Focused Care at Webster

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 2 of 17 rooms from hallway 200 affecting 2 of 14 residents (Resident #1 and Resident #2) reviewed for environment. The facility failed to clean food crumbs, and stains from the floor in Resident #1 and Resident #2's rooms that looked like dried coffee. The facility failed to repair the footboard of Resident #2 's bed that had exposed wooden particle board and splintered edges. The facility failed to repair the closet door of Resident #2's closet that was off of the hinges and could not be closed or opened properly. The facility failed to repair the overhead light above Resident #2's bed, which was cracked with jagged edges. These failures could place residents and staff at risk of living, working, and visiting in an unsafe, unsanitary, and uncomfortable environment. Findings included: 1. Record review of Resident # 1's admission record, dated 11/18/2025, revealed an [AGE] year-old female admitted on [DATE], with diagnoses of encephalopathy (disease or damage that affects the brains function or structure causing a change in mental status), dysphagia (difficulty swallowing with an inability to move food or liquids easily from the mouth to the stomach), chronic non-pressure ulcer (chronic non-healing wound of the skin that is not caused by prolonged pressure) of left foot, weakness and falls. Record review of Resident # 1's admission MDS assessment, dated 08/25/2025, revealed a BIMS score of 5 out of 15 indicating severe cognitive impairment. The resident's functional abilities revealed she needed moderate assistance with oral and personal hygiene, and substantial assistance with toileting hygiene, shower, lower body dressing and putting on or taking off footwear and was to remain at the facility long term. 2.Record review of Resident # 2's admission record, dated 11/18/2025, revealed a [AGE] year-old male, admitted [DATE] with diagnoses of cerebral infarction (the death of brain tissue caused by a prolonged lack of blood flow, which leads to stroke), lack of coordination, type II diabetes mellitus (a chronic disease where the body does not use insulin correctly causing blood sugar levels to remain high), hemiplegia (paralysis or weakness of muscles on one side of the body affecting the arm, leg and face), dysphagia (difficulty swallowing with an inability to move food or liquids easily from the mouth to the stomach), chronic obstructive pulmonary disease (a group of progressive lung diseases that block airflow to the lungs, causing breathing problems), alcoholic cirrhosis of the liver (a late stage of liver damage caused by excessive alcohol consumption, where scar tissue replaces healthy liver tissue, leading to liver failure) with ascites (a condition where severe scarring of the liver from chronic alcohol use causes a buildup of fluid in the abdomen) and colostomy (a surgically created opening that connects the colon to the outside of the body, allowing stool and gas to be collected in a pouch). Record review of Resident # 2's admission MDS assessment, dated 02/26/2025, revealed a BIMS score of 13 out of 15 indicating he was cognitively intact. The resident's functional abilities revealed he required maximal assistance with toileting, personal and oral hygiene, showers, lower body dressing and putting on or taking off footwear. In an observation and interview on 11/12/25 at 11:16 a.m. in Resident # 1's room, the floor had stains, food crumbs and plastic wrappers. Resident #1 was seated on her bed and when asked if staff cleaned her room, she said no. Resident #1 said the floors in her room were often dirty, and sticky and rarely swept or mopped. Resident #1 said she had bugs and the pest people would put out traps. Observed several round black disks in all four corners of her room, behind the toilet in the corners of her bathroom and around the entrance of her bifold closet door. During an observation and interview on 11/12/25 at 5:48 p.m. in Resident # 1's room, the floor remained stained with food crumbs and plastic wrappers. Resident #1 was seated to the side of her bed and was eating from a dinner tray. Resident#1's family member was seated in a chair at the bedside. Resident #1 said no one cleaned her room [ROOM NUMBER]/12/25. The family member said they visited Resident # 1 almost daily. The family member said they had not complained or said anything to management because they did not want to cause any trouble and usually when they point out the mess or lack of cleaning in the room to the resident's aide or nurse, someone comes to clean the room shortly thereafter. Resident #1 then said that if she asks someone to clean the room, they usually would l when they got around to it, but no one had on 11/12/25. Resident #1 shrugged her shoulders when asked how it made her feel when her room was not cleaned daily. Resident #1's family member said the facility should clean the residents' rooms daily. In an observation and interview on 11/18/25 at 1:17 p.m. in Resident #2's room, the floor was dirty with food crumbs, and stains that appeared to be dried coffee. The floor felt sticky with surveyor shoes sticking to the floor and the floor making squeaky noises when stepped on. Resident #2 was in bed and said his room was cleaned daily but had not been cleaned yet on 11/18/25. Resident #2 said normally the staff cleaned his room in the mornings, but it could be any time of day because there was no designated cleaner assigned to his hall. Observed the bifold closet door in Resident # 2's room off the top track and hanging forward out of the closet frame. Resident #2 said he complained that the closet doors did not open or close properly but could not remember who he told or when he reported it. Observed the footboard to Resident #2's bed splintered and broken. The resident said he had not noticed. Observed the light fixture above Resident #2's head of bed where he was laying was broken and cracked, with jagged pieces of plastic sticking out. Resident# 2 said a lot of things at the facility were broken or run down but it was home for now, and he was ok because the people treated him well and no place was perfect. Resident #2 said he would prefer if housekeeping cleaned in the morning and again in the evening but would be happy with once daily. Resident #2 said he there were ants crawling on him one time but could not recall when that happened. Resident #2 said it happened once and he had not seen any bugs, pests, insects, or rodents. Interview with DON and Administrator on 11/18/2025 at 1:24 p.m. in Resident # 2's room, the Administrator said he was unsure why Resident #2's room was not cleaned yet for the day. When shown the hanging, inoperable bifold closet doors, the Administrator said they should have reported that, and he would have maintenance fix it. When asked who he meant by the term they, he said the staff and or the resident. When shown the splintered footboard of Resident #2's bed the Administrator said they would have to fix that. When shown the dirty floor, the DON said Resident #2 sometimes threw trash on the floor. When asked when resident rooms should be cleaned both the Administrator and DON said daily. Both the Administrator and DON said Resident #2 notified them of any of the issues in his room. When asked if administrative staff conduct any kind of daily room rounds, the Administrator said yes and said the Central Supply/transport person was the assigned department head for Resident #2's daily room rounds, and he would have to locate her daily rounding sheets. Interview with Housekeeper A on 11/18/2025 at 3:44 p.m. said she worked at the facility for about a month and had completed her assigned hallway for cleaning, which was 100 hallway. Housekeeper A said that 200 Hallway was a hallway they all split because there were only 3 housekeepers and 4 hallways. She said 200 hallway did not have a designated regular daily housekeeper. Housekeeper A said she cleaned the front of 200 hallway, but Housekeeper B signed the sheet that she did it instead. She said the Housekeeping Manager assigned the housekeeper to split 200 hall and each of them had a designated area of that hallway to clean but Resident #1's and Resident #2's rooms were not part of her assignment. Housekeeper A said they had not seen any live bugs or insects but saw bait traps in various resident rooms on all four hallways. Housekeeper A said all the residents' rooms should be cleaned daily because resident deserved a clean room. Interview with Housekeeper C on 11/18/2025 at 3:48 p.m., said she worked at the facility for five years and the housekeeping department was having trouble retaining staff. She said that 200 hallway was the only hallway that did not have a regularly assigned housekeeper and the three housekeepers working that day, including herself, were assigned to split 200 hallway but the back of 200 hall, which included rooms [ROOM NUMBERS] were not her assigned rooms. Housekeeper C said the assignment sheet was in the housekeeping office. Housekeeper C said she saw flies and roaches on 200 hall in the past but not recently. Housekeeper B said she reported any insects to administrator, her supervisor (when they had one) and maintenance so they could contact pest control. Housekeeper C said the rooms can get dirty and floors should be swept and mopped, bathrooms cleaned, and trash emptied at least daily. Interview with Housekeeper B on 11/18/2025 at 3:53pm who was actively cleaning Resident #2's room, Housekeeper A said she worked at the facility since June 2025 and had cleaned on the front of 200 hallway earlier in the day but had not made it to the back of 200 hallway yet. She said that the housekeepers usually split 200 hallway because there was no permanently assigned housekeeper for that hall. Housekeeper B said Resident #2's room was dirty on the floors, but she cleaned it daily whenever she worked. Housekeeper B said that she may not always clean her assigned area on 200 hall in the morning but completed it daily prior to the end of her shift. Housekeeper B said having food debris on the floor was not acceptable because it could attract pests or insects which she said she had seen before all around the facility. Housekeeper B said she saw flies, gnats, and roaches on 200 hall in the past. Housekeeper B said she reported any insects to the administrator, her supervisor and maintenance so they could contact pest control. In an interview with the Administrator on 11/18/25 at 4:03 p.m. the surveyor requested the 200-hallway assignment sheet for 11/18/2025. In an interview on 11/18/2025 at 4:50 p.m., the Maintenance Director said he started working at the facility on 10/31/25 and was not asked to assist with the building's pest control. He said he was asked to notify the pest control company, which he did. He said residents and staff complained about pests, including roaches and rodents, throughout the facility. He said the pest control program was ineffective because some of the pests could have nests in the walls. He said some areas of the building seemed to be worse than others. He said some of the residents' rooms on 200 hall were affected but could not recall which ones. He said since working at the facility, he had mainly been doing painting and touch-ups of rooms and only completed repairs when he had the time to, because the priority seemed to be getting the rooms painted and ready for new admissions. He said there was a repair log located at the central nursing station, and he was not notified about repairs needed in room [ROOM NUMBER]. The Maintenance Director said the facility and resident rooms should be cleaned daily. He said there were a lot of new staff in those departments and they were trying to get things corrected. Record review on 11/18/2025 at 4:52 p.m. of facility maintenance log from October of 2025 through 11/18/2025 revealed no entries for repairs to Resident #2's foot board, closet door, or overhead light. In an interview on 11/18/2025 at 4:53 p.m. the Administrator said he could not locate the daily room rounding sheets for Resident #2's room or the 200-hallway housekeeping assignment sheet. The Administrator said the housekeeping and laundry departments had a recent large turnover with several housekeepers and the former housekeeping supervisor all quitting at the same time. The Administrator said he t hired a new laundry and housekeeping supervisor and was trying to slowly get the department back on track. He said the new supervisor was not at the facility and he would be the person to answer any surveyor questions because the new manager had no information. The Administrator said staff should report any repairs to himself or the maintenance director. The Administrator said the Maintenance Director was also new. He said that all staff were trained and knew how to submit a repair request and where to locate the maintenance repair book for Resident #2's closet door, overhead light, and footboard. The Administrator said he did not know why staff had not reported the need for those repairs. The Administrator said the resident rooms should be cleaned daily to minimize bugs and pests. He said the facility had a pest control program that came in monthly and as needed. Interview with the DON on 11/18/25 at 4:55 p.m. said most of the residents on 200 hallway were more independent and had their own snacks and food items. The DON said she did not know why Resident #2's room was not cleaned for the first time all day until after 1:00 p.m. and was not familiar with the housekeeping schedules. The DON said that Resident #1 could be confused at times and may not have noticed if a housekeeper had cleaned the room. The DON said all of the resident rooms should be cleaned daily and that the Administrator and Housekeeper supervisors were responsible for ensuring the cleanliness of the facility and that the Administrator oversaw the pest control program at the facility. The DON said Resident #2 never told her about having an ant crawling on him and had no other reports about the alleged incident saying she learned about it at the same time the surveyor did. In an interview with LVN A on 11/18/25 at 6:33 p.m. said she worked the 6pm-6am shift fulltime for about one year. LVN A said her regularly assigned hallway was 200 and there were housekeeping issues since she started. LVN A said she was unsure if the housekeeper had adequate supplies or training and the dirty rooms were repeatedly reported to administration, and it would get better for a little while and revert to being dirty. LVN A said none of the residents ever complained to her about dirty rooms, but she would prefer not to work in a dirty environment and usually brought her own cleaning supplies to work including wipes, hand sanitizer and garbage bags. LVN A said she felt sorry for the residents sometimes because they lived there and deserved a clean and healthy environment. LVN A said if the environment was dirty, it could spread bugs and infection. LVN A said she noticed the broken closet in Resident #2's room and reported it in the maintenance log but the facility did not have a maintenance director. LVN A said she had not noticed Resident #2's splintered foot board on his bed or the cracked overhead light. LVN A said the pest control program at the facility was ineffective because she and other staff saw roaches and bugs regularly throughout the facility. Record Review of the facility's policy titled Cleaning and Disinfection of Environmental Services, dated August 2019, revealed in part: 10. Environmental services will be disinfected or cleaned on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. Requested a policy and procedure on Maintenance Services from the Administrator on 11/18/25 at 5:15 p.m. and did not receive one prior to facility exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 4 hallways, (Hall 100) and Resident #4's room. The facility had a live roach and live flies in Resident #4's room. This failure could place residents at risk for decreased residents' health, safety, and quality of life. Findings included: Record review of Resident #4's admission Record dated 11/18/2025 revealed a [AGE] year-old female, admitted [DATE] and readmitted [DATE] with diagnoses of encephalopathy (disease or damage that affects the brains function or structure causing a change in mental status), dysphagia (difficulty swallowing with an inability to move food or liquids easily from the mouth to the stomach), history of falls, ataxic gait (an abnormal clumsy and staggering walk characterized by a lack of balance), atrial fibrillation (a common type of arrythmia[an abnormal heart rate]where the heart's upper chamber beat chaotically and irregularly, often too fast), and intellectual disability. Record review of Resident 4's admission MDS, dated [DATE], revealed a BIMS score of 9 out of 15, which indicated moderate cognitive impairment. The resident's functional abilities in section GG revealed she required maximal assistance with toileting, and personal hygiene, and moderate assistance with showers, lower body dressing and putting on or taking off footwear. Observation and interview with Administrator on 11/18/25 at 1:35 p.m. of an empty resident room # 209 with a live pile of ants or some type of crawling insects in a mound in the corner just inside the door of the room. The Administrator said the room was empty and he would call the pest control company to come out and do an off-schedule treatment. The Administrator said he was doing his best to stay on top of things after returning to the facility and he was just getting up to speed on a lot of things that had fallen through the cracks in his absence. During an observation and interview with the facility Ombudsman on 11/18/2025 at 3:18 p.m., in Resident #4's room with the Ombudsman to show a live roach on the floor in front of her recliner chair and 2 flies flying around in the room. Resident #4 was at an activity and the Ombudsman stepped on the roach killing it. The Ombudsman said the facility had an issue with roaches and other pests and would say they were addressing it but did not feel it was effective because there were pests all over the facility and this was not the first time she had seen or killed a live insect or bug, while visiting with residents at the facility. Observation and interview with Resident #4 on 11/18/25 at 3:27 p.m. in main dining room area. Resident #4 was appropriately dressed and groomed and seated in a chair. When asked if she had ever had any issues with bugs, roaches, flies or pests in her room she said from time to time. When asked what happened when she saw pests in her room, she said she would tell the nurse or aide and someone would kill it. When asked if her room was cleaned daily, she said yes. When asked if she felt like the facility did enough to make sure there were no bugs or pests in her room, she said yes. Resident #4 said she saw the pest control people regularly at the facility at least every few weeks. Interview with Housekeeper B on 11/18/2025 at 3:53 p.m. who was actively cleaning Resident #2's room Housekeeper A said she worked at the facility since June 2025 and had cleaned on the front of 200 hallway earlier in the day but had not made it to the back of 200 hallway yet. She said that the housekeepers usually split 200 hallway because there was no permanently assigned housekeeper for that hall. Housekeeper B said Resident #2's room was dirty on the floors, but she cleaned it daily whenever she worked. Housekeeper B said that she may not always clean her assigned area on 200 hall in the morning but completed it daily prior to the end of her shift. Housekeeper B said having food debris on the floor was not acceptable because it could attract pests or insects which she said she had seen before all around the facility. Housekeeper B said she saw flies, gnats, and roaches on 200 hall in the past. Housekeeper B said she reported any insects to the administrator, her supervisor and maintenance so they could contact pest control. Interview on 11/18/2025 at 4:50 p.m., the Maintenance Director said he started working at the facility on 10/31/25 and was not asked to assist with the building's pest control. He said he was asked to notify the pest control company, which he did. He said residents and staff complained about pests, including roaches and rodents, throughout the facility. He said the pest control program was ineffective because some of the pests could have nests in the walls. He said some areas of the building seemed to be worse than others. He said some of the residents' rooms on 200 hall were affected but could not recall which ones. In an interview on 11/18/2025 at 4:53 p.m. the Administrator said he could not locate the daily room rounding sheets for Resident #2's room or the 200-hallway housekeeping assignment sheet. The Administrator said the housekeeping and laundry departments had a recent large turnover with several housekeepers and the former housekeeping supervisor all quitting at the same time. The Administrator said he t hired a new laundry and housekeeping supervisor and was trying to slowly get the department back on track. He said the new supervisor was not at the facility and he would be the person to answer any surveyor questions because the new manager had no information. The Administrator said the resident rooms should be cleaned daily to minimize bugs and pests. He said the facility had a pest control program that came in monthly and as needed. The Administrator said he felt like they were doing all they could do to minimize and control pests at the facility. Interview with the DON on 11/18/25 at 4:55 p.m. said all of the resident rooms should be cleaned daily and the Administrator and Housekeeper supervisors were responsible for ensuring the cleanliness of the facility and that the Administrator oversaw the pest control program at the facility. The DON said Resident #2 never told her an ant was crawling on him and had no other reports about the ant crawling on Resident #2 and said she learned about the ant crawling on Resident #2 at the same time the surveyor did. In an interview with LVN A on 11/18/25 at 6:33 p.m. said she worked the 6pm-6am shift fulltime for about one year. LVN A said her regularly assigned hallway was 200 and there were housekeeping issues since she started. LVN A said she was unsure if the housekeeper had adequate supplies or training and the dirty rooms were repeatedly reported to administration, and it would get better for a little while and revert to being dirty. LVN A said none of the residents ever complained to her about dirty rooms, but she would prefer not to work in a dirty environment and usually brought her own cleaning supplies to work including wipes, hand sanitizer and garbage bags. LVN A said she felt sorry for the residents sometimes because they lived there and deserved a clean and healthy environment. LVN A said if the environment was dirty, it could spread bugs and infection. LVN A said she noticed the broken closet in Resident #2's room and reported it in the maintenance log but the facility did not have a maintenance director. LVN A said she had not noticed Resident #2's splintered foot board on his bed or the cracked overhead light. LVN A said the pest control program at the facility was ineffective because she and other staff saw roaches and bugs regularly throughout the facility. Record review on 11/18/25 at 6:37 p.m. of facility pest controls logs with an 11/06/2025 entry that read in part: room [ROOM NUMBER]: Resident present during service. Found live German roaches behind the nightstand. Applied roach gel bait and placed Lo-liner monitors, room [ROOM NUMBER]. Significant roach activity observed on glue boards and the floor. Applied roach gel bait and placed Lo-liner monitors. room [ROOM NUMBER]: Live German roach activity found; unit is infested. German roaches clean out service needed for 105/106 and 208. Record Review of the facility's policy titled Cleaning and Disinfection of Environmental Services, dated August 2019, revealed in part: 10. Environmental services will be disinfected or cleaned on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. Record review of the facility's undated pest control policy reflected in part: Our Facility shall maintain an effective pest control program. 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects. 6. Maintenance services assists, when appropriate and necessary, in providing pest control services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for 1 of 5 residents (Resident #1) reviewed for resident abuse.-The facility failed to ensure that Resident #1 was free from sexual abuse when Resident #1 wandered into Resident #2's room in the facility on 9/23/25, and Resident #2 sexually assaulted Resident #1.An Immediate Jeopardy (IJ) was identified on 10/02/2025 at 4:41 p.m. The IJ template was provided to the Administrator and DON on 10/02/25 at 4:41 p.m. While the IJ was removed on 10/06/25 at 1:28 p.m. the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that was not an immediate jeopardy and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems.This failure could place residents at risk of physical harm, mental anguish, and/or emotional distress. Record review of Resident #1's facility admission record dated 10/1/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with most current admission date of 6/26/18. Resident #1 admitted with diagnoses that included anoxic brain damage (a condition where the brain experiences a complete lack of oxygen supply. This deprivation of oxygen can lead to widespread damage to brain cells, resulting in severe neurological impairment or death) and epilepsy and epileptic syndromes (Epilepsy is a brain disorder characterized by recurrent, unprovoked seizures, while an epileptic syndrome is a specific, complex constellation of signs and symptoms that define a unique epilepsy condition. An epileptic syndrome includes specific seizure types, other clinical features).Record review of Residents #1's care plan date Initiated 9/15/21 and revised on 9/24/25 revealed she was care-planned for a high elopement risk/wandering in male residents' room and was at risk for possible injury r/t impaired safety awareness and diagnosis of dementia, Anoxic brain damage. Date Initiated: 09/15/2021. Revision on: 09/24/2025: Goals: Resident #1's safety will be maintained throughout the review date. Date Initiated: 09/15/2021. Revision on: 09/12/2025. Target Date: 10/19/2025 Interventions: Assess for fall risk. Date Initiated: 09/15/2021. Provide structured activities: Toileting, walking inside and outside, reorientation strategies, including signs, pictures, and memory boxes. Date Initiated: 09/15/2021. Wander guard placed for resident's safety, bracelet will alert staff if and when resident attempts to exit doors of facility. Staff to monitor daily. Date Initiated: 09/15/2021. Redirect resident. Date Initiated: 09/24/2025. A care plan to address Resident #1 identifies as a trauma survivor. 1.possible trigger of aggressive vocal stimuli. 2. Childhood trauma memories, Domestic abuse memories , Physical Abuse memories, Sexual Abuse memories. Date Initiated: 11/14/2019. Revision on: 05/07/2020. Goals: SHE will remain stable and adjusted to her environment. Date Initiated: 11/14/2019 Revision on: 09/12/2025. Target Date: 10/19/2025. Interventions: Ask for permission to enter resident's room, perform care, and/or assist with ADLs. Date Initiated: 09/08/2023. Explain all procedures to the resident before starting and allow the resident (X minutes) to adjust to changes when necessary. Date Initiated: 09/08/2023. Reduction of possible triggers in her environment. Date Initiated: 11/14/2019. A care plan to address Resident #1's impaired cognitive function or impaired thought processes r/t ANOXIC BRAIN INJURY. SHE has cognitive loss (loss of memory, time sense and requires assistance with decision making r/t Impaired decision-making abilities, is not always understood or able to understand verbal and non-verbal expression. Date Initiated: 05/07/2020. Revision on: 05/07/2020. Resident #1 will improve current level of cognitive function through the review date. Date Initiated: 02/09/2021. Revision on: 09/12/2025. Target Date: 10/19/2025.Record review of Resident #1's Quarterly MDS dated [DATE] revealed Cognitive Skills for Daily Decision Making (section C1000) were coded at 3, indicating her cognition was severely impaired. Resident #1 was coded to require substantial/maximal assistance with ADLs. She was always incontinent of bowels and bladder and used a wheelchair for mobility.Record review of Resident #1's physician orders dated September 2025 revealed orders with a start date of 9/25/25 to administer Emtricitabine- Tenofovir oral tablet 200-300 MG (Emtricitabine- Tenofovir Disoproxil Fumarate) Give 1 tablet by mouth one time a day for antiviral for 28 days at 9:00 AM. An order for Tivicay Oral (Dolutegravir Sodium) Tablet 50 MG Give 1 tablet by mouth one time a day for antiviral for 28 days at 9:00 AM. An order for Plan B One-Step Oral Tablet 1.5 MG (Levonorgestrel Emergency OC) Give 1 tablet by mouth one time only for contraceptive for 1 day with a start date of 9/24/25. Record review of Resident #1's MAR dated September 2025 revealed that Resident #1 was administered Emtricitabine and tenofovir antiretroviral medication (used to treat and prevent HIV infection) on 9/25/25 through 9/30/25. Resident #1 was administered Tivicay Oral (Dolutegravir Sodium) Tablet 50 MG Give 1 tablet by mouth one time a day for antiviral on 9/25/25 through 9/30/25. Resident #1 was administered Plan B One-Step Oral Tablet 1.5 MG (Levonorgestrel Emergency OC (Oral Contraceptive) 1 tablet by mouth on 9/25/25.Record review of Nurses Note dated 9/23/2025. Note Text: Called to room by CNA A and CNA B reported to staff nurses that resident was having sexual activity with Resident #1. Resident #1 was immediately removed for safety. When male resident questioned by staff nurse what happened male resident began to laugh and stated nothing happened . Female resident is not cognitively intact female resident monitored all safety measures in place. Male resident immediately monitored 1-1 by staff. DON notified of above. MD notified. Family notified by DON awaiting return call. The resident transferred to local hospital.Record review of Nurses Note dated 9/23/2025. Note Text: Spoke with forensic nurse at local hospital who reported that she completed an exam on resident . She stated she was able to get a swab for DNA and STD testing but was unable to do a vaginal exam because the resident closed her legs and would not allow her to examine her. She stated that a pregnancy test was performed and was negative, resident was treated prophylactically with ATBs and will discharge to facility with orders for ATBs to continue. Resident #1 will also return with an order for Plan B . Nurse stated that an official report will be available in 1-2 business days. Called RP to update her on report from the nurse, message left, awaiting call back.Record review of the post hospital discharge instructions and orders dated 9/24/25 revealed that Resident #1 was seen for sexual assault. A SANE (Sexual Assault Nurse Examiner) adult sexual assault exam was performed (a forensic exam was performed (results pending and coordinated with the local police department). Orders for STI Sexually Transmitted Infection Prophylaxis: Ondansetron 4 mg PO x1, Azithromycin 1gm PO x1, Metronidazole 2gms PO x1, Ceftriaxone 500mg IM reconstituted with 1.1 ml of 1% Lidocaine. Lab orders for Pharyngeal Gonorrhea ( a sexually transmitted infection (STI) caused by the Neisseria gonorrhoeae bacteria that infects the pharynx. It is spread through oral sex with an infected person and can be asymptomatic, but symptoms may include a sore throat, difficulty swallowing, swollen lymph nodes in the neck, or redness/swelling in the throat) and Chlamydia (a common sexually transmitted infection (STI) caused by the bacterium Chlamydia trachomatis. It is primarily spread through sexual contact with an infected person).Record review of Nurse Practitioner note dated 9/25/25 for Resident #1: Chief Complaint: Evaluation of patient for alleged sexual assault incident: Hospital Course: She was taken to the ER a few days ago after an incident with another resident of a sexual nature. She was examined for possible sexual assault and started on post-exposure prophylaxis (levonorgestrel single dose; dolutegravir 50 mg daily x28 days; emtricitabine/tenofovir 200/300 mg daily x28 days; PRN ondansetron). Hospital examination results are pending. Today she appears in no distress. History of Present Illness: Resident #1, a [AGE] years old female with history of anoxic brain damage, epilepsy, unsteadiness on the feet, ataxia (poor muscle control that causes clumsy movements), abnormal gait, generalized muscle weakness, dysphagia (swallowing difficulties), mixed receptive/expressive language disorder (is a neurodevelopmental condition that affects a child's ability to both understand and produce language), dysarthria (difficulty speaking because the muscles you use for speech are weak), severe hypoxic ischemic encephalopathy (a brain injury that happens before, during, or shortly after birth when oxygen or blood flow to the brain is reduced or stopped), hyperlipidemia (an elevated level of lipids - like cholesterol and triglycerides - in your blood), hypertensive heart disease (a constellation of structural and functional changes in the left ventricle, left atrium, and coronary arteries resulting from chronic blood pressure elevation), and hypothyroidism (a condition in which the thyroid gland does not make enough thyroid hormone) among other medical problems was seen today upon the request of the Nurse due to a reportable incident that happened between patient and another resident. Patient was examined in the dining room. She is nonverbal and not able to make needs known due to anoxic brain injury. Patient was taken to the ER a few days ago for an examination of an encounter with another resident of a sexual nature. She was examined for sexual assault. Findings were not available at the time of this visit; however, patient was placed on several medications including: Levonorgestrel 1.5 mg tablet 1 time only, dolutegravir 50 mg daily for 28 days, emtricitabine/tenofovir 200/300 mg daily for 28 days and as needed Zofran. The results of the patient's examination at the hospital are still pending. - Additional consultations: Psychiatry and Psychology evaluations requested for psychological support.Record Review of Resident #1's Diagnostic Assessment from Psychological Evaluation and Treatment Services dated 9/29/25 revealed that the referral was made due to possible sexual assault at the facility. Resident #1 was unable to answer assessment questions or questions regarding the alleged events therefore she is not a candidate for psychotherapy. Record review of Resident #1's Initial Psychiatric assessment dated [DATE] revealed that Resident #1 was referred due to recent sexual assault without ability to consent, patient was noted to not be able to respond, trauma screening was unable to be determined due to patient being unable to respond. Resident #2Record review of Resident #2's facility admission record dated 10/2/25 revealed a [AGE] year-old-male, admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side (a stroke damaged the right side of the brain, causing paralysis (hemiplegia) and/or weakness (hemiparesis) on the left side of the body) and Chronic Viral Hepatitis C (a long-term liver infection caused by the hepatitis C virus). Record review of Resident #2's care plan revealed care plans to address areas that included: The resident has a behavior problem r/t inappropriate verbal sexual comments towards staff. Date Initiated: 08/18/2025. Revision on: 09/23/2025 Goals: The resident will have fewer episodes of inappropriate behaviors by review date. Date Initiated: 08/18/2025 Revision on: 09/23/2025 Target Date: 12/18/2025: Interventions: The resident's behavior is de-escalated by redirection. Date Initiated: 08/18/2025. Revision on: 09/23/2025. Medication adjustment by psych Date Initiated: 10/01/2025. Minimize potential for the resident's disruptive behaviors. Date Initiated: 08/18/2025. Revision on: 09/23/2025, Psych consult date initiated: 08/18/2025. A care plan area to address the potential to be physically aggressive r/t Dementia Date Initiated: 09/09/2025. Revision on: 09/24/2025 and a care plan to address uses antidepressant medication r/t Depression. Date Initiated: 06/20/2025. Revision on: 09/24/2025. Interventions included to Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT, Monitor/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes. Date Initiated: 06/20/2025.Record review Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 12 out of 15, indicating he was moderately cognitively impaired. The complete MDS was requested but not received.Record review of Resident #2's physician orders for September 2025 for Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) give 2 tablet by mouth two times a day for mood with a start date of 9/26/25, and a Physician order dated 10/2/25 for Chlamydia and Gonorrhea.Record review of Resident #2's MAR dated September 2025 revealed that Resident #2 was administered Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) on 9/26/25 at 9:00 am and on 9/27 through 9/30 at 9:00 AM and 6 PM. Record Review of Resident #2's lab results dated 10/3/25 for Chlamydia and Gonorrhea revealed they were negative. Record review of lab results dated 10/4/ 25 revealed an abnormal and reactive result to the Hepatitis C Antibody (positive for Hepatitis C).Record review of Resident #2's Psychological Services Progress note dated 9/24/25 read in part.Clinician was notified that this patient was accused of sexually assaulting another resident and requested a crisis session. The clinician worked on developing a therapeutic relationship with the patient as he was new to her. Used supportive listening to validate patient's emotions and encouraged patient to tell their story Related to current difficulties and then focused more narrowly to intervene. Patient's Response to Intervention: Patient reported frustration and stated that a CNA accused him of raping another resident last night. He reported that the resident is frequently in his room because it used to be her room.Clinician then asked him to explain the events of last night. He stated that she was in his room watching TV and wet her clothes. He opened the door to the bathroom for her. She then wheeled to the support bar straight ahead and stood up holding onto the bar. He moved her wheelchair to the side so that he could help her get on the toilet. He acknowledged that her pants and brief were off but denied that his had been pulled down. He reported that he has helped her in the bathroom previously and that CNAs have had to come and assist in the past. He further reportedfrustration about being accused of rape. The clinician stated that if it was consensual there was not issue. He immediately stated that the other resident was not capable of consent, and he was not sure she was even at a five-year-old's level of understanding. Next, he reported the police taking his statement, clothing, and brief as evidence. He reported understanding the collection due to the allegation.Record review of Nurse Practitioner Progress note for Resident #2, dated 9/25/25 read in part.Patient, [AGE] years old male was seen today in his room due to incident involving another resident. According to resident, he was accused of having sex with another resident. Patient is now on one-on-one supervision and is wondering why he is on surveillance. According to the Resident, the female resident wanders into his room and bathroom all the time and he denies doing what he is accused of. However, according to the Nurse and Director of Nursing, there were eyewitnesses who saw what happened. Law enforcement is now involved, and patent {sic} has been made aware of that. Patent was made aware that he will continue to be on close supervision by staff until Law enforcement are done with their investigation. Verbalized understanding. Patient is alert during this assessment and was able to answer all questions appropriately. Patient has history of dementia but is still able to hold normal conversations. Psychological and psychiatric consultation requested. Will continue one-on-one supervision with this patient until incident is resolved.Record review of Resident #2's Psychiatric Subsequent Assessment/note dated 9/30/25 read in part.Reason for Referral: Sexually Inappropriate Behavior, Other: Alleged sexual assault of another resident. Patient seen today for a F/U visit. The last visit was on 9/26/2025. Initiated Depakote 250 mg tablet BID. Assess the Pt's behaviors, monitor the response to Depakote. ON EXAM, the Pt is in the room, w/ 1:1 staff, calm and not in distress. LAST visit: Per nursing staff, [Resident #1] was wandering to [Resident #2's] room on 9/23/25 and the Aid {sic} witnessed inappropriate behavior in [Resident #2's] bathroom. In addition, the Aid {sic} witnessed that [Resident #1] was facing the wall and [Resident #2] was behind her. [Resident #2] was placed to 1:1. [Resident #1] was sent out to the hospital for vaginal examination, however the patient refused to cooperate.Record review of Resident #2's Social Service Note dated 10/1/25. Note: interviewed resident regarding his statement of assisting female residents to the bathroom when they come into his room. Initially in the interview he stated that on the night of the alleged abuse he was assisting the female resident to the bathroom. He also stated that he helped another female resident to the bathroom. As the interview continued, he stated that he assisted the female resident to the bathroom on the night in question, however that was the only female resident he assisted to the bathroom. When asked why he did not report this initially, he stated I did not remember. When asked what did he do with the other female resident he stated that they visit, have conversations on various topics, and watch a tv show together. Resident was educated that if a female resident comes into his room, he should press the call light or go to the Nurse's station to request the assistance of the Charge Nurse but never provide any form of ADL care. Resident verbalized understanding of the conversation.Record Review of Resident #2's Social Services Note dated 10/2/25. Note Text: Director of Social Services informed by IDT that it was determined that resident would be discharged to another facility for safety of the other residents. DRSS met with resident and informed him of impending discharge. He expressed understanding of situation and agreed with discharge. After discussing options, resident stated he would like to explore being admitted to a personal care home. Since resident is his own RP, DRSS inquired if he would like me to contact family members listed on his face sheet to inform them and he stated yes. Afterwards, DRSS contacted residents' families. They expressed understanding of situation and discharge.Record review of Nurse's Note for Resident #2 dated 10/4/2025. Note Text: Resident discharged to a personal care home. Transported out to vehicle via wheelchair. Resident left the facility awake, alert, oriented, without any c/o pain or signs of distress.During an interview on 10/01/25 at 9:56 a.m., the DON said LVN Q called around 8:50 p.m., on 09/23/25, and said CNA A and CNA B called LVN Q to Resident #2's bathroom after they saw Resident #1 and Resident #2 with their clothes pulled down and exposed. Resident #2 was standing behind Resident #1, and his semen was everywhere. The DON said Resident #1 wanders, and the intervention was to redirect, and the facility staff made rounds frequently. She said Resident #1 often wanders to Resident #2's room and to other residents' rooms, and staff would remove her from his room. The DON said Resident #1's BIMS was 0, and she could not consent to having sex. When the surveyor asked what other interventions were put in place after redirecting was ineffective, the DON responded that the facility did not place wandering residents on one-on-one. Still, staff made frequent rounds to check on residents. The DON said Resident #2 was making sexual comments towards staff, but he had not had any physical sexual act until this incident. The DON said Resident #2 denied having any sexual act with Resident #1.During an observation and interview on 10/01/25 at 11:12 a.m., Resident #1 was dressed in her street clothes and was sitting in her wheelchair in the TV room. Resident #1 did not respond to the surveyor's greeting, and she was not able to make her needs known.During an interview on 10/01/25 at 11:18 a.m., Resident #2 said he did not have sex with Resident #1, but he was assisting her to the toilet, and she fell backward, and he had to hold onto her. Resident #2 said the day of the incident was not the first time he had taken Resident #2 to the bathroom and assisted her to the toilet, because Resident #1 often comes to his room, and the staff were aware she comes to his room. He denied having sexual intercourse and said he had not ejaculated in months, and nothing sexual happened.During an interview on 10/01/25 at 2:44 p.m., CNA A said she and CNA B went to Resident #2's room, and the entrance door to Resident #2's room was closed. CNA A said she knocked on Resident #2's room entrance door and announced herself before she opened the room door, and she saw Resident #2 was having sex with Resident #1. CNA A said she shouted what are doing and Resident #2 pulled his penis out of Resident #1 and there was semen coming out of his penis. Then she told CNA B to call LVN Q. CNA A said that Resident #1 and Resident #2 were laughing, and Resident #2 said he was assisting her to the toilet. CNA A said she told Resident #2 to go back to his room, waited for LVN Q, and when she came and assessed Resident #1, she told her to take Resident #1 to her room and not clean her, and she was going to call the DON and the Administrator. CNA A said the police came and took the brief, which had urine and bowel movement. CNA A said she placed a clean incontinent brief on Resident #1 but did not clean her. CNA A said the police officer interviewed her, and she wrote her statement for the incident.During an interview on 10/02/25 at 8:22 a.m., CNA B said she and CNA A went to provide care to Resident #2, and when they got to his room, the entrance door was closed. CNA A knocked on the door, introduced herself, and opened the door, and she was behind her. CNA B said CNA A shouted What are you doing? and when she came from behind CNA A and looked, she saw Resident #2 had only an incontinent pull-up, and his brief was pulled down, and his penis was out, and he had semen everywhere, and he was laughing.During an interview on 10/02/25 at 9:19 a.m., NP said one of the Nurses called and told him CNA A and CNA B found Resident #1 and Resident #2 having a sexual encounter. NP said Resident #1 was sent to the hospital. NP said he made rounds the next day after the Nurse told him and saw and assessed both Resident #1 and Resident #2. NP said Resident #1 was nonverbal and she could not respond to any question or tell you anything and could not consent to consensual sex. NP said the hospital staff gave Resident #1 medication to prevent pregnancy and two types of HIV medication. The NP said Resident #2 denied having sex with Resident #1. NP said the facility staff had not told him Resident # 2 made any sexual comments to staff or to other residents. NP said it is a possibility if Resident #2 had hepatitis C and had unprotected sex with Resident #1, she could contract hepatitis C. He said he was unsure whether Resident #1 had hepatitis C.During a telephone interview on 10/02/25 at 9:41 a.m., FM said Resident #1 could not consent to sexual activity. RP said she would not consent for Resident #1 to have sexual relations at the facility. FM said the facility failed to protect Resident # 1 from sexual assault.During a telephone interview on 10/02/25 at 10:23 a.m., the Detective said he would be investigating the incident, but it has not been assigned to him yet; it would be assigned to him in a couple of days. He said from the report that the officers who came out to the facility read, CNA A said she observed Resident #1 and Resident #2 having sexual intercourse. He said the Forensic Nurse did a sexual assault kit when Resident #1 was in the hospital, and it would take 4 to 6 weeks before the result would be ready.During an interview on 10/02/25 at 12:12 p.m., the DON said she was not aware Resident #2 had hepatitis C, and the NP would see Resident #1 and Resident #2 today, and he would order labs on Resident #2. The DON said Resident #1 could be infected with hepatitis C, and she would follow up with the NP.During an interview on 10/02/25 at 2:28 p.m., the Administrator said he was responsible for in-service training on abuse and neglect. He said the abuse policy was part of the admission paper. The DON, the Corporate Nurse, and the Administrator said they do not have any policy on how to educate the resident about safe consensual sex, but they would contact their corporate office.During an interview on 10/02/25 at 2:43 p.m., the Interim Administrator said he had been the interim at the facility for three weeks, did not have access to the facility computer, and could not recall when he was notified about the incident between Resident #1 and Resident #2. He said he was not aware that the facility had a policy on how residents would be educated on having safe consensual sex. He said they usually made rounds every two hours for residents and wandering residents, and if two hours were not safe for a wandering resident, the resident should be in a locked unit. The Interim Administrator said with regard to sexual abuse in service for the staff, they were educated to separate the residents and notify the Abuse Coordinator. He said it would be an awkward conversation with residents on consensual sex. He said his thoughts about any resident who wanted to be intimate would go to the Nurse or Social Worker, who would advise the resident on what to do.During an interview on 10/02/25 at 1:45 p.m., NP said he saw Resident #1 and Resident #2 today (10/02/25), and they are stable, and labs were ordered: HIV, hepatitis C profile, BMP, and CBC for Resident #2. He said he advised the facility to find another placement for Resident #2 after the investigation because the facility still has other female residents, which could prevent the incident from recurring. He said the facility should have involved Resident #1 in activities to occupy her time and put her to bed early to rest, which would have prevented her wandering, and the incident could have been prevented. Record review of the facility policy and procedure entitled Abuse dated last revised 1/1/23 read in part.The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement.Abuse is the willful infliction of injury or negligent, unreasonable confinement.resulting in physical or emotional harm or pain to a resident; or sexual abuse involuntary or nonconsensual sexual conduct that would constitute an offense under penal code S 21.08 (indecent exposure) or Penal Code chapter 22 (assaultive offenses) sexual harassment, sexual coercion or sexual assault.Residents will not be subjected to abuse by anyone including, but not limited to, community staff, other residents.This includes physical, verbal, sexual, physical/chemical restraint. An Immediate Jeopardy (IJ) was identified on 10/02/2025 at 4:41 p.m. The IJ template was provided to the Administrator and DON on 10/02/25 at 4:41 p.m.The following Plan of Removal submitted by the facility was accepted on 10/03/2025 at 1:46 p.m.Plan of Removal F600 October 2, 2025.What corrective actions have been implemented for the identified residents? Plan of Removal.Immediate Jeopardy On 10/2/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safetyThe facility failed to ensure Resident #1 was free from sexual abuse.F600 - Sexual abuse Immediate action Resident #1 sent to hospital for assessment and returned on 9/24/25. Resident placed on one on one 10/2/25 until alternative placement is found on secure unit. Family notified 10/2/2025 of plan for discharge Resident #1 was placed on 1:1 monitoring until alternate placement is found due to wandering into other resident's rooms. Alternate placement will be a secure unit or placement chosen by RP. The Regional director of clinical services (RDCO) in-serviced the Executive Director of operations (administrator) and Director of Nursing operation (DON) on abuse policy on 10/2/2025. The DON initiated In-service on Abuse and Neglect for all staff on 10/2/2025 to be completed on 10/3/2025. Residents #1 and #2 were assessed by charge Nurses on 10/2/2025, no concern noted. All residents that wanders were assessed by DCO and Charge Nurses with their care plan audit completed on 10/2/2025, and no concern noted. Resident #2 was placed on 1:1 monitoring until evaluated by psychiatrist for further direction on care. Resident #2 RP was notified of resident current status by social worker on 10/2/2025. Resident # 2 physicians was notified of current status by DCO on 10/2/2025. Resident #1 and #2 care plans were updated by MDS Nurse on 10/2/2025. DON trained all staff on rounding and supervision on residents to be completed on 10/3/2025. The Director of Social Service initiated education with residents on resident rights policy and procedure, notifying staff of unwanted visitors in their rooms to include wandering residents. Resident education was Completed on 10/3/2025.Identification of Residents Affected or Likely to be AffectedOn 10/2/2025 the DON and Social worker completed the audit for all residents who wander to other residents' room, none was identified. An audit was completed on 10/2/2025Facility's Plan to ensure compliance quickly DON will provide in-service to all staff on abuse policy and will be completed on 10/3/2025. Staff will not provide direct care until training is completed. DON will provide training for all staff on redirecting resident that wanders into other resident's room and to notify the charge Nurse immediately. DON trained Charge Nurse to assess the residents, notify the DON and Administrator and to monitor residents. Training to be completed on 10/3/2025. DCO will review residents that wander daily in IDT meetings to determine changes to where they wander to and determine if they need to revise their plan of care. Daily rounds will be conducted by the IDT during focus rounds to identify any concern with residents that wanders and discuss the concern with administrator. Social worker to contact resident #1 Rp to discuss plan of care to be completed 10/3/2025. The medical Director was notified of the immediate jeopardy on 10/2/2025 by the administrator. The medical director reviewed abuse and neglect policy and made no changes to the policy on 10/2/2025. Any staff member not available for training will not assume any job assignment until training is completed. Staff will identify residents with inappropriate behaviors such as sexual comments, wandering that poses a safety concern, or aggression. If a resident experiences inappropriate behaviors we immediately place them on a 1:1. Psych is then consulted to provide guidance on the behavior and to assist with a plan of care. IDT will ensure that proper interventions are in place. DCO and/or designee will communicate with staff. DCO and/or designee will monitor process. Monitoring of the plan of removal from 10/04/2025 through10/06/25 included:Record review of P

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 out of 5 residents (Resident #1 and Resident #2) reviewed for adequate supervision.- The facility failed to ensure Resident #1 who was severely cognitively impaired and nonverbal and Resident #2 who was moderately cognitively impaired and had behaviors of inappropriate sexual comments to staff received adequate supervision to prevent abuse after she wandered into Resident #2's room in facility on 9/23/25. Resident #1 was sexually assaulted by Resident #2. An Immediate Jeopardy (IJ) was identified on 10/02/2025 at 4:41 p.m. The IJ template was provided to the Administrator and DON on 10/02/25 at 4:41 p.m. While the IJ was removed on 10/06/25 at 1:28 p.m. the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that was not an immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.This deficiency exposed residents living in the facility to potential harm, injury, or death due to not being adequately monitored. Record review of Resident #1's facility admission record dated 10/1/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with most current admission date of 6/26/18. Resident #1 admitted with diagnoses that included anoxic brain damage (a condition where the brain experiences a complete lack of oxygen supply. This deprivation of oxygen can lead to widespread damage to brain cells, resulting in severe neurological impairment or death) and epilepsy and epileptic syndromes (Epilepsy is a brain disorder characterized by recurrent, unprovoked seizures, while an epileptic syndrome is a specific, complex constellation of signs and symptoms that define a unique epilepsy condition. An epileptic syndrome includes specific seizure types, other clinical features).Record review of Residents #1's care plan date Initiated 9/15/21 and revised on 9/24/25 revealed she was care-planned for a high elopement risk/wandering in male residents' room and was at risk for possible injury r/t impaired safety awareness and diagnosis of dementia, Anoxic brain damage. Date Initiated: 09/15/2021. Revision on: 09/24/2025: Goals: Resident #1's safety will be maintained throughout the review date. Date Initiated: 09/15/2021. Revision on: 09/12/2025. Target Date: 10/19/2025 Interventions: Assess for fall risk. Date Initiated: 09/15/2021. Provide structured activities: Toileting, walking inside and outside, reorientation strategies, including signs, pictures, and memory boxes. Date Initiated: 09/15/2021. Wander guard placed for resident's safety, bracelet will alert staff if and when resident attempts to exit doors of facility. Staff to monitor daily. Date Initiated: 09/15/2021. Redirect resident. Date Initiated: 09/24/2025. A care plan to address Resident #1 identifies as a trauma survivor. 1.possible trigger of aggressive vocal stimuli. 2. Childhood trauma memories, Domestic abuse memories , Physical Abuse memories, Sexual Abuse memories. Date Initiated: 11/14/2019. Revision on: 05/07/2020. Goals: SHE will remain stable and adjusted to her environment. Date Initiated: 11/14/2019 Revision on: 09/12/2025. Target Date: 10/19/2025. Interventions: Ask for permission to enter resident's room, perform care, and/or assist with ADLs. Date Initiated: 09/08/2023. Explain all procedures to the resident before starting and allow the resident (X minutes) to adjust to changes when necessary. Date Initiated: 09/08/2023. Reduction of possible triggers in her environment. Date Initiated: 11/14/2019. A care plan to address Resident #1's impaired cognitive function or impaired thought processes r/t ANOXIC BRAIN INJURY. SHE has cognitive loss (loss of memory, time sense and requires assistance with decision making r/t Impaired decision-making abilities, is not always understood or able to understand verbal and non-verbal expression. Date Initiated: 05/07/2020. Revision on: 05/07/2020. Resident #1 will improve current level of cognitive function through the review date. Date Initiated: 02/09/2021. Revision on: 09/12/2025. Target Date: 10/19/2025.Record review of Resident #1's Quarterly MDS dated [DATE] revealed Cognitive Skills for Daily Decision Making (section C1000) were coded at 3, indicating her cognition was severely impaired. Resident #1 was coded to require substantial/maximal assistance with ADLs. She was always incontinent of bowels and bladder and used a wheelchair for mobility.Record review of Resident #1's physician orders dated September 2025 revealed orders with a start date of 9/25/25 to administer Emtricitabine- Tenofovir oral tablet 200-300 MG (Emtricitabine- Tenofovir Disoproxil Fumarate) Give 1 tablet by mouth one time a day for antiviral for 28 days at 9:00 AM. An order for Tivicay Oral (Dolutegravir Sodium) Tablet 50 MG Give 1 tablet by mouth one time a day for antiviral for 28 days at 9:00 AM. An order for Plan B One-Step Oral Tablet 1.5 MG (Levonorgestrel Emergency OC) Give 1 tablet by mouth one time only for contraceptive for 1 day with a start date of 9/24/25. Record review of Resident #1's MAR dated September 2025 revealed that Resident #1 was administered Emtricitabine and tenofovir antiretroviral medication (used to treat and prevent HIV infection) on 9/25/25 through 9/30/25. Resident #1 was administered Tivicay Oral (Dolutegravir Sodium) Tablet 50 MG Give 1 tablet by mouth one time a day for antiviral on 9/25/25 through 9/30/25. Resident #1 was administered Plan B One-Step Oral Tablet 1.5 MG (Levonorgestrel Emergency OC (Oral Contraceptive) 1 tablet by mouth on 9/25/25.Record review of Nurses Note dated 9/23/2025. Note Text: Called to room by CNA A and CNA B reported to staff nurses that resident was having sexual activity with Resident #1. Resident #1 was immediately removed for safety. When male resident questioned by staff nurse what happened male resident began to laugh and stated nothing happened . Female resident is not cognitively intact female resident monitored all safety measures in place. Male resident immediately monitored 1-1 by staff. DON notified of above. MD notified. Family notified by DON awaiting return call. The resident transferred to local hospital.Record review of Nurses Note dated 9/23/2025. Note Text: Spoke with forensic nurse at local hospital who reported that she completed an exam on resident . She stated she was able to get a swab for DNA and STD testing but was unable to do a vaginal exam because the resident closed her legs and would not allow her to examine her. She stated that a pregnancy test was performed and was negative, resident was treated prophylactically with ATBs and will discharge to facility with orders for ATBs to continue. Resident #1 will also return with an order for Plan B . Nurse stated that an official report will be available in 1-2 business days. Called RP to update her on report from the nurse, message left, awaiting call back.Record review of the post hospital discharge instructions and orders dated 9/24/25 revealed that Resident #1 was seen for sexual assault. A SANE (Sexual Assault Nurse Examiner) adult sexual assault exam was performed (a forensic exam was performed (results pending and coordinated with the local police department). Orders for STI Sexually Transmitted Infection Prophylaxis: Ondansetron 4 mg PO x1, Azithromycin 1gm PO x1, Metronidazole 2gms PO x1, Ceftriaxone 500mg IM reconstituted with 1.1 ml of 1% Lidocaine. Lab orders for Pharyngeal Gonorrhea ( a sexually transmitted infection (STI) caused by the Neisseria gonorrhoeae bacteria that infects the pharynx. It is spread through oral sex with an infected person and can be asymptomatic, but symptoms may include a sore throat, difficulty swallowing, swollen lymph nodes in the neck, or redness/swelling in the throat) and Chlamydia (a common sexually transmitted infection (STI) caused by the bacterium Chlamydia trachomatis. It is primarily spread through sexual contact with an infected person).Record review of Nurse Practitioner note dated 9/25/25 for Resident #1: Chief Complaint: Evaluation of patient for alleged sexual assault incident: Hospital Course: She was taken to the ER a few days ago after an incident with another resident of a sexual nature. She was examined for possible sexual assault and started on post-exposure prophylaxis (levonorgestrel single dose; dolutegravir 50 mg daily x28 days; emtricitabine/tenofovir 200/300 mg daily x28 days; PRN ondansetron). Hospital examination results are pending. Today she appears in no distress. History of Present Illness: Resident #1, a [AGE] years old female with history of anoxic brain damage, epilepsy, unsteadiness on the feet, ataxia (poor muscle control that causes clumsy movements), abnormal gait, generalized muscle weakness, dysphagia (swallowing difficulties), mixed receptive/expressive language disorder (is a neurodevelopmental condition that affects a child's ability to both understand and produce language), dysarthria (difficulty speaking because the muscles you use for speech are weak), severe hypoxic ischemic encephalopathy (a brain injury that happens before, during, or shortly after birth when oxygen or blood flow to the brain is reduced or stopped), hyperlipidemia (an elevated level of lipids - like cholesterol and triglycerides - in your blood), hypertensive heart disease (a constellation of structural and functional changes in the left ventricle, left atrium, and coronary arteries resulting from chronic blood pressure elevation), and hypothyroidism (a condition in which the thyroid gland does not make enough thyroid hormone) among other medical problems was seen today upon the request of the Nurse due to a reportable incident that happened between patient and another resident. Patient was examined in the dining room. She is nonverbal and not able to make needs known due to anoxic brain injury. Patient was taken to the ER a few days ago for an examination of an encounter with another resident of a sexual nature. She was examined for sexual assault. Findings were not available at the time of this visit; however, patient was placed on several medications including: Levonorgestrel 1.5 mg tablet 1 time only, dolutegravir 50 mg daily for 28 days, emtricitabine/tenofovir 200/300 mg daily for 28 days and as needed Zofran. The results of the patient's examination at the hospital are still pending. - Additional consultations: Psychiatry and Psychology evaluations requested for psychological support.Record Review of Resident #1's Diagnostic Assessment from Psychological Evaluation and Treatment Services dated 9/29/25 revealed that the referral was made due to possible sexual assault at the facility. Resident #1 was unable to answer assessment questions or questions regarding the alleged events therefore she is not a candidate for psychotherapy. Record review of Resident #1's Initial Psychiatric assessment dated [DATE] revealed that Resident #1 was referred due to recent sexual assault without ability to consent, patient was noted to not be able to respond, trauma screening was unable to be determined due to patient being unable to respond. Resident #2Record review of Resident #2's facility admission record dated 10/2/25 revealed a [AGE] year-old-male, admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side (a stroke damaged the right side of the brain, causing paralysis (hemiplegia) and/or weakness (hemiparesis) on the left side of the body) and Chronic Viral Hepatitis C (a long-term liver infection caused by the hepatitis C virus). Record review of Resident #2's care plan revealed care plans to address areas that included: The resident has a behavior problem r/t inappropriate verbal sexual comments towards staff. Date Initiated: 08/18/2025. Revision on: 09/23/2025 Goals: The resident will have fewer episodes of inappropriate behaviors by review date. Date Initiated: 08/18/2025 Revision on: 09/23/2025 Target Date: 12/18/2025: Interventions: The resident's behavior is de-escalated by redirection. Date Initiated: 08/18/2025. Revision on: 09/23/2025. Medication adjustment by psych Date Initiated: 10/01/2025. Minimize potential for the resident's disruptive behaviors. Date Initiated: 08/18/2025. Revision on: 09/23/2025, Psych consult date initiated: 08/18/2025. A care plan area to address the potential to be physically aggressive r/t Dementia Date Initiated: 09/09/2025. Revision on: 09/24/2025 and a care plan to address uses antidepressant medication r/t Depression. Date Initiated: 06/20/2025. Revision on: 09/24/2025. Interventions included to Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT, Monitor/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes. Date Initiated: 06/20/2025.Record review Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 12 out of 15, indicating he was moderately cognitively impaired. The complete MDS was requested but not received.Record review of Resident #2's physician orders for September 2025 for Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) give 2 tablet by mouth two times a day for mood with a start date of 9/26/25, and a Physician order dated 10/2/25 for Chlamydia and Gonorrhea.Record review of Resident #2's MAR dated September 2025 revealed that Resident #2 was administered Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) on 9/26/25 at 9:00 am and on 9/27 through 9/30 at 9:00 AM and 6 PM. Record Review of Resident #2's lab results dated 10/3/25 for Chlamydia and Gonorrhea revealed they were negative. Record review of lab results dated 10/4/ 25 revealed an abnormal and reactive result to the Hepatitis C Antibody (positive for Hepatitis C).Record review of Resident #2's Psychological Services Progress note dated 9/24/25 read in part.Clinician was notified that this patient was accused of sexually assaulting another resident and requested a crisis session. The clinician worked on developing a therapeutic relationship with the patient as he was new to her. Used supportive listening to validate patient's emotions and encouraged patient to tell their story Related to current difficulties and then focused more narrowly to intervene. Patient's Response to Intervention: Patient reported frustration and stated that a CNA accused him of raping another resident last night. He reported that the resident is frequently in his room because it used to be her room.Clinician then asked him to explain the events of last night. He stated that she was in his room watching TV and wet her clothes. He opened the door to the bathroom for her. She then wheeled to the support bar straight ahead and stood up holding onto the bar. He moved her wheelchair to the side so that he could help her get on the toilet. He acknowledged that her pants and brief were off but denied that his had been pulled down. He reported that he has helped her in the bathroom previously and that CNAs have had to come and assist in the past. He further reportedfrustration about being accused of rape. The clinician stated that if it was consensual there was not issue. He immediately stated that the other resident was not capable of consent, and he was not sure she was even at a five-year-old's level of understanding. Next, he reported the police taking his statement, clothing, and brief as evidence. He reported understanding the collection due to the allegation.Record review of Nurse Practitioner Progress note for Resident #2, dated 9/25/25 read in part.Patient, [AGE] years old male was seen today in his room due to incident involving another resident. According to resident, he was accused of having sex with another resident. Patient is now on one-on-one supervision and is wondering why he is on surveillance. According to the Resident, the female resident wanders into his room and bathroom all the time and he denies doing what he is accused of. However, according to the Nurse and Director of Nursing, there were eyewitnesses who saw what happened. Law enforcement is now involved, and patent {sic} has been made aware of that. Patent was made aware that he will continue to be on close supervision by staff until Law enforcement are done with their investigation. Verbalized understanding. Patient is alert during this assessment and was able to answer all questions appropriately. Patient has history of dementia but is still able to hold normal conversations. Psychological and psychiatric consultation requested. Will continue one-on-one supervision with this patient until incident is resolved.Record review of Resident #2's Psychiatric Subsequent Assessment/note dated 9/30/25 read in part.Reason for Referral: Sexually Inappropriate Behavior, Other: Alleged sexual assault of another resident. Patient seen today for a F/U visit. The last visit was on 9/26/2025. Initiated Depakote 250 mg tablet BID. Assess the Pt's behaviors, monitor the response to Depakote. ON EXAM, the Pt is in the room, w/ 1:1 staff, calm and not in distress. LAST visit: Per nursing staff, [Resident #1] was wandering to [Resident #2's] room on 9/23/25 and the Aid {sic} witnessed inappropriate behavior in [Resident #2's] bathroom. In addition, the Aid {sic} witnessed that [Resident #1] was facing the wall and [Resident #2] was behind her. [Resident #2] was placed to 1:1. [Resident #1] was sent out to the hospital for vaginal examination, however the patient refused to cooperate.Record review of Resident #2's Social Service Note dated 10/1/25. Note: interviewed resident regarding his statement of assisting female residents to the bathroom when they come into his room. Initially in the interview he stated that on the night of the alleged abuse he was assisting the female resident to the bathroom. He also stated that he helped another female resident to the bathroom. As the interview continued, he stated that he assisted the female resident to the bathroom on the night in question, however that was the only female resident he assisted to the bathroom. When asked why he did not report this initially, he stated I did not remember. When asked what did he do with the other female resident he stated that they visit, have conversations on various topics, and watch a tv show together. Resident was educated that if a female resident comes into his room, he should press the call light or go to the Nurse's station to request the assistance of the Charge Nurse but never provide any form of ADL care. Resident verbalized understanding of the conversation.Record Review of Resident #2's Social Services Note dated 10/2/25. Note Text: Director of Social Services informed by IDT that it was determined that resident would be discharged to another facility for safety of the other residents. DRSS met with resident and informed him of impending discharge. He expressed understanding of situation and agreed with discharge. After discussing options, resident stated he would like to explore being admitted to a personal care home. Since resident is his own RP, DRSS inquired if he would like me to contact family members listed on his face sheet to inform them and he stated yes. Afterwards, DRSS contacted residents' families. They expressed understanding of situation and discharge.Record review of Nurse's Note for Resident #2 dated 10/4/2025. Note Text: Resident discharged to a personal care home. Transported out to vehicle via wheelchair. Resident left the facility awake, alert, oriented, without any c/o pain or signs of distress. During an interview on 10/01/25 at 9:56 a.m., the DON said LVN Q called around 8:50 p.m., on 09/23/25, and said CNA A and CNA B called LVN Q to Resident #2's bathroom after they saw Resident #1 and Resident #2 with their clothes pulled down and exposed. Resident #2 was standing behind Resident #1, and his semen was everywhere. The DON said Resident #1 wanders, and the intervention was to redirect, and the facility staff made rounds frequently. She said Resident #1 often wanders to Resident #2's room and to other residents' rooms, and staff would remove her from his room. The DON said Resident #1's BIMS was 0, and she could not consent to having sex. When the surveyor asked what other interventions were put in place after redirecting was ineffective, the DON responded that the facility did not place wandering residents on one-on-one. Still, staff made frequent rounds to check on residents. The DON said Resident #2 was making sexual comments towards staff, but he had not had any physical sexual act until this incident. The DON said Resident #2 denied having any sexual act with Resident #1.During an observation and interview on 10/01/25 at 11:12 a.m., Resident #1 was dressed in her street clothes and was sitting in her wheelchair in the TV room. Resident #1 did not respond to the surveyor's greeting, and she was not able to make her needs known.During an interview on 10/01/25 at 11:18 a.m., Resident #2 said he did not have sex with Resident #1, but he was assisting her to the toilet, and she fell backward, and he had to hold onto her. Resident #2 said the day of the incident was not the first time he had taken Resident #2 to the bathroom and assisted her to the toilet, because Resident #1 often comes to his room, and the staff were aware she comes to his room. He denied having sexual intercourse and said he had not ejaculated in months, and nothing sexual happened.During an interview on 10/01/25 at 2:44 p.m., CNA A said she and CNA B went to Resident #2's room, and the entrance door to Resident #2's room was closed. CNA A said she knocked on Resident #2's room entrance door and announced herself before she opened the room door, and she saw Resident #2 was having sex with Resident #1. CNA A said she shouted what are doing and Resident #2 pulled his penis out of Resident #1 and there was semen coming out of his penis. Then she told CNA B to call LVN Q. CNA A said that Resident #1 and Resident #2 were laughing, and Resident #2 said he was assisting her to the toilet. CNA A said she told Resident #2 to go back to his room, waited for LVN Q, and when she came and assessed Resident #1, she told her to take Resident #1 to her room and not clean her, and she was going to call the DON and the Administrator. CNA A said the police came and took the brief, which had urine and bowel movement. CNA A said she placed a clean incontinent brief on Resident #1 but did not clean her. CNA A said the police officer interviewed her, and she wrote her statement for the incident.During an interview on 10/02/25 at 8:22 a.m., CNA B said she and CNA A went to provide care to Resident #2, and when they got to his room, the entrance door was closed. CNA A knocked on the door, introduced herself, and opened the door, and she was behind her. CNA B said CNA A shouted What are you doing? and when she came from behind CNA A and looked, she saw Resident #2 had only an incontinent pull-up, and his brief was pulled down, and his penis was out, and he had semen everywhere, and he was laughing.During an interview on 10/02/25 at 9:19 a.m., NP said one of the Nurses called and told him CNA A and CNA B found Resident #1 and Resident #2 having a sexual encounter. NP said Resident #1 was sent to the hospital. NP said he made rounds the next day after the Nurse told him, and saw and assessed both Resident #1 and Resident #2. NP said Resident #1 was nonverbal and she could not respond to any question or tell you anything, and could not consent to consensual sex. NP said the hospital staff gave Resident #1 medication to prevent pregnancy and two types of HIV medication. The NP said Resident #2 denied having sex with the resident. NP said the facility staff had not told him Resident # 2 made any sexual comments to staff or to other residents. NP said it is a possibility if Resident #2 had hepatitis C and had unprotected sex with Resident #1, she could contract hepatitis C. He said he was unsure whether Resident #1 had hepatitis C.During a telephone interview on 10/02/25 at 9:41 a.m., FM said Resident #1 could not consent to sexual activity. RP said she would not consent for Resident #1 to have sexual relations at the facility. FM said the facility failed to protect Resident # 1 from sexual assault.During a telephone interview on 10/02/25 at 10:23 a.m., the Detective said he would be investigating the incident, but it has not been assigned to him yet; it would be assigned to him in a couple of days. He said from the report that the officers who came out to the facility read, CNA A said she observed Resident #1 and Resident #2 having sexual intercourse. He said the Forensic Nurse did a sexual assault kit when Resident #1 was in the hospital, and it would take 4 to 6 weeks before the result would be ready.During an interview on 10/02/25 at 12:12 p.m., the DON said she was not aware Resident #2 had hepatitis C, and the NP would see Resident #1 and Resident #2 today, and he would order labs on Resident #2. The DON said Resident #1 could be infected with hepatitis C, and she would follow up with the NP.During an interview on 10/02/25 at 2:28 p.m., the Administrator said he was responsible for in-service training on abuse and neglect. He said the abuse policy was part of the admission paper. The DON, the Corporate Nurse, and the Administrator said they do not have any policy on how to educate the resident about safe consensual sex, but they would contact their corporate office.During an interview on 10/02/25 at 2:43 p.m., the Interim Administrator said he had been the interim at the facility for three weeks, did not have access to the facility computer, and could not recall when he was notified about the incident between Resident #1 and Resident #2. He said he was not aware that the facility had a policy on how residents would be educated on having safe consensual sex. He said they usually made rounds every two hours for residents and wandering residents, and if two hours were not safe for a wandering resident, the resident should be in a locked unit. The Interim Administrator said with regard to sexual abuse in service for the staff, they were educated to separate the residents and notify the Abuse Coordinator. He said it would be an awkward conversation with residents on consensual sex. He said his thoughts about any resident who wanted to be intimate would go to the Nurse or Social Worker, who would advise the resident on what to do.During an interview on 10/02/25 at 1:45 p.m., NP said he saw Resident #1 and Resident #2 today (10/02/25), and they are stable, and labs were ordered: HIV, hepatitis C profile, BMP, and CBC for Resident #2. He said he advised the facility to find another placement for Resident #2 after the investigation because the facility still has other female residents, which could prevent the incident from recurring. He said the facility should have involved Resident #1 in activities to occupy her time and put her to bed early to rest, which would have prevented her wandering, and the incident could have been prevented.Record review of the facility policy and procedure entitled Incident and Accident dated 3-1-17 read in part.Accidents or incidents involving residents shall be investigated and reported to the Executive Director of Operations.Licensed nurse will complete an incident and accident report when staff is aware that an incident occurred. Review each incident report at daily clinical meeting.Licensed nurse will notify physician and responsible party and update resident's care plan.If resident requires one to one supervision, staff will document using the One-on-One Monitoring form.Record review of the facility policy and procedure entitled Elopement dated 11/01/2019, provided by facility DON who referred to this policy as the policy on wandering on 10/5/25 read in part. POLICY: To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing. Elopement drill will be held quarterly.Once it has been established that a patient/resident is missing, the following staff members are notified immediately: The charge nurse, Executive Director of Operations, Director of Clinical Operations, and social service designee, responsible party and the primary care physician. Conduct a headcount. An Immediate Jeopardy (IJ) was identified on 10/02/2025 at 4:41 p.m. The IJ template was provided to the Administrator and DON on 10/02/25 at 4:41 p.m. F689- Accident and SupervisionThe following Plan of Removal submitted by the facility was accepted on 10/03/2025 at 1:46 p.m.Plan of Removal F689 October 2, 2025.What corrective actions have been implemented for the identified residents? Plan of Removal.Immediate Jeopardy On 10/2/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safetyThe facility failed to ensure Resident #1 received adequate supervision to prevent abuse.F689- Accident and SupervisionImmediate Action Resident #1 sent to hospital for assessment and returned on 9/24/25. Resident placed on one on one 10/2/25 until alternative placement is found on secure unit. Family notified 10/2/2025 of plan for discharge. Resident #1 was placed on 1:1 on 10/2/2025 until alternate placement is found due to wandering into other resident's rooms. Alternate placement will be a secure unit or placement chosen by RP. Resident #2 was placed on 1:1 on 10/2/2025 until evaluated by psychiatrist for further direction on care. Identification of Residents Affected or Likely to be Affected: On 10/2/2025 the DON and Social worker completed the audit for all residents who wander to other residents' room, none was identified. An audit was completed on 10/2/2025.Facility's Plan to ensure compliance quickly #2 will be re-evaluated by the Psychiatry by 10/3/2025. Resident #2 is appropriate for group home as determined by psych services. Referral to group home sent by Social Services on 10.3.25 per family recommendation. The Director of Nurses initiated Inservice on 10/2/25 with all staff. Inservice was on Abuse and neglect, resident rights, Accident and Supervision which was conducted by the Director of Clinical Service. Inservice will be completed by 10/3/2025. The Director of Social Service initiated education with residents on resident rights policy and procedure, notifying staff of unwanted visitors in their rooms to include wandering residents. Resident education was Completed on 10/3/2025. The Director of Clinical Operations and Designee Assessed all wandering residents to determine if they are wandering into other resident rooms and if they are at risk. Resident assessment completed on 10/3/2025, Social worker completed audit on 10/2/2025 on all residents for inappropriate sexual behavior and none was identified. Medical Director notified of alleged facility noncompliance with ensuring supervision of wandering staff. Reviewed staff training on Resident Abuse, Accident and Supervision on 10/2/2025. No changes with policy will be made at this time. Staff are required to make rounds every 2 hours to monitor and supervise residents. All residents that wanders were assessed by DCO and Charge Nurses with their care plan audit completed on 10/2/2025, and no concern noted. Audit performed on 10.3.25 by Social Worker and DCO. No residents with inappropriate sexual behaviors were identified. Any staff member not available for training will not assume any job assignment until training is completed. All new hires will be educated on abuse policy, resident monitoring, and supervision. Ad Hoc QAPI completed to review all IJs, interventions and Plan of care taken with IDT and Medical director, all interventions are effective at this time.Mo

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from Misappropriation of property for one (Resident #15) of 18 residents reviewed for misappropriation of property.<BR/>The facility failed to ensure Resident #15 was free from misappropriation of property when an employee used her credit card for personal benefit.<BR/>The non-compliance was identified as past non-compliance. The facility had corrected the noncompliance before the survey began.<BR/>This failure could place residents at risk of Exploitation/Misappropriation of Property and financial distress.<BR/>Findings include: <BR/>Record review of Resident #15's face sheet dated 01/29/25 revealed [AGE] year-old female, with an original admission date of 05/25/24 and re admitted on [DATE]. Her diagnosis included acute pyelonephritis (A sudden and severe inflammation of kidney due to a bacterial infection). Muscle wasting, Hypothyroidism (a condition where the thyroid gland does not make enough hormone) communication deficit (Difficulty in communication that arises from impairments in cognitive process), unspecified lack of coordination, Unsteadiness on feet.<BR/>Record review of Resident #15's admission MDS assessment dated [DATE] revealed she had a BIMS score of 12 out of 15, which indicated moderate cognitive impairment. Resident #15 was independent with ADLs for toileting and personal hygiene coded as limited assistant.<BR/>Record review of PIR (Form 3613-A of Texas Health and Human Services) dated 12/30/24 read in part <BR/>Resident #15's responsible party reported that there were fraudulent charges on Resident #15's debit card. RP stated that Resident #15's debit card was mission and there were charges on the debit card.<BR/>Record review of Facility's communication with Resident #15's RP revealed Resident #15's debit card was stolen at the facility and two charges were made on the debit card as $30.66 at a gas station on Hwy 3 and $73.61 for margaritas down in Lake [NAME] Texas. <BR/>Observation and interview on interview on 01/27/25 at 10:00AM, revealed Resident #15 was present at the facility in her room, in bed, alert and oriented. During an interview she said she was doing well and sleepy.<BR/>In an interview with Resident #15 on 01/27/25 at 1:00PM, she said she remembered the incident very well. She said she wanted a cup of coffee and the girl (CNA T) said she was on her break and would get her the coffee. Resident #15 said e CNA T sat at the edge of her bed. Resident #15 said she took the $6 from her purse and her debit card might have fallen out and she did not know until her daughter called her to ask if she gave her debit card to anyone. Resident #15 said she told her RP no and explained to her RP that she sent someone out to the store to get her coffee but gave the staff the sum of #$6.00 for the coffee. Resident #15 said she remembered the staff very well and called CNA T by name and described her as golden girl because CNA T had some earrings on her face and nose. <BR/>Phone call was made to Resident #15's RP on 01/27/25 at 4:00pm, no answer. Second phone call was made on 01/28/24 at 11:00am and at 4:30pm no answer voice message was with a phone #. <BR/>During an interview with the Facility's Administrator and the DON on 01/28/24 at 2:00pm, the DON said the facility know exactly who the staff was by Resident #15's description of the staff, the schedule and sign in sheet. The DON identified the CNA' as CNA T. The DON said the police was called by Resident #15's RP as soon as she discovered that Resident #15's debit card was stolen and there were charges made on it. The DON said as soon as she received the e-mail, herself, the Administrator, and the Social Worker started an investigation and reported it to the State as required. The DON on said the police walk walked in almost at the same time while she was doing the investigation. She said the police asked for the staff that worked on the 29 and the 30th of December 2024. The DON said CNA T had gone out through the back door out of the facility. The DON said she called CNA T and CNA T told her that she had a ticket in at another county, and she was on her way to pay the ticket. The DON said the police gave a case # and a copy of the video that shows CNA T purchasing goods from the store. The DON said CNA CAN T worked from 12/11/24 through 12/30/24 the day the police showed up for the investigation. The DON provided CNACAN T. signed schedules and timecard that indicated CNA clocked in and out.<BR/>Phone call placed to CNA T on 01/28/25 at 3:00PM. No answer; message was left with a returned phone #.<BR/>During a phone interview on 1/29/25 at 2:30PM, CNA T said she worked at the facility for 3 days and she did not work with Resident #15. She said she worked with another CNA, CNA K that worked with Resident #15. She said the CNA K gave her ride to the store because CNA K was going to get coffee for Resident #15. CNA T said she bought some goods and paid for what she bought with her card. She said she does not remember CNA CAN K's full name. She gave a name that did not exist on the employee list provided by the facility. CNA T said she did not clock in at the facility because she did not have a pin # to clock in since she was on orientation. She said she wrote her hours on a paper and submitted it to the DON. She said she did not work at the facility on 12/29/2024 to 12/30/20244 because she lost her son on the 12/29/24. She said she did not go back to the facility to work due to poor working condition of not being trained and not having enough staff.<BR/>Phone call was made to Local Police department that investigated that investigated the case on 01/30/25 at 3:30pm. Message left with a returned call phone # and case #-2403057. Second attempt was made on 01/30/25 at 5:00pm.<BR/>Record review of facility's schedules with signatures revealed CNA T was hired on 12/10/24. She had two-day orientation on 12/11/24 and 12/12/24. Record review of signed schedules revealed CNA T worked till 12/30/24. <BR/>Record review of facility of facility's provided policy on abuse, neglect and exploitation dated 02/01/2017 revised 01/01/2023 read in part The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement, and or Misappropriation of property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that &sect;483.55(a)(5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay for 1 of 10 residents (Residents #70) reviewed for dental services. <BR/>-The facility failed to assist in providing emergency or routine dental services in a timely manner. <BR/>-The facility failed to promptly within 3 days, refer Resident #70 for dental services related to lost dentures.<BR/>-The facility failed to provide documentation of the extenuating circumstances that led to the delay in Resident #70 being seen by a dentist.<BR/>These failures could place residents at risk of oral complications, dental pain, and diminished quality of life. <BR/>Findings included:<BR/>Resident #70<BR/>Review of Resident #70's admission Record revealed she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included effusion of right wrist (condition in which there is an excessive build-up of fluid within the joint of the right wrist), protein calorie malnutrition (condition of nutritional status in which reduced availability of nutrients leads to changes in body composition and function), fracture of lower end of right radius (broken bone of lower right arm near the wrist), and abnormal weight loss (unintentional weight loss). <BR/>Review of Resident #70's admission MDS assessment dated [DATE] revealed she had a BIMS score of 14 out of 15 indicating she had intact cognitive function, she used a wheelchair for mobility, required set-up assistance with eating, received a regular diet and had no reported weight loss or gain and there was no documentation of mouth/dental pain or issues and no dental CAA's were triggered at the time of the assessment.<BR/>Record review on 1/29/25 at 2:12 pm of facility Grievance/Complaint Form for Resident #70 completed by Social Worker and dated 12/2/24 revealed in part: Family member reports that residents' dentures are missing . and listed the date incident occurred as 11/26/24. Recommendations/Corrective Action taken: Resident was placed on dental list to be fitted for new dentures . <BR/>Record review on 1/29/25 at 2:15pm of facility undated dental Appointment Pull Chart List revealed: Resident #70 had a dental appointment on 2/14/25 at 2:00 pm.<BR/>Telephone interview followed immediately by an in-person interview with family member of Resident #70 on 1/28/25 at 2:57 pm who said that he requested Resident #70 receive a puree diet back in early December 2024 because Resident #70 could not eat her regular diet without her upper denture which was lost back on 11/26/24. Family member said they spoke with the SW repeatedly immediately after the loss of the upper denture on 11/26/24 and was told that the facility assumed no responsibility for the loss of the dentures and would not pay to replace them. Family member said that he offered to split the cost of dentures 50%/50% with the facility but SW told him Administrator said no. Family member said they never spoke with Administrator or DON. The Family member said they only spoke with the SW and the SW said that Resident #70 needed a payor source to see the dentist. The Family member said that Resident #70 and had just gotten approved for Medicaid in January 2025. The family member said that after about 10 days to two weeks after Resident #70's upper dentures were lost, and Resident #70 still had not seen the dentist and when he asked the SW about this, he had repeatedly been given excuses about the holidays and the winter storm for why Resident #70 had not been seen by the dentist yet. <BR/>Interview on 1/28/25 at 4:08pm with Administrator who said that SW managed scheduling of dental consultations for residents and was responsible for the facility's dental program. The Administrator said he was advised by corporate oversight that they would not pay for dentures. The Administrator said he was not informed of family member's offer to split costs 50%/50%. The Administrator said that he did not know when Resident #70 was supposed to see the dentist for the first time. The Administrator said he thought the grievance had been resolved and that the SW was also responsible for the grievance follow ups. The Administrator did not respond when asked if he thought waiting from 11/26/24 until 2/14/25 to see a dentist was too long to wait. The Administrator said he was brand new and had only worked at the facility for few months. <BR/>Interview with the SW on 1/28/25 at 4:24pm he said he was responsible for sending referrals and for scheduling dental services for the facility residents. When asked if he had updated Resident #70 or her family member on the first dental visit being scheduled for 2/14/25, the SW said that he spoke with Resident #70's family member almost every day but could not recall if he told them that the first dental appointment was not until 2/14/25. When asked if he thought waiting from 11/26/24 until 2/14/25 to be seen by a dentist for new dentures was too long of a wait, the SW replied 12/2/24. The SW said that the grievance was on 12/2/24. The SW then said that he initiated the referral process on 12/10/24 and would look to see how he could provide documentation as he could not show surveyor in the facility's EMR or Resident #70's clinical notes, where his documentation of the referral with dental services and communications with Resident #70 or her family members could be located in Resident #70's clinical record. When asked if he had informed the DON and Administrator about any potential delays in Resident #70 being seen by a dentist, the SW huffed and said that he thought he had discussed the situation with everyone and moving forward he would document everything as it happened. <BR/>Interview on 1/29/25 with RD at 12:29 pm she said that Resident #70 had not triggered for weight loss despite not having her upper dentures, until January 2025. RD said that Resident #70 did not have significant weight loss and that she evaluated all facility residents upon admission and quarterly and as needed when clinically indicated. RD said that Resident #70 admitted to facility with history of significant weight loss but had not had a significant weight loss since admission. RD said that last month in December, it was brought to her attention that Resident #70 was having trouble chewing without her upper denture and the family member requested a pureed diet. RD said IDT and physician agreed with recommendation. RD said she had no updates on Resident #70's denture or dental visit status. <BR/>Interview and observation with on 1/30/25 at 8:15 am observed staff removing breakfast trays from hallway and observation of Resident #70's breakfast tray revealed she had consumed all of hot cereal on tray for a meal intake of 25%,. 100% of coffee and health shake were consumed. The DON proceeded to bedside with surveyor and had Corporate Clinical Nurse on telephone at the time of the observation and interview. Resident #70 who was seated in bed appropriately groomed and dressed. Resident #70 said she did not have any issue with eating soft foods now but said that if she had her dentures, she would eat regular food. Resident #70 said that she had no pain in her mouth. Resident #70 said that she did not know when she was supposed to see the dentist because her family member kept track of all of those things for her. Resident #70 said she wished she had her teeth but did not feel neglected over not having them because she can eat other things and was not a big eater anyway . Resident #70 said she did not know how long it had been since she lost her teeth and said she did not feel like it was taking too long to get new ones. Resident #70 shrugged her shoulders and stated, what's time in a place like this. Resident #70 said she was [AGE] years old and content for now. <BR/>Interview on 1/30/25 with DON at 09:00am she said she and her ADON were responsible for monitoring weights at the facility and that Resident #70 had no significant weight loss since the loss of her dentures. The DON said that the SW was responsible for ensuring residents were added to the dental list and that she was not aware of any significant delay in Resident #70 getting a dental referral and actual appointment with the dentist. The DON said that she did not believe Resident #70 had been neglected by having to eat a pureed diet due to not having her upper dentures and said that at one point Resident #70 had a referral to go home with family member on hospice. The DON said that she had not been updated on actual date of Resident #70's first dental appointment. The DON did not respond when asked if she thought waiting from November until February to see a dentist was too long. <BR/>Telephone interview on 1/30/25 at 11:10 am with MDD A who said that Resident #70 was [AGE] years old and had no bone for her upper denture to fit properly and comfortable. MDD A said that bone loss was a part of the aging process and that most likely once Resident #70 received the new upper dentures, they will not fit her well or be comfortable and Resident #70 will most likely end up not wearing them. MDD A said that waiting from late November until mid-February to be seen by a dentist would not have a negative clinical impact on Resident #70 . <BR/>Record review on 1/30/25 at 2:33pm of SW text message log revealed he placed calls and text messages to Dental Company A starting on 12/11/24. <BR/>Requested dental policy and procedure from DON on 1/30/25 at 09:00am and Administrator on 1/30/25 at 11:13 am. At time of survey exit on 1/30/25 at 5:00pm, no policy had been provided to the survey team for review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain medical records on each resident that are accurately documented for 1 (Resident #3) of 5 residents reviewed for resident records.<BR/>Resident #3's Medication Administration Record showed that Mucinex DM oral tablet extended release 12 Hour 30-600 mg was documented as being given when guaifenesin 400 mg tablet was administered. <BR/>The failure could place residents who receive medications from facility staff at risk for less than therapeutic benefits, and/or not receiving ordered medications due to inaccurate documentation of administration.<BR/>Findings include: <BR/>Record Review of Resident 3's face sheet dated 1/30/25 revealed resident was a [AGE] year old male admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (Stroke), Dysphagia (difficulty swallowing), Type 2 Diabetes Mellitus, Hypertensive Disease with Heart Failure with history of acute upper respiratory infection and acute bronchitis. <BR/>Record review of Resident's 3's quarterly MDS dated [DATE] revealed a BIMS score of 15 that suggests Resident #3's cognition is intact. <BR/>Record review of Resident 3's January Medication Administration Record printed on 1/30/25 revealed Mucinex DM Oral Tablet Extended Release 12 Hour 30-600 mg (Dextromethorphan-Guaifenesin) Give 1 tablet by mouth every 12 hours for Cough and congestion for 7 days with a start date of 1/22/25 at 9 a.m. and discontinue date of 1/28/25 at 4:57 p.m. Mucinex DM was documented as being administered from 1/22-1/27/25 at 9 a.m. and 9 p.m. and on 1/28/25 at 9 a.m. <BR/>Record review of Resident 3's Care Plan provided on 1/30/25 revealed a focus that Resident 3 is at risk for frequent infections related to diabetes mellitus with goal that Resident 3 will have no complications related to diabetes through the review date. <BR/>Observation of Resident 3's medication administration on 1/28/25 at 8:23 a.m. revealed that Resident 3 was administered guaifenesin 400 mg for order of Mucinex DM Oral Tablet Extended Release 12 Hour 30-600 mg (Dextromethorphan-Guaifenesin) Give 1 tablet by mouth every 12 hours by CMA A. <BR/>Observation of 100 hallway medication cart on 1/28/25 at 4:55 p.m. with CMA A revealed that no Mucinex DM could be found with either the over the counter medications or with Resident #3's medications from the pharmacy. <BR/>Interview of CMA A on 1/28/25 at 12:54 p.m. revealed that she notified the charge nurse (LVN B) about three days prior to interview when she could not find the Mucinex DM order and was instructed that she could give the guaifenesin 400 mg. CMA A said that the Mucinex was on order. CMA A said that Resident #3 was previously taking guaifenesin 400 mg and the order was recently changed to Mucinex DM . CMA A said that she normally works on the hall that Resident #3 is currently residing on which shows that CMA A is familiar with Resident #3 and gives his medications frequently.<BR/>Interview of LVN B on 1/28/25 at 1:02 p.m. revealed that she was not aware that Resident #3 was receiving guaifenesin 400 mg instead of Mucinex DM. LVN B said that Resident #3 had been taking guaifenesin 400 mg for years and it was changed to Mucinex DM for seven days last week when resident got sick. <BR/>Interview of CMA A on 1/28/25 at 4:47 p.m. revealed that she did not document in the facility's electronic medical record when she notified the nurse regarding needing Mucinex DM for Resident #3. CMA A stated that she does not chart notifications to the nurse in the electronic medical record. CMA A stated she has given Resident #3 guaifenesin 400 mg since she started working at the facility. <BR/>Interview of LVN C on 1/29/25 at 11:22 a.m. revealed she could not remember administering specific medication to Resident #3 but was not aware of him missing any medications. Per Resident 3's January MAR, LVN C had documented administering Mucinex DM at 9 p.m. 1/23/25, 1/24/25 and 1/25/25. <BR/>Interview of CMA B on 1/29/25 at 11:45 a.m. revealed that she would have administered medications to Resident #3 as what is documented on Resident 3's medication administration record. Per Resident 3's January MAR, CMA B had documented administering Mucinex DM at 9 a.m. on 1/25/25 and 1/26/25. <BR/>Record review of facility's policy General Guidelines for Medication Administration revealed that medications are to be administered as prescribed in accordance with good nursing principles and practices. <BR/>Record review of facility's policy Administration Procedures for All Medications revealed that after administration of a medication that staff should document administration in the MAR or TAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents or obtain them under an agreement described in &sect;483.70(f) for 1 (Resident #3) of 5 residents reviewed for pharmacy services.<BR/>The facility failed to provide Mucinex DM as ordered for Resident #3. <BR/>The failure could place residents at risk of receiving less than therapeutic benefits from medications.<BR/>Findings include: <BR/>Mucinex DM is a medication that has two ingredients which are guaifenesin and dextromethorphan. Guaifenesin is a medication that helps to clear chest congestion and dextromethorphan is a cough suppressant that relieves cough. Resident #3 was given only guaifenesin instead of Mucinex DM. <BR/>Record review of Resident 3's Progress Notes dated 1/28/25 at 5:02 p.m. revealed that LVN B spoke to the resident's NP and that new order was received to discontinue Mucinex DM and restart Guaifenesin 400 mg oral twice a day routine for cough and congestion. <BR/>Record Review of Resident 3's face sheet dated 1/30/25 revealed resident is a [AGE] year old male admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (Stroke), Dysphagia (difficulty swallowing), Type 2 Diabetes Mellitus, Hypertensive Disease with Heart Failure with history of acute upper respiratory infection and acute bronchitis. <BR/>Record review of Resident 3's quarterly MDS dated [DATE] revealed a BIMS score of 15 that suggests Resident #3's cognition is intact. <BR/>Record review of Resident 3's January Medication Administration Record printed on 1/30/25 revealed Mucinex DM Oral Tablet Extended Release 12 Hour 30-600 mg (Dextromethorphan-Guaifenesin) Give 1 tablet by mouth every 12 hours for Cough and congestion for 7 days with a start date of 1/22/25 at 9 a.m. and discontinue date of 1/28/25 at 4:57 p.m. Mucinex DM was documented as being administered from 1/22-1/27/25 at 9 a.m. and 9 p.m. and on 1/28/25 at 9 a.m. <BR/>Record review of Resident 3's Care Plan provided on 1/30/25 revealed a focus that Resident 3 is at risk for frequent infections related to diabetes mellitus with goal that Resident 3 will have no complications related to diabetes through the review date. <BR/>Observation of Resident 3's medication administration on 1/28/25 at 8:23 a.m. revealed that Resident 3 was administered guaifenesin 400 mg for order of Mucinex DM Oral Tablet Extended Release 12 Hour 30-600 mg (Dextromethorphan-Guaifenesin) Give 1 tablet by mouth every 12 hours by CMA A. <BR/>Interview of CMA A on 1/28/25 at 12:54 p.m. revealed that the process to order over the counter medications that are needed is to write the medication needed on a paper and give to the person who is over central supply. CMA A stated that over the counter medications are ordered twice a month. <BR/>Observation of the facility's medication room on 1/28/25 at 1:01 p.m. accompanied by CMA A revealed that no Mucinex DM could be found with the over the counter medications stock. <BR/>Interview of LVN B on 1/28/25 at 1:02 p.m. revealed that she was not aware that Resident #3 was receiving guaifenesin 400 mg instead of Mucinex DM and that the Mucinex DM was not in stock. LVN B said that when Mucinex DM was first ordered she found a box of Mucinex DM and had given it to the CMA. LVN B said that Resident #3 had been taking guaifenesin 400 mg for years and it was changed to Mucinex DM for seven days last week when resident got sick. <BR/>Interview of Central Supply/Transportation on 1/28/25 at 1:10 p.m. revealed that staff will notify her when medications are not in stock. Central Supply/Transportation said that orders are placed once a week on Mondays, but she can run to a local pharmacy to purchase medications if needed. <BR/>Observation of the facility's medication room on 1/28/25 at 1:25 p.m. accompanied by Central Supply/Transportation. No Mucinex DM could be found in the medication room with the assistance of Central Supply/Transportation. <BR/>Interview of Central Supply/Transportation on 1/28/25 at 1:25 p.m. revealed that Mucinex DM was ordered and was suppose to be delivered last week but was delayed due to the winter storm that occurred on 1/21/25. <BR/>Observation of 100 hallway medication cart on 1/28/25 at 4:55 p.m. with CMA A revealed that no Mucinex DM could be found with either the over the counter medications or with Resident #3's medications from the pharmacy. <BR/>Interview of Central Supply/Transportation on 1/29/25 at 9:21 a.m. revealed that she will notify the DON and administrator if the supply truck does not arrive. Central Supply/Transportation said that if the supply truck does not arrive that she will reach out to sister facility for supplies. Central Supply/Transportation said that she makes the orders on Monday and the truck usually comes on Tuesday but she will wait a day before checking on the order. Central Supply/Transportation said she reached out on 1/22/25 regarding the order that should have arrived on 1/21/25 and was told the truck should arrive by 1/23-1/24/25 and by 1/27-1/28/25 at the latest. Central Supply/Transportation said the truck arrived early this morning on 1/29/25.<BR/>Interview of DON on 1/29/25 at 11:06 a.m. revealed that the central supply person orders the over the counter medication after she is given a list from staff and that they inventory the over the counter stock as well. The DON stated that if there is a new order then the central supply person can go purchase the medication from a local pharmacy if needed. <BR/>Interview with LVN C on 1/29/25 at 11:22 a.m. revealed she could not remember administering specific medication to Resident #3 but was not aware of him missing any medications. LVN C said she was responsible for refiling missing medications from medication cart if needed. LVN C said she would check the over the counter medication stock and the automated medication dispensing system if she was unable to find a medication that was ordered.<BR/>Interview of CMA B on 1/29/25 at 11:45 a.m. revealed that if she needs an over the counter medication then she will check the medication room and if she is unable to find the medication that she would notify the charge nurse. CMA B said she would make a list for Central Supply/Transportation and give them the list directly.<BR/>Record review of facility's policy House Supplied (Floor Stock) Medications revealed that the facility may maintain a supply of commonly used over-the-counter (OTC) medications considered floor stock or house medications (not resident-specific), to be administered only upon receipt of an order from an authorized prescriber. <BR/>Record review of facility's policy General Guidelines for Medication Administration revealed that the facility is to have a sufficient medication distribution system to ensure safe administration of medications with unnecessary interruptions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for 1 of 5 residents (Resident #1) reviewed for resident abuse.-The facility failed to ensure that Resident #1 was free from sexual abuse when Resident #1 wandered into Resident #2's room in the facility on 9/23/25, and Resident #2 sexually assaulted Resident #1.An Immediate Jeopardy (IJ) was identified on 10/02/2025 at 4:41 p.m. The IJ template was provided to the Administrator and DON on 10/02/25 at 4:41 p.m. While the IJ was removed on 10/06/25 at 1:28 p.m. the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that was not an immediate jeopardy and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems.This failure could place residents at risk of physical harm, mental anguish, and/or emotional distress. Record review of Resident #1's facility admission record dated 10/1/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with most current admission date of 6/26/18. Resident #1 admitted with diagnoses that included anoxic brain damage (a condition where the brain experiences a complete lack of oxygen supply. This deprivation of oxygen can lead to widespread damage to brain cells, resulting in severe neurological impairment or death) and epilepsy and epileptic syndromes (Epilepsy is a brain disorder characterized by recurrent, unprovoked seizures, while an epileptic syndrome is a specific, complex constellation of signs and symptoms that define a unique epilepsy condition. An epileptic syndrome includes specific seizure types, other clinical features).Record review of Residents #1's care plan date Initiated 9/15/21 and revised on 9/24/25 revealed she was care-planned for a high elopement risk/wandering in male residents' room and was at risk for possible injury r/t impaired safety awareness and diagnosis of dementia, Anoxic brain damage. Date Initiated: 09/15/2021. Revision on: 09/24/2025: Goals: Resident #1's safety will be maintained throughout the review date. Date Initiated: 09/15/2021. Revision on: 09/12/2025. Target Date: 10/19/2025 Interventions: Assess for fall risk. Date Initiated: 09/15/2021. Provide structured activities: Toileting, walking inside and outside, reorientation strategies, including signs, pictures, and memory boxes. Date Initiated: 09/15/2021. Wander guard placed for resident's safety, bracelet will alert staff if and when resident attempts to exit doors of facility. Staff to monitor daily. Date Initiated: 09/15/2021. Redirect resident. Date Initiated: 09/24/2025. A care plan to address Resident #1 identifies as a trauma survivor. 1.possible trigger of aggressive vocal stimuli. 2. Childhood trauma memories, Domestic abuse memories , Physical Abuse memories, Sexual Abuse memories. Date Initiated: 11/14/2019. Revision on: 05/07/2020. Goals: SHE will remain stable and adjusted to her environment. Date Initiated: 11/14/2019 Revision on: 09/12/2025. Target Date: 10/19/2025. Interventions: Ask for permission to enter resident's room, perform care, and/or assist with ADLs. Date Initiated: 09/08/2023. Explain all procedures to the resident before starting and allow the resident (X minutes) to adjust to changes when necessary. Date Initiated: 09/08/2023. Reduction of possible triggers in her environment. Date Initiated: 11/14/2019. A care plan to address Resident #1's impaired cognitive function or impaired thought processes r/t ANOXIC BRAIN INJURY. SHE has cognitive loss (loss of memory, time sense and requires assistance with decision making r/t Impaired decision-making abilities, is not always understood or able to understand verbal and non-verbal expression. Date Initiated: 05/07/2020. Revision on: 05/07/2020. Resident #1 will improve current level of cognitive function through the review date. Date Initiated: 02/09/2021. Revision on: 09/12/2025. Target Date: 10/19/2025.Record review of Resident #1's Quarterly MDS dated [DATE] revealed Cognitive Skills for Daily Decision Making (section C1000) were coded at 3, indicating her cognition was severely impaired. Resident #1 was coded to require substantial/maximal assistance with ADLs. She was always incontinent of bowels and bladder and used a wheelchair for mobility.Record review of Resident #1's physician orders dated September 2025 revealed orders with a start date of 9/25/25 to administer Emtricitabine- Tenofovir oral tablet 200-300 MG (Emtricitabine- Tenofovir Disoproxil Fumarate) Give 1 tablet by mouth one time a day for antiviral for 28 days at 9:00 AM. An order for Tivicay Oral (Dolutegravir Sodium) Tablet 50 MG Give 1 tablet by mouth one time a day for antiviral for 28 days at 9:00 AM. An order for Plan B One-Step Oral Tablet 1.5 MG (Levonorgestrel Emergency OC) Give 1 tablet by mouth one time only for contraceptive for 1 day with a start date of 9/24/25. Record review of Resident #1's MAR dated September 2025 revealed that Resident #1 was administered Emtricitabine and tenofovir antiretroviral medication (used to treat and prevent HIV infection) on 9/25/25 through 9/30/25. Resident #1 was administered Tivicay Oral (Dolutegravir Sodium) Tablet 50 MG Give 1 tablet by mouth one time a day for antiviral on 9/25/25 through 9/30/25. Resident #1 was administered Plan B One-Step Oral Tablet 1.5 MG (Levonorgestrel Emergency OC (Oral Contraceptive) 1 tablet by mouth on 9/25/25.Record review of Nurses Note dated 9/23/2025. Note Text: Called to room by CNA A and CNA B reported to staff nurses that resident was having sexual activity with Resident #1. Resident #1 was immediately removed for safety. When male resident questioned by staff nurse what happened male resident began to laugh and stated nothing happened . Female resident is not cognitively intact female resident monitored all safety measures in place. Male resident immediately monitored 1-1 by staff. DON notified of above. MD notified. Family notified by DON awaiting return call. The resident transferred to local hospital.Record review of Nurses Note dated 9/23/2025. Note Text: Spoke with forensic nurse at local hospital who reported that she completed an exam on resident . She stated she was able to get a swab for DNA and STD testing but was unable to do a vaginal exam because the resident closed her legs and would not allow her to examine her. She stated that a pregnancy test was performed and was negative, resident was treated prophylactically with ATBs and will discharge to facility with orders for ATBs to continue. Resident #1 will also return with an order for Plan B . Nurse stated that an official report will be available in 1-2 business days. Called RP to update her on report from the nurse, message left, awaiting call back.Record review of the post hospital discharge instructions and orders dated 9/24/25 revealed that Resident #1 was seen for sexual assault. A SANE (Sexual Assault Nurse Examiner) adult sexual assault exam was performed (a forensic exam was performed (results pending and coordinated with the local police department). Orders for STI Sexually Transmitted Infection Prophylaxis: Ondansetron 4 mg PO x1, Azithromycin 1gm PO x1, Metronidazole 2gms PO x1, Ceftriaxone 500mg IM reconstituted with 1.1 ml of 1% Lidocaine. Lab orders for Pharyngeal Gonorrhea ( a sexually transmitted infection (STI) caused by the Neisseria gonorrhoeae bacteria that infects the pharynx. It is spread through oral sex with an infected person and can be asymptomatic, but symptoms may include a sore throat, difficulty swallowing, swollen lymph nodes in the neck, or redness/swelling in the throat) and Chlamydia (a common sexually transmitted infection (STI) caused by the bacterium Chlamydia trachomatis. It is primarily spread through sexual contact with an infected person).Record review of Nurse Practitioner note dated 9/25/25 for Resident #1: Chief Complaint: Evaluation of patient for alleged sexual assault incident: Hospital Course: She was taken to the ER a few days ago after an incident with another resident of a sexual nature. She was examined for possible sexual assault and started on post-exposure prophylaxis (levonorgestrel single dose; dolutegravir 50 mg daily x28 days; emtricitabine/tenofovir 200/300 mg daily x28 days; PRN ondansetron). Hospital examination results are pending. Today she appears in no distress. History of Present Illness: Resident #1, a [AGE] years old female with history of anoxic brain damage, epilepsy, unsteadiness on the feet, ataxia (poor muscle control that causes clumsy movements), abnormal gait, generalized muscle weakness, dysphagia (swallowing difficulties), mixed receptive/expressive language disorder (is a neurodevelopmental condition that affects a child's ability to both understand and produce language), dysarthria (difficulty speaking because the muscles you use for speech are weak), severe hypoxic ischemic encephalopathy (a brain injury that happens before, during, or shortly after birth when oxygen or blood flow to the brain is reduced or stopped), hyperlipidemia (an elevated level of lipids - like cholesterol and triglycerides - in your blood), hypertensive heart disease (a constellation of structural and functional changes in the left ventricle, left atrium, and coronary arteries resulting from chronic blood pressure elevation), and hypothyroidism (a condition in which the thyroid gland does not make enough thyroid hormone) among other medical problems was seen today upon the request of the Nurse due to a reportable incident that happened between patient and another resident. Patient was examined in the dining room. She is nonverbal and not able to make needs known due to anoxic brain injury. Patient was taken to the ER a few days ago for an examination of an encounter with another resident of a sexual nature. She was examined for sexual assault. Findings were not available at the time of this visit; however, patient was placed on several medications including: Levonorgestrel 1.5 mg tablet 1 time only, dolutegravir 50 mg daily for 28 days, emtricitabine/tenofovir 200/300 mg daily for 28 days and as needed Zofran. The results of the patient's examination at the hospital are still pending. - Additional consultations: Psychiatry and Psychology evaluations requested for psychological support.Record Review of Resident #1's Diagnostic Assessment from Psychological Evaluation and Treatment Services dated 9/29/25 revealed that the referral was made due to possible sexual assault at the facility. Resident #1 was unable to answer assessment questions or questions regarding the alleged events therefore she is not a candidate for psychotherapy. Record review of Resident #1's Initial Psychiatric assessment dated [DATE] revealed that Resident #1 was referred due to recent sexual assault without ability to consent, patient was noted to not be able to respond, trauma screening was unable to be determined due to patient being unable to respond. Resident #2Record review of Resident #2's facility admission record dated 10/2/25 revealed a [AGE] year-old-male, admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side (a stroke damaged the right side of the brain, causing paralysis (hemiplegia) and/or weakness (hemiparesis) on the left side of the body) and Chronic Viral Hepatitis C (a long-term liver infection caused by the hepatitis C virus). Record review of Resident #2's care plan revealed care plans to address areas that included: The resident has a behavior problem r/t inappropriate verbal sexual comments towards staff. Date Initiated: 08/18/2025. Revision on: 09/23/2025 Goals: The resident will have fewer episodes of inappropriate behaviors by review date. Date Initiated: 08/18/2025 Revision on: 09/23/2025 Target Date: 12/18/2025: Interventions: The resident's behavior is de-escalated by redirection. Date Initiated: 08/18/2025. Revision on: 09/23/2025. Medication adjustment by psych Date Initiated: 10/01/2025. Minimize potential for the resident's disruptive behaviors. Date Initiated: 08/18/2025. Revision on: 09/23/2025, Psych consult date initiated: 08/18/2025. A care plan area to address the potential to be physically aggressive r/t Dementia Date Initiated: 09/09/2025. Revision on: 09/24/2025 and a care plan to address uses antidepressant medication r/t Depression. Date Initiated: 06/20/2025. Revision on: 09/24/2025. Interventions included to Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT, Monitor/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes. Date Initiated: 06/20/2025.Record review Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 12 out of 15, indicating he was moderately cognitively impaired. The complete MDS was requested but not received.Record review of Resident #2's physician orders for September 2025 for Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) give 2 tablet by mouth two times a day for mood with a start date of 9/26/25, and a Physician order dated 10/2/25 for Chlamydia and Gonorrhea.Record review of Resident #2's MAR dated September 2025 revealed that Resident #2 was administered Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) on 9/26/25 at 9:00 am and on 9/27 through 9/30 at 9:00 AM and 6 PM. Record Review of Resident #2's lab results dated 10/3/25 for Chlamydia and Gonorrhea revealed they were negative. Record review of lab results dated 10/4/ 25 revealed an abnormal and reactive result to the Hepatitis C Antibody (positive for Hepatitis C).Record review of Resident #2's Psychological Services Progress note dated 9/24/25 read in part.Clinician was notified that this patient was accused of sexually assaulting another resident and requested a crisis session. The clinician worked on developing a therapeutic relationship with the patient as he was new to her. Used supportive listening to validate patient's emotions and encouraged patient to tell their story Related to current difficulties and then focused more narrowly to intervene. Patient's Response to Intervention: Patient reported frustration and stated that a CNA accused him of raping another resident last night. He reported that the resident is frequently in his room because it used to be her room.Clinician then asked him to explain the events of last night. He stated that she was in his room watching TV and wet her clothes. He opened the door to the bathroom for her. She then wheeled to the support bar straight ahead and stood up holding onto the bar. He moved her wheelchair to the side so that he could help her get on the toilet. He acknowledged that her pants and brief were off but denied that his had been pulled down. He reported that he has helped her in the bathroom previously and that CNAs have had to come and assist in the past. He further reportedfrustration about being accused of rape. The clinician stated that if it was consensual there was not issue. He immediately stated that the other resident was not capable of consent, and he was not sure she was even at a five-year-old's level of understanding. Next, he reported the police taking his statement, clothing, and brief as evidence. He reported understanding the collection due to the allegation.Record review of Nurse Practitioner Progress note for Resident #2, dated 9/25/25 read in part.Patient, [AGE] years old male was seen today in his room due to incident involving another resident. According to resident, he was accused of having sex with another resident. Patient is now on one-on-one supervision and is wondering why he is on surveillance. According to the Resident, the female resident wanders into his room and bathroom all the time and he denies doing what he is accused of. However, according to the Nurse and Director of Nursing, there were eyewitnesses who saw what happened. Law enforcement is now involved, and patent {sic} has been made aware of that. Patent was made aware that he will continue to be on close supervision by staff until Law enforcement are done with their investigation. Verbalized understanding. Patient is alert during this assessment and was able to answer all questions appropriately. Patient has history of dementia but is still able to hold normal conversations. Psychological and psychiatric consultation requested. Will continue one-on-one supervision with this patient until incident is resolved.Record review of Resident #2's Psychiatric Subsequent Assessment/note dated 9/30/25 read in part.Reason for Referral: Sexually Inappropriate Behavior, Other: Alleged sexual assault of another resident. Patient seen today for a F/U visit. The last visit was on 9/26/2025. Initiated Depakote 250 mg tablet BID. Assess the Pt's behaviors, monitor the response to Depakote. ON EXAM, the Pt is in the room, w/ 1:1 staff, calm and not in distress. LAST visit: Per nursing staff, [Resident #1] was wandering to [Resident #2's] room on 9/23/25 and the Aid {sic} witnessed inappropriate behavior in [Resident #2's] bathroom. In addition, the Aid {sic} witnessed that [Resident #1] was facing the wall and [Resident #2] was behind her. [Resident #2] was placed to 1:1. [Resident #1] was sent out to the hospital for vaginal examination, however the patient refused to cooperate.Record review of Resident #2's Social Service Note dated 10/1/25. Note: interviewed resident regarding his statement of assisting female residents to the bathroom when they come into his room. Initially in the interview he stated that on the night of the alleged abuse he was assisting the female resident to the bathroom. He also stated that he helped another female resident to the bathroom. As the interview continued, he stated that he assisted the female resident to the bathroom on the night in question, however that was the only female resident he assisted to the bathroom. When asked why he did not report this initially, he stated I did not remember. When asked what did he do with the other female resident he stated that they visit, have conversations on various topics, and watch a tv show together. Resident was educated that if a female resident comes into his room, he should press the call light or go to the Nurse's station to request the assistance of the Charge Nurse but never provide any form of ADL care. Resident verbalized understanding of the conversation.Record Review of Resident #2's Social Services Note dated 10/2/25. Note Text: Director of Social Services informed by IDT that it was determined that resident would be discharged to another facility for safety of the other residents. DRSS met with resident and informed him of impending discharge. He expressed understanding of situation and agreed with discharge. After discussing options, resident stated he would like to explore being admitted to a personal care home. Since resident is his own RP, DRSS inquired if he would like me to contact family members listed on his face sheet to inform them and he stated yes. Afterwards, DRSS contacted residents' families. They expressed understanding of situation and discharge.Record review of Nurse's Note for Resident #2 dated 10/4/2025. Note Text: Resident discharged to a personal care home. Transported out to vehicle via wheelchair. Resident left the facility awake, alert, oriented, without any c/o pain or signs of distress.During an interview on 10/01/25 at 9:56 a.m., the DON said LVN Q called around 8:50 p.m., on 09/23/25, and said CNA A and CNA B called LVN Q to Resident #2's bathroom after they saw Resident #1 and Resident #2 with their clothes pulled down and exposed. Resident #2 was standing behind Resident #1, and his semen was everywhere. The DON said Resident #1 wanders, and the intervention was to redirect, and the facility staff made rounds frequently. She said Resident #1 often wanders to Resident #2's room and to other residents' rooms, and staff would remove her from his room. The DON said Resident #1's BIMS was 0, and she could not consent to having sex. When the surveyor asked what other interventions were put in place after redirecting was ineffective, the DON responded that the facility did not place wandering residents on one-on-one. Still, staff made frequent rounds to check on residents. The DON said Resident #2 was making sexual comments towards staff, but he had not had any physical sexual act until this incident. The DON said Resident #2 denied having any sexual act with Resident #1.During an observation and interview on 10/01/25 at 11:12 a.m., Resident #1 was dressed in her street clothes and was sitting in her wheelchair in the TV room. Resident #1 did not respond to the surveyor's greeting, and she was not able to make her needs known.During an interview on 10/01/25 at 11:18 a.m., Resident #2 said he did not have sex with Resident #1, but he was assisting her to the toilet, and she fell backward, and he had to hold onto her. Resident #2 said the day of the incident was not the first time he had taken Resident #2 to the bathroom and assisted her to the toilet, because Resident #1 often comes to his room, and the staff were aware she comes to his room. He denied having sexual intercourse and said he had not ejaculated in months, and nothing sexual happened.During an interview on 10/01/25 at 2:44 p.m., CNA A said she and CNA B went to Resident #2's room, and the entrance door to Resident #2's room was closed. CNA A said she knocked on Resident #2's room entrance door and announced herself before she opened the room door, and she saw Resident #2 was having sex with Resident #1. CNA A said she shouted what are doing and Resident #2 pulled his penis out of Resident #1 and there was semen coming out of his penis. Then she told CNA B to call LVN Q. CNA A said that Resident #1 and Resident #2 were laughing, and Resident #2 said he was assisting her to the toilet. CNA A said she told Resident #2 to go back to his room, waited for LVN Q, and when she came and assessed Resident #1, she told her to take Resident #1 to her room and not clean her, and she was going to call the DON and the Administrator. CNA A said the police came and took the brief, which had urine and bowel movement. CNA A said she placed a clean incontinent brief on Resident #1 but did not clean her. CNA A said the police officer interviewed her, and she wrote her statement for the incident.During an interview on 10/02/25 at 8:22 a.m., CNA B said she and CNA A went to provide care to Resident #2, and when they got to his room, the entrance door was closed. CNA A knocked on the door, introduced herself, and opened the door, and she was behind her. CNA B said CNA A shouted What are you doing? and when she came from behind CNA A and looked, she saw Resident #2 had only an incontinent pull-up, and his brief was pulled down, and his penis was out, and he had semen everywhere, and he was laughing.During an interview on 10/02/25 at 9:19 a.m., NP said one of the Nurses called and told him CNA A and CNA B found Resident #1 and Resident #2 having a sexual encounter. NP said Resident #1 was sent to the hospital. NP said he made rounds the next day after the Nurse told him and saw and assessed both Resident #1 and Resident #2. NP said Resident #1 was nonverbal and she could not respond to any question or tell you anything and could not consent to consensual sex. NP said the hospital staff gave Resident #1 medication to prevent pregnancy and two types of HIV medication. The NP said Resident #2 denied having sex with Resident #1. NP said the facility staff had not told him Resident # 2 made any sexual comments to staff or to other residents. NP said it is a possibility if Resident #2 had hepatitis C and had unprotected sex with Resident #1, she could contract hepatitis C. He said he was unsure whether Resident #1 had hepatitis C.During a telephone interview on 10/02/25 at 9:41 a.m., FM said Resident #1 could not consent to sexual activity. RP said she would not consent for Resident #1 to have sexual relations at the facility. FM said the facility failed to protect Resident # 1 from sexual assault.During a telephone interview on 10/02/25 at 10:23 a.m., the Detective said he would be investigating the incident, but it has not been assigned to him yet; it would be assigned to him in a couple of days. He said from the report that the officers who came out to the facility read, CNA A said she observed Resident #1 and Resident #2 having sexual intercourse. He said the Forensic Nurse did a sexual assault kit when Resident #1 was in the hospital, and it would take 4 to 6 weeks before the result would be ready.During an interview on 10/02/25 at 12:12 p.m., the DON said she was not aware Resident #2 had hepatitis C, and the NP would see Resident #1 and Resident #2 today, and he would order labs on Resident #2. The DON said Resident #1 could be infected with hepatitis C, and she would follow up with the NP.During an interview on 10/02/25 at 2:28 p.m., the Administrator said he was responsible for in-service training on abuse and neglect. He said the abuse policy was part of the admission paper. The DON, the Corporate Nurse, and the Administrator said they do not have any policy on how to educate the resident about safe consensual sex, but they would contact their corporate office.During an interview on 10/02/25 at 2:43 p.m., the Interim Administrator said he had been the interim at the facility for three weeks, did not have access to the facility computer, and could not recall when he was notified about the incident between Resident #1 and Resident #2. He said he was not aware that the facility had a policy on how residents would be educated on having safe consensual sex. He said they usually made rounds every two hours for residents and wandering residents, and if two hours were not safe for a wandering resident, the resident should be in a locked unit. The Interim Administrator said with regard to sexual abuse in service for the staff, they were educated to separate the residents and notify the Abuse Coordinator. He said it would be an awkward conversation with residents on consensual sex. He said his thoughts about any resident who wanted to be intimate would go to the Nurse or Social Worker, who would advise the resident on what to do.During an interview on 10/02/25 at 1:45 p.m., NP said he saw Resident #1 and Resident #2 today (10/02/25), and they are stable, and labs were ordered: HIV, hepatitis C profile, BMP, and CBC for Resident #2. He said he advised the facility to find another placement for Resident #2 after the investigation because the facility still has other female residents, which could prevent the incident from recurring. He said the facility should have involved Resident #1 in activities to occupy her time and put her to bed early to rest, which would have prevented her wandering, and the incident could have been prevented. Record review of the facility policy and procedure entitled Abuse dated last revised 1/1/23 read in part.The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement.Abuse is the willful infliction of injury or negligent, unreasonable confinement.resulting in physical or emotional harm or pain to a resident; or sexual abuse involuntary or nonconsensual sexual conduct that would constitute an offense under penal code S 21.08 (indecent exposure) or Penal Code chapter 22 (assaultive offenses) sexual harassment, sexual coercion or sexual assault.Residents will not be subjected to abuse by anyone including, but not limited to, community staff, other residents.This includes physical, verbal, sexual, physical/chemical restraint. An Immediate Jeopardy (IJ) was identified on 10/02/2025 at 4:41 p.m. The IJ template was provided to the Administrator and DON on 10/02/25 at 4:41 p.m.The following Plan of Removal submitted by the facility was accepted on 10/03/2025 at 1:46 p.m.Plan of Removal F600 October 2, 2025.What corrective actions have been implemented for the identified residents? Plan of Removal.Immediate Jeopardy On 10/2/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safetyThe facility failed to ensure Resident #1 was free from sexual abuse.F600 - Sexual abuse Immediate action Resident #1 sent to hospital for assessment and returned on 9/24/25. Resident placed on one on one 10/2/25 until alternative placement is found on secure unit. Family notified 10/2/2025 of plan for discharge Resident #1 was placed on 1:1 monitoring until alternate placement is found due to wandering into other resident's rooms. Alternate placement will be a secure unit or placement chosen by RP. The Regional director of clinical services (RDCO) in-serviced the Executive Director of operations (administrator) and Director of Nursing operation (DON) on abuse policy on 10/2/2025. The DON initiated In-service on Abuse and Neglect for all staff on 10/2/2025 to be completed on 10/3/2025. Residents #1 and #2 were assessed by charge Nurses on 10/2/2025, no concern noted. All residents that wanders were assessed by DCO and Charge Nurses with their care plan audit completed on 10/2/2025, and no concern noted. Resident #2 was placed on 1:1 monitoring until evaluated by psychiatrist for further direction on care. Resident #2 RP was notified of resident current status by social worker on 10/2/2025. Resident # 2 physicians was notified of current status by DCO on 10/2/2025. Resident #1 and #2 care plans were updated by MDS Nurse on 10/2/2025. DON trained all staff on rounding and supervision on residents to be completed on 10/3/2025. The Director of Social Service initiated education with residents on resident rights policy and procedure, notifying staff of unwanted visitors in their rooms to include wandering residents. Resident education was Completed on 10/3/2025.Identification of Residents Affected or Likely to be AffectedOn 10/2/2025 the DON and Social worker completed the audit for all residents who wander to other residents' room, none was identified. An audit was completed on 10/2/2025Facility's Plan to ensure compliance quickly DON will provide in-service to all staff on abuse policy and will be completed on 10/3/2025. Staff will not provide direct care until training is completed. DON will provide training for all staff on redirecting resident that wanders into other resident's room and to notify the charge Nurse immediately. DON trained Charge Nurse to assess the residents, notify the DON and Administrator and to monitor residents. Training to be completed on 10/3/2025. DCO will review residents that wander daily in IDT meetings to determine changes to where they wander to and determine if they need to revise their plan of care. Daily rounds will be conducted by the IDT during focus rounds to identify any concern with residents that wanders and discuss the concern with administrator. Social worker to contact resident #1 Rp to discuss plan of care to be completed 10/3/2025. The medical Director was notified of the immediate jeopardy on 10/2/2025 by the administrator. The medical director reviewed abuse and neglect policy and made no changes to the policy on 10/2/2025. Any staff member not available for training will not assume any job assignment until training is completed. Staff will identify residents with inappropriate behaviors such as sexual comments, wandering that poses a safety concern, or aggression. If a resident experiences inappropriate behaviors we immediately place them on a 1:1. Psych is then consulted to provide guidance on the behavior and to assist with a plan of care. IDT will ensure that proper interventions are in place. DCO and/or designee will communicate with staff. DCO and/or designee will monitor process. Monitoring of the plan of removal from 10/04/2025 through10/06/25 included:Record review of P

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to immediately inform the resident representative(s) of the need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for one (Resident #1) of five residents reviewed for notification of changes. <BR/>-The facility failed to ensure they reported, to Resident #1's Representative on 09/30/2024, Resident #1's change of condition with moisture associated skin damage (MASD) on the sacrum and buttock to include new orders for zinc oxide (used to treat and prevent diaper rash and other minor skin irritations). <BR/>- The facility failed to ensure they reported, to Resident #1's Representative on 09/30/2024, when noted blanching redness to the left lateral forefoot and the left heel on Resident#1. <BR/>These failures could place residents at risk for harm and not allowing the opportunity for consent of care.<BR/>Findings included:<BR/>Record review of Resident #1's (undated) face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately, understanding jokes or metaphors, or following directions), dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage) and cellulitis (a common, potentially serious bacterial skin infection). Further review revealed Resident #1's family member was identified as Resident #1's Medical and Financial Power of Attorney, Responsible Party, and Emergency Contact. <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed she had a BIMS score 08 out of 15 which indicated she had moderately impaired cognition. She required partial/moderate assistance with toileting hygiene, shower/bathe self and required substantial/maximal assistance with personal hygiene. <BR/>Record review of Resident#1's care plan initiated 09/30/2024 and revised on 10/10/2024 revealed the following read in part: . Focus: The resident has potential/actual impairment to skin integrity of the Buttock r/t Incontinence and immobility.<BR/>Goal: The resident will maintain or develop clean and intact skin by the review date. Target Date: 12/31/2024. The resident will have no complications r/t (SPECIFY skin injury type) of the (SPECIFY location) through the review date. Target Date: 12/31/2024. <BR/>Interventions: Follow facility protocols for treatment of injury. Reposition resident while in bed every 2 hours to relieve pressure. Educate resident/family/caregivers of causative factors and measures to prevent skin injury .<BR/>Record review of Resident #1's Physician orders dated 09/30/2024 revealed an order to apply zinc oxide to MASD on the sacrum and buttock area every shift and PRN until healed. Every shift for Skin integrity. <BR/>Record review of Resident #1's Treatment Administration Record for the month of October 2024 revealed that Resident #1 was receiving zinc oxide on the 6am to 6pm shift and 6pm to 6am shift.<BR/>Record review of Resident #1's nurse's notes dated 09/30/2024 at 4:19 pm written by the Wound Care Nurse read in part: .Resident has noted MASD to the buttock zinc applied and treatment in place. Resident has blanching redness to the left lateral forefoot and the left heel .<BR/>Record review of Resident #1's electronic Medical Record revealed no documentation that the family representative was informed about that change in medication/skin impairment. <BR/>In a telephone interview on 10/21/2024 at 12:12 p.m., Resident #1's representative stated she had not received any communication that her loved one had bed sores until she learned herself by visiting Resident #1 at the hospital on [DATE].<BR/>In an interview on 10/21/2024 at 4:05 p.m., with the Wound Care Nurse stated she reviewed Resident #1's nurses notes with the Surveyor. The Wound Care Nurse stated that resident's responsible party should have been informed about the new order. The Wound Care Nurse stated that she did not see any documentation that she notified the Responsible party I forgot to notify the family . <BR/>In an interview on 10/21/2024 at 4:49 p.m., with LVN A, she stated any time a new mediation was ordered or there was a change in condition, family needed to be notified, so that they were aware of the resident's new order and document in the progress notes. <BR/>In an interview on 10/21/2024 at 5:04 p.m., with the Wound Care Nurse and the DON. The DON stated that nurses were to notify the family at the start of a new medication or change in condition. The DON stated she re-educated the Wound Care Nurse on the change of conditions protocols to include notifications for residents and their representatives any new orders and or treatments in their care. DON stated family/representatives needed to know so they could have ease of mind. Nurses needed to notify plan of care as it prevents the family from feeling their loved ones are not neglected and in the know of any changes in patients. <BR/>Record Review of the facility's Change in a Resident's Condition or Status policy (Revised May 2017) read in part: .Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: b. There is a significant change in the resident's physical, mental, or psychosocial status; 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. <BR/> .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received the necessary treatment and services, to promote healing, prevent infection for 1 of 5 residents (Resident #2) reviewed for pressure ulcers in that:<BR/>-The facility failed to ensure Resident #2's right buttock stage 3 wound had a dressing covering the wound on 10/25/24. <BR/>This failure could affect residents with wounds placing them at risk of infection, a decline in health, pain, and hospitalization.<BR/>Findings included:<BR/>Record review of Resident #2's (undated) face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included pressure ulcer of sacral region, stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) and bed confinement status (which is meant for patients confirmed to be bedridden). <BR/>Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed he had a BIMS score 10 out of 15 which indicated he had moderately impaired cognition. He required substantial/maximal assistance with toileting hygiene, shower/bathe self, and personal hygiene. <BR/>Record review of Resident #2's care plan initiated 03/21/2019 and revised on 10/25/2024 revealed the following: <BR/>Focus: The resident has Stage 3 pressure injury to the Rt. Buttock D/T immobility. <BR/>Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. Target Date: 12/31/2024.<BR/>Interventions: Monitor dressing daily to ensure it is intact and adhering. Report lose dressing to Treatment nurse.<BR/>Record review of the Physician's orders for Resident #2 revealed an order to Cleanse stage 3 Pressure Injury to the Rt. buttock with moistened 4x4 gauze with WC/NS, Pat dry, apply Honey and calcium alginate, cover with border gauze dressing daily and PRN for soilage/dislodgement until healed. as needed for soilage/dislodgment<BR/>Observation and attempted interview on 10/25/24 at 12:13 p.m., revealed Resident #2 was resting in his bed. He was alert and well groomed. The resident mumbled for 5 minutes while being interviewed and could not make himself understood and did not respond appropriately to asked questions about his pressure sore/injuries.<BR/>Observation on 10/25/24 at 12:18 p.m., revealed the Wound Care Nurse providing wound care for Resident #2. The Wound Care Nurse was assisted by ADON A. An open area of approximately 2.0 centimeters in diameter, was observed without a dressing on the right buttock. The Wound Care Nurse said, WCD did the dressing yesterday it must have come off.<BR/>In an interview on 10/25/24 at 12:36 p.m., with CNA BB, she stated she provided peri care and got the resident dressed for his appointment that morning around 7:20 am. She stated there was 1 patch on the resident's bottom which was pretty soiled with BM. She stated she did not notify the Wound Care nurse or the floor nurse that the dressing needed to be changed because the transport was already in the room waiting to take the resident. <BR/>In an interview on 10/25/24 at 12:41 p.m., with the Wound Care Nurse, she confirmed Resident #2's right buttock wound did not have a dressing on it. She said the CNA should have immediately notified her or the floor nurse because there were prn orders if the dressing became soiled or dislodged. The WCN stated it was important to provide dressings on the wound to keep it protected from infections. Wound bed could damage by scaping on brief itself . Feces can get in it and cause delayed healing.<BR/>In an interview on 10/25/24 at 1:01 p.m., the DON stated the Wound Care Nurse was responsible for wound care Monday through Friday and the floor nurses were responsible for wound care on the weekends. The Surveyor shared the observation from earlier. The DON said her exception was for wound dressings to be changed daily and as needed if soiled or dislodged according to physician's orders. She stated the CNA should have notified the charge nurse/wound care nurse so they could dress the wound. She stated it was important to dress the wound to prevent infection. If the wound was left open it can get germs, delayed wound healing and for patient's comfort . <BR/>In an interview on 10/25/24 at 2:11 p.m., with LVN Z, she said the CNA did not notify her that Resident #2's dressing had come off. She said the CNAs were supposed to come and tell the nurses right away so the nurse can dress the wound as there were prn orders for dressing change. <BR/>Record review of the facility's Skin Management policy (Last Revised: 10/06/2022) revealed read in part: .POLICY: The purpose of this procedure is for prevention and treatment of skin breakdown such as pressure injuries, diabetic ulcers, arterial ulcers, and skin wounds. 4. Treatment: Wound care dressings are dated and initialed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents or obtain them under an agreement described in &sect;483.70(f) for 1 (Resident #3) of 5 residents reviewed for pharmacy services.<BR/>The facility failed to provide Mucinex DM as ordered for Resident #3. <BR/>The failure could place residents at risk of receiving less than therapeutic benefits from medications.<BR/>Findings include: <BR/>Mucinex DM is a medication that has two ingredients which are guaifenesin and dextromethorphan. Guaifenesin is a medication that helps to clear chest congestion and dextromethorphan is a cough suppressant that relieves cough. Resident #3 was given only guaifenesin instead of Mucinex DM. <BR/>Record review of Resident 3's Progress Notes dated 1/28/25 at 5:02 p.m. revealed that LVN B spoke to the resident's NP and that new order was received to discontinue Mucinex DM and restart Guaifenesin 400 mg oral twice a day routine for cough and congestion. <BR/>Record Review of Resident 3's face sheet dated 1/30/25 revealed resident is a [AGE] year old male admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (Stroke), Dysphagia (difficulty swallowing), Type 2 Diabetes Mellitus, Hypertensive Disease with Heart Failure with history of acute upper respiratory infection and acute bronchitis. <BR/>Record review of Resident 3's quarterly MDS dated [DATE] revealed a BIMS score of 15 that suggests Resident #3's cognition is intact. <BR/>Record review of Resident 3's January Medication Administration Record printed on 1/30/25 revealed Mucinex DM Oral Tablet Extended Release 12 Hour 30-600 mg (Dextromethorphan-Guaifenesin) Give 1 tablet by mouth every 12 hours for Cough and congestion for 7 days with a start date of 1/22/25 at 9 a.m. and discontinue date of 1/28/25 at 4:57 p.m. Mucinex DM was documented as being administered from 1/22-1/27/25 at 9 a.m. and 9 p.m. and on 1/28/25 at 9 a.m. <BR/>Record review of Resident 3's Care Plan provided on 1/30/25 revealed a focus that Resident 3 is at risk for frequent infections related to diabetes mellitus with goal that Resident 3 will have no complications related to diabetes through the review date. <BR/>Observation of Resident 3's medication administration on 1/28/25 at 8:23 a.m. revealed that Resident 3 was administered guaifenesin 400 mg for order of Mucinex DM Oral Tablet Extended Release 12 Hour 30-600 mg (Dextromethorphan-Guaifenesin) Give 1 tablet by mouth every 12 hours by CMA A. <BR/>Interview of CMA A on 1/28/25 at 12:54 p.m. revealed that the process to order over the counter medications that are needed is to write the medication needed on a paper and give to the person who is over central supply. CMA A stated that over the counter medications are ordered twice a month. <BR/>Observation of the facility's medication room on 1/28/25 at 1:01 p.m. accompanied by CMA A revealed that no Mucinex DM could be found with the over the counter medications stock. <BR/>Interview of LVN B on 1/28/25 at 1:02 p.m. revealed that she was not aware that Resident #3 was receiving guaifenesin 400 mg instead of Mucinex DM and that the Mucinex DM was not in stock. LVN B said that when Mucinex DM was first ordered she found a box of Mucinex DM and had given it to the CMA. LVN B said that Resident #3 had been taking guaifenesin 400 mg for years and it was changed to Mucinex DM for seven days last week when resident got sick. <BR/>Interview of Central Supply/Transportation on 1/28/25 at 1:10 p.m. revealed that staff will notify her when medications are not in stock. Central Supply/Transportation said that orders are placed once a week on Mondays, but she can run to a local pharmacy to purchase medications if needed. <BR/>Observation of the facility's medication room on 1/28/25 at 1:25 p.m. accompanied by Central Supply/Transportation. No Mucinex DM could be found in the medication room with the assistance of Central Supply/Transportation. <BR/>Interview of Central Supply/Transportation on 1/28/25 at 1:25 p.m. revealed that Mucinex DM was ordered and was suppose to be delivered last week but was delayed due to the winter storm that occurred on 1/21/25. <BR/>Observation of 100 hallway medication cart on 1/28/25 at 4:55 p.m. with CMA A revealed that no Mucinex DM could be found with either the over the counter medications or with Resident #3's medications from the pharmacy. <BR/>Interview of Central Supply/Transportation on 1/29/25 at 9:21 a.m. revealed that she will notify the DON and administrator if the supply truck does not arrive. Central Supply/Transportation said that if the supply truck does not arrive that she will reach out to sister facility for supplies. Central Supply/Transportation said that she makes the orders on Monday and the truck usually comes on Tuesday but she will wait a day before checking on the order. Central Supply/Transportation said she reached out on 1/22/25 regarding the order that should have arrived on 1/21/25 and was told the truck should arrive by 1/23-1/24/25 and by 1/27-1/28/25 at the latest. Central Supply/Transportation said the truck arrived early this morning on 1/29/25.<BR/>Interview of DON on 1/29/25 at 11:06 a.m. revealed that the central supply person orders the over the counter medication after she is given a list from staff and that they inventory the over the counter stock as well. The DON stated that if there is a new order then the central supply person can go purchase the medication from a local pharmacy if needed. <BR/>Interview with LVN C on 1/29/25 at 11:22 a.m. revealed she could not remember administering specific medication to Resident #3 but was not aware of him missing any medications. LVN C said she was responsible for refiling missing medications from medication cart if needed. LVN C said she would check the over the counter medication stock and the automated medication dispensing system if she was unable to find a medication that was ordered.<BR/>Interview of CMA B on 1/29/25 at 11:45 a.m. revealed that if she needs an over the counter medication then she will check the medication room and if she is unable to find the medication that she would notify the charge nurse. CMA B said she would make a list for Central Supply/Transportation and give them the list directly.<BR/>Record review of facility's policy House Supplied (Floor Stock) Medications revealed that the facility may maintain a supply of commonly used over-the-counter (OTC) medications considered floor stock or house medications (not resident-specific), to be administered only upon receipt of an order from an authorized prescriber. <BR/>Record review of facility's policy General Guidelines for Medication Administration revealed that the facility is to have a sufficient medication distribution system to ensure safe administration of medications with unnecessary interruptions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASARR) program to the maximum extent practicable for 1 of 7 residents (Resident #53) reviewed for PASARR.<BR/>-The facility failed to update the PASARR Level 1 forms for Resident #53 after a diagnosis of intellectual disability.<BR/>This failure could place residents requiring PASARR services at risk of not having their special needs assessed and met by the facility. <BR/>Findings included:<BR/>Record review of Resident #53's admission Record, dated 12/29/2022, revealed a-[AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #53's had an active diagnosis of moderate intellectual disability (a condition that limits intelligence and disrupts abilities necessary for living independently). <BR/>Record review of the PASARR evaluation for Resident #53 revealed it was completed on 01/06/2023. It was determined that resident was not eligible for PASRR specialized services because serious mental illness. Resident # 53 was diagnosed with moderate intellectual disability on 03/01/2023. <BR/>Record review of Resident #53's care plan dated 11/30/2023 read in part Resident #53 has a communication problem related to intellectual disabilities. Goal-Resident #53 will maintain current level of communication function by making sounds, using appropriate gestures, responding to yes/no questions appropriately through the review date (no date indicated on review).' Interventions: Anticipate and meet needs (needs unspecified); Allow adequate time to respond, Repeat as necessary, Do not rush, Request clarification from him to ensure understanding, Face when speaking, make eye contact, Turn off TV/radio to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed; Monitor/document frustration level. Wait 30 seconds before providing him with word; Monitor/document/report PRN any changes in: Ability to communicate, Potential contributing factors for communication problems, Potential for improvement. <BR/>Observation and interview on 11/13/23 at 10:43 am revealed Resident #53 was in bed and easily arousable to verbal stimuli. Resident #53 had a slower speech pattern and said that he had no care concerns but would like to be moved from the facility. He said he received his medications but did not know what medications he had been taking. <BR/>12/06/23 11:56 AM Interview with MDS Coordinator who said she had worked at the facility for about 3 years but was new to her MDS Role and had only been working as an MDS Coordinator for 8 months. She said the RN at this facility could not sign the MDS' right now because she had to take a class. She said that she had been trained by corporate staff who had retired and then by Regional MDS staff. She said that the social worker was responsible for setting meetings with MHMRA or LIDAA. She said that she did not keep PASRR evaluation or Level II denial letters, and that perhaps the social worker had them.<BR/>12/07/23 10:00 PM Interview and record review with MDS Coordinator who revealed that she was not aware the PASRR evaluation Level II had not been completed for Resident #53's after Resident # 53 was diagnosed with an intellectual disability of 03/01/2023. <BR/>12/07/23 2:00 PM Interview and record review with MDS Coordinator who revealed that she was responsible for completing the PASRR. She stated that completed PASSR Level 1 referral update on 12/07/2023 after surveyors kept asking for the PASARR positive list of the residents with a denial of services letter. She said Resident #53's PASRR on admission was negative and he was diagnosed with an intellectual disability of 03/01/2023. She said she did not know that all residents with negative level 1 PASRR were supposed to be reassessed after a diagnosis of an intellectual disability. She stated that the PASSR should have been completed within 24 hours of Resident #53's updated diagnosis. The MDS Coordinator did not say whether or not she had received any training regarding PASARR. MDS Coordinator did not reveal how monitoring to ensure it was done timely and accurately. She said she would wait to see what the recommendations were after the referral was processed. She did not know why the referral had not been completed on 3/01/23 and she said that it would be important for a resident to receive PASARR services if they qualified. The MDS Coordinator said that the potential risk to a resident for not having the corrected referral submitted to identify intellectual disability, would be that resident would not receive the necessary services qualified for. <BR/>Record review of the facility's Resident Assessment-Coordination with PASARR Program policy dated implemented 6/2023 and Date Revised: 06/2023 revealed 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review .b. A resident whose intellectual disability or related was not previously identified and evaluated through PASARR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents or obtain them under an agreement described in &sect;483.70(f) for 1 (Resident #3) of 5 residents reviewed for pharmacy services.<BR/>The facility failed to provide Mucinex DM as ordered for Resident #3. <BR/>The failure could place residents at risk of receiving less than therapeutic benefits from medications.<BR/>Findings include: <BR/>Mucinex DM is a medication that has two ingredients which are guaifenesin and dextromethorphan. Guaifenesin is a medication that helps to clear chest congestion and dextromethorphan is a cough suppressant that relieves cough. Resident #3 was given only guaifenesin instead of Mucinex DM. <BR/>Record review of Resident 3's Progress Notes dated 1/28/25 at 5:02 p.m. revealed that LVN B spoke to the resident's NP and that new order was received to discontinue Mucinex DM and restart Guaifenesin 400 mg oral twice a day routine for cough and congestion. <BR/>Record Review of Resident 3's face sheet dated 1/30/25 revealed resident is a [AGE] year old male admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (Stroke), Dysphagia (difficulty swallowing), Type 2 Diabetes Mellitus, Hypertensive Disease with Heart Failure with history of acute upper respiratory infection and acute bronchitis. <BR/>Record review of Resident 3's quarterly MDS dated [DATE] revealed a BIMS score of 15 that suggests Resident #3's cognition is intact. <BR/>Record review of Resident 3's January Medication Administration Record printed on 1/30/25 revealed Mucinex DM Oral Tablet Extended Release 12 Hour 30-600 mg (Dextromethorphan-Guaifenesin) Give 1 tablet by mouth every 12 hours for Cough and congestion for 7 days with a start date of 1/22/25 at 9 a.m. and discontinue date of 1/28/25 at 4:57 p.m. Mucinex DM was documented as being administered from 1/22-1/27/25 at 9 a.m. and 9 p.m. and on 1/28/25 at 9 a.m. <BR/>Record review of Resident 3's Care Plan provided on 1/30/25 revealed a focus that Resident 3 is at risk for frequent infections related to diabetes mellitus with goal that Resident 3 will have no complications related to diabetes through the review date. <BR/>Observation of Resident 3's medication administration on 1/28/25 at 8:23 a.m. revealed that Resident 3 was administered guaifenesin 400 mg for order of Mucinex DM Oral Tablet Extended Release 12 Hour 30-600 mg (Dextromethorphan-Guaifenesin) Give 1 tablet by mouth every 12 hours by CMA A. <BR/>Interview of CMA A on 1/28/25 at 12:54 p.m. revealed that the process to order over the counter medications that are needed is to write the medication needed on a paper and give to the person who is over central supply. CMA A stated that over the counter medications are ordered twice a month. <BR/>Observation of the facility's medication room on 1/28/25 at 1:01 p.m. accompanied by CMA A revealed that no Mucinex DM could be found with the over the counter medications stock. <BR/>Interview of LVN B on 1/28/25 at 1:02 p.m. revealed that she was not aware that Resident #3 was receiving guaifenesin 400 mg instead of Mucinex DM and that the Mucinex DM was not in stock. LVN B said that when Mucinex DM was first ordered she found a box of Mucinex DM and had given it to the CMA. LVN B said that Resident #3 had been taking guaifenesin 400 mg for years and it was changed to Mucinex DM for seven days last week when resident got sick. <BR/>Interview of Central Supply/Transportation on 1/28/25 at 1:10 p.m. revealed that staff will notify her when medications are not in stock. Central Supply/Transportation said that orders are placed once a week on Mondays, but she can run to a local pharmacy to purchase medications if needed. <BR/>Observation of the facility's medication room on 1/28/25 at 1:25 p.m. accompanied by Central Supply/Transportation. No Mucinex DM could be found in the medication room with the assistance of Central Supply/Transportation. <BR/>Interview of Central Supply/Transportation on 1/28/25 at 1:25 p.m. revealed that Mucinex DM was ordered and was suppose to be delivered last week but was delayed due to the winter storm that occurred on 1/21/25. <BR/>Observation of 100 hallway medication cart on 1/28/25 at 4:55 p.m. with CMA A revealed that no Mucinex DM could be found with either the over the counter medications or with Resident #3's medications from the pharmacy. <BR/>Interview of Central Supply/Transportation on 1/29/25 at 9:21 a.m. revealed that she will notify the DON and administrator if the supply truck does not arrive. Central Supply/Transportation said that if the supply truck does not arrive that she will reach out to sister facility for supplies. Central Supply/Transportation said that she makes the orders on Monday and the truck usually comes on Tuesday but she will wait a day before checking on the order. Central Supply/Transportation said she reached out on 1/22/25 regarding the order that should have arrived on 1/21/25 and was told the truck should arrive by 1/23-1/24/25 and by 1/27-1/28/25 at the latest. Central Supply/Transportation said the truck arrived early this morning on 1/29/25.<BR/>Interview of DON on 1/29/25 at 11:06 a.m. revealed that the central supply person orders the over the counter medication after she is given a list from staff and that they inventory the over the counter stock as well. The DON stated that if there is a new order then the central supply person can go purchase the medication from a local pharmacy if needed. <BR/>Interview with LVN C on 1/29/25 at 11:22 a.m. revealed she could not remember administering specific medication to Resident #3 but was not aware of him missing any medications. LVN C said she was responsible for refiling missing medications from medication cart if needed. LVN C said she would check the over the counter medication stock and the automated medication dispensing system if she was unable to find a medication that was ordered.<BR/>Interview of CMA B on 1/29/25 at 11:45 a.m. revealed that if she needs an over the counter medication then she will check the medication room and if she is unable to find the medication that she would notify the charge nurse. CMA B said she would make a list for Central Supply/Transportation and give them the list directly.<BR/>Record review of facility's policy House Supplied (Floor Stock) Medications revealed that the facility may maintain a supply of commonly used over-the-counter (OTC) medications considered floor stock or house medications (not resident-specific), to be administered only upon receipt of an order from an authorized prescriber. <BR/>Record review of facility's policy General Guidelines for Medication Administration revealed that the facility is to have a sufficient medication distribution system to ensure safe administration of medications with unnecessary interruptions.

Based on interview and record review, the facility failed to ensure a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicalble diseases and infections and failed to notify HHSC as part of their infection prevention and control program when fifteen residents and three staff members, tested positive for COVID-19 between 02/17/2023 and 02/21/2023 for 15 of 16 residents, (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15), and 3 of 3 staff members (Staff A, Staff B, and Staff C) reviewed for infection control. <BR/>-The facility failed to notify HHSC as required by their infection prevention and control policy when fifteen residents and three staff members, tested positive for COVID-19 after the facility went approximately seven months with no COVID-19 positive staff or residents (the last COVID-19 positive case was reported to HHSC on 07/22/2022).<BR/>This failure could place all COVID-19 negative residents at risk of being exposed to the virus.<BR/>Findings included:<BR/>Record review of TULIP on 02/22/2023 revealed no self-reported incidents from this facility on 02/17/2023 and none regarding new COVID-19 positive cases at the facility since 07/22/2022. <BR/>Record review of the facility's COVID-19 Positive Resident Tracking and Staff COVID-19 Positive Tracking logs for February 2023 revealed the following:<BR/>-On 02/17/2023 two residents tested positive for COVID-19.<BR/>-On 02/18/2023 three residents and one staff member tested positive for COVID-19.<BR/>-On 02/20/2023 nine residents and two staff members tested positive for COVID-19.<BR/>-On 02/21/2023 one resident tested positive for COVID-19.<BR/>Interview with the DON on 02/22/2023 at 8:30 a.m., she stated the facility recently had an outbreak of COVID-19 with 15 positive residents and three positive staff members. The DON said the outbreak started on the previous Friday, 02/17/2023, when two residents exhibited symptoms of nasal congestion and cough. She stated she gave the facility's corporate Director of Infection Control Prevention all the information to submit to the state. The DON said nobody told her she had to report the COVID-19 positive cases to HHSC. She said she completed the necessary report and sent it in to the CDC on Monday, 02/20/2023 as required. The DON said she was not sure who normally called in COVID-19 incidents to HHSC. She said the current outbreak was the first the facility had since she was hired in September 2022, and she thought the CDC forms were all she had to do. <BR/>In an interview with the ADON on 02/22/2023 at 11:30 a.m., she stated she was also the facility's infection control preventionist. The ADON said as the facility's infection control preventionist, she was in charge of managing the COVID-19 outbreak and making sure CDC guidelines were followed. The ADON said she kept up with federal/state plan for COVID-19. She said the first resident, Resident #1, started showing symptoms on Friday, 02/17/2022. She said after Resident #1 tested positive for COVID-19, the facility started testing staff and other residents who were in contact with Resident #1. The ADON said the Administrator and DON completed the self-reported incident to the state (not HHSC). The ADON said she gathered all the necessary information to include in the report to state. She said she thought it was the DON's responsibility to call in COVID-19 incidents to HHSC. The ADON said she was aware the facility had to report new COVID-19 cases if there were no positive cases in 14 days. <BR/>In an interview with the Administrator on 02/22/2023 at 11:54 a.m., she said she was made aware of the COVID-19 outbreak on Friday, 02/17/2023. She said she believed the facility was supposed report the COVID-19 outbreak to HHSC, and she thought the DON reported it to HHSC on 02/21/2023. The Administrator said she would get the documentation from the DON to show the incident was reported to HHSC. She said it was the DON's responsibility to self-report COVID-19 positive cases. The Administrator said she knew the DON was having trouble sending in the report on 02/21/2023, so she sent the information to their corporate Director of Infection Control Prevention so she could send it. <BR/>In a follow-up interview with the Administrator and the DON on 02/22/2023 at 12:00 p.m., the Administrator stated their Director of Infection Control Prevention told the DON she needed to send the report to the state distribution and the Administrator and DON both thought that meant it would be sent to HHSC. She said the DON had trouble sending the report in, so the DON sent the information back to the Director of Infection Control Prevention so she could send it. The Administrator stated she reached out to the Director of Infection Control Prevention via email, and she (Director of Infection Control Prevention) informed the Administrator she (Director of Infection Control Prevention) did not send any report HHSC because they (the DON and Administrator) asked for information in regard to sending the outbreak information to state distribution (CDC requirement), not HHSC. The DON said she and the Administrator both thought they were sending the necessary information to HHSC as well and the CDC. The Administrator said neither she nor the DON were aware of how to send COVID-19 self-reports although they were aware of how to report regular self-reported incidents to HHSC. <BR/>An unsuccessful attempt was made to the Director of Infection Control Prevention on 02/22/2023 at 12:29 p.m. A voicemail message was left but not returned. <BR/>Record review of facility policy titled, COVID-19 Preparation Plan and Guidance dated 02/13/2023 revealed, . When to contact your local public health department/HHSC: . Positive COVID-19 test result; Report the first confirmed case of COVID-19 after a community has been without new cases for 14 days or more, to HHSC Complaint and Incident Intake through the Texas Unified Licensure Information Portal (TULIP) or by calling . within 24 hours of the confirmed positive result .<BR/>.

Based on interview and record review, the facility failed to ensure a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicalble diseases and infections and failed to notify HHSC as part of their infection prevention and control program when fifteen residents and three staff members, tested positive for COVID-19 between 02/17/2023 and 02/21/2023 for 15 of 16 residents, (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15), and 3 of 3 staff members (Staff A, Staff B, and Staff C) reviewed for infection control. <BR/>-The facility failed to notify HHSC as required by their infection prevention and control policy when fifteen residents and three staff members, tested positive for COVID-19 after the facility went approximately seven months with no COVID-19 positive staff or residents (the last COVID-19 positive case was reported to HHSC on 07/22/2022).<BR/>This failure could place all COVID-19 negative residents at risk of being exposed to the virus.<BR/>Findings included:<BR/>Record review of TULIP on 02/22/2023 revealed no self-reported incidents from this facility on 02/17/2023 and none regarding new COVID-19 positive cases at the facility since 07/22/2022. <BR/>Record review of the facility's COVID-19 Positive Resident Tracking and Staff COVID-19 Positive Tracking logs for February 2023 revealed the following:<BR/>-On 02/17/2023 two residents tested positive for COVID-19.<BR/>-On 02/18/2023 three residents and one staff member tested positive for COVID-19.<BR/>-On 02/20/2023 nine residents and two staff members tested positive for COVID-19.<BR/>-On 02/21/2023 one resident tested positive for COVID-19.<BR/>Interview with the DON on 02/22/2023 at 8:30 a.m., she stated the facility recently had an outbreak of COVID-19 with 15 positive residents and three positive staff members. The DON said the outbreak started on the previous Friday, 02/17/2023, when two residents exhibited symptoms of nasal congestion and cough. She stated she gave the facility's corporate Director of Infection Control Prevention all the information to submit to the state. The DON said nobody told her she had to report the COVID-19 positive cases to HHSC. She said she completed the necessary report and sent it in to the CDC on Monday, 02/20/2023 as required. The DON said she was not sure who normally called in COVID-19 incidents to HHSC. She said the current outbreak was the first the facility had since she was hired in September 2022, and she thought the CDC forms were all she had to do. <BR/>In an interview with the ADON on 02/22/2023 at 11:30 a.m., she stated she was also the facility's infection control preventionist. The ADON said as the facility's infection control preventionist, she was in charge of managing the COVID-19 outbreak and making sure CDC guidelines were followed. The ADON said she kept up with federal/state plan for COVID-19. She said the first resident, Resident #1, started showing symptoms on Friday, 02/17/2022. She said after Resident #1 tested positive for COVID-19, the facility started testing staff and other residents who were in contact with Resident #1. The ADON said the Administrator and DON completed the self-reported incident to the state (not HHSC). The ADON said she gathered all the necessary information to include in the report to state. She said she thought it was the DON's responsibility to call in COVID-19 incidents to HHSC. The ADON said she was aware the facility had to report new COVID-19 cases if there were no positive cases in 14 days. <BR/>In an interview with the Administrator on 02/22/2023 at 11:54 a.m., she said she was made aware of the COVID-19 outbreak on Friday, 02/17/2023. She said she believed the facility was supposed report the COVID-19 outbreak to HHSC, and she thought the DON reported it to HHSC on 02/21/2023. The Administrator said she would get the documentation from the DON to show the incident was reported to HHSC. She said it was the DON's responsibility to self-report COVID-19 positive cases. The Administrator said she knew the DON was having trouble sending in the report on 02/21/2023, so she sent the information to their corporate Director of Infection Control Prevention so she could send it. <BR/>In a follow-up interview with the Administrator and the DON on 02/22/2023 at 12:00 p.m., the Administrator stated their Director of Infection Control Prevention told the DON she needed to send the report to the state distribution and the Administrator and DON both thought that meant it would be sent to HHSC. She said the DON had trouble sending the report in, so the DON sent the information back to the Director of Infection Control Prevention so she could send it. The Administrator stated she reached out to the Director of Infection Control Prevention via email, and she (Director of Infection Control Prevention) informed the Administrator she (Director of Infection Control Prevention) did not send any report HHSC because they (the DON and Administrator) asked for information in regard to sending the outbreak information to state distribution (CDC requirement), not HHSC. The DON said she and the Administrator both thought they were sending the necessary information to HHSC as well and the CDC. The Administrator said neither she nor the DON were aware of how to send COVID-19 self-reports although they were aware of how to report regular self-reported incidents to HHSC. <BR/>An unsuccessful attempt was made to the Director of Infection Control Prevention on 02/22/2023 at 12:29 p.m. A voicemail message was left but not returned. <BR/>Record review of facility policy titled, COVID-19 Preparation Plan and Guidance dated 02/13/2023 revealed, . When to contact your local public health department/HHSC: . Positive COVID-19 test result; Report the first confirmed case of COVID-19 after a community has been without new cases for 14 days or more, to HHSC Complaint and Incident Intake through the Texas Unified Licensure Information Portal (TULIP) or by calling . within 24 hours of the confirmed positive result .<BR/>.

Based on observation, interview, and record review, the facility failed to post in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility with a census of 84.<BR/>-The facility failed to post notice of the availability of survey results in areas of the facility that are prominent and accessible to where individuals wishing to examine do not have to ask to see them.<BR/>This failure could place residents at risk of being uninformed of the facility's inspection history and any plans of correction the facility should have in place.<BR/>The findings included:<BR/>In an observation on 09/20/2022 at 8:30 a.m. during entrance revealed the lobby did not have a sign posted with notice of where to find the State Survey Results. <BR/>In an observation on 09/20/22 from 10:30 a.m.-12:00 p.m., during a general walk through of the facility revealed there was not a sign posted with notice of where to find the State Survey Results. Observation was made in the lobby outside of the business office which revealed there were three signs encased in a frame, on a shelf, with information regarding contacting Medicaid and Medicare, Social Security Administration, and the right to electronic surveillance. <BR/>In a confidential interview on 09/21/2022 with nine alert and oriented residents, they stated they were not aware of the location of the previous year surveyor results or how to find the information. All nine residents stated they would like to view the information. <BR/>In an interview and observation on 09/20/2022 at 12:56 a.m., the Administrator was observed looking on the receptionist's desk for the State Survey Results when asked for the location, and she was not able to locate the results. She stated there was not a sign posted with notice of where to find the State Survey Results.<BR/>In an interview and observation on 09/20/2022 at 1:00 p.m., the Hospitality Aide was observed looking on the receptionist's desk for the State Survey Results when asked for the location, and she was not able to locate the results. She stated she had worked at the facility for one year. She stated the results were kept on the receptionist's desk. She stated anyone wanting to see the results would ask the receptionist or hospitality aide for the results. She stated there was not a sign posted with notice of where to find the State Survey Results.<BR/>In an interview, observation, and record review on 09/20/2022 at 1:20 p.m., the Administrator presented a white binder labeled Survey Results 2021, and the results were reviewed to be inside. The Administrator stated the results were found in the lobby on the shelf located outside of the business office. The Administrator was informed the results had not been in that location during entrance or during general observations. The Administrator stated, I do not know what to tell you. She stated there was not a sign posted with notice of where to find the State Survey Results because the binder was always sitting in the lobby accessible for all to see. <BR/>In an interview and observation on 09/20/2022 at 1:29 p.m., the Receptionist stated she had worked at the facility for 3 years. She stated the State Survey Results are usually kept in a binder on her desk in the lobby. She stated there had never been a sign posted with notice of where to find the State Survey Results. She stated anyone who wished to see the result would have to ask the receptionists or staff working in the lobby at the time. She was observed searching for the results on the receptionist's desk, she was not able to locate the results, and she stated the results should not be anywhere else in the facility. She was shown the location of the results as indicated by the Administrator. She stated the results had been located on the shelf next to the business office in the past. She stated it was decided to move the results to the receptionist's desk after residents would move it from its location two months prior. <BR/>In an interview on 09/21/2022 at 3:30 p.m., the Administrator stated she had put the 2021 survey results binder together on 09/16/2022, and she placed the binder on the shelf as previously mentioned. She stated she had never received the form, Report of Contact, (ROC) or Survey/Inspection Summary, form 3630, from the SA which prevented her from having the binder completed. She stated she sent multiple emails requesting the needed documents to the SA, and she did not receive the information until 09/16/2022. She stated she could provide a copy of the email correspondence.<BR/>Record review of email correspondence between the Administrator and SSA dated 09/09/2022 at 8:22 a.m. and 9:00 a.m., reflected, I am writing to request the final ROC and cleared deficiencies report for survey date 07/21/2021.<BR/>Record review of email correspondence between the Administrator and SSA dated 09/16/2022 at 8:47 a.m., with subject line [facility name] 07/09/2021 reflected in part, I am writing to request the clearance of deficiencies for the attached survey. Is this something you can provide me?<BR/>Record review of email correspondence between the Administrator and SSA dated 09/16/2022 at 9:30 a.m., that the facility received SSA Form ROC and 3630 from the SA. <BR/>Record review of the facility's policy titled, Residents Rights, dated December 2016 reflected in part .Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to: w. examine survey results

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly investigate the allegation of misappropriation of property for 1 of 2 residents (Resident #12) reviewed for abuse, neglect, and exploitation in that:<BR/>-The facility failed to investigate an allegation of misappropriation when Resident #12 alleged CNA A took $180 from his room. <BR/>This failure could place residents at risk for incidents involving misappropriation of resident property by the facility not investigating such incidents.<BR/>Findings included:<BR/>Record review of the admission Record for Resident#12 revealed he was [AGE] year old male and was admitted to the facility on [DATE]. His diagnoses included paraplegia, hyperlipidemia, neuropathy, gastro-esophageal reflux disease, gastrointestinal hemorrhage, hypertension, chronic pain, major depressive disorder, anemia, muscle weakness, neuromuscular dysfunction of bladder, constipation, and peripheral vascular disease. <BR/>Record review of Resident #12's Quarterly MDS assessment dated [DATE] revealed BIMS score of 09 out of 15 indicating cognition that was moderately impaired. <BR/>In an interview on 09/20/22 at 11:35 a.m., Resident #12 stated that sometime in June of 2022 he noticed he was missing a large amount of money, but he could not remember the amount. He stated there was a (CNA A) whose name he could not remember that was accused of stealing from the residents. Resident #12 stated the (CNA A) was accused of taking jewelry from another resident. Resident #12 stated when he noticed he was missing a lot of money, he remembered that (CNA A) had been in his room. Resident #12 stated he reported the incident sometime in June of 2022 to a different CNA and Nurse whose names he could not remember, but he never heard anything back. Resident #12 stated the next month he told the Activities Director what happened. Resident #12 stated the Activities Director told him the facility was replacing the money, because (CNA A) was accused of stealing jewelry, and (CNA A) was being arrested after the items were found in a pawn shop. Resident #12 stated the Activities Director gave him a Visa gift card with the missing amount of money on it. Resident #12 stated the Activities Director told him that (CNA A) was fired. Resident #12 stated he thought the issue was resolved when the facility returned the money. He stated he did not talk with any other staff about the incident after the Activities Director got involved. <BR/>In an interview on 09/21/2022 at 2:37 PM, the Activities Director stated Resident #12 reported to her in July of 2022 that he had $180 missing from his room after an aide that she later found out was CNA A had been in the room. She stated Resident #12 disclosed that he had told staff before about the missing money. She stated she completed a grievance regarding the incident sometime in July of 2022, and she reported to the Administrator. She stated CNA A was investigated and terminated after she had stolen and pawned jewelry from two other residents. She stated that although it could not be proven that Resident #12's money was stolen by CNA A it was determined to be during the same time, and Resident #12 stated that CNA A had been in his room when he noticed the money was missing. She stated the facility reimbursed the money to Resident #12, and he accepted a reloadable gift card since the facility was not able to give him cash. She stated she only knew that both residents who had jewelry taken had their items returned after law enforcement found them at a pawn shop. <BR/>Record Review of the facility's grievance log revealed that on 07/12/2022 there was a grievance taken by the Activities Director logged involving Resident #12 for a missing item. The complianantt was described as Resident #12 reported $180 missing, and the incident was resolved by the Administrator replacing the money with a $180 Visa gift card, and was resolved on 07/14/2022. The grievance report was signed by the Administrator.<BR/>In an interview on 09/21/2022 at 3:30 p.m., the Administrator stated that one resident's bracelet was reported lost in April 2022. She stated the facility looked for the missing item, but it was never found. She stated that in June 2022 while the facility was investigating the missing jewelry of a second resident, law enforcement found both residents missing jewelry at a pawn shop. She stated it was determined that CNA A had taken both items and pawned them. She stated CNA A was terminated and was charged with theft. She stated Resident #12 lost money, it was not stolen, the money was never found, and the facility did not reimburse Resident #12. She stated the facility educated Resident #12 on keeping large amounts of money in his room, and he was given the option to keep his funds in a trust in which he declined. <BR/>In an interview on 09/23/2022 11:41 a.m., the Administrator stated she was the Abuse Coordinator. She stated the incident involving Resident #12 was not investigated as misappropriation because his money was not stolen and reported as missing. She stated Resident #12 reported that his money was missing in the month of July 2022 to the Activities Director after CNA A was already terminated, and CNA A would not have had the opportunity to take Resident #12's money from his room. She stated Resident #12 did not have the cognitive level to state names, dates, times, or if someone had been in his room to take the missing money. She stated no residents in the facility were aware of the events that lead to CNA A being terminated. She stated she was never made aware that Resident #12 reported his money missing in June 2022 to other staff at the facility.<BR/>Record review of an undated typed statement completed by the Administrator reflected in part, .[CNA A ] was terminated in June [2022]; [Resident #12's] money was missing in June [2022]. These 2 incidents are not correlated.<BR/>Record Review completed of the facility's staff sign in sheets for nursing staff from April 2022 through July 2022 revealed that CNA A worked on the following dates 06/01/2022, 06/03/2022, 06/04/2022, 06/05/2022, 06/09/2022, 06/10/20/22, 06/13/2022, 06/15/2022, 06/18/2022, and 06/19/2022.<BR/>Record review of the employee file for CNA A revealed a hire date of 08/30/2021 with a termination date of 06/20/2022.<BR/>Record review of the facility policy titled, Abuse, dated 2/01/2017 and revised 01/27/2020 reflected in part, .The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/confinement, and or Misappropriation of property. The administrator and/or designee are responsible for maintaining all facility polices that prohibit abuse, neglect, and misappropriation of funds/personal belongings, involuntary seclusion, or corporal punishment. Investigating allegations. Reporting incidents, investigations, and facility response to results of investigation withing mandated timeframes. Reporting/Investigation: The law requires the abuse coordinator/designee, or employee of the facility who believe that the physical or mental health or welfare of resident has been or may be adversely affected by abuse, neglect or exploitation caused by another person to report the abuse, neglect, or exploitation. All events that involve an allegation of abuse or involve a suspicious serious bodily injury of unknown origin must be reported immediately or not later than 2 hours of alleged violation. If the allegation does not involve abuse and the event does not result in serious bodily injury, the allegation should be reported within 24 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview 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 35 residents (Resident #62) reviewed for assessments in that: <BR/>-- Resident #62 was not re-assessed for her hospice (specific care for the sick or terminally ill) status.<BR/>This failure affected 1 resident and placed residents at risk for not having their individual needs met due to inaccurate assessment/s.<BR/>Findings Include:<BR/>Resident #62<BR/>Record review of Resident #62's admission record revealed she was an 89- year -old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included contracture (condition of shortening, hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) of right and left hand, history of falling, dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes and impaired reasoning), with behavioral disturbance, dysphagia (swallowing difficulties) and chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems). <BR/>Record review on 9/23/22 at 10:32 am of Resident #62's significant change MDS assessment dated [DATE] revealed she had a BIMS score of 2 indicating she had severely impaired cognition. In section G of the MDS, for functional status regarding Resident #62 was coded for transfer as total dependence on 2 people for physical assistance, bed mobility dressing, toileting, personal hygiene, and eating as total dependence of one person. Functioning limitation on range of motion was coded as (2) impairment on both sides on upper and lower extremities. In section H for bowel and bladder she was coded as always incontinent. In section O for Special Treatments, Procedures, and Programs, she was coded as receiving hospice services while a resident. <BR/>Record review of Resident #62's undated EMR care profile on 9/22/22 at 6:08pm revealed the following orders: <BR/> Please Admit to Hospice (Hospice Company P) 2815326498 DX. Alzheimer's Disease.<BR/> HOSPICE COMPANY P REEVALUATION PER FAMILY REQUEST .Status .Discontinued .End Date .7/2/2021.<BR/> Notify Hospice Company P for all (sic) beeds, concerns, falls and change in condition, refills if labs/x-ray needed or DEATH, Call Hospice Before Calling 911 .Status .Discontinued .End Date .7/2/2021.<BR/>Record reviews on 9/22/22 at 4:08 pm and on 9/23/22 at 10:33 am of Resident #62's EMR revealed there were no significant change MDS assessment for Resident #62 after she was discharged from hospice.<BR/>Record review of Resident #62's undated comprehensive care plan on 9/22/22 at 4:30pm revealed the following:<BR/>Focus .The resident has a terminal prognosis r/t Alzheimer's and is on Hospice .Goal .The resident's dignity and autonomy will be maintained at highest level through the review date .<BR/>Observation on 9/20/22 at 11:02 am of resident #62 she was in bed wearing personal pajamas and had carrot shaped hand rolls in both of her contracted hands. She was non-verbal, awake, alert and smiling. She did not appear to be in any distress and there were no foul odors or obvious hazards observed in her room or around the bed. <BR/>Interview on 9/22/22 at 4:10pm with the Administrator who said that Resident #62 was no longer on hospice when she was asked for the hospice contract for Resident #62's hospice services. The Administrator said that Resident #62 had been discharged a while ago. She did not remember exactly when and would have to look it up. She said that she believed the family wanted her on hospice care services but, hospice did not pick her back up or something to that effect. <BR/>Interview on 9/23/22 at 6:16pm with DON who said that she could not find a discharge order for Resident #62's discharge from hospice. She said that she believed the resident had been discharged from hospice, a while ago, but did not remember exactly when. The DON said that Resident #62 was not on hospice at this time. The DON also said that she did not see a significant change MDS in Resident #62's EMR and so that would mean that it probably was not there and had not been done. The DON said that she does not oversee the MDS department and did not sign any attestation or completion of MDS's for the facility.<BR/>Interview with MDS Coordinator on 9/23/22 at 9:22 am who said that there was no Significant Change MDS for Resident #62's discharge from hospice and she said there should have been one. She said that Resident #62 was not currently on any hospice care and had not received any hospice care services that she was aware of. She said she was not the MDS Coordinator at the time of Resident #62's discharge. She said that ordinarily MDS is responsible for completing any MDS assessment and she did not know why or how the Significant Change MDS got missed for Resident #62. She said that significant change MDS' should be done to accurately reflect the status of a resident. MDS Coordinator said she used the RAI manual to complete the MDS'.<BR/>In an interview with Regional Director of Clinical Reimbursement LVN, on 9/23/22 at 10:28 am she said she had been in her role for 3 years. She said that when a resident comes on or goes off hospice services, they were supposed to have an MDS assessment/specifically a significant change MDS, completed at that time. She said the previous MDS coordinator was responsible for completing the significant change MDS for Resident #62 at the time of her discharge from hospice, but she did not know why it had not been done. She said that the facility should have been having at least weekly IDT meetings to ensure changes in resident conditions were captured and MDS assessments and care plans were updated to reflect the residents' actual status. She said that she conducts audits of the MDS department but unfortunately only took over the building in [DATE] and the first audits she was able to conduct were in Jan/Feb of 2022. She said that the facility used the most up-to-date version of the RAI Manual as the policy and procedure used for guidance on completing MDS'.<BR/>Record review on 9/23/22 at 11:18am of facility provided in-service Attendance Record, dated 9/23/2022 at 10:45 am read in part: 4. Significant Change in Status Assessment (SCSA)-must be no later than 14 days from the determination date of the significant change in status. IE Resident is admitted to hospice on 8/1/2022, SCSA must be opened & completed within 14 days which in this scenario would be by 8/15/2022. Significant change is when a change had been identified with a resident, such as admission, hospice, discharge from hospice, a fracture that would limit mobility, two or more changes,<BR/>Record review of the CMS's RAI Version 3.0 Manual dated October 2019; page 2-22 read in part: 03. Significant Change in Status Assessment (SCSA) .The SCSA is a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline. It can be performed at any time after the completion of an admission assessment, and its completion dates depend on the date that the IDT's determination was made that the resident had a significant change. And defines a significant change as: A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to review and revise the person-centered care plan to reflect current condition for 1 of 35 residents reviewed for care plan accuracy. (Resident #62) in that-<BR/>--Resident # 62's care plan was not individualized or updated to reflect her discharge from Hospice services.<BR/>This failure affected 1 Resident and could affect residents and place them at risk of not having a comprehensive plan of care that addresses their specific needs. <BR/>Findings include:<BR/>Record review of Resident #62's admission record revealed she was an 89- year -old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included contracture (condition of shortening, hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) of right and left hand, history of falling, dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes and impaired reasoning), with behavioral disturbance, dysphagia (swallowing difficulties) and chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems). <BR/>Record review on 9/23/22 at 10:32am of Resident #62' s Quarterly MDS dated [DATE] revealed she had a BIMS score of 2 indicating she had severely impaired cognition. In section G of the MDS, for functional status regarding Resident #62 was coded for ADL assistance with transfer and eating as extensive assistance of at least 2 people and extensive physical assistance of at least 1 person for, bed mobility, locomotion on and off the unit, dressing, toilet use, and personal hygiene. Functioning limitation on range of motion was coded as (2) impairment on both sides on upper and lower extremities. In section H for bowel and bladder she was coded as always incontinent. In section O for Special Treatments, Procedures, and Programs, there was nothing coded for section K. Hospice care. <BR/>Record review of Resident #62's undated EMR care profile on 9/22/22 at 6:08pm revealed the following orders: <BR/> . Please Admit to Hospice (Hospice Company P) 2815326498 DX. Alzheimer's Disease.<BR/> . HOSPICE COMPANY P REEVALUATION PER FAMILY REQUEST .Status .Discontinued .End Date .7/2/2021.<BR/> . Notify Hospice Company P for all (sic) beeds, concerns, falls and change in condition, refills if labs/x-ray needed or DEATH, Call Hospice Before Calling 911 .Status .Discontinued .End Date .7/2/2021.<BR/>Record review of Resident #62's undated comprehensive care plan on 9/22/22 at 4:30pm revealed the following:<BR/>Focus .The resident has a terminal prognosis r/t Alzheimer's and is on Hospice .Goal .The resident's dignity and autonomy will be maintained at highest level through the review date .<BR/>Observation on 9/20/22 at 11:02 am of resident #62 she was in bed wearing personal pajamas and had carrot shaped hand rolls in both of her contracted hands. She was non-verbal, awake, alert and smiling. She did not appear to be in any distress and there were no foul odors or obvious hazards observed in her room or around the bed. <BR/>Interview on 9/22/22 at 4:10pm with the Administrator who said that Resident #62 was no longer on hospice when she was asked for the hospice contract for Resident #62's hospice services. The Administrator said that Resident #62 had been discharged a while ago. She did not remember exactly when and would have to look it up. She said that she believed the family wanted her on hospice care services but, hospice did not pick her back up or something to that effect. <BR/>Interview on 9/23/22 at 6:16pm with DON who said that she could not find a discharge order for Resident #62's discharge from hospice. She said that she believed the resident had been discharged from hospice, a while ago, but did not remember exactly when. The DON said that Resident #62 was not on hospice at this time. The DON also said that she did not see a significant change MDS in Resident #62's EMR and so that would mean that it probably was not there and had not been done. The DON said that she does not oversee the MDS department and did not sign any attestation or completion of MDS's for the facility and would not have known that her care plan had also not been updated regarding her hospice status/discharge from hospice. The DON said that MDS was responsible for annual, quarterly and signifcant change MDS's and the care plans that are associated with those assessments.<BR/>Interview with MDS Coordinator on 9/23/22 at 9:22 am who said that there was no Significant Change MDS for Resident #62's discharge from hospice and she said there should have been one. She said that Resident #62 was not currently on any hospice care and had not received any hospice care services that she was aware of. She said she was not the MDS Coordinator at the time of Resident #62's hospice discharge. She said that ordinarily MDS is responsible for completing any MDS assessment and she did not know why or how the Significant Change MDS got missed for Resident #62. MDS Coordinator said that the care plan and assessments are used to bill Medicaid and or Medicare for services related to a residents' actual status. She said that Resident #62's care plan should have been updated/revised at the time of the significant change assessment, but that since the significant change assessment was never done, the care plan also never got revised or updated. She said she used the RAI manual to complete the MDS'.<BR/>In an interview with Regional Director of Clinical Reimbursement LVN, on 9/23/22 at 10:28 am she said she had been in her role for 3 years. She said that when a resident comes on or goes off hospice services, they were supposed to have an MDS assessment/specifically a significant change MDS, completed at that time. She said that having the significant change MDS completed at that time would have prompted the update/revision of Resident #62's care plan. She said the previous MDS coordinator was responsible for completing the significant change MDS for Resident #62 at the time of her discharge from hospice, but she did not know why it had not been done. She said that the facility should have been having at least weekly IDT meetings to ensure changes in resident conditions were captured and MDS assessments and care plans were updated to reflect the residents' actual status. She said that she conducts audits of the MDS department but unfortunately had only took over the building in [DATE] and the first audits she was able to conduct were in Jan/Feb of 2022. She said that the facility used the most up-to-date version of the RAI Manual as the policy and procedure used for guidance on completing MDS'.<BR/>Record review of the facility policy and procedure dated as revised August 2006 and entitled Using the Care Plan on 9/23/22 at 3:13pm that read in part: The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to resident. 2. The Nurse Supervisor uses the care plan to complete the CNA's daily/weekly work assignment sheets and/or flow sheets. 5. Changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made.<BR/>Record review of the facility policy and procedure dated as revised May 2011 entitled Care Area Assessments on 9/23/22 at 3:23pm that read in part: b. Review the triggered CAA's by doing in-depth, resident-specific assessment of the triggered condition. (4). Sequencing of clinically significant events.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 11%, based on four errors out of 34 opportunities, which involved 3 of 8 residents (Resident #31, #51, and #12 and two of four staff (MA T and MA C) observed during medication administration reviewed for medication error, in that: <BR/>-MA C attempted to administer Resident #51's two blood pressure medications outside of prescribed parameters until surveyor intervened.<BR/>-MA T failed to ensure Resident #31's medication preparation order was clarified and then left Resident #31's medication at the bedside. <BR/>-MA C administered the wrong dose of Cranberry supplement tablet to Resident #12 as ordered by the physician. <BR/>These failures affected three residents and placed all residents residing on the 100, 200 and 400 halls at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. <BR/>Findings Include:<BR/>Resident #12<BR/>Record review of Resident #12's admission record revealed he was a [AGE] year old male, residing on hall 400, who admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the following diagnoses, paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord or nerve problem), presence or urogenital implants and peripheral vascular disease (low and progressive circulation disorder). <BR/>Record review of Resident #12's Physician order summary report on 9/21/22 at 4:18pm and dated as Active Orders As Of: 08/01/2022 revealed the following orders: Cranberry Tablet 500 MG Give 1 tablet by mouth one time a day for prophylaxis (preventatively), with an Order Status Active, and Order Date 05/31/2022 and Start Date 05/31/2022. <BR/>Record review of Resident #12's Medication Administration Record (MAR) on 9/21/22 at 4:28pm and dated 9/1/2022-9/30/2022 revealed the Cranberry Tablet 500 MG was scheduled for administration 2p-5p and had been initialed as being administered daily from 9/1/22 through 9/21/22.<BR/>Further record review of Resident #12's MAR dated 9/1/2022-9/30/2022 on 9/22/21 at 9:38am revealed the following entry: Cranberry Tablet 450 MG Give 1 tablet by mouth one time a day for prophylaxis .Start Date-09-23-2022 .2:00pm and had not been initialed as being administered.<BR/>Observation and interview during medication pass on 9/21/22 at 2:29pm revealed MA C removed one bottle of Cranberry 450 mg tablet from the 400-hall medication aide cart and removed one Cranberry 450mg tablet and placed it in a medication cup for Resident #12. MA C handed the bottle to the surveyor. The surveyor noted that the bottle was an OTC medication that had no resident name on it which was labeled, Cranberry tablet 450 mg. The bottle also had the following directions in part which read . Take 2 tablets daily .MA C handed Resident #12 the medication cup containing 1 tablet of Cranberry 450 mg and watched at bedside while Resident #12 took the medication. When asked by surveyor if Resident #12 only had to take 1 tablet or 2 tablets she said only one. When asked if she had ever looked at the mg strength of the cranberry tablets, she yes.<BR/>In an interview with the DON on 9/21/22 at 3:38pm she said that staff should be checking the dosage of medications being administered including the strength of even OTC medications. <BR/>Resident #31<BR/>Record review of Resident # 31's admission record revealed he was a [AGE] year old male who admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the following diagnoses: dysphagia (difficulty or discomfort in swallowing as a symptom of disease), need for assistance with personal care, contracture (condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) of left hand, and weakness. There was no diagnosis of constipation listed on Resident #31's admission record. <BR/>Record review of Resident #31's physician Order Summary Report on 9/22/22 at 3:48pm and dated as Active Orders As Of: 09/22/2022, revealed the following order: MiraLAX Packet 17 GM (Polyethylene Glycol 3350), Give 1 packet by mouth one time a day for constipation. Order Status .Active .Order Date .01/18/2022 . Start Date .01/19/2022 . Further record review revealed there were no instructions on how to mix the medication in its powered form or what liquids it could be or should be mixed with. <BR/>Observation and interview of medication administration with MA T, on 9/22/22 at 09:50 am revealed removed a bottle of (Polyethylene Glycol 3350) from the medication aide cart for 100 hall that had no residents name on it and poured a capful of powder into a clear plastic cup she then, added water to the cup and mixed the powder until dissolved for Resident #31. When asked by surveyor how did she know how much liquid to add to the powder, she said she normally just used the cups supplied on the cart. When asked how much liquid each cup could hold, she said she did not know. Surveyor asked MA T for an empty unused clear plastic cup, like the one she used to prepare Resident #31's medication mixture in, and she obliged. Surveyor looked on bottom of cup with read 7 oz. MA T said she was unaware she could look on the bottom of the cup to see how many ounces a cup could hold. When surveyor asked if MA T knew what type of liquids could be mixed with the MiraLAX, she said water and probably juice, but that the order did not actually say that specifically. When asked if she ever clarified orders if unsure what to give or how to give it, she said yes. When asked if the MiraLAX she had just prepared for Resident #31 came in a packet form as prescribed, she said she always just used the bottle of (Polyethylene Glycol 3350) as it was the generic version of the medication and was readily available on the cart. When surveyor asked how she would clarify an order, MA T said she would speak with the charge nurse. When surveyor asked if she would clarify the mixing instructions for Resident #31 with the charge nurse, she replied, I probably should. MA T proceeded to Resident #31's bedside and handed Resident #31 the clear plastic cup with the MiraLAX mixture and explained that it was his laxative. Resident #31 took a sip from the cup and then placed it on his bedside table. MA T thanked Resident #31 and left the room. When surveyor asked if MA T thought it was okay to leave the unfinished medication mixture at Resident #31's bedside, she said that Resident #31 takes his time and drinks it at his own pace. She said she would go back to the bedside later to check to see if Resident #31 had completed taking it. When asked by the surveyor if she had documented that Resident #31 had completed the full dose of his medication administration for the MiraLAX medication, she said yes, she would document that he had taken it, because Resident #31 had taken a sip of the medication, so she considered it to be given.<BR/>Further record review of Resident #31's MAR dated 9/1/2022-9/30/2022 on 9/22/22 at 11:17 am revealed the following: MiraLAX Packet 17 GM (Polyethylene Glycol 3350) Give 1 packet by mouth one time a day for constipation-Start Date-01192022 0600, and revealed MiraLAX Packet 17 GM was scheduled for administration at *6a and had been initialed as administered on 9/1/22 through 9/22/22. <BR/>Resident #51<BR/>Record review of Resident #51's admission record revealed he was a 62- year- old male who admitted to the facility on [DATE] with some of the following diagnoses: hypertensive heart disease without heart failure (changes in the left side of the heart and related arteries as a result of chronic elevated blood pressure), hyperlipidemia (blood that has too many lipids(fat), such as cholesterol and triglycerides), and unspecified sequelae of cerebral infarction (residual effects or conditions after acute damage to tissues in the brain due to the loss of oxygen to the affected area). There was no diagnosis of hypertension (high blood pressure) on Resident #51's admission record.<BR/>Record review of Resident #51's physician Order summary Report on 9/22/22 at 4:08 pm that was dated as Active Orders As Of: 09/22/2022, revealed the following orders: . Lisinopril-hydroCHLOROthiazide Tablet 20-12.5 MG Give 1 tablet by mouth one time a day for Hypertension Hold if SBP&lt;110 and HR&lt;60 .Order Status .Active .Order Date 12/30/2021 .Start Date .12/31/2021.<BR/> . Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG Give 1 tablet by mouth one time a day for Hypertension Hold if SBP &lt;110 and HR &lt;60 .Order status .Active .Order Date .12/30/2021 .Start Date .12/31/2021.<BR/>Observation and interview with MA C on 9/22/22 at 9:27 am during medication administration pass revealed MA C attempted to take Resident #51's blood pressure a total of 2 times, once on each arm. Initial blood pressure on Resident #51's left arm read: 97/86, HR 91 and the second reading:100/82, HR 88. MA C proceeded with the medication administration and removed the blister packs of medications for Resident #51 from the 200-hall medication aide cart, with resident #51's name on them. The blister packages read as follows: Lisinopril CTZ 20-12.5 mg 1 tablet PO QD Hold if &lt;110 hr &lt;60, and Metoprolol 25 mg ER 1 tab PO QD Hold if &lt;110 HR &lt; 60. MA C removed one pill from each packet and placed the 2 pills in a medication cup. MA C said to surveyor that Resident #51 preferred to have the medications dropped into his mouth and proceeded to put the medication cup to Resident #51's lips. The surveyor intervened and asked MA C to stop. The surveyor then asked MA C to repeat Resident #51's 2 previous blood pressure readings and asked her what she thought she should do and what she had been trained to do. MA C said, Oh yeah, I probably should not give him the blood pressure medications then?' MA C paused and said she would waste the blood pressure medications and notify the charge nurse that Resident #51's blood pressures were a little off. <BR/>Record review of Resident #51's MAR on 9/22/22 at 4:43pm that was dated 9/1/2022-9/30/2022, revealed the following:<BR/>Lisinopril-hydroCHLOROthiazide Tablet 20-12.5 MG Give 1 tablet by mouth one time a day for Hypertension Hold if SBP &lt;110 and HR &lt;60-Start Date-12/31/2021 0600, which was scheduled to be given at *6a and was initialed as administered by MA C at *6a 1 on 9/22/22, with a different blood pressure and pulse reading 132/76, 78. Resident #51's other blood pressure medication Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG Give 1 tablet by mouth one time a day for Hypertension Hold if SBP &lt;110 and HR &lt;60-Start Date-12/31/2021 0600, which was scheduled to be given at *6a, was also initialed as administered by MA C at *6a 1 on 9/22/22, with a different blood pressure reading 132/76, 78. <BR/>During a follow up interview with the DON on 9/22/22 at 4:50 pm, surveyor explained that record review of Resident #51's EMR and MAR did not have his initial blood pressure and heart rate readings on the MAR or in the EMR, from MA C's medication administration pass from earlier that morning. The DON said that she did not know why there were different blood pressure readings were documented on Resident #51's MAR or why there were no nursing notes regarding blood pressure medications not being administered at 6am or that Resident #51 had earlier blood pressure readings that were outside of the physician prescribed parameters. Surveyor asked DON if the EMR system allowed staff to delete or change information, she said she was not sure but believed they could and that she would try and find out what happened. When asked if staff had been trained to change or delete entries in any resident's clinical record, she said no. <BR/>Follow up interview with MA C on 9/22/22 at 5:54pm she said that she retook Resident #51's blood pressure around 11:30am after holding the medication and telling the charge nurse, LVN O of his other blood pressure readings that were outside of prescribed parameters. She said she had gone back into Resident #51's EMR and MAR around that time and updated the blood pressure readings. She said she was not sure how to add blood pressures but that she could change them and so she did. MA C said that since Resident #51's blood pressures were back within parameters, she gave his medications, Lisinopril and the Metoprolol at that time. <BR/>Interview with MA C and DON on 9/22/22 at 6:09pm DON said that she had LVN O enter a late entry note regarding the out of parameter blood pressure readings for Resident #51 on the earlier medication administration pass and that Resident #51's blood pressure medications had been held per parameters at that time. She provided the following copy of documentation by LVN O which read in part, as follows: Effective Date 9/22/22 11:41am .Created Date 9/22/22 at 5:24pm .Created by LVN O .BP rechecked 132/76, medication administered at this time, notified MD and RP. Asked DON why the note did not reflect the original blood pressure readings, or what medications had been held and then given at a later time and she said she told LVN O to do that and would have her redo the note. MA C then said that she did not have access to Resident #51's EMR nursing notes to document anything and only the nurses could document actual notes. MA C said she was able to delete the earlier blood pressure readings and replace them with the new blood pressure readings but did not know how to get the EMR system to accept both earlier and later blood pressure readings. The DON said she also did not know how to correct the issue.<BR/>Record review on 9/22/22 at 6:12pm of Resident #51's nursing notes revealed the following entry: Orders Administration Note .Effective Date: 09/22/2022 09:10 .Created By: LVN O .Created Date: 9/22/2022 5:47 pm .Lisinopril-hydrochlorothiazide Tablet 20-12.5 MG Give 1 tablet by mouth one time a day for Hypertension Hold if SBP &lt;100 and HR &lt;60 low bp 97/86 p91/changed arm, checked again bp100/82p88 nurse notified and will recheck. Orders-Administration Note .Effective Date: 9/22/2022 09:30 .Created by: LVN O .Created Date: 9/22/2022 5:22pm . med aide reported BP of 97/86,p91, rechecked at @ 0930 bp 100/82,88, bp medication held due v/s outside parameters, resident has no s/o of distress, will continue to monitor.<BR/>Record review of facility policy and procedure titled Oral Medication Administration with an Effective Date 09-2018 read in part .2. Refer to medication reference text for administration of any medication when added to any substance such as applesauce, juice, milk, etc., or confirm with a pharmacist.<BR/> .6. Administer medication and remain with the resident while medication is swallowed. Exercise caution with residents who have difficulty with swallowing. Do not leave medication at the bedside, unless specifically ordered by the prescriber.<BR/> .(. Chart each medication administration on the MAR or (eMAR) immediately following each resident's medication administration.<BR/>Record review of facility policy and procedure titled General Guidelines for Medication Administration with an Effective Date 09-2018 read in part: .4. At a minimum, the 5 rights-right resident, right drug, right dose, right route and right time-should be applied to all medication administration and reviewed at three steps in the process of preparation: (1) when medication is selected, (2) when the does is removed from the container, and (3) after the dose is prepared and the medication is put away .Always employ the MAR during medication administration. Prior to the administration of any medication, the medication and dosage schedule on the resident's MAR are compared with the medication label .2. Medications are administered in accordance with written orders of the prescriber.12. Medications are administered within 60 minutes of the scheduled administration time .17 .The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose was ingested, this is noted on the MAR and action is taken as appropriate.6. If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time .an explanatory note is entered on the reverse side of the record .Nursing documents the notification and physician response.

Based on interview and record review, the facility failed to ensure a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicalble diseases and infections and failed to notify HHSC as part of their infection prevention and control program when fifteen residents and three staff members, tested positive for COVID-19 between 02/17/2023 and 02/21/2023 for 15 of 16 residents, (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15), and 3 of 3 staff members (Staff A, Staff B, and Staff C) reviewed for infection control. <BR/>-The facility failed to notify HHSC as required by their infection prevention and control policy when fifteen residents and three staff members, tested positive for COVID-19 after the facility went approximately seven months with no COVID-19 positive staff or residents (the last COVID-19 positive case was reported to HHSC on 07/22/2022).<BR/>This failure could place all COVID-19 negative residents at risk of being exposed to the virus.<BR/>Findings included:<BR/>Record review of TULIP on 02/22/2023 revealed no self-reported incidents from this facility on 02/17/2023 and none regarding new COVID-19 positive cases at the facility since 07/22/2022. <BR/>Record review of the facility's COVID-19 Positive Resident Tracking and Staff COVID-19 Positive Tracking logs for February 2023 revealed the following:<BR/>-On 02/17/2023 two residents tested positive for COVID-19.<BR/>-On 02/18/2023 three residents and one staff member tested positive for COVID-19.<BR/>-On 02/20/2023 nine residents and two staff members tested positive for COVID-19.<BR/>-On 02/21/2023 one resident tested positive for COVID-19.<BR/>Interview with the DON on 02/22/2023 at 8:30 a.m., she stated the facility recently had an outbreak of COVID-19 with 15 positive residents and three positive staff members. The DON said the outbreak started on the previous Friday, 02/17/2023, when two residents exhibited symptoms of nasal congestion and cough. She stated she gave the facility's corporate Director of Infection Control Prevention all the information to submit to the state. The DON said nobody told her she had to report the COVID-19 positive cases to HHSC. She said she completed the necessary report and sent it in to the CDC on Monday, 02/20/2023 as required. The DON said she was not sure who normally called in COVID-19 incidents to HHSC. She said the current outbreak was the first the facility had since she was hired in September 2022, and she thought the CDC forms were all she had to do. <BR/>In an interview with the ADON on 02/22/2023 at 11:30 a.m., she stated she was also the facility's infection control preventionist. The ADON said as the facility's infection control preventionist, she was in charge of managing the COVID-19 outbreak and making sure CDC guidelines were followed. The ADON said she kept up with federal/state plan for COVID-19. She said the first resident, Resident #1, started showing symptoms on Friday, 02/17/2022. She said after Resident #1 tested positive for COVID-19, the facility started testing staff and other residents who were in contact with Resident #1. The ADON said the Administrator and DON completed the self-reported incident to the state (not HHSC). The ADON said she gathered all the necessary information to include in the report to state. She said she thought it was the DON's responsibility to call in COVID-19 incidents to HHSC. The ADON said she was aware the facility had to report new COVID-19 cases if there were no positive cases in 14 days. <BR/>In an interview with the Administrator on 02/22/2023 at 11:54 a.m., she said she was made aware of the COVID-19 outbreak on Friday, 02/17/2023. She said she believed the facility was supposed report the COVID-19 outbreak to HHSC, and she thought the DON reported it to HHSC on 02/21/2023. The Administrator said she would get the documentation from the DON to show the incident was reported to HHSC. She said it was the DON's responsibility to self-report COVID-19 positive cases. The Administrator said she knew the DON was having trouble sending in the report on 02/21/2023, so she sent the information to their corporate Director of Infection Control Prevention so she could send it. <BR/>In a follow-up interview with the Administrator and the DON on 02/22/2023 at 12:00 p.m., the Administrator stated their Director of Infection Control Prevention told the DON she needed to send the report to the state distribution and the Administrator and DON both thought that meant it would be sent to HHSC. She said the DON had trouble sending the report in, so the DON sent the information back to the Director of Infection Control Prevention so she could send it. The Administrator stated she reached out to the Director of Infection Control Prevention via email, and she (Director of Infection Control Prevention) informed the Administrator she (Director of Infection Control Prevention) did not send any report HHSC because they (the DON and Administrator) asked for information in regard to sending the outbreak information to state distribution (CDC requirement), not HHSC. The DON said she and the Administrator both thought they were sending the necessary information to HHSC as well and the CDC. The Administrator said neither she nor the DON were aware of how to send COVID-19 self-reports although they were aware of how to report regular self-reported incidents to HHSC. <BR/>An unsuccessful attempt was made to the Director of Infection Control Prevention on 02/22/2023 at 12:29 p.m. A voicemail message was left but not returned. <BR/>Record review of facility policy titled, COVID-19 Preparation Plan and Guidance dated 02/13/2023 revealed, . When to contact your local public health department/HHSC: . Positive COVID-19 test result; Report the first confirmed case of COVID-19 after a community has been without new cases for 14 days or more, to HHSC Complaint and Incident Intake through the Texas Unified Licensure Information Portal (TULIP) or by calling . within 24 hours of the confirmed positive result .<BR/>.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours after the allegation were made, to other officials, including the State Survey Agency(SSA), for 2 of 2 residents (#7 and #12); reviewed for reporting in that:<BR/>-The facility failed to report an incident to the SSA, Health and Human Service Commission (HHSC) immediately but not later than 24 hours of an incident of a missing jewelry on 06/20/2022 involving Resident #7 and $180 missing on 07/14/2022 involving Resident#12. <BR/>This failure could place residents at risk for incidents involving misappropriation of resident property by the facility not reporting such incidents to the State Survey Agency.<BR/>Findings included:<BR/>Record review of the admission Record for Resident#7 revealed she was [AGE] years old female and was admitted to the facility on [DATE]. Her diagnoses included hypothyroidism, hyperlipidemia, epilepsy, insomnia, chronic pain, idiopathic peripheral autonomic neuropathy, hypertension, atrial fibrillation, gastro-esophageal reflux disease, spinal stenosis, dysphagia, cognitive communication deficit, and weakness. <BR/>Record review of Resident #7's Quarterly MDS assessment dated [DATE] revealed BIMS score of 11 out of 15 indicating cognition that was moderately impaired. <BR/>Record review of the admission Record for Resident#12 revealed he was [AGE] years old male and was admitted to the facility on [DATE]. His diagnoses included paraplegia, hyperlipidemia, neuropathy, gastro-esophageal reflux disease, gastrointestinal hemorrhage, hypertension, chronic pain, major depressive disorder, anemia, muscle weakness, neuromuscular dysfunction of bladder, constipation, and peripheral vascular disease. <BR/>Record review of Resident #12's Quarterly MDS assessment dated [DATE] revealed BIMS score of 09 out of 15 indicating cognition that was moderately impaired. <BR/>In an interview on 09/20/22 at 11:35 a.m., Resident #12 stated that sometime in June of 2022 he noticed he was missing a large amount of money, but he could not remember the amount. He stated there was a (CNA A) whose name he could not remember that was accused of stealing from the residents. Resident #12 stated the (CNA A) was accused of taking jewelry from another resident. Resident #12 stated when he noticed he was missing a lot of money, he remembered that (CNA A) had been in his room. Resident #12 stated he reported the incident sometime in June of 2022 to a different CNA and Nurse whose names he could not remember, but he never heard anything back. Resident #12 stated the next month he told the Activities Director what happened. Resident #12 stated the Activities Director told him the facility was replacing the money, because (CNA A) was accused of stealing jewelry, and (CNA A) was being arrested after the items were found in a pawn shop. Resident #12 stated the Activities Director gave him a Visa gift card with the missing amount of money on it. Resident #12 stated the Activities Director told him that (CNA A) was fired. Resident #12 stated he thought the issue was resolved when the facility returned the money. He stated he did not talk with any other staff about the incident after the Activities Director got involved. <BR/>In a interview on 09/21/2022 at 10:30am, Resident #7 stated that (CNA A) whose name she could not remember was fired and arrest after stealing her bracelet that went missing in April of 2022. She stated that months later her bracelet was found at a pawn shop by the police, and it was returned to her. She stated that other residents had jewelry taken and pawned at the same place. <BR/>In an interview on 09/21/2022 at 2:37 PM, the Activities Director stated Resident #12 reported to her in July of 2022 that he had $180 missing from his room after an aide that she later found out was CNA A had been in the room. She stated Resident #12 disclosed that he had told staff before about the missing money. She stated she completed a grievance regarding the incident sometime in July of 2022, and she reported to the Administrator. She stated CNA A was investigated and terminated after she had stolen and pawned jewelry from two other residents to include Resident #7. She stated that although it could not be proven that Resident #12's money was stolen by CNA A it was determined to be during the same time, and Resident #12 stated that CNA A had been in his room when he noticed the money was missing. She stated the facility reimbursed the money to Resident #12, and he accepted a reloadable gift card since the facility was not able to give him cash. She stated she only knew that both residents who had jewelry taken had their items returned after law enforcement found them at a pawn shop. <BR/>In an interview on 09/21/2022 at 3:30pm, the Administrator stated that Resident #7's bracelet was reported lost in April of 2022. She stated that the facility looked for the missing item, but it was never found. She stated that in June of 2022 while the facility was investigating the missing jewelry of another resident, law enforcement found Resident #7's missing jewelry at a pawn shop with the other residents missing jewelry. She stated that it was determined that CNA A had taken both items and pawned them. She stated that CNA A was terminated and was charged with theft. She stated that the incident involving Resident # 7 was reported and investigated by the SSA the previous week. She agreed to provide documentation that the incident involving Resident #7 had been reported and investigated by the SSA. She stated that Resident#12 lost money, it was not stolen, the money was never found, and the facility did not reimburse Resident #12. She stated that the facility educated Resident #12 on keeping large amounts of money in his room, and he was given the option to keep his funds in a trust in which he declined. <BR/>Record Review completed on 09/21/2022 at 3:50pm of the facilities grievance log from April through July of 2022 did not reveal a grievance involving Resident #7. On 07/12/2022 there was a grievance logged involving Resident #12 for missing item taken by the Activities Director. The complianant was described as Resident #12 reported $180 missing, and the incident was resolved by the Administrator replacing the money with a $180 Visa gift card, and the grievance was resolved on 07/14/2022. The grievance report was signed by the Administrator.<BR/>Record Review completed on 09/21/22 at 4:00pm of the SSA Intake ID 358638 dated 06/20/2022, and Provider Investigation Report undated reported by the facility did not involve Resident #7. <BR/>In an interview on 09/23/2022 11:41am, the Administrator stated the Administrator stated she was the Abuse Coordinator. She stated that she was not able to provide documentation that the incident involving Resident #7 was reported to the SSA. She stated that after the investigation was submitted online to the SSA she was not given an option to print or save the document. She stated that the incident involving Resident #12 was not reported to the SSA because his money was not stolen and reported as missing. She stated she stated that Resident #12 reported that his money was missing in the month of July of 2022 to the Activities Director after CNA A was already terminated, and CNA A would not have had the opportunity to take Resident #12's money from his room. She stated that Resident #12 did not have the cognitive level to state names, dates, times, or if someone had been in his room to take the missing money. She stated that no resident in the facility were aware of the events that lead to CNA A being terminated. She stated that she was never made aware that Resident #12 reported his money missing in June of 2022 to other staff at the facility. <BR/>Record review of the facility policy titled, Abuse, dated 2/01/2017 revised 01/27/2020 read in part, .The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/confinement, and or Misappropriation of property. The administrator and/or designee are responsible for maintaining all facility polices that prohibit abuse, neglect, and misappropriation of funds/personal belongings, involuntary seclusion, or corporal punishment. Reporting incidents, investigations, and facility response to results of investigation withing mandated timeframes. Reporting/Investigation: The law requires the abuse coordinator/designee, or employee of the facility who believe that the physical or mental health or welfare of resident has been or may be adversely affected by abuse, neglect or exploitation caused by another person to report the abuse, neglect, or exploitation. All events that involve an allegation of abuse or involve a suspicious serious bodily injury of unknown origin must be reported immediately or not later than 2 hours of alleged violation. If the allegation does not involve abuse and the event does not result in serious bodily injury, the allegation should be reported within 24 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain medical records on each resident that are accurately documented for 1 (Resident #3) of 5 residents reviewed for resident records.<BR/>Resident #3's Medication Administration Record showed that Mucinex DM oral tablet extended release 12 Hour 30-600 mg was documented as being given when guaifenesin 400 mg tablet was administered. <BR/>The failure could place residents who receive medications from facility staff at risk for less than therapeutic benefits, and/or not receiving ordered medications due to inaccurate documentation of administration.<BR/>Findings include: <BR/>Record Review of Resident 3's face sheet dated 1/30/25 revealed resident was a [AGE] year old male admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (Stroke), Dysphagia (difficulty swallowing), Type 2 Diabetes Mellitus, Hypertensive Disease with Heart Failure with history of acute upper respiratory infection and acute bronchitis. <BR/>Record review of Resident's 3's quarterly MDS dated [DATE] revealed a BIMS score of 15 that suggests Resident #3's cognition is intact. <BR/>Record review of Resident 3's January Medication Administration Record printed on 1/30/25 revealed Mucinex DM Oral Tablet Extended Release 12 Hour 30-600 mg (Dextromethorphan-Guaifenesin) Give 1 tablet by mouth every 12 hours for Cough and congestion for 7 days with a start date of 1/22/25 at 9 a.m. and discontinue date of 1/28/25 at 4:57 p.m. Mucinex DM was documented as being administered from 1/22-1/27/25 at 9 a.m. and 9 p.m. and on 1/28/25 at 9 a.m. <BR/>Record review of Resident 3's Care Plan provided on 1/30/25 revealed a focus that Resident 3 is at risk for frequent infections related to diabetes mellitus with goal that Resident 3 will have no complications related to diabetes through the review date. <BR/>Observation of Resident 3's medication administration on 1/28/25 at 8:23 a.m. revealed that Resident 3 was administered guaifenesin 400 mg for order of Mucinex DM Oral Tablet Extended Release 12 Hour 30-600 mg (Dextromethorphan-Guaifenesin) Give 1 tablet by mouth every 12 hours by CMA A. <BR/>Observation of 100 hallway medication cart on 1/28/25 at 4:55 p.m. with CMA A revealed that no Mucinex DM could be found with either the over the counter medications or with Resident #3's medications from the pharmacy. <BR/>Interview of CMA A on 1/28/25 at 12:54 p.m. revealed that she notified the charge nurse (LVN B) about three days prior to interview when she could not find the Mucinex DM order and was instructed that she could give the guaifenesin 400 mg. CMA A said that the Mucinex was on order. CMA A said that Resident #3 was previously taking guaifenesin 400 mg and the order was recently changed to Mucinex DM . CMA A said that she normally works on the hall that Resident #3 is currently residing on which shows that CMA A is familiar with Resident #3 and gives his medications frequently.<BR/>Interview of LVN B on 1/28/25 at 1:02 p.m. revealed that she was not aware that Resident #3 was receiving guaifenesin 400 mg instead of Mucinex DM. LVN B said that Resident #3 had been taking guaifenesin 400 mg for years and it was changed to Mucinex DM for seven days last week when resident got sick. <BR/>Interview of CMA A on 1/28/25 at 4:47 p.m. revealed that she did not document in the facility's electronic medical record when she notified the nurse regarding needing Mucinex DM for Resident #3. CMA A stated that she does not chart notifications to the nurse in the electronic medical record. CMA A stated she has given Resident #3 guaifenesin 400 mg since she started working at the facility. <BR/>Interview of LVN C on 1/29/25 at 11:22 a.m. revealed she could not remember administering specific medication to Resident #3 but was not aware of him missing any medications. Per Resident 3's January MAR, LVN C had documented administering Mucinex DM at 9 p.m. 1/23/25, 1/24/25 and 1/25/25. <BR/>Interview of CMA B on 1/29/25 at 11:45 a.m. revealed that she would have administered medications to Resident #3 as what is documented on Resident 3's medication administration record. Per Resident 3's January MAR, CMA B had documented administering Mucinex DM at 9 a.m. on 1/25/25 and 1/26/25. <BR/>Record review of facility's policy General Guidelines for Medication Administration revealed that medications are to be administered as prescribed in accordance with good nursing principles and practices. <BR/>Record review of facility's policy Administration Procedures for All Medications revealed that after administration of a medication that staff should document administration in the MAR or TAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , interview, and record review the facility failed to ensure the resident's had the right to have reasonable access to the use of telephone and a place in the facility where calls can be made without being without being overheard for 1 of 3 (Resident #1) residents reviewed for communication.<BR/>The facility failed to provide a place for Resident #1 to make telephone calls without being overheard. <BR/>Observation of Resident #1 using the phone at nursing station while (3) nurses were at the nurse station and (2) other resident's at the nurse station receiving medication.<BR/>This failure could place residents at risk of conversation being overheard and privacy right's not being respected and could result in a decline in resident's psychosocial well-being and quality of life.<BR/>Findings include:<BR/>Record review of Resident #1 admission face sheet dated 01/14/2021 reflected a [AGE] year-old male admitted on [DATE].<BR/>Record review of Resident #1's History and Physical dated 01/28/23 revealed diagnosis of depression (a common mental health condition characterized by persistent low mood, loss of interest or pleasure in activities, and other symptoms that interfere with daily functioning.)<BR/>Record review of Resident #1's MDS dated [DATE] revealed a BIMS of 14 indicating the resident was cognitively intact.<BR/>During Interview with Resident #1 on 1/28/2025 at 10:30AM. Resident #1 said he called his friends or family on the phone at the nursing station he was told that is the only place to make a telephone call or if you have a cell phone. Resident #1 said the facility does not have a cordless phone to use and most of my conversations are heard by the nurses or anyone walking by. Resident #1 said we only get 15 minutes due to the nursing staff needing to use the phone. Resident #1 said he had not been offered any other phone to use in private. Resident #1 said he knows how to use the phone however staff will call the number for him. Resident #1 said he does not feel secure in his conversations and speaking in an open area, and he knows the nurse can hear his conversation. Resident #1 said it makes him feel like he does not have any privacy.<BR/>During Interview with DON on 1/28/2025 at 11:20 am the DON said the nurse's station is the only area for residents to use the phone. Many of the alert residents have their own personal cell phones. The DON said unfortunately we do not have an area for the Residents to use for privacy.<BR/>During Interview with facility Administrator on 1/28/2025 at 12:00 pm the Administrator said the residents are able to use the phone at the nurse station or at the receptionist desk if need be. He stated I have a phone by my office that they can use also but as of now we do not have designated area for the resident to use, we are currently working on that. The Administrator said the facility did not have a policy on resident phone use and privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders and consistent with professional standards for 1 (Resident #286) of 2 residents reviewed for intravenous fluids.<BR/>The facility failed to ensure that the dressing on Resident #286's mid-line intravenous line (a short flexible tube inserted into a vein to administer fluids and medications) was changed according to the doctor's order and facility's standard of care.<BR/>The failure could place residents at risk of infections. <BR/> Findings include: <BR/>Record Review of Resident 286's face sheet dated 1/30/25, revealed resident is a [AGE] year old female admitted to the facility on [DATE] with diagnoses including Unspecified Dementia, Urinary Tract Infection, Type 2 Diabetes and Unspecified Systolic (Congestive) Heart Failure. <BR/>Record review of Resident 286's quarterly MDS dated [DATE] revealed a BIMS score of 13 that suggests that Resident 286's cognition is intact. <BR/>Record review of Resident 286's order summary report dated 1/27/25 reflected the following orders: Mid line dressing and cap change weekly using sterile technique per protocol as needed with an order and start date of 01/20/2025. Mid line dressing and cap change weekly using sterile technique per protocol one time a day every Mon for prophylaxis with order date of 1/20/25 and start date of 1/27/25. <BR/>Record review of Resident 286's care plan with an admission date of 1/19/2025 revealed focus that resident is on antibiotic(s) and is at risk for adverse reactions. <BR/>Record review of Resident 286's January medication and treatment administration record printed on 1/30/25 revealed that there were no mid line dressing and cap changes documented during 1/20-1/26/25. Per treatment administration record Resident 286 was monitored for signs and symptoms of infection every 8 hours from 1/20-1/30/25. <BR/>Record review of Resident 286's January medication and treatment administration record printed on 1/30/25 revealed that Resident 286 received IV antibiotics (Meropenem) and Metronidazole every 8 hours as from 1/20-1/27/25. <BR/>Observation of Resident 286 on 1/27/25 at 11:55 a.m., revealed resident was in her room, lying in bed. Resident was observed to have a midline to her right upper arm with dressing dated 1/18/25. <BR/>Interview with LVA A on 1/27/25 at 11:55 a.m. revealed that she also confirmed that Resident 286's midline dressing was dated 1/18/25. LVA A stated that Resident 286's midline dressing should have been changed around 1/26/25 and that night shift usually changes the IV dressings. <BR/>Interview with DON on 1/27/25 at 3:36 p.m. revealed that they do not have a policy for midline dressing changes and the competency is the only form they have. The DON confirmed that IV dressing changes should be completed every five to seven days per facility's competency. <BR/>Interview of DON on 1/29/25 at 11:06 a.m. revealed that IV dressing changes are to be done every five to seven days and the nurse is responsible with the practice being the night shift changes the IV dressings. <BR/>Record review of the facility's competency assessment for peripheral IV dressing changes revealed that dressings are to be changed at least every 5 to 7 days.

**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 for 2 (Resident #15, Resident #56) of 18 residents reviewed for MDS transmission, in that: <BR/>-The facility failed to transmit a completed admission MDS assessment for Resident #15 <BR/>- The facility failed to ensure Resident #56's Significant change MDS Assessment was completed within 14 days significant change.<BR/>This failure could place residents at-risk of not having their assessments completed timely, which could result in denial of services and or payment for services.<BR/>Findings include: <BR/>Findings include. <BR/>Record review of Resident #15's face sheet dated 01/29/25 revealed Resident #15 was a [AGE] year-old female, with an original admission date of 05/25/24 and re admitted on [DATE]. Her diagnosis included acute pyelonephritis (A sudden and severe inflammation of kidney due to a bacterial infection). Muscle wasting, Hypothyroidism (a condition where the thyroid gland does not make enough hormone) communication deficit (Difficulty in communication that arises from impairments in cognitive process), unspecified lack of coordination, Unsteady feet.<BR/>Record review of Resident #15's admission MDS dated [DATE] was completed 02/13/25 which was 20 days after admission. <BR/>Resident #56<BR/>Record review of Resident #56's face sheet dated 01/27/25 revealed Resident #56 was a [AGE] year-old female, with an original admission date of 08/19/24 and re admitted on [DATE]. Her diagnosis included Respiratory failure, muscle wasting, hypothyroidism, Hypothyroidism (a condition where the thyroid gland does not make enough hormone) and depression.<BR/>Record review of Resident #56's significant change MDS dated [DATE] was signed as completed on 09/17/24 53 days after significant change MDS.<BR/>During an interview on 01/29/25 at 2:00PM, the MDS coordinator said she was not present at the facility during the time of the MDS assessment. She said the facility did an audit and was aware of the late MDS and had a plan of correction in place. She said she was responsible for ensuring that all MDS reflected resident's condition and are transmitted within a certain time frame. She said not completing the MDS in a timely manner could result in care plan not being completed and delay in care and services as well as denial of payment for services by payor source.<BR/>During an interview with the DON on 01/28/24 at 4:00PM , she said she was not trained to sign the MDS and there was a Cooperate staff that signed off on the MDS. <BR/>Policy on MDS completion and transmission was requested on 01/29/24 at 4:00 PM. MDS coordinator said she follows the RAI manual

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the comprehensive resident-centered care plan was reviewed and revised by the Interdisciplinary team after each assessment for 1 of 18 residents reviewed for care plan accuracy (Resident # 80) in that:<BR/>---Resident # 80 was care planned for Restorative Care Program, but facility does not have a Restorative program<BR/>This failure could place residents at risk of receiving inaccurate care and services.<BR/>Findings include:<BR/> Record review of Resident # 80's face sheet revealed a [AGE] year old male with admission date of 3/3/23 and diagnoses including traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), cerebral infarction (stroke), hemiplegia and hemiparesis (weakness and paralysis on one side of the body), following cerebral infarction, speech and language deficits following cerebral infarction, Diabetes (chronic disease causing elevated levels of blood glucose that cause damage to major organs) , depressive disorder (loss of interest), hypertension (high blood pressure), heart disease (damage of the major blood vessels of the heart), atrial fibrillation (irregular heart rate that causes poor blood flow).<BR/>Record review of Resident # 80 care plan for limited physical mobility, undated, revealed intervention for Nursing Rehabilitation/Restorative: Bed Mobility Program, with restorative aide to perform Range of motion exercises in all planes 3 to 5 times a week. <BR/>Record review of Resident # 80 MDS dated [DATE] revealed a BIMS score of 14, indicating no impairment of cognitive skills, limitation in range of motion with mobility impairments in upper and lower extremities and substantial/maximal assistance required for mobility. Resident # 80 was not coded as having therapy. <BR/>Observation of Resident #80 on 12/05/23 at 04:00 PM revealed resident in bed, covered with sheet, awake, alert, but unable to talk (stroke), gave thumbs up sign when asked how he was doing. He was asked about assistance from staff with moving his limbs while providing care, and he gave a thumbs up sign. <BR/>Observation of Resident #80 on 12/6/23 at 12:20pm revealed resident in bed, lunch tray on bedside table, resident picking at food, fork on table. CNA S came in room, asked if he wanted PBJ, unwrapped half sandwich, he took the sandwich and took one bite but put it down. CNA S went to get him more water and said he can feed himself. In further interview, she said the aides move his arms and legs while providing care throughout the day. <BR/>Record review of Resident #80's clinical physician order dated 3/3/23 revealed ST and OT to evaluate and treat as needed. Physician order dated 12/5/23 revealed ST to evaluate and treat as needed. <BR/>In an interview on 12/8/23 at 11:00 am, the Rehab Director said Resident # 80 had Physical Therapy for 8 weeks in April after he was admitted to the facility, and he was evaluated for therapy every quarter, and he was just evaluated by ST on 12/5/23. She said Resident # 80 was on Hospice services. <BR/>In an interview on 12/8/23 at 12:20 pm, the DON said there is no Restorative Program in the facility. She said the program ended, and CNA's work with the residents while they provide care. She said they did an audit of the care plans a few months ago to make sure the Restorative Program was removed, but they must have missed this one. She said the risk of having inaccurate care plans would be the resident would not receive proper care. <BR/>In an interview on 12/8/23 at 12:40 pm, the Administrator said they do not have a Restorative Program anymore because they did not have the necessary components. She said the Restorative program needed to be removed from the care plan since it was not accurate, and care plan should be correct for the care the resident receives. <BR/>In an interview on 12/8/23 at 1:40 pm, the MDS coordinator said the Restorative program has been discontinued, and an audit was done of all the care plans to remove it, but Resident # 80's care plan was missed, but it would be removed, since care plans needed to be accurate. She said the risk of not having accurate care plans would be the resident would not receive proper care. <BR/>In an interview on 12/8/23 at 2:40 pm, CNA S said Resident # 80 was on Hospice, and the Hospice aide comes twice a week to bathe him, and the aides in the facility check and change his brief as needed and perform some range of motion if he allows it. <BR/>Record review of the facility policy on Care Plans, dated 9/3/20XX, read, in part, .care plan is revised every quarter, significant change of condition, annual or a resident condition change on an individualized basis .

Based on observation, interview and record review, the facility failed to ensure waste were properly contained in dumpster and covered in that <BR/>-On 9-20-22 at 9:42 a.m. the facility's dumpster lid was open.<BR/>This failure has the potential to affect residents and place them at risk for infection and a decreased quality of life due to having an exterior environment which could attract pests, rodents, and other animals.<BR/>Findings include:<BR/>On 9-20-22 at 9:42 a.m., the surveyor and Director of Food Services observed the facility's dumpster area, in the lot behind the dietary department. The facility's commercial -sized dumpster (one dumpster with 2 lids were open and there was garbage in the dumpster. <BR/>Observation and interview on 9-20-22 at 9:42 a.m., the Director of Food Services stated the dumpster lids needed to be closed at all times due to garbage spreading everywhere, to avoid smells and to keep pests, rodents and insects out of the area. The Dietary Manager had a staff member close the dumpster lids.<BR/>Record review of facility's policy and procedure entitled Food-Related Garbage and Refuse Disposal, revised October 2017, reflected in part .garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pest .outside dumpsters provided by garbage pickup services will be routinely monitored and kept closed and free of surrounding litter. <BR/>CMS 672 (Resident Census and conditions of Residents Form) revealed a total census of 84.