Every finding on record at Willow Park Rehabilitation Health Care Center

Based on observations, interviews, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1's call light was within reach on 05/20/26. This failure could place residents at risk of their needs not being met.Findings included: Record Review of Resident #1's face sheet dated 05/20/26 reflected the resident was a [AGE] year-old male admitted on [DATE]. His diagnoses included bipolar disorder (a chronic mental health condition characterized by extreme mood swings, alternating between intense highs (mania or hypomania) and severe lows (depression)), muscle wasting and atrophy (the loss of muscle tissue and strength, typically caused by inactivity, malnutrition, aging (sarcopenia), or diseases affecting nerves or muscles), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), and peripheral vascular disease, also known as peripheral artery disease, (a condition that occurs when blood vessels narrow or become blocked, reducing blood flow to the body. Peripheral vascular disease can affect any blood vessel outside of the heart, but it most commonly affects the legs and feet). Record Review of Resident #1's Annual MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 13 which indicated Resident #1 was cognitively intact. The MDS reflected Resident #1 required setup or clean-up assistance for eating and was dependent on staff for toileting, showering, and personal hygiene. Record review of Resident #1's care plan dated 06/06/21 and revised 08/06/25 reflected: Resident had an ADL self-care performance deficit r/t quadriplegia (the partial or total loss of motor and sensory function in all four limbs ((arms and legs)) and the torso) from anoxic brain injury (when the brain is completely deprived of oxygen, leading to cell death within minutes), and contracture (a permanent, or long-lasting, tightening of muscles, tendons, ligaments, or skin that causes joints to become stiff and rigid, limiting mobility). Resident has need for assistance with personal care.Goal: Resident #1 would maintain current level of function in ADLs through the review date with target date: 07/06/26.Interventions included: Encourage the resident to use bell to call for assistance. During an observation and interview on 05/20/26 at 9:36 AM, Resident #1 stated he was doing ok and the staff here treated him well. He stated he had a way to call for help but he could not have reached it at this time if he tried. Resident #1's call light was observed under Resident #1's bed wrapped around the bed frame and hung near the floor, out of resident's reach. He stated if he needed help, he would have had to yell for someone because he would not have been able to get to his light. Resident #1 demonstrated that he could not reach his call light where it was placed. During an interview on 05/20/26 at 9:54, AM CNA C stated Resident #1 was alert enough to be able to tell her if he needed something and he called staff whenever he needed them to do something. She stated he yelled for help and he used his call light when he needed help. She stated Resident #1 could not have reached his call light where it was placed. She stated all residents' call lights should have been within their reach at all times. She stated she had been trained on call lights being within residents' reach at all times. She stated if a resident's call light had not been within their reach, they would not have been able to get ahold of staff if they needed something. During an interview on 05/20/26 at 10:21 AM, LVN A stated she had worked in the facility for about a year and a half. She stated she had been in-serviced on call light placement within residents reach at all times and resident rights. She stated all residents call lights should have been within reach at all times. She stated if a resident's call light was not in reach it could have caused a fall or a resident could have been in pain and could not have been able to call for staff. During an interview on 05/20/26 at 10:32 AM, CNA D stated she had worked in the facility for about 4 years. She stated she had been in-serviced on call light placement within residents' reach at all times and resident rights. She stated all residents' call lights should have been within reach at all times. She stated if a resident's call light was not in reach it could have caused something bad like a fall to happen. During an interview on 05/20/26 at 10:37 AM, LVN B stated she had worked in the facility for about a year and she worked on the secured unit. She stated she had been in-serviced on call light placement within residents' reach at all times and resident rights. She stated all residents call lights should have been within reach at all times. She stated if a resident's call light was not in reach it could have caused a resident to fall and not be able to get help in time or could have been having a serious issue and may not have been able to get the help they needed. During an interview on 05/20/26 at 10:48 AM, CNA E stated she had worked in the facility for about 4 years. She stated she had been in-serviced on call light placement within residents reach at all times and resident rights. She stated all residents' call lights should have been within reach at all times. She stated if a resident's call light was not in reach it could have caused a resident to fall and not have been able to call for help or a resident may have needed water or something and would not have been able to get staff. During an interview on 05/20/26 at 1:31 PM, the DON stated staff had been trained on call light placement within residents' reach and resident rights. She stated all residents' call lights should have been within reach at all times. She stated if a resident's call light was not in reach it could have caused the resident to not be able to get to staff when they needed help. During an interview on 05/20/26 at 1:43 PM, the ADM stated staff had been in-serviced on call light placement within residents' reach at all times and resident rights. She stated all residents' call lights should have been within reach at all times. She stated if a resident's call light was not in reach it could have caused a resident to fall or a resident may have been unable to let staff know they needed something. Record review of facility policy titled Answering the Call Light dated 2001 and revised September 2022 reflected Purpose: The purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines: 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. Record review of facility policy titled Resident Call System dated October 2022 and reviewed 03/28/2023 reflected Policy: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Policy Interpretation and Implementation: 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. Calls for assistance are answered as soon as possible. Urgent requests for assistance are addressed immediately.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse for 5 (Resident #6, Resident #11, Resident #57, Resident #84, and Resident #85) of 13 residents reviewed for abuse. The facility failed to ensure the safety of Resident #84 on 12/3/25 when Resident #11 hit him in the chest causing the resident to fall and hit the ground hard resulting in Resident #84 being sent out to the hospital for evaluation of injuries. The facility failed to ensure the safety of Resident #85 on 11/19/25 when Resident #11 punched him in the face. The facility failed to ensure the safety of Resident #6 on 11/22/25 when Resident #11 pushed him to the ground. The facility failed to ensure the safety of Resident #57 on 12/9/25 when Resident #11 hit him on the arm. An Immediate Jeopardy (IJ) was identified on 12/16/2025. The IJ template was provided to the facility on [DATE] at 4:45 PM. While the IJ was removed on 12/18/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on abuse/neglect. This failure placed residents at risk of abuse, trauma, and/or psychosocial harm. Findings included: Review of Resident #11's quarterly MDS dated [DATE] reflected a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's (mental deterioration), depression (persistent feelings of sadness and loss of interest), bipolar (periods of depression and abnormally elevated mood), anxiety (feelings of worry, nervousness, or unease), and mood disorder (imbalance of brain chemicals that can lead to long periods of extreme happiness, extreme sadness, or both). Resident #11 had a BIMS score of 01, indicating severely impaired cognition. His most current height was 6ft 9in and his weight was 238.4lbs. In section E - Behavior it was indicated that within the last 1 to 3 days Resident #11 exhibited physical behavioral symptoms toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) Review of Resident #11's comprehensive care plan dated 12/16/2025 reflected, The resident is physically aggressive at times r/t DementiaI can be combative with staff during care and also be resistant to care at times.08/06/2025 I have been physically aggressive with another resident.10/11/2025 I initiated physical aggression toward a peer.10/22/2025- I initiated physical aggression toward my peers and staff members X2 this day.10/23/2025- I initiated physical aggression toward my peers and staff members today11/15/2025- I initiated physical aggression toward my peers and staff members today. (while on 1:1)11/19/2025- I initiated physical aggression toward my peers and staff members today. (while on 1:1)11/22/2025- I initiated physical aggression toward my peer. (while on 1:1)12/03/2025- I initiated physical aggression toward my peer today. (while on 1:1)12/05/2025- resident became combative. After combative episode left knee skin tear noted. (while on 1:1)Resident #11 was put on 1:1 precaution on 11/11/2025 due to his behaviors with his peers. The goal was to have fewer episodes of aggressive behaviors, and no evidence of behavior problems (aggression/agitation and/or anxiety). The interventions listed were to anticipate and meet the resident's needs, caregivers to provide opportunity for positive interactions, attention, and to stop and talk with Resident #11 when passing, and to praise any indication of progress/improvement in behavior. Review of Resident #85's quarterly MDS dated [DATE] reflected a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: heart failure (when the heart cannot pump enough blood to meet the body's needs), high blood pressure, high cholesterol, Alzheimer's disease (mental deterioration), stroke (when blood supply to part of the brain is cut off), anxiety (feelings of worry, nervousness, or unease), depression (persistent feelings of sadness and loss of interest), cardiac pacemaker (device implanted in the heart to help regulate the heart's rhythm), and muscle weakness. Resident #85 had a BIMS score of 03, indicating severely impaired cognition. Review of Resident #85's comprehensive care plan dated 10/23/2025 reflected he received physical aggression from his peer, and the goal was to be safe and free from injury, and the interventions were that Resident #85 was removed from the aggressor and assessed for injuries and that staff monitored for delayed injuries. The care plan also indicated that Resident #85 received physical aggression from a peer on 11/19/2025.Review of Resident #6's comprehensive MDS dated [DATE] reflected a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: high blood pressure, arthritis (painful inflammation and stiffness of the joints), Non-Alzheimer's dementia (memory impairment and challenges in performing daily activities), anxiety (feelings of worry, nervousness, or unease), Post-Traumatic Stress Disorder (mental health condition that arises after experiencing or witnessing and extremely stressful or terrifying event). Resident #6 had a BIMS score of 01, indicating severely impaired cognition.Review of Resident #6's comprehensive care plan dated 11/19/2025 reflected that he received physical aggression from another resident, the goal was to demonstrate effective coping skills, and to not harm himself or others. The interventions were to administer medications as ordered, assess and address for contributing sensory deficits, and to assess and anticipate Resident #6's needs. Review of Resident #84's quarterly MDS dated [DATE] reflected a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: anemia (deficiency of red blood cells), high blood pressure, diabetes mellitus (a disease in which the body's ability to produce or respond to insulin is impaired, resulting in abnormal metabolism and elevated glucose levels). Resident #84 had a BIMS score of 09, indicating moderately impaired cognition. Review of Resident #84's comprehensive care plan dated 12/03/2025 revealed, I received physical aggression from my peer and fell on my elbow. The goal was to be safe and free from injury, the interventions included, sent to ER for evaluation, staff to monitor for residual effects of physical aggression and fall. Review of Resident #57's comprehensive care plan dated 11/04/2025 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: vascular dementia with anxiety (type of dementia caused by conditions that affect blood flow to the brain), cerebral infarction (when a blood vessel in the brain becomes blocked, cutting off oxygen supply to brain tissue), diabetes mellitus (a disease in which the body's ability to produce or respond to insulin is impaired, resulting in abnormal metabolism and elevated glucose levels), high blood pressure, major depressive disorder (persistent feelings of sadness and loss of interest). He was care planned with a focus of The resident is/has potential to be physically aggressive r/t Dementia, Poor impulse control . The interventions were to administer medications as ordered, monitor for effectiveness. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Assess and address for contributing sensory deficits. Access and anticipate resident's needs. Review of a progress note dated 12/09/2025 reflected, Resident #11 was sitting in hallway at nurse's station in front of dining room, another male resident [Resident #57] walked past [Resident #11] and [Resident #11] lunged forward and hit the other resident in the arm. In an interview/observation on 12/16/2025 at 9:53 AM CNA F was providing 1:1 supervision to Resident #11. CNA F stated that Resident #11 had been on 1:1 supervision for about a month, and it would be ongoing until 12/26/25 to her knowledge. She stated that Resident #11 was on 1:1 supervision because he was aggressive, swung at staff with his arms and legs, and was aggressive to his peers. Resident #11 was observed sitting atop a bed, watching television. In an interview on 12/16/2025 at 10:00 AM with LPN G she stated that the facility was trying to get Resident #11 help, but when they would send him to the hospital, the hospital staff reported that Resident #11 did not exhibit any combative or aggressive behaviors, and he would be sent back to the facility. The facility had been unable to get the county to do an emergency detention order, where he could be detained for 30 days, and potentially receive in-patient care. She stated that Resident #11 was very combative. In an interview on 12/16/2025 at 12:05 PM with the DON, she stated that the facility had tried to get Resident #11 help, but the county JOP nor the attorney would sign an Emergency Detention Order to get Resident #11 into inpatient psychiatric care, as they say the law prohibited them from doing that for a person with a Dementia diagnosis. She stated she had reached out to 5 other SNFs who all declined taking Resident #11. She stated the hospitals told her that Resident #11 must exhibit aggressive behavior at the hospital in order to initiate inpatient behavioral admission, which he does not do at the hospital. The DON stated she was in constant communication with Resident #11's RP , who was also Resident #11's POA , but she stated that the behavioral hospitals would not take POA paperwork for admission, they would need guardianship paperwork, to which she had discussed with the RP, and they were willing to get that paperwork. She said that her staff do not have the physical stature to manage his physical aggression. In an interview on 12/16/2025 at 12:57 PM with the psychiatric NP, she stated that she saw Resident #11 for telehealth visits and recently saw Resident #11 in person. She stated she had never seen him initiate aggression, but she observed him being intrusive, getting in people's faces, mumbling, and babbling toward people. She stated that for inpatient psychiatric services, people have to be able to cognitively process things in order to participate in group therapies, and Resident #11 did not have the capacity to do that. She stated she could give an order for the behavioral hospital, but she was pretty sure the facility had already reached out to them and was denied. She stated that the facility contacted her after each altercation to either provide a virtual or in-person visit to Resident #11. In an interview on 12/16/2025 at 2:16 PM with CNA A, she stated that recently when she was doing 1:1 with Resident #11, she saw him put his fist up, and she stepped between Resident #11 and another resident, she stated his fist landed on her chest. She saw him hitting/kicking/spitting at 3 CNAs and 1 RN just this morning. The RN was trying to administer the injection but that is when he was acting out. She stated she does not feel safe, nor does she feel residents are safe due to Resident 11's stature and his punch is hard and will knock someone backwards. In an interview on 12/16/2025 at 2:40 PM with LPN H, she stated that the bad thing about Resident #11 was that his incidents were almost always unprovoked. She stated that she would prefer not to answer if she felt residents were safe around Resident #11, because Resident #11 could be very aggressive and it was random with no signs. She stated it depended on the day and time as to what interventions worked for him. She stated it was really a guessing game to figure out what interventions would work because sometimes she could redirect him with conversation and food, but sometimes he was so worked up that those interventions would not work. She stated that the incidents were getting worse in frequency of him being aggressive. Review of the facility's abuse prevention policy dated 6/2/25 revealed, The facility will prohibit neglect, mental or physical abuse of residents. The safety and protection of other residents is the facility's primary concern. Review of the facility's Training on Resident-to-Resident Abuse Prevention and Response dated 10/22/25 revealed, 4. Prevention Strategies Screeningo Conduct thorough assessments of residents to identify those at risk of being victims or perpetrators of abuse.o Develop individualized care plans to address specific needs and risks The ADON, CCS, and RDO were notified on 12/16/2025 at 4:45 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 12/17/2025 at 11:30 AM: On 12/16/25 an abbreviated survey was initiated at Facility. On 12/16/25 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to residents' health and safety. The notification of Immediate Threat states that the facility failed to keep residents free from abuse, F600. Immediate ActionsStarted: 12/16/25 Director of Nursing ensured Resident #11 was placed on continuous 2:1 supervision at arm's length. Completion date: 12/16/25 and Ongoing Director of Nursing ensured that physical separation at arm's length was implemented between Resident #11 and all other residents at all times. Accomplished by in-services to all staff conducted by DON. Completion date: 12/16/25 and Ongoing Director of Nursing ensured resident #11 was placed in a controlled, low-stimulation environment Completion date: 12/16/25 and Ongoing Director of Nursing searched the memory care common area and Resident #11's room to ensure objects that could be used to cause harm were removed from the resident's environment. Completed 12/16/25 and ongoing Director of Nursing ensured a two-staff approach was implemented for all care interactions involving Resident #11. Completed 12/16/25 and ongoing Director of Nursing ensured a STAT psychiatric evaluation was requested for Resident #11 and completed on 12/16/25 by Psychiatric Nurse Practitioner. Medication changes and additional diagnosis resulted. Director of Nursing ensured the resident's medication regimen and PRN parameters were reviewed and adjusted as clinically indicated. Completed 12/16/25 On 12/16/25, the DON reviewed Resident #11's clinical status to assess for potential medical contributors to aggressive behavior. Pain assessment was completed and addressed. Vital signs and oxygen saturation were reviewed and within acceptable parameters. Infection screening was reviewed with no acute findings. Bowel and bladder status were assessed and addressed. Medication profile was reviewed for potential contributing side effects. No acute medical condition was identified contributing to behaviors. Findings were reviewed with the attending physician and psych provider. Plan of care was updated accordingly. Responsible: DON Systemic ActionsStart: 12/16/25 The facility revised its process for managing residents with aggressive behaviors What behaviors , including early identification of triggers, defined escalation thresholds, and clear staff response expectations. Revised process includes Identification, Immediate Risk Mitigation, Interdisciplinary Care Planning, Staff Assignment, Protection of Others and Monitoring and Oversight. Completion date 12/16/25 Resident #11's behavioral care plan was revised by the interdisciplinary team to include identified triggers, early warning signs, de-escalation techniques, and clear direction for escalation. Completion date 12/16/25. Corporate Clinical Specialist educated DON and ADON regarding dementia-related aggressive behaviors, resident to resident abuse prevention, and de-escalation strategies. Validation completed by quiz. Completion date 12/16/25 DON and ADON conducted education for staff on all shifts regarding dementia-related aggressive behaviors, resident-to-resident abuse prevention, and de-escalation strategies. Staff, including PRN and Agency, will be unable to work until education is completed. Completion date 12/17/25. Staff education was validated by quiz that was completed and documented. Staff will be unable to work until education is completed and validated by quizzes. Minimum score of 100% is expected to pass. Completion date: 12/17/25 The Abuse Prevention Policy was reinforced with specific focus on resident-to-resident aggression. Completion date: 12/16/25 Pathways of resources for staff for psychiatric consultation and alternative placement consideration were reinforced. Pathways will be in binder and placed at the nurses' station for staff accessibility. Completion date: 12/17/25 A house-wide assessment was conducted by Corporate Clinical Specialist and DON to identify residents at risk for harm, and protective interventions were implemented. As a result of the assessment, all residents in memory care unit were at risk. Completion date 12/17/25. Responsible: DON Monitoring Start Date: 12/16/25 The DON, or designee, provides immediate oversight of supervision levels and resident safety related to aggressive behaviors. Charge Nurse provides real time supervision during each shift to ensure protective interventions and separation measures remain in place. Any escalation in aggressive behaviors result in immediate re-assessment and modification of interventions. Leadership maintains active presence in oversight to ensure continued resident safety and adherence to interventions implemented to remove the jeopardy. Resident-to-resident aggression is monitored through the QAPI program with trend analysis. Findings are reviewed by the QAPI Committee 1x a month for 6 months and corrective actions are implemented as needed. Ongoing audits are conducted to ensure compliance with supervision, care planning, and staff response protocols. Responsible: Administrator The surveyor monitored the POR on 12/18/2025 as follows: Review of a psychiatric progress note dated 12/16/25 at 6:45 PM for Resident #11 revealed a new order for Haldol 2 mg BID. Resident #11's current medications were listed along with his diagnoses, and notes from the NP. Review of assessments completed on Resident #11 dated 12/16/2025 revealed the following assessments were completed: infection screening, pain evaluation, bowel evaluation, bladder evaluation which all revealed no acute findings. A note from the DON revealed she conducted a medication review for potential interactions, also with no findings. Review of an in-service dated 12/16/2025 conducted by the CCS and titled Managing Residents with aggressive behaviors reflected the signatures of the DON and ADON. Review of an in-service dated 12/16/2025 conducted by the DON and ADON titled Managing Residents with aggressive behaviors reflected 80+ staff were in-serviced either in person or over the phone and a quiz was given to every staff ensuring a 100% passing. The in-service covered abuse and neglect prevention, management of aggressive behavior, dementia-related aggressive behavior, resident-to-resident abuse, and de-escalation strategies. Review of an in-service dated 12/16/2025 conducted by the DON, and titled 2:1 Safety revealed, staff must consistently remain with Resident #11 under strict precautions to ensure the safety of Resident #11, staff, and peers. Staff are required to remain attentive, free from distractions, and within arm's reach of the Resident at all times. A minimum of two (2) staff members must be present with the Resident at all times. The two assigned staff are responsible for ensuring that all other staff and peers remain at an arm's-length distance from the Resident at all times. There are no exceptions to these requirements; failure to remain attentive or to follow these precautions will result in disciplinary action. 27 staff signatures were visible on the sign in sheet, across departments. Review of a binder placed at both nurses' stations on 12/17/2025 titled, Resources for Managing Aggressive Behavior revealed steps for managing residents with aggressive behaviors, the facility policy on management of residents with aggressive behaviors, and an in-service for managing residents with aggressive behaviors. Review of a facility census revealed that the CCN and DON identified the residents in the secured unit were at risk of harm. Review of QAPI meeting sign in sheet dated 12/17/2025, revealed the signatures of the MD, RDO, CCS, and other department head signatures. Review of an audit/monitoring form for Resident #11 revealed his care plan was audited on 12/17/25 and staff supervision was monitored on 12/18. Review of undated staff competency quizzes which posed questions about managing residents with aggressive behaviors, triggers, and escalation pathway, revealed all 9 CNA's, 2 MA 's, 4 LVN's, 2 RN's, and 8 housekeeping and dietary staff interviewed achieved 100% passing. Review of Resident #11's updated care plan dated 12/17/2025 reflected the following updates: Resident is two persons on one r/t resident behaviors and/or aggressions with peers. Intervene as necessary to protect the rights and safety of others. Approach/Speakin a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior andpotential causes. Staff to identify resident's triggers for behaviors and use de-escalation techniques. Staff to identify early warning signs for resident's behavior and triggers. Staff to identify resident's triggers for behaviors (loud noises, other peers in his personal space, people touching his clothing, he doesn't like to be changed when his clothing is soiled. Resident doesn't like crowded spaces.) Staff to identify early warning signs for residents' behaviors and triggers. (Resident starts fidgeting. Repeats words over and over and paces, starts pushing or pulling on staff.) In an observation/interview on 12/17/2025 at 9:04 AM, revealed 2 staff-CNA I and NA J stated they were assigned to work their 7am-7pm shift with Resident #11. They stated they were instructed by the DON that they were responsible for being within an arm's length away from Resident #11 and always keeping Resident #11 an arm's length away from his peers. They were to supervise him to ensure no altercations took place. They stated Resident #11 required 2 staff for care activities such as dressing, bathing, and changing. Resident #11 was observed sitting in a chair watching television in between CNA I and NA J. In interviews completed on 12/18/2025 between the time of 10:35 AM. and 12:00 PM with 9 CNA's, 2 MA's, 4 LVN's, 2 RN's, and 8 Housekeeping and Dietary staff, from various shifts, all staff were able to verbalize that they had been trained on managing residents with aggressive behaviors, Dementia related to aggressive behaviors, resident to resident abuse, prevention, and de-escalation. Staff were able to identify triggers that could possibly lead to incidents of aggressive behavior. Staff verbalized they were educated on Resident #11 requiring 2:1 supervision on the secured unit. They were able to locate the resident's care plan along with the process revised from managing residents with aggressive behaviors. Staff were able to give examples of abuse and identified the administrator as the abuse coordinator. The CCS and RDO were informed the IJ was removed on 12/18/2025 at 2:30 PM. The facility remained out of compliance at a severity level of no actual harm and a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation and interview, the facility failed to ensure a resident has a right to personal privacy and confidentiality of his or her personal and medical records for 2 of 3 computers reviewed for privacy and confidentiality. On 12/18/2025 LVN O left the facility's computer open and unattended at the nurse's station with resident's personal medical information was visible to anyone who passed by. On 12/18/2025 LPN K left the facility's computer open and unattended at the nurse's station with resident's personal medical information was visible to anyone who passed by. On 12/19/2025 LVN O left the facility's computer open and unattended at the nurse's station with resident's personal medical information was visible to anyone who passed by. These failures could place residents at risk of having their private information changed, viewed, and not kept secure. Findings included: During an observation on 12/18/2025 at 1:17 p.m., reflected LVN O left her computer unlocked/opened and unsupervised, vaguely visible in an open area for residents and other individuals/guests of the facility passing by the nurse's station, with resident information visible on the screen. At the time of the observation LVN O left her computer and walked towards the administrator's office. During an observation on 12/18/2025 at 1:25 p.m., reflected LPN K left his computer unlocked/opened and unsupervised, vaguely visible in an open area for residents and other individuals/guests of the facility passing by the nurse's station, with resident information visible on the screen. At the time of the observation LPN K left his computer and walked down the D hall. During an observation on 12/19/2025 at 2:15 p.m., reflected LVN O left her computer unlocked/opened and unsupervised, vaguely visible in an open area for residents and other individuals/guests of the facility passing by the nurse's station, with resident information visible on the screen. At the time of the observation LVN O left her computer and walked down the A hall. During an interview on 12/19/2025 at 12:45 p.m., the ADON stated the nurse using the computer was responsible for ensuring residents' information was not displayed on the unattended computer. The ADON stated a negative outcome of an unattended computer was that residents' information could be accessed by anyone. The ADON stated her expectations were for staff to ensure resident information was not displayed on unattended computer screens. During an interview on 12/19/2025 at 1:20 p.m., the ADM stated t was the staff using the computer responsibility for ensuring the computer screen was locked when unattended. The ADM stated a negative outcome could be that someone would have access to a resident's personal information. The ADM's expectations moving forward was for staff to ensure their computer screens were locked when unattended. Record review of the facility's Resident Rights, revised dated 2016, reflected, Employees shall treat all resident with kindness, respect, and dignity. Policy Interpretation and Implementation: 3. The unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues. All inquiries concerning the release of resident information should be directed to the HIPAA Compliance Officer .

Based on observation, interview and record review, the facility failed to ensure that the resident has the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 1 (Residents #9) of 6 residents reviewed for resident rights. The facility failed to obtain an informed consent for the use of Ativan (an antianxiety medication) used for Resident #9. This failure could place residents at risk of receiving medications without prior consent and without the option to choose alternative treatment or decline based on awareness of risk and benefits of the medications. Findings included: Record review of Resident #9's comprehensive care plan, dated 02/21/25, reflected Resident #9 used anti-anxietymedications related to anxiety disorder. Interventions included: Educate the residents/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of anti-anxiety medication drugs being given. Record review of Resident #9's Physicians Order Summary Report for the month of December 2025 reflected an order for Ativan (an antianxiety medication) one tablet by mouth two times daily for anxiety dated 06/17/2025. Record review of Resident #9's quarterly MDS assessment, dated 12/08/2025, reflected she was admitted on [DATE]. Her diagnoses included respiratory failure, atrial fibrillation (irregular heart rate), and hypertension (elevated blood pressure). Resident #9 was coded as being dependent on staff for shower/bathing. Resident #9 had a BIMS score of 02 , which indicated severe cognitive impairment. Record review of Resident #9's electronic medical records for dates of 02/08/2024 thru 12/19/2025 reflected there was no informed consent for Ativan on file. In an observation and interview on 12/16/2025 at 10:30 a.m., Resident #9 stated she had no complaints related to care. Resident #9 appeared clean with her hair combed and was dressed appropriacy for the weather. In an interview on 12/19/2025 at 1:15 p.m., LVN O stated, I don't think we have to do a consent for Ativan routine only as needed. She stated staff normally obtain consents for Ativan. She stated she was not sure where the Ativan consent was located at this time. LVN O stated the nurse who received the order for medication requiring a consent was responsible for obtaining it at the time the order was received. She stated if consent were not obtained the family would not be aware of side effects. In an interview on 12/19/25 at 1:30 p.m. ADON L stated the nurse who took the orders for any medication requiring informed consent, should obtain consent at that time. She stated the assistant directors were responsible for reviewing orders and ensuring consents were in the electronic medical record. ADON L stated the purpose of the consent was to ensure residents or responsible parties were informed related to purpose and side effects of the medication. The negative effects for not obtaining consent for anxiety medications would be that the resident/family may not be aware of side effects. Record review of facility policy dated 2001 titled Residents Rights reflected: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be notified of his or her medical condition and of any changes in his or her condition be informed of and participate in, his or her care planning and treatment.

Based on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 6 residents (Resident #65) reviewed for resident rights.The facility failed to ensure Residents #65's call light was within reach on 12/16/2025.This failure could place residents at risk of their needs not being met. Findings include:Record review of Resident #65's admission record, dated 12/19/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. Resident #65 had diagnoses which included: Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills), contracture right and left shoulder (permanent tightening and stiffing of muscles, tendons, skin, or other tissue causing joints or body parts to shorten and become fixed in a bent or awkward position), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), and pain (unpleasant feeling like sting, ache, or burn, that tells your brain something is wrong, like an injury or potential harm).Record review of Resident #65's Quarterly MDS assessment, dated 09/29/2025, reflected Resident #65 had a BIMS score of 03, which indicated severe cognitive impairment. Resident #65 required substantial/maximal assistance in the areas of shower/bathe self, upper body dressing, and personal hygiene. Resident #65 was dependent on staff in the areas of toileting hygiene, lower dressing, putting on/taking off footwear and personal hygiene. Record review of Resident #65's care plan, dated 12/19/2025, reflected high risk for fall r/t confusion, impaired balance, Vitamin D Deficiency, history of falling presence of left artificial hip joint unequal limb length, hyponatremia (salt level in your blood become abnormally low) Resident #65 had an intervention of be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. During an observation on 12/16/2025 at 09:59 a.m., Resident #65's call light was observed hanging towards the floor at the foot of her bed while Resident #65 sat in a Geri chair approximately three feet from where her call light was placed. Resident #65 could not be interviewed due to her cognitive status.During an interview with CNA B on 12/19/2025 at 12:20 p.m., CNA B stated she was assigned the D hall were Resident #65 resided. CNA B stated that it was everyone's responsibility to ensure call lights were always within reach. CNA B stated if a resident's call light was not within reach, then the resident would not be able to call for assistance. During an interview on 12/19/2025 at 12:45 p.m., the ADON stated it was everyone's responsibility to ensure resident call lights were within reach at all times. ADON stated that CNAs make round at least every two hours or as needed. The ADON stated during rounds CNAs should look to see if a resident's call light was within reach. The ADON stated if a resident call light was not within reach, then the resident would not be about to call for assistance if needed.During an interview on 12/19/2025 at 1:20 p.m., the ADM stated call lights should always be within reach. The ADM stated it was everyone's responsibility to ensure the call lights were within reach. The ADM stated if a resident's call light was not within reach, then the resident would not be able to express their needs nor have their needs met. The ADM stated her expectation was for staff members to ensure call lights were within reach prior to existing the resident's rooms.A record review of the facility's Resident Call System policy, October 2022, reflected Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation.Policy Interpretation and Implementation:1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor 4. If a resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan.

Based on observations, interviews, and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 3 of 6 residents (Resident #3, Resident #6, and Resident #84) who were reviewed for accuracy of assessments. 1. Resident #3's SCSA MDS did not indicate he was admitted to hospice in all the necessary sections. 2. Resident #6's most recent comprehensive MDS was coded as having a catheter, but Resident #6 did not have an order for a catheter, nor was he observed with one. 3. Resident #84's most recent comprehensive MDS was coded as resident having used insulin in the last 7 days, when medication review, orders, and interviews revealed that Resident #84 did not use insulin. This failure placed residents at risk of incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings included: Review of Resident #6's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: high blood pressure, arthritis (painful inflammation and stiffness of the joints), Non-Alzheimer's dementia (memory impairment and challenges in performing daily activities), anxiety (feelings of worry, nervousness, or unease), Post-Traumatic Stress Disorder (mental health condition that arises after experiencing or witnessing and extremely stressful or terrifying event). In section H - Bladder and Bowel, Resident #6 had a 'x' in box 'A. Indwelling catheter (including suprapubic catheter and nephrostomy tube)'. In section V - Care Area Assessment (CAA) Summary, under care area 06. Urinary Incontinence and Indwelling Catheter, there were 'x's in box 'A. Care Area Triggered' and box 'B. Care Planning Decision' Resident #6 had a BIMS score of 01, indicating severely impaired cognition. Review of Resident #6's comprehensive care plan dated 11/19/2025 reflected no interventions for catheter usage, monitoring, or output documentation needed. Review of Resident #6's active doctor's orders as of 12/17/2025 reflected no orders for a catheter. Review of Resident #84's quarterly MDS dated [DATE] reflected a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: anemia (deficiency of red blood cells), high blood pressure, diabetes mellitus (a disease in which the body's ability to produce or respond to insulin is impaired, resulting in abnormal metabolism and elevated glucose levels). In section N - Medications, under the Insulin category, MDS S indicated Resident #84 had been administered insulin 7 days out of the last 7 days. Resident #84 had a BIMS score of 09, indicating moderately impaired cognition. Review of Resident #84's comprehensive care plan dated 12/03/2025 reflected no interventions for insulin usage. Review of Resident #84's active doctor's orders as of 12/19/2025 dating back to November 20, 2025, reflected no orders for an insulin injection medication. In an observation on 12/16/2025 at 10:29 AM, Resident #6 was observed standing in the secured unit hallway, and no catheter collection bag was observed on his person. In an interview on 12/19/2025 at 11:49 AM with LPN G, she stated that she had never administered insulin to Resident #84 since she began working at the facility in October 2025. She stated that Resident #84 had low blood sugar, and he got finger sticks daily, but Resident #84 also had ESRD, and certain diabetes medications could cause a buildup of lactic acid enzymes. She stated that Resident #6 was not admitted to the facility with a catheter, but that he was admitted on hospice and was very thin at the time. In an interview on 12/19/2025 at 12:05 PM with MDS S, she stated that she was responsible for conducting MDS assessments and that she had completed Resident #84's MDS assessment. She stated that at one time Resident #84 may have taken insulin, but the coding was an error, and she would correct it. She also stated that indicating Resident #6 had a catheter was an error, and she would need to correct it. She stated that inaccurate assessments could lead to inadequate care because assessments helped direct care staff know what care to provide. In an interview on 12/19/2025 at 12:26 PM with MDS D, she stated that Resident #3 admitted to hospice on 9/13/2024 and that the SCSA not having Hospice indicated was just missed in section J, but it was listed in section O as having a life expectancy less than 6 months. In an interview on 12/19/2025 at 1:09 PM with the ADM, she stated that her expectation for MDS accuracy was for them to be done correctly and accurately. She stated that they have a regional specialist who oversaw MDS work . Review of the facility's MDS Coding Policy dated 06/02/2025 reflected, [Company] affiliated facilities utilize the most up to date Resident Assessment Instrument (RAI) manual for determination of coding each section of the Resident Assessment, timely and accurately.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 6 residents (Resident #73) reviewed for PASARR Level I screenings. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #73. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (Major Depressive Disorder) was present upon Resident #73's admission date on 01/17/2025. This failure could place residents at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needsFindings included: Record review of Resident #73's face sheet, dated 12/19/2025, reflected a [AGE] year-old male, admitted on [DATE]. Resident #73 had diagnoses which included: major depressive disorder (serious mood disorder causing persistent sadness, hopelessness, and loss of interest in activities, significantly impacting daily life), type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), and chronic pain syndrome (when pains lasts over 3-6 months). Record review of Resident #73's Quarterly MDS assessment, dated 11/28/2025, reflected Resident #73 had a BIMS score of 12, which indicated moderate cognitive impairment. Resident #73's Quarterly MDS also reflected Resident #73 had an active diagnosis of major depressive disorder. Record review of Resident #73's PASRR Level 1 Screening, dated 01/13/2025, reflected that Section C Mental Illness was marked as no, which indicated Resident #73 did not have a mental illness. Record review of Resident #73's care plan, dated 12/19/2025, reflected Resident #73 was care planned for depression r/t Disease Process Major Depressive disorder and the resident uses antidepressant medication (Duloxetine) r/t Depression. Record review of Resident #73's admission notes, dated 01/14/2025, reflected Resident #73 had a diagnosis of major depressive disorder. During an interview on 12/19/2025 at 10:10 a.m., MDS D stated Resident #73 had a diagnosis of major depressive disorder and does not have a diagnosis dementia. MDS D stated Resident #73 should have had a PASSR Level 2 assessment completed due to his diagnosis of major depressive disorder. MDS D stated a negative outcome would be Resident #73 would not receive the proper services he needed. During an interview on 12/19/2025 at 1:20 p.m., the ADM stated it was the MDS Coordinator's responsibility to ensure the PASRR level 1 was completed accurately. The ADM stated that Resident #73 should have received a PASSR Level 2 assessment due to his diagnosis of major depressive disorder. The ADM stated a negative outcome would be Resident #73 would not receive the proper services he needed. Record review of the facility's policy, Preadmission Screening and Resident Review (PASRR) revised 07/18/18 reflected: Health-related Quality of Life Individuals who have or are suspected to have MI, ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the state.Planning of Care The Level II PASRR determination and the evaluation report specify services to be provided by the nursing home and/or specialized services defined by the state. The services to be provided by the nursing home and/or specialized services provided by the State that are specified in the Level II PASRR determination and the evaluation report should be addressed in the plan of care .

Based on interviews , and record review the facility failed to develop a comprehensive person-centered care plan furnishing services to attain, or maintain, the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #6) reviewed for comprehensive care plans. The facility failed to care plan Resident #6's PTSD and/or triggers. This failure could place residents at risk of their needs going unmet. Findings included: Review of Resident #6's comprehensive MDS dated [DATE] reflected a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: high blood pressure, arthritis (painful inflammation and stiffness of the joints), Non-Alzheimer's dementia (memory impairment and challenges in performing daily activities), anxiety (feelings of worry, nervousness, or unease), Post-Traumatic Stress Disorder (mental health condition that arises after experiencing or witnessing and extremely stressful or terrifying event). Resident #6 had a BIMS score of 01, indicating severely impaired cognition. Review of Resident #6's comprehensive care plan dated 11/19/2025 reflected he had not been care planned for his PTSD and identified triggers were not listed. Review of Resident #6's social history assessment dated [DATE] and conducted by the facility SW, reflected a history of PTSD. In section G - Trauma Informed Care, Resident #6 was indicated as having a history of trauma, a diagnosis of PTSD, and triggers that caused emotional distress related to the condition were: loud noises such as banging doors/booming music, alarms. His occupational history reflected that he had been an infantry in the army. In an interview on 12/19/2025 at 12:26 PM with MDS D, she stated that a trauma assessment was something that the SW was responsible for, but the SW was out on leave. The MDS D stated she conducted a Trauma Informed Assessment on 12/17/2025 for Resident #6 after the surveyor brought it to the attention of the facility. She stated that the care plan was a team effort, and she added the triggers to Resident #6's care plan after she conducted the assessment. In an interview on 12/19/2025 at 1:09 PM with the ADM, she stated that the facility used a trauma informed evaluation upon admission, and she expected care plan meetings to be held with families to receive their input about things residents could not vocalize. She stated that sometimes the secured unit would get a little loud, but that she did not change the staff that work back there to help with routine. Review of the facility's policy titled 'Care Plans, Comprehensive Person-Centered' dated 6/02/2025 reflected, The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will: Incorporate identified problem areas; Incorporate risk factors associated with identified problems Review of the facility's policy titled 'Trauma-Informed and Culturally Competent Care' dated 6/17/2025 reflected, Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate.

Based on observations, interviews, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 1 of 6 residents (Resident #32) reviewed for quality of life.The facility failed to ensure Resident #32's nails were cleaned and trimmed.This failure could place residents at risk for poor hygiene, dignity issues, and decreased quality of life Findings included:Record review of Resident #32's admission record, dated 12/19/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #32 had diagnoses which included: Retty syndrome (a rare genetic neurological disorder mostly in girls that cause problems with movement, communication, and often having autistic like behavior and seizure), myopia (eye condition where closer objects appear clear but distant objects look blurry), and conversion disorder with seizure or convulsion (a disorder that affects the way your brain sends, receives and processes messages). Record review of Resident #32's Annual MDS assessment, dated 10/10/2025, reflected Resident #32 had a BIMS score of 00, which indicated severe cognitive impairment. Resident #32 was dependent on staff in the areas of eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene.Record review of Resident #32's care plan, dated 12/19/2025, reflected Resident #32 was care planned for ADL self-care performance deficit r/t Disease Process Rett's syndrome, Scoliosis, other acquitted deformities of right foot, profound ID, and muscle weakness. Resident #32 had intervention of PERSONAL HYGIENE/ORAL CARE: the resident is extensive assist on 1 staff for personal hygiene and oral care. During an observation on 12/16/2025 at 12:13 p.m., Resident #32's fingernails on her left hand were dirty and untrimmed. During an observation on 12/17/2025 at 2:01 p.m.PM, Resident #32's fingernails on her left hand were dirty and untrimmed.Resident #32 could not be interviewed due to her cognitive status.During an interview with CNA B on 12/19/2025 at 12:20 PM, CNA B stated any CNA could provide nail care if the resident was not diabetic. CNA B stated that Resident #32 was not diabetic. CNA B stated nail care was usually provided on the resident's shower days or as needed. CNA B stated Resident 32 shower days were Monday, Wednesday and Friday. CNA B stated if nail care is not provided as needed then the residents would have dirty nails or could possibly get sick from putting their dirty nails in their mouth. During an interview on 12/19/2025 at 12:45 PM, the ADON stated Resident #32 was not diabetic so any CNA could have provided nail care for her. The ADON stated that nail care should be provided as needed and on the resident's shower day. The ADON stated if residents' nails were not cleaned then the residents were at risks of infections. During an interview on 12/19/2025 at 1:20 PM, the ADM stated that CNAs should provide nail care as needed or during the resident's shower day if the resident is not diabetic. The ADM stated if a resident's nail care was not provided then the resident would be at risk for infections or possibly scratch themselves if their nails were not trimmed. The ADM stated her expectation was that resident's nail care be provided as needed or during the resident's shower day. A record review of the facility's Activities of Daily Living (ADL), Supporting policy, revised dated April 2025, reflected Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Policy Interpretation and Implementation 1. Residents are provided with care, treatment, and services to ensure their activities of daily living (ADLs) do not dimmish unless the circumstances of their clinical condition (s) demonstrate diminishing ADLs are unavoidable. 5. Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with consent of the resident, and in accordance with the plan of care, including appropriate support with assistance with: a. hygiene (bathing, dressing, grooming, and oral care) .

Based on observations, interviews, and record review the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 6 residents (Resident #36) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #36 did not leave the facility without nursing staff being aware and he was found by state survey staff in front of a store approximately 100 yards from the facility. 2. The facility failed to follow their elopement policy when informed of a missing resident. These failures placed residents at risk of elopement, falls, or other accidents. Findings included: Review of Resident #36's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: anemia (deficiency of red blood cells), Schizophrenia (mental disorder characterized by hallucinations, delusions, disorganized thinking or behavior), acquired absence of unspecified leg below knee (amputation), and diabetes mellitus (a disease in which the body's ability to produce or respond to insulin is impaired, resulting in abnormal metabolism and elevated glucose levels). His BIMS score was 14, indicating intact cognition. Review of Resident #36's comprehensive care plan dated 12/04/2024 reflected 11/7/2024 I am able to sign myself out and smoke independently outside.Resident refuses to wear a smoke apron during smoking. Resident noted to go to [store] and smoke in the front of the store.He was care planned for being at high risk of falls, refusing labs and immunizations, and being non-complaint with his diet pertaining to his diagnoses of diabetes. Review of resident sign out sheet revealed Resident #36 did not sign himself out on 12/19/2025. In an observation on 12/19/2025 at 8:28 AM, Resident #36 was observed to be maneuvering in a manual wheelchair in a store parking lot located approximately 100 yards to the right of the facility. He parked himself to the left side of the store's front door. In an interview on 12/19/2025 at 8:34 AM with LPN K, he stated that residents were able to go outside, but they were not allowed to leave the premises unless they had signed out. He stated there was a policy regarding residents signing out when they left the facility, and that residents knew they were supposed to sign out if they left the premises. He stated in order to account for the number of residents in the building, staff completed a head count at the beginning of their shift. He stated he did not know if there was a policy on missing residents. In an interview on 12/19/2025 at 8:40 AM with LVN C, she stated that Resident #36 would go in his wheelchair around the facility, smoke outside, and go to the store often. She stated Resident #36 was not in his room at the time of this interview, and Resident #36 had not informed her of his whereabouts. She stated Resident #36 may be somewhere around the facility at the time, or at the store that he frequently visited. In an interview on 12/19/2025 at 8:51 AM with the ADON, she stated that residents were able to go outside but they had to sign out if they left the premises. She stated there was a policy regarding residents signing out if they left the facility. She also stated there may be a policy on missing residents but had to look for it. In an additional interview on 12/19/2025 at 9:23 AM with the ADON, she stated that Resident #36 had returned to the facility, but that he had returned on his own, and staff had not gone to retrieve him. She stated he normally went to the store to smoke and sometimes stayed so long that the store would call the police and file a charge of criminal trespassing to get him to return to the facility. She stated he went to the store all the time and that they had educated him in the past on signing out before he went to the store. She stated there were no additional interventions in place to ensure residents signed out before they left the facility. She stated that 6 residents with high BIMS scores and low wandering risk assessment scores had the facility front door code, and Resident #36 was one of them. In an interview/observation on 12/19/2025 at 9:50 AM with Resident #36, he stated that he was at the store buying smoking materials. He stated that he let himself out of the door with the code and he forgot to sign out because he could not find the binder. He stated the binder was kept at the nurse's station. He was observed to have a manual wheelchair and was hard of hearing, having to turn his head so that his left ear was facing the surveyor. He stated he must get on the side of the road to get to the store. He stated he did not recall being educated by staff on the purpose of using the sign out book. In an interview on 12/19/2025 at 9:57 AM with LVN C, she stated that she went to the store and got Resident #36 to go back to the facility. She stated she started walking around the building and saw Resident #36 at the store. She stated that they had educated him before on signing out before leaving. She stated that he could have fallen, and that he used the side of the road to get to the store. She stated that he usually signed himself out but sometimes forgot. She stated he usually stayed at the store until he decided to go back to the facility. She stated in the past when he did not go back in a reasonable time, she would just lay eyes on him through a facility window and not go get him. In an interview on 12/19/2025 at 1:12 PM with Resident #36's PCP, he stated that Resident #36 went to the store quite often and had some underlying psychiatric issues. The PCP stated that the facility has had discussions with Resident #36, but he was not compliant, such as with drawing labs. He stated there was some concern with Resident #36's checking himself out and causing a [NAME] with the neighboring business's customers. He stated that for Resident #36's safety, he felt that Resident #36 needed to be signing out with his family. Review of the facility's policy titled, Wanderer Management, Monitoring System & Resident Elopement Protocol dated 5/2025 reflected, It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. Missing resident shall be defined as a resident who has left the facility grounds without signing him/herself out.F. Procedure for Missing residents/ Elopement:I. If a resident is noted to be missing, the following must be initiated immediately: Notify the Administrator/designee immediately. Perform a complete search of the interior of the building. This should include every room, including bathrooms, break rooms, storage rooms, closets, etc. Initiate an external search outside of the building, including the facility grounds and community, on foot and by vehicle.

Based on observation, interview, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for the residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 (Resident #6) of 6 residents reviewed for trauma-informed care. The facility failed to ensure Resident #6 had a trauma assessment completed upon admission to the facility that identified possible triggers when Resident #6 admitted with a diagnosis of PTSD. This failure could place residents at an increased risk of psychological distress due to re-traumatization. Findings included: Record review of Resident #6's comprehensive MDS, dated [DATE], reflected a [AGE] year-old male admitted on [DATE] with the following diagnoses: high blood pressure, arthritis (painful inflammation and stiffness of the joints), Non-Alzheimer's dementia (memory impairment and challenges in performing daily activities), anxiety (feelings of worry, nervousness, or unease), Post-Traumatic Stress Disorder (mental health condition that arises after experiencing or witnessing and extremely stressful or terrifying event). Resident #6 had a BIMS score of 01, indicating severely impaired cognition. Record review of Resident #6's comprehensive care plan, dated 11/19/2025, reflected he was not care planned for PTSD and identified triggers were not listed. Record review of Resident #6's social history assessment, dated 10/21/2025 and conducted by the facility SW, reflected a history of PTSD. In section G - Trauma Informed Care, Resident #6 was indicated as having a history of trauma, a diagnosis of PTSD, and triggers that caused emotional distress related to the condition were: loud noises such as banging doors/booming music, alarms. His occupational history reflected that he had been an infantry (ground combat/to fight on foot) in the army. In an observation on 12/16/2025 at 10:29 AM, Resident #6 was observed standing in the secured unit hallway, when the surveyor attempted to interview him, he just stared blankly and did not answer questions. He was determined to be non-interviewable due to cognitive impairments. In an interview on 12/19/2025 at 12:26 p.m. MDS D, stated a trauma assessment was something the SW was responsible for, but the SW was not at work. MDS D stated she conducted a Trauma Informed Assessment on 12/17/2025 for Resident #6 after the surveyor brought it to the attention of the facility. She stated the care plan was a team effort, and MDS D added the triggers to Resident #6's care plan after MDS D conducted the assessment. She stated triggers were important to document to help residents feel safe. In an interview on 12/19/2025 at 1:09 p.m., the ADM stated the facility used a trauma informed evaluation upon admission, and she expected care plan meetings to be held with families to receive their input about things residents could not vocalize. She stated that sometimes the secured unit was a little loud, but she did not change the staff that worked there to help with routine. Review of the facility's policy titled 'Trauma-Informed and Culturally Competent Care' dated 6/17/2025 reflected, Organizational Strategies3. Select screening and assessment tools in collaboration with the QAPI Committee. (See Trauma-Informed Care Screening and Assessment Toolkit for further resources)Resident Screening1. Perform universal screening of residents, which includes a brief, non-specialized identification of possible exposure to traumatic events.2. Utilize screening tools and methods that are facility-approved, competently delivered, culturally relevant and sensitive.Resident Assessment1. Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers.2. Utilize licensed and trained clinicians who have been designated by the facility to conduct trauma assessments.Resident Care PlanningDevelop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate.

Based on observation, interview and record review, the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 6 residents (Resident #13) whose records were reviewed for behavioral health services. The facility failed to provide psychological services for Resident #13 to treat her symptoms of depression noted by her recent behaviors and MDS assessment. This deficient practice could place residents with documented signs of depression at risk of increased decline in the psychosocial well-being and diminished quality of life. Findings included. Review of Resident #13's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included chronic kidney disease stage 5, muscle weakness, low thyroid hormone, and insomnia. Resident #13 was coded as being dependent on staff for shower/bathing. Resident #13 had a BIMS score of 12, which indicated moderate cognitive impairment. The MDS indicated Resident #13 was feeling down, depressed, or hopeless 7-11 days out of 14 within the last 2 weeks. Review of Resident #13's comprehensive care plan dated 09/26/25 revealed Resident #13 had chronic renal failure related tokidney disease stage 5, interventions included Monitor/document/report as needed any signs or symptoms of depression. Obtain order for mental health consult if needed. Record review of Resident #13's Physicians Order Summary Report reflected she was not on any medications to assist with depression symptoms and had no order for any counselling or psychiatric services. Record review of Progress notes dated 12/13/25 reflected Resident returned from dialysis after leaving AMA. Dialysis facility verbalized she was emotionally upset signed by LVN P. In an attempted interview and observation on 12/17/2025 11:44 a.m. Resident #13 was sitting up in her wheelchair in her room with her head looking down and declining to engage with surveyor. In an interview on 12/19/2025 at 1:24 pm LVN O stated she did feel like Resident #13 was depressed but had not been evaluated for psychiatric services. She stated she would notify the DON and primary doctor if a resident may need behavioral health services. LVN O stated the doctor was aware of Resident #13 behaviors of frequently refusing care. She stated the nurses are responsible for making the DON aware of need for services. She stated the importance of providing services was so residents could cope with ongoing medical issues', LVN O stated she had not notified the DON of her concerns for Resident #13's depression. In an interview on 12/19/25 at 1:30 p.m. ADON L stated the DON sets up mental health services for residents showing symptoms of depression. She stated the nurses would report to the doctor if there were some types of depression symptoms and obtain an order for psychiatric services or counselling. ADON L stated she was not sure if the facility provided counselling services, she thinks there is someone who does come but was not sure if they are counselling services or what they do. She stated the negative effects of not providing some sort of psych services could be decreased quality of life, and increased depression. Record review of facility policy dated 06/02/2025 titled Behavioral Health Services reflected: The facility will provide necessary behavioral health care and services which include: Ensuring that the necessary care and services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety that meets the needs of residents with mental disorders, substance use disorders, a history of past trauma, and other behavioral health needs and Provide care, in accordance with the individualized care plan.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services in that: The facility's dietary staff failed to discard an outdated item in the walk-in freezer. This failure could place residents at risk for food contamination and foodborne illness.The findings include:During a tour of the kitchen on 12/16/2025 at 09:00 AM the following was observed:The freezer contained an item labeled Tulip Greens with Butter in a clear plastic bag with a use by date of 11/10/2025.During an interview with DM on 12/18/2025 at 1:10 PM, DM stated that the cooks were responsible for ensuring that items were discarded by the used by date. DM stated that the item labeled Tulip Greens with Butter should have been used by or discarded by the 11/10/2025 as dated on the bag. DM stated that if an item was not used by or discarded by the used by date then that item could get cause residents to get sick. DM stated her expectation was for all items to be used or discarded by their used by date.During an interview with the [NAME] on 12/18/2025 at 1:15 PM, the [NAME] stated all kitchen staff were responsible for discarding items if their used by day had passed. The [NAME] stated that if an item's used by date had passed and the item was served, the resident could get sick. During an interview with the ADM on 12/19/2025 at 1:20 PM, the ADM stated all items passed the used by date should be thrown away immediately. The ADM stated that the kitchen staff should monitor the refrigerator and freezer daily for items that are outdated. The ADM stated that outdated items could cause residents to get sick if served. Record review of the facility's Food Receiving and Storage policy, revised dated 06/23/25, reflected:Policy StatementFoods shall be received and stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date).

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 of 6 residents reviewed for infection control (Resident #5, and Resident #70). 1) LVN C did not wash her hands when removing soiled gloves, prior to applying clean gloves on 12/17/2025 at 10:01 a.m. for Resident #5's wound care observation. 2) CNA M and CNA N failed to clean their hands prior to the start of and after changing gloves when moving from a dirty to clean site while performing peri care for Resident #70 on 12/17/2025 at 11:04 a.m. This failure could place residents at risk for cross contamination and the spread of infection. Findings included: 1. Record review of Resident #5's care plan, dated 10/21/2024, reflected, Resident #5 had a pressure area to mycoccyx related to immobility and I (Resident #5) have actual impairment to my skin integrity on the right outer ankle. Interventions included: Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration to medical doctor. Record review of Resident #5's Quarterly MDS, dated [DATE], reflected an admission date of 04/11/2023 with diagnoses of peripheral vascular disease (a circulation problem blocking blood flow to the lower extremities), hypertension (elevated blood pressure), and diabetes mellitus (elevated blood sugar). Resident #5 had a BIMS score of 12 indicating moderate cognitive impairment. Resident #5 required a wheelchair for mobility, substantial/maximal assistance for personal hygiene and was dependent for lower body dressing. The MDS reflected Resident #5 had one or more unhealed pressure ulcers and required an application of nonsurgical wound dressings (other than the feet) and an application of a wound dressing to the feet. Record review of Resident #5's Physicians Order Summary, dated 12/18/2025, reflected an order to cleanse wound to coccyx with wound cleanser, pat dry, spray with skin prep, apply collagen to the wound bed, cover and secure with bordered dressing everyMonday, Wednesday, and Friday and cleanse wound to right outer ankle with wound cleanser, pat dry, cover with collagen dressing (a type of wound dressing applied to promote cell growth and healing) to wound bed and secure with bordered gauze dressing every Monday, Wednesday and Friday. In an interview and observation on 12/17/2025 at 10:01 a.m. Resident #5 was lying in bed alert and stated he was feeling ok. He denied any pain. LVN C removed soiled dressing from coccyx (buttocks) and discarded it, removed her soiled gloves and applied clean gloves failing to cleanse hand prior to the application of clean gloves. LVN C proceeded with finishing wound care and covered Resident #5 up giving him his call light. In an interview on 12/17/2025 at 10:30 a.m., LVN C stated she was educated on infection control. LVN C stated she had forgotten to wash her hands in between glove changes. LVN C stated the risk or negative impact for not washing hands between clean and dirty was spreading germs and infection. 2. Record review of Resident #70's Quarterly MDS, dated [DATE], reflected an admission date of 05/22/2023 with diagnoses of hypertension (elevated blood pressure), diabetes mellitus (elevated blood sugar) and non-Alzheimer's dementia (impaired memory and cognition effecting daily routine). Resident #70 had a BIMS score of 3 indicating severe cognitive impairment. Resident #70 required a wheelchair for mobility, had upper and lower body mobility impairment, and was dependent on staff for personal hygiene. The MDS reflected Resident #70 was always incontinent of bowel and bladder. In an observation and interview on 12/17/2025 at 11:04 a.m. Resident #70 was lying in bed and gave permission for peri care. CNA M and CNA N proceeded to prepare to provide peri care to Resident #70. CNA M and CNA N did not wash or clean hands with Alcohol based hand sanitizer prior to applying gloves and starting peri care. They proceeded with care and removed soiled brief from Resident #70. CNA M and CNA N changed their gloves and did not wash their hands between changing of gloves. They both completed peri care for Resident #70, disposed of soiled brief, and washed their hands with soap and water. In an interview on 12/17/2025 at 11:44 a.m., CNA M and CNA N stated they forgot to change gloves and wash their hands or use alcohol-based hand sanitizer when changing their gloves. They stated generally it was routine for them to clean their hands between gloving and prior to the start of resident care. They stated they were nervous and forgot. They stated they were trained on infection control by the ADON. They stated not washing their hands could spread germs causing infections. In an interview on 12/19/25 at 1:30 p.m., ADON L stated it was her expectation that hand sanitizer was used in-between gloving, going from dirty to clean gloves. ADON L stated the staff were educated on infection control. ADON L stated the nursing administrative staff completed in-services and monitored infection control practices throughout the facility by making frequent nursing rounds and checking on the residents. ADON L stated there was not one administrative nurse specifically responsible for education, Record review of facility policy titled Handwashing-Hand Hygiene Policy and Procedures, dated March 2020 and revised October 2020, reflected hand hygiene was indicated before handling clean or soiled dressings/gauze pads, moving from work on a soiled body site to a clean body site on the same resident and after glove removal.

Based on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 5 (Resident #1) residents reviewed for quality of care.The facility failed to activate 911 emergency services response on 06/13/2025 for Resident #1 when he had a choking episode while eating resulting in his death. An IJ (Immediate Jeopardy) was identified on 07/08/2025. The IJ template was provided to the facility on [DATE] at 5:12 PM. While the IJ was removed on 07/10/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This failure could place residents at risk of physical harm, pain, mental anguish, or death. Findings included:Record review of Resident #1s clinical resident profile reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis of diabetes type 2 (elevated blood sugar), vascular dementia (difficulty thinking and processing thoughts), major depressive disorder, and anxiety.Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS of 11, which indicating mild cognitive impairment. It also indicated Resident #1 did not have any swallowing disorders such as holding food in his mouth, coughing, or choking during meals or difficulty or pain with swallowing. Record review of Resident #1's care plan dated 01/17/2024 reflected: Receives Therapeutic and Mechanically soft Diet, Resident has decreased appetite with poor meal intake at times. Interventions included: Assist resident with meals as needed. Set up meal tray, open beverages, cut foods, provide assistance as needed.Record review of Resident #1's progress notes dated 06/13/2025 reflected At approximately 1720, CNA heard calling out for help. This nurse entered Dining room and noted resident gasping and coughing. CNA stated that resident was eating dinner and began choking on his food. Noted mech soft dinner tray in front of resident, consistent with resident's diet orders. This nurse assessed Resident's mouth and noted food in airway. Finger sweep attempted while visualizing food without success. This nurse started abdominal thrusts and sent CNA to alert another nurse for additional assistance. LVN B arrived, and this nurse and attempted abdominal thrusts several more times without success. Resident's respirations ceased and pulse was unobtainable. Code status confirmed as DNR. No signs of life noted. Notified PCP, RP, and DON. Signed by LVN [NAME] an interview on 07/08/2025 at 1:00 pm, The VA Nurse stated she reviewed the incident at her monthly visit to monitor the VA contract residents that reside at the nursing facility. She asked the facility DON why 911 was not notified. She stated the DON stated that the facility was honoring the residents DNR wishes. She stated that the facilities failure to activate emergency services by calling 911 during the choking episode was a reportable incident. The VA nurse stated that Resident #1 having a DNR on file did not mean that the facility should not treat him if he was choking. The facility stated they followed their policy they did not call 911 because the resident did not lose consciousness until the very end of the choking episode and at that time he had no pulse. She stated the ADM and DON told her it was not reportable because they were aware of the incident, and it was not under suspicious circumstances that followed their policy. In an interview on 07/08/2025 at 1:46 pm, LVN A stated on 6/13/25 she was passing the dinner trays out to the residents on the secure unit when the CNA working with her started yelling for help. Resident #1 was choking so she did a mouth sweep and a visual check on his mouth. LVN A stated Resident #1 continued to choke so she began chest thrust and was unsuccessful. She sent the CNA to get assistance and 2 more LVNs came to attempt the chest thrust. The Choking episode all happened so quickly no one initiated a 911 call. She stated the resident went limp and no longer was breathing. LVN A stated the nurses checked his code status, and it as DNR. They called their supervisor who told them to honor the DNR. LVN A stated an RN later came and pronounced the resident's time of death at the facility. LVN A stated their policy stated if the resident was a DNR, they did not have to call 911. Normally if choking were to happen, they would call 911, but staff were trying to get his airway clear. The DON showed the policy to staff that stated if a resident actively passes during emergency treatment, and they had a DNR, the nurse did not have call 911 emergency services. LVN A stated negative effects for not having 911 emergency services dispatched during an emergency such as choking could be that the resident could die. In an interview on 07/08/2025 at 1:57 pm, LVN B stated he was called to the secure unit with a suction machine and responded to Resident #1's choking. He took the suction machine to the secure unit and began assisting with the Heimlich maneuver. LVN B stated he was doing the chest thrust, so he was not aware of anyone calling 911. Anyone who was present during an emergency, could dial 911 for emergency response. LVN B stated negative effects of not activating 911/an emergency response for resident during a choking episode, could be death.In an interview on 07/08/2025 at 2:03 pm, LVN C stated she was notified by another nurse to get a suction machine and come to the secure unit. They set up the suction machine and attempted chest thrust on Resident #1. LVN C stated she was not aware of anyone calling 911. Resident #1 did not lose consciousness until the very end before he passed away. LVN C stated it was the first time she had encountered a resident choking. LVN C stated the negative effects to a resident for not calling 911 in an emergency response, depended on the situation. If it were something the staff could take care of within the facility, they would not call 911. LVN C stated the facility was honoring the resident's wishes with his DNR.In an interview on 07/08/2025 at 2:21 pm, the DON stated it was her expectation that when a resident was choking, the staff should have assessed the resident, visualized the oral cavity, removed the object if they are able, and started the Heimlich. The DON stated staff should have activated 91l. She stated Resident #1 was a DNR, so they did not proceed with any other intervention after he became unresponsive. She had not educated staff on the choking policy in writing; it was verbalized only when they discussed the event. The DON stated the negative effects for not issuing a 911 emergency response when a resident was choking was that the patient could die.In an interview on 07/08/2025 at 2:26, The ADM stated if a resident was choking, she expected the staff to follow choking guidelines. This included calling 911. DNR did not mean do not treat. The ADM stated she addressed the issue in an in service on 6/18/2025 at an all-staff meeting.In an interview on 07/08/2025 at 3:00 PM, the Medical Director stated the facility should have activated 911 emergency services response when Resident #1 was choking, and nurses were unable to clear the airway. He stated just because there was a DNR, did not mean not to treat the resident. Resident #1 was a fast eater and did have a diagnosis of dysphagia. the Medical Director stated the negative effects for a resident for not initiating 911 in an emergency such as choking could be death.Record review of the facility's policy Titled Policy for Choking / Foreign Body Obstructing Airway dated August 2021 and updated 6/18/2025 reflected: 1. Stand behind the resident.2. Wrap your arms around the resident's waist.3. Make a fist with one hand.4. Place the thumb side of your fist against the resident's upper mid-abdomen, below the ribcage and above the navel.5. Grasp your clenched fist with your other hand.6. Press your fist into the resident's upper abdomen with a quick upward thrust.7. Do not squeeze the ribcage. Contain the force of the thrust to your hands.8. Repeat the thrusts until the foreign body is expelled or the resident loses consciousness.9. If the airway is cleared immediately, report to nursing administration, resident's Physician for follow up as needed.10. If the airway does not clear immediately, and the resident becomes unresponsive, activate medical emergency response (ex. Code blue, call 91 1) and continue to attempt to the airway of the unresponsive resident.11. If at any time the resident is assessed to have no pulse and no respirations, follow goals of the resident's code status to determine if CPR should be initiated.12. Continue CPR if indicated until Emergency Personnel assume care of resident.13. Complete incident report and notification of responsible party & MAn Immediate Jeopardy was identified on 07/08/2025 at 5:12 PM. and an IJ template was provided to the ADM and DON. A plan of removal was requested at that time.The following Plan of Removal, submitted by the facility, was accepted on 07/10/2025 at 12:58 PM. On 7/8/2025 an abbreviated survey was initiated at center. On 7/8/2025 the surveyor provided Immediate Jeopardy (IJ template provided) that the regulatory services have determined that the conditions at the facility constitute an immediate threat to residents' health and safety. Notification of Immediate Jeopardy states as follows Tag F689 based on observation interview and record review failed to provide adequate supervision and devices to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents and supervision. The facility failed to ensure Resident #1 received 911 emergency services during a choking episode on 6/13/2025 at 5:20 PM. The resident expired at the facility. 1. Corrective Action Taken:On July 8, 2025, Corporate Clinical Specialist in serviced Administrator and ADON on facility's emergency response policy, including the requirement to call 911 during a choking incident regardless of DNR status. Competency verified by quiz, requiring 100% to pass.On July 8, 2025, Administrator and DON conducted a facility-wide in-service training regarding facility's emergency response policy, including the requirement to call 911 during a choking incident regardless of DNR status. Competency verified by quiz, requiring 100% to pass. No staff will be able to work until in-servicing and competency completed. This will be conducted to all staff and monitored by Administrator. Evidence will be kept in a binder in the administrator's office. On July 9, 2025, Corporate Clinical Specialist, in-serviced DON and ADON regarding proper performance of abdominal thrust or other measures during a choking incident. Competency verified by return demonstration and documented on the skills check off. This will be monitored by the Administrator. Evidence will be kept in a binder in the administrator's office. On July 9, 2025, DON and ADON in-serviced nursing staff regarding proper performance of abdominal thrust or other measures during a choking incident. Competency verified by return demonstration and documented on the skills check off. This will be monitored by the Administrator. Evidence will be kept in a binder in the administrator's office. 2. Identification of Other Residents: A review of all current residents with DNR orders was completed on July 8, 2025, to ensure that advanced directives are clearly documented in the medical record. Completed by CCS and ADON.No other residents were found to be at immediate risk.A review of all current residents with swallowing difficulties was completed on July 9, 2025, to ensure that care plans are clearly documented in the medical record. This review was conducted by the CCS and Director of Nursing (DON) No issues identified they were immediately corrected on 7/9/2025. 3. Systemic Changes: The facility's choking and emergency response policy was revised on 7/9/2025 by Regional Director of Operations in consultation with Corporate Nurse. The statement Repeat thrust until the foreign body is expelled or the resident loses consciousness was revised to Repeat the thrust until the foreign body is expelled. The statement if the airway does not clear immediately, and the resident becomes unresponsive, activate medical emergency response (ex. Code blue, call 911) and continue to attempt to clear the airway of the unresponsive resident was removed. The new revisions states that If the airway does not clear immediately activate medical emergency response and continue to attempt to clear the airway. On July 8, 2025, the Administrator and Director of Nursing conducted a facility-wide in-service training on the facility's emergency response policy. Staff were educated that during any choking incident, 911 must be called immediately once the Heimlich maneuver is initiated, regardless of the resident's DNR status. Competency was verified through a mandatory quiz, with a required passing score of 100%. No employee will be permitted to work until both the in-service and competency have been successfully completed. This training will be provided to all staff and overseen by the Administrator. Documentation of completion and competency will be maintained in a binder located in the Administrator's office.All new hires will receive mandatory training by the DON, or designee, on emergency response protocols related to choking, incidents, and emergency responses during orientation. These drills will consist of Mock Drills with different choking-based scenarios.A competency quiz has been implemented to assess staff understanding of emergency procedures quarterly, requiring 100% to pass.CCS and DON are auditing diets to ensure correct completed 7/9/2025. 4. Monitoring and Quality Assurance: The Corporate Clinical Specialist educated the DON and ADON regarding emergency protocols and response.The Director of Nursing (DON) or designee will conduct random audits of staff knowledge and response by conducting medical emergency drills (i.e., choking episode) weekly for 8 weeks, then monthly for 4 months. Results of audits will be reviewed in the facility's Quality Assurance and Performance Improvement (QAPI) meetings.Any deficiencies will result in immediate re-education.Medical Director notified 7/9/2025, and reviewed Plan of Removal and approved. 5. Responsible Party: The Administrator and Director of Nursing are responsible for implementing and monitoring this Plan of Correction. 6. Completion Date: All corrective actions will be completed by July 9, 2025.On 07/10/2025 the Surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:1. Record review of in-service education dated 07/08/2025 for the ADM, DON, ADON and all staff reflected they had been educated over the policy on choking/relief of foreign body obstructing the airway. Verified with 4 signatures. Education provided on always calling 911 in an emergency no matter what the DNR status of the resident is. Understanding was verified by receiving 100% on post education quiz. Verified with 73 signatures.2. Record review of an audit dated 07/08/2025 reflected all residents with DNR orders to ensure that advanced directives were clearly documented in the medical record had been completed. Record review of an audit dated 07/08/2025 reflected A review of all current residents with swallowing difficulties was completed on July 9, 2025, to ensure that care plans are clearly documented in the medical record. This review was verified by an audit of 5 random residents medical records. The medical records reflected DNR / advanced directives were clearly documented and diet orders were correct. Medical record review of care plans reflected that resident with swallowing difficulties had interventions within the care plan. 3. Record review the facility's Choking and Emergency Response Policy was revised on 7/9/2025 by Regional Director of Operations in consultation with Corporate Nurse and again on 07/10/2025. The statement Repeat thrust until the foreign body is expelled or the resident loses consciousness was revised to Repeat the thrust until the foreign body is expelled. The statement if the airway does not clear immediately, and the resident becomes unresponsive, activate medical emergency response (ex. Code blue, call 911) and continue to attempt to clear the airway of the unresponsive resident was removed. The new revisions states that If the airway does not clear immediately activate medical emergency response and continue to attempt to clear the airway. On July 10, 2025, the Administrator and Director of Nursing conducted a facility-wide in-service training on the facility's emergency response policy. To clarify the policy revision, the facility contacted each employee and instructed them on the policy revision. Verified through sign-in sheet with 73 signatures and DON and ADM interview. 4. Record review of QAPI meeting held on 07/08/25 at 5:15pm revealed the meeting was attended by the Medical Director, Administrator, and DON.Interviews conducted on 07/10/2025 between 1:45 pm - 2:45 pm CNA C, CNA D, CNA E, CNA F, CNA G, MA H, CNA I, CNA J, Social Worker, LVN K, CNA L, LVN M, LVN N, LNV O, RN P, Business Office Manager, Activities Director, Activities assistant Director, Housekeeper, Dietary cook, Dietary Manager, and Laundry Supervisor, revealed that all verbalized if a resident were to have a choking episode, 911 emergency response should be activated. They stated that any staff member could dial 911. They stated they did not wait for a resident to become unconscious prior to calling 911. They stated 911 should be activated immediately if chocking was not cleared with coughing. They were able to demonstrate the chest thrust to dislodge objects obstructing the airway. The staff stated DNR did not mean do not treat. On 07/10/2025 at 3:04 pm, the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a level of no actual harm with the potential for more than minimal harm with a scope identified as isolated due to the facility's need to monitor the implementation and effectiveness of its POR.

Based on interviews, and record review the facility failed to ensure all alleged violations involving neglect were reported to the State Survey Agency in a timely manner for 1 of 5 (Resident #) residents reviewed for abuse and neglect. The facility failed to report an incident to the state survey agency when Resident #1 had a choking episode while eating, resulting in death, after staff failed to activate 911 emergency response on 06/13/2025. The failure could place residents at risk of physical harm, pain, mental anguish, or death. Findings included:Record review of Resident #1's clinical resident profile reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of diabetes type 2 (elevated blood sugar), vascular dementia (difficulty thinking and processing thoughts), major depressive disorder, and anxiety.Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS of 11, which indicating mild cognitive impairment. It also indicated Resident #1 did not have any swallowing disorders such as holding food in his mouth, coughing, or choking during meals or difficulty or pain with swallowing. Record review of Resident #1's care plan dated 01/17/2024 reflected: Receives Therapeutic and Mechanically soft Diet, Resident has decreased appetite with poor meal intake at times. Interventions included: Assist resident with meals as needed. Set up meal tray, open beverages, cut foods, provide assistance as needed.Record review of Resident #1's progress notes dated 06/13/2025 reflected At approximately 5:20, PM CNA heard calling out for help. This nurse entered Dining room and noted resident gasping and coughing. CNA stated that resident was eating dinner and began choking on his food. Noted mech soft dinner tray in front of resident, consistent with resident's diet orders. This nurse assessed Resident's mouth and noted food in airway. Finger sweep attempted while visualizing food without success. This nurse started abdominal thrusts and sent CNA to alert another nurse for additional assistance. LVN B arrived, and this nurse and attempted abdominal thrusts several more times without success. Resident's respirations ceased and pulse was unobtainable. Code status confirmed as DNR. No signs of life noted. Notified PCP, RP, and DON. Signed by LVN A In an interview on 07/08/2025 at 1:00 pm, the VA Nurse stated she reviewed the incident at her monthly visit to monitor the VA contract residents that reside at the nursing facility. She stated she asked the facility DON why 911 was not notified. She stated the DON stated that the facility was honoring the residents DNR wishes. She stated that the facility's failure to activate emergency services by calling 911 during the choking episode, was a reportable incident. The VA nurse stated that Resident #1 having a DNR on file did not mean that the facility should not treat him if he was choking. She stated the ADM and DON told her it was not reportable because they were aware of the incident, and it was not under suspicious circumstances that followed their policy. In an interview on 07/09/2025 at 3:15 pm, the DON stated she was the back up for reporting significant events to state when the ADM was out of the building. She stated the incident involving Resident #1 was not reported because it was not suspicious. She stated they knew exactly what happened. She stated she did not think it was neglectful that 911 was not called because it would not have changed the outcome. In an interview on 07/09/2025 at 3:47 pm, the ADM stated she was responsible for reporting incidents to the state if needed. She stated the incident involving Resident #1's death was not reportable because the facility knew the situation, there was no abuse or neglect, and they followed policy. She stated she did not know how to answer if not calling 911 was neglectful. Record review of the facility's policy titled Abuse Prohibition Policy reviewed 06/02/2025 reflected: The facility will report all allegations and substantiated occurrences of abuse, neglect or misappropriation of resident property to the state agency and to all other agencies as required by law and will take all necessary corrective actions depending on the results of the investigation. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury immediately or within two hours of the allegation. 'The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries of unknown source and misappropriation within 24 hours of the allegation.Record review of the facility's policy titled Resident Incident and Visitor Accident Report reviewed 10/08/2020, [DATE] and June 2024 reflected: The facility will conduct an investigation of all incidents involving residents of the facility. The facility will conduct an investigation of all non-resident accidents that occur on the property of the facility. The investigation will be conducted by designated personnel and reported to the Administrator/designee. Incidents/Accidents of Unknown Origin will be reported in accordance with state and federal regulations.

Based on observation, interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of six residents (Resident #1) reviewed for abuse. The facility failed to protect Resident #1 from abuse when CNA A placed her hand over Resident #1's mouth to keep her from talking while she provided care to the resident. This failure could place residents at risk of experiencing and enduring abuse by facility staff causing a decreased quality of life. Findings include: Record review of Resident # 1's face sheet dated, 10/21/2024, reflected a [AGE] year-old female with an admitted [DATE] . Resident # 1 had diagnoses of unspecified dementia( memory loss), Alzheimer's(memory loss), cognitive communication deficit(difficult paying attention to conversation), and major depressive disorder(loss of interest in activities). Record review of Resident # 1's admission care plan, dated 09/23/2024, reflected Resident #1 had impaired thought process r/t to dementia. Interventions to identify yourself at each interaction, face the resident when speaking , and make eye contact. Record review of Resident # 1's admission MDS, dated [DATE] reflected a BIMS score of 3, which indicated cognitive impairment. Record review of the facility's incident report, dated 10/03/2024 and 10/04/2024, did not reflect any report of the incident in PCC. Record review of - progress notes, dated 10/03/2024 and 10/04/2024 did not reflect any documentation of the abuse. Record review of Resident #1's assessments did not reflect any head-to-toe documentation on 10/03/2024 and 10/04/2024. Record review of Resident's 2's face sheet, dated 10/21/2024 reflected a [AGE] year-old female with an admitted [DATE]. Resident #2 had diagnoses which included heart failure(heart does not pump well as it should), hypertension(force against artery walls to high), and diabetes(too much sugar in the blood) Record Review of Resident's 2's admission MDS, dated [DATE], reflected a BIMS score of 13,which indicated cognition was intact. Observation of Resident #1 on 10/21/2024 at 1:20 PM revealed the resident was laying in the bed with her two dolls. Resident # 1 was unable to tell anything about the incident or if anything had happened to her with CNA A. Unable to interview Resident #2 on 10/21/2024 due to her passing away after the incident. Unable to interview the ADM due to her being out of the country on vacation. Attempted phone interview with CNA A on 10/21/2024 at 1:30 PM was unsuccessful. Left a voice message for her to return call with no response. Attempted interview with Resident #1's RP on 10/21/2024 at 1:38 PM was unsuccessful. Unable to leave a voice message. In an interview on 10/21/2024 at 11:45 AM with the DON revealed Resident # 2 made a report to CNA C on 10/03/2024 around 10:00 PM that CNA A had placed her hands around Resident #1's mouth to prevent her from talking while she was providing care to her. The DON stated Resident # 2 had a BIMS of 13 and was cognitively intact. The DON stated she was contacted right after the report was made to CNA C and immediately, she contacted CNA A by phone to let her know she was suspended pending the outcome of the investigation. Once the investigation was confirmed shortly after , CNA A was contacted by phone and advised she was terminated. The DON stated what CNA A did was abuse and abuse was not tolerated. The DON stated that abuse could lead to injuries to residents. In an interview on 10/21/2024 at 4:00 PM with LVN B revealed CNA C reported to her a little after 10:00 PM on 10/03/2024 what Resident # 2 reported to her that CNA A placed her hand over Resident # 1's mouth while providing care. LVN B stated she spoke with Resident # 2, and she told her the incident happened on the 2:00 PM- 10:00 PM shift but the time was not recalled. Resident # 2 told her she did not really want to tell CNA C or her, in fear of being retaliated against. Resident #2 told her when CNA A came in the room to assist Resident # 1, CNA A told Resident # 1 not to talk to her anymore and CNA A placed her hand over Resident #1's mouth to keep her from talking. LVN B stated she immediately contacted the ADM and assessed Resident #1. LVN B stated there was no actual harm and Resident # 1 did not remember anything about the incident. In an interview on 10/21/2024 at 5:48 PM with CNA C revealed she went to assist Resident # 2 with care around 10:00 PM on 10/03/2024. Resident # 2 asked her if she could tell he a secret and told her CNA A was assisting with care earlier for Resident # 1 and had placed her hand over her mouth to shut her up because she was talking to her. CNA A told Resident # 1 not to talk to her anymore. CNA C stated she immediately reported to LVN B and LVN B spoke with Resident # 1 and assessed her for harm. CNA C stated LVN B assessed Resident # 1 and there was no harm. Record review of the facility's policy titled abuse prohibition dated 01/01/2024 and reviewed 05/17/2024 reflected This protocol was intended to assist in the prevention of abuse, neglect, and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse.

Based on interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were complete and accurately documented for one of six residents (Resident #1) reviewed for accurate medical records. The facility failed to ensure Resident #1's medical chart contained incident reports, assessments , and nursing progress notes of an incident dated 10/03/2024 or 10/04/2024. This deficient practice could place residents at risks of errors in care and treatment. Findings include: Record review of Resident # 1's face sheet dated 10/21/2024 reflected a [AGE] year-old female with an admitted [DATE] . Resident # 1 had diagnoses of which included unspecified dementia( memory loss), Alzheimer's(memory loss), cognitive communication deficit(difficult paying attention to conversation), and major depressive disorder(loss of interest in activities). Record review of Resident # 1's admission care plan dated 09/23/2024, reflected Resident #1 had impaired thought process r/t to dementia. Interventions to identify yourself at each interaction, face the resident when speaking , and make eye contact. Record review of Resident # 1's admission MDS, dated [DATE] reflected a BIMS score 3, which indicated cognitive. impairment. Record review of the facility incident report, dated 10/03/2024 and 10/04/2024 did not reflect any report of the incident in PCC. Record review of - progress notes, dated 10/03/2024 and 10/04/2024 did not reflect any documentation of the incident. Record review of assessments did not reflect any head-to-toe assessment documentation on 10/03/2024 and 10/04/2024. In an interview on 10/21/2024 at 4:00 PM with LVN B stated once she assessed Resident # 1, she documented the assessment , entered the notes, and the incident report right after assessing Resident # 1. LVN B stated she did not know what happened and why there was no documentation in the system when she placed it in there. LVN B stated incident reports and documentation was entered immediately. LVN B stated she was responsible for the documentation to be entered and was not sure what happened or why it was not in the system. LVN B stated documentation was important for communicating resident's care among staff. In an interview on 10/21/2024 at 5:28 PM with the DON revealed she checked for documentation on 10/3/2024 and 10/04/2024 and there was not any for either day. The DON stated once the incident was reported it was expected to be documented at least by the end of the shift. The DON stated documentation was important because if there was no documentation noted it meant that it did not happen. Record review of the facility policy titled charting and documentation, dated revised 07/2017, reflected 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 the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

Based on observation, interview, and record review, the facility failed to ensure personnel provided basic life support, which included CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 5 residents (Resident #82) reviewed for cardio-pulmonary resuscitation. LVN B failed to initiate CPR when she found Resident #82, who was full code status, unresponsive and not breathing. Resident #82 was declared deceased . An Immediate Jeopardy (IJ) situation was identified on [DATE] at 4:42 PM. While the IJ was removed on [DATE] at 12:57 PM, the facility remained out of compliance at a scope of isolated identified as no actual harm with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of death from not receiving life-saving measures if needed. Findings included: Record review of Resident #82's Admission Record dated [DATE] revealed she was an [AGE] year-old female admitted to the facility on [DATE]. The area of the document under the title Advanced Directives was blank. Record review of Resident #82's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 12 indicating she had moderately impaired cognition. She required supervision during eating, maximum assistance for toileting and bathing, and was totally dependent on staff for bed to chair transfers. Her diagnoses included dementia with agitation (loss of memory or other thinking abilities that interferes with daily life); cognitive communication deficit (difficulty with communication caused by disruption in cognition); anemia (lack of red blood cells needed to carry oxygen throughout the body); hypertension (high blood pressure), anxiety disorder and depression. Record review of Resident #82's care plan reflected the following entry dated initiated [DATE], I and/or responsible party have been provided the information explaining the Advanced Directive process and following the education have decided that I am a FULL CODE .Goal: My Full Code will be honored by my family and staff .Interventions/Tasks: My family and staff are aware of my FULL CODE status .Review my Advanced Directive options and Resident Rights quarterly and PRN with me and my family . An entry initiated [DATE] reflected the following: admitted to [hospice company name] Hospice for dx of Dementia .Goal: I will have all needs met, over the next 90 days .Interventions/Tasks: Staff will monitor and report any changes to RP, hospice and physician . Record review of Resident #82's Order Recap Report dated [DATE] reflected the following orders: Full code status with a start date of [DATE]. Admit patient to [hospice company name] .call [hospice company name and phone number] for change in condition, falls, labs, Xray, transfer to hospital or in the event of death. Start date [DATE]. Record review of Resident #82's Progress notes reflected the following entries: Entry dated [DATE] at 11:12 AM: Spoke with resident RP [name] via telephone and informed him of resident's decline over the last two weeks. resident has had a loss of appetite, not eating meals normally, she requires more assistance from staff with eating, and now has pressure wounds to her ankles. resident expresses she is in pain lately as well. RP wishes to speak to brother regarding resident's decline so a decision may be made about a possible referral to hospice. social worker verbalized understanding and RP to reach back out once a decision is made. Signed by Social Worker. Entry dated [DATE] at 9:55 AM: Patient refuses to be fed by CNA for breakfast. Patient is lying peacefully with eyes closed unlabored breathing noted. No distress noted. Signed by LVN A. Entry dated [DATE] at 1:38 PM: family requesting hospice eval. social worker to send hospice referral to .hospice agency. Signed by Social Worker. Entry dated [DATE] at 12:38 PM: Patient admitting to hospice. Call [hospice company name and phone number] for change in condition, falls, labs, XRAY, transfer to hospital or in the event of death. PCP notified. Signed by LVN A. Entry dated [DATE] at 9:23 AM: [Hospice company name] hospice nurse visited patient this AM. Patient is gurgling, possible aspiration. Will change diet to pureed and thicken liquids for next meal. Patient is showing signs of swallowing issues. Patient is showing signs of pain PRN morphine given at 9:20AM. Signed by LVN A. Entry dated [DATE] at 6:35 PM: Residents medications were held this evening as she was unable to swallow medications. Resident had audible wet/congestion this afternoon. When resident was checked on prior to dinner resident was breathing, with increased secretions. After dinner resident had no respirations. DON notified. Hospice notified, awaiting response from Hospice Nurse at this time. Signed by LVN B. Entry dated [DATE] at 7:51 PM: Resident passed, awaiting hospice arrival Signed by LVN B. Entry dated [DATE] at 9:13 PM: Hospice nurse in facility for resident. Emergency contact [RP name] Notified of residents passing. MD Notified. Resident to be picked up by [transportation company name] services and taken to funeral home. Awaiting arrival. Signed by LVN B. Entry dated [DATE] at 9:58 PM: Resident taken by [company name] transportation services going to the funeral home. Signed by LVN B. Record review of Resident #82's hospice documentation-Visit Note Report dated [DATE] reflected the following: Visit Type: RN Hospice Start of Care. Narrative: [Resident #82] is an [AGE] year-old female who is being admitted to hospice services on [DATE] with a primary diagnosis of dementia under the care of medical director, [Hospice MD name]. patient's additional diagnoses include: cognitive communication deficit, htn, anemia, mdd [major depressive disorder], mood disorder, muscle weakness, unspecified abnormalities of gait and mobility [difficulty with walking], muscle wasting, insomnia, anxiety, abnormal uterine and vaginal bleeding, pain, rls [restless leg syndrome-an irresistible urge to move the legs], atrial fibrillation [abnormal heart rhythm], osteoarthritis. Patient is a full code . Patient has been a resident of [nursing facility name] since 2019. Patient is disoriented and unaware of time, place, and situation. Neurological deficits noted as follows: nonverbal, unable to make eye contact, incontinent of bowel and bladder, contractures (permanent or temporary tightening of muscles and tendons causing limited movement of a joint) of bilateral legs, patient unable to make needs known. lung sounds clear to auscultation. respirations even and unlabored. bowel sounds active in all quadrants. Bilateral legs contracted with noted redness to outer left ankle and inner right ankle due to pressure. Area being cleansed with skin prep and monitored. Patient nonambulatory [sic] and is max assist with transfers. six months ago, patient was able to get out of bed and participate with activities and sit up in wheelchair. Per staff, decline has been rapid. appetite is poor as currently patient is consuming ,d+[DATE] bites of 3 meals a day. Three months ago, patient was consuming 50% of three meals a day. Patient has lost 2 lbs in the past two weeks. Patient is bedbound and no longer getting out of bed. Patient has no history of falls . The document was signed by Hospice RN C. During an interview on [DATE] at 8:55 AM, LVN A stated she had worked at the facility for 2 years any worked the 7 AM to 2 PM shift. She stated she had cared for Resident #82 during the day shift on [DATE]. She stated a hospice nurse had been in to see Resident #82 that morning and she appeared to be very uncomfortable. She stated Resident #82 had been grimacing and yelling out. She stated Resident #82 had been declining for a while and her family had decided to place her on hospice services. LVN A stated she did not do a full assessment or get vital signs because the hospice nurse was with her. She stated she never checked the resident's code status because, when on hospice, you think DNR. When shown her progress note and asked about her possibly aspirating, LVN A stated she asked the hospice nurse about it and she wanted to try Resident #82 on a pureed diet. She stated she administered some morphine to the resident and she had slept a lot the remainder of her shift. She stated Resident #82 would not accept any food when the CNAs had attempted to feed her lunch. LVN A stated she knew how to locate the resident's code status by checking their electronic medical records or the binder at the nurse's station. LVN A stated she never checked the status for Resident #82 because she assumed she was DNR because she was on hospice. She stated the risk of not knowing a resident's code status was failing to do CPR which would result in death and not following the resident's rights. LVN A stated facility management had called her on [DATE] and she had received in-service training. She stated they added a binder to the crash cart that included a list of all resident's code status that would be updated daily. She stated, if a resident was DNR, she was supposed to check the documentation to ensure it was complete. If the resident had no code status or was full code, they should initiate CPR immediately and call emergency services. During an interview on [DATE] at 10:27 AM with MA D, she stated she had worked at the facility for the past 2 and a half years and had known Resident #82 for a while. She stated Resident #82's health had been declining and she had not been eating or drinking as much and she had begun to crush some of her medications for her. MA D stated, on [DATE], she thought she recalled the resident was able to take her meds that morning and she had seen her again around lunchtime. She stated she had opened her eyes and was able to reply, hey when greeted but did not speak any more than that. She stated that was the last time she had seen her before she passed away. MA D stated she could tell a resident's code status because it was in the computer and on their Medication Administration Records. She stated she did not know Resident #82's code status the day she passed, did not recall looking for it and was not present when she had stopped breathing. MA D stated she had received in-service training that day related to code status. She stated, she should always get the nurse if there was a change in a resident's condition. She stated, if a resident was unresponsive-they should yell for help, check the code status on the computer, in a binder at the nurse's station and on the crash chart. She stated CPR should be initiated immediately for any resident who was a full code or unknown status. MA D stated she was CPR certified and should assist the nurse as needed in emergency situations. She stated the risk of not knowing a resident's code status was not honoring the resident's wishes and death. On [DATE] at 4:10 PM, an attempt to reach LVN B via telephone was unsuccessful. During a telephone interview on [DATE] at 8:32 AM, LVN B stated she had worked for the facility for about 6 months and usually worked the 2 PM to10 PM shift. She stated she understood how to check a resident's code status and it could be found in the electronic medical record as well as a binder which was kept at the nurse's station. She stated, if a resident was DNR, they were to also check the document for the appropriate signatures. When asked about Resident #82's care on [DATE], she stated she arrived for work around 3:30 PM that day and it had been about 3 weeks since she had worked at the facility. She stated she checked Resident #82 during her initial rounds and noticed she had changed condition. LVN B stated she asked the CNAs and Medication Aide about her and learned Resident #82 was on hospice and had been declining. She stated she checked her vital signs and could not recall if she had documented them but remembers they were stable. She stated the resident would open her eyes and follow her with her eyes but did not speak. LVB B stated she checked on Resident #82 again before dinner and there had been no change. LVN B stated she then went to the dining room to feed residents. She stated she checked on Resident #82 after dinner, and she was very pale and was not breathing. She stated she reported it to the DON and Administrator who had told her to call the hospice company. LVN B stated she called the hospice company and believed it was the answering service. She stated they told her they would contact Resident #82's family and send a nurse out to pronounce death. LVN B stated she did not initiate CPR or call emergency services because she assumed, because Resident #82 was on hospice services, she was DNR status and had not looked for the information. LVN B stated she received a call from facility management on [DATE] and they conducted an in-service over the phone. She stated in-service included the importance of checking the resident's code status and contacting emergency services and initiating CPR for residents who were full-code status. She the facility was implementing an additional binder with all the resident's code status to be kept with the crash cart. LVN B stated the risk of not knowing a resident's code status was, like this, I messed up. I should have coded her and potentially brought her back. She stated the risk was death and not following the resident's wishes. During an interview with the Social Worker on [DATE] at 2:57 PM, she stated Resident #82's family was provided advanced directive information upon admission. She stated, if a resident does not have a DNR order, they typically review the advance directive information with them and provide a copy of the information for their review. The information is periodically reviewed again during subsequent care plan meetings. If no signed advanced directives are provided by a resident or their responsible party (RP), they resident is considered a full code. The Social Worker stated Resident #82 had begun to physically decline and she had conversations with her RP about the possibility of hospice services. She stated, initially, the RP wanted to send a family member to visit the resident first. She stated the family came to see Resident #82 and decided to place her on hospice services so she set up the referral. The Social Worker stated she did not bring up the issue of Advanced Directives or a Do Not Resuscitate order at that time because they had always opted out of the idea in the past. She stated she asked the hospice company to discuss it with her family during admission. The Social Worker stated she knew the hospice company was working toward getting a DNR order in place but she had not received any information from them. During an interview on [DATE] at 3:40 PM, Hospice RN C stated she was the nurse who admitted Resident #82 to hospice services and pronounced her death. She stated the resident had just come on hospice services three days before she died . Hospice RN C stated they were in the process of getting her DNR orders signed, and her RP had verbalized his wishes for a DNR verbally to her stating he knew she had stopped eating, was declining and losing weight. Hospice RN C stated Resident #82's RP was homebound and unable to physically travel to the facility. An employee of their company had travelled to his home to have him sign her admission documents and was planning another trip to have him sign the DNR documents, but the resident passed away before getting the paperwork done. She stated the physician would not enter an order for DNR without the signed document from the patient's RP. When asked about their protocol for a resident who was possibly aspirating (breathing food or fluids into the lungs) as noted in the nurse's notes on [DATE], she stated there was another Hospice nurse there that morning who had reported those concerns to her and she advised to administer hyoscyamine (a medication to decrease secretions such as excess saliva) and try pureed food or thick liquids. Hospice Nurse C stated she was contacted later that evening about Resident #82's passing and went to the facility to pronounce her death. She stated she contacted the resident's family and physicians. She stated she would not have advised the facility to call 911 because she knew the wishes of her family and she thought the resident had likely been deceased a while before they found her. During an interview on [DATE] at 4:42 PM the DON stated she was notified by LVN B after Resident #82 had passed away. She stated she knew Resident #82 was on hospice services but was unaware at the time the resident was a full code. She stated she was leaving the facility for the day when the nurse notified her, and she did not pronounce the resident's death because she was told the hospice nurse was on her way to the facility. She stated she told LVN B to call her if there was any delay and she would come right back. The DON stated she asked LVN B if the family had been notified and she said no. She stated she directed her to check with the hospice nurse to determine whether they had contacted the family. She stated she did not communicate with the hospice company when they were at the facility earlier the same day. The DON stated the risk of failure to perform CPR when it was appropriate to do so was death. In an interview on [DATE] at 12:59 PM, the Administrator stated she did not recall a nurse telling her Resident #82 had died while she was at the facility. She stated she had gone home sometime after dinner and learned later that she had passed away. She had previously been unaware Resident #82 was a full code at the time she died . Record review of the facility's policy titled CPR-AED Policy dated revised [DATE] reflected the following: 1. In the event of cardiopulmonary arrest of a resident/patient without DNR status, life support measures will be initiated according to either the American Heart Association/American Red Cross guidelines or per State Guidelines. According to the 2001 American Heart Association, BLS (Basic Life Support) for Healthcare Providers, prompt initiation of CPR remains the standard of care except when rigor mortis, lividity, tissue decomposition or obvious fatal trauma are present. Rescuers who initiate BLS should continue until one of the following occurs: o Restoration of effective spontaneous circulation and ventilation. o Transfer of care to emergency medical responders or other trained personnel who continue BLS or initiate advanced life support. o Transfer of care to a physician who determines that resuscitation should be discontinued. o Inability to continue resuscitation because of exhaustion, because environmental hazards endanger the rescuer, or because continued resuscitation would jeopardize the lives of others. o Recognition of reliable criteria for determination of death; or o Presentation of a valid no-CPR order to the rescuers. 2. At least one person at the scene of the arrest will remain with the victim and initiate the Code Blue [code used when someone has no heartbeat or stops breathing] procedure. (see guidelines below) 3. Any clinical employee trained in Basic Life Support may initiate CPR. 4. The Emergency Medical System (911 or local number) will be activated immediately. Additional Advanced Life Support functions will be instituted by paramedics with the EMS system. 5. EMS will transport resident/patient to the emergency room of the transfer agreement hospital. Guidelines: .B. Person who discovers arrest: 1. Calls for help while placing the resident/patient in flat position on back. C. Nurses Responding: .c. Begin CPR . The Administrator, DON, and Regional RN were notified of the IJ on [DATE] at 4:42 PM due to the above failures. The Administrator was provided with the IJ template on [DATE] at 4:52 PM. The following Plan of removal submitted by the facility was accepted on [DATE] at 12:57 PM and reflected the following: POR [LVN B] who was the nurse on duty did not perform CPR on a patient who she believed was a DNR. [Resident #82's RP] had not executed the DNR paperwork as Hospice was working out logistics to get the paperwork over to him. [LVN B] was inserviced by DON on [DATE] regarding CPR policy that included education on full code status, when to initiate a full code, and following physicians' orders in regard to code status. Competency was verified via quiz. Immediately on [DATE], CCS [Regional RN] inserviced Administrator and DON on CPR policy to included education on full code status, when to initiate a full code, and following physicians' orders in regard to code status. Competency was verified via quiz. On [DATE], DON/Designee initiated inserviced [sic] with the licensed nurses on CPR policy to include education on full code status, when to initiate a full code, and following physician orders regarding code status. Competency was verified via quiz. Nursing staff will not be allowed to work until inservicing has been completed on [DATE]. At this time, we do not use agency. However, the above content was incorporated into new hire orientation by Administrator effective [DATE]. On [DATE], an audit was completed of all resident code status by DON/Designee. The audit did not find any additional concerns. Medical Director was notified on [DATE]. In order to monitor current residents for potential risks, SW/designee will audit the code status of all residents weekly x4 weeks and monthly thereafter to ensure accuracy. Any negative findings will be corrected and reported to the QAPI committee to ensure continued compliance. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. Record review of the attached in-service content dated [DATE] revealed it included a copy of the facility's CPR-AED Policy dated revised [DATE] as well as the following: *CODE STATUS TO BE PRINTED NIGHTLY AND PLACED IN BINDER ON CRASH CART-BY NIGHT SHIFT (,d+[DATE]) *CPR MUST BE INITIATED ON ANY RESIDENT THAT DOES NOT HAVE AN OUT OF HOSPITAL DNR. THIS INCLUDES RESIDENTS THAT ARE ON HOSPICE *PHYSICAN ORDERS MUST BE FOLLOWED- FULL CODE/DNR *CODE STATUS IS ON THE PROFILE PAGE- IF YOU CLICK ON HYPERLINK YOU WILL VIEW THE DNR *THE CPR/AED POLICY MUST BE FOLLOWED- EACH NURSE WILL BE EDUCATED AND GIVEN A COPY *IF THE DNR IS NOT SIGNED BY A PHYSICIAN IT IS NOT COMPLETE-AND RESIDENT IS CONSIDERED A FULL CODE *IF FAMILY STATES THEIR LOVED ONE IS A DNR BUT NO DNR HAS BEEN FILLED OUT, CPR MUST BE INNITIATED [sic] *A RESIDENT THAT HAS A COMPLETE OUT OF HOSPITAL DNR AND PHYSICIAN ORDER FOR DNR. THE DNR MUST BE FOLLOWED AND NO CPR PROVIDED An attached Attendance/In-service Record dated [DATE] reflected the training had been conducted by the DON, ADON, and Regional RN and had been completed by 22 nursing staff with completed competency quizzes. Monitoring of the facility's Plan of Removal included the following: Observation on [DATE] at 4:35 PM, the facility's crash cart (a cart that contains emergency supplies to be used during CPR) revealed a binder that contained an Order Listing Report for Advanced Directives dated [DATE]. The report reflected there were 36 residents in the facility who had Full Code status. During an interview on [DATE] at 1:40 PM, the ADON stated she knew Resident #82's health had been declining but had been unaware of her placement on hospice services. She stated she was working in the facility on [DATE] and thought she left sometime around 6:00 PM that day. She stated she learned later in the evening Resident #82 had passed away. The ADON stated she knew Resident #82 had been full code status in the past but did not know whether anything had changed. She stated she was out of the facility a lot that week due to a personal family issue. The ADON stated she had received in-service training for her corporate management on [DATE] and had assisted with providing in-service training to the facility staff afterward. She stated, if a resident was found unresponsive, staff should call for help, have someone check code status and retrieve the crash cart, and call emergency services. If a resident is DNR and on hospice, they should contact the hospice company. She stated they added a list of residents along with their code status to the crash cart and the list would be updated daily. The ADON stated the risk of not knowing a resident's code status included death if the resident was full-code status and performance of CPR against the wishes of someone who desired DNR status. During a telephone interview on [DATE] at 2:47 PM, the Medical Director stated he had cared for Resident #82 for more than three years. He stated she had deteriorated quickly and had been transferred to hospice services. He stated he did not contract with the particular hospice company used by Resident #82 and he had been notified by the facility of Resident #82's death. The Medical Director stated he had been notified by the facility Administration about the IJ. He stated he had a huge ethical issue if they had done CPR on someone in [Resident #82's] state because of the trauma it would have caused her. When asked about the risk of failure to perform CPR on a resident who was full code status, the Medical Director stated, as a general rule, not taking into account anything else-you should initiate CPR or the resident could pass. The Medical Director stated he had spoken with the Administrator and her superiors about addressing this and other issues on a weekly basis. He stated he believed the nurses should not be placed in a position such as the one that had occurred. He stated he planned to have the issue addressed with the Quality Assurance committee. In an interview with CNA E on [DATE] at 3:39 PM, she stated she worked at the facility for 2 years and typically worked the 2 PM to 10 PM shift. She stated Resident #82 had declined over the previous weeks before she died and needed to be fed. She stated she worked with Resident #82 on the day she passed away and recalled checking on her and changing her. She stated she appeared to be sleeping during the shift and would not accept any dinner when she attempted to feed her. She stated she attempted to place a straw in her mouth and she would not take it and she did not want to push her to drink. She stated she thought she had possibly received some morphine and was on hospice. CNA E stated she had informed LVN B that Resident #82 would not accept any food or drinks. She stated she recalled LVN B checking her after dinner and she had died . CNA E stated she could check a resident's code status on the computer. She stated she had received in-service training. CNA E stated if a resident was found unresponsive, they should call for help, get the nurse, get the crash cart and follow any of the nurse's instructions to assist. She stated the resident's code status could be found in the computer, and in binders at the nurse's station and on the crash cart. During an interview with the Social Worker on [DATE] at 4:09 PM, she stated she had received in-service training related to Advanced Directives and had been assisting with the facility's Plan of Removal. The Social Worker demonstrated the binder kept at the nurse's station which included face sheets and copies of the DNR documents for all residents as applicable. She stated a full audit of all facility residents had been completed the binder was found to be up-to-date and accurate. The Social Worker stated resident status in the computer must never be changed unless all documents were in order and properly signed. She stated she and the MDS Nurse worked together to ensure any changes to a resident's code status was immediately addressed, and both ensured physician orders and properly signed documents were obtained. The Social Worker stated she would be auditing all resident records weekly for the next four weeks then monthly thereafter to ensure accuracy and ongoing compliance. She stated, if she was unable to complete the audit, the MDS Nurse or nursing administrative staff would complete the audit. The Social Worker stated the QA committee would be meeting weekly for the next 8 weeks to review the process and ensure compliance. Interviews were conducted with facility staff across all three shifts on [DATE] from 11:21 AM through 4:43 PM. The staff included, LVN A, CNA M, CNA N, RN F, LVN G, LVN H, LVN I, CNA E, LVN J, LVN K, and CNA L. The interviews revealed they had all received in-service training and could accurately describe how to determine the resident's code status, how to determine whether DNR documentation was complete, how and when to initiate CPR, and how long they should continue CPR. During an interview with the Administrator on [DATE] at 4:30 PM, she stated the IJ occurred because the charge nurse failed to check code status for a resident who was on hospice and initiate CPR and call 911 when she was found unresponsive. She stated the hospice company failed to ensure they received the proper documentation timely from Resident #82's RP when he expressed his desire for a DNR order. She stated the risk to residents included failure to honor the resident's wishes and death if no CPR was initiated. During an interview on [DATE] at 4:38 PM, the Regional RN stated the IJ occurred due to a failure to check and act upon the code status of a resident and assumed they were DNR because they were on hospice. She stated the risk for failure to initiate CPR was death and failure to honor a resident's wishes. The Administrator was informed the IJ was removed on [DATE] at 6:30 PM. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food was properly stored in the facility's kitchen. The facility failed to seal food and dispose of spoiled food. This failure could place residents at risk for food-borne illness. Findings Included: Observation of the facility's refrigerator on 09/24/24 beginning at 9:35 AM revealed: - 2 cantaloupes with fuzzy white and black spots; - 1 white onion with fuzzy white spots; - 1 bag of shredded carrots open and exposed to air; - 1 bag of shredded cheese open and exposed to air; - 1 red onion and small potato on the floor; and - meat thawing in a container with blood dripping on the floor. Observation of the facility's freezer on 09/24/24 beginning at 9:43 AM revealed: -1 bag of tortilla chips open and exposed to air; -1 box of pork steak fritters open and exposed to air; and - 1 box of beef patty fritters open and exposed to air. Observation of the facility's dry storage in the kitchen on 09/24/24 beginning at 9:48 AM revealed: -1 box of country style gray mix open and exposed to air; -1 box of instant puree rice open and exposed to air; and -1 instant food thickener open and exposed to air. Observation of the facility's seasoning shelf on 09/24/24 beginning at 9:56 AM revealed: -1 container of ground nutmeg open and exposed to air. In an interview with the Dietary Supervisor on 09/27/24 at 5:42 PM, revealed she completed walk throughs of the kitchen in the morning. She stated she checked everything including temperature logs. She stated she ensured dietary staff stored food properly by addressing issues (notifying dietary staff of improper storage and had them correct issue). She stated residents were at risk of food poisoning due to improper food storage . Record review of the facility policy titled Food Receiving and Storage, dated October 2022, revealed Food shall be received and stored in a manner that complies with safe food handling practices. Review of the Food and Drug Administration Food Code, dated 2017 , reflected, .3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .