Avir at Beaumont

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents with loss of bladder control receive treatment or services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 residents reviewed for incontinent care. (Resident #1) The facility failed to provide Resident #1 assistance with timely incontinence care from 09:30 a.m. until 01:45 p.m. on 10/06/2025. This failure could place the residents at risk for decreased feelings of self-worth, skin breakdown, and infection.Findings included: Record review of Resident #1's face sheet, dated 10/06/2025, indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE]. Record review of Resident #1's Quarterly MDS assessment, dated 08/19/2025, indicated Resident #1 had severe impairment of cognition abilities with a BIMS score of 05. Resident #1 was noted to be dependent on staff for toileting, showering, and lower body dressing. Resident #1 required substantial/max assistance with eating and oral hygiene. Resident #1 was always incontinent of urinary and bowel. During observations of Resident #1 on 10/06/2025 from 09:30 a.m. through 2:00 p.m., the following was noted: 09:30 a.m. - Resident #1 was watching TV while sitting in a wheelchair. No urine or body odor noted. 10:38 a.m. - A Priest visited facility and Resident #1 received communion; 10:47 a.m. - Resident #1 received one cup of water from the staff; 11:32 a.m. - Resident #1 transported via wheelchair to dining room for the noon meal; 11:36 a.m. - Resident #1 transported via wheelchair to outside smoking area for smoke time; 11:48 a.m. - Resident #1 returned to dining room for noon meal; 12:33 p.m. - Resident #1 remains in dining room eating meal; 12:54 p.m. - Resident #1 transported to common area Unit 100 and sat in wheelchair in front of the TV; 1:20 p.m. - Resident #1 remained sitting in front of the TV with his head down and was seen occasionally dozing off and on. No urine or body odor noted; and 1:45 - 2:00 p.m. Resident #1 was finally provided incontinent care after 4.5 hours of observations. Resident #1 was transported to his room by CNA A. Resident #1 was transferred to bed by CNA A and CNA B. Resident #1's brief was removed, and he had recently had bowel movement. Resident #1's brief was wet but not soaked. No open areas noted to buttocks. Incontinent care was provided, and CNA A applied a barrier ointment to Resident #1's buttocks as a preventative. Resident #1 tolerated well. During a joint interview on 10/07/2025 at 11:05 a.m., CNA B said they checked on residents as they passed by them or if they called out to them. She said they were supposed to do every 2-hour checks on residents, to assess whether they had been incontinent and the staff were constantly all over the area. She added it was important to check residents at least every 2 hours for incontinence due to potential skin breakdown from sitting in wet briefs. CNA B said they performed spot checks on residents to see if they need any care performed. CNA A said Resident #1 was not a heavy wetter and she should stop and check on Resident #1 and the others more frequently. CNA A said Resident #1 had no skin breakdown currently. She said she applied a barrier ointment to the buttocks with each incontinent episode as a preventative. During an interview on 10/07/2025 at 12:45 p.m., the Administrator said her expectations were for staff to check residents on rounds at least every 2 hours and throughout their shift when residents were in common areas. She added the staff should be offering fluids, snacks, and generally conversing with residents. During an interview on 10/08/2025 at 10:00 a.m., the DON said she expected the CNAs and the Nurses to work together to complete incontinent care as needed. The DON stated CNAs were responsible for doing rounds every 2 hours on residents to ensure they were clean and dry. The DON stated nurses were also responsible for checking on their residents to ensure they were doing okay. The DON stated leaving Resident #1 wet with urine or stool placed him at risk of skin breakdown, infection, and pressure sores. The DON said there was no facility policy on perineal care or incontinent care of residents. Record review of the facility's Activities of Daily Living policy, dated February 2025, indicated the following: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a) hygiene and c) elimination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 2 of 23 residents reviewed for medications. (Resident #22 and #64)<BR/>Resident #22 missed several doses of a PRN blood pressure medication when her blood pressure was extremely elevated.<BR/>Resident #64 received the antihypotension medication when it should have not been given and it was held when it should have been given on multiple occasions <BR/>This failure could place resident at risk of not receiving medications as prescribed and/or significant medication errors.<BR/>Findings included:<BR/>1. Physician orders dated February 2023 indicated Resident #22, admitted [DATE], was [AGE] years old with diagnosis of hypertension (high blood pressure). An order was received 01/06/23 for clonidine HCl 0.1 mg. Instructions included give 1 tablet by mouth every 8 hours as needed for B/P (blood pressure) at 160/90 and above.<BR/>The MAR dated February 2023 indicated on the following dates at 8:00 a.m., Resident #22's B/P was out of range of prescribed parameters and medication space was blank indicating clonidine was not administered:<BR/>*02/03/23, B/P was 180/82, medication space was blank; <BR/>*02/04/23, B/P was 185/63, ; medication space was blank<BR/>*02/08/23, B/P was 156/109, medication space was blank;<BR/>*02/13/23, B/P was 198/78, medication space was blank;<BR/>*02/24/23, B/P was 204/86, medication space was blank; and<BR/>*02/25/23, B/P was 164/95, medication space was blank.<BR/>The comprehensive care plan for Resident #22 dated revised on 02/28/23 indicated: Problem: Is at risk for complications/side effects of hypertension: .Interventions .Give antihypertensive medications as ordered. <BR/>During an interview and record review on 03/01/23 at 11:50 a.m., LVN B said Resident #22's B/P was normally 160's. She acknowledged the February 2023 MAR gave no indication Resident #22 had been administered clonidine HCl 0.1 mg per physician orders when the B/P was at 160/90 or above. She said the physician should have been notified and possibly adjust Resident #22's medications.<BR/>Progress Notes for Resident #22 dated 02/01/23 through 03/01/23 indicated Resident #22 was administered clonidine HCl 0.1 mg on 02/07/23 when B/P was at or above 160/90.<BR/>During an interview on 03/01/23 at 12:25 p.m., the DON said her expectations were for the LVNs to notify physicians of consistently elevated B/P readings to possibly adjust medications. Also, to check the resident's electronic record for PRN orders regarding elevated B/P readings. She said residents possibly would not achieve therapeutic levels of medications if not adjusted. The risk could potentially be having B/P go higher or could have a stroke. <BR/>2. Record review of an admission record indicated Resident #64 admitted [DATE], was [AGE] years old with diagnosis of hypotension (low blood pressure).<BR/>Physician orders dated February 2023 indicated Resident #64 had order for midodrine HCl (used for low blood pressure)Tablet 5 mg, give 1 tablet by mouth three times a day for Hypotension HOLD if B/P is GREATER THAN 100/60 with start date of 08/16/2022.<BR/>Record Review of the MAR dated February indicated Resident #64 received midodrine HCL tablet 5 mg 1 tablet on the following dates:<BR/>*2/17/23 at 1:00 p.m., B/P was 114/68, midodrine was given; <BR/>*2/20/23 at 7:00 a.m., B/P was 146/88, midodrine was given; and<BR/>*2/21/23 at 7:00 p.m., B/P was 134/62, midodrine was given.<BR/>Record Review of the MAR dated February 2023 indicated Resident #64's midodrine HCL tablet should have been given and was held as follows:<BR/>*2/1/23 at 1:00 p.m., B/P was 104/58, midodrine was held<BR/>*2/3/23 at 1:00 p.m., B/P was 100/58, midodrine was held<BR/>*2/6/23 at 7:00 a.m., B/P was 144/58, midodrine was held<BR/>*2/7/23 at 1:00 p.m. B/P was 114/58, midodrine was held<BR/>*2/8/23 at 1:00 p.m., B/P was 102/58, midodrine was held<BR/>*2/14/23 at 7:00 p.m., B/P was 102/58, midodrine was held<BR/>*2/23/23 at 1:00 p.m., B/P was 108/58, midodrine was held and<BR/>*2/24/23 at 1:00 p.m., B/P was 102/58, midodrine was held<BR/>Record review of the comprehensive care plan for Resident #64 dated revised on 01/19/23 indicated history of hypotension requiring Midodrine .Interventions . Give medications as ordered. Monitor for side effects and effectiveness.<BR/>Record review of the MDS dated [DATE] indicated Resident #64 had diagnosis hypotension and cognition was moderately impaired.<BR/>During an interview on 02/28/23 at 3:00 p.m., DON said she was going to call Resident #64's physician and clarify the order and she expected the nurses to follow orders and if the order was not clear to call physician or call her. <BR/>During an interview on 03/01/23 at 1:00 p.m., LVN E said the order for Resident #64 was not clear if both systolic and diastolic had to be below to give the parameters. She said midodrine was held on days it could have been given if using diastolic B/P, and on a couple of days she gave the med and should have been held. LVN E said after surveyor intervention the order has been clarified and the physician just wants parameters with the systolic B/P. LVN E said she was trained in the following orders and if it was not clear she should have reported to DON or the physician.<BR/>A facility policy dated 2022 and titled Medication Administration indicated the following . Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: . 8. Obtain and record vital signs, when applicable or per physician orders.10. Review MAR to identify medication to be administered. <BR/>A facility policy dated 2022 and titled Physician/Practitioner Orders indicated . 2. For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: a. Call the attending physician to verify the order .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 of 6 residents (Resident #1) reviewed for laboratory services. The facility failed to ensure Resident #1's Comprehensive Metabolic Panel, also known as CMP (a blood test that checks for a wide range of substances in your blood, including proteins, enzymes, electrolytes, and minerals), Complete Blood Count also known as CBC (a blood test that measures amounts and sizes of your red blood cells, hemoglobin, white blood cells and platelets), carcinoembryonic antigen also known as CEA (blood test measures the level of a specific protein in the blood, primarily used to monitor certain types of cancer), Thyroid-Stimulating Hormone also known as TSH (blood test to assess level of thyroid stimulating hormone and thyroid function and metabolism) and Thyroxine test also known as T4 (blood test that helps diagnosis thyroid conditions) was drawn every 14 days as ordered. This failure could place residents at risk of not receiving lab services as ordered and not managing medications at a therapeutic level.Finding included: Record review of Resident #1's face sheet indicated she was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include: Alzheimer's disease (progressive disease that destroys memory and other important mental functions), severe protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and malignant neoplasm of overlapping sites of bronchus and lung (a cancerous tumor which is located in the lungs and in the two main airways of the body that join the windpipe to each lung). Resident #1 discharged on 07/28/2025 to an acute care hospital. Record review of Resident #1's significant change in status MDS assessment dated [DATE], indicated she was severely impaired cognitively with a BIMS score of 01. She required maximal assistance with self-care and mobility. Record review of Resident #1's comprehensive care plan last revised 04/23/2025, indicated she had potential nutritional problem related to low body weight, cancer, and protein calorie malnutrition with interventions of health shakes with meals, magic cup, house supplement, liquid protein and obtain and monitor lab/diagnostic work as ordered, and report results to MD and follow up as indicated. Record review of Resident #1's physician's orders indicated: Obtain CBC w/diff, CEA, CMP, T4, and TSH every 14 day(s) for 6 occurrences start order dated 05/30/2025 and end date 08/08/2025. Record review of Resident #1's electronic health record lab results indicated that her CBC w/diff, CEA, CMP, T4, and TSH was due on 05/30/2025, 06/13/2025, 06/27/2025, 07/11/2025, 07/25/2025 and 08/08/2025. Her CBC w/ diff was obtained on 05/30/2025, 06/12/2025, 07/01/2025, and 07/25/2025. No indication that CBC w/ diff was obtained on 06/27/2025, and 07/11/2025 as ordered by physician. Her CEA was obtained on 05/30/2025 and 06/12/2025. No indication CEA was obtained on 06/27/2025, 07/11/2025, and 07/25/2025 as ordered by physician. Her CMP was obtained on 05/30/2025, 06/12/2025, 06/26/2025, 07/21/2025, and 07/25/2025. No indication CMP was obtained on 07/11/2025 as ordered by physician. Her TSH and T4 was obtained on 05/30/2025, 06/12/2025, 07/01/2025, and 07/25/2025. No indication TSH and T4 was obtained on 06/27/2025 and 07/11/2025 as ordered by physician. During an interview on 08/11/2025 at 3:05 p.m. and 3:20 p.m., LVN E and LVN G said when the nurses received an order for a lab, they would enter it in their electronic medical record system as a lab order and into a lab request electronic system. She said the two systems communicated and the request would generate a lab results entry into the medical records identifying that the labs were ordered and when obtained the results uploaded into the medical records. She said it was the responsibility of the nurse to go into the electronic medical record system periodically throughout the shift to check for lab and x-ray results, review results and report to the NP/MD if applicable. During an interview on 08/11/2025 at 5:05 p.m. and 5:35 p.m., LVN C and LVN H said when receiving orders from a physician via phone, fax or paper, the order was entered into the electronic medical record. They said if a lab was included on the order, the order must be entered into the electronic lab request system to notify the lab of the request. They said the lab system has a place to include date due and if reoccurring event, so one time ordered labs would have the specific date identified but if reoccurring labs would identify dates and that it was a reoccurring event. They said labs due were discussed during shift change and they print a copy of the lab request and place it at the nurses' station to identify any labs coming due and/or results pending. They said it was their responsibility to go into electronic medical records system several times during the shift to check for lab results, review and report to NP/MD if applicable. They said if the results were for upcoming appointments that the labs were also sent in the transfer packet. They said when residents were transferred out of facility to appointments or ER visits, they sent a copy of the resident's face sheet, list of medications and any recent labs with them to the appointment/ER visit. During an interview on 08/11/25 at 4:45 p.m., the ADON said she expected labs to be drawn per the physician's order. The ADON said she was unaware that Resident #1's was missing her labs until questioned by the state surveyor and provided the surveyor a copy of all Resident #1's labs in the electronic lab system for review. The ADON said she reviewed the labs routinely for completion. The ADON explained the process of entering the lab request into the electronic lab system for collection and how it communicated with the facility electronic medical records. The ADON was not able to provide why Resident #1's labs were not obtained as ordered. The ADON said that Resident #1 was transferred from Unit 3 to Unit 1 at the end of June 2025 and new management company made some changes with the electronic lab system. The ADON said she was made aware by the DON some labs had been missed on Resident #1 found during a discharge chart audit and concerns made by surveyor on 08/09/2025. The ADON said that the facility had initiated a new lab tracking form since identifying the issue. During an interview on 08/12/2025 at 1:30 p.m., the DON said she had identified missed labs on Resident #1 during surveyor intervention on 08/09/2025 and Resident #1 discharge chart review. She said she had initiated a new lab tracking form and was going to add lab collection per physician orders and obtaining results to the QAPI. The DON was not able to provide why Resident #1's labs were not obtained as ordered. The DON said she recalled all ordered labs were not completed on June 26, 2025, for Resident #1, and lab was contacted on 07/01/2025 to collect missed labs stat. The DON said that Resident #1 was transferred from Unit 3 to Unit 1 at the end of June 2025 and new management company made some changes with the electronic lab system which could have interfered with the reoccurring order for Resident #1's lab. The DON said it was important to ensure labs were drawn per the physician's order to ensure their health had been monitored per those lab values. The DON said Resident #1 did not miss any cancer center appointments or treatments due to the missed labs. During an interview on 08/11/2025 at 2:45 p.m., CM M with cancer center said that Resident #1 did not miss any scheduled appointment due to missing lab results, she said they ordered the labs every 14 days to verify that they would have a set of labs to review at least monthly for the required treatment provided. She said they expected labs to be drawn as ordered but unfortunately that does not always happen. She said that the missed labs did not alter Resident #1 cancer treatment plan. During an interview on 08/12/2025 at 1:45 p.m., the Administrator said she expected labs to be drawn as ordered. She said the DON/ADON oversaw the labs. She said the DON had already let her know they had identified missed labs on Resident #1 during surveyor intervention on 08/09/2025 and Resident #1 discharge chart review. The Administrator said it was important that labs were drawn per the physician's orders to ensure the residents were getting the highest quality of care for their health. Record review of the facility's policy titled Test Results revised April 2007 indicated . the resident's attending physician will be notified of the results of diagnostic test. 1. Results of laboratory, radiological, and diagnostic test shall be reported to the resident's attending physician or to the facility. 2. Should the test results be provided to the facility, the attending physician shall be promptly notified of the results. 3. The director of nursing services, or charge nurse receiving the test results, shall be responsible for notifying the physician of such test results. Signed and dated/electronic signature as applicable of all diagnostic services shall be made a part of the residence medical records. Requested a policy regarding laboratory services with no policy provided by the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events caused the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the State Survey Agency in accordance with State law through established procedures for 2 of 4 residents (Resident #3 and #4) reviewed for reporting allegations of abuse. The facility failed to report physical abuse and verbal abuse to the State Agency within 2 hours when it was reported to DON/delegated abuse coordinator Resident #3 threw a TV remote at Resident #4 causing a laceration to Resident #4's nose on 07/26/2025 at 7:48 p.m. and Resident #3 made a statement regarding needing a gun, so he could shoot up some people in this place on 07/30/2025 at 4:52 p.m. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.Findings included: 1. Record review of Resident #3's face sheet dated 08/07/2025 indicated he was a [AGE] year-old male, admitted on [DATE], and his diagnoses included chronic kidney disease (gradual loss of kidney function), anxiety disorder (persistent and excessive worry that interferes with daily activities), and dementia (loss of cognitive functioning). Record review of Resident #3's admission MDS assessment dated [DATE] indicated he can make himself understood and understands others. He had a BIMS score of 12 which indicated moderate cognitive impairment. He had verbal behavioral symptoms directed towards other occurring 1 to 3 days during the 7 days look back window and no physical behavioral symptoms identified. Record review of Resident #3's care plan dated 07/26/2025 indicated he was involved in a resident-to-resident altercation involving a TV remote. Interventions included residents were separated, room change performed, placed on 1:1 monitoring, MD and Psych services notified. Care plan dated 08/06/2025 indicated resident has potential to be verbally aggressive related to dementia, ineffective coping skills, mental/emotional illness, and poor impulse control with interventions analyze key times, places, circumstances, triggers and what de-escalates behavior and document, assess and anticipate resident's needs; administer medications as ordered and give the resident as many choices as possible about care and activities. Record review of Resident #3's nurse progress note authored by RN D indicated on 7/26/2025 at 11:30 p.m., Resident approached nurses' station and informed nurse my roommate was cursing and yelling at me and then threw the remote and hit me in the stomach, so I threw it back and busted his face. Resident #3 and Resident #4 were separated. RN D assessed Resident #3 with no new injuries noted at the time of the assessment. RN D notified DON, ADON, and the administrator of the incident. RN D inquired about local police department notification and the corporate nurse informed him this incident was not reportable to the local police department. Corporate Nurse spoke with the Resident #3 over the phone. Resident #3 was moved to another room and 1:1 monitoring was initiated. Resident #3 was his own responsible party, and MD was notified of the resident altercation. Record review of Resident #3's nurse progress note authored by RN D indicated on 7/30/2025 at 5:00 p.m., Resident #3 was watching TV show featuring guns and made the comment at 4:45 p.m. that I need a gun, so I can shoot up some people in this place. RN D notified DON at 4:52 p.m. of the incident. Resident #3 was placed on q 15-minute behavioral monitoring. Psych services was notified of incident. 2. Record review of Resident #4's face sheet dated 08/07/2025 indicated he was a [AGE] year-old male, initially admitted on [DATE] and readmitted on [DATE], and his diagnoses included metabolic encephalopathy (brain dysfunction caused by underlying metabolic disturbances, leading to symptoms like confusion, memory loss, and altered consciousness), vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), delusional disorders (mental health condition in which a person can't tell what's real from what's imagined), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #4's quarterly MDS assessment dated [DATE] indicated he usually made himself-understood and usually understands others. His BIMS was a 99 indicating that he was unable to successfully complete the interview to obtain a BIMS score. No behaviors of verbal or physical abuse were noted. Record review of Resident #4's care plan dated 07/26/2025 indicated verbal aggression of cursing at roommate and interventions included analyze key times, places, circumstances, triggers and what de-escalates behavior and document, assess and anticipate resident's needs; administer medications as ordered and give the resident as many choices as possible about care and activities. Record review of Resident #4's nurse's progress note authored by RN D indicated on 7/26/2025 at 11:28 p.m., Resident #3 (Resident #4's roommate) approached nurses' station and stated, Resident #4 (his roommate) threw the remote at me, so I threw it back and it busted his face. Resident #3 and Resident #4 were separated. RN D assessed Resident #4 and found a 2 cm laceration across his nose with a TV remote on floor next to Resident #4's bed. Resident #4 stated he was trying to fuck with me or something, I don't want him back in here. I'll beat his ass if he comes back in here. Resident #4 is bedbound/wheelchair bound with limited mobility. RN D notified MD/NP, DON, ADON, and the administrator of the incident. RN D inquired about local police department notification and the corporate nurse informed him this incident was not reportable to the local police department. NP provided orders for neurological checks, monitoring and wound care to laceration. RP notified of the incident. Wound care provided to nose laceration. Resident #3 (roommate) moved to a different room. Record review of the facility's provider investigation report (PIR) dated 08/01/2025 indicated the resident-to-resident incident (Resident #4 threw the TV remote at Resident #3 and Resident #3 threw the TV remote back at Resident #4 hitting him in the nose causing an injury) occurred on 07/26/2025 at 7:45 p.m. and was reported to the state agency on 07/27/2025 at 2:02 p.m. greater than two hours after the allegation was made. Record review of TULIP (state online abuse reporting portal) did not indicate any reports from facility regarding resident allegation of harm to self or others related to Resident #3's statement on 07/30/2025. During an interview on 08/06/2025 at 10:15 a.m., Resident #3 said he recalled the incident with him and his original roommate. He said Resident #4 had his TV up loud in a Spanish language and he told him to turn it down and off Spanish since he could not understand Spanish and he started cussing at him and threw the TV remote at him, so he threw it back at him hitting him on the nose causing an injury. He said he went to the nurses' station and told them what happen and said he just reacted and did not mean to harm Resident #4. Resident #3 denied the incident regarding wanting a gun to shoot up in this place, and he denied making any suicidal or homicidal ideations. He said, but one of the reasons I am here is because I can't remember. He said he was pleased with his new room and TV. During an interview on 08/06/2025 at 10:35 a.m., Resident #4 did not recall the incident between him and Resident #3 and denied any abuse from staff or other residents and said he felt safe at the facility. During an interview on 08/06/2025 at 12:15 p.m., CNA H said she was in-serviced on types of abuse and to keep residents safe and report abuse allegations to the administrator immediately. During an interview on 08/06/2025 at 12:30 p.m., CNA J said she was in-serviced on types of abuse and to keep residents safe and report abuse allegations to her nurse, DON, and the administrator/AC. She said report any concerns related to resident safety to the administrator immediately. During an interview on 08/06/2025 at 1:45 p.m., LVN F & LVN G said they were in-serviced on abuse and neglect. They said if abuse or neglect alleged to make sure resident is safe and then notify the administrator/AC immediately. They said would complete assessment, report to RP, NP/MD. During an interview on 08/06/2025 at 4:45 p.m., RN D said on 07/26/2025 around 8:00 p.m. Resident #3 came to nurses' station and reported his roommate (Resident #4) had thrown a TV remote at him, so he threw it back at him and hit him in the face with it. He said he told another staff member to monitor Resident #3 while he went to assess Resident #4 in their room. He said Resident #4 did have a laceration across his nose that was bleeding, and he was upset regarding the incident and did not want Resident #3 back in the room. He said he notified the MD/NP, DON, ADON, and the administrator of the incident. He said he provided ordered wound care to Resident #4, assigned both residents to be monitored (Resident #3 was placed on 1:1 monitoring, and Resident #4 had neurological checks with q 15-minute monitoring) and moved Resident #3 to another room. He said he questioned the DON and Corporate nurse about reporting the incident to the local police but was directed by the corporate nurse this incident was not to be reported. He said the administrator was on vacation, so the DON and corporate nurse was back up for her as the abuse coordinator. He said he was aware any resident-to-resident incidents had to be reported immediately to the abuse coordinator or designee, and he did report the incident immediately to the DON. RN D said he was the nurse on shift on 07/30/2025 when Resident #3 made a statement about needing a gun, so he could shoot up some people in this place which watching a TV show with guns (old western). He said he placed Resident #3 on behavioral monitoring because the resident was new to the facility, and he did not know if this was a behavior or post traumatic statement. He said Resident #3 did not have access to a gun nor was he acting aggressive during the statement just continued to watch the TV, but staff changed the channel to prevent in trigger of behaviors. He said he notified the DON of the statement and incident and was directed to continue to monitor the resident and notify MD/NP and psych services. RN D said that during the incidents with Resident #4 he followed facility protocol and reported the incidents to the DON who was the designated AC because the administrator was on vacation. RN D said he had been in-serviced on abuse, neglect, reporting allegations and timeframes to report. During an interview on 08/07/2025 at 1:30 p.m., CNA K said she was in-serviced on abuse and neglect including types of abuse and to report any abuse or neglect to the administrator immediately. During all interviews with staff on 08/06/2025 and 08/07/2025, including 2-RN's, 11- LVN's, 12 - CNA's, 2 - therapist, 2 - activity assistants, 1 - transportation aide, and 1 housekeeper, the staff were able to give examples of abuse and were able to identify interventions when dealing with behaviors. They said they had received training on identifying and reporting abuse immediately to the abuse coordinator, which was the administrator. During an interview on 08/07/2025 at 2:10 p.m., the DON said she was the acting abuse coordinator during the absence of the administrator, she said she was notified of the allegations with Resident #3. She said the first allegation between Resident #3 and Resident #4 was reported to her on 07/26/2025 but thought she had 24 hours to report after conferencing with her corporate nurse regarding the incident. She said she originally thought it needed to be reported to the state within two hours and should have reported it. She said she now realizes this was an allegation of resident-to-resident abuse and is required to be reported to the state agency within two hours. She said she had been re-trained by the administrator and all staff in serviced regarding abuse and neglect and reporting timeframes. She said the incident with Resident #3 making a statement regarding a gun on 07/30/2025 was not originally reported as stated in the nurses note, she said the reporting staff reported to her Resident #3 was watching a western and said he wanted a gun like the cowboys, and also seemed restless, so she instructed the nurse to contact Psych services for restlessness and to monitor Resident #3 every 15 minutes and if other behaviors noted to let her know. The DON said she assessed Resident #3 after the reported incident and he was in no distress and when asked about wanting a gun, he stated all cowboys have guns and I just wanted one. She said Resident # 3 denied having any intentions of harming others or himself. She said upon reviewing Resident #3's medical records after the reported incident she noticed RN D had not documented regarding the behavior, so he was counselled, and a late entry was documented. She said the late entry documented on 07/31/2025 in Resident #3's medical record was not the same verbiage that was originally reported on 07/30/2025 during the onset of the incident. She said when reviewed the late entry on 08/01/2025 she and the facility psych services reassessed Resident #3, and he denied suicidal or homicidal ideations and could not recall the incident regarding wanting to be a cowboy with a gun. She said if she would have been notified of a suicidal or homicidal ideation originally, she would have reported the allegation to the state agency within 2 hours. She said Resident #3 was a new resident to the facility and she did not know if his allegation was a behavior, experiencing sun downers, or the TV show triggered a post traumatic incident. She said she expected staff to report all allegations of abuse accurately to the abuse coordinator or designee and all allegations of abuse should be reported to the state agency within 2 hours of the allegations. During an interview on 08/07/2025 at 2:20 p.m., the Administrator said she was out on vacation during the last 2 weeks of July 2025, and the DON and corporate nurse were the designated abuse coordinators. She said reviewing back over the two incidents with Resident #3 she would have categorized the incidents as abuse and reported the allegations to the state agency within 2 hours. She said she had re-trained the DON regarding reporting abuse allegations and to utilize the long-term care regulatory provider letter issued in August of 2024 for guidance. She said her expectations was for all allegations of abuse to be reported to her/abuse coordinator immediately. She said allegations of abuse should be report within 2 hours to the State Agency. Record review of facility policy titled Abuse, Neglect and Exploitation dated 07/2022 indicated: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. VII. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 of 1 resident (Resident #2) reviewed for enteral feeding.<BR/>The facility failed to ensure LVN Q mixed each crushed medications with water and administered one medication at a time when giving medications to Resident #2 through his G-tube (a tube inserted through the wall of the abdomen directly into the stomach which allows the delivery of nutrition, fluids, and medications directly into the stomach). <BR/>The facility failed to ensure LVN Q administered Resident #2's G-tube medications by gravity, and instead she pushed the medications using the plunger of the syringe. <BR/>These failures could place residents receiving enteral nutrition and medications at increased risk of not receiving proper nutrition, infection, and aspiration. <BR/>Findings include:<BR/>Record review of a face sheet dated 06/18/25 indicated Resident #2 was a [AGE] year-old male and admitted to the facility 08/26/21. His diagnoses included cerebral infarction (a type of stroke that occurs when blood flow to the brain is blocked causing brain tissue to die), dysphagia (difficulty or discomfort swallowing) and gastrostomy (G-tube). <BR/>Record review of a care plan last revised 02/22/25 indicated Resident #2 was NPO (nothing by mouth) and was to receive all feedings, water, and medications via his G-tube. Interventions included to give medications as ordered. <BR/>Record review of the most recent quarterly MDS dated [DATE] indicated Resident #2 had unclear speech and was sometimes understood and usually understood most conversation. He had a staff assessment for mental status indicating moderate cognitive impairment, required substantial/maximal assistance with most ADLs, and required a feeding tube for all nutrition and fluid intake.<BR/>Record review of physician orders dated June 2025 indicated Resident #2 was NPO (nothing by mouth) and was to receive all feedings, water, and medications via G-tube. Orders indicated flush tubing with 30cc water before and after medication pass and 5cc water after each medication. <BR/>During an observation of medication administration and interview on 06/17/25 at 8:35 a.m., LVN Q crushed six medication tablets together and poured them in a measured drinking cup. She then added one scoop of laxative powder to the crushed tablet mixture. She then added 35ml of liquid medications to the medication powder in the measured drinking cup. She mixed the contents of the cup with water to the fill line of 200ml. She washed her hands and gowned and gloved. She checked placement of the G-tube by aspirating stomach contents and flushed the tubing with 30ml water. She then added the medication mixture to the open syringe connected to the G-tube and added more water to keep the mixture flowing. The mixture stopped flowing and she placed the plunger into the open end of the syringe, pushed it down approximately 1 inch and rocked the plunder side to side. The fluid began flowing again and stopped again. She repeated inserting the plunger into the open syringe approximately 1 inch and moved the plunger from side to side. The fluid began flowing again. She removed the syringe and the fluid flowed by gravity and stopped again. LVN Q again inserted the plunger into the syringe and moved it side to side. The rest of the medication flowed down the G-tube. She flushed the tubing with water and removed the syringe from the tubing and capped the tubing. <BR/>During an interview on 06/17/25 at 9:00 a.m., LVN Q said Resident #2 did not have an order to cocktail his medications together. She said she normally gave meds one at a time, but she was being watched and was nervous, so she gave all the meds mixed together to get them given faster. She said the facility policy said G-tube meds should be given one at a time and the facility had checked her off on giving G-tube meds and she did them one at a time. She said she should have given the meds one at a time. She said Resident #2's G-tube usually flowed freely, and she felt giving all the meds at once had caused the flow to stop several times. She said she knew she was not supposed to plunge medications through the G-tube using the plunger, but she didn't think it would hurt the resident if she just inserted the plunger and rocked the plunger to get the liquid flowing. She said she did not feel that rocking the plunger created pressure in the G-tube, it just got the fluid flowing. She said possible negative outcome for cocktailing all the medications together could be a clogged G-tube. She said she did not see a possible negative outcome for rocking the plunger in the syringe of the G-tube. <BR/>During an interview on 06/18/25 at 10:20 a.m., the DON said she expected all nurses to follow the facility policy when administering G-tube medications. She said the policy indicated to administer one medication at a time diluted by water and to never use the piston (plunger) of the syringe when flushing the G-tube or administering medications. She said LVN Q was observed during her orientation and yearly giving G-tube medications and during the observations she administered one medication at a time diluted in water and flushed the G-tube with water using gravity flow. She said giving all the medications at once could cause the G-tube to clog. She said using the plunger to unclog the G-tube could cause injury to the Resident. <BR/>Record review of a skills observation of administering medications/feedings through an enteral feeding tube dated 05/01/25 indicated LVN Q was competent of administer medications though a G-tube. <BR/>Record review of the facility policy titled Administering Medications through an Enteral Tube revised March 2015 indicated .The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. Do not mix medications together prior to administering through the enteral tube. Administer each medication separately unless resident has a physician's or order to mix (cocktail) medication.This procedure is contraindicated if the tube is obstructed or improperly positioned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 2 errors out of 25 opportunities which resulted in an 8 percent error rate involving Residents' #58 and #92.<BR/>LVN O administered Resident #58's midodrine HCL 5 mg (a medication used to treat low blood pressure) when the blood pressure was outside the prescribed parameters.<BR/>LVN P administered Resident #92's clopidogrel 75 mg (a medication used to thin blood and prevent clotting) over 3 hours past the administration time frame listed on the medication administration record, according to the facility's policy that medications are scheduled according to the routine schedule of 7am. <BR/>This failure could place residents at risk of not receiving the therapeutic benefits of their medications as ordered.<BR/>Findings included:<BR/>ERROR #1 <BR/>Physician orders dated April 2024 indicated Resident #58, admitted [DATE] was [AGE] years old with a diagnosis of high blood pressure. Physician orders indicated Resident #58 was to receive midodrine HCl tablet 5 mg. Give 1 tablet by mouth three times a day for hypotension (low blood pressure). Hold if SBP (systolic blood pressure - first number in a blood pressure reading) is greater than 100.<BR/>During an observation of the medication pass on 04/30/24 at 7:48 a.m., LVN O administered Resident #58's midodrine HCL 5 mg. Resident #58's blood pressure was 127/47.<BR/>During an interview and record review on 04/30/24 at 1:54 p.m., LVN O said she should have held Resident #58's midodrine due to prescribed parameters. She said she had misread the parameter and thought it was diastolic greater than 100 held instead of systolic. She said she should have held Resident #58's morning dose of midodrine medication. She said she was educated in medication administration and was aware of following prescribed parameters. She said she was responsible for giving the medication incorrectly. She said the risk for Resident #58 was hypertension.<BR/>During an interview on 04/30/24 at 2:31 p.m., the DON said Resident #58's midodrine should have been held when blood pressure was outside the prescribed parameters. <BR/>During an interview on 4/30/24 at 3:40 p.m., the administrator said the charge nurse was responsible for following physician orders administrating medication to the residents. She said her expectation was for physician orders to be followed and all medication to be given within parameters. She said the risk was that blood pressure could be lowered if medication was given out of parameters.<BR/>ERROR #2 <BR/>Physician orders dated April 2024 indicated Resident #92, admitted [DATE], was [AGE] years old with a diagnosis of coronary artery disease. Physician orders included clopidogrel bisulfate 75 mg daily as an anticoagulant. (Used to thin blood and prevent clotting). <BR/>During an observation of the medication pass on 04/30/24 at 10:55 a.m., LVN P administered clopidogrel bisulfate 75 mg tablet to Resident #92 over 3 hours past the designated administration time of 7:00 a.m.<BR/>During an interview on 04/30/24 at 12:25 p.m., LVN P said Resident #92 was administered clopidogrel bisulfate 75 mg tablet at 10:55 a.m. instead of the designated administration time of 7:00 a.m. She said we have 1 hour before and 1 hour after to give meds. She said she was just running late. She gave no reason.<BR/>During an interview on 04/30/24 at 1:00 p.m., the DON said her expectation was for medications to be given as ordered and in a timely manner. If medications were not given as ordered the nurses should notify the physician and herself. She said we have an hour before and after the medication is due to administer medications. She said none of the nurses had reported to her of medications being late.<BR/>A policy titled Administering Medications dated April 2019 indicated the following. 4. Medications are administered in accordance with prescriber orders.<BR/>A policy titled Medication Administration Schedule dated November 2020 indicated the following. Medications are administered according to established schedules. 1. Medications are administered according to the following routine schedule.daily.7 a.m. 3.Scheduled medications are administered within one hour of their prescribed time, unless otherwise specified.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles and provide separately locked, permanently affixed compartments for storage of controlled drugs for 1 of 21 residents (Resident #64) and 1 of 3 medication rooms reviewed for storage of medications and biologicals.<BR/>1. The facility failed to ensure the lockbox for controlled medications was permanently affixed to the refrigerator in the Hall 300 medication room.<BR/>2. The facility failed to ensure Resident #64's medication was secured inside the locked medication cart in the women's unit on Hall 300. <BR/>These failures could place residents at risk of not receiving prescribed drugs or contaminated medication.<BR/>Findings included:<BR/>1. During an observation and interview on 06/18/25 at 1:17 p.m. of the Hall 300 medication room the lockbox for controlled medications was locked but not permanently affixed to the refrigerator. LVN N said she had never seen the lockbox secured to the refrigerator. <BR/>During an observation and interview on 06/18/25 at 1:27 p.m., the DON viewed the controlled medication lockbox for hall 300 in the refrigerator and said it had been secured to the refrigerator with bolts and she was unsure when the bolts were removed or how long it had not been affixed. She said it was required that the lockbox to be permanently affixed to the refrigerator to prevent drug diversion. She said she would immediately get maintenance to affix the lockbox to the refrigerator. <BR/>During an interview on 06/18/25 at 2:30 p.m., the Administrator said she expected controlled medication lockboxes to be permanently affixed to medication room refrigerators as required by federal and state regulations. She said the possible negative outcome for not having the lockbox affixed inside the refrigerator could be drug diversion. <BR/>2. Record review of a face sheet dated 06/16/25 indicated Resident #64 was an [AGE] year-old-female readmitted on [DATE] with a diagnosis of hypertension (high blood pressure).<BR/>Record review of physician orders dated 06/16/25 indicated Resident #64 was prescribed enalapril 20 mg two times a day for hypertension with a start date of 05/20/21.<BR/> Record review of the quarterly MDS assessment dated [DATE] indicated Resident #64 had severely impaired cognition with a diagnosis of hypertension. <BR/>Record review of a care plan with a target date of 07/24/25 indicated Resident #64 had a history of hypertension and received enalapril.<BR/>During an observation and interview on 06/16/25 at 1:15 p.m. the women's side of the locked unit nurse's medication cart was parked beside the dining room unattended with a medication storage card of Enalapril (medication to lower blood pressure) 20 mg BID with 1 broken tab in the card not punched out lying on top of the medication cart. No staff was observed in sight of the medication cart. LVN R was observed retrieving resident's trays from the dining room. LVN R said she responsible for the nurse's medication cart. She said she walked away from the medication cart in doorway of the dining area to remove resident trays. LVN R said she should not have left the medication card on top of her nurse's medication cart unsecured. She said she pulled Resident # 64's medication card to get it replaced and should not have left it on top of her med cart. She said she was educated and knew not to leave medication unsecured. LVN R said the resident risk of a medication left unsecured on top of a medication cart was a resident could take it and possibly have an allergy to the medication or her blood pressure could drop if a resident took it that it did not belong to.<BR/>During an interview on 06/18/25 at 10:30 a.m., the DON said LVN R should not have left Resident #64's medication card unsecured on the nurse medication cart. She said all nurses were educated on keeping all medication secured. The DON said the resident risk of a medication unsecured on top of nurse's medication cart was a resident could take it and potentially have an adverse reaction. <BR/>During an interview on 06/18/25 at 10:42 a.m., the Administrator said the LVN's giving medication were responsible for ensuring all medication was secured and all residents were safe. She said the nurses were all educated on securing medication. She said the resident risk of a medication left unsecured was a resident could take it and potentially have side effects. The Administrator said her expectation was all medications locked and secured with no available access by any other staff or residents.<BR/>Record review of a facility policy titled Medication Labeling and Storage dated revised 02/23 indicated, .The facility stores all medication and biological in locked compartments under proper temperature, humidity and light control. Only authorized personnel have access to keys.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents reviewed for infection control. (Resident #49)<BR/>The facility failed to ensure CNA S performed proper hand hygiene while assisting to feed Resident #49.<BR/>This failure could place residents at risk for cross contamination and the spread of infection.<BR/>Findings include:<BR/>Record review of a face sheet dated 06/16/25 indicated Resident #49 was a [AGE] year-old-female readmitted on [DATE] with a diagnosis of dementia (a group of thinking and social symptoms that interfere with daily function).<BR/>Record review of the quarterly MDS assessment dated [DATE] indicated Resident #49 was severely impaired of cognition with a diagnosis of dementia and needed maximum assistance with eating. <BR/>Record review of a care plan with a target date of 07/07/25 indicated Resident #49 had required a regular diet and had a history of refusing assistance.<BR/>During an observation and interview on 06/16/25 at 10:10 a.m., Resident #49 was sitting in her wheelchair, she said the food was good here and she got plenty to eat.<BR/>During an observation and interview on 06/16/25 at 12:30 p.m., CNA S said she was responsible for providing care for Resident #49 today. She was assisting feeding Resident #49 by scooping food with Resident# 49's spoon and feeding Resident #49. After about 3 minutes she got up, walked to another resident, performed hand hygiene with ABH gel and sat down and assisted feeding the resident by scooping food with her spoon and feeding the resident. After a few minutes CNA S got up, walked to Resident #49 without performing hand hygiene, and assisted feeding her. After a few minutes CNA S got up, walked to another resident, performed hand hygiene with ABH gel and started assisting feeding her. After a few minutes CNA S got up, did not perform hand hygiene, walked over to Resident #49 and started assisting feeding her by scooping food with her spoon without hand hygiene a second time. After surveyor intervention CNA S, when asked if she forgot anything or missed anything, she said she did not perform hand hygiene between residents. She said she was educated and knew to perform hand hygiene between each resident. CNA S said her most recent reeducation on hand hygiene was last month. She said she was checked off on feeding residents with the DON on hire. CNA S said the potential resident risk was possible cross contamination between residents.<BR/>During an interview on 06/18/25 at 10:30 a.m., the DON said CNA S should have performed hand hygiene between each resident. She said the ADON/ IP did audits randomly to monitor staff performing resident care and ensured staff were performing hand hygiene with care as required. She said the CNAs were checked off on hand hygiene on hire, yearly and as needed. The DON said all staff have been educated to perform hand hygiene between residents. She said the resident risk was a potential to break infection control. The DON said her expectation was staff to perform hand hygiene per policy before and after an interaction with a resident.<BR/>During an interview on 06/18/25 at 10:36 a.m., ADON/ IP said she was the infection preventionist and ADON. She said CNA S should have cleaned her hands between residents during resident care. The ADON/ IP said she and the DON trained the staff on infection control and hand hygiene and checked off all staff on hand hygiene. She said the staff was educated on hand hygiene between resident care. The ADON/ IP said the resident risk of improper hand hygiene while feeding a resident was the potential sharing of germs or pass an infection from one resident to another.<BR/>During an interview on 06/18/25 at 10:42 a.m., the Administrator said CNA S should not have fed a resident without performing hand hygiene per policy. She said CNA S was responsible for ensuring proper hand hygiene with resident care. The Administrator said all staff have received hand hygiene education. She said the resident risk of improper hand hygiene during resident care was the potential to pass bacteria or spread germs between residents. The Administrator said her expectation was all staff follow the policy of the facility and complete hand hygiene as required and instructed. <BR/>Record review of a facility policy titled, Handwashing/Hand Hygiene dated 2001, indicated, . 1. Hand hygiene is indicated: a. immediately before touching a resident; b. before performing an aseptic task . c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching a resident's environment; .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse and neglect for 2 of 3 residents (Resident # 47, Resident #87, and Resident #106) reviewed for abuse. <BR/>The facility failed to ensure Resident #47 was free from sexual abuse when Resident #106 touched her face, hair, and breast area inappropriately on 05/28/2025.<BR/>The facility failed to ensure Resident #87 was free from physical abuse when Resident #87 and Resident #106 had a physical altercation on 06/05/2025.<BR/>The noncompliance was identified as PNC. The IJ began on 05/28/2025 and ended on 06/05/2025. The facility had corrected the noncompliance before the survey began. <BR/>These failures could place residents at risk for emotional distress, fear, decreased quality of care, and further abuse. <BR/>Findings included:<BR/>Resident #47<BR/>Record review of Resident #47's face sheet, dated 06/18/2025, indicated a [AGE] year-old female who was originally admitted to the facility on [DATE] with more recent admission date of 01/29/2025. Resident #47 had diagnoses which included PTSD (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). <BR/>Record review of Resident #47's quarterly MDS assessment, dated 04/04/2025, indicated she made herself understood and usually understood others. She had severe cognitive impairment, identified with a BIMS score of 6. She required supervision or touching assistance with most activities of daily living. <BR/>Record review of Resident #47's care plan dated 02/23/2025 and revised on 05/30/2025 indicated Resident #47 had potential for episodes of PTSD related to previous rape (as triggered by unwanted, unexplained touch). She was not having any negative effects from history of PTSD. Interventions included encourage resident to verbalize feelings and provide verbal and physical reassurance. Ensure all staff was aware of Resident #47's PTSD potential triggers and attempt to alleviate to the extent possible. Also, Resident #47 was sexual assaulted by another male resident. Intervention included head-to-toe assessment performed by female nurse, psych consult, and resident removed from area to safe environment.<BR/>Record review of Resident #47's undated witness statement indicated the following: . I was eating breakfast in the cafeteria at about 8:30 a.m., a white male [Resident #106] came up and sat on my right side. He told me he did not have a girlfriend and was glad he met me. I told him I was going outside to smoke, with him following me I gave him a cigarette believing he would go away, but he continued to follow me. He started rubbing my breast through my clothing even though I told him to stop. An employee saw what happened and told the administrator.<BR/>Record review of Resident #47's progress notes dated 05/28/2025 at 09:00 a.m. authored by the DON indicated [Resident #47] had another male resident (Resident #106) rubbing her back during smoke break, then went to touch her breast area. He was immediately separated from her, and she was brought to the front Administrator's office for statement. She stated that she did not tell him it was okay to touch her breast area. Police department notified at this time. Head to toe assessment performed with no negative findings noted. Physician was notified and gave order to consult Psychiatric services. Nurse practitioner for Psych services was notified, Telehealth performed at this time, no new orders noted at this time. Resident #47 stated, I am ok, just don't want to think about it Psych NP will see her again on Friday.<BR/>Record review of Resident #47's progress note dated 05/30/2025 at 10:44 a.m. and authored by Psych NP F indicated Patient [Resident #47] seen for follow up related to incident this week. Patient [Resident #47] is pleasant. She stated she had a history of past rape, and multiple times. She stated she is okay since he touched her, just made her think of the past. New diagnosis of PTSD, and new order for Xanax (used to treat anxiety and panic disorders) 0.25 mg - one tablet daily at 11:00 a.m. for 14 days to manage effective coping.<BR/>Record review of Resident #47's progress note dated 06/02/2025 at 4:58 p.m. authored by the Social Worker indicated visited with resident [Resident #47] today. She states she is feeling better. She states she is sleeping well and not having any negative dreams. She voiced no issues at this time. <BR/>Resident #106<BR/>Record review of Resident #106's face sheet, dated 06/18/2025, indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident #106 had diagnoses which included metabolic encephalopathy (a brain disorder characterized by altered mental status due to various factors like electrolyte imbalances, organ dysfunction, or nutritional deficiencies) and personality disorder (a group of mental health conditions characterized by inflexible and unhealthy patterns of behavior and thinking that differ from cultural norms). <BR/>Record review of Resident #106's admission MDS assessment, dated 05/16/2025, indicated he makes himself understood and understood others. He had no cognitive impairment, identified with a BIMS score of 12. He required partial/moderate assist with toileting, personal hygiene, and bathing. <BR/>Record review of Resident #106's care plan dated 05/28/2025 indicated Resident #106 had an episodic behavior of grabbing, suicidal ideations, and aggression. Intervention was admission to behavioral hospital for evaluation and admission. Place on 1:1 care until admission.<BR/>Record review of Resident #106's progress notes dated 05/28/2025 at 09:00 a.m. (as a late entry) authored by DON indicated Resident was witnessed by staff, rubbing a female resident's back, then went and placed hand on top of breast area during smoke break. Resident was immediately separated and placed 1:1 with CNA. When asked about the incident, he said it was consensual. I explained she did not see it that way and we had to notify the police. Resident stated I am going to my cave because I cannot commit suicide in the gym. Physician notified and received order to send to behavioral hospital.<BR/>Record review of Resident #106's progress note dated 05/28/2025 and authored by Psych NP G indicated [AGE] year-old male presents for weekly visit. Patient has indwelling catheter in place. Another resident reported being inappropriate with her. Psych and police notified. Patient being sent to behavioral center.<BR/>Record review of the facility's PIR (Provider Investigation Report), dated 06/04/2025, incident category as abuse, resident inappropriately touched another resident's breast and signed by the Administrator on 06/04/2025. PIR indicated the incident occurred 05/28/2025 at 09:00 a.m. in the smoking area. <BR/>Record review of Resident #106's progress notes indicated readmission to facility from the behavioral center on 06/05/2025. Resident #106 was admitted to all-male secure unit for behaviors and monitoring. There were no changes to medicine regimen.<BR/>Record review of Resident #106's care plan updated 06/05/2025 indicated goal/interventions to include placing in an all-male environment on secure unit to monitor behaviors and signs of depression such as isolation and crying. Resident #106 had a physical altercation with another resident. Interventions included monitor and document all behaviors, refer to psychiatric services, and was placed on 1:1 care.<BR/>Record review of Resident #106's electronic clinical record indicated on 06/05/2025 he signed an Unauthorized Discharge/Release of Responsibility (AMA) form and discharged from facility. (AMA is against medical advice)<BR/>During an observation and interview on 06/18/2025 at 9:45 a.m., Resident #47 was sitting in her room in her wheelchair. She said Resident #106 had come up beside her and touched her shoulder and breast. She said she had felt angry and fearful at the same time, and she did not want him touching her. Resident #47 said staff had intervened quickly. She said the incident was reported to the police and she was told Resident #106 was in another part of facility behind double locks. She said all she knew was that he was not in the facility.<BR/>During an interview on 6/18/2025 at 10:30 a.m., the Administrator said Residents #47 and #106 had been talking in the dining area and Resident #106 followed Resident #47 to the smoking area. While outside, Resident #106 put his hand on Resident #47's breast. The Administrator said the incident was witnessed by ADON E. Residents were immediately separated, and Resident #106 was placed on 1:1 monitoring due to expressing suicidal ideation. When administrator interviewed Resident #106, he denied the allegation. She said the incident had been reported to police. She said the police had taken written statements from Resident #47 and ADON E.<BR/>During an interview on 06/18/2025 at 1:30 p.m., ADON E said she was a witness to this incident. She said the residents were outside in the courtyard for smoke break. She said the maintenance man was with the residents at that time. She says he motioned for her to come outside when she was passing by the window facing the smoking area. She said about the time she got out to Resident #47, she saw that Resident #106 had his hand on her chest area. She said he was sitting by her side, and both were in wheelchairs. She said that he was touching the upper chest region area of Resident #47. She said Resident #106 normally did not come out of his room, and that he had just started coming out of his room a little more. She said he looked happy. She said Resident #106 was usually quiet. When asked about Resident #47's cognitive status, she said she is alert and interviewable. She stated her cognition would vary and sometimes she was all over the place. She said when she saw Resident #47, she did not seem afraid and was not crying. She said she wheeled Resident #47 straight to the Administrator's office to report. <BR/>During an interview on 06/18/2025 at 2:05 p.m., Maintenance A said on 05/28/2025 at approximately 09:00 a.m., he had been supervising the residents who smoked. He said yesterday was the first time Resident #47 and Resident #106 had met. He said Resident #106 never comes out of his room. He said he observed Resident #106 getting close to Resident #47 which he thought was odd behavior. He said Resident #106 had touched the face and caressed hair of Resident #47. He said she looked uncomfortable and pulled away from Resident #106. Maintenance A said he saw ADON E passing near windows with outside view to the smoking area, and he motioned her [ADON E] to come outside. He said Resident #47 was a large busty woman and he did not see Resident #106 touch her breast nor put his hand inside her blouse at the time. He said ADON E acted quickly and took Resident #47 to the Administrator's office to report the incident. <BR/>During an interview on 06/18/2025 at 2:23 p.m., RA H said she had served breakfast trays on 05/28/2025. She said Resident #47 and Resident #106 were sitting at the same table and having a cordial conversation and were laughing. She said this was the first time she had seen Resident #106 out of his room. RA H said she saw no discomfort between the two residents at breakfast. RA H said at around 09:00 a.m., she was instructed to monitor Resident #106 on a 1:1 basis. She said he was crying during her monitoring. She said he made statement that he was going to jail and was praying over the situation. She said Resident #106 required assistance for some activities of daily living. She said he had a foley catheter (inserted into bladder to drain urine) and would try to empty the drainage bag himself. <BR/>During an interview on 06/18/2025 at 2:44 p.m., the SW said she visited with Resident #47 for several days following the incident on 05/28/2025. She said Resident #47 was doing well until incident which triggered uncomfortable memories. Resident #47 said she felt safe knowing Resident #106 was no longer residing at the facility. The SW said she was unaware of Resident #47 having a diagnosis of PTSD because she had never mentioned it to her. <BR/>During an interview and record review on 6/18/2025 at 4:00 p.m., surveyor reviewed an undated Handwritten Witness Statement with ADON E. She said when the police came to the facility, he had requested ADON E to complete. In this statement she wrote As I walked past smoking area, I noticed [Resident #106] rubbing on Resident #47's neck, face, and breast region. I asked Resident #47 was this behavior consensual. She verbalized no. I removed Resident #47 from the smoking area and brought her to administrator office. After review of the written statement, ADON E verified her statement by signature and date. <BR/>Resident #87<BR/>Record review of Resident #87's face sheet, dated 06/18/2025, indicated a [AGE] year-old male who was originally admitted to the facility on [DATE] with more recent admission date of 03/10/2025. Resident #87 had diagnoses which included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). <BR/>Record review of Resident #87's discharge-return anticipated MDS assessment, dated 06/09/2025, indicated a short-term memory problem severely impaired for cognitive skills for daily decision making. He required supervision or touching assistance with most activities of daily living. <BR/>Record review of Resident #87's care plan dated 06/05/2025 and indicated Resident #87 had a physical altercation with another resident. Interventions included to monitor and document all behaviors, placed on 1:1 care, seen by psych service NP, and new order received for behavioral center referral related to delusions. Resident #87 resided on the memory care unit related to unaware of his safety needs and wandering. Interventions included encourage social interaction, give simple specific instructions for accomplishing tasks, maintain consistent routines, orient to reality as needed, and prevent excessive stimulation.<BR/>Record review of Resident #87's progress notes dated 06/05/2025 at 03:30 a.m. authored by LVN M indicated approached room [ROOM NUMBER] and Resident (#87) was standing near door skin tear noted to left and right hand. When asked what happened, resident did not respond. Sites cleaned and dressed. Head to toe evaluation done. Resident nose appeared to be red. No blood noted. Family notified. EMS called to transport resident to emergency room for eval.<BR/>Record review of Resident #87's progress note dated 06/05/2025 at 04:40 a.m. authored by LVN M indicated raised area to forehead and small laceration to upper lip. When EMS arrived, resident refused to go to ER. This nurse asked resident what happened, he stated they had a man in my room that wouldn't leave. He then started a confused conversation regarding being chased in a car.<BR/>Record review of Resident #87's progress note dated 06/05/2025 at 1:10 p.m. authored by Psych NP F indicated assessed patient due to incident this morning, and upon arrival he was pacing in room with aide present. Pt is confused with a BIMS of 3 (severe cognitive impairment). Pt is able to follow directions but does have times of delusions and is delusional currently about a car and police chase. Patient has a history of traumatic brain injury from years ago and schizoaffective. Patient has disorganized thought process and speech. I plan to send patient out for monitoring of delusions. I do not think he is a harm to others. Nursing staff are closely monitoring for any changes. <BR/>Record review of Resident #87's clinical record indicated he was placed on 1:1 monitoring by staff from 06/05/2025 at 3:30 a.m. until transferred to behavioral center on 06/05/2025 at 1:30 p.m.<BR/>Record review of the facility's Provider Investigation Report, dated 06/05/25, incident categorized as abuse and incident signed by the Administrator on 06/12/25. PIR indicated the incident occurred 06/05/25 at 3:20 a.m. on the secure unit. PIR indicated Resident #87, and Resident #106 had an un-witnessed resident-to-resident incident, both on the secure unit. Description of the Allegation: [Resident #106] was noted in the hallway by LVN M and stated that someone had come into his room. DON asked if the other patient hit him, and he stated: no, he swung first so I have a right to defend myself. So, I hit him. [Resident #87] would not give a statement at this time. PIR indicated LVN M provided head to toe assessment to Resident #87 and Resident #106 on 06/05/25 indicating Resident #87 had raised area noted to forehead and small laceration to upper lip, reddened nose and Resident #106 no visible injuries. PIR indicated Provider Response: patients were immediately separated, both patients were placed on one-on-one, roommate of Resident #106 was immediately removed, Neuro-checks initiated on Resident #87, both Residents immediately assessed for injuries and treated, MD/ RP/ PD/ Psych were notified, In-services, Safe surveys and Staff interviews initiated. PIR indicated Investigation Summary: Upon receipt investigation was immediately initiated. Admin interviewed Resident #106 on the incident. Mr. (Resident #106) stated, I was lying in bed, and he came into my room mumbling to himself. I screamed at him to leave, and he sat down in my wheelchair. So, I got up and hit him so he would leave. Admin asked if Mr. (Resident #87) hit him, Mr. (Resident #106) stated no. Admin asked him if he would go to the psych hospital, he stated no, there is no reason for me to go, I just want to go home and you can't keep me here. Admin went to get DON, and Social Worker in regard to possible discharge. Administrator, DON and Social Worker went back to speak with (Resident #106). Resident at this time has changed his statement to Mr. (Resident #87) came in his room, stood over his bed and would not leave then sat down in his wheelchair. Then proceeded to change statement again that he came in yelling and drug me out of the bed, while I was screaming, so I had to defend myself and I hit him, and I just want to go home now. Re-educated at this time it is not appropriate to touch other residents and psych would come see him and further explain the benefit of a behavioral hospital. Resident stated F**k you. I am not going anywhere but home and I want to go today, you cannot hold me here. Social worker asked how he would have care at home, and he said his friend is a caregiver and they live together. Explained we would notify MD for discharge orders and set up home health, but would take a little time, and he stated I am not waiting, I am leaving today. Friend was notified. Resident #106 discharged AMA home with Friend. APS was contacted. Admin went to interview Mr. (Resident #87) about what happened last night. Mr. (Resident #87) stated that he was in a car wreck in the middle of the night. I asked him if he was hurting or if he felt safe, Mr. (Resident #87) said yea, I am ok, but my car isn't. It's broke now. Admin reported the statement to charge nurse. Mr. (Resident #87) was sent out later for delusions per MD/ Psych. Admin then interviewed (Resident #106) roommate in regard to incident. Admin asked if he saw or heard anything. Roommate stated, I didn't hear or see anything, he couldn't have been too loud. Roommate BIMS of 10. Safe surveys completed with no negative findings. Staff interviews completed with no negative findings. In-servicing completed.<BR/>Record review of Resident #87's 1:1 monitoring record indicated on 06/05/2025 at 3:30 a.m., he was placed on 1:1 monitoring until approximately 2:15 p.m. when he was transferred to the behavioral center for evaluation. <BR/>Record review of Resident #106's 1:1 monitoring record indicated on 06/05/2025 at 3:30 a.m., he was placed on 1:1 monitoring until approximately 1:30 p.m. Resident #106's progress notes indicated multi entries of Resident #106 continuing with 1:1 monitoring by staff in his room.<BR/>Record review of Resident #106's progress notes dated 06/05/2025 at approximately 10:50 a.m., Resident #106 had stated to staff that he understood he was leaving facility AMA and signed the form. Review of progress notes indicated Resident #106 left facility at approximately 1:40 p.m. with a friend. <BR/>PIR indicated Provider investigation findings: Unconfirmed. PIR indicated Provider action taken post-investigation: Safe surveys completed with no negative findings, staff interviews completed with no negative findings and In-servicing completed.<BR/>During an interview on 6/18/2025 at 10:00 a.m., LVN N and LVN O said the incident occurred on the night shift and were told during report at shift change the following morning. She said this was in Resident #87's previous room and speculate due to his dementia, he thought he was in his room. <BR/>During an interview at on 06/18/2025 at 10:30 a.m., the Administrator said Resident #106 had changed his story several times. He said Resident #87 had come in and sat down, then that he was standing over him, also that he felt threatened and was defending himself, etc. He became upset and said he wanted to leave and go back to a motel and get stoned. <BR/>During an interview on 06/19/25 at 8:39 a.m., LVN N said she worked the 6a to 2p shift on the memory care unit on 06/05/25. LVN N said Resident #87 had a history of delusions, self-propelled wheelchair, pacing and often wandered into other residents' (on the memory care) rooms because he thought they were his room, and he would start undressing himself to get in the bed. LVN N said staff would often re-direct Resident #87 out of other resident's rooms and to his own room. LVN N said on the morning of 06/05/25, Resident #87 did not know what happened and that he thought the police or Nazis were after him. LVN N said she notified the Resident's physician of the incident and was given orders to send him to a behavior hospital. LVN N said Resident #87 was not acting any different from his baseline, because he always had delusions and wandered.<BR/>During an interview on 06/19/25 at 6:13 p.m., the Administrator said she was the Abuse Coordinator and was the one responsible for the investigation of the 06/05/25 altercation between Resident #87 and #106. The Administrator said Resident #106 had changed his statement multiple times. She stated one story was a man came into his room, stood over his bed, and hit him. Then later Resident #106 claimed he had to protect himself because Resident #87 tried to drag him out of bed and so he hit him. The Administrator said Resident #106 was mad, and refused to be transferred to the behavioral center for treatment. When he went to hospital, there were no medication changes. He was mad the police did not talk to him after incident. She stated the roommate [Resident #87] was interviewed and unaware of the incident until the resident screamed. Negative sex offender. UTI/ labs were off before the incident. The Administrator said there was nothing she would have done differently. She stated Resident #106 had no history of aggression and no issues with abuse.<BR/>During a phone interview on 06/19/25 at 11:25 a.m., CNA QQ said she worked the 10p to 6a shift on the Memory Care unit female hall, and on 06/05/25 CNA RR, on the men's side of the hall, called her to come help. CNA QQ said that Resident #87 was in Resident #106's room and Resident #87 was standing over Resident #106's, who was in bed. CNA QQ said she removed Resident #87 from the room and hollered for a nurse. CNA QQ said Resident #87 was bleeding from his face, lip and hands. CNA QQ said she could tell because there was blood coming from both his hands and his face. CNA QQ said they could use some help or use more help if they could get one more CNA to help monitor the residents because a lot of them wander into rooms. CNA QQ said that there's only two CNA's and one nurse working on the night shift. She said there's many residents that wander into other residents' rooms. She stated they redirected them and take them back to their room, they offer snacks, they may even get extra blankets if they're cold. <BR/>During a phone interview on 06/19/25 at 1:43 p.m. LVN M said she was the nurse on duty 10p to 6a on 06/05/25 on the Memory Care unit. LVN M said she was leaving the nurses station and Resident #106 was coming towards the nurses' station from his room in a wheelchair with blood on his hands saying he had the right to defend himself. LVN M said Resident #106 told her Resident #87 came in his room swinging at him, he had the right to defend himself. LVN M said Resident #87 had a raised area on his head, skin tears on both arms, and had a small cut on the upper lip. LVN M said Memory Care unit staffing at night was one CNA for each hall and one nurse for the entire unit. LVN M said there is enough help to provide care with only one CNA, and when they must go to lunch, another staff from 200 hall would come to help. LVN M said Resident #87 had been in his room most of the night, and no one saw when he left his room and entered Resident #106's room. LVN M said after the altercation, Resident #106 and Resident #87 had been on one-to-one monitoring, but she could not remember which staff did the 1 to 1 monitoring. LVN M said at night, the LVN must do frequent rounds and frequent redirection of the residents who wander.<BR/>During a phone interview on 06/19/25 at 12:45 p.m. CNA RR said she was working the floor 10p to 6a on 06/05/25 on the Memory Care unit, men's hall. CNA RR said she left her men's hall to go assist CNA QQ (women's hall) with care and LVN M came and got them to assist Resident #87 who was standing in the hall bleeding but not bad back to his room. CNA RR said Resident #106 was sitting in a wheelchair in the hall outside the door. She stated Resident #87 had said someone was in his room; Resident #106. CNA RR said Resident #106 told her Resident #87 was standing over him and he needed to defend himself, so he hit Resident #87. CNA RR said they helped put Resident #87 back in the wheelchair and put him in his room. CNA RR said Resident #87 had been in bed most of the night, but must had gotten up, and usually when Resident #87 does wander into someone else's room, they redirect him back to his room or they'll sit with them. CNA RR said she thought Resident #87 got up to use the bathroom and lost his way back to the bed, went to his old room where Resident #106 was. CNA RR said Resident #106 had never had contact or an altercation that she knew of with any other resident. CNA RR said she did the 1 to 1 monitoring and CNA QQ sat with Resident #106.<BR/>The Administrator was notified a past non-compliance situation had been identified due to the above failures.<BR/>It was determined these failures placed residents in an IJ situation on 05/28/2025 through 06/05/2025.<BR/>The facility had implemented the following interventions:<BR/>-Resident #47 immediately removed from the smoking area away from Resident #106 <BR/>-Resident #47 skin assessment performed<BR/>-Resident #106 was monitored 1:1 on 05/28/25 from 09:00 a.m. until transferred to behavioral center at around 6:00 p.m.<BR/>-Physician, Responsible Party, Police Department and Psych Services notified.<BR/>-Resident #47 and Resident #106 were seen by psych services on 05/28/2025<BR/>-Resident #106 was sent to behavioral center for evaluation and admission on [DATE]<BR/>- safe surveys were initiated by SW<BR/>-staff interviews initiated <BR/>-On 05/28/2025, all staff were educated by DON on Resident Rights, Abuse, Neglect, Exploitation, and Abuse Reporting. <BR/>-On 06/05/2025, Resident #87 was placed on 1:1 monitoring until approximately 2:15 p.m. when he was transferred to the behavioral center for evaluation. <BR/>-On 06/05/25, Resident #106 was placed on 1:1 monitoring by staff in his room until he discharged .<BR/>-On 06/05/2025, Resident #106 left the facility AMA at approximately 1:40 p.m. with a friend. <BR/>Record review indicated on 06/05/2025, the DON held an in-service on the following with 46 employees in attendance:<BR/>-resident rights;<BR/>-abuse, neglect, and abuse reporting; and<BR/>-managing behaviors and de-escalation.<BR/>Attendees included 2 RNs, 6 LVNs, 1 MA, 21 CNAs, 4 rehabilitation staff, 4 dietary staff, 5 housekeepers, 1 AD, 1 SW, and 1 receptionist.<BR/>Interviews conducted on 06/16/2025 from 09:00 a.m. through 06/20/2025 at 4:15 p.m., with the following staff through various shifts (6a-6p, 6p-6a, 6a-2p, 2p-10p, and 10p-6a) i floor tech T, ADON/ICP, LVN U, LVN ADON E, CNA V, CNA J, LVN W, CNA X, CNA L, CNA Y, RNA H, AD Z, DON, housekeeper AA, housekeeper BB, CNA V, Housekeeper CC, Housekeeper DD, Housekeeper EE, LVN FF, CNA GG, Environmental supervisor, Admissions, LVN HH, Housekeeper AA, LVN O, LVN KK, CNA LL, CNA MM, LVN N, CNA NN, Housekeeping OO, CNA PP, LVN M, CNA QQ and CNA RR, CNA SS, CNA PP, CNA WW, CNA K, CNA AA, CNA BB, CNA CC, CNA LL , LVN MMM, LVN M, LVN TT, LVN, R, LVN VV, MDS LVN JJJ, MDS LVN FF, RN UU, ADON E, ADON/ IP, Environmental supervisor, HK BB, HK XX, DM, Maintenance Assistant ZZ, Laundry DD, dietary aide EEE, Staffing, ST NNN, ST KKK, ABOM, Receptionist GG, Medical Records HH, PTA, and SW. The staff said they had been trained on abuse/neglect, abuse reporting, resident rights on hire and at least annually. The staff said they were retrained following the incidents that occurred on 05/28/2025 and 06/05/2025. The were able to voice what to do first such as separate the residents and get help as needed. They said they would report to nurses then report to the Abuse preventionist. They were able to identify different types of abuse i.e. verbal, sexual and physical.<BR/>The noncompliance was identified as PNC. The IJ began on 05/28/2025 and ended on 06/05/2025. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 2 of 3 resident (Residents #87 & #106) reviewed for accidents hazards and supervision.<BR/>1. The facility failed to provide adequate supervision on the facility's memory care unit, to prevent Resident #87, who had severe cognitive impairment from wandering into Resident #106 room at approximately 4:00 a.m. on 06/05/25. <BR/>2. The facility did not implement interventions to include adequate supervision prior to the incident or following the incident for all residents at risk for injuries related to wandering behaviors.<BR/>An Immediate Jeopardy (IJ) was identified on 06/19/25 at 4:50 p.m. The IJ template was provided to the facility on [DATE] at 5:08 p.m While the IJ was removed on 06/20/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal.<BR/>This failure could place residents at risk of emotional distress, fear, severe injury, hospitalization, and decline in quality of life.<BR/>Findings included: <BR/>Resident #87<BR/>Record review of Resident #87's face sheet, dated 06/21/25, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #87 had diagnoses which included Alzheimer (loss of cognitive functioning), schizoaffective disorder bi-polar type(mental health condition combination impacting a person's thoughts, emotions and behavior), cognitive communication deficit(difficulty communicating, understanding, speaking reading, writing and social interaction), psychosis(mental health condition characterized by a disconnection from reality) and anxiety(intense, excessive and persistent worry and fear about everyday situations).<BR/>Record review of Resident #87's quarterly MDS assessment dated [DATE] indicated Resident #87 was understood and had the ability to understand others. He had a BIMS score of 3 of 15 indicating his cognition was severely impaired for daily decision making, and had disorganized thinking. Resident #87 had minimal difficulty hearing, impaired vision, and clear speech. Resident #87 used a wheelchair and exhibited behavior of wandering 1 to 3 days. <BR/>Record review of Resident #87's care plan, revised 03/12/2025, reflected the following: Focus: The resident is/has potential to be physically aggressive r/t Anger, . Interventions: COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated .Focus: Resident to resident altercation; physical altercation became agitated with a confused resident and hit them. Interventions: counsel resident on acceptable vs unacceptable behaviors, monitor for potential altercation between residents . Refer to psych care as needed.<BR/>Record review of Resident #87's Progress Notes reflected the following:<BR/>06/05/2025 03:30 AM- approached room [ROOM NUMBER] resident was standing near door skin tear noted to left and right hand when asked what happened resident didn't respond resident cooperated and exited this room, sites cleaned and dressed head to toe eval done resident nose appeared to be red no blood noted. Family member OOO was notified 1st contact no answer DON notified of situation, EMS was call to transport resident to ER for eval neuoro checks iniated. This entry was written by LVN M.<BR/>06/05/2025 04:40 AM- raised area noted to forehead and small laceration to upper lip, when ems arrived resident refused to go to er, this nurse asked resident what happened this time he stated they had a man in my room that wouldn't leave then he started a confused conversation re being chased in a car. one on one staff with resident at this time neuro checks in progress. This entry was written by LVN M.<BR/>06/05/2025 12:57 PM- Resident Remains 1:1, is pacing with CNA at side and having delusions saying he was in a car wreck last night, then the germans are attacking, NP notified and is on way to round on resident. This entry was written by LVN N.<BR/>06/05/2025 2:24 PM- res transferred to behavioral hospital by their facility van called and gave report to the nurse there This entry was written by LVN N.<BR/>Record review of Resident #87's Provider Notes reflected the following:<BR/>06/05/2025 1:10 PM- I assessed pt due to incident this am, and upon arrival he was pacing in room with aid present. I went into room and greeted me with kindness. pt is pleasant. pt denied any problems. pt denies any suicidal or homicidal thoughts, pt is confused with a BIMs of 3. pt is able to follow directions but does have times of delusions and is delusional currently about a car and police chase. Pt has a history of traumatic brain injury from years ago and schizoaffective. pt has disorganized thought process and speech. I plan to send resident out for monitoring of delusions. I do not think he is a harm to others, Nursing staff are closely monitoring pt for any changes. This entry was written by Psych NP F. <BR/>Record review of the facility Incidents/Accidents reports reviewed for to June 2025 revealed there was no incident report regarding Resident #87's injuries, wandering or altercation.<BR/>Resident #106<BR/>Record review of Resident #106's face sheet, dated 06/21/25, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #106 had diagnoses which included adjustment disorder with depressed mood(mental health condition characterized by emotional and behavioral symptoms) and personality disorder(mental health condition characterized by inflexible and unhealthy patterns of behavior and thinking that differ from cultural norms).<BR/>Record review of Resident #106's admission MDS assessment dated [DATE] indicated Resident #106 was understood and had the ability to understand others. He had a BIMS score of 12 of 15 indicating his cogntition was moderately impaired for daily decision making, and had disorganized thinking. Resident #106 had adequate hearing, vision, and clear speech. Resident #106 used a wheelchair and exhibited no behavior of wandering. <BR/>Record review of Resident #106's care plan, initiated 05/28/25, reflected the following: Focus: RESIDENT HAD AN EPISODIC BEHAVIOR OF GRABBING, SUICIADAL IDEALATIONS, AGGRESSION, Interventions: .NEW ORDER NOTED FOR EVALUATION AND ADMIT.<BR/>Record review of Resident #87's Progress Notes reflected the following:<BR/>06/05/2025 3:21 AM- this nurse was leaving nurses station to make round this resident was coming down hall stated that another resident was in his room and swung at him so he hit him he continued screaming [NAME] have the right to defend myself man or woman i will knock the f out of them, this nurse ensured he was safe and could calm down small ampount of bllod was noted on his right hand . don was notified of situation and gave orders for this nurse to call the police to come out. This entry was written by LVN M.<BR/>06/05/2025 5:05 AM- Spoke with resident in regard to refusing to go to Hospital and he stated there was no need to, he was never touched by other resident and did not need psych services. Asked him again what happened, he stated, He came in my room, so I felt the need to defend myself so I did and will do again Asked what (Res #87) said to him, and he said he didn't say anything just came in here in the middle of the night. Denies any pain at this time, will continue with 1:1 monitoring and Psych to see today. This entry was written by DON.<BR/>06/05/2025 9:34 AM- Went to interview/assess resident with Administrator and social worker. Resident in room, with CNA FOR 1:1 monitoring. Resident at this time has changed his statement to Resident #87 came in his room, stood over his bed and would not leave then sat down in his wheelchair. Then proceeded to change statement again that he came in yelling and drug me out of the bed, while I was screaming, so I had to defend myself and I hit him, and I just want to go home now. Re-educated at this time it is not appropriate to touch other residents and psych would come see him and further explain the benefit of a behavioral hospital. Resident stated F. you, I am not going anywhere but home and want to go today, you cannot hold me here. Social worker asked how he would have care at home, and he said his friend is a caregiver and they live together. Explained we would notify MD for discharge orders and set up home health, but would take a little time, and he stated I am not waiting, I am leaving today. This entry was written by DON.<BR/>06/05/2025 10:09 AM- res in room no aggression noted res on 1:1 monitoring. This entry was written by LVN N.<BR/>06/05/2025 1:16 PM- Pt seen at this time r/t incident this am. He would not speak to me about it, no visible distress noted. When I asked what happened he said I don't have to answer you because I am going home now and no longer under your care. pt denies any suicidal or homicidal thoughts, I attempted to re-question/re-assess and he told me to get out. I exited the room, aid remained in room, and pt was ok with aid in room. This entry was written by Psych NP F.<BR/>06/05/2025 3:46 PM- SW made report to statewide intake as resident left AMA today. This entry was written by Social Worker.<BR/>Record review of the facility Incidents/Accidents reports reviewed for to June 2025 revealed there was no incident report regarding Resident #106's altercation or leaving AMA.<BR/>Record review of the facility's Provider Investigation Report, dated 06/05/25, incident category as abuse and incident signed by the Administrator on 06/12/25. PIR indicated the incident occurred 06/05/25 at 3:20 a.m. on the secure unit. PIR indicated Resident #87 and Resident #106 had a un-witnessed resident-to-resident incident, both on the secure unit. Description of the Allegation: Resident #106 was noted in the hallway by [LVN M] and stated that someone had come into his room. DON asked if the other patient hit him, and he stated: no, he swung first so I have a right to defend myself. So I hit him. Resident #87 would not give a statement at this time. PIR indicated LVN M provided head to toe assessment to Resident #87 and Resident #106 on 06/05/25 indicating Resident #87 had raised area noted to forehead and small laceration to upper lip, reddened nose and Resident #106 no visible injuries. PIR indicated Provider Response: patients were immediately separated, both patients were placed on one-on-one, roommate of Resident #106 was immediately removed, Neuro-checks initiated on Resident #87, both Residents immediately assessed for injuries and treated, MD/ RP/ PD/ Psych were notified, In-services, Safe surveys and Staff interviews initiated. PIR indicated Investigation Summary:Upon receipt investigation was immediately initiated. Admininistrator interviewed Resident #106 on the incident. Mr. (Resident #106) stated, I was lying in bed and he came into my room mumbling to himself. I screamed at him to leave and he sat down in my wheelchair. So I got up and hit him so he would leave. Administrator asked if Mr. (Resident #87) hit him, Mr. (Resident #106) stated no. Admin asked him if he would go to the psych hospital, he stated no, there is no reason for me to go, I just want to go home and you can't keep me here. Administrator went to get DON, and Social Worker in regards to possible discharge. Administrator, DON and Social Worker went back to speak with (Resident #106). Resident at this time has changed his statement to Mr. (Resident #87) came in his room, stood over his bed and would not leave then sat down in his wheelchair. Then proceeded to change statement again that he (Resident #106) came in yelling and drug me out of the bed, while I was screaming, so I had to defend myself and I hit him, and I just want to go home now. Re-educated at this time it is not appropriate to touch other residents and psych would come see him and further explain the benefit of a behavioral hospital. Resident stated Fuck you. I am not going anywhere but home and I want to go today, you cannot hold me here.Social worker asked how he would have care at home, and he said his friend is a caregiver and they live together. Explained we would notify MD for discharge orders and set up home health, but would take a little time, and he stated I am not waiting, I am leaving today. Friend was notified. Resident #106 discharged AMA home with Friend. APS was contacted. Administrator went to interview Mr. (Resident #87) about what happened last night. Mr. (Resident #87) stated that he was in a car wreck in the middle of the night. I asked him if he was hurting or if he felt safe, Mr. (Resident #87) said yea, I am ok, but my car isn't. It's broke now. Admin reported the statement to charge nurse. Mr. (Resident #87) was sent out later for delusions per MD/ Psych. Admin then interviewed (Resident #106) roommate in regards to incident. Admin asked if he saw or heard anything. Roommate stated I didn't hear or see anything, he couldn't have been too loud. Roommate BIMS of 10. Safe surveys completed with no negative findings. Staff interviews completed with no negative findings. In-servicing completed, Provider investigation findings: Unconfirmed, action taken post-investigation: Safe surveys completed with no negative findings, staff interviews completed with no negative findings and In-servicing completed.<BR/>Record review of the facility's employee sign-in sheet for the Memory Care Unit dated 06/04/25 indicated LVN M, CNA QQ, and CNA RR worked the 10p to 6a shift when the altercation between Resident #87 and Resident #106 to place.<BR/>Record review of facility's census report dated 06/18/25 indicated the Memory Care unit had a census of 19 males and 16 females. The DON highlighted and identified 18 residents on the Memory Care unit who wander.<BR/>During an interview on 06/19/25 at 8:39 a.m., LVN N said she worked the 6a to 2p shift on the memory care unit on 06/05/25. LVN N said Resident #87 had a history of delusions, self-propelled wheelchair pacing and often wandered into other resident's (on the memory care) rooms because he thought they were his room and he would start undressing himself to get in the bed. LVN N said staff would often re-direct Resident #87 out of other resident's rooms and to his own room. LVN N said on the morning of 06/05/25 Resident #87 did not know what happened and that he thought the police or Nazis were after him. LVN N said she notified the Resident's physician of the incident and was given orders to send him to behavior hospital. LVN N said Resident #87 was not acting any different from his baseline, because he always had delusions and wandered. <BR/>During an interview on 06/19/25 at 6:13 p.m., the Administrator said she was the Abuse Coordinator and was the one responsible for investigation of the 06/05/25 altercation between Resident #87 and #106. The Administrator said Resident #106 had changed his statement multiple times, one story was a man came into his room stood over his bed and hit him, then later Resident #106 claimed he had to protect myself because Resident #87 tried to drag him out of bed and so he hit him. The Administrator said Resident #106 was mad, refused behavior center. When he went to hospital no medication changes. He was mad the police did not talk to him after incident. Roommate was interviewed and unaware of incident until resident screamed. Negative sex offender. UTI/ labs were off before the incident. Admin said there was nothing she would have done differently Resident #106 had no history of aggression and no issues with abuse. <BR/>During a phone interview on 06/19/25 at 11:25 a.m. CNA QQ said she worked the 10p to 6a shift on the Memory Care unit female hall and on 06/05/25 CNA RR on the men's side of the hall called her to come help, which left the women hall unattended. CNA QQ said that Resident #87 was in Resident #106's room and said Resident #87 was standing over Resident #106's who was in bed. CNA QQ said she removed Resident #87 from the room and hollered for a nurse. CNA QQ said Resident #87 was bleeding from his face, lip and hands. CNA QQ said she could tell because there was blood coming from both his hands and his face. CNA QQ said they could use some help or use more help if they could get one more CNA to help monitor the residents because a lot of them wander into rooms. CNA QQ said that there's only two CNA's and one nurse working on the night shift she said there's a large amount of residents that wander into other residents rooms they redirect them and take them back to their room, they offer snacks, they may even get extra blankets if they're cold. CNA QQ said on 06/05/25, 2 CNAs came from unit 100 to help until after the police and EMS had been there and then they went back to their hall and she went back to the women's side and she says no one sat with Resident #87 or Resident #106.<BR/>During a phone interview on 06/19/25 at 1:43 p.m. LVN M said she was the nurse on duty 10p to 6a on 06/05/25 on the Memory Care unit. LVN M said she was leaving the nurses station and Resident #106 was coming towards nurses station from his room in a wheelchair with blood on his hands saying he had the right to defend himself. LVN M said Resident #106 told her Resident #87 came in his room swinging at him, he had the right to defend himself. LVN M said Resident #87 had a raised area on his head, skin tears on both arms, and had a small cut on the upper lip. LVN M said Memory Care unit staffing at night was one CNA for each hall and one nurse for the entire unit. LVN M said there is enough help to provide care with only one CNA, and when they have to go to lunch another staff from 200 hall would come to help. LVN M said Resident #87 had been in his room most of the night, and no one saw when he left his room and entered Resident #106's room. LVN M said after the altercation Resident #106 and Resident #87 had been on one to one but she could not remember which staff did the 1 to 1 monitoring. LVN M said at night the LVN has to do frequent rounds and frequent redirection of the residents who wander.<BR/>During a phone interview on 06/19/25 at 12:45 p.m. CNA RR said she was working the floor 10p to 6a on 06/05/25 on the Memory Care unit, men's hall. CNA RR said she left her men's hall to go assist CNA QQ (women's hall) with care and LVN M came and got them to assist Resident #87 who was standing in the hall bleeding but not bad back to his room. CNA RR said Resident #106 was sitting in a wheelchair in the hall outside the door, and Resident #87 had said someone was in his room Resident #106. CNA RR said Resident #106 told her Resident #87 was standing over him and he needed to defend himself so he hit Resident #87. CNA RR said they helped put Resident #87 back in the wheelchair and put him in his room. CNA RR said Resident #87 had been in bed most of the night but must have gotten up, and usually when Resident #87 does wander into someone else's room they redirect him back to his room or they'll sit with them. CNA RR said she thinks Resident #87 got up to use the bathroom and lost his way back to the bed, went to his old room where Resident #106 was. CNA RR said Resident #106 had never had contact or an altercation that she knows of with any other resident. CNA RR said she did the 1 to 1 and CNA QQ sat with Resident #106 and they didn't call for extra staff. <BR/>Interview on 06/19/25 at 5:30 p.m., the DON said that one nurse and two CNAs was sufficient because they had 35 residents in the Memory Care unit. She stated that they try to have additional staff on the day shift, the transportation person, when she is not doing transportation, is back there or hospitality aides. She stated that on the evening shift the nurses from hall 200 or 100 will go back there to help but it wasn't assigned to any particular person. The charge nurses were responsible to ensure the Memory Care unit was covered and if they couldn't get any one to help out they let me know. It was always one nurse and two CNAs, one for female side and other for male side. The DON said she was notified that Resident #87 had wandered into Resident #106 room and there was an altercation where Resident #106 hot Resident #87. The DON said LVN M was rounding and saw Resident #106 come out of his room saying he had to protect himself from Resident #87.The DON said LVN called the CNAs for Help and separated the residents She said Resident #106 had only been on the Memory Care unit for 2 days when the incident occurred. She said as an intervention, they placed both Resident #87 and #106 on 1:1 supervision until Resident #87 was sent to the hospital and #106 left AMA that same day.<BR/>Record review of the facility's Abuse Neglect and Exploitation policy, revised dated April 2021, read in part, . 3. Ensure adequate staffing and oversight/support to prevent burnout stressful working situations and high turnover rates . <BR/>Record review of the facility's Behavioral Assessment Intervention and monitoring policy dated revised dated March 2019, read in part, .11. The Director of Nursing or Designee will evaluate whether the staffing needs have changed based on acuity of the residents and their plans of care additional staff and our staff training will be provided if determined that the needs of the residents cannot be met with the current level of staff or staff training .<BR/>An Immediate Jeopardy/Immediate Threat was identified on 06/19/25 at 4:50 p.m. The Administrator was notified of the Immediate Jeopardy on 06/19/25 at 5:08 p.m. The IJ template was provided to the facility on [DATE] at 5:18 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy.<BR/>The facility's Plan of Removal for the Immediate Jeopardy was accepted on 06/19/25 at 9:29 p.m. and reflected the following:<BR/>Plan to Remove Immediate Jeopardy<BR/>The facility failed to adequately supervise residents to implement interventions to protect residents from injuries from resident-to-resident abuse. The facility did not implement interventions to include adequate supervision prior to the incident or following the incident for all residents at risk for injuries related to wandering behaviors. <BR/>On 6/5/25, resident #87 was discharged to the behavioral hospital for evaluation. On 6/5/25, a full assessment and prompt medical attention was provided to resident #87 by the assigned LVN. On 6/5/25, resident #10 refused a full assessment by the nurse. Resident #87 and Resident #106 were immediately separated by the charge nurse and certified nursing assistants on 6/5/25. Resident #106 and resident #87 immediately had a staff member monitoring them one on one until resident #87 was discharged to the behavioral center for delusions/hallucinations, on 6/5/25. Resident #87 remains at the behavioral center at this time. <BR/>On 6/19/25 the Director of Nursing, Regional Nurse Consultant, and Nursing Facility Administrator began conducting all staff in-service's for Abuse and Neglect, de-escalating resident behaviors, and monitoring residents while they wander, including residents who pace and potentially would wander into another resident's space. All staff will be in-serviced prior to the beginning of their next shift. Any new hires and/or agency staff will be in-serviced prior to their first shift on the floor, by the Director of Nurses or designee. The Director of Nursing or designee will question 3 random staff members weekly X4 weeks to ensure comprehension of the new procedures. <BR/>On 6/19/25 an in-service was initiated by the Director of Nursing, Regional Nurse Consultant, and Nursing Facility Administrator to ensure staffing patterns are increased to ensure that there are two staff members present on each hall of the facility secured unit at all times. If there are two staff required to perform care on a resident, there will be another staff member called in to the secured unit to supervise while two are performing care. When one staff member steps out for any reason, another staff member will take their place in the secured unit, to ensure adequate supervision of wandering residents. Any new hires and/or agency staff will be in-serviced prior to their first shift on the floor, by the Director of Nurses or designee. The Director of Nursing or designee will question 3 random staff members weekly X4 weeks to ensure comprehension of the new procedures. <BR/>On 06/19/2025 Ad-Hoc QAPI Held with Medical Director, Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant to review the alleged deficiency, policy and procedure and the plan of removal of immediacy.<BR/>The Nursing Home Administrator will be responsible for ensuring the plan is completed on 06/19/2025.<BR/>The RDO/Designee will provide oversight of Nursing Home Administrator and Director of Nurses, to ensure that the items on the plan of removal are reviewed and completed.<BR/>Monitoring of the facility's Plan of Removal included the following:<BR/>Observation and interview on the secure unit on 06/20/25 at 2:15 p.m. indicated Resident #87 and #106 no longer resided in the facility.<BR/>Observed and interview 06/20/25 at 2:15 p.m. with the RDO/Designee indicated she was in the facility rounding and providing oversight to Nursing Home Administrator and Director of Nurses, ensuring that the items on the plan of removal are reviewed and completed. <BR/>Inservice sign-in sheet reviewed with 66 staff signatures indicating participation , and included staff to ensure staffing patterns are increased to ensure that there are two staff members present on each hall of the facility secured unit at all times. If there are two staff required to perform care on a resident, there will be another staff member called in to the secured unit to supervise while two are performing care. When one staff member steps out for any reason, another staff member will take their place in the secured unit, to ensure adequate supervision of wandering residents<BR/>Interviews conducted on 06/20/2025 from 2:15 p.m. through 4:00 p.m. and 9:45 p.m. through 11:30 p.m. representing staff from various shifts (6a.m.-2p.m., 2p.m.-10p.m.,& 10p.m. -6a.m.) included the following staff: CNA SS, CNA PP, CNA RR, CNA WW, CNA K, CNA QQ, CNA AAA, CNA BBB, CNA CCC, CNA LLL, LVN MMM, LVN N, LVN M, LVN TT, LVN, R, LVN VV, MDS LVN JJJ, MDS LVN FFF, RN UU, ADON E, ADON/ IP, Environmental supervisor, HK BB, HK XX, DM, Maintenance Assistant ZZ, Laundry DDD, dietary aide EEE, Staffing, ST NNN, ST KKK, ABOM, Receptionist GGG, Medical Records HHH, PTA, SW. All staff were able to identify the different types of abuse, who to report any incidents of abuse de-escalating resident behaviors, and monitoring residents while they wander, including residents who pace and potentially would wander into another resident's space, what to do if they witness resident to resident abuse, what signs to watch for in residents to prevent resident to resident abuse,. Examples were given. To remove from reach of others, increase supervision of wandering by monitoring while they are wandering, and/or engaging in activity. Staff indicated they were to be aware of resident behaviors, monitor for behaviors, and how to de-escalate behaviors. Staff knew they were to separate residents immediately and ensure residents were safe. Staffing patterns were increased to ensure that there are two staff members present on each hall of the facility secured unit at all times. If there are two staff required to perform care on a resident, there will be another staff member called in to the secured unit to supervise while two are performing care. When one staff member steps out for any reason, another staff member will take their place in the secured unit, to ensure adequate supervision of wandering residents. All staff were able to identify the responsibilities for supervision and monitoring residents. Nursing staff identified that effective immediately 2 CNA were to be assigned to female hall and 2 CNAs to male hall of the Memory Care during the 10p to 6a shift due to increased amount patients with wandering. Staff interviewed said they had to be relieved before going on break/meal. All staff aware of supervising and monitoring is a preventive or proactive intervention. <BR/>During an interview on 06/20/2025 at 10:05 p.m., the Administrator and DON said the corporate office approved to have 2 CNAs for each hall (male and female hall) assigned to the Memory Care unit 10:00 p.m. to 6:00 a.m., on the unit at night as a permanent change in scheduling. She said all staff had received the additional training as outlined on the POR except for a couple of staff that were out on leave and would receive the required training before returning to work. She stated next week she would start the questioning of 3 random staff members weekly X4 weeks to ensure comprehension of the new procedures and in-service information.<BR/>Record review of the POR binder included:<BR/>Record review of Ad-Hoc QAPI agenda sign in page dated 06/19/25 held with Medical Director, Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant to review the alleged deficiency, policy and procedure and the plan of removal of immediacy.<BR/>Training records of 82 staff with completion dates ranging from 06/19/25-06/20/25 to identify the different types of abuse, who to report any incidents of abuse de-escalating resident behaviors, and monitoring residents while they wander, including residents who pace and potentially would wander into another resident's space, what to do if they witness resident to resident abuse, what signs to watch for in residents to prevent resident to resident abuse.<BR/>Training records of 66 staff with completion dates ranging from 06/19/25-06/20/25 for staffing patterns being increased to ensure that there are two staff members present on each hall of the facility secured unit at all times. If there are two staff required to perform care on a resident, there will be another staff member called in to the secured unit to supervise while two are performing care. Responsibilities for supervision and monitoring residents. When one staff member steps out for any reason, another staff member will take their place in the secured unit, to ensure adequate supervision of wandering residents.<BR/>An Immediate Jeopardy (IJ) was identified on 06/19/25 at 4:50 p.m. The IJ template was provided to the facility on [DATE] at 5:18 p.m. While the IJ was removed on 06/20/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure preadmission screening for individuals identified with MI, DD, or ID were evaluated for services for 1 of 24 residents reviewed for resident assessments (Resident #415). <BR/>The facility did not have an accurate PASRR level 1 screening (PL1) for Resident #415 upon admission. <BR/>This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. <BR/>Findings included: <BR/>Record review of a face sheet dated 04/29/24 indicated Resident #415 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included psychosis (a mental disorder characterized by a disconnection from reality), dementia (a group of thinking and social symptoms that interfere with daily functioning), and anxiety disorder (persistent and excessive worry that interferes with daily activities) on 04/11/24.<BR/>Record review of a PASRR level 1 screening completed by the transferring facility dated 04/11/24 indicated Resident #415 was negative for mental illness, intellectual disability, and developmental disability and negative for dementia as the primary diagnosis. There was no PASRR Level II Screening or Form 1012 (Mental Illness/Dementia Resident Review) found in the clinical record from the resident's admission on [DATE] to 04/29/24. <BR/>Record review of physician orders dated April 2024 indicated Resident #415 was prescribed quetiapine fumarate 75 mg (antipsychotic medication) at bedtime for psychosis with a start date of 04/17/24 and buspirone hcl 5 mg (used to treat anxiety) three times a day with a start date of 04/11/24.<BR/>Record review of a care plan dated 04/17/24 indicated Resident #415 had a care plan indicating she received the anti-anxiety medication buspirone and psychotropic medication quetiapine for psychosis.<BR/>Record review of an admission MDS dated [DATE] indicated Resident #415 was PASSR positive for MI and had a BIMS score of 13 indicating intact cognition. The MDS indicated Resident #415 had diagnoses of psychotic disorder, dementia, and anxiety. <BR/>During an observation and interview on 04/29/24 at 08:53 a.m., Resident #415 was sitting up in a recliner, she said she was treated great and received needed care. <BR/>During an interview on 04/30/24 at 2:21 p.m., MDS Nurse A said she was now responsible for PASRR forms. She said the previous MDS nurse left and had been doing the PASRR forms up until 2 weeks ago. MDS Nurse A said she was educated on PASRR forms on 04/29/24. She said she did a new PL1 form on 4/30/24 for Resident #415 after surveyor intervention. MDS Nurse A said Resident #415's PL1 should have been corrected sooner. She said the risk of an incorrect PL1 was a resident could miss out on deserved services. <BR/>During an interview on 04/30/24 at 2:39 p.m., the DON said the previous MDS nurse was terminated within the last two weeks for not doing all required duties and incorrect documentation. She said the MDS nurse A was now responsible for all PASRR forms. The DON said Resident #415's PL1 form should have been corrected sooner. She said the risk of an incorrect PL1 form was a resident missing out on qualifying services. The DON said her expectation was for all PASRR forms to be completed timely and correctly.<BR/>During an interview on 04/30/24 at 3:41 p.m., the Administrator said the MDS nurse was responsible for PASRR forms. She said her expectation was for all PASRR forms to be completed correctly and timely. The Administrator said the risk of a PL1 completed incorrectly was a resident may miss out on deserved services.<BR/>During an interview on 05/01/24 at 2:30 p.m., the DON said they did not have a facility PASRR policy, they followed the RAI.<BR/>Record review of the October 2023 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual titled, A1500: Preadmission Screening and Resident Review (PASRR) Item Rationale Health-related Quality of Life indicated . o All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions o Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 24 resident reviewed for range of motion. (Resident #7)<BR/>The facility did not ensure Resident #7's splint was placed in her contracted right hand. <BR/>This failure could place the residents at risk of not receiving the care and services to maintain their highest level of well-being.<BR/>Findings included:<BR/>Record review of physician orders dated April 2024 and May 2024 indicated Resident #7, admitted [DATE], was [AGE] years old with diagnoses of right sided hemiplegia (paralysis) and cerebrovascular disease (stroke). The order did not indicate the resident had a splint. <BR/>Record review of the most recent quarterly MDS dated [DATE] indicated Resident #7 was a BIMs score of 8 (moderate cognitive impairment) and did not have onset of acute mental status changes with inattention, disorganized thinking or altered level of consciousness. The resident had a functional limitation in ROM to one side of the upper extremities. <BR/>A care plan dated 09/07/21 indicated Resident #7 had a stroke with long term effects of hemiplegia. One of the interventions indicated to assist the resident with mobility as needed. A care plan initiated 04/15/24 indicated the resident was on restorative services. One of the interventions indicated to apply right hand splint daily for 2 hours.<BR/>Record review of a Task sheet dated April 2024 did not indicate Resident #7 received the Splint Brace Assistance Program on Sunday 4/28/24, Monday 04/29/24 or Tuesday 04/30/24. The columns for those dates did not contain signatures to indicate the task was completed. <BR/>Record review of a Restorative Plan dated 04/11/24 indicated Resident #7 was to receive splint/brace assistance to the right hand. Apply right hand splint daily for 2 hours.<BR/>During observation and interview on 04/29/24 at 9:29 a.m., Resident #7 was lying in bed. The fingers to her right hand were contracted upward to the bottom of hand. The resident said she could not move her fingers. The resident pointed to the top of the small refrigerator sitting on the bedside table where a splint was lying on top of the refrigerator. The splint was not in reach of the resident. The resident said she wanted the splint in her hand. She shook her head yes, when asked if staff had placed the splint in her hand the day before. <BR/>During the following observations, the splint was lying on the refrigerator in the same place as previously seen and Resident #7 did not have the splint in her hand:<BR/>*04/29/24 at 2:12 p.m., <BR/>*04/30/24 at 10:20 a.m.,<BR/>*04/30/24 at 3:01 p.m.; and <BR/>*05/01/24 at 8:42 a.m. <BR/>During an interview on 04/30/24 at 10:20 a.m., Resident #7 said the staff had not put the splint in her hand on 04/29/24 or today 04/30/24. <BR/>During an interview on 05/01/24 at 8:42 a.m., Resident #7 said the staff had not put the splint in her hand on 4/30/24 or today 05/01/24 and she wanted the splint placed in her hand. She said she had not refused to have the splint placed in her right hand. <BR/>During observation and interview on 05/01/24 at 8:54 a.m., CNA B said Resident #7 did not have the splint on her right hand and he did not place it on her today 05/01/24 or yesterday 04/30/24. He said he was working the day shift today 6:00 a.m. to 2:00 p.m. and he did not usually work Hall 100. He said he worked on 04/30/24, but not on Hall 100. He went to the closet and retrieved a knee brace and said he tried to put the knee brace on her but it would not fit. When asked if he saw the hand splint lying on the refrigerator, he said no and retrieved it. He said the possible negative outcome of not placing the splint in the resident's hand would be the contracture could worsen and possibly the nails could cut the skin. He slightly pulled the resident's finger's away from the palm of her hand. The fingers moved approximately 1/4 inch and would not move any further. There were no open areas to the resident's hand. Resident #7 said she did not want her fingernails cut. The restorative aide told CNA B to leave the splint off until after the resident had her bath. CNA B then placed the splint back on top of the refrigerator. <BR/>During an interview on 05/01/24 at 9:04 a.m., the restorative aide said she was responsible for ensuring the residents with contractures had the splints placed in their hands and said she had been off for 2 days on Sunday 04/28/24 and Monday 04/29/24 and returned yesterday on 04/30/24. She said she did not put the splint on Resident #7 on 04/30/24 because she was busy on Unit 2 and 3 trying toget the monthly weights completed. She said she had not placed the splint on the resident's hand today 05/01/24. She said the transportation driver had been trained in ROM and was her back-up when she was not available. She said she did not tell the transportation driver she was off or needed help and she was not sure who let the transportation driver know when she had to perform restorative duties. She said the possible negative outcome of not placing the splint in Resident #7's contracted hand would be an increase in the resident's contractures. The restorative aide said the resident received the splint about a month ago. <BR/>During an interview on 05/01/24 at 9:16 a.m., the DON said the restorative aide was responsible for ensuring the splints were in place. She said the nurses would be the person who would be responsible if the restorative aide was not available because the CNAs had not been trained on restorative care. She said her expectations were for the splint to be placed in Resident #7's hand to prevent further contractures. She said the possible negative outcome would be an increase in the contractures. She said the restorative schedule was Tuesdays through Saturdays. She said Resident #7's splint would be on the restorative aide's task sheet, so the resident's splint placement would not be on the nurses' MAR and would not be the nurses' responsibility. <BR/>During observation and interview on 05/01/24 at 9:29 a.m., RN N grabbed the splint from off the top of the refrigerator and began placing it in Resident #7's contracted right hand. She said Resident #7's right hand was contracted and should have the splint. She said the orders to put the splint on the resident's right hand were not on the nurses' MAR. She said the order was on the restorative aide's task sheet. She said the splint should have been applied as ordered. She said she was unaware she was supposed to place the splint on the resident's hand. <BR/>During an interview on 05/01/24 02:09 p.m., Transportation Attendant R said she had not been trained in restorative care and was not responsible for ensuring residents with contractures had splints placed in their hands. <BR/>During an interview on 05/01/24 at 2:13 p.m., Transportation Attendant S said she was trained in restorative care, so if the restorative aide called and let her know she needed help in restorative, then she would help her, if she could. She said the restorative aide never called her to assist with restorative care on Monday 04/29/24 or Tuesday 04/30/24. She said she did not assist with restorative care when the restorative aide was off Monday 04/29/24 or Tuesday 04/30/24 and said she did not see Resident #7 Monday for restorative care on 04/30/24 through today 05/01/24. She said she did not put the splint in Resident #7's hand. She said no one let her know she needed to. She said on the days she was busy transporting residents; she would not be able to help the restorative aide. She said it all depended on how busy she was. <BR/>During an interview on 05/06/24 at 9:00 a.m., the Administrator said the facility did not have a policy on contracture management or splint management. <BR/>Record review of a Range of Motion Exercises policy dated October 2010 indicated: Purpose- The purpose of this procedure it to exercise the resident's joints and muscles.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs when used without adequate monitoring for 2 of 24 residents reviewed for unnecessary medication. (Residents #58 and #415) <BR/>The facility failed to hold Resident #58's midodrine hcl (used to treat low blood pressure) when the resident's blood pressure was outside parameters set by the physician from 04/01/24 to 04/29/24.<BR/>The facility failed to monitor Resident #415 for side effects from 04/12/24 to 04/29/24 of the anticoagulant medication Eliquis (a blood thinning medication).<BR/>This failure could place residents at risk of complications and not receiving the intended therapeutic effects of their medications.<BR/>Findings included:<BR/>1. Record review of a face sheet dated 04/30/24 indicated Resident #58 was an [AGE] year-old male admitted on [DATE]. His diagnoses included hypertension (high blood pressure), hypotension (low blood pressure), atherosclerotic heart disease (a buildup of substances inside the walls of the arteries that can cause clots and put blood flow at risk from your heart to your body) and coronary angioplasty implant and graft (a procedure to open clogged blood vessels of the heart with a tiny balloon to improved blood flow to the heart.<BR/>Record review of physician orders dated April 2024 indicated Resident #58 was prescribed midodrine hcl 5 mg three times a day for hypotension, with prescribed parameters to hold for SBP (systolic blood pressure) greater than 100. <BR/>Record review of a care plan with a target date of 05/29/24 indicated Resident #58 had a care plan indicating he had hypotension and received midodrine. The care plan indicated interventions including hold midodrine if SBP greater than 100 initiated on 03/01/23.<BR/>Record review of an admission MDS dated [DATE] indicated Resident #58 had a BIMS score of 13 indicating intact cognition. The MDS indicated Resident #58 had diagnoses of hypertension, hypotension, atherosclerotic heart disease and coronary angioplasty implant and graft. <BR/>Record review of a MAR dated 04/30/24, indicated Resident #58 received midodrine hcl 5 mg three times a day for hypotension with a start date of 02/28/24 and prescribed parameter to hold for SBP greater than 100. <BR/>On the following dates the midodrine hcl 5 mg was administered to Resident #58 and should have been held at 7:00 a.m., 7 of 30 times, 1:00 p.m., 5 of 30 times and 7:00 p.m., 19 of 30 times.<BR/>*04/01/24 at 7:00 p.m., SBP 118;<BR/>*04/03/24 at 7:00 a.m., SBP 114;<BR/>*04/03/24 at 1:00 p.m., SBP 112;<BR/>*04/03/24 at 7:00 p.m., SBP 110;<BR/>*04/04/24 at 7:00 p.m., SBP 118;<BR/>*04/05/24 at 7:00 p.m., SBP 110;<BR/>*04/09/24 at 7:00 p.m., SBP 118;<BR/>*04/10/24 at 7:00 a.m., SBP 125<BR/>*04/10/24 at 7:00 p.m., SBP 102;<BR/>*04/11/24 at 7:00 p.m., SBP 105;<BR/>*04/13/24 at 7:00 p.m., SBP 112;<BR/>*04/14/24 at 7:00 p.m., SBP 108;<BR/>*04/15/24 at 7:00 a.m., SBP 140;<BR/>*04/15/24 at 7:00 p.m., SBP 118;<BR/>*04/16/24 at 7:00 p.m., SBP 118;<BR/>*04/19/24 at 7:00 a.m., SBP 127;<BR/>*04/19/24 at 7:00 p.m., SBP 112;<BR/>*04/20/24 at 7:00 p.m., SBP 114;<BR/>*04/22/24 at 7:00 p.m., SBP 110;<BR/>*04/23/24 at 1:00 p.m., SBP 104;<BR/>*04/24/24 at 7:00 p.m., SBP 102;<BR/>*04/25/24 at 7:00 p.m., SBP 118;<BR/>*04/26/24 at 7:00 a.m., SBP 111;<BR/>*04/26/24 at 7:00 p.m., SBP 118;<BR/>*04/27/24 at 1:00 p.m., SBP 118;<BR/>*04/27/24 at 7:00 p.m., SBP 112;<BR/>*04/28/24 at 7:00 p.m., SBP 112;<BR/>*04/29/24 at 7:00 a.m., SBP 112;<BR/>*04/29/24 at 1:00 p.m., SBP 124;<BR/>*04/30/24 at 7:00 a.m., SBP 127; and<BR/>*04/30/24 at 1:00 p.m., SBP 139.<BR/>During an observation on 04/30/24 at 07:48 a.m., Resident #58 was sitting on his bedside and said I feel good today,.he said he gets a pill for his blood pressure. <BR/>During an interview and record review on 04/30/24 at 1:54 p.m., LVN O said she was providing care for Resident #58 today. She said on review of Resident #58's medication record she should have held the midodrine hcl at 7:00 a.m., and 1:00 p.m. She said she misread the parameter and thought it was diastolic greater than 100 to be held instead of systolic. LVN O said she was educated in medication administration and was aware to follow parameters. She said she was responsible for giving the medication incorrectly. LVN O said the risk for Resident #58 was hypertension.<BR/>During an interview and record review on 04/30/24 at 3:02 p.m., LVN Q said she provided care for Resident # 58, 04/29/24 and previously this month. She said she was educated in medication administration and was aware to follow parameters. She said she misread the parameter she thought it said 110 or greater instead of 100. She said the risk for Resident #58 was his blood pressure being raised or too high.<BR/>LVN O said she gave the midodrine hcl out of parameters and should have held it after review, on; <BR/>*04/01/24 at 7:00 p.m.;<BR/>*04/03/24 at 7:00 p.m.;<BR/>*04/04/24 at 7:00 p.m.;<BR/>*04/05/24 at 7:00 p.m.;<BR/>*04/09/24 at 7:00 p.m.;<BR/>*04/10/24 at 7:00 p.m.;<BR/>*04/11/24 at 7:00 p.m.;<BR/>*04/13/24 at 7:00 p.m.;<BR/>*04/14/24 at 7:00 p.m.;<BR/>*04/15/24 at 7:00 p.m.;<BR/>*04/16/24 at 7:00 p.m.;<BR/>*04/19/24 at 7:00 p.m.;<BR/>*04/20/24 at 7:00 p.m.;<BR/>*04/22/24 at 7:00 p.m.;<BR/>*04/24/24 at 7:00 p.m.;<BR/>*04/25/24 at 7:00 p.m.;<BR/>*04/26/24 at 7:00 p.m.;<BR/>*04/27/24 at 7:00 p.m.;<BR/>*04/28/24 at 7:00 p.m.;<BR/>*04/29/24 at 7:00 a.m.; and<BR/>*04/29/24 at 1:00 p.m.<BR/>2. Record review of a face sheet dated 04/29/24 indicated Resident #415 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included atrial fibrillation (an irregular and often rapid heart rhythm that can lead to blood clots in the heart and increases the risk of a stroke).<BR/>Record review of physician orders dated April 2024 indicated Resident #415 was prescribed Eliquis 2.5 mg daily for atrial fibrillation with a start date of 04/12/24. The orders did not address monitoring the anticoagulant medication.<BR/>Record review of a care plan dated 04/17/24 indicated Resident #415 had a care plan indicating she received the anti-coagulant medication Eliquis for Atrial fibrillation.<BR/>Record review of an admission MDS dated [DATE] indicated Resident #415 had a BIMS score of 13 indicating intact cognition. The MDS indicated Resident #415 had a diagnosis of atrial fibrillation and received an anticoagulant medication during the look back period.<BR/>Record review of a MAR dated 04/29/24, indicated Resident #415 received Eliquis 2.5 mg two times a day from 04/11/24 to 04/29/24, and once a day on 04/12/24 the start date. <BR/>Record review of the electronic record for Resident #415 from 04/11/24 to 04/29/24 indicated the nurses did not document monitoring of side effects of the anticoagulant medication daily with medication administration. <BR/>During an observation on 04/29/24 at 08:53 a.m., Resident #415 was sitting up in a recliner. She said she was treated great here and received needed care.<BR/>During an interview on 04/30/24 at 02:07 p.m., LVN R said she provided care for Resident #415 today. LVN F said she proved care for Resident #415 on 04/26/24 and was currently taking over care for Resident #415 for today. LVN R and F said were educated on monitoring for side effects of anticoagulant medication. They said Resident #415 should have been monitored for side effects but was not. LVN F said as nurses they were aware and monitored anticoagulant medication for side effects it was just not documented correctly. They said the nurse admitting the resident was responsible for adding monitoring into the computer system and the DON and ADON double checked for monitoring. LVN F said she admitted Resident #415 and was responsible and started the orders but did not complete them. She said she was aware as a nurse to monitor the meds for side effects but if you did not document it, you did not do it. LVN F said the risk was the potential side effects were not being documented properly but no risk to residents. LVN R said the medication should have been documented in the system but was missed.<BR/>During an interview on 04/30/24 at 02:39 p.m., the DON said the admission nurse started the orders and monitoring of medication in the computer system and the IDT double checked medication for monitoring. She said Resident #415 should have been monitored for the anticoagulant Eliquis and was not. She said the nurses were educated with an annual check off on medication administration on 04/12/24. The DON said the monitoring was overlooked. She said the risk of an anticoagulant medication not monitored was potential adverse reactions and side effects. She said her expectation was all medication to be given as ordered by the physician and monitored for side effects as required. The DON said Resident #58's Midodrine should have been held when out of parameters. She said the nurse giving medication was responsible for holding a medication that was out of prescribed parameters. The DON said the risk of a medication given out of prescribed parameters was an increase in side effects and adverse reactions caused by the medication.<BR/>During an interview on 04/30/24 at 03:41 p.m., the Administrator said her expectation was all physician orders followed as ordered and all anticoagulant medication be monitored for side effects as required. She said her expectation was for all medication with prescribed parameters be given within parameters. The Administrator said the charge nurse was responsible for following physician orders, administrating medication to the residents. She said the risk of anticoagulant medication not monitored was potential side effects. She said the risk of a medication given out of parameters was the resident's blood pressure could be lowered.<BR/>Record review of a facility policy revised November 2018, titled, Anticoagulant -Clinical Protocol indicated, . 5. The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. a. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant.<BR/>Record review of a facility policy revised April 2019, titled, Administering Medications, indicated, . Medications administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders.<BR/>Record review of the Reference obtained from the internet on 10/12/23 from, How Rx ELIQUIS&reg; (apixaban) Can Help | Safety Info (bmscustomerconnect.com) indicated, . ELIQUIS can cause bleeding, which can be serious, and rarely may lead to death. This is because ELIQUIS is a blood thinner medicine that reduces blood clotting. While taking ELIQUIS, you may bruise more easily and it may take longer than usual for any bleeding to stop.<BR/>Call your doctor or get medical help right away if you have any of these signs or symptoms of<BR/> bleeding when taking ELIQUIS:<BR/>*unexpected bleeding or bleeding that lasts a long time, such as unusual bleeding from the<BR/> gums, nosebleeds that happen often, or menstrual or vaginal bleeding that is heavier<BR/> than normal<BR/>*bleeding that is severe or you cannot control<BR/>*red, pink, or brown urine; red or black stools (looks like tar)<BR/>*coughing up or vomiting blood or vomit that looks like coffee grounds<BR/>*unexpected pain, swelling, or joint pain<BR/>*headaches, or feeling dizzy or weak

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 2 errors out of 25 opportunities which resulted in an 8 percent error rate involving Residents' #58 and #92.<BR/>LVN O administered Resident #58's midodrine HCL 5 mg (a medication used to treat low blood pressure) when the blood pressure was outside the prescribed parameters.<BR/>LVN P administered Resident #92's clopidogrel 75 mg (a medication used to thin blood and prevent clotting) over 3 hours past the administration time frame listed on the medication administration record, according to the facility's policy that medications are scheduled according to the routine schedule of 7am. <BR/>This failure could place residents at risk of not receiving the therapeutic benefits of their medications as ordered.<BR/>Findings included:<BR/>ERROR #1 <BR/>Physician orders dated April 2024 indicated Resident #58, admitted [DATE] was [AGE] years old with a diagnosis of high blood pressure. Physician orders indicated Resident #58 was to receive midodrine HCl tablet 5 mg. Give 1 tablet by mouth three times a day for hypotension (low blood pressure). Hold if SBP (systolic blood pressure - first number in a blood pressure reading) is greater than 100.<BR/>During an observation of the medication pass on 04/30/24 at 7:48 a.m., LVN O administered Resident #58's midodrine HCL 5 mg. Resident #58's blood pressure was 127/47.<BR/>During an interview and record review on 04/30/24 at 1:54 p.m., LVN O said she should have held Resident #58's midodrine due to prescribed parameters. She said she had misread the parameter and thought it was diastolic greater than 100 held instead of systolic. She said she should have held Resident #58's morning dose of midodrine medication. She said she was educated in medication administration and was aware of following prescribed parameters. She said she was responsible for giving the medication incorrectly. She said the risk for Resident #58 was hypertension.<BR/>During an interview on 04/30/24 at 2:31 p.m., the DON said Resident #58's midodrine should have been held when blood pressure was outside the prescribed parameters. <BR/>During an interview on 4/30/24 at 3:40 p.m., the administrator said the charge nurse was responsible for following physician orders administrating medication to the residents. She said her expectation was for physician orders to be followed and all medication to be given within parameters. She said the risk was that blood pressure could be lowered if medication was given out of parameters.<BR/>ERROR #2 <BR/>Physician orders dated April 2024 indicated Resident #92, admitted [DATE], was [AGE] years old with a diagnosis of coronary artery disease. Physician orders included clopidogrel bisulfate 75 mg daily as an anticoagulant. (Used to thin blood and prevent clotting). <BR/>During an observation of the medication pass on 04/30/24 at 10:55 a.m., LVN P administered clopidogrel bisulfate 75 mg tablet to Resident #92 over 3 hours past the designated administration time of 7:00 a.m.<BR/>During an interview on 04/30/24 at 12:25 p.m., LVN P said Resident #92 was administered clopidogrel bisulfate 75 mg tablet at 10:55 a.m. instead of the designated administration time of 7:00 a.m. She said we have 1 hour before and 1 hour after to give meds. She said she was just running late. She gave no reason.<BR/>During an interview on 04/30/24 at 1:00 p.m., the DON said her expectation was for medications to be given as ordered and in a timely manner. If medications were not given as ordered the nurses should notify the physician and herself. She said we have an hour before and after the medication is due to administer medications. She said none of the nurses had reported to her of medications being late.<BR/>A policy titled Administering Medications dated April 2019 indicated the following. 4. Medications are administered in accordance with prescriber orders.<BR/>A policy titled Medication Administration Schedule dated November 2020 indicated the following. Medications are administered according to established schedules. 1. Medications are administered according to the following routine schedule.daily.7 a.m. 3.Scheduled medications are administered within one hour of their prescribed time, unless otherwise specified.<BR/>

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 3 dining rooms and 1 of 1 kitchen reviewed for sanitation. (Main dining room)<BR/>The facility failed to ensure an air conditioner return air vent in the dining room was free of dust particles. <BR/>The facility did not ensure kitchen equipment was sanitary and in good repair. <BR/>This failure could place the residents at risk of food borne illnesses. <BR/>Findings included:<BR/>1. During observations of the noon meal in the main dining room on 4/29/24 at 12:00 p.m., an AC return air vent, approximately 8 ft high by 4 foot wide, had dust approximately 1/4 thick on each slat of the vent. Air was blowing through the vent slats. Approximately 20 residents were sitting in the dining room eating lunch. <BR/>During an interview on 4/29/24 at 12:02 p.m., the DM said the air conditioner return air vent had thick dust and needed to be cleaned. She said maintenance was supposed to clean it. She stated the dust is thick and nasty. <BR/>During an interview on 4/29/24 at 12:07 p.m., the administrator said the return air vent was filthy and needed to be cleaned. She said it was housekeeping's responsibility to keep it clean. She said her expectations were for housekeeping to keep the air vents clean. She said the negative outcome would be the dust particles could get in the residents' food.<BR/>During an interview on 4/29/24 at 12:09 p.m., the HS said she was responsible for making sure the air conditioner return air vents were cleaned. She said the return air vent in the dining room had thick dust and needed to be cleaned. She said the possible negative outcome would be the dust could get in the resident's food and they could ingest it. <BR/>2. During observations of the kitchen on 4/29/24 at 8:47 a.m., the three-compartment sink's metal pipe frame was rusted, had chipped paint, was oxidized and corroded. A metal plate to the back inside of the left sink was rusted and the plate was hanging from a rusted opening that was approximately 4 inches in width. The paint on the wall behind the left sink had peeled and was hanging from the wet surface of the wall. There was an approximate 5 inch by 1 inch area of a brown/black substance in the crease between the wall and the floor to the left of the three-compartment sink. The floor had a small, pooled area of standing water under the left sink. <BR/>During an observation on 4/29/24 at 8:49 a.m., two slender refrigerators next to the box freezer had multiple lines of rust down the doors from the top of the refrigerators to the bottom. <BR/>During observations and interview on 4/29/24 at 8:57 a.m., the underside of 2 metal shelves that hung on the wall over the juice machine had multiple areas of rust on the surface. The DM said the shelves were rusted and were not sanitizable. <BR/>During observation and interview on 4/29/24 at 9:00 a.m., the double oven had a thick black substance on the interior walls, on the metal racks and on the base/floor of the oven. The DM said the oven was not used and had not worked since she started working at the facility about a year ago. The DM said the double oven did have thick build up and needed to be cleaned and repaired. <BR/>During observations and interview on 04/30/24 at 10:38 a.m., the seven water wells of the steam table had rust in the bottom of the pans and a thick brown build up on the sides of the pans. The base shelf and legs of the steam table had knicks in the paint and the metal was oxidized. The dietary manager said the pans were rusted and were not sanitizable. She said the water well pans had been like that for at least a year that she knew of. She said the pans needed to be replaced. She said the base of the steam table and the legs were not sanitizable. She said the water wells and steam table needed to be replaced. <BR/>During observation and interview on 5/01/24 at 8:34 a.m., the dietary manager observed the three-compartment sink, the double oven, the 2 refrigerators, the 2 shelves, the water wells and the base of steam table with the surveyor. She said the kitchen equipment was not sanitizable and the negative outcome was the rust could get in the resident's food. <BR/>During observations of the three-compartment sink and interview on 05/01/24 at 11:10 a.m., the dietary manager said the left sink leaked water onto the back wall because the metal plate inside of the sink had rusted through. The left sink of the three-compartment sink was filled with water. The water line was even with the rusted hole where the rusted round metal plate that was not attached on the inside back wall of the sink. The underside of each sink of the three-compartment sink had large areas of thick rust. The wall behind the left three-compartment sink had areas of peeled paint hanging from the wet surface of the wall. There was an approximate 5 inch by 1 inch area of a brown/black substance in the crease between the wall and the floor to the left of the three-compartment sink. The floor had a small, pooled area of standing water under the left sink. The DM said the public health department had come out a few months ago and told the facility then, that the three-compartment sink needed to be replaced. She said the three-compartment sink was not santizable and needed to be replaced. <BR/>During observations of the kitchen equipment and interview on 5/1/24 at 11:22 p.m., the dietitian said the three-compartment sink, the 2 shelves, the 2 refrigerators, the water wells, the base of the steam table, and the three-compartment sink were rusted, oxidized and unsanitizable. She said corporate office was aware of the concerns of the rusted kitchen equipment but had not fixed them at this time. She said the equipment should be in working condition and be sanitizable. She said the negative outcome would be the equipment would not be sanitizable and the residents could ingest the rust particles. <BR/>During an interview on 05/01/24 at 11:16 a.m. the Administrator said her expectations were for the kitchen equipment to be fixed, in working order, sanitizable and to not contain rust. She said the possible negative outcome of the kitchen equipment surfaces being chipped, oxidized and containing rust would be the surfaces would not be sanitizable and the residents could ingest food containing rust particles. <BR/>Record review of the Public Health Food Inspection Report dated 2/29/24 indicated: . Observed a kitchen shelf in disrepair, chipping, worn. <BR/>Record review of the Environment policy dated 01/2021 indicated: Policy Statement- All food preparation areas, food service areas and dining areas will be maintained in a clean and sanitary condition.<BR/>Record review of the Equipment policy dated 01/2001 indicated: Policy Statement- All food service equipment will be clean, sanitary and in proper working order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 23 residents reviewed for respiratory care and services. (Resident #100)<BR/>The facility failed to administer the correct dose of oxygen to Resident #100. <BR/>This failure could place the residents at risk for not receiving the appropriate care and services to maintain their highest level of well-being. <BR/>Findings included:<BR/>Record review of physician orders dated March 2023 indicated Resident #100, admitted [DATE], was [AGE] years old with diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), dependence on supplemental oxygen and shortness of breath. The resident was to receive oxygen at 3 liters per nasal cannula (a device used to deliver supplemental oxygen) continuously every shift with a start date of 12/6/21. <BR/>Record review of the most recent MDS dated [DATE] indicated Resident #100 was alert, oriented with a BIMS of 13 (brief interview for mental status with a score of 13 to 15 points indicating intact cognition), was totally dependent for transfer and locomotion on unit, had a diagnosis of chronic obstructive pulmonary disease and received oxygen therapy in the last 14 days. <BR/>Record review of the care plan revised 1/9/23 indicated Resident #100 required oxygen therapy. The interventions indicated the oxygen was 3 liters per nasal cannula. The intervention was assigned to the RT (respiratory therapist). <BR/>During observations, Resident #100 was observed to have oxygen in progress at 4.5 liters nasal cannula as follows:<BR/>*2/27/23 at 8:51 a.m.;<BR/>*2/28/23 at 12:35 p.m., and <BR/>*3/1/23 at 9:18 a.m.<BR/>During an interview on 3/1/23 at 9:20 a.m., CNA C said Resident #100 was maximum assistance to transfer out of bed and could not get out of bed to change the oxygen settings on the oxygen concentrator machine. <BR/>During observation, interview and record review on 3/1/23 at 10:28 a.m., LVN A, while reviewing Resident #100's clinical records with the surveyor, said the resident was ordered oxygen at 3 liters per nasal cannula. During observation of Resident #100's oxygen concentrator machine, LVN A said the oxygen machine was set to deliver 4.5 liters per minute and it should not be. She said the possible negative outcome would be it could blow her lungs out. She said she should have caught the fact that it was set too high when she did her nursing rounds. She said respiratory therapy was responsible for coming into the resident's rooms and checking all the respiratory equipment every Monday. <BR/> During an interview on 3/1/23 at 10:30 a.m., Resident #100 said she did not change the oxygen settings. She said she never had touched the machine or changed the settings. <BR/> During an interview on 3/1/23 at 10:36 a.m., the RT said she was responsible for checking each resident's respiratory equipment on Mondays. She said Resident #100 was supposed to receive oxygen at 3 liters per nasal cannula. She said she checked Resident #100's oxygen on Monday morning 2/27/23 at around 7:30 a.m. and the oxygen was set on 3 liters. She said the resident complains sometimes of not getting enough oxygen and someone must have bumped it up. She said there was not a negative outcome to having the oxygen set too high. She said the physician orders were supposed to be followed.<BR/> During an interview on 3/1/23 at 10:43 a.m., the DON said her expectation was for the oxygen to be administered as ordered by the physician. She said the negative outcome could be the high dose could change Resident #100's baseline of required oxygen needed. <BR/> During an interview on 3/1/23 at 1:20 p.m., the administrator said her expectations were for the oxygen to be administered as ordered and to investigate why it was not on the correct settings and instruct staff accordingly. <BR/> Record review of an Oxygen Concentrator policy dated 4/11/22 indicated: . An oxygen concentrator is a medical device that extracts oxygen from room air by filtering out or separating the nitrogen from the oxygen. Oxygen is administered under orders of the attending physician, except in the case of an emergency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 2 of 23 residents reviewed for medications. (Resident #22 and #64)<BR/>Resident #22 missed several doses of a PRN blood pressure medication when her blood pressure was extremely elevated.<BR/>Resident #64 received the antihypotension medication when it should have not been given and it was held when it should have been given on multiple occasions <BR/>This failure could place resident at risk of not receiving medications as prescribed and/or significant medication errors.<BR/>Findings included:<BR/>1. Physician orders dated February 2023 indicated Resident #22, admitted [DATE], was [AGE] years old with diagnosis of hypertension (high blood pressure). An order was received 01/06/23 for clonidine HCl 0.1 mg. Instructions included give 1 tablet by mouth every 8 hours as needed for B/P (blood pressure) at 160/90 and above.<BR/>The MAR dated February 2023 indicated on the following dates at 8:00 a.m., Resident #22's B/P was out of range of prescribed parameters and medication space was blank indicating clonidine was not administered:<BR/>*02/03/23, B/P was 180/82, medication space was blank; <BR/>*02/04/23, B/P was 185/63, ; medication space was blank<BR/>*02/08/23, B/P was 156/109, medication space was blank;<BR/>*02/13/23, B/P was 198/78, medication space was blank;<BR/>*02/24/23, B/P was 204/86, medication space was blank; and<BR/>*02/25/23, B/P was 164/95, medication space was blank.<BR/>The comprehensive care plan for Resident #22 dated revised on 02/28/23 indicated: Problem: Is at risk for complications/side effects of hypertension: .Interventions .Give antihypertensive medications as ordered. <BR/>During an interview and record review on 03/01/23 at 11:50 a.m., LVN B said Resident #22's B/P was normally 160's. She acknowledged the February 2023 MAR gave no indication Resident #22 had been administered clonidine HCl 0.1 mg per physician orders when the B/P was at 160/90 or above. She said the physician should have been notified and possibly adjust Resident #22's medications.<BR/>Progress Notes for Resident #22 dated 02/01/23 through 03/01/23 indicated Resident #22 was administered clonidine HCl 0.1 mg on 02/07/23 when B/P was at or above 160/90.<BR/>During an interview on 03/01/23 at 12:25 p.m., the DON said her expectations were for the LVNs to notify physicians of consistently elevated B/P readings to possibly adjust medications. Also, to check the resident's electronic record for PRN orders regarding elevated B/P readings. She said residents possibly would not achieve therapeutic levels of medications if not adjusted. The risk could potentially be having B/P go higher or could have a stroke. <BR/>2. Record review of an admission record indicated Resident #64 admitted [DATE], was [AGE] years old with diagnosis of hypotension (low blood pressure).<BR/>Physician orders dated February 2023 indicated Resident #64 had order for midodrine HCl (used for low blood pressure)Tablet 5 mg, give 1 tablet by mouth three times a day for Hypotension HOLD if B/P is GREATER THAN 100/60 with start date of 08/16/2022.<BR/>Record Review of the MAR dated February indicated Resident #64 received midodrine HCL tablet 5 mg 1 tablet on the following dates:<BR/>*2/17/23 at 1:00 p.m., B/P was 114/68, midodrine was given; <BR/>*2/20/23 at 7:00 a.m., B/P was 146/88, midodrine was given; and<BR/>*2/21/23 at 7:00 p.m., B/P was 134/62, midodrine was given.<BR/>Record Review of the MAR dated February 2023 indicated Resident #64's midodrine HCL tablet should have been given and was held as follows:<BR/>*2/1/23 at 1:00 p.m., B/P was 104/58, midodrine was held<BR/>*2/3/23 at 1:00 p.m., B/P was 100/58, midodrine was held<BR/>*2/6/23 at 7:00 a.m., B/P was 144/58, midodrine was held<BR/>*2/7/23 at 1:00 p.m. B/P was 114/58, midodrine was held<BR/>*2/8/23 at 1:00 p.m., B/P was 102/58, midodrine was held<BR/>*2/14/23 at 7:00 p.m., B/P was 102/58, midodrine was held<BR/>*2/23/23 at 1:00 p.m., B/P was 108/58, midodrine was held and<BR/>*2/24/23 at 1:00 p.m., B/P was 102/58, midodrine was held<BR/>Record review of the comprehensive care plan for Resident #64 dated revised on 01/19/23 indicated history of hypotension requiring Midodrine .Interventions . Give medications as ordered. Monitor for side effects and effectiveness.<BR/>Record review of the MDS dated [DATE] indicated Resident #64 had diagnosis hypotension and cognition was moderately impaired.<BR/>During an interview on 02/28/23 at 3:00 p.m., DON said she was going to call Resident #64's physician and clarify the order and she expected the nurses to follow orders and if the order was not clear to call physician or call her. <BR/>During an interview on 03/01/23 at 1:00 p.m., LVN E said the order for Resident #64 was not clear if both systolic and diastolic had to be below to give the parameters. She said midodrine was held on days it could have been given if using diastolic B/P, and on a couple of days she gave the med and should have been held. LVN E said after surveyor intervention the order has been clarified and the physician just wants parameters with the systolic B/P. LVN E said she was trained in the following orders and if it was not clear she should have reported to DON or the physician.<BR/>A facility policy dated 2022 and titled Medication Administration indicated the following . Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: . 8. Obtain and record vital signs, when applicable or per physician orders.10. Review MAR to identify medication to be administered. <BR/>A facility policy dated 2022 and titled Physician/Practitioner Orders indicated . 2. For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: a. Call the attending physician to verify the order .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a 30-day notice to the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand before the resident was discharged for 1 of 1 (Resident #101) reviewed for Discharge Rights.<BR/>The facility did not provide a written discharge notice to Resident #101 (who admitted on [DATE] and discharged on 08/30/23) or their representative prior to discharging the resident, not allowing the 30-day advance notice. The facility discharged Resident #101 to a behavioral hospital. <BR/>This failure could place residents who are transferred or discharged from the facility, at risk for not receiving care and services to meet their needs upon discharge and the right to appeal.<BR/>Findings included:<BR/>Record review of Resident #101's face sheet dated 01/09/24 indicated Resident #101 was a [AGE] year-old male who admitted on [DATE], readmitted on [DATE] with diagnoses including hepatic failure (loss of liver function), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities) and anxiety (a feeling of worry nervousness, or unease). He was discharged to a behavioral hospital on [DATE].<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #101 had a BIMS score of 6 out of 15 indicating severely impaired cognition and diagnoses of liver failure, anxiety, and depression. He was coded under delirium for inattention as the behavior is present but fluctuates and mood as feeling down, depressed, or hopeless and trouble falling or staying asleep or sleeping too much for 2 to 6 days during the 7-day look back period.<BR/>Record review of a nurses note dated 08/30/23 indicated Resident #101 was being discharged from the facility to a behavior hospital by ambulance. The note indicated Resident #101's responsible party (RP) stated her family member would come to the facility on [DATE] and pick up the rest of Resident #101's belongings.<BR/>Record review of a discharge summary signed 09/30/23 indicated Resident #101 discharged [DATE] to a behavior hospital by ambulance with diagnoses including major depressive disorder, anxiety, and hepatic failure. The note indicated the resident's family picked up his belongs due to the resident not returning to the facility per Resident #101's RP.<BR/>During an interview on 01/09/24 at 10:00 a.m., Case Manager C said she was the case manager on duty today at the behavioral hospital Resident #101 was transferred to. She said Case Manager B was Resident #101's case manager but she was off this week. Case Manager C said she could provide information from Case Manager C's notes. Case Manager C said the facility told them they would not take Resident #101 back and did not help find placement for him. She said the family said the facility kicked Resident #101 out. The behavior hospital provided the family with resources to find placement and placed him in a personal care home. Case Manager C said the facility should have been more active in finding placement for Resident #101. She said they did not find placement for residents. Case Manager C said the nurses at the behavioral hospital did the admissions; the case managers did discharges. She said the facility sending the resident to the behavioral hospital was responsible for finding alternate placement for residents or they were responsible for taking them back. Case Manager C said the behavioral hospital attempted 3 times on 09/13, 09/14 and 09/15/23 to return Resident #101 to the facility who sent him, but the facility refused to admit him back. Case Manager C said the notes did not indicate who refused but indicated spoke to facility. Case Manager C said were told by the facility the family discharged the resident. She said the DON said the family took him out and wanted him out of the facility. Case Manager C called the family for the discharge plan and received no answer. She said the family later said Resident #101 was kicked out of the facility. <BR/>During an Interview on 01/09/24 at 10:11 a.m., Resident #101's RP said he was sent out and the facility did not accept him back. She said the facility had to give them a 30-day notice before making him leave and did not. The RP said she did not plan to move the resident to another city. The RP said she got Resident #101's belongings when he was sent to the behavioral hospital because he was kicked out in the middle of the night. The RP said Resident #101 was now at another facility. <BR/>During an Interview on 01/10/24 at 2:52 p.m., the SW said Resident #101 was not given a discharge notice. She said the facility was going to provide one but Resident #101 transferred to a behavioral hospital and never returned to the facility. The SW said when Resident #101 went to the behavioral hospital his RP picked up Resident #101's belongings and said he was not returning to the facility. She said she did not speak with the behavioral hospital on any attempts to return the resident. The SW said she inquired at 7 nursing homes to assist with placement of Resident #101 with no positive response. The SW said she was not involved in admissions or readmissions. She said Resident #101 could take care of himself; he would need a follow up with his primary care physician and a care giver to watch him in the evening if he was wandering. <BR/>During an interview on 01/10/24 at 3:00 p.m., the DON said Resident #101 was not given a 30-day discharge notice because he left for a behavioral hospital and at the time of transfer the family said they wanted him transferred to a facility in another city so he would not return to this facility. She said the family picked up Resident #101's belongings and signed his personal inventory sheet. The DON said Resident #101's family did not like him being on the locked unit. She said the facility was under the assumption that Resident #101 was not returning to the facility. The DON said the behavioral hospital called the facility one time to report and she informed them the family had taken his belongings and discharged him. She said the family did not want him here and he was no longer their resident. The DON said the risk of not providing a 30-day notice was the potential of not giving the family time to make a safe discharge. <BR/>During an interview on 01/10/24 at 3:10 p.m., the Administrator said Resident #101 was not provided a 30-day discharge notice. She said if he had continued to stay at the facility, she should have provided one. The Administrator said she could not meet his needs; the resident did not want to be here, and the family did not want him here. The Administrator said the family wanted Resident #101 closer to family in another city. The Administrator said the behavior hospital accepted Resident #101 on the pretense that the resident and family did not want him to return to this facility and the facility could not meet his needs. She could not remember the name of whom she had spoken to. The Administrator said she informed the behavioral hospital she would help find placement for him if needed. She said the family had packed up all of Resident #101's belongings, signed his personal inventory sheet, discharged him, and said he was not returning. She said she thought it had just worked out. The Administrator said when Case Manager B at the behavioral hospital called wanting to readmit him, she said no because she had established with the hospital prior to them accepting him that he would go to another facility on discharge due to the family not wanting him to return. She informed the behavioral hospital she would assist finding him placement as needed. She said Case Manager B stated she understood, and she did not hear from the behavioral hospital after that and thought it was taken care of. The Administrator said she was responsible for giving residents a 30-day discharge notice. She said the risk of a resident not given the proper 30-day notice was a family may not be set up to properly care for a Resident.<BR/>During an Interview on 01/10/24 at 3:00 p.m., Activities Staff A said she was unsure if the facility provided a 30-day discharge notice to Resident #101. She said Resident #101 packed up his items frequently and said he was leaving. She said she frequently heard him say he was leaving, telling other residents he was leaving, and someone was coming to get him. He did not say where he was going or who was coming to get him.<BR/>Record review of a facility policy, revised March 2021, titled, Transfer or Discharge Notice indicated, .Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge.d. discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected.7. Residents have the right to appeal a facility-initiated transfer or discharge through the state agency that handles appeals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents reviewed for a written plan of care received care and services as ordered by the physician for 3 of 23 residents. (Resident #22, #64 and #109)<BR/>The facility failed to follow physician orders related to a blood pressure medication for Resident #22.<BR/>The facility failed to follow physician orders related to blood pressure medication for Resident #64. <BR/>The facility failed to initiate physician orders related to new order for anticoagulant for Resident #109. <BR/>This failure could place the residents at risk of not receiving care and services as ordered by the physician. <BR/>Findings included:<BR/>1.Physician orders dated February 2023 indicated Resident #22, admitted [DATE], was [AGE] years old with diagnosis of hypertension (high blood pressure). An order was received 01/06/23 for clonidine HCl 0.1 mg. Instructions included give 1 tablet by mouth every 8 hours as needed for B/P (blood pressure) at 160/90 and above.<BR/>The MAR dated February 2023 indicated on the following dates at 8:00 a.m., Resident #22's B/P was out of range of prescribed parameters and medication space was blank indicating clonidine was not administered:<BR/>*02/03/23, B/P was 180/82, medication space was blank; <BR/>*02/04/23, B/P was 185/63, ; medication space was blank<BR/>*02/08/23, B/P was 156/109, medication space was blank;<BR/>*02/13/23, B/P was 198/78, medication space was blank;<BR/>*02/24/23, B/P was 204/86, medication space was blank; and<BR/>*02/25/23, B/P was 164/95, medication space was blank.<BR/>The comprehensive care plan for Resident #22 dated revised on 02/28/23 indicated: Problem: Is at risk for complications/side effects of hypertension: .Interventions .Give antihypertensive medications as ordered. <BR/>During an interview and record review on 03/01/23 at 11:50 a.m., LVN B said Resident #22's B/P was normally 160's. She acknowledged the February 2023 MAR gave no indication Resident #22 had been administered clonidine HCl 0.1 mg per physician orders when the B/P was at 160/90 or above. She said the physician should have been notified and possibly adjust Resident #22's medications.<BR/>Progress Notes for Resident #22 dated 02/01/23 through 03/01/23 indicated Resident #22 was administered clonidine HCl 0.1 mg on 02/07/23 when B/P was at or above 160/90.<BR/>During an interview on 03/01/23 at 12:25 p.m., the DON said her expectations were for the LVNs to notify physicians of consistently elevated B/P readings to possibly adjust medications. Also, to check the resident's electronic record for PRN orders regarding elevated B/P readings. She said residents possibly would not achieve therapeutic levels of medications if not adjusted. The risk could potentially be having B/P go higher or could have a stroke. <BR/>2. Record review of an admission record indicated Resident #64 admitted [DATE], was [AGE] years old with diagnosis of hypotension (low blood pressure).<BR/>Physician orders dated February 2023 indicated Resident #64 had order for midodrine HCl (used for low blood pressure)Tablet 5 mg, give 1 tablet by mouth three times a day for Hypotension HOLD if B/P is GREATER THAN 100/60 with start date of 08/16/2022.<BR/>Record Review of the MAR dated February indicated Resident #64 received midodrine HCL tablet 5 mg 1 tablet on the following dates:<BR/>*2/17/23 at 1:00 p.m., B/P was 114/68, midodrine was given; <BR/>*2/20/23 at 7:00 a.m., B/P was 146/88, midodrine was given; and<BR/>*2/21/23 at 7:00 p.m., B/P was 134/62, midodrine was given.<BR/>Record Review of the MAR dated February 2023 indicated Resident #64's midodrine HCL tablet should have been given and was held as follows:<BR/>*2/1/23 at 1:00 p.m., B/P was 104/58, midodrine was held<BR/>*2/3/23 at 1:00 p.m., B/P was 100/58, midodrine was held<BR/>*2/6/23 at 7:00 a.m., B/P was 144/58, midodrine was held<BR/>*2/7/23 at 1:00 p.m. B/P was 114/58, midodrine was held<BR/>*2/8/23 at 1:00 p.m., B/P was 102/58, midodrine was held<BR/>*2/14/23 at 7:00 p.m., B/P was 102/58, midodrine was held<BR/>*2/23/23 at 1:00 p.m., B/P was 108/58, midodrine was held and<BR/>*2/24/23 at 1:00 p.m., B/P was 102/58, midodrine was held<BR/>Record review of the comprehensive care plan for Resident #64 dated revised on 01/19/23 indicated history of hypotension requiring Midodrine .Interventions . Give medications as ordered. Monitor for side effects and effectiveness.<BR/>Record review of the MDS dated [DATE] indicated Resident #64 had diagnosis hypotension and cognition was moderately impaired.<BR/>During an interview on 02/28/23 at 3:00 p.m., DON said she was going to call Resident #64's physician and clarify the order and she expected the nurses to follow orders and if the order was not clear to call physician or call her. <BR/>During an interview on 03/01/23 at 1:00 p.m., LVN E said the order for Resident #64 was not clear if both systolic and diastolic had to be below to give the parameters. She said midodrine was held on days it could have been given if using diastolic B/P, and on a couple of days she gave the med and should have been held. LVN E said after surveyor intervention the order has been clarified and the physician just wants parameters with the systolic B/P. LVN E said she was trained in the following orders and if it was not clear she should have reported to DON or the physician.<BR/>3. Physician orders dated February 2023 for Resident #109 indicated recommendation of a 6-week DVT. (Deep vein blood clot) prophylaxis (to prevent). Non-weight bearing to left lower extremity. Knee brace open to ROM. Please order long hinge knee brace for left lower extremity. Hinges open in flexion and extension with a start date of 02/23/23. The order was signed by LVN D.<BR/>Record review of the electronic record for Resident #109 did not indicate the initiation of the 6-week DVT prophylaxis. <BR/>During an interview on 2/28/23 at 9:00 a.m., the DON was unsure why the order was not clear, and then she said she was calling the ordering physician for clarification.<BR/>Record review of the nurse notes for Resident #109 indicated the DON called the physician on 2/28/2023 at 9:38 a.m. and the order was clarified as aspirin 81 mg BID for 6 weeks and she informed him the orders were not initiated on 2/23/23. She also notified the resident's responsible party.<BR/>During an interview on 02/28/23 at 10:15 a.m., the DON said if residents do not receive DVT prophylaxis after a fracture, they could have a DVT and have decline in their condition. DON said they review new orders weekly, however had not seen this one.<BR/>During an interview on 03/1/23 at 2:00 p.m., LVN D said she did not think DVT prophylaxis was a medication order, she thought it was just watching for a DVT. She said she was trained before on transcribing orders and now she had been retrained on DVT prophylaxis. She said if a resident does not receive anticoagulant, they could develop a DVT.<BR/>A facility policy dated 2022 and titled Medication Administration indicated the following . Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: . 8. Obtain and record vital signs, when applicable or per physician orders.10. Review MAR to identify medication to be administered. <BR/>A facility policy dated 2022 and titled Physician/Practitioner Orders indicated . 2. For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: a. Call the attending physician to verify the order .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to consult with the resident's physician when there was a need to alter treatment for 1 of 24 residents (Resident #92) reviewed for notification of changes.<BR/>The facility failed to ensure the physician was notified of a missed dose of Oxacillin (used to treat bacterial infections) 1gm IV Q6H x 5 days was to start at 6:00 a.m. on 04/30/24 and unable to start the prescribed Oxacillin for Resident #92. <BR/>The facility failed to ensure the physician was consulted when the pharmacy indicated the Oxacillin was outside of the recommended dose or frequency.<BR/>This failure could place residents at risk of not receiving appropriate medical treatments, which could result in severe illness or hospitalization.<BR/>Findings included:<BR/>Record review of a face sheet dated 04/30/24 indicated Resident #92 was admitted on [DATE] with diagnoses of urinary tract infection (UTI), altered mental status, and heart disease.<BR/>Record review of the quarterly MDS assessment dated [DATE] indicated Resident #92 had a BIMS score of 10 (moderate cognition impairment) and required moderate assistance with toileting hygiene and showering. <BR/>Physician orders dated 04/30/24 indicated Resident #92 had an order for Oxacillin Sodium in dextrose IV solution give 1 gram intravenously every 6 hours x 5 days ordered on 04/29/24 to start 04/30/24.<BR/>Record review of the MAR dated 04/30/24 indicated Resident #92 had a dose of Oxacillin IV due at 6:00 a.m. and was not initialed to indicated was given. <BR/>Record review of the care plan dated 04/30/2024 indicated for Resident #92 had a UTI / with Staphylococcus aureus (a major human bacterial pathogen which can cause serious infections) was prescribed: Oxacillin Sodium interventions include check at least every 2 hours for incontinence. Wash, rinse, and dry soiled areas. Encourage adequate fluid intake.<BR/>During an observation and interview on 04/30/24 at 10:45 a.m., Resident #92 had no IV infusing which was ordered on 04/29/24 at 9:56 p.m. He said he did not know about an antibiotic.<BR/>Record review of Resident #92 nurses' notes from 04/28/24 through 4/29/24 indicated:<BR/>*04/28/2024 11:29 a.m. Nursing Note- <BR/>Note Text: Received UA results. Called into Resident #92's physician's answering service. Awaiting call back.<BR/>*04/29/2024 9:49 p.m. Nursing Note- <BR/>Note Text: Received C&S results, positive for staph A. Per DON, patient needs to be isolated with contact precautions. Reported results to on call nurse for Resident #92's physician. N/O received: Oxacillin 1gm IV Q6H x 5 days. Left message for Resident #92's daughter.<BR/>*04/29/2024 9:56 p.m. Order Note- <BR/>Note Text: This order is outside of the recommended dose or frequency.<BR/>Oxacillin Sodium in Dextrose Intravenous Solution 1 GM/50ML Use 1 gram intravenously every 6 hours for UTI for 5 Days<BR/>- The daily dose of 4 grams is below the usual dose of 6 to 12 grams.<BR/>During an observation and interview on 04/30/24 at 10:45 a.m., LVN P was giving Resident #92's his morning meds and said the IV never came in and she will check the pix cart and call the pharmacy later. She said we have 1 hour before and 1 hour after to give meds. She said she was just running late. She gave no reason. <BR/>During an interview on 04/30/24 at 1:00 p.m., the DON said she was not sure why Resident #92 's antibiotic was not started or why the physician was not informed of the medication not coming in. She said her expectation was for medications to be given as ordered and in a timely manner or the nurses should notify the physician and herself. She said all nurses knew an hour before and after the medication was due to administer medications. She said no one had reported to her of medications being late this morning. She said when the order was outside of the recommended dose or frequency, the computer system would flag the nurse, who would call the physician, and she said on 04/29/24 the physician was not called and should have been. <BR/>Record review of Administering Medications dated April 2019 indicated Medications are administered in a safe and timely manner and as prescribed. 4. Medications are adminstered in accordance with prescriber orders, including any required time frame.7. Medications are administered one hour of their prescribed time, .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the status for 2 of 28 residents reviewed for assessments. (Residents #13 and #109)).<BR/>The facility failed to complete an accurate resident assessment for Resident #13. Resident #13's resident assessment did not reflect she was a tobacco user. <BR/>The facility failed to complete an accurate resident assessment for Resident #109. Resident #109's resident assessment did not reflect her active diagnosis of anxiety disorder.<BR/>This failure could place residents at risk of not having individual needs met and a decreased quality of life. <BR/>Findings included:<BR/>1. Record review of a face sheet dated 04/30/24 indicated Resident #13 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe) and respiratory failure (a serious condition that makes it difficult to breathe on your own).<BR/>Record review of a smoker list provided by the facility on 04/29/24 indicated Resident #13 was listed. <BR/>Record review of a Smoking assessment dated [DATE] indicated Resident #13 was a smoker. <BR/>Record review of a care plan revised 02/21/24 indicated Resident #13 was a smoker.<BR/>During an interview on 05/01/24 at 09:45 a.m., LVN C indicated Resident #13 smoked on occasion but not every day. She indicated the resident had the right to smoke and she would monitor her O2 sats after just to make sure not dropped too low because she had an episode of the O2 level dropping.<BR/>Record review of a Significant Change MDS dated [DATE] indicated Resident #13 was marked No for smoking.<BR/>2. Record review of a face sheet dated 04/30/24 indicated Resident #109 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included depression (mental illness that negatively affects how you feel, the way you think and how you act) and diabetes mellitus type 2 (chronic condition that affects the way the body processes blood sugar).<BR/>Record review of nurse note with an entry dated 02/21/24 at 07:49 p.m. written by LVN T indicated the NP saw Resident #109 and prescribed Depakote related to diagnosis of anxiety. <BR/>Record review of physician orders for April 2024 indicated Resident #109 had an order dated 02/21/24 for Depakote 125mg twice daily for anxiety/mood. <BR/>Record review of the MDS assessment dated [DATE] indicated Resident #109's diagnosis of anxiety disorder was not marked. <BR/>Record review of the MDS assessment dated [DATE] indicated Resident #109's diagnosis of anxiety disorder was not marked. <BR/>During an interview on 05/01/24 at 11:16 a.m., the DON indicated she expected the MDS to be filled out correctly. She indicated they discovered the previous MDS nurse who was responsible for the MDS was not filling them out correctly. The DON said they did not have a policy, they followed the MDS RAI manual. <BR/>During an interview on 05/01/24 at 01:08 p.m., the Administrator indicated she expected the MDS to be filled out correctly or it could affect residents receiving care and mess up the billing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to refer residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition to the State-designated authority for 1 of 12 residents (Resident #109) reviewed for PASRR.<BR/>The facility did not refer Resident #109 to the LMHA when the NP provided a new mental illness diagnosis of anxiety. <BR/>This failure could place residents at risk of not receiving the needed PASSAR services to meet their individual needs and could result in a decreased quality of life.<BR/>Findings included:<BR/>Record review of a face sheet dated 04/30/24 indicated Resident #109 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included depression (mental illness that negatively affects how you feel, the way you think and how you act) and diabetes mellitus type 2 (chronic condition that affects the way the body processes blood sugar).<BR/>Record review of a PASRR Level 1 Screen dated 02/15/24 indicated Resident #109 was negative. <BR/>Record review of nurse notes indicated the NP saw Resident #109 on 02/21/24 and prescribed Depakote related to diagnosis of anxiety. <BR/>Record review of physician orders for April 2024 indicated Resident #109 had an order dated 02/21/24 for Depakote 125mg twice daily for anxiety/mood. <BR/>Record review of the EMR for Resident #109 indicated no new PASRR Level 1 or PE was conducted.<BR/>During an observation and interview on 04/29/24 at 09:14 a.m., Resident #109 was ambulatory. She was sitting in a chair in common area. She indicated she had no issues. <BR/>During an interview on 05/01/24 at 10:54 a.m., the Corporate MDS/PASRR Nurse said a new P1 should have been done and referral for PE on Resident #109 with the new medication and new diagnosis.<BR/>During an interview on 05/01/24 at 11:16 a.m., the DON indicated the MDS nurse was responsible for the PASRRs-ensuring they were correct, following up for PE to be done, or when a resident had a new diagnosis a new P1 was to be done. She indicated they had discovered the previous MDS nurse was not checking the PASRRs like they should have been. She indicated they did not have a PASRR policy.<BR/>During an interview on 05/01/24 at 01:08 p.m., the Administrator indicated she expected PASRRs to be reviewed and done correctly or a new one filled out. She indicated it could affect residents from receiving services they would be entitled to receive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure based on the comprehensive assessment of a resident, residents who use psychotropic drugs received gradual dose reduction and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 24 residents (Resident #415) reviewed for unnecessary medications. <BR/>The facility failed to monitor Resident #415 for side effects of the antipsychotic medication quetiapine fumarate and Abilify and the antianxiety medication buspirone hcl.<BR/>This failure could place residents at risk for adverse consequences such as dizziness, drowsiness, oversedation, agitation, restlessness, and suicidal thoughts related to the use of psychotropic medications.<BR/>Findings include:<BR/>Record review of a face sheet dated 04/29/24 indicated Resident #415 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included psychosis (a mental disorder characterized by a disconnection from reality) and anxiety (a mental disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities).<BR/>Record review of physician orders dated April 2024 indicated Resident #415 was prescribed Abilify 10 mg daily for depression (a group of conditions associated with the elevation or lowering of a person's) with a start dated of 04/12/24, buspirone hcl 5 mg three times a day for anxiety with a start date of 04/12/24 and quetiapine fumarate 75 mg at bedtime for psychosis with a start date of 04/17/24. <BR/>Record review of a care plan dated 04/17/24 indicated Resident #415 had a care plan indicating she received the antianxiety medication buspirone for anxiety with an intervention of monitor for side effects and effectiveness every shift. The care plan indicated Resident #415 received Ability for depression with an intervention to monitor for side effects and effectiveness every shift and quetiapine for psychosis with an intervention to monitor for side effects and effective every shift.<BR/>Record review of an admission MDS dated [DATE] indicated Resident #415 had a BIMS score of 13 indicating intact cognition. The MDS indicated Resident #415 had a <BR/>diagnosis of anxiety, psychotic disorder and received antipsychotic medication and antianxiety medication during the look back period. <BR/>Record review of a MAR dated 04/29/24, indicated Resident #415 received Abilify 10 mg daily for depression from 04/13/24 to 04/29/24 with a start date if 04/13/24. The MAR indicated Resident #415 received quetiapine fumarate 75 mg at bedtime for psychosis 04/17/24 to 04/28/24 with a start date of 04/17/24. The MAR indicated Resident #415 received buspirone hcl 5 mg three times a day for anxiety from 04/13/24 to 04/28/24 and one time a day on 04/12/24 with a start date of 04/12/24.<BR/>Record review of the electronic record for Resident #415 from 04/11/24 to 04/29/24 indicated the nurses did not document monitoring of side effects of the antianxiety medication or antipsychotic medication daily with medication administration. <BR/>During an observation on 04/29/24 at 08:53 a.m., Resident #415 was sitting up in a recliner. She said she was treated great and received needed care. <BR/>During an interview on 04/30/24 at 02:07 p.m., LVN R said she provided care for Resident #415 today. LVN F said she proved care for Resident #415 on 04/26/24 and was currently taking over care for Resident #415 for today. LVN R and F said were educated on monitoring for side effects of antipsychotic medication. They said Resident #415 should have been monitored for side effects but was not. LVN F said as nurses they were aware and monitored antipsychotic medication for side effects it was just not documented correctly. They said the nurse admitting the resident was responsible for adding monitoring into the computer system and the DON and ADON double checked for monitoring. LVN F said she admitted Resident #415 and was responsible and started the orders but did not complete them. She said she was aware as a nurse to monitor the meds for side effects but if you did not document it, you did not do it. LVN F said the risk was the potential side effects were not being documented properly but no risk to residents. LVN R said the medication should have been documented in the system but was missed.<BR/>During an interview on 04/30/24 at 02:39 p.m., the DON said the admission nurse started the medication orders and monitoring of medication in the computer system and the IDT double checked medication for monitoring. She said Resident #415 should have been monitored for the antipsychotic medications Abilify, buspirone and quetiapine fumarate but was not. The DON said the nurses were educated through annual check offs on medication administration on 04/12/24. She said the monitoring was overlooked. She said the risk of antipsychotic medication not monitored was potential adverse reactions and side effects. The DON said her expectation was all medication to be given as ordered and monitored for side effects as required.<BR/>During an interview on 04/30/24 at 03:41 p.m., the Administrator said her expectation was all physician orders followed as ordered and all medication be monitored for side effects as required. She said the risk of antipsychotic medication not monitored was potential side effects.<BR/>Record review of the facility's policy, revised July 2022, titled, Antipsychotic Medication Use indicated: .Antipsychotic medication will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. 18. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medication to the attending physician: a general / anticholinergic: constipation, blurred vision, dry mouth, urinary retention, sedation, .

Based on interview and record review, the facility failed to ensure employees received the required training effective communications mandatory training was completed for 6 of 21 employees (LVN F, ST, PT, CNA K, CNA M, and the HS) reviewed for training.<BR/>The facility did not ensure effective communication training was completed by LVN F, ST, PT, CNA K, and CNA M during orientation.<BR/>The facility did not ensure effective communication training was completed by the HS annually.<BR/>These failures could place residents at risk of miscommunication and social isolation due to lack of staff training. <BR/>Findings included:<BR/>Record review of the employee files and trainings indicated:<BR/>* LVN F, hire date 02/29/24, had not completed a communication training during orientation;<BR/>* ST, hire date 04/18/24, had not completed a communication training during orientation;<BR/>* PT, hire date 05/23/23, had not completed a communication training during orientation;<BR/>* CNA K, hire date 04/23/24, had not completed a communication training during orientation;<BR/>* CNA M, hire date 04/23/24, had not completed a communication training during orientation; and <BR/>* HS, hire date 05/16/18, last completed a communication training on 03/21/23.<BR/>During an interview on 05/01/24 at 11:16 a.m. the DON indicated she expected nursing staff to have all of the trainings during orientation and for them to have their annual trainings as required. She indicated all trainings were done in the computer except for the skills competencies she conducted on CNAs and LVNs upon hire. She indicated staff not having the trainings as required could cause residents not to receive the care needed. <BR/>During an interview on 05/01/24 at 01:08 p.m. the Administrator indicated she expected all trainings required during orientation to be done during orientation. She indicated she also expected trainings to be done annually as required. She indicated ultimately, she was responsible to ensure staff completed their trainings. She indicated staff not completing the trainings could cause residents not to receive the care required. <BR/>During an interview on 05/01/24 at 01:32 p.m. the HR indicated there was an issue in the computer-based trainings and it did not triggered the required trainings for staff for orientation and annually. <BR/>Record review of a Training Programs policy dated October 2021 indicated Purpose: To ensure employees are provided the necessary training to perform their job at a high level while meeting state and federal regulations regarding annual training and in-servicing. Policy: Upon hire, and on an ongoing basis, employees will be provided the appropriate training to include state and federally mandated training information and topics. The Director of Staff Development along with the HR Director will be responsible for ensuring the appropriate training needs of staff are met.

Based on interview and record review, the facility failed to ensure the rights of the resident and responsibilities of the facility were completed for 3 of 21 employees (OT, CNA M, and HS) reviewed for training.<BR/>The facility failed to ensure the rights of the resident and responsibilities of the facility training was completed by OT and CNA M during orientation.<BR/>The facility failed to ensure the rights of the resident and responsibilities of the facility training was completed by HS annually.<BR/>These failures could affect residents and place them at risk of being uninformed due to lack of staff training. <BR/>Findings include:<BR/>Record review of the employee files and trainings indicated:<BR/>* OT, hire date 09/28/23, had not completed rights of the resident and responsibilities of the facility training during orientation;<BR/>* CNA M, hire date 04/23/24, had not completed rights of the resident and responsibilities of the facility training during orientation; and <BR/>* HS, hire date 05/16/18, last completed rights of the resident and responsibilities of the facility training on 03/23/23.<BR/>During an interview on 05/01/24 at 11:16 a.m. the DON indicated she expected nursing staff to have all of the trainings during orientation and for them to have their annual trainings as required. She indicated staff not having the trainings as required could cause residents not to receive the care needed. <BR/>During an interview on 05/01/24 at 01:08 p.m. the Administrator indicated she expected all trainings required during orientation to be done during orientation. She indicated she also expected trainings to be done annually as required. She indicated ultimately, she was responsible to ensure staff completed their trainings. She indicated staff not completing the trainings could cause residents not to receive the care required. <BR/>During an interview on 05/01/24 at 01:32 p.m. the HR indicated there was an issue in the computer-based trainings and it did not triggered the required trainings for staff for orientation and annually.<BR/>Record review of a Training Programs policy dated October 2021 indicated Purpose: To ensure employees are provided the necessary training to perform their job at a high level while meeting state and federal regulations regarding annual training and in-servicing. Policy: Upon hire, and on an ongoing basis, employees will be provided the appropriate training to include state and federally mandated training information and topics. The Director of Staff Development along with the HR Director will be responsible for ensuring the appropriate training needs of staff are met.

Based on interview and record review, the facility failed to ensure employees received the required training on Abuse, Neglect, and Exploitation (ANE) for 2 of 15 (OT and HS) and dementia management for 2 of 15 employees (OT and LVN C) reviewed for training.<BR/>The facility did not ensure dementia management training was completed by the OT and LVN C during orientation. <BR/>The facility did not ensure ANE training was completed by the OT during orientation. <BR/>The facility did not ensure ANE training was completed by the HS annually.<BR/>This failure could place residents with dementia at risk of abuse, neglect, and exploitation and a poor quality of care by staff with inadequate training when caring for dementia residents.<BR/>Findings included:<BR/>Record review of the employee files indicated:<BR/>* LVN C, hire date 07/12/23, had not completed dementia management training during orientation;<BR/>* OT, hire date 09/28/23, had not completed ANE and dementia management training during orientation ; and <BR/>* HS, hire date 05/16/18, last completed ANE training on 03/23/23.<BR/>During an interview on 05/01/24 at 11:16 a.m. the DON indicated she expected nursing staff to have all of the trainings during orientation and for them to have their annual trainings as required. She indicated staff not having the trainings as required could cause residents not to receive the care needed. <BR/>During an interview on 05/01/24 at 01:08 p.m. the Administrator indicated she expected all trainings required during orientation to be done during orientation. She indicated she also expected trainings to be done annually as required. She indicated ultimately, she was responsible to ensure staff completed their trainings. She indicated staff not completing the trainings could cause residents not to receive the care required. <BR/>During an interview on 05/01/24 at 01:32 p.m. the HR indicated there was an issue in the computer-based trainings and it did not triggered the required trainings for staff for orientation and annually.<BR/>Record review of a Training Programs policy dated October 2021 indicated Purpose: To ensure employees are provided the necessary training to perform their job at a high level while meeting state and federal regulations regarding annual training and in-servicing. Policy: Upon hire, and on an ongoing basis, employees will be provided the appropriate training to include state and federally mandated training information and topics. The Director of Staff Development along with the HR Director will be responsible for ensuring the appropriate training needs of staff are met.

Based on interview and record review, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program was completed for 15 of 21 employees (Administrator, BOM, DON, ST, PT, SW, AD, LVN C, LVN D, LVN F, CNA G, CNA H, CNA J, CNA K, CNA L and CNA M) reviewed for training.<BR/>The facility did not ensure QAPI training was completed by the Administrator, BOM, DON, ST, PT, SW, AD, LVN C, LVN D, LVN F, CNA G, CNA H, CNA J, CNA K, CNA L and CNA M.<BR/>This failure could place staff and residents at risk for not being aware of facility programs, implementation, and monitoring. <BR/>Findings included:<BR/>Record review of employee files indicated QAPI training was not done for the following staff:<BR/>* Administrator, hire date 01/17/23, <BR/>* BOM, hire date 03/18/24, <BR/>* DON, hire date 08/02/22, <BR/>* PT, hire date 05/25/23,<BR/>* ST, hire date 04/18/24, <BR/>* SW, hire date 02/29/24, <BR/>* AD, hire date 12/21/20, <BR/>* LVN C, hire date 07/12/23, <BR/>* LVN D, hire date 10/26/23, <BR/>* LVN F, hire date 02/29/24, <BR/>* CNA G, hire date 02/03/23,<BR/>* CNA H, hire date 08/03/22, <BR/>* CNA J, hire date 05/25/22, <BR/>* CNA K, hire date 04/23/24, <BR/>* CNA L, hire date 02/01/24, and <BR/>* CNA M, hire date 12/07/23.<BR/>During an interview on 05/01/24 at 11:16 a.m. the DON indicated she expected nursing staff to have all of the trainings during orientation and for them to have their annual trainings as required. She indicated all trainings were done in the computer except for the QAPI training she had done in January 2024. She indicated staff not having the trainings as required could cause residents not to receive the care needed. <BR/>During an interview on 05/01/24 at 01:08 p.m. the Administrator indicated she expected all trainings required during orientation to be done during orientation. She indicated she also expected trainings to be done annually as required. She indicated ultimately, she was responsible to ensure staff completed their trainings. She indicated staff not completing the trainings could cause residents not to receive the care required. <BR/>During an interview on 05/01/24 at 01:32 p.m. the HR indicated there was an issue in the computer-based trainings and it did not trigger the required trainings for staff for orientation and annually.<BR/>Record review of a Training Programs policy dated October 2021 indicated Purpose: To ensure employees are provided the necessary training to perform their job at a high level while meeting state and federal regulations regarding annual training and in-servicing. Policy: Upon hire, and on an ongoing basis, employees will be provided the appropriate training to include state and federally mandated training information and topics. The Director of Staff Development along with the HR Director will be responsible for ensuring the appropriate training needs of staff are met.

Based on interview and record review, the facility failed to ensure compliance and ethics training was completed for 21 of 21 employees (Administrator, BOM, DON, ADON, ST, OT, PT, SW LVN D, LVN E, LVN F, CNA G, CNA H, CNA J, CNA K, CNA L, and CNA M) reviewed for training.<BR/>The facility did not ensure compliance and ethics training was completed for the BOM, ADON, LVN C, LVN D, LVN F, ST, OT, PT, SW, MD, CNA K, CNA L, and CNA M during orientation.<BR/>The facility did not ensure compliance and ethics training was completed by the Administrator, DON, LVN E, AD, HS, CNA G, CNA H, and CNA J annually since the company had a total of 6 facilities.<BR/>This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. <BR/>Findings included: <BR/>Record review of employee files indicated the following staff had not completed compliance and ethics training during orientation:<BR/>* BOM, hire date 03/18/24, <BR/>* ADON, hire date 10/02/23, <BR/>* LVN C, hire date 07/12/23, <BR/>* LVN D, hire date 10/26/23, <BR/>* LVN F, hire date 02/29/24,<BR/>* ST, hire date 04/18/24, <BR/>* OT, hire date 09/28/23, <BR/>* PT, hire date 05/25/23, <BR/>* SW, hire date 02/29/24, <BR/>* MD, hire date 08/28/23, <BR/>* CNA K, hire date 04/23/24, <BR/>* CNA L, hire date 02/01/24, and <BR/>* CNA M, hire date 12/07/23. <BR/>Record review of employee files indicated the following staff had not completed compliance and ethics training annually:<BR/>* Administrator, hire date 01/17/23,<BR/>* DON, hire date 08/02/22, <BR/>* LVN E, hire date 03/01/15,<BR/>* AD, hire date 12/21/20,<BR/>* HS, hire date 05/16/18, <BR/>* CNA G, hire date 02/03/23, <BR/>* CNA H, hire date 08/03/22,and <BR/>* CNA J, hire date 05/25/22. <BR/>During an interview on 05/01/24 at 11:16 a.m., the DON indicated she expected nursing staff to have all of the trainings during orientation and for them to have their annual trainings as required. She indicated staff not having the trainings as required could cause residents not to receive the care needed. <BR/>During an interview on 05/01/24 at 01:08 p.m., the Administrator indicated she expected all trainings required during orientation to be done during orientation. She indicated she also expected trainings to be done annually as required. She indicated ultimately, she was responsible to ensure staff completed their trainings. She indicated staff not completing the trainings could cause residents not to receive the care required. <BR/>During an interview on 05/01/24 at 01:32 p.m., HR indicated there was an issue in the computer-based trainings and it did not trigger the required trainings for staff for orientation and annually.<BR/>Record review of a Training Programs policy dated October 2021 indicated Purpose: To ensure employees are provided the necessary training to perform their job at a high level while meeting state and federal regulations regarding annual training and in-servicing. Policy: Upon hire, and on an ongoing basis, employees will be provided the appropriate training to include state and federally mandated training information and topics. The Director of Staff Development along with the HR Director will be responsible for ensuring the appropriate training needs of staff are met. <BR/>

Based on interview and record review, the facility failed to ensure CNAcans completed Abuse, Neglect, and Exploitation (ANE) and dementia management trainings for 1 of 6 CNAs (CNA M) revicanewedreviewed for training.<BR/>The facility did not ensure ANE and dementia management trainings were completed by CNA M during orientation.<BR/>This failure could place residents with dementia at risk of abuse, neglect, and exploitation and a poor quality of care by staff with inadequate trainincang when caring for dementia residents. <BR/>Findings included:<BR/>Record review of employee files indicated:<BR/>* CNA M, hire date 12/07/23, had not completed ANE and dementia management trainings during orientation.<BR/>Record review of a Training Programs policy dated October 2021 indicated Purpose: To ensure employees are provided the necessary training to perform their job at a high level while meeting state and federal regulations regarding annual training and in-servicing. Policy: Upon hire, and on an ongoing basis, employees will be provided the appropriate training to include state and federally mandated training information and topics. The Director of Staff Development along with the HR Director will be responsible for ensuring the appropriate training needs of staff are met. <BR/>During an interview on 05/01/24 at 11:16 a.m., the DON indicated she expected nursing staff to have all of the trainings during orientation and for them to have their annual trainings as required. She indicated staff not having the trainings as required could cause residents not to receive the care needed. <BR/>During an interview on 05/01/24 at 1:08 p.m., the Administrator indicated she expected all trainings required during orientation to be done during orientation. She indicated she also expected trainings to be done annually as required. She indicated ultimately, she was responsible to ensure staff completed their trainings. She indicated staff not completing the trainings could cause residents not to receive the care required. <BR/>During an interview on 05/01/24 at 1:32 p.m. HR indicated there was an issue in the computer-based trainings and it did not trigger the required trainings for staff for orientation and annually.<BR/>Record review of a Training Programs policy dated October 2021 indicated Purpose: To ensure employees are provided the necessary training to perform their job at a high level while meeting state and federal regulations regarding annual training and in-servicing. Policy: Upon hire, and on an ongoing basis, employees will be provided the appropriate training to include state and federally mandated training information and topics. The Director of Staff Development along with the HR Director will be responsible for ensuring the appropriate training needs of staff are met.

Based on interview and record review, the facility failed to ensure training on behavioral health was completed for 4 of 21 employees (Administrator, OT, LVN C, and CNA M) reviewed for training. <BR/>The facility did not ensure behavioral health training was completed by the OT, LVN C, and CNA M during orientation.<BR/>The facility did not ensure behavioral health training was completed by the Administrator annually.<BR/>This failure could place residents with behaviors at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.<BR/>Findings included:<BR/>Record review of employee files indicated:<BR/>* OT, hire date 09/28/23, had not completed behavioral health training during orientation,;<BR/>* LVN C, hire date 07/12/23, had not completed behavioral health training during orientation,;<BR/>* CNA M, hire date 12/07/23, had not completed behavioral health training during orientation,; and <BR/>* Administrator, hire date 01/17/23, last completed behavioral health training on 01/24/23.<BR/>Record review of a Training Programs policy dated October 2021 indicated Purpose: To ensure employees are provided the necessary training to perform their job at a high level while meeting state and federal regulations regarding annual training and in-servicing. Policy: Upon hire, and on an ongoing basis, employees will be provided the appropriate training to include state and federally mandated training information and topics. The Director of Staff Development along with the HR Director will be responsible for ensuring the appropriate training needs of staff are met. <BR/>During an interview on 05/01/24 at 11:16 a.m., the DON indicated she expected nursing staff to have all of the trainings during orientation and for them to have their annual trainings as required. She indicated staff not having the trainings as required could cause residents not to receive the care needed. <BR/>During an interview on 05/01/24 at 01:08 p.m., the Administrator indicated she expected all trainings required during orientation to be done during orientation. She indicated she also expected trainings to be done annually as required including herself. She indicated ultimately, she was responsible to ensure staff completed their trainings. She indicated staff not completing the trainings could cause residents not to receive the care required. <BR/>During an interview on 05/01/24 at 01:32 p.m., the HR indicated there was an issue in the computer-based trainings and it did not trigger the required trainings for staff for orientation and annually.<BR/>Record review of a Training Programs policy dated October 2021 indicated Purpose: To ensure employees are provided the necessary training to perform their job at a high level while meeting state and federal regulations regarding annual training and in-servicing. Policy: Upon hire, and on an ongoing basis, employees will be provided the appropriate training to include state and federally mandated training information and topics. The Director of Staff Development along with the HR Director will be responsible for ensuring the appropriate training needs of staff are met.

Based on interviews, and record reviews, the facility failed provide sufficient support personnel to carry out the functions of the food and nutrition service safely and effectively for 3 out of 12 dietary staff (Dietary staff D, Dietary staff B, and Dietary staff C). <BR/>The facility did not ensure Dietary staff D, Dietary staff B, or Dietary staff C had current food handler permits.<BR/>This failure could place residents who consumed food prepared from the kitchen at-risk of foodborne illness or nutritional deficiencies. <BR/>Findings included:<BR/>Review of the food handler's certificates of completion provided by the facility on 06/16/2025 at 1:00 p.m., indicated the following:<BR/>Dietary staff D had a food handler certificate that expired on 01/08/2025.<BR/>Dietary staff B had a food handler certificate that expired on 01/10/2025.<BR/>Dietary staff C had a food handler certificate that expired on 01/10/2025.<BR/>An attempted telephone interview on 06/18/2025 at 09:57 a.m. with Dietary staff B was unsuccessful. <BR/>An attempted telephone interview on 06/18/2025 at 09:58 a.m. with Dietary staff C was unsuccessful. <BR/>During a telephone interview on 06/18/2025 at 10:00 a.m. with Dietary staff D, he said he had mistakenly thought his food handler certificate would not expire until September 2025. He said he must have looked at it incorrectly. Dietary staff D said he had been employed at facility since 2016. He said a negative outcome of not having an updated food handler certificate would be potential for food-borne illnesses and cross contamination. <BR/>During an interview on 06/18/25 at 09:00 a.m., the DM said the 3 dietary staff (Dietary staff D, Dietary staff B, and Dietary staff C) with expired food handlers' certificates had been working on a full-time basis since the expiration dates of January 2025. She said she had mentioned to them that their certificates needed to be renewed and was told they assumed they were good until the end of 2025. She said she failed to follow through on making sure they were renewed. She said the employees were responsible for keeping their certificates up to date, however she should have reviewed to ensure they were. The DM stated she relied on her staff to ensure their trainings were up to date. She said cross contamination and not being up to date with latest material as an ongoing training basis could pose negative outcome for residents who eat meals prepared from facility kitchen. <BR/>During an interview on 06/19/2025 at 3:00 p.m., the Administrator stated she expected the DM to ensure the dietary staff had their food handler certificates within 30 days of hire and before they expired. The Administrator stated the importance of obtaining and maintaining the food handler certificate training was to teach staff how to prevent food-borne illness and cross contamination. <BR/>Record review of facility policy titled Education and Training dated revised 10/2022 indicated <BR/>the following. All employees will be provided education and training upon hire and ongoing to ensure that they have the appropriate competencies and skill sets to carry out the functions of the food and nutrition services, taking into consideration the needs of the resident population.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free from pests in 2 of 2 resident rooms. <BR/>The facility failed to ensure two of two resident nightstands and rooms on Unit 2 were treated for cockroaches.<BR/>This failure could place residents at risk for an unsanitary environment and a decreased quality of life. <BR/>Findings included: <BR/>During an observation on 10/24/24 at 1:50 p.m., there were cockroaches in the nightstand drawers of Resident #1 and Resident #2. <BR/>During an interview on 10/24/24 at 1:50 p.m., Resident #1, who resided in room [ROOM NUMBER], said he reported the cockroaches a few weeks ago to the lady at the front of the facility. He said the cockroaches had infested his room for weeks. He said the cockroaches crawled on his face and woke him up at night. He said he should not have to deal with roaches crawling on him in his bed. He said the facility should have addressed the issue after he reported to staff. <BR/>During an interview on 10/24/24 at 2:00 p.m., Resident #2, who resided in room [ROOM NUMBER], said she had reported the roaches to staff but could not recall the name of the staff or when she reported the roaches. She said the cockroaches were in the drawers of the nightstand, closet, and bathroom. <BR/>During an interview on 10/24/24 at 2:10 p.m., the Administrator said the facility has monthly pest control and as needed. She said she was not aware of any reports of cockroach infestation. She said the facility has a pest control log located at the receptionist's desk. She said any staff could document issues in the log for the pest control company to review for treatments. She said the pest control company reviewed the log during the monthly visit to ensure the address any target areas. She said RT F should have notified her and the maintenance director immediately of Resident #1's report of cockroaches. She said she would have contacted the pest control company to address the issues immediately so the pest control company could treat for the cockroaches. She said residents were at risk of allergies and illness from cockroaches if they were left untreated by pest control. She said the facility did not have a policy for pest control.<BR/>During an interview on 10/24/24 at 2:25 p.m., RT F said Resident #1 reported on 10/01/24 he had cockroaches in his room, in his drawers and that crawled on him and woke him up at night. She said she wrote the Resident #1's allegation of cockroaches in the pest control log book on 10/01/24. She said she did not inform the Administrator or the Maintenance Director.<BR/>During an interview on 10/24/24 at 2:31 p.m., the Maintenance Director said he was not made aware of the cock roaches reported by Resident #1 or Resident #2. He said if he was made aware he would have contacted the pest control company. He said he did not know when the pest control company was scheduled to come to the facility for October 2024. He said residents were at risk of allergies and illness from cockroaches if they were left untreated by pest control.<BR/>Record review of the pest control log dated 10/01/24 indicated there were cock roaches witnessed by staff (staff were not identified) on the entire D hall on unit 2.<BR/>Record review of the pest control treatment records indicated the facility was treated for cockroaches on 09/02/24. The pest control service would return in October 2024 or as needed to continue service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe, clean and homelike environment for 1 of 24 residents (Resident #92) reviewed for environment.<BR/>The facility failed to provide Resident #92 with a thoroughly clean room without other resident's personal belongings in his room.<BR/>This failure could place residents at risk of unclean, unhomelike environment and a decline in health.<BR/>The findings included:<BR/>Record review of face sheet dated 04/30/24 indicated Resident #92 was admitted on [DATE] with diagnoses of urinary tract infection, altered mental status and heart disease.<BR/>Record review of the quarterly MDS assessment dated [DATE] indicated Resident #92 with a BIMS score of 10 (moderate cognition impairment) and moderate assistance with toileting hygiene and showering. <BR/>Record review of the care plan dated 04/30/2024 for Resident #92 has UTI / with Staphylococcus aureus was prescribed: Oxacillin Sodium. Interventions included to check at least every 2 hours for incontinence, wash, rinse, and dry soiled areas, and encourage adequate fluid intake.<BR/>During an observation and interview on 04/30/24 at 9:30 a.m., Resident #92's room had a stack of boxes and bags on the floor, which contained personal belongs for female clothes, stuffed animals and wrapped box with a female name. A plastic chest with personal belongings. He said he moved here last night and was not sure what that stuff was.<BR/>During an interview on 04/30/24 at 1:00 p.m., the DON said the personal belongings on the floor of Resident #92's room belong to a resident who discharged about 2 weeks ago. She said when a resident discharges all items sent home with the families or disposed of if the family desires the items to be disposed of. The room should had been deep cleaned to prevent spreading germs and then it could be occupied by another person. She said the room was for Resident #92 and no other resident's personal belongings should had been left in the room.<BR/>During an interview on 05/01/24 at 10:00 a.m., the ADON said all personal belongings of discharged resident should be removed then room should be deep cleaned before another resident could be placed in the room. She said to prevent the spread of germs.<BR/>During an interview on 05/01/24 at 10:10 a.m., Housekeeping Supervisor said her housekeepers would clean the rooms of discharged residents when personal belongs were removed. They have a place to put donated clothes. She said she would remove personal belongings and deep clean the room. She said she was not sure what happen. She said all rooms should be cleaned prior to someone being placed in the rooms to prevent spread of germs and so he has the space for his belongings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe, clean and homelike environment for 1 of 24 residents (Resident #92) reviewed for environment.<BR/>The facility failed to provide Resident #92 with a thoroughly clean room without other resident's personal belongings in his room.<BR/>This failure could place residents at risk of unclean, unhomelike environment and a decline in health.<BR/>The findings included:<BR/>Record review of face sheet dated 04/30/24 indicated Resident #92 was admitted on [DATE] with diagnoses of urinary tract infection, altered mental status and heart disease.<BR/>Record review of the quarterly MDS assessment dated [DATE] indicated Resident #92 with a BIMS score of 10 (moderate cognition impairment) and moderate assistance with toileting hygiene and showering. <BR/>Record review of the care plan dated 04/30/2024 for Resident #92 has UTI / with Staphylococcus aureus was prescribed: Oxacillin Sodium. Interventions included to check at least every 2 hours for incontinence, wash, rinse, and dry soiled areas, and encourage adequate fluid intake.<BR/>During an observation and interview on 04/30/24 at 9:30 a.m., Resident #92's room had a stack of boxes and bags on the floor, which contained personal belongs for female clothes, stuffed animals and wrapped box with a female name. A plastic chest with personal belongings. He said he moved here last night and was not sure what that stuff was.<BR/>During an interview on 04/30/24 at 1:00 p.m., the DON said the personal belongings on the floor of Resident #92's room belong to a resident who discharged about 2 weeks ago. She said when a resident discharges all items sent home with the families or disposed of if the family desires the items to be disposed of. The room should had been deep cleaned to prevent spreading germs and then it could be occupied by another person. She said the room was for Resident #92 and no other resident's personal belongings should had been left in the room.<BR/>During an interview on 05/01/24 at 10:00 a.m., the ADON said all personal belongings of discharged resident should be removed then room should be deep cleaned before another resident could be placed in the room. She said to prevent the spread of germs.<BR/>During an interview on 05/01/24 at 10:10 a.m., Housekeeping Supervisor said her housekeepers would clean the rooms of discharged residents when personal belongs were removed. They have a place to put donated clothes. She said she would remove personal belongings and deep clean the room. She said she was not sure what happen. She said all rooms should be cleaned prior to someone being placed in the rooms to prevent spread of germs and so he has the space for his belongings.

Based on interview and record review, the facility failed to ensure standards, policies, and procedures for an infection prevention and control program was completed for 4 of 21 staff (LVN C, OT, HS, and CNA M) reviewed for training.<BR/>The facility did not ensure infection prevention and control training was completed by the OT, CNA M, and LVN C during orientation.<BR/>The facility did not ensure infection prevention and control training was completed by the HS annually.<BR/>These failures could place residents at risk of illness due to lack of staff training. <BR/>Findings included:<BR/>Record review of employee files indicated: <BR/>* OT, hire date 09/28/23, had not completed infection prevention and control training during orientation;<BR/>* LVN C, hire date 07/12/23, had not completed infection prevention and control training during orientation;<BR/>* CNA M, hire date 04/23/24, had not completed infection prevention and control training during orientation; and <BR/>* HS, hire date 05/16/18, last completed infection prevention and control training on 03/31/23.<BR/>During an interview on 05/01/24 at 11:16 a.m., the DON indicated she expected nursing staff to have all of the trainings during orientation and for them to have their annual trainings as required. She indicated staff not having the trainings as required could cause residents not to receive the care needed. <BR/>During an interview on 05/01/24 at 01:08 p.m., the Administrator indicated she expected all trainings required during orientation to be done during orientation. She indicated she also expected trainings to be done annually as required. She indicated ultimately, she was responsible to ensure staff completed their trainings. She indicated staff not completing the trainings could cause residents not to receive the care required. <BR/>During an interview on 05/01/24 at 01:32 p.m. the HR indicated there was an issue in the computer-based trainings and it did not trigger the required trainings for staff for orientation and annually.<BR/>Record review of a Training Programs policy dated October 2021 indicated Purpose: To ensure employees are provided the necessary training to perform their job at a high level while meeting state and federal regulations regarding annual training and in-servicing. Policy: Upon hire, and on an ongoing basis, employees will be provided the appropriate training to include state and federally mandated training information and topics. The Director of Staff Development along with the HR Director will be responsible for ensuring the appropriate training needs of staff are met.

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for essential equipment. <BR/>The facility did not ensure the gas stove and the convection ovens were in safe operating condition. <BR/>This failure could place the residents at risk of a fire and not receiving their meals timely. <BR/>Findings included:<BR/>During observation and interview on 4/29/24 at 9:00 a.m., the double oven had a thick black substance on the interior walls, on the metal racks and on the base/floor of the oven. The DM said the oven was not used and had not worked since she started working at the facility about a year ago. The DM said the oven needed to be repaired. She said there was not an open work order for repair of the oven. <BR/>During observation and interview on 4/30/24 at 10:45 a.m., the left and right sides of oven were not hot and there was no food in the oven. The DM said the oven did not work, the single gas convection oven did not work and the bottom half of the double convection oven did not work, so they only had the top of the double convection oven for use in cooking the resident's food. She said if one cook had to bake a dessert and another cook had to bake food, they would have to wait on each other because all they had to use to cook the food was the top section of the double convection oven. She said she had worked at the facility for almost a year and the double oven, the single gas convection oven and the bottom section of the double convection oven had been broken since she started. <BR/>During an interview on 5/01/24 at 8:34 a.m., the dietary manager said the double oven was broke and should be in working order. She said the single gas convection oven and the double convection oven were broke and needed to be fixed. She said the possible negative outcome would be the residents may not receive their meals on time. She said her expectations were for the kitchen equipment to be in working order. <BR/>During an interview on 05/01/24 at 11:16 a.m., the Administrator said her expectations were for the kitchen equipment to be fixed, in working order, be able to be sanitized sanitizable and to not contain rust. She said the negative outcome of the kitchen equipment not working could be a delay in meal service. <BR/>Record review of the Equipment policy dated 01/2001 indicated: Policy Statement- All food service equipment will be clean, sanitary and in proper working order. <BR/>According to the FDA Food Code 2022 accessed at https://www.fda.gov/food/retail-food-protection/fda-food-code 4-5 Maintenance and Operation 4-501 Equipment 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure pharmaceutical services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required for 1 of 24 residents reviewed for physician orders. (Resident #92)<BR/>The facility failed to follow physician orders related to ferrous gluconate (used to treat or prevent low blood levels of iron) for Resident #92.<BR/>This failure could place the residents at risk of not receiving care and services as ordered by the physician. <BR/>Findings included:<BR/>Record review of face sheet dated 4/30/24 indicated Resident #92 was admitted on [DATE] with diagnoses of urinary tract infection, altered mental status and heart disease.<BR/>Record review of the physician's orders for Resident #92 dated 04/30/24 indicated ferrous gluconate tablet 324 mg, Give 1 tablet by mouth one time a day with start date of 04/18/2024.<BR/>Record review of the MAR for Resident #92 indicated from 4/18/24 to 4/29/24 the ferrous gluconate was not given and not initialed as being given.<BR/>Record review of the quarterly MDS assessment dated [DATE] indicated Resident #92 with a BIMS score of 10 (moderate cognition impairment) and moderate assistance with toileting hygiene and showering. <BR/>Record review of the care plan dated 12/06/23 for Resident #92 has diagnoses of anemia was prescribed iron supplement. Interventions included:<BR/> Educate the resident/family/caregivers to expect change in color of stools. (Dark<BR/>green to black) and give medications as ordered. Monitor for side effects, effectiveness. Monitor/document/report PRN following s/sx of anemia: Pallor, Fatigue, Dizziness.<BR/>During an interview on 4/30/24 at 1:00 p.m., the DON said Resident #92 was not given his iron as ordered, and she was going to call his physician. She said his ferrous gluconate tablet was not given because when the order was changed on 04/17/24 the order was placed on the MA MARS not the nurse MARS. She said the facility had not used medication aides. She said she was responsible for monitoring and ensuring medications were placed correctly on the MARs.<BR/>Record review of the policy titled Administering Medication dated April 2019 indicated Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with the prescribers orders, including any required tie frame.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure pharmaceutical services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required for 1 of 24 residents reviewed for physician orders. (Resident #92)<BR/>The facility failed to follow physician orders related to ferrous gluconate (used to treat or prevent low blood levels of iron) for Resident #92.<BR/>This failure could place the residents at risk of not receiving care and services as ordered by the physician. <BR/>Findings included:<BR/>Record review of face sheet dated 4/30/24 indicated Resident #92 was admitted on [DATE] with diagnoses of urinary tract infection, altered mental status and heart disease.<BR/>Record review of the physician's orders for Resident #92 dated 04/30/24 indicated ferrous gluconate tablet 324 mg, Give 1 tablet by mouth one time a day with start date of 04/18/2024.<BR/>Record review of the MAR for Resident #92 indicated from 4/18/24 to 4/29/24 the ferrous gluconate was not given and not initialed as being given.<BR/>Record review of the quarterly MDS assessment dated [DATE] indicated Resident #92 with a BIMS score of 10 (moderate cognition impairment) and moderate assistance with toileting hygiene and showering. <BR/>Record review of the care plan dated 12/06/23 for Resident #92 has diagnoses of anemia was prescribed iron supplement. Interventions included:<BR/> Educate the resident/family/caregivers to expect change in color of stools. (Dark<BR/>green to black) and give medications as ordered. Monitor for side effects, effectiveness. Monitor/document/report PRN following s/sx of anemia: Pallor, Fatigue, Dizziness.<BR/>During an interview on 4/30/24 at 1:00 p.m., the DON said Resident #92 was not given his iron as ordered, and she was going to call his physician. She said his ferrous gluconate tablet was not given because when the order was changed on 04/17/24 the order was placed on the MA MARS not the nurse MARS. She said the facility had not used medication aides. She said she was responsible for monitoring and ensuring medications were placed correctly on the MARs.<BR/>Record review of the policy titled Administering Medication dated April 2019 indicated Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with the prescribers orders, including any required tie frame.<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, staff, and the public for 1 of 1 staff smoking area reviewed for environmental concerns.<BR/>The designated staff smoking area was unkempt and had trash buried in the tall grass and weeds,<BR/>This failure placed the staff and visitors at risk of uncomfortable environment.<BR/>Findings included: <BR/>During an observation on 06/16/25 at 1:00 p.m., the grass in courtyard between hall 200 and 300 was approximately 20 inches high and the weeds were over 4 feet tall. There were plastic wrappers trash and, paper towels, and cigarette butts were buried in the vegetation.<BR/>During an interview on 06/16/25 at 2:00 p.m., Maintenance A said the maintenance department was responsible for ensuring the trash was picked up. He said this smoking area between hall 200 and 300 was for the staff and visitors smoking area. He said the areas should be maintained and be homelike for the residents. He said tall grass could lead to pest coming into the building. He said a contract lawn service was supposed to [NAME]. He said about a month ago, they tried to run a weed eater, but the weed eater broke.<BR/>During an interview on 06/18/25 at 2:00 p.m., the Administrator said she had been attempting to obtain a contract for lawn services and had one company coming out to [NAME], however, they did not show up. She said she would continue to obtain a lawn service, and have maintenance pick up the trash. She said she the expectation was for the facility to be maintained with a homelike environment. <BR/>Record Review of the policy Homelike Environment indicated Policy Statement<BR/>Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment.e. clean bed and bath linens that are in good condition.

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for essential equipment. <BR/>The facility did not ensure the gas stove and the convection ovens were in safe operating condition. <BR/>This failure could place the residents at risk of a fire and not receiving their meals timely. <BR/>Findings included:<BR/>During observation and interview on 4/29/24 at 9:00 a.m., the double oven had a thick black substance on the interior walls, on the metal racks and on the base/floor of the oven. The DM said the oven was not used and had not worked since she started working at the facility about a year ago. The DM said the oven needed to be repaired. She said there was not an open work order for repair of the oven. <BR/>During observation and interview on 4/30/24 at 10:45 a.m., the left and right sides of oven were not hot and there was no food in the oven. The DM said the oven did not work, the single gas convection oven did not work and the bottom half of the double convection oven did not work, so they only had the top of the double convection oven for use in cooking the resident's food. She said if one cook had to bake a dessert and another cook had to bake food, they would have to wait on each other because all they had to use to cook the food was the top section of the double convection oven. She said she had worked at the facility for almost a year and the double oven, the single gas convection oven and the bottom section of the double convection oven had been broken since she started. <BR/>During an interview on 5/01/24 at 8:34 a.m., the dietary manager said the double oven was broke and should be in working order. She said the single gas convection oven and the double convection oven were broke and needed to be fixed. She said the possible negative outcome would be the residents may not receive their meals on time. She said her expectations were for the kitchen equipment to be in working order. <BR/>During an interview on 05/01/24 at 11:16 a.m., the Administrator said her expectations were for the kitchen equipment to be fixed, in working order, be able to be sanitized sanitizable and to not contain rust. She said the negative outcome of the kitchen equipment not working could be a delay in meal service. <BR/>Record review of the Equipment policy dated 01/2001 indicated: Policy Statement- All food service equipment will be clean, sanitary and in proper working order. <BR/>According to the FDA Food Code 2022 accessed at https://www.fda.gov/food/retail-food-protection/fda-food-code 4-5 Maintenance and Operation 4-501 Equipment 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe, clean and homelike environment for 1 of 24 residents (Resident #92) reviewed for environment.<BR/>The facility failed to provide Resident #92 with a thoroughly clean room without other resident's personal belongings in his room.<BR/>This failure could place residents at risk of unclean, unhomelike environment and a decline in health.<BR/>The findings included:<BR/>Record review of face sheet dated 04/30/24 indicated Resident #92 was admitted on [DATE] with diagnoses of urinary tract infection, altered mental status and heart disease.<BR/>Record review of the quarterly MDS assessment dated [DATE] indicated Resident #92 with a BIMS score of 10 (moderate cognition impairment) and moderate assistance with toileting hygiene and showering. <BR/>Record review of the care plan dated 04/30/2024 for Resident #92 has UTI / with Staphylococcus aureus was prescribed: Oxacillin Sodium. Interventions included to check at least every 2 hours for incontinence, wash, rinse, and dry soiled areas, and encourage adequate fluid intake.<BR/>During an observation and interview on 04/30/24 at 9:30 a.m., Resident #92's room had a stack of boxes and bags on the floor, which contained personal belongs for female clothes, stuffed animals and wrapped box with a female name. A plastic chest with personal belongings. He said he moved here last night and was not sure what that stuff was.<BR/>During an interview on 04/30/24 at 1:00 p.m., the DON said the personal belongings on the floor of Resident #92's room belong to a resident who discharged about 2 weeks ago. She said when a resident discharges all items sent home with the families or disposed of if the family desires the items to be disposed of. The room should had been deep cleaned to prevent spreading germs and then it could be occupied by another person. She said the room was for Resident #92 and no other resident's personal belongings should had been left in the room.<BR/>During an interview on 05/01/24 at 10:00 a.m., the ADON said all personal belongings of discharged resident should be removed then room should be deep cleaned before another resident could be placed in the room. She said to prevent the spread of germs.<BR/>During an interview on 05/01/24 at 10:10 a.m., Housekeeping Supervisor said her housekeepers would clean the rooms of discharged residents when personal belongs were removed. They have a place to put donated clothes. She said she would remove personal belongings and deep clean the room. She said she was not sure what happen. She said all rooms should be cleaned prior to someone being placed in the rooms to prevent spread of germs and so he has the space for his belongings.