Every finding on record at Avir at San Knoll

Based on observation, interview, and record review the facility failed to provide a comfortable and homelike environment including comfortable and safe temperature levels for 1 of 2 dining rooms (main dining hall). The facility failed to ensure the temperature in the main dining room was not above 81 degrees on 6/25/26, 7/21/26, and 7/24/26;The facility was not consistently monitoring the temperature in the dining room;The facility did not complete air conditioning repairs to ensure the unit was cooling properlyThis failure could place any residents at risk of living in an unsafe environment and result in feelings of dissatisfaction. The findings were:Record review of the facility's Test and log air temperatures, reflected All buildings are required to maintain an ambient temperature throughout resident and patient areas in a temperature range of 71 to 81 degrees Fahrenheit or at a more restrictive range required by state or local requirements. Instructions: . 2. Using a digital thermometer take random location temperatures throughout the building. 3. The time of day that the temperatures are taken should vary to ensure that the desired temperature range is achieved under a variety of conditions. Record review of the test and log air temperatures revealed the following:Due date Task Completion04/18/2026 No action recorded.06/13/2026 No action recorded06/20/2026 Marked done on-time by the Maintenance Director on 06/25/202606/27/2026 Marked done on-time by the Maintenance Director on 06/25/202607/04/2026 Marked done on-time by the Maintenance Director on 07/02/202607/11/2026 Marked done on-time by the Maintenance Director on 07/17/202607/18/2026 Marked done on-time by the Maintenance Director on 07/17/2026The facility did not provide records for the temperature logs, dated 07/17/2026.The temperature log, dated 06/25/2026 with due date 06/20/2026, reflected temperatures within the limits required by state requirements (71 to 81 degrees Fahrenheit). No times were noted on the temperature log. The dining room was 78.2 degrees Fahrenheit but there was no notation of what dining room was checked. The temperature log, dated 06/25/2026 with due date 06/27/2026, reflected a temperature of 81.2 degrees in the dining room. No times were noted on the temperature log. The temperature log, dated 07/02/2026, reflected temperatures within the limits required by state requirements (71 to 81 degrees Fahrenheit). No times were noted on the temperature log. The dining room was 73.4 degrees Fahrenheit but there was no notation of what dining room was checked. Record review of Resident #1's Face Sheet, dated 07/24/2026, reflected a [AGE] year-old female initially admitted on [DATE] and re-admitted [DATE] with diagnoses including major depressive disorder, cognitive communication deficit. Record review of Resident #1's quarterly MDS assessment, dated 06/26/2026, reflected a BIMS score of 15 out of 15, indicating intact cognition. Record review of Resident #1's care plan, undated, reflected [Resident #1] enjoys attending group activities such as Morning Coffee, Bingo. Social/Special events, revised 02/18/2026, and [Resident #1] exhibits frequent allegations or reports that are unsubstantiated, inconsistent or delayed often during times outside of staff observation possibly seeking attention, revised 05/19/2026, with intervention staff will respond to all reports calmly, promptly, and respectfully without dismissing concerns, initiated 05/19/2026. During an interview on 07/24/26 at 10:20 AM, Resident #1 revealed she used to eat in the dining room, but she would sweat during lunch and dinner time because it was so hot. She revealed that she had to eat in her room because it was much cooler in her room. She revealed this had made her feel lonely because she liked to go to the dining room to socialize. She revealed she also went to the main dining room for bingo and she would sweat while she played bingo. She revealed she had not told staff that she stopped eating in the main dining room due to the temperature because she assumed they knew and she would hear staff (unable to name) complain about the heat. She revealed she did not know how long this had been happening but it felt like about a month or so. During an interview on an undisclosed date and time, Confidential staff member revealed in the main dining room the thermostat read 80 degrees Fahrenheit at lunch time, and above 81 degrees Fahrenheit at dinner time. They further revealed that the residents remained in the main dining room for meal service. They revealed this was reported to the ADM and the DON. They revealed the ADM said it was hot in the main dining room because the residents kept opening the door to smoke outside and staff kept breaking the thermostat by turning it down so low. They further revealed even if some residents like the temperature above 81 degrees that it was still not safe for the residents. They revealed most of the residents had psychological diagnoses and a lot of residents cannot voice for themselves. A picture provided by the confidential staff member revealed the thermostat in the dining room was 85 degrees on 07/21/2026 at 06:24 PM.During observations of the ambient temperature in the main dining room, the following was revealed on 07/24/2026:10:51 AM: the ambient temperature of the main dining room was 80.4, 80.2, and 79.7 degrees Fahrenheit (3 different locations)12:25 PM the ambient temperature in the main dining room was 80.4 and 79.7 degrees Fahrenheit (2 different locations)01:18 PM: the thermostat in the main dining room was 80 degrees Fahrenheit, but the cool setting was 72 degrees Fahrenheit03:50 PM: the thermostat in the main dining room was 82 degrees Fahrenheit, but the cool setting was 72 degrees Fahrenheit03:53 PM: the ambient temperature of the main dining room was 80.6 degrees Fahrenheit05:17 PM: the ambient temperature of the main dining room was 81.1 degrees Fahrenheit05:18 PM: the thermostat in the main dining room was 82 degrees Fahrenheit, but the cool setting was 71 degrees Fahrenheit and residents were taken to the other dining room During an interview and record review on 07/24/2026 at 05:14 PM, a service request, made by the Maintenance Director and dated 06/25/2026, revealed it was for Makeup Air units in the common area dining hall (main dining room) because the Makeup Air Units were not cooling. It further revealed the technician left and noted The work for this job is not yet complete for the following reason: Quote needed. The Maintenance Director revealed the project was not done but the higher ups were aware of the issue, and he thought it was a funding issue. He further revealed that he was in charge of checking the temperatures for the facility and if was not at the facility, he did not have any staff that checked the temperatures. During a combined interview on 07/24/2026 at 06:28 PM, the Maintenance Director revealed he could not find the temperature log for those that were due 07/11/2026 and 07/18/2026. He revealed he could not recall what times the temperatures were checked for the temperatures listed in the temperature logs provided. He revealed it was important to know the times in order to check temperatures at different times of the day. The Maintenance Director further revealed he could not explain what No actions recorded meant for the temperature logs on 06/13/2026 and 04/18/2026 and could not provide temperature logs for these days. He revealed he checked temperatures every week. He revealed it was important to know the times in order to check temperatures at different times of the day. The ADM and the Maintenance Director revealed there was a heat advisory for this week so it was hotter in the main dining room. The Maintenance Director revealed the main dining room was hot at the peak of the day but it cooled down around 10:30 AM and 7 PM. The Maintenance Director and the ADM revealed the main dining room was hot due to the amount of people in the dining room, the windows on one side of the dining room made the dining room hot because there were no curtains, the kitchen made the dining room hot, and the smoker's area was right next to the dining room and the residents going in and out caused the dining room to be hot. They revealed there was not an alternative for a smoker's area. They revealed the temperature was above 81 degrees Fahrenheit on the temperature log for the main dining room, dated 06/25/2026 with due date 06/27/2026, but had not been above 81 degrees since then but confirmed they did not have any records of temperatures after 07/02/2026 and could not recall exact temperatures but that they were not above 81 degrees. The Maintenance Director revealed that the two different temperatures on the thermostat (the cool setting and the current temperature) showed that the cool setting was what the temperature should be at, but the current temperature showed that the main dining room was not getting to the temperature that was set. The ADM and the Maintenance Director denied that this meant the air conditioner in the main dining room was broken. The ADM further revealed that she planned on calling in experts to check the thermostat and temperature in the main dining room and see what they have to say about the thermostat and follow their recommendations. The ADM and the Maintenance Director revealed the temperature in the main dining room would not affect the residents because they would move the residents to the other dining room. They further revealed that they had not heard any residents complain about the temperature. During exit on 07/24/2026 at 07:50 PM, the DON revealed that the residents in the main dining room for dinner did not want to leave the main dining room because it was not hot for them. Record review of the facility's policy Maintenance Service, revised December 2009, reflected 10. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned. Record review of the facility's policy Homelike Environment, revised February 2021, reflected Residents are provided with safe, clean. Comfortable environment. 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. h. comfortable and safe temperatures (71-81 [degrees Fahrenheit]).

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity and to provide care for each resident in a manner and in an environment that promotes, maintains, or enhances his or her quality of life 2 of 2 (Resident #1 and Resident #2) residents reviewed for resident rights. The facility failed to provide a dignified and respectful dining experience for Resident #1 and Resident #2 on 6/10/2026 during feeding assistance by standing in front of them. This failure could result in the loss of dignity of residents and decreased quality of life. The findings included: During an observation on 6/10/2026 at 1:09 PM, two residents (Resident #1 and Resident #2) were observed being fed by CNA A and LVN B at the nurse's station. CNA A was standing in front of Resident #1 who was seated in a chair. LVN B was standing in front of Resident #2 who was seated in a chair. During an interview on 6/10/2026 at 1:32 PM, CNA A said feeding assistance was a part of his daily responsibilities. He said that he received training on assisting residents with feeding in another facility. He revealed he received orientation training when he was hired but was not sure if it included training in assisting residents with feeding. He stated that he did not sit with the resident because he was not aware that a chair was available. He said that standing with the resident could impact the resident because food could be dropped. During an interview on 6/10/2026 at 1:32 PM, LVN B revealed she had received feeding assistance training in orientation. She said that she knew the proper position for assisting residents with feeding was to sit with them at face level. She said that they are normally assisting residents with feeding in the dining room but that they were doing work on it today and we do what we can with the resources we have. She said the impact to the resident was It's like a dignity thing. If you're standing, it may seem like we are rushing them. During an interview on 6/11/2026 at 2:06 PM, the DON said that feeding assistance training was a part of the nursing staff training to ensure competency. She said, They shouldn't be standing. They should be sitting with the resident. I conducted an in-service to make sure the appropriate diet was served, the residents ate without any issues and staff were feeding one person at a time. Hands should be sanitized. She said the impact to a resident was a dignity issue. She said, When seated you can see better, it's safer that way. Record review of the facility's policy titled, Dignity, revised February 2021, stated: Policy StatementEach resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.Policy Interpretation and Implementation1. Residents are treated with dignity and respect at all times.5. When assisting with care, residents are supported in exercising their rights. For example, residents are:e. provided with a dignified dining experience.

Based on interviews and record reviews the facility failed to treat residents with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 8 (Resident #1). The facility failed to ensure Resident #1 received respect and dignity when CNA F was observed using the word exorcist via electronic monitoring. This failure could place residents at risk of psychosocial harm, feeling disrespected or uncomfortable, decreased self-esteem, impaired quality of life. Findings included: Record review of Resident #1's Face Sheet, dated 5/18/26, revealed the resident was admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included: Irritable Bowel Syndrome (a gastrointestinal disorder characterized by abdominal pain, cramping, bloating, diarrhea and/or constipation) , Malignant Neoplasm (Uncontrollable cell growth that destroy body tissue) of left ovary, abnormalities of gait and mobility, Alzheimer's Disease (disease affecting memory and other important mental functions) , Dementia (group of thinking and social symptoms that interferes with daily functioning), and Cognitive Communication Deficit (difficulty with thinking and language). Record review of Resident #1's quarterly MDS dated [DATE] revealed the resident's cognitive skills for daily decision making was severely impaired. An interview with Resident #1 was attempted on 5/18/26 at 2:25 pm, Resident #1 was unable to reply to the questions. During an interview on 5/19/26 at 8:36 a.m., FM H said Resident #1 was unable to speak and believed that she would have been offended by the term exorcist because having a bowel movement was a natural body function and the resident was unable to control it. FM H further stated Resident #1 was on medication for constipation. FM H said Resident #1 was able to hear the staff and just because she was unable to talk did not mean she did not feel bad. Record review on 5/19/26 of resident electronic monitoring video, dated 5/10/26 at 4:09 p.m., revealed CNA F and RN C in Resident #1's room. RN C asked, what is that?, CNA F responded exorcist, RN C said, I don't know what they feeding her today and both CNA F and RN C walked out of Resident #1's room. During an interview on 5/19/26 at 9:07 a.m., CNA F confirmed it was her in the video saying exorcist. CNA F said, It wasn't even that word, but when I turned her, it gushed out. CNA F said she asked RN C if he had given Resident #1 a laxative because she was going all week. CNA F further stated that she thought Resident #1 had received an enema (fluid injection into the rectum/colon to relieve constipation) on the morning of the incident, 5/10/26. CNA F said that she told the nurse to stop giving Resident #1 medications and that next time she was going to press the call light so that he could come see. CNA F further stated that she had to change Resident #1's bed too much, about five times on that day, 5/10/26. CNA F said she believed that word exorcist would have made Resident #1 feel upset or angry because she and RN C were talking about her. CNA F further stated that all staff were responsible for treating the residents with dignity and respect. CNA F said she had received training on Resident Rights which included treating residents with dignity and respect. During an interview on 5/19/26 at 10:39 a.m., RN C said he did not remember a staff member calling Resident #1 an exorcist for having a bowel movement. RN C further stated he did not remember anyone speaking that word. During a joint interview on 5/19/26 at 10:48 am with the DON, RNC, ADON, and Administrator. The Administrator identified CNA F as the CNA in the video using the word exorcist while providing care to Resident #1. The Administrator said that it was not acceptable to use the exorcist when referring to the resident because it was a dignity issue. The Administrator said it was the responsibility of all staff at the facility to ensure residents were treated with respect and dignity. During an interview on 5/20/26 at 10:26 a.m., RN C confirmed it was him in the video on 5/10/26 but did not remember the incident. RN C said he remembered on that day, 5/10/26, Resident #1 was having a lot of bowel movements. RN C further stated he remembered that day but could not remember CNA F saying exorcist. RN C said he did not deny it because he was there. RN C said he did not report the incident to anyone because he did not know that he had to report that. RN C said that sort of behavior was not tolerated. RN C further stated that day was Mother's Day and CNA F had been having a hard day, so he did not give the comment exorcist a lot of importance. RN C said he knew CNA F had been having a hard day so he let it slide. RN C further stated he did not see any harm, so he did not give much importance to the comment. RN C said that thinking about it, it was offensive. RN C said it was the responsibility of everyone that worked with the residents to ensure residents were not verbally abused. RN C further stated at the moment the incident happened it was his responsibility because he was the nurse. Record review of facility's Resident Rights, revised February 2021, revealed: Policy Statement Employees shall treat all residents with kindness, respect, and dignity .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse.

Based on interview and record review, the facility failed to ensure that each resident had the right to secure and confidential personal and clinical records for 1 of 10 residents (Resident #9) reviewed for Privacy and Confidentiality. The facility failed to ensure resident clinical information was not discussed in other resident rooms and/or during electronic monitoring for Resident #9. This failure could result in residents' personal information being exposed to unauthorized individuals.Findings included: Record review on 5/19/26 of resident electronic monitoring video, dated 5/10/26 at 6:06 pm, revealed CNA F was giving report to CNA C about Resident #1 and Resident #9 in Resident #1's room, while the resident was in the room and the resident's electronic monitoring was active. During an interview on 5/19/26 at 9:07 a.m., CNA F said she was not aware if she had discussed resident information in resident rooms, adding if that were the case numbers were used instead of resident names. CNA F further stated she was currently unfamiliar with the residents' names and used case numbers. CNA F was hired by the facility on 4/16/26. CNA F verified she was the staff in the video discussing other resident information in Resident #1's room. CNA F said Yes, I was speaking about other residents by name in her room. CNA F said she was aware that Resident #1's room was electronically monitored but was not aware that the audio was monitored as well. CNA F said it was not okay to speak about other residents' information in front of other residents because it was confidential. CNA F further stated that divulging confidential information could make the residents stressed. CNA F said it was everyone's responsibility to ensure that resident information was kept confidential. During a joint interview on 5/19/26 at 10:48 a.m., with the DON, RNC, ADON, and Administrator. The Administrator identified CNA F as the CNA in the video discussing other residents' information in Resident #1's room with CNA C. The Administrator said discussing other residents' information in Resident #1's room was unacceptable and violated HIPAA. The Administrator further stated that it was all of the facility staff's responsibility to ensure that resident information was kept confidential. Record review of a Resident Rights policy, revised February 2021, revealed: .The unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues . Record review of the U.S. Department of Health and Human Services website at https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html accessed on 5/20/26, revealed: .The Privacy Rule protects all individually identifiable health information held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral. Individually identifiable health information is information, including demographic data, that relates to: the individual's past, present or future physical or mental health or condition, the provision of health care to the individual.

Based on interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 1 of 5 residents (Resident #1) reviewed for mechanical lift transfers. The facility failed to ensure transfers performed using a mechanical lift were completed by two staff members as per facility policy. This deficient practice could place residents at risk of falls and or accidents causing injuries.Findings included: Record review of Resident #1's Face Sheet, dated 5/18/26, revealed the resident was admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included: Irritable Bowel Syndrome (a gastrointestinal disorder characterized by abdominal pain, cramping, bloating, diarrhea and/or constipation) , Malignant Neoplasm (Uncontrollable cell growth that destroy body tissue) of left ovary, abnormalities of gait and mobility, Alzheimer's Disease (disease affecting memory and other important mental functions) , Dementia (group of thinking and social symptoms that interferes with daily functioning), and Cognitive Communication Deficit (difficulty with thinking and language). Record review of Resident #1's Care Plan, dated 11/15/25, revealed the resident required total assistance with transfers and read Mechanical Hoyer with a sling. Record review of Resident #1's quarterly MDS dated [DATE] revealed the resident's cognitive skills for daily decision making was severely impaired. Further review of the MDS revealed the resident was dependent (Helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers for the resident to complete the activity) for chair/bed-to-chair transfer. During an interview on 5/19/26 at 9:07 a.m., CNA F said the staff tried to use two people when transferring Resident #1 using the mechanical lift but sometimes it was hard to find someone else because staff were with other residents. CNA F said she had transferred residents using the mechanical lift without the assistance of a second staff member. CNA F further stated that she knew she was not supposed to. CNA F said she did transfer Resident #1 this month using a mechanical lift without another staff member because she was in a hurry. CNA F said that it was recommended that the mechanical lift be operated by two people because the lift could flip or the straps could bust. CNA F further stated that the resident could be badly injured or the resident could fall to the floor with the lift falling on her. Record review on 5/20/26 of resident electronic monitoring video, dated 5/18/26 at 8:42 am, revealed CNA F entered Resident #1's room with a mechanical lift. CNA F attached the sling to the arm of the mechanical lift and began to lift Resident #1 out of the wheelchair. CNA F lifted Resident #1 until she was completely out of the wheelchair and suspended without support. CNA F wheeled the lift to Resident #1's bed and lowered the resident onto the bed. Further review of the video revealed CNA F was not assisted by a second staff member with the transfer. During an interview on 5/20/26 at 9:29 a.m., CNA E said she transferred Resident #1 by herself using a mechanical lift. CNA E said it was important to have two staff members when operating a mechanical lift because anything could happen, a strap can break, the resident could be injured, or the resident could hit the floor. CNA E further stated that two people were needed when using a mechanical lift because the second person guided the left and for safety reasons. During a joint interview on 5/22/26 at 9:46 am, the DON identified the staff member in the electronic monitoring video. The Administrator said staff had been trained and she was not sure why staff did not use 2 people when transferring Resident #1 using the mechanical lift. Record review of facility policy Lifting Machine, Using a Mechanical, revised July 2017 revealed: .The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lift device. It is not a substitute for manufacturer's training or instructions .General Guidelines 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift.16. Gently support the resident as he or she is moved.

Based on observation, interview, and record review the facility failed to ensure, in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 2 of 4 medication carts (MC #1 and MC#2) reviewed for medication storage. The facility failed to ensure that MC #1 and MC #2 in public areas were locked on 5/19/26. This failure could place residents at risk of medication misuse and drug diversion. Findings included: During observation on 5/19/26 at 4:50 a.m., MC #1 was observed to be unlocked and unattended on the Rosewood hall, medication bottles and medication blister packs were noted in the drawers of the medication cart. During an interview with LVN B on 5/19/26 at 4:52 a.m., she said the medication cart was not supposed to be unlocked because residents could access the medications. During observation on 5/19/26 at 7:20 a.m., MC #2 was observed to be unlocked and unattended on the Brentwood Hall, medication bottles and medication blister packs were noted in the drawers of the medication cart. During an interview with LVN A on 5/19/26 at 7:21 a.m., she said she forgot to lock the cart because a call light had gone off and she responded to it. LVN A further stated the medication cart was not supposed to be left unlocked when unattended because anybody can get in and could take some of the medications. LVN A said if a resident ingested something from the cart it could hurt them. LVN A further stated the nurse was responsible for ensuring that the medication cart was locked when unattended. Record review of the facility's policy titled, Medication Labeling and Storage revised February 2023, revealed: .The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on observation, interview, and record review, the facility failed to ensure residents had a right to a safe, clean, comfortable and homelike environment, including but not limited to clean towels for showers for 4 of 4 (Resident #1, Resident #9, Resident #10 and Resident #12) reviewed for available linen. The facility failed to ensure Resident #9, Resident #10, and Resident #12 had clean towels available to them to shower.This failure could lead to residents feeling neglected, infection control concerns, and emotional well-being.The findings include:Record review of Resident #1's admission Record, dated 04/22/2026, revealed a [AGE] year-old-male that admitted on [DATE] with diagnoses that included Morbid Obesity (a chronic, complex disease defined by a body mass index of 40 or higher, or 35 or higher with serious obesity-related comorbidities); Psychoactive Substance Abuse; and Major Depressive Disorder (serious mental health condition characterized by persistent, severe low mood, loss of interest in activities, and fatigue lasting at least two weeks).Record review of Resident #1's Comprehensive MDS assessment completed 03/23/2026 revealed a BIMS score of 15 which indicated intact cognition.Record review of Resident #1's Care Plan completed 03/16/2026 revealed risk of elopement; wound management; ADL self-care performance deficit; medication refusal; verbal aggression; physical aggression; major depressive disorder; pressure ulcer development risk.Record review of Progress Notes dated 03/22/2026-04/22/2026 revealed no documentation of shower refusal.Record review of Resident #9's admission Record, dated 04/22/2026, revealed a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses that include Seizures (temporary uncontrolled surge of electrical activity in the brain that causes involuntary movements, sensory disturbances, or altered awareness); Hemiplegia Left side (severe or complete paralysis affecting one side of the body, usually caused by brain or spinal cord injury); Morbid Obesity (a chronic , complex disease defined by a body mass index of 40 or higher, or 35 or higher with serious obesity-related comorbidities); Nontraumatic Intracerebral Hemorrhage (severe type of stroke caused by bleeding within the brain tissue, not trauma); and Congestive Heart Failure (chronic, progressive condition where the heart cannot pump blood effectively, causing fluid buildup in the lungs and body).Record review of Resident #9's Quarterly MDS assessment completed 04/12/2026 revealed a BIMS score of 09 which indicated moderate cognitive impairment. Record review of Resident #9's Care Plan completed on 03/30/2026 revealed risk of alteration in comfort related to debility; an ADL self-care deficit; risk for urinary tract infections; and a potential for pressure ulcer development and skin breakdown. No mention of refusing care or showers was mentioned in care plan.Record review of Resident #9's Progress Notes, dated 03/24/2026-04/24/2026, revealed no documented refusals of showers.Record review of Resident #10's admission record, dated 04/22/2026, revealed a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses that include Quadriplegia (paralysis affecting all four limbs and the torso, usually caused by cervical spinal cord injury (C1-C8) from trauma, disease, or congenital conditions); Pressure Ulcer of Left buttocks (localized injuries to skin and underlying tissue, usually over bony prominences like hips, heels, or tailbone, caused by prolonged pressure, friction, or shear); Urinary Tract Infections (bacterial infection- most commonly E. coli- in the urinary system, causing burning pain during urination, frequent urges, and cloudy or foul-smelling urine); Irritant Contact Dermatitis due to fecal, urinary, or dual incontinence (non-allergic skin inflammation caused by direct damage from substances); Major Depressive Disorder (serious mental health condition characterized by persistent, severe low mood, loss of interest in activities, and fatigue lasting at least two weeks).Record review of Resident #10's Quarterly MDS assessment completed on 04/12/2026 revealed a BIMS score of 15 which indicated intact cognition.Record review of Resident #10's Care Plan completed on 02/20/2026 revealed incontinence; chronic pain related to wounds; colostomy; PASRR positive for MI; Impaired skin integrity related to immobility and incontinence; self-care performance deficit related to quadriplegia; major depressive disorder.Record review of Resident #10's Progress Notes, dated 03/24/2026-04/24/2026, revealed no documentation regarding refusals of showers.Record review of Resident #12's admission record, dated 04/22/2026, revealed a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses which include Dementia without Behavioral Disturbance (progressive;, umbrella term for a decline in cognitive function-memory, language, problem-solving- that interferes with daily life, typically caused by neurodegenerative diseases like Alzheimer's) Major Depressive Disorder (serious mental health condition characterized by persistent, severe low mood, loss of interest in activities, and fatigue lasting at least two weeks).; Contracture Left Knee (permanent tightening of muscles, tendons, ligaments, or skin, causing stiffened joints and restricted motion, often caused by prolonged immobility, scarring (burns), or neurological damage); and Cellulitis (common, potentially serious bacterial skin infection affecting deep dermis and subcutaneous tissues, usually caused by Streptococcus or Staphylococcus bacteria entering through broken skin).Record review of Resident #12's Quarterly MDS assessment completed on 04/06/2026 revealed a BIMS score of 15 which indicated intact cognition.Record review of Resident #12's Care Plan completed on 02/26/2026 revealed risk for depression; communication problem related neurological symptoms; contracture left knee; right artificial hip; and incontinence.During an observation on 04/22/2026 10:30 am of the linen closets on 100/200 hall and 300/400 hall, the surveyor observed no more than 4 towels in each closet. During an observation on 04/23/2026 1:45 pm of the linen closets on 100/200 hall and 300/400 hall, the surveyor observed no more than 5 towels in each closet. During an observation on 04/24/2026 3:30 pm of the linen closets on 100/200 hall and 300/400 hall, the surveyor observed 7 towels on 100/200 hall and 6 towels on 300/400 hall.During an interview on 04/22/2026 at 11:40 am, Resident #1 stated that he does not get showered regularly and staff tells him it is because they do not have towels. Resident #1 claimed he had told management multiple times and they do not care about the residents and do not do anything to fix the issue.During an interview on 04/22/2026 at 2:16 pm, CNA B stated that sometimes staff have issues getting towels. CNA B stated that she will even use blankets if she can and that management is aware. Laundry gave some poor excuse about how the towels shrank but she can tell they ordered the wrong size. She stated that the towels they bought are slightly larger than hand towels. CNA B stated that the towels are so thin that she can see light through the towels and it takes several towels for a shower. Especially if they only have these tiny ones.During an interview on 04/23/2026 at 10:19 am, LVN A stated that there is a towel shortage and that management is aware. LVN A stated that sometimes there are only 10 towels for the day and it takes several towels to shower a resident.During an interview on 04/23/2026 at 1:55 pm, Resident #9 stated that she had not had a bed bath in a week or so because the staff keeps saying that there are not any towels. Resident stated that staff claims they will give her one later when they get towels, but no one comes back to bathe her. Resident stated she has told management of this concern, but the towels are still an issue. During an interview on 04/23/2026 at 2:04pm, Resident #10 stated that she goes days without a shower due to the staff not having any towels. Resident stated that staff tells her they will do the shower later but they never come back. When she asks for a shower the next day the staff tell her that it is not her day.During an interview on 04/23/2026 at 3:02pm, HSK SUP stated that she bought towels and they shrank in the dryer. HSK SUP also stated that she ordered another case of towels. HSK SUP also stated that no one has mentioned needing more towels purchased at stand-up in the mornings. During an interview on 04/23/2026 at 3:10pm, Resident #12 stated that she misses showers because staff does not have any towels, Resident stated she would get one shower a week when she is supposed to get three. Resident claimed to have said something to management although she cannot recall for sure but feels like management should know because staff should be telling them. During an interview on 04/23/2026 at 3:15pm, CNA A stated that overnight just washes linen when they need it. There is never any linen.During an interview on 04/24/2026 at 1:22pm, ADON stated that there is a towel issue and that yes, some showers were missed because of it. ADON stated that towels were being ordered and there should be grievances for the towels. During an interview on 04/24/2026 at 1:44pm, ADMIN stated that towels were delivered and they shrank. Company keeps sending wrong size of towels when ordered. ADMIN did admit that there was a towels shortage and that the facility was actively working on it.Review of HSK SUP email revealed an order for a case of 75 towels with the confirmation email dated 04/23/2026. Facility does not currently have specific policies for towels per HSK SUP.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 2 of 2 halls (100 and 200 halls) for room trays and 1 of 1dining room reviewed, in that:1. On 04/22/2026, the facility failed to ensure CNA A sanitized her hands between resident meal trays while passing out room trays for 2 of 2 halls.2. On 04/22/2026, the facility failed to ensure LVN C sanitized her hands between resident trays in the dining room while checking trays for accuracy and passing out trays for staff to deliver to tables for 12 of 23 residents.3. On 4/23/2026, the facility failed to ensure CNA A sanitized her hands between resident meal trays while passing out room trays for 2 of 2 halls.4. On 04/23/2026, facility failed to ensure LVN C sanitized her hands between resident trays in the dining room while checking trays for accuracy and passing out trays for staff to deliver to tables for 10 of 25 residents. These failures could place residents at risk of cross-contamination and the spread of infection.The findings included:During an observation on 04/22/2024 at 11:27 am, CNA A was observed passing room trays to residents dining in their rooms. The surveyor observed the doors on both sides of the meal cart were open during the meal tray pass as well as CNA A not performing hand hygiene before or after passing meal trays to 8 or 8 residents on 100 hall and 4 of 4 residents on 200 hall. During an observation on 04/22/2026 at 12:03, DM was observed passing out meal trays to 5 of 5 residents who requested optional meal items without sanitizing before or after entering resident rooms with meal tray.During an observation on 04/22/2026 at 12:10 pm, LVN C was observed checking meal trays for dining room residents for accuracy and handing trays to other staff members to pass out without sanitizing hands before or after touching trays. LVN C was observed touching the meal cart, her scrubs, her hair, the doorframe and her face all between touching the meal trays.During an observation on 04/23/2026 at 11:27 am, CNA A was observed passing room trays to residents dining in their rooms. The surveyor observed CNA A passing out meal trays without sanitizing hands before or after passing out meal trays to 7 of 7 residents on 100 hall and 5 of 5 residents on 200 hall.During an observation on 04/23/2026 at 12:02 pm, LVN C was observed checking the meal trays for the dining room residents for accuracy and handing trays to other staff members to pass out without sanitizing hands before or after touching trays. LVN C was observed touching her face, touching her scrubs, brushing her hair out of her face, touching the rack that the trays sat on and touching the door and doorframe between the kitchen and dining room between trays.During an observation on 04/23/2026 at 1219 pm, ADMIN was observed switching residents for feeding assistance and did not sanitize or wash hands between residents.During an interview with CNA A on 04/23/2026 at 12:50 pm, CNA A stated that staff should wash and/or sanitize their hands before and after providing care to residents. CNA A stated that passing out meal trays and assisting to feed was considered care.During an interview with ADON on 04/24/2026 at 1:22 pm, ADON stated that hand hygiene should be performed between care, to include handing out meal trays. The negative outcome to residents could include acquiring an infection.During an interview with ADMIN on 04/24/2026 at 1:44 pm, ADMIN stated that the expectation is that staff perform hand hygiene between assisting residents, whether it is care or meals, it did not matter. The negative outcome to residents could be that they get sick. Record review of portion of Infection Control Policy for Handwashing/Hand Hygiene dated 2001 stated that Hand hygiene is indicated: after touching a resident's environment.

Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal reviewed for palatability, attractiveness, and appetizing foods. The facility failed to provide food that was palatable and at an appetizing temperature for residents related to cold, soggy shrimp and warm coleslaw. The temperature of the items on the meal tray were not within regulated safety guidelines to ensure residents are not exposed to hazardous bacterial growth.This failure could place residents at risk of a decrease in food intake, hunger, and unwanted weight loss.The findings included:During confidential resident interviews at an undisclosed date and time, multiple residents in a hallway stated that they ate in their rooms for meals and the food was always cold. Residents lived on two different halls and wanted to remian anonymous.Durning an observation on 04/22/2026 at 11:27 am, CNA A was pushing a meal tray cart down the 100 hall with the doors open on both sides of the cart during meal pass. CNA A closed the doors at the end of meal tray pass on the 100 hall to transition to the 200 hall and then proceeded to leave the doors on the meal tray cart open until completion of meal tray pass on the 200 hall. During an observation on 04/22/2026 at 12:17 pm, a meal was placed in front of an unknown resident with warming lid removed. Resident presented with contracted hands bilaterally. Unknown CNA sat down next to unknown resident to feed them at 12:25 pm. During an observation and interview on 04/24/2026 at 1101 am, the surveyor monitored meal tray preparation. DM stated that the 300/400 hall trays were the last sent out of the kitchen so the surveyor requested a food tray to be put on that cart last, and surveyor would obtain tray at end of meal pass. At 11:24 am the meal tray cart for 300/400 hall was wheeled to the halls and left with nursing staff. At 11:26 am RN A opened cart to check trays for accuracy. CNA D arrived and proceeded to pass out trays to 400 hall first at 11:31 am, with door open to meal tray cart. CNA D moved meal tray cart to 300 hall at 11:36 am. The surveyor obtained sample tray and took it to conference room at 11:44 am to test temperatures. Temperature for coleslaw was 86.0 degrees Fahrenheit, boiled shrimp at 96.4 degrees Fahrenheit, tater tots at 97.5 degrees Fahrenheit, hushpuppies at 103.6 degrees Fahrenheit, and fruit at 70.9 degrees Fahrenheit. During an interview on 04/24/2026 at 12:41 pm, DM stated that the expectation was that the residents receive meals at the appropriate temperatures to ensure they do not obtain a food borne illness and the food was palatable. DM stated that the fruit and coleslaw should have been cold, closer to 40 degrees and the rest of the food should not have been under 100 degrees Fahrenheit. DM stated that he understood that this could lead to residents not wanting to eat their meals.During an interview on 04/24/2026 at 1:44 pm, ADMIN stated that all foods should be provided to residents within the appropriate temperature ranges. ADMIN stated that the coleslaw should never be that warm and that the shrimp should have been warmer for sure. ADMIN confirmed that failure to serve food at appropriate temperatures could cause issues for residents like upset stomach, vomiting, and maybe diarrhea.Record review of the facility's the Food and Nutrition Services policy, dated 2001, stated that each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 4 residents (Resident #1, Resident #9, Resident #10, Resident #12) reviewed for ADL care.The facility failed to ensure that Resident #1, Resident #9, Resident #10, and Resident #12 regularly obtained showers, per resident rights. This failure could place residents at risk for altered social experiences, minimized emotional well-being, and infection control issues.The findings include:Record review of Resident #1's admission Record, dated 04/22/2026, revealed a [AGE] year-old-male that admitted on [DATE] with diagnoses that included Morbid Obesity (a chronic, complex disease defined by a body mass index of 40 or higher, or 35 or higher with serious obesity-related comorbidities); Psychoactive Substance Abuse; and Major Depressive Disorder (serious mental health condition characterized by persistent, severe low mood, loss of interest in activities, and fatigue lasting at least two weeks).Record review of Resident #1's Comprehensive MDS assessment completed 03/23/2026 revealed a BIMS score of 15 which indicated intact cognition. The ADL's section showed Resident #1 needed assistance to bathe.Record review of Resident #1's Care Plan completed 03/16/2026 revealed risk of elopement; wound management; ADL self-care performance deficit; medication refusal; verbal aggression; physical aggression; major depressive disorder; pressure ulcer development risk.Record review of Resident #1's Progress Notes dated 03/22/2026-04/22/2026 revealed no documentation of shower refusal.Record review of Resident #1's Shower Task List for April on 04/23/2026, revealed Resident#1 to be on a Monday, Wednesday, Friday shower schedule for nights. Resident #1 did not receive a shower between April 1st through April 6th, did not receive a shower April 10th through April 12th, and did not receive a shower April 19th through the 23rd of April. Record review of Resident #9's admission Record, dated 04/22/2026, revealed a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses that include Seizures (temporary uncontrolled surge of electrical activity in the brain that causes involuntary movements, sensory disturbances, or altered awareness); Hemiplegia Left side (severe or complete paralysis affecting one side of the body, usually caused by brain or spinal cord injury); Morbid Obesity (a chronic , complex disease defined by a body mass index of 40 or higher, or 35 or higher with serious obesity-related comorbidities); Nontraumatic Intracerebral Hemorrhage (severe type of stroke caused by bleeding within the brain tissue, not trauma); and Congestive Heart Failure (chronic, progressive condition where the heart cannot pump blood effectively, causing fluid buildup in the lungs and body).Record review of Resident #9's Quarterly MDS assessment completed 04/12/2026 revealed a BIMS score of 09 which indicated moderate cognitive impairment. The ADL's section showed Resident #9 needed assistance to bathe.Record review of Resident #9's Care Plan completed on 03/30/2026 revealed risk of alteration in comfort related to debility; an ADL self-care deficit; risk for urinary tract infections; and a potential for pressure ulcer development and skin breakdown. No mention of refusing care or showers was mentioned in care plan.Record review of Resident #9's Progress Notes, dated 03/24/2026-04/24/2026, revealed no documented refusals of showers.Record review of Resident #9's Shower Task List for April on 04/23/2026, revealed Resident #9 to be on a Monday, Wednesday, Friday shower schedule for days. Resident #9 did not receive a shower for the entire month of April according to the documentation.Record review of Resident #10's admission record, dated 04/22/2026, revealed a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses that include Quadriplegia (paralysis affecting all four limbs and the torso, usually caused by cervical spinal cord injury (C1-C8) from trauma, disease, or congenital conditions); Pressure Ulcer of Left buttocks (localized injuries to skin and underlying tissue, usually over bony prominences like hips, heels, or tailbone, caused by prolonged pressure, friction, or shear); Urinary Tract Infections (bacterial infection- most commonly E. coli- in the urinary system, causing burning pain during urination, frequent urges, and cloudy or foul-smelling urine); Irritant Contact Dermatitis due to fecal, urinary, or dual incontinence (non-allergic skin inflammation caused by direct damage from substances); Major Depressive Disorder (serious mental health condition characterized by persistent, severe low mood, loss of interest in activities, and fatigue lasting at least two weeks).Record review of Resident #10's Quarterly MDS assessment completed on 04/12/2026 revealed a BIMS score of 15 which indicated intact cognition. The ADL's section showed Resident #10 needed assistance to bathe.Record review of Resident #10's Care Plan completed on 02/20/2026 revealed incontinence; chronic pain related to wounds; colostomy; PASRR positive for MI; Impaired skin integrity related to immobility and incontinence; self-care performance deficit related to quadriplegia; major depressive disorder.Record review of Resident #10's Progress Notes, dated 03/24/2026-04/24/2026, revealed no documentation regarding refusals of showers.Record review of Resident #10's Shower Task List for April on 04/23/2026, revealed Resident #10 to be a Monday, Wednesday, Friday shower schedule for nights. Resident #10 did not receive a shower April 1st -3rd , 6th - 11th, 18th - 20th. Record review of Resident #12's admission Record, dated 04/22/2026, revealed a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses which include Dementia without Behavioral Disturbance (progressive;, umbrella term for a decline in cognitive function-memory, language, problem-solving- that interferes with daily life, typically caused by neurodegenerative diseases like Alzheimer's) Major Depressive Disorder (serious mental health condition characterized by persistent, severe low mood, loss of interest in activities, and fatigue lasting at least two weeks).; Contracture Left Knee (permanent tightening of muscles, tendons, ligaments, or skin, causing stiffened joints and restricted motion, often caused by prolonged immobility, scarring (burns), or neurological damage); and Cellulitis (common, potentially serious bacterial skin infection affecting deep dermis and subcutaneous tissues, usually caused by Streptococcus or Staphylococcus bacteria entering through broken skin).Record review of Resident #12's Quarterly MDS assessment completed on 04/06/2026 revealed a BIMS score of 15 which indicated intact cognition. The ADL's section showed Resident #12 needed assistance to bathe.Record review of Resident #12's Care Plan completed on 02/26/2026 revealed risk for depression; communication problem related neurological symptoms; contracture left knee; right artificial hip; and incontinence.Record review of Resident #12's Progress Notes, dated 03/24/2026 through 04/23/2026, revealed no refusals for showers documented.Record review of Resident #12's Shower Task List for April on 04/23/2026, revealed Resident #12 to be a Monday, Wednesday, Friday shower schedule for days. Resident #12 did not receive a shower April 2nd - 10th ,April 11th - April 14th , and April 18th - April 20th .During an observation on 04/22/2026 at 10:30am of the linen closets on 100/200 hall and 300/400 hall, the surveyor observed no more than 4 towels in each closet. During an observation on 04/23/2026 at 1:45 pm of the linen closets on 100/200 hall and 300/400 hall, the surveyor observed no more than 5 towels in each closet. During an observation on 04/24/2026 at #:30 pm of the linen closets on 100/200 hall and 300/400 hall, the surveyor observed 7 towels on 100/200 hall and 6 towels on 300/400 hall.During an interview on 04/22/2026 at 11:40 am, Resident #1 stated that he does not get showered regularly and staff tells him it is because they do not have towels. Resident #1 claimed he had told management multiple times and they do not care about the residents and do not do anything to fix the issue.During an interview on 04/22/2026 at 2:16 pm, CNA B stated that sometimes staff have issues getting towels. CNA B stated that she will even use blankets if she can and that management is aware. Laundry gave some poor excuse about how the towels shrank but she can tell they ordered the wrong size. She stated that the towels they bought are slightly larger than hand towels. CNA B stated that the towels are so thin that she can see light through the towels and it takes several towels for a shower. Especially if they only have these tiny ones. CNA B stated that this affects all of the residents in the facility as she cannot think of any who shower themselves with their own towels. During an interview on 04/23/2026 at 10:19 am, LVN A stated that there is a towel shortage and that management is aware. LVN A stated that sometimes there are only 10 towels for the day and it takes several towels to shower a resident. LVN A stated that some showers were missed, but he could not recall who.During an interview on 04/23/2026 at 1:55 pm, Resident #9 stated that she had not had a bed bath in a week or so because the staff keeps saying that there are not any towels. Resident stated that staff claims they will give her one later when they get towels, but no one comes back to bathe her. Resident stated she has told management of this concern, but the towels are still an issue. During an interview on 04/23/2026 at 2:04pm, Resident #10 stated that she goes days without a shower due to the staff not having any towels. Resident stated that staff tells her they will do the shower later but they never come back. When she asks for a shower the next day the staff tell her that it is not her day.During an interview on 04/23/2026 at 3:02pm, HSK SUP stated that she bought towels and they shrank in the dryer. HSK SUP also stated that she ordered another case of towels. HSK SUP also stated that no one has mentioned needing more towels purchased at stand-up in the mornings. During an interview on 04/23/2026 at 3:10pm, Resident #12 stated that she misses showers because staff does not have any towels, Resident stated she would get one shower a week when she is supposed to get three. Resident claimed to have said something to management although she cannot recall for sure but feels like management should know because staff should be telling them. During an interview on 04/23/2026 at 3:15pm, CNA A stated that overnight just washes linen when they need it. There is never any linen.During an interview on 04/24/2026 at 1:22pm, ADON stated that there is a towel issue and that yes, some showers were missed because of it. ADON stated that towels were being ordered and there should be grievances for the towels. During an interview on 04/24/2026 at 1:44pm, ADMIN stated that towels were delivered and they shrank. Company keeps sending wrong size of towels when ordered. ADMIN did admit that there was a towels shortage and that the facility was actively working on it. The shortage has caused some problems with showers.Review of HSK SUP email revealed an order for a case of 75 towels with the confirmation email dated 04/23/2026. Policy review of facility's Resident Rights policy, dated 2001, states that resident have a right to a dignified existence.Policy review of facility's Dignity policy, dated 2001, states when assisting with care residents are groomed as they wish allowed to choose when to conduct ADL's.Policy review of facility's Bath, Shower/Tub protocol, dated 2001, states that staff member will document when showers are given and/or if resident refused the shower.

Based on observation, interview and record review, the facility failed to ensure staff had successfully completed a State-approved training course for feeding assistance before feeding resident who required staff to feed them for 3 of 7 unknown residents in the dining room over 3-day period of observations.The facility did not ensure that the Administrator and the Medical Records clerk completed a state approved training course for feeding assistance before assisting residents to eat.This failure could place residents who require assistance with eating at risk of aspiration and choking.Findings include:During an observation on 04/22/2026 at 12:10pm, the surveyor observed the MR clerk assisting an unknown resident to eat. Unknown resident appeared to have bilateral upper extremities weakness and contractures. CNA D confirmed unknown resident needed feeding assistance.During an observation on 04/22/2026 at 12:10 pm, the surveyor observed the ADMIN assisting an unknown resident to eat. Unknown resident was sitting upright in specialized chair. Unknown resident did not make any effort to lift upper extremities bilaterally. CNA D confirmed unknown resident needed feeding assistance.During an observation on 04/23/2026 at 12:15 pm, the surveyor observed the ADMIN assisting an unknown resident to eat. Unknown resident was sitting slightly hunched over and was not trying to lift bilateral upper extremities. CNA D confirmed unknown resident needed feeding assistance. During an observation on 04/24/2026 at 12:20 pm, the surveyor observed the ADMIN assisting an unknow resident to eat. Unknown resident only opened mouth for ADMIN when verbally prompted. CNA D confirmed unknown resident needed feeding assistance.During an interview on 04/24/2026 at 10:20 am, the HR representative for the facility stated that the feeding assistance training for staff was not part of the new hire packet but sometimes there are trainings done that are more of an in-service or is specialized to a department. The surveyor asked if HR had the records of these trainings. HR could not locate the paper copies but did inform surveyor that the company switched systems when they were bought out by a new company last summer. HR stated that she would reach out to her regional boss to get the information. During an interview on 04/24/2026 at 11:05 am, HR handed the paperwork for the training before the new company's acquisition to the surveyor. The surveyor quickly reviewed the paper and did not see the training. HR stated that she would have the Administrator go through in-services and bring them to conference room. HR also stated that the training for feeding assistance would be done if there was an issue but she does not think that the training auto-populates anywhere for the new company.During an interview on 04/24/2026 at 1:22 pm, the ADON stated that she believed that the feeding assistance training was included in their dementia training that the facility does. The surveyor asked for that information and the ADON stated it was in Relias. The surveyor shared that HR could not find the training related to feeding assistance. The ADON then stated that they just did that training last month and it may be in the DON's office and that she would get with the Administrator to locate it.During an interview on 04/24/2026 at 1:44 pm, the ADMIN stated that she could not locate the trainings. The in-services the ADMIN brought did not have her name or the MR clerk's name listed as having attended. The ADMIN stated that maybe the RNC may have it as she was the one that gave the training.During a phone interview on 04/24/2026 at 2:21 pm, the RNC stated that she did not have the paperwork for the training with signatures, but she could verbally verify that the ADMIN and MR were present for training. The surveyor shared that she needed physical documentation, not verbal verification that the training happened.Record review of training records from hire to current date for ADMIN and MR on 04/24/2026 at 10:20 am revealed that there was not any training documented as completed for feeding assistance.Record review on 04/26/2026 at 1:44 pm revealed that the ADMIN and MR had not signed the in-service sheet acknowledging they attended the training for feeding assistance for residents.Facility did not have a policy on training for feeding assistance per ADMIN, however, Appendix PP of the State Operating Manual states, Use of Existing Staff as Paid Feeding Assistants - Facilities may use existing staff, i.e., licensed nurses, certified nursing assistants, to assist residents in feeding. However, other employees for example, administrative, clerical, housekeeping, dietary staff, or activity specialists, etc. must have successfully completed a State-approved training course for paid feeding assistants, as required in S483.160

Based on observation, interview, and record review, the facility failed to provide an environment that maintained or enhanced each resident's respect and dignity for 5 of 19 residents observed in dining room. The facility failed to provide a dignified and respectful dining experience for each resident in the dining room by allowing residents to watch their tablemates eat or be fed, and/or have their meals placed in front of them but they were not able to feed themselves due to physical or mental handicaps for extended periods of time. This failure could place residents at risk of embarrassment, low self-esteem, anxiety, or potential weight loss.The findings include:During an observation on 04/22/2026 at 12:10 pm, the surveyor observed a plate of food in front of an unknown resident in dining room. The resident appeared to need assistance to eat. The food was uncovered in front of resident until 12:22 pm when a staff member sat down next to resident to feed them. CNA D confirmed resident needed feeding assistance.During an observation on 04/22/2026 at 12:17 pm, the surveyor observed a plate of food was sat in front of an unknown resident in dining room. Unknown resident was in a specialized chair and had contractures to bilateral upper extremities. Staff member sat next to this resident at 12:25 pm to assist resident to eat. Food had sat uncovered in front of resident until then. CNA D confirmed resident needed feeding assistance.During an observation on 04/23/2026 at 12:05 pm, the surveyor observed an unknown resident sitting with two table mates that had their food in front of them while this resident did not. This resident had his tray placed in front of him and set up at 12:20 pm. A staff member returned to assist this resident, who had not touched the plate due to physical handicaps, at 12:23 pm to eat. CNA D confirmed resident needed feeding assistance.During an observation on 04/23/2026 at 12:04 pm, the surveyor observed an unknown resident at a table with table mates who had obtained their plates and were being assisted to eat while this resident had not received his tray. This resident's tray was brought at 12:20 pm, however a staff member did not sit to assist this resident to eat until 12:24 pm. CNA D confirmed resident needed feeding assistance.During an observation on 04/24/2026 at 12:09 pm, the surveyor observed a plate set up in front of an unknown resident and the staff member that brought the plate sitting down to assist this resident to eat. This resident had a tablemate that had not received his meal. The resident that was assisted finished at 12:19 pm and left the dining room while his table mate had still not received his plate. A staff member escorted a different unknown resident to that table and was presented with their tray at 12:21 pm to eat, while the original resident (tablemate) had still not received his meal. At 12:22 pm the original resident (tablemate) received his plate and it was set up. This resident could not feed himself and a staff member did not return to the table to assist the original resident (tablemate) till 12:24 pm. CNA D confirmed residents needed feeding assistance.During an interview on 04/24/3036 at 12:41 pm, the DM stated that the expectation when bringing plates to residents was that they need to be given in order of how the residents are at the table. There should not be a time gap between residents at the same table when receiving their plates. DM also stated the residents needing assistance to eat should be placed at same tables together and their food not given until someone is immediately ready to assist them to eat.During an interview on 04/24/2026 at 1:22 pm, the ADON stated that the plates in the dining room should be handed out in order and a table mate should not have to wait to receive their plate while the other residents at the table eat. ADON also stated that residents needing assistance should be given their food and then immediately fed.During an interview on 04/24/2026 at 1:44 pm, the ADMIN stated that resident needing assistance to eat should be given their food when a staff member is able to assist, not before. ADMIN also stated that the plates should be given to residents at the same table at the same time, no gaps or skipping over a resident so that they have to watch another resident eat.Record review of the facility's Dignity policy, dated 2001, stated that residents are provided with a dignified dining experience. Policy statement revealed that Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.Record review of the facility's Resident Rights policy, dated 2001, stated that Employees shall treat all residents with kindness, respect and dignity. Resident rights include: a dignified experience.Record review of the facility's Food and Nutrition Services policy, dated 2001, stated that staff will be available and adequately staffed to assist residents with eating as needed and that staff will provide support to enhance the resident experience in dining room.

Based on observation, interview, and record review, the facility failed to ensure that they established and maintained identical policies and practices regarding transfer, discharge and the provision of services under the State plan for all residents regardless of payment source as well as failing to ensure the residents were free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required for 1(Resident #2) of 1 residents reviewed.The facility failed to allow and assist Resident #2 to exercise his right to discharge from the facility to an outside provider per his request.The facility failed to ensure that Resident #2's rights to be free from interference from the facility were respected.This failure placed Resident #2 at risk of low self-esteem, increase in depression symptoms, breakthrough of repeat suicidal ideation and embarrassment due to facility's accusation of resident not being able to be successful outside of facility. The findings included:Review of Resident #2's face sheet, dated 04/22/2026, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Suicidal Ideation (thinking about, or considering,, or planning suicide); Schizoaffective Disorder, Bipolar type (a chronic mental health condition combining schizophrenia symptoms (psychosis) with mood disorder symptoms (mania and sometimes depression)); Schizoaffective Disorder, Depressive type (a chronic mental health condition combining schizophrenia symptoms (hallucinations, delusions) with major depressive episodes); Vascular Demetia without Behavioral Disturbance (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, often following a stroke or chronic vessel damage); and Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest).Review of Resident #2's Comprehensive MD assessment, dated 03/02/2026, revealed a BIMS score of 13, which indicated he was cognitively intact. The MDS also revealed that Resident #2 ambulated independently, felt that his daily preferences were very important to him, and needed supervision or was independent for ADL's. Review of Resident #2's Comprehensive Care Plan, dated 02/17/2026, indicated that Resident #2 was a smoker, left the facility when he wanted to, enjoyed sitting outside, and preferred his own routine.During an interview on 04/22/2026 at 3:40 pm, SW stated that she attempted to help Resident #2 find an outside group home and she was directed by the ADMIN to stop because the family did not want Resident #2 to move. SW claimed to have called the sister of Resident #2 and the sister stated that the original plan was for him to move to a group home after he was balanced out and better, in their mind about a year. SW then told ADMIN that the sister was on board with the move and SW claimed that the ADMIN called her into the office after that and told her to hold the discharge. SW claimed the ADMIN then told the SW that if she continued and did not stop discharging patients that she would be let go from the facility. SW stated that she then told Resident #2 when he came to follow-up that she could not help him. SW stated she informed the sister of her stopping the assistance to find a place. Resident #2's sister was upset and wanted to know how the ADMIN could stop the discharge and why the administrator was involved anyway. SW confirmed that Resident #2 mentioned discharge in his Quarterly Care Plan meeting.During an interview on 04/22/2026 at 4:53 pm Resident #2 stated that he wanted to discharge and that was the plan from admission. Resident #2 stated that SW told him she could not move him or they would fire her. Resident #2 shared that this upset him and made him sad. They just want to make money off of me, Resident #2 expressed. resident #2 shared that he felt that the facility was finding reasons to keep him here.During an interview on 04/22/2026 at 5:00 pm the ADMIN stated that she was not aware of Resident #2 attempting to discharge, stating He has not told me he wanted to go and she Did not know if he told anyone else. ADMIN stated that Resident #2 was not good with money, would need a Representative Payee to assist with bills and that she wanted residents set-up for success. ADMIN claimed if she knew they would have made sure that Resident #2 was ready and had everything in place for him to be successful in the community. ADMIN did recall a conversation, but not the timeframe, that Resident #2 told her he wanted to live independently in the community and go to nursing school.During an interview on 04/22/2026 at 5:21 pm on the phone with SW, Resident #2, and Resident's sister it was confirmed that the SW had told the sister everything she claimed she had. Resident #2's sister was upset that they would hold someone against their will and what happens to residents with no family involved that want to leave?. Resident #2's sister shared she took it upon herself to look for group homes in town that were within his budget and had found one but was not sure about the next steps. SW gave the sister needed information with surveyor on phone and Resident #2's discharge was set for Friday, April 24th. Record review of Resident #2's Progress Notes, dated, revealed on 11/18/2025 during a Quarterly Care Plan meeting that Resident #2 expressed his desire to move into the community to a group home. Resident asked SW to help him locate a group home around $700/month. No other Progress Note mentioning resident's desire to move afterwards.Review of facility policy, Resident Rights, dated 2001, revealed that residents within the facility should be able to exercise their rights without interference, coercion, discrimination, or reprisal from the facility.

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 residents (Resident #1) and 1 of 1 staff (LPN A) reviewed for infection control. The facility failed to ensure LPN A wore appropriate PPE for EBP during wound care for Resident #1 on 03/07/2026. This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices. The findings included: Record review of Resident #1's Face Sheet, dated 03/07/2026, reflected Resident #1 was initially admitted on [DATE] and readmitted on [DATE]. The face sheet indicated Resident #1 was [AGE] years old. Record review of Resident #1's Diagnosis Report, dated 03/07/2026, reflected Resident #1 diagnoses included cerebral infarction (a condition when blood supply to a part of the brain was interrupted resulting in the death of brain tissue), colostomy status (a surgically created opening in the body to allow stool to leave the body), and malignant melanoma (a type of skin cancer) of right upper limb (arm). Record review of Resident #1's Quarterly MDS assessment, dated 02/19/2026, reflected Resident #1 had a BIMS score of 15, indicating she was cognitively intact. The MDS indicated she had an indwelling catheter (a medical device that allows for continuous drainage of urine) and ostomy (a surgically created opening in the body to allow stool or urine to leave the body without going through the intestine or urinary tract). The MDS Skin Conditions section indicated she had open lesion(s) other than ulcers, rashes, or cuts. Record review of Resident #1's Order Summary Report, dated active orders as of 03/07/2026 reflected the orders:- Cleanse Upper Right Arm wound with wound cleanse. Pat dry with 4x4 gauze, apply calcium alginate, cover with border island dressing Daily/PRN [sic] every day shift. The order status was noted as Active with the order date of 09/16/2025 and start date of 10/01/2025.- EBP: Staff must use gown and gloves during high-contact resident care activities that could possibly to [sic] result in transfer of MDROs to hands and clothing of staff. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those who are not confirmed to have an MDRO (e.g., residents with wounds or indwelling medical devices). every [sic] shift for EBP Precautions. The order status was noted as Active with the order date and start date of 11/20/2025. - Staff may utilize EBP (enhanced barrier precautions) for high contact resident care r/t colostomy, chronic wound. The order status was noted as Active with the order date of 10/09/2025. During an observation and interview on 03/07/2026 at 03:20 p.m., LPN A was observed providing right upper arm wound care to Resident #1. LPN A was observed to not put on a personal protective gown during care. An EBP (enhanced barrier precaution) sign was observed next to Resident #1's door prior to entering room. LPN A stated the floor nurses normally did the residents' daily wound care, but she would round (visit each of the residents to assess their condition, status, and concerns) with the wound care physician weekly. Attempted follow up interview with LPN A on 03/07/2026 at 07:01 p.m. LPN A had left the facility for the day and did not answer her phone. During an interview on 03/07/2026 at 07:34 p.m., the DON stated her expectation was for staff to wear gloves and gowns when entering and performing care on a resident with enhanced barrier precautions. She stated the failure to wear a gown was that it put the resident at risk for getting an infection. During an interview on 03/07/2026 at 07:57 p.m., the ADMIN stated the precautionary signs on the resident doors notified staff what they needed to wear for precautions, and it might include gowns, gloves, footwear, and possibly eye protection. She stated she expected staff to wear gowns and gloves. She stated the risk of not wearing the appropriate personal protective equipment was they could put themselves and the resident at risk for infection. She stated that the gown was another layer of protection when providing care to a resident. Record review of the policy, Enhanced Barrier Precautions, dated as revised March 2024 and February 2025, reflected: Policy Statement'Enhanced Barrier Precautions' (EBP) refer [sic] to an infection control intervention designed to reduce transmission of multi-drug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.Policy Interpretation and Implementation1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug-resistant organisms (MDROs) to residents.2. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as apposed to before entering the room).3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: . h. wound care (any skin opening requiring a dressing).5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.

Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 (hall 100 exit door) exit doors reviewed for accident hazards and supervision. The facility failed the ensure the exit door alarm on hall 100 was not turned off where 14 of 47 residents resided. This failure could place residents who are exit seeking at risk for elopement and possible injuries. The findings included: Record review of Resident List Report, dated 03/07/2026, revealed the facility had 14 residents located on 100 hall and a total of 47 residents. During an observation on 03/07/2026 from 11:55 a.m. to 12:49 p.m. hall 100 was observed to have two staff members working in the hallway and four (4) resident room doors open with two (2) residents in beds and two (2) residents in their wheelchairs. The residents observed were not self-ambulating (walking on their own) or moving their wheelchairs on their own. During an observation and interview on 03/07/2026 from 02:09 p.m. to 02:22 p.m. with the Maintenance Director, seven (7) exit doors were identified and checks for functioning door alarms and secured access. At 02:10 p.m., the exit door located at the end of hall 100 was observed to not sound the alarm when the release bar was pushed and the door opened. The Maintenance Director was observed to insert a key into mounted, red exit door alarm, located to the left of the upper door frame, and he stated It works. I don't know why it was off. After turning the alarm box on, the door alarm was observed to alarm when the release bar was triggered, and the door was opened. The Maintenance Director stated one of the CNAs might have let a resident out to smoke. He stated the CNAs had a copy of the key and would occasionally let the residents out of the building through the door for smoking breaks. At 02:22 p.m., the Maintenance Director stated he checked the doors every Monday so the door on hall 100 would have been caught during his Monday door checks. He stated today, 03/07/2026 was the first time he had found an unsecured door and was surprised by the finding. He stated the staff would sometimes use that door to take a patient out because it was closer to the ramps or let the residents out for smoking. He stated the residents on 100 hall were unable to walk and were dependent on staff for wheelchair mobility. During an interview on 03/07/2026 at 07:34 p.m., the DON stated her expectation was for staff to turn the door alarms back on if they used the key to disable the alarm. She stated the risk of an alarm being disabled was residents could get out the door, and staff would not know. During an interview on 03/07/2026 at 07:57 p.m., the ADMIN stated she expected fire exit doors, when the handle was pushed, for the alarm to go off. She stated the risk of an alarm being disabled was if someone were to get out, staff might not know because the alarm did not sound. She stated residents could be at risk for potential elopement. She stated unless someone had taken something out of the building and forgot to re-arm the alarm, she did not know why the alarm was disabled. She stated staff would not have a reason to disable an alarm unless they were taking something out to back of the facility. Record review of policy Wandering and Elopements, dated as revised March 2019, revealed: Policy StatementOur facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.

Based on observation, interview, and record review, the facility failed to post on a daily basis and at the beginning of each shift information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for 1 of 1 days (03/07/2026) reviewed for posting of required information. The facility failed to post the required current nurse staffing and census information on 03/07/2026 at the beginning or within two (2) hours of the beginning of shift 6:00 a.m. to 6:00 p.m. This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census. The findings included: During an observation on 03/07/2026 at 12:00 p.m., a document labeled [facility name] Daily Staffing for Friday, March 6th, dated 03/06/2026, was posted on a wall of the front lobby. The document included the following information: current census and the scheduled number and hours worked of CNAs, LVNs, RNs, Hospitality Aides (Unlicensed Aides), and the total number of hours worked per shift 6:00 a.m. to 6:00 p.m. and shift 6:00 p.m. to 6:00 a.m. During an observation on 03/07/2026 at 12:49 p.m., a document labeled [facility name] Daily Staffing for Saturday, March 7th, dated 03/07/2026, was posted on a wall of the front lobby. During an interview on 03/07/2026 at 07:34 p.m., the DON stated the weekend supervisor was responsible for posting the daily census and nurse staffing document on the weekends. She stated the weekend supervisor did not work today, 03/07/2026, and the ADMIN posted the document, but it was posted late. The DON stated she was not sure who the weekend supervisor's backup was for this task. She stated she did not know the impact of posting the document late because it had never happened before. During an interview on 03/07/2026 at 07:57 p.m., the ADMIN revealed her expectation was for the daily census and nurse staffing document to be posted upfront by the weekend supervisor. She stated the facility did not have a weekend supervisor today, 03/07/2026 so the task would usually be the manager on duty. She stated she could not say why the document was not posted. She stated the document was a notification to the general public to let them know how many staff the facility had per shift. She stated the information was also available in the staffing book, located in the front lobby. She stated her expectation was that the documents be posted. Record review of the policy, Posting Direct Care Daily Staffing Numbers, dated as revised August 2022, reflected: Policy StatementOur facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents.Policy Interpretation and Implementation1. Within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs and NAs) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.3. Within two (2) hours of the beginning of each shift, the charge nurse or designee computes the number of direct care staff and completes the Nurse Staffing Information form. The charge nurse completes the form and posts the staffing information in the location(s) designated by the administrator.

Based on observations, interviews, and record reviews, the facility failed to ensure all allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 residents (Resident #1 and #2) of 10 residents reviewed for neglect and misappropriation. 1. The facility failed to report Resident #1's missing Tramadol and Tylenol #3 while he was out on leave on Thanksgiving to the ADM who was the abuse and neglect prevention coordinator. When Resident #1 returned the narcotic cards were missing which resulted in the possible misappropriation of the narcotics. 2. The facility failed to report that Resident #2 stated she was neglected for the first week of her admission, which was the week of December 8, 2025, and the SW failed to immediately report this to the ADM. This facility failure could affect residents who take narcotics for pain and residents who require care at the facility resulting in loss of medications and lack of appropriate care.The findings included: 1. Record review of Resident #1's electronic face sheet dated 12/16/2025 reflected he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: acute respiratory failure with hypoxia (a condition where there is insufficient oxygen delivery to the tissues leading to low oxygen in the blood), muscle weakness (lack of muscle strength), schizoaffective disorder (a mental health condition that is marked by a mix of symptoms such as hallucinations (hearing things not there) and delusions (seeing things not there) and age-related osteoporosis (loss of bone density and strength), anxiety (feeling of worry, nervousness or unease), heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs) and major depressive disorder (persistent feeling of sadness and loss of interest). Record review of Resident #1's annual MDS assessment dated [DATE] reflected he scored a 15 of 15 on his BIMS which signified his cognitive status was intact. He required minimal to no assistance with most of his ADLs. He utilized a motorized wheelchair and was taking opioid (class of drugs that include prescription pain killers) medications. Record review of Resident #1's comprehensive care plan dated 11/13/2025 reflected Focus, has osteoporosis and pain, interventions, give medications as ordered. Record review of Resident #1's Active Orders as of: 12/16/2025 reflected, he was ordered Acetaminophen with codeine (opioid), one tablet every 8 hours as needed for pain, start date 09/21/2025 and he received tramadol (opioid) 50mg tablet, 2 tablets by mouth three times a day for pain, start date 12/09/2025. During an interview on 12/16/2025 at 10:00 am, Resident #1 stated he went out on Thanksgiving and the agency nurse who signed him out gave him a bag with medications, and he asked her if they needed to count and sign, and she said that it was all taken care of. He stated he knew that was not the procedure and was out on pass for one night and came back with the medications he had left (tramadol and Tylenol #3's). He said he told LVN E that the nurse did not count with him when he left. He stated LVN E and LVN F counted the medication he had returned with which were 115 Tramadol and 27 Tylenol #3's. He stated he was not given the narcotic sheets with his medications when he left on pass. He stated he did not miss any of his medications but was concerned about the lack of accountability for the narcotics that the facility demonstrated. During an interview on 12/17/2025 at 2:24 pm, LVN E stated Resident #1 returned from his pass on Thanksgiving and brought his medications up to her and stated they were never counted when he left. She stated LVN F, and she counted his medications and LVN F went to get the narcotic sheets and stated the sheets were missing. She stated at that time, we created more sheets and accounted for what he brought into the facility. She stated that the agency nurse should have counted the narcotics with him and only provided him with what he needed while gone. She stated they reported the incident to the DON. An interview was attempted by phone on 12/17/2025 at 2:30 pm, with LVN F and Agency Nurse G with no response, phones were not accepting messages or calls. During an interview on 12/18/2025 at 08:40 am, the DON stated when she questioned Agency Nurse G about Resident #1's narcotics, she stated she gave him the narcotic sheets and the narcotics. She stated she contacted pharmacy, and they gave her what they had, but they were not able to figure out how many narcotics Resident #1 should have had left. She stated she did not know why she believed Agency Nurse G at the time, but they did not report it as a drug diversion, and it could have been. She stated the process was to have an order for out on pass and count with another nurse, have the resident sign for what they are given and never provide them with the narcotic sheets. She stated she should have reported it as a misappropriation because they did not know if Resident #1 was provided with all his narcotics and he denied having sheets given to him. During an interview on 12/18/2025 at 3:04 pm, the ADM stated that at the time Resident #1's narcotics were not accounted for she stated staff did not think it was a drug diversion but now admitted that it could have been. She stated the incident needed to be reported. The procedure was broken. During an interview on 12/18/2025 at 3:52 pm with the RNC, he stated he was mentoring the DON since she was new to the position. He stated he was aware now what happened when Resident #1 went out on pass and was given narcotics without any accountability. He stated he did not orient Agency Nurse G, and he should have about how to sign a resident out on pass with narcotics. He stated misappropriation and drug diversion could occur. Record review of Resident #1's Active Orders as of: 12/16/2025 reflected acetaminophen-codeine #3 tablet, one orally every 8 hours as needed for pain, start dated 09/01/2025. Tramadol hydrochloride, tablet, 50 mgs 2 by mouth three times a day for pain,2. Record review of Resident #2's electronic face sheet dated 12/17/2025 reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: type 2 diabetes mellitus (condition in which the body cannot use insulin correctly and sugar builds up in the blood), acute pain due to trauma (sudden or urgent pain that occurs as a result of an injury or trauma), acquired absence of left and right legs above knees (legs missing both right and left above knees), adult failure to thrive (significant decline in overall health and functional abilities, leading to a reduced quality of life), pressure ulcer of sacral region, stage III (full thickness skin loss that extends to the subcutaneous tissue layer (fatty tissue beneath skin)), and peripheral vascular disease (any disease or disorder of the circulatory system outside of the brain and heart). Record review of Resident #2's EMR reflected she had not been in the facility long enough for an MDS assessment. Record review of Resident #2's baseline care plan dated 12/08/2025 reflected it had not been completed. Record review of Resident #2's Active Orders as of: 12/17/2025 reflected Stage 4 Pressure wound to sacrum, she had a treatment ordered which included a dressing and she had a colostomy bag which was to be checked and changed every 72 hours and as needed with start dates of 12/09/2025. Record review on 12/17/2025 at 3:00 pm of Resident #2's comprehensive person-centered care plan on dated 12/10/2025 reflected Focus, stage 4 pressure ulcer to sacrum r/t immobility, interventions, apply treatment and dressing as ordered. Record review of Resident #2's baseline care plan dated 12/08/25 and comprehensive person-centered care plan dated 12/10-2025 did not reflect she had a colostomy bag which required monitoring and care. Observation on 12/17/2025 at 10:00 am of Resident #2 revealed she was lying in bed moaning, LVN C showed the surveyor that Resident #2 had a colostomy bag hanging and a dressing on her coccyx. During an interview on 12/17/2025 at 10:10 am, Resident #2 stated she felt like she was neglected on the first week she was admitted to the facility. She started her colostomy bag broke, and she tried to call people, and no one came. She stated she thought staff would misplace her call light intentionally. She stated she told the SW a couple of days ago she thought she was being neglected. During an interview on 12/17/2025 at 10:30 am, the SW stated Resident #2 did report she felt like she was neglected on 12/15/2025 and stated she reported it to the DON, who went and spoke with LVN C. The SW stated she did not report the incident to the ADM, who was the abuse coordinator as she was trained and did not know why she did not. She stated she assumed the DON would investigate the issue. She stated she was trained in abuse and neglect, was new at the facility, but had been oriented. During an interview on 12/18/2025 at 08:40 am, the DON stated she did not recall being told about Resident #2, and that any abuse and neglect allegations must be reported immediately to the ADM. During an interview on 12/18/2025 at 3:04 pm, the ADM stated she had spoken with the SW on 12/17/2025, and the incident with Resident #2 needed to be reported immediately. Record review of the facility policy and procedure titled Resident Rights dated February 2021 reflected Federal and state laws guarantee certain basic rights to all residents of this facility. The rights include the residents' right to be free from abuse, neglect, misappropriation of property and exploitation. Record review of the facility policy and procedure titled Discharge Medications dated November 2025 reflected Controlled Substances require written prescriber authorization, two-nurse count verification and documentation in the controlled substance disposition log. Record review of the facility staff in-service training titled Abuse/Neglect dated 10/31/2025 reflected training was provided to staff. Record review of the facility Agency Orientation Packet Checklist reflected an area for Abuse/Neglect Policy and DC medication protocol/process. Record review of the SW's orientation titled Abuse, Neglect, and Exploitation Statement dated 09/25/2025 reflected she was trained and oriented to report abuse and/or neglect immediately to the abuse and neglect prevention coordinator and she had signed the training. Record review of the facility staff in-service training titled Medication Administration dated 06/25/2025 reflected training was provided to staff who administered medications. Record review of TULIP on 12/16/2025 at 3:00 pm reflected the incident for Resident #1 and Resident #2 had not been reported by the facility. Record review of the facility policy and procedure titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated September 2022 reflected If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines, immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on observations, interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the residents that meet professional standards of quality care for 1 resident (Resident #2) of 10 residents reviewed for care plans. The facility failed to complete a baseline care plan within 48 hours of admission for Resident #2 that reflected she had a colostomy and required monitoring and care. This facility failure could affect residents who require care in the facility and could result in missed or inappropriate care.The findings included: Record review of Resident #2's electronic face sheet dated 12/17/2025 reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: type 2 diabetes mellitus (condition in which the body cannot use insulin correctly and sugar builds up in the blood), acute pain due to trauma (sudden or urgent pain that occurs as a result of an injury or trauma), acquired absence of left and right legs above knees (legs missing both right and left above knees), adult failure to thrive (significant decline in overall health and functional abilities, leading to a reduced quality of life), pressure ulcer of sacral region, stage III (full thickness skin loss that extends to the subcutaneous tissue layer (fatty tissue beneath skin)), and peripheral vascular disease (any disease or disorder of the circulatory system outside of the brain and heart). Record review of Resident #2's EMR reflected she had not been in the facility long enough for an MDS assessment. Record review of Resident #2's baseline care plan dated 12/08/2025 reflected it had not been completed. Record review of Resident #2's Active Orders as of: 12/17/2025 reflected she had a colostomy bag which was to be checked and changed every 72 hours and as needed with start dates of 12/09/2025. Record review on 12/17/2025 at 3:00 pm of Resident #2's baseline care plan dated 12/08/25 and comprehensive person-centered care plan dated 12/10-2025 did not reflect she had a colostomy bag which required monitoring and care. Observation on 12/17/2025 at 10:00 am of Resident #2 revealed she was lying in bed moaning, because she said she was in pain, LVN C showed the surveyor that Resident #2 had a colostomy bag. During an interview on 12/17/2025 at 10:10 am, Resident #2 stated staff were doing colostomy care as needed. During an interview on 12/18/2025 at 08:40 am, the DON stated she did open a baseline care plan for Resident #2, but did not complete it, she stated that she expected her nurses to complete the care plan, but it was not done. She stated Resident #2's colostomy bag had orders that needed to be added to the baseline care plan, or she could miss care. She stated she was accountable for nursing care in the facility. During an interview on 12/17/2025 at 3:12 am, LVN C stated she was not aware Resident #2's baseline care plan had not been completed, and she stated the resident received colostomy care by either herself or the CNA assigned. She stated she was aware Resident #2 had a colostomy even without it being on the care plan, and she was trained in colostomy care. Record review of the facility policy and procedure titled Care Plans-Baseline dated March 2022 reflected a baseline plan of care to meet the resident's immediate health and safety needs is developed within forty-eight hours of admission. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident.

Based on observations, interviews and record reviews the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment to receiving treatment and support for daily living safety for 1 resident (Resident #3) of 10 residents reviewed for safe and clean environment. The facility failed to ensure Resident #3's room which had urine and feces on the sticky floor was cleaned as required to provide a safe and clean environment. This failure could affect residents who have incontinence and unsanitary behaviors and could result in disease spread and accidents. The findings included: Record review of Resident #3's electronic face sheet dated 12/17/2025 reflected he was a [AGE] year-old-male who was admitted to the facility on [DATE]. His diagnoses included: chronic obstructive pulmonary disease (condition involving constriction of the airways and difficulty or discomfort in breathing), muscle weakness (reduction in strength in one or more muscles, making it harder to move or perform tasks), major depressive disorder (serious mood disorder, causing persistent sadness, loss of interest, fatigue, and difficulty with daily activities), vascular dementia (decline in thinking skills from conditions damaging brain blood vessels, reducing oxygen, causing issues with memory, planning, reasoning, and focus), type II diabetes mellitus (chronic condition where the body either doesn't use insulin effectively or can't produce enough insulin to manage blood sugar) and paranoid schizophrenia (brain creates a false, scary reality, feeling of being watched, plotted against or harmed, often hearing voices that are not there) . Record review of Resident #3's quarterly MDS dated [DATE] reflected he could usually understand and usually be understood. He scored 07 of 15 on his BIMS which indicated his cognitive status was severely impaired. He required maximum assistance with his ADLs except for eating. He was always incontinent with bowel and bladder. He required 1-2 people to assist him with toileting. Record review of Resident #3's comprehensive person-centered care plan dated 11/16/2025 reflected Focus, has urinary incontinence, bowel incontinence r/t dementia, Interventions, check the resident frequently for incontinence. Change clothing PRN after incontinence episodes. Further review reflected Focus, resistive to care r/t adjustment to new environment, at risk of fall due to trash and clothes being on floor, Interventions, housekeeping will make rounds and keep room clean, Focus, at risk for falling r/t unsteady gait, Interventions, staff to perform frequent rounding for bowel incontinence, Focus, on diuretic therapy r/t edema. Record review of Resident #3's Active Orders as of 12/17/2025 reflected Furosemide (diuretic) (medications that help the kidneys remove extra salt and water from the body, increasing urine output), 40mg tablet orally one time a day, start date 10/01/2025 r/t chronic ischemic heart disease (happens when narrowed arteries reduce blood flow and oxygen to the heart muscle, causing chest pain, shortness of breath or fatigue, and can lead to heart failure). Further review reflected he was prescribed Spironolactone (diuretic) oral tablet 25mg, give one tablet orally one time a day, start date 10/01/2025, r/t chronic ischemic heart disease. Observation and interview of Resident #3 in his room on 12/17/2025 at 09:00 am, accompanied by the DON revealed Resident #3's door was closed. After knocking and gaining entry into the room, Resident #3 was observed sitting in his wheelchair. There were wet pants lying on the floor near him. His call light was hooked to the privacy curtain within his reach. He was naked from the waist down, and the bathroom door was ajar with the light on, and smeared dried feces could be seen on the floor extending from the toilet to the sink. The air in the room was warm and smelled of urine and feces. The floor tiles were sticky and adhered to the bottom of shoes when walking. Near the window in his room was a pool of liquid approximately 2 ft by 2 1/2 foot. When asked by the surveyor what the pool of liquid was, he stated pee. He stated he waited, and no one had come into the room, and he could not hold the pee. When asked if he knew how to use his call light, he looked at it and did not respond.During an interview on 12/17/2025 at 09:05 am with Resident #3, he shook his head no when asked if anyone had come in to check on him since breakfast which was at 07:00 am. When asked how sitting in the room in the present condition and how he felt about it, he stated I feel bad, not good, it bothered me. When asked what the brown substance was in the restroom, he stated poop and said it was there for a while. When asked if staff came in frequently to check him, he shrugged his shoulders and turned his head.During an interview on 12/17/2025 at 2:45 pm with Housekeeper D, he stated he was assigned to Resident #3's hall. He stated the housekeeper for that hall does not come in to work until 10:00 am. He stated he mopped Resident #3's floor two times a day because of his poop and pee, and the feces were not there the day prior. He stated he tried to clean the sticky substance on Resident #3's floor but had not succeeded. During an interview on 12/17/2025 at 2:51 pm, CNA A, who was assigned to Resident #3, stated she did not enter his room or do rounds as she was supposed to and thought he could take himself to the restroom. She stated she did not always work in the hallway where he resided. She stated she cleaned his room, and with the smell, urine and feces on the floor and no pants, he must have felt embarrassed. She stated he deserved to have a clean room. During an interview on 12/17/2025 at 3:12 pm, LVN C, who was assigned to Resident #3, stated she was not aware if CNA A did rounds or not when she came to them. She stated she did not see Resident #3 in the morning and did not check him from 06:00 am to 09:00 am because she was busy giving medications. She stated Resident #3 could use his call light but would not call if he needed to be changed. She stated he needed to be checked on frequently, and urine, feces and room odor could affect his dignity and self-esteem. She stated his room was one that required cleaning at least twice a day. During an interview on 12/18/2025 at 08:40 am, the DON stated Resident #3's room is warm because that is what he liked. She stated Resident #3's room needed to be cleaned often, and he needed to be checked frequently, no later than every 2 hours. She stated he could take his brief off, and he had behaviors that resulted in peeing and poop on the floor. The DON stated with poop and pee on the floor, it could cause infection, unsanitary and health issues, she stated she was accountable for nursing care in the facility, and his room and condition were not acceptable. During an interview on 12/18/2025 at 3:04 pm, the ADM stated Resident #3 needed to be checked on frequently, and that was not done. She stated Resident #3 could have increased health issues being left in a room with feces and urine on the floor. Record review of the facility Job Description, Housekeeping dated 2021 reflected The housekeeper will be responsible for maintaining a high standard of cleanliness and sanitary conditions throughout the entire facility in compliance with the Department of Health Standards. Will work closely with facility Administrators and staff to maintain a safe, home-like atmosphere. Record review of the facility staff in-service training titled Resident Rights dated 11/20/2025 reflected Residents in Texas long-term care facilities have the right to receive care in a safe environment.Record review of the facility policy and procedure titled Safety and Supervision of Residents dated 2001 reflected Individualized, Resident-Centered Approach to Safety, the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision.

Based on observation, interviews, and record reviews the facility failed to ensure the resident had a right to a dignified existence, self-determination, and communication with and access to people and services inside and outside the facility for 1 resident (Resident #3) of 10 residents reviewed for dignity. The facility failed to ensure Resident #3 was checked on frequently and kept clean and dignified. This failure could affect residents who have incontinence and unsanitary behaviors and could result in diminished self-esteem.The findings included: Record review of Resident #3's electronic face sheet dated 12/17/2025 reflected he was a [AGE] year-old-male who was admitted to the facility on [DATE]. His diagnoses included: chronic obstructive pulmonary disease (condition involving constriction of the airways and difficulty or discomfort in breathing), muscle weakness (reduction in strength in one or more muscles, making it harder to move or perform tasks), major depressive disorder (serious mood disorder, causing persistent sadness, loss of interest, fatigue, and difficulty with daily activities), vascular dementia (decline in thinking skills from conditions damaging brain blood vessels, reducing oxygen, causing issues with memory, planning, reasoning, and focus), type II diabetes mellitus (chronic condition where the body either doesn't use insulin effectively or can't produce enough insulin to manage blood sugar) and paranoid schizophrenia (brain creates a false, scary reality, feeling of being watched, plotted against or harmed, often hearing voices that are not there) . Record review of Resident #3's quarterly MDS dated [DATE] reflected he could usually understand and usually be understood. He scored 07 of 15 on his BIMS which indicated his cognitive status was severely impaired. He required maximum assistance with his ADLs except for eating. He was always incontinent with bowel and bladder. He required 1-2 people to assist him with using the restroom. No behavior issues were noted. Record review of Resident #3's comprehensive person-centered care plan dated 11/16/2025 reflected Focus, has urinary incontinence, bowel incontinence r/t dementia, Interventions, check the resident frequently for incontinence. Change clothing PRN after incontinence episodes [sic] Further review reflected Focus, resistive to care r/t adjustment to new environment, at risk of fall due to trash and clothes being on floor, Interventions, housekeeping will make rounds and keep room clean, Focus, at risk for falling r/t unsteady gait, Interventions, staff to perform frequent rounding for bowel incontinence, Focus, on diuretic therapy r/t edema. Record review of Resident #3's Active Orders as of 12/17/2025 reflected Furosemide (diuretic) (medications that help the kidneys remove extra salt and water from the body, increasing urine output), 40mg tablet orally one time a day, start date 10/01/2025 r/t chronic ischemic heart disease (happens when narrowed arteries reduce blood flow and oxygen to the heart muscle, causing chest pain, shortness of breath or fatigue, and can lead to heart failure). Further review reflected he was prescribed Spironolactone (diuretic) oral tablet 25mg, give one tablet orally one time a day, start date 10/01/2025, r/t chronic ischemic heart disease. Observation and interview of Resident #3 in his room on 12/17/2025 at 09:00 am, accompanied by the DON revealed Resident #3's door was closed. After knocking and gaining entry into the room, Resident #3 was observed sitting in his wheelchair. There were wet pants lying on the floor near him. His call light was hooked to the privacy curtain within his reach. He was naked from the waist down, and the bathroom door was ajar with the light on, and smeared dried feces could be seen on the floor extending from the toilet to the sink. The air in the room was warm and smelled of urine and feces. The floor tiles were sticky and adhered to the bottom of shoes when walking. Near the window in his room was a pool of liquid approximately 2 ft by 2 1/2 foot. When asked by the surveyor what the pool of liquid was, he stated pee. He stated he waited, and no one had come into the room, and he could not hold the pee. When asked if he knew how to use his call light, he looked at it and did not respond. During an interview on 12/17/2025 at 09:05 am with Resident #3, he acknowledged that no one had checked on him since breakfast at 07:00 am. He stated he felt bad, sitting in the room with the soiled floors and urine and it bothered him. He stated the brown substance in the restroom was poop and had been there for awhile. He shrugged his shoulders and turned his head.During an interview on 12/17/2025 at 2:51 pm, CNA A, who was assigned to Resident #3, stated she did not enter his room or do rounds as she was supposed to and thought he could take himself to the restroom. She stated she did not always work in the hallway where he resided and should have checked his care plan or asked the nurse what he required. She stated she cleaned his room, and with the smell, urine and feces on the floor and no pants, he must have felt embarrassed. She stated he was left in an undignified position, and it could cause decreased self-esteem. She stated she was trained to do rounds at least every 2 hours and with Resident #3, due to his bowel and bladder behavior issues of going on the floor instead of using the restroom, she needed to check him frequently, at least each hour. During an interview on 12/17/2025 at 3:12 pm, LVN C, who was assigned to Resident #3, stated she was not aware if CNA A did rounds or not when she came to them. She stated she should have checked to see if CNA A did rounds, but she was busy. She stated she did not see Resident #3 in the morning and did not check him from 06:00 am to 09:00 am because she was busy giving medications. She stated Resident #3 could use his call light but would not call if he needed to be changed. She stated he needed to be checked on frequently, and urine, feces and room odor could affect his dignity and self-esteem. She stated the CNA and nurse should have made rounds and because of his habits, his room was one that required cleaning at least twice a day. During an interview on 12/18/2025 at 08:40 am, the DON stated Resident #3's room was warm because that was what he liked. She stated Resident #3's room needed to be cleaned often, and he needed to be checked frequently, no later than every 2 hours. She stated he could take his brief off, and he had behaviors that resulted in peeing and poop on the floor. The DON stated with poop and pee on the floor, it could cause infection, unsanitary and health issues, and a loss of self-esteem for the resident. She stated she was accountable for nursing care in the facility, and his room and condition were not acceptable. She stated CNA's and nurses were trained to make rounds. During an interview on 12/18/2025 at 3:04 pm, the ADM stated Resident #3 needed to be checked on frequently, and that was not done. She stated Resident #3 could have a loss of dignity and self-esteem being left in a room with feces and urine on the floor and not being changed. Record review of facility training dated 11/20/2025 reflected training was provided to staff titled Resident Rights and included dignity. CNA A and LVN C received the training. Record review of the facility policy and procedure titled Resident Rights, dated February 2021 reflected Employees shall treat all residents with kindness, respect, and dignity, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence.

Based on observation, interviews, and record reviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #1) reviewed for adequate supervision in that: The facility failed to ensure Resident #1 received supervision during mealtimes to prevent choking or aspiration. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 6:19 PM. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of isolated with a severity of potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of choking, weight loss, decline in health, and death. The findings included: Record review of Resident #1's face sheet dated [DATE] revealed a [AGE] year-old male, admitted on [DATE] and readmitted on [DATE] with diagnoses of seizures, cerebrovascular disease, aphasia following cerebral infarction (a person may be unable to comprehend or unable to formulate language because of damage to specific brain regions), contracture right elbow (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement), contracture right wrist, hemiplegia (weakness of one entire side of the body) and hemiparesis (complete paralysis of half of the body). The facesheet stated Resident #1 was allergic to morphine, mushrooms, and penicillins. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was severely impaired for daily decision making, dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with ADLs in the areas of eating and drinking, and was on a mechanically altered diet. Record review of Resident #1's comprehensive person-centered care plan, dated [DATE], revealed the resident's interventions for ADLs included REQUIRED***EATING: Resident requires set up assist. Resident #1 had unplanned/unexpected weight loss with interventions for ice cream as ordered, monitor and record food intake at each meal, notify the dietician of the weight loss upon their next visit, notify the physician, resident and family of the weight loss, provide verbal assistance and cues during meals, weigh the resident weekly for at least 4 weeks or until weight has stabilized. Record review of Resident#1's Physician Order, dated [DATE] revealed an order for diet-regular, mechanical soft, and thin fluids. Special instructions FMP to all meals. Divided plate for every meal. The order was signed on [DATE] by the physician. Record review of a nursing progress note, dated [DATE], stated Patient eating breakfast and begins coughing episode directly after eating. Patient airway patent upon assessment. Patient sitting upright in bed, call light with reach. NP notified RP, MD and staff nurse. Record review of document titled Speech Therapy Plan of Care - [DATE], dated [DATE], revealed profound language impairments and mild pharyngeal swallow function impairments (,d+[DATE]% ability). Section titled Underlying Impairments listed Verbal Expression- Automatic speech severe impairment, Auditory Comprehension- 1 step commands severe impairment, Auditory Comprehension- wh questions- Severe Impairment, and Pharyngeal Swallow Deficits- after swallow. The reasons for referral were without therapeutic intervention patient at risk for: choking, aspiration, weight loss, inability to meet nutritional needs via PO intake of least restrictive diet .Bedside Swallowing Assessment .Pharyngeal phase: Patient demonstrated no signs or symptoms of aspiration during meal or when drinking . Patient demonstrated strong reflexive coughing episode > 10 minutes after last PO intake with face reddening/eye tearing, suspected aspiration/penetration of secretions vs reflux material. Patient seized coughing and resumed normal breathing pattern within 20 seconds. Conclusion patient demonstrated grossly within functional limits oropharyngeal swallow at his current/baseline diet level however it is strongly recommended that the patient take meals in the dining room with staff supervision going forward, if he were to experience choking/aspiration during a meal in his room, staff would not be able to recognize the signs or help him in a timely manner, increasing his risk of an emergency event. Additionally patient shows signs that he may be aspirating/choking on reflux material after eating, and should be kept in an upright position, such as in his wheelchair and within close proximity to staff for supervision and assistance if necessary. SLP to provide skilled dysphasia intervention to provide staff education on choking/ reflux precautions and order/ complete MBSS to objectively assess for risk of aspiration, reflux, esophageal dysmotility, etc. Record review of Speech Therapy daily notes [DATE] through [DATE] stated: [DATE] patient taken for on site MBSS (Modified Barium Swallow Study (MBSS) is a specialized x-ray procedure that helps both the Radiologist (who specializes in using x-rays) and the Speech Language Pathologist (SLP) identify why someone is having trouble with swallowing). Patient presented with very high anxiety when SLP and transport aide attempted to bring him out- shaking, yelling, waving people away. Patient was briefly calmed while being taken to the van and set up. patient resumed elevated behavior when evaluating SLP presented trials. Patient accepted one teaspoon of thin liquid by cup and began to shout and rock back and forth violently before swallowing. Agitation continued across other trials/ consistencies attempted, and with multiple feeders. results inconclusive due to lack of patient participation, however no penetration/ aspiration observed with 1 swallow. Anatomy noted with cervical osteocytes (Osteophytes are exostoses (bony projections) that form along joint margins) and decreased lordodic curvature nearing pharyngeal space and creating pharyngeal pressure system deficit (the decrease of the normal curvature, near the throat, can cause increased pressure in the airway causing partial or complete block). Recommendations are to continue current diet (mechanical soft and thin liquid, crushed meds) while taking all meals upright and supervised with assistance as needed. [DATE] SLP discussed with CNA recommendations for patient to be up in wheelchair in dining room for lunch period CNA reported patient becoming severely agitated (screaming, shaking, vehemently refusing) during attempts to get him out of bed. CNA attempted again today and reported similar behavior. SLP acknowledged and documented CNA's report. [DATE] SLP assisted patient with lunch at bedside. Patient mostly self-fed with fingers, occasionally accepting prefilled spoons with help from SLP. Patient ate rapidly/ impulsively and was not responsive to verbal/ gestural cues to pace himself or alternate bites/sips. Patient refused liquid wash each time it was offered. No signs or symptoms aspiration T/ O meal, adequate oral clearance at the end of the meal. [DATE] patient had ,d+[DATE] PBJ sandwich, unmodified, self-fed. Patient was able to take bites out of the sandwich. Ataxia (neurological sign consisting of lack of voluntary coordination of muscle movements that can include trouble eating and swallowing) evident during mastication but patient still able to manipulate and propel bolus effectively. Patient used liquid wash on his own. SLP checked oral cavity to ensure no pocketing/stasis after he finished. During an observation on [DATE] at 11:13 a.m. Resident #1 was in his room alone in bed. Resident #1 was sitting up in bed. Resident #1 had a regular plate (not a divided plate as indicated in the resident's order) with spaghetti, cooked squash, a hard brown piece of toast, a dessert dish with watery gelatin snack, a coffee cup with no top, and a clear cup with a purple liquid drink with no top. The tray of food had liquid spilled all over it. A napkin was soaked with brown liquid and the diet sheet was also stained with brown liquid. Resident #1 grabbed the hard toast, took a bite, and a crunch noise was heard. The resident put the bread down. This survey asked Resident #1 if the bread was too hard and Resident #1 nodded his head yes. Resident #1 lifted his fork with his left hand. Resident #1's hand was shaking, and food fell off the fork. The Resident #1 put the fork down on the tray. Resident #1 grabbed a handful of spaghetti and began to shove it in his mouth. Resident #1 ate quickly. No straws, condiments, or cheesecake were noted on the tray of food. There was a diet sheet from the kitchen which showed Resident #1's name, stated he was on a regular mechanical soft diet with thin liquids, no allergies were listed, adaptive equipment: divided plate, entree: meat sauce, starch: spaghetti noodles, vegetable: zucchini, bread garlic toast, dessert: cheesecake, condiment salt/pepper/margarine, and beverage: choice of beverage and water. During an observation on [DATE] at 11:30 Resident #1 was delivered a meal tray by an unidentified male staff. The staff exited the room right after delivering the tray. Resident #1 was eating in his room alone. At 11:38 a.m. an unidentified female staff went into his room. The resident's plate had no food left. The staff lifted a utensil with the last bite of food for the resident to eat. The staff stated Resident #1 can eat on his own, but she will go in to help him because he made a mess. Resident #1 again had a regular plate. The staff stated the resident chose to eat with his hands. During an interview on [DATE] at 2:40 p.m. the Dietary Manager (DM) stated she had a binder of forms with dietary preferences and allergies for some residents but not all. The DM stated if a resident had an allergy, nursing would notify them with a paper . The DM stated she did not have a form in her binder for Resident #1. The DM stated they were not aware of Resident #1's food allergy to mushrooms and the spaghetti did not have mushrooms in it. The DM stated the kitchen did not have any mushrooms in it and it had been a while since the kitchen had any mushrooms. The DM stated the facility had divided plates available. The DM stated Resident #1 was supposed to receive a divided plate and staff needed to pay attention to what the diet sheet showed the resident needed for adaptive equipment. The DM stated the divided plate was needed to help the resident get his food better. The DM stated the cooks had over cooked the bread and needed to pay attention because residents would not be able to eat hard bread especially if they are on a mechanical soft diet. The DM stated the gelatin snack was not made right and was too watery. The DM stated the cooks had substituted the cheesecake with the gelatin snack but the resident should not have been served the watery gelatin snack. During an interview on [DATE] at 9:12 a.m. the Speech Therapist stated Resident #1 was evaluated in March. The SP stated she was working with the Resident due to history of stroke and he had dysphagia. The SP stated if Resident #1 was presented food he would not take it and preferred to eat with his hands. The SP stated in March she recommended Resident #1 eat in the dining room per her notes because he could not communicate to staff and in case of an emergency he needed to be with in sight. The SP stated she they attempted to take Resident #1 to the dining room for meals in March after her recommendation but the Resident had a panic attack. The SP stated her recommendations were given to the rehab director and to the DON. The SP stated the Resident should have a divided plate with meals and his cups should have plastic lids and a straw. The SP stated she did go in the room to assist the resident with meals because she also helped with other residents and could not always be in the room with him. During an interview on [DATE] at 12:35 a.m. the DON stated the Rehab director would usually let them know what findings they had from an evaluation. The DON stated Resident #1 was supervised only for meals, he was able to feed himself, he could use utensils, staff would set the tray up uncover everything for him, give him the spoon, he would pick it up and feed himself, and she did not see him shake or have tremors. The DON stated they were notified Resident #1 needed to eat in the dining room for queuing (prompting to eat) and or if he dropped his silverware. The DON stated the resident was very contracted and he refused to go to the dining room because it was painful for him to move. The DON stated staff would set the resident up at 90 degrees in bed, would set up his tray, and would go in and out of his room to supervise him during meals in his room. The DON stated they did not document or care plan the resident's refusals to go to the dining room. The DON stated staff would attempt 3 times to get the resident up and then would notify the nurse if he refused. The DON stated the SP would go in the room to sit with the resident and help him eat. The DON stated she had not read the SP evaluation and plan of care for Resident #1. The DON read the POC and stated she did not agree that staff would not be able to assist the resident in an emergency because the staff was CPR certified and could also perform the Heimlich maneuver. The DON stated she had never been notified that the resident would cough or choke while eating and the SP should have reported this to nursing. During a joint interview on [DATE] at 4:37 p.m. with Rehab director and SP stated it was the RD's responsibility to communicate any evaluations and recommendations at clinical meetings to the nursing staff. They stated they were unable to get the resident to the recommended barium swallow study because the residents refused cooperate. The SP stated the resident did not want to get into the wheelchair and he had no signs or symptoms of choking such as a pneumonia. The RD stated the evaluation was done in March of 2024 and since then the resident had progressed. The RD stated the resident did not need supervision with meals. The RD stated he would not get supervision from staff they would just check in on him when he ate. The RD stated the doctor signed the SP evaluation on [DATE] with no further recommendations. The RD stated she was never notified or told the resident was coughing while eating or choking. Record review of the facility's policy titled 'Nutritional Recommendations, dated ,d+[DATE], stated policy: it is the policy of this home that the deal in/ DON will address recommendations by the console dietitian within three working days, if possible, of the exit of the dietician consult. Procedure: 1. the consultation will complete the nutritional recommendation form and/ or enteral feeding recommendations, sign, and date. 2. The consult dietitian will discuss the recommendations and exit conference with the administrator, director of nursing, and dietary service manager for clarification. After completion of the discussion, each will sign the form. 3. The dietitian will keep one copy of the form and give the other copy to the director of nursing. 4. The director of nursing or designee will contact the physician for orders or denial of the recommendation. The director of nursing or designee will write the physician's response and date and the follow up section. A note should be made regarding the reason for refusal if the physician denies the recommendation. 5. when recommendations have been completed and follow up column filled in, the director of nursing gave a copy to the administrator and dietary service manager. 6. The director of nursing/ designee will write orders in the medical records to initiate the approval recommendations. 7. The [nursing/ dietary communication form] will be completed regarding any diet or supplement changes. The original copy will be placed in dietary section of the medical record and the copy will be given to the dietary. 8. On the console dietitian next visit, the completed recommendations will be reviewed, and if indicated, follow up will be made in the clinical software. 9. It is the administrator's responsibility to see that recommendations are addressed within three business days, if possible, of the consulting dietitians exit conference. The Administrator was given the IJ template and was notified of the IJ on [DATE] at 6:19 PM and a POR was requested. On [DATE] at 1:35 PM, the POR was accepted. It was documented as follows: [DATE] Plan of Removal - F 689 Immediate Action Taken Resident Specific Resident #1 will be supervised by staff during all 3 meals daily beginning on [DATE] at 7:00 pm. Resident #1 had the appropriate care plan updates completed on [DATE] at 11:20 am. System Changes On [DATE] at 7:00 pm a facility audit took place to ensure that all residents requiring supervision for meals will receive appropriate supervision. On [DATE] at 7:00 pm DON and therapy reviewed all residents who require supervision for meals have had their care plans audited to ensure that the care plans accurately reflect the residents need for supervision with meals. Starting on [DATE] and ongoing therapy will be present in morning meetings to ensure that all orders are communicated directly between nursing and therapy to ensure that residents requiring supervision with meals will have recommendations reviewed and carried out appropriately. Starting on [DATE] and ongoing the DON will monitor two meals daily x 5 days a week to ensure staff compliance with meal supervision for those residents requiring supervision. Starting on [DATE] and ongoing residents dietary and supervision statuses will be audited upon change of condition, appropriate MDS cycles or anytime necessary. Starting [DATE] at 11:00 am the facility's mechanism for ensuring correct diet texture for the residents is that all trays will be compared to the actual plated meal for the resident by a licensed staff member prior to being served to the resident. The meal ticket/diet order will be compared for accuracy. Education On [DATE] at 7:00 pm the Assistant Director of Nursing provided education to all staff regarding residents needing to have supervision at meals to ensure those residents will be supervised at mealtimes. Staff on future shifts will be educated prior to taking the floor. This will be accomplished by having a designated staff member in the building for that purpose and with that specific assignment. Licensed staff will be assigned by the DON to ensure that all trays/plates are correct prior to being served to the residents. Diet orders will match correctly to what is being served to the residents. This assigned licensed staff member will ensure specifically that texture, larger utensils, cup covers etc are being utilized for the residents. On [DATE] at 7:00 pm the Regional Clinical Consultant provided education to Administrator and Director of Nursing regarding residents needing supervision for meals. On [DATE] at 7:15 pm the Regional Clinical Consultant will educate DOR and clinical team as to communication and follow up during morning meetings. Starting on [DATE] at 7:00 pm the regional clinical consultant will be responsible for ensuring that staff receive the in-service/training regarding residents needing supervision during meals. Starting on [DATE] the residents dietary and supervision status will be communicated to facility staff directly by the DON and ADON. This process will be accomplished through photocopy and written communication. Starting on [DATE] the DON will be responsible for ensuring that the residents who require supervision during meals receive supervision. Starting on [DATE] at 7:00 pm during the daily stand up process all recommendations and orders will be audited by the clinical team in consultation with the therapy team to ensure compliance and follow up for all residents with orders and recommendations. The clinical consultant will review orders and recommendations daily x 4 weeks as a tool for oversight to ensure compliance. 100% Staff education compliance of the above mentioned by noon [DATE]. Verification of Plan of Removal: Confirmed via Observation of lunch and dinner meals on [DATE]. Confirmed via Record Review of Resident #1's care plan . Confirmed via Interview with Regional Clinical Consultant and DON. They each had a list of all staff with check marks. Interviewed about their process for identifying residents who needed supervision and how they ensured no one was falling through the cracks. Interviewed each independently and they both said they went through each clinical record looking at: therapy notes and recommendations, physician notes, POC notes from CNAs, progress notes from LVNs and RNs, MDS assessments, and care plans. On [DATE] at 7:00 pm DON and therapy reviewed all residents who require supervision for meals have had their care plans audited. Confirmed via Interview with Dir of Rehab and DON. Record review of the care plans for all eight of the residents (Resident #1 and additional seven who require assistance). Five care plans had been updated - edits were observed - and the updates clarified and added more specific language. For example, instead of saying supervision as needed the language was updated to read supervision at all times by nursing staff. The two that were not updated were already very precise and specific in their wording. Confirmed via Interview with Dir of Rehab DON, and Administrator Confirmed via Interview with DON. Record review of chart of items to check for each resident identified and had filled in the chart for each meal served since IJ was called. Confirmed via Interview with Regional Clinical Consultant, DON, MDS/Care Plan Coordinator, and Administrator. There were 52 total staff members 41 of the 52 staff have received in-service. Interview in person or by phone with 32 of the 52 staff members and confirmed they received the trainings and could verbalize understanding of the training. Of the 11 staff who did not receive the training: 1 FMLA, 1 vacation, and 9 PRN. Observation of a sign on the time clock stated for staff not to clock in for shift until they received in-service trainings dated [DATE]. Observation of both lunch and dinner service on [DATE] revealed each meal had an assigned licensed nurse to check meal tickets against trays. Observation of weekend RN meal tickets and trays revealed checking tickets for 15 residents versus what they had been served were completed and all were correct. The DON stated she would personally check two meals per day M-F, and weekend RN would check all three weekend meals (The DON and weekend RN work 6 am to 6 pm ). Observation of the residents who required assistance in dining hall revealed staff were treating them with dignity, their tickets and meals were correct, and assistive devices(e.g. divided plate, built up utensils) were in place. Observation of Resident #1 dining in his room revealed his ticket and meal were correct, a divided plate was in place, covered cups in place, and a member of nursing staff was providing 1 on 1 supervision. Interviews conducted on [DATE] from 3:42 p.m. to 7:45 p.m. and on [DATE] from 9:03 a.m. to 1:30 p.m. revealed there were 14 nurses on staff, and interviewed 12 of them and all have received the in-service trainings (more detail on trainings below). Interviews conducted on [DATE] from 3:42 p.m. to 7:45 p.m. and on [DATE] from 9:03 a.m. to 1:30 p.m. revealed there are 17 CNAs on staff, 13 of them were interviewed and all received the in-service trainings. Confirmed via Interview with Regional Clinical Consultant and Record Review of in-service training. Confirmed via Interview with DON and with ADON. Record review of the in-services. One of the in-services which was given to all nursing staff identified all eight residents who require supervision and/or assistance for dining. Confirmed via Interview with DON. Observation of lunch and dinner comparison of their care plans and meal tickets against the meal, assistive devices, and level of supervision for the eight residents who required assistance received during both lunch and dinner, revealed each was correct. Confirmed via Interview with Regional Clinical Consultant and DON, MDS/Care Plan Coordinator, and Administrator. During interviews staff confirmed abuse and neglect training was done in general and every staff member confirmed ANE trainings are provided at least monthly. Regional Clinical Consultant confirmed via interview that she was personally ensuring that all staff received in-service trainings. She was onsite today and planned to stay to catch the oncoming night shift. She provided her documentation via a staff list with check offs. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 8 residents (Resident #1) reviewed accidents and hazards in that: The facility failed to ensure Resident #1 did not elope after he was identified to be of high risk for elopement. Resident #1 eloped on 5/3/23 around 9:00 a.m. and was found on 5/4/23 around 6:47 p.m. The facility failed to implement measures to prevent future elopements. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 5/5/23 at 6:06 p.m. While the IJ was removed on 5/7/23, the facility remained out of compliance at a level of potential harm with a scope identified as a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This deficient practice could place the residents at risk for harm, serious injury or death. The findings were: Record review of Resident #1's face sheet, dated 5/5/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of complete traumatic amputation at level between knee and ankle, right lower leg, sequela-surgery [sequela is a condition following a previous disease or injury], attention and concentration deficit following cerebral infarction [a disruption in the brain's blood flow], Type 2 Diabetes Mellitus with diabetic neuropathy [nerve damage due to diabetes], unspecified, mild protein-calorie malnutrition, and essential (primary) hypertension. Further record review of this document revealed the following verbiage: Is Responsible for Self: No. Record review of Resident #1's signed Admission Agreement, dated 4/17/23, revealed Resident #1 did not sign his admission agreement. CO H signed the admission agreement above the line marked Signature of Responsible Party. Record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 had a BIMS of 14, signifying little or no cognitive impairment. Record review of Resident #1's physician orders, obtained 5/5/23, revealed Resident #1 had the following medication orders: - Levemir FlexTouch U-100 Insulin (insulin detemir u-100) [a type of injectable, long-acting medication that helps control high blood sugar levels] insulin pen; 100 unit/mL (3 mL); amt: 28 units; subcutaneous . Every 12 Hours; 09:00 [9:00 a.m.], 21:00 [9:00 p.m.]. Started on 4/18/23. - Humalog U-100 Insulin (insulin lispro) [a type of injectable, fast-acting medication that helps control high blood sugar levels] solution; 100 unit/mL; amt: Per Sliding Scale . Before Meals and At Bedtime; 07:30 [7:30 a.m.], 11:30 [11:30 a.m.], 16:30 [4:30 p.m.], 20:00 [8:00 p.m.]. Started on 4/25/23. - Acidophilus-Pectin (lactobacillus acidoph-pectin) [a medication that contains bacteria meant to maintain healthy bacteria in the intestines] capsule; 75 million cell -100 mg; amt: one capsule; oral . Twice A Day; 08:00 [8:00 a.m.], 20:00. Started on 4/18/23. - ascorbic acid (vitamin C) tablet; 500 mg; amt: one tablet; oral Once A Day; 09:00. Started on 4/18/23. - docusate sodium [OTC] capsule [a stool softener]; 100 mg; amt: one capsule; oral . Twice A Day; 09:00, 21:00. Started on 4/18/23. - gabapentin tablet [a medication that can treat seizures and nerve pain]; 600 mg; amt: one tablet; oral . Three Times A Day; 09:00, 13:00 [1:00 p.m.], 21:00. Started on 4/18/23. - melatonin tablet extended release [a hormone in the body that regulates sleep cycles]; 3 mg; amt: one tablet; oral . As Needed. Started on 4/18/23. - multivit-min-iron fum-folic ac tablet [a multivitamin and iron product used to treat or prevent vitamin deficiency due to poor diet, certain illnesses, or during pregnancy]; 7.5 mg iron-400 mcg; amt: one tablet; oral . Once A Day; 09:00. Started on 4/18/23. - oxycodone [a narcotic medication used to treat moderate to severe pain] - Schedule II tablet; 10 mg; amt: one tablet; oral Special Instructions: Give one tablet every 4 hours as needed for pain. Started on 4/18/23. - senna [OTC] tablet [a medication used to treat constipation]; 8.6 mg; amt: two tablets; oral . At Bedtime; 21:00. Started on 4/18/23. - lisinopril tablet [a medication used to treat high blood pressure]; 20 mg; amt: one tablet; oral Special Instructions: Hold if SBP <110. Once A Day; 09:00. Started on 4/20/23. Record review of Resident #1's May 2023 MAR and TAR, obtained 5/5/23, revealed the last time it was documented Resident #1 received his medications was the evening of 5/2/23. There was no documentation Resident #1 received his earliest dose of Insulin Humalog scheduled at 7:30 a.m. on 5/3/23. Record review of Resident #1's vitals documentation, reviewed on 5/5/23, revealed CNA E documented on 5/3/23 at 7:45 a.m. that Resident #3 ate 76% - 100% of his breakfast on 5/3/23. Record review of Resident #1's Elopement/Wandering Observation, completed 4/18/23 at 9:00 a.m. written by LVN D, revealed the following section: High Risk Factors: Residents exhibiting (1) one or more of the listed high-risk behaviors will be classified as HIGH RISK TO WANDER. Facility policy and procedure for wandering residents will be immediately implemented. Within this section the following item was checked off as yes: Resident verbalized the need and/or desire to go home or to another location AND has the ability to act on that verbalization. Further record review of this document revealed the following section: Potential Interventions: Select appropriate interventions. Within this section, the following was checked off: None of the above. There was no verbiage within this document accounting for a high BIMS score. Record review of Resident #1's Care Conference, dated 5/2/23 written by the DON, revealed the following: Pt also verbalized that he does not feel as though he needs to be here and there are many things at home that require his attention and that he needs to leave to [CO H] take care of things at home. Pt was educated on need to sign out if he leaves building to smoke and/or for any other reason. Record review of Resident #1's Safety Event - Elopement electronic document, dated 5/3/23 written by ADON LVN G, revealed the following: DESCRIPTION: elopement. Further record review of this document revealed the following: Did resident exhibit any of the following behaviors prior to elopement? Verbalizing Statements about Leaving . 5/2/23 Care plan completed with this resident where he verbalized, he did not want to be here at the facility anymore. Record review of a typed document regarding Resident #1 titled, [Facility Name] Missing Person Timeline, not dated, revealed the following: 5.3.23 . 8:21am - DON arrived to work and visualized resident. 8:30 am - Resident was seen in the dining room by nurse aide [CNA E.] 9:34am - Nurse [LVN A] pulled up meds, but did not administer them as [Resident #1] had left the dining room, was waiting for [Resident #1] to come to the nurse's med cart like he always does to get them, he never came to get them. 11:00am - Therapy . verbalized she can't find [Resident #1] at this time . 12:24pm - [family member] called back and stated when resident gets his check on the 3rd of every month he takes off with his friends for a few days and that is his M.O. 5.4.23 . 1915 [7:15 p.m.] DON notified pt has been located at local [store] with friend. Pt states that he is ok but will not be returning at this time. 2206 - Pt arrives in house with [CO H] and calls DON. DON instructed pt to go to local ED to for evaluation by a doctor prior to reconsideration of re admit to this facility. There was no documentation in this facility document detailing Resident #1 was offered the AMA form, signed the AMA form, or refused to sign the AMA form. Record review of local law enforcement Offense/Incident Report, dated 5/3/23, revealed the following: UPON MY ARRIVAL I MADE CONTACT WITH (R1) [Reporting Party-1, referring to the DON] WHO INFORMED THAT (SB1) [Subject-1, referring to Resident #1] LEFT THE LISTED LOCATION AGAINST MEDICAL ADVISE AT 0600 HOURS [6:00 a.m.] [The DON] EXPLAINED THAT [Resident #1] DID NOT HAVE A HISTORY OF MENTAL HEALTH RELATED ISSUES, WAS NOT SUICIDAL/HOMICIDAL . [The DON] MENTIONED THAT [CO H] INFORMED THE STAFF THAT AT THE BEGINNING OF THE MONTH WHEN [Resident #1] GETS PAID HE DISAPPEARS FOR A FEW DAYS POSSIBLY RELATED TO HIS HISTORY OF DRUG ABUSE. Record review of Resident #1's care plan, obtained 5/5/23, revealed no care plan for elopement or elopement behavior prior to 5/3/23 at 2:21 p.m., after it was discovered Resident #1 eloped on 5/3/23 at 11:00 a.m. The care plan regarding elopement included the following problem area with a problem start date of 5/2/23: Category: Behavioral Symptoms . Resident is a threat to self and/or others R/T RESIDENT HAS VERBALLY YELLED AT STAFF, THREATENED STAFF. RESIDENT WILL WHEEL OUTSIDE OF FACILITY AND HAS STATED THAT HE CAN GO TO THE STORE HIMSELF. WHEN STAFF ASKS/EDUCATES RESIDENT TO SIGN OUT OF FACILITY SO FACILITY STAFF KNOW WHERE HE IS, RESIDENT STATES I AM A GROWN MAN, I CAN GO AND DO AS I PLEASE. RESIDENT ALSO OCCASIONALLY REFUSES MEDICATIONS/ADL/CARE. This care plan regarding elopement had the following interventions: - Convey an attitude of acceptance toward the resident. - Maintain a calm environment and approach to the resident. - Obtain a psych consult/psychosocial therapy. - Provide care, activities, and a daily schedule that resembles the resident's prior lifestyle. - When resident becomes socially inappropriate/disruptive, move to a quiet, calm environment. Record review of Resident #1's EHR revealed no signed AMA form had been uploaded to Resident #1's EHR. Record review of Resident #1's physical chart revealed no signed AMA form. Record review of Resident #1's progress notes, dated from 4/1/2023 to 5/5/23, revealed no progress note describing that Resident #1 requested for an AMA form, signed an AMA form, or refused to sign an AMA form. Record review of a facility educational in-service titled Elopement, dated 5/3/23, revealed the facility educated 23 of their 49 staff members (which was less than 50% of their staff) on their elopement policy. This elopement policy described what to do if a resident was discovered missing but did not describe interventions to prevent elopement before an elopement occurred. Observation on 5/5/23 at 8:05 a.m. revealed a camera affixed to the ceiling of the entrance lobby. The camera lenses pointed towards the entrance. During an interview on 5/5/23 at 8:38 a.m., this surveyor requested from the Administrator to provide any camera footage about Resident #1's elopement on 5/3/23. The Administrator stated the cameras did not work. During an interview on 5/5/23 at 9:13 a.m., LVN B stated she did not work on 5/3/23, the day Resident #1 left the facility. LVN B stated she worked with Resident #1 before and recalled Resident #1 threatened to leave AMA before because Resident #1 wanted breakfast tacos one morning and he did not receive breakfast tacos. LVN B stated, but then he kind of calmed down. LVN B stated she was not given any direction in regards to Resident #1's verbalization of wanting to leave the facility. LVN B stated she had not received any new education since 5/3/23. During an interview on 5/5/23 at 9:40 a.m., CNA C stated she did not work on 5/3/23. CNA C stated, I remember [Resident #1] was upset about being here . I remember a case where he didn't like the meal and he said 'I'm going to get my stuff, bring me bags so I can pack up. I let the nurse [LVN B] know. But after a while he was fine. I guess he forgot. CNA C stated Resident #1 verbalized his desire to leave the facility last week. CNA C stated she did not receive any new education since 5/3/23. During an interview and record review on 5/5/23 at 10:33 a.m., LVN B stated a resident would sign themselves out using a sign-in sheet (which was titled RELEASE OF RESPONSIBILITY WHILE OUT OF THE FACILITY, not dated) located at the nurses' station in a resident's chart. LVN B stated a resident would sign, then write the date and the time and there would be a staff member's signature next to the resident's signature. LVN B stated the staff member who signed this document was the staff member who was aware the resident was about to leave the facility premises. Resident #1's RELEASE OF RESPONSIBILITY WHILE OUT OF THE FACILITY form was reviewed with LVN B at this time and Resident #1's signature was seen on this form but there was no date or time signifying when Resident #1 signed himself out of the facility. There was no nurse's signature in the sign out section of this form to indicate which staff member was aware Resident #1 was signing himself out at this unknown date and time. There was no resident signature, staff signature, date, or time signifying when Resident #1 signed himself back into the facility. During an interview on 5/5/23 at 10:56 a.m., Resident #1 stated I had an emergency and I had to leave . I had to make a decision. I had business endeavors that I've been neglecting since I left the facility and if I didn't take care of them I would have lost my business. Resident #1 stated he left early in the morning, around 4:00 a.m. - 4:30 a.m. Resident #1 stated he thought he told one of the nurses he was going to leave before he left the premises, but could not recall who he spoke to, only that he thought he spoke to a male nurse and it was still dark outside when he left the facility. Resident #1 stated he was fine but he was currently at the hospital because the DON wanted him to be checked by a doctor to ensure nothing was wrong with his right leg amputation. Resident #1 stated the facility had a meeting with him about his care on 5/2/23 and stated he did not explicitly verbalize a desire to leave in the meeting on 5/2/23. Resident #1 stated, But I threw it out there that there's some things I had to take care of. When asked if he was planning on eloping from the facility again, Resident #1 stated, No, I wouldn't do that. I actually want my medication. I'm off my medication and I want my medication when I leave from there. During an interview on 5/5/23 at 11:50 a.m., when asked how frequently he checked on his residents, LVN A stated, the protocol says at least once every 1 hour . but a lot of it depends on what's going on. LVN A stated he considered Resident #1 an elopement risk because of his history of drug addiction. And I had many years of dealing with addicts. They're always an elopement risk . They always want to have their freedom and get their drug of choice and chase that dragon [a phrase that refers to drug usage.] We were keeping an eye on [Resident #1] about his daily routine. How he moves, how he interacts . He's also a social butterfly. That's why I assumed that's where he was [on 5/3/23.] I figured he would get back to me at some point, especially because he was taking narcotics . I'm supposed to at least be aware and visually see them at least once every 2 hours. But that doesn't always work out based on what's going on. And I had an admission pending. I had a patient that was being discharged . I had a lot going on that morning . And normally I see him going from one end [of the facility] or the other and he's active . I think [Resident #1] probably left right before breakfast or right after. I would think before breakfast. I would think around 6:30ish . I think he went out of the front door . I realized he was missing when I went to his room when I went to give him his morning meds, I would say around 9:00 a.m. But I didn't panic because he was the person who was not really in his room. He's moving constantly . I think it was coming up to around when I was coming to check his blood sugar. It was around 11:00 a.m. or so and then I didn't see him. On 5/5/23 at 12:03 p.m., a phone interview was attempted with CNA E, but there was no answer. A voicemail containing this surveyor's name, phone number, and a brief purpose of call was left. A text message was also sent on 5/5/23 at 12:06 p.m. containing this surveyor's name, phone number, and request to return this surveyor's call. On 5/5/23 at 12:12 p.m., a phone interview was attempted with LVN D, but there was no answer. A text message was also sent on 5/5/23 at 12:14 p.m. containing this surveyor's name, phone number, and request to return this surveyor's call. During an interview on 5/5/23 at 1:42 p.m., this surveyor asked the DON if she [the DON] could have LVN D and CNA E call this surveyor. The DON stated she will try to have the aforementioned staff members call this surveyor back. This surveyor also requested Resident #1's signed admission agreement to include the document titled, Signing Out Policy that either Resident #1 or his Responsible Party must sign. Resident #1's signed Signing Out Policy, was not provided to this surveyor prior to exit. During an interview and record review on 5/5/23 at 2:46 p.m., the DON stated the staff should check on the residents every 2 hours or as needed. The DON stated the facility had an elopement assessment that was done upon admission and quarterly. The DON stated, It's [the Elopement assessment was] a bunch of questions that ask cognition and whether they're ambulatory. It does low, moderate, or high risk. The DON stated Resident #1 did not trigger as a high risk. Resident #1's Elopement/Wandering Observation, dated 4/18/23, was reviewed with the DON at this time. When this surveyor brought to attention that Resident #1 had one high risk factor for elopement checked off (Resident verbalized the need and/or desire to go home or to another location AND has the ability to act on that verbalization), the DON stated, with [Resident #1's] BIMS being as high as he was-Just because they're a high risk on the assessment they're not always listed as high because their BIMS and cognitive is very high . We never saw any exit-seeking behavior. The DON stated, when I came in, I came in through [the double doors], [Resident #1] was sitting in the hallway . Nurse Aide said he saw him in the dining room at 8:30 a.m., usually by then breakfast is over. After that, therapy came down and said 'I went to get [Resident #1], have you seen him?' I said, 'no, have you checked outside in the front?' And then we started looking . We searched the grounds, we searched the building. We went to his house. We called [CO H.] The DON stated, After speaking with [CO H] .she told me that this was a comment event for him. That when he would get his check on the 3rd of the month he'd run off and he'd do 'God knows what with his friends' . Because he'd go and get his check and get drunk and come back and act like nothing happened. The DON stated, After the police came they said they couldn't issue a silver alert [a phrase meant to notify the public of missing older adults with a documented mental condition] because his cognitive status was so high and his BIMS is a 14 and he's ambulatory and able to leave at his own free will. That they were going to treat it as an AMA and they were going to put on a [NAME] as opposed to a silver alert because the patient was cognitive . [Resident #1] did end up coming back last night [5/4/23] at 10:15ish. [CO H] called me and said, 'can he come back?' I said right now I can't say that he can come back because he's left us AMA . So my suggestion is that if you feel like you need medical attention, it's better for you to go to the hospital anyway. The DON stated Resident #1 did not verbalize a desire to leave the premises during the care plan meeting of 5/2/23. The DON stated during his care plan meeting on 5/2/23, she educated Resident #1 to sign out if he left the facility property. The DON stated she was not aware Resident #1 was going to leave the facility on 5/3/23. The DON stated there were no interventions to prevent elopement prior to Resident #1's elopement on 5/3/23. The DON stated He didn't display any elopement-type behaviors so that would have been the only thing we would have done is if we saw behaviors. The DON stated the camera in the entrance lobby was a fake camera. The DON stated after Resident #1 eloped from the facility they completed an in-service on elopement on 5/3/23. The DON stated the facility was considering putting keypads on the entrance door so that way a staff member had to input a keycode in the keypad to open the door from the inside. At this point, this surveyor requested for any construction quotes or emails discussing the addition of a keypad to the entrance door. No construction quotes or emails discussing the addition of a keypad to the entrance door was provided to this surveyor prior to exit. On 5/6/23 at 4:32 p.m., a second phone interview was attempted with CNA E with no answer. A second voicemail was left with this surveyor's name, phone number, and brief purpose of call. This surveyor did not receive a return call prior to exit. On 5/6/23 at 5:13 p.m., a second phone interview was attempted with LVN D with no answer. A second voicemail was left with this surveyor's name, phone number, and brief purpose of call. A successful interview could not be conducted prior to exit. Record review of a facility policy titled, Wandering Resident, dated 12/2017, revealed it is the policy of this home that residents at risk for wandering will be identified and monitored for safety . 1. Residents will be assessed for wandering risk factors upon admission, quarterly and with any change in condition 3. The IDCPT will be responsible to develop a care plan to assure the resident receives the appropriate monitoring to assure safety. Further record review of this document revealed no verbiage accounting for a resident's high BIMS score. Record review of a facility policy titled, Elopement, dated 12/2017, revealed no verbiage regarding the identification of high risk for elopement and interventions to address high risk for elopement. Further record review of this document revealed no verbiage accounting for a resident's high BIMS score. The Administrator was notified of an IJ on 5/5/23 at 5:47 p.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal accepted on 5/6/23 at 2:22 p.m. and included the following: Immediate Action Taken Resident Specific - Nurse administering medications to Resident #1 was given a counseling for failing to locate resident when medications were due to be given or notify DON/ADON for assistance - Nurse assigned to resident #1 was given in-service on facility policy for elopement. - Elopement protocols immediately activated when resident identified missing - Immediate search of building & outside parameters - Continued search of all possible areas around the facility the resident may have gone (Appointments, residents previous residence prior to admit & local bus stops and followed sidewalks surrounding facility) - Responsible party was notified - Physician was notified - [local police department] was notified - Resident #1 was located 5/4/23 @ 18:47 pm [6:47 p.m.] at the bus stop at [local street intersection] getting on the [local] bus, staff (Cook) followed the bus to [local store] where resident exited @ 19:04pm [7:04 p.m.] and stated he had an emergency and was not coming back. - Resident #1 came to the facility with [CO H] 5/4/23 @ 21:47pm [9:47 p.m.] to gather his belongings and refused to be assessed at this time, [CO H] encouraged to have resident assessed at the ER as he was refusing to stay or be assessed and refused to sign AMA form. - Resident stated he did not have any reason to be assessed and left the facility with his spouse. System Changes - Residents that sit outside on the porch or in front of the building will be assessed to have a BIMS establishing them to be cognitive to be outside unsupervised - On 5/5/23 100% of residents were audited for a current elopement assessment, then checked for accuracy and completeness. All residents had a current accurate elopement assessment by end of day 5/5/23. - Residents choosing to sit outside will be educated and care planned if they want to leave the facility grounds they will notify the staff and sign out via the accushield [a small computer where people can sign in and sign out of a building.] - If a resident verbalizes refusal to follow the facilities policies related to notifying the facility before leaving will be given a 30-day notice. - If resident is given a 30-day notice they will be supervised outside during the 30-days Staff will be in-serviced on facility elopement policy on hire prior to being placed on the floor alone. Education - DON/Designee will educate staff if a resident cannot be found to immediately initiate an Elopement protocol - DON/Designee will educate staff on elopement protocol - DON/Designee will educate staff on how to identify all residents at risk for elopement (Binder) - All in-servicing will be completed by Saturday 5/6/23 @ 6am and then all staff will receive the education prior to the start of their shift moving forward x 1 week to ensure all staff receives the education. Monitoring - Administrator/Designee will randomly interview staff daily on both shifts x4 weeks on elopement protocols - Maintenance/Designee will conduct elopement drills on both shifts on 5/6/23 with the 1st drill @ 8am and the second drill @ 6pm to ensure both shifts are addressed. - Maintenance/Designee will be responsible for quarterly elopement drills to ensure compliance with elopement protocols - Residents will have an elopement risk observation completed quarterly The surveyor verification of the Plan of Removal from 5/6/23 to 5/7/23 was as follows: Observation on 5/5/23 revealed Resident #1 was no longer in the facility. During an interview on 5/5/23 at 3:23 p.m., LVN A stated he had been counseled the same day Resident #1 eloped from the facility on 5/3/23. During an interview on 5/5/23 at 10:56 a.m. revealed Resident #1 stated he returned to the facility on [DATE] at around 10:30 p.m. but was advised by the DON to visit a local hospital. Record review of typed-up document titled [Facility Name] Missing Person Timeline, not dated, revealed the facility grounds were searched, the responsible party was notified, physician was notified, and SAPD was notified. Record review of local law enforcement report, dated 5/3/23, revealed law enforcement was notified and arrived on-site. Record review of Employee Disciplinary Report, dated 5/3/23, revealed LVN A was counseled on the need to notify the ADON/DON to follow the elopement protocol if a resident didn't receive medications within 1 hour window and resident was unable to be located. During interviews conducted from 5/6/23 at 2:05 p.m. - 5/7/23 at 11:00 a.m., 21 of the 49 staff (11 from day shift and 9 from night shift and including CNA, LVN, RNs, Dietary Staff, Housekeeping Staff) were interviewed. All staff members interviewed stated they received education on the elopement protocol and what to do if a resident eloped. During interviews conducted on 5/6/23, 2 residents stated they were educated on the importance of signing out at the nurses' station if they were going to sit outside and stated they were educated that if they had to use the accushield if they were going to leave the premises. During an interview on 5/7/23 at 10:14 a.m., the DON stated she conducted the BIMS audit, stated 6 residents had been identified as residents who like to sit outside in the facility's patio, these 6 residents had been educated on the importance of signing out when leaving the premises, and any residents who did not wish to comply with signing out will be provided with a 30 day discharge. The DON stated knowledge checks on the elopement protocol will be conducted on the staff and will be logged a facility document titled, Administrator/Designee will interview 2 staff member a day 5 times a week for 4 weeks. During an interview on 5/7/23 at 10:36 a.m., the Administrator stated 6 residents had been identified as residents who like to sit outside in the facility's patio, these 6 residents had been educated on signing out when leaving the premises, and any residents who did not wish to comply with signing out will be provided with a 30 day discharge. The Administrator stated knowledge checks on the elopement protocol will be conducted on the staff and will be logged a facility document titled, Administrator/Designee will interview 2 staff member a day 5 times a week for 4 weeks. Record review of facility's POR Binder revealed the facility has identified 6 residents who like to sit outside on the facility's patio had a BIMS score of 12 or greater. Further record review of this POR binder revealed all 50 residents in the facility have an elopement assessment within the last quarter, per their policy. Further record review of this POR binder revealed the facility did not have any residents who refused to follow the new process about signing out. Further record review of this POR binder revealed the facility's current policy titled Elopement, dated 12/20217, which detailed the protocol for residents who eloped as well as a table titled Missing Patient Action Table, not dated, which goes into further detail of what to do if a resident had eloped. Record review of the care plans of 3 of the 6 residents identified as liking to sit outside revealed there was a care plan regarding the resident liked to sit outside. Record review of a facility document titled Facility Observation Summary Report, dated 5/6/23, revealed all residents had an elopement assessment within the last quarter. Record review of Educational In-service, not dated, revealed the facility had educated their staff on the elopement policy and the elopement process. Record review of Education In-service, dated 5/5/23, revealed the facility educated their 6 residents who like to sit outside on signing out if they sit outside and to use the accushield if they have to leave the premises. Observation on 5/6/23 at 2 of 2 nurses stations revealed the facility had their Code Pink (which was the name of the facility's protocol when a resident was discovered missing) emergency code document posted in the nurses station and also a manila folder containing the Code Pink protocol. Observation on 5/6/23 at 6:30 p.m., revealed the Administrator was in-servicing his staff on the elopement (Code Pink) protocol. The elopement binder was observed at the 100-200 Hall nurses station. Record review of a facility document titled, Missing Patient Action Table, not dated, revealed the facility had a protocol listing step-by-step what to do if a resident was missing. Record review of an educational in-service, dated 5/5/23, revealed the facility educated their staff on the elopement protocol and also had post-test to confirm education. Record review of a facility document titled, Administrator/designee will interview 2 staff member a day 5 times a week for 4 weeks, not dated, revealed the facility conducted knowledge checks on 2 staff members a day since 5/5/23. Observation on 5/6/23 at 6:23 p.m. revealed the facility successfully conducted their Code Pink (elopement) Drill. During an interview on 5/6/23 at 5:04 p.m., the Maintenance Staff stated he conducted the Code Pink (elopement) Drill on 5/6/23 and stated the drills will be run quarterly. On 5/7/23 at 12:35 p.m., the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a level of potential harm with a scope identified as a pattern due to the facility's need to monitor the implementation and effectiveness of its POR.

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 3 of 14 residents (#1, 2, 3) reviewed for care in that: 1. Resident #1 was yelling and crying during perineal care and wound care and was not medicated or assessed for pain. Resident #1 had been out of [MEDICATION NAME] (Controlled narcotic pain medication) for 4 days. 2. Resident #2's urinary catheter tubing was pulled during catheter care. 3. Resident #3's urinary catheter bag was attached to his wheel chair above the level of the bladder. An Immediate Jeopardy (IJ) was identified on 04/22/15. While the IJ was removed on 04/23/15 prior to exit. The facility remained out of compliance at a severity level of actual harm with a scope of pattern. The plan of removal was still being monitored for compliance. This deficient practice could affect 41 residents on a pain management program and could result in pain not being managed; and placed 8 residents with urinary catheter at risk for an urinary tract infection. The findings were: 1. Review of the face sheet, dated 8/27/13, for resident #1 revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Consolidated Physician's orders, dated 4/1/15, for resident #1 revealed an order for [REDACTED]. Review of the Individual Control Drug Record for resident #1 for [MEDICATION NAME] with APAP 7.5-325 mg 2 tabs per tube every 4 hours revealed 180 tablets were sent on 2/1/15. The first dose was administered on 2/6/15 and the last dose was administered on 4/18/15. Review of the April 2015 MAR for resident #1 revealed an entry for [MEDICATION NAME]-[MEDICATION NAME] 7.5 mg/325 mg 2 tablets per gastrostomy every 4 hours as needed. [MEDICATION NAME] was administered on 4/1-4/8, 4/10-4/14 and 4/17 and 4/18 in the morning between 8:00 a.m. and 11:00 a.m. On 4/8 and 4/10 resident #1 was medicated twice that day. Resident #1 had a pain scale of 7 (Hurts whole lot)(The scale of pain was listed on the MAR) each day she received the pain medication except on 4/18 the pain scale was 8 (Hurts whole lot). Review of the Individual Control Drug Record for resident #1 revealed a total of 22 doses was administered in April. Further review of the MAR indicated [REDACTED]. Review of the March 2015 MAR for resident #1 revealed an entry for [MEDICATION NAME]-[MEDICATION NAME] 7.5 mg/325 mg 2 tablets per gastrostomy every 4 hours as needed. [MEDICATION NAME] was documented as administered 26 days with two of the days resident #1 received the [MEDICATION NAME] twice in a day. Resident #1's pain scale ranged between a 7 and 8. Review of the Individual Control Drug Record for resident #1 revealed a total of 39 doses was administered in March. (On two days only one [MEDICATION NAME] was given instead of two). Review of the February 2015 MAR for resident #1 revealed an entry for [MEDICATION NAME]-[MEDICATION NAME] 7.5 mg/325 mg 2 tablets per gastrostomy every 4 hours as needed. [MEDICATION NAME] was documented as administered 9 days with a pain scale of 6, 7 and 8. Review of the Individual Control Drug Record for resident #1 revealed a total of 30 doses was administered starting on 2/6/15. Review of the January 2015 MAR for resident #1 revealed an entry for [MEDICATION NAME]-[MEDICATION NAME] 7.5 mg/325 mg 2 tablets per gastrostomy every 4 hours as needed. [MEDICATION NAME] was documented as administered 2 days with a pain scale of 7. Review of the Annual MDS with an assessment reference date of 2/24/15 for resident #1 revealed she had a BIMS (Brief Interview for Mental Status) of 2 out of 15 (2 indicating severe impairment). The MDS indicated resident #1 usually makes self understood and usually understands others. Speech was documented as clear. Under the section for Behaviors no behaviors were documented. Activities of Daily Living to include dressing, eating, toilet use and personal hygiene required total assistance. Under the Pain Management section "Have you had pain or hurting at any time in the last 5 days?" Answer yes was marked. Under pain frequency "How much of the time have you experienced pain or hurting over the last 5 days?" Unable to answer was marked. Under Pain Intensity "Please rate the intensity of your worst pain over the last 5 days." Unable to answer was marked. Staff assessment for pain included non-verbal sounds, vocal complaints of pain and facial expressions. Contractures revealed impairment on both sides. Review of the comprehensive plan of care, dated 9/19/11 with a review date of 2/25/15 for resident #1 revealed problem/ need was resident #1 complains of increased pain/discomfort. Resident #1 will yell out and cry when she is in pain. Pain related to generalized pain in bilateral lower extremities and contractures. Goal: Will maintain current ADLs and pain/discomfort will be relieved with in one hour after intervention over next 90 days. Approach included 1) Observe for s/s (signs/symptoms) of increased pain/discomfort-assess resident for possible causes give meds (medications), txs (treatments), physical and relaxation modalities, etc. assess for relief. 2) Provide pressure relieving and positioning devices- as needed. 3) Assist with ADLs and comfort measures- as needed. 4) Allow to verbalize feelings of pain and discomfort. 5) Encourage socialization and activity attendance-as tolerated. Review of the comprehensive plan of care, dated 9/19/11 with a review date of 2/25/15 for resident #1 revealed problem/ need was resident has impaired communication evidenced by: Resident #1 mumbles at times when she speaks. Needs time to formulate her thoughts to words at times. Misses parts and intents of statements. Goal: Staff will anticipate and meet all needs that the resident is not able to communicate effectively over the next 90 days. Approach included 1) reduce or remove all interfering enviromental stimuli. 2) Use terms, gestures that resident can understand--repeat PRN. 3) Approach in a calm manner, call by name. 4) Allow time for resident to digest information--do not rush. Review of the Pain Evaluation, dated 3/2/15, for resident #1 revealed: 1. Pain Management: She received PRN (as needed) pain medications and received non-medication intervention for pain. 2. Pain Interview: Ask Resident "Have you had pain or hurting at any time in the last 5 days?" The answer marked was unable to answer. 3. Location of Pain/Hurting: The back was marked. 4. Potential Underlying Cause: included immobility, contracture and ulcer/wound. 5. Intensity of pain on scale 0-10: worst pain/hurting gets "7" (indicated hurts whole lot). 6. What Relieves the Pain/Hurting? Rest, massage, medication administration. 7. Describe Quality of Pain/Hurting: Throbbing. 8. Timing and Contributing Factors: Repositioning, with ADLs (Activities of Daily Living). 9. Manner of Expressing Pain & Associated Symptoms: Grimacing, Groaning and Screaming. 10: Has Pain Interfered with any of the Following: unable to verbalize. Review of a Physician's Progress Note, dated 1/15/15, for resident #1 by Physician HH revealed according to nursing staff's verbal report there had been no recent aggression or agitation towards staff or others, does at times yell out, scream but mostly b/c (because) of pain. Review of a Progress Note, dated 2/24/15 for resident #1 revealed [DIAGNOSES REDACTED]. Review of the Nursing Weekly/Monthly Summary, dated 3/2015, revealed resident #1's mental status was alert, unaware, confused, memory loss, orientation fluctuates, short-term and long-term. Cognition indicated frequently loses train of thought in conversation, attention deficit and disorientation. Pain revealed daily, moderate, back, relieved by medication. Observation on 4/21/15 at 1:30 p.m. revealed resident #1 lying in bed. Resident #1 was verbal, but hard to understand what she was saying at times. Observation on 4/21/15 at 4:10 p.m. with CNA FF and GG revealed they provided incontinent care for resident #1 in her room. When CNA FF and GG began to remove the covers and place resident #1 on her back she began to cry out. During the perineal care and repositioning resident #1 was crying out. A Stage II pressure sore was noted to the sacrum and excoriation to the rectal area. Observation on 4/22/15 at 11:45 a.m. revealed wound care with the Treatment Nurse for resident #1. Resident was crying out during the care. The Treatment Nurse said resident #1 likes to be left alone. Resident #1 had a soft formed stool which was cleaned by the Treatment Nurse. Excoriation was noted to the rectal area. The Treatment Nurse stated resident #1 had issues with diarrhea. During the cleaning of the stool and the wound care resident #1 was crying and yelling during the care. Four wounds were provided care. Resident #1 said she was hurting when she was asked by the staff after the care. During an interview on 4/22/15 at 12:10 p.m. the Treatment Nurse said she thinks resident #1 had a [MEDICATION NAME] Patch. The Treatment Nurse said Resident #1 had an [MEDICATION NAME]. "We deal with this daily." When asked about medicating resident #1 for pain the Treatment Nurse said "we definitely could medicate her for pain." Interview on 4/22/15 at 12:35 p.m. with LVN E, charge nurse revealed resident #1 was out of pain medication, [MEDICATION NAME]. She stated she had faxed resident #1's physician prior to resident #1 running out of the medication (did not remember the date) and had refaxed the physician again on 4/20/15 for a refill. LVN E provided a copy of the fax sent on 4/20/15. LVN E stated she had told ADON V resident #1 was out of her [MEDICATION NAME]. LVN E said resident #1's physician was in the building yesterday morning (4/21/15). When asked what she would do if resident #1 needed a pain medication she was unable to provide an answer. LVN E stated resident #1 did not have pain unless they were working with her and then she gets upset and agitated. During interview on 4/22/15 at 12:50 p.m. ADON V said it was like "pulling teeth" to get a triplicate from Physician J. Physician J has been changing all of his residents' [MEDICATION NAME] to Tylenol #3 (pain medication). The process for getting a refill was to call the physician a few days before a resident ran out of medication. During interview on 4/22/15 at 3:20 p.m. ADON V said the facility did not have an emergency narcotic kit. During interview on 4/22/15 at 3:25 p.m. LVN I, Charge Nurse, said when you start to provide care for resident #1 she tries to hit and uses foul words. LVN I confirmed she had contractures. LVN I said resident #1 had Tylenol and [MEDICATION NAME] as needed. LVN I said he did not notice resident #1 yelling when he applied the cream yesterday (4/21/15). LVN I said resident #1 can verbalize pain. LVN I was unaware resident #1 was out of her pain medication. Interview on 4/23/15 at 8:30 a.m. with the Treatment Nurse revealed resident #1 had excoriation from the stool. an order for [REDACTED]. When the slough was gone the area was a Stage III. The Treatment Nurse said Resident #1 now has a healing Stage III and excoriation to the buttocks and inner thighs. The Treatment Nurse said she assessed for pain and would medicate her if necessary prior to treatment. Resident #1 had behaviors and tells us to leave her alone. Resident #1 will tell us sometimes if in pain. The Treatment Nurse said she knew the excoriation was painful, and was not aware resident #1 was out of pain medication until yesterday (4/22/15). The Treatment Nurse said she asks resident #1 if in pain prior to beginning treatment. Interview on 4/27/15 at 11:48 a.m. with the Treatment Nurse revealed the Triad Colopast was a barrier cream. It was not an [MEDICATION NAME], but the physician ordered it to use to control pain. Interview on 4/22/15 at 3:45 p.m. with LVN E revealed she assessed the residents for pain. If a resident was verbal she would use the "0-10 scale." For a nonverbal resident she would watch for facial expressions, eyes get bigger. LVN E heard resident #1 yelling, and resident #1 can tell her yes or no. LVN E said she gave resident #1 her pain medication ([MEDICATION NAME]) in the morning when resident #1 told her she had pain. [MEDICATION NAME] was last given on 4/18/15. LVN E said between 4/18/15 and 4/22/15 resident #1 had not had pain. Surveyor observation on 4/21 and 4/22 revealed resident #1 was in pain during perineal care and wound care. LVN E said the Medical Director had not been contacted in regards to resident #1 being out of pain mediation. LVN E said there was no phone call to the Physician after she faxed the two requests to the Physician. The Administrator, DON and Regional Nurse were notified of the IJ on 4/22/15 at 5:12 p.m. Interview on 4/24/15 at 9:50 a.m. with the DON revealed she should be informed when medications are not available. The DON said she was not aware of resident #1 being out of [MEDICATION NAME] until 4/22/15 when the Tylenol #3 came in for resident #1. The DON said pain assessments were done on the monthly and quarterly summaries, on a change in condition and assessed on their ADLs by the CNAs. If the residents exhibit a change the CNA reports to the nurse who will assess the resident. The facility submitted a plan of removal dated 4/23/15 at 8:15 a.m. to remove the immediacy consisting of the following actions: Medication availability 1) The facility immediately contacted the physician and requested that if he insisted on DCing [MEDICATION NAME] that he could provide an alternative. MD again stated he was not going to continue resident on [MEDICATION NAME] and DCd [MEDICATION NAME], ordered Tylenol 3. Tylenol 3 delivered from pharmacy. This was completed on (4/22) and Tylenol 3 was received from pharmacy at 3:30pm. 2) The facility immediately assessed all residents who receive [MEDICATION NAME] routine and/or PRN for pain management to verify that those residents had [MEDICATION NAME] available. This was completed on (4/22) 3) All residents who are on [MEDICATION NAME] were identified as at risk for pain due to medication availability issues. There were 8 residents on halls 1 & 2 who receive [MEDICATION NAME] for pain management and residents 10 on Rosewood who receive [MEDICATION NAME] for pain. 4) Staff education was conducted for how to handle pain medication availability issues, assessing for pain, and notification of DON when unable to obtain pain medications for residents. RN and LVNs in serviced on notification of the Medical Director when unable to obtain pain medication to request medical director to help facility to obtain medication. All RNS and LVNs were in serviced by (4/22) with the exception of 4 who were out of town. These 4 will be in serviced by (4/23), prior to working any shift. 5) The DON and/or designee will check each hall for pain medication availability each day. DON will report any issues to QA subcommittee weekly for 1 month, and monthly for 2 months. 6) Date of correction 4/22/15 Pain Assessment 1) The facility immediately started in-servicing LVN/RN on how to conduct appropriate pain assessments. All RNs and LVNs were in serviced by (4/22) with the exception of 4 who were out of town. These 4 will be in serviced by (4/23) prior to working any shift. 2) Facility will begin pain assessments on all 81 residents utilizing the facility pain assessment form. These assessments will be complete by 11:00 pm on (4/22) 3) Any resident who is identified as flagging for pain, the MD will be notified and the care plan updated. Completed by (4/22) 4) DON will review all residents who are found to have pain, these will be reviewed with the QA subcommittee weekly for 1 month and monthly for 2 months. 5) Date of correction: 4/22/15 Verification of Plan of Removal: Observation of resident #1 on 4/23/15 at 7:40 a.m. revealed she was lying in bed with head of bed elevated. Resident #1 had her eyes closed and appeared to be comfortable. Interview on 4/23/15 at 2:50 p.m. with LVN D revealed that he had received an in-service on pain management and the documentation of pain both physical and non-verbal. Interview on 4/23/15 at 3:05 p.m. with LVN E revealed that she had received an in-service on pain management and the documentation of pain both physical and non-verbal. Interview on 4/23/15 at 3:15 p.m. with LVN F revealed that he had received an in-service on pain management and the documentation of pain both physical and non-verbal. On 4/23/15 at 2:40 p.m. the Administrator was informed the IJ was removed. However the facility remained out of compliance at a severity level of actual harm with a scope of pattern. 2. Review of resident #2's face sheet, dated 4/20/15, revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of catheter care on 4/23/15 at 3:07 p.m. for resident #2 with CNA AA revealed the CNA pulled the penis back towards the abdomen, which resulted in the catheter tubing to become taut and was stretched. Interview with CNA AA on 4/23/15 at 3:16 p.m. revealed she had not had much experience providing catheter care to residents. The CNA confirmed the catheter tubing was pulled during the catheter care to resident #2. Interview with resident #2 on 4/24/15 at 8:06 a.m. revealed he did not have any pain during catheter care on 4/23/15 with CNA AA. Resident #2 stated "it's always kind of sensitive down there in that area". 3. Review of resident #3's face sheet dated 4/9/15 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #3's medical record revealed a hospital discharge progress note dated 4/9/15 that indicated the resident was being discharged from the hospital to the facility with a urinary catheter due to [MEDICAL CONDITION]. A Physician Telephone Order in resident #3's medical record, dated 4/10/15, revealed an order to make an appoinment with a Urologist for [MEDICAL CONDITION] Bladder. Additionally, a care plan, dated 4/9/15, located in the record revealed resident #3 was non-compliant with anchoring his catheter on his wheel chair above the level of the bladder, placing him at risk for Urinary Tract Infections. Observation on 4/21/15 at 7:51 a.m., during initial rounds with ADON N on 400 Hall, revealed resident #3 was near the nurses station on the Rosewood side (300 and 400 Hall) in an electric motorized wheel chair. Closer observation of the resident revealed he had a urinary catheter bag attached to the arm rest on his wheel chair, causing the catheter bag to be raised above the level of the bladder, as well as not having a privacy bag. ADON N, who also observed the catheter bag attached to the wheel chair arm rest and without a privacy bag, asked LVN P to escort resident #3 to his room and assist him with attaching a privacy bag on his wheel chair for his catheter. Observation on 4/21/15 at 7:58 a.m. revealed resident #3 leaving his room in his electric wheel chair, and LVN P following behind him. Closer observation of the wheel chair revealed the resident's catheter had been placed in a privacy bag, however, the privacy bag was attached to the arm rest of the resident's wheel chair, causing the catheter to be above the level of the bladder. Interview on 4/21/15 at 8:12 a.m. with ADON N revealed she had not seen the catheter bag attached to the arm rest as resident #3 and LVN P left his room. The ADON went on to say he had probably gone outside to smoke a cigarette, but she would check it when he returned. Observation on 4/21/15 at 9:15 a.m., after finishing initial rounds with ADON N on 400 Hall, revealed resident #3 had returned from outside and he was heading toward his room in his electric wheel chair. Observation of his powered chair revealed the catheter bag was attached to the chair's arm rest, which caused the catheter to be above the level of the bladder. ADON N confirmed LVN P should have lowered the catheter bag when she attached it to his wheel chair. Review of the facility policy and procedure titled Lippincott Procedures-Indwelling catheter care and management, revised 10/3/2014, revealed: "When cleaning the periurethral area, clean the area carefully to prevent catheter movement and urethral traction, which increase the risk of CAUTI (Catheter Acquired Urinary Tract Infection)"; "Provide enough slack before securing the catheter to prevent tension on the tubing, which could injure the urethral lumen and bladder wall."; and "...keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder, which increases the risk of CAUTI". Review of CMS-672 Resident Census and Condition of Residents, completed by the facility on 4/21/15, revealed 41 residents (out of 81 census) were on a pain management program and 8 residents had indwelling or external catheters.