HARMONY CARE AT BEAUMONT

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for the residents in rooms 217 through 224 (8 rooms for this hallway) and 1 resident of 8 residents (Resident #1) that were observed for physical environment. The facility failed to ensure the hallway and the attached rooms 217 through 224 were free of odors. The facility failed to ensure a dresser in Resident #1's room was in good repair. These failures could place the residents at risk for diminished quality of life. Findings included: 1. An observation on 07/08/25 from 8:20 AM to 9:26 AM revealed a foul odor starting from the beginning of the hallway extending to the end of the hallway. As the State Surveyor walked through the hallway it was strongest of the odor in front of room [ROOM NUMBER]. The odor smelled of urine, feces, and body odor all combined making it hard to breath as the State Surveyor walked the length of the hallway (rooms 217 - 224). An observation on 07/08/25 at 11:27 AM revealed the odor was almost completely gone in the hallway for rooms 217 through 224 but the odor was still in front of room [ROOM NUMBER]. There were three housekeeping staff working on this hallway. An observation on 07/08/25 at 03:04 PM revealed there was a slight odor in the hallway for rooms 217 through 224, but the odor was still in front of room [ROOM NUMBER]. In an interview on 07/08/25 at 8:33 AM with Resident #1 revealed her roommate was gross and gets poop everywhere. She stated one housekeeper quit because of her roommate and they deep clean her room because of the behaviors her roommate has related to feces and urine. She stated it grossed her out. During this interview, a strong odor of feces came from the restroom. There were two brown spots on the bathroom floor as well as one brown spot on the toilet seat. There was a puddle of unknown liquid at the base of the sink. In an interview on 07/08/25 at 10:29 AM LVN A stated as far as she knew they cleaned all rooms daily. She stated the odor was due to some residents refusing hygiene care. She stated she knew of at least two rooms that had a stronger smell in their rooms. LVN A stated she did not always work that hall, but she had noticed the odor. LVN A stated the residents could feel disgusted and feel like the room was unclean. In an interview on 07/08/25 at 11:09 AM the Housekeeping Supervisor stated every room was cleaned daily. She stated rooms like 220 and 221 were cleaned three times a day. Regarding the hallway odor, she stated most people on that hall would not take a shower. She stated, we (housekeeping) come in and use certain chemicals to try to fight the odor. She stated she had not had any complaints about the odor, but she was sure it affected them some way. She stated that was why they deep cleaned to stay on top of it and disinfect everything. 2.An observation on 07/08/25 at 8:33 AM, revealed in Resident #1's room a dresser in need of repair. The top drawer had a loose handle and the drawer was crooked, the second drawer had a broken handle, the fourth drawer was sticking out and would not close, and the sixth drawer was missing a knob. During an interview on 07/08/25 at 12:19 PM, Resident #1 stated the broken drawers make me so mad. She stated it had been like that since at least the beginning of the year. She stated she thought they were working on getting a new one for her. During an interview on 07/08/25 at 2:26 PM, the Maintenance Director stated he was the one that repaired items if he could or ordered new ones. There was a clipboard at the nurses' station for maintenance activities. He stated he looked at the maintenance log every morning. He stated no one had reported the broken dresser to him. He stated staff or anyone that saw issues could report it. He stated it could affect the resident's quality of life and it could irritate them. He stated he tried to get on maintenance issues as quickly as he could. During an interview on 07/08/25 at 2:41 PM the Administrator stated they were going to replace the dresser, but they could not remove it until they received a new one. Otherwise- there was nowhere to put the resident's clothes. She stated she put in an order for a dresser in June 2025, but they still have not received it. She stated it could affect residents due to it not being a homelike environment. The administrator stated in regard to the odor in the hallway, there were at least five residents that refused to bathe. She stated no matter what they tried; they could not get them to bathe regularly. She stated housekeeping would go in twice a day to clean those rooms and the hallway. The Administrator stated housekeeping was responsible to stay on top of cleaning to prevent the odor. She stated, if the staff could get the residents to bathe to decrease the odor, the residents would like that. Review of the Policy and Procedure Quality of Life - Homelike Environment, no date, reflected Residents are provided with a safe, clean, comfortable, and homelike environment.cleanliness and order.inviting colors and decor.pleasant, natural scents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents the right to be free from abuse for 2 of 7 residents (Residents #2 and #3) reviewed for abuse. <BR/>1. On 04/03/24 Resident #3 self-propelled her wheelchair into Resident #1's room and Resident #1 pulled Resident #3 out of her wheelchair onto the floor. <BR/>2. On 04/19/24 Resident #1 placed a pillow over the face of Resident #2 and later admitted she was trying to kill Resident #2.<BR/>On 04/20/24 at 02:29 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 04/21/24, the facility remained out of compliance at a severity level with the potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of thei Plan of Removal. <BR/>These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.<BR/>Findings included:<BR/>1. Record review of Resident #1's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included schizophrenia (a serious mental condition involving breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion), persistent mood [affective] disorder (marked disruptions in emotions {severe lows called depression or highs called hypomania or mania]), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations).<BR/>Record review of Resident #1's care plan, dated 10/25/23, indicated Resident #1 had a diagnosis of schizophrenia and was at risk for manic episodes and increased behaviors. Interventions included monitor for delusions and hallucinations and monitor for increased agitation, anger, verbal, and physical aggression and document in clinical record. Resident #1 was taking psychotropic medication and was at risk for adverse reactions and depression, anxiety, and/or psychosis driven behaviors. Interventions included monitor for anxiety driven behaviors and report any noted behaviors to MD for further orders.<BR/>Record review of Resident #1's care plan, dated 10/25/23, indicated Resident #1 was taking psychotropic medication and was at risk for adverse reactions and depression, anxiety, and/or psychosis driven behaviors. Interventions included monitor for anxiety driven behaviors and report any noted behaviors to MD for further orders.<BR/>Record review of Resident #1's quarterly MDS assessment, dated 04/08/24, indicated Resident #1 was able to make herself understood and usually understand others, and had moderate cognitive impairment indicated by a BIMS score of 11. She had had no hallucinations, delusions, or physical or verbal behaviors. She required partial to moderate assistance with most ADLs.<BR/>Record review of Resident #1's clinical file revealed there were no care plans available for review related to homicidal ideations.<BR/>Record review of the incident report dated 04/19/24 at 03:40 a.m., completed by LVN A indicated she was notified by CNA B that Resident #2 was yelling for help because Resident #1 (her roommate) had placed a pillow over Resident #2's face and held it over her face. Resident #2 came out of her room yelling for help. The residents were separated, and Resident #2 was assessed with no bruising on her face and no shortness of breath. Resident #1 admitted she did it and stated, Don't send me to jail please send me to a mental institution. Resident #2 was moved to another room for her protection and safety. MD was paged and LVN A was awaiting response. Administrator was notified. <BR/>2. Record review of Resident #2's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility 12/05/23. Resident #2 had diagnosis which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning) with agitation, major depressive disorder (a metal health disorder characterized by persistently depressed mood causing significant impairment in daily life), and schizophrenia.<BR/>Record review of Resident #2's care plan, dated 07/31/23 indicated Resident #2 had an altered thought process and was at risk for further decline and injury as evidenced by dementia and short- and long-term memory deficit. Interventions included keep resident and others safe and monitor for mental status changes. <BR/>Record review of Resident #2's quarterly MDS dated [DATE] indicated Resident #2 was able to make herself understood and understood others, and had severe cognitive impairment indicated by a BIMS score of 6. She had feelings of being down, depressed, and hopeless 2-6 (several) days and had no behaviors. <BR/>During a telephone interview on 04/20/24 at 08:40 a.m., the Administrator said she received a text from LVN A on 04/19/24 at approximately 06:00 a.m. when she woke up reporting Resident #1 had placed a pillow over Resident #2's face and Resident #1 was requesting to go to a mental institution. She said her immediate action had been to request an additional CNA for the secure unit from her corporate office and she had just received approval for the CNA this morning but had not hired a new CNA yet. The Administrator said the secure unit had one dedicated CNA and one nurse that floats between the other rooms and the secure unit. She said Resident #2 had been moved into another room on the secure unit. <BR/>During an observation and interview on 04/20/24 at 09:05 a.m., CNA L said she was assigned the secure unit today with LVN C who was floating between the secure unit and rooms outside the unit. CNA L was sitting in the TV room with 4 residents and said Residents #1 and #2 were in their rooms alone. <BR/>During an observation and interview on 04/20/24 at 09:10 a.m., Resident #1 was alone in her room on the secure unit and resting in bed. She said yesterday (04/19/24) her roommate (Resident #2) was trying to put spells on her, and she had to stop her. She said she tried to hurt Resident #2. <BR/>During an observation and interview on 04/20/24 at 09:15 a.m., Resident #2 was alone in her room on the secure unit lying in bed. She said she had to be moved to a new room because her previous roommate had put a pillow over her face and tried to kill her while she was sleeping. She said she felt as safe as she could in her present surroundings. <BR/>During an interview on 04/20/24 at 09:35 a.m., the DON said she was not at the facility on 04/19/24 because she had to work the night shift last night. She said was notified on 04/19/24 about Resident #1 putting a pillow over Resident #2's face, but she was now looking back on what was done after the incident. She said LVN A reported the incident, but there was no documentation in the clinical record about the incident or if LVN A notified the police, the physician, or the responsible party. She said notifications should have been made and she was doing the notifications to the MD and RP. She said based on the aggression Resident #1 should have been transferred to a behavioral hospital for evaluation. <BR/>During a telephone interview on 04/20/24 at 09:55 a.m., LVN A said on 04/19/24 at 03:30 a.m. she received a call from CNA B who reported Resident #1 had placed a pillow over Resident #2's face and tried to smother her. She said CNA B had separated the residents when she arrived on the secure unit. LVN A said she assessed Resident #2 and found no visible injuries, but she kept repeating she tried to kill me. She said Resident #1 admitted she tried to kill Resident #2. LVN A said she paged the MD twice and he did not call by the end of her shift. She said she reported the incident to her Administrator via text and LVN C who was the nurse working the 06:00 a.m. to 02:00 p.m. shift. <BR/>During an interview on 04/20/24 at 10:05 a.m., LVN C said he received report from LVN A on 04/19/24 at 06:00 a.m. about the incident between Resident #1 and Resident #2. He said LVN A reported to him she had paged the MD twice and not received a response. He said he did not try to notify the MD or Resident #1's RP about the incident on 04/19/24. He said he never noticed if Resident #1 ever came out of her room on his shift and he wasn't sure if Resident #2 was in or out of her room during the day. <BR/>During a telephone interview on 04/20/24 at 10:21 a.m. CNA B said on 04/19/24 at approximately 03:20 a.m. she was passing by the room Resident #1 and Resident #2 shared when Resident #2 ran out of the room saying Resident #1 put a pillow over her head and tried to kill her. Resident #1 said Resident #2 had been naked during the day and she tried to kill her. Resident #1 then said she wanted to go to a mental hospital in Dallas because that was where her brother sent her whenever she tried to hurt people. CNA B said she separated the residents by bringing Resident #2 into the TV room with her and called LVN A and reported the incident. CNA B said after the incident Resident #1 was pacing up and down the hall talking loudly but not making any sense. She said then Resident #1 went into her room and pulled the mattress off her bed and disrobed and continued pacing around her room. She said Resident #2 said she was afraid to be alone in her room, so CNA B kept Resident #2 with her the rest of the night except when assisting other residents and she took her to sit with LVN A.<BR/>During an interview on 04/20/24 at 10:51 a.m., the DON said she notified the NP of the incident that occurred on 04/19/24 to the NP and Resident #1's RP on 04/20/24 at approximately 10:00 a.m. She said she had completed the referral to the behavioral hospital for Resident #1 and was awaiting her transfer. She said the NP gave no new orders for Resident #2. <BR/>During an observation and interview on 04/20/24 at 11:19 a.m., Police Officer M visited Resident #2 in her room. Resident #2 remained alone in her room made a verbal statement to Police Officer M that Resident #1 had tried to kill her by placing a pillow over her face while she was sleeping. She said she wanted to press charges against Resident #1 so she wouldn't try to kill her again. <BR/>During an observation on 04/20/24 at 11:26 a.m., Resident #1 was sleeping alone in her room. <BR/>During an interview on 04/20/24 at 03:59 p.m., the DON said she sat with Resident #1 until she was transported by ambulance to a behavioral hospital at approximately 03:30 p.m.<BR/>3. Record review of Resident #3's face sheet dated 04/20/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included cerebral infarction (stroke), spastic hemiplegia (a common post-stroke condition that causes stiff or rigid muscles) affecting right dominant side, vascular dementia (dementia [a condition characterized by progressive or persistent loss of intellectual functioning] caused by an impaired supply of blood to the brain), mood disorder (marked disruptions in emotions [severe lows called depression or highs called hypomania or mania]), and depression <BR/>Record review of Resident #3's care plan revised on 06/21/23 indicated Resident #3 was deemed at risk for wandering related to being ambulatory with her wheelchair, diagnosis of dementia, and history of exit seeking. Goals included Resident #3 would be able to wander in a safe environment (secure unit) with no occurrence of injury and dignity would be maintained. <BR/>Record review of Resident #3's annual MDS dated [DATE] indicated Resident #3 was sometimes able to make herself understood and usually understood others, and had severe cognitive impairment indicated by a staff assessment. She had mood of little interest or pleasure in doing things several (2-6 days) and behaviors directed toward others 1 to 3 days and no wandering behaviors.<BR/>Record review of Resident #1's clinical note (related to the incident with Resident #3) dated 04/03/24 at 11:30 a.m. and signed by LVN N indicated a CNA B came and informed LVN N that Resident #1 pulled Resident #3 out of her wheelchair onto the floor of Resident #1's room. Resident #1 said I'm not a fucking babysitter, I need help my motherfucking self she needs to keep her ass out of my motherfucking room. On arrival to the secure unit residents were already separated and in different rooms. LVN N educated and redirected Resident #1, she was informed that physical aggression would not be tolerated, and it was not her right to put hands on anyone. LVN A indicated that Resident #1 did not verbalize understanding. <BR/>During an observation and interview on 04/20/24 at 09:05 a.m., Resident #3 was sitting in the TV room of the secure unit. She was unable to answer question about the incident. She was holding her right arm against her, and it appeared to have contractures at her elbow and wrist. Resident #3 said her arm was not painful. CNA L said Resident #3's arm was paralyzed from a stroke. CNA L said staff tried to keep Resident #3 busy because she wandered into other resident's rooms. She said she was not working the day Resident #3 wandered into Resident #1's room and Resident #1 pulled her out of her wheelchair to the floor, but it had been reported to her by another CNA.<BR/>During an interview on 04/20/24 at 09:35 a.m. the DON said the only reason Resident #1 had pulled Resident #3 out of her wheelchair on 04/03/24 was because she went into Resident #1's room. She said she had instructed all staff on the secure unit to keep Resident #3 from wandering into other resident's rooms. <BR/>During a telephone interview on 04/22/24 at 11:35 a.m., LVN N said on 04/03/24 at approximately 11:30 a.m., a CNA reported to her that Resident #3 had self-propelled her wheelchair into Resident #1's room and Resident #1 pulled her out of her wheelchair and onto the floor. LVN N said she assessed Resident #3 who was sitting in the floor of Resident #1's room at the foot of her bed. She had no visible injuries, and she was assisted back into her wheelchair and out of the room. Resident #3 was unable to say how she got onto the floor. LVN N said she notified the ADON, the Administrator, the MD, and the RP of the incident. <BR/>During a telephone interview on 04/22/24 at 12:16 p.m., Resident #3's RP said she was notified on 04/03/24 by the nurse that Resident #3 had wheeled herself into another resident's room and the other resident had pulled Resident #3 out of her wheelchair and onto the floor. She said Resident #3's right arm had paralysis since her stroke. She said Resident #3 had no bruising or pain after she was pulled from her wheelchair. RP said she visited Resident #3 every day and she had witnessed residents on the secure unit being aggressive to staff and other residents. RP said she could not name the Residents she had seen be aggressive, but she had seen Resident #1 yell and cuss at other residents. She said she had not told the Administration about resident aggression. <BR/>Record review of the facility's Abuse and Neglect Policy dated June 2023 indicated It is the policy of the facility to administer care and services in an environment that is free of any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment .The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal guidelines of prevention and investigation .VI. Protect residents from physical and psychosocial harm during investigations.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 04/20/24 at 02:25 p.m. The Administrator was notified. The Administrator was provided the IJ template on 04/20/24 at 2:29 p.m.<BR/>The Facility's Plan of Removal for Immediate Jeopardy was accepted on 04/21/24 at 10:37 a.m. and reflected the following: <BR/>Immediate action:<BR/>On 4/20/24 Resident #1 was immediately placed on 1 on 1 monitoring until the facility could transfer Resident #1 to psychiatric hospital, waiting on approval from the behavioral hospital to transport. <BR/>*Charge nurse/ nurse managers Immediately assessed Resident #2 & Resident #3 and the rest of the residents in the secure unit for possible mental or physical abuse, no additional mental health needs were identified, nor any suspected physical abuse found at this time. <BR/>oAdministrator/abuse coordinator Immediately in-serviced all staff 100% completion on Abuse & Neglect policy.<BR/>o on 4/20/24 the Director of Nursing, Inservice all 100% of staff on behavioral management policy which included resident to resident abuse regarding residents exhibiting aggressive behaviors towards others, and steps to do, and how to approach the situation.<BR/>On 4/21/24 the MDS nurse reviewed all residents who have had aggressive behaviors, to make sure interventions were in place, for the floor staff to be able to see in electronic health record (EHR).<BR/>The facility reviewed the system for abuse identification and reporting. The facility created a plan of improvement to assure residents were free from abuse to address changes including education, daily chart reviews and IDT discussions. The DON and/or Designee will review incident reports and progress notes 5 days weekly to assure that there were no incidents that could meet the qualifications of abuse and discuss any concerns with the abuse coordinator immediately. <BR/>Resident #1 was placed on one-on-one monitoring until her transfer to a behavioral on 04/20/24. <BR/>The charge nurses and the nurse managers reviewed all residents on the secure unit on 04/20/24 that were involved in incidents within the last 30 days to ensure all residents had the correct supervision. No additional mental or physical abuse was identified. <BR/>On 04/20/24 the Administrator completed in-service with all facility staff regarding the behavioral management policy which included resident to resident abuse, residents exhibiting aggressive behaviors, and steps to approach a resident-to-resident situation. <BR/>On 04/21/23 at 11:48 a.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>During interviews conducted on 04/20/24 from 03:30 p.m. though 06:00 p.m. and 04/21/24 from 08:15 a.m. 11:48 a.m. included LVN A 10 p.m. - 6 a.m., LVN C (6:00 a.m. to 2:00 p.m.), LVN D (6:00 a.m. -2:00 p.m.), LVN E (6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.), LVN F (10:00 p.m. to 6:00 a.m.), LVN G (10 p.m. to 10 p.m.), LVN H (2:00 p.m. to 10:00 p.m., LVN I (2:00 a.m. to 10 p.m.),RN j (weekend shifts), and LVN K (6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.), CNA B (10:00 p.m. to 6:00 a.m.), CNA L (6:00 a.m. to 2:00 p.m.), CNA O (6:00 a.m. to 2:00 p.m.), CNA P (2:00 p.m. to 10:00 p.m.), CNA Q (2:00 p.m. to 10:00 p.m.), CNA R (10:00 p.m. to 6:00 a.m.), and CNA S (6:00 a.m. to 2:00 p.m.), the Dietary Manager, Dietary Aide T, Dietary Aide U, Housekeeper V, Housekeeper W, MDS Nurse and 1 ADON who worked all shifts. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/or identified, such as immediately removing the alleged perpetrators from providing care to residents and separating residents. Staff were educated on facility posting related to reporting abuse were able to locate numbers for reporting and alternate methods of reporting abuse such as department supervisors and/ or charge nurses. <BR/>During an interview on 04/21/24 at 10:20. a.m., the Administrator and the DON indicated the facility 24 Hour Report and Incident Reports would be reviewed in the morning clinical meetings attended by the Administrator and the Director of Nursing to review for any allegations or instances of abuse and/ or neglect. The weekend manager on duty and weekend RN Supervisor would report any incidents or allegations to the DON and administrator immediately.<BR/>The Administrator was informed the IJ was removed on 04/21/24 at 12:39 a.m. The facility remained out of compliance at potential for more than minimal harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the Administrator and the State Survey Agency, for 8 of 11 residents reviewed for reporting allegations of abuse. (Residents #3, #4, #5, #6, #7, #8, #9, and #10)<BR/>* The facility did not report within 2 hours when Resident #3 reported Resident #4 had touched her breast inappropriately (sexual abuse).<BR/>* The facility did not report within 2 hours when Resident #5 kicked Resident #6 in the back (physical abuse).<BR/>* The facility did not report within 2 hours when Resident #7 hit Resident #8 and he hit her back (physical abuse).<BR/>* The facility did not report within 2 hours when Resident #9 swung at Resident #10 with her fist and Resident #5 hit back causing scratches (physical abuse). <BR/>This failure could place the residents at risk of abuse and neglect.<BR/>Findings included:<BR/>1. An email to HHSC Complaint and Incident Intake dated 04/13/23 at 11:13 AM indicated the name and title of the person making the initial report; [ADM] the date and time the person became aware of the reportable incident; 04/12/23 approximately 07:20 PM a detailed narrative of the incident; [Resident #3] approached nurse after coming out of [Resident #4] room saying I have to tell you something. [Resident #3] then went on to say that yesterday [Resident #4] touched me on my breast .<BR/>Record review of the Provider Investigation Form indicated the following:<BR/>* Date Reported to HHSC-04/13/23 <BR/>* Time: 11:13 AM<BR/>* Incident Category: Other<BR/>* If other, specify: Resident to Resident contact<BR/>* Incident Date: 04/12/23; and <BR/>* Time of Incident: 06:30 PM.<BR/>2. An email to HHSC Complaint and Incident Intake dated 04/19/23 at 07:53 PM indicated the name and title of the person making the initial report; [ADM] the date and time the person became aware of the reportable incident; 04/19/23 approximately 04:40 PM a detailed narrative of the incident; Resident #5 kicked another resident [Resident #6] in her back. This resident stated she kicked her because she was in her way <BR/>Record review of the Provider Investigation Form indicated the following:<BR/>* Date Reported to HHSC-04/19/23 <BR/>* Time: 07:53 PM<BR/>* Incident Category: Other<BR/>* If other, specify: Resident to Resident contact<BR/>* Incident Date: 04/19/23; and <BR/>* Time of Incident: 04:00 PM.<BR/>3. An email to HHSC Complaint and Incident Intake dated 04/19/23 at 08:23 PM indicated the name and title of the person making the initial report; [ADM] the date and time the person became aware of the reportable incident; 04/19/23 approximately 04:40 PM a detailed narrative of the incident; Resident #7 said Resident #8 hit him when he was trying to pass her in his wheelchair. He stated he hit her back.<BR/>Record review of the Provider Investigation Form indicated the following:<BR/>* Date Reported to HHSC-04/19/23 <BR/>* Time: 08:23 PM<BR/>* Incident Category: Other<BR/>* If other, specify: Resident to Resident contact<BR/>* Incident Date: 04/19/23; and <BR/>* Time of Incident: 04:00 PM.<BR/>4. An email to HHSC Complaint and Incident Intake dated 04/24/23 at 11:30 AM indicated Reporter's Name and Title: [ADM] Date/Time you first learned of incident: 04/24/23 approximately 08:55 AM Brief narrative summary of the reportable incident: Upon investigation Resident #9 went into Resident #10 room and pulled her covers off and then proceeded to take clothing items out of closet. [Resident #10] stated she got up out of bed asked [Resident #9] to leave her room and [Resident #9] swung at her fist and she was simply defending herself <BR/>Record review of the Provider Investigation Form indicated the following:<BR/>* Date Reported to HHSC-04/24/23 <BR/>* Time: 11:30 AM<BR/>* Incident Category: Other<BR/>* If other, specify: Resident to Resident contact<BR/>* Incident Date: 04/24/23; and <BR/>* Time of Incident: left blank.<BR/>During an interview on 06/12/23 at 01:35 PM the DON said she was the acting Abuse Coordinator (AC) since 05/27/23 when the ADM resigned. She said initial reports of self-reported incidents were done through email since October of last year. She said one resident inappropriately touching another resident's private areas was sexual abuse. She said one resident hitting, slapping, or punching another resident was physical abuse. She said 2 residents fighting was physical abuse. She said all allegations of abuse were to be reported to the SA within 2 hours. She said the incidents regarding Residents #5, #6, #7, #8, #9, and #10 were physical abuse. She said the incident regarding Residents #3 and #4 was sexual abuse. She said all of the incidents should have been reported within 2 hours. <BR/>The facility did not have a current ADM. The former ADM was not available for interview. An attempt was made to call but no return call.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 12 residents (Resident #1) reviewed for comprehensive person-centered care plans.<BR/>The facility failed to develop and implement a care plan for Resident #1's aggressive behaviors toward others. <BR/>This failure could place residents at risk of not having individual needs met and a decreased quality of life. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 05/14/24 indicated he was [AGE] years old, admitted on [DATE], and his diagnoses included encephalopathy (brain dysfunction), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and cognitive communication deficit.<BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated he sometimes was able to make himself understood and understood others, and had severe cognitive impairment (BIMS score 00). His behaviors included physical behaviors directed at others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) that occurred 1 to 3 days (out of 7 day look back period)<BR/>Record review of Resident #1's electronic record indicated there was no care plan related to aggression towards others.<BR/>Record review of a progress note dated 05/12/24 at 10:23 p.m., completed by LVN L indicated she wheeled Resident #1 to his room for CNA R to provide care. CNA R reported Resident #1 initiated physical aggression and reached up and scratched CNA R's face. CNA N and CNA O entered Resident #1's room to complete Resident #1's care. <BR/>During an interview on 05/14/24 at 5:58 p.m., CNA R said she had been employed at the facility for 2 weeks and had worked at a secure unit as a CNA prior to this facility and had received training on abuse and self-defense tactics. She said that Resident #1 was never aggressive and she did not know what happened that day, but he was fighting all three of them, which included CNA N and CNA O, and her on 05/12/24. She said she was trying to get him dressed and he was so strong and grabbed her face and started scratching, punching, and kicking. She said she never hit him back and that she used the self-defense tactics of raising her arms like an x. She said he was fighting all three of them pretty hard and she did not see anyone ever hit him back. She said she was just trying to make sure he did not fall on the floor and resolve the situation. She said she had not worked with him since the incident and that she had observed his injuries. She said she did not know how he got those injuries other than he was fighting so hard and was not just fighting her that the other two girls were bigger than her. She said the administrator informed her that Resident #1 was never aggressive unless someone was mean to him and that it appeared she was getting the brunt of it. <BR/>During an interview on 05/22/24 at 12:30 p.m., CNA N said she overhead conversation on 05/12/24 when CNA R reported to LVN L that Resident #1 exhibited aggressive behaviors and had scratched CNA R on the face while she was trying to provide personal care. CNA N said she told CNA R and CNA O that she would try to assist with Resident #1 with care. CNA N said she and CNA O went back into Resident #1's room approximately 10 minutes after the incident of aggression with CNA R to assist resident with care. CNA N said she did not know what happened, but when she went to assist Resident #1, he started spitting and fighting. She said she and CNA O left the room, to allow Resident #1 to calm down. CNA N said Resident #1 had behaviors at times and they leave the room and try to go back later to assist him.<BR/>During an interview on 05/22/24 at 12:42 p.m., CNA O said she went to Resident #1's room to assist with care. She said CNA N and CNA R were already in the room. CNA O said she observed CNA N attempting to provide care to Resident #1, but Resident #1 was upset and was spitting at CNA N. CNA R was standing in room but not assisting with care because Resident #1 had already scratched her on the face. CNA O said Resident #1 was being aggressive spitting and slapping at CNA N. She left the room to notify LVN L of the incident and LVN L said she was aware of the incident and the behaviors. CNA O returned to Resident #1's room and notified CNA N and CNA R that LVN L was notified of Resident #1's behaviors.<BR/>During an interview on 05/22/24 at 2:08 p.m., LVN/MDS J said she was responsible for completing resident care plans. She said it was a mistake and she just missed completing a care plan related to Resident #1's aggression towards others.<BR/>During an interview on 05/22/24 at 1:14 p.m., the Administrator stated the DON and the MDS Coordinator were responsible for completing the care plans. The Administrator stated she expected them to include anything unusual or special for the resident's care. The Administrator stated it was important for Resident #1's aggressive behavior towards others to be included in the care plan so the staff could ensure the resident was receiving appropriate care. <BR/>During an interview on 05/22/24 at 2:45 p.m., LVN L said CNA R left Resident #1's room and reported Resident #1's aggressive behaviors and that he had scratched her face on 05/12/24. She said CNA N and CNA O went to complete Resident #1's care and he continued with his aggressive behaviors. She said the staff left his room to allow him to calm down. <BR/>Record review of the facility's Comprehensive Person-Centered Care plans policy dated 2001 (revised October 2018) indicated Policy Statement-A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 9 Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 residents (Resident #6) reviewed for infection control. <BR/>1. The facility failed to ensure Resident #6's central line (a tube that is inserted into a large vein in the neck, chest, groin, or arm to give fluids, blood, medications, or to do medical tests quickly) dressing was changed every seven days per the physician's order.<BR/>2. The facility failed to ensure the Treatment Nurse changed gloves and performed hand hygiene between glove changes during wound care, after picking up a packaged mint off the floor, and before and after entering and exiting Resident #6's room.<BR/>These failures could place residents at risk for infections.<BR/>Findings included:<BR/>1. Record review of the face sheet dated 7/1/24 indicated Resident #6 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including cellulitis (a common and potentially serious bacterial skin infection) of the left lower limb, hypertension (elevated blood pressure), diabetes, Charcot's joint syndrome (a rare complication of diabetes related neuropathy [nerve damage where feeling in the lower legs and feet are lost]. It can make injuries or infections much more serious).<BR/>Record review of the MDS dated [DATE] indicated Resident #6 admitted to the facility on [DATE]. The MDS indicated Resident #6 was usually understood by others and usually understood others. The MDS indicated Resident #6 had a BIMS of 08 and was moderately cognitively impaired. The MDS indicated Resident #6 required set-up assistance with eating and was dependent on staff for oral hygiene, showering/bathing, dressing, and transferring. <BR/>Record review of the physician orders dated 6/28/24 indicated Resident #6 had an order starting 6/7/24 to change the dressing to single lumen (one tubing and one cap end) PICC line to the left upper extremity every day shift every 7 days for IV (intravenous) management. <BR/>During an observation and interview on 6/28/24 at 11:47 a.m. Resident #6's PICC line dressing was dated 6/4/24. Resident #6 said the facility staff had not changed his PICC line dressing since he admitted to the facility. <BR/>During an interview on 7/1/24 at 11:23 am the Medical Director said he would expect a PICC line dressing to be changed every 7 days as ordered to prevent infection.<BR/>During an interview on 7/1/24 at 12:01 p.m. the Administrator said Resident #6 was the only resident at the facility with a PICC line. <BR/>During an interview on 7/2/24 at 10:04 a.m. LVN T said the treatment nurse, or a RN was responsible for changing PICC line dressings. LVN T said if she noticed a PICC line dressing had not been changed as ordered she would notify a supervisor. LVN T said PICC line dressing should be changed weekly. LVN T said she had only administered Resident #6's IV medication once or twice because it was due on the evening shift, and she normally worked day shift. LVN T said she had not assessed Resident #6's PICC line dressing. LVN T said the importance of ensuring PICC line dressings were changed weekly was to prevent bacteria from entering the site and to prevent dressing from rolling up. <BR/>2. During an observation on 6/28/24 at 1:22 p.m. the Treatment Nurse performed wound care to Resident #6's ankle. The Treatment Nurse wiped the bedside table with normal saline and did not put a barrier down between the bedside table and the wound care supplies. The Treatment Nurse cleansed the medial incision, lateral incision, and bottom of foot with same piece of gauze with normal saline on it. The Treatment Nurse removed her gloves, did not perform hand hygiene, and went to the treatment cart to retrieve a package of rolled gauze. The Treatment Nurse dropped a packaged mint on the floor, reached down to pick it up, did not perform hand hygiene, and then applied a new pair of gloves. The Treatment Nurse touched Resident #6's foot and incisions with her gloved hands to see if he could feel her touch. The Treatment Nurse went to the treatment cart to obtain a tube of ointment for Resident #6's wound without removing her gloves or performing hand hygiene. The Treatment Nurse returned to the room, applied ointment to the incisions with her gloved hand, removed her gloves, did not perform hand hygiene, and wrapped the foot/ankle with rolled gauze. <BR/>During an observation and interview on 06/29/24 at 11:50 a.m., the Treatment Nurse removed the kerlix wrap from Resident #6's left foot. The Treatment Nurse said Resident #6 was on isolation for MRSA (methicillin-resistant Staphylococcus aureus) of his surgery sites. The Treatment Nurse removed her gloves washed her hands applied new gloves and cleaned wounds with wound cleanser and 4 by 4 gauze for each site. The Treatment Nurse then applied clindamycin by using fingers on her gloved hand:<BR/>* applied clindamycin to the inside surgical wound using gloved the first finger applied directly to the wound. <BR/>*, applied clindamycin to the outside of the surgical wound using gloved the second finger applied directly to the wound; and<BR/>* applied clindamycin to the great left toe a necrotic area using gloved the ring finger applied directly to the wound. <BR/>The Treatment Nurse did not change her gloves or perform hand hygiene between treating areas on Resident #6's foot. The Treatment Nurse removed her gloves after she wrapped the left foot with kerlix wrap then walked out of the room down the hall approximately 7 feet to the hand sanitizer with her isolation gown on she wore while she performed wound care.<BR/>During an interview on 06/29/24 at 12:00 p.m., the Treatment Nurse said she should have removed her gown in the room and said she never told about changing gloves between areas. <BR/>During an interview on 7/1/24 at 11:23 a.m., the Medical Director said the Treatment Nurse cleaning Resident #6's wounds with the same gauze would not have spread the MRSA as it was systemic. The Medical Director said the treatment nurse not performing appropriate hand hygiene during wound care and leaving the room with gloved hands and without performing hand hygiene should be something staff were in-serviced regarding because the action could lead to the spread of infections.<BR/>During an interview on 7/2/24 at 12:36 p.m. DON JJ said an RN or trained LVN could change a PICC line dressing. DON JJ said the charge nurses were responsible for changing PICC line dressings. DON JJ said PICC line dressings should be changed weekly. DON JJ said the importance of ensuring PICC line dressings were changed weekly was for infection control. DON JJ said she expected staff to perform hand hygiene before entering a resident room, before patient care, during patient care when warranted, before leaving a resident room, and between glove changes. DON JJ said if a staff member picked an item up out of the floor, she expected them to perform hand hygiene afterwards. DON JJ said the importance of proper hand hygiene was infection control.<BR/>During an interview on 7/1/24 at 1:37 p.m. the Administrator said an RN was responsible for changing PICC line dressings. The Administrator said PICC line dressing changes were the responsibility of DON JJ or the weekend RN Supervisor. The Administrator said a PICC line dressing should be changed in accordance with the doctor's order. The Administrator said the importance of ensuring PICC line dressings were changed as ordered was infection control. The Administrator said she expected staff to perform hand hygiene when performing care for a resident, during different intervals of wound care including going from one wound site to another, and if they picked something up off the floor. The Administrator said the importance of proper hand hygiene was infection control. <BR/>Record review of the facility's undated Infections-Clinical Protocol policy indicated, During the initial assessment, the physician will help identify individuals who have had a recent infection or who are at risk for developing an infection .<BR/>Record review of the facility's undated Central Venous Catheter Dressing Changes policy indicated, The purpose of the procedure is to prevent catheter-related infections associated with contaminated, loosened, soiled, or wet dressings. Check the State's Nursing Practice Act for LPNs (Licensed Practical Nurse) regarding the scope of practice for changing a central venous catheter dressing. A physician's order is not needed for this procedure. Apply and maintain sterile dressing on intravenous access devices .Change dressings if any suspicion of contamination is suspected .Change transparent semi-permeable membrane (TSM) dressings at least every 5-7 days and PRN (when wet, soiled, or not intact) .<BR/>Record review of the facility's undated Handwashing/Hand Hygiene policy indicated, The facility considers hand hygiene the primary means to prevent the spread of infection .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water in the following situations .b. Before and after direct contact with residents; c. Before preparing or handling medications; c. Before performing a non-surgical invasive procedure .g. Before handling clean or soiled dressing, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care .k. After handling used dressings, contaminated equipment, etc.; l. after contact with objects in the immediate vicinity of the resident; m. After removing gloves; n. Before and after entering isolation precaution settings .9. The use of gloves does not replace hand washing/hand hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 1 of 5 residents (Resident #2) reviewed for accuracy of assessments. The facility did not accurately complete the MDS assessment to indicate Resident #2's active diagnoses. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: Record review of Resident #2's face sheet dated 08/28/25 indicated he was a [AGE] year old male, admitted to the facility on [DATE], and his diagnoses included C1-C4 complete quadriplegia (paralysis that affects all four limbs), diabetes (high blood sugar), hyperlipemia (high levels of fats in the blood), chronic embolism and deep vein thrombosis of bilateral lower extremities (presence of a blood clot), neuromuscular dysfunction of bladder (problem with brain , nerves or spinal cord causes loss of bladder control), hypertension (high blood pressure), neurogenic bladder (condition affects bladder function due to nervous system problems), chronic kidney disease (gradual loss of kidney function), obesity (excessive fat), atherosclerotic heart disease with unstable angina (heart muscle does not receive enough oxygen due to narrowed or blocked arteries caused by plaque buildup), spinal stenosis of cervical region (narrowed space in the spine), complete lesion at C6 of spinal cord (total loss of motor control and function below level of injury), generalized muscle weakness lack of energy and strength, and major depressive disorder (persistent feeling of sadness or loss of interest). Record review of Resident #2's admission MDS dated [DATE] indicated he was able to make himself understood, was able to understand others, was cognitively intact (BIMS-15), used a wheelchair for mobility, and was dependent for most ADLS. The MDS did not include the active diagnoses of coronary artery disease, neurogenic bladder, quadriplegia, or depression. During an interview on 08/29/25 at 9:00 a.m., the DON said the accuracy of MDS was the responsibility of the Administrator. She said Resident #2's MDS dated [DATE] had her signature but she could not verify it was her electronic signature. She said if the MDS did not include the required information, it was probably missed. She said the MDS Coordinator was directly under the supervision of the administrator and the Administrator was supposed to review to ensure the MDS was initiated and competed as required. She said she was never informed that she should review the MDS for accuracy and completion. During an interview on 08/29/25 at 10:26 a.m., the Administrator said the Regional MDS Coordinator was supposed to review the MDS completed by the facility MDS Coordinator for accuracy and timeliness of completion. She said the facility did not have an MDS Coordinator as of 07/23/25. She said it was her expectation was the DON would ensure the MDS was completed as required. The Administrator said the facility did not have an MDS policy and they followed the RAI. She said residents were at risks of not receiving care and services and required if the MDS was not completed as required. During an interview on 08/29/25 at 10:50 a.m., the VPO said the facility did not have a current MDS Coordinator. He said the Regional MDS Coordinator was supposed to fill in and ensure the residents' MDS assessments were completed as required. He said the Regional MDS Coordinator was terminated and a new one was recently hired. He said the leadership of the facility (the Administrator and the DON) were supposed to ensure the MDS was completed on time and accurate. He said residents were at risks of not receiving care and services and required if the MDS was not completed as required. Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2024 indicated .SECTION I: ACTIVE DIAGNOSES Intent: The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status. 0100-I8000: Active Diagnoses in the Last 7 Days Item Rationale Health-related Quality of Life Disease processes can have a significant adverse effect on an individual's health status and quality of life. Planning for Care This section identifies active diseases and infections that drive the current plan of care. Check the following information sources in the medical record for the last 7 days to identify active diagnoses: transfer documents, physician progress notes, recent history and physical, recent discharge summaries, nursing assessments, nursing care plans, medication sheets, doctor's orders, consults and official diagnostic reports, and other sources as available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team after each assessment for 3 of 7 residents (Residents #1, #2, and #3) reviewed for comprehensive person-centered care plans.<BR/>1. Resident #1's comprehensive person-centered care plan was not updated to reflect behavior of physical aggression toward another resident. <BR/>2. Resident #2's comprehensive person-centered care plan was not updated to reflect an altercation when another resident had been physically aggressive with her. <BR/>3. Resident #3's comprehensive person-centered care plan was not updated to reflect when another resident had been physically aggressive with her. <BR/>These failures could place residents at risk for not receiving the necessary care and services they required. <BR/>The findings were:<BR/>1. Record review of Resident #1's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included schizophrenia (a serious mental condition involving breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion), persistent mood [affective] disorder (marked disruptions in emotions {severe lows called depression or highs called hypomania or mania]), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations).<BR/>Record review of Resident #1's care plan, dated 10/25/23, indicated Resident #1 had a diagnosis of schizophrenia and was at risk for manic episodes and increased behaviors. Interventions included monitor for delusions and hallucinations and monitor for increased agitation, anger, verbal, physical aggression and document in the clinical record. The care plan was not updated with Resident #1's physical aggression toward other residents on 04/03/24 when she pulled Resident #3 out of her wheelchair or on 04/19/24 when she attempted to smother her roommate (Resident #2) with a pillow. <BR/>Record review of Resident #1's quarterly MDS assessment, dated 04/08/24, indicated Resident #1 was able to make herself understood and usually understand others, and had moderate cognitive impairment indicated by a BIMS score of 11. She had had no hallucinations, delusions, or physical or verbal behaviors. She required partial to moderate assistance with most ADLs.<BR/>Record review of Resident #1's clinical note (related to the incident with Resident #3) dated 04/03/24 at 11:30 a.m. and signed by LVN N indicated CNA came and informed LVN N that Resident #1 pulled Resident #3 out of her wheelchair onto the floor of Resident #1's room. Resident #1 said I'm not a fucking babysitter, I need help my motherfucking self she needs to keep her ass out of my motherfucking room. On arrival to the secure unit residents were already separated and in different rooms. LVN N educated and redirected Resident #1, she was informed that physical aggression would not be tolerated, and it was not her right to put hands on anyone. LVN A indicated that Resident #1 did not verbalize understanding. <BR/>Record review of the incident report dated 04/19/24 at 03:40 a.m., Completed by LVN A indicated she was notified by CNA that Resident #2 was yelling for help because Resident #1 (her roommate) had placed a pillow over Resident #2's face and held it over her face. Resident #2 came out of her room yelling for help. The residents were separated, and Resident #2 was assessed with no bruising on her face and no shortness of breath. Resident #1 admitted she did it and stated, Don't send me to jail please send me to a mental institution. Resident #2 was moved to another room for her protection and safety. MD was paged and LVN A was awaiting response. Administrator was notified. <BR/>During an interview on 04/22/24 at 01:05 p.m., the MDS nurse said she was responsible for updating resident care plans with the DON's supervision. She said she had not been aware of Resident #1's aggression toward other residents. She said she received updates concerning residents during the facility morning care meetings, through review of new orders, and reviewing the facility 24-hour updates. She said not updating care plans with changes in resident status or behaviors could result in staff being unaware of the changes. <BR/>During an interview on 04/22/22 at 01:26 p.m., the ADON stated Resident #1 was transferred to a behavioral hospital on [DATE] after her attempt to hurt Resident #2. The ADON stated he was not sure why Resident #1's comprehensive person-centered care plan was not updated and should have been because it would ensure the resident received consistent care. <BR/>2. Record review of Resident #2's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility 12/05/23. Resident #2 had diagnosis which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning) with agitation, major depressive disorder (a metal health disorder characterized by persistently depressed mood causing significant impairment in daily life), and schizophrenia.<BR/>Record review of Resident #2's care plan, dated 07/31/23 indicated Resident #2 had an altered thought process and was at risk for further decline and injury as evidenced by dementia and short- and long-term memory deficit. Interventions included keep resident and others safe and monitor for mental status changes. The care plan was not updated with the altercation 0n 04/19/24 when Resident #1 attempted to smother her with a pillow.<BR/>Record review of Resident #2's quarterly MDS dated [DATE] indicated Resident #2 was able to make herself understood and understood others, and had severe cognitive impairment indicated by a BIMS score of 6. She had feelings of being down, depressed, and hopeless 2-6 (several) days and had no behaviors. <BR/>Record review of Resident #2's clinical note dated 04/19/24 at 03:54 a.m. and signed by LVN A indicated she was notified by CNA B that Resident #2 came running out of her room yelling for help and saying her roommate (Resident #1) placed a pillow over her face and held it over her face. The residents were separated, and Resident #2 was assessed with no bruising on her face and no shortness of breath. Resident #2 was moved to another room for her protection and safety. <BR/>During an interview on 04/21/24 at 02:44 p.m., the DON said the MDS nurse was responsible for updating care plans with changes in resident status/behavior with her supervision. She said Residents #1, #2, and #3's care plans should have been updated that the physical altercations had happened and goals and interventions for those focuses. She said if care plans were not updated it put residents at risk for not receiving the care and services they needed. <BR/>During an interview on 04/22/24 at 01:05 p.m., the MDS nurse said she had not been aware that Resident #2 had been involved in an altercation with Resident #1 on 04/03/24 so she didn't update the care plan. <BR/>3. Record review of Resident #3's face sheet dated 04/20/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included cerebral infarction (stroke), spastic hemiplegia (a common post-stroke condition that causes stiff or rigid muscles) affecting right dominant side, vascular dementia (dementia [a condition characterized by progressive or persistent loss of intellectual functioning] caused by an impaired supply of blood to the brain), mood disorder (marked disruptions in emotions [severe lows called depression or highs called hypomania or mania]), and depression.<BR/>Record review of Resident #3's care plan revised on 06/21/23 indicated Resident #3 was deemed at risk for wandering related to being ambulatory with her wheelchair, diagnosis of dementia, and history of exit seeking. Goals included Resident #3 would be able to wander in a safe environment (secure unit) with no occurrence of injury and dignity would be maintained. The care plan was not updated with the incident from 04/03/24 when Resident #3 wandered into Resident #1's room and Resident #1 pulled her out of her wheelchair onto the floor. <BR/> Record review of Resident #3's annual MDS dated [DATE] indicated Resident #3 was sometimes able to make herself understood and usually understood others, and had severe cognitive impairment indicated by a staff assessment. She had mood of little interest or pleasure in doing things several (2-6 days) and behaviors directed toward others 1 to 3 days and no wandering behaviors.<BR/>During an interview on 04/22/24 at 01:05 p.m., the MDS nurse said she had not been aware Resident #3 was pulled out of her wheelchair onto the floor by Resident #1 on 04/03/24 so she had not updated the care plan with the altercation. <BR/>Record review of facility policy Care Plans, Comprehensive Person-Centered revised October 2018, indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 residents (Resident #6) reviewed for infection control. <BR/>1. The facility failed to ensure Resident #6's central line (a tube that is inserted into a large vein in the neck, chest, groin, or arm to give fluids, blood, medications, or to do medical tests quickly) dressing was changed every seven days per the physician's order.<BR/>2. The facility failed to ensure the Treatment Nurse changed gloves and performed hand hygiene between glove changes during wound care, after picking up a packaged mint off the floor, and before and after entering and exiting Resident #6's room.<BR/>These failures could place residents at risk for infections.<BR/>Findings included:<BR/>1. Record review of the face sheet dated 7/1/24 indicated Resident #6 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including cellulitis (a common and potentially serious bacterial skin infection) of the left lower limb, hypertension (elevated blood pressure), diabetes, Charcot's joint syndrome (a rare complication of diabetes related neuropathy [nerve damage where feeling in the lower legs and feet are lost]. It can make injuries or infections much more serious).<BR/>Record review of the MDS dated [DATE] indicated Resident #6 admitted to the facility on [DATE]. The MDS indicated Resident #6 was usually understood by others and usually understood others. The MDS indicated Resident #6 had a BIMS of 08 and was moderately cognitively impaired. The MDS indicated Resident #6 required set-up assistance with eating and was dependent on staff for oral hygiene, showering/bathing, dressing, and transferring. <BR/>Record review of the physician orders dated 6/28/24 indicated Resident #6 had an order starting 6/7/24 to change the dressing to single lumen (one tubing and one cap end) PICC line to the left upper extremity every day shift every 7 days for IV (intravenous) management. <BR/>During an observation and interview on 6/28/24 at 11:47 a.m. Resident #6's PICC line dressing was dated 6/4/24. Resident #6 said the facility staff had not changed his PICC line dressing since he admitted to the facility. <BR/>During an interview on 7/1/24 at 11:23 am the Medical Director said he would expect a PICC line dressing to be changed every 7 days as ordered to prevent infection.<BR/>During an interview on 7/1/24 at 12:01 p.m. the Administrator said Resident #6 was the only resident at the facility with a PICC line. <BR/>During an interview on 7/2/24 at 10:04 a.m. LVN T said the treatment nurse, or a RN was responsible for changing PICC line dressings. LVN T said if she noticed a PICC line dressing had not been changed as ordered she would notify a supervisor. LVN T said PICC line dressing should be changed weekly. LVN T said she had only administered Resident #6's IV medication once or twice because it was due on the evening shift, and she normally worked day shift. LVN T said she had not assessed Resident #6's PICC line dressing. LVN T said the importance of ensuring PICC line dressings were changed weekly was to prevent bacteria from entering the site and to prevent dressing from rolling up. <BR/>2. During an observation on 6/28/24 at 1:22 p.m. the Treatment Nurse performed wound care to Resident #6's ankle. The Treatment Nurse wiped the bedside table with normal saline and did not put a barrier down between the bedside table and the wound care supplies. The Treatment Nurse cleansed the medial incision, lateral incision, and bottom of foot with same piece of gauze with normal saline on it. The Treatment Nurse removed her gloves, did not perform hand hygiene, and went to the treatment cart to retrieve a package of rolled gauze. The Treatment Nurse dropped a packaged mint on the floor, reached down to pick it up, did not perform hand hygiene, and then applied a new pair of gloves. The Treatment Nurse touched Resident #6's foot and incisions with her gloved hands to see if he could feel her touch. The Treatment Nurse went to the treatment cart to obtain a tube of ointment for Resident #6's wound without removing her gloves or performing hand hygiene. The Treatment Nurse returned to the room, applied ointment to the incisions with her gloved hand, removed her gloves, did not perform hand hygiene, and wrapped the foot/ankle with rolled gauze. <BR/>During an observation and interview on 06/29/24 at 11:50 a.m., the Treatment Nurse removed the kerlix wrap from Resident #6's left foot. The Treatment Nurse said Resident #6 was on isolation for MRSA (methicillin-resistant Staphylococcus aureus) of his surgery sites. The Treatment Nurse removed her gloves washed her hands applied new gloves and cleaned wounds with wound cleanser and 4 by 4 gauze for each site. The Treatment Nurse then applied clindamycin by using fingers on her gloved hand:<BR/>* applied clindamycin to the inside surgical wound using gloved the first finger applied directly to the wound. <BR/>*, applied clindamycin to the outside of the surgical wound using gloved the second finger applied directly to the wound; and<BR/>* applied clindamycin to the great left toe a necrotic area using gloved the ring finger applied directly to the wound. <BR/>The Treatment Nurse did not change her gloves or perform hand hygiene between treating areas on Resident #6's foot. The Treatment Nurse removed her gloves after she wrapped the left foot with kerlix wrap then walked out of the room down the hall approximately 7 feet to the hand sanitizer with her isolation gown on she wore while she performed wound care.<BR/>During an interview on 06/29/24 at 12:00 p.m., the Treatment Nurse said she should have removed her gown in the room and said she never told about changing gloves between areas. <BR/>During an interview on 7/1/24 at 11:23 a.m., the Medical Director said the Treatment Nurse cleaning Resident #6's wounds with the same gauze would not have spread the MRSA as it was systemic. The Medical Director said the treatment nurse not performing appropriate hand hygiene during wound care and leaving the room with gloved hands and without performing hand hygiene should be something staff were in-serviced regarding because the action could lead to the spread of infections.<BR/>During an interview on 7/2/24 at 12:36 p.m. DON JJ said an RN or trained LVN could change a PICC line dressing. DON JJ said the charge nurses were responsible for changing PICC line dressings. DON JJ said PICC line dressings should be changed weekly. DON JJ said the importance of ensuring PICC line dressings were changed weekly was for infection control. DON JJ said she expected staff to perform hand hygiene before entering a resident room, before patient care, during patient care when warranted, before leaving a resident room, and between glove changes. DON JJ said if a staff member picked an item up out of the floor, she expected them to perform hand hygiene afterwards. DON JJ said the importance of proper hand hygiene was infection control.<BR/>During an interview on 7/1/24 at 1:37 p.m. the Administrator said an RN was responsible for changing PICC line dressings. The Administrator said PICC line dressing changes were the responsibility of DON JJ or the weekend RN Supervisor. The Administrator said a PICC line dressing should be changed in accordance with the doctor's order. The Administrator said the importance of ensuring PICC line dressings were changed as ordered was infection control. The Administrator said she expected staff to perform hand hygiene when performing care for a resident, during different intervals of wound care including going from one wound site to another, and if they picked something up off the floor. The Administrator said the importance of proper hand hygiene was infection control. <BR/>Record review of the facility's undated Infections-Clinical Protocol policy indicated, During the initial assessment, the physician will help identify individuals who have had a recent infection or who are at risk for developing an infection .<BR/>Record review of the facility's undated Central Venous Catheter Dressing Changes policy indicated, The purpose of the procedure is to prevent catheter-related infections associated with contaminated, loosened, soiled, or wet dressings. Check the State's Nursing Practice Act for LPNs (Licensed Practical Nurse) regarding the scope of practice for changing a central venous catheter dressing. A physician's order is not needed for this procedure. Apply and maintain sterile dressing on intravenous access devices .Change dressings if any suspicion of contamination is suspected .Change transparent semi-permeable membrane (TSM) dressings at least every 5-7 days and PRN (when wet, soiled, or not intact) .<BR/>Record review of the facility's undated Handwashing/Hand Hygiene policy indicated, The facility considers hand hygiene the primary means to prevent the spread of infection .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water in the following situations .b. Before and after direct contact with residents; c. Before preparing or handling medications; c. Before performing a non-surgical invasive procedure .g. Before handling clean or soiled dressing, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care .k. After handling used dressings, contaminated equipment, etc.; l. after contact with objects in the immediate vicinity of the resident; m. After removing gloves; n. Before and after entering isolation precaution settings .9. The use of gloves does not replace hand washing/hand hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for the residents in rooms 217 through 224 (8 rooms for this hallway) and 1 resident of 8 residents (Resident #1) that were observed for physical environment. The facility failed to ensure the hallway and the attached rooms 217 through 224 were free of odors. The facility failed to ensure a dresser in Resident #1's room was in good repair. These failures could place the residents at risk for diminished quality of life. Findings included: 1. An observation on 07/08/25 from 8:20 AM to 9:26 AM revealed a foul odor starting from the beginning of the hallway extending to the end of the hallway. As the State Surveyor walked through the hallway it was strongest of the odor in front of room [ROOM NUMBER]. The odor smelled of urine, feces, and body odor all combined making it hard to breath as the State Surveyor walked the length of the hallway (rooms 217 - 224). An observation on 07/08/25 at 11:27 AM revealed the odor was almost completely gone in the hallway for rooms 217 through 224 but the odor was still in front of room [ROOM NUMBER]. There were three housekeeping staff working on this hallway. An observation on 07/08/25 at 03:04 PM revealed there was a slight odor in the hallway for rooms 217 through 224, but the odor was still in front of room [ROOM NUMBER]. In an interview on 07/08/25 at 8:33 AM with Resident #1 revealed her roommate was gross and gets poop everywhere. She stated one housekeeper quit because of her roommate and they deep clean her room because of the behaviors her roommate has related to feces and urine. She stated it grossed her out. During this interview, a strong odor of feces came from the restroom. There were two brown spots on the bathroom floor as well as one brown spot on the toilet seat. There was a puddle of unknown liquid at the base of the sink. In an interview on 07/08/25 at 10:29 AM LVN A stated as far as she knew they cleaned all rooms daily. She stated the odor was due to some residents refusing hygiene care. She stated she knew of at least two rooms that had a stronger smell in their rooms. LVN A stated she did not always work that hall, but she had noticed the odor. LVN A stated the residents could feel disgusted and feel like the room was unclean. In an interview on 07/08/25 at 11:09 AM the Housekeeping Supervisor stated every room was cleaned daily. She stated rooms like 220 and 221 were cleaned three times a day. Regarding the hallway odor, she stated most people on that hall would not take a shower. She stated, we (housekeeping) come in and use certain chemicals to try to fight the odor. She stated she had not had any complaints about the odor, but she was sure it affected them some way. She stated that was why they deep cleaned to stay on top of it and disinfect everything. 2.An observation on 07/08/25 at 8:33 AM, revealed in Resident #1's room a dresser in need of repair. The top drawer had a loose handle and the drawer was crooked, the second drawer had a broken handle, the fourth drawer was sticking out and would not close, and the sixth drawer was missing a knob. During an interview on 07/08/25 at 12:19 PM, Resident #1 stated the broken drawers make me so mad. She stated it had been like that since at least the beginning of the year. She stated she thought they were working on getting a new one for her. During an interview on 07/08/25 at 2:26 PM, the Maintenance Director stated he was the one that repaired items if he could or ordered new ones. There was a clipboard at the nurses' station for maintenance activities. He stated he looked at the maintenance log every morning. He stated no one had reported the broken dresser to him. He stated staff or anyone that saw issues could report it. He stated it could affect the resident's quality of life and it could irritate them. He stated he tried to get on maintenance issues as quickly as he could. During an interview on 07/08/25 at 2:41 PM the Administrator stated they were going to replace the dresser, but they could not remove it until they received a new one. Otherwise- there was nowhere to put the resident's clothes. She stated she put in an order for a dresser in June 2025, but they still have not received it. She stated it could affect residents due to it not being a homelike environment. The administrator stated in regard to the odor in the hallway, there were at least five residents that refused to bathe. She stated no matter what they tried; they could not get them to bathe regularly. She stated housekeeping would go in twice a day to clean those rooms and the hallway. The Administrator stated housekeeping was responsible to stay on top of cleaning to prevent the odor. She stated, if the staff could get the residents to bathe to decrease the odor, the residents would like that. Review of the Policy and Procedure Quality of Life - Homelike Environment, no date, reflected Residents are provided with a safe, clean, comfortable, and homelike environment.cleanliness and order.inviting colors and decor.pleasant, natural scents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program, so the facility was free of pests and rodents for five (Residents #1, # 2, #3, #4, and #5) of fifty-five residents reviewed for effective pest control. The facility failed to ensure Resident #1, # 2, #3, #4, and #5's rooms were free of pests. These failures could place residents at risk of exposure to bugs and bug bites. Findings included: An observation and interview on 07/08/25 at 8:33 AM revealed two cockroaches scattered from the center of the room to the wall, as the State Surveyor entered Resident #1's room. Resident #1 stated her roommate was gross and gets poop everywhere. She has food and soda that attracts the roaches. An observation on 07/08/25 at 8:48 AM revealed five dead cockroaches and one live cockroach in Resident #2 and Resident #3's room. The residents were not in the room at the time. An observation and interview on 07/08/25 at 9:27 AM revealed a small cockroach ran across the dresser in Resident #4's room. There were two live spiders seen, one behind the head of the bed and one at the bottom of one of her dressers. Behind the head of the bed were three dead spiders and two dead cockroaches. Resident #4 stated this morning roaches were running on my breakfast tray. An observation on 07/08/25 at 3:02 PM revealed a cockroach running across the sink in Resident #5's restroom. During an interview on 07/08/25 at 12:19 PM, Resident #1 stated it makes her feel terrible to have cockroaches in her room. During an interview on 07/08/25 at 10:29 AM LVN A stated if staff saw any pests, they noted it in the pest control log that was kept at the nurses' station. The facility has a company come and spray everywhere and more in specific areas mentioned in the pest control log. LVN A stated they were in-serviced recently about keeping a separate book for reporting areas where pests have been seen. LVN A stated she saw pests, but not very often. She stated she saw flies and cockroaches a couple times a month. She stated it could make the residents feel disgusted and hesitant to eat facility made food. During an interview on 07/08/25 at 2:26 PM the Maintenance Director stated he maintained the monthly pest control records. He stated the contract stated they sprayed once a month and as needed. He stated they have a white binder at the nurses' station where staff can report pest control issues. He stated he has not had recent reports of roaches in the facility. He stated the issues were usually contained to one or two rooms due to food being kept in those rooms. They have provided plastic containers to those residents to help limit pest issues. The pest control company came out once last month and twice the month before that. He stated he also got spray and sprayed some rooms himself. The Maintenance Director stated the residents probably got irritated and did not like to have pests in their rooms. He stated pest control came and sprayed yesterday, so there was probably higher activity because they were trying to get away from the spray. During an interview on 07/08/25 at 2:41 PM the Administrator stated maintenance was in charge of pest control concerns. She stated her expectations were for the policy to be followed and pests to be eliminated. She stated, I feel they have been eliminated lately. She stated there anywhere no recent complaints from residents. She stated staff or residents could report pest control issues to maintenance. She stated pest control issues could affect the residents because it could be an unhomelike environment. Record review of the facility's Maintenance log requests revealed roaches in room [ROOM NUMBER] on 06/08/25 and roaches everywhere in room [ROOM NUMBER] on 05/28/25. Record review of the facility's Pest Control log revealed pest control had treated for cockroaches, spiders, and ants every month and twice in April 2025. The last visit was on 7/07/25. Review of the facility's policy Pest Control, no date, reflected: Our facility shall maintain an effective pest control program.to ensure that the building is kept free of insects and rodents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 of 10 residents (Resident #9) reviewed for advanced directives.The facility failed to ensure Resident #9 who was listed as a DNR (Do Not Resuscitate) had valid Out-of-Hospital Do Not Resuscitate (OOH-DNR) form that was not missing required information.This failure could place residents at risk of not having their end-of-life wishes honored and incomplete records.Findings included:Record Review of Resident #9's face sheet, dated [DATE] , indicated a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses that included: Major Depressive Disorder (a mental disorder characterized by pervasive low mood, low self-esteem, and loss of interest or pleasure in activities), and Schizoaffective disorder bipolar type [a serious mental illness combining symptoms of schizophrenia (hallucinations, delusions, disorganized thinking) with mood swings from bipolar disorder, specifically involving manic episodes (high energy, euphoria) and depressive episodes (low mood, hopelessness)], legal blindness and under the advance directive section was listed DNR-NO CPR. Record review of a quarterly MDS dated [DATE] indicated Resident #9 had minimal difficulty hearing, he had clear speech, he was able to make himself understood, he was able to understand others and he had severely impaired cognition with a BIMS score of 6 out of 15.Record Review of Resident #9's Care Plan dated [DATE] indicated: The resident request code status of: DNR., and interventions Make sure code status is signed and placed in clinical record.Record Review of Resident #9's physician order dated [DATE] indicated: communication method verbal, order status Active, orders placed for DNR - NO CPR.Record Review of Resident #9's OOH-DNR records dated [DATE] indicated: Under the section labeled, Directive by two physicians, next to each Physician's signature/printed name, a physician's license number was not listed and there was no date of when each Physician completed the DNR form.During an observation and interview on [DATE] at 10:28 a.m. Resident #9 was sitting up in his wheelchair in his room. He said he was doing fine. He said he did not want anyone to do CPR on him, he just wanted to pass-on peacefully.During an interview on [DATE] at 11:10 AM the ADON said Advance Directives were reviewed by the admitting nurse and social worker to ensure accuracy. The ADON said Advance Directives should be completed thoroughly. The ADON verified there were no additional advance directives for Resident #9. The ADON verified the current Advance Directives for Resident #9 was not completed, as it was missing both Physician's license number and missing the date the Physicians had signed the DNR Advance Directive. The ADON said it was important for Advance Directives to be completed thoroughly to ensure the documents were legally binding. The ADON said if an advance directive was not completed, the resident's wishes may not be honored. The ADON said she would ensure the advance directives for Resident #9 was updated as soon as possible. The ADON said that she had checked the other Residents with DNR Advance Directives, and they were complete.During an interview on [DATE] at 2:10 p.m. the DON said if a DNR form was not completed correctly with accurate dates and signatures, the DNR would be invalid. She said that in such a case, staff would be required to initiate CPR, which would go against the resident's expressed wishes. The DON said she believed it was the social worker's responsibility to ensure DNR forms were completed accurately and in accordance with requirements, and the social worker responsible at the time of Resident #9's admittance was no longer working for the facility. The DON said currently the facility did not have a social worker and that she would be responsible for making sure Advanced Directives were complete. The DON said hospice services obtained the DNR on Resident #9 and should have ensured it was complete but ultimately it was the facility's responsibility. The DON said the negative outcome would be the resident could have CPR performed on them against their wishes and she would check the other Residents with DNRs for completeness. During an interview on [DATE] at 3:00 PM, the Administrator said if a DNR form was not completed correctly with accurate dates and signatures, the DNR would be invalid. The Administrator said it was the social worker's responsibility to ensure DNR forms were completed accurately to include signatures and dates. The Administrator said the facility did not have a social worker. The Administrator said he had only worked for the facility one day before surveyors entered for survey. The Administrator said it was his expectation that advance directives would be completed properly and reviewed regularly. The Administrator said a resident's wishes may not have been followed if their advance directive was not completed.Record review of a Do Not Resuscitate Order policy revised [DATE] indicated: .2. A Do Not Resuscitate (DNR) order form must be completed and signed by the attending physician and resident (or resident's legal surrogate, as permitted by state law) and placed in the front of the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for the residents in rooms 217 through 224 (8 rooms for this hallway) and 1 resident of 8 residents (Resident #1) that were observed for physical environment. The facility failed to ensure the hallway and the attached rooms 217 through 224 were free of odors. The facility failed to ensure a dresser in Resident #1's room was in good repair. These failures could place the residents at risk for diminished quality of life. Findings included: 1. An observation on 07/08/25 from 8:20 AM to 9:26 AM revealed a foul odor starting from the beginning of the hallway extending to the end of the hallway. As the State Surveyor walked through the hallway it was strongest of the odor in front of room [ROOM NUMBER]. The odor smelled of urine, feces, and body odor all combined making it hard to breath as the State Surveyor walked the length of the hallway (rooms 217 - 224). An observation on 07/08/25 at 11:27 AM revealed the odor was almost completely gone in the hallway for rooms 217 through 224 but the odor was still in front of room [ROOM NUMBER]. There were three housekeeping staff working on this hallway. An observation on 07/08/25 at 03:04 PM revealed there was a slight odor in the hallway for rooms 217 through 224, but the odor was still in front of room [ROOM NUMBER]. In an interview on 07/08/25 at 8:33 AM with Resident #1 revealed her roommate was gross and gets poop everywhere. She stated one housekeeper quit because of her roommate and they deep clean her room because of the behaviors her roommate has related to feces and urine. She stated it grossed her out. During this interview, a strong odor of feces came from the restroom. There were two brown spots on the bathroom floor as well as one brown spot on the toilet seat. There was a puddle of unknown liquid at the base of the sink. In an interview on 07/08/25 at 10:29 AM LVN A stated as far as she knew they cleaned all rooms daily. She stated the odor was due to some residents refusing hygiene care. She stated she knew of at least two rooms that had a stronger smell in their rooms. LVN A stated she did not always work that hall, but she had noticed the odor. LVN A stated the residents could feel disgusted and feel like the room was unclean. In an interview on 07/08/25 at 11:09 AM the Housekeeping Supervisor stated every room was cleaned daily. She stated rooms like 220 and 221 were cleaned three times a day. Regarding the hallway odor, she stated most people on that hall would not take a shower. She stated, we (housekeeping) come in and use certain chemicals to try to fight the odor. She stated she had not had any complaints about the odor, but she was sure it affected them some way. She stated that was why they deep cleaned to stay on top of it and disinfect everything. 2.An observation on 07/08/25 at 8:33 AM, revealed in Resident #1's room a dresser in need of repair. The top drawer had a loose handle and the drawer was crooked, the second drawer had a broken handle, the fourth drawer was sticking out and would not close, and the sixth drawer was missing a knob. During an interview on 07/08/25 at 12:19 PM, Resident #1 stated the broken drawers make me so mad. She stated it had been like that since at least the beginning of the year. She stated she thought they were working on getting a new one for her. During an interview on 07/08/25 at 2:26 PM, the Maintenance Director stated he was the one that repaired items if he could or ordered new ones. There was a clipboard at the nurses' station for maintenance activities. He stated he looked at the maintenance log every morning. He stated no one had reported the broken dresser to him. He stated staff or anyone that saw issues could report it. He stated it could affect the resident's quality of life and it could irritate them. He stated he tried to get on maintenance issues as quickly as he could. During an interview on 07/08/25 at 2:41 PM the Administrator stated they were going to replace the dresser, but they could not remove it until they received a new one. Otherwise- there was nowhere to put the resident's clothes. She stated she put in an order for a dresser in June 2025, but they still have not received it. She stated it could affect residents due to it not being a homelike environment. The administrator stated in regard to the odor in the hallway, there were at least five residents that refused to bathe. She stated no matter what they tried; they could not get them to bathe regularly. She stated housekeeping would go in twice a day to clean those rooms and the hallway. The Administrator stated housekeeping was responsible to stay on top of cleaning to prevent the odor. She stated, if the staff could get the residents to bathe to decrease the odor, the residents would like that. Review of the Policy and Procedure Quality of Life - Homelike Environment, no date, reflected Residents are provided with a safe, clean, comfortable, and homelike environment.cleanliness and order.inviting colors and decor.pleasant, natural scents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents the right to be free from abuse for 2 of 7 residents (Residents #2 and #3) reviewed for abuse. <BR/>1. On 04/03/24 Resident #3 self-propelled her wheelchair into Resident #1's room and Resident #1 pulled Resident #3 out of her wheelchair onto the floor. <BR/>2. On 04/19/24 Resident #1 placed a pillow over the face of Resident #2 and later admitted she was trying to kill Resident #2.<BR/>On 04/20/24 at 02:29 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 04/21/24, the facility remained out of compliance at a severity level with the potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of thei Plan of Removal. <BR/>These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.<BR/>Findings included:<BR/>1. Record review of Resident #1's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included schizophrenia (a serious mental condition involving breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion), persistent mood [affective] disorder (marked disruptions in emotions {severe lows called depression or highs called hypomania or mania]), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations).<BR/>Record review of Resident #1's care plan, dated 10/25/23, indicated Resident #1 had a diagnosis of schizophrenia and was at risk for manic episodes and increased behaviors. Interventions included monitor for delusions and hallucinations and monitor for increased agitation, anger, verbal, and physical aggression and document in clinical record. Resident #1 was taking psychotropic medication and was at risk for adverse reactions and depression, anxiety, and/or psychosis driven behaviors. Interventions included monitor for anxiety driven behaviors and report any noted behaviors to MD for further orders.<BR/>Record review of Resident #1's care plan, dated 10/25/23, indicated Resident #1 was taking psychotropic medication and was at risk for adverse reactions and depression, anxiety, and/or psychosis driven behaviors. Interventions included monitor for anxiety driven behaviors and report any noted behaviors to MD for further orders.<BR/>Record review of Resident #1's quarterly MDS assessment, dated 04/08/24, indicated Resident #1 was able to make herself understood and usually understand others, and had moderate cognitive impairment indicated by a BIMS score of 11. She had had no hallucinations, delusions, or physical or verbal behaviors. She required partial to moderate assistance with most ADLs.<BR/>Record review of Resident #1's clinical file revealed there were no care plans available for review related to homicidal ideations.<BR/>Record review of the incident report dated 04/19/24 at 03:40 a.m., completed by LVN A indicated she was notified by CNA B that Resident #2 was yelling for help because Resident #1 (her roommate) had placed a pillow over Resident #2's face and held it over her face. Resident #2 came out of her room yelling for help. The residents were separated, and Resident #2 was assessed with no bruising on her face and no shortness of breath. Resident #1 admitted she did it and stated, Don't send me to jail please send me to a mental institution. Resident #2 was moved to another room for her protection and safety. MD was paged and LVN A was awaiting response. Administrator was notified. <BR/>2. Record review of Resident #2's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility 12/05/23. Resident #2 had diagnosis which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning) with agitation, major depressive disorder (a metal health disorder characterized by persistently depressed mood causing significant impairment in daily life), and schizophrenia.<BR/>Record review of Resident #2's care plan, dated 07/31/23 indicated Resident #2 had an altered thought process and was at risk for further decline and injury as evidenced by dementia and short- and long-term memory deficit. Interventions included keep resident and others safe and monitor for mental status changes. <BR/>Record review of Resident #2's quarterly MDS dated [DATE] indicated Resident #2 was able to make herself understood and understood others, and had severe cognitive impairment indicated by a BIMS score of 6. She had feelings of being down, depressed, and hopeless 2-6 (several) days and had no behaviors. <BR/>During a telephone interview on 04/20/24 at 08:40 a.m., the Administrator said she received a text from LVN A on 04/19/24 at approximately 06:00 a.m. when she woke up reporting Resident #1 had placed a pillow over Resident #2's face and Resident #1 was requesting to go to a mental institution. She said her immediate action had been to request an additional CNA for the secure unit from her corporate office and she had just received approval for the CNA this morning but had not hired a new CNA yet. The Administrator said the secure unit had one dedicated CNA and one nurse that floats between the other rooms and the secure unit. She said Resident #2 had been moved into another room on the secure unit. <BR/>During an observation and interview on 04/20/24 at 09:05 a.m., CNA L said she was assigned the secure unit today with LVN C who was floating between the secure unit and rooms outside the unit. CNA L was sitting in the TV room with 4 residents and said Residents #1 and #2 were in their rooms alone. <BR/>During an observation and interview on 04/20/24 at 09:10 a.m., Resident #1 was alone in her room on the secure unit and resting in bed. She said yesterday (04/19/24) her roommate (Resident #2) was trying to put spells on her, and she had to stop her. She said she tried to hurt Resident #2. <BR/>During an observation and interview on 04/20/24 at 09:15 a.m., Resident #2 was alone in her room on the secure unit lying in bed. She said she had to be moved to a new room because her previous roommate had put a pillow over her face and tried to kill her while she was sleeping. She said she felt as safe as she could in her present surroundings. <BR/>During an interview on 04/20/24 at 09:35 a.m., the DON said she was not at the facility on 04/19/24 because she had to work the night shift last night. She said was notified on 04/19/24 about Resident #1 putting a pillow over Resident #2's face, but she was now looking back on what was done after the incident. She said LVN A reported the incident, but there was no documentation in the clinical record about the incident or if LVN A notified the police, the physician, or the responsible party. She said notifications should have been made and she was doing the notifications to the MD and RP. She said based on the aggression Resident #1 should have been transferred to a behavioral hospital for evaluation. <BR/>During a telephone interview on 04/20/24 at 09:55 a.m., LVN A said on 04/19/24 at 03:30 a.m. she received a call from CNA B who reported Resident #1 had placed a pillow over Resident #2's face and tried to smother her. She said CNA B had separated the residents when she arrived on the secure unit. LVN A said she assessed Resident #2 and found no visible injuries, but she kept repeating she tried to kill me. She said Resident #1 admitted she tried to kill Resident #2. LVN A said she paged the MD twice and he did not call by the end of her shift. She said she reported the incident to her Administrator via text and LVN C who was the nurse working the 06:00 a.m. to 02:00 p.m. shift. <BR/>During an interview on 04/20/24 at 10:05 a.m., LVN C said he received report from LVN A on 04/19/24 at 06:00 a.m. about the incident between Resident #1 and Resident #2. He said LVN A reported to him she had paged the MD twice and not received a response. He said he did not try to notify the MD or Resident #1's RP about the incident on 04/19/24. He said he never noticed if Resident #1 ever came out of her room on his shift and he wasn't sure if Resident #2 was in or out of her room during the day. <BR/>During a telephone interview on 04/20/24 at 10:21 a.m. CNA B said on 04/19/24 at approximately 03:20 a.m. she was passing by the room Resident #1 and Resident #2 shared when Resident #2 ran out of the room saying Resident #1 put a pillow over her head and tried to kill her. Resident #1 said Resident #2 had been naked during the day and she tried to kill her. Resident #1 then said she wanted to go to a mental hospital in Dallas because that was where her brother sent her whenever she tried to hurt people. CNA B said she separated the residents by bringing Resident #2 into the TV room with her and called LVN A and reported the incident. CNA B said after the incident Resident #1 was pacing up and down the hall talking loudly but not making any sense. She said then Resident #1 went into her room and pulled the mattress off her bed and disrobed and continued pacing around her room. She said Resident #2 said she was afraid to be alone in her room, so CNA B kept Resident #2 with her the rest of the night except when assisting other residents and she took her to sit with LVN A.<BR/>During an interview on 04/20/24 at 10:51 a.m., the DON said she notified the NP of the incident that occurred on 04/19/24 to the NP and Resident #1's RP on 04/20/24 at approximately 10:00 a.m. She said she had completed the referral to the behavioral hospital for Resident #1 and was awaiting her transfer. She said the NP gave no new orders for Resident #2. <BR/>During an observation and interview on 04/20/24 at 11:19 a.m., Police Officer M visited Resident #2 in her room. Resident #2 remained alone in her room made a verbal statement to Police Officer M that Resident #1 had tried to kill her by placing a pillow over her face while she was sleeping. She said she wanted to press charges against Resident #1 so she wouldn't try to kill her again. <BR/>During an observation on 04/20/24 at 11:26 a.m., Resident #1 was sleeping alone in her room. <BR/>During an interview on 04/20/24 at 03:59 p.m., the DON said she sat with Resident #1 until she was transported by ambulance to a behavioral hospital at approximately 03:30 p.m.<BR/>3. Record review of Resident #3's face sheet dated 04/20/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included cerebral infarction (stroke), spastic hemiplegia (a common post-stroke condition that causes stiff or rigid muscles) affecting right dominant side, vascular dementia (dementia [a condition characterized by progressive or persistent loss of intellectual functioning] caused by an impaired supply of blood to the brain), mood disorder (marked disruptions in emotions [severe lows called depression or highs called hypomania or mania]), and depression <BR/>Record review of Resident #3's care plan revised on 06/21/23 indicated Resident #3 was deemed at risk for wandering related to being ambulatory with her wheelchair, diagnosis of dementia, and history of exit seeking. Goals included Resident #3 would be able to wander in a safe environment (secure unit) with no occurrence of injury and dignity would be maintained. <BR/>Record review of Resident #3's annual MDS dated [DATE] indicated Resident #3 was sometimes able to make herself understood and usually understood others, and had severe cognitive impairment indicated by a staff assessment. She had mood of little interest or pleasure in doing things several (2-6 days) and behaviors directed toward others 1 to 3 days and no wandering behaviors.<BR/>Record review of Resident #1's clinical note (related to the incident with Resident #3) dated 04/03/24 at 11:30 a.m. and signed by LVN N indicated a CNA B came and informed LVN N that Resident #1 pulled Resident #3 out of her wheelchair onto the floor of Resident #1's room. Resident #1 said I'm not a fucking babysitter, I need help my motherfucking self she needs to keep her ass out of my motherfucking room. On arrival to the secure unit residents were already separated and in different rooms. LVN N educated and redirected Resident #1, she was informed that physical aggression would not be tolerated, and it was not her right to put hands on anyone. LVN A indicated that Resident #1 did not verbalize understanding. <BR/>During an observation and interview on 04/20/24 at 09:05 a.m., Resident #3 was sitting in the TV room of the secure unit. She was unable to answer question about the incident. She was holding her right arm against her, and it appeared to have contractures at her elbow and wrist. Resident #3 said her arm was not painful. CNA L said Resident #3's arm was paralyzed from a stroke. CNA L said staff tried to keep Resident #3 busy because she wandered into other resident's rooms. She said she was not working the day Resident #3 wandered into Resident #1's room and Resident #1 pulled her out of her wheelchair to the floor, but it had been reported to her by another CNA.<BR/>During an interview on 04/20/24 at 09:35 a.m. the DON said the only reason Resident #1 had pulled Resident #3 out of her wheelchair on 04/03/24 was because she went into Resident #1's room. She said she had instructed all staff on the secure unit to keep Resident #3 from wandering into other resident's rooms. <BR/>During a telephone interview on 04/22/24 at 11:35 a.m., LVN N said on 04/03/24 at approximately 11:30 a.m., a CNA reported to her that Resident #3 had self-propelled her wheelchair into Resident #1's room and Resident #1 pulled her out of her wheelchair and onto the floor. LVN N said she assessed Resident #3 who was sitting in the floor of Resident #1's room at the foot of her bed. She had no visible injuries, and she was assisted back into her wheelchair and out of the room. Resident #3 was unable to say how she got onto the floor. LVN N said she notified the ADON, the Administrator, the MD, and the RP of the incident. <BR/>During a telephone interview on 04/22/24 at 12:16 p.m., Resident #3's RP said she was notified on 04/03/24 by the nurse that Resident #3 had wheeled herself into another resident's room and the other resident had pulled Resident #3 out of her wheelchair and onto the floor. She said Resident #3's right arm had paralysis since her stroke. She said Resident #3 had no bruising or pain after she was pulled from her wheelchair. RP said she visited Resident #3 every day and she had witnessed residents on the secure unit being aggressive to staff and other residents. RP said she could not name the Residents she had seen be aggressive, but she had seen Resident #1 yell and cuss at other residents. She said she had not told the Administration about resident aggression. <BR/>Record review of the facility's Abuse and Neglect Policy dated June 2023 indicated It is the policy of the facility to administer care and services in an environment that is free of any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment .The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal guidelines of prevention and investigation .VI. Protect residents from physical and psychosocial harm during investigations.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 04/20/24 at 02:25 p.m. The Administrator was notified. The Administrator was provided the IJ template on 04/20/24 at 2:29 p.m.<BR/>The Facility's Plan of Removal for Immediate Jeopardy was accepted on 04/21/24 at 10:37 a.m. and reflected the following: <BR/>Immediate action:<BR/>On 4/20/24 Resident #1 was immediately placed on 1 on 1 monitoring until the facility could transfer Resident #1 to psychiatric hospital, waiting on approval from the behavioral hospital to transport. <BR/>*Charge nurse/ nurse managers Immediately assessed Resident #2 & Resident #3 and the rest of the residents in the secure unit for possible mental or physical abuse, no additional mental health needs were identified, nor any suspected physical abuse found at this time. <BR/>oAdministrator/abuse coordinator Immediately in-serviced all staff 100% completion on Abuse & Neglect policy.<BR/>o on 4/20/24 the Director of Nursing, Inservice all 100% of staff on behavioral management policy which included resident to resident abuse regarding residents exhibiting aggressive behaviors towards others, and steps to do, and how to approach the situation.<BR/>On 4/21/24 the MDS nurse reviewed all residents who have had aggressive behaviors, to make sure interventions were in place, for the floor staff to be able to see in electronic health record (EHR).<BR/>The facility reviewed the system for abuse identification and reporting. The facility created a plan of improvement to assure residents were free from abuse to address changes including education, daily chart reviews and IDT discussions. The DON and/or Designee will review incident reports and progress notes 5 days weekly to assure that there were no incidents that could meet the qualifications of abuse and discuss any concerns with the abuse coordinator immediately. <BR/>Resident #1 was placed on one-on-one monitoring until her transfer to a behavioral on 04/20/24. <BR/>The charge nurses and the nurse managers reviewed all residents on the secure unit on 04/20/24 that were involved in incidents within the last 30 days to ensure all residents had the correct supervision. No additional mental or physical abuse was identified. <BR/>On 04/20/24 the Administrator completed in-service with all facility staff regarding the behavioral management policy which included resident to resident abuse, residents exhibiting aggressive behaviors, and steps to approach a resident-to-resident situation. <BR/>On 04/21/23 at 11:48 a.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>During interviews conducted on 04/20/24 from 03:30 p.m. though 06:00 p.m. and 04/21/24 from 08:15 a.m. 11:48 a.m. included LVN A 10 p.m. - 6 a.m., LVN C (6:00 a.m. to 2:00 p.m.), LVN D (6:00 a.m. -2:00 p.m.), LVN E (6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.), LVN F (10:00 p.m. to 6:00 a.m.), LVN G (10 p.m. to 10 p.m.), LVN H (2:00 p.m. to 10:00 p.m., LVN I (2:00 a.m. to 10 p.m.),RN j (weekend shifts), and LVN K (6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.), CNA B (10:00 p.m. to 6:00 a.m.), CNA L (6:00 a.m. to 2:00 p.m.), CNA O (6:00 a.m. to 2:00 p.m.), CNA P (2:00 p.m. to 10:00 p.m.), CNA Q (2:00 p.m. to 10:00 p.m.), CNA R (10:00 p.m. to 6:00 a.m.), and CNA S (6:00 a.m. to 2:00 p.m.), the Dietary Manager, Dietary Aide T, Dietary Aide U, Housekeeper V, Housekeeper W, MDS Nurse and 1 ADON who worked all shifts. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/or identified, such as immediately removing the alleged perpetrators from providing care to residents and separating residents. Staff were educated on facility posting related to reporting abuse were able to locate numbers for reporting and alternate methods of reporting abuse such as department supervisors and/ or charge nurses. <BR/>During an interview on 04/21/24 at 10:20. a.m., the Administrator and the DON indicated the facility 24 Hour Report and Incident Reports would be reviewed in the morning clinical meetings attended by the Administrator and the Director of Nursing to review for any allegations or instances of abuse and/ or neglect. The weekend manager on duty and weekend RN Supervisor would report any incidents or allegations to the DON and administrator immediately.<BR/>The Administrator was informed the IJ was removed on 04/21/24 at 12:39 a.m. The facility remained out of compliance at potential for more than minimal harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident drug regimen was free from unnecessary medications for 1 of 5 residents reviewed for unnecessary medications. (Resident #4)* The facility did not have appropriate diagnoses for Resident #4's Abilify (antipsychotic).* The facility did not have behavior monitoring for Resident#4's Lexapro (antidepressant).These failures could place residents at risk for unintended, harmful events attributed to the use of a medication without the appropriate monitoring or indication for use. Findings included: Record review of a face sheet dated 12/03/25 indicated Resident #4 was a [AGE] year-old male admitted on [DATE]. His diagnoses included paranoid schizophrenia (a mental disorder characterized variously by hallucinations, delusions, disorganized thinking and behavior, and flat or inappropriate affect with a strong belief that they are being persecuted, spied on, or conspired against by others), schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), psychosis (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality), hypertension (a condition in which the force of the blood against the artery walls is too high), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and cirrhosis of the liver (a condition in which healthy tissue is replaced with scar tissue). Record review of a psychiatric hospital Discharge summary dated [DATE] had no indication of a diagnosis of depression or major depressive disorder. Resident was seen at the hospital for because he was had not taken his medications for 16 years and had been having increased hallucinations and paranoia. He was having bad thoughts about hurting himself and people were messing with him. Record review of the admission MDS dated [DATE] indicated Resident #4 was cognitively intact with a BIMS of 13 out of 15 and he had diagnoses psychotic disorder and schizophrenia. The diagnosis of depression was not checked. Record review of physician orders for December 2025 indicated Resident #4 had the following orders:* Abilify (aripiprazole) 5mg daily for depression; and * Lexapro (escitalopram) 10mg daily for major depressive disorder.There was no indication of an order for behavior monitoring for the Lexapro (escitalopram) or diagnoses of depression or major depressive disorder. During an observation and interview on 12/01/25 at 10:48 a.m. Resident #4 was in his room. He awake and alert. He said he was doing just fine and had no issues at the facility. He said he had not been taking his medications for years for his paranoid schizophrenia or psychosis and was having issues with hearing people and wanting to hurt himself. He said the hospital put him back on medication and he was doing better now. During an interview on 12/03/25 at 01:10 p.m. LVN E said there was no behavior monitoring for Resident #4's Lexapro. She said they should monitor for behaviors to determine if the medication was working properly or if an increase/decrease in dosage was needed. She said she was not aware of Resident #4 not having a diagnosis of depression or major depressive disorder. She said if psychotropic medications do not have the monitoring then they would not know which behaviors to watch for and document. During an interview on 12/03/25 at 01:30 p.m. the DON said she did not realize behavior monitoring was not ordered for Resident #4's Lexapro. She said all psychotropic medications should have monitoring for behaviors and side effects. She said she thought he had a diagnosis of depression. She acknowledged the psychiatric hospital discharge with no diagnosis of depression. She said if a resident received a medication and the wrong diagnosis was associated with it the adverse effect could be a GDR on a medication for a psychiatric condition that should not have a GDR done resulting in increased behaviors, hallucinations, and different types of aggression. During an interview on 12/03/25 at 01:35 p.m. the Administrator said he expected staff to review all records that come from the hospital with a resident for diagnoses. Record review of an Antipsychotic Medication Use revised June 2022 indicated the following: Policy Statement: Antipsychotic/psychotropic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed.Policy Interpretation and Implementation:1. Residents will only receive antipsychotic/psychotropic medications when necessary to treat specific conditions for which they are indicated and effective.2. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 of 6 residents (Resident #4 and Resident #Unnamed) reviewed for abuse and neglect. <BR/>1. The facility failed to implement their written policies and procedures to prevent sexual abuse and potential further sexual abuse by Resident #1 when Resident #1 grabbed Resident #Unnamed's breast. <BR/>2. The facility failed to implement their written policies and procedures to prevent sexual abuse and potential further sexual abuse by Resident #1 when Resident #1 touched Resident #4's breast. <BR/>On 10/05/24 at 4:40 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/06/24, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of the Plan of Removal. <BR/>These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.<BR/>Findings include:<BR/>1. Record review of a face sheet dated 09/23/24 indicated Resident #1 was [AGE] years old, initially admitted to facility on 03/07/24 and readmitted to facility on 09/09/24. His diagnoses included dementia (loss of cognitive functioning), delusional disorder (a mental health condition that causes unshakable beliefs in something that's untrue), hypertension (condition in which the force of the blood against the artery walls is too high), dysphagia (difficulty swallowing) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). <BR/>Record review of Resident #1's care plan with revision dated 04/24/24 indicated Resident #1 had inappropriate sexual behaviors; resident seeks to satisfy his sexual desires. Interventions included to firmly approach resident that behaviors are not acceptable and document conversations and actions of resident; inform direct caregivers on methods to assist them in handling resident behaviors while providing care; monitor whereabouts of resident and keep distance from others; provide diversional activities and redirect when behaviors happen and document.<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #1 was usually able to make himself understood and usually understands others. He had a BIMS of 08 (moderately impaired cognitively). He exhibited no behaviors over the 7 days look back period. He required supervision or moderate assistance for most ADLS. He was frequently incontinent of bladder and bowel.<BR/>Record review of Resident #1's progress note authored by previous DON R indicated on 08/02/24 at 8:42 a.m., Resident #1 was in the dining room this morning grabbing other resident's breast when nurse tried to redirect him, he stated let me see your P---. Nurse informed him that this kind of behavior would not be accepted. Nurse phoned MD and made him aware of situation. Received one time order for lorazepam 1 milligram IM for agitation.<BR/>Record review of an unsigned 24-hour report indicated:<BR/>08/02/24 08:42 a.m. - Behavior Note<BR/>Resident #1 was in the dining room this morning grabbing other resident breasts. When SN tried to redirect him, he stated, Let me see your pussy. <BR/>SN informed him that this kind of behavior would not be accepted. SN phoned MD and made him aware of the situation. Received on time order for Lorazepam 1 mg IM for agitation. <BR/>08/02/24 10:21 a.m. - Social Services<BR/>SSD sent referral over to behavioral unit at local hospital per DON who said to refer Resident #1 due to behavior displayed. Spoke with rep who said that he would need to be transported to the ER to be assessed. SSD said she would speak to the ADON/DON on how to proceed. <BR/>08/02/24 11:29 a.m. - Behavior Note<BR/>Resident has been extremely inappropriate to staff and other residents sexually. Speaking graphically lewd and grabbing resident's breasts, then laughing and leering. Unable to redirect. DON notified. <BR/>08/02/24 12:32 a.m. - Nurses Note<BR/>Resident #1 sent to hospital ER for psych evaluation due to inappropriate sexual behavior. <BR/>Record Review of Resident #1's behavior monitoring log indicated on 08/02/24 Resident #1 was monitored hourly from 9:00 a.m. until 12:30 p.m.<BR/>Record review of Resident #1's progress note authored by LVN Q on 08/05/24 at 12:55 p.m., indicated the behavioral hospital called to inform facility that Resident #1 did not meet criteria for extended stay and the unit was full. Resident #1 would be transferred back to the facility (on 08/05/24). <BR/>Record review of Resident #1's behavior monitoring log did not indicate Resident #1 had any increased monitoring after discharge from behavioral hospital on [DATE].<BR/>During an observation and interview on 09/30/24 at 11:45 a.m., Resident #1 was sitting up in wheelchair in secure unit dining room. He said he did not recall the incident involving him inappropriately touching other residents that happened on 08/02/24. Resident #1 said that he knew that he was not supposed to touch or hit other residents or staff. Resident #1 was observed trying to stand up without assistance and staff intervened and redirect him by providing activities. Resident #1 was one of 6 residents in the dining room.<BR/>During an interview on 09/30/24 at 2:48 p.m., LVN Q said she was the CN on duty on 08/02/24 and vaguely recalled the incident with Resident #1 touching another female resident's breast. She said she recalled that the incident was in the dining room of the secure unit, and he touched the female's breast and was laughing and leering. He was unable to be redirected, and when removed from the area by staff he was talking sexually to staff and grabbing at their breast. She said that she notified the DON and MD. She said Resident #1 was monitored until he was transferred to a local hospital for evaluation for placement into their behavioral unit. She said she did not recall the female's name that he touched inappropriately. She said that she was in the unit covering for the CNA when the incident occurred, and it was not witnessed by other staff.<BR/>During an interview on 09/30/24 at 3:30 p.m., the previous DON R said she was the active DON at the facility on 08/02/24. She recalled the incident with Resident #1 touching another female resident's breast. She said she was called to the secure unit that morning after breakfast and the CN reported that Resident #1 had touched another female resident's breast and was laughing and leering and was unable to be redirected and when removed from the area by staff he was talking sexually to staff and grabbing at their breast. She said she told the CN to keep Resident #1 on one-on-one monitoring and that she requested the SW to contact a local behavioral hospital for a transfer due to the behavior. She said that she notified all department heads (including the Administrator) during the 9:00 am morning meeting that day. She said Resident #1 was monitored until he was transferred to a local hospital for evaluation for placement into their behavioral unit. She said she did not recall the female resident's name that Resident #1 touched inappropriately. <BR/>During an observation on 10/05/24 at 9:35 a.m., Resident #1 was in his wheelchair alone in the hallway of the secure unit. <BR/>During an observation and interview on 10/05/24 at 9:41 a.m., CNA E was in the dining room of the secure unit with 5 residents. She said she had never observed Resident #1 touch any residents or staff inappropriately. She said she was never told he needed to be monitored closely due to inappropriate sexual touching.<BR/>During an observation and interview on 10/05/24 at 9:44 a.m., CNA CC was in the dining room of the secure unit with 5 residents. She said Resident #1 always talked sexually to staff and he had said some vulgar things to her, but she was never told he had sexually/inappropriately touched another resident or to monitor him closely. <BR/>2. Record review of a face sheet dated 10/05/24 indicated Resident #4 [AGE] years old, initially admitted to the facility 03/13/24 and readmitted on [DATE]. Her diagnosis included dementia (loss of cognitive functioning), cognitive communication deficit (a difficulty with communication caused by disruption to cognition, or brain processes like attention, memory, and Problem solving), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #4 was usually understood and sometimes understands others. She had a BIMS of 08 (moderately impaired cognitively). She exhibited no behaviors over the 7 days look back period. She required moderate assistance for most ADLS. She was always incontinent of bladder and frequently incontinent of bowel.<BR/>Record review of a care plan last revised 07/19/24 for Resident #4 did not indicate she had been touched inappropriately on 08/25/24.<BR/>Record review of an incident report dated 08/25/24 at 7:45 a.m. and signed by RN U indicated CNA heard Resident #4 yell, let go of my titty. CNA saw Resident #1 grabbing Resident #4's breast and reported the incident to her. <BR/>Record review of an incident report dated 08/25/24 at 11:18 a.m. and signed by RN U indicated CNA reported to her that she saw Resident #1 touch a female resident on her breast. Residents were separated. Calls placed to notify ADON, NP, and RN T (previous Abuse Coordinator) and resident's FM UU. Resident #1 was on every 30-minute monitoring. <BR/>Record review of a behavior monitoring log indicated Resident #1 was monitored hourly from 08/25/24 at 8:00 a.m. to 08/27/24 at 10:00 p.m. There was no documentation of further monitoring. <BR/>Record review of a progress note dated 08/28/24 at 9:22 a.m. authored by previous MDS Coordinator DD indicated call placed to responsible party of Resident #1 to inform that resident has been having changes in behavior, both inappropriate sexual behaviors and aggressive behavior. Resident has been accepted to a behavioral hospital. <BR/>Record review of a Behavior Monitor Post an Incident in-service dated 8/28/24 indicated, Immediately after an incident involving resident with physical, verbal, or sexual aggression, the CN will place the resident on monitoring checks, and fill out the from q 1 hr, q 30 min, q 15 min. Call provider and supervisor to notify them of incident. They will continue monitoring checks until the IDT can review the incident and place further interventions. <BR/>During an interview on 09/25/24 at 10:21 a.m. RN T said she was made aware of the incident between Resident #1 and Resident #4. She said staff reported to her (the acting abuse coordinator) Resident #1 and Resident #4 were sitting at a dining table on the secure unit. Staff reported Resident #4 said Resident #1 grabbed her. Resident #1 denied he grabbed Resident #4's breast. She said both residents had low BIMS scores and there was no willful intent. <BR/>During an interview on 09/25/24 at 12:15 p.m., CNA BB said she was getting all the residents into the dining room for the breakfast meal. She said it looked like Resident #1 was touching Resident #4's breast and then he reached for the coloring book and crayons that was on the dining table. She said she told Resident #1 he did not need to be so close to the ladies and he moved away. She said she advised RN U of the incident. She said RN U called the abuse coordinator. She said Resident #4 did not say anything. She said Resident #1 said he did not touch Resident #4's breast. He said he was reaching for the crayons.<BR/>During an interview on 9/27/2024 at 4:00 pm, RN U said that on 8/25/2024 a CNA reported to her that Resident #1 touched a female resident on her breast. RN U said Resident #1 was separated from the female resident, assessed and behavioral monitoring initiated. RN U said she reported the incident to the ADON, NP/MD, AC (RN T) and RP. RN U said that Resident #1 was placed on behavioral monitoring for the incident until the AC (RN T) completed an abuse investigation. RN U said that there were 2 CNAs working the secure unit on 8/25/2024 to provide behavioral monitoring for Resident #1, but one-on-one monitoring was not initiated. She said Resident #1 was monitored q15 minutes. <BR/>During an observation and interview on 10/05/24 at 9:39 a.m., Resident #4 was sitting in her wheelchair in the dining room of the secure unit. She was appropriately dressed and well-groomed. She was unable to answer questions about the incident and just repeated words spoken to her. <BR/>During an interview on 10/05/24 at 3:55 p.m., the Administrator said that she was not the active Administrator/Abuse Coordinator at the time of the incidents with Resident #1 touching another female resident's breast on 08/02/24 or on 08/25/24 when Resident #1 touched Resident #4's breast. She said her expectation for incidents involving resident to resident abuse was for the residents to be separated and the aggressor to be placed on one-on-one monitoring for the protection of other residents. She said the facility policy on abuse and neglect addressed protecting residents from harm during the investigation of the incident and placing the resident on one-on-one monitoring. She said the facility abuse policy was not followed for the incidents involving Resident #1. She said the possible negative outcome of not performing one-on-one monitoring of the resident and protecting the other residents could be physical, emotional, or psychological harm of the residents. She said her expectation was care plans be updated when incidents occur, but the current MDS nurse worked remotely and might not have been aware of the incidents. <BR/>Record review of the undated facility's Abuse and Neglect policy indicated .It is the policy of the facility to administer care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. III. Prevention: Have procedures to: provide residents, families, and staff information on how and to whom they may report concerns, incidents and grievances without fear of retribution; and provide feedback regarding the concerns that have been expressed. Identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur. Establish a safe environment that supports consensual sexual relationship. Develop and implement policy on abuse, neglect, theft, exploitation, and misappropriation of property. Deployment of sufficient and trained staff to deal with behaviors in the units. Identification, assessment, care planning for intervention, and monitoring of residents with needs and behaviors that might lead to conflicts or neglect. The supervisions of staff to identify inappropriate behaviors .ensuring health and safety of residents .VI. Protect residents from physical and psychosocial harm during investigations. 1. If the allegation of abuse involves 2 or more residents, they will all be immediately separated for the protection of all residents involved and those potentially affected by the abuse. 2. Affected residents will be assessed for injury. 3. Attending physician will be notified. a. This includes but not limited to full assessment of physical and psychosocial well-being; sending resident to hospital if needed; depending on circumstance, keep resident on 1:1, assign a female/male depending on the accusation/allegation.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 10/05/24 at 4:40 p.m. The Administrator was notified. The Administrator was provided the IJ template on 10/05/24 at 4:45 p.m.<BR/>The Facility's Plan of Removal for Immediate Jeopardy was accepted on 10/06/24 at 1:50 p.m. and reflected the following: <BR/> Action: <BR/>On 10/05/24 R1 was immediately placed on q 15-minute checks for close monitoring for further behaviors. R1 will remain on q 15-minute checks until IDT team meets in 30 days and reevaluate his behaviors for medical adjustment and determine if R1 will remain on q 15-minute checks or can be discontinued. If Res #1 has additional behaviors, he will be placed one-on-one until psychiatric services can reevaluate his behaviors. Res #1 was placed on q 15 minutes checks due to the recurrent behaviors that require closer monitoring. <BR/>Charge nurse/nurse managers Immediately assessed R2 and the rest of the residents in the secure unit for possible mental, physical, or sexual abuse, no additional mental health needs were identified, nor any suspected physical abuse found at this time. 0 out of 10 residents were affected. <BR/>Administrator/abuse coordinator Immediately in-service all staff 100% completion on Abuse & Neglect policy. for types of abuse (physical, sexual, mental, verbal, neglect, exploitation, and misappropriation) through verbal in-service and written test. Staff were also reeducated for the identification, and intervention in a situation in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur. This education included protecting and/or removing the resident from the situation, as well as who the abuse coordinator is, when to report, and how to report abuse. Staff were reeducated to stay with the aggressor until further instruction from the abuse coordinator and/or until the evaluation or further intervention. <BR/>on 10/05/24 the Administrator, reeducated 100% of staff on behavioral management policy which included resident to resident abuse in regard to residents exhibiting sexual behaviors towards other and steps to do and approach the situation. Reeducation was provided for the staff with instructions for proper documentation for the behavior monitoring log through verbal in-service with monitoring log attached. Staff were reeducated through verbal in-servicing, tests, and questionnaires. <BR/>On 10/05/24 MDS nurse immediately reviewed and updated care plan to reflect sexually inappropriate behaviors. The MDS nurse will review all incident reports related to sexual behaviors to make sure interventions were in place, for the floor staff to be able to see in electronic health record (EHC). Administrator/and or designee will reeducate floor staff to review [NAME] in PCC (EHC) for updated interventions for each resident. <BR/>On 10/06/24 at 11:48 a.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>During interviews conducted on 10/06/24 from 11:05 a.m. though 3:48 p.m. included LVN EE 6:00 a.m. - 6:00 p.m. weekends, LVN FF (6:00 a.m. to 6:00 p.m.) weekends, LVN B (6:00 a.m. 2:00 p.m.), LVN GG (2:00 p.m. to 10:00 p.m.), LVN HH (10:00 p.m. to 6:00 a.m.), LVN X (10:00 p.m. to 6:00 a.m.), MA J (6:00 a.m. to 2:00 p.m & 2:00 p.m. to 10:00 p.m., CNA CC (6:00 a.m. to 2:00 p.m.), CNA E (6:00 a.m. to 2:00 p.m.), CNA JJ (6:00 a.m. to 2:00 p.m.), CNA KK (6:00 a.m. to 2:00 p.m.), CNA LL (6:00 a.m. to 2:00 p.m.), CNA D (2:00 p.m. to 10:00 p.m.), CNA MM (2:00 p.m. to 10:00 p.m.), CNA NN (10:00 p.m. to 6:00 a.m.), and CNA OO (10:00 p.m. to 6:00 a.m.), CNA PP (10:00 p.m. to 6:00 a.m.), Dietary Aide QQ, Housekeeper RR, Occupational Therapist SS, Staffing LVN TT and ADON who worked all shifts. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the Administrator and were able to give examples of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/or identified, such as immediately removing residents from the situation and stay with the aggressor one-on one until further instruction from the Abuse Coordinator. They verbalized proper documentation of behavior monitoring logs. CNA CC and CNA E said they were now aware of Resident #1's sexual behaviors and the resident was to be monitored q15 minutes. They said they documented every 15 minutes on Resident #1's behavior monitoring log. CNA CC and CNA E said they were in-serviced on abuse/neglect and gave examples of physical, verbal, and sexual abuse. They said the Administrator was the Abuse Coordinator and they would immediately report any abuse/neglect allegations to the Administrator. CNA CC and CNA E gave examples of immediate interventions they would take when an allegation or made incuding removing residents from the situation and staying with the aggressor one on one until the Administrator was notifed and gave further instruction. <BR/>During an interview on 10/06/24 at 3:55 p.m., the Administrator said she had conducted in-services with all staff addressing the facility abuse/neglect policy and initiating one-on-one monitoring with the aggressor until they were given further instructions on monitoring. She had addressed the different types of abuse and staff had passed a written test. She said she instructed staff on documentation in behavior monitoring logs. She in-serviced staff on the facility's behavioral management policy which included resident abuse. She said staff were required to pass behavioral management test. She said Resident #1's care plan had been updated and a q15 minute monitoring was required by staff until the IDT meeting in 30 days to re-evaluate his behaviors. <BR/>During an observation and interview on 10/06/24 at 1:15 p.m., Resident #1 was in the TV room with CNA E with no sexual behaviors noted. CNA E said she was assigned to monitor Resident #1 because he was being monitored q15 minutes for sexual behaviors and she was observed documenting the checks on his behavioral monitoring log. <BR/>Record review of behavioral monitoring logs for Resident #1 indicated he was being monitored by staff every 15 minutes beginning on 10/05/24 at 6:00 p.m. to monitor for sexually inappropriate behaviors. <BR/>Record review of a check off list of secured unit residents indicated all residents on the secure unit were assessed by charge nurses and the ADON. <BR/>Record review of nursing assessments completed by the ADON and charge nurses for Resident #4 and all other secure unit residents indicated all residents were assessed for physical and psychosocial changes on 10/05/24. There was no evidence of sexual abuse noted on the assessments.<BR/>Record review of Resident #1's care plan indicated it was updated on 10/05/24 and included he exhibiting unwanted sexual behaviors with interventions of referral to psychiatric services and increased monitoring for behaviors and changes in mental status. <BR/>Record review of Resident #4's care plan indicated it was updated on 10/05/24.<BR/>Record review of facility incident/accident reports indicated no other incidents of inappropriate sexual behaviors. <BR/>Record review of quiz results, dated 10/05/24 and 10/06/24, indicated all staff passed the quiz regarding abuse, neglect, reporting, and one-on-one monitoring.<BR/>Record review of a list of all facility staff used for tracking the required in-service training on abuse/neglect, behavioral monitoring, and behavioral management indicated all facility staff had received the in-service training in person or by phone. <BR/>The Administrator was informed the IJ was removed on 10/06/24 at 3:58 p.m. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 1 of 5 residents (Resident #2) reviewed for accuracy of assessments. The facility did not accurately complete the MDS assessment to indicate Resident #2's active diagnoses. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: Record review of Resident #2's face sheet dated 08/28/25 indicated he was a [AGE] year old male, admitted to the facility on [DATE], and his diagnoses included C1-C4 complete quadriplegia (paralysis that affects all four limbs), diabetes (high blood sugar), hyperlipemia (high levels of fats in the blood), chronic embolism and deep vein thrombosis of bilateral lower extremities (presence of a blood clot), neuromuscular dysfunction of bladder (problem with brain , nerves or spinal cord causes loss of bladder control), hypertension (high blood pressure), neurogenic bladder (condition affects bladder function due to nervous system problems), chronic kidney disease (gradual loss of kidney function), obesity (excessive fat), atherosclerotic heart disease with unstable angina (heart muscle does not receive enough oxygen due to narrowed or blocked arteries caused by plaque buildup), spinal stenosis of cervical region (narrowed space in the spine), complete lesion at C6 of spinal cord (total loss of motor control and function below level of injury), generalized muscle weakness lack of energy and strength, and major depressive disorder (persistent feeling of sadness or loss of interest). Record review of Resident #2's admission MDS dated [DATE] indicated he was able to make himself understood, was able to understand others, was cognitively intact (BIMS-15), used a wheelchair for mobility, and was dependent for most ADLS. The MDS did not include the active diagnoses of coronary artery disease, neurogenic bladder, quadriplegia, or depression. During an interview on 08/29/25 at 9:00 a.m., the DON said the accuracy of MDS was the responsibility of the Administrator. She said Resident #2's MDS dated [DATE] had her signature but she could not verify it was her electronic signature. She said if the MDS did not include the required information, it was probably missed. She said the MDS Coordinator was directly under the supervision of the administrator and the Administrator was supposed to review to ensure the MDS was initiated and competed as required. She said she was never informed that she should review the MDS for accuracy and completion. During an interview on 08/29/25 at 10:26 a.m., the Administrator said the Regional MDS Coordinator was supposed to review the MDS completed by the facility MDS Coordinator for accuracy and timeliness of completion. She said the facility did not have an MDS Coordinator as of 07/23/25. She said it was her expectation was the DON would ensure the MDS was completed as required. The Administrator said the facility did not have an MDS policy and they followed the RAI. She said residents were at risks of not receiving care and services and required if the MDS was not completed as required. During an interview on 08/29/25 at 10:50 a.m., the VPO said the facility did not have a current MDS Coordinator. He said the Regional MDS Coordinator was supposed to fill in and ensure the residents' MDS assessments were completed as required. He said the Regional MDS Coordinator was terminated and a new one was recently hired. He said the leadership of the facility (the Administrator and the DON) were supposed to ensure the MDS was completed on time and accurate. He said residents were at risks of not receiving care and services and required if the MDS was not completed as required. Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2024 indicated .SECTION I: ACTIVE DIAGNOSES Intent: The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status. 0100-I8000: Active Diagnoses in the Last 7 Days Item Rationale Health-related Quality of Life Disease processes can have a significant adverse effect on an individual's health status and quality of life. Planning for Care This section identifies active diseases and infections that drive the current plan of care. Check the following information sources in the medical record for the last 7 days to identify active diagnoses: transfer documents, physician progress notes, recent history and physical, recent discharge summaries, nursing assessments, nursing care plans, medication sheets, doctor's orders, consults and official diagnostic reports, and other sources as available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 12 residents (Resident #1) reviewed for comprehensive person-centered care plans.<BR/>The facility failed to develop and implement a care plan for Resident #1's aggressive behaviors toward others. <BR/>This failure could place residents at risk of not having individual needs met and a decreased quality of life. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 05/14/24 indicated he was [AGE] years old, admitted on [DATE], and his diagnoses included encephalopathy (brain dysfunction), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and cognitive communication deficit.<BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated he sometimes was able to make himself understood and understood others, and had severe cognitive impairment (BIMS score 00). His behaviors included physical behaviors directed at others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) that occurred 1 to 3 days (out of 7 day look back period)<BR/>Record review of Resident #1's electronic record indicated there was no care plan related to aggression towards others.<BR/>Record review of a progress note dated 05/12/24 at 10:23 p.m., completed by LVN L indicated she wheeled Resident #1 to his room for CNA R to provide care. CNA R reported Resident #1 initiated physical aggression and reached up and scratched CNA R's face. CNA N and CNA O entered Resident #1's room to complete Resident #1's care. <BR/>During an interview on 05/14/24 at 5:58 p.m., CNA R said she had been employed at the facility for 2 weeks and had worked at a secure unit as a CNA prior to this facility and had received training on abuse and self-defense tactics. She said that Resident #1 was never aggressive and she did not know what happened that day, but he was fighting all three of them, which included CNA N and CNA O, and her on 05/12/24. She said she was trying to get him dressed and he was so strong and grabbed her face and started scratching, punching, and kicking. She said she never hit him back and that she used the self-defense tactics of raising her arms like an x. She said he was fighting all three of them pretty hard and she did not see anyone ever hit him back. She said she was just trying to make sure he did not fall on the floor and resolve the situation. She said she had not worked with him since the incident and that she had observed his injuries. She said she did not know how he got those injuries other than he was fighting so hard and was not just fighting her that the other two girls were bigger than her. She said the administrator informed her that Resident #1 was never aggressive unless someone was mean to him and that it appeared she was getting the brunt of it. <BR/>During an interview on 05/22/24 at 12:30 p.m., CNA N said she overhead conversation on 05/12/24 when CNA R reported to LVN L that Resident #1 exhibited aggressive behaviors and had scratched CNA R on the face while she was trying to provide personal care. CNA N said she told CNA R and CNA O that she would try to assist with Resident #1 with care. CNA N said she and CNA O went back into Resident #1's room approximately 10 minutes after the incident of aggression with CNA R to assist resident with care. CNA N said she did not know what happened, but when she went to assist Resident #1, he started spitting and fighting. She said she and CNA O left the room, to allow Resident #1 to calm down. CNA N said Resident #1 had behaviors at times and they leave the room and try to go back later to assist him.<BR/>During an interview on 05/22/24 at 12:42 p.m., CNA O said she went to Resident #1's room to assist with care. She said CNA N and CNA R were already in the room. CNA O said she observed CNA N attempting to provide care to Resident #1, but Resident #1 was upset and was spitting at CNA N. CNA R was standing in room but not assisting with care because Resident #1 had already scratched her on the face. CNA O said Resident #1 was being aggressive spitting and slapping at CNA N. She left the room to notify LVN L of the incident and LVN L said she was aware of the incident and the behaviors. CNA O returned to Resident #1's room and notified CNA N and CNA R that LVN L was notified of Resident #1's behaviors.<BR/>During an interview on 05/22/24 at 2:08 p.m., LVN/MDS J said she was responsible for completing resident care plans. She said it was a mistake and she just missed completing a care plan related to Resident #1's aggression towards others.<BR/>During an interview on 05/22/24 at 1:14 p.m., the Administrator stated the DON and the MDS Coordinator were responsible for completing the care plans. The Administrator stated she expected them to include anything unusual or special for the resident's care. The Administrator stated it was important for Resident #1's aggressive behavior towards others to be included in the care plan so the staff could ensure the resident was receiving appropriate care. <BR/>During an interview on 05/22/24 at 2:45 p.m., LVN L said CNA R left Resident #1's room and reported Resident #1's aggressive behaviors and that he had scratched her face on 05/12/24. She said CNA N and CNA O went to complete Resident #1's care and he continued with his aggressive behaviors. She said the staff left his room to allow him to calm down. <BR/>Record review of the facility's Comprehensive Person-Centered Care plans policy dated 2001 (revised October 2018) indicated Policy Statement-A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 9 Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 preparation kitchen.<BR/>The facility did not ensure baking sheets and baking pans did not have dark colored build up on the outside and inside. <BR/>The facility did not ensure the foods labeled were disposed of after the use by date.<BR/>The facility did not ensure foods removed from their original package were labeled with the required information of what the food was in the container and the use by date or date it was placed in the container. <BR/>The facility did not ensure red bucket of sanitizing solution to clean surfaces in the kitchen had the right amount of cleaning solution.<BR/>These failures could place residents who ate food from the kitchen at risk of foodborne illness. <BR/>Findings included:<BR/>During observation and interview on 11/18/24 of the kitchen on initial tour indicated:<BR/>* at 08:22 a.m. there were <BR/>-4 large baking sheets with dark colored buildup on the inside corners and all along the outside edges; they were stacked together<BR/>-3 large baking pan with dark colored buildup on the inside corners and all along the outside edges; they were stacked together.<BR/>-1 baking pan 9 x 13 with dark colored buildup on the inside corners and all along the outside edges.<BR/>-2 large skillets dark colored buildup on the inside and outside.<BR/>-9 half baking sheets with dark colored buildup on the inside corners and all along the outside edges; they were stacked together.The DM said she had been trying to get them replaced meanwhile she would scrub them.<BR/>* at 08:30 a.m. the right walk-in cooler had a container of pureed food (it was hard to read what item was on the label) dated 11/09/24 and a container of what appeared to be fruit with no label. The DM said the food dated 08/09/24 should have been thrown out after 7 days and the other container should have a label with what was in the container and the date it was placed in the container.<BR/>* at 08:40 a.m. a red bucket of sanitizing solution to clean surfaces in the kitchen was checked and registered less than 50 ppm of chlorine indicating it had no solution. The DM noticed the chlorine solution container was not connected to the dispenser in the 3-compartment sink. The DM said the dispenser was used to fill up the red bucket and should be connected at all times.<BR/>Record review of an undated Food Receiving and Storage policy indicated the following: Policy Interpretation and Implementation: 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) <BR/>Record review of a Sanitation policy revised 2008 indicated the following: Policy Interpretation and Implementation: 4. Sanitizing of environmental surfaces must be performed with one of the following solutions: a. 50-100 ppm chlorine solution; <BR/>Record review of the 2022 Food Code dated 01/18/23 indicated the following:<BR/> 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers <BR/> 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils <BR/> (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. <BR/>(B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. <BR/>(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 residents (Resident #6) reviewed for infection control. <BR/>1. The facility failed to ensure Resident #6's central line (a tube that is inserted into a large vein in the neck, chest, groin, or arm to give fluids, blood, medications, or to do medical tests quickly) dressing was changed every seven days per the physician's order.<BR/>2. The facility failed to ensure the Treatment Nurse changed gloves and performed hand hygiene between glove changes during wound care, after picking up a packaged mint off the floor, and before and after entering and exiting Resident #6's room.<BR/>These failures could place residents at risk for infections.<BR/>Findings included:<BR/>1. Record review of the face sheet dated 7/1/24 indicated Resident #6 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including cellulitis (a common and potentially serious bacterial skin infection) of the left lower limb, hypertension (elevated blood pressure), diabetes, Charcot's joint syndrome (a rare complication of diabetes related neuropathy [nerve damage where feeling in the lower legs and feet are lost]. It can make injuries or infections much more serious).<BR/>Record review of the MDS dated [DATE] indicated Resident #6 admitted to the facility on [DATE]. The MDS indicated Resident #6 was usually understood by others and usually understood others. The MDS indicated Resident #6 had a BIMS of 08 and was moderately cognitively impaired. The MDS indicated Resident #6 required set-up assistance with eating and was dependent on staff for oral hygiene, showering/bathing, dressing, and transferring. <BR/>Record review of the physician orders dated 6/28/24 indicated Resident #6 had an order starting 6/7/24 to change the dressing to single lumen (one tubing and one cap end) PICC line to the left upper extremity every day shift every 7 days for IV (intravenous) management. <BR/>During an observation and interview on 6/28/24 at 11:47 a.m. Resident #6's PICC line dressing was dated 6/4/24. Resident #6 said the facility staff had not changed his PICC line dressing since he admitted to the facility. <BR/>During an interview on 7/1/24 at 11:23 am the Medical Director said he would expect a PICC line dressing to be changed every 7 days as ordered to prevent infection.<BR/>During an interview on 7/1/24 at 12:01 p.m. the Administrator said Resident #6 was the only resident at the facility with a PICC line. <BR/>During an interview on 7/2/24 at 10:04 a.m. LVN T said the treatment nurse, or a RN was responsible for changing PICC line dressings. LVN T said if she noticed a PICC line dressing had not been changed as ordered she would notify a supervisor. LVN T said PICC line dressing should be changed weekly. LVN T said she had only administered Resident #6's IV medication once or twice because it was due on the evening shift, and she normally worked day shift. LVN T said she had not assessed Resident #6's PICC line dressing. LVN T said the importance of ensuring PICC line dressings were changed weekly was to prevent bacteria from entering the site and to prevent dressing from rolling up. <BR/>2. During an observation on 6/28/24 at 1:22 p.m. the Treatment Nurse performed wound care to Resident #6's ankle. The Treatment Nurse wiped the bedside table with normal saline and did not put a barrier down between the bedside table and the wound care supplies. The Treatment Nurse cleansed the medial incision, lateral incision, and bottom of foot with same piece of gauze with normal saline on it. The Treatment Nurse removed her gloves, did not perform hand hygiene, and went to the treatment cart to retrieve a package of rolled gauze. The Treatment Nurse dropped a packaged mint on the floor, reached down to pick it up, did not perform hand hygiene, and then applied a new pair of gloves. The Treatment Nurse touched Resident #6's foot and incisions with her gloved hands to see if he could feel her touch. The Treatment Nurse went to the treatment cart to obtain a tube of ointment for Resident #6's wound without removing her gloves or performing hand hygiene. The Treatment Nurse returned to the room, applied ointment to the incisions with her gloved hand, removed her gloves, did not perform hand hygiene, and wrapped the foot/ankle with rolled gauze. <BR/>During an observation and interview on 06/29/24 at 11:50 a.m., the Treatment Nurse removed the kerlix wrap from Resident #6's left foot. The Treatment Nurse said Resident #6 was on isolation for MRSA (methicillin-resistant Staphylococcus aureus) of his surgery sites. The Treatment Nurse removed her gloves washed her hands applied new gloves and cleaned wounds with wound cleanser and 4 by 4 gauze for each site. The Treatment Nurse then applied clindamycin by using fingers on her gloved hand:<BR/>* applied clindamycin to the inside surgical wound using gloved the first finger applied directly to the wound. <BR/>*, applied clindamycin to the outside of the surgical wound using gloved the second finger applied directly to the wound; and<BR/>* applied clindamycin to the great left toe a necrotic area using gloved the ring finger applied directly to the wound. <BR/>The Treatment Nurse did not change her gloves or perform hand hygiene between treating areas on Resident #6's foot. The Treatment Nurse removed her gloves after she wrapped the left foot with kerlix wrap then walked out of the room down the hall approximately 7 feet to the hand sanitizer with her isolation gown on she wore while she performed wound care.<BR/>During an interview on 06/29/24 at 12:00 p.m., the Treatment Nurse said she should have removed her gown in the room and said she never told about changing gloves between areas. <BR/>During an interview on 7/1/24 at 11:23 a.m., the Medical Director said the Treatment Nurse cleaning Resident #6's wounds with the same gauze would not have spread the MRSA as it was systemic. The Medical Director said the treatment nurse not performing appropriate hand hygiene during wound care and leaving the room with gloved hands and without performing hand hygiene should be something staff were in-serviced regarding because the action could lead to the spread of infections.<BR/>During an interview on 7/2/24 at 12:36 p.m. DON JJ said an RN or trained LVN could change a PICC line dressing. DON JJ said the charge nurses were responsible for changing PICC line dressings. DON JJ said PICC line dressings should be changed weekly. DON JJ said the importance of ensuring PICC line dressings were changed weekly was for infection control. DON JJ said she expected staff to perform hand hygiene before entering a resident room, before patient care, during patient care when warranted, before leaving a resident room, and between glove changes. DON JJ said if a staff member picked an item up out of the floor, she expected them to perform hand hygiene afterwards. DON JJ said the importance of proper hand hygiene was infection control.<BR/>During an interview on 7/1/24 at 1:37 p.m. the Administrator said an RN was responsible for changing PICC line dressings. The Administrator said PICC line dressing changes were the responsibility of DON JJ or the weekend RN Supervisor. The Administrator said a PICC line dressing should be changed in accordance with the doctor's order. The Administrator said the importance of ensuring PICC line dressings were changed as ordered was infection control. The Administrator said she expected staff to perform hand hygiene when performing care for a resident, during different intervals of wound care including going from one wound site to another, and if they picked something up off the floor. The Administrator said the importance of proper hand hygiene was infection control. <BR/>Record review of the facility's undated Infections-Clinical Protocol policy indicated, During the initial assessment, the physician will help identify individuals who have had a recent infection or who are at risk for developing an infection .<BR/>Record review of the facility's undated Central Venous Catheter Dressing Changes policy indicated, The purpose of the procedure is to prevent catheter-related infections associated with contaminated, loosened, soiled, or wet dressings. Check the State's Nursing Practice Act for LPNs (Licensed Practical Nurse) regarding the scope of practice for changing a central venous catheter dressing. A physician's order is not needed for this procedure. Apply and maintain sterile dressing on intravenous access devices .Change dressings if any suspicion of contamination is suspected .Change transparent semi-permeable membrane (TSM) dressings at least every 5-7 days and PRN (when wet, soiled, or not intact) .<BR/>Record review of the facility's undated Handwashing/Hand Hygiene policy indicated, The facility considers hand hygiene the primary means to prevent the spread of infection .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water in the following situations .b. Before and after direct contact with residents; c. Before preparing or handling medications; c. Before performing a non-surgical invasive procedure .g. Before handling clean or soiled dressing, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care .k. After handling used dressings, contaminated equipment, etc.; l. after contact with objects in the immediate vicinity of the resident; m. After removing gloves; n. Before and after entering isolation precaution settings .9. The use of gloves does not replace hand washing/hand hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment for 1 of 2 Halls (Hall 200 long) and the dining room reviewed for physical environment.<BR/>The facility failed to maintain the 200 long hall. Door frames of resident's rooms were not intact. Floor tiles were discolored tiles. There was a buildup of glue, paint, and debris behind all the doors to resident's rooms.<BR/>The facility failed to maintain the exit corridor from the long hall 200 to the smoking area. There were 6 missing floor tiles that each measured 12 inch by 12 inch.<BR/>The facility failed to maintain the main dining room floor. The tile in the main dining room along the back wall on the floor had a 2-inch-wide buildup of old paint and dried glue. There was one missing tile near the door.<BR/>The facility failed to maintain an unlocked closet closet on the 200 long hall that was labeled oxygen on the door. The closet was empty and the walls were covered with black fuzzy substance in clusters on all walls and ceiling. The closet smelled like wet dirt. There was white substance in patches on the inside of the door. Spider webs with round sacs made of silk or web along both lower edge of the closet. <BR/>The facility failed to maintain room [ROOM NUMBER]. room [ROOM NUMBER] had 6-inch base trim detached from the wall and on the floor between the beds for approximately 5 feet.<BR/>The facility failed to maintain room [ROOM NUMBER]. room [ROOM NUMBER] had splashes of a beige substance measuring 2 feet by 3 feet on the ceiling and rips in the curtains covering the sliding door measuring 8 feet along the bottom of the curtains. <BR/>These failures could place residents, staff and visitors at risk of being in unsafe, uncomfortable environment and decreased quality of life due to poor conditions of the facility.<BR/>Findings included:<BR/>During observations on 11/18/24 from 9:00 a.m. to 10:30 a.m., the following was observed:<BR/>*The long hall 200 door frames of all resident rooms were missing paint and were not smooth the wood had missing pieces. The tile from the start of the hall to the end of the hall was discolored and had build-up of glue, paint. In the resident rooms had grime and debris behind all of the doors into the resident's rooms.<BR/>*The exit corridor from the long hall 200 to the smoking area was missing 6 tiles (12 inch by 12 inch tiles) and left the area with discolored concrete in the areas of missing tiles.<BR/>*The tile in the main dining room along the back wall on the floor had 2-inch-wide buildup of old paint and dried glue. There was one missing tile near the door and the floor was approximately 2 inches lower.<BR/>*There was an unlocked closet on the 200 long hall that was labeled oxygen on the door. The closet was empty and the walls were covered with black fuzzy substance in clusters on all walls and ceiling. The closet measured 3 feet by 5 feet and the closet smelled like wet dirt. There was white substance in patches on the inside of the door. There were spider webs with round sacs along both lower edges of the closet extended the full width of the closet. The inside of the door had white substance in patches/clusters covering the door.<BR/>During an observation on 11/20/24 at 11:00 a.m., room [ROOM NUMBER] had 6-inch base trim that was detached from the wall and on the floor between the beds for approximately 5 feet. room [ROOM NUMBER] had splashes of beige substance on the ceiling in an area of 2 feet by 3 feet. The curtains covering the sliding door were ripped and torn all along the bottom of the approximately 8 feet of the drapes.<BR/>During an interview on 11/18/24 at 10:45 a.m., the MD said he was responsible for the maintenance of the building. He said he never opened that closet and it would need to be painted and cleaned up. He said the closet should not be like that. He said the floors and door frames needed to be replaced and fixed and had not gotten to fix the other areas. <BR/>During an interview on 11/20/24 at 11:00 a.m., the Administrator said the floors needed to be replaced and door frames repaired. She said the base trim needed to be reattached in several resident rooms and would be repaired. She denied any documented plans for remodel or repairs. She said the facility had replaced the curtains in most of the rooms. She said in room [ROOM NUMBER], the curtains would be replaced again and raised so the resident's wheelchair would not roll on the drapes and tear them. She said all the staff were responsible for the facility being comfortable and in good repair. She said she was responsible for the facility.<BR/>Record review of an undated Maintenance Service policy indicated .Policy Interpretation and Implementation: 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents the right to be free from abuse for 2 of 7 residents (Residents #2 and #3) reviewed for abuse. <BR/>1. On 04/03/24 Resident #3 self-propelled her wheelchair into Resident #1's room and Resident #1 pulled Resident #3 out of her wheelchair onto the floor. <BR/>2. On 04/19/24 Resident #1 placed a pillow over the face of Resident #2 and later admitted she was trying to kill Resident #2.<BR/>On 04/20/24 at 02:29 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 04/21/24, the facility remained out of compliance at a severity level with the potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of thei Plan of Removal. <BR/>These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.<BR/>Findings included:<BR/>1. Record review of Resident #1's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included schizophrenia (a serious mental condition involving breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion), persistent mood [affective] disorder (marked disruptions in emotions {severe lows called depression or highs called hypomania or mania]), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations).<BR/>Record review of Resident #1's care plan, dated 10/25/23, indicated Resident #1 had a diagnosis of schizophrenia and was at risk for manic episodes and increased behaviors. Interventions included monitor for delusions and hallucinations and monitor for increased agitation, anger, verbal, and physical aggression and document in clinical record. Resident #1 was taking psychotropic medication and was at risk for adverse reactions and depression, anxiety, and/or psychosis driven behaviors. Interventions included monitor for anxiety driven behaviors and report any noted behaviors to MD for further orders.<BR/>Record review of Resident #1's care plan, dated 10/25/23, indicated Resident #1 was taking psychotropic medication and was at risk for adverse reactions and depression, anxiety, and/or psychosis driven behaviors. Interventions included monitor for anxiety driven behaviors and report any noted behaviors to MD for further orders.<BR/>Record review of Resident #1's quarterly MDS assessment, dated 04/08/24, indicated Resident #1 was able to make herself understood and usually understand others, and had moderate cognitive impairment indicated by a BIMS score of 11. She had had no hallucinations, delusions, or physical or verbal behaviors. She required partial to moderate assistance with most ADLs.<BR/>Record review of Resident #1's clinical file revealed there were no care plans available for review related to homicidal ideations.<BR/>Record review of the incident report dated 04/19/24 at 03:40 a.m., completed by LVN A indicated she was notified by CNA B that Resident #2 was yelling for help because Resident #1 (her roommate) had placed a pillow over Resident #2's face and held it over her face. Resident #2 came out of her room yelling for help. The residents were separated, and Resident #2 was assessed with no bruising on her face and no shortness of breath. Resident #1 admitted she did it and stated, Don't send me to jail please send me to a mental institution. Resident #2 was moved to another room for her protection and safety. MD was paged and LVN A was awaiting response. Administrator was notified. <BR/>2. Record review of Resident #2's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility 12/05/23. Resident #2 had diagnosis which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning) with agitation, major depressive disorder (a metal health disorder characterized by persistently depressed mood causing significant impairment in daily life), and schizophrenia.<BR/>Record review of Resident #2's care plan, dated 07/31/23 indicated Resident #2 had an altered thought process and was at risk for further decline and injury as evidenced by dementia and short- and long-term memory deficit. Interventions included keep resident and others safe and monitor for mental status changes. <BR/>Record review of Resident #2's quarterly MDS dated [DATE] indicated Resident #2 was able to make herself understood and understood others, and had severe cognitive impairment indicated by a BIMS score of 6. She had feelings of being down, depressed, and hopeless 2-6 (several) days and had no behaviors. <BR/>During a telephone interview on 04/20/24 at 08:40 a.m., the Administrator said she received a text from LVN A on 04/19/24 at approximately 06:00 a.m. when she woke up reporting Resident #1 had placed a pillow over Resident #2's face and Resident #1 was requesting to go to a mental institution. She said her immediate action had been to request an additional CNA for the secure unit from her corporate office and she had just received approval for the CNA this morning but had not hired a new CNA yet. The Administrator said the secure unit had one dedicated CNA and one nurse that floats between the other rooms and the secure unit. She said Resident #2 had been moved into another room on the secure unit. <BR/>During an observation and interview on 04/20/24 at 09:05 a.m., CNA L said she was assigned the secure unit today with LVN C who was floating between the secure unit and rooms outside the unit. CNA L was sitting in the TV room with 4 residents and said Residents #1 and #2 were in their rooms alone. <BR/>During an observation and interview on 04/20/24 at 09:10 a.m., Resident #1 was alone in her room on the secure unit and resting in bed. She said yesterday (04/19/24) her roommate (Resident #2) was trying to put spells on her, and she had to stop her. She said she tried to hurt Resident #2. <BR/>During an observation and interview on 04/20/24 at 09:15 a.m., Resident #2 was alone in her room on the secure unit lying in bed. She said she had to be moved to a new room because her previous roommate had put a pillow over her face and tried to kill her while she was sleeping. She said she felt as safe as she could in her present surroundings. <BR/>During an interview on 04/20/24 at 09:35 a.m., the DON said she was not at the facility on 04/19/24 because she had to work the night shift last night. She said was notified on 04/19/24 about Resident #1 putting a pillow over Resident #2's face, but she was now looking back on what was done after the incident. She said LVN A reported the incident, but there was no documentation in the clinical record about the incident or if LVN A notified the police, the physician, or the responsible party. She said notifications should have been made and she was doing the notifications to the MD and RP. She said based on the aggression Resident #1 should have been transferred to a behavioral hospital for evaluation. <BR/>During a telephone interview on 04/20/24 at 09:55 a.m., LVN A said on 04/19/24 at 03:30 a.m. she received a call from CNA B who reported Resident #1 had placed a pillow over Resident #2's face and tried to smother her. She said CNA B had separated the residents when she arrived on the secure unit. LVN A said she assessed Resident #2 and found no visible injuries, but she kept repeating she tried to kill me. She said Resident #1 admitted she tried to kill Resident #2. LVN A said she paged the MD twice and he did not call by the end of her shift. She said she reported the incident to her Administrator via text and LVN C who was the nurse working the 06:00 a.m. to 02:00 p.m. shift. <BR/>During an interview on 04/20/24 at 10:05 a.m., LVN C said he received report from LVN A on 04/19/24 at 06:00 a.m. about the incident between Resident #1 and Resident #2. He said LVN A reported to him she had paged the MD twice and not received a response. He said he did not try to notify the MD or Resident #1's RP about the incident on 04/19/24. He said he never noticed if Resident #1 ever came out of her room on his shift and he wasn't sure if Resident #2 was in or out of her room during the day. <BR/>During a telephone interview on 04/20/24 at 10:21 a.m. CNA B said on 04/19/24 at approximately 03:20 a.m. she was passing by the room Resident #1 and Resident #2 shared when Resident #2 ran out of the room saying Resident #1 put a pillow over her head and tried to kill her. Resident #1 said Resident #2 had been naked during the day and she tried to kill her. Resident #1 then said she wanted to go to a mental hospital in Dallas because that was where her brother sent her whenever she tried to hurt people. CNA B said she separated the residents by bringing Resident #2 into the TV room with her and called LVN A and reported the incident. CNA B said after the incident Resident #1 was pacing up and down the hall talking loudly but not making any sense. She said then Resident #1 went into her room and pulled the mattress off her bed and disrobed and continued pacing around her room. She said Resident #2 said she was afraid to be alone in her room, so CNA B kept Resident #2 with her the rest of the night except when assisting other residents and she took her to sit with LVN A.<BR/>During an interview on 04/20/24 at 10:51 a.m., the DON said she notified the NP of the incident that occurred on 04/19/24 to the NP and Resident #1's RP on 04/20/24 at approximately 10:00 a.m. She said she had completed the referral to the behavioral hospital for Resident #1 and was awaiting her transfer. She said the NP gave no new orders for Resident #2. <BR/>During an observation and interview on 04/20/24 at 11:19 a.m., Police Officer M visited Resident #2 in her room. Resident #2 remained alone in her room made a verbal statement to Police Officer M that Resident #1 had tried to kill her by placing a pillow over her face while she was sleeping. She said she wanted to press charges against Resident #1 so she wouldn't try to kill her again. <BR/>During an observation on 04/20/24 at 11:26 a.m., Resident #1 was sleeping alone in her room. <BR/>During an interview on 04/20/24 at 03:59 p.m., the DON said she sat with Resident #1 until she was transported by ambulance to a behavioral hospital at approximately 03:30 p.m.<BR/>3. Record review of Resident #3's face sheet dated 04/20/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included cerebral infarction (stroke), spastic hemiplegia (a common post-stroke condition that causes stiff or rigid muscles) affecting right dominant side, vascular dementia (dementia [a condition characterized by progressive or persistent loss of intellectual functioning] caused by an impaired supply of blood to the brain), mood disorder (marked disruptions in emotions [severe lows called depression or highs called hypomania or mania]), and depression <BR/>Record review of Resident #3's care plan revised on 06/21/23 indicated Resident #3 was deemed at risk for wandering related to being ambulatory with her wheelchair, diagnosis of dementia, and history of exit seeking. Goals included Resident #3 would be able to wander in a safe environment (secure unit) with no occurrence of injury and dignity would be maintained. <BR/>Record review of Resident #3's annual MDS dated [DATE] indicated Resident #3 was sometimes able to make herself understood and usually understood others, and had severe cognitive impairment indicated by a staff assessment. She had mood of little interest or pleasure in doing things several (2-6 days) and behaviors directed toward others 1 to 3 days and no wandering behaviors.<BR/>Record review of Resident #1's clinical note (related to the incident with Resident #3) dated 04/03/24 at 11:30 a.m. and signed by LVN N indicated a CNA B came and informed LVN N that Resident #1 pulled Resident #3 out of her wheelchair onto the floor of Resident #1's room. Resident #1 said I'm not a fucking babysitter, I need help my motherfucking self she needs to keep her ass out of my motherfucking room. On arrival to the secure unit residents were already separated and in different rooms. LVN N educated and redirected Resident #1, she was informed that physical aggression would not be tolerated, and it was not her right to put hands on anyone. LVN A indicated that Resident #1 did not verbalize understanding. <BR/>During an observation and interview on 04/20/24 at 09:05 a.m., Resident #3 was sitting in the TV room of the secure unit. She was unable to answer question about the incident. She was holding her right arm against her, and it appeared to have contractures at her elbow and wrist. Resident #3 said her arm was not painful. CNA L said Resident #3's arm was paralyzed from a stroke. CNA L said staff tried to keep Resident #3 busy because she wandered into other resident's rooms. She said she was not working the day Resident #3 wandered into Resident #1's room and Resident #1 pulled her out of her wheelchair to the floor, but it had been reported to her by another CNA.<BR/>During an interview on 04/20/24 at 09:35 a.m. the DON said the only reason Resident #1 had pulled Resident #3 out of her wheelchair on 04/03/24 was because she went into Resident #1's room. She said she had instructed all staff on the secure unit to keep Resident #3 from wandering into other resident's rooms. <BR/>During a telephone interview on 04/22/24 at 11:35 a.m., LVN N said on 04/03/24 at approximately 11:30 a.m., a CNA reported to her that Resident #3 had self-propelled her wheelchair into Resident #1's room and Resident #1 pulled her out of her wheelchair and onto the floor. LVN N said she assessed Resident #3 who was sitting in the floor of Resident #1's room at the foot of her bed. She had no visible injuries, and she was assisted back into her wheelchair and out of the room. Resident #3 was unable to say how she got onto the floor. LVN N said she notified the ADON, the Administrator, the MD, and the RP of the incident. <BR/>During a telephone interview on 04/22/24 at 12:16 p.m., Resident #3's RP said she was notified on 04/03/24 by the nurse that Resident #3 had wheeled herself into another resident's room and the other resident had pulled Resident #3 out of her wheelchair and onto the floor. She said Resident #3's right arm had paralysis since her stroke. She said Resident #3 had no bruising or pain after she was pulled from her wheelchair. RP said she visited Resident #3 every day and she had witnessed residents on the secure unit being aggressive to staff and other residents. RP said she could not name the Residents she had seen be aggressive, but she had seen Resident #1 yell and cuss at other residents. She said she had not told the Administration about resident aggression. <BR/>Record review of the facility's Abuse and Neglect Policy dated June 2023 indicated It is the policy of the facility to administer care and services in an environment that is free of any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment .The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal guidelines of prevention and investigation .VI. Protect residents from physical and psychosocial harm during investigations.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 04/20/24 at 02:25 p.m. The Administrator was notified. The Administrator was provided the IJ template on 04/20/24 at 2:29 p.m.<BR/>The Facility's Plan of Removal for Immediate Jeopardy was accepted on 04/21/24 at 10:37 a.m. and reflected the following: <BR/>Immediate action:<BR/>On 4/20/24 Resident #1 was immediately placed on 1 on 1 monitoring until the facility could transfer Resident #1 to psychiatric hospital, waiting on approval from the behavioral hospital to transport. <BR/>*Charge nurse/ nurse managers Immediately assessed Resident #2 & Resident #3 and the rest of the residents in the secure unit for possible mental or physical abuse, no additional mental health needs were identified, nor any suspected physical abuse found at this time. <BR/>oAdministrator/abuse coordinator Immediately in-serviced all staff 100% completion on Abuse & Neglect policy.<BR/>o on 4/20/24 the Director of Nursing, Inservice all 100% of staff on behavioral management policy which included resident to resident abuse regarding residents exhibiting aggressive behaviors towards others, and steps to do, and how to approach the situation.<BR/>On 4/21/24 the MDS nurse reviewed all residents who have had aggressive behaviors, to make sure interventions were in place, for the floor staff to be able to see in electronic health record (EHR).<BR/>The facility reviewed the system for abuse identification and reporting. The facility created a plan of improvement to assure residents were free from abuse to address changes including education, daily chart reviews and IDT discussions. The DON and/or Designee will review incident reports and progress notes 5 days weekly to assure that there were no incidents that could meet the qualifications of abuse and discuss any concerns with the abuse coordinator immediately. <BR/>Resident #1 was placed on one-on-one monitoring until her transfer to a behavioral on 04/20/24. <BR/>The charge nurses and the nurse managers reviewed all residents on the secure unit on 04/20/24 that were involved in incidents within the last 30 days to ensure all residents had the correct supervision. No additional mental or physical abuse was identified. <BR/>On 04/20/24 the Administrator completed in-service with all facility staff regarding the behavioral management policy which included resident to resident abuse, residents exhibiting aggressive behaviors, and steps to approach a resident-to-resident situation. <BR/>On 04/21/23 at 11:48 a.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>During interviews conducted on 04/20/24 from 03:30 p.m. though 06:00 p.m. and 04/21/24 from 08:15 a.m. 11:48 a.m. included LVN A 10 p.m. - 6 a.m., LVN C (6:00 a.m. to 2:00 p.m.), LVN D (6:00 a.m. -2:00 p.m.), LVN E (6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.), LVN F (10:00 p.m. to 6:00 a.m.), LVN G (10 p.m. to 10 p.m.), LVN H (2:00 p.m. to 10:00 p.m., LVN I (2:00 a.m. to 10 p.m.),RN j (weekend shifts), and LVN K (6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.), CNA B (10:00 p.m. to 6:00 a.m.), CNA L (6:00 a.m. to 2:00 p.m.), CNA O (6:00 a.m. to 2:00 p.m.), CNA P (2:00 p.m. to 10:00 p.m.), CNA Q (2:00 p.m. to 10:00 p.m.), CNA R (10:00 p.m. to 6:00 a.m.), and CNA S (6:00 a.m. to 2:00 p.m.), the Dietary Manager, Dietary Aide T, Dietary Aide U, Housekeeper V, Housekeeper W, MDS Nurse and 1 ADON who worked all shifts. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/or identified, such as immediately removing the alleged perpetrators from providing care to residents and separating residents. Staff were educated on facility posting related to reporting abuse were able to locate numbers for reporting and alternate methods of reporting abuse such as department supervisors and/ or charge nurses. <BR/>During an interview on 04/21/24 at 10:20. a.m., the Administrator and the DON indicated the facility 24 Hour Report and Incident Reports would be reviewed in the morning clinical meetings attended by the Administrator and the Director of Nursing to review for any allegations or instances of abuse and/ or neglect. The weekend manager on duty and weekend RN Supervisor would report any incidents or allegations to the DON and administrator immediately.<BR/>The Administrator was informed the IJ was removed on 04/21/24 at 12:39 a.m. The facility remained out of compliance at potential for more than minimal harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the Administrator and the State Survey Agency, for 8 of 11 residents reviewed for reporting allegations of abuse. (Residents #3, #4, #5, #6, #7, #8, #9, and #10)<BR/>* The facility did not report within 2 hours when Resident #3 reported Resident #4 had touched her breast inappropriately (sexual abuse).<BR/>* The facility did not report within 2 hours when Resident #5 kicked Resident #6 in the back (physical abuse).<BR/>* The facility did not report within 2 hours when Resident #7 hit Resident #8 and he hit her back (physical abuse).<BR/>* The facility did not report within 2 hours when Resident #9 swung at Resident #10 with her fist and Resident #5 hit back causing scratches (physical abuse). <BR/>This failure could place the residents at risk of abuse and neglect.<BR/>Findings included:<BR/>1. An email to HHSC Complaint and Incident Intake dated 04/13/23 at 11:13 AM indicated the name and title of the person making the initial report; [ADM] the date and time the person became aware of the reportable incident; 04/12/23 approximately 07:20 PM a detailed narrative of the incident; [Resident #3] approached nurse after coming out of [Resident #4] room saying I have to tell you something. [Resident #3] then went on to say that yesterday [Resident #4] touched me on my breast .<BR/>Record review of the Provider Investigation Form indicated the following:<BR/>* Date Reported to HHSC-04/13/23 <BR/>* Time: 11:13 AM<BR/>* Incident Category: Other<BR/>* If other, specify: Resident to Resident contact<BR/>* Incident Date: 04/12/23; and <BR/>* Time of Incident: 06:30 PM.<BR/>2. An email to HHSC Complaint and Incident Intake dated 04/19/23 at 07:53 PM indicated the name and title of the person making the initial report; [ADM] the date and time the person became aware of the reportable incident; 04/19/23 approximately 04:40 PM a detailed narrative of the incident; Resident #5 kicked another resident [Resident #6] in her back. This resident stated she kicked her because she was in her way <BR/>Record review of the Provider Investigation Form indicated the following:<BR/>* Date Reported to HHSC-04/19/23 <BR/>* Time: 07:53 PM<BR/>* Incident Category: Other<BR/>* If other, specify: Resident to Resident contact<BR/>* Incident Date: 04/19/23; and <BR/>* Time of Incident: 04:00 PM.<BR/>3. An email to HHSC Complaint and Incident Intake dated 04/19/23 at 08:23 PM indicated the name and title of the person making the initial report; [ADM] the date and time the person became aware of the reportable incident; 04/19/23 approximately 04:40 PM a detailed narrative of the incident; Resident #7 said Resident #8 hit him when he was trying to pass her in his wheelchair. He stated he hit her back.<BR/>Record review of the Provider Investigation Form indicated the following:<BR/>* Date Reported to HHSC-04/19/23 <BR/>* Time: 08:23 PM<BR/>* Incident Category: Other<BR/>* If other, specify: Resident to Resident contact<BR/>* Incident Date: 04/19/23; and <BR/>* Time of Incident: 04:00 PM.<BR/>4. An email to HHSC Complaint and Incident Intake dated 04/24/23 at 11:30 AM indicated Reporter's Name and Title: [ADM] Date/Time you first learned of incident: 04/24/23 approximately 08:55 AM Brief narrative summary of the reportable incident: Upon investigation Resident #9 went into Resident #10 room and pulled her covers off and then proceeded to take clothing items out of closet. [Resident #10] stated she got up out of bed asked [Resident #9] to leave her room and [Resident #9] swung at her fist and she was simply defending herself <BR/>Record review of the Provider Investigation Form indicated the following:<BR/>* Date Reported to HHSC-04/24/23 <BR/>* Time: 11:30 AM<BR/>* Incident Category: Other<BR/>* If other, specify: Resident to Resident contact<BR/>* Incident Date: 04/24/23; and <BR/>* Time of Incident: left blank.<BR/>During an interview on 06/12/23 at 01:35 PM the DON said she was the acting Abuse Coordinator (AC) since 05/27/23 when the ADM resigned. She said initial reports of self-reported incidents were done through email since October of last year. She said one resident inappropriately touching another resident's private areas was sexual abuse. She said one resident hitting, slapping, or punching another resident was physical abuse. She said 2 residents fighting was physical abuse. She said all allegations of abuse were to be reported to the SA within 2 hours. She said the incidents regarding Residents #5, #6, #7, #8, #9, and #10 were physical abuse. She said the incident regarding Residents #3 and #4 was sexual abuse. She said all of the incidents should have been reported within 2 hours. <BR/>The facility did not have a current ADM. The former ADM was not available for interview. An attempt was made to call but no return call.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the PASRR comprehensive service plan was implemented for 1 of 2 residents reviewed for PASRR assessments. (Closed Record #8) <BR/>The facility did not provide and arrange for specialized physical therapy, occupational therapy, and speech therapy services for Closed Record #8 as recommended and agreed upon by the IDT within the time frame set by PASRR.<BR/>This failure could place residents who are PASRR positive at risk of not receiving the necessary services that would enhance their quality of life. <BR/>Findings included:<BR/>Record review of a face sheet dated 10/22/24 indicated Closed Record #8 was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder, such as depression and bipolar disorder), cerebral palsy (a congenital disorder of movement, muscle tone, or posture due to abnormal brain development, often before birth), dysphagia (difficulty swallowing), and aphasia (a language disorder that affects a person's ability to understand and express written and spoken language). <BR/>Record review of a PASRR Comprehensive Service Plan (PCSP) dated 01/24/24 for Closed Record #8 indicated the IDT recommended and agreed on specialized occupational therapy, specialized physical therapy, and specialized speech therapy.<BR/>Record review of a care plan last revised 04/17/24 indicated Closed Record #8 was PASRR positive for intellectual disability. Goals included for Closed Record #8 to understand and participate in the treatment plan. <BR/>Record review of an MDS dated [DATE] indicated Closed Record #8 had severe cognitive impairment. He was considered by state level II PASRR process to have serious mental illness and intellectual disability. He had unclear speech and was usually understood and usually understood verbal communication. He required substantial or maximal assistance for most activities of daily living and used a wheelchair for mobility.<BR/>During an interview on 10/22/24 at 10:30 a.m., the Director of Rehabilitation said she submitted the occupational therapy, physical therapy, and speech therapy evaluations for Closed Record #8 to the previous MDS Nurse, but they were never authorized. She said he did not begin receiving therapy services through PASRR until 4/17/24 which was well after the time frame requirement from the PCSP and IDT meeting completed on 01/24/24. <BR/>During an interview on 10/23/24 at 4:05 p.m., the Regional Director of Reimbursement said PASRR requirements mandate that the facility complete an accurate request for NF specialized services recommended and agreed upon at the PCSP and IDT meeting into the online portal within 20 business days and therapy services started within 3 business days after receiving approval from HHSC in the online portal. She said CR #8 did not receive his therapy services through PASRR as agreed upon in the PCSP meeting completed on 01/24/24. She said Closed Record #8 was currently at a behavioral hospital and was expected to return to the facility. <BR/>During an interview on 10/23/24 at 4:15 p.m., the Administrator said she was not working at the facility during the time of Closed Record #8's PCSP and IDT meeting on 01/24/24. She said possible negative outcome of not meeting the PASRR timeframes for beginning recommended services could be residents not receiving services as approved through PASRR. <BR/>Record review of an undated facility policy titled PASRR indicated . If the Level II evaluation confirms an intellectual disability, mental disorder, or developmental disability diagnosis the facility collaborates with local resources when special services are required. If special services are required, the facility the facility will coordinate services per state policy and develop a care plan that addresses the specific needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents the right to be free from abuse for 2 of 7 residents (Residents #2 and #3) reviewed for abuse. <BR/>1. On 04/03/24 Resident #3 self-propelled her wheelchair into Resident #1's room and Resident #1 pulled Resident #3 out of her wheelchair onto the floor. <BR/>2. On 04/19/24 Resident #1 placed a pillow over the face of Resident #2 and later admitted she was trying to kill Resident #2.<BR/>On 04/20/24 at 02:29 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 04/21/24, the facility remained out of compliance at a severity level with the potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of thei Plan of Removal. <BR/>These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.<BR/>Findings included:<BR/>1. Record review of Resident #1's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included schizophrenia (a serious mental condition involving breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion), persistent mood [affective] disorder (marked disruptions in emotions {severe lows called depression or highs called hypomania or mania]), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations).<BR/>Record review of Resident #1's care plan, dated 10/25/23, indicated Resident #1 had a diagnosis of schizophrenia and was at risk for manic episodes and increased behaviors. Interventions included monitor for delusions and hallucinations and monitor for increased agitation, anger, verbal, and physical aggression and document in clinical record. Resident #1 was taking psychotropic medication and was at risk for adverse reactions and depression, anxiety, and/or psychosis driven behaviors. Interventions included monitor for anxiety driven behaviors and report any noted behaviors to MD for further orders.<BR/>Record review of Resident #1's care plan, dated 10/25/23, indicated Resident #1 was taking psychotropic medication and was at risk for adverse reactions and depression, anxiety, and/or psychosis driven behaviors. Interventions included monitor for anxiety driven behaviors and report any noted behaviors to MD for further orders.<BR/>Record review of Resident #1's quarterly MDS assessment, dated 04/08/24, indicated Resident #1 was able to make herself understood and usually understand others, and had moderate cognitive impairment indicated by a BIMS score of 11. She had had no hallucinations, delusions, or physical or verbal behaviors. She required partial to moderate assistance with most ADLs.<BR/>Record review of Resident #1's clinical file revealed there were no care plans available for review related to homicidal ideations.<BR/>Record review of the incident report dated 04/19/24 at 03:40 a.m., completed by LVN A indicated she was notified by CNA B that Resident #2 was yelling for help because Resident #1 (her roommate) had placed a pillow over Resident #2's face and held it over her face. Resident #2 came out of her room yelling for help. The residents were separated, and Resident #2 was assessed with no bruising on her face and no shortness of breath. Resident #1 admitted she did it and stated, Don't send me to jail please send me to a mental institution. Resident #2 was moved to another room for her protection and safety. MD was paged and LVN A was awaiting response. Administrator was notified. <BR/>2. Record review of Resident #2's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility 12/05/23. Resident #2 had diagnosis which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning) with agitation, major depressive disorder (a metal health disorder characterized by persistently depressed mood causing significant impairment in daily life), and schizophrenia.<BR/>Record review of Resident #2's care plan, dated 07/31/23 indicated Resident #2 had an altered thought process and was at risk for further decline and injury as evidenced by dementia and short- and long-term memory deficit. Interventions included keep resident and others safe and monitor for mental status changes. <BR/>Record review of Resident #2's quarterly MDS dated [DATE] indicated Resident #2 was able to make herself understood and understood others, and had severe cognitive impairment indicated by a BIMS score of 6. She had feelings of being down, depressed, and hopeless 2-6 (several) days and had no behaviors. <BR/>During a telephone interview on 04/20/24 at 08:40 a.m., the Administrator said she received a text from LVN A on 04/19/24 at approximately 06:00 a.m. when she woke up reporting Resident #1 had placed a pillow over Resident #2's face and Resident #1 was requesting to go to a mental institution. She said her immediate action had been to request an additional CNA for the secure unit from her corporate office and she had just received approval for the CNA this morning but had not hired a new CNA yet. The Administrator said the secure unit had one dedicated CNA and one nurse that floats between the other rooms and the secure unit. She said Resident #2 had been moved into another room on the secure unit. <BR/>During an observation and interview on 04/20/24 at 09:05 a.m., CNA L said she was assigned the secure unit today with LVN C who was floating between the secure unit and rooms outside the unit. CNA L was sitting in the TV room with 4 residents and said Residents #1 and #2 were in their rooms alone. <BR/>During an observation and interview on 04/20/24 at 09:10 a.m., Resident #1 was alone in her room on the secure unit and resting in bed. She said yesterday (04/19/24) her roommate (Resident #2) was trying to put spells on her, and she had to stop her. She said she tried to hurt Resident #2. <BR/>During an observation and interview on 04/20/24 at 09:15 a.m., Resident #2 was alone in her room on the secure unit lying in bed. She said she had to be moved to a new room because her previous roommate had put a pillow over her face and tried to kill her while she was sleeping. She said she felt as safe as she could in her present surroundings. <BR/>During an interview on 04/20/24 at 09:35 a.m., the DON said she was not at the facility on 04/19/24 because she had to work the night shift last night. She said was notified on 04/19/24 about Resident #1 putting a pillow over Resident #2's face, but she was now looking back on what was done after the incident. She said LVN A reported the incident, but there was no documentation in the clinical record about the incident or if LVN A notified the police, the physician, or the responsible party. She said notifications should have been made and she was doing the notifications to the MD and RP. She said based on the aggression Resident #1 should have been transferred to a behavioral hospital for evaluation. <BR/>During a telephone interview on 04/20/24 at 09:55 a.m., LVN A said on 04/19/24 at 03:30 a.m. she received a call from CNA B who reported Resident #1 had placed a pillow over Resident #2's face and tried to smother her. She said CNA B had separated the residents when she arrived on the secure unit. LVN A said she assessed Resident #2 and found no visible injuries, but she kept repeating she tried to kill me. She said Resident #1 admitted she tried to kill Resident #2. LVN A said she paged the MD twice and he did not call by the end of her shift. She said she reported the incident to her Administrator via text and LVN C who was the nurse working the 06:00 a.m. to 02:00 p.m. shift. <BR/>During an interview on 04/20/24 at 10:05 a.m., LVN C said he received report from LVN A on 04/19/24 at 06:00 a.m. about the incident between Resident #1 and Resident #2. He said LVN A reported to him she had paged the MD twice and not received a response. He said he did not try to notify the MD or Resident #1's RP about the incident on 04/19/24. He said he never noticed if Resident #1 ever came out of her room on his shift and he wasn't sure if Resident #2 was in or out of her room during the day. <BR/>During a telephone interview on 04/20/24 at 10:21 a.m. CNA B said on 04/19/24 at approximately 03:20 a.m. she was passing by the room Resident #1 and Resident #2 shared when Resident #2 ran out of the room saying Resident #1 put a pillow over her head and tried to kill her. Resident #1 said Resident #2 had been naked during the day and she tried to kill her. Resident #1 then said she wanted to go to a mental hospital in Dallas because that was where her brother sent her whenever she tried to hurt people. CNA B said she separated the residents by bringing Resident #2 into the TV room with her and called LVN A and reported the incident. CNA B said after the incident Resident #1 was pacing up and down the hall talking loudly but not making any sense. She said then Resident #1 went into her room and pulled the mattress off her bed and disrobed and continued pacing around her room. She said Resident #2 said she was afraid to be alone in her room, so CNA B kept Resident #2 with her the rest of the night except when assisting other residents and she took her to sit with LVN A.<BR/>During an interview on 04/20/24 at 10:51 a.m., the DON said she notified the NP of the incident that occurred on 04/19/24 to the NP and Resident #1's RP on 04/20/24 at approximately 10:00 a.m. She said she had completed the referral to the behavioral hospital for Resident #1 and was awaiting her transfer. She said the NP gave no new orders for Resident #2. <BR/>During an observation and interview on 04/20/24 at 11:19 a.m., Police Officer M visited Resident #2 in her room. Resident #2 remained alone in her room made a verbal statement to Police Officer M that Resident #1 had tried to kill her by placing a pillow over her face while she was sleeping. She said she wanted to press charges against Resident #1 so she wouldn't try to kill her again. <BR/>During an observation on 04/20/24 at 11:26 a.m., Resident #1 was sleeping alone in her room. <BR/>During an interview on 04/20/24 at 03:59 p.m., the DON said she sat with Resident #1 until she was transported by ambulance to a behavioral hospital at approximately 03:30 p.m.<BR/>3. Record review of Resident #3's face sheet dated 04/20/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included cerebral infarction (stroke), spastic hemiplegia (a common post-stroke condition that causes stiff or rigid muscles) affecting right dominant side, vascular dementia (dementia [a condition characterized by progressive or persistent loss of intellectual functioning] caused by an impaired supply of blood to the brain), mood disorder (marked disruptions in emotions [severe lows called depression or highs called hypomania or mania]), and depression <BR/>Record review of Resident #3's care plan revised on 06/21/23 indicated Resident #3 was deemed at risk for wandering related to being ambulatory with her wheelchair, diagnosis of dementia, and history of exit seeking. Goals included Resident #3 would be able to wander in a safe environment (secure unit) with no occurrence of injury and dignity would be maintained. <BR/>Record review of Resident #3's annual MDS dated [DATE] indicated Resident #3 was sometimes able to make herself understood and usually understood others, and had severe cognitive impairment indicated by a staff assessment. She had mood of little interest or pleasure in doing things several (2-6 days) and behaviors directed toward others 1 to 3 days and no wandering behaviors.<BR/>Record review of Resident #1's clinical note (related to the incident with Resident #3) dated 04/03/24 at 11:30 a.m. and signed by LVN N indicated a CNA B came and informed LVN N that Resident #1 pulled Resident #3 out of her wheelchair onto the floor of Resident #1's room. Resident #1 said I'm not a fucking babysitter, I need help my motherfucking self she needs to keep her ass out of my motherfucking room. On arrival to the secure unit residents were already separated and in different rooms. LVN N educated and redirected Resident #1, she was informed that physical aggression would not be tolerated, and it was not her right to put hands on anyone. LVN A indicated that Resident #1 did not verbalize understanding. <BR/>During an observation and interview on 04/20/24 at 09:05 a.m., Resident #3 was sitting in the TV room of the secure unit. She was unable to answer question about the incident. She was holding her right arm against her, and it appeared to have contractures at her elbow and wrist. Resident #3 said her arm was not painful. CNA L said Resident #3's arm was paralyzed from a stroke. CNA L said staff tried to keep Resident #3 busy because she wandered into other resident's rooms. She said she was not working the day Resident #3 wandered into Resident #1's room and Resident #1 pulled her out of her wheelchair to the floor, but it had been reported to her by another CNA.<BR/>During an interview on 04/20/24 at 09:35 a.m. the DON said the only reason Resident #1 had pulled Resident #3 out of her wheelchair on 04/03/24 was because she went into Resident #1's room. She said she had instructed all staff on the secure unit to keep Resident #3 from wandering into other resident's rooms. <BR/>During a telephone interview on 04/22/24 at 11:35 a.m., LVN N said on 04/03/24 at approximately 11:30 a.m., a CNA reported to her that Resident #3 had self-propelled her wheelchair into Resident #1's room and Resident #1 pulled her out of her wheelchair and onto the floor. LVN N said she assessed Resident #3 who was sitting in the floor of Resident #1's room at the foot of her bed. She had no visible injuries, and she was assisted back into her wheelchair and out of the room. Resident #3 was unable to say how she got onto the floor. LVN N said she notified the ADON, the Administrator, the MD, and the RP of the incident. <BR/>During a telephone interview on 04/22/24 at 12:16 p.m., Resident #3's RP said she was notified on 04/03/24 by the nurse that Resident #3 had wheeled herself into another resident's room and the other resident had pulled Resident #3 out of her wheelchair and onto the floor. She said Resident #3's right arm had paralysis since her stroke. She said Resident #3 had no bruising or pain after she was pulled from her wheelchair. RP said she visited Resident #3 every day and she had witnessed residents on the secure unit being aggressive to staff and other residents. RP said she could not name the Residents she had seen be aggressive, but she had seen Resident #1 yell and cuss at other residents. She said she had not told the Administration about resident aggression. <BR/>Record review of the facility's Abuse and Neglect Policy dated June 2023 indicated It is the policy of the facility to administer care and services in an environment that is free of any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment .The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal guidelines of prevention and investigation .VI. Protect residents from physical and psychosocial harm during investigations.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 04/20/24 at 02:25 p.m. The Administrator was notified. The Administrator was provided the IJ template on 04/20/24 at 2:29 p.m.<BR/>The Facility's Plan of Removal for Immediate Jeopardy was accepted on 04/21/24 at 10:37 a.m. and reflected the following: <BR/>Immediate action:<BR/>On 4/20/24 Resident #1 was immediately placed on 1 on 1 monitoring until the facility could transfer Resident #1 to psychiatric hospital, waiting on approval from the behavioral hospital to transport. <BR/>*Charge nurse/ nurse managers Immediately assessed Resident #2 & Resident #3 and the rest of the residents in the secure unit for possible mental or physical abuse, no additional mental health needs were identified, nor any suspected physical abuse found at this time. <BR/>oAdministrator/abuse coordinator Immediately in-serviced all staff 100% completion on Abuse & Neglect policy.<BR/>o on 4/20/24 the Director of Nursing, Inservice all 100% of staff on behavioral management policy which included resident to resident abuse regarding residents exhibiting aggressive behaviors towards others, and steps to do, and how to approach the situation.<BR/>On 4/21/24 the MDS nurse reviewed all residents who have had aggressive behaviors, to make sure interventions were in place, for the floor staff to be able to see in electronic health record (EHR).<BR/>The facility reviewed the system for abuse identification and reporting. The facility created a plan of improvement to assure residents were free from abuse to address changes including education, daily chart reviews and IDT discussions. The DON and/or Designee will review incident reports and progress notes 5 days weekly to assure that there were no incidents that could meet the qualifications of abuse and discuss any concerns with the abuse coordinator immediately. <BR/>Resident #1 was placed on one-on-one monitoring until her transfer to a behavioral on 04/20/24. <BR/>The charge nurses and the nurse managers reviewed all residents on the secure unit on 04/20/24 that were involved in incidents within the last 30 days to ensure all residents had the correct supervision. No additional mental or physical abuse was identified. <BR/>On 04/20/24 the Administrator completed in-service with all facility staff regarding the behavioral management policy which included resident to resident abuse, residents exhibiting aggressive behaviors, and steps to approach a resident-to-resident situation. <BR/>On 04/21/23 at 11:48 a.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>During interviews conducted on 04/20/24 from 03:30 p.m. though 06:00 p.m. and 04/21/24 from 08:15 a.m. 11:48 a.m. included LVN A 10 p.m. - 6 a.m., LVN C (6:00 a.m. to 2:00 p.m.), LVN D (6:00 a.m. -2:00 p.m.), LVN E (6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.), LVN F (10:00 p.m. to 6:00 a.m.), LVN G (10 p.m. to 10 p.m.), LVN H (2:00 p.m. to 10:00 p.m., LVN I (2:00 a.m. to 10 p.m.),RN j (weekend shifts), and LVN K (6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.), CNA B (10:00 p.m. to 6:00 a.m.), CNA L (6:00 a.m. to 2:00 p.m.), CNA O (6:00 a.m. to 2:00 p.m.), CNA P (2:00 p.m. to 10:00 p.m.), CNA Q (2:00 p.m. to 10:00 p.m.), CNA R (10:00 p.m. to 6:00 a.m.), and CNA S (6:00 a.m. to 2:00 p.m.), the Dietary Manager, Dietary Aide T, Dietary Aide U, Housekeeper V, Housekeeper W, MDS Nurse and 1 ADON who worked all shifts. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/or identified, such as immediately removing the alleged perpetrators from providing care to residents and separating residents. Staff were educated on facility posting related to reporting abuse were able to locate numbers for reporting and alternate methods of reporting abuse such as department supervisors and/ or charge nurses. <BR/>During an interview on 04/21/24 at 10:20. a.m., the Administrator and the DON indicated the facility 24 Hour Report and Incident Reports would be reviewed in the morning clinical meetings attended by the Administrator and the Director of Nursing to review for any allegations or instances of abuse and/ or neglect. The weekend manager on duty and weekend RN Supervisor would report any incidents or allegations to the DON and administrator immediately.<BR/>The Administrator was informed the IJ was removed on 04/21/24 at 12:39 a.m. The facility remained out of compliance at potential for more than minimal harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 of 6 residents (Resident #4 and Resident #Unnamed) reviewed for abuse and neglect. <BR/>1. The facility failed to implement their written policies and procedures to prevent sexual abuse and potential further sexual abuse by Resident #1 when Resident #1 grabbed Resident #Unnamed's breast. <BR/>2. The facility failed to implement their written policies and procedures to prevent sexual abuse and potential further sexual abuse by Resident #1 when Resident #1 touched Resident #4's breast. <BR/>On 10/05/24 at 4:40 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/06/24, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of the Plan of Removal. <BR/>These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.<BR/>Findings include:<BR/>1. Record review of a face sheet dated 09/23/24 indicated Resident #1 was [AGE] years old, initially admitted to facility on 03/07/24 and readmitted to facility on 09/09/24. His diagnoses included dementia (loss of cognitive functioning), delusional disorder (a mental health condition that causes unshakable beliefs in something that's untrue), hypertension (condition in which the force of the blood against the artery walls is too high), dysphagia (difficulty swallowing) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). <BR/>Record review of Resident #1's care plan with revision dated 04/24/24 indicated Resident #1 had inappropriate sexual behaviors; resident seeks to satisfy his sexual desires. Interventions included to firmly approach resident that behaviors are not acceptable and document conversations and actions of resident; inform direct caregivers on methods to assist them in handling resident behaviors while providing care; monitor whereabouts of resident and keep distance from others; provide diversional activities and redirect when behaviors happen and document.<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #1 was usually able to make himself understood and usually understands others. He had a BIMS of 08 (moderately impaired cognitively). He exhibited no behaviors over the 7 days look back period. He required supervision or moderate assistance for most ADLS. He was frequently incontinent of bladder and bowel.<BR/>Record review of Resident #1's progress note authored by previous DON R indicated on 08/02/24 at 8:42 a.m., Resident #1 was in the dining room this morning grabbing other resident's breast when nurse tried to redirect him, he stated let me see your P---. Nurse informed him that this kind of behavior would not be accepted. Nurse phoned MD and made him aware of situation. Received one time order for lorazepam 1 milligram IM for agitation.<BR/>Record review of an unsigned 24-hour report indicated:<BR/>08/02/24 08:42 a.m. - Behavior Note<BR/>Resident #1 was in the dining room this morning grabbing other resident breasts. When SN tried to redirect him, he stated, Let me see your pussy. <BR/>SN informed him that this kind of behavior would not be accepted. SN phoned MD and made him aware of the situation. Received on time order for Lorazepam 1 mg IM for agitation. <BR/>08/02/24 10:21 a.m. - Social Services<BR/>SSD sent referral over to behavioral unit at local hospital per DON who said to refer Resident #1 due to behavior displayed. Spoke with rep who said that he would need to be transported to the ER to be assessed. SSD said she would speak to the ADON/DON on how to proceed. <BR/>08/02/24 11:29 a.m. - Behavior Note<BR/>Resident has been extremely inappropriate to staff and other residents sexually. Speaking graphically lewd and grabbing resident's breasts, then laughing and leering. Unable to redirect. DON notified. <BR/>08/02/24 12:32 a.m. - Nurses Note<BR/>Resident #1 sent to hospital ER for psych evaluation due to inappropriate sexual behavior. <BR/>Record Review of Resident #1's behavior monitoring log indicated on 08/02/24 Resident #1 was monitored hourly from 9:00 a.m. until 12:30 p.m.<BR/>Record review of Resident #1's progress note authored by LVN Q on 08/05/24 at 12:55 p.m., indicated the behavioral hospital called to inform facility that Resident #1 did not meet criteria for extended stay and the unit was full. Resident #1 would be transferred back to the facility (on 08/05/24). <BR/>Record review of Resident #1's behavior monitoring log did not indicate Resident #1 had any increased monitoring after discharge from behavioral hospital on [DATE].<BR/>During an observation and interview on 09/30/24 at 11:45 a.m., Resident #1 was sitting up in wheelchair in secure unit dining room. He said he did not recall the incident involving him inappropriately touching other residents that happened on 08/02/24. Resident #1 said that he knew that he was not supposed to touch or hit other residents or staff. Resident #1 was observed trying to stand up without assistance and staff intervened and redirect him by providing activities. Resident #1 was one of 6 residents in the dining room.<BR/>During an interview on 09/30/24 at 2:48 p.m., LVN Q said she was the CN on duty on 08/02/24 and vaguely recalled the incident with Resident #1 touching another female resident's breast. She said she recalled that the incident was in the dining room of the secure unit, and he touched the female's breast and was laughing and leering. He was unable to be redirected, and when removed from the area by staff he was talking sexually to staff and grabbing at their breast. She said that she notified the DON and MD. She said Resident #1 was monitored until he was transferred to a local hospital for evaluation for placement into their behavioral unit. She said she did not recall the female's name that he touched inappropriately. She said that she was in the unit covering for the CNA when the incident occurred, and it was not witnessed by other staff.<BR/>During an interview on 09/30/24 at 3:30 p.m., the previous DON R said she was the active DON at the facility on 08/02/24. She recalled the incident with Resident #1 touching another female resident's breast. She said she was called to the secure unit that morning after breakfast and the CN reported that Resident #1 had touched another female resident's breast and was laughing and leering and was unable to be redirected and when removed from the area by staff he was talking sexually to staff and grabbing at their breast. She said she told the CN to keep Resident #1 on one-on-one monitoring and that she requested the SW to contact a local behavioral hospital for a transfer due to the behavior. She said that she notified all department heads (including the Administrator) during the 9:00 am morning meeting that day. She said Resident #1 was monitored until he was transferred to a local hospital for evaluation for placement into their behavioral unit. She said she did not recall the female resident's name that Resident #1 touched inappropriately. <BR/>During an observation on 10/05/24 at 9:35 a.m., Resident #1 was in his wheelchair alone in the hallway of the secure unit. <BR/>During an observation and interview on 10/05/24 at 9:41 a.m., CNA E was in the dining room of the secure unit with 5 residents. She said she had never observed Resident #1 touch any residents or staff inappropriately. She said she was never told he needed to be monitored closely due to inappropriate sexual touching.<BR/>During an observation and interview on 10/05/24 at 9:44 a.m., CNA CC was in the dining room of the secure unit with 5 residents. She said Resident #1 always talked sexually to staff and he had said some vulgar things to her, but she was never told he had sexually/inappropriately touched another resident or to monitor him closely. <BR/>2. Record review of a face sheet dated 10/05/24 indicated Resident #4 [AGE] years old, initially admitted to the facility 03/13/24 and readmitted on [DATE]. Her diagnosis included dementia (loss of cognitive functioning), cognitive communication deficit (a difficulty with communication caused by disruption to cognition, or brain processes like attention, memory, and Problem solving), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #4 was usually understood and sometimes understands others. She had a BIMS of 08 (moderately impaired cognitively). She exhibited no behaviors over the 7 days look back period. She required moderate assistance for most ADLS. She was always incontinent of bladder and frequently incontinent of bowel.<BR/>Record review of a care plan last revised 07/19/24 for Resident #4 did not indicate she had been touched inappropriately on 08/25/24.<BR/>Record review of an incident report dated 08/25/24 at 7:45 a.m. and signed by RN U indicated CNA heard Resident #4 yell, let go of my titty. CNA saw Resident #1 grabbing Resident #4's breast and reported the incident to her. <BR/>Record review of an incident report dated 08/25/24 at 11:18 a.m. and signed by RN U indicated CNA reported to her that she saw Resident #1 touch a female resident on her breast. Residents were separated. Calls placed to notify ADON, NP, and RN T (previous Abuse Coordinator) and resident's FM UU. Resident #1 was on every 30-minute monitoring. <BR/>Record review of a behavior monitoring log indicated Resident #1 was monitored hourly from 08/25/24 at 8:00 a.m. to 08/27/24 at 10:00 p.m. There was no documentation of further monitoring. <BR/>Record review of a progress note dated 08/28/24 at 9:22 a.m. authored by previous MDS Coordinator DD indicated call placed to responsible party of Resident #1 to inform that resident has been having changes in behavior, both inappropriate sexual behaviors and aggressive behavior. Resident has been accepted to a behavioral hospital. <BR/>Record review of a Behavior Monitor Post an Incident in-service dated 8/28/24 indicated, Immediately after an incident involving resident with physical, verbal, or sexual aggression, the CN will place the resident on monitoring checks, and fill out the from q 1 hr, q 30 min, q 15 min. Call provider and supervisor to notify them of incident. They will continue monitoring checks until the IDT can review the incident and place further interventions. <BR/>During an interview on 09/25/24 at 10:21 a.m. RN T said she was made aware of the incident between Resident #1 and Resident #4. She said staff reported to her (the acting abuse coordinator) Resident #1 and Resident #4 were sitting at a dining table on the secure unit. Staff reported Resident #4 said Resident #1 grabbed her. Resident #1 denied he grabbed Resident #4's breast. She said both residents had low BIMS scores and there was no willful intent. <BR/>During an interview on 09/25/24 at 12:15 p.m., CNA BB said she was getting all the residents into the dining room for the breakfast meal. She said it looked like Resident #1 was touching Resident #4's breast and then he reached for the coloring book and crayons that was on the dining table. She said she told Resident #1 he did not need to be so close to the ladies and he moved away. She said she advised RN U of the incident. She said RN U called the abuse coordinator. She said Resident #4 did not say anything. She said Resident #1 said he did not touch Resident #4's breast. He said he was reaching for the crayons.<BR/>During an interview on 9/27/2024 at 4:00 pm, RN U said that on 8/25/2024 a CNA reported to her that Resident #1 touched a female resident on her breast. RN U said Resident #1 was separated from the female resident, assessed and behavioral monitoring initiated. RN U said she reported the incident to the ADON, NP/MD, AC (RN T) and RP. RN U said that Resident #1 was placed on behavioral monitoring for the incident until the AC (RN T) completed an abuse investigation. RN U said that there were 2 CNAs working the secure unit on 8/25/2024 to provide behavioral monitoring for Resident #1, but one-on-one monitoring was not initiated. She said Resident #1 was monitored q15 minutes. <BR/>During an observation and interview on 10/05/24 at 9:39 a.m., Resident #4 was sitting in her wheelchair in the dining room of the secure unit. She was appropriately dressed and well-groomed. She was unable to answer questions about the incident and just repeated words spoken to her. <BR/>During an interview on 10/05/24 at 3:55 p.m., the Administrator said that she was not the active Administrator/Abuse Coordinator at the time of the incidents with Resident #1 touching another female resident's breast on 08/02/24 or on 08/25/24 when Resident #1 touched Resident #4's breast. She said her expectation for incidents involving resident to resident abuse was for the residents to be separated and the aggressor to be placed on one-on-one monitoring for the protection of other residents. She said the facility policy on abuse and neglect addressed protecting residents from harm during the investigation of the incident and placing the resident on one-on-one monitoring. She said the facility abuse policy was not followed for the incidents involving Resident #1. She said the possible negative outcome of not performing one-on-one monitoring of the resident and protecting the other residents could be physical, emotional, or psychological harm of the residents. She said her expectation was care plans be updated when incidents occur, but the current MDS nurse worked remotely and might not have been aware of the incidents. <BR/>Record review of the undated facility's Abuse and Neglect policy indicated .It is the policy of the facility to administer care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. III. Prevention: Have procedures to: provide residents, families, and staff information on how and to whom they may report concerns, incidents and grievances without fear of retribution; and provide feedback regarding the concerns that have been expressed. Identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur. Establish a safe environment that supports consensual sexual relationship. Develop and implement policy on abuse, neglect, theft, exploitation, and misappropriation of property. Deployment of sufficient and trained staff to deal with behaviors in the units. Identification, assessment, care planning for intervention, and monitoring of residents with needs and behaviors that might lead to conflicts or neglect. The supervisions of staff to identify inappropriate behaviors .ensuring health and safety of residents .VI. Protect residents from physical and psychosocial harm during investigations. 1. If the allegation of abuse involves 2 or more residents, they will all be immediately separated for the protection of all residents involved and those potentially affected by the abuse. 2. Affected residents will be assessed for injury. 3. Attending physician will be notified. a. This includes but not limited to full assessment of physical and psychosocial well-being; sending resident to hospital if needed; depending on circumstance, keep resident on 1:1, assign a female/male depending on the accusation/allegation.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 10/05/24 at 4:40 p.m. The Administrator was notified. The Administrator was provided the IJ template on 10/05/24 at 4:45 p.m.<BR/>The Facility's Plan of Removal for Immediate Jeopardy was accepted on 10/06/24 at 1:50 p.m. and reflected the following: <BR/> Action: <BR/>On 10/05/24 R1 was immediately placed on q 15-minute checks for close monitoring for further behaviors. R1 will remain on q 15-minute checks until IDT team meets in 30 days and reevaluate his behaviors for medical adjustment and determine if R1 will remain on q 15-minute checks or can be discontinued. If Res #1 has additional behaviors, he will be placed one-on-one until psychiatric services can reevaluate his behaviors. Res #1 was placed on q 15 minutes checks due to the recurrent behaviors that require closer monitoring. <BR/>Charge nurse/nurse managers Immediately assessed R2 and the rest of the residents in the secure unit for possible mental, physical, or sexual abuse, no additional mental health needs were identified, nor any suspected physical abuse found at this time. 0 out of 10 residents were affected. <BR/>Administrator/abuse coordinator Immediately in-service all staff 100% completion on Abuse & Neglect policy. for types of abuse (physical, sexual, mental, verbal, neglect, exploitation, and misappropriation) through verbal in-service and written test. Staff were also reeducated for the identification, and intervention in a situation in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur. This education included protecting and/or removing the resident from the situation, as well as who the abuse coordinator is, when to report, and how to report abuse. Staff were reeducated to stay with the aggressor until further instruction from the abuse coordinator and/or until the evaluation or further intervention. <BR/>on 10/05/24 the Administrator, reeducated 100% of staff on behavioral management policy which included resident to resident abuse in regard to residents exhibiting sexual behaviors towards other and steps to do and approach the situation. Reeducation was provided for the staff with instructions for proper documentation for the behavior monitoring log through verbal in-service with monitoring log attached. Staff were reeducated through verbal in-servicing, tests, and questionnaires. <BR/>On 10/05/24 MDS nurse immediately reviewed and updated care plan to reflect sexually inappropriate behaviors. The MDS nurse will review all incident reports related to sexual behaviors to make sure interventions were in place, for the floor staff to be able to see in electronic health record (EHC). Administrator/and or designee will reeducate floor staff to review [NAME] in PCC (EHC) for updated interventions for each resident. <BR/>On 10/06/24 at 11:48 a.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>During interviews conducted on 10/06/24 from 11:05 a.m. though 3:48 p.m. included LVN EE 6:00 a.m. - 6:00 p.m. weekends, LVN FF (6:00 a.m. to 6:00 p.m.) weekends, LVN B (6:00 a.m. 2:00 p.m.), LVN GG (2:00 p.m. to 10:00 p.m.), LVN HH (10:00 p.m. to 6:00 a.m.), LVN X (10:00 p.m. to 6:00 a.m.), MA J (6:00 a.m. to 2:00 p.m & 2:00 p.m. to 10:00 p.m., CNA CC (6:00 a.m. to 2:00 p.m.), CNA E (6:00 a.m. to 2:00 p.m.), CNA JJ (6:00 a.m. to 2:00 p.m.), CNA KK (6:00 a.m. to 2:00 p.m.), CNA LL (6:00 a.m. to 2:00 p.m.), CNA D (2:00 p.m. to 10:00 p.m.), CNA MM (2:00 p.m. to 10:00 p.m.), CNA NN (10:00 p.m. to 6:00 a.m.), and CNA OO (10:00 p.m. to 6:00 a.m.), CNA PP (10:00 p.m. to 6:00 a.m.), Dietary Aide QQ, Housekeeper RR, Occupational Therapist SS, Staffing LVN TT and ADON who worked all shifts. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the Administrator and were able to give examples of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/or identified, such as immediately removing residents from the situation and stay with the aggressor one-on one until further instruction from the Abuse Coordinator. They verbalized proper documentation of behavior monitoring logs. CNA CC and CNA E said they were now aware of Resident #1's sexual behaviors and the resident was to be monitored q15 minutes. They said they documented every 15 minutes on Resident #1's behavior monitoring log. CNA CC and CNA E said they were in-serviced on abuse/neglect and gave examples of physical, verbal, and sexual abuse. They said the Administrator was the Abuse Coordinator and they would immediately report any abuse/neglect allegations to the Administrator. CNA CC and CNA E gave examples of immediate interventions they would take when an allegation or made incuding removing residents from the situation and staying with the aggressor one on one until the Administrator was notifed and gave further instruction. <BR/>During an interview on 10/06/24 at 3:55 p.m., the Administrator said she had conducted in-services with all staff addressing the facility abuse/neglect policy and initiating one-on-one monitoring with the aggressor until they were given further instructions on monitoring. She had addressed the different types of abuse and staff had passed a written test. She said she instructed staff on documentation in behavior monitoring logs. She in-serviced staff on the facility's behavioral management policy which included resident abuse. She said staff were required to pass behavioral management test. She said Resident #1's care plan had been updated and a q15 minute monitoring was required by staff until the IDT meeting in 30 days to re-evaluate his behaviors. <BR/>During an observation and interview on 10/06/24 at 1:15 p.m., Resident #1 was in the TV room with CNA E with no sexual behaviors noted. CNA E said she was assigned to monitor Resident #1 because he was being monitored q15 minutes for sexual behaviors and she was observed documenting the checks on his behavioral monitoring log. <BR/>Record review of behavioral monitoring logs for Resident #1 indicated he was being monitored by staff every 15 minutes beginning on 10/05/24 at 6:00 p.m. to monitor for sexually inappropriate behaviors. <BR/>Record review of a check off list of secured unit residents indicated all residents on the secure unit were assessed by charge nurses and the ADON. <BR/>Record review of nursing assessments completed by the ADON and charge nurses for Resident #4 and all other secure unit residents indicated all residents were assessed for physical and psychosocial changes on 10/05/24. There was no evidence of sexual abuse noted on the assessments.<BR/>Record review of Resident #1's care plan indicated it was updated on 10/05/24 and included he exhibiting unwanted sexual behaviors with interventions of referral to psychiatric services and increased monitoring for behaviors and changes in mental status. <BR/>Record review of Resident #4's care plan indicated it was updated on 10/05/24.<BR/>Record review of facility incident/accident reports indicated no other incidents of inappropriate sexual behaviors. <BR/>Record review of quiz results, dated 10/05/24 and 10/06/24, indicated all staff passed the quiz regarding abuse, neglect, reporting, and one-on-one monitoring.<BR/>Record review of a list of all facility staff used for tracking the required in-service training on abuse/neglect, behavioral monitoring, and behavioral management indicated all facility staff had received the in-service training in person or by phone. <BR/>The Administrator was informed the IJ was removed on 10/06/24 at 3:58 p.m. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the Administrator and the State Survey Agency, for 8 of 11 residents reviewed for reporting allegations of abuse. (Residents #3, #4, #5, #6, #7, #8, #9, and #10)<BR/>* The facility did not report within 2 hours when Resident #3 reported Resident #4 had touched her breast inappropriately (sexual abuse).<BR/>* The facility did not report within 2 hours when Resident #5 kicked Resident #6 in the back (physical abuse).<BR/>* The facility did not report within 2 hours when Resident #7 hit Resident #8 and he hit her back (physical abuse).<BR/>* The facility did not report within 2 hours when Resident #9 swung at Resident #10 with her fist and Resident #5 hit back causing scratches (physical abuse). <BR/>This failure could place the residents at risk of abuse and neglect.<BR/>Findings included:<BR/>1. An email to HHSC Complaint and Incident Intake dated 04/13/23 at 11:13 AM indicated the name and title of the person making the initial report; [ADM] the date and time the person became aware of the reportable incident; 04/12/23 approximately 07:20 PM a detailed narrative of the incident; [Resident #3] approached nurse after coming out of [Resident #4] room saying I have to tell you something. [Resident #3] then went on to say that yesterday [Resident #4] touched me on my breast .<BR/>Record review of the Provider Investigation Form indicated the following:<BR/>* Date Reported to HHSC-04/13/23 <BR/>* Time: 11:13 AM<BR/>* Incident Category: Other<BR/>* If other, specify: Resident to Resident contact<BR/>* Incident Date: 04/12/23; and <BR/>* Time of Incident: 06:30 PM.<BR/>2. An email to HHSC Complaint and Incident Intake dated 04/19/23 at 07:53 PM indicated the name and title of the person making the initial report; [ADM] the date and time the person became aware of the reportable incident; 04/19/23 approximately 04:40 PM a detailed narrative of the incident; Resident #5 kicked another resident [Resident #6] in her back. This resident stated she kicked her because she was in her way <BR/>Record review of the Provider Investigation Form indicated the following:<BR/>* Date Reported to HHSC-04/19/23 <BR/>* Time: 07:53 PM<BR/>* Incident Category: Other<BR/>* If other, specify: Resident to Resident contact<BR/>* Incident Date: 04/19/23; and <BR/>* Time of Incident: 04:00 PM.<BR/>3. An email to HHSC Complaint and Incident Intake dated 04/19/23 at 08:23 PM indicated the name and title of the person making the initial report; [ADM] the date and time the person became aware of the reportable incident; 04/19/23 approximately 04:40 PM a detailed narrative of the incident; Resident #7 said Resident #8 hit him when he was trying to pass her in his wheelchair. He stated he hit her back.<BR/>Record review of the Provider Investigation Form indicated the following:<BR/>* Date Reported to HHSC-04/19/23 <BR/>* Time: 08:23 PM<BR/>* Incident Category: Other<BR/>* If other, specify: Resident to Resident contact<BR/>* Incident Date: 04/19/23; and <BR/>* Time of Incident: 04:00 PM.<BR/>4. An email to HHSC Complaint and Incident Intake dated 04/24/23 at 11:30 AM indicated Reporter's Name and Title: [ADM] Date/Time you first learned of incident: 04/24/23 approximately 08:55 AM Brief narrative summary of the reportable incident: Upon investigation Resident #9 went into Resident #10 room and pulled her covers off and then proceeded to take clothing items out of closet. [Resident #10] stated she got up out of bed asked [Resident #9] to leave her room and [Resident #9] swung at her fist and she was simply defending herself <BR/>Record review of the Provider Investigation Form indicated the following:<BR/>* Date Reported to HHSC-04/24/23 <BR/>* Time: 11:30 AM<BR/>* Incident Category: Other<BR/>* If other, specify: Resident to Resident contact<BR/>* Incident Date: 04/24/23; and <BR/>* Time of Incident: left blank.<BR/>During an interview on 06/12/23 at 01:35 PM the DON said she was the acting Abuse Coordinator (AC) since 05/27/23 when the ADM resigned. She said initial reports of self-reported incidents were done through email since October of last year. She said one resident inappropriately touching another resident's private areas was sexual abuse. She said one resident hitting, slapping, or punching another resident was physical abuse. She said 2 residents fighting was physical abuse. She said all allegations of abuse were to be reported to the SA within 2 hours. She said the incidents regarding Residents #5, #6, #7, #8, #9, and #10 were physical abuse. She said the incident regarding Residents #3 and #4 was sexual abuse. She said all of the incidents should have been reported within 2 hours. <BR/>The facility did not have a current ADM. The former ADM was not available for interview. An attempt was made to call but no return call.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record, and indicate the duration for the PRN order for 3 of 3 residents (Resident #s 1, 2, and 3) reviewed for pharmacy services.<BR/>1. The facility failed to ensure Residents #1, #2, and #3 had a stop date for PRN anti-anxiety and antipsychotic medications.<BR/>2. The facility failed to monitor Resident #1's behaviors for his prescribed Ativan during the months of August and [DATE].<BR/>These failures could place residents at risk of receiving unnecessary psychotropic medications and of not receiving the intended therapeutic benefits of their psychotropic medications. <BR/>The findings included:<BR/>Record review of a face sheet dated 09/23/24 indicated Resident #1 was [AGE] years old, initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. His diagnoses included dementia (loss of cognitive functioning), delusional disorder (a mental health condition that causes unshakable beliefs in something that's untrue), hypertension (condition in which the force of the blood against the artery walls is too high), dysphagia (difficulty swallowing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). <BR/>Record review of Resident #1's quarterly MDS dated [DATE] indicated he was usually understood and usually understood others and he had moderate cognitive impairment (BIMS score of 8). The MDS Antipsychotic Medication Review was incorrectly completed and indicated no antipsychotic medications received.<BR/>Record review of Resident #1's care plan dated 03/27/24 (revised 05/17/24) indicated Resident #1 was taking psychotropic medications and was at risk for adverse reactions and acute episodes of disease process (depression anxiety, delusional disorder, and/or psychosis driven) related to behaviors. Interventions included check for adverse reactions and check for effectiveness of psychotropic medication.<BR/>Record review of Resident #1's care plan dated 03/27/24 indicated Resident #1 had a potential for medication interaction/side effects related to receiving 9+ medications. Interventions included monthly pharmacy review.<BR/>Record review of Resident #1's physician orders dated 08/11/24 indicated Ativan oral tablet 1 mg give 1 tablet every 8 hours as need for anxiety.<BR/>Record review of Resident #1's physician orders dated 08/27/24 indicated Ativan Injection Solution 2 MG/ML inject 2 mg intramuscularly every 12 hours as needed for agitation.<BR/>Record review of Resident #1's physician orders dated 08/24/24 indicated monitor for the following behaviors: itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression and refusing care. Document 'Y' if monitored an any of the following occurred. 'N if monitored and any of the above were not observed, select chart codeother/See Nurses Notes and progress note findings.<BR/>Record review of Resident #1's MAR dated 08/2024 indicated he received Ativan injection 2 mg every 12 hours as needed for agitation on 08/27/24. <BR/>Record review of Resident #1's MAR dated 08/2024 i indicated he received Ativan oral tablet 1 mg every 8 hours as needed 8 instances between 08/13/24 and 08/28/24. <BR/>Record review of Resident #1's MAR dated 09/2024 in indicated he received Ativan injection 2 mg every 12 hours as needed for agitation on 09/18/24. <BR/>Record review of Resident #1's narcotic control count sheets dated 09/24/24 indicated: <BR/>Ativan injection 2 mg every 12 hours as needed on 09/13/24, 09/17/24, 09/18/24, and 09/19/24. <BR/>Record review of Resident #1's MAR dated 08/2024 indicated he received Ativan oral tablet 1 mg every 8 hours as needed 20 instances between 09/09/24 and 09/20/24. <BR/>Record review of Resident #1's pharmacy review dated 08/14/24 and completed by Pharmacist M indicated Ativan 1 mg every 8 hours prn from order date of August 11, 2024. Per CMS guidelines this med is not indicated prn past 14 days. Please dc this med or offer a benefit risk as to why this med is to continue prn. MD N signed (did not date) and indicated defer all psych meds to psychiatry team, please send this form to psychiatry team.<BR/>Record review of Resident #1's electronic record and consent forms indicated there was no consent forms for Ativan.<BR/>Record review of Resident #2's face sheet dated 09/30/24 indicated he was a [AGE] year-old male admitted on [DATE], and his diagnoses included schizoaffective disorder (chronic mental illness) and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). <BR/>Record review of Resident #2's quarterly assessment MDS dated [DATE] indicated he rarely made himself understood, usually understood others, and had severe cognitive impairment (BIMS score of 2). His signs and symptoms of delirium included inattention and disorganized thinking. He received antipsychotic medications on a routine basis. The MDS did not include PRN antipsychotic medication use. <BR/>Record review of Resident #2's care plan 07/07/23 (revised 07/23/23) indicated Resident #2 had the potential to be physically aggressive related to dementia. Interventions included administer medications as ordered. Monitor/document for side effects and effectiveness. <BR/>Record review of Resident #2's care plan dated 04/13/23 indicated Resident #2 had diagnoses of impaired thought process related to dementia. Interventions included administer medications as ordered. Monitor/document for side effect and effectiveness. <BR/>Record review of Resident #2's physician orders dated 08/09/24 indicated Ativan 2/MG/ML inject 1 ml intramuscularly every 6 hours as needed for agitation related to dementia.<BR/>Record review of Resident #2's MAR dated 08/2024 indicated he received Lorazepam IM injection 1 ml intramuscularly every 6 hours as needed on 08/09/24 and twice on 08/28/24.<BR/>Record review of the narcotic count sheet indicated Resident #2 received 1 IM at 9:00 a.m. and 1 IM at 6:30 p.m. on 08/28/24.<BR/>Record review of monthy pharmacy reviews indicated there was no pharmacy recommendation review completed for Resident #2's prn IM Ativan (the last pharmacy review in the facility was 08/16/24). <BR/>Record review of Resident #3's face sheet dated 09/30/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anxiety (feelings of fear, dread, uneasiness), major depressive disorder (a persistently low or depressed mood and a loss of interest in activities), and unspecified psychosis (collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not).<BR/>Record review of Resident #3's significant change MDS dated [DATE] indicated she was usually able to make herself understood, understood others, had severe cognitive impairment (BIMS score of 00), signs of delirium included inattention and disorganized thinking. She had physical and verbal behaviors directed at others that occurred 1 to 3 days. She had behavioral symptoms not directed at others that occurred 1 to 3 days. The MDS Antipsychotic Medication Review was incorrectly completed and indicated no antipsychotic medications received.<BR/>Record review of Resident #3's care plan dated 07/07/23 (revised 07/23/23) indicated Resident #3 exhibited signs and symptoms of anxiety. Interventions included medications as ordered.<BR/>Record review of Resident #3's physician orders dated 07/15/24 (discontinued 09/27/24) indicated Lorazepam Oral Tablet 1 MG give 1 tablet by mouth every 8 hours as needed.<BR/>Record review of Resident #3's physician orders dated 09/29/24 indicated Lorazepam oral concentrate 1 mg/.05 ml give 0.5 ml by mouth every 4 hours for anxiety.<BR/>Record review of Resident #3's MAR dated 08/2024 indicated she received 1 mg oral Lorazepam every 8 hours as needed for agitation/anxiety for 24 instances from 08/01/24 through 08/29/24.<BR/>Record review of Resident #3's MAR dated 09/2024 indicated she received 1 mg oral Lorazepam every 8 hours as needed for agitation/anxiety for 8 instances from 09/01/24 through 09/27/24.<BR/>Record review of Resident #3's pharmacy review dated 08/14/24 and completed by Pharmacist M indicated Ativan 1 mg every 8 hours prn from order date of July 15, 2024. Per CMS guidelines this med is not indicated prn past 14 days. Please dc this med or offer a benefit risk as to why this med is to continue prn. MD N signed (did not date) and indicated defer all psych meds to psychiatry team, please send this form to psychiatry team.<BR/>During an observation and interview on 09/23/24 at 12:29 p.m., Resident #1 was in the hospital and lying on a bed. There was a hospital staff sitter by the side of the bed. Resident #1 was speaking incoherently when asked how he was feeling. He had excessive drooling from the mouth and was making repeated attempts to leave the bed. He did not respond with coherent responses to questions regarding his medications.<BR/>During an interview on 09/23/24 at 3:09 p.m., LVN V said she administered Resident #1, Resident #2, and Resident #3's antipsychotic and anti-anxiety medications that included routine and PRN, and IM and PO. She said she was required to monitor for side effects. She said side effects could include lethargy or increased behaviors. She said she did not know why Resident #1's behaviors were not monitored. She said she was not aware it was the responsibility of the nurse who obtained the order to ensure PRN was only prescribed for 14 days. <BR/>During an interview on 09/23/24 at 3:21 p.m., the ADON said the QM pharmacist (she could not recall the name) had made the facility aware on 09/19/24 or 09/20/24 that Resident #1's PRN antipsychotic medications required a 14-day end date. She said she was not aware previously and she had not addressed the issues. She said the facility was advised to come up with a corrective action plan and include staff training. She said she had not completed an audit of residents' charts to address the issue of prn end dates because there was no DON or other ADON to assist. She said she was not aware Resident #1's behaviors were not being monitored in the EMR. <BR/>During an interview on 09/25/24 at 9:21 a.m., LVN B said she administered Resident #1, Resident #2, and Resident #3's antipsychotic and anti-anxiety medications that included routine and PRN, and IM and PO. She said she was required to monitor for side effects. She said side effects could include lethargy or increased behaviors. She said she did not know why Resident #1's behaviors were not monitored. She said she was not aware it was the responsibility of the nurse who obtained the order to ensure the PRN was only prescribed for 14 days. She said she thought the PRN orders were standing orders. <BR/>During an interview on 09/25/24 at 11:38 a.m., LVN Z said she administered routine PRN antipsychotics and antianxiety IM and PO medications to Residents #1, #2, and #3. She said she was required to monitor for side effects. She said side effects could include lethargy or increased behaviors. She said she did not know why Resident #1's behaviors were not monitored. She said she was not aware it was the responsibility of the nurse who obtained the order to ensure the PRN was only prescribed for 14 days. She said she thought the PRN orders were standing orders. <BR/>During an interview on 09/25/24 at 12:36 p.m., psych NP AA said he did not review Residents #1, #2, or #3's PRN anti-psychotic or anti-anxiety medications per the pharmacy recommendations to add a 14-day end date because he was not given the pharmacy recommendations to review. He said monitoring was important for medications to ensure it was needed and working effectively.<BR/>During an interview on 09/25/24 at 2:28 p.m. RNC T said she was made aware of by the QM pharmacist that PRN medications had to have a 14-day end date. She said she spoke to psych NP AA on 09/23/24 regarding the PRN antipsychotics. She said NP AA gave orders to discontinue the PRN antipsychotics and antianxiety medications and he would review them on his next visit to the facility. She said Pharmacist R gave all recommendations to the facility during his monthly reviews and she was not aware of why the recommendations were not addressed. She said she was not aware Resident #1's behavior monitoring in the EMR was not completed. She said it was ordered but was not populating in the EMR for the nurses to document. She said if the behavioral monitoring was not documented, the physician may not see the continued behaviors to determine if any treatment changes were needed.<BR/>During an interview on 09/25/24 at 1:29 p.m., MD N said he was aware IM and PO orders for PRN Ativan and other antipsychotic and anti-anxiety PRN medications required a 14-day end date. He said all pharmacy recommendations related to antipsychotic and anti-anxiety medications were deferred to psych services. He said PRN Ativan IM or PO with 14-day renewals were usual standard orders. He said he was also the facility provider and medical director. He said he was not aware the correct pharmacy protocols were not being followed. He said monitoring was important for medications to ensure it was needed and working effectively.<BR/>During an interview on 09/26/24 at 3:15 PM, LVN A said any resident on antipsychotics, antidepressants, or any mind-altering drug should be monitored for side effects and behaviors. She said that behaviors and side effects were documented on the MAR/TAR and if side effects and/or behaviors were identified those should be documented in the progress note. She said if resident identified to have behaviors that an assessment was completed and the MD notified and physicians orders followed which could include monitoring, referral to behavioral hospital, lab work, psych services evaluation, and/or transfer to local ER. She said she did not know there was no monitoring for behaviors for Resident # 1. She said residents on psychotropic medication prn (as needed) should have a stop date at 14-days or documentation from a physician of why it was necessary to continue beyond 14 days. She said that she did not know there was not a stop day on Resident #1, #2, and #3's prn psychotropic medications. She said not having a stop date on the prn psychotropic medications could cause ill effects or the resident to receive unnecessary medications. <BR/>During an interview on 09/26/24 at 4:20 p.m., MA J said she did not administer prn psychotropic medications that the CN administers prn medications. She said that she does administer psychotropic and sedative/hypnotic medications if ordered routinely. She said that behaviors and side effects were documented on the MAR/TAR and if side effects and/or behaviors were identified those should be documented in the progress note. <BR/>During an interview on 09/26/24 at 5:00 p.m., Pharmacist L said that he was the consulting pharmacist at the facility up until last month (August 16, 2024). During his visits to the facility, he reviewed resident's medications and provided the facility DON and the administrator a list of residents receiving psychotropic and sedative/hypnotic and consultant pharmacist/physician communication sheets to be provided to the physician. He said that the pharmacist/physician communication sheets identified MMR date and notations of residents receiving prn psychotropic drugs limited to 14 days and the physician was required to stop the psychotropic drug or offer a benefit risk as to why the medication was to continue prn. He said that the list of residents receiving psychotropic, and sedative/hypnotic included the resident name, medication class, medication, dose and direction, ordered date, last GDR date, and the next evaluation date. He said monitoring was important for medications to ensure it was needed and working effectively.<BR/>During an interview on 09/30/24 at 12:30 p.m., LVN B said any resident who was on psychotropic medication, or any mind-altering medication should be monitored for side effects and behaviors. She said it was important to monitor for the side effects of the medication to see if it helped the resident or not. She said if she administers psychotropic medication prn that she documents on the MAR/TAR effectiveness, side effects, and behaviors. She said she did not know there was no monitoring for behaviors for Resident # 1. She said residents on psychotropic medication prn (as needed) should have a stop date at 14 days or documentation from a physician why it was necessary to continue beyond 14 days. She said that she did not know there was not a stop day on Resident #1, #2, and #3's prn psychotropic medications. She said not having a stop date on the prn psychotropic medications could cause the resident to receive unnecessary medications.<BR/>During an interview on 09/30/24 at 1:30 p.m., LVN C said any resident who was on an antipsychotic, antidepressant, or any mind-altering medication should be monitored for side effects and behaviors. She said it was important to monitor for the side effects of the medication to see if it helped the resident or not. She said if she administers psychotropic medication prn that she documents on the MAR/TAR effectiveness, side effects, and behaviors. She said if the resident was not monitored, a side effect could be missed. She said residents on psychotropic medication prn (as needed) should have a stop date at 14 days or documentation from a physician why it was necessary to continue beyond the 14 days.<BR/>During an interview on 09/30/24 at 4:00 p.m., the ADON said any resident on antipsychotics, antidepressants, or any mind-altering drugs should be monitored for side effects and behaviors. She said that the quality monitoring team had identified that the psychotropic drugs where not being stopped or reviewed by a physician after 14 days and that she was made aware of that on September 20th, 2024, the Friday prior to the investigator entering the facility (on 09/23/24). She said she had reviewed all the resident's currently on prn psychotropic drugs and stopped the drugs. She consulted the physician for new orders and medication regimen review including the prn psychotropic drug, dosage, last doses of the psychotropic drugs, and indications of why administered. She said she put in those orders in 09/24/24 for Residents #1, #2, and #3. She said it was important to monitor to see if the medication was effective and monitoring the behaviors to address them before they got out of hand. She said she was currently responsible to make sure the orders were there; however, it was every nurse's responsibility. She said the orders for monitoring Resident #1's behaviors were not generated onto the MAR/TAR because the schedule was not assigned at the time the order was written. She said monitoring was important for medications to ensure it was needed and working effectively.<BR/>During an interview on 09/30/24 at 4:30 p.m., the Administrator said residents receiving prn psychotropic medication that it was important to monitor for side effects of medications and behaviors to look for negative side effects or negative behaviors. She said that resident's medication regimen should be free from unnecessary medications. She said that that MD giving orders for prn psychotropic medications would be asked for a stop date and/or reevaluation date (no longer than 14 days will be accepted for a stop date). She said staff had been recently in-serviced regarding no longer than 14 days for prn psychotropic medication and adding a stop date to these medications when ordered. She said the nurses should be putting in necessary orders but ultimately the DON was responsible for making sure stop dates on prn psychotropic medication, behaviors, and side effects of medications were monitored. She said that the ADON and the corporate nurse was currently reviewing the orders and behavioral monitoring since the facility did not currently have a DON. <BR/>Record review of the facility's undated policy antipsychotic use in residents with dementia indicated Objective: To ensure the facility is in compliance with the CMS regulations for proper management of antipsychotic medication in residents with dementia, who have behavioral issues. Procedure: 1. Upon admission of a resident who is ordered an antipsychotic medication and has a diagnosis of dementia, the nursing supervisor/staff will obtain from the physician an approved diagnosis for the antipsychotic medication and a specific behavior for its use. d. The facility will obtain an informed consent, from the resident / power of attorney, and or healthcare representative, before an antipsychotic medication is administered. 3. The nursing supervisor/staff will initiate a behavior sheet with the specific behavior(s) for which the antipsychotic medication was prescribed, in accordance with the physicians wishes when he reviews the medication orders. 4. The behavior sheet will include resident specific non-pharmacological interventions for the resident. a. These non-pharmacological interventions can be obtained from family members, physician/psychiatrist (he/she was seeing prior to admission to the facility), or attending physician. 5. The behavior sheet will be filled out at the end of each shift with the number of episodes the resident had for that shift, non-pharmacological interventions that were used and the result. 6. The resident's medical record and behavior sheet will be reviewed at the monthly Behavioral IDT meeting. 8. Upon monthly review of resident medical records, the Consultant Pharmacist will make recommendations for dosage reductions/ adjustment of antipsychotic medications for residents with dementia in accordance with the CMS regulations and guidelines. a. This review will also include any other psychotropic medication(s), which is due for review by the attending/psychiatrist at this time. 9. The physician will review the dosage recommendations and determine at such time, if a dose adjustment is medically indicated or clinically contraindicated. a. The reason for the medication to continue to be medically indicated will be answered in the response section on the consultant's recommendation or in the physician's progress note. B The note should demonstrate that the physician has carefully considered the risk/benefit for the current dose and for it to continue. The documentation should also include; that past gradual dose reduction, failures, and why any changes would aggravate the resident's general medical condition, functional status, or psychiatric stability. 12. Documentation of all gradual dose reductions attempts, failures, or usefulness of non-pharmacologic interventions, will be maintained by the facility and consultant pharmacist, using tracking tools to monitor progression.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview and record review the facility failed to ensure a resident with limited range of mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable for 1 of 5 residents (Resident #1) reviewed for range of motion.<BR/>The facility failed to assess and provide hand rolls and/or positioning devices in Resident #1's right hand to prevent future decline in ROM.<BR/>This failure could place resident at risk of not receiving the appropriate care and services to maintain their highest level of well-being.<BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated 06/20/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included epilepsy (seizures), falls, mood disorder (intense shifts in mood), intellectual disabilities, GERD (reflux disease), functional quadriplegia (complete immobility due to severe physical disability or frailty), dysphagia (difficulty swallowing), and psychosis (some loss of contact with reality), contracture of right shoulder, contracture of right wrist and contracture of right hand. <BR/>Record review of Resident #1's annual assessment, dated 07/27/23, reflected she had serious mental illness and intellectual disability. She had severe cognitive impairment, indicated with a BIMS score of 00. She required supervision and one person assist for eating. ROM was noted as no impairment.<BR/>Record review of Resident #1's MDS, dated [DATE], reflected she had serious mental illness and intellectual disability. She had severe cognitive impairment indicated with a BIMS score of 00. She was able to make herself understood. She required extensive assist of one staff for eating and extensive assist of two+ staff for bed mobility, transfers and toilet use. ROM was noted as 0 days provided of restorative therapy. <BR/>Record review of Resident #1's EHR reflected there was no care plan or interventions related to her contractures.<BR/>Record review of Resident #1's OT assessment, dated 03/05/24, reflected right UE severe flexed contractures, shoulder extension, rotated elbow flexed 115-120 degrees, wrist flexed 120 degrees with thumb abducted across palm, poor sitting balance, abnormal posturing, leaning to left side, increased need of assistance in self-care including feeding, bedfast 24/7, decreased ROM, and muscle weakness of LUE. Resident #1 was discharged from OT services due to no payer source. There was no recommendation for right hand roll or positioning device.<BR/>During an observation of an undated picture provided by a family member on 06/21/24, Resident #1's right hand was contracted, the fingers and thumb had extremely long nails, and there were excessive debris and unknown substance of various colors between her fingers, thumb and under her nails. There was no roll or brace in Resident #1's right hand.<BR/>During an observation and interview on 06/24/24 at 12:35 p.m., Resident #1's family member placed a folded wash cloth between Resident #1's fingers and palm of her hand. Resident #1's hand was clean and the nails were trimmed. The family member indicated the facility had not provided any assessment of hand roll or a brace for Resident #1's contacted hand.<BR/>During an interview on 06/24/24 at 3:56 p.m., DON II said she was new to the position of DON in the facility as of May 2024. DON II said she was not aware Resident #1's contracted right hand was not assessed for a hand roll or brace to prevent further contraction. She said Resident #1 was admitted to the facility on [DATE] and the contracture should have been assessed and addressed.<BR/>During an interview on 06/27/24 at 4:15 p.m., the Rehabilitation Director said Resident #1 should have been assessed for contractures and ROM upon admission. She said she was just made aware in April 2024 that Resident #1 should have been assessed quarterly. She said she believed a brace was attempted with Resident #1 when she was first admitted to the facility but there was no documentation because the previous owners took all documentation. She said Resident #1 did not receive OT/PT services due to no payer source. She said Resident #1 did receive restorative therapy but a hand roll or brace was not included in the restorative therapy. She said she never received a recommendation or request for a hand brace. She said Resident #1 was added to the list and would be seen by the brace consultant the next week.<BR/>During an interview on 07/02/24 at 2:36 p.m., DON JJ said she expected residents with contractures to receive contracture management to keep them mobile. DON JJ said it was a team effort and the ultimate responsibility of the restorative program and therapy. DON JJ said she would have to review the facility policy to ensure who the facility deemed responsible for contracture management. DON JJ said the importance of contracture management was to prevent further decline. <BR/>Record review of the facility's, undated, Joint Mobility/Range of Motion (ROM) Program and Splinting - Initiating the Program policy reflected POLICY:<BR/>Patients / residents will be assessed for joint mobility limitation upon admission, re-admission, quarterly, annually, and with significant changes through the comprehensive nursing assessment. A restorative program will be implemented through the care plan to increase, maintain, or prevent deterioration of joint mobility and to maximize physical function when referral to therapy is not indicated or upon discharge from skilled therapy. Orthotic, assistive, or prosthetic devices will be provided if indicated . TREATMENT PROTOCOLS: Individual positioning with splinting: Static or dynamic splinting and positioning are utilized to inhibit tone and maintain or prevent abnormal posturing or positioning. Appropriate use of splints to assist with positioning may enhance functional mobility.<BR/>Record review of the facility's policy, dated 2001 (revised April 2013), reflected Policy Statement Rehabilitative nursing care is provided for each resident admitted . Policy Interpretation and Implementation<BR/>1. <BR/>General rehabilitative nursing care is that which does not require the use of a qualified Professional Therapist to render such care.<BR/>2. <BR/>Nursing personnel are trained in rehabilitative nursing care. Our facility has an active program of rehabilitative nursing which is developed and coordinated through the resident's care plan.<BR/>3. <BR/>The facility's rehabilitative nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence.<BR/>4. <BR/>Rehabilitative nursing care is performed daily for those residents who require such service. Such program includes , but is not limited to:<BR/>a. <BR/>Maintaining good body alignment and proper positioning;<BR/>b. <BR/>Encouraging and assisting bedfast residents to change positions at least every two (2) hours (day and night) to stimulate circulation and to prevent decubitus ulcers, contractures, and deformities;<BR/>c. <BR/>Making every effort to keep residents active and out of bed for reasonable periods of time, except when contraindicated by physicians' orders, and encouraging residents to achieve independence in activities of daily living by teaching self care and ambulation activities;<BR/>d. <BR/>Assisting residents to adjust to their disabilities, to use their prosthetic devices, and to redirect their interests, if necessary;<BR/>e. <BR/>Assisting residents to carry out prescribed therapy exercises between visits of the therapists;<BR/>f. <BR/>Assisting residents with their routine range of motion exercises; .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain acceptable parameters, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise and the facility failed to offer a therapeutic diet when there was a nutritional problem and the healthcare provider ordered a therapeutic diet for 5 of 5 residents (Resident #s 1, 2, 3, 4, and 5) reviewed for weight loss and nutrition. <BR/>The facility failed to ensure systems were in place to monitor for weight changes.<BR/>1. The facility failed to ensure Resident #1 did not sustain a significant weight loss of 47 lbs./20% weight loss X 1 month, 51 lbs./22% weight loss X 3 months, and 49 lbs./21% weight loss X 6 months.<BR/>2. The facility failed to ensure Resident #2 did not sustain significant weight loss of 7.5% change (comparison weight 03/14/24, 117.6 lbs., -15.3%, -18 lbs.) <BR/>3. The facility failed to ensure Resident #3 did not sustain a significant weight loss. Weight changes - 10 lbs. 9 lbs. weight loss X 1 month, 10 lbs./8% weight loss X 3 months<BR/>4. The facility failed to ensure Resident #4 did not sustain a significant weight loss. Weight changes-7.5% change (Comparison Weight 04/05/24, 129.7 lbs., -13.6%, -17.7 lbs.) -10.0% change (Comparison Weight 12/23/23. 136.6 lbs., -18.0%, -24.6 lbs.)<BR/>5. The facility failed to ensure Resident #5 did not sustain a significant weight loss Weight changes-14 lbs./7% X 1 month (comparison weight 212 lbs.) <BR/>These failures could place residents at risk of severe weight loss, delayed interventions, hospitalization, worsening health condition and death.<BR/>Findings include: <BR/>1. Record review of Resident #1's face sheet, dated 06/20/24, reflected a [AGE] year old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included epilepsy (seizures), falls, mood disorder (intense shifts in mood), intellectual disabilities, GERD (reflux disease), functional quadriplegia (complete immobility due to severe physical disability or frailty), dysphagia (difficulty swallowing), and psychosis (some loss of contact with reality). <BR/>Record review of Resident #1's MDS, dated [DATE], reflected she had serious mental illness and intellectual disability. She had severe cognitive impairment, indicated with a BIMS score of 00. She was able to make herself understood. She required extensive assist of one staff for eating and extensive assist of two+ staff for bed mobility, transfers, and toilet use. Weight loss was unknown.<BR/>Record review of Resident #1's annual assessment, dated 07/27/23, reflected she had serious mental illness and intellectual disability. She had severe cognitive impairment, indicated with a BIMS score of 00. She required supervision and one person assist for eating. Her weight was noted as 250 lbs.<BR/>Record review of Resident #1's care plan, dated 08/19/23, reflected she was at risk for increased abdominal distress. Weight loss and GI bleed due to GERD. Intervention included check appetite, weight, and encourage appropriate intake, serve diet per order, and offer snacks within diet. Report to MD if resident complains of increased abdominal distress.<BR/>Record review of Resident #1's care plan, dated 08/19/23, reflected she was at risk for aspiration and choking related to dysphagia. Intervention included notify MD and RD of changes PRN, offer alternate meals when intake was less than 50%, and sit resident up during meals to decrease risk of choking. <BR/>Record review of Resident #1's clinical file reflected there were no care plans for weight loss available for review.<BR/>Record review of Resident #1's physician orders dated 04/11/24 reflected the diet as regular mechanical soft, thin consistency and chopped meat. There was no dietary supplements added as of 06/20/24.<BR/>Record review of Resident #1's meal intake record from 05/28/24 through 06/25/24 reflected there were 21 meals refused and 26 meals not documented out of 87 possible meals. Resident #1 intake was 0-25% for 2 meals, 26-50% for 2 meals, 51-75% for 5 meals, and 76-100% for 14 meals.<BR/>Record review of Resident #1's ADL-eating record for 04/01/24 through 04/30/24 reflected there were 38 meal refusals noted.<BR/>Record review of Resident #1's ADL-eating record for 05/01/24 through 05/31/24 reflected there were 34 meal refusals noted.<BR/>Record review of Resident #1's ADL-eating record for 06/01/24 through 06/24/24 reflected there were 30 meal refusals noted.<BR/>Record review of Registered Dietician note, dated 05/14/24, completed by RD DD, reflected Resident #1's weight was 187 lbs. She had 47 lbs./20% weight loss X 1 month, 51 lbs./22% weight loss X 3 months, and 49 lbs./21% weight loss X 6 months. RD DD noted poor intake at most meals, less than 50% intake at meals, and refused most meals. Recommendations included offering a house shake if intake was less than 51% at meals and encourage good intake. <BR/>Record review of Registered Dietician note, dated 06/14/24 and completed by RD DD, reflected Resident #1's weight was 187 lbs. 5% change (comparison weight 5/6/24 278.4 lbs. (error per RD interview-actual weight was 187 lbs. -33%, -91.9 lbs.) , 7.5 % change (comparison weigh 4/5/24 234.0 lbs., -20.3%, -47.5 lbs.), -10.0% change(comparison weight 01/08/24 236.7 lbs., -21.2%. -50.2 lbs.). Recommendations included: Resident #1 triggered for weight loss, needs some assistance with ADLS. <BR/>Record review of Resident #1's physician notes from 05/14/24 through 06/20/24 reflected there was no weight loss addressed. There were no physician or NP notes in Resident #1's electronic record related to weight loss.<BR/>During an interview on 06/24/24 at 9:20 a.m., CNA V said Resident #1 was offered her meal but she refused and the nurse was notified. She said she offered Resident #1 an alternate meal choice and it was refused. She said she was not aware of any supplements. <BR/>During an interview on 06/24/24 at 9:25 a.m., CNA FF said Resident #1 was offered her meal but she refused (06/24/24) and the nurse was notified. She said she offered Resident #1 an alternate meal choice and it was refused. She said she was not aware of any supplements.<BR/>During an interview on 06/25/24 at 9:30 a.m., LVN F said if Resident #1 refused meals it was documented and the physician was notified. She said she was made aware by DON II that the physician indicated he was not notified. LVN F said Resident #1 would be offered shakes but when Resident #1 said no it was no. She said she was not aware the physician or NP were not informed of Resident #1 refusing meals or her weight loss. <BR/>2. Record review of Resident #2's face sheet, dated 06/29/24, reflected a [AGE] year old female who was admitted to the facility on [DATE]. Her diagnoses included hepatic failure (liver failure), dementia (loss of cognitive functioning), dysphagia (difficulty swallowing), and GERD (Gastroesophageal reflux disease).<BR/>Record review of Resident #2's MDS, dated [DATE], reflected she was usually understood and able to understand others, she had severe cognitive impairment, indicated with a BIMS score of 2. <BR/>Record review of Resident #2's care plan, dated 04/12/24 (revised 04/30/24), reflected Resident #2 had potential problems related to CCD diet. Interventions included monitor, document and report PRN any signs or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, refusing to eat or appears concerned during meals.<BR/>Record review of Registered Dietician note, dated 06/11/24, completed by RD DD, reflected Resident #2 weighed 99 lbs. Weight changes-7.5% change (comparison weight 03/14/24, 117.6 lbs., -15.3%, -18 lbs.) No supplements noted. Recommendations: Resident #2 triggered for assessment/weight loss. Resident #2 had intermittent confusion and disoriented. She required supervision with meals. Add house shakes TID thickened. Resident met criteria for severe protein-calorie malnutrition related to unintentional weight loss and poor intake. Consider adding diagnoses to list.<BR/>Record review of Resident #2's physician notes from 05/14/24 through 06/20/24 reflected there was no weight loss addressed.<BR/>3. Record review of Resident #3's face sheet, dated 06/27/24, reflected a [AGE] year old female who was admitted to the facility on [DATE]. Her diagnoses included cerebral palsy (conditions that affect movement), dysphagia (difficulty eating) and diabetes (pancreas does not make enough insulin or any at all).<BR/>Record review of Resident #3's MDS, dated [DATE], reflected she was rarely understood, was usually able to understand others, had severe cognitive impairment, indicated with a BIMS score of 3. She was able to eat with supervision and supervisor may be provided.<BR/>Record review of Resident #3's care plan did not address diet or weight loss.<BR/>Record review of the Registered Dietician note, dated 05/14/24, completed by RD DD, reflected Resident #3 was 108.2 lbs. She was underweight for her age. Weight changes - 10 lbs. 9 lbs. weight loss X 1 month, 10 lbs./8% weight loss X 3 months. There were no supplements recorded. Recommendations included: Resident #1 triggered for quarterly weight loss. Recommend re-weighing Resident #3 using previous weight method from April. Add house shakes BID.<BR/>Record review of Registered Dietitian note, dated 06/14/24, completed by RD DD, reflected Resident #3's weight was 108.6 lbs. she was underweight for her age. Weight changes- 7.5 % change (comparison weight 04/05/24 118.6 lbs. -8.4%, -10 lbs.) No supplements noted. Recommendations included: Resident #1 triggered for weight loss. Resident required assistance with some ADLS. Predicted inadequate intake related to unintentional weight loss. Add house shake BID.<BR/>Record review of Resident #3's physician notes from 05/14/24 through 06/20/24 reflected there was no weight loss addressed.<BR/>Record review of Resident #3's physician order summary, dated 06/27/24, reflected were no current orders for supplements. <BR/>4. Record review of Resident #4's face sheet, dated 06/27/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included dementia (loss of cognitive functioning) and cognitive communication deficit (trouble participating in conversations).<BR/>Record review of Resident #4's MDS, dated [DATE], reflected she had severe cognitive impairment, indicated with a BIMS score-6, was usually understood and usually able to understand others. Her weight was noted as 133 lbs. She required supervision and/or assistance for eating.<BR/>Record review of Resident #4's care plan, dated 07/21/23, reflected Resident #4 was on a therapeutic diet due to heart disease and HTN. Interventions included: Serve diet as ordered and offer substitutions if less than 75% is eaten. Monitor intake. Resident #4 was on Megace for appetite stimulation. Weight monthly and PRN. Report 5% loss/gain to MD and RP. <BR/>Record review of the Registered Dietician note, dated 05/14/24, completed by RD DD, reflected Resident #4 weighed 113.2 lbs. She was underweight for her age. Weight changes-17 lbs./13% eight loss X 1 month, 17 lbs./13% weight loss X 3 months, and 18 lbs./14% weight loss X 6 months. No supplements were recorded. Recommendation included: Resident #4 triggered for weight loss/quarterly. Recommend re-weighing Resident #1 using previous weight method from April 2024. Add house shakes BID.<BR/>Record review of Registered Dietician note, dated 06/14/24, completed by RD DD, reflected Resident #4 weighed 112.5 lbs. She was underweight for her age. Weight changes-7.5% change (Comparison Weight 04/05/24, 129.7 lbs., -13.6%, -17.7 lbs.) -10.0% change (Comparison Weight 12/23/23. 136.6 lbs., -18.0%, -24.6 lbs.) No supplements noted. Recommendations included: Resident #4 triggered for weight loss. Resident #4 needed some assistance with ADLS. Add health shakes BID.<BR/>Record review of Resident #4's physician order summary reflected from 01/04/23 through 02/03/23, Resident #4 may have house shakes BID for weight loss for 30 days. There were no current orders for supplements. <BR/>Record review of Resident #4's physician notes from 05/14/24 through 06/20/24 reflected there was no weight loss addressed.<BR/>5. Record review of Resident #5's face sheet, dated 06/27/24, reflected he was a 67- year-old male who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included dementia (loss of cognitive functioning), complete traumatic amputation of left lower leg, diabetes (pancreas does not make enough insulin or any at all), and unspecified protein-calorie malnutrition (lack of sufficient energy or protein to meet the body's metabolic demands).<BR/>Record review of Resident #5's MDS, dated [DATE], reflected he was able to be understood and understood others and he was cognitively intact, indicated with a BIMS score of 15. He ate independently. His weight was noted as 209 lbs.<BR/>Record review of Registered Dietician note, dated 05/14/24, completed by RD DD reflected Resident #5's weight was 197.8 lbs. Weight changes-14 lbs./7% X 1 month (comparison weight 212 lbs.) Recommendations: Resident #5 triggered for weight loss quarterly. Re-weight using same as previous weight. Weight loss was not detrimental at this time.<BR/>Record review of Resident #5's physician notes from 05/14/24 through 06/20/24 reflected there was no weight loss addressed.<BR/>Record review of Resident #5's physician order summary, dated 06/27/24, reflected no current orders for supplements. <BR/>During an interview on 06/25/24 at 9:10 a.m., DM EE said she had not received any supplement dietary recommendations for Residents #1, #2, #3, #4 or #5. She said the recommendations had to be input into the EHR from the physician orders. She said house shakes and additional supplements would be added to the resident meal ticket but she was not made aware of any recommendations. She said the house shakes were not routinely put on the resident's meal trays. She said if a resident refused meals then the CNAs would come to the kitchen and request a shake.<BR/>During an interview on 06/24/24 at 3:56 p.m., DON II said the physician was not notified of resident weight loss or RD DD's recommendations. She said she made NP aware of Resident #1's weight loss and recommendations from 05/14/24. NP A ordered shakes TID with every meal and Megace to increase her appetite as of 06/24/24. She said she became DON the first part of May 2024 and the facility had also hired a new ADON. She said she was not aware of RD DD's recommendations. She said the restorative aide was responsible for weighing the residents. She said the weights were then put into the EHR by the previous DON . She said the physician should have been made aware of all resident weight loss and dietitian recommendations. She said the residents were at risk of continued weight loss, malnutrition, and health decline if their weight loss and the dietary recommendations were not addressed.<BR/>During an interview on 06/25/24 at 10:31 a.m., NP GG said she was not made aware of any resident weight loss. She said she was not made aware of any of RD DD's recommendations. She said she would have reviewed the weight loss and the recommendations and given new orders as appropriate for each resident.<BR/>During an interview on 06/25/24 at 10:44 a.m., MD HH said he was not made aware of any resident weight loss. He said if RD DD's recommendations were sent to him he would have addressed and signed the recommendations. He said he was made aware of Resident #1's meal refusals on 06/20/24 but could not recall previous notifications. He said he would expect DON II or the ADON would notify him of the RD DD's recommendations and all resident weight loss. He said residents were at risk of malnutrition, continued weight loss, and decline of health without adequate nutrition.<BR/>During an interview on 06/25/24 at 12:25 p.m., CNA J said Resident #1 refused her lunch tray. She said the tray did not include a shake. She said Resident #1 requested a ham sandwich with mustard.<BR/>During an interview on 06/25/24 at 3:55 p.m., LVN Z said Resident #1 often refused her meals. She said she would make the family aware but did not notify the physician or NP. She said on 06/24/24, Resident #1 refused her tray and threw the tray while in the dining room. Resident #1 was offered a supplement but refused. She said Resident #1 was offered a sandwich, cookies and cracker and it was accepted.<BR/>During an interview on 06/26/24 at 2:46 p.m., RD DD said she had been going to the facility monthly for the past two months (May 2024 and June 2024). She said when she arrived at the facility, she checked in with DON II/ADON to ask if there was anyone who needed to be seen. She said each visit, she screened for weight loss in the past 180 days. She said she would see new admissions during the visits. If a resident had weight loss they would be seen monthly along with pressure injuries and tube feedings. She said she ran an audit report from the electronic health record system and looked for weight variances and it calculated the percentages of weight loss. She said her last visit at the facility was on 06/14/24. She said during her visits, she conducted an audit of the recommendations from the previous month to ensure they were followed. She said if they were not, she would let DON II know that they were not done and would review the following month. She said during her monthly visits, she did not visit every resident in the facility, only the ones who were screened. RD DD said she sent her dietary reports for May 2024 and June 2024 with all recommendations to the administrator, DON II, and DM EE. She said she reviewed resident charts and weights and the reports were sent at the end of her visit. She said the reports and recommendations would then be reviewed by the physician and the physician would document any comments and sign the reports. She said Resident #1's documented weight for May 2024 was an error and her actual weight was 187 lbs. She said she was not aware any of the recommendations for May 2024 or June 2024 were not addressed. She said the residents were at risk of continued unwanted and unexpected with loss and malnutrition if the recommendations and weight loss were not addressed. She said the failure to obtain orders for the recommendations may have caused residents to lose unnecessary weight due to the recommendations were not acted on. She said resident weight loss was not addressed by the facility as needed. <BR/>During an interview on 06/26/24 at 3:00 p.m., the Administrator said resident weights and dietary recommendations were reviewed in the morning meeting. She said she was not made aware of any resident weight loss or dietician recommendations. She said she expected The DON or ADON to inform her of any resident weight loss and dietary recommendations. She said the physician should have been made aware of all resident weight loss and dietitian recommendations. She said the residents were at risk of continued weight loss, malnutrition, and health decline if their weight loss and the dietary recommendations were not addressed.<BR/>Record review of the facility's, undated, Weight Assessment and Intervention policy reflected:<BR/>Weight Assessment:<BR/>1. <BR/>The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter.<BR/>2. <BR/>Weights will be recorded in each unit's Weight Record chart or notebook and in the individual's medical record.<BR/>3. <BR/>Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing.<BR/>4. <BR/>The Dietitian will respond within 24 hours of receipt of written notification.<BR/>5. <BR/>The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met.<BR/>6. <BR/>The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight) / (usual weight) x 100]:<BR/>1. <BR/>1 month - 5% weight loss is significant; greater than 5% is severe.<BR/>3 months - 7.5% weight loss is significant; greater than 7.5% is severe.<BR/>6 months - 10% weight loss is significant; greater than 10% is severe.<BR/>7. <BR/>If the weight change is desirable, this will be documented and no change in the care plan will be necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 residents (Resident #6) reviewed for infection control. <BR/>1. The facility failed to ensure Resident #6's central line (a tube that is inserted into a large vein in the neck, chest, groin, or arm to give fluids, blood, medications, or to do medical tests quickly) dressing was changed every seven days per the physician's order.<BR/>2. The facility failed to ensure the Treatment Nurse changed gloves and performed hand hygiene between glove changes during wound care, after picking up a packaged mint off the floor, and before and after entering and exiting Resident #6's room.<BR/>These failures could place residents at risk for infections.<BR/>Findings included:<BR/>1. Record review of the face sheet dated 7/1/24 indicated Resident #6 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including cellulitis (a common and potentially serious bacterial skin infection) of the left lower limb, hypertension (elevated blood pressure), diabetes, Charcot's joint syndrome (a rare complication of diabetes related neuropathy [nerve damage where feeling in the lower legs and feet are lost]. It can make injuries or infections much more serious).<BR/>Record review of the MDS dated [DATE] indicated Resident #6 admitted to the facility on [DATE]. The MDS indicated Resident #6 was usually understood by others and usually understood others. The MDS indicated Resident #6 had a BIMS of 08 and was moderately cognitively impaired. The MDS indicated Resident #6 required set-up assistance with eating and was dependent on staff for oral hygiene, showering/bathing, dressing, and transferring. <BR/>Record review of the physician orders dated 6/28/24 indicated Resident #6 had an order starting 6/7/24 to change the dressing to single lumen (one tubing and one cap end) PICC line to the left upper extremity every day shift every 7 days for IV (intravenous) management. <BR/>During an observation and interview on 6/28/24 at 11:47 a.m. Resident #6's PICC line dressing was dated 6/4/24. Resident #6 said the facility staff had not changed his PICC line dressing since he admitted to the facility. <BR/>During an interview on 7/1/24 at 11:23 am the Medical Director said he would expect a PICC line dressing to be changed every 7 days as ordered to prevent infection.<BR/>During an interview on 7/1/24 at 12:01 p.m. the Administrator said Resident #6 was the only resident at the facility with a PICC line. <BR/>During an interview on 7/2/24 at 10:04 a.m. LVN T said the treatment nurse, or a RN was responsible for changing PICC line dressings. LVN T said if she noticed a PICC line dressing had not been changed as ordered she would notify a supervisor. LVN T said PICC line dressing should be changed weekly. LVN T said she had only administered Resident #6's IV medication once or twice because it was due on the evening shift, and she normally worked day shift. LVN T said she had not assessed Resident #6's PICC line dressing. LVN T said the importance of ensuring PICC line dressings were changed weekly was to prevent bacteria from entering the site and to prevent dressing from rolling up. <BR/>2. During an observation on 6/28/24 at 1:22 p.m. the Treatment Nurse performed wound care to Resident #6's ankle. The Treatment Nurse wiped the bedside table with normal saline and did not put a barrier down between the bedside table and the wound care supplies. The Treatment Nurse cleansed the medial incision, lateral incision, and bottom of foot with same piece of gauze with normal saline on it. The Treatment Nurse removed her gloves, did not perform hand hygiene, and went to the treatment cart to retrieve a package of rolled gauze. The Treatment Nurse dropped a packaged mint on the floor, reached down to pick it up, did not perform hand hygiene, and then applied a new pair of gloves. The Treatment Nurse touched Resident #6's foot and incisions with her gloved hands to see if he could feel her touch. The Treatment Nurse went to the treatment cart to obtain a tube of ointment for Resident #6's wound without removing her gloves or performing hand hygiene. The Treatment Nurse returned to the room, applied ointment to the incisions with her gloved hand, removed her gloves, did not perform hand hygiene, and wrapped the foot/ankle with rolled gauze. <BR/>During an observation and interview on 06/29/24 at 11:50 a.m., the Treatment Nurse removed the kerlix wrap from Resident #6's left foot. The Treatment Nurse said Resident #6 was on isolation for MRSA (methicillin-resistant Staphylococcus aureus) of his surgery sites. The Treatment Nurse removed her gloves washed her hands applied new gloves and cleaned wounds with wound cleanser and 4 by 4 gauze for each site. The Treatment Nurse then applied clindamycin by using fingers on her gloved hand:<BR/>* applied clindamycin to the inside surgical wound using gloved the first finger applied directly to the wound. <BR/>*, applied clindamycin to the outside of the surgical wound using gloved the second finger applied directly to the wound; and<BR/>* applied clindamycin to the great left toe a necrotic area using gloved the ring finger applied directly to the wound. <BR/>The Treatment Nurse did not change her gloves or perform hand hygiene between treating areas on Resident #6's foot. The Treatment Nurse removed her gloves after she wrapped the left foot with kerlix wrap then walked out of the room down the hall approximately 7 feet to the hand sanitizer with her isolation gown on she wore while she performed wound care.<BR/>During an interview on 06/29/24 at 12:00 p.m., the Treatment Nurse said she should have removed her gown in the room and said she never told about changing gloves between areas. <BR/>During an interview on 7/1/24 at 11:23 a.m., the Medical Director said the Treatment Nurse cleaning Resident #6's wounds with the same gauze would not have spread the MRSA as it was systemic. The Medical Director said the treatment nurse not performing appropriate hand hygiene during wound care and leaving the room with gloved hands and without performing hand hygiene should be something staff were in-serviced regarding because the action could lead to the spread of infections.<BR/>During an interview on 7/2/24 at 12:36 p.m. DON JJ said an RN or trained LVN could change a PICC line dressing. DON JJ said the charge nurses were responsible for changing PICC line dressings. DON JJ said PICC line dressings should be changed weekly. DON JJ said the importance of ensuring PICC line dressings were changed weekly was for infection control. DON JJ said she expected staff to perform hand hygiene before entering a resident room, before patient care, during patient care when warranted, before leaving a resident room, and between glove changes. DON JJ said if a staff member picked an item up out of the floor, she expected them to perform hand hygiene afterwards. DON JJ said the importance of proper hand hygiene was infection control.<BR/>During an interview on 7/1/24 at 1:37 p.m. the Administrator said an RN was responsible for changing PICC line dressings. The Administrator said PICC line dressing changes were the responsibility of DON JJ or the weekend RN Supervisor. The Administrator said a PICC line dressing should be changed in accordance with the doctor's order. The Administrator said the importance of ensuring PICC line dressings were changed as ordered was infection control. The Administrator said she expected staff to perform hand hygiene when performing care for a resident, during different intervals of wound care including going from one wound site to another, and if they picked something up off the floor. The Administrator said the importance of proper hand hygiene was infection control. <BR/>Record review of the facility's undated Infections-Clinical Protocol policy indicated, During the initial assessment, the physician will help identify individuals who have had a recent infection or who are at risk for developing an infection .<BR/>Record review of the facility's undated Central Venous Catheter Dressing Changes policy indicated, The purpose of the procedure is to prevent catheter-related infections associated with contaminated, loosened, soiled, or wet dressings. Check the State's Nursing Practice Act for LPNs (Licensed Practical Nurse) regarding the scope of practice for changing a central venous catheter dressing. A physician's order is not needed for this procedure. Apply and maintain sterile dressing on intravenous access devices .Change dressings if any suspicion of contamination is suspected .Change transparent semi-permeable membrane (TSM) dressings at least every 5-7 days and PRN (when wet, soiled, or not intact) .<BR/>Record review of the facility's undated Handwashing/Hand Hygiene policy indicated, The facility considers hand hygiene the primary means to prevent the spread of infection .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water in the following situations .b. Before and after direct contact with residents; c. Before preparing or handling medications; c. Before performing a non-surgical invasive procedure .g. Before handling clean or soiled dressing, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care .k. After handling used dressings, contaminated equipment, etc.; l. after contact with objects in the immediate vicinity of the resident; m. After removing gloves; n. Before and after entering isolation precaution settings .9. The use of gloves does not replace hand washing/hand hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility for 1 of 6 residents (Resident #1) reviewed for discharge requirements. <BR/>The facility failed to ensure Resident #1 was readmitted to the facility, after being treated at a behavior hospital. <BR/>This failure could place discharged residents and residents residing in the facility at risk of being discharged and not allowed to return to the facility causing a disruption in their care and/or services. <BR/>Findings included:<BR/>Record review face sheet dated 6/3/24 indicated Resident #1 was readmitted on [DATE] and her original admission date was 07/01/22. She was [AGE] years old with diagnoses included schizophrenia (a disorder that affects a person ability to think, feel and behave clearly), persistent mood disorder (chronic mental illness), and gastrostomy tube.<BR/>Record review physician orders dated June 2024 indicated Resident #1 received Haloperidol (treats mental disorder) 10 mg three times a day for schizophrenia, Seroquel (treats schizophrenia) 100 mg one time a day related to psychosis (mental disorder characterized by a disconnection from reality), and valproic acid (treats mental disorder) 250 mg three times a day. The orders included an order to transfer Resident #1 to the behavior hospital on [DATE].<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 11 which indicated impaired cognition and she required assistance with ADLs. She had no behaviors listed on this MDS. Section Q indicated no active discharge planning for Resident #1 to return to the community and did not want to be asked about returning to the community on all assessments.<BR/>Record review of the care plan dated 04/09/24 indicated Resident #1 had diagnoses of schizophrenia and was at risk of manic episodes and mood swings. Interventions included administering medications as ordered, to monitor the resident, and to notify psychiatric services as needed.<BR/>Record review of 30-day discharge notice with the reason of harm to self and others dated 05/10/24 indicated the effective date of discharge for Resident #1 was for 06/10/24. The letter was sent to the ombudsman and the responsible party for Resident #1 on 05/10/24. <BR/>Record review of nurse's notes dated 04/19/24 indicated Resident #1 was sent to Behavioral Hospital A after she placed a pillow over her roommate's face. <BR/>Record review of nurse's notes dated 06/03/24 Resident #1 returned to the facility from Behavioral Hospital A and was sent to Behavioral Hospital B on the same day.<BR/>Record review of the nurse's notes dated 06/07/24 indicated the Behavioral Hospital B sent Resident #1 back to the facility and the administrator told the nurse not to readmit the resident. <BR/>During an interview on 6/8/24 at 8:30 a.m., the Administrator stated, the facility had discharged Resident #1 before the 30th day of the 30-day discharge notice. She stated, the reason was because the Behavior Hospital B had dumped Resident #1 and if the facility would had accepted the resident on 06/07/24, it would have been an unsafe admission. She said Resident #1's bed had to be given to another resident who required the secure unit. The Administrator said there was no bed on the secure unit for Resident #1. She said on 4/19/24 Resident #1 had placed a pillow over another resident's face and she was sent to the hospital then on to the Behavior Hospital A. <BR/>During an interview on 06/08/24 at 10:00 a.m., the DON said the Administrator told her Resident #1 was discharged from the facility and the facility was not accepting her back. She said Resident #1 was sent to their facility on 06/07/24 and was not readmitted . She said the van driver said Resident #1 had vomited and he was taking her to the Hospital C. She said the effective date of the 30-day discharge notice was 06/10/24. She said she just did what the Administrator told her not to accept the resident back from Behavioral Hospital B<BR/>During an interview on 06/08/24 at 9:00 a.m., LVN A said she was the charge nurse on 06/07/24 when the Behavioral Hospital B sent Resident #1 back from the hospital. She said the DON and the Administrator told her Resident #1 was discharged from this facility and not to accept the resident back into the facility.<BR/>During an interview on 06/08/24 at 10:30 a.m., the ADON said the Administrator told her Resident #1 was discharged the facility. She said the resident had been given a 30-day notice of discharge and the resident was supposed to stay at the Behavior Hospital B until after 06/10/24. She said Resident #1's personal belongings were packed in a box and her room on the secure unit had been given to a new resident last week.<BR/>During an interview on 06/08/24 at 11:00 a.m., the SW said she had been trying to find placement for Resident #1 at other nursing homes and she was on a waiting list at the state mental hospital because of the diagnosis of harm to herself and others. She said on 06/07/24 during the morning she received a phone call from the discharge planner at the Behavioral Hospital B. She said Resident #1 was discharged and was going to be sent back to the facility. She said she texted the Administrator and called the DON and reported this. She said the plan was for the resident to stay at the Behavioral Hospital B until after 06/10/24, the effective date of the 30-day discharge notice. She said the family was to bring the resident to his home until placement at the state hospital could be completed.<BR/>During an interview on 06/08/24 at 12:15 p.m., the Case Manager at the Hospital C said Resident #1 was discharged however they were not going to send her out of the hospital due to her childlike behaviors and her inability to make decisions. She said no aggressive behaviors had been displayed while she had been at the hospital. She said the facility refused to accept Resident #1, so she would be trying to find placement at other facilities.<BR/>During an interview and observation on 06/08/24 at 12:30 p.m., Resident #1 was sitting in the bed in minor care at the local hospital. She was smiling and joking with the staff. She said when the facility would not let her back into the facility, she was upset but she said she did not want to be at that place. She said, I think I will just stay here at the hospital or go to a state mental hospital or live with you.<BR/>During an interview on 06/08/24 at 1:35 p.m., the Responsible Party for Resident #1 said the facility gave them a 30-day notice on 05/10/24. He said the reason the facility was discharging Resident #1 was because she was labeled a harm to herself and others. He said at the beginning of this week the facility blocked his email and was not returning his calls. He said the last he knew was the resident was on a waiting list for the state hospital. He said the Behavioral Hospital B informed him of them attempting to discharge the resident and the facility refused to admit her back. He said the Behavioral Hospital B said she vomited in the van during transport and was taken to Hospital C on 06/07/24.<BR/>During an interview on 06/08/24 at 2:45 p.m., the Director of the Behavioral Hospital B said Resident #1 was not having behaviors. She said report was called to the nursing home, and we made arrangement for transportation on 06/07/24. She said the report she received Behavioral Hospital B's van driver was that the facility would not accept their resident back into the building. She said the van driver placed Resident #1 back into the van and while at the facility parking lot Resident #1 vomited and her staff directed by Behavioral Hospital to take her to Hospital C. The van driver gave the hospital the nursing home phone number and left the resident at the hospital. <BR/>During an interview on 06/08/24 at 5:45 p.m., the Ombudsman said she received a 30-day discharge notice for Resident #1 and had spoken to the family and the facility. She said the facility was working to get her a room at the state hospital; however, the family voiced the resident was now at the local hospital and the facility discharged the resident before the 30 days' notice ended.<BR/>Record review of the policy titled Transfer or Discharge Notice dated 12/20/12 indicated Our facility shall provide a resident and /or resident's representative with a 30-day written notice of an impending discharge notice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and follow a written policy on permitting residents to return to the facility after they were hospitalized for 1 of 6 residents (Resident #1) reviewed for discharge requirements. <BR/>The facility failed to follow the written policy to ensure Resident #1 was readmitted to the facility, after being treated at the Behavior Hospital and after being treated at Hospital C. <BR/>This failure could affect discharged residents and placed residents residing in the facility at risk of being discharged and not allowed to return to the facility causing a disruption in their care and/or services. <BR/>Findings included:<BR/>Record review of the policy titled Transfer or Discharge Notice dated 12/20/12 indicated Our facility shall provide a resident and /or resident's representative with a 30-day written notice of an impending discharge notice .<BR/>Record review face sheet dated 6/3/24 indicated Resident #1 was readmitted on [DATE] and her original admission date was 07/01/22. She was [AGE] years old with diagnoses included schizophrenia (a disorder that affects a person ability to think, feel and behave clearly), persistent mood disorder (chronic mental illness), and gastrostomy tube.<BR/>Record review physician orders dated June 2024 indicated Resident #1 received Haloperidol (treats mental disorder) 10 mg three times a day for schizophrenia, Seroquel (treats schizophrenia) 100 mg one time a day related to psychosis (mental disorder characterized by a disconnection from reality), and valproic acid (treats mental disorder) 250 mg three times a day. The orders included an order to transfer Resident #1 to the behavior hospital on [DATE].<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 11 which indicated impaired cognition and she required assistance with ADLs. She had no behaviors listed on this MDS. Section Q indicated no active discharge planning for Resident #1 to return to the community and did not want to be asked about returning to the community on all assessments.<BR/>Record review of the care plan dated 04/09/24 indicated Resident #1 had diagnoses of schizophrenia and was at risk of manic episodes and mood swings. Interventions included administering medications as ordered, to monitor the resident, and to notify psychiatric services as needed.<BR/>Record review of 30-day discharge notice with the reason of harm to self and others dated 05/10/24 indicated the effective date of discharge for Resident #1 was for 06/10/24. The letter was sent to the ombudsman and the responsible party for Resident #1 on 05/10/24. <BR/>Record review of nurse's notes dated 04/19/24 indicated Resident #1 was sent to Behavioral Hospital A after she placed a pillow over her roommate's face. <BR/>Record review of nurse's notes dated 06/03/24 Resident #1 returned to the facility from Behavioral Hospital A and was sent to Behavioral Hospital B on the same day.<BR/>Record review of the nurse's notes dated 06/07/24 indicated the Behavioral Hospital B sent resident #1 back to the facility and the administrator told the nurse not to readmit the resident. <BR/>During an interview on 6/8/24 at 8:30 a.m., the Administrator stated, the facility had discharged Resident #1 before the 30th day of the 30-day discharge notice. She stated, the reason was because the Behavior Hospital B had dumped Resident #1 and if the facility would had accepted the resident on 06/07/24, it would have been an unsafe admission. She said Resident #1's bed had to be given to another resident who required the secure unit. The Administrator said there was no bed on the secure unit for Resident #1. She said on 4/19/24 Resident #1 had placed a pillow over another resident's face and she was sent to the hospital then on to the Behavior Hospital A. <BR/>During an interview on 06/08/24 at 10:00 a.m., the DON said the Administrator told her Resident #1 was discharged from the facility and the facility was not accepting her back. She said Resident #1 was sent to their facility on 06/07/24 and was not readmitted . She said the van driver said Resident #1 had vomited and he was taking her to the Hospital C. She said the effective date of the 30-day discharge notice was 06/10/24. She said she just did what the Administrator told her not to accept the resident back from Behavioral Hospital B<BR/>During an interview on 06/08/24 at 9:00 a.m., LVN A said she was the charge nurse on 06/07/24 when the Behavioral Hospital B sent Resident #1 back from the hospital. She said the DON and the Administrator told her Resident #1 was discharged from this facility and not to accept the resident back into the facility.<BR/>During an interview on 06/08/24 at 10:30 a.m., the ADON said the Administrator told her Resident #1 was discharged the facility. She said the resident had been given a 30-day notice of discharge and the resident was supposed to stay at the Behavior Hospital B until after 06/10/24. She said Resident #1's personal belongings were packed in a box and her room on the secure unit had been given to a new resident last week.<BR/>During an interview on 06/08/24 at 11:00 a.m., the SW said she had been trying to find placement for Resident #1 at other nursing homes and she was on a waiting list at the state mental hospital because of the diagnosis of harm to herself and others. She said on 06/07/24 during the morning she received a phone call from the discharge planner at the Behavioral Hospital B. She said Resident #1 was discharged and was going to be sent back to the facility. She said she texted the Administrator and called the DON and reported this. She said the plan was for the resident to stay at the Behavioral Hospital B until after 06/10/24, the effective date of the 30-day discharge notice. She said the family was to bring the resident to his home until placement at the state hospital could be completed.<BR/>During an interview on 06/08/24 at 12:15 p.m., the Case Manager at the Hospital C said Resident #1 was discharged however they were not going to send her out of the hospital due to her childlike behaviors and her inability to make decisions. She said no aggressive behaviors had been displayed while she had been at the hospital. She said the facility refused to accept Resident #1, so she would be trying to find placement at other facilities.<BR/>During an interview and observation on 06/08/24 at 12:30 p.m., Resident #1 was sitting in the bed in minor care at the local hospital. She was smiling and joking with the staff. She said when the facility would not let her back into the facility, she was upset but she said she did not want to be at that place. She said, I think I will just stay here at the hospital or go to a state mental hospital or live with you.<BR/>During an interview on 06/08/24 at 1:35 p.m., the Responsible Party for Resident #1 said the facility gave them a 30-day notice on 05/10/24. He said the reason the facility was discharging Resident #1 was because she was labeled a harm to herself and others. He said at the beginning of this week the facility blocked his email and was not returning his calls. He said the last he knew was the resident was on a waiting list for the state hospital. He said the Behavioral Hospital B informed him of them attempting to discharge the resident and the facility refused to admit her back. He said the Behavioral Hospital B said she vomited in the van while in the parking lot of the facility which refused to readmitted her and was taken to Hospital C on 06/07/24. He said the effective date of the 30-day notice was 06/10/24.<BR/>During an interview on 06/08/24 at 2:45 p.m., the Director of the Behavioral Hospital B said Resident #1 was not having behaviors. She said report was called to the nursing home, and we made arrangement for transportation on 06/07/24. She said the report she received Behavioral Hospital B's van driver was that the facility would not accept their resident back into the building. She said the van driver placed Resident #1 back into the van and while at the facility parking lot Resident #1 vomited and her staff directed by Behavioral Hospital to take her to Hospital C. The van driver gave the hospital the nursing home phone number and left the resident at the hospital. <BR/>During an interview on 06/08/24 at 5:45 p.m., the ombudsman said she received a 30-day discharge notice for Resident #1 and had spoken to the family and the facility. She said the facility was working to get her a room at the state hospital; however, the family voiced the resident was now at the local hospital and the facility discharged the resident before the 30 days' notice ended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 5 (Resident #1) residents reviewed for grievances.<BR/>The facility did not thoroughly investigate or take prompt action to resolve grievances voiced by Resident #1 that she did not want CNA A or CNA B enter her room or provide care.<BR/>This failure could place residents at risk of unresolved grievances and decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included dementia (loss of cognitive functioning), anxiety (intense, excessive and persistent worry and fear about everyday situations), schizophrenia (serious mental health condition that affects how people think, feel and behave), unspecified mood disorder (complex mental health condition), paranoid personality disorder (mental health condition marked by a long-term pattern of distrust and suspicion of others without adequate reason to be suspicious (paranoia). People with PPD often believe that others are trying to demean, harm or threaten them.), major depressive disorder (persistent feeling of sadness and loss of interest), and bipolar disorder (mental health condition that causes extreme mood swings).<BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated she was able to make herself understood and understood others and she was cognitively intact (BIMS-15).<BR/>Record review of Resident #1's care plan dated 08/25/23 indicated she had a history of confabulation (a memory error consisting of the production of fabricated, distorted, or misinterpreted memories about oneself or the world. It is generally associated with certain types of brain damage (especially aneurysm in the anterior communicating artery) or a specific subset of dementia) presented false information she believed to be true, and indicated aides did not provide the right care. Interventions included allow resident to verbalize feelings, redirect resident during episodes of confabulation, psych consult as ordered, and report to MD as needed and document episodes of confabulation in the clinical record.<BR/>Record review of Resident #1's care plan dated 04/06/2021 indicated Resident #1 had a behavior problem related to confabulation, schizophrenia, major depressive disorder, and bipolar disorder. Interventions included administer medications as ordered, anticipate and meet her needs, and assist her to develop more appropriate methods of coping and interacting without confabulation.<BR/>Record review of a grievance dated 02/05/25 and written by previous Administrator K indicated Resident #1 did not want CNA A or CNA B. Resident #1 could not tell me why she did not want the employee in her room. The DON indicated there was no CNA B employed with the facility (this was an error due to the name documented and it was not recognized by the DON). The DON informed CNA A not to go in Resident #1's room. Grievance was noted as resolved and Resident #1 said thank you and had no other concerns.<BR/>Record review of a grievance dated 02/12/25 and written by Resident #1 indicated she wanted CNA A and CNA B banned from her room related to putting on her diaper wrong and provoking her by not doing things as she asked. ADON E noted Resident #1 refused care from certain aides because she liked certain aides better and was used to them. Resident #1 was informed the facility could not assign specific aides to Resident #1. The grievance was not completed as resolved or if Resident #1 was satisfied with the resolution.<BR/>Record review of an undated grievance completed by the SW indicated Resident #1 did not like how CNA A set her meal tray down, the tray was not set up right and she did not want CNA in her room. The SW asked Resident #1 how she wanted her tray and Resident #1 directed the SW to set the tray up. The grievance was noted as resolved and Resident #1 was satisfied. There was no indication which aide was not wanted in her room or how it was addressed or resolved.<BR/>Record review of the facility staffing sheets indicated CNA A was assigned to provide care for Resident #1 on 03/05/25, 03/12/25, 03/24/25, and 03/30/25.<BR/>Record review of facility staffing sheets indicated CNA B was assigned to provide care for Resident #1 on 02/07/25, 02/10/25, 02/12/25, 02/18/25, 03/08/25, 03/13/25, 03/14/25, and 03/22/25.<BR/>During an interview on 03/30/25 at 9:10 a.m., MA G said Resident #1 complained about CNAs if she did not like how they did something. She said she was aware there were certain staff that Resident #1 did not want in her room. She said CNA A was assigned to provide Resident #1's care.<BR/>During an interview on 03/30/25 at 9:20 a.m., CNA A said she was assigned to provide Resident #1's care. She said she was not informed she was not supposed to go in to Resident #1's room or provide care. She said she was aware there was some staff Resident #1 did not like and those staff did not go in her room.<BR/>During an interview on 03/30/25 at 10:00 a.m., Resident #1 said she did not want CNA A or CNA B in her room or providing care. She said she felt they were not nice. She said she felt unsafe and afraid. She said told ADON E and other staff but could not recall who else she told. She could not recall the date she told ADON E. She did not tell the Administrator but she did tell other staff. She did not want to identify the other staff. She said the staff caused her anxiety because they did not do things right or how she wanted. She said it was abusive because the staff did not provide her care how she wanted.<BR/>During an interview on 03/30/25 at 11:06 a.m., LVN H said Resident #1 said she does not want certain staff in her room. She said when she was made aware of it, she would switch the assigned aide or do the care herself. She said she was not aware of a list of staff who were not supposed to go in Resident #1's room or provide care.<BR/>During an interview on 03/30/25 at 1:00 p.m., Resident #1 said CNA C came in her room on 03/30/31 and told her CNA A was assigned to her and would complete her care. She said she did not want CNA A and CNA C said she was too busy.<BR/>During an interview on 03/30/25 at 1:34 p.m., the SW said the previous administrator was the grievance official until the new administrator (Administrator J) took over and made her (the SW) the grievance official. She said she was the grievance official for approximately 1 month. She said she could not recall the exact date of the grievance she completed for Resident #1 related to CNA A not setting up Resident #1's tray as she wanted. She said she did not address which aide Resident #1 did not want in her room. <BR/>During an interview on 03/31/25 at 9:08 a.m., Administrator J said she was in the position for one month. She said the SW was the grievance official. She said the facility would try to best to accommodate Resident #1's request but sometimes there would not be enough staff or the staff she wanted so she would agree to care with a staff she did not want and a witness. She said she was not aware of any complaints or grievances related to CNA A but was aware she did not want CNA B in her room. She said if she were aware Resident #1 did not want a particular staff in her room, she would get someone else to go to the room. She said a few times there was no staff she wanted so Resident #1 agreed to a staff and a witness. <BR/>During an interview on 03/31/25 at 9:20 a.m., ADON E said Resident #1 told her she did not want CNA D and CNA I in her room but agree to let CNA D provide care after she was retrained. She said there was no allegations of abuse. She said Resident #1 indicated the staff were rushing and leaving. She said the facility was running out of options because Resident #1 only wanted certain staff to provide care for her. She said Resident #1 did not say she did not want CNA A or CNA B in her room or providing care. <BR/>During an interview on 03/31/25 at 10:56 a.m., the DON said she was not aware Resident #1 did not want CNA A or CNA B in her room to provide care. She said she was not aware of the grievance dated 02/05/25. She said ADON F did not write any grievances related to Resident #1 saying she did not want CNA A or CNA B.<BR/>During an interview on 03/31/25 at 11:57 a.m., Administrator J if aides were assigned to provide care to Resident #1 and it was aides she did not want then they should have been re-assigned and another staff would have to provide her care. She said Resident #1 was at risk of feeling a certain way, like she was not being heard if aides continued to provide care that she did not want providing her care.<BR/>During an interview on 03/31/25 at 12:04 p.m., previous Administrator K said he was made aware Resident #1 did not want CNA A and CNA B in her room or providing care but could not recall the date of the grievance. He said he informed the DON and he believed the staff were verbally told not to go in Resident #1's room. He said Resident #1 did not like how certain staff provided care. <BR/>During an interview on 03/31/25 at 12:24 p.m., ADON F said she gave Resident #1's grievance related to staff she did not want to the DON. She said she did not recall exactly what Resident #1 said or which staff she did not want in her room.<BR/>Record review of the facility's Complaints/Grievance policy revised 06/19 indicated It is the policy of this facility to adopt a process to support the resident's right to voice complaints/grievances to facility management and have those grievances/complaints investigated and resolved in a reasonable timeframe. 9. Grievances/complaints can be taken by any staff member and documented on a Concern Form. The concern form is then forwarded to the Grievance Official. 10. Immediately upon receiving a grievance/complaint, facility Leadership will seek a resolution and will keep the resident informed of the progress of the investigation/resolution. 11. The Facility will take immediate action to prevent further potential violation of any resident right while the alleged violation is being investigated

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 12 residents (Resident #1) reviewed for comprehensive person-centered care plans.<BR/>The facility failed to develop and implement a care plan for Resident #1's aggressive behaviors toward others. <BR/>This failure could place residents at risk of not having individual needs met and a decreased quality of life. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 05/14/24 indicated he was [AGE] years old, admitted on [DATE], and his diagnoses included encephalopathy (brain dysfunction), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and cognitive communication deficit.<BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated he sometimes was able to make himself understood and understood others, and had severe cognitive impairment (BIMS score 00). His behaviors included physical behaviors directed at others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) that occurred 1 to 3 days (out of 7 day look back period)<BR/>Record review of Resident #1's electronic record indicated there was no care plan related to aggression towards others.<BR/>Record review of a progress note dated 05/12/24 at 10:23 p.m., completed by LVN L indicated she wheeled Resident #1 to his room for CNA R to provide care. CNA R reported Resident #1 initiated physical aggression and reached up and scratched CNA R's face. CNA N and CNA O entered Resident #1's room to complete Resident #1's care. <BR/>During an interview on 05/14/24 at 5:58 p.m., CNA R said she had been employed at the facility for 2 weeks and had worked at a secure unit as a CNA prior to this facility and had received training on abuse and self-defense tactics. She said that Resident #1 was never aggressive and she did not know what happened that day, but he was fighting all three of them, which included CNA N and CNA O, and her on 05/12/24. She said she was trying to get him dressed and he was so strong and grabbed her face and started scratching, punching, and kicking. She said she never hit him back and that she used the self-defense tactics of raising her arms like an x. She said he was fighting all three of them pretty hard and she did not see anyone ever hit him back. She said she was just trying to make sure he did not fall on the floor and resolve the situation. She said she had not worked with him since the incident and that she had observed his injuries. She said she did not know how he got those injuries other than he was fighting so hard and was not just fighting her that the other two girls were bigger than her. She said the administrator informed her that Resident #1 was never aggressive unless someone was mean to him and that it appeared she was getting the brunt of it. <BR/>During an interview on 05/22/24 at 12:30 p.m., CNA N said she overhead conversation on 05/12/24 when CNA R reported to LVN L that Resident #1 exhibited aggressive behaviors and had scratched CNA R on the face while she was trying to provide personal care. CNA N said she told CNA R and CNA O that she would try to assist with Resident #1 with care. CNA N said she and CNA O went back into Resident #1's room approximately 10 minutes after the incident of aggression with CNA R to assist resident with care. CNA N said she did not know what happened, but when she went to assist Resident #1, he started spitting and fighting. She said she and CNA O left the room, to allow Resident #1 to calm down. CNA N said Resident #1 had behaviors at times and they leave the room and try to go back later to assist him.<BR/>During an interview on 05/22/24 at 12:42 p.m., CNA O said she went to Resident #1's room to assist with care. She said CNA N and CNA R were already in the room. CNA O said she observed CNA N attempting to provide care to Resident #1, but Resident #1 was upset and was spitting at CNA N. CNA R was standing in room but not assisting with care because Resident #1 had already scratched her on the face. CNA O said Resident #1 was being aggressive spitting and slapping at CNA N. She left the room to notify LVN L of the incident and LVN L said she was aware of the incident and the behaviors. CNA O returned to Resident #1's room and notified CNA N and CNA R that LVN L was notified of Resident #1's behaviors.<BR/>During an interview on 05/22/24 at 2:08 p.m., LVN/MDS J said she was responsible for completing resident care plans. She said it was a mistake and she just missed completing a care plan related to Resident #1's aggression towards others.<BR/>During an interview on 05/22/24 at 1:14 p.m., the Administrator stated the DON and the MDS Coordinator were responsible for completing the care plans. The Administrator stated she expected them to include anything unusual or special for the resident's care. The Administrator stated it was important for Resident #1's aggressive behavior towards others to be included in the care plan so the staff could ensure the resident was receiving appropriate care. <BR/>During an interview on 05/22/24 at 2:45 p.m., LVN L said CNA R left Resident #1's room and reported Resident #1's aggressive behaviors and that he had scratched her face on 05/12/24. She said CNA N and CNA O went to complete Resident #1's care and he continued with his aggressive behaviors. She said the staff left his room to allow him to calm down. <BR/>Record review of the facility's Comprehensive Person-Centered Care plans policy dated 2001 (revised October 2018) indicated Policy Statement-A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 9 Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

**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 the facility as outlined by the comprehensive care plan meets professional standards of quality for 3 of 6 residents (Resident #s 1, 2, and 3) reviewed for skin assessments. <BR/>The facility failed to ensure Residents #1, #2, and #3 received a weekly skin assessment.<BR/>This failure could place the resident at increased risk of not having their individual needs met and of not receiving adequate care and medical interventions to maintain their health and prevent worsening health conditions.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 05/14/24 indicated he was [AGE] years old, admitted on [DATE], and his diagnoses included encephalopathy (brain dysfunction), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), heart disease, acute kidney failure, chronic iron deficiency anemia secondary to blood loss, unspecified protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and cognitive communication deficit. His assigned room was 216.<BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated he sometimes was able to make himself understood and understood others, had severe cognitive impairment (BIMS score 00), was at risk of developing pressure ulcers/injuries, and had application of non-surgical dressing (with ow without topical medications other than to feet.<BR/>Record review of Resident #1's care plan dated 12/11/23 (revised 12/14/23) indicated Resident #1 was at risk for impaired skin integrity related to chronic fragile skin and self-inflicted skin tears. Interventions included ensure nails are clipped.<BR/>Record review of Resident #1's care plan dated 05/13/24 indicated Resident #1 is on anticoagulant therapy Plavix and ASA. Interventions included daily skin inspections.<BR/>Record review of Resident #1's physician orders dated 04/10/24 indicated perform head to toe assessment, assess all areas of skin and skin assessment to be done weekly.<BR/>Record review of Resident #1's daily skilled nurse assessment dated [DATE] indicated Resident #1 had no skin breakdown.<BR/>Record review of Resident #1's weekly skin assessment dated [DATE] indicated Resident #1's had a dark purplish bruise to right lower lip area, three scratches to left side of face (cleaned and treatment in place, and left and right arm bruising to numerous sites).<BR/>Record review of Resident #1's electronic record indicated there was no weekly skin assessment from 04/10/24 through 05/13/24.<BR/>Record review of Resident #2's face sheet dated 05/22/24 indicated she was [AGE] years old, was admitted [DATE], and her diagnoses included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), heart disease, cellulitis (deep bacterial infection of the skin), and muscle wasting and atrophy, edema (swelling caused by too much fluid trapped in the body's tissues), and phlebitis (inflammation that causes a blood clot to form in a vein, usually in the leg) and thrombophlebitis (an inflammatory process that causes a blood clot to form and block one or more veins, usually in the legs. The affected vein might be near the surface of the skin (superficial thrombophlebitis) or deep within a muscle -deep vein thrombosis, or DVT) of lower extremities. Her assigned room was 217.<BR/>Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated she was able to make herself understood and understood others, she was cognitively intact (BIMS score 15), was at risk of developing pressure ulcers/injuries, had MASD.<BR/>Record review of Resident #2's care plan dated 08/25/23 (revised 08/27/23) indicated Resident #2 was at risk for skin breakdown and injury due to not wanting to sleep on her bed. Interventions included assess skin on a weekly basis and as needed.<BR/>Record review of Resident #2's care plan dated 09/18/23 (revised 09/21/23) indicated Resident #2 had skin concerns and was at risk of further skin breakdown, infection, and pressure ulcer formation related to chronic edema and a history of cellulitis. Interventions included monitor areas of increased skin break down and signs and symptoms of infection. Perform treatments as ordered and if no improvement report to MD.<BR/>Record review of Resident #2's care plan dated 09/18/23 (revised 09/21/23) indicated Resident #2 had a history of cellulitis of bilateral lower extremities related to fragile skin and was on edema management. Interventions included monitor LE 2 times weekly and report any skin breakdown to MD immediately.<BR/>Record review of Resident #2's physician orders dated 04/10/24 indicated complete weekly head to toe skin assessment every day shift every Tuesday.<BR/>Record review of Resident #2's weekly skin monitoring (not weekly skin assessment) dated 04/30/24 and completed by LVN D indicated rear of left lower leg ulcerations was improved.<BR/>Record review of Resident #2's MAR/TAR dated April 2024 indicated a weekly skin assessment was completed on 04/30/24.<BR/>Record review of Resident #2's MAR/TAR dated May 2024 indicated there was no weekly skin assessment completed on 05/07/24 or 05/14/24.<BR/>Record review of Resident #2's electronic record indicated there were no weekly skin assessments from 04/10/24 through 05/14/24.<BR/>Record review of Resident #3's face sheet dated 05/23/24 indicated he was [AGE] years old, was admitted [DATE], and his diagnoses included hemiplegia (paralysis that affects one side of the body), hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing), morbid obesity, unspecified protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), cerebral infarction (stroke), and diabetes (a condition that happens when blood sugar is too high). His assigned room was 226.<BR/>Record review of Resident #3's significant change MDS assessment dated [DATE] indicated he was able to make himself understood and understood others, had moderate impaired cognition (BIMS score of 10), and was at risk of developing pressure ulcers/injuries.<BR/>Record review of Resident #3's physician orders dated 04/11/24 (start 04/18/24), indicated skin assessment was to be done weekly every day shift every Thursday.<BR/>Record review of Resident #3's weekly skin assessment completed by LVN G dated 04/09/24 indicated a groin rash was resolved.<BR/>Record review of Resident #3's electronic record indicated there was no weekly skin assessment for review from 04/18/24 through 05/22/24.<BR/>Record review of the skin assessment schedule dated 01/02/23 for the Long Hall indicated Skin assessments must be done every 7 days or within 7 days from the last one. Resident #1's (room [ROOM NUMBER]) weekly skin assessment was scheduled for Friday 2:00 p.m. -10:00 p.m.<BR/>Record review of the skin assessment schedule dated 01/02/23 for the Long Hall indicated Skin assessments must be done every 7 days or within 7 days from the last one. Resident #2's (room [ROOM NUMBER]) weekly skin assessment was scheduled for Tuesday 6:00 a.m.-2:00 p.m. Resident #3's (room [ROOM NUMBER]) weekly skin assessment was scheduled for Thursday 6:00 a.m.-2:00 p.m.<BR/>During an interview on 05/22/24 at 2:35 p.m., RN C said the previous DON was going to edit the weekly skin reports so the new wound care nurse could schedule how they wanted the weekly skin assessment completed. She said the previous DON then quit working at the facility and the weekly skin assessments were not re-scheduled in the electronic system and were not completed. <BR/>During an interview on 05/22/24 at 2:40 p.m., the Administrator said she was not aware Resident #1's weekly skin assessments were not completed as ordered by his physician. She said she expected the nurses to complete weekly skin assessments when the facility wound care nurse was not available. She said the facility had hired a new wound care nurse however she had not taken over the weekly skin assessments. She said the residents were at risk of not receiving care as necessary without assessments.<BR/>During an interview on 05/22/24 at 5:15 p.m., LVN S said she would complete weekly skin assessment if they were assigned or flagged in the resident's electronic record. She said the residents were at risk of not receiving care as necessary without assessments.<BR/>During an interview on 05/23/24 at 9:44 a.m., LVN E said all residents were assigned on a schedule for skin assessments. She said the resident weekly skin assessment was usually triggered in the electronic record and indicated the assessment is due. She said the residents were at risk of not receiving care as necessary without assessments.<BR/>During an interview on 05/23/24 at 10:15 a.m., LVN D said she did not complete Resident #1's weekly skin assessment as scheduled. She said there was a schedule for each room/bed of the facility. She said she did not do the assessment because she was busy and did not have enough time. She said she believed she reported to the next shift nurse that she was not able to complete the weekly skin assessment but could not recall the name of the nurse. She said she believed the wound care nurse was supposed to do the weekly skin assessment but did not know when the wound care nurse was available. She said the residents were at risk of not receiving care as necessary without assessments.<BR/>During an interview on 05/23/24 at 12:30 p.m., the Administrator said that the previous DON had deleted some of the history in the resident electronic record and if she deleted the task or did not re-assign the tasks, the nurse staff would not see the task as a scheduled assignment.<BR/>During an interview on 05/23/24 at 4:39 p.m., the Administrator said resident skin problems were discussed in the morning meetings. She said she was not aware the weekly skin assessments were not triggered in the electronic system. She said usually the assessments were scheduled and were triggered for the nurses to do and populate with the required information. She said the problem was the previous DON and wound care nurse were auditing the forms and had not put a new start date in the system. She said LVN E and LVN F were experienced nurses and were aware of the weekly forms and schedule and were able to complete their skin assessments as required. She said the newer nurses would have completed the skin assessment had the trigger in the resident's electronic record notified them that a skin assessment was due. She said the facility did not have a skin assessment policy.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene for 1 of 12 residents (Resident #1) reviewed for ADLS.<BR/>The facility failed to ensure Resident #1's fingernails were trimmed. <BR/>This failure could place the residents at risk of not receiving the care and services to maintain their highest level of physical, mental and psycho-social well-being. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 05/14/24 indicated he was [AGE] years old, admitted on [DATE], and his diagnoses included encephalopathy (brain dysfunction), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and cognitive communication deficit. <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated he sometimes was able to make himself understood and understood others, had severe cognitive impairment (BIMS score 00), required partial/moderate assistance for most ADLS including personal hygiene.<BR/>Record review of Resident #1's care plan dated 12/11/23 (revised 12/14/23) indicated Resident #1 was at risk for impaired skin integrity related to chronic fragile skin and self-inflicted skin tears. Interventions included to ensure nails were clipped.<BR/>Record review of Resident #1's care plan dated 05/13/24 indicated Resident #1 is on anticoagulant therapy Plavix and ASA. Interventions included daily skin inspections.<BR/>Record review of Resident #1's physician orders dated 04/10/24 indicated perform head to toe assessment, assess all areas of skin and skin assessment to be done weekly.<BR/>Record review of Resident #1's weekly skin assessment dated [DATE] indicated Resident #1's had a dark purplish bruise to right lower lip area, three scratches to left side of face (cleaned and treatment in place, and left and right arm bruising to numerous sites. Resident #1's finger nails were noted as not clean, neat or trimmed. Resident #1 required scheduled nail trimming from staff related to aggression and fighting staff during incontinent care changes.<BR/>Record review of Resident #1's [NAME] (electronic care record) dated 05/23/24 indicated ensure nails are clipped.<BR/>Record review of Resident #1's electronic record indicated there was no nail trimming documentation available for review for the previous 30 days (04/21/24 through 05/21/24) .<BR/>During observation and interview on 05/21/24 at 3:00 p.m., Resident #1 was sitting in the wheelchair in TV common area. All of Resident #1's finger nails were long and jagged. Resident #1's fingernails were approximately &frac14; inch past the tips of the fingers and thumbs on both hands. Resident #1 did not respond to questions about his nails. He laughed and held out his hand to the surveyor. <BR/>During an interview on 05/22/24 at 12:30 p.m. CNA N said she did not notice Resident #1's nails being too long. She could not say when Resident #1's nails were last trimmed. She said the aides were responsible for trimming resident nails as needed but the nurses completed nail care for the residents with diabetes. She said the residents who required nail care was usually noted in each resident's [NAME] and documented on the task in the electronic record.<BR/>During an interview on 05/23/24 12:35 p.m., the DON said she was not able to locate Resident #1's care sheets for nail trimming. She said he was not a diabetic and the aides were expected to complete nail care. She said the aides should report any issues or concerns to her (the DON) or the administrator.<BR/>During an interview on 05/23/24 at 12:40 p.m., the Administrator said her expectations were for the staff to keep the resident's nails trimmed. She said the possible negative outcome would be Resident #1 could scratch himself or get a skin tear.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents the right to be free from abuse for 2 of 7 residents (Residents #2 and #3) reviewed for abuse. <BR/>1. On 04/03/24 Resident #3 self-propelled her wheelchair into Resident #1's room and Resident #1 pulled Resident #3 out of her wheelchair onto the floor. <BR/>2. On 04/19/24 Resident #1 placed a pillow over the face of Resident #2 and later admitted she was trying to kill Resident #2.<BR/>On 04/20/24 at 02:29 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 04/21/24, the facility remained out of compliance at a severity level with the potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of thei Plan of Removal. <BR/>These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.<BR/>Findings included:<BR/>1. Record review of Resident #1's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included schizophrenia (a serious mental condition involving breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion), persistent mood [affective] disorder (marked disruptions in emotions {severe lows called depression or highs called hypomania or mania]), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations).<BR/>Record review of Resident #1's care plan, dated 10/25/23, indicated Resident #1 had a diagnosis of schizophrenia and was at risk for manic episodes and increased behaviors. Interventions included monitor for delusions and hallucinations and monitor for increased agitation, anger, verbal, and physical aggression and document in clinical record. Resident #1 was taking psychotropic medication and was at risk for adverse reactions and depression, anxiety, and/or psychosis driven behaviors. Interventions included monitor for anxiety driven behaviors and report any noted behaviors to MD for further orders.<BR/>Record review of Resident #1's care plan, dated 10/25/23, indicated Resident #1 was taking psychotropic medication and was at risk for adverse reactions and depression, anxiety, and/or psychosis driven behaviors. Interventions included monitor for anxiety driven behaviors and report any noted behaviors to MD for further orders.<BR/>Record review of Resident #1's quarterly MDS assessment, dated 04/08/24, indicated Resident #1 was able to make herself understood and usually understand others, and had moderate cognitive impairment indicated by a BIMS score of 11. She had had no hallucinations, delusions, or physical or verbal behaviors. She required partial to moderate assistance with most ADLs.<BR/>Record review of Resident #1's clinical file revealed there were no care plans available for review related to homicidal ideations.<BR/>Record review of the incident report dated 04/19/24 at 03:40 a.m., completed by LVN A indicated she was notified by CNA B that Resident #2 was yelling for help because Resident #1 (her roommate) had placed a pillow over Resident #2's face and held it over her face. Resident #2 came out of her room yelling for help. The residents were separated, and Resident #2 was assessed with no bruising on her face and no shortness of breath. Resident #1 admitted she did it and stated, Don't send me to jail please send me to a mental institution. Resident #2 was moved to another room for her protection and safety. MD was paged and LVN A was awaiting response. Administrator was notified. <BR/>2. Record review of Resident #2's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility 12/05/23. Resident #2 had diagnosis which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning) with agitation, major depressive disorder (a metal health disorder characterized by persistently depressed mood causing significant impairment in daily life), and schizophrenia.<BR/>Record review of Resident #2's care plan, dated 07/31/23 indicated Resident #2 had an altered thought process and was at risk for further decline and injury as evidenced by dementia and short- and long-term memory deficit. Interventions included keep resident and others safe and monitor for mental status changes. <BR/>Record review of Resident #2's quarterly MDS dated [DATE] indicated Resident #2 was able to make herself understood and understood others, and had severe cognitive impairment indicated by a BIMS score of 6. She had feelings of being down, depressed, and hopeless 2-6 (several) days and had no behaviors. <BR/>During a telephone interview on 04/20/24 at 08:40 a.m., the Administrator said she received a text from LVN A on 04/19/24 at approximately 06:00 a.m. when she woke up reporting Resident #1 had placed a pillow over Resident #2's face and Resident #1 was requesting to go to a mental institution. She said her immediate action had been to request an additional CNA for the secure unit from her corporate office and she had just received approval for the CNA this morning but had not hired a new CNA yet. The Administrator said the secure unit had one dedicated CNA and one nurse that floats between the other rooms and the secure unit. She said Resident #2 had been moved into another room on the secure unit. <BR/>During an observation and interview on 04/20/24 at 09:05 a.m., CNA L said she was assigned the secure unit today with LVN C who was floating between the secure unit and rooms outside the unit. CNA L was sitting in the TV room with 4 residents and said Residents #1 and #2 were in their rooms alone. <BR/>During an observation and interview on 04/20/24 at 09:10 a.m., Resident #1 was alone in her room on the secure unit and resting in bed. She said yesterday (04/19/24) her roommate (Resident #2) was trying to put spells on her, and she had to stop her. She said she tried to hurt Resident #2. <BR/>During an observation and interview on 04/20/24 at 09:15 a.m., Resident #2 was alone in her room on the secure unit lying in bed. She said she had to be moved to a new room because her previous roommate had put a pillow over her face and tried to kill her while she was sleeping. She said she felt as safe as she could in her present surroundings. <BR/>During an interview on 04/20/24 at 09:35 a.m., the DON said she was not at the facility on 04/19/24 because she had to work the night shift last night. She said was notified on 04/19/24 about Resident #1 putting a pillow over Resident #2's face, but she was now looking back on what was done after the incident. She said LVN A reported the incident, but there was no documentation in the clinical record about the incident or if LVN A notified the police, the physician, or the responsible party. She said notifications should have been made and she was doing the notifications to the MD and RP. She said based on the aggression Resident #1 should have been transferred to a behavioral hospital for evaluation. <BR/>During a telephone interview on 04/20/24 at 09:55 a.m., LVN A said on 04/19/24 at 03:30 a.m. she received a call from CNA B who reported Resident #1 had placed a pillow over Resident #2's face and tried to smother her. She said CNA B had separated the residents when she arrived on the secure unit. LVN A said she assessed Resident #2 and found no visible injuries, but she kept repeating she tried to kill me. She said Resident #1 admitted she tried to kill Resident #2. LVN A said she paged the MD twice and he did not call by the end of her shift. She said she reported the incident to her Administrator via text and LVN C who was the nurse working the 06:00 a.m. to 02:00 p.m. shift. <BR/>During an interview on 04/20/24 at 10:05 a.m., LVN C said he received report from LVN A on 04/19/24 at 06:00 a.m. about the incident between Resident #1 and Resident #2. He said LVN A reported to him she had paged the MD twice and not received a response. He said he did not try to notify the MD or Resident #1's RP about the incident on 04/19/24. He said he never noticed if Resident #1 ever came out of her room on his shift and he wasn't sure if Resident #2 was in or out of her room during the day. <BR/>During a telephone interview on 04/20/24 at 10:21 a.m. CNA B said on 04/19/24 at approximately 03:20 a.m. she was passing by the room Resident #1 and Resident #2 shared when Resident #2 ran out of the room saying Resident #1 put a pillow over her head and tried to kill her. Resident #1 said Resident #2 had been naked during the day and she tried to kill her. Resident #1 then said she wanted to go to a mental hospital in Dallas because that was where her brother sent her whenever she tried to hurt people. CNA B said she separated the residents by bringing Resident #2 into the TV room with her and called LVN A and reported the incident. CNA B said after the incident Resident #1 was pacing up and down the hall talking loudly but not making any sense. She said then Resident #1 went into her room and pulled the mattress off her bed and disrobed and continued pacing around her room. She said Resident #2 said she was afraid to be alone in her room, so CNA B kept Resident #2 with her the rest of the night except when assisting other residents and she took her to sit with LVN A.<BR/>During an interview on 04/20/24 at 10:51 a.m., the DON said she notified the NP of the incident that occurred on 04/19/24 to the NP and Resident #1's RP on 04/20/24 at approximately 10:00 a.m. She said she had completed the referral to the behavioral hospital for Resident #1 and was awaiting her transfer. She said the NP gave no new orders for Resident #2. <BR/>During an observation and interview on 04/20/24 at 11:19 a.m., Police Officer M visited Resident #2 in her room. Resident #2 remained alone in her room made a verbal statement to Police Officer M that Resident #1 had tried to kill her by placing a pillow over her face while she was sleeping. She said she wanted to press charges against Resident #1 so she wouldn't try to kill her again. <BR/>During an observation on 04/20/24 at 11:26 a.m., Resident #1 was sleeping alone in her room. <BR/>During an interview on 04/20/24 at 03:59 p.m., the DON said she sat with Resident #1 until she was transported by ambulance to a behavioral hospital at approximately 03:30 p.m.<BR/>3. Record review of Resident #3's face sheet dated 04/20/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included cerebral infarction (stroke), spastic hemiplegia (a common post-stroke condition that causes stiff or rigid muscles) affecting right dominant side, vascular dementia (dementia [a condition characterized by progressive or persistent loss of intellectual functioning] caused by an impaired supply of blood to the brain), mood disorder (marked disruptions in emotions [severe lows called depression or highs called hypomania or mania]), and depression <BR/>Record review of Resident #3's care plan revised on 06/21/23 indicated Resident #3 was deemed at risk for wandering related to being ambulatory with her wheelchair, diagnosis of dementia, and history of exit seeking. Goals included Resident #3 would be able to wander in a safe environment (secure unit) with no occurrence of injury and dignity would be maintained. <BR/>Record review of Resident #3's annual MDS dated [DATE] indicated Resident #3 was sometimes able to make herself understood and usually understood others, and had severe cognitive impairment indicated by a staff assessment. She had mood of little interest or pleasure in doing things several (2-6 days) and behaviors directed toward others 1 to 3 days and no wandering behaviors.<BR/>Record review of Resident #1's clinical note (related to the incident with Resident #3) dated 04/03/24 at 11:30 a.m. and signed by LVN N indicated a CNA B came and informed LVN N that Resident #1 pulled Resident #3 out of her wheelchair onto the floor of Resident #1's room. Resident #1 said I'm not a fucking babysitter, I need help my motherfucking self she needs to keep her ass out of my motherfucking room. On arrival to the secure unit residents were already separated and in different rooms. LVN N educated and redirected Resident #1, she was informed that physical aggression would not be tolerated, and it was not her right to put hands on anyone. LVN A indicated that Resident #1 did not verbalize understanding. <BR/>During an observation and interview on 04/20/24 at 09:05 a.m., Resident #3 was sitting in the TV room of the secure unit. She was unable to answer question about the incident. She was holding her right arm against her, and it appeared to have contractures at her elbow and wrist. Resident #3 said her arm was not painful. CNA L said Resident #3's arm was paralyzed from a stroke. CNA L said staff tried to keep Resident #3 busy because she wandered into other resident's rooms. She said she was not working the day Resident #3 wandered into Resident #1's room and Resident #1 pulled her out of her wheelchair to the floor, but it had been reported to her by another CNA.<BR/>During an interview on 04/20/24 at 09:35 a.m. the DON said the only reason Resident #1 had pulled Resident #3 out of her wheelchair on 04/03/24 was because she went into Resident #1's room. She said she had instructed all staff on the secure unit to keep Resident #3 from wandering into other resident's rooms. <BR/>During a telephone interview on 04/22/24 at 11:35 a.m., LVN N said on 04/03/24 at approximately 11:30 a.m., a CNA reported to her that Resident #3 had self-propelled her wheelchair into Resident #1's room and Resident #1 pulled her out of her wheelchair and onto the floor. LVN N said she assessed Resident #3 who was sitting in the floor of Resident #1's room at the foot of her bed. She had no visible injuries, and she was assisted back into her wheelchair and out of the room. Resident #3 was unable to say how she got onto the floor. LVN N said she notified the ADON, the Administrator, the MD, and the RP of the incident. <BR/>During a telephone interview on 04/22/24 at 12:16 p.m., Resident #3's RP said she was notified on 04/03/24 by the nurse that Resident #3 had wheeled herself into another resident's room and the other resident had pulled Resident #3 out of her wheelchair and onto the floor. She said Resident #3's right arm had paralysis since her stroke. She said Resident #3 had no bruising or pain after she was pulled from her wheelchair. RP said she visited Resident #3 every day and she had witnessed residents on the secure unit being aggressive to staff and other residents. RP said she could not name the Residents she had seen be aggressive, but she had seen Resident #1 yell and cuss at other residents. She said she had not told the Administration about resident aggression. <BR/>Record review of the facility's Abuse and Neglect Policy dated June 2023 indicated It is the policy of the facility to administer care and services in an environment that is free of any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment .The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal guidelines of prevention and investigation .VI. Protect residents from physical and psychosocial harm during investigations.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 04/20/24 at 02:25 p.m. The Administrator was notified. The Administrator was provided the IJ template on 04/20/24 at 2:29 p.m.<BR/>The Facility's Plan of Removal for Immediate Jeopardy was accepted on 04/21/24 at 10:37 a.m. and reflected the following: <BR/>Immediate action:<BR/>On 4/20/24 Resident #1 was immediately placed on 1 on 1 monitoring until the facility could transfer Resident #1 to psychiatric hospital, waiting on approval from the behavioral hospital to transport. <BR/>*Charge nurse/ nurse managers Immediately assessed Resident #2 & Resident #3 and the rest of the residents in the secure unit for possible mental or physical abuse, no additional mental health needs were identified, nor any suspected physical abuse found at this time. <BR/>oAdministrator/abuse coordinator Immediately in-serviced all staff 100% completion on Abuse & Neglect policy.<BR/>o on 4/20/24 the Director of Nursing, Inservice all 100% of staff on behavioral management policy which included resident to resident abuse regarding residents exhibiting aggressive behaviors towards others, and steps to do, and how to approach the situation.<BR/>On 4/21/24 the MDS nurse reviewed all residents who have had aggressive behaviors, to make sure interventions were in place, for the floor staff to be able to see in electronic health record (EHR).<BR/>The facility reviewed the system for abuse identification and reporting. The facility created a plan of improvement to assure residents were free from abuse to address changes including education, daily chart reviews and IDT discussions. The DON and/or Designee will review incident reports and progress notes 5 days weekly to assure that there were no incidents that could meet the qualifications of abuse and discuss any concerns with the abuse coordinator immediately. <BR/>Resident #1 was placed on one-on-one monitoring until her transfer to a behavioral on 04/20/24. <BR/>The charge nurses and the nurse managers reviewed all residents on the secure unit on 04/20/24 that were involved in incidents within the last 30 days to ensure all residents had the correct supervision. No additional mental or physical abuse was identified. <BR/>On 04/20/24 the Administrator completed in-service with all facility staff regarding the behavioral management policy which included resident to resident abuse, residents exhibiting aggressive behaviors, and steps to approach a resident-to-resident situation. <BR/>On 04/21/23 at 11:48 a.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>During interviews conducted on 04/20/24 from 03:30 p.m. though 06:00 p.m. and 04/21/24 from 08:15 a.m. 11:48 a.m. included LVN A 10 p.m. - 6 a.m., LVN C (6:00 a.m. to 2:00 p.m.), LVN D (6:00 a.m. -2:00 p.m.), LVN E (6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.), LVN F (10:00 p.m. to 6:00 a.m.), LVN G (10 p.m. to 10 p.m.), LVN H (2:00 p.m. to 10:00 p.m., LVN I (2:00 a.m. to 10 p.m.),RN j (weekend shifts), and LVN K (6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.), CNA B (10:00 p.m. to 6:00 a.m.), CNA L (6:00 a.m. to 2:00 p.m.), CNA O (6:00 a.m. to 2:00 p.m.), CNA P (2:00 p.m. to 10:00 p.m.), CNA Q (2:00 p.m. to 10:00 p.m.), CNA R (10:00 p.m. to 6:00 a.m.), and CNA S (6:00 a.m. to 2:00 p.m.), the Dietary Manager, Dietary Aide T, Dietary Aide U, Housekeeper V, Housekeeper W, MDS Nurse and 1 ADON who worked all shifts. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/or identified, such as immediately removing the alleged perpetrators from providing care to residents and separating residents. Staff were educated on facility posting related to reporting abuse were able to locate numbers for reporting and alternate methods of reporting abuse such as department supervisors and/ or charge nurses. <BR/>During an interview on 04/21/24 at 10:20. a.m., the Administrator and the DON indicated the facility 24 Hour Report and Incident Reports would be reviewed in the morning clinical meetings attended by the Administrator and the Director of Nursing to review for any allegations or instances of abuse and/ or neglect. The weekend manager on duty and weekend RN Supervisor would report any incidents or allegations to the DON and administrator immediately.<BR/>The Administrator was informed the IJ was removed on 04/21/24 at 12:39 a.m. The facility remained out of compliance at potential for more than minimal harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team after each assessment for 3 of 7 residents (Residents #1, #2, and #3) reviewed for comprehensive person-centered care plans.<BR/>1. Resident #1's comprehensive person-centered care plan was not updated to reflect behavior of physical aggression toward another resident. <BR/>2. Resident #2's comprehensive person-centered care plan was not updated to reflect an altercation when another resident had been physically aggressive with her. <BR/>3. Resident #3's comprehensive person-centered care plan was not updated to reflect when another resident had been physically aggressive with her. <BR/>These failures could place residents at risk for not receiving the necessary care and services they required. <BR/>The findings were:<BR/>1. Record review of Resident #1's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included schizophrenia (a serious mental condition involving breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion), persistent mood [affective] disorder (marked disruptions in emotions {severe lows called depression or highs called hypomania or mania]), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations).<BR/>Record review of Resident #1's care plan, dated 10/25/23, indicated Resident #1 had a diagnosis of schizophrenia and was at risk for manic episodes and increased behaviors. Interventions included monitor for delusions and hallucinations and monitor for increased agitation, anger, verbal, physical aggression and document in the clinical record. The care plan was not updated with Resident #1's physical aggression toward other residents on 04/03/24 when she pulled Resident #3 out of her wheelchair or on 04/19/24 when she attempted to smother her roommate (Resident #2) with a pillow. <BR/>Record review of Resident #1's quarterly MDS assessment, dated 04/08/24, indicated Resident #1 was able to make herself understood and usually understand others, and had moderate cognitive impairment indicated by a BIMS score of 11. She had had no hallucinations, delusions, or physical or verbal behaviors. She required partial to moderate assistance with most ADLs.<BR/>Record review of Resident #1's clinical note (related to the incident with Resident #3) dated 04/03/24 at 11:30 a.m. and signed by LVN N indicated CNA came and informed LVN N that Resident #1 pulled Resident #3 out of her wheelchair onto the floor of Resident #1's room. Resident #1 said I'm not a fucking babysitter, I need help my motherfucking self she needs to keep her ass out of my motherfucking room. On arrival to the secure unit residents were already separated and in different rooms. LVN N educated and redirected Resident #1, she was informed that physical aggression would not be tolerated, and it was not her right to put hands on anyone. LVN A indicated that Resident #1 did not verbalize understanding. <BR/>Record review of the incident report dated 04/19/24 at 03:40 a.m., Completed by LVN A indicated she was notified by CNA that Resident #2 was yelling for help because Resident #1 (her roommate) had placed a pillow over Resident #2's face and held it over her face. Resident #2 came out of her room yelling for help. The residents were separated, and Resident #2 was assessed with no bruising on her face and no shortness of breath. Resident #1 admitted she did it and stated, Don't send me to jail please send me to a mental institution. Resident #2 was moved to another room for her protection and safety. MD was paged and LVN A was awaiting response. Administrator was notified. <BR/>During an interview on 04/22/24 at 01:05 p.m., the MDS nurse said she was responsible for updating resident care plans with the DON's supervision. She said she had not been aware of Resident #1's aggression toward other residents. She said she received updates concerning residents during the facility morning care meetings, through review of new orders, and reviewing the facility 24-hour updates. She said not updating care plans with changes in resident status or behaviors could result in staff being unaware of the changes. <BR/>During an interview on 04/22/22 at 01:26 p.m., the ADON stated Resident #1 was transferred to a behavioral hospital on [DATE] after her attempt to hurt Resident #2. The ADON stated he was not sure why Resident #1's comprehensive person-centered care plan was not updated and should have been because it would ensure the resident received consistent care. <BR/>2. Record review of Resident #2's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility 12/05/23. Resident #2 had diagnosis which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning) with agitation, major depressive disorder (a metal health disorder characterized by persistently depressed mood causing significant impairment in daily life), and schizophrenia.<BR/>Record review of Resident #2's care plan, dated 07/31/23 indicated Resident #2 had an altered thought process and was at risk for further decline and injury as evidenced by dementia and short- and long-term memory deficit. Interventions included keep resident and others safe and monitor for mental status changes. The care plan was not updated with the altercation 0n 04/19/24 when Resident #1 attempted to smother her with a pillow.<BR/>Record review of Resident #2's quarterly MDS dated [DATE] indicated Resident #2 was able to make herself understood and understood others, and had severe cognitive impairment indicated by a BIMS score of 6. She had feelings of being down, depressed, and hopeless 2-6 (several) days and had no behaviors. <BR/>Record review of Resident #2's clinical note dated 04/19/24 at 03:54 a.m. and signed by LVN A indicated she was notified by CNA B that Resident #2 came running out of her room yelling for help and saying her roommate (Resident #1) placed a pillow over her face and held it over her face. The residents were separated, and Resident #2 was assessed with no bruising on her face and no shortness of breath. Resident #2 was moved to another room for her protection and safety. <BR/>During an interview on 04/21/24 at 02:44 p.m., the DON said the MDS nurse was responsible for updating care plans with changes in resident status/behavior with her supervision. She said Residents #1, #2, and #3's care plans should have been updated that the physical altercations had happened and goals and interventions for those focuses. She said if care plans were not updated it put residents at risk for not receiving the care and services they needed. <BR/>During an interview on 04/22/24 at 01:05 p.m., the MDS nurse said she had not been aware that Resident #2 had been involved in an altercation with Resident #1 on 04/03/24 so she didn't update the care plan. <BR/>3. Record review of Resident #3's face sheet dated 04/20/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included cerebral infarction (stroke), spastic hemiplegia (a common post-stroke condition that causes stiff or rigid muscles) affecting right dominant side, vascular dementia (dementia [a condition characterized by progressive or persistent loss of intellectual functioning] caused by an impaired supply of blood to the brain), mood disorder (marked disruptions in emotions [severe lows called depression or highs called hypomania or mania]), and depression.<BR/>Record review of Resident #3's care plan revised on 06/21/23 indicated Resident #3 was deemed at risk for wandering related to being ambulatory with her wheelchair, diagnosis of dementia, and history of exit seeking. Goals included Resident #3 would be able to wander in a safe environment (secure unit) with no occurrence of injury and dignity would be maintained. The care plan was not updated with the incident from 04/03/24 when Resident #3 wandered into Resident #1's room and Resident #1 pulled her out of her wheelchair onto the floor. <BR/> Record review of Resident #3's annual MDS dated [DATE] indicated Resident #3 was sometimes able to make herself understood and usually understood others, and had severe cognitive impairment indicated by a staff assessment. She had mood of little interest or pleasure in doing things several (2-6 days) and behaviors directed toward others 1 to 3 days and no wandering behaviors.<BR/>During an interview on 04/22/24 at 01:05 p.m., the MDS nurse said she had not been aware Resident #3 was pulled out of her wheelchair onto the floor by Resident #1 on 04/03/24 so she had not updated the care plan with the altercation. <BR/>Record review of facility policy Care Plans, Comprehensive Person-Centered revised October 2018, indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 7 residents (Resident #1) reviewed for accidents and supervision.<BR/>The facility failed to place Resident #1 on one-on-one supervision or move her to a private room after she pulled Resident #3 out of her wheelchair after Resident #3 self-propelled her wheelchair into Resident #1's room. <BR/>The facility failed to place Resident #1 on one-on-one supervision after Resident #1 tried to kill Resident #2 (her roommate) by placing a pillow over her face. <BR/>On 04/20/24 at 02:29 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 04/21/24, the facility remained out of compliance at a severity level with the potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.<BR/>These failures could place residents at risk of abuse, physical harm, mental anguish, emotional distress, and death.<BR/>Findings included:<BR/>1. Record review of Resident #1's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included schizophrenia (a serious mental condition involving breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion), persistent mood [affective] disorder (marked disruptions in emotions {severe lows called depression or highs called hypomania or mania]), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations).<BR/>Record review of Resident #1's care plan, dated 10/25/23, indicated Resident #1 had a diagnosis of schizophrenia and was at risk for manic episodes and increased behaviors. Interventions included monitor for delusions and hallucinations and monitor for increased agitation, anger, verbal, and physical aggression and document in clinical record. Resident #1 was taking psychotropic medication and was at risk for adverse reactions and depression, anxiety, and/or psychosis driven behaviors. Interventions included monitor for anxiety driven behaviors and report any noted behaviors to MD for further orders.<BR/>Record review of Resident #1's quarterly MDS assessment, dated 04/08/24, indicated Resident #1 was able to make herself understood and usually understand others, and had moderate cognitive impairment indicated by a BIMS score of 11. She had had no hallucinations, delusions, or physical or verbal behaviors. She required partial to moderate assistance with most ADLs.<BR/>Record review of Resident #1's clinical file revealed there were no care plans available for review related to homicidal ideations.<BR/>Record review of Resident #1's clinical note (related to the incident with Resident #3) dated 04/03/24 at 11:30 a.m. and signed by LVN N indicated CNA came and informed LVN N that Resident #1 pulled Resident #3 out of her wheelchair onto the floor of Resident #1's room. Resident #1 said I'm not a fucking babysitter, I need help my motherfucking self she needs to keep her ass out of my motherfucking room. On arrival to the secure unit residents were already separated and in different rooms. LVN N educated and redirected Resident #1, she was informed that physical aggression would not be tolerated, and it was not her right to put hands on anyone. LVN A indicated that Resident #1 did not verbalize understanding. <BR/>Record review of a psychiatric services visit note completed on 04/17/24 at 11:01 a.m. and signed by the NP indicated Resident #1 was being seen for schizophrenia and anxiety. Goals for treatment included compliance with treatment plan, reduced risk of assaultive or inappropriate behaviors, reduction of psychotic thinking, stabilization of anxious/irritable mood, stabilization of cognitive problems, stabilization of depressed mood, increased interpersonal interactions and reduced withdrawal. Resident #1 had shown mild improvement in response to treatment. <BR/>Record review of the incident report dated 04/19/24 at 03:40 a.m., Completed by LVN A indicated she was notified by CNA B that Resident #2 was yelling for help because Resident #1 (her roommate) had placed a pillow over Resident #2's face and held it over her face. Resident #2 came out of her room yelling for help. The residents were separated, and Resident #2 was assessed with no bruising on her face and no shortness of breath. Resident #1 admitted she did it and stated, Don't send me to jail please send me to a mental institution. Resident #2 was moved to another room for her protection and safety. MD was paged and LVN A was awaiting response. Administrator was notified. <BR/>During a telephone interview on 04/20/24 at 08:40 a.m., the Administrator said she received a text from LVN A on 04/19/24 at approximately 06:00 a.m. when she woke up reporting Resident #1 had placed a pillow over Resident #2's face and Resident #1 was requesting to go to a mental institution. She said her immediate action had been to request an additional CNA for the secure unit from her corporate office and she had just received approval for the CNA this morning but had not hired a new CNA yet. The Administrator said the secure unit had one dedicated CNA and one nurse that floats between the other rooms and the secure unit. She said Resident #2 had been moved into another room on the secure unit. She said no other safety measures had been put in place on the secure unit. <BR/>During an observation and interview on 04/20/24 at 09:05 a.m., CNA L said she was assigned the secure unit today with LVN C who was floating between the secure unit and rooms outside the unit. CNA L was sitting in the TV room with 4 residents and said Residents #1 and #2 were in their rooms alone. <BR/>During an observation and interview on 04/20/24 at 09:10 a.m., Resident #1 was alone in her room on the secure unit and resting in bed. She said yesterday (04/19/24) her roommate (Resident #2) was trying to put spells on her, and she had to stop her. She said she tried to hurt Resident #2. Resident #1 could not recall trying to hurt any other residents. <BR/>During an interview on 04/20/24 at 09:35 a.m., the DON said she was not at the facility on 04/19/24 because she had to work the night shift last night. She said was notified on 04/19/24 about Resident #1 putting a pillow over Resident #2's face, but she was now looking back on what was done after the incident. She said LVN A reported the incident, but there was no documentation in the clinical record about the incident or if LVN A notified the police, the physician or the responsible party. She said notifications should have been made and she was doing the notifications to the MD and RP. She said based on the aggression Resident #1 should have been transferred to a behavioral hospital for evaluation. The DON said the only reason Resident #1 had pulled Resident #3 out of her wheelchair on 04/03/24 was because she went into Resident #1's room. She said she had instructed all staff on the secure unit to keep Resident #3 from wandering into other resident's rooms, but no additional safety measures had been put in place.<BR/>During an interview on 04/20/24 at 10:05 a.m., LVN C said he received report from LVN A on 04/19/24 at 06:00 a.m. about the incident between Resident #1 and Resident #2. He said he was assigned to the secure unit and other rooms outside the secure unit on the 06:00 a.m. to 02:00 p.m. shift on 04/19/24. He said he never noticed if Resident #1 ever came out of her room on his shift and he wasn't sure if Resident #2 was in or out of her room during the day. <BR/>During an interview on 04/20/24 at 10:51 a.m., the DON said she notified the NP of the incident that occurred on 04/19/24 to the NP and Resident #1's RP on 04/20/24 at approximately 10:00 a.m. She said she had completed the referral to the behavioral hospital for Resident #1 and was awaiting her transfer. She said the NP gave no new orders for Resident #2. <BR/>During an observation on 04/20/24 at 11:26 a.m., Resident #1 was sleeping alone in her room. Staff were assisting other residents on the secure unit with ADLs. There was no one-on-one monitoring with Resident #1. <BR/>During an interview on 04/20/24 at 02:30 p.m., the DON said the facility only placed residents on one-on-one monitoring if they were homicidal or suicidal. She said Resident #1 was not placed on one-on one monitoring, but she should have been. The DON said was going to sit with Resident #1 (after surveyor intervention) until she was transported to the behavioral hospital. She said not having her under increased monitoring could result in harm to other residents on the secure unit. <BR/>During a telephone interview on 04/20/24 at 3:25 p.m., the MD said he did not receive any pages on 04/19/24 and the incident of Resident #1 putting a pillow over the face of Resident #2 had not been reported to him. The MD said if the incident had been reported to him, he would have given orders to transfer Resident #1 to a behavioral hospital.<BR/>During an interview on 04/20/24 at 03:59 p.m., the DON said she sat with Resident #1 until she was transported by ambulance to a behavioral hospital at approximately 03:30 p.m.<BR/>2. Record review of Resident #2's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility 12/05/23. Resident #2 had diagnosis which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning) with agitation, major depressive disorder (a metal health disorder characterized by persistently depressed mood causing significant impairment in daily life), and schizophrenia.<BR/>Record review of Resident #2's care plan, dated 07/31/23 indicated Resident #2 had an altered thought process and was at risk for further decline and injury as evidenced by dementia and short- and long-term memory deficit. Interventions included keep resident and others safe and monitor for mental status changes. <BR/>Record review of Resident #2's quarterly MDS dated [DATE] indicated Resident #2 was able to make herself understood and understood others, and had severe cognitive impairment indicated by a BIMS score of 6. She had feelings of being down, depressed, and hopeless 2-6 (several) days and had no behaviors. <BR/>Record review of a psychiatric visit note completed on 04/17/24 at 11:01 a.m. and signed by the NP indicated Resident #2 was being seen for anxiety, dementia, depression/sadness, schizophrenia, bipolar, and insomnia. Resident #2 was oriented to person, place, month, and situation. Resident #2 exhibited a logical thought process with fair insight and judgement. She had little to no risk of aggression. <BR/>Record review of Resident #2's clinical note dated 04/19/24 at 03:54 a.m. and signed by LVN A indicated she was notified by CNA that Resident #2 came running out of her room yelling for help and saying her roommate (Resident #1) placed a pillow over her face and held it over her face. The residents were separated, and Resident #2 was assessed with no bruising on her face and no shortness of breath. Resident #2 was moved to another room for her protection and safety. <BR/>During an observation and interview on 04/20/24 at 09:15 a.m., Resident #2 was alone in her room on the secure unit lying in bed. She said she had to be moved to a new room because her previous roommate had put a pillow over her face and tried to kill her while she was sleeping. She said she felt as safe as she could in her present surroundings. <BR/>During an observation and interview on 04/20/24 at 11:19 a.m., Police Officer M visited Resident #2 in her room. Resident #2 remained alone in her room and made a verbal statement to Police Officer M that Resident #1 had tried to kill her by placing a pillow over her face while she was sleeping. She said she wanted to press charges against Resident #1 so she wouldn't try to kill her again. <BR/>During an interview on 04/22/24 at 01:45 p.m., CNA O said she worked the 06:00 a.m. to 02:00 p.m. on 04/19/24 and the incident of Resident #1 putting a pillow over Resident #2's face was reported to her by CNA B. She said Resident #1 was in a happy mood all day going into and out of the TV room listening to the music that was playing in the room. CNA O said Resident #2 said she was afraid to be in her room and stayed close to her or other residents in the TV room. She said Resident #2 kept saying, why is she still here-she tried to kill me. <BR/>3. Record review of Resident #3's face sheet dated 04/20/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included cerebral infarction (stroke), spastic hemiplegia (a common post-stroke condition that causes stiff or rigid muscles) affecting right dominant side, vascular dementia (dementia [a condition characterized by progressive or persistent loss of intellectual functioning] caused by an impaired supply of blood to the brain), mood disorder (marked disruptions in emotions [severe lows called depression or highs called hypomania or mania]), depression <BR/>Record review of Resident #3's care plan revised on 06/21/23 indicated Resident #3 was deemed at risk for wandering related to being ambulatory with her wheelchair, diagnosis of dementia, and history of exit seeking. Goals included Resident #3 would be able to wander in a safe environment (secure unit) with no occurrence of injury and dignity would be maintained. <BR/>Record review of Resident #3's annual MDS dated [DATE] indicated Resident #3 was sometimes able to make herself understood and usually understood others, and had severe cognitive impairment indicated by a staff assessment. She had mood of little interest or pleasure in doing things several (2-6 days) and behaviors directed toward others 1 to 3 days and no wandering behaviors.<BR/>Record review of a psychiatric services visit note completed 04/10/24 at 11:06 a.m. and signed by the NP indicated Resident #3 was being seen for anxiety, dementia, and depression/sadness. Resident #3 was aphasic (unable to speak, write, or understand speech or writing because of damage to the brain) with no behavioral problems. Goals for treatment included adjustment to need for placement in facility, increased compliance with treatment plan, stabilization of anxious/irritable mood, stabilization of cognitive problems, stabilization of depressed mood, increased interpersonal interactions and reduced withdrawal. Resident had shown mild decline in response to treatment. <BR/>During an observation and interview on 04/20/24 at 09:05 a.m., Resident #3 was sitting in the TV room of the secure unit. She was unable to answer question about the incident. She was holding her right arm against her, and it appeared to have contractures at her elbow and wrist. CNA L said staff tried to keep Resident #3 busy because she wandered into other resident's rooms. She said she was not working the day Resident #3 wandered into Resident #1's room and Resident #1 pulled her out of her wheelchair to the floor, but it had been reported to her by another CNA.<BR/>During an interview on 04/20/24 at 09:35 a.m. the DON said the only reason Resident #1 had pulled Resident #3 out of her wheelchair on 04/03/24 was because she went into Resident #1's room. She said she had instructed all staff on the secure unit to keep Resident #3 from wandering into other resident's rooms.<BR/>During an interview on 04/20/24 at 10:51 a.m., the NP said the facility notified her on 04/03/24 of the incident of Resident #1 pulling Resident #3 out of her wheelchair and onto the floor. <BR/>During a telephone interview on 04/22/24 at 11:35 a.m., LVN N said on 04/03/34 at approximately 11:30 a.m., a CNA reported to her that Resident #3 had self-propelled her wheelchair into Resident #1's room and Resident #1 pulled her out of her wheelchair and onto the floor. Resident #3 was on the floor in Resident #3's room. LVN N said she assessed Resident #3 who was sitting in the floor of Resident #1's room at the foot of her bed. She had no visible injuries, and she was assisted back into her wheelchair and out of the room. Resident #3 was unable to say how she got onto the floor. LVN N said she notified the ADON, the Administrator, MD, and the RP of the incident. <BR/>During a telephone interview on 04/22/24 at 12:16 p.m., Resident #3's RP said she was notified on 04/03/24 by the nurse that Resident #3 had wheeled herself into another resident's room and the other resident had pulled Resident #3 out of her wheelchair and onto the floor. RP said she visited Resident #3 every day and she had witnessed residents on the secure unit being aggressive to staff and other residents. <BR/>Record review of the facility's Abuse and Neglect Policy dated June 2023 indicated VI. Protection: Have procedures to: Protect residents from physical or psychosocial harm during the investigation . 3. Attending physician will be notified. A. This includes but not limited to full assessment of physical and psychosocial well-being; sending resident to hospital if needed; depending on circumstance, keep resident on 1:1, assign a female/male depending on the accusation/allegation.<BR/>Record review of the facility's undated policy Problematic Behavior Management- Clinical Protocol indicated 2. The staff will identify, document, and inform the Physician about a resident's mental status, behavior, and cognition. This will include details about any problematic behavior such as onset, frequency, and precipitating factors. <BR/>This was determined to be an Immediate Jeopardy (IJ) on 04/20/24 at 02:25 p.m. The Administrator was notified. The Administrator was provided the IJ template on 04/20/24 at 2:29 p.m.<BR/>The Facility's Plan of Removal for Immediate Jeopardy was accepted on 04/21/24 at 10:37 a.m. and reflected the following: <BR/>Action: <BR/>o On 4/20/24 Resident #1 was immediately placed on 1 on 1 until the facility could transfer Resident #1 to psychiatric hospital, waiting on approval from the behavioral hospital to transport.<BR/>On 4/20/24 Charge nurse/ nurse managers Immediately reviewed residents in the secure unit that have had recent incidents within the last 30 days involving resident altercation to make sure they had the correct supervision. 0 residents besides Resident #1 were identified. Charge nurse/ nurse managers Immediately assessed Resident #2 & Resident #3 and the rest of the residents in the secure unit for possible mental or physical abuse, no additional mental health needs were identified, nor any suspected physical abuse found at this time.<BR/>o on 4/20/24 Administrator/ or designee Immediately in-service all staff 100% completion on behavioral management policy which included resident to resident abuse regarding residents exhibiting aggressive behaviors towards others, steps to do and how to approach the situation. <BR/>o On 4/20/24 the Administrator reviewed schedules and a second CNA was added in the secure unit for extra supervision. If a resident was identified as a repeated aggressor, the facility will immediately add additional support staff in order to keep residents safe.<BR/>On 4/21/24 Administrator/ DON were Inservice by Regional Director of Clinical Operations if additional staff was needed for immediate safety interventions no approval was needed from corporate to add additional staff for support. <BR/>After completion of secure unit resident review/assessments on 04/20/24 by charge nurses and nurse mangers, no other residents were found to have additional mental health needs and no other suspected physical abuse was found.<BR/>The facility reviewed the system for problematic behavior management. The facility created a plan of improvement to assure residents behaviors were monitored, documented, and reported to the MD. The Administrator reviewed schedules and a second CNA was added in the secure unit for extra supervision and if a resident was identified as a repeated aggressor, the facility will immediately add additional support staff in order to keep residents safe. <BR/>All staff were educated on behavioral management policy which included resident to resident abuse regarding residents exhibiting aggressive behaviors towards others. steps to do and how to approach the situation. <BR/>Until alternative and/or safe living arrangements were made the resident will be placed on one-on-one supervision with facility staff. Resident care plans will also be updated to include any acts of aggression or being to receiver of aggression. <BR/>Monitoring of the POR included the following: <BR/>During interviews conducted on 04/20/24 from 03:30 p.m. though 06:00 p.m. and 04/21/24 from 08:15 a.m. 11:48 a.m. included LVN A (10 p.m. - 6 a.m.), LVN C (6:00 a.m. to 2:00 p.m.), LVN D (6:00 a.m. -2:00 p.m.), LVN E (6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.), LVN F (10:00 p.m. to 6:00 a.m.), LVN G (10 p.m. to 10 p.m.), LVN H (2:00 p.m. to 10:00 p.m., LVN I (2:00 a.m. to 10 p.m.),RN j (weekend shifts), LVN K (6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.), CNA B (10:00 p.m. to 6:00 a.m.), CNA L (6:00 a.m. to 2:00 p.m.), CNA O (6:00 a.m. to 2:00 p.m.), CNA P (2:00 p.m. to 10:00 p.m.), CNA Q (2:00 p.m. to 10:00 p.m.), CNA R (10:00 p.m. to 6:00 a.m.), CNA S (6:00 a.m. to 2:00 p.m.), the Dietary Manager, Dietary Aide T, Dietary Aide U, Housekeeper V, Housekeeper W, MDS Nurse and 1 ADON who worked all shifts. Staff were able to verbalize procedure of separating residents during an act of aggression, reporting the aggression to a charge nurse, the ADON, the DON, and the Administrator. To maintain one-on one monitoring of the aggressor for the protection of other residents. Licensed staff verbalized aggression incidents should also be reported to the MD, police, and both resident's RPs. <BR/>Interviews conducted with five alert residents on 04/21/24 from 8:00 a.m. to 10:00 a.m. indicated they would report abuse to the administrator or the DON. They were not afraid of any residents.<BR/>During an interview on 04/21/24 at 10:20. a.m., the Administrator and the DON indicated the facility 24 Hour Report and Incident Reports would be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any allegations or instances physical aggression. The weekend manager on duty and weekend RN Supervisor would report any incidents or allegations to the DON and administrator immediately.<BR/>Record review of all incidents from the previous 90 days indicated there were no additional incidents of acts of physical aggression as of 04/21/24. <BR/>Record review of training records indicated all staff (nursing and non-nursing) were in-serviced on 04/20/24 and 04/21/24 regarding the facility abuse and neglect policy and the behavioral management policy, the procedure for reporting incidents and acts of aggression, suspected abuse/neglect, recognizing threats of harm (to self and others), and physician notification. <BR/>The Administrator was informed the Immediate Jeopardy was removed on 04/21/24 at 12:39 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and with a scope identified as isolated 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 observation, interview, and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), was provided to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 2 residents (Resident #1) reviewed for CPR.<BR/>The facility failed to ensure staff utilized the AED (automated external defibrillator- a medical device that analyzes the heart's rhythm and, if necessary, delivers an electrical shock to the heart in attempt to re-establish an effective rhythm) when Resident #1 was found on [DATE] unresponsive, not breathing, and no pulse. Resident #1 was pronounced deceased on [DATE].<BR/>An IJ was identified on [DATE] at 3:57 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. <BR/>This failure could place residents at risk of not receiving necessary life-saving measures, decline in health, and death. <BR/>Findings include:<BR/>Record review of Resident #1's face sheet dated [DATE] indicated he ws a [AGE] year old male admitted to the facility on [DATE] with diagnoses including type II diabetes (a disease that occurs when blood glucose, also called blood sugar, is too high), cerebral infarction (pathologic process that results in an area of necrotic tissue in the brain), chronic combined systolic and diastolic congestive heart failure (systolic CHF, the ventricles cannot produce enough pressure in the contraction phase to push blood into circulation, diastolic CHF, the ventricles cannot relax, expand, or fill with enough blood-combined CHF is a combination of the two), hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure, acute kidney failure (kidneys are suddenly not able to filter waste products from the blood), hyperlipidemia (also known as high cholesterol, means too many lipids (fats) in the blood), morbid obesity, hypokalemia (low blood potassium levels), respiratory failure with hypoxia (not have enough oxygen in your blood), and angina pectoris (chest pain or discomfort due to coronary heart disease). The face sheet indicated Resident #1 was a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures would be provided to keep them alive. This process can include chest compressions, artificial ventilation and defibrillation and is referred to as CPR.).<BR/>Record review of Resident #1's quarterly MDS dated [DATE] indicated he had clear speech, was usually understood and usually understood others, he had moderate impaired cognitive function (BIMS score 11).<BR/>Record review of Resident #1's care plan dated [DATE] (revised [DATE]) indicated Resident #1's RP requested full code status. Interventions included if Resident #1's heart stops, initiate CPR and call 911 for transfer to the hospital.<BR/>Record review of Resident #1's physician order dated [DATE] indicated Resident #1 was full code-CPR.<BR/>Record review of the facility's incident report dated [DATE] at 11:10 p.m. (per LVN A the time was an error) completed by LVN A indicated Resident #1 was noted lying face down on the floor. Resident #1 was unresponsive. His name was called and he was rolled on to his back. Code team was initiated and 911 was called. Staff performed resuscitation efforts until paramedics took over. Physician, RP, and DON notified. Resident #1's breathing was noted as noisy, labored, long period of hyperventilation, ([NAME] Stokes Respiration- respiration is a type of breathing disorder characterized by cyclical episodes of apnea and hyperventilation). He was comatose-(unrousable to verbal or physical stimuli).<BR/>Record review of the progress note dated [DATE] at 2:50 a.m., completed by LVN A indicated LVN A reassessed Resident #1 post fall. Resident #1 was lying on the floor face down. Resident #1 was not breathing. LVN attempted to get BP, pulse ox (electronic device that measures the saturation of oxygen carried in red blood cells). Resident #1 did not respond to his name or sternum rub. Code team was initiated and 911 was called. After several attempts to resuscitate Resident #1, he was pronounced expired by doctor via EMS. Notified physician. Family notified and present in facility. <BR/>Record review of the EMS run time provided by SW I indicated EMS received an alarm on [DATE] at 11:28 p.m. EMS left the faciity on [DATE] at 12:29 a.m.<BR/>Record review of the facility's crash cart check of list dated [DATE] and [DATE] indicated there was no AED device listed.<BR/>During an interview on [DATE] at 10:43 a.m., LVN A said Resident #1 had a fall at approximately 10:45 p.m. on [DATE]. She said the time indicated on the incident report was an approximate time and not the correct time. She said CNA B assisted to get Resident #1 up and into his wheelchair. She said he was yelling and cussing. When she asked him why he did not push the call light for help, Resident #1 got up from his wheelchair and went to the toilet then got clean clothes and went to bed. She said she assessed Resident #1 and all his vital were WNL . She said he did not hit his head and had clear speech. She said she told Resident #1 she would be back in 15 minutes to complete another set of neurological checks. She said she went to administer medications to two other residents and was returning to Resident #1's room at approximately 11:15 p.m. when CNA B indicated Resident #1 was on the floor. She said Resident #1 was face down on the floor and did not respond to his name or to sternum rub. She said he had no pulse and she could not get a pulse. She said she called for the crash cart and directed a CNA (she could not recall which CNA) to call 911. She said she began CPR because Resident #1 was a full code. She said she continued CPR until EMS arrived and took over. She said she did not call for the AED and did not use the AED during CPR for Resident #1. She said she could not recall why she did not call for the AED or use the AED during CPR. She said she had her CPR training and CPR card. She said she should have used the AED and followed the prompts. She said the AED device was used for giving the heart a shock if it was needed.<BR/>During an interview on [DATE] at 10:55 a.m., the DON said she received a call on [DATE] at 11:38 p.m. from LVN A. LVN A reported Resident #1 was unresponsive and the paramedics were working on him. She said she arrived in the facility on [DATE] at 11:42 p.m. to cover a shift.<BR/>Observation on [DATE] at 11:05 a.m. revealed the facility's crash cart was adjacent to the nurse station. The check off list did not include AED inspection. Observation of the AED device indicated it was in a red box with a sign hanging on a wall halfway between the nurse's station and the dining room area. There was no inspection or check off list available for review.<BR/>During an interview on [DATE] at 11:39 a.m., the DON said she asked LVN A why she did not use the AED during CPR for Resident #1 on [DATE]. She said LVN A said she did not know and that she was probably busy with CPR and did not think about the AED. She said LVN A should have called for the AED and the crash cart. She said the AED device was used for giving the heart a shock if it was needed. She said the only AED was located down the hall from where the crash cart was located (by the nurse station). She said she had scheduled training for 2:00 p.m. today ([DATE]) to re-train staff to remember to use the AED during CPR. The DON said there was no separate check off list for the AED device. She said she checked the device daily and replaced the pads when necessary.<BR/>During an interview on [DATE] at 3:15 p.m., CNA B said on [DATE] at approximately 11:15 p.m., she was passing Resident #1's door and saw he was lying face down on the floor . She said he did not respond when she called his name. She said she called for LVN A as LVN A was coming up the hall and she went immediately into the room. She said she assisted to roll Resident #1 over on to his back. She said LVN A called Resident #1's name and rubbed his chest and Resident #1 did not respond. She said CNA D arrived and was directed to call 911. She said LVN A began CPR. CNA B said she went to get LVN C from another area of the facility. She said LVN C brought the crash cart. She said CNA D returned to the room and said she called 911. She said she did not recall anyone calling for the AED device. She said she did not think or remember to get the AED device. She said she had her CPR card and knew the AED device was should have been implemented during the CPR for Resident #1. She said the AED device was used for giving the heart a shock if it was needed.<BR/>The surveyor called, left a voicemail, and sent a text to LVN C on [DATE] at 3:46 p.m. for an interview. The surveyor left her contact information. LVN C did not respond.<BR/>Record review of LVN A's CPR card was issued on [DATE] and valid until 10/2025.<BR/>Record review of LVN C's CPR card issued on [DATE] and valid for two years.<BR/>Record review of the facility's undated Emergency Procedure-Cardiopulmonary Resuscitation indicated Personnel have completed training on the initiation of the cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. 4. The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse, 5. Early delivery of a shock with a defibrillator plus CPR within 3 to 5 minutes of collapse can further increase chances of survival.<BR/>Record review of the facility's undated Automatic External Defibrillator policy indicated The facility has an automatic external defibrillator (AED) equipment available for emergency use.<BR/>The Administrator was notified on [DATE] at 3:57 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template and the plan of removal was requested on [DATE] at 4:06 p.m.<BR/>The facility's Plan of Removal was accepted on [DATE] at 8:14 a.m. and included:<BR/>Action:<BR/>Immediately an In-service was conducted with nurses on CPR/ and using AED machine when someone is in cardiac arrest, 100% in-service completion was done by Director of Nursing on [DATE]. Licensed nurses are the only ones to perform CPR and use AED currently at the facility.<BR/>The Clinical Director of Operations provided the Director Of Nursing (DON) a modified crash cart checklist which included AED machine, DON was in serviced on form to be checked off daily by nurses to ensure AED is operable and ready for usage. Director of Nursing completed services with nurses on [DATE]. AED will be placed with the Crash cart for easy access during CPR.<BR/>Please review and accept this Plan of Removal. All items above have been completed with completion date and time [DATE], at 8:30 pm. <BR/>On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Observation on [DATE] at 8:45 a.m. revealed the crash cart was located under the AED (located in a red box under a sign) in the hall between the nurse station and the dining room. The daily check sheet was updated with checks to include the AED and checked off by nursing staff. The green indicator light was flashing on the AED. The DON verified that the AED was functioning as intended.<BR/>Interviews were conducted on [DATE] from 9:00 a.m. through 10:35 a.m. with the Administrator, the DON, LVN E 6-2, LVN F 6-2, CNA G 6-2 and 2-10, CNA H 6-2, prn other shifts, CNA J 6-2, prn other shifts, RNA K 8-5 Monday-Friday, CMA L 6-2, prn other shifts, CNA M 10-6, LVN A 10-6, and LVN N weekend doubles. They indicated they received an in-service on [DATE] and were aware the AED was supposed to be collected with the crash cart and utilized when staff called for the crash cart/911. They were aware the crash cart was moved from the nurse station and located under the AED on the wall, in the hall between the nurse station and the dining room. The nurses also said that checking the box marked AED meant the AED was above the crash cart and the AED's blinking green indicator light was observed. The nurses said the flashing green indicator light the AED was ready for use. <BR/>Record review of an in-service dated [DATE] indicated all nursing staff were trained on the CPR policy including the use of AED and daily checks of the crash cart and of the AED to ensure it was working. <BR/>Record review of the daily check sheet for the crash cart was updated on [DATE] with checks to include the AED. The sheet was checked off on [DATE] by nursing staff. <BR/>While the IJ was removed on [DATE] at 10:37 a.m., the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately consult with the resident's physician of lab results and treatment recommendations for 1 of 8 residents (Resident #1) reviewed for change of condition. <BR/>The facility did not notify Resident #1's wound care doctor or primary physician of recommendations dated 11/16/22 for antibiotics for possible wound infection of the right foot and a CT or MRI to rule out (osteomyelitis inflammation or swelling that occurs in the bone). Resident #1 had a partial resection of the 5th metatarsal of the right foot and wound and muscle debridement of the left trans-metatarsal stump on 12/15/22. <BR/>The facility did not notify or consult Resident #1's physician of stat lab dated 11/22/22 results positive for MRSA.<BR/>An Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., 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 of not receiving immediate corrective actions necessary for their health and that could cause, or likely continue to cause, serious injury, harm, impairment or death.<BR/>Findings included: <BR/>Record review of physician orders dated 01/03/2022 indicated Resident #1 was a [AGE] year-old male re-admitted on [DATE] (originally admitted on [DATE]). His diagnoses included long term use of antibiotics, acute osteomyelitis (inflammation or swelling that occurs in the bone) right ankle and foot, diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high , cellulitis bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin, gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection), non-pressure chronic ulcer of left foot, cellulitis of left lower limb and acute osteomyelitis of left foot and ankle.<BR/>Record review of an MDS dated [DATE] indicated Resident #1 had moderate impaired cognition, was understood by others and usually understood others. He was not able to focus and had disorganized thinking. He had delusions. He required supervision for most ADLS. He utilized a wheelchair for mobility. He was continent of bladder and bowel. Resident #1 had surgical wounds and received surgical wound care. There was no antibiotic use noted.<BR/>Record review of a care plan dated 11/09/22 indicated Resident #1 had right foot amputation of small toe and was at risk of further skin breakdown, infection, and worsening surgical wound. Interventions included inform MD of progress and perform treatment per order and if no improvement report to MD.<BR/>Record review of a care plan dated 11/09/2022 indicated Resident #1 had a left foot amputation of toes and was at risk for further skin breakdown, infection and worsening surgical wound. Interventions included inform MD of progress and perform treatment per order and if no improvement report to MD.<BR/>Record review of a wound evaluation dated 11/16/22, completed by RN B, indicated Resident #1's right lateral toe's surgical wound measured 3.5 cm X 2.0 cm X .3 cm, 25 % slough (necrotic tissue that needs to be removed from the wound), and moderate serous exudate (type of exudate that is clear, thin, and watery in contrast to a purulent exudate that is opaque). There was purulent (discharging) pus present and RN B recommended ABT (Bactrim, Doxycycline) and a CT or MRI to rule out osteomyelitis (inflammation or swelling that occurs in the bone).<BR/>Record review of Resident #1's clinical record indicated there was no progress note or treatment note available for review from the wound care consult on 11/16/22.<BR/>Record review of progress note dated 11/21/22 at 12:08 p.m., completed by RN N (previous DON) indicated Resident #1 complained he had drainage to bilateral feet. Scant amount of clear drainage noted with no signs of infection. MD A's office was called and there was no answer and would follow-up.<BR/>Record review of progress note dated 11/21/22 at 4:57 p.m., completed by ADON D, indicated she contacted MD A's office and received order for wound culture of wounds to bilateral feet. Antibiotic to be ordered once results were received.<BR/>Record review of STAT lab results dated 11/22/22 indicated Resident #1 was positive for methicillin-resistant Staphylococcus aureus (MRSA) - (staph infection that is difficult to treat because of resistance to some antibiotics).<BR/>Record review of wound care report dated 12/13/22, competed by DPM C indicated Resident #1 was admitted to hospital for infection of right foot.<BR/>Record review of a history and physical report (included with the hospital records) dated 12/14/22 indicated Resident #1 had osteomyelitis with gangrene at right metatarsal site. <BR/>Record review of consult report (included with the hospital records) dated 12/15/22 indicated Resident #1 had a partial resection of the 5th metatarsal of the right foot and wound and muscle debridement of the left trans-metatarsal stump. The wound cultures were growing MRSA. Resident #1 returned to the facility on [DATE].<BR/>During an observation and interview on 12/30/23 at 10:50 a.m., Resident #1 was wearing a protective foot device on his right and left foot. He said he had a staph infection on his foot and was in the hospital and received intravenous antibiotics. He said he had to have more amputations because he did not get the antibiotics he was supposed to get. He could not recall who said he should have antibiotics.<BR/>During an interview on 01/04/23 at 10:07 a.m., TX LVN E said she made wound rounds with RN B (wound care consultant) on 11/16/22. She said it was toward the end of her shift and she asked a nurse to fax the wound care consult with recommendations to Resident #1's wound care doctor (DPM C) and to follow up because she was not returning to the facility. She said 11/16/22 was the last day she worked in the facility. She said she could not recall the name of the nurse she gave the recommendations or directions to notify the physician. She said she did not notify Resident #1's primary physician or DPM C. She said she could not recall if she documented the recommendations in a progress note.<BR/>During an interview on 01/04/23 at 1:40 p.m., LVN F said she worked on 11/16/22 and did not recall TX LVN E giving her a wound care recommendation for Resident #1 or being directed to fax it to DPM C.<BR/>During an interview on 01/04/23 at 2:00 p.m., ADON H said she worked on 11/16/22 and did not recall TX LVN E giving her a wound care recommendation for Resident #1 or being directed to fax it to DPM C.<BR/>During an interview on 01/4/23 at 3:26 p.m., RN L (from the wound care clinic) said they did not have any knowledge and were not informed of RN B's recommendations dated 11/16/22 for Resident #1 that included ABT (Bactrim, Doxycycline) and a CT or MRI to rule out osteomyelitis.<BR/>During an interview on 01/04/23 at 5:10 p.m., RN B said she was a wound care consultant and was contracted by the facility to observe wound care and train the staff. She said she completed rounds with TX LVN E on 11/16/22 and noted purulent pus and made recommendation for ABT and CT or MRI to rule out osteomyelitis. She said TX LVN E should have informed the primary physician of the assessment and recommendations. She said some primary physicians would direct the facility to forward the recommendations to the wound care physician. She said infection of the wound could get to the blood or get septic (infected with microorganisms, especially harmful bacteria).<BR/>During an interview on 01/05/23 at 9:43 a.m., ADON D said she did get the order for Resident #1's wound culture on 11/21/22. She said she was new to the position and should probably have followed up on the results. She said she was off sick and then forgot to follow up when she returned to work.<BR/>During an interview on 01/05/23 at 10:54 a.m., MD A said he did not receive notification of Resident #1's wound culture results dated 11/22/22 regarding positive MRSA results. He said the facility staff should have notified him of RN B's recommendations dated 11/16/22 for Residents #1. He said the delay of notification, treatment, or ABT most likely would not have made any difference because Resident #1 had been on multiple [NAME] and was ABT resistant. He said Resident #1 was non-compliant with wound care and physician orders. MD A said it was also most likely to require additional surgeries and amputations.<BR/>During an interview on 01/05/23 at 12:06 p.m., ADON H said if they received recommendations from consultants, they would contact the physician. ADON D said lab results were supposed to be called or faxed over to the physician for review. ADON H said the lab results should be noted in the progress notes and also in the 24-hour report.<BR/>During an interview on 01/05/23 at 12:27 p.m., LVN J said all recommendations for care, tests, or treatments were supposed to be sent to the physician for review. LVN M said lab results were supposed to be called or faxed over to the physician for review. LVN M They said the lab results are supposed to be noted in the progress notes and also in the 24-hour report.<BR/>During an interview on 01/05/23 at 8:25 a.m., the DON said Resident #1's lab results were not forwarded to MD A. She said the lab results should have been followed up by nursing staff to ensure Resident #1 received treatment. She said the results were in the facility electronic portal but not all staff had access to the portal. She said not informing the physician of recommendations or lab results could result in delay of treatment or further decline of condition. She said she could not attribute the delay of antibiotics to Resident #1 requiring additional amputation surgery because he was noncompliant with care and treatment. She said staff were in-serviced on 12/29/22 to ensure labs were documented and followed up as required.<BR/>During an interview on 01/05/23 at 8:30 a.m., LD I said Resident #1's lab results were available in the portal. He said the lab results were also faxed to the facility. He said he was not able to say who had access to the portal or who reviewed the labs. <BR/>The surveyors made three attempts on 01/03/23 and three attempts on 01/04/22 were made to contact DPM C regarding Resident #1 and there was no return call.<BR/>Record review of the facility's undated Laboratory Services and Reporting policy indicated .7. Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range.<BR/>Record review of the facility policy Change in Condition Communication dated 06/19 indicated physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patients/ residence condition, enter. Provide guidance for the notification of patients/ residents and their responsible party regarding changes in condition. F. Recent Labs <BR/>The Administrator and the DON were notified an Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., 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/>The facility's POR dated 01/26/23 indicated:<BR/>DON and CNO reviewed 24-hour report for the last 24 hours. Changes in condition noted on the 24-hour report were addressed and documented.<BR/>On 1.25.23 CNO re-educated facility nurses including nurse managers regarding:<BR/>Documentation on resident's change(s) in condition to include completion of SBAR assessment when notifying MD and documenting on 24-hour report. <BR/>During shift nurses were educated and those not scheduled to work will be in-serviced prior to their next scheduled shift. Completion Date 1.26.23 @ 12 pm.<BR/>ADON/Designee will pull 24-hour report and 24-hour lookback and SBARS for completion of MD notification and that orders were followed through.<BR/>ADONs will bring 24-hour report book and SBAR to clinical morning meeting to discuss follow-up if needed.<BR/>DON/Designee will audit 24-hour report and SBARS weekly on Wednesdays looking for MD notification and that orders were carried out and acted upon.<BR/>On 01/26/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record review of staff training dated 01/25/23 indicated all nursing staff were trained in person or by phone to notify the physician via phone call of lab results and document in the electronic records. If there was no response the nursing staff would notify the Medical Director. If there was no answer nursing staff would send the resident to the hospital if it was a critical lab result. <BR/>Record review of new hire education indicated the DON incorporated physician notification and the facility policy as part of the onboarding education as of 01/26/23. <BR/>Record review of the facility monitoring sheets indicated the Administrator would verify the education was done for new hires starting 01/26/23. There were no new hires as of 01/26/23.<BR/>Record review of the monitoring sheets indicated the Administrator reviewed at the morning meetings on 01/26/23 to verify that a change in condition requiring physician notification was done, physician orders, a follow up if physician deemed it necessary and the order was followed through for 3 residents.<BR/>Record review dated 01/25/23 indicated the Administrator was educated by Corporate Nurse on how review change of condition at morning meetings.<BR/>During an interview on 01/26/23 at 2:20 p.m., the Administrator was able to verbalize the monitoring for change of condition procedures. She said the DON and the ADON were designees if she was not able to complete the monitoring during morning meeting.<BR/>Record review of the facility's chart audit dated 01/25/23 indicated the facility had completed 100% chart audit and notified the physicians of any changes as required.<BR/>Interviews conducted on 01/26/23 from 1:15 p.m. through 2:30 p.m. with the DON, the 2 ADONs, 1 RN, and 6 LVNS, who worked all shifts, indicated they were able to correctly state the protocols for notification of the physician when there was a change of condition or a need to alter treatment for a resident, reviewing and reporting abnormal labs, clarification of verbal orders, ensuring the physician was made aware of the change or condition, and ensuring the physician received the lab results.<BR/>An Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., 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 ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and resident choices for 1 of 8 residents (Resident #1) reviewed for treatment and services. <BR/>The facility failed implement interventions and recommendations for Resident #1 dated 11/16/22 for antibiotics for possible wound infection of the right foot and a CT or MRI to rule out (osteomyelitis inflammation or swelling that occurs in the bone). Resident #1 he was admitted to the hospital on [DATE] had a partial resection of the 5th metatarsal of the right foot and wound and muscle debridement of the left trans-metatarsal stump. <BR/>The facility failed to address Resident #1's stat lab dated 11/22/22 results positive for MRSA.<BR/>An Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., 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 of not receiving care as required and could result in further decline of condition and possible death. <BR/>Findings included:<BR/>Record review of physician orders dated 01/03/2022 indicated Resident #1 was a [AGE] year-old male re-admitted on [DATE] (originally admitted on [DATE]). His diagnoses included long term use of antibiotics, acute osteomyelitis (inflammation or swelling that occurs in the bone) right ankle and foot, diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high , cellulitis bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin, gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection), non-pressure chronic ulcer of left foot, cellulitis of left lower limb and acute osteomyelitis of left foot and ankle.<BR/>Record review of an MDS dated [DATE] indicated Resident #1 had moderate impaired cognition, was understood by others and usually understood others. He was not able to focus and had disorganized thinking. He had delusions. He required supervision for most ADLS. He utilized a wheelchair for mobility. He was continent of bladder and bowel. Resident #1 had surgical wounds and received surgical wound care. There was no antibiotic use noted.<BR/>Record review of a care plan dated 11/09/22 indicated Resident #1 had a left foot amputation of toes and right foot amputation of small toe and was at risk of further skin breakdown, infection, and worsening surgical wound. Interventions included inform MD of progress and perform treatment per order and if no improvement report to MD.<BR/>Record review of a wound evaluation dated 11/16/22, completed by RN B (wound consultant), indicated Resident #1's right lateral toe's surgical wound measured 3.5 cm X 2.0 cm X .3 cm, 25 % slough (necrotic tissue that needs to be removed from the wound), and moderate serous exudate (type of exudate that is clear, thin, and watery in contrast to a purulent exudate that is opaque). There was purulent (discharging) pus present and RN B recommended ABT (Bactrim, Doxycycline) and a CT or MRI to rule out osteomyelitis (inflammation or swelling that occurs in the bone).<BR/>Review of Resident #1's clinical records indicated there was no progress note or treatment note available for review from the wound care consult on 11/16/22.<BR/>Record review of progress note dated 11/21/22 at 12:08 p.m., completed by RN N (previous DON) indicated Resident #1 complained he had drainage to bilateral feet. Scant amount of clear drainage noted with no signs of infection. MD A's office was called and there was no answer and would follow-up.<BR/>Record review of progress note dated 11/21/22 at 4:57 p.m., completed by ADON D, indicated she contacted MD A's office and received order for wound culture of wounds to bilateral feet. Antibiotic to be ordered once results were received.<BR/>Record review of STAT lab results dated 11/22/22 indicated Resident #1 was positive for methicillin-resistant Staphylococcus aureus (MRSA) - (staph infection that is difficult to treat because of resistance to some antibiotics). There was no documented evidence the results were reviewed by the physician or NP.<BR/>Record review of wound care report dated 12/13/22, competed by DPM C indicated Resident #1 was admitted to hospital for infection of right foot.<BR/>Record review of a history and physical report (included with the hospital records) dated 12/14/22 indicated Resident #1 had osteomyelitis with gangrene at right metatarsal site. <BR/>Record review of consult report (included with the hospital records) dated 12/15/22 indicated Resident #1 had a partial resection of the 5th metatarsal of the right foot and wound and muscle debridement of the left trans-metatarsal stump. The wound cultures were growing MRSA. Resident #1 returned to the facility on [DATE].<BR/>During an observation and interview on 12/30/23 at 10:50 a.m., Resident #1 was wearing a protective foot device on his right and left foot. He said he had a staph infection on his foot and was in the hospital and received intravenous antibiotics. He said he had to have more amputations because he did not get the antibiotics he was supposed to get. He could not recall who said he should have antibiotics.<BR/>During an interview on 01/04/23 at 10:07 a.m., TX LVN E said she made wound rounds with RN B (wound care consultant) on 11/16/22. She said it was toward the end of her shift and she asked a nurse to fax the wound care consult with recommendations to Resident #1's wound care doctor (DPM C) and to follow up because she was not returning to the facility. She said 11/16/22 was the last day she worked in the facility. She said she could not recall the name of the nurse she gave the recommendations or directions to notify the physician. She said she did not notify Resident #1's primary physician or DPM C. She said she could not recall if she documented the recommendations in a progress note.<BR/>During an interview on 01/04/23 at 1:40 p.m., LVN F said she worked on 11/16/22 and did not recall TX LVN E giving her a wound care recommendation for Resident #1 or being directed to fax it to DPM C.<BR/>During an interview on 01/04/23 at 2:00 p.m., ADON H said she worked on 11/16/22 and did not recall TX LVN E giving her a wound care recommendation for Resident #1 or being directed to fax it to DPM C.<BR/>During an interview on 01/4/23 at 3:26 p.m., RN L (from the wound care clinic) said they did not have any knowledge and were not informed of RN B's recommendations dated 11/16/22 for Resident #1 that included ABT (Bactrim, Doxycycline) and a CT or MRI to rule out osteomyelitis.<BR/>During an interview on 01/04/23 at 5:10 p.m., RN B said she was a wound care consultant and was contracted by the facility to observe wound care and train the staff. She said she completed rounds with TX LVN E on 11/16/22 and noted purulent pus and made recommendation for ABT and CT or MRI to rule out osteomyelitis. She said TX LVN E should have informed the primary physician of the assessment and recommendations. She said some primary physicians would direct the facility to forward the recommendations to the wound care physician. She said infection of the wound could get to the blood or get septic (infected with microorganisms, especially harmful bacteria).<BR/>During an interview on 01/05/23 at 9:43 a.m., ADON D said she did get the order for Resident #1's wound culture on 11/21/22. She said she was new to the position and should probably have followed up on the results. She said she was off sick and then forgot to follow up when she returned to work.<BR/>During an interview on 01/05/23 at 10:54 a.m., MD A said he did not receive notification of Resident #1's wound culture results dated 11/22/22 regarding positive MRSA results. He said the facility staff should have notified him of RN B's recommendations dated 11/16/22 for Residents #1. He said the delay of notification, treatment, or ABT most likely would not have made any difference because Resident #1 had been on multiple [NAME] and was ABT resistant. He said Resident #1 was non-compliant with wound care and physician orders. MD A said it was also most likely to require additional surgeries and amputations.<BR/>During an interview on 01/05/23 at 12:06 p.m., ADON H said if they received recommendations from consultants, they would contact the physician. ADON D said lab results were supposed to be called or faxed over to the physician for review. ADON H said the lab results should be noted in the progress notes and also in the 24-hour report.<BR/>During an interview on 01/05/23 at 12:27 p.m., LVN J said all recommendations for care, tests, or treatments were supposed to be sent to the physician for review. LVN M said lab results were supposed to be called or faxed over to the physician for review. LVN M They said the lab results are supposed to be noted in the progress notes and also in the 24-hour report.<BR/>During an interview on 01/05/23 at 8:25 a.m., the DON said Resident #1's lab results were not forwarded to MD A. She said the lab results should have been followed up by nursing staff to ensure Resident #1 received treatment. She said the results were in the facility electronic portal but not all staff had access to the portal. She said not informing the physician of recommendations or lab results could result in delay of treatment or further decline of condition. She said she could not attribute the delay of antibiotics to Resident #1 requiring additional amputation surgery because he was noncompliant with care and treatment. She said staff were in-serviced on 12/29/22 to ensure labs were documented and followed up as required.<BR/>During an interview on 01/05/23 at 8:30 a.m., LD I said Resident #1's lab results were available in the portal. He said the lab results were also faxed to the facility. He said he was not able to say who had access to the portal or who reviewed the labs. <BR/>The surveyors made three attempts on 01/03/23 and three attempts on 01/04/22 were made to contact DPM C regarding Resident #1 and there was no return call.<BR/>Record review of the facility's undated Laboratory Services and Reporting policy indicated .7. Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range.<BR/>Record review of the facility policy Change in Condition Communication dated 06/19 indicated physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patients/ residence condition, enter. Provide guidance for the notification of patients/ residents and their responsible party regarding changes in condition. F. Recent Labs <BR/>An Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., 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/>The facility's POR indicated:<BR/>CNO and DON reviewed recommendations from Wound Care Consultant's last visit. Recommendations were addressed with Primary Care Physician and followed through.<BR/>Nurses at the facility including nursing supervisors were re-educated on 1/25/2023 by CNO that:<BR/>When a recommendation is made to ask the physician for a decision on the recommendation and follow it through. <BR/>During shift nurses were educated and those not scheduled to work will be in-serviced prior to their next scheduled shift. Completion Date 1.26.23 @ 12 pm.<BR/>DON will incorporate this education as part of the onboarding education for any newly hired nurses.<BR/>Dietary, Wound Care, and Pharmacy Consultants will email recommendations to DON/Administrator once visit is complete. <BR/>DON will forward recommendations to assigned ADON/Designee for MD notification to obtain approval/denial of recommendation.<BR/>DON/Designee will audit recommendation(s) on day 4, for completion to include MD notification and that orders were carried out and acted upon.<BR/>On 01/26/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Review of recommendations from Wound Care Consultant's last visit were addressed with Primary Care Physician and followed through as of 01/26/23.<BR/>Review of nurse training and nursing supervisors indicated they were re-educated on 01/25/23 by the CNO to ask the physician for a decision on recommendations and follow it through. All nurses were educated as of 01/26/23 and those not scheduled to work would be in-serviced prior to their next scheduled shift. The DON will incorporate this education as part of the onboarding education for any newly hired nurses. As of 01/26/23 there were no untrained new hires.<BR/>Review of email notification sent to contracted consultants including dietary, wound care, and pharmacy, indicated they would ensure their recommendations were emailed to the DON and Administrator once they have completed their assessments. <BR/>During an interview on 01/26/23 at 2:30 p.m., the DON said she would forward all recommendations to assigned ADON/Designee for MD notification to obtain approval/denial of recommendation. She said she or the Designee would audit recommendation(s) on day 4, for completion to include MD notification and orders were followed.<BR/>Interviews conducted on 01/26/23 from 1:15 p.m. through 2:40 p.m. with the DON, 2 ADONs, 1 RN, and 6 LVNS, who worked all shifts, indicated they would document all recommendations in resident clinical record, shift report, and 24-hour report for follow-up and implementation of orders. They were able to correctly state the protocols for reviewing and reporting abnormal labs, clarification of verbal orders, ensuring the physician was made aware of the change or condition, and ensuring the physician received the lab results.<BR/>An Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., 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 interview and record review the facility failed to obtain laboratory services ordered by physician for 1 of 11 residents (Resident #1) reviewed for labs.<BR/>The facility did not obtain labs- CBC (complete blood count- used to measure different parts and features of blood), CMP (Complete Metabolic Panel-test used to monitor the blood sugar levels, the balance of electrolytes and fluid as well as the health of kidneys and liver), lipid (levels of cholesterol and other fats in the blood), A1C (blood test that measures average blood sugar levels over the past 3 months), thyroid (blood tests used to measure how well the thyroid gland is working), vitamin B12 and vitamin D hydroxy 25 as ordered by NP C on 02/23/24.<BR/>This failure could place residents at risk of a delay in treatment. <BR/>The findings were:<BR/>Record review of Resident #1's face sheet dated 03/12/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnosis included degenerative disease of nervous system, dementia the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities, and unspecified protein-calorie malnutrition a nutritional status in which reduced availability of nutrients leads to changes in body composition and function.<BR/>Record review of Resident #1's MDS dated [DATE] indicated she was able to make herself understood, sometimes understood others, had severe cognitive impairment (BIMS score of 4), used a wheelchair for mobility, required set up or clean up assistance prior to or following eating, and required substantial/maximal assistance for most ADLS.<BR/>Record review of Resident #1's physician orders (provided as evidence by NP C in a text message with a photo) dated 02/23/24 indicated NP C ordered CBC, CMP, lipid, A1C, thyroid, vitamin B12, and vitamin D hydroxy 25.<BR/>Record review of Resident #1's EMR indicated there were no lab results indicating the labs had been drawn in the facility since the 02/23/24's physician's order.<BR/>Resident #1 was discharged to hospital on [DATE] and not available for interview during the investigation.<BR/>Record review of Resident #1's hospital records dated 02/29/24 indicated Resident #1 presented with productive cough, shortness of breath, altered mental status, generalized weakness malaise, and some seizures fevers. Resident #1 had decreased appetite and worsening confusion over last 24 hours. Resident #1's Pulse Ox was 91%, she was in emotional distress, obviously demented, delirious, and agitated. Her eyes were sunken in. She was given a liter of fluid for hydration, and Rocephin (antibiotic) via IV, nebulizer treatments for wheezing, and supplemental oxygen. Resident #1 was dehydrated with acute renal failure, pneumonia, and a UTI. Hospital records further indicated: Please note that critical care services that were medically necessary and reasonable were provided by me for approximately just over 30-60 minutes excluding intubation procedures I believe that the failure to initiate my given interventions on an emergent basis would likely result in sudden clinical significant or life-threatening deterioration in the patient's condition. <BR/>Record review of Resident #1's hospital lab records dated 02/29/24 indicated <BR/>-BUN 68-High-Reference Range 10-20 mg/dL<BR/>-Creatinine 2.0-High-Reference Range 0.6-1.1 mg/dL<BR/>-Est GFR 25-Low-Reference Range 50-100 (stage 4 kidney disease)<BR/>-Glucose 119-High-Reference Range 60-100 mg/dL<BR/>During an interview on 03/27/24 at 11:56 a.m., NP C said he ordered Resident #1's labs for CBC , CMP, lipid, A1C, thyroid (blood tests used to measure how well the thyroid gland is working), vitamin B12, and vitamin D hydroxy 25 on 02/23/24 for a 6 month follow up to her (Resident #1) previous labs. He said he left the written orders at nurse station #1. He could not recall the nurse he gave the orders to. He said he was not able to locate the results to review. He said the lab results could indicate a need for treatment and not obtaining labs as ordered could place the resident at risk of health complications. <BR/>During an interview on 03/27/24 at 2:19 p.m., the DON said NP C's orders for Resident #1's labs written on 02/23/24 were not transcribed or entered into the portal. She said labs that were ordered on 02/23/24 would have been drawn on 02/26/24. She said she was not able to locate NP C's written orders. She said the orders were left at nurse station #1 and Resident #1's information was at nurse station #2. The DON said the risk of not doing labs if elevated or low results could be a potential problem and not get reported to the physician timely. The DON stated the nurse writing or receiving the order should follow through to completion to ensure the orders were entered in the electronic portal.<BR/>Record review of the facility's undated Lab and Diagnostic Test Results-Clinical Protocol indicated . 2. The staff will process test requisitions and arrange for tests.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 preparation kitchen.<BR/>The facility did not ensure baking sheets and baking pans did not have dark colored build up on the outside and inside. <BR/>The facility did not ensure the foods labeled were disposed of after the use by date.<BR/>The facility did not ensure foods removed from their original package were labeled with the required information of what the food was in the container and the use by date or date it was placed in the container. <BR/>The facility did not ensure red bucket of sanitizing solution to clean surfaces in the kitchen had the right amount of cleaning solution.<BR/>These failures could place residents who ate food from the kitchen at risk of foodborne illness. <BR/>Findings included:<BR/>During observation and interview on 11/18/24 of the kitchen on initial tour indicated:<BR/>* at 08:22 a.m. there were <BR/>-4 large baking sheets with dark colored buildup on the inside corners and all along the outside edges; they were stacked together<BR/>-3 large baking pan with dark colored buildup on the inside corners and all along the outside edges; they were stacked together.<BR/>-1 baking pan 9 x 13 with dark colored buildup on the inside corners and all along the outside edges.<BR/>-2 large skillets dark colored buildup on the inside and outside.<BR/>-9 half baking sheets with dark colored buildup on the inside corners and all along the outside edges; they were stacked together.The DM said she had been trying to get them replaced meanwhile she would scrub them.<BR/>* at 08:30 a.m. the right walk-in cooler had a container of pureed food (it was hard to read what item was on the label) dated 11/09/24 and a container of what appeared to be fruit with no label. The DM said the food dated 08/09/24 should have been thrown out after 7 days and the other container should have a label with what was in the container and the date it was placed in the container.<BR/>* at 08:40 a.m. a red bucket of sanitizing solution to clean surfaces in the kitchen was checked and registered less than 50 ppm of chlorine indicating it had no solution. The DM noticed the chlorine solution container was not connected to the dispenser in the 3-compartment sink. The DM said the dispenser was used to fill up the red bucket and should be connected at all times.<BR/>Record review of an undated Food Receiving and Storage policy indicated the following: Policy Interpretation and Implementation: 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) <BR/>Record review of a Sanitation policy revised 2008 indicated the following: Policy Interpretation and Implementation: 4. Sanitizing of environmental surfaces must be performed with one of the following solutions: a. 50-100 ppm chlorine solution; <BR/>Record review of the 2022 Food Code dated 01/18/23 indicated the following:<BR/> 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers <BR/> 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils <BR/> (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. <BR/>(B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. <BR/>(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment for 1 of 2 Halls (Hall 200 long) and the dining room reviewed for physical environment.<BR/>The facility failed to maintain the 200 long hall. Door frames of resident's rooms were not intact. Floor tiles were discolored tiles. There was a buildup of glue, paint, and debris behind all the doors to resident's rooms.<BR/>The facility failed to maintain the exit corridor from the long hall 200 to the smoking area. There were 6 missing floor tiles that each measured 12 inch by 12 inch.<BR/>The facility failed to maintain the main dining room floor. The tile in the main dining room along the back wall on the floor had a 2-inch-wide buildup of old paint and dried glue. There was one missing tile near the door.<BR/>The facility failed to maintain an unlocked closet closet on the 200 long hall that was labeled oxygen on the door. The closet was empty and the walls were covered with black fuzzy substance in clusters on all walls and ceiling. The closet smelled like wet dirt. There was white substance in patches on the inside of the door. Spider webs with round sacs made of silk or web along both lower edge of the closet. <BR/>The facility failed to maintain room [ROOM NUMBER]. room [ROOM NUMBER] had 6-inch base trim detached from the wall and on the floor between the beds for approximately 5 feet.<BR/>The facility failed to maintain room [ROOM NUMBER]. room [ROOM NUMBER] had splashes of a beige substance measuring 2 feet by 3 feet on the ceiling and rips in the curtains covering the sliding door measuring 8 feet along the bottom of the curtains. <BR/>These failures could place residents, staff and visitors at risk of being in unsafe, uncomfortable environment and decreased quality of life due to poor conditions of the facility.<BR/>Findings included:<BR/>During observations on 11/18/24 from 9:00 a.m. to 10:30 a.m., the following was observed:<BR/>*The long hall 200 door frames of all resident rooms were missing paint and were not smooth the wood had missing pieces. The tile from the start of the hall to the end of the hall was discolored and had build-up of glue, paint. In the resident rooms had grime and debris behind all of the doors into the resident's rooms.<BR/>*The exit corridor from the long hall 200 to the smoking area was missing 6 tiles (12 inch by 12 inch tiles) and left the area with discolored concrete in the areas of missing tiles.<BR/>*The tile in the main dining room along the back wall on the floor had 2-inch-wide buildup of old paint and dried glue. There was one missing tile near the door and the floor was approximately 2 inches lower.<BR/>*There was an unlocked closet on the 200 long hall that was labeled oxygen on the door. The closet was empty and the walls were covered with black fuzzy substance in clusters on all walls and ceiling. The closet measured 3 feet by 5 feet and the closet smelled like wet dirt. There was white substance in patches on the inside of the door. There were spider webs with round sacs along both lower edges of the closet extended the full width of the closet. The inside of the door had white substance in patches/clusters covering the door.<BR/>During an observation on 11/20/24 at 11:00 a.m., room [ROOM NUMBER] had 6-inch base trim that was detached from the wall and on the floor between the beds for approximately 5 feet. room [ROOM NUMBER] had splashes of beige substance on the ceiling in an area of 2 feet by 3 feet. The curtains covering the sliding door were ripped and torn all along the bottom of the approximately 8 feet of the drapes.<BR/>During an interview on 11/18/24 at 10:45 a.m., the MD said he was responsible for the maintenance of the building. He said he never opened that closet and it would need to be painted and cleaned up. He said the closet should not be like that. He said the floors and door frames needed to be replaced and fixed and had not gotten to fix the other areas. <BR/>During an interview on 11/20/24 at 11:00 a.m., the Administrator said the floors needed to be replaced and door frames repaired. She said the base trim needed to be reattached in several resident rooms and would be repaired. She denied any documented plans for remodel or repairs. She said the facility had replaced the curtains in most of the rooms. She said in room [ROOM NUMBER], the curtains would be replaced again and raised so the resident's wheelchair would not roll on the drapes and tear them. She said all the staff were responsible for the facility being comfortable and in good repair. She said she was responsible for the facility.<BR/>Record review of an undated Maintenance Service policy indicated .Policy Interpretation and Implementation: 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 of 6 residents (Resident #4 and Resident #Unnamed) reviewed for abuse and neglect. <BR/>1. The facility failed to implement their written policies and procedures to prevent sexual abuse and potential further sexual abuse by Resident #1 when Resident #1 grabbed Resident #Unnamed's breast. <BR/>2. The facility failed to implement their written policies and procedures to prevent sexual abuse and potential further sexual abuse by Resident #1 when Resident #1 touched Resident #4's breast. <BR/>On 10/05/24 at 4:40 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/06/24, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of the Plan of Removal. <BR/>These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.<BR/>Findings include:<BR/>1. Record review of a face sheet dated 09/23/24 indicated Resident #1 was [AGE] years old, initially admitted to facility on 03/07/24 and readmitted to facility on 09/09/24. His diagnoses included dementia (loss of cognitive functioning), delusional disorder (a mental health condition that causes unshakable beliefs in something that's untrue), hypertension (condition in which the force of the blood against the artery walls is too high), dysphagia (difficulty swallowing) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). <BR/>Record review of Resident #1's care plan with revision dated 04/24/24 indicated Resident #1 had inappropriate sexual behaviors; resident seeks to satisfy his sexual desires. Interventions included to firmly approach resident that behaviors are not acceptable and document conversations and actions of resident; inform direct caregivers on methods to assist them in handling resident behaviors while providing care; monitor whereabouts of resident and keep distance from others; provide diversional activities and redirect when behaviors happen and document.<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #1 was usually able to make himself understood and usually understands others. He had a BIMS of 08 (moderately impaired cognitively). He exhibited no behaviors over the 7 days look back period. He required supervision or moderate assistance for most ADLS. He was frequently incontinent of bladder and bowel.<BR/>Record review of Resident #1's progress note authored by previous DON R indicated on 08/02/24 at 8:42 a.m., Resident #1 was in the dining room this morning grabbing other resident's breast when nurse tried to redirect him, he stated let me see your P---. Nurse informed him that this kind of behavior would not be accepted. Nurse phoned MD and made him aware of situation. Received one time order for lorazepam 1 milligram IM for agitation.<BR/>Record review of an unsigned 24-hour report indicated:<BR/>08/02/24 08:42 a.m. - Behavior Note<BR/>Resident #1 was in the dining room this morning grabbing other resident breasts. When SN tried to redirect him, he stated, Let me see your pussy. <BR/>SN informed him that this kind of behavior would not be accepted. SN phoned MD and made him aware of the situation. Received on time order for Lorazepam 1 mg IM for agitation. <BR/>08/02/24 10:21 a.m. - Social Services<BR/>SSD sent referral over to behavioral unit at local hospital per DON who said to refer Resident #1 due to behavior displayed. Spoke with rep who said that he would need to be transported to the ER to be assessed. SSD said she would speak to the ADON/DON on how to proceed. <BR/>08/02/24 11:29 a.m. - Behavior Note<BR/>Resident has been extremely inappropriate to staff and other residents sexually. Speaking graphically lewd and grabbing resident's breasts, then laughing and leering. Unable to redirect. DON notified. <BR/>08/02/24 12:32 a.m. - Nurses Note<BR/>Resident #1 sent to hospital ER for psych evaluation due to inappropriate sexual behavior. <BR/>Record Review of Resident #1's behavior monitoring log indicated on 08/02/24 Resident #1 was monitored hourly from 9:00 a.m. until 12:30 p.m.<BR/>Record review of Resident #1's progress note authored by LVN Q on 08/05/24 at 12:55 p.m., indicated the behavioral hospital called to inform facility that Resident #1 did not meet criteria for extended stay and the unit was full. Resident #1 would be transferred back to the facility (on 08/05/24). <BR/>Record review of Resident #1's behavior monitoring log did not indicate Resident #1 had any increased monitoring after discharge from behavioral hospital on [DATE].<BR/>During an observation and interview on 09/30/24 at 11:45 a.m., Resident #1 was sitting up in wheelchair in secure unit dining room. He said he did not recall the incident involving him inappropriately touching other residents that happened on 08/02/24. Resident #1 said that he knew that he was not supposed to touch or hit other residents or staff. Resident #1 was observed trying to stand up without assistance and staff intervened and redirect him by providing activities. Resident #1 was one of 6 residents in the dining room.<BR/>During an interview on 09/30/24 at 2:48 p.m., LVN Q said she was the CN on duty on 08/02/24 and vaguely recalled the incident with Resident #1 touching another female resident's breast. She said she recalled that the incident was in the dining room of the secure unit, and he touched the female's breast and was laughing and leering. He was unable to be redirected, and when removed from the area by staff he was talking sexually to staff and grabbing at their breast. She said that she notified the DON and MD. She said Resident #1 was monitored until he was transferred to a local hospital for evaluation for placement into their behavioral unit. She said she did not recall the female's name that he touched inappropriately. She said that she was in the unit covering for the CNA when the incident occurred, and it was not witnessed by other staff.<BR/>During an interview on 09/30/24 at 3:30 p.m., the previous DON R said she was the active DON at the facility on 08/02/24. She recalled the incident with Resident #1 touching another female resident's breast. She said she was called to the secure unit that morning after breakfast and the CN reported that Resident #1 had touched another female resident's breast and was laughing and leering and was unable to be redirected and when removed from the area by staff he was talking sexually to staff and grabbing at their breast. She said she told the CN to keep Resident #1 on one-on-one monitoring and that she requested the SW to contact a local behavioral hospital for a transfer due to the behavior. She said that she notified all department heads (including the Administrator) during the 9:00 am morning meeting that day. She said Resident #1 was monitored until he was transferred to a local hospital for evaluation for placement into their behavioral unit. She said she did not recall the female resident's name that Resident #1 touched inappropriately. <BR/>During an observation on 10/05/24 at 9:35 a.m., Resident #1 was in his wheelchair alone in the hallway of the secure unit. <BR/>During an observation and interview on 10/05/24 at 9:41 a.m., CNA E was in the dining room of the secure unit with 5 residents. She said she had never observed Resident #1 touch any residents or staff inappropriately. She said she was never told he needed to be monitored closely due to inappropriate sexual touching.<BR/>During an observation and interview on 10/05/24 at 9:44 a.m., CNA CC was in the dining room of the secure unit with 5 residents. She said Resident #1 always talked sexually to staff and he had said some vulgar things to her, but she was never told he had sexually/inappropriately touched another resident or to monitor him closely. <BR/>2. Record review of a face sheet dated 10/05/24 indicated Resident #4 [AGE] years old, initially admitted to the facility 03/13/24 and readmitted on [DATE]. Her diagnosis included dementia (loss of cognitive functioning), cognitive communication deficit (a difficulty with communication caused by disruption to cognition, or brain processes like attention, memory, and Problem solving), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #4 was usually understood and sometimes understands others. She had a BIMS of 08 (moderately impaired cognitively). She exhibited no behaviors over the 7 days look back period. She required moderate assistance for most ADLS. She was always incontinent of bladder and frequently incontinent of bowel.<BR/>Record review of a care plan last revised 07/19/24 for Resident #4 did not indicate she had been touched inappropriately on 08/25/24.<BR/>Record review of an incident report dated 08/25/24 at 7:45 a.m. and signed by RN U indicated CNA heard Resident #4 yell, let go of my titty. CNA saw Resident #1 grabbing Resident #4's breast and reported the incident to her. <BR/>Record review of an incident report dated 08/25/24 at 11:18 a.m. and signed by RN U indicated CNA reported to her that she saw Resident #1 touch a female resident on her breast. Residents were separated. Calls placed to notify ADON, NP, and RN T (previous Abuse Coordinator) and resident's FM UU. Resident #1 was on every 30-minute monitoring. <BR/>Record review of a behavior monitoring log indicated Resident #1 was monitored hourly from 08/25/24 at 8:00 a.m. to 08/27/24 at 10:00 p.m. There was no documentation of further monitoring. <BR/>Record review of a progress note dated 08/28/24 at 9:22 a.m. authored by previous MDS Coordinator DD indicated call placed to responsible party of Resident #1 to inform that resident has been having changes in behavior, both inappropriate sexual behaviors and aggressive behavior. Resident has been accepted to a behavioral hospital. <BR/>Record review of a Behavior Monitor Post an Incident in-service dated 8/28/24 indicated, Immediately after an incident involving resident with physical, verbal, or sexual aggression, the CN will place the resident on monitoring checks, and fill out the from q 1 hr, q 30 min, q 15 min. Call provider and supervisor to notify them of incident. They will continue monitoring checks until the IDT can review the incident and place further interventions. <BR/>During an interview on 09/25/24 at 10:21 a.m. RN T said she was made aware of the incident between Resident #1 and Resident #4. She said staff reported to her (the acting abuse coordinator) Resident #1 and Resident #4 were sitting at a dining table on the secure unit. Staff reported Resident #4 said Resident #1 grabbed her. Resident #1 denied he grabbed Resident #4's breast. She said both residents had low BIMS scores and there was no willful intent. <BR/>During an interview on 09/25/24 at 12:15 p.m., CNA BB said she was getting all the residents into the dining room for the breakfast meal. She said it looked like Resident #1 was touching Resident #4's breast and then he reached for the coloring book and crayons that was on the dining table. She said she told Resident #1 he did not need to be so close to the ladies and he moved away. She said she advised RN U of the incident. She said RN U called the abuse coordinator. She said Resident #4 did not say anything. She said Resident #1 said he did not touch Resident #4's breast. He said he was reaching for the crayons.<BR/>During an interview on 9/27/2024 at 4:00 pm, RN U said that on 8/25/2024 a CNA reported to her that Resident #1 touched a female resident on her breast. RN U said Resident #1 was separated from the female resident, assessed and behavioral monitoring initiated. RN U said she reported the incident to the ADON, NP/MD, AC (RN T) and RP. RN U said that Resident #1 was placed on behavioral monitoring for the incident until the AC (RN T) completed an abuse investigation. RN U said that there were 2 CNAs working the secure unit on 8/25/2024 to provide behavioral monitoring for Resident #1, but one-on-one monitoring was not initiated. She said Resident #1 was monitored q15 minutes. <BR/>During an observation and interview on 10/05/24 at 9:39 a.m., Resident #4 was sitting in her wheelchair in the dining room of the secure unit. She was appropriately dressed and well-groomed. She was unable to answer questions about the incident and just repeated words spoken to her. <BR/>During an interview on 10/05/24 at 3:55 p.m., the Administrator said that she was not the active Administrator/Abuse Coordinator at the time of the incidents with Resident #1 touching another female resident's breast on 08/02/24 or on 08/25/24 when Resident #1 touched Resident #4's breast. She said her expectation for incidents involving resident to resident abuse was for the residents to be separated and the aggressor to be placed on one-on-one monitoring for the protection of other residents. She said the facility policy on abuse and neglect addressed protecting residents from harm during the investigation of the incident and placing the resident on one-on-one monitoring. She said the facility abuse policy was not followed for the incidents involving Resident #1. She said the possible negative outcome of not performing one-on-one monitoring of the resident and protecting the other residents could be physical, emotional, or psychological harm of the residents. She said her expectation was care plans be updated when incidents occur, but the current MDS nurse worked remotely and might not have been aware of the incidents. <BR/>Record review of the undated facility's Abuse and Neglect policy indicated .It is the policy of the facility to administer care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. III. Prevention: Have procedures to: provide residents, families, and staff information on how and to whom they may report concerns, incidents and grievances without fear of retribution; and provide feedback regarding the concerns that have been expressed. Identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur. Establish a safe environment that supports consensual sexual relationship. Develop and implement policy on abuse, neglect, theft, exploitation, and misappropriation of property. Deployment of sufficient and trained staff to deal with behaviors in the units. Identification, assessment, care planning for intervention, and monitoring of residents with needs and behaviors that might lead to conflicts or neglect. The supervisions of staff to identify inappropriate behaviors .ensuring health and safety of residents .VI. Protect residents from physical and psychosocial harm during investigations. 1. If the allegation of abuse involves 2 or more residents, they will all be immediately separated for the protection of all residents involved and those potentially affected by the abuse. 2. Affected residents will be assessed for injury. 3. Attending physician will be notified. a. This includes but not limited to full assessment of physical and psychosocial well-being; sending resident to hospital if needed; depending on circumstance, keep resident on 1:1, assign a female/male depending on the accusation/allegation.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 10/05/24 at 4:40 p.m. The Administrator was notified. The Administrator was provided the IJ template on 10/05/24 at 4:45 p.m.<BR/>The Facility's Plan of Removal for Immediate Jeopardy was accepted on 10/06/24 at 1:50 p.m. and reflected the following: <BR/> Action: <BR/>On 10/05/24 R1 was immediately placed on q 15-minute checks for close monitoring for further behaviors. R1 will remain on q 15-minute checks until IDT team meets in 30 days and reevaluate his behaviors for medical adjustment and determine if R1 will remain on q 15-minute checks or can be discontinued. If Res #1 has additional behaviors, he will be placed one-on-one until psychiatric services can reevaluate his behaviors. Res #1 was placed on q 15 minutes checks due to the recurrent behaviors that require closer monitoring. <BR/>Charge nurse/nurse managers Immediately assessed R2 and the rest of the residents in the secure unit for possible mental, physical, or sexual abuse, no additional mental health needs were identified, nor any suspected physical abuse found at this time. 0 out of 10 residents were affected. <BR/>Administrator/abuse coordinator Immediately in-service all staff 100% completion on Abuse & Neglect policy. for types of abuse (physical, sexual, mental, verbal, neglect, exploitation, and misappropriation) through verbal in-service and written test. Staff were also reeducated for the identification, and intervention in a situation in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur. This education included protecting and/or removing the resident from the situation, as well as who the abuse coordinator is, when to report, and how to report abuse. Staff were reeducated to stay with the aggressor until further instruction from the abuse coordinator and/or until the evaluation or further intervention. <BR/>on 10/05/24 the Administrator, reeducated 100% of staff on behavioral management policy which included resident to resident abuse in regard to residents exhibiting sexual behaviors towards other and steps to do and approach the situation. Reeducation was provided for the staff with instructions for proper documentation for the behavior monitoring log through verbal in-service with monitoring log attached. Staff were reeducated through verbal in-servicing, tests, and questionnaires. <BR/>On 10/05/24 MDS nurse immediately reviewed and updated care plan to reflect sexually inappropriate behaviors. The MDS nurse will review all incident reports related to sexual behaviors to make sure interventions were in place, for the floor staff to be able to see in electronic health record (EHC). Administrator/and or designee will reeducate floor staff to review [NAME] in PCC (EHC) for updated interventions for each resident. <BR/>On 10/06/24 at 11:48 a.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>During interviews conducted on 10/06/24 from 11:05 a.m. though 3:48 p.m. included LVN EE 6:00 a.m. - 6:00 p.m. weekends, LVN FF (6:00 a.m. to 6:00 p.m.) weekends, LVN B (6:00 a.m. 2:00 p.m.), LVN GG (2:00 p.m. to 10:00 p.m.), LVN HH (10:00 p.m. to 6:00 a.m.), LVN X (10:00 p.m. to 6:00 a.m.), MA J (6:00 a.m. to 2:00 p.m & 2:00 p.m. to 10:00 p.m., CNA CC (6:00 a.m. to 2:00 p.m.), CNA E (6:00 a.m. to 2:00 p.m.), CNA JJ (6:00 a.m. to 2:00 p.m.), CNA KK (6:00 a.m. to 2:00 p.m.), CNA LL (6:00 a.m. to 2:00 p.m.), CNA D (2:00 p.m. to 10:00 p.m.), CNA MM (2:00 p.m. to 10:00 p.m.), CNA NN (10:00 p.m. to 6:00 a.m.), and CNA OO (10:00 p.m. to 6:00 a.m.), CNA PP (10:00 p.m. to 6:00 a.m.), Dietary Aide QQ, Housekeeper RR, Occupational Therapist SS, Staffing LVN TT and ADON who worked all shifts. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the Administrator and were able to give examples of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/or identified, such as immediately removing residents from the situation and stay with the aggressor one-on one until further instruction from the Abuse Coordinator. They verbalized proper documentation of behavior monitoring logs. CNA CC and CNA E said they were now aware of Resident #1's sexual behaviors and the resident was to be monitored q15 minutes. They said they documented every 15 minutes on Resident #1's behavior monitoring log. CNA CC and CNA E said they were in-serviced on abuse/neglect and gave examples of physical, verbal, and sexual abuse. They said the Administrator was the Abuse Coordinator and they would immediately report any abuse/neglect allegations to the Administrator. CNA CC and CNA E gave examples of immediate interventions they would take when an allegation or made incuding removing residents from the situation and staying with the aggressor one on one until the Administrator was notifed and gave further instruction. <BR/>During an interview on 10/06/24 at 3:55 p.m., the Administrator said she had conducted in-services with all staff addressing the facility abuse/neglect policy and initiating one-on-one monitoring with the aggressor until they were given further instructions on monitoring. She had addressed the different types of abuse and staff had passed a written test. She said she instructed staff on documentation in behavior monitoring logs. She in-serviced staff on the facility's behavioral management policy which included resident abuse. She said staff were required to pass behavioral management test. She said Resident #1's care plan had been updated and a q15 minute monitoring was required by staff until the IDT meeting in 30 days to re-evaluate his behaviors. <BR/>During an observation and interview on 10/06/24 at 1:15 p.m., Resident #1 was in the TV room with CNA E with no sexual behaviors noted. CNA E said she was assigned to monitor Resident #1 because he was being monitored q15 minutes for sexual behaviors and she was observed documenting the checks on his behavioral monitoring log. <BR/>Record review of behavioral monitoring logs for Resident #1 indicated he was being monitored by staff every 15 minutes beginning on 10/05/24 at 6:00 p.m. to monitor for sexually inappropriate behaviors. <BR/>Record review of a check off list of secured unit residents indicated all residents on the secure unit were assessed by charge nurses and the ADON. <BR/>Record review of nursing assessments completed by the ADON and charge nurses for Resident #4 and all other secure unit residents indicated all residents were assessed for physical and psychosocial changes on 10/05/24. There was no evidence of sexual abuse noted on the assessments.<BR/>Record review of Resident #1's care plan indicated it was updated on 10/05/24 and included he exhibiting unwanted sexual behaviors with interventions of referral to psychiatric services and increased monitoring for behaviors and changes in mental status. <BR/>Record review of Resident #4's care plan indicated it was updated on 10/05/24.<BR/>Record review of facility incident/accident reports indicated no other incidents of inappropriate sexual behaviors. <BR/>Record review of quiz results, dated 10/05/24 and 10/06/24, indicated all staff passed the quiz regarding abuse, neglect, reporting, and one-on-one monitoring.<BR/>Record review of a list of all facility staff used for tracking the required in-service training on abuse/neglect, behavioral monitoring, and behavioral management indicated all facility staff had received the in-service training in person or by phone. <BR/>The Administrator was informed the IJ was removed on 10/06/24 at 3:58 p.m. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the Administrator and the State Survey Agency, for 8 of 11 residents reviewed for reporting allegations of abuse. (Residents #3, #4, #5, #6, #7, #8, #9, and #10)<BR/>* The facility did not report within 2 hours when Resident #3 reported Resident #4 had touched her breast inappropriately (sexual abuse).<BR/>* The facility did not report within 2 hours when Resident #5 kicked Resident #6 in the back (physical abuse).<BR/>* The facility did not report within 2 hours when Resident #7 hit Resident #8 and he hit her back (physical abuse).<BR/>* The facility did not report within 2 hours when Resident #9 swung at Resident #10 with her fist and Resident #5 hit back causing scratches (physical abuse). <BR/>This failure could place the residents at risk of abuse and neglect.<BR/>Findings included:<BR/>1. An email to HHSC Complaint and Incident Intake dated 04/13/23 at 11:13 AM indicated the name and title of the person making the initial report; [ADM] the date and time the person became aware of the reportable incident; 04/12/23 approximately 07:20 PM a detailed narrative of the incident; [Resident #3] approached nurse after coming out of [Resident #4] room saying I have to tell you something. [Resident #3] then went on to say that yesterday [Resident #4] touched me on my breast .<BR/>Record review of the Provider Investigation Form indicated the following:<BR/>* Date Reported to HHSC-04/13/23 <BR/>* Time: 11:13 AM<BR/>* Incident Category: Other<BR/>* If other, specify: Resident to Resident contact<BR/>* Incident Date: 04/12/23; and <BR/>* Time of Incident: 06:30 PM.<BR/>2. An email to HHSC Complaint and Incident Intake dated 04/19/23 at 07:53 PM indicated the name and title of the person making the initial report; [ADM] the date and time the person became aware of the reportable incident; 04/19/23 approximately 04:40 PM a detailed narrative of the incident; Resident #5 kicked another resident [Resident #6] in her back. This resident stated she kicked her because she was in her way <BR/>Record review of the Provider Investigation Form indicated the following:<BR/>* Date Reported to HHSC-04/19/23 <BR/>* Time: 07:53 PM<BR/>* Incident Category: Other<BR/>* If other, specify: Resident to Resident contact<BR/>* Incident Date: 04/19/23; and <BR/>* Time of Incident: 04:00 PM.<BR/>3. An email to HHSC Complaint and Incident Intake dated 04/19/23 at 08:23 PM indicated the name and title of the person making the initial report; [ADM] the date and time the person became aware of the reportable incident; 04/19/23 approximately 04:40 PM a detailed narrative of the incident; Resident #7 said Resident #8 hit him when he was trying to pass her in his wheelchair. He stated he hit her back.<BR/>Record review of the Provider Investigation Form indicated the following:<BR/>* Date Reported to HHSC-04/19/23 <BR/>* Time: 08:23 PM<BR/>* Incident Category: Other<BR/>* If other, specify: Resident to Resident contact<BR/>* Incident Date: 04/19/23; and <BR/>* Time of Incident: 04:00 PM.<BR/>4. An email to HHSC Complaint and Incident Intake dated 04/24/23 at 11:30 AM indicated Reporter's Name and Title: [ADM] Date/Time you first learned of incident: 04/24/23 approximately 08:55 AM Brief narrative summary of the reportable incident: Upon investigation Resident #9 went into Resident #10 room and pulled her covers off and then proceeded to take clothing items out of closet. [Resident #10] stated she got up out of bed asked [Resident #9] to leave her room and [Resident #9] swung at her fist and she was simply defending herself <BR/>Record review of the Provider Investigation Form indicated the following:<BR/>* Date Reported to HHSC-04/24/23 <BR/>* Time: 11:30 AM<BR/>* Incident Category: Other<BR/>* If other, specify: Resident to Resident contact<BR/>* Incident Date: 04/24/23; and <BR/>* Time of Incident: left blank.<BR/>During an interview on 06/12/23 at 01:35 PM the DON said she was the acting Abuse Coordinator (AC) since 05/27/23 when the ADM resigned. She said initial reports of self-reported incidents were done through email since October of last year. She said one resident inappropriately touching another resident's private areas was sexual abuse. She said one resident hitting, slapping, or punching another resident was physical abuse. She said 2 residents fighting was physical abuse. She said all allegations of abuse were to be reported to the SA within 2 hours. She said the incidents regarding Residents #5, #6, #7, #8, #9, and #10 were physical abuse. She said the incident regarding Residents #3 and #4 was sexual abuse. She said all of the incidents should have been reported within 2 hours. <BR/>The facility did not have a current ADM. The former ADM was not available for interview. An attempt was made to call but no return call.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy for 4 of 7 residents (Residents #1, #2, #3, and #4) reviewed for personal privacy in that: <BR/>CNA A failed to provide privacy for Resident #1 during bed mobility and personal care while Resident #2 was in the room. <BR/>The facility failed to provide privacy for Residents #3 and #4. The room did not have a privacy curtain to allow for privacy when the residents were in the room. <BR/>These failures could place residents at risk for low self-esteem, loss of dignity, and decreased quality of life due to a lack of privacy during their care.<BR/>Findings included: <BR/>1. Record review of Resident #1's electronic face sheet, undated, revealed the resident was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included stroke (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) with left side non-dominant side, Morbid obesity, hyperlipidemia (elevated level of lipids), depressive disorder (medical illness that negatively affects how you feel, the way you think and how you act), and anxiety (persistent and excessive worry that interferes with daily activities).<BR/>Record review of Resident #1's initial MDS assessment, dated 10/01/23, revealed Resident #1's BIMS score was 10, which indicated he was moderately impaired cognitively. He required supervision and moderate assistance in performing most activities of daily living. He was incontinent of bowel and bladder. He used electric wheelchair for mobility. <BR/>Record review of Resident #1's care plan, dated 06/15/23, revealed resident needed extensive assistance with bed mobility, personal hygiene/grooming, toileting and total assistance with bathing, dressing, and transfers.<BR/>2. Record review of Resident #2's electronic face sheet, undated, revealed the resident was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included intracranial injury (occurs when blood vessels burst between your brain and the outermost of three protective layers that cover your brain) without loss of consciousness, dementia (loss of cognitive functioning), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), schizoaffective disorder- mental health condition with a combination of symptoms of schizophrenia and mood disorder, depressive disorder (medical illness that negatively affects how you feel, the way you think and how you act), and anxiety (persistent and excessive worry that interferes with daily activities).<BR/>Record review of Resident #2's initial MDS assessment, dated 09/21/23, revealed Resident #2's BIMS score was 14, which indicated he was cognitively intact. He required supervision and limited assistance in performing most activities of daily living. He was occasionally incontinent of bowel and bladder. <BR/>Record review of Resident #2's care plan, dated 06/15/23, revealed resident needed assistance with bed mobility, personal hygiene/grooming, toileting, bathing, dressing, and transfers.<BR/>During an observation on 10/12/23 at 2:00 pm, CNA A provided ADL care for Resident #1 while the resident's roommate, Resident #2, was in the room. CNA A pulled the privacy curtain at the foot of Resident #1's bed but the curtain was not pulled between the residents' beds to allow for privacy. There was not a ceiling track to allow for a privacy curtain. CNA A removed Resident #1's shorts and checked his brief for incontinence. Resident #1's brief, buttocks and back was completely exposed. Resident #2 sitting at the side of his bed and able to see care being provided to Resident #1. <BR/>During an interview on 10/24/23 at 2:15 pm, CNA A said she had worked in the facility for 2 months. She said she transferred Resident #1 back to bed per his request and provided personal care for him. CNA A stated Resident #1 should have a privacy curtain between him and Resident #2 for resident privacy. She said she tried to use the sheet/blanket to keep him covered while providing the care to promote privacy. CNA A acknowledged Resident #2 was able to visually see Resident #1 being transferred to bed and personal care being provided. She said Resident #2 was usually not in the room when she provided care to Resident #1. <BR/>During an interview on 10/12/23 at 2:30 pm, Resident #1 said he was moved to his current room approximately 1 month ago and to his knowledge there had not been a privacy curtain between him and his roommate's beds. Resident #1 said when he first moved to this room, he requested a privacy curtain but does not recall whom he asked and unable to provide a name. Resident # 1 said he does not feel like he has any privacy or has lack of privacy due to not having a privacy curtain between the beds. Resident #1 said he wished he had a privacy curtain between the beds in the room so he could have privacy when he wanted it. <BR/>3. Record review of Resident #3's electronic face sheet, undated, revealed the resident was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included mood disorder, depressive disorder (medical illness that negatively affects how you feel, the way you think and how you act), diabetes mellitus-type 2 (A chronic condition that affects the way the body processes blood sugar), cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) and anxiety (persistent and excessive worry that interferes with daily activities).<BR/>Record review of Resident #3's initial MDS assessment, dated 8/13/23, revealed Resident #3's BIMS score was 15, which indicated he was cognitively intact. He required supervision and limited assistance in performing most activities of daily living. He was continent of bowel and bladder. <BR/>Record review of Resident #3's care plan, dated 08/1/23, revealed resident independent with bed mobility, personal hygiene/grooming, toileting and supervision with bathing, dressing, and transfers.<BR/>4. Record review of Resident #4's electronic face sheet, undated, revealed the resident was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included Hypertensive Heart Disease (condition in which the force of the blood against the artery walls is too high), End Stage Renal Disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), depressive disorder (medical illness that negatively affects how you feel, the way you think and how you act), diabetes mellitus-type 2 (A chronic condition that affects the way the body processes blood sugar), cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) and anxiety (persistent and excessive worry that interferes with daily activities).<BR/>Record review of Resident #4's initial MDS assessment, dated 09/08/23, revealed Resident #4's BIMS score was 15, which indicated he was cognitively intact. He required supervision and limited assistance in performing most activities of daily living. He was continent of bowel and bladder. <BR/>Record review of Resident #4's care plan, dated 06/15/23, revealed resident needed limited assistance with bed mobility, personal hygiene/grooming, toileting, bathing, dressing, and transfers.<BR/>During an observation on 10/12/23 at 2:40 pm, there was no privacy curtain between Resident #3 and Resident #4's beds. There was a ceiling tracks room divider for the privacy curtains to hang, but there was no curtain attached to the tracks. <BR/>During an interview on 10/12/23 at 2:42 pm, Resident #3 said he liked his roommate, Resident #4, but it would be nice to have the privacy curtain in case he wanted some privacy. He said they were both independent with their care, and when they would use the bathroom, they closed the door for privacy during personal care/toileting/bathing. <BR/>During an interview on 10/12/23 at 2:45 pm, the Housekeeping Supervisor, said it was housekeeping staff's responsibility to clean, install/re-install the privacy curtains. She said she was not aware of any rooms that did not have privacy curtains. She said extra privacy curtains were available in the storage closet. She said maintenance would have to install ceiling tracks for the privacy curtains if they were not already installed in the rooms. <BR/>During an interview on 10/12/2023 at 3:00 pm, the Maintenance Supervisor said he was unaware of any resident rooms that did not have ceiling tracks for privacy curtains, it had not been reported to the maintenance department. <BR/>During an interview on 10/12/2023 at 3:30 pm, the Administrator said all resident rooms that had more than one occupant should have privacy curtains. She said she was not aware of any rooms that did not have privacy curtains or hardware (ceiling track) to hang privacy curtain. She said housekeeping staff is responsible for cleaning and installing privacy curtains and maintenance staff is responsible for making sure hardware (ceiling track) is installed to hang privacy curtain. She said staff providing resident care should notify housekeeping if no privacy curtain in dual occupied rooms. She said staff were expected to keep the privacy curtains drawn and the door to the room closed during care for privacy. She said staff were trained on resident privacy while providing care. The Administrator said the risk of not ensuring resident privacy would be violating the resident rights to privacy.<BR/>Review of the facility policy Resident rights guidelines for all nursing procedures dated April 2013 revealed General Guidelines 1. For any procedure that involves direct resident care follow these steps: . f. Close the room entrance door and provide the resident's privacy.

Based on observations, interviews, and record reviews the facility's governing body failed to operate and provide services in compliance with all applicable Federal, State and local laws, regulations, and codes for 1 of 1 facility reviewed for ADM and SW.<BR/>* The facility did not immediately notify HHS when the ADM resigned and there was no ADM as required by state regulations.<BR/>* The facility did not employ a part time or contract a SW as required by state regulations. <BR/>These failures could place residents at risk of administrative duties not being carried out attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. <BR/>Findings included:<BR/>1. During an interview on 06/09/23 at 10:40 a.m., the DON said a car ran into something on the corner about two weeks prior. She said the water to the front of the building was temporarily cut off. She said the ADM at the time thought the water had been cut off due to non-payment. She said the ADM words to her were if [owner] did not care, then she did not care. She said the ADM gave her resignation immediately. She said there had not been an administrator since then. <BR/>During an interview on 06/09/23 at 12:26 p.m., the owner said the previous administrator walked out about two weeks earlier. He said he did not call HHS to let them know he did not have an administrator. He said he was not aware he needed to do that. <BR/>Record review of the ADM employee file indicated an Employee Change of Status Form dated 06/12/23. Further review of the form indicated her last working day was 05/27/23, voluntary termination of employment due to being dissatisfied with job or company was marked, and other was also marked-written next to this was quit via text to admin group.<BR/>During an interview on 06/12/23 at 01:35 PM the DON said she was the acting ADM since 05/27/23 when the ADM resigned.<BR/>Record review of the Texas Administrative Code 554.1902 (a)(2) indicated The facility must:<BR/> (2) ensure that a person designated as being in authority notifies HHSC immediately when the facility does not have an administrator.<BR/>2. In an interview on 6/12/2023 at 10:20am, the DON was asked about a SW, which she said the facility did not have one at that time. The DON was asked how long facility had been without a SW, she said she does not remember. She said there was no SW from corporate office or a sister facility assisting either.<BR/>During a phone interview on 06/12/23 at 01:59 PM the Ombudsman said the facility had not had a SW in several months. She said the DON and other staff were trying to keep up with the needs of the residents, but she felt them not having a SW there were some things not being taken care of. She said the SW could help with finding other placement for residents the facility does not feel like they can meet their needs because of behaviors which she had to intervene to prevent them from refusing to take a resident back from the hospital. <BR/>Record review of the Grievance Book indicated a grievance on 03/07/23 about not having a SW for assistance. <BR/>During an interview 6/14/2023 8:00 am with Resident #13's representative reports that he has been trying to get assistance from the facility to help resident #13 get on her disability and follow up on Medicaid application which are both still pending, she has recently been diagnosed as legally blind so she should qualify for these programs and other resources. <BR/>During a phone interview 6/14/2023 7:30 am with Resident #15's representative reports that resident #15 was transferred to another facility he feels the transfer to the other facility could have gone smoother if one person was handling the transfer (social worker) instead of several staff members, also reports during his stay at the facility the resident received a phone call from a soliciting insurance plan and resident's insurance was changed unbeknown to facility, resident or resident representative and the facility staff (social worker) did not assist in explaining/resolving this issue.<BR/>Record review of the SW employee file indicated a Disciplinary Action dated 01/09/23. Further review of the form indicated the SW was terminated on 01/09/23. <BR/>During an interview on 06/12/23 at 01:35 PM the DON said they had no SW since the previous SW was terminated. She said she and the ADONs were taking care of the resident needs as best as they could.<BR/>Record review of the Texas Administrative Code 554.703 (a)(2) indicated (2) A facility of 120 beds or less must employ or contract with a qualified social worker (or in lieu thereof, a social worker who is licensed by the Texas State Board of Social Worker Examiners, and who meets the requirements of subsection (b)(2) of this section) to provide social services a sufficient amount of time to meet the needs of the residents.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the Administrator and the State Survey Agency, for 8 of 11 residents reviewed for reporting allegations of abuse. (Residents #3, #4, #5, #6, #7, #8, #9, and #10)<BR/>* The facility did not report within 2 hours when Resident #3 reported Resident #4 had touched her breast inappropriately (sexual abuse).<BR/>* The facility did not report within 2 hours when Resident #5 kicked Resident #6 in the back (physical abuse).<BR/>* The facility did not report within 2 hours when Resident #7 hit Resident #8 and he hit her back (physical abuse).<BR/>* The facility did not report within 2 hours when Resident #9 swung at Resident #10 with her fist and Resident #5 hit back causing scratches (physical abuse). <BR/>This failure could place the residents at risk of abuse and neglect.<BR/>Findings included:<BR/>1. An email to HHSC Complaint and Incident Intake dated 04/13/23 at 11:13 AM indicated the name and title of the person making the initial report; [ADM] the date and time the person became aware of the reportable incident; 04/12/23 approximately 07:20 PM a detailed narrative of the incident; [Resident #3] approached nurse after coming out of [Resident #4] room saying I have to tell you something. [Resident #3] then went on to say that yesterday [Resident #4] touched me on my breast .<BR/>Record review of the Provider Investigation Form indicated the following:<BR/>* Date Reported to HHSC-04/13/23 <BR/>* Time: 11:13 AM<BR/>* Incident Category: Other<BR/>* If other, specify: Resident to Resident contact<BR/>* Incident Date: 04/12/23; and <BR/>* Time of Incident: 06:30 PM.<BR/>2. An email to HHSC Complaint and Incident Intake dated 04/19/23 at 07:53 PM indicated the name and title of the person making the initial report; [ADM] the date and time the person became aware of the reportable incident; 04/19/23 approximately 04:40 PM a detailed narrative of the incident; Resident #5 kicked another resident [Resident #6] in her back. This resident stated she kicked her because she was in her way <BR/>Record review of the Provider Investigation Form indicated the following:<BR/>* Date Reported to HHSC-04/19/23 <BR/>* Time: 07:53 PM<BR/>* Incident Category: Other<BR/>* If other, specify: Resident to Resident contact<BR/>* Incident Date: 04/19/23; and <BR/>* Time of Incident: 04:00 PM.<BR/>3. An email to HHSC Complaint and Incident Intake dated 04/19/23 at 08:23 PM indicated the name and title of the person making the initial report; [ADM] the date and time the person became aware of the reportable incident; 04/19/23 approximately 04:40 PM a detailed narrative of the incident; Resident #7 said Resident #8 hit him when he was trying to pass her in his wheelchair. He stated he hit her back.<BR/>Record review of the Provider Investigation Form indicated the following:<BR/>* Date Reported to HHSC-04/19/23 <BR/>* Time: 08:23 PM<BR/>* Incident Category: Other<BR/>* If other, specify: Resident to Resident contact<BR/>* Incident Date: 04/19/23; and <BR/>* Time of Incident: 04:00 PM.<BR/>4. An email to HHSC Complaint and Incident Intake dated 04/24/23 at 11:30 AM indicated Reporter's Name and Title: [ADM] Date/Time you first learned of incident: 04/24/23 approximately 08:55 AM Brief narrative summary of the reportable incident: Upon investigation Resident #9 went into Resident #10 room and pulled her covers off and then proceeded to take clothing items out of closet. [Resident #10] stated she got up out of bed asked [Resident #9] to leave her room and [Resident #9] swung at her fist and she was simply defending herself <BR/>Record review of the Provider Investigation Form indicated the following:<BR/>* Date Reported to HHSC-04/24/23 <BR/>* Time: 11:30 AM<BR/>* Incident Category: Other<BR/>* If other, specify: Resident to Resident contact<BR/>* Incident Date: 04/24/23; and <BR/>* Time of Incident: left blank.<BR/>During an interview on 06/12/23 at 01:35 PM the DON said she was the acting Abuse Coordinator (AC) since 05/27/23 when the ADM resigned. She said initial reports of self-reported incidents were done through email since October of last year. She said one resident inappropriately touching another resident's private areas was sexual abuse. She said one resident hitting, slapping, or punching another resident was physical abuse. She said 2 residents fighting was physical abuse. She said all allegations of abuse were to be reported to the SA within 2 hours. She said the incidents regarding Residents #5, #6, #7, #8, #9, and #10 were physical abuse. She said the incident regarding Residents #3 and #4 was sexual abuse. She said all of the incidents should have been reported within 2 hours. <BR/>The facility did not have a current ADM. The former ADM was not available for interview. An attempt was made to call but no return call.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 12 residents (Resident #1) reviewed for comprehensive person-centered care plans.<BR/>The facility failed to develop and implement a care plan for Resident #1's aggressive behaviors toward others. <BR/>This failure could place residents at risk of not having individual needs met and a decreased quality of life. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 05/14/24 indicated he was [AGE] years old, admitted on [DATE], and his diagnoses included encephalopathy (brain dysfunction), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and cognitive communication deficit.<BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated he sometimes was able to make himself understood and understood others, and had severe cognitive impairment (BIMS score 00). His behaviors included physical behaviors directed at others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) that occurred 1 to 3 days (out of 7 day look back period)<BR/>Record review of Resident #1's electronic record indicated there was no care plan related to aggression towards others.<BR/>Record review of a progress note dated 05/12/24 at 10:23 p.m., completed by LVN L indicated she wheeled Resident #1 to his room for CNA R to provide care. CNA R reported Resident #1 initiated physical aggression and reached up and scratched CNA R's face. CNA N and CNA O entered Resident #1's room to complete Resident #1's care. <BR/>During an interview on 05/14/24 at 5:58 p.m., CNA R said she had been employed at the facility for 2 weeks and had worked at a secure unit as a CNA prior to this facility and had received training on abuse and self-defense tactics. She said that Resident #1 was never aggressive and she did not know what happened that day, but he was fighting all three of them, which included CNA N and CNA O, and her on 05/12/24. She said she was trying to get him dressed and he was so strong and grabbed her face and started scratching, punching, and kicking. She said she never hit him back and that she used the self-defense tactics of raising her arms like an x. She said he was fighting all three of them pretty hard and she did not see anyone ever hit him back. She said she was just trying to make sure he did not fall on the floor and resolve the situation. She said she had not worked with him since the incident and that she had observed his injuries. She said she did not know how he got those injuries other than he was fighting so hard and was not just fighting her that the other two girls were bigger than her. She said the administrator informed her that Resident #1 was never aggressive unless someone was mean to him and that it appeared she was getting the brunt of it. <BR/>During an interview on 05/22/24 at 12:30 p.m., CNA N said she overhead conversation on 05/12/24 when CNA R reported to LVN L that Resident #1 exhibited aggressive behaviors and had scratched CNA R on the face while she was trying to provide personal care. CNA N said she told CNA R and CNA O that she would try to assist with Resident #1 with care. CNA N said she and CNA O went back into Resident #1's room approximately 10 minutes after the incident of aggression with CNA R to assist resident with care. CNA N said she did not know what happened, but when she went to assist Resident #1, he started spitting and fighting. She said she and CNA O left the room, to allow Resident #1 to calm down. CNA N said Resident #1 had behaviors at times and they leave the room and try to go back later to assist him.<BR/>During an interview on 05/22/24 at 12:42 p.m., CNA O said she went to Resident #1's room to assist with care. She said CNA N and CNA R were already in the room. CNA O said she observed CNA N attempting to provide care to Resident #1, but Resident #1 was upset and was spitting at CNA N. CNA R was standing in room but not assisting with care because Resident #1 had already scratched her on the face. CNA O said Resident #1 was being aggressive spitting and slapping at CNA N. She left the room to notify LVN L of the incident and LVN L said she was aware of the incident and the behaviors. CNA O returned to Resident #1's room and notified CNA N and CNA R that LVN L was notified of Resident #1's behaviors.<BR/>During an interview on 05/22/24 at 2:08 p.m., LVN/MDS J said she was responsible for completing resident care plans. She said it was a mistake and she just missed completing a care plan related to Resident #1's aggression towards others.<BR/>During an interview on 05/22/24 at 1:14 p.m., the Administrator stated the DON and the MDS Coordinator were responsible for completing the care plans. The Administrator stated she expected them to include anything unusual or special for the resident's care. The Administrator stated it was important for Resident #1's aggressive behavior towards others to be included in the care plan so the staff could ensure the resident was receiving appropriate care. <BR/>During an interview on 05/22/24 at 2:45 p.m., LVN L said CNA R left Resident #1's room and reported Resident #1's aggressive behaviors and that he had scratched her face on 05/12/24. She said CNA N and CNA O went to complete Resident #1's care and he continued with his aggressive behaviors. She said the staff left his room to allow him to calm down. <BR/>Record review of the facility's Comprehensive Person-Centered Care plans policy dated 2001 (revised October 2018) indicated Policy Statement-A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 9 Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team after each assessment for 3 of 7 residents (Residents #1, #2, and #3) reviewed for comprehensive person-centered care plans.<BR/>1. Resident #1's comprehensive person-centered care plan was not updated to reflect behavior of physical aggression toward another resident. <BR/>2. Resident #2's comprehensive person-centered care plan was not updated to reflect an altercation when another resident had been physically aggressive with her. <BR/>3. Resident #3's comprehensive person-centered care plan was not updated to reflect when another resident had been physically aggressive with her. <BR/>These failures could place residents at risk for not receiving the necessary care and services they required. <BR/>The findings were:<BR/>1. Record review of Resident #1's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included schizophrenia (a serious mental condition involving breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion), persistent mood [affective] disorder (marked disruptions in emotions {severe lows called depression or highs called hypomania or mania]), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations).<BR/>Record review of Resident #1's care plan, dated 10/25/23, indicated Resident #1 had a diagnosis of schizophrenia and was at risk for manic episodes and increased behaviors. Interventions included monitor for delusions and hallucinations and monitor for increased agitation, anger, verbal, physical aggression and document in the clinical record. The care plan was not updated with Resident #1's physical aggression toward other residents on 04/03/24 when she pulled Resident #3 out of her wheelchair or on 04/19/24 when she attempted to smother her roommate (Resident #2) with a pillow. <BR/>Record review of Resident #1's quarterly MDS assessment, dated 04/08/24, indicated Resident #1 was able to make herself understood and usually understand others, and had moderate cognitive impairment indicated by a BIMS score of 11. She had had no hallucinations, delusions, or physical or verbal behaviors. She required partial to moderate assistance with most ADLs.<BR/>Record review of Resident #1's clinical note (related to the incident with Resident #3) dated 04/03/24 at 11:30 a.m. and signed by LVN N indicated CNA came and informed LVN N that Resident #1 pulled Resident #3 out of her wheelchair onto the floor of Resident #1's room. Resident #1 said I'm not a fucking babysitter, I need help my motherfucking self she needs to keep her ass out of my motherfucking room. On arrival to the secure unit residents were already separated and in different rooms. LVN N educated and redirected Resident #1, she was informed that physical aggression would not be tolerated, and it was not her right to put hands on anyone. LVN A indicated that Resident #1 did not verbalize understanding. <BR/>Record review of the incident report dated 04/19/24 at 03:40 a.m., Completed by LVN A indicated she was notified by CNA that Resident #2 was yelling for help because Resident #1 (her roommate) had placed a pillow over Resident #2's face and held it over her face. Resident #2 came out of her room yelling for help. The residents were separated, and Resident #2 was assessed with no bruising on her face and no shortness of breath. Resident #1 admitted she did it and stated, Don't send me to jail please send me to a mental institution. Resident #2 was moved to another room for her protection and safety. MD was paged and LVN A was awaiting response. Administrator was notified. <BR/>During an interview on 04/22/24 at 01:05 p.m., the MDS nurse said she was responsible for updating resident care plans with the DON's supervision. She said she had not been aware of Resident #1's aggression toward other residents. She said she received updates concerning residents during the facility morning care meetings, through review of new orders, and reviewing the facility 24-hour updates. She said not updating care plans with changes in resident status or behaviors could result in staff being unaware of the changes. <BR/>During an interview on 04/22/22 at 01:26 p.m., the ADON stated Resident #1 was transferred to a behavioral hospital on [DATE] after her attempt to hurt Resident #2. The ADON stated he was not sure why Resident #1's comprehensive person-centered care plan was not updated and should have been because it would ensure the resident received consistent care. <BR/>2. Record review of Resident #2's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility 12/05/23. Resident #2 had diagnosis which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning) with agitation, major depressive disorder (a metal health disorder characterized by persistently depressed mood causing significant impairment in daily life), and schizophrenia.<BR/>Record review of Resident #2's care plan, dated 07/31/23 indicated Resident #2 had an altered thought process and was at risk for further decline and injury as evidenced by dementia and short- and long-term memory deficit. Interventions included keep resident and others safe and monitor for mental status changes. The care plan was not updated with the altercation 0n 04/19/24 when Resident #1 attempted to smother her with a pillow.<BR/>Record review of Resident #2's quarterly MDS dated [DATE] indicated Resident #2 was able to make herself understood and understood others, and had severe cognitive impairment indicated by a BIMS score of 6. She had feelings of being down, depressed, and hopeless 2-6 (several) days and had no behaviors. <BR/>Record review of Resident #2's clinical note dated 04/19/24 at 03:54 a.m. and signed by LVN A indicated she was notified by CNA B that Resident #2 came running out of her room yelling for help and saying her roommate (Resident #1) placed a pillow over her face and held it over her face. The residents were separated, and Resident #2 was assessed with no bruising on her face and no shortness of breath. Resident #2 was moved to another room for her protection and safety. <BR/>During an interview on 04/21/24 at 02:44 p.m., the DON said the MDS nurse was responsible for updating care plans with changes in resident status/behavior with her supervision. She said Residents #1, #2, and #3's care plans should have been updated that the physical altercations had happened and goals and interventions for those focuses. She said if care plans were not updated it put residents at risk for not receiving the care and services they needed. <BR/>During an interview on 04/22/24 at 01:05 p.m., the MDS nurse said she had not been aware that Resident #2 had been involved in an altercation with Resident #1 on 04/03/24 so she didn't update the care plan. <BR/>3. Record review of Resident #3's face sheet dated 04/20/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included cerebral infarction (stroke), spastic hemiplegia (a common post-stroke condition that causes stiff or rigid muscles) affecting right dominant side, vascular dementia (dementia [a condition characterized by progressive or persistent loss of intellectual functioning] caused by an impaired supply of blood to the brain), mood disorder (marked disruptions in emotions [severe lows called depression or highs called hypomania or mania]), and depression.<BR/>Record review of Resident #3's care plan revised on 06/21/23 indicated Resident #3 was deemed at risk for wandering related to being ambulatory with her wheelchair, diagnosis of dementia, and history of exit seeking. Goals included Resident #3 would be able to wander in a safe environment (secure unit) with no occurrence of injury and dignity would be maintained. The care plan was not updated with the incident from 04/03/24 when Resident #3 wandered into Resident #1's room and Resident #1 pulled her out of her wheelchair onto the floor. <BR/> Record review of Resident #3's annual MDS dated [DATE] indicated Resident #3 was sometimes able to make herself understood and usually understood others, and had severe cognitive impairment indicated by a staff assessment. She had mood of little interest or pleasure in doing things several (2-6 days) and behaviors directed toward others 1 to 3 days and no wandering behaviors.<BR/>During an interview on 04/22/24 at 01:05 p.m., the MDS nurse said she had not been aware Resident #3 was pulled out of her wheelchair onto the floor by Resident #1 on 04/03/24 so she had not updated the care plan with the altercation. <BR/>Record review of facility policy Care Plans, Comprehensive Person-Centered revised October 2018, indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the activity program was directed by a qualified professional who was licensed, registered, had qualified work experience, or had completed a training course approved by the State for 1 of 1 Activity Director (AD).<BR/>* The facility failed to have a qualified AD. <BR/>This failure could place residents at risk of receiving inappropriate activities and decreased quality of life. <BR/>Findings included:<BR/>During an interview on 6/12/2023 at 10:20am, the DON was asked about an AD and she said the facility did not have one at that time. The DON was asked how long facility had been without an AD, she said for a few weeks. The DON stated the facility was in the middle of changing ownership and it was supposed to happen June 1, 2023 so the owner was wanting to wait to hire any new staff, the new owner needs to be involved with the hiring process of new staff. The DON indicated the change of ownership did not happen on June 1, 2023, as planned it was postponed until June 15, 2023. DON reports that the facility does not currently have an AD to plan, create or implement resident activities. She said she tried to do some activities for the residents.<BR/>During an observation on 6/12/2023 at 2:00 pm, the DON was in the dining area with residents playing bingo.<BR/>Record review of the previous AD employee file indicated a Disciplinary Action dated 04/21/23. Further review of the form indicated the AD was terminated on 04/21/23.<BR/>During an observation and interview on 6/12/2023 at 02:10 pm Resident #13 was sitting up in wheelchair in her room alone. The resident was noted with left sided paralysis, she had a left-hand contracture, and no skin impairment. She said she was legally blind. Resident reported that this was the first time she had been up in wheelchair in a while. Resident reported that she did not participate in activities outside her room because she stayed in the bed most of the time. Resident replied, I watch TV. Resident could not recall when the last time was, she has been to a facility activity outside her room but stated it has been a while (&gt;1 month). <BR/>During an observation 6/13/2023 at 2:15 pm Resident #13 lying in bed, watching TV. <BR/>During an observation and interview on 6/14/2023 at 11:30 pm Resident #13 lying in bed with purse and makeup on bed, reports she is leaving at 12 noon to go to a GI appt in Galveston via ambulance transport. <BR/>Record review of Resident #13's face sheet dated 6/12/2023 she was a [AGE] year-old female admitted on [DATE]. Her diagnosis including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (stroke affecting non-dominant side), other seizures (sudden, temporary, bursts of electrical activity in the brain that change or disrupt the way messages are sent between brain cells), gastro-esophageal reflux disease without esophagitis(stomach contents leak backward from the stomach into the esophagus (food pipe)), abdominal pain, noninfective gastroenteritis and colitis (inflammation of your digestive tract - stomach and/or colon), urinary tract infection, site not specified (an infection in the kidneys, ureters, bladder, or urethra), presence of urogenital implants (suprapubic catheter), atherosclerotic heart disease of native coronary artery without angina pectoris (fats, cholesterols, and other substances collect on the inner walls of the blood vessels that supply blood to the heart) , systolic (congestive) heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should), neuromuscular dysfunction of bladder, type 2 diabetes mellitus with diabetic neuropathy, chronic kidney disease, stage 4 (severe)( a condition in which the kidneys are damaged and cannot filter blood as well as they should), major depressive disorder, recurrent, moderate, generalized anxiety disorder, hyperlipidemia (an elevated level of lipids - like cholesterol and triglycerides - in your blood), iron deficiency anemia (a condition in which the body does not have enough healthy red blood cells), celiac artery compression syndrome (a rare medical condition characterized by recurrent abdominal pain), hereditary and idiopathic neuropathy (a condition characterized by nerve abnormalities in the legs and feet), psoriasis (skin cells are replaced more quickly than usual)<BR/>Record Review of Resident #13's Minimum Data Set (MDS) dated [DATE], indicates she required extensive assistance 2+ person physical assist for bed mobility, bathing, and toilet use, requires one-person physical assist for transfer, locomotion, dressing, and personal hygiene. She has a suprapubic catheter and incontinent to bowel according to a care plan dated 4/1/2023. <BR/>During observation and interview 6/13/2023 10:30 am with Resident #4 lying in bed, resident reports limited activities in the facility - activities calendar on resident wall is from May 2023. He said he was pleased with the care received and had no unmet needs just wishes there was more activities available<BR/>Record review of Resident #4's face sheet dated 1/26/2023, he was [AGE] year-old male born 06/29/1968 and admitted on [DATE]. He had diagnosis including: hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side (stroke affecting non dominant side), protein-calorie malnutrition, vitamin b deficiency, vitamin d deficiency, morbid (severe) obesity due to excess calories, hyperlipidemia (an elevated level of lipids - like cholesterol and triglycerides - in your blood), other specified depressive episodes, depression, anxiety disorder, insomnia, polyneuropathy (many nerves in different parts of body involved), other chronic pain. <BR/>Record review of resident # 4's MDS dated [DATE], indicated he was cognitively intact. He required extensive assistance 2+ person physical assist for bed mobility, transfer, dressing, personal hygiene, and toilet use, requires one-person physical assist for locomotion and totally dependent on staff for bathing. <BR/>During observation and interview 6/13/2023 10:45 am with Resident # 14, wheelchair bound, sitting in room with back to door, resident reports that she does not participate in facility activities but does enjoy Sudoku and reading but the books she has in her room now she has read several times and she needs a new Sudoku book, and she wishes she had more books to read. Friend that usually brings her books has been ill and unable to visit. <BR/>Record review of resident #14, face sheet and physician orders dated 6/13/2023, she was a [AGE] year-old female born 9/17/1950 and admitted on [DATE]. Her diagnosis included bipolar disorder, major depressive disorder, and schizophrenia.<BR/>Record review of the MDS dated [DATE] indicated she had a BIMS score of 11 which indicated she had moderately impaired cognition. <BR/>During an interview on 06/13/23 at 02:20 PM the DON said since the AD was terminated on 4/21/2023 that they had hired someone to be the AD who was going to get her AD certification, but she had quit within her first week of employment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and resident choices for 1 of 8 residents (Resident #1) reviewed for treatment and services. <BR/>The facility failed implement interventions and recommendations for Resident #1 dated 11/16/22 for antibiotics for possible wound infection of the right foot and a CT or MRI to rule out (osteomyelitis inflammation or swelling that occurs in the bone). Resident #1 he was admitted to the hospital on [DATE] had a partial resection of the 5th metatarsal of the right foot and wound and muscle debridement of the left trans-metatarsal stump. <BR/>The facility failed to address Resident #1's stat lab dated 11/22/22 results positive for MRSA.<BR/>An Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., 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 of not receiving care as required and could result in further decline of condition and possible death. <BR/>Findings included:<BR/>Record review of physician orders dated 01/03/2022 indicated Resident #1 was a [AGE] year-old male re-admitted on [DATE] (originally admitted on [DATE]). His diagnoses included long term use of antibiotics, acute osteomyelitis (inflammation or swelling that occurs in the bone) right ankle and foot, diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high , cellulitis bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin, gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection), non-pressure chronic ulcer of left foot, cellulitis of left lower limb and acute osteomyelitis of left foot and ankle.<BR/>Record review of an MDS dated [DATE] indicated Resident #1 had moderate impaired cognition, was understood by others and usually understood others. He was not able to focus and had disorganized thinking. He had delusions. He required supervision for most ADLS. He utilized a wheelchair for mobility. He was continent of bladder and bowel. Resident #1 had surgical wounds and received surgical wound care. There was no antibiotic use noted.<BR/>Record review of a care plan dated 11/09/22 indicated Resident #1 had a left foot amputation of toes and right foot amputation of small toe and was at risk of further skin breakdown, infection, and worsening surgical wound. Interventions included inform MD of progress and perform treatment per order and if no improvement report to MD.<BR/>Record review of a wound evaluation dated 11/16/22, completed by RN B (wound consultant), indicated Resident #1's right lateral toe's surgical wound measured 3.5 cm X 2.0 cm X .3 cm, 25 % slough (necrotic tissue that needs to be removed from the wound), and moderate serous exudate (type of exudate that is clear, thin, and watery in contrast to a purulent exudate that is opaque). There was purulent (discharging) pus present and RN B recommended ABT (Bactrim, Doxycycline) and a CT or MRI to rule out osteomyelitis (inflammation or swelling that occurs in the bone).<BR/>Review of Resident #1's clinical records indicated there was no progress note or treatment note available for review from the wound care consult on 11/16/22.<BR/>Record review of progress note dated 11/21/22 at 12:08 p.m., completed by RN N (previous DON) indicated Resident #1 complained he had drainage to bilateral feet. Scant amount of clear drainage noted with no signs of infection. MD A's office was called and there was no answer and would follow-up.<BR/>Record review of progress note dated 11/21/22 at 4:57 p.m., completed by ADON D, indicated she contacted MD A's office and received order for wound culture of wounds to bilateral feet. Antibiotic to be ordered once results were received.<BR/>Record review of STAT lab results dated 11/22/22 indicated Resident #1 was positive for methicillin-resistant Staphylococcus aureus (MRSA) - (staph infection that is difficult to treat because of resistance to some antibiotics). There was no documented evidence the results were reviewed by the physician or NP.<BR/>Record review of wound care report dated 12/13/22, competed by DPM C indicated Resident #1 was admitted to hospital for infection of right foot.<BR/>Record review of a history and physical report (included with the hospital records) dated 12/14/22 indicated Resident #1 had osteomyelitis with gangrene at right metatarsal site. <BR/>Record review of consult report (included with the hospital records) dated 12/15/22 indicated Resident #1 had a partial resection of the 5th metatarsal of the right foot and wound and muscle debridement of the left trans-metatarsal stump. The wound cultures were growing MRSA. Resident #1 returned to the facility on [DATE].<BR/>During an observation and interview on 12/30/23 at 10:50 a.m., Resident #1 was wearing a protective foot device on his right and left foot. He said he had a staph infection on his foot and was in the hospital and received intravenous antibiotics. He said he had to have more amputations because he did not get the antibiotics he was supposed to get. He could not recall who said he should have antibiotics.<BR/>During an interview on 01/04/23 at 10:07 a.m., TX LVN E said she made wound rounds with RN B (wound care consultant) on 11/16/22. She said it was toward the end of her shift and she asked a nurse to fax the wound care consult with recommendations to Resident #1's wound care doctor (DPM C) and to follow up because she was not returning to the facility. She said 11/16/22 was the last day she worked in the facility. She said she could not recall the name of the nurse she gave the recommendations or directions to notify the physician. She said she did not notify Resident #1's primary physician or DPM C. She said she could not recall if she documented the recommendations in a progress note.<BR/>During an interview on 01/04/23 at 1:40 p.m., LVN F said she worked on 11/16/22 and did not recall TX LVN E giving her a wound care recommendation for Resident #1 or being directed to fax it to DPM C.<BR/>During an interview on 01/04/23 at 2:00 p.m., ADON H said she worked on 11/16/22 and did not recall TX LVN E giving her a wound care recommendation for Resident #1 or being directed to fax it to DPM C.<BR/>During an interview on 01/4/23 at 3:26 p.m., RN L (from the wound care clinic) said they did not have any knowledge and were not informed of RN B's recommendations dated 11/16/22 for Resident #1 that included ABT (Bactrim, Doxycycline) and a CT or MRI to rule out osteomyelitis.<BR/>During an interview on 01/04/23 at 5:10 p.m., RN B said she was a wound care consultant and was contracted by the facility to observe wound care and train the staff. She said she completed rounds with TX LVN E on 11/16/22 and noted purulent pus and made recommendation for ABT and CT or MRI to rule out osteomyelitis. She said TX LVN E should have informed the primary physician of the assessment and recommendations. She said some primary physicians would direct the facility to forward the recommendations to the wound care physician. She said infection of the wound could get to the blood or get septic (infected with microorganisms, especially harmful bacteria).<BR/>During an interview on 01/05/23 at 9:43 a.m., ADON D said she did get the order for Resident #1's wound culture on 11/21/22. She said she was new to the position and should probably have followed up on the results. She said she was off sick and then forgot to follow up when she returned to work.<BR/>During an interview on 01/05/23 at 10:54 a.m., MD A said he did not receive notification of Resident #1's wound culture results dated 11/22/22 regarding positive MRSA results. He said the facility staff should have notified him of RN B's recommendations dated 11/16/22 for Residents #1. He said the delay of notification, treatment, or ABT most likely would not have made any difference because Resident #1 had been on multiple [NAME] and was ABT resistant. He said Resident #1 was non-compliant with wound care and physician orders. MD A said it was also most likely to require additional surgeries and amputations.<BR/>During an interview on 01/05/23 at 12:06 p.m., ADON H said if they received recommendations from consultants, they would contact the physician. ADON D said lab results were supposed to be called or faxed over to the physician for review. ADON H said the lab results should be noted in the progress notes and also in the 24-hour report.<BR/>During an interview on 01/05/23 at 12:27 p.m., LVN J said all recommendations for care, tests, or treatments were supposed to be sent to the physician for review. LVN M said lab results were supposed to be called or faxed over to the physician for review. LVN M They said the lab results are supposed to be noted in the progress notes and also in the 24-hour report.<BR/>During an interview on 01/05/23 at 8:25 a.m., the DON said Resident #1's lab results were not forwarded to MD A. She said the lab results should have been followed up by nursing staff to ensure Resident #1 received treatment. She said the results were in the facility electronic portal but not all staff had access to the portal. She said not informing the physician of recommendations or lab results could result in delay of treatment or further decline of condition. She said she could not attribute the delay of antibiotics to Resident #1 requiring additional amputation surgery because he was noncompliant with care and treatment. She said staff were in-serviced on 12/29/22 to ensure labs were documented and followed up as required.<BR/>During an interview on 01/05/23 at 8:30 a.m., LD I said Resident #1's lab results were available in the portal. He said the lab results were also faxed to the facility. He said he was not able to say who had access to the portal or who reviewed the labs. <BR/>The surveyors made three attempts on 01/03/23 and three attempts on 01/04/22 were made to contact DPM C regarding Resident #1 and there was no return call.<BR/>Record review of the facility's undated Laboratory Services and Reporting policy indicated .7. Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range.<BR/>Record review of the facility policy Change in Condition Communication dated 06/19 indicated physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patients/ residence condition, enter. Provide guidance for the notification of patients/ residents and their responsible party regarding changes in condition. F. Recent Labs <BR/>An Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., 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/>The facility's POR indicated:<BR/>CNO and DON reviewed recommendations from Wound Care Consultant's last visit. Recommendations were addressed with Primary Care Physician and followed through.<BR/>Nurses at the facility including nursing supervisors were re-educated on 1/25/2023 by CNO that:<BR/>When a recommendation is made to ask the physician for a decision on the recommendation and follow it through. <BR/>During shift nurses were educated and those not scheduled to work will be in-serviced prior to their next scheduled shift. Completion Date 1.26.23 @ 12 pm.<BR/>DON will incorporate this education as part of the onboarding education for any newly hired nurses.<BR/>Dietary, Wound Care, and Pharmacy Consultants will email recommendations to DON/Administrator once visit is complete. <BR/>DON will forward recommendations to assigned ADON/Designee for MD notification to obtain approval/denial of recommendation.<BR/>DON/Designee will audit recommendation(s) on day 4, for completion to include MD notification and that orders were carried out and acted upon.<BR/>On 01/26/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Review of recommendations from Wound Care Consultant's last visit were addressed with Primary Care Physician and followed through as of 01/26/23.<BR/>Review of nurse training and nursing supervisors indicated they were re-educated on 01/25/23 by the CNO to ask the physician for a decision on recommendations and follow it through. All nurses were educated as of 01/26/23 and those not scheduled to work would be in-serviced prior to their next scheduled shift. The DON will incorporate this education as part of the onboarding education for any newly hired nurses. As of 01/26/23 there were no untrained new hires.<BR/>Review of email notification sent to contracted consultants including dietary, wound care, and pharmacy, indicated they would ensure their recommendations were emailed to the DON and Administrator once they have completed their assessments. <BR/>During an interview on 01/26/23 at 2:30 p.m., the DON said she would forward all recommendations to assigned ADON/Designee for MD notification to obtain approval/denial of recommendation. She said she or the Designee would audit recommendation(s) on day 4, for completion to include MD notification and orders were followed.<BR/>Interviews conducted on 01/26/23 from 1:15 p.m. through 2:40 p.m. with the DON, 2 ADONs, 1 RN, and 6 LVNS, who worked all shifts, indicated they would document all recommendations in resident clinical record, shift report, and 24-hour report for follow-up and implementation of orders. They were able to correctly state the protocols for reviewing and reporting abnormal labs, clarification of verbal orders, ensuring the physician was made aware of the change or condition, and ensuring the physician received the lab results.<BR/>An Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., 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 ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 3 residents (Resident #2) reviewed for pressure ulcers. <BR/>The facility failed to place wound vac to Resident #2's sacral wound as ordered by the physician from 01/02/23 to 01/04/23. A wound assessment dated [DATE], indicated Resident #2's Stage 4 sacral pressure wound measured 2.9 cm by 2.1 cm by 1.8 cm. On 01/05/22 on Resident #2's Stage 4 sacral wound had deteriorated and measurements were 3 cm length by 3.8 cm wide and 3 cm depth. <BR/>This failure could place residents at risk for developing or worsening of pressure injuries and infections.<BR/>Findings included:<BR/>Record review of a face sheet dated 01/04/23 indicated Resident #2 was a [AGE] year-old female was admitted on [DATE] with diagnoses including pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region (the portion of the back between the lower back and tail bone) Stage 4 (full thickness skin and tissue loss with exposed muscles, ligaments or bones). <BR/>Record review of the MDS dated [DATE] indicated Resident #2 had moderate cognitive impairment and required total assist to extensive assist of 1 staff for most ADLs.<BR/>Record review of MDS dated [DATE] indicated Resident #2 had moderate cognitive impairment and required total assist to extensive assist of 1 staff for most ADLs. Resident #1 had one Stage IV pressure ulcer that was present upon admission. She had one unstageable wound that was present upon admission. She had a pressure reducing mattress and received pressure/ulcer injury care.<BR/>Record review of a care plan dated 08/26/22 indicated Resident #2 had a stage 4 pressure ulcer. Interventions included administer medications as ordered, administer treatments as ordered, and monitor for effectiveness. Wound vac in place with dressing changes every Monday, Wednesday, and Friday. Assess/record/monitor wound healing with each treatment and follow facility policies/protocols for the prevention/treatment of skin breakdown.<BR/>Record review of a physician order summary dated 12/01/22 indicated Resident #2's treatments to be administered as Wound Vac (medical machine that gently pulls fluid from wounds, may help clean the wound and remove bacteria). Apply to sacral area with settings of 125 mmHg. Change dressing every M-W (Monday Wednesday) and prn every day shift Monday and Wednesday for wound care until resolved. Start date 08/12/22.<BR/>Record review of a physician order summary dated 01/04/23 indicated Resident #2's treatments to be administered as Wound Vac (medical machine that gently pulls fluid from wounds, may help clean the wound and remove bacteria). Apply to sacral area with settings of 125 mmHg. Change dressing every M-W (Monday Wednesday) and prn every day shift Monday and Wednesday for wound care until resolved. Start date 08/12/22.<BR/>Record review of a wound assessment dated [DATE], completed by MD O, indicated Resident #2's Stage 4 sacral pressure wound measured 2.9 cm by 2.1 cm by 1.8 cm. There was 100% slough and heavy serous drainage. Apply wound vac with new dressing on Monday and Wednesday. Remove wound vac on Friday and apply calcium alginate dressing.<BR/>During an observation on Tuesday, 01/03/23 at 2:20 p.m., Resident #2 was in isolation on the Covid unit. She was in her bed and LVN K and LVN J completed wound care to Resident #2's right heel. There was no wound vac in operation. LVN K and LVN J did not complete wound care to Resident #2's sacral wound. <BR/>During an interview on 01/04/23 at 9:55 a.m., LVN J said she thought the wound vac was discontinued. She said Resident #2 was moved to the COVID unit on 12/30/22. She said MD O did not make rounds to residents who were in COVID isolation. She could not say why she thought the wound vac was discontinued.<BR/>During an observation and interview on Wednesday, 01/04/23 at 10:00 a.m., Resident #2 was lying in bed on the COVID unit. There was no wound vac in operation on Resident #2's sacral wound. LVN K said there was no wound vac brought to Resident #2's room on the COVID unit. She said Resident #2 was on the COVID unit as of 12/30/22. The sacral wound dressing was dated 01/02/23. LVN K removed the sacral dressing and it was saturated with drainage from the sacral wound and urine leaking from the Foley. The wound was a stage 4 open area, with full thickness of skin loss, and moderate amount of slough. There was foul odor. LVN K said she did not complete the sacral wound treatment the previous day (01/03/22) because she thought another nurse on another shift would complete the treatment. She said she thought the wound vac was discontinued. LVN K could not remember how she knew the wound vac was discontinued or who discontinued the wound vac. She said she should have clarified the wound vac orders when Resident #2 was moved to the COVID unit.<BR/>During an interview on 01/04/23 at 11:52 a.m. Resident #2's MD O said , I think the wound vac was discontinued back in December 2022 and Resident #2 was to have daily dressing with calcium alginate.<BR/>During an interview on 01/04/23 at 12:00 p.m., LVN J said she found the wound vac in Resident #2's old room prior to being moved to the COVID unit on 12/30/22. The DON said Resident #2's wound vac was being charged. She said she called MD O for clarification of wound vac orders. She said the wound vac should have been moved to the COVID unit when Resident #2 was moved to isolation. She said the wound vac application did not populate on the TAR and was not monitored. The DON said the charge nurses completed the wound care and should have clarified the order. The DON said the nurses were to notify her if they were not able to follow the orders. She said the wounds could worsen if orders were not followed.<BR/>During an interview on 01/04/23 at 1:38 p.m., MD O said he reviewed Resident #2's chart and documents on his computer. He said Resident #2's wound vac was not discontinued. He said the nurse should apply the wound vac on Monday through Thursday with a new wound vac dressing Monday and Wednesday. He said on Fridays, the nurse should remove wound vac and apply daily dressing with calcium alginate. He said the dressing should be changed for cleanliness. He said he could not attribute wound worsening to the wound vac not being implemented. He said the wound vac was to speed up healing.<BR/>During an observation and interview on 01/05/23 at 11:55 a.m., ADON D removed the dressing dated 01/05/22 on Resident #2's Stage 4 sacral pressure wound and measured the wound. The sacral wound measurements were 3 cm length by 3.8 cm wide and 3 cm depth. There was no wound vac in operation. ADON D said the wound vac was discontinued 01/05/23 and only doing dressing changes. She said they did not apply the wound vac on 01/04/23 because they were waiting for MD O to call with clarifying orders to the facility.<BR/>The wound care policy dated September 2018 indicated The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident.<BR/>The administering medications policy dated 12/12/12 indicated Medications shall be administered in a safe and timely manner, and as prescribed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 1 of 5 residents (Resident #2) reviewed for accuracy of assessments. The facility did not accurately complete the MDS assessment to indicate Resident #2's active diagnoses. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: Record review of Resident #2's face sheet dated 08/28/25 indicated he was a [AGE] year old male, admitted to the facility on [DATE], and his diagnoses included C1-C4 complete quadriplegia (paralysis that affects all four limbs), diabetes (high blood sugar), hyperlipemia (high levels of fats in the blood), chronic embolism and deep vein thrombosis of bilateral lower extremities (presence of a blood clot), neuromuscular dysfunction of bladder (problem with brain , nerves or spinal cord causes loss of bladder control), hypertension (high blood pressure), neurogenic bladder (condition affects bladder function due to nervous system problems), chronic kidney disease (gradual loss of kidney function), obesity (excessive fat), atherosclerotic heart disease with unstable angina (heart muscle does not receive enough oxygen due to narrowed or blocked arteries caused by plaque buildup), spinal stenosis of cervical region (narrowed space in the spine), complete lesion at C6 of spinal cord (total loss of motor control and function below level of injury), generalized muscle weakness lack of energy and strength, and major depressive disorder (persistent feeling of sadness or loss of interest). Record review of Resident #2's admission MDS dated [DATE] indicated he was able to make himself understood, was able to understand others, was cognitively intact (BIMS-15), used a wheelchair for mobility, and was dependent for most ADLS. The MDS did not include the active diagnoses of coronary artery disease, neurogenic bladder, quadriplegia, or depression. During an interview on 08/29/25 at 9:00 a.m., the DON said the accuracy of MDS was the responsibility of the Administrator. She said Resident #2's MDS dated [DATE] had her signature but she could not verify it was her electronic signature. She said if the MDS did not include the required information, it was probably missed. She said the MDS Coordinator was directly under the supervision of the administrator and the Administrator was supposed to review to ensure the MDS was initiated and competed as required. She said she was never informed that she should review the MDS for accuracy and completion. During an interview on 08/29/25 at 10:26 a.m., the Administrator said the Regional MDS Coordinator was supposed to review the MDS completed by the facility MDS Coordinator for accuracy and timeliness of completion. She said the facility did not have an MDS Coordinator as of 07/23/25. She said it was her expectation was the DON would ensure the MDS was completed as required. The Administrator said the facility did not have an MDS policy and they followed the RAI. She said residents were at risks of not receiving care and services and required if the MDS was not completed as required. During an interview on 08/29/25 at 10:50 a.m., the VPO said the facility did not have a current MDS Coordinator. He said the Regional MDS Coordinator was supposed to fill in and ensure the residents' MDS assessments were completed as required. He said the Regional MDS Coordinator was terminated and a new one was recently hired. He said the leadership of the facility (the Administrator and the DON) were supposed to ensure the MDS was completed on time and accurate. He said residents were at risks of not receiving care and services and required if the MDS was not completed as required. Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2024 indicated .SECTION I: ACTIVE DIAGNOSES Intent: The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status. 0100-I8000: Active Diagnoses in the Last 7 Days Item Rationale Health-related Quality of Life Disease processes can have a significant adverse effect on an individual's health status and quality of life. Planning for Care This section identifies active diseases and infections that drive the current plan of care. Check the following information sources in the medical record for the last 7 days to identify active diagnoses: transfer documents, physician progress notes, recent history and physical, recent discharge summaries, nursing assessments, nursing care plans, medication sheets, doctor's orders, consults and official diagnostic reports, and other sources as available.

Based on observation, interview, and record review the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service department for 1 of 10 dietary staff (Cook B).<BR/>The facility failed to ensure dietary staff (Cook B) serving in the kitchen maintained a current food handlers' certificate. <BR/>This failure could place residents at risk of not having their nutritional needs met and place them at risk for foodborne illnesses.<BR/>Findings included:<BR/>Record review of an undated dietary staff list provided by the Dietary Manager (DM) titled, Dietary Staff indicated [NAME] B's name.<BR/>Record review of the food handlers' certificates provided by the DM on 09/26/23 revealed: [NAME] B's food handlers certificate was issued on 09/02/21 and valid through 09/02/2023.<BR/>During an observation and interview on 09/26/23 at 11:45 a.m., [NAME] B was sorting resident tray cards in the kitchen. She said she was unaware her food handler certificate was expired. <BR/>During an interview on 09/26/23 at 11:46 a.m., the DM said she started working at the facility 3 weeks ago and was unaware [NAME] B's food handlers' certificate was expired. She said [NAME] B had worked after 09/2/23 when the food handlers certificate expired. The DM said she saw the certificates hanging on the wall but did not read them closely and just missed [NAME] B's certificate being out of date. The DM immediately removed [NAME] B from the work schedule until the certificate was updated. The DM said she was responsible for making sure all food handlers' certificates were up to date. She said the risk of an expired certificate was possible sanitation and infection control concerns if they were unaware of any updates or unaware how to wash their hands.<BR/>During an interview on 09/27/23 at 1:40 p.m., [NAME] B said she was unaware her food handlers' certificate was out of date. She said no one told her it was out. She said she had a copy at home but was unaware of where it was. [NAME] B said she was unsure what the risk was of her food handlers' certificate being out of date, she just knew she needed one. [NAME] B said she completed the food handler training and had a new certificate as of 09/27/23.<BR/>During an interview on 09/27/23 at 2:00 p.m., the Administrator said she expected all kitchen staff to have an up-to-date food handlers' certificate and not work in the kitchen until they completed the training. The Administrator said she had a new DM and the expired food handler certificate was overlooked it. She said [NAME] B should have known it was going out and updated it. The Administrator said the risk of an employee working with an expired food handlers' certificate was not being in compliance with regulations and potential infection control concerns, if someone was expired, they would not be aware of new changes.<BR/>Record review of the Texas Food Establishment Rules dated October 2015 indicated . Certified Food Protection Manager and Food Handler Requirements. (d) . all food employees shall successfully complete an accredited food handler training course, within 60 days of hire. (e) The food establishment shall maintain on premises a certificate of completion of the food handler training course for each food employee. The requirement to complete a food handler course shall be effective September 1, 2016. <BR/> Record review of an undated policy titled, Nutrition Services Policies and Procedures, indicated, . Culinary employees practice good personal hygiene and are free of illnesses that can be transmitted through food. State and local regulations pertaining to personal and food handling may differ. Check state and local regulations for requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 residents (Resident #6) reviewed for infection control. <BR/>1. The facility failed to ensure Resident #6's central line (a tube that is inserted into a large vein in the neck, chest, groin, or arm to give fluids, blood, medications, or to do medical tests quickly) dressing was changed every seven days per the physician's order.<BR/>2. The facility failed to ensure the Treatment Nurse changed gloves and performed hand hygiene between glove changes during wound care, after picking up a packaged mint off the floor, and before and after entering and exiting Resident #6's room.<BR/>These failures could place residents at risk for infections.<BR/>Findings included:<BR/>1. Record review of the face sheet dated 7/1/24 indicated Resident #6 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including cellulitis (a common and potentially serious bacterial skin infection) of the left lower limb, hypertension (elevated blood pressure), diabetes, Charcot's joint syndrome (a rare complication of diabetes related neuropathy [nerve damage where feeling in the lower legs and feet are lost]. It can make injuries or infections much more serious).<BR/>Record review of the MDS dated [DATE] indicated Resident #6 admitted to the facility on [DATE]. The MDS indicated Resident #6 was usually understood by others and usually understood others. The MDS indicated Resident #6 had a BIMS of 08 and was moderately cognitively impaired. The MDS indicated Resident #6 required set-up assistance with eating and was dependent on staff for oral hygiene, showering/bathing, dressing, and transferring. <BR/>Record review of the physician orders dated 6/28/24 indicated Resident #6 had an order starting 6/7/24 to change the dressing to single lumen (one tubing and one cap end) PICC line to the left upper extremity every day shift every 7 days for IV (intravenous) management. <BR/>During an observation and interview on 6/28/24 at 11:47 a.m. Resident #6's PICC line dressing was dated 6/4/24. Resident #6 said the facility staff had not changed his PICC line dressing since he admitted to the facility. <BR/>During an interview on 7/1/24 at 11:23 am the Medical Director said he would expect a PICC line dressing to be changed every 7 days as ordered to prevent infection.<BR/>During an interview on 7/1/24 at 12:01 p.m. the Administrator said Resident #6 was the only resident at the facility with a PICC line. <BR/>During an interview on 7/2/24 at 10:04 a.m. LVN T said the treatment nurse, or a RN was responsible for changing PICC line dressings. LVN T said if she noticed a PICC line dressing had not been changed as ordered she would notify a supervisor. LVN T said PICC line dressing should be changed weekly. LVN T said she had only administered Resident #6's IV medication once or twice because it was due on the evening shift, and she normally worked day shift. LVN T said she had not assessed Resident #6's PICC line dressing. LVN T said the importance of ensuring PICC line dressings were changed weekly was to prevent bacteria from entering the site and to prevent dressing from rolling up. <BR/>2. During an observation on 6/28/24 at 1:22 p.m. the Treatment Nurse performed wound care to Resident #6's ankle. The Treatment Nurse wiped the bedside table with normal saline and did not put a barrier down between the bedside table and the wound care supplies. The Treatment Nurse cleansed the medial incision, lateral incision, and bottom of foot with same piece of gauze with normal saline on it. The Treatment Nurse removed her gloves, did not perform hand hygiene, and went to the treatment cart to retrieve a package of rolled gauze. The Treatment Nurse dropped a packaged mint on the floor, reached down to pick it up, did not perform hand hygiene, and then applied a new pair of gloves. The Treatment Nurse touched Resident #6's foot and incisions with her gloved hands to see if he could feel her touch. The Treatment Nurse went to the treatment cart to obtain a tube of ointment for Resident #6's wound without removing her gloves or performing hand hygiene. The Treatment Nurse returned to the room, applied ointment to the incisions with her gloved hand, removed her gloves, did not perform hand hygiene, and wrapped the foot/ankle with rolled gauze. <BR/>During an observation and interview on 06/29/24 at 11:50 a.m., the Treatment Nurse removed the kerlix wrap from Resident #6's left foot. The Treatment Nurse said Resident #6 was on isolation for MRSA (methicillin-resistant Staphylococcus aureus) of his surgery sites. The Treatment Nurse removed her gloves washed her hands applied new gloves and cleaned wounds with wound cleanser and 4 by 4 gauze for each site. The Treatment Nurse then applied clindamycin by using fingers on her gloved hand:<BR/>* applied clindamycin to the inside surgical wound using gloved the first finger applied directly to the wound. <BR/>*, applied clindamycin to the outside of the surgical wound using gloved the second finger applied directly to the wound; and<BR/>* applied clindamycin to the great left toe a necrotic area using gloved the ring finger applied directly to the wound. <BR/>The Treatment Nurse did not change her gloves or perform hand hygiene between treating areas on Resident #6's foot. The Treatment Nurse removed her gloves after she wrapped the left foot with kerlix wrap then walked out of the room down the hall approximately 7 feet to the hand sanitizer with her isolation gown on she wore while she performed wound care.<BR/>During an interview on 06/29/24 at 12:00 p.m., the Treatment Nurse said she should have removed her gown in the room and said she never told about changing gloves between areas. <BR/>During an interview on 7/1/24 at 11:23 a.m., the Medical Director said the Treatment Nurse cleaning Resident #6's wounds with the same gauze would not have spread the MRSA as it was systemic. The Medical Director said the treatment nurse not performing appropriate hand hygiene during wound care and leaving the room with gloved hands and without performing hand hygiene should be something staff were in-serviced regarding because the action could lead to the spread of infections.<BR/>During an interview on 7/2/24 at 12:36 p.m. DON JJ said an RN or trained LVN could change a PICC line dressing. DON JJ said the charge nurses were responsible for changing PICC line dressings. DON JJ said PICC line dressings should be changed weekly. DON JJ said the importance of ensuring PICC line dressings were changed weekly was for infection control. DON JJ said she expected staff to perform hand hygiene before entering a resident room, before patient care, during patient care when warranted, before leaving a resident room, and between glove changes. DON JJ said if a staff member picked an item up out of the floor, she expected them to perform hand hygiene afterwards. DON JJ said the importance of proper hand hygiene was infection control.<BR/>During an interview on 7/1/24 at 1:37 p.m. the Administrator said an RN was responsible for changing PICC line dressings. The Administrator said PICC line dressing changes were the responsibility of DON JJ or the weekend RN Supervisor. The Administrator said a PICC line dressing should be changed in accordance with the doctor's order. The Administrator said the importance of ensuring PICC line dressings were changed as ordered was infection control. The Administrator said she expected staff to perform hand hygiene when performing care for a resident, during different intervals of wound care including going from one wound site to another, and if they picked something up off the floor. The Administrator said the importance of proper hand hygiene was infection control. <BR/>Record review of the facility's undated Infections-Clinical Protocol policy indicated, During the initial assessment, the physician will help identify individuals who have had a recent infection or who are at risk for developing an infection .<BR/>Record review of the facility's undated Central Venous Catheter Dressing Changes policy indicated, The purpose of the procedure is to prevent catheter-related infections associated with contaminated, loosened, soiled, or wet dressings. Check the State's Nursing Practice Act for LPNs (Licensed Practical Nurse) regarding the scope of practice for changing a central venous catheter dressing. A physician's order is not needed for this procedure. Apply and maintain sterile dressing on intravenous access devices .Change dressings if any suspicion of contamination is suspected .Change transparent semi-permeable membrane (TSM) dressings at least every 5-7 days and PRN (when wet, soiled, or not intact) .<BR/>Record review of the facility's undated Handwashing/Hand Hygiene policy indicated, The facility considers hand hygiene the primary means to prevent the spread of infection .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water in the following situations .b. Before and after direct contact with residents; c. Before preparing or handling medications; c. Before performing a non-surgical invasive procedure .g. Before handling clean or soiled dressing, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care .k. After handling used dressings, contaminated equipment, etc.; l. after contact with objects in the immediate vicinity of the resident; m. After removing gloves; n. Before and after entering isolation precaution settings .9. The use of gloves does not replace hand washing/hand hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to be adequately equiped to allow for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 2 of 18 residents on Hall 100 reviewed for call lights. (Residents #104 and #6) <BR/>The facility did not have a monitoring system for the call lights on Hall 100 where Resident #6 and Resident #104 resided, and the call lights were not within reach. <BR/>This could place the residents at risk of not receiving the care and services to maintain their highest level of well-being. <BR/>Findings included: <BR/>1.Record review of physician orders dated September 2023 indicated Resident #6, admitted [DATE], was a [AGE] years old female with diagnoses of dementia (a condition characterized by progressive or persistent loss of intellectual functioning) and glaucoma (the nerve connecting to the eye is damaged causing slow loss of eyesight). <BR/>Record review of a MDS assessment dated [DATE] indicated Resident #6 had a BIMS score of 15 (intact cognition) and required supervision and set up for transfers, walking in the room, and walking in the corridor. <BR/>Record review of a care plan updated 08/02/23 indicated Resident #6 had an ADL self-care performance deficit. The interventions indicated the resident required limited to extensive assistance of one person for personal hygiene. Resident #6 had limited physical mobility and used a rollator walker for assistance with ambulation. <BR/>During observation and interview on 09/25/23 at 9:44 a.m., Resident #6 was lying in bed with her left arm in a sling. The resident's call light was lying on the floor next to the wall and was not within reach . Resident #6 said she fell near the Hall 200 nurses' station while ambulating. She said she fell after ambulating near the Hall 200 nurses' station to get herself ice. She said she did not use her call light to ask for ice and said she could ambulate without staff assistance. She said she could get up to go to the bathroom, but it was hard because she had to use the bed as leverage to pull herself up into a sitting position since her left arm was in the sling. She said if she needed assistance, she did not pull the call light because the call light signaled the nurses at the Hall 100 nurses' station but there were no staff there . She said no one would come if she pulled it. <BR/>2. Record review of physician orders dated September 2023 indicated Resident #104, re-admitted [DATE], was a [AGE] years old male with diagnoses of tremors, anxiety, and abnormality of gait. <BR/>Record review of a MDS assessment dated [DATE] indicated Resident #6 had a BIMS of 15 (intact cognition) and required supervision and set up for transfers, walking in the room and walking in the corridor and extensive assistance of one staff for eating. <BR/>Record review of a care plan updated 07/20/23 indicated Resident #6 had an ADL self-care performance deficit related to a history of falls and weakness. The interventions indicated the resident was able to self bathe with the supervision of one staff member to ensure the tasks are completed safely. <BR/>During observation and interview on 09/25/23 at 9:12 a.m., Resident #104 was lying in bed. His call light string was approximately 3 inches in length . He said he could get up and pull it, however there was no way to call the nurse anyway because the call light sounded at the Hall 100 nurses' station and there was no staff stationed on Hall 100. He said when he needed assistance, he had to walk down to Hall 200 nurses' station. He said the nurses and staff who were on Hall 200 did come down to check on the residents on Hall 100. The call light was pulled at 9:16 a.m. with no staff responding until surveyor intervention at 9:33 a.m. <BR/>During observations on 09/25/23 at 9:28 a.m., the Hall 100 nurses' station was approximately 25 to 30 feet from Resident #104's Room. There were no staff in the nurses' station. The lights at the nurses' station were off , and the door was shut. The call light continued to sound but was barely audible. The AD and BOM, who resided in the same office, were next to the Hall 100 nurses' station. The MDS nurse's office was across the hall from the Hall 100 nurses' station and the Administrator's office was [NAME]-cornered across the hall from Resident #104's room. <BR/>During an interview on 09/25/23 at 9:33 a.m., the MDS nurse , said the call light rang at the nurses' station on Hall 100 but there were no nurses at that station. She said she did not hear the call light going off. She said she was not assigned to answer the call lights or to monitor the call lights on Hall 100, so she did not answer the call light. She said the nurses on Hall 200 came down to check on the residents on Hall 100. <BR/>During an interview on 09/25/23 at 9:32 a.m., LVN A, who was assigned to Hall 100, said the call lights on Hall 100 did not go off at the Hall 200 nurses' station, where the nurses were at. She said she could not hear or see the Hall 100 lights go off from the Hall 200 nurses' station. She said the possible negative outcome could be a fall, choking, injury etc. She said there should be a call light system set up on Hall 100 so the residents could call the nurses at the Hall 200 nurses' station. LVN A said she was not sure why the Hall 100 call lights did not work at the nurses' station on Hall 200. She said she did rounds on Hall 100 every 2 hours. She denied there had been any emergencies on Hall 100 during her assigned shifts she had worked. <BR/>During an interview on 09/25/23 at 10:04 p.m., the Administrator said she recently started working at the facility in September 2023 and she was unaware the call lights on Hall 100 were not working at the Hall 200 nurse's station. She said there were no staff at the Hall 100 nurses' station, but she thought the call lights rang at the Hall 200 nurses' station. She said she did not monitor the call lights on Hall 100. She said her expectations were for the residents to be able to call the nurse in case of an emergency. She said the possible negative outcome could be injury to the residents. <BR/>During an interview on 09/25/23 at 10:08 a.m., the AD and the BOM were sitting in their office. The BOM said she would answer the call lights when she heard them. She said no one told her to monitor the call lights. The AD said she was not told to monitor the call lights and she was usually out of the office assisting the residents with activities. <BR/>During an interview on 09/25/23 at 10:14 a.m., the DON said there were only 4 residents on Hall 100 and they were ambulatory and could go to the nurses' station on Hall 200 if they needed something. She said there were no staff assigned to the Hall 100 nurses' station. She said the residents should be able to call the Hall 200 nurse in case of an emergency and they could not. She said the call lights on Hall 100 should be visible and audible at the Hall 200 nurses' station and were not. The DON said the nurses and CNAs were checking on the residents every 2 hours. She said no one was assigned to monitor the call lights on hall 100. She said the possible negative outcome of not having someone to monitor the call light system on Hall 100 could be injury to the resident. <BR/>Review of the facility's Call lights, Answering of policy dated March 2019 indicated: Policy: It is the policy of this facility that the facility staff will provide an environment of meeting the resident's needs. Procedure: 1. Respond to resident's call lights in a timely manner. 2. Answer emergency lights immediately. 7. When leaving the room, facility staff will place the call light within the resident's reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care and that was developed within 48 hours of a resident's admission for 1 of 7 residents (Resident #6) reviewed for baseline care plans.<BR/>The facility failed to ensure Resident #6 had a baseline care plan completed within 48 hours of his admission on [DATE].<BR/>This failure could place newly admitted residents at risk of receiving inadequate care and services.<BR/>Findings included: <BR/>1. Record review of the face sheet dated 7/1/24 indicated Resident #6 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including cellulitis (a common and potentially serious bacterial skin infection) of the left lower limb, hypertension (elevated blood pressure), diabetes (high blood sugar), Charcot's joint syndrome (a rare complication of diabetes related neuropathy [nerve damage where feeling in the lower legs and feet are lost]. It can make injuries or infections much more serious).<BR/>Record review of the MDS dated [DATE] indicated Resident #6 admitted to the facility on [DATE]. The MDS indicated Resident #6 was usually understood by others and usually understood others. The MDS indicated Resident #6 had a BIMS of 08 and was moderately cognitively impaired. The MDS indicated Resident #6 required set-up assistance with eating and was dependent on staff for oral hygiene, showering/bathing, dressing, and transferring.<BR/>Record review of Resident #6's EHR record indicated there was no baseline care plan for review.<BR/>During an interview on 6/28/24 at 12:37 p.m. the MDS Coordinator said there should have been a baseline care plan Resident #6. The MDS Coordinator said the baseline care plan was triggered when a resident was admitted or re-admitted to the facility. The MDS Coordinator said if Resident #6 did not have a baseline care plan it either did not trigger or was deleted. The MDS Coordinator said the importance of baseline care plans and comprehensive care plans was to know how to take care of the resident.<BR/>During an interview on 7/1/24 at 12:36 p.m., DON JJ said a baseline care plan should be completed within 3 days of a resident's admission to the facility. DON JJ said the importance of baseline and comprehensive care plans was, it was the framework that told staff how to care for a resident.<BR/>During an interview on 7/1/24 at 1:37 p.m., the Administrator said the baseline care plan should be completed upon admission to the facility. The Administrator said the importance of baseline and comprehensive care plans was they were a guideline of care to be performed on a resident to help maintain the resident's quality of life.<BR/>Record review of the facility's Care Plan-Baseline policy, revised December 2016, indicated, The baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission .The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan

Based on interview and record review, the facility failed to ensure they had an RN for 8 consecutive hours 7 days a week for 2 of 4 quarters of 2023 (Quarter 2 and Quarter) PBJ reports reviewed for RN coverage. <BR/>The facility did not have RN coverage for Saturdays and Sundays in January 2023, February 2023, March 2023, April 2023, May 2023, and June 2023.<BR/>This failure could place residents at risk of lack of nursing oversight and a higher level of care.<BR/>Findings included:<BR/>Record review of the CMS PBJ reports indicated:<BR/>* Quarter 2 2023 (January 1 through March 31) there was no RN hours on 01/28 (Saturday); 01/29 (Sunday); 02/03 (Friday); 02/06 (Monday); 02/07 (Tuesday); 02/08 (Wednesday); 02/09 (Thursday); 02/10 (Friday); 02/13 (Monday); 02/14 (Tuesday); 02/15 (Wednesday); 02/16 (Thursday); 02/25 (Saturday); 02/26 (Sunday); 03/17 (Friday); 03/20 (Monday; 03/21 (Tuesday); 03/22 (Wednesday); 03/23 (Thursday); 03/24 (Friday); 03/25 (Saturday); 03/26 (Sunday); 03/27 (Monday) 03/28 (Tuesday); 03/29 (Wednesday); and 03/30 (Thursday). <BR/>* Quarter 3 2023 (April 1 through June 30) there was no RN hours on 04/10 (Monday); 05/19 (Friday); 05/26 (Friday); 05/29 (Monday); 05/30 (Tuesday); 05/31 (Wednesday), 06/01 (Thursday); 06/02 (Friday); 06/03 (Saturday); 06/04 (Sunday); 06/05 (Monday); 06/07 (Wednesday); 06/08 (Thursday); 06/14 (Wednesday); 06/15 (Thursday); 06/16 (Friday); 06/17 (Saturday); 06/18 (Sunday); 06/19 (Monday); 06/20 (Tuesday; 06/21 (Wednesday); 06/22 (Thursday); 06/23 (Friday); 06/24 (Saturday); 06/25 (Sunday); 06/26 (Monday); 06/27 (Tuesday); 06/28 (Wednesday); 06/29 (Thursday); and 06/30 (Friday).<BR/>During an interview on 09/26/23 09:22 a.m., the HR said the PBJ reports were submitted by a third-party group. She said the third-party group told her they did not have a policy regarding PBJ reporting, they followed the CMS guidelines for PBJ reporting. <BR/>During an interview on 09/27/23 at 10:52 a.m. the Administrator said her start date at the facility was 09/01/23 so she had no knowledge regarding the prior quarterly PBJ report regarding staffing. <BR/>During an interview on 09/27/23 at 01:04 p.m., the DON said she tried to keep staffing according to the needs of the residents. She said she did not understand why the previous corporation did not submit the information in the PBJ report. A staffing policy was requested at this time. She said she would provide a policy. <BR/>No policy was provided prior to exit.

Based on observations, interviews, and record reviews the facility's governing body failed to operate and provide services in compliance with all applicable Federal, State and local laws, regulations, and codes for 1 of 1 facility reviewed for ADM and SW.<BR/>* The facility did not immediately notify HHS when the ADM resigned and there was no ADM as required by state regulations.<BR/>* The facility did not employ a part time or contract a SW as required by state regulations. <BR/>These failures could place residents at risk of administrative duties not being carried out attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. <BR/>Findings included:<BR/>1. During an interview on 06/09/23 at 10:40 a.m., the DON said a car ran into something on the corner about two weeks prior. She said the water to the front of the building was temporarily cut off. She said the ADM at the time thought the water had been cut off due to non-payment. She said the ADM words to her were if [owner] did not care, then she did not care. She said the ADM gave her resignation immediately. She said there had not been an administrator since then. <BR/>During an interview on 06/09/23 at 12:26 p.m., the owner said the previous administrator walked out about two weeks earlier. He said he did not call HHS to let them know he did not have an administrator. He said he was not aware he needed to do that. <BR/>Record review of the ADM employee file indicated an Employee Change of Status Form dated 06/12/23. Further review of the form indicated her last working day was 05/27/23, voluntary termination of employment due to being dissatisfied with job or company was marked, and other was also marked-written next to this was quit via text to admin group.<BR/>During an interview on 06/12/23 at 01:35 PM the DON said she was the acting ADM since 05/27/23 when the ADM resigned.<BR/>Record review of the Texas Administrative Code 554.1902 (a)(2) indicated The facility must:<BR/> (2) ensure that a person designated as being in authority notifies HHSC immediately when the facility does not have an administrator.<BR/>2. In an interview on 6/12/2023 at 10:20am, the DON was asked about a SW, which she said the facility did not have one at that time. The DON was asked how long facility had been without a SW, she said she does not remember. She said there was no SW from corporate office or a sister facility assisting either.<BR/>During a phone interview on 06/12/23 at 01:59 PM the Ombudsman said the facility had not had a SW in several months. She said the DON and other staff were trying to keep up with the needs of the residents, but she felt them not having a SW there were some things not being taken care of. She said the SW could help with finding other placement for residents the facility does not feel like they can meet their needs because of behaviors which she had to intervene to prevent them from refusing to take a resident back from the hospital. <BR/>Record review of the Grievance Book indicated a grievance on 03/07/23 about not having a SW for assistance. <BR/>During an interview 6/14/2023 8:00 am with Resident #13's representative reports that he has been trying to get assistance from the facility to help resident #13 get on her disability and follow up on Medicaid application which are both still pending, she has recently been diagnosed as legally blind so she should qualify for these programs and other resources. <BR/>During a phone interview 6/14/2023 7:30 am with Resident #15's representative reports that resident #15 was transferred to another facility he feels the transfer to the other facility could have gone smoother if one person was handling the transfer (social worker) instead of several staff members, also reports during his stay at the facility the resident received a phone call from a soliciting insurance plan and resident's insurance was changed unbeknown to facility, resident or resident representative and the facility staff (social worker) did not assist in explaining/resolving this issue.<BR/>Record review of the SW employee file indicated a Disciplinary Action dated 01/09/23. Further review of the form indicated the SW was terminated on 01/09/23. <BR/>During an interview on 06/12/23 at 01:35 PM the DON said they had no SW since the previous SW was terminated. She said she and the ADONs were taking care of the resident needs as best as they could.<BR/>Record review of the Texas Administrative Code 554.703 (a)(2) indicated (2) A facility of 120 beds or less must employ or contract with a qualified social worker (or in lieu thereof, a social worker who is licensed by the Texas State Board of Social Worker Examiners, and who meets the requirements of subsection (b)(2) of this section) to provide social services a sufficient amount of time to meet the needs of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care and that was developed within 48 hours of a resident's admission for 1 of 7 residents (Resident #6) reviewed for baseline care plans.<BR/>The facility failed to ensure Resident #6 had a baseline care plan completed within 48 hours of his admission on [DATE].<BR/>This failure could place newly admitted residents at risk of receiving inadequate care and services.<BR/>Findings included: <BR/>1. Record review of the face sheet dated 7/1/24 indicated Resident #6 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including cellulitis (a common and potentially serious bacterial skin infection) of the left lower limb, hypertension (elevated blood pressure), diabetes (high blood sugar), Charcot's joint syndrome (a rare complication of diabetes related neuropathy [nerve damage where feeling in the lower legs and feet are lost]. It can make injuries or infections much more serious).<BR/>Record review of the MDS dated [DATE] indicated Resident #6 admitted to the facility on [DATE]. The MDS indicated Resident #6 was usually understood by others and usually understood others. The MDS indicated Resident #6 had a BIMS of 08 and was moderately cognitively impaired. The MDS indicated Resident #6 required set-up assistance with eating and was dependent on staff for oral hygiene, showering/bathing, dressing, and transferring.<BR/>Record review of Resident #6's EHR record indicated there was no baseline care plan for review.<BR/>During an interview on 6/28/24 at 12:37 p.m. the MDS Coordinator said there should have been a baseline care plan Resident #6. The MDS Coordinator said the baseline care plan was triggered when a resident was admitted or re-admitted to the facility. The MDS Coordinator said if Resident #6 did not have a baseline care plan it either did not trigger or was deleted. The MDS Coordinator said the importance of baseline care plans and comprehensive care plans was to know how to take care of the resident.<BR/>During an interview on 7/1/24 at 12:36 p.m., DON JJ said a baseline care plan should be completed within 3 days of a resident's admission to the facility. DON JJ said the importance of baseline and comprehensive care plans was, it was the framework that told staff how to care for a resident.<BR/>During an interview on 7/1/24 at 1:37 p.m., the Administrator said the baseline care plan should be completed upon admission to the facility. The Administrator said the importance of baseline and comprehensive care plans was they were a guideline of care to be performed on a resident to help maintain the resident's quality of life.<BR/>Record review of the facility's Care Plan-Baseline policy, revised December 2016, indicated, The baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission .The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately consult with the resident's physician of lab results and treatment recommendations for 1 of 8 residents (Resident #1) reviewed for change of condition. <BR/>The facility did not notify Resident #1's wound care doctor or primary physician of recommendations dated 11/16/22 for antibiotics for possible wound infection of the right foot and a CT or MRI to rule out (osteomyelitis inflammation or swelling that occurs in the bone). Resident #1 had a partial resection of the 5th metatarsal of the right foot and wound and muscle debridement of the left trans-metatarsal stump on 12/15/22. <BR/>The facility did not notify or consult Resident #1's physician of stat lab dated 11/22/22 results positive for MRSA.<BR/>An Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., 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 of not receiving immediate corrective actions necessary for their health and that could cause, or likely continue to cause, serious injury, harm, impairment or death.<BR/>Findings included: <BR/>Record review of physician orders dated 01/03/2022 indicated Resident #1 was a [AGE] year-old male re-admitted on [DATE] (originally admitted on [DATE]). His diagnoses included long term use of antibiotics, acute osteomyelitis (inflammation or swelling that occurs in the bone) right ankle and foot, diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high , cellulitis bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin, gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection), non-pressure chronic ulcer of left foot, cellulitis of left lower limb and acute osteomyelitis of left foot and ankle.<BR/>Record review of an MDS dated [DATE] indicated Resident #1 had moderate impaired cognition, was understood by others and usually understood others. He was not able to focus and had disorganized thinking. He had delusions. He required supervision for most ADLS. He utilized a wheelchair for mobility. He was continent of bladder and bowel. Resident #1 had surgical wounds and received surgical wound care. There was no antibiotic use noted.<BR/>Record review of a care plan dated 11/09/22 indicated Resident #1 had right foot amputation of small toe and was at risk of further skin breakdown, infection, and worsening surgical wound. Interventions included inform MD of progress and perform treatment per order and if no improvement report to MD.<BR/>Record review of a care plan dated 11/09/2022 indicated Resident #1 had a left foot amputation of toes and was at risk for further skin breakdown, infection and worsening surgical wound. Interventions included inform MD of progress and perform treatment per order and if no improvement report to MD.<BR/>Record review of a wound evaluation dated 11/16/22, completed by RN B, indicated Resident #1's right lateral toe's surgical wound measured 3.5 cm X 2.0 cm X .3 cm, 25 % slough (necrotic tissue that needs to be removed from the wound), and moderate serous exudate (type of exudate that is clear, thin, and watery in contrast to a purulent exudate that is opaque). There was purulent (discharging) pus present and RN B recommended ABT (Bactrim, Doxycycline) and a CT or MRI to rule out osteomyelitis (inflammation or swelling that occurs in the bone).<BR/>Record review of Resident #1's clinical record indicated there was no progress note or treatment note available for review from the wound care consult on 11/16/22.<BR/>Record review of progress note dated 11/21/22 at 12:08 p.m., completed by RN N (previous DON) indicated Resident #1 complained he had drainage to bilateral feet. Scant amount of clear drainage noted with no signs of infection. MD A's office was called and there was no answer and would follow-up.<BR/>Record review of progress note dated 11/21/22 at 4:57 p.m., completed by ADON D, indicated she contacted MD A's office and received order for wound culture of wounds to bilateral feet. Antibiotic to be ordered once results were received.<BR/>Record review of STAT lab results dated 11/22/22 indicated Resident #1 was positive for methicillin-resistant Staphylococcus aureus (MRSA) - (staph infection that is difficult to treat because of resistance to some antibiotics).<BR/>Record review of wound care report dated 12/13/22, competed by DPM C indicated Resident #1 was admitted to hospital for infection of right foot.<BR/>Record review of a history and physical report (included with the hospital records) dated 12/14/22 indicated Resident #1 had osteomyelitis with gangrene at right metatarsal site. <BR/>Record review of consult report (included with the hospital records) dated 12/15/22 indicated Resident #1 had a partial resection of the 5th metatarsal of the right foot and wound and muscle debridement of the left trans-metatarsal stump. The wound cultures were growing MRSA. Resident #1 returned to the facility on [DATE].<BR/>During an observation and interview on 12/30/23 at 10:50 a.m., Resident #1 was wearing a protective foot device on his right and left foot. He said he had a staph infection on his foot and was in the hospital and received intravenous antibiotics. He said he had to have more amputations because he did not get the antibiotics he was supposed to get. He could not recall who said he should have antibiotics.<BR/>During an interview on 01/04/23 at 10:07 a.m., TX LVN E said she made wound rounds with RN B (wound care consultant) on 11/16/22. She said it was toward the end of her shift and she asked a nurse to fax the wound care consult with recommendations to Resident #1's wound care doctor (DPM C) and to follow up because she was not returning to the facility. She said 11/16/22 was the last day she worked in the facility. She said she could not recall the name of the nurse she gave the recommendations or directions to notify the physician. She said she did not notify Resident #1's primary physician or DPM C. She said she could not recall if she documented the recommendations in a progress note.<BR/>During an interview on 01/04/23 at 1:40 p.m., LVN F said she worked on 11/16/22 and did not recall TX LVN E giving her a wound care recommendation for Resident #1 or being directed to fax it to DPM C.<BR/>During an interview on 01/04/23 at 2:00 p.m., ADON H said she worked on 11/16/22 and did not recall TX LVN E giving her a wound care recommendation for Resident #1 or being directed to fax it to DPM C.<BR/>During an interview on 01/4/23 at 3:26 p.m., RN L (from the wound care clinic) said they did not have any knowledge and were not informed of RN B's recommendations dated 11/16/22 for Resident #1 that included ABT (Bactrim, Doxycycline) and a CT or MRI to rule out osteomyelitis.<BR/>During an interview on 01/04/23 at 5:10 p.m., RN B said she was a wound care consultant and was contracted by the facility to observe wound care and train the staff. She said she completed rounds with TX LVN E on 11/16/22 and noted purulent pus and made recommendation for ABT and CT or MRI to rule out osteomyelitis. She said TX LVN E should have informed the primary physician of the assessment and recommendations. She said some primary physicians would direct the facility to forward the recommendations to the wound care physician. She said infection of the wound could get to the blood or get septic (infected with microorganisms, especially harmful bacteria).<BR/>During an interview on 01/05/23 at 9:43 a.m., ADON D said she did get the order for Resident #1's wound culture on 11/21/22. She said she was new to the position and should probably have followed up on the results. She said she was off sick and then forgot to follow up when she returned to work.<BR/>During an interview on 01/05/23 at 10:54 a.m., MD A said he did not receive notification of Resident #1's wound culture results dated 11/22/22 regarding positive MRSA results. He said the facility staff should have notified him of RN B's recommendations dated 11/16/22 for Residents #1. He said the delay of notification, treatment, or ABT most likely would not have made any difference because Resident #1 had been on multiple [NAME] and was ABT resistant. He said Resident #1 was non-compliant with wound care and physician orders. MD A said it was also most likely to require additional surgeries and amputations.<BR/>During an interview on 01/05/23 at 12:06 p.m., ADON H said if they received recommendations from consultants, they would contact the physician. ADON D said lab results were supposed to be called or faxed over to the physician for review. ADON H said the lab results should be noted in the progress notes and also in the 24-hour report.<BR/>During an interview on 01/05/23 at 12:27 p.m., LVN J said all recommendations for care, tests, or treatments were supposed to be sent to the physician for review. LVN M said lab results were supposed to be called or faxed over to the physician for review. LVN M They said the lab results are supposed to be noted in the progress notes and also in the 24-hour report.<BR/>During an interview on 01/05/23 at 8:25 a.m., the DON said Resident #1's lab results were not forwarded to MD A. She said the lab results should have been followed up by nursing staff to ensure Resident #1 received treatment. She said the results were in the facility electronic portal but not all staff had access to the portal. She said not informing the physician of recommendations or lab results could result in delay of treatment or further decline of condition. She said she could not attribute the delay of antibiotics to Resident #1 requiring additional amputation surgery because he was noncompliant with care and treatment. She said staff were in-serviced on 12/29/22 to ensure labs were documented and followed up as required.<BR/>During an interview on 01/05/23 at 8:30 a.m., LD I said Resident #1's lab results were available in the portal. He said the lab results were also faxed to the facility. He said he was not able to say who had access to the portal or who reviewed the labs. <BR/>The surveyors made three attempts on 01/03/23 and three attempts on 01/04/22 were made to contact DPM C regarding Resident #1 and there was no return call.<BR/>Record review of the facility's undated Laboratory Services and Reporting policy indicated .7. Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range.<BR/>Record review of the facility policy Change in Condition Communication dated 06/19 indicated physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patients/ residence condition, enter. Provide guidance for the notification of patients/ residents and their responsible party regarding changes in condition. F. Recent Labs <BR/>The Administrator and the DON were notified an Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., 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/>The facility's POR dated 01/26/23 indicated:<BR/>DON and CNO reviewed 24-hour report for the last 24 hours. Changes in condition noted on the 24-hour report were addressed and documented.<BR/>On 1.25.23 CNO re-educated facility nurses including nurse managers regarding:<BR/>Documentation on resident's change(s) in condition to include completion of SBAR assessment when notifying MD and documenting on 24-hour report. <BR/>During shift nurses were educated and those not scheduled to work will be in-serviced prior to their next scheduled shift. Completion Date 1.26.23 @ 12 pm.<BR/>ADON/Designee will pull 24-hour report and 24-hour lookback and SBARS for completion of MD notification and that orders were followed through.<BR/>ADONs will bring 24-hour report book and SBAR to clinical morning meeting to discuss follow-up if needed.<BR/>DON/Designee will audit 24-hour report and SBARS weekly on Wednesdays looking for MD notification and that orders were carried out and acted upon.<BR/>On 01/26/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record review of staff training dated 01/25/23 indicated all nursing staff were trained in person or by phone to notify the physician via phone call of lab results and document in the electronic records. If there was no response the nursing staff would notify the Medical Director. If there was no answer nursing staff would send the resident to the hospital if it was a critical lab result. <BR/>Record review of new hire education indicated the DON incorporated physician notification and the facility policy as part of the onboarding education as of 01/26/23. <BR/>Record review of the facility monitoring sheets indicated the Administrator would verify the education was done for new hires starting 01/26/23. There were no new hires as of 01/26/23.<BR/>Record review of the monitoring sheets indicated the Administrator reviewed at the morning meetings on 01/26/23 to verify that a change in condition requiring physician notification was done, physician orders, a follow up if physician deemed it necessary and the order was followed through for 3 residents.<BR/>Record review dated 01/25/23 indicated the Administrator was educated by Corporate Nurse on how review change of condition at morning meetings.<BR/>During an interview on 01/26/23 at 2:20 p.m., the Administrator was able to verbalize the monitoring for change of condition procedures. She said the DON and the ADON were designees if she was not able to complete the monitoring during morning meeting.<BR/>Record review of the facility's chart audit dated 01/25/23 indicated the facility had completed 100% chart audit and notified the physicians of any changes as required.<BR/>Interviews conducted on 01/26/23 from 1:15 p.m. through 2:30 p.m. with the DON, the 2 ADONs, 1 RN, and 6 LVNS, who worked all shifts, indicated they were able to correctly state the protocols for notification of the physician when there was a change of condition or a need to alter treatment for a resident, reviewing and reporting abnormal labs, clarification of verbal orders, ensuring the physician was made aware of the change or condition, and ensuring the physician received the lab results.<BR/>An Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., 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.

Based on observations, interviews, and record reviews the facility's governing body failed to operate and provide services in compliance with all applicable Federal, State and local laws, regulations, and codes for 1 of 1 facility reviewed for ADM and SW.<BR/>* The facility did not immediately notify HHS when the ADM resigned and there was no ADM as required by state regulations.<BR/>* The facility did not employ a part time or contract a SW as required by state regulations. <BR/>These failures could place residents at risk of administrative duties not being carried out attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. <BR/>Findings included:<BR/>1. During an interview on 06/09/23 at 10:40 a.m., the DON said a car ran into something on the corner about two weeks prior. She said the water to the front of the building was temporarily cut off. She said the ADM at the time thought the water had been cut off due to non-payment. She said the ADM words to her were if [owner] did not care, then she did not care. She said the ADM gave her resignation immediately. She said there had not been an administrator since then. <BR/>During an interview on 06/09/23 at 12:26 p.m., the owner said the previous administrator walked out about two weeks earlier. He said he did not call HHS to let them know he did not have an administrator. He said he was not aware he needed to do that. <BR/>Record review of the ADM employee file indicated an Employee Change of Status Form dated 06/12/23. Further review of the form indicated her last working day was 05/27/23, voluntary termination of employment due to being dissatisfied with job or company was marked, and other was also marked-written next to this was quit via text to admin group.<BR/>During an interview on 06/12/23 at 01:35 PM the DON said she was the acting ADM since 05/27/23 when the ADM resigned.<BR/>Record review of the Texas Administrative Code 554.1902 (a)(2) indicated The facility must:<BR/> (2) ensure that a person designated as being in authority notifies HHSC immediately when the facility does not have an administrator.<BR/>2. In an interview on 6/12/2023 at 10:20am, the DON was asked about a SW, which she said the facility did not have one at that time. The DON was asked how long facility had been without a SW, she said she does not remember. She said there was no SW from corporate office or a sister facility assisting either.<BR/>During a phone interview on 06/12/23 at 01:59 PM the Ombudsman said the facility had not had a SW in several months. She said the DON and other staff were trying to keep up with the needs of the residents, but she felt them not having a SW there were some things not being taken care of. She said the SW could help with finding other placement for residents the facility does not feel like they can meet their needs because of behaviors which she had to intervene to prevent them from refusing to take a resident back from the hospital. <BR/>Record review of the Grievance Book indicated a grievance on 03/07/23 about not having a SW for assistance. <BR/>During an interview 6/14/2023 8:00 am with Resident #13's representative reports that he has been trying to get assistance from the facility to help resident #13 get on her disability and follow up on Medicaid application which are both still pending, she has recently been diagnosed as legally blind so she should qualify for these programs and other resources. <BR/>During a phone interview 6/14/2023 7:30 am with Resident #15's representative reports that resident #15 was transferred to another facility he feels the transfer to the other facility could have gone smoother if one person was handling the transfer (social worker) instead of several staff members, also reports during his stay at the facility the resident received a phone call from a soliciting insurance plan and resident's insurance was changed unbeknown to facility, resident or resident representative and the facility staff (social worker) did not assist in explaining/resolving this issue.<BR/>Record review of the SW employee file indicated a Disciplinary Action dated 01/09/23. Further review of the form indicated the SW was terminated on 01/09/23. <BR/>During an interview on 06/12/23 at 01:35 PM the DON said they had no SW since the previous SW was terminated. She said she and the ADONs were taking care of the resident needs as best as they could.<BR/>Record review of the Texas Administrative Code 554.703 (a)(2) indicated (2) A facility of 120 beds or less must employ or contract with a qualified social worker (or in lieu thereof, a social worker who is licensed by the Texas State Board of Social Worker Examiners, and who meets the requirements of subsection (b)(2) of this section) to provide social services a sufficient amount of time to meet the needs of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care and that was developed within 48 hours of a resident's admission for 1 of 7 residents (Resident #6) reviewed for baseline care plans.<BR/>The facility failed to ensure Resident #6 had a baseline care plan completed within 48 hours of his admission on [DATE].<BR/>This failure could place newly admitted residents at risk of receiving inadequate care and services.<BR/>Findings included: <BR/>1. Record review of the face sheet dated 7/1/24 indicated Resident #6 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including cellulitis (a common and potentially serious bacterial skin infection) of the left lower limb, hypertension (elevated blood pressure), diabetes (high blood sugar), Charcot's joint syndrome (a rare complication of diabetes related neuropathy [nerve damage where feeling in the lower legs and feet are lost]. It can make injuries or infections much more serious).<BR/>Record review of the MDS dated [DATE] indicated Resident #6 admitted to the facility on [DATE]. The MDS indicated Resident #6 was usually understood by others and usually understood others. The MDS indicated Resident #6 had a BIMS of 08 and was moderately cognitively impaired. The MDS indicated Resident #6 required set-up assistance with eating and was dependent on staff for oral hygiene, showering/bathing, dressing, and transferring.<BR/>Record review of Resident #6's EHR record indicated there was no baseline care plan for review.<BR/>During an interview on 6/28/24 at 12:37 p.m. the MDS Coordinator said there should have been a baseline care plan Resident #6. The MDS Coordinator said the baseline care plan was triggered when a resident was admitted or re-admitted to the facility. The MDS Coordinator said if Resident #6 did not have a baseline care plan it either did not trigger or was deleted. The MDS Coordinator said the importance of baseline care plans and comprehensive care plans was to know how to take care of the resident.<BR/>During an interview on 7/1/24 at 12:36 p.m., DON JJ said a baseline care plan should be completed within 3 days of a resident's admission to the facility. DON JJ said the importance of baseline and comprehensive care plans was, it was the framework that told staff how to care for a resident.<BR/>During an interview on 7/1/24 at 1:37 p.m., the Administrator said the baseline care plan should be completed upon admission to the facility. The Administrator said the importance of baseline and comprehensive care plans was they were a guideline of care to be performed on a resident to help maintain the resident's quality of life.<BR/>Record review of the facility's Care Plan-Baseline policy, revised December 2016, indicated, The baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission .The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 5 (Resident #1) residents reviewed for grievances.<BR/>The facility did not thoroughly investigate or take prompt action to resolve grievances voiced by Resident #1 that she did not want CNA A or CNA B enter her room or provide care.<BR/>This failure could place residents at risk of unresolved grievances and decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included dementia (loss of cognitive functioning), anxiety (intense, excessive and persistent worry and fear about everyday situations), schizophrenia (serious mental health condition that affects how people think, feel and behave), unspecified mood disorder (complex mental health condition), paranoid personality disorder (mental health condition marked by a long-term pattern of distrust and suspicion of others without adequate reason to be suspicious (paranoia). People with PPD often believe that others are trying to demean, harm or threaten them.), major depressive disorder (persistent feeling of sadness and loss of interest), and bipolar disorder (mental health condition that causes extreme mood swings).<BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated she was able to make herself understood and understood others and she was cognitively intact (BIMS-15).<BR/>Record review of Resident #1's care plan dated 08/25/23 indicated she had a history of confabulation (a memory error consisting of the production of fabricated, distorted, or misinterpreted memories about oneself or the world. It is generally associated with certain types of brain damage (especially aneurysm in the anterior communicating artery) or a specific subset of dementia) presented false information she believed to be true, and indicated aides did not provide the right care. Interventions included allow resident to verbalize feelings, redirect resident during episodes of confabulation, psych consult as ordered, and report to MD as needed and document episodes of confabulation in the clinical record.<BR/>Record review of Resident #1's care plan dated 04/06/2021 indicated Resident #1 had a behavior problem related to confabulation, schizophrenia, major depressive disorder, and bipolar disorder. Interventions included administer medications as ordered, anticipate and meet her needs, and assist her to develop more appropriate methods of coping and interacting without confabulation.<BR/>Record review of a grievance dated 02/05/25 and written by previous Administrator K indicated Resident #1 did not want CNA A or CNA B. Resident #1 could not tell me why she did not want the employee in her room. The DON indicated there was no CNA B employed with the facility (this was an error due to the name documented and it was not recognized by the DON). The DON informed CNA A not to go in Resident #1's room. Grievance was noted as resolved and Resident #1 said thank you and had no other concerns.<BR/>Record review of a grievance dated 02/12/25 and written by Resident #1 indicated she wanted CNA A and CNA B banned from her room related to putting on her diaper wrong and provoking her by not doing things as she asked. ADON E noted Resident #1 refused care from certain aides because she liked certain aides better and was used to them. Resident #1 was informed the facility could not assign specific aides to Resident #1. The grievance was not completed as resolved or if Resident #1 was satisfied with the resolution.<BR/>Record review of an undated grievance completed by the SW indicated Resident #1 did not like how CNA A set her meal tray down, the tray was not set up right and she did not want CNA in her room. The SW asked Resident #1 how she wanted her tray and Resident #1 directed the SW to set the tray up. The grievance was noted as resolved and Resident #1 was satisfied. There was no indication which aide was not wanted in her room or how it was addressed or resolved.<BR/>Record review of the facility staffing sheets indicated CNA A was assigned to provide care for Resident #1 on 03/05/25, 03/12/25, 03/24/25, and 03/30/25.<BR/>Record review of facility staffing sheets indicated CNA B was assigned to provide care for Resident #1 on 02/07/25, 02/10/25, 02/12/25, 02/18/25, 03/08/25, 03/13/25, 03/14/25, and 03/22/25.<BR/>During an interview on 03/30/25 at 9:10 a.m., MA G said Resident #1 complained about CNAs if she did not like how they did something. She said she was aware there were certain staff that Resident #1 did not want in her room. She said CNA A was assigned to provide Resident #1's care.<BR/>During an interview on 03/30/25 at 9:20 a.m., CNA A said she was assigned to provide Resident #1's care. She said she was not informed she was not supposed to go in to Resident #1's room or provide care. She said she was aware there was some staff Resident #1 did not like and those staff did not go in her room.<BR/>During an interview on 03/30/25 at 10:00 a.m., Resident #1 said she did not want CNA A or CNA B in her room or providing care. She said she felt they were not nice. She said she felt unsafe and afraid. She said told ADON E and other staff but could not recall who else she told. She could not recall the date she told ADON E. She did not tell the Administrator but she did tell other staff. She did not want to identify the other staff. She said the staff caused her anxiety because they did not do things right or how she wanted. She said it was abusive because the staff did not provide her care how she wanted.<BR/>During an interview on 03/30/25 at 11:06 a.m., LVN H said Resident #1 said she does not want certain staff in her room. She said when she was made aware of it, she would switch the assigned aide or do the care herself. She said she was not aware of a list of staff who were not supposed to go in Resident #1's room or provide care.<BR/>During an interview on 03/30/25 at 1:00 p.m., Resident #1 said CNA C came in her room on 03/30/31 and told her CNA A was assigned to her and would complete her care. She said she did not want CNA A and CNA C said she was too busy.<BR/>During an interview on 03/30/25 at 1:34 p.m., the SW said the previous administrator was the grievance official until the new administrator (Administrator J) took over and made her (the SW) the grievance official. She said she was the grievance official for approximately 1 month. She said she could not recall the exact date of the grievance she completed for Resident #1 related to CNA A not setting up Resident #1's tray as she wanted. She said she did not address which aide Resident #1 did not want in her room. <BR/>During an interview on 03/31/25 at 9:08 a.m., Administrator J said she was in the position for one month. She said the SW was the grievance official. She said the facility would try to best to accommodate Resident #1's request but sometimes there would not be enough staff or the staff she wanted so she would agree to care with a staff she did not want and a witness. She said she was not aware of any complaints or grievances related to CNA A but was aware she did not want CNA B in her room. She said if she were aware Resident #1 did not want a particular staff in her room, she would get someone else to go to the room. She said a few times there was no staff she wanted so Resident #1 agreed to a staff and a witness. <BR/>During an interview on 03/31/25 at 9:20 a.m., ADON E said Resident #1 told her she did not want CNA D and CNA I in her room but agree to let CNA D provide care after she was retrained. She said there was no allegations of abuse. She said Resident #1 indicated the staff were rushing and leaving. She said the facility was running out of options because Resident #1 only wanted certain staff to provide care for her. She said Resident #1 did not say she did not want CNA A or CNA B in her room or providing care. <BR/>During an interview on 03/31/25 at 10:56 a.m., the DON said she was not aware Resident #1 did not want CNA A or CNA B in her room to provide care. She said she was not aware of the grievance dated 02/05/25. She said ADON F did not write any grievances related to Resident #1 saying she did not want CNA A or CNA B.<BR/>During an interview on 03/31/25 at 11:57 a.m., Administrator J if aides were assigned to provide care to Resident #1 and it was aides she did not want then they should have been re-assigned and another staff would have to provide her care. She said Resident #1 was at risk of feeling a certain way, like she was not being heard if aides continued to provide care that she did not want providing her care.<BR/>During an interview on 03/31/25 at 12:04 p.m., previous Administrator K said he was made aware Resident #1 did not want CNA A and CNA B in her room or providing care but could not recall the date of the grievance. He said he informed the DON and he believed the staff were verbally told not to go in Resident #1's room. He said Resident #1 did not like how certain staff provided care. <BR/>During an interview on 03/31/25 at 12:24 p.m., ADON F said she gave Resident #1's grievance related to staff she did not want to the DON. She said she did not recall exactly what Resident #1 said or which staff she did not want in her room.<BR/>Record review of the facility's Complaints/Grievance policy revised 06/19 indicated It is the policy of this facility to adopt a process to support the resident's right to voice complaints/grievances to facility management and have those grievances/complaints investigated and resolved in a reasonable timeframe. 9. Grievances/complaints can be taken by any staff member and documented on a Concern Form. The concern form is then forwarded to the Grievance Official. 10. Immediately upon receiving a grievance/complaint, facility Leadership will seek a resolution and will keep the resident informed of the progress of the investigation/resolution. 11. The Facility will take immediate action to prevent further potential violation of any resident right while the alleged violation is being investigated

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow Federal, State and Local laws and regulations regarding smoking, smoking areas, and smoking safety for 1 of 3 residents (Resident #253) reviewed for smoking safety.<BR/>The facility did not have Smoking-Safety Screens completed for Residents #253 quarterly.<BR/>This failure could place residents at risk of harm or injury and contribute to avoidable accidents. <BR/>Findings included: <BR/>Record review of a face sheet dated 09/20/23 indicated Resident #253 was a [AGE] year-old female admitted on [DATE] with diagnosis of diabetes. <BR/>Record review of an annual MDS assessment dated [DATE] indicated Resident #253 was a smoker. <BR/>Record review care plan dated 09/15/23 indicated Resident #253's tobacco use and included interventions: Nurse Will Provide Tobacco Cessation Information to resident, determine if Resident has a desire to quit, o Educate Resident / Family on risks & health effects of tobacco use and If Resident would like to quit, contract provider to prescribe cessation aides. <BR/>Record review of Safe Smoking Evaluations indicated Resident #253 was last evaluated on 01/20/23. There were no other evaluations completed for 2023. <BR/>During an observation on 09/26/23 at 3:33 p.m., Resident #253 was smoking in the designated smoking area with staff supervising. <BR/>During an interview on 09/27/23 at 3:38 p.m. the DON said Resident #253 had not been assigned to the nurses. The DON said the last smoking assessment for Resident #253 was done in January 2023. <BR/>The undated smoking-safety screen policy indicated Residents who desire to smoke will be assessed using a Smoking- Safety Screen . will be conducted upon admission, quarterly, when a change occurs .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately consult with the resident's physician of lab results and treatment recommendations for 1 of 8 residents (Resident #1) reviewed for change of condition. <BR/>The facility did not notify Resident #1's wound care doctor or primary physician of recommendations dated 11/16/22 for antibiotics for possible wound infection of the right foot and a CT or MRI to rule out (osteomyelitis inflammation or swelling that occurs in the bone). Resident #1 had a partial resection of the 5th metatarsal of the right foot and wound and muscle debridement of the left trans-metatarsal stump on 12/15/22. <BR/>The facility did not notify or consult Resident #1's physician of stat lab dated 11/22/22 results positive for MRSA.<BR/>An Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., 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 of not receiving immediate corrective actions necessary for their health and that could cause, or likely continue to cause, serious injury, harm, impairment or death.<BR/>Findings included: <BR/>Record review of physician orders dated 01/03/2022 indicated Resident #1 was a [AGE] year-old male re-admitted on [DATE] (originally admitted on [DATE]). His diagnoses included long term use of antibiotics, acute osteomyelitis (inflammation or swelling that occurs in the bone) right ankle and foot, diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high , cellulitis bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin, gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection), non-pressure chronic ulcer of left foot, cellulitis of left lower limb and acute osteomyelitis of left foot and ankle.<BR/>Record review of an MDS dated [DATE] indicated Resident #1 had moderate impaired cognition, was understood by others and usually understood others. He was not able to focus and had disorganized thinking. He had delusions. He required supervision for most ADLS. He utilized a wheelchair for mobility. He was continent of bladder and bowel. Resident #1 had surgical wounds and received surgical wound care. There was no antibiotic use noted.<BR/>Record review of a care plan dated 11/09/22 indicated Resident #1 had right foot amputation of small toe and was at risk of further skin breakdown, infection, and worsening surgical wound. Interventions included inform MD of progress and perform treatment per order and if no improvement report to MD.<BR/>Record review of a care plan dated 11/09/2022 indicated Resident #1 had a left foot amputation of toes and was at risk for further skin breakdown, infection and worsening surgical wound. Interventions included inform MD of progress and perform treatment per order and if no improvement report to MD.<BR/>Record review of a wound evaluation dated 11/16/22, completed by RN B, indicated Resident #1's right lateral toe's surgical wound measured 3.5 cm X 2.0 cm X .3 cm, 25 % slough (necrotic tissue that needs to be removed from the wound), and moderate serous exudate (type of exudate that is clear, thin, and watery in contrast to a purulent exudate that is opaque). There was purulent (discharging) pus present and RN B recommended ABT (Bactrim, Doxycycline) and a CT or MRI to rule out osteomyelitis (inflammation or swelling that occurs in the bone).<BR/>Record review of Resident #1's clinical record indicated there was no progress note or treatment note available for review from the wound care consult on 11/16/22.<BR/>Record review of progress note dated 11/21/22 at 12:08 p.m., completed by RN N (previous DON) indicated Resident #1 complained he had drainage to bilateral feet. Scant amount of clear drainage noted with no signs of infection. MD A's office was called and there was no answer and would follow-up.<BR/>Record review of progress note dated 11/21/22 at 4:57 p.m., completed by ADON D, indicated she contacted MD A's office and received order for wound culture of wounds to bilateral feet. Antibiotic to be ordered once results were received.<BR/>Record review of STAT lab results dated 11/22/22 indicated Resident #1 was positive for methicillin-resistant Staphylococcus aureus (MRSA) - (staph infection that is difficult to treat because of resistance to some antibiotics).<BR/>Record review of wound care report dated 12/13/22, competed by DPM C indicated Resident #1 was admitted to hospital for infection of right foot.<BR/>Record review of a history and physical report (included with the hospital records) dated 12/14/22 indicated Resident #1 had osteomyelitis with gangrene at right metatarsal site. <BR/>Record review of consult report (included with the hospital records) dated 12/15/22 indicated Resident #1 had a partial resection of the 5th metatarsal of the right foot and wound and muscle debridement of the left trans-metatarsal stump. The wound cultures were growing MRSA. Resident #1 returned to the facility on [DATE].<BR/>During an observation and interview on 12/30/23 at 10:50 a.m., Resident #1 was wearing a protective foot device on his right and left foot. He said he had a staph infection on his foot and was in the hospital and received intravenous antibiotics. He said he had to have more amputations because he did not get the antibiotics he was supposed to get. He could not recall who said he should have antibiotics.<BR/>During an interview on 01/04/23 at 10:07 a.m., TX LVN E said she made wound rounds with RN B (wound care consultant) on 11/16/22. She said it was toward the end of her shift and she asked a nurse to fax the wound care consult with recommendations to Resident #1's wound care doctor (DPM C) and to follow up because she was not returning to the facility. She said 11/16/22 was the last day she worked in the facility. She said she could not recall the name of the nurse she gave the recommendations or directions to notify the physician. She said she did not notify Resident #1's primary physician or DPM C. She said she could not recall if she documented the recommendations in a progress note.<BR/>During an interview on 01/04/23 at 1:40 p.m., LVN F said she worked on 11/16/22 and did not recall TX LVN E giving her a wound care recommendation for Resident #1 or being directed to fax it to DPM C.<BR/>During an interview on 01/04/23 at 2:00 p.m., ADON H said she worked on 11/16/22 and did not recall TX LVN E giving her a wound care recommendation for Resident #1 or being directed to fax it to DPM C.<BR/>During an interview on 01/4/23 at 3:26 p.m., RN L (from the wound care clinic) said they did not have any knowledge and were not informed of RN B's recommendations dated 11/16/22 for Resident #1 that included ABT (Bactrim, Doxycycline) and a CT or MRI to rule out osteomyelitis.<BR/>During an interview on 01/04/23 at 5:10 p.m., RN B said she was a wound care consultant and was contracted by the facility to observe wound care and train the staff. She said she completed rounds with TX LVN E on 11/16/22 and noted purulent pus and made recommendation for ABT and CT or MRI to rule out osteomyelitis. She said TX LVN E should have informed the primary physician of the assessment and recommendations. She said some primary physicians would direct the facility to forward the recommendations to the wound care physician. She said infection of the wound could get to the blood or get septic (infected with microorganisms, especially harmful bacteria).<BR/>During an interview on 01/05/23 at 9:43 a.m., ADON D said she did get the order for Resident #1's wound culture on 11/21/22. She said she was new to the position and should probably have followed up on the results. She said she was off sick and then forgot to follow up when she returned to work.<BR/>During an interview on 01/05/23 at 10:54 a.m., MD A said he did not receive notification of Resident #1's wound culture results dated 11/22/22 regarding positive MRSA results. He said the facility staff should have notified him of RN B's recommendations dated 11/16/22 for Residents #1. He said the delay of notification, treatment, or ABT most likely would not have made any difference because Resident #1 had been on multiple [NAME] and was ABT resistant. He said Resident #1 was non-compliant with wound care and physician orders. MD A said it was also most likely to require additional surgeries and amputations.<BR/>During an interview on 01/05/23 at 12:06 p.m., ADON H said if they received recommendations from consultants, they would contact the physician. ADON D said lab results were supposed to be called or faxed over to the physician for review. ADON H said the lab results should be noted in the progress notes and also in the 24-hour report.<BR/>During an interview on 01/05/23 at 12:27 p.m., LVN J said all recommendations for care, tests, or treatments were supposed to be sent to the physician for review. LVN M said lab results were supposed to be called or faxed over to the physician for review. LVN M They said the lab results are supposed to be noted in the progress notes and also in the 24-hour report.<BR/>During an interview on 01/05/23 at 8:25 a.m., the DON said Resident #1's lab results were not forwarded to MD A. She said the lab results should have been followed up by nursing staff to ensure Resident #1 received treatment. She said the results were in the facility electronic portal but not all staff had access to the portal. She said not informing the physician of recommendations or lab results could result in delay of treatment or further decline of condition. She said she could not attribute the delay of antibiotics to Resident #1 requiring additional amputation surgery because he was noncompliant with care and treatment. She said staff were in-serviced on 12/29/22 to ensure labs were documented and followed up as required.<BR/>During an interview on 01/05/23 at 8:30 a.m., LD I said Resident #1's lab results were available in the portal. He said the lab results were also faxed to the facility. He said he was not able to say who had access to the portal or who reviewed the labs. <BR/>The surveyors made three attempts on 01/03/23 and three attempts on 01/04/22 were made to contact DPM C regarding Resident #1 and there was no return call.<BR/>Record review of the facility's undated Laboratory Services and Reporting policy indicated .7. Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range.<BR/>Record review of the facility policy Change in Condition Communication dated 06/19 indicated physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patients/ residence condition, enter. Provide guidance for the notification of patients/ residents and their responsible party regarding changes in condition. F. Recent Labs <BR/>The Administrator and the DON were notified an Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., 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/>The facility's POR dated 01/26/23 indicated:<BR/>DON and CNO reviewed 24-hour report for the last 24 hours. Changes in condition noted on the 24-hour report were addressed and documented.<BR/>On 1.25.23 CNO re-educated facility nurses including nurse managers regarding:<BR/>Documentation on resident's change(s) in condition to include completion of SBAR assessment when notifying MD and documenting on 24-hour report. <BR/>During shift nurses were educated and those not scheduled to work will be in-serviced prior to their next scheduled shift. Completion Date 1.26.23 @ 12 pm.<BR/>ADON/Designee will pull 24-hour report and 24-hour lookback and SBARS for completion of MD notification and that orders were followed through.<BR/>ADONs will bring 24-hour report book and SBAR to clinical morning meeting to discuss follow-up if needed.<BR/>DON/Designee will audit 24-hour report and SBARS weekly on Wednesdays looking for MD notification and that orders were carried out and acted upon.<BR/>On 01/26/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record review of staff training dated 01/25/23 indicated all nursing staff were trained in person or by phone to notify the physician via phone call of lab results and document in the electronic records. If there was no response the nursing staff would notify the Medical Director. If there was no answer nursing staff would send the resident to the hospital if it was a critical lab result. <BR/>Record review of new hire education indicated the DON incorporated physician notification and the facility policy as part of the onboarding education as of 01/26/23. <BR/>Record review of the facility monitoring sheets indicated the Administrator would verify the education was done for new hires starting 01/26/23. There were no new hires as of 01/26/23.<BR/>Record review of the monitoring sheets indicated the Administrator reviewed at the morning meetings on 01/26/23 to verify that a change in condition requiring physician notification was done, physician orders, a follow up if physician deemed it necessary and the order was followed through for 3 residents.<BR/>Record review dated 01/25/23 indicated the Administrator was educated by Corporate Nurse on how review change of condition at morning meetings.<BR/>During an interview on 01/26/23 at 2:20 p.m., the Administrator was able to verbalize the monitoring for change of condition procedures. She said the DON and the ADON were designees if she was not able to complete the monitoring during morning meeting.<BR/>Record review of the facility's chart audit dated 01/25/23 indicated the facility had completed 100% chart audit and notified the physicians of any changes as required.<BR/>Interviews conducted on 01/26/23 from 1:15 p.m. through 2:30 p.m. with the DON, the 2 ADONs, 1 RN, and 6 LVNS, who worked all shifts, indicated they were able to correctly state the protocols for notification of the physician when there was a change of condition or a need to alter treatment for a resident, reviewing and reporting abnormal labs, clarification of verbal orders, ensuring the physician was made aware of the change or condition, and ensuring the physician received the lab results.<BR/>An Immediate Jeopardy (IJ) situation was identified on at 01/25/23 at 12:58 p.m. While the IJ was removed on 01/26/23 at 2:40 p.m., 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 interview and record review, the facility failed to ensure that a comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team after each assessment for 3 of 7 residents (Residents #1, #2, and #3) reviewed for comprehensive person-centered care plans.<BR/>1. Resident #1's comprehensive person-centered care plan was not updated to reflect behavior of physical aggression toward another resident. <BR/>2. Resident #2's comprehensive person-centered care plan was not updated to reflect an altercation when another resident had been physically aggressive with her. <BR/>3. Resident #3's comprehensive person-centered care plan was not updated to reflect when another resident had been physically aggressive with her. <BR/>These failures could place residents at risk for not receiving the necessary care and services they required. <BR/>The findings were:<BR/>1. Record review of Resident #1's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included schizophrenia (a serious mental condition involving breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion), persistent mood [affective] disorder (marked disruptions in emotions {severe lows called depression or highs called hypomania or mania]), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations).<BR/>Record review of Resident #1's care plan, dated 10/25/23, indicated Resident #1 had a diagnosis of schizophrenia and was at risk for manic episodes and increased behaviors. Interventions included monitor for delusions and hallucinations and monitor for increased agitation, anger, verbal, physical aggression and document in the clinical record. The care plan was not updated with Resident #1's physical aggression toward other residents on 04/03/24 when she pulled Resident #3 out of her wheelchair or on 04/19/24 when she attempted to smother her roommate (Resident #2) with a pillow. <BR/>Record review of Resident #1's quarterly MDS assessment, dated 04/08/24, indicated Resident #1 was able to make herself understood and usually understand others, and had moderate cognitive impairment indicated by a BIMS score of 11. She had had no hallucinations, delusions, or physical or verbal behaviors. She required partial to moderate assistance with most ADLs.<BR/>Record review of Resident #1's clinical note (related to the incident with Resident #3) dated 04/03/24 at 11:30 a.m. and signed by LVN N indicated CNA came and informed LVN N that Resident #1 pulled Resident #3 out of her wheelchair onto the floor of Resident #1's room. Resident #1 said I'm not a fucking babysitter, I need help my motherfucking self she needs to keep her ass out of my motherfucking room. On arrival to the secure unit residents were already separated and in different rooms. LVN N educated and redirected Resident #1, she was informed that physical aggression would not be tolerated, and it was not her right to put hands on anyone. LVN A indicated that Resident #1 did not verbalize understanding. <BR/>Record review of the incident report dated 04/19/24 at 03:40 a.m., Completed by LVN A indicated she was notified by CNA that Resident #2 was yelling for help because Resident #1 (her roommate) had placed a pillow over Resident #2's face and held it over her face. Resident #2 came out of her room yelling for help. The residents were separated, and Resident #2 was assessed with no bruising on her face and no shortness of breath. Resident #1 admitted she did it and stated, Don't send me to jail please send me to a mental institution. Resident #2 was moved to another room for her protection and safety. MD was paged and LVN A was awaiting response. Administrator was notified. <BR/>During an interview on 04/22/24 at 01:05 p.m., the MDS nurse said she was responsible for updating resident care plans with the DON's supervision. She said she had not been aware of Resident #1's aggression toward other residents. She said she received updates concerning residents during the facility morning care meetings, through review of new orders, and reviewing the facility 24-hour updates. She said not updating care plans with changes in resident status or behaviors could result in staff being unaware of the changes. <BR/>During an interview on 04/22/22 at 01:26 p.m., the ADON stated Resident #1 was transferred to a behavioral hospital on [DATE] after her attempt to hurt Resident #2. The ADON stated he was not sure why Resident #1's comprehensive person-centered care plan was not updated and should have been because it would ensure the resident received consistent care. <BR/>2. Record review of Resident #2's face sheet, dated 04/20/24, indicated she was a [AGE] year-old female who was admitted to the facility 12/05/23. Resident #2 had diagnosis which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning) with agitation, major depressive disorder (a metal health disorder characterized by persistently depressed mood causing significant impairment in daily life), and schizophrenia.<BR/>Record review of Resident #2's care plan, dated 07/31/23 indicated Resident #2 had an altered thought process and was at risk for further decline and injury as evidenced by dementia and short- and long-term memory deficit. Interventions included keep resident and others safe and monitor for mental status changes. The care plan was not updated with the altercation 0n 04/19/24 when Resident #1 attempted to smother her with a pillow.<BR/>Record review of Resident #2's quarterly MDS dated [DATE] indicated Resident #2 was able to make herself understood and understood others, and had severe cognitive impairment indicated by a BIMS score of 6. She had feelings of being down, depressed, and hopeless 2-6 (several) days and had no behaviors. <BR/>Record review of Resident #2's clinical note dated 04/19/24 at 03:54 a.m. and signed by LVN A indicated she was notified by CNA B that Resident #2 came running out of her room yelling for help and saying her roommate (Resident #1) placed a pillow over her face and held it over her face. The residents were separated, and Resident #2 was assessed with no bruising on her face and no shortness of breath. Resident #2 was moved to another room for her protection and safety. <BR/>During an interview on 04/21/24 at 02:44 p.m., the DON said the MDS nurse was responsible for updating care plans with changes in resident status/behavior with her supervision. She said Residents #1, #2, and #3's care plans should have been updated that the physical altercations had happened and goals and interventions for those focuses. She said if care plans were not updated it put residents at risk for not receiving the care and services they needed. <BR/>During an interview on 04/22/24 at 01:05 p.m., the MDS nurse said she had not been aware that Resident #2 had been involved in an altercation with Resident #1 on 04/03/24 so she didn't update the care plan. <BR/>3. Record review of Resident #3's face sheet dated 04/20/24 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included cerebral infarction (stroke), spastic hemiplegia (a common post-stroke condition that causes stiff or rigid muscles) affecting right dominant side, vascular dementia (dementia [a condition characterized by progressive or persistent loss of intellectual functioning] caused by an impaired supply of blood to the brain), mood disorder (marked disruptions in emotions [severe lows called depression or highs called hypomania or mania]), and depression.<BR/>Record review of Resident #3's care plan revised on 06/21/23 indicated Resident #3 was deemed at risk for wandering related to being ambulatory with her wheelchair, diagnosis of dementia, and history of exit seeking. Goals included Resident #3 would be able to wander in a safe environment (secure unit) with no occurrence of injury and dignity would be maintained. The care plan was not updated with the incident from 04/03/24 when Resident #3 wandered into Resident #1's room and Resident #1 pulled her out of her wheelchair onto the floor. <BR/> Record review of Resident #3's annual MDS dated [DATE] indicated Resident #3 was sometimes able to make herself understood and usually understood others, and had severe cognitive impairment indicated by a staff assessment. She had mood of little interest or pleasure in doing things several (2-6 days) and behaviors directed toward others 1 to 3 days and no wandering behaviors.<BR/>During an interview on 04/22/24 at 01:05 p.m., the MDS nurse said she had not been aware Resident #3 was pulled out of her wheelchair onto the floor by Resident #1 on 04/03/24 so she had not updated the care plan with the altercation. <BR/>Record review of facility policy Care Plans, Comprehensive Person-Centered revised October 2018, indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 12 residents (Resident #1) reviewed for comprehensive person-centered care plans.<BR/>The facility failed to develop and implement a care plan for Resident #1's aggressive behaviors toward others. <BR/>This failure could place residents at risk of not having individual needs met and a decreased quality of life. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 05/14/24 indicated he was [AGE] years old, admitted on [DATE], and his diagnoses included encephalopathy (brain dysfunction), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and cognitive communication deficit.<BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated he sometimes was able to make himself understood and understood others, and had severe cognitive impairment (BIMS score 00). His behaviors included physical behaviors directed at others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) that occurred 1 to 3 days (out of 7 day look back period)<BR/>Record review of Resident #1's electronic record indicated there was no care plan related to aggression towards others.<BR/>Record review of a progress note dated 05/12/24 at 10:23 p.m., completed by LVN L indicated she wheeled Resident #1 to his room for CNA R to provide care. CNA R reported Resident #1 initiated physical aggression and reached up and scratched CNA R's face. CNA N and CNA O entered Resident #1's room to complete Resident #1's care. <BR/>During an interview on 05/14/24 at 5:58 p.m., CNA R said she had been employed at the facility for 2 weeks and had worked at a secure unit as a CNA prior to this facility and had received training on abuse and self-defense tactics. She said that Resident #1 was never aggressive and she did not know what happened that day, but he was fighting all three of them, which included CNA N and CNA O, and her on 05/12/24. She said she was trying to get him dressed and he was so strong and grabbed her face and started scratching, punching, and kicking. She said she never hit him back and that she used the self-defense tactics of raising her arms like an x. She said he was fighting all three of them pretty hard and she did not see anyone ever hit him back. She said she was just trying to make sure he did not fall on the floor and resolve the situation. She said she had not worked with him since the incident and that she had observed his injuries. She said she did not know how he got those injuries other than he was fighting so hard and was not just fighting her that the other two girls were bigger than her. She said the administrator informed her that Resident #1 was never aggressive unless someone was mean to him and that it appeared she was getting the brunt of it. <BR/>During an interview on 05/22/24 at 12:30 p.m., CNA N said she overhead conversation on 05/12/24 when CNA R reported to LVN L that Resident #1 exhibited aggressive behaviors and had scratched CNA R on the face while she was trying to provide personal care. CNA N said she told CNA R and CNA O that she would try to assist with Resident #1 with care. CNA N said she and CNA O went back into Resident #1's room approximately 10 minutes after the incident of aggression with CNA R to assist resident with care. CNA N said she did not know what happened, but when she went to assist Resident #1, he started spitting and fighting. She said she and CNA O left the room, to allow Resident #1 to calm down. CNA N said Resident #1 had behaviors at times and they leave the room and try to go back later to assist him.<BR/>During an interview on 05/22/24 at 12:42 p.m., CNA O said she went to Resident #1's room to assist with care. She said CNA N and CNA R were already in the room. CNA O said she observed CNA N attempting to provide care to Resident #1, but Resident #1 was upset and was spitting at CNA N. CNA R was standing in room but not assisting with care because Resident #1 had already scratched her on the face. CNA O said Resident #1 was being aggressive spitting and slapping at CNA N. She left the room to notify LVN L of the incident and LVN L said she was aware of the incident and the behaviors. CNA O returned to Resident #1's room and notified CNA N and CNA R that LVN L was notified of Resident #1's behaviors.<BR/>During an interview on 05/22/24 at 2:08 p.m., LVN/MDS J said she was responsible for completing resident care plans. She said it was a mistake and she just missed completing a care plan related to Resident #1's aggression towards others.<BR/>During an interview on 05/22/24 at 1:14 p.m., the Administrator stated the DON and the MDS Coordinator were responsible for completing the care plans. The Administrator stated she expected them to include anything unusual or special for the resident's care. The Administrator stated it was important for Resident #1's aggressive behavior towards others to be included in the care plan so the staff could ensure the resident was receiving appropriate care. <BR/>During an interview on 05/22/24 at 2:45 p.m., LVN L said CNA R left Resident #1's room and reported Resident #1's aggressive behaviors and that he had scratched her face on 05/12/24. She said CNA N and CNA O went to complete Resident #1's care and he continued with his aggressive behaviors. She said the staff left his room to allow him to calm down. <BR/>Record review of the facility's Comprehensive Person-Centered Care plans policy dated 2001 (revised October 2018) indicated Policy Statement-A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 9 Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observations, interviews, and record reviews the facility's governing body failed to operate and provide services in compliance with all applicable Federal, State and local laws, regulations, and codes for 1 of 1 facility reviewed for ADM and SW.<BR/>* The facility did not immediately notify HHS when the ADM resigned and there was no ADM as required by state regulations.<BR/>* The facility did not employ a part time or contract a SW as required by state regulations. <BR/>These failures could place residents at risk of administrative duties not being carried out attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. <BR/>Findings included:<BR/>1. During an interview on 06/09/23 at 10:40 a.m., the DON said a car ran into something on the corner about two weeks prior. She said the water to the front of the building was temporarily cut off. She said the ADM at the time thought the water had been cut off due to non-payment. She said the ADM words to her were if [owner] did not care, then she did not care. She said the ADM gave her resignation immediately. She said there had not been an administrator since then. <BR/>During an interview on 06/09/23 at 12:26 p.m., the owner said the previous administrator walked out about two weeks earlier. He said he did not call HHS to let them know he did not have an administrator. He said he was not aware he needed to do that. <BR/>Record review of the ADM employee file indicated an Employee Change of Status Form dated 06/12/23. Further review of the form indicated her last working day was 05/27/23, voluntary termination of employment due to being dissatisfied with job or company was marked, and other was also marked-written next to this was quit via text to admin group.<BR/>During an interview on 06/12/23 at 01:35 PM the DON said she was the acting ADM since 05/27/23 when the ADM resigned.<BR/>Record review of the Texas Administrative Code 554.1902 (a)(2) indicated The facility must:<BR/> (2) ensure that a person designated as being in authority notifies HHSC immediately when the facility does not have an administrator.<BR/>2. In an interview on 6/12/2023 at 10:20am, the DON was asked about a SW, which she said the facility did not have one at that time. The DON was asked how long facility had been without a SW, she said she does not remember. She said there was no SW from corporate office or a sister facility assisting either.<BR/>During a phone interview on 06/12/23 at 01:59 PM the Ombudsman said the facility had not had a SW in several months. She said the DON and other staff were trying to keep up with the needs of the residents, but she felt them not having a SW there were some things not being taken care of. She said the SW could help with finding other placement for residents the facility does not feel like they can meet their needs because of behaviors which she had to intervene to prevent them from refusing to take a resident back from the hospital. <BR/>Record review of the Grievance Book indicated a grievance on 03/07/23 about not having a SW for assistance. <BR/>During an interview 6/14/2023 8:00 am with Resident #13's representative reports that he has been trying to get assistance from the facility to help resident #13 get on her disability and follow up on Medicaid application which are both still pending, she has recently been diagnosed as legally blind so she should qualify for these programs and other resources. <BR/>During a phone interview 6/14/2023 7:30 am with Resident #15's representative reports that resident #15 was transferred to another facility he feels the transfer to the other facility could have gone smoother if one person was handling the transfer (social worker) instead of several staff members, also reports during his stay at the facility the resident received a phone call from a soliciting insurance plan and resident's insurance was changed unbeknown to facility, resident or resident representative and the facility staff (social worker) did not assist in explaining/resolving this issue.<BR/>Record review of the SW employee file indicated a Disciplinary Action dated 01/09/23. Further review of the form indicated the SW was terminated on 01/09/23. <BR/>During an interview on 06/12/23 at 01:35 PM the DON said they had no SW since the previous SW was terminated. She said she and the ADONs were taking care of the resident needs as best as they could.<BR/>Record review of the Texas Administrative Code 554.703 (a)(2) indicated (2) A facility of 120 beds or less must employ or contract with a qualified social worker (or in lieu thereof, a social worker who is licensed by the Texas State Board of Social Worker Examiners, and who meets the requirements of subsection (b)(2) of this section) to provide social services a sufficient amount of time to meet the needs of the residents.

Based on interview and record review, the facility failed to ensure they had an RN for 8 consecutive hours 7 days a week for 2 of 4 quarters of 2023 (Quarter 2 and Quarter) PBJ reports reviewed for RN coverage. <BR/>The facility did not have RN coverage for Saturdays and Sundays in January 2023, February 2023, March 2023, April 2023, May 2023, and June 2023.<BR/>This failure could place residents at risk of lack of nursing oversight and a higher level of care.<BR/>Findings included:<BR/>Record review of the CMS PBJ reports indicated:<BR/>* Quarter 2 2023 (January 1 through March 31) there was no RN hours on 01/28 (Saturday); 01/29 (Sunday); 02/03 (Friday); 02/06 (Monday); 02/07 (Tuesday); 02/08 (Wednesday); 02/09 (Thursday); 02/10 (Friday); 02/13 (Monday); 02/14 (Tuesday); 02/15 (Wednesday); 02/16 (Thursday); 02/25 (Saturday); 02/26 (Sunday); 03/17 (Friday); 03/20 (Monday; 03/21 (Tuesday); 03/22 (Wednesday); 03/23 (Thursday); 03/24 (Friday); 03/25 (Saturday); 03/26 (Sunday); 03/27 (Monday) 03/28 (Tuesday); 03/29 (Wednesday); and 03/30 (Thursday). <BR/>* Quarter 3 2023 (April 1 through June 30) there was no RN hours on 04/10 (Monday); 05/19 (Friday); 05/26 (Friday); 05/29 (Monday); 05/30 (Tuesday); 05/31 (Wednesday), 06/01 (Thursday); 06/02 (Friday); 06/03 (Saturday); 06/04 (Sunday); 06/05 (Monday); 06/07 (Wednesday); 06/08 (Thursday); 06/14 (Wednesday); 06/15 (Thursday); 06/16 (Friday); 06/17 (Saturday); 06/18 (Sunday); 06/19 (Monday); 06/20 (Tuesday; 06/21 (Wednesday); 06/22 (Thursday); 06/23 (Friday); 06/24 (Saturday); 06/25 (Sunday); 06/26 (Monday); 06/27 (Tuesday); 06/28 (Wednesday); 06/29 (Thursday); and 06/30 (Friday).<BR/>During an interview on 09/26/23 09:22 a.m., the HR said the PBJ reports were submitted by a third-party group. She said the third-party group told her they did not have a policy regarding PBJ reporting, they followed the CMS guidelines for PBJ reporting. <BR/>During an interview on 09/27/23 at 10:52 a.m. the Administrator said her start date at the facility was 09/01/23 so she had no knowledge regarding the prior quarterly PBJ report regarding staffing. <BR/>During an interview on 09/27/23 at 01:04 p.m., the DON said she tried to keep staffing according to the needs of the residents. She said she did not understand why the previous corporation did not submit the information in the PBJ report. A staffing policy was requested at this time. She said she would provide a policy. <BR/>No policy was provided prior to exit.

Based on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. The facility failed to submit direct care staffing information on the schedule specified by CMS (Centers for Medicare and Medicaid Services), but no less frequently than quarterly for 1 of 4 quarters reviewed for payroll data information. (Quarter 4 2022)<BR/>The facility failed to submit staffing information to CMS for the 4th quarter of the fiscal year 2022.<BR/>This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.<BR/>Findings included:<BR/>Record Review of the facility's Civil Rights form (3761) dated 09/26/23 indicated the following:<BR/>4 RNs <BR/>19 LVNs <BR/>31 Direct Care Staff<BR/>9 Dietary<BR/>8 Housekeeping & Laundry <BR/>21 All Others<BR/>Record review of the CMS PBJ Staffing Data Report (payroll-based staffing), CASPER Report (Certification and Survey Provider Enhanced Report)1705 D FY Quarter 4 2022 (July 1- September 30), dated 09/18/2023, indicated the following entry: Failed to Submit Data for the Quarter Triggered .Triggered=No Data Submitted for the Quarter.<BR/>During an interview on 09/26/23 at 09:22 a.m., HR said the corporate HR department was responsible for submission of the staffing data to CMS every quarter (every three months). A policy regarding the PBJ reporting was requested. <BR/>During an interview on 09/27/23 10:52 a.m. the Administrator said her start date at the facility was 09/01/23 so she had no knowledge regarding the prior quarterly PBJ report regarding staffing. <BR/>An undated Reporting Direct-Care Staffing Information (Payroll-Based Journal) Policy indicated:<BR/>Policy Statement: <BR/>Staffing and census information will be reported electronically to CMS through the Payroll-Based Journal system in compliance with 6106 of the Affordable Care Act.<BR/>Policy Interpretation and Implementation:<BR/> 9. Staffing information will be collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. Dates are as follows:<BR/>1 October 1 - December 31, February 14<BR/> 2 January 1 - March 31, May 15<BR/> 3 April 1 - June 30, August 14<BR/> 4 July 1 - September 30, November 14

Based on observation, interview, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for one of four quarters for 2023 (Quarter 3) reviewed for sufficient nursing staff.<BR/>*The facility did not have sufficient staff according to the PBJ report for Quarter 3 2023 (April 1 through June 30).<BR/>This failure could place residents at risk of diminished quality of life and quality of care.<BR/>Findings included:<BR/>Record review of the CMS PBJ reports Quarter 3 2023 (April 1 through June 30) indicated: the facility had a 1 star staffing rating;<BR/>* the facility failed to have Licensed Nursing Coverage 24 hours/Day on 06/15 (Thursday); 06/16 (Friday); 06/17 (Saturday); 06/18 (Sunday); 06/19 (Monday); 06/20 (Tuesday); 06/21 (Wednesday); 06/22 (Thursday); <BR/>06/23 (Friday); 06/24 (Saturday); 06/25 (Sunday); 06/26 (Monday); 06/27 (Tuesday); 06/28 (Wednesday); 06/29 (Thursday); and 06/30 (Friday); and<BR/>* the facility had excessively low weekend staffing. <BR/>During an interview on 09/27/23 at 10:52 a.m., the Administrator said her start date at the facility was 09/01/23 so she had no knowledge regarding the prior quarterly PBJ report regarding staffing. She said they had hired nurses and CNAs since she started because they did not have enough. <BR/>During an interview on 09/27/23 at 01:04 p.m., the DON said she tried to keep staffing according to the needs of the residents. She said she did not understand why the previous corporation did not submit the staffing information in the PBJ report. A staffing policy was requested at this time. She said she would provide a policy.<BR/>No policy was provided prior to exit.

Based on interview and record review, the facility failed to ensure they had an RN for 8 consecutive hours 7 days a week for 2 of 4 quarters of 2023 (Quarter 2 and Quarter) PBJ reports reviewed for RN coverage. <BR/>The facility did not have RN coverage for Saturdays and Sundays in January 2023, February 2023, March 2023, April 2023, May 2023, and June 2023.<BR/>This failure could place residents at risk of lack of nursing oversight and a higher level of care.<BR/>Findings included:<BR/>Record review of the CMS PBJ reports indicated:<BR/>* Quarter 2 2023 (January 1 through March 31) there was no RN hours on 01/28 (Saturday); 01/29 (Sunday); 02/03 (Friday); 02/06 (Monday); 02/07 (Tuesday); 02/08 (Wednesday); 02/09 (Thursday); 02/10 (Friday); 02/13 (Monday); 02/14 (Tuesday); 02/15 (Wednesday); 02/16 (Thursday); 02/25 (Saturday); 02/26 (Sunday); 03/17 (Friday); 03/20 (Monday; 03/21 (Tuesday); 03/22 (Wednesday); 03/23 (Thursday); 03/24 (Friday); 03/25 (Saturday); 03/26 (Sunday); 03/27 (Monday) 03/28 (Tuesday); 03/29 (Wednesday); and 03/30 (Thursday). <BR/>* Quarter 3 2023 (April 1 through June 30) there was no RN hours on 04/10 (Monday); 05/19 (Friday); 05/26 (Friday); 05/29 (Monday); 05/30 (Tuesday); 05/31 (Wednesday), 06/01 (Thursday); 06/02 (Friday); 06/03 (Saturday); 06/04 (Sunday); 06/05 (Monday); 06/07 (Wednesday); 06/08 (Thursday); 06/14 (Wednesday); 06/15 (Thursday); 06/16 (Friday); 06/17 (Saturday); 06/18 (Sunday); 06/19 (Monday); 06/20 (Tuesday; 06/21 (Wednesday); 06/22 (Thursday); 06/23 (Friday); 06/24 (Saturday); 06/25 (Sunday); 06/26 (Monday); 06/27 (Tuesday); 06/28 (Wednesday); 06/29 (Thursday); and 06/30 (Friday).<BR/>During an interview on 09/26/23 09:22 a.m., the HR said the PBJ reports were submitted by a third-party group. She said the third-party group told her they did not have a policy regarding PBJ reporting, they followed the CMS guidelines for PBJ reporting. <BR/>During an interview on 09/27/23 at 10:52 a.m. the Administrator said her start date at the facility was 09/01/23 so she had no knowledge regarding the prior quarterly PBJ report regarding staffing. <BR/>During an interview on 09/27/23 at 01:04 p.m., the DON said she tried to keep staffing according to the needs of the residents. She said she did not understand why the previous corporation did not submit the information in the PBJ report. A staffing policy was requested at this time. She said she would provide a policy. <BR/>No policy was provided prior to exit.

Based on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. The facility failed to submit direct care staffing information on the schedule specified by CMS (Centers for Medicare and Medicaid Services), but no less frequently than quarterly for 1 of 4 quarters reviewed for payroll data information. (Quarter 4 2022)<BR/>The facility failed to submit staffing information to CMS for the 4th quarter of the fiscal year 2022.<BR/>This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.<BR/>Findings included:<BR/>Record Review of the facility's Civil Rights form (3761) dated 09/26/23 indicated the following:<BR/>4 RNs <BR/>19 LVNs <BR/>31 Direct Care Staff<BR/>9 Dietary<BR/>8 Housekeeping & Laundry <BR/>21 All Others<BR/>Record review of the CMS PBJ Staffing Data Report (payroll-based staffing), CASPER Report (Certification and Survey Provider Enhanced Report)1705 D FY Quarter 4 2022 (July 1- September 30), dated 09/18/2023, indicated the following entry: Failed to Submit Data for the Quarter Triggered .Triggered=No Data Submitted for the Quarter.<BR/>During an interview on 09/26/23 at 09:22 a.m., HR said the corporate HR department was responsible for submission of the staffing data to CMS every quarter (every three months). A policy regarding the PBJ reporting was requested. <BR/>During an interview on 09/27/23 10:52 a.m. the Administrator said her start date at the facility was 09/01/23 so she had no knowledge regarding the prior quarterly PBJ report regarding staffing. <BR/>An undated Reporting Direct-Care Staffing Information (Payroll-Based Journal) Policy indicated:<BR/>Policy Statement: <BR/>Staffing and census information will be reported electronically to CMS through the Payroll-Based Journal system in compliance with 6106 of the Affordable Care Act.<BR/>Policy Interpretation and Implementation:<BR/> 9. Staffing information will be collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. Dates are as follows:<BR/>1 October 1 - December 31, February 14<BR/> 2 January 1 - March 31, May 15<BR/> 3 April 1 - June 30, August 14<BR/> 4 July 1 - September 30, November 14

Based on interview and record review, the facility failed to ensure they had an RN for 8 consecutive hours 7 days a week for 2 of 4 quarters of 2023 (Quarter 2 and Quarter) PBJ reports reviewed for RN coverage. <BR/>The facility did not have RN coverage for Saturdays and Sundays in January 2023, February 2023, March 2023, April 2023, May 2023, and June 2023.<BR/>This failure could place residents at risk of lack of nursing oversight and a higher level of care.<BR/>Findings included:<BR/>Record review of the CMS PBJ reports indicated:<BR/>* Quarter 2 2023 (January 1 through March 31) there was no RN hours on 01/28 (Saturday); 01/29 (Sunday); 02/03 (Friday); 02/06 (Monday); 02/07 (Tuesday); 02/08 (Wednesday); 02/09 (Thursday); 02/10 (Friday); 02/13 (Monday); 02/14 (Tuesday); 02/15 (Wednesday); 02/16 (Thursday); 02/25 (Saturday); 02/26 (Sunday); 03/17 (Friday); 03/20 (Monday; 03/21 (Tuesday); 03/22 (Wednesday); 03/23 (Thursday); 03/24 (Friday); 03/25 (Saturday); 03/26 (Sunday); 03/27 (Monday) 03/28 (Tuesday); 03/29 (Wednesday); and 03/30 (Thursday). <BR/>* Quarter 3 2023 (April 1 through June 30) there was no RN hours on 04/10 (Monday); 05/19 (Friday); 05/26 (Friday); 05/29 (Monday); 05/30 (Tuesday); 05/31 (Wednesday), 06/01 (Thursday); 06/02 (Friday); 06/03 (Saturday); 06/04 (Sunday); 06/05 (Monday); 06/07 (Wednesday); 06/08 (Thursday); 06/14 (Wednesday); 06/15 (Thursday); 06/16 (Friday); 06/17 (Saturday); 06/18 (Sunday); 06/19 (Monday); 06/20 (Tuesday; 06/21 (Wednesday); 06/22 (Thursday); 06/23 (Friday); 06/24 (Saturday); 06/25 (Sunday); 06/26 (Monday); 06/27 (Tuesday); 06/28 (Wednesday); 06/29 (Thursday); and 06/30 (Friday).<BR/>During an interview on 09/26/23 09:22 a.m., the HR said the PBJ reports were submitted by a third-party group. She said the third-party group told her they did not have a policy regarding PBJ reporting, they followed the CMS guidelines for PBJ reporting. <BR/>During an interview on 09/27/23 at 10:52 a.m. the Administrator said her start date at the facility was 09/01/23 so she had no knowledge regarding the prior quarterly PBJ report regarding staffing. <BR/>During an interview on 09/27/23 at 01:04 p.m., the DON said she tried to keep staffing according to the needs of the residents. She said she did not understand why the previous corporation did not submit the information in the PBJ report. A staffing policy was requested at this time. She said she would provide a policy. <BR/>No policy was provided prior to exit.

Based on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. The facility failed to submit direct care staffing information on the schedule specified by CMS (Centers for Medicare and Medicaid Services), but no less frequently than quarterly for 1 of 4 quarters reviewed for payroll data information. (Quarter 4 2022)<BR/>The facility failed to submit staffing information to CMS for the 4th quarter of the fiscal year 2022.<BR/>This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.<BR/>Findings included:<BR/>Record Review of the facility's Civil Rights form (3761) dated 09/26/23 indicated the following:<BR/>4 RNs <BR/>19 LVNs <BR/>31 Direct Care Staff<BR/>9 Dietary<BR/>8 Housekeeping & Laundry <BR/>21 All Others<BR/>Record review of the CMS PBJ Staffing Data Report (payroll-based staffing), CASPER Report (Certification and Survey Provider Enhanced Report)1705 D FY Quarter 4 2022 (July 1- September 30), dated 09/18/2023, indicated the following entry: Failed to Submit Data for the Quarter Triggered .Triggered=No Data Submitted for the Quarter.<BR/>During an interview on 09/26/23 at 09:22 a.m., HR said the corporate HR department was responsible for submission of the staffing data to CMS every quarter (every three months). A policy regarding the PBJ reporting was requested. <BR/>During an interview on 09/27/23 10:52 a.m. the Administrator said her start date at the facility was 09/01/23 so she had no knowledge regarding the prior quarterly PBJ report regarding staffing. <BR/>An undated Reporting Direct-Care Staffing Information (Payroll-Based Journal) Policy indicated:<BR/>Policy Statement: <BR/>Staffing and census information will be reported electronically to CMS through the Payroll-Based Journal system in compliance with 6106 of the Affordable Care Act.<BR/>Policy Interpretation and Implementation:<BR/> 9. Staffing information will be collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. Dates are as follows:<BR/>1 October 1 - December 31, February 14<BR/> 2 January 1 - March 31, May 15<BR/> 3 April 1 - June 30, August 14<BR/> 4 July 1 - September 30, November 14

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow Federal, State and Local laws and regulations regarding smoking, smoking areas, and smoking safety for 1 of 3 residents (Resident #253) reviewed for smoking safety.<BR/>The facility did not have Smoking-Safety Screens completed for Residents #253 quarterly.<BR/>This failure could place residents at risk of harm or injury and contribute to avoidable accidents. <BR/>Findings included: <BR/>Record review of a face sheet dated 09/20/23 indicated Resident #253 was a [AGE] year-old female admitted on [DATE] with diagnosis of diabetes. <BR/>Record review of an annual MDS assessment dated [DATE] indicated Resident #253 was a smoker. <BR/>Record review care plan dated 09/15/23 indicated Resident #253's tobacco use and included interventions: Nurse Will Provide Tobacco Cessation Information to resident, determine if Resident has a desire to quit, o Educate Resident / Family on risks & health effects of tobacco use and If Resident would like to quit, contract provider to prescribe cessation aides. <BR/>Record review of Safe Smoking Evaluations indicated Resident #253 was last evaluated on 01/20/23. There were no other evaluations completed for 2023. <BR/>During an observation on 09/26/23 at 3:33 p.m., Resident #253 was smoking in the designated smoking area with staff supervising. <BR/>During an interview on 09/27/23 at 3:38 p.m. the DON said Resident #253 had not been assigned to the nurses. The DON said the last smoking assessment for Resident #253 was done in January 2023. <BR/>The undated smoking-safety screen policy indicated Residents who desire to smoke will be assessed using a Smoking- Safety Screen . will be conducted upon admission, quarterly, when a change occurs .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to equip each room to assure full visual privacy for each resident for 2 (Rooms 221 A & B and room [ROOM NUMBER] A & B) of 26 dual rooms reviewed for privacy.<BR/>The facility failed to provide curtains to ensure residents' privacy in 2 dual occupancy rooms throughout the facility.<BR/>This failure could place residents at risk of decreased self-worth by being exposed during resident care. <BR/>Findings included:<BR/>During an observation and interview on 10/12/2023 at 2:30 pm, resident in room [ROOM NUMBER]A was sitting in his wheelchair in his room. There was not a privacy curtain between resident in room [ROOM NUMBER]A and resident in room [ROOM NUMBER]B. Resident in room [ROOM NUMBER]A bed (nearest to the door). Resident in room [ROOM NUMBER]A bed said he wished he had a privacy curtain between the beds in the room so he could have privacy when he wanted it. Resident in room [ROOM NUMBER]A bed said he had been in this room for approximately 1 month and had never had a privacy curtain between the beds.<BR/>During an observation on 10/12/2023 at 1:00 pm, 1:34 pm, 2:25 pm, 2:54 pm, and 3:00 pm, there was no privacy curtains in room [ROOM NUMBER] (A and B bed) and room [ROOM NUMBER] (A and B bed).<BR/>During an interview on 10/12/23 at 2:42 pm, resident in room [ROOM NUMBER]B said he liked his roommate, but it would be nice to have the privacy curtain in case he wanted some privacy. <BR/>During an interview on 10/12/23 at 2:45 pm, the Housekeeper Supervisory said it was the responsibility of her housekeeping staff to ensure each room had privacy curtains. The Housekeeper Supervisory said she was not aware of any rooms missing privacy curtains. The Housekeeper Supervisor said each dual occupied room should have privacy curtains to provide total privacy during care. <BR/>During an interview on 10/12/2023 at 3:00 pm, the Maintenance Supervisor said he had not had any residents or staff request privacy curtains recently. He said it was housekeeping's responsibility to ensure each room had a privacy curtain and it was maintenance staff's responsibility for installing any ceiling tracks needed in residents' rooms for privacy curtains. <BR/>During an interview on 10/12/2023 at 3:30 pm, the Administrator said all resident rooms that had more than one occupant should have privacy curtains. She said she was not aware of any rooms that did not have privacy curtains or hardware (ceiling track) to hang privacy curtain. She said housekeeping staff is responsible for cleaning and installing privacy curtains and maintenance staff is responsible for making sure hardware (ceiling track) is installed to hang privacy curtain. She said staff providing resident care should notify housekeeping if no privacy curtain in dual occupied rooms. She said staff were expected to keep the privacy curtains drawn and the door to the room closed during care for privacy. She said staff were trained on resident privacy while providing care. The Administrator said the risk of not ensuring resident privacy would be violating the resident rights to privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for 1 (Resident #28) of 13 residents reviewed for pharmacy services.<BR/>The facility failed to ensure Resident #28's nystatin powder (prescription powder treats fungus or yeast) was not left on her nightside table and within the eyesight of the nurse<BR/>This failure could place residents at risk for medication overdose, medication under-dose, ineffective therapeutic outcomes, and drug diversion. <BR/>Findings included:<BR/>Record review of Resident #28's face sheet dated 11/20/24 indicated Resident #28 was admitted on [DATE] was [AGE] years old female with diagnoses of severe obesity and diabetes (too much sugar in the blood).<BR/>Record review of Resident #28's MDS assessment dated [DATE] indicated Resident #28's cognition was intact and had diabetes.<BR/>Review of Resident #28's physician orders dated November 2024 indicated Resident #28 had an order for Nystatin External Powder, Apply to abdominal folds topically every day and evening shift for yeast. Cleanse area with soap and water, pat dry, then apply Nystatin powder under abdominal folds twice daily, until resolved with start date of 07/16/24.<BR/>Record review of the MDS dated [DATE] indicated Resident #28 was cognitively intact and had diabetes. <BR/>During observation on 11/18/24 at 9:45 a.m., there was a 30-cc medicine cup with approximately 20 cc of white powder on the nightside table next to Resident #28's bed.<BR/>During an interview on 11/18/24 at 9:55 a.m., Resident #28 said the powder was not her medication. She said she did not know who put it there or why it was there.<BR/>During an interview on 11/18/24 at 10:00 a.m., ADON A said the white powder was nystatin powder and was used under the breast and skin folds. She said no medications/treatments should have been left in Resident #28's room or in any resident's' rooms. She said the nurses were responsible for medication/treatment items and should have been stored in the cart unless when were being used.<BR/>During an interview on 11/20/24 at 1:30 p.m., the Administrator said her expectation was for the nurses not to leave medications or treatments at bedside. The medications should have been within the eyesight of the nurse. She said all of the staff should have reported medication left in resident rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for 1 (Resident #28) of 13 residents reviewed for pharmacy services.<BR/>The facility failed to ensure Resident #28's nystatin powder (prescription powder treats fungus or yeast) was not left on her nightside table and within the eyesight of the nurse<BR/>This failure could place residents at risk for medication overdose, medication under-dose, ineffective therapeutic outcomes, and drug diversion. <BR/>Findings included:<BR/>Record review of Resident #28's face sheet dated 11/20/24 indicated Resident #28 was admitted on [DATE] was [AGE] years old female with diagnoses of severe obesity and diabetes (too much sugar in the blood).<BR/>Record review of Resident #28's MDS assessment dated [DATE] indicated Resident #28's cognition was intact and had diabetes.<BR/>Review of Resident #28's physician orders dated November 2024 indicated Resident #28 had an order for Nystatin External Powder, Apply to abdominal folds topically every day and evening shift for yeast. Cleanse area with soap and water, pat dry, then apply Nystatin powder under abdominal folds twice daily, until resolved with start date of 07/16/24.<BR/>Record review of the MDS dated [DATE] indicated Resident #28 was cognitively intact and had diabetes. <BR/>During observation on 11/18/24 at 9:45 a.m., there was a 30-cc medicine cup with approximately 20 cc of white powder on the nightside table next to Resident #28's bed.<BR/>During an interview on 11/18/24 at 9:55 a.m., Resident #28 said the powder was not her medication. She said she did not know who put it there or why it was there.<BR/>During an interview on 11/18/24 at 10:00 a.m., ADON A said the white powder was nystatin powder and was used under the breast and skin folds. She said no medications/treatments should have been left in Resident #28's room or in any resident's' rooms. She said the nurses were responsible for medication/treatment items and should have been stored in the cart unless when were being used.<BR/>During an interview on 11/20/24 at 1:30 p.m., the Administrator said her expectation was for the nurses not to leave medications or treatments at bedside. The medications should have been within the eyesight of the nurse. She said all of the staff should have reported medication left in resident rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 stove, 1 of 2 walk-in coolers, 1 of 1 milk box in the kitchen; and 1 of 15 resident rooms on 1 of 2 Halls (long part of Hall 200) reviewed for essential equipment. <BR/>* The facility failed to ensure the gas stove was in safe operating condition. Two burners on the back of the stove and 1 burner on the front of the stove would not ignite when the knobs were turned. The side of the griddle next to the burners had black buildup. <BR/>* The facility failed to maintain the walk-in freezer. The walk-in freezer had a door gasket that was loose and hanging. <BR/>* The facility failed to maintain the milk box. The milk box had a loose gasket with mildew on it. <BR/>* The facility failed to ensure room [ROOM NUMBER]'s electric bed was in safe operating condition. The electrical cord plugged into the wall socket was spliced together.<BR/>These failures could place the residents at risk of a fire and not having safe operating equipment. <BR/>Findings included: <BR/>1. During observations and interviews on 11/18/24 during initial tour indicated the following: <BR/>* at 08:15 a.m. the milk box gasket was loose and had mildew on it. The DM said they were supposed to be getting a new gasket. <BR/>* at 08:18 a.m. of the stove, the rear left and right burners and the front right burner were not lighting when the knobs were turned on. The side of the griddle area next to the burners had a black buildup. The DM said she did not realize the burners were not lighting and the stove had been cleaned recently. <BR/>* at 08:30 a.m. left walk-in freezer had the door gasket loose and hanging, icy frost on the clear flaps hanging over the door, and frozen liquid on the floor. The DM said she did not realize the gasket was that bad. <BR/>During an observation and interview on 11/18/24 at 10:53 a.m. the MD was working on the stove burners. He was lighting the rear right burner with a wand type lighter. He said he was not sure why the burners were not lighting with the turning the knobs on. He said staff should not have to use a lighter to light burners as it could cause an explosion. He acknowledged the gaskets needed to be changed on the milk box and the walk-in freezer. <BR/>2. During an observation on 11/20/24 at 11:45 a.m., room [ROOM NUMBER] was an occupied resident's room. On the floor bedside the electric bed was a black cord plugged into the wall socket and approximately 2 feet towards the bed was a white cord spliced into the black cord. Three wires of the white and black cords were cut and held together with twist type wire connectors. There was no tape or connection box covering the connectors of the wires to prevent access to the live wires. <BR/>During an interview on 11/20/24 at 11:50 a.m., the Administrator said her expectation was for the electric beds to be in good working condition. She said a new cord should have been ordered. She said her staff had not reported this type of wire connection was in a resident ' s room or the need of a new wire for the electric bed. <BR/>Record review of an undated Maintenance Service policy indicated .Policy Interpretation and Implementation: 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 stove, 1 of 2 walk-in coolers, 1 of 1 milk box in the kitchen; and 1 of 15 resident rooms on 1 of 2 Halls (long part of Hall 200) reviewed for essential equipment. <BR/>* The facility failed to ensure the gas stove was in safe operating condition. Two burners on the back of the stove and 1 burner on the front of the stove would not ignite when the knobs were turned. The side of the griddle next to the burners had black buildup. <BR/>* The facility failed to maintain the walk-in freezer. The walk-in freezer had a door gasket that was loose and hanging. <BR/>* The facility failed to maintain the milk box. The milk box had a loose gasket with mildew on it. <BR/>* The facility failed to ensure room [ROOM NUMBER]'s electric bed was in safe operating condition. The electrical cord plugged into the wall socket was spliced together.<BR/>These failures could place the residents at risk of a fire and not having safe operating equipment. <BR/>Findings included: <BR/>1. During observations and interviews on 11/18/24 during initial tour indicated the following: <BR/>* at 08:15 a.m. the milk box gasket was loose and had mildew on it. The DM said they were supposed to be getting a new gasket. <BR/>* at 08:18 a.m. of the stove, the rear left and right burners and the front right burner were not lighting when the knobs were turned on. The side of the griddle area next to the burners had a black buildup. The DM said she did not realize the burners were not lighting and the stove had been cleaned recently. <BR/>* at 08:30 a.m. left walk-in freezer had the door gasket loose and hanging, icy frost on the clear flaps hanging over the door, and frozen liquid on the floor. The DM said she did not realize the gasket was that bad. <BR/>During an observation and interview on 11/18/24 at 10:53 a.m. the MD was working on the stove burners. He was lighting the rear right burner with a wand type lighter. He said he was not sure why the burners were not lighting with the turning the knobs on. He said staff should not have to use a lighter to light burners as it could cause an explosion. He acknowledged the gaskets needed to be changed on the milk box and the walk-in freezer. <BR/>2. During an observation on 11/20/24 at 11:45 a.m., room [ROOM NUMBER] was an occupied resident's room. On the floor bedside the electric bed was a black cord plugged into the wall socket and approximately 2 feet towards the bed was a white cord spliced into the black cord. Three wires of the white and black cords were cut and held together with twist type wire connectors. There was no tape or connection box covering the connectors of the wires to prevent access to the live wires. <BR/>During an interview on 11/20/24 at 11:50 a.m., the Administrator said her expectation was for the electric beds to be in good working condition. She said a new cord should have been ordered. She said her staff had not reported this type of wire connection was in a resident ' s room or the need of a new wire for the electric bed. <BR/>Record review of an undated Maintenance Service policy indicated .Policy Interpretation and Implementation: 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times