Every finding on record at Avir at Commerce

Based on observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete, and accurately documented for 1 of 4 (Resident #1) residents reviewed for medical records. The facility failed to document and record in the electronic medical record attempts at titration (gradual reduction) of Resident #1's oxygen rate according to physician's order. This failure could place residents at risk of inaccurate and complete records. The findings included: Record review of Resident #1's face sheet, dated 07/07/2026, revealed an [AGE] year-old female admitted [DATE] and readmitted [DATE] with diagnoses that included Alzheimer's Dementia (a progressive brain disease and the most common cause of memory loss), dysphagia (difficulty swallowing), heart failure (occurs when the heart muscle is too weak or stiff to pump enough oxygen-rich blood to meet the body's needs), chronic pulmonary edema (a long-term buildup of fluid in the lungs), hypertension (high blood pressure), hypothyroidism (a condition where the thyroid gland does not produce enough thyroid hormones to meet the body's needs), diabetes type II (a chronic condition where the body does not produce insulin causing sugar buildup in the bloodstream), seizures (a sudden, uncontrolled surge of abnormal electrical activity in the brain), hyperlipidemia (abnormally high levels of fats in the blood), anxiety (feelings of tension, worried thoughts and physical changes that increase the heart rate), and major depressive disorder (a serious mood disorder causing persistent sadness, emptiness, and loss of interest). Record review of Resident #1's significant change MDS assessment, dated 07/01/2026, revealed highly impaired hearing, unclear speech, was usually understood by others, sometimes understood what was said to her and wore glasses due to impaired vision. Resident #1 was unable to complete the BIMS assessment, and the staff assessment revealed short-term and long-term memory deficit with severely impaired cognitive skills for daily decision making. Resident #1 required the use of a wheelchair for mobility, moderate assistance with eating, maximum assistance with upper body dressing and was totally dependent in toileting, bathing, lower body dressing, bed mobility, transfers and wheelchair mobility. Record review of Resident #1's physician's orders revealed an order dated 06/23/2026 for O2 at 2LPM N/C q shift, check O2 Sats as needed. Further review of Resident #1's physician's orders revealed an order dated 07/01/2026 to taper (gradually reducee) and discontinue oxygen as needed every shift to maintain oxygen saturation level (measured using a device that clips onto the finger to estimate the amount of oxygen in the blood) greater than 90%. Record review of Resident #1's June 2026 MAR revealed oxygen saturation levels were monitored every shift from 06/23/2026-06/30/2026 while receiving oxygen with no evidence of attempts to titrate oxygen rate recorded. Record review of Resident #1's July 2026 MAR revealed oxygen saturation levels were monitored every shift from 07/01/2026-07/07/2026 while receiving oxygen with no evidence of attempts to titrate oxygen rate recorded. Record review of nursing progress notes from 06/23/2026 - 07/07/2026 did not reveal any evidence that nursing staff attempted to titrate resident's oxygen. During an observation and attempted interview with Resident #1 on 07/07/2026 at 11:19 a.m. revealed the resident was receiving oxygen via nasal cannula at 2 liters. Resident #1 was observed lying in bed, clean and odor free and was minimally responsive to direct questions. No signs of distress were indicated. During an interview on 07/07/2026 at 12:53 p.m., LVN A stated she attempted to titrate Resident #1's oxygen but that attempts were unsuccessful, and resident was not able to maintain oxygen levels above 90% without the use of supplemental oxygen. LVN A stated she had not recorded the attempts in the EMR. LVN A stated that this failure did not necessarily effect the resident's well-being because she did check her oxygen saturations after lowering Resident #1's oxygen rate and observed that the resident was not able to maintain a lower level of oxygen and immediately raised the oxygen rate. During an interview on 07/07/2026 at 1:24 p.m., LVN B stated she was aware Resident #1 was on continuous (constant) oxygen but that she had not made attempts to titrate the rate of oxygen because she had not recently worked with Resident #1. During an interview on 07/07/2026 at 1:35 p.m., the MDS Nurse stated she had completed the significant change assessment for Resident #1 after readmission on hospice services. The MDS Nurse stated she was aware of the orders to attempt to titrate the oxygen rate for Resident #1 and that so far the attempts were unsuccessful. After reviewing the EMR, the MDS Nurse confirmed that the nursing staff did not document attempts to titrate the oxygen rate and that this could put the resident at risk for receiving medication that they may not have needed. During a telephone interview on 07/07/2026 at 2:00 p.m., LVN C confirmed that she made attempts to titrate the oxygen rate for Resident #1, that the attempt was not successful and that she did not document the results in the electronic medical record. LVN C stated that the risk to the resident was minimal, and that the medical records did not accurately reflect the work she did. During an interview on 07/07/2026 at 3:30 p.m., the DON confirmed that she had viewed the EMR and that the nursing staff were not documenting their attempts to titrate Resident #1's oxygen rate. The DON stated she believed attempts were made, so the risk to Resident #1 receiving medication she did not need was minimal, and that the risk of inaccurate documentation did not directly affect the resident. The DON confirmed that it was important that the EMR accurately reflect the implementation of the physician's orders and the order should have been discontinued after attempts to titrate the oxygen levels were unsuccessful, and the physician notified that Resident #1 did not tolerate a lower level of oxygen. The DON stated it is ultimately her responsibility to ensure that the orders are correctly recorded in the EMR to ensure accurate documentation. During an interview on 07/07/2026 at 3:45 p.m., the Administrator stated that the DON was ultimately responsible for ensuring the accuracy of the medical records and that he would assist in monitoring by completing spot checks of assessment documentation with the DON. Record review of the facility policy titled, Oxygen Administration, revised October 2010, revealed, Documentation: .the following information should be recorded in the resident's medical record: 3. The rate of oxygen flow, route, and rationale; 6. All assessment data obtained before, during, and after the procedure; and 7. How the resident tolerated the procedure.

Based on interview and record review the facility failed to develop and implement a comprehensive person centered care plan for 3 of 3 residents reviewed for care plan.The facility failed to implement the intervention to keep glasses clean for Residents #1 and Resident #3. The facility to develop a care plan with interventions for Resident #2's eyeglasses to ensure they stay clean. This failure could place residents at risk of falls and decrease quality of life. Findings include:Record review of Resident #1's face sheet dated 05/28/2026 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included COPD (Chronic Obstructive Pulmonary Disease, a progressive lung disease that makes it difficult to breathe), malnutrition (a deficiency or imbalance of nutrients that affect the body's health and development), lumbar radiculopathy (a condition in which a nerve root in the lower back becomes compressed or irritated causing pain), dysphagia (difficulty swallowing), hyperlipidemia (elevated levels of cholesterol in the blood) and hypertension (high blood pressure). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed impaired vision with the use of prescription glasses and a BIMS score of 12 which indicated moderate cognitive impairment. Record review of Resident #1's care plan dated 05/14/2026 revealed a focus area of visual impairment with interventions that included ensuring appropriate visual aids were available, clean, free from scratches and in good repair and focus area reflected at risk for falls with a recent fall on 03/20/2026.In an interview and observation on 05/28/2026 at 11:39 a.m., Resident #1 was observed wearing prescription glasses that had a film like pattern on both lenses. Resident #1 stated she wears her glasses every day but does not have anything to clean them with but tissues and that does not work very well. Resident #1 confirmed she has seen an eye doctor and the glasses were still good. Resident #1 stated she does not recall if the staff have cleaned her glasses.Record review of Resident #2's face sheet dated 05/25/2026 revealed a [AGE] year-old male admitted [DATE] with diagnoses which included autistic disorder ( a condition related to brain development that impacts how a person perceives and socializes with others), Diabetes Mellitus Type II (a chronic condition in which the body does not produce enough insulin or cannot use the insulin effectively leading to high blood sugar), Hyperlipidemia (elevated levels of cholesterol in the blood), Hypertension (high blood pressure), and Major Depression disorder (sever and persistent low mood, sadness or sense of despair).Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed impaired vision with the use of prescription glasses and a BIMS score of 99 indicating he was unable to complete the BIMS assessment, and the staff assessment indicated short term and long term memory deficits with impaired decision-making skills.Record review of Resident #2's care plan dated 03/27/2026 revealed a focus area of impaired visual function with interventions that included ensuring appropriate visual aids were available and focus area reflected at risk for falls due to poor balance and safety with no recent falls noted. The care plan did not address the cleaning of the resident's glasses. In an interview and observation on 05/28/26 at 10:43 a.m., observed a light-colored dust like substance on both lenses. Resident #2 stated, they are dirty, but they work. Resident #2 was unable to recall if staff members assisted him with cleaning his glasses. Record review of Resident #3's face sheet dated 05/28/2026 revealed a [AGE] year-old female admitted [DATE] and readmitted [DATE] with diagnoses which included cerebral infarction (a medical condition that occurs when blood flow is blocked to the brain), dysphagia (difficulty swallowing), congestive heart failure (a chronic condition where the heart muscle becomes too weak to pump blood effectively), Osteoarthritis (a type of arthritis that affects joints), Hypertension (high blood pressure), Guillain-Barre Syndrome (a neurological disorder where you immune system mistakenly attacks your peripheral nerves).Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed Resident #3 had impaired vision with the use of prescription glasses and a BIMS score of 15 which indicated intact cognition. Record review of Resident #3's care plan dated 05/07/2026 revealed a focus area that indicated impaired visual function with interventions that included ensuring appropriate visual aids were available, clean, free from scratches and in good repair and focus area reflected at risk for falls due to weakness and paresis with no recent falls.In an interview and observation on 05/28/2026 at 11:58 a.m., Resident #3 was observed wearing glasses that had a yellow dried substance on the left lens. When the surveyor stated that the glasses appeared to be dirty, Resident #3 removed the glasses, shook them and said, Yes! Resident #3 had difficult speech and was unable to provide further information. Resident #3 could not report if staff members have assisted her with cleaning her glasses.In an interview on 05/28/2026 at 11:55 a.m., CNA A stated that many of her residents wore glasses and that if they were broken or missing, she would notify the charge nurse. CNA A stated that cleaning of glasses is not on the assignments, but that the staff should help the residents keep their glasses clean to help them see better.In an interview on 05/28/2026 at 12:03 p.m., LVN B stated that she expects the nurse aids to help keep the residents' glasses clean and if she observed that a resident's glasses were dirty, she would clean them herself. LVN B stated dirty glasses could cause difficulty seeing and increase potential for falls.In an interview on 05/28/2026 at 12:18 p.m., LVN C stated that keeping resident glasses clean should be part of the daily routine and if the glasses were dirty, could affect the resident's safety and ability to complete daily tasks.In an interview on 05/28/2026 at 12:22 p.m., CMA D stated that it was important to keep the residents' glasses clean on a daily basis to help them with their daily routine. CMA D stated she would clean them if she noticed they were dirty.In an interview on 05/28/2026 at 12:30 p.m., the Social Worker stated that she is only at the facility two days a week and does not usually check the resident's glasses for cleanliness, but that if she observed a resident's glasses were dirty, she would clean them. The Social Worker stated she does assist with scheduling optometry exams as needed. The Social Worker stated that if a resident's glasses were not cleaned, it could cause them to have difficulty seeing.In an interview on 05/28/2026 at 1:54 p.m., the Activity Director stated that she does assist with cleaning the residents' glasses when needed. Stated she would try to check them when they are at an activity event or when she visited them in their rooms. The Activity Director stated it was important for the residents to have clean glasses to help them with their daily movements and care. The surveyor advised the Activity Director of the three residents observed to have dirty glasses and she stated she would clean them. In an interview on 05/28/2026 at 2:07 p.m., CNA E stated he had been working at this facility since August of 2025 and that the cleaning of glasses was not specifically assigned to the nurse aids, but that it should be the responsibility of all staff. CNA E stated that a good number of residents wear glasses and that whenever he sees the glasses are dirty, he will take the time to clean them. CNA E stated this is not part of the assignment specifically, but that it is important for the residents' well-being and to make the day easier.In an interview on 05/28/2026 at 2:17 p.m., CNA F stated she had been working at the facility for approximately one week and that even though she was not specifically trained to ensure the glasses are clean, it was a task that she learned in CNA school. CNA F stated that she had not noticed that any of her assigned residents had dirty glasses, but that if she observed their glasses were dirty, she would clean them, In an interview on 05/28/2026 at 2:28 p.m., CNA G stated that she had been working at this facility for approximately 3 weeks and that to her knowledge, cleaning glasses is not part of the nurse aid assignment. CNA G stated that it is important that residents' glasses are clean for the residents that need them to help the residents see clearly. CNA G stated she would clean the glasses if she observed they were dirty.In an interview on 05/28/2026 at 2:40 p.m., the DON stated that she expects all staff to be observant when working with the residents and to assist in cleaning of glasses as needed. The DON stated that dirty glasses could cause the residents to have increased vision impairment which could result in falls and injury, poor self-esteem and behavioral changes.In an interview on 05/28/2026 at 2:50 p.m., the Administrator stated he expects all facility staff to assist in cleaning of residents' glasses if they are dirty and that this is not a task that can only be done by the nursing department. The Administrator stated failure to ensure the residents had clean and serviceable glasses could result in diminished quality of life for the residents and that he would monitor that glasses are clean and serviceable through daily spot checks of residents who wear glasses.

Based on interview and record review the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis or have a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for nursing services.The facility did not have 8 hours of RN coverage for 17 of 121 days (10/10/25, 10/11/25, 10/12/25, 10/16/25, 10/17/25, 10/18/25, 10/19/25, 11/15/25, 12/01/25, 12/14/25, 12/21/25, 12/25/25, 01/18/26, 01/24/26, 01/27/26, 01/28/26 and 02/06/26).The facility did not have a designated DON to work full time of at least 40 hours a week from 01/20/26 till current (02/12/26).This deficient practice could place 49 residents at risk of not receiving adequate care by not having staff available with the ability to perform assessments as needed. Findings included: Record review of the facility RN timesheets revealed there were no RN hours for 10/10/25 10/11/25, 10/12/25, 10/16/25, 10/17/25, 10/18/25, 10/19/25, 11/15/25, 12/1/25, 12/14/25, 12/21/25, 12/25/25, and 1/24/26. Record review of the facility RN timesheets revealed there were not 8 hours of RN coverage on the following dates:1/18/26 had 7.32 hours, 1/27/26 had 3.25 hours, 1/28/26 had 6.25 hours and 2/6/26 had 4.75 hours. Record review of the facility time sheets revealed RN K was employed 10/01/25 through 11/23/25. The time sheet did not indicate any hours worked on 10/10/25, 10/11/25, 10/12/25, 10/16/25, 10/17/25, 10/18/25, and 10/19/25 for RN K. Record review of the facility time sheets revealed RN L was employed 12/15/25 through 01/20/26. The time sheet did not indicate any hours worked on12/1/25, 12/14/25, 12/21/25, or 12/25/25 for RN L. Record review of the facility time sheets revealed the ADON was employed 12/22/25 through present (02/12/26). The time sheet did not indicate any hours worked on12/25/25 or 1/24/26 and 7.32 hours on 1/18/26, 3.25 hours on1/27/26, 6.25 hours on 1/28/26, and 4.75 hours on 2/6/26 During an observation and interview 02/12/26 at 9:16 a.m., Human Resources said she knew they had no RN coverage on 10/10/25 10/11/25, 10/12/25, 10/16/25, 10/17/25, 10/18/25, and 10/19/25 because RN K had requested those dates off. She said she could not say about the other days but verified she had no time punch for RN's on 12/1/25, 12/14/25, 12/21/25, 12/25/25, and 1/24/26. She said the prior DON E's last physical day of work was 01/20/26. She said they have not had a DON for the facility since 01/20/26. During an interview 02/12/26 at 11:08 a.m., the ADON said she started working at the end of December 2025 till present. She said she started out as the weekend supervisor and started the ADON position three weeks ago. She said when she did work at the facility she clocked in for her time. She said she did not work 12/25/25 because she thought she was sick, or 1/24/26 because of the weather. She said she thought she had worked 8 hours on 1/18/26. She said she had doctors' appointments on 1/27/26, 1/28/26 and 2/6/26 and had left early. She said during those times there was not another RN working the facility to cover for her. During an interview 02/12/26 at 1:58 p.m., RN K said she worked from October 2025 through end of November 2025 as the ADON. She said she had prior engagement on the following days and did not work them, 10/10/25 10/11/25, 10/12/25, 10/16/25, 10/17/25, 10/18/25, and 10/19/25. She said she had told an unknown person prior to being hired that she could not work those days. She said she could not say about 11/15/25 but said she clocked in when she did work at the facility. During an interview on 02/12/26 at 3:56 p.m., the ADON said they did not have a DON currently. She said they hired a new DON whose attentive date of hire would be in March 2026. She said she did not know the last date of employment for the previous DON but knew it was in January 2026. During an interview on 02/12/26 at 4:15 p.m., the Administrator said he did not have a waiver for the DON. He said he started at the facility 01/28/26 and when he was hired, they did not have a DON. He said he was aware of the regulation that an RN had to be in the facility for 8 hours daily. He said he had the ADON who was an RN and thought she was working 8 hours per day. He said he was not aware of the DON or RN hours before he started working at the facility. The Administrator said they required an RN to work 8 hours daily to carry out the daily aspects of the facility. The policy for RN/DON coverage was requested but was not provided. During a phone interview on 02/12/26 at 6:00p.m., RN L said she was employed from the middle of December 2025 to the end of January 2026 but could not recall exact dates. This surveyor asked about the following dates: 12/1/25, 12/14/25, 12/21/25, and 12/25/25. She said she did not work 12/25/25 but could not recall if she worked the other dates. She said when she did work, she clocked in. Review of document titled, Job Description Director of Nursing undated, revealed: The primary role of the Director of Nursing (DON) is to plan, develop, organize, and direct the day-to-day functions of the Nursing Services Department in accordance with current Federal, State and local regulations as well as maintain compliance with policies and procedures. The DON ensures that the highest degree of quality care is maintained. The Director of Nursing has delegated administrative authority, responsibility, and accountability to carry out your assigned duties. In the absence of the Administrator, you are charged with carrying out the policies established by the Facility. The DON Maintains the Rights of Residents as set forth by the Texas Department of Health laws and regulations. Review of document titled, Job Description Registered Nurse undated, revealed: The primary purpose of your job position is to provide direct nursing care to the residents and to supervise the day-to-day nursing activities of your assigned unit. Such supervision must be in accordance with current Federal, State, and local standards, guidelines and regulations that govern the Long-term care facility, as well as our established policies and procedures, and as may be directed by the Director of Nursing Services, to ensure that the highest degree of quality care is always maintained.

Based on observation, interview, and record review, the facility failed to establish policies regarding smoking areas, and smoking safety for 1 of 1 smoking area reviewed for physical environment. 1. The facility failed to provide a metal container with a self-closing cover device. 2. The facility did not ensure smoked cigarettes were extinguished in a fire-retardant receptacle. This failure could place residents at risk of unsafe smoking and injury.Findings Included:During an observation on 02/10/26 at 6:01 p.m., a group smoke break of five residents smoking revealed cigarette butts on the ground outside in the smoking area, trash in the red noncombustible cigarette butt receptacle can, and the self-closing ashtray was malfunctioning. During the observation cigarettes were put on top of the self-closing ashtray with other old cigarette butts. During an interview on 02/10/26 at 6:15 PM, the Director of Dietary Services stated she was responsible for the 6:00 p.m. smoke break. The Director of Dietary Services stated there should not be trash in the red receptacle where cigarette butts were thrown, cigarette butts were to not be on the ground, and the ashtrays should be fully functioning. The Director of Dietary Services stated the residents were at risk of fire and burning due to incorrectly extinguishing the cigarette butts. During an interview on 02/11/26 at 9:15 a.m., the Maintenance Director stated he was unaware there was trash in the red receptacle can, there were cigarette butts on the ground, and the ashtrays were not functioning properly. The Maintenance Director stated he was responsible for ensuring the facility was in good repair. The Maintenance Director stated the residents were at risk of fire when cigarettes were not properly extinguished. The Maintenance Director stated he was one of the many people from each department that was assigned to take the residents out to smoke. The Maintenance Director stated he did not have any in-services to ensure all staff were aware of their responsibilities. The Maintenance Director stated he performed morning rounds daily, Monday-Friday, to check for issues in the repair of the facility and in these rounds, he observed the smoking area. The Maintenance Director stated that he did random rounds, indicating he did not check daily. During an interview on 02/12/26 at 2:31 p.m., the Housekeeping Supervisor stated she was responsible for ensuring the facility was well kept and cleaned. The Housekeeping Supervisor stated she was unaware of the cigarette butts on the ground, the trash in the cigarette butt disposal can, and the malfunctioning ashtray. The Housekeeping Supervisor stated the facility was at risk of fire. During an interview on 02/12/26 at 3:50 p.m., the ADON stated she expected the Maintenance Director to get a cigarette disposal metal can that did not have trash in it and ashtrays that were fully functioning. The ADON stated the facility was at risk of causing a fire and putting residents at a safety risk. The ADON stated she had not done an in-service since she took the ADON position three weeks prior. The ADON stated the facility scheduled smoking breaks by department. The ADON stated at each scheduled smoking time, a staff member was assigned to the outdoor smoking area to directly observe residents during the smoking break to ensure supervision and safety. The ADON stated nursing completed safe smoking assessments. During an interview on 02/12/2026 4:48 p.m., the Administrator revealed he expected the smoking area to be free of cigarette butts on the ground, functional ashtrays, and there should not be trash in the red can used to dispose of cigarette butts. The Administrator stated residents during smoke break were at risk of fire due to the cigarette butts on the ground, the trash in the red can, and self-closing ashtrays not functioning. The Administrator stated housekeeping, and maintenance should be checking those areas daily during their rounds and smoking schedule assignments are done by department. The Administrator stated it was his responsibility to educate and in-service them on smoking safety. The Administrator stated nursing clinical staff completed safe smoking assessments. The Administration stated he along with other department administrators were responsible for rounding every day to check for safety. The Administration claimed responsibility for ensuring and monitoring staff scheduled to supervise smoking breaks were informed of their duties related to resident safety, disposal of cigarette butts, and the smoking areas. Record review of the facility policy titled, Smoking Policy- Resident, dated October 2022, revealed.Metal containers, with self-closing cover devices, are available in smoking area and ashtrays are emptied only into designated receptables.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen and 1 of 2 residents (Resident #23 and Resident #35) reviewed for food safety. 1.The facility failed to ensure they had pasteurized eggs in the refrigerator. 2.The facility failed to ensure the Maintenance Supervisor wore a hairnet and beard guard while in the kitchen on 02-09-26. These failures could place residents at risk for food contamination and foodborne illness. Findings included:1. During observations with Dietary Manager on 02/09/25 beginning at 9:39 am, the following observation was made in the kitchen Refrigerator (1 of 2): 1 box of 80 unpasteurized eggs.During an observation and interview on 02/10/26 at 10:00 a.m., the Dietary Manager said she did not know the eggs were unpasteurized until state surveyor intervention. The Dietary Manager said two residents received fried eggs, Resident #23 and Resident #35. She said sometimes their eggs would be soft fried (characterized by fully set, tender whites and a warm, liquid yolk) but mostly hard fried. She said she instructed staff not to prepare any more fried eggs until the pasteurized eggs were delivered. She said she knew the potential of fried eggs not cooked properly could make the resident sick.During an interview on 02/10/26 at 2:16 p.m., Resident #23 said she received fried eggs. She said sometimes they were runny or soft fried eggs and other times they were fried hard. She said she never had any illness related to the eggs being runny.During an interview on 02/10/26 at 2:17 p.m., Resident #35 said she received fried eggs, but could not say if they were fried hard or soft fried. She denied being sick related to receiving fried eggs.2. During an observation and interview on 02/09/26 at 12:34 p.m., the Maintenance Supervisor walked into the kitchen without a hair net or beard covering. He proceeded to walk past the stove to the sink where he washed off a part belonging to the ice machine. The Maintenance Supervisor said he was supposed to put on a beard guard when he entered the kitchen. He said he forgot. He said he had not been wearing a hairnet when he entered the kitchen because he wore a baseball cap. The Maintenance Supervisor was observed with hair hanging outside of the baseball cap. The Maintenance Supervisor said there was hair hanging and uncovered by the baseball cap. He said he should have worn a beard guard and hairnet to prevent hair from getting into the food.During an interview on 02/10/26 at 10:00 a.m., the Dietary Manager said she was responsible for the kitchen and was responsible for ensuring any person who entered the kitchen wore a hairnet and beard guard if needed. She said a hairnet or beard guard should be worn to prevent hair from getting into the food. During an interview on 02/10/26 at 3:56 p.m., the ADON said everyone that entered the kitchen should have on a hairnet. She said if someone had a beard then they should put on a beard guard. She said both were needed to protect hair from getting in the food. She said the kitchen staff should redirect anyone coming into the kitchen without a hairnet or beard guard and the Dietary Manager was responsible to ensure no one came into the kitchen without a hairnet or beard guard. She said she was not sure about the process of pasteurized eggs or the potential if not cooked properly. She said the Dietary Manager was responsible for ensuring they had the correct type of eggs in the kitchen.During an interview on 02/10/26 at 4:15 p.m., the Administrator said he expected the kitchen staff to follow the policy. He said if someone did not have proper protection (hairnet/beard guard) they could potentially get hair in the food. The Administrator said if a resident had an unpasteurized egg, it could potentially place the residents at risk for food-borne illness. He said the Dietary Manager was responsible for monitoring and overseeing the kitchen. Record review of the facility's policy titled, Food Preparation and Service revised 11/2022, indicated, Policy Statement: Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices. General Guidelines: #1. Identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby minimize the risk of foodborne illness. #3. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Food Preparation, Cooking and Holding Time temperature: #12. Only pasteurized shell eggs are cooked and served when: a. residents request undercooked, soft-served, or sunny side up eggs; and b. preparing foods that will not be thoroughly cooked (e.g., hollandaise sauce, French toast, ice cream etc.), #13. Unpasteurized eggs are cooked until all parts of the egg (yolk and whites) are completely firm. Food Distribution and Service: #8 Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food.Record review of FDA 2-402.11, dated 2022, revealed FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE_SERVICE and SINGLE-USE ARTICLES.

Based on observation, interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASRR) to the maximum extent practicable to avoid duplicative testing and effort for 3 of 3 residents (Residents #17, #12, and #16) reviewed for PASRR. 1. The facility failed to provide documentation of Residents #17 and #16's habilitation coordination as requested in the PCSP Form. 2. The facility failed to provide documentation of Resident #12's independent living skills services as requested in the PCSP Form.These failures could cause residents with mental health disorders and psychiatric conditions to have a delay in services or not receive specialized services or equipment that may be needed.Findings included: Resident #17 1. Record review of Resident #17's face sheet, dated 02/12/26, reflected Resident #17 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included cerebral palsy (lifelong neurological disorders caused by abnormal brain development or damage, typically before, during, or shortly after birth). Record review of Resident #17's annual MDS assessment, dated 11/6/25, reflected Resident #17 Section A1500 asked Is the resident currently considered by the state level II PASRR process to have serious mental ill ness and/or intellectual disability or a related condition? This section was marked 1 which meant Yes. Resident #17 understood others and made herself understood. Resident #17 had a BIMS score of 15, which reflected her cognition was intact. Resident #17 had an active diagnosis of cerebral palsy. Record review of Resident #17's comprehensive care plan, revised 01/28/26, reflected Resident #17 had been identified as having PASRR positive status related to a developmental disability. Resident #17 was receiving habilitation coordination. The care plan interventions included: provide service coordination with a representative from LIDDA. Record review of PCSP meeting dated 12/22/25 reflected that habilitation coordination services were recommended for Resident #17. Record review of PCSP meeting dated 02/05/26 reflected that habilitation coordination services were recommended for Resident #17. Record review of Resident #17's EMR dated 02/12/26 reflected no documentation of habilitation coordination notes. Resident #16 Record review of Resident #16's face sheet, dated 02/12/26, reflected Resident #16 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included cerebral palsy. Record review of Resident #16's annual MDS assessment, dated 01/26/26, reflected Resident #16 understood others and made herself understood. Resident #16 had a BIMS score of 15, which reflected her cognition was intact. Record Review of Resident #16's comprehensive care plan, revised 12/22/25, reflected Resident #16 had been identified as having PASRR positive status related to an intellectual/ developmental disability. Resident #16 was receiving habilitation coordination. The care plan included interventions of: Provide service coordination with a representative from LIDDA. Record review of Resident #16's PASRR Comprehensive Service Plan (PSPC) Form, dated 02/05/2026, reflected that habilitation coordination was recommended for Resident #16. Record review of Resident #16's EMR dated 02/12/26 reflected no documentation of habilitation coordination notes. During a telephone interview on 02/12/26 at 9:54 a.m., the Habilitation Coordinator Supervisor stated the habilitation coordinator comes to the facility monthly to meet with the residents to ensure their needs were being met such as an advocate. The Habilitation Coordinator stated documentation was not left because they were not the ones being audited by the state. During an interview on 02/12/26 at 10:17 a.m., the MDS Coordinator stated she was responsible for ensuring monthly visits were conducted by the habilitation coordinator. The MDS Coordinator stated she was not aware when the coordinator comes to the facility. The MDS Coordinator stated she was at the facility on Monday, Wednesday, Thursday, Friday and if she happened to be at the facility when the coordinator comes, she would follow up verbally. The MDS Coordinator stated they have never left anything in writing such as a progress note, letter, etc. The MDS Coordinator stated it was important documentation was received after every visit to ensure the best possible care was received. During an interview on 02/12/26 at 3:27 p.m., the ADON stated she expected some type of documentation to be provided after every visit to show the coordinator was in the building that month. The ADON stated she was not aware there was no documentation in the residents EMR of when the coordinator came to the facility. The ADON stated she believed the social worker was responsible for ensuring notes of some kind were put in the resident's file. The ADON stated it was important to ensure documentation was provided for continuity of care. During an interview on 02/12/26 at 4:12 p.m., the Social Services stated she did not deal with PASRR. The Social Services stated the MDS Coordinator coordinates with PASRR. During an interview on 02/12/26 at 4:17 p.m., the Administrator stated he expected to maintain documents regarding PASRR that fall in line with the required documents per the facility policy. The Administrator was unable to provide what exact documents were required per the policy. The Administrator stated medical records were responsible for ensuring documentation was provided monthly after every visit. The Administrator stated he would monitor the PASSR process moving forward. The Administrator stated it was important to ensure documentation was provided to fulfill the residents PASRR needs. 2. Record review of Resident #12's face sheet, dated 02/12/26, reflected Resident #12 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included cerebral palsy. Record review of Resident #12's annual MDS assessment dated [DATE], reflected Resident #12's Section A1500 asked Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? This section was marked 1 which meant Yes. The assessment did not address Resident #12's BIMS score but reflected he had long term and short-term memory problems. Record review of Resident #12's comprehensive care plan, revised 01/26/26, reflected Resident #12 had been identified as having PASRR positive status related to an intellectual/developmental disability. Resident #12 was receiving habilitation services and independent living skills. The care plan included interventions of: provide service coordination with a representative from LIDDA. Record review of Resident #12's PASRR Comprehensive Service Plan (PSPC) Form, dated 01/16/2026, reflected that habilitation coordination and independent living skills were recommended for Resident #12. Record review of Resident #12's EMR dated 02/12/26 reflected no documentation of habilitation coordination notes or independent living skills notes. Call attempted to special services/ independent living skills supervisor on 2/12/26 at 12:10pm. Phone extension does not receive voicemails. Call attempted to special services/ independent living skills supervisor on 2/12/26 at 2:50 pm. Phone extension does not receive voicemails. During an interview on 02/12/26 at 2:23 p.m., the MDS Coordinator stated she was responsible for ensuring monthly visits were conducted by the habilitation coordinator and independent living services. The MDS Coordinator stated she was not aware when independent living services came to the facility. The MDS Coordinator stated she was at the facility on Monday, Wednesday, Thursday, Friday and if she happened to be at the facility when the coordinator comes, she would follow up verbally. The MDS Coordinator stated the independent living skills services coordinator does not document in writing anywhere at the facility they have visited. The MDS Coordinator stated it was important documentation was received after every visit to ensure the best possible care was received. During an interview on 02/12/26 at 3:27 p.m., the ADON stated she expected the same thing from independent living skills services as she does from habilitation coordination, that some type of documentation is to be provided after every visit to show the independent living skills services coordinator was in the building that month. The ADON stated she was not aware there was no documentation in the residents EMR of independent living skills visits to the facility. The ADON stated she believed the social worker was responsible for ensuring notes of some kind were put in the resident's file. The ADON stated it was important to ensure documentation was provided for continuity of care. During an interview on 02/12/26 at 4:12 p.m., the Social Services stated she did not deal with PASRR. Social Services stated the MDS Coordinator coordinates with PASRR. During an interview on 02/12/26 at 4:31 p.m., the Administrator stated he expected to maintain documents regarding PASRR that fall in line with the required documents per the facility policy. The Administrator was unable to provide what exact documents were required per the policy. The Administrator stated medical records was responsible for ensuring documentation was provided monthly after every visit. The Administrator stated he would monitor PASSR either by taking part or having a representative in the PASRR meeting to obtain documentation. The Administrator stated it was important to ensure documentation was provided to fulfill the residents PASRR needs. Record review of the facility's policy titled PASRR dated 07/29/25 reflected, . The PASRR program aims to ensure that individuals with mental illness or intellectual disabilities receive appropriate care and services. It assessed whether the nursing home is the most suitable setting for the individual's needs. 3. Documentation: Facilities must maintain thorough documentation of the PASRR assessments, including the Level I and Level II evaluation, as well as the recommendations made.5. Ongoing Review: Residents who are admitted under PASRR guidelines may undergo periodic reviews to ensure that their needs are being met and that they continue to require nursing home care .

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 1 resident (Resident #23) reviewed for treatment and services related to indwelling catheters. The facility failed to ensure Resident #23's foley catheter (tube inserted into bladder) was secured on 02/10/26, 02/11/26, and 02/12/26. This failure could place residents at risk for urinary tract infections and a decreased quality of life. Findings included: Record review of Resident #23's face sheet, dated 02/12/26, reflected Resident #23 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included neuromuscular dysfunction of bladder (lack bladder control due to brain, spinal cord or nerve problems). Record review of Resident #23's annual MDS assessment dated [DATE], reflected Resident #23 made herself understood and understood others. Resident #23 had a BIMS score of 15, which reflected her cognition was intact. Resident #23 had an indwelling catheter. Record review of Resident #23's comprehensive care plan, revised 12/10/25, reflected Resident #23 had a foley catheter due to obstructive uropathy (urine flow is obstructed). The care plan interventions included: ensure staff aware of correct placement of catheter gravity drainage bag and tubing, keep tubing/bag below the bladder and do not kink tubing. Record review of Resident #23's nurse's note dated 02/10/26 completed by LVN D reflected she had changed Resident #23's catheter due to leakage. Record review of Resident #23's physician order summary report dated 02/12/26 reflected an active physician's order for foley catheter 26 French/30 ml every shift related to neuromuscular dysfunction of bladder with a start date 12/09/25. The order summary did not address catheter securement. During an observation and interview on 02/10/26 at 8:53 a.m., Resident #23 stated LVN D changed her catheter last night but did not secure her tubing. The state surveyor asked if she could bring an aide in to see the catheter, Resident #23 stated, yes. CNA B came in, pulled the sheet back and showed the state surveyor the catheter. The catheter tubing was under Resident #23's left thigh unsecured. CNA B never addressed catheter tubing, not being secured. During an observation and interview on 02/11/26 at 8:40 a.m., Resident #23 was lying in bed and stated her catheter tubing was not secured. During an observation and interview on 02/12/26 at 8:55 a.m., the state surveyor asked CNA B if she could see Resident #23's catheter again. CNA B pulled the sheet back and showed the state surveyor the catheter. Resident #23's catheter was not secured. The state surveyor asked CNA B if her catheter should be secured. CNA B stated it was supposed to be anchored to her leg to prevent trauma. CNA B stated the CNAs should report to the nurse if they noticed the tubing was not secured when providing care. CNA B stated she had reported it to LVN A on 02/10/26 after she had shown the state surveyor Resident #23's catheter and noticed it was not secured. CNA B stated it was important to ensure Resident #23's foley catheter was secured to prevent trauma. During an interview on 02/12/26 at 9:01 a.m., LVN A stated Resident #23's catheter should always be secured. LVN A stated initially the nurse that placed the catheter should have made sure the catheter tubing was secured but if the device comes off the nurse should replace it, or the aide should report it to the nurse. LVN A stated she could not recall CNA B telling her the tubing was not secured. LVN A stated to be honest she did not pay attention Tuesday or Wednesday to ensure the catheter was secured. LVN A stated this morning (02/12/26) she noticed it was not secured. LVN A stated this failure could potentially cause trauma to the perineum. An attempted telephone interview on 02/12/26 at 2:40 p.m., with LVN D, the nurse that changed Resident #23's catheter on 02/10/26. A message was left for a return phone call. During an interview on 02/12/26 at 3:27 p.m., the ADON stated she expected catheters to be always secured. The ADON stated LVN D should have ensured the catheter was secured when she changed her catheter on 02/10/26 but if the CNAs noticed it was not secured, she should have reported it to the nurse, and the nurse should have gone and secured the tubing. The ADON stated she monitored catheter securement by random rounds. The ADON stated it was important to ensure the catheter was secured to prevent the catheter being pulled and caused severe pain/bleeding or trauma to the perineal area. During an interview on 02/12/26 at 4:17 p.m., the Administrator stated he expected catheters to be secured upon the resident's request. The Administrator stated the nurse who inserted the catheter was responsible for ensuring the tubing was secured. The Administrator stated the ADON was responsible for monitoring and overseeing catheter securement. The Administrator stated it was important to ensure the catheter was secured to prevent any harm to the perineal area. Record review of the facility's policy titled, Catheter Care, Urinary, revised 07/2024 reflected. The purpose of this procedure is to prevent catheter-associated urinary tract infections. Maintaining Unobstructed Urine Flow. 1. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Changing Catheters.2. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. Steps in the Procedure. 18. Secure catheter utilizing a leg band.

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 of 18 (Resident #40) residents reviewed for ADL care. 1. The facility did not ensure Resident #40 was provided with his scheduled bath/showers. 2. The facility did not ensure Resident #40's fingernails were trimmed and free from a black colored substance routinely. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.Findings included:Record review of Resident #40's face sheet, dated 02/12/26, reflected Resident #40 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included cerebral infarction due to embolism of left middle cerebral artery (when a blood clot forms in one part of the body and then travels through the blood to the brain, where it blocks adequate oxygen and blood flow). Record review of Resident #40's quarterly MDS assessment, dated 12/17/25 reflected Resident #40 usually made herself understood and usually understood others. Resident #40 had a BIMS score of 11, which reflected her cognition was moderately impaired. Resident #40 required partial/moderate assistance with personal hygiene and substantial/maximum assistance with shower/bath. Record review of Resident #40's comprehensive care plan, revised on 02/09/26, reflected Resident #40 had ADL self-care performance deficit related to history of CVA. The care plan interventions included: Resident #40 required assistance by 1 staff with bathing/showering and check nail length, trim and clean on bath day and as necessary. Record review of Resident #40's North Side Shower Schedule reflected Resident #40 was scheduled to receive showers on Monday, Wednesday and Friday. The sheet dated 01/02/26-02/11/26 reflected no documentation for scheduled bath/showers on 01/09/26, 01/12/26, 01/30/26, 02/06/26, 02/09/26, and 02/11/26. During an observation and interview on 02/09/26 at 10:50 a.m., Resident #40 was lying in bed wearing a hospital gown. Resident #40's hair was oily with white substance noted. Resident #40's fingernails on both hands were jagged and appeared to be approximately 0.25-0.50 cm long with a thin line of black substance under them. Resident #40 stated she preferred a bed bath and did not know the last time she received one. Resident #40 stated not getting her bed bath made her feel dirty. During an observation on 02/10/26 at 8:44 a.m., Resident #40 was lying in bed wearing a hospital gown. Resident #40 hair was oily with white substance noted. Resident #40 fingernails on both hands were jagged and appeared to be approximately 0.25-0.50 cm long with a thin line of black substance under them. During an observation on 02/11/26 at 9:05 a.m., Resident #40 was lying in bed wearing a blue/teal color shirt. Resident #40 stated an aide changed her out of the gown yesterday. Resident #40 was unable to recall the aide's name. Resident #40 stated the aide did not provide her with a bed bath or shower when she changed her from her gown. Resident #40 hair was oily with white substance noted. Resident #40 fingernails on both hands were jagged and appeared to be approximately 0.25-0.50 cm long with a thin line of black substance under them. An attempted telephone interview on 02/12/26 at 10:30 a.m., with LVN F, the 6p-6a charge nurse for 02/11/26. An attempted telephone interview on 02/12/26 at 10:32 a.m. with CNA E, the CNA that was responsible for providing Resident #40 a bed bath or shower on 02/09/26, was unsuccessful. During a telephone interview on 02/12/26 at 10:33 a.m., CNA C stated CNAs were responsible for giving residents baths or showers. CNA C stated Resident #40 should receive a bed bath or shower on Monday, Wednesday, and Friday on the 2p-10p shift.CNA C stated 02/10/26 was her first day working at the facility. CNA C stated she did not provide Resident #40 a bed bath or shower on 02/11/26. CNA C stated she believed Resident #40 refused a bed bath. CNA C stated she did not report that to her charge nurse nor document it. CNA C stated it was important for the residents to receive their baths/showers to make sure they were getting the care they needed. During an observation and interview on 02/12/26 at 9:01 a.m., LVN A stated CNAs were responsible for giving bed baths or showers. LVN A stated Resident #40 should receive showers or bed baths on Monday, Wednesday, and Friday on the 2p-10p shift. LVN A observed Resident #40 with the state surveyor and agreed Resident #40's hair was greasy with white substances and fingernails on both hands were jagged and appeared to be approximately 0.25-0.50 cm long with a thin line of black substance under them. LVN A stated the aides for this week were new to the facility. LVN A stated if the CNAs could not provide a shower or bed bath, they were supposed to report that to her or the 6p-6a charge nurse. LVN A stated it was not reported to her by either aide they were not able to give the shower or Resident #40 refused. LVN A stated the charge nurses were responsible for monitoring by reviewing the shower sheets daily. LVN A stated she did not review the shower sheets this week because the shower was not given yet. LVN A stated the aide had until 10p to give residents a shower. LVN A stated this failure was a dignity issue. An attempted telephone interview on 02/12/26 at 2:40 p.m., with LVN D, the 6p-6a charge nurse for 02/09/26. During an interview on 02/12/26 at 3:27 p.m., the ADON stated the charge nurses were responsible for ensuring the CNAs performed ADLs. The ADON stated CNAs were supposed to complete bed baths/showers according to their schedule and the nurses were supposed to follow up and ensure the baths/showers were completed by reviewing the shower sheets daily. The ADON stated she monitored by daily observations and any concerns with care were addressed immediately. The ADON stated she was not aware Resident #40 was not receiving her bed baths/showers as scheduled. The ADON stated she had not spoken with Resident #40 since Saturday. The ADON stated it was important to ensure showers/bed baths were given to help with skin integrity, reduce infections, and overall help the residents to feel clean. During an interview on 02/12/26 at 4:17 p.m., the Administrator stated he expected bed baths/showers to be given at minimum every other day and upon resident request. The Administrator stated CNAs were supposed to complete bed bath/showers according to their schedule. The Administrator stated the nurses should be holding the CNAs accountable by reviewing the shower sheets daily. The Administrator stated it was important to ensure showers/bed baths were given because good hygiene equates to good health. Record review of the facility's policy titled Activities of Daily Living (ADL), Supporting revised 02/2025 reflected, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the residents and in accordance with the plan of care, including appropriate support and assistance with. a. hygiene (bathing, dressing, grooming, and oral care) .

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 18 residents (Resident #3) reviewed for accidents hazards.The facility did not ensure acetone was not stored on Resident #3's dresser on 02/10/26. This failure could place residents at risk for injury. Findings included: Record review of Resident #3's face sheet, dated 02/12/26, reflected Resident #3 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included chronic systolic heart failure (occurred when the left ventricle weakens and cannot pump blood effectively, causing blood to back up in the body). Record review of Resident #3's quarterly MDS assessment, dated 01/18/26, reflected Resident #3 made herself understood and understood others. Resident #3's BIMS score was 15, which reflected her cognition was intact. Resident #3 required set-up or clean up assistance with personal hygiene. Record review of Resident #3's comprehensive care plan, revised 12/15/25 reflected Resident #3 had an ADL self-care performance deficit. The care plan interventions included: the resident required set up staff participation with personal hygiene. During an interview and observation on 02/10/26 at 8:50 a.m., the state surveyor observed a small clear bottle that was labeled 100% pure acetone nail polish remover on Resident #3's dresser. Resident #3 stated a family member brought it to her and she was unsure if staff knew she had it. During an interview on 02/12/26 at 8:55 a.m., CNA B stated all staff should be aware and observant of items that did not belong at residents' bedside. CNA B stated she did not recall seeing the acetone on Resident #3's dresser but Resident #3 told her the state surveyor had asked about it. CNA B stated acetone cannot be in the building. CNA B stated there were residents that wandered the hall and this failure could potentially put them and other residents at risk for harm. During an interview on 02/12/26 at 9:01 a.m., LVN A stated all staff were responsible for ensuring items were stored properly and securely. LVN A stated Resident #3 could not have acetone at her bedside. LVN A stated Resident #3 stated a family member had brought it to her. LVN A stated it was important to ensure items were not left at bedside for residents' safety. During an interview on 02/12/26 at 3:27 p.m. the ADON stated all staff should be monitoring for things that could possibly harm a resident. The ADON stated acetone should be taken out of the resident room immediately and not be brought into the facility. The ADON stated she monitored by random rounds and making observations. The ADON stated it was important acetone was not left at bedside for resident's safety. During an interview on 02/12/26 at 4:17 p.m., the Administrator stated acetone should not be in a residents' room. The Administrator stated he was not aware Resident #3 had acetone at her bedside. The Administrator stated all staff should be monitoring and observant of what was at the residents' bedside. The Administrator stated it was important to ensure items were not left at bedside for residents' safety. Record review of the Safety and Supervision of Residents .revised on 07/2017 reflected. Our community strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are community-wide priorities. Individualized, Resident-Centered approach to Safety.1. Our individualized, resident-centered approach to safety addressed safety and accident hazards for individual residents.Resident Risks and Environmental Hazards.f. poison control.

Based on observation, interview, and record review, the facility failed to provide food and drink that accommodated the residents' preferences for 1 of 23 residents (Resident #16) reviewed for preferences. The facility did not honor Resident #16's preference for no lima beans on 02/09/26. This failure could place residents at risk for a decrease in residents' choices and weight loss. Findings included: Record review of Resident #16's face sheet, dated 02/12/26, indicated a 54 -year-old female, admitted [DATE] and re-admitted on [DATE], with diagnoses including diabetes, high blood pressure, and cerebral palsy (a group of conditions that affect movement and posture). Record review of Resident #16's quarterly MDS assessment, dated 01/26/26, indicated Resident #16 understood and was understood by others. Her BIMS score was 15, which indicated she was cognitively intact. The MDS indicated she was independent in eating and oral hygiene. Record review of Resident #16 's physician orders, dated 11/05/25, indicated regular diet, regular texture, regular consistency. Record review of Resident #16's comprehensive care plan, dated/revised 10/20/25, indicated Resident #16 was on a regular diet with a potential for malnutrition (undernutrition) related to diagnosis of cerebral palsy and diabetes. Record review of the lunch meal ticket, dated 02/09/26, for Resident #16 indicated regular diet, and under the note section indicated dislikes lima beans. Record review of Resident #16's medical records did not indicate she had a weight loss. During an observation and interview on 02/09/26 at 12:21 p.m., Resident #16 was in the main dining room eating her lunch. She said, I guess I will just pick the lima beans out of the vegetables, although I should not have to. She said she did not like lima beans, but she received them. During an observation and interview on 02/09/26 at 12:23 p.m., the ADON was in the dining room assisting staff pass out lunch trays. The surveyor and the ADON read Resident #16's meal ticket indicating Resident #16 disliked lima beans. The ADON said it should have been caught when the nurse passed the tray to Resident #16. During an interview on 02/10/26 at 10:00 a.m., the Dietary Manager said she expected Resident #16 not to receive her dislikes of lima beans. She said Resident #16 told her about two weeks ago about her dislike of lima beans and she added it to the tray card. She said the kitchen staff were responsible for ensuring they were reading the tray card and not serving anything a resident disliked. The Dietary Manager said it was important for all residents to receive their preference of food choices so they would eat. During an interview on 02/10/26 at 10:14 a.m., Dietary [NAME] M said she was the person who fixed Resident #16's lunch tray. She said she did not notice Resident #16's dislike of lima beans. She said she did not think about the Italian blend having lima beans in them. She said the risk of serving a resident something they did not like could cause them not to eat. During an interview on 02/12/26 at 3:56 p.m., the ADON said if Resident #16 did not like lima beans, then she should never have been served them. She said the process started in the kitchen with the cook and then to the staff who served the tray. She said dietary and nursing staff were responsible for ensuring they followed Resident #16's meal ticket. She said it was important to serve the correct diet and preference to prevent weight loss. During an interview on 02/12/26 at 4:15 p.m., the Administrator said he wanted Resident #16's' preferences to be known. The Administrator said he expected the kitchen staff to look at the tray cards and not serve something to the Resident #16 she disliked. He said the CNAs should ensure it was not on the tray, and the nurses were responsible for ensuring staff followed the tray card directions. The Administrator said it was important for their food preferences to be honored to prevent the residents from not eating. Record review of the facility's policy titled, Food and Nutrition Services , undated, indicated, Policy Statement: Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Policy Interpretation and Implementation: #1. The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. #4. Reasonable efforts will be made to accommodate resident choices and preferences.

Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 1 resident (Resident #14) reviewed for hospice services. The facility did not ensure Resident #14's hospice records were a part of their records in the facility. This deficient practice could place residents at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings included: Record review of Resident #14's face sheet, dated 02/12/26, reflected Resident #14 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnosis which included Alzheimer's (progressive disease that destroys memory and other important mental functions). Record review of the order summary report dated 02/12/26 reflected Resident #14 had an order to admit to hospice with an order date 12/23/25. Record review of Resident #14's significant change in status MDS assessment, 01/01/26, reflected Resident #14 usually made herself understood and usually understood others. Resident #14's BIMS score was 5, which reflected her condition was severely impaired. The assessment reflected Resident #14 had a life expectancy of less than 6 months and received hospice services. Record review of Resident #14's comprehensive care plan, revised on 12/24/25, reflected Resident #14 had a terminal prognosis related to Alzheimer's, end stage. The care plan interventions included work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physician and social needs were met. Record review of Resident #14's hospice binder, accessed by the state surveyor on 02/11/26 at 12:30 p.m. revealed no updated CTI, POC, medication list, nurses and aides note since the last IDT meeting (12/23/25). During an attempted interview on 02/09/26 at 11:15 with Resident #14, revealed she was non-interview able. During a telephone interview on 02/11/26 at 12:41 p.m., the RN Case Manager stated Resident #14 was admitted to hospice on 12/23/25 for Alzheimer's. The RN Case Manager stated the last visit was on 02/04/26. The RN Case Manager stated every other week either she or the aide would bring the IDT meetings notes which included the medication profile, and POC from all disciplines. The RN Case Manager stated the last IDT meeting was on 12/23/25. The RN Case Manager stated the process for coordinating with the facility was in person. During an interview and record review on 02/12/26 at 3:27 p.m., the ADON stated she was unaware Resident #14's hospice binder was not updated. The ADON stated honestly, she could not state who was responsible for ensuring the hospice book was updated with all required information before she became the ADON on 01/21/26. The ADON stated here on out it will be herself. The ADON stated the updated POC, aides, nurses and IDT meeting notes should be included in the binder. After reviewing the hospice binder with the state surveyor, the ADON stated the binder was not updated to include all information that was needed. The ADON stated the nurses communicated verbally one on one with the hospice staff. The ADON stated it was important to ensure recent hospice documentation was in the facility to keep communication between the facility and hospice for continuation of care. During an interview on 02/12/26 at 4:17 p.m., the Administrator stated he would expect the documents that were mutual agreed between the facility and hospice to be placed in the binder. The Administrator stated he had only been in this position since 01/28/26 therefore he did not know what documents were required. The Administrator stated the nurses at the facility/hospices including the nurse management were responsible for ensuring the binder was updated. The Administrator stated it was important to ensure recent hospice documentation was in the facility for continuity of care. Record review of the facility's policy titled Hospice Program, revised on 07/2017, reflected, . Hospice services are available to residents at the end of life.12. Our facility has designated (blank) to coordinate care provided to the residents by our facility staff and the hospice staff. Obtaining the following information from the hospice:The most recent hospice plan of care specific to each resident;Hospice election form;Physician certification and recertification of the terminal illness specific to each resident;Names and contact information for hospice personnel involved in hospice care of each resident;Instructions on how to access the hospice's 24-hour on-call system;Hospice medication information specific to each resident; andHospice physician and attending physician (if any) orders specific to each resident.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #6) reviewed for infection control. The facility failed to ensure CNA B and CNA H followed EBP and put on gown and gloves while providing incontinent care to Resident #6 on 02/11/26. This failure could place residents at risk for cross-contamination and the spread of infection. Findings Included:Record review of face sheet, dated 02/11/26, indicated Resident #6 was a [AGE] year-old male, admitted [DATE] and readmitted on [DATE], with diagnoses of Alzheimer's disease with late onset (progressive memory loss and cognitive decline), benign prostatic hyperplasia with lower urinary tract symptoms (enlargement of the prostate gland) and chronic kidney disease stage 3A (moderate kidney damage and moderate decreased kidney functioning). Record review of comprehensive MDS, dated [DATE], indicated Resident #6 admitted following a short-term hospital stay with an indwelling catheter. This MDS indicated Resident #6 was always incontinent of bowel. This MDS indicated Resident #6 was diagnosed with benign prostatic hyperplasia and obstructive uropathy (blocking urine flow). Record review of Resident #6's care plan, dated 11/23/25, for EBP with intervention listed of staff must wear gowns and gloves during high-contact resident care activities. Record review of Resident #6 order summary report, dated 02/12/26, indicated an order for EBP including a gown and gloves were required for high contact activities started on 12/10/25. During an observation on 02/11/26 at 1:35 p.m., CNA B and CNA H entered Resident #6's room, performed hand hygiene, put on gloves, and began catheter care without gowns on. Observation of the door on the outside of Resident #6's room was a posted sign indicating EBP of gown and gloves required for high contact care with a box storing all needed supplies for care. During an interview on 02/12/26 at 8:46 a.m., CNA H stated she was not trained to wear PPE (personal protective equipment) when providing care to Resident #6. CNA H stated Resident #6 had a catheter and, to her knowledge, only residents with a wound were on EBP. CNA H stated that EBP was to be worn to protect them (the staff and the residents) from being splashed (particles coming in contact with their clothes and face) and spread infection. During an interview on 02/12/26 at 9:05 a.m., CNA B stated she forgot to wear PPE when providing care to Resident #6. CNA B stated she was not trained on PPE recently but she could not recall the exact date. CNA B stated residents with a wound and catheter required PPE when providing care to them. CNA B stated PPE was used to protect staff and residents from the spread of infection. CNA B stated it was CNA B's and CNA H's responsibility to put on PPE when providing care to Resident #6 who was on EBP. During an interview on 02/12/26 at 9:27 a.m., LVN G stated Resident #6 was on EBP and all staff were responsible for wearing PPE who provided direct contact care. LVN G stated that PPE was to prevent the spread of multidrug-resistant organisms. During an interview on 02/12/26 at 3:45 p.m., the ADON stated she expected all staff who provided direct care to Resident #6 to wear PPE when they provided direct contact care. The ADON stated that EBP was defined by gown and gloves. The ADON stated EBP was to be worn for residents with a catheter, wound, communicable disease or infection. The ADON stated that EBP was worn to protect them from being sprayed (particles coming in contact with their clothes and face) and to prevent the spread of infection. The ADON stated that she had not conducted an EBP training during the three weeks she was in the position. The ADON stated Resident #6 was at risk of infection and UTI when PPE was not worn during care. During an interview on 02/12/2026 at 4:45 p.m., the Administrator stated he expects his staff to wear EBP PPE when providing care to Resident #6 because he had an indwelling catheter. The Administrator stated his staff should put on and take off gowns and gloves when providing direct patient care. The Administrator stated EBP was for protection and preventing the spread of infection of communicable diseases. The Administrator stated nursing administration was responsible for ensuring EBP PPE was used during direct patient care. The Administrator stated EBP was a mandatory annual training but since he had taken on this role, 2 weeks ago, he had not done an in-service. Record review of the facility policy titled, Enhanced Barrier Precautions, dated February 2025, revealed, 'Enhance barrier precautions' refer to an infection control interventions designed to reduce transmission of multidrug-resistant organisms to residents. EBPs employs targeted gown and glove use in addition to standard precautions during high contact resident care activities.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 12 resident rooms (Resident #16) reviewed for physical environment. The facility failed to ensure Resident #16's windowsill was in good repair without exposed and splintered wood. This failure could place residents at risk for further deterioration, uncomfortable temperatures, the inability to properly clean, and possible pest infestation.Findings included: During an observation and interview on 02/10/2026, at 5:30 p.m., Resident #16's room windowsill had a visible hole and separated wood along the lower interior portion beneath the window. The opening measured approximately 10-12 inches in length and approximately 1-2 inches in width. The area contained cracked, splintered, and deteriorated wood with exposed inner material. The damaged section of the windowsill was located at resident height and was accessible to the resident. The surface was not smooth, intact, or cleanable. The windowsill had no protective covering, or repair was in place at the time of observation. Resident #16 stated the broken windowsill was there when she moved into the room. Resident #16 stated she did not remember the exact date she moved in, but she stated it was several months ago. Resident#16 stated she reported the broken windowsill via the TELS (Technology Enabled Life Safety) application but did not remember the date. Resident #16 stated it was several months ago. Resident #16 was not aware of any attempts to repair the window since she had moved into the room. During an interview on 02/10/2026 at 5:35 p.m., the Maintenance Supervisor stated he knew about the window for a while but just had not done the repairs. The Maintenance Supervisor stated, I just let it slip. The Maintenance Supervisor stated he finally got the approval to fix the windowsill this week. The Maintenance Supervisor did not have any documentation showing when a request for supplies to fix the window was submitted. The Maintenance Supervisor stated it was important for the windowsill to be fixed because the splintered wood could hurt someone, the temperature could be hard to control in the room, and it was not homelike. During an interview on 02/10/2026 at 6:20 p.m., the Maintenance Supervisor stated he learned about maintenance requests via the TELS (The Environmental Log System) platform used to track repairs. The Maintenance Supervisor stated again he had known about the issue for a long time but never had the budgeted money to fix the windowsill due to the facility changing owners. The Maintenance Supervisor said his budget was recently approved and the windowsill would be fixed. The Maintenance Supervisor said he used a bonding agent to patch it and that worked for a while, but then the windowsill got hit by a bed again and the windowsill broke again. The Maintenance Supervisor said he did not remember when he used the bonding agent to repair the windowsill, and he was not able to repair it since. During an interview on 02/10/2026 at 3:00 p.m., LVN G, assigned to Resident #16's hall, said it was her third day working at the facility. LVN G stated Resident #16 had not said anything to her about the broken windowsill. LVN G stated if she saw something that needed repair, she would report it to the ADON or the administrator. LVN G also stated she would put a ticket in TELS and the Maintenance Supervisor would see it. LVN G said it was important to repair broken items for the residents' safety. LVN G said insects could get in a hole or there could be a draft which could make a resident sick. During an interview on 02/12/2026 at 3:27 p.m., the ADON stated she was not aware of a hole in Resident 16's windowsill. The ADON stated if she saw something that needed attention, in the past she would tell the Maintenance Supervisor, but now the needed repair must be documented in the computer and put in a work order on the TELS application. The ADON said her expectation was an identified issue was fixed within three days, unless materials had to be ordered, then as soon as possible. The ADON said the Maintenance Supervisor was responsible for ensuring repairs were made. The ADON said she and the facility administrator were responsible for making rounds and monitoring for repairs. The ADON said repairing broken items was important because this was the residents' home. The ADON said it was important to fix because there could be a draft, or bugs could get in the room from the opening. During an interview on 02/12/2026 at 4:18 p.m., the facility Administrator said he was not aware of a broken windowsill in Resident 16's room, but when he learned of it this week, he bought the tools to fix it. The Administrator said everyone was responsible for reporting needed repairs using a facility wide system called TELS app. The Administrator said that this system notified the Maintenance Supervisor something needed repairing. The Administrator said he expected broken items to be fixed. The Administrator said repairs were triaged based on the concern and gave an example of a gas leak or a light out, the Maintenance Supervisor would address the gas leak first. The Administrator said it was important to fix broken items because residents deserve a nice home. Record review of policy and procedure, Maintenance Service dated 12/2009, indicated maintenance service shall be provided to all areas of the building, grounds, and equipment. Functions of maintenance personnel include but are not limited to: maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines; and, maintaining the building in good repair and free of hazards.

Based on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goal and preferences for 1 of 2 residents (Resident #40) reviewed for oxygen therapy. The facility failed to have Resident #40's oxygen sign outside the door on 02/09/26, 02/10/26, 02/11/26, and 02/12/26. This failure could place residents who receive respiratory care at risk for respiratory infections including pneumonia, shortness of breath and even death. Findings included: Record review of Resident #40's face sheet, dated 02/12/26, reflected Resident #40 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included Asthma (condition that causes airways to swell, narrow and fill with mucus), and wheezing (whistling sound made when air flows through narrowed airways in the lungs). Record review of Resident #40's quarterly MDS assessment, dated 12/17/25 reflected Resident #40 usually made herself understood and usually understood others. Resident #40 had a BIMS score of 11, which reflected her cognition was moderately impaired. During the 7-day look-back period the assessment did not indicate Resident #40 was receiving oxygen. Record review of Resident #40's physician order summary report, dated 02/12/26 reflected an active order for oxygen at 2L via N/C every 8 hours as needed for SOB with a start date 01/22/26. Record review of Resident #40's comprehensive care plan, revised on 02/09/26, reflected Resident #40 was on oxygen therapy related to decreased oxygen saturations and diagnoses of asthma and wheezing. The care plan interventions included oxygen settings at 2L/ml via NC and monitor oxygen saturations. During an observation and interview on 02/09/26 at 10:50 a.m., Resident #40 was lying in her bed wearing O2 at 2L/min via NC. Resident #40 stated she wore oxygen due to SOB. No oxygen sign was noted outside her door. During an observation on 02/10/26 at 8:44 a.m., Resident #40 was lying in her bed wearing O2 at 2L/min via NC. No oxygen sign was noted outside her door. During an observation on 02/11/26 at 9:05 a.m., Resident #40 was lying in her bed wearing O2 at 2L/min via NC. No oxygen sign was noted outside her door. During an observation and interview on 02/12/26 at 9:01 a.m., LVN A stated Resident #40 wore oxygen related to SOB. LVN A stated an oxygen sign should be on the outside of Resident #40's door. LVN A and the state surveyor went to Resident #40's door and saw there was no oxygen sign. LVN A stated she thought she had one at one time. LVN A stated all staff were responsible for ensuring an oxygen sign was outside Resident #40's door to let visitors/staff know that they should not smoke in the room because Resident #40 was on oxygen. LVN A stated the oxygen was not combustible, but it could potentially feed the fire. During an interview on 02/12/26 at 3:27 p.m., the ADON stated her expectation was an oxygen sign should be on Resident #40's door facing the hall. The ADON stated the nurses were responsible for ensuring an oxygen sign was always on the door. The ADON stated she monitored by random rounds, and she had not noticed there was no sign on Resident #40's door until state surveyor intervention. The ADON stated it was important to let everyone know that Resident #40 wore oxygen and if they smoked in her room, it could cause fire and to let staff know if power went out Resident #40's oxygen concentrator would need to be plugged into a red outlet (indicates an emergency backup power). During an interview on 02/12/26 at 4:17 p.m., the Administrator stated his expectation was an oxygen sign to be outside Resident #40's door. The Administrator stated nursing and maintenance were responsible for ensuring the sign was on the door. The Administrator stated he monitored by random rounds. The Administrator stated he did not notice the sign was not on her door until state surveyor intervention. The Administrator stated the facility was currently out of signs, but he will be placing an order. The Administrator stated it was important to notify everyone entering the room there was a combustible gas that could potentially cause a fire. Record review of the facility's undated policy titled Oxygen Storage, reflected, It is the policy of this center to maintain appropriate and safe storage of oxygen. 5. No smoking signage will be posted to prohibit smoking within fifty feet of the storage area.

Based on interview and record review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and the facility assessment for 1 of 1 facility reviewed for care and services. The facility failed to provide sufficient CNAs according to the facility assessment on 02/01/2025, 02/04/2025, 02/05/2025, 02/06/2025, 02/07/2025, 02/08/2025, 03/01/2025, 03/07/2025, 03/10/2025, 03/12/2025, 03/25/2025, 03/29/2025, 04/01/2025. This failure placed residents at risk of inadequate supervision, an unsafe environment, falls, serious harm and injury, exacerbations of disease processes, abuse, and death. Findings included: During an interview Anonymous Staff Member #1 said they had been working short staffed for a while, but it was getting better. Anonymous Staff Member #1 said there were multiple nights where there was one CNA for the whole building. Anonymous Staff Member #1 said they worked as a team to care for the residents. Anonymous Staff Member #1 said they provided care to the residents as they could that it might not be as timely as the residents required but the care was provided. Anonymous Staff Member #1 said the residents had to wait until they could get to them. Anonymous Staff Member #1 said not having enough staff placed the residents at risk of not receiving the care they needed. Anonymous Staff Member #1 said management was aware that they were short, and it was difficult to provide timely care to the residents. During an interview Anonymous Staff Member #2 said the facility was short staffed, and some of the residents required the use of a mechanical lift. Anonymous Staff Member #2 said at times they had used a mechanical lift without the assistance of another staff member because the nurses were not helping. Anonymous Staff Member #2 said they had made management aware of the difficulty completing tasks due to the staffing shortage and was told they were trying to get more help. During an interview Anonymous Staff Member #3 said there had been nights when they were the only CNA for the entire building. Anonymous Staff Member #3 said they were not able to round on the residents every 2 hours. Anonymous Staff Member #3 said nobody could provide the care the residents needed on their own. Anonymous Staff Member #3 said management was aware they were unable to complete all the resident care as the only CNA for the building. Anonymous Staff Member #3 said this placed the residents at risk for being neglected. During an interview on 05/08/2025 at 3:54 PM, the DON said staffing had been better that they were having a lot of people all in. The DON said to cover the shifts she had worked the floor, her previous ADON had work, and they had CNAs stay over. The DON said their goal was to have 3 CNAs on the 6 AM-2 PM shift, 3 CNAs on the 2 PM-10 PM shift, and 2 CNAs on the 10 PM-6 AM shift. The DON said she thought the facility assessment said something different. The DON said they had worked with 2 CNAs on the 6 AM-2 PM shift, 2 CNAs on the 2 PM-10 PM shift, and 1 CNA on the 10 PM-6 AM shift. The DON said she believed the 10 PM-6 AM shift could be covered with 1 CNA. The DON said there were 2 nurses during that shift, and the nurses could help the CNAs. The DON said when they first started having 1 CNA on the night shift one of the CNAs had reported to her, she did not know how she was going to do it, and then she did not hear anymore complaints after that. The DON said typically their census was 44-45 residents. The DON said if they did not have enough nursing staff they would be slower getting to the residents' needs. During an interview on 05/08/25 at 4:51 PM, the Administrator said the staff had not made her aware they were having difficulties providing care with 1 CNA on the 10 PM-6 AM shift. The Administrator said they had 2 nurses on the night shift, and they had a lot of independent residents. The Administrator said they started hiring agency staff to fill in for the staffing shortage. The Administrator said according to their facility assessment they could have 1-2 CNAs on the night shift. The Administrator said where the facility assessment indicated direct staff ratio 1:30 it was referring to the number of CNAs required, so if their census was more than 30, they required 2 CNAs on the night shift. The Administrator said she thought they ultimately were providing the care the residents needed because the CNA had the support of the nurses. Record review of the Facility Assessment with date of assessment or update 01/31/2025 indicated, Direct care staff, Plan 1: 30 ratio Nights. This indicated 1 CNA was necessary per 30 residents for the night shift (10 PM-6 AM). Record review of the Daily Census Report indicated: 02/01/2025, the census was 47. 02/04/2025, the census was 48. 02/05/2025, the census was 48. 02/06/2025, the census was 49. 02/07/2025, the census was 49. 02/08/2025, the census was 48. 03/01/2025, the census was 45. 03/07/2025, the census was 47. 03/10/2025, the census was 48. 03/12/2025, the census was 47. 03/25/2025, the census was 47. 03/29/2025, the census was 49. 04/01/2025, the census was 49. Record review of the time sheets indicated only 1 CNA worked on the 10 PM-6 AM shift on the following dates: 02/01/2025 02/04/2025 02/05/2025 02/06/2025 02/07/2025 02/08/2025 03/01/2025 03/07/2025 03/10/2025 03/12/2025 03/25/2025 03/29/2025 04/01/2025. Record review of the facility's policy titled, Staffing, revised September 2023, indicated, Our center provides sufficient nursing staff with the appropriate skills and competencies necessary to provide care and related services to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with resident care plans and the facility assessment.

Based on observation, interview, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 2 medication carts (South Hall Nurse Medication Cart) reviewed for drugs and biologicals. The facility failed to ensure LVN C secured the South Hall Nurse Medication Cart, when it was not in use on 05/07/2025. This failure could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion. Findings included: During an observation on 05/07/2025 starting at 1:22 PM, there was an unlocked medication cart next to the nurse's station. The housekeeper was cleaning and moved the unlocked medication cart to the opposite side of the hallway. The nurse was not observed near the medication cart or in the hallway. The housekeeper said she thought the nurse, LVN C, was at break. During an interview on 05/07/2025 at 1:27 PM, LVN C said she was on break, and the medication cart was hers. LVN C said she guessed she got distracted and did not realize she did not lock it. LVN C said the nurse should ensure the medication cart was locked when not in use. LVN C said it was important for the medication cart to be locked because they had dementia patients, and someone could go and inject themselves or someone could take stuff. LVN C said that is was super dangerous for the medication cart to be left unlocked. During an interview on 05/08/2025 at 3:54 PM, the DON said the medication cart needed to be locked at all times when not in use. The DON said she conducted rounds daily to check to ensure the medication carts were locked. The DON said the nurses were responsible for ensuring the medication carts were locked. The DON said if the medication cart was left unlocked somebody could access the medications or treatments in it. During an interview on 05/08/2025 at 5:12 PM, the Administrator said she expected for the medication carts to be locked anytime the nurses were not in front of them. The Administrator said if the medication cart was left unlocked a resident could get into the medication cart. Record review of the facility's policy, titled, Security of Medication Cart, revised April 2007, indicated, 4. Medication carts must be securely locked at all times when out of the nurse's view.

Based on interview and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1 was treated respectfully when CNA B spoke to Resident #1 in a loud manner and patted her hand on 04/14/2025. This failure could place residents at risk of embarrassment, feelings of worthlessness, decreased self-worth, loss of dignity, and a diminished quality of life. Findings included: 1. Record review of a face sheet dated 05/08/2025 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Parkinsonism (condition that impacts movement and causes muscle stiffness, slow movement, speech impairment, tremors, slowed reaction time, frequent falls), anxiety disorder (mental illness defined by feelings of uneasiness, worry and fear), and major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks). Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #1 was usually understood and usually understood others. The MDS assessment indicated Resident #1 had a BIMS score of 10, which indicated her cognition was intact. The MDS assessment indicated Resident #1 required substantial/maximal assistance with showering/bathing, toileting, and partial to moderate assistance with personal hygiene. Record review of Resident #1's care plan revised 04/15/2025 indicated, she screamed out at staff/other residents during anxious episodes and is at times hard to redirect or console related to anxiety. Resident #1's interventions indicated to maintain a calm environment and approach. Record review of the Provider Investigation Report with incident date 4/14/2025 at 2:25 PM, indicated Description of Allegation CNA B went and told the BOM Resident #1 was hitting her and cussing at her. CNA B stated she smacked Resident #1's hand like you would a toddler. The Provider Investigation Report indicated the conclusion of the investigation was that it was unfounded. CNA B had no intention to harm resident and was only attempting to distract resident from aggressive behavior. During an interview on 05/07/2025 at 11:08 AM, when Resident #1 was asked if staff had yelled at her, she said I am sure they have, but was unable to report who it was or when it happened. Resident #1 said she did not remember any staff hitting her or patting her hand. Resident #1 said she felt safe in the facility. During an interview on 05/07/2025 at 12:26 PM, LVN A said she was the nurse when the incident between Resident #1 and CNA B occurred. LVN A said Resident #1 was agitated when CNA B started her shift that day. LVN A said she was sitting at the nurse's station behind the desk and heard CNA B raise her voice at Resident #1, so she told her hey you need to stop doing that, and CNA B walked away. LVN A said she did not see CNA B hit Resident #1. LVN A said CNA B could get loud sometimes, and she had to tell her that was not how she needed to talk to the residents. LVN A said examples were CNA B would tell the residents you are my patient and you are not doing what I want you to do or ma'am we need to go in and get you cleaned up, we need to do it now, and if the they said no CNA B told them yes, we are we are going to go do it now. LVN A said she had to step in and tell CNA B if the resident was agitated, she was not going to be able to care for them. LVN A said CNA B speaking to the residents loudly and making such comments was disrespectful, and she was not treating the residents with dignity. LVN A said she had reported this to management when they asked her to write a witness statement for the incident between CNA B and Resident #1. During an interview on 05/07/2025 at 4:28 PM, CNA B said Resident #1 was in her room and she was trying to change her, and Resident #1 was hitting her and being physically and verbally abusive towards her, so she tapped her hand to try to calm her down, when she saw that she was not deescalating, she walked out of her room and went to get Resident #1's wheelchair. CNA B said she went back into Resident #1's room and got her in her chair and Resident #1 did it again and she said to her stop hitting. CNA B said after this, she went to the BOM and told her Resident #1 was hitting her and she tapped her hand because she was hitting. CNA B said she had not gotten loud with Resident #1, and she had removed herself from the situation. CNA B said when a resident was aggressive, she should stop providing care, and return later. CNA B said she had made comments to the residents such as they were her patients and they needed to do things now. CNA B said speaking to the residents this way could make them feel like poop and that their rights did not matter. CNA B said she had received training on how to handle residents with behaviors and how to speak to the residents when she first started, but she had not received any training since then. During an interview on 05/07/2025 at 5:34 PM, the BOM said CNA B went in her office and told her Resident #1 was pushing and hitting her. The BOM said she told CNA B Resident #1 could not swing that far so she needed to just back up. The BOM said CNA B told her she got Resident #1's hand and tapped it. The BOM said she told CNA B to hold on and got the DON to takeover. During an interview on 05/08/2025 at 3:54 PM, the DON said the BOM had gone to her and told her CNA B just told her she hit Resident #1 on the hand. The DON said she asked CNA B to explain what happened with Resident #1. CNA B said Resident #1 was hitting and flinging her arms and CNA B could not get Resident #1's attention so she grabbed Resident #1's hand and patted it to get her attention. The DON said she did not allow CNA B to return to provide care. The DON said she sent CNA B home. The DON said CNA B had no history of abuse. The DON said if the residents refused care they should not continue and get the social worker involved. The DON said she was not aware CNA B was loud with the residents, and LVN A had not reported the comments CNA B made to the residents to her. The DON said the residents should be treated respectfully, and CNA B speaking to them in such way could make them feel pressured into doing what she wanted them to, and it could be misconstrued by the residents as the staff being confrontational. During an interview on 05/08/2025 at 4:51 PM, the Administrator said she was not aware CNA B was loud with the residents or of her speaking to the residents disrespectfully. The Administrator said she expected for the staff to speak to the residents gently and encourage them to be assisted. The Administrator said if the resident was refusing, the staff should leave and return later. The Administrator said she expected for the staff to explain what they were doing to the residents, and not just tell them they were going to do something. The Administrator said if the residents were spoken to loudly and told what to do this could make them feel like they were pressured to do things right then and there and like they were on a time schedule. Record review of an Inservice Attendance Record dated 04/17/2025, indicated the subject was Abuse/Neglect-Dealing with resident behaviors, the instructors were the Administrator and the DON, and for the name of attendee it indicated, by phone with CNA B prior to returning----verbalizes understanding. Summary of Meeting indicated reviewed abuse/neglect policy discussed ways to deal with dementia and other resident behaviors such as distraction, activities, offering snacks or getting a different caregiver. Record review of the facility's policy titled, Resident Rights, revised February 2021, indicated, Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity .

Based on observations, interviews, and record review, the facility failed to promptly resolve grievances for 3 out of 24 residents (Resident's #42, #44, #47) reviewed for grievances. The facility did not ensure Resident's #42, #44, and #47 grievances concerning coffee temperature were addressed. This deficient practice could place the residents at risk for decreased quality of life and feelings of neglect. The findings included: 1. Record review of the face sheet, dated 11/07/24, reflected Resident #42 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of COPD (an ongoing lung condition caused by damage to the lungs resulting in limited air flow into and out of the lungs). Record review of the quarterly MDS assessment, dated 10/16/24, reflected Resident #42 had clear speech and usually understood others. The MDS reflected Resident #42 was usually able to understand others. The MDS reflected Resident #42 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS reflected Resident #12 was independent eating, which included bringing liquid to the mouth. Record review of Resident #42's comprehensive care plan, edited 08/26/24, reflected she was at risk for nutritional impairment. The interventions included: determine likes/dislikes; regular diet with thin liquids; monitor meal percentages. Record review of the general order, start date 04/21/23, reflected Resident #42 had an order for a regular diet texture with a thin fluid consistency. Record review of the grievance form dated 07/16/24, reflected all residents complained of the coffee temperatures being lukewarm. During an interview on 11/04/24 beginning at 11:28 AM, Resident #42 stated the coffee was served cold. Resident #42 said the facility staff said it was the state's fault. Resident #42 said everyone gripes about the coffee. Resident #42 stated she wanted hot coffee. Resident #42 said the facility staff were aware of the coffee being served cold, but they have not addressed the issue. 2. Record review of the face sheet, dated 11/06/24, reflected Resident #47 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease (neurological disorder that involves irreversible worsening changes in the ability to think and remember). Record review of the quarterly MDS assessment, dated 10/20/24, reflected Resident #47 had clear speech and was understood by others. The MDS reflected Resident #47 was able to understand others. The MDS reflected Resident #47 had a BIMS score of 9, which indicated moderately impaired cognition. The MDS reflected Resident #47 was independent with eating, which included bringing liquid to the mouth. Record review of the comprehensive care plan, edited 10/04/24, reflected Resident #47 was at risk for nutritional impairment. The interventions included: determine likes/dislikes; regular diet with thin liquids; and monitor meal percentages. Record review of the general order, start date 03/06/24, reflected Resident #47 had an order for regular diet texture with a thin fluid consistency. Record review of the grievance form dated 07/29/24, reflected Resident #47 complained that the coffee was cold. During an interview on 11/04/24 beginning at 12:06 PM, Resident #47 stated the coffee was served cold. Resident #47 stated multiple complaints had been made but it has not gotten better. Resident #47 said she has drunk hot coffee her whole adult life and wanted her coffee to have been served hot, not cold. During an observation and interview on 11/05/24 beginning at 8:28 AM, Resident #47 was standing at the coffee thermos outside the dining room. Resident #47 said she was getting some coffee. Resident #47 took a sip of the coffee and said it was cold. 3. Record review of the face sheet, dated 11/05/24, reflected Resident #44 was a [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of liver cell carcinoma (liver cancer). Record review of the quarterly MDS assessment, dated 09/17/24, reflected Resident #44 had clear speech and was understood by others. The MDS reflected Resident #44 was able to understand others. The MDS reflected Resident #44 had a BIMS score of 15, which indicated he was cognitively intact. The MDS reflected Resident #44 was independent with eating, which included bringing liquids to his mouth. Record review of the comprehensive care plan, edited 10/30/24, reflected Resident #44 was on a regular diet with a thin fluid consistency. The interventions included: determine likes/dislikes. Record review of the general order, start date 08/09/24, reflected Resident #44 had an order for regular diet texture with a thin fluid consistency. Record review of the grievance form dated 08/22/24, reflected Resident #44 complained that the coffee was cold. During an interview on 11/04/24 beginning at 1:10 PM, Resident #44 said the coffee was cold. Resident #44 said someone burnt themselves on the coffee so they could not serve it unless it was at 140 degrees or less. Resident #44 said it would be fine if by the time they got it was actually at 130 - 140 degrees. Resident #44 said by the time it got to his room it was much colder. Resident #44 said he liked drinking hot coffee and it was not pleasurable drinking cold coffee. Resident #44 stated when he has complained or filed a grievance, it was not addressed. During an observation and interview on 11/05/24 beginning at 8:34 AM, DA C temped the coffee in the thermos outside the dining room. DA C read the thermometer at 119.8 degrees F. DA C stated the coffee could have been hotter. DA C stated the temperature should have been at 140 degrees F or below. DA C stated she waited until the coffee was at least 135 degrees F before she served it. DA C stated she had received numerous complaints about the coffee being too cold. DA C said, the residents were always on her back about the coffee. DA C stated the residents were used to having coffee that was scalding hot. DA C stated she did not have a set schedule for checking the coffee, but she checked it periodically for temperature and refreshed it when it became cold. DA C stated she made coffee throughout the day. DA C stated the CNAs placed the coffee on the trays before they were passed out. DA C stated she had to follow the policy and she was not allowed to serve the coffee above 140 degrees F. During an interview on 11/06/24 beginning at 12:33 PM, the DM stated she had received complaints about the coffee being too cold. The DM said the coffee had to be served between 130- and 140-degrees F. The DM stated the residents hate it and she did not blame them. The DM stated coffee served at 119.8 degrees F could have been considered luke warm. She said it could have been warmer. The DM stated when the residents complained she took the policy to educate them or had the Administrator or Social Worker talk to them. During an interview on 11/07/24 beginning at 12:20 PM, the Administrator stated she had received grievances on the coffee temperature being too cold. The Administrator stated when she received a grievance regarding coffee temperatures, she notified the DM and the DM started monitoring the coffee temperatures. The Administrator stated random temperatures were obtained to ensure the coffee was staying hot in thermos. The Administrator stated she had not identified any problems with the coffee temperatures. The Administrator stated she expected coffee to be served at 140 degrees F or less. The Administrator stated coffee served at 119.8 degrees could have been warmer. The Administrator stated it was important to ensure grievances were resolved or addressed for the residents so they could feel satisfied with the temperature of the coffee. Record review of the Grievances, Recording and Investigating policy, revised 01/12/23, reflected the resident grievance form will be filed with the Administrator of designee and the resolution will be identified within three working days of the concern .

Based on observation, interviews, and record review the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives and to choose the option he or she prefers for 2 of 5 residents reviewed for the right to be informed. (Resident's #1 and #9) 1. The facility failed to ensure Resident #1's psychotropic consent for trazadone (antidepressant), Xanax (antianxiety), lorazepam (antianxiety), and sertraline (antidepressant) reflected the clinical indication for use, the benefits of the medication, and the statement of consent. 2. The facility failed to ensure Resident #9's psychotropic consent form for Zyprexa (antipsychotic) reflected the resident or resident representative's signature for consent. These failures could place residents at risk for treatment or services provided without their informed consent. The findings included: 1. Record review of the face sheet, dated 11/07/24, reflected Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (neurological disorder that involves irreversible worsening changes in the ability to think and remember), anxiety disorder, and depression. Record review of the quarterly MDS assessment, dated 08/29/24, reflected Resident #1 had clear speech and was usually understood by others. The MDS reflected Resident #1 was usually able to understand others. The MDS reflected Resident #1 had a BIMS score of 1, which indicated severe cognitive impairment. The MDS reflected Resident #1 had no behaviors or refusal of care. The MDS reflected Resident #1 received an antianxiety medication and an antidepressant medication during the 7-day look back period. Record review of the comprehensive care plan, edited 10/04/24, reflected Resident #1 received an antianxiety medication related to a diagnosis of anxiety disorder. The care plan further reflected Resident #1 received an antidepressant medication related to a diagnosis of depression. Record review of the general order received and started on 09/28/23, reflected Resident #1 had an order for trazadone (antidepressant) 100 mg - give one tablet by mouth at bedtime. Record review of Resident #1's informed consent for use of psychotropic medication form for trazadone (antidepressant), dated 02/09/24, had no clinical indications for use, no benefits from medications, and no statement of consent (I DO, or I DO NOT) checked or filled out. Record review of the general order received and started on 11/29/23, reflected Resident #1 had an order for Xanax (antianxiety) 0.25 mg - give one tablet by mouth twice daily. Record review of Resident #1's informed consent for use of psychotropic medication form for Xanax (antianxiety), dated 03/11/24, had no clinical indications for use, no benefits from medications, and no statement of consent (I DO, or I DO NOT) checked or filled out. Record review of the general order received and started on 02/01/24, reflected Resident #1 had an order for sertraline (antidepressant) 50 mg - give 2 tablets by mouth once per day. Record review of Resident #1's informed consent for use of psychotropic medication form for sertraline (antidepressant), dated 02/09/24, had no clinical indications for use, no benefits from medications, and no statement of consent (I DO, or I DO NOT) checked or filled out. Record review of the general order received and started on 10/14/24, reflected Resident #1 had an order for lorazepam (antianxiety) 0.5 mg - give one tablet by mouth every 6 hours as needed. Record review of Resident #1's informed consent for use of psychotropic medication form for lorazepam (antianxiety), dated 03/11/24, had no clinical indications for use, no benefits from medications, and no statement of consent (I DO, or I DO NOT) checked or filled out. During an observation and attempted interview on 11/04/24 beginning at 1:36 PM, Resident #1 was wheeling herself down the hallway. Resident #1 had a WanderGauard to her left ankle. Resident #1 had Geri-sleeves to both arms and non-skid socks to both feet. Resident #1 was non-interviewable as evidenced by confused conversation. 2. Record review of the face sheet, dated 11/06/24, reflected Resident #9 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of bipolar disorder (serious mental illness characterized by extreme mood swings). Record review of the significant change MDS assessment, dated 10/01/24, reflected Resident #9 had clear speech and was usually understood by others. The MDS reflected Resident #9 was usually able to understand others. The MDS reflected Resident #9 had a BIMS score of 15, which indicated he was cognitively intact. The MDS reflected Resident #9 had no behaviors or refusal of care. The MDS reflected Resident #9 received an antipsychotic medication during the 7-day look back period. Record review of the comprehensive care plan, edited 09/24/24, reflected Resident #9 had bipolar and was currently taking an antipsychotic medication. Record review of the general order received and started on 06/05/24, reflected Resident #9 had an order for Zyprexa (antipsychotic) 5 mg - give one tablet by mouth at bedtime. Record review of the Consent for Antipsychotic or Neuroleptic Medication Treatment form, dated 03/13/24, reflected Resident #9 had not signed the form. During an interview on 11/04/24 beginning at 1:45 PM, Resident #9 said he knew he was taking an antipsychotic for his bipolar disorder. Resident #9 said he knew and understood the risks and benefits, but he needed the medication. Resident #9 stated he had not signed a consent form. During an interview on 11/07/24 beginning at 11:48 AM, LVN D stated when the nurse received an order for a psychotropic medication, it was their responsibility to ensure a consent form was completed. LVN D stated consent forms should have been filled out completely. LVN D stated consent forms should have had a signature from the resident or responsible party. LVN D was unsure why Resident #1's consent forms were missing the clinical indication for use, the benefits from use, and a statement of consent. LVN D was unsure why Resident #9's psychotropic consent form was missing his signature. LVN D stated it was important to ensure psychotropic consent forms were filled out completely so the facility could prove the resident, or the responsible party made an informed decision. During an interview on 11/07/24 beginning at 11:54 AM, the DON stated the ADON was previously responsible for ensuring the psychotropic consent forms were completely filled out and placed in a binder. The DON stated the ADON walked out of the facility at the beginning of last month (October 2024). The DON stated she was to be responsible for ensure psychotropic consent forms were completely filled out and uploaded in the electronic health record moving forward. The DON stated she expected the nurses to have completed or filled out every part of the psychotropic consent forms. The DON stated it was important to ensure consent forms were completely filled out and signatures were in place, so the resident or responsible party were fully aware of the risks and benefits. The DON said so they could have made an informed decision. During an interview on 11/07/24 beginning at 12:20 PM, the Administrator stated she did not have a clinical background. The Administrator stated she expected the nursing management to monitor to ensure psychotropic consent forms were filled out completely with all required signatures. The Administrator stated it was important to ensure consent forms were completely filled out with all required signatures for good documentation and so the resident or responsible party clearly understood the risk and benefits of the psychotropic medication. Record review of the Psychoactive Medications policy, dated July 2024, reflected Consent must be obtained from the resident or resident representative prior to administering a psychotropic medication A consent from for antipsychotic medication .must be completed and signed by the resident or resident representative .consent must be obtained in writing .a consent form for other psychotropic medications must be completed and signed by the resident or resident representative using the psychotropic consent form

Based on interview and record review, the facility failed to ensure that residents who required dialysis (treatment that filters water and waste from the blood when the kidneys are no longer able to do so) received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #49) reviewed for dialysis. The facility failed to ensure all pre and post-dialysis assessments were completed for Resident #49. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving adequate care and treatment to meet their needs. Findings included: Record review of Resident #49's face sheet, dated 11/06/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including fluid overload (which happens when there is too much fluid in your body. It can raise blood pressure, cause swelling, and impact organ function), End-Stage Renal Disease also known as ESRD (a permanent condition that occurs when the kidneys stop working and require dialysis or a kidney transplant to sustain life), high blood pressure, and depression (sadness). Record review of Resident #49's 5-day MDS Assessment, dated 10/14/24 indicated Resident #49 usually made himself understood and usually understood others. Resident #49 had a BIMS score of 01 indicating his cognition was severely impaired. The MDS indicated Resident #49 required assistance with transfers, dressing, toileting, bed mobility, personal hygiene, bathing, and set-up for eating. The MDS for Resident #49 indicated he received hemodialysis (while a resident and on admission). Record review of the care plan initiated on 10/27/24 indicated he had a diagnosis of ESRD and was dependent on dialysis. He went to dialysis on Tuesday, Thursday, and Saturday. He had a left fistula on his inner arm. The interventions were for staff to administer medications as ordered, monitor the fistula site, and report any abnormalities to the physician. Record review of Resident #49's Order Summary, dated 10/17/24, revealed orders: Hemodialysis: AV Fistula/AV Graft to the left upper arm. Auscultate bruits and palpate thrill every shift. Hemodialysis performed on Tuesday, Thursday, and Saturday with a chair time of 6 a.m. Special Instructions: Fill out the form (Pre-Dialysis Assessment), and send medications, snacks, and a blanket with the resident. Record review of Resident #49's Dialysis Notebook undated revealed the following: *10/10/24 Pre-dialysis and post-dialysis assessment completed. *10/12/24 Pre-dialysis and post-dialysis assessment completed. *10/19/24 Pre-dialysis and post-dialysis assessment completed. *10/29/24 Pre-dialysis and post-dialysis assessment completed. Further review revealed there were no pre-dialysis or post-dialysis communication sheets located for following dates: 10/10/24, 10/15/24, 10/17/24, 10/22/24, 10/24/24, 10/26/24, 10/31/24 and 11/2/24. Record review of Resident #49's electronic medical records revealed there were no pre-dialysis or post-dialysis assessments for the following dates: 10/10/24, 10/15/24, 10/17/24, 10/22/24, 10/24/24, 10/26/24, 10/31/24 and 11/2/24. During an interview on 11/05/24 at 9:07 a.m., LVN E said Resident #49 had a dialysis communication book. She said sometimes Resident #49 did not bring back the communication sheets. She said if he did not bring back the communication sheet, she would assess him, but she did not place the assessment (communication sheet) in his book or document the assessment his electronic medical records. She said it was reported (unknown source) to her that Resident #49 had thrown his communication sheets in the trash or out the window of the van. She said she had never called the dialysis center to inquire about his communication sheets, any new orders, or any concerns during dialysis. During an interview on 11/05/24 at 12:24 p.m., Resident #49 was sitting on the side of his bed eating lunch. He said the staff usually gave him some paperwork to take to dialysis and he brought it back. He said he sometimes gave it to the van person or someone at the facility. During an interview on 11/07/24 at 10:37 a.m., the DON said the nurses sent communication forms with Resident #49 to dialysis. She said she expected the nurses to do the pre and post-dialysis assessment to ensure the resident was okay before and after dialysis. She said Resident #49 had a communication book, but she wanted to change the process and start scanning them into his electronic medical records. During an interview on 11/07/24 at 11:22 a.m., the Administrator said all dialysis residents should have communication sheets for any changes. She said the DON was the overseer of Dialysis. Record review of the facility policy titled, End-Stage Renal Disease, Care of a Resident with . revised date of September 2010, indicated, Policy Interpretation and Implementation: 1. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. 2. Education and training of staff includes, specifically: The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis. Signs and symptoms of worsening condition and/or complications of ESRD; Timing and administration of medications, particularly those before and after dialysis; The care of grafts and fistulas; and the handling of waste. 3. Education and training of staff in the care of ESRD/dialysis residents may be managed by the contracted dialysis facility or by a clinician with special training in ESRD and dialysis care. 4. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: How the care plan will be developed and implemented and how information will be exchanged between the facilities.