Every finding on record at Avir at Kennedale

Based on observations, interviews, and record reviews, the facility failed to report violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property to the State Survey Agency for 1 of 7 residents (Resident #1) reviewed for abuse and neglect. The facility failed to report an injury of unknown source to HHSC when Resident #1 sustained a dislocated left shoulder on 04/19/26.This failure could place the residents at risk of injuries not being thoroughly investigated and potential neglect. Findings included:Record review of Resident #1's quarterly MDS, dated [DATE], revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included emphysema, dementia, and cognitive impairment. Her BIMS score was 1, indicating severe cognitive impairment. Her Functional Ability assessment indicated she used a manual wheelchair for mobility and was reliant on staff for her ADLs; the resident had no impairment of upper extremities (arms). Record review of Resident #1's care plan, dated 03/19/26, revealed she had a history of past collar bone, and shoulder dislocation with loose hardware in the shoulder. Resident #1 had limited physical mobility, was a high fall risk with no history of falls and was a two-person lift assist with a gait belt. Record review of Resident #1's EHR revealed progress notes:04/18/26 by the ADON Resident c/o pain to left shoulder MD notified and X- Ray ordered STAT. PRN pain medication administered resident made comfortable in bed n/o placed on MAR. Awaiting X-Ray. RP notified no concerns. 4/19/26 by LVN-A Upon getting report from night nurse. X-ray of left shoulder results printed, on coming nurse notified MD at 0647 [AM]. Nurse then goes into resident room to assess resident, notice redness and swelling to left shoulder, grimacing noted by resident upon nurse touching site. Administrator, DON, and NP notified. NP recommended resident be sent out to ER for further evaluation. EMT services called report given. EMT arrives at 1145[AM]. [Family members] called no pick up, message left by charge nurse. Charge Nurse called Hospital ER to give report. Report given to ER charge nurse, at [Hospital].Record review of Fire Department's EMS report, dated 04/19/26, revealed Medic XX dispatched to traumatic injury .Medic XX arrived on scene to find PT [patient] laying [sic] in nursing home bed conscious and alert in no apparent distress. PT has obvious swollen left shoulder with deformity. Staff states i just got here and did not know the events leading up to this morning and that she just got orders to transfer the PT to the hospital for a dislocated shoulder. Other staff stated she arrived at work yesterday and sent the in charge nurse a picture of the injury at 658am and was advised to not call 911 that they would do their own imaging, image does show obvious deformity at that time. PT injury is over 24 hours at this point. PT is normal mentation for history of dementia. PT states she does not hurt anywhere and does not have any head injury signs. Pupils are equal and reactive. PT was moved to stretcher via sheet lift, secured with straps and loaded into ambulance without incident. Vitals are assessed. PT remained calm and did not have any complaints during transport.Record review of Resident#1's hospital records, dated 04/19/26 revealed a left shoulder x-ray was performed and the radiologist noted there was hardware from a rotator cuff repair present and the left shoulder was dislocated. During an observation on 05/05/26 at 11:23 AM, revealed Resident #1 was in her bed, wakes to verbal stimuli, and holding her left hand to her chest. Attempted to shake the resident's left hand was met with a grimace and pulled back. The resident did not answer questions and easily fell asleep. Resident #1 had an arm sling that was off to the side of the resident, not under her left arm. During an interview on 05/05/26 at 11:28 AM, LVN-B stated she was notified by CNA-C of Resident #1's shoulder being discolored and swollen. LVN-B contacted the physician and received orders for a portable x-ray. She stated the report came back indicating a left shoulder dislocation. She stated the resident had not fallen that she knew of. The resident was unable to verbalize what happened. During an interview on 05/05/24 at 11:44 AM, LVN-A stated she received report from the night shift nurse and was told about Resident#1's shoulder being dislocated and no further orders from the physician. LVN-A stated she assessed the resident after report and notified the Administrator of the situation; she was told to contact the nurse practitioner for orders. The Nurse Practitioner ordered the resident be sent to the ER. LVN-A stated Resident #1 normally transferred with two people to assist, using a gait belt. Once in her wheelchair she could move around the facility, using her arms to propel herself. LVN-A stated if Resident #1 had fallen without someone seeing it, she would not have been able to get herself off the floor and back to bed without assistance. LVN-A stated the shoulder might have been dislocated during a transfer. During an interview on 05/05/26 at 12:20 PM, CNA-C stated she was getting Resident #1 ready for bed, changing her into her gown, when she noted the left shoulder was discolored and did not look right. She stated she took a photo of the shoulder and took it to LVN-B to show her. LVN-B stated to leave the resident as is and she would call the physician. She stated later the x-ray company showed up and took the x-ray. The resident slept for the rest of the night. During an interview on 05/05/26 at 1:05 PM, the Administrator stated after the Nurse Practitioner ordered the resident sent to the hospital, 911 was called and the resident was transported. She stated Resident #1 was a fall risk, but had not had a fall in a long time. She stated Resident #1 would wheel herself around the facility with no issues and she was not one to get out of her wheelchair and walk around. The Administrator stated she did not report the injury because the resident had a chronically dislocated shoulder and the physician did not think it was an acute injury, and there was no investigation because it was not new. The Administrator stated there was no policy on reporting injuries, they followed CMS guidelines. During an interview on 05/05/26 at 3:10 PM, the Physician stated he was contacted on 04/18/26 about Resident #1's shoulder and when he looked at the x-ray report he did not feel the dislocation was new as she had a known dislocation of that shoulder. The Physician stated if the shoulder had been dislocated since the report in 2023, she would not have been able to use her left arm to move her wheelchair. The Physician stated the resident most likely reduced the dislocation on her own at some point and had recently dislocated it again. The Physician stated the dislocation was most likely acute, not chronic. Record review of left shoulder x-ray report, dated 11/24/23 reflected the resident's left shoulder was dislocated and the bones were thin. Record review of Resident #1's pain management physician assessment, dated 12/28/23 reflected the resident was able to move her arms and legs without pain. Indicating the shoulder dislocation noted on 11/24/23 was not an issue and may have been reduced by then.

Based on interview and record review, the facility failed to use the service of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 13 of 60 days reviewed during a look back period from 02/07/26 to 04/05/26 for weekend coverage. The facility failed to have RN coverage in the facility for eight consecutive hours on 02/08/26, 02/14/26, 02/15/26, 02/21/26, 02/22/26, 02/29/26, 03/07/26, 03/08/26, 03/14/26, 03/15/26, 03/22/26, 03/28/26, 03/29/26.This failure could place residents at risk of not having their nursing and medical needs met and improper care.Findings included: Record review of the facility's Detailed Hours report, printed on 04/15/26, reflected there was no RN coverage on the weekends for the following dates:02/08/26, 02/14/26, 02/15/26, 02/21/26, 02/22/26, 02/29/26, 03/07/26, 03/08/26, 03/14/26, 03/15/26, 03/22/26, 03/28/26, and 03/29/26.During an interview on 04/15/26 at 3:09 PM, the ADON revealed the facility was having a hard time finding and keeping an RN for weekend RN coverage and they had been without one for quite a while. The ADON said the facility should have an RN on the weekends to cover in case something happened that was out of the scope of an LVN. During an interview on 04/15/26 at 4:09 PM, the DON revealed she had only been at the facility for three days and said she had been told they had recently lost their weekend RN and did not realize there were so many days without one. The DON said it was important to have an RN for 8 consecutive hours Monday through Sunday because it was a state regulation. During an interview on 04/15/26 at 4:18 PM, the Administrator revealed the facility did not have a weekend RN for quite a while and would try to hire one soon. The Administrator said it was important to have an RN seven days a week for eight hours in case there was something that needed to be done that was out of the scope of practice of an LVN and for better oversight. Record review of the facility's Staffing, Sufficient, and Competent Nursing policy, revised August 2022, reflected the following: .Sufficient Staff.3. A registered nurse provides services at least eight (8) hours every 24 hours, seven (7) day a week.

Based on observation, interview, and record review, the facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to prevent complications for 1 of 1 resident (Resident #2) reviewed for feeding tubes.LVN C failed to follow physician orders and added water to Resident #2's g-tube (device inserted through the belly into the stomach to deliver nutrition, fluids, and medications). formula prior to administering her feeding. This failure could place residents at risk for a decline in health or adverse effects due to inappropriate management of G-tube care.Findings included:Record review of Resident #2's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), hyperlipidemia (a condition of high cholesterol), respiratory failure (a condition in which there is not enough oxygen in the tissues in the body), diabetes (a condition that happens when blood sugar is too high), end stage renal disease (the final stage of chronic kidney disease), and pain. The MDS reflected Resident #2's cognition was moderately impaired with a BIMS score of 11. The MDS further reflected that the resident had a g-tube. Record review of Resident #2's care plan revised on 12/02/25 reflected she required tube feeding related to dysphagia (swallowing problem). Interventions included to assist with administration of tube feeding per MD order. Record review of Resident #2's monthly physician's orders for April 2026 reflected the resident was on enteral feeding three times a day Bolus 237mL one carton of Glucerna 1.5 at 8:00 AM and two cartons at both 12:00 PM and 4:00 PM feeding.During an observation on 04/15/26 at 10:43 AM, revealed LVN C was at the medication cart about to prepare Resident #2's g-tube feeding. Once in the room, LVN C poured an undisclosed amount of tap water into each of the cups that contained the g-tube formula. LVN C put on her gloves and poured the formula that was in the cups into the syringe that was attached to the g-tube and let it flow to gravity and there were no concerns with the pour or the g-tube. After the formula had all been poured into the syringe attached to the g-tube, LVN C flushed with water. During an interview on 04/15/26 at 1:38 PM, LVN C revealed she poured water into the cups of formula but did not recall how much it was. LVN C said she poured the water into the formula so she could dilute it because it would take the formula a long time to go down the tube if she did not add water. LVN C said she was told by the ADON she could dilute the formula with water but would get with management again to verify that. During an interview on 04/15/26 at 3:09 PM, the ADON revealed she was not aware LVN C would dilute Resident #2's g-tube formula with water and never told her to do that. The ADON said they could only dilute the g-tube formula with water if they had a physician's order to do it. The ADON said the risks of adding water to the g-tube formula included overfeeding the resident, which would give the resident a sense of feeling full. During an interview on 04/15/26 at 4:09 PM, the DON revealed Resident #2's formula should not have been diluted with water without a physician order. The DON said the formula should not be diluted with water because it could affect the concentration of formula or the resident could cause overload and put the resident at risk of aspiration (accidental breathing of [NAME], liquid, or stomach contents into the airway and lungs instead of the esophagus). Record review of the facility's Enteral Nutrition policy, revised January 2014, reflected the following: Adequate nutritional support through enteral feeding will be provided as ordered.4. Enteral nutrition will be ordered by the Physician based on the recommendations of the Dietitian.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assured the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 4 resident (Resident #2) reviewed for pharmaceutical services.LVN C failed to follow the facility policy when she mixed and crushed Resident #2's medications and administered them via g-tube (device inserted through the belly into the stomach to deliver nutrition, fluids, and medications).This failure placed residents at risk of not receiving the therapeutic dosages of their medications, gastric upset, pain, and symptomatic changes. Findings included:Record review of Resident #2's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), hyperlipidemia (a condition of high cholesterol), respiratory failure (a condition in which there is not enough oxygen in the tissues in the body), diabetes (a condition that happens when blood sugar is too high), end stage renal disease (the final stage of chronic kidney disease), and pain. The MDS reflected Resident #2's cognition was moderately impaired with a BIMS score of 11. The MDS further reflected that the resident had a g-tube. Record review of Resident #2's care plan revised on 12/02/26 reflected that she required tube feeding related to dysphagia (swallowing problem). Interventions included assisting with administration of tube feeding per physician orders. Record review of Resident #2's monthly physician's orders for April 2026 reflected the resident was on the following medications:- Apixaban Oral Tablet 5mg; give 1 tablet via g-tube two times a day related to atrial fibrillation (rapid irregular heartbeat)- Atorvastatin Calcium Oral Tablet 40mg; give 1 tablet via g-tube one time a day related to hyperlipidemia - Acetaminophen-Codeine Oral Tablet 300mg-30mg; give 1 tablet via g-tube every 6 hours as needed for pain- Calcium Carbonate-Vitamin D with Minerals; give 1 tablet via g-tube one time a day related to vitamin deficiency During an observation on 04/15/26 at 9:50 AM, revealed LVN C was at the medication cart and crushing 4 pills in a clear pouch and poured them into a clear cup. Upon entering the room, LVN C filled the crushed medication cup with 110 ml of water per the measurement lines on the cup. LVN C put on gloves and used a stethoscope to check Resident #2's g-tube placement. LVN C flushed the g-tube with water and then poured the medication mixture with the 110 ml of water into the g-tube syringe, and used gravity to administer the medications. The resident did not display any signs of discomfort or distress. LVN C then poured a small amount of water into the empty medication cup to clear some of the residual medications and poured it into the g-tube and finally flushed the g-tube with more water. LVN C proceeded to administer the feeding formula. During an interview on 04/15/26 at 1:38 PM, LVN C revealed she always combined and crushed Resident #2's medications. LVN C said she heard other nurses gave the crushed medications one by one but that would take too long, so she would give them all together. LVN C said no one told her she was not supposed to cocktail (mix) them together. LVN C further stated she did not realize she had poured so much water into the cup with crushed medications and usually only poured them in 30 cc of water. LVN C said risks of cocktailing could possibly affect the effectiveness of the medications. During an interview on 04/15/26 at 3:09 PM, the ADON revealed she was not aware LVN C was cocktailing Resident #2's medications. The ADON said g-tube medications should be crushed, put in separate cups, and given one at a time with a water flush in between each medication. The ADON said cocktailed medication could be unsafe. During an interview on 04/15/26 at 4:09 PM, the DON revealed she was not aware LVN C was cocktailing Resident #2's medication and should only be given that way with an order. The DON said the medications should be given one at a time diluted with a small amount of water, 15ml to 30ml and with a water flush at the beginning of, in between each medication and at the end of the medication administration. The DON said the medication should not be cocktailed because there could be contraindications and/or medication interactions, or it could be too hard on the resident's digestive system. Record review of the facility's Administering Medications through an Enteral Tube policy, revised March 2015, reflected the following: PurposeThe purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube.3. Do not mix medications together prior to administering through an enteral tube. Administer each medication separately unless resident has physician's orders to mix (cocktail) medication.23. Dilute the crushed or split medication with 15-30 mL room temperature tap water (or prescribed amount).26. If administering more than one medication, flush with 15 mL (or prescribed amount) room temperature tap water between medications.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #1) reviewed for infection control practices. CNA A failed to perform hand hygiene and glove changes while providing Resident #1 with incontinence care and a shower.These failures could place residents at risk of cross-contamination and infections. Findings included: Record review of Resident #1's Face Sheet, dated 04/15/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE].Record review of Resident #1's Quarterly MDS, dated [DATE], reflected the resident's diagnoses included: hemiplegia following cerebral infarction (one-sided paralysis caused by brain tissue damage), non-Alzheimer's dementia (cognitive disorders caused by diseases other than Alzheimer's), and aphasia (language disorder caused by brain damage). The MDS reflected Resident #1 had moderate cognitive impairment with a BIMS score of 8. The MDS reflected she was incontinent of bowel and bladder and was dependent on staff for all care. Record review of Resident #1's Care Plan, revised 04/01/26, reflected the resident was incontinent with interventions for staff to use mild cleansers for perineal care (the cleaning or washing of the genitals and anal area) and that the resident request staff assistance to turn and reposition. During an observation on 04/15/26 at 9:30 AM revealed CNA A and CNA B preparing to take Resident #1 to the shower. After CNA A informed Resident #1, CNA A put on clean gloves, closed the door to the room, and pulled the privacy curtain. The Hoyer lift (a mechanical device designed to safely transfer patients with limited mobility) and shower chair were observed in the resident's room. CNA A prepared the incontinence care supplies on a clean barrier. She then opened Resident #1's brief and began to clean the resident's perineal area. On the last wipe of Resident #1's perineal care, CNA A got brown fecal matter on her gloves. Next, CNA A and CNA B assisted Resident #1 to turn onto her left side. CNA A was observed to reach over Resident #1 and brown fecal matter residue was left on Resident #1's left leg and on the bed pad. CNA A then used new wipes to clean Resident #1's buttocks. Resident #1 had a soft bowel movement (the feces discharged in an act of defecation). Once Resident #1's buttocks were cleaned, CNA A rolled the soiled brief within itself and discarded the brief into the trash. CNA A still had brown fecal matter on her gloves. Without performing hand hygiene or changing her gloves, CNA A obtained a clean brief and placed it under Resident #1's buttocks. CNA A then retrieved the Hoyer sling (specialized fabric used with a Hoyer lift to transfer) and placed it underneath the clean brief. Next, CNA A and CNA B turned Resident #1 and secured her clean brief. While still wearing the same soiled gloves, CNA A retrieved the Hoyer lift, and CNA A and CNA B transferred Resident #1 safely into the shower chair. Without performing hand hygiene or a glove change, CNA A pushed Resident #1 out into the hallway and then into the shower room. CNA A was observed to give Resident #1 a shower while wearing the same gloves she wore while providing the resident with incontinence care. Once Resident #1 was washed and rinsed, CNA A removed her gloves and began to dry Resident #1. CNA did not perform hand hygiene prior to or after providing incontinence care or a shower. CNA A also did not change her gloves or perform hand hygiene when soiled during incontinence care. During an interview on 04/15/26 at 12:24 PM, CNA B revealed he had been working at the facility for one month. CNA B stated gloves should be changed and hands washed when they were visibly dirty. He stated he was not aware that CNA A had fecal matter on her gloves when they were providing Resident #1 with incontinence care. CNA B stated he was trying to keep Resident #1 calm and was not paying attention. CNA B stated if hand hygiene was not performed and gloves were not changed appropriately, that it could cause an infection, cause fungal issues or worsen the resident's condition. During an interview on 04/15/26 at 2:09 PM, CNA A revealed she had worked at the facility for eight years. CNA A stated hand hygiene should be performed before putting on gloves and when changing or removing gloves. She stated she changed her gloves when going from dirty to clean during incontinence care of if her gloves became soiled. She stated she was supposed to wash her hands when entering or exiting a room. CNA A stated she did not recall seeing bowel movement on her gloves during incontinence care. CNA A stated she forgot to change gloves or wash her hands because Resident #1 was fighting with her and tried to grab her. CNA A stated she was just trying to get things done quickly. She stated not changing her gloves when they were soiled or performing hand hygiene could cause an infection. CNA A stated she has had training on incontinence care. During an interview on 04/15/26 at 3:26 PM, the ADON revealed she expected staff to perform hand hygiene when entering or leaving the room. She stated with any incontinence care, hand hygiene should be performed with any glove changes. The ADON stated gloves should be changed when soiled or when going from dirty to clean. The ADON stated not performing hand hygiene and glove changes appropriately could cause cross contamination, spread germs, and cause infections. She stated there had been recent in-services on incontinence care and infection prevention. The ADON stated the nurse managers were responsible for ensuring incontinence care and infection control measures were followed. The ADON stated she usually did spot checks with the CNAs, but recently she had needed to work the floor, so she had not been able to do the spot checks. The ADON stated she would start back doing the spot checks and continue in-service training with the CNAs. During an interview on 04/15/26 at 4:17 PM, the DON stated she had been working at the facility for three days. She stated her expectation was that staff change their gloves when in contact with any bodily fluids or when going form dirty to clean. The DON stated she expected staff to perform hand hygiene when entering or leaving the room, and with any glove changes. The DON stated she, the ADON, and nurses were responsible for ensuring incontinence care and infection control were done properly. The DON stated it was unacceptable for staff to not change gloves when they were visibly dirty with stool (feces) or when leaving the room. She stated there was a risk for infection if hand hygiene was not performed and gloves were not being changed properly. During an interview on 04/15/26 at 4:48 PM, the Administrator stated she would expect staff to change gloves if they were soiled. She stated hand hygiene was also expected to be performed when entering and exiting a resident's room. The Administrator stated not changing gloves or performing hand hygiene was an infection control and dignity issue. Record review of the facility's Perineal Care policy, revised February 2018, reflected the following: .If resident is heavily soiled with feces, turn resident on side and clean away feces with tissue, wipes, or incontinent brief. Discard soiled gloves along with the soiled brief and/or wipes in trash bag. Cover the resident, provide safety measures and wash hands with soap and water.4. Discard soiled gloves, sanitize hands. Re-glove prior to touching clean linens / adult brief.Record review of the facility's Standard Precautions policy, revised September 2022, reflected the following: .Gloves are changed and hand hygiene performed before moving from a contaminated-body site to a clean-body site during resident care. Gloves are changed as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one). Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. After gloves are removed, hands are washed immediately to avoid transfer of microorganisms to other residents or environments.

Based on observations, interviews and record review, the facility failed to ensure that residents receive proper treatment and care to maintain mobility and good foot health by providing foot care and treatment, in accordance with professional standards of practice for 1 of 6 residents (Resident #1) reviewed for foot care.The facility failed to follow physician orders for Resident #1's wound care on her toe.This failure could place residents with wounds to their feet at risk of not receiving proper foot care and developing infections in their wounds. Findings included: Record review of Resident #1's quarterly MDS assessment, dated 12/11/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses which included a stroke that affected the left side of her body, pressure ulcers, and morbid obesity. Record review of Resident #1's care plan, dated 09/23/25, reflected she had skin concerns related to mobility issues, and ADL self-care deficit related to her stroke. Record review of physician orders revealed an order dated 02/09/26 for Mupirocin Ointment 2% (an antibiotic ointment used to treat bacterial skin infections) to be applied to the left great toe two times a day. Cleanse with antimicrobial solution, apply mupirocin, and cover with dry dressing or band aid.Record review of Resident #1's February 2026 Treatment Administration Record reflected there was no documentation by the nursing staff showing that wound care was provided twice a day on February 11th, 12th, 13th, 14th, 16th, and 18th. Record review of progress notes indicate on 02/09/26 Resident #1's left great toenail was removed due to ingrown toenail. During an observation on 02/19/26 at 10:20 AM, Resident #1 was observed to have a dressing on her left great toe dated 2/18. The dressing was clean, dry and intact. Interview attempt on 2/19/26 at 10:20 AM with Resident #1 was unsuccessful, resident was non-verbal. Observation on 2/19/26 at 12:20 PM, revealed Resident #1's dressing remained unchanged. During an observation and interview on 02/19/26 at 2:30 PM, Resident #1's dressing remained unchanged. The Treatment Nurse stated she provided wound care for major wounds (pressure ulcers) and minor (cuts, and abrasions) wound care was done by the bedside nurse. She stated Resident #1's wound care was to be done once a day. She stated she did not know why the wound care had not been done on 02/19/26. During an observation Resident #1's dressing was removed by the Treatment Nurse, left great toe toenail was missing, the wound bed was observed to have pink healthy tissue present in the nailbed, and no redness or indication of infection was observed. The Treatment Nurse stated the risk of not providing wound care twice a day was the wound getting infected. Interview on 02/19/26 at 2:35 PM, LVN A stated she normally did wound care at the end of her shift (6:00 AM-2:00 PM) and she had not provided Resident #1's wound care. LVN-A stated wound care was once a day. She stated she was not aware Resident #1's order was for twice a day wound care. She stated the risk of not following the physician's order for twice a day wound care was the wound getting infected. Interview on 02/19/26 at 2:49 PM, the Regional Nurse Consultant stated staff followed physician orders for wound care. She stated the risk of not following the physician's order was the physician would be upset. Record review of the facility's policy Wound Care, dated October 2010, reflected: Preparation:1. Verify the physician's order for the procedure.Documentation:1. The date the wound care was given2. The initials of the individual performing the wound care.

Based on interview and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 4 resident (Resident #1) reviewed for pressure ulcers.The facility failed to ensure Resident #1 received wound care according to physician orders on 11/05/25, 11/21/25, 11/24/25 and 11/27/25.The failure placed residents at risk for pressure ulcer deterioration and infection.Findings included:Record review of Resident #1's face sheet, dated 12/15/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE], readmitted on [DATE] and discharged on 12/02/25. Record review of Resident #1's admission MDS assessment, dated 11/06/25, reflected his diagnoses included chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs), essential hypertension (high blood pressure), hyperlipidemia (high cholesterol), and type 1 diabetes mellitus (blood glucose, or blood sugar, levels are too high). Resident #1's BIMS score was 10 which indicated moderate cognitive impairment. The MDS further revealed Section M - Skin Conditions indicated Resident #1 had 1 unstageable pressure injuries presenting as deep tissue injury that were present upon admission/entry to the facility, surgical wound and skin tear(s). Record review of Resident #1's care plan, undated, reflected Resident #1 had pressure ulcers or the potential for pressure ulcer development. The care plan interventions included: Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection wound size, state. The resident requires the bed as flat as possible to reduce shear. The resident prefers to be repositioned with (2 people, lifter, slider). Follow facility policies/protocols for the preventions/treatment of skin breakdown. The resident requires (Specify: Pressure relieving/reducing device) on (Specify: bed/chair). Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort.Record review of Resident #1's physician orders, dated 10/31/25 reflected: cleanse with NS, pat dry, paint with betadine and leave open to air every evening shift. right lower leg(front): cleanse with NS, pat dry, apply Xeroform and cover with dry DRSG every evening shiftRecord review of Resident #1's Initial Wound Evaluation & Management Summary, dated 11/12/25, reflected the following Treatment Plan/Orders: (Site 1) Non-Pressure wound of the right, distal shin partial thickness: Sodium hypochlorite gel (Anasept) apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days; Collagen powder apply once daily and as needed: if saturated, soiled, or dislodged. (Site 2) Unstageable DTI of the right heel undetermined thickness: Betadine apply once daily and as needed: if saturated, soiled, or dislodged. (Site 3) Non- Pressure wound of the right, anterior, medial ankle: Betadine apply once daily and as needed: if saturated, soiled or dislodged.Record review of Resident #1's TAR for November 2025 reflected there was no documentation showing that wound care was provided on 11/05/25, 11/21/25, 11/24/25 and 11/27/25.Interview on 12/15/25 at 3:01 PM, ADON A revealed the charge nurses were responsible for providing daily wound care to the nurses. She stated it was her responsibility to ensure wound care was being provided. ADON A reviewed Resident #1's TAR and stated the TAR had some days that were not documented. She stated she was not aware, and it was unknown if the wound care was provided or if the nurse forgot to sign the TAR. She stated she could not recall being told Resident #1 refuse any wound care treatment. ADON A stated the expectation for the nurses were for them to follow the physician orders, provide the wound care and document that the wound care was provided. She stated the potential risk of not providing wound care would be wound getting worse or infected. She stated the potential risk of not documenting correctly would be staff not knowing if the wound care was provided. ADON A stated LVN B was the assigned nurse for Resident #1 on 11/05/25, 11/21/25, 11/24/25 and 11/27/25.An attempt was made to interview LVN B on 12/15/25 at 3:15 PM by phone; however, call was unsuccessful. Interview on 12/15/25 at 4:25 PM, the Wound Care Doctor revealed treatment should be followed. He stated he could not say what could happen if a treatment was missed, he stated it would all depend on the type of wound the resident had.Interview on 12/15/25 at 5:05 PM, the DON revealed she was not aware wound care was not provided to Resident #1. She stated nurses were responsible for performing wound care on Resident #1. The DON stated wound care might have been provided and the nurse failed to document. She stated she could not recall being told Resident #1 refuse any wound care treatment. She stated she expects her staff to follow the treatment orders. She stated ADON A was responsible for ensuring wound care was provided and ensure it was documented. She stated the potential risk could result in the wounds worsening and getting infected. She stated she had completed in-service on wound care and documentation.Record review of Inservice Training Report subject Wounds was completed on 10/10/25 reflected the following: Weekly skin assessment to be completed on day and shift assigned. For any wound - Weekly skin assessment completed.Record review of Inservice Training Report subject Communication and Documentation/Following Provider Orders was completed on 11/05/25 reflected the following: Communicating Lab Results and changes in condition, documentation and follow-up, communication with oncoming nurse. Record review of facility Wound Care policy, updated July 2024, reflected the following: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. 1. Verify that there is a physician's order for this procedure. Documentation: The following information should be recorded in the resident's medical record: 1. The date the wound care was given. 2. The initials of the individual performing the wound care 3. Any changes in the resident's condition. 4. Any problems or complaints made by the resident related to the procedure.5. If the resident refused the treatment and the reason(s) why. 6. The signature and title of the person recording the data.

Based on interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 resident (Resident #24) of 6 residents reviewed for care plans. The facility failed to develop a person-centered comprehensive care plan for Resident #24, who was at high risk for elopement and who had exit-seeking behaviors. Resident #24 eloped from the facility on 08/08/25, she was found near an apartment complex on a busy street next to the facility by a passerby and brought her back to the facility. The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 08/08/25 and ended on 08/12/25. The facility had corrected the noncompliance before the survey began. The failure placed the resident at risk for serious adverse outcomes including serious harm.Findings included: Record review of Resident #24's annual MDS assessment, dated 07/10/25, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's Disease (brain disorder caused by damage to nerve cells in the brain), anxiety disorder (a mood disorder characterized by excessive, persistent, and uncontrollable fear and worry about everyday situations), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), diabetes mellitus (a chronic disease characterized by high level of sugar in the blood), muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), unsteadiness on feet and unspecified lack of coordination. The MDS reflected Resident #24 had moderate cognitive impairment with a BIMS score of 11. The MDS further reflected Resident #24 did not exhibit wandering behaviors. Record review of Resident #24's care plan, dated 06/19/25, reflected care plan did not address Resident #24 exit seeking behaviors. Record review of Resident #24's Elopement/Wandering Observation quarterly, dated 06/18/25, reflected Resident #24 was high risk for elopement. The evaluation indicated resident had a medical diagnosis associated with confusion, which may indicate future likelihood of high-risk behavior(s). Mobility: Resident is physically able to exit on foot or by wheelchair. Record review of Resident #24's Elopement Risk Evaluation, dated 08/08/25, reflected Resident #24 was at risk for elopement. The evaluation indicated Resident #24 had a history of attempting to leave the facility one or more times in last week. Statement and/or treats to leave facility. Record review of Resident #24's progress notes dated 08/08/25 at 10:55 AM reflected: This nurse was notified by [NAME] Hall nurse that resident was found next door by a resident of the apartment complex. Vitals and skin assessment normal to resident baseline. MD/DON/RP notified. New orders given via telephone from MD: CBS/CMP/UA/Chest Xray. DON will enter the orders. Resident reports she was going back home attempted to redirect resident and successful. Record review of facility Twenty-Four Hour Report dated 08/08/25 reflected: Resident Name: Resident #24; 6AM-2PM: Eloped @ 1055 [10:55AM]; 1:1 ratio at all times. 2PM-10PM: Elope cont. 1:1, stable, in bed. Record review of facility Event Report for Resident dated 08/08/25, time of event 1055 [10:55AM] reflected: Type of Event: Elopement, Note how long missing: 3-5 mins. Heat to toe assessment: no new injuries noted. Skin warm to touch. MD & RP notified of event. Nurse on St.2 told Administrator resident went out front door behind another resident's family [Initial Name] daughter. 3-5 min later [NAME] as with a lady. Statement of resident obtained: Not able to recall. No injury. List new interventions: Resident on 1:1 supervision. Interview on 09/03/25 at 12:06 PM, LVN A revealed she was the nurse assigned to Resident #24 when she eloped from the facility. She stated she could not recall the exact time, but it was between the times of 10AM - 11AM when Resident #24 eloped. She stated she was getting ready to do blood sugar checks when RN B brought Resident #24 to her and told her someone from the apartment complex saw the resident outside and brought her back to the facility, rang the doorbell and asked if this resident lived here. LVN A stated the Activity Director opened the door and verified Resident #24 was a resident from the facility and brought Resident #24 back to her hall. She stated the last time she observed Resident #24 she was in the dining area. She stated it was about a 5 - 10-minute window from when she last observed Resident #24 to when she was brought back to the facility. She stated she does not know exactly how Resident #24 exited the facility, she stated no alarm doors were heard. LVN A stated after Resident #24 was brought back they checked all the doors to ensure they were all closed and alarms working properly. LVN A stated that morning a visitor had come to visit another resident, and she believes when the visitor left the facility the visitor did not checked behind her and Resident #24 followed her out. LVN A stated Resident #24 saw the opportunity and went for it. She stated Resident #24 had history of exit seeking, she stated she would always say I want the code for the door, if someone was leaving the building resident would say I am going with them, she stated she would try to push the door, and the alarms would go off. LVN A stated Resident #24 would be easily redirected and they would keep her busy with activities. She stated resident would propel in her wheelchair and she was fast moving around. LVN A stated she completed a head-to-toe assessment on Resident #24, and no injuries were noted skin was intact. She stated she notified the doctor and Resident #24 family member. She stated Resident #24 was placed on 1:1 supervision until she discharged to another facility on 08/11/25. LVN A stated she could not recall if Resident #24's was care planned for being at risk of elopement. She stated the DON was responsible for updating care plans. She stated if Resident #24 was exhibiting exit seeking behaviors it should had been care planned. She stated care plans were needed to keep up with resident's care, safety and have interventions in place. Interview on 09/03/25 at 12:38 PM, the DON revealed she was informed by LVN A Resident #24 was found by a lady coming out of the apartment complex. The lady saw resident, stopped her car and brought the resident back to the facility and asked if the resident lived here. She stated the Activity Director was the one who opened the door and informed the lady that Resident #24 was a resident at the facility. She stated per LVN A last time she observed Resident #24 she was in the dining area and resident was out for about 3-5 minutes. She stated Resident #24 would ambulate in her wheelchair and was known to peddle fast on it. The DON stated Resident #24 was an elopement risk, she stated an elopement assessment was completed on 08/08/25, and resident scored high risk. The DON stated she could not locate any prior elopement assessment completed on Resident #24, then stated she did not look to ensure if any were completed prior to the elopement but she knew resident was a high risk. She stated Resident #24 had history of attempting to leave the facility, she stated one time unknown of date of when it happened, Resident #24 was attempting to leave but was within eyesight of hers and she immediately stopped her and redirected her. The DON stated Resident #24 was placed on 1:1 supervision until she discharged to another facility. She stated she was not sure if Resident #24 was care planned for her exit seeking behaviors prior to being updated on 08/08/25. The DON reviewed Resident #24 and stated resident had not been care planned for her behaviors. She stated the ADON C was responsible for reviewing and updating care plans but since the ADON C left, she was not responsible for care plans. She stated Resident #24 care plan was updated after her elopement and being on 1:1 supervisor. She stated the potential risk of not care planning elopement behaviors would be staff not knowing the interventions in place for high-risk residents for elopements. Interview on 09/03/25 at 1:03 PM, the Administrator revealed Resident #24 had exited the facility on 08/08/25. She stated till this day they still do not know how resident exited the facility. She stated someone from next door apartment complex found Resident #24 and brought her back to the facility and asked if she lived here. The Administrator stated Resident #24 was only gone for a couple of minutes. She stated she was in her office and could not recall when the last time Resident #24 was last seen. She stated Resident #24 eats her breakfast in her room, once done she is out and about. The Administrator stated Resident #24 was an exit seeker, has tried in the past to exit but was not successful. She stated Resident #24 would always say her car was outside. She stated they would try to redirect resident, keep her busy with activities and watch her within eyesight. She stated after the elopement Resident #24 was placed on 1:1 supervision until they could find an appropriate placement for her. She stated a QAPI meeting was completed with the DON and MD regarding the elopement and suggested Resident #24 required a secure unit. She stated the DON reached out to the family twice on 08/08/24 and LVN B was able to notify the family regarding the incident. The Administrator stated Resident #24 discharged from the facility on 08/11/25. She stated she was not aware Resident #24 exit seeking behaviors were not care planned. The Administrator stated at that time the ADON C and Social Worker were responsible for reviewing and updating care plans, but they left after transitioning to the new company. She stated care plans were important so that staff can keep up with the resident's care. She stated the potential risk would be staff not knowing the interventions in place for resident who are high risk of elopement. The Administrator stated all staff were inserviced elopement risk assessments were completed on all residents, care plans were updated on residents identified as being at high risk of elopement. Record review of the facility's policy Care Plan-Resident, dated December 2018, reflected:It is the policy of this home that staff must develop a comprehensive care plan to meet the needs of the resident. 5. Resident Goalsa. List a measurable, reasonable goal for each problem identified.This was determined to be a Past Non-Compliance Immediate Jeopardy on 09/03/25 at 4:15 PM. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 09/03/25 at 4:40 PM. The facility took the following actions to correct the non-compliance prior to the survey: Record review of facility QAPI revealed a meeting was completed on 08/08/25. Record review of Resident #24's care plan, updated on 08/08/25, reflected Problem: Resident is at risk of elopement as evidenced by. Goals: Resident will not leave the facility. Approach(s): Notify physician and family of any further concerns. Discuss secure unit placement. Monitor and record behavior with it occurs. 1:1 monitoring within eyesight. Divert residents attention and refocus attention elsewhere, staff to orient and redirect resident as needed if she talks of leaving. Record review of Resident #8, Resident #9, Resident #14, Resident #30 and Resident #35's Care Plans reflected care plans were reviewed and updated from 08/08/25 through 08/12/25 to reflect them as being high risk for elopements and to monitor for exit seeking behaviors. Record review of in-services with a start date of 08/08/25 reflected all facility staff were in-serviced on Elopement Risk Report, Elopement & Binder, what to do for Elopement, Elopement Risk Assessments. Summary of Meeting: Elopement risk assessments assist staff in knowing what residents are at risk to elope/try to leave facility. High risk residents' pace, wander, pack their items, talk about going home, watches the doors that are exits. Residents who are bed bound, can't push or move their w/cs on their own and can't transfer out of bed are less likely to be high risk. We care completing Elopement Risk assessments, updating care plans, updating elopement binder if any residents are exit seeking nurse, DON, Administrator be told immediately. Elopement Risk Binder will be set up with ALL resident's elopement risk assessment, face sheet, resident at high risk for elopement - (want to be able to walk or use own w/c to push, packs items)- will be at front of binder. Low risk will be next, no risk - (bed bound can't transfer or move w/c independently) -no risk back of binder. Do not provide codes to visitors, during an elopement check inside and outside, complete a head count, make sure visitor check in. Inservices were completed by 08/12/25. Interviews on 09/03/25 from 12:25 PM through 3:30PM with LVN A, RN B, LVN J, LVN K, who worked the shifts of 6:00 AM-2:00 PM and 2:00 PM-10:00 PM revealed the facility staff were able to verify education was provided to them. Nursing staff stated elopement risk assessments were reviewed/competed (an evaluation to determine any resident at risk of elopement), and care plans were updated on residents who were identified as high risk of elopement. Nursing staff stated if any resident exhibits any behaviors, they will report to the DON for care plans to be updated.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 6 residents (Resident #24) reviewed for supervision. The facility failed to ensure Resident #24, who had a history of exit seeking behaviors and was a high risk for elopement, eloped from the facility on 08/08/25. The resident was found near an apartment complex on a busy street next to the facility by a passerby, who brought her back to the facility. The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 08/08/25 and ended on 08/12/25. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of harm and/or serious injury.Findings included: Record review of Resident #24's annual MDS assessment, dated 07/10/25, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's Disease (brain disorder caused by damage to nerve cells in the brain), anxiety disorder (a mood disorder characterized by excessive, persistent, and uncontrollable fear and worry about everyday situations), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), diabetes mellitus (a chronic disease characterized by high level of sugar in the blood), muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), unsteadiness on feet and unspecified lack of coordination. The MDS reflected Resident #24 had moderate cognitive impairment with a BIMS score of 11. The MDS further reflected Resident #24 did not exhibit wandering behaviors. Record review of Resident #24's care plan, dated 06/19/25, reflected care plan did not address Resident #24 exit seeking behaviors. Care Plan was updated on 08/08/25, reflected Problem: Resident is at risk of elopement as evidenced by. Goals: Resident will not leave the facility. Approach(s): Notify physician and family of any further concerns. Discuss secure unit placement. Monitor and record behavior with it occurs. 1:1 monitoring within eyesight. Divert residents attention and refocus attention elsewhere, staff to orient and redirect resident as needed if she talks of leaving. Record review of Resident #24's Elopement/Wandering Observation quarterly, dated 06/18/25, reflected Resident #24 was high risk for elopement. The evaluation indicated resident had a medical diagnosis associated with confusion, which may indicate future likelihood of high-risk behavior(s). Mobility: Resident is physically able to exit on foot or by wheelchair. Record review of Resident #24's Elopement Risk Evaluation, dated 08/08/25, reflected Resident #24 was at risk for elopement. The evaluation indicated Resident #24 had a history of attempting to leave the facility one or more times in last week. Statement and/or treats to leave facility. Record review of Resident #24's progress notes dated 08/08/25 at 10:55 AM reflected: This nurse was notified by [NAME] Hall nurse that resident was found next door by a resident of the apartment complex. Vitals and skin assessment normal to resident baseline. MD/DON/RP notified. New orders given via telephone from MD: CBS/CMP/UA/Chest Xray. DON will enter the orders. Resident reports she was going back home attempted to redirect resident and successful. Record review of facility Twenty-Four Hour Report dated 08/08/25 reflected: Resident Name: Resident #24; 6AM-2PM: Eloped @ 1055 [10:55AM]; 1:1 ratio at all times. 2PM-10PM: Elope cont. 1:1, stable, in bed. Record review of facility Event Report for Resident dated 08/08/25, time of event 1055 [10:55AM] reflected: Type of Event: Elopement, Note how long missing: 3-5 mins. Heat to toe assessment: no new injuries noted. Skin warm to touch. MD & RP notified of event. Nurse on St.2 told Administrator resident went out front door behind another resident's family [Initial Name] daughter. 3-5 min later she as with a lady. Statement of resident obtained: Not able to recall. No injury. List new interventions: Resident on 1:1 supervision. Interview on 09/03/25 at 12:06 PM, LVN A revealed she was the nurse assigned to Resident #24 when she eloped from the facility. She stated she could not recall the exact time, but it was between the times of 10AM - 11AM when Resident #24 eloped. She stated she was getting ready to do blood sugar checks when RN B brought Resident #24 to her and told her someone from the apartment complex saw the resident outside and brought her back to the facility, rang the doorbell and asked if this resident lived here. LVN A stated the Activity Director opened the door and verified Resident #24 was a resident from the facility and brought Resident #24 back to her hall. She stated the last time she observed Resident #24 she was in the dining area. She stated it was about a 5 - 10-minute window from when she last observed Resident #24 to when she was brought back to the facility. She stated she does not know exactly how Resident #24 exited the facility, she stated no alarm doors were heard. LVN A stated after Resident #24 was brought back they checked all the doors to ensure they were all closed and alarms working properly. LVN A stated that morning a visitor had come to visit another resident, and she believes when the visitor left the facility the visitor did not checked behind her and Resident #24 followed her out. LVN A stated Resident #24 saw the opportunity and went for it. She stated Resident #24 had history of exit seeking, she stated she would always say I want the code for the door, if someone was leaving the building resident would say I am going with them, she stated she would try to push the door, and the alarms would go off. LVN A stated Resident #24 would be easily redirected and they would keep her busy with activities. She stated resident would propel in her wheelchair and she was fast moving around. LVN A stated she completed a head-to-toe assessment on Resident #24, and no injuries were noted skin was intact. She stated she notified the doctor, Resident #24 family member/POA, the DON and the Administrator. She stated Resident #24 was placed on 1:1 supervision until she discharged to another facility on 08/11/25. LVN A stated staff were in serviced on elopement, what to do when a resident goes missing, elopement binder was updated, the front pages of the elopement binder were the residents who were high risk. She stated elopement risk assessment were completed on all residents, care plans were updated, she stated she completes a head count of resident upon the start of her shift. LVN A stated when a visitor visits, they must open the door for them and when they leave the staff puts in the code for them to exit, she stated staff were not allowed to give out codes. Interview on 09/03/25 at 12:19 PM, RN B revealed she was working on 08/08/25 on [NAME] Hall. She stated she was not the nurse assigned to Resident #24; however, she was behind the Activity Director when she opened the door, saw a woman returning Resident #24 and asked if the resident lived here. She stated Resident #24 was in her wheelchair and the woman said she had seen the resident next door in the apartment complex in the middle of the street. RN B stated she asked Resident #24 what she was doing, and Resident #24 told her she was going to go get her car. RN B stated she took Resident #24 back to her hall and told LVN A resident was outside in the street, and someone found her next door and brought her back. RN B stated she could not recall the exact time she had last seen Resident #24, she stated it was after breakfast, before lunch when she was brought back to the facility. She stated when Resident #24 exhibits those behaviors of wanting to leave, they monitor her more frequent and redirect her. RN B stated Resident #24 had a history of exit seeking and trying to open doors. She stated Resident #24 was placed on 1:1 supervision. She stated staff were inserviced on elopement, what to do when a resident goes missing, elopement risk assessment was completed on all residents, care plans were updated, all doors were checked and ensure alarms door worked properly and ensure when a visitor visit staff must open the door and when they leave staff are the ones put the code in. RN B stated staff should not provide door codes to visitors. Interview on 09/03/25 at 12:31 PM, the Activity Director revealed she was working on 08/08/25 when Resident #24 eloped from the facility. She stated the last time she observed Resident #24 she was eating breakfast in the dining room around 8-8:30AM. She stated she could not recall the time, but someone ranged the doorbell, and she opened the door. She stated a women asked if the resident lived here, and she told her yes. She stated she notified the nurse and to take her to her hall. She stated the women stated resident was around the apartment complex next door to the facility. Activity Director stated no alarms were heard that morning. She stated Resident #24 was an elopement risk but she had not seen her open doors. She stated she was inserviced on elopement, elopement binder, where to locate it, and what to do when a resident goes missing. She stated staff are not allowed to give out codes to visitors and staff must always open the door for them when entering and leaving. Interview on 09/03/25 at 12:38 PM, the DON revealed she was informed by LVN A Resident #24 was found by a lady coming out of the apartment complex. The lady saw resident, stopped her car and brought the resident back to the facility and asked if the resident lived here. She stated the Activity Director was the one who opened the door and informed the lady that Resident #24 was a resident at the facility. She stated per LVN A last time she observed Resident #24 she was in the dining area and resident was out for about 3-5 minutes. She stated Resident #24 would ambulate in her wheelchair and was known to peddle fast in it. The DON stated Resident #24 was an elopement risk, she stated an elopement assessment was completed on 08/08/25, and resident scored high risk. The DON stated she could not locate any prior elopement assessment completed on Resident #24, then stated she did not look to ensure if any were completed prior to the elopement but she knew resident was a high risk. She stated Resident #24 had history of attempting to leave the facility, she stated one time unknown of date of when it happened, Resident #24 was attempting to leave but was within eyesight of hers and she immediately stopped her and redirected her. The DON stated Resident #24 was placed on 1:1 supervision until she discharged to another facility. She stated LVN A notified the doctor and family member. She stated elopement risk assessment were completed on all residents, the elopement binder was updated and can be located at the nurse's station. Staff were inserviced on elopement, elopement book, complete head count prior to start of shift, what to do if a resident goes missing, making sure when visitor visit only staff can use the code to open the door. The DON stated they put signs on all the doors to ensure visitors to check behind them when leaving and ensure doors are closed. Interview on 09/03/25 at 1:03 PM, the Administrator revealed Resident #24 had exited the facility on 08/08/25. She stated till this day they still do not know how resident exited the facility. She stated someone from next door apartment complex found Resident #24 and brought her back to the facility and asked if she lived here. The Administrator stated Resident #24 was only gone for a couple of minutes. She stated she was in her office and could not recall when the last time Resident #24 was last seen. She stated Resident #24 eats her breakfast in her room, once done she was out and about. The Administrator stated Resident #24 was an exit seeker, has tried in the past to exit but was not successful. She stated Resident #24 would always say her car was outside. She stated they would try to redirect resident, keep her busy with activities and watch her within eyesight. She stated after the elopement Resident #24 was placed on 1:1 supervision until they could find an appropriate placement for her. She stated a QAPI meeting was completed with the DON and MD regarding the elopement and suggested Resident #24 required a secure unit. She stated the DON reached out to the family twice on 08/08/25 and LVN B was able to notify the family regarding the incident. The DON stated Resident #24 discharged from the facility on 08/11/25. She stated all staff were inserviced on elopement, what to do if a resident elopes from the facility, where to find elopement binder, signs of elopement, and not to provide door codes to visitors, complete head counts at the beginning of every shift. Elopement risk assessments were completed on all residents, care plans were updated on residents identified as being at high risk of elopement, and she completes door audits weekly to ensure doors alarms were working properly. Interview on 09/03/25 at 3:03 PM, CNA E revealed she was the CNA assigned to Resident #24 when she eloped. She stated the last time she observed Resident #24 she was in the dining area around 10:30AM. She stated she could not recall if any visitors visited the morning of 08/08/25. She stated she did not observe Resident #24 exit the facility. She stated Resident #24 was found on the road next to the apartment complex and was brought back to the facility. She stated no injuries were noted on the resident. She stated Resident #24 was known to exit seek, she stated Resident #24 was easily to redirect when she would get close by the doors. She stated Resident #24 would have the tendency of saying she needed to go find her car outside. CNA E stated Resident #24 was placed on 1:1 supervision until she discharged . Record review of facility Elopements policy, dated 12/2017, reflected the following: It is the policy of this home to provide a systematic approach to searching for a resident who may have left the home and/or home grounds. PROCEDUREThe following steps are to be followed when a resident is noted absent and is not found on initial search of the home. This also includes when a resident leaves the home grounds without staff notification. Home Staff will:-Search the home and grounds-Send staff member(s) out to locate the resident-Notify Administrator or on-call person immediately-If resident is not located within 30 minutes, call the local police. Administrative / Supervisory Staff will:-Determine if elopement is reportable to state regulatory agency-Interview staff and obtain written statements. If resident was returned by outside personnel, obtain name, phone number and details with any information of where resident was found and under what circumstances the resident was found.-Establish a monitoring system for resident until flight risk is resolved-Determine what measures can be taken to prevent it from happening again-If elopement is reported, contact appropriate corporate personnel. This was determined to be a Past Non-Compliance Immediate Jeopardy on 09/03/25 at 4:15 PM. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 09/03/25 at 4:40 PM. The facility took the following actions to correct the non-compliance prior to the survey: Record review of facility QAPI revealed a meeting was completed on 08/08/25. Record review of Elopement Risk Assessment reflected they were reviewed and completed on Resident #8, Resident #9, Resident #14, Resident #24, Resident #30 and Resident #35 on 08/08/25. Record review of Resident #8, Resident #9, Resident #14, Resident #24, Resident #30 and Resident #35's Care Plans reflected care plans were reviewed and updated from 08/08/25 through 08/12/25 to reflect them as being high risk for elopements and to monitor for exit seeking behaviors. Record review of facility Elopement binders located on main nurse's station reflected facesheets of residents who were high risk of elopement with pictures and elopement risk assessment on all residents. Record review of facility Audit to Ensure the Doors are Secure and Alarm Working forms for all exit doors from 08/08/25 through 09/02/25 reflected door checks were being completed weekly. Observation on 09/03/25 from 2:06 PM through 2:12 PM revealed all facility door alarms were checked with the Maintenance Director and doors were functioning properly. Alarms were loud enough to be heard throughout the facility. A code was needed to turn off the alarms. Observed signs on all the doors indicating: Caution Make sure this door locks. Do not let any resident out behind you, and main entrance door: Attention Visitors Do Not let residents out without speaking to nursing staff. Record review of in-services with a start date of 08/08/25 reflected all facility staff were in-serviced on Elopement Risk Report, Elopement & Binder, what to do for Elopement, Elopement Risk Assessments. Summary of Meeting: Elopement risk assessments assist staff in knowing what residents are at risk to elope/try to leave facility. High risk residents' pace, wander, pack their items, talk about going home, watches the doors that are exits. Residents who are bed bound, can't push or move their w/cs on their own and can't transfer out of bed are less likely to be high risk. We care completing Elopement Risk assessments, updating care plans, updating elopement binder if any residents are exit seeking nurse, DON, Administrator be told immediately. Elopement Risk Binder will be set up with ALL resident's elopement risk assessment, face sheet, resident at high risk for elopement - (want to be able to walk or use own w/c to push, packs items)- will be at front of binder. Low risk will be next, no risk - (bed bound can't transfer or move w/c independently) -no risk back of binder. Do not provide codes to visitors, during an elopement check inside and outside, complete a head count, make sure visitor check in. In-services were completed by 08/12/25. Interviews on 09/03/25 from 12:25 PM through 3:30PM with LVN A, RN B, [NAME] D, Activity Director, Dietary Manager, CNA E, Dietary Aide G, CNA H, Laundry Aide, CNA I, LVN J, LVN K, Rehab L, Rehab Director, Maintenance Director who worked the shifts of 6:00 AM-2:00 PM, 6AM - 6PM, and 2:00 PM-10:00 PM revealed the facility staff were able to verify education was provided to them. Facility staff were able to accurately summarize the in-service on elopement, signs of elopement, elopement binder, and what to do in case of an elopement/missing person. Nursing staff stated they must complete head counts at the beginning of every shift, elopement risk assessment was reviewed/competed (an evaluation to determine any resident at risk of elopement), where to locate elopement binders, care plans were updated on resident who were identified as high risk of elopement. Staff stated when a resident goes missing/elopes they must stop what they are doing, report to all staff a resident was missing, ensure all residents were counted for, ensure all doors are closed, check inside and outside the facility perimeter. Staff stated door codes were not to be provide to visitors, when a visitor visits, they must open the door for them when entering and exiting the facility.

Based on observation, interview, and record review the facility failed to provide a private meeting space for the residents' monthly council meetings for 8 of 8 confidential residents reviewed for resident council. The facility failed to provide a private space for resident council meetings.This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy. Findings included:During a confidential resident group interview with eight residents on 08/06/25 beginning at 3:00 PM, the facility arranged for the meeting to be held in an open dining room located near the facility's central nurses' station and front entry door. There were no doors that could be closed to ensure the residents' privacy during the meeting. The Activity Director placed portable privacy screens in the middle of the dining room and one by an entry door to the dining room. The Activity Director placed two signs outside the dining room, which reflected: STOP Resident Council in Progress. Although the privacy screen provided visual privacy, it did not provide any audial (sound) privacy. During the meeting, staff were observed walking through the area while the meeting was in progress and there were staff standing by the central nurses' station. The eight residents in attendance all reported that their monthly resident council meetings were held in this open dining room area. The residents stated they had tried other areas of the facility, but there were no private areas in the facility that would hold residents, especially if they used wheelchairs. The residents stated they were used to the open area in the dining room. The residents denied expressing their concern about the location. Interview on 08/07/25 at 11:05 AM, with the Activity Director revealed she had only been at the facility for about a week. She stated yesterday (08/06/25) was the first time she had assisted with scheduling a resident council meeting. She stated she had not had a resident council meeting for the month of August 2025. The Activity Director stated she was not sure where to have the resident council meeting. She stated she was trying to find a private place, and she thought it could be either outside or in the conference room. She stated neither the Administrator, nor the DON, provided any recommendations of where to have the resident council meeting. The Activity Director stated the residents had the right to have a private meeting and be free to express themselves without having anyone who was not in the meeting listening to them. Interview on 08/07/25 at 1:54 PM, with the Administrator revealed since being the administrator at the facility the resident council meetings had been held in the dining area. She stated the dining area would be blocked off, and they would place signs indicating that a meeting was in progress. The Administrator stated before resident council meeting was held in a room, but depending on the number of residents, who attended the meetings, they would move it to the dining area for more space. She stated she was aware resident council meetings needed to be in a private area, that was why they got the portable privacy screen dividers. She stated they were exploring options to find a better place for resident council meetings. The Administrator stated resident council meetings were a time for residents to address issues, talk freely, and not have any concerns of retaliation. Record review of the resident council minutes for April 2025 and July 2025 revealed no requests for a private area. Record review of the facility's current, undated Resident Council policy reflected in part the following: The facility is responsible for providing an adequate space that residents may gather in confidence. A Do Not Disturb, Meeting in progress sign should be posted.

Based on observations, record reviews, and interviews the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 2 residents (Resident #6 and #7) of 5 residents reviewed for quality of care. 1. The facility failed to ensure Resident #6, who received nutrition via tube feeding and had unavoidable weight loss, was weighed weekly as ordered by the physician. 2. The facility failed to ensure Resident #7, who had unplanned weight gain, was weighed weekly as ordered by the physician. This failure could place the residents at risk of weight changes going unnoticed leading to a worsening of their medical conditions. Findings included:1. Record review of Resident #6's quarterly MDS, dated [DATE], reflected the resident was an [AGE] year-old female, who admitted to the facility on [DATE]. The resident's cognition was intact with a BIMS score of 15. The MDS reflected the resident had a diagnosis of malnutrition (lack of proper nutrition), she required substantial assistance with eating, and she had a feeding tube. The resident also had a diagnosis of a pressure ulcer, which had resolved as of 08/03/25. Record review of Resident #6's care plan, dated 04/10/25, reflected the resident was on a therapeutic diet, had poor nutritional intake, and required a feeding tube. The care plan interventions included monthly weights and reporting to the physician if the resident had a 5% weight loss or weight gain. The resident was also on hospice care. Record review of Resident #6's physician orders reflected there was an order dated 11/12/24 for Resident #6 to be weighed weekly due to the resident weighing less than 100 pounds and have a feeding tube. Record review of Resident #6's weight records reflected she was weighed weekly after the physician order was issued on 11/12/24 until 03/26/25. After 03/26/25, the resident was only weighed twice a month, instead of weekly, until 05/07/25. After 05/07/25, the facility only weighed Resident #6 once a month instead of weekly. The weight records reflected:01/01/25 - 87.2 pounds01/08/25 - 87.8 pounds01/15/25 - 93 pounds01/29/25 - 93 pounds02/05/25 - 94 pounds02/19/25 - 94 pounds02/26/25 - 89.6 pounds03/05/25 - 93 pounds03/12/25 - 92.7 pounds03/26/25 - 89.4 pounds04/09/25 - 90 pounds04/23/25 - 88.5 pounds05/05/25 - 86 pounds05/07/25 - 88.4 pounds06/24/25 - 85.2 pounds07/05/25 - 80.2 poundsRecord review of Dietician notes from January 2025 to June 2025 reflected Resident #6's Dietician notes revealed she was seen once a month until she entered hospice on 6/2/25. The dietician was aware of the resident's weight losses, she made adjustments to the resident's enteral feedings, increasing the hourly amount from 60 ml/hr. to 70 ml/hr. and finally 80 ml.hr. Health shakes were added to her diet, two cans a day and then three cans a day. Fortified foods were added to her menu selections as well.Record review of Resident #6's hospice book records from 6/2/25 to 8/6/25 reflected the resident admitted herself to hospice because she knew she was deteriorating, and a recent chest x-ray revealed a mass in her chest that was assumed to be cancer. The hospice nursing notes revealed the resident complained of pain and anxiety at almost every visit, and her pain and anxiety medications had been increased several times. Interview on 08/22/25 at 12:15 PM with Resident #6 revealed she was aware she was losing weight. She stated she just did not have an appetite. She stated she opted for hospice to spare her spouse from having to take care of her. She stated the last time she was in the hospital (July 2025), a mass was discovered in her chest. She stated she refused any diagnostic testing and assumed it was some form of cancer. Resident #6 stated she received her g-tube feedings at nighttime and during the day she received her meals with a shake. Interview on 08/6/25 at 11:10 AM with LVN A revealed she was unaware of the resident's weight loss. She stated the CNAs were responsible for weighing the residents and reporting the weight back to the nurse for the nurse to enter into the electronic record. She stated she was unaware Resident #6 had an order to be weighed weekly. Interview on 08/06/25 at 11:45 AM via telephone with Resident #6's physician, Physician F, revealed Resident #6 was on hospice for end of life. He stated Resident #6's weight loss would be expected as her condition deteriorated. Interview on 08/06/25 at 12:05 PM with the DON stated she was unaware of Resident #6's weight loss. She stated the nurses were responsible for monitoring the resident's weights and reporting any concerns to her and the physician. In an interview on 08/06/25 at 12:23 PM with CNA E stated she was the CNA assigned to Resident #6. She stated Resident #6 health had been declining. She stated staff assist the resident with eating, but the resident did not eat most of her meals. She stated Resident #6 was given a health shake with her meals. She stated the CNAs were responsible weighing the residents, and they were supposed to report to the nurses if a resident had weight loss or weight gain. Interview on 08/22/25 at 2:10 PM with the Dietitian revealed she visited Resident #6 monthly. She stated Resident #6 struggled to maintain her weight, and adjustments had been made to the resident's diet and tube feeding. Also, health shakes were added to supplement the resident's diet. She stated the resident's caloric needs were met by her tube feedings, and any other intake was just extra calories. The Dietitian stated with the mass in the resident's chest being cancer the calories Resident #6 was taking in most likely were feeding it instead of her. She stated Resident #6's weight loss was unavoidable, but the resident could not afford to lose much moreInterview on 08/22/25 at 2:33 PM with the Dietary Manager revealed she was aware of Resident #6 weight loss. She stated Resident #6 was currently on high calorie foods, health shakes, milk with each meal and extra butter. She stated Resident #6 was also on a g-tube and receiving extra bolus feedings. She stated Resident #6's weight loss was unavoidable, and the resident refused most of her meal. The Dietary Manager stated Resident #6 ate most of her breakfast but when it came to lunch and dinner she refused to eat.2. Record review of Resident #7's quarterly MDS, dated [DATE], reflected the resident was a [AGE] year-old female, who admitted to the facility on [DATE]. The resident had moderate cognitive impairment with a BIMS score of 8. The MDS reflected Resident #7's diagnoses included morbid (severe) obesity due to excess calories and Type 2 diabetes mellitus. The resident required substantial to maximal assistance (helper does more than half the effort; helper lifts or holds trunk or limbs and provides more than half the effort) for transfers and was dependent for bed mobility (helper does all the effort). The resident required only set-up or clean-up assistance with eating.Record review of Resident #7's care plan, dated 06/8/25, indicated she had an unexpected weight gain on 04/14/25 of 48 pounds with interventions of weighing monthly. Record review of Resident #7's physician orders, dated 01/06/25, reflected there was an order for Resident #7 to be weighed every three days. The order reflected the physician was to be notified if Resident #7 gained 3 pounds or more. Review of Resident #7's lab work revealed she had a CBC and a BMP drawn in January 2025, with no abnormal findings. Review of Resident #7's weight records revealed she was weighed every three days from 01/06/25 until 01/25/25. After 01/25/25, Resident #7 was only weighed once a month except for April 2025 where there was no documented weight. From 01/25/25 to 05/05/25, the resident went from 362 pounds to 382.2 pounds, a 20-pound or a 5.58% gain. 01/02/25 - 365 pounds01/07/25 - 365.4 pounds01/10/25 - 366.6 pounds01/15/25 - 367.8 pounds01/25/25 - 362 pounds02/05/25 - 361.4 pounds03/04/25 - 361.2 pounds05/05/25 - 382.2 poundsObservation on 08/06/25 at 11:00 AM revealed Resident #7 was weighed via sling and weighed 371.8 pounds. Interview on 08/06/25 at 11:05 AM with LVN A revealed Resident #7 was weighed every month. LVN A revealed she was unaware Resident #7 had a physician order to be weighed every three days. Interview on 08/06/25 at 11:45 AM with the Physician revealed his physician group had assumed care of the facility in June of 2025. Interview on 08/22/25 at 12:07 PM with Resident #7 stated she was doing well. Resident #7 stated she had been working on losing weight. Interview on 08/06/25 at 12:23 PM with CNA E revealed the CNAs were responsible for weighing the residents. She stated CNAs would report to the nurses if a resident had any weight loss or weight gain. She stated she had not noticed Resident #7 having a significant weight gain, and the resident seemed to be her usual self. She stated she had not noticed the resident being puffier or her clothing being too tight. Interview on 08/22/25 at 1:24 PM with LVN A revealed she obtained Resident #7's weight had been consistent. Interview on 08/22/25 at 1:40 PM with RN B revealed the nurses knew who needed to be weighed by what was on the TAR. The TAR indicated if a resident was supposed to be weighed monthly, weekly, etcetera. She stated there was nothing in the EHR that would alert them to a sudden weight gain or loss. She stated the ADON was responsible for monitoring resident weights.Interview on 08/22/25 at 2:10 PM with the Dietician revealed she evaluated Resident #7 in January 2025 as part of her annual evaluation. She was not aware of any weight issues of Resident #7. Record review of the facility's Weight System policy, dated December 2017, reflected: .Residents will be weighed within a timely manner of admission/Readmission. Residents will be weighed by the 5th of the month. Any Resident with a significant weight loss will be reweighed within 24 hours. The monthly weights will be entered into the computer by the 7th of every month. Weight variances will be reviewed at the weekly (?) The DON/ designee will ensure the physician, Responsible Party, and Dietician will be notified in a timely manner and documented in clinical record software.

Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 5 of 34 days (04/20/25, 06/01/25, 06/21/25, 7/19/25 and 07/27/25) reviewed during a look back period from 04/01/25 to 07/31/25 for weekend coverage. The facility failed to have RN coverage in the facility for eight consecutive hours on 04/20/25, 06/01/25, 06/21/25, 7/19/25 and 07/27/25. This failure could place residents at risk for not having their nursing and medical needs met and improper care.Findings included:Record review of facility Employee Timecards, dated 08/06/25 reflected no RN coverage for the following days: 04/20/25 (SUN), 06/01/25 (SUN), 06/21/25 (SAT), 7/19/25 (SAT) and 07/27/25 (SUN). Interview on 08/07/25 at 11:13 AM, with the DON revealed ADON C was responsible for completing nursing schedules. She stated she recently took over schedules after ADON C left on 07/23/25. The DON stated she was not aware the facility did not have RN coverage for the dates listed above. She stated ADON C never mentioned anything to her about not having an RN. She stated she would review the schedules once it was completed by the ADON C and did not realize there was no RN. The DON stated there was no potential risk for not having an RN in the building because she was on call 24 hours. An attempt was made to contact ADON C by phone on 08/07/25 at 11:25 AM; however, there was no answer. Interview on 08/07/25 at 11:27 AM, with the Administrator revealed it was the responsibility of ADON C for completing nursing schedules and the DON to review. She stated she was not aware the facility did not have RN coverage for the dates listed above. The Administrator stated the potential risk of not having an RN in the facility would be if a resident were to expire, they would not have anyone in the building to pronounce and LVNs did not have the same responsibility that an RN for signing off on things. Interview on 08/07/25 at 2:10 PM, with the Administrator revealed the facility did not have a policy for RN coverage and instead followed the CMS guidelines.

Based on observation, interview, and record review, the facility failed to ensure the menus met the nutritional needs of residents in accordance with the established national guidelines and were followed for 1 of 3 meals (lunch meal 08/06/25) observed. [NAME] D failed to follow the menu when preparing the pureed lunch meal on 08/06/25. The failure could place residents, who were on a pureed diet, at risk for a decrease in nutritive status, loss of appetite, decreased intake and unwanted weight loss.Findings included:Record review of the facility Week at a Glance menu dated Week 1 Spring/Summer2025, reflected the menu for the lunch service for Wednesday (Day 4) was Cilantro Lime Chicken, [NAME] Pilaf, Squash & Red Peppers, Dinner Roll, Margarine, Fruit Crisp, Beverage.Record review of the Pureed Cilantro Lime Chicken recipe reflected the following: .Add broth, as needed; blend until smooth. 1. If product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency.Record review of Pureed [NAME] Pilaf recipe reflected the following: Place prepared rice in a washed and sanitized food processor. Gradually add broth as needed and blend until smooth. 1. If product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistencyObservation on 08/06/25 at 10:45 AM revealed [NAME] D making pureed lunch. [NAME] D put the lime chicken in the processor, then proceeded to use the processor food pusher to add water twice and added it to the chicken. [NAME] D added the water without measuring, added thickener and blended the mixture. [NAME] D blended the chicken for about 5-10 seconds and then poured it into small food cups. The pureed cilantro lime chicken appeared to have a mashed potato consistency; however, the chicken did not appear to be fully blended. [NAME] D then was observed to put rice pilaf in the processor, then proceed to use the processor food pusher to add water twice and added it to the rice. [NAME] D added the water without measuring, added thickener and blended the mixture. The pureed rice pilaf appeared to have a mashed potato consistency.Interview on 08/06/25 at 12:49 PM with [NAME] D revealed she had been employed for over a month. She stated she reviewed the puree recipe to ensure she had all the ingredients. She stated she was aware the recipe stated not to add water, and she added water to the chicken and rice. [NAME] D stated the chicken and rice were thick and she added water to loosen them up. She stated she could have used chicken stock instead of water, but they did not have any. She stated by adding water it could take away the flavor. Interview on 08/06/25 at 12:53 PM with the Dietary Manager revealed her expectation was for the Cooks to follow the recipes and have the correct food consistency. She stated they had chicken stock in the kitchen, but the [NAME] failed to use it today (08/06/25). She stated it was her responsibility to ensure kitchen staff followed the recipes. The Dietary Manager stated kitchen staff should know not to add water when pureeing food. She stated water could not be added to the pureed foods because it diluted them and took away the nutrients and flavor. Record review of facility's Pureed policy, dated 2022, reflected the following: The Puree Diet is designed for those individuals who have difficulty swallowing or cannot chew foods of the dental soft consistency. Drain liquid from portions needed for pureed preparation. Reserve liquid in case additional liquid is needed when pureeing to the correct consistency. NEVER USE WATER AS THE LIQUID ADDED TO A PUREED ITEM.the following liquids would be acceptable to use when pureeing foods: prepared broth, gravy, sauce, milk, juice and melted margarine/butter.

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 2 meals (lunch) reviewed for food meeting residents' needs.The facility failed to prepare and serve pureed Cilantro Lime Chicken as a pudding consistency for residents who required pureed diets during the lunch meal on 08/06/25.This deficient practice could affect residents and place them at risk of not receiving meals that meet their needs.Findings included:Record review of the facility Week at a Glance menu dated Week 1 Spring/Summer2025, reflected the menu for the lunch service for Wednesday (Day 4) was Cilantro Lime Chicken, [NAME] Pilaf, Squash & Red Peppers, Dinner Roll, Margarine, Fruit Crisp, Beverage.Observation on 08/06/25 at 10:45 AM revealed [NAME] D making pureed lunch. [NAME] D put the lime chicken in the processor, then proceeded to use the processor food pusher to add water twice and added it to the chicken. [NAME] D added the water without measuring, added thickener and blended the mixture. [NAME] D blended the chicken for about 5-10 seconds and then poured it into small food cups. The pureed cilantro lime chicken appeared to have a mashed potato consistency; however, the chicken did not appear to be fully blended. Neither [NAME] D nor the Dietary Manager checked the consistency or ensured it was all blended to have a pudding smooth consistency.Observation of the test tray on 08/06/25 beginning at 12:42 PM with the Dietary Manager, revealed the test tray included the regular textured menu items and the pureed menu items. The pureed cilantro lime chicken did not have a smooth/pudding consistency. The cilantro lime chicken had bristle in it. The Dietary Manager stated the pureed cilantro lime chicken was not the correct consistency.Interview on 08/06/25 at 12:49 PM, with [NAME] D revealed pureed food needed to have a smooth/mashed potatoes consistency. She stated normally when she blended the food, she could see what kind of consistency it had. She stated she checked the chicken consistency and thought the consistency was correct. She stated the potential harm to residents was the possibility of choking.Interview on 08/06/25 at 12:53 PM, with the Dietary Manager revealed her expectations were for the Cooks to follow the recipe and have the correct food consistency. She stated the pureed meal should be blended thoroughly. The Dietary Manager stated when deboning the chicken, the cooks needed to check thoroughly to ensure there was no bristles or pieces of bones. She stated the potential risk would be residents choking. Record review of the Pureed Cilantro Lime Chicken recipe reflected the following: Remove any skin and bones. Avoid hard, crispy crusts and toppings.2. If the product needs thickening, gradually add a commercial or natural food thickener to achieve a smooth, pudding or soft mashed potato consistency.Record review of the facility's, Pureed policy, dated 2022, reflected the following: The Puree Diet is designed for those individuals who have difficulty swallowing or cannot chew foods of the dental soft consistency.

Based on interview, and record review, the facility failed to ensure residents had the right to participate in the development and implementation of their person-centered plan of care for 1 of 6 residents (Resident #32) reviewed for quarterly care plans.The facility failed to invite Resident #32 and responsible parties with 4 quarterly care plan conference meetings for the last 12 months. Resident #32's last care plan meeting was dated 08/07/24. This failure could place residents at risk of not receiving inadequate interventions not individualized to their care needs.Findings included:Record review of Resident #32's face sheet, dated 08/07/25, reflected the resident was a [AGE] year-old female with an admission date of 08/03/23 and returned 03/08/25. Record review of Resident #32's quarterly MDS assessment dated [DATE] reflected her diagnoses included hypertension (high blood pressure), dementia, cognitive communication deficit, and depression. The MDS reflected the resident had severe cognitive impairment with a BIMS score of 4. Record review of Resident #32's care plan, last reviewed/revised date 04/24/25 reflected Category: Return to community referral POA had no desire for [Resident #32] to return to community. Staff will revisit on comprehensive assessments only. Goal: Resident needs will be met by facility staff through the next review period. Approach: 1. Keep POA/[Resident #32] updated on the resident plan of care. 2. Staff will maintain [Resident #32] needs. 3. Follow up with the [Resident #32]/POA annually. Record review of Resident #32's Care Conference Report reflected the last care plan meeting was completed on 08/07/24 for Annual Care Conference. Record review of Resident #32's progress notes reflected no documentation regarding care plan meetings or family being made aware of care plan conference meetings. Interview on 08/05/25 at 1:20 PM, Resident #32's Family Member A/POA revealed he had concerns regarding Resident #32's care and wanted to address it with the facility. Resident #32's Family Member A/POA stated he had not been invited to any care plan meetings to address his concerns. Resident #32's Family Member A/POA stated he was not aware care plan meetings were held quarterly. The last care plan meeting he had been invited and attended was sometime last year 2024, exact date unknown.Interview on 08/05/25 at 1:23 PM, Resident #32 revealed she had no concerns regarding her care. Resident #32 was not a good historian and could not recall if she had attended a care plan meeting or been asked to attend one.An attempt was made on 08/07/25 at 11:25 AM to contact the ADON C/MDS Coordinator by phone; however, there was no answer. Interview on 08/07/25 at 12:52 PM, with the DON revealed the Social Worker and ADON C, who was the MDS Coordinator, were responsible for coordinating the care plan meetings. The DON stated the Social Worker or ADON C would inform her when a care plan meeting was scheduled, and she would attend. She stated care plan meetings should be documented in the residents' charts, and the Social Worker would keep notes of what was discussed during the meeting. The DON stated she had been employed since February 2025, and she could not recall if Resident #32 had had a care plan meeting. She stated care plan meetings should be completed quarterly with family. She stated both the Social Worker and ADON C were no longer employed by the facility. The DON stated she was not aware Resident #32's care plan meetings were not being completed quarterly. She stated the potential risk of not completing care plan meetings would be the team, family, and resident not being informed about changes or areas that needed to be addressed regarding the resident. Interview on 08/07/25 at 1:50 PM, with the Administrator revealed the Social Worker and ADON C were responsible for scheduling care plan meetings. She stated she was not aware Resident #32 had not had a care plan meeting since 2024. She stated the IDT was responsible for conducting the care plan meetings. She stated the potential risk of not having the care plan meetings would be family not being able to communicate their concerns regarding the resident's care or not being able to know the level of care the resident was receiving. She stated Resident #32's family had not mentioned anything to them about a care plan meeting. An attempt was made to contact the Social Worker by phone on 08/07/25 at 2:17 PM; however, there was no answer.Record review of the facility's Statement of Resident Right policy dated 12/01/18 reflected the following: .To participate in developing a plan of care that describes their medical, psychological, and nursing needs and how the needs will be met .

Based on interview and record review, the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 6 residents (Resident #24) reviewed for abuse and neglect. The facility failed to implement their policy on reporting an incident involving Resident #24, who had a history of exit seeking behaviors and was a high risk for elopement, eloped from the facility on 08/08/25. The resident was found near an apartment complex on a busy street next to the facility by a passerby who brought her back to the facility. This failure could place the residents in the facility at risk of neglect and lack of timely reporting of incidents.Findings included: Record review of the facility's current Abuse/ Reportable Events policy, dated 1/10/17, revealed the following: It is everyone's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Adverse event. An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. Record review of Resident #24's annual MDS assessment, dated 07/10/25, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's Disease (brain disorder caused by damage to nerve cells in the brain), anxiety disorder (a mood disorder characterized by excessive, persistent, and uncontrollable fear and worry about everyday situations), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), diabetes mellitus (a chronic disease characterized by high level of sugar in the blood), muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), unsteadiness on feet and unspecified lack of coordination. The MDS reflected Resident #24 had moderate cognitive impairment with a BIMS score of 11. The MDS further reflected Resident #24 did not exhibit wandering behaviors. Record review of Resident #24's care plan, dated 06/19/25, reflected care plan did not address Resident #24's exit seeking behaviors. Care Plan was updated on 08/08/25, reflected Problem: Resident is at risk of elopement as evidenced by. Goals: Resident will not leave the facility. Approach(s): Notify physician and family of any further concerns. Discuss secure unit placement. Monitor and record behavior with it occurs. 1:1 monitoring within eyesight. Divert residents attention and refocus attention elsewhere, staff to orient and redirect resident as needed if she talks of leaving. Record review of Resident #24's Elopement/Wandering Observation quarterly, dated 06/18/25, reflected Resident #24 was high risk for elopement. The evaluation indicated resident had a medical diagnosis associated with confusion, which may indicate future likelihood of high-risk behavior(s). Mobility: Resident is physically able to exit on foot or by wheelchair. Record review of Resident #24's Elopement Risk Evaluation, dated 08/08/25, reflected Resident #24 was at risk for elopement. The evaluation indicated Resident #24 had a history of attempting to leave the facility one or more times in last week. Statement and/or treats to leave facility. Record review of Resident #24's progress notes dated 08/08/25 at 10:55 AM reflected: This nurse was notified by [NAME] Hall nurse that resident was found next door by a resident of the apartment complex. Vitals and skin assessment normal to resident baseline. MD/DON/RP notified. New orders given via telephone from MD: CBS/CMP/UA/Chest Xray. DON will enter the orders. Resident reports she was going back home attempted to redirect resident and successful. Record review of facility Twenty-Four Hour Report dated 08/08/25 reflected: Resident Name: Resident #24; 6AM-2PM: Eloped @ 1055 [10:55AM]; 1:1 ratio at all times. 2PM-10PM: Elope cont. 1:1, stable, in bed. Record review of facility Event Report for Resident dated 08/08/25, time of event 1055 [10:55AM] reflected: Type of Event: Elopement, Note how long missing: 3-5 mins. Heat to toe assessment: no new injuries noted. Skin warm to touch. MD & RP notified of event. Nurse on St.2 told Administrator resident went out front door behind another resident's family [Initial Name] daughter. 3-5 min later [NAME] as with a lady. Statement of resident obtained: Not able to recall. No injury. List new interventions: Resident on 1:1 supervision. Interview on 09/03/25 at 12:06 PM, LVN A revealed she was the nurse assigned to Resident #24 when she eloped from the facility. She stated she could not recall the exact time, but it was between the times of 10AM - 11AM when Resident #24 eloped. She stated she was getting ready to do blood sugar checks when RN B brought Resident #24 to her and told her someone from the apartment complex saw the resident outside and brought her back to the facility, rang the doorbell and asked if this resident lived here. LVN A stated the Activity Director opened the door and verified Resident #24 was a resident from the facility and brought Resident #24 back to her hall. She stated the last time she observed Resident #24 she was in the dining area. She stated it was about a 5 - 10-minute window from when she last observed Resident #24 to when she was brought back to the facility. She stated she does not know exactly how Resident #24 exited the facility, she stated no alarm doors were heard. LVN A stated after Resident #24 was brought back they checked all the doors to ensure they were all closed and alarms working properly. LVN A stated that morning a visitor had come to visit another resident, and she believes when the visitor left the facility the visitor did not checked behind her and Resident #24 followed her out. LVN A stated Resident #24 saw the opportunity and went for it. She stated Resident #24 had history of exit seeking, she stated she would always say I want the code for the door, if someone was leaving the building resident would say I am going with them, she stated she would try to push the door, and the alarms would go off. LVN A stated Resident #24 would be easily redirected and they would keep her busy with activities. She stated resident would propel in her wheelchair and she was fast moving around. LVN A stated she completed a head-to-toe assessment on Resident #24, and no injuries were noted skin was intact. She stated she notified the doctor, Resident #24 family member/POA, the DON and the Administrator. She stated Resident #24 was placed on 1:1 supervision until she discharged to another facility on [DATE]. Interview on 09/03/25 at 12:19 PM, RN B revealed she was working on 08/08/25 on [NAME] Hall. She stated she was not the nurse assigned to Resident #24; however, she was behind the Activity Director when she opened the door, saw a woman returning Resident #24 and asked if the resident lived here. She stated Resident #24 was in her wheelchair and the woman said she had seen the resident next door in the apartment complex in the middle of the street. RN B stated she asked Resident #24 what she was doing, and Resident #24 told her she was going to go get her car. RN B stated she took Resident #24 back to her hall and told LVN A resident was outside in the street, and someone found her next door and brought her back. RN B stated she could not recall the exact time she had last seen Resident #24, she stated it was after breakfast, before lunch when she was brought back to the facility. She stated when Resident #24 exhibits those behaviors of wanting to leave, they monitor her more frequent and redirect her. RN B stated Resident #24 had a history of exit seeking and trying to open doors. She stated Resident #24 was placed on 1:1 supervision. Interview on 09/03/25 at 12:31 PM, the Activity Director revealed she was working on 08/08/25 when Resident #24 eloped from the facility. She stated the last time she observed Resident #24 she was eating breakfast in the dining room around 8-8:30AM. She stated she could not recall the time, but someone ranged the doorbell, and she opened the door. She stated a women asked if the resident lived here, and she told her yes. She stated she notified the nurse and to take her to her hall. She stated the women stated resident was around the apartment complex next door to the facility. Activity Director stated no alarms were heard that morning. She stated Resident #24 was an elopement risk but she had not seen her open doors. Interview on 09/03/25 at 12:38 PM, the DON revealed she was informed by LVN A Resident #24 was found by a lady coming out of the apartment complex. The lady saw resident, stopped her car and brought the resident back to the facility and asked if the resident lived here. She stated the Activity Director was the one who opened the door and informed the lady that Resident #24 was a resident at the facility. She stated per LVN A last time she observed Resident #24 she was in the dining area and resident was out for about 3-5 minutes. She stated Resident #24 would ambulate in her wheelchair and was known to peddle fast on it. The DON stated Resident #24 was an elopement risk, she stated an elopement assessment was completed on 08/08/25, and resident scored high risk. The DON stated she could not locate any prior elopement assessment completed on Resident #24, then stated she did not look to ensure if any were completed prior to the elopement but she knew resident was a high risk. She stated Resident #24 had history of attempting to leave the facility, she stated one time unknown of date of when if happened, Resident #24 was attempting to leave but was within eyesight of hers and she immediately stopped her and redirected her. The DON stated Resident #24 was placed on 1:1 supervision until she discharged to another facility. She stated LVN A notified the doctor and family member. The DON stated everyone was responsible for reporting any abuse and neglect allegations to the abuse coordinator who was the Administrator. She stated she did not think the incident with Resident #24 was a reportable because resident was brought back quickly to the facility with no injuries. The DON stated after reviewing and discussing the incident pertaining the elopement it should had been reported to the HHSC. Interview on 09/03/25 at 1:03 PM, the Administrator revealed Resident #24 had exited the facility on 08/08/25. She stated till this day they still do not know how resident exited the facility. She stated someone from next door apartment complex found Resident #24 and brought her back to the facility and asked if she lived here. The Administrator stated Resident #24 was only gone for a couple of minutes. She stated she was in her office and could not recall when the last time Resident #24 was last seen. She stated Resident #24 eats her breakfast in her room, once done she is out and about. The Administrator stated Resident #24 was an exit seeker, has tried in the past to exit but was not successful. She stated Resident #24 would always say her car was outside. She stated they would try to redirect resident, keep her busy with activities and watch her within eyesight. She stated after the elopement Resident #24 was placed on 1:1 supervision until they could find an appropriate placement for her. She stated a QAPI meeting was completed with the DON and MD regarding the elopement and suggested Resident #24 required a secure unit. She stated the DON reached out to the family twice on 08/08/25 and LVN B was able to notify the family regarding the incident. The Administrator stated Resident #24 discharged from the facility on [DATE]. The Administrator stated she was the abuse coordinator, and she was responsible for reporting to HHSC. She stated she did not report the incident pertaining Resident #24 to HHSC because she was only gone for a couple of minutes. She stated she reached out to her higher ups and with the DON whether the incident was a reportable and concluded it was not.

Based on interview and record review the facility failed to ensure all alleged violations involving neglect, which included injuries of unknown source, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, which included the State Survey Agency, in accordance with State law through established procedures for 1 of 6 residents (Resident #24) reviewed for abuse and neglect. The facility failed to report an incident to HHSC involving Resident #24, who had a history of exit seeking behaviors and was a high risk for elopement, eloped from the facility on 08/08/25. The resident was found near an apartment complex on a busy street next to the facility by a passerby who brought her back to the facility. This deficient practice could affect any resident and contribute to resident neglect. Findings included: Record review of Resident #24's annual MDS assessment, dated 07/10/25, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's Disease (brain disorder caused by damage to nerve cells in the brain), anxiety disorder (a mood disorder characterized by excessive, persistent, and uncontrollable fear and worry about everyday situations), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), diabetes mellitus (a chronic disease characterized by high level of sugar in the blood), muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), unsteadiness on feet and unspecified lack of coordination. The MDS reflected Resident #24 had moderate cognitive impairment with a BIMS score of 11. The MDS further reflected Resident #24 did not exhibit wandering behaviors. Record review of Resident #24's care plan, dated 06/19/25, reflected care plan did not address Resident #24 exit seeking behaviors. Care Plan was updated on 08/08/25, reflected Problem: Resident is at risk of elopement as evidenced by. Goals: Resident will not leave the facility. Approach(s): Notify physician and family of any further concerns. Discuss secure unit placement. Monitor and record behavior with it occurs. 1:1 monitoring within eyesight. Divert residents attention and refocus attention elsewhere, staff to orient and redirect resident as needed if she talks of leaving. Record review of Resident #24's Elopement/Wandering Observation quarterly, dated 06/18/25, reflected Resident #24 was high risk for elopement. The evaluation indicated resident had a medical diagnosis associated with confusion, which may indicate future likelihood of high-risk behavior(s). Mobility: Resident is physically able to exit on foot or by wheelchair. Record review of Resident #24's Elopement Risk Evaluation, dated 08/08/25, reflected Resident #24 was at risk for elopement. The evaluation indicated Resident #24 had a history of attempting to leave the facility one or more times in last week. Statement and/or treats to leave facility. Record review of Resident #24's progress notes dated 08/08/25 at 10:55 AM reflected: This nurse was notified by [NAME] Hall nurse that resident was found next door by a resident of the apartment complex. Vitals and skin assessment normal to resident baseline. MD/DON/RP notified. New orders given via telephone from MD: CBS/CMP/UA/Chest Xray. DON will enter the orders. Resident reports she was going back home attempted to redirect resident and successful. Record review of facility Twenty-Four Hour Report dated 08/08/25 reflected: Resident Name: Resident #24; 6AM-2PM: Eloped @ 1055 [10:55AM]; 1:1 ratio at all times. 2PM-10PM: Elope cont. 1:1, stable, in bed. Record review of facility Event Report for Resident dated 08/08/25, time of event 1055 [10:55AM] reflected: Type of Event: Elopement, Note how long missing: 3-5 mins. Heat to toe assessment: no new injuries noted. Skin warm to touch. MD & RP notified of event. Nurse on St.2 told Administrator resident went out front door behind another resident's family [Initial Name] daughter. 3-5 min later [NAME] as with a lady. Statement of resident obtained: Not able to recall. No injury. List new interventions: Resident on 1:1 supervision. Interview on 09/03/25 at 12:06 PM, LVN A revealed she was the nurse assigned to Resident #24 when she eloped from the facility. She stated she could not recall the exact time, but it was between the times of 10AM - 11AM when Resident #24 eloped. She stated she was getting ready to do blood sugar checks when RN B brought Resident #24 to her and told her someone from the apartment complex saw the resident outside and brought her back to the facility, rang the doorbell and asked if this resident lived here. LVN A stated the Activity Director opened the door and verified Resident #24 was a resident from the facility and brought Resident #24 back to her hall. She stated the last time she observed Resident #24 she was in the dining area. She stated it was about a 5 - 10-minute window from when she last observed Resident #24 to when she was brought back to the facility. She stated she does not know exactly how Resident #24 exited the facility, she stated no alarm doors were heard. LVN A stated after Resident #24 was brought back they checked all the doors to ensure they were all closed and alarms working properly. LVN A stated that morning a visitor had come to visit another resident, and she believes when the visitor left the facility the visitor did not checked behind her and Resident #24 followed her out. LVN A stated Resident #24 saw the opportunity and went for it. She stated Resident #24 had history of exit seeking, she stated she would always say I want the code for the door, if someone was leaving the building resident would say I am going with them, she stated she would try to push the door, and the alarms would go off. LVN A stated Resident #24 would be easily redirected and they would keep her busy with activities. She stated resident would propel in her wheelchair and she was fast moving around. LVN A stated she completed a head-to-toe assessment on Resident #24, and no injuries were noted skin was intact. She stated she notified the doctor, Resident #24 family member/POA, the DON and the Administrator. She stated Resident #24 was placed on 1:1 supervision until she discharged to another facility on 08/11/25. Interview on 09/03/25 at 12:19 PM, RN B revealed she was working on 08/08/25 on [NAME] Hall. She stated she was not the nurse assigned to Resident #24; however, she was behind the Activity Director when she opened the door, saw a woman returning Resident #24 and asked if the resident lived here. She stated Resident #24 was in her wheelchair and the woman said she had seen the resident next door in the apartment complex in the middle of the street. RN B stated she asked Resident #24 what she was doing, and Resident #24 told her she was going to go get her car. RN B stated she took Resident #24 back to her hall and told LVN A resident was outside in the street, and someone found her next door and brought her back. RN B stated she could not recall the exact time she had last seen Resident #24, she stated it was after breakfast, before lunch when she was brought back to the facility. She stated when Resident #24 exhibits those behaviors of wanting to leave, they monitor her more frequent and redirect her. RN B stated Resident #24 had a history of exit seeking and trying to open doors. She stated Resident #24 was placed on 1:1 supervision. Interview on 09/03/25 at 12:31 PM, the Activity Director revealed she was working on 08/08/25 when Resident #24 eloped from the facility. She stated the last time she observed Resident #24 she was eating breakfast in the dining room around 8-8:30AM. She stated she could not recall the time, but someone ranged the doorbell, and she opened the door. She stated a women asked if the resident lived here, and she told her yes. She stated she notified the nurse and to take her to her hall. She stated the women stated resident was around the apartment complex next door to the facility. Activity Director stated no alarms were heard that morning. She stated Resident #24 was an elopement risk but she had not seen her open doors. Interview on 09/03/25 at 12:38 PM, the DON revealed she was informed by LVN A Resident #24 was found by a lady coming out of the apartment complex. The lady saw resident, stopped her car and brought the resident back to the facility and asked if the resident lived here. She stated the Activity Director was the one who opened the door and informed the lady that Resident #24 was a resident at the facility. She stated per LVN A last time she observed Resident #24 she was in the dining area and resident was out for about 3-5 minutes. She stated Resident #24 would ambulate in her wheelchair and was known to peddle fast on it. The DON stated Resident #24 was an elopement risk, she stated an elopement assessment was completed on 08/08/25, and resident scored high risk. The DON stated she could not locate any prior elopement assessment completed on Resident #24, then stated she did not look to ensure if any were completed prior to the elopement but she knew resident was a high risk. She stated Resident #24 had history of attempting to leave the facility, she stated one time unknown of date of when if happened, Resident #24 was attempting to leave but was within eyesight of hers and she immediately stopped her and redirected her. The DON stated Resident #24 was placed on 1:1 supervision until she discharged to another facility. She stated LVN A notified the doctor and family member. The DON stated everyone was responsible for reporting any abuse and neglect allegations to the abuse coordinator who was the Administrator. She stated she did not think the incident with Resident #24 was a reportable because resident was brought back quickly to the facility with no injuries. The DON stated after reviewing and discussing the incident pertaining the elopement it should had been reported to the State. Interview on 09/03/25 at 1:03 PM, the Administrator revealed Resident #24 had exited the facility on 08/08/25. She stated till this day they still do not know how resident exited the facility. She stated someone from next door apartment complex found Resident #24 and brought her back to the facility and asked if she lived here. The Administrator stated Resident #24 was only gone for a couple of minutes. She stated she was in her office and could not recall when the last time Resident #24 was last seen. She stated Resident #24 eats her breakfast in her room, once done she is out and about. The Administrator stated Resident #24 was an exit seeker, has tried in the past to exit but was not successful. She stated Resident #24 would always say her car was outside. She stated they would try to redirect resident, keep her busy with activities and watch her within eyesight. She stated after the elopement Resident #24 was placed on 1:1 supervision until they could find an appropriate placement for her. She stated a QAPI meeting was completed with the DON and MD regarding the elopement and suggested Resident #24 required a secure unit. She stated the DON reached out to the family twice on 08/08/25 and LVN B was able to notify the family regarding the incident. The Administrator stated Resident #24 discharged from the facility on 08/11/25. The Administrator stated she was the abuse coordinator, and she was responsible for reporting to HHSC. She stated she did not report the incident pertaining Resident #24 to HHSC because she was only gone for a couple of minutes. She stated she reached out to her higher ups and with the DON whether the incident was a reportable and concluded it was not. Record review of the facility's current Abuse/ Reportable Events policy, dated 1/10/17, revealed the following: It is everyone's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Adverse event. An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. Reporting: Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC. -If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. -If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation.

Based on interview and record review, the facility failed to develop and implement an effective discharge planning process that is consistent with the discharge rights set forth at 483.15(b) as applicable and involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan for 1 of 3 residents (Resident #24) reviewed for discharges. The facility failed to involve Resident #24's POA in the discharge plan prior to Resident #24 being transferred to a different facility on 08/11/25. This failure could place residents at risk of not having complete records after permanent discharge from the facility. Findings included: Record review of Resident #24's discharged MDS assessment, dated 08/11/25, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE] and discharged on 08/11/25 to Nursing Home. Resident #24 entry/discharge reporting - Discharge assessment -return not anticipated. The resident's diagnoses included Alzheimer's Disease (brain disorder caused by damage to nerve cells in the brain), anxiety disorder (a mood disorder characterized by excessive, persistent, and uncontrollable fear and worry about everyday situations), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), diabetes mellitus (a chronic disease characterized by high level of sugar in the blood), muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), unsteadiness on feet and unspecified lack of coordination. The MDS reflected Resident #24 had moderate cognitive impairment with a BIMS score of 11. Record review of Resident #24's care plan, dated 06/19/25, reflected: Problem: Category: Return to Community Referral POA has no desire for [Resident #24] to return to community. Staff will revisit on comprehensive assessments only. Goal: [Resident #24] needs will be met by facility staff through the next review period. Approach: 1. Keep POA.u pdated on the [Resident #24] residents plan of care. 2. Staff will maintain [Resident #24] needs 3. Follow up with.POA annually. Record review of Resident #24's progress notes on 08/11/25 at 10:30AM by LVN A reflected: Resident is calm and oriented to self. vitals assessed, normal to residents baseline BM reported this morning. Spoke with [family member] facility to give report. Medications reconciled. Meds from med cart, included Lyrica and Norco counted with west side Hall nurse. Majority of residents belongings gathered. Resident in route to [Facility] family in location. Record review of Resident #24's clinical records reflected there was no documented evidence reflecting Resident #24's legal representative or family member was notified of the discharge or involved in the planning of the discharge. Interview on 09/02/25 at 1:23 PM with Resident #24's family member, Family Member C, revealed Resident #24 was transferred to another facility without family consent. Family Member C stated they had two missed calls on Friday 08/08/25 regarding Resident #24's elopement. Family Member C stated they called back and were notified of the elopement, but they were never told about the transfer. They stated they only had a voicemail from the DON stating she wanted to talk to the family member about moving the resident to a secure unit. Family Member C called the facility on Monday 08/11/25 and was told Resident #24 was already moved to another facility Family Member C stated they called the Administrator and expressed their concerns to the Administrator regarding the resident being moved. Family Member C stated the Administrator was under the impression family was aware of the transfer; however, they were not. Family Member C stated the family was aware Resident #24 had exit-seeking behaviors, was at risk of eloping from the facility, and required a secure unit. Family Member C stated the family would have preferred to be given the opportunity to find a more suitable placement for the resident. Interview on 09/03/25 at 12:06 PM with LVN A revealed she was the nurse assigned to Resident #24 when the resident discharged on 08/11/25. She stated Resident #24 eloped from the facility on 08/08/25 and was placed on 1:1 supervision until she discharged on 08/11/25. She stated when she returned to work on 08/11/25, she noticed Resident #24 was scheduled to be discharged . She stated before she released Resident #24, she contacted the DON to ensure this was the plan to transfer the resident. She stated the DON notified her that everything was in place for Resident #24 to discharge to a different facility. LVN A stated she was never told to contact family. She stated the DON was the one who handled the discharge planning for Resident #24. LVN A stated she never contacted the family regarding the discharge, and she only talked to the family on 08/08/25 to notify them of the resident's elopement. On the day of the discharge, LVN A stated she assisted Resident #24 with her belongings. She stated Resident #24 was doing well with the discharge, and the resident was not crying or upset about the transfer. Interview on 09/03/25 at 12:53 PM with the DON revealed she or LVN A had notified Resident #24's family of the resident's discharge on [DATE]. The DON stated she left a voicemail for Family Member C stating she needed to talk to them about moving the resident to a secure unit. The DON stated she was not in the building on 08/11/25 when Resident #24 discharged . She stated it was a mutual decision between herself, the Administrator, and MD to discharge Resident #24 to a more appropriate facility because the resident was no longer safe at the facility. The DON stated she did not have a conversation with Resident #24's family regarding the discharge, but she assumed someone had. She stated she spoke to Family Member C on 08/11/25 around 2:00-3:00 PM and informed Family Member C that Resident #24 had already discharged from the facility. She told the family member she assumed someone had contacted the family prior to the resident's discharge. The DON stated the facility's process for handling discharges involved the facility having a discussion with the family, and this discussion included the Administrator and MD.Interview on 09/03/25 at 1:03 PM with the Administrator revealed when a resident discharged , the facility staff must notify the family and the doctor. Resident #24 discharged from the facility on 08/11/25 due to the facility not being able to meet her needs. She stated Resident #24 was an elopement risk and required a more appropriate placement. She stated on 08/11/25 she assisted Resident #24 with packing her belongings. She stated the resident was pleasant and was okay with the transfer. She stated she was under the impression Resident #24's family was aware of the discharge. She stated she received a call on 08/11/25 around 4:00-5:00 PM from Family Member C asking where the resident was, and she had told Family Member C that Resident #24 had already discharged , and she thought the family member already knew. The Administrator stated she contacted the DON and asked if she had contacted the family prior to the Resident #24's discharge, the DON told her someone from the nursing department had called the family. She stated she spoke to LVN A and LVN A told her she reached out to the DON, and the DON told her to go ahead to discharge Resident #24. The Administrator stated she reached out again to the DON, and the DON told her she was not quite sure if the family was notified. The Administrator stated she reached out to Resident #24's family to apologize, and she provided the family with the location of the facility to which Resident #24 had transferred. She stated the following day she followed-up with the family, and the family informed her the other facility was a better fit for the resident. The Administrator stated she was upset at how Resident #24's transfer was not handled appropriately by the DON. She stated it was a lack of communication. She stated the potential risk would be the family not knowing where the resident had transferred. Interview on 09/03/25 at 3:42 PM with Resident #24's POA revealed she was informed by a family member of Resident #24's discharge. The POA stated prior to Resident #24 discharging she only received a voicemail on Friday 08/08/25 regarding the resident's elopement with consideration to possibly moving the resident to a secure unit. She stated no agreement was made for Resident #24 to be discharged from the facility. Interview on 09/03/25 at 6:08 PM with the MD revealed he was made aware of Resident #24's discharge. He stated Resident #24 eloped from the facility and was at high risk for elopement. The MD stated he approved the resident's transfer to another facility. He stated he expected for the facility to notify the family of the transfer prior to the resident discharging. Record review of the facility's Discharge - Transfer of the Resident, dated 12/2017, reflected the following: It is the policy of this home that residents and/or responsible parties will be notified prior to transfer or discharge. discharged residents will have documentation related to discharge or transfer in clinical software .

Based on interview and record review, the facility failed to ensure a resident had a discharge summary that included, but not limited to a recapitulation of the resident's stay, that included but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultant results and a final summery of the resident's status to include items, at the time of the discharge that was available to release to authorized persons and agencies, with the consent of the resident or resident's representative for 1 of 3 residents (Resident #24) reviewed for discharge summary. The facility failed to complete a discharge summary for Resident #24. This failure could place residents at risk of not having complete records after permanent discharge from the facility. Findings included: Record review of Resident #24's Discharge MDS assessment, dated 08/11/25, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE] and discharged on 08/11/25 to Nursing Home. Resident #24 entry/discharge reporting - Discharge assessment -return not anticipated. The resident's diagnoses included Alzheimer's Disease (brain disorder caused by damage to nerve cells in the brain), anxiety disorder (a mood disorder characterized by excessive, persistent, and uncontrollable fear and worry about everyday situations), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), diabetes mellitus (a chronic disease characterized by high level of sugar in the blood), muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), unsteadiness on feet and unspecified lack of coordination. The MDS reflected Resident #24 had moderate cognitive impairment with a BIMS score of 11. Record review of Resident #24's care plan, dated 06/19/25, reflected: Problem: Category: Return to Community Referral POA has no desire for [Resident #24] to return to community. Staff will revisit on comprehensive assessments only. Goal: [Resident #24] needs will be met by facility staff through the next review period. Approach: 1. Keep POA.u pdated on the [Resident #24] residents plan of care. 2. Staff will maintain [Resident #24] needs 3. Follow up with.POA annually. Record review of Resident #24's progress notes on 08/11/25 at 10:30 AM by LVN A reflected: Resident is calm and oriented to self. vitals assessed, normal to residents baseline BM reported this morning. Spoke with [family member] facility to give report. Medications reconciled. Meds from med cart, included Lynca and Norco counted with west side Hall nurse. Majority of residents belongings gathered. Resident in route to [Facility] family in location. Record review of Resident #24's clinical record reflected there was no documented evidence showing that a discharge summary had been completed for Resident #24. Interview on 09/02/25 at 1:23 PM, Resident #24 Family Member C revealed Resident #24 was transferred to another facility without family consent. Interview on 09/03/25 at 12:06 PM with LVN A revealed she was the nurse assigned to Resident #24 when she discharged on 08/11/25. LVN A stated she documented a progress note regarding the discharge which was her discharge summary. Interview on 09/03/25 at 12:53 PM with the DON revealed a mutual decision had been made between herself, the Administrator and MD to discharge Resident #24 to a more appropriate facility because resident was no longer safe at the facility. Interview on 09/03/25 at 6:08 PM with the Administrator revealed the Social Worker was responsible for completing discharge summaries. She stated since the Social Worker's employment ended prior to Resident #24's discharge on [DATE], the discharge nurse or DON were responsible for completing the discharge summary. She stated when Resident #24 discharged from the facility, the DON was not in the building. She stated the LVN who discharged Resident #24 should had completed a discharge summary, and the DON should have followed-up on it. She stated the expectation was for discharge summary to be developed and completed. Interview on 09/03/25 at 6:14 PM with the DON revealed the discharge nurse was responsible for completing discharge summaries. She stated if the discharge nurse was unable to complete the discharge summary, the nurse should notify her, and she would complete it. The DON stated due to the change of system they were behind on things, and Resident #24's discharge summary was one of the things that needed to be completed. She stated it was her responsibility to ensure discharge summaries were completed. Record review of the facility's Discharge - Transfer of the Resident policy, dated December 2017, reflected the following: It is the policy of this home that residents and/or responsible parties will be notified prior to transfer or discharge. discharged residents will have documentation related to discharge or transfer in clinical software.9. Discharge Summary completed by DON/designee.

Based on interview, and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 (Resident #32) of 6 residents for care plan revisions. The facility failed to review and revise Resident #32's comprehensive care plan after the MDS assessment was completed on 06/25/25. Resident #32's last care plan meeting was dated 08/07/24.This failure could affect residents and could result in resident's needs not being met. Record review of Resident #32's face sheet, dated 08/07/25, reflected the resident was a [AGE] year-old female with an admission date of 08/03/23 and returned 03/08/25. Record review of Resident #32's quarterly MDS assessment dated [DATE] reflected her diagnoses included hypertension (high blood pressure), dementia, cognitive communication deficit, and depression. The MDS reflected the resident had severe cognitive impairment with a BIMS score of 4. Record review of Resident #32's care plan, last reviewed/revised date 04/24/25 reflected Category: Return to community referral POA had no desire for [Resident #32] to return to community. Staff will revisit on comprehensive assessments only. Goal: Resident needs will be met by facility staff through the next review period. Approach: 1. Keep POA/[Resident #32] updated on the resident plan of care. 2. Staff will maintain [Resident #32] needs. 3. Follow up with the [Resident #32]/POA annually. Record review of Resident #32's Care Conference Report reflected the last care plan meeting was completed on 08/07/24 for Annual Care Conference. Record review of Resident #32's progress notes reflected no documentation regarding care plan meetings or family being made aware of care plan conference meetings. Interview on 08/05/25 at 1:20 PM, Resident #32's Family Member A/POA revealed he had concerns regarding Resident #32's care and wanted to address it with the facility. Resident #32's Family Member A/POA stated he had not been invited to any care plan meetings to address his concerns. Resident #32's Family Member A/POA stated he was not aware care plan meetings were held quarterly. The last care plan meeting he had been invited to and attended was sometime last year 2024, exact date unknown.Interview on 08/05/25 at 1:23 PM, Resident #32 revealed she had no concerns regarding her care. Resident #32 was not a good historian and could not recall if she had attended a care plan meeting or been asked to attend one.An attempt was made on 08/07/25 at 11:25 AM to contact the ADON C/MDS Coordinator by phone; however, there was no answer. Interview on 08/07/25 at 12:52 PM, with the DON revealed the Social Worker and ADON C, who was the MDS Coordinator, were responsible for coordinating the care plan meetings. The DON stated the Social Worker or ADON C would inform her when a care plan meeting was scheduled, and she would attend. She stated care plan meetings should be documented in the residents' charts, and the Social Worker would keep notes of what was discussed during the meeting. The DON stated she had been employed since February 2025, and she could not recall if Resident #32 had had a care plan meeting. She stated care plan meetings should be completed quarterly with family. She stated both the Social Worker and ADON C were no longer employed by the facility. The DON stated she was not aware Resident #32's care plan meetings were not being completed quarterly. She stated the potential risk of not completing care plan meetings would be the team, family, and resident not being informed about changes or areas that needed to be addressed regarding the resident. Interview on 08/07/25 at 1:50 PM, with the Administrator revealed the Social Worker and ADON C were responsible for scheduling care plan meetings. She stated she was not aware Resident #32 had not had a care plan meeting since 2024. She stated the IDT was responsible for conducting the care plan meetings. She stated the potential risk of not having the care plan meetings would be family not being able to communicate their concerns regarding the resident's care or not being able to know the level of care the resident was receiving. She stated Resident #32's family had not mentioned anything to them about a care plan meeting. An attempt was made to contact the Social Worker by phone on 08/07/25 at 2:17 PM; however, there was no answer.Record review of the facility's Statement of Resident Right policy dated 12/01/18 reflected the following: .To participate in developing a plan of care that describes their medical, psychological, and nursing needs and how the needs will be met .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (Residents #1, #2, #3, and #4) of six residents and two (CNA B and CNA C) out of five staff in the facility reviewed for infection control practices and transmission-based precautions. 1. The facility failed to ensure Residents #1 and #2 were separated after Resident #2 tested positive for COVID on 10/19/23, and Resident #1 did not. 2. The facility failed to ensure Residents #3 and #4 were separated after Resident #4 tested positive for COVID on 10/19/23, and Resident #3 did not. 3. The facility failed to ensure staff utilized PPE appropriately to prevent cross contamination between residents positive with COVID-19 and residents who were not positive for the virus. An Immediate Jeopardy (IJ) was identified on 10/23/23 at 3:45 PM. While the IJ was removed on 10/24/23, the facility remained out of compliance at no actual harm with the potential for more than minimal harm with a scope identified as pattern because the facility needed to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at increased risk for serious complications from a communicable disease that could diminish the resident's quality of life. The findings included: Review of Resident #1's face sheet, dated 10/24/23, reflected the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included alzheimer's disease (a common and devastating form of dementia that affects memory, thinking, and behavior), chronic obstructive pulmonary disease with acute exacerbation (a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation), and cognitive communication deficit (difficulties with thinking and using language that occur after a neurological damage). Review of Resident #1's physician's orders for October 2023 did not reveal an order for isolation related to COVID-19. Review of Resident #1's quarterly MDS Assessment, dated 10/11/23, reflected she had a BIMS score of 09 indicating moderate cognitive impairment. Review of Resident #1's continuity of care document, dated 10/24/23, reflected under the results category that the resident had tested negative for COVID-19 on 10/16/23, 10/19/23, 10/23/23, and 10/24/23. Review of Resident #3's face sheet, dated 10/24/23, reflected the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included acute respiratory failure (a condition where the lungs cannot provide enough oxygen), dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally), and Alzheimer's disease (a common and devastating form of dementia that affects memory, thinking, and behavior). Review of Resident #3's physician's orders for October 2023 did not reveal an order for isolation related to COVID-19. Review of Resident #3's quarterly MDS Assessment, dated 07/26/23, reflected she had a BIMS score of 11, indicating moderate cognitive impairment. Review of Resident #3's continuity of care document, dated 10/24/23, reflected under the results category that the resident had tested negative for COVID-19 on 10/16/23, 10/19/23, 10/23/23, and 10/24/23. Review of Resident #2's face sheet, dated 10/24/23, reflected the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included 2019-nCov acute respiratory disease (COVID-19), alzheimer's disease (a common and devastating form of dementia that affects memory, thinking, and behavior), and cerebral infarction (a stroke). Review of Resident #2's physician's orders for October 2023 reflected the following: isolation precaution [dx: 2019-nCov acute respiratory disease] which began on 10/19/23. Review of Resident #2's quarterly MDS Assessment, dated 08/31/23, reflected she had a BIMS score of 02 indicating severe cognitive impairment. Review of Resident #2's continuity of care document, dated 10/24/23, reflected under the results category that the resident had tested positive for COVID-19 on 10/19/23. Review of Resident #2's care plan, dated 08/31/23, reflected the following: Problem: Problem Start Date: 10/20/23, [Resident #2] requires isolation r/t: COVID POSITIVE .Approach: Approach Start Date: 1) Follow facility isolation policy Review of Resident #4's face sheet, dated 10/24/23, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included transient cerebral ischemic attack (a stroke), 2019-nCov acute respiratory disease (COVID-19), and dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally). Review of Resident #4's physician's orders for October 2023 reflected the following: isolation precaution [dx: 2019-nCov acute respiratory disease] which began on 10/19/23. Review of Resident #4's significant change in status MDS Assessment, dated 08/30/23, reflected she had a BIMS score of 13, indicating no cognitive impairment. Review of Resident #4's continuity of care document, dated 10/24/23, reflected under the results category that the resident had tested positive for COVID-19 on 10/19/23. Review of Resident #4's care plan, dated 07/13/23, reflected the following: Problem: Problem Start Date: 10/20/23, [Resident #2] requires isolation r/t: COVID POSITIVE .Approach: Approach Start Date: 1) Follow facility isolation policy . Observation on 10/23/23 at 8:15 AM revealed Residents #1 and #2 were in their rooms together. Resident #1 was not wearing a mask and was sitting in her wheelchair next to her bed a few feet from Resident #2 who was in her bed asleep and not wearing a mask. Observation on 10/23/23 at 8:16 AM revealed Residents #3 and #4 were in their rooms together. Resident #3 was not wearing a mask and was sitting in her wheelchair with her bedside table in front of her eating breakfast. Resident #4 was not wearing a mask and was sitting on her bed and was a few feet from Resident #3. Observation on 10/23/23 at 8:17 AM outside Residents #1, #2, #3, and #4's room revealed two three-drawer bins with PPE in them including gowns, gloves, and face shields. There was also a sign posted that read to see nurse before entering room. Observation on 10/23/23 at 8:18 AM revealed CNA B walked into Residents #3 and #4's room wearing only an N95 mask and gloves. CNA B walked into the room and went to Resident #3 to retrieve her breakfast tray, took the tray to the cart on the hall, walked back into the room and went to Resident #4. CNA B tried taking Resident #4's tray and Resident #4 told her she was not finished with her breakfast and did not want her to take it yet. CNA B took her gloves off and walked out of the room without performing hand hygiene. Observation on 10/23/23 at 4:10 PM of Resident #1 revealed she was sitting in her wheelchair and had rolled to Resident #2's side of the room. Resident #1 was observed so close to Resident #2 that Resident #1's knees were touching the railing on Resident #2's bed. Neither resident has a mask on. Observation on 10/23/23 at 4:20 PM of Resident #4 revealed she was sitting in her wheelchair in the doorframe of her room, making her perpendicular to Resident #3's bed where she was currently lying down. LVN D walked down the hall towards Resident #4 and asked/encouraged her to go back to her side of the room. Neither resident was wearing a mask. Observation on 10/23/23 at 4:25 PM of Resident #1 revealed she was sitting in her wheelchair and had rolled to Resident #2's side of the room. Resident #1 was observed so close to Resident #2 that Resident #1's knees were touching the railing on Resident #2's bed. Neither resident has a mask on and Resident #2 was currently yelling for staff to help her and the residents were having a conversation with each other about waiting for the staff to come and help Resident #2. In an interview on 10/23/23 at 8:20 AM with CNA B revealed both residents in the room she just left were positive for COVID-19 or had been exposed to it. CNA B said she only went into Residents #3 and #4's room to get their breakfast trays and wore her N95 mask and gloves. CNA B said what she wore in the room was fine so long as she was not changing the residents. CNA B said she did not feel like putting on all the PPE like the gown just to retrieve a breakfast tray from the residents. CNA B said no one told her she should or should not make this choice, she did what she felt like she should do and that was what she did. CNA B said she did not want to continue talking about this and ended the interview. In an interview on 10/23/23 at 8:25 AM with the Activity Director revealed she provided a census and indicated a plus sign next to Residents #2 and #4. The Activity Director said that meant those two residents were positive for COVID-19. The Activity Director said since the roommates of those residents did not have a plus sign next to them it meant they were negative for COVID-19. The Activity Director confirmed that Residents #1 and #3 were negative for COVID-19 and each in a room with a positive for COVID-19 resident (Residents #2 and #4). In an interview on 10/23/23 at 8:30 AM with LVN D revealed she cared for Residents #1, #2, #3, and #4. LVN D said Residents #2 and #4 were positive for COVID-19 and their roommates Residents #1 and #3 were negative for COVID-19. LVN D said the residents were in the same room because there was no where else to move them without contaminating the new room if they did become positive for COVID-19 later on. LVN D said that was why the choice was made to keep them all in the same room. In an interview on 10/23/23 at 8:45 AM with the Administrator revealed the facility hired a new DON last week who was out of the building for a few days so she was acting as the facility's Infection Preventionist for now. The Administrator/IP said Residents #2 and #4 were positive for COVID-19. In an interview on 10/23/23 at 10:35 AM with LVN D revealed since she knew Residents #1 and #3 were negative for COVID-19 and were in the same room as Residents #2 and #4 who were positive for COVID-19 she always wore PPE when entering their rooms. LVN D said she already had an N95 mask on so she put on a gown, gloves, and a face shield when caring for the residents. LVN D said she tried to care for the COVID-19 negative residents first, performed hand hygiene, changed her PPE, and then cared for the COVID-19 positive residents next. In an interview on 10/23/23 at 10:52 AM with CNA B revealed she knew to wear her N95 mask while in the facility because there were positive residents. CNA B said she knew that when caring for Residents #1, #2, #3, and #4 that she was supposed to wear a gown, gloves, and a face shield. CNA B said she was supposed to care for the COVID-19 negative residents, which were #1 and #3, first and perform hand hygiene and change her PPE before caring for the COVID-19 positive residents, which were #2 and #4. In an interview on 10/23/23 at 11:01 AM with CNA C revealed she knew to wear her N95 mask while in the facility because there were positive residents. CNA C said while she was not assigned to Residents #1, #2, #3, and #4 she knew that Residents #2 and #4 were COVID-19 positive and Residents #1 and #3 were COVID-19 negative. CNA C said if she had to care for these residents she would treat them the same and wear full PPE including a gown and gloves. Observation on 10/23/23 at 11:25 AM of Residents #3 and #4 revealed there was a family member in their room and they were telling Resident #3 to stay on their side of the room so they did not also catch COVID-19. Resident #3 was observed standing in the middle of the room with her walker and Resident #4 was sitting in her wheelchair a few feet away. Resident #3 began to walk backwards and sat down on her bed. Neither resident was wearing a mask. Continuous observation on 10/23/23 at 11:56 AM of CNA B, CNA C, and LVN D passing trays to Residents #1, #2, #3, and #4's rooms revealed the following: - CNA B was wearing an N95 mask, put on a gown but did not put on gloves or a face shield and walked into Residents #1 and #2's room to take Resident #1 her lunch tray. CNA B asked LVN D if she needed to change her gown before taking Resident #2's tray to her and LVN D told her yes. CNA B took off her gown and washed her hands inside the room. CNA B put on a new gown, face shield, and gloves. CNA B walked into the room and sat down next to Resident #2 to assist her with her lunch meal. - CNA C was wearing an N95 mask, put on a gown but did not put on gloves or a face shield and walked into Residents #2 and #4's room to take Resident #4 her tray. CNA C took off her gown and gloves, did not wash her hands, and walked out of the room. CNA C put on new gloves, a gown, and a face shield. CNA C walked to Resident #3's bed and sat her lunch tray down. CNA C took off her gown, gloves, and face shield and washed her hands before leaving the room. - LVN D was attempting to correct CNA B and CNA C in live time ensuring they were wearing the correct PPE and washing their hands but they were not listening. LVN D was visibly frustrated and ended up leaving the area saying she could no longer be a part of the situation. In an interview on 10/23/23 at 12:10 PM with CNA C revealed she could not remember what she did or did not do because there was too much going on all at once. CNA C said she thought she did everything right. In an interview on 10/23/23 at 1:15 PM with CNA B revealed she knew what she did wrong but did not want to specify. In an interview on 10/23/23 at 4:30 PM with LVN D revealed she had a conversation before the lunch meal service with CNA B and CNA C and went through what they needed to do and what PPE they needed to have on. LVN D said there were also signs posted on the outside of the doors to the residents' rooms both inside and outside. LVN D said she was not sure why CNA B and CNA C failed to put on the correct PPE and failed to perform hand hygiene properly. In an interview on the phone on 10/23/23 at 5:41 PM with Physician A revealed he was one of the doctor's treating residents at the facility. Physician A said he was aware the facility had experienced a COVID-19 outbreak and had positive residents. Physician A said he was last at the facility on 10/19/23 to check on residents and provide support to the facility. Physician A said he did not know there were both COVID-19 positive and negative residents together in the same room. Physician A said he would not advise the facility to cohort residents unless they were both positive for COVID-19. Physician A said he did not think it would be wise or allowed by CMS or the state of Texas to cohort residents if one was COVID-19 positive and the other COVID-19 negative. In an interview on 10/23/23 at 12:18 PM with the Administrator/IP revealed the facility had recently experienced an outbreak of COVID-19 beginning on 10/11/23 when LVN E tested positive. The Administrator/IP said she immediately began testing all residents and staff and found five positive residents on 10/11/23, one positive resident on 10/12/23, and then four positive residents on 10/19/23. The Administrator/IP said Residents #2 and #4 were two of the four residents who tested positive on 10/19/23. The Administrator/IP said both residents #2 and #4 had roommates which were Residents #1 and #3. The Administrator/IP said based on a lot of times previously the roommates of positive residents test positive for COVID-19 the next day after being exposed so she did cohort the positive and negative residents (referring to Residents #1, #2, #3, and #4). The Administrator/IP said she felt it would be upsetting and detrimental to move the residents around especially the specific groups of roommates (referring to Residents #1 and #2, and #3 and #4). The Administrator/IP said she and the staff were trying to keep the residents apart in the rooms and use separate PPE when caring for them. The Administrator/IP said it would also have triggered a lot of other residents to have had to move rooms if they did separate the positive and negative COVID-19 residents since the facility did not currently have any empty rooms. The Administrator/IP said she looked at the CDC's recommendations to see what their isolation guidelines were and informed the local health department the facility had COVID-19 positive residents and staff. The Administrator/IP said she could not find any information from the CDC about cohorting residents and only saw information regarding isolation and quarantine periods. The Administrator/IP said she usually wanted to try and move residents and not cohort them together in the same room if one was COVID-19 positive and the other was COVID-19 negative but was not sure what the facility's policy was and would have to look at it first. The Administrator/IP said the purpose of cohorting residents correctly based on their COVID-19 status was to stop the spread of the infection. The Administrator/IP said the risk of residents not cohorted based on their COVID-19 status put them at risk of getting infected by COVID-19. The Administrator/IP said when caring for these residents staff should be putting on full PPE meaning a gown, gloves, and a face shield. The Administrator/IP said PPE was available outside the residents' rooms and there were signs posted for staff to follow that showed the order to put the PPE on. The Administrator/IP said the purpose of putting on the PPE was to prevent others from getting COVID-19 germs on them and spreading that to other residents. The Administrator/IP said the risk of staff not putting on the correct PPE while caring for COVID-19 positive residents was that they could spread the infection to other residents. The Administrator/IP said she expected staff to also perform hand hygiene when entering/exiting a resident's room or putting on/taking off their PPE. The Administrator/IP said the purpose of performing hand hygiene was to get the germs off their hands to not spread infection. The Administrator/IP said staff had been in-serviced on what PPE to wear when going into rooms and when to wash their hands or use hand sanitizer. The Administrator/IP said the nursing staff and management were monitoring staff to ensure they were following infection control practices and procedures correctly. Review of the facility's policy, titled COVID-19 Plan, revised 03/24/21, reflected the following: Suspected case(s) of COVID-19 in the Facility .only patients with the same respiratory pathogen may be housed in the same room. For example, a patient with COVID-19 should not be housed in the same room as a patient with an undiagnosed respiratory infection .For a resident with known or suspected COVID-19: staff wear gloves, isolation gown, eye protection and an N95 or higher-level respirator if available Review of the facility's Infection Control- Precautions- Categories and Notices policy, dated August 2020, reflected the following: .3. Standard Precautions will be used in the care of all residents regardless of their diagnosis, or suspected or confirmed infection status .5. In addition to Standard Precautions, Droplet Precautions must be implemented for a resident documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets [larger than 5 microns in size] that can be generated by the resident coughing, sneezing, talking, or the performance of procedures.) .b. Resident placement .place the resident in a private room, when a private room is not available, residents with the same infection with the same microorganism, but with no other infection may be co-horted Review of the facility's Hand Washing policy, dated August 2020, reflected: .It is the policy of this home that hand hygiene is the primary means to prevent the spread of infection .1. The use of gloves does not replace proper hand washing .Employees must wash their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: .before and after direct resident contact .before and after entering isolation precaution settings .after removing gloves Review of the CDC's website on 10/23/23 (accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html) Reflected the following Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated 05/08/23 .2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection . The IPC recommendations described below (e.g., patient placement, recommended PPE) also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for empiric Transmission-Based Precautions based on close contact with someone with SARS-CoV-2 infection. However, these patients should NOT be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing . Patient Placement .Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room .Personal Protective Equipment .HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). The Administrator was notified on 10/23/23 at 3:45 PM that an IJ situation was identified due to the above failures. The Administrator was provided the IJ template on 10/23/23 at 3:49 PM. The facility's plan of removal was accepted on 10/24/23 at 9:52 AM and included the following: 10/23/2023 Plan of Removal - F 880 Immediate Action Taken Resident Specific All residents tested for Covid 19 by rapid antigen card on 10/23/23 at 4:02 pm. All residents negative. All staff in facility tested on ,d+[DATE] and were all negative. All nursing staff currently on Staff inserviced regarding PPE usage at 12:00 pm by Administrator. Resident #[1] and # [3] (negative residents) moved to room [#] at 10/23/23 at 4:55 pm. MD notified of the IJ on 10/23/2023 at 3:53 pm by Administrator, no new orders received. Resident #[2] and Resident #[4] (positive residents) moved to room [#] on 10/23/23 at 5: All other staff in facility(including housekeeping, laundry, dietary) inserviced on PPE usage by Administrator. System Changes Facility will ensure that positive and negative residents are not cohorted together in the same room. Education Administrator providing education to all staff regarding correct PPE usage for Covid Positive staff and and educated on not cohorting positive and negative residents together, and hand washing. All staff present in the facility were educated on 10/23/2023. Return demonstration will be performed on all staff in facility on 10/23. All Staff (including housekeeping, laundry, dietary) not present for the education will receive the education prior to their next shift with return demonstration on proper PPE usage and hand washing. Nurse consultant to educate Administrator on proper PPE usage and hand washing. Monitoring Residents are monitored daily for signs/symptoms of Covid while in outbreak. Staff will be monitored for correct PPE usage by Administrator/designee each day and logged on a monitoring tool. Staff will be monitored for correct hand washing/hand sanitizer usage by Administrator/designee each day and logged on a monitoring tool. On 10/24/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Monitoring observations on 10/24/23 at 12:15 PM revealed Residents #1 and #3 were in a room together and Residents #2 and #4 were in a room together. Positive and negative residents were no longer cohorted together in the same room. Monitoring observations on 10/24/23 from 12:20 PM to 1:11 PM revealed staff performing hand hygiene before/after entering/exiting a residents' room and before/after donning/doffing PPE. Staff were observed donning gowns, gloves, and a face shield before entering Residents #1, #2, #3, and #4's rooms to care for them. Staff were observed performing hand hygiene, doffing their PPE, and donning new PPE before interacting with another resident. Monitoring interviews were conducted on 10/24/23 starting at 1:11 PM and continued through 2:44 PM with the following staff from various shifts: CNA B, CNA C, CNA F, CNA G, CNA H, LVN D, LVN E, LVN I, LVN J, the Dietary Manager, the Activity Director, the Housekeeping Director, and the Administrator/IP. Staff knew that residents who were positive and negative for COVID-19 could not be in the same room together. Staff knew what PPE to wear when caring for a positive COVID-19 resident, in what order the PPE was to be put on and taken off, and when to perform hand hygiene. On 10/24/23, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with the potential for more than minimal harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.