Harmony Care at Golfcrest

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish an infection prevention and control program that included handling of soiled linen, and patient care equipment as well as to help prevent the development of communicable diseases and infections, on 2 of 3 halls (Hall 100 and Hall 200) observed for infection control.<BR/>CNA D and CNA E were observed taking dirty linen and soiled brief to the trash can across the hallway and they were not in clear trash bag.<BR/>Personal care basins and bed pans were on the bathroom floor not labeled with resident's name and not in plastic bags.<BR/>These failures have the potential to affect all residents by placing them at risk of infections and diminishing quality of life. <BR/>Findings included: <BR/>Observation on 3/27/2025 between 9:30am and 10:30am revealed the following:<BR/>In room [ROOM NUMBER], 118, 112, 218, 219, 209 and 208 personal care wash basins on the floor in the bathroom with no name and two residents share the rooms. In room [ROOM NUMBER] was a urinal and a bed pan on the floor in the bathroom not in a plastic bag with no name and two residents share the room.<BR/>Observation on 3/27/2025 at 4:00pm revealed CNA D leaving room [ROOM NUMBER] with soiled brief with feces not in a clear bag to the trash can across the hallway. Further observation at that time revealed CNA E, at the doorway with soiled towels heading to the trash cannot in a bag. At that point the Surveyor asked what was going on and she stopped, and CNA D brought her a clear plastic bag and CNA E put the soiled linen in the bag and took it to the dirty barrel. <BR/>In an interview on 3/27/2025 at 4:00pm with CNA E she said she was in training. She said that they should not be walking with the dirty linen and soiled brief. She said they should place the soiled linen and brief into plain plastic bags to dispose of them. <BR/>In an interview on 3/27/2025 at 4:05pm with CNA D she said she should have clear plastic bags in the room during incontinent care. She said having to walk across the hallway with the soiled brief could cause waste to drop on the floor which could cause infection. She said she was in-serviced on infection control, and she should have bags in the room when incontinent was being provided. <BR/>In an interview on 3/27/2025 at 4:29pm the DON said nursing staff were in-serviced on infection control and ensuring that soiled briefs were in plain plastic bags and disposed in the trash bins and linen be placed in plain plastic bags and placed in the dirty barrel. She said resident personal care basins, urinal, and bed pans should be in clear plastic bags and the names of the residents be written on them. She said this could cause infection when using resident care equipment for multiple residents. She said she was going to immediately start in-servicing the staff. <BR/>Record review of the facility policy on Standard Precautions dated 2/2023 read in part .<BR/>Policy Statement<BR/>Standard Precautions will be used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents.<BR/>Policy Interpretation and Implementation<BR/>5. <BR/>Resident-Care Equipment<BR/>a. <BR/>Handle used resident-care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of other microorganisms to other residents and environments.<BR/>b. <BR/>Ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned and reprocessed and single use items are properly discarded.<BR/>7. <BR/>Linen<BR/>a. <BR/>Handle, transport, and process used linen soiled with blood, body fluids, secretions, excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and avoids transfer of microorganisms to other residents and environments.<BR/>Record review of the undated facility's Policies and Practices - Infection Control read in part .<BR/>Policy Statement<BR/>This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.<BR/>Policy Interpretation and Implementation<BR/>1. <BR/>This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payor source.<BR/>2. <BR/>The objectives of our infection control policies and practices are to:<BR/>a. <BR/>Prevent, detect, investigate, and control infections in the facility.<BR/>b. <BR/>Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public;<BR/>f. <BR/>Provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents on 2 of 3 Halls (100 and 200 Halls) reviewed for environmental concerns. <BR/>1. Overhead light was not illuminating in the bathroom of room [ROOM NUMBER].<BR/>2. Baseboard coming off the wall in rooms 118, 201, <BR/>3. Broken sheet rack in rooms 113, 219, 206<BR/>4. Peeling paint on the wall in rooms 103, 120, <BR/>5. Floor tile lifting in room [ROOM NUMBER]<BR/>6. Strong urine/feces odor in room [ROOM NUMBER], 116 and 120. In 116 and 120 brown substance that looked like feces the toilet and floor. <BR/>This deficient practice could affect residents who resided in rooms on hall 100 and hall 200 by causing the residents to live in an environment that would not improve their quality of life. <BR/>Findings Included:<BR/>Observation on 3/27/2025 between 9:30am and 10:30am revealed the following. <BR/>In room [ROOM NUMBER] the light in the bathroom was not illuminating. <BR/>In rooms [ROOM NUMBERS] the baseboard coming off the wall. 201 window blinds were broken.<BR/>In rooms 113, 219 and 206 revealed broken sheet rack.<BR/>In rooms [ROOM NUMBERS] has peeling paint on the wall.<BR/>In room [ROOM NUMBER] there was a hole under the window where the tape was not affixed to the wall and a hole in the sheet rack near the entrance door. There was an electric cord plug in the wall across the floor to bed A. <BR/>Rooms 112,116 and 120 had strong offensive urine/feces odor. In room [ROOM NUMBER] and 120 the toilet bowl, seat and floor had brown stains and smear that looked and smelled like feces. In rooms [ROOM NUMBERS] the floor had an accumulation of brown stains on it. <BR/>Interview on 3/27/2025 at 9:35am. with an unidentified resident revealed that there was no light in the bathroom of113. <BR/>Interview on 3/27/2025 at 1:25pm with the Maintenance Supervisor revealed that he was not aware of the light not working in room113. He said maybe it was just the bulb that needed to be changed. He said he was going to check the bathroom I 13 and change the bulb. He said he had just gotten the position as maintenance supervisor, and he was going to address all concerns brought to him. He said there was a book on all stations and concerns were documented in them. He said each morning he would check the books and see what needed to be done and try to address them as quickly as possible. <BR/>In an interview on 3/27/2025 at 4:00pm the Administrator said Maintenance Supervisor said he had just taken the position as supervisor, and he was going to hire an assistant for him. He said he was going to address the concerns brought to him. <BR/>Record review of the facility's policy and procedures revised August 2009 revealed Quality of Life-Homelike Environment read in part .<BR/>Policy Statement: Resident are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to extent possible. <BR/>Policy Interpretation and Implementation<BR/>1. Staff provide person-centered care that emphasizes the resident comfort, independence and personal needs preferences.<BR/>2. 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:<BR/>a. cleanliness and order.<BR/>b. Comfortable (minimum glare) yet adequate (suitable to the task) lighting.<BR/>e. Pleasant neutral scents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #77) out of 6 residents reviewed for pain management. The facility failed to ensure Resident #77's pain medications were administered timely prior to traveling in an ambulance to the dialysis facility on 07/23/25 when he rated his pain as an 8 out of 10 pain scale. This failure could place Resident #77 and other residents at risk of not receiving timely pain management care which could result in prolonged pain and diminished quality of life.Findings included: Record review of Resident #77's face sheet dated 07/23/25 revealed a [AGE] year-old male readmitted to the facility on [DATE], initially admitted on [DATE] and originally admitted on [DATE]. His diagnoses included fracture of the shin bones of left and right leg, COPD (chronic obstructive pulmonary disease - a lung condition caused by damage to the airway), end stage renal disease (kidneys no longer function adequately requiring dialysis or transplant), cirrhosis of the liver (abnormal liver function), Osteoarthritis (degeneration of joint cartilage and bone), hypotension, heart failure, depression, anxiety, chronic pain syndrome and dependence on renal dialysis. Record review of Resident #77's quarterly MDS dated [DATE] revealed a BIMs score of 14 out of 15 indicating intact cognition. He had no behaviors or rejection of care. He used a wheelchair for mobility. Pain intensity over the last 5 days was rated at a 6 out of 10, with zero being no pain and 10 being the worst pain ever imagined. Further review revealed he was taking antianxiety and opioid medications. Record review of Resident #77's undated care plan revealed: Focus - Resident #77 was at risk for increased pain and further decreased circulation as evidenced by venous ulcers to bilateral lower extremities. Interventions included - give medications per order. Focus - Resident #77 was on pain medication therapy Oxycodone r/t disease process. Interventions included - administer analgesic medications as ordered by physician. Monitor/document side effects and effectiveness every shift. Focus - Resident #77 had chronic pain r/t neuropathy. Interventions included: anticipate the resident's need for pain relief and response immediately to any complaint of pain. Focus - Resident #77 had episodes of manipulative behaviors as evidenced by pain med seeking behavior and at risk for further episodes. Interventions included - distract resident with activities based on resident's preferences, notify MD/RP of behaviors. Focus - Resident #77 at risk for further skin breakdown r/t left lower leg, closed surgical on 6/10/25. Interventions included - observe for pain, give medication per order, check for relief. Focus - Resident #77 needs dialysis r/t renal failure, M/W/F. Interventions included - work with resident to relieve discomfort for side effects of the disease and treatment.Focus - Resident #77 was at risk for shortness of breath, chest pain, elevated blood pressure, infected access site, dry/itchy skin as evidenced by diagnosis of ESRD. Dialysis schedule: 3 times per week on M/W/F. Pick up time: 7:00AM, revised on 02/04/25. No recent revisions were made. Record review of Resident #77's order summary report of active orders as of 07/23/25 revealed orders for: -Oxycodone HCL oral tablet 10mg every 12 hours at 9:00AM and 9:00PM for pain management, order date 07/10/25. -Oxycodone HCL oral tablet 5mg every 6 hours as needed for pain, order date 06/24/25. -Hydrocodone-Acetaminophen oral tablet 10-325mg one tablet every 6 hours as needed for pain, order date 07/02/25. -Methocarbamol 750mg every 12 hours at 9:00AM and 9:00 PM for muscle relaxer, order date 06/10/25 - May go to dialysis on: Monday, Wednesday, Friday at 7:00 AM, order date 06/10/25.Record review of Resident #77's completed orders revealed and order started 06/10/25 for taper dose of Oxycodone HCL 10mg: give 4 tablets by mouth every 12 hours for pain for 6 days, 1 tablet for 7 days; give 3 tablets by mouth every 12 hours for pain for 7 days, 1 tablet for 7 days; give 2 tablets by mouth every 12 hours for pain for 7 days, 1 tablet for 7 day; give 1tablets by mouth every 12 hours for pain for 7 days, 1 tablet for 7 day. The end date for the order was 07/08/25. Record review of Resident #77's June 2025 MAR/TAR revealed pain assessments were completed every shift and pain scores were zero to 5 out of 10. Record review of Resident #77's July 2025 MAR revealed the Oxycodone HCL 10mg to be given every 12 hours, due at 8:00 AM was not given on 7/2/25 and 7/14/25. Further review revealed the Methocarbamol 750mg tablet every 12 hours at 9:00 AM and 9:00 PM for muscle relaxer was not given at 9:00 AM on 07/02/25, 07/14/25 and 07/23/25 and to refer to the progress notes for both Oxycodone HCL 10mg and Methocarbamol 750mg. Record review of Resident #77's Administration progress note revealed on 07/02/25 at 8:29 AM, MA-E noted the resident was at dialysis. On 07/14/25 at 11:52 AM, CNA-H documented the resident was at dialysis. On 07/23/25 at 8:38 AM, CNA-B documented the resident was at dialysis. Record review of Resident #77's July 2025 MAR revealed from 7/01/25 to 07/24/25: - Hydrocodone-Acetaminophen oral tablet 10-325mg one tablet every 6 hours as needed for pain was documented as administered 2-4 times per day. Pain levels were documented as 4 to 8 out of 10 (10 being the worst pain imagined). All administrations were documented as effective.-Oxycodone HCL 5mg every 6 hours as needed for pain was documented as administered 17 days, 1 to 3 times per day. Pain levels were documented from 4 to 9 out of 10. All administrations were documented as effective. -The scheduled Oxycodone 10mg twice a day was documented as administered. -Further review revealed Resident #77 was monitored for opioid adverse events every shift. Most entries revealed none was observed. Record review of Resident #77's Administration notes written by RN-A revealed on 07/23 25 at 8:38 AM it was noted the resident was at dialysis. On 07/23/25 at 9:00AM a note by RN-A revealed the follow up pain scale was 0 and effective. On 07/23/25 at 2:00 PM, RN-A documented the administration of Oxycodone HCL 5mg tablet by mouth every 6 hours as needed for pain: request for pain medication for breakthrough leg pain. Further review revealed there was no follow up pain assessment. Record review of Resident #77's July 2025 administration progress notes revealed on 07/23/25 at 3:00 PM, RN-D noted the administration of Hydrocodone/Acetaminophen 10-325mg every 6 hours as needed for pain: one tablet given as directed. Record review of Resident #77's July 2025 MAR revealed on 07/23/25 at 3:00 PM, the resident received Hydrocodone/Acetaminophen 10-325mg and RN-D noted the pain level of 5 and that it was effective. Record review of Resident #77's Administration progress note on 07/23/25 at 3:51 PM, revealed RN-A documented Hydrocodone/Acetaminophen 10-325mg follow up pain was: 0 and the administration was effective. Record review of Resident #77's History and Physical, date of service 7/2/25, by Physician-F revealed he had fracture pain and was still appropriate to continue for Hydrocodone-Acetaminophen 10-325mg and Oxycodone. Continued review indicated the resident was known to have alcohol abuse and very close monitoring would be needed in the facility for s/sx of intoxication and withdrawal. Record review of Resident #77's nurse note dated 07/02/25 at 5:11 PM and written by the ADON/IP indicated that the resident expressed that he had been drinking large amounts of alcohol the prior night. Further review of the nurse note indicated ADON/IP educated the resident of the risks of drinking alcohol and taking medication regimen. Continued review indicated the resident verbalized understanding, and the NP/MD were made aware. Record review of Resident #77's behavior note dated 07/02/25 at 6:00 PM and written by LVN-G, indicated Resident #77 refused medication from the med aide and med aide reassured the medication would be provided, but he still refused. Further review revealed RN-D wrote on 04/25/25 at 7:06 AM, Resident #77 was upset because the Hydrocodone-Acetaminophen oral tablet 10-325mg could not be given at the time due to the fact the night time nurse had given a dose at 5:00 AM. Continued review of Resident #77's behavior notes dated 09/24/22 to 07/17/25 revealed no documentation regarding the resident crying out in pain. Record review of Resident #77's Administration progress notes on 07/02/25 at 8:29AM noted the resident went to dialysis. Continued review of the progress notes revealed an administration note on 07/14/25 at 7:32AM for Hydrocodone-Acetaminophen 10/325mg. The next entry was on 07/14/25 at 11:52, AM and noted the resident was at dialysis. There was no entry on 07/14/25 noting the resident was at dialysis at 9:00AM. Record review of Resident #77's Medical Professional Note, date of service 7/9/25 by Physician-F revealed in part: .Pain Management Continue Oxycodone 10 mg every 12 hours scheduled and 5 mg every 6 hours as needed for breakthrough pain. Also continue Hydrocodone-Acetaminophen 10-325 mg every 6 hours as needed. Monitor pain levels, effectiveness of regimen, and signs of sedation, constipation, or misuse. Consider simplifying opioid regimen to avoid overlapping narcotics if sedation or altered mental status arises. Observation and interview on 07/22/25 at 12:56PM, revealed Resident #77 was in the dining room, reclined in a specialized wheelchair. He had an external fixator/traction device, the pins were in his left leg. He had dressings to his feet. He was feeding himself and in no distress. Resident #77 stated he was hit by a truck and was in the hospital for surgery to his leg. Observation and interview on 07/23/25 at 6:55 AM, Resident #77 stated the transportation to dialysis would be arriving soon and that he was due for pain medications: Oxycodone and Hydrocodone-Acetaminophen 10-325mg at 7:30AM. He stated sometimes it may take 2.5 hours before he received pain meds after he asked for them. He stated because of the delay in receiving pain medication when he requested, it would disrupt his medication schedule preventing him from adequate pain control before going to dialysis. He stated it infuriated him and sometimes he cried when he ended up missing a dose of pain medication. He was observed scratching his skin and moving his upper body without any hesitation. At 7:15 AM Resident #77 turned on the call light. Nursing staff answered a few minutes later. Resident #77 requested his pain meds and told the nurse he was going to dialysis very soon. Resident #77 stated he usually asked multiple times to get what he needed before leaving for dialysis and at times he would not receive his pain meds. He stated his pain was in his leg and his back. At 7:35 AM RN-A assessed Resident #7, checked his vital signs then Resident #77 told her his pain level was 8 out of 10. Interview on 07/23/25 at 7:45 AM, RN-A stated Resident #77's Oxycodone was scheduled every 12 hours and was due at 9:00AM, the Hydrocodone-Acetaminophen 10-325mg was as needed for pain. RN-A stated she would need to wait closer to 8:00AM to administer the medications as the scheduled Oxycodone could only be given one hour before or one hour after 9:00 AM RN-A stated the plan was to wean down the amount of narcotics Resident #77 was taking and that he had history of drug seeking and that he was used to the drugs he was receiving while in hospital. Observation on 7/23/25 at 7:55 AM, revealed Resident #77 was in the gurney as transportation attendants wheeled the resident down the hall. Observation on 7/23/25 at 8:00AM revealed Resident #77 was taken back to his room. RN-A administered Oxycodone IR 10mg and Hydrocodone-Acetaminophen 10-325mg one tablet to Resident #77, attendants then wheeled him back down the hall to transport in the ambulance to dialysis. IIn an Interview on 07/24 25 at 9:30AM, ADON-I stated she would expect a resident's pain to be addressed in a timely manner, get them the pain med, offer repositioning, if still not working she would notify the MD. ADON-I stated 2 hours is not acceptable for waiting on pain med and maybe 1-2 hours would be maximum, but she was unsure and would have to check the policy. ADON-I stated the pain level would depend on the individual resident's interpretation of pain. ADON-I stated if the pain level was a 4 or 5 and the resident was comfortable and wanted more pain medication, she would administer what was due, try repositioning or call the doctor. ADON-I stated she expected the nursing staff to do the same. ADON-I stated no one wants to be in constant pain, the resident may be grumpy and not want to do any ADLs. ADON-I stated it could worsen their health status. ADON-I stated medications can be given one hour before or one hour after scheduled order for time. ADON-I stated Resident #77 was followed by pain management doctor at one time, she was unsure but may be due to insurance. ADON-I stated Resident #77's pain management was under Physician-F who was the primary care physician. In an interview on 07/24/25 at 9:45 AM, the ADON/IP stated she was familiar with Resident #77. The ADON/IP stated if a resident asks for pain medication immediately, she expected nursing staff to check in 30minutes to see if the pain had subsided and if not, she would notify the MD for further instructions. The ADON/IP stated they[BR10] would try comfort measures as well to help manage pain. The ADON/IP stated if a resident had uncontrolled pain, she would contact the MD to adjust the meds. The ADON/IP stated most of the time medications would be scheduled around appointments, if not then the MD would be contacted to reschedule. The ADON/IP stated Resident #77 had a pain specialist and then pain management was transitioned to the provider. The ADON/IP stated transportation for dialysis would usually leave at 8:15am and as far as she knew he was receiving the 9:00AM meds before leaving. The ADON/IP stated Resident #77 does have breakthrough pain, she visits with him on multiple occasions and had not mentioned any issues about not getting his pain meds. The ADON/IP stated the medication aide was responsible for administering his 9:00AM medications and if they were missed, she expected to be notified so she can contact the MD and adjust the times. In a telephone interview on 07/24/25 at 12:40 PM, Physician-F stated he was very familiar with Resident #77 and that he was responsible for managing his pain meds. Physician-F stated Resident #77 was pain med seeking and that his subjective determination of pain can be different for everyone and his was a little bit off. Physician-F stated he does not use a pain scale but uses objective findings instead. Physician-F stated he received calls about his pain every week about his pain status and the nurses will also text him on his cell phone frequently. Physician-F stated he sees Resident #77 three days a week and would have complaints about pain. Physician-F stated Resident #77 can get his medications either before or after dialysis and he had already made the changes when ADON/IP notified him. In an observation and interview on 07/23/25 at 1:45 PM, revealed Resident #77 returned from dialysis and was in the dining room playing cards, no distress was noted. He stated normally it would take about one hour to receive his pain medications. When asked if he remembers what time he asked for pain medication this morning, he stated it was just before the surveyors entered his room around 7:00AM. He stated the ride in the ambulance was rough and his pain level was 8-9/10 at the time. He stated he would ask the drivers to avoid bumps in the road, but they could not promise that. In an Interview on 07/24/25 at 1:47 PM, LVN-C stated when Resident #77 requests pain medication, he reports his pain to be a 7 or 8 out of 10, she would then check which pain medication could be given. LVN-C stated she has seen Resident #77 cry or scream loudly in the last month when he did not get his pain medications when he asked. LVN-C stated she would address the pain by offering available pain medication, repositioning such as moving him into his wheelchair and if that did not work, she would contact the MD for further instructions. Interview on 07/24/25 at 2:00 PM, RN-D stated Resident #77 received all his scheduled and PRN pain medications. RN-D stated his tolerance to pain medications was high, however with his illness and injury he was often in pain and that his pain level was a 7 or 8 out of 10. RN-D stated she would use non-pharmacological interventions to help him with the pain. RN-D stated he did well when up in the wheelchair with activities for distraction. RN-D stated she would contact the physician after two to three episodes of no pain relief for further instructions. Interview on 7/25/25 at 9:40 AM, RN-A stated on dialysis days she was aware Resident #77 would be gone for at least 6 hours and that he would need the pain coverage so that was why she gave both the Oxycodone and Hydrocodone-Acetaminophen oral tablet 10-325mg at 8:00 AM on 07/23/25. RN-A stated sometimes it could take a little time to get what Resident #77 needed especially when in the middle of doing something for another resident and could not always respond as quickly as he would like but she tried to get to him in an hour or less. Record review of the facility policy and procedure for Administering Pain Medication, revised October 2022, revealed in part: The purpose of this procedure is to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication.General Guidelines 1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. 2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals.5. Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after onset and reassessed as indicated until relief is obtained.7.a. Any resident who uses opioids for long-term management of chronic pain is at risk for opioid overdose.9. Re-evaluate the resident's level of pain 30-60 minutes after administering.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Resident #77) reviewed for pharmacy services.MA-B failed to administer Sevelamer (a phosphate binder used to control high phosphorus levels in residents on dialysis) as instructed on the pharmacy label.This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings included:Record review of Resident #77's face sheet dated 07/23/25 revealed a [AGE] year-old male readmitted to the facility on [DATE], initially admitted on [DATE] and originally admitted on [DATE]. His diagnoses included fracture of the shin bones of left and right leg, end stage renal disease (kidneys no longer function adequately requiring dialysis or transplant), Osteoarthritis (degeneration of joint cartilage and bone), anxiety, and dependence on renal dialysis.Record review of Resident #77's quarterly MDS dated [DATE] revealed a BIMs score of 14 out of 15 indicating intact cognition. Section I - Active Diagnoses included renal failure.Record review of Resident #77's undated care plan indicated a plan of care that included: Focus - Resident #77 was receiving dialysis for ESRD and at risk for symptoms including dry/itchy skin. Interventions included to give medications as ordered.Record review of Resident #77 active orders as of 07/23/25 revealed an order for Sevelamer HCL 800mg, take 3 tablets by mouth with meals for phosphorous control.Record review of Resident #77's July 2025 MAR/TAR indicated MA-B administered Sevelamer 800mg, 3 tablets on 07/23/25 at 8:00 AM. Further review revealed the MAR included give 800mg by mouth with meals for control of phosphorous level, take 3 tablets.Observation and interview on 07/23/25 at 6:55 AM, revealed Resident #77 was scratching his back and front of body using a back scratcher. His skin was dry. He stated he takes the phosphate binder Sevelamer with meals.Observation of medication pass on 07/23/25 at 7:45 AM, revealed MA-B administered Sevelamer Carbonate 800mg, three tablets to Resident #77. The pharmacy label instructions were to take with meals. MA-B did not administer with food.In a telephone interview on 7/25/25 at 9:40AM, RN-A was the nurse in charge of Resident #77 on 7/23/25 and was unaware that Resident #77 received the Sevelamer without food and that the orders should have been followed.A telephone interview was attempted on 07/26/25 at 9:00AM with MA-B. A message was left on voicemail to return surveyor call. Received no call back.Record review of the facility policy and procedure for Administering oral medications, revised October 2010, read in part: The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Preparation 1. Verify that there is a physician's medication order for the procedure.Steps in the Procedure.6. Check the label on the medication and confirm the medication name and dose with the MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1 of 5 residents (Resident #44) reviewed for medication administration were free of significant medication errors.<BR/>MA L administered Doxazosin Tablet 4mg and Amiodarone HCl Tablet 200mg (medications used to treat high blood pressure), while Resident #44 was assessed with blood pressure lower than the physician recommended parameters for administering the medications. <BR/>This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. <BR/>Findings included:<BR/>Review of Resident #44's face sheet, dated 05/02/2024, revealed that the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis of hypertensive heart disease with heart failure (condition that occurs when high blood pressure damages the heart and reduces its ability to pump blood effectively).<BR/>Review of Resident #44's quarterly MDS assessment, dated 03/25/24, revealed a BIMS score of 15 (an intact cognitive response.<BR/>Review of Resident #44's May/2024 active Physician Order Summary revealed the following orders: <BR/>Amiodarone HCl Tablet 200 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold For SBP&lt;110 DBP&lt;60 <BR/>Doxazosin Mesylate Tablet 4 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold for SBP&lt;110 DBP&lt;60<BR/>Observation on 05/02/2024 at 8:15am revealed MA L was observed obtaining Resident #44's blood pressure with a blood pressure reading of 100/65. MA L proceed by administering the medications and verbalizing to Resident #44 that he was receiving all morning medications including blood pressure medications. <BR/>Review of Resident #44's May/2024 Medication Administration Record (MAR) revealed that MA L administered Doxazosin Tablet 4mg and Amiodarone HCI Tablet 200mg. Each of the medications were administered outside of the physician indicated parameters on 05/02/2024. Resident #44's systolic blood pressure was documented by MA L with a systolic blood pressure of 100 and a diastolic blood pressure of a 65.<BR/>Interview with MA L on 05/02/2024 at 8:20am, MA L denied administering Resident #44's blood pressure medication, stated that she had discarded the medication in Resident #44's designated trash bin in his room. There was no observation of the referenced discard of the medications.<BR/>Interview and observation with ADON on 05/02/2024 at 8:30am, ADON was notified of the surveyor's observation of MA L administering blood pressure medication outside of the indicated parameters; and MA L denial of administering the medications. ADON proceeded to assess Resident #44 for adverse side effects. The ADON stated that MA L was not able to produce the pills and that the medication was not in the trash bin as alleged by MA L. The ADON stated that MA L later disclosed that she had administered the medications. The ADON stated that the physician was notified. MA L was removed from the floor and provided in-service and educated on medication administration. <BR/>Interview on 05/02/2024 at 9:30AM with MA L, MA L stated that if blood pressure medication is administered outside of the recommended parameters, the resident's blood pressure could drop too low causing the resident to have severe complications. MA L stated that staff administering the medications was responsible for ensuring that a medication was given within recommended parameters. MA L stated if blood pressure medication was given out of recommended parameters the medication could cause the blood pressure to become too elevated or too low. <BR/>Observation on 05/02/2024 at 9:33 AM revealed Resident #44 was observed sitting in bed watching television. Resident reported that he was feeling well. <BR/>Interview on 05/02/2024 at 1:22 PM with the DON, stated that MA L later disclosed that she had administered the medications. The DON stated that the physician was notified. MA L was removed from the floor and provided in-service and educated on medication administration. The DON stated medication should be held if the vitals were out of parameters. The DON stated the medication aide should have notified the nurse and the nurse would have notified the doctor that the medication was not administered because the resident's vitals were out of parameters. The DON stated that the purpose of the recommended parameters for the medication is to ensure that the resident remains in a safe blood pressure range identified for the resident. <BR/>Review of the facility's Medication Administration policy, not dated, reflected: .Medications must be administered in accordance with the written orders of the physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish an infection prevention and control program that included handling of soiled linen, and patient care equipment as well as to help prevent the development of communicable diseases and infections, on 2 of 3 halls (Hall 100 and Hall 200) observed for infection control.<BR/>CNA D and CNA E were observed taking dirty linen and soiled brief to the trash can across the hallway and they were not in clear trash bag.<BR/>Personal care basins and bed pans were on the bathroom floor not labeled with resident's name and not in plastic bags.<BR/>These failures have the potential to affect all residents by placing them at risk of infections and diminishing quality of life. <BR/>Findings included: <BR/>Observation on 3/27/2025 between 9:30am and 10:30am revealed the following:<BR/>In room [ROOM NUMBER], 118, 112, 218, 219, 209 and 208 personal care wash basins on the floor in the bathroom with no name and two residents share the rooms. In room [ROOM NUMBER] was a urinal and a bed pan on the floor in the bathroom not in a plastic bag with no name and two residents share the room.<BR/>Observation on 3/27/2025 at 4:00pm revealed CNA D leaving room [ROOM NUMBER] with soiled brief with feces not in a clear bag to the trash can across the hallway. Further observation at that time revealed CNA E, at the doorway with soiled towels heading to the trash cannot in a bag. At that point the Surveyor asked what was going on and she stopped, and CNA D brought her a clear plastic bag and CNA E put the soiled linen in the bag and took it to the dirty barrel. <BR/>In an interview on 3/27/2025 at 4:00pm with CNA E she said she was in training. She said that they should not be walking with the dirty linen and soiled brief. She said they should place the soiled linen and brief into plain plastic bags to dispose of them. <BR/>In an interview on 3/27/2025 at 4:05pm with CNA D she said she should have clear plastic bags in the room during incontinent care. She said having to walk across the hallway with the soiled brief could cause waste to drop on the floor which could cause infection. She said she was in-serviced on infection control, and she should have bags in the room when incontinent was being provided. <BR/>In an interview on 3/27/2025 at 4:29pm the DON said nursing staff were in-serviced on infection control and ensuring that soiled briefs were in plain plastic bags and disposed in the trash bins and linen be placed in plain plastic bags and placed in the dirty barrel. She said resident personal care basins, urinal, and bed pans should be in clear plastic bags and the names of the residents be written on them. She said this could cause infection when using resident care equipment for multiple residents. She said she was going to immediately start in-servicing the staff. <BR/>Record review of the facility policy on Standard Precautions dated 2/2023 read in part .<BR/>Policy Statement<BR/>Standard Precautions will be used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents.<BR/>Policy Interpretation and Implementation<BR/>5. <BR/>Resident-Care Equipment<BR/>a. <BR/>Handle used resident-care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of other microorganisms to other residents and environments.<BR/>b. <BR/>Ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned and reprocessed and single use items are properly discarded.<BR/>7. <BR/>Linen<BR/>a. <BR/>Handle, transport, and process used linen soiled with blood, body fluids, secretions, excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and avoids transfer of microorganisms to other residents and environments.<BR/>Record review of the undated facility's Policies and Practices - Infection Control read in part .<BR/>Policy Statement<BR/>This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.<BR/>Policy Interpretation and Implementation<BR/>1. <BR/>This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payor source.<BR/>2. <BR/>The objectives of our infection control policies and practices are to:<BR/>a. <BR/>Prevent, detect, investigate, and control infections in the facility.<BR/>b. <BR/>Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public;<BR/>f. <BR/>Provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1 of 5 residents (Resident #44) reviewed for medication administration were free of significant medication errors.<BR/>MA L administered Doxazosin Tablet 4mg and Amiodarone HCl Tablet 200mg (medications used to treat high blood pressure), while Resident #44 was assessed with blood pressure lower than the physician recommended parameters for administering the medications. <BR/>This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. <BR/>Findings included:<BR/>Review of Resident #44's face sheet, dated 05/02/2024, revealed that the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis of hypertensive heart disease with heart failure (condition that occurs when high blood pressure damages the heart and reduces its ability to pump blood effectively).<BR/>Review of Resident #44's quarterly MDS assessment, dated 03/25/24, revealed a BIMS score of 15 (an intact cognitive response.<BR/>Review of Resident #44's May/2024 active Physician Order Summary revealed the following orders: <BR/>Amiodarone HCl Tablet 200 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold For SBP&lt;110 DBP&lt;60 <BR/>Doxazosin Mesylate Tablet 4 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold for SBP&lt;110 DBP&lt;60<BR/>Observation on 05/02/2024 at 8:15am revealed MA L was observed obtaining Resident #44's blood pressure with a blood pressure reading of 100/65. MA L proceed by administering the medications and verbalizing to Resident #44 that he was receiving all morning medications including blood pressure medications. <BR/>Review of Resident #44's May/2024 Medication Administration Record (MAR) revealed that MA L administered Doxazosin Tablet 4mg and Amiodarone HCI Tablet 200mg. Each of the medications were administered outside of the physician indicated parameters on 05/02/2024. Resident #44's systolic blood pressure was documented by MA L with a systolic blood pressure of 100 and a diastolic blood pressure of a 65.<BR/>Interview with MA L on 05/02/2024 at 8:20am, MA L denied administering Resident #44's blood pressure medication, stated that she had discarded the medication in Resident #44's designated trash bin in his room. There was no observation of the referenced discard of the medications.<BR/>Interview and observation with ADON on 05/02/2024 at 8:30am, ADON was notified of the surveyor's observation of MA L administering blood pressure medication outside of the indicated parameters; and MA L denial of administering the medications. ADON proceeded to assess Resident #44 for adverse side effects. The ADON stated that MA L was not able to produce the pills and that the medication was not in the trash bin as alleged by MA L. The ADON stated that MA L later disclosed that she had administered the medications. The ADON stated that the physician was notified. MA L was removed from the floor and provided in-service and educated on medication administration. <BR/>Interview on 05/02/2024 at 9:30AM with MA L, MA L stated that if blood pressure medication is administered outside of the recommended parameters, the resident's blood pressure could drop too low causing the resident to have severe complications. MA L stated that staff administering the medications was responsible for ensuring that a medication was given within recommended parameters. MA L stated if blood pressure medication was given out of recommended parameters the medication could cause the blood pressure to become too elevated or too low. <BR/>Observation on 05/02/2024 at 9:33 AM revealed Resident #44 was observed sitting in bed watching television. Resident reported that he was feeling well. <BR/>Interview on 05/02/2024 at 1:22 PM with the DON, stated that MA L later disclosed that she had administered the medications. The DON stated that the physician was notified. MA L was removed from the floor and provided in-service and educated on medication administration. The DON stated medication should be held if the vitals were out of parameters. The DON stated the medication aide should have notified the nurse and the nurse would have notified the doctor that the medication was not administered because the resident's vitals were out of parameters. The DON stated that the purpose of the recommended parameters for the medication is to ensure that the resident remains in a safe blood pressure range identified for the resident. <BR/>Review of the facility's Medication Administration policy, not dated, reflected: .Medications must be administered in accordance with the written orders of the physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 4 for of 10 residents reviewed for abuse (Residents #1, #2, #3 and #4) were kept free form abuse, in that:<BR/>- Resident #1 had 3 incidents of resident-to resident altercations.<BR/>- On 12/01/2023, Resident #1 hit Resident #2 in the face which resulted in laceration to the lips<BR/>- On 01/01/2023, Resident #1 hit Resident #3 in the face unprovoked. <BR/>- On 01/15/2023, Resident #1 hit Reident #4 in the face twice unprovoked. <BR/>- CNA A, CNA B, RN C and the DON all reported Resident #1's aggressive behaviors were unpredictable or unprovoked and difficult to prevent without continuous one-on-one supervision. <BR/>An Immediate Jeopardy (IJ) was identified on 03/15/2023 at 3:00PM. The IJ template was provided to the facility on [DATE] at 4:25PM, While the IJ was removed on 03/17/2023 at 2:00PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm as there is no evidence of actual harm and CMS has indicated IJ must be lowered to second level.<BR/>These failures placed residents on the secured unit at risk of abuse, injuries and diminished quality of life. <BR/>Findings included : <BR/>Record review of Resident #1 was an [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with cerebral infarction (disrupted blood flow to brain), Alzheimer's disease, dementia, and psychosis. <BR/>Record review of Resident #1's MDS, dated [DATE], revealed the resident had a BIMS score of 3, indicating the resident's cognitions was severely impaired. It also reflected the resident was an independent walker while needing setup help for transferring . The MDS reflected no pertinent assessments on Resident #1's behaviors or mood.<BR/>Record review of Resident #1's care plan, undated, reflected a focus on Resident #1's aggression initiated 01/02/2024 and revised on 01/16/2024. The focus revealed, .[Resident #1] was physically aggressive with a female resident on 1/1/2024 while on the unit when she unintentionally was ambulating within his path of ambulating on the unit as they passed each other. [Resident #1] does have a BIM score of 3 [severe impairment]. The goal was to have no other reports of injury to self or others due to aggressiveness through the next review target date, 03/27/2024. Interventions listed, included, . If [Resident #1] becomes combative, aggressive or refuse care, provide for safety, offer alternative time for care, back away, seek assistance as needed, notify Nurse of behaviors or refusal, assess reports of behaviors, assess for pain, change in mental status. Explain reason/need for care and risk due to refusal, why behavior is inappropriate. Implement appropriate interventions, document and Notify MD and RP if interventions are not effective . If [Resident #1] behaviors are affecting others, remove from area to quieter setting, and offer diversional activity as appropriate . The care plan had no consistent interventions in place to prevent future episodes of aggression, but only interventions to manage Resident #1 after an aggressive episode or an altercation had occurred.<BR/>Record review of the resident roster , 03/13/2024, revealed Resident #1, #2, #3 and #4 all resided in hall 300, the secured unit. There were a total of 21 residents residing in the secured unit.<BR/>Record review of Resident #2's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with dementia, Alzheimer's disease and psychosis.<BR/>Record review of Resident #2's MDS, dated [DATE], revealed the resident had a BIMS score of 4 indicating her cognition was severely impaired. The MDS reflected the resident's need for setup help to supervision for most ADLs .<BR/>Record review of the facility's investigation report, dated 12/08/2023, revealed the investigation was conducted by Administrator A reflected that on 12/01/23, an unidentified resident reported witnessing Resident #1 hit Resident #2 while both residents were ambulating in the hallway. Resident #2 sustained a small laceration to here lips. It was documented that, .residents both suffer from dementia with noted cognitive deficits . Based on interviews with staff and lack of prior events, it is believed that [Resident #1] was startled as [Resident #2] passed him and he indistinctively swung at her. Even though we confirm this event did occur, there is no evidence that it was with intent to harm based on cognitive deficits presented; meaning no abuse occurred . There were no documented interventions placed after the incident to prevent aggressive behaviors by Resident #1.<BR/>Record review of Resident #1's progress notes, dated 12/01/2023, revealed LVN D wrote, . staff instructed to keep [Resident #1] in constant supervision and away from other residents .<BR/>Record review of Resident #3's face sheet revealed [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with bipolar disorder, depression and acute pain due to trauma.<BR/>Record review of Resident #3's MDS, dated [DATE] revealed the resident had a BIMS score of 3 indicating her cognition was severely impaired and it also noted the resident's use of a walker to ambulate .<BR/>Record review of the facility's investigation report, for incident dated 01/01/2024, revealed the investigation was conducted by Administrator B and reflected Resident #1 reached out and slapped Resident #3 while they were sitting close to each other in the TV room. No injury resulted from this incident. It was concluded in the investigation that, . the facility does not believe there was any intent for abuse and neglect. Both residents suffer from dementia and neither remember the incident .<BR/>Record review of Resident #1's progress notes, dated 01/01/2024, revealed LVN E wrote, . [unidentified CNA] reported that this resident hit another resident in the face while the two of them was sitting on the sofa without being provoked. Resident unable to give explanation of what happened and why it happened due to cognition issues. Both residents were separated immediately. Resident sent to hospital for medical clearance and psych evaluation .<BR/>Record review of Resident #1's care plan, undated reflected a focus on Resident #'1 aggression initiated 01/02/2024 and revised on 01/16/2024. It revealed, .[Resident #1] was physically aggressive with a female resident on 1/1/2024 while on the unit when she unintentionally was ambulating within his path of ambulating on the unit as they passed each other. [Resident #1] does have a BIM score of 3. The goal was to have no other reports of injury to self or others due to aggressiveness through the next review target date, 03/27/2024. Interventions listed, included, . If Resident #1 becomes combative, aggressive or refuse care, provide for safety, offer alternative time for care, back away, seek assistance as needed, notify Nurse of behaviors or refusal, assess reports of behaviors, assess for pain, change in mental status. Explain reason/need for care and risk due to refusal, why behavior is inappropriate. Implement appropriate interventions, document and Notify MD and RP if interventions are not effective . If [Resident #1] behaviors are affecting others, remove from area to quieter setting, and offer diversional activity as appropriate . The care plan had no consistent interventions in place to prevent future episodes of aggression, but only interventions to manage Resident #1 after an aggressive episode or an altercation had occurred.<BR/>Record review of Resident #1's hospital records, dated 01/01/2024 - 01/02/2024 , revealed after being assessed for mental status, the resident was not given any new medication orders, but was instructed to follow up with mental health outpatient.<BR/>Record review of Resident #1's progress notes, dated 01/05/2023, revealed he was assessed by the Psych NP who observed Resident #1 to very calm. The Psych NP recommended no med changes at the time and for, .staff to monitor closely and redirect other residents promptly and away from [sic] resident .<BR/>Record review of Resident #4's face sheet revealed a [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with dementia, type 2 diabetes and insomnia.<BR/>Record review of Resident #4's MDS, dated [DATE], revealed the resident had a BIMS score of 2 indicating his cognition was severely impaired. The MDS reflected the resident's need for setup help to partial assistance for most ADLs .<BR/>Record review of Resident #4's incident report , dated 01/15/2024, revealed Resident #1 was witnessed by an unidentified staff member to have been struck in the face twice by Resident #1 while sleeping and seated next to Resident #1. No injury resulted from this incident.<BR/>Record review of Resident #1's incident report , dated 01/15/2024, reflected Resident #1 hit Resident ##4 twice in the face unprovoked. Resident #1 returned to his normal mood [NAME] after. As a result of the incident, immediate actions documented to be taken by staff included they separated the residents, performed assessments for injuries and aggressive moods, notified the Administrator, physician and responsible party, placed Resident #1 on one-on-one supervision by a CNA until the resident was picked up for transport to the ER.<BR/>Record review of the facility's self-report, for an incident dated 01/15/2024, revealed the incident involved Residents #1 and #4 was conducted by Administrator B .<BR/>Record review of Resident #1's hospital records, dated 01/15/2024 - 01/18/2024 , revealed it was documented the resident was to receive an in-patient consult with psychiatry but there was no documentation of a psych evaluation note on the patient. Records revealed the only new psych medication order by a physician was a PRN 50mg trazadone every 12 hours for up to 60 days.<BR/>Record review of Resident #1's physician's orders, dated 03/14/2024, revealed the resident's only active psych med order was one daily 50mg tablet Trazodone at bedtime for insomnia and he had no medication changes since November 2023.<BR/>In an interview with RN A on 03/13/2024 at 12:43PM, she reported she was only aware of two incidents in which Resident #1 hit Resident #2 and Resident #3. She stated she believed the resident tended to hit other residents who exhibited startling movements or residents who failed to respond to him while talking to them. She stated Resident #2 tended to have outbursts saying mean things like calling people stupid or saying, you stink, while Resident #3 swatted her arms in the air as if she was telling someone who was not there to get away. She stated Resident #1's actions were so unpredictable that she wouldn't know if he would exhibit the same aggressive behaviors today or not. When asked who Resident #1 was allowed to sit next to, she stated Resident #2 and Resident #3 were usually kept away from him. When asked if Resident #4 was also allowed to sit next to Resident #1 since their altercation, she asked, [Resident #4]? How many people did he hit? She stated Resident #1 did not have any medication changes following the evaluation at the hospital most likely because the resident was on his best behavior during his stay at the hospital When asked if she viewed Resident #1's actions as abuse, she stated it could be because he was not supposed to be hitting random people .<BR/>In an interview with CNA A on 03/13/2024 at 12:58AM, she reported being aware of Resident #1's unpredictable aggressive behaviors and witnessed the incident on 01/01/24 but believed Resident #1's actions were not abuse because he was likely provoked in each situation, in that he was startled by the other person. She said she allowed Resident #1 to sit with another male resident for lunch today and Resident #2 usually sat by Resident #1 for mealtimes up until a month ago when a spot at the table reserved for women opened up. She stated she was not aware of all the residents Resident #1 had hit and she was not aware of a specific plan of care for Resident #1 regarding supervision to prevent future altercations. She stated at most, the charges nurses would verbally report to them which residents to keep separate from others depending on the residents' moods for that day.<BR/>In an interview with CNA B 03/14/2024 at 10:35AM, she reported working in the secured unit for the past 6 months but not knowing of Resident #1's past incidents with other residents until yesterday on 03/13/24. She stated until then, she generally kept an eye on all residents in the secured unit but there was no specific plan of care regarding supervision for Resident #1. She stated she did not see Resident #1's actions as abuse because he had no intention behind it due to his dementia. She stated she did understand how other residents were at risk for experiencing abuse because his aggressive behaviors were unpredictable.<BR/>In an interview with the DON on 03/14/2024 at 1:05PM, she stated she was aware of Resident #1's incidents in which he hit other residents. She stated Resident #1's episodes of aggression were unpredictable and attributed it to the resident being easily startled. She stated they could only try to separate the residents and redirect them to calm them down. She stated the altercations were like falls, for which they could put interventions in place but that's not to say that they won't fall again, but you can only prayerfully prevent an injury. She stated the only intervention they could impose was to separate the residents after the incident and send the aggressor to the hospital after the family was notified about the efforts made to safeguard the other residents. When asked if she believed that was an abuse concern, she stated they did all they can do to immediately respond after the incidents have occurred and Resident #1 did not intentionally abuse other residents due to his dementia nor did the staff know the incidents were going to happen. She said she did not know if a psych doctor had adjusted his medications as a result of the incidents. She said since the incident on 01/15/24, he had not had another incident of aggressive behavior. She stated he was not a candidate for one-on-one supervision at the moment because he had not had any other incidents since January . When asked how many incidents it would take for Resident #1 to be managed differently to prevent further incidents, she stated she could not put a number on that. She stated she did not know what else to say and that they could not prevent it because they did not know when the behaviors could start again. When asked if she believed the facility's abuse policy was followed, she stated the only thing they could do is put interventions in place which was done for all of Resident #1's incidents and that should suffice.<BR/>In an interview with Administrator C on 03/14/2024 at 1:30PM, he reported it was his first day at the facility and based on the information he had learned about Resident #1, he said he would have discharged Resident #1 from the facility based on the established pattern of unpredictable episodes of aggression. He stated there would not have been a third incident by Resident #1 and the facility was not able to provide prolonged one-on-one supervision to prevent future incidents. He stated Resident #1 remaining at the facility could place residents at risks of unprovoked encounters with him. He stated there should have been an individualized training for staff on the resident's triggers which were difficult to determine considering he was unprovoked. He stated general knowledge of Resident #1's history and the need for increased monitoring would have been the most important things to educate staff on. <BR/>Record review of facility's policy on Abuse Investigation and Reporting reflected Administrator's duty to, .ensure any further potential abuse . is prevented.<BR/>An Immediate Jeopardy (IJ) was identified on 03/15/2024 at 3:00PM.<BR/>On 03/15/2024 at 4:25PM the Administrator was notified of the IJ. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. <BR/>The POR was accepted on 03/16/2024 at 12:53PM. The POR reflected:<BR/>PLAN OF REMOVAL OF IMMEDIATE JEOPARDY<BR/>F 600 <BR/>On 03/15/2024 at approximately 4:15 PM, [facility name] was notified by an HHSC employee the facility was in Immediate Jeopardy (IJ) with allegations of Abuse & Neglect (F600) noncompliance.<BR/>On 03/15/2024, at approximately 4:22 PM, the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. <BR/>The notification of Immediate Jeopardy states as follows: F 600 - Alleging the facility failed to HHSC guidelines addressing Abuse and Neglect and an allegation of noncompliance.<BR/>Resident #1 injured Resident # 2 causing a laceration of the lips and was observed to punch Residents #3 and #4 in the face. Due to pattern of aggressive behaviors and staff reporting the unpredictability of those events, it places all residents in the secured unit at risk for abuse.<BR/>Action:<BR/>o Charge nurse/ nurse managers Immediately assessed residents in the secure unit for possible abuse, no suspected abuse found at this time. <BR/>oAdministrator/abuse coordinator Immediately in-service all staff 100% completion on Abuse & Neglect policy.<BR/>oDirector of Nursing, Inservice all 100% of staff on current interventions in place for those residents with behavioral problems, 4 were identified in the secured unit care plans and interventions were updated and staff received the training of the current interventions. <BR/>oResident #1 has been discharged to [behavioral hospital] on 3/14/24, care plan interventions updated .<BR/>Monitoring :<BR/>In-service record and policy titled, Preventing Resident-to-Resident Altercations in Nursing Homes, undated was reviewed. <BR/>Policy used for staff training titled, Abuse Investigation and Reporting, dated July 2017, was reviewed. <BR/>Record review of Resident #1's electronic health chart revealed the resident was discharged from the facility on 03/14/2024.<BR/>Record review of care plans, undated, for Residents #5, #6, #7, #8 and #9 revealed updates of interventions to limit residents' aggressive behaviors were made on 03/16/2023.<BR/>In an interview with CNA C and CNA D on 03/16/2024 at 2:04PM, they both correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Resident #8 on hall 200 as a resident to supervise closely and prevent episodes of aggression.<BR/>In an interview with CNA E on 03/16/2024 at 2:12PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression.<BR/>In an interview with CNA F and CNA G on 03/16/2024 at 2:34PM, they both correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #5, #6 and #7 on hall 100 as a residents to supervise closely and prevent episodes of aggression.<BR/>In an interview with CNA H on 03/16/2024 at 3:15PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression.<BR/>In a phone interview with LVN C on 03/17/2024 at 10:50AM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression.<BR/>In a phone interview with CNA I on 03/17/2024 at 11:27AM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Resident #8 on hall 200 as residents to supervise closely and prevent episodes of aggression.<BR/>In a phone interview with CNA J on 03/17/2024 at 12:03PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, and identified who they would report incidents of resident-to-resident altercations to.<BR/>In a phone interview with LVN B on 03/17/2024 at 12:59PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to, and identified Residents #5, #6 and #7 on hall 100 as a residents to supervise closely and prevent episodes of aggression.<BR/>In a phone interview with Administrator C on 03/17/2024 at 12:06PM, he stated the whole IDT was involved in reviewing incident reports, determining appropriate interventions for the resident, updating the care plan and educate staff on new plan of care. He stated residents with aggressive behaviors had been listed on the communication board for staff to reference and the facility would develop personal care plans and approaches with each resident to prevent abuse. He stated for the future when dealing with residents with unprovoked aggressive behaviors, he would resort to finding more appropriate placement for that resident to protect other residents. <BR/>In a phone interview with the DON on 03/17/2024 at 12:16PM, she stated the IDT was responsible for care planning residents with aggressive behaviors. She stated residents with aggressive behaviors had been listed on the communication board for staff to reference and they would continue to education to staff to ensure proper interventions are in implemented.<BR/>In a phone interview with the Social Worker on 03/17/2024 at 1:00PM, she stated the IDT and the doctor were responsible for updating plans of care for residents with aggressive behaviors. She stated to ensure prevention of aggressive behaviors, all residents would be kept safe, incident reports would be reviewed, staff would be in-serviced and the Ombudsman would be notified. In the case they could not ensure the safety of residents, her along with the IDT would look for alternative placement that would produce a more positive outcome for the resident identified as the aggressor. She stated they would also have the family and Ombudsman involved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the written policies and procedure to prevent abuse were implemented for 4 for of 10 residents reviewed for abuse (Residents #1, #2, #3 and #4), in that:<BR/>- Resident #1 had 3 incidents of resident-to resident altercations.<BR/>- On 12/01/2023, Resident #1 hit Resident #2 in the face which resulted in laceration to the lips<BR/>- On 01/01/2023, Resident #1 hit Resident #3 in the face unprovoked. <BR/>- On 01/15/2023, Resident #1 hit Reident #4 in the face twice unprovoked. <BR/>- CNA A, CNA B, RN C and the DON all reported Resident #1's aggressive behaviors were unpredictable or unprovoked and difficult to prevent without continuous one-on-one supervision. <BR/>- The facility failed to develop and implement interventions to prevent Resident #1's aggression and abuse of Residents #3 and #4. <BR/>An Immediate Jeopardy (IJ) was identified on 03/15/2023 at 3:00PM. The IJ template was provided to the facility on [DATE] at 4:25PM, While the IJ was removed on 03/17/2023 at 2:00PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm as there is no evidence of actual harm and CMS has indicated IJ must be lowered to second level.<BR/>These failures placed residents on the secured unit at risk of abuse, injuries and diminished quality of life. <BR/>Findings included : <BR/>Record review of Resident #1 was an [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with cerebral infarction (disrupted blood flow to brain), Alzheimer's disease, dementia, and psychosis. <BR/>Record review of Resident #1's MDS, dated [DATE], revealed the resident had a BIMS score of 3, indicating the resident's cognitions was severely impaired. It also reflected the resident was an independent walker while needing setup help for transferring . The MDS reflected no pertinent assessments on Resident #1's behaviors or mood.<BR/>Record review of Resident #1's care plan, undated, reflected a focus on Resident #1's aggression initiated 01/02/2024 and revised on 01/16/2024. The focus revealed, .[Resident #1] was physically aggressive with a female resident on 1/1/2024 while on the unit when she unintentionally was ambulating within his path of ambulating on the unit as they passed each other. [Resident #1] does have a BIM score of 3 [severe impairment]. The goal was to have no other reports of injury to self or others due to aggressiveness through the next review target date, 03/27/2024. Interventions listed, included, . If [Resident #1] becomes combative, aggressive or refuse care, provide for safety, offer alternative time for care, back away, seek assistance as needed, notify Nurse of behaviors or refusal, assess reports of behaviors, assess for pain, change in mental status. Explain reason/need for care and risk due to refusal, why behavior is inappropriate. Implement appropriate interventions, document and Notify MD and RP if interventions are not effective . If [Resident #1] behaviors are affecting others, remove from area to quieter setting, and offer diversional activity as appropriate . The care plan had no consistent interventions in place to prevent future episodes of aggression, but only interventions to manage Resident #1 after an aggressive episode or an altercation had occurred.<BR/>Record review of the resident roster , 03/13/2024, revealed Resident #1, #2, #3 and #4 all resided in hall 300, the secured unit. There were a total of 21 residents residing in the secured unit.<BR/>Record review of Resident #2's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with dementia, Alzheimer's disease and psychosis.<BR/>Record review of Resident #2's MDS, dated [DATE], revealed the resident had a BIMS score of 4 indicating her cognition was severely impaired. The MDS reflected the resident's need for setup help to supervision for most ADLs .<BR/>Record review of the facility's investigation report, dated 12/08/2023, revealed the investigation was conducted by Administrator A reflected that on 12/01/23, an unidentified resident reported witnessing Resident #1 hit Resident #2 while both residents were ambulating in the hallway. Resident #2 sustained a small laceration to here lips. It was documented that, .residents both suffer from dementia with noted cognitive deficits . Based on interviews with staff and lack of prior events, it is believed that [Resident #1] was startled as [Resident #2] passed him and he indistinctively swung at her. Even though we confirm this event did occur, there is no evidence that it was with intent to harm based on cognitive deficits presented; meaning no abuse occurred . There were no documented interventions placed after the incident to prevent aggressive behaviors by Resident #1.<BR/>Record review of Resident #1's progress notes, dated 12/01/2023, revealed LVN D wrote, . staff instructed to keep [Resident #1] in constant supervision and away from other residents .<BR/>Record review of Resident #3's face sheet revealed [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with bipolar disorder, depression and acute pain due to trauma.<BR/>Record review of Resident #3's MDS, dated [DATE] revealed the resident had a BIMS score of 3 indicating her cognition was severely impaired and it also noted the resident's use of a walker to ambulate .<BR/>Record review of the facility's investigation report, for incident dated 01/01/2024, revealed the investigation was conducted by Administrator B and reflected Resident #1 reached out and slapped Resident #3 while they were sitting close to each other in the TV room. No injury resulted from this incident. It was concluded in the investigation that, . the facility does not believe there was any intent for abuse and neglect. Both residents suffer from dementia and neither remember the incident .<BR/>Record review of Resident #1's progress notes, dated 01/01/2024, revealed LVN E wrote, . [unidentified CNA] reported that this resident hit another resident in the face while the two of them was sitting on the sofa without being provoked. Resident unable to give explanation of what happened and why it happened due to cognition issues. Both residents were separated immediately. Resident sent to hospital for medical clearance and psych evaluation .<BR/>Record review of Resident #1's care plan, undated reflected a focus on Resident #'1 aggression initiated 01/02/2024 and revised on 01/16/2024. It revealed, .[Resident #1] was physically aggressive with a female resident on 1/1/2024 while on the unit when she unintentionally was ambulating within his path of ambulating on the unit as they passed each other. [Resident #1] does have a BIM score of 3. The goal was to have no other reports of injury to self or others due to aggressiveness through the next review target date, 03/27/2024. Interventions listed, included, . If Resident #1 becomes combative, aggressive or refuse care, provide for safety, offer alternative time for care, back away, seek assistance as needed, notify Nurse of behaviors or refusal, assess reports of behaviors, assess for pain, change in mental status. Explain reason/need for care and risk due to refusal, why behavior is inappropriate. Implement appropriate interventions, document and Notify MD and RP if interventions are not effective . If [Resident #1] behaviors are affecting others, remove from area to quieter setting, and offer diversional activity as appropriate . The care plan had no consistent interventions in place to prevent future episodes of aggression, but only interventions to manage Resident #1 after an aggressive episode or an altercation had occurred.<BR/>Record review of Resident #1's hospital records, dated 01/01/2024 - 01/02/2024 , revealed after being assessed for mental status, the resident was not given any new medication orders, but was instructed to follow up with mental health outpatient.<BR/>Record review of Resident #1's progress notes, dated 01/05/2023, revealed he was assessed by the Psych NP who observed Resident #1 to very calm. The Psych NP recommended no med changes at the time and for, .staff to monitor closely and redirect other residents promptly and away from [sic] resident .<BR/>Record review of Resident #4's face sheet revealed a [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with dementia, type 2 diabetes and insomnia.<BR/>Record review of Resident #4's MDS, dated [DATE], revealed the resident had a BIMS score of 2 indicating his cognition was severely impaired. The MDS reflected the resident's need for setup help to partial assistance for most ADLs .<BR/>Record review of Resident #4's incident report , dated 01/15/2024, revealed Resident #1 was witnessed by an unidentified staff member to have been struck in the face twice by Resident #1 while sleeping and seated next to Resident #1. No injury resulted from this incident.<BR/>Record review of Resident #1's incident report , dated 01/15/2024, reflected Resident #1 hit Resident ##4 twice in the face unprovoked. Resident #1 returned to his normal mood [NAME] after. As a result of the incident, immediate actions documented to be taken by staff included they separated the residents, performed assessments for injuries and aggressive moods, notified the Administrator, physician and responsible party, placed Resident #1 on one-on-one supervision by a CNA until the resident was picked up for transport to the ER.<BR/>Record review of the facility's self-report, for an incident dated 01/15/2024, revealed the incident involved Residents #1 and #4 was conducted by Administrator B .<BR/>Record review of Resident #1's hospital records, dated 01/15/2024 - 01/18/2024 , revealed it was documented the resident was to receive an in-patient consult with psychiatry but there was no documentation of a psych evaluation note on the patient. Records revealed the only new psych medication order by a physician was a PRN 50mg trazadone every 12 hours for up to 60 days.<BR/>Record review of Resident #1's physician's orders, dated 03/14/2024, revealed the resident's only active psych med order was one daily 50mg tablet Trazodone at bedtime for insomnia and he had no medication changes since November 2023.<BR/>In an interview with RN A on 03/13/2024 at 12:43PM, she reported she was only aware of two incidents in which Resident #1 hit Resident #2 and Resident #3. She stated she believed the resident tended to hit other residents who exhibited startling movements or residents who failed to respond to him while talking to them. She stated Resident #2 tended to have outbursts saying mean things like calling people stupid or saying, you stink, while Resident #3 swatted her arms in the air as if she was telling someone who was not there to get away. She stated Resident #1's actions were so unpredictable that she wouldn't know if he would exhibit the same aggressive behaviors today or not. When asked who Resident #1 was allowed to sit next to, she stated Resident #2 and Resident #3 were usually kept away from him. When asked if Resident #4 was also allowed to sit next to Resident #1 since their altercation, she asked, [Resident #4]? How many people did he hit? She stated Resident #1 did not have any medication changes following the evaluation at the hospital most likely because the resident was on his best behavior during his stay at the hospital When asked if she viewed Resident #1's actions as abuse, she stated it could be because he was not supposed to be hitting random people .<BR/>In an interview with CNA A on 03/13/2024 at 12:58AM, she reported being aware of Resident #1's unpredictable aggressive behaviors and witnessed the incident on 01/01/24 but believed Resident #1's actions were not abuse because he was likely provoked in each situation, in that he was startled by the other person. She said she allowed Resident #1 to sit with another male resident for lunch today and Resident #2 usually sat by Resident #1 for mealtimes up until a month ago when a spot at the table reserved for women opened up. She stated she was not aware of all the residents Resident #1 had hit and she was not aware of a specific plan of care for Resident #1 regarding supervision to prevent future altercations. She stated at most, the charges nurses would verbally report to them which residents to keep separate from others depending on the residents' moods for that day.<BR/>In an interview with CNA B 03/14/2024 at 10:35AM, she reported working in the secured unit for the past 6 months but not knowing of Resident #1's past incidents with other residents until yesterday on 03/13/24. She stated until then, she generally kept an eye on all residents in the secured unit but there was no specific plan of care regarding supervision for Resident #1. She stated she did not see Resident #1's actions as abuse because he had no intention behind it due to his dementia. She stated she did understand how other residents were at risk for experiencing abuse because his aggressive behaviors were unpredictable.<BR/>In an interview with the DON on 03/14/2024 at 1:05PM, she stated she was aware of Resident #1's incidents in which he hit other residents. She stated Resident #1's episodes of aggression were unpredictable and attributed it to the resident being easily startled. She stated they could only try to separate the residents and redirect them to calm them down. She stated the altercations were like falls, for which they could put interventions in place but that's not to say that they won't fall again, but you can only prayerfully prevent an injury. She stated the only intervention they could impose was to separate the residents after the incident and send the aggressor to the hospital after the family was notified about the efforts made to safeguard the other residents. When asked if she believed that was an abuse concern, she stated they did all they can do to immediately respond after the incidents have occurred and Resident #1 did not intentionally abuse other residents due to his dementia nor did the staff know the incidents were going to happen. She said she did not know if a psych doctor had adjusted his medications as a result of the incidents. She said since the incident on 01/15/24, he had not had another incident of aggressive behavior. She stated he was not a candidate for one-on-one supervision at the moment because he had not had any other incidents since January . When asked how many incidents it would take for Resident #1 to be managed differently to prevent further incidents, she stated she could not put a number on that. She stated she did not know what else to say and that they could not prevent it because they did not know when the behaviors could start again. When asked if she believed the facility's abuse policy was followed, she stated the only thing they could do is put interventions in place which was done for all of Resident #1's incidents and that should suffice.<BR/>In an interview with Administrator C on 03/14/2024 at 1:30PM, he reported it was his first day at the facility and based on the information he had learned about Resident #1, he said he would have discharged Resident #1 from the facility based on the established pattern of unpredictable episodes of aggression. He stated there would not have been a third incident by Resident #1 and the facility was not able to provide prolonged one-on-one supervision to prevent future incidents. He stated Resident #1 remaining at the facility could place residents at risks of unprovoked encounters with him. He stated there should have been an individualized training for staff on the resident's triggers which were difficult to determine considering he was unprovoked. He stated general knowledge of Resident #1's history and the need for increased monitoring would have been the most important things to educate staff on. <BR/>Record review of facility's policy on Abuse Investigation and Reporting reflected Administrator's duty to, .ensure any further potential abuse . is prevented.<BR/>An Immediate Jeopardy (IJ) was identified on 03/15/2024 at 3:00PM.<BR/>On 03/15/2024 at 4:25PM the Administrator was notified of the IJ. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. <BR/>The POR was accepted on 03/16/2024 at 12:53PM. The POR reflected:<BR/>PLAN OF REMOVAL OF IMMEDIATE JEOPARDY<BR/>F 600 <BR/>On 03/15/2024 at approximately 4:15 PM, [facility name] was notified by an HHSC employee the facility was in Immediate Jeopardy (IJ) with allegations of Abuse & Neglect (F600) noncompliance.<BR/>On 03/15/2024, at approximately 4:22 PM, the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. <BR/>The notification of Immediate Jeopardy states as follows: F 600 - Alleging the facility failed to HHSC guidelines addressing Abuse and Neglect and an allegation of noncompliance.<BR/>Resident #1 injured Resident # 2 causing a laceration of the lips and was observed to punch Residents #3 and #4 in the face. Due to pattern of aggressive behaviors and staff reporting the unpredictability of those events, it places all residents in the secured unit at risk for abuse.<BR/>Action:<BR/>o Charge nurse/ nurse managers Immediately assessed residents in the secure unit for possible abuse, no suspected abuse found at this time. <BR/>oAdministrator/abuse coordinator Immediately in-service all staff 100% completion on Abuse & Neglect policy.<BR/>oDirector of Nursing, Inservice all 100% of staff on current interventions in place for those residents with behavioral problems, 4 were identified in the secured unit care plans and interventions were updated and staff received the training of the current interventions. <BR/>oResident #1 has been discharged to [behavioral hospital] on 3/14/24, care plan interventions updated .<BR/>Monitoring :<BR/>In-service record and policy titled, Preventing Resident-to-Resident Altercations in Nursing Homes, undated was reviewed. <BR/>Policy used for staff training titled, Abuse Investigation and Reporting, dated July 2017, was reviewed. <BR/>Record review of Resident #1's electronic health chart revealed the resident was discharged from the facility on 03/14/2024.<BR/>Record review of care plans, undated, for Residents #5, #6, #7, #8 and #9 revealed updates of interventions to limit residents' aggressive behaviors were made on 03/16/2023.<BR/>In an interview with CNA C and CNA D on 03/16/2024 at 2:04PM, they both correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Resident #8 on hall 200 as a resident to supervise closely and prevent episodes of aggression.<BR/>In an interview with CNA E on 03/16/2024 at 2:12PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression.<BR/>In an interview with CNA F and CNA G on 03/16/2024 at 2:34PM, they both correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #5, #6 and #7 on hall 100 as a residents to supervise closely and prevent episodes of aggression.<BR/>In an interview with CNA H on 03/16/2024 at 3:15PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression.<BR/>In a phone interview with LVN C on 03/17/2024 at 10:50AM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression.<BR/>In a phone interview with CNA I on 03/17/2024 at 11:27AM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Resident #8 on hall 200 as residents to supervise closely and prevent episodes of aggression.<BR/>In a phone interview with CNA J on 03/17/2024 at 12:03PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, and identified who they would report incidents of resident-to-resident altercations to.<BR/>In a phone interview with LVN B on 03/17/2024 at 12:59PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to, and identified Residents #5, #6 and #7 on hall 100 as a residents to supervise closely and prevent episodes of aggression.<BR/>In a phone interview with Administrator C on 03/17/2024 at 12:06PM, he stated the whole IDT was involved in reviewing incident reports, determining appropriate interventions for the resident, updating the care plan and educate staff on new plan of care. He stated residents with aggressive behaviors had been listed on the communication board for staff to reference and the facility would develop personal care plans and approaches with each resident to prevent abuse. He stated for the future when dealing with residents with unprovoked aggressive behaviors, he would resort to finding more appropriate placement for that resident to protect other residents. <BR/>In a phone interview with the DON on 03/17/2024 at 12:16PM, she stated the IDT was responsible for care planning residents with aggressive behaviors. She stated residents with aggressive behaviors had been listed on the communication board for staff to reference and they would continue to education to staff to ensure proper interventions are in implemented.<BR/>In a phone interview with the Social Worker on 03/17/2024 at 1:00PM, she stated the IDT and the doctor were responsible for updating plans of care for residents with aggressive behaviors. She stated to ensure prevention of aggressive behaviors, all residents would be kept safe, incident reports would be reviewed, staff would be in-serviced and the Ombudsman would be notified. In the case they could not ensure the safety of residents, her along with the IDT would look for alternative placement that would produce a more positive outcome for the resident identified as the aggressor. She stated they would also have the family and Ombudsman involved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise the comprehensive person-centered care plan used to maintain the resident's highest practicable physical well-being for 1 (Resident #1) of 6 residents reviewed for care plans in that:<BR/>- Resident #1 had 3 incidents of resident-to resident altercations.<BR/>- On 12/01/2023, Resident #1 hit Resident #2 in the face which resulted in laceration to the lips<BR/>- On 01/01/2023, Resident #1 hit Resident #3 in the face unprovoked. <BR/>- On 01/15/2023, Resident #1 hit Reident #4 in the face twice unprovoked. <BR/>- CNA A, CNA B, RN C and the DON all reported Resident #1's aggressive behaviors were unpredictable or unprovoked and difficult to prevent without continuous one-on-one supervision. <BR/>- The facility failed to develop and implement interventions to prevent Resident #1's aggression and abuse of Residents #3 and #4. <BR/>An Immediate Jeopardy (IJ) was identified on 03/15/2023 at 3:00PM. The IJ template was provided to the facility on [DATE] at 4:25PM, While the IJ was removed on 03/17/2023 at 2:00PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm as there is no evidence of actual harm and CMS has indicated IJ must be lowered to second level.<BR/>These failures placed residents on the secured unit at risk of abuse, injuries and diminished quality of life. <BR/>Findings included : <BR/>Record review of Resident #1 was an [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with cerebral infarction (disrupted blood flow to brain), Alzheimer's disease, dementia, and psychosis. <BR/>Record review of Resident #1's MDS, dated [DATE], revealed the resident had a BIMS score of 3, indicating the resident's cognitions was severely impaired. It also reflected the resident was an independent walker while needing setup help for transferring . The MDS reflected no pertinent assessments on Resident #1's behaviors or mood.<BR/>Record review of Resident #1's care plan, undated, reflected a focus on Resident #1's aggression initiated 01/02/2024 and revised on 01/16/2024. The focus revealed, .[Resident #1] was physically aggressive with a female resident on 1/1/2024 while on the unit when she unintentionally was ambulating within his path of ambulating on the unit as they passed each other. [Resident #1] does have a BIM score of 3 [severe impairment]. The goal was to have no other reports of injury to self or others due to aggressiveness through the next review target date, 03/27/2024. Interventions listed, included, . If [Resident #1] becomes combative, aggressive or refuse care, provide for safety, offer alternative time for care, back away, seek assistance as needed, notify Nurse of behaviors or refusal, assess reports of behaviors, assess for pain, change in mental status. Explain reason/need for care and risk due to refusal, why behavior is inappropriate. Implement appropriate interventions, document and Notify MD and RP if interventions are not effective . If [Resident #1] behaviors are affecting others, remove from area to quieter setting, and offer diversional activity as appropriate . The care plan had no consistent interventions in place to prevent future episodes of aggression, but only interventions to manage Resident #1 after an aggressive episode or an altercation had occurred.<BR/>Record review of the resident roster , 03/13/2024, revealed Resident #1, #2, #3 and #4 all resided in hall 300, the secured unit. There were a total of 21 residents residing in the secured unit.<BR/>Record review of Resident #2's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with dementia, Alzheimer's disease and psychosis.<BR/>Record review of Resident #2's MDS, dated [DATE], revealed the resident had a BIMS score of 4 indicating her cognition was severely impaired. The MDS reflected the resident's need for setup help to supervision for most ADLs .<BR/>Record review of the facility's investigation report, dated 12/08/2023, revealed the investigation was conducted by Administrator A reflected that on 12/01/23, an unidentified resident reported witnessing Resident #1 hit Resident #2 while both residents were ambulating in the hallway. Resident #2 sustained a small laceration to here lips. It was documented that, .residents both suffer from dementia with noted cognitive deficits . Based on interviews with staff and lack of prior events, it is believed that [Resident #1] was startled as [Resident #2] passed him and he indistinctively swung at her. Even though we confirm this event did occur, there is no evidence that it was with intent to harm based on cognitive deficits presented; meaning no abuse occurred . There were no documented interventions placed after the incident to prevent aggressive behaviors by Resident #1.<BR/>Record review of Resident #1's progress notes, dated 12/01/2023, revealed LVN D wrote, . staff instructed to keep [Resident #1] in constant supervision and away from other residents .<BR/>Record review of Resident #3's face sheet revealed [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with bipolar disorder, depression and acute pain due to trauma.<BR/>Record review of Resident #3's MDS, dated [DATE] revealed the resident had a BIMS score of 3 indicating her cognition was severely impaired and it also noted the resident's use of a walker to ambulate .<BR/>Record review of the facility's investigation report, for incident dated 01/01/2024, revealed the investigation was conducted by Administrator B and reflected Resident #1 reached out and slapped Resident #3 while they were sitting close to each other in the TV room. No injury resulted from this incident. It was concluded in the investigation that, . the facility does not believe there was any intent for abuse and neglect. Both residents suffer from dementia and neither remember the incident .<BR/>Record review of Resident #1's progress notes, dated 01/01/2024, revealed LVN E wrote, . [unidentified CNA] reported that this resident hit another resident in the face while the two of them was sitting on the sofa without being provoked. Resident unable to give explanation of what happened and why it happened due to cognition issues. Both residents were separated immediately. Resident sent to hospital for medical clearance and psych evaluation .<BR/>Record review of Resident #1's care plan, undated reflected a focus on Resident #'1 aggression initiated 01/02/2024 and revised on 01/16/2024. It revealed, .[Resident #1] was physically aggressive with a female resident on 1/1/2024 while on the unit when she unintentionally was ambulating within his path of ambulating on the unit as they passed each other. [Resident #1] does have a BIM score of 3. The goal was to have no other reports of injury to self or others due to aggressiveness through the next review target date, 03/27/2024. Interventions listed, included, . If Resident #1 becomes combative, aggressive or refuse care, provide for safety, offer alternative time for care, back away, seek assistance as needed, notify Nurse of behaviors or refusal, assess reports of behaviors, assess for pain, change in mental status. Explain reason/need for care and risk due to refusal, why behavior is inappropriate. Implement appropriate interventions, document and Notify MD and RP if interventions are not effective . If [Resident #1] behaviors are affecting others, remove from area to quieter setting, and offer diversional activity as appropriate . The care plan had no consistent interventions in place to prevent future episodes of aggression, but only interventions to manage Resident #1 after an aggressive episode or an altercation had occurred.<BR/>Record review of Resident #1's hospital records, dated 01/01/2024 - 01/02/2024 , revealed after being assessed for mental status, the resident was not given any new medication orders, but was instructed to follow up with mental health outpatient.<BR/>Record review of Resident #1's progress notes, dated 01/05/2023, revealed he was assessed by the Psych NP who observed Resident #1 to very calm. The Psych NP recommended no med changes at the time and for, .staff to monitor closely and redirect other residents promptly and away from [sic] resident .<BR/>Record review of Resident #4's face sheet revealed a [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with dementia, type 2 diabetes and insomnia.<BR/>Record review of Resident #4's MDS, dated [DATE], revealed the resident had a BIMS score of 2 indicating his cognition was severely impaired. The MDS reflected the resident's need for setup help to partial assistance for most ADLs .<BR/>Record review of Resident #4's incident report , dated 01/15/2024, revealed Resident #1 was witnessed by an unidentified staff member to have been struck in the face twice by Resident #1 while sleeping and seated next to Resident #1. No injury resulted from this incident.<BR/>Record review of Resident #1's incident report , dated 01/15/2024, reflected Resident #1 hit Resident ##4 twice in the face unprovoked. Resident #1 returned to his normal mood [NAME] after. As a result of the incident, immediate actions documented to be taken by staff included they separated the residents, performed assessments for injuries and aggressive moods, notified the Administrator, physician and responsible party, placed Resident #1 on one-on-one supervision by a CNA until the resident was picked up for transport to the ER.<BR/>Record review of the facility's self-report, for an incident dated 01/15/2024, revealed the incident involved Residents #1 and #4 was conducted by Administrator B .<BR/>Record review of Resident #1's hospital records, dated 01/15/2024 - 01/18/2024 , revealed it was documented the resident was to receive an in-patient consult with psychiatry but there was no documentation of a psych evaluation note on the patient. Records revealed the only new psych medication order by a physician was a PRN 50mg trazadone every 12 hours for up to 60 days.<BR/>Record review of Resident #1's physician's orders, dated 03/14/2024, revealed the resident's only active psych med order was one daily 50mg tablet Trazodone at bedtime for insomnia and he had no medication changes since November 2023.<BR/>In an interview with RN A on 03/13/2024 at 12:43PM, she reported she was only aware of two incidents in which Resident #1 hit Resident #2 and Resident #3. She stated she believed the resident tended to hit other residents who exhibited startling movements or residents who failed to respond to him while talking to them. She stated Resident #2 tended to have outbursts saying mean things like calling people stupid or saying, you stink, while Resident #3 swatted her arms in the air as if she was telling someone who was not there to get away. She stated Resident #1's actions were so unpredictable that she wouldn't know if he would exhibit the same aggressive behaviors today or not. When asked who Resident #1 was allowed to sit next to, she stated Resident #2 and Resident #3 were usually kept away from him. When asked if Resident #4 was also allowed to sit next to Resident #1 since their altercation, she asked, [Resident #4]? How many people did he hit? She stated Resident #1 did not have any medication changes following the evaluation at the hospital most likely because the resident was on his best behavior during his stay at the hospital When asked if she viewed Resident #1's actions as abuse, she stated it could be because he was not supposed to be hitting random people .<BR/>In an interview with CNA A on 03/13/2024 at 12:58AM, she reported being aware of Resident #1's unpredictable aggressive behaviors and witnessed the incident on 01/01/24 but believed Resident #1's actions were not abuse because he was likely provoked in each situation, in that he was startled by the other person. She said she allowed Resident #1 to sit with another male resident for lunch today and Resident #2 usually sat by Resident #1 for mealtimes up until a month ago when a spot at the table reserved for women opened up. She stated she was not aware of all the residents Resident #1 had hit and she was not aware of a specific plan of care for Resident #1 regarding supervision to prevent future altercations. She stated at most, the charges nurses would verbally report to them which residents to keep separate from others depending on the residents' moods for that day.<BR/>In an interview with CNA B 03/14/2024 at 10:35AM, she reported working in the secured unit for the past 6 months but not knowing of Resident #1's past incidents with other residents until yesterday on 03/13/24. She stated until then, she generally kept an eye on all residents in the secured unit but there was no specific plan of care regarding supervision for Resident #1. She stated she did not see Resident #1's actions as abuse because he had no intention behind it due to his dementia. She stated she did understand how other residents were at risk for experiencing abuse because his aggressive behaviors were unpredictable.<BR/>In an interview with the DON on 03/14/2024 at 1:05PM, she stated she was aware of Resident #1's incidents in which he hit other residents. She stated Resident #1's episodes of aggression were unpredictable and attributed it to the resident being easily startled. She stated they could only try to separate the residents and redirect them to calm them down. She stated the altercations were like falls, for which they could put interventions in place but that's not to say that they won't fall again, but you can only prayerfully prevent an injury. She stated the only intervention they could impose was to separate the residents after the incident and send the aggressor to the hospital after the family was notified about the efforts made to safeguard the other residents. When asked if she believed that was an abuse concern, she stated they did all they can do to immediately respond after the incidents have occurred and Resident #1 did not intentionally abuse other residents due to his dementia nor did the staff know the incidents were going to happen. She said she did not know if a psych doctor had adjusted his medications as a result of the incidents. She said since the incident on 01/15/24, he had not had another incident of aggressive behavior. She stated he was not a candidate for one-on-one supervision at the moment because he had not had any other incidents since January . When asked how many incidents it would take for Resident #1 to be managed differently to prevent further incidents, she stated she could not put a number on that. She stated she did not know what else to say and that they could not prevent it because they did not know when the behaviors could start again. When asked if she believed the facility's abuse policy was followed, she stated the only thing they could do is put interventions in place which was done for all of Resident #1's incidents and that should suffice.<BR/>In an interview with Administrator C on 03/14/2024 at 1:30PM, he reported it was his first day at the facility and based on the information he had learned about Resident #1, he said he would have discharged Resident #1 from the facility based on the established pattern of unpredictable episodes of aggression. He stated there would not have been a third incident by Resident #1 and the facility was not able to provide prolonged one-on-one supervision to prevent future incidents. He stated Resident #1 remaining at the facility could place residents at risks of unprovoked encounters with him. He stated there should have been an individualized training for staff on the resident's triggers which were difficult to determine considering he was unprovoked. He stated general knowledge of Resident #1's history and the need for increased monitoring would have been the most important things to educate staff on. <BR/>Record review of facility's policy on Abuse Investigation and Reporting, not dated, reflected Administrator's duty to, .ensure any further potential abuse . is prevented.<BR/>Record review of facility's policy on Care Plans, not dated, reflected, .The comprehensive, person-centered care plan will: a)include measureable objectives and timeframes b) describe the [NAME] that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being .<BR/>An Immediate Jeopardy (IJ) was identified on 03/15/2024 at 3:00PM.<BR/>On 03/15/2024 at 4:25PM the Administrator was notified of the IJ. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. <BR/>The POR was accepted on 03/16/2024 at 12:53PM. The POR reflected:<BR/>PLAN OF REMOVAL OF IMMEDIATE JEOPARDY<BR/>F 600 <BR/>On 03/15/2024 at approximately 4:15 PM, [facility name] was notified by an HHSC employee the facility was in Immediate Jeopardy (IJ) with allegations of Abuse & Neglect (F600) noncompliance.<BR/>On 03/15/2024, at approximately 4:22 PM, the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. <BR/>The notification of Immediate Jeopardy states as follows: F 600 - Alleging the facility failed to HHSC guidelines addressing Abuse and Neglect and an allegation of noncompliance.<BR/>Resident #1 injured Resident # 2 causing a laceration of the lips and was observed to punch Residents #3 and #4 in the face. Due to pattern of aggressive behaviors and staff reporting the unpredictability of those events, it places all residents in the secured unit at risk for abuse.<BR/>Action:<BR/>o Charge nurse/ nurse managers Immediately assessed residents in the secure unit for possible abuse, no suspected abuse found at this time. <BR/>oAdministrator/abuse coordinator Immediately in-service all staff 100% completion on Abuse & Neglect policy.<BR/>oDirector of Nursing, Inservice all 100% of staff on current interventions in place for those residents with behavioral problems, 4 were identified in the secured unit care plans and interventions were updated and staff received the training of the current interventions. <BR/>oResident #1 has been discharged to [behavioral hospital] on 3/14/24, care plan interventions updated .<BR/>Monitoring :<BR/>In-service record and policy titled, Preventing Resident-to-Resident Altercations in Nursing Homes, undated was reviewed. <BR/>Policy used for staff training titled, Abuse Investigation and Reporting, dated July 2017, was reviewed. <BR/>Record review of Resident #1's electronic health chart revealed the resident was discharged from the facility on 03/14/2024.<BR/>Record review of care plans, undated, for Residents #5, #6, #7, #8 and #9 revealed updates of interventions to limit residents' aggressive behaviors were made on 03/16/2023.<BR/>In an interview with CNA C and CNA D on 03/16/2024 at 2:04PM, they both correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Resident #8 on hall 200 as a resident to supervise closely and prevent episodes of aggression.<BR/>In an interview with CNA E on 03/16/2024 at 2:12PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression.<BR/>In an interview with CNA F and CNA G on 03/16/2024 at 2:34PM, they both correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #5, #6 and #7 on hall 100 as a residents to supervise closely and prevent episodes of aggression.<BR/>In an interview with CNA H on 03/16/2024 at 3:15PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression.<BR/>In a phone interview with LVN C on 03/17/2024 at 10:50AM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Residents #1 and #9 on hall 300 as residents to supervise closely and prevent episodes of aggression.<BR/>In a phone interview with CNA I on 03/17/2024 at 11:27AM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to and identified Resident #8 on hall 200 as residents to supervise closely and prevent episodes of aggression.<BR/>In a phone interview with CNA J on 03/17/2024 at 12:03PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, and identified who they would report incidents of resident-to-resident altercations to.<BR/>In a phone interview with LVN B on 03/17/2024 at 12:59PM, she correctly reported the importance of prevention of resident-to-resident altercations, listed examples of aggressive behaviors, listed practical methods to reduce aggressive episodes and keep residents calm, identified who they would report incidents of resident-to-resident altercations to, and identified Residents #5, #6 and #7 on hall 100 as a residents to supervise closely and prevent episodes of aggression.<BR/>In a phone interview with Administrator C on 03/17/2024 at 12:06PM, he stated the whole IDT was involved in reviewing incident reports, determining appropriate interventions for the resident, updating the care plan and educate staff on new plan of care. He stated residents with aggressive behaviors had been listed on the communication board for staff to reference and the facility would develop personal care plans and approaches with each resident to prevent abuse. He stated for the future when dealing with residents with unprovoked aggressive behaviors, he would resort to finding more appropriate placement for that resident to protect other residents. <BR/>In a phone interview with the DON on 03/17/2024 at 12:16PM, she stated the IDT was responsible for care planning residents with aggressive behaviors. She stated residents with aggressive behaviors had been listed on the communication board for staff to reference and they would continue to education to staff to ensure proper interventions are in implemented.<BR/>In a phone interview with the Social Worker on 03/17/2024 at 1:00PM, she stated the IDT and the doctor were responsible for updating plans of care for residents with aggressive behaviors. She stated to ensure prevention of aggressive behaviors, all residents would be kept safe, incident reports would be reviewed, staff would be in-serviced and the Ombudsman would be notified. In the case they could not ensure the safety of residents, her along with the IDT would look for alternative placement that would produce a more positive outcome for the resident identified as the aggressor. She stated they would also have the family and Ombudsman involved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1 of 5 residents (Resident #44) reviewed for medication administration were free of significant medication errors.<BR/>MA L administered Doxazosin Tablet 4mg and Amiodarone HCl Tablet 200mg (medications used to treat high blood pressure), while Resident #44 was assessed with blood pressure lower than the physician recommended parameters for administering the medications. <BR/>This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. <BR/>Findings included:<BR/>Review of Resident #44's face sheet, dated 05/02/2024, revealed that the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis of hypertensive heart disease with heart failure (condition that occurs when high blood pressure damages the heart and reduces its ability to pump blood effectively).<BR/>Review of Resident #44's quarterly MDS assessment, dated 03/25/24, revealed a BIMS score of 15 (an intact cognitive response.<BR/>Review of Resident #44's May/2024 active Physician Order Summary revealed the following orders: <BR/>Amiodarone HCl Tablet 200 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold For SBP&lt;110 DBP&lt;60 <BR/>Doxazosin Mesylate Tablet 4 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold for SBP&lt;110 DBP&lt;60<BR/>Observation on 05/02/2024 at 8:15am revealed MA L was observed obtaining Resident #44's blood pressure with a blood pressure reading of 100/65. MA L proceed by administering the medications and verbalizing to Resident #44 that he was receiving all morning medications including blood pressure medications. <BR/>Review of Resident #44's May/2024 Medication Administration Record (MAR) revealed that MA L administered Doxazosin Tablet 4mg and Amiodarone HCI Tablet 200mg. Each of the medications were administered outside of the physician indicated parameters on 05/02/2024. Resident #44's systolic blood pressure was documented by MA L with a systolic blood pressure of 100 and a diastolic blood pressure of a 65.<BR/>Interview with MA L on 05/02/2024 at 8:20am, MA L denied administering Resident #44's blood pressure medication, stated that she had discarded the medication in Resident #44's designated trash bin in his room. There was no observation of the referenced discard of the medications.<BR/>Interview and observation with ADON on 05/02/2024 at 8:30am, ADON was notified of the surveyor's observation of MA L administering blood pressure medication outside of the indicated parameters; and MA L denial of administering the medications. ADON proceeded to assess Resident #44 for adverse side effects. The ADON stated that MA L was not able to produce the pills and that the medication was not in the trash bin as alleged by MA L. The ADON stated that MA L later disclosed that she had administered the medications. The ADON stated that the physician was notified. MA L was removed from the floor and provided in-service and educated on medication administration. <BR/>Interview on 05/02/2024 at 9:30AM with MA L, MA L stated that if blood pressure medication is administered outside of the recommended parameters, the resident's blood pressure could drop too low causing the resident to have severe complications. MA L stated that staff administering the medications was responsible for ensuring that a medication was given within recommended parameters. MA L stated if blood pressure medication was given out of recommended parameters the medication could cause the blood pressure to become too elevated or too low. <BR/>Observation on 05/02/2024 at 9:33 AM revealed Resident #44 was observed sitting in bed watching television. Resident reported that he was feeling well. <BR/>Interview on 05/02/2024 at 1:22 PM with the DON, stated that MA L later disclosed that she had administered the medications. The DON stated that the physician was notified. MA L was removed from the floor and provided in-service and educated on medication administration. The DON stated medication should be held if the vitals were out of parameters. The DON stated the medication aide should have notified the nurse and the nurse would have notified the doctor that the medication was not administered because the resident's vitals were out of parameters. The DON stated that the purpose of the recommended parameters for the medication is to ensure that the resident remains in a safe blood pressure range identified for the resident. <BR/>Review of the facility's Medication Administration policy, not dated, reflected: .Medications must be administered in accordance with the written orders of the physician's order.

Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 1 of 4 quarters (1st quarter October 1, 2023-December 31, 2023) reviewed for fiscal year quarter one of 2024. <BR/>The facility failed to submit staffing information to CMS for the 1st quarter of the fiscal year 2024.<BR/>The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, and a decline in health status. <BR/>The findings included:<BR/>Review of the facility's staff roster indicated the following:<BR/>1 Administrator<BR/>7 Administrative Staff<BR/>6 Nursing Administration (Includes 1 DON)<BR/>86 Nursing Staff (includes 2 ADON)<BR/>28 Therapist (Includes Respiratory Therapy and Rehabilitation Services)<BR/>11 Dietary Staff<BR/>10 Housekeeping/Laundry Staff<BR/>2 Activities Staff<BR/>1 Social Service Staff<BR/>2 Maintenance Staff<BR/>Record review of the CMS PBJ Staffing Data Report, CASPER Report 1705D FY Quarter 1 2024 (October 1 - December 31, 2023), dated 04/25/2024, revealed the following entry: Failed to Submit Data for the Quarter .Triggered=No data submitted for quarter. <BR/>Interview on 05/02/24 at 11:02 a.m. with the Regional Director of Clinical Operations. She said an outside 3rd party HR company was responsible for submitting payroll and the PBJ for the facility. Due to the lapse in submitting the PBJ by the deadline, the contract with the HR 3rd party company was terminated in February 2024. The risk of not submitting the PBJ per guidelines was that the facility was not reporting staffing accurately and not getting credit for being adequately staffed. <BR/>Interview on 05/03/24 at 10:52 a.m. with the Administrator, who said he started working at the facility on March 14, 2024. He said he was unaware that the PBJ had not been submitted for the 1st quarter of 2024 until the survey team arrived, and it was being discussed with the Clinical Operation Director on 5/2/24. He said the Clinical Operations Director will be responsible for submitting the PBJ for the next quarter. The Administrator said late or omitted PBJ submissions was a deficient practice because the report did not accurately capture the staffing component at the facility to meet the needs of the residents. <BR/>Record review of facility provided policy and procedure entitled Reporting Direct-Care Staffing Information (Payroll-Based Journal), revealed in part: 9. Staffing information will be collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. Dates are as follows: Fiscal Quarter 1 .Date Range .October 1-December 31 .Submission Deadline .February 14 .Fiscal Quarter 2 .Date Range .January 1-March 31 .Submission Deadline .May 15 .Fiscal Quarter .3 .Date Range .April 1- June 30 .Submission Deadline .August 14 .Fiscal Quarter 4 .Date Range .July 1- September 30 .Submission Deadline .November 14.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based onobservation, interviews, and record reviews, the facility failed to ensure a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #1) of 3 residents reviewed for pressure ulcers.<BR/>- The facility failed to prevent Resident #1's healed sacrum pressure ulcer from reopening and deteriorated to completely covered with necrotic (dead) tissue in the wound.<BR/>This failure could place residents at risk for new development or worsening of existing pressure injuries, infection, pain, and decreased quality of life.<BR/>Findings included: <BR/>Record review of Resident #1's face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses were, encephalopathy (any disease of the brain that alters brain function), dementia (impaired ability to remember, think, that interferes with everyday activities), dysphagia, and respiratory failure (when lungs cannot get enough oxygen into the blood).<BR/>Record review of Resident #1's 5-day MDS dated [DATE] revealed section C1000 cognitive skills read severely impaired. Further review revealed the resident needed extensive to total care with all ADL with one to two people assist. It also revealed the resident was incontinent of bowel and bladder. Resident #1 was at risk of developing pressure ulcers. Interventions: Pressure reducing device for the bed and turning/repositioning. <BR/>Record review of Resident #1's care plan dated 02/08/23 revealed Resident #1 developed facility acquired unstageable pressure ulcer on sacrum which measured:<BR/>-02/08/23, 7. 5 x 7 cm<BR/>-02/10/23, 6.01 x 9.9 cm <BR/>-02/17/23, 6.00 x 9.9 cm <BR/>Interventions: treatment per MD orders, measure weekly, support air mattress, and turning and repositioning.<BR/>Record review of Resident #1's admission skin assessment dated [DATE] revealed resident had pink fragile skin on sacrum and ischium.<BR/>Record review of Resident #1's Braden scale for predicting pressure sore risk dated 02/01/23 revealed the resident scored 10 which indicated the resident was high risk of developing pressure sores. <BR/>Record review of Resident # 1's Braden scale for predicting pressure sore risk dated 02/08/23 revealed the resident scored 13 which indicated the resident was moderate risk of developing pressure sores. <BR/>Record review of Resident #1's wound weekly observation tool dated 02/08/23 revealed the resident developed 100% necrotic pressure ulcer on his sacrum and it measured 7.5 x 7.0 cm.<BR/>Record review of the wound care doctor's initial exam dated 02/10/23 for the sacrum wound read unstable pressure injury obscured full - thickness skin and tissue loss and had 100% necrotic tissue. It was measured at 6.01 x 9.9x 0 cm.<BR/>Record review of the wound care doctor's initial exam dated 02/10/23 for the sacrum wound read unstable pressure injury obscured full - thickness skin and tissue loss and had 30% slough /70% necrotic tissue. It was measured at 6.0 x 9.9 cm. treatment was clean with normal saline apply Santyl, calcium alginate and cover with dry dressing.<BR/>Record review of Resident #1's shower sheet dated 02/03/23, and 02/06/23 revealed the resident sacrum was intact. <BR/>Reocrd review of Resident #1's shower sheet dated 02/08/23 revealed the resident had circle drawn on the sacrum area on the paper.<BR/>Record review of the TAR (Treatment administration record) dated February 2023 revealed apply zinc ointment to the sacrum every shift and as needed. Every shift for incontinent, prophylaxis. Discontinued 02/22/23 at 1443. It also revealed the nurses signed off on the TAR on day, evening, and night shifts.<BR/>Observation of wound care on 02/22/23 at 1:07 p.m., during Resident #1's wound care on the sacrum, revealed the resident had an unstageable wound on his sacrum. The wound measured 6.5 cm x10.3 cm. It appeared to contain black Eschar and some yellow slough. Resident #1 was lying on the right side before treatment. Resident #1 was turned to his right side. <BR/>Observation and Interview on 02/22/23 at 1:20 p.m. during Resident#1's wound care, the DON said the wound bed was primarily covered with black necrotic tissue and some yellow slough at 100%. He said he had not seen the wound before now.<BR/>Interview on 02/22/23 at 1:45 pm, the Wound Care Nurse said Resident #1 was admitted to the facility on [DATE], and he developed a wound on the sacrum on 02/08/23. She said when she was notified about the wound, it was already unstageable and 100 % necrotic. The Wound Care Nurse said when the resident was admitted , she did a skin assessment, and he did have a pink and healed wound on the sacrum. The Wound Care Nurse said the nurse does the weekly skin assessment, and his assessment was due on Friday on 10 pm to 6 am shift. She said she checked the shower sheets every day, and there was no documentation of any skin issues on Resident #1's shower sheets. She said the first treatment she did was Santyl and alginate on 02/08/23, and it was changed to betadine and dry dressing on 02/10/23 when the Wound Care Doctor first saw the wound on Resident #1's sacrum. The doctor changed it back to Santyl and alginate on 02/17/23. Surveyor Requested for Braden scale, initial and weekly skin assessment, and wound care training, which she said was done by a wound company. <BR/>She said the facility does Braden scale to see if the resident is at risk, and she would put an intervention in place. She said the initial Braden scale at admission showed Resident #1 was at high risk for pressure sores, and the shower sheet should have alerted any change in skin condition. The Wound Care Nurse said that was why she ordered zinc ointment every shift and as needed, and it was on the nurse's MAR. She said the nurses signed off on the MAR every day until today. The Wound Care Nurse said the nurses should have observed changes on the sacrum when they applied the ointment and notified her or called the doctor before the area became unstageable. She said somebody dropped the ball, and it is what it is and she indicated that they would treat what the resident had now. The Wound Care Nurse said when she was made aware of the wound, it was already 100 % necrotic. She said she had not notified the dietitian about Resident #1 wound, and she should have informed the dietitian by now.<BR/>Interview on 02/22/23 at 2:20 p.m. ADON said she had not looked at Resident #1's wound. She said the Wound Care Doctor and the Wound Care Nurse do the wound assessment and treatment. She said the admission nurse does the skin assessment, and Braden was done on admission, and it is done weekly for four weeks, then quarterly. The ADON said if the resident came with a wound, then the resident was turned/repositioned every two hours and put on an air mattress. She said she did not know the facility protocol for monitoring residents to prevent wounds because she did not do wound care. She said the question should be directed to the Wound Care Nurse.<BR/>Interview on 02/22/23 at 4:57 p.m., the Administrator said Resident #1 sacrum area was pink and fragile on admission. She said the Wound Care Nurse did a skin assessment on 02/08/23, which was how she found out the resident had a sacral wound. The Administrator said Resident #1 could develop a wound in one day, and there was no issue with his sacrum, which was why there was no documentation on the sacrum. She said in a nursing home, they do problem charting. She did not respond when asked if the nurses and aides did not see any change in Resident #1's skin before the sacral area turned from pick to necrosis. <BR/>The Surveyor requested in-service wound assessment for all the nurses who worked with Resident #1 for the first week who applied zinc oxide on his sacrum and the aides who worked with the resident for the first seven days, and any training or in-service on skin monitoring and assessment training.<BR/>Interview on 02/23/23 at 8:15 a.m., Resident #1's PCP, he said he became aware of Resident #1's wound on the sacrum this week, but the Wound Care Doctor was involved in the resident's care. He said the resident had comorbidities that could contribute to wound development and healing. He was asked what the nurses expected to do when they knew a resident was at risk of developing pressure ulcers and the area was already compromised. He said he understood what you are asking, but you should direct the question to the Wound Doctor because he was involved in the resident care .<BR/>Interview on 02/23/23 at 8:28 a.m., the DON did not respond when asked how Resident#1, who had no wound on his sacrum, deteriorated to unstageable with 100% necroses before treatment was started. DON said the resident skin was monitored during the weekly skin assessment, and there was no documentation on the shower sheets of any skin issues until 02/08/23. Then the Administrator said they would treat the wound if they had an order. She said if zinc oxide was ordered and the nurses signed off on the TAR, the treatment was done. When asked when the nurses applied the zinc oxide to the sacrum, did the nurses assess the area and observe any change on the sacrum before it turned necrotic? She asked why you asked about what happened on February 8, today, February 23. She further said that the facility found out about the wound, which is being treated, and the wound care doctor saw the resident weekly. DON said the wound care company trained the Wound Care Nurse. He said the facility monitored Resident #1's skin when the nurse did a weekly skin assessment, and the resident was turned and repositioned every two hours.<BR/>Interview on 02/23/23 at 8:37 a.m., the Wound Care Nurse said an outside wound care company trained her on how to provide wound care, and she had a skill check-off done by the facility. She said that Resident #1's the sacrum was not open but pink and fragile. The Wound Care Nurse said she expected the nurses to treat the resident and call her if there was any change in the skin or call the doctor. She said the nurses did not tell her that the area was changing color. The Wound Care Nurse said the ADON told her on 02/08/23 that resident #1 wound looked different because somebody told her. She said that no Nurse Manager makes rounds to see the wounds. She said the wound was moist black necroses at 100% but was not draining. She said she called the resident's PCP, spoke to the NP, who gave the order to use Santyl, and had the wound doctor look at it. She said she notified the wound doctor when he came to see Resident #1 on 02/10/23. She said the Wound Care Doctor measured it and said to apply betadine.<BR/>Interview on 02/23/23 at 8:53 a.m., the ADON said a CNA told her that there was an open spot on the resident sacrum, and she told the Wound Care Nurse. However, she said was not sure which CNA, because the facility uses a lot of agency staff, and she cannot remember who told her.<BR/>Interview on 02/23/23 at 9:08 a.m., CNA A said Resident #1's sacrum was clear, and there was no redness or open area (02/05/23) when he worked with the resident, and he said Resident #1 did not have any nurse apply any cream on his bottom. CNA A said he did not use a protective barrier on his bottom.<BR/>Observation and attempted Interview on 02/23/23/ at 9:05 a.m. revealed Resident #1 was lying on the right side facing the window. Resident #1 was not able to verbalize if he had a wound on his sacrum or if any treatment was done on his sacrum.<BR/>Interview on 02/23/23 at 9:17 a.m., LVN B said she saw the area on Resident #1 sacrum with the wound care nurse on 02/02/22. LVN B said the sacrum was pink to red. She said she believed the aides were putting zinc on Resident #1's sacrum. She said she did not apply any cream on his sacrum. Instead, she said she would ask the aides to reposition the resident. She said she was unaware that the resident had developed a wound on the sacrum. She said she only looked at the site again once the wound care nurse started treating Resident #1.<BR/>Interview on 02/23/23 at 11:00 a.m., LVN B said she signed the treatment for zinc to the sacrum, but she gave the cream to the aide to apply on Resident #1 sacrum, and she believed the aide would have told her if the resident had any open wound. LVN B said if she had applied the cream herself, she would have seen if the area had changed, and she would have notified the doctor and the wound care nurse earlier before it became necrotic.<BR/>Observation on 02/23/23 at 11:05 p.m., resident was on his back.<BR/>Interview on 02/23/23 at 12:49 p.m., the Wound care doctor said wound color could change within 24 hours, and if different nurses were caring for Resident #1's wound, they could interpret the different shades of the skin differently. He said he told the Wound Care Nurse if she found any change in the resident's wound, she should send a picture, and they could talk about it through zoom instead of waiting until he came to make regular rounds. He said the first time he saw the wound on Resident #1's sacrum was on 02/10/23. He said Resident #1 had comorbidities and would affect the development and healing of the wound.<BR/>Interview on 02/23/23 at 1:36 p.m. LVN C said he gave the cream to the aides to apply to Resident #1 sacrum, and he knew the aide would tell him if Resident #1 had any open area on his sacrum. He said the aides should apply zinc oxide on the Resident's sacrum, and if the Resident had an actual wound, the Wound Care Nurse would treat the resident. LVN C said he did not look at the resident sacrum because they do weekly skin assessments, and he would look at the resident's skin during the skin assessment. LVN C was asked why he signed the TAR when the aide applied the cream. LVN C said it was what the nurses do if the Resident does not have a wound. When asked if he had applied the cream on Resident #1, would he have noticed the change on the Resident's sacrum, he did not respond. He said he had skills check off, which had a section about skin assessment.<BR/>Record review of the facility policy on skin assessment monitoring guidelines dated 10/2021 read, . all residents will be assessed upon admission . to identify risk factors that may lead to impaired skin integrity . nursing personnel will begin implementation of intervention within 24 hours and should complete all intervention within 72 hours . all residents receiving a Braden scale of 18 will be considered at risk for developing a pressure sore <BR/>Record review of the undated facility policy on wound monitoring guidelines read, . a resident who has developed or is admitted with wound will receive necessary treatment and services to promote healing . prevent new wound from developing .<BR/>.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents on 2 of 3 Halls (100 and 200 Halls) reviewed for environmental concerns. <BR/>1. Overhead light was not illuminating in the bathroom of room [ROOM NUMBER].<BR/>2. Baseboard coming off the wall in rooms 118, 201, <BR/>3. Broken sheet rack in rooms 113, 219, 206<BR/>4. Peeling paint on the wall in rooms 103, 120, <BR/>5. Floor tile lifting in room [ROOM NUMBER]<BR/>6. Strong urine/feces odor in room [ROOM NUMBER], 116 and 120. In 116 and 120 brown substance that looked like feces the toilet and floor. <BR/>This deficient practice could affect residents who resided in rooms on hall 100 and hall 200 by causing the residents to live in an environment that would not improve their quality of life. <BR/>Findings Included:<BR/>Observation on 3/27/2025 between 9:30am and 10:30am revealed the following. <BR/>In room [ROOM NUMBER] the light in the bathroom was not illuminating. <BR/>In rooms [ROOM NUMBERS] the baseboard coming off the wall. 201 window blinds were broken.<BR/>In rooms 113, 219 and 206 revealed broken sheet rack.<BR/>In rooms [ROOM NUMBERS] has peeling paint on the wall.<BR/>In room [ROOM NUMBER] there was a hole under the window where the tape was not affixed to the wall and a hole in the sheet rack near the entrance door. There was an electric cord plug in the wall across the floor to bed A. <BR/>Rooms 112,116 and 120 had strong offensive urine/feces odor. In room [ROOM NUMBER] and 120 the toilet bowl, seat and floor had brown stains and smear that looked and smelled like feces. In rooms [ROOM NUMBERS] the floor had an accumulation of brown stains on it. <BR/>Interview on 3/27/2025 at 9:35am. with an unidentified resident revealed that there was no light in the bathroom of113. <BR/>Interview on 3/27/2025 at 1:25pm with the Maintenance Supervisor revealed that he was not aware of the light not working in room113. He said maybe it was just the bulb that needed to be changed. He said he was going to check the bathroom I 13 and change the bulb. He said he had just gotten the position as maintenance supervisor, and he was going to address all concerns brought to him. He said there was a book on all stations and concerns were documented in them. He said each morning he would check the books and see what needed to be done and try to address them as quickly as possible. <BR/>In an interview on 3/27/2025 at 4:00pm the Administrator said Maintenance Supervisor said he had just taken the position as supervisor, and he was going to hire an assistant for him. He said he was going to address the concerns brought to him. <BR/>Record review of the facility's policy and procedures revised August 2009 revealed Quality of Life-Homelike Environment read in part .<BR/>Policy Statement: Resident are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to extent possible. <BR/>Policy Interpretation and Implementation<BR/>1. Staff provide person-centered care that emphasizes the resident comfort, independence and personal needs preferences.<BR/>2. 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:<BR/>a. cleanliness and order.<BR/>b. Comfortable (minimum glare) yet adequate (suitable to the task) lighting.<BR/>e. Pleasant neutral scents.

Based on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for one of four medication carts reviewed for storage of medications. RN-M failed to ensure the 200 Hall nurse medication cart was locked when unattended. This deficient practice could place residents at risk for loss of biologicals and place residents at risk of access to hazards.Findings included:In an observation and interview on 07/23/25 at 5:15 AM, revealed the 200 Hall Nurse Medication Cart was in the hallway positioned just outside the entrance to a resident's open room. The medication cart was unattended and unlocked, the lock was visibly not engaged. The medication cart contained a variety of medications labeled with Resident names and over-the-counter medications. The controlled substances were locked within the medication cart. RN-M was observed walking from one end of the hall towards the medication cart. RN-M stated she was called away to get something and forgot to lock the cart. RN-M stated the medication cart should be locked when unattended otherwise a confused resident could open the cart and take the medications. RN-M stated it was facility protocol to lock the cart before walking away and leaving the area.In an interview on 07/26/25 at 9:15 AM, the DON stated the nurse or medication aide assigned to the medication cart was responsible to make sure the cart is secure and not accessible to anyone who was not authorized access. The DON stated she would conduct a 1:1 in-service for medication storage.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen in that:<BR/>1. <BR/>Food items were not sealed and/or not dated in the facility pantry .<BR/>2. <BR/>One can of canned food was dented and stored with the non-dented food cans .<BR/>These deficient practices could place 89 residents who received meals from the main kitchen at risk for food borne illness.<BR/>Findings included:<BR/>1. Observation in the pantry of the food items on 04/30/24 at 08:32 am revealed one 16 oz bag of tortilla chips was opened, not sealed, not dated.<BR/>Observation in the pantry of the food items on 04/30/24 at 08:33 am revealed one 80 oz bag of instant oatmeal was dated, not sealed.<BR/>Interview with the Dietary Manager on 4/30/24 at 2:08 pm she said the food items that were not sealed should have either been destroyed or their entire contents should have been used because of the small amount of food that was in the bags. She said all kitchen staff were responsible for checking if food is sealed and dated in the pantry. She said she would go behind kitchen staff and double check food items in the pantry. She said the risk to the resident would be food poisoning.<BR/>Interview with the Dietary Aide on 4/30/24 at 2:14 pm, she said she has worked at the facility for 8 months. She said kitchen staff were supposed to store leftover food in Ziploc bags and date. She said everyone in the kitchen was responsible for labeling and dating opened food items. She said the risk to the resident could make them sick.<BR/>Interview with the Dietary [NAME] on 4/30/24 at 2:22 pm she said she has worked at the facility for 1 year and 5 months. She said the food items in the pantry were supposed to be stored in a Ziploc bag and dated. She said everyone in the kitchen was responsible for labeling and dating food items and the next shift would check for food items in case any were missed by the previous shift. She said the risk to the resident if food items were not sealed or dated would cause the resident to get sick.<BR/>2. Observation in the pantry of the non-dented cans on 04/30/24 at 08:35 AM revealed one 104 oz can of apples in water had a small dent on the bottom of the seam.<BR/>Interview with the Dietary Manager on 4/30/24 at 8:36 am confirmed the dented can of apples should have been stored with the dented cans.<BR/>Interview with the Dietary Manager on 4/30/24 at 2:09 pm, she said the dented cans should be stored on a separate shelf away from the non-dented cans. She said everyone in the kitchen was responsible for checking dented cans and she would go behind to double check. She said the risk to the resident would be exposure to botulism.<BR/>Interview with the Dietary Aide on 4/30/24 at 2:15 pm, she said dented cans should be stored away from regular cans in their own designated area. She said kitchen staff go behind each other to double check for dented cans. She said the risk to the resident would cause them to get sick.<BR/>Interview with the Dietary [NAME] on 4/30/24 at 2:23 pm, she said the dented cans should be stored on a separate shelf. She said everyone in the kitchen should check for dented cans. She said each shift goes behind the previous shift and checked for dented cans. She said the risk to the resident would cause them to get sick.<BR/>Record review of the facility's Food Receiving and Storage undated policy under section 13e read in part . opened containers must be dated with use by date and sealed or covered during storage .<BR/>Record review of the U.S. Food and Drug Administration dated 1/18/23 under Chapter 3 read in part . FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act .rusted and dented cans may also present a serious potential hazard .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to maintain an effective pest control program so the facility was free of pests on two of three halls (Hall 100 and Hall 200) reviewed for pest control. <BR/>The facility failed to ensure the building was free of roaches and gnats. <BR/>This failure could place residents at risk of infection, skin irritation, allergies, and unsanitary living conditions which could result in a decline in health and well-being. <BR/>Finding included:<BR/>Observation during the survey process on 3/27/2025 between 9:30am and 10:30am revealed the following:<BR/>In room [ROOM NUMBER] there were gnats flying in the room. In room [ROOM NUMBER] there was a live roach crawling on the resident's over bed table and there was a dead roach on the floor near the resident's bedside to the closet area. In room [ROOM NUMBER] was a roach crawling in the corner near the closet of bed A.<BR/>In interviews on 3/27/2025 between 9:30 am and 10:30am with 2 unidentified residents revealed that roaches were always in their rooms. They said they would spray the roaches, but the roaches would always come back. One resident said he tried to follow the rules but sometimes he would get his own spray and spray his room to get rid of the roaches. <BR/>In an interview on 3/27/2024 at 10:50am Resident #1 said roaches were always in her room. She said they usually spray her room but there were still roaches. She said the last time she saw a roach was the morning of the survey crawling on her overbed table.<BR/>Observation on 3/27/2025 at 10:52am the resident pointed a live roach crawling on her overbed table to the surveyor. The roach was crawling from one end of the overbed table to the other. It was pointed out to the CNA who was working the floor. At that point the CNA said she would take care of it.<BR/>In an interview on 3/27/2025 at 1:25pm with the Maintenance Supervisor he said the pest control company was in the building two days ago. He said they were spraying for roaches. He said they were coming once a month, but they were now set up for them to come once a week for four weeks and then back to monthly spraying. <BR/>In an interview with the Administrator on 3/27/2025 at 4:10pm regarding pest control issues in the facility, he said the pest control company was in the building a few days ago. He said they used to come monthly but they just changed the contract to once a week for four weeks and then back to monthly visits.<BR/>Record review of the grievance log for March 2025 revealed that on 3/24/2025 insects were observed on the resident's plate. No location was documented on the grievance log.<BR/>Record review of the pest control receipt dated 1/10/2025 revealed the pest control company was in the building on 1/16/2025, 2/25/2025, 3/14/2025 and 3/25/2025 to treat spiders, roaches, and ants. They treated patient and guest rooms for roaches, spiders and ants and on 3/25/2024 the kitchen was treated for roaches and fumigated, and resident rooms and office treated for roaches. Further record review revealed the rooms that were identified with roaches and gnats were not included on the list of rooms that were treated on 3/25/3035. <BR/>Record review of the undated pest control policy and procedures read in part .<BR/>Policy Statement:<BR/>Our facility shall maintain an effective pest control program.<BR/>1. <BR/>This facility has an ongoing pest control program to ensure that the building is kept free of insect and rodent.