Every finding on record at Allen Oaks Nursing and Rehab Center

Based on record review and interviews, the facility failed to designate an individual as Infection Preventionist who was responsible for the facility's infection prevention and control program who has completed specialized training in infection prevention and control. Findings:In an interview on 06/17/2026 at 12:45 p.m., S7 RN TX revealed she oversees the Infection Prevention and Control Program. S7 RN TX confirmed she does not have the Infection Preventionist training.In an interview on 06/17/2026 at 2:51 p.m., S2 DON confirmed S7 RN TX oversees the Infection Prevention and Control Program and does not have the Infection Preventionist training but should have.

Based interview and record review, the facility failed to ensure a resident was free of chemical restraints for 1 (Resident #8) of 5 residents reviewed for unnecessary medications by failing to ensure: 1. A new order was obtained for an as-needed (PRN) psychotropic drug after 14 days; and2. Indications of use were documented for the administration of a PRN psychotropic drug Review of the facility's undated policy titled, Antipsychotic Medication Use revealed in part . Antipsychotic medications may be considered for residents with dementia, but only after medical, physical, functional, psychological, emotional, psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosages for the shortest period of time and are subject to gradual dose reduction and re-review. 14. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. Review of Resident #8's medical record revealed an admission date of 11/25/2019 with diagnoses that included, in part. Unspecified Dementia Severe with Psychotic Disturbance, Depression, and Adjustment Disorder with Mixed Anxiety and Depressed Mood. Review of Resident #8's Quarterly MDS with ARD of 04/06/2026 revealed Resident #8 had a BIMS score of 5, indicating severe cognitive impairment. Review of Resident #8's 06/2026 active orders revealed in part. Ativan Oral Tablet 2 MG (Lorazepam) Give 2 mg by mouth every 8 hours as needed for target behavior: skin picking, agitation, restlessness related to depression, unspecified. Start date: 02/12/2026 and End date: Indefinite. 1. In an interview on 06/16/2026 at 2:59 p.m., S2 DON revealed that per the facility policy and procedure, PRN psychotropic drugs can only be ordered for 14 days at a time. Resident #8's 06/2026 medication administration record (MAR) was reviewed with S2 DON. S2 DON confirmed Resident #8's PRN Ativan order did not have a stop date and should have. S2 DON confirmed that Resident #8's PRN Ativan order should have been discontinued after 14 days, but was not.2.Review of Resident #8's 05/2026 MAR documentation revealed in part. Ativan oral tablet 2 MG by mouth every 8 hours as needed for target behavior: Skin picking, agitation, restlessness, related to depression. 05/19/2026: No behaviors observed. Administered 08:46 p.m.05/23/2026: No behaviors observed. Administered 08:15 a.m.05/23/2026- No behaviors observed. Administered 08:14 p.m.05/24/2026: No behaviors observed. Administered 08:30 p.m. Review of Resident #8's 05/2026 progress notes revealed no documentation of the behaviors that prompted the above listed PRN Ativan 2mg administrations. Review of 05/2026 MAR for behavior monitoring every shift revealed no behaviors documented for 05/19/2026, 05/23/2026, or 05/24/2026.In an interview on 06/17/2026 at 10:58 a.m. Resident #8's 05/2026 MAR was reviewed with S2 DON. S2 DON confirmed that the above documentation indicated no behaviors were observed for the above listed PRN Ativan medication administrations. In an interview on 06/17/2026 at 11:20 a.m. S2 DON confirmed that behaviors should have been documented, reflecting the need for PRN Ativan on the MAR, but were not. S2 DON confirmed Resident #8's medical record did not have any documentation reflecting the indications of use for the above PRN doses of Ativan, but should have

Based on observation and interview, the facility failed to ensure menus were followed to meet the nutritional needs of residents. This failure had the potential to affect every resident who received meals from the kitchen, 3 residents on puree diets, and Resident #36 of 27 sampled residents. The facility failed to: Ensure the appropriately sized scoops were used to serve meal trays; Ensure pureed menus were followed; and Follow menu preferences for Resident #36. #1 & #2 Findings: Review of a policy with a revision date of April 2007 titled, Kitchen Weights and Measures revealed in part.Policy Statement: Food Services staff will be trained in proper use of cooling and serving measurements to maintain portion control. 6. Staff will be trained in the appropriate measurement and type of serving utensil to use for each food. Signs or posters explaining coded measurement indicators on utensils will be prominently displayed for reference. Review of a policy with a revision date of April 2007 titled, Standardized Recipes revealed in part.Policy Statement: Standardized recipes shall be developed and used in the preparation of foods. Interview on 06/15/2026 at 10:36 a.m., S11 [NAME] stated there are 3 residents on puree diets. Observation on 06/15/2026 at 11:12 a.m., revealed S11 [NAME] preparing puree diet meal trays using a 2oz scoop of pureed rice, approximately 4.5 oz of beans, 3 oz of pureed sausage, and one container of yogurt for each of the 3 residents. Observation on 06/15/2026 at 11:20 a.m., revealed the menu for Diet Extensions, Monday Week 5 for Regular/Pureed as follows: Red Beans and Sausage, Steamed Rice, Sliced Carrots, Cornbread, and Bread Pudding. Observation on 06/15/2026 at 11:20 a.m., revealed Residents receiving puree diets were not served carrots. Interview on 06/15/2026 at 4:00 p.m., S6 DM confirmed the 3 residents on a puree diet did not receive carrots or any other vegetable on their lunch trays but should have. Review on 06/15/2026 at 11:20 a.m. of the menu revealed residents were to receive 6 oz of red beans and sausage. Observation on 06/15/2026 at 12:20 p.m., S6 DM prepared meal trays using a 4oz scoop to serve the red beans and sausage. Interview on 06/15/2026 at 2:20 p.m., S6 DM confirmed residents should have received 6 oz of red beans and sausage and that she had not used the appropriate scoop size for serving. #3 Findings: Review of Resident # 36's medical record revealed an admission date of 12/18/2020 with a re-entry date of 12/10/2022 with the following diagnoses in part, Combined Systolic and Diastolic (Congestive) Heart Failure; Chronic Kidney Disease, Stage 4; Hypertensive Heart Disease; and Morbid (Severe) Obesity. Review of Resident #36's 06/2026 Physician Orders dated 05/29/2024 revealed Resident #36 was on a regular diet. Review of Resident #36's Quarterly MDS (Minimum Data Sets) with an ARD of 04/14/2026 revealed a BIMS (Brief Interview of Mental Status) score of 15 which indicated Resident #36 was cognitively intact. Review of Resident # 36's Dietary Manager assessment dated [DATE] revealed in part, dislikes: oatmeal and all veggies (vegetables). Interview on 06/15/2026 at 9:55 a.m., Resident #36 stated that she eats in her bedroom and staff never serve her the correct food according to her meal ticket. Resident #36 stated her meal ticket reads no veggies and she continued to receive veggies on her meal trays. Resident #36 stated she doesn't like eating vegetables which is why her meal ticket read no veggies. Interview and observation on 06/16/2026 at 11:26 a.m. of Resident #36's lunch meal tray. Resident #36 was served cucumbers and onions. Observation of Resident #36's meal ticket read in part, no veggies. Interview on 06/16/2026 at 12:00 p.m., S6 DM (Dietary Manager) stated that Resident #36 has voiced multiple complaints about the food and that she tries to honor her likes and dislikes. S6 DM stated Resident #36 doesn't like any vegetables to be served to her and will become very upset if she is served any vegetables. S6 DM accompanied surveyor to Resident #36's room and observed that Resident #36 was served cucumbers and onions. S6 DM stated Resident #36's meal ticket had no veggies listed on it and she shouldn't have been served vegetables. S6 DM confirmed Resident #36 should've been served according to her meal preference and was not.

Based on observation and interviews the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store, prepare, and serve food in accordance with professional standards for food safety. This deficient practice had the potential to affect all residents who received meals prepared by the kitchen. The facility failed to ensure:Expired Food Items were not available for use; andFoods were not labeled and stored appropriately Findings:Observation of the pantry on 06/15/2026 at 8:28 a.m. accompanied by S6 DM revealed the following expired food items: 3 plastic containers of Herdez Verde salsa with expiration date of January 20262 bags of chocolate frosting mix with an expiration date of 05/15/20261 can of sliced apples with an expiration date of 04/06/2025Observation of the walk-in cooler on 06/15/2026 at 8:28 a.m. accompanied by S6 DM revealed the following expired food items, wilted fruits, and molded fruits:4 quarts of heavy whipping cream with expiration date of 06/10/20263 cartons of thickened water with expiration date of 06/02/20265 wilted fruits (3 oranges and 2 apples) in a carboard box with molded spots on the box1 box of 6 or more green bell peppers with mold on each.Observation of the refrigerator in the kitchen area on 06/15/2026 at 8:28 a.m. accompanied by S6 DM revealed the following food items that were improperly stored:Large bowl of ranch dressing covered with foil paper-undated and not labeled1/2 large stick of butter-undated and open to air2 covered bowls of labeled pureed dessert-undated1 sandwich wrapped in foil paper-undated and not labeledFindings confirmed with S6 DM at the time of observation.In an interview on 06/15/2026 at 4:00 p.m., S10 RD acknowledged the kitchen should not have expired, molded, wilted, undated, or unlabeled foods available for use.

Based on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 2 (Resident #29 and Resident #59) of 2 sampled residents investigated for PASARR. Findings: Resident #29 Review of Resident #29's medical record revealed an admission date of 10/01/2021 with a re-entry date of 07/14/2022 with diagnoses that included in part. Bipolar Disorder and Anxiety Disorder. Further review revealed he was admitted with Bipolar Disorder on 07/14/2022. Review of Resident #29's Level 1 Pre-admission Screening and Resident Review dated 09/29/2021 revealed no mental illness/diagnosis checked, therefore no Level 2 was determined at this time. Further review of Resident #29's record revealed there was no evidence that a new Level 1 Pre-admission Screening and Resident Review or a Level II PASARR was submitted to the appropriate state-designated authority after the new diagnosis of Bipolar Disorder on 07/14/2022. Interview on 06/16/2026 at 2:16 p.m. with S8 SSD revealed she was responsible for sending referrals to the appropriate state-agencies for Level II PASARR evaluations. S8 SSD confirmed Resident #29's Level 1 Pre-admission Screening and Resident Review form on 09/29/2021 did not include his Bipolar Disorder diagnosis and stated that a Level 1 was not resubmitted after this diagnosis. S8 SSD confirmed that Resident #29 should have had a Level II PASARR evaluation completed but did not. Resident #59 Review of Resident #59's medical record revealed an admission date of 03/13/2018 with diagnoses that included in part. Major Depressive Disorder and Generalized Anxiety Disorder. Review of Resident #59's Level 1 Pre-admission Screening and Resident Review dated 09/06/2016 revealed no mental illness/diagnosis checked, therefore no Level 2 was determined at this time. Further review of Resident #59's record revealed there was no evidence that a new Level 1 Pre-admission Screening or a Level II PASARR was submitted to the appropriate state-designated authority after the new diagnosis of Major Depressive Disorder and Generalized Anxiety Disorder on 03/18/2018. Interview on 06/17/2026 12:58 p.m., S8 SSD revealed she was responsible for sending referrals to the appropriate state-agencies for Level II PASARR evaluations. S8 SSD confirmed Resident #59's Level 1 Pre-admission Screening and Resident Review form on 09/06/2016 did not include her diagnoses of Major Depressive Disorder and Generalized Anxiety Disorder. S8 SSD confirmed that the Level 1 Pre-admission Screening was not resubmitted after these diagnoses, nor was a Level 2 submitted for evaluation, but should have been.

Based on interview and record review, the facility failed to include the Medical Director or his designee and Administrator in the Quality Assessment and Assurance (QAA) committee quarterly meeting, as required. The facility's total census was 82. Findings:Review of a facility policy on 06/17/2026 at 5:26 p.m. titled, Quality Assurance and Performance Improvement (QAPI) Plan with a revision date of 04/2014 revealed in part.The Administrator is responsible for assuring that this facility's QAPI Program complies with federal, state, and local regulatory agency requirements. Review of the facility's documented quarterly Quality Assurance (QA) meeting held on 03/12/2026 revealed S1 ADM and the facility Medical Director did not sign the member sign-in document. There was no other documented evidence of the facility Medical Director nor S1 ADM attending the QA meeting held on 03/12/2026. In an interview on 06/17/2026 at 2:00 p.m., S2 DON revealed she was the facility QAPI Coordinator, conducted the QA meeting on 03/12/2026, and confirmed the above findings. S2 DON confirmed for the QA meeting held on 03/12/2026, the Medical Director and S1 ADM did not attend and S2 DON did not have evidence of them attending the QA meeting, but should have. No other documented evidence was presented during the survey process of the facility Medical Director or S1 ADM in attendance of the QA meeting held on 03/12/2026.

Based on observation, interview, and record review, the facility failed to meet the nutritional needs for residents in accordance with established national guidelines. The facility failed to follow the menu for all residents receiving puree diet. 5 residents in the facility received a puree diet. Findings: On 06/30/2025 at 3:25 p.m., review of facility undated policy titled, Puree Diet, revealed in part . the puree diet is based on the regular diet, therefore, all the same guidelines apply with alterations being made only to allow for ease and chewing and swallowing. On 07/01/2025 at 9:15 a.m., review of facility policy titled, Menus, with revision date of October 2017 revealed in part, Menus meet the nutritional needs of residents in accordance with recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Sciences). If a food group is missing from a resident's daily diet, the resident is provided an alternate means of meeting his or her nutritional needs. On 06/30/2025 at 10:00 a.m., observation of the menu posted revealed lunch menu for 06/30/2025 included: meatloaf, black eyed peas, cauliflower and cheese, dinner roll, and lemon glazed cake. On 06/30/2025 at 10:30 a.m., observation revealed S7 [NAME] prepare meatloaf, black-eyed peas, and cauliflower and cheese puree. On 06/30/2025 at 10:52 a.m., an interview with S7 cook confirmed she did not puree glazed cake because pudding was being provided as an alternative for all puree diets. S7 [NAME] confirmed she did not puree dinner rolls for any of the residents who received puree diets. During an interview on 06/30/2025 at 3:52 p.m., S3 Dietary Manager revealed facility cooks did not puree bread and did not provide an alternate for bread when bread is served. S3 Dietary Manager confirmed S7 [NAME] did not follow the menu for all residents that received a puree diet, and should have.

Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary kitchen and failed to store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect all 72 residents who resided in the facility. The facility failed to ensure: 1. Food items in the refrigerators and freezers were labeled and dated; 2. Dry food items were labeled with an open date and stored in a sealed container; 3. Dishware was clean and stored under sanitary conditions; 4. Staff were wearing hair restraints, including beard restraints, to prevent hair from contacting food. Findings: On 07/01/2025 at 9:50 a.m., review of facility policy titled, Food Receiving and Storage, with revision date of July 2014, revealed in part . Food shall be received and stored in a manner that complies with safe food handling and practices. All food stored in the refrigerator or freezer will be covered, labeled, and dated. 1. On 06/30/2025 at 8:47 a.m., observation of the freezer in the kitchen food prep area with S3 Dietary Manager revealed one 1-gallon Ziploc bag of chicken nuggets open and undated. S3 Dietary manager confirmed the 1-gallon bag of chicken nuggets was not sealed and dated, and should have been. On 06/30/2025 at 9:10 a.m., observation of the outdoor walk-in refrigerator with S3 Dietary Manager revealed one 1-gallon tub of mayonnaise open and undated. S3 Dietary manager confirmed the 1 gallon tub of mayonnaise was open and undated, and should not have been. 2. On 06/30/2025 at 8:52 a.m., observation of a flour container in the food prep area with S3 Dietary Manager revealed a scoop stored in the flour container. S3 Dietary Manager confirmed the scoop was stored in the flour container and should not have been. On 06/30/2025 at 9:04 a.m., observation of the pantry with S3 Dietary Manager revealed one 50-pound bag of pinto beans open. S3 Dietary Manager confirmed that pinto beans should have been stored in a sealed container, but were not. On 06/30/2025 at 10:10 a.m., observation of Dining room [ROOM NUMBER] serving area with S3 Dietary Manager revealed one small bag of powdered substance not labeled and undated. S3 Dietary Manager stated that the powder was powdered creamer. S3 Dietary Manager confirmed that powdered creamer should have been labeled, dated, and in a sealed container, and it was not. 3. On 06/30/2025 at 8:50 a.m., observation of open shelving that stored clean dishware revealed all dishware plates stored face up, 3 visibly dirty plates, and 1 plate visibly dirty with 3 paperclips in the plate. S3 Dietary Manager was present and confirmed 3 dishware plates stored on clean dishware shelving were dirty and should not have been. S3 Dietary Manager confirmed there were paperclips on clean dishware plates and should not have been. S3 Dietary Manager confirmed clean dishware should be stored facedown, and it was not. 4. On 06/30/2025 at 9:00 a.m., observation revealed S8 Dietary Aide was present in the kitchen with facial hair not contained by a hairnet. S3 Dietary Manager confirmed S8 Dietary Aide should have had a hairnet containing facial hair, and did not.

Based on observation and interview, the facility failed to maintain an effective pest control program by failing to ensure the facility was free from flies. The deficient practice had the potential to affect 72 residents who resided in the facility. Findings: On 07/01/2025 11:00 a.m., review of facility policy titled Pest Control with revision date of May 2008 revealed in part . Our facility shall maintain an effective pest control program. This facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. Observation of the facility's kitchen on 06/30/2025 at 9:06 a.m., accompanied by S3 Dietary Manager, revealed multiple flies observed throughout the kitchen area, with flies landing on the food being prepared and the food prep area. On 06/30/2025 at 10:25 a.m., during a return trip to the kitchen, multiple flies were observed in the kitchen food prep area. On 06/30/2025 at 3:50 p.m., during a return trip to the kitchen area for an interview with S3 Dietary Manager, multiple flies were observed in the kitchen area. S3 Dietary Manager confirmed the kitchen area had a fly problem. S3 Dietary Manager confirmed the kitchen area should be free of pests, but it was not. On 07/01/2025 at 8:00 a.m., observation revealed multiple flies present in Room A. On 07/02/2025 10:04 a.m., observation revealed multiple flies present in Room A. On 07/02/2025 at 12:16 p.m., S1 Admin acknowledged the facility had a current issue with flies in the building.

Based on interview, observations, and record review, the facility failed to ensure a resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of his or her own quality of life by failing to apply a privacy cover to an indwelling catheter urinary drainage bag for 1 (#61) of 1 residents reviewed for dignity. Findings: Review of Resident #61's medical record revealed an admission date of 04/04/2025, with diagnoses that included in part . Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct; Hypospadias, Penile; Encounter for Palliative Care; Presence of Urogenital Implants; Neuromuscular Dysfunction of Bladder; and Retention of Urine. Review of Resident #61's Significant Change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 06/25/2025 revealed a BIMS score of 14, which indicated intact cognition. Resident #61 used an indwelling urinary catheter for urine elimination. Review of Resident #61's current clinical physician's orders revealed an order date of 04/24/2025-catheter care every shift: to keep Foley catheter clean to prevent infection related to Presence of Urogenital Implants. On 06/30/2025 at 9:59 a.m., Resident #61 was observed lying in bed with the door closed. Upon entrance into Resident #61's bedroom, Resident #61's indwelling catheter urinary drainage bag was observed with 200-300ml (milliliters) of yellow urine in the collection bag and without a privacy cover. On 06/30/2025 at 3:44 p.m., Resident #61 was observed sitting up in bed watching television. Upon entrance into Resident #61's bedroom, Resident #61's indwelling catheter urinary drainage bag was observed with about 150ml of yellow urine in the collection bag and without a privacy cover. On 06/30/2025 at 3:52 p.m., in an interview and observation with S5 LPN to Resident #61's bedroom, S5 LPN stated Resident #61's urine output is monitored and flushed every 2 hours. S5 LPN confirmed Resident #61's indwelling catheter urinary drainage bag should have a privacy cover, but had not. S5 LPN stated I'll go look for one right now.

Based on observation, interview, and record review, the facility failed to ensure a resident received reasonable accommodation of needs by failing to have an assistive device accessible to 1 (Resident #45) of 26 sampled residents. Findings: On 07/2/2025 at 1:50 p.m., review of the facility policy titled. Assistive Devices and Equipment, with a revision date of July 2017, revealed in part . Our facility provides, maintains, trains, and supervises the use of assistive devices and equipment for residents. Devices and equipment that assist with resident mobility, safety, and independence are provided for residents. These include, but are not limited to, walkers. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the residents' plan of care. Review of Resident #45's electronic medical record revealed an admit date of 12/26/2024 with diagnoses that included but not limited to: Malignant Neoplasm of Prostate, Secondary and Unspecified Malignant Neoplasm of Lymph Nodes of Head, Neck, and face, Heart Failure, Acquired Absence of other Right Toes, Cognitive Communication Deficit, Difficulty Walking, Not elsewhere Specified, Other Lack of Coordination, Unspecified Dementia. On 07/01/2025 at 1:43 p.m., review of Resident #45's Quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 04/04/2025, revealed a BIMS Score of 6, indicating severe cognitive impairment. Resident #45 utilized a walker. On 07/01/2025 at 1:28 p.m., review of Resident #45's care plan with start date of 04/21/2025 revealed Resident #45 was a fall risk and had two previous falls on 04/03/2025 and 04/11/2025. Interventions included in part . encourage the resident to use a walker and wear shoes, call for assistance to ambulate due to dizziness and weakness, and ensure the resident has assistive devices and understands how to properly use them. On 06/30/2025 at 09:50 a.m., observation revealed Resident #45 ambulating throughout his room without supervision or an assistive device. Resident #45's gait was shuffled. Resident #45 walker was not present in the room. On 07/01/2025 at 11:37 a.m., observation revealed Resident #45 was lying in his bed awake, alert, and confused. Resident #45's walker was not present in the room. On 07/01/2025 at 11:40 a.m. S5 LPN accompanied the surveyor to Resident #45's room. S5 LPN confirmed Resident #45's walker was not present in the room. S5 LPN stated she worked the day prior and did not see the resident ambulate with a walker. S5 LPN stated the last time she could recall Resident #45 ambulating with a walker was the week prior, and was unsure where Resident #45's walker was located. S5 LPN confirmed Resident #45 required a walker to ambulate safely and should have had a walker present in the room with him, but did not.

Based on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing to ensure a resident received enteral feedings as ordered by the physician for 1 (#65) of 1 residents reviewed for tube feeding. Total sample size 26. Findings: Review of Resident #65's Clinical Record revealed an admit date of 07/10/2024 with diagnoses which included: Pneumonitis due to Inhalation of Food and Vomit; Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation; Heart Failure; Anxiety; Cerebral Infarction; Hyperlipidemia; Aphasia; Hypertension; Dysarthria and Anarthria. Review of Resident #65's Annual MDS with an ARD of 05/24/2025 revealed a BIMS score of 0 indicating Resident #65 rarely/never understood. Resident #65 was dependent for bed mobility, transfers, eating, and toileting. Review of Resident #65's Physician Orders revealed the following, in part: 06/27/2025-Enteral feedings: Osmolite 1.2 at 40 milliliters (ml) /hour via pump Review of Resident #65's Care Plan dated 04/28/2025 read in part: Resident #65 requires tube feeding related to diagnoses of Dysphagia following a Cerebral Vascular Accident. Interventions included: Osmolite 1.2 at a rate of 40 ml/hour with a 30 ml/ hour water flush. An observation on 06/30/2025 at 10:49 a.m. revealed tube feeding Osmolite 1.2 infusing at 50 ml/ hour continuous via pump. Interview on 06/30/2025 at 03:48 p.m. with S4 LPN confirmed Osmolite 1.2 should have been infusing at 40 ml/hour as ordered by the physician and was not. Interview on 07/01/2025 at 02:10 p.m. with S10 ADON confirmed that physician decreased tube feeding rate during rounds on 06/27/2025. S10 ADON confirmed that Resident #65 should have received Osmolite 1.2 at 40 ml/hour starting on 06/27/2025. Interview on 07/01/2025 at 02:13 p.m. with S2 DON confirmed Osmolite 1.2 should have been infusing at 40 ml/ hour as ordered by the physician and was not.

Based on record review, observations and interviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure oxygen was administered as ordered by the physician for 1 (#55) of 2 (#14 and #55) residents reviewed for respiratory care. Findings: Review of the facility's policy titled Oxygen Administration, with a revised date of 10/2010 revealed the following in part, Policy: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Assessment: Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 4. All assessment data obtained before, during, and after the procedure. Review of Resident #55's medical record revealed an admission date of 10/15/2024 with diagnoses that included in part, Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation (COPD), Other Disorders of Lung, Dependence on Supplemental Oxygen, and Dyspnea. Review of current Physician Orders for Resident #55 revealed continuous O2 (oxygen) at 2 liters per minute via nasal cannula, every day and night shift related to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation with an order date of 11/18/2024. Review of Resident #55's Quarterly Minimum Data Set (MDS) with an ARD (Assessment Reference Date) dated 08/27/2025 revealed the resident has a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. Further review revealed Resident #55 requires oxygen therapy. Review of Resident #55's Care Plan revealed in part, Resident #55 has oxygen therapy related to ineffective gas exchange, respiratory illness (COPD, Dyspnea, Pneumonia: reoccurring frequently). Interventions to include: Continuous oxygen at all times, give medications as ordered by physician. Observation on 06/30/2025 at 9:35 a.m., revealed Resident #55 sitting up in a chair in her bedroom. Resident #55 observed with oxygen in progress at 3.5 liters/minute via nasal cannula per oxygen concentrator. Resident #55 stated she wears oxygen via nasal cannula continuously. Observation on 07/01/2025 at 8:39 a.m., revealed Resident #55 sitting up in her recliner with oxygen in progress at 3.5 liters/minute via nasal cannula. Resident #55 stated no one comes to check to see how many liters of oxygen she is on. Observation on 07/01/2025 at 1:37 p.m., revealed Resident #55 sitting up in her recliner with oxygen in progress at 3.5 liters/minute via nasal cannula.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services that assured accurate disposition and/or administration of medications to meet the needs of each resident. The facility failed to: 1. Ensure proper nursing procedures and documentation were completed at the time of wasting/destroying narcotics on 1 (Med Cart 1) of 2 (Med Cart 1 and Med Cart 2) medication carts for Resident #26. 2. Ensure proper nursing procedures for wasting of controlled substances were completed when Resident #60's controlled medication was not administered. Findings: Review of a facility policy on 07/01/2025 at 9:50 a.m. titled, Discarding and Destroying Medications revised on 10/2014 revealed the following part . Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. 6. for unused, non-hazardous controlled substances that are not disposed of by an authorized collector, c. dispose with the solid waste in the presence of two witnesses. e. include the signature(s) of at least two witnesses. 7. destruction of a controlled substance must render it non-retrievable, meaning that the process permanently alters the physical or chemical properties of the substance so that it is no longer available or usable, and cannot be illegally diverted. Review of a facility policy on 07/01/2025 at 9:50 a.m. titled, Controlled Substances revised on 12/2012 revealed the following in part .The facility shall comply with laws, regulations, and other requirements related to handling, storage, disposal, and documentation of schedule II and other controlled substances. 8. When a resident refuses a non-unit dose medication (or it is not given), or a resident receives partial tablets or single dose ampules (or it is not given), the medication shall be destroyed and may not be returned to the container. 1. On 07/01/2025 at 9:38 a.m. a controlled medications reconciliation was conducted with S5 LPN of Med Cart 1. Review of Resident #26's document titled, Controlled Substance Count Sheet for Tramadol 50mg tablets revealed one entry on 06/13/2025 at 8:00 a.m. where one tablet was documented as wasted by a nurse. Further review of the document revealed no evidence of a destruction witness signature for the waste entry. S5 LPN confirmed there should had been a witness/second signature when Resident #26's Tramadol tablet was wasted on 06/13/2025, but there was not. 2. On 07/01/2025 at 9:38 a.m. a controlled medications reconciliation was conducted with S5 LPN on Med Cart 1. Review of Resident #60's blister medication card package for Hydrocodone/APAP 5mg-325mg tablets revealed that tablet #41 was opened/popped and the back of the packaging was taped with clear tape. Further review revealed a white pill was placed back into tablet #41's packaging of the medication card. S5 LPN confirmed that Resident #60's Hydrocodone/APAP 5mg-325mg blister package should never have medications taped back into the package after it has been popped or opened. S5 LPN confirmed tablet #41 should have been wasted appropriately and not placed back into the packaging, but was not. In an interview on 07/01/2025 at 11:43 a.m., S2 DON revealed that the floor nurses are aware of the proper procedures for wasting of controlled substances/narcotics. S2 DON stated there should always be two nurses to witness any wasting/destruction of controlled substances and both nurses are to document in the clinical record. S2 DON confirmed the nurse failed to follow proper nursing procedures for wasting Resident #26's narcotic medications on 06/13/2025. S2 DON revealed that the nurses are never to tape the back of a blister medication package and place a tablet back into the packaging. S2 DON confirmed the nurse failed to follow proper nursing procedures for wasting Resident #60's controlled medications by placing the tablet back into the packaging.

Based on observation and interview, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with current accepted professional principles. This deficient practice has the potential to affect all 72 residents residing in the facility. The facility failed to: 1. Ensure expired medications were not available for administration to residents in 1 (Med Room B) of 2 (Med Room A and Med Room B) medication rooms. 2. Ensure controlled substances were properly stored in a permanently affixed compartment and had restricted access until destroyed appropriately. Findings: Review of a facility policy on 07/01/2025 at 9:50 a.m. titled, Controlled Substances revised on 12/2012 revealed the following in part .The facility shall comply with laws, regulations, and other requirements related to handling, storage, disposal, and documentation of schedule II and other controlled substances. Review of a facility policy on 07/01/2025 at 9:50 a.m. titled, Storage of Medications revised on 04/2007 revealed the following in part .the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Review of a facility policy on 07/01/2025 at 9:50 a.m. titled, Discarding and Destroying Medications revised on 10/2014 revealed the following in part . Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. 1. All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of. 1. On 07/01/2025 at 8:20 a.m., an observation of Med Room B was conducted accompanied by S4 LPN and revealed the following items in the medication room for use: 1. One opened and used tube of Hydrocortisone cream with an expiration date of 04/15/2025. 2. One opened and used tube of Clobetasol Propionate 0.05% cream with an expiration date of 04/22/2025. At the time of observation, S4 LPN confirmed both creams were expired and should have been disposed of properly, but were not. In an interview on 07/01/2025 at 8:35 a.m., S2 DON confirmed that Med Room B should not have any expired medications available for usage. 2. Observation on 07/01/2025 at 11:08 a.m. of the facility's narcotic destruction locked box, accompanied by S10 ADON, revealed the box was located on a shelf in S10 ADON's shared office. Interview with S10 ADON at the time of observation confirmed that the locked box was not permanently affixed to any surface. S10 ADON was observed unlocking the narcotic box which revealed the box contained multiple medication cards and bottles of controlled substances. S10 ADON confirmed the narcotics destruction locked box did have controlled medication inside, was not permanently affixed to any surface, and that two other employees had access to the shared office space where the box was stored. S10 ADON revealed she was responsible for the controlled substance destruction process, which included storing, handling, documentation, and destroying of narcotics.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by: 1. Failing to store clean unused resident care items in a sanitary manner on Hall Z 2. Failing to ensure opened resident care items were not stored on the clean linen cart on Hall Z after use 3. Failing to practice Enhanced Barrier Precautions for Resident #63. Findings: 1. Observation on 07/02/2025 at 10:18 a.m., of the dirty soiled linen closet on Hall Z accompanied with S6 Laundry revealed 6 clean water basins stored on the top shelf, un-bagged. Observation revealed a large yellow barrel overflowed with dirty and soiled linen next to the shelf. S6 Laundry stated staff brings dirty and soiled linen in this closet to be stored and then washed. S6 Laundry confirmed the 6 water basins were clean, used for resident use, should be bagged, and not stored in this closet on Hall Z. S6 Laundry stated its cross-contamination. 2. Observation on 07/02/2025 at 10:40 a.m., of the clean linen cart on Hall Z with S11 CNA Supervisor revealed 1 pack of opened wipes used for resident care and 2 pink denture cups, which contained baby powder. S11 CNA Supervisor stated anytime staff uses resident care items such as wipes or baby powder it is to be left in the resident's room. S11 CNA Supervisor confirmed the 1 pack of opened wipes and 2 pink denture cups of baby powder should not have been left on the clean linen cart. Observation on 07/02/2025 at 12:20 p.m., of the clean linen cart on Hall Z with S12 CNA stated she gathers resident care items such as wash, wipes, adult briefs, and resident linen from the clean linen cart and places them in a clear bag. S12 CNA stated these items are to remain in the resident's room since all rooms are now private. S12 CNA stated some staff have a habit of using these items, bringing them back out of a resident's room, and placing them back on the clean linen cart. S12 CNA confirmed the 1 bottle of skin and hair cleanser was used for resident care and shouldn't have been placed back on the clean linen cart. 3. Resident #63 On 07/1/2025 at 3:07 p.m., review of facility policy titled, Enhanced Barrier Precautions, dated 05/01/2024, revealed in part . Facility shall ensure that Enhanced Barrier Precautions (EBP) are utilized in the infection control program. Enhanced Barrier Precautions is used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROS to staff hands and clothing. EBP are indicated for residents with any of the following .Indwelling medical devices . even if the resident is not known to be infected or colonized with Multi-drug Resistant Organism (MDRO). Indwelling medical devices include central lines. Review of Resident #63's electronic medical record revealed an admit date of 12/13/2024 with diagnosis that included but not limited to: End Stage Renal Disease, Hypotension, Moyamoya Disease, Paroxysmal Atrial Fibrillation, Presence of other vascular implants and grafts, Encounter for fitting and adjustment of Extracorporeal Dialysis Catheter, Dependence of Renal Dialysis. On 07/01/2025 at 9:33 a.m., review of Resident #63's Significant Change MDS with ARD of 06/21/2025 revealed a BIMS Score of 8, indicating moderate cognitive impairment. On 07/01/2025 at 9:28 a.m., review of Resident #63's July 2025 Physican's Orders revealed an active order for Enhanced Barrier Precautions with initiation date of 12/24/2024. On 07/01/2025 at 9:45 a.m., review of Resident #63's care plan with initiation date of 12/15/2024 revealed Resident #63 was on enhanced barrier precautions for dialysis catheter access with interventions that included: Enhanced Barrier Precautions will be used for dialysis catheter and EBP as instructed, hanging outside of door. On 07/01/2025 at 12:03 p.m., observation of the interior and exterior of Resident #63's room revealed no EBP signage or caddy with appropriate PPE for enhanced barrier precautions. During an interview on 07/01/2025 at 11:37 a.m. Resident #63 stated that staff only applied gloves when caring for him. Resident #63 denied staff wore gowns when caring for him. During an interview on 07/01/2025 at 12:12 p.m., S9 CNA revealed she had been employed at the facility since 2018 and was familiar with the care Resident #63 required. S9 CNA stated Resident #63 did not require any special precautions. S9 CNA confirmed she applied only gloves before caring for Resident #63. On 07/01/2025 at 12:20 p.m., an interview with S4 LPN revealed she has been employed at the facility for about 2 years and was familiar with Resident #63 and the care he required. S4 LPN stated Resident #63 was not on EBP. Resident #63's active orders and care plan were reviewed with S4 LPN during the interview. S4 LPN confirmed Resident #63 had an active order for enhanced barrier precautions. On 07/01/2025 at 12:25 p.m., S4 LPN accompanied the surveyor to Resident #63's room. S4 LPN confirmed enhanced barrier precautions were not in place for Resident #63 and should have been. On 07/01/2025 at 2:30 p.m., S2 DON and S10 ADON acknowledged that Resident #63 should have had enhanced barrier precautions in place and did not.

Based on interview and record review the facility failed to ensure each resident had a comprehensive person-centered care plan developed and implemented to meet his or her goals and address the resident's medical, physical, mental, and psychosocial needs for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: Review of Resident #2's medical record revealed an admitted [DATE] with diagnoses that included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting right non-dominant side, Other Muscle Spasms, Major Depressive Disorder, Insomnia, and Type 2 Diabetes Mellitus. Review of Resident #2's Admission/OSA MDS with an ARD of 07/24/2024 revealed a BIMS score of 15, indicating intact cognition. Resident #2's MDS revealed she required extensive assistance with 2 plus persons for bed mobility, transfers, and toilet use. Review of Resident #2's Care Plan with a Target Date of 10/18/2024 revealed in part . History of Drug Abuse. Date initiated 07/22/2024. Intervention: Resident noted to be lethargic, slurred speech, unable to perform ADL's at her normal capacity, found to have container of synthetic THC gummies, container taken to the nurses' station. Date initiated 08/22/2024. Interview on 09/03/2024 at 2:31 p.m. with S6 LPN MDS revealed Resident #2 had a history of drug abuse on admission. S6 LPN MDS confirmed Resident #2's Care Plan should have had interventions in place other than the intervention initiated on 08/22/2024.

Based on interview and record review, the facility failed to ensure services were provided to meet professional standards of quality for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents by providing Resident #2 with THC gummies without consulting the resident's physician. Findings: Review of Resident #2's medical record revealed an admitted [DATE] with diagnoses that included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Non-Dominant Side, Other Muscle Spasms, Major Depressive Disorder, Insomnia, and Type 2 Diabetes Mellitus. Review of Resident #2's Admission/OSA MDS with an ARD of 07/24/2024 revealed a BIMS score of 15, indicating intact cognition. Resident #2's MDS revealed she required extensive assistance with 2 plus persons for bed mobility, transfers, and toilet use. Review of Resident #2's Care Plan with a Target Date of 10/18/2024 revealed in part . History of Drug Abuse. Intervention: Resident #2 noted to be lethargic, slurred speech, unable to perform ADL's at her normal capacity, found to have container of synthetic THC gummies, container taken to the nurses' station. Diagnosis of Depression. Interventions: 08/22/2024 Resident #2 reported suicidal ideations to nurse, PEC per Psychiatrist to inpatient psych hospital. Administer medications as ordered. Consult to see Psychiatrist for medication management. Encourage Resident #2 to express feelings (anger, sadness, guilt) and come up with alternative ways to handle feelings. Monitor for any signs and symptoms of depression: feelings of guilt, helplessness, or hopelessness, poor concentration, sleep disturbances, lethargy, appetite loss or weight gain, anhedonia, loss of mood reactivity, and thoughts of death. Mood and behavior monitored every shift. Review of Resident #2's Progress Notes revealed in part . 08/22/2024 12:00 a.m. Resident remains up in wheelchair in room .her speech is slurred, and she appeared to be intoxicated, staff .finds gummies in an opened container, with a few missing .she has torn the room up, items on the floor, food, and other items, when Resident #2 came back in, she was asked what else did she have beside the prescribed medicine that she received at facility, she replied nothing . By: S4 LPN 08/23/2024 3:01 p.m. On 08/22/2024 at 10:21 a.m., I was notified by nursing staff that Resident #2 was verbalizing threats to harm herself and that she was being sent out to the local ER for psychiatric evaluation .On 08/23/2024 at 10:07 a.m. I spoke with S2 DON on the phone. S2 DON stated .Resident #2 asked him to pick up some THC gummies from the gas station earlier this week and he did so. I was not notified until after this occurred. I did not give an order for them .I told him that he shouldn't have given Resident #2 gummies . By: Physician Review of a Disciplinary Warning Notice for S2 DON dated 08/26/2024 revealed in part . This is a record showing S2 DON and S1 ADM had a meeting regarding that THC gummies will no longer be allowed at the nursing home . Interview on 08/27/2024 11:07 a.m. with S1 ADM revealed Resident #2 was depressed about being in a nursing home after having a massive stroke and her boyfriend recently broke up with her. S1 ADM revealed when S2 DON talked to Resident #2, she asked him to get her marijuana and S2 DON told her he could not. S1 ADM reported S2 DON asked her if he could get THC gummies for Resident #2 and she told him he could. S1 ADM revealed S2 DON bought THC-P gummies and gave the can of 10 gummies to Resident #2. S1 ADM revealed she did not consider the complications of allowing S2 DON to purchase THC gummies, and confirmed she should have called the doctor prior to allowing the S2 DON to purchase the gummies for Resident #2. Interview on 08/27/2024 at 2:53 p.m. with S2 DON revealed on 08/20/2024 he heard and saw Resident #2 crying on the patio. S2 DON revealed he went out to speak with Resident #2 and when he asked her what was wrong, she said Nothing, It's Nothing. S2 DON reported Resident #2 then asked him for a marijuana joint and he told her he could not do that, but he could see about getting her THC gummies. S2 DON revealed he spoke to S1 ADM and S1 ADM told him it was legal and he could get it for Resident #2. S2 DON revealed Resident #2 asked about the THC gummies on 08/21/2024 and he went that afternoon and got them for her. S2 DON reported he got a container that had 10 gummies and gave Resident #2 the whole container. Interview on 08/29/2024 at 1:58 p.m. with S2 DON confirmed he did not call Resident #2's physician prior to buying the THC gummies and giving them to her, but he should have. Telephone interview on 08/30/2024 at 9:07 a.m. with S4 LPN revealed during her medication pass on 08/21/2024, staff notified her Resident #2 voiced she wanted to kill herself and those around her. S4 LPN revealed she could not recall the time or name of the staff. S4 LPN reported she told the staff to monitor Resident #2 when she went into her room. S4 LPN revealed she could not recall if she notified the Resident #2's physician. S4 LPN revealed when passing Resident #2's room she saw it was in disarray and she went in. S4 LPN reported she found food on the floor and some blue THC gummies in a tin can with 8 gummies remaining in the can. Interview on 08/30/2024 at 12:55 p.m. with Resident #2's physician revealed he heard S2 DON had given Resident #2 THC gummies, he said he was not notified, and would have never agreed to it. He revealed he was never made aware Resident #2 was asking staff about marijuana, nor did any staff speak to him about THC gummies, until after they were given to Resident #2 and she was in the hospital. Interview on 09/03/2024 at 3:00 p.m. with Resident #2 revealed she just returned to the facility today after being treated at a behavioral hospital. Resident #2 reported she does not recall exactly what happened on 08/21/2024 or what she said to staff because she was in and out of it. Resident #2 reported she just knows she was very depressed. Resident #2 revealed she had taken THC gummies in the past prior to being admitted to the facility. Resident #2 reported the THC gummies that were purchased by S2 DON were stronger and she did not like the way they made her feel.

Based on interview and record review, the facility failed to ensure a resident who displays or is diagnosed with a mental disorder received appropriate treatment and services to correct the assessed problem and to attain the highest practicable mental and psychosocial well-being for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: Review of a facility policy titled Change in a Resident's Condition or Status dated 12/2016 read in part . Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc). 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): d. significant change in the resident's physical, emotional, mental condition . Review of Resident #2's medical record revealed an admitted [DATE] with diagnoses that included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Non-Dominant Side, Other Muscle Spasms, Major Depressive Disorder, Insomnia, and Type 2 Diabetes Mellitus. Review of Resident #2's Admission/OSA MDS with an ARD of 07/24/2024 revealed a BIMS score of 15, indicating intact cognition. Resident #2's MDS revealed she required extensive assistance with 2 plus persons for bed mobility, transfers, and toilet use. Review of Resident #2's Care Plan with a Target Date of 10/18/2024 revealed in part . History of Drug Abuse. Intervention: Resident #2 noted to be lethargic, slurred speech, unable to perform ADL's at her normal capacity, found to have container of synthetic THC gummies, container taken to the nurses' station. Diagnosis of Depression. Interventions: 08/22/2024 Resident #2 reported suicidal ideations to nurse, PEC per Psychiatrist to inpatient psych hospital. Administer medications as ordered. Consult to see Psychiatrist for medication management. Encourage Resident #2 to express feelings (anger, sadness, guilt) and come up with alternative ways to handle feelings. Monitor for any signs and symptoms of depression: feelings of guilt, helplessness, or hopelessness, poor concentration, sleep disturbances, lethargy, appetite loss or weight gain, anhedonia, loss of mood reactivity, and thoughts of death. Mood and behavior monitored every shift. Review of Resident #2's Progress Notes revealed in part . 08/21/2024 6:30 p.m. Resident #2 on the outside on patio, saying she wanted to speak to someone, anyone, staff says that she was just talking about a lot of nothing, until she replied, that she wanted to kill herself and those around her, writer was inside the building .when Resident #2 did come inside passed me .she went to her room, and did not wait nor ask for anything. By: S4 LPN 08/22/2024 12:00 a.m. Resident remains up in wheelchair in room .her speech is slurred, and she appeared to be intoxicated, staff .finds gummies in an opened container, with a few missing .she has torn the room up, items on the floor, food, and other items, when Resident #2 came back in, she was asked what else did she have beside the prescribed medicine that she received at facility, she replied nothing . By: S4 LPN 08/22/2024 9:30 a.m. Resident #2 noted to be agitated this am. Yelling out help me from room. Stated that she wanted to kill herself to the night time nurse. Psychiatrist here on rounds .PEC filled out for transfer to facility for psych evaluation. Send to local hospital for evaluation r/t verbal threats to harm self. By: S5 LPN 08/23/2024 3:01 p.m. On 08/22/2024 at 10:21 a.m., I was notified by nursing staff that Resident #2 was verbalizing threats to harm herself and that she was being sent out to the local ER for psychiatric evaluation .On 08/23/2024 at 10:07 a.m. I spoke with S2 DON on the phone. S2 DON stated .Resident #2 asked him to pick up some THC gummies from the gas station earlier this week and he did so. I was not notified until after this occurred. I did not give an order for them .I told him that he shouldn't have given Resident #2 gummies . By: Physician Review of Resident #2's PEC dated 08/22/2024 at 1:00 p.m. revealed in part .stating she wants to kill herself, not sleeping. Mental condition: depressed, anxious, crying, not sleeping, not cooperative. Suicidal. Dangerous to self. Unwilling. Signed by: Psychiatrist Review of a Disciplinary Warning Notice for S4 LPN Dated 08/23/2024 revealed in part . Resident #2 stated she wanted to kill herself and S4 LPN did not put Resident #2 on one on one or notify the physician . Signed by: S3 ADON and S2 DON Interview on 08/27/2024 11:07 a.m. with S1 ADM revealed Resident #2 was depressed about being in a nursing home after having a massive stroke and her boyfriend recently broke up with her. S1 ADM revealed when S2 DON talked to Resident #2, she asked him to get her marijuana and S2 DON told her he could not. S1 ADM reported S2 DON asked her if he could get THC gummies for Resident #2 and she told him he could. S1 ADM revealed S2 DON bought THC-P gummies and gave the can of 10 gummies to Resident #2. S1 ADM revealed she did not consider the complications of allowing S2 DON to purchase THC gummies, and confirmed she should have called the doctor prior to allowing the S2 DON to purchase the gummies for Resident #2. Interview on 08/27/2024 at 2:53 p.m. with S2 DON revealed on 08/20/2024 he heard and saw Resident #2 crying on the patio. S2 DON revealed he went out to speak with Resident #2 and when he asked her what was wrong, she said Nothing, It's Nothing. S2 DON reported Resident #2 then asked him for a marijuana joint and he told her he could not do that, but he could see about getting her THC gummies. S2 DON revealed he spoke to S1 ADM and S1 ADM told him it was legal and he could get it for Resident #2. S2 DON revealed Resident #2 asked about the THC gummies on 08/21/2024 and he went that afternoon and got them for her. S2 DON reported he got a container that had 10 gummies and gave Resident #2 the whole container. Interview on 08/29/2024 at 1:58 p.m. with S2 DON confirmed he did not call Resident #2's physician prior to buying the THC gummies and giving them to her, but he should have. S2 DON revealed it was reported to him on 08/22/2024 that Resident #2 had behaviors the night before of wanting to kill herself and others, and S4 LPN did not follow policy and procedure. S2 DON reported once he found out Resident #2 had threatened to kill herself and others, she was immediately placed on 1:1 and he got a PEC from the psychiatrist to send her to a psych facility. S2 DON reported they could not find placement therefore, Resident #2 was sent to a local hospital, and then was eventually transferred to a behavioral hospital. S2 DON reported S4 LPN should have taken immediate action, the physician should have been called, and Resident #2 should have been on 1:1 for close monitoring to ensure her safety as well as others in the facility. Telephone interview on 08/30/2024 at 9:07 a.m. with S4 LPN revealed during her medication pass on 08/21/2024, staff notified her Resident #2 voiced she wanted to kill herself and those around her. S4 LPN revealed she could not recall the time or name of the staff. S4 LPN reported she told the staff to monitor Resident #2 when she went into her room. S4 LPN revealed she could not recall if she notified the Resident #2's physician. S4 LPN revealed when passing Resident #2's room she saw it was in disarray and she went in. S4 LPN reported she found food on the floor and some blue THC gummies in a tin can with 8 gummies remaining in the can. Interview on 08/30/2024 at 12:55 p.m. with Resident #2's physician revealed he was notified by S5 LPN on 08/22/2024 around 10:00 a.m. that Resident #2 was suicidal and was being sent to the local ER. He reported about an hour later, around 11:00 a.m., he received a message from S2 DON saying the resident needed a PEC. He revealed S2 DON told him Resident #2 was suicidal and threatened to kill herself and everyone else at the nursing home. He revealed he was told Resident #2 was already placed on 1:1 and he said he would write the PEC. He reported he wrote the PEC and S2 DON came by his clinic and picked it up. He revealed he found out that the psychiatrist had gone to see Resident #2 and had also written a PEC for Resident #2 and was helping with trying to find placement at an inpatient psychiatric hospital. He revealed he was made aware by S1 ADM and S3 ADON on 08/29/2024 that Resident #2 was suicidal on 08/21/2024 and he was not notified by staff until 08/22/2024. He reported Resident #2 should have gone straight to the local ER if she was suicidal and threatening to harm others. He revealed he heard S2 DON had given Resident #2 THC gummies, he said he was not notified, and would have never agreed to it. He revealed he was never made aware Resident #2 was asking staff about marijuana, nor did any staff speak to him about THC gummies, until after they were given to Resident #2 and she was in the hospital. Interview on 08/30/2024 at 2:11 p.m. with S5 LPN revealed on 08/22/2024 S4 LPN informed her during report for her 6:00 a.m. to 6:00 p.m. shift, THC gummies were found in Resident #2's purse. S5 LPN revealed Resident #2 woke up screaming and hollering for S3 ADON because S4 LPN had called S3 ADON on the 6:00 p.m. to 6:00 a.m. shift to let her know about Resident #2's behaviors. S5 LPN reported the psychiatrist saw Resident #2 and wrote a PEC. S5 LPN revealed Resident #2 went out around 2:00 p.m. to the local ER. S5 LPN reported she was not instructed to have staff sit 1:1 with Resident #2. S5 LPN reported from 6:00 a.m. to around 2:00 p.m. when Resident #2 went to the hospital, whenever she went in the room to provide care, Resident #2 was alone. S5 LPN revealed when the psychiatrist came, she woke up and starting screaming, and then was screaming again right before she went to the hospital. Interview on 09/03/2024 at 11:04 a.m. with S3 ADON revealed Resident #2 reported to staff on 08/21/2024 around 6:20 p.m. that she wanted to kill herself and others. S3 ADON reported Resident #2's physician was not notified until around 9:30 a.m. to 10:00 a.m. the following morning on 08/22/2024. S3 ADON reported she got a call at around 12:30 a.m. on 08/22/2024 notifying her Resident #2 was yelling out, they found THC gummies in her room, and her room was a mess. S3 ADON reported they did not tell her Resident #2 voiced wanting to kill herself and others. S3 ADON confirmed the resident was not placed on 1:1, but should have been. Interview on 09/03/2024 at 3:00 p.m. with Resident #2 revealed she just returned to the facility today after being treated at a behavioral hospital. Resident #2 reported she does not recall exactly what happened on 08/21/2024 or what she said to staff because she was in and out of it. Resident #2 reported she just knows she was very depressed. Resident #2 revealed she had taken THC gummies in the past prior to being admitted to the facility. Resident #2 reported the THC gummies that were purchased by S2 DON were stronger and she did not like the way they made her feel.

Based on record reviews, observations, and interviews, the facility failed to ensure a cognitively impaired resident who had a history of wandering, was adequately supervised and not allowed to exit the building without staff knowledge, for 1 Resident (#R7) of 12 sampled residents (#1, #2, #3, #R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, and #R9). This deficient practice resulted in an Immediate Jeopardy situation on 06/25/2024 at 3:59 p.m., when Resident #R7, a severely cognitively impaired resident who had a history of wandering, followed visitors out of the building via the front entrance door, and walked into the parking lot unsupervised on 06/25/2024 and 08/03/2024. S1 ADM was notified of the Immediate Jeopardy on 08/16/2024 at 6:50 p.m. The Immediate Jeopardy was removed on 08/19/2024 at 5:13 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. Findings: Review of the facility's policy titled, Elopements, dated 12/2007, revealed in part . Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. Review of Resident #R7's medical record revealed she was admitted to the facility on [DATE]. Resident #R7 had diagnoses that included in part . Alzheimer's Disease, Schizoaffective Disorder, Generalized Muscle Weakness, Major Depressive Disorder, Unspecified Behavioral and Emotional Disorders, Anxiety Disorder, and Bipolar Disorder. Review of Resident #R7's Quarterly Wandering Risk Scale dated 05/23/2024, completed by S13LPN, revealed a score of 13, which indicated she was at high risk to wander. Review of Resident #R7's Quarterly MDS with an ARD of 05/23/2024, revealed a BIMS score of 3, which indicated severely impaired cognition. Review of the MDS revealed Resident #R7 used a wander/elopement alarm daily. Review of Resident #R7's current comprehensive plan of care with a target date of 08/21/2024, revealed Resident #R7 was at risk for elopement; initiated on 04/17/2023. Interventions included in part .04/19/2023 - Coded locks on doors and gates to prevent elopement of residents, gates are kept closed; 04/19/2023 - Monitor every 1 hour to prevent elopement; and 04/19/2023 - Signs are posted for visitors to not let residents out without staff approval, and keep gates closed after entry, and 06/25/2024 - Went outside behind a visitor, wander guard in place, resident seen, and brought back inside by staff. Further review revealed no new interventions were put into place after the 06/25/2024 or 08/03/2024 elopements. Review of Resident #R7's Elopement Risk Evaluation dated 06/26/2024, and completed by S11ADON, revealed the following: Elopement Score: 4.0 (At Risk) BIMS Score: 3 History of elopement while at home: Yes. History of attempting to leave the facility without informing staff: Yes. Verbally expressed the desire to go home, packed belongings to go home, or stayed near an exit door: Yes. Wanders: No. Wandering behavior a pattern or goal-directed: Yes. Review of Resident #R7's current 08/2024 physician orders revealed in part . 07/31/2024: Wanderguard to ankle for elopement risk every shift. 07/31/2024: Monitor every hour due to elopement attempts. Review of Resident #R7's record revealed no evidence of hourly monitoring. Review of Resident #R7's Departmental Progress Notes revealed the following in part . 06/16/2024 11:13 a.m., documented by S10LPN, read in part . Behavior issues noted this shift. Resident pacing in hallways, attempting to get out of doors when someone enters or exit. 6/20/2024 3:16 p.m., documented by S10LPN, read in part . Attempting to exit facility, went to north reception screaming and cursing pushing on front door. 08/04/2024 17:34 p.m., documented by S8LPN, read in part . Resident walks in hallways independently, Resident often asking when she can go home, re direction difficult at times. Active exit seeker. Safety maintained. Review of Departmental Progress Notes dated 05/2024 - 08/2024 revealed no documentation of Resident #R7's elopements on 06/25/2024 and 08/03/2024. Telephone interview on 08/16/2024 at 9:07 a.m., with S8LPN revealed she was assigned care of Resident #R7 on 08/03/2024. S8LPN revealed she was seated at the nurse's station charting when she heard a wanderguard alarm go off at the X Hall front door. S8LPN revealed Resident #R7 went out the front door without staff, and ambulated a few feet, before a CNA was able to get to Resident #R7. S8LPN revealed #R7 was outside for about 1 minute, and was located in the facility's driveway when staff responded. S8LPN revealed staff immediately brought Resident #R7 back into the facility. S8LPN revealed Resident #R7 was able to get out the X Hall front door, unsupervised by staff, due to a visitor entering the facility and allowing #R7 outside. S8LPN confirmed #R7 had active exit seeking behaviors, wore a wanderguard, and staff were to monitor Resident #R7 every 1 hour. S8LPN was unable to recall the last time she had visually seen Resident #R7 prior to the elopement. S8LPN revealed Resident #R7 had another elopement on 06/25/2024, but she was unable to recall details of that incident. Observation on 08/16/2024 at 12:40 p.m., revealed there was no signage posted at the front entrance of X Hall side of facility, that instructed that visitors were not to let residents out without staff approval, as noted in Resident #R7's care plan. Observation on 08/16/2024 at 1:56 p.m., revealed there was no signage posted at the front entrance of Z Hall side of facility, that instructed that visitors were not to let residents out without staff approval, as noted in Resident #R7's care plan. Observation on 08/16/2024 at 1:59 p.m. revealed Resident #R7 was ambulating on X Hall, and had a wanderguard device located on her left ankle. Interview on 08/16/2024 at 2:04 p.m. with Resident #R7 revealed she stated I want to go home so bad, I can taste it! Resident #R7 stated Can you do something for me? Can you call my son? I want to see my kids so bad, I got to go! If you have kids you understand what I'm saying. Interview on 08/16/2024 at 2:15 p.m. with S2DON, revealed Resident #R7 went out the X Hall front door, unsupervised by staff on 06/25/2024 and 08/03/2024. Review of the facility's video camera footage on 08/16/2024, revealed on 06/25/2024 at 3:59:36 p.m., a group of visitors entered the access code to unlock the X Hall front door. Before the door closed, Resident #R7 was seen ambulating briskly behind the group of visitors, unsupervised by staff, and quickly ambulated down the sidewalk towards a high traffic road adjacent to the front side of facility. Observation revealed there was no staff present in the X Hall lobby at the time Resident #R7 exited the facility. S14CNA was observed running to respond to the wandergaurd alarm, and on 06/25/2024 at 4:00:36 p.m., S14CNA brought Resident #R7 back into the facility. Review of the facility's video camera footage on 08/16/2024, revealed on 08/03/2024 at 1:39:17 p.m., Resident #R7 was observed ambulating from X Hall, and continued to walk towards the X Hall front door. Observation revealed there was no staff present in the X Hall lobby at the time Resident #R7 was in the lobby. At that time, a visitor was seen entering the access code to unlock the front door. As the visitor walked in, Resident #R7 walked out of the facility door unsupervised, and briskly ambulated into the parking lot walking towards a high traffic road adjacent to the front side of facility. S15CNA was observed running out X Hall front door at 1:39:39 p.m. to respond to the wanderguard alarm. S15CNA, S16CNA, and S8LPN were observed speaking to Resident #R7 in the facility's parking lot, and was able to get Resident #R7 back into the facility at 1:40:07p.m. Interview on 08/16/2024 at 2:25 p.m. with S2DON, following review of video camera footage, revealed he was unsure of the last time staff had visually monitored Resident #R7 before she exited the facility unsupervised, as every 1 hour monitoring had not been documented by staff. S2DON revealed Resident #R7 was able to ambulate very quickly. S2DON revealed the facility had not implemented any further interventions to #R7's plan of care following elopements on 06/25/2024 and 08/03/2024. S2DON reported no new in-services related to elopement were done as a result of Resident #R7's elopements. S2DON reported he did not consider these incidents as elopements because Resident #R7 did not leave the facility grounds, and that was why the facility had not implemented further interventions or investigate. Interview on 08/16/2024 at 6:50 p.m. with S1ADM, revealed she was aware of Resident #R7's elopements that occurred on 06/25/2024 and 08/03/2024, and the facility did not feel the incidents were elopements. S1ADM revealed Resident #R7 was able to ambulate very quickly, and stated She's fast! S1ADM revealed the facility did not have 1 hour monitoring documentation for Resident #R7 as ordered and care planned. S1ADM confirmed the facility had not updated Resident #R7's plan of care with further interventions following Resident #R7's elopements, to prevent the likelihood of further elopements by Resident #R7, but should have.

Based on record review and interview, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 1 Resident (#R7), of 12 sampled residents (#1, #2, #3, #R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, and #R9). The facility failed to: 1. Have an effective system in place to ensure Resident #R7 was adequately supervised to prevent her from exiting the building unsupervised on 06/25/2024 and 08/03/2024; 2. Complete an incident report and/or thoroughly investigate Resident #R7's elopements on 06/25/2024 and 08/03/2024; and 3. Update Resident #R7's care plan to include new interventions to prevent the resident from exiting the building unsupervised after two previous elopements. This deficient practice resulted in an Immediate Jeopardy situation on 06/25/2024 at 3:59 p.m. when Resident #R7, a severely cognitively impaired resident who had a history of wandering, followed visitors out of the building via the front entrance door, and walked into the parking lot unsupervised on 06/25/2024 and 08/03/2024. S1 ADM was notified of the Immediate Jeopardy on 08/16/2024 at 6:50 p.m. The Immediate Jeopardy was removed on 08/19/2024 at 5:13 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. Findings: Cross Reference to F689 Review of the facility's policy titled, Elopements dated 12/2007 revealed in part . Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse of Director of Nursing. Review of the facility's policy titled, Accidents and Incidents-Investigating and Reporting dated 07/2017 revealed in part . All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Interview on 08/16/2024 at 2:15 p.m. with S2 DON revealed Resident #R7 went out the X Hall front door, unsupervised by staff on 06/25/2024 and 08/03/2024. S2 DON confirmed the facility did not complete an incident report on 06/25/2024. S2 DON revealed the facility had not investigated Resident #R7's elopement incidents as there was no incident to investigate. Interview on 08/16/2024 at 2:25 p.m. with S2 DON revealed the facility had not implemented any further interventions to Resident #R7's plan of care following elopements on 06/25/2024 and 08/03/2024. S2 DON revealed no new in-services related to elopement were done as a result of Resident #R7's elopements. S2 DON revealed he did not consider these incidents an elopement because Resident #R7 did not leave the facility grounds. Interview on 08/16/2024 at 3:19 p.m. with S2 DON revealed the facility did not have a policy related to training staff on risk for elopement, how to respond after an elopement, or a policy specific to Elopement/Wandering Assessments. Interview on 08/16/2024 at 6:50 p.m. with S1 ADM revealed she was aware of Resident #R7's elopements that occurred on 06/25/2024 and 08/03/2024, and the facility did not complete incident reports or in-servicing because the facility did not feel the incidents were elopements. S1 ADM confirmed the facility had not updated Resident #R7's plan of care with further interventions following elopements to prevent the likelihood of elopement, but should have.

Based on interview and record review, the facility failed to ensure a resident's right to be free from verbal and mental abuse by staff for 1 (Resident #1) of 12 (Resident #1, Resident #2, Resident #3, #R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, and #R9) sampled residents. This failed practice resulted in an actual harm situation for Resident #1 on 07/23/2024 on the 6:00 p.m. to 6:00 a.m. shift when Resident #1, who was severely impaired cognitively, and had diagnoses of Dementia and Major Depressive Disorder, was verbally and mentally abused by S3 CNA. Review of Resident #1's video camera footage revealed on 07/23/2024 at 7:54 p.m., S3 CNA while in Resident #1's room stated to Resident #1 You old meanie. At 11:00 p.m., while S3 CNA and S4 CNA were providing ADL assistance to Resident #1, S3 CNA stated to Resident #1 Why you gotta be like that man? Resident #1 replied I love Jesus. S3 CNA stated If you loved Jesus, you wouldn't be ugly every time someone came in here. That's not loving Jesus, that's loving the Devil. At 11:07 p.m., S3 CNA and S4 CNA were in Resident #1's room. S3 CNA stated to Resident #1, You act a F****** animal. A reasonable person in Resident #1's situation would have experienced severe psychosocial harm and humiliation as a result of this verbal and mental abuse. Findings: Review of the facility's policy titled Abuse and Neglect - Clinical Protocol dated 07/2017, read in part .1. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse . Review of Resident #1's medical record revealed an admitted on 03/24/2021, with diagnoses that included: Altered Mental Status, Dementia, Pseudobulbar Affect, Muscle Weakness, Difficulty in Walking, Anxiety Disorder, and Major Depressive Disorder. Review of Resident #1's Significant Change MDS with an ARD of 05/01/2024, revealed a BIMS score of 00, indicating severe cognitive impairment. Resident #1's MDS revealed she had the ability to express her ideas and wants which could be understood. Resident #1's MDS stated she required moderate assistance with upper body dressing, lower body dressing and personal hygiene; maximal assistance with bathing; and she was dependent on staff for toileting hygiene. Review of Resident #1's Care Plan with a Target Date of 08/30/2024 revealed in part .Communication problem related to dementia. Interventions: Anticipate and meet needs. Allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, face when speaking, make eye contact, ask yes/no questions if appropriate, use simple brief consistent words/cues, use alternative communication tools as needed. Monitor/document for physical/nonverbal indicators of discomfort or distress, and follow up as needed. ADL self-care performance. Interventions: Camera in room provided per family. Encourage the resident to participate to the fullest extent possible with each interaction. Praise all efforts at self-care. Review of video camera footage of Resident #1's room dated 07/23/2024 at approximately 7:54 p.m., revealed Resident #1 lying in bed with S3 CNA standing near the head of the bed. S3 CNA stated You old meanie to Resident #1, while adjusting the foot of the electric bed. Review on 08/12/2024 of video camera footage of Resident #1's room, dated 07/23/2024 at approximately 11:00 p.m., revealed Resident #1 in bed, and S3 CNA and S4 CNA changing her gown. As S3 CNA was removing her gown, she stated Why you gotta be like that man? Resident #1 responded I love Jesus. S3 CNA then stated If you loved Jesus you wouldn't be ugly every time someone came in here. That's not loving Jesus, that's loving the Devil. Review on 08/12/2024 of video camera footage of Resident #1's room, dated 07/23/2024 at approximately 11:07 p.m., revealed S3 CNA near Resident #1's bed, and S4 CNA present in the room. As S3 CNA was adjusting Resident #1's gown, she stated to her You act a F****** animal. The video camera footage of Resident #1's room, dated 07/23/2024 at 7:54 p.m., 11:00 p.m., and 11:07 p.m. was reviewed with S1 ADM and S2 DON on 08/15/2024 at 2:15 p.m. S1 ADM confirmed the above statements were made to Resident #1 by S3 CNA. S1 ADM confirmed verbal and mental abuse of Resident #1 by S3 CNA was evident in the camera footage. Review of S4 CNA's, undated, written statement provided by S1 ADM on 08/15/2024 read in part .To my knowledge, S3 CNA and I went into Resident #1's room .While in there providing care, S3 CNA did make some comments that were not appropriate to Resident #1 and mishandled her. I was in shock .All I could do was be quiet and try the best to give her care. After all of this, I did inform the nurse about what took place that night. Telephone interview on 08/16/2024 at 11:50 a.m. with S4 CNA revealed she worked with S3 CNA on 07/23/2024. S4 CNA reported when they provided care to Resident #1 together, S3 CNA was going off. S4 CNA revealed S3 CNA was not speaking to Resident #1 the way she should. S4 CNA reported Resident #1 was scared because of the way S3 CNA was talking to her. S4 CNA reported she could recall S3 CNA saying something along the lines of If you hit me, I don't know what my reflexes might do, but could not recall everything else she said. S4 CNA stated she was unsure of the number times S3 CNA acted like that throughout that night. Telephone interview on 08/16/2024 at 2:26 p.m. with Resident #1's daughter revealed Resident #1 had always listened to Christian music. She revealed she was Pentecostal, and raised her and her sisters Pentecostal. She reported prior to being in the nursing home, Resident #1 went to church services faithfully on Wednesdays and Sundays. She reported Resident #1, prior to having dementia, would have been mad and upset by the way S3 CNA cursed at her, and called her names. She reported Resident #1 would have responded in a Christian manner even if she was mad and upset. Resident #1's daughter stated it would have hurt Resident #1's feelings, upset her, and she would have felt extremely disrespected.