FOCUSED CARE OF CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the right to be free from misappropriation of resident property for 5 of 10 residents (Resident #1, Resident #5, Resident #6, Resident #8, and Resident #12) reviewed for misappropriation of resident property.The facility failed to ensure the [NAME] did not use Resident #1, #5, #6, #8, and #12's food debit card for personal use on 6/28/2025, 7/26/2025, 8/26/2025, and 8/31/2025.This failure could place residents at risk for decreased quality of life, misappropriation, and dignity.Findings include:1.Record review of a facility admission record for Resident #1 dated 10/6/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia (occurs when the brain nerve cells die), type 2 diabetes, major depressive disorder (persistent sadness and loss of interest in doing things), and heart failure. She was discharged from the facility on 9/19/2025.Record review of a Quarterly MDS Assessment for Resident #1 dated 9/12/2025 indicated she did not have any impairment in thinking with a BIMS score of 14. She was independent with activities of daily living except for toileting hygiene and shower/bathing when she needed setup or clean-up assistance.Record review of a care plan for Resident #1 dated 4/21/2025 indicated she had impaired cognitive function or impaired thought processes. Interventions included to keep the routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion.2. Record review of a facility admission record for Resident #6 dated 10/7/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of major depressive disorder, dementia, hypertension, and osteoarthritis (stiffness, joint pain). She was discharged on 10/3/2025 to the hospital.Record review of a Quarterly MDS Assessment for Resident #6 dated 9/24/2025 indicated she had moderate impairment in thinking with a BIMS score of 9. She required supervision with eating, oral and toileting hygiene.Record review of a care plan for Resident #6 dated 10/23/2023 indicated she had impaired cognitive function or impaired thought processes with interventions to keep the resident's routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion.3. Record review of a facility admission record for Resident #8 dated 10/8/2025 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of COPD (a group of diseases that affect breathing), mild intellectual disabilities (a condition that limits intelligence and disrupts abilities to live independently), hypertension, and chronic kidney disease stage 4 (kidney failure).Record review of a Quarterly MDS for Resident #8 dated 9/1/2025 indicated he had moderate impairment in thinking with a BIMS score of 12. He was independent in eating.Record review of a care plan for Resident #8 revised 5/12/2024 indicated he had ADL self-care performance deficits related to disease processes. Interventions included the was able to feed himself with set-up and supervision to be able to complete meal and have not become too tired to feed himself.4. Record review of an admission record for Resident #12 dated 10/8/2025 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia, bipolar disorder (a mental illness that causes extreme mood swings), type 2 diabetes, and hypertension.Record review of a Quarterly MDS Assessment for Resident #12 dated 8/15/2025 indicated he had moderate impairment in thinking with a BIMS score of 8. He was independent in eating and required supervision or touching assistance with oral hygiene.Record review of a care plan for Resident #12 dated 6/3/2024 indicated he had impaired cognitive function or impaired thought processes. Interventions included to keep the resident's routine consistent and try to provide consistent caregivers as much as possible.5. Record review of an admission record for Resident #5 dated 10/8/2025 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Alzheimer's Disease (a progressive and irreversible decline in memory and cognitive abilities), major depressive disorder (persistent sadness and loss of interest), anemia (decreased production of red blood cells in the body), and BPH (the prostate glands grows larger than normal).Record review of a Quarterly MDS Assessment for Resident #5 dated 9/3/2025 indicated he had severe impairment in thinking with a BIMS score of 3. He was independent with eating and supervision or touching assistance with oral hygiene and toileting.Record review of a care plan for Resident #5 dated 4/21/2025 indicated he had impaired cognitive function or impaired thought processes. Interventions included to present just one thought, idea, questions, or command at a time.Record review of the personnel file for BOM/[NAME] indicated she was hired at the facility on 10/13/2022. She had an initial criminal history check on 10/12/2022. An annual EMR was checked on 1/1/2025 and she was not listed as being unemployable. She had annual training on abuse on 4/1/2025.Record review of a [store name] receipt dated 8/31/2025 at 2:33 p.m., revealed a total purchase was made to buy food items using the food debit card that belonged to Resident #1. The total purchase was $89.00 that was charged. Some food items purchased included: energy drinks, spaghetti noodles, alfredo noodles, etc.Record review of a [store name] receipt dated 8/26/2025 at 2:38 p.m., revealed a total purchase was made to buy food items using the food debit card that belonged to Resident #6. The total purchase was $98.17 that was charged. Some food items purchased included: Starbucks coffee, guacamole, French mustard, and mayonnaise.Record review of a [store name] receipt dated 8/26/2025 at 11:26 a.m., revealed a total purchase was made to buy food items using the food debit card that belonged to Resident #6. The total purchase was $1.68 that was charged.Record review of a [store name] receipt dated 7/26/2025 at 10:55 a.m., revealed a total purchase was made to buy food items using food debit cards that belonged to Resident #1 and Resident #5. The total purchase was $102.33 that was charged to both cards used. Resident #1's card was charged $100.00 and Resident #5's card was charged $2.33. Some food items purchased included: pizza rolls, tater tots, broccoli rice, flour tortillas, etc.Record review of a [store name] receipt dated 7/26/2025 at 10:51 a.m., revealed a total purchase was made to buy food items using the food debit cards that belonged to Resident #8 and Resident #12. The total purchase was $179.04 that was charged to both cards used. Resident #8's card was charged $86.16 and Resident #12's card was charged 92.88. Some food items purchased included: Brussel sprouts, fettuccini, energy drinks, etc.Record review of a [store name] receipt dated 6/28/2025 at 1:47 a.m., revealed a total purchase was made to buy food items using the food debit cards that belonged to Resident #1 and Resident #6. The total purchase was $200.00 that was charged to both cards used. Resident #1 and Resident #6 cards were both charged $100.00 each. Some food items purchased included: New York strip steak, cubed steak, tater tots, instant potatoes, country gravy mixes, baked beans, etc.The total of the receipts reviewed was $670.22.During a confidential interview on 10/6/2025 at an undisclosed time, a complainant reported that the facility had a program where many residents in the facility received a food card that they could use to buy food at [store name]. The complainant reported they had overheard facility staff talk about the person who was over the money in the facility had spent some of the money from the resident's food cards and wanted it investigated.During an interview on 10/6/2025 at 11:44 a.m., the [NAME] said the food cards provided by [insurance company name] allowed the residents who was signed up on the program to buy anything that was edible that included snacks, drinks, etc. She said that each resident that received the benefit received $100 at the beginning of the month. She said some residents kept their cards in their possession and some were in the possession of family members. She said for everyone else their cards were locked in her office for the staff to use to buy items for the residents. She said the Activities Director would shop for most of the residents in the facility along with some of the resident care partners. She said the residents received $100 monthly and the benefits did not roll over, so whatever was not spent each month, they would lose. She said the residents would provide the staff members with a list and the staff would shop for them at [store name] which was the designated store to use the cards. She said the staff was to give her the receipt for purchases when they returned to the facility. She said they had a binder she kept in her office. They started in July 2025 in which the staff was to sign out the cards and sign them back in along with placing the receipts for the purchase in the binder under the resident's name. She said she shopped for some of the residents in the facility as well.During an interview on 10/6/2025 at 11:57 a.m., the LED said some of the residents in the facility received a food card as part of their insurance benefits for $100 monthly and the money did not roll over each month on what they did not spend. She said the program started sometime between December 2024 to January 2025 when she was out for maternity leave. She said she shopped for most of the residents and only a few had cards that was checked out by family to use. She said on the first of every month the cards reloaded with $100. She said every other week she went to the store and shopped for the residents in the facility and would go about 2-3 times a month. She said the residents would give her a list and she would shop for them. She said she had to get their cards if they were not in their possession from the [NAME] and would have to sign the cards out and back in once back in the facility. She said they wrote the resident's names on the receipts so they could keep track of what was spent for each resident and the receipt was placed in the binder. She said there were a few people in the facility that was authorized to shop for the residents, including the [NAME] and RCP B.During an interview on 10/6/2025 at 3:17 p.m., the DRSS said she did not shop for any of the residents in the facility. She said it was done by the LED. She said PTA A called her on the day she was in [store name] when she tried to purchase food for Resident #6 when the card declined. She said she told PTA A to call and speak to the Administrator or the [NAME].During a phone interview on 10/6/2025 at 3:30 p.m., the Transport Driver said she shopped for some of the residents in the facility. She said the last time she shopped for them was Sunday a week ago (9/28/2025). She said a couple of months ago she shopped for Resident #6 but did not remember what date it was. She said Resident #6 was not a snacker and had a twelve pack of sodas that had been in her room for a while. She said when she shopped for the residents, she used their food card that was provided to them by their insurance company. She said the [NAME] would give them the cards and when they returned to the facility, they would print the resident name on the receipt and turn it into the [NAME]. She said she never had a problem with the cards for the residents she shopped for, and all had enough money to buy what they wanted. She said the facility had used the cards for some months. She said she did not remember the facility providing any training or in-service to the staff on the use of the cards.During an interview on 10/6/2025 at 2:50 p.m., PTA A said Resident #6 was a resident at the facility who was like a grandmother to her and the POA had asked her about a month ago (August 2025) to go to the store and purchase some things for her. She said she received the card from the LED and went to [store name] to buy the resident some food items and when she tried to check out, the card declined. She said she called the number on the back of the card and listened to the most recent transactions, and it revealed multiple purchases in June 2025, July 2025 and August 2025 that was close to $100 that was made and the POA had not made any purchases for Resident #6. She said she contacted the POA and discussed what she had discovered and talked to [store name] about video surveillance but was told they could not give her video footage without a police report. She said she reported the information to the facility and was told they would conduct an investigation to see if there were any discrepancies with the food cards.During an interview on 10/6/2025 at 3:09 p.m., the Administrator said the [NAME] was responsible for overseeing the food card program and had the cards locked up until they were needed. She said the LED/Activities Director, DRSS/SW, [NAME]/BOM and some of the resident care partners could use the cards to purchase food items for the residents. She said she was aware of an issue with the use of the cards and had planned to audit last week (9/29/2025-10/3/2025) but did not get a chance to and then planned to the week of 10/6/2025-10/10/2025. She said the LED had used the cards of some of the residents and the cards declined. She said charges were made and thought someone had gone to shop for the residents and did not turn in the receipts. She said she had no idea someone had used the resident food cards for their personal use and just thought someone did not turn in receipts for purchases made.During a phone interview on 10/6/2025 at 3:52 p.m., the POA for Resident #6 said the resident was at the hospital. She said she was made aware by PTA A whom she had asked to buy some food for Resident #6 using her food card that was provided by her insurance company. She said she was informed that when PTA A went to [store name], there was not anything on the card as the card declined. She said she had not talked to the Administrator about the incident and PTA A was going to let her know what to do. She said Resident #6 did not snack a lot and had sodas in her room and had them for a while. She said she was picky with her foods. She said she would wait and see what was discovered about the food cards.During an interview on 10/7/2025 at 12:24 p.m., the Administrator said reviewing the receipts that was requested, she saw some things that were troubling that included large purchases for items such as steaks and multiple resident cards was used for the purchases. She said she filed a police report and was going to start an internal investigation into the matter. She said the officer went to [store name] and reviewed video footage for the dates of the receipts that had large purchase amounts and described the BOM/[NAME] as the person who made the purchases. She said charges would be filed and she would be suspended until her investigation was complete and was going to take possession of the food cards. She was going to in-service staff on proper use of the cards according to their policy. She said they would conduct a complete audit of all residents in the facility who had the food cards on tomorrow 10/8/2025. She said she expected the staff to use the food cards for the people for whom they were designated.Record review of a disciplinary action record signed and dated 10/7/2025 for the [NAME]/BOM by the BOM indicated she was suspended for an allegation of misappropriation of resident funds. The date of occurrence was 6/28/2025.During a follow up interview on 10/7/2025 at 12:28 p.m., the [NAME]/BOM said she had been in the position as the Director of Resident Accounts for about a year. She said she was responsible for keeping up with the food cards for the residents in the facility. She said the program started around January 2025. She said she had made purchases on the weekends on her off time a few months ago. She said the staff were not supposed to be on the clock when they shopped for the residents. When asked about her using the food cards for her personal benefit, she admitted that she had. She said she bought food for herself and had used the cards of Resident #1 and Resident #6. She said she could not remember what other cards she had in her possession at the times she used the cards but there were multiple cards she had with her. She said she knew what she did was wrong and did not have an explanation as to why she did it. She said she knew the residents received $100 each month and whatever they did not use, they would lose. She said she hated that the residents would lose the money when it could have been used. She said she knew it was theft as the cards were not hers and she did not have permission to use their cards for her personal benefit. She said initially when the food card program started at the facility, they were told repeatedly to use the cards and spend the money, if not they would lose the money at the end of the month. When questioned if the facility told her, it was ok for the staff to use the resident cards for their personal use, she said they did not specifically tell her that. She said she made purchases for herself at the end of the month with the resident food cards when she knew they had money left on the cards and they were about to get reloaded. She said she would not like it if someone took advantage of a family member if they were in a facility. She said it would be hurtful to think someone did that to a family member of hers. She said what she did was theft. She said she took an unethical route and accepted full responsibility for her actions. She said she could not remember how many purchases she made but thinks she only used cards for her personal benefit at the end of June and July 2025. She said she had annual training on abuse.During a phone interview on 10/9/2025 at 10:15 a.m., loss prevention manager at [store name] said all the receipts that were in question from June 2025, July 2025, and August 2025 was all purchased by the same person (BOM/[NAME]).During a phone interview on 10/9/2025 at 10:18 a.m., the detective assigned to the case said he was off yesterday 10/8/2025. He said the initial reporting officer indicated in his narrative that the Administrator of the facility had filed a report on 10/7/2025 to report a staff member had been using the debit cards of residents in the facility. He said the investigation was ongoing and the police report would not be available for a while.Record review of a facility policy titled And More Grocery Benefit Card by PPHP dated 1/10/2025 indicated, .The $100 grocery benefit card should be stored in the business office and made available to the responsible party or the resident themselves. The community LED will also be able to support the use of this card as an activity for the residents. This process will support the utilization for the residents' benefit and appropriate use of their funds as it is intended. 1. Storage a. The grocery benefit cards will need to be stored in a secure location in the business office as they are received via mail. Check in & check out process for the cards may only be exercised by the responsible party for the resident, the resident themselves or the community LED. All staff are expected to adhere to the policy provided for the use of this card to maximize and protect residents' supplemental benefits. 2. The EDO will oversee the proper use of these benefits. 3. [NAME] will: c. keep sign out log in binder-require proper ID. D. Keep all receipts received by the LED of the facility.Record review of a facility policy titled Abuse revised 1/27/2020 indicated, .the purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse and or Misappropriation of property. The facility staff will adhere to the policies and procedures and will follow the guidelines in the written policy and procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 4 of 7 residents (Resident #3, Resident #4, Resident #5 and Resident #6) reviewed for abuse and neglect. <BR/>1. The facility failed to prevent a Resident-to-Resident altercation when Resident #3 and Resident #4 began fighting and both residents fell to the ground in the smoking area on 11/30/2024. <BR/>2. The facility failed to protect Resident #6 from abuse from an Unidentified Resident on 1/5/2025 when an Unidentified Resident grabbed Resident #6 by the arm and threatened him.<BR/>3. The facility failed to prevent a Resident-to-Resident altercation when Resident #5 hit Resident #3 with a walker and then began fighting and both residents fell to the ground in the dining room on 2/15/2025. <BR/>4. The facility failed to protect Resident #6 from abuse from Resident #3 on 3/25/2025 when Resident #3 kicked Resident #6 in the dining room at breakfast.<BR/>An Immediate Jeopardy (IJ) situation was identified on 4/16/2025. While the IJ was removed on 4/17/2025, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>These failures could place residents at risk for severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. <BR/>Findings include:<BR/>1. Record review of the electronic face sheet for Resident #3 indicated the resident was admitted to the facility on [DATE] with the most recent readmission on [DATE]. Resident #3 had diagnoses which included: bipolar disorder (significant shifts in mood, energy, and activity levels, causing periods of intense highs and lows), impulse disorder (difficulty controlling impulses, urges, or behaviors, leading to harmful or inappropriate actions), Parkinson's (neurological disorder that primarily affects movement) and Wilson's disease (causes copper to build up in the liver, brain, and other organs).<BR/>Record review of Resident #3's admission MDS assessment, dated 2/8/2025, indicated a BIMS of 15, which indicated no cognitive impairment. <BR/>Record review of Resident #3's care plan, dated 11/15/2024, indicated: I am exhibiting behavior of making flirtatious comments towards staff and some female residents. Interventions included: 1. [Counseling] services evaluate and treat. 2. Monitor/document/report PRN any signs/symptoms of resident posing danger to self and others. 3. Staff will monitor for safe environment and to ensure no unusual episodes occur. The care plan dated 3/4/2025, indicated I am exhibiting behavior of-verbal aggression to other residents, I like to 'stir the pot', boss people around and tell people what they can and can't do. I am often loud and obnoxious and often instigate arguments with staff and residents. Interventions included: 1. Monitor/document/report PRN and signs/symptoms of resident posing danger to self and others. 2. Psychological services evaluate and treat. 3. Staff will monitor for safe environment and to ensure no unusual episodes occur. 4. When the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away and approach later.<BR/>Record review of the facility's incident report for Resident #3, dated 2/15/2025 at 2:38 PM, completed by LVN A, indicated: Heard loud noises coming from dining room, when arrived to dining room, saw resident sitting on floor along with the other resident. Resident stated the CNA was in the way and [Resident #5] asked him to move and resident yelled back at him. Resident stated they both were going back and forth. [Resident #5] got angry and hit him on top of his head with walker. Staff member broke incident up.<BR/>2. Record review of the electronic face sheet for Resident #4 indicated the resident was admitted to the facility on [DATE] with the most recent admission on [DATE]. Resident #4 had diagnosis which included: vascular dementia (difficulty thinking, memory and behavior), Hemiplegia (paralysis on the left side of the body) and muscle weakness.<BR/>Record review of Resident #4's admission MDS assessment, dated 4/4/2025, indicated a BIMS of 13, which indicated no cognitive impairment. It also indicated Resident #4 was independent with walking 150 feet.<BR/>Record review of Resident #4's care plan, dated 11/15/2024, indicated: I have a ADL self-care performance deficits related to disease processes. I am mostly independent with ADLs with some assistance with set-up and supervision with locating thing. I have left side hemiplegia and walk with a cane. Interventions included: 1. Transfer: The resident requires supervision and set-up assistance by 1 staff to move between surfaces as necessary.<BR/>Record review of the facility's incident report for Resident #4, dated 11/30/2024 at 6:45 PM, indicated: Resident stated he was outside smoking when he and another male resident started arguing, he stated he walked up to the other resident and the other resident pulled himself up out of his wheelchair using him they began hitting one another and fell to the ground. The notes section indicated: Resident involved in physical altercation with [Resident #3]. Resident had words with other resident and both decided to show who was boss. Few slaps back and forth, easily redirected by staff present. No injury noted or complaint of pain. Both residents redirected to their room and further smoke breaks this evening.<BR/>Record review of the facility's progress note for Resident #4, dated 11/30/2024 at 7:31 PM, completed by LVN C, indicated: This nurse was at the medication cart when a dietary worker came in the hallway and stated 'hey they need some help out here.' Nurse went to the dining room and the door leading out to the smoke area was open. Resident was observed laying in the smoke area with the other male resident beside him and they were both arguing and still trying to engage physically. Nurse stepped between them and assisted this resident up. Resident was assisted back in the facility and sat in a chair. After he got his shoes back on he was assisted to his room. Resident described in his words what happened. DON was notified. Resident was instructed to stay away from the other male resident and there would be no other smoke breaks for him. Resident did not have any visible physical injuries after assessment. Denies any physical or emotional distress <BR/>3. Record review of the electronic face sheet for Resident #5 indicated the resident was admitted to the facility on [DATE]. Resident #5 had diagnoses which included: toxic encephalopathy (brain disorder caused by exposure to toxic substances), chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe) and type 2 diabetes (high blood sugar).<BR/>Record review of Resident #5's quarterly MDS assessment, dated 2/5/2025, indicated a BIMS of 14, which indicated no cognitive impairment. It also indicated Resident #2 was independent with walking 150 feet.<BR/>Record review of Resident #5's care plan, dated 2/21/2025, indicated: The resident was/has potential to be physically aggressive hit another resident with walker, related to anger, poor impulse control 2/15/25-became impatient with another resident and hit that resident with walker. Interventions included: 1. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document . 3. Monitor/document/report PRN any s/sx of resident posing danger to self and others. 4. Offer psych or psychology services as needed. 5. Social Worker to talk and evaluate resident after any incidents. 6. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.<BR/>Record review of the facility's progress notes for Resident #5, dated 2/15/2025 at 3:16 PM, completed by the LVN A indicated: Resident had a witnessed physical altercation with another resident. Resident was found sitting on the floor in front of his walker. Resident denies pain or discomfort at this time. Resident vital signs are stable. No injuries noted at this time.<BR/>4. Record review of the electronic face sheet for Resident #6 indicated the resident was admitted to the facility on [DATE]. Resident #6 had diagnoses which included: intracerebral hemorrhage (stroke), Hemiplegia (paralysis on the right side of the body), and muscle weakness.<BR/>Record review of Resident #6's annual MDS assessment, dated 2/25/2025, indicated a BIMS of 03, which indicated severe cognitive impairment. It also indicated Resident #6 required substantial to maximal assistance with transfers.<BR/>Record review of Resident #6's care plan, dated 1/5/2025, indicated: I received physical and verbal aggression from another resident when he was grabbed by the hand and another resident told him he would knock the hell out of him. I am still protective of other residents and may act aggressively towards others. Interventions included: 1. Resident will be assessed for emotional distress and physical injuries after incident and as needed. 2. Resident will be redirected when appropriate. 3. Resident will not go on the same smoke breaks as physically aggressive resident . 5. Staff will monitor for safe environment and to ensure no unusual episodes occur.<BR/>Record review of the facility's incident report for Resident #6, dated 1/5/2025 at 8:30 am, indicated: Resident was in dining room near the smoking door with another resident when his w/c bumped into the other resident's chair. The other resident grabbed his and told him if he did it again he would knock the shit out of him. Residents were separated and no further physical contact was made. Resident was assessed for injuries with none observed. Resident showed no signs of emotional trauma. Residents will not go on the same smoke breaks together.<BR/>5. Record review of the electronic face sheet for Resident #7 indicated the resident admitted to the facility on [DATE] with the most recent admission on [DATE]. Resident #7 had diagnoses diagnosis which included: major depressive disorder (persistently low mood), chronic respiratory failure with hypoxia (lungs cannot adequately provide oxygen to the blood), and muscle weakness.<BR/>Record review of Resident #7's quarterly MDS assessment, dated 2/18/2025, indicated a BIMS of 15, which indicated no cognitive impairment. It also indicated Resident #4 required supervision or touching assistance with walking 150 feet.<BR/>Record review of Resident #7's care plan, dated 4/15/2022, indicated: I may have a potential for Coping Impaired related to situational and social factors including loss of autonomy or independence; disrupted family life, grief, loneliness, helplessness, or hopelessness. I am seeing counselor at facility and have visits with [Psychiatrist] as needed. Interventions included: Monitor/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing medication or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness.<BR/>During an interview on 4/15/2025 at 10:48 AM, Resident #5 said Resident #3 was in the way while he was trying to get out the door to the smoking area. He said he asked him to let him get by and he said Resident #3 talked noise and cussed him out. He said Resident #3 was agitated and spoke in Spanish. He said Resident #3 turned around and was raising up out of his chair like he was going to fight. He said he then hit him with his walker. He said they both fell on the floor in the dining room. He said Resident #3 called the police and they came and talked to him and told him the next time they would take him to jail. He said if Resident #3 acted that way again he would hit him again. He said that had been the only physical incident he had with Resident #3. He said there was another guy on the 300 hall, Resident #4 had a physical altercation with Resident #3. He said Resident #3 had problems with a lot of residents because he was always in other people's business and cussing other residents.<BR/>During an interview on 4/15/2025 at 11:11 AM, Resident #7 said she called bingo when the activity director couldn't and said Resident #3 yelled out at her when she called bingo like a bully would. She said they sent Resident #3 to a behavioral hospital because he was physical with Resident #6. She said they initially put Resident #3 on another hall, but he was now back on her hall. She said Resident #3 would throw things. She said Resident #6 was really the only resident she had ever seen Resident #3 kick or get physical with. She said he kissed the older ladies', hands a lot and did not feel it was appropriate. She said one lady (unknown) finally yelled at him to stop and leave her alone. She said Resident #3 did a lot of cussing and calling people names. She said Resident #3 had asked her for sex, and she turned him down and he didn't like it. She said he asked a lot of the ladies and employees for sex. She said she was not afraid of him physically, but she was afraid of what he brought out in her and was afraid she would hit him. She said one time they got in an argument, and he tried to charge at her, and staff pulled him back. She said she felt so much better when he resided on a different hallway. She said he had just moved back to this hall yesterday 4/14/2025 because he got into an altercation with his roommate on the 300 hall and his roommate called the police. She said all altercations or arguments were always centered around Resident #3.<BR/>During an interview on 4/15/2025 at 11:25 AM revealed Resident #6 could not answer questions due to a diagnosis of aphasia (language disorder that results from damage to the brain's language centers).<BR/>During an interview on 4/15/2025 at 11:31 AM, CNA D said Resident #3 moved back to the 500 hall yesterday 4/14/2025. She said she did not know what prompted the move back to the 500 hall. She said Resident #3 was smart mouthed and disrespectful to staff and residents. She said a staff member would be talking to another resident and Resident #3 would chime in with his negative input. She said she had seen the arguing with Resident #3 but had never seen him get physical with anyone.<BR/>During an interview on 4/15/2025 at 12:52 PM, the ADON said he was an instigator and liked to create tiffs until other residents went off on him. She had been employed at the facility since December 2024, Resident #3 was sent to a behavioral hospital and had 2 room changes, and medication changes. She said the SW was sending out referrals to discharge Resident #3, but no one would accept him.<BR/>During an interview on 4/15/2025 at 1:13 pm, the DON said Resident #3 liked to stir the pot and instigate arguments with residents and staff. She said Resident #3 had been in a group home and multiple nursing homes prior to being at the facility. She said Resident #3 had issues when he was living at home with his mother and thought that adult protective services had been involved because Resident #3 had acted out and called the police many times while he was there. She said Resident #3 was sent to after he kicked Resident #6 at breakfast.<BR/>During an interview on 4/16/2025 at 10:01 am, the SW said on 3/25/25 Resident #3 kicked Resident #6 during breakfast because he was making some noise and Resident #3 did not like it. She said he came to her office that morning and said he had kicked Resident #6 but did not know why he did it. She said on 2/15/25 the residents were going out to smoke and Resident #3 was in the doorway and Resident #5 was telling him to go go go and he said he couldn't go so he was cussing Resident #5, and Resident #5 picked up his walker and hit Resident #3, and both residents began fighting and fell on the floor. She said Resident #3's head was sore from being hit and he had an abrasion but otherwise there were no other injuries. She said she saw the video footage and could not tell if Resident #3 was hit on the head or shoulder area. She said on 11/30/2024 Resident #3 and Resident #4 were outside in the smoking area and were going back and forth arguing and both residents ended up on the ground. She said she couldn't remember if either one actually hit the other one. She said she couldn't remember any other physical altercations she was aware of. She said Resident #3 was referred to counseling services on 11/5/24 but refused. She said on 2/19/25 the order and consent were received for counseling services, and he was evaluated by the counselor on 2/26/25. She said he had a verbal altercation a few days earlier and if another incident happened then they needed to seek further help for him. She said the Resident #3 received counseling services on Wednesday and the Psych MD and saw him monthly. She said she sent out 6 referrals to seek alternate placement for Resident #3 between 4/1/2025 and 4/15/2025 and all had been denied.<BR/>During an interview on 4/16/2025 at 11:50 am, the Administrator said Resident #3 had a history of behaviors. She said she knew Resident #3 had behaviors before the resident was admitted to the facility, but she accepted him anyway because she felt like they could help Resident #3. She said Resident #3 liked to instigate and stir the pot with other residents and staff. She said Resident #3 often inserted himself into conversations with staff and residents who were not about him. She said Resident #3 knew what he was doing and would often apologize after an altercation with staff or other residents.<BR/>During an interview on 4/16/2025 at 1:21 PM, Resident #3 said when he was 28 he was in the hospital for 2 months and that's when he was diagnosed with the Wilson's disease. He said he is a sweet guy but when you him make him mad, he turns into the devil. He said he did not receive counseling services at the facility. He said he had only talked to a counselor 1 time since he had been at the facility. He said when he had the incidents with other residents he would go and apologize after the incident was over. He said he did not have control over his actions when he got mad and he got anxious. He said he told Resident #4 to tie his shoe and Resident #4 told him to shut up and for him to tie it and said he got up and started walking over to him and they just began fighting and fell to the ground in the smoking area. He said Resident #5 told him to go out the door and he said Resident #5 took his walker and put it over his head and jerked it back as if to choke him. He said he kicked Resident #6 because he was jealous the staff were feeding Resident #6 and not him. He said he went to the behavior hospital after he kicked Resident #6. He said he got kicked out of another nursing facility for trying to bite the medication aide's finger.<BR/>During an interview on 4/17/2025 at 1:25 PM, Resident #4 said he did not like Resident #3 and said on the day in question he was in the smoking area. He said Resident #3 told him his shoe was untied and he told Resident #3 it was none of his business. He said Resident #3 would not leave him alone and he got mad and him and Resident #3 mutually began fighting and fell on the ground. He said after the incident he did not like Resident #3, but he just tried to stay away from him and stay out of trouble.<BR/>During an interview on 4/22/2025 at 9:28 AM, LVN A said on 2/15/2025 someone came and got her and let her know Resident #3 and Resident #5 were fighting in the kitchen. She said Resident #5 told her Resident #3 was talking bad to him. She said Resident #5 said he hit him. She said when she asked Resident #3 what happened he said Resident #5 was talking to someone else and Resident #3 got in their business and started the argument with Resident #5. She said both residents fell on the floor in the dining room. She said Resident #3 was always in someone else's business. She said she thought Resident #3 was just angry because he was in the nursing home. She said Resident #3 would wake up and just be mad at the world.<BR/>During an interview on 4/22/2025 at 10:14 AM, CNA E said on 2/15/2025 she was taking the smokers out and stook in the doorway. She said she heard Resident #5 tell Resident #3 to go and he said don't you see CNA E in the way. She said she didn't hear him say anything else and then Resident #5 put his walker over Resident #3 like he was trying to choke him with it. She said then Resident #3 started shaking and fell on the floor. She said Resident #3 called the police. Said she thought both residents had been arguing prior to the incident. She said Resident #3 could not get along with anyone.<BR/>Record review of the facility's policy titled Abuse, dated 2/1/2017, reflected: The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement, and or Misappropriation of property . Residents will not be subjected to abuse by anyone, including, but not limited to community staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, care taker, friends, or other individuals .<BR/>This was determined to be an Immediate Jeopardy (IJ) on 04/16/2025 at 5:42 PM. The facility Administrator was notified. The Administrator was provided with the IJ template on 4/16/2025 at 5:42 PM.<BR/>The following Plan of Removal submitted by the facility was accepted on 4/17/2025 at 2:07 PM:<BR/>The following is a plan of removal, which has been immediately implemented at the facility, to remedy the immediate jeopardy as a result of alleged deficient practices, which was imposed on April 16, 2025, at 5:45 PM. <BR/>F600 Abuse <BR/>11-30-24: Resident #3 was assessed on 11-30-24 after incident and had scratches to left arm that were treated in house. Resident #4 was assessed on 11-30-24 after incident and had no injuries or physical or emotional distress. DCO and LVNs redirected residents to their rooms and with no further smoke breaks for them that evening. Psych Services conducted a patient care call with Resident #3 on 12-2-24 with a new order for an increase to his Depakote ER to 1500 mg qhs. Psych Services conducted a patient care call with Resident #4 on 12-2-24 with no new orders. <BR/>2-15-25: Resident #3 was assessed on 2-15-25 after incident and had a small abrasion to right midback. Resident #5 was assessed on 2-15-25 after the incident and had no injuries. Police were called and they came and spoke to both residents and left. DRSS spoke with both residents individually on 2-17-25, and they reported no emotional effects from the incident and both residents were offered counseling services, which were refused. Psych services conducted a patient follow up visit on 2-18-25 on Resident #3 with no new orders or interventions. Resident #3 was reeducated on counseling services on 2-19-25 and agreed to the service and signed consent for treatment. Resident #5 refused counseling services again on 2-18-25.<BR/>3-25-25: Resident #3 was discharged to Behavioral hospital on 3-25-25 for behaviors. Resident #6 was assessed on 3-25-25 after the incident with no injuries. Psych Services visited Resident #6 on 3-29-25 with no new orders. <BR/>Immediate Action<BR/>All staff in-serviced on April 16, 2025, by Executive Director of Operations (EDO)/Director of Clinical Operations (DCO) and/or designee on the following topics: Prevention, Identification and Reporting/Investigation of Abuse; How to Immediately Protect Residents when abuse is suspected; Possible Interventions to Assist with De-escalation after an Incident. All staff not present at time of in-service will not be permitted back to work until in-service is complete. <BR/>4-16-25: Resident #3 was placed on one-to-one monitoring at 7:20pm. Discharge Planning initiated to family. Family agreed by phone to discharge resident to their care on 4-16-25 at 9pm. Resident remained on one-to-one monitoring until discharge on [DATE] at 7:52am.<BR/>4-16-25: Safe Surveys were conducted by DRSS and/or designee with all residents cognitively able to participate. Results of and action after Safe Surveys are as follows: 3 residents expressed that Resident #3 was rude- Resident #3 was on one-on-one monitoring, 1 resident expressed that a nurse was unsure of what to do for his wound care-resident no longer in facility, 1 resident expressed a CNA was rough during her bed bath-the resident was reinterviewed by DCO to get details, the resident did not think the CNA had been abusive or intentionally rough, it was determined that due to her current clinical condition she requires 2 person assistance for bed mobility and personal care, the care plan and tasks were updated on 4-17-25, One-on-one in-service to be completed on 4-17-25 with CNA.<BR/>4-17-25: All residents identified as at risk for physically aggressive behaviors were reviewed by the CRC/ADCO to ensure they had an accurate care plan, appropriate interventions and appropriate Psych Services or Counseling Services<BR/>The DCO/ADCO/EDO will monitor EMR documentation including the 24-hour report, incident reports and alerts, and Grievances to identify potential abuse or situations requiring further investigation during morning meeting. Abuse allegations will be reported and investigated according to company policy and THHS regulations. Potential abuse or situations requiring further investigation will be documented on a Grievance form with any investigation documentation attached. All staff in-serviced on April 17, 2025, on the Grievance process and utilizing the Grievance form to document the potential abuse or situation and the investigation.<BR/>The Medical Director was initially made aware on April 16, 2025, of the immediate jeopardy, and has been involved in the development of the plan to remove during an abbreviated QA. These conversations are considered a part of the QA process. Next schedule QA meeting set for April 21, 2025 at 12pm.<BR/>All in-servicing began on 4/16/2025.<BR/>This plan was initially implemented on 4/16/2025 and will be monitored, through personal observation, through completion by Regional [NAME] President of Operation and Regional Director of Clinical Services.<BR/>Monitoring of the Plan of Removal included the following:<BR/>During interviews on 4/17/2025 between 3:56 PM and 4:32 PM the following staff across multiple shifts were able to appropriately describe abuse, ways to prevent abuse, de-escalation techniques of abuse, 1 to 1 monitoring and the grievance process: CNA F, LVN G, LVN H, CNA J, Floor Tech, CNA K, LVN L, CNA M, Activity Director, CNA N, Cook, Dietary Aide, and CNA E. <BR/>Record review of skin assessment dated [DATE] for Resident #3.<BR/>Record review of skin assessment dated [DATE] for Resident #3.<BR/>Record review of behavioral hospital paperwork for Resident #3 dated 3/25/2025 through 4/2025.<BR/>Record review of in-service, dated 4/16/2025, on the following topics: Prevention, Identification and Reporting/Investigation of Abuse; How to Immediately Protect Residents when abuse is suspected; Possible Interventions to Assist with De-escalation after an Incident with 39 staff signatures.<BR/>Record review of every 15-minute monitoring for Resident #3 revealed 1 to 1 monitoring started on 4/16/2025 at 7:30PM and ended on 4/17/2025 at 7:52AM when Resident #3 discharged from the facility. <BR/>Record review of 66 safe surveys conducted on 4/16/2025 with no noted concerns.<BR/>Record review of inservice dated 4/17/2025 for completing grievance/complaint investigation report for with 11 staff signatures.<BR/>The Administrator was informed the Immediate Jeopardy was removed on 4/17/2025 at 4:35 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, which included to the State Survey Agency, in accordance with State law through established procedures for 3 of 7 residents (Resident #3, Resident #4 and Resident #6) reviewed for abuse. <BR/>1. The facility failed to immediately report an allegation of resident-to-resident abuse to HHSC after the allegation was made on 11/30/2024. On 11/30/2024 at 6:45 PM Resident #4 and Resident #3 had a physical altercation while outside in the smoking area.<BR/>2. The facility failed to report immediately report an allegation of resident-to-resident abuse to HHSC after the allegation was made on 3/25/2025 at 8:09 AM. On 3/25/2025 Resident #3 kicked Resident #6 multiple times during breakfast.<BR/>These failures could place residents at risk of further potential abuse. <BR/>Findings include: <BR/>1. Record review of the electronic face sheet for Resident #3 indicated Resident #3 admitted to the facility on [DATE] with the most recent readmission on [DATE] with diagnosis that included: bipolar disorder (significant shifts in mood, energy, and activity levels, causing periods of intense highs and lows), impulse disorder (difficulty controlling impulses, urges, or behaviors, leading to harmful or inappropriate actions), parkinsons (neurological disorder that primarily affects movement), wilsons disease (causes copper to build up in the liver, brain, and other organs).<BR/>Record review of Resident #3's admission MDS assessment dated [DATE] indicated a BIMS of 15, which indicates no cognitive impairment. <BR/>Record review of Resident #3's care plan dated 11/15/2024 indicated: I am exhibiting behavior of making flirtatious comments towards staff and some female residents. Interventions included: 1. [Counseling] services evaluate and treat. 2. Monitor/document/report PRN any signs/symptoms of resident posing danger to self and others. 3. Staff will monitor for safe environment and to ensure no unusual episodes occur. The care plan dated 3/4/2025 indicated I am exhibiting behavior of-verbal aggression to other residents, I like to stir the pot, boss people around and tell people what they can and can't do. I am often loud and obnoxious and often instigate arguments with staff and residents. Interventions included: 1. Monitor/document/report PRN and signs/symptoms of resident posing danger to self and others. 2. Psychological services evaluate and treat. 3. Staff will monitor for safe environment and to ensure no unusual episodes occur. 4. When the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away and approach later.<BR/>Record review of nursing progress notes, dated 3/25/2025 at 8:09 AM, written by the LVN A, indicated: It was reported to this nurse that [Resident #3] kicked another resident for no reason this morning at breakfast time. CNA E was feeding another resident and [Resident #3] decided to kick him multiple times. Resident is aware of possible consequences of his actions. Notified [DON].<BR/>2. Record review of the electronic face sheet for Resident #4 indicated Resident #4 admitted to the facility on [DATE] with the most recent admission on [DATE] with diagnosis that included: vascular dementia (difficulty thinking, memory and behavior), Hemiplegia (paralysis on the left side of the body), and muscle weakness.<BR/>Record review of Resident #4's admission MDS assessment dated [DATE] indicated a BIMS of 13, which indicates no cognitive impairment. It also indicated Resident #4 was independent with walking 150 feet.<BR/>Record review of Resident #4's care plan dated 11/15/2024 indicated: I have a ADL self-care performance deficits related to disease processes. I am mostly independent with ADLs with some assistance with set-up and supervision with locating thing. I have left side hemiplegia and walk with a cane. Interventions included: 1. Transfer: The resident requires supervision and set-up assistance by 1 staff to move between surfaces as necessary.<BR/>Record review of facility incident report for Resident #4 dated 11/30/2024 at 6:45pm indicated: Resident stated he was outside smoking when he and another male resident started arguing, he stated he walked up to the other resident and the other resident pulled himself up out of his wheelchair using him they began hitting one another and fell to the ground. The notes section indicated: Resident involved in physical altercation with [Resident #3]. Resident had words with another resident and both decided to show who was boss. Few slaps back and forth, easily redirected by staff present. No injury noted or complaint of pain. Both residents redirected to their room and further smoke breaks this evening.<BR/>Record review of facility progress note for Resident #4 dated 11/30/2024 at 7:31pm completed by the LVN C indicated: This nurse was at the medication cart when a dietary worker came in the hallway and stated, hey they need some help out here. Nurse went to the dining room and the door leading out to the smoke area was open. Resident was observed laying in the smoke area with<BR/>the other male resident beside him and they were both arguing and still trying to engage physically. Nurse stepped between them and assisted this resident up. Resident was assisted back in the facility and sat in a chair. After he got his shoes back on he was assisted to his room. Resident described in his words what happened. DON was notified. Resident was instructed to stay away from the other male resident and there would be no other smoke breaks for him. Resident did not have any visible physical injuries after assessment. Denies any physical or emotional distress.<BR/>3. Record review of the electronic face sheet for Resident #6 indicated Resident #6 admitted to the facility on [DATE] with diagnosis that included: intracerebral hemorrhage (stroke), Hemiplegia (paralysis on the right side of the body), and muscle weakness.<BR/>Record review of Resident #6's annual MDS assessment dated [DATE] indicated a BIMS of 03, which indicates severe cognitive impairment. It also indicated Resident #6 required substantial to maximal assistance with transfers.<BR/>Record review of Resident #6's care plan dated 1/5/2025 indicated: I received physical and verbal aggression from another resident when he was grabbed by the hand and another resident told him he would knock the hell out of him. I am still protective of other residents and may act aggressively towards others. Interventions included: 1. Resident will be assessed for emotional distress and physical injuries after incident and as needed. 2. Resident will be redirected when appropriate. 3. Resident will not go on the same smoke breaks as physically aggressive resident . 5. Staff will monitor for safe environment and to ensure no unusual episodes occur.<BR/>Record review of facility incident report for Resident #6 dated 1/5/2025 at 8:30am indicated: Resident was in dining room near the smoking door with another resident when his w/c bumped into the other resident's chair. The other resident grabbed his and told him if he did it again, he would knock the shit out of him. Residents were separated and no further physical contact was made. Resident was assessed for injuries with none observed. Resident showed no signs of emotional trauma. Residents will not go on the same smoke breaks together.<BR/>During an interview on 4/15/2025 at 11:25 AM revealed Resident #6 could not answer questions due to diagnosis of aphasia (language disorder that results from damage to the brain's language centers).<BR/>During an interview on 4/15/2025 at 11:31am CNA D said Resident #3 moved back to the 500 hall yesterday 4/14/2025. She said she did not know what prompted the move back to the 500 hall. She said Resident #3 was smart mouthed and disrespectful to staff and residents. She said a staff member would be talking to another resident and Resident #3 will chime in with his negative input. She said she had seen the arguing with Resident #3 but had never seen him get physical with anyone.<BR/>During an interview on 4/15/2025 at 12:52pm the ADON said he was an instigator and liked to create tiffs until other residents go off on him. She she had been employed at the facility since December 2024, Resident #3 had been sent to a behavioral hospital and had 2 room changes, and medication changes. She said the SW had been sending out referrals to discharge Resident #3, but no one would accept him.<BR/>During an interview on 4/15/2025 at 1:13pm the DON said Resident #3 liked to stir the pot and instigate arguments with residents and staff. She said Resident #3 had been in a group home and multiple nursing homes prior to being at the facility. She said Resident #3 had issues when he was living at home with his mother and thought that APS had been involved because Resident #3 had acted out and called the police many times while he was there. She said Resident #3 was sent to Brentwood after he kicked Resident #6 at breakfast.<BR/>During an interview on 4/16/2025 at 10:01am the SW said on 3/25/25 Resident #3 kicked Resident #6 during breakfast because he was making some noise and Resident #3 did not like it. She said he came to her office that morning and said he had kicked Resident #6 but did not know why he did it. She said on 11/30/2024 Resident #3 and Resident #4 were outside in the smoking area and were going back and forth arguing and both residents ended up on the ground. She said she couldn't remember if either one actually hit the other one. She said she couldn't remember any other physical altercations that she was aware of. She said Resident #3 was referred to counseling services on 11/5/24 but refused. She said on 2/19/25 the order and consent were received for counseling services, and he was evaluated by the counselor on 2/26/25. She said he had a verbal altercation a few days earlier and if another incident happened then they needed to seek further help for him. She said the Resident #3 received counseling services on Wednesday and the Psych MD and sees him monthly. She said she sent out 6 referrals to seek alternate placement for Resident #3 between 4/1/2025 and 4/15/2025 and all had been denied.<BR/>During an interview on 4/16/2025 at 11:50am the Administrator said had a history of behaviors. She said she knew that the Resident #3 had behaviors before Resident #3 admitted to the facility, but she accepted him anyway because she felt like they could help Resident #3. She said Resident #3 liked to instigate and stir the pot with other residents and staff. She said Resident #3 often inserted himself into conversations with staff and residents that were not about him. She said Resident #3 knew what he was doing and would often apologize after an altercation with staff or other residents. She said her expectation was to do their best to prevent abuse and if something did happen they reported and took action.<BR/>During an interview on 4/16/2025 at 1:21pm Resident #3 said when he was 28, he was in the hospital for 2 months and that's when he was diagnosed with the Wilson's disease. He said he is a sweet guy but when you him make him mad, he turns into the devil. He said he did not receive counseling services at the facility. He said he had only talked to a counselor 1 time since he had been at the facility. He said when he has the incidents with other residents, he will go an apologize after the incident was over. He said he did not have control over his actions when he gets mad, and he gets anxious. He said he told Resident #4 to tie his shoe and Resident #4 told him to shut up and for him to tie it and said he got up and started walking over to him and they just began fighting and fell to the ground in the smoking area. He said he kicked Resident #6 because he was jealous the staff were feeding Resident #6 and not him. He said he went to the behavior hospital after he kicked Resident #6. He said he got kicked out of another nursing facility for trying to bite the medication aide's finger.<BR/>During an interview on 4/17/2025 at 1:25pm Resident #4 said he did not like Resident #3 and said on the day in question he was in the smoking area. He said Resident #3 told him his shoe was untied and he told Resident #3 it was none of his business. He said Resident #3 would not leave him alone and he got mad and him and Resident #3 mutually began fighting and fell on the ground. He said after the incident he did not like Resident #3 but he just tried to stay away from him and stay out of trouble.<BR/>Record review of the facility's policy titled Abuse, dated 2/1/2017, reflected: . All events that involve an allegation of abuse or involve a suspicious serious bodily injury of unknown origin must be reported immediately or not later than 2 hours of alleged violation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have evidence that all alleged violations were thoroughly investigated and prevented further abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 3 of 7 residents (Residents #3, Resident #4 and Resident #6) reviewed for abuse/neglect.<BR/>The facility failed to prevent further potential abuse and mistreatment of Resident #4 and Resident #6 by allowing the alleged perpetrator Resident #3 to remain in the facility and to have direct contact with the residents. <BR/>An Immediate Jeopardy (IJ) situation was identified on 4/16/2025. While the IJ was removed on 4/17/2025, the facility remained out of compliance at a scope of a pattern with the potential for more than minimal harm due to the facility need to evaluate the effectiveness of the corrective systems.<BR/>This failure could place residents at risk for abuse, physical harm, psychosocial harm, trauma, unrecognized abuse and emotional distress.<BR/>The findings include: <BR/>1. Record review of the electronic face sheet for Resident #3 indicated Resident #3 admitted to the facility on [DATE] with the most recent readmission on [DATE] with diagnosis that included: bipolar disorder (significant shifts in mood, energy, and activity levels, causing periods of intense highs and lows), impulse disorder (difficulty controlling impulses, urges, or behaviors, leading to harmful or inappropriate actions), parkinsons (neurological disorder that primarily affects movement), wilsons disease (causes copper to build up in the liver, brain, and other organs).<BR/>Record review of Resident #3's admission MDS assessment dated [DATE] indicated a BIMS of 15, which indicates no cognitive impairment. <BR/>Record review of Resident #3's care plan dated 11/15/2024 indicated: I am exhibiting behavior of making flirtatious comments towards staff and some female residents. Interventions included: 1.[Counseling] services evaluate and treat. 2. Monitor/document/report PRN any signs/symptoms of resident posing danger to self and others. 3. Staff will monitor for safe environment and to ensure no unusual episodes occur. The care plan dated 3/4/2025 indicated I am exhibiting behavior of-verbal aggression to other residents, I like to stir the pot, boss people around and tell people what they can and can't do. I am often loud and obnoxious and often instigate arguments with staff and residents. Interventions included: 1. Monitor/document/report PRN and signs/symptoms of resident posing danger to self and others. 2. Psychological services evaluate and treat. 3. Staff will monitor for safe environment and to ensure no unusual episodes occur. 4. When the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away and approach later.<BR/>Record review of facility incident report for Resident #3 dated 2/15/2025 at 2:38pm completed by the LVN A indicated: Heard loud noises coming from dining room, when arrived to dining room, saw resident sitting on floor along with the other resident. Resident stated the CNA was in the way and [Resident #5] asked him to move and resident yelled back at him. Resident stated they both were going back and forth. [Resident #5] got angry and hit him on top of his head with walker. Staff member broke incident up.<BR/>Record review of nursing progress notes, dated 1/1/2025 at 4:30 PM, written by the LVN P, indicated: [Resident #3] is verbally aggressive towards another resident. Intervened at this time and DON aware.<BR/>Record review of nursing progress notes, dated 1/6/2025 at 12:38 PM, written by the SW, indicated: Spoke to [Resident #3] about an incident that occurred during a smoke break on 01/05/25. [Resident #3] stated that a male resident was hollering, cussing and calling his friend/another resident racial slurs. [Resident #3] said that he started to holler back at the male resident since his friend could not defend himself. [Resident #3] stated he was fine with the other resident now and that he just puts his headphones in his ears during smoke breaks to avoid the other resident. [Resident #3] was encouraged to keep doing that and to avoid any other future conflicts with the male resident.<BR/>Record review of nursing progress notes, dated 1/24/2025 at 9:59 AM ,written by the SW, indicated: Spoke to [Resident #3] about the way he talks to other residents in the facility. [Resident #3] stated he cares for some of the residents and wants to teach them and keep them from getting into things they are not supposed to. Educated [Resident #3] that when he cusses, hollers and tells other residents what to do - it is not helping them. Informed [Resident #3] to let the staff redirect other residents. [Resident #3] understood and stated he would stop 'getting onto' and hollering at residents.<BR/>Record review of nursing progress notes, dated 2/19/2025 at 3:25 PM, written by the SW, indicated: Spoke with [Resident #3] with EDO regarding comments that resident was making towards staff, and reports of him touching female staff inappropriately. Education was provided to resident on why the statements he was making, and his actions were not appropriate. Also educated [Resident #3] that the facility cannot tolerate him touching the female staff on the bottoms or anywhere else [Resident #3] stated he understood and would not do those things anymore. [Resident #3] was educated on [counseling] clinical services to help with these behaviors and [Resident #3] agreed to these services.<BR/>Record review of nursing progress notes, dated 2/20/2025 at 3:46 PM, written by the SW, indicated: Spoke with [Resident #3] with EDO regarding behaviors that were observed by staff today. Educated [Resident #3] again on the expectations that the facility has for him on his treatment towards staff and other residents. [Resident #3] stated that he is 'trying to remember when we talked last, and to do better.' [Resident #3] stated he understood that he is not supposed to touching staff inappropriately, other residents or cursing towards staff and residents. Educated [Resident #3] again on reporting to nursing staff if he has a concern with other residents - that he should not try and 'help' the resident himself. [Resident #3] stated he understood and that he wants to stay at the facility. [Resident #3] was informed that alternate placement would be considered if resident's behaviors continued. [Resident #3] is now receiving services from Psychiatry and [counseling] Clinical Services to help with behaviors.<BR/>Record review of nursing progress notes, dated 3/16/2025 at 3:03 PM, written by the RN O, indicated: [Resident #3] was heard yelling at another resident to pull his pants up. Both residents were yelling at each other. Resident was redirected to the dining area.<BR/>Record review of nursing progress notes, dated 3/24/2025, written by the SW, indicated: Care Plan meeting with resident, Ombudsman, DCO, ADCO and DRSS. Discussed residents behavior towards staff and how the facility will not tolerate them. Ombudsman educated resident on his rights and other residents rights and education on the facility discharging him if behaviors continue. Resident stated he understood and that he wanted to stay at the facility. Resident also stated that he understands that he should not holler and 'pick on' other residents. DCO and ADCO educated resident on all interventions the facility have made to improve behaviors and resident stated he understood. Resident stated he would limit behaviors.<BR/>Record review of nursing progress notes, dated 3/25/2025 at 8:09 AM, written by LVN A indicated: It was reported to this nurse that [Resident #3] kicked another resident for no reason this morning at breakfast time. Staff CNA was feeding another resident and [Resident #3] decided to kick him multiple times. Resident is aware of possible consequences of his actions. Notified [DON].<BR/>Record review of nursing progress notes, dated 3/25/2025 at 8:16 AM, written by the SW, indicated: [Resident #3 came into DRSS office stating, 'I have to tell you something before anyone else does.' [Resident #3] stated that he 'kicked' another male resident during breakfast and that he did it for no real reason. [Resident #3] stated he knew it was wrong and that he would apologize to male resident. [Resident #3] went to doorway of my office and said 'I'm sorry' to male resident then asked if this SW heard him apologize. Reminded [Resident #3] that we just had a meeting yesterday with the ombudsman about his behaviors towards other residents. [Resident #3] stated he remembered the meeting and that is why he wanted to tell me and apologize.<BR/>Record review of nursing progress notes, dated 4/14/2025 at 7:28 AM, written by the ADON, indicated: This nurse was in office when a verbal altercation between this [Resident #3] and roommate. [Resident #3] states that his roommate was on the phone and 'he was lying to whoever he was talking, all he does is lie when what he needs to do is get his fat ass up. But I never threatened him' This nurse informed resident that the phone conversation that roommate is having has nothing to do with [Resident #3]. [Resident #3] states 'well, I am sick of him lying all the time.' [Resident #3] was assisted in getting dressed and was taken from room. Roommate called police department over altercation, officer was dispatched, where it was determined that no offense occurred. Administrator notified of situation.<BR/>Record review of nursing progress notes, dated 4/14/2025 at 11:30 AM, written by the SW, indicated: Spoke to [Resident #3] regarding an altercation he had with his roommate. [Resident #3] stated he 'didn't meant to holler' towards roommate and that his roommate 'lies to people' on the phone all the time. Educated [Resident #3] that he did not need to intervene in other resident's business. Educated resident that if he had any concerns to come to staff - [Resident #3] understood that hollering towards resident was inappropriate and that he would not do that again. [Resident #3] agreed to room change as well.<BR/>2. Record review of the electronic face sheet for Resident #4 indicated Resident #4 admitted to the facility on [DATE] with the most recent admission on [DATE] with diagnosis that included: vascular dementia (difficulty thinking, memory and behavior), Hemiplegia (paralysis on the left side of the body), and muscle weakness.<BR/>Record review of Resident #4's admission MDS assessment dated [DATE] indicated a BIMS of 13, which indicates no cognitive impairment. It also indicated Resident #4 was independent with walking 150 feet.<BR/>Record review of Resident #4's care plan dated 11/15/2024 indicated: I have a ADL self-care performance deficits related to disease processes. I am mostly independent with ADLs with some assistance with set-up and supervision with locating thing. I have left side hemiplegia and walk with a cane. Interventions included: 1. Transfer: The resident requires supervision and set-up assistance by 1 staff to move between surfaces as necessary.<BR/>Record review of facility incident report for Resident #4 dated 11/30/2024 at 6:45pm indicated: Resident stated he was outside smoking when he and another male resident started arguing, he stated he walked up to the other resident and the other resident pulled himself up out of his wheelchair using him they began hitting one another and fell to the ground. The notes section indicated: Resident involved in physical altercation with [Resident #3]. Resident had words with other resident and both decided to show who was boss. Few slaps back and forth, easily redirected by staff present. No injury noted or complaint of pain. Both residents redirected to their room and further smoke breaks this evening.<BR/>Record review of facility progress note for Resident #4 dated 11/30/2024 at 7:31pm completed by the LVN C indicated: This nurse was at the medication cart when a dietary worker came in the hallway and stated hey they need some help out here. Nurse went to the dining room and the door leading out to the smoke area was open. Resident was observed laying in the smoke area with<BR/>the other male resident beside him and they were both arguing and still trying to engage physically. Nurse stepped between them and assisted this resident up. Resident was assisted back in the facility and sat in a chair. After he got his shoes back on he was assisted to his room. Resident described in his words what happened. DON was notified. Resident was instructed to stay away from the other male resident and there would be no other smoke breaks for him. Resident did not have any visible physical injuries after assessment. Denies any physical or emotional distress.<BR/>3. Record review of the electronic face sheet for Resident #5 indicated Resident #5 admitted to the facility on [DATE] with diagnosis that included: toxic encephalopathy (brain disorder caused by exposure to toxic substances), chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe), type 2 diabetes (high blood sugar).<BR/>Record review of Resident #5's quarterly MDS assessment dated [DATE] indicated a BIMS of 14, which indicates no cognitive impairment. It also indicated Resident #2 was independent with walking 150 feet.<BR/>Record review of Resident #5's care plan dated 2/21/2025 indicated: The resident was/has potential to be physically aggressive hit another resident with walker, related to anger, poor impulse control 2/15/25-became impatient with another resident and hit that resident with walker. Interventions included: 1. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document . 3. Monitor/document/report PRN any s/sx of resident posing danger to self and others. 4. Offer psych or psychology services as needed. 5. Social Worker to talk and evaluate resident after any incidents. 6. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.<BR/>Record review of facility progress notes for Resident #5 dated 2/15/2025 at 3:16pm completed by the LVN A indicated: Resident had an witnessed physical altercation with another resident. Resident was found sitting on the floor in front of his walker. Resident denies pain or discomfort at this time. Resident vital signs are stable. No injuries noted at this time.<BR/>4. Record review of the electronic face sheet for Resident #6 indicated Resident #6 admitted to the facility on [DATE] with diagnosis that included: intracerebral hemorrhage (stroke), Hemiplegia (paralysis on the right side of the body), and muscle weakness.<BR/>Record review of Resident #6's annual MDS assessment dated [DATE] indicated a BIMS of 03, which indicates severe cognitive impairment. It also indicated Resident #6 required substantial to maximal assistance with transfers.<BR/>Record review of Resident #6's care plan dated 1/5/2025 indicated: I received physical and verbal aggression from another resident when he was grabbed by the hand and another resident told him he would knock the hell out of him. I am still protective of other residents and may act aggressively towards others. Interventions included: 1. Resident will be assessed for emotional distress and physical injuries after incident and as needed. 2. Resident will be redirected when appropriate. 3. Resident will not go on the same smoke breaks as physically aggressive resident . 5. Staff will monitor for safe environment and to ensure no unusual episodes occur.<BR/>Record review of facility incident report for Resident #6 dated 1/5/2025 at 8:30am indicated: Resident was in dining room near the smoking door with another resident when his w/c bumped into the other resident's chair. The other resident grabbed his and and told him if he did it again he would knock the shit out of him. Residents were separated and no further physical contact was made. Resident was assessed for injuries with none observed. Resident showed no signs of emotional trauma. Residents will not go on the same smoke breaks together.<BR/>5. Record review of the electronic face sheet for Resident #7 indicated Resident #7 admitted to the facility on [DATE] with the most recent admission on [DATE] with diagnosis that included: major depressive disorder (persistently low mood), chronic respiratory failure with hypoxia (lungs cannot adequately provide oxygen to the blood), and muscle weakness.<BR/>Record review of Resident #7's quarterly MDS assessment dated [DATE] indicated a BIMS of 15, which indicates no cognitive impairment. It also indicated Resident #4 required supervision or touching assistance with walking 150 feet.<BR/>Record review of Resident #7's care plan dated 4/15/2022 indicated: I may have a potential for Coping Impaired related to situational and social factors including loss of autonomy or independence; disrupted family life, grief, loneliness, helplessness, or hopelessness. I am seeing counselor at facility and have visits with [Psychiatrist] as needed. Interventions included: Monitor/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness.<BR/>During an interview on 4/15/2025 at 10:48am Resident #5 said Resident #3 was in the way while he was trying to get out the door to the smoking area. He said he asked him to let him get by and he said Resident #3 talked noise and cussed him out. He said Resident #3 was agitated and speaking in Spanish. He said Resident #3 turned around and was raising up out of his chair like he was going to fight. He said he then hit him with his walker. He said they both fell on the floor in the dining room. He said Resident #3 called the police and they came and talked to him and told him the next time they would take him to jail. He said if Resident #3 acted that way again he would hit him again. He said that had been the only physical incident he had with Resident #3. He said there was another guy on the 300 hall Resident #4 that had a physical altercation with Resident #3. He said Resident #3 had problems with a lot of residents because he was always in other peoples business and cussing other residents.<BR/>During an interview on 4/15/2025 at 11:11am Resident #7 Said she calls bingo when the activity director can't and said Resident #3 yells out at her when she calls bingo like a bully would. She said they sent Resident #3 to a behavioral hospital because he was physical with Resident #6. She said they initially put Resident #3 on another hall, but he is now back on her hall. She said Resident #3 will throw things. She said Resident #6 is really the only resident she had ever seen Resident #3 kick or get physical with. She said he kissed the older ladies' hands a lot and did not feel it was appropriate. She said one lady (unknown) finally yelled at him to stop and leave her alone. She said Resident #3 did a lot of cussing and calling people names. She said Resident #3 had asked her for sex, and she turned him down and he didn't like it. She said he asked a lot of the ladies and employees for sex. She said she was not afraid of him physically, but she was afraid of what he brought out in her and was afraid she would hit him. She said one time they got in an argument, and he tried to charge at her, and staff pulled him back. She said she felt so much better when he resided on a different hallway. She said he had just moved back to this hall yesterday 4/14/2025 because he got into an altercation with his roommate on the 300 hall and his roommate called the police. She said all altercations or arguments is always centered around Resident #3.<BR/>During an interview on 4/15/2025 at 11:25am Resident #6 could not answer questions due to diagnosis of aphasia (language disorder that results from damage to the brain's language centers).<BR/>During an interview on 4/15/2025 at 11:31am CNA D said Resident #3 moved back to the 500 hall yesterday 4/14/2025. She said she did not know what prompted the move back to the 500 hall. She said Resident #3 was smart mouthed and disrespectful to staff and residents. She said a staff member would be talking to another resident and Resident #3 will chime in with his negative input. She said she had seen the arguing with Resident #3 but had never seen him get physical with anyone.<BR/>During an interview on 4/15/2025 at 12:52pm the ADON said he was an instigator and liked to create tiffs until other residents go off on him. She she had been employed at the facility since December 2024, Resident #3 had been sent to a behavioral hospital and had 2 room changes, and medication changes. She said the SW had been sending out referrals to discharge Resident #3, but no one would accept him.<BR/>During an interview on 4/15/2025 at 1:13pm the DON said Resident #3 liked to stir the pot and instigate arguments with residents and staff. She said Resident #3 had been in a group home and multiple nursing homes prior to being at the facility. She said Resident #3 had issues when he was living at home with his mother and thought that APS had been involved because Resident #3 had acted out and called the police many times while he was there. She said Resident #3 was sent to Brentwood after he kicked Resident #6 at breakfast.<BR/>During an interview on 4/16/2025 at 10:01am the SW said on 3/25/25 Resident #3 kicked Resident #6 during breakfast because he was making some noise and Resident #3 did not like it. She said he came to her office that morning and said he had kicked Resident #6 but did not know why he did it. She said on 2/15/25 the residents were going out to smoke and Resident #3 was in the doorway and Resident #5 was telling him to go go go and he said he couldn't go so he was cussing Resident #5 and Resident #5 picked up his walker and hit Resident #3 and both residents began fighting and fell on the floor. She said Resident #3's head was sore from being hit and he had an abrasion but otherwise there were no other injuries. She said she saw the video footage and could not tell if Resident #3 was hit on the head or shoulder area. She said on 11/30/2024 Resident #3 and Resident #4 were outside in the smoking area and were going back and forth arguing and both residents ended up on the ground. She said she couldn't remember if either one actually hit the other one. She said she couldn't remember any other physical altercations that she was aware of. She said Resident #3 was referred to counseling services on 11/5/24 but refused. She said on 2/19/25 the order and consent were received for counseling services, and he was evaluated by the counselor on 2/26/25. She said he had a verbal altercation a few days earlier and if another incident happened then they needed to seek further help for him. She said the Resident #3 received counseling services on Wednesday and the Psych MD and sees him monthly. She said she sent out 6 referrals to seek alternate placement for Resident #3 between 4/1/2025 and 4/15/2025 and all had been denied.<BR/>During an interview on 4/16/2025 at 11:50am the Administrator said had a history of behaviors. She said she knew that the Resident #3 had behaviors before Resident #3 admitted to the facility, but she accepted him anyway because she felt like they could help Resident #3. She said Resident #3 liked to instigate and stir the pot with other residents and staff. She said Resident #3 often inserted himself into conversations with staff and residents that were not about him. She said Resident #3 knew what he was doing and would often apologize after an altercation with staff or other residents.<BR/>During an interview on 4/16/2025 at 1:21pm Resident #3 said when he was 28 he was in the hospital for 2 months and that's when he was diagnosed with the Wilson's disease. He said he is a sweet guy but when you him make him mad, he turns into the devil. He said he did not receive counseling services at the facility. He said he had only talked to a counselor 1 time since he had been at the facility. He said when he has the incidents with other residents he will go an apologize after the incident was over. He said he did not have control over his actions when he gets mad and he gets anxious. He said he told Resident #4 to tie his shoe and Resident #4 told him to shut up and for him to tie it and said he got up and started walking over to him and they just began fighting and fell to the ground in the smoking area. He said Resident #5 told him to go out the door and he said Resident #5 took his walker and put it over his head and jerked it back as if to choke him. He said he kicked Resident #6 because he was jealous the staff were feeding Resident #6 and not him. He said he went to the behavior hospital after he kicked Resident #6. He said he got kicked out of another nursing facility for trying to bite the medication aide's finger.<BR/>During an interview on 4/17/2025 at 1:25pm Resident #4 said he did not like Resident #3 and said on the day in question he was in the smoking area. He said Resident #3 told him his shoe was untied and he told Resident #3 it was none of his business. He said Resident #3 would not leave him alone and he got mad and him and Resident #3 mutually began fighting and fell on the ground. He said after the incident he did not like Resident #3 but he just tried to stay away from him and stay out of trouble.<BR/>During an interview on 4/22/2025 at 9:28am LVN A said on 2/15/2025 someone came and got her and let her know Resident #3 and Resident #5 were fighting in the kitchen. She said Resident #5 told her that Resident #3 was talking bad to him. She said Resident #5 said he hit him. She said when she asked Resident #3 what happened he said Resident #5 was talking to someone else and Resident #3 got in their business and started the argument with Resident #5. She said both residents fell on the floor in the dining room. She said Resident #3 was always in someone else's business. She said she thought Resident #3 was just angry because he was in the nursing home. She said Resident #3 would wake up and just be mad at the world.<BR/>During an interview on 4/22/2025 at 10:14am CNA E said on 2/15/2025 she was taking the smokers out and was standing in the doorway. She said she heard Resident #5 tell Resident #3 to go and he said don't you see CNA E in the way. She said she didn't hear him say anything else and then Resident #5 put his walker over Resident #3 like he was trying to choke him with it. She said then Resident #3 started shaking and fell on the floor. She said Resident #3 called the police. Said she thought both residents had been arguing prior to the incident. She said Resident #3 could not get along with anyone.<BR/>Record review of the facility's policy titled Abuse, dated 2/1/2017, reflected: . Residents will not be subjected to abuse by anyone, including, but not limited to community staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, care taker, friends, or other individuals .Upon notification of an allegation of physical or mental abuse, neglect or involuntary seclusion, the facility will conduct interviews that include documented statement summaries from the alleged perpetrator, the alleged victim, family members, visitors who may have made observations, roommate, and any staff who worked prior to and during the time of the incident. Investigations will focus on determining if the abuse occurred, the extent of the abuse and potential causes . <BR/>This was determined to be an Immediate Jeopardy (IJ) on 04/16/2025 at 5:42 PM. The facility Administrator was notified. The Administrator was provided with the IJ template on 4/16/2025 at 5:42 PM.<BR/>The following Plan of Removal submitted by the facility was accepted on 4/17/2025 at 2:07 PM:<BR/>The following is a plan of removal, which has been immediately implemented , to remedy the immediate jeopardy as a result of alleged deficient practices, which was imposed on April 16, 2025 at 5:45pm. <BR/>F610 Investigate/Prevent/Correct Alleged Violation <BR/>11-30-24: Resident #3 was assessed on 11-30-24 after incident and had scratches to left arm that were treated in house. Resident #4 was assessed on 11-30-24 after incident and had no injuries or physical or emotional distress. DCO and LVNs redirected residents to their rooms and with no further smoke breaks for them that evening. Psych Services conducted a patient care call with Resident #3 on 12-2-24 with a new order for an increase to his Depakote ER to 1500 mg qhs. Psych Services conducted a patient care call with Resident #4 on 12-2-24 with no new orders. <BR/>2-15-25: Resident #3 was assessed on 2-15-25 after incident and had a small abrasion to right midback. Resident #5 was assessed on 2-15-25 after the incident and had no injuries. Police were called and they came and spoke to both residents and left. DRSS spoke with both residents individually on 2-17-25, and they reported no emotional effects from the incident and both residents were offered counseling services, which were refused. Psych services conducted a patient follow up visit on 2-18-25 on Resident #3 with no new orders or interventions. Resident #3 was reeducated on counseling services on 2-19-25 and agreed to the service and signed consent for treatment. Resident #5 refused counseling services again on 2-18-25.<BR/>3-25-25: Resident #3 was discharged to Behavioral hospital on 3-25-25 for behaviors. Resident #6 was assessed on 3-25-25 after the incident with no injuries. Psych Services visited Resident #6 on 3-29-25 with no new orders. <BR/>Immediate Action<BR/>All staff in-serviced on April 16, 2025 by Executive Director of Operations (EDO)/Director of Clinical Operations(DCO) and/or designee on the following topics: Prevention, Identification and Reporting/Investigation of Abuse. All staff not present at time of in-service will not be permitted back to work until in-service is complete. <BR/>The EDO/DCO were in-serviced on 4-16-25 by the RDCO on Prevention, Identification and Reporting/Investigation of Abuse.<BR/>4-16-25: Resident #3 was placed on one-to-one monitoring at 7:20pm. Discharge Planning initiated to family. Family agreed by phone to discharge resident to their care on 4-16-25 at 9pm. Resident remained on one-to-one monitoring until discharge on [DATE] at 7:52am.<BR/>4-16-25: Safe Surveys were conducted by DRSS and/or designee with all residents cognitively able to participate. Results of and action after Safe Surveys are as follows: 3 residents expressed that Resident #3 was rude- Resident #3 was on one-on-one monitoring, 1 resident expressed that a nurse was unsure of what to do for his wound care-resident no longer in facility, 1 resident expressed a CNA was rough during her bed bath-the resident was reinterviewed by DCO to get details, the resident did not think the CNA had been abusive or intentionally rough, it was determined that due to her current clinical condition she requires 2 person assistance for bed mobility and personal care, the care plan and tasks were updated on 4-17-25, One-on-one in-service to be completed on 4-17-25 with CNA.<BR/>4-17-25: All residents identified as at risk for physically aggressive behaviors were reviewed by the CRC/ADCO to ensure they had an accurate care plan, appropriate interventions and appropriate Psych Services or Counseling Services<BR/>The DCO/ADCO/EDO will monitor EMR documentation including the 24-hour report, incident reports and alerts, and Grievances to identify potential abuse or situati[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 7 (Resident #1 and Resident #2) residents reviewed for supervision.<BR/>The facility failed to ensure the secured unit courtyard gates were locked after lawn care services on 6/3/2024. On 6/3/2024 Resident #1 eloped from the facility grounds through an unlocked gate in the courtyard of the secured unit. A good Samaritan encountered Resident #1 at a nearby doctor's office and Resident #1 was returned to the facility.<BR/>The facility failed to provide adequate supervision for Resident #2. On 1/3/2025 Resident #2 eloped from the facility through the front door. A good Samaritan encountered Resident #2 at a nearby roadway intersection and returned Resident #2 to the facility.<BR/>An IJ was identified on 4/15/2025. The IJ template was provided to the facility on 4/15/2025 at 4:51 PM. While the IJ was removed on 4/17/2025, 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 because (e.g.) all staff had not been trained on the facilities elopement policy.<BR/>This failure could place residents at risk of not being properly supervised resulting in injury or death. <BR/>Findings included: <BR/>1.Record review of the electronic face sheet for Resident #1 indicated Resident #1 admitted to the facility on [DATE] with diagnosis that included: dementia (decline in cognitive function), muscle weakness, type 2 diabetes (high blood sugar).<BR/>Record review of Resident #1's annual MDS assessment dated [DATE] indicated a BIMS of 03, which indicates severe cognitive impairment. It also indicated Resident #1 was independent with walking 150 feet.<BR/>Record review of Resident #1's care plan dated 3/11/2024 indicated: I am exhibiting behavior of wandering. I have dementia and may wander or pace. I may enter other's rooms uninvited. I respond well to redirection at this time. I have been moved to secured unit for safety. Interventions included: Staff will monitor for safe environment and to ensure no unusual episodes occur.<BR/>Record review of Resident #1's elopement risk assessment dated [DATE] indicated an elopement score of 15 which was of high risk category.<BR/>Record review of Resident #1's elopement risk assessment dated [DATE] indicated an elopement score of 3 which was of medium risk category.<BR/>Record review of facility incident report for Resident #1 dated 6/3/2024 at 3:31pm completed by the DON indicated: Resident had finished eating lunch and asked to go outside in the courtyard, approximately, 12:55pm. At 1:08pm a family member of a staff member, [family member] called facility asking if we were missing one of our residents. Staff immediately left facility, where [family member] had resident and brought him back to facility at approximately 1:13pm just smiling. When SW interviewed resident, he remembers leaving facility on foot but doesn't know where he was going. <BR/>2. Record review of the electronic face sheet for Resident #2 indicated Resident #2 admitted to the facility on [DATE] with diagnosis that included: anxiety (feelings of worry or unease), metabolic encephalopathy (brain dysfunction), type 2 diabetes (high blood sugar).<BR/>Record review of Resident #2's admission MDS assessment dated [DATE] indicated a BIMS of 01, which indicates severe cognitive impairment. It also indicated Resident #2 partial to moderate assistance with walking 150 feet.<BR/>Record review of Resident #2's care plan dated 1/3/2025 indicated: I will reside on the facility secured care unit due to wander/elopement risks. Related to disoriented to place, history of attempts to leave facility unattended, impaired safety awareness. Interventions included: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book.<BR/>Record review of Resident #2's elopement risk assessment dated [DATE] indicated an elopement score of 3 which was of medium risk category.<BR/>Record review of Resident #2's elopement risk assessment dated [DATE] indicated an elopement score of 9 which was of high risk category.<BR/>Record review of facility incident report for Resident #2 dated 1/3/2025 at 8:30am completed by the ADON indicated: A community member knocked on front entrance door with resident noted to be sitting in wheelchair, stating he was down there in the road Resident assessed with no noted distress. Resident #2 said I just want to go home.<BR/>Record review of facility incident report for Resident #2 dated 1/3/2025 at 8:30am notes completed by the DON indicated: from review of cameras-resident left building behind [family member] family member who did not close the door after him. Per staff-they saw resident on 400 hall approximately, 8 am as they went into a staff meeting, when they came out at approximately 8:10 he was out of facility and in process of being returned.<BR/>Record review of Resident #2's electronic medical record indicated Resident #2 expired in the facility on 1/18/2025. <BR/>During an interview on 4/15/2025 at 11:44am CNA Q said they document once a shift to check the outside doors and gates to make sure they are locked. She said for the back door you have to put in the door code and that unlocks the door and the outside gate. She said you have to be fast to go down to the gate because it locks back pretty fast. She said the dining room door is unlocked and residents can come and go as they want. She said they have to push the emergency exit button that unlocks all doors in the secured unit to unlock the gate in the dining room courtyard. She said they have to push and turn the emergency exit button again to lock the gate back. She said when the [NAME] come the button releases the gate and one of them goes and opens the gate and then the other pushes the button to lock all the doors back. She said when the lawn care service was at the facility, they had to watch the residents in the secure unit to ensure no one got out of the locked doors. She said the staff had to remember to relock the doors and gates after the lawn care service was finished.<BR/>During and observation and interview on 4/15/2025 at 11:44am CNA R said that all gates are checked once a shift and CNA Q usually already checked them prior to him getting to work so he typically did not check them. CNA R put in the code on the back door of the secured unit. CNA R said the code would release the back door and also the gate outside of the back hallway door. Surveyor observed the gate being released and the gate required being pushed back so the magnets on the gate would reattach and lock the gate. If the gate was not pushed back together the gate would not lock. The secured unit dining room door was observed with no lock and residents could come and go freely to the outside courtyard. CNA Q pushed the emergency exit button which then released all locked doors of the secured unit. CNA Q then pushed and turned the emergency exit button in the dining room to relock the secured unit doors and gates. The Surveyor observed the courtyard gate had to be physically pushed back together in order for the magnets to reattach and lock the gate. Resident #1 was sitting outside during this observation and got up and went and checked to see if the gate was locked. CNA R said they had to keep a closer watch on the residents when the lawn care service was there and then had to remember to relock the doors and gates once they were finished.<BR/>During an interview on 4/15/2025 at 12:52pm the ADON said she started in December 2024 right before the Resident #2's elopement. She said a passerby came and knocked on the door and said Resident #2 was out and had brought him back to the door. She said she didn't know where she had encountered Resident #2 and did not have contact with anyone at the facility and was just driving by. She said they took Resident #2 to the unit and assessed Resident #2 and then checked the door locks and alarms. She said she saw Resident #2 at around 8:00am and she didn't know how long Resident #2 was out before being brought back to the facility. <BR/>During an interview on 4/15/2025 at 1:13pm the DON said Resident #1 got out the gate and went to a nearby doctor's office. She said Resident #1 was brought back to the facility at 1:13pm. She said at 12:55pm Resident #1 was last seen after he had just finished lunch and then was returned to the facility at 1:13pm. She said they believed there was an issue with the magnetic lock but when the lock was checked it was fine. She said the lawn care service had been there the day before but is not sure if that was the cause. She said staff were supposed to do 4-hour checks on the gates that was started prior to the elopement. She said they had a monitoring sheet for the gate checks but was not able to find any monitoring sheets since December 2024. She said Resident #2 admitted on [DATE] and eloped on 1/3/25. She said Resident #2 went to the door and wheeled out the door right behind another family member. She said a passerby brought the resident back from down the street on the corner at the redlight. She said Resident #2 went out at 8:10am and was brought back to the facility at 8:26am.<BR/>During an interview on 4/22/2025 at 9:28am LVN A said she was here the day Resident #2 eloped but said all she remembered was that Resident #2 kept saying he wanted to go home. She said Resident #2 kept going to the doors trying to get out and someone would redirect him and then he eloped.<BR/>During an interview on 4/22/2025 at 9:50am LVN H said Resident #1 had gotten out of the secured unit before the elopement. He said Resident #1 liked standing by the doors and one day he didn't close the door soon enough and Resident #1 got out of the secured unit and was walking around the nurse's station. He said he had eyes on Resident #1 the whole time and was easy to get back into the secured unit. He said he didn't remember the day he got out of the gate. He said he was here the day Resident #2 eloped but by the time he knew anything about it they had already gotten Resident #2 back in the facility.<BR/>During an interview on 4/22/2025 at 10:48am with the Administrator via phone, she said her expectation was to prevent elopements. She said if a resident were to elope that resident was in danger of being hurt.<BR/>Record review of the facilities Elopement policy dated 11/1/2019 indicated: To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing .<BR/>This was determined to be an Immediate Jeopardy (IJ) on [Date] at [Time]. The [Titles of people identified] were notified. The [Name of person given the IJ template] was provide with the IJ template on [Date] at [Time].<BR/>I<BR/>. <BR/>The facility's plan of removal was accepted on 4/16/2025 at 9:16 am and included:<BR/>The following is a plan of removal, which has been immediately implemented at the facility to remedy the immediate jeopardy as a result of alleged deficient practices, which was imposed on April 15, 2025 at 5:26pm. <BR/>Resident #1 was assessed and interviewed upon return on 6-3-24. The resident was not injured and was not in distress. The Maintenance Director checked the functioning of the magnetic locks on the doors and gates on the secured unit, all were in working order. Secured Unit staff were educated on 6-3-24 on the required gate lock checks every 4 hours and to complete the Secured Unit Gate Monitoring Log.<BR/>Resident #2 was assessed upon return on 1-3-25. The resident was not injured and was not in distress. The Maintenance Director and EDO checked all exit doors for functioning of key pads and alarms, all were in working order. Video footage revealed the resident exited the front door behind another resident's family member. The resident was moved to the secured unit due to the new elopement risk on 1-3-25. The front door code was changed on 1-3-25, and a staff in-service was completed on 1-3-25 on keeping the code confidential.<BR/>All staff in-serviced on Elopement/Missing Resident on April 15, 2025 by Executive Director of Operations (EDO)/Director of Clinical Operations(DCO) and/or designee. All staff not present at time of in-service will not be permitted back to work until in-service is complete. <BR/>All staff in-serviced on magnetic lock reset function during power disruption on April 15, 2025 by EDO and DCO. All staff not present at time of in-service will not be permitted back to work until in-service and competency test is complete. implemented and educated all staff on new process during lawn care services on April 15, 2025. New process adopted by facility is as follows: Facility staff will bring residents inside during lawn care and monitor all exit doors to not allow residents to leave secured unit hallway. Staff will then reengage the magnetic locks when lawncare is completed and verify that each door and gate are secured.<BR/>Lawn vendor contacted on April 15, 2025 at 8:45 pm by EDO and educated on communication with EDO and/or DCO about exiting the property and verifying the gate is secured. <BR/>All staff in-serviced on facility door code confidentiality and who to contact if he/she feels the code has been compromised on April 15, 2025 by EDO and DCO. All staff not present at time of in-service will not be permitted back to work until in-service is completed. Facility EDO reviewed and in-serviced on facility policy to door code changes. <BR/>All resident with risk of elopement have the potential to be affected by the this alleged deficient practice. An audit was completed on 4-15-25 by the CRC to ensure all residents had a current elopement risk assessment and accurate care plan.<BR/>The Medical Director was initially made aware on April 15, 2025 of the immediate jeopardy, and has been involved in the development of the plan to remove during an abbreviated QA. These conversations are considered a part of the QA process. Next schedule QA meeting set for April 21, 2025 at 12pm.<BR/>All in-servicing began 4/15/2025.<BR/>This plan was initially implemented 4/15/2025 and will be monitored, through personal observation, through completion by Regional [NAME] President of Operation and Regional Director of Clinical Services.<BR/>On 4/17/2025 the Surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:<BR/>Record review of skin assessment completed 6/3/24 on Resident #1. Record review of inservice record dated 6/3/2024 regarding required gate lock checks on secured unit every 4 hours and check the courtyard gate to ensure the lock is secure and complete the log attached. 18 staff signatures on inservice. <BR/>Record review confirmed Resident #2 was moved to the secured unit on 1/3/25. Record review of an untitled document dated 1/03/25 revealed maintenance director and ADO together checked all exit doors for functioning of keypads and alarms, and all were in working order. <BR/>Record review of inservice record dated 1/03/2025 titled Do not give the door codes to anyone other than staff. Staff are to let visitors out of the doors. 34 staff signatures on inservice.<BR/>Record review of inservice dated 4/15/25 at 7:00pm titled 1. All staff inservices on the elopement/missing resident protocol. With 33 employee signatures.<BR/>Record review of inservice dated 4/15/25 at 7:00pm titled 2. All staff inservices on the magnetic lock reset function. 3. All staff inservices on process during lawn care visits. With 33 employee signatures.<BR/>Record review of inservice dated 4/15/25 at 8:45pm titled Lawn vendors to communicate with ADM/DCO each time they need to enter and exit the secured unit patio/lawn care areas. Doors and Gates must be secured before they leave the area lawn care service inserviced via phone.<BR/>Record review of inservice dated 4/15/25 at 7:00pm titled 4. Door codes-are confidential and are never to be given to residents/family members or vendors at any time With 33 employee signatures.<BR/>Record review of residents with risk of elopement audit completed by the CRC on 4/15/25.<BR/>Record review of Ad Hoc Qapi meeting held on 4/15/25 at 7:15pm attended by the medical director, Administrator and DON.<BR/>During interviews conducted on 4/17/2025 between 8:45 am - 9:15 am CNA M, PTA, CNA B, CNA F, CNA N, Activity Director, HSK, Floor Tech, Laundry U, Laundry V, Receptionist, BOM, CNA K, ADON, CNA S, LVN H, LVN T, LVN A, and LVN G all verbalized if a resident is missing a code pink is called. They all said the codes to the doors are never to be shared with visitors and if a visitor is observed entering a code the Administrator was to be notified so it can be changed. They all said the gates on the unit must be checked every 4 hours and the inside buttons to be checked to make sure the light was green. They said if the lawn care service was present, they were to be let in and then back out when they were finished.<BR/>On 4/17/2025 at 9:55am, 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 15 residents (Resident # 52) observed for care in that: <BR/>The COTA failed to knock and ask for permission to enter Resident #52's room causing him to be exposed to the hallway during personal care. <BR/>This failure could affect all residents in the facility who received care and could result in residents not being treated with dignity and respect and being exposed during care. <BR/>Findings:<BR/>Record review of facility face sheet dated 03/21/2023 indicated Resident # 52 admitted to the facility originally on 12/05/2022 and was readmitted [DATE], and 03/13/2023 with diagnoses of pneumonia (lung infection), hypoglycemia (low blood sugar), and major depressive disorder.<BR/>Record review of admission MDS dated [DATE] indicated Resident # 52 had a BIMS score of 11 indicating moderate cognitive impairment and required extensive assistance times one person for toilet use.<BR/>Record review of comprehensive care plan dated 03/13/2023 indicated Resident # 52 had ADL self-care performance deficits with intervention for toilet use for extensive assistance times one person and alteration in bowel elimination with intervention of providing adequate time and privacy for elimination.<BR/>During an observation of Resident # 52's room on 03/20/2023 at 11:39 am Resident # 52 was lying in bed located closest to the door and the room had 1 curtain suspended in the middle of the room. No curtain was present on Resident # 52's side of the room to allow for full privacy.<BR/>During an observation on 03/21/2023 at 08:22 am Resident # 52 was receiving incontinent care from CNA C with the door closed to the room but no curtain available to pull for full privacy. While CNA C performed incontinent care the COTA knocked on Resident # 52's door and opened the door after CNA C voiced 2 times patient care was in progress exposing Resident # 52 to the hallway. Resident # 52 was in the bed on his left side without any clothing from waist down. The COTA stood at the doorway talking to CNA C and Resident # 52 for approximately 45 seconds. <BR/>During an interview on 03/21/2023 at 08:29 am Resident # 52 stated he was embarrassed by the therapist coming in his room during incontinent care and his private area being exposed. He stated it has happened before but he had not told anyone. He stated there had not been a curtain around his bed since arriving at the facility, he preferred the bed closest to the door, and would like a curtain for privacy. <BR/>During an interview on 03/21/2023 at 08:32 am CNA C stated she should have pulled the bed linen over Resident # 52 when the therapist opened the door. She stated by not doing so it exposed Resident # 52 to the hallway and could have caused him embarrassment. CNA C stated she did not know why there was no curtain to provide full privacy for Resident # 52. She stated she had been trained on dignity and privacy and would never want any of her residents to feel bad. <BR/>During an interview on 03/21/2023 at 08:39 am the COTA stated she knocked, heard someone inside the room and thought it was ok to enter. She stated when she saw Resident # 52 exposed, she should have closed the door and come back at another time. She also stated she should have not entered the room until the resident said for her to come in. She stated the risk to the resident would be not protecting their privacy and dignity. <BR/>During an interview on 03/21/2023 at 08:42 am the DON stated that a closed door was the resident's privacy and if a CNA voiced patient care in progress no one should enter that room. She stated the room in which Resident # 52 resides was set up to be a private room and only had the privacy curtain in the middle. She stated Resident # 52 does prefer the bed next to the door and should have a curtain on that side to provide full privacy. She stated she would see that a privacy curtain was installed and that all staff are retrained on maintaining privacy and dignity for all residents. She stated the risk could be embarrassment.<BR/>During an interview on 03/21/2023 at 08:45 am the administrator stated Resident # 52's room was set up as a private room a few years back and she had not realized Resident # 52 was residing in the bed closest to the door. She stated that all residents should be able to have full visible privacy and would see that a curtain was put in place today. She stated that by not having a curtain in place could allow exposure of resident during care causing embarrassment or humiliation. <BR/>Record review of facility policy and procedure titled, Quality of Life - Dignity dated August 2009 indicated, .#6. Resident's private space and property shall be always respected. a. Staff will knock and request permission before entering resident's room, 10. Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide comfortable and safe temperature levels for 1 of 12 residents (Resident #1) reviewed for comfortable environment.<BR/>The facility failed to prevent the temperature from being 67&deg;F in Resident #1's room on 5/13/2024.<BR/>This failure placed the residents at risk for harm by a diminished quality of life and discomfort.<BR/>Findings:<BR/>Record review of a facility face sheet dated 5/13/2024 indicated Resident #1 was [AGE] years old and admitted to the facility on [DATE] with diagnosis of Alzheimer's.<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS of 8 indicating moderate cognitive impairment and was independent with ADL's. <BR/>Record review of a comprehensive care plan dated 01/30/2024 indicated Resident #1 had behaviors related to disturbed sleep and to monitor for safe environment. <BR/>During an interview on 05/13/24 at 1:50 pm Resident # 1 said her room was too cold. She was upset and said they must stop turning the air down so low. She said she doesn't know what the facility has changed but when she wakes up now her room is so cold, and she did not like it that cold. <BR/>During an observation and interview on 05/13/2024 at 1:58 pm the maintenance director came to Resident #1's room to check the room temperature. Thermostat on hall read 71 degrees and temperature per portable thermometer on resident side of room read 67 degrees Fahrenheit. The door was opened, and the air vent was closed. The maintenance director stated the temperature should be 71-81 degrees and they would adjust the air and monitor the temperature until the temperature was above 71 degrees Fahrenheit. He said the temperature should be maintained between those ranges for resident health.<BR/>During an interview on 5/13/2024 at 2:05 pm Resident # 1 said she was going back to bed and cover up until the room warmed up. <BR/>Record review of a facility temperature log dated 5/13/2024 for Resident #1's room indicated at 2:00 pm the room temperature was 69.3 degrees and then 70 degrees Fahrenheit. Every 1-hour checks completed until 3:00 pm and temperature in Resident #1's room was 74 degrees.<BR/>During an observation and interview on 05/14/24 at 7:45 am Resident #1 was in her room asleep. The room temperature was comfortable and the temperature on the hall thermostat stated 72 degrees. The maintenance director increased the temperature back to 74 degrees and locked the thermostat cover. He stated the temperature should be 71-81 degrees Fahrenheit and he had placed signs on the thermostat, but staff would adjust the temperature up and down themselves. He said if a resident voiced they were hot the staff would move the temperature down without thinking about other residents being cold. He said that temperatures should be maintained per the regulation for resident comfort and safety. <BR/>During an interview on 5/14/2024 at 9:50 am CNA E said that the temperature was controlled by management, but some staff would adjust the temperature on their own if a resident voiced being too hot or too cold. She said she was not aware that a facility had to maintain a certain temperature range but could see how that would be necessary. She said if a resident was too cold it could cause them to get sick. <BR/>During an interview on 5/14/2024 at 3:45 pm the administrator said that the maintenance department was responsible for maintaining the correct temperatures in the facility, but the staff did adjust the temperature as needed for spikes and drops in temperatures. She said that she was not aware that Resident #1's room was getting too cold but would continue to monitor and place a thermometer in the room to monitor. She said that if temperature ranges were not maintained per the regulation there could be a potential for a negative resident outcome. <BR/>Record review of a facility policy titled Quality of Life-Homelike Environment dated May 2017 indicated, .comfortable and safe temperatures of 71F-81F .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 4 residents (Resident #51) reviewed for pharmacy services. <BR/>The facility did not ensure medications were administered by licensed staff for Resident #51. <BR/>This failure could place residents at risk for the unsafe administration of medications, not receiving prescribed doses of ordered medications and infection.<BR/>Findings included:<BR/>During a record review physician order summary dated 3/21/23 for Resident #51 indicated he was [AGE] years old with diagnosis of diabetes (high glucose in the blood), blindness and chronic pain with an admission date of 10/01/22. Resident #51 Physician orders indicated an order for Latanoprost Solution 0.005% instill 1 drop in both eyes at bedtime and Lubricating Plus Eye Drops Solution 0.5% (carboxymethylcellulose Sodium) instill one drop in both eyes four time a day for dry eye, blindness.<BR/>During a record review of Resident #51's MDS dated [DATE] indicated he was legally blind, cognitively intact with a BIMS score of 15 and required supervision with setup help only for ADLs except bathing in which he required assistance of one person for showering.<BR/>During an interview and observation on 03/20/23 at 2:12 PM with Resident #51 revealed a white plastic medication bottle was on the bedside table with a handwritten label indicating eye drops were inside. After asking permission from resident this surveyor opened the bottle and found a vial of Latanoprost Solution 0.005% with prescription label for resident #51. Resident #51 said he puts his own drops in nightly and his own lubricating eye drops in four times a day. Resident #51 showed this surveyor his vial of lubricating drops.<BR/>During an interview and observation on 03/21/23 at 08:05 AM of medication administration with LVN A and Resident # 51, LVN A said that the eye drops were kept at bedside for resident use. She said she was not aware the resident needed an assessment to self-administer his eye drops. Resident #51 agreed that he kept and administered his own eye drops at night and lubricating eye drops during the day. He said I put them in, so I don't have to bother anyone for help. Resident #51 said I can do that myself. LVN A said that applying his eye drops without washing his hands could cause infection. Resident #51 said he could not see well but he touched the vial to his eye to make sure the drop went in.<BR/> During an interview on 03/21/23 at 09:41 AM the DON said that the resident could not keep his eye drops at bedside without an MD order and an assessment for safe medication administration. She said she would remove the eye drops, complete an assessment today and contact the Physician if it was appropriate. She said if the resident was unable to safely administer his eye drops it could cause an eye infection or under dosing and overdosing. <BR/>During an interview on 3/22/23 at 11:30 the Administrator said that resident #51 could not self-medicate without an assessment and an order from his medical doctor. The administrator said the medication had been removed. She said that the DON and ADON were responsible for ensuring medications were administered according to regulation. The administrator said there was a risk to the resident for infection or incorrect dosages. The administrator said that the staff had already received an Inservice for safe administration of medication to ensure this problem is corrected.<BR/>Review of a Pharmscript Policy revision date 08-2020, General Guidelines for Medication Administration reflected: Medications are administered as prescribed in accordance with good nursing principles and practices and only by person legally authorized to administer .13. Residents are permitted to self-administer medications when specifically authorized by the attending physician and in accordance with the procedures for self-administration of medications.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen observed for kitchen sanitation.<BR/>The kitchen floor, walls, and handles of the refrigerator had buildup of a sticky substance on 5/13/2024.<BR/>There was a fan in use in the kitchen with dark thick substance on the fan blades and fan cover on 5/13/2023.<BR/>The drink dispenser located in the kitchen had undated boxes of concentrate liquid and the orange liquid concentrate was on the floor and connected to the machine on 5/13/2024.<BR/>The coffee dispenser had undated boxes of coffee concentrate connected to the machine and the machine had dried dark brown substance on the inside on 5/13/2024.<BR/>The kitchen refrigerator stored unlabeled and expired objects on 5/13/2024.<BR/>These deficient practices could place residents who ate food from the kitchen at risk for foodborne illness.<BR/>Findings include:<BR/>During an observation on 5/13/2024 at 9:03 am the kitchen had buildup on the floors, walls, and handles of refrigerator of a dark sticky substance. There was a fan present in the prep area with dark thick buildup on blades and outside cover. The drink dispenser in the kitchen had 3 concentrated juices attached. The 3 containers were undated and the bag with an orange liquid concentrate was laying on the floor. The coffee dispenser in the dining room had 2 boxes of coffee concentrate and neither were dated and inside of the machine had a dark brown dried liquid substance on the inside. The refrigerator had 2 containers of cottage cheese container with best by date of 4/19/24, cranberry sauce in a reusable container dated to use by 5/11/24, an unlabeled meat link in a plastic bag, a bottle of red sauce dated as opened 5/5/2024 and the directions read to use within 5 days of opening, an unlabeled yellow thick substance in a reusable container, and an unlabeled green pea substance in a reusable container.<BR/>During an observation on 5/13/2024 at 9:20 am of a coffee dispenser located in the dining room had a cleaning schedule located on the inside of the door that indicated a daily rinsing schedule and a weekly sanitizing schedule per manufacturer recommendations. <BR/>During an interview on 5/13/2024 at 9:26 am [NAME] F said that everyone was responsible for checking the refrigerator daily for unlabeled and expired items. She said that items should be labeled and dated and disposed of within 3 days or per the label or directions. She said she was not sure on the drink dispensers and if the boxes needed to be dated or not and was not aware of a cleaning schedule for the dispensers or the kitchen. She said she cleaned as she cooked. She said she had been trained on properly storing items and did the best she could, but other workers had to do their part when they were working. She said that an unsanitary kitchen and improper storage of foods could cause illness. <BR/>During an interview on 5/13/2024 at 9:40 am the DM said she was responsible for all duties in the kitchen and dining room and the kitchen staff should be cleaning daily, labeling, and storing food appropriately and all items should be dated. She said the staff had been trained on maintaining the kitchen in a sanitary condition. She said there was a cleaning schedule and the staff had been signing off that cleaning had been done. She said the drink dispensers were wiped down but the company that provided them were to deep clean them. She said she was not aware of the manufacturer weekly cleaning schedule listed inside the drink dispensers but would check into it. She said that by not maintaining kitchen sanitation it could lead to contamination and illness.<BR/>During an interview on 5/14/2024 at 4:00 pm the administrator said the dietary manager was responsible for oversight of the kitchen and she expected the kitchen to be cleaned and items stored in a sanitary manner. She said the staff had been trained on proper cleaning of the kitchen and how to label and store foods but would oversee more training was done. She said that an unsanitary kitchen could lead to illness and expected the kitchen to be maintained in a sanitary condition. <BR/>Record review of a monthly kitchen cleaning schedule log indicated full cleaning performed in January 2024, February 2024, March 2024, and April 2024. <BR/>Record review of an in-service training dated 3/21/2024 titled Dating and Labeling and cleaning indicated staff had been trained.<BR/>Record review of an in-service training dated 12/21/2023 titled deep cleaning kitchen and dating and labeling indicated staff had been trained. <BR/>Record review of a facility policy titled Food Storage dated 4/11/2022 indicated' .4. foods are stored at least 6 inches off the floor, 6. food removed from its original packaging will be labeled .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Resident #29 and Resident #39) and 2 of 5 staff (CNA D and CNA H) reviewed for infection control.<BR/>CNA D did not change gloves and sanitize/wash hands when providing incontinent care to Resident #29 on 5/13/2024.<BR/>CNA H did not sanitize or wash her hands after changing gloves when providing incontinent care to Resident #39 on 5/14/2024.<BR/>These failures could place residents at risk of exposure to communicable diseases and infections.<BR/>Findings include:<BR/>1.Record review of a facility face sheet dated 5/13/2024 indicated Resident #29 was [AGE] years old and admitted to the facility on [DATE] with diagnosis of cerebral infarction (lack of blood to the brain).<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #29 had a BIMS of 4 indicating severe cognitive impairment and was always incontinent of bowel and bladder and required maximum assistance with toileting.<BR/>Record review of a comprehensive care plan dated 3/22/2024 indicated Resident #29 had ADL self-performance deficit and required extensive assistance with toileting.<BR/>During an observation on 05/13/24 at 10:05 AM Resident # 29 was receiving care from CNA D. CNA D had gloves on, Resident #29's brief was opened and pulled down forward, CNA D wiped front to back with stool present. Resident #29 turned self on right side, CNA D wiped stool from buttocks using wipes. CNA D placed soiled brief in a bag, and wiped buttocks until clean. She placed soiled wipes in bag. Without changing gloves and performing hand hygiene, CNA D applied barrier clean to buttocks and placed clean brief under Resident #29. Resident #29 rolled back over, and CNA D continued to apply skin barrier to front peri-area and pulled clean brief into place. Wearing same soiled gloves, CNA D placed pillow under Resident #29's right arm and adjusted linen on bed. CNA D then removed gloves and washed her hands before leaving room. <BR/>During an interview on 05/13/24 at 10:15 AM CNA D said she had been a CNA for 21 years. She said she had received training on incontinent care recently and was checked off. She said she was nervous and should have changed her gloves from dirty to clean to prevent infections. <BR/>Record review of a competency evaluation for hand hygiene indicated CNA D was last evaluated for competency on 11/12/2023.<BR/>2. Record review of an admission Record for Resident #39 dated 5/14/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnosis of major depressive disorder (persistent sadness or loss of interest), diastolic heart failure (condition in the heart that causes the heart to become stiff and unable to fill properly) , morbid obesity (overweight), and hypertension (high blood pressure).<BR/>Record review of a Quarterly MDS Assessment for Resident #39 dated 2/15/2024 indicated she did not have any impairment in thinking with a BIMS score of 14. She required substantial/maximal assistance with toileting. She was always incontinent of bladder and bowel. <BR/>Record review of a care plan for Resident #39 revised on 9/30/2023 indicated she was incontinent of bladder and bowel with interventions to monitor for incontinence every 2 hr/prn, change promptly.<BR/>During an observation on 5/14/2024 at 11:05 AM in the room of Resident #39, CNA H was present to provide incontinent care. She removed gloves from her scrub top pocket and placed them on her hands without washing or sanitizing them. She opened the brief of Resident #39 and pulled it down between the resident's thighs. She removed wipes and wiped the resident's lower abdomen and then wiped down the left inner thigh and placed the wipe in the trash. She removed a wipe and wiped down the right inner thigh and placed it in the trash. She removed a wipe and wiped down the middle of peri area from front to back. She rolled the resident onto her left side and removed her gloves and placed them in the trash. She removed gloves from her pocket and placed them on her hands without washing or sanitizing them. She removed wipes and wiped the resident's rectal area from front to back. She rolled the brief underneath the resident's buttocks. She opened a clean brief and placed it underneath the dirty brief and removed the dirty brief. She rolled the residents onto her back and secured the brief. She removed her gloves and placed them in the trash. She went to the resident's closet and picked out a dress for the resident to wear. She said she had to leave the room to get the mechanical lift to transfer the resident from the bed to her wheelchair and did not wash or sanitize her hands.<BR/>During an interview on 5/14/2024 at 3:20 PM, CNA H said she had been employed at the facility since October 2023 and was full time and worked the hall where Resident #39 resided. She said during the incontinent care provided to Resident #39, she did not wash her hands before care was started, during or after the care provided. She said when she thought about sanitizing her hands it was too late. She said she did not have her sanitizer in her pocket like normal because she was wearing a different jacket. She said her gloves should have been in a plastic bag and not stored in her pocket. She said she recently had a skills check off by the ADON last month April 2024. She said residents could be at risk for infections if staff did not wash or sanitize their hands when providing care.<BR/>Record review of a Hand Hygiene Competency Check Off Audit Form dated May 2024 conducted by the ADON indicated CNA H was checked on 5/2/2024 for hand hygiene and passed. <BR/>Record review of a competency skills evaluation for CNA H dated 12/10/2023 indicated she was satisfactory with providing incontinent to a female resident that included hand hygiene.<BR/>During an interview on 05/14/24 at 1:37 PM the DON said that CNA D had been trained on proper hygiene and had been a CNA for many years. She said she expected all staff to follow proper hand hygiene when providing care. She stated the risk of improper incontinent care could lead to infections and negative resident outcomes. <BR/>During an interview on 5/14/2024 at 3:33 pm the administrator said that nurse management was responsible for oversight of resident care like incontinent care and hand hygiene. She said CNA D had been a CNA for many years and expected all staff to follow proper hand hygiene and incontinent care. She said that the CNA not performing correct peri care and hand hygiene could cause cross contamination.<BR/>During an interview on 5/15/2024 at 9:50 AM, the ADON said she was the IP and responsible for training staff on hand hygiene. She said she conducted quarterly check offs with staff on hand hygiene. She said CNA H was present on 5/2/2024 when she had a training on hand hygiene. She said staff should perform hand hygiene before starting care, between care, and before exiting the room. She said residents could be at risk of cross contamination and infections if they did not wash or sanitize their hands.<BR/>During an interview on 5/15/2024 at 10:00 AM, the DON said staff should wash or sanitize their hands before starting care, when going from dirty to clean, and before leaving the room. She said the ADON was responsible for training staff on hand hygiene, and it was done quarterly. She said going forward, they would continue training staff on hand hygiene with check offs. She said there was a risk of cross contamination and infections if staff did not wash or sanitize their hands.<BR/>During an interview on 5/15/2024 10:20 AM, the Administrator said hand hygiene should be done before care was started, when changing gloves, between dirty to clean procedures, at the end of care, and any time hands were visibly soiled. She said the ADON was the IP and had been doing hand hygiene competencies quarterly and as needed. She said residents could be at risk for infections if staff did not perform hand hygiene.<BR/>Record review of a facility policy titled Perineal Care dated 10/01/21 indicated, .to prevent infections and skin irritation;11. remove gloves and discard, wash hands, 12. reposition bed covers . <BR/>Record review of a facility policy titled Hand Hygiene dated 8/4/21 indicated, .Hand hygiene is used to prevent the spread of pathogens in healthcare settings. 1. You should always perform hand hygiene: before applying and after removing personal protective equipment (e.g., gloves), before and after providing any type of care; 2. You must perform hand hygiene (handwashing or the use of an ABHR) after contact with bodily fluids, such as urine .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide comfortable and safe temperature levels for 1 of 12 residents (Resident #1) reviewed for comfortable environment.<BR/>The facility failed to prevent the temperature from being 67&deg;F in Resident #1's room on 5/13/2024.<BR/>This failure placed the residents at risk for harm by a diminished quality of life and discomfort.<BR/>Findings:<BR/>Record review of a facility face sheet dated 5/13/2024 indicated Resident #1 was [AGE] years old and admitted to the facility on [DATE] with diagnosis of Alzheimer's.<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS of 8 indicating moderate cognitive impairment and was independent with ADL's. <BR/>Record review of a comprehensive care plan dated 01/30/2024 indicated Resident #1 had behaviors related to disturbed sleep and to monitor for safe environment. <BR/>During an interview on 05/13/24 at 1:50 pm Resident # 1 said her room was too cold. She was upset and said they must stop turning the air down so low. She said she doesn't know what the facility has changed but when she wakes up now her room is so cold, and she did not like it that cold. <BR/>During an observation and interview on 05/13/2024 at 1:58 pm the maintenance director came to Resident #1's room to check the room temperature. Thermostat on hall read 71 degrees and temperature per portable thermometer on resident side of room read 67 degrees Fahrenheit. The door was opened, and the air vent was closed. The maintenance director stated the temperature should be 71-81 degrees and they would adjust the air and monitor the temperature until the temperature was above 71 degrees Fahrenheit. He said the temperature should be maintained between those ranges for resident health.<BR/>During an interview on 5/13/2024 at 2:05 pm Resident # 1 said she was going back to bed and cover up until the room warmed up. <BR/>Record review of a facility temperature log dated 5/13/2024 for Resident #1's room indicated at 2:00 pm the room temperature was 69.3 degrees and then 70 degrees Fahrenheit. Every 1-hour checks completed until 3:00 pm and temperature in Resident #1's room was 74 degrees.<BR/>During an observation and interview on 05/14/24 at 7:45 am Resident #1 was in her room asleep. The room temperature was comfortable and the temperature on the hall thermostat stated 72 degrees. The maintenance director increased the temperature back to 74 degrees and locked the thermostat cover. He stated the temperature should be 71-81 degrees Fahrenheit and he had placed signs on the thermostat, but staff would adjust the temperature up and down themselves. He said if a resident voiced they were hot the staff would move the temperature down without thinking about other residents being cold. He said that temperatures should be maintained per the regulation for resident comfort and safety. <BR/>During an interview on 5/14/2024 at 9:50 am CNA E said that the temperature was controlled by management, but some staff would adjust the temperature on their own if a resident voiced being too hot or too cold. She said she was not aware that a facility had to maintain a certain temperature range but could see how that would be necessary. She said if a resident was too cold it could cause them to get sick. <BR/>During an interview on 5/14/2024 at 3:45 pm the administrator said that the maintenance department was responsible for maintaining the correct temperatures in the facility, but the staff did adjust the temperature as needed for spikes and drops in temperatures. She said that she was not aware that Resident #1's room was getting too cold but would continue to monitor and place a thermometer in the room to monitor. She said that if temperature ranges were not maintained per the regulation there could be a potential for a negative resident outcome. <BR/>Record review of a facility policy titled Quality of Life-Homelike Environment dated May 2017 indicated, .comfortable and safe temperatures of 71F-81F .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 of 4 residents reviewed for ADL care. (Resident #38) <BR/>The facility failed to ensure Resident #38 received timely incontinent care. <BR/>This failure could place residents at risk of embarrassment, discomfort, and skin breakdown.<BR/>Findings included:<BR/>Record review of an admission Record dated 3/21/2023 for Resident #38 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of schizoaffective disorder (a mental illness that can affect thoughts, mood and behavior), bipolar type (extreme mood swings), unspecified dementia (impaired ability to remember, think or make decisions), type 2 Diabetes and venous insufficiency (veins unable to send blood back from the legs to the heart). <BR/>Record review of a care plan for Resident #38 dated 1/20/2022 with a revision on 11/14/2022 indicated, I am incontinent of bowel and bladder. I have no control of bladder or bowel. Interventions included to monitor for incontinence every 2 hours and prn (as needed), change promptly and apply protective skin barrier. <BR/>Record review of a Quarterly MDS assessment for Resident #38 indicated he had severe impairment in thinking with a BIMS score of 5. He required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene with one to two persons assist. He was totally dependent in bathing with one person assist.<BR/>During an observation and interview on 3/20/2023 at 3:16 PM in Resident #38's room, Resident #38 was lying in bed with a wet gown and sheet on bed. The room had a strong urine odor smell that filled the room. CNA E entered the room looking for CNA F and CNA E observed resident lying in bed. and this surveyor had CNA E to verbalize what condition she observed Resident #38 in at that time. CNA E said there was a ring of urine on the bed that Resident #38 was lying in that had extended past his shoulders and his gown was wet. CNA E said she was not assigned to the hall for Resident #38 and would find CNA F and bring her back to the room.<BR/>During an observation and interview on 3/20/2023 at 3:33 PM CNA F entered the room of Resident #38 and said it was about 1:40 PM today when she last checked on Resident #38 and she changed his brief and rotated him in bed and then went on her break. CNA F was assisted by CNA E, both washed their hands in the bathroom in the room and applied gloves. Both removed the wet hospital gown from Resident #38, brief pulled down and thick, yellow-green discharge was present coming out of his penis. CNA F said she didn't notice any drainage earlier during her shift from his penis. CNA F used wipes to clean Resident #38's penis. There was a small open wound noted to his sacrum that was bleeding, no dressing was noted. Resident #38's back had wrinkles on his skin, the draw sheet was saturated in urine, his sacral area was red and macerated (skin wrinkly from being in moisture too long), excoriation (red and raw) on both inner thighs. Both CNA E and F provided incontinent care to Resident #38 and applied barrier cream to his sacrum. Resident #38's linens were changed, and the mattress was wiped down because of urine saturation on the mattress , there was no water proof cover on the mattress. CNA E exited the room to notify the charge nurse of the drainage from Resident #38's penis and bleeding noted from his sacrum.<BR/>During an interview on 3/20/2023 at 4:08 PM, CNA F said she had been employed at the facility for a year. She said she normally worked hall 100 where Resident #38 was. She said she checked on the dependent residents about 5 times during her 12-hour shift. She said Resident #38 was wet the last time she checked on him about 1:40 PM, and she changed him. She said she checked on the residents every 2 hours. She said he had been saturating the bed but did not tell the nurse that he was very wet. She said that was the first time to see the drainage around his penis. She said he has had the redness on his bottom for a couple of weeks and staff was applying barrier cream to the area. She said the open area on his bottom was noted earlier and Resident #38 has had it for a while, but it was not bleeding earlier. She said the ADON conducted skills check off on incontinent care at the beginning of last month with her. She said the resident could be at risk of skin break down if the resident was left in urine for extended periods. She said she could have done more and checked him again before she went on her break and to her it looked like he had not been changed at all that day. <BR/>During an interview on 3/21/2023 at 12:35 PM, with the DON and ADON. The DON said she was aware of the condition that Resident #38 was found in yesterday afternoon. The DON said she talked with CNA F who told her the last time she changed Resident #38 was before lunch (noon). She said they conducted check offs with the CNA's annually and periodically if they see there had been a problem. The ADON said CNA F completed a check off on incontinent care in November 2022 with her. The DON said Resident #38 was a dependent resident and the CNAs should be checking and changing the resident at least 3 times during their 12-hour shift. The DON said a resident that was left in urine for extended periods of time could develop wounds, excoriation, and discomfort. The DON said she met with her staff on 3/20/2023 and had an in-service on turning and repositioning of dependent residents. The DON said going forward she would make the nurses more responsible and have the staff make more rounds. She said CNA F should have checked on Resident #38 more often. The DON said the facility did not have a policy specific on ADLs, but they did expect the staff to follow the resident's care plan.<BR/>During an interview on 3/22/2023 at 1:43 PM, the Administrator said she was made aware of the condition that Resident #38 was in on 3/20/2023 by the DON. She said all residents would receive their care timely based on individual needs. She said the risk for residents not receiving care timely would be skin break down. She said going forward she would make sure all the residents who were dependent would be assessed for their needs on an individual basis, and their care plans would be up to date along with their tasks if they needed more frequent attention.<BR/>Record review of a Competency Evaluation dated 11/26/2022 for CNA F indicated she was checked off on incontinent care of a male resident without a catheter by the ADON. <BR/>Record review of a facility policy titled Comprehensive Care Plan with a revised date of 4/25/2021 indicated, .Every resident will have an individualized interdisciplinary plan of care in place. The interdisciplinary team will continue to develop the plan in conjunction with the RAI (resident assessment instrument) MDS and CAAS (care area assessment). 2. To assure that the resident's immediate care needs are met and maintained .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and offered a therapeutic diet when there was a nutritional problem, and the healthcare provider orders a therapeutic diet for 1 of 3 residents (#33) reviewed for weight loss and nutrition. <BR/>The facility failed to provide Resident #33 with nutritional supplements as indicated by the physician orders for health shakes.<BR/>These failures could place residents at risk for unplanned weight loss, malnutrition, and failure to thrive.<BR/>The findings included:<BR/>Record review of an admission Record dated 5/14/2024 for Resident #33 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of acute chronic respiratory failure with hypoxia (not enough oxygen in the blood that causes breathing problems), hypertension (high blood pressure), type 2 diabetes, and COPD (lung disease that causes obstructed airflow from the lungs).<BR/>Record review of active physician orders for Resident #33 dated 5/13/2024 indicated an order for dietary supplements for a house shake with meals for weight loss for poor oral intake for 90 days with a start date of 3/11/2024.<BR/>Record review of a Quarterly MDS assessment dated [DATE] for Resident #33 indicated she had moderate impairment in thinking with a BIMS score of 11. She required set up or clean up assistance with eating. She had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and was not on a physician-prescribe weight-loss regimen.<BR/>Record review of a care plan revised on 3/11/2024 for Resident #33 indicated she may have nutritional deficits with weight loss related to diagnoses, meds, diet, and appetite. Interventions included add one house shake BID x60 days related to weight loss. 3/11/2024-increase to TID x90 days.<BR/>Record review of a progress note dated 3/21/2024 by the RD indicated, Resident #33 has unstageable pressure injury to right heel measuring that resolved on 3/15/24 weekly wound assessment. Weight 106.2# with BMI 20.1 WNL for height. Medication reviewed; furosemide (fluid medication) ordered. Diet: Carb Controlled, Regular texture, Regular consistency with majority of PO intake 51-100% of meals. Supplements: House shake BID and Active Liquid Protein 30 ml BID. GOAL: Provide adequate nutrition for weight maintenance, promote wound healing, and prevent dehydration. Intervention: Continue diet and Active Liquid Protein as ordered. Change House shakes from BID to TID x 90 days. Encourage fluids to prevent dehydration: 6-7 cups fluid daily. Monitor weight, skin, and PO intake.<BR/>Record review of a Nutrition Recommendation to Physician by the RD dated 3/8/2024 indicated an order to change house shake from bid to TID x90 days related to weight loss.<BR/>Record review of a Nutrition Recommendation to Physician by the RD dated 2/9/2024 indicated an order to add one house shake bid x60 days related to weight loss. <BR/>Record review of weight logs for Resident #33 revealed:<BR/>5/9/2024 11:53 <BR/>107.0 Lbs <BR/>Standing <BR/>4/5/2024 19:07 <BR/>106.0 Lbs <BR/>Wheelchair <BR/>3/11/2024 09:42 <BR/>106.2 Lbs <BR/>Wheelchair <BR/>3/8/2024 16:35 <BR/>104.5 Lbs <BR/>Wheelchair <BR/>2/8/2024 15:16 <BR/>110.0 Lbs <BR/>Mechanical Lift <BR/>1/28/2024 14:53 <BR/>110.0 Lbs <BR/>Standing <BR/>1/25/2024 17:27 <BR/>116.0 Lbs <BR/>Standing <BR/>1/15/2024 15:01 <BR/>118.5 Lbs <BR/>Wheelchair <BR/>1/8/2024 18:57 <BR/>118.5 Lbs <BR/>Wheelchair <BR/>1/5/2024 19:49 <BR/>118.5 Lbs <BR/>Wheelchair<BR/>During an observation on 5/13/2024 at 12:10 PM, Resident #33 was eating in the dining room and her tray card read house shake x90 days ending 6/9/2024: house shake at breakfast, lunch, and dinner. There was not a health shake on her tray. <BR/>During an observation and interview on 5/13/2024 at 1:51 PM, Resident #33 was in her room sitting in a wheelchair and said she did not get a health shake at lunch today and had only been getting them at breakfast and supper.<BR/>Record review of Dietary Sticker Sheet for Residents that were to receive shakes undated indicated Resident #33 was listed for AM and Supper. There was not a sticker for lunch.<BR/>During an interview on 5/14/2024 at 3:20 PM, CNA H said she had been employed at the facility since October 2023 fulltime and worked the hall where Resident #33 resided. She said Resident #33 was supposed to get health shakes twice a day with meals. She said sometimes the health shakes were not on the trays and would have to go to the kitchen to get one. She said Resident #33 usually ate in her room and this morning she had a health shake on her morning and lunch tray. She said on yesterday 5/13/2024 she was not aware that the resident did not get a health shake at lunch in the dining room. She said it depended on who was working in the dining room to ensure the residents received them with their meals. She said the dietary staff do not usually put them on the trays and the staff had to get health shakes for the residents. <BR/>During an interview on 5/15/2024 at 9:28 AM, Dietary Aide said she worked at the facility for over a year part time. She said she helped set up trays for meals and placed health shakes on the trays. She said Resident #33 received a health shake for breakfast and lunch but was not sure about supper and was on the list of residents who were to receive health shakes. She said she did not work on Monday 5/13/2024. She said some residents were given health shakes if they did not eat. She said she did not know what could happen if a resident did not get their shake.<BR/>During an interview on 5/15/2024 at 9:35 AM, the DM said Resident #33 was supposed to get a health shake three times a day. She said the RD sends a copy of the recommendations and when she received the communication form from the DON, she would make changes to the orders in the dietary system. She said she was told not to change anything with the orders until a communication form was received from the DON. She said residents could be at risk for weight loss if they did not get their ordered supplements such as health shakes. She said the Dietary aides were responsible for putting the shakes on the trays. She said on 5/13/2024, Resident #33 was just missed at lunch. She said she had a system in place already that included stickers to help the dietary staff visualize who needed health shakes.<BR/>During an interview on 5/15/2024 at 10:00 AM, the DON said the RD visited the facility monthly and saw people based on risk factors. She said the RD reviewed the report twice a month and would send recommendations to her. She said Resident #33 triggered for a 10.5% weight loss in April 2024 and an order was given to put her on health shakes. She said her weight has stabilized now and the health shakes have been increased to TID and before it was BID. She said the dietary staff were responsible for placing the health shakes on the meal trays and the nurses were supposed to check the diet orders and tray cards to ensure the residents were getting what was ordered. She said there was a risk for weight loss. Going forward she would talk to the DM and have her pull the order from the computer to ensure it matched the tray cards along with in-service nursing staff to make sure they are looking for the shakes.<BR/>During an interview on 5/15/2024 at 10:20 AM, the Administrator said the dietician sent recommendations to the DON and the DM. She said then the DON talked to the physician and received approval for the order, would put the order in the system and would write a communication form for dietary to let them know and then the DM would then enter the orders in the dietary system She said she was not aware that Resident #33 was not receiving her ordered health shakes. She said going forward she would retrain nursing to read the tray cards and retrain dietary staff. She said there was a risk of not getting the nutritional value the residents needed if they did not receive their supplements. She said the facility did not have a policy on dietary orders or recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 4 residents (Resident #51) reviewed for pharmacy services. <BR/>The facility did not ensure medications were administered by licensed staff for Resident #51. <BR/>This failure could place residents at risk for the unsafe administration of medications, not receiving prescribed doses of ordered medications and infection.<BR/>Findings included:<BR/>During a record review physician order summary dated 3/21/23 for Resident #51 indicated he was [AGE] years old with diagnosis of diabetes (high glucose in the blood), blindness and chronic pain with an admission date of 10/01/22. Resident #51 Physician orders indicated an order for Latanoprost Solution 0.005% instill 1 drop in both eyes at bedtime and Lubricating Plus Eye Drops Solution 0.5% (carboxymethylcellulose Sodium) instill one drop in both eyes four time a day for dry eye, blindness.<BR/>During a record review of Resident #51's MDS dated [DATE] indicated he was legally blind, cognitively intact with a BIMS score of 15 and required supervision with setup help only for ADLs except bathing in which he required assistance of one person for showering.<BR/>During an interview and observation on 03/20/23 at 2:12 PM with Resident #51 revealed a white plastic medication bottle was on the bedside table with a handwritten label indicating eye drops were inside. After asking permission from resident this surveyor opened the bottle and found a vial of Latanoprost Solution 0.005% with prescription label for resident #51. Resident #51 said he puts his own drops in nightly and his own lubricating eye drops in four times a day. Resident #51 showed this surveyor his vial of lubricating drops.<BR/>During an interview and observation on 03/21/23 at 08:05 AM of medication administration with LVN A and Resident # 51, LVN A said that the eye drops were kept at bedside for resident use. She said she was not aware the resident needed an assessment to self-administer his eye drops. Resident #51 agreed that he kept and administered his own eye drops at night and lubricating eye drops during the day. He said I put them in, so I don't have to bother anyone for help. Resident #51 said I can do that myself. LVN A said that applying his eye drops without washing his hands could cause infection. Resident #51 said he could not see well but he touched the vial to his eye to make sure the drop went in.<BR/> During an interview on 03/21/23 at 09:41 AM the DON said that the resident could not keep his eye drops at bedside without an MD order and an assessment for safe medication administration. She said she would remove the eye drops, complete an assessment today and contact the Physician if it was appropriate. She said if the resident was unable to safely administer his eye drops it could cause an eye infection or under dosing and overdosing. <BR/>During an interview on 3/22/23 at 11:30 the Administrator said that resident #51 could not self-medicate without an assessment and an order from his medical doctor. The administrator said the medication had been removed. She said that the DON and ADON were responsible for ensuring medications were administered according to regulation. The administrator said there was a risk to the resident for infection or incorrect dosages. The administrator said that the staff had already received an Inservice for safe administration of medication to ensure this problem is corrected.<BR/>Review of a Pharmscript Policy revision date 08-2020, General Guidelines for Medication Administration reflected: Medications are administered as prescribed in accordance with good nursing principles and practices and only by person legally authorized to administer .13. Residents are permitted to self-administer medications when specifically authorized by the attending physician and in accordance with the procedures for self-administration of medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 medication carts (nurse cart 600 hall) reviewed for labeling and storage.<BR/>The facility failed to remove expired insulin from the nurse medication cart on hall 600. <BR/>This deficient practice could place residents at risk for improper glucose monitoring and could result in residents not receiving the intended therapeutic effects of their medications causing a health decline.<BR/>Findings include:<BR/>Record Review of physician order summary dated 3/21/23 reflected Resident #36 was a [AGE] year old admitted [DATE] with a diagnosis of diabetes (high blood sugar), alcoholic cirrhosis of liver and alcohol dependence with dementia. Review of physician orders reflected Insulin Detemir solution 100 unit per milliliter 20 units subcutaneously at bedtime for diabetes dated 6/12/22.<BR/>During observation and interview on 03/21/23 at 8:45 AM of the nurse cart on 600 hall revealed a vial of Levemir Insulin was dated as opened on 10/22/2022 and the package insert indicated to discard 42 days after opening, (discard date 12/03/22). LVN A said she had been employed at the facility for 6 years. LVN A said the nurses were responsible for checking that insulin was within administration dates before administration. LVN A said she was not aware how long the insulin was good for, maybe six months from the date opened. LVN A said she had not received any education recently on when the multi dose vials expire. She said the risk could be ineffective medication action, injection site infections and elevated blood sugar readings. <BR/>During an interview on 03/21/23 at 12:30 PM, the DON said she and the ADON were responsible for ensuring the carts are checked for expired medications and supplies. The DON stated she had just performed a total audit last week on all carts and the medication room was surprised that expired insulin was found on the cart. The DON said that the consultant pharmacist also checks carts and medication rooms for expired medications monthly during the medication review. <BR/>During an interview and record review of Resident #36's medication administration record on 03/21/23 at 1:00 PM, the DON said that the resident had a history of refusing his insulin and the last day of documented insulin administration was 2/23/23. The DON said Resident #36's Glycosylated Hemoglobin on 3/21/23 was 5.5. The DON said Resident #36's physician was contacted, and the insulin was then discontinued on 3/21/23 due to resident refusals. The DON said that insulins were good for so many days depending on manufacturer and should be removed from the cart when expired. <BR/>During an interview on 03/21/2023 at 5:00 PM, the Administrator stated the DON and ADON were responsible for oversight in the nursing department. She stated she would assist with overseeing the DON and ADON retrained nursing staff on policy and procedures and those policies were followed. She said that the negative outcome of not removing expired medications could be that residents are given medications that have lost their effectiveness. <BR/>Record review of the facility policy and procedure titled Vials and Ampules of Injectable Medications, revision date 09/2020, indicated, Quality of Control solutions and test strips, Policy: Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations of the provider pharmacy's directions for storage, use and disposal. 1 Vials and ampules dispensed by the pharmacy are maintained in the box or container with the pharmacy label in which they are dispensed .4. The solution in multi-dose vials (MDV) is inspected prior to each use for unusual cloudiness, precipitation, or foreign bodies If the Multi dose vial is opened and does not indicate an opened date the open date reverts to the dispensing date .6. Medication in multi-use vials may be used until the manufacture's recommended expiration date .

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen observed for kitchen sanitation.<BR/>The kitchen floor, walls, and handles of the refrigerator had buildup of a sticky substance on 5/13/2024.<BR/>There was a fan in use in the kitchen with dark thick substance on the fan blades and fan cover on 5/13/2023.<BR/>The drink dispenser located in the kitchen had undated boxes of concentrate liquid and the orange liquid concentrate was on the floor and connected to the machine on 5/13/2024.<BR/>The coffee dispenser had undated boxes of coffee concentrate connected to the machine and the machine had dried dark brown substance on the inside on 5/13/2024.<BR/>The kitchen refrigerator stored unlabeled and expired objects on 5/13/2024.<BR/>These deficient practices could place residents who ate food from the kitchen at risk for foodborne illness.<BR/>Findings include:<BR/>During an observation on 5/13/2024 at 9:03 am the kitchen had buildup on the floors, walls, and handles of refrigerator of a dark sticky substance. There was a fan present in the prep area with dark thick buildup on blades and outside cover. The drink dispenser in the kitchen had 3 concentrated juices attached. The 3 containers were undated and the bag with an orange liquid concentrate was laying on the floor. The coffee dispenser in the dining room had 2 boxes of coffee concentrate and neither were dated and inside of the machine had a dark brown dried liquid substance on the inside. The refrigerator had 2 containers of cottage cheese container with best by date of 4/19/24, cranberry sauce in a reusable container dated to use by 5/11/24, an unlabeled meat link in a plastic bag, a bottle of red sauce dated as opened 5/5/2024 and the directions read to use within 5 days of opening, an unlabeled yellow thick substance in a reusable container, and an unlabeled green pea substance in a reusable container.<BR/>During an observation on 5/13/2024 at 9:20 am of a coffee dispenser located in the dining room had a cleaning schedule located on the inside of the door that indicated a daily rinsing schedule and a weekly sanitizing schedule per manufacturer recommendations. <BR/>During an interview on 5/13/2024 at 9:26 am [NAME] F said that everyone was responsible for checking the refrigerator daily for unlabeled and expired items. She said that items should be labeled and dated and disposed of within 3 days or per the label or directions. She said she was not sure on the drink dispensers and if the boxes needed to be dated or not and was not aware of a cleaning schedule for the dispensers or the kitchen. She said she cleaned as she cooked. She said she had been trained on properly storing items and did the best she could, but other workers had to do their part when they were working. She said that an unsanitary kitchen and improper storage of foods could cause illness. <BR/>During an interview on 5/13/2024 at 9:40 am the DM said she was responsible for all duties in the kitchen and dining room and the kitchen staff should be cleaning daily, labeling, and storing food appropriately and all items should be dated. She said the staff had been trained on maintaining the kitchen in a sanitary condition. She said there was a cleaning schedule and the staff had been signing off that cleaning had been done. She said the drink dispensers were wiped down but the company that provided them were to deep clean them. She said she was not aware of the manufacturer weekly cleaning schedule listed inside the drink dispensers but would check into it. She said that by not maintaining kitchen sanitation it could lead to contamination and illness.<BR/>During an interview on 5/14/2024 at 4:00 pm the administrator said the dietary manager was responsible for oversight of the kitchen and she expected the kitchen to be cleaned and items stored in a sanitary manner. She said the staff had been trained on proper cleaning of the kitchen and how to label and store foods but would oversee more training was done. She said that an unsanitary kitchen could lead to illness and expected the kitchen to be maintained in a sanitary condition. <BR/>Record review of a monthly kitchen cleaning schedule log indicated full cleaning performed in January 2024, February 2024, March 2024, and April 2024. <BR/>Record review of an in-service training dated 3/21/2024 titled Dating and Labeling and cleaning indicated staff had been trained.<BR/>Record review of an in-service training dated 12/21/2023 titled deep cleaning kitchen and dating and labeling indicated staff had been trained. <BR/>Record review of a facility policy titled Food Storage dated 4/11/2022 indicated' .4. foods are stored at least 6 inches off the floor, 6. food removed from its original packaging will be labeled .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Resident #29 and Resident #39) and 2 of 5 staff (CNA D and CNA H) reviewed for infection control.<BR/>CNA D did not change gloves and sanitize/wash hands when providing incontinent care to Resident #29 on 5/13/2024.<BR/>CNA H did not sanitize or wash her hands after changing gloves when providing incontinent care to Resident #39 on 5/14/2024.<BR/>These failures could place residents at risk of exposure to communicable diseases and infections.<BR/>Findings include:<BR/>1.Record review of a facility face sheet dated 5/13/2024 indicated Resident #29 was [AGE] years old and admitted to the facility on [DATE] with diagnosis of cerebral infarction (lack of blood to the brain).<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #29 had a BIMS of 4 indicating severe cognitive impairment and was always incontinent of bowel and bladder and required maximum assistance with toileting.<BR/>Record review of a comprehensive care plan dated 3/22/2024 indicated Resident #29 had ADL self-performance deficit and required extensive assistance with toileting.<BR/>During an observation on 05/13/24 at 10:05 AM Resident # 29 was receiving care from CNA D. CNA D had gloves on, Resident #29's brief was opened and pulled down forward, CNA D wiped front to back with stool present. Resident #29 turned self on right side, CNA D wiped stool from buttocks using wipes. CNA D placed soiled brief in a bag, and wiped buttocks until clean. She placed soiled wipes in bag. Without changing gloves and performing hand hygiene, CNA D applied barrier clean to buttocks and placed clean brief under Resident #29. Resident #29 rolled back over, and CNA D continued to apply skin barrier to front peri-area and pulled clean brief into place. Wearing same soiled gloves, CNA D placed pillow under Resident #29's right arm and adjusted linen on bed. CNA D then removed gloves and washed her hands before leaving room. <BR/>During an interview on 05/13/24 at 10:15 AM CNA D said she had been a CNA for 21 years. She said she had received training on incontinent care recently and was checked off. She said she was nervous and should have changed her gloves from dirty to clean to prevent infections. <BR/>Record review of a competency evaluation for hand hygiene indicated CNA D was last evaluated for competency on 11/12/2023.<BR/>2. Record review of an admission Record for Resident #39 dated 5/14/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnosis of major depressive disorder (persistent sadness or loss of interest), diastolic heart failure (condition in the heart that causes the heart to become stiff and unable to fill properly) , morbid obesity (overweight), and hypertension (high blood pressure).<BR/>Record review of a Quarterly MDS Assessment for Resident #39 dated 2/15/2024 indicated she did not have any impairment in thinking with a BIMS score of 14. She required substantial/maximal assistance with toileting. She was always incontinent of bladder and bowel. <BR/>Record review of a care plan for Resident #39 revised on 9/30/2023 indicated she was incontinent of bladder and bowel with interventions to monitor for incontinence every 2 hr/prn, change promptly.<BR/>During an observation on 5/14/2024 at 11:05 AM in the room of Resident #39, CNA H was present to provide incontinent care. She removed gloves from her scrub top pocket and placed them on her hands without washing or sanitizing them. She opened the brief of Resident #39 and pulled it down between the resident's thighs. She removed wipes and wiped the resident's lower abdomen and then wiped down the left inner thigh and placed the wipe in the trash. She removed a wipe and wiped down the right inner thigh and placed it in the trash. She removed a wipe and wiped down the middle of peri area from front to back. She rolled the resident onto her left side and removed her gloves and placed them in the trash. She removed gloves from her pocket and placed them on her hands without washing or sanitizing them. She removed wipes and wiped the resident's rectal area from front to back. She rolled the brief underneath the resident's buttocks. She opened a clean brief and placed it underneath the dirty brief and removed the dirty brief. She rolled the residents onto her back and secured the brief. She removed her gloves and placed them in the trash. She went to the resident's closet and picked out a dress for the resident to wear. She said she had to leave the room to get the mechanical lift to transfer the resident from the bed to her wheelchair and did not wash or sanitize her hands.<BR/>During an interview on 5/14/2024 at 3:20 PM, CNA H said she had been employed at the facility since October 2023 and was full time and worked the hall where Resident #39 resided. She said during the incontinent care provided to Resident #39, she did not wash her hands before care was started, during or after the care provided. She said when she thought about sanitizing her hands it was too late. She said she did not have her sanitizer in her pocket like normal because she was wearing a different jacket. She said her gloves should have been in a plastic bag and not stored in her pocket. She said she recently had a skills check off by the ADON last month April 2024. She said residents could be at risk for infections if staff did not wash or sanitize their hands when providing care.<BR/>Record review of a Hand Hygiene Competency Check Off Audit Form dated May 2024 conducted by the ADON indicated CNA H was checked on 5/2/2024 for hand hygiene and passed. <BR/>Record review of a competency skills evaluation for CNA H dated 12/10/2023 indicated she was satisfactory with providing incontinent to a female resident that included hand hygiene.<BR/>During an interview on 05/14/24 at 1:37 PM the DON said that CNA D had been trained on proper hygiene and had been a CNA for many years. She said she expected all staff to follow proper hand hygiene when providing care. She stated the risk of improper incontinent care could lead to infections and negative resident outcomes. <BR/>During an interview on 5/14/2024 at 3:33 pm the administrator said that nurse management was responsible for oversight of resident care like incontinent care and hand hygiene. She said CNA D had been a CNA for many years and expected all staff to follow proper hand hygiene and incontinent care. She said that the CNA not performing correct peri care and hand hygiene could cause cross contamination.<BR/>During an interview on 5/15/2024 at 9:50 AM, the ADON said she was the IP and responsible for training staff on hand hygiene. She said she conducted quarterly check offs with staff on hand hygiene. She said CNA H was present on 5/2/2024 when she had a training on hand hygiene. She said staff should perform hand hygiene before starting care, between care, and before exiting the room. She said residents could be at risk of cross contamination and infections if they did not wash or sanitize their hands.<BR/>During an interview on 5/15/2024 at 10:00 AM, the DON said staff should wash or sanitize their hands before starting care, when going from dirty to clean, and before leaving the room. She said the ADON was responsible for training staff on hand hygiene, and it was done quarterly. She said going forward, they would continue training staff on hand hygiene with check offs. She said there was a risk of cross contamination and infections if staff did not wash or sanitize their hands.<BR/>During an interview on 5/15/2024 10:20 AM, the Administrator said hand hygiene should be done before care was started, when changing gloves, between dirty to clean procedures, at the end of care, and any time hands were visibly soiled. She said the ADON was the IP and had been doing hand hygiene competencies quarterly and as needed. She said residents could be at risk for infections if staff did not perform hand hygiene.<BR/>Record review of a facility policy titled Perineal Care dated 10/01/21 indicated, .to prevent infections and skin irritation;11. remove gloves and discard, wash hands, 12. reposition bed covers . <BR/>Record review of a facility policy titled Hand Hygiene dated 8/4/21 indicated, .Hand hygiene is used to prevent the spread of pathogens in healthcare settings. 1. You should always perform hand hygiene: before applying and after removing personal protective equipment (e.g., gloves), before and after providing any type of care; 2. You must perform hand hygiene (handwashing or the use of an ABHR) after contact with bodily fluids, such as urine .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for 5 of 14 employees (Administrator, Director of Resident Support Service, Director of Life Enrichment, DM, and CNA J) reviewed for training. <BR/>The facility failed to ensure the Administrator was trained on restraint reduction annually.<BR/>The facility failed to ensure the Director of Resident Support Service was trained on restraint reduction annually.<BR/>The facility failed to ensure the Director of Life Enrichment was trained on restraint reduction annually.<BR/>The facility failed to ensure the DM was trained on fall prevention and restraint reduction annually.<BR/>The facility failed to ensure CNA J was trained on fall prevention annually.<BR/>These failures could place residents at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.<BR/>Findings include:<BR/>Record review of a facility assessment dated [DATE] and reviewed on 3/11/2024 indicated Training: Upon initial new hire (all staff) receive training on Resident Rights, Abuse policy, Blood borne pathogens, Infection Control. Competencies should be completed annually. Regular training in services are used to complete new hire orientation and annually (HIV, Abuse, Falls, Dementia, Restrain Free environment, Ethics). Required in-service training for CNA and CMA: Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year.<BR/>Record review of the personnel file for the Administrator indicated she hired at the facility on 6/21/2022 and did not have an annual training on restraints.<BR/>Record review of the personnel file for the Director of Support Service indicated she hired at the facility on 11/3/2022 and did not have an annual training on restraints.<BR/>Record review of the personnel file for the Director of Life Enrichment indicated she hired at the facility on 7/26/2021 and did not have an annual training on restraints.<BR/>Record review of the personnel file for the DM indicated she hired at the facility on 10/13/2022 and did not have an annual training on fall prevention and restraints.<BR/>Record review of the personnel file for CNA J indicated she hired at the facility on 10/4/2022 and did not have an annual training on fall prevention.<BR/>During an interview on 5/14/2024 at 11:30 AM, the BOM said the facility did not have a person in house that was designated for HR duties. She said corporate was responsible for all of the required trainings for new and existing staff. She said she was responsible for completing the orientation of new hires. <BR/>During an interview on 5/14/2024 at 2:34 PM, the HR Business Partner said the facility was fairly new to her and she acquired it at the end of January 2024. She said on hire the required trainings should be done at orientation in the facility. She said some of the facilities used the monthly electronic version and others still used paper documentation for the trainings. She said when trainings were sent out to the facilities, they were sent via email by the Director of Clinical Education. She said then the facility should be completing them accordingly. She said if someone was not present at the time of the monthly in-service training, when that staff returned to work, they should follow-up to ensure they received the training. She said the trainings for on hire included: Abuse, Dementia Care, HIPAA, Human Immunodeficiency Virus (HIV), Texas House [NAME] 300, Restraints, and Slips, Trips, and Falls. <BR/>During an interview on 5/15/2024 at 8:36 AM, the Director of Clinical Education said she was responsible for the trainings for staff on hire and annually. She said the facility had a centralized onboarding with new hires with corporate. She said the on boarding started with corporate and new hires received training on Abuse, Dementia Care, HIPAA, Human Immunodeficiency Virus (HIV), Texas House [NAME] 300, Restraints, and Slips, Trips, and Falls on hire and annually. She said the facility was in the process of ensuring the orientation and on boarding with staff included the additional education on trainings that included behavioral health, compliance and ethics and QAPI. She said every month she sent the facilities a different topic for training and included who the training should be given to. She said if staff were not present at the time of the trainings, then education should be provided to that staff member when they returned to work. She said the facilities could provide training as much as they needed to. She said if staff did not receive the required training, they could potentially have a knowledge deficit. She said the facility did not have a policy on trainings for staff. She said there was an oversight issue with the email on the restraint training that was sent out to the facility because it did not include all staff to be trained and only said for nursing staff.<BR/>Record review of an email dated June 2, 2023, by the Director of Clinical Education indicated a monthly education for June 2023 to include training on restraint for all nursing staff. All nursing staff includes any nurse, medication aide, certified nurse aide, restorative aide, and uncertified aide.<BR/>During an interview on 5/15/2024 at 10:00 AM the DON said she was responsible for the trainings that was sent by the Director of Education. She said the Director of Education sent the facility a monthly list of trainings and it told them who gets what and they scheduled the training with staff. She said they just went by the list that was sent and the Director of Education was responsible for ensuring the facility received the required trainings. She said going forward they would ensure the staff received any missing trainings. She said there was a risk of staff not knowing how to do their jobs. She said all of the state required trainings came from corporate.<BR/>During an interview on 5/15/2024 at 10:20 AM, the Administrator said the trainings were split between the DON and herself. She said she received an email monthly for what trainings were needed. She said corporate would send the trainings and it would indicate who needed the training. She said they have always just gone by what corporate sent to them. She said she thought that the trainings that were sent out to the facilities were being done correctly. She said there was a risk of staff not knowing how to handle situations if they did not receive training. She said the facility did not have a policy on the required trainings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 1 of 14 staff (CNA J) reviewed for training.<BR/>The facility failed to ensure infection prevention and control training was provided CNA J on hire.<BR/>This failure could place residents at risk of the spread of illness due to lack of staff training. <BR/>The findings were:<BR/>Record review of the personnel file for CNA J indicated she hired at the facility on 3/5/2024 and did not have training on infection control on hire.<BR/>During an interview on 5/14/2024 at 11:30 AM, the BOM said the facility did not have a person in house that was designated for HR duties. She said corporate was responsible for all of the required trainings for new and existing staff. She said she was responsible for completing the orientation of new hires. <BR/>During an interview on 5/14/2024 at 2:34 PM, the HR Business Partner said the facility was fairly new to her and she acquired it at the end of January 2024. She said on hire the required trainings should be done at orientation in the facility. She said some of the facilities used the monthly electronic version and others still used paper documentation for the trainings. She said when trainings were sent out to the facilities, they were sent via email by the Director of Clinical Education. She said then the facility should be completing them accordingly. She said if someone was not present at the time of the monthly in-service training, when that staff returned to work, they should follow-up to ensure they received the training.<BR/>During an interview on 5/15/2024 at 8:36 AM, the Director of Clinical Education said she was responsible for the trainings for staff on hire and annually. She said the facility had a centralized onboarding of new hires with corporate. She said the on boarding started with corporate and new hires received training on Abuse, Dementia Care, HIPAA, Human Immunodeficiency Virus (HIV), Texas House [NAME] 300, Restraints, and Slips, Trips, and Falls on hire and annually. She said the facility was in the process of ensuring the orientation and on boarding with staff included the additional education on trainings that included behavioral health, infection control, compliance and ethics and QAPI. She said every month she sent the facilities a different topic for training and included who the training should be given to. She said if staff were not present at the time of the trainings, then education should be provided to that staff member when they returned to work. She said the facilities could provide training as much as they needed to. She said if staff did not receive the required training, they could potentially have a knowledge deficit. She said the facility did not have a policy on trainings for staff. <BR/>During an interview on 5/15/2024 at 10:00 AM the DON said she was responsible for the trainings that was sent by the Director of Education. She said the Director of Education sent the facility a monthly list of trainings and it told them who gets what and they scheduled the training with staff. She said they just went by the list that was sent and the Director of Education was responsible for ensuring the facility received the required trainings. She said going forward they would ensure the staff received any missing trainings. She said there was a risk of staff not knowing how to do their jobs. She said all of the state required trainings came from corporate.<BR/>During an interview on 5/15/2024 at 10:20 AM, the Administrator said the trainings were split between the DON and herself. She said she received an email monthly for what trainings were needed. She said corporate would send the trainings and it would indicate who needed the training. She said they have always just gone by what corporate sent to them. She said she thought that the trainings that were sent out to the facilities were being done correctly. She said there was a risk of staff not knowing how to handle situations if they did not receive training. She said the facility did not have a policy on the required trainings.<BR/>Record review of a facility assessment dated [DATE] reviewed on 3/11/2024 indicated Training: Upon initial new hire (all staff) receive training on Resident Rights, Abuse policy, Blood borne pathogens, Infection Control. Competencies should be completed annually. Regular training in services are used to complete new hire orientation and annually (HIV, Abuse, Falls, Dementia, Restrain Free environment, Ethics). Required in-service training for CNA and CMA: Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year.<BR/>Record review of a facility policy titled Infection Control revised 10/25/22 indicated, .This communities' infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. 5. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop a person-centered comprehensive care plan to address medical needs for 1of 8 residents (Resident #1) reviewed for comprehensive care plans.<BR/>The facility failed to ensure Resident #1's care plan was revised to reflect measurable objectives, interventions, and time frames to promote skin wellness, and prevention and healing pressure ulcers.<BR/>This failure could place the resident at increased risk of not receiving necessary care, and a decreased quality of life.<BR/>The findings included:<BR/>Record review of Resident #1's face sheet dated 10/10/23 indicated Resident #1 was an [AGE] year-old female admitted to the facility 10/11/22 with diagnoses of Alzheimer's disease (A type of brain disorder that causes problems with memory, thinking and behavior), muscle wasting, osteoporosis (a disease that weakens your bones), dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities), and dysphagia ( difficulty in swallowing) following cerebral infarction (the most common form of stroke).<BR/>Record review of Resident #1s quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 7, indicating she had severely impaired cognition. The MDS indicated Resident #1 required extensive assistance with personal hygiene and dressing. The MDS indicated Resident #1 was always incontinent of bowel and bladder. The MDS indicated Resident #1 was at risk for developing pressure ulcers/injuries and had no unhealed ulcers/injuries at this time.<BR/>Record review of Resident #1's care plan with a revision date of 10/23/22 indicated the following: Focus: I may have skin breakdown. Interventions: Document each incident of bruising, skin tear, or other skin problems noted and tailor interventions to prevent further occurrences.<BR/>During an interview on 10/11/23 at 9:56 a.m. LVN A stated that residents who had pressure ulcers or at risk for pressure ulcers received frequent turning, attempts to keep them hydrated, make sure they received protein supplements, and kept clean and dry. LVN A stated she was not sure who was responsible for placing interventions on the care plan and felt interventions should be specific for all residents. <BR/>During an interview on 10/11/23 at 10:45 a.m. LVN B stated residents at risk for pressure injuries were frequently repositioned with pillows. LVN B stated all interventions should be on the care plan, and she was not sure who was responsible for updating care plans.<BR/>During an interview on 10/11/23 at 11:15 a.m. LVN C stated interventions used for residents with elevated risk for pressure ulcers included turning every 2 hours, pillows between legs, or behind back, and making sure residents were kept clean and dry. LVN C stated there was a how to book about wound care kept at the nurses station they could use if needed for reference on wound care. <BR/>During an interview on 10/11/23 at 2:10 p.m. LVN D stated she updated care plans when she received new orders. LVN F stated the DON and ADON reviewed care plans.<BR/>During an interview on 10/12/23 at 3:00 p.m. the Administrator stated the DON reviewed care plans, and any staff member could put interventions in.<BR/>During an interview on 10/16/23 at 9:29 a.m. the ADON stated the DON reviewed the care plans. The ADON stated interventions such as pillows for offloading and turning every 2 hours should be in the care plan. <BR/>During an interview on 10/16/23 at 10:20 a.m. LVN E stated the DON had showed the staff how to put information into the care plan, before she left on leave about a month ago, but she had forgotten how to do it. LVN E stated that interventions used for residents with or at risk for pressure ulcers included repositioning every 2 hours and offloading heels. LVN E stated all specific interventions should be on the care plan. Stated the DON had told the staff to put interventions into the computer the time the incident occurred. <BR/>During an interview on 10/16/23 at 11:26 a.m. the Interim DON stated ideally, specific interventions should be on the care plan. Interim DON stated the wound care company the facility was contracted with provided a manual to assist staff in identifying and staging wounds as well as providing treatment guidelines and protocols. Interim DON stated staff were expected to follow these guidelines. Stated any staff member could update care plans and was not sure if there was one person who was responsible for them.<BR/>Record Review of policy titled Skin Management: Prevention and Treatment of Wounds with a revision date of 10/6/2022 indicated the following: Residents at risk for developing pressure ulcers based on the Braden Score will have care plan developed to include interventions to prevent skin breakdown .<BR/>Record review of a policy titled Comprehensive Care Plan with a revision date of 4/25/21 indicated the following: the care plan is revised every quarter, significant change of condition, annual or as the resident condition changes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure services provided or arranged by thge facility as outlined by the comprehensive care plan meets professional standards of quality for 1 of 8 residents (Resident #1) reviewed for skin assessments. <BR/>The facility failed to ensure Resident #1 received a weekly skin assessment.<BR/>This failure could place the resident at increased risk of not having their individual needs met.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 10/10/23 indicated Resident #1 was an [AGE] year-old female admitted to the facility 10/11/22 with diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), muscle wasting, osteoporosis (a disease that weakens your bones), dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities), and dysphagia ( difficulty in swallowing) following cerebral infarction (the most common form of stroke).<BR/>Record review of Resident #1s quarterly MDS dated [DATE] indicated Resident #1 had a BIMS score of 7, indicating she had severely impaired cognition. The MDS indicated Resident #1 required extensive assistance with personal hygiene and dressing. The MDS indicated Resident #1 was always incontinent of bowel and bladder. The MDS indicated Resident #1 was at risk for developing pressure ulcers/injuries and had no unhealed ulcers/injuries at this time.<BR/>Record review of Resident #1's physician orders dated 10/1/23-10/31/23 indicated the following: nursing to perform weekly skin assessment. Every night shift, every Monday.<BR/>During an interview on 10/11/23 at 9:56 a.m. LVN A said skin assessments were done weekly. LVN A stated there was a schedule at the desk and the dates they need to be completed. LVN A stated there was also an alert that popped up on the computer screen when assessments were due. LVN A stated night shift and day shift were responsible to see that all skin assessments were done. LVN A stated if a skin assessment was not completed, the alert turned red and stayed on the computer until it has been done. LVN A stated if she found any new skin concern on a resident, she would do a full skin assessment from head to toe, and she would report it to the DON, ADON, MD, and family. LVN A stated that all clothing needed to be removed for proper skin assessment to be done.<BR/>During an interview on 10/11/23 at 10:45 a.m. LVN B stated skin assessments were done weekly. LVN B stated the computer alerted staff to residents who were due for an assessment, and when they needed to be done. LVN B stated a full skin assessment included removing clothing from head to toe. LVN B stated on 10/1/23 she was notified by another staff that Resident #1 had 2 open areas. LVN B stated she assessed Resident #1 and it looked like 2 scratches on the top and bottom of Resident #1's right hip. LVN B stated she did not complete a full head to toe assessment. LVN B stated she just assessed Resident #1's bottom. LVN B stated that if any new wound/skin condition were found, staff were to do a full skin assessment. <BR/>During an interview on 10/11/23 at 11:15 a.m. LVN C said skin assessments were to be done weekly. LVN C stated residents skin was to be looked at from head to toe. LVN C stated clothing would be removed to get a good look at all the skin. LVN C stated if a new skin condition were observed, she would do a complete head to toe skin observation.<BR/>During an interview on 10/11/23 at 12:30 p.m. Interim DON said the LVN charge nurses did head to toe skin assessments weekly. Interim DON stated LVNs could measure wounds but not stage them. Interim DON stated her expectation, and what she would like the staff to do is a new full skin assessment when any new skin issue was identified. <BR/>During an interview on 10/12/23 at 10:15 a.m. the ADON stated staff were to do complete head to toe skin assessments weekly, and if they were notified of any skin issue, they should also do a full assessment. <BR/>During an interview on 10/12/23 at 10:28 a.m. LVN F stated head to toe skin assessments were done every week. LVN F stated there was a pop up on the computer to let staff know when the assessments were due. LVN F stated when she did her assessments, she would make the resident stand up, lie down, and remove all clothes including any socks. LVN F stated if she found any skin issues, or any were reported to her she would do a complete skin assessment. LVN F stated staff were also supposed to do a complete head to toe skin assessment whenever there was a fall. LVN F stated she always had another staff member look at any wounds she found as she did not feel comfortable measuring them.<BR/>During an interview on 10/12/23 at 3:00 p.m. the Administrator stated skin assessments are done weekly, and all clothing should be removed. Administrator stated when staff identified a new skin condition, they were to do a skin assessment, and typically would do a full assessment.<BR/>During an interview on 10/16/23 at 10:20 a.m. LVN E stated she did 5-6 skin assessments per week. LVN E stated there were alerts on the computer to alert staff when skin assessments were due. LVN E stated she tried to do her assessments when the residents were in the shower so she could get a good look at their skin. LVN E stated if she found, or was notified of any new skin condition, she would do a complete head to toe assessment removing clothing including socks. LVN E stated she received training when she was hired which consisted of doing overall skin assessments/wound reports. <BR/>Record review of a policy titled Skin Management: Prevention and Treatment of Wounds with a revision date of 10/6/2022 indicated the following: .skin assessments will be conducted at a minimum of every 7 days on a week on a Weekly Skin Assessment . Residents at risk for developing pressure ulcers based on the Braden Score will have care plan developed to include interventions to prevent skin breakdown. Dependent residents will have heels floated while in bed and be turned and repositioned at a minimum of every 2 hours .Wound Protocols will be used for wound care guidelines and reference for staging wounds .care plan will be developed by the IDT to include risk factors, interventions to promote skin wellness and healing pressure ulcers .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure correct installation, use, and maintenance of bed rails for two of twenty-one residents (Resident #1 and Resident #2) reviewed for bed rails.<BR/>The facility failed to follow the manufacturers' recommendations and specifications for installing bed rails and developing care plan interventions for risk of entrapment. The facility assist bars installed on Resident #1 and Resident #2 ' s bed were not intended for use and care plans did not include risk for entrapment per manufacturer ' s specifications. Resident #1 expired at the facility after CNA A found him in his room with his neck between the assist bar and bed face down with his legs on the floor mat. <BR/>An IJ was identified on 10/02/2023. The IJ template was provided to the facility on [DATE] at 2:12 p.m. While the IJ was removed on 10/03/2023, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>This failure could place residents at risk for entrapment with serious injury or death. <BR/>Findings included:<BR/>Resident #1<BR/>Review of a face sheet for Resident #1. Dated 10/01/2023, revealed he was a [AGE] year old male admitted to the facility on [DATE] and had diagnoses including moderate dementia with mood disturbance, muscle wasting and atrophy to right and left shoulders, erosive osteoarthritis to left knee, and transient alteration of awareness.<BR/>Review of Physician Orders, dated 11/06/2022, revealed Resident #1 may have assist bars x 2 on bed to facilitate with turning and repositioning every day and night shift for bed mobility.<BR/>Review of Resident #1 ' s Bed Rail Mobility Device Assessment, dated 08/31/2023, revealed no concerns for risks of entrapment and assist bars were installed for bed mobility post falls following prior interventions of a floor mat and bed in low position.<BR/>Review of Resident #1 ' s MDS, dated [DATE], revealed he had a Brief Interview for Mental Status score of 04, indicating severe cognitive impairment. Resident # ' 1 ' s functional status revealed he was non-ambulatory and required a two person assist for bed mobility. <BR/>Review of Resident #1 ' s care plan, revised 09/11/2023, revealed the resident had a history of falls and sliding off the bed with a recent fall on 9/16/2023 where he was found on the floor mat with no injuries. The care plan revealed Resident #1 had a focus of being unable to bear weight or walk and limitations to legs and shoulders with interventions to include bilateral transfer bars. The care plan did not address the residents risk of entrapment. <BR/>Bed Mobility Device Assessment<BR/>Review of incident report log from September 2023 to October 2023 revealed Resident #1 had a fall on 09/16/2023 and incident category listed as other 09/30/2023. <BR/>Review of Provider Timeline Report, dated 09/30/2023, revealed the following:<BR/>*3:00 a.m., revealed CNA A last saw Resident #1 prior to incident during incontinent care check. <BR/>*4:10 a.m., revealed CNA A found resident unresponsive with his head and neck between the assist bar and mattress. LVN A assessed, 911 was notified, AED device was placed by staff and CPR was initiated. EMS assisted with CPR.<BR/>*4:38 a.m., EMS pronounced Resident #1 ' s death.<BR/>*4:56 a.m., the administrator was notified of death.<BR/> *5:17 a.m., revealed Regional Director of Operations was notified.<BR/>*6:23 a.m., revealed police were notified. Three officers arrived, assessed incident, obtained witness statements, and notified the Justice of the Peace that ordered an autopsy. <BR/>During an interview on 10/01/2023 at 11:35 a.m., the Administrator said the Director of Plant Operations was responsible for bed and assist bar installation and maintenance. The Administrator said CNA A last saw Resident #1 during incontinent care rounds at 3:00 a.m. on 09/30/2023 and he was doing fine and upon rounding at 4:10 a.m. CNA A noticed his legs were hanging off the bed and found him on the floor mat face down with his head and neck between the assist bar and bed. LVN A and the ADON assessed Resident #1 and there were no apparent injury or bruising at the time of the incident. AED device was obtained, and resident was a full code. CPR was initiated and EMS arrived and hooked him up to EKG, there were no readings, resident was determined deceased , and CPR was halted. The Administrator said Resident #1 ' s roommate was asleep and not aware of what had happened until the police came. The Administrator said Resident #1 ' s family member was notified by the ADON, and she called law enforcement and an autopsy was ordered. <BR/>During an interview on 10/01/2023 at 3:39 p.m., CNA A said she went in to check on Resident #1 at 3:00 a.m. on 09/30/2023 and he was good, awake, and not trying to get off the bed. CNA A said when she went by his room at 4:10 a.m., Resident #1 was hanging off the bed with legs crossed on the floor, right arm was on the floor, and his neck was in between bed and rail. CNA A said she did not notice any injuries or bruising. CNA A said Resident #1 never used the assist bars on his bed and did not know why they were in place because he could not grip the bar to hold. CNA A said his bed did not appear to have any concerns with integrity of equipment. CNA A said it was important for assist bars to be installed per manufacturer ' s specifications to prevent all residents from getting hurt and pose a risk of entrapment to all resident using assist bars. CNA A said the Director of Plant Operations was responsible for installing and maintaining assist bars on beds and the facility has not provided her any training on bed safety or assist bars. <BR/>During an interview on 10/01/2023 at 2:49 p.m., LVN A said she last saw resident #1 during medication pass on 09/29/2023 at 9:00 p.m. and said he was at baseline. LVN A said maintenance, the Director of Plant Operations, would be responsible for installing assist bars on the beds. LVN A said when someone falls, she typically does interventions such as placing a fall mat or providing education. She stated she did not know why the assist bar were installed on the residents bed and she was aware they could pose a risk of entrapment. LVN A said it was important for assist bars to be properly installed to prevent injury or death for all residents.<BR/>During an interview on 10/01/2023 at 12:28 p.m., the Administrator said following the incident with Resident #1, staff were in-serviced on bed safety and audit checks were completed on all resident beds with assist bars thoroughly checked and there were no concerns with integrity of assist bar equipment.<BR/>During an interview on 10/01/2023 at 2:15 p.m., LVN B said she was informed Resident #1 had gotten out of bed and got hung in the rail. LVN B said Resident #1 was a repeat faller, could not walk, had little movement, and could get his legs off the bed somehow with fall risk interventions of fall mat at bedside and keeping his bed low to the floor. LVN B said he has rolled of the bed before and have caught him with his legs off the bed and had to reposition him. LVN B said she did not know why they put the assist bar on his bed . She stated she had no concerns related to the beds ,assist bars or the use of the rail bars. She stated if she did, she would report to maintenance, the Director of Plant Operations. LVN B said following Resident #1 ' s incident, in-services were provided on bed safety. LVN B said hazards with using air mattresses and assist bars on beds could pose a risk of entrapment.<BR/>During an interview and observation on 10/01/2023 at 4:45 p.m., the Director of Plant Operations said the bed located in Resident #1 ' s room was the original bed and equipment for resident. The Director of Plant Operations said the bed manufacturer was [company 2], model P503, and the assist bar was manufactured by [company 1]. The Director of Plant operations said there was no gap allowed between the assist bar and bed for this type of assist bar. The Director of Plant Operations said he completed bed safety checks for all beds following Resident #1 ' s incident. The Director of Plant Operations said he was not aware that the assist bar was intended for use on[company 1].beds only per manufacturer ' s specification and that he installed the assist bars if the holes in resident bed frames lined up with the holes in assist bar. The Director of Plant Operations said it was important for assist rails to be installed properly to prevent the risk of injury or death and that improperly installed assist bars could pose a risk of entrapment. The Director of Plant Operations said he completed bed rail safety checks monthly and did not know if there were any [company 1]manufactured beds in the facility and that he did not keep an inventory of beds available. The Director of Plant Operations said the different white colored assist bars used in the facility were universal and that he did not have the manual for the universal assist bars.<BR/>Review of [company 1] assist bar manual undated revealed the following:<BR/>Warning: Possible Injury Or Death. This product is intended for use with [company 1] bed models ECS Series beds, B784, B694, B684, B624, B675, B530, B330, and B40/41. Use of this product on any bed it was not designed for could result in an unproven or unsafe configuration, potentially resulting in serious injury or death . and It is also extremely important to review the resident/patient ' s physical and mental condition and initiate an appropriate individual care plan to address entrapment risk.<BR/>Resident #2<BR/>Review of face sheet for Resident #2, dated 10/02/2023, revealed she was a [AGE] year-old female admitted on [DATE] and had diagnoses including muscle wasting and atrophy to right and left shoulders, acquired absence of left leg above knee, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, age related osteoporosis, and encephalopathy.<BR/>Review of Resident #2 ' s MDS, dated [DATE], revealed she a Brief Interview for Mental Status Score of 04, indicating severe impairment. Resident #2 ' s functional status revealed she was non-ambulatory and required a two person assist with bed mobility.<BR/>Review of Resident #2 ' s care plan, revised 08/10/2023, revealed she required extensive assist of two staff with bed mobility with intervention of bilateral transfer bars to assist with positioning and care. The care plan did not address the residents risk of entrapment. <BR/>Review of Bed Mobility Device Assessment for Resident #2, dated 09/30/2023, revealed no concerns for risks of entrapment and assist bars were installed for bed mobility.<BR/>During an observation on 10/2/2023 at 1:25 p.m., Resident #2 had a white universal assist bar installed to [company 2] manufactured bed, model P503.<BR/>During an interview on 10/02/2023 at 2:22 p.m., the Director of Plant Operations said he did not have a manual for the universal assist bars and provided a manufacture and model number of [company 3] 54588.<BR/>Review of [company 3] 54588 assist bar manual from supplier online website, undated, revealed the following:<BR/>Warning: Risk of serious injury or death. This product is intended only for use with [company 3] 1500, 3000, 3250, and 3500 beds. Do not use this device with any other model or brand of bed. Use of this product on any bed it was not designed for could result in an unproven or unsafe configuration, potentially resulting in serious injury or death.<BR/>During an interview on 10/02/2023 at 3:30 p.m., the Executive Director of Operations, Regional Nurse, and Clinical Reimbursement Coordinator said they will address Resident #2 ' s [company 3] assist bar installed on [company 2] manufactured bed not intended for use as soon as possible following HHSC Investigator intervention to ensure safety.<BR/>During an interview on 10/02/2023 at 3:50 p.m., the Executive Director of Plant Operations said [company 2] assist bar was available for Resident #2 ' s bed, however, the assist bar was removed following an assessment and determination that resident was not using assist bars as intended for repositioning and were removed with approval from the representative. <BR/>During an interview and record review on 10/02/2023 at 3:53 p.m., the Clinical Reimbursement Coordinator revealed care plan verbiage to be added to residents with assist bars that included risk for entrapment.<BR/>Review of facility in-services, dated 09/30/2023, revealed bed safety education was provided to nursing staff. <BR/>Review of facility policy, titled Bed Safety, effective 04/2021, revealed the following:<BR/>Policy<BR/>Focused Communities will strive to provide a safe sleeping environment for the resident. <BR/>PROCEDURE<BR/>1. <BR/>The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement,<BR/>as well as input from the resident and family regarding previous sleeping habits and bed environment.<BR/>2. <BR/>To try to prevent deaths/injuries from the beds and related equipment (including the<BR/>frame, mattress, side rails, headboard, footboard, and bed accessories), the facility<BR/>shall promote the following approaches:<BR/>a. <BR/>An inspection should be done by the Director of Plant Operations at installation/before use and quarterly thereafter of all beds and related equipment as part of<BR/>our regular bed safety program to identify risks and problems including potential entrapment risks;<BR/>b. <BR/>Review that gaps within the bed system are within the dimensions established by<BR/>the FDA (Note: The review shall consider situations that could be caused by the resident's weight, movement, or bed position.<BR/>c. <BR/>Ensure that when bed system components are worn and need to be replaced, they are replaced with compatible components that meet manufacturer specifications;<BR/>d. <BR/>Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard and footboard, etc.); and .<BR/>10. <BR/>When using side rails for any reason, the staff shall take measures to reduce related risks.<BR/>The Executive Director of Operations was notified of the Immediate Jeopardy on 10/02/2023 at 2:12 p.m. and was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy.<BR/>The Facility's Plan of Removal was accepted on 10/03/23 at 12:54 p.m. and reflected the following:<BR/>Part 1: Identification of Recipients: <BR/> 1 The resident directly affected by the deficient practice is no longer in the community.<BR/>Part 2: Actions to Prevent Occurrence or Recurrence:<BR/>1. Universal Assist bar was removed from additional resident with air mattress on 10/2/2023.<BR/>2. All facility policies and procedures regarding assist rails were reviewed during Ad Hoc QAPI with Medical Director on 10/2/23.<BR/>3. The DON or designee will educate all staff, prior to their next scheduled shift, on the proper use of assist rails per facility policy, the process of determining proper use of side rails depending on resident ' s mental and physical status, and the increased risk of injury and death when assist rails are used improperly. Education will include bed mobility device inspection, FDA recommended space and instruction to report gaps greater than recommendation to DON/Administrator/Maintenance Director. Education will begin 10/2/23 and completed 10/3/2023 before the start of their next scheduled shift. <BR/>a. Newly hired personnel will be educated on the proper use of assist rails per facility policy, the process of determining proper use of side rails depending on resident ' s mental and physical status, and the increased risk of injury and death when assist rails are used improperly. <BR/>4. Maintenance personnel provided 1:1 inservice on installation of all assist bars per manufacture guideline on 10/2/2023 by the Regional Nurse. Manufacturer guidelines will be available to any staff installing assist bars. The guidelines will be located in the Administrator and Maintenance Director ' s office and at nurse ' s station. <BR/>5. The IDT reviewed all residents with assist bars to determine the appropriateness of continued assist bar placement and risk of entrapment on 10/2/2023. All residents utilizing assist bars will have a Bed Mobility Device assessment completed on 10-3-2023 by 1p.m.<BR/>6. The IDT reviewed the care plans of residents with bed rails to ensure they include risk associated with use of assist bars completed on 10/2/2023.<BR/>On 10/03/23 at 5:30 p.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: <BR/>Removal of assist bars not intended for use from beds and replacement with approved assist bar per manufacturer ' s specification, <BR/>Review of in-services revealed staff training was completed on bed mobility zone gap recommendations, care plans updates included entrapment risk for residents with assist bars, interviews with staff demonstrating knowledge and location of bed mobility inspection sheet at nursing station, and bed inventory list with approved bed manufacture for assist bars used.<BR/>During an interview and record review on 10/03/2023 at 4:03 p.m., the Executive Director of Operations said the interdisciplinary team consisted of the DON or Interim Administrator, MDS Coordinator, Activity Director, Social Worker, Rehab Director, ADON, Maintenance Director, Medical Director, and included herself. The Executive Director of Plant Operations said staff received in-services per plan of removal, care plans were updated to include risk of entrapment, and assist bars not intended for use were removed from service. The Executive Director of Operations said only[company 2] manufactured beds with[company 2] assist bars were now utilized for resident beds at the facility to ensure manufacturer specifications were being met and was in the process of obtaining and replacing approved beds. Review of resident assist bar audit tool, care plan tasks, and physician order listing report, dated 10/3/2023, revealed rental beds were listed, [company 2] manufactured beds were rented, care plans were updated, and physician orders revealed assist bars were in place for repositioning and turning of residents. The Executive Director of Operations said it was important for staff to follow the assist bar manufacturer guidelines to ensure they are properly installed and used accordingly to reduce risks for any hazards including injury or entrapment and that not following manufacturer ' s guidelines could pose a risk to the residents that are using assist rails. The Executive Director of Operation said the facility has reassessed residents with assist bars installed and determined that some assist bars were no longer needed based on their ability to use the bar as intended for bed mobility. The Executive Director said family was contacted to approve removal of bars prior to removal and education was provided to residents and representatives on risks of using them. The Executive Director of Operations said the facility provided a legend with 4-3/4 inch requirement on bed mobility inspection sheet from FDA (Food and Drug Administration) recommendation for Zone 3 between assist bar and mattress and that the sheet will be located at the nurse station in the bed assist form manual and provided to every employee. The Executive Director of Operations said completion of[company 2] manufactured assist bars installation on Drive manufactured beds will be done by the end of the day. <BR/>Review of in-service, dated 10/02/2023, revealed training was provided to nursing staff on proper use of assist rails to include assessment for assist bars on care plan prior to usage. In-service revealed bed mobility inspection sheet that included gap recommendation of less than 4-3/4 for Zone 3 located between bed rail and mattress. <BR/>During an interview on 10/03/2023 at 4:15 p.m., CNA B said she had been employed at the facility for 3 years and that training was provided on bed safety via in-services. CNA B said the maintenance man, Director of Plant Operations, would be responsible for installing bed rails or assist bars. CNA B said if assist bars were not installed per manufacturer guidelines it could pose a risk of entrapment and affect any resident with an assist bar. <BR/>During an interview on 10/03/2023 at 4:23 p.m., CNA C said to ensure beds are safe she made sure the bed was low, and made sure bed rails are secure, and look for space in between assist bar and bed so residents cannot get stuck in between them and uses length of badge as a reference for gap recommendation. CNA C said it was important for assist bars to be installed properly to prevent entrapment and could pose a risk of death if installed on beds not intended for use.<BR/>During an interview on 10/03/2023 at 4:41 p.m., LVN C said she had been employed by facility for a year and a half. LVN C said residents were reassessed for assist bar use and knew that one resident had assist bars removed due to risk. LVN C said the facility provided training on bed safety today and that maintenance would be responsible for installing assist bars on the beds. LVN C said it would be a risk if a bed was not intended for use with an assist bar because it may malfunction and cause a risk for entrapment. <BR/>During an interview on 10/03/2023 at 4:48 p.m., LVN D said she had been employed for 3 and a half years. LVN D said the facility provided in-services and the manual at the nurse station goes over bed rails. LVN D said it was important to install the assist bar as intended to prevent incidents or accidents and said residents could fall and get injured and posed a risk for entrapment. LVN D said if there was gap in Zone 3 that was bigger than 4-3/4 she would notify maintenance and Administrator to make sure they addressed concerns.<BR/>During an interview and record review on 10/03/2023 at 5:10 p.m., the Clinical Reimbursement Coordinator said blanks on the assist bar assessment audit tool were residents waiting on new beds.<BR/>During an interview on 10/03/2023 at 5:20 p.m., the Director of Plant Operations said assist bars had been replaced and were now only using [company 2] brand assist bars., model P503 and P903. The Director of plant Operation said he reviewed with the Regional Nurse on how to properly install the Drive assist bars and ensure safety by making sure we are following manufacturer guidelines. The Director of Plant Operations said he was checking beds weekly for proper install and that all staff were provided and referring to gap recommendation of less than 4-3/4 on the bed mobility device inspection sheet for Zone 3 between bed rail and mattress. The Director of Plant Operations said staff are being asked questions and that a small test will be conducted on bed safety in a couple of days to demonstrate retention of knowledge. <BR/>On 10/03/2023 at 5:30 p.m., the Executive Director of Operations was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 4 residents (Resident #51) reviewed for pharmacy services. <BR/>The facility did not ensure medications were administered by licensed staff for Resident #51. <BR/>This failure could place residents at risk for the unsafe administration of medications, not receiving prescribed doses of ordered medications and infection.<BR/>Findings included:<BR/>During a record review physician order summary dated 3/21/23 for Resident #51 indicated he was [AGE] years old with diagnosis of diabetes (high glucose in the blood), blindness and chronic pain with an admission date of 10/01/22. Resident #51 Physician orders indicated an order for Latanoprost Solution 0.005% instill 1 drop in both eyes at bedtime and Lubricating Plus Eye Drops Solution 0.5% (carboxymethylcellulose Sodium) instill one drop in both eyes four time a day for dry eye, blindness.<BR/>During a record review of Resident #51's MDS dated [DATE] indicated he was legally blind, cognitively intact with a BIMS score of 15 and required supervision with setup help only for ADLs except bathing in which he required assistance of one person for showering.<BR/>During an interview and observation on 03/20/23 at 2:12 PM with Resident #51 revealed a white plastic medication bottle was on the bedside table with a handwritten label indicating eye drops were inside. After asking permission from resident this surveyor opened the bottle and found a vial of Latanoprost Solution 0.005% with prescription label for resident #51. Resident #51 said he puts his own drops in nightly and his own lubricating eye drops in four times a day. Resident #51 showed this surveyor his vial of lubricating drops.<BR/>During an interview and observation on 03/21/23 at 08:05 AM of medication administration with LVN A and Resident # 51, LVN A said that the eye drops were kept at bedside for resident use. She said she was not aware the resident needed an assessment to self-administer his eye drops. Resident #51 agreed that he kept and administered his own eye drops at night and lubricating eye drops during the day. He said I put them in, so I don't have to bother anyone for help. Resident #51 said I can do that myself. LVN A said that applying his eye drops without washing his hands could cause infection. Resident #51 said he could not see well but he touched the vial to his eye to make sure the drop went in.<BR/> During an interview on 03/21/23 at 09:41 AM the DON said that the resident could not keep his eye drops at bedside without an MD order and an assessment for safe medication administration. She said she would remove the eye drops, complete an assessment today and contact the Physician if it was appropriate. She said if the resident was unable to safely administer his eye drops it could cause an eye infection or under dosing and overdosing. <BR/>During an interview on 3/22/23 at 11:30 the Administrator said that resident #51 could not self-medicate without an assessment and an order from his medical doctor. The administrator said the medication had been removed. She said that the DON and ADON were responsible for ensuring medications were administered according to regulation. The administrator said there was a risk to the resident for infection or incorrect dosages. The administrator said that the staff had already received an Inservice for safe administration of medication to ensure this problem is corrected.<BR/>Review of a Pharmscript Policy revision date 08-2020, General Guidelines for Medication Administration reflected: Medications are administered as prescribed in accordance with good nursing principles and practices and only by person legally authorized to administer .13. Residents are permitted to self-administer medications when specifically authorized by the attending physician and in accordance with the procedures for self-administration of medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide food that was palatable and at an appetizing temperature for 1 of 1 resident (#52) and 10 confidential residents reviewed for food palatability and temperature. <BR/>The facility failed to serve food that had a palatable flavor and temperature. <BR/>This failure could affect residents who ate their meals from 1 of 1 kitchen by placing them at risk for weight loss, altered nutrition status and a diminished quality of life. <BR/>Findings Include:<BR/>During a confidential group interview on 03/21/23 at 9:47AM with ten residents, identified as being alert, oriented and cognitively intact. All ten residents said the food was cold all the time. <BR/>During an observation on 03/21/23 at 1:29 PM the test tray- pureed was cold when served to the surveyors. The tray included that turnip greens, baked beans, and pork roast. <BR/>During an observation and interview on 03/22/23 at 7:25 AM Resident #52 was observed up in bed with his breakfast tray on the over bed table. He said, it is what it is. He said he eats in his room daily and his food is cold when he gets it every time. He said he has not complained or told anyone because he did not want to be a bother. He said he would let the staff know he wanted a new tray that was hot. <BR/>During an interview on 03/22/23 at 1:04 PM CNA D said she had been a CNA for 11 years and employed at the facility for 2. She said the dietary staff prepared the hall trays and put them on the cart to go down each hall, while the nursing staff are assisting in the dining room. She said she had to finish assisting residents in the dining room before taking trays down the hall and sometimes trays sit for longer times. She said that residents may not eat well if their food is cold. <BR/>Record Review of facility face sheet dated 03/21/23 indicated resident #52 admitted to the facility on [DATE] and was readmitted [DATE], and 03/13/2023 with diagnosis of pneumonia (lung infection), hypoglycemia (low blood sugar), and major depressive disorder. <BR/>Record review of admission MDS dated [DATE] indicated resident #52 had a BIMS score of 11 indicating moderate cognitive impairment and required setup assist for eating. <BR/>Record Review of comprehensive care plan dated 03/13/2023 indicated resident #52 may have an altered nutritional status, weight loss, dehydration, and skin breakdown with an intervention to serve diet as ordered and monitor intake every meal. <BR/>During a phone interview on 03/22/23 at 12:57 PM the RD said she was last in the building on 03/16/23, and the food was hot on the sample food tray on that day. She said she did not provide any in-service training during the visit on 03/16/23. She said she would send any in-services needed to the dietary manager for her to perform. She said, I would not be happy if I received a food tray that was cold. She said the Administrator was responsible for training the dietary manager and the dietary manager would be responsible for training her staff in the kitchen. She said the facility served the dining room first, secured unit second and then the trays go down the hall. <BR/>During a phone interview on 03/22/23 at 1:00PM with the Regional Dietician Consultant, she said the RD had on going in service training with the DM which started during orientation and continued during every visit to the facility. The RD would identify issues during her visit to the facility and have on going-trainings with the DM. The DM is responsible for in servicing her staff in the kitchen. The Administrator and the RD are responsible for providing oversight to the DM. The RD will get with the Administrator about concerns to monitor in the kitchen, what observations were noted during the visit. The Regional Dietary Consultant said it was not the first time to hear anything about cold food items and they have had issues in the past. She said the facility does not have plate warmers or insulated carts. <BR/>During an interview on 03/22/23 at 1:33PM with the DM and the Administrator, the DM said she had been employed at the facility for a year and had been the DM since July 2022. She said she was responsible for training the staff in the kitchen. She said she was aware of the test tray served to the RD being cold on the last visit. She said the RD said she was not aware if it just took too long for the test tray to get to her, was the reason the food was cold. The RD said the facility does not have the plug ins for plate warmers. She said the facility also only has one insulated cart and it goes to the unit. The DM said they would keep the food in the oven longer, wrapped in foil before plating it to go down the halls and that would help keep it warm. The Administrator said they would look at the timing of how long it takes for the trays to be passed on the hall. The Administrator said the secured unit is the only hall that has an insulated cart.<BR/>Record Review of the Registered Dietician Consultant Report dated 02/28/23 by the RD indicated meal/rounds/dining service observation tasks: hot food items not hot. Meatloaf and pureed item's not on steam table. Salad not cold; should have been on ice during meal service. Additional recommendations: Will provide in-service for kitchen staff next visit. Next RD visit scheduled March 15, 2023. <BR/>Record Review of facility policy titled Food Production Meal Service dated 04/2022 indicated, .Residents will be provided with nourishing, palatable, and attractive meals .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 15 residents (Resident # 52) observed for care in that: <BR/>The COTA failed to knock and ask for permission to enter Resident #52's room causing him to be exposed to the hallway during personal care. <BR/>This failure could affect all residents in the facility who received care and could result in residents not being treated with dignity and respect and being exposed during care. <BR/>Findings:<BR/>Record review of facility face sheet dated 03/21/2023 indicated Resident # 52 admitted to the facility originally on 12/05/2022 and was readmitted [DATE], and 03/13/2023 with diagnoses of pneumonia (lung infection), hypoglycemia (low blood sugar), and major depressive disorder.<BR/>Record review of admission MDS dated [DATE] indicated Resident # 52 had a BIMS score of 11 indicating moderate cognitive impairment and required extensive assistance times one person for toilet use.<BR/>Record review of comprehensive care plan dated 03/13/2023 indicated Resident # 52 had ADL self-care performance deficits with intervention for toilet use for extensive assistance times one person and alteration in bowel elimination with intervention of providing adequate time and privacy for elimination.<BR/>During an observation of Resident # 52's room on 03/20/2023 at 11:39 am Resident # 52 was lying in bed located closest to the door and the room had 1 curtain suspended in the middle of the room. No curtain was present on Resident # 52's side of the room to allow for full privacy.<BR/>During an observation on 03/21/2023 at 08:22 am Resident # 52 was receiving incontinent care from CNA C with the door closed to the room but no curtain available to pull for full privacy. While CNA C performed incontinent care the COTA knocked on Resident # 52's door and opened the door after CNA C voiced 2 times patient care was in progress exposing Resident # 52 to the hallway. Resident # 52 was in the bed on his left side without any clothing from waist down. The COTA stood at the doorway talking to CNA C and Resident # 52 for approximately 45 seconds. <BR/>During an interview on 03/21/2023 at 08:29 am Resident # 52 stated he was embarrassed by the therapist coming in his room during incontinent care and his private area being exposed. He stated it has happened before but he had not told anyone. He stated there had not been a curtain around his bed since arriving at the facility, he preferred the bed closest to the door, and would like a curtain for privacy. <BR/>During an interview on 03/21/2023 at 08:32 am CNA C stated she should have pulled the bed linen over Resident # 52 when the therapist opened the door. She stated by not doing so it exposed Resident # 52 to the hallway and could have caused him embarrassment. CNA C stated she did not know why there was no curtain to provide full privacy for Resident # 52. She stated she had been trained on dignity and privacy and would never want any of her residents to feel bad. <BR/>During an interview on 03/21/2023 at 08:39 am the COTA stated she knocked, heard someone inside the room and thought it was ok to enter. She stated when she saw Resident # 52 exposed, she should have closed the door and come back at another time. She also stated she should have not entered the room until the resident said for her to come in. She stated the risk to the resident would be not protecting their privacy and dignity. <BR/>During an interview on 03/21/2023 at 08:42 am the DON stated that a closed door was the resident's privacy and if a CNA voiced patient care in progress no one should enter that room. She stated the room in which Resident # 52 resides was set up to be a private room and only had the privacy curtain in the middle. She stated Resident # 52 does prefer the bed next to the door and should have a curtain on that side to provide full privacy. She stated she would see that a privacy curtain was installed and that all staff are retrained on maintaining privacy and dignity for all residents. She stated the risk could be embarrassment.<BR/>During an interview on 03/21/2023 at 08:45 am the administrator stated Resident # 52's room was set up as a private room a few years back and she had not realized Resident # 52 was residing in the bed closest to the door. She stated that all residents should be able to have full visible privacy and would see that a curtain was put in place today. She stated that by not having a curtain in place could allow exposure of resident during care causing embarrassment or humiliation. <BR/>Record review of facility policy and procedure titled, Quality of Life - Dignity dated August 2009 indicated, .#6. Resident's private space and property shall be always respected. a. Staff will knock and request permission before entering resident's room, 10. Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 of 4 residents reviewed for ADL care. (Resident #38) <BR/>The facility failed to ensure Resident #38 received timely incontinent care. <BR/>This failure could place residents at risk of embarrassment, discomfort, and skin breakdown.<BR/>Findings included:<BR/>Record review of an admission Record dated 3/21/2023 for Resident #38 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of schizoaffective disorder (a mental illness that can affect thoughts, mood and behavior), bipolar type (extreme mood swings), unspecified dementia (impaired ability to remember, think or make decisions), type 2 Diabetes and venous insufficiency (veins unable to send blood back from the legs to the heart). <BR/>Record review of a care plan for Resident #38 dated 1/20/2022 with a revision on 11/14/2022 indicated, I am incontinent of bowel and bladder. I have no control of bladder or bowel. Interventions included to monitor for incontinence every 2 hours and prn (as needed), change promptly and apply protective skin barrier. <BR/>Record review of a Quarterly MDS assessment for Resident #38 indicated he had severe impairment in thinking with a BIMS score of 5. He required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene with one to two persons assist. He was totally dependent in bathing with one person assist.<BR/>During an observation and interview on 3/20/2023 at 3:16 PM in Resident #38's room, Resident #38 was lying in bed with a wet gown and sheet on bed. The room had a strong urine odor smell that filled the room. CNA E entered the room looking for CNA F and CNA E observed resident lying in bed. and this surveyor had CNA E to verbalize what condition she observed Resident #38 in at that time. CNA E said there was a ring of urine on the bed that Resident #38 was lying in that had extended past his shoulders and his gown was wet. CNA E said she was not assigned to the hall for Resident #38 and would find CNA F and bring her back to the room.<BR/>During an observation and interview on 3/20/2023 at 3:33 PM CNA F entered the room of Resident #38 and said it was about 1:40 PM today when she last checked on Resident #38 and she changed his brief and rotated him in bed and then went on her break. CNA F was assisted by CNA E, both washed their hands in the bathroom in the room and applied gloves. Both removed the wet hospital gown from Resident #38, brief pulled down and thick, yellow-green discharge was present coming out of his penis. CNA F said she didn't notice any drainage earlier during her shift from his penis. CNA F used wipes to clean Resident #38's penis. There was a small open wound noted to his sacrum that was bleeding, no dressing was noted. Resident #38's back had wrinkles on his skin, the draw sheet was saturated in urine, his sacral area was red and macerated (skin wrinkly from being in moisture too long), excoriation (red and raw) on both inner thighs. Both CNA E and F provided incontinent care to Resident #38 and applied barrier cream to his sacrum. Resident #38's linens were changed, and the mattress was wiped down because of urine saturation on the mattress , there was no water proof cover on the mattress. CNA E exited the room to notify the charge nurse of the drainage from Resident #38's penis and bleeding noted from his sacrum.<BR/>During an interview on 3/20/2023 at 4:08 PM, CNA F said she had been employed at the facility for a year. She said she normally worked hall 100 where Resident #38 was. She said she checked on the dependent residents about 5 times during her 12-hour shift. She said Resident #38 was wet the last time she checked on him about 1:40 PM, and she changed him. She said she checked on the residents every 2 hours. She said he had been saturating the bed but did not tell the nurse that he was very wet. She said that was the first time to see the drainage around his penis. She said he has had the redness on his bottom for a couple of weeks and staff was applying barrier cream to the area. She said the open area on his bottom was noted earlier and Resident #38 has had it for a while, but it was not bleeding earlier. She said the ADON conducted skills check off on incontinent care at the beginning of last month with her. She said the resident could be at risk of skin break down if the resident was left in urine for extended periods. She said she could have done more and checked him again before she went on her break and to her it looked like he had not been changed at all that day. <BR/>During an interview on 3/21/2023 at 12:35 PM, with the DON and ADON. The DON said she was aware of the condition that Resident #38 was found in yesterday afternoon. The DON said she talked with CNA F who told her the last time she changed Resident #38 was before lunch (noon). She said they conducted check offs with the CNA's annually and periodically if they see there had been a problem. The ADON said CNA F completed a check off on incontinent care in November 2022 with her. The DON said Resident #38 was a dependent resident and the CNAs should be checking and changing the resident at least 3 times during their 12-hour shift. The DON said a resident that was left in urine for extended periods of time could develop wounds, excoriation, and discomfort. The DON said she met with her staff on 3/20/2023 and had an in-service on turning and repositioning of dependent residents. The DON said going forward she would make the nurses more responsible and have the staff make more rounds. She said CNA F should have checked on Resident #38 more often. The DON said the facility did not have a policy specific on ADLs, but they did expect the staff to follow the resident's care plan.<BR/>During an interview on 3/22/2023 at 1:43 PM, the Administrator said she was made aware of the condition that Resident #38 was in on 3/20/2023 by the DON. She said all residents would receive their care timely based on individual needs. She said the risk for residents not receiving care timely would be skin break down. She said going forward she would make sure all the residents who were dependent would be assessed for their needs on an individual basis, and their care plans would be up to date along with their tasks if they needed more frequent attention.<BR/>Record review of a Competency Evaluation dated 11/26/2022 for CNA F indicated she was checked off on incontinent care of a male resident without a catheter by the ADON. <BR/>Record review of a facility policy titled Comprehensive Care Plan with a revised date of 4/25/2021 indicated, .Every resident will have an individualized interdisciplinary plan of care in place. The interdisciplinary team will continue to develop the plan in conjunction with the RAI (resident assessment instrument) MDS and CAAS (care area assessment). 2. To assure that the resident's immediate care needs are met and maintained .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 medication carts (nurse cart 600 hall) reviewed for labeling and storage.<BR/>The facility failed to remove expired insulin from the nurse medication cart on hall 600. <BR/>This deficient practice could place residents at risk for improper glucose monitoring and could result in residents not receiving the intended therapeutic effects of their medications causing a health decline.<BR/>Findings include:<BR/>Record Review of physician order summary dated 3/21/23 reflected Resident #36 was a [AGE] year old admitted [DATE] with a diagnosis of diabetes (high blood sugar), alcoholic cirrhosis of liver and alcohol dependence with dementia. Review of physician orders reflected Insulin Detemir solution 100 unit per milliliter 20 units subcutaneously at bedtime for diabetes dated 6/12/22.<BR/>During observation and interview on 03/21/23 at 8:45 AM of the nurse cart on 600 hall revealed a vial of Levemir Insulin was dated as opened on 10/22/2022 and the package insert indicated to discard 42 days after opening, (discard date 12/03/22). LVN A said she had been employed at the facility for 6 years. LVN A said the nurses were responsible for checking that insulin was within administration dates before administration. LVN A said she was not aware how long the insulin was good for, maybe six months from the date opened. LVN A said she had not received any education recently on when the multi dose vials expire. She said the risk could be ineffective medication action, injection site infections and elevated blood sugar readings. <BR/>During an interview on 03/21/23 at 12:30 PM, the DON said she and the ADON were responsible for ensuring the carts are checked for expired medications and supplies. The DON stated she had just performed a total audit last week on all carts and the medication room was surprised that expired insulin was found on the cart. The DON said that the consultant pharmacist also checks carts and medication rooms for expired medications monthly during the medication review. <BR/>During an interview and record review of Resident #36's medication administration record on 03/21/23 at 1:00 PM, the DON said that the resident had a history of refusing his insulin and the last day of documented insulin administration was 2/23/23. The DON said Resident #36's Glycosylated Hemoglobin on 3/21/23 was 5.5. The DON said Resident #36's physician was contacted, and the insulin was then discontinued on 3/21/23 due to resident refusals. The DON said that insulins were good for so many days depending on manufacturer and should be removed from the cart when expired. <BR/>During an interview on 03/21/2023 at 5:00 PM, the Administrator stated the DON and ADON were responsible for oversight in the nursing department. She stated she would assist with overseeing the DON and ADON retrained nursing staff on policy and procedures and those policies were followed. She said that the negative outcome of not removing expired medications could be that residents are given medications that have lost their effectiveness. <BR/>Record review of the facility policy and procedure titled Vials and Ampules of Injectable Medications, revision date 09/2020, indicated, Quality of Control solutions and test strips, Policy: Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations of the provider pharmacy's directions for storage, use and disposal. 1 Vials and ampules dispensed by the pharmacy are maintained in the box or container with the pharmacy label in which they are dispensed .4. The solution in multi-dose vials (MDV) is inspected prior to each use for unusual cloudiness, precipitation, or foreign bodies If the Multi dose vial is opened and does not indicate an opened date the open date reverts to the dispensing date .6. Medication in multi-use vials may be used until the manufacture's recommended expiration date .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that each resident had a right to privacy during medical care for 1 of 24 residents (Residents # 52) observed for privacy.<BR/>The facility failed to ensure full visual privacy during incontinent care for Resident # 52. <BR/>This deficient practice placed residents at risk of loss of privacy and dignity.<BR/>Findings:<BR/>Record review of facility face sheet dated 03/21/2023 indicated Resident # 52 admitted to the facility originally on 12/05/2022 and was readmitted [DATE], and 03/13/2023 with diagnoses of pneumonia (lung infection), hypoglycemia (low blood sugar), and major depressive disorder.<BR/>Record review of admission MDS dated [DATE] indicated Resident # 52 had a BIMS score of 11 indicating moderate cognitive impairment and required extensive assistance times one person for toilet use.<BR/>Record review of comprehensive care plan dated 03/13/2023 indicated Resident # 52 had ADL (activities of daily living) self-care performance deficits with intervention for toilet use for extensive assistance times one person and alteration in bowel elimination with intervention of providing adequate time and privacy for elimination.<BR/>During an observation on 03/21/23 at 08:52 am Resident # 52 resided on the side of room next to the door with only a curtain suspended from the middle of the room.<BR/>During an observation on 03/20/2023 at 11:39 am Resident # 52 was lying in bed located closest to the door and room only had 1 curtain suspended in the middle of the room. No curtain present on Resident # 52's side of the room to allow for full privacy.<BR/>During an observation on 03/21/2023 at 08:22 am Resident # 52 was receiving incontinent care from CNA C with the door closed to the room but no curtain available to pull for full privacy. While performing incontinent care the COTA knocked on Resident # 52's door and opened the door after CNA C voiced 2 times patient care was in progress exposing Resident # 52 to the hallway. Resident # 52 was in the bed on his left side without any clothing from waist down. The COTA stood at the doorway talking to CNA C and Resident # 52 for approximately 45 seconds. <BR/>During an interview on 03/21/2023 at 08:29 am Resident # 52 stated he was embarrassed by the therapist coming in his room during incontinent care and his private area being exposed. He stated it has happened before but had not told anyone. He stated there had not been a curtain around his bed since arriving at the facility, he preferred the bed closest to the door, and would like a curtain for privacy. <BR/>During an interview on 03/21/2023 at 08:32 am CNA C stated she should have pulled the bed linen over Resident # 52 when the therapist opened the door. She stated by not doing so it exposed Resident # 52 to the hallway and could have caused him embarrassment. CNA C stated she did not know why there was no curtain to provide full privacy for Resident # 52. She stated she had been trained on dignity and privacy and would never want any of her residents to feel bad. <BR/>During an interview on 03/21/2023 at 08:39 am the COTA stated she knocked, heard someone inside the room and thought it was ok to enter. She stated when she saw Resident # 52 exposed, she should have closed the door and come back at another time. She also stated she should have not entered the room until the resident said for her to come in. She stated the risk to the resident would be not protecting their privacy and dignity. <BR/>During an interview on 03/21/2023 at 08:42 am the DON stated that a closed door was the resident's privacy and if a CNA voiced patient care in progress no one should enter that room. She stated the room in which Resident # 52 resides was set up to be a private room and only had the privacy curtain in the middle. She stated Resident # 52 does prefer the bed next to the door and should have a curtain on that side to provide full privacy. She stated she would see that a privacy curtain was installed and that all staff are retrained on maintaining privacy and dignity for all residents. She stated the risk could be embarrassment.<BR/>During an interview on 03/21/2023 at 08:45 am the administrator stated Resident # 52's room was setup as a private room a few years back and had not realized Resident # 52 was residing in the bed closest to the door. She stated that all residents should be able to have full visible privacy and would see that a curtain was put in place today. She stated that by not having a curtain in place could allow exposure of resident during care causing embarrassment or humiliation. <BR/>Record review of facility policy and procedure titled, Quality of Life - Dignity dated August 2009 indicated, .#6. Resident's private space and property shall be always respected. a. Staff will knock and request permission before entering resident's room, #10. Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on observation, interview, and record review, the facility failed to provide an effective pest control program to ensure the facility is free of pests and rodents in 1 of 1 facility kitchens. <BR/>The facility failed to address the roaches in the facility kitchen, which staff was aware of and had reported to the Dietary Manager and ADM. <BR/>This failure could place all residents who eat meals prepared in the facility kitchen at risk of food borne illness and cross contamination.<BR/>Findings included:<BR/>An observation on 4/17/25 at 12:30 p.m. in the facility kitchen revealed dead insects on top of dry-food storage shelves and stuck to the walls below a food preparation area. <BR/>During an interview on 4/17/2025 at 12:40 p.m., the Dietary Aide said there had been roaches in the kitchen for at least a month. She said had reported the roaches to the Dietary Manager and ADM, but the issue had not been addressed.<BR/>During an interview on 4/17/2025 at 12:45 p.m., the [NAME] said there had been roaches in the kitchen off and on since December of 2024. She said she had reported the issue to both Dietary Manager and ADM but there were still roaches in the kitchen.<BR/>During an interview on 4/17/2025 at 1:00 p.m., the Dietary Manager said she had worked at the facility for 4 months and there had been an issue with roaches in the facility kitchen. She said pest control had come out today to spray for pests.<BR/>During an interview on 4/17/25 at 2:00 p.m., the ADM said the facility had roaches in the walls in the kitchen since December of 2024. She said facility maintenance staff saw roaches in the walls in the kitchen while repairing a leak on or around 4/11/25. She said facility staff sprayed the area with a can of pesticide, but she did not call pest control because they were coming out next week for a scheduled monthly visit. She said there was no risk to residents from roaches in the kitchen.<BR/>Review of the Pest Control service visits revealed a Service Order for a visit on 4/16/25. The service order instructions indicated there were reports of roaches in the dining room cabinets and kitchen. Pest control products were applied in the kitchen, dish pit, dining room, break room, and common area targeting pests American Roaches and German Roaches with a follow-up visit recommended to be scheduled in a week.<BR/>Review of a facility policy titled Pest Control last revised in May 2008 indicated .This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .

Based on interview and record review the facility failed to review the work of each Certified Nurse Assistant (CNA) at least once every 12 months, for 1 of 6 (CNA G) reviewed for annual competency evaluations.<BR/>The facility failed to complete a performance review of CNA G and conduct inservices based on the results of the review.<BR/>This deficient practice could affect residents and place them at risk of not receiving consistent, appropriate interventions necessary to meet the residents' needs.<BR/>Findings included:<BR/>Record review of a personnel file review for CNA G indicated she was hired at the facility on 1/17/2023, with no evidence of a competency evaluation in the past 12 months. Last evaluation was on 1/17/2023.<BR/>During an interview on 5/15/2024 at 9:50 AM, the ADON said she was responsible for conducting the competency evaluations for staff in the facility. She said skill check offs were conducted annually in December. She said CNA G was not conducted at that time because the facility had an outbreak of COVID in November 2023 and some did not get theirs done. She said there could a risk for cross contamination, infections, safety issues, falls and injuries if staff did not have a competency evaluation. <BR/>During an interview on 5/15/2024 at 10:00 AM, the DON said the ADON was responsible for conducting the competency evaluations yearly. She said the facility had not completed the nurse aide evaluations this year. She said they had a set month to do competency evaluations and would try to keep the same month yearly. She said she had not seen any increased infections or any negative outcomes from not having them completed. She said they had QAPI and if they noticed any increased risk areas, they would take it to them. She said there was always a potential risk for infections and cross contamination.<BR/>During an interview on 5/15/2024 at 10:20 AM, the Administrator said nursing was responsible for ensuring staff received their competency evaluations. She said they were to be done on hire and yearly thereafter. She said she was made aware of CNA G not having an annual evaluation done. She said CNA G changed from a part time position to prn and the facility had a COVID outbreak in November 2023 and the ADON had to shift focus and did not get a change to get hers done. She said there was a risk of staff not remembering the proper way to perform tasks if they did not have a competency evaluation. She said the facility did not have a policy on competency evaluations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 2 of 7 residents (Resident #58 and #61) reviewed for baseline care plans. <BR/>The facility failed to complete a baseline care plan within 48 hours of admission on Resident # 58 and provide a care plan summary to the resident or representative.<BR/>The facility failed to complete a baseline care plan within 48 hours of admission on Resident # 61 and provide a care plan summary to the resident or representative.<BR/>This failure could place residents at risk of not receiving correct and/or necessary care/treatment.<BR/>Findings included:<BR/>1. Record review of a facility face sheet dated 5/13/2024 indicated Resident #61 was [AGE] years old and admitted to the facility on [DATE] with diagnosis of encephalopathy (brain changes).<BR/>Record review of an admission MDS assessment dated [DATE] indicated Resident #61 had a BIMS of 99 indicating Resident #61 was not able to complete the interview. <BR/>Record review of a baseline care plan for Resident # 61 indicated he was admitted on [DATE] and baseline care plan was not completed until 12/27/2023.<BR/>2. Record review of a facility face sheet dated 5/13/2024 indicated Resident #58 was [AGE] years old and admitted to the facility on [DATE] with diagnosis of intervertebral disc degeneration (changes in the bones in the back).<BR/>Record review of an admission MDS assessment dated [DATE] indicated Resident #58 had a BIMS of 13 indicating intact cognition and required supervision with ADL's. <BR/>Record review indicated Resident # 58 admitted to the facility on [DATE] and her baseline care plan was not completed until 10/15/2023. <BR/>During an interview on 05/14/24 at 2:40 pm LVN A said that when a resident was going to be admitted the RN opened the baseline care plan, the admitting nurse entered the information into the assessment, then the RN reviewed and finalized the care plan. She said a copy of the summary was given to the resident or representative by the RN once completed and the process should be completed within 48 hours of admission. She said that if the baseline care plan was not completed timely it could cause missed resident care.<BR/> During an interview on 5/14/2024 at 2:45 pm the clinical reimbursement coordinator said that the admitting nurse was to enter the information into the baseline care plan, she then reviewed the information, and the DON finalized the care plan. She said that if a resident was admitted after hours or weekends the DON or RN supervisor was responsible for the task. She said once completed the family or resident should receive a copy of the summary and all should be done within 48 hours of admission. She said that failure to complete baseline care plans timely could cause care delays.<BR/>During an interview on 5/14/2024 at 2:55 pm the DON said that baseline care plans should be done on admission by the admitting nurse, the MDS nurse should review them and then she finalized the care plan. She said the baseline should be completed within 48 hours, but she was behind. She said the weekend RN supervisor helped as well but she had been the supervisor on the weekends recently. She said once the care plan was completed the resident and family should receive a copy of the summary. She said if the baseline care plan was not completed per the regulation could be a potential for inaccurate care. <BR/>During an interview on 5/14/2024 at 3:30 pm the administrator said the DON was responsible for ensuring the baseline care plan was completed and the family received a copy of the summary. She said that the baseline care plan should be completed within 48 hours of admission and if not done could lead to care delays. She said there was not a specific policy for base line care plans and the nurse was to follow the admission checklist. <BR/>Record review of an undated facility admission checklist indicated, .must initiate baseline care plan and give summary to resident and resident representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 8 residents (Resident #8) reviewed for accomodation of needs.<BR/>The facility failed to ensure Resident #8's call light in the room was left within reach on 4/17/2024.<BR/>This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.<BR/>Findings included:<BR/>Record review of an admission Record dated 4/17/2025 for Resident #8 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of dementia (altered cognition) and secondary diagnoses of hemiplegia and hemiparesis (weakness or paralysis on one side of the body) and muscle weakness.<BR/>Record review of an MDS assessment dated [DATE] for Resident #8 indicated he had a BIMS score of 12 which indicated moderate cognitive impairment. He was dependent on staff for most ADLs except for eating. He was always incontinent of bladder and had an ostomy.<BR/>Record review of Resident #8's care plan dated 4/5/22 and revised on 2/25/24 indicated he had a history of falls and was at risk for future falls due to diagnosis of hemiplegia/hemiparesis. An intervention was in place to Ensure call light is in reach and answer promptly. <BR/>During an observation and interview on 4/17/25 at 11:00 AM, Resident #8 was in his room lying in his bed in a semi-private room with no roommate. His call light was lying on the unoccupied bed in the room. Resident #8 said CNA B assisted him with personal care and left his call light lying out of reach. He said he used a trapeze bar (bed pull up assistance device) to sit up in bed and could not stand or walk independently. <BR/>During an interview on 4/17/2025 at 11:30 AM, CNA B said she was assigned to hall 500 today, 4/17/2025, where Resident #8 resided. CNA B said she had recently rounded on Resident #8 and assisted him with personal care. She said CNAs were responsible for ensuring call lights were left accessible to residents before leaving the room. <BR/>During an interview on 4/17/25 at 2:00 PM, the ADM said direct care staff were expected to round on every resident at least every two hours. She said direct care staff were expected to ensure call lights were left within reach before leaving the room. The ADM said the DON was responsible for ensuring all nursing staff and CNAs received required training and successfully completed skill competency checkoffs. <BR/>During an interview on 4/17/2025 at 2:45 PM, the DON said she was responsible ensuring all CNAs and nursing staff successfully complete competency checkoffs. She said CNAs and nurses were expected to ensure call lights were accessible by residents before leaving the room.<BR/>Record review of a facility policy titled Bedrooms revised in May 2017 indicated .All resident rooms are equipped with a resident call system that allows residents to call for staff assistance .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 8 residents (Resident #8) reviewed for accomodation of needs.<BR/>The facility failed to ensure Resident #8's call light in the room was left within reach on 4/17/2024.<BR/>This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.<BR/>Findings included:<BR/>Record review of an admission Record dated 4/17/2025 for Resident #8 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of dementia (altered cognition) and secondary diagnoses of hemiplegia and hemiparesis (weakness or paralysis on one side of the body) and muscle weakness.<BR/>Record review of an MDS assessment dated [DATE] for Resident #8 indicated he had a BIMS score of 12 which indicated moderate cognitive impairment. He was dependent on staff for most ADLs except for eating. He was always incontinent of bladder and had an ostomy.<BR/>Record review of Resident #8's care plan dated 4/5/22 and revised on 2/25/24 indicated he had a history of falls and was at risk for future falls due to diagnosis of hemiplegia/hemiparesis. An intervention was in place to Ensure call light is in reach and answer promptly. <BR/>During an observation and interview on 4/17/25 at 11:00 AM, Resident #8 was in his room lying in his bed in a semi-private room with no roommate. His call light was lying on the unoccupied bed in the room. Resident #8 said CNA B assisted him with personal care and left his call light lying out of reach. He said he used a trapeze bar (bed pull up assistance device) to sit up in bed and could not stand or walk independently. <BR/>During an interview on 4/17/2025 at 11:30 AM, CNA B said she was assigned to hall 500 today, 4/17/2025, where Resident #8 resided. CNA B said she had recently rounded on Resident #8 and assisted him with personal care. She said CNAs were responsible for ensuring call lights were left accessible to residents before leaving the room. <BR/>During an interview on 4/17/25 at 2:00 PM, the ADM said direct care staff were expected to round on every resident at least every two hours. She said direct care staff were expected to ensure call lights were left within reach before leaving the room. The ADM said the DON was responsible for ensuring all nursing staff and CNAs received required training and successfully completed skill competency checkoffs. <BR/>During an interview on 4/17/2025 at 2:45 PM, the DON said she was responsible ensuring all CNAs and nursing staff successfully complete competency checkoffs. She said CNAs and nurses were expected to ensure call lights were accessible by residents before leaving the room.<BR/>Record review of a facility policy titled Bedrooms revised in May 2017 indicated .All resident rooms are equipped with a resident call system that allows residents to call for staff assistance .

Based on observation, interview and record review the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 2 of 2 days reviewed (6/10/2025 and 6/11/2025) for nurse staffing posting.<BR/>The facility failed to post accurate daily staffing information on 6/10/2025 and 6/11/2025. <BR/>This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.<BR/>Findings included:<BR/>During an observation on 6/10/2025 at 7:45 AM, the daily staffing census information was posted by the front entrance on a wall dated 6/9/2025.<BR/>During an observation on 6/11/2025 at 8:14 AM, the daily staffing census information was posted by the front entrance on a wall dated 6/9/2025.<BR/>During an interview on 6/11/2025 at 8:16 AM, the ADON said she and the DON were responsible for posting the daily staffing census information. She said she was not sure why the posting was not put out up yesterday 6/10/2025. She said the posting showed the staff coverage for the facility based on the census for the residents and if it were not posted then family or visitors would not have the information. ADON said she was about to post the daily census information for today 6/11/2025.<BR/>During an interview on 6/11/2025 at 9:35 AM, the DON said she was responsible for putting up the daily staff posting. She said she forgot to put it up yesterday 6/10/2025. She said the posting was put up so people would know who was staffed in the facility.<BR/>During an interview on 6/11/2025 at 10:26 AM, the Administrator said the DON was responsible for putting up the daily staff posting. She said the posting was put up so that residents and families could see what staff were in the facility for the day. She said if the posting were not put up then visitors and residents would not be able to see how the facility was staffed.<BR/>Record review of a facility policy titled Posting Direct Care Daily Staffing Numbers revised July 2016 indicated, .Our facility will post, on a daily basis for each shift, the number of personnel responsible for providing direct care to residents. 1. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses and the number of unlicensed nursing personnel directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clean and readable format .

Based on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety that also consider non-smoking residents for 1 of 2 smoking areas (secured unit smoking area) reviewed for smoking safety.<BR/>The facility failed to ensure paper and plastic trash were not discarded into the fire safety can on 6/09/2025.<BR/>This failure could place residents at risk of injury, burns, and an unsafe smoking environment.<BR/>Findings included:<BR/>During an observation on 06/09/25 at 9:03 AM the designated smoking area off the secured unit was observed with one fire can that contained cigarette butts, 1 plastic bottle and an empty cigarette package. There was no ashtray in the area. <BR/>During an interview on 06/09/25 at 9:04 AM CNA A said the housekeeping staff were responsible for cleaning the fire can daily. She said smokers were supervised during smoking and there were no ashtrays because the residents dug in them. CNA A said they put the resident's cigarette butts in the fire can because it had a lid and there should not be any trash in the fire can because it was a fire hazard. <BR/>During an interview on 06/10/25 at 3:20 PM Housekeeper B said that the housekeepers were responsible for cleaning the designated smoking areas daily. She said the staff that supervise the smokers should also make sure that the fire cans did not have any trash and was only for cigarette butts. Housekeeper B said trash in the fire can could result in a fire. <BR/>During an interview on 06/11/25 at 8:23 AM the Administrator said that housekeeping was responsible for maintaining the designated smoking areas and cleaned them daily. She said the staff supervising the smokers should also be checking for any trash in the fire cans and expected staff to regularly inspect the area before and after smoke breaks for any fire hazards. Administrator said trash in the fire can could cause a fire. <BR/>Record review of a facility policy titled Smoking dated 10/12/2022 revealed, .policy of this community to provide a safe environment, 2. smoking by residents is allowed with the following safety measures readily available: ashtrays made of noncombustible material, metal containers with self-closing covers into which ashtrays can be emptied .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 2 of 7 residents (Resident #58 and #61) reviewed for baseline care plans. <BR/>The facility failed to complete a baseline care plan within 48 hours of admission on Resident # 58 and provide a care plan summary to the resident or representative.<BR/>The facility failed to complete a baseline care plan within 48 hours of admission on Resident # 61 and provide a care plan summary to the resident or representative.<BR/>This failure could place residents at risk of not receiving correct and/or necessary care/treatment.<BR/>Findings included:<BR/>1. Record review of a facility face sheet dated 5/13/2024 indicated Resident #61 was [AGE] years old and admitted to the facility on [DATE] with diagnosis of encephalopathy (brain changes).<BR/>Record review of an admission MDS assessment dated [DATE] indicated Resident #61 had a BIMS of 99 indicating Resident #61 was not able to complete the interview. <BR/>Record review of a baseline care plan for Resident # 61 indicated he was admitted on [DATE] and baseline care plan was not completed until 12/27/2023.<BR/>2. Record review of a facility face sheet dated 5/13/2024 indicated Resident #58 was [AGE] years old and admitted to the facility on [DATE] with diagnosis of intervertebral disc degeneration (changes in the bones in the back).<BR/>Record review of an admission MDS assessment dated [DATE] indicated Resident #58 had a BIMS of 13 indicating intact cognition and required supervision with ADL's. <BR/>Record review indicated Resident # 58 admitted to the facility on [DATE] and her baseline care plan was not completed until 10/15/2023. <BR/>During an interview on 05/14/24 at 2:40 pm LVN A said that when a resident was going to be admitted the RN opened the baseline care plan, the admitting nurse entered the information into the assessment, then the RN reviewed and finalized the care plan. She said a copy of the summary was given to the resident or representative by the RN once completed and the process should be completed within 48 hours of admission. She said that if the baseline care plan was not completed timely it could cause missed resident care.<BR/> During an interview on 5/14/2024 at 2:45 pm the clinical reimbursement coordinator said that the admitting nurse was to enter the information into the baseline care plan, she then reviewed the information, and the DON finalized the care plan. She said that if a resident was admitted after hours or weekends the DON or RN supervisor was responsible for the task. She said once completed the family or resident should receive a copy of the summary and all should be done within 48 hours of admission. She said that failure to complete baseline care plans timely could cause care delays.<BR/>During an interview on 5/14/2024 at 2:55 pm the DON said that baseline care plans should be done on admission by the admitting nurse, the MDS nurse should review them and then she finalized the care plan. She said the baseline should be completed within 48 hours, but she was behind. She said the weekend RN supervisor helped as well but she had been the supervisor on the weekends recently. She said once the care plan was completed the resident and family should receive a copy of the summary. She said if the baseline care plan was not completed per the regulation could be a potential for inaccurate care. <BR/>During an interview on 5/14/2024 at 3:30 pm the administrator said the DON was responsible for ensuring the baseline care plan was completed and the family received a copy of the summary. She said that the baseline care plan should be completed within 48 hours of admission and if not done could lead to care delays. She said there was not a specific policy for base line care plans and the nurse was to follow the admission checklist. <BR/>Record review of an undated facility admission checklist indicated, .must initiate baseline care plan and give summary to resident and resident representative.

Based on interview and record review, the facility failed to provide the required compliance and ethics training for 1 of 14 employees (CNA J) reviewed for training.<BR/>The facility failed to ensure compliance and ethics training was provided to CNA J.<BR/>This failure could affect residents and place them at risk of staff not being aware of facility standards/policies due to lack of staff training. <BR/>Findings included: <BR/>Record review of the personnel file for CNA J indicated she hired at the facility on 3/5/2024 and did not have training on compliance and ethics training.<BR/>During an interview on 5/14/2024 at 11:30 AM, the BOM said the facility did not have a person in house that was designated for HR duties. She said corporate was responsible for all of the required trainings for new and existing staff. She said she was responsible for completing the orientation of new hires. <BR/>During an interview on 5/14/2024 at 2:34 PM, the HR Business Partner said the facility was fairly new to her and she acquired it at the end of January 2024. She said on hire the required trainings should be done at orientation in the facility. She said some of the facilities used the monthly electronic version and others still used paper documentation for the trainings. She said when trainings were sent out to the facilities, they were sent via email by the Director of Clinical Education. She said then the facility should be completing them accordingly. She said if someone was not present at the time of the monthly in-service training, when that staff returned to work, they should follow-up to ensure they received the training. She said the trainings for on hire included: Abuse, Dementia Care, HIPAA, Human Immunodeficiency Virus (HIV), Texas House [NAME] 300, Restraints, and Slips, Trips, and Falls. <BR/>During an interview on 5/15/2024 at 8:36 AM, the Director of Clinical Education said she was responsible for the trainings for staff on hire and annually. She said the facility had a centralized onboarding with new hires with corporate. She said the on boarding started with corporate and new hires received training on Abuse, Dementia Care, HIPAA, Human Immunodeficiency Virus (HIV), Texas House [NAME] 300, Restraints, and Slips, Trips, and Falls on hire and annually. She said the facility was in the process of ensuring the orientation and on boarding with staff included the additional education on trainings that included behavioral health, compliance and ethics and QAPI. She said every month she sent the facilities a different topic for training and included who the training should be given to. She said if staff were not present at the time of the trainings, then education should be provided to that staff member when they returned to work. She said the facilities could provide training as much as they needed to. She said if staff did not receive the required training, they could potentially have a knowledge deficit. She said the facility did not have a policy on trainings for staff. <BR/>During an interview on 5/15/2024 at 10:00 AM the DON said she was responsible for the trainings that was sent by the Director of Education. She said the Director of Education sent the facility a monthly list of trainings and it told them who gets what and they scheduled the training with staff. She said they just went by the list that was sent and the Director of Education was responsible for ensuring the facility received the required trainings. She said going forward they would ensure the staff received any missing trainings. She said there was a risk of staff not knowing how to do their jobs. She said all of the state required trainings came from corporate.<BR/>During an interview on 5/15/2024 at 10:20 AM, the Administrator said the trainings were split between the DON and herself. She said she received an email monthly for what trainings were needed. She said corporate would send the trainings and it would indicate who needed the training. She said they have always just gone by what corporate sent to them. She said she thought that the trainings that were sent out to the facilities were being done correctly. She said there was a risk of staff not knowing how to handle situations if they did not receive training. She said the facility did not have a policy on the required trainings.