's Plan of Care dated 4/23/12 reflected "I stated I hit another wheelchair while in the facility van during transportation on 4/23/12.- Interventions:x-ray to rule out fracture, assess pain and administer pain medication as ordered.-Check to ensure wheelchair is secure during transport on facility van" - "I have an ADL self care performance deficit related to pain, impaired balance" -"I am at high risk for falls related to vision/hearing problems. Gait/balance problems, Incontinence, fall history:12/9/11, 3/29/12" Review of Resident #1's Progress Notes/ Incident Report dated 4/24/12-4:42 PM reflected the following : "Resident stated she was having pain in left breast. Resident was not sure why but thought she may have hit another wheelchair on bus.- Description of Initial Action Follow up to action: I did not take vitals at the time of report. Resident was vague with statement and it is not unusual for resident to have pain without specific cause. No injury was noted and it was unsure at the time that an incident had occurred." the note was signed by LVN A. Review of the Provider Investigation Reports dated 4/24/12 reflected the following: "Resident #1 was seated in her handlebar steered scooter. This scooter is smaller than other joystick steered scooters. The transport van is not equipped with anchoring straps that fit Resident #1's scooter. VD secured all other wheelchairs except Resident #1's. VD proceeded to drive to Walmart. At some point during the trip, the van made a right turn. When it did, Resident #1 fell to the left, still seated in her scooter. Resident #1 became pinned between the van seat and her scooter. Upon noticing her fall,VD stopped the van and along with the assistance of AA, repositioned Resident #1 back in her scooter, still without anchoring it. The Group arrived at Walmart and went shopping including Resident #1. After shopping the group returned to the Home without incident. Resident #1's scooter was not anchored on the trip to Walmart nor was it anchored on the return trip. Neither VD nor AA seated Resident #1 in a passenger seat with a seat belt following this incident. Resident #1 began to complain of pain the afternoon following the Walmart trip.- Description of injury: 4 x 3 cm irregular shaped bruise to the upper left torso.-Resident #1 was given Vicodin for pain following her complaints of pain. DON (director of nurses) received hand written note from 10-6 CNA (certified nurses assistant ) Z detailing her conversation with Resident #1. Investigation Summary: VD and AA were both present and witnessed the fall of Resident #1. They both admit that they did not secure Resident #1's scooter in the van according to policy. Nor did they offer to seat Resident #1 in a passenger seat and secure her with a seat belt. Neither VD or AA reported this incident to a charge nurse, nurse manager or to the Administrator. AA did report it to her supervisor. Her supervisor did not report the incident to anybody." Review of a written statement dated 4/23/12-/4/24/12 and signed by CNA Z reflected the following: "At 12:15 AM Resident #1 turned call light on stated she was in pain. I asked her what happened. Resident said she fell on facility van going to Walmart and her electric wheelchair fell over on her. Her breast is hurting on left side and wanted a pain pill. I asked her did she tell anyone. She said she told the 2-10 nurse and she gave her a pain pill and the the VD and lady over activities knew because they got the wheel chair off of her but it could not be buckled in because the van seat belts don't work on electric chairs. I then reported this to nurse. Nurse came in to give pain pill and talk to resident." In an interview on 5/2/12 at 12:25 PM CNA Z stated Resident #1 turned on her call light, and when she went to sit her up, she sighed heavily. CNA Z stated Resident #1 told her when she went to Walmart that previous morning, the van turned a corner and her scooter fell on top of her. CNA Z stated Resident #1 told her they picked me up and we went to Walmart.. CNA Z stated she reported the conversation to her charge nurse. In an interview on 5/2/12 at 9:10 AM, the Van Driver (VD) stated there is no way to secure a scooter in the straps equipped for wheelchairs. The VD stated he placed Resident #1 seated on her scooter next to a secured wheelchair with her sitting on it. The VD stated he stopped at a red light, took a right hand turn and Resident #1's scooter tipped, causing her to fall out into the wheelchair next to her. The VD stated he stopped the van and the Activity Assistant (AA) and himself rushed to assist Resident #1. The VD stated Resident #1 stated at the time she was okay and wanted to go on to Walmart. The VD stated the AA and himself assisted Resident #1 back onto her scooter and proceeded to Walmart. The VD stated Resident #1 usually rides in her regular wheelchair when participating in outings in the van. The VD stated he was "not told much" about transporting scooters and has always transported scooters this way. The VD stated he figured Resident #1 was safe and okay. The VD stated he has taken a safety course since the incident. In an interview on 5/2/12 at 9:15 AM, the Administrator stated if a chair or scooter can not be secured, a resident should be taken out of the wheelchair or scooter and assisted to sit in a seat with a seatbelt. The Administrator stated this would be implemented immediately to prevent a reoccurance of this accident. The Administrator stated he was unaware the VD was transporting residents on scooters in this manner. The Administrator stated he assumed every resident was securely strapped in. The Administrator stated Resident #1 did not complain of any pain at the time and insisted on going to Walmart. The Administrator stated Resident #1 complained of pain later on in the afternoon. The Administrator stated the VD provides approximately 25-30 transports a week. In an interview on 5/2/12 at 9:45 AM, the Activity Assistant (AA) stated on 4/23/12 during an outing to Walmart, Resident #1's scooter tipped over on the van causing her to fall between the scooter and a wheelchair next to her. The AA stated she witnessed the fall and called out to the driver to stop the van. The AA stated Resident #1 usually rides in a regular wheelchair, this is a new scooter for her. The AA stated she and the VD were able to get the scooter up and Resident #1 back onto it. The AD stated Resident #1's left shoulder and upper chest area were against the chair next to her. The AD stated Resident #1 insisted she was okay and wanted to go on to Walmart. The AD stated she should have called the incident into the facility, but instead asked the VD to report it when he returned to the facility and he said he would. The AD stated when she returned to the facility following the outing she could not find the VD, and reported the incident to her supervisor. The AA stated she found out later the VD and her supervisor did not report the incident. The AA stated the problem was, all of them assumed the other had reported the incident. The AA stated the evening nurse reported the incident after hearing it from Resident #1. The AA stated she did not complete an incident/accident report and was asked to write a statement the following day. In an interview on 5/2/12 at 10:00 AM, the Activity Director (AD) stated she is the AA's supervisor. The AD stated the AA came to her and told her about an incident that occurred on the van that morning. The AD stated she asked the AA if she or the VD was going to write an incident report and the AA told her the VD would. The AD stated she "expected that adults would take care of things but they did not." The AD stated the night nurse completed an incident/accident report and the Administrator received it the following day. The AD stated she would have expected the AA to follow up with the VD or write the report herself as a witness. The AD stated "we all know what to do, it is just neglect on our part." In an observation/ interview on 5/2/12 at 10:45 AM Resident #1 was observed seated on her scooter. The scooter had 2 wheels in the back and 1 wheel in the front. Resident #1 stated she was the last person to be loaded on to the van that day for a trip to Walmart. Resident #1 stated she was placed in the back "crosswise" behind the driver. Resident #1 stated the driver was not going very fast, went around a corner and she tipped over to the left. Resident #1 stated she did not feel any pain until later that day. Resident #1 stated she had a bruise under her left breast and it was just now getting better. Resident #1 stated she could not use her arms for a day or 2 after the incident, and suffered bad pain.. Resident #1 stated she had previously ridden on the van in her scooter to the dentist and nothing happened. Resident #1 stated she could not be strapped in but was placed at an "angle." Resident #1 stated she did not report the incident to anyone upon return to the facility, but supposed the AA reported it. In an interview on 5/2/12 at 10:48 AM, Resident #1's private sitter recalled accompanying Resident #1 on a trip to the dentist in the facility van. The sitter stated Resident #1 rode on her scooter. The sitter stated Resident #1's scooter was not secured during the trip to or from the dentist's office. In an interview on 5/2/12 at 12:40 PM, LVN A stated Resident #1 did not tell her about the incident, just that she had a pain in her left breast. LVN A stated Resident #1 informed her she may have bumped it, but was pretty vague. LVN A stated she did not document her assessment because she was just looking and there was nothing there. LVN A stated she never heard about Resident #1 falling on the bus, but was told by another LVN to generate an incident report because she had failed to do one. LVN A stated she did not feel like Resident A had an injury at the time. In an interview on 5/2/12 at 12:30 PM, the VD stated he had another run that day following his return from the Walmart trip and did not return back to the facility until 5:00 PM. The DV stated "I guess it just slipped my mind." The VD stated he does not recall if the AA asked him to report the incident upon return to the facility. The VD stated he was up front and the AA was in the back of the van. The VD stated it was the "communication, we thought each other would report it". The VD stated Resident #1 reported it to the nurse because she asked him about it the following morning. Review of Resident #1's nurses progress notes dated 4/24/12 reflected " Resident has bruise under left breast 3.5 X 1.5. Resident is sore in that area. PRN Vicodin given 9 PM. resident has no shortness of breath. X-ray results are negative for fracture. Resident informed night nurse of fall occurring while out on pass with activities". Review of Resident #1's nurses notes dated 4/25/12 reflected : "Resident requires more help due to injury sustained on outing on 4/23/12. CNA continues to assist resident to and from electric chair to bathroom , then back to bed. Will continue to monitor resident. Previous pain medication effective as resident states "it only hurts when I move." In an interview on 5/2/12 at 2:05 PM, the Director of Nurses stated her expectations would be for the VD to turn the van around and come immediately back to the facility for the charge nurse to assess the resident. The DON stated following an assessment, she would expect the nurse to initiate an incident report, contact the physician and responsible party, and get statements from the witnesses. The DON stated the incident should have been reported. Review of a facility policy dated 02/2012 Accidents and Incidents Reporting/Investigation reflected the following: "Objective: All accidents or incidents involving residents, employees, visitors, occurring on our premises will be investigated and reported to the licensed nurse/administrator/designee. These reports will be utilized for bruises, skin tears, abrasions, etc. observed on the resident. a. An accident or incident will be reported to the department supervisor/designee as soon as such accident/incident is discovered or when information of such accident/incident is learned. c. An employee witnessing an accident or incident involving a resident, employee, visitor, etc. will report such occurrence to his or her immediate supervisor/designee as soon as practical. Do not leave an accident victim unattended unless it is absolutely necessary to summon assistance. d. The nurse supervisor/charge nurse will be informed of accidents or incidents so that medical attention can be provided." Review of the VD job description dated 9/2005 reflected "the primary purpose of your job position is to transport residents in accordance with current applicable federal, state, and local standards, guidelines, and regulations, and as may be directed by the administrator, to assure that resident and employee safety can be maintained at all times. Administrative functions: Develop and maintain safety objectives and standards in accordance with current regulations and guidelines. Safety and Sanitation: Ensure that established safety precautions are being implemented and followed at all times." Review of an In-service training report dated 4/27/12 reflected: "Explain safe transport of passengers. Any resident who can transfer to a van seat shoud be seated in van seat and secured with a safety belt. Wheelchairs, scooters can be folded and/or secured with straps in rear of bus/van. Any passenger/resident who falls, or otherwise gets injured or ill must be returned to the community to be assessed by a nurse. This should be done immediately or call 911." Per Administrator the facility census was 155. A facility acquired list reflected 25 electric wheelchairs and 4 scooters.The list included Resident #1 in addition to 2 scooters "do not use" and 1 resident "no outings" A facility acquired list " Residents who go on outings" listed 14 including Resident #1. Per Activity Director, Resident #1 is the only resident who chooses to participate in facility outings who uses a scooter.

Based on observation, interview, and record review, the facility failed to implement their written policy and procedure to prohibit mistreatment, neglect, and abuse of residents for 1 (resident #1) of 1 resident reviewed for accidents during transport. Resident #1 sustained a bruise under her left breast due to an incident. Resident #1 was placed in the facility van in an unrestrained scooter. The scooter tipped over, resulting in Resident #1 falling out onto another wheelchair and injuring her breast area. The (van driver) VD and Activity Assistant (AA) witnessed the incident and failed to report to the Charge nurse or Administrator. This failure caused a delay in Resident #1's treatment, pain and discomfort and could place any resident who recieves an injury during transport at risk for improper assessment and treatment, resulting in serious injury. Findings include: Review of a facility policy dated 02/2012 Accidents and Incidents Reporting/Investigation reflected the following: "Objective: All accidents or incidents involving residents, employees, visitors, occurring on our premises will be investigated and reported to the licensed nurse/administrator/designee. These reports will be utilized for bruises, skin tears, abrasions, etc. observed on the resident. a. An accident or incident will be reported to the department supervisor/designee as soon as such accident/incident is discovered or when information of such accident/incident is learned. c. An employee witnessing an accident or incident involving a resident, employee, visitor, etc. will report such occurrence to his or her immediate supervisor/designee as soon as practical. Do not leave an accident victim unattended unless it is absolutely necessary to summon assistance. d. The nurse supervisor/charge nurse will be informed of accidents or incidents so that medical attention can be provided." Observation on 5/2/12 at 9:10 AM revealed the inside of the facility van equipped with devices to securely strap in 2 wheelchairs. The seats of the van were equipped with seatbelts. Review of Resident #1 Admission Record reflected a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] reflected the following: BIMS (brief interview for mental status) score of 15. (cognitively intact) - no mood or behavior concerns.- extensive assist with most ADLs. (activities of daily living) Pain-occasional, moderate pain. Review of Resident #1's Plan of Care dated 4/23/12 reflected "I stated I hit another wheelchair while in the facility van during transportation on 4/23/12.- Interventions:x-ray to rule out fracture, assess pain and administer pain medication as ordered.-Check to ensure wheelchair is secure during transport on facility van" - "I have an ADL self care performance deficit related to pain, impaired balance" -"I am at high risk for falls related to vision/hearing problems. Gait/balance problems, Incontinence, fall history:12/9/11, 3/29/12" Review of Resident #1's Progress Notes/ Incident Report dated 4/24/12-4:42 PM reflected the following : "Resident stated she was having pain in left breast. Resident was not sure why but thought she may have hit another wheelchair on bus.- Description of Initial Action Follow up to action: I did not take vitals at the time of report. Resident was vague with statement and it is not unusual for resident to have pain without specific cause. No injury was noted and it was unsure at the time that an incident had occurred." the note was signed by LVN A. Review of the Provider Investigation Reports dated 4/24/12 reflected the following: "Resident #1 was seated in her handlebar steered scooter. This scooter is smaller than other joystick steered scooters. The transport van is not equipped with anchoring straps that fit Resident #1's scooter. VD secured all other wheelchairs except Resident #1's. VD proceeded to drive to Walmart. At some point during the trip, the van made a right turn. When it did, Resident #1 fell to the left, still seated in her scooter. Resident #1 became pinned between the van seat and her scooter. Upon noticing her fall,VD stopped the van and along with the assistance of AA, repositioned Resident #1 back in her scooter, still without anchoring it. The Group arrived at Walmart and went shopping including Resident #1. After shopping the group returned to the Home without incident. Resident #1's scooter was not anchored on the trip to Walmart nor was it anchored on the return trip. Neither VD nor AA seated Resident #1 in a passenger seat with a seat belt following this incident. Resident #1 began to complain of pain the afternoon following the Walmart trip.- Description of injury: 4 x 3 cm irregular shaped bruise to the upper left torso.-Resident #1 was given [MEDICATION NAME] for pain following her complaints of pain. DON (director of nurses) received hand written note from 10-6 CNA (certified nurses assistant ) Z detailing her conversation with Resident #1. Investigation Summary: VD and AA were both present and witnessed the fall of Resident #1. They both admit that they did not secure Resident #1's scooter in the van according to policy. Nor did they offer to seat Resident #1 in a passenger seat and secure her with a seat belt. Neither VD or AA reported this incident to a charge nurse, nurse manager or to the Administrator. AA did report it to her supervisor. Her supervisor did not report the incident to anybody." Review of a written statement dated 4/23/12-/4/24/12 and signed by CNA Z reflected the following: "At 12:15 AM Resident #1 turned call light on stated she was in pain. I asked her what happened. Resident said she fell on facility van going to Walmart and her electric wheelchair fell over on her. Her breast is hurting on left side and wanted a pain pill. I asked her did she tell anyone. She said she told the 2-10 nurse and she gave her a pain pill and the the VD and lady over activities knew because they got the wheel chair off of her but it could not be buckled in because the van seat belts don't work on electric chairs. I then reported this to nurse. Nurse came in to give pain pill and talk to resident." In an interview on 5/2/12 at 12:25 PM CNA Z stated Resident #1 turned on her call light, and when she went to sit her up, she sighed heavily. CNA Z stated Resident #1 told her when she went to Walmart that previous morning, the van turned a corner and her scooter fell on top of her. CNA Z stated Resident #1 told her they picked me up and we went to Walmart.. CNA Z stated she reported the conversation to her charge nurse. In an interview on 5/2/12 at 9:10 AM, the Van Driver (VD) stated there is no way to secure a scooter in the straps equipped for wheelchairs. The VD stated he placed Resident #1 seated on her scooter next to a secured wheelchair with her sitting on it. The VD stated he stopped at a red light, took a right hand turn and Resident #1's scooter tipped, causing her to fall out into the wheelchair next to her. The VD stated he stopped the van and the Activity Assistant (AA) and himself rushed to assist Resident #1. The VD stated Resident #1 stated at the time she was okay and wanted to go on to Walmart. The VD stated the AA and himself assisted Resident #1 back onto her scooter and proceeded to Walmart. The VD stated Resident #1 usually rides in her regular wheelchair when participating in outings in the van. The VD stated he was "not told much" about transporting scooters and has always transported scooters this way. The VD stated he figured Resident #1 was safe and okay. The VD stated he has taken a safety course since the incident. In an interview on 5/2/12 at 9:15 AM, the Administrator stated if a chair or scooter can not be secured, a resident should be taken out of the wheelchair or scooter and assisted to sit in a seat with a seatbelt. The Administrator stated this would be implemented immediately to prevent a reoccurance of this accident. The Administrator stated he was unaware the VD was transporting residents on scooters in this manner. The Administrator stated he assumed every resident was securely strapped in. The Administrator stated Resident #1 did not complain of any pain at the time and insisted on going to Walmart. The Administrator stated Resident #1 complained of pain later on in the afternoon. The Administrator stated the VD provides approximately 25-30 transports a week. In an interview on 5/2/12 at 9:45 AM, the Activity Assistant (AA) stated on 4/23/12 during an outing to Walmart, Resident #1's scooter tipped over on the van causing her to fall between the scooter and a wheelchair next to her. The AA stated she witnessed the fall and called out to the driver to stop the van. The AA stated Resident #1 usually rides in a regular wheelchair, this is a new scooter for her. The AA stated she and the VD were able to get the scooter up and Resident #1 back onto it. The AD stated Resident #1's left shoulder and upper chest area were against the chair next to her. The AD stated Resident #1 insisted she was okay and wanted to go on to Walmart. The AD stated she should have called the incident into the facility, but instead asked the VD to report it when he returned to the facility and he said he would. The AD stated when she returned to the facility following the outing she could not find the VD, and reported the incident to her supervisor. The AA stated she found out later the VD and her supervisor did not report the incident. The AA stated the problem was, all of them assumed the other had reported the incident. The AA stated the evening nurse reported the incident after hearing it from Resident #1. The AA stated she did not complete an incident/accident report and was asked to write a statement the following day. In an interview on 5/2/12 at 10:00 AM, the Activity Director (AD) stated she is the AA's supervisor. The AD stated the AA came to her and told her about an incident that occurred on the van that morning. The AD stated she asked the AA if she or the VD was going to write an incident report and the AA told her the VD would. The AD stated she "expected that adults would take care of things but they did not." The AD stated the night nurse completed an incident/accident report and the Administrator received it the following day. The AD stated she would have expected the AA to follow up with the VD or write the report herself as a witness. The AD stated "we all know what to do, it is just neglect on our part." In an observation/ interview on 5/2/12 at 10:45 AM Resident #1 was observed seated on her scooter. The scooter had 2 wheels in the back and 1 wheel in the front. Resident #1 stated she was the last person to be loaded on to the van that day for a trip to Walmart. Resident #1 stated she was placed in the back "crosswise" behind the driver. Resident #1 stated the driver was not going very fast, went around a corner and she tipped over to the left. Resident #1 stated she did not feel any pain until later that day. Resident #1 stated she had a bruise under her left breast and it was just now getting better. Resident #1 stated she could not use her arms for a day or 2 after the incident, and suffered bad pain.. Resident #1 stated she had previously ridden on the van in her scooter to the dentist and nothing happened. Resident #1 stated she could not be strapped in but was placed at an "angle." Resident #1 stated she did not report the incident to anyone upon return to the facility, but supposed the AA reported it. In an interview on 5/2/12 at 10:48 AM, Resident #1's private sitter recalled accompanying Resident #1 on a trip to the dentist in the facility van. The sitter stated Resident #1 rode on her scooter. The sitter stated Resident #1's scooter was not secured during the trip to or from the dentist's office. In an interview on 5/2/12 at 12:40 PM, LVN A stated Resident #1 did not tell her about the incident, just that she had a pain in her left breast. LVN A stated Resident #1 informed her she may have bumped it, but was pretty vague. LVN A stated she did not document her assessment because she was just looking and there was nothing there. LVN A stated she never heard about Resident #1 falling on the bus, but was told by another LVN to generate an incident report because she had failed to do one. LVN A stated she did not feel like Resident A had an injury at the time. In an interview on 5/2/12 at 12:30 PM, the VD stated he had another run that day following his return from the Walmart trip and did not return back to the facility until 5:00 PM. The DV stated "I guess it just slipped my mind." The VD stated he does not recall if the AA asked him to report the incident upon return to the facility. The VD stated he was up front and the AA was in the back of the van. The VD stated it was the "communication, we thought each other would report it". The VD stated Resident #1 reported it to the nurse because she asked him about it the following morning. Review of Resident #1's nurses progress notes dated 4/24/12 reflected " Resident has bruise under left breast 3.5 X 1.5. Resident is sore in that area. PRN [MEDICATION NAME] given 9 PM. resident has no shortness of breath. X-ray results are negative for fracture. Resident informed night nurse of fall occurring while out on pass with activities". Review of Resident #1's nurses notes dated 4/25/12 reflected : "Resident requires more help due to injury sustained on outing on 4/23/12. CNA continues to assist resident to and from electric chair to bathroom , then back to bed. Will continue to monitor resident. Previous pain medication effective as resident states "it only hurts when I move." In an interview on 5/2/12 at 2:05 PM, the Director of Nurses stated her expectations would be for the VD to turn the van around and come immediately back to the facility for the charge nurse to assess the resident. The DON stated following an assessment, she would expect the nurse to initiate an incident report, contact the physician and responsible party, and get statements from the witnesses. The DON stated the incident should have been reported. Review of the VD job description dated 9/2005 reflected "the primary purpose of your job position is to transport residents in accordance with current applicable federal, state, and local standards, guidelines, and regulations, and as may be directed by the administrator, to assure that resident and employee safety can be maintained at all times. Administrative functions: Develop and maintain safety objectives and standards in accordance with current regulations and guidelines. Safety and Sanitation: Ensure that established safety precautions are being implemented and followed at all times." Review of an In-service training report dated 4/27/12 reflected: "Explain safe transport of passengers. Any resident who can transfer to a van seat shoud be seated in van seat and secured with a safety belt. Wheelchairs, scooters can be folded and/or secured with straps in rear of bus/van. Any passenger/resident who falls, or otherwise gets injured or ill must be returned to the community to be assessed by a nurse. This should be done immediately or call 911." Per Administrator the facility census was 155. A facility acquired list reflected 25 electric wheelchairs and 4 scooters.The list included Resident #1 in addition to 2 scooters "do not use" and 1 resident "no outings" A facility acquired list " Residents who go on outings" listed 14 including Resident #1. Per Activity Director, Resident #1 is the only resident who chooses to participate in facility outings who uses a scooter.

Based on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for 1 (resident #1) of 1 resident reviewed for accidents during transport. Resident #1 sustained a bruise under her left breast due to an incident. Resident #1 was placed in the facility van in an unrestrained scooter. The scooter tipped over, resulting in Resident #1 falling out onto another wheelchair and injuring her breast area. This failure contributed to bruising and injuries with pain for Resident #1. Findings include: Observation on 5/2/12 at 9:10 AM revealed the inside of the facility van equipped with devices to securely strap in 2 wheelchairs. The seats of the van were equipped with seatbelts. Review of Resident #1 Admission Record reflected a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] reflected the following: BIMS (brief interview for mental status) score of 15. (cognitively intact) - no mood or behavior concerns.- extensive assist with most ADLs. (activities of daily living) Pain-occasional, moderate pain. Review of Resident #1's Plan of Care dated 4/23/12 reflected "I stated I hit another wheelchair while in the facility van during transportation on 4/23/12.- Interventions:x-ray to rule out fracture, assess pain and administer pain medication as ordered.-Check to ensure wheelchair is secure during transport on facility van" - "I have an ADL self care performance deficit related to pain, impaired balance" -"I am at high risk for falls related to vision/hearing problems. Gait/balance problems, Incontinence, fall history:12/9/11, 3/29/12" Review of Resident #1's Progress Notes/ Incident Report dated 4/24/12-4:42 PM reflected the following : "Resident stated she was having pain in left breast. Resident was not sure why but thought she may have hit another wheelchair on bus.- Description of Initial Action Follow up to action: I did not take vitals at the time of report. Resident was vague with statement and it is not unusual for resident to have pain without specific cause. No injury was noted and it was unsure at the time that an incident had occurred." the note was signed by LVN A. Review of the Provider Investigation Reports dated 4/24/12 reflected the following: "Resident #1 was seated in her handlebar steered scooter. This scooter is smaller than other joystick steered scooters. The transport van is not equipped with anchoring straps that fit Resident #1's scooter. VD secured all other wheelchairs except Resident #1's. VD proceeded to drive to Walmart. At some point during the trip, the van made a right turn. When it did, Resident #1 fell to the left, still seated in her scooter. Resident #1 became pinned between the van seat and her scooter. Upon noticing her fall,VD stopped the van and along with the assistance of AA, repositioned Resident #1 back in her scooter, still without anchoring it. The Group arrived at Walmart and went shopping including Resident #1. After shopping the group returned to the Home without incident. Resident #1's scooter was not anchored on the trip to Walmart nor was it anchored on the return trip. Neither VD nor AA seated Resident #1 in a passenger seat with a seat belt following this incident. Resident #1 began to complain of pain the afternoon following the Walmart trip.- Description of injury: 4 x 3 cm irregular shaped bruise to the upper left torso.-Resident #1 was given [MEDICATION NAME] for pain following her complaints of pain. DON (director of nurses) received hand written note from 10-6 CNA (certified nurses assistant ) Z detailing her conversation with Resident #1. Investigation Summary: VD and AA were both present and witnessed the fall of Resident #1. They both admit that they did not secure Resident #1's scooter in the van according to policy. Nor did they offer to seat Resident #1 in a passenger seat and secure her with a seat belt. Neither VD or AA reported this incident to a charge nurse, nurse manager or to the Administrator. AA did report it to her supervisor. Her supervisor did not report the incident to anybody." Review of a written statement dated 4/23/12-/4/24/12 and signed by CNA Z reflected the following: "At 12:15 AM Resident #1 turned call light on stated she was in pain. I asked her what happened. Resident said she fell on facility van going to Walmart and her electric wheelchair fell over on her. Her breast is hurting on left side and wanted a pain pill. I asked her did she tell anyone. She said she told the 2-10 nurse and she gave her a pain pill and the the VD and lady over activities knew because they got the wheel chair off of her but it could not be buckled in because the van seat belts don't work on electric chairs. I then reported this to nurse. Nurse came in to give pain pill and talk to resident." In an interview on 5/2/12 at 12:25 PM CNA Z stated Resident #1 turned on her call light, and when she went to sit her up, she sighed heavily. CNA Z stated Resident #1 told her when she went to Walmart that previous morning, the van turned a corner and her scooter fell on top of her. CNA Z stated Resident #1 told her they picked me up and we went to Walmart.. CNA Z stated she reported the conversation to her charge nurse. In an interview on 5/2/12 at 9:10 AM, the Van Driver (VD) stated there is no way to secure a scooter in the straps equipped for wheelchairs. The VD stated he placed Resident #1 seated on her scooter next to a secured wheelchair with her sitting on it. The VD stated he stopped at a red light, took a right hand turn and Resident #1's scooter tipped, causing her to fall out into the wheelchair next to her. The VD stated he stopped the van and the Activity Assistant (AA) and himself rushed to assist Resident #1. The VD stated Resident #1 stated at the time she was okay and wanted to go on to Walmart. The VD stated the AA and himself assisted Resident #1 back onto her scooter and proceeded to Walmart. The VD stated Resident #1 usually rides in her regular wheelchair when participating in outings in the van. The VD stated he was "not told much" about transporting scooters and has always transported scooters this way. The VD stated he figured Resident #1 was safe and okay. The VD stated he has taken a safety course since the incident. In an interview on 5/2/12 at 9:15 AM, the Administrator stated if a chair or scooter can not be secured, a resident should be taken out of the wheelchair or scooter and assisted to sit in a seat with a seatbelt. The Administrator stated this would be implemented immediately to prevent a reoccurance of this accident. The Administrator stated he was unaware the VD was transporting residents on scooters in this manner. The Administrator stated he assumed every resident was securely strapped in. The Administrator stated Resident #1 did not complain of any pain at the time and insisted on going to Walmart. The Administrator stated Resident #1 complained of pain later on in the afternoon. The Administrator stated the VD provides approximately 25-30 transports a week. In an interview on 5/2/12 at 9:45 AM, the Activity Assistant (AA) stated on 4/23/12 during an outing to Walmart, Resident #1's scooter tipped over on the van causing her to fall between the scooter and a wheelchair next to her. The AA stated she witnessed the fall and called out to the driver to stop the van. The AA stated Resident #1 usually rides in a regular wheelchair, this is a new scooter for her. The AA stated she and the VD were able to get the scooter up and Resident #1 back onto it. The AD stated Resident #1's left shoulder and upper chest area were against the chair next to her. The AD stated Resident #1 insisted she was okay and wanted to go on to Walmart. The AD stated she should have called the incident into the facility, but instead asked the VD to report it when he returned to the facility and he said he would. The AD stated when she returned to the facility following the outing she could not find the VD, and reported the incident to her supervisor. The AA stated she found out later the VD and her supervisor did not report the incident. The AA stated the problem was, all of them assumed the other had reported the incident. The AA stated the evening nurse reported the incident after hearing it from Resident #1. The AA stated she did not complete an incident/accident report and was asked to write a statement the following day. In an interview on 5/2/12 at 10:00 AM, the Activity Director (AD) stated she is the AA's supervisor. The AD stated the AA came to her and told her about an incident that occurred on the van that morning. The AD stated she asked the AA if she or the VD was going to write an incident report and the AA told her the VD would. The AD stated she "expected that adults would take care of things but they did not." The AD stated the night nurse completed an incident/accident report and the Administrator received it the following day. The AD stated she would have expected the AA to follow up with the VD or write the report herself as a witness. The AD stated "we all know what to do, it is just neglect on our part." In an observation/ interview on 5/2/12 at 10:45 AM Resident #1 was observed seated on her scooter. The scooter had 2 wheels in the back and 1 wheel in the front. Resident #1 stated she was the last person to be loaded on to the van that day for a trip to Walmart. Resident #1 stated she was placed in the back "crosswise" behind the driver. Resident #1 stated the driver was not going very fast, went around a corner and she tipped over to the left. Resident #1 stated she did not feel any pain until later that day. Resident #1 stated she had a bruise under her left breast and it was just now getting better. Resident #1 stated she could not use her arms for a day or 2 after the incident, and suffered bad pain.. Resident #1 stated she had previously ridden on the van in her scooter to the dentist and nothing happened. Resident #1 stated she could not be strapped in but was placed at an "angle." Resident #1 stated she did not report the incident to anyone upon return to the facility, but supposed the AA reported it. In an interview on 5/2/12 at 10:48 AM, Resident #1's private sitter recalled accompanying Resident #1 on a trip to the dentist in the facility van. The sitter stated Resident #1 rode on her scooter. The sitter stated Resident #1's scooter was not secured during the trip to or from the dentist's office. In an interview on 5/2/12 at 12:40 PM, LVN A stated Resident #1 did not tell her about the incident, just that she had a pain in her left breast. LVN A stated Resident #1 informed her she may have bumped it, but was pretty vague. LVN A stated she did not document her assessment because she was just looking and there was nothing there. LVN A stated she never heard about Resident #1 falling on the bus, but was told by another LVN to generate an incident report because she had failed to do one. LVN A stated she did not feel like Resident A had an injury at the time. In an interview on 5/2/12 at 12:30 PM, the VD stated he had another run that day following his return from the Walmart trip and did not return back to the facility until 5:00 PM. The DV stated "I guess it just slipped my mind." The VD stated he does not recall if the AA asked him to report the incident upon return to the facility. The VD stated he was up front and the AA was in the back of the van. The VD stated it was the "communication, we thought each other would report it". The VD stated Resident #1 reported it to the nurse because she asked him about it the following morning. Review of Resident #1's nurses progress notes dated 4/24/12 reflected " Resident has bruise under left breast 3.5 X 1.5. Resident is sore in that area. PRN [MEDICATION NAME] given 9 PM. resident has no shortness of breath. X-ray results are negative for fracture. Resident informed night nurse of fall occurring while out on pass with activities". Review of Resident #1's nurses notes dated 4/25/12 reflected : "Resident requires more help due to injury sustained on outing on 4/23/12. CNA continues to assist resident to and from electric chair to bathroom , then back to bed. Will continue to monitor resident. Previous pain medication effective as resident states "it only hurts when I move." In an interview on 5/2/12 at 2:05 PM, the Director of Nurses stated her expectations would be for the VD to turn the van around and come immediately back to the facility for the charge nurse to assess the resident. The DON stated following an assessment, she would expect the nurse to initiate an incident report, contact the physician and responsible party, and get statements from the witnesses. The DON stated the incident should have been reported. Review of a facility policy dated 02/2012 Accidents and Incidents Reporting/Investigation reflected the following: "Objective: All accidents or incidents involving residents, employees, visitors, occurring on our premises will be investigated and reported to the licensed nurse/administrator/designee. These reports will be utilized for bruises, skin tears, abrasions, etc. observed on the resident. a. An accident or incident will be reported to the department supervisor/designee as soon as such accident/incident is discovered or when information of such accident/incident is learned. c. An employee witnessing an accident or incident involving a resident, employee, visitor, etc. will report such occurrence to his or her immediate supervisor/designee as soon as practical. Do not leave an accident victim unattended unless it is absolutely necessary to summon assistance. d. The nurse supervisor/charge nurse will be informed of accidents or incidents so that medical attention can be provided." Review of the VD job description dated 9/2005 reflected "the primary purpose of your job position is to transport residents in accordance with current applicable federal, state, and local standards, guidelines, and regulations, and as may be directed by the administrator, to assure that resident and employee safety can be maintained at all times. Administrative functions: Develop and maintain safety objectives and standards in accordance with current regulations and guidelines. Safety and Sanitation: Ensure that established safety precautions are being implemented and followed at all times." Review of an In-service training report dated 4/27/12 reflected: "Explain safe transport of passengers. Any resident who can transfer to a van seat shoud be seated in van seat and secured with a safety belt. Wheelchairs, scooters can be folded and/or secured with straps in rear of bus/van. Any passenger/resident who falls, or otherwise gets injured or ill must be returned to the community to be assessed by a nurse. This should be done immediately or call 911." Per Administrator the facility census was 155. A facility acquired list reflected 25 electric wheelchairs and 4 scooters.The list included Resident #1 in addition to 2 scooters "do not use" and 1 resident "no outings" A facility acquired list " Residents who go on outings" listed 14 including Resident #1. Per Activity Director, Resident #1 is the only resident who chooses to participate in facility outings who uses a scooter.

Based on observation, interview and record review the facility failed to protect 1 of 4 sampled residents (Resident #15) on the special care unit reviewed for Abuse/Neglect by facility staff when: 1. Resident #15 was physically forced to use a bed pan by 2 of 2 Certified Nurse Aides (CNA)s B and C) working nights on the special care unit; 2. Confined to a wheel chair and brought to the nurses' station under the direction of Licensed Vocational Nurse (LVN) D; 3. CNA B verbally threatened her life resulting in ongoing mental anguish and emotional distress; and 4. CNA C continued working of the special care unit until 5/10/11 when she was transferred to A unit. LVN D remained on the schedule for the special care unit on the current schedule. This resulted in an Immediate Jeopardy (IJ) on 5/27/11. While the IJ was lowered on 5/28/11, the facility remained out of compliance at a severity of actual harm with scope isolated that is not an IJ as the facility had not had time to implement, monitor and evaluate the effectiveness of their Plan of Removal. This deficient practice caused Resident #15 mental anguish and emotional distress and placed the additional 27 residents that reside on the special care unit at risk for abuse. Findings include: Review of the face sheet reflected Resident #15 was [AGE] years old admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #15's care plan dated 4/17/11 reflected a problem of MIXED bladder incontinence related to overactive bladder. Interventions included the following: Check and/or change every 2 hours and as needed. Ensure an unobstructed path to the bathroom. Monitor/document for signs and symptoms of urinary tract infections. Interviews on 5/27/11 at 8:45 AM and 5/28/11 at 12:45 PM Certified Nurse Aide (CNA) A stated the night of 4/16/11 she had been working on the secured unit and went to get a snack. She saw Resident #15 sitting up in a wheel chair in front of the special care nurses' station. CNA A stopped and asked Resident #15 if she had trouble sleeping and she said "No"; however, Resident #15 was crying and upset. CNA A stated she had to get back on the secured unit and could not take time to console Resident #15. When she got off that morning Resident #15 was still up. The next night (4/17/11) she worked on the special care hall and answered Resident #15's call light. They started talking and Resident #15 told her about the other night aides being tired of her being on the call light all the time. The resident stated, 'Last night they (CNA B and CNA C) made her use a bedpan because they were tired of getting her up'. Resident #15 told CNA A that there were three of them and 'she fought them as hard as she could'. They held her on the bedpan until she got quiet then left the room. She also told CNA A that a few nights earlier an aide told her 'she had to sit at the table until she could hold her bladder for longer'. CNA A stated, "I was concerned for Resident #15's well-being". CNA B had threatened Resident #15's life. CNA A took their private discussion very seriously and advised Resident #15 that she needed to talk to the unit manager or Director of Nurses about this problem. On 4/17/11 CNA A wrote an anonymous 'Record of Concern' and put it in the facility concern box. CNA A did not notify the charge nurse (LVN D) because she was involved, and CNA A was scared to lose her job and fear of reprisal. An interview on 5/27/11 at 11:45 AM with the Social Worker (SW) revealed on 4/18/11 she brought Resident #15 into her office to talk with her. Once Resident #15 started talking the SW felt there should be other witnesses to the resident's statement and asked her if it would be 'OK' to bring a couple friends in to listen. The Director of Nurses (DON) and Texas Veterans Land Board Representative (TVLB Rep) came in and they let Resident #15 tell her story. The SW stated she had heard the statements 2 or 3 times and it remains the same. Resident #15 stated, "I never had to fight anybody like that." She told them she didn't want to go on the bedpan and was not going to. But they made her lay there and they hurt her shoulder. There were 2 or 3 of them. She teared up and said, "I remember them putting me in my chair and saying 'Do you want to die standing up or laying down'. My last breath here will be my first one in heaven". Resident #15 said they made her sit and watch a scary movie. She was in a manual wheel chair not her motorized scooter. An observation on 5/27/11 at 9:45 AM revealed an unidentified aide applied a gait belt and completed a stand pivot transfer with Resident #15 from her wheelchair to the commode without difficulty. She was able to stand once she was up in the standing position. During interview on 5/27/11 at 1:45 PM (following the SW intervention) with the resident concerning an incident on 4/16/11 her first statement was, "I was hurt." Resident #15 was alert, oriented and willing to discuss the incident. She became tearful and was ringing her hands several times during this interview. When describing the incident on 4/16/11, she stated, "The aide tried two times to get me up (from the bed) but my feet kept slipping. She (CNA B) called two of her friends to put me (Resident #15) on the bedpan." She stated, "I told them I was NOT going to sit on a bedpan. One pulled my arm and they fought me just as hard as they could. I layed there it seemed like an hour or longer. They were doing a lot of talking but I wasn't saying anything. They put me back in the chair (manual wheel chair) and took me to the front desk (nurses' station). I asked to be turned loose so I could go back to bed. I don't know how long I sat there. Finally I needed to go to the bathroom and they said to wait a few minutes." Resident #15 kept worrying and thought they were taking her to the public bathroom but they went down the hall. The aide said, "If I make a mess she was gonna {SIC} see that I cleaned it up." Resident #15 stated they told her several things they were going to do to her. Resident #15 stated, "They asked me did I want to die standing up or lying down. The next morning I had lived through what ever they were going to do. I never said anything to them." She was tearful during this interview. She stated, "They got rid of the one woman because she was the one who said that about killing me. An interview with the DON on 5/27/11 at 3:20 PM revealed that Resident #15 had several falls and had been instructed to call to get up. They told her (Resident #15) she needed to use the bedpan. She did not want to be on the bedpan. They held her shoulders down. On nights when Resident #15 was awake, the night nurse (LVN D) would put her up by the nurses' station. Resident #15 felt like it was punishment. One night they had a scary movie on. The DON stated, "We narrowed it down to 2 CNAs (CNA B and CNA C). CNA B was terminated and CNA C was moved to A wing (not until 5/10/11). The aides were talking and Resident #15 thought they were talking about her. One night (5/23/11) while CNA C was working on A wing she got irritated and left the facility leaving only 1 aide on the hall " . No other residents complained about the aides. None were threatened by CNA B. The DON stated, "It was a difficult investigation to do". Resident #15 did not change her story about the bedpan and being put at the nurses' station with a scary movie on. The DON wanted to be sure it was the right employee. The DON stated, "I had a gut feeling to terminate both aides but felt I had nothing on CNA C. The SW joined the conversation and stated, "I was in the office with Resident #15 while the DON went to find pictures of the aides to show the resident. That's when the Administrator came to the office and started asking Resident #15 questions. He would not let her talk to explain her story. So she didn't tell him what she told the others. He was asking her leading questions like 'Do you feel like you were abused or was it an employee with a bad attitude'. Resident #15 said 'bad attitude' and he said, 'That's all I need'. The administrator did not listen to what the resident was trying to say. "Since the Administrator didn't let her talk she really told us more than when he was in the room". Review of confidential information from an unidentified individual reflected statements made by Resident #15 on 4/18/11 during the meeting with staff including the following: 1. A night shift aide asked her if she wanted to die standing up or laying down. 2. The aide told her if she made a mess in the bathroom she would have to clean it up herself. 3. The aide told her that she may not wake up in the morning because they could 'shoot something into her while she was sleeping ...take room mate to the hall, close the door and curtains ... 4. They (night shift staff) put her in a manual wheel chair in the middle of the night, put her 'in the front office' (in front of the nurses' station where residents eat). The first time was for an hour with a scary movie on TV. 5. She said she was not afraid to die, but only when it's her time. She said 'her last breath in this place will be her first breath in heaven'. 6. She was glad to see the sun 'they didn't kill her overnight'. 7. Three (3) of them (night shift staff) forcefully put her on a bedpan and left her there over 30 minutes. 8. She said she didn't want the bedpan, she wanted to go to the bathroom, but they physically forced her to sit on the bedpan instead. Review of the facility policy titled 'Reporting Abuse to Community Management' dated 1/2009 Policy Statement: It is the responsibility of our team members, Community consultants, attending physicians, family members, visitors, etc. to promptly report any incident of suspected incident of neglect or resident abuse, including injuries of an unknown source, and theft or misappropriation of resident property to Community management. Policy interpretation and Implementation: 1. Our Community will not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff or other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals ... 5. All personnel, residents, family members, visitors, etc. are encouraged to report incidents of resident abuse or suspected incidents of abuse. Such reports may be made without fear of retaliation from the community or other staff ... 7. Any individual observing an incident of resident abuse or suspecting resident abuse must promptly report such incident to a member of the nursing staff working management ... 15. Any person who has knowledge or reason to believe that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense SHALL report the mistreatment or offense. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information. During an interview on 5/27/11 at 7:38 PM the facility's Administrator, DON and TVLB Representative were notified that an IJ was identified due to the facility's failure to protect Resident #15 from physical, verbal and emotional abuse resulting in mental anguish on 4/16/11. The facility provided a Plan of Removal on 5/27/11 at 9:30 PM. The final Plan of Removal accepted on 5/28/11 at 3:15 PM included the following: 1. Immediate in-servicing has begun on Abuse/Neglect and the right of residents to be free of abuse and neglect and the right to reach their highest practicable level of well-being physically/mentally/psycho-socially. In-services will be done by Administrator/SW/Nursing/designee. Night shift from 5/27/11 had in-servicing started. Day shift (5/28/11) is currently being inserviced. Beginning with evening shift and moving forward (5/28/11) the in-service will continue to be given on Abuse/Neglect. Team members will not be allowed on their assigned shift until this has been completed. 2. Team members providing in-services to staff members have had a review of abuse/neglect and the right of each resident to be free of abuse and neglect and the right to reach their highest practicable level of well-being physically/mentally/psychosocially provided by Clinical Services representative completed on 5/28/11. 3. The nurse identified in allegation is on vacation and unable to be reached. DON will suspend the nurse pending investigation once we are able to reach her. The nurse is scheduled to return June 3, 2011. 4. Medical Director has been notified by DON on the Immediate Jeopardy ...completed on 5/28/11. 5. Regional Nurse/designee will do formal in-service training of all team members on abuse/neglect and the right of each resident to be free of abuse/neglect as well as the right of each resident to reach their highest practicable level of well being physically/mentally/psycho-socially to include but not limited to: a. Definition of abuse/neglect b. Types of abuse/neglect c. Review our P&P of abuse/neglect d. Occurrences/events that constitute abuse/neglect e. Immediately reporting abuse/neglect ...the need to report if you witness or hear of incidents f. Immediately removing resident from the potentially abusive situations/conditions g. Suspension of those involved or suspected to be involved pending thorough investigation h. No threat or retaliation to resident(s) or person(s) reporting ...target date completion June 1, 2011 6. Licensed Nursing will be in-serviced by DON/designee on areas of staff supervision to include but not limited to: a. Derogatory language b. Rough Handling c. Ignoring residents while giving care d. Forcing "care" on residents e. Intimidation of residents f. Involuntary placement of resident against their will g. Responsibility to prevent h. Burn-out i. Responsibility to report (Senate Bill 9 they signed on hire, fines, etc.) j. Administrative actions ...target date June 3, 2011 Review of employee files of staff identified as perpetrators reflected the following: a. On 4/18/11 CNA B was called to the facility and the DON and the SW talked to her. They had no question that they had one of the perpetrators. She was terminated. b. On 5/10/11 CNA C was written up for 'attitude'. On that day she was re-assigned to A-Hall with a probationary period. No evidence of counseling for the 4/16/11 incident could be found. However, she remained an active employee at the facility until 5/23/11 when she abandoned her residents and left the building. c. On 5/10/11 LVN D was counseled about reporting disciplinary issues to the RN Supervisor on nights. No evidence of counseling for the 4/16/11 incident could be found. However, she was currently on vacation due to return 6/3/11. Review of the facility direct care staff schedule and time card reports for 4/16/2011 reflected CNA B, CNA C, and LVN D worked 10:00 PM to 6:00 AM on the special care hall. On 4/17/11 CNA B did not work. CNA A, CNA C, and LVN D worked the special care hall. CNA B and CNA C no longer work at the facility. LVN D will not return from vacation until 6/3/11. Review of facility's inservices on abuse/neglect had been initiated on 5/27/11 at 11:50 PM . The RN supervisors were included in the inservice. Corporate staff were in the facility. On 5/28/11 the medical director was in the facility as well as the vice president of clinical services that supervises the nurse consultants. Interviews on 5/28/11 with various staff after receiving the facility plan of removal revealed training on abuse/neglect and reporting had been given. While the IJ was removed on 5/28/11 at 3:15 PM, the facility remained out of compliance at an isolated incident of actual harm that is not IJ. The facility had not had time to implement, monitor and evaluate the Plan of Removal for effectiveness. Review of the Facility's CMS 672 reflected a facility census of 154 residents. The facility matrix reflected 28 residents resided on the Special Care Unit.

Based on observation, interview and record review the facility failed to thoroughly investigate, and protect residents on the special care unit when: CNA A failed to immediately report an allegation of abuse. One (1) of 4 sampled residents (Resident #15) that resided on the special care unit alleged she was physically, mentally and emotionally abused by 3 of 3 night shift staff.(Certified Nurse Aide (CNA) B, CNA C, and Licensed Vocational Nurse (LVN) D). Two (2) of three (3) staff (CNA C and LVN D) continued working with the resident during and after the facility investigated the allegation. On 5/10/11 CNA C was transferred to A wing but LVN D continued to be scheduled on the special care unit. Resident #15 alleged that on night shift 4/16/11 CNA B, CNA C and LVN D made her use a bedpan instead of assist her to the bathroom, confined her to a wheel chair when she normally utilized a motorized scooter, and verbally threatened her life. This resulted in an Immediate Jeopardy (IJ) on 5/27/11. While the IJ was lowered on 5/28/11, the facility remained out of compliance at a severity of actual harm with scope isolated that is not an IJ as the facility had not had time to implement, monitor and evaluate the effectiveness of their Plan of Removal. This deficient practice caused Resident #15 mental anguish and emotional distress, and placed 27 residents residing on the special care unit at risk for abuse. Findings include: Review of the face sheet reflected Resident #15 was [AGE] years old admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #15's care plan dated 4/17/11 reflected a problem of MIXED bladder incontinence related to overactive bladder. Interventions included the following: Check and/or change every 2 hours and as needed. Ensure an unobstructed path to the bathroom. Monitor/document for signs and symptoms of urinary tract infections. There was no care plan for behaviors. Review of Resident #15's nurses' notes dated 4/18/11 at 4:00 PM reflected Resident voiced a complaint to the Social Worker (SW) and Texas Veterans Land Board Representative (TVLB Rep.) Will follow up with resident and both parties. Nurses' notes dated 4/19/11 at 9:30 AM reflected issue with resident resolved. No further documentation in nurses' notes. Interviews on 5/27/11 at 8:45 AM and 5/28/11 at 12:45 PM Certified Nurse Aide (CNA) A stated the night of 4/16/11 she had been working on the secured unit and went to get a snack. She saw Resident #15 sitting up in a wheel chair in front of the special care nurses' station. CNA A stopped and asked Resident #15 if she had trouble sleeping and she said "No"; however, Resident #15 was crying and upset. CNA A stated she had to get back on the secured unit and could not take time to console Resident #15. When she got off that morning Resident #15 was still up. The next night (4/17/11) she worked on the special care hall and answered Resident #15's call light. They started talking and Resident #15 told her about the other night aides being tired of her being on the call light all the time. The resident stated, 'Last night they CNA B and CNA C) made her use a bedpan because they were tired of getting her up'. Resident #15 told CNA A that there were three of them and 'she fought them as hard as she could'. They held her on the bedpan until she got quiet then left the room. She also told CNA A that a few nights earlier an aide told her 'she had to sit at the table until she could hold her bladder for longer'. CNA A stated, "She was concerned for Resident #15's well-being". CNA B had threatened Resident #15's life. CNA A took their private discussion very seriously and advised Resident #15 that she needed to talk to the unit manager or Director of Nurses about this problem. On 4/17/11 CNA A wrote an anonymous 'Record of Concern' and put it in the facility concern box. CNA A did not notify the charge nurse (LVN D) because she was involved, and CNA A was scared to lose her job and fear of reprisal. An interview on 5/27/11 at 11:45 AM with the Social Worker (SW) revealed on 4/18/11 she brought Resident #15 into her office to talk with her. Once Resident #15 started talking the SW felt there should be other witnesses to the resident's statement and asked her if it would be 'OK' to bring a couple friends in to listen. The Director of Nurses (DON) and Texas Veterans Land Board Representative (TVLB Rep) came in and they let Resident #15 tell her story. The SW stated she had heard the statements 2 or 3 times and it remains the same. Resident #15 stated, "I never had to fight anybody like that." She told them she didn't want to go on the bedpan and was not going to. But they made her lay there and they hurt her shoulder. There were 2 or 3 of them. She teared up and said, "I remember them putting me in my chair and saying 'Do you want to die standing up or laying down'. My last breath here will be my first one in heaven". Resident #15 said they made her sit and watch a scary movie. She was in a manual wheel chair not her scooter. An observation on 5/27/11 at 9:45 AM revealed an unidentified aide applied a gait belt and completed a stand pivot transfer with Resident #15 from her wheelchair to the commode without difficulty. She was able to stand once she was up in the standing position. During interview on 5/27/11 at 1:45 PM (following the SW intervention) with the resident concerning an incident on 4/16/11 her first statement was, "I was hurt." Resident #15 was alert, oriented and willing to discuss the incident. She became tearful and was ringing her hands several times during this interview. When describing the incident on 4/16/11, she stated, "The aide tried two times to get me up (from the bed) but my feet kept slipping. She (CNA B) called two of her friends to put me (Resident #15) on the bedpan." She stated, "I told them I was NOT going to sit on a bedpan. One pulled my arm and they fought me just as hard as they could. I layed there it seemed like an hour or longer. They were doing a lot of talking but I wasn't saying anything. They put me back in the chair (manual wheel chair) and took me to the front desk (nurses' station). I asked to be turned loose so I could go back to bed. I don't know how long I sat there. Finally I needed to go to the bathroom and they said to wait a few minutes." Resident #15 kept worrying and thought they were taking her to the public bathroom but they went down the hall. The aide said, "If I make a mess she was gonna see that I cleaned it up." Resident #15 stated they told her several things they were going to do to her. Resident #15 stated, "They asked me did I want to die standing up or lying down. The next morning I had lived through what ever they were going to do. I never said anything to them." She was tearful during this interview. She stated, "They got rid of the one woman because she was the one who said that about killing me. An interview with the DON on 5/27/11 at 3:20 PM revealed that Resident #15 was verbalizing about the night shift aides. She had several falls and had been instructed to call to get up. They told her (Resident #15) she needed to use the bedpan. She did not want to be on the bedpan. They held her shoulders down. When Resident #15 was awake, the night nurse would put her up by the nurses' station. Resident #15 felt like it was punishment. One night they had a scary movie on. The DON stated, "We narrowed it down to 2 CNAs (CNA B and CNA C). CNA B was terminated and CNA C was moved to A wing. The aides were talking and Resident #15 thought they were talking about her. One night (5/23/11) while CNA C was working on A wing she got irritated and left the facility leaving only 1 aide on the hall " . No other residents complained about the aides. None were threatened by CNA B. The DON stated, "It was a difficult investigation to do". Resident #15 did not change her story about the bedpan and being put at the nurses' station with a scary movie on. The DON wanted to be sure it was the right employee. The DON stated, "I had a gut feeling to terminate both aides but felt I had nothing on CNA C. The SW joined the conversation and stated, "I was in the office with Resident #15 while the DON went to find pictures of the aides to show the resident. That's when the Administrator came to the office and started asking Resident #15 questions. He would not let her talk to explain her story. So she didn't tell him what she told the others. He was asking her leading questions like 'Do you feel like you were abused or was it an employee with a bad attitude'. Resident #15 said 'bad attitude' and he said, 'That's all I need'. The administrator did not listen to what the resident was trying to say." Since the Administrator didn't let her talk she really told us more than when he was in the room. Review of confidential information from an unidentified individual reflected statements made by Resident #15 on 4/18/11 including the following: 1. A night shift aide asked her if she wanted to die standing up or laying down. 2. The aide told her if she made a mess in the bathroom she would have to clean it up herself. 3. The aide told her that she may not wake up in the morning because they could ' shoot something into her while she was sleeping ...take room mate to the hall, close the door and curtains ... 4. They (night shift staff) put her in a manual wheel chair in the middle of the night, put her 'in the front office' (in front of the nurses' station where residents eat). The first time was for an hour with a scary movie on TV. 5. She said she was not afraid to die, but only when it's her time. She said 'her last breath in this place will be her first breath in heaven'. 6. She was glad to see the sun 'they didn't kill her overnight' . 7. Three (3) of them (night shift staff) forcefully put her on a bedpan and left her there over 30 minutes. 8. She said she didn't want the bedpan, she wanted to go to the bathroom, but they physically forced her to sit on the bedpan instead. The investigation conducted by this Registered Nurse Surveyor included multiple staff interviews and record reviews that found conflicting information from what was in the facility investigation conducted by the Administrator. Review of the facility investigation submitted to state 4/25/11 conducted by the Administrator reflected multiple conflicting information contrary to what the resident said. The administrator eluded that attitude was the only problem throughout the investigation. An interview on 5/27/11 at 3:20 PM the Social Worker stated that when the Administrator interviewed Resident #15 he would not let her tell him what happened. She stated that the Administrator kept telling Resident #15 that she had not been abused and that the CNA just had an attitude, until the resident finally just agreed with him. In an interview on 5/27/11 at 3:30 PM the TVLB representative stated that the Administrator had been made aware that Resident #15 had been held down on the bedpan against her will; she was placed in a wheelchair in the SCU in front of the television in the dining area with a scary movie playing and that she had been threatened by the staff on the night shift. The TVLB representative stated that Resident #15 was able to propel herself around the facility in her electric scooter; however, the night shift staff had placed Resident #15 in a manual wheelchair in the SCU dining area in front of the television. There was a scary movie playing on the television and Resident #15 was not able to maneuver the manual wheelchair on her own. In an interview on 5/27/11 at 4:50 PM the Administrator stated that the written statement by CNA A did not say anything about abuse. He stated that CNA A reported to him that CNA B had an 'attitude' and talked rudely sometimes. He stated that CNA B was terminated due to her 'attitude' and that CNA C was moved to another hall. In an interview on 5/27/11 at 5:00 PM the Activity Director stated that the Administrator did not question CNA A about abuse but rather, the 'attitude' of CNA B. Review of the facility policy titled 'Reporting Abuse to Community Management' dated 1/2009 Policy Statement: It is the responsibility of our team members, Community consultants, attending physicians, family members, visitors, etc. to promptly report any incident of suspected incident of neglect or resident abuse, including injuries of an unknown source, and theft or misappropriation of resident property to Community management. Policy interpretation and Implementation: 1. Our Community will not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff or other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals ... 5. All personnel, residents, family members, visitors, etc. are encouraged to report incidents of resident abuse or suspected incidents of abuse. Such reports may be made without fear of retaliation from the community or other staff ... 7. Any individual observing an incident of resident abuse or suspecting resident abuse must promptly report such incident to a member of the nursing staff working management ... 15. Any person who has knowledge or reason to believe that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense SHALL report the mistreatment or offense. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information. Review of the facility policy titled 'lll. Abuse Investigations' dated 1/2009 Policy Statement All reports of resident abuse, neglect and injuries have an unknown source shall be promptly and thoroughly investigated by the Community management. Policy interpretation and implementation 1. Should an incident or suspected incident of resident abuse, neglect or injury of an unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. In the event the Administrator is accused, the Director of Nursing will be the primary member of management to investigate. 3. The management-appointed individual conducting the investigation will, at a minimum: a. Review the completed Resident Abuse Report Form;.. f. Interview the resident's attending physician to determine the resident's current mental status; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors;... 4. The following guidelines will be used when conducting interviews: a. Each interview will be conducted separately and in private locations; b. The purpose and confidentiality of the interview will be explained to each person involved in the interview process; and c. Should a person disclose information that may be self-incriminating, that individual will be informed of his/her rights to terminate the interview until such time as his/her rights are protected (e.g., representation be legal counsel) 7. Team members of this Community who have been accused of resident abuse may be reassigned to nonresident care duties or suspended from duty until the results of the investigation have been reviewed by the Administrator. 9. The Administrator will keep the resident and his/her Representative (sponsor) informed of the progress of the investigation. 12. The Administrator will inform the resident and his/her Representative (sponsor) of the results of the investigation and corrective action taken within five days of the completion of the investigation. 16. Policies governing abuse reporting are outlined in separate policies entitled " Reporting Abuse to Community Management " and " Reporting Abuse to State Agencies and Other Entities/Individuals. " 17. Inquiries concerning abuse reporting and investigation should be referred to the Administrator or to the Director of Nursing Services. 18. Action will be taken based on Community policy on Protection of Residents During Abuse Investigation. V. Protection of Residents during Abuse Investigations Policy Statement: Our Community will protect residents from harm during investigations of abuse allegations. Policy Interpretation and Implementation: 1. During abuse investigations, residents will be protected from harm by the following measures: a. Team members accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended without pay until the findings of the investigation have been reviewed by the Administrator... During an interview on 5/27/11 at 7:38 PM the facility's Administrator, DON and TVLB Representative were notified that an IJ was identified due to the facility's failure to protect Resident #15 from physical, verbal and emotional abuse resulting in mental anguish on 4/16/11. The facility provided a Plan of Removal on 5/27/11 at 9:30 PM. The final Plan of Removal accepted on 5/28/11 at 3:15 PM included the following: 1. Immediate in-servicing has begun on Abuse/Neglect and the right of residents to be free of abuse and neglect and the right to reach their highest practicable level of well-being physically/mentally/psycho-socially. In-services will be done by Administrator/SW/Nursing/designee. Night shift from 5/27/11 had in-servicing started. Day shift (5/28/11) is currently being inserviced. Beginning with evening shift and moving forward (5/28/11) the in-service will continue to be given on Abuse/Neglect. Team members will not be allowed on their assigned shift until this has been completed. 2. Team members providing in-services to staff members have had a review of abuse/neglect and the right of each resident to be free of abuse and neglect and the right to reach their highest practicable level of well-being physically/mentally/psychosocially provided by Clinical Services representative completed on 5/28/11. 3. The nurse identified in allegation is on vacation and unable to be reached. DON will suspend the nurse pending investigation once we are able to reach her. The nurse is scheduled to return June 3, 2011. 4. Medical Director has been notified by DON on the Immediate Jeopardy ...completed on 5/28/11. 5. Regional Nurse/designee will do formal in-service training of all team members on abuse/neglect and the right of each resident to be free of abuse/neglect as well as the right of each resident to reach their highest practicable level of well being physically/mentally/psycho-socially to include but not limited to: a. Definition of abuse/neglect b. Types of abuse/neglect c. Review our P&P of abuse/neglect d. Occurrences/events that constitute abuse/neglect e. Immediately reporting abuse/neglect ...the need to report if you witness or hear of incidents f. Immediately removing resident from the potentially abusive situations/conditions g. Suspension of those involved or suspected to be involved pending thorough investigation h. No threat or retaliation to resident(s) or person(s) reporting ...target date completion June 1, 2011 6. Licensed Nursing will be in-serviced by DON/designee on areas of staff supervision to include but not limited to: a. Derogatory language b. Rough Handling c. Ignoring residents while giving care d. Forcing "care" on residents e. Intimidation of residents f. Involuntary placement of resident against their will g. Responsibility to prevent h. Burn-out i. Responsibility to report (Senate Bill 9 they signed on hire, fines, etc.) j. Administrative actions ...target date June 3, 2011 Review of employee files of staff identified as perpetrators reflected the following: a. On 4/18/11 CNA B was called to the facility and the DON and the SW talked to her. There was no question that they had one of the perpetrators. She was terminated. b. On 5/10/11 CNA C was written up for 'attitude'. On that day she was re-assigned to A-Hall with a probationary period. No evidence of counseling for the 4/16/11 incident could be found. However, she remained an active employee at the facility until 5/23/11 when she abandoned her residents and left the building. c. On 5/10/11 LVN D was counseled about reporting disciplinary issues to the RN Supervisor on nights. No evidence of counseling for the 4/16/11 incident could be found. However, she is currently on vacation due to return 6/3/11. Review of the facility direct care staff schedule and time card reports for 4/16/2011 reflected CNA B, CNA C, and LVN D worked 10:00 PM to 6:00 AM on the special care hall. On 4/17/11 CNA B did not work. CNA A, CNA C, and LVN D worked the special care hall. CNA B and CNA C no longer work at the facility. LVN D will not return from vacation until 6/3/11. Review of facility's inservices on abuse/neglect had been initiated on 5/27/11 at 11:50 PM . The RN supervisors were included in the inservice. Corporate staff were in the facility. On 5/28/11 the medical director was in the facility as well as the vice president of clinical services that supervises the nurse consultants. Interviews on 5/28/11 with various staff after receiving the facility plan of removal revealed training on abuse/neglect and reporting had been given. While the IJ was removed on 5/28/11 at 3:15 PM, the facility remained out of compliance at an isolated incident of actual harm that is not IJ. The facility had not had time to implement, monitor and evaluate the Plan of Removal for effectiveness. Review of the Facility's CMS 672 reflected a facility census of 154 residents. The facility matrix reflected 28 residents resided on the Special Care Unit.

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit abuse for 1 of 4 sampled residents (Resident #15) on the special care unit by 3 of 3 night shift staff (Certified Nurse Aide (CNA) B, CNA C, and Licensed Vocational Nurse (LVN) D) that work on the special care unit. CNA C continued working of the special care unit until 5/10/11 when she was transferred to A unit. LVN D remained on the schedule for the special care unit on the current schedule. Resident #15 alleged that on night shift 4/16/11 CNA B, CNA C and LVN D made her use a bedpan instead of assist her to the bathroom, confined her to a wheel chair when she normally utilized a motorized scooter, and verbally threatened her life resulting in physical harm and mental anguish. This resulted in an Immediate Jeopardy (IJ) on 5/27/11. While the IJ was lowered on 5/28/11, the facility remained out of compliance at a severity of actual harm with scope isolated that is not an IJ as the facility had not had time to implement, monitor and evaluate the effectiveness of their Plan of Removal. This deficient practice caused Resident #15 and could affect 27 residents at risk of abuse when policies for abuse prohibition are not adhered to and strictly enforced to protect the residents. Findings include: Review of the face sheet reflected Resident #15 was [AGE] years old admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #15's care plan dated 4/17/11 reflected a problem of MIXED bladder incontinence related to overactive bladder. Interventions included the following: Check and/or change every 2 hours and as needed. Ensure an unobstructed path to the bathroom. Monitor/document for signs and symptoms of urinary tract infections. Interviews on 5/27/11 at 8:45 AM and 5/28/11 at 12:45 PM Certified Nurse Aide (CNA) A stated the night of 4/16/11 she had been working on the secured unit and went to get a snack. She saw Resident #15 sitting up in a wheel chair in front of the special care nurses' station. CNA A stopped and asked Resident #15 if she had trouble sleeping and she said "No"; however, Resident #15 was crying and upset. CNA A stated she had to get back on the secured unit and could not take time to console Resident #15. When she got off that morning Resident #15 was still up. The next night (4/17/11) she worked on the special care hall and answered Resident #15's call light. They started talking and Resident #15 told her about the other night aides being tired of her being on the call light all the time. The resident stated, 'Last night they CNA B and CNA C) made her use a bedpan because they were tired of getting her up'. Resident #15 told CNA A that there were three of them and 'she fought them as hard as she could'. They held her on the bedpan until she got quiet then left the room. She also told CNA A that a few nights earlier an aide told her 'she had to sit at the table until she could hold her bladder for longer'. CNA A stated, "She was concerned for Resident #15's well-being". CNA B had threatened Resident #15's life. CNA A took their private discussion very seriously and advised Resident #15 that she needed to talk to the unit manager or Director of Nurses about this problem. On 4/17/11 CNA A wrote an anonymous 'Record of Concern' and put it in the facility concern box. CNA A did not notify the charge nurse (LVN D) because she was involved, and CNA A was scared to lose her job and fear of reprisal. An interview on 5/27/11 at 11:45 AM with the Social Worker (SW) revealed on 4/18/11 she brought Resident #15 into her office to talk with her. Once Resident #15 started talking the SW felt there should be other witnesses to the resident's statement and asked her if it would be 'OK' to bring a couple friends in to listen. The Director of Nurses (DON) and Texas Veterans Land Board Representative (TVLB Rep) came in and they let Resident #15 tell her story. The SW stated she had heard the statements 2 or 3 times and it remains the same. Resident #15 stated, "I never had to fight anybody like that." She told them she didn't want to go on the bedpan and was not going to. But they made her lay there and they hurt her shoulder. There were 2 or 3 of them. She teared up and said, "I remember them putting me in my chair and saying 'Do you want to die standing up or laying down'. My last breath here will be my first one in heaven". Resident #15 said they made her sit and watch a scary movie. She was in a manual wheel chair not her scooter. An observation on 5/27/11 at 9:45 AM revealed an unidentified aide applied a gait belt and completed a stand pivot transfer with Resident #15 from her wheelchair to the commode without difficulty. She was able to stand once she was up in the standing position. During interview on 5/27/11 at 1:45 PM (following the SW intervention) with the resident concerning an incident on 4/16/11 her first statement was, "I was hurt." Resident #15 was alert, oriented and willing to discuss the incident. She became tearful and was ringing her hands several times during this interview. When describing the incident on 4/16/11, she stated, "The aide tried two times to get me up (from the bed) but my feet kept slipping. She (CNA B) called two of her friends to put me (Resident #15) on the bedpan." She stated, "I told them I was NOT going to sit on a bedpan. One pulled my arm and they fought me just as hard as they could. I layed there it seemed like an hour or longer. They were doing a lot of talking but I wasn't saying anything. They put me back in the chair (manual wheel chair) and took me to the front desk (nurses' station). I asked to be turned loose so I could go back to bed. I don't know how long I sat there. Finally I needed to go to the bathroom and they said to wait a few minutes." Resident #15 kept worrying and thought they were taking her to the public bathroom but they went down the hall. The aide said, "If I make a mess she was gonna (SIC} see that I cleaned it up." Resident #15 stated they told her several things they were going to do to her. Resident #15 stated, "They asked me did I want to die standing up or lying down. The next morning I had lived through what ever they were going to do. I never said anything to them." She was tearful during this interview. She stated, "They got rid of the one woman because she was the one who said that about killing me. An interview with the DON on 5/27/11 at 3:20 PM revealed that Resident #15 had several falls and had been instructed to call to get up. They told her (Resident #15) she needed to use the bedpan. She did not want to be on the bedpan. They held her shoulders down. On nights when Resident #15 was awake, the night nurse (LVN D) would put her up by the nurses' station. Resident #15 felt like it was punishment. One night they had a scary movie on. The DON stated, "We narrowed it down to 2 CNAs (CNA B and CNA C). CNA B was terminated and CNA C was moved to A wing (not until 5/10/11). The aides were talking and Resident #15 thought they were talking about her. One night (5/23/11) while CNA C was working on A wing she got irritated and left the facility leaving only 1 aide on the hall " . No other residents complained about the aides. None were threatened by CNA B. The DON stated, "It was a difficult investigation to do". Resident #15 did not change her story about the bedpan and being put at the nurses' station with a scary movie on. The DON wanted to be sure it was the right employee. The DON stated, "I had a gut feeling to terminate both aides but felt I had nothing on CNA C. The SW joined the conversation and stated, "I was in the office with Resident #15 while the DON went to find pictures of the aides to show the resident. That's when the Administrator came to the office and started asking Resident #15 questions. He would not let her talk to explain her story. So she didn't tell him what she told the others. He was asking her leading questions like 'Do you feel like you were abused or was it an employee with a bad attitude'. Resident #15 said 'bad attitude' and he said, 'That's all I need'. The administrator did not listen to what the resident was trying to say. "Since the Administrator didn't let her talk she really told us more than when he was in the room". Review of confidential information from an unidentified individual reflected statements made by Resident #15 on 4/18/11 including the following: 1. A night shift aide asked her if she wanted to die standing up or laying down. 2. The aide told her if she made a mess in the bathroom she would have to clean it up herself. 3. The aide told her that she may not wake up in the morning because they could 'shoot something into her while she was sleeping ...take room mate to the hall close the door and curtains ... 4. They (night shift staff) put her in a manual wheel chair in the middle of the night, put her 'in the front office' (in front of the nurses' station where residents eat). The first time was for an hour with a scary movie on TV. 5. She said she was not afraid to die, but only when it's her time. She said 'her last breath in this place will be her first breath in heaven'. 6. She was glad to see the sun 'they didn't kill her overnight'. 7. Three (3) of them (night shift staff) forcefully put her on a bedpan and left her there over 30 minutes. 8. She said she didn't want the bedpan, she wanted to go to the bathroom, but they physically forced her to sit on the bedpan instead. The investigation conducted by this Registered Nurse Surveyor included multiple staff interviews and record reviews that found conflicting information from what was in the facility investigation conducted by the Administrator. Review of the facility investigation submitted to state 4/25/11 conducted by the Administrator reflected multiple conflicting information contrary to what the resident said. The administrator eluded that attitude was the only problem throughout the investigation. Review of the facility policy titled: I. 'Reporting Abuse to Community Management' dated 1/2009 Policy Statement: It is the responsibility of our team members, Community consultants, attending physicians, family members, visitors, etc. to promptly report any incident of suspected incident of neglect or resident abuse, including injuries of an unknown source, and theft or misappropriation of resident property to Community management. Policy interpretation and Implementation: 1. Our Community will not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff or other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals ... 5. All personnel, residents, family members, visitors, etc. are encouraged to report incidents of resident abuse or suspected incidents of abuse. Such reports may be made without fear of retaliation from the community or other staff ... 7. Any individual observing an incident of resident abuse or suspecting resident abuse must promptly report such incident to a member of the nursing staff working management ... 15. Any person who has knowledge or reason to believe that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense SHALL report the mistreatment or offense. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information... Review of the facility policy titled 'lll. Abuse Investigations' dated 1/2009 Policy Statement All reports of resident abuse, neglect and injuries have an unknown source shall be promptly and thoroughly investigated by the Community management. Policy interpretation and implementation 1. Should an incident or suspected incident of resident abuse, neglect or injury of an unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. In the event the Administrator is accused, the Director of Nursing will be the primary member of management to investigate. 3. The management-appointed individual conducting the investigation will, at a minimum: a. Review the completed Resident Abuse Report Form; b. Review the resident's medical record to determent events leading up to the incident; f. Interview the resident's attending physician to determine the resident ' s current mental status; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; 4. The following guidelines will be used when conducting interviews: a. Each interview will be conducted separately and in private locations; b. The purpose and confidentiality of the interview will be explained to each person involved in the interview process; and c. Should a person disclose information that may be self-incriminating, that individual will be informed of his/her rights to terminate the interview until such time as his/her rights are protected (e.g., representation be legal counsel) 5. Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports. (Note: a copy of such reports must be attached to the Abuse Investigation Report Form. " ) 7. Team members of this Community who have been accused of resident abuse may be reassigned to nonresident care duties or suspended from duty until the results of the investigation have been reviewed by the Administrator. 9. The Administrator will keep the resident and his/her Representative (sponsor) informed of the progress of the investigation. 12. The Administrator will inform the resident and his/her Representative (sponsor) of the results of the investigation and corrective action taken within five days of the completion of the investigation. 14. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency with five days of the reported incident. 17. Inquiries concerning abuse reporting and investigation should be referred to the Administrator or to the Director of Nursing Services. 18. Action will be taken based on Community policy on Protection of Residents During Abuse Investigation. V. Protection of Residents during Abuse Investigations Policy Statement: Our Community will protect residents from harm during investigations of abuse allegations. Policy Interpretation and Implementation: 1. During abuse investigations, residents will be protected from harm by the following measures: a. Team members accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended without pay until the findings of the investigation have been reviewed by the Administrator... 2. Upon completion of the investigation, the resident, the resident's representative (sponsor), state survey and certification agencies, accused individuals, will be provided a written report of the findings of the investigation and a summary of the corrective action taken to prevent such incident from recurring. 3. Should the results indicate that abuse occurred, appropriate authorities will be notified. An interview on 5/27/11 at 3:20 PM the Social Worker stated that when the Administrator interviewed Resident #15 he would not let her tell him what happened. She stated that the Administrator kept telling Resident #15 that she had not been abused and that the CNA just had an attitude, until the resident finally just agreed with him. In an interview on 5/27/11 at 3:30 PM the TVLB representative stated that the Administrator had been made aware that Resident #15 had been held down on the bedpan against her will; she was placed in a wheelchair in the SCU in front of the television in the dining area with a scary movie playing and that she had been threatened by the staff on the night shift. The TVLB representative stated that Resident #15 was able to propel herself around the facility in her electric scooter; however, the night shift staff had placed Resident #15 in a manual wheelchair in the SCU dining area in front of the television. There was a scary movie playing on the television and Resident #15 was not able to maneuver the manual wheelchair on her own. In an interview on 5/27/11 at 4:50 PM the Administrator stated that the written statement by CNA A did not say anything about abuse. He stated that CNA A reported to him that CNA B had an attitude and talked rudely sometimes. He stated that CNA B was terminated due to her attitude and that CNA C was moved to another hall. In an interview on 5/27/11 at 5:00 PM the Activity Director stated that the Administrator did not question CNA A about abuse but rather, the attitude of CNA B. During an interview on 5/27/11 at 7:38 PM the facility's Administrator, DON and TVLB Representative were notified that an IJ was identified due to the facility's failure to protect Resident #15 from physical, verbal and emotional abuse resulting in mental anguish on 4/16/11. The facility provided a Plan of Removal on 5/27/11 at 9:30 PM. The final Plan of Removal accepted on 5/28/11 at 3:15 PM included the following: 1. Immediate in-servicing has begun on Abuse/Neglect and the right of residents to be free of abuse and neglect and the right to reach their highest practicable level of well-being physically/mentally/psycho-socially. In-services will be done by Administrator/SW/Nursing/designee. Night shift from 5/27/11 had in-servicing started. Day shift (5/28/11) is currently being inserviced. Beginning with evening shift and moving forward (5/28/11) the in-service will continue to be given on Abuse/Neglect. Team members will not be allowed on their assigned shift until this has been completed. 2. Team members providing in-services to staff members have had a review of abuse/neglect and the right of each resident to be free of abuse and neglect and the right to reach their highest practicable level of well-being physically/mentally/psychosocially provided by Clinical Services representative completed on 5/28/11. 3. The nurse identified in allegation is on vacation and unable to be reached. DON will suspend the nurse pending investigation once we are able to reach her. The nurse is scheduled to return June 3, 2011. 4. Medical Director has been notified by DON on the Immediate Jeopardy ...completed on 5/28/11. 5. Regional Nurse/designee will do formal in-service training of all team members on abuse/neglect and the right of each resident to be free of abuse/neglect as well as the right of each resident to reach their highest practicable level of well being physically/mentally/psycho-socially to include but not limited to: a. Definition of abuse/neglect b. Types of abuse/neglect c. Review our P&P of abuse/neglect d. Occurrences/events that constitute abuse/neglect e. Immediately reporting abuse/neglect ...the need to report if you witness or hear of incidents f. Immediately removing resident from the potentially abusive situations/conditions g. Suspension of those involved or suspected to be involved pending thorough investigation h. No threat or retaliation to resident(s) or person(s) reporting ...target date completion June 1, 2011 6. Licensed Nursing will be in-serviced by DON/designee on areas of staff supervision to include but not limited to: a. Derogatory language b. Rough Handling c. Ignoring residents while giving care d. Forcing "care" on residents e. Intimidation of residents f. Involuntary placement of resident against their will g. Responsibility to prevent h. Burn-out i. Responsibility to report (Senate Bill 9 they signed on hire, fines, etc.) j. Administrative actions ...target date June 3, 2011 Review of employee files of staff identified as perpetrators reflected the following: a. On 4/18/11 CNA B was called to the facility and the DON and the SW talked to her. They had no question that they had one of the perpetrators. She was terminated. b. On 5/10/11 CNA C was written up for 'attitude'. On that day she was re-assigned to A-Hall with a probationary period. No evidence of counseling for the 4/16/11 incident could be found. However, she remained an active employee at the facility until 5/23/11 when she abandoned her residents and left the building. c. On 5/10/11 LVN D was counseled about reporting disciplinary issues to the RN Supervisor on nights. No evidence of counseling for the 4/16/11 incident could be found. However, she is currently on vacation due to return 6/3/11. Review of the facility direct care staff schedule and time card reports for 4/16/2011 reflected CNA B, CNA C, and LVN D worked 10:00 PM to 6:00 AM on the special care hall. On 4/17/11 CNA B did not work. CNA A, CNA C, and LVN D worked the special care hall. CNA B and CNA C no longer work at the facility. LVN D will not return from vacation until 6/3/11. Review of facility's inservices on abuse/neglect had been initiated on 5/27/11 at 11:50 PM . The RN supervisors were included in the inservice. Corporate staff were in the facility. On 5/28/11 the medical director was in the facility as well as the vice president of clinical services that supervises the nurse consultants. Interviews on 5/28/11 with various staff after receiving the facility plan of removal revealed training on abuse/neglect and reporting had been given. While the IJ was removed on 5/28/11 at 3:15 PM, the facility remained out of compliance at an isolated incident of actual harm that is not IJ. The facility had not had time to implement, monitor and evaluate the Plan of Removal for effectiveness. Review of the Facility's CMS 672 reflected a facility census of 154 residents. The facility matrix reflected 28 residents resided on the Special Care Unit.

Based on observation, interview, and record review the facility failed to ensure provision of services were provided by 3 of 3 night shift staff(Certified Nurse Aide (CNA) B, CNA C and Licensed Vocational Nurse (LVN) D) to enhance Quality of Life and preserve dignity and respect for 1 of 4 sampled residents (Resident #15) that resided on the special care unit when: 1. Resident #15 was physically forced to use a bed pan by 2 of 2 (Certified Nurse Aides (CNA)s B and C) working nights on the special care unit; 2. Confined to a wheel chair and brought to the muses' station under the direction of Licensed Vocational Nurse (LVN) D; and 3. CNA B verbally threatened with her life resulting in ongoing mental anguish and emotional distress. This resulted in an Immediate Jeopardy (IJ) on 5/27/11. While the IJ was lowered on 5/28/11, the facility remained out of compliance at a severity of actual harm with scope isolated that is not an IJ as the facility had not had time to implement, monitor and evaluate the effectiveness of their Plan of Removal. This deficient practice affected Resident #15 and could affect the additional 27 residents that reside on the special care unit to feel dehumanized, intimidated, and experience mental anguish. Findings include: Review of the face sheet reflected Resident #15 was [AGE] years old admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #15's care plan dated 4/17/11 reflected a problem of MIXED bladder incontinence related to overactive bladder. Interventions included the following: Check and/or change every 2 hours and as needed. Ensure an unobstructed path to the bathroom. Monitor/document for signs and symptoms of urinary tract infections. An observation on 5/26/11 at 10:45 AM revealed Resident #15 had an electric scooter in her room. She was in therapy in a manual wheelchair. Interviews on 5/27/11 at 8:45 AM and 5/28/11 at 12:45 PM Certified Nurse Aide (CNA) A stated the night of 4/16/11 she had been working on the secured unit and went to get a snack. She saw Resident #15 sitting up in a wheel chair in front of the special care nurses' station. CNA A stopped and asked Resident #15 if she had trouble sleeping and she said "No"; however, Resident #15 was crying and upset. CNA A stated she had to get back on the secured unit and could not take time to console Resident #15. When she got off that morning Resident #15 was still up. The next night (4/17/11) she worked on the special care hall and answered Resident #15's call light. They started talking and Resident #15 told her about the other night aides being tired of her being on the call light all the time. The resident stated, 'Last night they (CNA B and CNA C) made her use a bedpan because they were tired of getting her up'. Resident #15 told CNA A that there were three of them and 'she fought them as hard as she could'. They held her on the bedpan until she got quiet then left the room. She also told CNA A that a few nights earlier an aide told her 'she had to sit at the table until she could hold her bladder for longer'. CNA A stated, "I was concerned for Resident #15's well-being". CNA B had threatened Resident #15's life. CNA A took their private discussion very seriously and advised Resident #15 that she needed to talk to the unit manager or Director of Nurses about this problem. On 4/17/11 CNA A wrote an anonymous 'Record of Concern' and put it in the facility concern box. CNA A did not notify the charge nurse (LVN D) because she was involved, and CNA A was scared to lose her job and fear of reprisal. An interview on 5/27/11 at 11:45 AM with the Social Worker (SW) revealed on 4/18/11 she brought Resident #15 into her office to talk with her. Once Resident #15 started talking the SW felt there should be other witnesses to the resident's statement and asked her if it would be 'OK' to bring a couple friends in to listen. The Director of Nurses (DON) and Texas Veterans Land Board Representative (TVLB Rep) came in and they let Resident #15 tell her story. The SW stated she had heard the statements 2 or 3 times and it remains the same. Resident #15 stated, "I never had to fight anybody like that." She told them she didn't want to go on the bedpan and was not going to. But they made her lay there and they hurt her shoulder. There were 2 or 3 of them. She teared up and said, "I remember them putting me in my chair and saying 'Do you want to die standing up or laying down'. My last breath here will be my first one in heaven". Resident #15 said they made her sit and watch a scary movie. She was in a manual wheel chair not her motorized scooter. An observation on 5/27/11 at 9:45 AM revealed an unidentified aide applied a gait belt and completed a stand pivot transfer with Resident #15 from her wheelchair to the commode without difficulty. She was able to stand once she was up in the standing position. During interview on 5/27/11 at 1:45 PM (following the SW intervention) with the resident concerning an incident on 4/16/11 her first statement was, "I was hurt." Resident #15 was alert, oriented and willing to discuss the incident. She became tearful and was ringing her hands several times during this interview. When describing the incident on 4/16/11, she stated, "The aide tried two times to get me up (from the bed) but my feet kept slipping. She (CNA B) called two of her friends to put me (Resident #15) on the bedpan." She stated, "I told them I was NOT going to sit on a bedpan. One pulled my arm and they fought me just as hard as they could. I layed there it seemed like an hour or longer. They were doing a lot of talking but I wasn't saying anything. They put me back in the chair (manual wheel chair) and took me to the front desk (nurses' station). I asked to be turned loose so I could go back to bed. I don't know how long I sat there. Finally I needed to go to the bathroom and they said to wait a few minutes." Resident #15 kept worrying and thought they were taking her to the public bathroom but they went down the hall. The aide said, "If I make a mess she was gonna see that I cleaned it up." Resident #15 stated they told her several things they were going to do to her. Resident #15 stated, "They asked me did I want to die standing up or lying down. The next morning I had lived through what ever they were going to do. I never said anything to them." She was tearful during this interview. She stated, "They got rid of the one woman because she was the one who said that about killing me. An interview with the DON on 5/27/11 at 3:20 PM revealed that Resident #15 had several falls and had been instructed to call to get up. They told her (Resident #15) she needed to use the bedpan. She did not want to be on the bedpan. They held her shoulders down. On nights when Resident #15 was awake, the night nurse (LVN D) would put her up by the nurses' station. Resident #15 felt like it was punishment. One night they had a scary movie on. The DON stated, "We narrowed it down to 2 CNAs (CNA B and CNA C). CNA B was terminated and CNA C was moved to A wing (not until 5/10/11). The aides were talking and Resident #15 thought they were talking about her. One night (5/23/11) while CNA C was working on A wing she got irritated and left the facility leaving only 1 aide on the hall " . No other residents complained about the aides. None were threatened by CNA B. The DON stated, "It was a difficult investigation to do". Resident #15 did not change her story about the bedpan and being put at the nurses' station with a scary movie on. The DON wanted to be sure it was the right employee. The DON stated, "I had a gut feeling to terminate both aides but felt I had nothing on CNA C. The SW joined the conversation and stated, "I was in the office with Resident #15 while the DON went to find pictures of the aides to show the resident. That's when the Administrator came to the office and started asking Resident #15 questions. He would not let her talk to explain her story. So she didn't tell him what she told the others. He was asking her leading questions like 'Do you feel like you were abused or was it an employee with a bad attitude'. Resident #15 said 'bad attitude' and he said, 'That's all I need'. The administrator did not listen to what the resident was trying to say. "Since the Administrator didn't let her talk she really told us more than when he was in the room". Review of confidential information from an unidentified individual reflected statements made by Resident #15 on 4/18/11 during the meeting with staff including the following: 1. A night shift aide asked her if she wanted to die standing up or laying down. 2. The aide told her if she made a mess in the bathroom she would have to clean it up herself. 3. The aide told her that she may not wake up in the morning because they could 'shoot something into her while she was sleeping ...take room mate to the hall, close the door and curtains ... 4. They (night shift staff) put her in a manual wheel chair in the middle of the night, put her 'in the front office' (in front of the nurses' station where residents eat). The first time was for an hour with a scary movie on TV. 5. She said she was not afraid to die, but only when it's her time. She said 'her last breath in this place will be her first breath in heaven'. 6. She was glad to see the sun 'they didn't kill her overnight'. 7. Three (3) of them (night shift staff) forcefully put her on a bedpan and left her there over 30 minutes. 8. She said she didn't want the bedpan, she wanted to go to the bathroom, but they physically forced her to sit on the bedpan instead. The investigation conducted by this Registered Nurse Surveyor included multiple staff interviews and record reviews that found conflicting information from what was in the facility investigation conducted by the Administrator. Day and evening staff had not used a bed pan with Resident #15, they assisted her to the bathroom. An interview on 5/28/11 at 11:10 AM with LVN Q revealed she could not think of Resident #15 ever using a bedpan. Review of the facility investigation submitted to state 4/25/11 conducted by the Administrator reflected multiple conflicting information contrary to what the resident said. The administrator eluded that attitude was the only problem throughout the investigation. During an interview on 5/27/11 at 7:38 PM the facility's Administrator, DON and TVLB Representative were notified that an IJ was identified due to the facility's failure to protect Resident #15 from physical, verbal and emotional abuse resulting in mental anguish on 4/16/11. The facility provided a Plan of Removal on 5/27/11 at 9:30 PM. The final Plan of Removal accepted on 5/28/11 at 3:15 PM included the following: 1. Immediate in-servicing has begun on Abuse/Neglect and the right of residents to be free of abuse and neglect and the right to reach their highest practicable level of well-being physically/mentally/psycho-socially. In-services will be done by Administrator/SW/Nursing/designee. Night shift from 5/27/11 had in-servicing started. Day shift (5/28/11) is currently being inserviced. Beginning with evening shift and moving forward (5/28/11) the in-service will continue to be given on Abuse/Neglect. Team members will not be allowed on their assigned shift until this has been completed. 2. Team members providing in-services to staff members have had a review of abuse/neglect and the right of each resident to be free of abuse and neglect and the right to reach their highest practicable level of well-being physically/mentally/psychosocially provided by Clinical Services representative completed on 5/28/11. 3. The nurse identified in allegation is on vacation and unable to be reached. DON will suspend the nurse pending investigation once we are able to reach her. The nurse is scheduled to return June 3, 2011. 4. Medical Director has been notified by DON on the Immediate Jeopardy ...completed on 5/28/11. 5. Regional Nurse/designee will do formal in-service training of all team members (including the Administrator) on abuse/neglect and the right of each resident to be free of abuse/neglect as well as the right of each resident to reach their highest practicable level of well being physically/mentally/psycho-socially to include but not limited to: a. Definition of abuse/neglect b. Types of abuse/neglect c. Review our P&P of abuse/neglect d. Occurrences/events that constitute abuse/neglect e. Immediately reporting abuse/neglect ...the need to report if you witness or hear of incidents f. Immediately removing resident from the potentially abusive situations/conditions g. Suspension of those involved or suspected to be involved pending thorough investigation h. No threat or retaliation to resident(s) or person(s) reporting ...target date completion June 1, 2011 6. Licensed Nursing will be in-serviced by DON/designee on areas of staff supervision to include but not limited to: a. Derogatory language b. Rough Handling c. Ignoring residents while giving care d. Forcing "care" on residents e. Intimidation of residents f. Involuntary placement of resident against their will g. Responsibility to prevent h. Burn-out i. Responsibility to report (Senate Bill 9 they signed on hire, fines, etc.) j. Administrative actions ...target date June 3, 2011 The Facility's Plan of Removal was accepted on 5/28/11 at 3:15 PM. Observations on 5/27/11 at 7:00 PM revealed department heads interviewing residents in the facility. Review of an inservice dated 4/25/11 reflected 'No one is to go into Resident #15's room alone. Two (2) CNAs are to tend to her needs at all times for her safety and team members safety'. Nine employees signed the inservice sign-in. Although CNA B was terminated on 4/18/11, CNA C and LVN D continued working with the resident following the incident. Review of employee files of staff identified as perpetrators reflected the following: a. On 4/18/11 CNA B was called to the facility and the DON and the SW talked to her. They had no question that they had one of the perpetrators. She was terminated. b. On 5/10/11 CNA C was written up for 'attitude'. On that day she was re-assigned to A-Hall with a probationary period. No evidence of counseling for the 4/16/11 incident could be found. However, she remained an active employee at the facility until 5/23/11 when she abandoned her residents and left the building. c. On 5/10/11 LVN D was counseled about reporting disciplinary issues to the RN Supervisor on nights. No evidence of counseling for the 4/16/11 incident could be found. However, she is currently on vacation due to return 6/3/11. Review of the facility direct care staff schedule and time card reports for 4/16/2011 reflected CNA B, CNA C, and LVN D worked 10:00 PM to 6:00 AM on the special care hall. On 4/17/11 CNA B did not work. CNA A, CNA C, and LVN D worked the special care hall. Review of facility's inservices on abuse/neglect had been initiated on 5/27/11 at 11:50 PM . The RN supervisors were included in the inservice. Corporate staff were in the facility. On 5/28/11 the medical director was in the facility as well as the vice president of clinical services that supervises the nurse consultants. Interviews on 5/28/11 with various staff after receiving the facility plan of removal revealed training on abuse/neglect and reporting had been given. While the IJ was removed on 5/28/11 at 3:15 PM, the facility remained out of compliance at an isolated incident of actual harm that is not IJ. The facility had not had time to implement, monitor and evaluate the Plan of Removal for effectiveness. Review of the Facility's CMS 672 reflected a facility census of 154 residents.