FOCUSED CARE OF WAXAHACHIE

**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 right to a safe, clean, comfortable, and homelike environment for 1 (Resident #1) of 5 residents reviewed for environment. The facility failed to ensure Resident #1 was provided clean bed linens that were in good condition. This failure placed residents at risk of living in an uncomfortable environment leading to a diminished quality of life. Findings included: Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Diabetes Mellitus with Diabetic Nephropathy (elevated blood sugar that has caused kidney damage) and constipation. Record review of Resident #1's Baseline Care Plan, dated 06/17/2025, reflected Resident #1 was dependent for transferring from chair to bed and bed to chair, toileting hygiene, showering and bathing, and lower and upper body dressing. The care plan reflected Resident #1 was always incontinent of bowel and bladder and used a wheelchair for mobility. Record review of Resident #1's admission MDS assessment dated [DATE], reflected the resident had a BIMS score of 14, which indicated she was cognitively intact. In an interview and observation on 07/01/2025 at 12:00 PM Resident #1was lying in bed, her hair was unbrushed, and her clothing had food crumbs on it. Her sheets had a urine odor. She stated she was not ok. She stated she had not been showered in 8 days. She stated she had asked to get up but was told she must stay in the bed today. She pointed to her sheets at a basketball size brown dried stained ring on her Resident #1 sheets. She then pulled her sheet back and rolled to the side revealing 2 (two) additional large brown rings under her padding that was placed on the bed between her body and the bottom fitted sheet. She stated not being clean made her feel dirty and trashy. In an interview on 07/01/2025 at 12:10 PM CNA A stated she had been a certified nurse aide since January 2025, but this was her fourth day at this facility. She stated she received 2 days of orientation in the facility. She stated she had not worked with Resident #1 prior to today. She stated she had received a verbal report from the nurse this morning on residents needs and was told to not get Resident #1 up out of bed. She stated she did not realize Resident #1's bottom bed sheets were stained. She stated the CNAs were responsible for changing residents' sheets. She stated having dirty sheets would make the residents feel dirty. In an interview on 07/01/2025 at 12:15 PM CNA B stated she was responsible for resident transfers to and from appointments but was assisting on the floor today. She stated there were 2 staff members that did call in today, so the staff were all working together to meet the needs of the residents. She stated she was not aware Resident #1 had brown stained sheets. CNA B stated the CNAs were responsible for changing residents' sheets. She stated she was heading to assist the other CNA A to help clean Resident #1 up now. She stated not having clean sheets could impact a resident negatively. She stated it could bother the resident and make them uncomfortable and feel dirty. In an interview on 07/01/2025 at 1:45 PM LVN C stated she had worked at the facility for 2 years. She stated Resident #1 was a new admit to the facility. She stated she did tell CNA A that Resident #1 did not get up for breakfast. She stated the aide must have misunderstood her and left Resident #1 in bed. LVN C stated if Resident #1 asked to get up then the staff should get her up. LVN C stated the CNAs were responsible for changing residents' sheets. She stated sheets were to be changed on shower days and as needed if soiled. She stated no residents should be left in dirty sheets. She stated leaving a resident in dirty sheets and not showered could impact their dignity making a resident depressed. In an interview on 07/01/2025 at 2:30pm The Director of Clinical Operation stated she expected residents' bed sheets were changed on shower days and as needed. She stated the facility practice was to throw away stained or worn sheets in the trash to ensure they were not used on residents' beds. She stated leaving a resident in soiled or dirty sheets, physically it can cause skin breakdown, emotionally it can make them feel unclean. Record review of the undated facility's policy titled Quality of Life Homelike Environment reflected Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management shall Maximize, to the extent possible. the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include Clean, sanitary, and orderly environment and clean bed and bath linens that are in good condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 1 of 5 residents (Resident #1) reviewed for ADLs. The facility failed to ensure Resident #1 received showers on 06/18/2025, 06/23/2025, 06/27/2025, and 06/30/2025. This failure could place residents at risk of not being provided care and assistance when needed. Findings Included: Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Diabetes Mellitus with Diabetic Nephropathy (elevated blood sugar that has caused kidney damage) and constipation. Record review of Resident #1's Baseline Care Plan, dated 06/17/2025, reflected Resident #1 was dependent for transferring from chair to bed and bed to chair, toileting hygiene, showering, bathing, lower and upper body dressing. The care plan reflected Resident #1 was always incontinent of bowel and bladder and used a wheelchair for mobility. Record review of Resident #1's admission MDS assessment dated [DATE], reflected the resident had a BIMS score of 14, which indicated she was cognitively intact. Record review of Resident #1 Documentation Survey Report V2 (a report reflecting care provided to the resident) reflected Resident #1 was assigned to receive her shower every Monday, Wednesday, and Friday. The report reflected Resident #1 did not receive her showers on 06/18/2025, 06/23/2025, 06/27/2025, and 06/30/2025. There was no documentation of Resident #1 refusing her showers. Record review of Resident #1's Progress Notes dated 06/17/2025 through 07/01/2025 reflected there was no documentation of Resident #1 refusing care. In an interview and observation on 07/01/2025 at 12:00 PM Resident #1was lying in bed, her hair was unbrushed, and her clothing had food crumbs on it. Her sheets had a urine odor. She stated she was not ok. She stated she had not been showered in 8 days. She stated she had asked to get up but was told she must stay in the bed today. She pointed to her sheets at a basketball size brown dried stained ring on her sheets. She then pulled her sheet back and rolled to the side revealing 2 addition large brown rings under her padding that was placed on the bed between her body and the bottom fitted sheet. She stated not being clean made her feel dirty and trashy. In an interview on 07/01/2025 at 12:10 PM CNA A stated she had been a certified nurse aide since January 2025, but this was her fourth day at this facility. She stated she received 2 days of orientation in the facility. She stated she had received a verbal report from the nurse this morning on residents needs and was told to not get Resident #1 up out of bed. She stated the CNAs were responsible for giving Resident #1 a shower and cleaning her. She stated she was not sure of Resident #1's shower days. She stated not getting showers would make the resident feel dirty. In an interview on 07/01/2025 at 12:15 PM CNA B stated she was responsible for resident transfers to and from appointments but was assisting on the floor today. She stated she was not sure when Resident #1 had her last shower. She stated that the shower schedule was at the nurse's station. She stated she was heading to assist the other CNA to help clean Resident #1 up now. She stated not having been showered could impact a resident negatively. She stated it could bother the resident and make them uncomfortable and feel dirty. In an interview on 07/01/2025 at 1:45 PM LVN C stated she had worked at the facility for 2 years. She stated Resident #1 was a new admit to the facility. She stated her showers were scheduled for 2pm-10pm shift on Monday, Wednesday, and Friday. She stated the aides looked at the shower book to find out who needed showers and what days. She stated she was telling CNA A that Resident #1 did not get up for breakfast. She stated the aide must have misunderstood her and left Resident #1 in bed. She stated if Resident #1 asked to get up then the staff should get her up. She stated residents should get their showers on shower days and as needed. She stated Resident #1 has not refused showers that she was aware of. She stated if a resident were to refuse a shower, then the nurses must follow up and document the refusal. She stated leaving a resident dirty and not showered could impact their dignity making a resident depressed. In an interview on 07/01/2025 at 2:30pm The Director of Clinical Operations stated she expected showers to be completed on a resident's assigned shower days. She stated the nursing assistants were responsible for showers. She stated the certified nursing assistants had access to the Kardex which gives a detailed schedule of residents' needs including shower days and schedule. She stated there was also a schedule for residents' showers at the nurse's station. She stated the nurse aides were instructed on the Kardex and shower schedule upon orientation. She stated she was not aware of Resident #1 refusing any showers. She stated the nurse should have followed up with any shower refusal. She stated not bathing a resident routinely physically it can cause skin breakdown, emotionally it can make them feel unclean. Record review of the undated facility's policy titled Quality of Life-Resident Self Determination reflected Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life including Daily routine, such as sleeping and waking, eating, exercise and bathing schedules.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 (Resident #12) of 8 residents who were reviewed for accuracy of assessments.<BR/>The facility failed to ensure Resident #12's MDS assessment accurately reflected his hearing ability and use of hearing aids. <BR/>This failure could place residents at risk of their needs going unmet. <BR/>Findings included:<BR/>Record review of Resident #12's quarterly MDS, dated [DATE], indicated Resident #12 was a [AGE] year-old male, who was admitted to the facility on [DATE]. He had diagnoses of dementia, major depressive disorder, depression, hereditary and idiopathic neuropathy (nervous system disorders that interfere with normal nerve function). His MDS reflected he had minimal difficulty with his ability to hear, (difficulty in some environments (e.g., when person speaks softly or setting is noisy), as well as that he did not have hearing aids or other hearing appliances. His BIMS score was 12, indicated moderately impaired cognition.<BR/>Record review of Resident #12's care plan dated last revised on 01/31/2025 reflected resident had special instructions Very hard of hearing. It stated, the resident has a communication problem related to hearing loss The interventions listed included for staff to anticipate and meet needs, encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense or responds to the feeling resident is trying to express and refer to speech therapy for evaluation and treatment as ordered. Hearing aids were not care planned. <BR/>Record review of Resident #12's doctor's order dated 9/24/2024 reflected, May have podiatry, dental, audiologist, & ophthalmologist consults PRN.<BR/>Interview and Observation on 02/10/2025 at 10:24 a.m., revealed Resident #12 sitting in his recliner in his room watching television. The resident voiced that his hearing aids needed to be repaired and that his family member was going to come get them to be fixed/replaced. The state surveyor had to stand close, yell, speak slowly, and often repeat questions to the resident during the observation. The resident was unable to give an answer when the state surveyor asked him if the facility helps him with audiology appointments, even after writing the questions down for him due to the hearing impairment. <BR/>Interview on 02/12/2025 at 10:17 a.m., with LVN C revealed she had been working remotely to help the facility since January 2025. She stated that the way she completed the MDS assessment was by looking at the social worker's assessment as well as the skilled nursing assessments in PCC, but that she did not know the residents and did not go see them before completing and signing off the MDS assessment. She stated that Resident #12 MDS should have been coded differently if the resident had hearing aids and had significant hearing impairment. <BR/>Interview on 02/12/2025 at 11:40 a.m., with the DON revealed she had started working at the facility 3 weeks ago. She stated that her expectation would be that hearing aids were care planned. She stated that Resident #12 had hearing aids in his room but refused to wear them and did not like them. She said that the resident's family member had planned to take the hearing aids home with him due to the resident not wearing them. She said he reads lips very well and can sign for things he needed. She said that it should have been care planned that he did not wear them.<BR/>Interview on 02/12/2025 at 12:48 p.m., with CNA A revealed she had worked at the facility for 2 years. She stated that Resident #12 would wear his hearing aids sometimes, but he had a hard time getting them to stay in his ears. She stated that she had to make sure she talked loudly and stood close to him when talking, but that most times she still had to repeat herself multiple times. She did not think he was good at reading lips due to the number of times she would have to repeat herself during conversations.<BR/>Interview on 02/12/2025 at 2:00 p.m., with the CMDS revealed she had been the CMDS since 2019. She stated that when an MDS nurse was out on leave for one facility there would be another MDS nurse covering for the facility, and it was not normally the process for the MDS coordinator to work remotely and not lay eyes on the residents. She stated that the MDS nurse was responsible for ensuring MDS assessment accuracy but in this instance the covering MDS nurse should have left the assessment open for the CMDS to check for accuracy. She stated that a negative outcome for an incorrect assessment could be residents having their needs being unmet by staff. <BR/>Interview on 2/12/2025 at 2:00pm, with the CMDS revealed that any inaccuracy on the MDS would be the responsibility of the MDS nurse to correct. The CMDS stated that a negative outcome for an incorrect assessment could lead to the resident receiving the wrong treatment, incorrect labs, and the plan of care not being completed as it should. She stated that her expectation was that an anticoagulant should not be included in the MDS if it was not ordered. She stated that the MDS should accurately reflect the resident's complete medical picture.<BR/>Record review of the facility's Resident Assessment Instrument policy dated last revised September 2010 revealed, 3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. 4. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her practicable level of functioning.<BR/>Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.19.1, dated October 2024, reflected, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status. (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide accurate PASRR screenings for individuals with a mental disorder for 2 (Resident #16 and Resident #52) of 14 residents reviewed for PASSAR assessments.<BR/>Resident #16 did not have a new PASSAR level I screening completed or a PASSAR level II screening completed although a diagnosis of mental illness was diagnosed after the admission date. <BR/>Resident #52 did not have an accurate PASSAR Level 1 screening after Resident #52 was admitted with a negative PASSAR Level 1 screening but had a mental illness.<BR/>These failures could place all residents who had a mental illness or intellectual or developmental disability at risk for not receiving needed assessment, care, and services to meet their needs. <BR/>Findings Included:<BR/>Record review of Resident #165's Face Sheet indicated the resident was a [AGE] year-old male who admitted to the facility with an original admission date of 02/06/2015., an initial admission date of 06/10/2022, and an admission date of 10/07/2024. Resident #156's face sheet revealed a diagnosis of Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) on 05/15/2024. Resident #15 also had others diagnoses of Hemiplegia and Hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (complete weakness and completed paralysis of one side of the body), Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) and Unspecified Dementia (symptoms that affect memory, thinking and social abilities). <BR/>Record review of Resident #15's Quarterly MDS assessment dated [DATE], revealed an active diagnosis of Anxiety Disorder, Depression, and Psychotic Disorder and a BIMS of 13 which indicates moderate cognitive impairment. <BR/>Record review of Resident #15's Comprehensive Care Plan revealed a Focus Area that stated that Resident #15 was PASSAR PE negative due to primary diagnosis of dementia, despite diagnosis of MI dated 04/15/2022. Another Focus Area stated Mr. Resident #16 uses antidepressant medication related to Depression dated 01/01/2022. <BR/>Record review of Resident #15's PASSAR records indicated no mental illness, intellectual disability and/or developmental disability were present on PASSAR I dated 06/10/2022 and Resident #15 did not qualify for PASSAR II or services. <BR/>On 02/10/2025 at 11:15 AM an interview was attempted with Resident #16 in which the resident refused to be interviewed with state surveyor. <BR/>On 02/11/2025 at 2:15 PM another additional interview was attempted with Resident #16 in which the resident had refused again an interview again. <BR/>Observation on 02/10/2025 at 10:30 AM revealed Resident #52 laying in her bed in her room curled up in the fetal position asleep.<BR/>Observation on 02/11/2025 at 10:22 AM revealed Resident #52 laying in her bed in her room curled up in the fetal position asleep. <BR/>Record review of Resident #52's quarterly MDS assessment, dated January 29, 2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. She had diagnoses of bipolar disorder (significant mood swings), depression (feelings of sadness and loss of interest), cognitive communication deficit (brain injuries that affect a person's ability to communicate effectively), muscle wasting (loss of muscle mass), lack of coordination, and intestinal obstruction (bowel blockage). Her BIMS score was a 00, which indicated severe cognitive impairment. <BR/>Record review of Resident #52's care plan dated last revised 02/09/2025 reflected resident was on an antipsychotic medication due to bipolar, dementia. <BR/>Record review of Resident #52's PASRR Level 1 screening, dated 10/16/2024 conducted by an acute care hospital, reflected Resident #52 was negative for mental illness, intellectual disability, and developmental disability. The PASRR Level 1 screening also indicated that a physician certified the individual is likely to require less than 30 days of Nursing Facility services. <BR/>On 02/12/2025 at 1:01 PM an interview was completed with the Director Of Nursing (DON) who stated they had been employed with the facility since January 2025. The DON stated that they were unable to provide a description of the policy for PASSAR screenings. The DON stated the importance of PASSAR screenings was to ensure that the residents have their needs met. The DON stated that a PASSAR screening should be provided before admission into the facility. The DON stated that the facility should have provided PASSAR services to a resident with a positive mental illness diagnosis. The DON stated that people outside of the facility provide PASSAR screenings. The DON stated that the DON completes a screening of the resident's documents when residents are admitted to the facility. The DON stated that a negative impact that could result from residents not receiving PASSAR services, was the residents not receiving holistic care. The DON stated she did not know the PASSAR results of Resident #16 because she was DON is new to the facility. <BR/>On 02/12/2025 at 1:20PM an interview was conducted with the ADM of the facility who has been employed at the facility for 3 months. The ADM stated that the policy for PASSAR screenings was that it should be completed upon admission. The ADM stated that it was important to complete screenings because it was important to know if the resident was PASSAR positive or not. The ADM stated if a resident has a positive diagnosis of Mental illness, the facility needs to ensure that the resident should have the resources for it. The ADM stated that PASSAR screenings were completed by the MDS coordinator with the region. The ADM stated he ensures that PASSAR screenings were completed by the previous facility and if it was not provided at admission, the ADM would reach out to obtain it. The ADM stated a negative impact for the resident if PASSAR services were not provided was that the resident may not have a proper diagnosis and resources. The ADM stated a new PASSAR screening should occur after a change of condition. The ADM stated that Resident #16 had a negative PASSAR screening. The ADM denied being aware of a mental illness diagnosis. <BR/>On 02/12/2025 at 02:45PM an interview was conducted with the Corporate MDS Coordinator (CMDS) who stated they had been employed with the facility since 2019. The CMDS stated that they completed audits once a month to ensure PASSAR screenings were up to date. The CMDS stated a 1012 audit had not been completed in February yet. The CMDS stated that a form 1012 should be completed and communicated with the doctor to get a new PL1, if a resident had a change of condition. The CMDS stated that if a resident had a diagnosis of Major Depressive Disorder the results should be positive. The CMDS stated that the resident should be provided with a level II PASSAR screening and notify local authorities of the results. The CMDS stated a negative outcome that could occur if a resident had a mental diagnosis but did not receive services, was the needs not being met for the resident. She stated that if a resident has a diagnosis of bipolar their PASRR should not say negative on the Level 1 screening. She stated that the facility should have reviewed the PASRR Level 1 and compared it to Resident #52's diagnoses. She stated that a negative outcome for a negative PASRR Level 1 that should have been positive and required a Level 2 screening by the LIDDA could be that the residents' needs went unmet for not receiving needed services. She stated that to ensure PASRR screenings are up to date audits were done once monthly. She stated that there has been a lot of staff turnover and that the MDS coordinator was responsible for checking these. <BR/>Record Review of Resident Assessment PASSAR dated 11/2023 indicated the purpose of this policy is to ensure PASSAR's are being obtained and completed timely and accurately. This policy listed the following procedures:<BR/>1. <BR/>PASSARs are obtained from referring entity by the admissions department. <BR/>2. <BR/>PL 1s are put in to Simple LTC by the facility CRC within 72 hours of resident admitting to facility. The completed PL 1 must also be uploaded into the resident's EMR.<BR/>3. <BR/>Communicate with LIDDA/LMHA to ensure all active positive PL 1s have a completed PE and upload the PE into the resident's EMR.<BR/>4. <BR/>Review recommended Specialized Services on the PE once the PE is submitted. <BR/>5. <BR/>When discharging a resident to another NF, the facility is responsible for completing a PASSARR for the NF. <BR/>6. <BR/>Follow Texas PASSAR policy for all mandatory meetings and care coordination including any changes that may require a change in resident's PASSAR status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure the resident care plan accurately reflected the resident's status for 1 of 4 residents (Resident #12) who were reviewed for care plans.<BR/>The facility failed to care plan Resident #12's use of hearing aids. <BR/>This failure could place residents at risk of their needs going unmet. <BR/>Findings included:<BR/>Record review of Resident #12's quarterly MDS, dated [DATE], indicated Resident #12 was a [AGE] year-old male, who was admitted to the facility on [DATE]. He had diagnoses of dementia, major depressive disorder, depression, hereditary and idiopathic neuropathy (nervous system disorders that interfere with normal nerve function). His MDS also reflected in Section B Hearing, Speech, and Vision that Resident #12's ability to hear, had minimal difficulty, as well as that he did not have hearing aids or other hearing appliances. His BIMS score was 12, which indicated moderately impaired cognition.<BR/>Record review of Resident #12's care plan dated last revised on 01/31/2025 reflected resident had special instructions Very hard of hearing. He had a focus of the resident has a communication problem related to hearing loss The interventions listed included for staff to anticipate and meet needs, encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense or responds to the feeling resident is trying to express and refer to speech therapy for evaluation and treatment as ordered. His care plan did not have any indication of hearing aid use or refusal of usage. <BR/>Record review of Resident #12's doctor's order dated 9/24/2024 reflected, May have podiatry, dental, audiologist, & ophthalmologist consults PRN.<BR/>Observation on 02/10/2025 at 10:24 a.m., revealed Resident #12 sitting in his recliner in his room watching television. The resident voiced that his hearing aids needed to be repaired and that his family member was going to come get them to be fixed/replaced. The hearing aids were sitting on his bedside table. The state surveyor had to stand close, yell, speak slowly, and often repeat questions to the resident during the observation. The resident was unable to give an answer when the state surveyor asked him if the facility helped him with audiology appointments, even after writing the questions down for him due to the hearing impairment. <BR/>Interview on 02/12/2025 at 11:40 a.m., with the DON revealed she had started working at the facility 3 weeks ago. She stated that her expectation would be that hearing aids were care planned. She stated that Resident #12 had hearing aids in his room but refused to wear them and did not like them. She said that the resident's family member had planned to take the hearing aids home with him due to the resident not wearing them. She said he reads lips very well and can sign for things he needed. She said that it should have been care planned that he did not wear them.<BR/>Interview on 02/12/2025 at 12:48 p.m., with CNA A revealed she had worked at the facility for 2 years. She stated that Resident #12 would wear his hearing aids sometimes, but he had a hard time getting them to stay in his ears. She stated that she had to make sure she talked loudly and stood close to him when talking, but that most times she still had to repeat herself multiple times. She did not think he was good at reading lips due to the number of times she would have to repeat herself during conversations. <BR/>Record review of the facility's Comprehensive Care Plan policy dated last revised on 4/25/2021 revealed, Every resident will have an individualized interdisciplinary plan of care in place. The Interdisciplinary Team will continue to develop the plan in conjunction with the MDS 3.0, completing and conducting Comprehensive Care Plan Meeting and Reviews by day 21 after admission. The Interdisciplinary Team will review the healthcare practitioner's notes and orders and implement a comprehensive care plan to meet the residents' immediate care needs including but not limited to: therapy services, social services, psychosocial mood state needs as indicated, specific care plan on the main reason for admission to the community. Any updated information based on the details of the comprehensive care plan, as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide residents with an ongoing resident centered activity program, designed to meet the interests of and support the physical, mental, and psychosocial well-being of 3 (Residents #25, #31, and #42) of 8 residents reviewed for activities.<BR/>The facility failed to provide activities as scheduled from January 23, 2025, through February 12, 2025.<BR/>This failure placed residents at risk of boredom, depression, isolation, and a diminished quality of life.<BR/>Findings include:<BR/>Record review of Resident #25's face undated sheet reflected a [AGE] year-old male initially admitted to the facility on [DATE], and readmitted on [DATE], with the following diagnoses: Type 2 Diabetes Mellitus (a chronic disease that causes a person's blood glucose levels to rise too high) Chronic Pulmonary Edema (a condition where fluid accumulates in lung tissues, making it difficult to breathe), Acute Respiratory Failure with Hypoxia (acute impairment in gas exchange between the lungs and the blood), Major Depressive Disorder (a mood disorder characterized by persistent feelings of sadness), and Anxiety Disorder (mental disorder characterized by significant and uncontrollable feeling of anxiety and fear that affect daily life).<BR/>Record review of Resident #25's Annual Comprehensive MDS assessment dated [DATE], revealed Resident #25's activity preferences of strong importance to him were: listening to music, being around animals such as pets, keeping up with the news, doing things with groups of people, going outside when the weather is good, and participating in religious services and practices.<BR/>Record review of Resident #25's Quarterly MDS assessment dated [DATE], revealed Resident #25 had a BIMS score of 12, indicating intact cognition.<BR/>Record review of Resident #25's Comprehensive Care Plan focus dated 1/17/2025 regarding activities revealed Resident #25 attended most events, but also liked to do individual activities in his room. Resident #25's goal was to continue to participate in at least 4 activities per week. Interventions included posting calendars in the resident's room, reminding and encouraging the resident, thanking the resident for participating, allowing the resident to refuse to participate [in activities], and promoting the resident's love of music and storytelling with staff and other residents.<BR/>Record review of Resident #31's undated face sheet, reflected a [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: Major Depressive Disorder (a mood disorder characterized by persistent feelings of sadness), Muscle Weakness, Pulmonary Fibrosis (a condition in which the lungs become scarred over time causing breathing difficulties), need for assistance with personal care, and difficulty walking. <BR/>Record review of Resident #31's Comprehensive Care Plan initiated on 4/27/2022, revealed the focus regarding activities to be self-directed activities. Resident #31's goal regarding activities was to continue to do Bible studies with other residents through the next review date. Interventions included posting activity calendars in the resident's room, assisting the resident with activities when he agrees to participate, and praising and thanking the resident for attending an activity.<BR/>Record review of Resident #31's Annual Comprehensive MDS assessment dated [DATE], revealed Resident #31 had a BIMS score of 15, indicating intact cognition, a very important activity preference of participating in religious services or practices, and a somewhat important activity preference of going outside when the weather is good.<BR/>Record review of Resident #42's undated face sheet, reflected a [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: Type 2 Diabetes with Diabetic Autonomic (Poly)Neuropathy (a chronic disease that causes a person's blood glucose levels to rise too high; damage to multiple nerves in the peripheral nervous system in different parts of the body at the same time), Disorder of the teeth and supporting structures, muscle weakness, and Depression.<BR/>Record review of Resident #42's admission MDS assessment dated [DATE], revealed having books, newspapers, and magazines to read, and listening to music he likes as being very important activity preferences. <BR/>Record review of Resident #42's Comprehensive Care Plan initiated on 10/13/2022 and revised on 12/27/2023, revealed the resident's activity-related focus to be attending activities of his choice and that the resident will speak his mind and let you know when something is wrong. Resident's #42's activity related goal was to continue to participate in at least 3 activities per week. Interventions included posting an activity calendar in the resident's room, reminding and encouraging the resident daily, promoting the resident's activity ideas and ability to express himself, and the resident's joy and talent in playing the piano, singing, and doing artwork such as drawing.<BR/>Record review Resident #42's Quarterly Activity Participation Review dated 11/27/2024 revealed the resident attends most large events. The resident's favorite activity and interest were smoking and cooking. The resident's activity-related focuses, goals, and interventions remained the same.<BR/>Record review of Resident #42's Quarterly MDS assessment dated [DATE], revealed Resident #42 had a BIMS score of 15, indicating intact cognition.<BR/>Observation and interview 2/11/2025 at 10:11AM, revealed Resident #42 sitting in a chair at the foot of his bed watching a game show on television. Resident #42 expressed boredom and disinterest in watching television, but stated this was something to do to pass the time as there was nothing else to do. Resident #42 stated the activities offered at the facility are not good or of interest to him. The resident stated that lately no activities have been offered. The resident stated that the facility's activity director was fired, and no one had assumed activity duties The resident stated that prior to the activity director's termination, the activity calendar was not being followed. The resident stated that occasionally they played BINGO, but it had been a while. Resident #42 stated the activities program has always been inconsistent and unorganized. The resident stated that suggestions for activities and activity spaces go ignored. Resident #42 stated that he would like more community involvement. He stated that pet therapy and church services stopped because the providers were not allocated a specific time or space to provide the services. Resident #42 stated that the residents need more than occaisonal parties. He stated the residents need activities that enhance their well-being and morale, and that promote positive feelings toward facility staff. Resident #42 stated life at the facility is the same every day, with most residents spending their time watching television with no socializing.<BR/>Observation of the facility on 2/10/2024, through 2/12/2024, from approximately 9AM-4PM daily, revealed no formal activities being provided to the residents.<BR/>Observation of the facility activity room on 2/11/2025 at 3PM, revealed no coordinated activities being offered. The television in the activity room was on with 2 residents quietly watching without conversation or interaction with each other. No staff were present in the activity room. It did not appear as if any activity had been provided immediately prior to observation or that any activity was being set up or coordinated in the activity room to be provided following observation. The activity room was orderly and appeared undisturbed. The activity room contained a bookshelf with approximately 20 books, one jigsaw puzzle, and a few videos and audio books. The extra-large, printed activity calendar posted in or near the activity room was observed to be for January 2025, not February 2025. <BR/>In an interview on 2/11/2025 at 10:59AM, Resident #25 reported the facility was not offering activities as the facility had no AD on staff. The resident stated that the scheduled Valentine's Day party had been cancelled. The resident stated that the last time the residents were provided with an activity was 2 weeks prior, when they were given popsicles.<BR/>In an interview on 2/11/2025 at approximately 1:15PM, Resident #31 stated the facility was not offering activities. The resident stated that it had been about 2 weeks since any activity was provided.<BR/>In an interview on 2/12/2025 at 11:16AM, the ADM stated the activity director position is currently vacant as the FAD abruptly vacated the position without notice. The ADM stated that the FAD's last physical day of work was on 1/22/2025. The ADM stated that he and a former hospitality aide had been providing impromptu activities for the residents following the departure of the FAD until the former hospitality aide also vacated her position. The ADM stated that the former hospitality aide's last day of employment with the facility was on 2/7/2025. <BR/>In an interview on 2/12/2025 at 12:45PM, LVN A stated that she is a Charge Nurse and has been employed with the facility for 4 years. LVN A said the last formal activity provided for the residents was on 2/7/2025. The activity was conducted by a former hospitality aide who no longer works at the facility. LVN A stated the therapy staff have been providing activities for the residents recently. LVN A stated the offering of activities to residents is very important because it gives the residents motivation. LVN A stated that any complaints or suggestions made by residents to her regarding activities would be typically shared during their morning meetings. LVN A said the FAD discontinued her employment with the facility 2 weeks ago. LVN A said she is unsure of who is responsible for making sure the activity calendar has been followed since the FAD left. LVN A said she doesn't know if activities have been provided as listed on the activity calendar.<BR/>In an interview on 2/12/2025 at 12:50PM, the COTA said she has been employed with the facility for 2 years. The COTA stated that the therapy department staff have been assisting with activities. The COTA stated that the therapy staff help set up games and puzzles for the residents in the activity room, and the therapy room is always open to residents. The COTA stated therapy staff do not provide scheduled activities for the residents. The COTA stated the last formal activity provided to the residents was on 2/7/2025. The COTA stated the quality of activities offered to the residents could be better, but she believes this will improve once a new activity director is hired and an activity calendar is established. The COTA stated there were no scheduled activities being offered on this day to her knowledge.<BR/>In an interview on 2/12/2025 at 12:50PM, the PTA stated she has been employed with the facility for 2 years. The PTA said the therapy department staff have been helping with activities when they can. Their assistance consists of setting up activities and supporting the residents. <BR/>In an interview on 2/12/2025 at 12:50PM, the RD stated he has been employed with the facility for 2 months. The RD stated the therapy staff have been providing impromptu activities for residents when they can. The RD said these activities are not scheduled and the therapy staff are not responsible for following the activity calendar. The RD said therapy staff assist with setting up activities in the activity room. The RD stated activities are an important because they promote positivity, give residents something to do, improve residents' quality of life, and provide opportunities to socialize.<BR/>In an interview on 2/12/2025 at 12:55PM, the ADM stated the residents complained about the lack of activities during the Resident Council meeting on 2/5/2025. The ADM stated the lack of activities was due the vacant activity director position. The ADM stated that he is in the process of hiring a new activity director. The ADM stated that he plans to continue to use other staff members to assist with activities until a new activity director is hired. The ADM stated that activities would be provided as scheduled and as listed on the activity calendar, except for the evening activities, as there are no staff available in the evening to conduct activities. The ADM stated that he recently hired HA. HA's first day of employment was on 2/10/2025. The ADM stated that HA will also help with resident activities. The ADM acknowledged that some scheduled activities have been missed, but stated that the facility is in their rebuilding stage and he expects things to improve.<BR/>In an interview on 2/12/2025 at 1:01PM, HA stated that she began working at the facility this week. Her scheduled hours are 8AM-5PM. HA stated that her duties include passing out ice to the residents twice a day, assist residents with smoke breaks, assist with making residents' beds as needed, and assisting with passing and picking up meal trays as needed. HA stated that she was not aware that her duties would include assisting with activities. HA stated that she has not assisted with activities this week. HA stated that she has not been formally trained or certified as activity personnel. HA stated the benefits of activities is that they keep residents active, they can provide a form of exercise, and it allows residents to interact with each other. HA said the lack of activities for residents could cause a loss of interest in life and isolation.<BR/>In an interview on 2/12/2025 at 1:04PM, the IDON stated that he has been employed with the facility for 2 months. He said that he doesn't pay attention to the activities offered to residents. He stated that the FAD was believed to be successfully carrying out the activity program for residents, but that was not be the case. The IDON stated that the residents were dissatisfied with the inconsistency of activities and the types of activities offered by the FAD. The IDON stated that the ADM is in the process of hiring a new activity director. The IDON stated that he has not assisted or provided activities for the residents. The IDON stated the benefits of activities include social enrichment, engagement, and improved quality of life. He said the lack of activities for residents could cause depression and isolation.<BR/>Record review of the facility's activity calendars for January 23, 2025, through February 12, 2025, revealed the following scheduled activities:<BR/>January 23, 2025:<BR/>8:30am Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>11am-Karaoke <BR/>1pm-In room visits<BR/>2pm-Resident Council Meeting<BR/>3:30pm-UNO Game<BR/>6:30pm-Table Puzzles<BR/>7:30pm-Activity Cart<BR/>January 24, 2025<BR/>8:30am-Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>10:30am-S&C<BR/>1pm-In room visits<BR/>2pm-Birthday Party<BR/>3:30pm-Jewelry Art <BR/>6:30pm-Table Puzzles<BR/>7:30pm-Activity Cart<BR/>January 25, 2025<BR/>8:30am-Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>11am-Table Puzzles<BR/>1pm-In room visits<BR/>2pm-LPT<BR/>3:30pm-Make a Word Game<BR/>6:30pm-Table Puzzles<BR/>7:30pm-Activity Cart<BR/>January 26, 2025<BR/>8:30am-Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>11am-TBS TV in the Sunroom<BR/>1pm-In room visits<BR/>2pm-Church Service<BR/>3:30pm-Church <BR/>6:30pm-Table Puzzles<BR/>7:30pm-Activity Cart<BR/>January 27, 2025<BR/>8:30am-Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>11am-Tea Party<BR/>1pm-In room visits<BR/>2pm-Spelling Bee<BR/>3:30pm Let's Make a Deal<BR/>6:30pm-Table Puzzles<BR/>7:30pm-Activity Cart<BR/>January 28, 2025<BR/>8:30am-Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>11am-Rebus Puzzle<BR/>1pm-In room visits<BR/>2pm-Crafts & Art<BR/>3:30pm-[NAME] Game<BR/>6:30pm-Table Puzzles<BR/>7:30pm-Activity Cart<BR/>January 29, 2025<BR/>8:30am-Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>11am-Reading Rainbow<BR/>1pm-In room visits<BR/>2pm-Brush painting<BR/>3:30pm-Clue words<BR/>6:30pm-Table Puzzles<BR/>January 30, 2025<BR/>8:30am-Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>11am-Memory Lane<BR/>1pm-In room visits<BR/>2pm-Family Feud<BR/>3:30pm-Indoor Bowling<BR/>6:30pm-Table Puzzles<BR/>7:30pm-Activity Cart<BR/>January 31, 2025<BR/>8:30am-Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>10:30am-S&C<BR/>1pm-In room visits<BR/>2pm-Name that Tune<BR/>3:30pm-Happy Hour<BR/>6:30pm-Table Puzzles<BR/>7:30pm-Activity Cart<BR/>February 1, 2025-February 6, 2025, the activities scheduled were the same as follows:<BR/>8:30am-Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>11am-FF N.D. Church<BR/>1pm-In room visits<BR/>2pm-Dominos Games<BR/>3:30pm-Board Games<BR/>6:30pm-Table Puzzles<BR/>7:30pm-Activity Cart<BR/>February 7, 2025<BR/>8:30am-Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>11am-<BR/>1pm-In room visits<BR/>2pm-<BR/>3:30pm-<BR/>6:30pm-Table Puzzles<BR/>7:30pm-Activity Cart<BR/>February 8, 2025<BR/>8:30am-Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>11am-<BR/>1pm-In room visits<BR/>2pm-<BR/>3:30pm-Spades Games<BR/>6:30pm-Table Puzzles<BR/>7:30pm-Activity Cart<BR/>February 9, 2025-February 12, 2025<BR/>8:30am-Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>11am-FF N.D. Church<BR/>1pm-In room visits<BR/>2pm-Dominos Games<BR/>3:30pm-Board Games<BR/>6:30pm-Table Puzzles<BR/>7:30pm-Activity Cart<BR/>Record review of the Activity Director job description (revised 11/2020) states in part:<BR/>Position Summary: To develop and provide a comprehensive holistic resident wellness program that meets the individual interests and capabilities of the resident population. Activities will encompass the body (physical), mind (cognitive), spirit, and social engagement dimensions.<BR/>Record review of the Activities and Social Services policy and procedures (revised December 2006) states in part:<BR/>Residents shall have the right to choose the type of activities and social events in which they wish to participate as long as such activities do not interfere with the rights of other residents in the facility.<BR/>3. When the Care Planning Team develops the resident's activity and social care plans, the resident will be given an opportunity to choose when, where, and how he or she will participate in activities and social events. As much as possible, the facility will provide activities, social events, and schedules that are compatible with the resident's interests, physical and mental assessment, and overall plan of care.<BR/>7. Activities will be scheduled periodically during the day, as well as during evenings, weekends, and holidays.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 2 of 7 residents (Residents #1 & #2) reviewed for resident rights in that: <BR/>The facility failed to ensure Residents #1 and #2 call lights was within reach on 10/29/24. <BR/>This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met. <BR/>Findings included: <BR/>Record review of Resident #1's admission record dated 10/29/24 documented a [AGE] year-old male admitted on [DATE]. Resident #1 had diagnoses which included: sepsis (serious condition in which the body responds improperly to an infection), major depressive disorder (persistent low mood and loss of interest in activities that people enjoy), muscle weakness (lack of muscle strength), and gastro esophageal reflux disease without esophagitis (a digestive disorder that occurs when stomach acid flows back into the esophagus without causing inflammation of the esophagus). <BR/>Record review of Resident #1's Quarterly MDS assessment, dated 09/22/24, revealed the resident had a BIMS score of 00 indicating the resident had severe cognitive impairment. The MDS also revealed Resident #1 was dependent in various areas of activities of daily living such as eating, oral hygiene, toileting hygiene, shower/bathe self, upper and lower dressing, and personal hygiene.<BR/>Record review of Resident #1's care plan, dated 10/29/24, revealed Resident #1 was care planned for falls and had an intervention of: ensure call light is in reach and answer promptly. <BR/>No interview could be conducted with Resident #1 due to the resident not being interview able. <BR/>Observation on 10/29/24 at 9:24 a.m., revealed Resident #1's call light was tied to his nightstand and out of his reach. <BR/>Observation on 10/29/24 at 11:24 a.m., revealed Resident #1's call light was tied to his nightstand and out of his reach. <BR/>Observation on 10/29/24 at 12:20 p.m., revealed Resident #1's call light was tied to his nightstand and out of his reach. <BR/>Observation on 10/29/24 at 1:49 p.m., revealed Resident #1's call light was tied to his nightstand and out of his reach. <BR/>Record review of Resident #2's admission record dated 10/24/24 documented an [AGE] year-old male admitted on [DATE]. Resident #1 had diagnoses which included: cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) essential primary hypertension (abnormally high blood pressure that not caused by a medical condition), and gastro esophageal reflux disease without esophagitis (a digestive disorder that occurs when stomach acid flows back into the esophagus without causing inflammation of the esophagus). <BR/>Record review of Resident #2's Quarterly MDS assessment, dated 08/20/24, revealed the resident had a BIMS score of 15 indicating the resident was cognitively intact. The MDS also revealed Resident #2 was dependent in various areas of activities of daily living such as eating, oral hygiene, toileting hygiene, shower/bathe self, upper and lower dressing, putting on/taking of footwear, and personal hygiene.<BR/>Record review of Resident #2's care plan, dated 10/29/24, revealed Resident #2 was care planned for falls and had an intervention of: ensure call light is in reach and answer promptly. <BR/>During an interview with Resident #2 on 10/29/24 at 1:49 p.m., Resident #2 stated that his call light clip has been broken for a while so staff put his call light on his nightstand. Resident #2 stated if he needed assistance, he would wait on staff to make rounds or yell for help. <BR/>Observation on 10/29/24 at 12:20 p.m., revealed Resident #1's call light was laid on top of his nightstand and out of his reach. <BR/>Observation on 10/29/24 at 1:49 p.m., revealed Resident #1's call light was laid on top of his nightstand and out of his reach.<BR/>During an interview on 10/29/24 at 1:00 p.m., CNA A stated that CNAs should make rounds at least every two hours. CNA A stated that CNAs should be looking to see if a resident needs assistance, ensuring call lights were within reach, and making sure all residents were comfortable. CNA A stated if a resident call light was not within reach, then they resident could fall attempting to reach it or the resident would not receive assistance.<BR/>During an interview on 10/29/24 at 4:10 p.m., the DON stated that anyone that entered the resident's room was responsible for ensuring the call light was within reach. The DON stated that CNAs frequently make rounds so they would be most likely to notice if a call light was not within reach. The DON stated if a call light was out of reach, then they resident would not be able to call for assistance if they needed. <BR/>During an interview on 10/29/24 at 4:00 p.m., the ADM stated a call light is a communication medium between residents and staff. The ADM stated if a call light was not within reach, then a resident would not be able to call for help if needed. The ADM stated it's everyone responsibility to ensure the call lights are within reach. The ADM stated his expectations are for all call lights to be within reach. <BR/>Review of the facility's Answering the Call Light policy, revised September 2022, reflected, Purpose: The purpose of this procedure is to ensure timely responses to the resident's requests and needs.<BR/>General Guidelines<BR/>1. <BR/>Upon admission and periodically as needed, explain and demonstrate use of the call light to the resident.<BR/>2. <BR/>Ask the resident to return the demonstration.<BR/>3. <BR/>Explain to the resident that a call system is also located in his/her bathroom.<BR/>4. <BR/>Be sure that the call light is pulled in and functioning at all times.<BR/>5. <BR/>Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and form the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure the resident care plan accurately reflected the resident's status for 1 of 4 residents (Resident #12) who were reviewed for care plans.<BR/>The facility failed to care plan Resident #12's use of hearing aids. <BR/>This failure could place residents at risk of their needs going unmet. <BR/>Findings included:<BR/>Record review of Resident #12's quarterly MDS, dated [DATE], indicated Resident #12 was a [AGE] year-old male, who was admitted to the facility on [DATE]. He had diagnoses of dementia, major depressive disorder, depression, hereditary and idiopathic neuropathy (nervous system disorders that interfere with normal nerve function). His MDS also reflected in Section B Hearing, Speech, and Vision that Resident #12's ability to hear, had minimal difficulty, as well as that he did not have hearing aids or other hearing appliances. His BIMS score was 12, which indicated moderately impaired cognition.<BR/>Record review of Resident #12's care plan dated last revised on 01/31/2025 reflected resident had special instructions Very hard of hearing. He had a focus of the resident has a communication problem related to hearing loss The interventions listed included for staff to anticipate and meet needs, encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense or responds to the feeling resident is trying to express and refer to speech therapy for evaluation and treatment as ordered. His care plan did not have any indication of hearing aid use or refusal of usage. <BR/>Record review of Resident #12's doctor's order dated 9/24/2024 reflected, May have podiatry, dental, audiologist, & ophthalmologist consults PRN.<BR/>Observation on 02/10/2025 at 10:24 a.m., revealed Resident #12 sitting in his recliner in his room watching television. The resident voiced that his hearing aids needed to be repaired and that his family member was going to come get them to be fixed/replaced. The hearing aids were sitting on his bedside table. The state surveyor had to stand close, yell, speak slowly, and often repeat questions to the resident during the observation. The resident was unable to give an answer when the state surveyor asked him if the facility helped him with audiology appointments, even after writing the questions down for him due to the hearing impairment. <BR/>Interview on 02/12/2025 at 11:40 a.m., with the DON revealed she had started working at the facility 3 weeks ago. She stated that her expectation would be that hearing aids were care planned. She stated that Resident #12 had hearing aids in his room but refused to wear them and did not like them. She said that the resident's family member had planned to take the hearing aids home with him due to the resident not wearing them. She said he reads lips very well and can sign for things he needed. She said that it should have been care planned that he did not wear them.<BR/>Interview on 02/12/2025 at 12:48 p.m., with CNA A revealed she had worked at the facility for 2 years. She stated that Resident #12 would wear his hearing aids sometimes, but he had a hard time getting them to stay in his ears. She stated that she had to make sure she talked loudly and stood close to him when talking, but that most times she still had to repeat herself multiple times. She did not think he was good at reading lips due to the number of times she would have to repeat herself during conversations. <BR/>Record review of the facility's Comprehensive Care Plan policy dated last revised on 4/25/2021 revealed, Every resident will have an individualized interdisciplinary plan of care in place. The Interdisciplinary Team will continue to develop the plan in conjunction with the MDS 3.0, completing and conducting Comprehensive Care Plan Meeting and Reviews by day 21 after admission. The Interdisciplinary Team will review the healthcare practitioner's notes and orders and implement a comprehensive care plan to meet the residents' immediate care needs including but not limited to: therapy services, social services, psychosocial mood state needs as indicated, specific care plan on the main reason for admission to the community. Any updated information based on the details of the comprehensive care plan, as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he prefers for one (Resident #1) of four residents reviewed for consents.<BR/>The facility failed to obtain a written consent from Resident #1 before administering the following psychoactive medications: Risperdal (anti-psychotic), Paroxetine (anti-depressant) , Depakote (mood stabilizer , Nudexta (anti-depressant), Quetiapine (antipsychotic), Lorazepam (anti-anxiety).<BR/>This failure placed residents who received psychoactive medications at risk for not understanding the risks and dangerous side effects of psychoactive medications without their opportunity for informed consent and opportunity to refuse the drug. <BR/>Findings included:<BR/>Review of Resident #1's face sheet dated 9/23/2024 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (mood disorder) and Traumatic Brain Injury (injury to the brain). Resident #1 was his own responsible party.<BR/>Review of Resident #1's quarterly MDS assessment, dated 08/12/2024, reflected a BIMS of 14, suggesting no cognitive impairment. Section D (Mood) reflected he had been feeling down, depressed, or hopeless for several days. Section E (Behavior) reflected he had not had any hallucinations, delusions, or physical or verbal altercations directed towards others. <BR/>Review of Resident #1's current care plan, dated 09/23/2024, reflected he had a behavior problem related to schizoaffective disorder yelling, hitting himself, impulsiveness, racial slurs, name calling.<BR/>Review of Resident #1's physician orders dated 12/14/2023 reflected an order for Depakote 500 mg tablet - give one tablet by mouth two times a day for mood at 9:00 am and 5:00 pm.<BR/>Review of Resident #1's physician orders dated 03/07/2024 reflected an order for Depakote 500 mg tablet - give one tablet by mouth two times a day for mood at 9:00 am and 9:00 pm.<BR/>Review of Resident #1's MARs for December 2023, January 2024, February 2024, and March 2024 revealed resident was administered Depakote from 12/14/2023 until 3/7/2024; Then again from 3/7/2024 until 6/26/2024.<BR/>Review of Resident #1's EMR dated 9/23/2024 reflected a signed consent for Depakote dated 3/14/2024 but no signed consent prior to 3/14/2024.<BR/>Review of Resident #1's physician orders dated 12/14/2023 reflected an order for Risperidone, 1 mg tablet - give one tablet two times a day for mood.<BR/>Review of Resident #1's MARs for December 2023, January 2024, February 2024, and March 2024 revealed resident was administered Risperidone from 12/14/2023 until 3/7/2024.<BR/>Review of Resident #1's EMR dated 9/23/2024 reflected no signed consent form for Risperidone.<BR/>Review of Resident #1's physician orders dated 12/15/2023 reflected an order for Paroxetine HCL, 40 mg tablet - give one tablet in the morning for depression.<BR/>Review of Resident #1's MARs for December 2023 to September 2024 revealed resident was administered Paroxetine from 12/15/2023 until MAR review date of 9/24/2024.<BR/>Review of Resident #1's EMR dated 9/23/2024 reflected a signed consent form for Paroxetine HCL dated 1/26/2024, but no signed consent when medication was started on 12/15/2024.<BR/>Review of Resident #1's physician orders dated 9/9/2024 reflected an active order for Quetiapine 100 mg - give one tablet by mouth three times a day for schizophrenia.<BR/>Review of Resident #1's MARs for August 2024 to current revealed resident was administered Quetiapine until MAR review date of 9/24/2024.<BR/>Review of Resident #1's EMR dated 9/23/2024 reflected no signed consent form for Quetiapine.<BR/>Review of Resident #1's physician orders dated 8/19/2024 reflected a PRN order for Lorazepam - give one tablet every 6 hours as needed for anxiety.<BR/>Review of Resident #1's August and September 2024 MARs reflected he was administered Lorazepam on 8/27/2024 - 8/31/2024 and 9/19/2024.<BR/>Review of Resident #1's EMR dated 9/23/2024 reflected no signed consent form for Lorazepam.<BR/>Review of Resident #1's physician orders dated 4/20/2024 reflected an order for Nudexta 20-10 mg - give one capsule in the morning for Pseudobulbar affect.<BR/>Review of Resident #1's physician orders dated 4/28/2024 reflected an order for Nudexta 20-10 mg - give one capsule in the morning for Pseudobulbar affect.<BR/>Review of Resident #1's April [DATE] reflected he was administered Nudexta on 4/21/2024 - 4/26/2024 and 4/29/2024 and 4/30/2024.<BR/>Review of Resident #1's EMR dated 9/23/2024 reflected no signed consent form for Nudexta.<BR/>Review of progress notes for Resident #1 from 12/14/2023 to 9/24/2024 revealed no progress notes related to medication consent forms or education related to psychoactive medications.<BR/>During an interview with Resident # 1's FM on 11/6/2024 at 11:24 am the FM revealed Resident #1 had been discharged and transferred to another facility. The FM stated the facility asked FM to sign a consent form for Depakote back in March of 2024, but to their knowledge no other consent forms had been signed by either FM or Resident #1 for any of the other psychoactive medications. The FM stated Resident #1 was his own RP, but due to his TBI he sometimes forgot things. The FM stated they were very upset that the facility did not explain the medications to Resident #1 prior to administering them so Resident #1 could understand the affect and use of each mediation. The FM stated the nursing facility asked her to sign a consent for Depakote on 3/14/2024 but she had not signed any other medication consent forms. She stated, they gave {Resident #1} medications that he had no idea what they were for or understand the affects of use.<BR/>During an interview with ADON on 11/6/2024 at 4:30 pm, she stated she was unable to find any medication consent forms for Resident #1 except for the Depakote consent form signed 3/14/2024 by FM. She stated there were no other signed medication consent forms signed by either the resident or FM.<BR/>During an interview with the Medical Director on 11/7/2024 at 2:44 pm, he stated he was not aware that consent forms needed to be signed for psychoactive medications in the Nursing Facility setting. He stated he was coming from the acute clinical setting and worked in a pain clinic where consents are done in the clinic. He stated he will have to revisit education with psychiatric team - he was not aware they were missing or were done well after the fact of the medication being prescribed and given. He stated consent forms are important, so residents or RPs are aware of the medication uses and side effects. He stated residents have a right to make informed decisions.<BR/>During an interview with ADON on 11/7/2024 at 3:00 pm she stated her expectation was that nurses would talk to the resident or the RP when starting a new psychoactive medication and educate them on the medication. She stated her concerns were if the resident or FM were not notified that education would not have been done and they could not be aware of side effects or the reason for the medication.<BR/>During an interview with RVP on 11/7/2024 at 3:30 pm he stated his expectations were that consent forms were signed before starting medications. If they are not, residents were not fully informed of the care, and it was a resident right to be informed. He stated it was part of their process and it should have been done. He stated they were not able to find a facility policy specifically on the use pf psychoactive medications, but consent would fall under resident rights.<BR/>Record Review of psychoactive medication consent for Depakote for Resident #1 reflected it was signed 3/14/2024 by Resident #'s FM.<BR/>Review of facility Policy Resident Rights dated December 2016 reflected 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: <BR/>e. self-determination.<BR/>j. be informed about his or her rights and responsibilities;<BR/>o. be notified of his or her medical condition and of any changes to his or her condition;<BR/>p. be informed of, and participate in, his or her care planning and treatment;<BR/>s. choose an attending physician and participate in decision-making regarding his or her care.<BR/>A facility policy on psychoactive medication and consents was requested but not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 2 of 7 residents (Residents #1 & #2) reviewed for resident rights in that: <BR/>The facility failed to ensure Residents #1 and #2 call lights was within reach on 10/29/24. <BR/>This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met. <BR/>Findings included: <BR/>Record review of Resident #1's admission record dated 10/29/24 documented a [AGE] year-old male admitted on [DATE]. Resident #1 had diagnoses which included: sepsis (serious condition in which the body responds improperly to an infection), major depressive disorder (persistent low mood and loss of interest in activities that people enjoy), muscle weakness (lack of muscle strength), and gastro esophageal reflux disease without esophagitis (a digestive disorder that occurs when stomach acid flows back into the esophagus without causing inflammation of the esophagus). <BR/>Record review of Resident #1's Quarterly MDS assessment, dated 09/22/24, revealed the resident had a BIMS score of 00 indicating the resident had severe cognitive impairment. The MDS also revealed Resident #1 was dependent in various areas of activities of daily living such as eating, oral hygiene, toileting hygiene, shower/bathe self, upper and lower dressing, and personal hygiene.<BR/>Record review of Resident #1's care plan, dated 10/29/24, revealed Resident #1 was care planned for falls and had an intervention of: ensure call light is in reach and answer promptly. <BR/>No interview could be conducted with Resident #1 due to the resident not being interview able. <BR/>Observation on 10/29/24 at 9:24 a.m., revealed Resident #1's call light was tied to his nightstand and out of his reach. <BR/>Observation on 10/29/24 at 11:24 a.m., revealed Resident #1's call light was tied to his nightstand and out of his reach. <BR/>Observation on 10/29/24 at 12:20 p.m., revealed Resident #1's call light was tied to his nightstand and out of his reach. <BR/>Observation on 10/29/24 at 1:49 p.m., revealed Resident #1's call light was tied to his nightstand and out of his reach. <BR/>Record review of Resident #2's admission record dated 10/24/24 documented an [AGE] year-old male admitted on [DATE]. Resident #1 had diagnoses which included: cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) essential primary hypertension (abnormally high blood pressure that not caused by a medical condition), and gastro esophageal reflux disease without esophagitis (a digestive disorder that occurs when stomach acid flows back into the esophagus without causing inflammation of the esophagus). <BR/>Record review of Resident #2's Quarterly MDS assessment, dated 08/20/24, revealed the resident had a BIMS score of 15 indicating the resident was cognitively intact. The MDS also revealed Resident #2 was dependent in various areas of activities of daily living such as eating, oral hygiene, toileting hygiene, shower/bathe self, upper and lower dressing, putting on/taking of footwear, and personal hygiene.<BR/>Record review of Resident #2's care plan, dated 10/29/24, revealed Resident #2 was care planned for falls and had an intervention of: ensure call light is in reach and answer promptly. <BR/>During an interview with Resident #2 on 10/29/24 at 1:49 p.m., Resident #2 stated that his call light clip has been broken for a while so staff put his call light on his nightstand. Resident #2 stated if he needed assistance, he would wait on staff to make rounds or yell for help. <BR/>Observation on 10/29/24 at 12:20 p.m., revealed Resident #1's call light was laid on top of his nightstand and out of his reach. <BR/>Observation on 10/29/24 at 1:49 p.m., revealed Resident #1's call light was laid on top of his nightstand and out of his reach.<BR/>During an interview on 10/29/24 at 1:00 p.m., CNA A stated that CNAs should make rounds at least every two hours. CNA A stated that CNAs should be looking to see if a resident needs assistance, ensuring call lights were within reach, and making sure all residents were comfortable. CNA A stated if a resident call light was not within reach, then they resident could fall attempting to reach it or the resident would not receive assistance.<BR/>During an interview on 10/29/24 at 4:10 p.m., the DON stated that anyone that entered the resident's room was responsible for ensuring the call light was within reach. The DON stated that CNAs frequently make rounds so they would be most likely to notice if a call light was not within reach. The DON stated if a call light was out of reach, then they resident would not be able to call for assistance if they needed. <BR/>During an interview on 10/29/24 at 4:00 p.m., the ADM stated a call light is a communication medium between residents and staff. The ADM stated if a call light was not within reach, then a resident would not be able to call for help if needed. The ADM stated it's everyone responsibility to ensure the call lights are within reach. The ADM stated his expectations are for all call lights to be within reach. <BR/>Review of the facility's Answering the Call Light policy, revised September 2022, reflected, Purpose: The purpose of this procedure is to ensure timely responses to the resident's requests and needs.<BR/>General Guidelines<BR/>1. <BR/>Upon admission and periodically as needed, explain and demonstrate use of the call light to the resident.<BR/>2. <BR/>Ask the resident to return the demonstration.<BR/>3. <BR/>Explain to the resident that a call system is also located in his/her bathroom.<BR/>4. <BR/>Be sure that the call light is pulled in and functioning at all times.<BR/>5. <BR/>Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and form the floor.

**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 right to a safe, clean, comfortable, and homelike environment for 1 (Resident #1) of 5 residents reviewed for environment. The facility failed to ensure Resident #1 was provided clean bed linens that were in good condition. This failure placed residents at risk of living in an uncomfortable environment leading to a diminished quality of life. Findings included: Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Diabetes Mellitus with Diabetic Nephropathy (elevated blood sugar that has caused kidney damage) and constipation. Record review of Resident #1's Baseline Care Plan, dated 06/17/2025, reflected Resident #1 was dependent for transferring from chair to bed and bed to chair, toileting hygiene, showering and bathing, and lower and upper body dressing. The care plan reflected Resident #1 was always incontinent of bowel and bladder and used a wheelchair for mobility. Record review of Resident #1's admission MDS assessment dated [DATE], reflected the resident had a BIMS score of 14, which indicated she was cognitively intact. In an interview and observation on 07/01/2025 at 12:00 PM Resident #1was lying in bed, her hair was unbrushed, and her clothing had food crumbs on it. Her sheets had a urine odor. She stated she was not ok. She stated she had not been showered in 8 days. She stated she had asked to get up but was told she must stay in the bed today. She pointed to her sheets at a basketball size brown dried stained ring on her Resident #1 sheets. She then pulled her sheet back and rolled to the side revealing 2 (two) additional large brown rings under her padding that was placed on the bed between her body and the bottom fitted sheet. She stated not being clean made her feel dirty and trashy. In an interview on 07/01/2025 at 12:10 PM CNA A stated she had been a certified nurse aide since January 2025, but this was her fourth day at this facility. She stated she received 2 days of orientation in the facility. She stated she had not worked with Resident #1 prior to today. She stated she had received a verbal report from the nurse this morning on residents needs and was told to not get Resident #1 up out of bed. She stated she did not realize Resident #1's bottom bed sheets were stained. She stated the CNAs were responsible for changing residents' sheets. She stated having dirty sheets would make the residents feel dirty. In an interview on 07/01/2025 at 12:15 PM CNA B stated she was responsible for resident transfers to and from appointments but was assisting on the floor today. She stated there were 2 staff members that did call in today, so the staff were all working together to meet the needs of the residents. She stated she was not aware Resident #1 had brown stained sheets. CNA B stated the CNAs were responsible for changing residents' sheets. She stated she was heading to assist the other CNA A to help clean Resident #1 up now. She stated not having clean sheets could impact a resident negatively. She stated it could bother the resident and make them uncomfortable and feel dirty. In an interview on 07/01/2025 at 1:45 PM LVN C stated she had worked at the facility for 2 years. She stated Resident #1 was a new admit to the facility. She stated she did tell CNA A that Resident #1 did not get up for breakfast. She stated the aide must have misunderstood her and left Resident #1 in bed. LVN C stated if Resident #1 asked to get up then the staff should get her up. LVN C stated the CNAs were responsible for changing residents' sheets. She stated sheets were to be changed on shower days and as needed if soiled. She stated no residents should be left in dirty sheets. She stated leaving a resident in dirty sheets and not showered could impact their dignity making a resident depressed. In an interview on 07/01/2025 at 2:30pm The Director of Clinical Operation stated she expected residents' bed sheets were changed on shower days and as needed. She stated the facility practice was to throw away stained or worn sheets in the trash to ensure they were not used on residents' beds. She stated leaving a resident in soiled or dirty sheets, physically it can cause skin breakdown, emotionally it can make them feel unclean. Record review of the undated facility's policy titled Quality of Life Homelike Environment reflected Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management shall Maximize, to the extent possible. the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include Clean, sanitary, and orderly environment and clean bed and bath linens that are in good condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident was free from abuse for 4 (Residents #2, #3, #4, and #5) of 5 residents reviewed for abuse.<BR/>The facility failed to ensure Resident #2, #3, #4, and #5 were protected from verbal abuse including verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group and intimidating from Resident #1; and sexually lewd behavior and questions; including urination in cups at breakfast from Resident #6.<BR/>As a result of the facility's failures Residents #2, #3, #4, and #5 suffered continual negative psychosocial outcomes including crying, fear and anxiety, feelings of hopelessness, and withdrawal from former social patterns.<BR/>An IJ was identified on 03/11/23. The IJ template was provided to the facility on [DATE] at 6:45 pm. While the IJ was removed on 03/13/23 at 4:45 pm, the facility remained out of compliance at a scope of pattern and a severity level of actual harm to resident health or safety due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.<BR/>This failure caused actual harm to 4 residents and placed all residents in the facility at risk for severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being.<BR/>Findings included:<BR/>Abuse neglect and exploitation policy <BR/>Record review of the facility abuse policy, dated 2/1/17, revised 1/1/23; right to be free from any type of abuse . Residents will not be subjected to abuse by anyone including other residents This includes physical, verbal, sexual (including indecent exposure), physical/chemical restraint<BR/>Record review of Resident #1's undated face sheet revealed a [AGE] year-old male admitted to the facility 10/23/21 with diagnoses including: epilepsy (seizures), cerebral infarction (stroke), hemiplegia (partial paralysis), insomnia, depression, repeated falls, mood disorder, and anxiety.<BR/>Record review of Resident #1's quarterly MDS , dated 12/09/22 revealed:<BR/>Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact.<BR/>Section E Behavior Symptom - presence and frequency revealed a 0 for physical behavioral symptoms directed toward others, verbal behavioral symptoms directed towards others, and other behavioral symptoms not directed toward others; this indicated that these behaviors were not present.<BR/>Record review of Resident #1's undated care plan revealed: he has a history of high-risk heterosexual behaviors, makes sexual advances towards female staff members and grabs their private parts and touches them inappropriately. Intervention included monitoring every shift and redirecting. It further revealed that Resident #1 has a potential to be physically aggressive, he assaulted his roommate 04/13/21.<BR/>Record review of Resident #1's progress notes, printed 03/13/23 revealed:<BR/>03/09/23 9:23 pm behavior note: Resident had several issues today where he hit this nurse and other staff . hit this nurse four times<BR/>10/28/22 8:18 am nurse note: Resident in hall way and called another female resident a bitch<BR/>08/01/22 12:47 pm nurse note: resident and another got in altercation and were hitting each other outside in smoking area, <BR/>07/13/22 6:30 am nurse note: resident angry called nurse a bitch and demanded she come to his room now, <BR/>07/12/22 1:09 pm nurse note: housekeeper saw Resident #1 in another resident room and asked him to leave and he started hitting her with a wash cloth and refused to stop when asked<BR/>07/10/22 10:15 am nurse note: Resident #1 pointing at vagina of staff stating I want that pussy and I'm watching your ass , <BR/>07/03/22 1:40 am behavior note: Resident #1 tried to reach down CNA top, tried to kiss her while she changed his brief, This is a frequent behavior from resident <BR/>05/26/22 11:45 am nurse note: resident in dining room blaring music, said fuck you when nurse asked him to lower volume, only lowered it after several requests, record review of facility incident list printed 03/13/23 showed no incident report on this date<BR/>05/26/22 8:20 am behavior note: wanted to smoke, tried to hit staff with wheelchair, told female resident to shut her mouth and called her a fat bitch, note states this is not the first time he behaved like this<BR/>4/13/21 Note Text: CNA reported to this nurse that this resident bumped into his roommate's wheelchair and hit resident with his fist. Both residents became physically aggressive towards each other. Resident denies physical altercation, but roommate states resident punched him after moving his wheelchair off of his leg, roommate states he hit resident back after he was hit, residents separated at this time resident moved to another room, Dr. notified, and family member notified, Will continue to monitor. <BR/>Record review of the facility's incident list, printed on 03/13/23 revealed no incident reports no incident report for any of the progress notes reviewed above.<BR/>Record review of the grievance log shows Resident #1 was in an altercation with another resident on 03/08/22.<BR/>Record review of Resident #2's undated face sheet revealed a [AGE] year-old female originally admitted [DATE] with diagnoses including: type 2 diabetes, obesity, hepatitis C, dementia, bipolar disorder, and absence of left leg below the knee.<BR/>Record review of Resident #2's most recent MDS date 01/30/23 revealed:<BR/>Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact.<BR/>Record review of Resident #3's undated face sheet revealed that he was a [AGE] year-old male admitted [DATE] with diagnoses including: type 2 diabetes, depression, dementia, and anxiety.<BR/>Record review of Resident #3's quarterly MDS dated [DATE] revealed:<BR/>Section C for Brief Interview for Mental Status score revealed a score of 14, which indicated the resident's cognition was intact.<BR/>Record review of Resident #4's undated face sheet revealed that she was a [AGE] year-old female first admitted to the facility on [DATE], and most recently admitted on [DATE] with diagnoses including: Chronic post-traumatic stress disorder, major depressive disorder, obesity, hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke), and obesity.<BR/>Record review of Resident #4's significant change MDS, dated [DATE], revealed:<BR/>Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact.<BR/>Record review of Resident #5's undated face sheet revealed that he was a [AGE] year-old male admitted [DATE] with diagnoses including: type 2 diabetes, anxiety, bipolar disorder, stroke causing partial paralysis, repeated falls, and Parkinson's.<BR/>Record review of Resident #5's quarterly MDS dated [DATE] revealed:<BR/>Section C for Brief Interview for Mental Status score revealed a score of 13, which indicated the resident's cognition was intact.<BR/>Record review of Resident #6's undated face sheet revealed that he was a [AGE] year-old male admitted [DATE] with diagnoses including traumatic brain injury, intermittent explosive disorder (unpredictable outbursts of anger), falls, dementia, anxiety, and depression.<BR/>Record review of Resident #6's admission MDS dated [DATE] revealed:<BR/> Section C for Brief Interview for Mental Status score revealed a score of 11, which indicated the resident's cognition was moderately impaired. <BR/>Section E Behavior Symptom - presence and frequency revealed a 0 for physical behavioral symptoms directed toward others, verbal behavioral symptoms directed towards others, which indicated that the behavior did not occur and 1 for other behavioral symptoms not directed toward others; this indicated that these behaviors occurred 1 to 3 days. It further indicated on E0500 Impact on the resident was marked as 0 indicating behaviors did not impact the resident. On section E0600 Impact on Others was marked 0 indicating the behaviors did not impact other residents.<BR/>Record review of Resident #6's undated care plan revealed The resident has a behavior problem related to inappropriate behaviors, cusses, talks inappropriate to staff, throws urine on floor, turns over bedside table when laying in bed; Resident will place himself on the floor to urinate and defecate on floor. Resident will inappropriately touch staff at times. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Minimize potential for the resident's disruptive behaviors inappropriate touching and<BR/>urinating in cups by offering tasks which divert attention such as puzzles.<BR/>Record review of Resident #6's progress notes, printed 3/11/23 revealed:<BR/>Nurses note dated 3/6/23 9:46 pm resident removed his brief and threw it on the floor, also urinated in cup and threw it on the floor<BR/>Nurses note dated 3/6/23 12:19 pm resident was banging on walls all morning long, continues cussing at staff<BR/>Nurses note dated 3/4/23 12:39 pm resident yelling and cursing at staff<BR/>Nurses note dated 3/3/23 1:19 pm resident yelling, banging on walls, cursing at staff<BR/>Nurses note dated 3/3/23 3:37 am resident banging on walls<BR/>Nurses note dated 3/2/23 10:49 am resident banging on walls, yelling, cursing staff, calling them bitch<BR/>Nurses note dated 2/27/23 12:16 pm resident banging on walls and yelling<BR/>Nurses note dated 2/26/23 11:05 am resident in sunroom with female resident and proceeded to pee in cup, educated, stated he did not care<BR/>Nurses note dated 2/24/23 12:52 pm resident in dining room attempting to urinate in flower vase<BR/>Nurses note dated 2/24/23 9:07 am resident banging on walls, bed pulled from wall, pouring urine on floor, roommate stated all night long pouring urine on floor, nurse went to tell him to stop banging on the walls he stated you bitch, you bitch I will punch you in your fucking face<BR/>Nurses note dated 2/22/23 1:59 pm resident peeing in hallway<BR/>Nurses note dated 2/10/23 12:11 pm yelling at housekeeper to suck his penis and calling her a bitch.<BR/>Nurses note dated 2/8/23 Note Text: Resident was in the dining room for breakfast and he was trying to pee in a plastic cup like he did yesterday. He was taken out and taken to his room.<BR/>Nurses note dated 2/7/23 Note Text: Resident was cursing the CNA this morning calling her a Bitch. Following her down the hallway. He then started yelling at another CNA and I informed him to stop. Resident went into the dining room and peed in a glass and poured it in the floor<BR/>Resident #6 was not interviewable.<BR/>In an interview and observation on 03/10/23 at 3:37 pm with Resident #4, she stated, Resident #1 is angry she was elected to the Resident Council and not him. She stated she felt harassed by him since she arrived in December. She stated he was also hostile towards her and she constantly feared encountering Resident #1. He also called her a fat cow, she told administrator two or three weeks ago, who told him not to do it anymore, but she said he harasses her and she tries to avoid him at all times. He plays his music so loud that it disrupts her sleep and rest and the music is vulgar. He cranks it in the dining room and common areas too. He was in a resident room and raised his hand to hit a little lady in a wheelchair who has severe dementia until Resident #4 intervened verbally. While surveyor was speaking with Resident #4, Resident #1 approached to try to listen in to the conversation and ended up kicking the back of Resident #4's wheelchair. Staff that were outside in the smoking area did not intervene when Resident #1 approached Surveyor and Resident #4 during interview. She stated Resident #1 continues to harass her, call her names and cause her distress. She stated it began when he made sexual advances towards her that she declined. Resident #4 said he has brought her to tears at times and that she has to walk on eggshells and try to avoid contact with Resident #1. When Resident #4 was describing the interactions with Resident #1 she appeared distressed and her eyes watered. At times her voice trembled as she recounted specific details. She stated that her room was directly across the hall from his room, and he blares vulgar music in common areas and in his room (which disrupts her). Resident #4 stated she told the ADM about the inappropriate advances and him calling her names and nothing changed. She also stated she was tired of Resident #6 being disruptive, which included him urinating on her chair in the dining room, urinating in cups in the dining room, and constant banging on walls and screaming and cursing. <BR/>In an interview and observation on 03/13/23 at 6:43 pm with Resident #4, she stated that she liked her roommate and that she was upset because Resident #1 was across the hall, but it was very hard that her tormentor is across the hall because it was a reminder of my abuse and the only time I feel 100% safe is when he is in his bed. She stated she felt safe when he was in bed because he was partially paralyzed and not able to get out of bed without staff assistance While being interviewed outside in the smoking area, Resident #1 was outside with one aide watching the 7 residents outside; as Resident #4 was speaking with surveyor, Resident #1 wheeled over to within 2 feet of Resident #4 and no staff intervened. Resident #4 stated that if she made an allegation of abuse that she would be moved from her room, which greatly upset Resident #4 because she stated she helps her roommate and cares for her.<BR/>In an interview and observation on 03/10/23 at 3:37 pm with Resident #5 stated Resident #1 blares loud music and he feels bullied by Resident #1 and 2 other residents also bullied him, all of whom hang out. One of the reasons he resigned from the office on the Resident Council to which he was elected after less than 1 week is intimidation by Resident #1. He stated that he does not attend social events anymore due to fear of running across Resident #1. He stated he would enjoy these activities if Resident #1 were not present. Resident #5 stated that he is disgusted by the behavior of Resident #6 and that he doesn't belong at the facility with all of his sexually lewd talk and inappropriate behaviors such as urinating in the dining room. During the interview with Resident #5 his voice trembled and his hands started to shake when he described encounters with Resident #1 and his ongoing fear of being bullied by Resident #1 and the other 2 residents that bullied him.<BR/>In an interview and observation on 03/10/23 at 3:37 pm with Resident # 3 he stated that Resident #1 threw a bottle of hot sauce on his face in the dining room in front of everyone; he stated a staff member even took pictures, but the staff member was no longer here. He stated this occurred a few months ago, possibly December or January. He stated that Resident #6 was asking sexually inappropriate questions about Resident #3's grandchildren. He stated Resident #6 makes sexually inappropriate comments on a daily basis. He further stated that Resident #6's inappropriate behavior was ignored by staff. When he was describing the sexually inappropriate speech and behavior of Resident #6, he lowered his voice to almost a whisper. When he discussed Resident #1 throwing the bottle of hot sauce on him and constant blaring of inappropriate music his voice became elevated and his face turned red. He reiterated that Resident #1 disrupted the calm environment.<BR/>On 03/11/23 at 12:00 pm during an interview with Interim DON the results of the safe surveys were reviewed and an additional victim of verbal abuse, Resident #2 was identified as being fearful of Resident #1.<BR/>In an interview and observation on 03/11/23 at 3:00 pm with Resident #2 she stated that Resident #1 has on 5 or 6 occasions called Resident #2 names such as 1 legged bitch and fat slob. This verbal abuse started about a year ago, and she stated she has told the prior administrator, the current interim administrator, and the interim director of nurses and all said they would talk to him. She won't cry in front of him but goes to her room and sobs uncontrollably. This has caused her to change directions any time she sees him, avoid activities when he is present and causes her ongoing anxiety. She cried after each event. She also witnessed him and another resident almost come to blows (engage in physical aggression). When she was being interviewed, Resident #2 appeared tearful and agitated. She was emotional as she spoke.<BR/>In an interview with Resident #1 on 03/11/23 at 9:25 am he stated that Resident #4 doesn't do her job as an elected official on the Resident Council like he did when he [NAME] the position; she hasn't been here 6 months and he has been here over 2 years. He complained the whole cabinet was appointed by her and all of them are [NAME] (all positions are elected per DON). He stated she doesn't care about Black residents. When he was on the council he got up and did rounds on all of the residents in the facility. He stated, I admit, I called her a pig, one time. He stated she doesn't like Black people, but he doesn't know if it just him. He also admitted throwing a bottle of hot sauce at another resident.<BR/>In an interview on 03/09/23 at 2:00 pm with the DON and ADM, the Adm stated that Resident #1 called Resident #4 a fat pig. He stated he spoke to Resident #1 and told him he could not talk to people like that and the resident apologized and stated he would not do it again. <BR/>In an interview on 03/10/23 at 8:30 am with the DON and ADM, the DON stated that the three residents who were the victims of abuse all had psychological diagnoses and asked where does Resident #1's rights stop; DON stated that is how he was raised . The ADM stated that Resident #5 was a music teacher and is just sensitive. He further stated he did not get involved with petty disputes between residents. They both denied knowledge of Resident #1 throwing a bottle of hot sauce at Resident #3, which caused it to shatter on his beard. They stated Resident #6 had these behaviors, such as sexually inappropriate comments and banging on the walls all nights, and urinating in public places. DON stated he apologized when she spoke to him, but then resumed the behaviors; she did stated that Resident #6 knew what he was doing and continued the behaviors. <BR/>On 03/11/23 at 6:45 pm the Interim DON and Interim Administrator were informed that an Immediate Jeopardy (IJ) for abuse was identified and were provided the Immediate Jeopardy template.<BR/>On 03/13/23 at 4:45 pm the following plan of removal was accepted:<BR/>Impact Statement <BR/>F600 Abuse<BR/>The resident has the right to be free from abuse, neglect misappropriation of resident property as defined in this subpart. This includes but is not limited to freedom from corporal punishment involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.<BR/>Identify residents who could be affected<BR/>All residents who came into contact with Residents #1 and #6 have the potential to be affected by this alleged deficient practice<BR/>Problem<BR/>F600- The facility failed to prevent ongoing verbally aggressive behaviors, such as screaming, cursing, bossing around/demanding, insulting race or ethnic group, intimidating, sexually lewd behavior and questions; including urinating in cups at breakfast by 2 residents resulting in 4 residents reporting secluding in rooms and/or avoiding activities previously enjoyed.<BR/>Action Taken <BR/>Resident #1 was placed on 1:1 on 3/10/23 and it will be ongoing until residents exhibit improved behaviors or alternate placement is arranged; the Interim Direct of Nurse will ensure the resident remains on 1:1. Beginning 3/10/23 at 5pm Staff members will be assigned and notified of assignment to include always keeping resident within eyesight. The interim administrator will oversee actions taken. <BR/>Resident #6 was placed on 1:1 on 3/10/23 Resident will remain 1:1 until behaviors are improved or alternate placement is arranged; the Interim Direct of Nurse will ensure the resident remains on 1:1. Beginning 3/10/23 at 5pm Staff members will be assigned and notified of assignment to include always keeping resident within eyesight. The interim administrator will oversee actions taken. <BR/>Psych services were consulted on 3/11/23 to evaluate both Resident #1 and Resident #6 to determine a course of treatment to assist with alleged inappropriate behaviors. Psych services will provide counseling on 3/12/23. Psych services will be care planned on 3/12/23 by the Regional Clinical Reimbursement Coordinator. Verified by Corporate Clinical Reimbursement Specialist.<BR/>Psych services were consulted on 3/11/23 to evaluate Residents #2, #3, #4, and #5 to assist with any alleged psychosocial distress from behaviors by Residents #1 and #6. Psych services will provide counseling on 3/12/23. Psych services will be care planned on 3/12/23 by the Regional Clinical Reimbursement Coordinator. Verified by Corporate Clinical Reimbursement Specialist.<BR/>Safe Surveys were conducted by administrative nurses on 3/11/23 with all alert and oriented residents to determine if there were any residents who did not feel safe in the facility. Verification of completion was done by the Interim Administrator. Two residents reported that they did not feel safe, the individuals that they are reportedly fearful of are on 1:1 observation and have been evaluated by psych services and will be seen at least weekly for 4 weeks.<BR/>Regional Director of Clinical Operations educated Interim administrator and Interim Director of Nursing on reporting of abuse and neglect allegations on 3/11/23.<BR/>The Interim Director of Nursing and/or designee began educating all staff on the facility's Abuse and Neglect policy on 3/11/23. All staff will be educated prior to their next assigned shift. Training will continue until all staff has been educated. This training will be part of any new hire orientation on the next schedule orientation 3/14/23. <BR/>The Interim Director of Nursing and/or designee began educating nurses on when to complete an Incident Report on 3/11/23. All nurses will be educated prior to their next assigned shift. Training will continue until all nurses have been educated. This training will be part of any new hire orientation for nurses. This training will be part of any new hire orientation on the next schedule orientation 3/14/23. <BR/>Involvement of Medical Director and Quality Assurance<BR/>Ad HOC QA meeting held with the medical director on 03/11/23 at 7:38 pm to review all aspects of Immediate Jeopardy and Initial Plan of removal. <BR/>QAPI meetings are held on a monthly basis and all allegations, incidents, and accidents will be reviewed during the QAPI meeting. This will be an ongoing process.<BR/>POR monitoring .<BR/>An observation on 03/12/23 at 11:15 am revealed Resident #1 at the facility entrance sitting in a wheelchair being assisted by a cna in a 1 to 1 with the resident.<BR/>An observation on 03/12/23 at 11:20 am revealed Resident #6 in the sunroom sitting in a wheelchair playing a board game assisted by a cna in a 1 to 1 with the resident.<BR/>An observation on 03/12/23 at 11:45 am revealed Resident #1 in a 1 to 1 with a CNA in his room.<BR/>An observation on 03/12/23 at 1:00 pm revealed Resident #6 in the sunroom sitting in a wheelchair playing a board game assisted by a cna in a 1 to 1 with the resident.<BR/>An observation on 03/12/23 at 1:10 pm revealed Resident #1 in a 1 to 1 with a CNA in his room.<BR/>An observation on 03/13/23 at 6:00 pm revealed Resident #6 was outdoors with a CNA taking a walk one on one.<BR/>An observation on 03/13/23 at 6:15 pm revealed Resident #1 was observed with CNA one-on-one walking down the hall<BR/>An interview on 03/13/23 at 6:32 pm revealed that CMA A was able to answer questions regarding abuse, reporting and resident on resident abuse; stated in-service today on abuse.<BR/>An interview on 03/13/23 at 6:36 pm revealed LVN B was able to answer questions related to abuse, reporting, verbal abuse, and resident abusing other residents and stated she was in-serviced this weekend.<BR/>Record review of the medical records safe surveys were conducted on 03/11/23. In addition, psyc services were consulted according to the medical records. <BR/>Based on observation, interview and record review the plan of removal was implemented and the IJ was removed on 03/13/23 at 4:45 pm, the facility remained out of compliance at a scope of pattern and a severity level of actual harm to resident health or safety due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure the resident care plan accurately reflected the resident's status for 1 of 4 residents (Resident #12) who were reviewed for care plans.<BR/>The facility failed to care plan Resident #12's use of hearing aids. <BR/>This failure could place residents at risk of their needs going unmet. <BR/>Findings included:<BR/>Record review of Resident #12's quarterly MDS, dated [DATE], indicated Resident #12 was a [AGE] year-old male, who was admitted to the facility on [DATE]. He had diagnoses of dementia, major depressive disorder, depression, hereditary and idiopathic neuropathy (nervous system disorders that interfere with normal nerve function). His MDS also reflected in Section B Hearing, Speech, and Vision that Resident #12's ability to hear, had minimal difficulty, as well as that he did not have hearing aids or other hearing appliances. His BIMS score was 12, which indicated moderately impaired cognition.<BR/>Record review of Resident #12's care plan dated last revised on 01/31/2025 reflected resident had special instructions Very hard of hearing. He had a focus of the resident has a communication problem related to hearing loss The interventions listed included for staff to anticipate and meet needs, encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense or responds to the feeling resident is trying to express and refer to speech therapy for evaluation and treatment as ordered. His care plan did not have any indication of hearing aid use or refusal of usage. <BR/>Record review of Resident #12's doctor's order dated 9/24/2024 reflected, May have podiatry, dental, audiologist, & ophthalmologist consults PRN.<BR/>Observation on 02/10/2025 at 10:24 a.m., revealed Resident #12 sitting in his recliner in his room watching television. The resident voiced that his hearing aids needed to be repaired and that his family member was going to come get them to be fixed/replaced. The hearing aids were sitting on his bedside table. The state surveyor had to stand close, yell, speak slowly, and often repeat questions to the resident during the observation. The resident was unable to give an answer when the state surveyor asked him if the facility helped him with audiology appointments, even after writing the questions down for him due to the hearing impairment. <BR/>Interview on 02/12/2025 at 11:40 a.m., with the DON revealed she had started working at the facility 3 weeks ago. She stated that her expectation would be that hearing aids were care planned. She stated that Resident #12 had hearing aids in his room but refused to wear them and did not like them. She said that the resident's family member had planned to take the hearing aids home with him due to the resident not wearing them. She said he reads lips very well and can sign for things he needed. She said that it should have been care planned that he did not wear them.<BR/>Interview on 02/12/2025 at 12:48 p.m., with CNA A revealed she had worked at the facility for 2 years. She stated that Resident #12 would wear his hearing aids sometimes, but he had a hard time getting them to stay in his ears. She stated that she had to make sure she talked loudly and stood close to him when talking, but that most times she still had to repeat herself multiple times. She did not think he was good at reading lips due to the number of times she would have to repeat herself during conversations. <BR/>Record review of the facility's Comprehensive Care Plan policy dated last revised on 4/25/2021 revealed, Every resident will have an individualized interdisciplinary plan of care in place. The Interdisciplinary Team will continue to develop the plan in conjunction with the MDS 3.0, completing and conducting Comprehensive Care Plan Meeting and Reviews by day 21 after admission. The Interdisciplinary Team will review the healthcare practitioner's notes and orders and implement a comprehensive care plan to meet the residents' immediate care needs including but not limited to: therapy services, social services, psychosocial mood state needs as indicated, specific care plan on the main reason for admission to the community. Any updated information based on the details of the comprehensive care plan, as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (Resident #1) of three residents reviewed for transfer and discharge rights, in that:<BR/>The facility failed to provide documentation that Resident #1 received sufficient preparation and orientation when he was discharged to a group home to ensure a safe discharge. Resident #1 was discharged from the facility on 10/11/24.<BR/>This failure could place residents at risk of not receiving care and services to meet their needs upon discharge. <BR/>Findings Included:<BR/>Review of Resident #1's face sheet, dated 10/11/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included diffuse traumatic brain injury (occurs when the brain is injured by blunt force, causing the brain's nerve fibers to shear of tear), depression and heart failure. Resident #1 is listed as his own responsible party. <BR/>Review of Resident #1's quarterly MDS assessment, dated 08/27/24, reflected a BIMS score of 15 indicating intact cognition. Neither device was listed in his MDS. No information was provided in section E regarding Resident #1's behavior and did not include information about physical or verbal behaviors directed at others. <BR/>On 10/11/24 at 12:30 observed Resident #1 ambulated using a wheelchair and he had a cane with him.<BR/>Review of Resident #1's quarterly care plan reflected:<BR/>Focus and revision dated 09/20/23 Discharge has been determined to not be feasible based on Resident #1's inability to ambulate and care for self at home. Resident physician, resident representative agree on long-term care placement<BR/>Goal - Resident and Resident Representative will express satisfaction with community through next review date, date initiated and date revision 09/10/24 target dated 12/03/24.<BR/>Interventions - discuss placement goals for staying in community and refine and redefine and adjust as needed date initiated 09/20/23, encourage resident to verbalize fears and concerns and clarity any misconceptions he/she may have regarding not being able to meet previous discharge goals and continuing to stay at community date initiated 09/20/23, resident and or responsible party will define expectations for community care, date initiated 09/20/24.<BR/>Review of Resident #1's progress note date 10/11/24 reflected social worker followed up with Resident #1 discussed his feelings, respecting individuals and placement. Resident #1 was not very receptive due to him being angry and upset but became cooperative and verbalized understanding later. Resident #1 refused and was not open to receiving treatment/counseling from inpatient hospital. Social worker emailed/faxed Resident #1's clinicals to various nursing facilities and was informed that he was declined due to aggressive behavior. Clinicals were sent to three skilled nursing facilities who declined admission and a fourth facility that was awaiting. Clinicals were faxed to a group home and Resident #1 was accepted. Resident #1's needs will be met at the group home and is schedule to leave on 10/11/24 at 8:00 am. <BR/>Review of Resident #1's progress note dated 10/11/24 reflected Resident #1 was discharged to a group living home to evaluate and treat for skilled nursing, physical therapy and occupational therapy. Facility driver transported Resident #1 with all his belongings and medications. Resident was cooperative. <BR/>Review of Resident #1's progress note LATE ENTRY (neither the date or the time of this entry was indicated) placed call and spoke with ombudsman regarding situation with incident involving the resident. Explained to ombudsman the initial discharge for resident to a safe environment for the safety of the other resident. Follow up from facility to follow. <BR/>Review of Resident #1's order, by the Medical Director, date 10/13/24 stated discharge patient [Resident #1].<BR/>Interview on 10/11/24 at 5:32 p.m., with the ombudsman revealed she was not aware of Resident #1's discharge. She said she knew about Resident #1's incident with Resident #2 on 10/09/24 but did not know about the discharge and had not had a conversation with facility about Resident #1 being discharged . She said the facility knew they had to tell her about a discharge, she did not receive a discharge letter. She revealed she did not have any time to address anything involving the discharge. She stated that the discharge would fall under a 7-day discharge and the resident or the family member needed time in case they wanted to appeal.<BR/>Interview on 10/13/24 at 4:04 p.m., with the facility Medical Director revealed he spoke with the facility DON and approved Resident #1's discharge from the facility on 10/11/24 and did not have a problem with the discharge. The medical director understood that Resident #1 was the instigator in many circumstances involving another resident and he had no problem with the discharge, but he did not enter the order in the record until 10/13/24. <BR/>Review of facility discharge policy included long-term care ombudsman program policies and procedures:<BR/>Notice of discharge from a Medicaid certified nursing facility introduction: the facility must ensure that transfer or discharge is documents in the resident's medical record and the information must be communicated to the receiving provider. If the facility is citing needs cannot be met as a reason for discharge, documentation must include the facilities attempts to meet these needs and the services available at the receiving facility to meet these needs. <BR/>The written discharge notice must include: <BR/>the reason for the transfer or discharge<BR/>a statement of the resident's appeal rights, including <BR/>o <BR/>the resident has the right to appeal the action as outlined in HHSC's Fair Fraud Hearings handbook within 90 days after the date of the notice<BR/>o <BR/>information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request <BR/>o <BR/>the name, address, email address, and telephone number of the managing local ombudsman and the toll-free number of the managing local ombudsman program <BR/>Review of facility eMAR discharge instruction date 10/11/24 reflected:<BR/>the name of the person Resident #2 is discharging from the facility with (Resident #1 was discharged from the facility via facility van with a facility transportation driver).<BR/> The primary physicians name and telephone number (the facility medical director's name and telephone number)<BR/>Pharmacy name and telephone number<BR/>In home care or services listed the name of the group home and the telephone where Resident #1 was being discharge to<BR/>No medical equipment arrangement (Resident #1 was in his wheelchair and holding his cane)<BR/>Housing arrangements stated group home<BR/>Medical Education contained comments only - medication list and instructions attached provide by nurse<BR/>Prevention and disease management education listed verbal and written by not dopic of education provided<BR/>Summary of Resident #1's stay reflected [Resident #1] was admitted into the facility at receive nursing care 7/24<BR/>Describe any treatments to continue after discharge reflected [Resident #1] will continue treatment in a group home<BR/>Current ambulation/locomotion support: uses wheelchair<BR/>Current eating support: independent<BR/>Current toileting support: needs supervision<BR/>Current dressing support: needs supervision<BR/>Scheduled appointments and tests appointment Primary Care Physician wellness/health on 10/14/24<BR/>Signed by LVN and LVSW, MA<BR/>Discharge Instructions revealed I am signing these discharge instructions have been reviewed with me in a language I understand, and my questions have been answered Signed by Resident #1<BR/>Disposition of valuables - belongings in Resident #1's possession <BR/>Medications reconciled with Resident/Representative Party - No <BR/>Review of Facility Transfer or Discharge, Preparing a Resident for:<BR/>Residents will be prepared in advance for discharge. Policy interpretation and implementation:<BR/>1. <BR/>When a resident is schedule for transfer or discharge, the business office will notify services of the transfer or discharge so that appropriate procedure can be implemented.<BR/>2. <BR/>A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four hours before the resident's discharge or transfer from the facility. <BR/>3. <BR/>Nursing services is responsible for:<BR/>a. <BR/>obtaining orders for discharge or transfer, as well as the recommended discharge services and equipment<BR/>b. <BR/>preparing the discharge summary and post-discharge planforwarding charge slips to the business office <BR/>c. <BR/>Providing the resident or representative with required documents (i.e. discharge summary and plan)<BR/>d. <BR/>Completing discharge note in the medical record<BR/>e. <BR/>Forwarding charge slips to the business office<BR/>f. <BR/>Directing the resident or representative to the business office prior to the transfer or discharge <BR/>g. <BR/>Forwarding completed records to the business office<BR/>h. <BR/>The business office is responsible for:<BR/>a. <BR/>Informing appropriate departments of the resident's transfer or discharge<BR/>b. <BR/>Informing the resident, or his or her representative of the facility's readmission appeal rights, bed-holding policies etc. and <BR/>c. <BR/>Others as appropriate or as necessary

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure adequate supervision and assistive devices to prevent accidents for 1of 6 residents (Resident #1) reviewed for accidents and supervision.<BR/>The facility failed to ensure Resident # 1 was free from accidents. Resident # 1's leg was hit on a table by CNA A that resulted in a Tibial fracture to her right leg and was sent to the hospital for treatment services. The staff who caused the injury was moved to another hall. <BR/>This failure placed residents at risk of being injured by CNA A.<BR/>Findings included: <BR/>Resident #1 was a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses of Unspecified dementia (progressive or persistent loss of intellectual functioning, with impairment of memory and thinking), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.<BR/>Record review of Resident's #1 quarterly MDS dated [DATE] reflected Resident #1 has a BIMS score of 3 indicating severe impairment. Section GG functional ability reflected Resident # 1 was dependent for dressing, showering, putting on clothes, and toileting. Section J Health condition reflected Resident #1 had a history of falls and 1 fall since being admitted the facility. <BR/>Record review of Resident #1 care plan dated 2/5/2024 reflected Resident #1 assessed for falls with interventions: Call light within reach, Fall mat beside bed.<BR/>Record review of the facility progress note dated 4/8/2024 regarding an incident on 4/5/2024 by LVN D reflected the following: <BR/>Resident #1 notified therapy that her right knee was hurting. Therapy placed ice on it. NP notified and gave orders for STAT right knee Xray. Xray ordered. Resident told therapy someone pushed me under the table and hit my knee.<BR/>During an Interview on 4/16/2024 at 1:38pm with CNA A revealed she was pushing Resident # 1 up to the dining table and hit Resident # 1's leg on the table. CNA A stated she did not realize Resident #1 had her leg up, she stated the impact did not seem that hard, so she did not let the nurse know. CNA A stated she straightened out Resident #1's leg and pushed her up to the table. CNA A stated she later found out that Resident #1's leg had swelled up and there was a fracture. CNA A stated she was moved to another hall at the request of the family. <BR/>During an interview on 4/16/2024 at 2:09pm with LVN A, stated on 4/5/2024 later that day Resident # 1 went to therapy. LVN A stated she was advised by therapy that Resident #1's knee was swollen and unable to bend. She stated they ordered x-rays 'Stat and found received the results the following day on 4/6/202, she stated the results indicated there was a fracture. LVN A stated Resident #1 was sent to the hospital for more treatment services. LVN A stated CNA A should have gotten a nurse at the time when she hit the resident's knee on the table.<BR/>During an interview on 4/16/2024 at 3:50pm with the DCO, revealed she was made aware of the incident the next day when she was advised Resident #1 was sent out to the hospital. The DCO stated she was advised by LVN A, that Resident # 1 hit her knee and yelled out ouch. The DCO stated CNA A should have gotten the nurse to assess the resident at that time she hit her leg.<BR/>During an interview on 4/16/2024 at 4:05pm with the EDO revealed there was no investigation completed because they were able to determine what happened. The EDO stated CNA A should have reported hitting Resident #1's leg to the nursing staff. He stated CNA A was moved from Resident #1's hall at the request of the family due a previous fall in which this staff was on duty. The EDO stated the family felt it would be best if she did not work on that hall anymore, so she was moved to another hall. The EDO stated they did not think that it was intentional by CNA A that she hit her leg and stated that was the extent of their investigation. <BR/>Record Review of Resident # 1's hospital discharge medical records dated 4/6/2024. The medical records reflected Resident #1 was admitted to the ER on [DATE]. The medical records reflected Resident #1 sustained a Tibial fracture to the right leg. The medical records reflected Resident # 1's right leg was placed in a splint and medication for pain was prescribed. Resident # 1 was released from the hospital later the same day on 4/6/2024 back to the facility. <BR/>Record review of the facility Abuse/Neglect policy dated 2/1/2017, the policy reflected the following: <BR/>Each resident has the right to be free from Abuse/Neglect <BR/>Resident will not be subjected to abuse/neglect by anyone. <BR/>Record review of facility Incident an Accident policy dated 3/1/2017 reflected the following: <BR/>Accidents or incidents involving residents shall be investigated and reported to the EDO.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure the resident care plan accurately reflected the resident's status for 1 of 4 residents (Resident #12) who were reviewed for care plans.<BR/>The facility failed to care plan Resident #12's use of hearing aids. <BR/>This failure could place residents at risk of their needs going unmet. <BR/>Findings included:<BR/>Record review of Resident #12's quarterly MDS, dated [DATE], indicated Resident #12 was a [AGE] year-old male, who was admitted to the facility on [DATE]. He had diagnoses of dementia, major depressive disorder, depression, hereditary and idiopathic neuropathy (nervous system disorders that interfere with normal nerve function). His MDS also reflected in Section B Hearing, Speech, and Vision that Resident #12's ability to hear, had minimal difficulty, as well as that he did not have hearing aids or other hearing appliances. His BIMS score was 12, which indicated moderately impaired cognition.<BR/>Record review of Resident #12's care plan dated last revised on 01/31/2025 reflected resident had special instructions Very hard of hearing. He had a focus of the resident has a communication problem related to hearing loss The interventions listed included for staff to anticipate and meet needs, encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense or responds to the feeling resident is trying to express and refer to speech therapy for evaluation and treatment as ordered. His care plan did not have any indication of hearing aid use or refusal of usage. <BR/>Record review of Resident #12's doctor's order dated 9/24/2024 reflected, May have podiatry, dental, audiologist, & ophthalmologist consults PRN.<BR/>Observation on 02/10/2025 at 10:24 a.m., revealed Resident #12 sitting in his recliner in his room watching television. The resident voiced that his hearing aids needed to be repaired and that his family member was going to come get them to be fixed/replaced. The hearing aids were sitting on his bedside table. The state surveyor had to stand close, yell, speak slowly, and often repeat questions to the resident during the observation. The resident was unable to give an answer when the state surveyor asked him if the facility helped him with audiology appointments, even after writing the questions down for him due to the hearing impairment. <BR/>Interview on 02/12/2025 at 11:40 a.m., with the DON revealed she had started working at the facility 3 weeks ago. She stated that her expectation would be that hearing aids were care planned. She stated that Resident #12 had hearing aids in his room but refused to wear them and did not like them. She said that the resident's family member had planned to take the hearing aids home with him due to the resident not wearing them. She said he reads lips very well and can sign for things he needed. She said that it should have been care planned that he did not wear them.<BR/>Interview on 02/12/2025 at 12:48 p.m., with CNA A revealed she had worked at the facility for 2 years. She stated that Resident #12 would wear his hearing aids sometimes, but he had a hard time getting them to stay in his ears. She stated that she had to make sure she talked loudly and stood close to him when talking, but that most times she still had to repeat herself multiple times. She did not think he was good at reading lips due to the number of times she would have to repeat herself during conversations. <BR/>Record review of the facility's Comprehensive Care Plan policy dated last revised on 4/25/2021 revealed, Every resident will have an individualized interdisciplinary plan of care in place. The Interdisciplinary Team will continue to develop the plan in conjunction with the MDS 3.0, completing and conducting Comprehensive Care Plan Meeting and Reviews by day 21 after admission. The Interdisciplinary Team will review the healthcare practitioner's notes and orders and implement a comprehensive care plan to meet the residents' immediate care needs including but not limited to: therapy services, social services, psychosocial mood state needs as indicated, specific care plan on the main reason for admission to the community. Any updated information based on the details of the comprehensive care plan, as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that all drugs and biologicals were properly stored and inaccessible to unauthorized staff and residents for one resident (Resident #2) of four residents reviewed for medication storage. <BR/>The facility failed to ensure narcotics were received and then stored in a manner to prevent diversion on 03/04/2024 when a refill of Hydrocodone, 10-325 milligrams, quantity of 75, for Resident #2 was received from the pharmacy by LVN A, given to LVN B on 3/4/2024 and discovered missing on 03/06/2024. <BR/>This failure could place residents at risk for drug diversion and access to medications that could cause harm, sickness, or hospitalization. <BR/>Findings included: <BR/>Review of Resident #2's face sheet dated 3/26/2024 reflected an eighty-three-year-old male admitted on [DATE] with diagnoses that included: Senile Degeneration of Brain (gradual loss of thinking ability), Hypertension (high blood pressure), Dementia (progressive loss of intellectual functioning), Shoulder pain, and a History of Falls. <BR/>During an interview on 3/26/2024 at 3:32 pm, the AD stated a card of hydrocodone medication, and the narcotic sheet were discovered missing on 3/6/2024. He stated he had reviewed video coverage from 3/4/2024 and could see that LVN A handed the cards of medications from a recent delivery to LVN B. He stated after that the staff walked out of video range. He stated an investigation was completed and the incident reported but was deemed inconclusive because no one saw LVN B take the medications. The AD stated all staff involved had completed a urine test and all tested negative.<BR/>During an interview on 3/27/2024 at 2:22 pm, LVN A stated she had been working day shift on 3/4/2024. She stated just before shift change at 2:00 pm the pharmacy made a medication delivery, and she took the medications and signed for them. She stated she was sitting at the nurses station charting and had the medications with her when the oncoming nurse for the 2-10pm shift, LVN B came on shift. She stated she handed the medications to LVN B. She stated shortly after that, her and LVN B walked over to the nurse's medication cart for the 400/500 hall and completed a narcotic count, including the newly delivered narcotic medications. She stated she did not witness LVN B put the narcotic medications in to the cart. LVN A was asked if she was aware of the facility policy for receiving controlled substances required two nurses to witness placement of the controlled medication in the secure compartment of the medication cart and she stated Honestly, no, I was not aware of that. I did not watch her put them in the cart, so I'm not sure if she did nor not.<BR/>During a joint interview on 3/27/2024 at 2:45 pm with the AD and DON, the DON stated on 3/6/2024 a pack of hydrocodone was identified as missing. All staff involved were interviewed and gave written statements. It was discovered that the medications were last in the possession of LVN B. The DON stated LVN B was interviewed and initially denied getting the meds, then stated she had handed them off to another staff. The DON stated LVN B refused to give a written statement to her. LVN B was suspended pending results of the investigation. The DON stated the resident did not miss any medication as they still some remaining and was assessed for any pain - none was reported. The DON stated she was not aware of the criteria of two nurse witnessing controlled substances being properly stored in the facility's current policy. The AD stated he expected his staff to follow facility policy when receiving medications from the pharmacy.<BR/>LVN B was contacted by phone on 3/27/2024 at 3:22 pm and 4:02 pm and voicemails were left requesting a return call, but the calls were never returned.<BR/>Review of Facility Incident Report dated 3/13/2024 revealed a card of Hydrocodone-APAP, 10-325 milligrams, quantity of 75 was discovered missing for Resident #2 on 3/6/2024. The incident report revealed the medication was received on 3/4/2024.<BR/>Review of facility policy Receiving Controlled Substances dated 08-2020 revealed Policy: Medications classified by the Drug Enforcement Administration as controlled substances and medications classified as controlled substances by state law are subject to special ordering, receipt and recordkeeping requirements by the facility in accordance with federal and state laws and regulations. Further the policy stated, 11. Only licensed personnel may receive controlled substances from the pharmacy courier. Procedures for receiving controlled substances include c. The receiving nurse transfers medications and accompanying inventory sheets to an authorized nurse on the unit (if different than the nurse who received the medication) or in accordance with facility policy, d. Two nurses, and/or in accordance with facility policy, witness placement of the controlled substance in the secured compartment of the medication cart. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure adequate supervision and assistive devices to prevent accidents for 1of 6 residents (Resident #1) reviewed for accidents and supervision.<BR/>The facility failed to ensure Resident # 1 was free from accidents. Resident # 1's leg was hit on a table by CNA A that resulted in a Tibial fracture to her right leg and was sent to the hospital for treatment services. The staff who caused the injury was moved to another hall. <BR/>This failure placed residents at risk of being injured by CNA A.<BR/>Findings included: <BR/>Resident #1 was a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses of Unspecified dementia (progressive or persistent loss of intellectual functioning, with impairment of memory and thinking), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.<BR/>Record review of Resident's #1 quarterly MDS dated [DATE] reflected Resident #1 has a BIMS score of 3 indicating severe impairment. Section GG functional ability reflected Resident # 1 was dependent for dressing, showering, putting on clothes, and toileting. Section J Health condition reflected Resident #1 had a history of falls and 1 fall since being admitted the facility. <BR/>Record review of Resident #1 care plan dated 2/5/2024 reflected Resident #1 assessed for falls with interventions: Call light within reach, Fall mat beside bed.<BR/>Record review of the facility progress note dated 4/8/2024 regarding an incident on 4/5/2024 by LVN D reflected the following: <BR/>Resident #1 notified therapy that her right knee was hurting. Therapy placed ice on it. NP notified and gave orders for STAT right knee Xray. Xray ordered. Resident told therapy someone pushed me under the table and hit my knee.<BR/>During an Interview on 4/16/2024 at 1:38pm with CNA A revealed she was pushing Resident # 1 up to the dining table and hit Resident # 1's leg on the table. CNA A stated she did not realize Resident #1 had her leg up, she stated the impact did not seem that hard, so she did not let the nurse know. CNA A stated she straightened out Resident #1's leg and pushed her up to the table. CNA A stated she later found out that Resident #1's leg had swelled up and there was a fracture. CNA A stated she was moved to another hall at the request of the family. <BR/>During an interview on 4/16/2024 at 2:09pm with LVN A, stated on 4/5/2024 later that day Resident # 1 went to therapy. LVN A stated she was advised by therapy that Resident #1's knee was swollen and unable to bend. She stated they ordered x-rays 'Stat and found received the results the following day on 4/6/202, she stated the results indicated there was a fracture. LVN A stated Resident #1 was sent to the hospital for more treatment services. LVN A stated CNA A should have gotten a nurse at the time when she hit the resident's knee on the table.<BR/>During an interview on 4/16/2024 at 3:50pm with the DCO, revealed she was made aware of the incident the next day when she was advised Resident #1 was sent out to the hospital. The DCO stated she was advised by LVN A, that Resident # 1 hit her knee and yelled out ouch. The DCO stated CNA A should have gotten the nurse to assess the resident at that time she hit her leg.<BR/>During an interview on 4/16/2024 at 4:05pm with the EDO revealed there was no investigation completed because they were able to determine what happened. The EDO stated CNA A should have reported hitting Resident #1's leg to the nursing staff. He stated CNA A was moved from Resident #1's hall at the request of the family due a previous fall in which this staff was on duty. The EDO stated the family felt it would be best if she did not work on that hall anymore, so she was moved to another hall. The EDO stated they did not think that it was intentional by CNA A that she hit her leg and stated that was the extent of their investigation. <BR/>Record Review of Resident # 1's hospital discharge medical records dated 4/6/2024. The medical records reflected Resident #1 was admitted to the ER on [DATE]. The medical records reflected Resident #1 sustained a Tibial fracture to the right leg. The medical records reflected Resident # 1's right leg was placed in a splint and medication for pain was prescribed. Resident # 1 was released from the hospital later the same day on 4/6/2024 back to the facility. <BR/>Record review of the facility Abuse/Neglect policy dated 2/1/2017, the policy reflected the following: <BR/>Each resident has the right to be free from Abuse/Neglect <BR/>Resident will not be subjected to abuse/neglect by anyone. <BR/>Record review of facility Incident an Accident policy dated 3/1/2017 reflected the following: <BR/>Accidents or incidents involving residents shall be investigated and reported to the EDO.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview and record review, the facility failed to ensure that 1 (Resident #62) of 6 residents was free of any significant medication errors.<BR/>The facility failed to ensure Resident #62 was administered Midodrine (medication used to increase blood pressure) as ordered per physician. <BR/>The facility failed to ensure that Resident #62 was administered medications per physician's order.<BR/>These failures could affect the resident by placing resident at risk for not receiving therapeutic dosages of medications as ordered by the physician which could result in a decline in health status. <BR/>Findings included:<BR/> Record Review on 10/13/22 of Resident #62's face sheet dated 10/13/22 reflected Resident #62 was a [AGE] year-old male with an admission date of 08/09/22. Resident #62's diagnoses included diabetes type 2 (high blood sugar, insulin resistance, and relative lack of insulin), hypertension (high blood pressure - long term condition in which blood pressure in arteries is persistently elevated), hypothyroidism (disorder of the endocrine system in which the thyroid gland does not produce enough thyroid hormone), and dysphagia (difficulty in swallowing).<BR/>Record Review on 10/13/22 of the most recent MDS assessment dated [DATE] reflected Resident #62 had a BIMS score of 03 indicating Resident #62 was severely cognitively impaired.<BR/>Record review on 10/13/22 of resident #62's clinical physician orders dated 10/13/22 revealed: Midodrine HCL tablet 5 mg give 1 tablet via G-tube three times a day for preventative - hold for systolic above 100 and DBP above 60 <BR/>Record review on 10/13/22 of Resident #62's clinical physician orders on 10/13/22 revealed: start date of 9/11/2022 for Midodrine HCL tablet 5 mg give 1 tablet via G-tube three times a day. <BR/>Record review of Resident #1's MAR dated October 2022 revealed no evidence that Midodrine was held in the month of October and blood pressure readings were recorded to be outside of parameters to be given for 23 of 36 doses that were administered. <BR/>During an interview on 10/13/22 at 10:56 AM, the DON stated it is her expectation that medications be given to residents as ordered by the doctor. She stated she expects staff to follow parameters for heart rate, blood pressure, and respiratory rate when giving medications. She stated if medication parameters were not followed it could potentially cause residents blood pressure or heart rate to bottom out and could lead to potential problems for the residents. She stated they have done in-servicing with staff on medication administration and the 5 rights of medication administration regularly.<BR/>During an observation on 10/13/22 at 12:03 PM of Resident # 62's blood pressure medication, medication parameters were provided on the medication card and the were 24 tablets remaining.<BR/>During an interview on 10/13/22 at 12:04 PM, LVN A stated she administered medications to Resident # 62 regularly. She stated she had been giving Resident # 62 Midodrine HCL 10 mg (medication that increases the blood pressure) that he is ordered to get 3 times a day. She stated, regarding parameters of medication, she has not had to hold Resident # 62's blood pressure medication because Resident # 62's blood pressure has been pretty good. She stated the parameters of the medications are right above the medication order on the medication administration record. She stated Resident # 62's parameters are to hold if systolic blood pressure is above 100 and diastolic blood pressure is above 60. She stated the blood pressure medication should have been held any time Resident # 62's blood pressure was over the parameters. She stated that blood pressure medication is given to raise the blood pressure and if given outside of parameters it could cause the residents blood pressure to get high.<BR/>During an interview on 10/13/22 at 12:09 PM, LVN B stated she stated she has given medications to Resident # 62. She stated she had been administering Resident # 62 all of the medications that he had been ordered to get when she worked that hall and she had not held any of Resident # 62's blood pressure medications at any time that she remembered. She stated if she signed the medication administration record then she gave the medication. She stated she was aware that some medications have parameters on them. She stated she should not have given medications if they were outside of the ordered parameters. She stated she was aware of where to find parameters on the medication administration record. She stated if Resident #62 was given this medication outside of parameters it could cause the blood pressure to be too high and possibly cause a stroke.<BR/>During an interview on 10/12/22 at 1:04 PM, ADM stated it was his expectation that medications should have been given as ordered per physician order. He stated it is expected that staff follow blood pressure parameters when administering medications and that if they did not, the residents blood pressure may go too high or too low. He stated he has in-serviced staff on the 5 rights of medication and medication administration.<BR/>Record Review on 10/13/22 at 3:18 PM of the General Guidelines for Medication Administration policy dated 09-2018 (revised08-2020) provided by the DON, revealed the following: procedures: preparation: 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 3 steps in the process of preparation.

Based on observation, interviews, and record reviews the facility failed to store, prepare, and serve food in accordance with professional standards for one of one kitchen reviewed for kitchen sanitation.<BR/>A. The facility failed to properly store and label food in the facilities one unit with 6 doors open front refrigerator, one unit with 3 doors open front refrigerator and 2 open front freezers and one open top deep freezer in the kitchen.<BR/>B. The facility failed to prevent grease from the oven/griddle leaking onto the floor. <BR/>C. The facility failed to sanitize one deep fryer, two ovens, griddle, kitchen floor, a kitchen utility 3 shelf rolling cart and a storage bin for meal<BR/>This failure placed residents who were served from the kitchen at risk for health complications and foodborne illnesses.<BR/>Findings included:<BR/>A. Observation of the 2 units open front refrigerators in the kitchen on 10/12/2022 at 8:10 AM- 8:20 AM revealed the following:<BR/>-leftover bacon not in the original package without a label or date on the clear zip plastic bag. <BR/>-two large bags of leftover red sauce used for pasta not in the original package without a label or date on the clean zip plastic bag.<BR/>Observation of the open front freezer in the kitchen on 10/12/2022 at 8:24 AM - 8:30 AM revealed the following:<BR/>- opened package of biscuits not in the original package without a label or date on it. There were approximately &frac12; inch of ice on the biscuits.<BR/>- partially opened &frac12; gallon of vanilla ice cream without a date when the ice cream was last used. The ice cream had approximately &frac12; to &frac34; inch of ice on the ice cream. <BR/>- partially opened leftover cheese sticks not in the original package without a label or date on the package. <BR/>-breaded frozen of some type of meat not in original package not labeled or dated. <BR/>B. Observation on 10/11/2022 at 8:40 revealed a bedspread with grease on it laying on the floor beside the griddle. There was dried brownish substance on the side of the griddle from approximately 8 inches from the top of the griddle to the bottom of the griddle. <BR/>Interview on 10/11/2022 at 8:43 AM the Dietary [NAME] stated they had to put the bedspread on the floor to catch the grease. She stated whenever they use the griddle the grease leaks and flows onto the floor. She stated the griddle was leaking past few days. She stated maybe 3 or 4 days. She stated she did report the grease leaking to the Dietary Manager on Monday (10/12/2022). <BR/>Interview on 10/11/2022 at 8:50 AM the Dietary Manager stated someone contracted had been called about the issue with griddle leaking grease. She stated she didn't recall name of the company came to the facility to check the griddle. The company was returning to the facility to make the repairments. The Dietary Manager 5 stated the staff could use a bucket or something else to catch the grease when it leaks instead of a bedspread. <BR/>C. Observation on 8/30/2022 at 8:30 AM - 8:50 AM of the kitchen equipment and storage bins revealed the following:<BR/>- the deep fryer had approximately 6 inches of crumbs from the side to middle of the grease. The grease was very dark and had a mild unpleasant odor. The top/front of the fryer where the handles of the baskets are rested when finished frying had approximately 3 inches of crumbs covering the entire area. The back of the fryer had a hardened built up blackish/ brownish substance approximately 1-2 inch thick. There was brownish/ blackish/ white substance dried from the top to bottom of both sides of the fryer. <BR/>- one of the three open front ovens revealed on top of the oven door and inside the oven door was covered with a brownish/ blackish hard substance. Bottom of the outside of the oven door was blackish/ brownish/ white substance. Outside of the oven door was white/ brownish dried substance. Top of the oven where the burners were located was a stainless silver part of the oven against the wall. It had approximately 4 inches of hardened blackish/ brownish substance from top to bottom covering over half this section of the oven. All three ovens were located beside each other. <BR/>-two of the three open front ovens revealed inside of the oven were hard blackish / brownish substance approximately 1-2-inch-thick had a white unknown substance inside the oven. <BR/>- one of one griddles had blackish hard substance on the inside of the griddle. On the outside of the griddles on both sides had white, brownish/ blackish hard substance. In front of the griddle had brownish hard substance. The griddle had been leaking grease on this date and past 3-4 days. Where it was leaking on the top left side of the griddle was a hard blackish/ brownish substance. <BR/>- kitchen floor beside the griddle, in front of the griddle, in front of the oven and, in front of utility cart located beside the fryer and in front of the fryer was French fries. The French fries had been cooked for supper on 10/11/2022. The floor had dirt, dust, and grease on the floor in front of the oven and in front of the kitchen utility rolling cart. These areas were not where the grease was leaking on the floor. <BR/>- utility kitchen 3 shelf rolling cart located beside the griddle had a large flat cooking pan with parchment paper on top of the pan. The paper was soaked in grease. There were French fries on the pan. The pan was sitting on the top shelf of the cart and there was dust and dried crumbs covering the top shelf of the cart. The middle shelf of the cart had dust, brownish substance, 2 containers with grime and brownish substance in both of the containers and also a pipe. On the bottom shelf there was dust, brownish/ blackish substance. <BR/>- one of three large open from top bins had brownish sticky substance on the area where the button was to open the bin. Meal was stored in the bin. Across the entire bin where you open to get the meal had yellowish/ brownish hard substance and sticky substance on it. <BR/>In an interview on 10/11/2022 at 8:43 AM the Dietary [NAME] stated the night shift was responsible to wipe all the equipment and clean the kitchen before the end of their shift. She stated chicken was cooked at lunch on Sunday 10/10/2022. She stated the fryer is cleaned once a week if didn't use it during the week, but the night shift was required to clean the fryer. She stated the night shift used the fryer in late afternoon on Monday (10/11/2022) and the night shift didn't clean the fryer and left dirty pan on the cart and French fries on the floor. She stated the floor was dirty when she came to work this AM (10/12/2022). She did state the three-shelf cart was not in the kitchen area when she left for the day on 10/11/2022. But when she came to work on 10/12/2022 in early AM the three-shelf rolling utility cart was beside the fryer and she stated it should have been cleaned before the night shift used it to put food on it. <BR/>In an interview on 10/11/2022 at 10:45 AM the Dietary Manager was requested to provide cleaning schedule . <BR/>In an interview on 10/12/2022 at 11:15 AM the Dietary Manager was requested to provide cleaning schedule, cleaning schedule policy, in services on cleaning equipment. A blank cleaning schedule was provided. The Dietary Manager did not have a cleaning schedule for staff to clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's medical record included documentation that indicated the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal for 2 of 5 residents (Residents #23 and Resident #63) reviewed for influenza and pneumococcal immunizations.<BR/>The facility failed to document pneumococcal immunizationstatus for Resident #23 and Resident #63.<BR/>These failures could place residents at risk for contracting a viral disease and cause respiratory complications and potential adverse health outcomes.<BR/>Findings included:<BR/>Review of Resident #23's undated face sheet reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hemiplegia (paralysis on one side of the body), congestive heart failure (progressive heart disease that affects pumping action of the heart muscles), hypertension (high blood pressure), cerebral infarction (stroke), aphasia (comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain), anxiety disorder (an unpleasant state of inner turmoil and feelings of dread), and gastrostomy status (an opening into the stomach for placement of a tube for nutrition).<BR/>Review of Resident #23's quarterly MDS assessment dated [DATE] reflected no BIMS score as resident was rarely/never understood and had no speech . His cognitive skills for daily decision making were severely impaired. <BR/>Review of Resident #23's physician order dated 03/23/22 reflected, 'May have pneumonia vaccine.<BR/>Review of Resident #23's undated immunization record reflected no documentation of a pneumococcal immunization.<BR/>Review of Resident #63's undated face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included acute respiratory failure with hypoxia (a condition where the lungs cannot provide enough oxygen to the blood and organs), pressure ulcer (bed sore), heart failure (progressive heart disease that affects pumping action of the heart muscles), type 2 diabetes (a problem with how the body regulates and uses sugar), chronic obstructive pulmonary disease (progressive lung disease that limits airflow), tracheostomy status (a surgical opening in the neck where a tube is inserted for airway management/breathing), and gastrostomy status (an opening into the stomach for placement of a tube for nutrition).<BR/>Review of Resident #63's significant change in status MDS assessment dated [DATE] reflected resident was in a persistent vegetative state/no discernible consciousness.<BR/>Review of Resident #63's physician order dated 09/05/23 reflected, May have pneumonia vaccine.<BR/>Review of Resident #63's undated immunization record reflected no documentation of a pneumococcal immunization.<BR/>During an interview on 12/20/23 at 11:52 AM with the DON, she stated she and the ADON administered immunizations. <BR/>During an interview on 12/21/23 at 9:30 AM with the DON, the documentation of pneumococcal immunization administration or refusal for Resident #23 and Resident #63 was requested. <BR/>During an interview on 12/21/23 at 8:40 AM with LVN F she stated, the ADON and DON gave vaccines to the residents. She stated the vaccine information was printed and provided before the vaccine was administered to the resident.<BR/>During an interview on 12/21/23 at 11:22 AM with the ADON , when asked if pneumococcal vaccines were offered to residents, she stated, Corporate takes care of that. All the information about the resident's vaccines comes from the paperwork they provide. She stated she did not know if offering pneumonia vaccines was part of the admission process. She stated she was responsible for giving immunizations, providing education, and obtaining consent. She stated a resident was at risk of infection if an immunization was not administered.<BR/>During an interview on 12/21/23 at 12:32 PM with the DON, she stated the ADONs give immunizations. She stated the administrative staff called the responsible parties and obtained consent for immunizations then the nurse provided the education. The nurse then administered the immunization and documented on the immunization record. When asked if Residents #23 and #63 had been offered the pneumonia vaccine, she stated the facility would get a list of everyone that wanted a vaccine before they called the pharmacy to place the order. She stated the facility had standard orders on admission for pneumonia vaccines but she did not know if offering the vaccines was part of the admission process. She did not say who was responsible for monitoring the immunizations. She stated a consequence of not providing immunizations could put the resident at risk for pneumonia or the flu.<BR/>During an interview on 12/21/23 at 1:12 PM with the ADM, he stated the immunization records came in the paperwork packet prior to a resident being admitted . He stated he was not sure of the process if a pneumonia immunization was not listed on the paperwork provided. He reviewed the electronic medical record of Resident #63 and was unable to find documentation of a pneumonia vaccine. He stated a potential adverse outcome of a resident not getting a pneumonia vaccine could be pneumonia or infection.<BR/>Review of the facility policy Resident/Staff Immunization last revised 10/20/23 reflected in part, To administer immunizations to resident and staff to prevent the spread of communicable disease in communities . Any resident who has never received a pneumococcal vaccine or those with unknown vaccinations (resident who has no written documentation of pneumococcal vaccination), should receive the PCV20 vaccine which will complete the pneumococcal vaccine .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system, which relays the call directly to a staff member or to a centralized staff work area, for 1 of 6 residents (RES #59) who were observed for access to facility services.<BR/>The facility failed to ensure RES #59 had access to a functioning call light button. <BR/>This failure could place residents at risk for unmet needs.<BR/>Findings include:<BR/>Record review of RES #59's AR reflected she was an [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with Moderate Vascular Dementia (which resulted in problematic reasoning, planning, judgement, memory, and other thought processes) and Cognitive Communication deficit (which resulted with difficulty in thought and how she used language.)<BR/>Record review of RES #59's Quarterly MDS assessment, dated 11/29/2023, reflected Section C0500, Cognitive Patterns, indicated RES #59 had a BIMS Score of 10. A BIMS Score of 10 indicated RES #59 had moderate cognitive impairment. Section GG0115, Functional Limitations of Range of Motion, indicated RES # 59 had no impairment with upper extremities (shoulders, elbows, wrists, and hand) or lower extremities (hip, knee, ankle, and feet.) Section GG0120, Mobility Devices, indicated RES #59 utilized a wheelchair. Section GG0130, Self-Care, indicated RES #59 was dependent upon staff to perform all the effort for toileting; all the effort for bathing; maximum assistance for dressing upper body; all the effort for dressing lower body; all the effort to put on and take off footwear; and maximum assistance for personal hygiene. Section GG0170, Mobility, indicated RES # 59 was dependent on staff to perform all the effort for rolling left and right; sitting to lying; lying to sitting on side of bed; sitting to standing; chair to bed transfer; toilet transfer; and tub transfer. Section H0200, Urinary Continence, indicated RES #59 was frequently incontinent. Section H0300, Bowel Continence, indicated RES #59 was always incontinent.<BR/>Record review or RES #59's CP, indicated a Focus Area initiated 5/11/2023, for Falls, evidenced by RES #59 having been a risk for increased falls and fractures related to muscle wasting and atrophy. The Goals, initiated on 5/11/2023, were the resident will be free from preventable injuries from preventable falls. The interventions for LPN, RN, and CNAs, initiated on 5/11/2023, were to anticipate needs and provide prompt assistance; assure lighting is adequate and areas are free of clutter; encourage residents to ask for assistance of staff; encourage socialization and activity attendance as tolerated; therapy to evaluate and treat per orders; and insure car light is in reach and answer calls promptly. Res # 59 had a Focus Area, initiated 5/11/2023, for ADLs, evidenced by RES #59 having self-care performance deficit related to disease process, deterioration of muscle, and muscle atrophy. The Goal, initiated on 5/11/2023, was the resident would improve current level of function in bed mobility. The interventions for LPN, RN, and CNAs, initiated on 5/11/2023, were to provide total assistance with toilet use; total assistance for transferring; encourage resident participation to the furthest extent; and for the resident to use the call light button for assistance.<BR/>Observation and interview on 12/19/2023 at 11:01 AM reflected RES #59's call light button was within her reach, but the call light button was inoperative. The cord stretched from the wall to RES #59's bed, but the red push button at the end of the device was missing. When asked if she needed staff help, she gestured an affirmative response having pressed her call light. RES # 59 asked why no was coming after she pressed the button and appeared worried no one would help her. After RES #59 realized her call light button was broken, she seemed to express understanding by relaxed body posture and relaxed facial expression. Staff was summoned to the room to render aid. <BR/>Interview on 12/19/2023 at 11:08 AM with CNA M revealed RES #59's call light was functioning last night, 12/18/2023, and did not know what happened to the call light button. <BR/>Interview and observation on 12/19/2023 at 11:15 AM with MW revealed he received notification that the call light button in RES #59's room was not working. He stated staff informed him if something was broken by telling him or writing it in the maintenance book, which he stated he checked daily. MW was observed with a new cord in hand and having entered RES#59's room. <BR/>Observation on 12/19/2023 at 11:20 AM reflected RES #59's call light button was within her reach and was in functional operation. <BR/>Observation on 12/20/2023 at 07:12 AM reflected RES #59's call light button was within her reach and was in functional operation.<BR/>Interview on 12/20/23 at 07:16 AM with CNA M revealed she was trained to make sure each resident had their call light button within reach before having left each resident's room. CNA M stated RES #59 usually had her call button in hand and did not notice the red button on top of the call light was not connected. CNA M stated RES #59 utilized her call button the night before and she responded. CNA M stated she did not notice the red button missing from the call light. She did not notice the red button on RES #59's floor or in RES #59's dirty linens. <BR/>Interview on 12/20/2023 at 9:29 AM with LVN M, reflected staff were trained to make sure each resident's call light buttons were within reach, such as pinned to their bedding or chair, when staff left the resident's room. As well, LNV M stated staff were trained to make sure the call light was functioning each day. She stated that staff were trained to press the button, seek confirmation of the alert, and silence the alarm in the room. Dangers for residents without a functioning call light button could include possible falls, having sat in wet or soiled clothing, or having gotten upset and angry. LVN M stated staff were trained to identify broken equipment and the training covered how to document needed repairs in the maintenance book and having informed building maintenance of the needed repairs. <BR/>Observations on 12/20/2023 at 1:33 PM reflected RES #59's call button was in functional operation.<BR/>Interview on 12/20/2023 at 2:10 PM with the ADON revealed staff were trained to place the call light button within arm's reach of each resident and check for functionality. Staff were supposed to press the button and visually check for the light above the door and listen for the audible tone at the nurse's station. Staff were trained to identify broken equipment and write the description and location in the maintenance logs. Residents without a functioning call light were at risk of falls if they tried to move; being exposed to wet or soiled clothing; having their needs go unmet; and feeling ignored. The DON stated staff members conducted rounds each morning, using a checklist, to make sure the resident's call light buttons were within reach. Upon request, there was no electronic record of call light activation or call light response for the system currently being used. <BR/>Interview on 12/21/2023 at 2:41 PM with the DON stated staff were trained to ensure resident' call light buttons were always within arm's reach. She stated that staff rounds took place each morning and verified each resident had access their call light button. <BR/>Interview, record review, and observations on 12/21/2023 at 11:50 AM with the ADM revealed the facility used a Focused Care Partner Checklist each morning to ensure residents had access to their call light button. The ADM presented a copy of the Focused Care Partner Rounds Checklist. The check list consisted of a heading which contained RES Room Number, RES name, Focused Care Partner, and Month/Year. The Focused Care Partner Rounds Checklist addressed the resident's call light and if it was within the resident's reach. The Focused Care Partner Rounds Checklist did not indicate a specific activity to assess if the call light button was operational. The ADM was unable to provide the Focused Care Partner Rounds Checklist, which would have had the dates and initials for the most recent morning rounds. The ADM stated that the Focused Care Partner Rounds Checklist was more a guide and did not get initialed as each item was checked. He stated staff were trained to ensure the call light was in reach and test for functionality. If not working, staff would enter the deficiency in the maintenance book and let the MW know about the faulty equipment. The ADM pointed to a cardboard box, which contained 4-inch-tall silver bells, which would be given to residents while the repairs were made. Negative outcomes of a faulty call light system would lead to possible falls, unmet needs, or resident frustration. The ADM stated the failure to recognize a resident's call light button was broken was the lack of a system in place to ensure functionality. Upon request, the ADM was unable to present a facility policy which governed the details of how staff were trained on the call light system. <BR/>Record review of the facility's Focused Care Partner Rounds Checklist, undated, designated a check for the resident's call light button in reach. The check list did not contain specific instructions to check for call light functionality.<BR/>Record review of a facility in-service training, dated 12/20/2023, indicate a training for staff to record any fixtures or other emergency items needing repair to maintenance for immediate repair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident and the resident's representative(s)were notified of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood, and the facility failed to ensure the a copy of the notice was sent to a representative of the Office of the State Long-Term Care Ombudsman for one of six residents (Resident #1) reviewed for discharges.<BR/>The facility failed to provide a 30-day discharge notice as soon as practicable to Resident #1's RP and the ombudsman. <BR/>This failure could place residents at risk for not receiving care and services to meet their needs upon discharge, a disruption of care, and being discharged without alternate placement. <BR/>Findings include:<BR/>Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old male was admitted to the facility on [DATE] with diagnoses which included ataxia (poor muscle control), cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, or responding accurately), type 2 diabetes mellitus (blood sugar is too high), hyperlipidemia (excess of lipids or fats in your blood), bipolar disorder (Mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), major depressive disorder (Depressed mood and loss of interest in activities that once brought joy), and essential primary hypertension (Blood is pumping with more force than normal through your arteries). <BR/>Record review of Resident #1's admission MDS assessment, dated 05/20/2023, revealed Resident #1's BIMS summary score was 12 indicating moderated cognitive impairment.<BR/>Record review of Resident #1's, undated, care plan, revealed Resident #1 received insulin SQ injections r/t. Resident #1 was at risk for Skin Breakdown related to: Diabetes Mellitus, repeated finger sticks, and SQ insulin diabetes dx. Resident #1 was on antipsychotic medication (Escitalopram, Alprazolam, Levetiracetam and Depakote Sprinkles) r/t: Major Depressive Disorder, Bipolar disorder, and Depression. Resident #1 had a psychosocial well-being problem r/t Disease Process: bipolar disorder, major depression, and other disorders of the brain. Resident #1 had demonstrated physically aggression toward another male resident. Resident #1 had a seizure disorder.<BR/>Record review of Resident #1 progress notes, dated 05/26/2023 at 2:50 PM, revealed the SW called and faxed clinical to [named hospital] for Resident to be assessed. [Named hospital] nurse stated that after speaking with [Resident #1] nurse, it was stated that [Resident #1] has a diabetic wound on his foot. [named hospital] declined [Resident #1] due to the facility not being able to provide wound care. [Named hospital] Nurse referred [Resident #1] to [named psychiatric hospital]. [Named psychiatric hospital]'s nurse came out to assess Resident #1. Resident #1 was appropriated for the facility and was willing to receive help. [Resident #1] was cooperative and taken to [named psychiatric hospital] without incident. <BR/>Record review of Resident #1 progress notes, dated 05-26/2023 at 8:02 PM, revealed Resident #1 was discharged to the psychiatric hospital. <BR/>During an interview on 08/30/2023 at 9:22 AM, the RP #1 stated Resident #1 or his family was notified he would be discharged from the facility. RP #1 stated she reached out to the facility for assistance to find Resident #1 another facility to reside in but no one returned her called. RP #1stated there was no discharge meeting and all she knew was Resident #1 was going to a psychiatric hospital for help. RP #1 stated she never received a discharge notice from the facility.<BR/>During an interview on 08/30/2023 at 10:20 AM, the SW stated Resident #1 was sent to the hospital initially, but they couldn't provide services for him then he was referred to the psychiatric hospital. The SW stated the psychiatric hospital was a short-term facility but she didn't know if Resident #1 was going to return to the facility or not. The Social Worker stated cooperate and the Administrator would have more information regarding the discharge of Resident #1. The SW stated no discharge summary was completed for Resident #1. <BR/>During an interview on 08/30/2023 at 10:45 AM, the ADM stated there was no discharge notice given to Resident #1. The ADM stated the facility did not anticipate Resident #1 returning due to Resident #1 hitting another resident and the other residents were in fear of him. The ADM stated the SW and Resident #1's responsible party discussed Resident #1 being discharged to the psychiatric hospital but there was no documentation of it. The ADM stated the facility did not assist the family with location placement for Resident #1 once he was released from the psychiatric hospital. The ADM stated there was no discharge summary done for Resident #1.<BR/>Record review of the facility's transfer and discharge notice policy, dated 12/2016, revealed Policy Statement .Our facility shall provide a resident and/or the resident's representative (sponsor) with a thirty (30)-day written notice of an impending transfer or discharge.<BR/>Policy Interpretation and Implementation<BR/>1. <BR/>A resident, and/or his or her representative (sponsor), will be given a thirty (30)-day advance notice of and impending transfer or discharge from our facility .<BR/>4. A copy of the notice will be sent to the Office of the State Long-term Ombudsman

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (Resident #1) of three residents reviewed for transfer and discharge rights, in that:<BR/>The facility failed to make arrangements for safe and orderly discharge through care planning and involving the RP (Representative) for Resident #1.<BR/>This failure placed residents at risk of not receiving care and services to meet their needs upon discharge. <BR/>Findings Included:<BR/>Review of Resident #1's undated face sheet reflected a [AGE] year-old male was admitted to the facility on [DATE] with a diagnosis of ataxia (poor muscle control), cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, or responding accurately), type 2 diabetes mellitus (blood sugar is too high), hyperlipidemia (excess of lipids or fats in your blood), bipolar disorder (Mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), major depressive disorder (Depressed mood and loss of interest in activities that once brought joy), and essential primary hypertension (Blood is pumping with more force than normal through your arteries). <BR/>Record review of Resident #1's admission MDS assessment, dated 05/20/2023, revealed Resident #1's BIMS summary score was 12 indicating moderated cognitive impairment.<BR/>Review of Resident on 08/30/2023, revealed there was no discharge summary completed for Resident #1.<BR/>During an interview on 08/30/2023 at 9:22 AM, the RP #1 stated Resident #1 or his family was notified he would be discharged from the facility. RP #1 stated she reached out to the facility for assistance to find Resident #1 another facility to reside in but no one returned her called. RP #1stated there was no discharge meeting and all she knew was Resident #1 was going to a psychiatric hospital for help. RP #1 stated she never received a discharge notice from the facility.<BR/>During an interview on 08/30/2023 at 10:20am, the SW stated Resident #1 was sent to [named hospital] initially, but they couldn't provide services for him then he was referred to [named psychiatric hospital]. The SW stated the [named psychiatric hospital] was a short-term facility but stated she didn't know if Resident #1 was going to return to the facility or not. The social worker stated the cooperate and the administrator would have more information regarding the discharge of Resident #1. The SW stated no discharge summary was completed for Resident #1. <BR/>During an interview on 08/30/2023 at 10:45am, ADM stated there was no discharge notice given to Resident #1. The ADM stated that the facility did not anticipate Resident #1 returning due to Resident #1 hitting another resident and other resident were in fear of him. The ADM stated the SW and Resident #1 responsible party discussed Resident #1 being discharged to [named psychiatric hospital] but there was no documentation of it. The ADM stated the facility did not assist the family with location placement for Resident #1 once he was released from [named psychiatric hospital]. ADM stated there was no discharge summary done for Resident #1.<BR/>Review of the facility's transfer and discharge notice policy dated 12/2016, revealed Policy Statement Our facility shall provide a resident and/or the resident's representative (sponsor) with a thirty (30)-day written notice of an impending transfer or discharge.<BR/>Policy Interpretation and Implementation<BR/>2. <BR/>A resident, and/or his or her representative (sponsor), will be given a thirty (30)-day advance notice of and impending transfer or discharge from our facility.<BR/>3. <BR/>Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: <BR/>A. <BR/>The transfer is necessary for the residents' welfare and the resident's needs cannot be met in the facility;<BR/>B. <BR/>The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility:<BR/>C. <BR/>The safety of individuals in the facility is endangered;<BR/>D. <BR/>The health of individuals in the facility would otherwise be endangered;<BR/>E. <BR/>The resident has failed; after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility;<BR/>F. <BR/>An immediate transfer or discharge is required the resident's urgent medical needs;<BR/>G. <BR/>The resident has not resided in the facility for (30) days; and or<BR/>H. <BR/>The facility ceases to operate.<BR/>4. <BR/>The resident and/or representative (sponsor) will be notified in writing of the following information:<BR/>A. <BR/>The reason for the transfer or discharge;<BR/>B. <BR/>The effective date of the transfer or discharge;<BR/>C. <BR/>The location of which the resident is being transferred or discharged ;<BR/>D. <BR/>A statement of the resident's rights to appeal the transfer or discharge; include<BR/>1. <BR/>the name, address, email and telephone number of the entity which receives such requests;<BR/>2. <BR/>information about how to obtain, complete and submit an appeal form; and<BR/>3. <BR/>how to get assistance completing the appeal process;<BR/>E. <BR/>The facility bed hold policy.<BR/>F. <BR/>The name, address and telephone number of the Office of the State Long-term Care Ombudsman;<BR/>G. <BR/>The name, address and telephone number of the agency responsible for the protection and advocacy of residents with intellectual and developmental (or related) disabilities (as applies);<BR/>H. <BR/>The name, address and telephone number of the agency responsible for the protection and advocacy of residents with mental disorder or related disabilities (as applies); and <BR/>I. <BR/>The name, address and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices.<BR/>4. A copy of the notice will be sent to the Office of the State Long-term Ombudsman.<BR/>5. The reason for the transfer or discharge will be documented in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident was free from abuse for 4 (Residents #2, #3, #4, and #5) of 5 residents reviewed for abuse.<BR/>The facility failed to ensure Resident #2, #3, #4, and #5 were protected from verbal abuse including verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group and intimidating from Resident #1; and sexually lewd behavior and questions; including urination in cups at breakfast from Resident #6.<BR/>As a result of the facility's failures Residents #2, #3, #4, and #5 suffered continual negative psychosocial outcomes including crying, fear and anxiety, feelings of hopelessness, and withdrawal from former social patterns.<BR/>An IJ was identified on 03/11/23. The IJ template was provided to the facility on [DATE] at 6:45 pm. While the IJ was removed on 03/13/23 at 4:45 pm, the facility remained out of compliance at a scope of pattern and a severity level of actual harm to resident health or safety due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.<BR/>This failure caused actual harm to 4 residents and placed all residents in the facility at risk for severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being.<BR/>Findings included:<BR/>Abuse neglect and exploitation policy <BR/>Record review of the facility abuse policy, dated 2/1/17, revised 1/1/23; right to be free from any type of abuse . Residents will not be subjected to abuse by anyone including other residents This includes physical, verbal, sexual (including indecent exposure), physical/chemical restraint<BR/>Record review of Resident #1's undated face sheet revealed a [AGE] year-old male admitted to the facility 10/23/21 with diagnoses including: epilepsy (seizures), cerebral infarction (stroke), hemiplegia (partial paralysis), insomnia, depression, repeated falls, mood disorder, and anxiety.<BR/>Record review of Resident #1's quarterly MDS , dated 12/09/22 revealed:<BR/>Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact.<BR/>Section E Behavior Symptom - presence and frequency revealed a 0 for physical behavioral symptoms directed toward others, verbal behavioral symptoms directed towards others, and other behavioral symptoms not directed toward others; this indicated that these behaviors were not present.<BR/>Record review of Resident #1's undated care plan revealed: he has a history of high-risk heterosexual behaviors, makes sexual advances towards female staff members and grabs their private parts and touches them inappropriately. Intervention included monitoring every shift and redirecting. It further revealed that Resident #1 has a potential to be physically aggressive, he assaulted his roommate 04/13/21.<BR/>Record review of Resident #1's progress notes, printed 03/13/23 revealed:<BR/>03/09/23 9:23 pm behavior note: Resident had several issues today where he hit this nurse and other staff . hit this nurse four times<BR/>10/28/22 8:18 am nurse note: Resident in hall way and called another female resident a bitch<BR/>08/01/22 12:47 pm nurse note: resident and another got in altercation and were hitting each other outside in smoking area, <BR/>07/13/22 6:30 am nurse note: resident angry called nurse a bitch and demanded she come to his room now, <BR/>07/12/22 1:09 pm nurse note: housekeeper saw Resident #1 in another resident room and asked him to leave and he started hitting her with a wash cloth and refused to stop when asked<BR/>07/10/22 10:15 am nurse note: Resident #1 pointing at vagina of staff stating I want that pussy and I'm watching your ass , <BR/>07/03/22 1:40 am behavior note: Resident #1 tried to reach down CNA top, tried to kiss her while she changed his brief, This is a frequent behavior from resident <BR/>05/26/22 11:45 am nurse note: resident in dining room blaring music, said fuck you when nurse asked him to lower volume, only lowered it after several requests, record review of facility incident list printed 03/13/23 showed no incident report on this date<BR/>05/26/22 8:20 am behavior note: wanted to smoke, tried to hit staff with wheelchair, told female resident to shut her mouth and called her a fat bitch, note states this is not the first time he behaved like this<BR/>4/13/21 Note Text: CNA reported to this nurse that this resident bumped into his roommate's wheelchair and hit resident with his fist. Both residents became physically aggressive towards each other. Resident denies physical altercation, but roommate states resident punched him after moving his wheelchair off of his leg, roommate states he hit resident back after he was hit, residents separated at this time resident moved to another room, Dr. notified, and family member notified, Will continue to monitor. <BR/>Record review of the facility's incident list, printed on 03/13/23 revealed no incident reports no incident report for any of the progress notes reviewed above.<BR/>Record review of the grievance log shows Resident #1 was in an altercation with another resident on 03/08/22.<BR/>Record review of Resident #2's undated face sheet revealed a [AGE] year-old female originally admitted [DATE] with diagnoses including: type 2 diabetes, obesity, hepatitis C, dementia, bipolar disorder, and absence of left leg below the knee.<BR/>Record review of Resident #2's most recent MDS date 01/30/23 revealed:<BR/>Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact.<BR/>Record review of Resident #3's undated face sheet revealed that he was a [AGE] year-old male admitted [DATE] with diagnoses including: type 2 diabetes, depression, dementia, and anxiety.<BR/>Record review of Resident #3's quarterly MDS dated [DATE] revealed:<BR/>Section C for Brief Interview for Mental Status score revealed a score of 14, which indicated the resident's cognition was intact.<BR/>Record review of Resident #4's undated face sheet revealed that she was a [AGE] year-old female first admitted to the facility on [DATE], and most recently admitted on [DATE] with diagnoses including: Chronic post-traumatic stress disorder, major depressive disorder, obesity, hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke), and obesity.<BR/>Record review of Resident #4's significant change MDS, dated [DATE], revealed:<BR/>Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact.<BR/>Record review of Resident #5's undated face sheet revealed that he was a [AGE] year-old male admitted [DATE] with diagnoses including: type 2 diabetes, anxiety, bipolar disorder, stroke causing partial paralysis, repeated falls, and Parkinson's.<BR/>Record review of Resident #5's quarterly MDS dated [DATE] revealed:<BR/>Section C for Brief Interview for Mental Status score revealed a score of 13, which indicated the resident's cognition was intact.<BR/>Record review of Resident #6's undated face sheet revealed that he was a [AGE] year-old male admitted [DATE] with diagnoses including traumatic brain injury, intermittent explosive disorder (unpredictable outbursts of anger), falls, dementia, anxiety, and depression.<BR/>Record review of Resident #6's admission MDS dated [DATE] revealed:<BR/> Section C for Brief Interview for Mental Status score revealed a score of 11, which indicated the resident's cognition was moderately impaired. <BR/>Section E Behavior Symptom - presence and frequency revealed a 0 for physical behavioral symptoms directed toward others, verbal behavioral symptoms directed towards others, which indicated that the behavior did not occur and 1 for other behavioral symptoms not directed toward others; this indicated that these behaviors occurred 1 to 3 days. It further indicated on E0500 Impact on the resident was marked as 0 indicating behaviors did not impact the resident. On section E0600 Impact on Others was marked 0 indicating the behaviors did not impact other residents.<BR/>Record review of Resident #6's undated care plan revealed The resident has a behavior problem related to inappropriate behaviors, cusses, talks inappropriate to staff, throws urine on floor, turns over bedside table when laying in bed; Resident will place himself on the floor to urinate and defecate on floor. Resident will inappropriately touch staff at times. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Minimize potential for the resident's disruptive behaviors inappropriate touching and<BR/>urinating in cups by offering tasks which divert attention such as puzzles.<BR/>Record review of Resident #6's progress notes, printed 3/11/23 revealed:<BR/>Nurses note dated 3/6/23 9:46 pm resident removed his brief and threw it on the floor, also urinated in cup and threw it on the floor<BR/>Nurses note dated 3/6/23 12:19 pm resident was banging on walls all morning long, continues cussing at staff<BR/>Nurses note dated 3/4/23 12:39 pm resident yelling and cursing at staff<BR/>Nurses note dated 3/3/23 1:19 pm resident yelling, banging on walls, cursing at staff<BR/>Nurses note dated 3/3/23 3:37 am resident banging on walls<BR/>Nurses note dated 3/2/23 10:49 am resident banging on walls, yelling, cursing staff, calling them bitch<BR/>Nurses note dated 2/27/23 12:16 pm resident banging on walls and yelling<BR/>Nurses note dated 2/26/23 11:05 am resident in sunroom with female resident and proceeded to pee in cup, educated, stated he did not care<BR/>Nurses note dated 2/24/23 12:52 pm resident in dining room attempting to urinate in flower vase<BR/>Nurses note dated 2/24/23 9:07 am resident banging on walls, bed pulled from wall, pouring urine on floor, roommate stated all night long pouring urine on floor, nurse went to tell him to stop banging on the walls he stated you bitch, you bitch I will punch you in your fucking face<BR/>Nurses note dated 2/22/23 1:59 pm resident peeing in hallway<BR/>Nurses note dated 2/10/23 12:11 pm yelling at housekeeper to suck his penis and calling her a bitch.<BR/>Nurses note dated 2/8/23 Note Text: Resident was in the dining room for breakfast and he was trying to pee in a plastic cup like he did yesterday. He was taken out and taken to his room.<BR/>Nurses note dated 2/7/23 Note Text: Resident was cursing the CNA this morning calling her a Bitch. Following her down the hallway. He then started yelling at another CNA and I informed him to stop. Resident went into the dining room and peed in a glass and poured it in the floor<BR/>Resident #6 was not interviewable.<BR/>In an interview and observation on 03/10/23 at 3:37 pm with Resident #4, she stated, Resident #1 is angry she was elected to the Resident Council and not him. She stated she felt harassed by him since she arrived in December. She stated he was also hostile towards her and she constantly feared encountering Resident #1. He also called her a fat cow, she told administrator two or three weeks ago, who told him not to do it anymore, but she said he harasses her and she tries to avoid him at all times. He plays his music so loud that it disrupts her sleep and rest and the music is vulgar. He cranks it in the dining room and common areas too. He was in a resident room and raised his hand to hit a little lady in a wheelchair who has severe dementia until Resident #4 intervened verbally. While surveyor was speaking with Resident #4, Resident #1 approached to try to listen in to the conversation and ended up kicking the back of Resident #4's wheelchair. Staff that were outside in the smoking area did not intervene when Resident #1 approached Surveyor and Resident #4 during interview. She stated Resident #1 continues to harass her, call her names and cause her distress. She stated it began when he made sexual advances towards her that she declined. Resident #4 said he has brought her to tears at times and that she has to walk on eggshells and try to avoid contact with Resident #1. When Resident #4 was describing the interactions with Resident #1 she appeared distressed and her eyes watered. At times her voice trembled as she recounted specific details. She stated that her room was directly across the hall from his room, and he blares vulgar music in common areas and in his room (which disrupts her). Resident #4 stated she told the ADM about the inappropriate advances and him calling her names and nothing changed. She also stated she was tired of Resident #6 being disruptive, which included him urinating on her chair in the dining room, urinating in cups in the dining room, and constant banging on walls and screaming and cursing. <BR/>In an interview and observation on 03/13/23 at 6:43 pm with Resident #4, she stated that she liked her roommate and that she was upset because Resident #1 was across the hall, but it was very hard that her tormentor is across the hall because it was a reminder of my abuse and the only time I feel 100% safe is when he is in his bed. She stated she felt safe when he was in bed because he was partially paralyzed and not able to get out of bed without staff assistance While being interviewed outside in the smoking area, Resident #1 was outside with one aide watching the 7 residents outside; as Resident #4 was speaking with surveyor, Resident #1 wheeled over to within 2 feet of Resident #4 and no staff intervened. Resident #4 stated that if she made an allegation of abuse that she would be moved from her room, which greatly upset Resident #4 because she stated she helps her roommate and cares for her.<BR/>In an interview and observation on 03/10/23 at 3:37 pm with Resident #5 stated Resident #1 blares loud music and he feels bullied by Resident #1 and 2 other residents also bullied him, all of whom hang out. One of the reasons he resigned from the office on the Resident Council to which he was elected after less than 1 week is intimidation by Resident #1. He stated that he does not attend social events anymore due to fear of running across Resident #1. He stated he would enjoy these activities if Resident #1 were not present. Resident #5 stated that he is disgusted by the behavior of Resident #6 and that he doesn't belong at the facility with all of his sexually lewd talk and inappropriate behaviors such as urinating in the dining room. During the interview with Resident #5 his voice trembled and his hands started to shake when he described encounters with Resident #1 and his ongoing fear of being bullied by Resident #1 and the other 2 residents that bullied him.<BR/>In an interview and observation on 03/10/23 at 3:37 pm with Resident # 3 he stated that Resident #1 threw a bottle of hot sauce on his face in the dining room in front of everyone; he stated a staff member even took pictures, but the staff member was no longer here. He stated this occurred a few months ago, possibly December or January. He stated that Resident #6 was asking sexually inappropriate questions about Resident #3's grandchildren. He stated Resident #6 makes sexually inappropriate comments on a daily basis. He further stated that Resident #6's inappropriate behavior was ignored by staff. When he was describing the sexually inappropriate speech and behavior of Resident #6, he lowered his voice to almost a whisper. When he discussed Resident #1 throwing the bottle of hot sauce on him and constant blaring of inappropriate music his voice became elevated and his face turned red. He reiterated that Resident #1 disrupted the calm environment.<BR/>On 03/11/23 at 12:00 pm during an interview with Interim DON the results of the safe surveys were reviewed and an additional victim of verbal abuse, Resident #2 was identified as being fearful of Resident #1.<BR/>In an interview and observation on 03/11/23 at 3:00 pm with Resident #2 she stated that Resident #1 has on 5 or 6 occasions called Resident #2 names such as 1 legged bitch and fat slob. This verbal abuse started about a year ago, and she stated she has told the prior administrator, the current interim administrator, and the interim director of nurses and all said they would talk to him. She won't cry in front of him but goes to her room and sobs uncontrollably. This has caused her to change directions any time she sees him, avoid activities when he is present and causes her ongoing anxiety. She cried after each event. She also witnessed him and another resident almost come to blows (engage in physical aggression). When she was being interviewed, Resident #2 appeared tearful and agitated. She was emotional as she spoke.<BR/>In an interview with Resident #1 on 03/11/23 at 9:25 am he stated that Resident #4 doesn't do her job as an elected official on the Resident Council like he did when he [NAME] the position; she hasn't been here 6 months and he has been here over 2 years. He complained the whole cabinet was appointed by her and all of them are [NAME] (all positions are elected per DON). He stated she doesn't care about Black residents. When he was on the council he got up and did rounds on all of the residents in the facility. He stated, I admit, I called her a pig, one time. He stated she doesn't like Black people, but he doesn't know if it just him. He also admitted throwing a bottle of hot sauce at another resident.<BR/>In an interview on 03/09/23 at 2:00 pm with the DON and ADM, the Adm stated that Resident #1 called Resident #4 a fat pig. He stated he spoke to Resident #1 and told him he could not talk to people like that and the resident apologized and stated he would not do it again. <BR/>In an interview on 03/10/23 at 8:30 am with the DON and ADM, the DON stated that the three residents who were the victims of abuse all had psychological diagnoses and asked where does Resident #1's rights stop; DON stated that is how he was raised . The ADM stated that Resident #5 was a music teacher and is just sensitive. He further stated he did not get involved with petty disputes between residents. They both denied knowledge of Resident #1 throwing a bottle of hot sauce at Resident #3, which caused it to shatter on his beard. They stated Resident #6 had these behaviors, such as sexually inappropriate comments and banging on the walls all nights, and urinating in public places. DON stated he apologized when she spoke to him, but then resumed the behaviors; she did stated that Resident #6 knew what he was doing and continued the behaviors. <BR/>On 03/11/23 at 6:45 pm the Interim DON and Interim Administrator were informed that an Immediate Jeopardy (IJ) for abuse was identified and were provided the Immediate Jeopardy template.<BR/>On 03/13/23 at 4:45 pm the following plan of removal was accepted:<BR/>Impact Statement <BR/>F600 Abuse<BR/>The resident has the right to be free from abuse, neglect misappropriation of resident property as defined in this subpart. This includes but is not limited to freedom from corporal punishment involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.<BR/>Identify residents who could be affected<BR/>All residents who came into contact with Residents #1 and #6 have the potential to be affected by this alleged deficient practice<BR/>Problem<BR/>F600- The facility failed to prevent ongoing verbally aggressive behaviors, such as screaming, cursing, bossing around/demanding, insulting race or ethnic group, intimidating, sexually lewd behavior and questions; including urinating in cups at breakfast by 2 residents resulting in 4 residents reporting secluding in rooms and/or avoiding activities previously enjoyed.<BR/>Action Taken <BR/>Resident #1 was placed on 1:1 on 3/10/23 and it will be ongoing until residents exhibit improved behaviors or alternate placement is arranged; the Interim Direct of Nurse will ensure the resident remains on 1:1. Beginning 3/10/23 at 5pm Staff members will be assigned and notified of assignment to include always keeping resident within eyesight. The interim administrator will oversee actions taken. <BR/>Resident #6 was placed on 1:1 on 3/10/23 Resident will remain 1:1 until behaviors are improved or alternate placement is arranged; the Interim Direct of Nurse will ensure the resident remains on 1:1. Beginning 3/10/23 at 5pm Staff members will be assigned and notified of assignment to include always keeping resident within eyesight. The interim administrator will oversee actions taken. <BR/>Psych services were consulted on 3/11/23 to evaluate both Resident #1 and Resident #6 to determine a course of treatment to assist with alleged inappropriate behaviors. Psych services will provide counseling on 3/12/23. Psych services will be care planned on 3/12/23 by the Regional Clinical Reimbursement Coordinator. Verified by Corporate Clinical Reimbursement Specialist.<BR/>Psych services were consulted on 3/11/23 to evaluate Residents #2, #3, #4, and #5 to assist with any alleged psychosocial distress from behaviors by Residents #1 and #6. Psych services will provide counseling on 3/12/23. Psych services will be care planned on 3/12/23 by the Regional Clinical Reimbursement Coordinator. Verified by Corporate Clinical Reimbursement Specialist.<BR/>Safe Surveys were conducted by administrative nurses on 3/11/23 with all alert and oriented residents to determine if there were any residents who did not feel safe in the facility. Verification of completion was done by the Interim Administrator. Two residents reported that they did not feel safe, the individuals that they are reportedly fearful of are on 1:1 observation and have been evaluated by psych services and will be seen at least weekly for 4 weeks.<BR/>Regional Director of Clinical Operations educated Interim administrator and Interim Director of Nursing on reporting of abuse and neglect allegations on 3/11/23.<BR/>The Interim Director of Nursing and/or designee began educating all staff on the facility's Abuse and Neglect policy on 3/11/23. All staff will be educated prior to their next assigned shift. Training will continue until all staff has been educated. This training will be part of any new hire orientation on the next schedule orientation 3/14/23. <BR/>The Interim Director of Nursing and/or designee began educating nurses on when to complete an Incident Report on 3/11/23. All nurses will be educated prior to their next assigned shift. Training will continue until all nurses have been educated. This training will be part of any new hire orientation for nurses. This training will be part of any new hire orientation on the next schedule orientation 3/14/23. <BR/>Involvement of Medical Director and Quality Assurance<BR/>Ad HOC QA meeting held with the medical director on 03/11/23 at 7:38 pm to review all aspects of Immediate Jeopardy and Initial Plan of removal. <BR/>QAPI meetings are held on a monthly basis and all allegations, incidents, and accidents will be reviewed during the QAPI meeting. This will be an ongoing process.<BR/>POR monitoring .<BR/>An observation on 03/12/23 at 11:15 am revealed Resident #1 at the facility entrance sitting in a wheelchair being assisted by a cna in a 1 to 1 with the resident.<BR/>An observation on 03/12/23 at 11:20 am revealed Resident #6 in the sunroom sitting in a wheelchair playing a board game assisted by a cna in a 1 to 1 with the resident.<BR/>An observation on 03/12/23 at 11:45 am revealed Resident #1 in a 1 to 1 with a CNA in his room.<BR/>An observation on 03/12/23 at 1:00 pm revealed Resident #6 in the sunroom sitting in a wheelchair playing a board game assisted by a cna in a 1 to 1 with the resident.<BR/>An observation on 03/12/23 at 1:10 pm revealed Resident #1 in a 1 to 1 with a CNA in his room.<BR/>An observation on 03/13/23 at 6:00 pm revealed Resident #6 was outdoors with a CNA taking a walk one on one.<BR/>An observation on 03/13/23 at 6:15 pm revealed Resident #1 was observed with CNA one-on-one walking down the hall<BR/>An interview on 03/13/23 at 6:32 pm revealed that CMA A was able to answer questions regarding abuse, reporting and resident on resident abuse; stated in-service today on abuse.<BR/>An interview on 03/13/23 at 6:36 pm revealed LVN B was able to answer questions related to abuse, reporting, verbal abuse, and resident abusing other residents and stated she was in-serviced this weekend.<BR/>Record review of the medical records safe surveys were conducted on 03/11/23. In addition, psyc services were consulted according to the medical records. <BR/>Based on observation, interview and record review the plan of removal was implemented and the IJ was removed on 03/13/23 at 4:45 pm, the facility remained out of compliance at a scope of pattern and a severity level of actual harm to resident health or safety due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident was free from abuse for 4 (Residents #2, #3, #4, and #5) of 5 residents reviewed for abuse.<BR/>The facility failed to ensure Resident #2, #3, #4, and #5 were protected from verbal abuse including verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group and intimidating from Resident #1; and sexually lewd behavior and questions; including urination in cups at breakfast from Resident #6.<BR/>As a result of the facility's failures Residents #2, #3, #4, and #5 suffered continual negative psychosocial outcomes including crying, fear and anxiety, feelings of hopelessness, and withdrawal from former social patterns.<BR/>An IJ was identified on 03/11/23. The IJ template was provided to the facility on [DATE] at 6:45 pm. While the IJ was removed on 03/13/23 at 4:45 pm, the facility remained out of compliance at a scope of pattern and a severity level of actual harm to resident health or safety due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.<BR/>This failure caused actual harm to 4 residents and placed all residents in the facility at risk for severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being.<BR/>Findings included:<BR/>Abuse neglect and exploitation policy <BR/>Record review of the facility abuse policy, dated 2/1/17, revised 1/1/23; right to be free from any type of abuse . Residents will not be subjected to abuse by anyone including other residents This includes physical, verbal, sexual (including indecent exposure), physical/chemical restraint<BR/>Record review of Resident #1's undated face sheet revealed a [AGE] year-old male admitted to the facility 10/23/21 with diagnoses including: epilepsy (seizures), cerebral infarction (stroke), hemiplegia (partial paralysis), insomnia, depression, repeated falls, mood disorder, and anxiety.<BR/>Record review of Resident #1's quarterly MDS , dated 12/09/22 revealed:<BR/>Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact.<BR/>Section E Behavior Symptom - presence and frequency revealed a 0 for physical behavioral symptoms directed toward others, verbal behavioral symptoms directed towards others, and other behavioral symptoms not directed toward others; this indicated that these behaviors were not present.<BR/>Record review of Resident #1's undated care plan revealed: he has a history of high-risk heterosexual behaviors, makes sexual advances towards female staff members and grabs their private parts and touches them inappropriately. Intervention included monitoring every shift and redirecting. It further revealed that Resident #1 has a potential to be physically aggressive, he assaulted his roommate 04/13/21.<BR/>Record review of Resident #1's progress notes, printed 03/13/23 revealed:<BR/>03/09/23 9:23 pm behavior note: Resident had several issues today where he hit this nurse and other staff . hit this nurse four times<BR/>10/28/22 8:18 am nurse note: Resident in hall way and called another female resident a bitch<BR/>08/01/22 12:47 pm nurse note: resident and another got in altercation and were hitting each other outside in smoking area, <BR/>07/13/22 6:30 am nurse note: resident angry called nurse a bitch and demanded she come to his room now, <BR/>07/12/22 1:09 pm nurse note: housekeeper saw Resident #1 in another resident room and asked him to leave and he started hitting her with a wash cloth and refused to stop when asked<BR/>07/10/22 10:15 am nurse note: Resident #1 pointing at vagina of staff stating I want that pussy and I'm watching your ass , <BR/>07/03/22 1:40 am behavior note: Resident #1 tried to reach down CNA top, tried to kiss her while she changed his brief, This is a frequent behavior from resident <BR/>05/26/22 11:45 am nurse note: resident in dining room blaring music, said fuck you when nurse asked him to lower volume, only lowered it after several requests, record review of facility incident list printed 03/13/23 showed no incident report on this date<BR/>05/26/22 8:20 am behavior note: wanted to smoke, tried to hit staff with wheelchair, told female resident to shut her mouth and called her a fat bitch, note states this is not the first time he behaved like this<BR/>4/13/21 Note Text: CNA reported to this nurse that this resident bumped into his roommate's wheelchair and hit resident with his fist. Both residents became physically aggressive towards each other. Resident denies physical altercation, but roommate states resident punched him after moving his wheelchair off of his leg, roommate states he hit resident back after he was hit, residents separated at this time resident moved to another room, Dr. notified, and family member notified, Will continue to monitor. <BR/>Record review of the facility's incident list, printed on 03/13/23 revealed no incident reports no incident report for any of the progress notes reviewed above.<BR/>Record review of the grievance log shows Resident #1 was in an altercation with another resident on 03/08/22.<BR/>Record review of Resident #2's undated face sheet revealed a [AGE] year-old female originally admitted [DATE] with diagnoses including: type 2 diabetes, obesity, hepatitis C, dementia, bipolar disorder, and absence of left leg below the knee.<BR/>Record review of Resident #2's most recent MDS date 01/30/23 revealed:<BR/>Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact.<BR/>Record review of Resident #3's undated face sheet revealed that he was a [AGE] year-old male admitted [DATE] with diagnoses including: type 2 diabetes, depression, dementia, and anxiety.<BR/>Record review of Resident #3's quarterly MDS dated [DATE] revealed:<BR/>Section C for Brief Interview for Mental Status score revealed a score of 14, which indicated the resident's cognition was intact.<BR/>Record review of Resident #4's undated face sheet revealed that she was a [AGE] year-old female first admitted to the facility on [DATE], and most recently admitted on [DATE] with diagnoses including: Chronic post-traumatic stress disorder, major depressive disorder, obesity, hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke), and obesity.<BR/>Record review of Resident #4's significant change MDS, dated [DATE], revealed:<BR/>Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact.<BR/>Record review of Resident #5's undated face sheet revealed that he was a [AGE] year-old male admitted [DATE] with diagnoses including: type 2 diabetes, anxiety, bipolar disorder, stroke causing partial paralysis, repeated falls, and Parkinson's.<BR/>Record review of Resident #5's quarterly MDS dated [DATE] revealed:<BR/>Section C for Brief Interview for Mental Status score revealed a score of 13, which indicated the resident's cognition was intact.<BR/>Record review of Resident #6's undated face sheet revealed that he was a [AGE] year-old male admitted [DATE] with diagnoses including traumatic brain injury, intermittent explosive disorder (unpredictable outbursts of anger), falls, dementia, anxiety, and depression.<BR/>Record review of Resident #6's admission MDS dated [DATE] revealed:<BR/> Section C for Brief Interview for Mental Status score revealed a score of 11, which indicated the resident's cognition was moderately impaired. <BR/>Section E Behavior Symptom - presence and frequency revealed a 0 for physical behavioral symptoms directed toward others, verbal behavioral symptoms directed towards others, which indicated that the behavior did not occur and 1 for other behavioral symptoms not directed toward others; this indicated that these behaviors occurred 1 to 3 days. It further indicated on E0500 Impact on the resident was marked as 0 indicating behaviors did not impact the resident. On section E0600 Impact on Others was marked 0 indicating the behaviors did not impact other residents.<BR/>Record review of Resident #6's undated care plan revealed The resident has a behavior problem related to inappropriate behaviors, cusses, talks inappropriate to staff, throws urine on floor, turns over bedside table when laying in bed; Resident will place himself on the floor to urinate and defecate on floor. Resident will inappropriately touch staff at times. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Minimize potential for the resident's disruptive behaviors inappropriate touching and<BR/>urinating in cups by offering tasks which divert attention such as puzzles.<BR/>Record review of Resident #6's progress notes, printed 3/11/23 revealed:<BR/>Nurses note dated 3/6/23 9:46 pm resident removed his brief and threw it on the floor, also urinated in cup and threw it on the floor<BR/>Nurses note dated 3/6/23 12:19 pm resident was banging on walls all morning long, continues cussing at staff<BR/>Nurses note dated 3/4/23 12:39 pm resident yelling and cursing at staff<BR/>Nurses note dated 3/3/23 1:19 pm resident yelling, banging on walls, cursing at staff<BR/>Nurses note dated 3/3/23 3:37 am resident banging on walls<BR/>Nurses note dated 3/2/23 10:49 am resident banging on walls, yelling, cursing staff, calling them bitch<BR/>Nurses note dated 2/27/23 12:16 pm resident banging on walls and yelling<BR/>Nurses note dated 2/26/23 11:05 am resident in sunroom with female resident and proceeded to pee in cup, educated, stated he did not care<BR/>Nurses note dated 2/24/23 12:52 pm resident in dining room attempting to urinate in flower vase<BR/>Nurses note dated 2/24/23 9:07 am resident banging on walls, bed pulled from wall, pouring urine on floor, roommate stated all night long pouring urine on floor, nurse went to tell him to stop banging on the walls he stated you bitch, you bitch I will punch you in your fucking face<BR/>Nurses note dated 2/22/23 1:59 pm resident peeing in hallway<BR/>Nurses note dated 2/10/23 12:11 pm yelling at housekeeper to suck his penis and calling her a bitch.<BR/>Nurses note dated 2/8/23 Note Text: Resident was in the dining room for breakfast and he was trying to pee in a plastic cup like he did yesterday. He was taken out and taken to his room.<BR/>Nurses note dated 2/7/23 Note Text: Resident was cursing the CNA this morning calling her a Bitch. Following her down the hallway. He then started yelling at another CNA and I informed him to stop. Resident went into the dining room and peed in a glass and poured it in the floor<BR/>Resident #6 was not interviewable.<BR/>In an interview and observation on 03/10/23 at 3:37 pm with Resident #4, she stated, Resident #1 is angry she was elected to the Resident Council and not him. She stated she felt harassed by him since she arrived in December. She stated he was also hostile towards her and she constantly feared encountering Resident #1. He also called her a fat cow, she told administrator two or three weeks ago, who told him not to do it anymore, but she said he harasses her and she tries to avoid him at all times. He plays his music so loud that it disrupts her sleep and rest and the music is vulgar. He cranks it in the dining room and common areas too. He was in a resident room and raised his hand to hit a little lady in a wheelchair who has severe dementia until Resident #4 intervened verbally. While surveyor was speaking with Resident #4, Resident #1 approached to try to listen in to the conversation and ended up kicking the back of Resident #4's wheelchair. Staff that were outside in the smoking area did not intervene when Resident #1 approached Surveyor and Resident #4 during interview. She stated Resident #1 continues to harass her, call her names and cause her distress. She stated it began when he made sexual advances towards her that she declined. Resident #4 said he has brought her to tears at times and that she has to walk on eggshells and try to avoid contact with Resident #1. When Resident #4 was describing the interactions with Resident #1 she appeared distressed and her eyes watered. At times her voice trembled as she recounted specific details. She stated that her room was directly across the hall from his room, and he blares vulgar music in common areas and in his room (which disrupts her). Resident #4 stated she told the ADM about the inappropriate advances and him calling her names and nothing changed. She also stated she was tired of Resident #6 being disruptive, which included him urinating on her chair in the dining room, urinating in cups in the dining room, and constant banging on walls and screaming and cursing. <BR/>In an interview and observation on 03/13/23 at 6:43 pm with Resident #4, she stated that she liked her roommate and that she was upset because Resident #1 was across the hall, but it was very hard that her tormentor is across the hall because it was a reminder of my abuse and the only time I feel 100% safe is when he is in his bed. She stated she felt safe when he was in bed because he was partially paralyzed and not able to get out of bed without staff assistance While being interviewed outside in the smoking area, Resident #1 was outside with one aide watching the 7 residents outside; as Resident #4 was speaking with surveyor, Resident #1 wheeled over to within 2 feet of Resident #4 and no staff intervened. Resident #4 stated that if she made an allegation of abuse that she would be moved from her room, which greatly upset Resident #4 because she stated she helps her roommate and cares for her.<BR/>In an interview and observation on 03/10/23 at 3:37 pm with Resident #5 stated Resident #1 blares loud music and he feels bullied by Resident #1 and 2 other residents also bullied him, all of whom hang out. One of the reasons he resigned from the office on the Resident Council to which he was elected after less than 1 week is intimidation by Resident #1. He stated that he does not attend social events anymore due to fear of running across Resident #1. He stated he would enjoy these activities if Resident #1 were not present. Resident #5 stated that he is disgusted by the behavior of Resident #6 and that he doesn't belong at the facility with all of his sexually lewd talk and inappropriate behaviors such as urinating in the dining room. During the interview with Resident #5 his voice trembled and his hands started to shake when he described encounters with Resident #1 and his ongoing fear of being bullied by Resident #1 and the other 2 residents that bullied him.<BR/>In an interview and observation on 03/10/23 at 3:37 pm with Resident # 3 he stated that Resident #1 threw a bottle of hot sauce on his face in the dining room in front of everyone; he stated a staff member even took pictures, but the staff member was no longer here. He stated this occurred a few months ago, possibly December or January. He stated that Resident #6 was asking sexually inappropriate questions about Resident #3's grandchildren. He stated Resident #6 makes sexually inappropriate comments on a daily basis. He further stated that Resident #6's inappropriate behavior was ignored by staff. When he was describing the sexually inappropriate speech and behavior of Resident #6, he lowered his voice to almost a whisper. When he discussed Resident #1 throwing the bottle of hot sauce on him and constant blaring of inappropriate music his voice became elevated and his face turned red. He reiterated that Resident #1 disrupted the calm environment.<BR/>On 03/11/23 at 12:00 pm during an interview with Interim DON the results of the safe surveys were reviewed and an additional victim of verbal abuse, Resident #2 was identified as being fearful of Resident #1.<BR/>In an interview and observation on 03/11/23 at 3:00 pm with Resident #2 she stated that Resident #1 has on 5 or 6 occasions called Resident #2 names such as 1 legged bitch and fat slob. This verbal abuse started about a year ago, and she stated she has told the prior administrator, the current interim administrator, and the interim director of nurses and all said they would talk to him. She won't cry in front of him but goes to her room and sobs uncontrollably. This has caused her to change directions any time she sees him, avoid activities when he is present and causes her ongoing anxiety. She cried after each event. She also witnessed him and another resident almost come to blows (engage in physical aggression). When she was being interviewed, Resident #2 appeared tearful and agitated. She was emotional as she spoke.<BR/>In an interview with Resident #1 on 03/11/23 at 9:25 am he stated that Resident #4 doesn't do her job as an elected official on the Resident Council like he did when he [NAME] the position; she hasn't been here 6 months and he has been here over 2 years. He complained the whole cabinet was appointed by her and all of them are [NAME] (all positions are elected per DON). He stated she doesn't care about Black residents. When he was on the council he got up and did rounds on all of the residents in the facility. He stated, I admit, I called her a pig, one time. He stated she doesn't like Black people, but he doesn't know if it just him. He also admitted throwing a bottle of hot sauce at another resident.<BR/>In an interview on 03/09/23 at 2:00 pm with the DON and ADM, the Adm stated that Resident #1 called Resident #4 a fat pig. He stated he spoke to Resident #1 and told him he could not talk to people like that and the resident apologized and stated he would not do it again. <BR/>In an interview on 03/10/23 at 8:30 am with the DON and ADM, the DON stated that the three residents who were the victims of abuse all had psychological diagnoses and asked where does Resident #1's rights stop; DON stated that is how he was raised . The ADM stated that Resident #5 was a music teacher and is just sensitive. He further stated he did not get involved with petty disputes between residents. They both denied knowledge of Resident #1 throwing a bottle of hot sauce at Resident #3, which caused it to shatter on his beard. They stated Resident #6 had these behaviors, such as sexually inappropriate comments and banging on the walls all nights, and urinating in public places. DON stated he apologized when she spoke to him, but then resumed the behaviors; she did stated that Resident #6 knew what he was doing and continued the behaviors. <BR/>On 03/11/23 at 6:45 pm the Interim DON and Interim Administrator were informed that an Immediate Jeopardy (IJ) for abuse was identified and were provided the Immediate Jeopardy template.<BR/>On 03/13/23 at 4:45 pm the following plan of removal was accepted:<BR/>Impact Statement <BR/>F600 Abuse<BR/>The resident has the right to be free from abuse, neglect misappropriation of resident property as defined in this subpart. This includes but is not limited to freedom from corporal punishment involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.<BR/>Identify residents who could be affected<BR/>All residents who came into contact with Residents #1 and #6 have the potential to be affected by this alleged deficient practice<BR/>Problem<BR/>F600- The facility failed to prevent ongoing verbally aggressive behaviors, such as screaming, cursing, bossing around/demanding, insulting race or ethnic group, intimidating, sexually lewd behavior and questions; including urinating in cups at breakfast by 2 residents resulting in 4 residents reporting secluding in rooms and/or avoiding activities previously enjoyed.<BR/>Action Taken <BR/>Resident #1 was placed on 1:1 on 3/10/23 and it will be ongoing until residents exhibit improved behaviors or alternate placement is arranged; the Interim Direct of Nurse will ensure the resident remains on 1:1. Beginning 3/10/23 at 5pm Staff members will be assigned and notified of assignment to include always keeping resident within eyesight. The interim administrator will oversee actions taken. <BR/>Resident #6 was placed on 1:1 on 3/10/23 Resident will remain 1:1 until behaviors are improved or alternate placement is arranged; the Interim Direct of Nurse will ensure the resident remains on 1:1. Beginning 3/10/23 at 5pm Staff members will be assigned and notified of assignment to include always keeping resident within eyesight. The interim administrator will oversee actions taken. <BR/>Psych services were consulted on 3/11/23 to evaluate both Resident #1 and Resident #6 to determine a course of treatment to assist with alleged inappropriate behaviors. Psych services will provide counseling on 3/12/23. Psych services will be care planned on 3/12/23 by the Regional Clinical Reimbursement Coordinator. Verified by Corporate Clinical Reimbursement Specialist.<BR/>Psych services were consulted on 3/11/23 to evaluate Residents #2, #3, #4, and #5 to assist with any alleged psychosocial distress from behaviors by Residents #1 and #6. Psych services will provide counseling on 3/12/23. Psych services will be care planned on 3/12/23 by the Regional Clinical Reimbursement Coordinator. Verified by Corporate Clinical Reimbursement Specialist.<BR/>Safe Surveys were conducted by administrative nurses on 3/11/23 with all alert and oriented residents to determine if there were any residents who did not feel safe in the facility. Verification of completion was done by the Interim Administrator. Two residents reported that they did not feel safe, the individuals that they are reportedly fearful of are on 1:1 observation and have been evaluated by psych services and will be seen at least weekly for 4 weeks.<BR/>Regional Director of Clinical Operations educated Interim administrator and Interim Director of Nursing on reporting of abuse and neglect allegations on 3/11/23.<BR/>The Interim Director of Nursing and/or designee began educating all staff on the facility's Abuse and Neglect policy on 3/11/23. All staff will be educated prior to their next assigned shift. Training will continue until all staff has been educated. This training will be part of any new hire orientation on the next schedule orientation 3/14/23. <BR/>The Interim Director of Nursing and/or designee began educating nurses on when to complete an Incident Report on 3/11/23. All nurses will be educated prior to their next assigned shift. Training will continue until all nurses have been educated. This training will be part of any new hire orientation for nurses. This training will be part of any new hire orientation on the next schedule orientation 3/14/23. <BR/>Involvement of Medical Director and Quality Assurance<BR/>Ad HOC QA meeting held with the medical director on 03/11/23 at 7:38 pm to review all aspects of Immediate Jeopardy and Initial Plan of removal. <BR/>QAPI meetings are held on a monthly basis and all allegations, incidents, and accidents will be reviewed during the QAPI meeting. This will be an ongoing process.<BR/>POR monitoring .<BR/>An observation on 03/12/23 at 11:15 am revealed Resident #1 at the facility entrance sitting in a wheelchair being assisted by a cna in a 1 to 1 with the resident.<BR/>An observation on 03/12/23 at 11:20 am revealed Resident #6 in the sunroom sitting in a wheelchair playing a board game assisted by a cna in a 1 to 1 with the resident.<BR/>An observation on 03/12/23 at 11:45 am revealed Resident #1 in a 1 to 1 with a CNA in his room.<BR/>An observation on 03/12/23 at 1:00 pm revealed Resident #6 in the sunroom sitting in a wheelchair playing a board game assisted by a cna in a 1 to 1 with the resident.<BR/>An observation on 03/12/23 at 1:10 pm revealed Resident #1 in a 1 to 1 with a CNA in his room.<BR/>An observation on 03/13/23 at 6:00 pm revealed Resident #6 was outdoors with a CNA taking a walk one on one.<BR/>An observation on 03/13/23 at 6:15 pm revealed Resident #1 was observed with CNA one-on-one walking down the hall<BR/>An interview on 03/13/23 at 6:32 pm revealed that CMA A was able to answer questions regarding abuse, reporting and resident on resident abuse; stated in-service today on abuse.<BR/>An interview on 03/13/23 at 6:36 pm revealed LVN B was able to answer questions related to abuse, reporting, verbal abuse, and resident abusing other residents and stated she was in-serviced this weekend.<BR/>Record review of the medical records safe surveys were conducted on 03/11/23. In addition, psyc services were consulted according to the medical records. <BR/>Based on observation, interview and record review the plan of removal was implemented and the IJ was removed on 03/13/23 at 4:45 pm, the facility remained out of compliance at a scope of pattern and a severity level of actual harm to resident health or safety due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure the resident care plan accurately reflected the resident's status for 1 of 4 residents (Resident #12) who were reviewed for care plans.<BR/>The facility failed to care plan Resident #12's use of hearing aids. <BR/>This failure could place residents at risk of their needs going unmet. <BR/>Findings included:<BR/>Record review of Resident #12's quarterly MDS, dated [DATE], indicated Resident #12 was a [AGE] year-old male, who was admitted to the facility on [DATE]. He had diagnoses of dementia, major depressive disorder, depression, hereditary and idiopathic neuropathy (nervous system disorders that interfere with normal nerve function). His MDS also reflected in Section B Hearing, Speech, and Vision that Resident #12's ability to hear, had minimal difficulty, as well as that he did not have hearing aids or other hearing appliances. His BIMS score was 12, which indicated moderately impaired cognition.<BR/>Record review of Resident #12's care plan dated last revised on 01/31/2025 reflected resident had special instructions Very hard of hearing. He had a focus of the resident has a communication problem related to hearing loss The interventions listed included for staff to anticipate and meet needs, encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense or responds to the feeling resident is trying to express and refer to speech therapy for evaluation and treatment as ordered. His care plan did not have any indication of hearing aid use or refusal of usage. <BR/>Record review of Resident #12's doctor's order dated 9/24/2024 reflected, May have podiatry, dental, audiologist, & ophthalmologist consults PRN.<BR/>Observation on 02/10/2025 at 10:24 a.m., revealed Resident #12 sitting in his recliner in his room watching television. The resident voiced that his hearing aids needed to be repaired and that his family member was going to come get them to be fixed/replaced. The hearing aids were sitting on his bedside table. The state surveyor had to stand close, yell, speak slowly, and often repeat questions to the resident during the observation. The resident was unable to give an answer when the state surveyor asked him if the facility helped him with audiology appointments, even after writing the questions down for him due to the hearing impairment. <BR/>Interview on 02/12/2025 at 11:40 a.m., with the DON revealed she had started working at the facility 3 weeks ago. She stated that her expectation would be that hearing aids were care planned. She stated that Resident #12 had hearing aids in his room but refused to wear them and did not like them. She said that the resident's family member had planned to take the hearing aids home with him due to the resident not wearing them. She said he reads lips very well and can sign for things he needed. She said that it should have been care planned that he did not wear them.<BR/>Interview on 02/12/2025 at 12:48 p.m., with CNA A revealed she had worked at the facility for 2 years. She stated that Resident #12 would wear his hearing aids sometimes, but he had a hard time getting them to stay in his ears. She stated that she had to make sure she talked loudly and stood close to him when talking, but that most times she still had to repeat herself multiple times. She did not think he was good at reading lips due to the number of times she would have to repeat herself during conversations. <BR/>Record review of the facility's Comprehensive Care Plan policy dated last revised on 4/25/2021 revealed, Every resident will have an individualized interdisciplinary plan of care in place. The Interdisciplinary Team will continue to develop the plan in conjunction with the MDS 3.0, completing and conducting Comprehensive Care Plan Meeting and Reviews by day 21 after admission. The Interdisciplinary Team will review the healthcare practitioner's notes and orders and implement a comprehensive care plan to meet the residents' immediate care needs including but not limited to: therapy services, social services, psychosocial mood state needs as indicated, specific care plan on the main reason for admission to the community. Any updated information based on the details of the comprehensive care plan, as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 (Resident #4) of 1 residents reviewed for trauma-informed care.<BR/>The facility failed to protect Resident #4 from being re-traumatized by allowing her to be subjected to verbal abuse and verbal sexual abuse which led to her not feeling safe in her environment, feeling fear of being around another resident, and increased anxiety in her environment.<BR/>This failure placed Resident #4 at risk for severe negative psychosocial outcomes which could prevent her from achieving her highest practicable physical, mental, and psychosocial well-being.<BR/>Findings included:<BR/>Record review of Resident #4's undated face sheet revealed that she was a [AGE] year-old female first admitted to the facility on [DATE], and most recently admitted on [DATE] with diagnoses including: Chronic post-traumatic stress disorder, major depressive disorder, obesity, hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke), and obesity.<BR/>Record review of Resident #4's undated active care plan, accessed 03/13/23 revealed no mention of trauma, post-traumatic stress disorder, nor potential triggers from her history of trauma.<BR/>Record review of Resident #4's significant change MDS, dated [DATE], revealed:<BR/>Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact.<BR/>Section I Active Diagnoses was marked Anxiety, Depression, and Post Traumatic Stress Disorder<BR/>Section N Medications received A. Antipsychotic - given 7 of the last 7 days, C. Antidepressant - given 7 of the last 7 days, however question Antipsychotic Medication Review, question A was marked with a 0 indicating no antipsychotics were received<BR/>Section O Special treatments, procedures, and programs, section E Psychological therapy had 0 minutes marked<BR/>Record review of Resident #4's progress notes revealed a noted on 12/12/22 written by Social Services that stated resident survived physical and sexual abuse as a child.<BR/>Record review of Resident #4's Medication Administration Report for the month of March 2023 printed 03/13/23 revealed Paroxetine HCl Tablet 40 MG Give 1 tablet by mouth one time a day for depression and Olanzapine Tablet 5 MG Give 1 tablet by mouth one time a day for depression.<BR/>Record review of Resident #1's undated face sheet revealed a [AGE] year-old male admitted to the facility 10/23/21 with diagnoses including: epilepsy (seizures), cerebral infarction (stroke), hemiplegia (partial paralysis), insomnia, depression, repeated falls, mood disorder, and anxiety.<BR/>Record review of Resident #1's quarterly MDS, dated [DATE] revealed:<BR/>Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact.<BR/>Section E Behavior Symptom - presence and frequency revealed a 0 for physical behavioral symptoms directed toward others, verbal behavioral symptoms directed towards others, and other behavioral symptoms not directed toward others.<BR/>In an interview on 03/09/23 at 2:00 pm with the DON and ADM revealed the facility does not currently have an MDS nurse, the facility does not currently have a social worker, and the facility does not currently have an activities director. The ADM stated that Resident #1 called Resident #4 a fat pig. He stated he spoke to Resident #1 and told him he could not talk to people like that and the resident apologized and stated he would not do it again. He stated he filed a grievance report, handed it to the social worker, but she was let go from her position and they are not able to find grievances for February or March 2023.<BR/>In an interview and observation on 03/10/23 at 3:37 pm with Resident #4, she stated, Resident #1 is angry she was elected to the Resident Council and not him. She stated she felt harassed by him since she arrived in December. She stated he was also hostile towards her and she constantly feared encountering Resident #1. He also called her a fat cow, she told administrator two or three weeks ago, who told him not to do it anymore, but she said he harasses her and she tries to avoid him at all times. He plays his music so loud that it disrupts her sleep and rest and the music is vulgar. He cranks it in the dining room and common areas too. He was in a resident room and raised his hand to hit a little lady in a wheelchair who has severe dementia until Resident #4 intervened verbally. While surveyor was speaking with Resident #4, Resident #1 approached to try to listen in to the conversation and ended up kicking the back of Resident #4's wheelchair. Staff that were outside in the smoking area did not intervene when Resident #1 approached Surveyor and Resident #4 during interview. She stated Resident #1 continues to harass her, call her names and cause her distress. She stated it began when he made sexual advances towards her that she declined. Resident #4 said he has brought her to tears at times and that she has to walk on eggshells and try to avoid contact with Resident #1. She stated she had to attend activities due to her role as elected member of the Resident Council, so it was her duty to attend activities and this would cause her to be around Resident #1. She stated that she dreads being around Resident #1, it caused her cocnern and distress. When Resident #4 was describing the interactions with Resident #1 she appeared distressed and her eyes watered. At times her voice trembled as she recounted specific details. She stated that her room was directly across the hall from his room, and he blares vulgar music in common areas and in his room (which disrupts her). Resident #4 stated she told the ADM about the inappropriate advances and him calling her names and nothing changed. She also stated she was tired of Resident #6 being disruptive, which included him urinating on her chair in the dining room, urinating in cups in the dining room, and constant banging on walls and screaming and cursing. <BR/>In an interview on 03/10/23 at 6:45 pm with Adm and DON, they both stated they were unaware of Resident #4's diagnosis of chronic Post-traumatic stress disorder. The Adm stated the social worker was terminated in February, which he stated was good because she seemed incompetent. He had no knowledge of Resident #4's trauma, he was aware she had psychological issues. The Adm stated he was not aware of any special planning that was required for survivors of trauma and he did not know if the facility trained staff to protect residents from being re-traumatized as he had not heard of trauma informed care. The DON stated that both she and Adm were interim and had only started recently, so she was not able to speak to the care planning for Resident #4 since she was admitted in December before she started as interim DON.<BR/>In an interview with Resident #1 on 03/11/23 at 9:25 am he stated that Resident #4 doesn't do her job as an elected member of the Resident Council like he did when he held the position. He stated, I admit, I called her a pig, one time. <BR/>In an interview and observation with Resident #4 on 03/13/23 at 6:43 pm, she stated that she liked her roommate and that she was upset because Resident #1 was across the hall, but it was very hard that her tormentor is across the hall because it was a reminder of my abuse and the only time I feel 100% safe is when he is in his bed. She stated she felt safe when he was in bed because he was partially paralyzed and not able to get out of bed without staff assistance While being interviewed outside in the smoking area, Resident #1 was outside with one aide watching the 7 residents outside; as Resident #4 was speaking with surveyor, Resident #1 wheeled over to within 2 feet of Resident #4 and no staff intervened. Resident #4 stated that if she made an allegation of abuse that she would be moved from her room, which greatly upset Resident #4 because she stated she helps her roommate and cares for her.<BR/>Record review of the grievance logs for the facility revealed no grievance form was found for this resident despite her statement that she brought the issue to the ADM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide residents with an ongoing resident centered activity program, designed to meet the interests of and support the physical, mental, and psychosocial well-being of 3 (Residents #25, #31, and #42) of 8 residents reviewed for activities.<BR/>The facility failed to provide activities as scheduled from January 23, 2025, through February 12, 2025.<BR/>This failure placed residents at risk of boredom, depression, isolation, and a diminished quality of life.<BR/>Findings include:<BR/>Record review of Resident #25's face undated sheet reflected a [AGE] year-old male initially admitted to the facility on [DATE], and readmitted on [DATE], with the following diagnoses: Type 2 Diabetes Mellitus (a chronic disease that causes a person's blood glucose levels to rise too high) Chronic Pulmonary Edema (a condition where fluid accumulates in lung tissues, making it difficult to breathe), Acute Respiratory Failure with Hypoxia (acute impairment in gas exchange between the lungs and the blood), Major Depressive Disorder (a mood disorder characterized by persistent feelings of sadness), and Anxiety Disorder (mental disorder characterized by significant and uncontrollable feeling of anxiety and fear that affect daily life).<BR/>Record review of Resident #25's Annual Comprehensive MDS assessment dated [DATE], revealed Resident #25's activity preferences of strong importance to him were: listening to music, being around animals such as pets, keeping up with the news, doing things with groups of people, going outside when the weather is good, and participating in religious services and practices.<BR/>Record review of Resident #25's Quarterly MDS assessment dated [DATE], revealed Resident #25 had a BIMS score of 12, indicating intact cognition.<BR/>Record review of Resident #25's Comprehensive Care Plan focus dated 1/17/2025 regarding activities revealed Resident #25 attended most events, but also liked to do individual activities in his room. Resident #25's goal was to continue to participate in at least 4 activities per week. Interventions included posting calendars in the resident's room, reminding and encouraging the resident, thanking the resident for participating, allowing the resident to refuse to participate [in activities], and promoting the resident's love of music and storytelling with staff and other residents.<BR/>Record review of Resident #31's undated face sheet, reflected a [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: Major Depressive Disorder (a mood disorder characterized by persistent feelings of sadness), Muscle Weakness, Pulmonary Fibrosis (a condition in which the lungs become scarred over time causing breathing difficulties), need for assistance with personal care, and difficulty walking. <BR/>Record review of Resident #31's Comprehensive Care Plan initiated on 4/27/2022, revealed the focus regarding activities to be self-directed activities. Resident #31's goal regarding activities was to continue to do Bible studies with other residents through the next review date. Interventions included posting activity calendars in the resident's room, assisting the resident with activities when he agrees to participate, and praising and thanking the resident for attending an activity.<BR/>Record review of Resident #31's Annual Comprehensive MDS assessment dated [DATE], revealed Resident #31 had a BIMS score of 15, indicating intact cognition, a very important activity preference of participating in religious services or practices, and a somewhat important activity preference of going outside when the weather is good.<BR/>Record review of Resident #42's undated face sheet, reflected a [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: Type 2 Diabetes with Diabetic Autonomic (Poly)Neuropathy (a chronic disease that causes a person's blood glucose levels to rise too high; damage to multiple nerves in the peripheral nervous system in different parts of the body at the same time), Disorder of the teeth and supporting structures, muscle weakness, and Depression.<BR/>Record review of Resident #42's admission MDS assessment dated [DATE], revealed having books, newspapers, and magazines to read, and listening to music he likes as being very important activity preferences. <BR/>Record review of Resident #42's Comprehensive Care Plan initiated on 10/13/2022 and revised on 12/27/2023, revealed the resident's activity-related focus to be attending activities of his choice and that the resident will speak his mind and let you know when something is wrong. Resident's #42's activity related goal was to continue to participate in at least 3 activities per week. Interventions included posting an activity calendar in the resident's room, reminding and encouraging the resident daily, promoting the resident's activity ideas and ability to express himself, and the resident's joy and talent in playing the piano, singing, and doing artwork such as drawing.<BR/>Record review Resident #42's Quarterly Activity Participation Review dated 11/27/2024 revealed the resident attends most large events. The resident's favorite activity and interest were smoking and cooking. The resident's activity-related focuses, goals, and interventions remained the same.<BR/>Record review of Resident #42's Quarterly MDS assessment dated [DATE], revealed Resident #42 had a BIMS score of 15, indicating intact cognition.<BR/>Observation and interview 2/11/2025 at 10:11AM, revealed Resident #42 sitting in a chair at the foot of his bed watching a game show on television. Resident #42 expressed boredom and disinterest in watching television, but stated this was something to do to pass the time as there was nothing else to do. Resident #42 stated the activities offered at the facility are not good or of interest to him. The resident stated that lately no activities have been offered. The resident stated that the facility's activity director was fired, and no one had assumed activity duties The resident stated that prior to the activity director's termination, the activity calendar was not being followed. The resident stated that occasionally they played BINGO, but it had been a while. Resident #42 stated the activities program has always been inconsistent and unorganized. The resident stated that suggestions for activities and activity spaces go ignored. Resident #42 stated that he would like more community involvement. He stated that pet therapy and church services stopped because the providers were not allocated a specific time or space to provide the services. Resident #42 stated that the residents need more than occaisonal parties. He stated the residents need activities that enhance their well-being and morale, and that promote positive feelings toward facility staff. Resident #42 stated life at the facility is the same every day, with most residents spending their time watching television with no socializing.<BR/>Observation of the facility on 2/10/2024, through 2/12/2024, from approximately 9AM-4PM daily, revealed no formal activities being provided to the residents.<BR/>Observation of the facility activity room on 2/11/2025 at 3PM, revealed no coordinated activities being offered. The television in the activity room was on with 2 residents quietly watching without conversation or interaction with each other. No staff were present in the activity room. It did not appear as if any activity had been provided immediately prior to observation or that any activity was being set up or coordinated in the activity room to be provided following observation. The activity room was orderly and appeared undisturbed. The activity room contained a bookshelf with approximately 20 books, one jigsaw puzzle, and a few videos and audio books. The extra-large, printed activity calendar posted in or near the activity room was observed to be for January 2025, not February 2025. <BR/>In an interview on 2/11/2025 at 10:59AM, Resident #25 reported the facility was not offering activities as the facility had no AD on staff. The resident stated that the scheduled Valentine's Day party had been cancelled. The resident stated that the last time the residents were provided with an activity was 2 weeks prior, when they were given popsicles.<BR/>In an interview on 2/11/2025 at approximately 1:15PM, Resident #31 stated the facility was not offering activities. The resident stated that it had been about 2 weeks since any activity was provided.<BR/>In an interview on 2/12/2025 at 11:16AM, the ADM stated the activity director position is currently vacant as the FAD abruptly vacated the position without notice. The ADM stated that the FAD's last physical day of work was on 1/22/2025. The ADM stated that he and a former hospitality aide had been providing impromptu activities for the residents following the departure of the FAD until the former hospitality aide also vacated her position. The ADM stated that the former hospitality aide's last day of employment with the facility was on 2/7/2025. <BR/>In an interview on 2/12/2025 at 12:45PM, LVN A stated that she is a Charge Nurse and has been employed with the facility for 4 years. LVN A said the last formal activity provided for the residents was on 2/7/2025. The activity was conducted by a former hospitality aide who no longer works at the facility. LVN A stated the therapy staff have been providing activities for the residents recently. LVN A stated the offering of activities to residents is very important because it gives the residents motivation. LVN A stated that any complaints or suggestions made by residents to her regarding activities would be typically shared during their morning meetings. LVN A said the FAD discontinued her employment with the facility 2 weeks ago. LVN A said she is unsure of who is responsible for making sure the activity calendar has been followed since the FAD left. LVN A said she doesn't know if activities have been provided as listed on the activity calendar.<BR/>In an interview on 2/12/2025 at 12:50PM, the COTA said she has been employed with the facility for 2 years. The COTA stated that the therapy department staff have been assisting with activities. The COTA stated that the therapy staff help set up games and puzzles for the residents in the activity room, and the therapy room is always open to residents. The COTA stated therapy staff do not provide scheduled activities for the residents. The COTA stated the last formal activity provided to the residents was on 2/7/2025. The COTA stated the quality of activities offered to the residents could be better, but she believes this will improve once a new activity director is hired and an activity calendar is established. The COTA stated there were no scheduled activities being offered on this day to her knowledge.<BR/>In an interview on 2/12/2025 at 12:50PM, the PTA stated she has been employed with the facility for 2 years. The PTA said the therapy department staff have been helping with activities when they can. Their assistance consists of setting up activities and supporting the residents. <BR/>In an interview on 2/12/2025 at 12:50PM, the RD stated he has been employed with the facility for 2 months. The RD stated the therapy staff have been providing impromptu activities for residents when they can. The RD said these activities are not scheduled and the therapy staff are not responsible for following the activity calendar. The RD said therapy staff assist with setting up activities in the activity room. The RD stated activities are an important because they promote positivity, give residents something to do, improve residents' quality of life, and provide opportunities to socialize.<BR/>In an interview on 2/12/2025 at 12:55PM, the ADM stated the residents complained about the lack of activities during the Resident Council meeting on 2/5/2025. The ADM stated the lack of activities was due the vacant activity director position. The ADM stated that he is in the process of hiring a new activity director. The ADM stated that he plans to continue to use other staff members to assist with activities until a new activity director is hired. The ADM stated that activities would be provided as scheduled and as listed on the activity calendar, except for the evening activities, as there are no staff available in the evening to conduct activities. The ADM stated that he recently hired HA. HA's first day of employment was on 2/10/2025. The ADM stated that HA will also help with resident activities. The ADM acknowledged that some scheduled activities have been missed, but stated that the facility is in their rebuilding stage and he expects things to improve.<BR/>In an interview on 2/12/2025 at 1:01PM, HA stated that she began working at the facility this week. Her scheduled hours are 8AM-5PM. HA stated that her duties include passing out ice to the residents twice a day, assist residents with smoke breaks, assist with making residents' beds as needed, and assisting with passing and picking up meal trays as needed. HA stated that she was not aware that her duties would include assisting with activities. HA stated that she has not assisted with activities this week. HA stated that she has not been formally trained or certified as activity personnel. HA stated the benefits of activities is that they keep residents active, they can provide a form of exercise, and it allows residents to interact with each other. HA said the lack of activities for residents could cause a loss of interest in life and isolation.<BR/>In an interview on 2/12/2025 at 1:04PM, the IDON stated that he has been employed with the facility for 2 months. He said that he doesn't pay attention to the activities offered to residents. He stated that the FAD was believed to be successfully carrying out the activity program for residents, but that was not be the case. The IDON stated that the residents were dissatisfied with the inconsistency of activities and the types of activities offered by the FAD. The IDON stated that the ADM is in the process of hiring a new activity director. The IDON stated that he has not assisted or provided activities for the residents. The IDON stated the benefits of activities include social enrichment, engagement, and improved quality of life. He said the lack of activities for residents could cause depression and isolation.<BR/>Record review of the facility's activity calendars for January 23, 2025, through February 12, 2025, revealed the following scheduled activities:<BR/>January 23, 2025:<BR/>8:30am Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>11am-Karaoke <BR/>1pm-In room visits<BR/>2pm-Resident Council Meeting<BR/>3:30pm-UNO Game<BR/>6:30pm-Table Puzzles<BR/>7:30pm-Activity Cart<BR/>January 24, 2025<BR/>8:30am-Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>10:30am-S&C<BR/>1pm-In room visits<BR/>2pm-Birthday Party<BR/>3:30pm-Jewelry Art <BR/>6:30pm-Table Puzzles<BR/>7:30pm-Activity Cart<BR/>January 25, 2025<BR/>8:30am-Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>11am-Table Puzzles<BR/>1pm-In room visits<BR/>2pm-LPT<BR/>3:30pm-Make a Word Game<BR/>6:30pm-Table Puzzles<BR/>7:30pm-Activity Cart<BR/>January 26, 2025<BR/>8:30am-Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>11am-TBS TV in the Sunroom<BR/>1pm-In room visits<BR/>2pm-Church Service<BR/>3:30pm-Church <BR/>6:30pm-Table Puzzles<BR/>7:30pm-Activity Cart<BR/>January 27, 2025<BR/>8:30am-Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>11am-Tea Party<BR/>1pm-In room visits<BR/>2pm-Spelling Bee<BR/>3:30pm Let's Make a Deal<BR/>6:30pm-Table Puzzles<BR/>7:30pm-Activity Cart<BR/>January 28, 2025<BR/>8:30am-Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>11am-Rebus Puzzle<BR/>1pm-In room visits<BR/>2pm-Crafts & Art<BR/>3:30pm-[NAME] Game<BR/>6:30pm-Table Puzzles<BR/>7:30pm-Activity Cart<BR/>January 29, 2025<BR/>8:30am-Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>11am-Reading Rainbow<BR/>1pm-In room visits<BR/>2pm-Brush painting<BR/>3:30pm-Clue words<BR/>6:30pm-Table Puzzles<BR/>January 30, 2025<BR/>8:30am-Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>11am-Memory Lane<BR/>1pm-In room visits<BR/>2pm-Family Feud<BR/>3:30pm-Indoor Bowling<BR/>6:30pm-Table Puzzles<BR/>7:30pm-Activity Cart<BR/>January 31, 2025<BR/>8:30am-Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>10:30am-S&C<BR/>1pm-In room visits<BR/>2pm-Name that Tune<BR/>3:30pm-Happy Hour<BR/>6:30pm-Table Puzzles<BR/>7:30pm-Activity Cart<BR/>February 1, 2025-February 6, 2025, the activities scheduled were the same as follows:<BR/>8:30am-Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>11am-FF N.D. Church<BR/>1pm-In room visits<BR/>2pm-Dominos Games<BR/>3:30pm-Board Games<BR/>6:30pm-Table Puzzles<BR/>7:30pm-Activity Cart<BR/>February 7, 2025<BR/>8:30am-Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>11am-<BR/>1pm-In room visits<BR/>2pm-<BR/>3:30pm-<BR/>6:30pm-Table Puzzles<BR/>7:30pm-Activity Cart<BR/>February 8, 2025<BR/>8:30am-Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>11am-<BR/>1pm-In room visits<BR/>2pm-<BR/>3:30pm-Spades Games<BR/>6:30pm-Table Puzzles<BR/>7:30pm-Activity Cart<BR/>February 9, 2025-February 12, 2025<BR/>8:30am-Daily Chronicle<BR/>9:45am-Daily Devotion<BR/>11am-FF N.D. Church<BR/>1pm-In room visits<BR/>2pm-Dominos Games<BR/>3:30pm-Board Games<BR/>6:30pm-Table Puzzles<BR/>7:30pm-Activity Cart<BR/>Record review of the Activity Director job description (revised 11/2020) states in part:<BR/>Position Summary: To develop and provide a comprehensive holistic resident wellness program that meets the individual interests and capabilities of the resident population. Activities will encompass the body (physical), mind (cognitive), spirit, and social engagement dimensions.<BR/>Record review of the Activities and Social Services policy and procedures (revised December 2006) states in part:<BR/>Residents shall have the right to choose the type of activities and social events in which they wish to participate as long as such activities do not interfere with the rights of other residents in the facility.<BR/>3. When the Care Planning Team develops the resident's activity and social care plans, the resident will be given an opportunity to choose when, where, and how he or she will participate in activities and social events. As much as possible, the facility will provide activities, social events, and schedules that are compatible with the resident's interests, physical and mental assessment, and overall plan of care.<BR/>7. Activities will be scheduled periodically during the day, as well as during evenings, weekends, and holidays.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist for 2 of 2 residents reviewed for drug regimen review (Resident's #163 and # 51).<BR/>The facility failed to ensure Resident # 163 and 51's physician and medications orders were reviewed by the licensed pharmacist monthly.<BR/>This failure could place residents at risk of having adverse consequences related to medications not being properly reviewed.<BR/>Findings included: <BR/>Record Review Resident #51's face sheet dated 10/13/22 reflected Resident #51 was an [AGE] year-old female with an admission date of 06/20/22. Resident #51's diagnoses included dementia (disorder which manifests as a set of related symptoms, which usually surfaces when the brain is damaged by injury or disease), muscle wasting and atrophy (when muscles waste away), anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), and muscle weakness (a lack of muscle strength). <BR/>Record Review of the most recent MDS assessment dated [DATE] reflected Resident #51 had a BIMS score of 03 indicating Resident #51 was severely cognitively impaired.<BR/>Record review of Resident # 51's clinical physician orders dated 10/13/2022 revealed resident # 51 was prescribed Alprazolam 0.5 mg, Quietapine Fumarate 50 mg, Quietapine Fumarate 100 mg, and Eliquis 2.5 mg.<BR/>Record Review of Resident #163's face sheet dated 10/13/22 reflected Resident #163 was a [AGE] year-old female with an admission date of 12/07/21. Resident #163's diagnoses included dementia (disorder which manifests as a set of related symptoms, which usually surfaces when the brain is damaged by injury or disease), diabetes type 2 (high blood sugar, insulin resistance, and relative lack of insulin), hypertension (high blood pressure - long term condition in which blood pressure in arteries is persistently elevated), and muscle wasting and atrophy (when muscles waste away)<BR/>Record Review of the most recent MDS assessment dated [DATE] reflected Resident #163 had a BIMS score of 06 indicating Resident #163 was severely cognitively impaired.<BR/>Record review of Resident # 163's clinical physician orders dated 10/13/2022 revealed Resident # 163 was prescribed Insulin Lispro (1 Unit Dial) 100 UNIT/ML, Paroxetine HCl Tablet 20 MG, Depakote ER Tablet Extended Release 24 Hour 500 MG, Seroquel Tablet 50 MG, Aricept Tablet 10 MG, and Buspirone HCl Tablet 15MG.<BR/>During an interview on 10/13/22 at 10:56 AM, the DON stated the pharmacy did not come in August for the medication regimen review because she believes the pharmacist was on vacation. She stated she did not even realize that the pharmacist did not come in August until it was already September. She stated they did not do anything specific or different when the pharmacist doesn't come for a month, and she doesn't know if the pharmacist has a back-up or anything. She stated she doesn't know if there are any policies from the pharmacy that are specific to medication regimen review. She stated the possible outcome of the pharmacist not coming for a month is that a gradual dose reduction recommendation may not be done, added parameters may not be recommended, orders to be reviewed could be skipped, and orders may be incomplete. She stated she thinks it could possibly have a negative effect on the residents. She stated the pharmacist consultant comes in and reviews the residents charts and medications and makes recommendations, but she doesn't know which residents the pharmacist picks to monitor. She stated if she has issues or questions about the pharmacy, she doesn't know specific names, but she has business cards to contact the correct people regarding the issue.<BR/>During an interview on 10/12/22 at 1:04 PM, ADM stated the pharmacists should have come immediately in September if they didn't in August. He stated the pharmacy does not have any policies specific to monthly medication regimen reviews that he is aware of. He stated the potential for negative outcome could exist if the pharmacist skips their monthly visits.<BR/>Record Review on 10/13/22 of pharmacy consultant's monthly medication regimen reviews it was noted by DON that the licensed pharmacist did not come to facility to review medications for the month of August in 2022. There were no documents available for review from the month of August 2022 from the licensed pharmacist. <BR/>Record Review on 10/13/22 of pharmacy consultant's monthly medication regimen reviews revealed licensed pharmacist came to facility for medication regimen review on 07/19/22 and not again until 09/27/22.<BR/>Record Review on 10/13/22 of the pharmacy services overview policy dated 2001 (revised April 2007) revealed: policy statement: the facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medications and biologicals, and the service of a licensed Pharmacist: i. help establish procedures for conducting the monthly medication regimen review (MRR) for each resident in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 6.45 % based on 2 errors out of 31 opportunities, which involved 1 of 5 residents (Resident #61) and 1 of 2 staff (MA) reviewed for medication errors, in that: <BR/>MA D administered 2 medications which was ordered to be given before meals after a meal was provided and consumed.<BR/>This failure could place residents at risk of medication errors that could cause a decline in health<BR/>Findings included:<BR/>Record Review on 10/13/22 of Resident #61's face sheet dated 10/13/2022 reflected Resident #61 was a [AGE] year-old female with an admission date of 10/20/2016. Resident #61's diagnoses included hypertension (high blood pressure - long term condition in which blood pressure in arteries is persistently elevated), bipolar disorder (mental disorder characterized by periods of depression and periods of abnormally elevated mood that lasts from days to weeks each), dysphagia (difficulty in swallowing), hemiplegia (paralysis of one side of the body, and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). <BR/>Record Review on 10/13/22 of the most recent MDS assessment dated [DATE] reflected Resident #61 had a BIMS score of 08 indicating Resident #61 was moderately cognitively impaired.<BR/>Record review on 10/13/22 of Resident #61's clinical physician orders dated 10/13/22 revealed: Sucralfate 1 gm 1 by mouth before meals (30 min before meals) and Metoclopramide 10 mg 1 by mouth before meals and at bedtime (30 minutes to an hour before meals). <BR/>During an observation on 10/12/22 at 9:22 AM, MA D was observed passing medication to Resident # 61 which included 2 medications (Sucralfate 1 gm and Metoclopramide 10 mg) that were ordered by the physician to be given prior to resident eating meal. Breakfast meal had already been served and completed. <BR/>During an interview on 10/12/22 at 9:47 AM, MA D stated she has been in-serviced on medication administration and the 5 rights of medication. She stated she was aware that 2 of resident # 61's medications (Sucralfate 1 gm and Metoclopramide 10 mg) were ordered to be given before meals and she tried her best to get to Resident # 61 before he eats but she just couldn't get to him. She stated she couldn't get to Resident # 61 in time to give her the medication before her meal. She stated it could possibly have a negative effect and cause the medications to not work properly for Resident # 61 if he did not get the 2 medications as ordered before meals.<BR/>During an interview on 10/13/22 at 10:56 AM, the DON stated it is her expectation that medications be given to residents as ordered by the doctor. She stated if a medication is ordered to be given before meals, the medication should be given before residents eat. She stated if the medication is given with or after a meal that is ordered to be given before meals it may cause the medication to not work properly. She stated they have done in-servicing on medication administration and the 5 rights of medication administration regularly.<BR/>During an interview on 10/12/22 at 1:04 PM, ADM stated it was his expectation that medications should have been given as ordered per physician order. He stated if a medication was ordered to be given before meals it should have given before meals. He stated if a medication was ordered before meals and not given correctly, it could possibly cause a reaction to the meal, or the interaction could be off for the medication. He stated he has in-serviced staff on the 5 rights of medication, medication administration.<BR/>Record Review on 10/12/22 of the Administration Procedures for All Medications policy dated 09-2018 (revised 08-2020) provided by the DON revealed the following: Policy: Medications will be administered in a safe and effective manner. The guidelines of this policy apply to all medications.<BR/>Record Review on 10/13/22 of the General Guidelines for Medication Administration policy dated 09-2018 (revised08-2020) provided by the DON, revealed the following: procedures: preparation: 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 3 steps in the process of preparation. 12. Medications are administered within 60 minutes of the scheduled administration time except before, with or after mealtime orders, which are administered based on mealtimes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview and record review, the facility failed to ensure that 1 (Resident #62) of 6 residents was free of any significant medication errors.<BR/>The facility failed to ensure Resident #62 was administered Midodrine (medication used to increase blood pressure) as ordered per physician. <BR/>The facility failed to ensure that Resident #62 was administered medications per physician's order.<BR/>These failures could affect the resident by placing resident at risk for not receiving therapeutic dosages of medications as ordered by the physician which could result in a decline in health status. <BR/>Findings included:<BR/> Record Review on 10/13/22 of Resident #62's face sheet dated 10/13/22 reflected Resident #62 was a [AGE] year-old male with an admission date of 08/09/22. Resident #62's diagnoses included diabetes type 2 (high blood sugar, insulin resistance, and relative lack of insulin), hypertension (high blood pressure - long term condition in which blood pressure in arteries is persistently elevated), hypothyroidism (disorder of the endocrine system in which the thyroid gland does not produce enough thyroid hormone), and dysphagia (difficulty in swallowing).<BR/>Record Review on 10/13/22 of the most recent MDS assessment dated [DATE] reflected Resident #62 had a BIMS score of 03 indicating Resident #62 was severely cognitively impaired.<BR/>Record review on 10/13/22 of resident #62's clinical physician orders dated 10/13/22 revealed: Midodrine HCL tablet 5 mg give 1 tablet via G-tube three times a day for preventative - hold for systolic above 100 and DBP above 60 <BR/>Record review on 10/13/22 of Resident #62's clinical physician orders on 10/13/22 revealed: start date of 9/11/2022 for Midodrine HCL tablet 5 mg give 1 tablet via G-tube three times a day. <BR/>Record review of Resident #1's MAR dated October 2022 revealed no evidence that Midodrine was held in the month of October and blood pressure readings were recorded to be outside of parameters to be given for 23 of 36 doses that were administered. <BR/>During an interview on 10/13/22 at 10:56 AM, the DON stated it is her expectation that medications be given to residents as ordered by the doctor. She stated she expects staff to follow parameters for heart rate, blood pressure, and respiratory rate when giving medications. She stated if medication parameters were not followed it could potentially cause residents blood pressure or heart rate to bottom out and could lead to potential problems for the residents. She stated they have done in-servicing with staff on medication administration and the 5 rights of medication administration regularly.<BR/>During an observation on 10/13/22 at 12:03 PM of Resident # 62's blood pressure medication, medication parameters were provided on the medication card and the were 24 tablets remaining.<BR/>During an interview on 10/13/22 at 12:04 PM, LVN A stated she administered medications to Resident # 62 regularly. She stated she had been giving Resident # 62 Midodrine HCL 10 mg (medication that increases the blood pressure) that he is ordered to get 3 times a day. She stated, regarding parameters of medication, she has not had to hold Resident # 62's blood pressure medication because Resident # 62's blood pressure has been pretty good. She stated the parameters of the medications are right above the medication order on the medication administration record. She stated Resident # 62's parameters are to hold if systolic blood pressure is above 100 and diastolic blood pressure is above 60. She stated the blood pressure medication should have been held any time Resident # 62's blood pressure was over the parameters. She stated that blood pressure medication is given to raise the blood pressure and if given outside of parameters it could cause the residents blood pressure to get high.<BR/>During an interview on 10/13/22 at 12:09 PM, LVN B stated she stated she has given medications to Resident # 62. She stated she had been administering Resident # 62 all of the medications that he had been ordered to get when she worked that hall and she had not held any of Resident # 62's blood pressure medications at any time that she remembered. She stated if she signed the medication administration record then she gave the medication. She stated she was aware that some medications have parameters on them. She stated she should not have given medications if they were outside of the ordered parameters. She stated she was aware of where to find parameters on the medication administration record. She stated if Resident #62 was given this medication outside of parameters it could cause the blood pressure to be too high and possibly cause a stroke.<BR/>During an interview on 10/12/22 at 1:04 PM, ADM stated it was his expectation that medications should have been given as ordered per physician order. He stated it is expected that staff follow blood pressure parameters when administering medications and that if they did not, the residents blood pressure may go too high or too low. He stated he has in-serviced staff on the 5 rights of medication and medication administration.<BR/>Record Review on 10/13/22 at 3:18 PM of the General Guidelines for Medication Administration policy dated 09-2018 (revised08-2020) provided by the DON, revealed the following: procedures: preparation: 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 3 steps in the process of preparation.

Based on observation, interviews, and record reviews the facility failed to store, prepare, and serve food in accordance with professional standards for one of one kitchen reviewed for kitchen sanitation.<BR/>A. The facility failed to properly store and label food in the facilities one unit with 6 doors open front refrigerator, one unit with 3 doors open front refrigerator and 2 open front freezers and one open top deep freezer in the kitchen.<BR/>B. The facility failed to prevent grease from the oven/griddle leaking onto the floor. <BR/>C. The facility failed to sanitize one deep fryer, two ovens, griddle, kitchen floor, a kitchen utility 3 shelf rolling cart and a storage bin for meal<BR/>This failure placed residents who were served from the kitchen at risk for health complications and foodborne illnesses.<BR/>Findings included:<BR/>A. Observation of the 2 units open front refrigerators in the kitchen on 10/12/2022 at 8:10 AM- 8:20 AM revealed the following:<BR/>-leftover bacon not in the original package without a label or date on the clear zip plastic bag. <BR/>-two large bags of leftover red sauce used for pasta not in the original package without a label or date on the clean zip plastic bag.<BR/>Observation of the open front freezer in the kitchen on 10/12/2022 at 8:24 AM - 8:30 AM revealed the following:<BR/>- opened package of biscuits not in the original package without a label or date on it. There were approximately &frac12; inch of ice on the biscuits.<BR/>- partially opened &frac12; gallon of vanilla ice cream without a date when the ice cream was last used. The ice cream had approximately &frac12; to &frac34; inch of ice on the ice cream. <BR/>- partially opened leftover cheese sticks not in the original package without a label or date on the package. <BR/>-breaded frozen of some type of meat not in original package not labeled or dated. <BR/>B. Observation on 10/11/2022 at 8:40 revealed a bedspread with grease on it laying on the floor beside the griddle. There was dried brownish substance on the side of the griddle from approximately 8 inches from the top of the griddle to the bottom of the griddle. <BR/>Interview on 10/11/2022 at 8:43 AM the Dietary [NAME] stated they had to put the bedspread on the floor to catch the grease. She stated whenever they use the griddle the grease leaks and flows onto the floor. She stated the griddle was leaking past few days. She stated maybe 3 or 4 days. She stated she did report the grease leaking to the Dietary Manager on Monday (10/12/2022). <BR/>Interview on 10/11/2022 at 8:50 AM the Dietary Manager stated someone contracted had been called about the issue with griddle leaking grease. She stated she didn't recall name of the company came to the facility to check the griddle. The company was returning to the facility to make the repairments. The Dietary Manager 5 stated the staff could use a bucket or something else to catch the grease when it leaks instead of a bedspread. <BR/>C. Observation on 8/30/2022 at 8:30 AM - 8:50 AM of the kitchen equipment and storage bins revealed the following:<BR/>- the deep fryer had approximately 6 inches of crumbs from the side to middle of the grease. The grease was very dark and had a mild unpleasant odor. The top/front of the fryer where the handles of the baskets are rested when finished frying had approximately 3 inches of crumbs covering the entire area. The back of the fryer had a hardened built up blackish/ brownish substance approximately 1-2 inch thick. There was brownish/ blackish/ white substance dried from the top to bottom of both sides of the fryer. <BR/>- one of the three open front ovens revealed on top of the oven door and inside the oven door was covered with a brownish/ blackish hard substance. Bottom of the outside of the oven door was blackish/ brownish/ white substance. Outside of the oven door was white/ brownish dried substance. Top of the oven where the burners were located was a stainless silver part of the oven against the wall. It had approximately 4 inches of hardened blackish/ brownish substance from top to bottom covering over half this section of the oven. All three ovens were located beside each other. <BR/>-two of the three open front ovens revealed inside of the oven were hard blackish / brownish substance approximately 1-2-inch-thick had a white unknown substance inside the oven. <BR/>- one of one griddles had blackish hard substance on the inside of the griddle. On the outside of the griddles on both sides had white, brownish/ blackish hard substance. In front of the griddle had brownish hard substance. The griddle had been leaking grease on this date and past 3-4 days. Where it was leaking on the top left side of the griddle was a hard blackish/ brownish substance. <BR/>- kitchen floor beside the griddle, in front of the griddle, in front of the oven and, in front of utility cart located beside the fryer and in front of the fryer was French fries. The French fries had been cooked for supper on 10/11/2022. The floor had dirt, dust, and grease on the floor in front of the oven and in front of the kitchen utility rolling cart. These areas were not where the grease was leaking on the floor. <BR/>- utility kitchen 3 shelf rolling cart located beside the griddle had a large flat cooking pan with parchment paper on top of the pan. The paper was soaked in grease. There were French fries on the pan. The pan was sitting on the top shelf of the cart and there was dust and dried crumbs covering the top shelf of the cart. The middle shelf of the cart had dust, brownish substance, 2 containers with grime and brownish substance in both of the containers and also a pipe. On the bottom shelf there was dust, brownish/ blackish substance. <BR/>- one of three large open from top bins had brownish sticky substance on the area where the button was to open the bin. Meal was stored in the bin. Across the entire bin where you open to get the meal had yellowish/ brownish hard substance and sticky substance on it. <BR/>In an interview on 10/11/2022 at 8:43 AM the Dietary [NAME] stated the night shift was responsible to wipe all the equipment and clean the kitchen before the end of their shift. She stated chicken was cooked at lunch on Sunday 10/10/2022. She stated the fryer is cleaned once a week if didn't use it during the week, but the night shift was required to clean the fryer. She stated the night shift used the fryer in late afternoon on Monday (10/11/2022) and the night shift didn't clean the fryer and left dirty pan on the cart and French fries on the floor. She stated the floor was dirty when she came to work this AM (10/12/2022). She did state the three-shelf cart was not in the kitchen area when she left for the day on 10/11/2022. But when she came to work on 10/12/2022 in early AM the three-shelf rolling utility cart was beside the fryer and she stated it should have been cleaned before the night shift used it to put food on it. <BR/>In an interview on 10/11/2022 at 10:45 AM the Dietary Manager was requested to provide cleaning schedule . <BR/>In an interview on 10/12/2022 at 11:15 AM the Dietary Manager was requested to provide cleaning schedule, cleaning schedule policy, in services on cleaning equipment. A blank cleaning schedule was provided. The Dietary Manager did not have a cleaning schedule for staff to clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 3 of 3 residents reviewed for medication administration (Residents # 61, # 1, and # 32) and for 1 of 1 resident (resident # 16) reviewed for wound care as indicated by:<BR/>MA failed to properly wash or sanitize her hands when moving from resident to resident when administering medications to Residents # 61, # 1, and # 32.<BR/>LVN 1 used gloves stored in her scrub's pocket during wound care for Resident # 16.<BR/>This deficient practice placed all residents identified at risk for cross contamination and the spread of infection.<BR/>Findings include:<BR/>Record Review on 10/13/22 of Resident #61's face sheet dated 10/13/2022 reflected Resident #61 was a [AGE] year-old female with an admission date of 10/20/2016. Resident #61's diagnoses included hypertension (high blood pressure - long term condition in which blood pressure in arteries is persistently elevated), bipolar disorder (mental disorder characterized by periods of depression and periods of abnormally elevated mood that lasts from days to weeks each), dysphagia (difficulty in swallowing), hemiplegia (paralysis of one side of the body, and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). <BR/>During an observation on 10/12/22 at 9:21 AM, MA was observed passing medication to Residents #43 and #61 without sanitizing hands in between.<BR/>Record Review on 10/13/22 of the most recent MDS assessment dated [DATE] reflected Resident #61 had a BIMS score of 08 indicating Resident #61 was moderately cognitively impaired. <BR/>Record Review on 10/13/22 of Resident #1's face sheet dated 10/13/2022 reflected Resident #1 was a [AGE] year-old male with an admission date of 09/15/2016. Resident #1's diagnoses included dementia (disorder which manifests as a set of related symptoms, which usually surfaces when the brain is damaged by injury or disease), hypertension (high blood pressure - long term condition in which blood pressure in arteries is persistently elevated), hypertensive heart disease (includes a number of complications of high blood pressure that affect the heart), and rheumatoid arthritis (chronic inflammatory disorder that can affect more than just your joints).<BR/>Record Review on 10/13/22 of the most recent MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 15 indicating Resident #1 was cognitively intact and able to complete an interview.<BR/>Record Review on 10/13/22 of Resident #32's face sheet dated 10/13/22 reflected Resident #32 was a [AGE] year-old female with an admission date of 08/30/22. Resident #32's diagnoses included dementia (disorder which manifests as a set of related symptoms, which usually surfaces when the brain is damaged by injury or disease), hypertension (high blood pressure - long term condition in which blood pressure in arteries is persistently elevated), insomnia (sleep disorder in which you have trouble falling and/or staying asleep), and anemia (blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells).<BR/>Record Review on 10/13/22 of the most recent MDS assessment dated [DATE] reflected Resident #32 had a BIMS score of 03 indicating Resident #32 was severely cognitively impaired.<BR/>Review of Resident # 16's medical record reflected a [AGE] year-old male originally admitted on [DATE]and the recent admission on [DATE]. Diagnoses included Dementia with Behaviors, COPD ( an inflammatory lung disease), Hemiplegia (one-sided paralysis. ), Cerebrovascular Disease (restricted blood flow into the brain ), Chronic Kidney Disease, Atherosclerotic Heart Disease ( buildup of fats in the arteries on the heart ), Angina Pectoris (severe pain in the chest due to limited supply of blood to the heart), Type 2 Diabetes Mellitus with Foot Ulcer, Peripheral Vascular Disease ( a slow and progressive circulation disorder), Polyosteoarthritis (arthritis due to degeneration of the protein makeup of cartilages.) , Unspecified Psychosis( a kind of mental disorder) ,Major Depressive Disorder and Dysphagia( difficulty to swallow) . <BR/>Record Review of the wound assessment dated [DATE] Resident #16 has a stage 3 Pressure Ulcer on his left heel measuring 7 cm L, 0.6 cm W and 0.2cm D and an Arterial Wound on left foot dorsum(top side) proximal (nearer to the center) measuring 0.5cm L x0.3cm W and 0.3cm D. <BR/>Record review of intervention dated 10/12/2022 says Cleanse with NS, Pat dry, apply medihoney, cover with silicone dressing, QOD <BR/>During an observation on 10/12/22 at 9:41 AM, MA was observed passing medication to Residents #61 and #1 without sanitizing hands in between. MA opened straw and placed straw in cup of water for resident # 1 to drink with medications. MA poured cup of medications into resident # 1's mouth then held cup of water for resident # 1 to drink through straw. <BR/>During an observation on 10/12/22 at 9:43 AM, hand sanitizer containing clear gel fluid was observed hanging on wall in hallway beside medication cart which MA was using for medication pass. <BR/>During an observation on 10/12/22 at 9:46 AM, MA was observed passing medication to Residents #1 and #32 without sanitizing hands in between.<BR/>During an interview on 10/12/22 at 9:47 AM, MA stated she did not sanitize her hands in between passing medications to the last few residents. She stated she usually had hand sanitizer available on her medication cart or she used the hand sanitizer on the wall (pointing to the hand sanitizer observed by surveyor on wall), but she forgot because she was nervous with surveyor watching her. She stated she felt as though not washing or sanitizing her hands could put residents at risk by spreading infection. She stated she has been in-serviced on washing or sanitizing her hands while passing medications and going from one resident to another, medication administration, and the 5 rights of medication. <BR/>During an interview on 10/13/22 at 10:56 AM, the DON stated it is her expectation that She stated the facility has done hand washing and infection control in-servicing quarterly. She stated it is her expectation that staff sanitize or wash their hands in between every resident when passing medications. She stated the possible risks of staff not washing their hands could be carrying germs from resident to resident and spreading infection or there could be some medication residual that could affect other residents. <BR/>During an interview on 10/13/22 at 12:04 PM, LVN 1 stated staff should wash or sanitize their hands prior to administering insulin or any medication to residents. <BR/>In an observation on 10/13/2022 at 11:00AM of Wound Care Nurse LVN 1 provided wound care to Resident # 16's wounds on his left foot. She cleansed top of the table. She washed hands and applied nonsterile gloves. She set up supplies, then changed the gloves and cut open the bandage wrapped around the foot. Then removed the gloves and donned new pair of gloves that she took from her scrub's pocket. She cleansed the wound with normal saline soaked gauze. She then applied honey and covered the wound with silicone dressing. She took gloves off, gathered supplies, washed hands, and left the room after cleaning the tabletop. <BR/>During the interview on 10/13/22at 12.30 pm LVN 1 stated that she did not realize storing gloves in scrubs pocket could contaminate the gloves. She said that it was a mistake that she never thought of. <BR/>During an interview on 10/12/22 at 1:04 PM, ADM stated it was his expectation that staff wash or sanitize their hands in between every resident when passing medications. He stated there could be risks of spreading infection or possible contamination if staff did not wash their hands in between residents while passing medications. He stated he in-serviced staff on handwashing and infection control regularly. <BR/>During the interview on 10/13/2022 at 2:00pm the DON stated the staff were expected to practice clean techniques while providing wound care as part of effective infection control practice. When asked, she replied that the staff should not use gloves stored in the scrub's pocket as the contact with the body and scrub might contaminate the gloves.<BR/>Record review on 10/12/22 at 2:44 PM of documents dated 07/11/22 revealed staff was in-serviced on techniques for using alcohol-based hand sanitizer per CDC recommendation: During resident's routine care use alcohol-based hand sanitizer: immediately before touching a resident, between residents' care, and before and after caring for a resident, after touching resident's belongings or immediate environment. <BR/>Record review on 10/12/22 at 2:52 PM of documents dated 07/11/22 on techniques for using alcohol-based hand sanitizer per CDC recommendation, revealed MA attended this in-service.<BR/>Record review on 10/13/22 at 3:27 PM of document dated 07/11/22 on techniques for using alcohol-based hand sanitizer per CDC recommendation, revealed MA attended this in-service.<BR/>Record Review on 10/12/22 at 2:06 PM of the Policy - Infection Control policy dated 6/8/2021 (revised 1/15/22) provided by the DON, revealed the following: Policy: This communities' infection control policies are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Procedure: This communities' infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payor source. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct and job responsibilities.<BR/>Record Review on 10/12/22 at 2:13 PM of the Administration Procedures for All Medications policy dated 09-2018 (revised 08-2020) provided by the DON revealed the following: Policy: Medications will be administered in a safe and effective manner. The guidelines of this policy apply to all medications. IV. Administration 3. Cleanse hands using antimicrobial soap and water or facility-approved hand sanitizer before beginning a med pass, before handling medication, and before contact with a resident. 12. When finished administering medication to each resident, wash hands with antimicrobial soap and water or use facility-approved hand sanitizer. <BR/>Record review on 10/13/22 at 3:03 PM of the Infection Control/Hand Hygiene policy dated 8/4/2021, provided by the DON, revealed the following: policy: Hand hygiene is used to prevent the spread of pathogens in healthcare settings. Hand hygiene is a general term that describes hand washing using soap and water or the use of an alcohol-based hand rub (ABHR) to destroy harmful pathogens, such as bacteria or viruses, on the hands. 1. You should always perform hand hygiene: Before and after providing any care.<BR/>Record Review on 10/13/22 at 3:18 PM of the General Guidelines for Medication Administration policy dated 09-2018 (revised08-2020) provided by the DON, revealed the following: procedures: preparation:2. Hand washing and hand sanitation: 1. Before beginning a medication pass, 2. Prior to handling any medication, 3. After coming into direct contact with a resident: c. hand sanitation is done with a facility approved sanitizer: 2. At regular intervals during the medication pass such as after each room. <BR/>Review of the facility policy titled Infection Control: Personal Protective Equipment dated 08/01/2021 stated, Personal protective equipment appropriate to specific task requirements is always available.4. Not all tasks involve the same risk of exposure, or the same kind or extend of protection. The type of PPE required for a task based on, a. The type of transmission-based precaution .c. The likelihood of exposure, . e. The probable route of exposure; and f. The overall working conditions and job requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure an allegation of abuse was reported immediately but not later than 24 hours after the allegation was made for 1 of 5 residents (Resident #4) reviewed for incidents.<BR/>The facility failed to timely report an allegation of resident abuse after the allegation was made to the administrator. <BR/>This failure could affect all residents by placing them at risk of abuse if the reportable allegations are not reported timely after they are discovered.<BR/>Findings included:<BR/>Record review of Resident #4's undated face sheet revealed that she was a [AGE] year-old female first admitted to the facility on [DATE], and most recently admitted on [DATE] with diagnoses including: Chronic post-traumatic stress disorder, major depressive disorder, obesity, hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke), and obesity.<BR/>Record review of Resident #4's significant change MDS, dated [DATE], revealed:<BR/>Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact.<BR/>Record review of Resident #1's undated face sheet revealed a [AGE] year-old male admitted to the facility 10/23/21 with diagnoses including: epilepsy (seizures), cerebral infarction (stroke), hemiplegia (partial paralysis), insomnia, depression, repeated falls, mood disorder, and anxiety.<BR/>Record review of Resident #1's quarterly MDS, dated [DATE] revealed:<BR/>Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact.<BR/>In an interview on 03/09/23 at 2:00 pm with the DON and ADM, the ADM stated he was the abuse coordinator and responsible for reporting to the State Agency. The ADM stated that Resident #1 called Resident #4 a fat pig a few weeks ago and that he should have but did not file an incident and notify the State Agency. He stated he spoke to Resident #1 and told him he could not talk to people like that and the resident apologized and stated he would not do it again. <BR/>In an interview on 03/10/23 at 4:18 pm with Resident #4, she stated that Resident #1 has made verbal sexual advances toward her, which she declined and since that time Resident #1 has been verbally abusive toward her. He has told her to shut up you fat pig on more than one occasion. Resident #4 stated she told the ADM about the inappropriate advances and him calling her names and nothing changed.<BR/>In an interview with Resident #1 on 03/11/23 at 9:25 am he stated that Resident #4 doesn't do her job as an elected member of the resident council like he did. He stated, I admit, I called her a pig, one time. <BR/>Record review of the facility policy titled Abuse effective 02/01/17 and revised 01/01/23 revealed that all allegations of abuse must be reported immediately or not later than 2 hours after learning of the alleged violation. <BR/>Record review of the facility's account on the Texas Unified Licensure Information Portal on 03/14/23 revealed no report to Health and Human Services Commission was made regarding the allegations made by Resident #4 being verbally abused by Resident #1.<BR/>A review of Provider Letter (PL) 19-17, performed 03/10/23 at 12:00 pm reflected an accusation of abuse was an incident that needed to be reported immediately, but not later than 24 hours after the incident occurred or was suspected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 6.45 % based on 2 errors out of 31 opportunities, which involved 1 of 5 residents (Resident #61) and 1 of 2 staff (MA) reviewed for medication errors, in that: <BR/>MA D administered 2 medications which was ordered to be given before meals after a meal was provided and consumed.<BR/>This failure could place residents at risk of medication errors that could cause a decline in health<BR/>Findings included:<BR/>Record Review on 10/13/22 of Resident #61's face sheet dated 10/13/2022 reflected Resident #61 was a [AGE] year-old female with an admission date of 10/20/2016. Resident #61's diagnoses included hypertension (high blood pressure - long term condition in which blood pressure in arteries is persistently elevated), bipolar disorder (mental disorder characterized by periods of depression and periods of abnormally elevated mood that lasts from days to weeks each), dysphagia (difficulty in swallowing), hemiplegia (paralysis of one side of the body, and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). <BR/>Record Review on 10/13/22 of the most recent MDS assessment dated [DATE] reflected Resident #61 had a BIMS score of 08 indicating Resident #61 was moderately cognitively impaired.<BR/>Record review on 10/13/22 of Resident #61's clinical physician orders dated 10/13/22 revealed: Sucralfate 1 gm 1 by mouth before meals (30 min before meals) and Metoclopramide 10 mg 1 by mouth before meals and at bedtime (30 minutes to an hour before meals). <BR/>During an observation on 10/12/22 at 9:22 AM, MA D was observed passing medication to Resident # 61 which included 2 medications (Sucralfate 1 gm and Metoclopramide 10 mg) that were ordered by the physician to be given prior to resident eating meal. Breakfast meal had already been served and completed. <BR/>During an interview on 10/12/22 at 9:47 AM, MA D stated she has been in-serviced on medication administration and the 5 rights of medication. She stated she was aware that 2 of resident # 61's medications (Sucralfate 1 gm and Metoclopramide 10 mg) were ordered to be given before meals and she tried her best to get to Resident # 61 before he eats but she just couldn't get to him. She stated she couldn't get to Resident # 61 in time to give her the medication before her meal. She stated it could possibly have a negative effect and cause the medications to not work properly for Resident # 61 if he did not get the 2 medications as ordered before meals.<BR/>During an interview on 10/13/22 at 10:56 AM, the DON stated it is her expectation that medications be given to residents as ordered by the doctor. She stated if a medication is ordered to be given before meals, the medication should be given before residents eat. She stated if the medication is given with or after a meal that is ordered to be given before meals it may cause the medication to not work properly. She stated they have done in-servicing on medication administration and the 5 rights of medication administration regularly.<BR/>During an interview on 10/12/22 at 1:04 PM, ADM stated it was his expectation that medications should have been given as ordered per physician order. He stated if a medication was ordered to be given before meals it should have given before meals. He stated if a medication was ordered before meals and not given correctly, it could possibly cause a reaction to the meal, or the interaction could be off for the medication. He stated he has in-serviced staff on the 5 rights of medication, medication administration.<BR/>Record Review on 10/12/22 of the Administration Procedures for All Medications policy dated 09-2018 (revised 08-2020) provided by the DON revealed the following: Policy: Medications will be administered in a safe and effective manner. The guidelines of this policy apply to all medications.<BR/>Record Review on 10/13/22 of the General Guidelines for Medication Administration policy dated 09-2018 (revised08-2020) provided by the DON, revealed the following: procedures: preparation: 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 3 steps in the process of preparation. 12. Medications are administered within 60 minutes of the scheduled administration time except before, with or after mealtime orders, which are administered based on mealtimes.

Based on observation, interview and record review the facility failed to ensure the residents received a safe appetizing temperature from one of one kitchen.<BR/>The facility failed to maintain proper temperature of food before serving from the steam table. <BR/>This failure placed the residents who ate their meals prepared by the facility kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. <BR/>Findings include:<BR/>Observation on 10/12/2022 at 11:40 AM revealed Dietary Manager checked temperatures of food on the steam table prior to serving. The temperature of food not meeting the require was the following:<BR/>- <BR/>Temperature for Country Fried Steak was held for 20 seconds and the temperature was 130 degrees. <BR/>- <BR/>Temperature for Mechanical Soft Country Fried Stead was held for 20 second and the temperature was 110 degrees<BR/>- <BR/>Temperature for Peas was held for 20 seconds and the temperature was 125 degrees. <BR/>- <BR/>Temperature for Gravy was held for 20 seconds and the temperature was 125 degrees.<BR/>In an interview on 10/12/2022 at 11:50 AM the Dietary Manager stated the temperatures was not correct. She stated all the food checked the temperature should have been higher. She stated the meat was expected to be 160 degrees. She stated the Peas and Gravy temperature required to be at 135 degrees. She stated she did not know what could happen to residents if their food was not cooked in the proper temperature. She stated I assume the residents could become ill with a virus. <BR/>In an interview on 10/12/2022 at 11: 58 AM the Dietary [NAME] stated all meats temperature required to be at 160 degrees, vegetables and the gravy was required to be at 135 degrees. She stated it was the cook's responsibility to check the temperatures and the Dietary Manager was required to monitor the temperatures of food. <BR/>In an interview on 10/13/2022 at 2:00 PM the Administrator stated it was possible a resident could obtain some type of illness if the food wasn't prepared according to federal guidelines. He stated it was Dietary Manager responsibility to ensure all food was cooked properly and served at the correct temperature and if the Dietary Manager was not in the kitchen it would be the cook's responsibility. <BR/>Review of Facility Policy on Food Preparation and Service dated 2001 and revised October 2017 reflected the following internal cooking temperatures/ times for specific foods must be reached to kill or sufficiently inactivate pathogenic microorganisms:<BR/>a. Poultry and stuffed foods- 165 degrees.<BR/>b. Fish and other meats 145 degrees for 15 seconds<BR/>c. Fresh, frozen, or canned fruit/ vegetables - 135 degrees<BR/>d. Mechanically altered hot foods prepared for a modified consistency diet must stay above 135 degrees during preparation or they must be reheated to 165 degrees for at least 15 seconds<BR/>e. Ground meat, ground fish and eggs held for service at least 115 degrees.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one (Resident #1) of three resident reviewed for feeding tubes.<BR/>The ADON failed to set Resident #1's enteral feeding rate per the physician's order. <BR/>The ADON failed to set Resident #1's enteral water flush per the physician's order. <BR/>These failures could place residents at risk for fluid overload and inadequate nutrition which could lead to injury or harm.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet revealed she was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses a diagnosis of Dysphasia (difficulty swallowing foods or liquids), Malignant Neoplasm of Thyroid Gland (thyroid cancer), Post-Procedural Hypothyroidism (low thyroid levels after thyroid surgery), and Hyperlipidemia (high levels of fat particles in the blood).<BR/>Record review of Resident #1's MDS dated [DATE] revealed a BIMS Score of 12 indicating her cognition was moderately intact. Resident #1 received 51 percent or more of the total calories through tube feeding. Resident #1 received 501 cc's a day or more fluid through tube feeding.<BR/>Record review of Resident #1's undated Care Plan revealed Resident #1 was at risk for nutritional deficits and/or dehydration related to dependence on a G-Tube. Staff were to administer a diet as ordered and administer flushes as ordered.<BR/>Record review of Resident #1's Physician's Orders dated 1/16/2023 revealed Enteral Feed Order one time a day Osmolite 1.5 cal at 4:00 PM. Start date 12/23/2022.<BR/>Record review of Resident #1's Physician's Orders dated 1/16/2023 revealed Enteral Feed Order every shift for Preventative Start feedings at 4 PM and stop at 8 AM. <BR/>Record review of Resident #1's Physician's Orders dated 1/16/2023 revealed Flush with 10 mL H2O before and after medication/feeding every shift.<BR/>Record review of Resident #1's Physician's Orders dated 1/16/2023 revealed Free Water at 130 mls/4hrs every 4 hours for Free Water Flushes 4 PM 130ml flush at beginning of hook up and then every 4 hours thereafter until 8 AM and 130 ml flush at 12 noon daily total - 780 ml daily. Start date 1/16/2023.<BR/>In an interview on 1/18/2023 at 1:45 PM with the MD he stated the ADON informed him Resident #1 received extra free water through the night. He stated this could have led to her having hyponatremia (meaning low sodium.) He stated staff needed to be in-serviced on watching and reading the Physician' Orders in order to get the orders correct.<BR/>In an interview on 1/18/2023 at 2:05 PM with RN A she stated the ADON set the pump incorrectly and then notified the doctor. The pump should have been set at 130 ML every 4 hours. The ADON mistakenly set the pump at 130ML every 1 hour. She stated the miscalculation could have caused Resident #1 to have fluid volume overload.<BR/>In an interview on 1/18/2023 at 2:30 PM with the ADON she stated Resident #1 returned from the hospital with paperwork that read 130ml every 4 hours, but the paperwork also said not to give her a lot at one time for fear of her throwing it up. The ADON stated she called the doctor that day and went over Resident #1's paperwork. She confirmed 72cc of water and 75cc of Osmolyte every hour. On this specific day, she went into Resident #1's room to start her feeding, and Resident #1's family member informed her at Resident #1's doctor's appointment, the doctor said she needs to be on 130ml every 4 hours. The ADON stated she then turned the machine to 130 ml and did not think to turn the machine to 4 hours. In her opinion, it was a huge mistake that resulted in Resident #1 receiving 2,080 ccs from 4 PM until 8 AM. She stated Resident #1 could have aspirated or experienced fluid overload.<BR/>In an interview on 1/18/2023 at 3:30 PM with the AIT she stated if Resident #1was not receiving enough water, there was a potential for dehydration and kidney injury. If the feeding formula is was too little, she will have weight loss. If Resident #1 received too much fluid, Resident #1 could get fluid overload. If too much was pumping into her stomach, she can get too full and aspirate, causing her to breathe fluid into the lungs.<BR/>In an interview on 1/18/2023 at 4:00 PM with the [NAME] she stated she was informed by the DON on yesterday morning, 1/17/2023, that Resident #1's family member was upset due to the tube flushes being incorrect. She pulled up the Tube Feeding Orders and Flushes, and went over them with Resident #1's family member due to Resident #1 being discharged home early the next morning on 1/18/2023 at 07:00 AM. She called the MD and verified the Orders with him again. She stated not reading and following the Orders correctly, could cause Resident #1 to not receive the nutrition that she needed and too much or too little fluid. It could also cause Resident #1 to have decreased sodium levels and if continued, it could cause weight loss. She stated her expectations were for the nurses to follow the physician's orders when providing enteral feedings. She stated nurses were expected to check the feedings during rounds. <BR/>Record review of the facility's policy Enteral Nutrition with a revised date of January 2014 revealed, Adequate nutritional support through enteral feeding will be provided to residents as ordered.

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1of 2 medication storage rooms (room located by Hall 300). <BR/>The facility failed to ensure expired medication administration supplies were removed from the medication room located by hall 300.<BR/>These failures could place residents at risk for ineffective treatments, intravenous catheter dislodgements and infections. <BR/>Findings include:<BR/>Observation on 2/11/25 at 10:30 AM of the Hall 300 Medication Storage Room revealed the following:<BR/>8 Zyno IV Administration sets expired 3/19/2023.<BR/>7 Zyno IV Administration sets expired 6/20/2022<BR/>1 Stat lock PICC PLUS Catheter stabilizer expired 4/28/2023.<BR/>1 Central Line Dressing Kit expired 2/28/2021.<BR/>In an interview on 2/12/25 at 12:48 PM LVN-A stated, the policy on expired medical supplies was to take them back to medical records department where they get rid of them. She stated the nurses, and the medication aides were responsible for checking the rooms. She said this was important because the supplies may not be good to use, and they could hurt the residents by causing infections if they were used. <BR/>In an interview on 2/12/25 at 12:54 PM LVN-B stated, the policy for expired medical supplies was to pull them out of the medication storage rooms. She stated the nurses, and the medication aides were responsible for checking the medication rooms. She stated that it was important to do this because otherwise someone could grab the expired supplies and accidentally use them. She stated the negative outcome to using expired supplies was that residents could have side effects and the expired supplies could be damaged and not work properly. <BR/>In an interview on 2/12/25 at 12:59 PM the DON stated, the policy for expired medical supplies was to throw them out/dispose of them. She stated she was responsible for removing expired supplies. She stated, anyone else who finds expired supplies was also responsible for removing them. She stated it was important to remove expired items because they could have lost integrity and materials could be bad which could cause IV dressings to breakdown and come off. <BR/>In an interview on 2/12/25 at 1:04 PM the ADM stated, the policy on expired medical supplies was to discard them and the nurse's and the nurse supervisors were responsible for doing that. He stated it was important to discard expired items because they could lose effectiveness and then they would not stick to cover the IV sites. <BR/>Record review of the facility's undated policy labeled Pharmscript-Storage of Medications Policy # 4.1, reflected:<BR/>Outdated medications are immediately removed from inventory. <BR/>Expired medications will be removed from the active supply and destroyed

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1of 2 medication storage rooms (room located by Hall 300). <BR/>The facility failed to ensure expired medication administration supplies were removed from the medication room located by hall 300.<BR/>These failures could place residents at risk for ineffective treatments, intravenous catheter dislodgements and infections. <BR/>Findings include:<BR/>Observation on 2/11/25 at 10:30 AM of the Hall 300 Medication Storage Room revealed the following:<BR/>8 Zyno IV Administration sets expired 3/19/2023.<BR/>7 Zyno IV Administration sets expired 6/20/2022<BR/>1 Stat lock PICC PLUS Catheter stabilizer expired 4/28/2023.<BR/>1 Central Line Dressing Kit expired 2/28/2021.<BR/>In an interview on 2/12/25 at 12:48 PM LVN-A stated, the policy on expired medical supplies was to take them back to medical records department where they get rid of them. She stated the nurses, and the medication aides were responsible for checking the rooms. She said this was important because the supplies may not be good to use, and they could hurt the residents by causing infections if they were used. <BR/>In an interview on 2/12/25 at 12:54 PM LVN-B stated, the policy for expired medical supplies was to pull them out of the medication storage rooms. She stated the nurses, and the medication aides were responsible for checking the medication rooms. She stated that it was important to do this because otherwise someone could grab the expired supplies and accidentally use them. She stated the negative outcome to using expired supplies was that residents could have side effects and the expired supplies could be damaged and not work properly. <BR/>In an interview on 2/12/25 at 12:59 PM the DON stated, the policy for expired medical supplies was to throw them out/dispose of them. She stated she was responsible for removing expired supplies. She stated, anyone else who finds expired supplies was also responsible for removing them. She stated it was important to remove expired items because they could have lost integrity and materials could be bad which could cause IV dressings to breakdown and come off. <BR/>In an interview on 2/12/25 at 1:04 PM the ADM stated, the policy on expired medical supplies was to discard them and the nurse's and the nurse supervisors were responsible for doing that. He stated it was important to discard expired items because they could lose effectiveness and then they would not stick to cover the IV sites. <BR/>Record review of the facility's undated policy labeled Pharmscript-Storage of Medications Policy # 4.1, reflected:<BR/>Outdated medications are immediately removed from inventory. <BR/>Expired medications will be removed from the active supply and destroyed

Based on interviews, and record reviews, the facility failed to ensure a person designated as the infection preventionist worked at least part-time at the facility for 1 of 1 Infection Preventionist reviewed. <BR/>The facility did not have an infection preventionist in place who worked at least part-time at the facility. The DON was the infection preventionist and did not work at least part-time in the position at the facility. <BR/>This deficient practice could place residents at risk of cross contamination and infection.<BR/>Findings included:<BR/>During an interview on 12/19/23 at 9:35 AM with the ADM, he stated the DON was the infection preventionist for the facility.<BR/>During an interview on 12/21/23 at 11:22 AM with the ADON, she stated she had completed the IP training but only helped with IP duties if needed.<BR/>During an interview on 12/20/23 at 11:52 AM with the DON, she stated she was the infection preventionist. She stated the previous ADON had been the IP, but she no longer worked at the facility and had been gone about three or four weeks. She stated she works as the DON usually about nine or ten hours a day. She stated she did not have specific hours as the IP. She stated she did everything she could but if there was an emergency that took priority over tracking infections.<BR/>During an interview on 12/21/23 at 12:32 PM with the DON, she stated she added the IP duties to her task every day and did what she could. She stated it took a lot of time to complete the IP duties. She stated they had talked about the need to hire someone for the position. She stated a potential consequence of not having an IP was things could be missed because there was so much to do.<BR/>During an interview on 12/21/23 at 1:12 PM with the ADM, he stated the ADON who was the IP had left the facility which left them without a dedicated IP. He stated he was working on filling the position. He stated an adverse outcome of not having an IP was increased infections, missing tracking or trending of infections.<BR/>Review of the DONs time sheet for the month of November 2023 revealed the DON worked as a floor nurse on 11/18/23 and 11/19/23 for a total of 20.37 hours. The rest of the time was allocated as Director of Clinical Operations.<BR/>Review of the facility policy Infection Preventionist effective 06/01/21 reflected in part, 1. The Infection Preventionist (or designee) shall coordinate the development and monitoring of our community's established infection prevention and control policies and practices. 5. The Infection Preventionist will collect, analyze and provide infection and antibiotic usage data and trends to nursing staff and health care practitioners; consult on infection risk assessment and prevention control strategies; provide education and training; and implement evidenced-based infection prevention and control practices. <BR/>