Every finding on record at Avir at Caldwell

Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with residents care, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #1) of 8 residents reviewed for care plans. 1.The facility failed to ensure that Resident #1's comprehensive care plan was updated to address the lower leg fracture sustained in the fall, including the physician ordered immobilizer/brace, instructions for use of brace, monitoring and staff interventions specific to injury. 2. The facility failed to ensure Resident #1's comprehensive care plan addressed the diagnosis of major depressive disorder, including interventions related to ongoing psychiatric services follow-up, after the resident having recently been found with call light cord around their neck-and incident indicating a need for care planning around safety monitoring and self-harm risks. This failure could place residents at risk of not receiving necessary care or receiving incorrect care and services related to their identified needs to maintain or reach their highest practicable physical, mental, and psychosocial wellbeing. Findings included: Record review of Resident #1's Face sheet dated 08/20/2026 reflected a 68 -year-old female, admitted to the facility on [DATE]. Diagnoses included: Cerebral infraction (blood vessel supplying the brain is blocked cutting off oxygen, causing brain tissue to die), major severe depressive disorder recurrent without psychotic features (intense sadness, emptiness, and loss of interest in life), Hemiplegia and hemiparesis following cerebral infarction affecting dominate right side (complete paralysis or weakness on one side of the body that controls your main preferred side) , unspecified dementia without behavior disturbance memory loss and trouble thinking but isn't aggressive), generalized weakness, and dysphagia following cerebrovascular disease (difficulty or trouble swallowing after the cerebral infraction). Record review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 4 (severe cognitive impairment). Section D indicated the resident answered no to having little interest in doing things and no to feeling down, depressed, or hopeless. MDS Section GG indicated supervision or touching needed to eat, and with maximal assistance needed in oral hygiene, bathing and lower body dressing and personal hygiene. The MDS indicated Resident #1 required maximal assistance to roll, lay, lying to sit at side of bed, and could not attempt to sit to stand or walk 10 feet. Record review of Resident #1's Physician Orders dated 08/20/2026, reflected an order dated 10/29/2024, which stated, antidepressant medications Mirtazapine 15mg and was increased to Mirtazapine 45mg on 4/3/25 for major depressive disorder and then Mirtazapine 45mg was discontinued on 8/8/2026. Mirtazapine states on the orders one time a day related to major depressive disorder, without psychotic features. Paxil 30mg was ordered on 4/15/2026 and dose was increased to 40mg on 5/13/2026 for Depression. The MD orders indicated Paxil 50mg extended release was ordered on 7/23/2026 and is currently still effective for dementia without behavior disturbance (memory loss and trouble thinking but isn't aggressive), mood disturbance (shift of emotional state) and anxiety. Record Review of Resident #1's care plan dated 8/20/2026 reflected Focus area risk of falls related to unsteady gait, history of fall, muscle weakness, cognitive impairment, medication side effects, poor vision, and incontinence dated 6/27/2025 as initiated. Resident #1s care plan goal is to remain free from injury due to falls and used safety measures with support over the next 90 days initiated 6/27/2025 revied 6/22/2026. Interventions included assist with walking, transfers, or toileting based on ability, use non-skid socks, remind to use call light, and my care plan will be updated with any fall or change in condition - date initiated 6/27/2025. The Care plan indicated falls due to impaired visual function and referral to vision services and psychoactive drug use initiated on 9/27/2025 was revised on 2/5/2026. Goal initiated 9/27/2025 revised on 7/17/2026 included Resident #1 would be free of falls through review date. Care plan interventions initiated date of 9/27/2025 included resident was educated what do if falls, ensure resident is wearing appropriate footwear and nonskid socks and follow facility fall protocol. Record Review of Resident #1's care plan dated 8/20/2026 reflected focus area and diagnosis of depression and is receiving antidepressant with medication Zoloft initiated on 9/18/2024 and revision was on 6/27/2025. Care Plans Goals, or Interventions/Tasks related depression state Resident #1 will exhibit indicators of depression anxiety or sad mood less than daily initiated on 6/20/2024. Last revision was on 6/22/2026. Interventions include medications as ordered, monitor and report depression and to be treated by psych services for monitoring and management of depression. Record Review of Resident #1's Progress Notes reflected on 08/4/2026 at resident had fallen out of bed at 3:00pm and knee was swollen and pain with palpation and EMS was called for transport to emergency room. Resident #1s progress note dated 8/5/2026 indicated the resident had a femur fracture (broken leg) and was in the hospital. Progress notes dated 8/8/2026 indicated resident back to facility with L knee immobilizer/brace in place. Record Review of Resident #1's Progress on 7/20/2026 at 8:20 indicated that a report was received and Resident #1 had call light wrapped around neck and verbalized I need to kill myself. CNA removed cord and ensured safety and notified staff. Resident's hospice nurse and brother were informed and resident transferred to closest hospital. In an observation and interview with Resident #1 on 08/20/2026 at 04:00 PM, resident stated Im ok. Observed left lower leg immobilizer on a pillow and resident grimaces when sheet is moved off leg. On 8/21/2026 at 11:30am Resident #1 observed brace on and intact and resident states don't move that. Resident #1 states, Im fine and nods head. In an interview on 08/21/2026 at 11:30 am, LVN A stated I am not sure who updated the care plans. LVN A stated Resident #1 was in a good mood and that Resident #1's brace/immobilizer was handled by Hospice. LVN A said, skin checks around the brace were done but we did not remove the brace. LVN A said, Hospice staff inspected the skin under the brace when they give the resident a bath. LVN #1 said, I had heard about Resident #1 being depressed but had not seen it. In an interview with CNA A on 08/21/2026 at 11:35 am, CNA A stated, they were not sure who updated the care plans. CNA stated we used the Kardex which comes from the care plan and usually is updated with orders or whatever changes occur. CNA A said Resident #1's care plans should have been updated, but CNAs do not use care plans. CNA stated Resident #1 was cheerful and CNA knew Resident #1 before resident came to the nursing facility. CNA A said resident #1, let us roll resident, but we do not undo the brace/immobilizer. CNA A stated Resident #1's brace/immobilizer was handled by Hospice and if directions were not right on brace, it could harm the resident by rubbing skin. In an interview on 8/21/2026 at 2:31PM, the MDS Coordinator said normally either nurse on floor, the DON or MDS Coordinator updated the care plans for the facility. MDS Coordinator said, for example if a fall happens, the nurse does the assessment, and the facility would update the care plan to show any acute changes and add needed interventions. MDS Coordinator said all changes and interventions should be added to care plans. MDS Coordinator stated by Resident #1 not having information in resident's care plan about depressive episode on 7/20/2026 and then no information on the fracture with the leg immobilizer, resident is not getting best care. If updates are not in care plan, MDS coordinator said, things are missed. Facility plan is to get better at putting updated information in care plan. The MDS Coordinator said facility is updating all care plans to make sure plans match the residents. Corporate nurses and facility are working on care plans and updating ADLs/Kardex. Care plans information should go on the Kardex to show care for the residents. In an interview with DON at 5:33pm on 8/21/26 DON discussed orders received from the hospital or emergency room, when a resident discharged back to the facility. DON stated facility is currently making changes so that staff knows the updated orders. DON stated facility understands if the orders do not get back to the facility, it could cause issues. Harm could come to the resident if not getting updated care plan and updated orders. Facility and everyone treating resident needs to be aware of most up to date information. DON stated, that if a change in orders occurs, and plans are not updated, the resident may not get the medication or treatment needed. DON stated the facility has been updating the care plans, working on updating the entire facility. That is the plan going forward. DON states facility updated Resident 1's care plan today and trained staff regarding it. DON stated the care plan for Resident #1 was updated and brace/ lower leg of immobilizer and skin care around it was added on 8/21/2026. DON stated Resident #1 spirits have improved since call light cord issue. In an interview with administrator on 08/21/2026 at 5:45pm the administrator said after a hospitalization, the expectation of the facility is to get orders from the hospital, add them to facility's records in Point Click Care. That way anyone working at the facility can see the care they are supposed to do for residents. Administrator said orders needed to be reviewed, the next morning when a resident comes from hospital and immediately care plan should be updated. Administrator has gotten with the nursing staff to make sure that everything goes in the point-click care system. If this didn't happen, it could cause the resident harm by not getting the medicine or the treatments that they need. Administrator said, care plans are to be updated anytime a change in condition happens The administrator is aware system updates and care plans updates are slow and facility started a plan to correct that, but the plan has not gotten that far yet. Review of the facility's policy of comprehensive person-centered care plans dated 03/2022 reflected findings that a A comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility's policy states, reviews and updates of the care plan are done: when there is a significant change in resident's condition, when desired outcome is not met, when the resident has been readmitted from the facility from a hospital stay and at least quarterly in conjunction with the required MDS assessment.

Based on observations, interviews, and record review, the facility failed to ensure that a resident received necessary care and treatment in accordance with professional standards of practice for 1 of 7 residents (Resident #2) reviewed for quality of care. The facility failed to ensure staff administered/applied Nystatin powder to Resident #2's groin and buttocks per the physicians PRN order for a fungal/yeast skin condition, resulting in the resident developing redness and pain to the affected area. The facility failed to provide skin care and treatment consistent with professional standards of practice and Resident #2's assessment for skin breakdown, as identified on the resident's MDS, resulting in preventable skin irritation rather than maintaining the resident's highest practicable quality of life. Resident review of Resident #2's face sheet dated 08/20/2026 indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis included: Fusion of the spine, lumbar region (permanently welds bones so they heal solid); hypothyroidism (thyroid doesn't make enough thyroid hormone), type 2 diabetes mellitus without complications (body cannot use sugar from your food properly so builds up in blood), chronic kidney disease (kidneys lose the ability to clean waste out of your blood over time), ankylosing hyperostosis (excess bone tissue growing into soft tissue) and protein calorie malnutrition (not enough protein in diet). Record review of Resident quarterly MDS dated [DATE] indicated a BIMS score of 15 (cognitively intact) In MDS section M -skin conditions indicated resident was at risk for developing pressure, ulcers, or injuries, and none were currently present. Under functional limitations section GG indicated the resident used a wheelchair for mobility, and resident was totally dependent on toileting, lower body dressing and taking on or off footwear. Record review of resident #2 revised care plan dated 8/20/2026 and initiated 7/9/2026 reflected a focus area diabetes mellitus. The goal was the resident would be free of signs and symptoms of hyperglycemia, and the intervention was to check all body for breaks in skin and treat promptly as ordered by doctor date initiated 7/14/2026. Record review of Resident #2's physician order reflected an order dated 7/6/2026 resident may have pressure reduction mattress to minimize the risk of skin breakdown and an order dated 7/3/2026 for Nystatin powder apply to skin topically as needed for irritation apply twice a day. Record review of Resident #2's medication administration sheet showed nystatin powder applied to skin topically as needed for irritation. Apply twice a day starting 7/3/2026 at 12:30 PM. Review of the Medication Administration Record (MAR), treatment record, and/or other facility documentation revealed Nystatin was not administered/applied despite the resident exhibiting signs and symptoms for which the PRN medication was ordered. During an observation and interview on 08/20/2026 at 2:15p, observation of peri-care and lift transfer from chair to bed to have brief changed on Resident #2 with-CNA A and the ADON. CNA A cleaned around scrotum area and wet wipes. Red area noted and Resident #2 said it burns. Resident #2 was rolled slight pink/red macerated area observed to left buttocks area. CNA A applied barrier cream to area after cleaning with wipes. When questioned cream, CNA A stated it is just a barrier to protect the skin. A clean brief applied and resident moved up in bed. Resident #1 stated burning occurs when they wipe him. Resident #2 stated has had burning for a week and especially when they use wet wipes. During an interview on 8/20/2026 at 2:45pm, the ADON stated they aren't applying the Nystatin prn to resident #2. ADON investigates facility system and states I guess we should start using Nystatin- I don't think we knew that order was there. I guess we should try it for discomfort, itching, burning.Interview on 8/20/26 at 4:10pm DON stated we now called Nurse Practitioner and have a regular order to apply the nystatin BID (twice a day), and it will no longer be prn for Resident #2. Now he will get it twice a day every day. DON stated they should do prn medications as needed for the resident. I don't know why we didn't try it. DON stated, facility now put it on regular schedule, so it doesn't get missed. 8/20/2026 at 2:15pm Interview with CNA A stated, red area just started maybe last night, and now they are adding new treatment. CNA A stated, they use barrier cream and should report any changes in skin to the nurse. Interviewed LVN A 8/20/2026 at 12:56pm states resident's bottom was a little red this morning, I am not sure nystatin was ordered, was it prn before? LVN A said, I know there is barrier cream at bedside. On Resident #2 it is a small spot red, like a burn. LVN A stated, prn, we usually don't use prn unless it is bad. Resident #2 was still small area- macerated area so I wasn't concerned.

Based on observation, interviews, and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent fire affecting 44 of 44 Residents. The facility failed to implement effective interventions to prevent a second fire on [DATE] after a fire on [DATE] in the dining room. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:37 pm. While the IJ was removed on [DATE] at 3:45 pm, the facility remained out of compliance at a scope of widespread and severity level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for injury and even death. Findings included: Record review of Resident #1's face sheet dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including mild persistent asthma ( a person experiences symptoms such as wheezing, coughing, shortness of breath or chest tightness more than twice a week, but less often than every day), chronic obstructive pulmonary disease, unspecified ( a long-term lung disease that blocks airflow and makes it hard to breathe - the exact disease has not been specified), allergic rhinitis, unspecified and anxiety disorder, unspecified ( excessive fear or worry, feeling restless, and trouble focusing there is not enough detail for a precise label by a medical professional). Record review of Resident #1's Quarterly MDS dated [DATE] reflected Resident #1 had a BIMS score of 10 indicating her cognition was moderately impaired. Resident #1 was assessed to have diagnoses of anxiety, chronic obstructive pulmonary disease, and asthma. Record review of Resident #1's Comprehensive Care Plan, revised on [DATE] and on [DATE] reflected Resident #1 had an increased risk of impaired respiratory status related to her medical diagnosis of asthma. Interventions: Give medications as ordered, monitor/document any side effects and effectiveness. Give oxygen therapy as ordered by the physician. Monitor/ document/ report to MD as needed any signs or symptoms of respiratory infection: fever or chills, increase in sputum (document the amount , color and consistency), chest pain, increased difficulty breathing, increased coughing and wheezing. Record review of Resident #1's Physician Orders with a start date of [DATE] and revised on [DATE] reflected Resident #1 was ordered Ipratropium-Albuterol inhalation solution 0.5-2.5 (3) mg/3ml. Change nebulizer tubing and mask every night shift every Sunday. Interview on [DATE] at 8:45 a.m. the Administrator stated there was a fire in the dining room on [DATE] and no residents were in the dining room and there were not any residents injured. She stated Dietary Aide A was in the dining room and saw smoke and some flames coming from the light in the ceiling. The Administrator stated Dietary Aide A exited the dining room and walked to the Business Office Manager office and explained to the Business office Manager there was a fire in the dining room. The Business office Manager exited her office and told the Administrator there was a fire in the dining room. The Administrator stated she immediately exited her office and obtained the fire extinguisher and she walked down one side of the facility and the Business Office Manager walked down the other side of the facility as they were walking to the dining room in the back of the facility. She stated, I was yelling code red and the Business Office Manager was also yelling code red. The Administrator stated when they got to the dining room there was smoke in the dining room and some flames coming from the light in the ceiling. She stated the windows had been opened to get the smoke out. The Administrator stated they called the fire department on [DATE] and the fire was likely caused by the light bulbs being too high of wattage for the light fixture. She stated the fire was extinguished prior to fire department entering the facility and the administration staff completed staff training and a fire drill in response. She stated that the other light bulbs were not checked in the dining room after the fire on [DATE]. She stated there had not been another incident with fire since [DATE]. The Administrator stated Dietary Aide A did not yell code red when she was walking down the hall from the dining room to the Business Office Manager. She stated she did not know if the facility had an intercom system or not, she would check and report this information at a later time. The Administrator stated she expected anyone observing a fire to yell code red or use the intercom system if available in the facility. She stated Dietary Aide A did not follow the facility policy or protocol when she observed the fire in dining room. She stated the fire alarm did sound on [DATE] and a staff did pull the fire alarm. She did not recall the name of the staff that pulled the fire alarm. Interview on [DATE] at 8: 50 a.m. the Maintenance Supervisor stated, There was a fire on [DATE] in the dining room. He stated he was not in the facility when the fire occurred on [DATE]. The Maintenance Supervisor stated he received a phone call about the fire at the facility and he returned to the facility. He stated when he got to the facility the fire marshal and fire department had already left and he began to try and get the smoke out of the dining room. When asked about the investigation and what the fire marshal stated to the Administrator, the Maintenance Supervisor stated there were no wires burned and no indication any wires were on fire. He stated the wrong wattage bulbs were in the light fixture. He stated the wattage was 120 to 277 and it was supposed to be 277. He stated the breaker was 277. The Maintenance Supervisor stated it was approximately 1 year ago he had checked the wattage prior to the fire on [DATE]. He stated the fire department stated the lights failed and he had questions over the fire marshal's assessment. The Maintenance Supervisor did not elaborate on his questions over the fire marshal's assessment or the wattage of the bulbs or lights. He stated, I do not know where you received your [surveyor] information about the Fire Marshal and the light bulbs Record review with the Maintenance Supervisor and the Administrator on [DATE] at 8:55 a.m. of the intake information provided by the Administrator via phone reflected (Dietary Aide A) reported to Business Office Manager that there was a fire in the dining room light fixture. There were no residents in the room. The reporter ( Administrator) brought a fire extinguisher, and the office manager ( Business Office Manager) put the fire out. The fire department was called, and the fire marshal stated that it was not an electrical fire because the wires were not burnt. He ( Fire Marshal) suggested it was caused by a light bulb with a wattage too high for the light socket. Interview on [DATE] at 9:00 a.m. the Administrator stated she did call in the incident to HHSC via phone and the information reviewed with (surveyor) on the intake with was the information she gave over the phone. The Administrator verified what she called in to HHSC was her knowledge of the incident with the fire on [DATE]. Observation on [DATE] at 9:10 a.m. the dining room was in the back of the facility, and it was approximately 400 feet from the front of the facility. (Requested measurement from the Maintenance Supervisor of the distance between the dining room and the lobby where the offices of Administrator and Business Office Manager were located but did not get this measurement prior to exit on [DATE] and requested on [DATE], [DATE], and [DATE] from the Maintenance Supervisor). Observation on [DATE] at 9:15 a.m. the lights were off in the dining room, and the dining room doors were closed. There was a burned area around the light fixture where the fire occurred on [DATE]. In the corridor near the kitchen approximately 10 feet from the light fixture that burned on [DATE] there was another light fixture with a burned area on this light fixture. There was a fire extinguisher in the dining room. Interview on [DATE] at 9:19 a.m. the Maintenance Supervisor stated the dining room had been closed since [DATE]. He stated he kept the lights off in the dining room since [DATE]. The Maintenance Supervisor stated the area on the second light in the corridor next to the kitchen was a concern. He did not elaborate or respond to any further questions about the burn area on this light fixture or the fire extinguisher. Observation throughout the facility on [DATE] at 9:22 a.m. through 9:50 a.m. the fire extinguishers had white tags on them and were up to date on their inspection. There was one fire extinguisher not in the hallway near the Director of Nurses Office. Interview on [DATE] at 9:50 a.m. the Maintenance Supervisor stated he did not know where this fire extinguisher beside the Director of Nursing Office was located. He stated he did not recall seeing it in the dining room. Observation on [DATE] at 10:00 a.m. the fire extinguisher had not been removed from the dining room when made the observation on [DATE] at 9:15 a.m. Interview on [DATE] at 10:05 a.m. the Maintenance Supervisor stated he did not know who carried the fire extinguisher to the dining room. He stated the fire extinguisher had not been in the dining room since [DATE]. The Maintenance Supervisor stated he thought the Director of Nurses took the fire extinguisher in the dining room. When asked if the fire extinguisher had been in the dining room since [DATE] the Maintenance Supervisor did not respond to the question. He would not respond to any further questions about what happened after the fire on [DATE]. Observation on [DATE] at 10:15 a.m. of the fire alarm panel near the nurses' desk on 100 hall a Texas State Fire Marshal service record on the fire alarm panel revealed there was a red label ( a red label or red tag on a fire alarm panel in a nursing home is an emergency impairment designation. It officially indicates that the fire protection system- or a critical component of it- is inoperable, faulty, or completely compromised, meaning it will likely fail during a fire emergency) dated on [DATE] that was corrected on [DATE]. List of services were the following: replaced 5 smoke heads and 2 duct heads by a protection service company. In an interview on [DATE] at 10:45 a.m. the Administrator stated the fire extinguisher had not been in the dining room since [DATE]. She stated the facility did have another incident with smoke coming from the light in the corridor near the kitchen on [DATE]. She stated it was in the same area as the fire incident on [DATE]. The Administrator stated the facility did not complete an investigation of the smoke coming from light on [DATE]. The Administrator stated she nor the Maintenance Supervisor did not contact the following: Fire Department, HHSC, Electricians, or the Sprinkler/ Fire alarm company. She stated the facility was not expected to contact anyone due to there were no flames, only smoke coming from the light in the ceiling. The Administrator stated the Dietary Manager was coming out of the kitchen and smelled smoke and saw smoke coming from the ceiling. The Dietary Manager yelled code red, and the Director of Nurses obtained a fire extinguisher and pulled the pin from the extinguisher, however, it was not required to use the extinguisher. She stated there was not as much smoke in the dining room as there was on [DATE]. She stated there was very little smoke on [DATE]. She stated the dining room was closed for dinner on [DATE] until all the smoke was cleared and the dining room was cleaned. She stated the dining room has not been closed since [DATE]. She stated the dining room was reopened on [DATE] for meals and activities. The Administrator stated she did not know why the Maintenance Supervisor stated the dining room had been closed since [DATE]. She stated the dining room was closed after the incident on [DATE]. The Administrator stated it was not required to report any type of smoke coming from anywhere in the facility. She stated they were only required to report if there were flames. The Administrator stated the incident on [DATE] occurred approximately around 2:30 pm. She stated there were not any residents in the dining room during the incident on [DATE] and on [DATE]. She stated the facility had 24 hours to report any incident to HHSC per their protocol. She did not respond when asked why did she not reveal this information when asked if any other incidents occurred with smoke/ fire from the lights after [DATE] when she was asked this morning ( [DATE]). She stated the Maintenance Supervisor on [DATE] turned off the breaker in the dining room and the dining room was currently closed for the residents to do activities and for their meals. She denied there were additional follow-up with residents or the Maintenance Supervisor to prevent a new fire. The Administrator stated she was grateful there were no residents in the dining room on [DATE] and on [DATE]. She never reported if there was an intercom system in the facility. In an interview on [DATE] at 11:15 a.m. the Maintenance Supervisor stated he was not in the facility on [DATE] when smoke was seen in the dining room by the Dietary Manager. He stated he arrived at the facility approximately 45 minutes after receiving the phone call. He did not recall who called him about the incident on [DATE]. The Maintenance Supervisor stated when he arrived at the facility on [DATE] he did not recall the time) he observed very little smoke. He stated he did not call the fire department, electricians, or the sprinkler/ fire alarm company. He stated it was only smoke and no flames and he did not think anyone needed to be contacted. He stated he turned off the breaker in the dining room. The Maintenance Supervisor stated he followed the facility fire policy and protocol. The Maintenance Supervisor did not respond when asked why he did not report this incident when asked this morning ([DATE]) if there had been any further incidents with fire or lights after the incident on [DATE]. He stated he did not know why he stated the dining room had been closed since [DATE]. He stated this was not accurate information. The Maintenance Supervisor stated he got both incidents confused and he realized he only spoke of the one incident. He walked away from the interview and did not respond to any further questions. In an interview on [DATE] at 11:35 a.m. attempted to call the Dietary Manager and unable to leave message. In an interview on [DATE] at 11:40 a.m. attempted to call the Dietary Aide A and unable to leave message. In an interview on [DATE] at 12:42 p.m. the Fire Marshall stated he was concerned about a fire in the future at the facility. He stated he was concerned about the facility containing the fire on [DATE] due to the fire doors not being closed, the windows were opened and the fire system sprinklers did not go off in response to the fire which was concerning for future safety. He stated the facility was not to open windows or the fire doors until the fire department was in the facility to ensure the fire was contained. He stated the facility did everything wrong on [DATE] with the fire in the dining room. The Fire Marshal stated they were at the facility on [DATE] related to the fire sprinkler having a leak in the attic and water was coming from the attic into the hall. He stated the staff were not trained on fire safety preparedness. The Fire Marshal stated when he asked questions about what had been done prior to the fire department arrival no one could answer any questions of fire safety. He stated the fire department was not notified of the second fire on [DATE]. He was unable to respond to any further questions he had another phone call. In an interview on [DATE] at 1:30 p.m. the Maintenance Supervisor stated there was an incident on [DATE] with the sprinkler system. He stated this occurred around 10:00 pm or 11:00 pm on [DATE]. He stated he could not recall if he came to the facility on [DATE]. The Maintenance Supervisor stated there was a water leak from the sprinkler system. He stated he contacted the sprinkler system company, and they came out to work on the pipes. He stated at this time they are repaired. The Maintenance Supervisor stated he did not have a report of the sprinkler company coming out to repair the pipes from [DATE] and did not have any of the invoices of the companies that came to the facility after the fire on [DATE]. He stated he would contact the companies and request the invoices. The Maintenance Supervisor stated he did not know if this was reported to HHSC and was not aware of the protocol of reporting anything to HHSC. He stated the Administrator or the Director of Nurses usually did those types of reports. In an interview on [DATE] at 1:35 p.m. the Administrator stated there was an incident that occurred on [DATE] related to sprinkler system having a water leak in the attic. She stated it occurred on the night shift around 10:00 p.m. or 11:00 p.m. She stated she did not report this to HHSC. She stated residents were not hurt and she did not believe it was a reportable incident. The Administrator did not respond to any further questions about the incident on [DATE]. In an interview on [DATE] at 2:46 p.m. the Maintenance Supervisor stated the process he used to ensure there were no faulty light bulbs or light fixtures was to visually check them as needed. He stated he replaced the light bulbs when they died and checked the light fixtures as needed. The Maintenance Supervisor stated he did not call any electrician, fire department, or anyone after there was smoke near the light bulbs on [DATE]. He stated this was the second incident in the dining room where the light bulb was smoking and on [DATE] there was a small fire. He stated the fire department was not contacted. In an interview on [DATE] at 3:25 p.m. the Director of Nurses stated there were residents coming out of the dining room after she was notified of smoke coming from the light fixture on [DATE]. She stated staff was yelling code red. The Director of Nurses did not recall who was yelling code red. She stated on [DATE] when she was entering the dining room with the fire extinguisher there were 3 residents coming out of the dining room. She did not recall who the 3 residents were, but she would find out. The Director of Nurses stated no one completed any type of assessments on the 3 residents (Resident #1, Resident #2, or Resident #3) to ensure there were no emotional or physical complications. She stated these residents should have been assessed by nursing and the Social Worker. She stated the facility did not have an overhead intercom, however, they had an intercom system they can use that goes to each facility phone in the building. The Director of Nurses stated if anyone had used the phone intercom system and staff were at the nurses' desk or in their office they would have heard code red immediately and a staff would not have had to walk from the back of the facility to the front of the facility to report there was a fire in the dining room. She stated offices were nowhere near the dining room. She stated she did not have to use the fire extinguisher, and she had used a fire extinguisher at another facility during an in-service on fires. In an interview on [DATE] at 3:30 p.m. the Activity Director stated the names of the three residents (Resident #1, Resident #2, and Resident #3) who were playing dominoes in the dining room on [DATE] and were asked to leave the dining room area when there was smoke. In an interview on [DATE] at 3:38 p.m. Resident #1 stated she was in the dining room yesterday ( [DATE]) afternoon playing dominoes with two other residents ( Resident #2 and Resident #3). She stated she saw smoke, and someone asked them to leave the dining room. Resident #1 stated it did bother her because she uses a nebulizer for her asthma and she did have some difficulty with breathing yesterday ([DATE]) after she left the dining room. She stated she went to her room and used her nebulizer. Resident #1 stated no one assessed her after she was around the smoke in the dining room. Resident #1 stated, I hope someone came today and fixed the problem. This is the second time in a week we had a fire in the dining room. She stated she was not going back in the dining room until she knew it was safe. Resident #1 stated she felt safe in her room and other areas in the facility. In an interview on [DATE] at 3:45 p.m. Resident #2 stated there was smoke in the dining room yesterday ([DATE]). She stated someone asked them to leave the dining room. Resident #2 stated the smoke did not bother her, but it was not as bad as it was last week when there was a fire in the dining room. She stated she was in the dining room when the first fire started last week, and it was a lot worse than yesterday. She stated she hoped they got it fixed because she did not want to be around any smoke. She would not respond to the question if she felt safe at the facility. In an interview on [DATE] at 3:55 p.m. Resident #3 was at dialysis and unable to interview. Record review of the facility's Policy on Fire Policy and Procedure Code Red ( dated [DATE]) reflected To ensure the safety of the residents, this policy provides instructions for staff to know and follow in the event of a fire. Every employee is responsible to understand and follow these procedures. Procedure:Upon finding a fire staff must:Yell CODE RED and the location of the fire remove any residents in immediate danger.Remove any residents in immediate danger.Pull the alarm.Use the overhead paging system and announce, CODE RED and give a brief description of the location of the fire.Contain the fire by closing the doors and/or windows.Extinguish fire if possible.Close all the doors in the area, checking bathrooms.Close remaining windows and doors on the floor.Do NOT cross the fire area.Visitors will not be permitted to enter floors. They will be permitted to remain in the lobby until the fire emergency is cleared.Remember RACE: R- Rescue/remove resident from fire location and yell out CODE RED.Alarm: pull the fire alarm and tell someone to overhead page CODE REDContain: close all doors in the area.Extinguish: while removing residents from the area.Department Responsibilities: Action to be taken in your department when the Fire alarm has sounded: Nursing:1)Place resident in a non-involved room beyond the fire doors.2)Close all windows and doors.3)Clear all Halls.4) The Director of Nursing or Nursing Supervisor must respond to the fire floor and will be in charge in the absence of the Director of Maintenance and Administrator.5) Complete a head count per each unit, nursing supervisor collects and hands in head count to Director of Maintenance or designated personnel. Units/Halls:Nurse Managers/ Charge Nurse/Designee shall lead (non-fire unit) staff in taking head count, ensuring all safety on floor and then wait by nurse station for further instruction. Dietary:Turn off all appliances.Close the doors and windows, including main dining room.Should the dining room be occupied at the time of the alarm, the Dietary Staff ensures that residents stay in the dining room until an All Clear or Evacuation order is given and performs a head count of all residents.If there are no residents in the dining room, staff is to report to the nursing station. Laundry:Shut off machines. Dryers are to be shut off in cool down mode only.Close all doors, windows, and clear hallwayRemian in area for further instructions.If external evacuation order is given, staff must gather extra blankets from laundry to be used for residents to keep warm during external evacuation.If on floor delivering, you assist nursing on that floor. Housekeeping:Housekeeping employees report to the location of the fire to assist as necessary. Activities /Physical/ Occupational Therapy, Business Office, Social Worker, Medical Records, Central Supply and Hair Salon Barber:Residents that are in these rooms will stay. The highest authority staff person present is responsible for the head count and will assign a staff person to take the head count to the Director of Maintenance or Nursing Supervisor. Close all windows, doors and files following paged instructions.Secure the are you are in and then wait for instruction. Maintenance:8:00 a.m.- 5:30 p.m. Monday through Friday: the Director of Maintenance or Administrator is in charge until the Fire Department arrives, at which time, the fire chief has authority over all staff and visitors.8:00 p.m. - 8:00 a.m. Monday through Friday, Weekends and Holidays: the Nursing Supervisor is in charge until the Fire Department arrives.All Maintenance Staff will report to the fire scene and assist. Note: Any staff on halls will stay and assist on that hall. Nursing Supervisors:Will check the fire enunciator/ fire alert station and make a general announcement (3 times) Code Red status until further notice, when code status known, announce 3 times.Take resident calls on emergency basis. Calls from fire area will be priorityWill make backup call to the Fire Department giving building and hall location.Will announce exact location of fire when call received from staff. CODE RED status until further notice when code statis is not known announce 3 times.Actual fire only, call:AdministratorDirector of MaintenanceDirector of NursingSee Emergency Contact ListWill page All Clear when informed by person in charge. Department Heads:Any and All Department Heads on site during a fire drill or fire will report to the location of the fire to assist as needed. The Administrator was notified on [DATE] at 5:37 pm that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. An IJ template was provided and a POR was requested.Interview on [DATE] at 5:40 p.m. LVN B stated if she saw a fire she would tell the other staff on her halls there was a fire and to assist residents to somewhere else away from the fire. She stated she would call the Administrator on the phone and tell her there was a fire. LVN B stated she would yell fire to alert all the staff there was a fire. She stated she would get a fire extinguisher and attempt to put out the fire. LVN B stated she had never used a fire extinguisher and knew you had to pull something (she was unable to describe what to pull on the fire extinguisher). She would point the fire extinguisher toward the fire. LVN B stated there were two other things to do with the fire extinguisher, however, she was unable to recall them. She stated she had been in-serviced on fire extinguishers. LVN B stated the fire extinguisher was not demonstrated on how to use it. She stated the Maintenance Supervisor explained it verbally. LVN B stated she did not recall the last time she received in-service on how to use a fire extinguisher or the facility's policy on what to do when there is a fire.Interview on [DATE] at 5:50 p.m. CNA C stated if she saw a fire she would yell fire and would assist the residents to their rooms and close the residents' doors. She stated if the fire was near these residents' rooms she would assist the residents somewhere else in the facility. She did not respond when asked where she would assist the residents to if the fire was near the residents' rooms. CNA C stated she would wait and for further directions from Administer on what to do after she moved the residents. She stated she had been in-serviced on what to do if there was a fire and participated in fire drills, however, she did not recall the date of these in-services. She stated the Maintenance Supervisor gave the in-services and explained how to use fire extinguisher. CNA C stated the Maintenance Supervisor did not demonstrate how to use a fire extinguisher. She stated there was something about RACE you followed when there was a fire. CNA C stated she needed to check on a resident and did not finish the interview.Interview on [DATE] at 6:05 p.m. LVN D stated if there was a fire in the facility she would run and check all the doors in residents' rooms and she would close the doors. She stated she would yell fire and would find a fire extinguisher. LVN D stated she could not describe how to use a fire extinguisher. She stated she had never used a fire extinguisher, and she heard the Maintenance Supervisor explain how to use it and never seen a demonstration on how to use a fire extinguisher. LVN D stated the administration would call the fire department and if administration was not in the facility she would ask someone to call the fire department while she was closing the doors to residents' rooms. She stated if the fire was around residents' rooms she would assist the residents to another area in the facility. She did not specify the location she would assist the residents to in the facility. LVN D stated she was in-serviced on what to do if there was a fire within the past few weeks. She did not remember the date of the in-service. She stated the Maintenance Supervisor discussed about PASS when using fire extinguisher. LVN D stated she was to pull something on the extinguisher. She stated she could not recall what she was expected to pull on the fire extinguisher. She stated she was to aim the extinguisher at the fire. LVN D stated this was all she could recall on what to do when there is a fire. Interview on [DATE] at 6:16 p.m. CNA E stated she had been trained by the Maintenance Supervisor on fires in the facility. She stated the last time she received training on fires was approximately 1 or 2 weeks prior to today ([DATE]). CNA E stated if she saw a fire she would call the Fire Department and Director of Nurses. She stated she would pull the fire alarm and would check the residents' rooms and close the residents' doors to their rooms. CNA E stated she would obtain a fire extinguisher and use the extinguisher to contain the fire. She stated she had not used a fire extinguisher , however, the Maintenance Supervisor verbally explained how to use a fire extinguisher. CNA E stated she would evacuate the residents to the facility's parking lot. CNA E did not respond to any further questions about fires in the facility.Interview on [DATE] at 6:26 p.m. RN Charge Nurse F stated if he witnessed a fire in the facility he would follow the RACE guide such as R: rescue residents such as assisting the residents away from the fire ( he did not elaborate where he would assist the residents in the facility). A - Activate the fire alarm and call 911. He would obtain the fire extinguisher and evacuate all the residents ( he did not specify where he would assist the residents when he was evacuating). He stated he has not participated in a fire drill within the past 3 months. He stated he had been in-serviced on what to do if there was a fire in the facility within approximately 1 or 2 weeks ago. RN Charge Nurse F stated he had never used a fire extinguisher or observed anyone demonstrating how to use fire extinguisher. He stated the Maintenance Supervisor has explained it verbally.Interview on [DATE] at 6:40 p.m. LVN G stated she would investigate where the fire was located and would rescue the residents away from the fire (she did not state where she would assist the residents to in the facility). LVN G stated she would yell fire and then she would call 911. LVN G stated she would assist the ambulatory residents first, then the residents in the wheelchairs, and last she would assist residents in their beds. When asked where these residents would be evacuated to in the facility, LVN G did not respond to the question. LVN G stated once the residents were evacuated she would get

Based on interview and record review; the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (Including the State Agency) for incidents involving the environment for 44 of 44 residents.The facility failed to report smoke coming from the light fixture on 07/28/2026 in the dining room and assess Resident #1 after the smoke in the dining room on 07/28/2026. This failure could place residents at risk for injury or even death. Findings included:In an interview on 07/29/2026 at 10:45 a.m. the Administrator stated the facility did have an incident with smoke coming from the light in the corridor near the kitchen on 07/28/2026. She stated it was in the same area as the fire incident on 07/22/2026. The Administrator stated the facility did not complete an investigation of the smoke coming from light on 07/28/2026. The Administrator stated she or the Maintenance Supervisor did not contact the following: Fire Department, HHSC, Electricians, or the Sprinkler/ Fire alarm company. She stated the facility was not expected to contact anyone due to there were no flames, only smoke coming from the light in the ceiling. The Administrator stated the Dietary Manager was coming out of the kitchen and smelled smoke and saw smoke coming from the ceiling. The Dietary Manager yelled code red, and the Director of Nurses obtained fire extinguisher and pulled the pin from the extinguisher, however, was not required to use the extinguisher. She stated there was not as much smoke in the dining room as there was on 07/22/2026. She stated there was very little smoke on 07/28/2026. She stated the dining room was closed for dinner on 07/22/2026 until all the smoke was cleared and the dining room was cleaned. She stated the dining room has not been closed since 07/22/2026. She stated the dining room was reopened on 07/23/2026 for meals and activities. The Administrator stated she did not know why the Maintenance Supervisor stated the dining room had been closed since 07/22/2026. She stated the dining room was closed after the incident on 07/28/2026. The Administrator stated it was not required to report any type of smoke coming from anywhere in the facility. She stated they were only required to report if there were flames. The Administrator stated the incident on 07/28/2026 occurred approximately around 2:30 pm. She stated there were not any residents in the dining room during the incident on 07/22/2026 and on 07/28/2026. She stated the facility had 24 hours to report any incident to HHSC per their protocol. She did not respond when asked why did she not reveal this information when asked if any other incidents occurred with smoke/ fire from the lights after 07/22/2026 when she was asked this morning (07/29/2026). She stated the Maintenance Supervisor on 07/28/2026 turned off the breaker in the dining room and the dining room was currently closed for the residents to do activities and for their meals. She denied there was additional follow-up with residents or the maintenance director to prevent a new fire. The Administrator stated she was grateful there were no residents in the dining room on 07/22/2026 and on 07/28/2026 In an interview on 07/29/2026 at 3:38 p.m. Resident #1 stated she was in the dining room yesterday ( 07/28/2026) afternoon playing dominoes with two other residents (Resident #2 and Resident #3). She stated she saw smoke, and someone asked them to leave the dining room. Resident #1 stated it did bother her because she used a nebulizer for her asthma and she did have some difficulty with breathing yesterday (07/28/2026) after she left the dining room. She stated she went to her room and used her nebulizer. Resident#1 stated no one assessed her after she was around the smoke in the dining room. Resident #1 stated I hope someone came today and fixed the problem. This is the second time in a week we had a fire in the dining room. She stated she was not going back in the dining room until she knew it was safe. Resident #1 stated she felt safe in her room and other areas in the facility.Requested policy and protocol of reporting events to HHSC via email to the Administrator on 07/31/2026 at 2:54 p.m. The Administrator responded via email on 07/31/2026 at 3:36 p.m. We do not have a reporting policy or protocol. We follow the guidance provided in HHSC provider letter. Long-term care regulations provider letter for NF's ( Nursing Facilities) on abuse, neglect, exploitation, misappropriation of resident property, and other incidents that a nursing facility must report to the health and human services commission. The Administrator did not provide the provider letter.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained free of accidents hazards as was possible for one of two housekeeping carts (Housekeeping Cart #1) reviewed for hazards.The facility failed to ensure Housekeeping Cart #1, with chemicals inside the compartments, was locked when unsupervised. This failure could place residents at risk for injuries, illness, and hospitalization. Findings included: During an observation on 06/20/2026 at 8:15 a.m., Housekeeping Cart #1 was located on 100 hall in front of room [ROOM NUMBER]. Observation reflected the compartment where chemicals were stored was not locked and contained micro-kill bleach, disinfectant cleaner, and two bottles filled with chemicals without a label on the bottles. Observation reflected Housekeeper A was not standing near the housekeeping cart. She exited room [ROOM NUMBER] at 8:20 a.m. and walked to the housekeeping cart and was standing beside the cart. There were no residents or staff in the hallway when observation was made of Housekeeping Cart #1 unlocked.During an interview on 06/20/2026 at 8:19 a.m., Housekeeper A stated Housekeeping Cart #1 was expected to be locked anytime the housekeeper walked away from the cart. Housekeeper A stated she could not see Housekeeping Cart #1 from inside room [ROOM NUMBER] with the door partially closed. She stated there was a possibility that if a resident drank some of the chemicals the resident may become sick with stomach issues or have an allergic reaction. She stated it was possible a resident may need to be evaluated at the hospital. Housekeeper A stated all chemicals were required to have labels on the bottles. She stated she did have a key to the housekeeping cart.During an interview on 06/20/2026 at 3:30 p.m., the Housekeeping Supervisor stated all bottles with chemicals were expected to be labeled. He stated if a resident swallowed the chemical the nurse would not know what type of care to give the resident without knowing the name of the chemical. He stated all housekeeping carts were expected to be locked anytime the housekeeper was not standing in front of the cart. The Housekeeping Supervisor stated if a resident ingested some chemicals there was a potential for an allergic reaction, such as burning their throat, stomach and may need to be assessed at the hospital. He stated all housekeeping staff were in-serviced on locking housekeeping carts. He stated there was a possibility that if a resident spilled a chemical on their skin it may cause irritation to the skin. During an interview on 6/20/2026 at 4:00 p.m., the Administrator stated he expected the housekeeping cart to be locked at all times when the housekeeper was not obtaining an item from the housekeeping cart. She stated all chemical bottles were expected to be labeled with the correct chemical name and directions how to use the chemical. The Administrator stated all housekeeping staff had been in-serviced on locking the housekeeping carts. She stated she checked with the nursing staff and there were not any residents who wandered on the 100 hall. The Administrator stated if a resident drank a chemical there was a possibility a resident may become ill with nausea and vomiting. She stated there was a possibility a resident may need to be transported to the emergency room for further evaluation. Record review of the facility policy titled, Facilities Hazardous Areas, Devices and Equipment, dated 2001, reflected, All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. A hazard is defined as anything in the environment that has the potential to cause injury or illness such as access to toxic chemicals. Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous.

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 permitted only authorized personnel to have access to 1 of 3 medication carts (Medication Cart #1) reviewed for drug storage and labeling.The facility failed to ensure Medication Cart #1, was locked, medications secured, and not accessible to other staff, residents, or visitors.This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications. Findings included:During an observation of the 300 hall Nurses Station on 06/21/2026 at 7:34 a.m., revealed Medication Cart #1 was facing toward the hall area near the nurses' station. Observation reflected there was not any staff in the hall or near the nurse's station. Med Aide B exited a room approximately 7:45 a.m. on 300 hall and walked toward the nurse's station.During an interview with LVN B on 06/20/2026 at 7:50 a.m., he stated he was trained on medication storage. He stated the policy was staff must lock the medication carts any time the nurse walked away from the medication cart. He stated the nurse or medication aide who was working on the cart was responsible for locking the medication cart. He stated if the staff left the medication cart unlocked and unattended a resident could get into the medication cart and take medication that did not belong to them. LVN B stated everyone monitored to ensure the medication carts were locked. He stated he had been in-serviced on locking medication cart; however, he did not recall the date or time.During an interview with the Director of Nurses on 06/20/2026 at 3:00 p.m., she stated all medication carts were expected to be locked when the med-aide or nurse was not standing in front of the medication cart. She stated the nurse or the medication aide who was on the medication cart was responsible for ensuring the medication cart was locked. She stated if the medication cart was left unlocked and unattended a resident could get into the medication cart and take medications. The Director of Nurses stated leadership monitored to ensure staff locked the medication cart. She stated nurse leadership were to monitor by doing observations and in-service training. She stated she did not know why LVN B left the medication carts unlocked.During an interview with the Administrator on 06/20/2026 at 4:00 p.m., She stated the medication cart was to always be locked. She stated no matter what time of day the medication cart should be locked. She stated the nurse or medication aide who was assigned the medication cart were responsible for ensuring the medication cart was locked. The Administrator stated if the medication cart was left unlocked and unattended a resident could take medication that was harmful to them or an employee could steal medications. She stated the DON or any management should be monitoring, by observations, to ensure the staff were locking the medication cart. She said she did not know why LVN B left the medication cart unlocked.Record review of the Facility's Policy titled, Medication Labeling and Storage, revised 2023 reflected, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others

Based on observation, interview and record review the facility failed to ensure residents were free from verbal abuse from staff for 1 of 5 residents (Residents #1) reviewed for verbal abuse. The facility failed to ensure Resident #1 was protected from verbal abuse on 04/25/2026 when CNA A confronted Resident #1 and proceeded to yell and threaten her after Resident #1 reported her for sleeping at the nurse's station. This failure could place residents at risk of fear, depression, intimidation, and diminished quality of life.Findings included: Review of Resident #1's face sheet dated 06/10/2026 reflected a [AGE] year old female admitted to the facility on [DATE] with the following diagnoses: major depressive disorder (A mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts.) and anxiety (Fear characterized by behavioral disturbances.). Review of Resident #1's quarterly MDS assessment dated [DATE] reflected Resident #1 was assessed to have a BIMS score of 13 indicating she was cognitively intact. Resident #1 was assessed to not have any behaviors. Review of Resident #1's comprehensive care plan reflected no entries related to the allegations of verbal abuse or her psychological diagnoses. Review of Resident #1's psychiatry progress notes dated 04/01/2026 reflected the resident was seeing psychiatry, the notes reflected the resident had no behaviors and was diagnosed with major depressive disorder and post-traumatic stress disorder. Review of the facility's self-report dated 04/25/2026 at 10:30 pm reflected the facility first learned of the allegation of verbal abuse at approximately 7:40 pm on 04/25/2026. The reported reflected Resident #1 went to the nurses' station to ask for medication. CNA A. Had her head wrapped up and head on the desk. Resident #1 stood there for a min. Then RN D came down the hallway and asked resident if she needed something. Resident then went back to bed. Resident #1 told RN D that CNA A was asleep at the nurses' station last night. RN D told CNA A that she cannot sleep at the nurses' station or while on duty. CNA A then went down to Resident #1's room and proceeded to yell at her and tell her she is a liar for saying she was asleep. CNA A told her, I don't like you and kept yelling. RN D came by and told CNA A to leave the area. RN D then called Director of Nurses. Further review of the facility's investigation report reflected the AP (CNA A) denied the allegations. The facility confirmed the allegations and terminated the AP. Interview attempts for RN D on 06/10/2206 at 10:30 am and 2:30 pm were unsuccessful. Review of RN D's written statement dated 04/26/2026 reflected During the overnight shift on April 24, 2026, I observed CNA A take a blanket and fell asleep at the Nurse's Station. As call lights were activated, she remained unresponsive, forcing me to interrupt my own duties to wake her and request that she attend to the residents. When I addressed this, CNA A questioned why I could not handle the calls myself. I informed her that I was occupied with my own responsibilities and that it was unreasonable to expect me to perform both of our roles while she slept. CNA A remained uncooperative for the remainder of the shift, continuing to ignore call lights and requiring repeated prompts to fulfill her basic job requirements. I am submitting this statement to formally document these lapses in resident care, professional conduct, and workplace accountability. Signed by RN D. Review of Resident #1's nursing progress note dated 04/25/2026 at 6:30 pm reflected I promptly presented to the facility to assess the situation. The alleged perpetrator was instructed to remain in the parking lot of the facility until receiving further instructions. She was notified of her suspension pending the investigation. Upon arrival, I assessed the resident and engaged in conversation to evaluate her condition and well-being. The resident was alert and able to provide her account of the events. She reported that the CNA had been pointing her finger in her face and yelling at her. The resident stated the CNA told her that she was a liar, that she was not asleep, and questioned why she would lie to get her in trouble. The resident further reported the CNA stated she did not like her anyway and said, 'I don't need this job, I work at the school full time. During the assessment, the resident was noted to be tearful; however, she stated that she was okay overall. She was asked if she felt safe in the facility, to which she responded that she did feel safe. The resident expressed that she did not wish for disciplinary action against the staff member abut requested that the CNA no longer be assigned to her hall. She also stated that she would like an apology from the CNA and indicated that this would be acceptable to her. A full physical assessment was completed, and no injuries or signs of physical harm were observed. Safe surveys were conducted on all residents on that unit. Residents that were awake had no complaints and stated feeling safe in the facility. Nursing progress note was signed by the DON. In an observation and interview on 06/11/2026 at 9:45 am Resident #1 was in her room alert and oriented. Resident #1 stated she has not seen CNA A since the incident she state that the facility fired her. Resident #1 stated she went to nurses' station to ask for medication and CNA A was sleeping at the nurses' station. Resident #1 later told the night nurse about it (RN D) stated he is a PRN staff. Resident #1 stated CNA A confronted her yelling and threating her, she stated she got right in her face. She stated the incident did trigger her PTSD, she stated she was in a bad relationship with her family member and the yelling and aggression triggered her. She stated CNA A had not acted like that before she was grouchy but not like that. Resident #1 stated she felt safe at the facility and was happy with how staff handled the situation. She stated her neighbor Resident #2 was a witness to the incident, she stated he was in the hospital. Interview attempt with the witness Resident #2 on 06/10/2026 at 9:30am was unsuccessful due to Resident #2 was in the hospital. Review of Resident #2's statement provided to the facility on [DATE] reflected I was down the hall from my room and heard shouting. It went on for quite a while, probably 7-10 minutes and at one point I felt the need to get closer in case it became physical. I cannot do anything, but I can get in the way. I heard the staff member yelling at my neighbor, and it was terrible. I felt bad for my neighbor because she didn't deserve it. The staff member was saying that she wasn't asleep and calling her a liar. She basically told her she didn't need this job. I talked to my neighbor afterwards and she was upset and crying. In an interview on 06/10/2026 at 10:35 am CNA A stated she went to Resident #1 and ask her why she told the nurse that she was sleeping. CNA A stated she told the resident she saw her when she went to get ice so how can you say I was sleeping. She stated the resident said because she had a blanket over her head and CNA A told her she was not sleeping. She stated she told Resident #1 that she was just mad at her because she would not talk to her after she told people she was stealing snacks. CNA A stated that was when she knew she was not someone who did not tell the truth. CNA A denied calling the resident a liar or any other names. She stated the resident called her a Bi**h. CNA A stated she was not yelling at the resident that she talked loudly and had a loud tone. CNA A denied getting in the resident's face. CNA A stated no confronting a resident was not an appropriate response, and she should have just talked to the supervisor. CNA A stated she was trained regarding resident behavior and de-escalation of situations and stated that confronting the resident was not a de-escalation but an escalation of the situation. She stated she did not know the incident would go this way stated at the time did not know confronting the resident was bad. CNA A stated she was trained on abuse and neglect. Review of the statement provided to the facility from CNA A on 04/27/2026 sent via email reflected On April 25, 2026, at approximately 7:30 p.m., during my shift, I had an interaction with a resident in the hallway. I approached the resident to ask about a statement she made to another staff member. My intent was to clarify what she said. During this conversation, the resident became upset, called me a bi**h, and stated that I was asleep. She then changed her statement and said she thought I was asleep because I had a blanket around me. She also stated that when people come into her room, they sometimes think she is asleep. I responded by asking her to clarify what she meant and stated that I had just seen her sit down after getting ice, which had only been a few minutes prior. My tone remained calm, and I did not use any profanity or abusive language at any time. I did not verbally abuse the resident. This statement is provided to document the interaction as it occurred. Review of the facility's termination record of CNA A reflected that she was terminated on 05/13/2026 that her last day worked was 04/25/2026. The documented reflected that she was not eligible for rehire and was terminated due to misconduct. In an interview on 06/10/2026 at 1:30 PM the Administrator stated the findings of the abuse investigation for Resident #1 was confirmed and CNA A was terminated. She stated the facility had a zero tolerance policy regarding abuse of residents. Review of the facility's policy on abuse, neglect, exploitation and misappropriation prevention program dated April 2021 reflected Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the residents' symptoms.Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.6. Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. 7.Implement measures to address factors that may lead to abusive situations, for example: a. adequately prepare staff for caregiving responsibilities. b. provide staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation. c. instruct staff regarding appropriate ways to address interpersonal conflicts; and d. help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts. Further review of the facility's policy reflected an abuse, neglect, and exploitation statement which reflected In keeping with the facility belief that the residents are the most important persons and are the reasons for our Company's existence, the facility observes the following with respect to treatment of residents, Residents of the facility shall not be subject to abuse, neglect or exploitations by company employees, and if a resident accuses an employee of abuse certain procedures will be followed (sec Abuse Policy in the facility Policies and Procedures). Abuse.shall be defined as follows: a) The negligent willful infliction of injury unreasonable confinement, intimidation, or cruel punishment with resulting physical or emotional harm or pain to an elderly or disabled person by the person's caretaker, family member, or other individual who has an ongoing relationship with the person.

Based on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive care plan that describes the services that are to be furnished to maintain the resident's highest practicable physical, mental, and psychological well-being for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1 comprehensive care plan reflected a plan of care for her diagnoses of PTSD and major depressive disorder that included medication management and psychiatric services. This failure could place residents at risk of increased symptoms, lack of treatment or diminished quality of life.Findings included: Review of Resident #1's face sheet dated 06/10/2026 reflected a [AGE] year old female admitted to the facility on [DATE] with the following diagnoses: major depressive disorder (A mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts.) and anxiety (Fear characterized by behavioral disturbances.). Review of Resident #1's quarterly MDS assessment dated [DATE] reflected Resident #1 was assessed to have a BIMS score of 13 indicating she was cognitively intact. Resident #1 was assessed to not have any behaviors. Resident #1 was assessed to have diagnosis of anxiety disorder and depression. Review of Resident #1's consolidated physician orders dated 06/10/2026 reflected an order dated 05/13/2026 for Lexapro (an antidepressant) and trazodone HCL dated 05/13/2026 for major depressive disorder. Review of Resident #1's psychiatry progress notes dated 04/01/2026 reflected the resident was seeing psychiatry, the notes reflected the resident had no behaviors and was diagnosed with major depressive disorder and post-traumatic stress disorder. Review of Resident #1's comprehensive care plan reflected no entries related to her psychological diagnosis of PTSD or major depression, her antidepressant medication use or her treatment with psych services. In an observation and interview on 06/11/2026 at 9:45 am Resident #1 was in her room alert and oriented. Resident #1 stated she had PTSD from a bad relationship with her family, and the yelling and aggressive behaviors were a trigger for her. She stated she was seeing psych services. In an interview on 06/10/2026 at 11:52 am the MDS RN stated she was responsible for care plans. She stated after reviewing Resident #1's care plan she stated Resident #1 was not care planned for her diagnoses or treatment of her psychological conditions of major depression or PTSD and should be. She stated she was new at the facility but had missed her being diagnosed with PTSD. She stated she would update Resident #1 care plan to include these areas. In an interview on 06/10/2026 at 2:12 pm the RNC stated that residents' care plans should be updated to include all their problems and should be updated when their needs change to accurately reflected the residents' needs to ensure their needs are met. Review of the facility's policy care plans, comprehensive person-centered dated March 2022 reflected A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including:. any specialized services to be provided as a result of recommendations; and which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions.

Based on interview and record review, the facility failed to provide an ongoing activity program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 2 (Residents #28 and #40) of 10 residents reviewed for activities. The facility failed to provide activities for Resident #28 and Resident #40 for the months of November and December 2025.This failure could place residents at risks of boredom, depression, behavior, diminished quality of life and decreased cognitive function.Findings included:Review of Resident #28's face sheet, dated 01/07/2026, reflected a [AGE] year-old male admitted on [DATE] with a diagnosis of major depressive disorder, single episode, severe without psychotic features (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep or feelings of guilt without behaviors), osteoarthritis, unspecified site ( gradual loss of joint cartilage, but the exact joint was not specified), and generalized muscle weakness (feeling of lack of strength throughout most of your body, requiring extra effort to move arms, legs, and other muscles, often accompanied by fatigue).Review of Resident #28's Annual MDS, dated [DATE], reflected Resident #28 had a BIMS score of 15 indicated his cognition was intact. Resident #28's activity preferences were the following: doing favorite activities, keeping up with the news, going outside to get fresh air.Review of Resident #28's Quarterly MDS, dated [DATE], reflected Resident #28 had a BIMS score of 14 indicating his cognition was intact. Resident #28 had feelings of feeling down, depressed, or hopeless.Review of Resident #28's Comprehensive Care Plan, dated 12/14/2025, reflected the activity care plan was initiated on 05/14/2025 and reviewed on 12/14/2025. Resident #28 did not want to attend group activities. He enjoyed working on puzzles in his room and visit with other residents. He also enjoyed watching sports on television. Interventions: help Resident #28 glue his puzzles.Record Review on 01/06/2026 at 11:00 a.m. of the activity participation records for the year 2025 and 2026 reflected there were not any participation records for Resident #28 for the months of November 2025, December 2025, and from January 1, 2026, through January 6, 2026.Observation and interview on 01/06/2026 at 7:50 a.m., revealed Resident #28 was sitting in his room sitting in his wheelchair watching news on television. He stated he was bored a lot and there was not a lot of activities to do in the facility. Resident #28 stated he wished there were more activities. He stated he was not sad. Resident #28 stated he wished there was more things for men to do in the facility as a group especially at night and on weekends. He stated it would be fun if the men could get together and watch football on television somewhere and have snacks. Resident #28 stated no one had discussed his activity preferences with him in a long time. He stated he enjoyed doing jigsaw puzzles in his room, but that activity was getting old, and he wanted to do something new. Resident #28 stated he would preferred to discuss options of what activities were available and have input on group activities. He stated he did not always go to Resident Council. He stated he felt more comfortable speaking about his activities preferences in private with staff instead in a group. Resident #28 denied being depressed or sad during the times he was not attending group activities. He was smiling and stated he enjoyed living at the facility. Record review of Resident #40's face sheet, dated 01/07/2026, reflected a [AGE] year-old female resident admitted on [DATE] with the following diagnoses major depressive disorder, recurrent severe without psychotic features (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep or feelings of guilt without behaviors), muscle weakness (feeling of lack of strength throughout most of your body, requiring extra effort to move arms, legs, and other muscles, often accompanied by fatigue), and Alzheimer's disease ( a progressive brain disorder, that slowly destroys memory, thinking, and reasoning skills, eventually making it hard to perform simple tasks).Record review of Resident #40's Annual MDS Assessment, dated 01/13/2025, reflected Resident #40 had a BIMS score of 13 indicating her cognition was intact. The following activities were Resident #40's preferences: doing things in groups of people, doing favorite activities, participating in religious services or practices, listening to music, having books or magazines to read, and going outside to get fresh air when the weather was good.Record review of Resident #40's Quarterly MDS Assessment, dated 11/14/2025, reflected Resident #40 had a BIMS score of 15 indicating her cognition was intact. She had diagnoses of depression and Alzheimer's disease.Record review of Resident #40's Comprehensive Care Plan, dated 11/16/2025, reflected the activity care plan initiated on 01/23/2024 Resident #40 was active in groups and independent activities. Her activity preferences were church, music, Bible study, crafts, and food related activities. She enjoyed attending mass and receiving communion on Sundays. Interventions were revised on 10/01/2025: Keep dominoes available to play independently. Will provide appropriate activities.Observation and interview on 01/06/2026 at 8:20 a.m. revealed Resident #40 was sitting in her room watching the news on television. She was smiling during conversation. She stated there were not many activities in the facility. She stated she was bored, and she was not aware of any activities in the past month. Resident #40 stated there was someone who came by her room approximately two times a month and gave her communion. She stated she preferred to attend mass. Resident #40 stated she wished there was a mass church service provided on Sundays. Resident #40 stated no one had interviewed her about her activity preferences over 4 months. She stated her activity preferences had changed, and she would prefer to speak with someone about her new activity preferences. Resident #40 stated she did not want to discuss her activity preferences in a group meeting, she preferred for someone to come to her room and discuss her activity preferences with her in private. She stated she did become bored during the week and on weekends. Resident #40 stated she did receive visits from family, however, she wanted to do something to keep active and to help prevent her becoming forgetful. She denied being sad or depressed when she became bored. Resident #40 stated she watched catholic church on television, and she never became depressed.Record Review of the activity participation records on 01/06/2026 at 11:00 a.m. for the year 2025 reflected there were not any participation records for Resident #40 for the months of November 2025, December 2025 and from January 1, 2026, thru January 6, 2026.Interview on 01/08/2026 at 11:05 a.m. the Activity Director stated she did not have any participation records for Resident #28 or Resident #40 during the months of November 2025, December 2025 and from January 1, 2026, thru January 6, 2026. She stated she began working at the facility 12/08/2025. She stated she received training through an online activity course and completed her training yesterday on 01/07/2026. The Activity Director stated she was in the process of interviewing all the residents in the facility related to their activity preferences. She stated there were 47 residents in the facility, and she did not have time to finish the interviews within the past few weeks. The Activity Director stated she was not aware Resident #28 and Resident #40 were bored and did not feel there was enough activities in the facility. She stated if a resident was not receiving activities there was a possibility a resident may become depressed, have a decrease quality of life and become isolated in their room. She stated she did provide jigsaw puzzles for Resident # 28. The Activity Director stated she was expected to document resident's independent activities and group activity involvement on participation records. She stated she did provide some activities during months of December 2025 and January 2026, however, she did not remember if she invited Resident #28 or Resident #40 to the activity programs. Interview on 01/08/2026 11:45 a.m. the Administrator stated she expected a variety of activities to be provided for all residents. She stated each resident's activity preference needed to be assessed, and each resident's activity was expected to be planned according to their activity preferences. She stated activities such as independent, in-room, and/or group activities were to be documented on participation records. The Administrator stated she expected all residents to be interviewed, and their activity preferences updated and all care plans to be revised to reflect each resident's activity preferences. She stated the activity department was already discussed and a Performance Improvement Project known as a PIP was in place to improve the activity program in the facility. The Administrator did not recall the exact date the PIP was executed during the QAPI meetings, but it was within the past 7 days. She stated if a resident was not receiving activities there was a potential a resident would have a decline in their cognition, mental status, physical status and quality of life. She stated a resident with a history of depression may become depressed and isolate themselves in their rooms. The Administrator stated the Activity Director was responsible for the activity programming and documentation of all activities department including participation records. She stated she was the Activity Director supervisor. Record review of the Activity Director's Personnel file on 01/08/2026, revealed the Activity Director completed the 45 hours of study and testing for Activity Director and received her activity certification on 01/07/2026.Record review of the Facility Activity Programs Policy, dated 2001, reflected Activity programs are designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident. The activities program was provided to support the well-being of residents and to encourage both independence and community interaction. Activities offered are based on the preferences of each resident. Activities are considered any endeavor, other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive or emotional health. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. Residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs. All activities are documented in the resident's medical record.

Based on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 of 3 medication carts (Medication Cart #1 and Medication Cart #2) reviewed for medication storage.The facility failed to ensure Medication Cart #1 and Medication Cart #2 were locked and medications were secured and not accessible to other staff, residents, or visitorsThis failure could place residents at risk of having unauthorized access to prescriptions, biologicals, and over-the counter medications.Findings included:Observation on 01/06/2026 at 7:04 a.m. revealed the locking mechanism protruding outward (indicated the medication cart was unlocked) on the Medication cart #1 located in front of one of one nurses' station on unit 3. RN C was standing near room [ROOM NUMBER] and was unable to view the Medication Cart #1. She walked towards the nurses' desk when she observed the surveyor at Medication Cart #1, and she locked the cart immediately.Interview on 10/28/2025 at 7:09 a.m. RN C stated she did not realize the medication cart was unlocked. She stated all medication carts were to be locked except when a nurse was obtaining medications from the cart. RN C stated if a resident did ingest medications the resident was allergic to there was a possibility the resident may have a reaction and possibly die. She stated a resident also had a potential of overdosing on medications or give the medications to another resident. RN C stated she had been in-serviced on locking medication carts; however, she did not recall the date of this in-service. She stated there were all types of medications prescribed by the physician in the Medication Cart #1 except for narcotics.Interview on 01/06/2026 at 8:30 a.m. the ADON stated her expectation was for all medication carts to be locked when the nurse was not administering medications. She stated the staff had been in-serviced on securing the medication carts when not in use. The ADON stated she was starting an in-service today and she did not recall the last time the facility had in-service on locking medication carts with the nurses and medication aides. She stated it was the nurse's responsibility to ensure the medication cart was locked when not dispensing a resident's medication.Observation on 01/07/2025 at 8:35 a.m. revealed Medication Cart #2 the locking mechanism protruding outward (indicated the medication cart was unlocked) in front of room [ROOM NUMBER]. MA D was in room [ROOM NUMBER] and had her back turned to the door and Medication Cart #2. She exited room [ROOM NUMBER] and walked to Medication Cart #2.In an interview on 01/07/2026 at 8: 45 a.m. MA D stated the medication cart was to always be locked except when she was dispensing medications from the medication cart. She stated it was her responsibility to ensure the medication cart was locked and secure. MA D stated if residents had accessed the medication cart they could have overdosed, taken wrong medication, had an allergic reaction, and could require admission to the hospital. She stated she had previously been in-serviced on locking the medication carts and could not recall the specific date. She stated she was aware the medication cart should have been locked. MA D stated narcotics was not in the medication cart. She stated all of the other medications prescribed by the physician was in the medication cart. She stated there were too many medications to mention.Interview on 01/08/2026 at 1:00 p.m. the Director of Nurses stated her expectation was for all medication carts to be locked when the nurse was not administering medications. She stated the staff had been in-serviced on securing the medication carts when not in use. The Director of Nurses stated she did not know the exact date of the in-service. She stated residents, other staff, and visitors would have access to the medications in the unlocked medication cart. She stated if a resident ingested medications not prescribed to them, there was a potential the resident may have an allergic reaction or may need to be admitted to the hospital. She stated it was the nurse or MAs responsibility to ensure the medication cart was locked when not dispensing a resident's medication. The Director of Nurses stated she was responsible for monitoring the nurse supervisors. Record review of the facility's Medication Labeling and Storage Policy, dated 2001, reflected The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for 1 of 3 residents (Resident #40) reviewed for personal privacy and confidentiality of records The facility failed to ensure MA D provided privacy by locking the privacy screen on the laptop and leaving the laptop unattended in the hallway on the medication cart which displayed Resident #40's medical information on 01/07/2026. This failure could place residents at risk of having medical information, personal or care instructions exposed to others and misuse of personal information.Findings included:Record review of Resident #40's face sheet, dated 01/07/2026, reflected an [AGE] year-old female resident admitted on [DATE] with the following diagnoses: major depressive disorder, recurrent severe without psychotic features (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep or feelings of guilt without behaviors), muscle weakness (feeling of lack of strength throughout most of your body, requiring extra effort to move arms, legs, and other muscles, often accompanied by fatigue), Alzheimer's disease (a progressive brain disorder, that slowly destroys memory, thinking, and reasoning skills, eventually making it hard to perform simple tasks), type 2 diabetes ( your body does not make enough insulin or does not use insulin properly, causing sugar to build up in the blood instead of entering cells for energy, leading to high blood sugar), chronic obstructive pulmonary disease, unspecified (a long term lung condition that obstructs flow, but the specific type was not identified in the medical record, meaning it is a general diagnosis encompassing persistent cough, wheezing from airway inflammation or damage). Record review of Resident #40's Annual MDS Assessment, dated 01/13/2025, reflected Resident #40 had a BIMS score of 13 indicating her cognition was intact. During an observation on 01/07/2025 at 8:35 a.m., revealed the medication cart was parked near Resident #40's room. The screen on the laptop was not secured and displayed Resident #40's medical information such as medications. MA D exited room [ROOM NUMBER] approximately 3 minutes after making observation. She immediately closed the computer screen and enabled the security screen.During an interview on 01/07/2026 at 8:45 a.m. MA D stated she forgot to close Resident #40s information about her medications and diagnoses when she entered Resident #40's room. She stated anytime she walked away from the medication cart she was expected to place the computer screen on privacy to prevent anyone from viewing medical information on any of the residents. MA D stated that was against Resident #40's privacy and resident rights. She stated she had been in-serviced on resident rights and on locking the screen when away from the medication cart. MA D stated she did not recall the date of the in-service.During an interview on 01/07/2026 at 9:05 a.m., the Assistant Director of Nurses stated all computers on medication carts were expected to be locked. She stated anyone could walk by the medication cart and view a resident's medical information such as another resident, a family member and/or unauthorized staff. The Assistant Director of Nurses stated anyone could give medical information to others and may post it on any social platform. She stated all medical records were expected to remain private where unauthorized people did not have any medical information on a resident. She stated that was against a resident's privacy and resident rights. She stated it was a HIPAA violation. The Assistant Director of Nurses stated she had been in-serviced on resident rights, HIPAA and residents' privacy; however, she did not remember the date of the in-service.During an interview on 01/08/2026 at 1:00 p.m. the Director of Nurses stated all electronic screens were expected to be on lock when staff was not in front of the electronic device. She stated MA D was expected to lock the computer screen when she entered Resident #40's room. The Director of Nurses stated no medical information was to be reviewed by any visitor, other residents or unauthorized staff. She stated it was against Resident #40's privacy and resident rights. The Director of Nurses stated anyone could report to another person Resident #40's medical information and if Resident #40 learned of her medical information being discussed by other residents or visitors it could be very humiliating to Resident #40. She stated she had been trained on HIPAA, protecting residents' medical information, privacy and resident rights. She stated she did not recall the date of the training. She stated the nurse supervisor was responsible for monitoring the MAs to ensure they were following resident rights for medical privacy.Record review of the facility's resident rights provided during in-service dated 08/08/2024 to 08/14/2024, reflected Privacy and confidentiality: The resident has a right to personal privacy and confidentiality of his or her personal [NAME] records. The resident has a right to secure and confidential personal and medical records.

Based on observation, interview, and record review, the facility failed to develop a baseline care plan that included instructions needed to provide effective and person-centered care of the residents, for 2 of four residents (Resident #53 and Resident #55) reviewed for baseline care plans. A) The facility failed to ensure a baseline care plan was completed within 48 hours of admission that addressed the care needs of newly admitted Resident #53. B) The facility failed to ensure a baseline care plan was completed within 48 hours of admission that addressed the care needs of newly admitted Resident #55. This failure could place residents at risk of not receiving necessary care and services. The findings included: A) Review of Resident #53's face sheet dated 01/08/2026 reflected a [AGE] year-old male admitted on [DATE] with the following diagnoses cerebral infarction (stroke that causes brain damage), diabetes mellitus type 2, and dysphagia (difficulty swallowing). Review of Resident #53's admission assessment dated [DATE] reflected Resident #53 was assessed to be oriented x3 indicating he was cognitively intact. Resident #53 was further assessed to be fed by a gastrostomy tube. Review of Resident #53's EMR for a base line care plan on 01/08/2026 reflected no base line care plan was completed within 48 hours of admission. In an interview on 01/08/2026 at 11:35 AM the ADON stated Resident #53's should have had orders for his G-tube care and maintenance immediately on admission and they should be on his base line care plan. By not having base line care it could cause the Resident #53 to have complications or tube clogging. B) Review of Resident #55's face sheet dated 01/07/2026 reflected an [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses atherosclerotic heart disease, diabetes mellitus type 2, morbid obesity and hypertension. Review of Resident #55 admission assessment dated [DATE] reflected that he was assessed to have a BIMS score of 6 indicating moderate cognitive impairment. Resident #55 was assessed to have wounds. Review of Resident #55's electronic medical record reflected that no base line care plan was completed. In an interview on 01/08/2026 at 8:55 AM the DON stated, It may not be started yet she stated the MDS guy is pretty new. The DON stated after looking in the EMR that she did not see a base line care plan for Resident #55. The DON stated she would work on it now. She stated she knew there should be a baseline care plan done in 48 hours after admission and PCC showed the triggered items already. She stated sometimes they slipped through the cracks, The DON stated she shared the responsibility with the MDS coordinator for the care planning and baseline care plans. In an interview on 01/08/2026 at 11:30 AM the RNC stated that baseline care plans should be completed within 48 hours to ensure the residents receive the appropriate care. Review of the facility's policy Care plans- Baseline dated March 2022 reflected A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. Physician orders.The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission). The baseline care plan is updated as needed to meet the residents' needs until the comprehensive care plan is developed.

Based on interviews and record reviews, the facility failed to develop and implement a person-centered comprehensive care plan to meet the preferences and goals of each resident and address the resident's medical, physical, mental and psychosocial needs for 2 of 7 residents (Residents #1 and #5) reviewed for care plans. The facility failed to ensure Resident #1's care plan was comprehensive and updated to reflect Resident #1 was on Enhanced Barrier Precautions. The facility failed to ensure Resident #5's care plan was comprehensive and updated to reflect Resident #1 was on Enhanced Barrier Precautions.This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included: Record review of Resident #1's face sheet, accessed on 1/06/2026, revealed the resident was an [AGE] year old male admitted to the facility on [DATE] and again on 10/04/2025 with diagnoses including metabolic encephalopathy(brain dysfunction), hypokalemia (a condition where the potassium levels in the blood are lower than normal), cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing brain tissue to die), and type II diabetes (a chronic condition where the body does not use insulin effectively or does not produce enough insulin, leading to high blood sugar levels).Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS of 03, indicating the resident had severe cognitive impairment. Section H-Bladder and Bowel reflected Resident #1 has an indwelling catheter.Record review of Resident #1s consolidated physician's orders accessed on 01/07/2026 revealed there was an order on 9/18/2025 for Enhanced Barrier Precautions: Resident requires enhanced barrier precautions. Wear PPE per facility protocol.Record review of Resident #1's comprehensive care plan, last review completed 09/15/2025, revealed a focus area indicating: I have indwelling catheter r/t diagnosis of other obstructive and reflux uropathy (urine flows backward from the bladder into the kidneys). Date Initiated: 09/15/2025. Revision on: 10/14/2025. The goal was to be/remain free from catheter-related trauma, and show no s/sx of urinary infection r/t catheter use. Interventions did not include EBP and further review of the comprehensive care plan did not indicate a focus area indicating enhanced barrier precautions.Record review of Resident #5's face sheet, accessed on 01/06/2025, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage in hemisphere, cortical (medical condition when blood vessel in the brain ruptures), dysphagia, oropharyngeal (swallowing disorder), and other encephalopathy (disease of the brain).Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed a BIMS of 14, indicating the resident had full cognition. Section K0520 reflects Resident# 5 has a feeding tube.Record review of Resident #5's consolidated physician's orders accessed on 01/07/2026, revealed there was an order upon admission on [DATE] for enhanced barrier precautions. Record review of Resident #5's comprehensive care plan, completed 08/07/2025, with an uncompleted scheduled review date of 10/27/2025, revealed a focus area indicating: The resident requires tube feeding r/t. The goal The resident will remain free of side effects or complications related to tube feeding through review date. The resident's insertion site will be free of s/sx of infection through the review date. Interventions did not include EBP and further review of the comprehensive care plan did not indicate a focus area indicating enhanced barrier precautions.In an interview conducted on 01/08/2026 at 12:17 PM, the MDS nurse stated he had been with the facility since March 2025. He stated that responsibility for ensuring enhanced barrier infection control precautions were included in the resident's comprehensive care plan rests with the MDS nurse, ADON, DON, Nursing, and the SW. He stated that all identified disciplines were responsible for adding these interventions to the care plan. The MDS nurse stated that MDS nurses were trained on when enhanced barrier precautions were required and that residents were assessed and identified based on their clinical conditions, including the presence of wounds, catheters, or PEG (feeding tube) tubes. The MDS nurse stated that enhanced barrier precautions should be incorporated into the resident's comprehensive care plan; however, he was unable to explain why the precautions were not included. He stated that staff were informed of enhanced barrier precautions through signage posted outside the resident's room and through review of the resident's electronic medical record. The MDS nurse stated that failure to include enhanced barrier precautions or failing to timely revise the comprehensive care plan placed the resident at risk for harm, including an increased risk of infection.In an interview conducted on 01/08/2026 at 12:34 PM, the ADON stated that the MDS nurse was responsible for completing care plans; however, the facility was now transitioning to a team-based approach. She stated that infection control was everyone's responsibility, with primary responsibility resting with nursing staff. The ADON stated that residents with foreign objects, including catheters, G -tubes(device for access to stomach for feeding), tracheostomies (surgical hole through neck to help with breathing), wounds, or IVs , are assessed for the need for enhanced barrier precautions upon admission, at the time of any new physician order, or upon a change in condition as identified through the ADL assessment. She stated that when enhanced barrier precautions were identified, they should be incorporated into the resident's comprehensive care plan. The ADON stated that nursing staff had access to resident information through the facility's electronic medical record system. She stated that if enhanced barrier precautions were not timely incorporated into the resident's comprehensive care plan, the resident could be at risk for infection or bacterial transmission. The ADON stated she was unable to explain why the enhanced barrier precautions were not previously included in the care plans; however, she stated that all care plans were updated approximately 30 minutes prior to the interview. The ADON stated the facility had implemented a new care plan library and that the enhanced barrier precaution information should now be reflected in the residents' comprehensive care plans.In an interview conducted on 01/08/2026 at 12:54 PM, the DON stated that responsibility for updating comprehensive care plans currently lies with all members of the interdisciplinary team. She stated that the MDS Coordinator was new to the role and transitioned into the MDS position approximately one month ago. The DON stated that residents with indwelling devices, including IVs, catheters, or wounds, are assessed for the need for enhanced barrier precautions to prevent infection. She stated that enhanced barrier precautions should be included in each affected resident's comprehensive care plan. The DON acknowledged that the enhanced barrier precaution interventions were missed on the care plans and stated she was not going to lie about the omission. The DON stated that nursing staff, including nurse aides, were informed of enhanced barrier precautions through in-services, signage posted outside residents' rooms, and notifications within the facility's electronic medical record system. The DON stated that the potential harm or adverse outcome of failing to timely revise the resident's comprehensive care plan was that staff or others could introduce germs to the resident, placing the resident at increased risk for infection.In an interview conducted on 01/08/2026 at 1:49 PM, the ADM stated she had been employed at the facility since March 2025. She stated her expectation was that comprehensive care plans were revised in a timely manner when residents' needs change and that revisions are completed in accordance with facility policy. The ADM stated that a new baseline care plan is initiated upon admission and that the comprehensive care plan was completed within the required timeframe. She stated that the entire interdisciplinary team was responsible for adding appropriate interventions to the care plan. The ADM stated that enhanced barrier precautions should be included in the comprehensive care plans for all residents who require them. She stated the facility was aware that multiple care plans required updating and that the facility has a new MDS nurse in the role. The ADM stated that the potential harm of not timely updating comprehensive care plans was that critical information could be missed by staff, which could negatively affect resident care and outcomes.Record review on 1/08/2026 of facility policy Care Plans, Comprehensive Person-Centered revised March 2022 revealed, Policy Statement : A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status}, and no more than 21 days after admission.3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan:a. includes measurable objectives and timeframes;b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including:(1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;(2) any specialized services to be provided as a result of PASARR recommendations; and(3) which professional services are responsible for each element of care;c. includes the resident's stated goals upon admission and desired outcomes;d. builds on the resident's strengths; ande. reflects currently recognized standards of practice for problem areas and conditions. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.12. The interdisciplinary team reviews and updates the care plan:a. when there has been a significant change in the resident's condition;b. when the desired outcome is not met;c. when the resident has been readmitted to the facility from a hospital stay; andd. at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interview and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing for one of three residents reviewed for pressure ulcers. (Resident #46) The facility failed to ensure Resident #46's unavoidable sacral unstageable pressure ulcer (a severe type of wound where the full depth cannot be assessed due to the presence of necrotic tissue, slough or eschar covering the wound base) treatment was done per physician orders. These failures could cause severe pain, and lead to systemic infections for residents that have or are at risk for pressure ulcers.Findings: Review of Resident #46's face sheet dated 01/08/2026 reflected she was admitted on [DATE] and readmitted on [DATE] with the following diagnoses unspecified intracranial injury, schizophrenia, Diabetes Mellitus Type II and intellectual disabilities. Review of Resident #46's Significant change in status assessment dated [DATE] reflected that she was assessed to have a BIMS score of one indicating severe cognitive impairment. Resident #46 was further assessed to be dependent on staff for all ADLs. Resident #46 was assessed to be at risk of developing pressure ulcers/injuries and was assessed to have unhealed pressure ulcers/injuries. Resident #46 was further assessed to have one unstageable pressure ulcer which was present upon admission/reentry. Resident #46 was also assessed to be on hospice care. Review of Resident #46's comprehensive care plan reflected a focus are dated 11/24/2025 which reflected I am receiving hospice care related to a terminal illness, and my goal is to focus on comfort, dignity, and quality of life during my remaining time. Further review reflected a focus area dated 12/05/2025 I have an unstageable pressure ulcer to the coccyx related to immobility. Interventions included Administer my medication and treatment as ordered. Review of Resident #46's Wound Assessment Report dated 12/26/2025 reflected the wound was classified as an unstageable end of life skin failure to the sacrum with measurements of 9.40cm x 4.8 cm x 0.4cm. The wound was classified as stable with 30% slough and 30% eschar. Treatment was documented as Cleanse with wound cleanser use Dakins (a dilute solution of sodium hypochlorite (bleach) moistened fluffed gauze and cover with superabsorbent dressing. (the order did not include an order for Santyl (an enzymatic debridement agent). Review of Resident #46's consolidated physician orders reflected an order dated 12/27/2025 Clean sacrum with wound cleanser pat dry apply Dakins moistened fluffed gauze to base of wound secure with superabsorbent dressing until resolved two times a day for wound care may use normal saline if Dakins unavailable. Observation on 01/07/2026 at 9:55 AM revealed LVN A outside of Resident #46's room to gather supplies for wound care. LVN A got a bottle of wound cleanser, a tube of Santyl, a bottle of betadine and two bordered gauze dressings. LVN A took all items into Resident #46's room in the original packaging and placed them on a towel on Resident #46's overbed table. LVN A removed a dressing from Resident #46's sacrum that was dated 01/06/2025. (The dressing was a bordered gauze dressing. No wound packing was removed from the wound.) Resident #46's sacral pressure ulcer had substantial depth > (greater than) 0.4 cm with undermining (erosion beneath the wound edges, leading to a larger wound area with a smaller visible opening) from 12 o'clock to 3 o'clock, the wound bed was covered in slough. Resident #46's wound edges were necrotic; and the peri wound was red and excoriated (missing top layer of skin). LVN A cleaned the wound edges and peri wound (refers to tissue surrounding a wound, extending up to 4cm outside the wound edge) with wound cleanser. LVN A then retrieved the tube of Santyl and using her finger as an applicator applied the ointment to the wound edges and peri wound. LVN A performed hand hygiene and changed her gloves and applied the boarded gauze dressing over the wound. LVN A did not pack the wound and did not use a superabsorbent dressing to cover the wound. LVN A took all the treatment supplies she brought into the room back to her chart. In an interview on 01/07/2026 at 10:15 am LVN A stated she did not pack the wound because the facility was out of Dakins' solution. LVN A further stated they had been out of the solution since 01/06/2026. When asked why she did not use normal saline as a substitute she stated Resident #46's order stated to just put a dry dressing on if the Dakins solution was not available. She stated she did Resident #46's treatment yesterday the same and stated she did not pack it because she did not have the Dakins solution In an interview on 01/07/2026 at 11:06 am the Wound Care NP stated Resident #46's sacral wound was an end of life skin failure possibly a Kennedy ulcer (is a rapidly developing skin wound that typically appears on the sacrum during the final stages of life). Resident #46's NP stated the wounds were unavoidable due to the number of things she has going on, and the resident was on hospice. Resident #46's NP stated the facility should be packing the wound. He stated he wanted them to use Dakins solution but if it was unavailable using normal saline or wound cleanser moistened gauze would be an appropriate substitute. He stated that by not packing the wound it could cause accumulation of fluid which could lead to structural failure, infection or abscess formation. Resident #46's NP stated he expected the facility nurses to do the appropriate treatments. He stated they should not be using Santyl, that the order was changed after his 12/26/2025 visit. He stated the facility nurses should never apply Santyl to the wound edges or healthy skin because it would cause skin breakdown and should only be used on a wound bed with slough. He further stated the nurses should be using a superabsorbent dressing like Gentell (an Opti foam dressing that pulls the exudate away from the wound) to prevent the peri wound from declining. Resident #46's NP stated he did not expect Resident #46's wound to heal but appropriate treatment needed to be done to prevent setbacks. In a follow-up interview on 01/07/206 at 11:20 AM LVN A stated she should have packed Resident #46's wound. She stated she went over the treatment with her DON and stated she went back down to Resident #46's room and packed her wound with normal saline gauze. She stated that the times she had seen Santyl being used that it was applied to the peri wound she did not know that it was not to be applied to normal skin. She stated the order for Santyl was not on the treatment order but was listed under her medications and that was why she used it. She stated she used the boarded gauze dressing because she thought that was what was ordered. In an interview on 01/07/2026 at 11:30 AM the DON stated Resident #46's sacral pressure ulcer treatment should have been done as ordered. She stated the order did reflect that normal saline could be used. She further stated everyone should know that Santyl was a debridement agent and should not be used on healthy skin or the peri wound because it could cause skin breakdown. She stated by staff doing the wrong treatment it could cause delayed healing, decline in the wound or infection. In an interview on 01/07/2026 at 11:35 AM the RNC stated the Dakins solution was ordered Friday (01/02/2026). She stated LVN A was provided a wound competency prior to doing wounds but would be taken off treatment and would be trained. She stated that Santyl should not be used on healthy skin or on the peri wound. She stated she expected the nursing staff to follow physician orders while performing wound care to ensure wounds do not decline. Review of the facility's policy Wound Care dated 10/2010 reflected The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. 1.Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. a. For example, the residents may have PRN orders for pain medication to be administered prior to would care. 3. Assemble the equipment and supplies as needed. Date and initial all bottles and jars upon opening. (Note: This may be performed at the treatment cart.) . 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field Arrange the supplies so they can be easily reached.2. Wash and dry your hands thoroughly. 3. Position resident. If necessary, place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on exam gloves. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly (hand sanitizer can be used). 6. Put on gloves. Gown as indicated based on EBP definition. Masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely. 7. Use no-touch technique. Use tongue blades and applicators to remove ointments and creams from their containers. 8. Pour liquid solutions directly on gauze sponges on their papers. 9 Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound. 10.Wear gloves when physically touching the wound or holding a moist surface over the wound. 11.Wash tissue around the wound that is usually covered by the dressing, tape or gauze with antiseptic or normal saline solution. 12. Apply treatments as indicated. 13. Dress wound. 14. Be certain all clean items are on clean fields. 15. Remove the disposable cloth (if applicable) next to the resident and discard into the designated container. 16. Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard them into designated containers. Wash and dry your hands thoroughly. 19. Disinfect overbed table. 21. Wipe reusable supplies with alcohol as indicated (i.e., outsides of containers that were touched by unclean hands, scissor blades, etc.). Return reusable supplies to residents' drawer in treatment cart. 22. Take only the disposable supplies that are necessary for the treatment into the room. Disposable supplies cannot be returned to the cart.

Based on observation, interview and record review the facility failed to ensure a resident who is fed by enteral means received appropriate treatment and services for 1 of 1 resident reviewed for feeding tubes. (Resident #53) The facility failed to ensure Resident #53 had physician's orders for care of his gastrostomy tube site treatment, tube placement checks, or water flushes. The facility further failed to have a plan of care in place for Resident #53's gastrostomy tube. This failure placed residents with tube feedings at risk of injury, pain, and/or significant changes in condition.Findings Include: Review of Resident #53's face sheet dated 01/08/2026 reflected a [AGE] year-old male admitted on [DATE] with the following diagnoses cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain.), diabetes mellitus type 2, and dysphagia (swallowing problems). Review of Resident #53's admission assessment dated [DATE] reflected Resident #53 was assessed to be oriented to person, place and time indicating he was cognitively intact. Resident #53 was further assessed to be fed by a gastrostomy tube. Review of Resident #53's base line care plan reflected no base line care plan was completed within 48 hours of admission. Review of Resident #53's consolidated physician's orders dated 01/05/2026 reflected an order dated 01/05/2026 Glucerna 1.5 calorie oral liquid (nutritional supplements) give one can via G-tube four times a day for nutrition. The consolidated physician's orders reflected no other orders for the treatment or care of Resident #53's G-Tube. Observation and interview on 01/06/2026 at 11:00 AM revealed Resident #53 in his room in bed. Resident #53 stated he came to the facility yesterday. He stated he was fed through his G-Tube. He stated he had not had any issues so far with his care. In an interview on 01/08/2026 at 11:30 AM the RNC stated the physician's orders for immediate care should be completed right away. In an interview on 01/08/2026 at 11:35 AM the ADON stated Resident #53's should of had orders for his G-tube care and maintenance immediately on admission. By not having the orders it could cause the Resident #53 to have complications or tube clogging. In an interview on 01/08/2026 at 11:46 PM LVN A stated she admitted Resident #53. She stated after looking in his record that the resident did not have physician's orders for checking his tube placement or flushing the tube with water to prevent clogging. LVN A stated she should have called the physician after he got to the facility to make sure, he had all the necessary orders for treatment. She stated she should have also checked with her ADON or DON to make sure he had everything in place. She stated, We should have noticed there wasn't any flush or placement check orders. LVN A stated Resident #53 should have an order for treatment of his G-Tube site and she did not see one. Review of Resident #53's care plan initiated 01/08/2026 after surveyor interventions reflected The resident requires tube feeding (related to Dysphagia, Chewing problem, Swallowing problem). Interventions included The resident needs the head of bed elevated 45 degrees during and thirty minutes after tube feed. Check for tube placement and gastric contents/residual volume per facility protocol and record. Hold feed if greater than (SPECIFY) cc aspirate.Listen to lung sounds: Monitor/document/report PRN any signs or symptoms of: Aspiration- fever, SOB, Tube dislodged, Infection at tube site, Self-extubating (removing), Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, and Dehydration. Provide local care to gastrostomy tube site as ordered and monitor for signs or symptoms of infection. On 01/07/2026 at 2:00 PM a policy for gastrostomy tubes was requested and not provided prior to exit.

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 2 of 25 residents (Resident #56 and Resident #27) reviewed for infection control practices during medication pass. MA B failed to sanitize the blood pressure cuff during medication pass before and after using it on Resident #56 and Resident #27. These failures could place residents at risk for cross-contamination and infections.Findings include: Review of Resident #56's face sheet dated 01/07/2026 reflected a [AGE] year old male admitted to the facility on [DATE] with the following diagnoses congestive heart failure (long-term condition in which your heart can't pump blood well enough to meet your body's needs.), diabetes mellitus type II (A condition results from insufficient production of insulin, causing high blood sugar.) and hypertension (High pressure in the arteries). Review of Resident #27's face sheet dated 01/07/2026 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnosis hypertension (High pressure in the arteries). Observation on 01/06/2026 at 7:38 AM revealed MA B outside of Resident #56 room to prepare for medication administration. MA B grabbed the rolling blood pressure machine from the hall on her way to the room. MA B went into Resident #56's room and took his blood pressure without cleaning the blood pressure cuff. Observation on 01/06/2026 at 8:02 AM revealed MA B outside of Resident #27's room to prepare his medication for administration. MA B using the same blood pressure machine used on Resident #56 entered Resident #27's room and took his blood pressure without cleaning the blood pressure cuff. In an interview on 01/06/2025 at 8:10 am MA B stated she should have cleaned the blood pressure cuff prior to using it on Resident #56 and Resident #27. MA B stated she did not have any wipes on her cart and stated she would have to go to another unit to get sanitizing wipes. She stated by not cleaning the blood pressure cuff it could spread germs. In an interview on 01/07/2025 at 1:10 PM the DON stated she expected staff to clean reusable resident equipment between residents to prevent cross contamination. Review of the facility's policy Standard Precautions dated September 2022 reflected Standard precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Personnel are trained in the various aspects of standard precautions to ensure appropriate decision-making in various clinical situations. Resident-Care Equipment a. Resident-care equipment soiled with blood, body fluids, secretions, and excretions are handled in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other residents and environments. b. Reusable equipment is not used for the care of more than one resident until it has been appropriately cleaned and reprocessed. c. Single use items are properly discarded.

Based on observation, interview, and record review, the facility failed to ensure based on the comprehensive assessment of a resident, the 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: 1. Ensure ants were not found on Resident #1's body on 08/13/25 and 08/15/25 which caused large papules (small bumps on the skin that contain fluid or pus) from his right shoulder to elbow, right hip to mid-thigh, abdomen, and between the toes of his feet.2. Accurately document in Resident #1's EMR regarding the presence of ants/ant bites on his body.3. Ensure Resident #1 was moved to a different room after ants were found on his body on 08/13/25 until 08/15/25.This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/25/25 at 7:10 PM and a template was provided. While the IJ was removed on 08/26/25 at 7:06 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk of discomfort, pain, worsening skin impairment issues, and a decreased quality of life. Findings included:Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, dysphagia (difficulty swallowing), muscle weakness, and need for assistance with personal care. Review of Resident #1's quarterly MDS assessment, dated 07/22/25, reflected a BIMS score of 00, indicating he had a severe cognitive deficit. Review of Resident #1's quarterly care plan, dated 07/06/25, reflected he had skin tears related to fragile skin, aging, medication effects, or mobility with an intervention of making sure his environment was safe. Review of Resident #1's NP assessment, dated 08/13/25, reflected the following: [Resident #1] is seen today for a report of possible ant bites to the right arm and right leg. Small red lesions noted to [Resident #1]'s right arm and leg. Review of Resident #1's hospice note, dated 08/13/25 at 12:57 PM and documented by HN D, reflected the following: PC from [LVN A] at (facility) requesting order for Benadryl RN due to ant bites on [Resident #1]'s arm and itching. Verbal order given per s/sx management for Benadryl 25mg 1-2 tablets every 6 hours as needed for itching. Review of Resident #1's progress note, dated 08/13/25 at 3:09 PM and documented by LVN A, reflected the following: [Resident #1] continues with red raised rash to right upper arm and a few patchy areas to the right thigh. He has no complaints of pain or itching at this time. Received PRN order for Benadryl from hospice. Review of Resident #1's physician order, dated 08/13/25, reflected Benadryl Oral Tablet 25 MG - Give 1 tablet by mouth every 6 hours as needed for rash. Review of Resident #1's skin assessment, dated 08/13/25 and completed by LVN A, reflected a rash to his right upper arm. There were no further skin assessments conducted. Review of the facility's pest control invoice, dated 08/14/25, reflected the following: I spoke with the administrator while on site, and she noted nuisance ant activity in room [ROOM NUMBER] (Resident #1's room) . room [ROOM NUMBER] was inspected with live activity of nuisance ants not being observed. Bait was placed in the restroom and bedroom as a precaution. Review of Resident #1's HN B's skin assessment, dated 08/15/25 at 10:44 AM, reflected he had generalized ant bites that were not healing and were pink and beefy red pustules. Review of Resident #1's HN B's progress note, dated 08/15/25 from 10:40 AM - 11:40 AM, reflected the following: [HN B] entered [Resident #1]'s room and found pt awake in bed, [HN B] noted ants crawling on pt's bedding. [HN B] returned to nurses station to tell [LVN C] that the pt needed to be moved to a new room and they needed to contact an exterminator, as ants were in pt's bed. [LVN C] offered for facility aides to change pt bedding. [HN B] stated she would change the bedding, but ants need to be addressed as pt had ant bites on Wednesday (08/13/25). [LVN C] stated the assessment from Wednesday stated pt had a rash. [HN B] went back to pt room, took a picture of ant bites on pt's arm and showed them to [LVN C] who stayed at the nurses station. [HN B] returned to change pt bedding and noted at least 100 ants in pts bed and on pt. [HN B] returned to nurses station to tell [LVN C] that there is a serious issue and pt need to be moved immediately. [HN B] returned to pt room to find [LVN C] had not followed her and was still at nursing station. [HN B] stated loudly that [LVN C] needed to get the DON or the administrator into the patient's room immediately. Multiple HCAs showed up to help [HN B], and eventually [LVN C] did too. [HN B] showed all staff members the multitude of ants in pt's bed. Ants were in between the pt's toes, and on his body from his right leg up to stomach, also removed ants from under pt's scrotum. [LVN C] stated that she was on her first day and was unaware. [The ADM] showed up and said, these [NAME] fire ants, I was told they were fire ants. [HN B] replied, I dont care what they are, this is unacceptable. [The ADM] stated that a pest control person treated the room yesterday and said he left live traps for ants, so it would be normal to see ants going to the live traps. [HN B] asked [The ADM] if the pest control person put live traps in the pt's bed, as that is where the majority of the ants are. [The ADM] did not answer, but stated that the bird feeder outside of the pt's window was a big problem and a cause of ants. [HN B] asked [The ADM] if the facility staff was putting bird feed underneath the pt. Again, [The ADM] did not answer. [HN B] showed everyone in the room the pt's right upper arm, which was covered in ant bites, [LVN C] stated that the patient's arm did not look like that on Wednesday. [HN B] asked [LVN C] how she knows what patient's arm looked like if today was her first day, no one answered. [HN B] stated that staff needed to get the hoyer lift so that pt can be transferred out of his bed to high back WC immediately. WC, in pt's bathroom, also found to have ants on it. [The ADM] left and came back several minutes later stating that pt would be moved to another room, but instructed facility aides to just get pt to high back WC and take him to the cafeteria for lunch, not to move his belongings at this time. SKIN: Skin is thin/fragile with Ecchymosis to BUE, with ruddy BLE. Pt has generalized ant bites all over his body. Pt's right arm from shoulder to elbow is approximately 85% covered in numerous erythematous papules (red lesions on the skin that may resemble elevated rashes) and vesiculopustular lesions that range from 1-5mm in diameter. Many with vesicopustule (a vesicle which is developing pus) formation with erythema (redness or discoloration of the skin) at the base. Similar lesions are present from pt's right hip to mid thigh, covering approximately 30-40% of the surface area and multiple lesions are also present between the toes of bilateral feet. Facility staff reports pt's itching has been controlled with PRN Benadryl and Hydrocortisone cream.Please ensure that pt has been moved to new room and that no ants or other insects are present in pt's bed. I did not leave medihoney in pt room so that Administrator could not blame ants on medihoney. Review of Resident #1's progress note, dated 08/15/25 at 11:09 AM and documented by LVN A, reflected the following: Notified [Resident #1's RP] and [Resident #1] that he is moving to 214 (room) today. Review of Resident #1's HN B's progress note, dated 08/18/25 at 12:07 PM, reflected he had generalized ant bites that were not healing with raised heads. Review of maintenance log requests, from 07/01/25 - 08/20/25, reflected ants were found in resident's rooms on 07/11/25, 07/22/25, 07/24/25, and 07/25/25.Review of a pest control invoice, dated 07/14/25, reflected they spot treated a proximity [sic] a dozen fire ant mounds. Review of a pest control invoice, dated 07/29/25, reflected the following: (Pest control company) responded to an emergency call regarding ant activity in rooms [ROOM NUMBERS]. Upon arrival, I met with the social worker at the front desk. We first inspected room [ROOM NUMBER], where staff reported ant activity throughout the room and restroom. During my inspection, I confirmed the presence of fire ants in the restroom and along the baseboards near the dresser. I applied a liquid treatment around all baseboards in the room and restroom. Next, we proceeded to room [ROOM NUMBER], which previously housed the resident from room [ROOM NUMBER]. Although no live ant activity was observed during the inspection, I performed a preventative treatment by baiting the restroom baseboards and the sink area. Afterward, I met with the [MAINTD], to access the courtyard and inspect for ant mounds near the affected units. Several mounds were located and treated. I recommended a long-term control solution, and the [ADM] requested a quote. I will be contacting my superiors to have this quote forwarded to her.Reported ants in room [ROOM NUMBER]. Facility has made multiple requests for ants. Please evaluate if larger scale of services needed. Review of pest control invoice, dated 08/14/25, reflected the following: I spoke with the administrator while on site, and she noted nuisance ant activity in room [ROOM NUMBER] (Resident #1's room) . room [ROOM NUMBER] was inspected with live activity of nuisance ants not being observed. Bait eas [sic] placed in the restroom and bedroom as a precaution. After this I made my way outside for an exterior inspection and granular perimeter application. Active ant mounds were treated with a bait application. A liquid residual perimeter application was performed on entry ways to aid in control of ants. I spoke with the administrator to wrap up the service. She was notified that our products take a few days to achieve full effect. During an observation on 08/20/25 at 10:52 AM revealed Resident #1 asleep in his bed and was unable to arouse. Visible beneath the right sleeve of his hospital gown revealed approximately 50 dark pink/red ant-like bites on his upper arm/shoulder. There were no visible ants in his bed, room, or bathroom. During a telephone interview on 08/20/25 at 12:04 PM, Resident #1's NP stated she was notified of redness to his arm on 08/13/25. She stated she looked at it but could not determine what it was, it was too difficult to say. She stated she wrote an order for Benadryl for dermatitis (a skin condition that causes redness, irritation, or rash). She stated he was on hospice services, so they oversaw his care. During an interview on 08/2025 at 12:55 PM, CNA E stated Resident #1 had recently been moved to her hall (200) but was not sure why. She stated she was not told what happened. She stated he had redness to his arms and stomach. During an interview on 08/20/25 at 1:03 PM, LVN C stated she was not working the day Resident #1 appeared with a rash. She stated she first saw it the following day, 08/14/25 and was asked if she would describe it. She stated she would not be able to because she was not a doctor. During an interview on 08/10/25 at 1:10 PM, the ADM stated on 08/13/25 she was grabbed by an aide stating Resident #1 had ants in his bed. She stated they had already cleaned up his bed but was shown a picture and they looked like sugar ants and sugar ants did not bite. She stated she told them to get him up and asked the housekeepers to clean his room. She stated she had the NP and her ADON assess his skin and the ADON said it looked more like a rash. She stated the NP looked at it and said she did not think they were ant bites by the way they were raised up from his skin and that it may be a reaction to something or a rash. She stated she contacted pest control, and they came the following day, 08/14/25, to treat his room. She stated on 08/15/25, HN B pulled back his covers on his bed and found ants on his abdomen. She stated she had not moved him rooms because pest control had already treated the room and the ADON and NP had told her it was a rash, not ant bites. She stated she called the pest control company again and they told her it could take up to a week before all the ants were killed. She stated she had not known that before. She stated she had not seen his skin since 08/13/25 and was shown a current picture. When she saw the picture, she stated it did look like they could be bites. During a telephone interview on 08/25/25 at 11:50 AM, HN B stated she found out ants were in Resident #1's bed on 08/13/25 when LVN A contacted their agency requesting Benadryl for ant bites and him itching. She stated on 08/15/25, when she arrived, she could not believe what she saw. She stated there were hundreds of ants all over him actively biting and she had to remove them from his right arm, right leg, abdomen, and under his scrotum. She stated his bites had little white heads and she had no doubt they were from the ants. She stated she even found ants on his wheelchair in his bathroom. She stated she went to tell LVN C who blew her off and kept telling her it was a rash. She stated she finally got the ADM in the room and showed her the ants and told her to get her staff to move him rooms as it was completely unacceptable. She stated her HCAs provided him with a shower and removed his linens to be laundered. During an interview on 08/26/25 11:57 AM, LVN C stated she worked the 6:00 AM - 6:00 PM shift on 08/15/25. She stated when HN B came in to do wound care on Resident #1, she was shown a picture of his skin, and she believed it was a rash. She then stated HN B found the ants on him and in his bed. She stated they then removed all of his linens and took them to the laundry room and moved him to a room on the 200 hall. She stated she did see the ants in his bed but did not perform a skin assessment because she saw one had already been done that day and a rash was noted. She stated the importance of skin assessments was to make sure the skin was good, for skin integrity, and to ensure there was no skin breakdown. During an interview on 08/26/25 at 12:10 PM, the ADM stated the pest control company they used brought up doing extra services on the grounds (outside of facility) but not the inside of the facility. She stated she asked for a quote but never received one. She stated a negative outcome of not following up with the pest control company would be that you could have pests in the building that could contribute to negative outcomes for the residents. She stated they could be a nuisance, could carry germs, or they could bite the residents which could lead to more negative outcomes. She stated the importance of accurate nursing documentation was so there was a clear picture of what was happening with the resident. She stated her expectations on nursing documentation was that all issues and concerns of the residents were documented. She stated if the documentation was not accurate, the resident could have an issue or concern that the nurses were not aware of, and it would not get addressed. She stated a skin assessment should have been conducted by the nurses every day after Resident #1 acquired his rash to ensure they were assessing the area and to ensure the MD was notified if there was a change. During a telephone interview on 08/26/25 at 12:46 PM, the ADON stated he was told by LVN A that Resident #1 had a skin impairment issue (could not remember the date). He stated he went and assessed him but did not see anything visible at that time. He stated he did not see anything that was consistent with bite marks. He stated he had ben out sick so he had not assessed Resident #1 since 08/13/25. He stated even though he was under hospice's care, they (facility staff) were still responsible for the welfare of the resident. He stated the importance of accurate skin assessments were to ensure there were no areas on the residents and to make sure there were no skin issues going unaddressed. During a telephone interview on 08/26/25 at 1:18 PM, LVN A stated she was working on Resident #1's hall on 08/13/25. She stated CNAs F and G came to her and told her he had raised areas to his right arm. She stated there was mention of ant this and ant that but when she inspected his room, she saw no ants. After the NP assessed him and did not note ant bites, she completed her skin assessments and documented a rash to his right arm. During a telephone interview on 08/26/25 at 4:25 PM, CNA G stated she worked on Resident #1's hall on 08/13/25. She stated she had worked with him for 3-4 years and he was unable to use his call light, so when he was in distress or needed something, he would whistle. She stated on 08/13/25, she heard him whistling so she went to his room with CNA F. She stated they pulled back his covers and saw about 15 ants or more crawling on his right thigh. She stated there were bites all over his legs, stomach, and right arm. She stated there the bites were blotchy red spots. She stated she and CNA G told LVN A that they needed to get the ADM to his room. She stated the ADM told them to give him a shower and she would call for pest control to come and treat the room. She stated the HCAs provided the shower while they removed the linens to be laundered. During an interview on 08/26/25 at 4:40 PM, CNA F stated she worked on Resident #1's hall on 08/13/25. She stated she and CNA G uncovered him, and they saw ants and ant bites on his right side, right arm, right upper thigh, and on his stomach. She stated the bites looked red like little dots and she estimated there were 15-20 ants on him. She stated his body was moving in frustrated movements, which was not normal. She stated she and CNA G reported it to LVN A. Review of the facility's Pest Control Policy, revised May 2008, reflected the following: This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Review of the facility's Charting and Documentation Policy, dated July 2017, reflected the following: The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Review of the facility's Pressure Injury Risk Assessment, dated March 2020, reflected the following: Documentation:The following information should be recorded in the resident's electronic health record utilizing facility forms.:.4. Any change in the resident's condition, if identified.5. The condition of the resident's skin (i.e., the size and location of any red or tender areas), if identified. Review of the facility's Skin System Process Policy, dated May 2025, reflected the following: PCC Skin and Wound Total Body Skin Assessment: assessment is completed weekly until pressure injury or skin issue (skin tears, lacerations, abrasions, surgical incisions, diabetic, arterial, stasis, venous ulcers) is resolved. The ADM was notified on 08/25/25 at 7:10 PM that an IJ had been identified and an IJ template was provided at that time.The following Plan of Removal submitted by the facility was approved accepted on 08/26/25 at 12:30 PM: Resident #1 was assessed for skin alterations by the Director of Nursing on 08/25/2025. An entire building skin sweep was initiated and completed on 8/25/25 by the Director of Nursing to ensure no more residents had skin alterations from possible ant bites. Skin assessments on all residents are documented in the electronic health record of the individual residents. On 8/25/25, the regional nurse consultant educated the administrator, business office manager, and the director of nursing on abuse, neglect, identifying pest control issues, skin abnormalities in regards to insect bites. The Business Office Manager searched all residents' rooms on 08/25/25 for any evidence of ants, no concerns were notes. Interviewable residents were asked if they had noticed any ants or pests in their rooms, on 08/25/25By the Business Office Manager. All residents interviewed stated they had not seen any ants or pests. This was documented on a facility form. The charge nurse that did not report the alleged neglect, was counseled by the director of nursing on 08/25/25 on the Abuse and Neglect policy, documentation, assessment, physician notification of change, skin assessment, immediately moving a resident if pests are found in room, notification of RP for change in condition, rounding, documentation in medical record. Charge nurse signature on in-service indicates understanding. The pest control company was at facility to exterminate inside and outside for ants on 8/14/25. The pest control company was at the facility on 8/26/25 to exterminate inside and outside the facility. This will be documented in the pest control book. All staff were in-serviced on Abuse, Neglect, and Exploitation, and reporting Abuse and Neglect to the abuse coordinator/facility administrator immediately, beginning on 8/25/25 and will be completed on 8/26/2025. In-services were completed per the Director of Nursing. Any new staff or agency staff will be in-serviced by the DON on Abuse, Neglect, and Exploitation policy before the start of their first shift. Verification of education will be completed by administrator/designee, three (3) times a week for thirty (30) days and randomly thereafter. Results will be kept on a facility audit form. Department heads will round in the morning all resident rooms. Focus will be ensuring there is no evidence of ants or pests in the resident rooms, daily M-F X3 months. Dept heads will be educated on this practice by the administrator on 08/26/2025. Results will be kept on a facility rounding form. DON and the Administrator will interview 3 staff daily related to their understanding of the in-service education provided, for the next 4 weeks. Results will be kept on a facility audit form. An Ad Hoc QAPI was held by the Facility Administrator, Director of Nursing, , and Asst. Director of Nurses on 08/25/2025 at 8:30 PM to review the alleged deficiency and plan. The surveyor monitored the POR on 08/26/25 as followed: Observations made on 08/26/25 from 12:45 PM - 1:18 PM revealed six randomly picked resident rooms without any ants/pest sightings. The residents that occupied these rooms denied seeing any pests/ants. During interviews on 08/26/25 from 3:18 PM - 6:20 PM, the following staff were interviewed from all shifts: CNA E, CNA F, CNA G, the DM, HSK H, HSK I, DA J, MA K, CNA L, LVN M, MA N, CNA O, MA P, CNA Q, LVN R, and LVN S. All stated they were in-serviced on abuse and neglect and pest control prior to their shift. The nurses stated they were also interviewed on documentation and skin assessments. All staff stated their ADM was the abuse and neglect coordinator and they should report to her immediately if they heard of or saw any allegation of abuse or neglect. They were able to give examples of abuse such as verbal, physical, or emotional. They all stated if they saw any pests, such as roaches, ants, or flies, they would immediately notify the ADM and MAINTD and fill out the pest control log that was located at the nurse's station. They all stated if a pest was found on a resident they needed to be showered, moved to another room, an all their linens and clothes would need to be laundered. The CNAs stated they would notify the nurses immediately if they saw any bites on a resident during personal care. The nurses stated the importance of skin assessments were to give an accurate depiction of the resident's skin, such as potential bug bites. The nurses stated they were to document all skin impairments along with the size/measurements (if applicable), color, and any other indications. The nurses stated anything that happened to a resident medically or physically should be accurately documented in the resident's chart to paint a clear picture of what was going on with them. All nursing staff stated residents should be rounded on at least every two hours to ensure their safety and health needs were being met. During an interview on 08/26/25 at 3:02 PM, the PCS stated the facility contacted his company on 08/25/25 and requested service as soon as possible. He stated he treated the facility inside and outside on 08/26/25. He stated he did not observe any ants inside the facility. During an interview on 08/26/25 at 4:54 PM, the RNC stated she in-serviced the ADM and DON on 08/25/25 regarding staff rounding, reporting pests, abuse and neglect, skin assessments, nursing documentation, and moving residents to a pest-free room if pests were observed in their room. During an interview on 08/26/25 at 5:14 PM, the ADM stated she and the DON were in-service by the RNC prior to in-servicing staff on pest control, what to do when pests were located, and skin assessments prior to a resident being potentially bitten. She stated they were also in-serviced on abuse and neglect, reporting/investigation time frames, skin assessments, and nursing documentation. She stated when pests/ants were observed in a resident's room, they should be moved immediately, showered, and linens laundered. She stated pest control would be contacted immediately for service. During an interview on 08/26/25 at 5:32 PM, MAINTD stated he completed a thorough assessment of the perimeter and the inside of the facility that day (08/26/25) and he brought up concerns of wasp nests to the attention of the PCS for mitigation. Review of the facility's QAPI meeting agenda, dated 08/25/25, reflected the ADM, the MD, the DON, the ADON, the RVP, and the BOM were in attendance. Review of an in-service entitled Pest Control and Resident Assessment/Safety, dated 08/25/25 and conducted by the RNC, reflected the ADM and DON were in-serviced on the facility's pest control policy. The in-service also covered abuse and neglect, accurate skin assessments, and nursing documentation. Review of Resident #1's skin assessment, on 08/25/25, reflected multiple scabs to his right elbow, abdomen, chest, right thigh, and right antecubital (inner arm). Review of skin assessments conducted on all residents, dated 08/25/25, reflected no new skin issues (including bites). Review of the facility's document for checking for pests, dated 08/25/25 and documented by the BOM, reflected she interviewed 11 residents who were asked if they saw any pests of any kind and all residents stated they had not. Review of room rounds, dated 08/26/25, reflected all residents' rooms were searched for pests and none were observed. Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all staff were in-serviced on abuse and neglect. Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all staff were in-serviced on safety and supervision of residents. Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all staff were in-serviced on moving residents to a pest-free room should pests be identified in their room that could/would bite.[TF1] Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all staff were in-serviced on the facility's pest control policy. Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all nurses were in-serviced on skin assessments: Skin assessments should be completed no less than weekly and should reflect all skin impairments and documented in the resident's chart and notification of any new skin impairments should be communicated to the RP, physician, and DON.The ADM was notified on 08/26/25 at 7:20 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for one (Resident #1) of five residents reviewed for physical environment. The facility failed to ensure ants were not found on Resident #1's body on 08/13/25 and 08/15/25 which caused papules (small bumps on the skin that contain fluid or pus) from his right shoulder to elbow, right hip to mid-thigh, abdomen, and between the toes of his feet. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/25/25 at 7:10 PM and a template was provided. While the IJ was removed on 08/26/25 at 7:06 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of discomfort, pain, or infection. Findings included:Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, dysphagia (difficulty swallowing), muscle weakness, and need for assistance with personal care. Review of Resident #1's quarterly MDS assessment, dated 07/22/25, reflected a BIMS score of 00, indicating he had a severe cognitive deficit. Review of Resident #1's quarterly care plan, dated 07/06/25, reflected he had skin tears related to fragile skin, aging, medication effects, or mobility with an intervention of making sure his environment was safe. Review of Resident #1's NP assessment, dated 08/13/25, reflected the following: [Resident #1] is seen today for a report of possible ant bites to the right arm and right leg. Small red lesions noted to [Resident #1]'s right arm and leg. Review of Resident #1's hospice note, dated 08/13/25 at 12:57 PM and documented by HN D, reflected the following: PC from [LVN A] at (facility) requesting order for Benadryl RN due to ant bites on [Resident #1]'s arm and itching. Verbal order given per s/sx management for Benadryl 25mg 1-2 tablets every 6 hours as needed for itching. Review of Resident #1's progress note, dated 08/13/25 at 3:09 PM and documented by LVN A, reflected the following: [Resident #1] continues with red raised rash to right upper arm and a few patchy areas to the right thigh. He has no complaints of pain or itching at this time. Received PRN order for Benadryl from hospice. Review of Resident #1's physician order, dated 08/13/25, reflected Benadryl Oral Tablet 25 MG - Give 1 tablet by mouth every 6 hours as needed for rash. Review of Resident #1's skin assessment, dated 08/13/25 and completed by LVN A, reflected a rash to his right upper arm. There was no documented evidence of further skin assessments conducted. Review of the facility's pest control invoice, dated 08/14/25, reflected the following: I spoke with the administrator while on site, and she noted nuisance ant activity in room [ROOM NUMBER] (Resident #1's room) . room [ROOM NUMBER] was inspected with live activity of nuisance ants not being observed. Bait was placed in the restroom and bedroom as a precaution. Review of Resident #1's HN B's skin assessment, dated 08/15/25 at 10:44 AM, reflected he had generalized ant bites that were not healing and were pink and beefy red pustules. Review of Resident #1's HN B's progress note, dated 08/15/25 from 10:40 AM - 11:40 AM, reflected the following: [HN B] entered [Resident #1]'s room and found pt awake in bed, [HN B] noted ants crawling on pt's bedding. [HN B] returned to nurses station to tell [LVN C] that the pt needed to be moved to a new room and they needed to contact an exterminator, as ants were in pt's bed. [LVN C] offered for facility aides to change pt bedding. [HN B] stated she would change the bedding, but ants need to be addressed as pt had ant bites on Wednesday (08/13/25). [LVN C] stated the assessment from Wednesday stated pt had a rash. [HN B] went back to pt room, took a picture of ant bites on pt's arm and showed them to [LVN C] who stayed at the nurses station. [HN B] returned to change pt bedding and noted at least 100 ants in pts bed and on pt. [HN B] returned to nurses station to tell [LVN C] that there is a serious issue and pt need to be moved immediately. [HN B] returned to pt room to find [LVN C] had not followed her and was still at nursing station. [HN B] stated loudly that [LVN C] needed to get the DON or the administrator into the patient's room immediately. Multiple HCAs showed up to help [HN B], and eventually [LVN C] did too. [HN B] showed all staff members the multitude of ants in pt's bed. Ants were in between the pt's toes, and on his body from his right leg up to stomach, SN also removed ants from under pt's scrotum. [LVN C] stated that she was on her first day and was unaware. [The ADM] showed up and said, these [NAME] fire ants, I was told they were fire ants. [HN B] replied, I dont care what they are, this is unacceptable. [The ADM] stated that a pest control person treated the room yesterday and said he left live traps for ants, so it would be normal to see ants going to the live traps. [HN B] asked [The ADM] if the pest control person put live traps in the pt's bed, as that is where the majority of the ants are. [The ADM] did not answer, but stated that the bird feeder outside of the pt's window was a big problem and a cause of ants. [HN B] asked [The ADM] if the facility staff was putting bird feed underneath the pt. Again, [The ADM] did not answer. [HN B] showed everyone in the room the pt's right upper arm, which was covered in ant bites, [LVN C] stated that the patient's arm did not look like that on Wednesday. [HN B] asked [LVN C] how she knows what patient's arm looked like if today was her first day, no one answered. [HN B] stated that staff needed to get the hoyer lift so that pt can be transferred out of his bed to high back WC immediately. WC, in pt's bathroom, also found to have ants on it. [The ADM] left and came back several minutes later stating that pt would be moved to another room, but instructed facility aides to just get pt to high back WC and take him to the cafeteria for lunch, not to move his belongings at this time. SKIN: Skin is thin/fragile with Ecchymosis to BUE, with ruddy BLE. Pt has generalized ant bites all over his body. Pt's right arm from shoulder to elbow is approximately 85% covered in numerous erythematous papules (red lesions on the skin that may resemble elevated rashes (and vesiculopustular lesions that range from 1-5mm in diameter. Many with vesicopustule (a vesicle which is developing pus) formation with erythema (redness or discoloration of the skin) at the base. Similar lesions are present from pt's right hip to mid thigh, covering approximately 30-40% of the surface area and multiple lesions are also present between the toes of bilateral feet. Facility staff reports pt's itching has been controlled with PRN Benadryl and Hydrocortisone cream.Please ensure that pt has been moved to new room and that no ants or other insects are present in pt's bed. SN did not leave medihoney in pt room so that Administrator could not blame ants on medihoney. Review of Resident #1's progress note, dated 08/15/25 at 11:09 AM and documented by LVN A, reflected the following: Notified [Resident #1's RP] and [Resident #1] that he is moving to 214 (room) today. Review of Resident #1's HN B's progress note, dated 08/18/25 at 12:07 PM, reflected he had generalized ant bites that were not healing with raised heads. Review of maintenance log requests, from 07/01/25 - 08/20/25, reflected ants were found in resident's rooms on 07/11/25, 07/22/25, 07/24/25, and 07/25/25.Review of a pest control invoice, dated 07/14/25, reflected they spot treated a proximity [sic] a dozen fire ant mounds. Review of a pest control invoice, dated 07/29/25, reflected the following: (Pest control company) responded to an emergency call regarding ant activity in rooms [ROOM NUMBERS]. Upon arrival, I met with the social worker at the front desk. We first inspected room [ROOM NUMBER], where staff reported ant activity throughout the room and restroom. During my inspection, I confirmed the presence of fire ants in the restroom and along the baseboards near the dresser. I applied a liquid treatment around all baseboards in the room and restroom.Next, we proceeded to room [ROOM NUMBER], which previously housed the resident from room [ROOM NUMBER]. Although no live ant activity was observed during the inspection, I performed a preventative treatment by baiting the restroom baseboards and the sink area. Afterward, I met with the [MAINTD], to access the courtyard and inspect for ant mounds near the affected units. Several mounds were located and treated. I recommended a long-term control solution, and the [ADM] requested a quote. I will be contacting my superiors to have this quote forwarded to her. Reported ants in room [ROOM NUMBER]. Facility has made multiple requests for ants. Please evaluate if larger scale of services needed. Review of pest control invoice, dated 08/14/25, reflected the following: I spoke with the administrator while on site, and she noted nuisance ant activity in room [ROOM NUMBER] (Resident #1's room) . room [ROOM NUMBER] was inspected with live activity of nuisance ants not being observed. Bait eas [sic] placed in the restroom and bedroom as a precaution. After this I made my way outside for an exterior inspection and granular perimeter application. Active ant mounds were treated with a bait application. A liquid residual perimeter application was performed on entry ways to aid in control of ants. I spoke with the administrator to wrap up the service. She was notified that our products take a few days to achieve full effect. During an observation on 08/20/25 at 10:52 AM revealed Resident #1 asleep in his bed and was unable to arouse. Visible beneath the right sleeve of his hospital gown revealed approximately 50 dark pink/red ant-like bites on his upper arm/shoulder. There were no visible ants in his bed, room, or bathroom. During a telephone interview on 08/20/25 at 12:04 PM, Resident #1's NP stated she was notified of redness to his arm on 08/13/25. She stated she looked at it but could not determine what it was, it was too difficult to say. She stated she wrote an order for Benadryl for dermatitis (a skin condition that causes redness, irritation, or rash). She stated he was on hospice services, so they oversaw his care. During an interview on 08/2025 at 12:55 PM, CNA E stated Resident #1 had recently been moved to her hall (200) but was not sure why. She stated she was not told what happened. She stated he had redness to his arms and stomach. During an interview on 08/20/25 at 1:03 PM, LVN C stated she was not working the day Resident #1 appeared with a rash. She stated she first saw it the following day, 08/14/25 and was asked if she would describe it. She stated she would not be able to because she was not a doctor. During an interview on 08/10/25 at 1:10 PM, the ADM stated on 08/13/25 she was grabbed by an aide stating Resident #1 had ants in his bed. She stated they had already cleaned up his bed but was shown a picture and they looked like sugar ants and sugar ants did not bite. She stated she told them to get him up and asked the housekeepers to clean his room. She stated she had the NP and her ADON assess his skin and the ADON said it looked more like a rash. She stated the NP looked at it and said she did not think they were ant bites by the way they were raised up from his skin and that it may be a reaction to something or a rash. She stated she contacted pest control, and they came the following day, 08/14/25, to treat his room. She stated on 08/15/25, HN B pulled back his covers on his bed and found ants on his abdomen. She stated she had not moved him rooms because pest control had already treated the room and the ADON and NP had told her it was a rash, not ant bites. She stated she called the pest control company again and they told her it could take up to a week before all the ants were killed. She stated she had not known that before. She stated she had not seen his skin since 08/13/25 and was shown a current picture. She stated what she saw in the picture did look like they could be bites. During a telephone interview on 08/25/25 at 11:50 AM, HN B stated she found out ants were in Resident #1's bed on 08/13/25 when LVN A contacted their agency requesting Benadryl for ant bites and him itching. She stated on 08/15/25, when she arrived, she could not believe what she saw. She stated there were hundreds of ants all over him actively biting and she had to remove them from his right arm, right leg, abdomen, and under his scrotum. She stated his bites had little white heads and she had no doubt they were from the ants. She stated she even found ants on his wheelchair in his bathroom. She stated she went to tell LVN C who blew her off and kept telling her it was a rash. She stated she finally got the ADM in the room and showed her the ants and told her to get her staff to move him rooms as it was completely unacceptable. She stated her HCAs provided Resident #1 a shower and his linens were removed to be laundered. During an interview on 08/26/25 11:57 AM, LVN C stated she worked the 6:00 AM - 6:00 PM shift on 08/15/25. She stated when HN B came in to do wound care on Resident #1, she was shown a picture of his skin by HN B, and she believed it was a rash. She then stated HN B found the ants on him and in his bed. She stated they then removed all of his linens and took them to the laundry room and moved him to a room on the 200 hall. During an interview on 08/26/25 at 12:10 PM, the ADM stated the pest control company they used brought up doing extra services on the grounds (outside of facility) but not the inside of the facility. She stated she asked for a quote but never received one. She stated a negative outcome of not following up with the pest control company would be pests in the building that could contribute to negative outcomes for the residents. She stated they could be a nuisance, could carry germs, or they could bite the residents which could lead to more negative outcomes. During a telephone interview on 08/26/25 at 12:46 PM, the ADON stated he was told by LVN A that Resident #1 had a skin impairment issue (could not remember the date). He stated he went and assessed him but did not see anything visible at that time. He stated he did not see anything that was consistent with bite marks. He stated he was off since the incident and had not assessed his skin since. He stated even though he was under hospice's care, they (facility staff) were still responsible for the welfare of the resident. During a telephone interview on 08/26/25 at 1:18 PM, LVN A stated she was working on Resident #1's hall on 08/13/25. She stated CNAs F and G came to her and told her he had raised areas to his right arm. She stated there was mention of ant this and ant that but when she inspected his room, she saw no ants. After the NP assessed him and did not note ant bites, she completed her skin assessments and documented a rash to his right arm. During a telephone interview on 08/26/25 at 4:25 PM, CNA G stated she worked on Resident #1's hall on 08/13/25. She stated she had worked with him for 3-4 years and he was unable to use his call light, so when he was in distress or needed something, he would whistle. She stated on 08/13/25, she heard him whistling so she went to his room with CNA F. She stated they pulled back his covers and saw about 15 ants or more crawling on his right thigh. She stated there were bites all over his legs, stomach, and right arm. She stated there the bites were blotchy red spots. She stated she and CNA G told LVN A that they needed to get the ADM to his room. She stated the ADM told them to give him a shower and she would call for pest control to come and treat the room. She stated the HCAs provided Resident #1 with a shower and they removed his linens. During an interview on 08/26/25 at 4:40 PM, CNA F stated she worked on Resident #1's hall on 08/13/25. She stated she and CNA G uncovered him, and they saw ants and ant bites on his right side, right arm, right upper thigh, and on his stomach. She stated the bites looked red like little dots and she estimated there were 15-20 ants on him. She stated his body was moving in frustrated movements, which was not normal. She stated she and CNA G reported it to LVN A. Review of the facility's Pest Control Policy, revised May 2008, reflected the following: This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.The ADM was notified on 08/25/25 at 7:10 PM that an IJ had been identified and an IJ template was provided.The following Plan of Removal submitted by the facility was accepted on 08/26/25 at 12:30 PM: F925 Pest Control The facility failed to check the other residents' rooms 08/13/25. The facility staff failed to notify management that ants had been discovered 08/13/25. The facility failed to ensure that the unit was free from fire ants. The facility failed to assess other residents on the unit when Resident #1 was identified to have ant bites on 08/13/25. The facility failed to ensure Resident #1 was kept free of harm when they were found to have ants on their body, sheet and room. The facility did not move resident to another room when ants were found on the resident skin on 08/13/25 The facility failed to protect Resident #3 from potential harm as resident was left in the same room on 08/13/25. Identify residents who could be affected All Residents have the potential to be affected. Identify responsible staff/ what action taken The facility administrator requested Pest Control to visit the facility as soon as possible on 8/25/25. On 8/25/25, the regional nurse consultant educated the director of nursing regarding staff rounding, reporting pests in the facility immediately to the administrator/maintenance, skin assessments and notifications to MD/RP, and removing residents from their room if pests are found and showering of the resident who has any evidence of bites from pests. On 8/25/25, the director of nursing began education to direct care staff (RN, LVN, CNA, CMA, RNA), housekeeping, laundry, dietary, maintenance, office staff, and rehabilitation staff. Any agency staff utilized by facility or staff who did not receive the in-service on 8/25/25 will receive in-services prior to starting their assigned shift. The in-service addresses proper notifications when pest/ants are identified inside or outside the facility. Any resident that is identified as exposed to ants will immediately be removed from that area, head to toe assessment completed, will receive a shower and then proper notifications will be made to the responsible party, attending physician, the administrator, the director of maintenance and the director of nursing. The in-service also included conducting proper skin assessments on residents and complete rounds on all rooms/areas that pests or ants have been identified. If the administrator, director of maintenance or director of nursing did not answer the staff must continue to call department managers until they are able to reach someone. This in-service was started on 08/25/25 and will be completed on 08/26/25. Any staff who are unable to attend will receive the in service prior to beginning their shift and will not work until they receive the in service. New hires will receive same in service as part of their onboarding and will not work the floor until in service completed. Resident #1 was moved to another room on 08/15/25. A head-to-toe assessment was completed on 08/25/25 and residents' skin is clear. The maintenance director, completed a thorough assessment of the perimeter of the facility on 08/25/25. Any concerns identified were brought to the attention of pest control for mitigation. This will be documented in the pest control binder. Implementation of Changes Pest Control will service the facility weekly x4 weeks and then monthly and as needed thereafter. The maintenance director/designee will conduct thorough rounds throughout the facility QDay x30days and then prn thereafter to monitor for any pest/ant activity. This will be documented on a form in the pest control binder. The maintenance director/designee will round daily and ensure all food items are stored properly to prevent pest/ant activity daily x 30days and prn. This will be documented on a form in the pest control binder. During morning meeting TELS will be reviewed for any new concerns regarding pest/ant activity and that appropriate interventions have been implemented daily x 30days and prn. Perimeter checks of the facility will be conducted twice a day x 30days and prn to monitor for pest/ant mounds by the maintenance director/designee. This will be documented on a form in the pest control binder. During clinical morning meeting and during clinical stand down the Director of nursing/Assistant Director of Nursing will discuss with each charge nurse regarding any pest/ant activity x30days and prn. This will be documented on the room rounds form. Pest Control will service the facility weekly x4 weeks and then monthly and as needed thereafter. This will be documented in the pest control binder. All monitoring and any negative findings will be reported to QAPI monthly. The Director of Nursing/Assistant Director of Nursing/Designee will conduct five staff interviews, three (3) times a week for thirty (30) days to validate staff knowledge of education. This will be documented on interview questionnaire. Involvement of Medical Director The facility held an ad.hoc QAPI with the medical director to discuss a plan of removal on 08/25/25 at 8:30PM Who is responsible for implementation of process? The Administrator will be responsible for implementation of New Process. The New Process/ system will be started on 08/25/25. Please accept this letter as our plan of removal for the determination of revised Immediate Jeopardy issued on 08/25/25. Starting 8/26/25, education understanding will be completed with 3 staff members, three (3) times a week for one (1) month by the administrator/designee by questioning the facility staff about what they do if ants/pests are observed in the facility, to notify the administrator immediately. The Regional VP of Operations will ensure the administrator understands the directive to notify pest control, move the resident, direct nursing to complete skin assessment and notify the Rp and provider immediately. This will be documented on an audit flow sheet. The Surveyor monitored the POR on 08/26/25 as followed: Observations made on 08/26/25 from 12:45 PM - 1:18 PM revealed six randomly picked resident rooms without any ants/pest sightings. The residents that occupied those rooms denied observing any pests/ants. During interviews on 08/26/25 from 3:18 PM - 6:20 PM, the following staff were interviewed from all shifts: CNA E, CNA F, CNA G, the DM, HSK H, HSK I, DA J, MA K, CNA L, LVN M, MA N, CNA O, MA P, CNA Q, LVN R, and LVN S. All stated they were in-serviced on pest control issues prior to their shift. They all stated if they saw any pests, such as roaches, ants, or flies, they would immediately notify the ADM and MAINTD and fill out the pest control log that was located at the nurse's station. They all stated if a pest was found on a resident they needed to be showered, moved to another room, an all their linens and clothes would need to be laundered. The CNAs stated they would notify the nurses immediately if they saw any bites on a resident during personal care. During an interview on 08/26/25 at 3:02 PM, the PCS stated the facility contacted his company on 08/25/25 and requested service as soon as possible. He stated he treated the facility inside and outside on 08/26/25. He stated he did not observe any ants inside the facility. During an interview on 08/26/25 at 4:54 PM, the RNC stated she in-serviced the ADM and DON on 08/25/25 regarding staff rounding, reporting pests, and moving residents to a pest-free room if pests were observed in their room. During an interview on 08/26/25 at 5:14 PM, the ADM stated she and the DON were in-serviced by the RNC prior to in-servicing staff on pest control, what to do when pests were located (remove the resident from the room, provide a shower, and wash their linens), and skin assessments prior to a resident being potentially bitten. During an interview on 08/26/25 at 5:32 PM, MAINTD stated he completed a thorough assessment of the perimeter and the inside of the facility that day (08/26/25) and he brought up concerns of wasp nests to the attention of the PCS for mitigation. There was no documentation of ant mounds. Review of the facility's QAPI meeting agenda, dated 08/25/25, reflected the ADM, the MD, the DON, the ADON, the RVP, and the BOM were in attendance. Review of an in-service entitled Pest Control, dated 08/25/25 and conducted by the RNC, reflected the ADM and DON were in-serviced on the facility's pest control policy. Review of Resident #1's skin assessment, on 08/25/25, reflected multiple scabs to his right elbow, abdomen, chest, right thigh, and right antecubital (inner arm). Review of skin assessments conducted on all residents, dated 08/25/25, reflected no new skin issues (which included bites). Review of the facility's document for checking for pests, dated 08/25/25 and documented by the BOM, reflected she interviewed 11 residents who were asked if they saw any pests of any kind and all residents stated they had not. Review of room rounds, dated 08/26/25, reflected all residents' rooms were searched for pests and none were observed. Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all staff were in-serviced on moving residents to a pest-free room should pests be identified in their room that could/would bite. Review of an in-service, dated 08/25/25 - 08/26/25 and conducted by the ADM and DON, reflected all staff were in-serviced on the facility's pest control policy.The ADM was notified on 08/26/25 at 7:20 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to ensure sanitation practices (cleaning the ice machine, cleaning the ice machine scoop receptacle, storing, and stacking wet dishes on top of each other, ensure dish machine sanitizer levels are within the required range, utilization of an ice scoop receptacle with a lid, cleaning the walk-in cooler floor of food debris) for facility annual survey [DATE]-[DATE]. 2. The facility failed to ensure temperature logs were being completed for nourishment refrigerators for the facility annual survey [DATE]-[DATE]. 3. The facility failed to ensure all items were covered and stored properly for the facility annual survey on [DATE]-[DATE]. 4. The facility failed to label and date all food items in the kitchen for facility annual survey on [DATE]-[DATE]. 5. The facility failed to discard expired food product in the kitchen for facility survey on [DATE]-[DATE]. These failures could place residents at risk of foodborne illness. Findings included: Observation on [DATE] at 9:35 AM revealed an ice scoop receptacle to have water standing in bottom of the bin with what appeared to be black and brown debris floating on water surface and under water surface on bottom of scoop receptacle. Further observation revealed the scoop receptacle lid was broke off and in the bottom of the sink next to the ice machine. Observation on [DATE] at 9:37 AM revealed the inside of the ice machine door seal and inside of ice machine door to have what appeared to be white, black, and brown mold growth on upper inside of the door and seal. Observation on [DATE] at 9:40 AM revealed the clean dish storage to have trays of drinking glasses stored upside down while still wet on the inside. Observation on [DATE] at 9:44 AM of sliced bread, hot dog buns, and hoagie buns that had receipt date of [DATE]. Observation on [DATE] at 9:48 AM of dry storage area revealed: 1. An opened package of spaghetti noodles that were sealed properly with a date of ,d+[DATE] (unsure if this is receipt date open date or use by date). 2. An opened package of macaroni noodles that were sealed properly with a receipt date of [DATE]. No open date or discard date. 3. An opened package of spiral pasta noodles that were sealed properly with a receipt date of [DATE]. No open date or discard date. 4. A container labeled noodles that contained salad croutons. 5. A opened box of egg noodles not sealed properly and undated. 6. A opened container of cornstarch dated with an open date of [DATE] and a discard date of [DATE]. 7. A opened container of granola cereal dated with an open date of ,d+[DATE] and a discard date of ,d+[DATE]. 8. A case of oat and fruit granola with an expiration date of ,d+[DATE]. 9. A case of popcorn with a best by date of [DATE]. 10. A case of instant oatmeal with a best by date of [DATE]. 11. A dry supply bin of oatmeal with a scoop inside the bin. Observation on [DATE] at 9:59 AM of the walk-in refrigerator cooler revealed a bag of shredded cheese not sealed properly with a date of ,d+[DATE] (unsure if this is receipt date, open date, or discard date). Further observation of walk-in cooler revealed floor to have food debris all over the floor. Observation on [DATE] at 10:03 AM of the baking ingredient shelf revealed an opened package of brownie mix with a date of ,d+[DATE] (unsure if this is receipt date, open date, or discard date). Observation on [DATE] at 10:09 AM of clean dish storage revealed a stack of clean food storage bins stored upside down stacked together while still wet on the inside. Observation on [DATE] at 10:27 AM of nourishment refrigerator temperature logs revealed evening temperature for [DATE] not recorded and morning temperature for [DATE] not recorded. Observation on [DATE] at 10:43 AM of [NAME] G doing pureed preparation for lunch meal service revealed [NAME] G just rinsed the blender under hot running water. [NAME] G did not wash or sanitize the blender prior to use after receiving it dirty from having the dessert already been pureed. [NAME] G did not wash the blender in between food items of chicken and collard greens. [NAME] G just rinsed the blender under hot running water between food products. In an interview on [DATE] at 10:43 am [NAME] G stated they normally wash, rinse, and sanitize the blender and allow it to dry between each food product but they did not this time because the state surveyor was here to watch the puree process and she was trying to hurry so we did not have to wait. This failure could negatively affect the residents by cross contamination of food products and possible food allergy reactions. In an interview on [DATE] at 10:43 AM CNA E stated it was the nurse's responsibility for taking the temperatures twice daily on the nourishment refrigerators. This failure could negatively affect residents if the temperature range of the refrigerator was not within regulation and possible food borne illness. In an interview on [DATE] at 11:22 AM DM H stated their expectation concerning labeling and dating of food items were that the food items would be labeled and dated upon receipt, when opened or prepared, and dated at that time with a discard date. DM H stated if the food items were not labeled and dated appropriately then the facility could possibly be using expired food which could lead to food borne illness. DM H stated it was everybody's responsibility for labeling and dating but that the ultimate responsibility was theirs to ensure the labeling and dating was occurring. DM H stated their expectation concerning general cleaning was that daily and weekly, deep cleaning was being completed per the cleaning schedules. DM H stated their expectation for dish washing of food production equipment was that the proper 3 step process was followed of wash, rinse, and then sanitize. DM H stated taking the temperature and the cleaning of the nourishment refrigerators responsibility was on the nursing staff. In an interview on [DATE] at 1:40 PM the ADM stated labeling and dating were very important and that they were a big fan of it. The ADM stated if the labeling and dating were not done correctly then the residents run the risk of receiving expired food or getting food poising. The ADM stated it was the DM H 's responsibility to ensure that labeling and dating was occurring in the kitchen. The ADM stated they expected the kitchen to be kept as clean as possible to follow regulations. The ADM stated if the kitchen was not kept clean then the residents could get food borne illness. Review of kitchen cleaning schedules dated for the week of [DATE] reflected the weekly cleaning schedule had been completed for cleaning of the microwave, ovens, plate lowerator, and steam table. The weekly cleaning schedule for ingredient bins, janitors closet, and kitchen cabinets and drawers had not been completed. The monthly cleaning schedule had been completed for the freezers dated [DATE]. The monthly cleaning schedule for ice machine, kitchen floor power cleaned refrigerators and cooler, vent hood and filters, and surfaces-clean, vacuum, and dust behind and under appliances had not been completed. The daily cleaning schedule had been completed for Monday [DATE] for the following items: can opener, coffee machine, dish machine, juice machine, knife rack, microwave, range and grill, steam table, steamer and steam kettle. The daily cleaning schedule had not been completed on Monday [DATE] for the following items: storeroom, sinks ad faucets, scales, robocoupe & mixers & blenders, refrigerator & freezer & cooler wipe out and sweep, other equipment, food & dish carts, empty garbage, doors & walls & windows, cleaning cloths, counters, cutting boards, dining room tables & chairs & floors. Review of Cleaning Schedule policy dated [DATE] reflected under heading policy: The facility will maintain a cleaning schedule prepared by the Nutrition & Foodservice Manager and followed by employees as assigned to ensure that the kitchen is clean and free of hazards. Under heading procedure: 1. The Nutrition & Foodservice Manager will develop a cleaning schedule for daily, weekly, and monthly cleaning. Sample forms for daily cleaning, weekly cleaning, and monthly cleaning follow this policy. 2. Cleaning tasks will be assigned to positions and included in the job descriptions. 3. The cleaning list will be posted weekly and initialed off and dated by each employee upon completion of the task. The Nutrition & Foodservice Manager or designee will verify that the tasks were completed as assigned. Review of Food Storage policy dated [DATE] and revised on [DATE] reflected under heading policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes an HACCP guidelines. Under heading procedure: d. To ensure freshness. store opened and bulk items in tightly covered containers. All containers must be labeled and dated. e. Provide scoops for items stored in bins, such as sugar, flour, rice and other items. Store scoops covered in a protected area near the food containers. Wash and sanitize scoops weekly or as needed. f. Where possible, leave items in the original cartons placed with the date visible. g. Use the first-in, first-out (FIFO) rotation method. Date packages and place items behind existing supplies, so that the older items are used first. h. Store all items at least 6 above the floor with adequate clearance bet ween goods and ceiling to protect from overhead pipes and other contamination

Based on observations, interviews, and record review, the facility failed to ensure the meals served reflected the nutritional needs of residents in accordance with established national guidelines for all residents when the facility failed to ensure menus were followed for all residents for 2 of 2 meals observed. The facility failed to follow the posted menus for two lunch services served at the facility on Monday, 10/14/2024 and Tuesday, 10/15/2024. These failures could place residents that eat food from the kitchen at risk of poor intake, chemical imbalance, and/or weight loss. Findings included: Observation of posted menus on 10/14/2024 at 9:30 AM revealed menu items for lunch meal service to be chicken fried chicken, cream gravy, mashed potatoes, parslied carrots, dinner roll, and bread pudding. Observation of lunch meal service on 10/14/2024 at 12:08 PM revealed resident meal trays being served with chicken fried steak, cream gravy, mashed potatoes, parslied carrots, dinner roll, and bread pudding. Observation of posted lunch menus on 10/15/2024 at 10:40 AM revealed menu items for lunch meal service to be pinto beans and sausage, steamed rice, mixed greens, cornbread, and frosted red velvet cake. Observation of lunch meal preparation and pureed process on 10/15/2024 at 10:43 AM revealed residents on pureed diets were to be receiving pureed chicken. Further observation revealed all residents were to be receiving glazed vanilla cake. Observation revealed pureed residents did not receive pureed cornbread. Observation on 10/15/2024 at 1:15 PM of Resident # 3's tray card slip revealed menu items of pureed baked pork chop, pureed cornbread, and pureed red velvet cake. In an interview on 10/16/2024 at 11:22 AM The Dietary Manager stated the chicken fried chicken that was supposed to be on Monday lunch menu was unavailable. The Dietary Manager stated the RD had texted a response to DM H stating that the chicken fried steak was an appropriate substitution. The Dietary Manager stated when substitutions were made the substitution log was completed. The Dietary Manager stated any menu substitutions were communicated to residents and staff by being written on the dry erase board that was in the dining room and told to the residents when the dietary staff go to get daily meal selections. The Dietary Manager stated they had not completed the substitution log for the chicken fried chicken because they had not had the time to complete the log yet. The Dietary Manager stated they do not reprint the daily posted menus or the week at-a-glance menu when any substitutions were made since they write the menu with any substitutions on the dry erase board. This failure could affect the resident's negatively by them not knowing what foods are being served for their meals. In an interview on 10/16/2024 at 1:40 PM the ADM stated menus being followed was essential, so the resident was aware of the foods being offered. The ADM stated it was essential for the menus that were posted to be accurate. The ADM stated if the menus posted were not accurate this could negatively affect the residents because it could lead to resident confusion. The ADM stated it was the Dietary Managers responsibility to ensure the menus were posted and that they were accurate. The ADM stated they expected the substitutions logs to be completed and any substitutions to be communicated to the staff and residents. The ADM stated if the substitutions were not communicated to the residents that the residents could be surprised when they received their meals. Review of substitution log reflected no documentation for the lunch meal on 10/14/2024 of chicken fried steak being substituted for chicken fried chicken. Further record review of substitution log reflected documentation for lunch meal on 10/15/2024 incorrectly dated with date of 10/14/2024 for lunch meal pureed pork chops being substituted with pureed chicken. No documentation recorded for red velvet cake being substituted with vanilla cake. Review of the menu substitutions policy dated 10/1/2018 and revised on 06/01/2019 reflected under heading policy: The facility believes that a well-balanced menu, planned in advanced and served as posted, is important to the well-being of its residents. The menus will be served as planned except for emergency situations when a food item is unavailable. Under heading procedure: 4. All changes to the menu will be recorded on the Menu Substitution Approval Form. Review of the menu planning policy dated 10/1/2018 and revised on 06/01/2019 reflected under heading procedure: Dated current menus will be posted in all dining areas.

Based on observation, interview and record review the facility failed to immediately consult with the resident's physician; and notify the resident representative when there was a deterioration in health with a need to commence a new treatment for one (1) of five (5) residents reviewed for notifications (Resident #1). The facility failed to ensure Resident #1's Physician and family were notified when his pressure ulcer declined to an infected unstageable pressure ulcer on 01/06/2020. Resident #1 was admitted to the hospital on [DATE] [MEDICAL CONDITION] and required surgical intervention. These failure could cause severe pain, and lead to systemic infections causing harm or death for residents that have or are at risk for pressure ulcers. Findings: Review of Resident #1's Face Sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's Admission/ PPS 5-day Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #1 was assessed to have a Brief Interview of Mental Status score of seven (7) indicating severe cognitive impairment. Resident #1 was assessed to require extensive assist with all Activities of Daily Living (ADLs). Resident #1 was further assessed to be at risk for developing pressure ulcers and was assessed to have one (1) unstageable Deep Tissue Injury (DTI) (Persistent non-blanchable deep red, maroon or purple discoloration Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue.) Review of Resident #1's Comprehensive Care Plan dated 12/20/2019 reflected a focus area The resident was admitted with a DTI pressure ulcer to the sacral area related to decreased mobility, fragile skin. Interventions included to assess/record and monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD and to monitor/ document/ report any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size and stage. Resident #1's Comprehensive Care Plan further reflected a focus area The resident has the potential for impairment to skin integrity/ pressure ulcer development related to surgically closed rectal site, decreased mobility, and fragile skin. Further review of Resident #1's Comprehensive Care Plan reflected a focus area The resident is resistive to care by refusing to turn off of his back, refusing an air mattress, and refusing general care at times. In an interview on 02/08/2020 at 2:14 PM Resident #1's Family Member (FM) stated that Resident #1 was admitted to the facility with a pressure ulcer to his coccyx. The FM stated Resident #1's pressure ulcer was the size of a quarter and the facility staff stated the pressure ulcer was healing great. The FM stated on 01/07/2020 Resident #1 reported not feeling well and his spouse requested blood work. The FM stated on [DATE]20 the resident appeared dehydrated and lethargic. The FM stated the nursing staff stated they were waiting on lab work results that were drawn that morning and the Nurse Practitioner (NP) had seen him that morning and was in house waiting for the lab results. The FM stated she demanded Resident #1 be sent to the ER right away. The FM stated Resident #1 was admitted to the hospital with [REDACTED]. The FM stated Resident #1's pressure ulcer smelled of death and required multiple debridements and antibiotics. The FM stated the facility did not notify the family or the doctor about Resident #1's worsening pressure ulcer and they were shocked when they saw it in the hospital. Observation on 02/08/2020 of the Photo provided by the Resident #1's FM and time stamped 12/18/2019 at 10:26 AM revealed a sacral pressure ulcer approximately 6 cm x 5 cm and >.3 depth with a Stage III area on left of the sacral area with slough, and with multiple areas of possible DTI on right side of the sacral area. (approximations by Surveyor). Review of Resident #1's physician progress notes [REDACTED].#1 had a Stage III decubitus that opened up during his hospitalization to his sacrum. Review of Resident #1's Nursing Admission assessment dated [DATE] reflected Resident #1 was admitted for wound care and was assessed to have the following wounds Coccyx and Groin. The assessment did not include information on the type of wounds, measurements or stage. Review of the Facility's Pressure Ulcer/ Wound Log dated 12/23/2019 reflected no entry for Resident #1's sacral pressure ulcer. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's Weekly skin/ wound assessment dated [DATE] reflected Resident #1 was assessed to have a pressure ulcer to the sacrum area 2.5 cm x 2 cm (no depth). No stage was indicated. Review of the Facility's Pressure Ulcer/ Wound Log dated 12/30/2019 reflected an entry for Resident #1's DTI measuring 2.5 cm x 2 cm (no depth). Review of Resident #1's Weekly skin/ wound assessment dated [DATE] reflected Resident #1 was assessed to have a DTI to his sacrum. No measurements or stage was indicated. Review of Resident #1's Weekly skin/ wound assessment dated [DATE] reflected wound measurements of 6 cm x 8.8 cm no depth and necrotic tissue. Observation of the Facility's photo assessment dated [DATE] of Resident #1's sacral pressure ulcer revealed an unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar)pressure ulcer to his sacral area with necrotic tissue, slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) and redness. (indicating an infection). Review of Resident #1's Physician orders [REDACTED]. Review of Resident #1's Hospital Record dated [DATE]20 reflected after examination patient has decubitus ulcer which has black eschar over it with surrounding [DIAGNOSES REDACTED] and foul smell with discharge most likely infected. [DIAGNOSES REDACTED]. In an interview on 02/10/2020 at 10:44 AM the Treatment Nurse stated Resident #1 had a discoloration and a DTI to his sacral area on admission. The Treatment Nurse stated Resident #1's sacral pressure ulcer changed on 01/02/2020 but remained a DTI that was not open. The Treatment nurse stated she looked at it on Friday 01/03/2020 and it looked the same as the day before. The Treatment nurse stated she tried to call the wife to inform her about the change and the wound but was not able to get in touch with her. The Treatment Nurse stated when she came back to work on 01/06/2020 Resident #1's pressure ulcer had declined. The Treatment Nurse stated she assessed the pressure ulcer and told the Director of Nursing. The Treatment Nurse stated she did not call the Physician or send the assessment information to the Physician. In an interview on 02/10/2020 at 11:30 AM the NP stated she was in the facility on [DATE]20 to assess Resident #1 related to reports of a change in condition. The NP stated Resident #1 was experiencing altered mental status and felt he had some kind of infection and his urine had a foul odor, so she ordered lab work. The NP stated she was not notified on 01/06/2020 of a change in Resident #1's pressure ulcer. The NP stated she did not see the pressure ulcer on [DATE]20 related to residents change in condition. After looking at the facility's photo of Resident #1's pressure ulcer from 01/06/2020 the NP stated if the facility had notified her that his pressure ulcer looked like that she would have sent him out on 01/06/2020. The NP stated the pressure ulcer appeared infected. The NP stated she used to get weekly skin assessment from the facility but had no gotten them in a few months. The NP stated she was disappointed in the facility regarding the assessment and notification of changes in Resident #1's pressure ulcer. In an interview on 02/10/2020 at 3:44 PM the DON stated she could not remember if she went to see Resident #1's pressure ulcer on 01/06/2020. The DON stated she did not call Resident #1's NP regarding any change in his pressure ulcer. In an interview on 02/10/2020 at 4:10 AM the Administrator stated she expected the Treatment Nurse to do accurate weekly wound assessments and to notify the physician if there are changes in the wounds. The Administrator stated she asked the DON about notifying the physicians of the weekly wound assessments and the DON stated she stopped sending the notifications at the beginning of the year because their sister facilities weren't doing it. When asked how the facility was notifying the physicians about wounds she stated they were doing it verbally. The Administrator stated she instructed the DON to resume the weekly physician fax notification. Review of the facility's policy Pressure Ulcer Management dated 05/2012 reflected .Notify the physician on any changes in skin conditions .

Based on observation, interview and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing for one (1) five (5) residents reviewed for pressure ulcers. (Resident #1) The facility failed to ensure Resident #1 who was admitted with a Stage III pressure ulcers (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) to his sacral area on 12/20/2019 did not experience a decline in his pressure ulcer. The facility failed to thoroughly and accurately assess Resident #1's sacral pressure ulcer and failed to notify Resident #1's physician and family when his pressure ulcer declined to an infected unstageable pressure ulcer on 01/06/2020. Resident #1 was admitted to the hospital on [DATE] with an infected pressure ulcer and required surgical intervention. These failures could cause severe pain, and lead to systemic infections causing harm or death for residents that have or are at risk for pressure ulcers. Findings: Review of Resident #1's Face Sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's Admission/ PPS 5-day Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #1 was assessed to have a Brief Interview of Mental Status score of seven (7) indicating severe cognitive impairment. Resident #1 was assessed to require extensive assist with all Activities of Daily Living (ADLs). Resident #1 was further assessed to be at risk for developing pressure ulcers and was assessed to have one (1) unstageable Deep Tissue Injury (DTI) (Persistent non-blanchable deep red, maroon or purple discoloration Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue.) Review of Resident #1's Comprehensive Care Plan dated 12/20/2019 reflected a focus area The resident was admitted with a DTI pressure ulcer to the sacral area related to decreased mobility, fragile skin. Interventions included to assess/record and monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD and to monitor/ document/ report any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size and stage. Resident #1's Comprehensive Care Plan further reflected a focus area The resident has the potential for impairment to skin integrity/ pressure ulcer development related to surgically closed rectal site, decreased mobility, and fragile skin. Further review of Resident #1's Comprehensive Care Plan reflected a focus area The resident is resistive to care by refusing to turn off of his back, refusing an air mattress, and refusing general care at times. In an interview on 02/08/2020 at 2:14 PM Resident #1's Family Member (FM) stated that Resident #1 was admitted to the facility with a pressure ulcer to his coccyx. The FM stated Resident #1's pressure ulcer was the size of a quarter and the facility staff stated the pressure ulcer was healing great. The FM stated on 01/07/2020 Resident #1 reported not feeling well and his spouse requested blood work. The FM stated on [DATE]20 the resident appeared dehydrated and lethargic. The FM stated the nursing staff stated they were waiting on lab work results that were drawn that morning and the Nurse Practitioner (NP) had seen him that morning and was in house waiting for the lab results. The FM stated she demanded Resident #1 be sent to the ER right away. The FM stated Resident #1 was admitted to the hospital with [REDACTED]. The FM stated Resident #1's pressure ulcer smelled of death and required multiple debridements and antibiotics. The FM stated Resident #1 was on an air mattress at the facility and was at times non-complaint with turning. The FM stated the facility did not notify the family or the doctor about Resident #1's worsening pressure ulcer and they were shocked when they saw it in the hospital. The FM stated she took a picture of Resident #1's pressure ulcer on 12/18/2019 prior to admission to the facility. The FM stated Resident #1 had a catheter and a [MEDICAL CONDITION] bag. The FM stated Resident #1's rectum had been surgically closed. Observation on 02/08/2020 of the Photo provided by the Resident #1's FM and time stamped 12/18/2019 at 10:26 AM revealed a sacral pressure ulcer approximately 6 cm x 5 cm and >.3 depth with a Stage III area on left of the sacral area with slough, and with multiple areas of possible DTI on right side of the sacral area. (approximations by Surveyor). Further observed in the photo taken on 12/18/2019 was a surgically closed rectum. Review of Resident #1's physician progress notes [REDACTED].#1 had a Stage III decubitus that opened up during his hospitalization to his sacrum. Review of Resident #1's Nursing Admission assessment dated [DATE] reflected Resident #1 was admitted for wound care and was assessed to have the following wounds Coccyx and Groin. The assessment did not include information on the type of wounds, measurements or stage. Review of Resident #1's Physician order [REDACTED]. Review of the Facility's Pressure Ulcer/ Wound Log dated 12/23/2019 reflected no entry for Resident #1's sacral pressure ulcer. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's Weekly skin/ wound assessment dated [DATE] reflected Resident #1 was assessed to have a pressure ulcer to the sacrum area 2.5 cm x 2 cm (no depth). No stage was indicated. Review of the Facility's Pressure Ulcer/ Wound Log dated 12/30/2019 reflected an entry for Resident #1's DTI measuring 2.5 cm x 2 cm (no depth). Review of Resident #1's Weekly skin/ wound assessment dated [DATE] reflected Resident #1 was assessed to have a DTI to his sacrum. No measurements or stage was indicated. Review of Resident #1's Weekly skin/ wound assessment dated [DATE] reflected wound measurements of 6 cm x 8.8 cm no depth and necrotic tissue. Observation of the Facility's photo assessment dated [DATE] of Resident #1's sacral pressure ulcer revealed an unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar)pressure ulcer to his sacral area with necrotic tissue, slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) and redness. (indicating an infection). Review of Resident #1's Physician orders [REDACTED]. Review of Resident #1's Physician orders [REDACTED].#1's physician orders [REDACTED]. Review of Resident #1's Hospital Record dated [DATE]20 reflected after examination patient has decubitus ulcer which has black eschar over it with surrounding [DIAGNOSES REDACTED] and foul smell with discharge most likely infected. [DIAGNOSES REDACTED]. In an interview on 02/10/2020 at 10:44 AM the Treatment Nurse stated Resident #1 had a discoloration and a DTI to his sacral area on admission. The Treatment Nurse stated Resident #1's sacral pressure ulcer changed on 01/02/2020 but remained a DTI that was not open. The Treatment nurse stated she looked at it on Friday 01/03/2020 and it looked the same as the day before. The Treatment nurse stated she tried to call the wife to inform her about the change and the wound but was not able to get in touch with her. The Treatment Nurse stated when she came back to work on 01/06/2020 Resident #1's pressure ulcer had declined. The Treatment Nurse stated she assessed the pressure ulcer and told the Director of Nursing. The Treatment Nurse stated she did not call the Physician or send the assessment information to the Physician. In an interview on 02/10/2020 at 11:15 AM the DON stated Resident #1 was non-complaint with turning and he always wanted to stay on his back. When the DON was asked about the decline of Resident #1's sacral pressure ulcer she stated, Well I know he was non-complainant with turning. The DON stated Resident #1 had a change of condition and was sent to the hospital on [DATE]. In an interview on 02/10/2020 at 11:30 AM the NP stated she was in the facility on [DATE]20 to assess Resident #1 related to reports of a change in condition. The NP stated Resident #1 was experiencing altered mental status and felt he had some kind of infection and his urine had a foul odor, so she ordered lab work. The NP stated she was not notified on 01/06/2020 of a change in Resident #1's pressure ulcer. The NP stated she did not see the pressure ulcer on [DATE]20 related to residents change in condition. After looking at the facility's photo of Resident #1's pressure ulcer from 01/06/2020 the NP stated if the facility had notified her that his pressure ulcer looked like that she would have sent him out on 01/06/2020. The NP stated the pressure ulcer appeared infected. The NP stated she used to get weekly skin assessment from the facility but had no gotten them in a few months. The NP stated she was disappointed in the facility regarding the assessment and notification of changes in Resident #1's pressure ulcer. In an interview on 02/10/2020 at 3:44 PM the DON stated she could not remember if she went to see Resident #1's pressure ulcer on 01/06/2020. The DON stated she did not call Resident #1's NP regarding any change in his pressure ulcer. In an interview on 02/10/2020 at 4:10 AM the Administrator stated she expected the Treatment Nurse to do accurate weekly wound assessments and to notify the physician if there are changes in the wounds. The Administrator stated she asked the DON about notifying the physicians of the weekly wound assessments and the DON stated she stopped sending the notifications at the beginning of the year because their sister facilities weren't doing it. When asked how the facility was notifying the physicians about wounds she stated they were doing it verbally. The Administrator stated she instructed the DON to resume the weekly physician fax notification. Review of the facility's policy Pressure Ulcer Management dated 05/2012 reflected On admission every resident will have a skin assessment completed .Describe the location of any existing pressure ulcers. Stage any pressure ulcer present .comment regarding wound bed color, type of exudate if present, and odor .Notify the physician on any changes in skin conditions .

Based on observation, interview and record review the facility failed to ensure that 1 of 4 residents reviewed for falls received care by qualified persons in accordance with the written plan of care (Resident #9). Resident #9 had a care plan and physician's orders [REDACTED]. On [DATE], Certified Nurses Aide (CNA)/Nurses' Aide (NA) B manually transferred Resident #9 from her wheelchair to her bed. Resident #9 slid off of the bed and was assisted to the floor by CNA (NA) B resulting in a contusion with swelling and bruising to her right lower extremity. Resident #9 expired at the facility on [DATE]. This deficient practice caused bruising and swelling to Resident #9's right leg and could cause injury for 7 other residents in the facility, whose written plan of care includes the use of a Sara lift. Findings include: Review of the face sheet for Resident #9 reflected she was originally admitted to the facility on [DATE], readmitted on [DATE] and again on [DATE] with [DIAGNOSES REDACTED]. Review of consolidated physician's orders [REDACTED]. She received [MEDICATION NAME] (a blood thinner) daily. Added to the orders on [DATE]- "Use Sara Lift for all transfers per Resident #9 ' s request." Observation on [DATE] at 12:30 PM revealed Resident #9 lying in bed with the head of her bed elevated. She had ? side rails up on both sides of the bed. She was awake and alert but speaking unintelligibly. Her feet were elevated on pillows and she had bilateral heel protectors on. Her right leg had a fading bruise to her outer thigh and below her right knee. Review of the Incident Report dated [DATE] reflected that on [DATE] at 1:25 PM Resident #9 was eased to the floor by a "CNA" during a transfer. Resident #9 complained of right knee pain and discoloration (Hematoma-bruising) to the right inner forearm. The "CNA" did not let Resident #9 fall as she eased her to the floor. Review of Nurses' Notes dated [DATE] reflected the following: -During a transfer from wheelchair to bed at 1:25 PM the "CNA" eased Resident #9 to the floor off of the bed. Resident #9 complained of right knee pain and had discoloration to her right inner forearm. Resident #9 was placed back in bed after and assessed for any further injuries. Her right knee had no redness or [MEDICAL CONDITION]. Will continue to monitor. -Resident #9 complained of right knee pain at 8:00 PM. Her right knee was swollen and discolored. Resident #9's family was present and requested an X-ray be done tomorrow. Review of Nurses' Notes dated [DATE] reflected the following: -Resident #9 had blue bruising and swelling to her right lower extremity, from her knee down at 6:45 AM. -Received orders to transport Resident #9 to the emergency room (ER) for evaluation at 10:15 AM. -Resident #9's right leg had more [MEDICAL CONDITION] and a larger surface area of bruising to the right outer leg below the knee extending to the posterior calf area at 10:40 AM. -Emergency Medical Services (EMS) arrived and transported Resident #9 to the hospital at 10:50 AM. -Resident #9 returned to the facility by EMS at 4:50 PM. Her right lower extremity had a large amount of bruising and swelling. Review of a Fax dated [DATE] reflected Resident #9 returned from the ER with a [DIAGNOSES REDACTED]. Review of the current Care Plan dated [DATE] reflected Resident #9 had Arthritic Contractures of her hands, legs and feet. She was at risk for falls. She had the potential for pain secondary to [MEDICAL CONDITION] Arthritis. Review of the Acute Care Plan dated [DATE] reflected Resident #9 had an incident which was written in above the word "Fall" and the word "Fall" was crossed out, with injury to her right knee and right forearm. Resident #9 will have no further incidents ("Falls"-crossed out) and will be assessed for injury to her right knee and arm for the next 24 hours. Pain will be controlled and skin will remain intact until [MEDICAL CONDITION] resolves. Review of the undated Resident Status Sheet located at the nurses' station reflected Resident #9 was a two-person transfer using a Sara lift. Review of the Activities of Daily Living (ADL) sheets dated ,[DATE], ,[DATE] and ,[DATE] reflected that staff initialed daily that Resident #9 transferred with two staff and a lift. In an interview on [DATE] at 8:00 AM Licensed Vocational Nurse (LVN) A stated that Resident #9 had a fall about a week ago and had bruising and swelling from the knee down on her right leg which had since, spread up her lateral (outer) thigh. LVN A stated that it was not an actual fall because CNA (NA) B, who was assisting Resident #9 to transfer at the time, lowered her to the floor when she began to fall. LVN A further stated that the Resident Status Sheet at the nurses' station was the plan of care used by the CNAs and reflected the resident's daily needs. She confirmed that Resident #9's Resident Status Sheet did not have a date on it but stated that the sheet had Resident #9 to use a Sara lift with the assistance of two staff members for a very long time. In an interview on [DATE] at 8:15 AM the Director of Nurses (DON) stated that the CNA/NA B who transferred Resident #9 was a new CNA and it was about her fourth day of work. The DON stated that CNA/NA B did not use a Sara lift during the transfer on [DATE]. CNA/NA B was assigned to work along side another CNA. The DON stated that when she interviewed CNA/NA B about the incident, CNA/NA B informed her that Resident #9 told her that she could stand if she could help her sit on the bed. After Resident #9 sat on the bed she slid to the floor with the assistance of CNA/NA B and landed on her right leg. In an interview on [DATE] at 9:00 AM the Administrator stated that CNA/NA B did not have her Certification. She stated that she had completed the CNA course, but had not taken her exam. The Administrator stated that CNA/NA B was not to work without another staff member present. She stated that CNA/NA B was assigned to work with another CNA and should not have transferred Resident #9 by herself. In an interview on [DATE] at 9:30 AM the Director of Nurses (DON) stated that when CNA/NA B was hired, she had just completed the CNA class. The DON stated that she instructed CNA/NA B that she was to "shadow" another CNA. She stated that she reiterated that CNA/NA B was to be with another CNA at all times when providing care before CNA/NA B worked the floor. She stated that after CNA/NA B's first day she asked her if there was anything she needed or if she had any questions. Her only question was about the Activities of Daily Living (ADL) sheets. She stated that she told CNA/NA B that she didn't need to worry about those yet and she wanted CNA/NA B to focus on resident care first. The DON stated that she thought she made herself very clear that CNA/NA B was not to do resident care without a CNA until she got her Certification. The DON stated that CNA/NA B kept telling her that she was supposed to take the CNA exam at the end of the month but could never provide a scheduled date. In an interview on [DATE] at 9:55 AM CNA C stated that CNA/NA B was assigned to work with her on [DATE]. She stated that she was still in the dining room when she heard that Resident #9 had fallen. CNA C stated that CNA/NA B was not to provide care without a CNA. Review of the employee file for CNA/NA B reflected she was hired for the position as a CNA on [DATE]. There was no Certificate of Certification in her employee file. In an interview on [DATE] at 12:30 PM CNA (NA) B stated that she was a Nurses' Aide. She stated that she had completed the CNA course but had not taken the exam for Certification. She stated that she had only worked at the facility for four days. She stated that for the first few days she worked with a CNA but on that day she "really thought she was working on her own". She stated that she was not assigned to Resident #9 but took her to her room after lunch. She stated that Resident #9 wanted her to put her to bed and she told her that she had to get someone to help her. CNA (NA) B stated that Resident #9 said that she could stand and grab the side rail on the bed to transfer. So she pushed the wheelchair close to the bed so Resident #9 could grab the side rail. Resident #9 didn't stand so she helped her stand. She stated that she got Resident #9 sitting on the side of the bed all right but then Resident #9 started to slide off of the bed. CNA (NA) B stated that she grabbed her and lowered her to the floor. She stated that Resident #9 landed on her leg and started screaming. She stated that she tried to transfer Resident #9 by herself because Resident #9 said she could walk. CNA (NA) B stated that the day before, someone walked her around and pointed out all of the residents that used a mechanical lift but she had not worked on that hall yet and was not familiar with Resident #9 at all. She stated that she felt like she was just put out on the floor taking care of the residents and really didn't know what she was doing. When asked if she was instructed to work with a CNA she stated that she was, but was not clear that she couldn't do patient care on her own. Review of the CMS 672 reflected a facility census of 91. The facility identified 7 residents who required the use of a Sara lift for transfer.

Based on observation, interview and record review the facility failed to ensure that the environment remained free of accident hazards as possible and that each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents reviewed for falls (Resident #9). On [DATE] Certified Nurses' Aide/Nurses' Aide CNA/NA B manually transferred Resident #9 from her wheelchair to her bed. Resident #9 had a care plan and physician's orders [REDACTED]. Resident #9 slid off of the bed and was assisted to the floor by CNA/NA B resulting in a contusion with swelling and bruising to her right lower extremity. Resident #9 expired at the facility on [DATE]. This deficient practice caused bruising and swelling to Resident #9's right leg when she slid off her bed and had to be lowered to the floor with the potential for injury for 7 other resident's when the sara lift is not used for transfers as care planned. Findings include: Review of the face sheet for Resident #9 reflected she was originally admitted to the facility on [DATE], readmitted on [DATE] and again on [DATE] with [DIAGNOSES REDACTED]. Review of consolidated physician's orders [REDACTED]. She received Coumadin (a blood thinner) daily. Added to the orders on [DATE]- 'Use Sara Lift for all transfers per Resident #9's request'. Observation on [DATE] at 12:30 PM revealed Resident #9 lying in bed with the head of her bed elevated. She had ? side rails up on both sides of the bed. She was awake and alert but speaking unintelligibly. Her feet were elevated on pillows and she had bilateral heel protectors on. Her right leg had a fading bruise to her outer thigh and below her right knee. Review of the Incident Report dated [DATE] reflected that on [DATE] at 1:25 PM Resident #9 was eased to the floor by a "CNA" during a transfer. Resident #9 complained of right knee pain and discoloration (Hematoma-bruising) to the right inner forearm. The "CNA" did not let Resident #9 fall as she eased her to the floor. Review of Nurses' Notes dated [DATE] reflected the following: -During a transfer from wheelchair to bed at 1:25 PM the "CNA" eased Resident #9 to the floor off of the bed. Resident #9 complained of right knee pain and had discoloration to her right inner forearm. Resident #9 was placed back in bed after and assessed for any further injuries. Her right knee had no redness or edema. Will continue to monitor. -Resident #9 complained of right knee pain at 8:00 PM. Her right knee was swollen and discolored. Resident #9's family was present and requested an X-ray be done tomorrow. Review of Nurses' Notes dated [DATE] reflected the following: -Resident #9 had blue bruising and swelling to her right lower extremity, from her knee down at 6:45 AM. -Received orders to transport Resident #9 to the emergency room (ER) for evaluation at 10:15 AM. -Resident #9's right leg had more edema and a larger surface area of bruising to the right outer leg below the knee extending to the posterior calf area at 10:40 AM. -Emergency Medical Services (EMS) arrived and transported Resident #9 to the hospital at 10:50 AM. -Resident #9 returned to the facility by EMS at 4:50 PM. Her right lower extremity had a large amount of bruising and swelling. Review of a Fax dated [DATE] reflected Resident #9 returned from the ER with a [DIAGNOSES REDACTED]. Review of the current Care Plan dated [DATE] reflected Resident #9 had Arthritic Contractures of her hands, legs and feet. She was at risk for falls. She had the potential for pain secondary to Rheumatoid Arthritis. Review of an Acute Care Plan dated [DATE] reflected Resident #9 had an incident which was written in above the word "Fall" and the word "Fall" was crossed out, with injury to her right knee and right forearm. Resident #9 will have no further incidents ("Falls"-crossed out) and will be assessed for injury to her right knee and arm for the next 24 hours. Pain will be controlled and skin will remain intact until edema resolves. On [DATE] she was evaluated in the emergency room (ER) and returned to the facility with [DIAGNOSES REDACTED]. Documented at the bottom of the Acute Care Plan with a date of [DATE] 'DO NOT take resident out of bed per her Responsible Party (RP)'. Review of the undated Resident Status Sheet located at the nurses' station reflected Resident #9 was a two-person transfer using a Sara lift. Review of the Activities of Daily Living (ADL) sheets dated ,[DATE], ,[DATE] and ,[DATE] reflected that staff initialed each day that Resident #9 transferred with two staff and a lift. In an interview on [DATE] at 8:00 AM Licensed Vocational Nurse (LVN) A stated that Resident #9 had a fall about a week ago and had bruising and swelling from the knee down on her right leg which had since, spread up her lateral (outer) thigh. LVN A stated that it was not an actual fall because CNA/NA B , who was assisting Resident #9 to transfer at the time, lowered her to the floor when she began to fall. LVN A stated that following the fall, Resident #9's family, who rarely visited, began visiting daily. LVN A further stated that the Resident Status Sheet at the nurses' station was the plan of care used by the CNAs and reflected the resident's daily needs. She confirmed that Resident #9's Resident Status Sheet did not have a date on it but stated that the sheet had Resident #9 to use a Sara lift with the assistance of two staff members for a very long time. LVN A stated that Resident #9 had been slowly declining mentally for the past year. However, she was able to speak clearly. She also stated that Resident #9 was confused at time and would talk about her kids as though they were still small children as she would talk as if she was still in her younger years. LVN A stated that prior to Resident #9's fall on [DATE], her condition seemed to be improving and she was getting out of bed more often, but after the fall, she began staying in bed more often. LVN A stated that while Resident #9 was staying in bed her health began to decline once again. LVN A stated that on [DATE] at approximately 10:00 AM, Resident #9's RP requested an X-ray of her right leg. She stated that a Fax had already been sent to Resident #9's physician requesting an X-ray earlier that morning. LVN A stated that she then called the physician's assistant who had just talked to one of Resident #9's family members, and received orders to send Resident #9 to the ER for evaluation. In an interview on [DATE] at 8:15 AM the Director of Nurses (DON) stated that the CNA who transferred Resident #9 was a new employee and it was only her fourth day at work. The DON stated that CNA/NA B did not use a Sara lift during the transfer on [DATE]. She stated that CNA/NA B was assigned to work with another CNA. The DON stated that when she interviewed CNA/NA B about the incident, CNA/NA B stated that Resident #9 told her that she could stand if she could help her sit on the bed. After Resident #9 sat on the bed she slid to the floor landing on her right leg. She stated that after the incident, she did explain to Resident #9's RP that Resident #9 was lowered to the floor and explained that the bruising may get worse due to her Coumadin therapy. In an interview on [DATE] at 9:00 AM the Administrator stated that CNA/NA B did not have her Certification. She stated that she had completed the CNA course but had not taken her exam. The Administrator stated that CNA/NA B was not to work without another staff member present. She stated that CNA/NA B was assigned to work with another CNA and should not have transferred Resident #9 by herself. In an interview on [DATE] at 9:30 AM the DON stated that when CNA/NA B was hired she explained to her that she would be paired with another CNA and she was to be their shadow. She had not taken her Certification exam yet. She stated that she reiterated that CNA/NA B was to be with another CNA at all times when providing care before CNA/NA B worked the floor. She stated that after CNA/NA B's first day she asked her if there was anything she needed or if she had any questions. Her only question was about Activity of Daily Living (ADL) sheets. She stated that she told CNA/NA B that she didn't need to worry about those yet and she wanted CNA (NA) B to focus on resident care first. The DON stated that she thought she made herself very clear that CNA/NA B was not to do resident care without a CNA until she got her Certification. In an interview on [DATE] at 9:55 AM CNA C (DE) stated that CNA/NA B was assigned to work with her on [DATE]. She stated that she was still in the dining room when she heard that Resident #9 had fallen. CNA C stated that CNA/NA B was not to provide care without a CNA. Review of the employee file for CNA/NA B reflected she was hired on [DATE] for a CNA position however; there was no Certificate of Certification in her file. In an interview on [DATE] at 12:30 PM CNA/NA B stated that she was a Nurses' Aide. She stated that she had completed the CNA course but had not taken the exam for Certification. She stated that she had only worked at the facility for four days. She stated that for the first few days she worked with CNA but on that day she "really thought she was working on her own". She stated that she was not assigned to Resident #9 but took her to her room after lunch. She stated that Resident #9 wanted her to put her to bed and she told her that she had to get someone to help her. CNA/NA B stated that Resident #9 said that she could stand and grab the side rail on the bed to transfer. So she pushed the wheelchair close to the bed so Resident #9 could grab the side rail. Resident #9 didn't stand so she helped her stand. She stated that she got Resident #9 sitting on the side of the bed all right but then Resident #9 started to slide off of the bed. CNA/NA B stated that she grabbed her and lowered her to the floor. She stated that Resident #9 landed on her leg and started screaming. She stated that she transferred Resident #9 by herself because Resident #9 said she could walk. CNA/NA B stated that the day before, someone walked her around and pointed out all of the residents that used a mechanical lift but she had not worked on that hall yet and was not familiar with Resident #9 at all. She stated that she felt like she was just put out on the floor taking care of the residents and really didn't know what she was doing. When asked if she was instructed to work with a CNA she stated that she was but was not clear that she couldn't do patient care on her own. Review of the CMS 672 reflected a facility census of 91. The facility identified 7 residents who required the use of a Sara lift for transfer.