**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.Record review of Resident #22's face sheet, dated 04/23/25, reflected Resident #22 was a [AGE] year-old male, readmitted to the facility on [DATE] with a diagnosis which included multiple sclerosis (chronic, progressive disease involving damage to the sheaths of nerves cells in the brain and spinal cord causing numbness, impairment of speech, and of muscular coordination, blurred vison and sever fatigue). Record review of Resident #22's significant change in status MDS, dated [DATE], reflected Resident #22 made himself understood, and understood others. Resident #22's BIMS score was 15, which indicated his cognition was intact. Resident #22 required substantial/maximum assistance with eating, oral hygiene, upper body dressing, personal hygiene and dependent with toileting, shower/bath, and lower body dressing. Record review of the comprehensive care plan, revised 04/23/25, reflected Resident #22 was at risk for injury due to his smoking preference. The care plan interventions included to educate Resident #22 and encourage him to follow facility smoking times, designated smoking areas as needed. The care plan initiated on 03/31/25, reflected Resident #22 had a history of being signed out of facility in parking lot in electric wheelchair using his chair to block staff from parking their cars. The care plan interventions included staff to call into facility for assistance if they could not park their vehicle due to Resident #22 blocking parking spaces or entrances to parking lot. Record review of a quarterly smoking/vaping safety evaluation dated 03/31/25 reflected Resident #22 had a DX of multiple sclerosis and had burned himself during previous admission when he dropped a cigarette on himself while signed out to smoke. The evaluation reflected Resident #22 was confirmed not to be a safe smoker/vaper. Record review of a resident sign out/in log reflected on 04/21/25 Resident #22 signed out at 10:00 a.m. and did not sign back in until 12:02 p.m. During an observation on 04/21/25 at 10:15 a.m., Resident #22 and Resident #32 was observed in the wheelchairs sitting directly on a public roadway, near a residential home while they smoked without supervision. There were no sidewalks provided off the roadway. During an interview and observation on 04/22/25 at 10:21 a.m., Resident #22 was sitting outside in front of the facility vaping without supervision. Resident #22 stated he was told by the facility if he wanted to smoke a cigarette, outside the smoking times, he must sign out and go across the road. Resident #22 was unsure why he was made to do that. Resident #22 stated if he vaped, he could just come outside the facility to do that. Resident #22 stated he did not require supervision unless he went to smoke during the smoke breaks. Resident #22 stated he kept 1 vape on him and the facility kept the other one. Resident #22 stated his lighter was battery operated and was able to light his own cigarette unless the battery was dead. Resident #22 stated if the battery was dead, he would stop and ask someone that was driving by or walking to light his cigarette. During an observation on 04/22/25 at 2:00 p.m., Resident #22 was sitting in his electric wheelchair visiting with another resident. A vape was noted on top of his dresser. During an interview and observation on 04/22/25 at 2:15 p.m., Resident #22 was observed sitting outside in front of the facility vaping with cigarettes noted in the black pouch. Resident #22 stated he was not signed out at the moment, but he knew if he went across the street to smoke, he must go in and sign out. During an interview on 04/22/25 at 2:36 p.m., the ADON stated Resident #22 had to sign out if he wanted to smoke outside the smoke breaks. The ADON stated there was an incident, prior to him been readmitted to the facility, where he was signed out and when he came back, burn holes were noted to the hoyer sling and his shorts. The ADON stated if Resident #22 vapes, he did not have to sign out, but he must go outside in the front of the facility to vape. The ADON stated he was not considered a safe smoker, but he was alert and oriented x3, so he was able to make decisions on his own. The ADON stated Resident #22 did keep a few cigarettes in his pouch that he keeps on him, but he was aware that he must sign out to smoke the cigarettes he had in the pouch. The ADON stated Resident #22 did not require supervision unless during smoke breaks. After reviewing Resident #22's smoking evaluation with the state surveyor, the ADON stated he should not have the cigarettes or vapes on him because he was deemed not a safe smoker/vaper. The ADON stated she was not aware the policy stated, when deemed not a safe smoker/vaper, the resident required supervision. During an interview on 04/22/25 at 2:31 p.m., LVN A said Resident #22 had the right to smoke if he wanted to. She said Resident #22 was not a safe smoker. She said Resident #22 had to sign himself out if he wanted to go across the street to smoke. She said Resident #22 always kept a small bag with cigarettes in it with him. She said she was not aware of any vapes he had. She said Resident #22 did not always comply with the rules, and it was his right to keep his cigarettes if he wanted them. During an interview on 04/22/25 at 2:40 p.m., LVN E said residents could sign out independently. She said Resident #22 had a little pouch that he always kept his cigarettes in. She said he would sign himself out and go smoke. She said she had never gave him a vape but only his cigarettes when he asked for them. She said she was aware he had a special lighter that he used to light his cigarettes but felt he was an unsafe smoker because of his hand dexterity. She said he kept his cigarette in his mouth, which put him at risk of burning his lips or dropping his ashes. She said when he signed out to go smoke, he was supposed to return his cigarettes when he came in, but sometimes he did not. She said that because he would go in and out so much, he would keep his cigarettes until the next time he wanted to smoke. During an interview on 04/22/25 at 3:19 p.m., the Administrator stated he was told by the Regional Director of Operations that Resident #22 was allowed to vape outside the facility without supervision. The Administrator stated Resident #22 should be signing himself out to smoke when he was off the property. The Administrator stated he did not know why Resident #22 had to sign himself to go across the street to smoke. The Administrator stated he was unaware Resident #22 was deemed as not a safe smoker/vaper. The Administrator stated if that was the case, he should always be supervised per the policy. The Administrator stated for as he knew, Resident #22 could not light his cigarette himself and he did not know who did it for him. The Administrator stated he was not aware Resident #22 had a battery-operated lighter he could use for himself. The Administrator stated he was unaware that he kept a vape and cigarettes on him. 3.Record review of Resident #48's face sheet, dated 04/24/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included urinary tract infection, also known as a UTI (is an infection in any part of the urinary system), stroke, diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), chronic obstructive pulmonary disease also known as COPD (a common lung disease causing restricted airflow and breathing problems), and high blood pressure. Record review of Resident #48's admission MDS assessment, dated 03/10/25, indicated Resident #48 understood others and was understood by others. The MDS assessment indicated she had a BIMS score of 15, indicating she was cognitively intact. Resident #48 required assistance with bathing and dressing, and was independent with toileting, bed mobility, personal hygiene, and eating. Record review of Resident #48's smoking assessment dated [DATE] indicated she was safe to smoke independently. Record review of Resident #48's care plan dated 3/31/25 indicated she was a safe smoker. The interventions were for staff to educate her and encourage her to follow the facility's smoking times, designated smoking areas, and policy as needed. During an observation on 04/22/25 at 7:58 a.m., Resident #48 was across the street, sitting on her rolling walker, smoking on the side of the road. During an observation on 04/22/25 at 2:02 p.m., Resident #48 was sitting on the front porch smoking. Resident #48 said she had signed out, so she could smoke. Review of the sign-out book, revealed on (date) Resident #48 had signed out at 1:50 pm. During an interview on 04/23/25 at 8:52 a.m., Resident #48 said she was told that if she wanted to smoke outside of the designated smoking times, she had to go across the street to smoke. She said she was told to sign out and go across the street. She said today (04/23/25), she was told she no longer had to sign out and smoke across the street. She said she could smoke on the premises if someone was smoking with her. 4.Record review of Resident #32's face sheet, dated 04/24/25, indicated an [AGE] year-old female who was admitted to the facility on 03/27 /25 with diagnoses which included urinary tract infection, also known as a UTI (is an infection in any part of the urinary system), stroke, diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), chronic obstructive pulmonary disease also known as COPD (a common lung disease causing restricted airflow and breathing problems), and high blood pressure. Record review of Resident #32's admission MDS assessment, dated 04/03/25, indicated Resident #32 understood others and was understood by others. The MDS assessment indicated she had a BIMS score of 0, indicating she was severely cognitively impaired. Resident #32 required assistance with bathing, toileting, dressing, bed mobility, personal hygiene, and eating. The MDS did not indicate she required oxygen. Record review of Resident #32's smoking assessment dated [DATE] indicated she was not a safe smoker/vaper related to contractures. Record review of Resident #32's smoking assessment dated [DATE] indicated she was safe to smoke/vape independently. Record review of Resident #32's care plan revised on 1/07/25, indicated Resident #32 was a safe smoker. The interventions were for staff to educate her and encourage her to follow the facility's smoking times, designated smoking areas, and policy as needed. During an interview on 04/23/25 at 8:30 a.m., Resident #32 said she was told that if she wanted to smoke outside of the designated smoking times, she had to go across the street to smoke. She said today (04/23/25) she was informed she no longer had to sign out to go across the street to smoke. She said she was able to smoke on the premises. During an interview on 04/22/25 at 2:40 p.m., LVN E said residents could sign out independently. She said Resident #32 often signed out and went across the street with Resident #22 to smoke. She was not sure of Resident #22's smoking assessment. During an interview on 04/24/25 at 3:27 p.m., LVN U said before the in-service today (04/24/25), she was under the impression that the resident who wished to smoke outside of designated smoking times had to sign out to go across the street. During an interview on 04/22/25 at 2:36 p.m., the ADON said the residents signed themselves out to smoke. She said Resident #48 and Resident #32 were safe smokers. She said she thought they wanted to go smoke across the street. During an interview on 04/22/25 at 3:20 p.m., the Administrator said residents were supposed to smoke in the back courtyard, and if it were raining, they could smoke on the front porch. He said they had the proper disposal out back and on the front porch. He said if a resident had been deemed a safe smoker, then they could smoke on the premises on the back or the front porch. He said he was not aware why Resident #48 and 32 signed out to go smoke. He said he thought Resident #48 and Resident #32 were safe smokers. 5.Record review of Resident #15's face sheet dated 04/30/25 indicated he was an [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses atherosclerotic heart disease (disease in which the build up of fat and cholesterol cause decreased blood flow), diabetes mellitus (disease that causes too much sugar in the blood stream), parkinsonism (neurogenerative disease that causes motor symptoms like tremors and slow movements), and anxiety (characterized by emotions involving increased fear or worry). Record review of Resident #15's quarterly MDS dated [DATE] indicated he understood others and could make himself understood. The MDS also indicated he had a BIMS score of 8 which meant he had moderate cognitive impairment. The MDS also indicated Resident #15 was dependent on staff for personal hygiene. Record review of Resident #15's care plan dated 2/14/23 indicated he had impaired cognitive function and an ADL self-care performance deficit and was dependent on staff for personal hygiene and required extensive assistance from the staff for personal hygiene. During an observation on 04/22/25 at 05:08 PM, Resident #15 had a light blue stainless-steel cup on his mini refrigerator with 7 disposable razors in it. During an observation on 04/23/25 at 07:53 AM, CNA X was in the room feeding Resident #15 and the light blue cup with 7 disposable razors were still sitting on the mini refrigerator in Resident #15's room. During an observation and interview on 04/23/25 at 09:30 AM, Resident #15 was in bed and continued to have the 7 disposable razors on the fridge in the blue cup. CNA X came in to Resident #15's room and said the facility CNAs shaved him but the disposable razors should not have been left there on Resident #15's refrigerator. CNA X said the disposable razors were not to be kept in the residents' rooms She said the disposable razors were kept in the locked bin for the CNAs to use and placed in the sharp's container after use. CNA X said Resident #15's family member would bring things into the facility at times. CNA X said the failure of the disposable razors being left out placed a risk for danger of the resident or other residents cutting themselves, but the facility did not have residents who wander. During an observation and interview on 04/23/25 at 09:41 AM, LPN A said the CNAs should keep the disposable razors stored in the sharp's containers in the bathroom after use. She said no disposable razors should have been left in any resident's room and in reach. LPN A said the failure placed a risk for residents to be injured or cut someone else. LPN A said all the staff were responsible for ensuring the razors were not left in resident's as she went and removed the disposable razors from the room and discarded them in the sharp's container. During an interview on 04/23/25 at 01:52 PM, the ADON said her expectation was for the disposable razors to be used and then disposed of properly in a sharp's container immediately after use. The ADON said the failure placed a risk for other residents getting the disposable razors and cutting themselves. She said all staff were responsible for ensuring no disposable razors or sharp objects were left out in reach of residents. During an interview on 04/23/25 at 02:04 PM, the Administrator said his expectation was for the CNAs to dispose of the disposable razors in the sharp's containers when they complete the residents' ADL care. He said the CNA assigned to the Resident #15 was responsible for ensuring the disposable razors were not left out in the room. The Administrator said the failure placed a risk for the resident or other resident to cut themselves. This was determined to be an Immediate Jeopardy (IJ) on 04/22/25 at 4:34 PM. The Administration was informed of the IJ. The Administrator was provided with the IJ template amendment on 04/23/25 at 11:54, and a plan of removal was requested. Record review of the facility's policy titled, Smoking Policy-Supervised and Unsupervised, revised 07/21/18 , indicated Safe Smoking Environment: it is the responsibility of the facility to provide a safe and hazard-free environment for those residents who have been assessed as being safe for facility smoking privileges. The facility is responsible for informing residents, staff, visitors, and other affected parties of the smoking policies through verbal means, distribution, and posting. This facility is intended to minimize the risk to residents: residents who smoke, including possible adverse effects on treatment; Passive smoke to others; and fire. Smoking accommodation: E cigarettes will be treated like cigarettes per policy at no time will E cigarettes be permitted for inside use of the facility. The facility is responsible for the enforcement of the smoking policy. Smoking is prohibited in any room or area within the facility. All residents who wish to smoke must provide funds to purchase their own smoking paraphernalia. Smoking Evaluation: Residents wishing to smoke while at the facility will have a smoking safety evaluation completed by the interdisciplinary team to determine the resident's ability to follow the smoking policy safely. If a resident is determined to be a safe smoker, the resident can smoke unsupervised, resident can keep their smoking supplies and smoke in a designated area at their leisure. Or a resident can smoke unsupervised, the facility will keep all smoking supplies, and the resident can smoke in designated areas at their leisure. If a resident is determined to be unsafe smoker then they must be supervised at all times when smoking facility staff will keep all smoking supplies and smoking times will be established by the facility and adhered to by the resident a supervised smoking schedule will be posted and residents will be required to smoke with supervision only according to the schedule. Record review of Plan of Removal accepted on 04/23/25 at 8:19 p.m. reflected the following: Plan of Removal Starting on 4/23/2025, resident #22, #48, and #32 will be supervised when in an unsafe area. The physician was notified of both the smoking and residents leaving safe supervised area. Immediately on 4/22/2025, all smoking assessments were audited for accuracy and care plan updated as indicated. Residents #22, #48, and #32 were reassessed and evaluation determined they are safe smokers and able to vape safely. Resident #25 was reassessed and evaluation determined he is an unsafe smoker. All smokers were reassessed, and changes made to safe or unsafe smoking, including vaping as indicated. Assessments completed by Corporate Clinical Specialist and Corporate Case Mix. Residents assessed to be unsafe will be supervised and smoking supplies will be held at the nurse's station. Residents assessed to be a safe smoker will be able to smoke unsupervised at their leisure in the designated smoking area. On 4/23/2025, an emergency care plan meeting was conducted with residents (#22, #48, #32, and #25) regarding safe supervision and smoking policy, to include vaping. Residents #22, #48 and #32 were informed they can smoke only in the smoking area of the facility. Resident #25 was informed that he remains and unsafe smoker and must be supervised. All smoking residents were educated in regards to the smoking area of the facility and informed that location is the only place they can smoke. Care plans updated as indicated to include education regarding safety plan and pedestrian safety. On 4/23/2025, Ombudsman notified of the incident with Resident #22, #48, and #32 smoking unsupervised in an unsafe area. Informed of Resident #25 incident of cigarette burn from 8/24/2024. On 4/23/2025, Medical Director notified of the incident with Resident #22, #48, and #32 smoking unsupervised in an unsafe area. Informed of Resident #25 incident of cigarette burn from 8/24/2024. On 4/22/2025, Corporate Clinical Specialist in-serviced Administrator and ADON regarding Accident/Hazard Supervision, specifically in regard to safe smoking policy, smoking assessment accuracy, designated smoking areas, and remaining in safe supervised area. Competency verified by quiz. Completed 4/22/2025. On 4/22/2025, facility Administrator and ADON in-serviced all staff regarding Accident/Hazard Supervision, specifically in regard to safe smoking policy, designated smoking areas, and remaining in safe supervised area. Competency verified by quiz. Staff will not be allowed to work until completion. Completed on 4/22/2025. On 4/23/2025, Corporate Clinical Specialist in-serviced staff on residents that are safe smokers and those that are not, and how to find that information. Completed 4/23/2025 On 4/23/2025, Corporate Clinical Specialist, or designee, in-serviced licensed nurses on completing smoking risk assessment accurately as related to current health concerns/conditions, resident capabilities, and resident smoking material preference (cigarettes and/or electronic cigarettes). In-service included that Licensed Nurses are responsible for completing the smoking assessments upon admission, change of condition, and quarterly. The above training regarding Accident/Hazard Supervision, specifically in regard to safe smoking and safe supervision will be implemented into new hire orientation effective 4/22/2025. To monitor compliance, residents will be monitored by the DON/designee through observations and communication with staff daily x4 weeks and monthly x3 months. DON/designee will review smoking assessments weekly x4weeks monthly x3 months. The QA committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, the facility will continue to be monitored as per the routine facility QA committee. On 04/24/2025 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an observation on 04/24/2025 at 01:35 PM, Resident #22 was in the designated smoking area with supervision while smoking. Record review of an in-service dated 4/22/2025 provided by Corporate Clinical Specialist to the Administrator and ADON regarding Accident/Hazard Supervision, specifically in regard to safe smoking policy, smoking assessment accuracy, designated smoking areas, and remaining in safe supervised area. Record review of competency verified by quiz, including all unsafe smokers to be supervised, encourage and educate on safe supervision areas, storage of paraphernalia, smoking assessments, and smoking violations were dated 4/22/2025 completed by the Administrator and ADON. Record review of an in-service dated 4/22/2025 provided by the facility Administrator and ADON was initiated to all staff regarding Accident/Hazard Supervision, specifically in regard to safe smoking policy, designated smoking areas, and remaining in a safe supervised area. Record review of 51 employees with a total of 51 competencies included questions regarding Accident/Hazard Supervision, specifically in regard to safe smoking policy, designated smoking areas, and remaining in safe supervised areas were verified by a quiz completed on 4/22/2025. Record review of in-service dated 04/23/2025, Corporate Clinical Specialist in-serviced staff on residents who were safe smokers and those who were not, and how to find that information. Record review of an in-service dated 04/23/2025 provided by Corporate Clinical Specialist indicated 8 licensed nurses completed smoking risk assessment accurately as related to current health concerns/conditions, resident capabilities, and resident smoking material preference (cigarettes and/or electronic cigarettes). In-service included that Licensed Nurses are responsible for completing the smoking assessments upon admission, change of condition, and quarterly. Record review of all residents' smoking assessments and care plans completed by unit managers and ADON indicated they were updated and accurate for each resident who smoked. Record review of the updated Resident Smoking List revealed it was located at each nurse station in a binder, which included accommodations for smoking based upon the smoking assessments. Record review of the updated smoking schedule and designated smoking locations was updated on 04/23/25. Record review of the Facility Smoking Policy - Supervised and Unsupervised dated 11/2024. Record review of the QAPI Committee Review revealed the committee meeting was completed on 04/23/25 held with the Administrator, ADON, the Physician, Activity Director, Maintenance Supervisor, MDS nurse, and the Dietary manager. During an interview on 04/24/25 at 11:52 a.m., the facility physician was aware of the IJ and said he was on the phone during the QAPI meeting. Interviews of the following staff, on the following shifts: 6AM - 6PM staff: ADON, MDS Nurse, CNA K, CNA L, CNA M, CNA N, LPN O, LVN P, CMA Q, CMA R, Administrator, Dietary Manager, Business office Manager, Maintenance Director, Activity Director, Housekeeping Supervisor, Director of Rehabilitation, Laundry Aide T. 2PM - 10PM staff: LVN U, LVN V, CNA W, CNA X, CNA Y, CMA Z. 10PM - 6AM staff: CNA AA, LVN BB. revealed staff were able to correctly identify the following information: Accidents/Hazard Supervision involving safe smoking policy, designated smoking areas, and remaining in safe supervised area, assessments of smokers - safe vs unsafe (accommodations) location of the information, and when the assessments for smokers are completed. On 04/24/2025 at 2:45 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 5 (Resident #25, Resident #22, Resident #48, Resident #32, and Resident #15) of 53 residents reviewed for accidents and hazards. 1.The facility failed to ensure Resident #25 did not receive a cigarette burn on 08/24/24. 2.The facility did not ensure Resident #22, who was assessed as an unsafe smoker, signed out to smoke in an unsafe area on 04/21/25 and kept his cigarettes, vapor and lighter in his possession. 3.The facility did not ensure that Resident #48, who was assessed as a safe smoker, did not sign out of the facility to smoke on the side of a residential street on 04/22/25. 4.The facility did not ensure Resident #32, who was assessed as an unsafe smoker, signed herself out to smoke in an unsafe area on 03/31/25. 5. The facility failed to ensure Resident #15 did not have 7 razors stored insecurely in a light blue stainless-steel cup in his room on the mini refrigerator. An Immediate Jeopardy (IJ) situation was identified on 04/22/25. The IJ template was provided to the facility on [DATE] at 4:34 pm, and an amendment IJ template was provided on 04/23/25 at 11:54 a.m. While the IJ was lowered on 04/24/25 at 2:45 p.m., the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, with a scope of pattern due to the facility's need to evaluate the effectiveness of its corrective actions. These failures could put residents at risk of accidents and could result in burn injuries related to smoking paraphernalia that was not monitored/secured by the facility, harm, impairment, and death. Findings included: 1.Record review of Resident #25's face sheet, dated 04/24/25, indicated an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included seizures, anemia (a condition where the blood doesn't have enough healthy red blood cells or hemoglobin to carry oxygen to the body's organs and tissues), glaucoma (a group of eye conditions that damage the optic nerve, potentially leading to vision loss or blindness), and high blood pressure. Record review of Resident #25's quarterly MDS assessment dated [DATE] indicated Resident #25 understood others and was understood by others. The MDS assessment indicated he required assistance with bathing, toileting, dressing, bed mobility, personal hygiene, and eating independently. Record review of Resident #25's comprehensive care plan, dated on 8/26/24, indicated he had a cigarette burn on 08/24/24. The intervention dated 11/22/24 was for staff to provide a smoking apron. Record review of Resident #25's comprehensive care plan, dated on 04/23/25, indicated he was an unsafe smoker. The interventions were to evaluate his smoking safety ability and provide appropriate interventions as indicated by the smoking apron. Record review of Resident #25's smoking assessment dated [DATE] indicated that he required supervision while smoking. Record review of Resident #25 's progress note dated 08/24/24 by LVN CC indicated she was alerted by a laundry staff member that Resident #25 dropped his cigarette and burned himself. LVN CC assessed Resident #25 and noted a small burn to his right bilateral thigh. The area was cleaned, and Triple Antibiotic Ointment was applied. The physician was notified. LVN CC attempted to notify a family member, but there was no answer, so she left a message. Record review of Resident #25 's incident report dated 08/24/24 by LVN CC indicated Resident #25 said he burned his thigh when his cigarette dropped. Record review of Resident #25's skin assessment done on 08/24/24 indicated he had a burn to his bilateral right thigh measuring 1.5 x 1.3. Record review of Resident #25's smoking assessment dated [DATE] indicated that he required supervision and the use of an apron. Record review of Resident #25 's progress note dated 08/26/24 by LVN DD indicated she looked at the burned area on Resident #25's distal back of his right thigh. The area had a small intact blister with no redness or swelling. Record review of Resident #25's skin assessment done on 08/27/24 indicated he had no skin issues. Record review of Resident #25's physician orders dated 8/01/24 through 08/30/24 did not indicate any treatment orders for the right thigh. Record review of the Texas Unified Licensure Information Portal, also known as TULIP (It is an online system used by the Texas Health and Human Services Commission (HHSC) for managing long-term care licensure applications and other related activities) did not reveal an intake on Resident #25's related to a burn. During an observation on 04/22/25 at 11:00 a.m., Resident #25 was supervised while smoking outside. Resident #25 did not have on an apron. During an interview on 04/23/25 at 10:00 a.m., Resident #25 said he could not remember anything about a cigarette burn. During an interview on 04/23/25 at 3:27 p.m., the ADON said she vaguely remembered that incident. She said she was the MDS nurse back in August 2024, so she was unaware of what happened during the investigation process. The ADON said she was unaware if Resident #25's cigarette burn was reported to the state of Texas. She said if someone reported a cigarette burn to her, she would do an assessment and check for any injuries. She would apply treatment and notify the doctor and the responsible party if injuries were noted. She said she would do another smoking assessment and then call her corporate nurse to see what else she needed to do. During an interview on 04/23/25 at 3:32 p.m., the Administrator said he was not aware of Resident #25's burn. He said he was not employed at the facility at the time of that incident. He said he was not aware of any investigation into Resident #25's burn. The Administrator and the surveyor went over the notes in the chart, and he said he was not sure what steps he would have taken but said he wou[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the resident environment remained free of accident hazards and each resident was provided adequate supervision to prevent injuries for 1 of 6 residents (Resident #1) reviewed for accident hazards. The facility failed to ensure Resident #1's bed was locked while providing care resulting in a fall with fractures to the orbital floor (a break to the thin, bony plate that forms the bottom of the eye socket) and cervical spine on 1/30/25. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 2/26/25 at 12:00 p.m. While the IJ was removed on 2/27/25, the facility remained out of compliance at no actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for serious harm, impairment, or death. Findings include: 1. Record review of the face sheet dated 2/26/25 indicated Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including heart failure, hypertension (elevated blood pressure), diabetes, anxiety, and COPD. Record review of the admission MDS dated [DATE] indicated Resident #1 admitted to the facility from a short-term general hospital on 1/30/25. Record review of the Discharge MDS dated [DATE] indicated Resident #1 discharged from the facility with return anticipated to a short-term general hospital on 1/30/25. Record review of Resident #1's medical records indicated Resident #1 did not have a care plan or physician orders at the time of her discharge from the facility. Record review of the progress note dated 1/30/25 written by RN A indicated, [Resident #1] admitted facility, while doing assessment and applying wound Vac. [CNA B was] on left side of bed, bed did not lock as was thought, bed moved causing resident to fall to floor bed in semi high position. [CNA B] was unable to keep [Resident #1] from falling to floor. [Resident #1] hit her head causing a laceration to top of left forehead and also hit her left eye causing a hematoma (a localized collection of blood outside of the blood vessel) to eye. Due to nature of fall [Resident #1] was sent to local ER for sutures and evaluation. [Family] and MD made aware of incident. Record review of the incident report dated 1/30/25 written by RN A indicated, While doing assessment on [Resident #1] and wound measurements and to apply wound vac [CNA B] on other side [of bed] to hold [Resident #1], bed moved causing [CNA B] to lose her hold on [Resident #1]. The incident report indicated immediate action taken by the facility was Resident #1 was sent out to the ER. Record review of the hospital records for Resident #1's admission starting 1/30/25 indicated, [Resident #1] arrived by EMS due to fall/AMS from [nursing facility], [Resident #1] just arrived to the facility from the hospital for unknown reasons. staff was working on patients wound vacs, the bed was not locked, and patient fell out onto face, swelling, bruising to [left] eye, [laceration] to [left] side of forehead. The hospital records indicated Resident #1 had a notable orbital fracture and nondisplaced fractures (a type of fracture where the bone fragments remain in their original position without shifting) on C-spine (cervical spine) osteophytes (a bony growth that develops on the edge of a bone). The hospital records discharge summary indicated Resident #1 was status post fall from the bed with an orbital wall fracture with possible muscle entrapment and equivocal (a situation where the muscle gets trapped within a fractured bone or other tissue, often causing limitation in movement, while equivocal means uncertain or ambiguous), tiny acute or subacute fractures (stress fracture) of the anterior (nearer to the front) osteophytes along the inferior endplate of C6 bilaterally (a flat, bilayer cartilage that helps stabilize the vertebral column). During an interview on 2/20/25 at 10:03 a.m. the MDS Coordinator/ADON said Resident #1 was only in the facility for approximately an hour before she was sent to the ER, and they did not have time to complete a baseline care plan or any of her stuff in their computer system. During an interview on 2/26/25 at 9:38 a.m. RN A said Resident #1 entered the facility at the end of her shift on 1/30/25. RN A said she went to Resident #1's room to perform a skin assessment and apply the wound vac to the wound on her bottom. RN A said she had her head down when CNA B said, Oh no. RN A said Resident #1 fell to the floor. RN A said she thought she locked the bed but could not say for sure if it was locked. During an interview on 2/26/25 at 9:46 a.m. CNA B said on 1/30/25 she was assisting RN A with wound care on Resident #1. CNA B said Resident #1 was rolled up on her side. CNA B said she and RN A had thought the bed was locked but it was not, and the bed moved. CNA B said she attempted to hold Resident #1 up from falling but was unable to. CNA B said Resident #1 fell to the floor. Record review of the facility's Fall Prevention Program policy revised 6/10/24 indicate, All resident will be assessed for the risk for falls at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Based on the results of this assessment, specific interventions will be implemented to minimize falls, avoid repeat falls, and minimize falls resulting in significant injury . The Administrator was notified on 2/26/25 at 12:06 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 2/26/25 at 12:11 p.m. The facility's Plan of Removal was accepted on 2/26/25 at 6:30 p.m. and included: Immediately on 2/26/25, Regional Nurse in-serviced Administrator and ADON regarding Accident Hazards/Supervision/Devices, making sure all beds are properly locked prior to providing care to resident. If not working, ensure resident safety, remove equipment from use and notify maintenance director immediately. Competency verified via quiz. Licensed nurse was in-serviced by ADON on 2/26/25 with competency validation. On 2/26/25, the ADON/Designee initiated in-services with all facility staff regarding Accident Hazards/Supervision/Devices, making sure all beds are properly locked prior to providing care to resident. If not working, ensure resident safety, remove equipment from use and notify maintenance director immediately. Competency was verified via quiz. Staff will not be allowed to work until in-servicing has been completed on 2/26/25. The above content was incorporated into new hire orientation by Administrator effective 2/26/25. On 2/26/25, the Maintenance Director checked all beds and mobility devices to ensure safe working order. Any concerns were immediately repaired or replaced. The Medical Director was notified on 2/26/25. In order to monitor compliance, the Maintenance Director will check beds and mobility equipment weekly x4 weeks and monthly thereafter x 3 months. The ADON/designee will do periodic checks during resident care to ensure compliance daily x4 weeks than monthly thereafter x 3 months. Any negative findings will be corrected and reported to the QAPI committee to ensure continued compliance. The facility will meet weekly for the next eight weeks to review compliance with the plan of action. No further concerns are noted, will continue to monitor as per routine facility QA Committee. On 2/27/25 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the monitoring sheets indicated on 2/26/25 all beds and wheelchairs in the facility were checked to ensure they locked and working properly. Observations on 2/27/25 of randomly selected beds in the facility indicated 10 out of 10 beds checked locked properly and did not move when locked. Record review of in-services dated 2/26/25 indicated the Administrator, MDS Coordinator/ADON, and facility staff had been in-serviced regarding accidents hazards/supervision/devices, making sure all equipment (beds and wheelchairs) were in proper working order and the locks were working, and if equipment locks were not working properly notify maintenance. Record review of competency quizzes dated 2/26/25 indicated all staff interviewed by the surveyor as listed below had completed the competency quiz with questions including do you check to confirm bed is locked each time before providing care; if you are providing care for a resident and lock the bed, how do you confirm it is locked; what do you do if you test the bed and the lock is not working; and if you noticed equipment is not working, you should immediately ensure resident safety, remove equipment form you, and report to the Administrator/Maintenance Director with 100% accuracy. During an interview on 2/27/25 at 9:20 a.m. the Adminsitrator said he had been in-serviced by the Regional Nurse regarding ensuring locks on beds and wheelchairs were routinely checked and in working order, ensuring beds were locked prior to staff providing care for a resident, and staff's responsibility for reporting to management and the Maintenance Director of locks not working properly on beds or whellchairs. Staff interviewed (MA C, CNA B, CNA D, CNA E, LVN F, RN G, LVN H, CNA J, CNA K, Housekeeper L, CNA M, the AD, LVN N, and the MDS Coordinator/ADON) who worked across all shifts on 2/27/25 between 9:23 a.m. and 10:22 a.m. were able to verbalize when locks should be checked on beds and wheelchairs, the importance of ensuring locks were properly locked and working prior to providing care for a resident, and what to do if a lock was not working properly. During an interview on 2/27/25 at 10:24 a.m. the Maintenance Director said he had checked to ensure all beds in the facility had proper working locks and logged the results. The Maintenance Director said he would be checking the locks weekly for a few weeks and then monthly thereafter. On 2/27/25 at 10:29 a.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 of 6 residents reviewed for quality of care. (Resident #1) The facility failed to provide an in-house wound evaluation for treatment of Resident #1's left foot declining condition. The facility failed to provide an evaluation to ensure Resident #1's mental health did not complicate her physical health. The facility failed to provide a recent to provide psychiatric services when Resident #1's behaviors continued. The facility failed to accurately assess Resident #1's left foot wound. The facility failed to inform the physician of continued refusals of medical care and psychiatric care . An IJ was identified on 1/11/2024 at 12:56 p.m. The IJ template was provided to the facility on 1/11/2024 at 1:11 p.m. While the IJ was removed on 1/12/2024, the facility remained out of compliance at a scope of isolated and a severity level of actual harm because all staff had not been trained on neglect. These failures could place residents at risk for further neglect, lack of services, and a decreased quality of life. Findings included: Record review of an undated face sheet indicated Resident #1 was a [AGE] year-old female, who admitted on [DATE] with the diagnosis of unspecified psychosis (Psychosis is when people lose some contact with reality. This might involve seeing or hearing things that other people cannot see or hear (hallucinations) and believing things that are not actually true (delusions), motivational impairment, social withdrawal, flat emotions, negative symptoms worsen a person's quality of life and functioning (negative symptoms). It may also involve confused (disordered) thinking and speaking) not due to a substance or known physiological condition, Buerger's disease (also known as thromboangitis obliterans) affects blood vessels in the body, most commonly in the arms and legs. Blood vessels swell, which can prevent blood flow, causing clots to form. This can lead to pain, tissue damage, and even gangrene (the death or decay of body tissues), and major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.) Record review of the consolidated physician's orders dated 1/09/2024 indicated Resident #1 had an ordered referral for psychiatric services on 4/14/2022, and on 8/29/2023. There were no antipsychotic or antidepressant medications ordered on Resident #1's consolidated physician's orders. Record review of Quarterly MDS dated [DATE] indicated Resident #1 understood and was understood by others. The MDS in the section of Cognition Pattern C0100 had a (-) meaning unable to determine the response, in the section for the BIMS assessment C0200 also had a (-), in the section Recall C0400 there was also a (-). The MDS in section C0700 indicated Resident #1's memory short-term and long-term both indicated her memory was intact. The MDS in the section C1310 indicated there was no evidence of an acute change in mental status, and no behaviors of inattention, or disorganized thinking. The MDS in the section Mood D0100 indicated a (-). The MDS section D0150 Resident Mood Interview indicated (-) in column 1 and blank in column 2. The MDS in section D0160 a (-) was documented. The MDS section D Mood the staff assessment of Resident #1's mood indicated she had no symptoms of little interest or pleasures, feeling down or depressed, feeling tired, poo appetite, indicating they feel bad about self, trouble concentrating, moving, or speaking slowly or fast, stating life not worth living. The MDS reflected in Mood J being short-tempered, easily annoyed marked yes and 12-14 days in column 2. Section E Behaviors of the MDS indicated Resident #1 had no hallucinations or delusions. The MDS indicated in E0200 Behavioral Symptoms indicated physical behaviors directed toward others occurred 1-3 days, verbal behavior symptoms directed at others occurred 4-6 days, and other behavioral symptoms not directed at others (such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, or disruptive sounds). The MDS in section E0800 Rejection of care indicated Resident #1 displayed this behavior 4-6 days but less than daily. The MDS indicated in Section GG Resident #1 was independent with eating, dependent with toileting and personal hygiene, and refused bathing, dressing. The MDS in section I Active Diagnosis indicated Resident #1 had depression other than bipolar, and psychotic disorder other than schizophrenia. The MDS assessment did not indicate Resident #1 had a diagnosis of schizophrenia. The MDS in section M indicated Resident #1 had no skin conditions. Section M of the MDS indicated Resident #1 was not receiving any antipsychotic or antidepressant medications. The MDS indicated in Section Q the family, significant other, legal guardian, and other legally authorized representative participated in the assessment and goal setting. The MDS indicated Resident #1's assessments in sections B, C, E, and Q were completed by the social service staff. Record review of the care plan dated 9/21/2021 and revised on 9/25/2023 indicated Resident #1 makes poor safety choices as evidenced by refusal of wound care to foot, hospitalization, and hospice. The goal of the care plan was Resident #1 wound not have adverse effects related to the refusal of care. The interventions of the care plan were to attempt to monitor resident in regard to safety choices; notify the doctor, administrator, DON, and supervisor in regard to poor safety choices that place resident at risk implemented on 8/19/2021 and educated Resident on risks associated with poor safety choices implemented on 8/19/2021 this care plan failed to implement any current interventions. The care plan indicated Resident #1 was at risk for infections related to refusal to allow her room to be cleaned. The goal of the care plan was Resident #1 would not have any adverse effects related to her refusal. The interventions included attempt to clean the room throughout the day by housekeeping and nursing dated 10/28/2022, attempt to tidy the room when care provided dated 10/28/2022, and educate Resident #1 on the risks of living in unclean environment dated 10/28/2022 there care plan failed to implement current interventions. The care plan dated 8/19/2021 and revised on 11/30/2022 indicated Resident #1 had a behavior problem as evidenced by yelling and cursing at staff, demeaning and derogatory comments to staff, allowing only limited staff members to provide care, calling 911, refuse to allow trays to be removed from room, making false accusations, refusing to allow call light to be turned off the goal of the care plan was Resident #1 would have fewer episodes of outbursts. Resident #1's care plan interventions included 2 persons to offer and provide care at all times, anticipate and meet the resident needs allowed reviewed on 8/31/2023, anticipate and meet the resident's needs as allowed revised on 8/31/2023, assist the resident to develop more appropriate methods of coping and interacting and encouraged Resident #1 to express feeling appropriately revised on 8/19/2021. Resident #1's care plan interventions indicated she would have all procedure explained before starting and allow time for adjustment to change dated 8/19/2021. Resident #1's care plan intervention included to monitor behavior episodes and attempt to determine underlying cause and document dated 8/19/2021. Resident #1's care plan interventions indicated to refer Resident #1 to psychological services dated 8/30/2023. Resident #1's care plan failed to address her behaviors with new interventions and revise with interventions that promoted stability with her mental illness. Record review of a Comprehensive Care Plan Conference Summary dated 8/30/2023 indicated Resident #1 refused environmental care, refuses care, yells, curses, calls 911, verbal outbursts, and was at high risk for impaired skin. The care plan conference was signed by the AD, occupational therapist, the social services staff person, dietary manager, and the DON. The care plan conference was not signed by Resident #1 or the responsible party. Record review of an undated Comprehensive Care Plan Conference Summary indicated Resident #1 had multiple behaviors, unavoidable skin issues, and Buerger's disease. The conference was signed by the MDS nurse, the activity director, and social services staff person. Resident #1 or the responsible party signature area was left blank. Record review of a Wound-Weekly Observation Tool dated 2/16/2023 indicated Resident #1's left toes wound site was acquired since admission with a date of 11/21/2022. Resident #1's wound measured 0x0x0, with no undermining, no tunneling, 100 % skin intact, no eschar, no drainage, an odor was present, but the wound was determined to be healed . Record review of a PHQ-9 (an objective assessment of the severity of depression) dated 2/21/2023 indicated Resident #1 scored a 0 due to not being assessed. Resident #1 refused to participate in the assessment and the assessment indicated Resident #1 said close the door when you leave. Record review of a BIMS (Brief Interview for Mental Status) assessment dated [DATE] indicated Resident #1 score was a 10 indicating moderately impairment. Record review of a BIMS assessment dated [DATE] indicated Resident #1's score was 0 with the category of severe impairment. Record review of a Psychotherapy Intake Note dated 4/20/2022 indicated Resident #1 was seen by a therapist for 1 hour. The therapist indicated Resident #1 was referred due to a history of depression and psychosis. The note indicated Resident #1 was oriented to person, place, and time. The note indicated Resident #1's mood was euthymic (normal display of emotion), affect was congruent with Resident #1's mood, Resident #1 had good attention, and appropriate thought content. The note indicated Resident #1 denied any mental health issues and indicated her health records were falsified to keep her in the facility against her will. The note indicated she believed the staff were trying to murder her and the only way to get help was to meet her fiancé. The note indicated Resident #1 believed the business office had stolen money and the claim was validated by the state agency even though she had not found a letter stating so. Resident #1 discussed previous traumas at other nursing facilities and alluded to some abuse when growing up. The note indicated Resident #1 believed she was in a relationship with a famous musician. The note indicated Resident #1 hoped to buy a gift card to purchase a fan club membership in so that she could spend time with the musician in person. The therapist documented the diagnosis of Major depressive disorder, single episode severe, and schizophrenia spectrum and other psychotic disorders. The note indicated Resident #1's presented with depression and psychosis. The goal of Resident #1's treatment was to reduce depression, psychosis, and improve sense of well-being in the facility. The estimated completion was 12 months for Resident #1. The note indicated Resident #1 would be seen weekly. Record review of a Psychotherapy Progress Note dated 5/04/2022 indicated the session lasted 53 minutes with Resident #1. The note indicated Resident #1 had the diagnosis of Major Depressive Disorder, single episode severe, and Schizophrenia Spectrum and other psychotic disorder. The note indicated Resident #1 was alert oriented to person, place, and time. The note indicated her mood was normal, and her affect was congruent with her mood. The note indicated Resident #1 was not having a good week. The note indicated Resident #1 continued to believe she was held against her will and they were still trying to kill her. The note indicated Resident #1 continues to hope to see her fiancé soon and believed he was trying to come and visit with her. The note indicated Resident #1 was unable to call the person because he was in Europe and her phone does not call Internationally. The note indicated Resident #1 continues to be upset no one will purchase her a $2000 gift cared for her. Resident #1 said she could not notify the ombudsman or the state agency as they hang up on her. The note indicated Resident #1's interventions included rapport building, exploration of coping patterns, exploration of emotion, exploration of relationship patters, supportive reflection and symptom management. The note indicated there was no progress in the reduction of symptoms of depression, symptoms of psychosis, or an improved sense of well-being. The note indicated Resident #1 would be treated weekly. Record review of a Psychotherapy Progress Note dated 5/11/2022 indicated the therapist was with Resident #1 53 minutes. The note indicated Resident #1 oriented to person, place, and time. The note indicated Resident #1's mood and affect were congruent, attention was good, thought content appropriate. The resident reported she is not having a good week. The note indicated Resident #1 continues to believe she is held against her will and they were trying to kill her. The note indicated Resident #1 believes her fiancé would be able to visit. Resident #1 said she had been able to speak with her fiancé some this week but had not mentioned to issues of international calling. According to the note Resident #1 continued to be upset with not being able to purchase the $2000 gift card. The note indicated Resident #1 was hoping to see the orthopedic surgeon to strengthen her leg. The note indicated Resident #1 believed she needed someone in Dallas as they provide better care. Resident #1 was noted as indicating she would need physical therapy after the surgery. The note indicated Resident #1 does not want to stay in any nursing facility. Staff had reported Resident #1 called 911 twice last week and left the line open. Resident #1 reported a police officer had come to the facility and called her crazy in front of the staff. The note indicated Resident #1 indicated the police officer threatened to take her to court and make the facility her guardian. The note indicated Resident #1 believed this was a violation of her rights. The notes indicated the progress in reduction of symptoms of depression, reduction of symptoms of psychosis, and the reduction of sense of well-being was maintained. The note indicated Resident #1 called the therapist's office on 5/13/2022. The note indicated Resident #1 wanted to inform the therapist of her big toe on her bad foot was infected. The note indicated Resident #1 indicated the staff were not helping or treating her foot. The note indicated Resident #1 would be seen weekly. Record review of a Psychotherapy Progress note dated 6/01/2022 indicated the therapist was with Resident #1 60 minutes. The note indicated Resident #1's diagnoses were Major Depressive Disorder, single episode, severe, and Schizophrenia Spectrum and other Psychotic Disorder. The note indicted Resident #1 was oriented to person, place and time. The note indicated Resident #1 continued to report not having a good week, as indicated by expressing she believed she was held against her will, and they were trying to kill her. Resident #1 indicated to the therapist had found some new orthopedic surgeons in a hospital in Dallas. The note indicated Resident #1 hoped the therapist called all the physician's and to explain her emergency situation so they will quickly take her. The note indicated Resident #1 attempted to message one of the surgeons on an App, but never received a response. The note indicated Resident #1 hoped the FBI would find her friends in Arizona who would loan her some money so she could leave with her fiancé's manager. The note indicated Resident #1 had spoken of suicide attempts but had promised God she would never try gain. The note indicated Resident #1 denied any current suicidal ideation, plan, means, or intent. The note indicated the treatment progress for Resident #1 continued to be maintained. The note indicated Resident #1 called the therapist's office indicating she had something urgent to discuss. The therapist indicated Resident #1 had not mentioned this concern during the therapy session. The note indicated Resident #1 would continue to be seen weekly. Record review of a Psychotherapy Progress Note dated 6/22/2022 indicated Resident #1 was seen by the therapists for 46 minutes. The therapist indicated Resident #1 was angry this week. The note indicated Resident #1 was upset with the therapist since the therapist had not provided an envelope and stamps for Resident #1 to mail money to her fiancé. The note indicated the therapist indicated the dangers of mailing cash as well as the therapeutic boundaries. The note indicated Resident #1 attempted to switch places and tried to provide therapy to the therapist and become frustrated when the therapist would not allow this to occur. The note indicated Resident #1 believed the therapist was there to get easy blood money from Medicare and does not believe the therapeutic relationship was what she needed at present. The note indicated Resident #1 was placed on an as needed status. The note indicated Resident #1 had no progress in the reduction of depressive symptoms, psychosis symptoms or in the sense of well-being . Record review of Resident #1's clinical record revealed there were no further treatments noted from a psychotherapist after 6/22/2022. Record review of a PHQ-9 (an objective assessment of the severity of depression) dated 8/03/2023 indicated Resident #1 scored an 8 indicating she was mildly depressed. Record review of a Unavoidable Wound Documentation assessment dated [DATE] indicated Resident #1 had peripheral vascular disease, chronic bowel incontinence, thyroid disease, impaired mobility, and cognitive impairment. The assessment indicated Resident #1 had the head of her bed elevated the majority of the day. The assessment in Resident Compliance indicated Resident #1 refuses care and has psychosis this form was signed by the physician on 9/21/2023. Record review of a PHQ-9 (an objective assessment of the severity of depression) dated 10/23/2023 indicated Resident #1 was not assessed for depression due to her refusal to participate. Record review of a BIMS assessment dated [DATE] indicated Resident #1's score was 0 with the category of severe impairment. Record review of the medication administration record dated December 2023 (a seperate treatment administration record was not avaiable) indicated Resident #1 had an order dated 9/22/2022 for the application of Betadine to the left great toe redness three times daily as needed. The medicaton administration had no indications this treatment was offered, refused, or performed. Record review of the electronic medication administration record dated December 2023 indicated Resident #1 accepted her medications. The medication administration record indicated Resident #1 was not treated pharmacologically for her depression or psychosis. Record review of the electronic medication administration record dated January 2024 indicated Resident #1 accepted her medications. The medication administration record indicated Resident #1 was not treated pharmacologically for her depression or psychosis. Record review of a physician's progress note dated 12/20/2023 completed by the nurse practitioner indicated Resident #1 was seen for her high blood pressure, and reflux disease (stomach acid or bile irritates the food pipe lining). The physician's progress note indicated the past medical history of psychosis and major depressive disorder (recurrent and moderate). The physician's progress note failed to address a psychological examination and indicated Resident #1's skin was warm, dry, no rashes, and no suspicious lesions. The note failed to mention the stability of Resident #1's psychosis and depression. Record review of a physician's progress note dated 7/20/2023 completed by the nurse practitioner indicated Resident #1 was seen for coronary artery disease (damage or disease in the heart's major blood vessels) and weakness. Resident #1's past medical history included psychosis and major depressive disorder. The assessment indicated Resident #1 had warm and dry skin with no suspicious lesions. The neurological assessment indicated non-focal (not specific to a certain area of the brain. It may be a general loss of consciousness or emotional problem). The note failed to mention the stability of Resident #1's psychosis and depression. Record review of a physician's progress note dated 8/09/2023 completed by the nurse practitioner indicated Resident #1 was seen for neuropathy (weakness, numbness, and pain from nerve damage usually in the hands and feet) and reflux disease. The note indicated the nature of the neuralgia was general neuralgia affecting both legs with a moderate severity. The note indicated Resident #1's skin was warm, dry, no suspicious lesions, and no rashes. The note failed to mention Resident #1's left foot condition, and the neurological exam indicated non-focal (not specific to a certain area of the brain. It may be a general loss of consciousness or emotional problem). The note failed to mention the stability of Resident #1's psychosis and depression . Record review of a Social Determinants of Health assessment dated [DATE] completed by the social worker designee/marketer indicated Resident #1's assessment included her ethnicity, race, language, need of interpreter to communicate with a doctor or health team, lack of transportation, how often does she require assistance with reading, and how often does she feel lonely or isolated. The social health assessment failed to ascertain information regarding Resident #1's current or past behavioral health needs, assess the on-going behaviors and identify triggers and interventions, provide in-sight on the need of outside resources. Record review of Resident #1's progress notes dated 9/12/2023 to 1/11/2024 indicated: Progress note dated 9/12/2023 at 2:57 p.m., LVN G documented the psychiatric nurse practitioner was present for a psychological exam and Resident #1 refused. The progress note failed to reflect Resident #1's physician was notified of the refusal for psychiatric services. Progress note dated 9/23/2023 at 11:21 p.m., LVN C documented he offered incontinent care and Resident #1 started yelling get out, get out, you murderers! The progress note failed to denote Resident #1's physician was notified of the delusions. Progress note dated 9/26/2023 at 4:00 a.m., LVN C documented Resident #1 cursed loudly and yelled obscenities at the nursing staff when offering incontinent care. The note failed to indicate LVN C notified the physician of the verbal aggressive behaviors. Progress note dated 9/26/2023 at 7:30 a.m., LVN A documented Resident #1 indicated she need a brief change. LVN A indicated she offered a total bed bath. LVN A indicated Resident #1 refused and stated, I don't want you tearing my flesh apart more than you already have. LVN A documented Resident #1 stated during repositioning stating, you both are going to hell, [NAME]. God does me justice and you will both rot in hell and burn for eternity. The note failed to indicate LVN A notified Resident #1's physician of the delusions (of being harmed) and religiosity thoughts. Progress note dated 10/02/2023 at 9:17 a.m., LVN A indicated, Resident #1 continued to refuse care and left foot continued to decline related to Bueger's Syndrome. The note indicated Resident #1 refused to allow staff to touch her foot, clean or treat. The note indicated staff had made multiple attempts. The note indicated the foot appeared to be black on the toes with crusty like covering up to ankles. The note indicated multiple attempts were made to send Resident #1 to the hospital as the foot had no circulation and become necrotic. Progress note dated 10/02/2023 at 1:14 p.m., LVN A indicated the wound care specialist visited and Resident #1 refused care and treatment. The progress note indicated Resident #1 commenced to yelling and screaming at staff. The note failed to indicate Resident #1's physician was notified of her refusal of care and verbally aggressive behaviors. Progress note dated 10/03/2023 at 5:05 a.m., LVN B documented Resident #1 refused incontinent care this shift. The progress noted failed to reflect the acknowledgement of this behavior as a negative symptom of schizophrenia and seek psychological care. Progress note dated 10/13/2023 at 8:55 a.m., LVN A documented Resident #1 requested to have incontinent care performed. LVN A documented after Resident #1's medication administration, and a sip of water Resident #1 threw the remaining water on LVN A and said, cool off bitch and burn in hell. The note indicated the Administrator was informed. LVN A failed to document the notification of the physician related to the aggressive physical behaviors. Progress note dated 10/30/2023 at 10:25 a.m., LVN A documented Resident #1 continue to refuse care and her left foot continued to decline. The progress noted indicated Resident #1 refused to allow staff to touch foot, clean, or treat. The progress note indicated LVN A documented the foot has black toes with crusty like covering up to Resident #1's ankles. LVN A documented Resident #1's left foot had no circulation and was necrotic. LVN A failed to document to notify Resident #1's physician. Progress note dated 11/03/2023 at 10:21 a.m., the DON documented during the weekly skin check Resident #1 refused care. The DON documented the Resident #1's left foot was withering and changing to a dark color with dry skin flaking off related to the diagnosis of Buerger's Syndrome. The DON documented the Resident #1's refusal of staff to touch the foot, clean or treat the foot. The DON documented Resident #1's left foot had black toes with a crusty like covering up to sock line. The DON documented Resident #1's fingertips had discolored areas on the middle of the fingers. The DON documented the physician was notified and the nurse practitioner was present for the offering of treatment, hospitalization, or hospice. The DON documented after extensive attempts Resident #1 was screaming get out of my room. The progress note failed to indicate any behavioral health care was offered. Progress note dated 11/05/2023 at 2:21 a.m., LVN C documented Resident #1 refused peri-care during each round and said, you all are bothering me so much on purpose. Progress note dated 11/06/2023 at 8:52 a.m., LVN A documented the weekly skin assessment was performed and Resident #1 has withering and callus with discoloration to the left great toe. LVN A documented Resident #1 refused care to the toe. LVN A documented Resident #1 stated it is a science project and staff shouldn't worry themselves about it. LVN A documented the physician had been notified. Progress note dated 11/09/2023 at 9:28 a.m., LVN B documented Resident #1 refused staff to assist with reposition or incontinent care. Progress note dated 11/11/2023 at 5:43 a.m., LVN C documented Resident #1 refused peri-care throughout the shift. Progress note dated 11/27/2023 at 3:37 p.m., LVN G documented Resident #1 asked to be changed. LVN G said Resident #1 had a strong body odor and a brown drainage coming from Resident #1's left foot. The note indicated LVN G documented Resident #1 refused the bath and refused a shower. LVN G documented Resident #1 stated I don't refuse care as they say, I refuse abuse, and no one has ever offered me a bath. LVN G documented she heard Resident #1 shouting and cursing a nurse aide. LVN G documented Resident #1 said nobody had ever tried to take care of her foot. LVN G indicated she advised Resident #1 the drainage from her foot was a sign of infection. LVN G documented Resident #1 said yes I know its infected, what do you expect? LVN G documented Resident #1 said, all of you are going to hell, you falsify my records, you abuse me if you touch me, it will be too late for you, and no one touches my flesh. LVN G said Resident #1 gets louder, cursing the nurse. LVN G documented she left the room to allow Resident #1 to calm down. The note failed to indicate LVN G notified the physician of these behaviors and the condition of the left foot and seek psychological care. Progress note dated 11/30/2023 at 1:10 a.m., LVN C documented Resident #1 refused peri-care during rounds. LVN C documented Resident #1 said just get out and leave me alone. Progress note dated 12/14/2023 at 9:00 a.m., LVN A documented performed care for Resident #1 when apple juice accidently spilled. The note indicated Resident #1 indicated the nurse spilled the juice on purpose and then threw the apple juice on the nurse. LVN A failed to document the physician was notified on the aggressive behavior. Progress note dated 12/17/2023 at 11:00 p.m., LVN C documented Resident #1 refused routine rounds from this nurse and attempts to ignore nursing staff. Resident #1 stated the only way for you to leave me alone is to answer your questions? LVN C documented Resident #1 refused repositioning. Progress note dated 12/28/2023 at 1:35 a.m., LVN C documented Resident #1 refused routine peri-care and began yelling go to hell and just go to hell. LVN C documented Resident #1 was upset concerning not having a phone cord. The note failed to indicate LVN C notified the physician of the behavior refusing care and having verbal aggressive behaviors. Progress note dated 12/29/2023 at 5:05 a.m., LVN C documented Resident #1 refused incontinent care all shift. Progress note dated 12/29/2023 at 9:38 p.m., LVN G documented Resident #1 refused foot care from this nurse but allowed the nurse to trim her fingernails. LVN G documented Resident #1's left foot was withered with dead skin on the foot but Resident #1 refused care from the staff. Progress note dated 12/30/2023 at 11:22 p.m., LVN C indicated Resident #1 with the complaint her room was too hot and requested personal fan be turned on. The note indicated LVN C offered incontinent care and Resident #1 refused stating you can go now; you did all I needed you to do. The note indicated Resident #1 refused to allow the dinner tray to be removed from bedside. Progress note dated 1/01/2024 at 3:04 a.m., LVN B documented Resident #1 refused incontinent care. The progress note failed to reflect the physician was notified negative symptom of schizophrenia and seek psychological care. Progress note dated 1/04/2024 at 1:37 a.m., LVN C documented Resident #1 refused incontinent care by CNA F, and LVN C. The note indicated Resident #1 refused oral fluids and snacks offered. LVN C documented Resident #1 refused the removal of the dinner tray. Progress note dated 1/06/2024 at 8:30 p.m., LVN D documented she and CNA E were changing Resident #1. LVN D documented after providing peri-care she looked for barrier cream to apply in Resident #1's drawers. Resident #1 was noted to have said there was cream in the drawer. The note indicated LVN D obtained barrier cream returned to Resident #1. The note indicated LVN D rolled Resident #1 using the draw sheet when Resident #1 began screaming at the top of her lungs, Oh, my finger, you all hurt my finger. You are murdering me, and you are abusing me. LVN D said she left the room and obtained another CNA to assist with care. LVN D documented she notified the Administrator of Resident #1 accused LVN D of hurting her finger. Resident #1 was provided a phone and the Administrator spoke to Resident #1 where she alleged they're abusing me tonight. The note failed to indicate Resident #1's ph[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received necessary behavioral health care services to maintain the highest practicable mental and psychosocial wellbeing for 1 of 6 residents (Resident #1) reviewed for behavioral services. The facility failed to have Resident #1 evaluated for decision making capacity. The facility failed to provide a psychological evaluation to determine if Resident #1 was a harm to herself. The facility failed to re-offer psychiatric services since 8/2023 for Resident #1. The facility failed to develop interventions to address the resident's acute schizophrenic behaviors. The facility failed to implement licensed social services to provide crises support, and coordination with the healthcare team. The facility failed to recognize and obtain Resident #1's schizophrenia diagnosis from behavioral health care. An IJ was identified on 1/11/2024 at 12:56 p.m. The IJ template was provided to the facility on 1/11/2024 at 1:11 p.m. While the IJ was removed on 1/12/2024, the facility remained out of compliance at a scope of isolated and a severity level of potential for [NAME] than minimal harm because all staff had not been trained on neglect. These failures could placed residents at risk for the lack of behavioral health services with the potential for serious injury and death. Findings included: Record review of an undated face sheet indicated Resident #1 was a [AGE] year-old female, who admitted on [DATE] with the diagnosis of unspecified psychosis (Psychosis is when people lose some contact with reality. This might involve seeing or hearing things that other people cannot see or hear (hallucinations) and believing things that are not actually true (delusions), motivational impairment, social withdrawal, flat emotions, negative symptoms worsen a person's quality of life and functioning (negative symptoms). It may also involve confused (disordered) thinking and speaking) not due to a substance or known physiological condition, Buerger's disease (also known as thromboangitis obliterans) affects blood vessels in the body, most commonly in the arms and legs. Blood vessels swell, which can prevent blood flow, causing clots to form. This can lead to pain, tissue damage, and even gangrene (the death or decay of body tissues), and major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.) Record review of the consolidated physician's orders dated 1/09/2024 indicated Resident #1 had an ordered referral for psychiatric services on 4/14/2022, and on 8/29/2023. There were no antipsychotic or antidepressant medications ordered on Resident #1's consolidated physician's orders. Record review of Quarterly MDS dated [DATE] indicated Resident #1 understood and was understood by others. The MDS in the section of Cognition Pattern C0100 had a (-) meaning unable to determine the response, in the section for the BIMS (Brief Interview Mental Status) assessment C0200 also had a (-), in the section Recall C0400 there was also a (-). The MDS in section C0700 indicated Resident #1's memory short-term and long-term both indicated her memory was intact. The MDS in the section C1310 indicated there was no evidence of an acute change in mental status, and no behaviors of inattention, or disorganized thinking. The MDS in the section Mood D0100 indicated a (-). The MDS section D0150 Resident Mood Interview indicated (-) in column 1 and blank in column 2. The MDS in section D0160 a (-) was documented. The MDS section D Mood the staff assessment of Resident #1's mood indicated she had no symptoms of little interest or pleasures, feeling down or depressed, feeling tired, poo appetite, indicating they feel bad about self, trouble concentrating, moving, or speaking slowly or fast, stating life not worth living. The MDS reflected in Mood J being short-tempered, easily annoyed marked yes and 12-14 days in column 2. Section E Behaviors of the MDS indicated Resident #1 had no hallucinations or delusions. The MDS indicated in E0200 Behavioral Symptoms indicated physical behaviors directed toward others occurred 1-3 days, verbal behavior symptoms directed at others occurred 4-6 days, and other behavioral symptoms not directed at others (such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, or disruptive sounds). The MDS in section E0800 Rejection of care indicated Resident #1 displayed this behavior 4-6 days but less than daily. The MDS indicated in Section GG Resident #1 was independent with eating, dependent with toileting and personal hygiene, and refused bathing, dressing. The MDS in section I Active Diagnosis indicated Resident #1 had depression other than bipolar, and psychotic disorder other than schizophrenia. The MDS assessment did not indicate Resident #1 had a diagnosis of schizophrenia. The MDS in section M indicated Resident #1 had no skin conditions. Section M of the MDS indicated Resident #1 was not receiving any antipsychotic or antidepressant medications. Record review of a PHQ-9 (an objective assessment of the severity of depression) dated 2/21/2023 indicated Resident #1 scored a 0 due to not being assessed. Resident #1 refused to participate in the assessment and the assessment indicated Resident #1 said close the door when you leave. Record review of a BIMS (Brief Interview for Mental Status) assessment dated [DATE] indicated Resident #1 score was a 10 indicating moderately impairment. Record review of the care plan dated 9/21/2021 and revised on 9/25/2023 indicated Resident #1 makes poor safety choices as evidenced by refusal of wound care to foot, hospitalization, and hospice. The goal of the care plan was Resident #1 wound not have adverse effects related to the refusal of care. The interventions of the care plan were to attempt to monitor resident in regard to safety choices; notify the doctor, administrator, DON, and supervisor in regard to poor safety choices that place resident at risk implemented on 8/19/2021 and educated Resident on risks associated with poor safety choices implemented on 8/19/2021 this care plan failed to implement any current interventions. The care plan indicated Resident #1 was at risk for infections related to refusal to allow her room to be cleaned. The goal of the care plan was Resident #1 would not have any adverse effects related to her refusal. The interventions included attempt to clean the room throughout the day by housekeeping and nursing dated 10/28/2022, attempt to tidy the room when care provided dated 10/28/2022, and educate Resident #1 on the risks of living in unclean environment dated 10/28/2022 there care plan failed to implement current interventions. The care plan dated 8/19/2021 and revised on 11/30/2022 indicated Resident #1 had a behavior problem as evidenced by yelling and cursing at staff, demeaning and derogatory comments to staff, allowing only limited staff members to provide care, calling 911, refuse to allow trays to be removed from room, making false accusations, refusing to allow call light to be turned off; the goal of the care plan was Resident #1 would have fewer episodes of outbursts. Resident #1's care plan interventions included 2 persons to offer and provide care at all times, anticipate and meet the resident needs allowed reviewed on 8/31/2023, anticipate and meet the resident's needs as allowed revised on 8/31/2023, assist the resident to develop more appropriate methods of coping and interacting and encouraged Resident #1 to express feeling appropriately revised on 8/19/2021. Resident #1's care plan interventions indicated she would have all procedure explained before starting and allow time for adjustment to change dated 8/19/2021. Resident #1's care plan intervention included to monitor behavior episodes and attempt to determine underlying cause and document dated 8/19/2021. Resident #1's care plan interventions indicated to refer Resident #1 to psychological services dated 8/30/2023. Resident #1's care plan failed to address her behaviors with new interventions and revise with interventions that promoted stability with her mental illness. Record review of a PHQ-9 (an objective assessment of the severity of depression) dated 8/03/2023 indicated Resident #1 scored an 8 indicating she was mildly depressed. Record review of a Comprehensive Care Plan Conference Summary dated 8/30/2023 indicated Resident #1 refused environmental care, refuses care, yells, curses, calls 911, verbal outbursts, and was at high risk for impaired skin. The care plan conference was signed by the AD, occupational therapist, the social services staff person, dietary manager, and the DON. The care plan conference was not signed by Resident #1 or the responsible party. Record review of a PHQ-9 (an objective assessment of the severity of depression) dated 10/23/2023 indicated Resident #1 was not assessed for depression due to her refusal to participate. Record review of an undated Comprehensive Care Plan Conference Summary indicated Resident #1 had multiple behaviors, unavoidable skin issues, and Buerger's disease. The conference was signed by the MDS nurse, the activity director, and social services staff person. Resident #1 or the responsible party signature area was left blank. Record review of a BIMS assessment dated [DATE] indicated Resident #1's score was 0 with the category of severe impairment. Record review of a Psychotherapy Intake Note dated 4/20/2022 indicated Resident #1 was seen by a therapist for 1 hour. The therapist indicated Resident #1 was referred due to a history of depression and psychosis. The note indicated Resident #1 was oriented to person, place, and time. The note indicated Resident #1's mood was euthymic (normal display of emotion), affect was congruent with Resident #1's mood, Resident #1 had good attention, and appropriate thought content. The note indicated Resident #1 denied any mental health issues and indicated her health records were falsified to keep her in the facility against her will. The note indicated she believed the staff were trying to murder her and the only way to get help was to meet her fiancé. The note indicated Resident #1 believed the business office had stolen money and the claim was validated by the state agency even though she had not found a letter stating so. Resident #1 discussed previous traumas at other nursing facilities and alluded to some abuse when growing up. The note indicated Resident #1 believed she was in a relationship with a famous musician. The note indicated Resident #1 hoped to buy a gift card to purchase a fan club membership in so that she could spend time with the musician in person. The therapist documented the diagnosis of Major depressive disorder, single episode severe, and schizophrenia spectrum and other psychotic disorders. The note indicated Resident #1's presented with depression and psychosis. The goal of Resident #1's treatment was to reduce depression, psychosis, and improve sense of well-being in the facility. The estimated completion was 12 months for Resident #1. The note indicated Resident #1 would be seen weekly. Record review of a Psychotherapy Progress Note dated 5/04/2022 indicated the session lasted 53 minutes with Resident #1. The note indicated Resident #1 had the diagnosis of Major Depressive Disorder, single episode severe, and Schizophrenia Spectrum and other psychotic disorder. The note indicated Resident #1 was alert oriented to person, place, and time. The note indicated her mood was normal, and her affect was congruent with her mood. The note indicated Resident #1 was not having a good week. The note indicated Resident #1 continued to believe she was held against her will and they were still trying to kill her. The note indicated Resident #1 continues to hope to see her fiancé soon and believed he was trying to come and visit with her. The note indicated Resident #1 was unable to call the person because he was in Europe and her phone does not call Internationally. The note indicated Resident #1 continues to be upset no one will purchase her a $2000 gift cared for her. Resident #1 said she could not notify the ombudsman or the state agency as they hang up on her. The note indicated Resident #1's interventions included rapport building, exploration of coping patterns, exploration of emotion, exploration of relationship patters, supportive reflection and symptom management. The note indicated there was no progress in the reduction of symptoms of depression, symptoms of psychosis, or an improved sense of well-being. The note indicated Resident #1 would be treated weekly. Record review of a Psychotherapy Progress Note dated 5/11/2022 indicated the therapist was with Resident #1 53 minutes. The note indicated Resident #1 oriented to person, place, and time. The note indicated Resident #1's mood and affect were congruent, attention was good, thought content appropriate. The resident reported she is not having a good week. The note indicated Resident #1 continues to believe she is held against her will and they were trying to kill her. The note indicated Resident #1 believes her fiancé would be able to visit. Resident #1 said she had been able to speak with her fiancé some this week but had not mentioned to issues of international calling. According to the note Resident #1 continued to be upset with not being able to purchase the $2000 gift card. The note indicated Resident #1 was hoping to see the orthopedic surgeon to strengthen her leg. The note indicated Resident #1 believed she needed someone in Dallas as they provide better care. Resident #1 was noted as indicating she would need physical therapy after the surgery. The note indicated Resident #1 does not want to stay in any nursing facility. Staff had reported Resident #1 called 911 twice last week and left the line open. Resident #1 reported a police officer had come to the facility and called her crazy in front of the staff. The note indicated Resident #1 indicated the police officer threatened to take her to court and make the facility her guardian. The note indicated Resident #1 believed this was a violation of her rights. The notes indicated the progress in reduction of symptoms of depression, reduction of symptoms of psychosis, and the reduction of sense of well-being was maintained. The note indicated Resident #1 called the therapist's office on 5/13/2022. The note indicated Resident #1 wanted to inform the therapist of her big toe on her bad foot was infected. The note indicated Resident #1 indicated the staff were not helping or treating her foot. The note indicated Resident #1 would be seen weekly. Record review of a Psychotherapy Progress note dated 6/01/2022 indicated the therapist was with Resident #1 60 minutes. The note indicated Resident #1's diagnoses were Major Depressive Disorder, single episode, severe, and Schizophrenia Spectrum and other Psychotic Disorder. The note indicted Resident #1 was oriented to person, place and time. The note indicated Resident #1 continued to report not having a good week, as indicated by expressing she believed she was held against her will, and they were trying to kill her. Resident #1 indicated to the therapist had found some new orthopedic surgeons in a hospital in Dallas. The note indicated Resident #1 hoped the therapist called all the physician's and to explain her emergency situation so they will quickly take her. The note indicated Resident #1 attempted to message one of the surgeons on an App, but never received a response. The note indicated Resident #1 hoped the FBI would find her friends in Arizona who would loan her some money so she could leave with her fiancé's manager. The note indicated Resident #1 had spoken of suicide attempts but had promised God she would never try gain. The note indicated Resident #1 denied any current suicidal ideation, plan, means, or intent. The note indicated the treatment progress for Resident #1 continued to be maintained. The note indicated Resident #1 called the therapist's office indicating she had something urgent to discuss. The therapist indicated Resident #1 had not mentioned this concern during the therapy session. The note indicated Resident #1 would continue to be seen weekly. Record review of a Psychotherapy Progress Note dated 6/22/2022 indicated Resident #1 was seen by the therapists for 46 minutes. The therapist indicated Resident #1 was angry this week. The note indicated Resident #1 was upset with the therapist since the therapist had not provided an envelope and stamps for Resident #1 to mail money to her fiancé. The note indicated the therapist indicated the dangers of mailing cash as well as the therapeutic boundaries. The note indicated Resident #1 attempted to switch places and tried to provide therapy to the therapist and become frustrated when the therapist would not allow this to occur. The note indicated Resident #1 believed the therapist was there to get easy blood money from Medicare and does not believe the therapeutic relationship was what she needed at present. The note indicated Resident #1 was placed on an as needed status. The note indicated Resident #1 had no progress in the reduction of depressive symptoms, psychosis symptoms or in the sense of well-being. Record review of Resident #1's clinical record revealed there were no further treatments noted from a psychotherapist after 6/22/2022. Record review of a Unavoidable Wound Documentation assessment dated [DATE] indicated Resident #1 had peripheral vascular disease, chronic bowel incontinence, thyroid disease, impaired mobility, and cognitive impairment. The assessment indicated Resident #1 had the head of her bed elevated the majority of the day. The assessment in Resident Compliance indicated Resident #1 refuses care and has psychosis this form was signed by the physician on 9/21/2023. Record review of a BIMS assessment dated [DATE] indicated Resident #1's score was 0 with the category of severe impairment. Record review of the electronic medication administration record dated December 2023 indicated Resident #1 accepted her medications. The medication administration record indicated Resident #1 was not treated pharmacologically for her depression or psychosis. Record review of a physician's progress note dated 12/20/2023 completed by the nurse practitioner indicated Resident #1 was seen for her high blood pressure, and reflux disease (stomach acid or bile irritates the food pipe lining). The physician's progress note indicated the past medical history of psychosis and major depressive disorder (recurrent and moderate). The physician's progress note failed to address a psychological examination and indicated Resident #1's skin was warm, dry, no rashes, and no suspicious lesions. The note failed to mention the stability of Resident #1's psychosis and depression. Record review of the electronic medication administration record dated January 2024 indicated Resident #1 accepted her medications. The medication administration record indicated Resident #1 was not treated pharmacologically for her depression or psychosis. Record review of a physician's progress note dated 7/20/2023 completed by the nurse practitioner indicated Resident #1 was seen for coronary artery disease (damage or disease in the heart's major blood vessels) and weakness. Resident #1's past medical history included psychosis and major depressive disorder. The assessment indicated Resident #1 had warm and dry skin with no suspicious lesions. The neurological assessment indicated non-focal (not specific to a certain area of the brain. It may be a general loss of consciousness or emotional problem). The note failed to mention the stability of Resident #1's psychosis and depression. Record review of a physician's progress note dated 8/09/2023 completed by the nurse practitioner indicated Resident #1 was seen for neuropathy (weakness, numbness, and pain from nerve damage usually in the hands and feet) and reflux disease. The note indicated the nature of the neuralgia was general neuralgia affecting both legs with a moderate severity. The note indicated Resident #1's skin was warm, dry, no suspicious lesions, and no rashes. The note failed to mention Resident #1's left foot condition, and the neurological exam indicated non-focal (not specific to a certain area of the brain. It may be a general loss of consciousness or emotional problem). The note failed to mention the stability of Resident #1's psychosis and depression. Record review of a Social Determinants of Health assessment dated [DATE] completed by the social worker designee indicated Resident #1's assessment included her ethnicity, race, language, need of interpreter to communicate with a doctor or health team, lack of transportation, how often does she require assistance with reading, and how often does she feel lonely or isolated. The social health assessment failed to ascertain information regarding Resident #1's current or past behavioral health needs, assess the on-going behaviors and identify triggers and interventions, provide in-sight on the need of outside resources. Record review of Resident #1's progress notes dated 9/12/2023 to 1/11/2024 indicated: Progress note dated 9/12/2023 at 2:57 p.m., LVN G documented the psychiatric nurse practitioner was present for a psychological exam and Resident #1 refused. The progress note failed to reflect Resident #1's physician was notified of the refusal for psychiatric services. Progress note dated 9/23/2023 at 11:21 p.m., LVN C documented he offered incontinent care and Resident #1 started yelling get out, get out, you murderers! The progress note failed to denote Resident #1's physician was notified of the delusions. Progress note dated 9/26/2023 at 4:00 a.m., LVN C documented Resident #1 cursed loudly and yelled obscenities at the nursing staff when offering incontinent care. The note failed to indicate LVN C notified the physician of the verbal aggressive behaviors. Progress note dated 9/26/2023 at 7:30 a.m., LVN A documented Resident #1 indicated she needed a brief change. LVN A indicated she offered a total bed bath. LVN A indicated Resident #1 refused and stated, I don't want you tearing my flesh apart more than you already have. LVN A documented Resident #1 stated during repositioning , you both are going to hell, [NAME]. God does me justice and you will both rot in hell and burn for eternity. The note failed to indicate LVN A notified Resident #1's physician of the delusions (of being harmed) and religiosity thoughts. Progress note dated 10/02/2023 at 9:17 a.m., LVN A indicated, Resident #1 continued to refuse care and left foot continued to decline related to Buerger's Syndrome. The note indicated Resident #1 refused to allow staff to touch her foot, clean or treat. The note indicated staff had made multiple attempts. The note indicated the foot appeared to be black on the toes with crusty like covering up to ankles. The note indicated multiple attempts were made to send Resident #1 to the hospital as the foot had no circulation and become necrotic. The note failed to indicate Resident #1's physician was notified of the negative symptoms of psychosis/schizophrenia. Progress note dated 10/02/2023 at 1:14 p.m., LVN A indicated the wound care specialist visited and Resident #1 refused care and treatment. The progress note indicated Resident #1 commenced to yelling and screaming at staff. The note failed to indicate Resident #1's physician was notified of her refusal of care and verbally aggressive behaviors. Progress note dated 10/03/2023 at 5:05 a.m., LVN B documented Resident #1 refused incontinent care this shift. Progress note dated 10/13/2023 at 8:55 a.m., LVN A documented Resident #1 requested to have incontinent care performed. LVN A documented after Resident #1's medication administration, and a sip of water Resident #1 threw the remaining water on LVN A and said, cool off bitch and burn in hell. The note indicated the Administrator was informed. LVN A failed to document the notification of the physician related to the aggressive physical behaviors. Progress note dated 10/30/2023 at 10:25 a.m., LVN A documented Resident #1 continue to refuse care and her left foot continued to decline. The progress noted indicated Resident #1 refused to allow staff to touch foot, clean, or treat. The progress note indicated LVN A documented the foot has black toes with crusty like covering up to Resident #1's ankles. LVN A documented Resident #1's left foot had no circulation and was necrotic. LVN A failed to document to notify Resident #1's physician. Progress note dated 11/03/2023 at 10:21 a.m., the DON documented during the weekly skin check Resident #1 refused care. The DON documented the Resident #1's left foot was withering and changing to a dark color with dry skin flaking off related to the diagnosis of Buerger's Syndrome. The DON documented the Resident #1's refusal of staff to touch the foot, clean or treat the foot. The DON documented Resident #1's left foot had black toes with a crusty like covering up to sock line. The DON documented Resident #1's fingertips had discolored areas on the middle of the fingers. The DON documented the physician was notified and the nurse practitioner was present for the offering of treatment, hospitalization, or hospice. The DON documented after extensive attempts Resident #1 was screaming get out of my room. The progress note failed to indicate any behavioral health care was offered. Progress note dated 11/05/2023 at 2:21 a.m., LVN C documented Resident #1 refused peri-care during each round and said, you all are bothering me so much on purpose. The note failed to indicate Resident #1's physician was notified on the negative symptoms, and paranoid thoughts. Progress note dated 11/06/2023 at 8:52 a.m., LVN A documented the weekly skin assessment was performed and Resident #1 has withering and callus with discoloration to the left great toe. LVN A documented Resident #1 refused care to the toe. LVN A documented Resident #1 stated it is a science project and staff shouldn't worry themselves about it. LVN A documented the physician has been notified. The note failed to reflect Resident #1 was disconnected from reality related to her left toe condition and seek psychological care. Progress note dated 11/09/2023 at 9:28 a.m., LVN B documented Resident #1 refused staff to assist with reposition or incontinent care. The note failed to reflect acknowledgement of this behavior as a negative symptom of schizophrenia and seek psychological care. Progress note dated 11/11/2023 at 5:43 a.m., LVN C documented Resident #1 refused peri-care throughout the shift. The note failed to reflect acknowledgement of this behavior as a negative symptom of schizophrenia and seek psychological care. Progress note dated 11/27/2023 at 3:37 p.m., LVN G documented Resident #1 asked to be changed. LVN G said Resident #1 had a strong body odor and a brown drainage coming from Resident #1's left foot. The note indicated LVN G documented Resident #1 refused the bath and refused a shower. LVN G documented Resident #1 stated I don't refuse care as they say, I refuse abuse, and no one has ever offered me a bath. LVN G documented she heard Resident #1 shouting and cursing a nurse aide. LVN G documented Resident #1 said nobody had ever tried to take care of her foot. LVN G indicated she advised Resident #1 the drainage from her foot was a sign of infection. LVN G documented Resident #1 said yes I know its infected, what do you expect? LVN G documented Resident #1 said, all of you are going to hell, you falsify my records, you abuse me if you touch me, it will be too late for you, and no one touches my flesh. LVN G said Resident #1 gets louder, cursing the nurse. LVN G documented she left the room to allow Resident #1 to calm down. The note failed to indicate LVN G notified the physician of these behaviors including grandiose behavior, insight not appropriate for the situation, fabrication, and the condition of the left foot and seek psychological care. Progress note dated 11/30/2023 at 1:10 a.m., LVN C documented Resident #1 refused peri-care during rounds. LVN C documented Resident #1 said just get out and leave me alone. The note failed to reflect acknowledgement of this behavior as a negative symptom of schizophrenia and seek psychological care. Record review of a skin check dated 12/07/2023 indicated Resident #1 had no skin issues, and a wound observation assessment was not started. Record review of a skin check dated 12/14/2023 indicated Resident #1 had no skin issues, and a wound observation assessment was not started. Progress note dated 12/14/2023 at 9:00 a.m., LVN A documented performed care for Resident #1 when apple juice accidently spilled. The note indicated Resident #1 indicated the nurse spilled the juice on purpose and then threw the apple juice on the nurse. LVN A failed to document the physician was notified on the aggressive behavior. Progress note dated 12/17/2023 at 11:00 p.m., LVN C documented Resident #1 refused routine rounds from this nurse and attempts to ignore nursing staff. Resident #1 stated the only way for you to leave me alone is to answer your questions? LVN C documented Resident #1 refused repositioning. Progress note dated 12/28/2023 at 1:35 a.m., LVN C documented Resident #1 refused routine peri-care and began yelling go to hell and just go to hell. LVN C documented Resident #1 was upset concerning not having a phone cord. The note failed to indicate LVN C notified the physician of the behavior refusing care and having verbal aggressive behaviors. Record review of a skin check dated 12/28/2023 indicated Resident #1 had no skin issues, and a wound observation assessment was not started. Progress note dated 12/29/2023 at 5:05 a.m., LVN C documented Resident #1 refused incontinent care all shift Progress note dated 12/29/2023 at 9:38 p.m., LVN G documented Resident #1 refused foot care from this nurse but allowed the nurse to trim her fingernails. LVN G documented Resident #1's left foot was withered with dead skin on the foot but Resident #1 refused care from the staff. Progress note dated 12/30/2023 at 11:22 p.m., LVN C indicated Resident #1 with the complaint her room was too hot and requested personal fan be turned on. The note indicated LVN C offered incontinent care and Resident #1 refused stating you can go now; you did all I needed you to do. The note indicated Resident #1 refused to allow the dinner tray to be removed from bedside. The progress note failed to reflect the physician was notified of the behaviors and to seek psychological care. Progress note dated 1/01/2024 at 3:04 a.m., LVN B documented Resident #1 refused incontinent care. Progress note dated 1/04/2024 at 1:37 a.m., LVN C documented Resident #1 refused incontinent care by CNA F, and LVN C. The note indicated Resident #1 refused oral fluids and snacks offered. LVN C documented Resident #1 refused the removal of the dinner tray. Record review of a skin check dated 1/04/2024 indicated Resident #1 had no skin issues, and a wound observation assessment was not started. Progress note dated 1/06/2024 at 8:30 p.m., LVN D documented she and CNA E were changing Resident #1. LVN D documented after providing peri-care she looked for barrier cream to apply in Resident #1's drawers. Resident #1 was noted to have said there was cream in the drawer. The note indicated LVN D obtained barrier cream returned to Resident #1. The note indicated LVN D rolled Resident #1 using the draw sheet when Resident #1 began screaming at the top of her lungs, Oh, my finger, you all hurt my finger. You are murdering me, and you are abusing me. LVN D [TRUNCATED]