Every finding on record at Arlington Residence and Rehabilitation Center

Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for seven of twelve Resident rooms (Rooms #1, #2, #3, #4, #5, #6, and #7) on the Sunflower Hall, and one of three shower rooms observed for cleanliness. The facility failed to ensure Resident Rooms #1, #2, #3, #4, #5, #6, and #7 on the Sunflower Hall were thoroughly cleaned and sanitized.The facility failed to ensure the shower room on the Sunflower Hall was thoroughly cleaned and sanitized.These failures could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.Findings included:During an observation on 04/07/26 at 10:39 a.m., a shower room on the Sunflower hall had a tub in it. The tub was observed with brownish and grayish stains near the drain hole and on the front panel of the tub. During an observation on 04/07/26 at 10:39 a.m., of room [ROOM NUMBER] reflected the bathroom floor had dark stains in the corners of the floor, and behind the toilet. The bathroom floor had white shredded little pieces of tissue near a wall. The wall near the handrail had brownish stains on it. The room floor near the bed had dark stains in the corner of the floor. During an observation on 04/07/26 at 10:58 a.m., of room [ROOM NUMBER] reflected the room floor had built up dirt in the corners of the door frame and corners of the floor. During an observation on 04/07/26 at 11:02 a.m., of room [ROOM NUMBER] reflected the room floor had built up dirt in the corners of the door frame and corners of the floor. The middle of the room floor had grayish stains. During an observation on 04/07/26 at 11:06 a.m., of room [ROOM NUMBER] reflected the room floor had grayish stains in the corners of the door frame and corners of the floor. The floor near the closet had dark stains. The middle of the room floor had dak grayish stains. The bathroom floor had brownish stains behind the toilet. During an observation on 04/07/26 at 11:12 a.m., of room [ROOM NUMBER] reflected the room floor had a brownish substance on the floor near a wall. The walls near the door and behind the resident's bed had brownish stains streaking down the wall. The bathroom floor had brownish stains along the edges of the floor and behind the toilet. During an observation on 04/07/26 at 11:15 a.m., of room [ROOM NUMBER] reflected the privacy curtain had reddish and black stains all over it. The room floor had grayish stains all over the floor. During an observation on 04/07/26 at 11:19 a.m., of room [ROOM NUMBER] reflected the room floor had grayish stains all over the floor. The bathroom floor had dark stains in the corners of the floor, and behind the toilet. During an interview on 04/09/26 at 10:24 a.m., Housekeeping L was informed by the Surveyor of concerns observed in the Shower room in the Sunflower section. She stated housekeeping was to clean the entire shower area, which included the tub in it. She stated it was hard to get it cleaned and she was not assigned to the Sunflower section but will be assigned to cleaning this section moving forward. She stated not cleaning the areas thoroughly could cause residents to get an infection.During an interview on 04/09/26 at 10:24 a.m., Housekeeping M was informed by the Surveyor of concerns observed in Resident rooms #1, #2, #3, #4, #5, #6, and #7. She stated housekeeping was responsible for cleaning the entire rooms and the areas shown in the photos. She stated she was responsible for cleaning the rooms mentioned in the Sunflower area. She stated she did not know the risk to residents if rooms were not thoroughly cleaned.During an interview on 04/09/26 at 10:24 a.m., the Housekeeping Supervisor, stated she had been the supervisor for the past 4 months. She stated housekeeping was to clean the entire resident room, including the bathrooms. She stated housekeeping were to clean the entire shower room. She was shown by the Surveyor photos of Resident rooms #1, #2, #3, #4, #5, #6, and #7 and the shower room on the Sunflower hall. She stated housekeeping were to clean the areas mentioned. She stated if the rooms and shower rooms were not thoroughly clean it could impact the resident's health.During an interview on 04/08/26 at 12:10 p.m., the Administrator was informed by the Surveyor of the concerns observed in Resident rooms #1, #2, #3, #4, #5, #6, and #7 and the shower room on the Sunflower hall. She stated the rooms needed to be thoroughly cleaned because it should be a homelike environment for the residents.Review of the facility's policy on Safe and Homelike Environment (05/02/25) revealed In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 3 of 6 residents (Residents #1, #7, and #34 ) reviewed for care plan. The facility failed to ensure Resident #1 was care planned for catheter (flexible tube inserted into the bladder to remove the urine) care when he was re-admitted to the facility on [DATE].The facility failed to ensure Resident #7's care plan reflected an intervention which included bed being in the lowest position and fall mat alongside bed. The facility failed to ensure Resident #34's care plan reflected a care plan for smoking.These failures could place residents at risk of their needs not being met. Findings include:Record review of Resident #1's Face Sheet, dated 04/07/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with neuromuscular dysfunction of bladder (the muscles and nerves that control the bladder do not work properly due to illness).Record review of Resident #1's Comprehensive MDS Assessment, dated 03/09/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment indicated the resident had an indwelling catheter (a thin, flexible tube inserted in the bladder to allow the urine to flow in the catheter bag).Record review of Resident #1's Physician Order, dated 03/09/2026, reflected Foley (device used to help drain urine from bladder)/Suprapubic (device inserted into the stomach to the bladder to drain urine) Catheter Care every shift and as needed.Record review on 04/07/2026 of Resident #1's Comprehensive Care Plan reflected no care plan for catheter. Record review of Resident #1's Progress Notes, dated 03/09/2026, reflected Resident . Foley catheter 16 Fr (French: unit of measurement for catheter sizes) in place draining clear yellow urine.During an observation on 04/07/2026 at 9:17 a.m. revealed Resident #1 was in his bed with eyes closed. It was observed that the resident had a catheter bag hanging on the resident's bed frame.During an interview on 04/07/2026 at 2:31 p.m., CNA C said Resident #1 had the catheter for almost a month. She said the resident went to the hospital and came back to the facility with a catheter. She said she would empty his catheter when it was already half full during her shift.During an interview on 04/08/2026 at 1:17 p.m., RN F said Resident #1 was re-admitted last March 07, 2026 after he was sent out to the hospital. She said the resident had a catheter when he was re-admitted to the facility. She said the MDS Nurse was the one doing the care plan.During an observation and interview on 04/09/2026 at 7:48 a.m., the MDS Coordinator said the nursing department was responsible in doing the acute care plan when a resident was re-admitted to the facility. She said if the resident was re-admitted with a catheter, then a care plan for catheter care should been completed so that the staff would be aware of the specific care needed by the resident and so that the staff taking care of the resident would be in the same page in terms of the resident's care. She logged on to her computer and saw that the Resident #1 did not have a care plan for his catheter. She said the care plan should reflect the current status of the resident. She said she would do the comprehensive care plan. She said if the residents did not have a care plan, there could be confusion on their care or care would be not provided at all. She said she already started auditing the care plans of the residents. During an observation and interview on 04/09/2026 at 8:04 a.m., the ADON saidcare plans were important so the staff would be in the same with regards to the care of the residents. She said she thought she did a care plan for Resident #1's catheter when he was re-admitted to the facility. She logged on to her computer and saw that the resident did not have a care plan for the resident. She said it was an oversight on her part because she was responsible in making the care plan of the residents re-admitted to the facility or if there was a change in condition. She said she would coordinate with the DON and the MDS Nurse to make sure the residents had appropriate care plans. During an observation and interview on 04/09/2026 at 8:34 a.m., the DON said care plans were important so the staff would be in sync with the care of the residents. She said without the care plan, needed interventions might not be provided. She said Resident #1's catheter should be care planned because he was re-admitted with it. She logged on to her computer and saw that the resident did not have a care plan for his catheter. She said she did not know why the resident did not have a care plan since they talked about it during their morning meetings. She said it was an oversight on het part because she did not check on it. She said she would coordinate with the MDS Coordinator to audit the care plans of the residents. She said the expectation was all the issues of the residents were care planned. During an interview on 04/09/2026 at 8:59 a.m., the Administrator said that all the residents should have a care plan in line to their needs. She said without the care plan, the staff would not know the goals and the interventions needed by the residents. She said the expectation was for all the residents were care planned appropriately. She said she would coordinate with the DON to make sure all the residents were care planned.Record review of Resident #7's Face Sheet, dated 04/07/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #7 had a diagnosis of muscle wasting.Record review of Resident #7's Initial MDS Assessment, dated 03/19/26, reflected the Resident had a BIMS score of 6 (severe cognitive impairment). The MDS assessment reflected the resident had an active diagnosis of inflammation and infection of his bones.Record review of Resident #7's Comprehensive Care Plan, dated 03/20/26, reflected the resident being a fall risk; however, there were no interventions for bed being in the lowest position and fall mat alongside bed. During an observation on 03/24/26 at 11:36 a.m., Resident #7 was observed lying in bed. His bed was in the lowest position, and a fall mat was placed alongside his bed.During an interview on 04/08/26 at 9:13 a.m., the ADON stated Resident #7 was a fall risk and his bed should be in a low position, fall mat in place, and call light within reach. She was informed by the Surveyor the care plan had no interventions for the bed being in a low position and fall mat alongside his bed. She stated the care plan needed to be updated to reflect the resident's plan of care. She stated the ADON updated the baseline care plan, the MDS Nurse updated the Comprehensive care plan, and the DON updated the care plan for interventions when there was a change of condition. During an interview on 04/08/26 at 9:34 a.m., the MDS Nurse stated she was responsible for updating Resident #7's Comprehensive care plan. She stated the resident was a fall risk and she added the intervention of the resident needing a fall mat alongside his bed today. She was informed by the Surveyor of the resident's bed being in a low position and the resident having a fall mat. She stated updating the resident's care plan may have been an oversight. She stated the ADON and DON should have also added interventions during their IDT meetings. She stated if the interventions were not included in the care plan, staff may not be aware of care needed and the interventions may not be in place.During an interview and observation on 04/08/26 at 10:51 a.m., the DON stated Resident #7 was a fall risk and his bed was to be placed be in a low position, fall mat in place, and call light within reach. She was informed by the Surveyor the care plan of no interventions for the bed being in a low position and fall mat alongside his bed. She stated the interventions should have been included to ensure staff was aware of the plan of care. She stated it was the ADON, DON, and MDS nurse responsibility to update the resident's care plan.Record review of Resident #34's Face Sheet, dated 04/08/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #34 had a diagnosis of mental and behavior disorders.Record review of Resident #34's Initial MDS Assessment, dated 03/11/26, reflected the Resident had a BIMS score of 4 (severe cognitive impairment). The MDS assessment reflected the resident had an active diagnosis of dementia (cognitive decline).Record review of Resident #34's Comprehensive Care Plan, dated 01/04/26, did not reflect the resident was a smoker.Record review of Resident #34's Smoking Assessment, dated 12/12/25, reflected the resident used tobacco products.During an interview on 04/08/26 at 12:10 p.m., the DON and MDS Nurse were informed of Resident #34 not being care planned for smoking. The DON stated she thought Resident #34 had quit smoking. The DON stated if the resident was still a smoker, she needed to be care planned because it was an area that required monitoring.During an interview on 04/09/26 at 11:10 a.m., the ADON stated she had completed Resident #34's smoking assessment on 04/08/26 and she had confirmed Resident #34 was still a smoker and had observed her smoking outside on 04/08/26.Record review of facility's policy, Comprehensive Care Plans, 4/8/2026, reflected It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of hazards as was possible for six of eighteen residents (Residents #7, #34, #41, #54, #66) reviewed for accident hazards. The facility failed to ensure Residents #7 and #66 had physician orders for a scoop mattress (a scoop mattress features raised sides and a concave center). The facility failed to ensure Residents #34 and #41 had Quarterly Smoking Assessments completed.The facility failed to ensure Resident #41 did not have tobacco products in his room. The facility failed to ensure there was no container of odor neutralizer left inside Resident #54's room on 04/07/2026. These failures could prevent the residents from having an environment that was free from accidents, potential injury, and exposure to toxic chemicals.Findings included: Record review of Resident #7's Face Sheet, dated 04/07/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #7 had a diagnosis of muscle wasting.Record review of Resident #7's Initial MDS Assessment, dated 03/19/26, reflected the Resident had a BIMS score of 6 (severe cognitive impairment). The MDS assessment reflected the resident had an active diagnosis of inflammation and infection of his bones.Record review of Resident #7's Comprehensive Care Plan, dated 03/20/26, reflected the resident being a fall risk; and an intervention included a scoop mattress. Record review of Resident #7's Physician Order, dated 04/08/26, reflected no Physician orders for a scoop mattress. During an observation on 04/07/2026 at 11:42 a.m., Resident #7 was observed lying in bed on a scoop mattress. During an interview on 04/08/26 at 9:05 a.m., LVN A, stated Resident #7 was a fall risk and his bed should be in a low position and a fall mat alongside his bed. He stated the scoop mattress was to provide support on his side because he always wanted to get out of bed without help. He stated the resident needed physician orders for the scoop mattress so it would not be considered a restraint. Record review of Resident #66's Face Sheet, dated 04/07/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #66 had a diagnosis of muscle weakness and lack of coordination.Record review of Resident #66's Quarterly MDS Assessment, dated 03/21/26, reflected the Resident had a BIMS score of 99 (unable to complete the interview). The MDS assessment reflected the resident had an active diagnosis of lack of coordination.Record review of Resident #66's Comprehensive Care Plan, dated 02/03/26, reflected the resident being a fall risk; and an intervention included a scoop mattress. Record review of Resident #66's Physician Order, dated 04/08/26, reflected no Physician orders for a scoop mattress.During an observation on 04/07/2026 at 11:14 a.m., Resident #66 was observed lying in bed on a scoop mattress. During an interview on 04/08/26 at 9:13 a.m., the ADON stated Residents #7 and #66 were fall risk and an intervention included the use of a scoop mattress. The ADON was informed by the Surveyor of Residents #7 and #66 not having physician orders for the scoop mattress. She stated she was not aware the residents required physician orders for the mattress. She stated physician orders were needed so the physician was aware of the care being provided to the resident. She stated all nurses were responsible for obtaining physician orders. During an interview on 04/08/26 at 10:51 a.m., the DON stated Residents #7 and #66 were fall risk and an intervention included the use of a scoop mattress. The DON was informed by the Surveyor of Resident #7 and not having physician orders for the scoop mattress. She stated she was not aware the resident needed physician orders for the mattress. She stated physician orders were needed so the physician approved of the care being provided to the resident. She stated all nurses were responsible for obtaining physician orders. Record review of Resident #34's Face Sheet, dated 04/08/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #34 had a diagnosis of mental and behavior disorders.Record review of Resident #34's Initial MDS Assessment, dated 03/11/26, reflected the Resident had a BIMS score of 4 (severe cognitive impairment). The MDS assessment reflected the resident had an active diagnosis of dementia (cognitive decline).Record review of Resident #34's Comprehensive Care Plan, dated 01/04/26, did not reflect the resident was a smoker.Record review of Resident #34's Smoking Assessment, dated 12/12/25, reflected the resident used tobacco products. Record review of Resident #41's Face Sheet, dated 04/08/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #41 had a diagnosis of chronic obstructive pulmonary disease (difficulty breathing). Record review of Resident #41's Initial MDS Assessment, dated 03/09/26, reflected the Resident had a BIMS score of 7 (severe cognitive impairment). The MDS assessment reflected the resident had an active diagnosis of chronic obstructive pulmonary disease.Record review of Resident #41's Comprehensive Care Plan, dated 01/06/26, reflected the resident dipped snuff (smokeless tobacco) and required no supervision.Record review of Resident #41's Smoking Assessment, dated 08/22/25, reflected the resident did not use any tobacco products. During an observation and interview on 04/07/26 at 2:00 p.m., Resident #41 was observed sitting in a wheelchair in his room. He was observed with a can of chewing tobacco on his nightstand. He stated he chewed tobacco and he stated he currently had chewing tobacco in his mouth. During an interview and observation on 04/08/26 at 10:37 a.m., the ADON was informed by the Surveyor of Resident #41 having cans of smokeless tobacco in his room. She stated she was unaware the resident used smokeless tobacco. She stated if she did not know, then her staff may not have known also. She stated the risk of the resident using smokeless tobacco in his room could result in him choking. She stated the resident should have had a smoking assessment completed quarterly. She was informed the resident had a smoking assessment last completed on 08/23/25. She stated it was the nursing staff's responsibility to complete the assessment quarterly. She stated not completing the quarterly assessments could result in the resident choking. During an interview on 04/08/26 at 10:51 a.m., the DON was informed by the Surveyor of Resident #41 having cans of smokeless tobacco in his room. She stated she did not know what smokeless tobacco was and only knew of the tobacco that was smoked. She stated she was unaware the resident used smokeless tobacco. She stated the risk of the resident using smokeless tobacco was a safety concern. She stated the resident should have had a smoking assessment completed quarterly. She was informed the resident had a smoking assessment last completed on 08/23/25. She stated it was the nursing staff's responsibility to complete the evaluation quarterly. She stated not completing the quarterly assessment was a safety concern.During an interview on 04/08/26 at 12:10 p.m., the DON and MDS Nurse were informed of Residents #34 and #41 not having an updated quarterly smoking assessment nor did she have a care plan for smoking. The DON stated she thought Resident #34 had quit smoking. The ADON stated she had completed Resident #34's smoking assessment on 04/08/26 and she had confirmed Resident #34 was still a smoker and had observed her smoking outside on 04/08/26. The DON and ADON stated the resident being a smoker needed to be care planned because it was an area that required monitoring and her.During an interview on 04/08/26 at 12:20 p.m., the Administrator and the Regional Director of Operations were informed by the Surveyor of Residents #34 and #41 not having accurate and updated smoking assessments. They stated the nursing staff was not familiar with smokeless tobacco and they did not know what to look for when they observed Resident #41's room. They stated Resident #41 should not have had the items in his room and they were removed and secured with the other smoking products. The RDO stated she had educated them about smokeless tobacco. They stated the assessments needed to be done quarterly to ensure the residents were safe smokers. Record review of Resident #54's Face Sheet, dated 04/08/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with bipolar disorder (a mental health condition that causes extreme mood swings between emotional highs and lows) and peptic ulcer (open sores in the lining of the stomach). Record review of Resident #54's Comprehensive MDS Assessment, dated 03/09/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated that the resident had bipolar disorder and peptic ulcer.Record review of Resident #54's Comprehensive Care Plan, dated 01/30/2026, reflected the resident had a diagnosis of bipolar disorder, characterized by alternating episodes of mania (abnormally elevated mood) and depression (persistent feeling of sadness or loss of interest), placing the resident at risk for mood instability, impaired judgment, safety concerns and had a history of peptic ulcer. The interventions for both was to administer medications as ordered.During an observation on 04/07/2026 at 9:15 a.m. revealed a container of odor neutralizer on top of Resident #54's mini refrigerator. At the back of container was written, Warning: May cause sensitivity or irritation to skin, eyes, and/or lungs and Keep out of the reach of children. The container was accessible and was on plain view.During an interview on 04/07/2026 at 9:16 a.m., Resident #54 said it was left by a housekeeper the day before but she did not know the name of the housekeeper.During an observation and interview on 04/07/2026 at 9:45 a.m., revealed LVN B went inside Resident #54's room and saw the odor deodorizer on top of the resident's mini refrigerator. She took the container of odor deodorizer and read the warning at the back of the container. She said it should have not been left inside the room of the resident because the deodorizer had chemicals that might be hazardous to the resident. She said confused residents might spray the deodorizer on their face. She said housekeeping was the ones using the deodorizer and they usually store it inside their carts. She said she did not notice the deodorizer when she did her morning round and she had no idea how long the deodorizer was inside the resident's room. She took the deodorizer and said she would give it to housekeeping.During an observation and interview on 04/07/2026 at 9:49 a.m., HK E said she was not the one who left the container of deodorizer inside Resident #54's room. She opened her cart and took the deodorizer that she was using. She said it would be dangerous if a resident would drink the deodorizer because it had chemicals in it.During an interview on 04/08/2026 at 9:02 a.m., the HK Supervisor said she was told about the deodorizer left inside Resident #54's room. She said she asked HK E but said she was not the one who left the deodorizer inside the room. She said she also asked the other HK but all of them said they did not. She said deodorizers had chemicals in them and would be dangerous if the resident would drink them of put them in their eyes. She said HK used gloves when they use it because it could cause irritation to the skin.During an interview on 04/09/2026 at 8:04 a.m., the ADON said the container of odor neutralizer should not have been left inside the resident's room because they were hazardous and might cause irritations. She said the content of the container was harmful if the resident accidentally sprayed it on her face and skin. She said the odor neutralizer should be stored inside the carts of housekeeping. She said they would coordinate with housekeeping to do an in-service about not leaving the container of odor neutralizer inside the rooms of the residents.During an interview on 04/09/2026 at 8:34 a.m., the DON said the containers of odor neutralizer should be locked in the housekeeping carts and not left inside the rooms of the residents because its content was unsafe if it had contact with the eyes and skin. She said anything that indicated Keep out of reach of children. should be considered harmful because the facility had confused residents that may not know the outcome if the germicidal wipes were used. She said she would coordinate with the housekeeping department to re-educate the housekeepers to not leave anything hazardous inside the room of the residents.During an interview on 04/09/2026 at 8:59 a.m., the Administrator said anything harmful should not be left inside the rooms of the residents and should be locked inside the carts of the housekeepers because hazardous to the residents if consumed or used to clean the skin. She said she would collaborate with housekeeping so that the incident of the unattended container of odor deodorizer would not happen again.Record review of facility's policy, Resident Smoking, 03/20/26, reflected It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and nonsmoking residents. Smoking is prohibited in all areas except the designated smoking area. A Designated Smoking Area sign will be prominently posted. Residents must complete a Resident Safe Smoking Assessment and be determined safe to smoke independently without supervision. The assessment will evaluate cognitive status, physical ability, judgment, coordination, vision, respiratory status, oxygen use, and prior smoking-related safety concerns. Determinations will be documented in the medical record and reflected in the resident's plan of care. Smoking materials must be stored in the lock box when not in use. Materials may not be stored in resident rooms outside of the lock box, common areas, or near oxygen, heat sources, or flammable materials. Storage location will be identified in the care plan and comply with life safety requirements. All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment process.Record review of facility's policy, Resident Smoking, undated, reflected The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Record review of the facility's policy Medication Storage The Compliance Store revised November 02, 2025 reflected Policy Explanation and Compliance Guidelines . External Products: Disinfectants . are stored separately.Record review of the facility's policy, Resident Rights The Compliance Store, undated, reflected 8. Safe environment. The resident has a right to a safe . environment.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of eighteen residents (Resident #19, #23 and #86) reviewed for infection control. 1. The facility failed to ensure CNA C performed hand hygiene and changed her gloves during Resident #19's incontinent care on 04/07/2026. 2. The facility failed to ensure CNA D performed hand hygiene, changed her gloves, did not put gloves inside her pockets, and wore a gown during Resident #23's incontinent care on 04/08/2026. 3. The facility failed to ensure LVN A performed hand hygiene before checking Resident #86's blood sugar on 04/08/2026. These failures could place residents at risk of cross-contamination and development of infections.Findings included: 1. Record review of Resident #19's Face Sheet, dated 04/08/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle wasting and atrophy.Record review of Resident #19's Comprehensive MDS Assessment, dated 01/11/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 0. The Comprehensive MDS Assessment indicated the resident had bowel and bladder incontinence.Record review of Resident #19's Care Plan, dared 01/30/2026, reflected the resident experienced involuntary loss of stool and urine and one of the interventions was to clean her perineal (area between the legs) area after each episode.During an observation on 04/07/2026 at 2:02 p.m. revealed CNA C was about to do Resident #19's incontinent care. She washed her hands, put on a pair of gloves, and proceeded with incontinent care. After fixing the brief under the resident, she noticed that the resident's left inner upper leg was still soiled. She took some wipes and cleaned the inner leg. She then proceeded to fix the brief without changing her gloves.During an interview on 04/07/2026 at 2:31 p.m., CNA C said she should have changed her gloves when she wiped the resident's legs to prevent urinary tract infection.2. Record review of Resident #23's Face Sheet, dated 04/08/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #23's Comprehensive MDS Assessment, dated 03/10/2026, reflected that the resident was not able to complete the interview to determine the BIMS score. The Staff Assessment for Mental Status reflected that the resident had memory problems and was severely impaired for daily decision making. The assessment indicated the resident was incontinent for bladder and bowel. Record review of Resident #23's Comprehensive Care Plan, dated 01/30/2026, reflected that the resident was incontinent for bowel and bladder and one of the interventions was to clean, and dry the perineum. The plan indicated that the resident had a pressure injury due to limited mobility and one of the interventions was to use pressure- relieving devices.Record review of Resident #23's Physician Order, dated 03/18/2026, reflected Wound Location: SACRUM (bone at the lower back) Cleanse wound with NS/wound cleanser Peri (around) wound: House Barrier Cream Primary Dressing: CALCIUM ALGINATE with SILVER Secondary Dressing: Secure with: Dry gauze dressing every 8 hours as needed WHEN SOILED OR DISLODGE.Record review of Resident #23's Physician Order, dated 03/27/2026, reflected ENHANCED BARRIER PRECAUTIONS: Resident requires enhanced barrier precautions. Wear PPE per facility protocol. Required for high contact resident care activities. Indications: wound. During an observation on 04/08/2026 at 9:23 a.m. revealed CNA D was about to do incontinent care for Resident #23, who had an open wound to her sacrum. She went inside the room and put on a pair of gloves. She did not wash her hands before putting on her gloves. She also did not wear a gown before doing incontinent care. It was observed that there were no gloves and sanitizer on the resident's table. She took a brief from the resident's overbed table, opened it, and placed it on the resident's side. She cleaned the resident's perineal area using the front to back technique. She took off her gloves, pulled a pair of gloves from her pocket, and put them on. She did not sanitize her hands when she changed her gloves. She then rolled the resident and cleaned the resident's bottom. After cleaning the resident's bottom, she pulled the soiled brief and threw it to the trash can. She took the opened brief from the side of the resident, placed it under the resident, and fixed it. She did not change her gloves after cleaning the resident's bottom and before touching the new brief. She took off her gloves when she was done with incontinent care. There was a sign outside the resident's room that stated the resident was on EBP and a gown was required when changing the brief. The sign also indicated to clean the hands before entering and when leaving the room.During an interview on 04/08/2026 at 9:40 a.m., CNA D said the EBP sign outside the room was for Resident #23 because she had a wound on her bottom. She said the sign outside indicated to wear gloves and a gown during care for residents with open wound. She said she forgot to wear a gown. She said the gown served as an added protection to prevent cross contamination. She said hands should be washed before and after incontinent care to make sure her hands were clean before touching the resident. She said she was supposed to change her gloves after cleaning the resident's bottom and before touching the new brief to prevent using dirty gloves that could result in cross contamination. She said gloves should not be placed in the pockets because the pockets were not always clean. She said her actions could contribute to cross contamination and infection. 3. Record review of Resident #86's Face Sheet, dated 04/08/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus (high blood sugar). Record review of Resident #86's Comprehensive MDS Assessment, dated 03/18/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had diabetes mellitus and was receiving insulin. Record review of Resident #86's Comprehensive Care Plan, dated 03/21/2026, reflected that the resident had diabetes mellitus and one of the interventions was to administer insulin.Record review of Resident #86's Physician Order, dated 03/28/2026, reflected Insulin Lispro Injection Solution (Insulin Lispro) Inject 3 units subcutaneouslythree times a day for DM TYPE 2 HOLD IF BS LESS THAN 110.During an observation on 04/08/2026 at 11:21 a.m. revealed LVN A was about to check Resident #86's blood sugar. He parked his cart in front of the resident's room, prepared his glucometer, alcohol wipes, and test strips. He then put on a pair of gloves and proceeded to check the resident's blood sugar. He did not sanitize his hands before checking the resident's blood sugar.During an interview on 04/08/2026 at 11:28 a.m., LVN A said he should have sanitized his hands before checking Resident #86's blood sugar to make sure his hands were clean before touching the gloves that he would be using to check the blood sugar. He said he would be mindful the next time he would do treatment to do hand hygiene before and after treatment.During an interview on 04/09/2026 at 8:04 a.m., the ADON said gloves should not be placed inside the pockets because the pockets were dirty, rendering the gloves dirty when used during incontinent care. She said hands should be washed before any care and treatment. She said the staff should change their gloves after cleaning the resident's bottom to make sure the staff were not using soiled gloves when they touched the new brief. She said staff should also sanitize their hands when they were changing their gloves. She said if the resident was on EBP, then the staff should wear a gown in addition to the gloves. She said hand hygiene, changing of gloves, sanitizing in between changing of gloves, not putting gloves in the pocket, and wearing PPE were ways to prevent cross contamination and spread of infections. She said they would re-educate the staff on the importance of hand hygiene and infection control.During an interview on 04/09/2026 at 8:34 a.m., the DON said if a resident was on EBP, then the staff doing care should wear a gown every time they had contact with the resident to prevent cross contamination and spread of infection. She said hand hygiene was the most effective way to prevent cross contamination and spread of infection and staff should do hand hygiene before, during, and after any care. She said gloves should have been changed after cleaning the resident's bottom and before touching the new brief. She said there might be no policy that would say not to put the gloves in the pockets, but the best practice was not to put gloves inside the pockets to make sure the gloves being used were clean. She said it was also an infection control issue if the staff did not sanitize their hands when changing their gloves. She said the expectation was for the staff to be mindful not to spread any infection and that the staff would adhere to the policy of hand hygiene, EBP, and infection control. She said she would start an in-service about hand hygiene, EBP, and infection control.During an interview on 04/09/2026 at 8:59 a.m., the Administrator said that the expectation was for the staff to wear gowns in addition to the gloves if the residents were on EBP, not to put gloves in their pockets, to perform hand hygiene before and after care and treatment, and to change their gloves if required. She said the concerns discussed would all contribute to the development and spread of infection. She said she was not a clinician and would let the DON take the lead on the issue of infection control.Record review of the facility's policy Enhanced Barrier Precautions The Compliance Store revised April 04, 2026 reflected Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms . 3. Implementation of Enhanced Barrier Precautions . b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities . 4. High-contact resident care activities include . h. Wound care: any skin opening requiring a dressing.Record review of the facility's policy Hand Hygiene The Compliance Store revised April 09, 2026 reflected Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors . 1. Staff will perform hand hygiene when indicated . 3. Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations . Hands are visibly soiled with blood or other body fluids . After handling contaminated objects . Before applying and after removing personal protective equipment (PPE), including gloves . Before preparing or handling medications . Before performing resident care procedures . After handling items potentially contaminated with blood, body fluids, secretions, or excretions . When, during resident care, moving from a contaminated body site to a clean body site.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. The Dietary Manager failed to wear a head cover and she failed to ensure a vendor was wearing a beard cover in the kitchen while food was being prepared.The facility failed to properly label and date stored food received from vendors.The facility failed to ensure the ice machine in the kitchen was thoroughly cleaned.The facility failed to ensure the deep fryer was properly cleaned.These failures placed residents at risk of exposure to food contamination and illness. Findings included:Observations on 04/07/26 from 9:08 a.m. to 9:20 a.m. in the facility's only kitchen revealed: The Dietary Manager was in the kitchen near a pot of food being cooked and she was not wearing a head cover. A vendor was in the kitchen making repairs near a pot of food being cooked and he was not wearing a beard cover. The vendor's beard was at least half inch in length. An ice machine, located in the kitchen had reddish stains along the inside panel wall of the ice machine. Two large bags of sausages, located in the freezer, were not dated with the month, day, and year they were stored upon receipt from the vendor. One large bag of taquitos, located in the freezer, was not dated with the month, day, and year it was stored upon receipt from the vendor. One large bag of cookie dough, located in the freezer, was not dated with the month, day, and year it was stored upon receipt from the vendor. The deep fryer, in the kitchen area, had light brownish substances floating all over the top of the cooking oil in the fryer. During an interview on 04/08/26 at 1:15 p.m., the Dietary Manager was informed by the Surveyor of the concerns observed in the kitchen area on 04/07/26. She stated she had a hairnet but had taken it off when she briefly left the kitchen. She stated she was busy preparing food for lunch and forgot to put a hairnet back on. She stated she had the vendor place a hairnet on his head but forgot to have him place a beard covering on. She stated she cleaned the ice machine weekly, which included the inside of the unit. She stated the kitchen staff stored food first in and first out, so she did not think the year had to be included on the food when stored. She stated the deep fryer had not been used for a long period of time, so she did not think it needed cleaning since it was inoperable. She stated the concerns observed in the kitchen could result in food contamination. During an interview on 04/08/26 at 12:10 p.m., the Administrator was informed by the Surveyor of the concerns observed in the kitchen area on 04/07/26. She stated she expected the kitchen to comply with policy and the concerns observed could result in food contamination.Record Review of the Facility's policy titled Food Storage and Supplies, dated 2012, revealed, All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. Dry bulk foods (e.g. flour, sugar) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled. Best practice is that scoops should not be left in food containers or bins, but if so, handles should be upright and not contacting the food item. Containers are cleaned regularly. When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it so it is readily visible and noticeable. It is important to distinguish between an expiration date and a production date, or a best by or use by date. Production dates indicate when the product was manufactured, not when it expires, and should not be interpreted as a best by or use by date. Best by or use by dates indicate when a product will have best flavor or quality and are not an indicator of the product's safety. As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still good quality. If in doubt, discard the product. If any stamped date is unclear, contact the food vendor for clarification. If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf-stable items will be stored in a first in, first out manner, to be used within one year. After one year, any product that is shelf stable will be inspected by the dietary manager to ensure that it is good quality before it is used. Any product with a stamped expiration date will be discarded once that date passes. Review of TITLE 21--FOOD AND DRUGS CHAPTER I--FOOD AND DRUG ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICESSUBCHAPTER B - FOOD FOR HUMAN CONSUMPTION PART 110 -- CURRENT GOOD MANUFACTURING PRACTICE IN MANUFACTURING, PACKING, OR HOLDING HUMAN FOOD Texas Chapter 228 Retail Food adopts the U.S FDA Food Code. 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. Commercially processed food Open and hold cold (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. Pf (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest prepared or first-prepare. Review of TITLE 21--FOOD AND DRUGS CHAPTER I--FOOD AND DRUG ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICESSUBCHAPTER B - FOOD FOR HUMAN CONSUMPTION PART 110 -- CURRENT GOOD MANUFACTURING PRACTICE IN MANUFACTURING, PACKING, OR HOLDING HUMAN FOOD

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for four of eighteen residents (Resident #20, #22, #39, and #67) reviewed for medication storage.1. The facility failed to ensure Resident #22 did not have a roll-on medication inside her room on 04/07/2026.2. The facility failed to ensure Resident #20's zinc oxide was not left on top of the resident's overbed table beside the resident's food tray on 04/07/2026.3. The facility failed to ensure Resident #39's zinc oxide was not left on top of the resident's drawer on 04/7/2026.4. The facility failed to ensure Resident #67's opened sachet of barrier cream was not left on top of the resident's side table on 04/07/2026.These failures could place residents at risk of wrong medication administration, not getting the full benefit of the medication, accidental overdose, misuse of medications, and possible adverse reactions.Findings included: 1. Record review of Resident #22's Face Sheet, dated 04/07/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), bipolar disorder (a mental health condition that causes extreme mood swings between emotional highs and lows), and pain to the right leg. Record review of Resident #22's Comprehensive MDS Assessment, dated 03/09/2026, reflected the resident has a moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated the resident received PRN pain medication, had Alzheimer's disease, and bipolar disorder.Record review of Resident #22's Comprehensive Care Plan, dated 02/15/2026, reflected that the resident had a diagnosis of bipolar disorder and borderline personality disorder, characterized by alternating episodes of mania and depression, placing them at risk for mood instability, impaired judgment, safety concerns and one of the interventions was to administer medications as ordered. The plan indicated that the resident was at risk for pain and had an impaired cognitive function and the intervention for both was to administer medications as ordered.Record review on 04/07/2026 of Resident #22's Clinical Assessment Notes reflected that the resident did not have an assessment for self-administration of medications.Record review on 04/07/2026 of Resident #22's Physician Order reflected the resident did not have an order for a topical roll-on analgesic.During an observation on 04/07/2026 at 9:15 a.m. revealed that Resident #22 was in her bed with eyes closed. It was observed that a roll-on pain relieving gel was observed on the resident's overbed table at bedside that was in plain view and accessible.During an observation and interview on 04/07/2026 at 9:45 a.m., revealed LVN B stated the topical pain relieving medication should not be inside the resident's room unless they have an assessment that it was safe for them to administer the medication themselves. She said even though the resident was independent and doing things by themselves, there should be assessment. She said confused residents sometimes go inside other resident's rooms and might get hold of the medication and use it inappropriately. She went inside Resident #22's room and saw the medication. She took the roll-on pain-relieving gel and said she would talk to the resident when she woke up. She said she would also check if the resident had an order for the topical analgesic.2. Record review of Resident #20's Face Sheet, dated 04/07/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dementia (a condition characterized by loss of memory and ability to reason) and depression (persistent feeling of sadness or loss of interest). Record review of Resident #20's Comprehensive MDS Assessment, dated 03/04/2026, reflected the resident has a severe impairment in cognition with a BIMS score of 06. The Comprehensive MDS Assessment indicated the resident was incontinent (unable to control) for bowel and bladder.Record review of Resident #20's Comprehensive Care Plan, dated 01/01/2026, reflected the resident experienced urinary loss of urine and one of the interventions was barrier cream would be applied as needed. Record review on 04/07/2026 of Resident #20's Clinical Assessment Notes reflected that the resident did not have an assessment for self-administration of medications.During an observation and interview on 04/07/2026 at 9:25 a.m. revealed Resident #20 was in his bed, awake. It was observed that a tube of zinc oxide (a form of barrier cream used to treat skin irritations, diaper rash, and other skin conditions) was on top of the resident's overbed table, beside a tray of food. When asked about who left the zinc oxide, the resident shrugged his shoulder. 3. Record review of Resident #39's Face Sheet, dated 04/08/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dementia. Record review of Resident #39's Comprehensive MDS Assessment, dated 03/11/2026, reflected the resident had a moderate impairment in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated the resident was incontinent for bladder and bowel.Record review of Resident #39's Comprehensive Care Plan, dated 03/10/2026, reflected the resident experienced urinary loss of urine and one of the interventions was barrier cream would be applied as needed.Record review on 04/07/2026 of Resident #39's Clinical Assessment Notes reflected that the resident did not have an assessment for self-administration of medications.During an observation on 04/07/2026 at 9:27 a.m. revealed Resident #39 was not inside his room. A tube of zinc oxide was observed on top of the resident's drawer. The zinc oxide was accessible and was visible from the hallway.During an observation and interview on 04/07/2026 at 9:30 a.m., LVN A said barrier cream with zinc oxide should not be within reach of the resident to prevent misuse of the medication. He said zinc oxide was a form of topical medication used to prevent skin issues. He said confused residents might consume the cream or put it in their eyes resulting in irritation. He took the tubes of zinc oxide from Resident #20 and Resident #39's room and said he would put them in a zip lock and put them in his cart. He said the CNAs might have forgotten them when they changed the residents. He said he would remind them not to leave the zinc oxide where the residents could reach them.4. Record review of Resident #67's Face Sheet, dated 04/09/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with cognitive impairment (difficulty in thinking, remembering, and making decisions) and kidney disease. Record review of Resident #67's Quarterly MDS Assessment, dated 02/23/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident was incontinent for bowel and bladder.Record review of Resident #67's Comprehensive Care Plan, dated 01/26/2026, reflected the resident had bowel and bladder incontinence and one of the interventions was to monitor for signs and symptoms of urinary tract infection. The plan indicated that the resident had the potential for pressure ulcer due to incontinence and one of the interventions was to apply barrier cream.Record review on 04/07/2026 of Resident #67's Clinical Assessment Notes reflected that the resident did not have an assessment for self-administration of medications.During an observation on 04/07/2026 at 10:35 a.m. revealed Resident #67 was not inside his room. It was observed that two sachets of barrier cream were on top of the resident's side table. One of the sachets was open. During an observation and interview on 04/07/2026 at 10:42 a.m., CNA C said she was not the one who left the sachets of barrier cream inside Resident #67's room. She said the barrier cream should not be left inside the rooms because the resident might eat it. She went inside the resident's room and took the sachets from the side table and threw them in the trash can. During an interview on 04/09/2026 at 8:04 a.m., the ADON said medicated creams should not be left accessible to the residents because a confused resident might get a hold of them and use them inappropriately. She said residents with poor eyesight might mistakenly think that zinc oxide was a condiment and put it on their food. She said there should not be a topical analgesic inside the room unless the resident could self-administer medications safely. She said they would sweep the rooms and check if there were any medications inside the rooms of the residents. She said they would re-educate the staff not to leave the tubes of zinc oxides inside the rooms of the residents.During an interview on 04/09/2026 at 8:34 a.m., the DON said medications should not be inside the rooms of the residents because it could cause probable harm such as irritation and allergic reactions. She said the residents should have an assessment for self-medication to determine if they were able and if it was safe for the residents to administer their own medications. She said the same rationale applied to the zinc oxides. She said confused residents might use the creams inappropriately such as consume them or use them in their eyes. She said she would start an in-service about medication storage.During an interview on 04/09/2026 at 8:59 a.m., the Administrator said the expectation was if the resident did not have an assessment for self-medication, then there should not be any medication inside the room of the resident. She said the staff should be the one administering the medication. She said the zinc oxides should not be accessible to the residents to prevent them from using them inappropriately. She said she would let the DON take the lead about the issue of medication storage. Record review of the facility's policy Medication Storage The Compliance Store revised November 02, 2025 reflected Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms . and sufficient to ensure proper . security . Policy Explanation and Compliance Guidelines . 1. General Guidelines . a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) . b. Only authorized personnel will have access to the keys to locked compartments.

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one of three residents (Resident #7) reviewed for feeding tube management.The facility failed to ensure LVN A checked Resident #7's g-tube placement and flushed the g-tube before and after medication administration as ordered on 04/08/2026.This failure could place residents with g-tubes at risk for tube displacement, clogging, aspiration, and dehydration.Findings included:Record review of Resident #7's Face Sheet, dated 04/08/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing).Record review of Resident #7's Comprehensive MDS Assessment, dated 03/19/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 06. The Comprehensive MDS Assessment indicated the resident had a feeding tube (a way of providing nutrition directly to the stomach).Record review of Resident #7's Quarterly Care Plan, dated 03/12/2026, reflected the resident required tube feeding (delivery of nutrition through a tube inserted in the stomach) and one of the interventions was to monitor for nausea, vomiting, bloating, and discomfort during or after feeding.Record review of Resident #7's Physician Order, dated 03/12/2026, reflected Check enteral tube (flexible tube used to deliver nutrition directly to the stomach) placement prior to giving meds or bolus (large dose of medication or food given at once) feed by air auscultation (listening to the sounds inside the body using a stethoscope) & aspirate (to draw by suction) contents, then return contents to stomach, if > 100 ml stop feeding and notify physician. every shift AND as needed.Record review of Resident #7's Physician Order, dated 03/12/2026, reflected Flush enteral tube with 60 ml H2O before and after meds or bolus feedings.During an observation on 04/08/2026 at 1:19 p.m., revealed LVN A was about to give Resident #7's medication via g-tube. He sanitized his hands, put the medication in a small plastic cup, crushed it, returned the crushed medication to the small plastic cup, and dissolved it. He put the cup of crushed medication in a tray along with a cup of half-filled water. He then went inside the resident's room and placed the tray on top of the resident's overbed table. He took a 60 ml piston syringe from the IV pole at bedside. He put on a gown and a pair of gloves, raised the bed, elevated the head of the bed, turned off the g-tube pump, and disconnected the g-tube (gastrostomy tube: a tube inserted through the abdomen that delivers nutrition directly to the stomach) from the formula. After disconnecting the g-tube, he attached the syringe to the g-tube, and checked the residual (food, liquid, and secretions remaining in the stomach). He disconnected the syringe, pulled the plunger of the syringe, and connected the barrel of the syringe. He flushed the g-tube with 20 cc of water, poured the dissolved medication, and flushed the g-tube with 10 cc of water. He did not check for placement of the resident's g-tube before flushing and administering the medication. After he was done administering the medications, she detached the syringe, connected the g-tube to the formula, and cleaned the table and the syringe. It was observed that a stethoscope was hanging on the computer brace of his cart.During an observation and interview on 04/08/2026 at 1:47 p.m., LVN A said he forgot to check Resident #7's g-tube placement before flushing the g-tube. He said the placement should be checked to make sure that the g-tube was not dislodged. He said the dislodged g-tube could cause aspiration. He logged on to his computer and saw that the order specified to check for placement through auscultation. He said he did flush the g-tube before and after medication administration. He checked the order for flushing and saw the order specified to flush 60 cc before and after medication administration. He said he only flushed the g-tube with 10 cc of water before and 20 cc after medication. He said the g-tube should be flushed to make sure that the medication went through the tube to the stomach. He said a specific amount of water was ordered to help with the resident's hydration as well.During an interview on 04/09/2026 at 8:04 a.m., the ADON said g-tube placement should be checked before giving the medications to ensure the g-tube was in the right place and would not cause aspiration. She said even though the residents were on continuous feeding, the placement should still be checked. She said if the order said through auscultation, then a stethoscope should have been used. She said the g-tube should be flushed to make sure the tube was patent (unobstructed), functioning well, and was not clogged. She said if the order said to flush 60 cc before and after medication then the staff should have flushed it with 60 cc before and after medication administration. She said a specific amount of water was ordered to ensure hydration and that the medication was delivered safely. She said she would coordinate with the DON about the issue during medication administration via g-tube.During an interview on 04/09/2026 at 8:34 a.m., the DON said the placement of the g-tube was done through the use of a stethoscope. She said it was important to check for placement before flushing it and before medication administration to ensure the medications and the fluid would enter the stomach and not the lungs. She said if the order specified 60 cc then the staff should have given 60 cc before and after medication administration. She said the staff should have followed the order because water intake for residents with g-tube was calculated based on the individual needs, to prevent dehydration and fluid overload. She said the expectation was for the staff to follow the orders in medication administration via g-tube. She said she would start an in-service about g-tube medication administration.During an interview on 04/09/2026 at 8:59 a.m., the Administrator said the expectation was for the staff to check the g-tube placement and flush as per order. She said she was not a clinician and would let the DON take a lead on the issue about g-tube. Record review of the facility's policy Care and Treatment of Feeding Tubes The Compliance Store revised April 09, 2026 reflected Policy: It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible . Policy Explanation and Compliance Guidelines . 1. Feeding tubes will be utilized according to physician orders . 4. The facility will utilize the Registered Dietitian in estimating and calculating a resident's daily nutritional and hydration needs . 6. In accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location . a. Tube placement will be verified before beginning a feeding and before administering medications.

Based on interview, and record review, the facility failed to ensure the resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance for 1 of 3 residents (Residents #7) reviewed for assisted nutrition and hydration.The facility failed to notify the Dietician of Resident #7's weight loss of over 12% within a week.This failure could prevent the Dietician from reviewing the resident's plan of care and addressing the excessive weight loss.Findings include:Record review of Resident #7's Face Sheet, dated 04/07/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #7 had a diagnosis of malnutrition.Record review of Resident #7's Initial MDS Assessment, dated 03/19/26, reflected the Resident had a BIMS score of 6 (severe cognitive impairment). The MDS assessment reflected the resident had an active diagnosis of malnutrition.Record review of Resident #7's Comprehensive Care Plan, dated 03/20/26, reflected Monitor/record report to MD PRN signs of malnutrition, muscle wasting, significant weight loss: 3 lbs. in 1 week; >5% in 1 month; >7.5% in 3 months; >10% in 6 months. Record review of Resident #7's weight was recorded on 03/12/26 at 140 lbs. and the resident's weight on 03/19/26 was reported at 122 lbs., which was over a 12% decrease of weight in a week. During an observation on 03/24/26 at 11:36 a.m., Resident #7 was observed lying in bed. The resident appeared thin.During an interview on 04/08/26 at 11:15 a.m., the DON and ADON were informed by the Surveyor of Resident #7 having a care plan for possible nutritional problems, and an intervention included reporting significant weight loss of 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, and >10% in 6 months. They were informed of the system of record only reflecting the resident's initial weight of 140 lbs. on 03/12/26 and no other weight recorded. The DON stated they had captured the resident's weekly weight and charted it on a paper. The paper chart provided reflected Resident #7 was weighed on 03/19/26 and his weight was reported at 124 lbs. The DON stated she did not think the resident's original weight was recorded correctly and she did not think he weighed 140 lbs., upon admission. The DON stated she doubted the resident had sustained an 18-pound weight loss within a week because she and the ADON did not observed the resident to be thinner compared to the prior week. The DON stated she had not reported the weight loss to the Dietician at the time this was observed and she was waiting to notify the Dietician when she had visited the facility on 04/08/26. The DON stated not notifying the Dietician of the suspected weight loss, would prevent the Dietician from implementing an intervention to address the weight loss.During an interview on 04/08/26 at 11:39 a.m., the Consulting Dietitian stated Resident #7 could be at risk of weight loss. She stated she did not update care plans. She stated she pulled reports twice a month to alert her of any residents with significant weight loss, or staff reached out to her and notified her. She stated the resident's records only reflected his initial weight on 03/12/26 of 140 lbs., and no other records were inputted in the facility's system of record. She was informed by the Surveyor of the resident having an initial weight of 140 lbs. on 03/12/26, and on 03/19/26 the resident weighed 124 lbs. She stated the facility should have notified her so she could make modifications to the resident tube feeding if needed. She stated she was not made aware of this reduction in weight. She stated she would review the resident's weight and address the potential weight loss.Record review of the facility's policy Weight Monitoring, dated 4/9/26, reflected Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. a. The physician should be informed of a significant change in weight and may order nutritional interventions. b. The physician should be encouraged to document the diagnosis or clinical conditions that may be contributing to the weight loss. e. The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes.

Based on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy during personal care and confidentiality of personal and medical records for two of twenty residents (Resident #7 and Resident #19) reviewed for privacy and confidentiality.1. The facility failed to ensure LVN A closed, locked, or minimized his laptop monitor before leaving his cart, thus exposing Resident #7's medical information, on 04/08/2026. 2. The facility failed to ensure CNA C closed the blinds of Resident #19's window, which was overlooking to the parking lot, during incontinent care on 04/07/2026. These failures could place the residents at risk of not having their personal privacy maintained while care was provided, which could result in the residents feeling uncomfortable during care and having their personal and medical record exposed to unauthorized individuals.Findings included: 1. Record review of Resident #7's Face Sheet, dated 04/08/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hypotension (low blood pressure) and hypertension (High blood pressure).Record review of Resident #7's Comprehensive MDS Assessment, dated 03/19/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 06. The Comprehensive MDS Assessment indicated the resident had hypotension and hypertension.Record review of Resident #7's Care Plan, dated 03/01/2026, reflected the resident had a history of hypertension and hypotension and one of the interventions was to administer antihypertensive/antihypotensive medications as ordered.Record review of Resident #7's Physician Order, dated 03/12/2026, reflected Midodrine HCl Oral Tablet 10 MG (Midodrine HCl) Give 1 tablet via PEG-Tube (a flexible feeding tube inserted directly to the stomach) every 8 hours for low blood pressure HOLD IF SBP > 140 OR DBP > 90.During an observation on 04/08/2026 at 11:22 a.m. revealed LVN A was looking at his computer in the hallway. He then left his cart to go to the other hall. He left his computer open with Resident #7's medical information exposed. He then went back to his computer and looked at his computer again. He then left his computer again with the resident's medical information still exposed. The computer was on top of his cart and was facing the hallway. The screen of the laptop displayed Resident #7's name, date of birth , name of his physician, location, code status, allergies, special instructions, his latest vital signs, his latest weight, his latest pain level, and his medication for low blood pressure.During an interview on 04/08/2026 at 11:42 a.m., LVN A said he went to get something, that was why he left his cart. He said it was a HIPAA (law protecting health information aimed to ensure confidentiality) violation because the personal and medical information of Resident #7 was exposed. He said information should be secure and confidential. He said he should have minimized or locked the screen of his laptop before leaving his cart.2. Record review of Resident #19's Face Sheet, dated 04/08/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle wasting (loss of muscle leading to its shrinking and weakening) and atrophy (decrease in size of a body part).Record review of Resident #19's Comprehensive MDS Assessment, dated 01/11/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had bowel and bladder incontinence.Record review of Resident #19's Care Plan, dated 01/30/2026, reflected the resident experienced involuntary loss of stool and urine and one of the interventions was to maintain privacy and dignity during incontinence care to support emotional well-being.During an observation on 04/07/2026 at 2:02 p.m. revealed CNA C was about to do Resident #19's incontinent care. It was observed that the resident's bed was parallel to the window, which was overlooking the parking lot. CNA C pulled the privacy curtain but did not close the window blinds before doing incontinent care. She did not tell the resident that she would close her blinds nor did the resident tell CNA C that she did not want her blinds closed. During incontinent care, CNA C went to the room's sink to wash her hands leaving the resident without any brief and with the perineal area exposed. After incontinent care was done, CNA C took off the resident's hospital gown exposing her breasts. At this point, the blinds were still open and it was observed that the window did not have a curtain.During an observation and interview on 04/07/2026 at 2:31 p.m., CNA C said she thought the window blinds were not working and that was why she did not close them. She went to check on the blinds and the blinds worked. She said she should have closed them during Resident #19's incontinent care to provide privacy from the outside of the facility. During an interview on 04/07/2026 at 2:36 p.m. Resident #19 did not reply when asked if it was okay that her blinds were open during incontinent care.During an interview on 04/09/2026 at 8:04 a.m., the ADON said leaving the computer open with residents' personal and medical information exposed was a HIPAA violation because that information should be confidential. She said the staff should minimize or lock the screen of the laptop before leaving it unattended. She said the blinds should have been closed when incontinent care was being done to provide privacy and open it again when it was done. She said staff closed the doors and pull privacy curtains to provide privacy from the inside of the facility and the staff should be mindful to provide privacy from the outside of the facility. She said it did not matter if the residents mind or not, but the expectation was for the staff to be sensible enough that if they were in the residents' position, they might want the blinds closed so that those individuals walking in the parking lot would not see their private areas. She said they would re-educate the staff regarding privacy during care and confidentiality of residents' information.During an interview on 04/09/2026 at 8:34 a.m., the DON said the staff should have closed the blinds during incontinent care so that the resident would not be exposed from the parking lot. She said she did not know that there was no curtain on Resident #19's window because if the resident did not want her blinds closed, at least the curtain could be used to provide privacy. She said, the issue was not if the residents minded or not, but that the staff did not provide privacy. She said leaving the computer open with a resident's medical information exposed was a HIPAA violation. She said the medical information of a resident should be protected and could not be shared without the permission of the resident or the resident's responsible party. She said all the staff were expected to provide full privacy during care and confidentiality of information for all residents. The DON stated she would start an inservice about privacy and confidentiality and would personally monitor if the staff were in compliance to the policy.During an interview on 04/09/2026 at 8:59 a.m., the Administrator said the staff should have closed the lid of the computer before leaving the cart to ensure no medical information about the residents was exposed. She said medical information should be secured because it was confidential. She said privacy should be provided during care. She said she would collaborate with the DON about the issue regarding privacy and confidentiality.Record review of the facility's policy, Confidentiality of Personal and Medical Records The Compliance Store, undated, reflected Policy: This facility honors the resident's right to secure and confidential personal and medical records. This includes the right to confidentiality of all information contained in a resident's records, regardless of the form of storage or location of the record.Record review of the facility's policy, Resident Rights The Compliance Store, undated, reflected Policy: The facility will inform the resident both orally and in writing . of his or her rights . 7. Privacy and confidentiality . The resident has a right to personal privacy and confidentiality of his or her personal and medical records . a. Personal privacy includes . personal care . b. The resident has a right to secure and confidential personal and medical records.

Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #34 and Resident #60) of twenty residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #34 and Resident #60's rooms was in a position that was accessible to the resident on 04/07/2026.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Resident #34 Record review of Resident #34's Face Sheet, dated 04/08/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with abnormalities of gait and physical debility (weakness).Record review of Resident #34's Quarterly MDS Assessment (assessment used to determine functional capabilities and health needs), dated 03/11/2026, reflected the resident had a severe (resident required significant assistance and support in daily life) impairment in cognition with a BIMS (screening tool used to assess cognitive status) score of 04. The Quarterly MDS Assessment indicated the resident needed assistance for hygiene, shower, dressing, and transfer.Record review of Resident #34's Comprehensive Care Plan, dated 04/04/2026, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach.During an observation and interview on 04/07/2026 at 9:09 a.m., revealed Resident #34 was in her bed, awake. It was observed that the resident's call light was on the floor and tucked behind the resident's side table. When asked where her call light was, the resident looked for call light. She said the staff forgot to clip her call light again. She said she had been looking for it since morning but her call light was nowhere to be found. Resident #60 Record review of Resident #60's Face Sheet, dated 04/07/2026, reflected a [AGE] year-old male admitted on [DATE]. The resident was diagnosed with muscle weakness, visual (pertaining to the eyes) loss, chronic pain.Record review of Resident #60's Quarterly MDS Assessment, dated 02/20/2026, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident needed assistance for hygiene, shower, dressing, and transfer.Record review of Resident #60's Comprehensive Care Plan, dated 01/30/2026, reflected the resident was at risk for fall due to poor safety awareness and one of the interventions was for the call light to be in reach.During an observation and interview on 04/07/2026 at 9:04 a.m. revealed Resident #60 was in his bed, awake. It was observed that the resident's call light was on the floor and was under the roommate's bed. When asked where his call light was, the resident said he was looking for his call light since the day before. He said he looked for his call light at the side of his bed but could not find it.During an observation and interview on 04/07/2026 at 9:38 a.m., LVN B said call lights were used by the residents to call the attention of the staff when they needed something or needed assistance. She said the call lights were supposed to be accessible to all the residents always to ensure prompt actions from the staff to meet their needs. She said the residents would call if they needed to be changed, for a refill of their pitcher, or if they were having pain and discomfort. She went inside Resident #60's room, looked for the call light, and found it under the roommate's bed. She said it must have fallen when the staff fixed Resident #60's bed. She picked up the call light and clipped it at the side of Resident #60's bed. She then went to Resident #34's room and looked for the call light and found it behind the resident's side table. She pulled the call light and clipped it where the resident could access it. She said she did not notice the call light was on the floor when she checked on the residents. She said staff should have made sure the call light was with Resident #34 and Resident #60 before leaving the room, because even though the resident could stand up and walk. She said the resident might be having distress and could not get up to pick-up or pull the call light. During an interview on 04/07/2026 at 11:06 a.m., CNA C said call lights were important for the residents because the residents used them to call the staff when they needed something or needed assistance. She said the residents might fall trying to get the call light or trying to do some activities that needed assistance. She said she would check the call lights of the residents assigned to her. She said she did her morning round but did not notice that Resident #34 and Resident #60's call lights were not with them.During an interview on 04/09/2026 at 8:04 a.m., the ADON said call lights should always be with the residents or within reach of the residents to prevent falls. She said the staff should make sure that the call lights were with the residents before they leave the room. She said the call lights had clips on them and the staff could use them to prevent the call lights from falling. She said the call lights were for all residents, regardless of whether they were dependent or independent. She said independent residents might be in distress and could not call the staff because their call lights were not with them. She said everybody was responsible in making sure the call lights were with the residents. She said housekeeping could call the nurses or the CNAs if they see the call lights were on the floor or not within reach. She said the expectation was for the staff to make sure that all the call lights were within reach of the residents. She said they would re-educate the staff regarding call lights. During an interview on 04/09/2026 at 8:34 a.m., the DON said call lights were used by the residents to communicate with the staff if they needed something. She said residents would call the staff if they needed any medication, they needed to be changed, or if they wanted to get up. She said if the call lights were not within reach, their needs would not be met. She said the call lights were for all residents and all the staff were responsible for the call lights. She said the expectation was for the staff to inspect the residents' room when they did their rounds and make sure the call lights were within reach of the residents before they leave the room. She said she just bought some clips to replace the clips of the call lights that were already worn out. She said she would start an in-service about call light placement and would continually educate the staff about the importance of call lights for the residents. During an interview on 04/09/2026 at 8:59 a.m., the Administrator said call lights should be within the reach of the residents at all times, whether the resident was mobile or not. She said some residents use the call light in cases of emergencies, if they needed any medication, or even a glass of water. She said without the call lights, their needs would not be met and the residents might be upset. She said everybody was responsible in making sure the call lights were with the residents, whether the resident was independent or not. She said she would collaborate with the DON about the issue regarding call lights.Record review of facility's policy Call Lights: Accessibility and Timely Response The Compliance Store revised April 08, 2026 reflected Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside . 5. Staff will ensure the call light is within reach of resident and secured . 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Based on observation, interviews, and record reviews the facility failed to treat residents with respect and dignity for one of six residents (Resident #1) reviewed for resident rights. The facility failed to ensure RN A did not stand over Resident #1 while opening his brief and looking at his genitals with the door open and no curtain used, for anyone to see from the hallway on 08/29/25. This failure could affect residents who require assistance with ADLs of not wanting to get staff assistance if it were not done in private which could cause a decrease in the resident's self-esteem and psycho-social well-being resulting in embarrassment. Findings included: Observation on 08/29/25 at 2:40 PM, the door to Resident #1's room was open revealing RN A and CNA B in Resident #1's room. RN A had on gloves and was standing over Resident #1 with the resident's brief unfastened. RN A was looking at the resident's genital area, and the resident's legs was uncovered with his bedsheets at his ankles. When RN A saw the investigator, she quickly closed the brief back and pulled his bed covers up to his chest. CNA B walked out of the room with a bag of dirty wipes and brief. RN A then completed hand hygiene and walked out of the room. Record review of Resident #1's Annual MDS assessment dated [DATE] by RN Consultant reflected the resident was a [AGE] year-old male who admitted [DATE]. He had a Staff Assessment score of 00 and severely impaired cognition. And had no upper impairment and bilateral lower extremity impairment and used a walker. He was dependent and help did all ADL assistance. He required substantial/maximal assist with transfers and turning from side to side and always incontinent of bowel and bladder. He had progressive neurological conditions with diagnosis, anemia (low iron), HTN (high blood pressure), GERD (digestive disease/stomach acid), DM (diabetes mellites), hyperlipidemia (high fat particles), thyroid disorder (hormone gland disorder), osteoporosis (bone weakness), cerebral palsy (abnormal developed brain), seizure disorder (disruption in normal brain activity), malnutrition (lack of nutrients/digestive condition). Record review of Resident #1's Care Plan printed 08/29/25 reflected: Revision date 08/06/25 has potential impairment to skin integrity related to diabetes, incontinence of bowel and bladder and limited mobility. And had a communication problem and at increased risk for shears, and impaired skin integrity 2/2 (two muscle limbs tightening) contractures and impaired ADL's. Observation on 08/29/25 at 2:45 PM revealed Resident #1 was lying flat on his back with a blanket up to his chest. The resident was not able to communicate. There were no odors noted. Interview on 08/29/25 at 2:42 PM, CNA B stated Resident #1 was covered up after the nurse checked him. She stated she was not sure why Resident #1 did not have a privacy curtain and why his room door was not closed. She stated RN A checked to see if Resident #1 needed to be changed and was waiting for ADON C to come to the room for something (after several attempts she did not say what they were waiting for). Interview on 08/29/25 at 2:46 PM, RN A stated she had asked CNA B if she had changed Resident #1, and CNA B said she had. RN A stated she then went to check for herself because Resident #1 could not speak for himself. She stated the staff needed to give the residents privacy, and the only thing she forgot to do when checking Resident #1 was close the door. She stated she normally closed the door when checking the resident's briefs, and she forgot this time. She stated she was sorry for that she knew she should have closed the door and was checking Resident #1's brief quickly. She stated CNA B forgot to close the door and was also waiting for ADON C to bring some gloves to Resident #1's room. She stated they did not have any gloves on Resident #1's side of the room and had told Maintenance to put some in Resident #1's room but he had not done so yet, so they did not have to look for them. She stated for future reference the CNA and herself needed to have everything in the room so they would not have to wait for other staff to bring them. She stated she was not sure why Resident #1 did not have a privacy curtain and said she would ensure she notified laundry to get one put up. She stated she needed to ensure she closed the door and pulled the curtains forward for the resident's privacy. Interview on 08/29/25 at 3:10 PM, ADON C stated she had just put some gloves in the Resident #1's room because RN A and CNA B said there were none on his side of the room. She stated they asked for some gloves and just put one full box of large and one full box of medium gloves in Resident #1's. Interview on 08/29/25 at 7:47 PM, the Administrator stated the privacy curtains should cover residents, even if their briefs were being checked and hoped that was being done. She stated there were no reports why Resident #1 did not have a privacy curtain. She stated she was aware of what happened earlier in Resident #1's room of RN A leaving Resident #1's door open while checking his brief. She stated it could affect the residents who got their briefs checked may not like being seen by anyone passing their rooms and some residents may care and some may not. She stated the person providing care was responsible and DON ultimately for ensuring the residents had privacy for personal care including checking the resident's briefs. She stated the nursing staff probably ran out of supplies and needed to get more and left the door open. She stated she was not aware of Resident #1's privacy curtain being missing and would have to get with the laundry department about putting another one up. She stated before touching a resident the nursing staff needed to talk to the resident to let them know what they were about to do and to provide them privacy. She stated when the nursing staff provided care to the residents they needed to look to see if they had gloves in the room before they started. She stated the CNAs, nurses and Central Supply were supposed to look to see what supplies they were out of and replenish it, to prevent having to open the door during resident care. Record review of the Facility's Resident Rights policy dated 2025 reflected: Policy: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility will also provide the resident with prompt notice (if any) of changes in any State or Federal laws relating to resident rights or facility rules during the resident's stay in the facility. Receipt of any such information must be acknowledged in writing. The resident has the right to a dignified existence.

Based on interview and record review, the facility failed to ensure when discharge is anticipated, a resident had a discharge summary that included, but not limited to a recapitulation of the resident's stay, that included but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultant results and a final summery of the resident's status to include items, at the time of the discharge that was available to release to authorized persons and agencies, with the consent of the resident or resident's representative for 1 of 3 residents (Resident #1) reviewed for discharge summary. The facility failed to complete a discharge summary for Resident #1. This failure could place residents at risk of not having complete records after permanent discharge from the facility. Findings included: Record review of Resident #1's face sheet, dated 05/29/25, reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Record review of Resident #1's Discharge MDS Assessment, dated 02/11/25, reflected Resident #1 was discharged to Long-Term Care Hospital without a return anticipated. Resident #1 had diagnoses which included unspecified dementia (decline in mental ability, affecting thinking, and memory), anxiety disorder (a type of mental health condition), bipolar disorder (extreme mood swings, ranging from periods of elevated mood), schizophrenia (a chronic brain disorder that affects thinking, feeling, and behavior), and insomnia (sleep disorder), unspecified . Resident #1 cognitive skills for daily decision making was modified independence. Resident #1 required maximal/moderate assistance with toileting, showering and personal hygiene. Record review of Resident #1's physician order, dated 02/11/25, reflected May transfer out to [Hospital]. Record review of Resident #1's nursing progress note by LVN A, dated 02/11/25 at 14:30 [2:30 PM], reflected Res. has discharged to [Hospice Name] in [city]. Res. alert and oriented x3, able to make needs known. Res. stable, no c/o pain or discomfort. Wheeled to front door for his transportation to [city]. 127/65, 71, 18, 97.9, 96% RA. Record review of Resident #1's Summary Episode Note, dated/timed 02/11/24 8:40 PM, reflected resident information, emergency contact, allergies, assessment, diagnosis, goals, medications names, immunizations, and problems. Summary Episode Note did not address reason for discharge, date of discharge, reconciled medications sent to new facility, personal belongings disposition or physician signature. Record review of Resident #1's care plan, revised date 02/13/25, did not address discharge goals. Record review of Resident #1's clinical records reflected no discharged summary. Interview with on 05/29/25 at 2:15 PM with LVN A revealed she was notified Resident #1 was discharging from the facility and to get him ready. She stated when Resident #1 discharged , she provided a copy of the Resident #1's face sheet, medication orders and belongings. She stated she documented in the Resident #1's progress notes of where he was going. Interview on 05/29/25 at 4:46 PM with the DON revealed Resident #1 transferred to another facility. She stated prior to the change of management, the nurse, who discharged a resident, was responsible for documenting in the progress notes when a resident transferred or discharged from the facility regarding where the resident was going. The nurse would also be responsible for obtaining a physician order, and then their electronic health records systems, PCC, would generate a summary episode note. She stated the summary episode note provided the resident information. The DON stated she considered the Summary Episode Note, physician order, and progress note the discharge summary. She stated she was not sure of another discharge summary. Interview on 05/29/25 at 5:29 PM with the Administrator revealed she had been employed at the facility since mid-March 2025. She stated based on the new company's policy expectations the staff were expected to document any discharge planning with the family, discharge physician order, medications, belongings, and to document in the progress notes. She stated she was still not familiar with PCC clinical standpoint; however, the Social Worker would initiate the discharge summary. If the Social Worker was not in the facility, the discharge nurse would complete it. She revealed she was only familiar with the new company's policy regarding discharge summaries. She stated Resident #1 discharged prior to the change of management which occurred at the beginning of March 2025. Record review of the facility's Transfer and Discharge (including AMA), dated 09/1/23 and revised 04/25/25, reflected the following: . A member of the interdisciplinary team will complete relevant sections of the Discharge summary. The nursing caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to, the following: A recap of the resident's stay that includes diagnoses, course of illness/treatment or therapy and pertinent lab, radiology, and consultation results. A final summary of the resident's status. Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter). A post discharge plan of care that is developed with the participations of the resident and the resident representative(s) which will assist the resident to adjust to his or her new living environment.

Based on observation, interview and record review, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for one (Residents #323) of three residents reviewed for elopement. 1. The facility failed to ensure Resident #323 was provided with adequate supervision to prevent him from eloping from the facility on 12/24/24 and 01/06/25. The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 12/24/24 and ended on 01/06/25. The facility corrected the non-compliance before surveyor's entrance. This failure placed residents at risk of harm and/or serious injury. Findings included: Review of Resident #323's Admission MDS dated [DATE] reflected the resident was an [AGE] year-old resident admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure). Resident #323 had a BIMS of 1 indicating his cognition was severely impaired. The MDS further reflected the resident did not have impairment to his upper and lower extremities and ambulated with no assistance. Review of Resident #323's care plan initiated on 12/24/24 reflected the resident was at risk for elopement/wandering related to dementia and required placement on the secure unit to provide a secure environment due to risk of elopement. Interventions included to frequent monitor and identified a pattern of wandering and assess reason for wandering and provide redirection as needed . Review of Resident #323's hospital records dated 12/01/24 reflected the following: Patient is a [AGE] year-old male who presents to [emergency room ] primarily for pneumonia and neurology was consulted for patient's recent history of elopement and getting lost concerning for newly diagnosed dementia. On chart review is noted that patient had eloped and gotten lost 5 times and family found him after he had fled Observation on 02/04/25 at 11:19 PM, revealed there was wooden privacy fence around the outside of the building of the secure unit with three rails inside of the fence, one at the bottom, one in the middle and one towards the top of the fence. Review of the facility's PIR dated 01/02/25 reflected that on 12/24/24 Resident #323 had left the facility without signing out and was found by the police department and was returned to his family. The resident was on enhanced supervision until the window of his room was repaired and installation of a fence on the side of the building with potential exiting windows was completed. Review of Resident #323 progress notes dated 12/24/24 documented by LVN J reflected the following: Resident was up from breakfast in the dining area. Resident ate 100% of meal. Resident showed no signs of pain or discomfort. At 1145, the patient was last observed entering his room. During routine rounds at approximately 12:45 PM, the patient was found to be absent from their room. A code white was initiated promptly, and the search for the patient is currently ongoing [Police] notified the facility that resident had be [sic] found by [Police] 2 hours ago and told resident to [family]. Interview on 02/05/25 at 10:45 AM, with CNA N revealed she was working the morning of 12/24/24 and sometime after breakfast they staff noticed Resident #323 was not in the secure unit. The CNA N said after breakfast the resident would normally go back to his room and only come out for meals. When they staff realized the resident could not be located, they all began to search the rooms and the bathrooms. After a while, they discovered the window to Resident #323's room was broken and that is how the resident had gotten out. CNA N described Resident #323 as being independent with his ADL's and very pleasant. There were times the resident was seen carrying his bag with his belongings and stand at the exit doors but he was usually easily redirected to go back to his room. Interview on 02/05/25 at 11:29 AM, with LVN M revealed she was working during the elopement on 12/24/24 and during her morning rounds during breakfast all residents were accounted for in the secure unit and Resident #323 had gone to the dining room to eat. The LVN M said after breakfast she sat in the hall monitoring and around 11:30 AM she noticed the resident was not in his room so they began to look for him room by room and alerted the rest of the staff the resident was missing. They checked the secure unit doors and they remained locked and after that they noticed the window to his room was broke. They alerted management staff and 911 was also called and later found out he had been found by the police and taken to his family's home. LVN M said she normally did not work the secure unit and had been filling in for someone else. She said Resident #323 did not appear to be exit seeking that day and had not been carrying a packed bag stating he wanted to go home. Interview on 02/05/25 at 12:40 PM, with MA O revealed he was working on 12/24/24 he was assisting other staff gather residents in the secure unit into the dining room for lunch. MA O said they realized Resident #323 was not in his room and they began to check every room and around the facility when they realized the window to his room was broken and appeared that is how he had eloped. Management was notified and 911 was also called. MA O said he was told the resident had been found by the police and take to his family's home. MA O further stated Resident #323 was very mobile, independent, with confusion and would only come out of his room for meals. The MA said he never recalled the resident to be exit seeking or saying he wanted to leave the facility. Review of the facility's PIR dated 01/10/25 reflected on 01/06/25: This resident had previously broken a window and left the facility. As the facility response, we built a wooden fence around the windows on this area of the secured unit. The resident broke a window on the same section and scaled the fence. Staff witnessed the resident scaling and because of the location of the exit had to respond by going around the building. Once they were on the other side of the fence the resident was gone. Staff initiated searchs [sic] for the resident and contacted the police and the police were able to find him two hours later Interview on 02/06/25 at 10:25 PM, with LVN Q revealed she worked on 01/04/25 and Resident #323 had dinner in the dining room and had gone back to his new room he was placed in after he was brought back by his family after his first elopement. LVN Q said she was she was sitting in the hallway and during her rounds, sometime after dinner, did not recall the time, she went to Resident #323's room to check on him and did not find him. She happened to glance down the hall and noticed he was headed into his old room, the room he first eloped from, and as she went into that room she did not see Resident #323. LVN Q noticed the window had been forced open and as she went to look outside, she saw Resident #323 on top of the fence, that had been built after his first elopement, but she was not able to get to the resident fast enough even after calling after him. LVN Q alerted staff and by the time they went outside to look for the resident, he was nowhere to be found. LVN Q further stated she alerted management and 911 was called and she was later told the resident had been found by the police and again take to his family's home. Interview on 02/05/25 at 3:50 PM, with CNA R revealed he was working on 01/04/25 outside of the secure unit when he was alerted that Resident #323 had eloped from the facility through a window. CNA R said all of the staff began to look for the resident but he was not found. CNA R further stated he did work on the secure unit but has assisted in looking for Resident #323. Interview on 02/04/25 at 10:54 AM, with CNA L revealed she was not at the facility during incidents where Resident #323 eloped. CNA L said Resident #323 was independent and very nice. She said the resident was able to communicate his needs and at times he would pack his bag and stand next to the exit doors but was easily redirected back to his room. CNA L stated after his first elopement, the staff had put up a fence around the outside rooms. Resident #323 was taken back to the facility and was put in another room, facing the enclosed courtyard. Interview on 02/05/25 at 1:08 PM, with LVN P revealed she worked with Resident #323 and he was usually anxious to be picked up by his family so they could take him home and had a cell phone he would use to call his family. Resident #323 was cooperative and very pleasant with everyone and would stay in room and only come out for meals. LVN P further stated one day she noticed Resident #323 has packed his bag and said he wanted to leave but he had never tried to open the doors or leave and was easily redirected to his room. Interview on 02/05/25 at 1:26 PM, with the DON revealed on 12/24/24 staff alerted her that Resident #323 could not be located and they had noticed the window to the resident's room had been broken out. The DON said all the staff were searching for the resident and 911 had been called. The facility later got a call from the police about 4:30 PM stating Resident #323 has been found and take to his family's home. The DON said she was not told how far from the facility he had been found. After that elopement Resident #323's family kept the resident over the holidays and had been taken back the facility on 12/31/24 and placed in another room that did not face the outside of the facility. The DON said while the resident was gone they had fixed the window to his previous room, and they had put up a wooden fence around the perimeter of the secure unit. On 01/04/25 she again was alerted that while making rounds they noticed Resident #323 was not in his room and the window to his old room had been opened and the resident had been seen jumping over the wooden fence. The staff immediately ran outside to look for the resident but he was not found so they called 911. The DON further stated that the police had found Resident #323 and again had been taken back to his family's home. The DON did not know how far from the facility he had been located. Resident #323 did to return to the facility and the family decided to keep him at home. The DON said after each of Resident #323's elopement all the staff were re-in serviced on their elopement policy. Staff participated in an elopement drill to ensure they were competent during a resident elopement. All resident in the secure unit were put on 15-minute checks to make sure there were no other resident that were exit seeking. Interview on 02/05/25 at 11:06 AM, with the Director of Maintenance revealed he had built the wooden fence around the outside of the secure unit and was not aware the fence rails should have faced the outside of the fence and not the inside due to the safety of someone being able to climb the fence. The Director of Maintenance further stated that would be a fast and easy fix and he would just have to turn the fence around by sections. A Past Non-Compliance Immediate Jeopardy/Immediate Threat was identified on 02/05/25. The Administrator, the Regional Consultant were notified of the Past Non-Compliance Immediate Jeopardy on 02/05/25 at 4:04 PM. The IJ template was provided to the facility on [DATE] at 4:10 PM. Review of the facility's policy titled Elopements dated 2018 reflected the following: Staff shall investigate and report all cases of missing residents. .1. 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/designee .c. if a resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative the Attending Physician, law enforcement officials Observation on 02/04/25 at 10:27 AM revealed there was a staff member sitting in the hallway with a bedside table charting on a laptop. The staff member had visual of the hall where the resident rooms were located and the dining room where other resident were. Observation of the secure unit at various times from 02/04/25 to 02/06/25 revealed there were no residents that appeared to have the physical and mental capabilities of climbing the fence. Review of the Enhanced Supervision Monitoring Tool dated 12/24/24 and 12/25/24 revealed all the residents in the secure unit has been put on 15-minute checks by staff to ensure no other residents were exit seeking or showing signs of wanting to leave the secure unit. Further review of the Enhanced Supervision Monitoring Tool revealed there were no other residents identified as being exit seeking. Review of the Elopement Drill/Actual Event Participation dated 12/27/24 and 12/28/24 revealed staff members actively participated in a drill on what to do when and if a resident went missing. Review of the in-services dated 12/24/24 and 01/06/25 revealed staff were in-serviced on the facility's elopement and wandering policy. Interview on from 02/04/25 to 02/06/25 at various times with LVN J, LVN P, LVN Q, LVN V, MA O, CNA S, CNA N, CNA T, CNA U, CNA I, and CNA R revealed residents were checked on at the beginning of their shift to ensure all resident were accounted for frequent round were made to monitor all resident for signs of exit seeking. They all said if they were to notice a resident was missing, they were to alert all staff working and begin to look for the resident. If the resident was not located in the building, they would notify management and call 911.

Based on observation, interview, and record review, the facility failed to establish procedures to ensure that enough water was available in the facility in the event of a loss of normal water supply, for 1 of 1 facility. The facility's emergency water supply consisted of 0 gallons of water on hand for a census of 68 residents. This failure could place all residents in the facility at serious risk for complications from dehydration and sanitation. Findings included: Observation on 02/06/25 beginning at 12:50 PM of the facility revealed no emergency water in the facility. The kitchen was observed and the dietary manager was interviewed. No emergency was located. Two additional closets in the facility were observed and no emergency was located. Interview on 02/06/25 at 1:10 PM with the Dietary Manager revealed that the Dietary Manager was unaware of any placement of emergency water. The Dietary Manager stated that she had never ordered emergency water for the facility and had no knowledge of emergency water stored in the facility. The Dietary Manager said that she was unaware of any policy of emergency water storage for the facility and had never been assigned the task of keeping emergency water for the facility on hand. The Dietary Manager also said that she had never been in-serviced on emergency water for the facility. Interview on 02/06/25 at 2:22 PM with the Administrator revealed that he was unaware of any emergency water on site at the facility. The Administrator stated that he had asked the facility staff if they knew where emergency water was stored, and staff had told him they were not aware of any stored emergency water. The Administrator stated that the facility should have three days of water for each resident population of water on hand. The Administrator stated that there is a method of estimating the amount of emergency water required for a facility. But the Administrator stated he did not have the policy and would have corporate send it to him. The Administrator said that it was his responsibility to ensure that sufficient emergency water was on the premises for residents and staff. The Administrator also revealed that not having an adequate supply of water during an emergency could lead to dehydration for residents. Interview on 02/06/25 at 2:41 PM with the Chief Nursing Officer revealed that the facility should have at least one gallon per resident for three days. The Chief Nursing Officer stated the facility should have 204 gallons of emergency water on hand at a minimum. The Chief Nursing Officer said that if residents do not get enough water, it could cause residents to need additional emergency medical interventions. The Chief Nursing Officer also stated that it was a combination of the Dietary Manager's responsibility and the Administrator's responsibility to ensure emergency water is kept at the facility. The Chief Nursing Officer placed an order for emergency water following this conversation. Record review of the facility's current, undated Water/Dietary Considerations for Residents reflected: :Policy Statement This facility has planned for the dietary needs of its residents in the case of an emergency situation. .4. A minimum of food and water to last for three days shall be maintained at the facility in a specific location. This minimal amount of food and water should be determined based on the number of residents, employees and visitors during a crisis or disaster situation. Record review of the facillity's Emergency Preparedness; Loss of Water Supply revised October 2021, reflected: Under procedure; Preparation, 1. Each center maintains a supply of drinking water based on state-specific requirements (see OP6 1511.00, state emergency water requirements). It is recommended that, at minimum, the center have on hand two gallons of water per resident (2 gallons per resident x 68 residents = 136 gallons needed per day) and per employee (2 gallons x 105 employees = 210 gallons per day) per day for at least three days (136 gallons for residents + 210 gallons for employees = 346 gallons x 3 days = 1,038 gallons needed for residents and employees for 3 days), or more, for patients who are on medications or who are at risk for dehydration. Record review of the facility's State emergency water requirements for Texas policy, revised June 2015, reflected: Keep at least a three-day supply of water per person; each person will need a gallon per day. (68 residents + 105 employees = 173 gallons x 3 days = 519 gallons)

Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and of exploitation of residents and misappropriation of resident property for 1 of 8 employees (CNA D) reviewed for employment registry screenings. The facility failed to ensure a search of the EMR/NAR was completed for CNA D prior to employment and before providing direct patient care. This failure could place residents at risk for abuse, neglect, exploitation and misappropriation of property. Record review of CNA D's personnel file reflected a hire date of 07/07/23 and no EMR/NAR check was completed prior to this date. Interview on 02/06/22 at 12:12 PM with the HR Manager revealed she began working at the facility in March of 2024. The HR Manager stated that CNA D had no EMR/NAR checks completed prior to her employment and hire date of 07/07/2023 nor the annual EMR/NAR check. The HR Manager stated that she discovered this when she was asked by this surveyor for the documentation. The HR Manager said that it was her responsibility to complete the annual EMR/NAR background checks for staff as well as upon hire. The HR Manager revealed that the staff member was suspended immediately until the EMR/NAR check was completed. The HR Manager stated that EMR/NAR checks were important to prevent abuse and neglect to residents. Interview on 02/06/25 at 1:12 PM with the Administrator revealed EMR/NAR checks were supposed to be completed upon hire and annually by the HR Manager. The Administrator stated it was his responsibility to monitor that EMR/NAR checks were completed annually and upon hire. The Administrator revealed the importance of EMR/NAR checks were to prevent potential harm to a resident. Record review of the facility's current, undated Abuse Prevention Program reflected the following: .2. Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has: a. Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; b. Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or c. Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 7 residents (Residents #8) reviewed for pharmacy services. Facility failed to ensure Ranolazine 1000 mg ER (extended release) used for chest pain was administered on 02/03/25, 02/04/25 and 02/05/25 as ordered for Resident #8. This failure could place residents at risk of not receiving the therapeutic value of the ordered medications and leading to potential hospitalization . The findings were: Record review of Resident #8's entry MDS assessment, dated 11/27/24, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. The resident had diagnoses which included: chest pain. Resident #8 had moderate cognition with a BIMS(Brief Interview for Mental Status) score of 11. Record review of Resident #18's care plan initiated 01/06/25 reflected: Focus: Resident has altered cardiovascular status rule out Angina. Goal: Resident will be free from signs and symptoms of complications of cardiac problems through the review date. Interventions: Assess for chest pain. Enforce the need to call for assistance if pain starts. Record review of Resident #8's physician orders dated 11/15/24, revealed, Ranolazine ER oral tablet extended release 12 Hour 1000MG. Give 1 tablet by mouth every 12 hours for ANGINA (chest pain). Record review of Resident #8's February 2025 Medication Administration Record (MAR) reflected; the resident was not administered Ranolazine ER 1000mgs on: 02/03/25 at 09:00 PM 02/04/25 at 09:00 AM and 09:00 PM 02/05/25 at 09:00 AM it was documented see nurses notes . Observation and interview on 02/04/25 at 10:52 AM revealed Resident #8 in her room. Resident#8 stated she had been out of Ranolazine for 2 days. She stated she uses the medication for her heart. She denied pains. Observation on 02/05/25 at 07:48 AM revealed MA E administering medication to Resident #8. She checked the blood pressure sanitized and popped the following morning medications for Resident#8:. -Entacapone 200 mg 1 tablet three times daily p.o -Escitalopram 5 mg 1 tablet daily p.o -Plavix 75mgs 1 tablet daily p.o -Pantoprazole 40 mg 1 tablet twice daily p.o -Carbodo/levodopa 25-100 mg 2 tablet three times a day p.o -Lidocaine patch 4%- apply to the lower back daily p.o -Potassium cl 10 meq 1 tablet daily p.o. -Metoprolol succinate ER 25 mg 1 tablet daily p.o. -Gabapentin Oral Capsule 300 mg three times a day p.o -Candesartan Cilexetil Oral Tablet 4 mg 1 tablet daily p.o. -MA failed to administer Ranolazine extended release 1000mgs. Interview with MA E on 02/05/25 at 10:21 AM revealed, she administered the last tablet of Ranolazine extended release on 02/04/25 in the morning. MA E stated she had ordered the medication from the pharmacy twice and the pharmacy had not sent the medication to facility. She stated she was aware the resident had missed the medication on 02/03/24,02/04/24 and 02/05/24 and she had notified the nurse . She stated she was supposed to order the medication when she had 7 left on the bubble pack. She stated she had notified the nurse her medications were missing, but she did not notify the management. She stated the risk of missing those doses was Resident #8 having chest pains. She stated she had done training on medication administration. She stated she was checking with the resident for changes of condition while administering other medications and checking vitals. Interview with LVN L on 02/05/25 at 10:35 AM revealed he was the charge nurse for Resident #8 from 02/03/25 to 02/05/25. He stated MA E had not notified him of Resident#8 missing her Ranolazine ER 1000 mg until a few minutes ago and he was to call pharmacy. He stated the MA was supposed to notify him when they order medication from pharmacy, and they fail to receive refills, or the medication has finished so that he can check from the emergency kit and follow up with pharmacy. He stated the risk of Resident#8 missing the doses was having increased heart rate and having shortness of breath. She stated he had done training on medication administration and ordering. Interview on 02/05/25 at 12:34 PM with the ADON revealed, she was not aware Resident#8 was missing her Ranolazine ER 1000 MG. She was notified on the morning of 02/5/25 by MA E and she stated she had reported it to the charge nurse. The ADON stated her expectation was the MA to order medication when she had 7 tablets remaining on the bubble pack and they had done training on their staffs. She stated she called the pharmacy, and they were waiting for the insurance clearance. She stated the risk of missing the doses was Resident #8 experiencing chest pain. Interview on 02/05/25 at 01:38 PM with DON revealed, she was not aware Residentt#8 was missing her Ranolazine ER 1000 MG. She stated her expectation was the MA to notify the nurses once they order medication from pharmacy and do not receive the refills and they nurses should notify her. She stated she expected the staffs to order medication for refills when they have 7 remaining on the bubble. She stated it was her responsibility to check the Medication administration record every day for holes and missing tablets, but she had not checked until 02/04/25, when she saw she had not been receiving and she was to address the issue when the MA came and notified her that the surveyor was asking about the missing doses. She stated the risk of Resident #8 missing the doses was delay in treatment. She stated she called the physician assistant on 02/05/25 and she was told to hold the medication until when available. She stated she had done training on medication refills and administration. The last training was on 1/31/25 and [NAME] was in attendance. Interview with the chief Nursing Officer on 02/06/25 at 12:57PM revealed her expectation was MA to report to the nurse on the medication that were not refilled by pharmacy and nurse to call pharmacy, know what was delaying delivery. The nurse should contact the doctor for alternate medication and decision making. She stated per state regulations they have enough medication for 72 hours always remaining. She stated there were no risk since she could see Resident #8 up and about and medications were delivered on the night of 02/05/25. Interview on 02/06/25 at 03:10 PM with Pharmacist consultant revealed, the records show that Resident#7 had missed 4 doses and she was not able to tell the history of when the medication was last ordered by checking on the records. She stated it was her expectation the facility should order for refills a week before the supply finishes because of insurance or any other issue that could delay refilling. She stated facility was supposed to follow up with pharmacy 24 hours after ordering and she fills there was issue with communication because any time the pharmacy note something they communicate through writing or call the facility. She stated the facility was supposed to have notified the doctor for a substitute. She stated the risk of missing those doses for extended-release medication Resident #8 would lack sustainability of therapy. Interview with on 02/10/25 at 01:38 PM with physician assistant while returning a missed call for 2/6/25 revealed, she was not aware Resident#8 was missing her Ranolazine ER 1000 MG. She was notified on the morning of 02/5/25 and she told them to hold until available. She stated her expectation was the facility to ensure all medication are available and ordered timely and if there were issues with pharmacy she should be notified. She stated the risks are there for Resident missing those does but she had not complained of chest pain, and she had other extended-release medications. Review of the facility training records revealed training on medication ordering dated 1/31/25 and MA E was in attendance. Record review of the facility undated policy on medication administration revealed the following . 3. Medications must be administered in accordance with the orders, including any required time frame .

Based on interview and record review, the facility failed to ensure it received registry verification for 2 (CNA D and CNA E) of 5 employees reviewed for registry verification prior to allowing an applicant to serve as a nurse aide. The facility failed to ensure CNA D and CNA E had a current nurse aide certification while employed at the facility, while actively providing care for residents. This failure could result in residents being provided care by staff who have not provided documentation of training and competency in providing care. Findings included: Record review of CNA D's personnel file reflected a date of hire of [DATE]. The facility did not complete an EMR/NAR check upon hire or annually. Record review of CNA E's personnel file reflected a date of hire of [DATE]. The last Employability Stats Check Search that was completed on [DATE] reflected CNA E's NAR status would expire on [DATE]. Record review of the daily nursing staff schedule, for [DATE] reflected CNA D worked on [DATE] on shift 6:00 PM - 6:00 AM under the CNA Assignments section. Interview on [DATE] at 12:12 PM with the HR Manager revealed that she had been the HR Manager since March of 2024. The HR Manager stated that EMR/NAR should be completed annually. The HR Manager stated that she was told by regional on [DATE] that if a staff had both a CNA and a MA, then both certifications must be updated annually. The HR Manager said that until she was told this by regional, she was unaware of the regulation. The HR Manager stated that she had spoken to CNA D last May when she reviewed her personnel file. The HR Manager said CNA D was instructed to renew her CNA certification by her. The HR Manager said she thought CNA D had renewed her license. The HR Manager said that she discovered CNA D's certification had not been renewed when she was asked by the surveyor for evidence of the renewed certification. The HR Manager revealed that she notified the aide that she was suspended immediately. The HR Manager stated that she was notified on [DATE] CNA E's certification was expired. The HR Manager said that she spoke with CNA E on [DATE]. The HR Manager stated that CNA E told her she was unaware her CNA certification had to be renewed. CNA E said she thought if her MA certification was renewed, her CNA certification was automatically renewed. The HR Manager stated she was now aware that CNA E's certification was expired and had notified CNA E that she was suspended immediately. The HR Manager revealed it was her responsibility to ensure that EMR/ENR checks were conducted annually to ensure that all staff working have updated certifications. The HR Manager stated that it was the staff's responsibility to keep their own certifications current. The HR Manager said that if staff did not keep their certifications updated, it could lead to increased falls, accidents, abuse allegations, and infection control issues. Interview on [DATE] at 12:30 PM with the DON revealed that it was the HR Manager's responsibility to ensure that the EMR/NAR check were conducted annually for all cna's and medication aides. The DON stated that there was no one that monitored this system to ensure that all certified nurse's aides and medication aides' certifications were active. The DON said that if certified nurse's aides and medication aides' certifications were not active, it could lead to falls, fractures, incorrect transfers and other incorrect procedures. Interview on [DATE] at 1:12 PM with the Administrator revealed that EMR/NAR is supposed to be checked by the HR Manager annually and upon hire. The administrator said that it was his responsibility to monitor the process. The Administrator also stated that there was potential for harm to a resident when no EMR/NAR checks are completed on hire or annually. Record review of the facility's current, undated Competency of Nursing Staff reflected the following: Policy statement 1. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law .

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being for 1 secure unit reviewed for activities. The facility failed to ensure there were organized activities provided to the residents in the secure unit . The failure placed residents at risk for a diminished quality of life, isolation, lack of stimulation. Findings included: Review of the facility's current February 2025 Activities Calendar for the secure unit reflected the following: 02/04/24 10:30 AM - Pretty Nails 2:00 PM - National Homemade Soup Day 3:00 PM - Table Games 02/05/24 10:00 AM - Exercise/Movie 10:30 AM - Arts and Crafts 2:00 PM - Resident Birthday Party 3:00 PM - Cookie and Apple Cider Social 02/06/24 10:00 AM - Exercise/Movie 2:00 PM Bingo 3:00 PM Senior Trivia Observation on 02/04/25 at 10:22 AM, of the secure unit revealed there were 7 residents in the dining room and the TV was on and there were no activities going on at the time. At 12:04 PM staff began to gather the residents for lunch and surveyor exited the secure unit and not activities were noted during the continuous observation. Observation on 02/05/25 at 10:37 AM, revealed there were 6 residents in the dining area and the TV was on and the radio was playing music in the background. Residents were noted to be wandering to and from their rooms and no activities were observed. Observation on 02/06/25 from 10:42 AM to 12:20 PM, revealed some residents were sitting in the dining room and others were wandering in and out of the dining room and there was a staff member in the dining room monitoring the residents. No activities were observed during that time. Interview on 02/06/25 at 1:45 PM, LVN M revealed she had been working at the facility on the secure unit for about 2 weeks and during her 6AM to 6PM shift, she had never seen any activities in the secure unit. LVN M said one of those days she did see the Activity Director paint a resident's nails. Interview on 02/06/25 at 1:45 PM, the Activity Director revealed none of the activities that were on the calendar during 02/04/25 to 02/06/25 had been done on the secure unit. The Activity Director said it was difficult to try and do activities both on and off the unit and at times she would try to do some room rounds and paint their nails or comb their hair. Interview on 02/06/25 at 4:02 PM, the Administrator revealed he thought there was some discrepancy in the amount of activities that were being done in the secure unit but was not aware none of them had been done during the last few days. The Administrator said they would need to review the schedule and ensure activities were being done on the secure unit. The Administrator further stated activities were important because lack of could lead to resident boredom which could increase resident behaviors. Review of the facility's undated policy titled Activity Programs reflected the following: Activity programs designed to meet the needs of each resident are available daily. .1. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs

Based on observation, interview, and record review, the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 3 of 14 residents (Residents #29, #48, and #57) reviewed for ADLs. The facility failed to ensure Resident #29, #48, and #57 received showers as scheduled. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem. Findings included: Record review of Resident #29's Quarterly MDS Assessment, dated 01/23/25, reflected the resident was a [AGE] year-old female who was first admitted to the facility on [DATE], readmitted on [DATE], and then readmitted again on 11/20/24. Resident #29 had a BIMS score of 15, which indicated her cognition was intact. Her diagnosis included quadriplegia (paralysis of all four limbs), neurogenic bladder (urinary problems caused by nerve problems affecting bladder control), and osteomyelitis of vertebra, sacral and sacrococcygeal region (spinal infection in the sacrum). The MDS further review reflected Resident #29 was dependent on staff regarding bathing. Record review of Resident #29's Care Plan, dated 02/05/25, reflected Focus: Resident #29 has an ADL Self Care Performance Deficit r/t quadriplegia. Goal: The resident will maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene, mobility through the review date. Interventions: Eating-The resident requires max staff participation to eat. Bed Mobility- The resident requires max X 2 staff participation to reposition and turn in bed. Transfer- The resident requires total dependence X 2 staff participation with transfers. Toilet use- The resident requires total staff participation to use toilet. The care plan did not address Bathing/Showering. Record review of Resident #29's POC Response History for 01/24/25 to 02/06/25 under Task - ADL- Bathing reflected no showers or bed baths provided during the time period and no indications of refusals. Record review of Resident #29's Shower Sheets completed by the facility CNAs reflected Resident #29 refused showers on: 01/14/25 twice, 01/30/25, 01/18/25, and 02/01/25 and received showers on 01/07/25 and 01/16/25. Record review of Resident # 48's undated Admission Record reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included total paralysis related to multiple sclerosis. Record review of Resident #48's quarterly MDS, dated [DATE], reflected a BIMS score of 14 indicating he was cognitively intact. His Functional Status reflected he was totally dependent on staff for his ADLs. Record review of Resident #48's care plan, dated 12/08/24, reflected it was not individualized to the resident, he had a pressure ulcer, and had a self-care deficit. Record review of Resident #48's shower sheets for December 2024 and January 2025 reflected he had a bed bath on 01/13/25, and 01/26/25. Record review of Resident #57's undated Admission Record reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included diabetes, morbid obesity, heart failure, and high blood pressure. Record review of Resident #57's quarterly MDS, dated [DATE], reflected a BIMS score of 15 indicating he was cognitively intact. His Functional Status indicated he required substantial assistance with his bathing and ADLs. Record review of Resident #57's care plan, dated 11/29/24, reflected he refused care, becoming verbally abusive towards staff. He also had an ADL self-care deficit requiring mas staff participation with hygiene. Record review of Resident #57's shower sheets for December 2024 and January 2025 reflected a bed bath on 12/30/24, 1/13/25, 1/15/25, and 1/22/25. He refused a bed bath on 1/1/25 and 1/8/25. Observation and interview on 02/04/25 at 11:33 AM revealed Resident #48 was in bed. His sheets had brown stains surrounding his body, his blanket had red stains on it. Resident #48's hair was unkempt and appeared greasy. There was a strong odor of body odor about the resident. Resident #48 stated he did not recall his last bath, and his sheets had not been changed in a long time. Resident #48 stated the red stain on his blanket was from a spilled drink from three days prior. Observation and interview on 02/04/25 at 12:05 PM revealed Resident #29 had not been bathed in three weeks. Resident #29's shower days were Tuesday, Thursday, and Saturdays Resident #29 stated she had not been showered because she was told by staff that there were no clean linen and no clean towels. Resident #29 said that she could not recall the name of staff that told her she could not be showered. Resident #29 stated she did not feel like a lady. Resident #29 also stated she had more than one wound on her that required wound care treatment. Observation and interview on 02/04/25 at 12:27 PM revealed Resident #57's linen had large brown stains outlining his body, a heavy smell of body odor. Resident #57 stated his sheets had not been changed in over a week, he stated he had heard from staff the washing machine was broken and there was not enough linen. Resident #57 stated he did refuse a bed bath if the staff did not have clean linen for his bed, Why wash up just to get back into filthy bed?. Interview on 02/05/25 at 11:41 AM CNA I revealed Resident #29 was a Tuesday, Thursday, and Saturday shower. CNA I stated it was the CNA's responsibility to offer showers and document refused showers. CNA I said that if a resident refuses a shower, she would report it to her nurse. CNA I also stated Resident #29 often refused showers and other personal care like wound care. When asked if Resident #29 was offered more than seven showers in the last 30 days, CNA I stated she was. CNA I stated she did not know where more shower sheets showing Resident #29's refusals were located. CNA I said that showers were important because it could increase bed sores and smells. CNA I did not recall her last in-service on ADL's. Interview on 02/05/25 at 11:48 AM LVN J revealed showers were supposed to be offered three times per week, three times per shift, and as needed or requested. LVN J stated Resident #29 being offered seven showers during the last 30 days was not sufficient. LVN J said that if a resident refused a shower, the aide was supposed to notify the nurse. LVN stated the nurse should educate Resident #29 about the importance of showers. LVN J stated the nurse should offer to shower the resident again at this time. LVN J stated the resident's skin was best assessed when the resident was showered, and the resident was more comfortable when they were clean. LVN J also said that if a resident did not receive regular showers, it could lead to skin breakdown. LVN J stated Resident J often refused showers for an entire week. LVN J stated the shower sheets could not be located, and it was not documented in the facility POC Response History, Task-ADL-Bathing portion of the facility EHR. LVN J revealed if a resident refused a shower, the family and DON should be notified. Interview on 02/06/25 at 3:31 PM the ADON revealed residents should be offered showers three times per week and three times per shift. The ADON stated if the resident refused a shower, then the nurse should be notified by the aide. Then the nurse should alert the family, ADON, and the DON about the shower refusal. The ADON said that if a resident continued to decline a shower, she would notify the DON and the family. The ADON stated the importance of showers was for infection control, dignity, resident rights, skin issues, and so that the resident feels comfortable. The ADON revealed she would also educate the resident on the importance of showers when she was notified about shower refusals. The ADON stated Resident #29 was offered showers and refused them, but she could not locate shower sheets, and it was not documented in the EHR. The ADON said that it was the nurse's responsibility to document the resident shower refusals and that she would notify the DON and Administrator if she saw refusals not documented. Interview on 02/07/25 at 9:55 AM the DON revealed residents should be offered showers three times per week by the aides. And if the resident refuses, the nurse should go and offer another shower during that shift after the aide notifies the nurse of the refusal. If the resident refuses the shower, the nurse will educate the resident on the importance of a shower. The DON stated if the resident continued to refuse a shower, then the resident's family would be notified. The DON said that refusals should be documented by both the aide and the charge nurse. The DON revealed showers were important because without them there was a risk of skin breakdown and infection and a loss of dignity. Record Review of facility undated policy Activities of Daily Living (ADLs), Supporting reflected the following: Policy Statement Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who were unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.2. Appropriate care and services will be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); 48236 Based on observation, interview, and record review, the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 3 of 14 residents (Residents #29, #48, and #57) reviewed for ADLs. The facility failed to ensure Resident #29, #48, and #57 received showers as scheduled. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem. The findings include: Record Review of Resident #29's Quarterly MDS Assessment, dated 01/23/25, reflected a [AGE] year-old female who was first admitted to the facility on [DATE], readmitted on [DATE], and then readmitted again on 11/20/24. Resident #29 had a BIMS score of 15, which indicated her cognition was intact. Her diagnosis included quadriplegia (paralysis of all four limbs), neurogenic bladder (urinary problems caused by nerve problems affecting bladder control), and osteomyelitis of vertebra, sacral and sacrococcygeal region (spinal infection in the sacrum). MDS further review reflected Resident #29 was dependent on staff regarding bathing. Record Review of Resident #29's Care Plan, dated 02/05/25, reflected Focus: Resident #29 has an ADL Self Care Performance Deficit r/t quadriplegia. Goal: The resident will maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene, mobility through the review date. Interventions: Eating-The resident requires max staff participation to eat. Bed Mobility- The resident requires max X 2 staff participation to reposition and turn in bed. Transfer- The resident requires total dependence X 2 staff participation with transfers. Toilet use- The resident requires total staff participation to use toilet. The care plan did not address Bathing/Showering. Record Review of Resident #29's POC Response History for 01/24/25 to 02/06/25 under Task - ADL- Bathing reflected no showers or bed baths provided during the time period and no indications of refusals. Record Review of Resident #29's Shower Sheets completed by the facility CNA's reflected Resident #29 refused showers on:1/14/25 X 2, 1/30/25, 1/18/25, and 02/01/25 and received showers on 1/7/25 and 1/16/25. Record review of Resident # 48's undated Admission Record reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included total paralysis related to multiple sclerosis. Record review of Resident #48's quarterly MDS, dated [DATE], reflected a BIMS score of 14 indicating he was cognitively intact. His Functional Status reflected he was totally dependent on staff for his ADLs. Record review of Resident #48's care plan, dated 12/08/24, reflected it was not individualized to the resident, he had a pressure ulcer, and had a self-care deficit. Record review of Resident #48's shower sheets for December and January reflected he had a bed bath on 1/13/25, and 1/26/25. Record review of Resident #57's undated Admission Record reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included diabetes, morbid obesity, heart failure, and high blood pressure. Record review of Resident #57's quarterly MDS, dated [DATE], reflected a BIMS score of 15 indicating he was cognitively intact. His Functional Status indicated he required substantial assistance with his bathing and ADLs. Record review of Resident #57's care plan, dated 11/29/24, reflected he refused care, becoming verbally abusive towards staff. He also had an ADL self-care deficit requiring mas staff participation with hygiene. Record review of Resident #57's shower sheets for December and January reflected a bed bath on 12/30/24, 1/13/25, 1/15/25, and 1/22/25. He refused a bed bath on 1/1/25 and 1/8/25. Observation and interview on 02/04/25 at 11:33 AM Resident #48 was in bed. His sheets had brown stains surrounding his body, his blanket had red stains on it. Resident #48's hair was unkempt and appeared greasy. There was a strong odor of body odor about the resident. Resident #48 stated he did not recall his last bath, and his sheets had not been changed in a long time. Resident #48 stated the red stain on his blanket was from a spilled drink from three days prior. Observation and interview on 02/04/25 at 12:05 PM with Resident #29 revealed she had not been bathed in three weeks. Resident #29's shower days were Tuesday, Thursday, and Saturdays Resident #29 stated she had not been showered because she was told by staff that there were no clean linen and no clean towels. Resident #29 said that she could not recall the name of staff that told her she could not be showered. Resident #29 stated she did not feel like a lady. Resident #29 also stated she had more than one wound on her that required wound care treatment. Observation and interview on 2/4/25 at 12:27 PM Resident #57 reflected the resident's linen had large brown stains outlining his body, a heavy odor of body odor. Resident #57 stated his sheets had not been changed in over a week, he stated he had heard from staff the washing machine was broken and there was not enough linen. Resident #57 stated he did refuse a bed bath if the staff did not have clean linen for his bed, Why wash up just to get back into filthy bed?. Interview on 02/05/25 at 11:41 AM with CNA I revealed Resident #29 was a Tuesday, Thursday, and Saturday shower. CNA I stated it was the CNA's responsibility to offer showers and document refused showers. CNA I said that if a resident refuses a shower, she would report it to her nurse. CNA I also stated Resident #29 often refused showers and other personal care like wound care. When asked if Resident #29 was offered more than seven showers in the last 30 days, CNA I stated she was. CNA I stated she did not know where more shower sheets showing Resident #29's refusals were located. CNA I said that showers were important because it could increase bed sores and smells. CNA I did not recall her last in-service on ADL's. Interview on 02/05/25 at 11:48 AM with LVN J revealed showers were supposed to be offered three times per week, three times per shift, and as needed or requested. LVN J stated Resident #29 being offered seven showers during the last 30 days was not sufficient. LVN J said that if a resident refused a shower, the aide was supposed to notify the nurse. LVN stated the nurse should educate the resident about the importance of showers. LVN J stated the nurse will offer to shower the resident again at this time. LVN J stated the resident's skin was best assessed when the resident was showered, and the resident was more comfortable when they were clean. LVN J also said that if a resident did not receive regular showers, it could lead to skin breakdown. LVN J stated Resident J often refused showers for an entire week. LVN J stated the shower sheets could not be located, and it was not documented in the facility POC Response History, Task-ADL-Bathing portion of the facility EHR. LVN J revealed if a resident refused a shower, the family and DON should be notified. Interview on 02/06/25 at 3:31 PM with the ADON revealed residents should be offered showers three times per week and three times per shift. The ADON stated if the resident refused a shower, then the nurse should be notified by the aide. Then the nurse should alert the family, ADON, and the DON about the shower refusal. The ADON said that if a resident continued to decline a shower, she would notify the DON and the family. The ADON stated the importance of showers was for infection control, dignity, resident rights, skin issues, and so that the resident feels comfortable. The ADON revealed she would also educate the resident on the importance of showers when she was notified about shower refusals. The ADON stated Resident #29 was offered showers and refused them, but she could not locate shower sheets, and it was not documented in the EHR. The ADON said that it was the nurse's responsibility to document the resident shower refusals and that she would notify the DON and Administrator if she saw refusals not documented. Interview on 02/07/25 at 9:55 AM with the DON revealed residents should be offered showers three times per week by the aides. And if the resident refuses, the nurse should go and offer another shower during that shift after the aide notifies the nurse of the refusal. If the resident refuses the shower, the nurse will educate the resident on the importance of a shower. The DON stated if the resident continued to refuse a shower, then the resident's family would be notified. The DON said that refusals should be documented by both the aide and the charge nurse. The DON revealed showers were important because without them there was a risk of skin breakdown and infection and a loss of dignity. Record review of the facility's current, undated Activities of Daily Living (ADLs), Supporting reflected the following: Policy Statement Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who were unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene 2. Appropriate care and services will be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) .

Based on observation, interview, and record review, the facility failed to ensure residents had a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 3 of 16 rooms (Rooms #118, #126, and #147) and 2 of 14 residents (Resident #37 and Resident #66) reviewed for clean, comfortable, and homelike environment and clean bed and bath linens that are in good condition. 1. The facility failed to replace stained ceiling tiles in room [ROOM NUMBER] 2. The facility failed to repair a ceiling HVAC vent in room [ROOM NUMBER]. 3. The facility failed to maintain a clean environment for Resident #37. 4. The facility failed to ensure there was an adequate supply of linens to meet resident needs. 5. The facility failed to repair the room door for Resident #66. This failure placed residents at risk of decreased feelings of self-worth and possible infections. Findings included: 1. Observation on 02/04/25 at 9:35 AM revealed the ceiling tiles above the Resident #48's bed had multiple brown stains on three ceiling tiles. The resident stated the tiles had been stained for over a month. The resident stated he notified nursing staff about them, but no one ever did anything about it. 2. Observation on 02/04/25 at 9:41 AM revealed the ceiling vent in Resident #9's room was missing one screw and was hanging down, only one screw was preventing it from falling. The vent was not directly above the resident's bed. The resident was non-verbal and could not state how long the vent had been like that. 3. Observation and interview on 02/04/25 at 11:00 AM with Resident #37 revealed the resident's fitted sheets had multiple large, dark yellow stains. Resident #37 stated that his sheets had not been changed in approximately six days. Resident #37 also said that staff told him that there was no clean linen available. Resident #37 could not recall the names of the aides that told him no clean linen was available. Observation on 02/04/25 at 11:10 AM of linen closet A revealed 14 resident hospital gowns were available. No other linen was available in the closet. Observation on 02/04/25 at 11:30 AM of linen closet B revealed 13 hospital gowns and 6 fitted sheets were available. No other linen was available. Observation on 02/04/25 at 3:04 PM of the laundry facilities revealed there was no clean linen for residents' beds. No clean fitted sheets or clean top sheets were observed. Interview and observation on 02/04/25 at 11:24 AM CNA K revealed linens should be changed when residents were showered and when they were dirty. CNA K stated that she had not changed Resident #37's linens because she had been busy providing patient care to other residents. CNA K stated she was PRN; therefore, she did not know how long Resident #37's sheets had been on his bed. CNA K then went to linen closet A, and there was no clean linen was available. CNA K and surveyor then went to linen closet B. Only six fitted sheets were available. CNA K revealed that when clean linen was not available in the linen closets, she would go to the laundry facilities to locate clean linen. CNA K stated that it was her responsibility to ensure that residents had clean linen on their beds. Interview on 02/04/25 at 3:02 PM with the Laundry Supervisor revealed that she was aware that the facility had a shortage of linen. The Laundry Supervisor stated that she knew that the Administrator had purchased new linen. However, the Laundry Supervisor revealed that she believed that staff were throwing dirty linens in the garbage instead of sending them to the laundry. The Laundry Supervisor stated that the facility had one functioning residential washing machine. The Laundry Supervisor stated that the laundry department ran two shifts per day to attempt to keep up with the facility's laundry. The Laundry Supervisor said that the first shift was 6:00 AM to 2:00 PM and the second shift was 4:00 PM to 12:00 AM. The Laundry Supervisor stated that it was her responsibility to ensure that the linens in the facility were clean so that staff could change the residents' bed linens in a timely manner. The Laundry Supervisor revealed that she had notified the Administrator of the shortage of linen in the facility but did not say the specific date or time. The Laundry Supervisor did not have access to the facility to the facility policy on linen. Interview on 02/04/25 at 3:06 PM with the Administrator revealed that he was aware of the shortage of linen at the facility. The Administrator stated that he had made multiple orders of linen since his employment at the facility beginning at the end of December 2024. The Administrator said that he believed staff were throwing the linen in the thrash instead of rinsing them off and taking them to the laundry room. The Administrator revealed that part of reason for the shortage of linen in the facility was because the facility had only one working residential washing machine. The Administrator stated that corporate had not approved a commercial washing machine within his allowed budget to purchase for the facility. The Administrator stated that it was his responsibility to ensure enough linen was available to meet the daily needs of the residents. The Administrator revealed he was aware that there was not enough linen in the facility to meet the daily needs of the residents. The Administrator did not know the facility policy on linen. 4. Observation and interview on 02/04/25 at 11:15 AM, of Resident #66 room door to be broken, an attempt was made to enter; however, Resident #66 had a wheelchair behind the door that made it difficult to open. Resident #66 moved her wheelchair and gave permission to enter. Observed Resident #66 door to not latch and would keep the door open. Resident #66 stated her door had been broken for a couple of months, unknown of the exact time. She stated she kept her wheelchair by the door so that other residents do not come in her room. She stated her restroom had another door where she could enter and exit her room. Interview on 02/06/25 at 11:01 AM, with CNA B revealed she was aware of Resident #66's door not closing; she does not know how it broke. CNA B stated she had Resident #66 usually puts her wheelchair by the door to close it. She stated she does not know how long the door had been broken. CNA B stated she had notified the maintenance staff about it, but it had not been fixed. She stated she could not recall when she notified the maintenance staff. Interview on 02/06/25 at 11:09 AM, with LVN M revealed she had not noticed Resident #66's door did not close. She stated usually Resident #66 kept her door closed by using the wheelchair. LVN M stated Resident #66 would use the bathroom door to enter and exit her room. She stated she was unsure if the maintenance staff was aware that it needed to be fixed. She stated it was the responsibility of the nurses to notify maintenance staff if any maintenance was needed in a room. Interview on 02/06/25 at 3:25 PM, with Maintenance Director revealed he was aware Resident #66 room door was broken, it would not close. He stated he was told a resident had kicked it and it broke the latch and would not close. Maintenance Director stated he was told about a week ago, unknown of the exact date. He stated Resident #66 liked her door closed and would usually keep her wheelchair by the door to close it. He stated it was the resident rights to have a door that closes and opens properly. Review of the facility's undated policy Quality of Life- Homelike Environment reflected the following: Residents were provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. . 2. The facility staff and management shall maximize, the extent possible, the characteristics of the facility that reflect a personalized homelike setting. These characteristics include: a. Clean, sanitary, and orderly environment e. Clean bed and bath linens that were in good condition. 44140 48236

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Resident #4) reviewed for accidents. The facility failed to ensure Resident #4 was provided with adequate supervision to prevent him from eloping from the facility's secured unit that was not in proper working condition on 07/24/24. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 07/24/24 and ended on 07/26/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of harm, severe injury, and possible death to residents who require supervision. Findings included: Review of Resident #4's Admission Record, dated 09/11/24, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included parkinsonism (not a single disease, but a term for a group of conditions that affect movement and mimic Parkinson's disease), schizoaffective disorder (A mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), and anxiety disorder (persistent and excessive distress that affects daily life). Review of Resident #4's Optional State Assessment MDS Assessment, dated 06/27/24, reflected he had a BIMS score of 11 indicating moderate cognitive impairment. Review of the section regarding behavior reflected there was no wandering behavior exhibited. There were no active diagnoses listed on Resident #4's MDS Assessment. Review of Resident #4's physician's orders reflected an order to admit the resident 0to the secured unit of the facility on 06/18/24. Review of Resident #4's care plan, revised 07/26/24 reflected the following: Focus: The resident is at risk for elopement/wandering r/t History of attempts to leave facility unattended, Impaired safety awareness, Resident wanders aimlessly .Goal: The resident will not leave facility unattended through the next review date .Interventions: Exit and stairwell alarms, Frequent Monitoring, Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Staff aware of resident's wander risk. Review of Resident #4's July 2024 progress notes reflected staff documented the frequent monitoring of him from 07/26/24 to 07/29/24. Review of Resident #4's Elopement Risk Evaluation, dated 06/18/24, reflected a score of 3 putting him at risk. Review of Resident #4's Elopement Risk Evaluation, dated 07/26/24, reflected a score of putting him at risk. Interview on 09/11/24 at 10:00 AM with Resident #4 revealed he remembered leaving the facility because the back door was open so he walked through it. Resident #4 said he did not hear an alarm going off when the door was open. Resident #4 said he wanted to go to the store and was by himself walking down the road and no one was with him. Resident #4 said he did not make it to the store because staff eventually caught up with him and put him in a car to take him back to the facility. Review of a provider investigation report reflected the following under the Investigation Summary section: On 07-24-2024 around 8 pm, [Resident #4] exited the back unit door and door alarm went off, staff promptly responded and ran after the resident and never losses sight off of the resident and returned him back to the facility safely, upon asking resident state that he wanted to walk to the convenience store. Head to toe assessment done no injury noted .elopement assessments completed .Facility checked the functioning of the back door and adjusted the door to ensure it closed completely and locked, additionally facility maintenance director changed the self closing hinge of the unit back door and started q 30 checking exit door by charge nurse and maintenance director daily. Staff were in serviced on elopement and an elopement drill was completed on all 3 shifts including weekends shift. Staff were in serviced on exit doors checking,proper functioning and reporting to maintenance director promptly in case of any technical error. Facility updated care plan of the resident,facility contacted residents rp but no one answered the call [sic]. Review of the facility's maintenance log reflected the following: 7/26 and 7/27: Exit door by unit not properly latched/door frame sets loose/must be reset twice to ensure door is locked behind all exit doors must be checked daily for proper latching and closure reset [sic]. Review of an invoice dated 08/09/24, from an Electronic Engineering company reflected the following: Description Service Call: Maglock on secure unit is going into delayed egress and needs to be adjusted .The second set of doors were located in the rear of the secured unit. Found that these doors were not locking and found no power present at the Maglock. Troubleshot the XDT board and found no issues & then traced the power wire to determine where it was receiving power from. While tracing the wire found an area that had been compacted near an AC duct. Cut and spliced the wire & then reconnected all wires. After reconnecting the wires, tested the Maglock and the keypad and everything is now working as designed. Job complete. Attempted telephone interview on 09/10/24 at 3:31 PM with CNA F was unsuccessful as there was no answer or return call. A witness statement, dated 07/24/24, written and signed by CNA F reflected the following: I was in the room taking care of residence the I saw one resident through the window running then I first called the memory nurse that one of you resident is out side I then came back and call other staffs [sic]. Attempted telephone interview on 09/10/24 at 3:33 PM to MA H was unsuccessful as there was no answer or return call. An undated witness statement signed by MA H reflected the following: On Wenesday July 24th when I was about to pass the bedtime meds on bluebonnet the charge nurse came to me and ask me to check all rooms on bluebonnet if everyone was there. Before my charge nurse instruct me one of the nurse came on [the hall] call the CNA and say to him help him because she is looking for somebody [sic]. Telephone interview on 09/10/24 at 3:38 PM with CNA K revealed she was in a room helping a resident and heard the nurse calling out for help. CNA K said she stayed behind to care for the residents while the other CNA left with the nurse to run after the resident. CNA K said the door alarm did not go off and the back door to the secured unit was wide open. CNA K explained that she had been trained on what do when a resident eloped from the facility. Telephone interview on 09/11/24 at 9:16 AM with CNA I revealed it was around 8:30 PM when she was in a room assisting a resident to bed and changing them. CNA I said she heard the nurse said a resident was out of the facility so she left to help the nurse. CNA I said the resident left through the back door of the secured unit and the door alarm did not go off. CNA I explained that she had been trained on what do when a resident eloped from the facility. Attempted telephone interview on 09/11/24 at 3:37 PM to LVN J was unsuccessful as there was no answer or return call. An undated witness statement reflected the following: I [LVN J], charge nurse on 7/24/24, [the facility's] Memory Care [unit], while admitting a new resident the alarm was sounded off. I checked around and noted [Resident #4] had gotten out of the building. I immediately went after the resident. [CNA F] also noted resident coming around the building headed toward [a street near the facility]. CNA made this nurse aware that she would notify other staff to assist getting [Resident #4] back in the building. We were able to safely get resident back on unit. I never lost sight of resident and made sure he was safe resident verbalized I'm ok, 'I just wanted to take a walk' [sic]. Telephone interview on 09/11/24 at 9:45 AM with RN L revealed he was not working on the unit the day a resident eloped. RN L said he was helping to send a resident to the hospital and heard someone shout that a resident had eloped. RN L said he stayed in the facility to be with the other residents while the aide and nurse went to find the resident. RN L explained that she had been trained on what do when a resident eloped from the facility. Telephone interview on 09/11/24 at 9:37 AM with CNA M revealed he was doing rounds when the nurse (LVN G) called and said a resident ran outside and she needed help bringing him back to the facility. CNA M said he and LVN G found the resident before the stop light before the railroad down the street from the facility. CNA M said the laundry lady had put the resident in her car to drive him back to the facility. CNA M said it was very late at night and were worried about walking him back to the facility. CNA M explained that she had been trained on what do when a resident eloped from the facility. Interview on 09/11/24 at 10:37 AM with LVN N revealed she was not there the day Resident #4 eloped. LVN N said afterwards she continued to monitor him and completed every 15-minute checks on him for a week to make sure he was safe in the facility. LVN N said she was also told to check the exit door to the secured unit every shift to make sure it was working properly. LVN N said if the exit door was not working she was supposed to notify the Administrator and Maintenance Director immediately. LVN N explained that she had been trained on what do when a resident eloped from the facility. Observation on 09/11/24 at 11:30 AM of the secured unit's exit door revealed it was locked and the keypad next to it had the light on indicating it was working. An attempt to push on the door to open it was unsuccessful, the door stayed closed and never opened. A piece of paper posted next to the door reflected: In case if alarm goes off, ensure that door is properly closed after resetting the password,if not than immedietly inform Administrator/Maintenance Director and log it in Maintenance log book. Please ensure that residents are safely back in the unit and follow P/P of elopement. Thank you, management. [sic] Interview on 09/11/24 at 11:33 AM with the Maintenance Director revealed he had only been at the facility for two months. The Maintenance Director said he has had to fix the back door to the secured unit a few times. The Maintenance Director said the facility called an engineering company to come out and permanently fix the door. The Maintenance Director said since the repair no other residents have eloped from the secured unit. The Maintenance Director said the door used to be able to be opened after pushing on it for so long but now it would not open unless the fire alarm went off or the staff entered the code to unlock it. The Maintenance Director said this change was made because residents were setting the door alarm off too many times at night, and it would not lock back so he would have to go to the facility to fix it to secure the door. The Maintenance Director said he checked the secured unit exit door regularly and completed a log for it. Interview on 09/11/24 at 11:57 AM with the DON revealed she was told Resident #4 pushed through the secured unit's exit door and started running away from the facility. The DON said staff told her they ran after him, but he was running very fast. The DON said staff brought him back to the facility and he was not harmed but he did make it off the facility property. The DON said afterwards they in-serviced all their staff regarding elopements. The DON said they also completed elopement drills and completed an elopement assessment on Resident #4. The DON said the Administrator had a company come out to fix the door as well. The DON said the facility knew Resident #4 was at risk of elopement because he came from another facility that did not have a secured unit where he was trying to elope from there. The DON said a lot can happen when a resident elopes from the facility such as they can be out of food and be hungry, become dehydrated, could be hit by a car, or could die. The DON said all staff were responsible for making sure residents do not elope. Interview on 09/11/24 at 12:20 PM with the Administrator revealed the DON told her that Resident #4 had eloped from the facility. The Administrator said Resident #4 had opened the door and the door alarm went off the nurse saw him and left after him, but he was very fast. The Administrator said multiple staff left to find Resident #4 and they found him on a road near the facility. The Administrator said staff got Resident #4 in one of their cars to bring him back to the facility. The Administrator said Resident #4 was not harmed and told staff he was going to the convenient store to get something. The Administrator said staff were in-serviced on elopements after the incident occurred. The Administrator said the nurse completed multiple assessments on Resident #4 such as skin, pain, and a head to toe which resulted in no findings. The Administrator said an elopement risk evaluation was also completed on Resident #4. The Administrator said the Maintenance Director checked the door and thought there was a glitch in the door alarm or something. The Administrator said they monitored the door for functionality for the next 72 hours and called an engineering company to fix it. The Administrator said two elopement drills were completed, one on 07/25/24 and one on 07/27/24. The Administrator said they knew Resident #4 was an elopement risk when he admitted because he was from another nursing facility where he wandered a lot and was at risk of eloping. The Administrator said anything can happen to a resident when they elope, and all staff were responsible for ensuring they did not. Interview on 09/11/24 at 2:22 PM with CNA D revealed she had been trained on what do when a resident eloped from the facility. Telephone interview on 09/12/24 at 8:52 AM with LVN G revealed an aide called that a resident had left the building. LVN G said she went out of the facility and tried to follow that aide and saw another aide also trying to find the resident. LVN G said she saw one of the laundry ladies take her car and drive off to find the resident. LVN G said she went out to road and off to the side she saw a nurse and an aide with the resident. LVN G said they found the resident around [street name] before the train tracks. LVN G explained that she had been trained on what do when a resident eloped from the facility. Interview on 09/12/24 at 9:16 AM with LVN B revealed she had been trained on what do when a resident eloped from the facility. Interview on 09/12/24 at 10:34 AM with LVN O revealed she had been trained on what do when a resident eloped from the facility. Interview on 09/12/24 at 10:55 AM with CNA P revealed she had been trained on what do when a resident eloped from the facility. The Administrator was notified on 09/11/24 at 4:05 PM, that a past non-compliance IJ situation had been identified due to the above failures. It was determined this failure placed Resident #4 in an IJ situation on 07/24/24. The facility implemented the following interventions: Review of an Elopement Tool worksheet reflected the facility held an elopement drill on 07/27/24. Review of an Elopement Drill/Actual Event Participation Log reflected a date of 07/25/24. Review of an Elopement Drill/Actual Event Participation Log reflected a date of 07/26/24. Review of an Elopement Prevention and Management Program Evaluation worksheet reflected it had been completed. Review of an Exit Doors Check worksheet reflected the secured unit door was checked daily from 07/01/24 to 07/25/24. Review of Enhanced Supervision Monitoring Tools reflect staff were signing off that they had monitored the secured unit exit door on the following dates: 07/26/24, 07/27/24, 07/28/24, 07/29/24, 07/30/24, 08/01/24, 08/02/24, 08/03/24, 08/04/24, 08/05/24, 08/06/24, 08/07/24, 08/08/24, 08/10/24, and 08/11/24. Review of a sheet of paper titled Facility Personal Safety Device and Exit Door Alarm Testing Log for July 2024 reflected there were checks on all the doors, including the secured unit exit door. Review of an in-service titled Elopement and wandering policy and procedure aims to prevent and manage situations where individuals, particularly those with cognitive impairment, leave a designated safe area without authorization or supervision dated 07/26/24 reflected staff had been trained on the facility's policy and procedures. Review of an in-service titled Abuse and neglect, reporting abuse and neglect, forms of abuse, rounding Q 30 minutes in unit, rounding Q hour on the floor dated 07/26/24 reflected staff had been trained on the facility's policy and procedures. Review of an in-service titled Door exits/alarms ringing, all staff must ensure after resetting the password the exit doors are latched/closed and properly functioning dated 07/26/24 reflected staff had been trained on the facility's policy and procedures. Review of the facility's undated policy, titled Elopement reflected: .2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity, if necessary .4. If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 3 of 11 residents (Residents #1, #2, and #3) reviewed for accidents. 1. The facility failed to ensure Resident #1 was provided with adequate supervision to prevent an unwitnessed fall with injury (non-displaced sacrum ring fracture) on 03/18/24. 2. The facility failed to ensure Resident #2 was provided with adequate supervision to prevent him from eloping from the facility's secured unit on 01/31/24. 3. The facility failed to ensure the staff break room was locked at all times and residents did not have access to the microwave. Resident #3 sustained burns on his left foot first toe and second toe. An Immediate Jeopardy (IJ) situation was identified on 03/28/24 at 1:41 PM. While the IJ was removed on 03/29/2024, the facility remained out of compliance at a scope of pattern for a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of harm, severe injury, and possible death to residents who require supervision. Findings included: 1. Review of Resident #1's face sheet, dated 03/28/24 revealed the resident was a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included epilepsy (a brain condition that causes recurring seizures), seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness of one entire side of the body) following cerebral infarction (a stroke) affecting right dominant side. Review of Resident #1's quarterly MDS assessment, dated 01/31/24, reflected he had a BIMS score of 06, which indicated severe cognitive impairment. His functional abilities for toileting hygiene and personal hygiene indicated he required substantial/maximal assistance meaning the helper did more than half of the effort. He was also substantial/maximal assistance for rolling left and right, sit to lying, lying to sitting on side of the bed, sit to stand, and chair/bed-to-chair transfer. Review of Resident #1's care plan, dated 11/01/23 , reflected the following: Focus: [Resident #1] [was] at risk for fall due to: unsteady gait, decreased balance and poor safety awareness .01/17/24 fall with no injury .Goal: Resident will have no reports of injuries that requires hospitalization or fractures related fall through next review date .Interventions: 01/17/24 Resident re-educated on the importance of calling for help for safety .Focus: [Resident #1] [had] an ADL Self Care Performance Deficit r/t Hemiplegia, Impaired balance, Limited Mobility .Goal: the resident will maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene, mobility through the review date .Interventions: Personal Hygiene: The resident requires total assistance with personal hygiene care. Bed Mobility: The resident requires (X1) staff participation to reposition and turn in bed. Toilet Use: The resident is totally dependent on staff for toilet use. Review of Resident #1's progress notes for March 2024 reflected the following: - On 03/18/24 at 05:04 AM, LVN Z wrote: This nurse was alerted by resident yelling. The CNA explained that she went to gather more wipes as they run out during cleaning session, resident was found at the foot of the bed. Resident was assessed for external injuries, helped back in bed and assessed some more, he denied any pain for the moment being, V/S = 132/71 mmHg, P=74 bpm. R= 17, T=97.9, O2 SAT= 98% room air. Teachings were provided to resident on importance of safety, and how he needed help to move out of bed. DON was made aware, a message has been left for the on-call number, resident family was informed. Neuro ongoing. [sic]. - On 03/18/24 at 11:08 AM, LVN Y wrote: On continue follow up post fall Res complained of pain to right ankle. On Assessment, red area noted to right ankle with Rest of VS WNL. Tylenol 325mg 2 tabs given as ordered and was effective. NP [NP X] notified and X-ray proposed which she accepted. X-ray to right ankle called in STAT. RP [RP V] notified. [sic]. - On 03/18/24 at 5:52 PM, LVN Y wrote: X-ray to right ankle done and results pending with RP at bed side. - On 03/18/24 at 6:00 PM, LVN Y wrote: Res Transfer to ER for further evaluation post fall as decided by RP [RP V] who called 911 herself. [sic]. - On 03/20/24 at 2:53 PM, LVN Y wrote: Res arrived the building via a stretcher AAOX3 and denies any pain. VS WNL with no discomfort reported. DX of sacral fracture .[sic]. Review of an incident report for Resident #1, dated 03/18/24, prepared by LVN Z reflected the following: - Incident Description: Nurse Description: Nurse was alerted by resident yelling, the nurse headed to resident's room where she found him next to bed, yelling 'wipes, wipes'. The cna explained to the nurse that they run out of wipes during the cleaning session, she explained to resident that she will go get some more wipes from the supply room. [sic] .Resident Description: Resident kept screaming 'wipes, wipes' [sic]. - Immediate Action Taken: Resident was assessed for any external injuries, helped back in bed and assessed some more, he denied any pain for the moment being, V/S = 132/71 mmHG, P=74 bpm. R= 17, T= 97.9, o2 SAT= 98% room air. Teachings were provided to resident on importance of safety, and how he needed help to move out of bed. Review of Resident #1's hospital records, dated 03/18/24, reflected the following: History of present illness: .presents to the ED after falling out of bed while undergoing changing at his extended care facility yesterday. All HPI and past medical history have been obtained from patient's [RP] who is POA and states that while the patient was being changed/turned at the extended care facility yesterday afternoon, the patient accidentally rolled off the bed, hitting his entire right side .Assessment and Plan: 1: Sacral fracture, 2: Pelvic ring fracture .History: Additional Comments: CT scan of the pelvis was reviewed which shows very subtle sacral S2 fracture without significant displacement Review of Resident #1's x-ray results for his right ankle, dated 03/18/24, reflected there was no acute fracture or dislocation. Review of a form titled Extended Care Employee Termination Form, dated 03/27/24, reflected CNA T was terminated for negligence and was not eligible for rehire. Observation and interview on 03/26/24 at 10:45 AM with Resident #1 revealed he was sitting in his wheelchair in the activity room drinking coffee. Resident #1 was dressed, groomed, and appeared content; there were no obvious signs or symptoms of pain noted. Resident #1 replied with no to each question the State Surveyor asked so it was difficult to ascertain if he understood what he was being asked based on how he was answering. Observation on 03/28/24 at 9:59 AM of CNA JJ and CNA R providing incontinent care for a resident revealed they gathered all supplies and did not leave the resident alone. Interview on 03/26/24 at 2:30 PM with LVN Y revealed he came in on Monday (03/18/24) morning and the outgoing nurse said the resident fell at about 3:00 AM. LVN Y said he made his rounds and saw Resident #1 laying in bed and he was fine. LVN Y said he contacted RP #4 because the outgoing nurse was unable to contact her earlier. LVN Y said he completed an assessment on Resident #1 and noted he complained of pain to his right ankle and he administered Tylenol. LVN Y said he called Resident #1's doctor and got an order for an x-ray. LVN Y said the X-ray company took a few hours to get to the facility, but they came during his shift and so did RP V. LVN Y said RP V wanted Resident #1 to go to the hospital for further evaluation and called 911 herself. LVN Y said the ankle X-ray results came in the next day when Resident #1 was already at the hospital, but the results were negative, which indicated no injury. Attempted interview via phone on 03/27/24 at 10:02 AM with LVN Z was unsuccessful. Interview on 03/27/24 at 11:50 AM with CNA W revealed when she came in for her shift on 03/18/24, she was informed Resident #1 had a fall on the night shift. CNA W said Resident #1 was a two-person assist and he only complained of pain to his ankle where there was a bruise. Attempted interview via phone on 03/27/24 at 1:23 PM with NP X was unsuccessful. Interview on 03/27/24 at 1:54 PM with ADON U revealed Resident #1 had a fall on 03/18/24 and during the initial assessment there was no complaints of pain. ADON U said an X-ray was done after Resident #1 started to complain of pain and the results were negative. ADON U said Resident #1's RP wanted him to go to the hospital and they found a fracture of some sort on his sacrum. ADON U said CNA T was providing care and in midst of this service ran out of material so she told the resident she would be back. ADON U said she left to go and get more wipes and by the time she came back Resident #1 had fallen out of the bed. ADON U said Resident #1 was total care meaning staff providing all care for his incontinent needs. ADON U said at the time of the fall Resident #1 was a one-person assist but after the fall he was changed to be a two-person assist. ADON U said CNA T should have called for help to ask another co-worker or nurse to retrieve what she needed and stayed with Resident #1. ADON U said CNA T should not have left Resident #1 alone in the condition he was in being in the middle of providing him incontinent care. ADON U said CNA T was suspended pending the investigation and staff were in-serviced on fall risks and prevention and abuse/neglect. Interview via phone on 03/27/24 at 3:05 PM with CNA T revealed on 03/18/24 she went in to answer Resident #1's call light after her lunch break. CNA T said when she went into his room he wanted to be changed so she got her supplies and started changing him. CNA T said in the middle of care, the wipes finished, and she still needed to keep cleaning him. CNA T said she told him she was going to grab some more wipes and was going to come back and finish cleaning him. CNA T said she stepped out of the room to get wipes and came back to the room, and he was on the floor. CNA T said she could have called someone to come and bring wipes or stay with him before leaving to get more wipes. CNA T said she knew better than to leave a resident alone in the middle of providing care. CNA T said she was informed after the fall on 03/18/24 that Resident #1 was now a two-person assist. Interview on 03/27/24 at 3:25 PM with ADON S revealed on 03/18/24 Resident #1 had his call light on and he needed to be changed. ADON S said Resident #1 was a one-person assist at the time and CNA T was caring for him. ADON S said Resident #1 was very impulsive and didn't understand having to wait and hold on for something or for care. ADON S said if staff were running out of supplies during care, they should ensure the resident was safe and try calling someone else and not leaving the resident alone. ADON S said when Resident #1 was found the nurse assessed him and he had no injuries or pain noted at the time. ADON S said later on in the day he complained of pain to his ankle so an x-ray for his ankle was ordered and was negative. ADON S said Resident #1's RP came to the facility and requested him to be sent to the hospital because she felt as if something was broken. ADON S said the hospital found Resident #1 had a sacrum fracture. ADON S said the risk of leaving a resident in the middle of care was they were at increased risk of falls or injuries. ADON S said all staff were responsible for ensuring residents were always left in a safe and comfortable manner. Interview on 03/27/24 at 4:23 PM with the DON revealed Resident #1 had a fall on 03/18/24 and she went to go and see him and speak to LVN Y. The DON said LVN Y told her Resident #1 hurt the right side of his leg, that he was going to call the doctor to get an x-ray ordered. The DON said after the x-ray technician came and took the x-ray, Resident #1's RP said she did not want to wait for the results and wanted him to go to the hospital instead. The DON said on 03/20/24 the facility found out Resident #1 had a pelvic fracture. The DON said LVN Z was the one who found him the morning of 03/18/24 around between 4 and 6 AM when she heard a noise and saw him on the floor. The DON said CNA T went into Resident #1's room to answer his call light, began to gather supplies to care for him and realized she did not have enough to complete the job so she assured him she would be right back. The DON said she was not told by CNA T that she had actually started providing care and then ran out of supplies and left the room. The DON said if that was the case, CNA T should have asked someone for help by bringing her the additional items she needed. Interview on 03/27/24 at 5:23 PM with the Administrator revealed she was still investigating what happened on 03/18/24 with Resident #1. The Administrator said in the middle of the night when the CNA was rounding and checking on residents CNA T saw Resident #1's call light on. The Administrator said she went in to turn off the lights and saw Resident #1 wanted her to change his brief. The Administrator said CNA T agreed to change him so she put his bed to a high position to be able to start care, she had wipes and started caring for the resident. The Administrator said CNA T told her the bed was in a low position before she left the room because she ran out of wipes. The Administrator said Resident #1 was very impulsive and when CNA T left the room and returned, he was at the foot of the bed and screaming about wipes. The Administrator said CNA T should not have left Resident #1 in the middle of caring for him. The Administrator said during the initial assessment by LVN Z, Resident #1 did not have any complaints of pain or injuries. The Administrator said later in the day the next nurse checked on Resident #1 and he was noted to have complaints of pain to his ankle, so an x-ray was ordered. The Administrator said Resident #1's RP requested for him to be sent to the hospital where it was found he had a sacral non-displaced fracture. The Administrator said CNA T was suspended for almost 4 days during the investigation and before she was brought back to work a skills check off was completed for peri-care. The Administrator said Resident #1 has one word that someone says to him and he sticks to that word such as wipes so it was hard to understand from him what happened. The Administrator said all staff were in-serviced on abuse/neglect and fall prevention regarding the incident. The Administrator said CNA T should never have left Resident #1 after beginning care and should have ensured she had enough supplies before beginning peri-care. The Administrator said CNA T could have asked for help and stayed with Resident #1 to keep him safe because he has a history of impulsiveness and this incident caused harm to him. Follow-up interview on 03/28/24 at 8:42 AM with the Administrator revealed CNA T was terminated as of 03/27/24 because the facility confirmed her negligence regarding Resident #1's fall on 03/18/24 . The Administrator said CNA T told her last night (03/27/24) via phone she was providing care to Resident #1, ran out of wipes, and then left him to get additional wipes outside of the room and he ended up falling and sustained a fracture. The Administrator said she began an additional in-service regarding providing care to residents but had only been able to re-educate the day shift so far for today (03/28/24). Attempted an interview via phone on 03/28/24 at 9:49 AM with RP #4 was unsuccessful. Follow-up interview on 03/28/24 at 11:02 AM with the DON revealed as of this morning (03/28/24) she had just started an additional in-service with staff regarding following the facility's policy and procedures for peri-care. The DON said she was re-educating staff on making sure they had all supplies gathered and ready before beginning incontinent care for a resident. The DON said she was also completing skills check off competencies with staff regarding incontinent care as well. The DON said this was prompted because her and the Administrator contacted CNA T again last night to discuss what happened with Resident #1's fall on 03/18/24. Interview on 03/28/24 at 11:30 AM with CNA R revealed she knew to get all supplies before providing incontinent care and to not leave a resident alone during incontinent care. CNA R said she would use the call light to get the attention of someone else if she did run out of supplies during care. Interview on 03/28/24 at 11:35 AM with CNA Q revealed she knew to get all supplies before providing incontinent care and to not leave a resident alone during incontinent care. CNA R said she would use the call light to get the attention of someone else if she did run out of supplies during care. Review of the facility's undated policy titled Perineal Care reflected the following: Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies needed. Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure: 1. Disposable wipes, 2. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed). Review of the facility's undated and blank Peri Care Audit Tool reflected the following actions: 2. Staff must gather supplies, have bags ready for linen and garbage and wash hands 2. Review of Resident #2's face sheet, dated 03/28/24, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included dementia (a group of symptoms that affects memory, thinking and interferes with daily life), seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and schizoaffective disorder (a mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder.) Review of Resident #2's care plan, updated 01/31/24, reflected the following: Focus: [Resident #2] is an elopement risk/wandered has History of attempts to leave facility unattended, Resident wanders aimlessly. [Resident #2] got out of the facility on 01/31/24 .Goal: The resident will not leave facility unattended through the review date. The resident's safety will be maintained through the review date .Interventions: 01/31/24 30 minute checks x 6 days .Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate [sic]. Review of Resident #2's quarterly MDS Assessment, dated 02/29/24, reflected he had a BIMS score of 6, which indicated severe cognitive impairment. Review of an elopement risk evaluation, dated 01/31/24, reflected Resident #2 was at risk of eloping. Review of an incident report, dated 01/31/24, reflected for the Incident Description: Nursing Description: Res. had finished his breakfast and directed to his room. Apparently, able to leave the unit without any alarm sounds noted. Res. was found by another staff coming to work, and brought back resident to the facility. Res. noted holding his Bible and card that he received from his mother recently. Resident Description: Res. Stated that he went to the back door and was trying to get home to his mother. [sic]. Completed by LVN BB. Observation and interview on 03/26/24 at 10:40 AM with Resident #2 revealed he was laying in his bed with a blanket covering him. Resident #2 said he left the facility but could not remember how or why or where he went or when it was. Resident #2 said he felt safe in the facility and did not travel much anymore. Observation on 03/26/24 at 11:00 AM of the secured unit's back door revealed it was secured, locked, and appeared to be functioning properly. Interview on 03/26/24 at 2:30 PM with LVN Y revealed he was aware of the facility's policy and procedures regarding a resident eloping. LVN Y explained that he knew the facility's code color for when a resident has eloped and what steps to take to try and find an eloped resident by searching the entire facility and around the facility. LVN Y said he knew to immediately report any exit door that was not functioning properly to the Maintenance Director so that it could be fixed quickly. Interview on 03/26/24 at 2:50 PM with CNA J revealed she was aware of the facility's policy and procedures regarding a resident eloping. CNA J explained that she knew the facility's code color for when a resident has eloped and what steps to take to try and find an eloped resident by searching the entire facility and around the facility. CNA J said she knew to immediately report any exit door that was not functioning properly to the Maintenance Director so that it could be fixed quickly. Interview on 03/26/24 at 4:08 PM with LVN BB revealed early in the morning on 01/31/24 she was serving breakfast in the dining room on the secured unit. LVN BB said Resident #2 was always the first resident to finish their breakfast and she had to redirect him to his room afterwards. LVN BB said she took Resident #2 to the hallway and then went back to the dining room because she was helping other residents finish their meals. LVN BB said the next thing she knew the front desk was calling saying Resident #2 was seen by Housekeeper KK on her way to work. LVN BB said apparently Resident #2 pushed on the back door of the secured unit and walked around the back and went to the front of the building. LVN BB said she called the DON and Administrator immediately to report what happened. LVN BB was instructed to count all residents and ensure no one else was missing or had eloped. LVN BB said all residents were accounted for and Resident #2 was back in the building . LVN BB said she spoke with Resident #2 and said he was carrying his Bible and a card sent to him by his [family member] so he was trying to get home to her. LVN BB said she checked his skin and he had no injuries. LVN BB said she thought something was wrong with the door to the secured unit at the time since there was not an alarm that went off. LVN BB said usually when someone tried to open that door the alarm would go off letting staff know that someone was trying to leave. LVN BB said the ADON came to check the door as well and she was able to just push the door open, it was not locked and did not require a 15-second release, and the alarm did not sound. LVN BB said the Maintenance Director came and fixed the door right away that day (01/31/24). LVN BB was able to explain the facility's policy and procedures regarding a resident eloping. Interview on 03/27/24 at 5:20 PM with LVN K revealed she was aware of the facility's policy and procedures regarding a resident eloping. LVN K explained that she knew the facility's code color for when a resident has eloped and what steps to take to try and find an eloped resident by searching the entire facility and around the facility. LVN K said she knew to immediately report any exit door that was not functioning properly to the Maintenance Director so that it could be fixed quickly. Interview on 03/28/24 at 9:58 AM with LVN L revealed he was aware of the facility's policy and procedures regarding a resident eloping.LVN L explained that he knew the facility's code color for when a resident has eloped and what steps to take to try and find an eloped resident by searching the entire facility and around the facility. LVN L said he knew to immediately report any exit door that was not functioning properly to the Maintenance Director so that it could be fixed quickly. Interview via phone on 03/28/24 at 11:35 AM with CNA LL revealed Resident #2 eloped from the secured unit back in January. CNA LL said it happened during breakfast time and she was helping other residents to eat their food. CNA LL said Resident #2 finished his meal and liked to go to his room after so when the nurse saw him finish his food she directed him to his room. CNA LL said all of a sudden she heard Resident #2 was found out of the facility and she was not sure how he got out. CNA LL said she asked Resident #2 how he got out of the facility, and he said he went out the back door, but the alarm did not go off. CNA LL said she never noticed the back door to the secured unit was not working. CNA LL said she no longer worked at the facility. Interview via phone on 03/27/24 at 12:49 PM with the Regional Maintenance Director revealed he did not know anything about the back door to the secured unit not functioning back in January because he was not specifically assigned to this facility. Attempted interview via phone on 03/27/24 at 12:56 PM with the Maintenance Director was unsuccessful. Interview on 03/27/24 at 1:54 PM with ADON U revealed Resident #2 eloped from the secured unit and was found down the street at the stop sign. ADON U said a Housekeeper was driving to work and saw Resident #2 and brought him back to the facility. ADON U said an incident report, pain assessment, and skin assessment were completed on Resident #2 and nothing was found. ADON U said Resident #2 was also placed on 30-minute checks by staff, the doctor, and the RP were also notified of the incident. ADON U said the facility checked the back door to the secured unit and there was something wrong with the door arm that they readjusted to make sure it shut and locked. ADON U said after they readjusted the door arm, they noticed it was closing faster and was now locking. ADON U said after the incident occurred, all staff were educated on the facility's policy and procedures for elopements. ADON U said when residents eloped they were at risk of a lot, including injury or death. Interview via phone on 03/28/24 at 4:02 PM with Housekeeper KK revealed she was driving to work on 01/31/24 and found Resident #2 walking outside. Housekeeper KK said she put Resident #2 in her car and brought him back to the facility. Housekeeper KK said she found Resident #2 down the street from the facility about 5 minutes away . Interview on 03/28/24 at 3:25 PM with ADON S revealed Resident #2's (family member) sent him something in the mail with an address on it and that was where he was going to when he eloped. ADON S said Resident #2 was on the secured unit of the facility because he had a history of eloping from previous facilities where he admitted from. ADON S said the facility completed elopement drills, completed in-services for staff, and also put Resident #2 on 30- minute checks. ADON S said the elopement drills were completed on 01/31/24 and 02/06/24. ADON S said the risk of residents eloping from the facility was they could get injured. ADON S said all staff were responsible for making sure residents did not elope. Interview on 03/28/24 at 4:23 PM with the DON revealed a Housekeeper staff member came to the facility and said she thought this person was their resident. The DON said the previous receptionist for the facility told the Housekeeper staff member that it was a resident and identified the person as Resident #2. The DON said she asked where he was going and he was going to the address on the envelope he received from his family member. The DON said Resident #2 was found down at the corner to the left of the facility. The DON said Resident #2 told her he got out of the secured unit through the back door and jumped over the fence. The DON said the nurse had just walked him to his room after eating breakfast when this occurred. The DON said she had the Maintenance Director check on the door to evaluate what happened and why the alarm did not go off. The DON said the Maintenance Director readjusted the door and it was fixed to where the alarm would go off and it was locking. The DON said Resident #2 was assessed and placed on 30-minute checks. The DON said Resident #2 had not eloped again since this incident on 01/31/24. The DON said all staff were educated to know about the facility's elopement policy and procedures. Review of an elopement drill log, dated 02/06/24, indicated the facility completed an elopement drill with staff on this day. Review of an elopement drill log, dated 03/17/24, indicated the facility completed an elopement drill with staff on this day. Review of maintenance logs titled Monthly door Check included a check of the rear exit from the locked unit was checked on the following dates: 01/22/24, 01/29/24, 02/05/24, 02/12/24, and 02/19/24. Review of maintenance logs titled Doors, Locks, and Alarms Inspection Log included a check of the rear memory care exit was checked on the following dates: 02/26/24, 03/01/24, 03/04/24, 03/08/24, 03/11/24, 03/15/24 and 03/25/24. Review of an in-service titled: Code white= missing person policy and procedure, dated 01/31/24, reflected staff were in-serviced on the facility's policy and procedures regarding elopements. Review of an in-service titled: Elopement Monitoring Safety of Residents, dated 03/28/24, reflected staff were in-serviced on the facility's policy and procedures regarding elopements. Review of the facility's policy, dated July 2017, and titled Wandering and Elopement reflected: Definition: a resident who does not have the capacity who leaves the facility unaccompanied. VIII. Response to Resident Elopement, A. The Facility Staff member who finds that a resident is missing will alert Facility Staff. B. The Charge Nurse will call Code ________ and organize a search. Facility Staff will search areas of the Facility, including common areas, bathrooms, showers, outside areas, etc .F. The Licensed Nurse most familiar with the incident will document in the resident's medical record how the elopement occurred IX. Return of a Resident .H. all facility will receive an inservice on hire and annually regarding the elopement policy [sic]. 3. Record review of Resident #3's face sheet revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included: depression (mental health disorder), nasal bone fracture (a break in the bone over the ridge of the nose) and contusion of scalp (a bruise on the scalp). Record review of Resident #3's quarterly MDS assessment, dated 01/8/24, reflected Resident#3's cognitive skills for daily decision making were moderately impaired with a BIMS score of 07. Record review of Resident #3's care plan, revised 02/15/24, reflected: [Residents #3] was at risk for skin breakdown rule out decreased mobility . 1/24/24 burn wound to left dorsal 2nd toe, 1/24/24 burn wound to left dorsal 1st toe resolved on 2/14/24. Goals: Resident will have no reports of skin breakdown through next review date. Interventions: 1/24/24 burn to left dorsal first toe size 1.3 x 1.5 x no measurements. Treatment of hydrogel and bordered gauze dressing daily. 2/14/24 Burn wound to left dorsal 2nd toe size 2.1 x 1.1 x 0.1cm. Treatment to continue with xeroform and bordered island gauze dressing. 2/21/24 burn to left dorsal 2nd toe size 1.3 x 0.7 x 0.1cm. Treatment to continue with xeroform and bordered gauze dressing and skin prep (A waterproof skin barrier which protects the skin from irritation and trauma resulting from tape or dressing applications.). 3/13/24 Burn to left 2nd toe size 0.7 x 0.2 x 0.1 cm. Treatment skin prep. Record review of Resident #3's skin assessment, dated 01/22/24, reflected skin was intact. Record review of Resident #3's incident report, dated 01/24/24, reflected the resident wound on his second toe. Resident #3 reported his second toe was hurting. Record review of the facility's provider investigation report reflected; staf [TRUNCATED]

Based on observation, interview and record review the facility failed to provide a comfortable and safe temperature levels maintained within a range of 71 to 81 degrees Fahrenheit for 9 of 9 residents (Residents #48, #3, #43, #6, #76, #45, #135, #7, and #23) and 3 of 3 zones (Zones #1, #2, and #3) reviewed for environment. The facility failed to ensure temperatures were above 71 degrees Fahrenheit after the heater went out on the night of 01/08/24 to the morning of 01/09/24. An Immediate Jeopardy (IJ) situation was identified on 01/09/24. While the IJ was removed on 01/10/24, the facility remained out of compliance at a scope of widespread with the potential for more than minimal harm that was not immediate, due to the facility's need to evaluate the effectiveness of the corrective systems . This failure could place residents at risk of hypothermia and extreme cold. Findings included: Observation on 01/09/24 at 8:30 AM when entering the facility, revealed it was noticeably cold and staff were still wearing their coats while in the building. Observation on 01/09/24 at 8:39 AM of Zone #1's thermostat on the wall showed it was 60 degrees F. Observation on 01/09/24 at 8:41 AM of the activity room's thermostat on the wall showed it was 63 degrees F. Observation on 01/09/24 at 9:31 AM of Zone #1's thermostat showed it was 59 degrees F. Observation on 01/09/24 at 9:34 AM of Zone #3's thermostat showed it was 65 degrees F. Observation on 01/09/24 at 9:35 AM of Zone #2's thermostat showed it was 67 degrees F. Interview on 01/09/24 at 8:35 AM with the Administrator revealed something happened to the heater and there was not heat in the facility. Interview on 01/09/24 at 8:37 AM with Resident #48 revealed he was in his room laying in bed under blankets. Resident #48 said he was freezing cold and noticed it getting colder through the night. Resident #48 said he was not offered any extra blankets or anything after it started getting colder and had to get his coat to put underneath his blankets to keep him warm. Interview on 01/09/24 at 9:02 AM with Resident #3 revealed she was in her room laying in her bed under blankets and was visibly shivering. Resident #3 said she had two blankets but needed a third one. Resident #3 said she noticed it started getting very cold last night. Interview on 01/09/24 at 9:05 AM with CNA O revealed she noticed it was unusually cold this morning when she came in for her shift. CNA O said she reported this to her nurse because two residents (Residents #43 and #33) were in the Activity Room earlier and wanted to leave because it was too cold so they wanted to go back to their rooms. CNA O said she did not call the Administrator when she came in for her shift because she did not see a reason to do so. CNA O said everyone in the facility was already aware it was cold in the building because everyone could feel it. Interview on 01/09/24 at 9:08 AM with Resident #43 revealed she was in her room sitting in a geri-chair with a blanket over her. Resident #43 said she was very cold and was waiting for more blankets. Resident #43 said she noticed last night that it got very cold, and she had to leave the activity room earlier because it was so cold. Interview on 01/09/24 at 9:10 AM with Resident #6 revealed she was sitting at a table in the dining room with a coat and blanket covering her, eating her breakfast. Resident #6 said she was very cold last night and had to ask for two additional blankets from staff. Resident #6 said it was still cold this morning and she was not sure what happened with the heat in the building. Interview on 01/09/24 at 9:11 AM with Resident #76 revealed he was in the dining room standing up drinking hot coffee. Resident #76 said he noticed it got very cold last night and the coffee was helping to warm him up. Interview on 01/09/24 at 9:14 AM with Resident #135 revealed she woke up at 4:00 AM because she was so cold and had to get a thick blanket. Resident #135 said she had not been able to get warm since and last night when she went to bed she was okay. Interview on 01/09/24 at 9:30 AM with Resident #7 revealed she was cold last night and was given a blanket a few minutes ago and was now getting warmer. Observation and interview on 01/09/24 at 9:38 AM with Resident #23 revealed she was cold around midnight when she was woken up for her medication. Resident #23 said she felt cold and asked for an extra blanket. Interview on 01/09/24 at 9:41 AM with Resident #45 revealed she was in her room and had all of her clothes piled on top of her in her bed. Resident #45 said it was very cold in the facility and she woke up about 2:00 AM last night and had to pile her clothes on top of her to keep warm. Resident #45 said she asked for blankets from staff but never got any from them. Resident #45 said she had not been able to warm up yet. Interview on 01/09/24 at 9:46 AM with CNA B revealed she came to the facility at 6:00 AM this morning and noticed it was cold. CNA B said she did not notify anyone that the facility felt cold. Interview on 01/09/24 at 9:59 AM, RN OO said he came to the facility around 5:45 AM and noticed it was cold. RN OO said the night shift also told him it was cold in the facility. RN OO said he tried to adjust the temperature and he could not tell what the temperature was, but he tried to get it up to 80 degrees F. RN OO said he started walking around giving blankets to residents. Interview on 01/09/24 at 10:01 AM with LVN JJ revealed she worked the night shift, and it was cold in the facility. LVN JJ said she tried to increase the temperature and the temperature was going up and down and then went off. LVN JJ said she realized the hall started getting cold and she adjusted the thermostat on the wall. LVN JJ said she gave extra blankets to some residents but could not remember who they were. Attempted interview via phone on 01/09/24 at 10:32 AM with LVN N was unsuccessful. Attempted interview via phone on 01/09/24 at 10:37 AM with LVN Q was unsuccessful. Interview via phone on 01/09/24 at 10:39 AM with CNA K revealed she worked last night from 6:00 PM to 6:00 AM and noticed it started getting cold in the facility around 11:00 PM/Midnight/1:00 AM. CNA K said she did not check the thermostats in the facility but stated it was cold. CNA K said several residents started asking for blankets and she provided those for them. CNA K said the facility did not normally feel that cold inside. CNA K said everyone could feel the cold in the facility but she was not sure why it was so cold and did not report it to the Administrator. CNA K said she was not aware the heat was out in the facility. Interview via phone on 01/09/24 at 10:50 AM with LVN J revealed she worked last night from 6:00 PM to 6:00 AM and noticed it started getting cold in the facility early this morning. LVN J said she did not report it to the Administrator because she was not aware the heat was out. In an interview on 01/09/24 at 12:00 PM with the Administrator revealed he was told by the alarm company that a wire was dislodged in one of the panels that the heater was connected to and that was what caused it to go out. The Administrator said he was notified on his way to work this morning around 7:00 AM or 7:15 AM by ADON X that the heat was out at the facility . The Administrator said he was not contacted by any staff who worked the overnight shift regarding the heat being out in the facility. The Administrator said he contacted the Maintenance Director immediately who was at the facility within minutes to assess where in the building the heat was out. The Administrator said when he got to the building, he did see that the thermostats in the building were reading in the 60s. The Administrator said he knew the weather outside was very cold and the wind made it even colder. The Administrator said he knew the temperature inside the facility was supposed to be between 71 to 81 degrees F per federal and state requirements. The Administrator said he expected staff to contact him anytime they noticed the heat was out at the facility and as soon as they noticed it. The Administrator said the risk of not having heat in the building put residents at risk of hypothermia or becoming sick from being too cold. The Administrator said while checking on residents this morning, a few of them had complained about the cold. Interview on 01/09/24 at 12:25 PM with ADON X revealed she got to the building after 6:00 AM and noticed it was extra cold in the facility. ADON X said she checked each thermostat to make sure the heat was on and noticed a few were off so she turned them on and gave them a few minutes to kick on. ADON X said after 7:00 AM she called the Administrator to let him know it was very cold in the building and the heat was not working. ADON X said she saw the thermostats on the walls were in the 60s. ADON X said she was not contacted by anyone from the overnight shift about there not being heat in the building. ADON X said when she got to the building the overnight shift had already left but the day shift staff did tell her it was a lot colder than normal. ADON X said she told staff to start offering blankets to residents and passed warm liquids to them. ADON X said if the overnight shift started to notice it getting cooler in the facility, they should have contacted the Administrator or any manager to let them know what was going on, immediately. Interview on 01/09/24 at 1:02 PM with the DON revealed she was on her way to the facility this morning when ADON X called her to say it was cold in the facility. The DON said she was not contacted by anyone on the overnight shift regarding the lack of heat in the building. The DON said she saw one thermostat on the wall in the facility and it was in the 60s. The DON said if the overnight staff noticed it getting cold in the facility during their shift, they should have immediately contacted the Administrator. Interview on 01/09/24 at 2:58 PM with the Maintenance Director revealed he got to the facility early this morning around 6:35 AM and was outside the building for a while and when he came into the building, he noticed it was cold. The Maintenance Director said he noticed the A/C units outside were not running and then the Administrator called him to say that there was not any heat in the building. The Maintenance Director said he contacted the HVAC company to come out and help turn the heat on. The Maintenance Director said he noticed the thermostats read in the 60s. The Maintenance Director said he was not contacted by any overnight staff about the lack of heat in the building. The Maintenance Director said if he had been called by the overnight staff he would have come to the facility to try and fix everything immediately. Record review of the local temperatures for the area (accessed at: National Weather Service: Observed Weather for past 3 Days: reflected the temperature at midnight on 01/09/24 was 49 degrees F with a wind chill temperature of 44 degrees F; the temperature at 5:00 AM was 35 degrees F with a wind chill temperature of 25 degrees F; and the temperature at 9:00 AM was 37 degrees F with a wind chill temperature of 28 degrees F. Record review of the facility's policy, dated 2018, and titled Resident Rights reflected: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. This was determined to be an Immediate Jeopardy on 01/09/24 at 4:55 PM. The Administrator was notified. The Administrator was provided the Immediate Jeopardy template on 01/09/24 at 4:59 PM. The following Plan of Removal submitted by the facility was accepted on 01/10/24 at 9:35 AM: Plan of Removal Immediate Jeopardy On 01/09/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy of resident health and safety. The notification of Immediate Jeopardy states as follows: F584 - The facility failed to establish and maintain a comfortable environment for residents when the heat went out in the facility and the temperature in the facility was as low as 59 degrees F. There is likely a serious adverse outcome that will occur due to the facility not taking immediate action when the facility's temperature was at 59 degrees F. Staff overnight did not immediately contact the Administrator when they noticed the building becoming unusually cold. The facility puts the residents at risk of not having a comfortable environment putting them at risk of being exposed to the cold. All facility residents have the potential to be affected by deficient practice. This is an isolated event; no residents, staff, or visitors suffered a serious adverse outcome due to the facility staff not immediately contacting the facility administrator when the facility's temperature in the building became unusually cold. The facility needs to take immediate action to ensure all staff are aware of who/when to contact the Administrator in times of extreme cold/heat and know what actions to take to keep the residents safe and comfortable. 1). Action: The facility administrator upon becoming aware at 7 am (01/09/2024), immediately called the facility Maintenance Director, who was at the facility to troubleshoot the heating system; upon becoming aware that the heating system would not turn on, the facility administrator called HVAC and Electronic Engineer vendor to report to the facility to assist in repairing the heating system and ordered spot heaters to be delivered to the facility; spot heaters arrived at 9:30 am and installed portable heaters . The Electronic Engineer discovered a loose wire and repaired the loose connection at 11 am. Start Date: 01/09/2024 Completion Date: 01/09/2024 Responsible: Facility Maintenance Director and Facility administrator 2). Action: The facility administrator assigned wellness checks (assessing for signs of hypothermia) on 01/09/2024 at 7 am to the facility Assistant Director of Nursing hourly until the facility temperature came into acceptable range ; residents needing extra blankets and warm fluids were provided promptly. All resident complaints about uncomfortable temperatures were resolved at noon. On 01/09/2024. No resident suffered a serious adverse outcome. Start Date: 01/09/2024 Completion Date: 01/09/2024 Responsible: Facility administrator and Facility Assistant Director 3). Action: The Chief Nursing Officer updated and re-educated the facility Administrator and Director of Nursing on the Policy and Procedure for a). Reporting Unusual Occurrences/Events; which included the importance of prompt reporting of unacceptable temperatures and the importance of the facility always maintaining a temperature range of 71 F to 81 F. If/when unacceptable temperatures are observed such occurrence must be reported to the facility administrator immediately. The mode of education was a memo in the form of a copy of the Policy and Procedure and occurred in a face-to-face meeting on 01/09/2024. Comprehension was assessed by the Chief Nursing Officer via the teach-back method on 01/09/2024. Start Date: 01/09/2024 Completion Date: 01/10/2024 Responsible: Chief Nursing Officer 4). Action: The facility administrator educated Department managers on policy and procedure for reporting unusual occurrences and events , who then educated the facility staff in their departments which included the Director of Nursing educating Licensed Nurses (RNs/LVNs), Certified Medication Aides (CMAs), Certified Nursing Assistants (CNAs), the Environmental Services Supervisor educating both Housekeeping and laundry persons), Dietary Manager educating the Dietary Personnel (Cooks, Tray Aides), the Rehab Director educating therapy staff (Physical Therapist, Occupational Therapist, Speech Therapists) on duty of the facility Policy and Procedure for reporting unusual occurrences/events that could affect the health, safety, or welfare of the facility residents, employees, or visitors which include and is not limited to: a. Interruptions of essential services (e.g. heating, air conditioning, food, water, linens, sewage, or needed medical supplies; b. earthquakes, floods, gas explosions, fires, power outages; c. Communicable disease; d. Poisonings; e. Death of a resident; f. Inoperable emergency systems, equipment, or resident call systems; and g. Allegations of abuse, neglect, and misappropriation of resident property. Staff not on duty during the training period will receive 1:1 training before starting their next shift from the Director of Nursing (DON), Assistant Director of Nursing (ADON), or the facility Administrator (LNFA) and will not be allowed to work until education has been completed. The mode of education was /will be a memo in the form of a copy of the Policy and Procedure and occurred in a face-to-face meeting on 01/09/2024 and ongoing until all facility staff have been re-educated. Education is to be added as part of the orientation for ongoing training of new hires, agency, and PRN staff through a combination of employee training, employee monitoring, and reporting processes. The teach-back method will be used to assess comprehension on 01/09/2024, in addition to a signed affidavit; education will be ongoing until all facility staff have been re-educated. Start Date: 01/09/2024 Completion Date: 01/10/2024 Responsible: Director of Nursing, Administrator, Director of Rehab, SVE Supervisor, Dietary Manager 5). Action: The Director of Nursing educated Licensed Nurses (RNs/LVNs), Certified Medication Aides, and Certified Nursing Assistants (CNAs) specifically on the need to keep residents and staff inside; ensure all windows and doors are closed and provide extra blankets and hot drinks/warm soups during extremely cold temperatures . Additionally, specific education was provided to Licensed Nurses (RNs/LVNs) on the need to assess and report signs of hypothermia to medical providers by the facility Staff Development Coordinator. The Director of Nursing will provide additional education as deemed necessary to maintain ongoing compliance. Comprehension checks will be completed weekly x 4 weeks by the Administrator; Comprehension will be gauged by score on a random quiz given to two staff persons on each shift; a score of ninety percent or greater will equate to comprehension; those scoring less than 90% will received immediate reeducation before being allowed to continue working. Issues and re-education identified by the Director of Nursing and/or Administrator will be tracked weekly x 4 in Standards of Care (SOC) meetings and compliance will be reviewed as part of monthly QAPI x 3 months. Start Date: 01/09/2024 Completion Date: 01/10/2024 Responsible: The Director of Nursing, Staff Development Coordinator, and Administrator 6). Action: An ad-hoc QAPI meeting was held, and the facility Medical Director was notified of the deficient practice and the plan of removal. Action items will be reviewed monthly during the QAPI meetings for the next 3 months and ongoing as needed. Meeting minutes will be taken and maintained for 12 months. Start Date: 01/09/2024 Completion Date: 01/10/2024 Responsible: Administrator The facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Observations on 01/10/24 and 01/11/24 of each zone's thermostats read above 71 degrees F and it was noticeably a comfortable temperature in the facility. Interviews with LVN A, CNA B, LVN C, CNA S, MA D, RN E, LVN F, LVN L, CNA I, CNA AA, CNA BB, the Staffing Coordinator, ADON G, LVN T, CNA CC, CNA DD, RN EE, LVN FF, CNA GG, CNA HH, LA II, LVN N, LVN JJ, LVN Q, LVN KK, Cook W, the Dietary Manager, Dietary Aide LL, the Maintenance Director, ADON X, the DON, and the Administrator started on 01/10/24 thru 01/11/24 revealed they worked multiple shifts (6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM) on multiple days, including weekends. Staff knew to immediately notify the Administrator if they noticed an unusual occurrence, which included if the heat went out in the building. Staff were also able to explain that they would provide blankets, warm liquids, and ensure all doors and windows were closed to keep the heat inside. Record review of in-service sheet, dated 01/10/24, and titled Unusual Occurrences revealed multiple staff had completed the training which included ensuring the Administrator was immediately notified, staff began to provide warm liquids and additional blankets to residents, and ensured all doors/windows were closed in the facility. The Administrator was informed the Immediate Jeopardy was removed on 01/10/24. The facility remained out of compliance at a severity of potential for more than minimal harm that was not immediate jeopardy and a scope of widespread due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care. The facility failed to care plan, assess, follow physician orders, and notify provider of a change in Resident #1's [CONDITION(S)] which led to an increase in the [CONDITION(S)]'s size and the development of hard, dark brown skin tissue. This failure placed residents with diabetic ulcers at risk for developing new wounds or pressure ulcers, pain, deterioration in existing wounds, and infections such as gangrene. Findings Included: Resident #1's MDS assessment dated [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMS score was a 5 and indicated a severe cognitive impairment. His functional status assessment reflected he needed extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A diabetic ulcer was not listed in his diagnoses. His skin condition assessment reflected Resident #1 had a open lesion(s) on the foot, but he did not have a [CONDITION(S)]. Record review of Resident #1's care plans reflected he did not have a care plan or interventions to address a diabetic ulcer to his left foot prior to 03/05/22. Record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review did not reflect an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's progress notes from 02/02/22 until 03/05/22 reflected: a. 02/02/22 at 7:03 PM, LVN F documented an admission note and documented Resident #1 had an open wound to sole of left foot 5 mm X 7.8 mm . b. 02/03/22 at 12:24 PM, LVN F documented the following: [NP H] contacted . request for treatment order to wound of sole of left foot. New order to [paint] sole of left foot with [MEDICATION(S)] and leave open to air one time daily received . c. 02/23/22 at 5:27 PM, the ADON documented Resident #1's skin had no impairments. d. 02/24/22 at 5:27 PM, the ADON documented Resident #1's skin had no impairments. e. 02/25/22 at 5:27 PM, LVN N documented Resident #1's skin had no impairments. f. 02/27/22 at 5:27 PM, LVN A documented Resident #1 had a wound to his left sole that required wound care daily. Review of Resident #1's weekly skin assessments since his admission on 02/02/22 reflected his assessments on 02/10/22, 02/17/22, 03/03/22 documented his skin was intact. His assessment on 02/24/22 reflected Resident #1 had a [CONDITION(S)] but did not identify: which foot, skin condition, measurements. Review of Resident #1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] a. 02/16/21- services rendered by MD G.Admit History - Reason for Admission for this Stay . comes from stay at [hospital] from 1/25-2/2/22 . Patient also received wound care to the left foot and sharp excisional debridement was performed to left plantar foot wound on 1/27. He now comes here for continued treatment and care . Skin: No Unusual Rashes or [CONDITION(S)], No Petechiae, Normal . b. 02/21/22- services rendered by NP H. Skin: No Unusual Rashes or [CONDITION(S)], No Petechiae, Normal . c. 02/23/22- services rendered by MD L. Daughter requesting wound care due to history of [CONDITION(S)] . Skin: No Unusual Rashes or [CONDITION(S)], No Petechiae, Normal .Will consult wound care for diabetic ulcer as daughter's request . d. 02/28/22- services rendered by NP H. [right] leg/foot trace [CONDITION(S)], none on left . Skin: No Unusual Rashes or [CONDITION(S)], No Petechiae, Normal . Will consult wound care for diabetic ulcer as daughter's . e. 03/03/22- services rendered by MD L. Skin: No Unusual Rashes or [CONDITION(S)], No Petechiae, Normal Color . Will consult wound care for diabetic ulcer as daughter's request . During a confidential interview, interviewee stated the facility was unaware of the wound to Resident #1's left bottom foot for 3 weeks after his admission on 02/02/22. Interviewee stated the floor nurses were unaware of the wound to Resident #1's bottom left foot and, since admission, the wound to Resident #1's bottom left foot was definitely bigger than before, maybe by an inch. Interviewee stated MD L called them on 02/23/22 and said a physical assessment was completed on 02/23/22 for Resident #1 and, during the call, MD L said she was sorry she was unaware of the foot ulcer to Resident #1's bottom left foot. In an interview and observation on 03/05/22 at 9:35 AM, LVN A stated she was an agency nurse and had worked at the facility for 3 weeks. She stated she worked 6AM to 10 PM on weekends. She said she was the nurse assigned to Resident #1 that weekend (03/05/22-03/06/22) and the previous weekend (02/26/22-02/27/22). She stated there was not a wound care nurse at the facility and she was responsible for performing the wound care on the residents she was assigned. She stated she was not currently caring for any residents with wounds. She stated she believed Resident #1 previously had a wound to his left great toe to which they were applying [MEDICATION(S)], but that it had healed. In an observation, LVN A removed the socks from Resident #1's feet. There was not a wound to Resident #'1's left great toe. Resident #1 had a large dry wound to the bottom of his left foot with cracked skin and 3 areas of dark brown, hard skin. There was not any drainage. LVN A stated she was unaware of the wound to Resident #1's bottom left foot. In an observation on 03/05/22 at 10:52 AM, the ADON entered Resident #1's room and measured the wound to his bottom left foot. The measurements were 4cm width, 3.3 cm length, and 0 cm depth. In an interview on 03/05/22 at 1:15 PM, the ADON stated she had looked at Resident #1's left bottom foot wound about 3 weeks ago, during routine rounds. She stated she did not make a note in the resident's chart regarding her assessment. She stated the appearance and size of the wound on 03/05/22 did not differ much from when she saw it about 3 weeks ago. She stated she believed it was in Resident #1's best interest to see a wound care provider. The ADON said the facility did not have a wound care nurse but she was wound care certified. She said the process for seeing a wound care provider at the facility had recently changed as the facility had changed providers. She said Resident #1 was not referred to a wound care physician when she saw his wound about 3 weeks ago because they did not have a wound care provider at that time, and she was unaware of the new process. She said previously she could just send a text to the wound care provider and the resident would be seen, but now they had to fax over all the resident's information before the resident was seen. The ADON said Resident #1 probably should have been referred to a wound care physician when she observed the wound to his left bottom foot about 3 weeks ago. The ADON stated the weekly skin assessment for Resident #1 on 02/10/22, 02/17/22, 03/03/22 were incorrect and Resident #1 did have a wound on those dates to the bottom of his left foot. She said the facility had been using a lot of agency nurses and they needed to complete in-services with them regarding documentation. In an interview on 03/06/22 at 9:30 AM, the DON said she observed Resident #1's wound weekly and the wound had not deteriorated but she did not document these observations in the resident's records. The DON said there was room to grow regarding documentation of wounds. The DON stated she was unaware Resident #1 had debridement of wound on 01/27/22. In an interview on 03/06/22 at 12:44 PM, MD G verified he was the facility's medical director but was no longer Resident #1's physician since about a week ago. MD G said he was pretty sure he was notified of the diabetic ulcer to Resident #1's left foot but did not recall if he ever assessed the diabetic ulcer. MD G said Resident #1 definitely needs a wound care assessment ASAP. MD G said it was his expectation nurses should have been completing and documenting a daily assessment of Resident #1's wound. MD G said it sounded like wound care didn't even assess Resident #1. MD G said when the admitting nurse documented a wound to Resident #1, that should have triggered a wound care consult. In an interview on 03/07/22, NP H said she was aware of Resident #1's [CONDITION(S)] and gave the admitting nurse an order to paint it with [MEDICATION(S)] and consult wound care on 02/03/22. NP H stated it was her expectation when she gave an order the nurse would enter the order immediately. She said since the wound care provider came to the facility on ce a week, Resident #1 should have been seen by the wound care provider no longer than one week after she gave the order for the consult on 02/03/22. NP H stated if an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . NP H stated it was her expectation nurses would assess and document the assessment of a wound anytime a treatment is done. NP H stated the assessment should include measurements, size, depth, what the wound bed looks like, drainage, and staging. In an interview on 03/08/22 at 11:34 AM, LVN O said she worked the 2PM to 10 PM shift. She said Resident #1 had a wound to his left bottom foot. She said he had a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] #1 recently and had not looked at his recently. During an interview on 03/08/22 at 11:45 AM, MDS Nurse E stated Resident #1's care plan did not address wounds because he believed the ADON would create the care plan after he was seen by the wound care physician. He stated he was unaware Resident #1 had a [CONDITION(S)] and he first learned Resident #1 had a [CONDITION(S)] when the HHSC Surveyor asked about it on 03/05/22. In an interview on 03/08/22 at 12:17 PM, LVN F said she assessed Resident #1 when he was admitted on [DATE]. She said he had a diabetic to his left foot, and she noted the measurements in mm instead of cm. She said she called NP H got a treatment order for it, but she did not receive an order to consult wound care.

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care and services to ensure one (Resident #4) of ten sampled residents reviewed for pain management were assessed for pain and/or received appropriate pain control. Resident #4 had chronic pain due to a torn rotator cuff. Despite the resident's recent increase in pain, the physician was not notified, the resident was not assessed for pain when complaining of pain and was not evaluated following pain administration to determine how effective the pain medication was. The resident refused to attend activities due to his pain. Following surveyor inquiry, new orders were received for pain medication for the resident. These failures resulted in Resident #4 experiencing unrelenting pain resulting in self-induced social isolation with a preference to remain in bed and watch TV, with a loss of sleep due to his pain. The increase in pain medication allowed the resident to sleep. Findings included: 1) Resident #4 was initially observed during rounds on 03/21/11 at 9:35 a.m. awake in bed complaining of right shoulder pain. The resident stated he had received pain medication earlier. However, the medication only helped a "little." The resident further stated he had been experiencing the pain for a "long time" that morning. Resident #4 further stated he had attempted to "suffer" through the pain and not be a "sissy." The surveyor activated the call bell for the resident. CNA T responded and informed the nurse, LVN S, of Resident #4's complaint of pain. At 9:40 a.m. on 03/21/11, LVN S entered the room with pain medication for Resident #4. The nurse queried the resident about his pain intensity on a scale of 1 to 10. Resident #4 stated the pain was at a 10, and LVN S administered one tablet of the prn pain medication [MEDICATION NAME] (narcotic [MEDICATION NAME]) 10/325 mg. LVN S explained to the resident he could have pain medication every four hours as needed, and the last dose had been administered the previous evening. On 03/21/11 at 9:40 a.m. LVN S told the surveyor Resident #4 had a history of [REDACTED]. An interview with Resident #4 on 03/21/11 at 12:45 p.m. revealed his pain prevented him from participating in the facility's activity program. The resident stated he preferred to stay in bed and watch television. An observation of Resident #4 on 03/22/11 at 8:00 a.m. revealed the resident was again in bed, crying in pain. Resident #4 stated he was hurting all over, especially his right shoulder. The resident further stated he had requested pain medication an hour ago but had not received any. Resident #4 stated he was hurting "really bad." On 03/22/11 at 8:05 a.m., LVN S stated she had administered the pain medication [MEDICATION NAME] to Resident #4 "an hour ago." However, she had not "checked" back with the resident yet. LVN S and CNA T entered Resident #4's room, on 03/22/11 at 8:05 a.m. They assisted the resident to stand and began to straighten/change his bed linens. Resident #4 remained standing in a stooped position while LVN S provided hands on assistance for the resident to stand. Resident #4 stated and kept repeating, "I got to lay down. I got to lay down. I got to lay down." CNA T and LVN S continued to straighten the resident's bed linens. (An unoccupied wheelchair was noted in the room.) Resident #4's individual control drug record and MAR dated March 2011 were reviewed with LVN S. There was no documentation of any pain medication administered on 03/22/11. The last documented dose of pain medication was on 03/21/11 at 3:30 p.m. According to LVN S, she had administered one 10/325 mg tablet of [MEDICATION NAME] at 7:00 a.m. on 03/22/11. The nurse stated she forgot to sign it out and to document the administration of the medication, and Resident #4 had forgotten it had been administered. When queried at that time about notifying Resident #4's physician, LVN S stated the physician did not want any of his residents to receive routine pain medication. The surveyor queried the nurse about how she would address Resident #4's continued complaints of pain. The CN was present during this time and instructed LVN S to place Resident #4 on the 24-hour nursing report to be assessed every four hours for pain. Review of Resident #4's undated Admission Record revealed a current admission date of [DATE] with a [DIAGNOSES REDACTED]. Resident #4's most recent pain evaluation was dated 02/04/11 and reflected the resident was at risk for pain, was exhibiting symptoms of pain and medications were somewhat effective. The resident's MAR and consolidated physician orders [REDACTED]. [MEDICATION NAME] 10/325 mg one tablet orally every four hours as needed, [MEDICATION NAME] 7.5/325 mg one tablet orally every six hours as needed, Tylenol 325 mg two tablets orally every six hours as needed and one [MEDICATION NAME] topically once a day. An interview with the evening charge nurse, LVN N, on 03/22/11 at 3:30 p.m. revealed Resident #4 often complained of pain. An interview with CNA U and CNA T on 03/23/11 at 10:00 a.m. revealed they provided care for Resident #4. The CNAs stated the resident had been staying in bed and complaining of pain more often than usual. A care plan conference summary dated 03/10/11 reflected Resident #4 was spending more time in bed. Corresponding care plans reflected the problems of chronic shoulder pain, cognitive impairment and forgetfulness was addressed. The chronic pain care plan's only goal was the resident would develop effective coping strategies to help adapt to the pain. There were no interventions related to how the resident's pain would be controlled. The care plan did not address any effective or practical interventions to manage Resident #4's pain or the planning of care around the resident's periods of greatest comfort whenever possible. Non-pharmacological interventions were not addressed in the care plan. Resident #4's care plan was generic in nature and approaches/interventions included: monitoring and recording complaints and non verbal signs of pain; assessing the effects of pain on the resident's sleep, activity, self care and appetite; acknowledging to the resident his pain was unique/believable; and evaluating and recording the effectiveness of pain medications. Resident #4's most recent quarterly MDS assessment was dated 03/01/11 and reflected the resident had experienced pain occasionally, which made it difficult to sleep. The assessment further reflected the resident's day-to-day activities had been limited because of pain. This assessment reflected Resident #4 rated his worst pain as a ten on a scale of zero to ten (with zero being no pain and ten as the worst pain you can imagine). Review of Resident #4's entire clinical record revealed there was no documentation in the resident's clinical record related to the effectiveness of pain interventions. Documentation on the back of the MARs reflected only the resident's complaints of pain and the administration of pain medication. There was no documented assessment of the intensity of the pain or of the effectiveness of the medication administered. A new physician's orders [REDACTED]. An observation of Resident #4 on 03/23/11 at 8:20 a.m. revealed he was awake in bed and complaining of shoulder pain. RN V assessed the resident's pain intensity and administered two tablets of [MEDICATION NAME] according to the new orders. At 9:15 a.m. on 03/23/11, Resident #4 was observed asleep in bed. 2) The facility's policy/procedure (P/P) entitled "Pain Management" and dated as revised May 2009 was provided by the Administrator on 03/23/11 and identified as current. The P/P reflected in part; facility staff would implement the pain management program, including evaluation/re-evaluation of residents experiencing either acute or chronic pain. According to the P/P, residents would be assessed upon admission, readmission, quarterly, and with a significant change using section E of the Nursing Data Collection Tool. A. If pain was triggered, a pain management care plan would be initiated and would include pharmacological and non-pharmacological interventions for the resident's pain relief. B. Interventions should be specific for the resident. C. A "Pain Flow Sheet" would be initiated for ongoing documentation of as needed medication administration and effectiveness. 6. Consider a Pain Specialist consultation if pain management continues to be ineffective. The P/P further reflected pain should be documented as the fifth vital sign, and resident's assessed for the presence of pain during the morning, afternoon, evening medication pass and as needed. 3) On 03/23/11 at 9:30 a.m., the CN provided an action plan to address residents' pain/comfort. The action plan included re-educating nurses, review charts for pain assessments and requesting orders from physicians. On 03/23/11, the CN provided a list of 18 residents, who were identified as currently being on a pain management program. However the facility's form CMS 672 (Resident Census and Conditions of Residents) dated 03/22/11 and signed by the Administrator reflected 22 residents were on a pain management program. 4) Review of the facility's current wound care p/p diabetic ulcer, revealed the goal of treatment was to prevent loss of a limb. The policy reflected due to the complexity of the disease process and the variety of diabetic ulcers that may occur, a Physician, ET Nurse, Wound Care Specialist or a Podiatry consult is recommended for the management and treatment of [REDACTED]. The management of the diabetic ulcer included: 1) assessment: determine if they are ischemic or neuropathic... 2) correct causative factors - if able to and eliminate infection: a) Infection mandates ulcer debridement... c) Orthopedic consult, d) Culture and sensitivity with appropriate antibiotics.