KENNEDY HEALTH & REHAB

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure residents had the right to be free from verbal abuse by staff for 2 (Resident #1 and Resident #2) of 10 residents reviewed for abuse. <BR/>The facility failed to prevent verbal abuse by CNA A. On 3/3/2025 CNA A told Resident #1 She was stinky and needed to take a shower.<BR/>The facility failed to prevent verbal abuse by the Cook. On 4/6/2025 the [NAME] cussed Resident #2 in a verbal altercation. <BR/>This failure could place all residents in the facility at risk for severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. <BR/>Findings included:<BR/>1.Record review of Resident #1's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with the most recent admission on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (progressive lung disease that makes breathing difficult), pseudobulbar affect (neurological condition), and major depressive disorder (persistent feelings of sadness). <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated no cognitive impairment. <BR/>Record review of Resident #1's care plan revealed she had an ADL self-care performance deficit with interventions that included: The resident is totally dependent on 1-2 staff to provide bath/shower. <BR/>Record review of psychiatric assessment completed on 3/5/2025 indicated: Patient states one of the nurse aides told her she was stinky and needed to shower. She says she was offended by this and feels sad. She verbalizes she will be okay though and is grateful for the concerns. She states she gets regular showers from the hospice nurse every MWF. Patient says she eats and sleeps okay/good. Anxiety: Patient denies symptoms of excessive worry.<BR/>Record review of Resident #1's nursing progress note dated 4/20/2025 at 12:36 AM, written by RN C indicated Resident #1 expired in the facility.<BR/>Record review of witness statement provided by Hospice CNA B dated 3/5/2025 indicated: On 3/3/2025 she was taking Resident #1 to the shower room and was told that someone was in the shower room and to go around to the 200 hall, on the way around CNA A started saying out loud that time does not go on her time and she needed to wait her turn. CNA A made the statement a few times before Resident #1 turned around and said never mind she was not going to shower if she (CNA A) was going to keep saying stuff. Resident #1 headed back to her room when CNA A told her no go ahead go take the shower because she stinks and needed it. CNA A said you know what let me go get Resident #1's roommate up to that room stinks she needs to get up too so we can air out that and strip the beds. Resident #1 got back to her door she turned around and decided to go ahead and go take the shower on her hall. <BR/>Record review of witness statement provided by CNA A on 3/5/2025 indicated: I [CNA A] don't recall what happen Monday beside me telling [another resident] I am not his auntie and am not married to that. I don't think I cussed anyone.<BR/>Record review of the facility new hire/status change form indicated CNA A was terminated on 3/5/2025. <BR/>During an attempted interview on 4/30/2025 at 2:00 p.m. the DON had left the facility and was no longer employed at the facility. <BR/>During an interview on 5/1/2025 at 9:24 AM, the Activity Director said CNA A talked a little hateful to the residents but not to a point that it was abuse. She said CNA A was a good CNA and her residents were taken care of. <BR/>During an interview on 5/1/2025 at 1:49 PM, CNA A said all she said to Resident #1 was that she smelled really bad, and she needed to take a shower. She said she never cussed Resident #1. <BR/>2. Record review of Resident #2's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included type 2 diabetes (high blood sugar), insomnia (sleep disorder), and depression (persistent feelings of sadness). <BR/>Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 13, which indicated no cognitive impairment. <BR/>Record review of Resident #2's care plan dated 6/12/2024 revealed he had the potential to be verbally aggressive with interventions that included: When the resident becomes agitated; intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later.<BR/>Record review of witness statement dated 4/6/2025 written by the BOM indicated: was sitting in my office when I heard screaming from dietary went to dietary [Cook] was screaming at [Resident #2] I then told her to stop she begin yelling louder stating she is sick of the way he talks to her that we need to do something with his fucking ass cause he ain't going to talk like that no more to her. I asked him to go outside and calm down she keep on screaming back and forth with [Resident #2]. [sic]<BR/>During an interview on 4/29/2025 at 11:04 AM, Resident #2 said when he gets upset, he cusses that was just who he was. He said the staff was there to work for him. He said he did remember the incident in the kitchen, but he was over it and that [NAME] no longer worked at the facility. He said he was over that incident, and it was in the past. <BR/>During an interview on 5/1/2025 at 9:24 AM the Activity Director said Resident #2 is mean and a smart [NAME]. She said he cusses the staff and tells them that he signs their paycheck. She said Resident #2 had called the kitchen staff fat sloppy [NAME]. She said he wass very hateful over the TV and food. She said she was not here the day the argument took place with the Cook. <BR/>During an interview on 5/1/2025 at 10:39 AM, the BOM said she heard the [NAME] being loud then she heard Resident #2, so she went to the kitchen. She said Resident #2 was in the doorway and the [NAME] was screaming at Resident #2. She said Resident #2 was yelling calling the staff names. She said the [NAME] was saying she was not in the pen with him, and she told the [NAME] to stop screaming at the Resident #2. She said the [NAME] called her supervisor on the phone and she kept screaming. The BOM said she told the [NAME] she was suspended to leave the building. She said Resident #2 does talk to the staff and call them names when he gets upset. She said she did not feel like the incident affected the resident in anyway.<BR/>During an interview on 5/1/2025 at 1:54 PM the [NAME] said Resident #2 came to the kitchen and there was a new girl in the kitchen, and she did not know Resident #2 was not supposed to get beef. The [NAME] said she had hot dogs for him but in the meantime, Resident #2 came down and started cussing them and calling them names. She said the BOM did not try stop him from doing all the cussing of the staff. She said she did not cuss Resident #2, but she did tell the BOM person that she was motherfucking wrong for letting him get away with everything. She said the facility suspended her and then about a week later they called her and let her know she was terminated.<BR/>Record review of the facility's New Hire/Status Change Form indicated: the [NAME] was terminated on 4/25/2025 for verbal abuse. <BR/>Record review of the facility's Abuse-Reportable Events policy dated 05/2017 indicated: It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law and incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person.5. Investigation: a. When an employee becomes aware of an allegation or suspicion of abuse or reportable event the employee should: Immediately report the allegation or suspicion to the charge nurse on the unit on which the resident resides immediately to ensure immediate safety of the resident. B. The charge nurse will: Assess the resident or resident(s). Notify the Administrator or the person on-call, if after hours. The person on-call will notify the Administrator, if unavailable, the Director of nurses will be notified. Nursing facility but the above immediately but not later than 2 hours after the allegation is made, if the events that caused the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the event that caused the allegation do not involve abuse and do not result in serious bodily injury .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for 6 of 11 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) reviewed for abuse policies. 1. The facility failed to follow their policy by not reporting abuse within the 2-hour required time frame when on Resident # 3 hit Resident #1, on 9/19/25. The facility did not report the incident to the state agency until 9/22/25. 2. The facility failed to follow their policy by not reporting abuse within the 2-hour required time frame when on Resident # 4 scratched and held Resident #5's hand, on 9/24/25. The facility did not report the incident to the state agency until 9/26/25. 3. The facility failed to follow their policy by not reporting an incident of abuse on 10/8/25 when Resident #2 punched Resident #1 in the face which caused a non-displaced nose fracture. 4. The facility failed to gather written statements for incidents that occurred on 9/19/25, 9/24/25 or 10/8/25, as per facility policy. 5. The facility failed to complete the State Provider Investigation Report (5-day report) for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25 and 10/8/25, per facility policy. 6. The facility failed to review corrective actions for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25, per facility policy. 7. The facility failed to analyze the occurrence to determine what changes, if any, were needed to the policies and procedures to prevent further occurrences for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25, as per facility policy. 8. The facility failed to refer all occurrences to the QAPI committee to be analyzed to determine what change or changes were needed, if any, to the facility's policies and procedures to prevent further occurrences for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25 as per facility policy. An Immediate Jeopardy (IJ) situation was identified on 10/21/2025. While the IJ was removed on 10/22/2025, the facility remained out of compliance at a scope of a pattern with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse which could lead to further abuse and neglect of other residents. Findings included: 1. Record review of Resident #1's electronic face sheet indicated a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease (progressive neurodegenerative disorder that affects memory, thinking, and behavior), anxiety (excessive worry, fear, and nervousness), and psychotic disorder with hallucinations (disconnect from reality, may see, hear, smell, taste or feel things that are not there). Record review of Resident #1's quarterly MDS assessment, dated 06/23/2025, indicated a BIMS score of 99, which indicated Resident #1 was unable to complete the interview. Resident #1's cognitive skills for daily decision making were severely impaired and never or rarely made decisions. Record review of Resident #1's care plan dated 9/09/2024 indicated Resident #1 had the potential to be physically aggressive with interventions which included: 1. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. 2. Assess and address for contributing sensory deficits. 3. Assess and anticipate residents' needs: food, thirst, toileting needs, comfort level, body positioning and pain. Record review of Resident #1's progress note, dated 9/19/2025 at 10:15 PM, written by LVN J, indicated Resident #3 hit Resident #1 in the back. Record review of Resident #1's progress note, dated 10/08/2025 at 8:48 AM, written by LVN C, indicated Resident #1 was pushing the dining room table while Resident #2 was eating. Resident #2 asked Resident #1 not to push the table. Resident #1 continued to push the table. Resident #2 stood up and started punching Resident #1 in the face. Resident #1 had epistaxis (bleeding from the nose). LVN C notified the DON, Administrator and the Nurse Practitioner and sent Resident #1 to the hospital for x-rays of the face. Record review of Resident #1's progress note, dated 10/08/2025 at 12:28 PM, written by LVN C, indicated she received report from the hospital RN that Resident #1 had a non-displaced fracture to his nose. Record review of an incident report, dated 9/19/2025, written by LVN J, indicated: CNA reported to this nurse that she was taking [Resident #1] past [Resident #3] when [Resident #3] hit [Resident #1] in the back. Record review of an incident report, dated 10/08/2025 at 8:30 AM, written by LVN C, indicated: This [Resident #1] was sitting at the dining room table across from [Resident #2]. This [Resident #1] was moving the table when [Resident #2] asked him to stop moving the table. This [Resident #1] continued to move the table. [Resident #2] stood up and started hitting [Resident #1] with closed fists. Resident #1 was not able to be interviewed due to Resident #1 being in the behavioral hospital. 2. Record review of Resident #2's facility face sheet, dated 10/20/25, indicated an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Alzheimer's disease and dementia (decline in cognitive abilities such as memory, thinking, and problem solving). Resident #2 was discharges to a psychiatric hospital on [DATE]. Record review of Resident #2's Quarterly MDS assessment, dated 5/27/25, indicated a BIMS score of 3, which indicated a severe cognitive impairment. He exhibited no behavioral symptoms directed toward others. He was independent with most ADLs. Record review of Resident #2's comprehensive care plan, dated 10/3/25, indicated he received aggression on 10/3/25 when he was pushed by another resident. Record review of Resident #2's incident report, dated 10/3/25, indicated he was pushed by another resident and landed on the floor on his left side. Resident #2 complained of 10/10 pain to his lower back and sustained a skin tear to the left side of his neck measuring 1.2cm X 0.5cm. He was sent to the emergency room for CT scan. Record review of Resident #2's emergency room records, dated 10/3/25, indicated he received a CT of the head without contrast and a CT of the cervical spine without contrast. Both were negative for fractures. There was no documentation of Resident #2 receiving a CT for the lumbar region. Record review of Resident #2's nursing progress note, dated 10/4/25 at 4:27 PM, for indicated: .Resident up and about to D/R moving very slow and not straighten lower extremities when walking and assisted by staff to walk, PRN Tylenol given and was effective. Neuro's WNL will monitor. signed by LVN M. Record review of Resident #2's nursing progress note, dated 10/5/25 at 3:03 PM, indicated Resident #2 was still experiencing pain and the MD was notified. New order was received for arthritis cream to back and to send to hospital for evaluation. Resident #2 refused to go to the hospital. Progress note was signed by LVN M. Record review of Resident #2's nursing progress note, dated 10/6/25 at 8:36 AM, indicated he complained of severe pain to the lower back and was unable to sit up. The progress note was signed by LVN M. Record review of Resident #2's nursing progress note, dated 10/6/25 at 9:43 AM, indicated: .Resident states he would go to Hospital. he is hurting very bad sitting in w/c [family member] notified that residents agreed to go into E.R. at [hospital name] D/T increased back pain, [family member] agreed and states she's on her way she will meet him at E.R. signed by LVN M. Record review of Resident #2's nursing progress note, dated 10/6/25 at 3:00 PM, indicated he returned to the facility after ER visit with diagnosis of Vertebral Compression acute Fracture of L2. Record review of Resident #2's emergency room records, dated 10/6/25, indicated he received a CT scan of the lumbar spine without contrast which showed an acute compression fracture of L2. Resident #2 was not able to be interviewed due to Resident #2 currently in the behavioral hospital. 3. Record review of Resident #3's electronic face sheet indicated a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease (progressive neurodegenerative disorder that affects memory, thinking, and behavior), anxiety (excessive worry, fear, and nervousness), and bipolar disorder with psychotic features (hallucinations and delusions, during episodes of mania or depression). Record review of Resident #3's quarterly MDS assessment, dated 07/02/2025, indicated a BIMS score of 09, which indicated Resident #3 had moderate cognitive impairment. Record review of Resident #3's care plan, dated 4/03/2025, indicated Resident #3 had a mood problem related to the disease process of bipolar disorder with interventions which included: 1. Administer medications per MD order for mood management. 2. Encourage resident to express feelings and verbalize concerns during episodes of mood changes and or increased irritability. Allow adequate time to talk and actively listen in a non-judgmental manner. 3. Observe for and report to nurse any acute episode or complaints of feeling sad, loss of pleasure and interest in activities; feelings or worthlessness or guilt; change in appetite/eating habits; change in sleep patterns decreased ability to concentrate; change in ability to make purposeful move.4. Psychiatric/psychological consults as ordered by MD. Record review of Resident #1's progress note, dated 9/19/2025 at 10:30 PM, written by LVN J, indicated: CNA reported to this nurse that this [Resident #3] had hit [Resident #1] in the back. [Resident #3] was assessed and had no sign of injury. The 2 residents were separated for the night into different rooms, both laying in their own beds, eyes closed, even respirations, no signs or symptoms of discomfort. Notified MD and Administrator of incident and separating the 2 residents for the night. Record review of incident report for Resident #3 dated 9/19/2025 at 8:00 PM, completed by LVN J, indicated: CNA reported to this nurse that she was walking past [Resident #3] with [Resident #1] when [Resident #3] hit [Resident #1] in the back. Record review of the state agency reporting system website https://txhhs.my.salesforce.com indicated the facility Administrator reported the resident-to-resident altercation on 9/22/2025 at 2:48 PM which occurred on 9/19/2025 at 8:00 PM. Record review of the state agency reporting system website https://txhhs.my.salesforce.com indicated the facility Administrator did not report the resident-to-resident altercation which occurred on 10/08/2025 at 8:48 AM. During an interview on 10/20/2025 at 10:15 AM, Resident #3 said he never had an altercation with anyone at the facility. 4. Record review of Resident #4's facility face sheet, dated 10/20/25, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included bipolar disorder (extreme mood swings between mania and depression) and Epilepsy (seizures). Record review of Resident #4's MDS tab in the electronic medical record indicated there had been no MDS assessment completed. Record review of Resident #4's care plan tab in the electronic medical record indicated there had been no comprehensive care plan completed. Record review of Resident #4's assessments tab in an electronic medical record indicated there had been no baseline care plan completed with 48 hours of admission. Record review of Resident #4's incident report, dated 9/24/25, indicated Resident #4 grabbed the hand of another resident and pulled on her, leaving red marks and a scratch mark. 5. Record review of Resident #5's facility face sheet, dated 10/20/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes (high blood sugar) and dementia (loss of memory, language, problem solving and other thinking abilities). Record review of Resident #5's Quarterly MDS assessment, dated 9/26/25, indicated a BIMS score of 13, which indicated intact cognition. She exhibited no behavioral symptoms directed toward others. She required set-up or clean-up assistance with most ADLs. Record review of Resident #5's comprehensive care plan, dated 6/4/25, indicated she had cognitive impairment related to dementia. Record review of Resident #5's incident report, dated 9/24/25, indicated: .Resident came to nurse and showed me her right hand having red streaks and a small scratch on the back of her hand. Resident stated, 'that crazy man grabbed my hand and scratched me pulling on it and he said f.u. bitch.' During an interview on 10/20/25 at 10:43 AM, Resident #5 denied any altercations with any residents where she was injured. 6. Record review of Resident #6's facility face sheet, dated 10/20/25, indicated he was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included Major Depressive (feelings of sadness, hopelessness) Disorder, and schizoaffective disorder (combines symptoms of schizophrenia and mood disorders such as depression or mania), Bipolar Type (extreme mood swings between mania and depression). Record review of Resident #6's Quarterly MDS assessment, dated 8/18/25, indicated a BIMS score of 3, which indicated a severe cognitive impairment. He exhibited no behavioral symptoms directed toward others. He required substantial/maximal assistance with most ADLs. Record review of Resident #6's comprehensive care plan, dated 10/3/25, indicated he initiated aggressive behavior to another resident (pushing) on 10/3/25. Record review of Resident #6's incident report, dated 10/3/25, indicated he pushed another resident causing the other resident to fall. Record review of Resident #6's nursing progress note, dated 10/3/25 at 7:30 AM, indicated he was observed pushing another resident while in the dining room. The progress note was signed by LVN C. During an interview on 10/20/25 at 10:20 AM Resident # 6 did not recall any incidents where he pushed another resident. During a interview on 10/20/2025 at 10:38 AM, CNA K said on 10/08/2025 she was working on the secure unit. She said Resident #1 was in the dining room at breakfast and was moving the table. She said Resident #3 told Resident #1 to stop moving the table. She said Resident #1 continued to move the table and Resident #3 got up and went over to Resident #1 and started punching him in the face with a closed fist. She said her, the nurse and the other CNA separated Resident #1 and Resident #3, and both residents were sent out to the hospital. She said both residents returned from the hospital and both residents were sent out to the behavioral hospital the same day. She said if a resident-to-resident altercation occurred she would separate the residents and make sure they were safe, then she would notify the nurse and the Administrator of the incident. During an interview on 10/20/2025 at 11:00 AM, the Administrator said she had 24 hours to report abuse to the state agency. She asked after further questioning am I supposed to report abuse within 2 hours? She said she did not have an excuse why she did not report the resident-to-resident altercations within the 2-hour required reporting time frame. She said she did not report the incident with Resident #1 and Resident #2 to the state survey agency because neither resident was hurt and she just didn't report it. She said she did not know Resident #1 had a non-displaced fracture on the nose. She said she did not know she was supposed to complete a 5-day investigation and submit it to the state agency. The Administrator said she did not know what the 3613A was. She said she had not completed them nor sent in any 5-day investigations to the state agency's reporting website. When asked what the reporting time frame was for abuse, she stated 24 hours. When surveyor further questioned administrator, she asked if it was 2 hours. During an interview on 10/21/2025 at 3:35 PM, CNA L said Resident #1 and Resident #2 were at the dining room table eating and Resident #1 kept moving the table. She said Resident #2 got up and started punching Resident #1 in the face. She said LVN C stepped in and stopped the altercation. She said if she witnessed a resident-to-resident altercation, she would make sure the residents were safe and then notify the charge nurse. During an interview on 10/21/2025 at 3:44 PM, LVN C said on 10/08/2025 she was passing medications in the secure unit. She said Resident #1 and Resident #2 were sitting at the dining room table and Resident #1 was pushing the table. She said Resident #2 asked Resident #1 to stop moving the table and Resident #1 did not stop. She said Resident #2 started punching Resident #1 in the face. She said her and the CNA's separated Resident #1 and Resident #2, and Resident #1 had blood dripping down his face. She said she notified the DON and the Administrator and sent both residents out to the hospital. She said Resident #1 had a non-displaced nose fracture. She said both residents returned from the hospital and then both residents were sent to the behavioral hospital on the same day. LVN C said Resident #6 was upset because he had just finished getting a shower and was upset because he did not like to shower. She said Resident # 2 walked past Resident #6 and Resident #6 and pushed Resident #2 down. She said there were no warning signs that indicated Resident #6 was upset. She said the DON and MDS nurse were there and came down to the secure unit. She said the Administrator was not in the facility. She said if there was a resident-to-resident altercation she would make sure the residents were safe then she would notify the DON and the Administrator. During an interview on 10/22/2025 at 10:45 AM, the ADON said she found out about the resident-to-resident altercation between Resident #1 and Resident #2 in the morning meeting the day after the incident occurred. She said the residents were separated and sent to the behavioral hospital. She said she knew the Administrator was supposed to report abuse to the state agency within 2 hours. She said the charges nurses do not normally notify her of resident-to-resident altercations but if they did, she would notify the DON and Administrator of the incident. During an interview on 10/22/2025 at 3:23 PM, the DON said the staff usually notified her of resident-to-resident altercations. She said she would ask staff if they notified the Administrator and if they had not then she would notify the Administrator. She said she immediately notified the Administrator of the altercation with Resident #1 and Resident #2. She said the state agency should be notified within 2 hours of an abuse allegation. Record review of the facility's policy titled Resident to Resident Abuse, dated May 2017, indicated: .2. The Administrator will: 1. Notify state agency as required. 2. Notify local law enforcement as required . This was determined to be an Immediate Jeopardy (IJ) on 10/21/2025 at 12:35 PM. The facility Administrator was notified. The Administrator was provided with the IJ template on 10/21/2025 at 12:35 PM. The following plan of removal submitted by the facility was accepted on 10/22/2025 at 2:54 PM: Summary of Details which lead to outcomes:On 10/20/2025 a complaint survey was initiated at the facility. On 10/21/2025 a surveyor provided an IJ Template notification that it has been determined that conditions at the facility constitute an immediate jeopardy to the health and safety of the residents. The notification of the immediate jeopardy state as follows: Tag #Tag: F607 - Development/Implementation of Abuse Policy FAILURE: The failure to keep residents free from abuse or neglect related to not developing or implementing the abuse policy and this puts residents at risk for serious injury, harm, impairment, or death from abuse allegations and delays in reporting abuse allegations and delays in reporting abuse allegations to the abuse coordinator to implement preventative measures. Identify residents who could be affected:All residents Problem 1: The facility failed to develop and implement policies to investigate, prevent and report incidents for resident abuse. The facility failed to develop and implement policies to investigate, prevent, and report incidents of staff to resident abuse. The facility failed to follow their policy by not reporting abuse within the 2 hour required time frame when on 9/19/25 Resident [TF36] # 3 hit Res #1. The facility did not report the incident to the state agency until 9/22/25.The facility failed to follow their policy by not reporting abuse within the 2 hour required time frame when on 9/24/25 Res # 4 scratched and held Res #5's hand. The facility did not report the incident to the state agency until 9/26/25.The facility failed to follow their policy by not reporting an incident of abuse on 10/8/25 when Res #2 punched Res #1 in the face causing a non-displaced nose fracture.The facility failed to gather written statements for incidents that occurred on 9/19/25, 9/24/25, or 10/8/25 as per facility policy.The facility failed to complete the State Provider Investigation Report (5-day report) for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25 as per facility policy. The facility failed to review corrective actions for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25 as per facility policy.The facility failed to analyze the occurrence to determine what changes, if any, are needed to the policies and procedures to prevent further occurrences for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25 as per facility policy.The facility failed to refer all occurrences to QAPI committee to be analyzed to determine what change or changes are needed, if any, to the facilities policies and procedures to prevent further occurrences for incidents of resident-lo-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25 as per facility policy. Action Taken: Residents had interventions put in place including separation from other residents when resident to resident altercations occurred. Resident #4 was separated from Resident #5, referral sent to behavioral inpatient for Resident #4 resident admitted to behavioral inpatient on 9/25/2025. Resident #6 and Resident #2 were separated from one another. Both Resident #6 & Resident #2 were sent to the ER for evaluation and treatment. Once returned both were placed on monitoring until no signs of behavior were noted. Resident #2 & Resident #1 were separated from one another and both sent to ER, while in ER staff made referral to impatient behavioral hospital. Both Residents #2 & #1 were admitted to inpatient behavioral hospital.Abuse reportable events policy was reviewed and revised on 10/21/2025 to include steps for reporting, documentation required and time to report events. Abuse/neglect in services were started with all staff on 10/21/2025 by the Administrator, the DON, nurse managers and department supervisors, all employees must be educated before working their scheduled shift. Social Services in serviced Administer on 10/20/2025 to complete safety surveys with each incident especially any allegations of abuse/neglect to ensure residents feel safe in the facility and they have not experienced any negative events. The DON and Nurse manager assigned to educate nurse on documentation related to incidents, including incident reports, witness statements, progress notes, monitoring logs and head to toe skin assessments. Per facility policy charge nurse will be the staff member that begins taking written statements after the allegation is reported to the Administrator and DON. 10/20/2025 safety surveys started by department heads for residents that could answer survey questions, secured unit charge nurse contacting family members for residents on the secured unit with impaired cognition. Resident council meeting scheduled for residents on 10/22/2025. 10/22/2025 to discuss revision to policy including the steps to reporting and the required documentation that was needed for completing an investigation related to an incident that occurred and was a reportable event. Department heads would speak to resident's individually that did not attend the meeting and call family members with residents that have impaired cognition. The Administrator would be completing the meeting with residents. The Regional director of operations in serviced the DON and Administrator on revision to policy on abuse/neglect allegations. Policy only stated notify state agency as required. The revision now has specific contact information with multiple methods of notification including email, phone, and TULIP. Multiple methods on how to submit 3613 investigation report including email, TULIP, and fax. No other incidents were found at this time. Regional Director of operations visited the facility on a monthly basis and would follow up with the Administrator/DON with each self-report to ensure the investigation of self-reports were completed in timely manner and 3613 was submitted to state with all the documentation gathered with investigation. All communication between monthly visits were to be sent through email. The Nurse manager started Inservice with nurses to 10/21/2025 to discuss Documentation including incident reports, witness statements, skin assessments, treatments for injuries, interventions that were put in place to protect the residents, in services to help prevent incident from further occurring, monitoring documentation, any hospital records, safety surveys and any additional information that was required for investigation. Inservice was related to having more thorough assessment and appropriate documentation in place. In-services would be completed before staff worked the next shift. Monitoring: The facility's Abuse Reportable events Policy was reviewed and revised on 10/21/25 to clarify timelines for internal/external reporting and investigation steps.The revised policy was approved by the Governing Body and redistributed to all departments. Future new hires will receive abuse prevention and reporting training during orientation before working any shift.The DON or designee will initiate and complete all abuse investigations within five days using the state-approved Form 3613-A process.All investigations will be reviewed and signed by the Administrator for accuracy and timeliness before submission.The Administrator or DON will audit all incident reports weekly for 90 days to ensure proper reporting, investigation, and documentation.Results will be presented to the QA Committee monthly for review and any needed corrective actions.The QA Committee will evaluate compliance and determine if further education or policy revisions are needed. Monitoring of the POR included the following: Record review of inservice, dated 10/20/2025, titled Safety Surveys after abuse/neglect allegation which indicated random safety surveys must be completed after each abuse/neglect allegation signed by the SW . Record review of inservice, dated 10/21/2025, titled Documentation requirements for incidents which indicated all incident reports require the following documentation: head to toe assessments, progress notes, witness statements, monitoring log for behaviors, treatment orders for injuries, completed incident reports, and requested hospital documentation signed by 24 employees. Record review of 61 resident safety surveys completed 10/21/2025 documented no concerns for abuse or neglect. Record review of resident council minutes, dated 10/22/2025 at 11:12 AM, with 11 residents in attendance. Record review of inservice titled Form 3613 Quick Reference & Staff Training Guide, dated 10/21/2025, signed by the DON and Administrator. Record review of inservice titled Abuse and Neglect P&P, dated 10/21/2025, signed by the DON and Administrator. Record review of inservice titled Abuse/Neglect Policy-reporting/investigating/Implementing, dated 10/21/2025, signed by the DON and Administrator. During interviews conducted on 10/22/2025 between 3:00 PM and 4:30 PM the following staff were able to verbalize understanding of developing and implementing the facilities abuse policy: Administrator, DON, ADON, SW, CNA A, CNA B, LVN C, Housekeeper D, LVN O, MDS Coordinator, MA E, CNA N, CNA F, LVN G, CNA H, and the Activity Director. The Administrator was informed the Immediate Jeopardy was removed on 10/22/2025 at 4:30 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to in response to allegations of abuse, neglect, exploitation, or mistreatment, prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress for 1 of 6 (Resident #1) residents reviewed for abuse. LVN A physically abused Resident #1 on 9/9/25 and the facility failed to protect residents from further potential abuse when LVN A returned to the facility on the night shift of 9/10/2025 after being suspended at 7:50 a.m. on 9/10/25. An IJ was identified on 9/12/25. The IJ template was provided to the facility on 9/12/25 at 3:34 pm. While the IJ was removed on 9/13/25 the facility remained out of compliance at a scope of Isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ due to ongoing need for in-services on abuse and neglect, abuse coordinator and notification of abuse process. This failure could place residents at risk for physical and verbal abuse, psychosocial harm, and decreased quality of life.Findings included: Record review of the face sheet dated 9/11/2025 indicated that Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including severe intellectual disability which was below average intelligence, anxiety disorder which was intense, excessive, and persistent worry and fear about everyday situations, schizoaffective disorder which was a lifelong pattern of social withdrawal and limited emotional expression, ADHD which was a chronic condition including attention difficulty, hyperactivity and impulsiveness, cerebral palsy which was a congenital disorder of movement, muscle tone or posture, and cognitive communication deficit which was a group of disorders that affect a person's ability to communicate effectively due to underlying cognitive impairments. Record review of the MDS dated [DATE] indicated that Resident #1 had a BIMS score of 03 which was indicative of severe cognitive impairment. Record review of the care plan dated 9/7/25 which showed that Resident#1 was last admitted to the facility on [DATE] and was receiving services at the facility. During an interview on 9/11/25 at 4:11 p.m. CNA B said that on 9/10/25 she worked with CNA C on the evening shift. She said that they were outside smoking around 9:40 p.m. when LVN A approached them and asked them about the incident the night before between LVN A and Resident #1 and that he did not remember but was at the facility to document an incident report about it. She said that she did not know that LVN A was under investigation and that if she had she would have reported it. She said that the risk of not knowing that he was under investigation was that he could have come to the facility for retaliation which placed the staff and residents at risk of abuse. She said that LVN A got onto the computer and went onto the secured unit but she did not see him interact with any residents. CNA A said that the incident the night before that she was referring to was LVN A grabbing Resident # 1 by the shirt and making him choke. Record review of the voice recording provided by CNA B on 9/11/25 at 4:30 p.m. that was recorded on 9/10/25 sometime after 6:00 p.m. and included the voice of LVA A, CNA B, and CNA C as identified by CNA B. A summary of the recording was that CNA B and CNA C acknowledged that they observed LVN A grab Resident #1 by the shirt and around his neck on 9/9/25. LVN A admitted that he had returned to the facility to document the incident from last night with Resident #1. LVN A said that he got allegations for beating up on [unintelligible]. During an interview on 9/11/25 at 3:18 p.m. Resident #1 said that LVN A had choked him and that he was scared of LVN A. Resident #1 cried and left the interview. During an interview on 9/11/25 at 3:57 p.m. LVN A said that on 9/9/2025 he worked at the facility. He went into Resident #1's bedroom when he was fighting with his roommate. LVN A said that he was trying to calm Resident #1 down by rubbing his back and trying to talk to him. LVN A said that Resident #1 was on the floor and he was assisting him back to his chair and his hand got caught in Resident #1's t-shirt and when he pulled his hand out of Resident #1's shirt and his hand went up toward Resident #1's neck . LVN A said that Resident #1 was one of his favorite residents and that he would never abuse him. He said that residents have called him the N word before and he was not one so it does not bother him. LVN A said that he did not choke Resident #1. LVN A said that there were two CNAs in the room with him when his hand got caught in Resident #1's t-shirt. LVN A confirmed that the CNA's in the room were CNA B and CNA C. LVN A said that he was informed by DON that he was suspended pending an investigation on the morning of 9/10/25 and was told that he could likely return to work on Saturday if everything looked good. During an interview on 9/12/25 at 1:18 p.m. CNA C said that she worked on the night shift on 9/10/2025 alongside CNA B. She said around 9:30 p.m. LVN A came up to her and CNA B and started talking to them about the incident that had occurred the night before with LVN A grabbing Resident #1 by the shirt and throat and making him make a choking sound. She said that he told them that he comes back to work on Saturday 9/13/25, but he had come up to the facility on the night of 9/10/25 to document an incident report about the night before. She said that she did not know he was suspended and if she had she would have reported it and not allowed him to have access to the residents. She said that she saw LVN A get on the computer but did not see him go onto the secured unit or interact with any residents. She said the risk of not knowing who was suspended was that the suspended person could come to the facility to do harm to staff or residents. Record review of facility Incident Audit Report indicated that LVN A entered an incident audit report into PCC on 9/10/25 at 10:53 p.m. PCC was the electronic medical record used by the facility. The note indicated that LVN A entered the bedroom of Resident #1 and Resident #1 was on the floor trying to fight with his roommate. LVN A documented that he directed the CNA to put Resident #1 in his wheelchair and get him out of the room. LVN A documented that Resident #1 was agitated and that LVN A was rubbing his back to calm him down and then was rubbing his chest as a calming procedure. LVN A documented that his hand slipped inside the shirt of Resident #1 as he was bending down to fight with his roommate and LVN A stated that he removed his hand immediately and asked the CNAs to removed Resident #1 from the room. LVN A noted that Resident #1 was assessed for injury and none were found. During an interview on 9/11/25 at 11:55 a.m. the Administrator said she expected suspended staff to not enter the facility during their suspension and there was a policy entitled Disciplinary Action and Suspension Pending Investigation Policy that told them. She said that they did not tell other staff when a staff member was suspended as they did not want to spread their business and that she was not aware of any policy that directed the Administrator or DON to notify anyone of a suspended staff member. She said she assumed that a suspended staff member's common sense would tell them that they should not be at the facility during suspension in addition to that policy. She said that she understands the need for a process for others to know about the suspension as a suspended person coming to the facility places everyone at the facility at risk of abuse or assault. She said that she was not aware that LVN A was at the facility after he was notified on 9/10/25 at 7:50 a.m. that he was suspended. She said that they started the investigation upon being notified of the incident by interviewing CNA B and CNA C, assessing Resident # 1 and in-servicing staff on abuse and neglect. Record review of facility's Disciplinary Action and Suspension Pending Investigation Policy undated indicated, .In cases involving serious allegations, employees may be placed on suspension pending investigation and are not permitted to return to the facility until the investigation was concluded.the employee was not permitted on facility premises or to engage with residents or staff during the suspension . Record review of the document titled {Facility} New Hire/Status Change Form which indicated that LVN A was terminated on 9/11/25 for abuse. This document did not show a suspension date or time. Record review of facility's Employee Discipline Policies and Professional and Personal Responsibility policy indicated that the suspended employee was not to enter premises until suspension was complete or until results are determined from suspension. Record review of facility's Abuse-Reportable Events policy last revised May 2017 indicated, .it is the policy of this home to prohibit resident abuse or neglect in any form . The Administrator was notified on 9/12/25 at 3:30 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 9/12/25 at 3:34 p.m. The facility's plan of removal was accepted on 9/13/2025 at 7:46 p.m. and included: Interventions: LVN A suspended on 9/10/25 at 7:50 a.m. Resident # 1 assessed for injury on 9/10/25 at 11:44 a.m. Roommate of Resident #1 assessed on 9/10/25. Residents on secured unit were not showing signs of distress or pain on 9/10/25. LVN A terminated on 9/12/25 at 2:00 p.m. In-services related to abuse/neglect started 9/10/2025 at 8:00am. Updated policy on suspension pending investigation with Be informed when an employee is suspended-suspended employee is not allowed to be in facility and all staff must ask the suspended staff to leave and call the administrator/DON if they enter the facility. Monitoring: Policy on suspension pending investigation updated. All staff will be informed each time an employee was suspended and will be responsible for asking staff to leave if they come to the premises and contact Administrator and DON. Any employee suspected of abuse will be removed from the facility immediately. Abuse coordinator signs are throughout the facility and there will continue to be ongoing training to ensure the staff was knowledgeable of who to report to and what to report. Staff was in serviced by Administrator, DON, Dietary supervisor, and housekeeping supervisor. All staff in facility must be in serviced. As of 9/13/2025 at 11:54am 66 employees in all departments have signed in services. There are twelve employees that need to be still in-services. All employees must be in-serviced by 9/13/2025 by 3:30pm. Any staff that has not been in-serviced was not to clock into the facility until they have been in serviced by DON or administrator. Anyone who fails to complete in-service will be removed from schedule and not allowed to work until they have been in-serviced. On 9/13/25 at 8:30 p.m. the investigator confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: During an interview with LVN F who worked the 2-10 shift on 9/13/25 at 4:38 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN D who worked the 2-10 shift on 9/13/25 at 4:40 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN E who worked the 2-10 shift on 9/13/25 at 4:54 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA J who worked the 6 p.m. to 6 a.m. shift on 9/13/25 at 4:52 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA K who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 4:54 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA L who worked the 2-10 shift on 9/13/25 at 5:00 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA B who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 5:40 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA C who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 5:52 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN G who worked the 6 p.m. to 6 a.m. shift on 9/13/25 at 6:50 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with RN H who worked the 8 a.m.-5 p.m. shift on 9/13/25 at 6:53 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with DON who worked the 8 a.m.-5 p.m. shift on 9/13/25 at 6:58 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with Resident # 2 on 9/13/25 at 6:15 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 3 on 9/13/25 at 6:20 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 4 on 9/13/25 at 6:23 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 5 on 9/13/25 at 6:27 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 6 on 9/13/25 at 6:33 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 7 on 9/13/25 at 6:37 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 8 on 9/13/25 at 6:42 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 1 on 9/13/25 at 6:46 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 9 on 9/13/25 at 7:52 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 10 on 9/13/25 at 7:55 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 11 on 9/13/25 at 7:57 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 12 on 9/13/25 at 8:00 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 13 on 9/13/25 at 8:05 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 14 on 9/13/25 at 8:08 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 15 on 9/13/25 at 8:12 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 16 on 9/13/25 at 8:15 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 17 on 9/13/25 at 8:18 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 18 on 9/13/25 at 8:20 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 19 on 9/13/25 at 8:23 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 20 on 9/13/25 at 8:25 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. Record review of facility's in-service documentation reviewed on 9/11/25 for Reporting Abuse and Neglect dated 9/10/2025 indicated that 13 employees had been in-serviced. CNA B and CNA C were not listed on this document. Record review on 9/13/25 at 8:10 p.m. of in-service documentation showed that all but six staff had been in-serviced on the changes to the suspension pending investigation policy and all staff had been notified that they would be taken off the schedule until they had been in-serviced. Record review of in-service documentation dated 9/12/2025 indicated that CNA B and CNA C were in-serviced on abuse, neglect and reporting requirements. This in-service shows that it included specific reporting requirements that abuse must be reported immediately to the abuse coordinator and that it must be reported by voice phone call, not text message. Record review on 9/13/25 at 8:12 p.m. of the facility suspension pending investigation policy update. There was no date on the policy but the change from the old policy to the new policy was the addition that was as follows: All staff must be informed when an employee is suspended- Suspended employee is not to be in the facility and staff must ask them to leave and call the administrator/DON if they enter the facility. Observation conducted on 9/13/25 at 8:00 p.m. of abuse coordinator signs located on each hallway, at each nurses station and in the dining room. It included the name of the Administrator as well as the number to the abuse hotline. Observation conducted on 9/13/25 at 8:15 p.m. showed a notice over all facility time clocks notifying staff not to clock in until they had completed the required in-services on recent policy changes. Record review of Resident #1's skin assessment dated [DATE] at 11:44 a.m. showed no signs of injury. Notification to Administrator on 9/13/2025 at 8:30 p.m. that the IJ had been lifted. An IJ was identified on 9/12/25 The IJ template was provided to the facility on 9/12/25 at 3:34 p.m. While the IJ was removed on 9/13/25 the facility remained out of compliance at a scope of Isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ due to ongoing need for in-services on abuse and neglect, abuse coordinator and notification of abuse process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Record review and interview, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System within 14 days after a facility completes the resident's assessment for 1 (Resident #4) of 6 residents reviewed for MDS transmission, in that: The facility failed to complete and transmit an Entry and Discharge MDS assessment for Resident #4 within 14 days of completion.These failures could place residents at risk of not having their assessment and care plan completed timely, which could result in denial of services and/or payment for services.Findings include: Record review of a facility face sheet dated 10/20/25 for Resident #4 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Bipolar disorder (a mental health condition characterized by extreme mood swings, including emotional highs (mania or hypomania) and lows (depression) and Epilepsy (seizures). Face sheet indicated also indicated a discharge date of 9/25/25 to a psychiatric hospital. Record review of an MDS tab in Resident #4's electronic medical record indicated there had been no MDS assessments completed. MDS tracking tab in PCC indicated an entry MDS was due with an ARD of 9/9/25, a discharge MDS was due with an ARD of 9/11/25, an entry MDS was due with an ARD of 9/23/25, and a discharge MDS was due with an ARD of 9/23/25. None had been completed, nor transmitted. During an interview on 10/21/25 at 2:43 pm MDS nurse said she started as the MDS nurse on 9/29/25 and she had no prior experience with MDS assessments. She said she had had a little bit of training with the previous MDS nurse where she would show her regulations in RAI, but she had received no formal training. She said all residents should have an entry MDS on admission and a discharge assessment with discharged . She said she did remember reading that in the RAI manual. She said she was not doing MDSs when Residents #2 and #4 were admitted and discharged . She said the Administrator did tell her yesterday (10/20/25) that there were a lot of MDSs that had not been done, completed, or transmitted. She said she was trying to get them completed now and able to submit. She said if MDSs are not completed timely, accurately and not submitted as required, the facility would not receive payments. She said care plans may not be completed accurately, and staff would not know how to take care of the residents. During an interview on 10/22/25 at 3:23 pm DON said the MDS coordinator was responsible for completing and transmitting MDS assessments. She said the care plans may not be up to date if MDSs are not completed timely. She said going forward she would be responsible for monitoring and ensuring timely completion and submissions. During an interview on 10/22/25 at 4:19 pm the Administrator said she would be responsible for MDS being completed and transmitted going forward. She said care plans could be missed if MDSs were not completed timely and transmitted as required and residents could be at risk of harm. Record review of a facility policy titled Electronic Transmission of the MDS dated September 2010 read: .All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed for 1 of 6 residents (Resident #4)reviewed for care plans . The facility failed to complete baseline care plans within 48 hours of admission for Residents #4. This failure could place residents at risk of not receiving care and services to meet their needs.Findings included:Record review of a facility face sheet dated 10/20/25 for Resident #4 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including bipolar disorder (a mental health condition characterized by extreme mood swings, including emotional highs (mania or hypomania) and lows (depression) and Epilepsy (seizures).Record review of an MDS tab in an electronic medical record for Resident #4 indicated there had been no MDS assessment completed.Record review of a care plan tab in an electronic medical record for Resident #4 indicated there had been no comprehensive care plan completed.Record review of an assessments tab in an electronic medical record for Resident #4 indicated there had been no baseline care plan completed.During an interview on 10/21/25 at 2:43 pm MDS Coordinator said she had started doing MDSs on 9/29/25 and had no prior experience. She said the floor nurses should be responsible for completing the baseline care plan, but she said she did not know how long the facility had to complete the baseline care plan. She said if they were not completed the staff may not know how to take care of the residents. During an interview and observation on 10/21/25 at 3:15 pm LVN J said she was a floor nurse but said she did not complete the baseline care plans. She said she thought the ADON did them. She said she thought they must be done by an RN. She gave me a checklist from a book at the nurses' station that she said the floor nurses use to complete admissions. Baseline care plan was not included on the checklist. During an interview on 10/21/25 at 3:50 pm LVN J brought another list that she said came out with the checklist in July or August and baseline care plans were included on that list. She said she was not aware that they were to be completing them.During an interview on 10/22/25 at 10:45 am ADON said she had worked at the facility since July 2024, but she had been ADON since 10/1/25. She said she did not know baseline care plans were supposed to be done on admission until yesterday (10/21/25). She said she did not know how long the facility had to do a baseline care plan. She said moving forward her and the DON would be checking over new admissions to make sure baseline care plans were done. She said staff would not know how to take care of the residents without the baseline care plan.During an interview on 10/22/25 at 3:23pm DON said the admission nurse would be responsible for baseline careplans going forward. She said going forward her and the ADON would be responsible for making sure those are being completed. She said residents potentially would not be cared for properly without a baseline care plans.During an interview on 10/22/25 at 4:19pm Administrator said the MDS coordinator would be responsible for baseline care plans. She said care could be missed if baseline care plans were not completed and residents could be at risk of harm. Record review of a facility policy titled Care Plans - Baseline dated December 2016 read: .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. and .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.

Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.<BR/>The facility failed to provide a safe, functional, sanitary, and comfortable environment by ensuring windows in resident rooms 808, 901, 902, 903, 904, 906, 907, 909, and 911 were operable and had screens in place.<BR/>This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. <BR/>Findings included:<BR/>Observations on 2/27/23 revealed that on the secure unit, 9 of 11 windows were found to be either inoperable or operable without a window screen.<BR/>9 windows were without screens: Rooms 808, 901, 902, 903, 904, 906, 907, 909, and 911.<BR/>5 windows were also found to be screwed down, rendering them inoperable: Rooms 902, 904, 906, 907, and 909.<BR/>In an interview with the Administrator and the DON on 02/28/23 at 08:21 AM, both the DON and the Administrator said that they did not know that it was a regulation that windows must have a screen. They did say that they could see the need for screens for pest control and to allow residents to open their windows if they desired.<BR/>In an interview with MAINT on 02/28/23 at 09:08 AM, he said that window latches already had holes in them from being screwed down previously and were re-screwed down after an elopement incident. He said that he does not know when the screens were removed from the windows on the unit. He said that most windows in the facility do have screens, and if he noticed any that were off, that he would pick them up and put them back on. He said that sometimes when the lawn is being mowed or weed-eated, a rock or something might hit them, knocking them down. He said he had not thought about screens being in place for pest control, but that he could see where that could be an issue.<BR/>In an interview with the Administrator on 3/1/23 at 9:30am, she said that the only harm to residents that she could think of might be pest control. She said she really can not think of any other harm that might come to residents. She said that she will see what can be done about the windows on the unit being screwed down, that they may try to figure out how to limit them to opening a minimal amount to keep residents safe. She was not aware previously that it was a regulation. She said that by ensuring that residents were able to open their windows if they chose to do so, it could make their environment more comfortable, and screens in place could ensure safety.<BR/>In an interview with the DON on 3/1/23 at 11:00am, she said that if residents were to open their windows without a screen in place, that they could potentially elope or be stung by an insect if an insect were to be able to fly in. She said that having screens in place could help ensure resident safety.<BR/>Record review of facility policy titled maintenance service dated December 2022 states .the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . and .Functions of maintenance personnel include, but are not limited to: a) maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines; b) maintaining the building in good repair and free from hazards; and .k) maintaining doors, windows and screens (where indicated) in appropriate working order .<BR/>No policy was provided for safe, comfortable, homelike environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure residents had the right to be free from verbal abuse by staff for 2 (Resident #1 and Resident #2) of 10 residents reviewed for abuse. <BR/>The facility failed to prevent verbal abuse by CNA A. On 3/3/2025 CNA A told Resident #1 She was stinky and needed to take a shower.<BR/>The facility failed to prevent verbal abuse by the Cook. On 4/6/2025 the [NAME] cussed Resident #2 in a verbal altercation. <BR/>This failure could place all residents in the facility at risk for severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. <BR/>Findings included:<BR/>1.Record review of Resident #1's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with the most recent admission on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (progressive lung disease that makes breathing difficult), pseudobulbar affect (neurological condition), and major depressive disorder (persistent feelings of sadness). <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated no cognitive impairment. <BR/>Record review of Resident #1's care plan revealed she had an ADL self-care performance deficit with interventions that included: The resident is totally dependent on 1-2 staff to provide bath/shower. <BR/>Record review of psychiatric assessment completed on 3/5/2025 indicated: Patient states one of the nurse aides told her she was stinky and needed to shower. She says she was offended by this and feels sad. She verbalizes she will be okay though and is grateful for the concerns. She states she gets regular showers from the hospice nurse every MWF. Patient says she eats and sleeps okay/good. Anxiety: Patient denies symptoms of excessive worry.<BR/>Record review of Resident #1's nursing progress note dated 4/20/2025 at 12:36 AM, written by RN C indicated Resident #1 expired in the facility.<BR/>Record review of witness statement provided by Hospice CNA B dated 3/5/2025 indicated: On 3/3/2025 she was taking Resident #1 to the shower room and was told that someone was in the shower room and to go around to the 200 hall, on the way around CNA A started saying out loud that time does not go on her time and she needed to wait her turn. CNA A made the statement a few times before Resident #1 turned around and said never mind she was not going to shower if she (CNA A) was going to keep saying stuff. Resident #1 headed back to her room when CNA A told her no go ahead go take the shower because she stinks and needed it. CNA A said you know what let me go get Resident #1's roommate up to that room stinks she needs to get up too so we can air out that and strip the beds. Resident #1 got back to her door she turned around and decided to go ahead and go take the shower on her hall. <BR/>Record review of witness statement provided by CNA A on 3/5/2025 indicated: I [CNA A] don't recall what happen Monday beside me telling [another resident] I am not his auntie and am not married to that. I don't think I cussed anyone.<BR/>Record review of the facility new hire/status change form indicated CNA A was terminated on 3/5/2025. <BR/>During an attempted interview on 4/30/2025 at 2:00 p.m. the DON had left the facility and was no longer employed at the facility. <BR/>During an interview on 5/1/2025 at 9:24 AM, the Activity Director said CNA A talked a little hateful to the residents but not to a point that it was abuse. She said CNA A was a good CNA and her residents were taken care of. <BR/>During an interview on 5/1/2025 at 1:49 PM, CNA A said all she said to Resident #1 was that she smelled really bad, and she needed to take a shower. She said she never cussed Resident #1. <BR/>2. Record review of Resident #2's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included type 2 diabetes (high blood sugar), insomnia (sleep disorder), and depression (persistent feelings of sadness). <BR/>Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 13, which indicated no cognitive impairment. <BR/>Record review of Resident #2's care plan dated 6/12/2024 revealed he had the potential to be verbally aggressive with interventions that included: When the resident becomes agitated; intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later.<BR/>Record review of witness statement dated 4/6/2025 written by the BOM indicated: was sitting in my office when I heard screaming from dietary went to dietary [Cook] was screaming at [Resident #2] I then told her to stop she begin yelling louder stating she is sick of the way he talks to her that we need to do something with his fucking ass cause he ain't going to talk like that no more to her. I asked him to go outside and calm down she keep on screaming back and forth with [Resident #2]. [sic]<BR/>During an interview on 4/29/2025 at 11:04 AM, Resident #2 said when he gets upset, he cusses that was just who he was. He said the staff was there to work for him. He said he did remember the incident in the kitchen, but he was over it and that [NAME] no longer worked at the facility. He said he was over that incident, and it was in the past. <BR/>During an interview on 5/1/2025 at 9:24 AM the Activity Director said Resident #2 is mean and a smart [NAME]. She said he cusses the staff and tells them that he signs their paycheck. She said Resident #2 had called the kitchen staff fat sloppy [NAME]. She said he wass very hateful over the TV and food. She said she was not here the day the argument took place with the Cook. <BR/>During an interview on 5/1/2025 at 10:39 AM, the BOM said she heard the [NAME] being loud then she heard Resident #2, so she went to the kitchen. She said Resident #2 was in the doorway and the [NAME] was screaming at Resident #2. She said Resident #2 was yelling calling the staff names. She said the [NAME] was saying she was not in the pen with him, and she told the [NAME] to stop screaming at the Resident #2. She said the [NAME] called her supervisor on the phone and she kept screaming. The BOM said she told the [NAME] she was suspended to leave the building. She said Resident #2 does talk to the staff and call them names when he gets upset. She said she did not feel like the incident affected the resident in anyway.<BR/>During an interview on 5/1/2025 at 1:54 PM the [NAME] said Resident #2 came to the kitchen and there was a new girl in the kitchen, and she did not know Resident #2 was not supposed to get beef. The [NAME] said she had hot dogs for him but in the meantime, Resident #2 came down and started cussing them and calling them names. She said the BOM did not try stop him from doing all the cussing of the staff. She said she did not cuss Resident #2, but she did tell the BOM person that she was motherfucking wrong for letting him get away with everything. She said the facility suspended her and then about a week later they called her and let her know she was terminated.<BR/>Record review of the facility's New Hire/Status Change Form indicated: the [NAME] was terminated on 4/25/2025 for verbal abuse. <BR/>Record review of the facility's Abuse-Reportable Events policy dated 05/2017 indicated: It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law and incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person.5. Investigation: a. When an employee becomes aware of an allegation or suspicion of abuse or reportable event the employee should: Immediately report the allegation or suspicion to the charge nurse on the unit on which the resident resides immediately to ensure immediate safety of the resident. B. The charge nurse will: Assess the resident or resident(s). Notify the Administrator or the person on-call, if after hours. The person on-call will notify the Administrator, if unavailable, the Director of nurses will be notified. Nursing facility but the above immediately but not later than 2 hours after the allegation is made, if the events that caused the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the event that caused the allegation do not involve abuse and do not result in serious bodily injury .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the administrator of the facility and to other officials including to the State Survey Agency in accordance with State law through established procedures for 1 of 6 (Resident #1) residents reviewed for abuse. The facility failed to ensure an allegation of abuse was immediately reported to the abuse coordinator. The facility failed to report the allegation of abuse within 2 hours. An IJ was identified on 9/12/25 The IJ template was provided to the facility on 9/12/25 at 3:34 p.m While the IJ was removed on 9/13/25 the facility remained out of compliance at a scope of Isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ due to ongoing need for in-services on abuse and neglect, abuse coordinator and notification of abuse process. This failure could place residents at risk for physical and verbal abuse, psychosocial harm, and decreased quality of life. Findings included: Record review of the face sheet dated 9/11/2025 indicated that Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including severe intellectual disability which was below average intelligence, anxiety disorder which was intense, excessive, and persistent worry and fear about everyday situations, schizoaffective disorder which was a lifelong pattern of social withdrawal and limited emotional expression, ADHD which was a chronic condition including attention difficulty, hyperactivity and impulsiveness, cerebral palsy which was a congenital disorder of movement, muscle tone or posture, and cognitive communication deficit which was a group of disorders that affect a person's ability to communicate effectively due to underlying cognitive impairments. Record review of the MDS dated [DATE] indicated that Resident #1 had a BIMS score of 03 which was indicative of severe cognitive impairment. Record review of the care plan dated 9/7/25 which shows that Resident#1 was last admitted to the facility on [DATE] and was receiving services at the facility. Record review of progress note dated 9/10/2025 indicated that Resident #1 was on the floor of his bedroom fighting with his roommate and LVN A documented attempting to sooth Resident#1 by rubbing his back and his chest and his hand getting caught in the shirt of Resident #1. It indicated that LVN A instructed CNA B and CNA C to take Resident # 1 into the hallway. LVNA indicated that he assessed Resident # 1 and noted no injury. During an interview on 9/11/25 at 4:11 p.m. CNA B said that on 9/9/25 she worked with CNA C on the evening shift. She said that at around 10:30 p.m. she observed LVN A grab Resident #1 by the shirt near his neck and that she heard Resident #1 make a choking noise and cry once released. She said that she would consider the actions she witnessed LVN A carry out to be abuse. She said she sent a text to the DON at 10:39 p.m. and 10:46 p.m. letting the DON know about the incident and that she did not know what to do. She said she did not contact anyone else and did not try to call the DON. CNA B said she did not know who the abuse coordinator was at the time of the incident and did not recall being trained on abuse and neglect. She said she got a text the next morning at 6:38 a.m. from the DON asking her to call her. She said that the risk of not reporting abuse immediately was that LVN A could have gone back and carried out more abuse or abused other residents before his shift ended. Record review of the voice recording provided by CNA B on 9/11/25 at 4:30 p.m. that was recorded on 9/10/25 sometime after 6:00 p.m. and included the voice of LVA A, CNA B, and CNA C as identified by CNA B. A summary of the recording was that CNA B and CNA C acknowledged that they observed LVN A grab Resident #1 by the shirt and around his neck on 9/9/25. Both CNA B and CNA C told him that they had observed him grab Resident #1 by the shirt around his neck and got into Resident #1's face when Resident #1 used a racial slur toward his roommate. During an interview on 9/11/25 at 3:18 p.m. Resident #1 said that LVN A had choked him and that he was scared of LVN A. Resident #1 cried and left the interview. During an interview on 9/11/25 at 3:57 p.m. LVN A said that on 9/9/2025 he worked at the facility. He went into Resident #1's bedroom when he was fighting with his roommate. LVN A said that he was trying to calm Resident #1 down by rubbing his back and trying to talk to him. LVN A said that Resident #1 was on the floor and he was assisting him back to his chair and his hand got caught in Resident #1's t-shirt and when he pulled his hand out of Resident #1's shirt and it went up toward Resident #1's neck. LVN A said that Resident #1 was one of his favorite residents and that he would never abuse him. He said that residents have called him the N word before and he was not one so it does not bother him. LVN A said that he did not choke Resident #1. LVN A said that there were two CNAs in the room with him when his hand got caught in Resident #1's t-shirt. LVN A confirmed that the CNA's in the room were CNA B and CNA C. During an interview on 9/12/25 at 1:18 p.m. CNA C said that she worked on the night shift on 9/9/2025 alongside CNA B. She said around 10:30 p.m. she witnessed LVN A enter the bedroom and grab Resident #1 by the shirt causing him to make a choking noise and cry when he was released. She said that what she witnessed was abuse and she had 24 hours to report it and intended to after the shift was over, but never got the chance to report it because she was contacted by the DON at around 7:00 a.m. the next morning. She said the Administrator was the abuse coordinator. She said that the risk of not reporting abuse immediately was that further abuse can occur. During and interview with the DON on 9/12/2025 at 9:11 a.m. DON said that she was notified by text of the abuse at 10:45 p.m. on 9/9/2025 but did not see the text until the following morning and immediately asked CNA B to call her. She said that once she spoke to CNA B and CNA C she reported the incident to the abuse coordinator who was the administrator and started the investigation process. During an interview on 9/11/25 at 11:55 a.m. the Administrator said she expected staff to report abuse within two hours so that appropriate protections can be put in place to protect the residents. The Administrator said she reported the incident of alleged abuse on 9/10/25 as soon as she found out about the incident on 9/9/25. The Administrator said she expected staff to immediately report any incidents of alleged or suspected abuse to her immediately. The Administrator said the importance of reporting abuse to the state agency in a timely manner was to aid in preventing further abuse and to protect the residents from abuse. Record review in TULIP on 9/11/25 indicated that the incident of abuse occurred on 9/9/25 at 10:45 p.m. and was reported to the State on 9/10/25 at 8:30 a.m. TULIP is a web based online platform developed and maintained by the Texas Health and Human Services Commission. It served as a centralized electronic system for handling licensure, credentialing, renewals, and related regulatory processes for long-term care providers in Texas, with a particular focus on nursing facilities. Record review of a screenshot obtained on 9/11/25 at 4:25 p.m. showed a text message from CNA B to DON at 10:39 p.m. asking if DON was awake. Another message sent at 10:44 p.m. indicated that CNA B did not know what to do in a situation that she described by saying that Resident #1 had been combative and that LVN A had put his hands around Resident #1's neck causing him to make a choking noise. LVN A was raising his voice and Resident #1 was crying. A return text from DON at 6:38 a.m. asked CNA B to call her. Record review of facility's Abuse and Neglect Clinical Protocol policy last revised March 2018 indicated, .This policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish . Record review of facility's Abuse-Reportable Events policy last revised May 2017 indicated, .it was the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law and any incident/event in which there was cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person.Nursing facility must report the above immediately but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury . The Administrator was notified on 9/12/25 at 3:30 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 9/12/25 at 3:34 p.m. The facility's plan of removal was accepted on 9/13/2025 at 7:46 p.m. and included: Interventions: LVN A suspended on 9/10/25 at 7:50 a.m. Resident # 1 assessed for injury on 9/10/25 at 11:44 a.m. Roommate of Resident #1 assessed. Residents on secured unit were not showing signs of distress or pain on 9/10/25. LVN A terminated on 9/12/25 at 2:00 p.m. In-service of all staff regarding abuse and neglect to include reporting abuse immediately to the administrator who was the abuse coordinator. Administrator completed one on one in-service with both witness CNA B on 9/12/2025 at 10:00pm. Witness CNA C was in serviced on 9/13/2025 at 1:30pm. Resident counsel held on 9/13/2025 at 10:00am was held to discuss the incident, what was considered abuse and who must be called immediately when abuse was suspected. Residents were informed that abuse coordinator signs are posted at the end of each hall and throughout facility. Monitoring: Staff in-serviced on abuse and neglect included types of abuse, reporting timely, who to report to and when to report In-service on facility abuse coordinator and back up coordinator and that a phone call must be made, text was not acceptable when it was regarding abuse. All residents were given a safety survey asking if they felt safe in the facility, whether they had seen anyone in the facility being abused or neglected and who they are to report abuse to if they have a concern of abuse or neglect. Abuse coordinator signs are throughout the facility and there will continue to be ongoing training to ensure the staff was knowledgeable of who to report to and what to report. Staff was in serviced by Administrator, DON, Dietary supervisor, and housekeeping supervisor. All staff in facility must be in serviced. As of 9/13/2025 at 11:54am 66 employees in all departments have signed in services. Twelve employees that need to be still in-services, all employees must be in-serviced by 9/13/2025 by 3:30pm any staff that has not been in-serviced was not to clock into the facility until they have been in serviced by DON or administrator anyone who fails to complete in-service will be removed from schedule and not allowed to work until they have been in serviced. On 9/13/25 at 8:30 p.m. the investigator confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: During an interview with LVN F who worked the 2-10 shift on 9/13/25 at 4:38 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN D who worked the 2-10 shift on 9/13/25 at 4:40 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN E who worked the 2-10 shift on 9/13/25 at 4:54 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA J who worked the 6 p.m. to 6 a.m. shift on 9/13/25 at 4:52 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA K who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 4:54 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA L who worked the 2-10 shift on 9/13/25 at 5:00 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA B who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 5:40 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA C who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 5:52 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN G who worked the 6 p.m. to 6 a.m. shift on 9/13/25 at 6:50 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with RN H who worked the 8 a.m.-5 p.m. shift on 9/13/25 at 6:53 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with DON who worked the 8 a.m.-5 p.m. shift on 9/13/25 at 6:58 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with Resident # 2 on 9/13/25 at 6:15 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 3 on 9/13/25 at 6:20 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 4 on 9/13/25 at 6:23 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 5 on 9/13/25 at 6:27 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 6 on 9/13/25 at 6:33 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 7 on 9/13/25 at 6:37 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 8 on 9/13/25 at 6:42 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 1 on 9/13/25 at 6:46 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 9 on 9/13/25 at 7:52 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 10 on 9/13/25 at 7:55 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 11 on 9/13/25 at 7:57 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 12 on 9/13/25 at 8:00 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 13 on 9/13/25 at 8:05 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 14 on 9/13/25 at 8:08 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 15 on 9/13/25 at 8:12 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 16 on 9/13/25 at 8:15 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 17 on 9/13/25 at 8:18 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 18 on 9/13/25 at 8:20 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 19 on 9/13/25 at 8:23 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 20 on 9/13/25 at 8:25 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. Record review of facility's in-service documentation reviewed on 9/11/25 for Reporting Abuse and Neglect dated 9/10/2025 indicated that 13 employees had been in-serviced. CNA B and CNA C were not listed on this document. Record review of safety surveys conducted on 9/13/25 indicated that they had conducted a safety survey with all residents at the facility and all who were able to participate were able to identify who to report abuse to and how to report and all indicated that they had not observed any abuse or neglect. Record review on 9/13/25 at 8:10 p.m. of in-service documentation showed that all but six staff had been in-serviced on abuse and neglect and all staff had been notified that they would be taken off the schedule until they had been in-serviced on abuse and neglect and reporting requirements. Record review of in-service documentation dated 9/12/2025 indicated that CNA B and CNA C were in-serviced on abuse, neglect and reporting requirements. This in-service shows that it included specific reporting requirements that abuse must be reported immediately to the abuse coordinator and that it must be reported by voice phone call, not text message. Observation conducted on 9/13/25 at 8:15 p.m. showed a notice over all facility time clocks notifying staff not to clock in until they had completed required in-services on abuse and neglect. Observation conducted on 9/13/25 at 8:00 p.m. of abuse coordinator signs located on each hallway, at each nurses station and in the dining room. It included the name of the Administrator as well as the number to the abuse hotline. Record review of Resident #1's skin assessment dated [DATE] at 11:44 a.m. showed no signs of injury. Notification to Administrator on 9/13/2025 at 8:30 p.m. that the IJ had been lifted. An IJ was identified on 9/12/25. The IJ template was provided to the facility on 9/12/25 at 3:34 p.m. While the IJ was removed on 9/13/25 the facility remained out of compliance at a scope of Isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ due to ongoing need for in-services on abuse and neglect, abuse coordinator and notification of abuse process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to in response to allegations of abuse, neglect, exploitation, or mistreatment, prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress for 1 of 6 (Resident #1) residents reviewed for abuse. LVN A physically abused Resident #1 on 9/9/25 and the facility failed to protect residents from further potential abuse when LVN A returned to the facility on the night shift of 9/10/2025 after being suspended at 7:50 a.m. on 9/10/25. An IJ was identified on 9/12/25. The IJ template was provided to the facility on 9/12/25 at 3:34 pm. While the IJ was removed on 9/13/25 the facility remained out of compliance at a scope of Isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ due to ongoing need for in-services on abuse and neglect, abuse coordinator and notification of abuse process. This failure could place residents at risk for physical and verbal abuse, psychosocial harm, and decreased quality of life.Findings included: Record review of the face sheet dated 9/11/2025 indicated that Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including severe intellectual disability which was below average intelligence, anxiety disorder which was intense, excessive, and persistent worry and fear about everyday situations, schizoaffective disorder which was a lifelong pattern of social withdrawal and limited emotional expression, ADHD which was a chronic condition including attention difficulty, hyperactivity and impulsiveness, cerebral palsy which was a congenital disorder of movement, muscle tone or posture, and cognitive communication deficit which was a group of disorders that affect a person's ability to communicate effectively due to underlying cognitive impairments. Record review of the MDS dated [DATE] indicated that Resident #1 had a BIMS score of 03 which was indicative of severe cognitive impairment. Record review of the care plan dated 9/7/25 which showed that Resident#1 was last admitted to the facility on [DATE] and was receiving services at the facility. During an interview on 9/11/25 at 4:11 p.m. CNA B said that on 9/10/25 she worked with CNA C on the evening shift. She said that they were outside smoking around 9:40 p.m. when LVN A approached them and asked them about the incident the night before between LVN A and Resident #1 and that he did not remember but was at the facility to document an incident report about it. She said that she did not know that LVN A was under investigation and that if she had she would have reported it. She said that the risk of not knowing that he was under investigation was that he could have come to the facility for retaliation which placed the staff and residents at risk of abuse. She said that LVN A got onto the computer and went onto the secured unit but she did not see him interact with any residents. CNA A said that the incident the night before that she was referring to was LVN A grabbing Resident # 1 by the shirt and making him choke. Record review of the voice recording provided by CNA B on 9/11/25 at 4:30 p.m. that was recorded on 9/10/25 sometime after 6:00 p.m. and included the voice of LVA A, CNA B, and CNA C as identified by CNA B. A summary of the recording was that CNA B and CNA C acknowledged that they observed LVN A grab Resident #1 by the shirt and around his neck on 9/9/25. LVN A admitted that he had returned to the facility to document the incident from last night with Resident #1. LVN A said that he got allegations for beating up on [unintelligible]. During an interview on 9/11/25 at 3:18 p.m. Resident #1 said that LVN A had choked him and that he was scared of LVN A. Resident #1 cried and left the interview. During an interview on 9/11/25 at 3:57 p.m. LVN A said that on 9/9/2025 he worked at the facility. He went into Resident #1's bedroom when he was fighting with his roommate. LVN A said that he was trying to calm Resident #1 down by rubbing his back and trying to talk to him. LVN A said that Resident #1 was on the floor and he was assisting him back to his chair and his hand got caught in Resident #1's t-shirt and when he pulled his hand out of Resident #1's shirt and his hand went up toward Resident #1's neck . LVN A said that Resident #1 was one of his favorite residents and that he would never abuse him. He said that residents have called him the N word before and he was not one so it does not bother him. LVN A said that he did not choke Resident #1. LVN A said that there were two CNAs in the room with him when his hand got caught in Resident #1's t-shirt. LVN A confirmed that the CNA's in the room were CNA B and CNA C. LVN A said that he was informed by DON that he was suspended pending an investigation on the morning of 9/10/25 and was told that he could likely return to work on Saturday if everything looked good. During an interview on 9/12/25 at 1:18 p.m. CNA C said that she worked on the night shift on 9/10/2025 alongside CNA B. She said around 9:30 p.m. LVN A came up to her and CNA B and started talking to them about the incident that had occurred the night before with LVN A grabbing Resident #1 by the shirt and throat and making him make a choking sound. She said that he told them that he comes back to work on Saturday 9/13/25, but he had come up to the facility on the night of 9/10/25 to document an incident report about the night before. She said that she did not know he was suspended and if she had she would have reported it and not allowed him to have access to the residents. She said that she saw LVN A get on the computer but did not see him go onto the secured unit or interact with any residents. She said the risk of not knowing who was suspended was that the suspended person could come to the facility to do harm to staff or residents. Record review of facility Incident Audit Report indicated that LVN A entered an incident audit report into PCC on 9/10/25 at 10:53 p.m. PCC was the electronic medical record used by the facility. The note indicated that LVN A entered the bedroom of Resident #1 and Resident #1 was on the floor trying to fight with his roommate. LVN A documented that he directed the CNA to put Resident #1 in his wheelchair and get him out of the room. LVN A documented that Resident #1 was agitated and that LVN A was rubbing his back to calm him down and then was rubbing his chest as a calming procedure. LVN A documented that his hand slipped inside the shirt of Resident #1 as he was bending down to fight with his roommate and LVN A stated that he removed his hand immediately and asked the CNAs to removed Resident #1 from the room. LVN A noted that Resident #1 was assessed for injury and none were found. During an interview on 9/11/25 at 11:55 a.m. the Administrator said she expected suspended staff to not enter the facility during their suspension and there was a policy entitled Disciplinary Action and Suspension Pending Investigation Policy that told them. She said that they did not tell other staff when a staff member was suspended as they did not want to spread their business and that she was not aware of any policy that directed the Administrator or DON to notify anyone of a suspended staff member. She said she assumed that a suspended staff member's common sense would tell them that they should not be at the facility during suspension in addition to that policy. She said that she understands the need for a process for others to know about the suspension as a suspended person coming to the facility places everyone at the facility at risk of abuse or assault. She said that she was not aware that LVN A was at the facility after he was notified on 9/10/25 at 7:50 a.m. that he was suspended. She said that they started the investigation upon being notified of the incident by interviewing CNA B and CNA C, assessing Resident # 1 and in-servicing staff on abuse and neglect. Record review of facility's Disciplinary Action and Suspension Pending Investigation Policy undated indicated, .In cases involving serious allegations, employees may be placed on suspension pending investigation and are not permitted to return to the facility until the investigation was concluded.the employee was not permitted on facility premises or to engage with residents or staff during the suspension . Record review of the document titled {Facility} New Hire/Status Change Form which indicated that LVN A was terminated on 9/11/25 for abuse. This document did not show a suspension date or time. Record review of facility's Employee Discipline Policies and Professional and Personal Responsibility policy indicated that the suspended employee was not to enter premises until suspension was complete or until results are determined from suspension. Record review of facility's Abuse-Reportable Events policy last revised May 2017 indicated, .it is the policy of this home to prohibit resident abuse or neglect in any form . The Administrator was notified on 9/12/25 at 3:30 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 9/12/25 at 3:34 p.m. The facility's plan of removal was accepted on 9/13/2025 at 7:46 p.m. and included: Interventions: LVN A suspended on 9/10/25 at 7:50 a.m. Resident # 1 assessed for injury on 9/10/25 at 11:44 a.m. Roommate of Resident #1 assessed on 9/10/25. Residents on secured unit were not showing signs of distress or pain on 9/10/25. LVN A terminated on 9/12/25 at 2:00 p.m. In-services related to abuse/neglect started 9/10/2025 at 8:00am. Updated policy on suspension pending investigation with Be informed when an employee is suspended-suspended employee is not allowed to be in facility and all staff must ask the suspended staff to leave and call the administrator/DON if they enter the facility. Monitoring: Policy on suspension pending investigation updated. All staff will be informed each time an employee was suspended and will be responsible for asking staff to leave if they come to the premises and contact Administrator and DON. Any employee suspected of abuse will be removed from the facility immediately. Abuse coordinator signs are throughout the facility and there will continue to be ongoing training to ensure the staff was knowledgeable of who to report to and what to report. Staff was in serviced by Administrator, DON, Dietary supervisor, and housekeeping supervisor. All staff in facility must be in serviced. As of 9/13/2025 at 11:54am 66 employees in all departments have signed in services. There are twelve employees that need to be still in-services. All employees must be in-serviced by 9/13/2025 by 3:30pm. Any staff that has not been in-serviced was not to clock into the facility until they have been in serviced by DON or administrator. Anyone who fails to complete in-service will be removed from schedule and not allowed to work until they have been in-serviced. On 9/13/25 at 8:30 p.m. the investigator confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: During an interview with LVN F who worked the 2-10 shift on 9/13/25 at 4:38 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN D who worked the 2-10 shift on 9/13/25 at 4:40 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN E who worked the 2-10 shift on 9/13/25 at 4:54 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA J who worked the 6 p.m. to 6 a.m. shift on 9/13/25 at 4:52 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA K who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 4:54 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA L who worked the 2-10 shift on 9/13/25 at 5:00 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA B who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 5:40 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with CNA C who worked the 6 p.m.-6 a.m. shift on 9/13/25 at 5:52 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with LVN G who worked the 6 p.m. to 6 a.m. shift on 9/13/25 at 6:50 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with RN H who worked the 8 a.m.-5 p.m. shift on 9/13/25 at 6:53 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with DON who worked the 8 a.m.-5 p.m. shift on 9/13/25 at 6:58 p.m. she was able to articulate who the abuse coordinator was, the types of abuse, reporting timeframes and appropriate methods of reporting. During an interview with Resident # 2 on 9/13/25 at 6:15 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 3 on 9/13/25 at 6:20 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 4 on 9/13/25 at 6:23 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 5 on 9/13/25 at 6:27 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 6 on 9/13/25 at 6:33 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 7 on 9/13/25 at 6:37 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 8 on 9/13/25 at 6:42 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 1 on 9/13/25 at 6:46 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 9 on 9/13/25 at 7:52 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 10 on 9/13/25 at 7:55 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 11 on 9/13/25 at 7:57 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 12 on 9/13/25 at 8:00 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 13 on 9/13/25 at 8:05 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 14 on 9/13/25 at 8:08 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 15 on 9/13/25 at 8:12 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 16 on 9/13/25 at 8:15 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 17 on 9/13/25 at 8:18 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 18 on 9/13/25 at 8:20 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 19 on 9/13/25 at 8:23 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. During an interview with Resident # 20 on 9/13/25 at 8:25 p.m. he was able to confirm that they had completed the safe survey on 9/13/2025 and been asked about abuse and neglect, whether they felt safe and who they were to report abuse to. Record review of facility's in-service documentation reviewed on 9/11/25 for Reporting Abuse and Neglect dated 9/10/2025 indicated that 13 employees had been in-serviced. CNA B and CNA C were not listed on this document. Record review on 9/13/25 at 8:10 p.m. of in-service documentation showed that all but six staff had been in-serviced on the changes to the suspension pending investigation policy and all staff had been notified that they would be taken off the schedule until they had been in-serviced. Record review of in-service documentation dated 9/12/2025 indicated that CNA B and CNA C were in-serviced on abuse, neglect and reporting requirements. This in-service shows that it included specific reporting requirements that abuse must be reported immediately to the abuse coordinator and that it must be reported by voice phone call, not text message. Record review on 9/13/25 at 8:12 p.m. of the facility suspension pending investigation policy update. There was no date on the policy but the change from the old policy to the new policy was the addition that was as follows: All staff must be informed when an employee is suspended- Suspended employee is not to be in the facility and staff must ask them to leave and call the administrator/DON if they enter the facility. Observation conducted on 9/13/25 at 8:00 p.m. of abuse coordinator signs located on each hallway, at each nurses station and in the dining room. It included the name of the Administrator as well as the number to the abuse hotline. Observation conducted on 9/13/25 at 8:15 p.m. showed a notice over all facility time clocks notifying staff not to clock in until they had completed the required in-services on recent policy changes. Record review of Resident #1's skin assessment dated [DATE] at 11:44 a.m. showed no signs of injury. Notification to Administrator on 9/13/2025 at 8:30 p.m. that the IJ had been lifted. An IJ was identified on 9/12/25 The IJ template was provided to the facility on 9/12/25 at 3:34 p.m. While the IJ was removed on 9/13/25 the facility remained out of compliance at a scope of Isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ due to ongoing need for in-services on abuse and neglect, abuse coordinator and notification of abuse process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure residents had the right to be free from verbal abuse by staff for 2 (Resident #1 and Resident #2) of 10 residents reviewed for abuse. <BR/>The facility failed to prevent verbal abuse by CNA A. On 3/3/2025 CNA A told Resident #1 She was stinky and needed to take a shower.<BR/>The facility failed to prevent verbal abuse by the Cook. On 4/6/2025 the [NAME] cussed Resident #2 in a verbal altercation. <BR/>This failure could place all residents in the facility at risk for severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. <BR/>Findings included:<BR/>1.Record review of Resident #1's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with the most recent admission on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (progressive lung disease that makes breathing difficult), pseudobulbar affect (neurological condition), and major depressive disorder (persistent feelings of sadness). <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated no cognitive impairment. <BR/>Record review of Resident #1's care plan revealed she had an ADL self-care performance deficit with interventions that included: The resident is totally dependent on 1-2 staff to provide bath/shower. <BR/>Record review of psychiatric assessment completed on 3/5/2025 indicated: Patient states one of the nurse aides told her she was stinky and needed to shower. She says she was offended by this and feels sad. She verbalizes she will be okay though and is grateful for the concerns. She states she gets regular showers from the hospice nurse every MWF. Patient says she eats and sleeps okay/good. Anxiety: Patient denies symptoms of excessive worry.<BR/>Record review of Resident #1's nursing progress note dated 4/20/2025 at 12:36 AM, written by RN C indicated Resident #1 expired in the facility.<BR/>Record review of witness statement provided by Hospice CNA B dated 3/5/2025 indicated: On 3/3/2025 she was taking Resident #1 to the shower room and was told that someone was in the shower room and to go around to the 200 hall, on the way around CNA A started saying out loud that time does not go on her time and she needed to wait her turn. CNA A made the statement a few times before Resident #1 turned around and said never mind she was not going to shower if she (CNA A) was going to keep saying stuff. Resident #1 headed back to her room when CNA A told her no go ahead go take the shower because she stinks and needed it. CNA A said you know what let me go get Resident #1's roommate up to that room stinks she needs to get up too so we can air out that and strip the beds. Resident #1 got back to her door she turned around and decided to go ahead and go take the shower on her hall. <BR/>Record review of witness statement provided by CNA A on 3/5/2025 indicated: I [CNA A] don't recall what happen Monday beside me telling [another resident] I am not his auntie and am not married to that. I don't think I cussed anyone.<BR/>Record review of the facility new hire/status change form indicated CNA A was terminated on 3/5/2025. <BR/>During an attempted interview on 4/30/2025 at 2:00 p.m. the DON had left the facility and was no longer employed at the facility. <BR/>During an interview on 5/1/2025 at 9:24 AM, the Activity Director said CNA A talked a little hateful to the residents but not to a point that it was abuse. She said CNA A was a good CNA and her residents were taken care of. <BR/>During an interview on 5/1/2025 at 1:49 PM, CNA A said all she said to Resident #1 was that she smelled really bad, and she needed to take a shower. She said she never cussed Resident #1. <BR/>2. Record review of Resident #2's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included type 2 diabetes (high blood sugar), insomnia (sleep disorder), and depression (persistent feelings of sadness). <BR/>Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 13, which indicated no cognitive impairment. <BR/>Record review of Resident #2's care plan dated 6/12/2024 revealed he had the potential to be verbally aggressive with interventions that included: When the resident becomes agitated; intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later.<BR/>Record review of witness statement dated 4/6/2025 written by the BOM indicated: was sitting in my office when I heard screaming from dietary went to dietary [Cook] was screaming at [Resident #2] I then told her to stop she begin yelling louder stating she is sick of the way he talks to her that we need to do something with his fucking ass cause he ain't going to talk like that no more to her. I asked him to go outside and calm down she keep on screaming back and forth with [Resident #2]. [sic]<BR/>During an interview on 4/29/2025 at 11:04 AM, Resident #2 said when he gets upset, he cusses that was just who he was. He said the staff was there to work for him. He said he did remember the incident in the kitchen, but he was over it and that [NAME] no longer worked at the facility. He said he was over that incident, and it was in the past. <BR/>During an interview on 5/1/2025 at 9:24 AM the Activity Director said Resident #2 is mean and a smart [NAME]. She said he cusses the staff and tells them that he signs their paycheck. She said Resident #2 had called the kitchen staff fat sloppy [NAME]. She said he wass very hateful over the TV and food. She said she was not here the day the argument took place with the Cook. <BR/>During an interview on 5/1/2025 at 10:39 AM, the BOM said she heard the [NAME] being loud then she heard Resident #2, so she went to the kitchen. She said Resident #2 was in the doorway and the [NAME] was screaming at Resident #2. She said Resident #2 was yelling calling the staff names. She said the [NAME] was saying she was not in the pen with him, and she told the [NAME] to stop screaming at the Resident #2. She said the [NAME] called her supervisor on the phone and she kept screaming. The BOM said she told the [NAME] she was suspended to leave the building. She said Resident #2 does talk to the staff and call them names when he gets upset. She said she did not feel like the incident affected the resident in anyway.<BR/>During an interview on 5/1/2025 at 1:54 PM the [NAME] said Resident #2 came to the kitchen and there was a new girl in the kitchen, and she did not know Resident #2 was not supposed to get beef. The [NAME] said she had hot dogs for him but in the meantime, Resident #2 came down and started cussing them and calling them names. She said the BOM did not try stop him from doing all the cussing of the staff. She said she did not cuss Resident #2, but she did tell the BOM person that she was motherfucking wrong for letting him get away with everything. She said the facility suspended her and then about a week later they called her and let her know she was terminated.<BR/>Record review of the facility's New Hire/Status Change Form indicated: the [NAME] was terminated on 4/25/2025 for verbal abuse. <BR/>Record review of the facility's Abuse-Reportable Events policy dated 05/2017 indicated: It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law and incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person.5. Investigation: a. When an employee becomes aware of an allegation or suspicion of abuse or reportable event the employee should: Immediately report the allegation or suspicion to the charge nurse on the unit on which the resident resides immediately to ensure immediate safety of the resident. B. The charge nurse will: Assess the resident or resident(s). Notify the Administrator or the person on-call, if after hours. The person on-call will notify the Administrator, if unavailable, the Director of nurses will be notified. Nursing facility but the above immediately but not later than 2 hours after the allegation is made, if the events that caused the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the event that caused the allegation do not involve abuse and do not result in serious bodily injury .

Based on observation, interview, and record review, the governing body failed to appoint an Administrator licensed by the state who was responsible for management of the facility for 1 of 1 facility reviewed for governing body. <BR/>The governing body failed to designate a person in the role of an Administrator from December 13 2024, to February 12, 2025.<BR/>This deficient practice could result in the facility not being managed in a responsible manner, which could affect the health and safety of all residents. <BR/>The findings included: <BR/>During an observation and interview on 3/4/2025 at 7:45 AM, an entrance conference was conducted with the DON only being present. She said the facility did not have a full time Administrator, but they had recently hired an interim one. She said the interim Administrator was not in the facility and was unsure if she would be in that day. The DON called the interim Administrator and put her on speaker phone. The interim Administrator said her first day in the facility was on 2/12/2025 and she had been at the facility about four times since she started and tried to visit at least two times a week. <BR/>During an interview on 3/4/2025 at 1:25 PM, LVN E said she had been employed at the facility for a long time. She said the facility had been without an Administrator since sometime in December 2024. She said the new interim Administrator started at the facility one day last week or the week prior. She said after the previous Administrator left; the staff were reporting things to the DON.<BR/>During an interview on 3/4/2025 at 2:08 PM, the BOM said the previous Administrator's last day was December 13, 2024. She said the facility currently had an interim Administrator and her first day in the facility was February 12, 2025.<BR/>During a follow-up interview on 3/4/2025 at 3:36 PM, the DON said the previous Administrator last day in the facility was on December 12, 2024, and did not return. She said during that time after the previous Administrator left, she would notify the facility's ADO who had an Administrator license for guidance and support, but she did not have a Texas license. She said she also contacted other Administrators who she knew for advice and guidance as the ADO would not always be available to answer the phone. She said not having an Administrator in the facility put them at risk of not having a leader and not knowing which way to go. She said she had access to the state regulations and thought that an Administrator should be in the facility for at least 40 hours a week full time. <BR/>During an interview on 3/4/2025 at 4:28 PM, the interim Administrator said her first day in the facility was 2/12/2025. She said having an Administrator in the facility was to provide oversight and conduct meetings with the team. She said she met with the team everyday over the phone but not physically in the facility. She said an Administrator should have 40 hours of administrative hours and she did not clock in or out. She said she was not aware the facility did not have an Administrator from December to when she started at the facility. She said there could be a risk of not watching out for the team and missing critical compliance if the facility did not have an Administrator.<BR/>Record review of a facility policy titled Administration dated 3/2020 indicated, .It is the policy of this home to follow TAC rule for Nursing Home Administrator. The facility must have a governing body, or designated persons functioning as a governing body that is legally responsible for establishing and implementing polices regarding the management and operation of the facility. 3. The governing body appointed, and the facility must operate under supervision of a nursing facility administrator who is: 1) Licensed by the Texas Board of Nursing Facility Administrators. 2) Responsible for management of the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 8 residents reviewed for infection control. (Resident #1 and Resident #2)<BR/>The facility did not ensure CNA A wore gloves or a gown when passing lunch trays to the rooms of Resident #1 and Resident #2 who were both on contact precautions for COVID.<BR/>These failures could place residents at risk of exposure to communicable diseases and infections.<BR/>Findings included:<BR/>1. An admission Record for Resident #1 dated 1/3/2023 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia and hemiparesis (one sided weakness), COVID-19, alcohol dependence, and hypertension.<BR/>Record review of the physician orders for Resident #1 indicated an order dated 12/26/2022 for vitamin c 500 mg 1 tablet my mouth one time a day and zinc 100 mg 1 tablet by mouth one time a day for COVID protocol for 14 days started on 12/26/2022 with an end date of 1/9/2023.<BR/>Record review of Quarterly MDS Assessment for Resident #1 dated 10/17/2022 indicated he had no impairment in thinking with a BIMS score of 15. He required extensive assistance with two-person assist with bed mobility, transfers, dressing, toilet use and personal hygiene. <BR/>Record review of a Care Plan for Resident #1 dated 12/26/2022 indicated a focus of: I have tested positive for COVID-19 with an intervention/task that was initiated on 1/3/2023 to accommodate as possible within the limitations of isolation precautions.<BR/>During on observation on 1/3/2023 at 11:55 AM, CNA A was wearing a N95 mask. She sanitized her hands and removed Resident #1's lunch tray from the cart in the hallway and entered Resident #1's room without putting on gloves or a gown. Resident #1's door had signage that indicated he was on contact precautions and for providers and staff were to put on gloves, gown, and a mask before entering the room. PPE was noted in a container outside of his door in the hallway. CNA A exited the room and sanitized her hands.<BR/>2. An admission Record for Resident #2 dated 1/3/2023 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of COVID-19, anemia (low red blood cells), Type 2 diabetes, and hypertension.<BR/>Record review of a Physician Order for Resident #2 dated 12/28/2022 indicated an order for [NAME] 100 mg 1 tablet by mouth one time a day for COVID for 14 days that started on 12/29/2022 with an end date of 1/12/2023.<BR/>Record review of a Quarterly MDS Assessment for Resident #2 dated 10/24/2022 indicated he had no impairment in thinking with a BIMS score of 15. He required extensive assistance with one person assist with dressing and toilet use. He required supervision and one person assist with bed mobility, transfers, and eating. <BR/>Record review of a Care Plan for Resident #2 dated 12/28/2022 indicated a focus of I have tested positive for COVID-19. Intervention/task initiated on 1/3/2023 to accommodate as possible within the limitation of isolation precautions. <BR/>During an observation on 1/3/2023 at 11:59 AM, CNA A was wearing a N95 mask. She sanitized her hands and removed Resident #2's lunch tray from the cart in the hallway and entered Resident #1's room without putting on gloves or a gown. Resident #2's door had signage that indicated he was on contact precautions and indicated for providers and staff to put on gloves, gown, and a mask before entering the room. PPE was noted in a container outside of his door in the hallway. CNA A exited the room and sanitized her hands.<BR/>During an observation and interview on 1/3/2023 at 12:00 PM, CNA A was wearing a N95 mask and said she was the shower tech for the facility and was helping today with passing lunch trays on the halls. She said she had been employed at the facility for 9 months. When asked why Resident #1 and Resident #2 had signs on their doors, she indicated they were both positive for COVID. When asked if the residents were on isolation, she said they both were positive with COVID, and she should have put on a gown and gloves before entering their rooms. She said she did sanitize her hands before entering and after exiting their rooms. She said COVID could be transported to other residents if staff did not wear the proper PPE or sanitize/wash their hands. She said she had received trainings on isolation residents and COVID.<BR/>During an interview on 1/3/2023 at 1:27 PM, the DON said the facility staff received training on COVID and isolation residents on 12/19/2022. She said if staff went in and out of the isolation rooms without wearing appropriate PPE, and then went into resident rooms that were not in isolation, the potential risk would be to carry that infection to another resident. She said the ADON and herself were monitoring staff daily to ensure they were wearing PPE appropriately daily, but were not writing anything down or conducting check offs with the staff. She said since the outbreak started on 12/18/2022, they had not had any issues with staff not wearing PPE appropriately. She said the ADON would conduct an in-service with all staff that day with return demonstration on isolation and donning (put on)/doffing (take off) of PPE.<BR/>Record review of a facility in-service training report dated 12/19/2022 indicated the facility conducted training on COVID, PPE, Isolation Procedure, Donning and Doffing and Testing by the DON and CNA A received training on that date. <BR/>Record review of a facility policy and procedure titled Infection Control-Precautions-Categories and Notices dated 5/2017 indicated, .It is the policy of this home to assure that appropriate precautions will be established to ensure that the necessary isolation techniques are implemented. Precaution notices will be posted when isolation precautions are implemented. 4. In addition to Standard Precautions, Contact Precautions must be implemented for residents known or suspected to be infected, c. remove gloves before leaving the room and wash hands immediately, d. in addition to wearing a gown as outlined under standard precautions, g. signs will be used to alert staff of the implementation of precautions, while protected the privacy of the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and home like environment for 1 of 2 dining rooms (the main dining room did not have adequate lighting) observed for environment. <BR/>The facility failed to ensure there were adequate lighting in the main dining room. <BR/>This failure could place the residents, who eat in the dining room at risk of injury, and a non-home like dining experience due to inadequate lightening. <BR/>Finding included:<BR/>During an observation on 06/23/2025 at 11:30am there were 3 of 8 florescent lights not working in the main dining room. <BR/>Record review of a facility's face sheet dated 6/23/25 for Resident #21 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Cervical spinal stenosis (narrowing of the vertebra in the neck), muscle weakness and diabetes (too much glucose in the blood).<BR/>Record review of a Quarterly MDS assessment dated [DATE] for Resident #21 indicated that he had a BIMS score of 13 indicating he was cognitively intact. Assessment also indicated that he was totally dependent with transfers. <BR/>Record review of a comprehensive care plan dated 6/18/25 indicated that Resident #21 was totally dependent of 2 persons for transfers and at risk for falls.<BR/>Record review of a facility's face sheet dated 6/25/25 for Resident #39 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Type 2 diabetes mellitus, depression, chronic diastolic(congestive) heart failure, muscle wasting and atrophy and unsteadiness on feet. <BR/>Record review of a Quarterly MDS assessment dated [DATE] for Resident #39 indicated that he had a BIMS score of 13 indicating he was cognitively intact. Assessment also indicated that he was totally dependent with transfers. <BR/>Record review of a comprehensive care plan dated 6/04/25 indicated that Resident #39 was independent/dependent on staff etc.) for meeting emotional, intellectual, physical, and social needs.<BR/>During an interview on 6/23/2025 at 11:45 AM, Resident #21 said it was dark and dreary in the dining room, he said the lights had not worked properly in a long time.<BR/>During an interview on 6/23/2025 at 11:50 AM, Resident #39 said it was always dim with some lights out. He said he does not think all the lights ever worked in the dining room. He said some days the lighting seems better than other days, but it never lit up bright like it should be. <BR/> During an interview with CNA-J on 6/25/2025 at 9:00am she said she has not had a resident complain about the lights being dim in the dining room. She said the lights have been the same for a long time. She said she did not notice the lights were out in the dining room.<BR/>During an interview with the MA on 6/25/2025 at 9:15am said she has not had a resident complain about it being dim or dark in the dining room. She said she has noticed some of the light bulbs being out and did not report the lights out to maintenance or the administrator. She said maintenance checks the building and thought they would eventually replace the light bulbs.<BR/>During an interview with LVN-H at 9:30am on 06/25/2025 she said the residents seems content and has not complained about the lighting in the dining room to her. She said she has not noticed the lights being out in the dining room. She said she have not worked at the facility long and it always looks the same as far as lighting and did not notice a low lighting level. <BR/>During an interview with the Maintenance Director on 6/25/2025 at 9:55am she said she has not noticed, nor has it been reported to her that the lights were out in the dining room. <BR/>During an interview the with the DON on 6/25/2025 at 1:45pm she said she has noticed the lighting in the dining room being dim. She said she did not notice the lights were out and knows the facility being dim in areas was a problem when she began working at the facility. She said she thought the facility being old and having repairs the lighting was normal for the building. She said no resident or other staff members have reported or complained of dim or inappropriate lighting. <BR/>During an interview with the Administrator on 6/25/2025 at 2:25pm she said she did notice some lights being out and have since asked her maintenance to walk the building and replace all light bulbs and report any issues they find. She said no one has reported any issues about the lighting in the building. She said low lightening could cause a resident to fall and not enjoy their meal in a home like environment.<BR/>Record review of a Quality of Life-homelike Environment Policy dated (Revised 2024) Policy Statement reads Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation reads: 4. Comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable, and homelike environment. The lightening design emphasizes: a. Sufficient general lighting in resident-use areas; b. Task lighting as needed; d. Even light levels;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 2 of 11 residents reviewed for quality of care, (Residents #21 and #2) in that:<BR/>The facility failed to remove worn and damaged mechanical lift slings from service for Resident's #21 and #2.<BR/>This failure could result in a loss of quality of life due to injuries.<BR/>Findings included:<BR/>Record review of a facility's face sheet dated 6/23/25 for Resident #21 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: cervical spinal stenosis (narrowing of the vertebra in the neck), muscle weakness and diabetes (too much glucose in the blood).<BR/>Record review of a Quarterly MDS assessment dated [DATE] for Resident #21 indicated that he had a BIMS score of 13 indicating he was cognitively intact. Assessment also indicated that he was totally dependent with transfers. <BR/>Record review of a comprehensive care plan dated 6/18/25 indicated that Resident #21 was totally dependent of 2 persons for transfers and at risk for falls.<BR/>Record review of a facility's face sheet dated 6/25/25 for Resident #2 indicated that he was a [AGE] year-old male re-admitted to the facility on [DATE] with diagnoses including: cerebral infarction (blockage of blood flow to the brain leading to death of tissue), cerebral palsy (a congenital disorder of movement, muscle tone or posture), and anxiety.<BR/>Record review of a Quarterly MDS assessment dated [DATE] for Resident #2 indicated that he had a BIMS score of 99 indicating he was severely cognitively impaired. Assessment also indicated that he was totally dependent with transfers. <BR/>Record review of a comprehensive care plan dated 4/10/25 indicated that Resident #2 was totally dependent of 2 persons for transfers and at risk for falls.<BR/>During an observation and interview 06/23/25 at 12:30 PM Resident #21 was sitting in his wheelchair on a mechanical lift sling. The mechanical lift sling had one of the 4 black main straps loop that was torn in half, the other loops were frayed, and stitching was loose. The care tag was not legible. Resident #21 said he had no falls during use of the mechanical lift during transfers. Resident #21 said they didn't always use the lift during his transfers but today he was feeling weak.<BR/>During an observation and interview on 06/23/25 at 12:45 PM the Administrator observed the mechanical lift sling under Resident #21. She said the risk to the resident was injury if the sling broke during transfer and caused a fall. The Administrator said she would remove the damaged sling from service, and she would order replacements.<BR/>During an observation on 06/25/25 10:45 AM, Resident #2 had a mechanical lift sling underneath him. The mechanical lift sling had 2 green colored loops and a blue loop that were frayed almost worn in half and one of the 4 black main straps was torn in half.<BR/>There was a hole in the mesh body of the sling and the stitching was loose. There was no care tag on the mechanical lift sling. <BR/>During an interview on 06/25/25 at 11:21 AM, the ADON said she had worked at the facility since 5/16/2025. The ADON said she would remove the sling under Resident #2 and replace with a new one. She said the straps could break and cause a fall with resulting injuries. She said she would do a facility sweep to remove any worn mechanical lift slings from service and start servicing staff. The ADON said there were 11 residents living in the facility that used the mechanical lift for transfers.<BR/>During an interview on 06/25/25 at 11:40 AM, the DON said had worked at the facility since 5/15/2025. She said the straps could break and cause a fall with resulting injuries. <BR/>During an Interview on 06/25/25 at 12:45 PM, CNA E, CNA G and LVN F said they had received training on 6/25/25 on when to remove mechanical lift slings from service. LVN F said the resident could be seriously injured if the straps broke on the mechanical lift sling and the resident fell during a transfer.<BR/>Record review of a revised facility's policy titled Lifting Machine, using a Mechanical dated 2024 reads .Sling care .3. Discard any worn, frayed, or ripped slings<BR/>Record review of manufacture guidelines Full Body Slings - Instructions for use accessed at www.medline.com on 06/14/25 read .Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use .

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen observed for kitchen sanitation.<BR/>The microwave had food debris and splatters.<BR/>The bulk flour bin had a measuring cup inside.<BR/>The DM dropped a thermometer into the pureed meat and served the food.<BR/>Cook A touched the inside of the plates and food with her gloved hands. She was not wearing an apron and used her body to keep the plates with food on the tray line.<BR/>DA B touched the inside of the plates with her bare hand and placed bread on top of the food using her hand and not a utensil.<BR/>Cook A returned food that had spilled onto the prep area to the pan of food on the steam table.<BR/>These failures could place residents who ate food from the kitchen at risk of foodborne illness.<BR/>Findings included:<BR/>During observations and interviews on 04/22/24 of the kitchen the following was noted:<BR/>*at 10:00 AM Microwave had food debris and liquid splatters inside.<BR/> *at 10:20 AM the bulk flour bin had a measuring cup stored inside product. The DM removed the cup from the flour and said that wasn't supposed to be in there.<BR/>During observations and interviews on 04/23/24 of the kitchen the following was noted:<BR/>*at 12:40 PM the DM was taking the holding temperature of the pureed chicken breasts and dropped the thermometer into the food. She dipped the thermometer out of the pureed meat with another utensil, wiped off the face of the dial with her bare hand, and continued to try and get a temperature reading. She said the steam was hot on her arm.<BR/>*at 12:45 PM the tray line service started. [NAME] A placed 9-10 plates at a time in their insulated bottoms on the prep area beside the steam table and along the tray line on the steam table. She placed her gloved hands in the bottom of the plates. She began serving the food and scooping the food into the utensils and dumping it on the plates. She contained the food to the plate using her hands.<BR/>*at 12:47 PM DA B was placing the sauerkraut and bread on the plates, picking the plates up and placing them on the delivery cart. She was wearing a glove on her right hand but not her left hand. She picked up the plates using her left hand and her thumb was inside the plate. Using her gloved hand, instead of tongs, she picked up a half a piece of toast and placed it on top of the food and covered the plate with a lid.<BR/>*at 12:50 PM [NAME] A kept rapidly tossing food onto plates using her gloved hands to scoot the food around on the plates because it had been so forcefully placed. Sausage slices came out of the serving utensil and landed on the prep area around the steam table and she picked up the slices and returned them to the container of sausage on the steam table.<BR/>*at 12:55 PM [NAME] A was using her body to keep plates on the steam table tray line. She was not wearing an apron, just her street clothes, and was bumping the plates of food with her stomach area.<BR/>During the observation the DM was not observing food service and was not aware of what activities were taking place on the serving line. She had not checked the utensils used for service or made sure the foods were served appropriately.<BR/>Food Code 2013 - Hands and Arms 2-301.11 Clean Condition. The hands are particularly important in transmitting foodborne pathogens. Food employees with dirty hands and/or fingernails may contaminate the food being prepared. Therefore, any activity which may contaminate the hands must be followed by thorough handwashing in accordance with the procedures outlined in the Code. Even seemingly healthy employees may serve as reservoirs for pathogenic microorganisms that are transmissible through food. Staphylococci, for example, can be found on the skin and in the mouth, throat, and nose of many employees. The hands of employees can be contaminated by touching their nose or other body parts. 2-301.12 Cleaning Procedure. Handwashing is a critical factor in reducing fecal-oral pathogens that can be transmitted from hands to RTE food as well as other pathogens that can be transmitted from environmental sources.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items, per facility policy, for 1 of 3 resident's (Resident #40) personal refrigerators reviewed for food and nutrition services.<BR/>The facility failed to ensure a personal refrigerator for Resident #40 was clean, defrosted and did not contain unidentifiable food items in the freezer on 6/23/25.<BR/>These failures could place residents at risk for food borne illnesses.<BR/>Findings included:<BR/>Record review of a facility face sheet dated 7/24/25 for Resident # 40 indicated that he was a [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnosis of congestive heart failure (a long-term condition in which the heart is unable to pump enough blood to meet the body's needs).<BR/>Record review of a Comprehensive MDS assessment dated [DATE] for Resident #40 indicated that he had a BIMS score of 13, which indicated he was cognitively intact. He required setup or clean-up assistance with eating. <BR/>Record review of a comprehensive care plan dated 6/16/25 for Resident #40 indicated that he had a personal refrigerator in his room and was at risk for illness related to food-borne illness. Care plan included an intervention that read: .deep clean fridge as needed . and .monitor the fridge temp daily to ensure proper temp is maintained .<BR/>During an observation on 6/23/25 at 10:03 am a freezer section in a personal refrigerator in Resident #40's room was observed with thick ice buildup and the ice was red in color on the bottom and a drip tray underneath the freezer section was observed with red tinged ice accumulated in it. Inside the freezer compartment was an unidentifiable plastic container with a green substance inside that was unable to be removed from the ice buildup. <BR/>During an interview on 6/23/25 at 2:30 pm Resident #40 said he would not eat anything inside the refrigerator, and it needed to be cleaned and defrosted. He said it was gross.<BR/>During an interview on 6/25/25 at 1:43 pm DON said if a resident's personal refrigerator was not properly cleaned and defrosted, it could lead to illness if a resident were to eat bad food. She said housekeeping staff was responsible for personal refrigerators. <BR/>During an interview on 6/25/25 at 1:50 pm Housekeeping supervisor said she tried to clean out the refrigerators at least once per week. She said some residents would not allow her to but Resident #40 had never given her any trouble. She said she was unsure how his refrigerator had gotten missed, but she said she and her staff would keep a better eye on it going forward. She said residents could get sick if their refrigerators were not cleaned out.<BR/>During an interview on 6/25/25 at 2:07 pm Administrator said housekeeping was responsible for personal refrigerators in resident's rooms. She said residents could be at risk for foodborne illnesses and pests if refrigerators were not cleaned appropriately. <BR/>Record review of a facility policy titled Bedrooms dated 6/2024 read: .Residents are allowed to have refrigerators as long as they are considerate of diet and roommates. Housekeeping will be responsible for checking temps and cleanliness of the fridges .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 8 residents reviewed for infection control. (Resident #1 and Resident #2)<BR/>The facility did not ensure CNA A wore gloves or a gown when passing lunch trays to the rooms of Resident #1 and Resident #2 who were both on contact precautions for COVID.<BR/>These failures could place residents at risk of exposure to communicable diseases and infections.<BR/>Findings included:<BR/>1. An admission Record for Resident #1 dated 1/3/2023 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia and hemiparesis (one sided weakness), COVID-19, alcohol dependence, and hypertension.<BR/>Record review of the physician orders for Resident #1 indicated an order dated 12/26/2022 for vitamin c 500 mg 1 tablet my mouth one time a day and zinc 100 mg 1 tablet by mouth one time a day for COVID protocol for 14 days started on 12/26/2022 with an end date of 1/9/2023.<BR/>Record review of Quarterly MDS Assessment for Resident #1 dated 10/17/2022 indicated he had no impairment in thinking with a BIMS score of 15. He required extensive assistance with two-person assist with bed mobility, transfers, dressing, toilet use and personal hygiene. <BR/>Record review of a Care Plan for Resident #1 dated 12/26/2022 indicated a focus of: I have tested positive for COVID-19 with an intervention/task that was initiated on 1/3/2023 to accommodate as possible within the limitations of isolation precautions.<BR/>During on observation on 1/3/2023 at 11:55 AM, CNA A was wearing a N95 mask. She sanitized her hands and removed Resident #1's lunch tray from the cart in the hallway and entered Resident #1's room without putting on gloves or a gown. Resident #1's door had signage that indicated he was on contact precautions and for providers and staff were to put on gloves, gown, and a mask before entering the room. PPE was noted in a container outside of his door in the hallway. CNA A exited the room and sanitized her hands.<BR/>2. An admission Record for Resident #2 dated 1/3/2023 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of COVID-19, anemia (low red blood cells), Type 2 diabetes, and hypertension.<BR/>Record review of a Physician Order for Resident #2 dated 12/28/2022 indicated an order for [NAME] 100 mg 1 tablet by mouth one time a day for COVID for 14 days that started on 12/29/2022 with an end date of 1/12/2023.<BR/>Record review of a Quarterly MDS Assessment for Resident #2 dated 10/24/2022 indicated he had no impairment in thinking with a BIMS score of 15. He required extensive assistance with one person assist with dressing and toilet use. He required supervision and one person assist with bed mobility, transfers, and eating. <BR/>Record review of a Care Plan for Resident #2 dated 12/28/2022 indicated a focus of I have tested positive for COVID-19. Intervention/task initiated on 1/3/2023 to accommodate as possible within the limitation of isolation precautions. <BR/>During an observation on 1/3/2023 at 11:59 AM, CNA A was wearing a N95 mask. She sanitized her hands and removed Resident #2's lunch tray from the cart in the hallway and entered Resident #1's room without putting on gloves or a gown. Resident #2's door had signage that indicated he was on contact precautions and indicated for providers and staff to put on gloves, gown, and a mask before entering the room. PPE was noted in a container outside of his door in the hallway. CNA A exited the room and sanitized her hands.<BR/>During an observation and interview on 1/3/2023 at 12:00 PM, CNA A was wearing a N95 mask and said she was the shower tech for the facility and was helping today with passing lunch trays on the halls. She said she had been employed at the facility for 9 months. When asked why Resident #1 and Resident #2 had signs on their doors, she indicated they were both positive for COVID. When asked if the residents were on isolation, she said they both were positive with COVID, and she should have put on a gown and gloves before entering their rooms. She said she did sanitize her hands before entering and after exiting their rooms. She said COVID could be transported to other residents if staff did not wear the proper PPE or sanitize/wash their hands. She said she had received trainings on isolation residents and COVID.<BR/>During an interview on 1/3/2023 at 1:27 PM, the DON said the facility staff received training on COVID and isolation residents on 12/19/2022. She said if staff went in and out of the isolation rooms without wearing appropriate PPE, and then went into resident rooms that were not in isolation, the potential risk would be to carry that infection to another resident. She said the ADON and herself were monitoring staff daily to ensure they were wearing PPE appropriately daily, but were not writing anything down or conducting check offs with the staff. She said since the outbreak started on 12/18/2022, they had not had any issues with staff not wearing PPE appropriately. She said the ADON would conduct an in-service with all staff that day with return demonstration on isolation and donning (put on)/doffing (take off) of PPE.<BR/>Record review of a facility in-service training report dated 12/19/2022 indicated the facility conducted training on COVID, PPE, Isolation Procedure, Donning and Doffing and Testing by the DON and CNA A received training on that date. <BR/>Record review of a facility policy and procedure titled Infection Control-Precautions-Categories and Notices dated 5/2017 indicated, .It is the policy of this home to assure that appropriate precautions will be established to ensure that the necessary isolation techniques are implemented. Precaution notices will be posted when isolation precautions are implemented. 4. In addition to Standard Precautions, Contact Precautions must be implemented for residents known or suspected to be infected, c. remove gloves before leaving the room and wash hands immediately, d. in addition to wearing a gown as outlined under standard precautions, g. signs will be used to alert staff of the implementation of precautions, while protected the privacy of the resident .

Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.<BR/>The facility failed to provide a safe, functional, sanitary, and comfortable environment by ensuring windows in resident rooms 808, 901, 902, 903, 904, 906, 907, 909, and 911 were operable and had screens in place.<BR/>This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. <BR/>Findings included:<BR/>Observations on 2/27/23 revealed that on the secure unit, 9 of 11 windows were found to be either inoperable or operable without a window screen.<BR/>9 windows were without screens: Rooms 808, 901, 902, 903, 904, 906, 907, 909, and 911.<BR/>5 windows were also found to be screwed down, rendering them inoperable: Rooms 902, 904, 906, 907, and 909.<BR/>In an interview with the Administrator and the DON on 02/28/23 at 08:21 AM, both the DON and the Administrator said that they did not know that it was a regulation that windows must have a screen. They did say that they could see the need for screens for pest control and to allow residents to open their windows if they desired.<BR/>In an interview with MAINT on 02/28/23 at 09:08 AM, he said that window latches already had holes in them from being screwed down previously and were re-screwed down after an elopement incident. He said that he does not know when the screens were removed from the windows on the unit. He said that most windows in the facility do have screens, and if he noticed any that were off, that he would pick them up and put them back on. He said that sometimes when the lawn is being mowed or weed-eated, a rock or something might hit them, knocking them down. He said he had not thought about screens being in place for pest control, but that he could see where that could be an issue.<BR/>In an interview with the Administrator on 3/1/23 at 9:30am, she said that the only harm to residents that she could think of might be pest control. She said she really can not think of any other harm that might come to residents. She said that she will see what can be done about the windows on the unit being screwed down, that they may try to figure out how to limit them to opening a minimal amount to keep residents safe. She was not aware previously that it was a regulation. She said that by ensuring that residents were able to open their windows if they chose to do so, it could make their environment more comfortable, and screens in place could ensure safety.<BR/>In an interview with the DON on 3/1/23 at 11:00am, she said that if residents were to open their windows without a screen in place, that they could potentially elope or be stung by an insect if an insect were to be able to fly in. She said that having screens in place could help ensure resident safety.<BR/>Record review of facility policy titled maintenance service dated December 2022 states .the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . and .Functions of maintenance personnel include, but are not limited to: a) maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines; b) maintaining the building in good repair and free from hazards; and .k) maintaining doors, windows and screens (where indicated) in appropriate working order .<BR/>No policy was provided for safe, comfortable, homelike environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and home like environment for 1 of 2 dining rooms (the main dining room did not have adequate lighting) observed for environment. <BR/>The facility failed to ensure there were adequate lighting in the main dining room. <BR/>This failure could place the residents, who eat in the dining room at risk of injury, and a non-home like dining experience due to inadequate lightening. <BR/>Finding included:<BR/>During an observation on 06/23/2025 at 11:30am there were 3 of 8 florescent lights not working in the main dining room. <BR/>Record review of a facility's face sheet dated 6/23/25 for Resident #21 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Cervical spinal stenosis (narrowing of the vertebra in the neck), muscle weakness and diabetes (too much glucose in the blood).<BR/>Record review of a Quarterly MDS assessment dated [DATE] for Resident #21 indicated that he had a BIMS score of 13 indicating he was cognitively intact. Assessment also indicated that he was totally dependent with transfers. <BR/>Record review of a comprehensive care plan dated 6/18/25 indicated that Resident #21 was totally dependent of 2 persons for transfers and at risk for falls.<BR/>Record review of a facility's face sheet dated 6/25/25 for Resident #39 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Type 2 diabetes mellitus, depression, chronic diastolic(congestive) heart failure, muscle wasting and atrophy and unsteadiness on feet. <BR/>Record review of a Quarterly MDS assessment dated [DATE] for Resident #39 indicated that he had a BIMS score of 13 indicating he was cognitively intact. Assessment also indicated that he was totally dependent with transfers. <BR/>Record review of a comprehensive care plan dated 6/04/25 indicated that Resident #39 was independent/dependent on staff etc.) for meeting emotional, intellectual, physical, and social needs.<BR/>During an interview on 6/23/2025 at 11:45 AM, Resident #21 said it was dark and dreary in the dining room, he said the lights had not worked properly in a long time.<BR/>During an interview on 6/23/2025 at 11:50 AM, Resident #39 said it was always dim with some lights out. He said he does not think all the lights ever worked in the dining room. He said some days the lighting seems better than other days, but it never lit up bright like it should be. <BR/> During an interview with CNA-J on 6/25/2025 at 9:00am she said she has not had a resident complain about the lights being dim in the dining room. She said the lights have been the same for a long time. She said she did not notice the lights were out in the dining room.<BR/>During an interview with the MA on 6/25/2025 at 9:15am said she has not had a resident complain about it being dim or dark in the dining room. She said she has noticed some of the light bulbs being out and did not report the lights out to maintenance or the administrator. She said maintenance checks the building and thought they would eventually replace the light bulbs.<BR/>During an interview with LVN-H at 9:30am on 06/25/2025 she said the residents seems content and has not complained about the lighting in the dining room to her. She said she has not noticed the lights being out in the dining room. She said she have not worked at the facility long and it always looks the same as far as lighting and did not notice a low lighting level. <BR/>During an interview with the Maintenance Director on 6/25/2025 at 9:55am she said she has not noticed, nor has it been reported to her that the lights were out in the dining room. <BR/>During an interview the with the DON on 6/25/2025 at 1:45pm she said she has noticed the lighting in the dining room being dim. She said she did not notice the lights were out and knows the facility being dim in areas was a problem when she began working at the facility. She said she thought the facility being old and having repairs the lighting was normal for the building. She said no resident or other staff members have reported or complained of dim or inappropriate lighting. <BR/>During an interview with the Administrator on 6/25/2025 at 2:25pm she said she did notice some lights being out and have since asked her maintenance to walk the building and replace all light bulbs and report any issues they find. She said no one has reported any issues about the lighting in the building. She said low lightening could cause a resident to fall and not enjoy their meal in a home like environment.<BR/>Record review of a Quality of Life-homelike Environment Policy dated (Revised 2024) Policy Statement reads Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation reads: 4. Comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable, and homelike environment. The lightening design emphasizes: a. Sufficient general lighting in resident-use areas; b. Task lighting as needed; d. Even light levels;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 2 of 11 residents reviewed for quality of care, (Residents #21 and #2) in that:<BR/>The facility failed to remove worn and damaged mechanical lift slings from service for Resident's #21 and #2.<BR/>This failure could result in a loss of quality of life due to injuries.<BR/>Findings included:<BR/>Record review of a facility's face sheet dated 6/23/25 for Resident #21 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: cervical spinal stenosis (narrowing of the vertebra in the neck), muscle weakness and diabetes (too much glucose in the blood).<BR/>Record review of a Quarterly MDS assessment dated [DATE] for Resident #21 indicated that he had a BIMS score of 13 indicating he was cognitively intact. Assessment also indicated that he was totally dependent with transfers. <BR/>Record review of a comprehensive care plan dated 6/18/25 indicated that Resident #21 was totally dependent of 2 persons for transfers and at risk for falls.<BR/>Record review of a facility's face sheet dated 6/25/25 for Resident #2 indicated that he was a [AGE] year-old male re-admitted to the facility on [DATE] with diagnoses including: cerebral infarction (blockage of blood flow to the brain leading to death of tissue), cerebral palsy (a congenital disorder of movement, muscle tone or posture), and anxiety.<BR/>Record review of a Quarterly MDS assessment dated [DATE] for Resident #2 indicated that he had a BIMS score of 99 indicating he was severely cognitively impaired. Assessment also indicated that he was totally dependent with transfers. <BR/>Record review of a comprehensive care plan dated 4/10/25 indicated that Resident #2 was totally dependent of 2 persons for transfers and at risk for falls.<BR/>During an observation and interview 06/23/25 at 12:30 PM Resident #21 was sitting in his wheelchair on a mechanical lift sling. The mechanical lift sling had one of the 4 black main straps loop that was torn in half, the other loops were frayed, and stitching was loose. The care tag was not legible. Resident #21 said he had no falls during use of the mechanical lift during transfers. Resident #21 said they didn't always use the lift during his transfers but today he was feeling weak.<BR/>During an observation and interview on 06/23/25 at 12:45 PM the Administrator observed the mechanical lift sling under Resident #21. She said the risk to the resident was injury if the sling broke during transfer and caused a fall. The Administrator said she would remove the damaged sling from service, and she would order replacements.<BR/>During an observation on 06/25/25 10:45 AM, Resident #2 had a mechanical lift sling underneath him. The mechanical lift sling had 2 green colored loops and a blue loop that were frayed almost worn in half and one of the 4 black main straps was torn in half.<BR/>There was a hole in the mesh body of the sling and the stitching was loose. There was no care tag on the mechanical lift sling. <BR/>During an interview on 06/25/25 at 11:21 AM, the ADON said she had worked at the facility since 5/16/2025. The ADON said she would remove the sling under Resident #2 and replace with a new one. She said the straps could break and cause a fall with resulting injuries. She said she would do a facility sweep to remove any worn mechanical lift slings from service and start servicing staff. The ADON said there were 11 residents living in the facility that used the mechanical lift for transfers.<BR/>During an interview on 06/25/25 at 11:40 AM, the DON said had worked at the facility since 5/15/2025. She said the straps could break and cause a fall with resulting injuries. <BR/>During an Interview on 06/25/25 at 12:45 PM, CNA E, CNA G and LVN F said they had received training on 6/25/25 on when to remove mechanical lift slings from service. LVN F said the resident could be seriously injured if the straps broke on the mechanical lift sling and the resident fell during a transfer.<BR/>Record review of a revised facility's policy titled Lifting Machine, using a Mechanical dated 2024 reads .Sling care .3. Discard any worn, frayed, or ripped slings<BR/>Record review of manufacture guidelines Full Body Slings - Instructions for use accessed at www.medline.com on 06/14/25 read .Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 6 residents (Resident #3) reviewed for clinical records. <BR/>The facility failed to ensure the medication administration records (MAR) for Resident #3 reflected discontinuation of medications on 10/09/2024 and non-administered medications when Resident #3 was out of the facility on 10/10/24 and 10/14/2024.<BR/>This failure could place residents at risk of improper care due to inaccurate records. <BR/>Findings:<BR/>Record review of Resident #3's facility face sheet dated 12/09/2024 revealed she was [AGE] years old and was admitted to the facility on [DATE] with diagnosis of major depressive disorder (mood disorder that causes persistent feelings of sadness and loss of interest).<BR/>Record review of Resident #3's comprehensive care plan dated 9/07/2024 revealed she refused medications at intervals.<BR/>Record review of Resident #3's significant change MDS dated 10/082024 revealed a BIMS of 9 indicating moderately impaired cognition. <BR/>Record review of Resident #3's MDS list revealed a discharge MDS was completed on 10/10/2024.<BR/>Record review Resident #3's order summary report revealed on 10/09/2024, Depakote 250mg 1 tab three times a day and Paroxetine 30mg 1 tab daily was discontinued.<BR/>Record review of Resident #3's MAR dated October 2024 revealed the Depakote 250mg 1 tab three times a day and Paroxetine 30mg 1 tab daily was not discontinued on 10/09/24. <BR/>Record review of Resident #3's nurses notes from 10/09/2024 to 10/15/2024 revealed she was discharged from the facility on 10/10/2024 at 12:55 pm and returned on 10/12/2024 at 12:35 pm and again on 10/13/2024 at 3:00 pm and returned 10/14/2024 at 12:11 am.<BR/>Record of Resident #3's medication administration record dated October 2024 revealed [NAME] in the hospital the MAR did not indicate her hospitalization and nurses were initialing that medications were administered.<BR/>During an interview on 12/9/24 at 3:31 p.m., LVN A stated she had worked at the facility since April 2024. She said when a doctor gave a new order the nurse was responsible for entering the new order into the computer, placing the new order on the MAR, notifying the pharmacy and family. She said if a medication was discontinued the medication would be removed from the orders, the MAR would reflect the order was discontinued and the card should be pulled and placed in the discontinued box for destruction. She said she was not the nurse that received the order changes for Resident #3 but did administer her medications while she was at the facility. She said she was not sure why she initialed that she administered Resident #3's medications when she was out to the hospital, and it was a data entry error. She said when Resident #3 was discharged to the hospital she was the nurse that sent her on 10/13/2024 but not 10/10/2024 and she should have flagged the MAR indicating the resident was out of the facility but was not sure why that was not done. She said that inaccurate medical records could cause improper care of a resident. <BR/>During a phone interview on 12/9/24 at 3:50 p.m., LVN B said she had worked at the facility for 1 year and had been an LVN since 1986. She said she remembered caring for Resident #3. She said when receiving a new or discontinued medication order the order was placed in the computer, the MAR was updated, the medication that was discontinued was pulled from the cart and the pharmacy and family were notified of the order. She said she was the nurse that took the order to discontinue Depakote 250mg three times a day and Paroxetine 30mg daily for Resident #3 on 10/09/2024. She said she pulled the medications from the cart for destruction but failed to indicate on the MAR the medication was discontinued. She said that Resident #3 no longer received the discontinued medications effective 10/09/2024. She said she was the nurse that sent Resident #3 to the hospital on [DATE] and she should have flagged her MAR indicating resident was out of the facility. She said she could not remember why she did not do that and was off work on the days Resident #3 was in the hospital. She said if the MAR was not accurate it could cause the residents to receive or not receive accurate medications.<BR/>Attempted phone interview on 12/09/2024 at 3:55 p.m., with LVN D. LVN D worked night shift the days Resident #3 was in the hospital and initialed Resident #3's MAR as if medications were administered. <BR/>During an interview on 12/10/24 at 10:12 am LVN C said she had worked at the facility for 30 years. She said the process for new orders were to transcribe the order in the computer, place in the nurses notes, notify the pharmacy and family and then update the MAR with the new order and place a dc out in front of any medication that was discontinued. She said if a medication was discontinued then that medication was to be removed from the cart. She said if a resident is out of the facility for any reason the MAR should be flagged and there should not be initials next to an order that was carried out. She said inaccurate recording of medications could result in medication error or inaccurate resident care. <BR/>During an interview on 12/11/2024 at 10:00 am the DON said all the nurses had received training on proper charting and recording of resident orders. She said the nurses should be placing discontinued in front of any order on the MAR, flagging the MAR when the resident was out of the facility and reflecting accurately when an order is not performed and why. She said she expected all nurses to chart correctly and accurately to prevent a resident negative outcome.<BR/>Record review of a facility policy titled Medication Administration dated 5/2017 indicated, .medications will be documented as ordered by the physician. 10. If a dose of regularly scheduled medication is withheld or refused the space provided on the MAR for that dosage administration is initialed and circled .<BR/>Record review of a facility policy titled Charting and Documentation dated July 2024 indicated, .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .

Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.<BR/>The facility failed to provide a safe, functional, sanitary, and comfortable environment by ensuring windows in resident rooms 808, 901, 902, 903, 904, 906, 907, 909, and 911 were operable and had screens in place.<BR/>This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. <BR/>Findings included:<BR/>Observations on 2/27/23 revealed that on the secure unit, 9 of 11 windows were found to be either inoperable or operable without a window screen.<BR/>9 windows were without screens: Rooms 808, 901, 902, 903, 904, 906, 907, 909, and 911.<BR/>5 windows were also found to be screwed down, rendering them inoperable: Rooms 902, 904, 906, 907, and 909.<BR/>In an interview with the Administrator and the DON on 02/28/23 at 08:21 AM, both the DON and the Administrator said that they did not know that it was a regulation that windows must have a screen. They did say that they could see the need for screens for pest control and to allow residents to open their windows if they desired.<BR/>In an interview with MAINT on 02/28/23 at 09:08 AM, he said that window latches already had holes in them from being screwed down previously and were re-screwed down after an elopement incident. He said that he does not know when the screens were removed from the windows on the unit. He said that most windows in the facility do have screens, and if he noticed any that were off, that he would pick them up and put them back on. He said that sometimes when the lawn is being mowed or weed-eated, a rock or something might hit them, knocking them down. He said he had not thought about screens being in place for pest control, but that he could see where that could be an issue.<BR/>In an interview with the Administrator on 3/1/23 at 9:30am, she said that the only harm to residents that she could think of might be pest control. She said she really can not think of any other harm that might come to residents. She said that she will see what can be done about the windows on the unit being screwed down, that they may try to figure out how to limit them to opening a minimal amount to keep residents safe. She was not aware previously that it was a regulation. She said that by ensuring that residents were able to open their windows if they chose to do so, it could make their environment more comfortable, and screens in place could ensure safety.<BR/>In an interview with the DON on 3/1/23 at 11:00am, she said that if residents were to open their windows without a screen in place, that they could potentially elope or be stung by an insect if an insect were to be able to fly in. She said that having screens in place could help ensure resident safety.<BR/>Record review of facility policy titled maintenance service dated December 2022 states .the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . and .Functions of maintenance personnel include, but are not limited to: a) maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines; b) maintaining the building in good repair and free from hazards; and .k) maintaining doors, windows and screens (where indicated) in appropriate working order .<BR/>No policy was provided for safe, comfortable, homelike environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident was treated with respect, dignity, and care for 2 of 3 residents (Resident #1 and Resident #5) observed for care in that:<BR/>The facility failed to ensure Resident #1's and Resident #5's urinary drainage bag (a bag at the end of an indwelling catheter that drains urine from the bladder) had a privacy cover in place on 10/26/24.<BR/>This failure could affect residents in the facility who received care and could result in residents not being treated with dignity and respect.<BR/>Findings include:<BR/>1.Record review of a facility face sheet dated 10/26/24 for Resident #1 indicated that he was a [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses that included: quadriplegia (a symptom of paralysis that affects all limbs and body from the neck down), urinary tract infection, and neuromuscular dysfunction of bladder (when a problem in your brain, spinal cord, or central nervous system makes you lose control of your bladder).<BR/>Record review of a comprehensive MDS assessment dated [DATE] for Resident #1 indicated that interview for BIMS score should not be conducted due to resident being rarely/never understood. Section C (cognitive patterns) indicated that he was independent with cognitive skills for daily decision making. He was dependent with all ADLs. He had an indwelling urinary catheter and an ostomy.<BR/>Record review of a comprehensive care plan dated 10/3/24 for Resident #1 indicated that he had an indwelling catheter due to wounds with the following intervention: .ensure catheter is placed in a privacy bag .<BR/>2.Record review of a facility face sheet dated 10/26/24 for Resident #5 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: epilepsy (a seizure disorder), type 2 diabetes (uncontrolled blood sugar), and peripheral vascular disease (a condition in which narrowed arteries reduce blood flow to the arms or legs).<BR/>Record review of an admit/readmit screener dated 10/25/24 for Resident #5 indicated that she was oriented to person, place, time, and situation; she was dependent for most all ADLs; and she had a catheter. Record review of electronic medical record for Resident #5 indicated that MDS assessment was in process and not completed yet. <BR/>Record review of a baseline care plan for Resident #5 dated 10/25/24 indicated that she had an indwelling catheter with no interventions listed. <BR/>During an observation on 10/26/24 at 12:20 pm Resident #1 was observed up in a motorized wheelchair in the dining room. He was observed with a urinary drainage bag on the left side of his chair with no privacy cover in place. <BR/>During an observation and interview on 10/26/24 at 12:35 pm Resident #5 was observed lying in bed. She had a urinary drainage bag hanging on the side of her bed with no privacy cover in place. Resident's door was open, which would allow passersby to see her urinary drainage bag. She said she had just admitted last night. She said no one at the facility had said anything about a privacy cover for her urinary drainage bag. She said, That would be really nice.<BR/>During an interview on 11/1/24 at 9:57 am Administrator said she started at the facility in August of 2024. She said privacy bags needed to be in place for resident's dignity. <BR/>During an interview on 11/2/24 at 3:56 pm DON said she expected her staff to ensure privacy bags were in place for residents with a urinary drainage bag. She said it was a dignity issue for the residents. She said she would be monitoring to ensure they were used going forward. <BR/>Record review of a facility policy titled Catheters - Insertion and Care - Indwelling, Straight, Supra-pubic and External dated 5/2017 read .place catheter drainage bag in a cover to preserve dignity of the resident .<BR/>Record review of a facility policy titled Resident Rights dated 2001 and revised in December 2016, read .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good personal hygiene for 2 of 24 residents (Resident #24 and<BR/> #49) reviewed for ADLs. <BR/>Resident #24 missed 7 scheduled baths in February 2023. <BR/>Resident #49 missed 8 scheduled baths in February 2023<BR/>These failures could cause all residents not to receive daily personal hygiene services and cause the resident to have health, social, and emotional issues. <BR/>Findings included:<BR/>1.Record review of a Face Sheet dated 3/1/2023 for Resident #24 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hypothyroidism (thyroid gland does not make enough thyroid hormone), Type 2 diabetes, bipolar (shifts in a person's mood) and hypertension (high blood pressure).<BR/>Record review of a Quarterly MDS dated [DATE] for Resident #24 indicated she did not have any impairment in thinking with a BIMS score of 15. She was totally dependent in bathing with one person assist.<BR/>Record review of a Care plan dated 3/1/2023 for Resident #24 indicated resident refuses care at times. On 7/21/2022 resident refused a shower with an intervention to re-approach at intervals. ADL functions bathing-total assist 1-2 dated 4/2/2020 with interventions to set-up, assist and give shower per schedule and prn.<BR/>Record review of a shower schedule dated 2/22/2023 indicated Resident #24's shower days were scheduled for Tuesday, Thursday, and Saturday on hall 500. <BR/>Record review of a task documentation report for Resident #24 dated 3/1/2023 for the month of February 2023 indicated the bathing task:<BR/>2/4/2023 was blank.<BR/>2/11/2023, 2/14/2023, 2/16/2023 had N/A-not applicable with initials for CNA C.<BR/>2/18/2023 was blank.<BR/>2/25/2023 had N/A with initials for LVN D.<BR/>2/28/2023 had N/A with initials for CNA C.<BR/>Record review of an In-Service Training Report dated 12/2/2022 by the DON indicated that showers must be completed per schedule, if resident refuses, the CNA must report to the nurse and document, then notify RP with any refusals. The facility is to ensure showers are completed. CNA C and LVN D were not in attendance on the sign in sheet.<BR/>During an observation and interview on 3/01/2023 at 8:41 AM, Resident #24 was lying in bed awake and said she had not had a shower in a long time and the last day she received a bed bath was last Thursday (2/23/2023). She said they did not wash her hair at that time. She said she was supposed to get her showers on Tuesday and Thursdays. She said the staff did not give showers on the weekends. She said getting a bath regularly on her scheduled days stopped when the shower tech (CNA C) at that time quit. She said CNA C was back working the floor and not doing the showers anymore. She said it made her feel terrible not getting her showers when she was supposed to. She said she was stuck in her room in the bed and was not able to get up and talk to people because she was not able to walk and had bilateral foot drop. Resident #24 did not have an odor but had a few dandruff flakes in her scalp.<BR/>During an interview on 3/1/2023 at 10:40 AM, CNA C said she had been employed at the facility for 5 years. She said she was the shower tech for 2 years and quit that position in November 2022. She said there was no one at the facility designated as the shower tech. She said the facility had a shower tech who was responsible for providing showers to the residents Monday-Friday. She said they did not have a shower tech on the weekends. She said she worked the north side of the facility which included halls 400, 500, 600, and 700. She said she returned to work from vacation this past Monday on 2/27/2023 and did not give any showers or bed baths to any residents on 2/27/2023 or 2/28/2023. She said Resident #24 did not get a shower or bed bath on 2/28/2023 and her shower schedule was on Tuesdays, Thursdays, and Saturdays. She said since she had been working at the facility, no residents received any baths or showers on the weekends. She said today was the first time that she heard anything about the CNAs would be responsible for giving the residents their baths or showers per their assigned schedule. She said she did not know why Resident #24 did not get a shower or bath on 2/28/2023 and she was assigned to her hall. She said N/A was placed when a resident did not get a shower on that day. She said she had been off and was not sure how long the facility had been without a shower tech.<BR/>2. Record review of a Face Sheet dated 3/1/2023 for Resident #49 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of osteomyelitis of right ankle and foot (infection of the bone), Type 2 diabetes (high blood glucose levels), and hypertension (high blood pressure).<BR/>Record review of an admission MDS dated [DATE] for Resident #49 indicated he had moderately impaired thinking with a BIMS score of 11. He required extensive assistance in bathing with one person assist and had no behaviors of rejecting care.<BR/>Record review of progress notes for Resident #49 dated 2/01/23 thru 3/1/23 had no documentation of being resistive or refusing care.<BR/>Record review of a care plan dated 2/20/2023 for Resident #49 indicated resident requires assistance with ADLs, will maintain a sense of dignity by being clean, dry, odor free and well-groomed over the next 90 days. Interventions: set-up, assist and give shower per schedule and prn. Shave, oral and hair care per schedule and prn.<BR/>Record review of a shower schedule dated 2/2023 indicated Resident #49's shower days were scheduled for Monday, Wednesday, and Friday on hall 800. <BR/>Record review of a task documentation report for Resident #49 dated 3/1/2023 for the month of February 2023 indicated the bathing task:<BR/>2/1/2023, 2/3/2023, 2/6/2023 and 2/13/2023 had N/A-not applicable with <BR/>initials for CNA E.<BR/>2/8/2023 had N/A with initials for CNA F<BR/>2/20/2023, 2/22/2023 and 2/24/2023 were blank.<BR/>Record review of an In-Service Training Report dated 12/2/2022 by the DON indicated that showers must be completed per schedule, if resident refuses, the CNA must report to the nurse and document, then notify RP with any refusals. The facility is to ensure showers are completed. CNA E and CNA F were in attendance on the sign in sheet.<BR/>During an observation and interview on 3/01/2023 at 10:00 AM, Resident #49 was in his room sitting in his wheelchair. He was dressed and had a not been shaved recently. The room and resident had a smell of urine. <BR/>During an interview and record review on 03/01/23 at 10:30am with MA A, she said she always documents in PCC when she gives a shower or bath. She stated that they had a shower aide in the past but currently they do not and that the CNAs assigned for resident care are expected give the showers. MA A opened the electronic record and showed this surveyor documentation of baths given to Resident #49 by her on 2/10/23, 2/15/23 and 2/27/23, three of the only four baths given for the month of February 2023.<BR/>During an interview on 3/01/23 at 12:45 p.m. with resident #49's RP and the ADM in the common area of the locked unit. The RP told the administrator and this surveyor she had repeatedly asked for Resident #49 to get a bath. She said she comes to the facility almost every day to see about him, since his admission and baths are very infrequent. She had asked the staff to make sure he was cleaned up and ready to go to his appointment with the surgeon today, but when she arrived, he had not been given a bath. The ADM said that it was unacceptable for resident #49 not to get his baths and personal care needed. She would be conducting a full investigation and make sure this problem was solved. The ADM said that not getting personal care and baths could lead to low self-esteem, skin breakdown and skin infections.<BR/>During an interview on 3/1/2023 at 1:42 PM, the DON said N/A on the documentation survey report for the tasks indicated it was not applicable but was unsure what it meant and would have to ask the CNAs. She said if there was a blank then it indicated that the task was not done. She said they had a shower tech for the facility who was responsible for providing showers to residents on hall 400, 500, 600 and 700 Monday-Friday. She said there was not a shower tech on the weekends. She said on the weekends the CNAs were responsible for giving showers to the residents. She said the current shower tech was out on leave as of Monday 2/28/2023. She said as of right now the CNAs were responsible for giving showers until the shower tech returned. She said the charting system at the facility indicated on the schedule for the CNAs which residents needed a shower on what day. She said on the documentation survey report for tasks if there was an (X) for a date then it indicated that the task was not due on that day. She said she was not aware Resident #24 and Resident #49 were not receiving their showers according to their schedules. She said it was standard for all residents to receive a shower at least 3 days a week. She said she was in the process of conducting an audit at the facility to see if residents received their showers according to documentation in the charting system. She said she conducted an in-service today about showers with staff and the CNAs were to give the residents showers. She said if a resident did not receive showers there could a risk of skin breakdown. <BR/>Record review of a facility policy titled Bathing/Showering Documentation with a date of 5/2017 indicated, .It is the policy of this home that residents will be assisted with their bathing needs and will be bathed on a routine basis. 1. Staff must document bathing/showering on schedule days for each resident. 2. Staff must report all refusals to charge nurse and document refusals .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident received care consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated it was unavoidable and 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 2 of 4 residents (Resident #6 and Resident #7) reviewed for pressure ulcers.<BR/>The facility failed to ensure Resident's #6 and #7 received accurate and weekly skin assessments to prevent the development of or worsening of pressure ulcers.<BR/>These failures could place residents at risk for improper wound management, the development of new pressure ulcers and deterioration in existing pressure ulcers/injuries.<BR/>The findings include:<BR/>1. Record review of an admission Record for Resident #6 dated 10/30/2024 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of type 2 diabetes, quadriplegia (paralyzed from the neck down that affected both arms and legs), contracture to right elbow (shortening and hardening of the muscles leading to deformities).<BR/>Record review of a Significant Change MDS assessment dated [DATE] for Resident #6 indicated he did not have any impairment in thinking with a BIMS score of 15. He was dependent on staff with showering/bathing and personal hygiene. He was at risk for developing pressure ulcer/injuries but did not have any unhealed pressure ulcers/injuries.<BR/>Record review of a care plan for Resident #6 dated 6/18/2024 indicated he had actual impairment to skin integrity of the right lateral ankle related to immobility revised on 8/19/2024 with interventions to monitor/document location, size, and treatment of skin injury. Had actual impairment to skin of the sacrum initiated on 8/16/2024. <BR/>Record review of active orders for Resident #6 dated 10/30/2024 indicated an order to clean sacral wound with normal saline, apply collagen powder, hydrogel with silver and cover with gauze island border one time a day that started on 10/18/2024.<BR/>Record review of weekly skin assessments for Resident #6 indicated he did not have a skin assessment for the following weeks:<BR/>o <BR/>8/18/2024-8/24/2024 <BR/>o 10/20/2024-10/26/2024<BR/>During an observation and interview on 10/30/2024 at 7:35 AM, Resident #6 was in the hospital in bed awake. He was alert and oriented to person, place, and time. He said he has a wound to his left leg and the facility performed wound care about once a month and he did not refuse care from anyone at the facility. He said he also had a wound to his left knee and buttocks.<BR/> 2. Record review of an admission Record for Resident #7 dated 10/30/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of displaced intertrochanteric fracture of right femur (break in the upper part of the thigh bone between the bony protrusions where the thigh and hip muscles attach), hypothyroidism (when the thyroid gland does not make enough thyroid hormone) and Alzheimer's disease. <BR/>Record review of an Admission/5 Day MDS Assessment for Resident #7 dated 10/28/2024 was in progress and not completed. <BR/>Record review of a care plan for Resident #7 indicated she had actual impairment to skin integrity of the right hip related to surgical wound date initiated on 10/30/2024 with interventions to monitor/document location, size, and treatment of skin injury. Follow facility protocols for treatment of injury. <BR/>Record review of active physician orders dated 10/30/2024 for Resident #7 indicated an order to change enclosed dressing system once a week on 2 pm-10 pm one time a day every Monday.<BR/>Record review of a skin assessment for Resident #7 dated 10/21/2024 indicated there were skin issues noted that included bruising to groin and right thigh with three incisions with staples present and wound vac to incision lines. The skin assessment did not indicate any other skin issues.<BR/>During an observation and interview on 10/30/2024 at 10:45 AM, the Sitter of Resident #7 was at the nurse desk talking to LVN C. The Sitter showed LVN C a picture of an area she found on Resident #7's right heel that morning. LVN C followed the Sitter to the room for a skin assessment. Resident #7's right heel was noted with a hardened area, pink and blue discolored area to back of her heel. LVN C said she would notify the physician.<BR/>During an observation and interview on 10/30/2024 at 10:50 AM, the Sitter of Resident #7 was in the room after LVN C left. She said the facility staff would only come in the room when she told them to. She said she was not providing care to Resident #7 and was only a companion to her. She said she visited Monday-Thursday from 8:30 am -12:30 pm. She said on admission last Monday (10/21/2024) to the facility, she had a small hardened callous area to her right heel and thinks it was from the swelling she had while in the hospital. She said the area had increased in size from last Monday (10/21/2024) and she alerted the nurse to be aware. She said she did not think they were aware of it until she showed LVN C the picture. She said the resident would speak occasionally but had Alzheimer's.<BR/>During an interview on 10/30/2024 at 1:11 pm, CNA F said she had been employed at the facility for 3 years and worked 6 am - 2 pm and rotated halls when she worked. She said if the nurse aides observed a new skin area, they were to report as soon as possible to the charge nurse and they could also chart in the computer. She said she had been off for a few days and that day 10/30/2024was her first day with Resident #7. She said she assisted with getting her up out of bed and changed her. She said the resident had a private sitter that would feed and sit with the resident. She said she did not notice anything new skin issues with the resident during care that morning. She said the resident did have boots on and the sitter removed them when she was positioned in her chair. She said the facility had a lack of communication.<BR/>During an interview on 10/30/2024 at 1:16 PM, LVN C said she had been employed at the facility for 4 months and worked 6 am-2 pm. She said the nurses were responsible for skin assessments on the day shift on Tuesdays. She said she was not aware of the area on Resident #7's heel until the sitter brought it to her attention that morning. She said the residents all had a different schedule for skin assessments, but all residents should have a skin assessment conducted weekly. She said there could be a risk of not having treatment orders, risk for decline in health and medical conditions, if left untreated could lead to worsening of things. She said the charge nurses have a printed TAR in a binder on the nurse cart for treatment orders, but the skin assessments were done in the computer system. <BR/>During an interview on 11/1/2024 at 9:30 AM, the DON said the floor nurses were responsible for skin assessment and should be done once a week. She said she recognized an issue with skin assessments not being done and had been an ongoing issue for about a month. She said she made a list for the nurses and was making them go back and complete the skin assessments. She said skin assessments were documented in the electronic health record. She said and on admission it was inside the admission assessment. She said there could be a risk for missed assessments with wounds or something else if they were not done weekly. <BR/>During an interview on 11/1/2024 at 9:57 AM, the Administrator said she hired at the facility in August 2024. She said the nurses were responsible for the skin assessments in the facility. She said the skin assessments should be done weekly and as needed. She said there could be risk for unnoticed wounds starting, venous, and pressure sores if they did not get their weekly skin assessment. She said the skin did not take long to break down due to being compromised.<BR/>Record review of a facility policy titled Skin-Treatment Guidelines for Pressure Injuries revised 5/2017 indicated, .It is the policy of this home to utilize treatment guidelines when providing care for residents with pressure injury and to prevent further deterioration of pressure injury. Stage 4: 14. Indicate dressing change date, time, and initials on dressing. Complete the skin assessment flow sheet form in the clinical software weekly until injury is resolved. 15. Document dressing completion on the treatment administration record (TAR). Unstageable: 13. Indicate dressing change date, time, and initials on dressing. Complete the skin assessment flow sheet form in the clinical software weekly until injury is resolved. 14. Document dressing completion on the treatment administration record (TAR) .<BR/>Record review of a facility policy titled Skin-Integrity Monitoring System dated 5/2017 indicated, .It is the policy of this home that: 1. A system will be in place to assure that all residents will be assessed and monitored for any type of skin breakdown. 2. A system will be in place to assure that all residents will be assessed, and preventative measures will be in place to prevent the development of pressure injuries. 3. A system will be in place to assure any type of skin conditions that do not constitute pressure injuries, will be monitored closely for any type of complications. Assessment and monitoring: 3. All residents will be assessed weekly using the (Weekly Skin Assessment) form for any type of skin integrity complications; this will include pressure injury and non-pressure related complications. The (Weekly Skin Assessment) will be documented on the (Weekly Skin Assessment) in clinical software .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 4 residents (Resident #2 and Resident #5) reviewed for incontinent care and catheter care. <BR/>The facility failed to ensure CNA A and CNA B properly cleaned the penis of Resident #2 during incontinent care.<BR/>The facility failed to ensure Resident #5's indwelling catheter (drains urine from your bladder into a bag outside your body) had a securement device to anchor her catheter.<BR/>The facility failed to ensure Resident#5's urinary catheter drainage bag tubing did not touch the floor. <BR/>This failure could place residents at risk for urinary tract infections and catheter related injuries.<BR/>Findings include:<BR/>Resident #2<BR/>Record review of a facility face sheet dated 10/26/24 for Resident #2 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses that included: cerebral infarction (stroke), cerebral palsy (a group of conditions that affect movement and posture caused by brain damage before birth), and hyperlipidemia (high cholesterol).<BR/>Record review of a comprehensive MDS assessment dated [DATE] for Resident #2 indicated that he had a BIMS score of 3, which indicated that he had severely impaired cognition. He was dependent with toileting hygiene. He was always incontinent of bladder and bowel. <BR/>Record review of a comprehensive care plan dated 10/17/24 for Resident #2 indicated that he was incontinent of both bladder and bowel and had an intervention to monitor for incontinence every 2 hours and prn and change promptly.<BR/>During an observation on 10/26/24 at 3:10 pm CNA A and CNA B were observed performing incontinent care on Resident #2. During incontinent care, CNA A was observed to wipe down the penis from the bottom of the shaft to the tip, on the topside. She did not pick up the penis and clean the tip or the entire shaft. <BR/>During an interview on 10/26/24 at 3:30 pm CNA A said she did not pick up the penis and clean it properly. She said she should have cleaned the tip and the shaft. She said today was her fourth day at the facility and she did not know why she did not properly clean Resident #2's penis.<BR/>Resident #5<BR/>Record review of a facility face sheet dated 10/26/24 for Resident #5 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: epilepsy (a seizure disorder), type 2 diabetes (uncontrolled blood sugar), and peripheral vascular disease (a condition in which narrowed arteries reduce blood flow to the arms or legs).<BR/>Record review of an admit/readmit screener dated 10/25/24 for Resident #5 indicated that she was oriented to person, place, time, and situation; she was dependent for most all ADLs; and she had a catheter. <BR/>Record review of electronic medical record for Resident #5 indicated that MDS assessment was in process and not completed yet. <BR/>Record review of a baseline care plan for Resident #5 dated 10/25/24 indicated that she had an indwelling catheter with no interventions listed.<BR/>During an observation on 10/26/24 at 12:35 pm Resident #5 was observed lying in bed with a urinary drainage bag hanging on the side of her bed. The tubing for the urinary drainage bag was observed lying on the floor. There was no catheter strap to secure tubing to her leg.<BR/>During an interview on 11/1/24 at 9:30 am the DON said when peri care was provided to a male resident, staff should be wiping the tip of penis and wipe downward. She said tubing for foley drainage bags should never be on the floor and it should be anchored to the skin on the resident's thigh. She said residents could be at risk for infections due to improper peri care. <BR/>During an interview on 11/1/24 at 9:57 am the Administrator said she had been employed at the facility since August of 2024. She said residents could be at risk for trauma and infection if staff do not follow proper procedures with incontinent care and foley care. She said the tubing should be positioned on the thigh with a secured clamp, and never on the floor. <BR/>Record review of a facility form titled CNA Proficiency Audit for CNA A dated 10/3/24 indicated that CNA A had been trained on perineal care for a male. <BR/>Record review of a facility policy titled Incontinent Care/Perineal Care with or without a catheter dated 5/2017 read .clean head of penis in a circular motion .wash complete shaft of penis working down the shaft - pat dry .<BR/>Record review of a facility policy titled Catheters - Insertion and Care - Indwelling, Straight, Suprapubic and External dated 5/2017 read .secure urinary drainage bag below the level of the bladder and keep off the floor. Coil extra tubing and secure .attach catheter strap to leg to assist in securing tubing .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #1) reviewed for respiratory care. <BR/>The facility failed to ensure LVN C did not reuse a single use suction catheter with Resident #1 on 10/31/24.<BR/>The facility failed to ensure LVN C employed sterile technique during suctioning and tracheostomy care with Resident #1 on 10/31/24.<BR/>The facility failed to ensure LVN C did not use tap water when performing tracheal suctioning for Resident #1 on 10/31/24. <BR/>The facility failed to ensure LVN C used intermittent suctioning during care on 10/31/24.<BR/>The facility failed to train nursing staff on proper tracheostomy care and tracheal suctioning procedures. <BR/>An Immediate Jeopardy (IJ) was identified on 10/31/2024. While the IJ was removed on 11/2/2024 at 3:02 p.m., the facility remained out of compliance at a scope of no actual harm with potential for more than minimal harm that is not immediate jeopardy and scope of isolated due to the facility's need to monitor and evaluate the effectiveness of their corrective systems. <BR/>These failures could place residents requiring tracheostomy care and tracheal suctioning at risk for respiratory complications, infections, and/or death.<BR/>Findings included:<BR/>Record review of a facility face sheet dated 10/26/24 for Resident #1 indicated that he was a [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses that included: quadriplegia (a symptom of paralysis that affects all limbs and body from the neck down.<BR/>Record review of a comprehensive MDS assessment dated [DATE] for Resident #1 indicated that interview for BIMS score should not be conducted due to resident being rarely/never understood. Section C (cognitive patterns) indicated that he was independent with cognitive skills for daily decision making. He was dependent with all ADLs. He had a tracheostomy, an indwelling urinary catheter and an ostomy.<BR/>Record review of a comprehensive care plan dated 10/3/24 for Resident #1 indicated that he had a tracheostomy and had the following interventions: .will have sterile suctioning procedure as needed . and .will have sterile tracheostomy care: cleanse around trach site and replace drain sponge. Change trach ties as needed .<BR/>Record review of a physician's order summary report dated 11/2/24 for Resident #1 indicated he had the following physician's orders: .Tracheostomy care one time a day . and .may suction prn for secretions .<BR/>During an interview and observation on 10/28/24 at 2:30 pm Resident #1 was observed at [hospital name] lying in his hospital bed. Resident #1 said the facility changed his ties and did trach care once a week. He said he felt like the facility was unequipped to handle his trach care.<BR/>During an interview and observation on 10/31/24 at 7:50 am Resident #1 was observed in bed sitting up in bed. He said the facility did not have the staff to properly take care of him and they did not clean his trach often as they should. <BR/>During an observation on 10/31/24 at 7:37 am LVN C was in Resident #1's room to provide suctioning to his trach per his request. She went into the room and washed her hands, put on a gown and nonsterile gloves in the hallway and entered the room with a plastic cup and a sterile water container. She then put on another pair of nonsterile gloves on top of the pair of gloves that were on her hands for a total of 2 gloves on each hand. She then placed the cup and sterile water on the nightstand beside the bed. She turned on the overbed light and then removed a pair of gloves and placed them in the trash. She placed another pair of nonsterile gloves on top of the gloves that were on her hands. She pulled the linens down on the resident and removed the cap that was on the trach. She removed a pair of gloves and placed them in the trash. She put on another pair of nonsterile gloves on top of the pair of gloves that were already present on her hands for a total of 2 gloves on each hand. She turned the suction machine on and removed the suction tubing from the plastic package that was already opened on one end and inserted the tubing down into the trach and suctioned. She placed the tubing in the sterile water to clean the tubing of any secretions and placed it back inside the plastic packaging that it was in previously. She placed the cap on the trach and removed her gloves and gown and placed them in the biohazard box that was in the room. She washed her hands in the bathroom and exited the room.<BR/>During an observation on 10/31/24 at 9:25 am LVN C was observed performing suctioning and tracheostomy care on Resident #1. She did not use sterile technique during care. She was observed wiping down overbed table, she then washed her hands, donned gown, mask, and non-sterile gloves. She was observed to apply a second pair of non-sterile gloves over the first pair. She then opened a packet containing a sterile drape/towel and laid it on the cleaned table. She then opened trach care kit and with non-sterile gloved hands, removed each item from kit and placed it on the sterile field/drape that had been laid on an overbed table. She then opened the sterile water container and poured it into the open tray that was on sterile field with lid folded underneath it. She then opened the peroxide, also pouring it into the tray. She was observed touching all the ends of the cotton swabs and twirling them around in her fingers before placing them back down onto the sterile field. She then opened another trach kit and removed supplies from it with non-sterile gloved hand, also placing them on the sterile field and placed kit tray with lid folded underneath it on sterile field as well. She then removed top pair of gloves and discarded them. Resident #1 then requested to be suctioned. She walked away from sterile field with the supplies on it and left room. She reenters room with another sterile water container. She then removed her PPE, placed water on table next to sterile field and washed hands in restroom. She returned to hall to don more PPE, re-entered room and with non-sterile gloved hands, applied a second pair of non-sterile gloves. She then poured sterile water into a non-sterile plastic cup, turned on suction machine and removed the purple cap from resident's trach. She laid the cap on his hoodie on his chest. She then took the suction tubing in non-sterile gloved hand and removed suction catheter from previously opened bag and inserted it into resident's tracheostomy opening. After resident began to cough, she put her thumb over the opening in the tubing and suctioned the entire time she slowly withdrew (approximately 10-15 seconds, then suctioned water into the tubing. She repeated this twice. She then placed the suction catheter back into the open packaging and laid it back on table. Resident exhibited facial grimacing during the procedure. She threw away the outer gloves and applied another pair of non-sterile gloves over the first pair. She then removed the inner cannula. Inner cannula was placed in peroxide to soak. She picked up the package of sterile gloves and moved them to the edge of the sterile field. She then unvelcroed the right side of his trach collar and removed the split gauze. She then removed outer gloves and opened sterile gloves. She applied the sterile gloves over her non-sterile gloves. She then took sterile drape and placed it over his chest and just underneath his neck. She poured sterile water into the 2nd trach care plastic tray and then peroxide as well. She then placed gauze in the peroxide, squeezed out excess liquid and cleaned top of trach tube flange. She then repeated to clean the bottom. She then cleaned with cotton swabs to remove thick, yellow substance from underneath trach tube. She was observed cleaning the inside of inner cannula with pipettes and then placed it in sterile water to soak. She then removed the trach collar from the right side and attached the new collar to the right side and then walked around to the other side of resident, held outer tube in place with her left hand and unvelcroed the left side of old collar. She then pulled new collar behind his neck and velcroed in place. She then secured both sides with Velcro and placed a new split gauze. She then was observed patting dry the inner cannula with gauze pad and placed it back inside trach tube. She then removed her sterile gloves and put on a pair of non-sterile gloves over the original pair. She placed another sterile drape over his chest, turned on suction machine, took a non-sterile plastic cup into bathroom and came out with water in cup. She then suctioned him again using same technique as above with same suction catheter and then replaced suction tubing catheter back into packaging and left it lying on table. Resident again exhibited facial grimacing while suctioning. She then replaced purple trach tube cap, removed gloves and PPE, washed hands, and exited room. Date and time on suction catheter tubing observed to be 10/31/24 8:39 am.<BR/>During an interview on 10/31/24 at 11:50 am LVN C said she had been employed at the facility for approximately 4 months. She said during the trach care provided to Resident #1 this morning, she was not sure what she did wrong, just maybe would have changed her gloves more. She said she did have training before employment but not a check off at the facility on trach care. She said she had never had any competency training with someone where she had to do a return demonstration and was told if the skills were correct or not. She said no skills check off were conducted. She said she thought that she had done all the correct steps. She said she was told the suction tubing was supposed to be changed out today, she thought it was changed out that morning. She said they normally use sterile water or distilled or sometimes they must use the water from the bathroom sink. She said she had not actually received any training. She said when she started, they asked her if she had trach training at another facility. She said she had 3 days of orientation, and she wasn't physically shown how to do the care but had just been told verbally how to do it. She said she was never asked if she felt comfortable with caring for him. She said sometimes she did not feel comfortable with caring for him and did not have the skills nor training to care for him. She said residents could be at risk for harm and not being properly cared for.<BR/>During a telephone interview on 10/30/24 at 3:31 pm LVN D said she had been employed at the facility since August of 2024 and worked the 6am-2pm shift, rotating halls. She said she had not received any training since being in the facility. She said she had not had any training on trach care and suctioned him at least twice during her shifts and sometimes more. She said she had some trach knowledge from a previous job.<BR/>During an interview on 10/31/24 at 12:20 pm the DON said trach care training with nursing staff was done on hire and yearly thereafter. She said they had an RT who would come to the facility yearly to conduct trach training with the staff. She said the last time they were at the facility was about a year ago and it was time for them to come back. She said she had trained the new employees in the facility as she had been trained by RT to train other staff on the proper procedures to care for a trach resident. She said she would train the staff unless the RT would be conducting the training. She said the training she provided to the staff was not as extensive as the RT's training. She said once the training was completed, the staff were to complete a return demonstration to show competency. She said there was a risk for improper care to the residents in the facility if the staff had not been trained on how to care for a resident who had a trach. She said trach care was a sterile technique and sterile water should be used when cleaning or suctioning. She said suction should be intermittent and not continuous when pulling the tubing out. She said trach care should be performed once a day and the floor nurses were responsible for providing trach care.<BR/>During an interview on 10/31/24 at 12:46 pm Medical Director said he was the facility medical director and began his employment with the facility in September 2024. He said nursing was responsible for training the staff on proper tracheostomy care and technique. He said there was a risk for introducing organisms into the trach if the care was not done properly. He said he was not aware of any issues with tracheostomy procedures at the facility. He said he had made rounds at the facility the other day and he was aware that Resident #1 did have a trach. He said staff should follow sterile technique when providing care to a resident who had a trach. He said if care was not done properly with a trach resident, they could be at risk for pneumonia and aspiration. He said it was never acceptable for staff to use tap water when providing trach care.<BR/>During a telephone interview on 10/31/24 at 4:10 pm LVN G said she had been trained on trach care by LVN C but mainly with LVN D. She said they had shown her how to suction Resident #1, clean the tubing, flush before and after fluid return, and if he asked her to go deeper when she suctioned him to tell him she could not go any farther than resistance when she inserted the tubing. She said she was told to tell him that she could not. She said she did not receive any training from RT or the DON on trach care. <BR/>During an interview on 11/1/24 at 9:30 am the DON said in the last year they have had a lot of new staff, new management, and no consistent nurse manager to help her. She said LVN C was observed by her initially to do trach care and suctioning and breathing treatments, but she never received the training on trach care. The DON said she filled out the form yesterday for LVN C because she had done observation with her but did not take the test. She said the nurses should be trained yearly. She said they were done yearly. She said residents could be at risk for infections and incorrect care from not having proper training. <BR/>During an interview on 11/1/24 at 9:57 am the Administrator said she was hired at the facility in August 2024. She said DON was responsible for training staff on respiratory care and said she was going to see about getting an RT to train the staff for more expertise in that area. She said residents could be at risk for trauma, infection if staff do not follow proper procedures. <BR/>Record review of a competency evaluation for LVN D indicated that on 8/1/24 she was satisfactory with trach care.<BR/>Record review of a competency evaluation for LVN K indicated that on 5/9/24 she was satisfactory with trach care. <BR/>Record review of a competency evaluation for LVN C indicated that on 6/5/34 she was satisfactory with trach care. <BR/>Record review of a competency evaluation for LVN J indicated that on 6/2/22 she was successfully trained on respiratory/trach.<BR/>Record review of a facility policy titled Tracheostomy Care dated 5/2017 read .It is the policy of this home to provide Tracheostomy care in accordance with current standards of practice to ensure airway patency, maintain skin integrity, and prevent infection . and .Aseptic technique must be used/sterile gloves must be worn: during tracheostomy tube changes (non-disposable and disposable); during cleaning and sterilization of non-disposable tracheostomy tubes; .and .during endotracheal suctioning .<BR/>The Administrator and DON were notified of an IJ on 10/31/24 at 2:07 pm and was given a copy of the IJ template and a Plan of Removal (POR) was requested.<BR/>The Plan of Removal was accepted on 10/31/24 at 5:18 pm and included the following:<BR/>10/31/2024 Trach care<BR/>Immediate actions:<BR/>o <BR/>Review of facility records identified 1 resident receiving Trach care. This was verified on 11/2/24 - Resident #1 <BR/>o <BR/>Resident #1 PCP notified, and care plan reviewed and updated as needed. <BR/>o <BR/>Resident #1 will be assessed and monitored q Shift for signs and/or symptoms of infection related to trach care. <BR/>o <BR/>One on one training and return demonstration to be conducted with LVN identified. <BR/>o <BR/>All nurses will show understanding by return demonstration.<BR/>o <BR/>One nurse from each shift will be properly trained by DON with return demonstration and be the sole nurse providing trach care on that shift by 5 pm on 10/31/2024 DON will be responsible for the procedure until <BR/>one nurse on each shift is trained. <BR/>o <BR/>Remaining nurses will be trained and provide return demonstration by: in-service completed On: 11/01/2024 by 5 PM. Any nurse that is not trained will be trained prior to returning to their next shift. <BR/>On 11/2/24 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:<BR/>Verified that Resident #1 was the only resident in facility with a tracheostomy.<BR/>PCP notification verified on 11/2/24 by record review of a progress note documenting MD notification and record review of Resident #1's care plan indicating update occurred on 11/2/24.<BR/>Record review of TAR verified that trach monitoring was now included for Resident #1.<BR/>In-service regarding tracheostomy care and suctioning and respiratory therapy training was held on 11/2/24 at 6 am and was signed by DON (instructor) and LVN C<BR/>In-services on tracheostomy care and suctioning and respiratory therapy trainings were held 10/31/24 through 11/2/24, instructed by DON and attended by 14 licensed nurses.<BR/>Return demonstration on dummy setup observed on 11/2/24 with 7 nurses in facility. At least one nurse from each shift.<BR/>Observations and interviews on 11/2/24 between the hours of 12:00 pm and 2:45 pm Licensed nurses (LVN C, LVN G, LVN J, LVN L, LVN M, and LVN N) were observed performing a verbal return demonstration on a dummy setup and were able to verbalize procedure was a sterile technique and demonstrate sterile technique via return demonstration on dummy set-up. LVN C, LVN G, LVN J, LVN L, LVN M, and LVN N said they were in-serviced on tracheostomy care and suctioning. They said they would never use any water other than sterile water and would use intermittent suctioning and never continuous suctioning. <BR/>Observation on 11/2/24 at 1:00 pm the DON was observed performing appropriate tracheostomy care and suctioning on Resident #1 with no breaks in infection control or sterile technique. She wore appropriate PPE, used sterile water in sterile water container, and appropriately used intermittent suctioning. <BR/>On 11/2/24 at 3:02 pm the DON was informed the IJ was removed; however, the facility remained out of compliance at a scope of no actual harm with potential for more than minimal harm that is not immediate jeopardy and scope of isolated due to the facility's need to monitor and evaluate the effectiveness of their corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 4 of 4 staff (CNA A, CNA B, LVN C, and LVN D) reviewed for competent nursing care. <BR/>CNA A failed to clean Resident # 2's penis properly during incontinent care provided on 10/26/24.<BR/>CNA A and CNA B failed to wear PPE for enhanced barrier precautions during incontinent care for Resident #2 on 10/26/24.<BR/>LVN D failed to wear PPE for enhanced barrier precautions during wound care on Resident # 3 on 10/28/24.<BR/>LVN C failed to utilize sterile technique when performing trach care and suctioning on Resident #1 on 10/31/24.<BR/>These deficient practices affect residents who depend on nursing care and could place residents at risk for infection and harm.<BR/>Findings included:<BR/>Resident #2<BR/>Record review of a facility face sheet dated 10/26/24 for Resident #2 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses that included: cerebral infarction (stroke), cerebral palsy (a group of conditions that affect movement and posture caused by brain damage before birth), and hyperlipidemia (high cholesterol).<BR/>Record review of a comprehensive MDS assessment dated [DATE] for Resident #2 indicated that he had a BIMS score of 3, which indicated that he had severely impaired cognition. He was dependent with toileting hygiene. He was always incontinent of bladder and bowel. <BR/>Record review of a comprehensive care plan dated 10/17/24 for Resident #2 indicated that he was incontinent of both bladder and bowel and had an intervention to monitor for incontinence every 2 hours and prn and change promptly. He also had a pressure ulcer to the sacrum with focus initiated on 9/18/24 with the following intervention: .administer treatments as ordered and monitor for effectiveness . Care plan did not address enhanced barrier precautions. <BR/>Resident #3<BR/>Record review of a facility face sheet dated 10/27/24 for Resident #3 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: dementia, anemia (low iron in blood), and hypertension (high blood pressure).<BR/>Record review of a quarterly MDS assessment dated [DATE] for Resident #3 indicated that she had a BIMS score of 11, which indicated that she had moderately impaired cognition. She required moderate to total assist with most all ADLs. She was always incontinent of bowel and bladder. <BR/>Record review of a physician's progress note dated 10/24/24 for Resident #3 indicated that she had a stage 3 pressure wound to the right buttock for greater than 48 days. <BR/>Record review of a comprehensive care plan for Resident #3 dated 8/23/24 indicated that care plan did not address enhanced barrier precautions. <BR/>Resident #1<BR/>Record review of a facility face sheet dated 10/26/24 for Resident #1 indicated that he was a [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses that included: quadriplegia (a symptom of paralysis that affects all limbs and body from the neck down), urinary tract infection, and neuromuscular dysfunction of bladder (when a problem in your brain, spinal cord, or central nervous system makes you lose control of your bladder).<BR/>Record review of a comprehensive MDS assessment dated [DATE] for Resident #1 indicated that interview for BIMS score should not be conducted due to resident being rarely/never understood. Section C (cognitive patterns) indicated that he was independent with cognitive skills for daily decision making. He was dependent with all ADLs. He received tracheostomy care and suctioning.<BR/>Record review of a comprehensive care plan dated 10/3/24 for Resident #1 indicated that he had a tracheostomy with the following interventions: .will have sterile suctioning procedure as needed . and .will have sterile tracheostomy care: cleanse around trach site and replace drain sponge. Change trach ties as needed .<BR/>During an observation on 10/26/24 at 3:10 pm CNAs A and B were observed to provide incontinent care on Resident #2. Both were observed to wash their hands before beginning care. Neither one donned PPE for enhanced barrier precautions. CNA A donned gloves and unfastened resident's brief and exposed his peri area. She then wiped each side of groin/inner thigh area and was then observed to wipe straight down middle of peri area, over the topside of resident's penis. She did not pick penis up to clean tip or shaft. Resident was then turned, and CNA B completed incontinent care on resident's anal/rectal/buttocks area. They were then observed to place new brief on resident, reposition him in bed, lower his bed to lowest position and place his call light within reach. Both were then observed to wash their hands and dispose of trash.<BR/>During an interview on 10/26/24 at 3:25 pm CNA A said she should have picked the penis up and cleaned the tip and shaft appropriately. She did not know why she did not do that. She said she had been trained on proper peri care for male residents. She said she had not been trained on enhanced barrier precautions and she did not know what they were. <BR/>During an interview on 10/26/24 at 3:30 pm CNA B said she also did not know what enhanced barrier precautions were and had not been trained on them. <BR/>During an interview on 10/16/24 at 3:40 pm Administrator was asked for the policy on enhanced barrier precautions. She said she had already given it to me, it was the one titled MDRO When informed that CNA A and B both said they had not been trained on enhanced barrier precautions, her reply was They probably haven't, if that is what they said. She said Resident #2 did not have an MDRO and did not need enhanced barrier precautions. <BR/>During an interview on 10/26/24 at 3:45 pm DON said she had not considered Resident #2's wound chronic. She said it was open and he had had it for about 2 months. She said they would train staff on enhanced barrier precautions. She said they had now printed out the provider letter and they would have a meeting and would also be training new staff. She said both CNA A and CNA B were new. <BR/>During an observation on 10/28/24 at 1:00 pm LVN D was observed to perform wound care on Resident #3. She did not don PPE for enhanced barrier precautions during wound care. <BR/>During an interview on 10/28/24 at 1:15 pm LVN D said she was not aware of enhanced barrier precautions and had not been trained on them. <BR/>During a telephone interview on 10/30/24 at 3:31 pm LVN D said she had been employed at the facility since August of 2024 and worked the 6am-2pm shift, rotating halls. She said she had not received any training since being in the facility. She said she had not had any training on trach care and suctioned him at least twice during her shifts and sometimes more. She said she had some trach knowledge from a previous job.<BR/>During an observation on 10/31/24 at 7:37 am LVN C was in Resident #2's room to provide suctioning to his trach per his request. She went into the room and washed her hands, put on a gown and nonsterile gloves in the hallway and entered the room with a plastic cup and a sterile water container. She then put on another pair on nonsterile gloves on top of the pair of gloves that were on her hands for a total of 2 gloves on each hand. She then placed the cup and sterile water on the nightstand beside the bed. She turned on the overbed light and then removed a pair of gloves and placed them in the trash. She placed another pair of nonsterile gloves on top of the gloves that were on her hands. She pulled the linens down on the resident and removed the cap that was on the trach. She removed a pair of gloves and placed them in the trash. She put on another pair of nonsterile gloves on top of the pair of gloves that were already present on her hands for a total of 2 gloves on each hand. She turned the suction machine on and removed the suction tubing from the plastic package that was already opened on one end and inserted the tubing down into the trach and suctioned for about 15 seconds with continuous suction when she was pulling the tubing back up out of the trach. The resident had facial grimacing and was trying to cough. She removed the tubing and placed in the container of sterile water to remove any secretions that were present. She inserted the tubing a second time down the trach and suctioned for about 15 seconds with continuous suction when she was pulling the tubing back up out of the trach. The resident continued to have facial grimacing when she was suctioning and was trying to cough. She placed the tubing in the sterile water to clean the tubing of any secretions and placed it back inside the plastic packaging that it was in previously. She placed the cap on the trach and removed her gloves and gown and placed them in the biohazard box that was in the room. She washed her hands in the bathroom and exited the room.<BR/>During an observation on 10/31/24 at 9:25 am LVN C was observed performing suctioning and tracheostomy care on Resident #1. She did not use sterile technique during care. She was observed wiping down overbed table, she then washed her hands, donned gown, mask, and non-sterile gloves. She was observed to apply a second pair of non-sterile gloves over the first pair. She then opened a packet containing a sterile drape/towel and laid it on the cleaned table. She then opened trach care kit and with non-sterile gloved hands, removed each item from kit and placed it on the sterile field/drape that had been laid on an overbed table. She then opened the sterile water container and poured it into the open tray that was on sterile field with lid folded underneath it. She then opened the peroxide, also pouring it into the tray. She was observed touching all the ends of the cotton swabs and twirling them around in her fingers before placing them back down onto the sterile field. She then opened another trach kit and removed supplies from it with non-sterile gloved hand, also placing them on the sterile field and placed kit tray with lid folded underneath it on sterile field as well. She then removed top pair of gloves and discarded them. Resident #1 then requested to be suctioned. She walked away from sterile field with the supplies on it and left room. She reentered room with another sterile water container. She then removed her PPE, placed water on table next to sterile field and washed hands in restroom. She returned to hall to don more PPE, re-entered room and with non-sterile gloved hands, applied a second pair of non-sterile gloves. She then poured sterile water into a non-sterile plastic cup, turned on suction machine and removed the purple cap from resident's trach. She laid the cap on his hoodie on his chest. She then took the suction tubing in non-sterile gloved hand and removed suction catheter from open bag and inserted it into resident's tracheostomy opening. After resident began to cough, she put her thumb over the opening in the tubing and suctioned the entire time she slowly withdrew (approximately 10-15 seconds, then suctioned water into the tubing. She repeated this twice. She then placed the suction catheter back into the open packaging and laid it back on table. Resident exhibited facial grimacing during the procedure. She threw away the outer gloves and applied another pair of non-sterile gloves over the first pair. She then removed the inner cannula. Inner cannula was placed in peroxide to soak. She picked up the package of sterile gloves and moved them to the edge of the sterile field. She then unvelcroed the right side of his trach collar and removed the split gauze. She then removed outer gloves and opened sterile gloves. She applied the sterile gloves over her non-sterile gloves. She then took sterile drape and placed it over his chest and just underneath his neck. She poured sterile water into the 2nd trach care plastic tray and then peroxide as well. She then placed gauze in the peroxide, squeezed out excess liquid and cleaned top of trach tube flange. She then repeated to clean the bottom. She then cleaned with cotton swabs to remove thick, yellow substance from underneath trach tube. She was observed cleaning the inside of inner cannula with pipettes and then placed it in sterile water to soak. She then removed the trach collar from the right side and attached the new collar to the right side and then walked around to the other side of resident, held outer tube in place with her left hand and unvelcroed the left side of old collar. She then pulled new collar behind his neck and velcroed in place. She then secured both sides with Velcro and placed a new split gauze. She then was observed patting dry the inner cannula with gauze pad and placed it back inside trach tube. She then removed her sterile gloves and put on a pair of non-sterile gloves over the original pair. She placed another sterile drape over his chest, turned on suction machine, took a non-sterile plastic cup into bathroom and came out with water in cup. She then suctioned him again using same technique as above with same suction catheter and then replaced suction tubing catheter back into packaging and left it lying on table. Resident again exhibited facial grimacing while suctioning. She then replaced purple trach tube cap, removed gloves and PPE, washed hands, and exited room.<BR/>During an interview on 10/31/24 at 11:50 am LVN C said she had been employed at the facility for approximately 4 months. She said during the trach care provided to Resident [NAME] this morning, she was not sure what she did wrong, just maybe would have changed her gloves more. She said she did have training before employment but not a check off at the facility on trach care. She said she had never had any competency training with someone where she had to do a return demonstration and was told if the skills were correct or not. She said no skills check off were conducted. She said she thought that she did all the correct steps. She said she was told the suction tubing was supposed to be changed out today, she thought it was changed out that morning. She said the Administrator had told her that she would have to change the tubing out. She said they normally use sterile water or distilled or sometimes they must use the water from the bathroom sink. She said she had not actually received any training. She said when she started, they asked her if she had trach training at another facility. She said she had 3 days of orientation, and she wasn't physically shown how to do the care, but just told verbally. She said she was never asked if she felt comfortable with caring for him. She said sometimes she did not feel comfortable with caring for him and did not have the skills nor training to care for him. She said residents could be at risk for harm and not being properly cared for.<BR/>During an interview on 10/31/24 at 12:20 pm DON said trach care training with nursing staff was done on hire and yearly thereafter. She said they had an RT who would come to the facility yearly to conduct trach training with the staff. She said the last time they were at the facility was about a year ago and it was time for them to come back. She said she had trained the new employees in the facility as she had been trained by RT to train other staff on the proper procedures to care for a trach resident. She said she would train the staff unless the RT would be conducting the training. She said the training she provided to the staff was not as extensive as the RT's training. She said once the training was completed, the staff were to complete a return demonstration to show competency. She said there was a risk for improper care to the residents in the facility if the staff had not been trained on how to care for a resident who had a trach. She said trach care was a sterile technique and sterile water should be used when cleaning or suctioning. She said suction should be intermittent and not continuous when pulling the tubing out. She said trach care should be performed once a day and the floor nurses were responsible for providing trach care.<BR/>During an interview on 11/1/24 at 9:30 am DON said in the last year they have had a lot of new staff, new management, and no consistent nurse manager to help her. She said LVN C was observed by her initially to do trach care and suctioning and breathing treatments, but she never received the training on trach care. DON said she filled out the form yesterday for LVN C because she had done observation with her but did not take the test. She said the nurses should be trained yearly. She said they were done yearly. She said when care was provided to a male resident, staff should be wiping the tip of penis and wipe downward. She said residents could be at risk for infections and incorrect care from not having proper training. <BR/>During an interview on 11/1/24 at 9:57 am Administrator said she had started at the facility in August 2024. She said she had in serviced staff on EBP. DON was the Infection Preventionist and was responsible for training staff on infection control. The ADON was new and would be responsible for training staff on hire and once a year. DON was responsible for training staff on respiratory care. She said she was going to see about getting an RT to train the staff for more expertise in that area. Residents could be at risk for trauma and infections if staff do not follow proper procedures with incontinent care.<BR/>Record review of a competency evaluation for LVN D indicated that on 8/1/24 she was satisfactory with trach care.<BR/>Record review of a competency evaluation for LVN C indicated that on 6/5/34 she was satisfactory with trach care. <BR/>Record review of a facility form titled CNA Proficiency Audit for CNA A and dated 10/3/24 indicated that CNA A had been trained on perineal care for a male. <BR/>Record review of a facility policy titled Incontinent Care/Perineal Care with or without a catheter dated 5/2017 read .clean head of penis in a circular motion .wash complete shaft of penis working down the shaft - pat dry .<BR/>Record review of a facility policy titled Tracheostomy Care dated 5/2017 read .It is the policy of this home to provide Tracheostomy care in accordance with current standards of practice to ensure airway patency, maintain skin integrity, and prevent infection . and .Aseptic technique must be used/sterile gloves must be worn: during tracheostomy tube changes (non-disposable and disposable); during cleaning and sterilization of non-disposable tracheostomy tubes; .and .during endotracheal suctioning .<BR/>Record review of a facility policy titled Competency of Nursing Staff dated 1/2024 read .licensed nurses and nursing assistants employed (or contracted) by the facility will: a. participate in a facility-specific, competency-based staff development and training program; and b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care . and .facility and resident-specific competency evaluations will include: a. lecture with return demonstration for physical activities; a pre- and post-test for documentation issues; c. demonstrated ability to use tools, devices, or equipment used to care for residents .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 8 residents reviewed for infection control. (Resident #1 and Resident #2)<BR/>The facility did not ensure CNA A wore gloves or a gown when passing lunch trays to the rooms of Resident #1 and Resident #2 who were both on contact precautions for COVID.<BR/>These failures could place residents at risk of exposure to communicable diseases and infections.<BR/>Findings included:<BR/>1. An admission Record for Resident #1 dated 1/3/2023 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia and hemiparesis (one sided weakness), COVID-19, alcohol dependence, and hypertension.<BR/>Record review of the physician orders for Resident #1 indicated an order dated 12/26/2022 for vitamin c 500 mg 1 tablet my mouth one time a day and zinc 100 mg 1 tablet by mouth one time a day for COVID protocol for 14 days started on 12/26/2022 with an end date of 1/9/2023.<BR/>Record review of Quarterly MDS Assessment for Resident #1 dated 10/17/2022 indicated he had no impairment in thinking with a BIMS score of 15. He required extensive assistance with two-person assist with bed mobility, transfers, dressing, toilet use and personal hygiene. <BR/>Record review of a Care Plan for Resident #1 dated 12/26/2022 indicated a focus of: I have tested positive for COVID-19 with an intervention/task that was initiated on 1/3/2023 to accommodate as possible within the limitations of isolation precautions.<BR/>During on observation on 1/3/2023 at 11:55 AM, CNA A was wearing a N95 mask. She sanitized her hands and removed Resident #1's lunch tray from the cart in the hallway and entered Resident #1's room without putting on gloves or a gown. Resident #1's door had signage that indicated he was on contact precautions and for providers and staff were to put on gloves, gown, and a mask before entering the room. PPE was noted in a container outside of his door in the hallway. CNA A exited the room and sanitized her hands.<BR/>2. An admission Record for Resident #2 dated 1/3/2023 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of COVID-19, anemia (low red blood cells), Type 2 diabetes, and hypertension.<BR/>Record review of a Physician Order for Resident #2 dated 12/28/2022 indicated an order for [NAME] 100 mg 1 tablet by mouth one time a day for COVID for 14 days that started on 12/29/2022 with an end date of 1/12/2023.<BR/>Record review of a Quarterly MDS Assessment for Resident #2 dated 10/24/2022 indicated he had no impairment in thinking with a BIMS score of 15. He required extensive assistance with one person assist with dressing and toilet use. He required supervision and one person assist with bed mobility, transfers, and eating. <BR/>Record review of a Care Plan for Resident #2 dated 12/28/2022 indicated a focus of I have tested positive for COVID-19. Intervention/task initiated on 1/3/2023 to accommodate as possible within the limitation of isolation precautions. <BR/>During an observation on 1/3/2023 at 11:59 AM, CNA A was wearing a N95 mask. She sanitized her hands and removed Resident #2's lunch tray from the cart in the hallway and entered Resident #1's room without putting on gloves or a gown. Resident #2's door had signage that indicated he was on contact precautions and indicated for providers and staff to put on gloves, gown, and a mask before entering the room. PPE was noted in a container outside of his door in the hallway. CNA A exited the room and sanitized her hands.<BR/>During an observation and interview on 1/3/2023 at 12:00 PM, CNA A was wearing a N95 mask and said she was the shower tech for the facility and was helping today with passing lunch trays on the halls. She said she had been employed at the facility for 9 months. When asked why Resident #1 and Resident #2 had signs on their doors, she indicated they were both positive for COVID. When asked if the residents were on isolation, she said they both were positive with COVID, and she should have put on a gown and gloves before entering their rooms. She said she did sanitize her hands before entering and after exiting their rooms. She said COVID could be transported to other residents if staff did not wear the proper PPE or sanitize/wash their hands. She said she had received trainings on isolation residents and COVID.<BR/>During an interview on 1/3/2023 at 1:27 PM, the DON said the facility staff received training on COVID and isolation residents on 12/19/2022. She said if staff went in and out of the isolation rooms without wearing appropriate PPE, and then went into resident rooms that were not in isolation, the potential risk would be to carry that infection to another resident. She said the ADON and herself were monitoring staff daily to ensure they were wearing PPE appropriately daily, but were not writing anything down or conducting check offs with the staff. She said since the outbreak started on 12/18/2022, they had not had any issues with staff not wearing PPE appropriately. She said the ADON would conduct an in-service with all staff that day with return demonstration on isolation and donning (put on)/doffing (take off) of PPE.<BR/>Record review of a facility in-service training report dated 12/19/2022 indicated the facility conducted training on COVID, PPE, Isolation Procedure, Donning and Doffing and Testing by the DON and CNA A received training on that date. <BR/>Record review of a facility policy and procedure titled Infection Control-Precautions-Categories and Notices dated 5/2017 indicated, .It is the policy of this home to assure that appropriate precautions will be established to ensure that the necessary isolation techniques are implemented. Precaution notices will be posted when isolation precautions are implemented. 4. In addition to Standard Precautions, Contact Precautions must be implemented for residents known or suspected to be infected, c. remove gloves before leaving the room and wash hands immediately, d. in addition to wearing a gown as outlined under standard precautions, g. signs will be used to alert staff of the implementation of precautions, while protected the privacy of the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests for 2 of 2 hallways, 1 of 1 nurses station, 2 of 8 residents (Resident #1 and Resident #8), and 1 of 1 ice chest reviewed for pest control.<BR/>The facility failed to ensure the 100 and 300 hallways and the common nurse's station between the 2 hallways were free of gnats and pests on 10/30/31 through 11/2/24.<BR/>The facility failed to ensure Resident #8's room was free on gnats on 10/30/24.<BR/>The facility failed to ensure the Ice Chest located at nurses' station for 100 and 300 hallway residents did not have a gnat inside it on 10/30/24.<BR/>The facility failed to ensure Resident #1's room was free of gnats on 10/31/24.<BR/>This failure could place residents at risk of a diminished quality of life due to an unsanitary environment.<BR/>Findings include:<BR/>Record review of a facility face sheet dated 10/26/24 for Resident #1 indicated that he was a [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses that included: quadriplegia (a symptom of paralysis that affects all limbs and body from the neck down).,<BR/>Record review of a comprehensive MDS assessment dated [DATE] for Resident #1 indicated Section C (cognitive patterns) indicated that he was independent with cognitive skills for daily decision making. He had a tracheostomy (an opening in the front of the throat allowing resident to breath.<BR/>During an observation on 10/31/24 at 9:25 am LVN C was observed performing tracheostomy care and suctioning on Resident #1 in his room. She had to swat at gnats during the provision of tracheostomy care and suctioning. Gnats were observed flying around Resident #1's open tracheostomy. <BR/>During an observation on 10/31/24 at 4:10 pm Resident #1's chair was observed with multiple gnats flying and landing all over the chair cushion. <BR/>Record review of a facility face sheet dated 11/2/24 for Resident #8 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of dementia.<BR/>Record review of a comprehensive MDS assessment dated [DATE] for Resident #8 indicated that she had a BIMS score of 9, which indicated that she had moderately impaired cognition. <BR/>During an observation and interview on 10/30/24 at 12:30 pm Resident #8's Family Member said they had brought Resident #8 chicken for lunch yesterday (10/29/24) and the box was still in her trash can in her room. Chicken box observed in residents' trash can with gnats flying all around and inside can. He said Resident #8 could not even eat in peace.<BR/>During observations on 10/26/24 between the hours of 2:15 pm and 3:10 pm gnats were observed flying on hallway 300.<BR/>During an observation on 10/28/24 at 12:20 pm gnats were observed flying on hallway 100.<BR/>During an observation on 10/29/24 at 9:47 am a CNA was observed sitting at the nurse's station between hallways 100 and 300 swatting at gnats.<BR/>During an observation on 10/30/24 at 4:32 pm an ice chest was observed at the nurse's station for 100 and 300 hallways. Ice in chest was observed with a gnat in the ice.<BR/>During a joint interview on 10/26/24 at 3:45 pm the DON and Administrator both said that pest control company was coming next week to spray for the gnats.<BR/>During an interview on 10/29/24 at 3:40 pm LVN K said there were always gnats in the facility, and someone was at the facility now to spray for them. <BR/>During an interview on 10/30/24 at 11:30 am Family Member of Resident #8 said the facility had had gnats for about a month and a half. He said he had told the facility, and they just came in the room and mopped with bleach. Resident #8 observed sitting up in bed trying to eat lunch with gnats flying around food while she tried to eat. <BR/>During an interview on 10/30/24 at 12:19 pm the Maintenance Man said they had had problems with gnats for about 2 to 3 weeks and pest control sprayed weekly. He said he did not have documentation of this nor of what they sprayed because they do not give that to him unless they were called out special like they were yesterday. He said as far as he was aware, yesterday (10/29/24) was the first time they had sprayed for gnats.<BR/>During an interview on 10/30/24 at 4:00 pm the Housekeeping Supervisor said her staff emptied resident room trash cans daily.<BR/>During an interview on 10/31/24 at 3:25 pm the Pest Control representative said her company provided pest control for the facility. She said the facility was set up as a commercial customer and they provide them with a monthly service which included spraying for ants, roaches, and spiders. She said she did not have any documentation of her company providing any spraying for flies or gnats until 10/29/24. She said flies and gnats were not included in their monthly service for commercial customers. <BR/>During an interview on 11/1/2024 at 9:30 am the DON said they had noticed gnats a few weeks ago in the facility and they were scattered throughout. She said they had notified maintenance and had pest control come out. She said they came this week and sprayed foam down the drains and not sure what drains were treated. She said it was much improved the next day. <BR/>During an interview on 11/1/24 at 9:57 am the Administrator said she was hired at the facility in August 2024. She said pest control come on a regular basis, but they came out special and treated the drains this week. She said they shot some foam down them. She also said food left out was a problem. She said she planned to continue to see the underlying cause of the gnats and get the housekeeping department to make sure they are doing their jobs and emptying the trash daily. <BR/>Record review of an invoice from [Company name] pest control dated 10/29/24 indicated that facility drains were treated for ants, cockroaches, beetles, gnats, fruit flies, drain flies, acrobat ants, little black ants, odorous house ants, flies, sugar ants, and fungus. Invoice read .foamed all floor drains in facility. Also foamed sinks of some bathrooms .<BR/>Record review of a facility policy titled Pest Control dated 2001 and revised in October 2023 read .Our facility shall maintain an effective pest control program . and .Garbage and trash are not permitted to accumulate and are removed from the facility daily .

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 2 of 2 meals reviewed for menus and nutritional adequacy. (Lunch meals 04/22/24, 04/23/24).<BR/>Resident # 21 did not receive pureed bread on her lunch tray on 04/22/24.<BR/>Incorrect utensils were used for serving food during lunch on 04/23/24 resulting in improper portion sizes.<BR/>Cook A served the lunch meal on 04/23/24 in a haphazard manner inadequately filling the serving utensils with food and did not deliver the required amount of foods consistently.<BR/>Pureed diets did not receive pureed bread during lunch on 04/23/24.<BR/>Regular and mechanical diets received a half portion of bread during lunch on 04/23/34.<BR/>These failures could place residents who eat foods from the kitchen at risk of not having their nutritional needs met. <BR/>Findings included: <BR/>A review of the dietary spreadsheet dated Day: 30 Monday (04/22/24) for the noon meal indicated a pureed diet should receive a #20 dip (1.52 oz.) of pureed buttered white bread.<BR/>During an observation on 04/22/24 at 1:15 PM Resident #21 was eating in her room and being fed by staff a pureed diet. The divided plate contained pureed soup, corn, and rice. A pureed ice cream sandwich was in a separate bowl. There was no pureed bread served.<BR/>During an interview on 04/23/24 at 1:07 PM, the DM said the pureed bread was placed in a small black plastic cup on the tray because the divided plates did not have room for the bread on the plate but on 04/22/24 the bread was probably in the vegetables. When asked if the vegetable serving size had been adjusted by the RD to include the pureed bread she said no.<BR/>A review of the planned menu dated Week 1 Tuesday (04/23/24) for the noon meal was smoked sausage, sauerkraut, breaded okra, Texas toast, and apple crisp. The dietary spreadsheet indicated a regular diet should receive 3 oz. of sausage, &frac12; cup of sauerkraut, &frac34; cup of breaded okra, 1 slice of Texas toast, and &frac12; cup of apple crisp. The dietary spreadsheet indicated a pureed diet should receive 1/3 cup of sausage, 3/8 cup of sauerkraut, &frac12; cup fried okra, 1/3 cup Texas toast, 3/8 cup of apple crisp.<BR/>During observations and interviews in the kitchen on 04/23/24 the following was noted:<BR/>*at 11:25 AM it was noted regular sliced bread was being used instead of Texas toast and cake with frosting was substituted for apple crisp.<BR/>*at 11:35 AM the DM was pureeing fried okra but found the consistency could not be smoothed to the proper consistency. She threw it way and had [NAME] A get a can of black beans from the pantry to heat up as a substitute for the okra. She said she was substituting creamed corn for the sauerkraut. She said she had 5 residents receiving the pureed diets. She attempted to puree chopped ham instead of sausage for the meat item but could not get it to puree to the proper consistency. She threw the pureed ham away.<BR/>*at 11:45 AM [NAME] A took 4 full sized baking trays of sliced/buttered bread from the oven that had been toasted. The DM instructed her to cut the slices into halves, which she did and placed in a stainless steel pan on the griddle area of the stove for service. One tray of toast was not sliced and prepared for service.<BR/>*at 11:50 AM the DM took 2 dessert dishes containing a serving of cake with frosting and placed them in the food processor. She added 1% milk to the processor and processed to a smooth consistency. She was asked how many desserts she needed to prepare and she said the residents receiving pureed foods were on low concentrated sweets diets and only received a half portion. She pureed 2 servings for 5 residents. She said there were 5 residents receiving pureed diets. She did not use any utensil to measure the amount of processed cake poured into a serving dish. She did not follow a recipe for preparation of the pureed dessert. <BR/>*at 12:00 PM [NAME] A mechanically chopped about 4-5 scoops of sausage slices for the mechanical meat. She said there was not enough sausage slices to make 12 mechanically chopped servings and still have enough whole slices for the regular residents. She placed the chopped sausage on the steam table. DM said she had 10 pounds of smoked sausage to be prepared for the lunch meal. [NAME] A ignored any questions directed towards her regarding how much mechanical sausage she was preparing for service.<BR/>*at 12:12 PM DA B was frying breaded chicken breasts to be used for the pureed meat instead of ham.<BR/>*at 12:17 PM DA B prepared the pureed chicken in the food processor using cold 1% milk as a thinning agent. There was no recipe being used. The chicken was cooled by using cold milk from the refrigerator. [NAME] A was continuing to walk around the kitchen swinging her arms and talking loudly about everything being late but not assisting anyone with preparations. The chicken was placed in the oven to re-heat.<BR/>*at 12:20 PM chopped ham was being heated in a pan on the stove with some BBQ sauce to add to the mechanical sausage that was on the steam table.<BR/>The following the following serving utensils were used during meal service::<BR/>Sausage slices 3 oz;<BR/>fried okra /2 cup (should be 3/4 cup);<BR/>sauerkraut 1/2 cup; creamed corn 6 oz (should be 4 oz);<BR/>mechanical sausage/chopped ham mix 6 oz. (should be 3 oz);<BR/>puree meat 8 oz (should be 1/3 cup);<BR/>puree corn 6 oz (should be 4 oz);<BR/>puree black beans 6 oz (should be 4 oz);<BR/>half slices of buttered toast were in a stainless steel pan on the griddle area of the stove (should be full slice)<BR/>no puree bread was prepared.<BR/>*at 12:45 PM tray line service started and [NAME] A began serving the food by scooping food into the utensils, the utensil was not always full of food.<BR/>*at 12:47 PM DA B plated a half piece of toast with her gloved hand and covered the plate with an insulated lid.<BR/>*at 12:52 PM pureed items were served using the 6 oz scoops placed in the containers of beans and corn. The utensils were filled partially with an indeterminate amount of food and placed on the plates. Using an 8 oz scoop for the meat the utensil was partially filled and an undetermined amount was placed on the plates. No pureed bread was prepared and placed on the plate or tray during this meal service.<BR/>*at 12:55 PM the last pureed plates were served using partially filled scoops. [NAME] A and DA B were scraping the puree containers on the steam table to get a little bit of food into the serving utensils and placed that on the last plate. They were laughing about having to scrape so hard to get some food to place on the plate.<BR/>*at 1:00 PM DA C came to the kitchen from delivering a tray cart and she said the nurse said Resident #308 was to get large portions and he did not receive them. [NAME] A said no one was getting large portions or double portions today because there was not enough food. She said all the residents were just going to get regular portions.<BR/>A review of the dietary roster dated 04/22/24 indicated there were 5 residents receiving pureed diets and 5 residents receiving large portions, double entrees, or double meat/protein portions. There were 2 residents that did not receive food from the kitchen.<BR/>The DM said she had not checked the utensils used for service or made sure the foods served was appropriate. When asked about the lack of serving utensils she said she tried to order one on each order.<BR/>During an interview on 04/23/24 at 1:20 PM the DM said residents should have received a whole slice of bread. She said the cook must have misunderstood her when she told her to cut the toast slices in half. She said she meant for them to be cut in half so they could be placed on the plates easier. The DM seemed resigned to the type of staff she had and said she was just lucky to have anyone that would work.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen observed for kitchen sanitation.<BR/>The microwave had food debris and splatters.<BR/>The bulk flour bin had a measuring cup inside.<BR/>The DM dropped a thermometer into the pureed meat and served the food.<BR/>Cook A touched the inside of the plates and food with her gloved hands. She was not wearing an apron and used her body to keep the plates with food on the tray line.<BR/>DA B touched the inside of the plates with her bare hand and placed bread on top of the food using her hand and not a utensil.<BR/>Cook A returned food that had spilled onto the prep area to the pan of food on the steam table.<BR/>These failures could place residents who ate food from the kitchen at risk of foodborne illness.<BR/>Findings included:<BR/>During observations and interviews on 04/22/24 of the kitchen the following was noted:<BR/>*at 10:00 AM Microwave had food debris and liquid splatters inside.<BR/> *at 10:20 AM the bulk flour bin had a measuring cup stored inside product. The DM removed the cup from the flour and said that wasn't supposed to be in there.<BR/>During observations and interviews on 04/23/24 of the kitchen the following was noted:<BR/>*at 12:40 PM the DM was taking the holding temperature of the pureed chicken breasts and dropped the thermometer into the food. She dipped the thermometer out of the pureed meat with another utensil, wiped off the face of the dial with her bare hand, and continued to try and get a temperature reading. She said the steam was hot on her arm.<BR/>*at 12:45 PM the tray line service started. [NAME] A placed 9-10 plates at a time in their insulated bottoms on the prep area beside the steam table and along the tray line on the steam table. She placed her gloved hands in the bottom of the plates. She began serving the food and scooping the food into the utensils and dumping it on the plates. She contained the food to the plate using her hands.<BR/>*at 12:47 PM DA B was placing the sauerkraut and bread on the plates, picking the plates up and placing them on the delivery cart. She was wearing a glove on her right hand but not her left hand. She picked up the plates using her left hand and her thumb was inside the plate. Using her gloved hand, instead of tongs, she picked up a half a piece of toast and placed it on top of the food and covered the plate with a lid.<BR/>*at 12:50 PM [NAME] A kept rapidly tossing food onto plates using her gloved hands to scoot the food around on the plates because it had been so forcefully placed. Sausage slices came out of the serving utensil and landed on the prep area around the steam table and she picked up the slices and returned them to the container of sausage on the steam table.<BR/>*at 12:55 PM [NAME] A was using her body to keep plates on the steam table tray line. She was not wearing an apron, just her street clothes, and was bumping the plates of food with her stomach area.<BR/>During the observation the DM was not observing food service and was not aware of what activities were taking place on the serving line. She had not checked the utensils used for service or made sure the foods were served appropriately.<BR/>Food Code 2013 - Hands and Arms 2-301.11 Clean Condition. The hands are particularly important in transmitting foodborne pathogens. Food employees with dirty hands and/or fingernails may contaminate the food being prepared. Therefore, any activity which may contaminate the hands must be followed by thorough handwashing in accordance with the procedures outlined in the Code. Even seemingly healthy employees may serve as reservoirs for pathogenic microorganisms that are transmissible through food. Staphylococci, for example, can be found on the skin and in the mouth, throat, and nose of many employees. The hands of employees can be contaminated by touching their nose or other body parts. 2-301.12 Cleaning Procedure. Handwashing is a critical factor in reducing fecal-oral pathogens that can be transmitted from hands to RTE food as well as other pathogens that can be transmitted from environmental sources.

Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.<BR/>The facility failed to provide a safe, functional, sanitary, and comfortable environment by ensuring windows in resident rooms 808, 901, 902, 903, 904, 906, 907, 909, and 911 were operable and had screens in place.<BR/>This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. <BR/>Findings included:<BR/>Observations on 2/27/23 revealed that on the secure unit, 9 of 11 windows were found to be either inoperable or operable without a window screen.<BR/>9 windows were without screens: Rooms 808, 901, 902, 903, 904, 906, 907, 909, and 911.<BR/>5 windows were also found to be screwed down, rendering them inoperable: Rooms 902, 904, 906, 907, and 909.<BR/>In an interview with the Administrator and the DON on 02/28/23 at 08:21 AM, both the DON and the Administrator said that they did not know that it was a regulation that windows must have a screen. They did say that they could see the need for screens for pest control and to allow residents to open their windows if they desired.<BR/>In an interview with MAINT on 02/28/23 at 09:08 AM, he said that window latches already had holes in them from being screwed down previously and were re-screwed down after an elopement incident. He said that he does not know when the screens were removed from the windows on the unit. He said that most windows in the facility do have screens, and if he noticed any that were off, that he would pick them up and put them back on. He said that sometimes when the lawn is being mowed or weed-eated, a rock or something might hit them, knocking them down. He said he had not thought about screens being in place for pest control, but that he could see where that could be an issue.<BR/>In an interview with the Administrator on 3/1/23 at 9:30am, she said that the only harm to residents that she could think of might be pest control. She said she really can not think of any other harm that might come to residents. She said that she will see what can be done about the windows on the unit being screwed down, that they may try to figure out how to limit them to opening a minimal amount to keep residents safe. She was not aware previously that it was a regulation. She said that by ensuring that residents were able to open their windows if they chose to do so, it could make their environment more comfortable, and screens in place could ensure safety.<BR/>In an interview with the DON on 3/1/23 at 11:00am, she said that if residents were to open their windows without a screen in place, that they could potentially elope or be stung by an insect if an insect were to be able to fly in. She said that having screens in place could help ensure resident safety.<BR/>Record review of facility policy titled maintenance service dated December 2022 states .the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . and .Functions of maintenance personnel include, but are not limited to: a) maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines; b) maintaining the building in good repair and free from hazards; and .k) maintaining doors, windows and screens (where indicated) in appropriate working order .<BR/>No policy was provided for safe, comfortable, homelike environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 8 residents reviewed for infection control. (Resident #1 and Resident #2)<BR/>The facility did not ensure CNA A wore gloves or a gown when passing lunch trays to the rooms of Resident #1 and Resident #2 who were both on contact precautions for COVID.<BR/>These failures could place residents at risk of exposure to communicable diseases and infections.<BR/>Findings included:<BR/>1. An admission Record for Resident #1 dated 1/3/2023 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hemiplegia and hemiparesis (one sided weakness), COVID-19, alcohol dependence, and hypertension.<BR/>Record review of the physician orders for Resident #1 indicated an order dated 12/26/2022 for vitamin c 500 mg 1 tablet my mouth one time a day and zinc 100 mg 1 tablet by mouth one time a day for COVID protocol for 14 days started on 12/26/2022 with an end date of 1/9/2023.<BR/>Record review of Quarterly MDS Assessment for Resident #1 dated 10/17/2022 indicated he had no impairment in thinking with a BIMS score of 15. He required extensive assistance with two-person assist with bed mobility, transfers, dressing, toilet use and personal hygiene. <BR/>Record review of a Care Plan for Resident #1 dated 12/26/2022 indicated a focus of: I have tested positive for COVID-19 with an intervention/task that was initiated on 1/3/2023 to accommodate as possible within the limitations of isolation precautions.<BR/>During on observation on 1/3/2023 at 11:55 AM, CNA A was wearing a N95 mask. She sanitized her hands and removed Resident #1's lunch tray from the cart in the hallway and entered Resident #1's room without putting on gloves or a gown. Resident #1's door had signage that indicated he was on contact precautions and for providers and staff were to put on gloves, gown, and a mask before entering the room. PPE was noted in a container outside of his door in the hallway. CNA A exited the room and sanitized her hands.<BR/>2. An admission Record for Resident #2 dated 1/3/2023 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of COVID-19, anemia (low red blood cells), Type 2 diabetes, and hypertension.<BR/>Record review of a Physician Order for Resident #2 dated 12/28/2022 indicated an order for [NAME] 100 mg 1 tablet by mouth one time a day for COVID for 14 days that started on 12/29/2022 with an end date of 1/12/2023.<BR/>Record review of a Quarterly MDS Assessment for Resident #2 dated 10/24/2022 indicated he had no impairment in thinking with a BIMS score of 15. He required extensive assistance with one person assist with dressing and toilet use. He required supervision and one person assist with bed mobility, transfers, and eating. <BR/>Record review of a Care Plan for Resident #2 dated 12/28/2022 indicated a focus of I have tested positive for COVID-19. Intervention/task initiated on 1/3/2023 to accommodate as possible within the limitation of isolation precautions. <BR/>During an observation on 1/3/2023 at 11:59 AM, CNA A was wearing a N95 mask. She sanitized her hands and removed Resident #2's lunch tray from the cart in the hallway and entered Resident #1's room without putting on gloves or a gown. Resident #2's door had signage that indicated he was on contact precautions and indicated for providers and staff to put on gloves, gown, and a mask before entering the room. PPE was noted in a container outside of his door in the hallway. CNA A exited the room and sanitized her hands.<BR/>During an observation and interview on 1/3/2023 at 12:00 PM, CNA A was wearing a N95 mask and said she was the shower tech for the facility and was helping today with passing lunch trays on the halls. She said she had been employed at the facility for 9 months. When asked why Resident #1 and Resident #2 had signs on their doors, she indicated they were both positive for COVID. When asked if the residents were on isolation, she said they both were positive with COVID, and she should have put on a gown and gloves before entering their rooms. She said she did sanitize her hands before entering and after exiting their rooms. She said COVID could be transported to other residents if staff did not wear the proper PPE or sanitize/wash their hands. She said she had received trainings on isolation residents and COVID.<BR/>During an interview on 1/3/2023 at 1:27 PM, the DON said the facility staff received training on COVID and isolation residents on 12/19/2022. She said if staff went in and out of the isolation rooms without wearing appropriate PPE, and then went into resident rooms that were not in isolation, the potential risk would be to carry that infection to another resident. She said the ADON and herself were monitoring staff daily to ensure they were wearing PPE appropriately daily, but were not writing anything down or conducting check offs with the staff. She said since the outbreak started on 12/18/2022, they had not had any issues with staff not wearing PPE appropriately. She said the ADON would conduct an in-service with all staff that day with return demonstration on isolation and donning (put on)/doffing (take off) of PPE.<BR/>Record review of a facility in-service training report dated 12/19/2022 indicated the facility conducted training on COVID, PPE, Isolation Procedure, Donning and Doffing and Testing by the DON and CNA A received training on that date. <BR/>Record review of a facility policy and procedure titled Infection Control-Precautions-Categories and Notices dated 5/2017 indicated, .It is the policy of this home to assure that appropriate precautions will be established to ensure that the necessary isolation techniques are implemented. Precaution notices will be posted when isolation precautions are implemented. 4. In addition to Standard Precautions, Contact Precautions must be implemented for residents known or suspected to be infected, c. remove gloves before leaving the room and wash hands immediately, d. in addition to wearing a gown as outlined under standard precautions, g. signs will be used to alert staff of the implementation of precautions, while protected the privacy of the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good personal hygiene for 2 of 24 residents (Resident #24 and<BR/> #49) reviewed for ADLs. <BR/>Resident #24 missed 7 scheduled baths in February 2023. <BR/>Resident #49 missed 8 scheduled baths in February 2023<BR/>These failures could cause all residents not to receive daily personal hygiene services and cause the resident to have health, social, and emotional issues. <BR/>Findings included:<BR/>1.Record review of a Face Sheet dated 3/1/2023 for Resident #24 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hypothyroidism (thyroid gland does not make enough thyroid hormone), Type 2 diabetes, bipolar (shifts in a person's mood) and hypertension (high blood pressure).<BR/>Record review of a Quarterly MDS dated [DATE] for Resident #24 indicated she did not have any impairment in thinking with a BIMS score of 15. She was totally dependent in bathing with one person assist.<BR/>Record review of a Care plan dated 3/1/2023 for Resident #24 indicated resident refuses care at times. On 7/21/2022 resident refused a shower with an intervention to re-approach at intervals. ADL functions bathing-total assist 1-2 dated 4/2/2020 with interventions to set-up, assist and give shower per schedule and prn.<BR/>Record review of a shower schedule dated 2/22/2023 indicated Resident #24's shower days were scheduled for Tuesday, Thursday, and Saturday on hall 500. <BR/>Record review of a task documentation report for Resident #24 dated 3/1/2023 for the month of February 2023 indicated the bathing task:<BR/>2/4/2023 was blank.<BR/>2/11/2023, 2/14/2023, 2/16/2023 had N/A-not applicable with initials for CNA C.<BR/>2/18/2023 was blank.<BR/>2/25/2023 had N/A with initials for LVN D.<BR/>2/28/2023 had N/A with initials for CNA C.<BR/>Record review of an In-Service Training Report dated 12/2/2022 by the DON indicated that showers must be completed per schedule, if resident refuses, the CNA must report to the nurse and document, then notify RP with any refusals. The facility is to ensure showers are completed. CNA C and LVN D were not in attendance on the sign in sheet.<BR/>During an observation and interview on 3/01/2023 at 8:41 AM, Resident #24 was lying in bed awake and said she had not had a shower in a long time and the last day she received a bed bath was last Thursday (2/23/2023). She said they did not wash her hair at that time. She said she was supposed to get her showers on Tuesday and Thursdays. She said the staff did not give showers on the weekends. She said getting a bath regularly on her scheduled days stopped when the shower tech (CNA C) at that time quit. She said CNA C was back working the floor and not doing the showers anymore. She said it made her feel terrible not getting her showers when she was supposed to. She said she was stuck in her room in the bed and was not able to get up and talk to people because she was not able to walk and had bilateral foot drop. Resident #24 did not have an odor but had a few dandruff flakes in her scalp.<BR/>During an interview on 3/1/2023 at 10:40 AM, CNA C said she had been employed at the facility for 5 years. She said she was the shower tech for 2 years and quit that position in November 2022. She said there was no one at the facility designated as the shower tech. She said the facility had a shower tech who was responsible for providing showers to the residents Monday-Friday. She said they did not have a shower tech on the weekends. She said she worked the north side of the facility which included halls 400, 500, 600, and 700. She said she returned to work from vacation this past Monday on 2/27/2023 and did not give any showers or bed baths to any residents on 2/27/2023 or 2/28/2023. She said Resident #24 did not get a shower or bed bath on 2/28/2023 and her shower schedule was on Tuesdays, Thursdays, and Saturdays. She said since she had been working at the facility, no residents received any baths or showers on the weekends. She said today was the first time that she heard anything about the CNAs would be responsible for giving the residents their baths or showers per their assigned schedule. She said she did not know why Resident #24 did not get a shower or bath on 2/28/2023 and she was assigned to her hall. She said N/A was placed when a resident did not get a shower on that day. She said she had been off and was not sure how long the facility had been without a shower tech.<BR/>2. Record review of a Face Sheet dated 3/1/2023 for Resident #49 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of osteomyelitis of right ankle and foot (infection of the bone), Type 2 diabetes (high blood glucose levels), and hypertension (high blood pressure).<BR/>Record review of an admission MDS dated [DATE] for Resident #49 indicated he had moderately impaired thinking with a BIMS score of 11. He required extensive assistance in bathing with one person assist and had no behaviors of rejecting care.<BR/>Record review of progress notes for Resident #49 dated 2/01/23 thru 3/1/23 had no documentation of being resistive or refusing care.<BR/>Record review of a care plan dated 2/20/2023 for Resident #49 indicated resident requires assistance with ADLs, will maintain a sense of dignity by being clean, dry, odor free and well-groomed over the next 90 days. Interventions: set-up, assist and give shower per schedule and prn. Shave, oral and hair care per schedule and prn.<BR/>Record review of a shower schedule dated 2/2023 indicated Resident #49's shower days were scheduled for Monday, Wednesday, and Friday on hall 800. <BR/>Record review of a task documentation report for Resident #49 dated 3/1/2023 for the month of February 2023 indicated the bathing task:<BR/>2/1/2023, 2/3/2023, 2/6/2023 and 2/13/2023 had N/A-not applicable with <BR/>initials for CNA E.<BR/>2/8/2023 had N/A with initials for CNA F<BR/>2/20/2023, 2/22/2023 and 2/24/2023 were blank.<BR/>Record review of an In-Service Training Report dated 12/2/2022 by the DON indicated that showers must be completed per schedule, if resident refuses, the CNA must report to the nurse and document, then notify RP with any refusals. The facility is to ensure showers are completed. CNA E and CNA F were in attendance on the sign in sheet.<BR/>During an observation and interview on 3/01/2023 at 10:00 AM, Resident #49 was in his room sitting in his wheelchair. He was dressed and had a not been shaved recently. The room and resident had a smell of urine. <BR/>During an interview and record review on 03/01/23 at 10:30am with MA A, she said she always documents in PCC when she gives a shower or bath. She stated that they had a shower aide in the past but currently they do not and that the CNAs assigned for resident care are expected give the showers. MA A opened the electronic record and showed this surveyor documentation of baths given to Resident #49 by her on 2/10/23, 2/15/23 and 2/27/23, three of the only four baths given for the month of February 2023.<BR/>During an interview on 3/01/23 at 12:45 p.m. with resident #49's RP and the ADM in the common area of the locked unit. The RP told the administrator and this surveyor she had repeatedly asked for Resident #49 to get a bath. She said she comes to the facility almost every day to see about him, since his admission and baths are very infrequent. She had asked the staff to make sure he was cleaned up and ready to go to his appointment with the surgeon today, but when she arrived, he had not been given a bath. The ADM said that it was unacceptable for resident #49 not to get his baths and personal care needed. She would be conducting a full investigation and make sure this problem was solved. The ADM said that not getting personal care and baths could lead to low self-esteem, skin breakdown and skin infections.<BR/>During an interview on 3/1/2023 at 1:42 PM, the DON said N/A on the documentation survey report for the tasks indicated it was not applicable but was unsure what it meant and would have to ask the CNAs. She said if there was a blank then it indicated that the task was not done. She said they had a shower tech for the facility who was responsible for providing showers to residents on hall 400, 500, 600 and 700 Monday-Friday. She said there was not a shower tech on the weekends. She said on the weekends the CNAs were responsible for giving showers to the residents. She said the current shower tech was out on leave as of Monday 2/28/2023. She said as of right now the CNAs were responsible for giving showers until the shower tech returned. She said the charting system at the facility indicated on the schedule for the CNAs which residents needed a shower on what day. She said on the documentation survey report for tasks if there was an (X) for a date then it indicated that the task was not due on that day. She said she was not aware Resident #24 and Resident #49 were not receiving their showers according to their schedules. She said it was standard for all residents to receive a shower at least 3 days a week. She said she was in the process of conducting an audit at the facility to see if residents received their showers according to documentation in the charting system. She said she conducted an in-service today about showers with staff and the CNAs were to give the residents showers. She said if a resident did not receive showers there could a risk of skin breakdown. <BR/>Record review of a facility policy titled Bathing/Showering Documentation with a date of 5/2017 indicated, .It is the policy of this home that residents will be assisted with their bathing needs and will be bathed on a routine basis. 1. Staff must document bathing/showering on schedule days for each resident. 2. Staff must report all refusals to charge nurse and document refusals .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 3 medication carts (nurse cart for locked unit) reviewed for pharmacy services. <BR/>The facility did not dispose of expired insulin pens from the nurse medication cart for the locked unit. <BR/>These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life, and hospitalization.<BR/>Findings included:<BR/>Record review of the Physician orders dated February 2023 indicated Resident #26 was a [AGE] year-old female admitted on [DATE]. Her diagnosis included type 1 diabetes. An order dated 06/08/22 indicated Resident #26 was to have NovoLog Solution 100 unit/ml (Insulin) Inject as per sliding scale (amount of insulin given per level of blood sugar at time of testing): if 60 - 150 = 0 units; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units subcutaneously and call physician.<BR/>During an observation of the nurse medication cart for the locked hall on 02/28/2023 at 8:45 AM with the DON revealed the following:<BR/>Novolog Solution 100 unit per milliliter flex pen open date 01/15/23 and expired date 02/15/23. <BR/>Glargine Solution 100 unit per milliliter flex pen open date 01/16/23 and expired date 02/16/23. <BR/>During an interview and observation on 02/28/2023 at 09:00 AM, the DON said she did not know the medication cart had expired insulins. She discarded the expired insulin, and she obtained two new vials of insulin and placed them in the cart for use. She said most insulins were to be replaced 28 days after opening. She said all insulins should have an open date on them since they were only good for so many days after opening. She said the number of days depended on the insulin. She said if a resident was given medications that were expired, the medications may not provide an effective result.<BR/>She said the nurses and medication aides were responsible for ensuring their carts did not have expired medications. She said going forward she would provide more frequent monitoring of the medication carts. She said the facility did not have an ADON and she had many things that she was responsible for but would try to do better. <BR/>Record review of the Physician orders dated February 2023 indicated Resident #26 had an order dated 06/08/22 for Glargine Solution 100 unit/ml (Insulin) inject 10 units subcutaneously two times a day, am and pm.<BR/>Record review of a facility policy titled Storage of Medications in the Home, dated 05/2017. It is the policy of this home that medications will be stored appropriately as to be secure from tampering, exposure or misuse .12. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of per procedures for medications destruction, and reordered from the pharmacy, if a current order exits.<BR/>Record review of a facility policy titled Medication-Vials and Ampules of Injectable with a revised date of 05/2017 indicated, .2. The date opened and the initials of the first person to use the vial are recorded on multi-dose vials. 4 .Medication may be used until the manufacturer's expiration date or for the length of time allowed by state law if inspection reveals no problems. <BR/>Record review of the package insert for Novolog (insulin aspart flex pen) accessed at https://www.novo-pi.com/novolog.pdf on 02/28/23 indicated unopened and stored at room temperature was good for 28 days, unopened and refrigerated was good until the expiration date, and opened was good for 28 days.<BR/>Record review of the package insert for Glargine (insulin flex pen) accessed at https://basaglar.com on 02/28/23 indicated unopened and stored at room temperature was good for 28 days, unopened and refrigerated was good until the expiration date, and opened was good for 28 days.

Based on observation, interview, and record review, the governing body failed to appoint an Administrator licensed by the state who was responsible for management of the facility for 1 of 1 facility reviewed for governing body. <BR/>The governing body failed to designate a person in the role of an Administrator from December 13 2024, to February 12, 2025.<BR/>This deficient practice could result in the facility not being managed in a responsible manner, which could affect the health and safety of all residents. <BR/>The findings included: <BR/>During an observation and interview on 3/4/2025 at 7:45 AM, an entrance conference was conducted with the DON only being present. She said the facility did not have a full time Administrator, but they had recently hired an interim one. She said the interim Administrator was not in the facility and was unsure if she would be in that day. The DON called the interim Administrator and put her on speaker phone. The interim Administrator said her first day in the facility was on 2/12/2025 and she had been at the facility about four times since she started and tried to visit at least two times a week. <BR/>During an interview on 3/4/2025 at 1:25 PM, LVN E said she had been employed at the facility for a long time. She said the facility had been without an Administrator since sometime in December 2024. She said the new interim Administrator started at the facility one day last week or the week prior. She said after the previous Administrator left; the staff were reporting things to the DON.<BR/>During an interview on 3/4/2025 at 2:08 PM, the BOM said the previous Administrator's last day was December 13, 2024. She said the facility currently had an interim Administrator and her first day in the facility was February 12, 2025.<BR/>During a follow-up interview on 3/4/2025 at 3:36 PM, the DON said the previous Administrator last day in the facility was on December 12, 2024, and did not return. She said during that time after the previous Administrator left, she would notify the facility's ADO who had an Administrator license for guidance and support, but she did not have a Texas license. She said she also contacted other Administrators who she knew for advice and guidance as the ADO would not always be available to answer the phone. She said not having an Administrator in the facility put them at risk of not having a leader and not knowing which way to go. She said she had access to the state regulations and thought that an Administrator should be in the facility for at least 40 hours a week full time. <BR/>During an interview on 3/4/2025 at 4:28 PM, the interim Administrator said her first day in the facility was 2/12/2025. She said having an Administrator in the facility was to provide oversight and conduct meetings with the team. She said she met with the team everyday over the phone but not physically in the facility. She said an Administrator should have 40 hours of administrative hours and she did not clock in or out. She said she was not aware the facility did not have an Administrator from December to when she started at the facility. She said there could be a risk of not watching out for the team and missing critical compliance if the facility did not have an Administrator.<BR/>Record review of a facility policy titled Administration dated 3/2020 indicated, .It is the policy of this home to follow TAC rule for Nursing Home Administrator. The facility must have a governing body, or designated persons functioning as a governing body that is legally responsible for establishing and implementing polices regarding the management and operation of the facility. 3. The governing body appointed, and the facility must operate under supervision of a nursing facility administrator who is: 1) Licensed by the Texas Board of Nursing Facility Administrators. 2) Responsible for management of the facility .

Based on interview and record review, the facility failed to ensure residents were informed orally, of their rights, for 8 of 8 residents interviewed during a group meeting. Resident #s #15, #16, #25, #29, #31, #40 and #303. <BR/>Residents were not provided on going communication of their rights, during their stay in the facility. <BR/>This failure could place the residents at risk of a decreased quality of life, decreased awareness of their right and decreased execution of their rights. <BR/>Findings include:<BR/>During record review of monthly resident council meeting minutes, on 04/23/2024 at 8:50AM, revealed resident rights were not reviewed, over the past five months; April, March, February and January 2024 and December 2023. <BR/>During interview on 04/23/2024 at 10:00AM, Residents #15, #16, #25, #26, #29, #31, #40 and #303 said, the Activity Director had not reviewed or explained resident rights to them . <BR/>During interview on 04/24/2024 at 10:55AM, the Activity Director said she never reviewed the list of resident rights with the residents. She said she did not know she should have been reviewing the rights. She said if a resident brought up an issue that involved a right, she would discuss that right for that particular situation. She said she will start reviewing the list of resident rights at future resident council meetings.<BR/>During interview on 04/24/2024 at 4:30PM, the Administrator said the resident receive a copy of the resident rights, when they receive their admission packet, upon admission. She said she has not reviewed the list of resident rights with the residents. <BR/>Review of a document titled Resident Right, with a revised date of 2016, Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation #1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include . The policy does not addressng, orally explaining the resident rights to the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good personal hygiene for 2 of 24 residents (Resident #24 and<BR/> #49) reviewed for ADLs. <BR/>Resident #24 missed 7 scheduled baths in February 2023. <BR/>Resident #49 missed 8 scheduled baths in February 2023<BR/>These failures could cause all residents not to receive daily personal hygiene services and cause the resident to have health, social, and emotional issues. <BR/>Findings included:<BR/>1.Record review of a Face Sheet dated 3/1/2023 for Resident #24 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of hypothyroidism (thyroid gland does not make enough thyroid hormone), Type 2 diabetes, bipolar (shifts in a person's mood) and hypertension (high blood pressure).<BR/>Record review of a Quarterly MDS dated [DATE] for Resident #24 indicated she did not have any impairment in thinking with a BIMS score of 15. She was totally dependent in bathing with one person assist.<BR/>Record review of a Care plan dated 3/1/2023 for Resident #24 indicated resident refuses care at times. On 7/21/2022 resident refused a shower with an intervention to re-approach at intervals. ADL functions bathing-total assist 1-2 dated 4/2/2020 with interventions to set-up, assist and give shower per schedule and prn.<BR/>Record review of a shower schedule dated 2/22/2023 indicated Resident #24's shower days were scheduled for Tuesday, Thursday, and Saturday on hall 500. <BR/>Record review of a task documentation report for Resident #24 dated 3/1/2023 for the month of February 2023 indicated the bathing task:<BR/>2/4/2023 was blank.<BR/>2/11/2023, 2/14/2023, 2/16/2023 had N/A-not applicable with initials for CNA C.<BR/>2/18/2023 was blank.<BR/>2/25/2023 had N/A with initials for LVN D.<BR/>2/28/2023 had N/A with initials for CNA C.<BR/>Record review of an In-Service Training Report dated 12/2/2022 by the DON indicated that showers must be completed per schedule, if resident refuses, the CNA must report to the nurse and document, then notify RP with any refusals. The facility is to ensure showers are completed. CNA C and LVN D were not in attendance on the sign in sheet.<BR/>During an observation and interview on 3/01/2023 at 8:41 AM, Resident #24 was lying in bed awake and said she had not had a shower in a long time and the last day she received a bed bath was last Thursday (2/23/2023). She said they did not wash her hair at that time. She said she was supposed to get her showers on Tuesday and Thursdays. She said the staff did not give showers on the weekends. She said getting a bath regularly on her scheduled days stopped when the shower tech (CNA C) at that time quit. She said CNA C was back working the floor and not doing the showers anymore. She said it made her feel terrible not getting her showers when she was supposed to. She said she was stuck in her room in the bed and was not able to get up and talk to people because she was not able to walk and had bilateral foot drop. Resident #24 did not have an odor but had a few dandruff flakes in her scalp.<BR/>During an interview on 3/1/2023 at 10:40 AM, CNA C said she had been employed at the facility for 5 years. She said she was the shower tech for 2 years and quit that position in November 2022. She said there was no one at the facility designated as the shower tech. She said the facility had a shower tech who was responsible for providing showers to the residents Monday-Friday. She said they did not have a shower tech on the weekends. She said she worked the north side of the facility which included halls 400, 500, 600, and 700. She said she returned to work from vacation this past Monday on 2/27/2023 and did not give any showers or bed baths to any residents on 2/27/2023 or 2/28/2023. She said Resident #24 did not get a shower or bed bath on 2/28/2023 and her shower schedule was on Tuesdays, Thursdays, and Saturdays. She said since she had been working at the facility, no residents received any baths or showers on the weekends. She said today was the first time that she heard anything about the CNAs would be responsible for giving the residents their baths or showers per their assigned schedule. She said she did not know why Resident #24 did not get a shower or bath on 2/28/2023 and she was assigned to her hall. She said N/A was placed when a resident did not get a shower on that day. She said she had been off and was not sure how long the facility had been without a shower tech.<BR/>2. Record review of a Face Sheet dated 3/1/2023 for Resident #49 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of osteomyelitis of right ankle and foot (infection of the bone), Type 2 diabetes (high blood glucose levels), and hypertension (high blood pressure).<BR/>Record review of an admission MDS dated [DATE] for Resident #49 indicated he had moderately impaired thinking with a BIMS score of 11. He required extensive assistance in bathing with one person assist and had no behaviors of rejecting care.<BR/>Record review of progress notes for Resident #49 dated 2/01/23 thru 3/1/23 had no documentation of being resistive or refusing care.<BR/>Record review of a care plan dated 2/20/2023 for Resident #49 indicated resident requires assistance with ADLs, will maintain a sense of dignity by being clean, dry, odor free and well-groomed over the next 90 days. Interventions: set-up, assist and give shower per schedule and prn. Shave, oral and hair care per schedule and prn.<BR/>Record review of a shower schedule dated 2/2023 indicated Resident #49's shower days were scheduled for Monday, Wednesday, and Friday on hall 800. <BR/>Record review of a task documentation report for Resident #49 dated 3/1/2023 for the month of February 2023 indicated the bathing task:<BR/>2/1/2023, 2/3/2023, 2/6/2023 and 2/13/2023 had N/A-not applicable with <BR/>initials for CNA E.<BR/>2/8/2023 had N/A with initials for CNA F<BR/>2/20/2023, 2/22/2023 and 2/24/2023 were blank.<BR/>Record review of an In-Service Training Report dated 12/2/2022 by the DON indicated that showers must be completed per schedule, if resident refuses, the CNA must report to the nurse and document, then notify RP with any refusals. The facility is to ensure showers are completed. CNA E and CNA F were in attendance on the sign in sheet.<BR/>During an observation and interview on 3/01/2023 at 10:00 AM, Resident #49 was in his room sitting in his wheelchair. He was dressed and had a not been shaved recently. The room and resident had a smell of urine. <BR/>During an interview and record review on 03/01/23 at 10:30am with MA A, she said she always documents in PCC when she gives a shower or bath. She stated that they had a shower aide in the past but currently they do not and that the CNAs assigned for resident care are expected give the showers. MA A opened the electronic record and showed this surveyor documentation of baths given to Resident #49 by her on 2/10/23, 2/15/23 and 2/27/23, three of the only four baths given for the month of February 2023.<BR/>During an interview on 3/01/23 at 12:45 p.m. with resident #49's RP and the ADM in the common area of the locked unit. The RP told the administrator and this surveyor she had repeatedly asked for Resident #49 to get a bath. She said she comes to the facility almost every day to see about him, since his admission and baths are very infrequent. She had asked the staff to make sure he was cleaned up and ready to go to his appointment with the surgeon today, but when she arrived, he had not been given a bath. The ADM said that it was unacceptable for resident #49 not to get his baths and personal care needed. She would be conducting a full investigation and make sure this problem was solved. The ADM said that not getting personal care and baths could lead to low self-esteem, skin breakdown and skin infections.<BR/>During an interview on 3/1/2023 at 1:42 PM, the DON said N/A on the documentation survey report for the tasks indicated it was not applicable but was unsure what it meant and would have to ask the CNAs. She said if there was a blank then it indicated that the task was not done. She said they had a shower tech for the facility who was responsible for providing showers to residents on hall 400, 500, 600 and 700 Monday-Friday. She said there was not a shower tech on the weekends. She said on the weekends the CNAs were responsible for giving showers to the residents. She said the current shower tech was out on leave as of Monday 2/28/2023. She said as of right now the CNAs were responsible for giving showers until the shower tech returned. She said the charting system at the facility indicated on the schedule for the CNAs which residents needed a shower on what day. She said on the documentation survey report for tasks if there was an (X) for a date then it indicated that the task was not due on that day. She said she was not aware Resident #24 and Resident #49 were not receiving their showers according to their schedules. She said it was standard for all residents to receive a shower at least 3 days a week. She said she was in the process of conducting an audit at the facility to see if residents received their showers according to documentation in the charting system. She said she conducted an in-service today about showers with staff and the CNAs were to give the residents showers. She said if a resident did not receive showers there could a risk of skin breakdown. <BR/>Record review of a facility policy titled Bathing/Showering Documentation with a date of 5/2017 indicated, .It is the policy of this home that residents will be assisted with their bathing needs and will be bathed on a routine basis. 1. Staff must document bathing/showering on schedule days for each resident. 2. Staff must report all refusals to charge nurse and document refusals .

Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.<BR/>The facility failed to provide a safe, functional, sanitary, and comfortable environment by ensuring windows in resident rooms 808, 901, 902, 903, 904, 906, 907, 909, and 911 were operable and had screens in place.<BR/>This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. <BR/>Findings included:<BR/>Observations on 2/27/23 revealed that on the secure unit, 9 of 11 windows were found to be either inoperable or operable without a window screen.<BR/>9 windows were without screens: Rooms 808, 901, 902, 903, 904, 906, 907, 909, and 911.<BR/>5 windows were also found to be screwed down, rendering them inoperable: Rooms 902, 904, 906, 907, and 909.<BR/>In an interview with the Administrator and the DON on 02/28/23 at 08:21 AM, both the DON and the Administrator said that they did not know that it was a regulation that windows must have a screen. They did say that they could see the need for screens for pest control and to allow residents to open their windows if they desired.<BR/>In an interview with MAINT on 02/28/23 at 09:08 AM, he said that window latches already had holes in them from being screwed down previously and were re-screwed down after an elopement incident. He said that he does not know when the screens were removed from the windows on the unit. He said that most windows in the facility do have screens, and if he noticed any that were off, that he would pick them up and put them back on. He said that sometimes when the lawn is being mowed or weed-eated, a rock or something might hit them, knocking them down. He said he had not thought about screens being in place for pest control, but that he could see where that could be an issue.<BR/>In an interview with the Administrator on 3/1/23 at 9:30am, she said that the only harm to residents that she could think of might be pest control. She said she really can not think of any other harm that might come to residents. She said that she will see what can be done about the windows on the unit being screwed down, that they may try to figure out how to limit them to opening a minimal amount to keep residents safe. She was not aware previously that it was a regulation. She said that by ensuring that residents were able to open their windows if they chose to do so, it could make their environment more comfortable, and screens in place could ensure safety.<BR/>In an interview with the DON on 3/1/23 at 11:00am, she said that if residents were to open their windows without a screen in place, that they could potentially elope or be stung by an insect if an insect were to be able to fly in. She said that having screens in place could help ensure resident safety.<BR/>Record review of facility policy titled maintenance service dated December 2022 states .the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . and .Functions of maintenance personnel include, but are not limited to: a) maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines; b) maintaining the building in good repair and free from hazards; and .k) maintaining doors, windows and screens (where indicated) in appropriate working order .<BR/>No policy was provided for safe, comfortable, homelike environment.

Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in 1 of 1 refrigerator in the facility kitchen.<BR/>The facility failed to assure a refrigerator door latch adequately closed and sealed in the kitchen on 06/23/2025. <BR/>These failures could affect residents who eat food from the kitchen placing them at risk of food borne illness.<BR/>Findings included:<BR/>During an observation on 6/23/2025 at 9:00 a.m., of the only refrigerator in the kitchen revealed the door would not latch or seal. The latch was broken, and the refrigerator door would not close properly. The refrigerator door stayed slightly open due to the broken latch. <BR/>Interview with DA-L at 2:09pm on 6/24/2025 who said the refrigerator could cause a problem if it's not sealed. She said food could lose appropriate temperature and spoil. She said inappropriate temperatures could make consumption of the food dangerous to the residents. <BR/>Interview with [NAME] at 2:32pm on 6/24/2025 who said if the refrigerator was not sealed tight food could spoil, bugs or cleaning substances could get inside the refrigerator, get on the food, and make the residents sick. <BR/>Interview with DA-K at 2:59pm on 6/24/2025 who said the refrigerator should always have a good seal. She said the food could get hot and spoil quicker. She said if food was not held at the right temperature, it could make the residents ill. <BR/>Interview with Dietary Supervisor at 3:09pm on 6/24/2025 who said issues with essential equipment should be reported to maintenance and the administrator immediately. She said the refrigerator door has been reported for not being sealed and able to close tightly in the past but never have been fixed. She said the refrigerator should be sealed to assure it's held at the appropriate temperature and to keep food from spoiling. She said if the food spoils if could make the residents sick. <BR/>During an interview with the administrator on 6/25/2025 at 2:25pm who said the refrigerator should be closed tightly at all times unless dietary staff is getting food items out or putting food items in the refrigerator. She said the door latch was reported to her as of 6/23/2025 but the kitchen staff did not report to broken refrigerator latch prior to the state inspection. She said parasites could easily enter the refrigerator, the food could be of an inappropriate temperature causing bacteria to grow, and the food could spoil and possibly make the residents ill. <BR/>Record review of a Refrigerators and Freezers Policy dated (revised June 2024) Policy Statement reads This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation reads.<BR/>8. Supervisors will inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs will be initiated immediately.

Based on record review and interviews, the facility failed to conduct and document a comprehensive facility-wide assessment for the past year to determine what resources were necessary to care for its residents competently during day-to-day operations and review and update the assessment at least annually for 1 of 1 facility reviewed. <BR/>The Facility Assessment had not been updated since February 2023.<BR/>This failure could place residents at risk of their needs going unmet and result in a lack of services provided by the facility to competently care for all residents.<BR/>The findings included: <BR/>Record review of the Facility Assessment indicated last review date of February 2023.<BR/>During an interview on 10/31/2024 at 8:10 AM, the Administrator said she had been employed at the facility since July 26, 2024, but her first day in the facility was not until August 1, 2024. She said she looked at the facility assessment shortly after she started work and knew that there were some new requirements per state and saw that the number for the acuity of the resident population was accurate. She said the facility bed classification was updated on October 1, 2024. She said the last time the facility assessment was updated was in February 2023. She said at a minimum it should be updated at least once a year. She said she updated the first page to reflect the facility had a new Medical Director and dated it August 2024 but did not update anything else in the assessment. She said she thought she had more things to tend to, looked through the assessment and it was accurate. She said she knew it should have been updated prior to her employment at the facility.<BR/>Record review of a facility policy titled Facility Assessment revised October 2023 indicated, .A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. 9. The facility assessment is reviewed and updated annually, and as needed .

Based on observation, interview, and record review the facility failed to post accurate daily information that included the total number and actual hours worked by registered nurses and licensed practical or licensed vocational nurses directly responsible for resident care per shift for the 6-2 shift on 3 of 3 days reviewed for posted nursing staff information. <BR/>The facility did not post the accurate actual number and hours worked by registered nurses and licensed practical nurses directly responsible for resident care per shift on 04/22/2024, 04/23/2024, and 04/24/2024. <BR/>This failure could place all residents, their families, and facility visitors at risk of not having access to accurate information regarding staffing data. <BR/>Findings included: <BR/>Observation on 04/22/2024 at 08:50 AM of the DAILY NURSE POSTING REPORT dated for the day of 04/22/2024 and posted at the nurse station at the south entrance of the facility indicated there was 1 RN for a total of 8 hours and 5 LVNs for a total of 21 hours directly responsible for resident care on the 6 AM-2 PM shift. <BR/>Observation on 04/23/20244 at 08:35 AM of the DAILY NURSE POSTING REPORT dated for the day of 04/23/2024 and posted at the nurse station at the south entrance of the facility indicated there was 1 RN for a total of 8 hours and 5 LVNs for a total of 21 hours directly responsible for resident care on the 6 AM-2 PM shift. <BR/>Observation on 04/24/20244 at 08:35 AM of the DAILY NURSE POSTING REPORT dated for the day of 04/24/2024 and posted at the nurse station at the south entrance of the facility indicated there was 1 RN for a total of 8 hours and 5 LVNs for a total of 21 hours directly responsible for resident care on the 6 AM-2 PM shift. <BR/>During an interview with the DON on 04/23/2024 at 11:45 AM, she said she was the only RN in the facility. She said the 1 RN for 8 hours on the 6-2 shift listed on the posted Daily Nurse Posting Reports observed was for herself. She said she did not provide direct resident care. The DON said the 5 LVNs on the 6-2 shift included her ADON and MDS Nurse. She said the ADON worked 2-3 hours a day doing treatments and the remaining 5-6 hours performing other duties unrelated to direct resident care. She said the MDS Nurse did not perform direct resident care. The DON said she included herself, the MDS Nurse, and the ADON in the count of nurses because that was how she was taught to do it. <BR/>A review of the nursing schedule for 04/22/2024 indicated there were 2 LVNs assigned to Halls 200, 300, and 400 on the north side of the facility and 1 LVN assigned to Halls 800 and 900 on the south side of the facility for the 6-2 shift. There was no RN assigned to provide direct resident care for the 6-2 shift.<BR/>A review of the nursing schedule for 04/23/2024 indicated there were 2 LVNs assigned to Halls 200, 300, and 400 on the north side of the facility and 1 LVN assigned to Halls 800 and 900 on the south side of the facility for the 6-2 shift. There was no RN assigned to provide direct resident care for the 6-2 shift.<BR/>A review of the nursing schedule for 04/24/2024 indicated there were 2 LVNs assigned to Halls 200, 300, and 400 on the north side of the facility and 1 LVN assigned to Halls 800 and 900 on the south side of the facility for the 6-2 shift. There was no RN assigned to provide direct resident care for the 6-2 shift.<BR/>A review of the facility's policy titled Staffing included the following:<BR/>2. Staffing numbers and the skill requirements are determined by the census, needs of the residents This will be posted prominently inside the facility entrance and shows .direct care staff with titles and hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to be adequately equipped to allow residents to call for staff through a communication system which relayed the call directly to a staff member or to a centralized staff work area from toilet and bathing facilities for 1 of 6 residents (Resident #12) reviewed for call lights.<BR/>The facility failed to ensure Resident #12's bathroom call light pull string was not wrapped up and inaccessible from the floor on 06/23/2025.<BR/>This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.<BR/>Findings included:<BR/>Record review of a facility face sheet dated 6/24/25 for Resident #12 indicated that she was a [AGE] year-old female originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnosis of type 2 diabetes.<BR/>Record review of a quarterly MDS assessment dated [DATE] for Resident #12 indicated that she had a BIMS score of 15, indicating that she was cognitively intact. She was independent with toileting hygiene and toileting transfers. <BR/>Record review of a comprehensive care plan dated 5/30/25 for Resident #12 indicated that she was at risk for falls and had an intervention to ensure call light was in reach. <BR/>During an observation on 6/23/25 at 10:10 am the bathroom call light in Resident #12's restroom was observed to be wrapped up and was inaccessible from floor in event of resident fall.<BR/>During an interview on 6/24/25 at 9:15 am Resident #12 said she did use the restroom independently and she denied having had any falls in the restroom.<BR/>During an interview on 6/25/25 at 1:40 pm Maintenance said she had only been employed here a couple of weeks and was still learning all of her responsibilities. She said she was responsible for call lights and would fix the call light in Resident #12's restroom. She said if a resident were to fall in the bathroom and could not reach the call light string, they would be unable to call for help.<BR/>During an interview on 6/25/25 at 1:43 pm DON said maintenance was responsible for ensuring call lights were in working order and strings were long enough. She said if a resident fell in the bathroom and could not reach the light, they would be unable to call for help.<BR/>During an interview on 6/25/25 at 2:07 pm Administrator said she would ensure all call lights were checked and fixed. She said residents could be at risk of injury if they could not call for help.<BR/>Record review of a facility policy titled Call Light - Use of dated 5/2017 read: .It is the policy of this home to ensure residents have a call light within reach that they are physically able to access and that they have been instructed on its use .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to be adequately equipped to allow residents to call for staff through a communication system which relayed the call directly to a staff member or to a centralized staff work area from toilet and bathing facilities for 1 of 6 residents (Resident #12) reviewed for call lights.<BR/>The facility failed to ensure Resident #12's bathroom call light pull string was not wrapped up and inaccessible from the floor on 06/23/2025.<BR/>This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.<BR/>Findings included:<BR/>Record review of a facility face sheet dated 6/24/25 for Resident #12 indicated that she was a [AGE] year-old female originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnosis of type 2 diabetes.<BR/>Record review of a quarterly MDS assessment dated [DATE] for Resident #12 indicated that she had a BIMS score of 15, indicating that she was cognitively intact. She was independent with toileting hygiene and toileting transfers. <BR/>Record review of a comprehensive care plan dated 5/30/25 for Resident #12 indicated that she was at risk for falls and had an intervention to ensure call light was in reach. <BR/>During an observation on 6/23/25 at 10:10 am the bathroom call light in Resident #12's restroom was observed to be wrapped up and was inaccessible from floor in event of resident fall.<BR/>During an interview on 6/24/25 at 9:15 am Resident #12 said she did use the restroom independently and she denied having had any falls in the restroom.<BR/>During an interview on 6/25/25 at 1:40 pm Maintenance said she had only been employed here a couple of weeks and was still learning all of her responsibilities. She said she was responsible for call lights and would fix the call light in Resident #12's restroom. She said if a resident were to fall in the bathroom and could not reach the call light string, they would be unable to call for help.<BR/>During an interview on 6/25/25 at 1:43 pm DON said maintenance was responsible for ensuring call lights were in working order and strings were long enough. She said if a resident fell in the bathroom and could not reach the light, they would be unable to call for help.<BR/>During an interview on 6/25/25 at 2:07 pm Administrator said she would ensure all call lights were checked and fixed. She said residents could be at risk of injury if they could not call for help.<BR/>Record review of a facility policy titled Call Light - Use of dated 5/2017 read: .It is the policy of this home to ensure residents have a call light within reach that they are physically able to access and that they have been instructed on its use .

Based on interview and record review, the facility failed to ensure the residents received mail for 7 of 8 residents reviewed for rights to privacy and confidentiality. (Residents #1, #11, #15, #16, #34, #39 and #103) <BR/>The facility did not implement a system for delivering mail on Saturdays. Residents #1, #11, #15, #16, #34, #39 and #103 said the mail was not delivered to them on Saturdays<BR/>The facility failed to ensure mail was unopened when delivered to Residents #16 and #39. <BR/>These failures could place the residents at risk of not receiving mail in a timely manner, the right to privacy and a diminished quality of life.<BR/>Findings included:<BR/>During a group interview on 2/28/23 at 10:55 AM, Residents #1, #11, #15, #16, #34 and #103 said mail was delivered to the facility on Saturdays but no one delivered it to them and they would have to wait until Monday when the BOM arrived to get their mail or packages. Residents #16 and #39 said their mail had been opened before and the mail was addressed to them and not the facility.<BR/>During an interview on 2/28/2023 at 11:15 AM, the BOM said she was responsible for checking and delivering the mail to the residents at the facility. She said the mail was delivered daily to the residents except on Saturdays and Sundays. She said mail was delivered to the facility on Saturdays and one of the charge nurses would lock the mail in the nurse cart or in the medication room until Monday when she arrived. She said there was not anyone designated to deliver mail on Saturdays. She said she only opened mail that came from Health and Human Services and the mail would have the resident's name and care of BOM with the facility address. She said if the mail was addressed to the residents, then she would have the resident open it. She said one day last week she accidentally opened mail that was addressed to a resident, but she immediately gave it to the resident. She said a risk involved with opening mail that was not addressed to the facility would be having access to confidential information and it could upset the resident. She said someone should be designated to deliver mail to the residents on Saturdays.<BR/>During an interview on 2/28/2023 at 2:45 PM, the DON said the BOM was responsible for delivering the mail to the residents and on the weekends the nursing staff received the mail and would put it up for the BOM on Mondays when she returned to work. She said she guessed someone could deliver the mail to the residents on Saturdays and was not aware that any residents received their mail opened. She said going forward someone would be designated to deliver mail to the residents on Saturdays and their mail would not be opened if it was addressed to the resident only. <BR/>During an interview on 2/28/2023 at 2:55 PM, the LNFA said she started at the facility on 2/6/2023. She said the BOM was responsible for delivering the mail to the residents Monday-Friday and was not sure anyone was delivering mail to the residents on Saturdays. She said she was not aware of residents receiving mail already opened but going forward would ensure someone was designated to deliver mail on Saturdays to the residents and the mail would not be opened. She said the risk to the residents involved the resident's right to privacy and resident rights. She said she would do an in-service with the BOM. <BR/>Record review of a facility policy with a revised date of 2022 titled Mail and Electronic Communication indicated, .1. Mail will be delivered to the resident unopened. 2. Staff members of this facility will not open mail for the resident unless the resident requests them to do so. (Such request will be documented in the resident's plan of care). 4. Mail and packages will be delivered to the resident within twenty-four (24) hours of delivery of premises or to the facility's post office box (including Saturday deliveries) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening for 2 of 12 residents reviewed for PASRR (Residents #33 and #35).<BR/>The facility failed to ensure Residents #33 and Resident #35 had accurate PASRR Level 1 Screenings indicating diagnoses of mental illness and refer the residents to the state designated authority. <BR/>This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.<BR/>Findings included:<BR/>Resident #33<BR/>Record review of a face sheet dated 04/24/2024 indicated Resident #33 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included major depressive disorder with behaviors (a mental illness indicated by a persistent feeling of sadness and loss of interest with symptoms of irritability, restlessness, and /or angry outbursts). <BR/>Record review of Section I of the Comprehensive (admission) MDS assessment, dated 12/04/2023, indicated Resident #33 had a diagnosis of depression. Section N of the same MDS assessment indicated Resident #33 had received antidepressant and antipsychotic medications for treatment of major depressive disorder during the 7 days of the assessment period. <BR/>Record review of a physician's orders dated 11/29/2023 indicated Resident #13 was to receive Remeron (an antidepressant medication), Lexapro (an antidepressant medication), and Risperidone (an antipsychotic medication) for treatment of major depressive disorder with severe psychotic behaviors. <BR/>Record review of Resident #33's PASRR Level 1 Screening completed on 11/27/2023 indicated in section C0100 there was no evidence of this individual having mental illness. <BR/>Resident #35<BR/>Record review of a face sheet dated 04/24/2024 indicated Resident #35 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included mood disorder (a disorder described by marked disruptions in emotions of severe lows called depression or highs called mania also called bipolar disorder).<BR/>Record review of Section I of the Comprehensive (admission) MDS assessment, dated 11/20//2023, indicated Resident #35 had a diagnosis of bipolar disorder. Section N of the same MDS assessment indicated Resident #35 had received antipsychotic and antidepressant medications during the 7 days of the assessment period. <BR/>Record review of physician's order dated 11/10/2023 indicated Resident #35 was receiving the medications, Lexapro (an antidepressant medication) and Seroquel (an antipsychotic medication) for treatment of mood disorder. <BR/>Record review of Resident #35's PASRR Level 1 Screening completed on 11/09/2023 indicated in section C0100 there was no evidence of this individual having mental illness. <BR/>During an interview on 04/24/2024 at 09:50 AM with the DON, she said the MDS Nurse was responsible for tasks associated with the MDS and PASRR. <BR/>During an interview on 04/24/2024 at 11:10 AM, the MDS Nurse said her department was responsible for reviewing the Level I PASRRs to ensure accuracy and appropriate follow-up actions. She said she was training a second MDS nurse at the time Resident #33 and Resident #35 admitted to the facility and the MDS Nurse Trainee was responsible for reviewing PASRR I screenings. The MDS Nurse said she did not know why the inaccurate PASRR I was not addressed. The MDS Nurse said the LA should have been notified of Resident #33's and Resident #35's inaccurate PASRR Level 1 screenings. The MDS Nurse said she was the only MDS Nurse currently and was responsible for reviewing PASRR Level I Screenings. The MDS Nurse said it was important for the PASRR Level 1 Screenings to be accurate because the facility needed to make sure the residents were getting the correct resources and services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to complete a significant change MDS assessment within 14 days after a significant change in the resident's mental and physical condition for 1 of 6 residents (Resident #56) reviewed for assessments. <BR/>The facility failed to reassess Resident #56 following a hospice admission (specific care for the sick or terminally ill) on 05/27/25.<BR/>This failure could place residents at risk for not having their individual needs met due to inaccurate assessments.<BR/>The findings included:<BR/>Record review of facility face sheet dated 6/25/25 for Resident #56 indicated that he was an [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnosis of traumatic hemorrhage of cerebrum (brain bleed).<BR/>Record review of a Quarterly MDS assessment dated [DATE] for Resident #56 indicated that he had a BIMS score of 99, which indicated he was unable to complete the interview. He had severely impaired cognition. <BR/>Record review of a comprehensive care plan dated 5/30/25 for Resident #56 indicated that he was receiving hospice services.<BR/>Record review of a physician's order summary report dated 6/25/25 for Resident #56 indicated he had the following order dated 5/27/25: .Resident may admit to Hospice .<BR/>Record review of a nurse note dated 5/27/25 for Resident #56 indicated he had a nursing progress note which read: .Resident admitted to [name of hospice] Hospice Dx Alzheimer's Disease . and was signed by LVN .<BR/>MDS nurse was unavailable for interview during survey. <BR/>During an interview on 6/25/25 at 1:43 pm the DON said she was not aware that a significant change MDS was required when a resident admitted to hospice until today (6/25/25). She said her MDS nurse was responsible for MDS assessments, and she was unavailable right now due to hospitalization. She said if MDS assessments were not completed appropriately, it could affect the residents' care plan interventions as the MDS was where the care plan triggers were generated. <BR/>During an interview on 6/25/25 at 2:07 pm the Administrator said she expected all significant change MDS's to be done timely. She said residents could be at risk for not having changes in their condition recognized. She said she would in service the MDS nurse when she returned to work to ensure MDS assessments were completed appropriately going forward.<BR/>Record review of a facility policy titled Assessment - Comprehensive Resident dated 5/2017 read: .It is the policy of this home that staff will upon admission, annually and with significant change of condition conduct an accurate comprehensive assessment of the resident's functional ability utilizing the R.A.I. process .<BR/>Record review of the CMS RAI version 2.0 revised December 2002 indicated, .A Significant Change in Status Assessment must be completed within 14 days after a determination has been made that a significant change in the resident's status from baseline occurred. A Significant Change in Status MDS is required when: a resident enrolls in a hospice program .