Every finding on record at Deer Creek Nursing and Rehabilitation

Based on observation, interview, and record review, the facility failed to establish 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 4 residents (Resident #7, Resident # 32, Resident # 24 and Resident # 35) observed for infection control issues in that: The facility failed to ensure that RN P performed hand hygiene while providing Resident # 24 with a cup of ice on 08/18/2026.The facility failed to ensure CNA H followed infection control protocol while providing incontinence care with Foley catheter for Resident #35 on 08/18/2026.The facility failed to ensure that CNA G performed hand hygiene prior to providing dining assistance to Resident #32 on 08/18/2026 at 01:29 p.m.The facility failed to ensure RN P performed hand hygiene while providing 2 residents lunch trays in the dining room on 08/18/2026 at 01:24 p.m.The facility failed to ensure CNA F performed hand hygiene before entering Resident # 7's room to serve a lunch tray on 08/18/2026 at 1:49 p.m., These failures could place residents at risk of the spread of communicable diseases and infections and a diminished quality of life.Record review of Resident # 35's undated face sheet reflected [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included unspecified fracture of sacrum, subsequent encounter for fracture with routine healing (a tailbone or sacral break that is currently in the normal recovery and healing phase after initial active medical care), urinary tract infection, site not specified (a urinary tract infection, but the exact anatomical location such as the bladder or urethra), neuromuscular dysfunction of the bladder, unspecified (neurogenic bladder dysfunction when the specific type of neuromuscular or nerve-related impairment has not been detailed), need for assistance with personal care (help with everyday activities like bathing, dressing, and eating). Record review of Resident #35's MDS assessment dated [DATE], reflected a BIMS score of 10, which indicated moderate cognitive impairment. Resident's MDS assessment reflected that he had indwelling catheter (flexible tube placed into the bladder to drain urine continuously). Resident #35's MDS also reflected that he needed help with toileting hygiene and shower/bathe self: Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Record review of Resident #35's Order Summary Report reflected:Enhanced Barrier Precautions r/t indwelling medical device: Foley Catheter every shift. Start date: 06/19/2026Foley catheter 16 Fr, 10cc, DX: Urinary retention. Clean with soap and water, record OP every shift everyshift for Urinary Retention. Start date: 06/19/2026Wound Care for MASD to buttock and redness to right testicle: clean with hygiene wipes and apply triadevery shift for healing and infection prevention. Start date: 08/19/2026 Record review of Resident # 35's undated care plan reflected a Focus which included:Potential for complications r/t History of recurrent UTI (Urinary tract infection). Date Initiated: 07/13/2026This focus area included the following Interventions/Tasks: Administer physician prescribed antibiotics as ordered to treat the underlying bacterial infection.Date Initiated: 07/13/2026 During observation on 08/18/2026 at 10:53 a.m., revealed RN P went to residents' room [ROOM NUMBER] without sanitizing her hands, she did not sanitize her hands after she exited the room, [SP49.1]pulled out controlled medication book from the nurses' cart and started writing something in the book. Further observation revealed that approximately at 11: 08 a.m. Resident #24 was trying to open the door at the nurses' station 100 Hall. Resident #24 stated that he wanted to get some ice in this room when RN P offered resident her help. RN P locked the nurses' cart, took an empty cup from Resident #24's hand and brought a cup of ice for Resident #24 from the room.RN P did not sanitize her hands before taking the cup from resident's hand and after giving the cup with ice back to resident. RN P went back to the nurses' cart and continued writing in the controlled medication book. Observation on 08/18/2026 at 11:23 a.m. of the room at the nurses' station 100 Hall where ice was stored inside of a large ice chest revealed that the room had no faucet with running water, hand sanitizer or gloves were available in the room.During observation of incontinent care with Foley catheter on 08/18/2026 around 2:37 p.m., revealed the Resident #35's room had an EBP sign on his door; PPEs were available at the entrance of Resident #35's room. CNA H knocked on the resident's door and introduced himself to Resident #35. Resident #35 was lying in supine position (on his back) in his bed. CNA H explained his intention to perform incontinent care; Resident #35 verbalized a response. CNA H exited the resident's room and put on gown and entered the resident's room carrying a box of gloves. CNA H entered Resident #35's room without sanitizing his hands. CNA opened Resident #35's door on the resident's drop front chest creating a field to place a box of gloves, resident's briefs and a package with wipes. CNA H provided privacy to Resident #35 by closing his window's curtain and the privacy curtain in resident's room. CNA H put gloves on and removed Resident # 35's briefs. Observation of Resident #35's Foley catheter revealed the catheter near the insertion site was covered with a brown substance. CNA started cleaning resident's left side of the groin fold; CNA H made 2 strokes by folding the same wipe and then he throwed it into a trashcan. CNA H pulled out a fresh wipe and cleaned resident's penis by going in circular motions from the tip of penis down using the same wipe to make 2 circular motions down the penis shaft. CNA H started cleaning the resident's Foley catheter by holding resident's penis by his two fingers in the middle of the resident's penis and using his left hand to clean the Foley catheter; CNA H used one wipe for multiple strokes going from the tip of the resident's penis and down the catheter. CNA H pulled out a clean wipe and made 2 strokes using the same wipe, going from the tip of the resident's penis and down the catheter. CNA H started cleaning Resident #35's right side of the groin fold. Observation of the left side of the resident's groin fold revealed resident had a red irritated skin area approximately 7 centimeters wide and 12 centimeters long. Resident stated that he had no pain or itchy feeling in this area. ADON B and RN O came into Resident #35's room to assess the new skin problem. ADON B and CNA H put on gowns, washed their hands and put on gloves. ADON B and CNA H assessed the resident's groin fold area and then removed their gowns and gloves, washed their hands before leaving the room. ADON B and CNA H brought basin, washcloths, cleansing soap and a tube with Triad paste (a sterile, zinc oxide-based topical ointment) for skin irritation. ADON B put on gown, washed her hands, and put on gloves. She removed the Foley catheter's holding lock from resident's left thigh area and cleaned Resident #35's genital area following the incontinent care protocols. ADON B secured resident's Foley catheter by applying a new holding lock. ADON B applied the triad paste on the left side of the Resident #35's groin fold area. She removed and disposed of her dirty gloves and put on new gloves after finishing cleaning the resident's genital area. ADON B did not sanitize her hands after removing dirty gloves. CNA H removed his dirty gloves and without sanitizing his hands put on clean gloves. CNA H assisted Resident # 35 to his right side where the resident's buttocks were now exposed. CNA H pulled out one wipe and made 2 strokes on both sides of resident's buttocks area from front to back by folding the wipe with each stroke. CNA H pulled out a clean wipe to clean resident's anal area going from front to back and by folding the wipe with each stroke. CNA H removed his gloves and put on clean gloves without sanitizing his hands. ADON B and CNA H applied a clean brief on Resident #35. CNA H removed his gloves and put on clean gloves and then placed the bag with wipes inside of the resident's drop front chest top shelf and closed the chest's door. ADON B and CNA H gathered cleaning supplies and trash. They removed their gowns and gloves, went to the resident's bathroom and washed their hands. 35's During an interview on 08/20/2026 at 10:51 a.m. with RN O, she stated that she had been working in the facility for 2 years. She stated that she did not have any infection control and hands-on incontinence care checkoffs in the facility. She stated that she had her online RELIAS (a software and online learning company that provides training, compliance, and workforce solutions for the healthcare industry) training which also covered incontinence care. RN O stated that staff were expected to wash their hands before and after providing incontinence care and sanitize hands every time gloves were removed. Also, staff were expected to sanitize their hands before going in and out of the residents' rooms. RN stated that CNAs were expected to use one wipe for one stroke. She stated that CNAs were to report any skin issues to a nurse. She stated that she was aware of Resident #35's skin issues until 8/19/26. CNAs must hold the catheter at the insertion site to clean the Foley catheter. She stated that holding resident's penis while cleaning the Foley catheter could pull the catheter or cause the resident pain. RN O stated that not following hand hygiene and incontinence care protocols could cause residents developing infections and UTIs. During an interview on 08/20/2026 at 11:18 a.m. with CNA M she stated that she had been working in the facility for 5 months. She stated that she did not have infection control and incontinence care training in this facility, but she had these trainings provided while she was working in other nursing homes. She stated that her on boarding to this job in the facility was one hour. CNA M stated that staff must sanitize their hands before and after going into residents' rooms and hands must be sanitized every time after removing gloves. She stated that CNAs must use one wipe for one swipe going from clean to dirty area. She stated that CNAs were to hold the Foley catheter at the insertion site while cleaning the catheter. She stated that holding resident's penis in the middle of the penis shaft while cleaning the Foley catheter could potentially cause resident pain. During a phone interview on 08/20/2026 at 3:13 p.m. CNA H stated that he had his incontinent care training in June of 2026. He stated that he was confused about when to sanitize or wash hands when providing incontinent care for the residents in EBP rooms. He stated that he has to go now since the ER doctor was ready to see him. The phone call interview ended by CNA H. During an interview on 08/20/2026 at 3:19 p.m. with the ADON, she stated that she had been working in the facility since May of this year. She stated that she did not have any infection control, hand hygiene and incontinent care training in this facility. She stated that her last training in infection control was when she completed her IPTC online a month ago. She stated that staff were expected to wash hands before start providing incontinent care and after the incontinent care was complete. Staff were to sanitize hands every time the gloves were removed and before putting on clean gloves to prevent spread of infection. Staff were expected to thoroughly clean resident's genital and perineal areas going from dirty to clean and going from front to back using one wipe for one swipe to prevent infections and skin issues. She stated that she was not aware of the Resident#35's skin problem. She stated CNAs were to report any residents' skin issues to charge nurse. She stated staff were to hold residents' penis while cleaning the Foley catheter. During an interview on 08/20/2026 at 3:56 p.m. with the DON, she stated that she had been working in the facility since October of 2025. She stated that her last infection control training was when she completed her IPTC online on 10/06/2025. She stated that the course covered microbial things, prevention of infection, and hand hygiene. The DON stated that staff were expected to wash hands before and after providing incontinent care. Staff were expected to sanitize their hands before and after going to the residents' rooms and every time after removing gloves to prevent cross contamination.She stated that CNAs had incontinence care competency checkoff training on 6/11/2026. She stated that CNAs were expected to use one wipe for one swipe going from front to back. She stated that not following the proper incontinence care protocols while providing care for residents could possibly cause residents developing skin issues and UTIs. CNAs were expected to report any skin issues to nurses She stated that CNAs had incontinence care competency checkoff training on 6/11/2026. She stated that CNAs were expected to use one wipe for one swipe going from front to back. She stated that not following the proper incontinence care protocols while providing care for residents could possibly cause residents developing skin issues and UTIs. CNAs were expected to report any skin issues to nurses. Record review of Resident # 32's face sheet dated 08/18/2026 at 8:40 p.m., reflected the [AGE] year-old female resident was admitted on [DATE] and she was diagnosed with Alzheimer's Disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia.), Anxiety,(feeling of uneasiness or worry) and Gasto-Esophageal Reflux Disease(stomach acid flows back up into the esophagus and causes heartburn). Record review of Resident # 32's MDS assessment dated [DATE] revealed she had a BIMS score of 03 indicating she had a severe problem with thinking and memory. Resident # 32 required setup or clean-up assistance for ADLs of eating and oral hygiene. Resident # 32 was dependent on ADLs of toileting hygiene, Showers/ bathing, upper and lower body dressing. Record review of Resident # 32's Comprehensive care plan dated 04/06/2026 and updated 04/07/2026 revealed resident required tray set up with supervision by staff to eat. Record review of Resident # 7's face sheet dated 08/18/2026 at 8:37 p.m., reflected a 71-year -old female resident was admitted to the facility on [DATE] and she was readmitted [DATE]. She was diagnosed with Chronic Obstructive Pulmonary Disease, (Is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough.) Urinary Tract infection, ( an infection in any part of the urinary system). and hypertension (high blood pressure). Record review of Resident # 7's MDS assessment date 07/01/2026 revealed she had a BIMS score of 13 indicating she had normal thinking and memory (no or very little impairment). Resident # 7 required assistance with set up or clean-up for eating, oral hygiene, lower and upper body dressing. Record review of Resident # 7's Comprehensive care plan dated 08/19/2025 and updated 03/22/2026 revealed staff were to encourage small frequent meals of high calories and high protein foods. During an observation on 08/18/2026 at 01:24 p.m., revealed, CNA G failed to use hand sanitizer prior to delivering 2 lunch trays to residents in the dining room. Observation and interview on 08/18/2026 at 01:29 p.m., revealed CNA G failed to use hand sanitizer prior to assisting Resident # 32 with eating her lunch meal. CNA G stated, she did not remember if she used hand sanitizer prior to delivering trays to residents and prior to assisting Resident # 32 with eating her lunch meal. During an observation and interview on 08/18/2026 1:15 p.m., revealed RN P failed to use hand sanitizer prior to delivering 2 lunch trays to residents in the dining room. RN P stated she was trained in hand sanitation, and she said CNAs were expected to utilize hand sanitizer between tray passes. RN P stated she was not aware that she had not used hand sanitizer prior to serving meals to residents. She said that the purpose of hand hygiene was to prevent spread of infection. During an observation on 08/18/2026 at 1:49 p.m., revealed CNA F failed to use hand sanitizer prior picking up a lunch tray from the hall cart and before entering room # 102 to deliver the tray to Resident # 7. An interview on 08/20/2026 at 12:19 p.m., reflected CNA F had been employed at this facility since 2002 and she stated she had been trained in infection control and proper hand sanitization. CNA F stated that she knows that this as a sanitation process regarding dining. She stated, we are to sanitize hands before we pick up a tray and give it to a resident and again before we pick up another tray to deliver to another resident. CNA F stated a resident could get sick if we don't' use hand sanitizer before serving a resident a meal. Record review of the facility Catheter Care, Urinary Policy dated: 2021, reflected: Steps in the ProcedureRoutine Perineal Hygiene2. Wash and dry your hands thoroughly.5. Put on gloves.10. Remove catheter from securement device.14. For a male resident:a. Use a washcloth with warm water and soap (or clean bathing wipe) to cleanse around the meatus.b. Cleanse the glans using circular strokes from the meatus outward.c. Change the position of the washcloth (or wipe) with each cleansing stroke.d. With a clean washcloth (or wipe), rinse using the above technique.e. Return foreskin to normal position.15. Use a clean washcloth with warm water and soap (or bathing wipe) to cleanse and rinse the catheterfrom insertion site to approximately four inches outward.16. Secure catheter with catheter securement device. Handwashing/ Hand Hygiene Policy Statement: Record review of the facility's policy titled, Handwashing/ Hand Hygiene dated 2001 and revised on 08/2013, reflected: Hand hygiene is the primary means for preventing healthcare-associated infections and the transmission of multidrug-resistant organisms. This facility requires strict adherence to evidence-based hand hygiene practices (as described in this policy) for all personnel, including licensed, unlicensed, contracted, therapy, dining, housekeeping, volunteers, and students. Policy Interpretation and Implementation. Administrative Practices to Promote Hand Hygiene. Washing Hands1.Wet hands first with warm (not hot) water.2. Rub hands together vigorously.3. Rinse hands with water. 4. Use towel to turn off the faucet. Applying Alcohol- Based Hand Rubs.Apply generous amount of product to palm of hands .2. Rub hands together for at least 20 seconds. Infection Prevention and Control

Based on observations, interviews, and record reviews, the facility failed to ensure the residents received services with reasonable accommodation of residents' needs and preferences, except when to do so would endanger the health and safety of 3 of 15 residents (Resident #39, Resident #14, and Resident #47) on the 100 halls, who did not have the call light within reach. The facility failed to ensure the call light system was accessible to Residents #39, #14, and #47 on 8-18-2026.This failure could place residents at risk of falling if they cannot call for staff assistance to meet their care needs. A record review of Resident #39's admission records dated 8/20/2026 revealed she was admitted to the facility on [DATE]. She was diagnosed with Alzheimer's disease (A progressive brain disorder that causes memory loss and cognitive decline), Osteoarthritis (A degenerative joint disease that causes pain, swelling, and stiffness), Needing assistance with personal care (Requiring help with daily living activities like bathing, dressing, or eating), Hypertension (A chronic medical condition where the blood pressure in the arteries is persistently elevated).A record review of Resident #39's MDS dated [DATE] revealed her BIMS score was 00, which indicated that the Resident was unable to complete the interview.A record review of Resident #39's Care plan dated 5/8/2019 revealed that the Resident should have the call light within easy reach. A record review of Resident #14's admission records dated 8/20/2026 revealed he was admitted to the facility on [DATE]. He was diagnosed with Alzheimer's disease (a progressive brain disorder that slowly destroys memory and thinking skills), dementia (a general term for a decline in mental ability severe enough to interfere with daily life), and the need for assistance with personal care (requiring help with everyday tasks like bathing, dressing, and eating)A record review of Resident #14's MDS dated [DATE] revealed he had a BIMS score of 9, which indicates moderate cognitive impairment. He had upper and lower extremity limitations and range of motion which require the use of a cane or crutch.A record review of Resident #14's Care Plan dated 4/11/2017 revealed the Resident's bed was to be positioned for easy access to the restroom, and the floor was to be kept free of clutter. The call light and cane should be easy to reach.A record review of Resident #46's admission records dated 8/20/2026 revealed that he was admitted to the facility on [DATE]. He was diagnosed with Type 2 diabetes (A chronic condition that affects how the body processes blood sugar), Irritable bowel syndrome (A common disorder affecting the large intestine, causing cramping, abdominal pain, bloating, gas, diarrhea, or constipation), Major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Heart disease (A catch-all term for a variety of conditions that affect the heart's structure and function, such as coronary artery disease)Unsteadiness on feet (A sensation of instability, dizziness, or lack of balance while standing or walking).A record review of Resident #46's dated 6/09/2026 revealed he had a BIMS score of 14, which indicated his memory skills are considered cognitively intact with no or very little impairment. He needs assistance with his ADLs and uses a wheelchair.A record review of Resident #46's Care plan dated 4/06/2026 revealed a call bell placed in the room at all times, within reach and not malfunctioning. On 8/18/2026 at 10:32 AM, interview/observation with Resident #46 in the room. His call light was hanging off the side of the bed between the bed and the nightstand. He stated that he was unable to reach the call light and asked where it was. He stated that he does not really use the call light that much, but if he did, he was not able to reach it. On 8/18/2026 at 10:36 AM, interview/observation of Resident #39 revealed the Resident was in her wheelchair, close to the window. She was unresponsive to questions at the time. She was unable to maneuver her wheelchair; her call light was on the bed and not close to her wheelchair.On 8/18/2026 at 10:54 AM, interview/observation. Resident #14 was in bed at the time with his cane next to him. He stated that he does not use the call light very often. His call light was on the bedside table next to the empty bed in the room, which was not close to the Resident. He stated that he has not had any falls.An interview on 8/20/2026 at 1:36 PM, CNA G stated that call lights should always be reachable for the residents when they're in the room. She stated that staff make frequent rounds to residents to ensure their call lights were in place and reachable. She stated that the call light has a clip so staff can attach it to the sheets or pillow, keeping it close. She stated that the call light should not be dangling off the side of the bed, or if a resident was in a wheelchair, the call light should be close to them and not on the bed. She stated that if the call light was not close to the residents, they could try to get up and do something on their own and fall and get hurt. She stated that she has had in-service training on calls, and the last time was seven months ago. She stated that they discuss call light placement daily in their daily meeting.An interview on 8/20/2026 at 2:43 PM with CNA H, she stated that a resident's call light should be within reach when they were in the room. She stated that the call light has a clip, so it stays within reach. She stated that they do rounds every two hours to make sure all lights were in place. She stated that the call light should not hang off the side of the bed close to the floor or be on the bed when the resident was in their wheelchair and should not be close to the call light. She stated that if residents' call lights were not close to them, they could fall trying to do something on their own. She stated that she had in-service training a month ago for call lights. She stated that they talk about call lights regularly.An interview on 8/24/2026 at 3:50 PM with ADON B, she stated that the facility's call placement policy requires the call light to be within reach when the resident was in their room. She stated that they remind residents to use the call light. She stated that they use the clip on the call light to attach it to the side of the bed or the pillow so the resident can reach it. She stated that call lights should not hang off the side of the bed near the floor or be placed on the bed when the resident was in their wheelchair, not close to the bed. She stated that she has not had an in-service on call lights because she has not been there very long, but they talk about call lights daily. She stated that if a call light was not within reach, a resident could try to do something on their own, fall, and get hurt. An interview on 8/24/2026 at 4:04 PM with the DON, she stated that if the resident was in bed, the call should be close to them. She stated that if the resident was in their wheelchair and could not move it, the call light should be close to them and not on the bed. She stated that staff were expected to do frequent rounds with residents to make sure the call lights were reachable. She stated that if a resident cannot reach the call light, they could have a medical emergency, and someone would not be able to get to them. She stated that she has had in-service on call, and the last time was a few months ago. She stated that they talk about call light placement regularly. She stated that she has not talked to the staff about the call lights not being close bit was going to have an in-service training on call light placement. Record review of facility policy titled Answering the Call Light that was not dated read: 5.Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor.

Based on observation, record review, and interviews, the facility failed to ensure each resident was treated with respect and dignity, and failed to maintain a dining environment that enhanced the residents' quality of life and individuality.On 8/18/2026 the facility failed to promote and protect the dignity of residents requiring eating assistance by allowing staff to refer to them as feeders and by not providing food to residents while they watched others finish theirs. This failure could place residents at risk of feeling left out and experiencing shame. Findings include Observation on 8/18/2026 at 1:35 PM in the dining room revealed the following: There were several residents that came to the dining room around 12:20 PM for lunch. Lunch was served around 12:45 PM. Several residents sitting at different tables waited until 1:35 PM to receive their food. Those residents did not get their food until other residents had finished eating their lunch.An interview on 8/20/2026 at 1:36 PM with CNA G, she stated that Residents sitting at the same table should be fed approximately at the same time. She stated that residents sometimes decide not to eat in their rooms and come to the dining room. She stated that staff and the kitchen do not communicate when a resident was brought from their room to the dining room. She stated that residents could be left out and hungry because their food tray was being passed out on the floor and not brought to the dining room.An interview on 8/24/2026 at 2:23 PM with the DA, he stated that residents should be eating at approximately the same time. He stated that sometimes floor staff do not communicate with the kitchen to let them know the resident was eating in the dining room. He stated, it also depends on the residents because they were feeders and they have to wait for someone to help them eat. He stated that many staff call residents who need assistance eating feeders. He stated that he did not know residents could not be called feeders. He stated that if residents are not fed at approximately the same time, they could be hungry and watch other residents need assistance. An interview on 8/24/2026 at 2:32 PM with CK C, she stated that residents sitting at the same table in the dining room should be fed at approximately the same time. She stated that when a resident comes from the room to eat on the dining room floor, staff do not tell them residents are coming, so they won't have their tray ready. She stated that this was a dignity issue if a resident has to watch other residents eat their food while they don't have any. She stated that she has heard nurses and CNAs call residents feeders. She stated that this could cause the resident to have distress.An interview on 8/20/2026 at 2:43 PM with CNA H, she stated that residents in the dining room should be getting fed at the same table at approximately the same time. She stated that floor staff should communicate with the kitchen if a resident was not going to eat in their room, so the kitchen can send the tray to the dining room and staff were not watching other residents eat. She stated that she does not call residents feeders, but she has heard other staff call residents who need assistance eating feeders. She stated that if residents watch other residents eat, they could feel left out. She stated that calling residents feeders was a dignity issue and should not happen.An interview on 8/24/2026 at 3:50 PM with ADON B, she stated that if residents were sitting at the table in the dining room, they should all be fed at approximately the same time. She stated that there was a communication issue with staff not telling the kitchen when a resident was coming to the dining room to eat. She stated that this miscommunication between staff and the kitchen could make the resident mad that they have to wait for their food. She stated that residents should not be called feeders. She stated that she has heard other staff call residents feeders. She stated that if she hears a staff member call a resident a feeder, she will let them know that they can't do that. She stated that this was a dignity issue for the residents.An interview on 8/24/2026 at 4:04 PM with the DON, she stated that if a resident changes their mind and decides to eat in the kitchen, then staff should let the kitchen know so they can bring their food to the dining room. She stated that if this was not done, the resident could miss their food tray or the meal could be delayed. She stated that a resident needing assistance to eat should not be called a feeder. She stated that not being fed on time and being called a feeder was a dignity issue for the residents. She stated that she did not know residents were being called feeders.A record review of the resident rights policy they completed in February 2021 revealed the following.1. Residents are treated with dignity and respect at all times.2. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. This begins with the initial admission and continues throughout the resident's facility stay.e. Provided with a dignified dining experience.8. Staff speak respectfully to residents at all times, including addressing the resident by their name of choice and not labeling or referring to the resident by their room number, diagnosis, or care needs.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received food that was prepared and served in a manner that was palatable and appealing.On 8/20/2026, at 1:25 PM, Resident #55 personally delivered their food tray to the conference room to prove to state surveyors that her lunch tray was not palatable and did not contain the same portion that other residents in the facility received on 8/20/2026, at 1:25 PM.This failure could place residents at risk for poor nutrition, hydration and reduced quality of life.A record review of resident #55's admission records dated 8/20/2026, revealed she was diagnosed with cerebral infarction, anxiety disorder, overactive bladder, hyperlipidemia, major depressive disorder, glaucoma, hypertension, and pain in the left knee.An observation on 08/20/2026 at 8:22 AM, revealed Resident #55's lunch tray contained meat that could not be identified, along with corn and cauliflower. According to the Residents meal tickets provided by the facility the residents were served Garlic Pepper pork chops (3 oz) , Butter Corn (1/2 cup), Cauliflower w/ Red Peppers (1/2 cup) , Margine (1 each), Wheat Bread (1 Slice), Sugar (1 each), Pepper(1 each), Non Dairy Creamer(1 each), Baked Apples(1/2 cup), Coffee or Tea (1 cup), Milk (1/2 cup), Garnish Parsley Sprig(1 each), Fruit punch In an interview on 8/20/2026 at 01:25 PM, Resident #55 stated the facility has been without a cook for several months. She stated she has made several grievances regarding these issues, however the issue never got better. In an interview on 8/20/2026 at 01:35 PM, CNA G said she would not eat what was in Resident #55's tray. She stated the food does not look palatable and the portion was very small. In an interview on 8/20/2026 at 02:30 PM, CK C stated that when residents were dissatisfied with the food they would knock on the kitchen door, and they will tell her face to face. She stated currently in the kitchen they do not have a process in place to ensure meals were served correctly because no manager has been in place in the kitchen.In an interview on 8/20/2026 at 03:57 PM, the DON stated she only knows residents were dissatisfied with their food when they are vocal then she will pass the information on to the dietitian. She stated currently at the facility they have weekly meetings to ensure meals match the diet for the residents. She stated if the facility was unable to serve a menu item not listed, they would make a substitution, and this should be logged in the kitchen, and all substitution should be approved by the dietitian.Record review of the facility's Food and Nutrition Services Policy dated 2001 revealed the following. 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.7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided for each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature.a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the food service manager so that a new food tray can be issued.b. Foods that are left without a source of heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded.

Based on observation, interviews and record reviews the facility failed to properly label and store all drugs and biological in accordance with currently accepted professional principles. 1.The facility failed to ensure MA L did not leave Resident #70's scheduled medications in the dining room during lunch on 08/19/2026.2.The facility failed to ensure 2 of 2 medication carts (Cart Hall 100 and Cart Hall 200) were properly labeled observed for medication storage and labeling on 08/18/2026. These failures could place residents at risk for infection, hospitalization, and decreased quality of life. Findings included:1.Record review of Resident #70's undated face sheet reflected [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included sepsis, unspecified organism (a life-threatening body reaction to an infection, but the specific germ such as a certain bacterium or fungus has not yet been identified or named), unspecified atrial fibrillation (irregular, chaotic heart rhythm in the upper chambers of the heart, but the medical record does not state whether it is paroxysmal, persistent, or permanent), type 2 diabetes mellitus without complications ( high blood sugar from insulin resistance, but the condition has not yet caused damage to the organs, eyes, nerves, or blood vessels).Record review of Resident #70's comprehensive MDS assessment dated [DATE], reflected a BIMS score of 15, which indicated cognition is intact. Residents MDS assessment reflected that he has Diabetes Mellitus (DM)Record review of Resident #70's Order Summary Report reflected:- Atorvastatin Calcium Oral Tablet 10 MG (Atorvastatin Calcium) Give 1 tablet by mouth one time a day forHLD (Hyperlipidemia). Start date: 08/13/2026- Eliquis Oral Tablet 2.5 MG (Apixaban). Give 1 tablet by mouth two times a day for A_Fib (Atrial fibrillation is a common heart rhythm disorder where the upper chambers of the heartbeat chaotically and out of sync with the lower chambers). Start date: 08/13/2026- Folic Acid Oral Tablet 1 MG (Folic Acid). Give 1 tablet by mouth in the morning for supplement. Januvia Oral Tablet 50 MG (Sitagliptin Phosphate). Give 1 tablet by mouth in the morning for Diabetes. Start date: 08/13/2026- Januvia Oral Tablet 50 MG (Sitagliptin Phosphate). Give 1 tablet by mouth in the morning for Diabetes. Start date: 08/18/2026- Metoprolol Tartrate Oral Tablet (Metoprolol Tartrate). Give 12.5 mg by mouth one time a day for HTN HoldSBP< 116 or pulse < 60. Start date: 08/19/2026- Ocuvite Adult 50+ Oral Capsule (Multiple Vitamins with Minerals). Give 1 tablet by mouth one time a day forSupplement. Start date: 08/13/2026Record review of Resident #70's MAR dated 08/19/2026 MAR [SP22.1]reflected that resident refused the following morning medications:-Atorvastatin Calcium Oral Tablet10 MG for hyperlipidemia. - Folic Acid Oral Tablet 1 MG for supplement- Januvia Oral Tablet 50 MG for Diabetes- Metoprolol Tartrate Oral Tablet 12.5 mg by mouth one time a day for Hypertension. - Ocuvite Adult 50+ Oral Capsule (Multiple Vitamins w/ Minerals) for supplement- Eliquis Oral Tablet 2.5 MG for A_FibRecord review on 08/20/2026 of Resident # 70's medication administration audit report for 08/19/2026 reflected: -Atorvastatin Calcium Oral Tablet10 MG for hyperlipidemia -Administration time: 12:58 p.m. Documented by CMA L- Folic Acid Oral Tablet 1 MG for supplement-Administration time: 12:58 p.m. Documented by CMA L- Januvia Oral Tablet 50 MG for Diabetes -Administration time: 12:58 p.m. Documented by CMA L- Metoprolol Tartrate Oral Tablet 12.5 mg by mouth one time a day for Hypertension -Administration time: 12:58 p.m. Documented by CMA L- Ocuvite Adult 50+ Oral Capsule (Multiple Vitamins w/ Minerals) for supplement -Administration time: 12:58 p.m. Documented by CMA L- Eliquis Oral Tablet 2.5 MG for A_Fib -Administration time: 12:58 p.m. Documented by CMA LRecord review of Resident #70's progress notes revealed: Resident refusing to come out of the dining to have blood glucose taken. Finally, convinced patient to come out of the dining room. Blood glucose 430. Patient wheeled himself away from nurse. Called Dr., order to give Humalog 10 units SQ now. Patient refused insulin at this time, will attempt after lunch. Documented by RN O on 08/19/2026 at 11:55 a.m. Resident refused medications 3x, charge nurse notified Documented by CMA L on 08/19/2026 at 11:58 a.m. During observation on 08/19/2026 around 12:42 p.m., in the dining room revealed Resident #70 was seating at the dining table and no other residents were seating at the table with him and there were 28 residents in the dining room. Resident #70 had a medication cup with 6 medications on his tray. During an interview on 08/19/2026 around 12:45 p.m. Resident #70 stated that he did not know the reason for the medications being on his tray. Resident #70 did not want to talk. In an interview on 08/19/2026 at 6:20 pm with Resident #70, he stated that he did not take his medications that were left by CMA on his tray. He did not know what happened to these medications after he finished eating his lunch and left the dining room. 2.Observation and interview on 08/18/2026 around 2:04 p.m., during observation for medication storage and labeling of Hall 100 medication cart with CMA N revealed the top drawer of the medication cart with the residents' OTC medications had two loose white and orange color rounded pills lying next to the residents' OTC medication bottles. CMA N stated that it was the CMA's responsibility for keeping the medication cart free of loose pills. She stated that these medications should not be lying loose inside of the med cart drawer because the medication was contaminated and could have been administered to a resident by mistake. She stated that these medications should have been placed inside of the drug destroying solution container for destruction. Observation and interview on 08/18/2026 around 3:12 p.m. during observation for medication storage and labeling medication cart with CMA L revealed the top drawer of the nurses' cart with the residents' OTC medications had a one loose white rounded pill lying next to the residents' OTC medication bottles. CMA L stated that he did not know the reason for this pill lying loose in the drawer. CMA stated that it was the CMAs responsibility for keeping the medication cart free of loose pills. He stated that the medication could have been administered to a resident by mistake and could have caused a bad allergic reaction. During an interview on 08/20/2026 at 10:51 a.m. with RN O, she stated that loose medication pills should not be inside of nurses' or medications carts because it was not certain what pills they were, and these medications could be administered to the residents by mistake causing residents' potential allergic reaction. RN O stated that it was also infection control issue. She stated that nurses and med aides were responsible for keeping their carts clean and free of loose pills. During an interview on 08/19/2026 around 2:40 p.m. CMA L stated that Resident #70 refused his morning medications. He stated that he left Resident #70's medication on his tray. CMA L stated that he reported that Resident #70 refused his medications to charge nurse. During an interview on 08/19/2026 around 2:47 p.m. RN O stated that Resident #70 was refusing all his medications. She stated that she submitted SBAR report in progress notes. She stated that she notified Resident #70's PCP about medication refusal. RN O stated that she did not know the reason for leaving medications on Resident #70's tray in the dining room.During an interview on 08/20/2026 at 10:51 a.m. with RN O she stated that she documented that Resident #70 refused his morning medications on 08/19/2026 and she notified resident's daughter [SP23.1][AG23.2]and his PCP about refusal of the medications. She stated that nurses and CNAs were expected to observe when resident took medication and it was to be documented. She stated that it was dangerous to leave resident's medications on the table in the dining room because anyone could take the medications and this could potentially them allergic reactions, overdose or hospitalization. During an interview on 08/20/2026 at 11:30 a.m. with CMA M she stated that med aides were required to observe while residents were taking their medications. She stated that leaving residents' medications on the table of dining room was dangerous because any resident could take the medications and it could cause overdose or allergic reactions. CMA M stated that the med aides carts should be free medication pills laying loose inside of the med carts. She stated that it would be infection control problem and it could be administered to the residents by mistake which could cause very negative health issues for residents.During an interview on 08/20/2026 at 3:19 p.m. with ADON B stated that med aides and nurses were expected to watch residents while they were taking their medications. She stated that residents' medications were not to be left on the table of dining room because other residents could take these medications and it potentially could cause negative health issues. She stated that she was not aware of medications left on the table in the dining room. ADON B she stated that nurses and staff were expected to keep their carts clean and free of clutter and loose pills. She stated that nurses and CNAs were expected to remove loose medication pills and dispose of them properly. She stated that the DON was responsible for auditing the medication carts. ADON B stated that loose medications in carts were infection control issue and could affect residents in negative way. During an interview on 08/20/2026 at 3:56 p.m. with the DON, she stated that she was not aware that CNA left resident's medications in the dining room. She stated that other residents in the dining room could take these medications and it potentially could cause all kinds of health issues to the residents. The DON stated that loose medications should not be found lying in nurses' or med aide carts. She stated that it was infection control problem and these loose medications could have been mistakenly administered to residents causing them adverse reaction and harm. Record review of the document provided by the facility titled Medication Labeling and Storage and dated 2025 reflected: 1. Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers.2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.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.5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Based on observation, interview, and record review, the facility failed to implement a comprehensive, person-centered care plan that met the nutritional needs and consistent resident rights for 1 of 16 residents (Resident #52) reviewed. The facility failed to ensure that Resident #52 was provided with care-planned dietary interventions (yogurt at every meal), resulting in a high risk for protein or calorie malnutrition.The facility failed to provide Resident #52 with yogurt as identified in her care plan. This failure could result in residents not receiving necessary nutrition.Findings Included:A record review of Resident #52's admission records dated 8/20/2026 revealed she was diagnosed with Cervical radiculopathy (pinched nerve in the neck causing pain or numbness down the arm), Lower back pain (physical discomfort or ache in the lumbar region of the spine), Muscle weakness (decrease in the strength of one or more muscles), Major depressive disorder (persistent and severe feelings of sadness, emptiness, and loss of interest), Anxiety disorder (excessive, persistent worry and fear about everyday situations).A record review of Resident #52 MDS dated [DATE] revealed she had a BIMS score of 15, which indicates her thinking and memory are completely intact with no cognitive impairment. She was at risk of protein or calorie malnutrition.A record review of Resident #52's Care plan dated 6/16/2026 listed that she should receive yogurt with every meal.A record review of Resident #52's orders dated 6/16/2026 shows that she should be getting yogurt at every meal An observation and interview on 8/18/2026 at 1:15 PM in the dining room, Resident #52 stated that she was supposed to get yogurt with every meal. She stated that she does not get yogurt with every meal. She stated that her care plan includes yogurt with every meal. She did not have yogurt on her tray during the lunch service. Staff provided the Resident with yogurt after being notified.Observation/interview on 8/19/2026 at 12:40 PM revealed Resident #56 did not have her yogurt on her tray again. She stated that this was an ongoing issue with the kitchen. She said she gets frustrated when she has to keep reminding the kitchen to bring her yogurt. An interview with CNA G on 8/20/2026 at 1:36 PM, she stated that she does not really deal with the care plans. She stated that several residents have complained about not getting everything on their ticket. She stated that when a resident tells her an item was missing, she goes to the kitchen, and they usually get it for her. She stated that there were times that they do not have the item in the kitchen, so the residents do not get it. She stated that this could negatively affect the residents because they may be getting that item for nutritional services. An interview on 8/24/2026 at 2:23 PM with DA, he stated that sometimes the ticket does not show everything the resident was supposed to get. He stated that when a resident does not receive something, a staff member usually comes to the kitchen and gets that item. He stated that he does not usually deal with the tickets; he just reads them and puts what was supposed to be on the tray to give to the resident. He stated that if a resident does not get what they're supposed to get, they could be upset.An interview on 8/24/2026 at 2:32 PM with CK C, she stated that they currently do not have a dietary manager, and the tickets have not been updated. She stated that the last dietary manager just left, and they were not able to get into the system. She stated that if a resident does not get an item on their tray, staff have been coming to the kitchen to get that item. She stated that if a resident does not get the right item on their tray, it could affect her diet.An interview on 8/20/2026 at 2:43 PM with CNA H, she stated that if a resident was missing an item off their tray, they usually tell the staff, and the staff will go back to the kitchen and get that item. She stated that if a resident was unable to tell them what they're missing, then they would not be getting everything that they were supposed to get. She stated that this could be a nutrition issue if residents were not getting the food that was in the care plan. She stated that she does not really deal with the care plans and that the nurses would.An interview on 8/24/2026 at 3:50 PM with ADON B, she stated that if a resident has a care plan to get yogurt on their tray for every meal, then that should be happening. She stated that there has been a recent issue with tickets not being updated. She stated that if her resident was not getting the food item in her care plan, it could be an issue with the resident's nutrition.An interview on 8/24/2026 at 4:04 PM with the DON, she stated that if there was an order for the yogurt and it was on the resident's care plan, the resident should be getting that yogurt for every meal. She stated that there has been an issue with the tickets recently because of the previous dietary manager leaving. She stated that if a resident was not getting a food item on their tray, it could lead to weight loss or not getting calories. Record review of facility policy titled Care Plans, Comprehensive Person-Centered not dated read:7.The comprehensive, person-centered care plan:a.includes measurable objectives and timeframes;b.describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including:(1)services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;

Based on observation, interview and record review, the facility failed to ensure residents were free of any significant medication errors for 3 of 5 residents (Resident #13, Resident #23 and Resident #60) reviewed for medication errors.1.The facility failed to administer scheduled time-sensitive Anticonvulsant and Thyroid agent medications to Resident #13 on 08/19/26. 2.The facility failed to administer scheduled time-sensitive antibiotic medication to Resident #23 on 08/19/26.3.The facility failed to administer scheduled time-sensitive diabetic medications to Resident #60 on 08/19/26.These failures could place residents at risk for seizures, decrease quality of life and hospitalizations. Findings included:1.Record review of Resident #13's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included diffuse traumatic brain injury with loss of consciousness of unspecified duration, subsequent encounter (widespread damage to the brain's nerve where the exact length of time of the lost consciousness was not recorded), hypothyroidism, unspecified (body has a low thyroid hormone level, but the exact underlying cause is not yet identified or written down in the medical record), post-traumatic seizures (sudden bursts of abnormal electrical activity in the brain caused by a head injury). Record review of Resident #13's quarterly MDS assessment dated [DATE] reflected a BIMS score of 13, which indicated intact cognition. Resident #13's MDS assessment also reflected that she had Seizure Disorder or Epilepsy and Traumatic Brain Injury (TBI).Record review of Resident # 13's undated care plan reflected a Focus which included: Resident #13 has hypothyroidism, she is prescribed levothyroxine. Date Initiated: 04/06/2018This focus area included the following Interventions/Tasks: Give thyroid replacement therapy as ordered. Date Initiated: 04/06/2018Record review of Resident # 13's undated care plan also reflected a Focus which included: Resident # 13 has a seizure disorder r/t her diagnosis of TBI. Date Initiated: 03/22/2022This focus area included the following Interventions/Tasks: Ask resident/resident about presence/absence of aura prior to seizure.Give medications as ordered. Observe/document for effectiveness and side effects.Record review of Resident #13's Order Summary Report reflected:-Observe closely for significant side effects of Anticonvulsant medication including drowsiness, ataxia, nystagmus, dizziness, blurred vision, nausea, rash, gum enlargement, jaundice. Document: 'Yes' if monitored and none of the above observed. 'No' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progressnote findings. every shift. Start date: 05/23/2026- Depakote Tablet Delayed Release 500 MG (Divalproex Sodium) Give 2 tablet by mouth two timesa day related to POST TRAUMATIC SEIZURES. DO NOT CRUSH. Start date: 08/16/2026- Levo-T Oral Tablet 25 MCG (Levothyroxine Sodium). Give 1 tablet by mouth before meals for hypothyroidism related to HYPOTHYROIDISM. Start date: 06/19/2026. Record review of Resident # 13's order details reflected:Medication: Depakote Tablet Delayed Release 500 MG.Medication class: AnticonvulsantsDose of administrating quantity:2Frequency: Two times a day.Schedule type: Every day.Facility Time code: Twice a day 8 a.m., 4 p.m.Related diagnoses: Post traumatic seizures Record review of Resident # 13's order details reflected:Medication: Levo-T Oral Tablet 25 MCG.Medication class: Thyroid AgentsDose of administrating quantity:1Frequency: Before meals.Schedule type: Every day.Facility Time Code: 7 a.m. Related diagnoses: Hypothyroidism Record review of Resident # 13's medication administration audit report reflected Depakote Tablet Delayed Release 500 MG medication was administered on 08/19/2026 at 10:09 a.m. Record review of Resident # 13's medication administration audit report reflected Levo-T Oral Tablet 25 MCG medication was administered on 08/19/2026 at 10:09 a.m. Record review of Resident #13's progress notes reflected no entries on 08/19/2026 or 08/20/2026 concerning medication errors or issues.2.Record review of Resident #23's undated face sheet reflected [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included essential primary hypertension (high blood pressure), unspecified dementia, unspecified severity (a cognitive decline or memory loss characteristic of dementia, but the exact underlying cause and severity are not specified), need for assistance with personal care (personal care assistance includes help with daily self-care tasks like bathing, dressing, eating, and mobility). Record review of Resident #23's quarterly MDS assessment dated [DATE] reflected a BIMS score of 13, which indicated intact cognition. Resident #23's MDS assessment also reflected that she was frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding).Record review of Resident # 23's undated care plan reflected a Focus which included: Resident #23 admitted with bladder /bowel incontinence r/t Impaired Mobility, Physical limitations, pain, decline in mobility and transfer, 2/2 to multiple fractures from a recent fall. Date Initiated: 02/20/2026This focus area included the following Interventions/Tasks: Monitor and document intake and output as per facility policy.Monitor/document for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Date Initiated: 02/20/2026Record review of Resident #23's Order Summary Report reflected:-Cipro Oral Tablet 500 MG (Ciprofloxacin HCl) Give 1 tablet by mouth two times a day for UTI for 5 DaysRecord review of Resident # 23's order details reflected:Medication: Cipro Oral Tablet 500 MGMedication class: Fluoroquinolones Dose of administrating quantity:1 tabFrequency: Two times a day.Schedule type: Every day.Facility Time code: Twice a day 9 a.m., 8 p.m.For (Indications for use): UTIRecord review of Resident # 23's medication administration audit report reflected Cipro Oral Tablet 500 MG medication was administered on 08/19/2026 at 11:01 a.m. Record review of Resident #23's progress notes on 08/20/2026 reflected no entries on 08/19/2026 or 08/20/2026 concerning medication errors or issues.3.Record review of Resident #60's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included sepsis, unspecified organism (a life-threatening body reaction to an infection, but the specific germ such as a certain bacterium or fungus has not yet been identified or named in the current report), type 2 diabetes mellitus without complications (body has high blood sugar from insulin resistance, but it has not caused damage to eyes, kidneys, nerves, or heart).Record review of Resident #60's 5-day scheduled MDS assessment dated [DATE] reflected a BIMS score of 13, which indicated intact cognition. Resident #60's MDS assessment also reflected that he had High-Risk Drug Classes- Hypoglycemic (including insulin).Record review of Resident # 60's undated care plan reflected a Focus which included: has dx. of Diabetes Mellitus. Date Initiated: 08/18/2026This focus area included the following Interventions/Tasks: Check all of body for breaks in skin and treat promptly as ordered by doctor.Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness.Record review of Resident #13's Order Summary Report reflected:Metformin HCl Oral Tablet 1000 MG (Metformin HCl) Give 1 tablet by mouth two times a day for diabetes. Start date: 08/12/2026.Glipizide Oral Tablet 5 MG (Glipizide) Give 1 tablet by mouth one time a day for DM II. Start date: 08/17/2026.Record review of Resident # 60's order details reflected:Medication: Metformin HCl Oral Tablet 1000 MG (Metformin HCl)Medication class: Antidiabetics, ChemicalsDose of administrating quantity:1Frequency: Two times a day.Schedule type: Every day.Facility Time Code: Twice a day 8 a.m., 6 p.m.For (Indications for use): DiabetesRecord review of Resident # 60's order details reflected:Medication: Glipizide Oral Tablet 5 MGMedication class: AntidiabeticsDose of administrating quantity:1Frequency: One time a day.Schedule type: Every day.Facility Time Code: One time a day 8 a.m.For (Indications for use): DM IIRecord review of Resident # 60's medication administration audit report reflected Metformin HCl Oral Tablet 1000 MG medication was administered on 08/19/2026 at 10:05 a.m. Record review of Resident # 60's medication administration audit report reflected Glipizide Oral Tablet 5 MG medication was administered on 08/19/2026 at 10:05 a.m. Record review of Resident #60's progress notes on 08/20/2026 reflected no documentation on late administration of medication and notification of the resident's PCP on 08/19/2026 or 08/20/2026 concerning medication errors or issues. No notification In an interview on 08/19/2026 approximately at 8:27 a.m. with MA L he stated that he was late to report to work this morning due to the school buses.During an interview on 08/20/2026 at 10:51 a.m. with RN O she stated that MA L and MA N both were late to report at work today and it happened multiple times in the past. She stated that MAs were expected to start administering residents' medications at 7:00 a.m. because some residents must take their medications before meals and some medications must be taken with meals. She stated that administering some medications later than ordered potentially could cause health issues; for example, seizure medications since they were time critical meds. During an interview on 08/20/2026 at 11:30 a.m. with MA M she stated that she has been working in the facility for almost 5 years. MA M stated that there were 5 medication administration rights: Right patient, right dose, right resident, right time, right route and right documentation. She stated that late administration of resident's medications must be reported to a nurse and then the nurse was to notify resident's PCP and to obtain new orders. MA M stated that late administration of medications could be very dangerous for a resident's health and it depends on the medication. For example, not administering BP medication on time could potentially cause resident a stroke. During an interview on 08/20/2026 at 3:19 p.m. with ADON she stated that she had been working in the facility since May of this year. The ADON stated that she was aware of late medication administration yesterday (on 08/19/2026) because both med aides were late and she had to start administering residents' medication on 100 Hall until CMA N reported at work and took over. The ADON stated that late administration of medications could possibly cause residents discomfort, pain, worsening symptoms and potentially hospitalization. ADON stated that CMAs were expected to notify a charge nurse when medications have been given late. She stated that charge nurses, ADON and DON oversees that the residents' medications administered in timely manner. During an interview on 08/20/2026 at 6:12 p.m. with DON she stated that she was aware of late administration of residents' medications yesterday (on 08/19/2026). She stated that she must ask the med aides if there were any issues for giving residents' medications late. The DON stated that medication administration audit report was done randomly in the facility, she could not recall when it was done last time. The DON stated that most of the residents' medications had liberalized medication administration regimen which had long time frame for these medications to be administered, for example; if the order was to administer medication from 6:00 a.m. to 10.00 a.m. this medication was allowed to be administered anytime between this time frame and also one hour before 6:00 a.m. and one hour after 10:00 a.m. She stated that the liberalized medication administration order allowed residents to make choices. The DON stated she could not locate the liberalized medication administration policy. The DON stated that if the liberalized medication was given too close to each other it could potentially cause resident sedation, overmedication. Record review of the Medication Aide Skills Performance Evaluation reflected CMA L successfully completed this training on 05/25/2026: Prior to Medication Administration the CMA:Checked medication administration record (MAR) and reviewed for completeness, accuracy, known allergies cation resources and references as needed ions with the nurse.During Medication Administration the CMA:Selected the right medication (e.g. from patient's med drawer)Completed the Rights of medication administration including right drug, dose, route, time, and patientIdentified patient according to agency policy (e.g. checked patient ID bracelet against MAR, [NAME] name, or used bar code scanner)The Medication Administration Policy was verbally requested from ADON on 08/19/2026; The Medication Administration Policy was not provided.The Medication Administration Policy, Liberalized Medication Policy and Medication Administration Audit Report were requested verbally on August 20, 2026, at approximately 11:56 a.m., and again by email at 1:24 p.m. The audit report was received at 4:20 p.m. that day. The facility did not provide either policy.

Based on observation, interviews and record review, the facility failed to ensure residents had the right to be free from exploitation and misappropriation of property for three of three residents ((Resident #1, Resident #2, Resident #3) reviewed for misappropriation of residents' property.The facility failed to prevent a diversion (misappropriation) of Resident #1's PRN Oxycodone-Acetaminophen 10-325 MG medication. (Oxycodone-Acetaminophen was used to treat pain.)The facility failed to prevent a diversion (misappropriation) of Resident #2's PRN Oxycodone 5 MG medication. (Oxycodone was used to treat pain.)The facility failed to prevent a diversion (misappropriation) of Resident #3's Oxycodone HCl Oral Tablet 15 MGThe facility failed to prevent a diversion (misappropriation) of Resident #4's 60 tablets of Oxycodone 5 MG reported missing on 06/29/2026. (Oxycodone was used to treat pain.)This failure could place residents at risk for decreased quality of life, unrelieved pain, and dignity. Findings included: Record review of Resident #1's face sheet reflected a [AGE] year-old male initially admitted to the facility on [DATE] and with the admission date on 09/03/2024. His diagnoses included presence of a left artificial hip joint (a surgical hip replacement), other chronic pain (pain lasting longer than 3 to 6 months), unspecified osteoarthritis, unspecified site (degenerative joint disease specific location or underlying cause hasn't been precisely identified), left hand contracture (the tissue under the skin of the palm thickens, causing one or more fingers to curl inward), hemiplegia (complete paralysis) and hemiparesis (muscle weakness) following cerebral infarction (cerebral infarction, also known as an ischemic stroke, is a type of stroke that occurs when a blocked or narrowed blood vessel disrupts blood flow to the brain) affecting the left non-dominant side. Record review of Quarterly MDS assessment for Resident #1 dated 12/19/2025 reflected a BIMS score of 13, indicating intact cognition. Resident received scheduled and PRN pain medications.Review of Resident #1's physician's order report reflected:-Monitor for pain, numbness, swelling, tingling, skin color, warmth, redness or coolness, pulse, capillary refill, and drainage under the splint and left upper extremity. Enter Yes if monitored and no abnormal findings were observed; Enter No if monitored and abnormal findings were observed. Document findings in a progress note every shift for maintenance. Start Date: 03/06/2024-Pain Scale Q shift: 0 = NO PAIN, 1-3 = MILD PAIN, 4-7 = MOD PAIN, 8-10 =SEVERE PAIN. PAIN SCALE AFTER INTERVENTION every shift for monitoring. Start Date-10/13/2023.-Acetaminophen Extra Strength Oral Tablet 500 MG (Acetaminophen). Give 2 tablets by mouth every 8 hours asneeded for pain not to exceed 3grams/day. Start Date: 12/15/2025.- Oxycodone-Acetaminophen Oral Tablet 10-325 MG. Give 1 tablet by mouth every 6 hours as needed for pain.Start Date: 05/28/2025- Tramadol HCl Oral Tablet 25 MG. Give 25 mg by mouth every 12 hours as needed for pain. Start Date-06/15/2026Record review of Resident #1's MAR for month of June of 2026 reflected resident received his PRN Oxycodone-Acetaminophen 10-325 MG medication on 06/27/2026 at 7:00 a.m. -for pain level 6 and at 1:18 p.m. -for pain level 6.Record review of Resident #1's MAR for month of July of 2026 reflected resident received his PRN Oxycodone-Acetaminophen 10-325 MG medication on 07/01/2026 at 3:17 p.m. -for pain level 8.Record review of Resident #1's Individual Resident's controlled substance record reflected Resident #1's PRN Oxycodone-Acetaminophen 10-325 MG medication was signed out by RN F on 07/02/2026 at 3:17 p.m. and at 9:15 p.m. 2. Record review of the undated face sheet for Resident #2 reflected an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included unspecified fracture of sacrum, subsequent encounter for fracture without routine healing (a break in the triangular bone at the base of the spine where the exact type or location is not detailed in initial medical records with delayed healing or nonunion fracture failing to heal), cognitive communication deficit (an impairment in communication caused by disruptions in underlying thinking skills like memory, attention, or executive function), need for assistance with personal care (help with daily activities like bathing, dressing, grooming, mobility, and eating), history of falling (a critical clinical marker in medicine indicating a patient's past experience with accidental falls).Review of the comprehensive MDS for Resident #2 dated 06/22/2026 reflected a BIMS score of 12, indicating a moderate cognitive impairment. Resident received scheduled and PRN pain medications.Review of the undated care plan for Resident #2 reflected the following: Focus:Resident #2's pain is related to bilateral (having or involving two sides) sacral fractures.Date Initiated: 06/19/2026Goal:Resident #2 will not have an interruption in normal activities due to pain through the reviewdate. Date Initiated: 06/19/2026Interventions:Anticipate need for pain relief and respond immediately to any complaint of pain.Date Initiated: 06/19/2026Monitor/document for side effects of pain medication. Observe for constipation, newonset or increased agitation, restlessness, confusion, hallucinations, dysphoria (a profound, persistent state of unease, dissatisfaction, and emotional distress, nausea, vomiting, dizziness and falls). Report occurrences to the physician.Date Initiated: 06/19/2026Monitor/record pain characteristics and PRN: Quality (e.g. sharp, burning), severity (1 to 10 scale), anatomical location, onset, duration (e.g., continuous, intermittent), aggravating factors, relieving factors. Date Initiated: 06/19/2026Monitor/record/report to Nurse any s/sx of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow), vocalizations (grunting, moans, yelling out, silence), mood/behavior (changes, more irritable, restless, aggressive, squirmy (something characterized by wriggling, twisting motions, or movements that make someone feel physically or emotionally uncomfortable), constant motion), eyes (wide open/narrow slits/shut, glazed, tearing, no focus), face (sad, crying, worried, scared, clenched teeth, grimacing), body (tense, rigid, rocking, curled up, thrashing).Date Initiated: 06/19/2026Notify physician if interventions are unsuccessful or if current complaints are a significant change from resident's experience of pain. Date Initiated: 06/19/2026Review of Resident #2's order summary report reflected:-Acetaminophen Oral Tablet 500 MG (Acetaminophen) Give 2 tablets by mouth three times a day for pain.Start date- 06/19/2026-Lidocaine External Patch 4 % (Lidocaine) Apply to lumbar spine topically one time a day for pain. Start date- 06/20/2026-Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl). Give 1 tablet by mouth every 6 hours as needed for Pain.Start date- 06/19/2026-Tramadol HCl Oral Tablet 50 MG (Tramadol HCl). Give 1 tablet by mouth every 6 hours for pain. Start date- 06/26/2026Record review of Resident #2's MAR for the month of June of 2026 reflected resident received his PRN Oxycodone HCl Oral Tablet 5 MG medication on 06/20/2026 at 7:34 a.m. -for pain level 7 and on 06/21/2026 at 7:19 a.m. -for pain level 8.Record review of Resident #2's Individual Resident's controlled substance record reflected Resident #2's PRN Oxycodone HCl Oral Tablet 5 MG medication was signed out by RN F on 06/20/2026 at 3:34 p.m. and at 1:45 p.m. and on 06/21/2026 at 7:20 a.m. and at 1:30 p.m. 3. Review of the undated face sheet for Resident #3 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included encounter for orthopedic aftercare following surgical amputation (ongoing post-surgical care like physical therapy, occupational therapy, wound care, pain management, and prosthetic evaluation), cognitive communication deficit (an impairment in communication caused by disruptions in underlying thinking skills like memory, attention, or executive function).Review of the comprehensive MDS for Resident #3 dated 06/08/2026 reflected a BIMS score of 15, indicating an intact cognition. Resident received scheduled and PRN pain medications.Review of the undated care plan for Resident #3 reflected the following: Focus:Resident #3 has pain related to foot pain, neuropathy, and status post-surgery, and amputation of the left toe.Date Initiated: 06/10/2026.Goal:Resident #3 will not have an interruption in normal activities due to pain through the review date. Date Initiated: 06/10/2026.Interventions:Anticipate need for pain relief and respond immediately to any complaint of pain. -Date Initiated: 06/10/2026Continue on pain management as ordered. - Date Initiated: 06/10/2026Encouraged to call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increase or alleviate pain). -06/10/2026Evaluate the effectiveness of pain interventions. Review for compliance, alleviating symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. -Date Initiated: 06/10/2026Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. - Date Initiated: 06/10/2026Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. -Date Initiated: 06/10/2026Review of Resident #3's order summary report reflected:-Acetaminophen Oral Tablet 500 MG (Acetaminophen). Give 2 tablet by mouth every 6 hours as needed for Pain.Start date: 06/02/202-Gabapentin Capsule 300 MG Give 1 capsule by mouth three times a day for Pain. Start date: 06/03/202.-Oxycodone HCl Oral Tablet 15 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for PAIN.Start date: 06/02/202-Tramadol HCl Tablet 50 MG Give 1 tablet by mouth every 6 hours as needed for moderate and severe pain.Start date: 06/06/202Record review of Resident #3's MAR for the month of June of 2026 reflected resident received her PRN Oxycodone HCl Oral Tablet 15 MG medication was signed out by RN F on 06/27/2026 at 8:53 a.m., 3:00 p.m., 5:15 p.m. and 8:25 p.m. 4. Record review of Resident #4 undated face sheet reflected [AGE] years old female with DOB: [DATE] was admitted to the facility on [DATE]. Her diagnoses included unspecified fracture of the upper end of the left humerus, subsequent encounter for fracturewith routine healing (healing phase after breaking the upper portion of the left arm near the shoulder), encounter for other orthopedic aftercare (follow-up care for a musculoskeletal condition, excluding traumatic fractures or joint), other specified disorders of bone density and structure, unspecified site (specific, diagnosed skeletal conditions related to abnormal bone mass or structure, but without designating a particular anatomic area). Date of discharge: [DATE]. Time of discharge: 10:00 a.m. Length of stay: 9 days. discharged to: Assisted/Independent Living: Other ALF. Review of Resident #4's order report reflected:-Monitor for pain, numbness, swelling, tingling, skin color, warmth, redness or coolness, pulse, capillary refill, and drainage under the splint and left upper extremity. Enter Yes if monitored and no abnormal findings were observed; Enter No if monitored and abnormal findings were observed. Document findings in a progress note every shift for maintenance. Start Date: 06/23/2026.-Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl). Give 1 tablet by mouth every 4 hours as needed for Pain. Start date- 06/23/2026.-Tramadol HCl Oral Tablet 50 MG (Tramadol HCl). Give 1 tablet by mouth every 12 hours for pain. Start date- 06/26/202.-Morphine Oral Tablet 15 mg. Give 1 tablet twice a day for pain. Start date- 06/26/202. Review of the Provider Investigation Report dated 06/30/2026 reflected, 2-30 count blister packs of 5 mg. oxycodone are not account for. No physical assessment was conducted due to the lack of physical nature of the incident. Resident #4 has 4 blister packs of 30 mg of oxycodone in the facility for administration. The blister packs unaccounted for will be replaced at the facility's expense.'The Facility immediately followed drug diversion protocol:Self-report completed 06/30/2026Staff that could have potentially been involved have been interviewed and all have been drug tested.Card count sheet has been initiatedCounts have been verified for every controlled drug in the facility.Narcotic shift change sheets have been auditedMedical Director, pharmacy consultant, and police have all been notified. The police report case number was not provided at this time.Nursing staff have been in-serviced related to controlled medication counting procedures; counting with oncoming nurse, logging individual controlled dose at the time of medication administration, abuse and neglect.Drug test results reveal that no nurse had tested positive for the narcotic that was missing.Other parties notified: physician, pharmacy and police.The facility was unable to locate the missing narcotics.Review of the complaint submitted on 07/02/2026 by the facility staff LPN H reflected, On 06/29/2026, Oxycodone 5 mg. pills went missing at the facility. The medications belong to Resident #4. The narcotic log reflects nurse [NAME] was the last person interacting with the medications. The facility director [NAME] has initiated an internal investigation and has informed staff she initiated the State of Texas and Police. Resident 1 was to be taking two oxycodone every four hours for pain management. Resident #4 has more Oxycodone left. Resident #4 also takes 50 mg. Tramadol, one tab every 12 hours and Morphine tablets 15 mg. twice a day. Resident #1 continues to have medications for pain management with no reports of increase in pain. The facility has history of missing medications. The complaint wants the narcotics not to be stolen.Record Review of the consolidated delivery sheet reflected that LPN H received 12 blister packs from the pharmacy on 06/25/2026 at 10:30 pm. LPN H added these 12 blister packs to the carts on 06/25/2026. 4 blister packs were logged onto Narcotic inventory page for the med cart hall 200. LPN H added 8 blister packs of oxycodone 5 mg. to the nurses' cart where 6 blister packs of oxycodone 5 mg were for Resident #4, and 2 blister packs of oxycodone 5 mg was for Resident #2. Over the weekend on 06/27/2026 and on 06/28/2026 a total of 5 blister packs was subtracted out, and they are not logged on the back of the narcotic inventory log. The DON should have all 5 blister packs of oxycodone 5 mg to zero it out on the count sheets along with the empty blister packs of oxycodone 5 mg itself, but the DON had 3 blister packs of oxycodone 5 mg to zero out narcotic sheets/blister packs. The other 2 blister packs of oxycodone 5 mg were the 2 missing blister packs of oxycodone 5 mg for Resident #4. The morning shift nurse RN M discovered 2 missing blister packs of oxycodone 5 mg in the morning of 06/29/2026 and reported it to ADON.Staff interviews did not identify an eyewitness to the medications being taken. The facility could not identify anyone with access to the carts besides those designated to be on their designated shifts.Observation on 07/02/2026 at 10:58 a.m. of the 100 and 200 hall nurses' narcotics books and carts, and 100 and 200-halls medication aide narcotics books and carts revealed all medications, and blister packs were correct per the narcotic count. In an interview 07/02/2026 at 11:40 a.m. with Resident #1 he stated that his pain level was about 3 so he wants his Tylenol. He stated that his cognition is very intact and he does not take Oxycodone unless it was before physical therapy or sometimes at night when he can't go to sleep because of pain. He stated that he does not want to be addicted to Oxycodone.Review of the complaint submitted on 07/02/2026 by the facility staff LPN H reflected, On 06/29/2026, Oxycodone 5 mg. pills went missing at the facility. The medications belong to Resident #4. The narcotic log reflects nurse [NAME] was the last person interacting with the medications. The facility director [NAME] has initiated an internal investigation and has informed staff she initiated the State of Texas and Police. Resident 1 was to be taking two oxycodone every four hours for pain management. Resident #4 has more Oxycodone left. Resident #4 also takes 50 mg. Tramadol, one tab every 12 hours and Morphine tablets 15 mg. twice a day. Resident #1 continues to have medications for pain management with no reports of increase in pain. The facility has history of missing medications. The complaint wants the narcotics not to be stolen.In an interview on 07/02/2026 at 2:12 p.m. with RN F she stated she was working in the facility for 5 years. She stated she was trained in medication administration; her last medication administration in-service training was yesterday. She stated the medication administration in-service training covered more involvement of DON and ADON when handling narcotic medication; it was required that two nurses sign the narcotics when received from the pharmacy and to notify the DON and ADON about receiving the medications. RN F named 5 rights for administering medications: right order, right route, right medication, right time, right resident. RN F stated that when the narcotic medication was popped out of the blister pack it was to be signed out from the narcotics book after verifying orders in the resident's MAR and assessing resident's pain level. RN F stated that she was aware that two blister packs of Oxycodone were missing and she did not eyewitness to the medications being taken. She stated as soon as the facility became aware of it the DON and ADON were checking all nurses and medication carts for the missing medications. They could not locate the missing narcotics at that time. RN F could not recall that narcotics were missing before. RN F stated that missing medication could cause delay of resident's care treatment, resident could have been in pain. RN F stated if the resident had no pain medications available, she would notify the doctor to see what the order would be until the meds were received from the pharmacy. RN F stated that if residents were in pain, it would affect the quality of residents' life, they would be unhappy and depressed.In an interview 07/02/2026 at 2:35 p.m. with RN M she stated she was working in the facility for about 2 years. She stated that she was trained in medications administration. RN M stated that before administering medications to a resident she was to follow the 6 rights of medication administration: right resident, right order, right dose, route, time and right documentation. She stated if it was for pain medication she would assess resident for pain level, location and check when the pain medication was given last time. She stated if it was for oxycodone pain medication she would pop it and sign the narcotics book and after the medication was given, she would check it as given in the resident's MAR. RN M stated that she had narcotics count procedures in-service training a day ago. She stated that the training was how to count narcotic cards, count blister packs, the requirement of 2 nurses to be present to count and sign the narcotics delivered by the pharmacy and only DON or ADON were to remove empty blister packs and discontinued narcotics from the nurses and med carts. RN M stated she did not work on weekends and when she came back to work on Monday morning (on 06/29/2026) she discovered that 2 blister packs (60 pills) for Resident #4 were missing. RN M stated that RN F worked double shifts last Saturday (06/27/2026) and Sunday (06/28/2026) and those 2 blister packs have gone missing over the weekend on nurses' cart Hall 200. RN M stated that she reported about 2 missing blister packs to ADON. She stated that residents not receiving pain medications can negatively affect their mood, behavior, appetite. RN M stated that the facility had another 3 times when narcotics were missing in the facility. She stated that she does not know if they all were reported to State. In an interview on 07/02/2026 at 4:57 p.m. Resident #1 stated to ADON and this surveyor that he did not take any Oxycodone last weekend (on 06/27/2026 and 06/28/2026). Resident #1 stated that he was cognitively intact and he was aware that Oxycodone could lead to narcotic addiction, that is why he was taking Oxycodone only when he had his physical therapy or sometimes when he had pain at night.In an interview on 07/02/2026 at 5:18 p.m. with RN H she stated that she has been working in the facility for about 11 months. She stated that she had her medication administration training annually in the different facility where she was currently employed. RN H named 6 rights for administering medications. She stated that she had in-service training in this facility yesterday which covered 2 nurses to sign out narcotics. She stated that she was aware of 2 missing blister packs of Oxycodone, but she did not know what happened to the medications. She stated that if residents were not receiving pain medications it would be difficult for them to do rehabilitation therapy. RN H stated that pain medication was to be administered after accessing resident's pain level, starting from the low dosing of pain medication first. She stated that for the nonverbal residents the assessment was to be observing facial grimacing, inability to move because of pain, holding body part. RN H stated before giving narcotics she was following 6 medication rights. She stated the steps were to pull out the narcotic medication, pop it and sign it in the narcotics sheet by writing the date and time and then to check it as given in the resident's MAR so the date and time in MAR and Norco book were matching.In the interview on 07/03/2026 at 6:19 a.m. with LPN H she stated that she received 12 blister packs from the pharmacy in the evening of 06/25/2026. LPN H stated that she added these 12 blister packs to the carts on 06/25/2026. 4 blister packs were logged onto Narcotic inventory page for the med cart hall 200. LPN H stated that she added 8 blister packs of oxycodone 5 mg. to the Nurses' cart Hall 200 where 6 blister packs of oxycodone 5 mg were for Resident #4, and 2 blister packs of oxycodone 5 mg was for Resident #2. She stated that over the weekend on 06/27/2026 and on 06/28/2026 a total of 5 blister packs was subtracted out, and they are not logged on the back of the narcotic inventory log. The DON should have all 5 blister packs of oxycodone 5 mg to zero it out on the count sheets along with the empty blister packs of oxycodone 5 mg itself, but the DON had 3 blister packs of oxycodone 5 mg to zero out narcotic sheets/blister packs. The other 2 blister packs of oxycodone 5 mg were the 2 missing blister packs of oxycodone 5 mg for Resident #4. The morning shift nurse RN M discovered 2 missing blister packs of oxycodone 5 mg in the morning of 06/29/2026 and reported it to ADON. LPN H stated that there were another 3 incidents that occurred with missing narcotic medications and she was not sure if they were reported to the State. She stated that she was concerned about the residents' pain management. LPN H stated she was worried about her license and the licenses of good nurses. During an observation of interview on 07/03/2026 at 9:16 p.m. Resident #1 stated to ADM and DON that he took Oxycodone last night (on 07/02/2026 around 9:30 p.m.). Resident #1 stated that he took his Oxycodone medication just once yesterday.In an interview on 07/03/2026 at 12:03 pm with Resident #3 she stated that she received her Oxycodone medication on 06/27/2026 at 9:00 a.m. and around 8:25 p.m. Resident #3 stated that she was aware that her Oxycodone was scheduled to be given every 6 hours. She stated that her doctor told her that she will be having pain when she is moving her feet. She stated that her doctor told her that she will be having some pain for a while, and she can ask for her PRN pain medication if she is having pain.In an interview on 07/03/2026 at 12:15 p.m. Resident #2 he stated that he was aware that he was scheduled to be receiving his Oxycodone 5 mg every 6 hours but some days he was not receiving it at all. He stated that he was currently in pain and the nurse was to administer him his pain medication Oxycodone. Resident stated that he received his Oxycodone medication once a day on 06/20/2026 in the morning and on 06/21/2026 around 7:00 a.m. He stated he did not receive any other Oxycodone medications, but he received one tramadol medication during that weekend.In an interview on 07/03/2026 at 12:21 p.m. with ADON she stated she has been working in the facility for a few months.She stated that she was trained in medication administration. ADON named 5 rights for administration of medications: right resident, right time, right dose, right route, right strength. She stated that as soon as she was notified about 2 missing Oxycodone 5 mg blister packs (60 Oxycodone tablets), she notified the ADM and DON about it. She stated that DON and she started looking for the missing medications in all the medication and nurses' carts. She stated that they could not locate the missing medications and there was no eyewitness to the medications being taken. This was reported to State after the facility could not locate the missing medications. She stated that no nurse had tested positive for the narcotic that was missing. ADON stated that there should not be a discrepancy between the Medication Administration Record and the Individual Resident's Controlled Substance Record. She stated that these two records must match: every time a pill is popped from the narcotic blister pack, it must be subtracted from the log and documented as administered on the MAR; it will show how many narcotics was administered to resident on the MAR and indicate the exact amount that should be subtracted from the resident's remaining narcotic count.In an interview on 07/03/2026 at 12:33 p.m. with DON she stated that she was trained in medication administration. DON named 5 rights for administration of medications: right resident, right time, right dose, right route, right documentation. She stated that the ADON notified her about missing Oxycodone 5 mg blister packs for one of the Resident She stated that the ADON and she started looking for the missing medications in all the medication and nurses' carts and even went looking for them in recycling bin. She stated that after they could not locate the missing medications the facility reported it to State. She stated that staff were in-serviced for Shift-to-Shift Report-Narcotic count. The facility nurses were expected to add count sheets and 2 nurses where to sign it. She stated that now only DON or ADON were to remove the empty narcotic blister packs and discontinued narcotics from the medication and nurses' carts. DON stated that resident's MAR report and resident's narcotic log must match because it shows how many narcotics were signed off from the resident's narcotic log and how many narcotics were administered; there should not be any discrepancies. [NAME] stated that not receiving pain medications by the residents could negatively affect residents' quality of life.In an interview on 07/03/2026 at 1:03 p.m. with ADM she stated that she had been working in the facility since October of 2025. She stated she was not trained in medication administration, but she was familiar with it through reviewing the medications administration policy. ADM stated that there were 5 medications administration rights: Right person, right medication, right time, right route, right documentation. ADM stated that nurses were responsible for maintaining the nurses' carts in a safe manner. ADM stated that all facility nurse personnel were scheduled for audits once a month. ADM stated that based on the internal investigation there was no strictly hard evidence to identify what happened to the missing narcotic medications. She stated that the drug test results revealed that no nurse had tested positive for the narcotic at this time. ADM stated that the facility put an additional narcotics monitor in place. ADM stated that not receiving pain medications by the residents to control pain could potentially create frustration for residents. She stated that it was, eye opening for her to learn when Resident #1 reported to her that he received his Oxycodone medication only once yesterday (on 07/02/2026) despite Resident #1's Oxycodone was signed off twice in the Resident #1's controlled substance record by RN H on 07/02/2026. ADM stated that after consulting with the regional leadership, the decision has been made to terminate RN H today.Record review of a document provided by the facility titled Injection Safety-Drug Diversion with Date Implemented on 6/23/2025 reflected: Policy:This facility recognizes the risks for contamination and infection associated with diversion of injectable medications and monitors staff with access to injectable controlled substances to prevent transmission of infections.Definitions:Drug diversion refers to theft or other deviation that removes a prescription drug from its intended path from the manufacturer to the patient. For example, a staff member steals a controlled substance (i.e. opioid) for personal use.Injectable mediations are liquid medications designed to be administered via injection, including but not limited to subcutaneous, intramuscular, and intravenous injections.Controlled substances are medications that can cause physical and mental dependence and have restrictions on how they can be filled and refilled. They are regulated and classified by the Drug Enforcement Agency (DEA).Policy Explanation and Compliance Guidelines:1. All drugs and biologicals, including controlled substances, are stored in locked compartments and only authorized personnel have access to the keys to locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms).2. Staff with access to medications are trained on their responsibilities for safe storage and administration of medications, including documentation and disposition of medications.3. Staff with access to controlled medications are trained on the facility's policy for the administration and accountability of controlled substances. Each employee is required to report suspicion or known diversion of a controlled substance to the Director of Nursing or Administrator.5. Ongoing supervision and auditing are conducted in accordance with fa are following policies as written. This includes oversight by charge nurse, nursing leadership, and pharmacy consultants.6. Potential signs of drug diversion in healthcare personnel:a. Has many unscheduled absences, sick days, and [NAME] arrivals.b. Disappears frequently from the unit, such as frequent long trips to the bathrooms or medication room.c. Volunteers for overtime and is at work when not scheduled to be there. Arrives at work early and stays late.d. Has a pattern of removal of controlled substances near or at the end of a shift.e. Frequent suspicious withdrawals such as when not needed, duplicate dose, or for a resident who has been discharged .f. Frequent null transactions and discrepancies.g. Alternates between periods of high and low productivity.h. Has poor interpersonal relationships with colleagues.Insists on personal administration of injected medications.j. Has heavy or no wastage of medications.k. Exhibits a habit of holding waste until oncoming shift.1. Offers to help in non-assigned areas.m. Prefers to work with new personnel or orientees.7. Procedure when diversion of injectable medication is suspected or occurs:a. The employee will be removed from access to residents through suspension until an investigation is complete. Access to controlled substances will be revokedb. Appropriate entities will be notified, including but not limited to, the Administrator, department of public health, law enforcement, DEA, FDA, licensing board, and state survey agency.c. The facility will assess any harm to residents that may have occurred.8. Risk assessment to residents:a. Assess the means by which the medication was diverted. Consider risks associated with reuse of syringes or inserting non

Based on interviews and record reviews the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for one (Resident #1) reviewed for medications.The facility failed to document the receipt and disposition Resident #1's Oxycodone HCI medication.This failure could result in controlled medications not accurately and periodically reconciled.Findings included:Record review of Resident #1's face sheet reflected a [AGE] year-old female with diagnoses which included chronic diastolic (congestive) heart failure, essential (primary) hypertension, and generalized muscle weakness. Resident #1 also had diagnoses for pain in both the right and left knees, along with other chronic pain issues, highlighting a potential need for effective pain management.A record review of Resident #1's medication administration record (MAR), dated 12/22/2025, reflected on 11/20/2025, Resident #1 was ordered Oxycodone HCl oral tablets, 5 mg, to be administered as needed for pain every 12 hours. The MAR reflected this medication was discontinued as of 11/18/2025.Record review of Resident # 1's progress notes, dated 12/4/2025, reflected she was discharged home with all personal belongings and prescriptions. The staff reviewed the medication orders with her, and she understood the list provided. Notably, the patient refused to take her PRN oxycodone and was picked up by a family member in a private vehicle. In an interview on 12/22/2025 at 2:08 PM, RN A stated if medications were left behind by discharged residents, they should be signed for and documented by the Director of Nursing (DON).In an interview on 12/22/2025 at 2:11 PM, RN B indicated all narcotics and discharge records were managed by the DON and must be logged, with non-narcotic medications stored separately.In an interview on 12/22/2025 at 2:15 PM, LVN A noted any medications left with him would be reported to the DON immediately for tracking and logging, emphasizing all tracking required two staff signatures.In an interview on 12/22/2025, at 2:35 PM, Medication Aide A explained her protocol for disposing of medications left by discharging residents, which included removing the blister pack and bringing the pills to the DON for proper disposal.Observation on 12/22/2025 at 3:54 PM of the medication storage room revealed the facility did not utilize written logs, only an electronic deviceIn an interview on 12/22/2025 at 3:55 PM, LVN A stated while all narcotic drugs required two staff members for sign-out, the process differed for discharged patients, with the understanding that drugs left behind should be logged by the DON.An attempted interview by telephone with Resident #1 at 4:33 PM was unsuccessful. A voicemail was left and a return call was requested.In an interview at 4:45 PM, the DON stated the issue surrounding the undocumented oxycodone and stated she could not provide a log for medications left behind by residents. The DON stated she recognized this as a serious problem and was committed to working with her staff to rectify the situation.Record review on Google.com at 4:06 PM reflects that BD Pyxis(tm) MedBank(tm) is designed to enhance safe storage, dispensing, and tracking of medications, which aims to improve patient safety and operational efficiency in medication management.Record review of the facility's ----- policy, reflected the following:Compliance Guidelines:1. The facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice.b. Establishes a system of records of receipt and disposition of all controlled drugs in sufficientdetail to enable accurate reconciliation; andc. Determines that drug records are in order and that an account of all controlled drugs ismaintained and periodically reconciled.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. The facility failed to ensure all items were covered and stored properly.The facility failed to label and date all food items in the kitchen.The facility failed to ensure all staff in the kitchen wore hairnets or beard guards. These failures could place residents at risk of foodborne illness.Findings included: An observation on 09/25/25 at 9:58 AM revealed a partially used 50-pound bag of refined sugar, open and undated, on a shelf in the storage room. An observation on 09/25/25 at 9:59 AM revealed a large bag of enriched flour, open and undated on a shelf in the storage room. An observation on 09/25/25 at 9:59 AM revealed a large plastic storage bin labeled Flour 07/22. The lid was not secure on the storage bin. An observation on 09/25/25 at 10:01 AM revealed a brownish-orange pudding like substance in a plastic container in the walk-in refrigerator. The container was not dated or labeled. An observation on 09/25/25 at 10:02 AM revealed an unidentified brownish substance in a plastic container in the walk-in refrigerator. The container was not dated or labeled. An observation on 09/25/25 at10:02 AM revealed an open package of sliced honey ham with juices in an unsealed plastic bag stored in the same bin as unsealed bags of shredded cheese. During an interview on 09/25/25 at 10:22 AM, the DM stated all food was dated when opened and everything was kept in a sealed container. She stated it did not meet her expectations that the large flour and sugar bags were not sealed. She stated bugs or animals could get into open containers and cause food-borne illness. She stated it did not meet her expectations that the ham and cheese were in unsealed bags and in the same bin. An observation on 09/25/25 at 10:30 AM revealed the MS with facial hair, without a hairnet or a beard guard, walked through the food prep area and clean dish area to the dishwasher. During an interview on 09/25/25 at 10:42 AM, the MS stated he was aware that hairnets and beard guards were required in the kitchen. He stated he got in a hurry and forgot. The MS stated not wearing the hairnet or beard guard could have caused contamination or hair to get in food. During an interview on 09/25/25 at 12:29 PM, the DM stated she was responsible for training the dietary staff. She stated the dietitian was in the facility frequently and observed staff and educated as needed. During an interview on 09/25/25 at 2:15 PM, the CK stated everything in the pantry was dated and was good for three days once opened. She stated everything had to be in sealed containers. She stated bugs could get into open containers. She stated the open ham should not have been stored in bin with open containers of cheese. She stated staff were required to wear hairnets in the kitchen because the hair can get in the food or fly everywhere. During an interview on 09/26/26 at 3:45 PM, the ADM stated it was her expectation that food was stored in the right place and dated properly. She stated a package, once opened was dated then kept in a sealed container. She stated if food were not stored properly, it could cause everyone to get sick. The ADM stated it was her expectation that hairnets or beard guards were worn any time staff were near a food prep area. The ADM stated the DM was responsible for training the dietary staff. Review of the in-service titled Labeling and Dating provided by the DM and dated 07/28/25, reflected, Label all non-identifiable food items. Date all Open / Prepped / Leftover food items. Date LEFTOVER items as follows: Open or prep date / 3 Day DC date. Example: [NAME] Beans P: 05/16/18 / D: 05/18/18. Note: Dressings / Cheese / Mayo - Open Date / DC + 1 month. Review of the Food Receiving and Storage policy, revised November 2022, reflected in part, Dry Food Storage 4. Dry foods that are stored in bins are removed from original packaging, labeled and dated ( use by date). Refrigerated/Frozen Storage 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. Review of the Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices Policy, dated October 2017, reflected in part, 12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens.

Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared by methods that conserve nutritive value, flavor, and appearance for 1 of 1 meal (lunch) reviewed for pureed diet texture. The facility failed to ensure the nutritional content of the pureed food when the facility used water only to puree the chicken tenders and broccoli on 09/25/25. This deficient practice could place residents at-risk for poor intake and malnutrition related to decreased calorie intake.Findings included: An observation on 09/25/25 at 12:17 PM revealed the CK pureed about twelve chicken tenders and added water to the food processor. After several minutes, the CK evaluated the consistency of the puree, put more tap water into a pitcher, and poured the water into the food processor. After cleaning the processor, the CK repeated the process of using tap water to puree the broccoli. During an interview on 09/25/25 at 12:24 PM, the CK stated she did not have a recipe but knew the puree was supposed to look like pudding. She stated little by little she added water to get to the right consistency. During an interview on 09/25/25 at 12:29 PM, the DM stated she worked with the nutritionist but did not yet have all the recipes. She stated the ADM did have access to get the recipes from the computer system. She stated many of the staff were new and she had done initial training with them. She stated the initial training included making the different types of diets including puree. She stated she had trained the CK. She stated she instructed staff to start with a small amount of water, about two ounces, and add a little at a time until the food was the right consistency. The DM stated she would have used chicken broth, not water to puree the chicken tenders. The DM stated water could have diluted the taste and the nutritional value of the food. During a telephone interview on 09/25/25 at 1:46 PM, the RD stated typically to puree a food item, they used about a tablespoon of excess cooking liquids (drippings) per serving and adjusted as needed. She stated usually the recipe would recommend a broth or something similar that did not alter the taste of the food. The RD stated water was not used as it would dilute the nutrients. The RD stated the contracted food vendor had recipes available for most items on the menu. She stated she monitored food preparation and service during her visits to the facility and provided training or education as needed. During an interview on 09/25/25 at 2:15 PM, the CK stated she had been trained to use the juice from the meat or vegetables to puree the food. She stated the chicken tenders did not have any juice, so she added water today. She stated she should have used chicken broth, but she was in a hurry because she was already so far behind schedule. She stated using water to puree food could have taken away the flavor. During an interview on 09/25/25 at 3:45 PM, the ADM stated it did not meet her expectations that water was used to puree the chicken and broccoli. She stated using plain water could alter the nutritive value of the food. She stated she expected the menus to be followed. She stated the DM was responsible for training staff. She stated the RD was in on a regular basis and made frequent observations in the kitchen. The ADM stated the facility did not have a policy regarding therapeutic diets. The ADM stated she printed recipes multiple ways, but she was still unable to find the directions to puree chicken tenders. Review of the in-service Menus Adequate Nutrition & Thickener dated 06/29/25, reflected in part, Add liquid: Incorporate broth, milk, or juice to adjust thickness as needed.

Based on observation, interviews and records review the facility failed to ensure that residents (Resident #1) environment remains as free of accident hazards. The facility failed to ensure Resident #1 was free of accidents and hazards, as Resident #1 spilled a hot liquid onto her leg. Resident #1 sustained a second-degree burn to her left thigh. This failure placed residents at risk of serious harm and injuries which could result in hospitalization and a diminished quality of life. Findings included: Observations on 9/26/2025, at 10:00 a.m. revealed no hot water dispensers were observed in the halls of the facility. Observation and interview on 09/26/2025, at 12:25 p.m. revealed Resident# 1 was observed lying in bed and watching TV. Resident#1 stated she expressed that she is doing well overall. While she did mention having a burn on her leg, she said she was not in pain, and that she felt safe in the facility. Resident #1 mentioned that she was aware that the water dispenser provided hot water and had used it in the past without any issues. Additionally, Resident #1 expressed interest in having a coffee machine available for use. Record Review of Resident #1's face sheet, revealed an [AGE] year-old-female, with a current admit date of 01/02/2024. Resident #1's face sheet further revealed diagnoses including senile degeneration of the brain, arthritis, unspecified dementia, and mobility issues. Review of Resident #1's Minimum Data Set (MDS) dated [DATE], for Resident #1 indicated a BIMS score of 10, suggesting moderate cognitive impairment.Record Review of Resident # 1's Provider Investigation Report, reflects on 9/21/2025 the Resident let CMA know she had spilled hot water on her lap. The water machine was immediately unplugged, and the resident was assessed. POA, Physician and DON were notified. Record Review of Resident #1's progress dated and timed 09/22/2025 at 10:04 PM (p.m.), revealed, the resident was seen today after she spilled hot water on her leg causing a burn. The resident was seen sitting in her wheelchair, able to stand to remove pants for assessment. No pain with standing. The exam showed Resident with a second degree burn to Resident #1's thigh and a Left lateral upper leg with 2 open areas from hot water burn. Record Review of Resident #1's wound care notes created and signed by PA-C - 1, date and timed 09/23/2025 at 07:11 PM, revealed, an [AGE] year-old English speaking female was being seen today for wound(s). At the request of a thorough wound care assessment and evaluation was performed today. Exam showed Resident #1 sustained burns to her left thigh on 9/21/25 when she spilled 180 degrees F water onto her lap. Reports moderate pain. Comprehensive wound care orders require the application of Silvadene to wound beds. Layer with xeroform. Secure with dry dressing or bordered dressing. Record review of Resident #1's physician's orders, dated 9/25/2025, revealed Resident #1's injury was being treated with Silvadene External Cream 1 %. Record review for Resident# 1 in the assessment section of PCC revealed a Hot liquid Assessment was not found. Interview on 9/26/2025, at 1:32 pm CNA A stated she had been employed at the facility for 10 years and attended an in-service training session yesterday. She received training on handling hot beverages as well as protocols related to abuse and neglect. CNA A was knowledgeable about the proper reporting procedures for incidents and understood the importance of safety regarding hot beverages. She utilized the EMR to verify which residents were permitted to have hot drinks and knew to consult with the nurse for any further clarification on this matter. Interview on 9/26/2025, at 1:41pm CNA B stated her commitment to resident safety. CNA B participated in monthly in-service training on abuse and neglect and understood the importance of reporting any incidents to the administration. CNA B recently completed training focused on beverage temperatures, ensuring that they remain below 135 F. When a resident requested a hot drink, CNA B took the necessary precautions by holding the item for them and confirming that it was safe. CNA B also checked the computer for any restrictions related to hot items for residents. Interview on 9/26/2025, at 1:53pm RN A stated she actively participated in monthly in-service trainings focused on preventing abuse and neglect and was well-versed on the procedures for reporting incidents to administration. Recently, RN A completed an in-service training session on the safe preparation and serving of hot beverages, including teas and coffee. This training highlighted the importance of checking beverage temperatures to ensure resident safety. She emphasized the necessity of assessing each resident's abilities to determine their safety in performing specific activities. Interview on 9/26/2025, at 1:56pm the DON stated that all staff members received in-service training on abuse and neglect in August of 2025. An upcoming in-service session focused on the safe handling of beverages and snack drinks was scheduled for Monday, October 1, 2025. The DON shared a recent incident in which a Resident # 1 accidentally spilled a drink. Resident# 1 had placed the cup between her leg and the wheelchair, resulting in a spill on her leg. The DON emphasized the facility's commitment to continuous education and the safety and well-being of both residents and staff. Interview on 9/26/2025, at 1:56pm, with the DON stated that she has neither seen nor heard of a hot liquid assessment related to hot beverages. She indicated that decisions regarding beverage safety were typically based on the residents' diagnosis and functional abilities. When asked about the potential impact of such an assessment on residents, she acknowledged uncertainty, as she was not familiar with its specifics. The DON confirmed that there has been no implementation of a hot beverage assessment at the facility.Hot Liquid Safety Policy Provided on 9/27/2025:Hot liquids are to be served at proper (safe and appetizing) temperatures using appropriate safety precautions.Definitions:Proper (safe and appetizing) temperature means both appetizing to the resident and minimizing the risk forscalding and bums.Scalding is a bum caused by spills, immersion, splashes, or contact with hot water, food and hot beverages,or steam.Policy Explanation and Compliance Guidelines:1. Hot liquids can cause scalding and bums. The degree of injury depends on the temperature, the amount ofskin exposed, and the duration of exposure. Refer to the table attached to this policy for an illustration ofthe time required for a bum to occur at various temperatures.2. The temperatures of hot liquids will be checked in the dietary department prior to distribution to thenursing units. If the temperature is greater than 140 degrees Fahrenheit, hold the liquid in the dietarydepartment until it reaches an appropriate: temperature.3. All residents are assessed for their ability to handle containers and consume hot liquids. Residents withdifficulties will receive appropriate supervision and use of assistive devices in order to consume hotliquids. Interventions will be individualized and noted on the resident's plan of care. Interventions include,but are not limited to:a. Wide-based cupsb. Cups with lids and handlesc. Limit Styrofoam cups to residents with no difficultiesd. Apronse. Disallow hot liquids while lying in bed4. Staff shall respond immediately to spills or other accidents with hot liquids to minimize the risk for burns.Follow procedures regarding incidents/accidents should anyone experience exposure to hot liquids.5. Monitor residents for at least 24 hours following exposure to hot liquids, as redness or blisters may notappear initially.6. General safety precautions when serving hot liquids include, but are not limited to:a. Make sure residents are alert and in proper positioning to consume hot liquids.b. Use cups, mugs, or other containers that are appropriate for hot beverages.c. Do not overfill containers.d. Regulate temperature of hot liquids to which residents have direct access.e. Place filled containers directly on table. Do not hand them directly to residents.f. Keep hot liquids away from edges of the table.g. Do not refill containers while the resident is holding the container.

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of four residents reviewed for quality of care. The facility failed to: - Notify Resident #1's NP when her diabetic insulin pump malfunctioned in July of 2025. - Ensure nursing staff were trained on Resident #1's insulin pump.- Ensure nursing staff were aware of how much insulin Resident #1 was receiving and not relying on her for blood sugar readings.- Ensure there were parameters in place on when to notify Resident #1's NP when her readings were abnormal.These failures resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/25 at 2:14 PM and a template was provided. While the IJ was removed on 08/01/25 at 2:13 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of DKA, dizziness, nausea, and a decreased quality of life, and death. Findings included:Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including type I diabetes, gastroparesis (a condition in which the muscles in the stomach do not move well), chronic kidney disease, and muscle weakness. Review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 15, indicating she was cognitively intact. Section N (Medications) reflected she received insulin injections since admission. Review of Resident #1's admission care plan, dated 06/30/25, reflected there was not a focus regarding her being a diabetic or having an insulin pump. Review of Resident #1's physician order, dated 07/03/25, reflected the following: Dexcom G7 Receiver Device (Continuous Glucose System Receiver) - Apply to bar of upper arm topically one time a day every 10 day(s) for DM management. Review of Resident #1's TAR, July of 2025, reflected the receiver was changed on 07/03/25 and 07/13/25. Review of Resident #1's physician order, dated 07/01/25, reflected the following: Omnipod 5 Libre2 Plus G6 Kit (Insulin Infusion Disposable Pump) - Inject 200 ml subcutaneously one time a day every 3 day(s) for DM management. Review of Resident #1's MAR, July of 2025, reflected insulin was placed in the pump on 07/01/25, 07/04/25, 07/10/25, and 07/14/25. It reflected she refused on 07/07/25. Review of Resident #1's physician order, dated 07/01/25, reflected Glucagon Emergency Kit 1 MG - Inject 1 mg intramuscularly as need for hypoglycemia per protocol if patient is unconscious or unable to swallow. Review of Resident #1's MAR, July of 2025, reflected she was administered the Glucagon three times: *07/08/25 at 4:36 AM - BS: 74*07/09/25 at 4:48 PM - BS: 53*07/11/25 at 3:49 AM - BS: 65 Review of Resident #1's blood sugar readings in her EMR, from 07/01/25 - 07/15/25, reflected the following days/times her blood sugar was abnormally out of normal the range (normal range is 70 mg/dL -100 mg/dL): *07/01/25 10:43 PM - 42.0 mg/dL*07/05/25 6:21 PM - 300.0 mg/dL*07/06/25 6:33 AM - 326.0 mg/dL*07/09/25 4:49 PM - 52.9 mg/dL*07/13/25 8:55 PM - 350.0 mg/dL*07/14/25 7:09 AM - 400.0 mg/dL*07/14/25 12:09 PM - 399.0 mg/dL Review of Resident #1's physician order, dated 07/15/25, reflected to d/c insulin pump. Review of Resident #1's physician order, dated 07/15/25, reflected HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML - Inject subcutaneously before meals for DM. Review of Resident #1's physician order, dated 07/15/25, reflected Lantus Subcutaneous Solution 100 UNIT/ML - Inject 10 unit subcutaneously in the morning for DM - hold if BG is less than 110. During a telephone interview on 07/15/25 at 12:23 PM, Resident #1's NP stated she had been working with the facility for about a week but was familiar with Resident #1. She stated she had a conversation with her that morning (on 07/15/25) and there were concerns the pump was not functioning the way it should be, so she put in orders to discontinue the pump. She stated she should not have it on her if it was not working. She stated she ordered a sliding scale to better manage her blood sugars. She stated the staff had been informing her of general concerns regarding Resident #1 such as refusing showers and not eating much of her meals, but they had not mentioned irregular blood sugar readings. She stated if she had been, she would have discontinued the pump sooner. She stated if the pump was not working, a negative outcome could be potentially all the negative things with diabetes. She stated there was not a way to check those pumps in these environments. During a telephone interview on 07/15/25 at 12:38 PM, RN A stated she was very familiar with Resident #1. She stated since she had a pump, she would tell the nurses what her blood sugar was, and they would document it. She stated her biggest concern was that the nurses did not know what the pump was set at, so they did not know how much insulin she was getting. She stated Resident #1 had also not been eating much and that was a problem as well. She stated she did relay to the NP that she was not eating but not about the irregular blood sugar readings. She stated a few days prior in the morning (could not remember date), her blood sugar was 400 and she realized the pump was off. She stated there had been a time when her blood sugar was in the 60's and she realized it was not working and changed it out. She stated the day prior, 07/14/25, she had never seen Resident #1 with so much anger. She stated she was mad her pump was off and was not getting the insulin she needed. She stated she notified the NP who said she was going to put her on a sliding scale. She stated insulin pumps were rare in nursing facilities because they are hard to regulate. She stated Resident #1 had a history of being nauseous and did not notice an increase when her blood sugars were extremely high or extremely low. During an interview on 07/15/25 at 12:58 PM, Resident #1 stated the NP saw her that morning and discontinued her insulin pump. She stated that was what she requested because she was having a hard time keeping her blood sugar level up. She stated when it would get really high or really low, she would get extremely nauseated, more than normal. She stated she would get sweaty, dizzy, and was miserable. She stated she had difficulty sleeping and the nurses were aware. During an interview on 07/15/25 at 2:00 PM, the DON stated she had been working at the facility for about a month. She stated if Resident #1's blood sugar was in the 300-400 range that would be abnormal for her. She stated if it were her, she would have rechecked her blood sugar in an hour with one of their glucometers because the insulin pumps were not always accurate. She stated she would expect the nurses to follow-up on the blood sugar and notify the NP. She stated if she had known her blood sugar had not been stable, she would have spoken to the NP sooner about getting the pump discontinued and getting her on a sliding scale. She stated with really high or low blood sugar, a negative outcome could be DKA or feeling really hot or dizzy. During an interview on 07/30/25 at 12:52 PM, RN A stated there was a time (could not remember the date) when Resident #1's diabetic pump had been turned off or was not working properly. She stated she was not trained on the pump and had read the instructions inside the monitor's box on how to apply a new one. She stated the monitoring was being done on Resident #1's phone and she would go into her room every morning to the blood sugar readings off her phone so that she could document the numbers. She stated prior to the removal of her pump, there were no parameters of when to notify the NP in the (electronic monitoring system). She stated after it was removed, she was put on a sliding scaled and nursing staff were in-serviced to notify the NP if her blood sugar was above 400. During an interview on 07/30/25 at 1:13 PM, RN B stated she started working at the facility about two weeks prior and did not work with Resident #1 when she had the insulin pump. She stated when she was hired, she was in-serviced on rechecking the blood sugar when a reading was too high or too low to ensure the reading was accurate. She stated she the in-service also included when to notify the NP (blood sugar above 400). She stated she could not recall if the in-serviced including applying a sensor or pump. During an interview on 07/30/25 at 1:24 PM, RN C stated she had not worked with Resident #1. She stated a few weeks ago (could not remember the date), the DON present an in-service on insulin pumps and continuous glucose monitoring. She stated if there was a high reading (above 400), they would need to do a finger stick to have a comparison reading and then notify the NP. She stated if a resident was being administered insulin, there needed to be parameters in their chart of when to notify the NP if a reading was out of range. She stated if there were no parameters listed, the nurses needed to reach out the NP to get those parameters. She stated if a resident's blood sugar was too high or too low, they could experience increased confusion, drowsiness, and dizziness. During an interview on 07/30/25 at 1:33 PM, the DON stated the glucose monitoring devices/pumps were pretty self-explanatory and had directions in the box. She stated the staff had to read the device instructions to be able to apply it. She stated she was not at the facility at the time that it had to be applied to Resident #1 after it was found nonfunctional, so she did not check or verify that the new one was functioning. She stated she conducted an in-service to nurses on 07/15/25 on what to do if blood sugars were out of range on a Dexcom or Libre and they were required to re-check with a finger stick. She stated there was no in-service conducted on the application of the device itself (when Resident #1 was admitted ). She stated it was her expectation that there be parameters in residents' charts for glucose readings especially if there were fluctuating high and low numbers like she (Resident #1) did. She stated that was her expectation and felt like my nurses all knew that. She stated residents could experience out of parameter symptoms such as being hot or cold, clammy, thirsty, dizziness, and as nurses, we knew to look for those symptoms as they were very educated and taught that in nursing school. She stated there were no diabetic pumps currently in the facility and those devices were not seen much in nursing facilities. She stated if another resident was admitted with one, she would ensure parameters were in place and ensure glucose levels were checked manually AC and HS and that the NP was involved. She stated she would conduct in-services regularly on parameters, monitoring, and what to do if out of range. Review of the facility's undated Change in a Resident's Condition or Status Policy, reflected the following: Our facility shall promptly notify the reside, his or her Attending Physician, and representative of any changes in the resident's medical/mental condition and/or status. Review of the facility's Blood Glucose Monitoring Policy, revised 05/13/25, reflected the following: For residents who have continuous glucose monitoring systems, blood glucose via glucometer for verification of results will be done as per physician order. Review of the facility's Insulin Pump Use Policy, dated 05/16/25, reflected the following: It is the policy of this facility to allow access to administration of insulin via insulin pump in order to meet the needs of residents requiring the use of insulin and to prevent adverse effects on a resident's condition.1. Insulin pump settings will be in accordance with physician's orders. Depending on the pump, settings may include: insulin correction factor, carbohydrate to insulin ratio, basal and bolus settings, maximum bolus limits, glucose goals, correction above what glucose value, target ranges, duration of insulin action, temporary basal and activity settings and pump software updates.2. A hypoglycemia management plan will be documented and followed per physician's orders.The ADM and DON were notified on 07/30/25 at 2:14 PM that an IJ had been identified and an IJ template was provided.The following POR was approved on 07/31/25 at 3:50 PM: IMMEDIATE CORRECTIVE ACTIONS FOR REMOVAL OF IMMEDIATE JEPOARDY:On July 30,2025 at approximately 3:00 pm the following actions were initiated upon facility identification of concern. Action: Resident # 1 was assessed to ensure that the resident was not suffering from ongoing negative effects. Prior Glucose Dexcom Receiver Devise (Continuous Glucose System Receiver) was discontinued, and new orders were put in place for monitoring on 7.15.25. There are no other pumps in the facility at this time.Start Date: 7/30/2025Completion Date: 7/30/2025Responsible: Director of Nursing Action: Director of Nursing was educated on Insulin Pumps, Continuous Glucose Monitors and expectations when monitoring glucose and to check manually with glucometer if readings on a device are out of normal range.Start Date: 7/30/2025Completion Date: 7/30/2025Responsible: Director of Clinical Services Action: All Nurses were educated on Insulin Pumps, Continuous Glucose Monitors and expectations when monitoring glucose and to check manually with glucometer if readings on a device are out of normal range.Start Date: 7/30/2025Completion Date: This was initiated and completed on 7/30/2025. The Director of Nursing/designee will utilize staff roster to track those who have received education and to determine those who still require it. Anyone not able to be reached by phone or in person, agency and new hires will be educated prior to the start of their next shift. Responsible: Director of Nursing IDENTIFICATION OF OTHER AFFECTED: All residents with diabetes have the potential to be affected by this alleged deficient practice.Action: Review of 22 residents who have diabetes diagnoses for proper orders and hypo/hyper glycemic protocols in place and care planned. Three were sent to MD to review and see if any orders wanted to be changed. One changed to a sliding scale, one added accucheck schedule. The third one we are requesting labs today. Nurse will inform physician when admissions occur and go over any devices to ensure proper monitoring and orders are in place.Start Date: 7/30/2025Completion Date: 7/31/2025Responsible: Director of Nursing SYSTEMIC CHANGES AND/OR MEASURES: Action: ADHOC QAPI was performed for blood glucose monitoring and how to proceed with equipment failure. To perform in service and training to nurses. All residents with accuchecks will be audited to ensure appropriate orders are in place.Start Date: 7/30/2025Completion Date: 7/30/2025Responsible: Director of Nursing Action: All residents with diabetes were audited to ensure checks were occurring and that hypo/hyper glycemic protocols were in placed and care planned. Start Date: 7/30/2025Completion Date: 7/30/2025Responsible: Director of Nursing TRACKING AND MONITORING: Action: Audits will be conducted on blood sugar monitoring daily for a week, biweekly for 2 weeks and then monthly for 2 months. This will be tracked on a log.Start Date: 7/30/2025Completion Date: 7/30/2025. Responsible Party: Director of Nursing/Designee Action: Any new admissions will be reviewed by Director of Nursing/Designee to ensure physician is aware of any devices and that proper orders are in place. This review will take place daily for 2 weeks, then biweekly for 2 weeks, then monthly for 2 months. Any noncompliance will be communicated to nurse responsible and counseled accordingly. This will be tracked on a log. Start Date: 7/30/2025Completion Date: 7/31/2025. Responsible Party: Director of Nursing/DesigneeThe Surveyor monitored the POR from 07/31/25 - 08/01/25 as followed: During interviews on 08/01/25 from 11:54 AM - 1:05 PM with staff from all shifts - RN A, RN B, RN D, MA E, MA F, CNA G, and CNA H all stated they had been in-serviced before their shifts by the DON. The CNAs and MAs stated they closely monitored the residents for any changes in condition or changes from their baselines. The CNAs and MAs stated they would notify their nurse immediately of any changes and would document in their documenting system. The RNs stated they were in-serviced on changes in condition and notifying the NP/MD immediately. The RNs stated if a residents BS readings were not within parameters it was important for the NP/MD to be informed and for a change of condition form to be completed in their charts. The nurses stated if a resident was on an insulin pump and their sugar level was too high or too low (out of parameters), they were to recheck it with glucometer to ensure accuracy. The nurses stated if they believed an insulin pump was malfunctioning, they would notify the DON and NP/MD immediately. The nurses stated any resident that was administered insulin should have parameters in place on when to notify the NP/MD. The nurses stated signs and symptoms of blood sugar being outside of parameters could be nausea, dizziness, lethargy, or being unable to swallow. During an interview on 08/01/25 at 1:30 PM, the DON stated Resident #1 remained on long-acting insulin. She stated Resident #1 had type I diabetes and her pancreas did not work, so in her case her blood sugar would remain and, go up and down, and will always have to be closely monitored. She stated she and the ADM were in-serviced by their corporate nurse before providing education to the staff on notification on changes in condition, glucose monitoring, and insulin pumps. She stated any time a resident's blood sugar was outside of the parameters, the physician needed to be notified. During an interview on 08/01/25 at 1:38 PM, the ADM stated she and the DON were in-serviced by their DCS on notification of changes in condition, glucose monitoring, and insulin pumps before the staff were in-serviced. She stated 94% of the nursing staff had been in-serviced, and none could work the floor until they were. Review of Resident #1's physician order, dated 07/22/25, reflected record blood sugar AC/HS (before meals and at bedtime for monitoring). Review of Resident #1's physician order, dated 07/35/25, reflected HumaLOG Injection Solution - 100 UNIT/ML - Inject subcutaneously before meals for DM. Review of Resident #1's physician order, dated 08/01/25 reflected Insulin Glargine Subcutaneous Solution - 100 UNIT/ML - Inject 14 units subcutaneously in the morning for DM1. Hold if less than 110. Review of five sampled residents' charts that required insulin, on 08/01/25, reflected their care plans had diabetic interventions and there were ordered parameters for their blood sugar levels. Review of the facility's ADHOC meeting agenda, dated 07/30/25, reflected the ADM, DON, MDSC, DOR, and MD were in attendance. Review of an in-service, dated 07/30/25 and conducted by the DCS, reflected the ADM and DON were in-serviced on two key points: A malfunctioning diabetic pump and/or elevated blood glucose levels require immediate attention and notification to MD and nurse management. Provider and representative notification must be timely and clearly documented. Documentation should include date/time of change identification, communication, provider response, and new orders. Timely recognition and management of changes in condition, including care and management of diabetic pumps, and blood glucose readings. Clinical assessments and documentation must reflect staff recognizing when a blood glucose reading is inconsistent or clinically abnormal. Staff to recognize when to utilize a backup manual finger stick for malfunctioning diabetic pumps. Delay in response or lack of intervention may constitute a deficiency. Review of an audit conducted by the DON, dated 07/30/25 - 07/31/25, reflected all 22 residents who had a diagnosis of diabetes were audited for proper orders and hyper/hypo glycemic protocols in place and care planned. Of the 22 audited residents, three residents' clinicals were sent to the MD to review for a determination if any orders wanted to be changed. One resident was put on a sliding scale, one resident was added to the accucheck schedule, and one received an order for lab work. Review of their monitoring audit tool for review the 24-hour report for any changes in condition, on 08/01/25, reflected three different residents had been sampled on 07/30/25 and 08/01/25. It reflected if there was a change in condition in 24 hours, order listing report reviewed, notifications completed, and corrective actions taken if change in condition was identified. Four residents were idented with a change of condition and corrective actions were taken appropriately and verified. Review of an in-service dated 07/30/25 - 08/01/25 and conducted by the DON, reflected all nursing staff were notified on of their Notification of Changes/Change in Condition Policy. The CNAs and MAs were expected to notify the nurses of any change and nurses were expected to complete a change of condition form and to notify the NP and DON. Review of an in-service dated 07/30/25 - 08/01/25 and conducted by the DON, reflected all nurses were in-serviced on their Continuous Glucose Monitors Policy. Review of an in-service dated 07/30/25 - 08/01/25 and conducted by the DON, reflected all nurses were in-serviced on their Insulin Pump Use Policy.The ADM and DON were notified on 08/01/25 at 2:13 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change for one (Resident #1) of four residents reviewed for notification of changes. The facility failed to notify the NP when Resident #1's diabetic pump malfunctioned in July of 2025. Resident #1's blood sugar readings were sporadically out of range which led her to experience increased dizziness, nausea, and sweatiness. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/25 PM and a template was provided. While the IJ was removed on 08/01/25 at 2:13 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of DKA, dizziness, nausea, and a decreased quality of life. Findings included:Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including type I diabetes, gastroparesis (a condition in which the muscles in the stomach do not move well), chronic kidney disease, and muscle weakness. Review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 15, indicating she was cognitively intact. Section N (Medications) reflected she received insulin injections since admission. Review of Resident #1's admission care plan, dated 06/30/25, reflected there was not a focus regarding her being a diabetic or having an insulin pump. Review of Resident #1's physician order, dated 07/03/25, reflected the following: Dexcom G7 Receiver Device (Continuous Glucose System Receiver) - Apply to bar of upper arm topically one time a day every 10 day(s) for DM management. Review of Resident #1's TAR, July of 2025, reflected the receiver was changed on 07/03/25 and 07/13/25. Review of Resident #1's physician order, dated 07/01/25, reflected the following: Omnipod 5 Libre2 Plus G6 Kit (Insulin Infusion Disposable Pump) - Inject 200 ml subcutaneously one time a day every 3 day(s) for DM management. Review of Resident #1's MAR, July of 2025, reflected insulin was placed in the pump on 07/01/25, 07/04/25, 07/10/25, and 07/14/25. It reflected she refused on 07/07/25. Review of Resident #1's physician order, dated 07/01/25, reflected Glucagon Emergency Kit 1 MG - Inject 1 mg intramuscularly as need for hypoglycemia per protocol if patient is unconscious or unable to swallow. Review of Resident #1's MAR, July of 2025, reflected she was administered the Glucagon three times: 07/08/25 at 4:36 AM - BS: 7407/09/25 at 4:48 PM - BS: 5307/11/25 at 3:49 AM - BS: 65 Review of Resident #1's blood sugar readings in her EMR, from 07/01/25 - 07/15/25, reflected the following days/times her blood sugar was abnormally out of normal the range (normal range is 70 mg/dL -100 mg/dL): 07/01/25 10:43 PM - 42.0 mg/dL07/05/25 6:21 PM - 300.0 mg/dL07/06/25 6:33 AM - 326.0 mg/dL07/09/25 4:49 PM - 52.9 mg/dL07/13/25 8:55 PM - 350.0 mg/dL07/14/25 7:09 AM - 400.0 mg/dL07/14/25 12:09 PM - 399.0 mg/dL Review of Resident #1's physician order, dated 07/15/25, reflected to d/c insulin pump. Review of Resident #1's physician order, dated 07/15/25, reflected HumaLOG KwikPen Subcutaneous Solution Pen-inject 100 UNIT/ML - Inject subcutaneously before meals for DM. Review of Resident #1's physician order, dated 07/15/25, reflected Lantus Subcutaneous Solution 100 UNIT/ML - Inject 10 unit subcutaneously in the morning for DM - hold if BG is less than 110. During a telephone interview on 07/15/25 at 12:23 PM, Resident #1's NP stated she had been working with the facility for about a week but was familiar with Resident #1. She stated she had a conversation with her that morning (on 07/15/25) and there were concerns that the pump was not functioning the way it should be, so she put in orders to discontinue the pump. She stated she should not have it on her if it was not working. She stated she ordered a sliding scale to better manage her blood sugars. She stated the staff had been informing her of general concerns regarding Resident #1 such as refusing showers and not eating much of her meals, but they had not mentioned irregular blood sugar readings. She stated if she had been, she would have discontinued the pump sooner. She stated if the pump was not working, a negative outcome could be potentially all the negative things with diabetes. She stated there was not a way to check those pumps in these environments. During a telephone interview on 07/15/25 at 12:38 PM, RN A stated she was very familiar with Resident #1. She stated since she had a pump, she would tell the nurses what her blood sugar was, and they would document it. She stated her biggest concern was that the nurses did not know what the pump was set at, so they did not know how much insulin she was getting. She stated Resident #1 had also not been eating much and that was a problem as well. She stated she did relay to the NP that she was not eating but not about the irregular blood sugar readings. She stated a few days prior in the morning (could not remember date), her blood sugar was 400 and she realized the pump was off. She stated there had been a time when her blood sugar was in the 60's and she realized it was not working and changed it out. She stated the day prior, 07/14/25, she had never seen Resident #1 with so much anger. She stated she was mad her pump was off and was not getting the insulin she needed. She stated she notified the NP who said she was going to put her on a sliding scale. She stated insulin pumps were rare in nursing facilities because they are hard to regulate. She stated Resident #1 had a history of being nauseous and did not notice an increase when her blood sugars were extremely high or extremely low. During an interview on 07/15/25 at 12:58 PM, Resident #1 stated the NP saw her that morning and discontinued her insulin pump. She stated that was what she requested because she was having a hard time keeping her blood sugar level up. She stated when it would get really high or really low, she would get extremely nauseated, more than normal. She stated she would get sweaty, dizzy, and was miserable. She stated she had difficulty sleeping and the nurses were aware.During an interview on 07/15/25 at 2:00 PM, the DON stated she had been working at the facility for about a month. She stated if Resident #1's blood sugar was in the 300-400 range that would be abnormal for her. She stated if it were her, she would have rechecked her blood sugar in an hour with one of their glucometers because the insulin pumps were not always accurate. She stated she would expect the nurses to follow-up on the blood sugar and notify the NP. She stated if she had known her blood sugar had not been stable, she would have spoken to the NP sooner about getting the pump discontinued and getting her on a sliding scale. She stated with really high or low blood sugar, a negative outcome could be DKA or feeling really hot or dizzy. During an interview on 07/30/25 at 12:52 PM, RN A stated there was a time (could not remember the date) when Resident #1's diabetic pump had been turned off or was not working properly. She stated she was not trained on the pump and had read the instructions inside the monitor's box on how to apply a new one. She stated the monitoring was being done on Resident #1's phone and she would go into her room every morning to the blood sugar readings off her phone so that she could document the numbers. She stated prior to the removal of her pump, there were no parameters of when to notify the NP in the (electronic monitoring system). She stated after it was removed, she was put on a sliding scaled and nursing staff were in-serviced to notify the NP if her blood sugar was above 400. During an interview on 07/30/25 at 1:13 PM, RN B stated she started working at the facility about two weeks prior and did not work with Resident #1 when she had the insulin pump. She stated when she was hired, she was in-serviced on rechecking the blood sugar when a reading was too high or too low to ensure the reading was accurate. She stated she the in-service also included when to notify the NP (blood sugar above 400). She stated she could not recall if the in-serviced including applying a sensor or pump. During an interview on 07/30/25 at 1:24 PM, RN C stated she had not worked with Resident #1. She stated a few weeks ago (could not remember the date), the DON present an in-service on insulin pumps and continuous glucose monitoring. She stated if there was a high reading (above 400), they would need to do a finger stick to have a comparison reading and then notify the NP. She stated if a resident was being administered insulin, there needed to be parameters in their chart of when to notify the NP if a reading was out of range. She stated if there were no parameters listed, the nurses needed to reach out the NP to get those parameters. She stated if a resident's blood sugar was too high or too low, they could experience increased confusion, drowsiness, and dizziness. During an interview on 07/30/25 at 1:33 PM, the DON stated the glucose monitoring devices/pumps were pretty self-explanatory and had directions in the box. She stated the staff had to read the device instructions to be able to apply it. She stated she was not at the facility at the time that it had to be applied to Resident #1 after it was found nonfunctional, so she did not check or verify that the new one was functioning. She stated she conducted an in-service to nurses on 07/15/25 on what to do if blood sugars were out of range on a Dexcom or Libre and they were required to re-check with a finger stick. She stated there was no in-service conducted on the application of the device itself (when Resident #1 was admitted ). She stated it was her expectation that there be parameters in residents' charts for glucose readings especially if there were fluctuating high and low numbers like she (Resident #1) did. She stated that was her expectation and felt like my nurses all knew that. She stated residents could experience out of parameter symptoms such as being hot or cold, clammy, thirsty, dizziness, and as nurses, we knew to look for those symptoms as they were very educated and taught that in nursing school. She stated there were no diabetic pumps currently in the facility and those devices were not seen much in nursing facilities. She stated if another resident was admitted with one, she would ensure parameters were in place and ensure glucose levels were checked manually AC and HS and that the NP was involved. She stated she would conduct in-services regularly on parameters, monitoring, and what to do if out of range. Review of the facility's undated Change in a Resident's Condition or Status Policy, reflected the following: Our facility shall promptly notify the reside, his or her Attending Physician, and representative of any changes in the resident's medical/mental condition and/or status.The ADM and DON were notified on 07/30/25 at 2:14 PM that an IJ had been identified and an IJ template was provided.The following POR was approved on 07/31/25 at 3:50 PM: IMMEDIATE CORRECTIVE ACTIONS FOR REMOVAL OF IMMEDIATE JEPOARDY:On July 30,2025 at approximately 3:00 pm the following actions were initiated upon facility identification of concern. Action: Resident # 1 was assessed to ensure that the resident was not suffering from ongoing negative effects. Prior Glucose Dexcom Receiver Devise (Continuous Glucose System Receiver) was discontinued, and new orders were put in place for monitoring on 7.15.25. There are no other pumps in the facility at this time.Start Date: 7/30/2025Completion Date: 7/30/2025Responsible: Director of Nursing Action: Director of Nursing was educated on Notification of Changes and Change of Condition protocols.Start Date: 7/30/2025Completion Date: 7/30/2025Responsible: Director of Clinical Services Action: All Nurses were educated on Notification of Changes. Nursing should also complete Change of Condition in system as well as notify physician and Director of Nursing. Certified Medication Aides and Certified Nursing Aides were also educated on Notifying Charge Nurse of any Change in Condition.Start Date: 7/30/2025Completion Date: This was initiated and completed on 7/30/2025. The Director of Nursing/designee will utilize staff roster to track those who have received education and to determine those who still require it. Anyone not able to be reached by phone or in person, agency and new nurses will be educated prior to the start of their next shift. Responsible: Director of Nursing IDENTIFICATION OF OTHER AFFECTED: All residents with diabetes have the potential to be affected by the alleged deficient practice. Action: Review of 22 residents who have diabetes diagnoses for proper orders and hypo/hyper glycemic protocols in place and care planned. Three were sent to MD to review and see if any orders wanted to be changed. One change to a sliding scale, one added accucheck schedule. The third one we are requesting labs. Nurse will inform physician when admissions occur and go over any devices to ensure proper monitoring and orders are in place.Start Date: 7/30/2025Completion Date: 7/30/2025Responsible: Director of Nursing SYSTEMIC CHANGES AND/OR MEASURES: Action: ADHOC QAPI was performed for blood glucose monitoring and how to proceed with equipment failure. To perform in service and training to nurses. All residents with accuchecks will be audited to ensure appropriate orders are in place.Start Date: 7/30/2025Completion Date: 7/30/2025Responsible: Director of Nursing Action: All residents that with diabetes were audited to ensure checks were occurring and that hypo/hyper glycemic protocols were in placed and care planned. Start Date: 7/30/2025Completion Date: 7/30/2025Responsible: Director of Nursing TRACKING AND MONITORING: Action: Change of Condition will be monitored by running 24 hour report and order listing report. This will be completed daily for a week, then biweekly for 2 weeks, then monthly for 2 months. This will be kept on a log.Start Date: 7/30/2025Completion Date: 7/30/2025. Responsible Party: Director of Nursing/DesigneeAction: Any new admissions will be reviewed by Director of Nursing/Designee to ensure physician is aware of any devices and that proper orders are in place. This review will take place daily for 2 weeks, then biweekly for 2 weeks, then monthly for 2 months. Any noncompliance will be communicated to nurse responsible and counseled accordingly. This will be tracked on a log.Start Date: 7/30/2025Completion Date: 7/31/2025. Responsible Party: Director of Nursing/DesigneeAction: Implemented interventions immediately if notifications have not been made to the provider of any suspected change in condition. Documentation of notifications made to resident/representative and physician will be noted in the resident's electronic medical record to include alert charting for change in condition if warranted. Staff responsible for the deficient practice will be contacted and counseled accordingly.Start Date: 7/30/2025Completion Date: 7/30/2025. Responsible Party: Director of Nursing/DesigneePlease accept this letter as our plan of removal for determination of the alleged Immediate Jeopardy issued 7/31/2025. The Surveyor monitored the POR from 07/31/25 - 08/01/25 as followed: During interviews on 08/01/25 from 11:54 AM - 1:05 PM with staff from all shifts - RN A, RN B, RN D, MA E, MA F, CNA G, and CNA H all stated they had been in-serviced before their shifts by the DON. The CNAs and MAs stated they closely monitored the residents for any changes in condition or changes from their baselines. The CNAs and MAs stated they would notify their nurse immediately of any changes and would document in their documenting system. The RNs stated they were in-serviced on changes in condition and notifying the NP/MD immediately. The RNs stated if a residents BS readings were not within parameters it was important for the NP/MD to be informed and for a change of condition form to be completed in their charts. During an interview on 08/01/25 at 1:30 PM, the DON stated Resident #1 remained on long-acting insulin. She stated Resident #1 had type I diabetes and her pancreas did not work, so in her case her blood sugar would remain and, go up and down, and will always have to be closely monitored. She stated she and the ADM were in-serviced by their corporate nurse before providing education to the staff on notification on changes in condition. She stated any time a resident's blood sugar was outside of the parameters, the physician needed to be notified. During an interview on 08/01/25 at 1:38 PM, the ADM stated she and the DON were in-serviced by their DCS on notification of changes in condition before the staff were in-serviced. She stated 94% of the nursing staff had been in-serviced, and none could work the floor until they were.Review of Resident #1's physician order, dated 07/22/25, reflected record blood sugar AC/HS (before meals and at bedtime for monitoring). Review of Resident #1's physician order, dated 07/35/25, reflected HumaLOG Injection Solution - 100 UNIT/ML - Inject subcutaneously before meals for DM. Review of Resident #1's physician order, dated 08/01/25 reflected Insulin Glargine Subcutaneous Solution - 100 UNIT/ML - Infect 14 units subcutaneously in the morning for DM1. Hold if less than 110. Review of the facility's ADHOC meeting agenda, dated 07/30/25, reflected the ADM, DON, MDSC, DOR, and MD were in attendance. Review of an in-service, dated 07/30/25 and conducted by the DCS, reflected the ADM and DON were in-serviced on NP notification of changes with a key point: A malfunctioning diabetic pump and/or elevated blood glucose levels require immediate attention and notification to MD and nurse management. Provider and representative notification must be timely and clearly documented. Documentation should include date/time of change identification, communication, provider response, and new orders. Review of their monitoring audit tool for review the 24-hour report for any changes in condition, on 08/01/25, reflected three different residents had been sampled on 07/30/25 and 08/01/25. It reflected if there was a change in condition in 24 hours, order listing report reviewed, notifications completed, and corrective actions taken if change in condition was identified. Four residents were idented with a change of condition and corrective actions were taken and verified. Review of an in-service dated 07/30/25 - 08/01/25 and conducted by the DON, reflected all nursing staff were notified on of their Notification of Changes/Change in Condition Policy. The CNAs and MAs were expected to notify the nurses of any change and nurses were expected to complete a change of condition form and to notify the NP and DON.The ADM and DON were notified on 08/01/25 at 2:13 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1.The facility failed to ensure sanitation practices (cleaning the ice machine, cleaning the juice machine dispenser, cleaning the inside of the microwave, covering lemonade and iced tea drink receptacles to ensure they remain free of contamination, storing the ice scoop in an ice scoop receptacle that had a lid and that was free from standing water accumulation and free from food debris buildup, ensuring staff utilize hair restraints while in the kitchen, ensuring trash receptacles in the kitchen had lids secured covering contents, cleaning the walk in refrigerator unit shelving and walls to ensure they are free of mold and debris, sweeping the kitchen prep area floors to be free of debris and crumbs, and cleaning the kitchen prep area shelving to be free of debris and crumbs) 2.The facility failed to ensure cleaning logs were being completed. 3.The facility failed to ensure all items were covered and stored properly. 4.The facility failed to label and date all food items in the kitchen. 5. The facility failed to ensure all flooring was free from cracks and breakage and ice buildup and not a fall hazard. These failures could place residents at risk of foodborne illness. Findings included: Observation on 6/24/25 at 9:11 AM of 55-gallon trash can without a lid near 3 compartments sink area. Observation on 6/24/25 at 9:12 AM of broken kitchen floor tiles in speed rack / cart storage area near ovens. Observation on 6/24/25 at 9:15 AM of juice dispenser machine revealed the underside of the nozzle dispensing area to be covered in orange and red sticky buildup with fuzzy mold appearing substance on dispensing nozzles. Observation on 6/24/25 at 9:16 AM of 1 5-gallon container of lemonade and 2 5-gallon containers of iced tea without a lid or covering to prevent debris or containment from falling in. Observation on 6/24/25 at 9:17 AM of 55-gallon trash can near ice machine without lid. Observation on 6/24/25 at 9:18 AM of ice machine revealed mineral deposit buildup on outside of machine all around door and seal. Further observation revealed black and brown mold appearing substance and a pink and reddish slime appearing substance on the interior of the ice machine on the ice guard, door, door seal, and interior wall. Observation on 6/24/25 at 9:20 AM of the microwave revealed the interior of the microwave to have dried food debris on the interior top and in the corners. Observation on 6/24/25 at 9:22 AM of the kitchen dry goods pantry revealed a package of dry jello mix unsealed, dated 7/5, unsure if that is receipt date, open date, or use by date. Further observation revealed an undated, opened but securely sealed package of penne pasta. Observation on 6/24/25 at 9:26 AM of walk-in refrigerator unit revealed dunnage racks where crates of milk were being stored to be covered in a gray black mold appearing substance. Further observation revealed shelving and walls to have gray and black mold appearing substance on underside and tops of shelving and on walls behind shelving. Observation on 6/24/25 at 9:28 AM of walk-in freezer unit revealed ice buildup on floor of unit. Observation on 6/24/25 at 9:30 AM of kitchen prep area shelving to have crumbs and food debris on lower level. Observation on 6/24/25 at 9:33 Am of kitchen floor revealed crumbs and food debris on flooring. Observation on 6/25/25 at 12:11 PM of floor dolly where dish machine racks were stored with drinking glasses to have black and brown mold appearing substance on it. Observation on 6/26/25 at 10:15 AM of MS entering kitchen without hairnet or beard guard wearing ball cap. MS walked over to ice machine to perform checks on it. MS walked to back of kitchen to chemical storage closet and back to front of kitchen near DM office before exiting thru side door of kitchen. Interview on 6/26/25 at 10:50 AM with RD revealed the evening shift staff complete the cleaning logs. RD stated she was unsure of what the monthly ice machine cleaning entailed, and she was unsure of the specifics of the cleaning logs in general. RD stated she was unsure how often the walk-in refrigerator was supposed to be cleaned. RD stated all staff were to wear hair restraints while in the kitchen. RD stated she just consulted for the facility and was at the facility 1-2 times a week. RD stated the day to day running of the kitchen was the responsibility of the DM who was currently on vacation. RD stated if the kitchen sanitation was not maintained, and hair restraints were not worn then the residents have the potential for food borne illness and food contaminants. Interview on 6/26/25 at 11:10 AM with MS revealed he services the ice machine quarterly and deep cleans it twice a year. MS stated when he cleans and services the ice machine it was for the internal electrical and plumbing components of the machine not the interior or exterior cleaning of the machine. MS stated a hair restraint is to be always worn in the kitchen unless a ball cap was worn then that would count as a hair restraint and a beard guard was required for any facial hair more than 1 inch long. MS stated this was to prevent hair getting into the food and the food being contaminated. Interview on 6/26/25 at 1:49 PM with DM revealed it was expectation of the staff to follow the cleaning logs concerning the kitchen sanitation. DM stated he was unaware of the issues with the ice machine mold, juice machine buildup and mold, and walk-in refrigerator buildup and mold. DM stated he was also unaware of the food debris and crumbs on the kitchen prep area lower shelving and floors. DM stated it was his expectation that all food items were to be labeled, dated, and sealed properly. DM stated he was unaware of the broken floor tiles near the oven and the ice buildup in the freezer. DM stated all staff were to be wearing hair restraints while in the kitchen including beard guards if they have facial hair. DM stated it was his responsibility to ensure staff are completing the kitchen cleaning logs and to be monitoring the kitchen for proper sanitation practices. DM stated the kitchen staff needs to ensure proper sanitation practices, so the residents do not become sick. Interview on 6/26/25 at 5:26 PM with DON revealed it was her expectation that the kitchen be kept clean, and everything should be labeled, dated, and organized. DON stated she expected the staff to be following appropriate hand hygiene and hair restraint practices. DON stated it was the responsibility of the DM to ensure kitchen sanitation. DON stated if the kitchen sanitation is not maintained it can negatively affect the residents with the potential of food borne illness. Interview on 6/26/25 at 6:00 PM with ADM revealed she expected the kitchen staff were following a cleaning schedule and maintaining it. ADM stated it was her expectation that the staff were following policy concerning hair restraints. ADM stated it was the responsibility of the DM and the ADM to ensure kitchen sanitation was maintained. ADM stated it could potentially negatively affect the residents if kitchen sanitation was not maintained by food borne illness. ADM stated if hair restraints were not worn there was potential for contamination of food from hair. Record review of cleaning logs revealed there to gaps in completion in the logs from 2/25, 3/25, 4/25, 5/25, and 6/25. Attempted record review of kitchen sanitation policy was unsuccessful as the policy was requested on 6/26/25 at 1:33 pm with response from ADM on 6/26/25 at 3:48 pm that the facility does not have a kitchen sanitation policy. Record review of Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices policy undated reflected under policy interpretation and implementation: 12. Hair nets or caps and / or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens .

Based on observations, interviews, and record review, the facility failed to serve foods that were palatable and attractive and prepare food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchen observed. 1.The pureed kitchen test tray of the lunch meal foods were unappealing and lacked flavor. The pureed kitchen test tray lacked condiments, the food items did not hold their form and ran together, there was no garnishment of the food tray, and the dessert of lemon pie parfait was so thick, gummy, and tasted of food thickener it was inedible. 2. The regular texture kitchen test tray of the lunch foods were unappealing and lacked flavor. The regular texture kitchen test tray lacked condiments, the food items of roast pork loin was dried out, Harvard beet juice had run into the rice pilaf, the dessert of lemon pie parfait was not a full serving size of ½ cup, and there was no garnishment of the food tray. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life. Findings included: Observation on 6/25/25 at 10:30 AM of lunch meal puree preparation revealed CK K was pureeing pork loin. CK K was observed pouring food thickener from thickener container into puree machine with pork loin and broth. CK K did not measure food thickener just poured straight from container on 3 different occasions while pureeing pork loin. Further observation revealed CK K did not taste the pork loin after the pureed process was complete. Observation on 6/25/25 at 1:13 PM of Pureed texture lunch kitchen test tray revealed the test tray did not have any condiments on the tray, the food items of (roast pork loin, Harvard beets, rice pilaf, and dinner roll) did not hold their form and ran together. There was no garnishment on the meal tray. The dessert of lemon pie parfait was so thick, gummy, and tasted of food thickener it was inedible. The pureed foods items were unappealing in appearance and lacked flavor. Observation on 6/25/25 at 1:13 PM of the Regular texture lunch kitchen test tray revealed the test tray did not have any condiments on the tray, the food items of roast pork loin was dried out and had no gravy or sauce to give any moisture, Harvard beet juice had ran all over the plate and got into the rice pilaf, and the dessert of lemon pie parfait was not a full serving size of ½ cup (per diet spreadsheet and recipe), and there was no garnishment for the food tray. Observation on 6/26/25 at 10:05 AM of lunch meal puree preparation revealed CK K was pureeing Salisbury steak, carrots, dinner rolls, and strawberries. CK K stated the food thickener scoop was missing from the container and proceeded to use a table cutlery teaspoon to measure food thickener for each of the food items prepared. CK K visually looked at each food item to ensure desired consistency was achieved. CK K did not taste any of the food items prepared after the puree process was complete. During a confidential resident council interview on 6/25/25 at 2:03 PM it was revealed that several concerns and complaints were made of the food being inedible and being told when asking for alternatives that none are available. Ombudsman present at resident council meeting confirmed food concerns have been brought up for the last several months at the resident council meetings with no resolution being provided. Interview on 6/25/25 at 3:24 PM with CK J revealed CK J stated when pureeing foods, you need to start with 2 oz of liquid then add more as needed. CK J stated the next step is to use the spoon test to see if the desired consistency has been achieved and add food thickener as needed until the desired consistency is reached. CK J stated you always need to use the least amount of liquid and food thickener as possible so as not to compromise the flavor or nutrients of the food. Interview on 6/26/25 at 10:33 AM with CK K revealed CK K stated she had received 1 month of training from the DM. CK K stated the method she used was to start the puree machine, count 30 seconds, then check the consistency of the food item to see if food thickener needs to be added. CK K stated, I add 1 tsp at a time if the scoop is missing from the thickener container, I just use a regular teaspoon that the residents receive on their trays. CK K stated you visually check the food item, and you also taste the food items. CK K could not explain or give an answer as to why she had not tasted any of the food items when she completed the puree process. Interview on 6/26/25 at 10:50 AM with RD revealed the RD stated she expected the meals served to be attractive and palatable to the residents. When shown photos of the pureed texture test tray, RD stated the foods are not supposed to run together and the food items should hold their form. RD stated the dessert item lemon pie parfait should not be as thick as it appeared in the photo. RD stated all food items should have the flavor of the food item and not just the flavor of food thickener. When shown photos of the regular texture test tray, RD stated the Harvard beets could have been drained better before plating so the juices did not run into the other food items. RD stated she was unsure if the dessert item of lemon pie parfait was the correct serving size as it was hard to tell from a photo. When asked if the RD watched the tray line process RD responded, yes. When asked if the RD felt the dessert items were of the correct serving size, RD stated she was unsure as she had not specifically looked at the dessert items. When asked if condiments were supposed to be on the meal trays RD stated, Yes condiments should be on the meal trays. RD stated she was unsure about the cook training specifics, RD stated she knew the DM had trained the cook. RD stated if she sees a concern when she is present then she works with the staff member in the moment and alerts the DM for further training and or follow up. RD stated she was unsure if the diet spreadsheet and recipes address the pureed texture diets. Telephone interview on 6/26/25 at 1:49 PM with DM revealed the DM stated the cooks were trained on how to prepare pureed foods from the corporate office. DM stated corporate had a trainer come to the facility and train and that the ADM had a copy of the in-service training provided. DM stated he was aware that the pureed recipes were not in the diet spreadsheet binder. DM stated he had contacted the food service company that the facility used to request these recipes be sent to him to add to the diet binder. DM stated he had not received a reply from the food service company at this time. DM stated he expected the meal trays to be attractive and palatable to the residents. Interview on 6/26/25 at 5:26 PM with the DON revealed she expected the meal tray to be clean, meal ticket to be correct with all the information needed, and the meal to be presentable and appealing. DON stated she was unsure if there should be recipes for the pureed foods in the diet spreadsheet binder. DON stated she was unsure how the cooks were trained about how to puree foods. DON stated she had only been employed at the facility for a couple of weeks and she was still unsure about several of the processes, but she felt the DM was responsible for the kitchen and the kitchen staff. Interview on 6/26/25 at 6:00 PM with ADM revealed the cooks work with the DM for a minimum of 3 days of training and that the RD and speech therapist both assist as needed for training and coaching the staff. ADM stated recipes for pureed foods were not necessarily needed to be in the diet spreadsheet binder as the cooks should be visually looking at the food items to see if the desired consistency has been achieved and tasting all the foods items to ensure the desired flavor was present. ADM stated the cooks had received training on the puree process from the corporate office. ADM further stated that the cooks were to be using the least amount of food thickener as possible to achieve the desired consistency and taste. ADM stated she expected the tray appearance to be appetizing for the regular texture and for the pureed texture she expected those trays to also be appetizing in appearance and for the food to hold its consistency. Record review of diet spreadsheet binder reflected no recipes available for pureed food items. Record review of food thickener container listed specific thickener mixing chart instructions depending on desired consistency of food item. Pureed fruits 4 oz drained use 3/4-1 1/2 tsp thickener Pureed vegetables 4 oz drained uses ¾-1 1/2 tsp thickener Pureed meats 3 oz uses 1 oz meat broth slurry. Meat broth slurry =4 oz meat broth thickened with 1 Tbsp. thickener Record review of Menus and Adequate Nutrition policy undated reflected under heading policy: The purpose of this policy is to assure menus are developed and prepared to meet resident choices including their nutritional, religious, cultural, and ethnic needs, while using established guidelines. Under heading policy explanation and compliance guidelines: 5. Menus shall reflect input from residents and resident groups. a. Resident preferences, including likes and dislikes will be documented in the resident's chart, and shall be reviewed when planning menus. i. Alternatives shall be immediately available if the primary menu or selections for a particular meal is not to a resident's liking. ii. Each resident's plan of care will reflect interventions to accommodate nutritional needs. when his/her preferences exclude a food group (i.e. vegetarian, does not eat dairy). b. The resident council will be included periodically in menu planning, and efforts will be made. to accommodate requests. The facility shall make the final decision on all menus. Record review of IDDSI implementation in-service training log dated 5/20/21 reflected DM, CK J, and CK K had attended the training. Record review of pureed recipes provided by ADM reflected: 1. Prepare food item according to regular recipe. 2. Prepare slurry. 3. Process until smooth adding 1oz slurry per portion. Notes: 1. Amount of thickener required may vary relative to liquid content of cooked product. For best results alternate thickener and processing checking product consistency periodically. Record review of always available menu posted on bottom of daily menu reflected options of cottage cheese w/fruit, baked potato (butter, cheese, and sour cream), and sandwich (ham, turkey, chicken salad, tuna salad, peanut butter & jelly). Record review of grievance binder reflected 10 grievances filed since 1/2025 concerning food preferences no grievances had resolution part of grievance form completed.

Based on observations, interviews, and record review, the facility failed to adequately equip residents the ability to call for staff assistance through a communication system, which relays the call directly to a staff member or to a centralized staff work area, from the bathroom for 56 of 61 resident rooms reviewed for resident call systems. The facility failed to ensure resident bathrooms had a pull string attached to the push button call light switch making the call light button inaccessible if the resident was lying on the floor in their bathrooms in rooms: 1) 100 2) 102 3) 103 4) 105 5) 106 6) 107 7) 110 8) 111 9) 113 10) 115 11) 116 12) 117 13) 118 14) 119 15) 120 16) 121 17) 122 18) 123 19) 124 20) 125 21) 126 22) 127 23) 128 24) 129 25) 130 26) 131 27) 200 28) 201 29) 202 30) 203 31) 204 32) 205 33) 206 34) 207 35) 208 36) 209 37) 210 38) 211 39) 212 40) 213 41) 214 42) 215 43) 217 44) 219 45) 221 46) 222 47) 223 48) 224 49) 225 50) 226 51) 227 52) 228 53) 229 54) 230 55) 231 56) 232 This failure could place residents at risk of harm by not being able to call for help when needed and at risk of not receiving the care and services to maintain their highest level of well-being. Findings included: Observations on 06/24/2025 by the survey team during the initial pool screening of residents' rooms in the 100 and 200 halls from 9:30 AM to 4:30 PM revealed most bathrooms (56 rooms in total) had a push button call light system next to the toilet on the wall. There were no strings attached to the push call light buttons that extended to the floor. In an interview on 06/25/2025 at 02:50 PM RN G stated she was familiar with the facility's call light policy. Call lights must be within reach of the resident. In the bathroom, RN G stated she did not know exactly where the placement should be, but the current push button call light system in room [ROOM NUMBER], and many other rooms, would not be within reach if a resident was lying on the floor and that could potentially cause harm if the resident fell and could not call for help. RN G stated that help could be delayed due to the resident not being able to reach the call light. RN G stated she thought the call light system should have a pull string cord. In an interview on 06/25/2025 at 03:04 PM CNA H stated he was aware of the facility's call light policy. He stated the call light policy was for the call light to be within reach of the resident and he would clip the call light bedroom call light to the resident or the bedding. In the bathroom, CNA H stated he did not know exactly where the placement should be, but the current push button call light system in room [ROOM NUMBER], and many other rooms, would not be within reach if the resident was lying on the floor and that could potentially cause harm if the resident fell and could not call for help. He stated help would be delayed due to the resident not being able to reach the call light. CNA H stated he thought the call light should have a pull string, which is the new system and easier for the residents to use as it took less effort and force on the resident's part. The old system call light system was the push button. In an interview on 06/25/2025 at 03:22 PM the Maintenance Director stated he was responsible for repairing call lights. He stated that their policy was that call lights needed to be within reach if the resident was lying on the floor. He stated he did not know why some bathrooms had pull string cords vs. push buttons but stated that a resident could not reach the push call button if they were on the floor and that could cause a delay in staff's response to provide care, which would not be good for the resident. During observations and an interview on 06/26/2025 at 08:31 AM the Maintenance Director measured the distance from the floor to the push call light button in three random rooms (205, 211, and 223) using a standard hard tape measure. The push button call lights were 41 inches from the base of floor to the push button. The Maintenance Director stated 41 inches was the standard placement and it should be the same in all rooms. The State Surveyor also measured with own tape measuring device and got the same measurement of 41 inches from the base of floor to the push button call light. All these rooms also have a shower in them, and it would not be accessible from the shower area as the call light is on the opposite wall of the shower, next to the toilet. The Maintenance Director stated the push call lights could not be reached by a resident lying on the floor. In an interview on 06/26/2025 at 09:20 AM the DON stated she did not know what the policy said about call light placement because she has only been at the facility for two weeks. The DON stated there were some pull lights with strings and some push buttons call lights in bathrooms and she had not had any complaints about the call light system. The DON stated she did not think either pull string or push button would be accessible to a resident lying on the floor. The DON stated it was important for a resident to be able to reach the call light and if they could not, they might try to get up by themselves and fall. Also, not being able to reach the call light could cause a delay in response time by staff. In an interview on 06/26/2025 at 10:12 AM the ADM stated that their policy for call lights placement in the bathrooms were to be accessible to a resident lying on the floor. The ADM stated she was not sure if a resident lying on the floor could reach the call push button or not. She stated she was not sure if a resident on the floor could reach a pull cord string call light either. The ADM stated those push button call lights were old and had been in the facility for years. The pull string system was new. She thought there were 55 rooms with the old push button call light system. The ADM stated it was important for a resident to be able to call for assistance so their needs can be met timely and not being able to reach the call light could cause a delay in care, which could result in potential harm depending on the situation. The ADM stated she did not believe any residents had fallen in the bathrooms and had tried to use the call lights. The ADM stated that when residents fell, they usually do not use the call lights because they were on the floor. The ADM stated this was a list of rooms with push buttons for call lights in the bathrooms: 100 102 103 105 106 107 110 111 113 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 217 219 221 222 223 224 225 226 227 228 229 230 231 232 Review of the facility policy Call lights: Accessibility and Timely Response, undated, reflected: Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. 7. The call system must be accessible to the resident at each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor.

Based on interviews and records review, the facility failed to allow residents to manage his or her financial affairs for 1 of 1 resident council reviewed. The facility failed to ensure all residents whose funds are managed by the facility had ready access to his or her funds upon request in a timely manner, including non-business days, Saturday, and Sundays. This failure could place all residents whose funds were managed by the facility of not receiving funds deposited with the facility and not having their rights and preferences honored. Findings included: During a Resident Council meeting on 6/25/2025 at 2:00 PM, 16 anonymous residents stated they were allowed to access their petty trust funds during the week. They all stated they were not aware of a petty cash fund policy, but they know it is accessible on the weekdays and to work with RECP to withdraw petty cash. They all stated they liked to get dollar bills for the vending machines. They all stated they were not able to access funds during the weekend as the RECP did not work those days. The VP and President both stated there was a time when they could access funds on the weekend when there was an employed RECP, but it had been over a year since one was employed. They all stated they wanted to see the facility hire a new staff to help with this task for residents. In an interview on 6/25/2025 at 3:27 PM RECP stated petty cash for trust fund accounts could be accessed by residents only Monday - Friday, 8 AM - 4 PM. She stated there was no weekend access to funds. She stated she locked up the petty cash on Friday and no other staff had access. RECP stated she was given a daily balance if a resident inquired on their fund availability. She stated some residents would visit her daily for a few dollars as they enjoyed making purchases out of the soda and snack vending machines and required dollar bills. RECP stated the residents were aware there was no weekend access to the petty cash and to make sure on Friday to withdraw funds for the weekend if needed. She stated there was a weekend receptionist for a few months to help with petty cash, but she didn't last long. She stated she was not sure if there was a specific policy for resident access to their funds. In an interview on 6/26/2025 at 11:48 AM AD stated for the residents that require funds for community outings she worked with RECP to withdraw funds. She stated funds could be accessed Monday - Friday as there was no weekend RECP. She stated residents were aware of the rule to withdraw funds Monday - Friday. AD stated last year, resident council asked about money on the weekends and facility hired a receptionist, and they had access to it on the weekend, after one month she quit, and they never hired another receptionist. Weekend petty cash access was implemented for a month. She stated she was not familiar with the policy on trust funds and to reach out to the Business Office Manager for more details. In an interview on 06/26/2025 at 3:20 PM BOM stated RECP is responsible for trust fund petty cash for residents. She stated every morning she would provide RECP a total account balance that gives totals for each resident and if the residents asked to withdraw petty cash funds, they would sign the money out with RECP. She stated the petty cash funds were available Monday-Friday 8 AM - 5 PM. She stated she had open communication with all the residents and if they needed money for the weekend, she would be happy to assist, but the residents made sure they came up on Fridays to get the appropriate amount for weekends. BOM stated some residents did not remember withdrawals occurred Monday - Friday but it was repetitive. She stated a few residents would ask the same questions. The BOM stated she believed 99% of the residents were aware of how to access funds on the weekend. She stated there was no policy in place that outlined when trust fund petty cash was available and how the residents could access it. She stated a resident would not go without funds on the weekend and ADM or DON would be notified if funds were needed. She stated residents were notified of trust funds with their admission paperwork and she talked to residents individually and passed this information on. She stated the residents would not have a negative impact as there was always a way to accommodate the resident's trust fund petty cash needed it just was not documented in a policy. In an interview on 6/26/2025 at 6:15 PM ADM stated the petty cash process was taken care of by RECP, it was available to residents Monday - Friday 8 AM - 5 PM and it was not available on weekends as she did not have anyone at the facility to access the funds on the weekends. She stated a while back a few residents asked if someone could be available on the weekends to access personal funds and a part-time RECP was hired. She stated the part-time RECP did not last long, and the position had since been vacant. She couldn't recall how long back. She stated she did not believe there was an impact to residents if they were unable to access personal funds as staff could help them purchase something until Monday mornings. Review of Resident Funds Management Service Withdrawal Records reflected petty cash account funds withdrawal is only accessed Monday - Friday: 5/7/2025 Petty Cash Account - Petty cash trust fund check logs for week dated 4/29/2025 - 5/1/2025. 5/12/2025 Petty Cash Account - Petty cash trust fund check logs for week dated 5/6/2025 - 5/9/2025. 5/16/2025 Petty Cash Account - Petty cash trust fund check logs for week dated 5/12/2025 - 5/15/2025. 5/27/2025 Petty Cash Account - Petty cash trust fund check logs for week dated 5/19/2025 - 5/23/2025. 6/6/2025 Petty Cash Account - Petty cash trust fund check logs for week dated 5/27/2025 - 5/30/2025. 6/11/2025 Petty Cash Account - Petty cash trust fund check logs for week dated 6/2/2025 -6/4/2025. 6/12/2025 Petty Cash Account - Petty cash trust fund check logs for week dated 6/9/2025 -6/12/2025. Review of facility policy dated Quarter 3, 2022 and titled Resident Rights reflected the following: r. manages his or her personal funds, or have the facility manage his or her funds (if he or she wishes). Review of facility policy no date noted and titled Resident Trust Policy and Procedures reflected the following: The facility Business Office Manager is responsible for maintaining patient trust accounts and is required to leave a sufficient balance (State Allowance) in the account to cover unforeseen personal needs the resident may request or require in the immediate future (such as hair care, outing expenses, etc.). Review of facility policy dated 2025 and titled Resident Personal Funds reflected the following: 2. If the resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility. Review of facility policy dated Quarter 3, 2022 and titled Resident Rights reflected the following: 2. Copies of our resident rights are posted throughout the facility, and a copy is provided to each employee, provider, and contracted staff member. In addition, staff will have appropriate in-service training on resident rights prior to having direct-care responsibilities for residents and 4. Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights. Review of facility admission Packet dated 9.2022 and titled Statutory Patient's Rights - Statement of Resident's Rights in Texas reflected the following: 13. You have a right to: Access money and property you have deposited with the facility and to an accounting of your money and property that are deposited with the facility and of all financial transactions made with or on behalf of you.

Based on interview and record review, the facility failed to consider the views of the resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility or to demonstrate their response and rationale for such response for 1 of 1 resident council reviewed. The facility failed to follow up on concerns and requests expressed in resident council meetings from January 2025 through June 2025. This failure placed residents at risk of not having their preferences honored. Findings included: Review of Resident Council minutes reflected the following with no documentation of the facility's responses to the grievances: February 2025 reflected: choose 5 entrees with sides and dietary manager will try to choose 3 he can possibly make for the future month. 1 meal can be chosen out of the 3 for a meal of the month. 3/6/2025 reflected: wanting to know when we can start meal of the month. 4/3/2025 reflected: 2. Resolutions from last month are not satisfactory or even resolutions. 3. Will start by taking ideas for meal of the month. Spoke about why we are not allowed to have fried chicken. April meal of the month by vote - Frito chili pie with baked beans and 2 cookies. 5/1/2025 reflected: 7. food committee would like to meet with dietary manager about the meal of the month. 14. Get some decent coffee. 6/6/2025 reflected: 2. introduce new dietary manager. 6. Residents wanting to know how to talk to dietary manager directly. During a Resident Council meeting on 6/25/2025 at 2:00 PM, 16 anonymous residents stated the SS helps to document the minutes for each monthly meeting. They all stated when there is a concern, they address it in the Resident Council meeting monthly and a grievance is documented, but these grievances are not being addressed. They all stated they were not aware of any method by which the facility management provided resolutions to the concerns that came up in the resident council minutes. They all stated most of the complaints were about the food, the facility being short staffed, and the maintenance of the physical environment. They stated they have discussed the meal of the month and better coffee in numerous monthly meetings over the last six months. They all stated they have filed a grievance each time as these are a priority of the residents. They all stated that they discuss their resident rights during meetings, but feel they are not being taken seriously. They stated they had never seen any kind of written paper or grievance form that reflected their concerns and requests during resident council or explained any resolution. They stated they had become tired of saying anything to the staff because nothing ever changed. They all stated with the turnover of SSs it is hard to get anything resolved. They stated they tried to speak with the SS two months back, they would go by her office, left a note almost weekly, and no response. Stated they have worked with the RECP to get a message to the new SS and even a phone message was left for her a week back and there is yet to be a response. They all stated the meal of the month is a small ask and has been discussed for more than six months now and when they thought it was going to happen and the DM scheduled a day for it last month it was cancelled without warning or information as to why. They all stated they drink coffee daily and have asked for better coffee, but this also falls on deaf ears. In an interview on 6/26/2025 at 3:00 PM Ombudsman stated he has attended the monthly Resident Council meetings on numerous occasions and the residents have addressed the meal of the month grievance as their top priority issue they would like addressed. He stated he has received individual food complaints from residents here at the facility and has been working directly with the ADM to address. He stated he has not received any information on resolution of said complaints other than an email from the ADM that it would be addressed. In an interview on 6/26/2025 at 11:48 AM AD stated Resident Council grievances are followed-up by the Resident Council President and VP. She stated she was voted in to help take the minutes at the monthly meetings and she doesn't give input or voice her opinions, she just takes notes for the group as they have challenges with writing and keeping order. She stated if there is a grievance addressed in the meeting, she will work with the resident council president and write a grievance report and give directly to the SS who in turn is responsible for passing it out to the head of department the concern addresses, it is investigated, reviewed by the ADM, signed, and entered in the grievance binder. She stated at the following resident council meeting she will read the resolution to the grievance. She stated the #1 complaint is food. AD stated the meal of the month grievance was provided to the dietary manager to address. She stated the DM stated the resident council could vote on 3 meals and he would choose one. AD stated the previous month she completed a grievance form, and the meal of the month was voted on, and the chili dogs and Fritos were chosen. She stated she did not receive the form back from the SS or ADM. When asked about following up on the grievance she stated she doesn't follow-up on grievances and this responsibility is that of the ADM and SS. She stated the SS has been employed a month at this facility and she was aware of this grievance and would be taking care of it. AD stated grievances are discussed in the morning meetings with all department heads in attendance. She stated she has brought up the Resident Council grievances regarding the meal of the month and coffee and the heads of the departments inform the ADM they would handle the grievance. AD stated that the potential impact of not having the Resident Council receive follow up on their concerns can be frustrating and disappointing. In an interview on 6/26/2025 at 1:45 PM RD stated she has not been made aware of the meal of the month grievance request. She stated she was not aware this was a request. She stated her understanding of this process would be to have the AD and DM plan the menu and consult with her on menu options. In an interview on 6/26/2025 at 2:00 PM CK J stated about a year back the facility did away with the meal of the month. She stated the DM has been made aware of this request but because he has only been in this position since December 2024, he has not been able to implement. She stated she and the DM were made aware of this grievance about two months back and the DM is planning to get to working on it as soon as he returns from vacation next week. She stated the kinds need to be worked out for the special meal of the month and believes this is the responsibility of dietician, DM, and ADM. She stated the meal of the month is needed in the facility as the residents want it and are constantly asking for this. She would like to see this implemented again. In an interview on 6/26/2025 at 3:00 PM SS stated she has been employed one month with this facility. She stated her first week here at the facility she was invited by the council to the monthly meeting to introduce herself and to discuss the submission of grievances. She stated the Resident Council residents stated they did not like agency staff, and this was documented on a grievance form. She stated to resolve this issue the residents were informed that staff would be utilized first then last resort to bring on agency staff, but if staff are not available there is no other option as they need to have staff present on each shift. She stated the current grievance process is for staff to assist resident with filling out a grievance form, getting it over to her or ADM so it can be assigned to the department head to address. She stated depending on the type of grievance there should be a 72-hour turnaround, it is then returned to her for review and to provide follow-up. She stated she and the ADM will provide resolution information to the individual or group. She stated if the grievance is given directly to the department head, she is sure it will be worked on. She stated her understanding is that the resolution of a grievance would be provided at the next meeting by the AD. She stated she is sure this information would get passed on to the residents. When asked how the grievance is tracked to ensure it was returned by the department head or if it was resolved and residents notified, she stated she is not currently doing this. She stated if no resolution or response to a grievance is provided to residents it can impact them. She stated if just one grievance on a particular issue may not cause an impact, but if continuously happening residents can become upset. She stated she was not aware of the meal of the month grievance, but she is familiar with the better coffee grievance. She stated there are few residents who have a concern with the quality of the coffee and those few residents have been notified they can get a better-quality coffee from the nurses' stations. In an interview on 6/26/2025 at 5:50 PM DON stated she has been employed only two weeks at this facility. She stated grievances are discussed in morning meetings, SS will discuss any new or pending grievances. She stated she has not heard of any Resident Council grievances mentioned. She stated when grievances are not addressed this can impact the resident by feeling they are not important, or their concern is not a priority, and this can cause mental health anguish. In an interview on 6/26/2025 at 6:15 PM ADM stated grievance forms are located directly outside of her door, the RECP helps log them and assigns them to head of department staff to be resolved within 5 days. She stated individual and group grievances are addressed in the morning meetings and assigned to department heads. She stated she and the SS will usually go and speak to the individual or resident council to follow-up on grievance and to notify them of the resolution. She stated she was notified of the meal of the month grievance filed by the Resident Council a few months back, but she couldn't recall the month. ADM stated the DM took over the position 6 months back, has worked a lot of shifts himself, has had to fire staff not following regulations in the kitchen and hire and train new staff. She stated the DM would like to coordinate more with the Resident Council on the meal of the month, but he doesn't have the ability to do this at this time, hard to make progress, and if going to commit he needs to have enough staff to do this monthly. She stated the meal of the month is on hold and can be revisited later. She stated this information has been provided to the Resident Council members. Review of Grievance/Concern Report dated 5/1/2025, reflected: Resident Council communicated concern, get some decent coffee was assigned to the DM by the SS and the date of resolution was 6/6/2025 noting, No changes have been made to the coffee that has been ordered over the last year, nor under this dietary manager. Each nurse's break room has a Keurig if residents want a more specialized coffee than either resident or family can purchase, and staff can make the coffee and temp prior to serving. The investigation results and resolution reported to resident council. Review of facility admission Packet dated 9.2022 and titled 15. Resident Grievances reflected the following: We urge you to bring any grievances concerning the Facility to the attention of the Facility Administrator. Please know that you have the right to voice grievances to the Facility personnel without reprisal. Review of facility admission Packet dated 9.2022 and titled Statutory Patient's Rights - Statement of Resident's Rights in Texas reflected the following: 7. You have a right to: Complain about the facility and to organize or participate in any program that presents residents' concerns to the administrator of the facility. Review of facility admission Packet dated 9.2022 and titled Resident's Rights Under Federal Regulations reflected the following: A facility must protect and promote the rights of each resident, including each of the following rights: (f) Grievances. A resident has the right to - (1) Voice grievances without discrimination or reprisal; and (2) Prompt efforts by the facility to resolve grievances the resident may have. Review of facility policy dated Quarter 3, 2022 and titled Resident Rights reflected the following: h. be supported by the facility in exercising his or her rights. Review of facility policy dated Quarter 3, 2022 and titled Resident Rights reflected the following: u. voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal and v. have the facility respond to his or her grievances. Review of facility policy dated Quarter 3, 2022 and titled Resident Rights reflected the following: 2. Copies of our resident rights are posted throughout the facility, and a copy is provided to each employee, provider, and contracted staff member. In addition, staff will have appropriate in-service training on resident rights prior to having direct-care responsibilities for residents and 4. Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights.

Based on observation, interview, and record review, the facility failed to ensure that residents had suitable, nourishing meals and snacks outside of scheduled meal service times for 2 of 2 halls (100 and 200 halls) and 2 of 2 refrigerators in 2 of 2 nourishment rooms (100 hall and 200 hall) reviewed for evening snack. The facility failed to ensure residents were offered snacks at bedtime on the 100 and 200 halls. The facility failed to have reserves of snacks for after dinner and at bedtime in 2 of 2 refrigerators in the nourishment rooms. This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for unplanned weight loss, side effects from medication given without food, and diminished quality of life. Finding included: Observation on 6/24/2025 at 9:39 AM of hall 200 nourishment room revealed health shakes, cartons of milk, and containers of yogurt in refrigerator. One peanut butter and jelly sandwich on nourishment room shelf dated 6/23 and several packages of peanut butter crackers. Further observation revealed no temperature monitoring log on nourishment room refrigerator. Observation on 6/24/2025 at 12:52 PM of hall 100 nourishment room revealed no refrigerator in nourishment room. Further observation revealed no snacks on shelving in nourishment room. Nourishment room contained ice chest with ice in it and a coffee maker with a tray of mugs. Observation on 6/26/2025 at 4:41 PM of hall 200 nourishment room revealed health shakes, 2 cartons of milk, 1 container of thickened milk, 11 bottles of Boost supplement drink and a thermometer. No resident snacks available in refrigerator. On nourishment room shelving revealed to have 5 packages of peanut butter crackers, and a supermarket bag with 3 packages of pudding cups. Observation on 6/26/2025 at 4:44 PM of hall 100 nourishment room revealed nourishment room now has a refrigerator. Refrigerator only has a thermometer and a jar of picante sauce with a resident name labeled on it. During a Resident Council meeting on 6/25/2025 at 2:00 PM, 16 anonymous residents stated snacks were not offered and were not aware they could ask for them. Some residents stated they have asked for a snack during bedtime and have been informed they do not have any or are told they will come back with one and the staff does not return. Interview on 6/26/2025 at 10:50 AM with RD revealed RD stated she was unsure about what the daily snack rotation was. RD stated she did not know the snack policy or procedure for this facility specifically but stated that generally snacks are offered 3 times a day. RD stated she knew the snacks were delivered to the nursing station on each hall by the dietary staff. Interview on 6/26/2025 at 1:49 PM with DM revealed DM stated the dietary staff deliver a tray of snacks and health shakes to the nursing station in the morning and then the nurses are responsible for storage and passing of snacks. DM stated the one tray of snacks supplies for the entire day. DM states the snacks consist of half sandwiches, cookies, peanut butter crackers, yogurt, and health shakes. Interview on 6/26/2025 at 4:35 PM with RN I revealed the dietary staff deliver the morning snacks consisting of yogurt, sandwiches, cookies, and peanut butter crackers which are brought with the morning coffee and the nursing staff pass the snacks to the residents. RN I stated any snacks left are placed into the nourishment room refrigerator. RN I stated she was unsure of who was responsible for cleaning the nourishment room refrigerator and has asked that since she started working at the facility and has not received an answer yet. Interview on 6/26/2025 at 4:38 PM with LVN F revealed there were never any snacks brought to the nurse station for residents. If a resident requested a snack, then the nurse needed to go to the kitchen and ask for something. LVN F stated if the kitchen was already closed for the day, then the nurse needed to go into the kitchen and find some options for the resident as a snack. LVN F stated the only option usually available to the residents was peanut butter crackers. Interview on 6/26/2025 at 5:26 PM with DON revealed she was unsure of the facility snack process as she had just started at the facility a couple of weeks ago. Interview on 6/26/2025 at 6:00 PM with ADM revealed the nursing staff had resident snacks available in the nourishment room on each station. ADM stated typically the morning dietary staff deliver a tray of snacks to cover the entire day. ADM stated the snack rotation consists of sandwiches, peanut butter crackers, cookies, and yogurt. Policy regarding snacks was requested on 6/26/2025 at 3:41 PM. Email correspondence from ADM on 6/26/2025 at 3:45 PM revealed the facility did not have a snack policy. Review of facility policy dated Quarter 3, 2022 and titled Resident Rights reflected the following: 2. Copies of our resident rights are posted throughout the facility, and a copy is provided to each employee, provider, and contracted staff member. In addition, staff will have appropriate in-service training on resident rights prior to having direct-care responsibilities for residents and 4. Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights.

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change for one (Resident #1) of four residents reviewed for notification of changes. The facility failed to ensure the NP was notified on 02/10/25 when there was reported swelling and tenderness to Resident #1's incision sites. On 02/11/25 one of the incisions dehisced requiring hospitalization where he was diagnosed with an infection to the surgical site requiring antibiotics. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/02/25 at 4:44 PM. While the IJ was removed on 05/05/25 12:46 PM, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving necessary medical care, pain, infection, and hospitalization . Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including chronic pain, osteoarthritis (inflammation of one or more joints), hemiplegia (paralysis or severe weakness on one side of the body), and hemiparesis (one-sided muscle weakness). Review of Resident #1's quarterly MDS assessment, dated 01/19/25, reflected a BIMS score of 13, indicating he was cognitively intact. Section J (Health conditions) reflected he was almost constantly in pain. Review of Resident #1's quarterly care plan, revised 01/30/25, reflected he had chronic pain and neuropathy with an intervention of having a pain stimulator in place. Revision on 03/20/25 reflected he had the potential for infections related to infection to back pain stimulator with an intervention of notifying the MD as needed. Review of Resident #1's document from the surgical center, dated 01/06/25, reflected he was scheduled for a Spinal Cord Stimulator Implant on 01/07/25. Review of Resident #1's EMR, on 04/05/25, reflected no physician orders to monitor the surgical sites. Review of Resident #1's skin assessment, dated 01/16/25 and completed by RN E, reflected he had a total of 18 staples - 9 in the middle of the back and 9 on the left flank. Review of Resident #1's skin assessment, dated 01/26/25 and completed by LVN D, reflected s/p spinal cord stimulator placement. Incisions OTA closed/healed. (Staples presumably removed at recent ortho appointment - unknown date) Review of Resident #1's progress notes, dated 02/11/25 at 9:34 PM and documented by LVN A, reflected the following: [Resident #1] was sent to (hospital), [Resident #1]'s surgical site from pain stimulator was bleeding, mixture of blood and puss [sic] over left hip, bleeding was persistent . Review of Resident #1's hospital records, dated 02/11/25, reflected he had a left lower back spinal stimulator placed one month ago, site had dehisced, and there was purulent drainage. Review of the facility's Infection Control binder, on 04/16/25, reflected Resident #1 had a skin infection on 02/11/25 with symptoms of pus/bleeding. Review of Resident #1's progress notes, dated 02/12/25 at 3:22 AM and documented by LVN B, reflected the following: [Resident #1] returned to room at 3:15am with personal belongings . rcvd 1G Rocephin and 1L NS at hospital, dressing clean, dry and intact. New orders for clindamycin 150mg . Review of Resident #1's Infection Surveillance Form, dated 02/12/25, reflected pus was present at wound, skin, or soft tissue site and he met McGreers (infection surveillance checklist). Review of Resident #1's physician orders, dated 02/12/25, reflected Clindamycin HCl Oral Capsule 150 MG - Give 3 capsules by mouth three times a day for cellulitis for 10 days and Bactrim DS Oral Tablet 800-160 MG - Give 1 tablet by mouth two times a day. Review of Resident #1's physician orders, dated 02/13/25, reflected wound care with dressing changes twice daily, partially open to air to allow drainage two times a day. During a telephone interview on 04/16/25 at 12:28 PM, Resident #1's NP was asked if pus was related to cellulitis and she stated it could be, but it could also be an infected surgical site. She stated it would depend on what she was looking at. She stated if there was pus, redness, blood, or warmth at a surgical site, there would be concern for infection. During a telephone interview on 04/15/25 at 12:42 PM, Resident #1's FR stated he was currently in the hospital. She stated when he had his procedure in January (2025) he had staples closing it shut. She stated she did not think the staff did anything for the incision and believed that was why he got an infection. During a telephone interview on 04/16/25 at 1:16 PM, LVN A stated she was the nurse who sent him to the hospital in February (2025) when there was drainage to the surgical site. She stated he came back from the hospital with orders for dressing changes and antibiotics. During a telephone interview on 04/16/25 at 1:33 PM, LVN C stated she worked with Resident #1. She stated she did not remember seeing staples to his incision site but did remember it being glued shut. During an interview on 04/16/25 at 2:09 PM, the DON was asked how Resident #1's incision could have dehisced in February (2025) if there was no opening, she stated that was not possible. She stated he went back to the clinic for a follow-up on 01/12/25 and again did not return with any new orders nor was she notified he had his staples removed. She stated if Resident #1 had sutures after his procedure, she would have expected him to have orders to monitor the site for signs and symptoms of infection, and she was not aware if there had been an actual opening. During a telephone interview on 04/16/25 at 3:30 PM, LVN B stated she had recently started working at the facility when Resident #1 had his procedure for the pain stimulator. She stated she remembered he had staples closing the incision on his back. She stated she remembered he began having a lot of bloody drainage and they had to start covering it with a dressing. During an observation and interview on 05/02/25 at 10:42 AM revealed Resident #1 watching television in his room. He stated he did not remember if the nurses were checking his surgical sites after the staples were removed. His incision sites were intact with no redness or swelling. He stated he remembered a for a few days before he was sent to the hospital (02/11/25), the sites felt sore, but he thought it was just part of the process. He stated he could not see the incisions so he could not tell if anything else was going on, but he knew they were not completely healed yet. He stated on the day he was sent out to the hospital, CNA F was giving him a bed bath and he saw some blood coming out of one of the incisions. He stated he got the nurse came and pushed on it and told him blood and pus were coming out. He stated he was sent to the hospital and was prescribed antibiotics. During a phone interview on 05/02/25 at 11:08 AM, LVN A stated she worked with Resident #1 on 02/10/25 and 02/11/25. She stated days leading up to the day the site had drainage (on 02/11/25), the sites looked like they were healing, and she had no concerns. She stated the day prior (02/10/25), CNA F informed her that the sites appeared swollen. She stated she assessed them, notified ADON G, who told her she would look at it in the morning with the NP. She stated she did not remember if she documented it. She stated Resident #1 was not complaining of pain just that they felt a little tender. She stated the following day (02/11/25), CNA F was giving him a bed bath and when he rolled him on his side, one of the sites (the one on the left, closer to his buttocks) began leaking. She stated CNA F came and informed her and she went to assess and saw what looked to be a pinhole to the site draining pus and blood. She stated she applied pressure with gauze and sent him to the ER. During an interview on 05/02/25 at 11:17 AM, ADON H stated she was also the WCN at the facility. She stated she primarily covered the 200 hall and ADON G covered the 100 hall, but she provided wound care for the whole facility. She stated if a resident had a procedure that required a surgical incision, she and the NP would assess the surgical sites. She stated neither she nor the NP ever assessed his surgical sites because they had not been communicated to about the procedure. She stated it was her expectations she be notified of any skin integrity issues, including surgical incision sites. She stated the facility did contract with an outside WCD, but she only followed some residents. She stated they decided collectively as a nursing team who should be followed by the WCD. During a telephone interview on 05/02/25 at 11:42 AM, CNA F stated Resident #1 had two incisions after his procedure in January (2025), one on his spine (which was bigger) and one on his left side close to his buttocks. He stated after the procedure he had a lot of staples but was not sure how many. He stated the incision sites looked fine until 02/10/25 when they appeared swollen, and Resident #1 complained of them feeling tender/sore. He stated he informed LVN A and assumed she had passed it on to the doctor. He stated the follow day, he was giving Resident #1 a bed bath and when he turned him on his side, the incision on his left side started dripping, and that was when he went and got LVN A. He stated when LVN A assessed it, the incision opened a little bit and started oozing much more. He stated the opening was bigger than a pinhole. During a telephone interview on 05/02/25 at 12:02 PM, ADON G stated she over-saw the 100 hall (the hall Resident #1 resided on). She stated if a wound was brought to her attention and ADON H was not there, she would do the assessment. She stated she was aware of Resident #1's procedure and thought ADON H knew about it. She stated the admitting nurse after the procedure should have notified ADON H. She stated she never assessed or saw the incisions and did not know what they looked like. She stated if there was a change with the incision sites, her expectation would be for the nurse to notify the WCN and NP. She stated a change could be redness, warmth, drainage, or swelling. She stated she was never informed Resident #1's incision sites had become swollen on 02/10/25. She stated she would have expected to have been notified so she could also follow-up with the WCN and NP. During a telephone interview on 05/02/25 at 12:19 PM, Resident #1's NP stated she did lay eyes on his surgical incisions right after the procedure (on 01/07/25). She stated she pulled off the dressing and noted the staples and that they did not show any signs of infection. She stated she was not notified of swelling to the sites on 02/10/25 but she her expectation was that she was notified with any change for with any resident. She stated if she had been notified, she would have assessed the sites, ordered labs, notified the clinic of where he got the procedure done, and would have started Rocephin (antibiotic) temporarily. She stated if the incision sites had been completely healed, she could not image they could dehisce, but anything was possible. During an interview on 05/02/25 at 1:01 PM, RN E stated she worked the day shift with Resident #1 and was not working when his incision site opened (it happened during the night shift). She stated she was not notified or aware if there was any swelling to the sites (on 02/10/25). She stated if she had been notified, she would have notified the NP immediately. She stated swelling could indicate infection, pus, or leakage. She stated nurses could not determine if a wound or surgical site was healed, it had to be the NP or MD. During an interview on 05/02/25 at 1:23 PM, the DON stated usually a physician was who determined a site was healed. She stated normally the WCN will clear it and then the NP or physician would follow-up. She stated she was not notified the day before Resident #1 was sent to the hospital (on 02/11/25) that his surgical sites were swollen. She stated she did not always expect to be notified. She would expect the nurses to follow up with the NP. She stated swelling to an incision site was natural. She stated if the sites were healed and was swollen a week later, she would think maybe something happened like his body was rejecting the pain stimulator or there could be other factors that would warrant a concern. When asked if a healed wound could dehisce, she stated, His (Resident #1) surgical site? I do not know anything about that. During a telephone interview on 05/02/25 at 4:07 PM, LVN D stated she did not remember if she completed a skin assessment on 01/26/25 for Resident #1, but if her name was on it, she completed it. She stated if she documented the surgical sites were healed, that was what she thought. She could not answer if a nurse was able to determine if a wound/surgical site was healed. Review of the facility's undated Change in a Resident's Condition or Status Policy reflected the following: Our facility shall promptly notify the resident, his or her Attending Physician . of changes in the resident's medical/mental condition and/or status. . Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. The ADM and DON were notified on 05/02/25 at 4:44 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 05/03/25 at 6:23 PM: IMMEDIATE CORRECTIVE ACTIONS FOR REMOVAL OF IMMEDIATE JEOPARDY: On May 2,2025 at approximately 5:00 pm the following actions were initiated upon facility identification of concern: Action: Assessed Resident #1 to validate that the resident was not suffering from any ongoing negative effects related to the deficient practice and that there were no new issues with skin integrity that would need to be reported to the physician. Resident #1 was found to be free from adverse effects related to deficiency. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Director of Nursing/Designee Action: Administrator was educated on Change in a Resident's Condition or Status, Surgery-Related (Pre-Postoperative) Management - Clinical Protocol in accordance with professional standards. Nursing should notify physician on call when there is change in status, Director of Nursing/Assistant Director of Nursing and resident family. Review questions were answered correctly. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Area President Action: Director of Nursing was educated on Change in a Resident's Condition or Status, Surgery-Related (Pre-Postoperative) Management - Clinical Protocol in accordance with professional standards. Nursing should notify physician on call when there is change in status, Director of Nursing/Assistant Director of Nursing and resident family. Review questions were answered correctly. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Chief Nursing Officer IDENTIFICATION OF OTHER AFFECTED: All residents with surgical sites or skin integrity issues have the potential to be affected by the deficient practice. Action: A skin sweep of current residents to identify residents who have surgical sites or other skin integrity issues and initiated evaluations these residents through chart review and physical exam/interview, to determine if any were suffering a change in condition related to their skin impairment such as increased redness, swelling, drainage, increased or unmanaged pain or any other signs or symptoms of infection such as fever. The above was completed with 0 of 72 residents identified as having a change in condition related to their skin impairment. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Director of Nursing/Designee SYSTEMIC CHANGES AND/OR MEASURES: Action: An ADHOC QAPI was conducted. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Administrator, Director of Nursing, ADON, MDS, Staffing Nurse and Medical Director. Action: Nurses including new and PRN and agency employees, were education regarding the expectation that skin integrity issues (including residents admitted after surgical procedure) be reported to the wound care nurse, DON, provider upon identification or with any noted change in condition that would indicate deterioration or infection and that interventions be implemented timely to ensure residents are being cared for appropriately. Start Date: 5/2/2025 Completion Date: This was initiated and completed on 5/2/2025. Staff not onsite or unable to reached, agency and new employees will be in-serviced upon hire and prior to the start of their first shift. Responsible Party: Director of Nursing/Designee. Action: Assistant Director of Nursing was educated on Change in a Resident's Condition or Status, Surgery-Related (Pre-Postoperative) Management - Clinical Protocol in accordance with professional standards. Nursing should notify physician on call when there is change in status, Director of Nursing/Assistant Director of Nursing and resident family. Review questions were answered correctly. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Director of Nursing Action: Director of Maintenance, Directory of Rehabilitation, Medical Data Set Nurse, Business Office Manager, Activities, Marketing, Social Worker and Housekeeping/Laundry Manager were educated on Change in a Resident's Condition or Status, Surgery-Related (Pre-Postoperative) Management - Clinical Protocol in accordance with professional standards. Nursing should notify physician on call when there is change in status, Director of Nursing/Assistant Director of Nursing and resident family. Review questions were answered correctly. Start Date: 5/2/2025 Completion Date: This was initiated and completed on 5/2/2025. Leaders not able to be present were educated by phone and will complete the checklist before starting work. Responsible Party: Administrator/Designee Action: Certified nurses aides were educated regarding the expectation that concern for skin integrity issues be reported to the licensed nurse on duty and Assistant Director of Nurses upon identification or with any noted change that might indicate deterioration or infection such as increased pain, redness, swelling, fever or increased or foul drainage so that further evaluation may be conducted. Start: 5/2/2025 Completion Date: This was initiated and completed on 5/2/2025. The Director of Nursing/Designee will utilize a signed staff roster to track those who have received education and to determine those who still require it. Anyone not in attendance at education sessions, or unable to be reached by phone, as evidenced by missing signatures on the staff roster sheet, due to vacation, sick leave, or casual work status will be educated upon their return, prior to their first shift worked. Responsible Party: Director of Nursing/Designee. TRACKING AND MONITORING: Action: Audits will be conducted on skin assessments for 7 days then daily Monday-Friday for 3 weeks, then weekly thereafter to ensure that providers are notified of any changes in skin condition timely to ensure that residents with skin integrity issues are cared for appropriately. This will be tracked on a log. Start Date: 5/2/2025 Completion Date: 5/2/2025. Responsible Party: Director of Nursing/Designee. Action: Implemented interventions immediately if notifications have not been made to the provider of any suspected change in condition related to skin integrity. Documentation of notifications made to resident/representative and physician will be noted in the resident's electronic medical record to include alert charting for change in skin condition. Staff responsible for the deficient practice will be contacted and counseled accordingly. Start Date: 5/2/2025 Completion Date: 5/2/2025. Responsible Party: Director of Nursing/Designee. Action: Audit alert charting daily in the morning meeting, M-F, to validate that alert charting for changes in skin condition is present for those who need it. Any trends or concerns will be addressed with the Quality Assurance Performance Committee and monitoring will continue until a lessor frequency is deemed appropriate. Results of audits will be presented by the Administrator or designee at the monthly QAPI meeting with the IDT and Medical Director on or before 5/30/2025 then monthly and as needed thereafter to identify trends and sustainability. If ongoing deficiencies or concerns are noted through these audits, resident interventions and staff education will be implemented immediately. Monitoring will not be discontinued until the facility completes three consecutive rounds of monthly monitoring that demonstrate sustained compliance as approved by the QAPI committee and medical director. Additional interventions, education and monitoring will be implemented, as needed, based on the recommendations of the QAPI committee for any negative trends identified to ensure sustainability. Start Date: 5/2/2025 Completion Date: 5/2/2025. Responsible Party: Director of Nursing/Designee. Please accept this letter as our plan of removal for determination of the alleged Immediate Jeopardy issued 5/2/2025. The Surveyor monitored the POR from 05/04/25 - 05/05/25 as followed: During observations on 05/05/25 from 10:52 AM - 11:05 AM revealed the WCN conducting a skin assessment on three residents. There was no skin breakdown, redness, or any concerns. During interviews on 05/04/25 from 2:26 PM - 4:02 PM and on 05/05/25 from 11:15 AM - 11:38 AM, staff from both shifts including three RNs, three LVNs, and three CNAs all stated they were interviewed before their shifts on abuse and neglect, changes in condition, skin assessments, and reporting skin issues/concerns. All staff knew their Abuse and Neglect Coordinator was their ADM and were able to give several times of abuse such as emotional, physical, and sexual. The CNAs all stated it was important to check all areas of a resident's skin when providing care so they could notify the nurse, so nothing worsened. The CNAs stated they would report to their nurse rashes, redness, skin tears, swelling, or any open areas. The CNAs all stated they also documented any changes on a resident's skin on their shower sheets. The nurses all stated their expectations were for the CNAs to report any change in a resident's skin to them immediately. They stated they would complete a skin assessment and notify the WCN. The nurses all stated skin assessments should be conducted weekly in order to ensure the residents' skin was intact or nothing was worsening. The nurses all stated any changes such as swelling, redness, or drainage would be relayed to the WCN and NP immediately. The nurses stated only the NP or MD could determine if a wound was healed. Review of the Facility's Ad Hoc QAPI Agenda, dated 05/02/25, reflected the ADM, the DON, ADON G, ADON H, the MDSC, and the MD were in attendance. Review of an in-service titled Regulatory Education - Resident Surgical Wound Case, dated 05/02/25 and conducted by the AP, reflected the ADM and DON were educated on the following: Timely recognition and management of changes in condition, including a wound deterioration, is required. Clinical assessments and documentation must reflect wound progression and corresponding interventions. Review of an audit, dated 05/02/25 and conducted by the DON, reflected seven residents with skin integrity issues that had treatment orders in place and had no signs or symptoms of infection. Review of an in-service, dated 05/01/25 - 05/03/25 and conducted by the DON, reflected all staff were in-serviced on their Abuse and Neglect Policy. Review of In-Service Education Quiz, dated 05/01/25 - 05/03/25, reflected all licensed nurses and agency staff completed a quiz covering skin issues with no concerns. Review of an in-service, dated 05/01/25 - 05/03/25 and conducted by the DON, reflected all staff were in-serviced on their Change of Condition Policy. Review of In-Service Education Quiz, dated 05/01/25 - 05/03/25, reflected all staff completed a quiz covering Notification of Changes with no concerns. Review of eight resident's EMR, on 05/05/25, reflected they had a skin assessment conducted with no concerns on 05/02/25. The ADM and DON were notified on 05/02/25 12:46 that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of isolated 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 that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of four residents reviewed for quality of care. The facility failed to ensure Resident #1's surgical sites were determined to be healed by the NP or MD. On 02/10/25 there was reported swelling to the incisions and on 02/11/25 one of the incisions dehisced requiring hospitalization where he was diagnosed with an infection to the surgical site requiring antibiotics. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/02/25 at 4:44 PM. While the IJ was removed on 05/05/25 12:46 PM, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving necessary medical care, pain, infection, and hospitalization . Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including chronic pain, osteoarthritis (inflammation of one or more joints), hemiplegia (paralysis or severe weakness on one side of the body), and hemiparesis (one-sided muscle weakness). Review of Resident #1's quarterly MDS assessment, dated 01/19/25, reflected a BIMS score of 13, indicating he was cognitively intact. Section J (Health conditions) reflected he was almost constantly in pain. Review of Resident #1's quarterly care plan, revised 01/30/25, reflected he had chronic pain and neuropathy with an intervention of having a pain stimulator in place. Revision on 03/20/25 reflected he had the potential for infections related to infection to back pain stimulator with an intervention of notifying the MD as needed. Review of Resident #1's document from the surgical center, dated 01/06/25, reflected he was scheduled for a Spinal Cord Stimulator Implant on 01/07/25. Review of Resident #1's EMR, on 04/05/25, reflected no physician orders to monitor the surgical sites. Review of Resident #1's skin assessment, dated 01/16/25 and completed by RN E, reflected he had a total of 18 staples - 9 in the middle of the back and 9 on the left flank. Review of Resident #1's skin assessment, dated 01/26/25 and completed by LVN D, reflected s/p spinal cord stimulator placement. Incisions OTA closed/healed. (Staples presumably removed at recent ortho appointment - unknown date) Review of Resident #1's progress notes, dated 02/11/25 at 9:34 PM and documented by LVN A, reflected the following: [Resident #1] was sent to (hospital), [Resident #1]'s surgical site from pain stimulator was bleeding, mixture of blood and puss [sic] over left hip, bleeding was persistent . Review of Resident #1's hospital records, dated 02/11/25, reflected he had a left lower back spinal stimulator placed one month ago, site had dehisced, and there was purulent drainage. Review of the facility's Infection Control binder, on 04/16/25, reflected Resident #1 had a skin infection on 02/11/25 with symptoms of pus/bleeding. Review of Resident #1's progress notes, dated 02/12/25 at 3:22 AM and documented by LVN B, reflected the following: [Resident #1] returned to room at 3:15am with personal belongings . rcvd 1G Rocephin and 1L NS at hospital, dressing clean, dry and intact. New orders for clindamycin 150mg . Review of Resident #1's Infection Surveillance Form, dated 02/12/25, reflected pus was present at wound, skin, or soft tissue site and he met McGreers (infection surveillance checklist). Review of Resident #1's physician orders, dated 02/12/25, reflected Clindamycin HCl Oral Capsule 150 MG - Give 3 capsules by mouth three times a day for cellulitis for 10 days and Bactrim DS Oral Tablet 800-160 MG - Give 1 tablet by mouth two times a day. Review of Resident #1's physician orders, dated 02/13/25, reflected wound care with dressing changes twice daily, partially open to air to allow drainage two times a day. During a telephone interview on 04/16/25 at 12:28 PM, Resident #1's NP was asked if pus was related to cellulitis and she stated it could be, but it could also be an infected surgical site. She stated it would depend on what she was looking at. She stated if there was pus, redness, blood, or warmth at a surgical site, there would be concern for infection. During a telephone interview on 04/15/25 at 12:42 PM, Resident #1's FR stated he was currently in the hospital. She stated when he had his procedure in January (2025) he had staples closing it shut. She stated she did not think the staff did anything for the incision and believed that was why he got an infection. During a telephone interview on 04/16/25 at 1:16 PM, LVN A stated she was the nurse who sent him to the hospital in February (2025) when there was drainage to the surgical site. She stated he came back from the hospital with orders for dressing changes and antibiotics. During a telephone interview on 04/16/25 at 1:33 PM, LVN C stated she worked with Resident #1. She stated she did not remember seeing staples to his incision site but did remember it being glued shut. During an interview on 04/16/25 at 2:09 PM, the DON was asked how Resident #1's incision could have dehisced in February (2025) if there was no opening, she stated that was not possible. She stated he went back to the clinic for a follow-up on 01/12/25 and again did not return with any new orders nor was she notified he had his staples removed. She stated if Resident #1 had sutures after his procedure, she would have expected him to have orders to monitor the site for signs and symptoms of infection, and she was not aware if there had been an actual opening. During a telephone interview on 04/16/25 at 3:30 PM, LVN B stated she had recently started working at the facility when Resident #1 had his procedure for the pain stimulator. She stated she remembered he had staples closing the incision on his back. She stated she remembered he began having a lot of bloody drainage and they had to start covering it with a dressing. During an observation and interview on 05/02/25 at 10:42 AM revealed Resident #1 watching television in his room. He stated he did not remember if the nurses were checking his surgical sites after the staples were removed. His incision sites were intact with no redness or swelling. He stated he remembered a for a few days before he was sent to the hospital (02/11/25), the sites felt sore, but he thought it was just part of the process. He stated he could not see the incisions so he could not tell if anything else was going on, but he knew they were not completely healed yet. He stated on the day he was sent out to the hospital, CNA F was giving him a bed bath and he saw some blood coming out of one of the incisions. He stated he got the nurse came and pushed on it and told him blood and pus were coming out. He stated he was sent to the hospital and was prescribed antibiotics. During a phone interview on 05/02/25 at 11:08 AM, LVN A stated she worked with Resident #1 on 02/10/25 and 02/11/25. She stated days leading up to the day the site had drainage (on 02/11/25), the sites looked like they were healing, and she had no concerns. She stated the day prior (02/10/25), CNA F informed her that the sites appeared swollen. She stated she assessed them, notified ADON G, who told her she would look at it in the morning with the NP. She stated she did not remember if she documented it. She stated Resident #1 was not complaining of pain just that they felt a little tender. She stated the following day (02/11/25), CNA F was giving him a bed bath and when he rolled him on his side, one of the sites (the one on the left, closer to his buttocks) began leaking. She stated CNA F came and informed her and she went to assess and saw what looked to be a pinhole to the site draining pus and blood. She stated she applied pressure with gauze and sent him to the ER. During an interview on 05/02/25 at 11:17 AM, ADON H stated she was also the WCN at the facility. She stated she primarily covered the 200 hall and ADON G covered the 100 hall, but she provided wound care for the whole facility. She stated if a resident had a procedure that required a surgical incision, she and the NP would assess the surgical sites. She stated neither she nor the NP ever assessed his surgical sites because they had not been communicated to about the procedure. She stated it was her expectations she be notified of any skin integrity issues, including surgical incision sites. She stated the facility did contract with an outside WCD, but she only followed some residents. She stated they decided collectively as a nursing team who should be followed by the WCD. During a telephone interview on 05/02/25 at 11:42 AM, CNA F stated Resident #1 had two incisions after his procedure in January (2025), one on his spine (which was bigger) and one on his left side close to his buttocks. He stated after the procedure he had a lot of staples but was not sure how many. He stated the incision sites looked fine until 02/10/25 when they appeared swollen, and Resident #1 complained of them feeling tender/sore. He stated he informed LVN A and assumed she had passed it on to the doctor. He stated the follow day, he was giving Resident #1 a bed bath and when he turned him on his side, the incision on his left side started dripping, and that was when he went and got LVN A. He stated when LVN A assessed it, the incision opened a little bit and started oozing much more. He stated the opening was bigger than a pinhole. During a telephone interview on 05/02/25 at 12:02 PM, ADON G stated she over-saw the 100 hall (the hall Resident #1 resided on). She stated if a wound was brought to her attention and ADON H was not there, she would do the assessment. She stated she was aware of Resident #1's procedure and thought ADON H knew about it. She stated the admitting nurse after the procedure should have notified ADON H. She stated she never assessed or saw the incisions and did not know what they looked like. She stated if there was a change with the incision sites, her expectation would be for the nurse to notify the WCN and NP. She stated a change could be redness, warmth, drainage, or swelling. She stated she was never informed Resident #1's incision sites had become swollen on 02/10/25. She stated she would have expected to have been notified so she could also follow-up with the WCN and NP. During a telephone interview on 05/02/25 at 12:19 PM, Resident #1's NP stated she did lay eyes on his surgical incisions right after the procedure (on 01/07/25). She stated she pulled off the dressing and noted the staples and that they did not show any signs of infection. She stated she was not notified of swelling to the sites on 02/10/25 but she her expectation was that she was notified with any change for with any resident. She stated if she had been notified, she would have assessed the sites, ordered labs, notified the clinic of where he got the procedure done, and would have started Rocephin (antibiotic) temporarily. She stated if the incision sites had been completely healed, she could not image they could dehisce, but anything was possible. During an interview on 05/02/25 at 1:01 PM, RN E stated she worked the day shift with Resident #1 and was not working when his incision site opened (it happened during the night shift). She stated she was not notified or aware if there was any swelling to the sites (on 02/10/25). She stated if she had been notified, she would have notified the NP immediately. She stated swelling could indicate infection, pus, or leakage. She stated nurses could not determine if a wound or surgical site was healed, it had to be the NP or MD. During an interview on 05/02/25 at 1:23 PM, the DON stated usually a physician was who determined a site was healed. She stated normally the WCN will clear it and then the NP or physician would follow-up. She stated she was not notified the day before Resident #1 was sent to the hospital (on 02/11/25) that his surgical sites were swollen. She stated she did not always expect to be notified. She would expect the nurses to follow up with the NP. She stated swelling to an incision site was natural. She stated if the sites were healed and was swollen a week later, she would think maybe something happened like his body was rejecting the pain stimulator or there could be other factors that would warrant a concern. When asked if a healed wound could dehisce, she stated, His (Resident #1) surgical site? I do not know anything about that. During a telephone interview on 05/02/25 at 4:07 PM, LVN D stated she did not remember if she completed a skin assessment on 01/26/25 for Resident #1, but if her name was on it, she completed it. She stated if she documented the surgical sites were healed, that was what she thought. She could not answer if a nurse was able to determine if a wound/surgical site was healed. Review of the facility's undated Change in a Resident's Condition or Status Policy reflected the following: Our facility shall promptly notify the resident, his or her Attending Physician . of changes in the resident's medical/mental condition and/or status. . Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. A request was made to the ADM on 04/16/25 at 3:35 PM and 5:09 PM and 05/02/25 at 2:16 PM for a policy on wound care/treatment orders. A policy was not received prior to exit. The ADM and DON were notified on 05/02/25 at 4:44 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 05/03/25 at 6:23 PM: IMMEDIATE CORRECTIVE ACTIONS FOR REMOVAL OF IMMEDIATE JEOPARDY: On May 2,2025 at approximately 5:00 pm the following actions were initiated upon facility identification of concern. Action: Administrator was educated on abuse and neglect, resident's rights, comprehensive person-centered care plans and the treatment and care in accordance with professional standards. Ensure care plans are up to date for the individual resident and constantly monitored. If there is anything identified that needs to be updated, immediate notification to Directory of Nursing. Ensure documentation and all notifications occur timely. Review questions were answered correctly. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Area President Action: Director of Nursing was educated on abuse and neglect, resident's rights, comprehensive person-centered care plans and the treatment and care in accordance with professional standards. Ensure care plans are up to date for the individual resident and constantly monitored. If there is anything identified that needs to be updated, immediate notification to Directory of Nursing. Ensure documentation and all notifications occur timely. Review questions were answered correctly. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Chief Nursing Officer Action: Assistant Director of Nursing was educated on abuse and neglect, resident's rights, comprehensive person-centered care plans and the treatment and care in accordance with professional standards. Ensure care plans are up to date for the individual resident and constantly monitored. If there is anything identified that needs to be updated, immediate notification to Directory of Nursing. Ensure documentation and all notifications occur timely. Review questions were answered correctly. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Director of Nursing Action: Resident #1 was assessed to ensure that the resident was not suffering from any ongoing negative effects related to the deficient practice and that there were no new issues with skin integrity that would need to be reported to the physician. Resident #1 was found to be free from adverse effects related to deficiency. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Director of Nursing or Designee Action: A skin sweep of current residents was completed to identify residents who have surgical sites or other skin integrity issues and initiated evaluations these residents, through chart review and physical exam/interview, to determine if any areas were in need of treatment, that providers, responsible parties, and residents were aware of status of wounds, and if any were suffering ongoing negative consequences related to the deficient practice such as redness, swelling, increased or unmanaged pain or any other signs or symptoms of infection such as fever. 0 residents were found to have a change in condition related to their skin impairment. Skin assessments are in the medical record. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Director of Nursing/Designee Action: Nursing staff including new hires and PRN employees, were educated on abuse and neglect, resident's rights, comprehensive person-centered care plans and the treatment and care in accordance with professional standards. Ensure care plans are up to date for the individual resident and constantly monitored. If there is anything identified that needs to be updated, immediate notification to Directory of Nursing. Ensure documentation and all notifications occur timely. Review questions were answered correctly. A checklist verifying understanding of policies was completed. Staff not onsite or unable to reached, agency and new employees will be in-serviced upon hire and prior to the start of their first shift. Start Date: 5/2/2025 Completion Date: This was initiated and completed on 5/2/2025. Responsible Party: Director of Nursing/Designee. Action: Director of Maintenance, Directory of Rehabilitation, Medical Data Set Nurse, Business Office Manager, Activities, Marketing, Social Worker and Housekeeping/Laundry Manager were educated on abuse and neglect, resident's rights, comprehensive person-centered care plans and treatment and care in accordance with professional standards. Ensure care plans are up to date for the individual resident and constantly monitored. If there is anything identified that needs to be updated, immediate notification to Directory of Nursing. Ensure documentation and all notifications occur timely. Review questions were answered correctly. Start Date: 5/2/2025 Completion Date: This was initiated and completed on 5/2/2025. Leaders not able to be present were educated by phone and will complete the checklist before starting work. Responsible Party: Administrator/Designee IDENTIFICATION OF OTHER AFFECTED: All residents with skin conditions have the potential to be affected by the deficient practice. Action: Skin assessment on 72 of 72 residents. No new skin conditions were identified. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Director of Nursing/Designee SYSTEMIC CHANGES AND/OR MEASURES: Action: An ADHOC QAPI was conducted. Start Date: 5/2/2025 Completion Date: 5/2/2025 Responsible Party: Administrator, Director of Nursing, ADON, MDS, Staffing Nurse and Medical Director. Action: Initiated process effective immediately, all new surgical wounds/incisions will be referred to the ADON/designee upon admission or upon return from a procedure. The ADON/designee will complete wound assessments weekly (or more often as needed) until wounds/incisions are determined healed by NP or MD. All referrals will be tracked on a Wound Care Log maintained by the ADON/designee. Start Date: 5/2/2025 Completion Date: 5/3/2025 Responsible Party: Director of Nursing/Designee TRACKING AND MONITORING: Action: Audits will be performed on residents with surgical sites and other wounds to ensure that NP or MD determination of wound/incision healing is documented, and wound changes are promptly reported and addressed. A log will be kept. Start Date: 5/2/2025 Completion Date: 5/3/2025 Responsible Party: Director of Nursing/Designee Action: Wound care log will be submitted weekly to Director of Nursing and Regional Clinical Nurse to ensure compliance with notification and documentation. Start Date: 5/2/2025 Completion Date: 5/3/2025 Responsible Party: Director of Nursing/Designee Action: Audits will be conducted daily x 2 weeks, 3x weekly x 2 weeks, and then weekly x 4 weeks, or until sustained compliance is achieved. A log will be kept. Start Date: 5/2/2025 Completion Date: 5/3/2025 Responsible Party: Director of Nursing/Designee Action: Results will be provided to the Quality Assurance Committee monthly, for three months and as needed thereafter. Start Date: 5/2/2025 Completion Date: 5/3/2025 Responsible Party: Director of Nursing/Designee The Surveyor monitored the POR from 05/04/25 - 05/05/25 as followed: During observations on 05/05/25 from 10:52 AM - 11:05 AM revealed the WCN conducting a skin assessment on three residents. There was no skin breakdown, redness, or any concerns. During interviews on 05/04/25 from 2:26 PM - 4:02 PM and on 05/05/25 from 11:15 AM - 11:38 AM, staff from both shifts including three RNs, three LVNs, and three CNAs all stated they were interviewed before their shifts on abuse and neglect, changes in condition, skin assessments, and reporting skin issues/concerns. All staff knew their Abuse and Neglect Coordinator was their ADM and were able to give several times of abuse such as emotional, physical, and sexual. The CNAs all stated it was important to check all areas of a resident's skin when providing care so they could notify the nurse, so nothing worsened. The CNAs stated they would report to their nurse rashes, redness, skin tears, swelling, or any open areas. The CNAs all stated they also documented any changes on a resident's skin on their shower sheets. The nurses all stated their expectations were for the CNAs to report any change in a resident's skin to them immediately. They stated they would complete a skin assessment and notify the WCN. The nurses all stated skin assessments should be conducted weekly in order to ensure the residents' skin was intact or nothing was worsening. The nurses all stated any changes such as swelling, redness, or drainage would be relayed to the WCN and NP immediately. The nurses stated only the NP or MD could determine if a wound was healed. Review of the Facility's Ad Hoc QAPI Agenda, dated 05/02/25, reflected the ADM, the DON, ADON G, ADON H, the MDSC, and the MD were in attendance. Review of an in-service titled Regulatory Education - Resident Surgical Wound Case, dated 05/02/25 and conducted by the AP, reflected the ADM and DON were educated on the following: Timely recognition and management of changes in condition, including a wound deterioration, is required. Clinical assessments and documentation must reflect wound progression and corresponding interventions. Delay in response or lack of intervention may constitute a deficiency under F684. Review of an audit, dated 05/02/25 and conducted by the DON, reflected seven residents with skin integrity issues that had treatment orders in place and had no signs or symptoms of infection. Review of an in-service, dated 05/01/25 - 05/03/25 and conducted by the DON, reflected all staff were in-serviced on their Abuse and Neglect Policy. Review of In-Service Education Quiz, dated 05/01/25 - 05/03/25, reflected all licensed nurses and agency staff completed a quiz covering skin issues with no concerns. Review of an in-service, dated 05/01/25 - 05/03/25 and conducted by the DON, reflected all staff were in-serviced on their Change of Condition Policy. Review of In-Service Education Quiz, dated 05/01/25 - 05/03/25, reflected all staff completed a quiz covering Notification of Changes with no concerns. Review of eight resident's EMR, on 05/05/25, reflected they had a skin assessment conducted with no concerns on 05/02/25. The ADM and DON were notified on 05/02/25 12:46 that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of isolated 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 the residents had the right to be free from neglect for one (Resident #1) out of three residents reviewed for neglect, in that: The facility failed to ensure Resident #1's environment was safe and comfortable when she was left alone in a hot motorized van with the doors open for 14 minutes causing her to feel dizzy, thirsty, panicked, and the fearful she would lose consciousness. This failure placed residents at risk of experiencing helplessness, heat exhaustion, dehydration, and a decrease of self-worth. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including bradycardia (slow resting heart rate), syncope (fainting), and hypertension (high blood pressure). Review of Resident #1's quarterly MDS assessment, dated 09/18/23, reflected a BIMS of 15, indicating she was cognitively intact. Review of Resident #1's quarterly care plan, dated 09/12/23, reflected she was at risk for falls related to weakness, fatigue, and unsteadiness with an intervention of assessing for pain each shift. During an interview on 09/26/23 at 9:54 AM, Resident #1 stated on 09/20/23, the MKD took her to her appointment with her cardiologist. She stated when they left the appointment, they had to stop at the hospital to pick up a resident. She stated she felt like she was left in the van for over 30 minutes. She stated the van and AC were on, but it was blowing out hot air. She stated she was so damn hot, she felt dizzy, like her brain was sinking and she was panicked she would faint because she had a history of fainting episodes. She stated she felt absolutely helpless as she had no control over the situation. She stated after awhile she called the facility, spoke to the Receptionist, and told her she did not know when the MKD was going to return and she felt like she was going to pass out. She stated once the MKD did return, she asked if they could stop for something cold to drink and the MKD stated they could not because she had no money. Resident #1 stated she told her, I have 15 dollars in cash, I'll buy everyone a drink!, but the MKD did not stop. She stated her mouth and throat felt so dry on the drive to the facility and she did not get anything cold to drink until she arrived back. She stated for the rest of the evening she felt nauseous and dizzy. She stated a staff member told her that what they did to her (leaving her in a hot van) was against the law. She stated she was disappointed that the MKD had put too many appointments on her schedule, which led to her having to go through that situation. She stated she felt as though she had PTSD from it and stated, there was an activity outing later that afternoon, but I do not feel comfortable getting in the van yet. She stated, What truly frosted the pumpkin was that the MKD would not stop to get her something to drink and that was what felt like the ultimate wound. She stated the ADM did come and speak to her the following day and asked if she wanted to file a grievance, but she declined as she did not want to ruffle any feathers or get anyone in trouble. During an interview on 09/26/23 at 10:15 AM, the MAINTD stated he had not heard any complaints regarding the AC in the facility van. He stated their van driver had recently quit and she had been the one to get the van serviced when it needed to be. During an interview on 09/26/23 at 10:34 AM, the MKD stated she was very rarely asked to transport residents to appointments but had done it before. She stated she was asked to take Resident #1 to her appointment on 09/20/23 because their van driver had recently left and they were in the middle of hiring a new one. She stated she knew she also had to pick up a new admission from the hospital between 3:00 - 3:30 PM that day so she asked the DON if it would be okay to have Resident #1 wait in the van. She stated the DON told her if the van and AC were going to be on, on it would be fine. She stated she was not in the hospital longer than 20 minutes when she returned to the van. She stated Resident #1 immediately stated, It is fucking hot in here. She stated she noticed Resident #1 had removed her long sleeve shirt and did appear uncomfortable. She stated the van did feel warm and she felt uncomfortable and thought the AC vents were blowing warm air while the van was idled. She teared up and stated she felt horrible that Resident #1 had been in that situation, but there had been no way for her to know the AC was not working properly. She stated once they left the hospital to return to the facility, a 20 - 30-minute drive, the van immediately cooled down. She stated Resident #1 had asked to stop for a drink, but she did not want to stop in fear the AC would again blow hot air while the van was idled and did not want to put the residents in that situation. She stated she had notified the ADM upon their return to the facility. During an interview on 09/26/23 at 11:10 AM, the Receptionist stated she remembered Resident #1 calling her in the afternoon on 09/20/23 and told her, I'm stuck in the van and needed to get out. The MKD had been in the hospital for at least 30 minutes, I'm thirsty, I don't feel well, and I feel like I'm going to faint. The Receptionist stated the call dropped, and by the time she got ahold of Resident #1 again, the MKD had returned to the van. She stated Resident #1 had sounded frightened and anxious. She stated she had not notified the ADM. She stated Resident #1 returned to the facility around 4:15 or 4:30 PM and she appeared pale, tired, and upset. During an observation and interview on 09/26/23 at 11:24 AM, the MAINTD was asked if he could turn the van on and let it run for ten minutes while a small dial thermometer was placed in the front seat (where Resident #1 had been sitting). At 11:34 AM, the thermometer read 74 degrees Fahrenheit. During an interview on 09/26/23 at 1:44 PM, the ADM stated she spoke to Resident #1 the morning after the incident on 09/20/23 when she found out about it from an anonymous email that was sent to their head of corporate. She stated Resident #1 told her the van was warm and she called the facility and she had not mentioned feeling dizzy or like she was about to faint. She stated she believed the van had gotten warm possibly because the MKD had left the front and back door open with the wheelchair lift in the back down, to be able to get the new resident (from the hospital) into the van quickly. She stated she was not sure if it was because of the open doors or if the AC was not working properly. She stated she had not self-reported the incident because she saw it as a service failure, and not that Resident #1 was at risk of harm since she was not privy to all of the information that had been detailed to the Surveyor by Resident #1. She stated it was not normal to leave a resident in the van while out in the community, but the MKD had gotten approval by the DON earlier that morning. She stated they did not have a policy on anything related to the transporting of residents. During an interview on 09/26/23 at 2:07 PM, Resident #1's FM stated that Resident #1 had informed her of the incident on 09/20/23 and it was a very big deal. She stated Resident #1 had told her she was left on the van for around 30 minutes. She stated, we are not allowed to leave a dog in a car, so you sure should not leave a [AGE] year-old in one. She stated Resident #1 told her while in the van she felt like her mind was slipping and she had been about to faint. She stated Resident #1 told her the MKD would not get her something cold to drink. She stated Resident #1 was obviously very upset. She stated the ADM contacted her and told her she spoke with Resident #1 and she had not wanted to file a grievance. She stated she was not surprised as Resident #1 did not like to make waves or upset anyone. During an interview on 09/26/23 at 3:31 PM, the DON stated she gave the MKD approval to let Resident #1 wait in the van while she picked up the new resident because Resident #1 was cognitively intact and knew it would not take long in the hospital. She stated she had not been informed that Resident #1 experienced dizziness or felt like she was going to faint. During a telephone interview on 09/26/23 at 3:42 PM, Resident #1's NP stated that any amount of time in the heat could be detrimental to anyone's health. She stated it also depended on the person and what diagnoses they had. She stated being in the extreme heat for any amount of time could lead to heat exhaustion or dehydration. Review of the MKD's GPS reading on her cell phone, dated 09/20/23, reflected she and Resident #1 had arrived at the hospital at 3:17 PM and departed at 3:31 PM for a total of 14 minutes. Review of the website Timeanddate.com/weather, on 09/26/23, reflected the temperature outside reached 97 degrees on 09/20/23 at 3:00 PM. Review of the facility's Resident Rights Policy, dated 2022, reflected the following: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . c. be free from abuse, neglect, . Review of the facility's Abuse and Neglect Policy, revised March 2018, reflected the following: 2. Neglect means the failure of the facility, its employees or service provers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of an in-service entitled Identifying and Reporting Abuse, dated 09/26/23, reflected staff were educated on reporting all allegations or concerns of abuse to the ADM immediately. Review of an in-service entitled Heat Exhaustion, dated 09/26/23, reflected staff were educated on the following: Without prompt treatment, heat exhaustion can lead to heatstroke, a life-threatening illness. Symptoms: heavy sweating, faintness, dizziness, fatigue, nausea, headache . Review of an in-service entitled Transportation, dated 09/26/23, reflected staff were educated on the facility's updated Transportation policy. Review of the facility's Transportation policy, revised 2023, reflected the following: Policy Statement: Our facility may provide transportation for residents as needed. . 4. Drivers will assure vehicle is equipped and prepared for inclement weather should need arise during transport (e.g. Fluids for residents, blankets/coats, etc.) 5. Drivers will not leave resident unattended or without appropriate precautions taken and the resident having the ability to communicate needs, during transportation to and from appointments. Review of the facility's undated Van Checklist reflected it was revised to include a cooler with ice and water and two blankets.

Based on observations, interviews, and record review, the facility failed to provide adequate supervision and assistive devices for one out of of ten residents (Resident #1) reviewed for wandering and elopement, in that: - The facility failed to ensure that a newly admitted resident (Resident #1) with a known history of wandering and exit-seeking behaviors was supervised closely enough to be free from risk of harm from outside elements. Resident #1 eloped from the facility for a minimum of an hour and 15 minutes. - The facility failed to ensure wander guard functioning for at least one resident (Resident #1). These failures resulted in an identification of an Immediate Jeopardy (IJ) on 12/30/2020 at 4:40 PM. While the IJ was removed on 1/3/21 at 5:05 AM, the facility remained out of compliance at a severity of actual harm that is not Immediate Jeopardy and a scope of isolated due to the facilty's need to evaluate the effectiveness of the corrective systems. These failures placed all residents with wandering tendencies to be at risk for elopement resulting in serious injury, serious impairment, and death. Findings include: Review of Resident #1's medical chart reflected an [AGE] year-old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan, dated 12/24/20, reflected that (Resident #1) is an elopement risk and wanderer r/t dementia. Review of Resident #2's medical chart reflected a [AGE] year-old female who was admitted to the facility on 12/ that 15/28 with [DIAGNOSES REDACTED]. Review of Resident #2's Care Plan reflected that the task for testing her wander guard each night was updated 12/29/20. Observation on 12/30/20 at 11:00 AM revealed Resident #2 was asleep in her bed. RN C used the wander guard testing device to test the wander guard on her leg. The device revealed that the wander guard was not functioning. During an interview on 12/29/20 at 10:52 AM, Paramedic stated that they were contacted by the police department on 12/27/20 around 11:30 PM. She stated that the facility next-door to (facility) contacted the police department initially when they saw a person laying in their parking lot, and thought it was a homeless person. The police told her that it was an elderly gentleman, and they had been attempting to get someone at (facility) to answer their front door to see if they were missing a resident. When Rep A and her partner arrived at the facility, they found Resident #1 on the ground next to a 4-foot concrete wall. She stated that his left leg was externally located, which is normally seen in [MEDICAL CONDITION] patients. He also had a deep laceration on his left elbow and swelling/deformity to his left knee. Rep A stated that it was 48 degrees outside, per the temperature gauge in the ambulance, and Resident #1's body temperature read at 92 degrees. Rep A She stated that with her medical knowledge and experience, it would be safe to say that the resident had been outside for more than an hour. Due to his mental state, it was difficult to figure out where he was hurting. Rep A she stated she and her partner had a difficult time starting his IV, due to his veins being so cold. She stated that by the time they got close to the hospital and his temperature had risen, Resident #1 was more coherent. She stated that her biggest concern was the lack of concern for Resident #1 by the (facility), and the fact that they never noticed him missing, especially when he had a wander guard on his person. During an interview on 12/29/20 at 11:15 AM, An employee from the facility nextdoor stated that on the night of 12/27/20, one of their employees went to get something out of her car, and she noticed someone laying in their parking lot up against a concrete wall. She stated that they thought it was a homeless person and called 911. She stated that they have a security camera and it caught Resident #1 falling and laying on the ground for over an hour. She invited Surveyor to their facility to review the tape. Observation of security camera footage from the facility nextdoor on 12/30/20 at 9:00 AM revealed Resident #1 walking towards a concrete wall that separates their parking lot from (facility)'s parking lot at 11:14 PM. The concrete wall was approximately 4-feet high. Once he got to the ledge of the wall, he was seen falling to the concrete ground. The video showed the police showing up to (facility) at 12:29 AM, and began searching for him. The concrete wall was approximately 40 yards from the facility. It was seen in the video that at 12:35 AM, an officer located Resident #1 and motioned to the other officer. EMS arrived at 12:39 AM. During an interview on 12/29/20 at 12:13 PM, the RP of Resident #1 was extremely tearful when speaking of the incident regarding the resident. She stated that she was notified of the incident in the early morning hours of 12/28 by RN A, who stated that he must have eloped during shift change. She stated that before being admitted to (facility), Resident #1 had been at the hospital due to experiencing hallucinations. They noticed that his behaviors of agitation, disorientation, and restlessness seemed to increase as it got later in the day, and the doctors told her he was experiencing sun-downing, which is typical with people diagnosed with [REDACTED]. During an interview on 12/29/20 at 12:33 PM, the MD stated that he tested the door alarms Monday-Friday and kept a log of these tests. He stated that there are 7 exit doors, and only one does not have an alarm, nor was it ever locked. Observation on 12/29/20 at 12:55 PM revealed the exit door without an alarm, which opened to a patio on the left side of the facility. Resident #1's room was located on the same hallways as this door. During an interview on 12/29/20 at 1:11 PM, the DON stated the nurses are supposed to be checking/testing the wander guards per shift. During the over-night shift, the nurses should be testing the wander guard for function, and morning and afternoon shifts should be verifying that it was physically on the resident. Once there was an order for [REDACTED].#1 when he was first admitted . She doesn't believe it was put on correctly, and since the task was never generated on the TAR, she knew the function of the wander guard had not been tested initially or the days following. Review of Resident #1's TAR reflected that there was not a task requiring the wander guard to be checked and tested . During an interview on 12/29/20 at 1:39 PM with RN A, she stated that she had worked a 16-hour shift on 12/27/20. She was officially off work at 10:00 PM but stayed to work on documentation. She stated that she was walking from the 100 hall to the 200 hall through the lobby when she saw a flashlight, which happened to be a police officer. She stated that he walked in through the un-locked door off of the patio. He asked if they had a resident that she was missing, and she stated that she didn't know. She went outside and noticed that it was Resident #1 from the 200 hall which is where RN D was working. She stated that she believed he must of eloped during shift change at 10:00 PM. She stated that shift change usually took around 10-15 minutes. She stated that she believed he must have left from the door that doesn't have an alarm. Since he was wearing a wander guard, they would have heard the alarm should he had gone out of a door with an alarm system. Observation of security camera footage from the facility nextdoor on 12/30/20 at 9:00 AM revealed Resident #1 walking towards a concrete wall that separates their parking lot from (facility)'s parking lot at 11:14 PM. The concrete wall was approximately 4-feet high. Once he got to the ledge of the wall, he was seen falling to the concrete ground. The video showed the police showing up to (facility) at 12:29 AM, and began searching for him. The concrete wall was approximately 40 yards from the facility. It was seen in the video that at 12:35 AM, an officer located Resident #1 and motioned to the other officer. EMS arrived at 12:39 AM. During an interview on 12/30/20 at 10:24 AM, RN B stated that she checked the wander guards of residents that have them every shift. There was a check-off in the TAR's that had to be clicked upon completion. She stated that there are times she was unable to check the wander guards because the facility only had one tester, and if she was unable to locate it, she didn't check the functioning. During an interview on 12/30/20 at 2:15 PM, RN F stated that she worked the 200 hall, the hall Resident #1's room was on, the day he was initially admitted , 12/24. She stated that he arrived late in the afternoon and he was really aggressive with her. She stated that he was grabbing her while attempting to move her to get the exit door. She stated that due to those behaviors, she contacted EMS around 12:32 AM on 12/25. Hospital staff reported Resident #1 to be calm when arriving at the hospital, so he was sent back to the facility. She stated that it was reported to her that RN E had put a wander guard on him that morning. She stated that she did try testing it with the testing machine, but it wasn't lighting up, so she would just verify that it was on his leg. She stated that on her 2 PM - 10 PM shift on 12/27, Resident #1 was fine during the afternoon, but began exit-seeking behaviors around 6 PM. She believed he was sun-downing . She stated that she could not keep him in his room and was constantly re-directing him. She stated that the last time she saw him during her shift was at 9:48 PM when she took his vitals. She then attended the shift change report which lasted until 10:15 PM. Review of the facility's policy, Testing the WanderGuard System, revised February 2010, reflected the following: Signaling Device Placement Verification: 1. Nursing staff will perform daily checks t verify the operation of the signaling device using a signaling device tester. Use the 'Daily Checklist for Signaling Devices in the WanderGuard Instruction Manual. 2. Test the signaling device of each resident wearing a device. 3. Check the wristbands for tears or other damage. Replace damaged bands immediately. 4. Nurses will record the test conducted in the resident's record. Review of the facility's policy, Elopement Management, revised July 2017, reflected the following: Each resident is assisted in attaining/maintain his or her highest practicable level of function by providing the resident with adequate supervision, activity/functional programs as appropriate and safe interventions to minimize elopement risk. Signaling devices may be used and determined to be an appropriate intervention While alarms can help to monitor a resident's activities, staff must be vigilant in order to respond to them in a timely manner. Alarms do not replace necessary supervision. The DON was notified on 12/30/2020 at 4:40 PM that an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided to The Administrator on 12/30/2020 at 5:00 PM. A Plan of Removal was first submitted by the DON on 12/30/2020 at 5:59 PM and the following POR was accepted on 12/31/20 at 1:23 PM: (Facility) Plan of Removal The facility failed to ensure that a newly admitted resident with a known history of wandering and exit seeking was supervised closely enough to be free from risk of harm from outside elements. 1. The facility assessed all residents elopement risk on12/31/20 by completion of the Elopement Risk Assessment. The facility identified 10 residents with a risk score >12 and determined at risk. All residents identified at risk for elopement have a wanderguard bracelet implemented and documented on the care plan. The IDT reviewed these residents and none are exhibiting exit seeking behaviors or any attempted elopements in the last 90 days and determined that no current residents are needing additional supervision or a referral to a secure unit. The facility will assess all new residents on admission and readmission. The facility will place a wanderguard bracelet. The facility will implement care plan interventions to provide increased supervision for these residents if exit seeking. The facility will place these residents on one to one supervision. The DON will assign a designated staff member for each shift until the resident is determined to be appropriate for transfer to a secure unit or until the resident's condition changes. This will be documented in the progress notes and communicated on the 24 hour report and assignment sheets. The DON/ADON reviewed all new admission charts and 24 hour reports to ensure there were no exit seeking or wandering behavior in the last 90 days and found no other incidents or residents at risk. The DON will continue to do this daily to ensure the Elopement Risk Assessment is completed and wanderguards are placed and intervention implemented for increased supervision on all residents identified at risk for elopement . The facility failed to ensure the resident's safety by not properly securing an exit door from the outside community. 1. On 12/30/20 the facility had a wanderguard monitoring system installed on the patio exit door. The maintenance director will checked the function of doors and found them all working. The maintenance director will check function of all doors daily on Monday to Friday and document these in the TELS system. The weekend supervisor will check the doors on Saturday and Sunday and document on Monthly Door Function Log to be maintained and checked weekly by the Maintenance Director. The Weekend supervisor was inserviced on 12/31/20 on checking all doors daily on Saturday and Sunday. The facility failed to place wander guard checks/test orders in a resident's TAR and failed to ensure function on wander guards for at least two residents. 1. On 12/29/20 the facility reviewed all resident at risk for elopement and 10 residents were identified to be at risk for elopement. The facility ensured orders to check daily for function, every shift for placement and changed every 90 days were placed on the TAR. The facility checked all residents with wanderguards to ensure they were working on 12/30/20 and changed out all devices that were not functioning. The assigned charge nurse will check the function of the signaling device daily (wanderguard bracelet) using the tester box and document on the Treatment Administration Record (TAR) and will immediately replace the signaling device if the device fails the function test. The DON/ADON will review the TAR for all residents with wanderguards weekly to validate daily function checks are taking place. The facility failed to educate staff on how to properly test wander guards to ensure they are working properly. 1. The DON educated all facility staff on 12/28/20 and will complete by 01/02/20 on the facility wanderguard monitoring system, to include checking the doors for function, appropriate latching of the door, checking the function of the electronic monitoring device and procedure in the event of an elopement. 2. The DON educated all licensed nurses on 12/28/20 and will complete by 12/31/20 checking for the placement of the signaling device every shift and documenting it on the Treatment Administration Record (TAR). Nurses also were re-educated regarding the importance of checking the function of the signaling device daily using the tester box and documenting the results on the Treatment Administration Record (TAR). The licensed nurses must immediately replace the signaling device if the device fails the function test. The facility failed to put a plan in place for a newly-admitted resident exhibiting exit-seeking behaviors. 1. The facility assessed all residents elopement risk on12/31/20 by completion of the Elopement Risk Assessment. The facility identified 10 residents with a risk score >12 and determined at risk. All residents identified at risk for elopement have a wanderguard bracelet implemented and documented on the care plan. The IDT reviewed these residents and none are exhibiting exit seeking behaviors or any attempted elopements in the last 90 days and determined that no current residents are needing additional supervision or referral to a secure unit. The facility will assess all new residents on admission and readmission. The facility will place a wanderguard bracelet. The facility will implement care plan interventions to provide increased supervision for these residents if exit seeking. The facility will place these residents on one to one supervision. The DON will assign a designated staff member for each shift until the resident is determined to be appropriate for transfer to a secure unit or until the resident's condition changes. This will be documented in the progress notes and communicated on the 24 hour report and assignment sheets. The DON/ADON reviewed all new admission charts and 24 hour reports to ensure there were no exit seeking or wandering behavior in the last 90 days and found no other incidents or residents at risk. The DON will continue to do this daily to ensure the Elopement Risk Assessment is completed and wanderguards are placed and intervention implemented for increased supervision on all residents identified at risk for elopement. The facility failed to recognize that a resident was missing from their facility for the minimum of an hour and 15 minutes. 1. The facility assessed all residents elopement risk on12/31/20 by completion of the Elopement Risk Assessment. The facility identified 10 residents with a risk score >12 and determined at risk. All residents identified at risk for elopement have a wanderguard bracelet implemented and documented on the care plan. The IDT reviewed these residents and none are exhibiting exit seeking behaviors or any attempted elopements in the last 90 days and determined that no current residents are needing additional supervision or referral to secure unit.The facility will assess all residents on admission and readmission for elopement risk by completion of the Elopement Risk Assessment. All residents identified at risk for elopement will have a wanderguard bracelet implemented by the assigned charge nurse and documented on the care plan. The facility will implement care plan interventions to provide increased supervision for these residents if exit seeking. The facility will place these residents on one to one supervision. The DON will assign a designated staff member for each shift until the resident is determined to be appropriate for transfer to a secure unit or until the resident's condition changes. This will be documented in the progress notes and communicated on the 24 hour report and assignment sheets. The DON/ADON will review all residents through the 24 hours report to ensure the Elopement Risk Assessment is completed, wanderguards are placed and intervention implemented for one to one supervision on all residents identified at risk for elopement with exit seeking behavior. The survey team monitored the plan of removal from 12/31/20 through 1/3/21 as follows: Observation on 1/1/21 at 11:08 AM revealed the new alarm system that was installed on the exit door. Surveyor had RN B test the alarm with a wander guard bracelet which sent the alarm off. Observations on 1/1/21 at 11:15 AM revealed no residents in the halls of the 100 and 200 hall. No residents were seen attempting to exit the facility. During an interview on 1/1/21 at 11:20 AM, RN B stated that she had been in-serviced on wander guards that morning by the DON. She stated that she is to verify the wander guard is on the resident every shift, and the nurse on the overnight shift will test it. She stated that she is to notify the DON immediately if a resident needed a new wander guard. During an interview on 1/1/21 at 11:28 AM, LVN A stated that she had been educated on wander guards and elopement risk that morning by the DON. She stated that she had a tester in her cart. She tested Resident #2's wander guard, and it showed to be functioning. She stated that she always has extra wander guards in her cart in case she needs one. During an interview on 1/1/21 at 11:40 AM, the DON stated that they had implemented the Wanderguard Function Checks to be physically put on each nursing chart that must be completed each shift. She stated that she was doing one-on-one education with each staff member and showed Surveyor her in-services and current staff signatures. She stated that she has purchased more wander guard testing devices. During an interview on 1/3/21 at 4:45 AM, RN G stated that she has received education on wander guards and elopement. She stated that she puts eyes on her residents every two hours and tests the function of the wander guards every shift. She stated that if she was unable to find a function testing device, she would take her residents to the door to ensure the alarm goes off. Observation on 1/3/21 at 4:55 AM revealed all doors to the courtyard and were closed. There were not any residents inside the courtyard, nor were any seen outside of their rooms. Review of Wanderguard Function Checks sheets on both hallways for ten residents reflected them to be filled out appropriately and consistantly. The DON was notified on 1/3/21 at 5:05 AM that the IJ had been lowered. The facility remained out of compliance at a severity of actual harm that is not Immediate Jeopardy and a scope of isolated due to the facilty's need to evaluate the effectiveness of the corrective systems.

Based on observations, interviews, and record reviews the facility failed to ensure the resident environment remained as free of accident hazards as possible; and each resident receives adequate supervision to prevent accidents when: A. Elopement One (1) of 7 (Resident #20) residents with a history of exit seeking behaviors, wearing a Wanderguard (electronic monitoring bracelet) eloped from the 200 hall exit door, due to lack of supervision and a failure in the Wanderguard system. This failure resulted in an identification of an Immediate Jeopardy on 6/14/11 at 8:10 PM. The IJ was removed on 06/15/11 at 6:15 PM. The facility remained out of compliance at a potential for more than minimal harm with a scope identified as a pattern The deficient practice to supervise residents at risk for wandering and have a working Wanderguard system contributed to Resident #20's elopement resulting in injuries and could affect the other 6 residents who had been identified by the facility as a risk for wandering and could lead to serious injury or death. B. Hot Water Temperatures The facility failed to ensure hot beverage temperatures were safe for three ( 3) of 3 residents, reviewed for hot liquid spills and burns, when they received burns from spilled hot beverages (Resident #22, Resident #7, and Resident #3). 1. Resident #22 received a 10 cm (centimeter) 2nd degree burn to inner right thigh on 6/15/11 from her spilled coffee. 2. Resident #7 received a 7cm x 8cm 2nd degree burn to the right thigh after spilling hot tea on 5/30/11. 3. Resident #3 on 2/17/11 spilling coffee on abdomen no injuries were noted. The deficient practice to supervise and monitor residents at risk for burns from hot liquids contributed to Resident #3, #7, and #22's burns and had the potential to affect the other 35 residents who had been identified at risk of hot liquid spills to receive serious burns or injuries as result of an accidental spill of hot liquids. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 6/15/11 at 2:05 PM. The IJ was removed on 06/15/11 at 6:15 PM. The facility remained out of compliance at a potential for more than minimal harm with a scope identified as a pattern. The findings include: A. Review of Resident #20's Face Sheet indicated a [AGE] year old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #20's Physician Telephone Order dated 05/11/2011 revealed the following: Wanderguard bracelet due to exit seeking behavior. Check placement every shift. Check function every 10 AM-6 PM shift. Review of Resident #20's Elopement Risk Review dated 05/24/11 indicated a score of 25. The review documented a score of 12 or higher is at risk for elopement. Review of Resident #20's Plan of Care dated 05/13/11 revealed the following: "Care Plan- Elopement. 05/11/11 Elopement, at risk related to wandering/ current confusion or disorientation. 5/11/11 Attempted to leave building, Wanderguard bracelet in place. Approach: Provide safe location for wandering behaviors as needed. Increase observation of individual during and after visitors. 05/03/11 At risk for Fall: New admission, Poor safety awareness- Personal alarms, bed and chair- Wanderguard bracelet." Review of Resident #20's Nursing Notes dated 05/11/11 revealed the following: "1:00 AM - (resident) up ambulating towards exit Certified Nurses Assistant (CNA) asked where he was going. (Resident) stated "there" and pointed towards the exit. Wanderguard to be applied secondary to risk of elopement, poor safety awareness." "7:00 AM - Resident activated Wanderguard alarm trying to exit facility." "(Resident) did attempt to leave facility through side exit door nearest room at 9:00 PM. Alarm sounded and noted (resident) at door." "05/11/11 11:10 PM (Resident) up out of bed walking to "exit" by (room) 215." Review of Resident #20's Nurses Notes dated 05/12/11at 1:00 AM revealed the following entry: "(Resident) up out of bed walking to exit by (room) 215. No alarm sounded. (Resident) went out the door with CNA's out to get him. He had removed his Wanderguard bracelet." Review of Resident #20's Incident/Accident Report dated 05/29/11 revealed the following: "Incident injury Type: fall- Location: outside end door, Hall 200. Findings: Resident rolled outside to get some fresh air and rolled off sidewalk and turned over causing scrapes to hip, forehead, nose, and open area to corner of right eye." Review of Resident #20's Interdisciplinary Post Fall Review dated 05/29/11 revealed the following: "Time of fall: 7:30 AM, unwitnessed. Injury: scrape to forehead, nose and skin tear to corner of right eye. Summary of Interdisciplinary team: Wanderguard failed to alert. Notified Maintenance Supervisor who repaired the back door Wanderguard system." Review of Resident #20's Incident/Accident Investigation Follow-Up dated 05/29/11 revealed the following: "Summary: Wanderguard system failure." Review of Resident #20's Nursing Notes dated 05/27/11 revealed the following " Risk Management summary documented: Wanderguard in place due to high risk of elopement." Observation on 06/14/11 at 5:00 PM revealed an area outside of the 200 Hall exit door. The area consisted of a ramped sidewalk with a drop off of approximately 6 inches on either side. The right side of the ramp had gravel, multiple rocks, and a broken plastic pipe protruding from the ground. The pipe had sharp jagged edges. The left side of the ramped area consisted of gravel and rocks. Both sides of the area were uneven. In an observation on 06/14/11 at 5:02 PM, the 200 Hall exit door by room 215 was observed as not latching properly when closed and remained open by one inch from the frame to the door upon each closing attempt. Six attempts were made by the Surveyor to close the 200 hall exit door near room 215. The door continued to remain ajar and unlatched on each of the six attempts to close the door. Observation on 06/14/11 at 5:06 PM revealed Resident #20 in his wheelchair. Resident #20 had a steri-strip over his right eye. During an interview on 06/14/11 at 5:09 PM, Resident # 20, when questioned by the Surveyor why he had a bandage on his eye, stated "I fell on a rock a couple of weeks ago." Observation and interview on 06/14/11 at 5:10 PM reveal Resident #20's Wanderguard bracelet was in place on his wrist. Resident #20 was wheeled to the hall 200 exit door near room 215 by an unidentified staff and escorted by Assistant Director of Nurses (ADON A). During this time, resident #20 reached up and pushed the 200 hall exit door open. The alarm did not sound. ADON A stated "Make sure the door is closed hard." ADON A stated it has to be closed tightly in order for the Wanderguard alarm to be activated. Once the door was closed tightly the alarm still did not activate. In an observation on 06/14/11 at 5:15 PM, the Maintenance Supervisor (MS) tested the function of Resident #20 ' s Wanderguard bracelet using the Wanderguard testing device. The device indicated the Wanderguard was functioning properly. In an interview on 06/14/11 at 5:16 PM, the MS stated he has now repaired the door. The MS stated he was aware the door was not latching but because of the amount of traffic that comes through the door it is difficult to monitor the door closing properly. During an interview on 06/14/11at 5:20 PM, in reference to the previous elopement on 05/29/11, the MS stated he replaced the entire Wanderguard alarm for the 200 hall exit door near room 215 with a new Wanderguard alarm system following Resident #20's elopement on 05/29/11. The MS stated there was a transformer in the Wanderguard alarm on that particular door that malfunctioned. The MS stated the door is frequently used by UPS (United Parcel Service) for deliveries, family members, and staff. The MS stated the door must have been jarred from frequent use or recent high winds. Observation and interview on 06/14/11 at 6:00 PM revealed an unidentified visitor coming in through the 200 hall exit door near room 215. The visitor stated she always comes in this door. The visitor stated the door is convenient to her family member's room. The visitor stated several family members use this door. During an interview on 06/14/11 at 6:40 PM, ADON A stated people are frequently in and out of the door. ADON A stated the wind has blown the door open in the past, but the MS has fixed it. ADON A stated she knows the door needs to be closed tightly in order to engage the Wanderguard, based on prior experience. During an interview on 06/14/11 at 6:50 PM, the Administrator and Director of Nurses (DON) stated they are not aware of the door alarms being tested during weekends and holidays. The Administrator stated the incident on 05/29/11 when Resident #20 eloped occurred on a Sunday. The Administrator stated there is not a log that is signed off on. The Administrator and DON stated the conclusion to Resident #20's accident was the installation of the new alarm system on the 200 hall exit door by room 215. During an interview on 06/14/11 at 7:25 PM, Licensed Vocational Nurse (LVN) F stated he observed the Exit door on Hall 200 near room 215 malfunction once before on 05/29/11. LVN F stated the MS fixed the Wanderguard system on 05/29/11. LVN F stated he always pulls on the door to close it tightly; otherwise it does not shut completely. LVN F stated he was trained to respond immediately if the door alarm sounds. LVN F stated this particular door sticks, he does not feel others make an attempt to close the door properly. Review of the Wander Guard Departure Alert System User and Installation Manual dated 2010 documented the following: Verifying Monitor Operation: 1. Make sure the door is closed or the Passive Infrared Sensor (PIR) is not detecting motion. The Facility ' s Administrator and DON were notified of the Immediate Jeopardy on 06/14/11 at 8:10 PM. Plan of Removal: (A) On 06/14/11, the facility immediately assessed all doors for functioning of the electronic monitoring system, to include complete latching of the exit door on the 200 hall. Bracelets of all residents wearing electronic monitoring alarms were checked for function. All doors and bracelets were functioning correctly and documented on the residents TAR (Treatment Administration Record). Elopement Risk Assessments were completed on all residents by the DON/ADON/Staff Development Coordinator/ MDS (Minimum Data Set) Nurse on 06/15/11. There are seven (7) residents who are at risk for elopement and who wear electronic monitoring bracelets. The care plans and Nursing Treatment Administration Record (TAR) for the seven (7) are current and will be updated with changes as indicated. Upon admission, readmission and significant change residents will be assessed for elopement risk by completion of the Elopement Risk Section of the Nursing Admission Assessment. All residents identified at risk for elopement will have a Wanderguard bracelet implemented by the assigned charge nurse and documented on the care plan. The TAR will be updated to reflect interventions. Residents will continue to be assessed for elopement risk quarterly, annually, and with a significant change in condition. The assigned charge nurse for any newly assessed residents as risk for elopement will notify the physician to obtain orders for an electronic monitoring device. The device will be checked for placement every shift and documented on the TAR. The assigned charge nurse will check the function of the signaling device daily using the Wanderguard tester box and document on the TAR. If the Wanderguard wrist band fails the function test, the assigned charge nurse will immediately replace the Wanderguard wrist band with a new band. The DON/ADON will review the TAR for all residents with Wanderguards weekly to validate daily function checks are taking place for one month and then monthly thereafter. Residents at risk for elopement will be reviewed by the IDT (Inter-Disciplinary Team) during the Care Management Risk Review meeting at least quarterly or after experiencing a change of condition. The Maintenance Director/200 Hall Charge Nurse will check the doors/electronic monitoring system daily including weekends and holidays to ensure doors are functioning. Doors that are not functioning will immediately be secured and the Administrator/DON will be notified immediately. The Maintenance Director was educated on the importance of checking the doors daily including weekends and holidays for proper functioning. The DON/Staff Education Coordinator educated all facility staff on the facility electronic monitoring system, to include checking the doors for function, appropriate latching of the door, checking the function of the electronic monitoring device and procedure in the event of an elopement. An in-service on the above items will be completed annually. The Human Resources Coordinator (HR Coordinator) will monitor all employees training records to ensure this education is done annually. The HR Coordinator will educate all new employees during orientation on Wanderguard and elopement procedures. The DON/Staff Education Coordinator educated all licensed nurses on testing Wanderguard wrist bands with the signaling device tester every shift and documenting it on the TAR. Nurses were educated regarding the importance of checking the function of the signaling device daily. Following the implementation of the Plan of Removal, in an observation on 06/15/11 at 9:05 PM, Resident #20 was escorted to the 200 Hall exit door. Resident #20 pushed on the door and the alarm was activated. In an observation on 06/15/11 at 9:07 PM, Wanderguard bracelets were tested . All Wander guard bracelets were operational. The IJ was removed on 06/14/11 at 9:15 PM and the Administrator was notified. However, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a pattern. The facility was continuing to monitor implementation of the plan of removal. B. 1. Resident #22 Review of Resident #22's change of condition form dated 6/15/11 with a time of 8:30 a.m. revealed "resident returned from the dinning room after a reported coffee spill between her legs, resident noted with a 10 c red area inner right thigh". Review of Incident/Accident Report dated 6/15/11 at 7:30 a.m. revealed "resident returned from the dinning room after a reported coffee spill between her legs." Review of Non-Pressure Skin Condition Record dated 6/15/11 revealed the size of the burn to Resident #22's inner right thigh was 10c x 6. The same day Non-Pressure Skin Condition Record it was reassessed and the size of the blisters from the burn was noted to be 2.5 x1.3 cm, 3.9 x 2.2 cm, 2.6 x 0.8cm. Also documented was "burn area right inner thigh generalized redness resolving with 3 fluid filled blisters" Observation on 6/15/11 at 1:20pm of resident #22 revealed a 10cm x 2cm reddened area with scattered intact fluid filled blisters of various sizes on the right, inner thigh. Resident #22 stated "it really hurt when the coffee spilled on my leg." During this observation Resident #22 also revealed the accident occurred as she was filling coffee cup with regular coffee, from dispenser in dining room and cup ran over and spilled onto her leg. In reference to the National Institutes of Health a second degree burn causes pain, redness, swelling, and blistering. During an interview with Resident #22's spouse on 6/15/11 at 2:40 PM he stated "I have burned my hand before getting coffee at the self-serve coffee area at the facility. " Resident #22 ' s spouse stated he did not make facility aware of this. During an interview on 6/15/11 at 5:51 PM, the Corporate Regional Director stated the facility confirmed through interview with a CNA that Resident #22 did get her own coffee that morning. 2. Resident #7 During an interview with LVN G on 6/12/11 at 8:50 a.m., during initial rounds, she stated Resident #7 had a burn to her thigh from coffee. Review of Resident #7's incident/accident report dated 5/30/11 revealed Resident #7 was in dining room at 7:30 a.m. and "spilled hot tea onto thin blanket and dress onto right lateral thigh". The report also revealed Resident #7 had reddened area, noted with "flat blistering to center area." Review of Resident #7's nursing daily skilled summary dated 5/30/11 revealed "7cm x 8cm area with flat blistering area to right lateral thigh after" Resident #7 "spilled hot tea on self." Review of Resident #7's physician progress notes [REDACTED]." Under "Assessment" on same progress note revealed "burn: right lateral thigh, from spilled coffee, 3"x3", blistering, skin intact, continue to monitor". During an interview with RN "B" on 6/15/11 at 11:34 a.m. she stated she did not see how Resident #7 got her burn. She stated an unidentified CNA heard Resident #7 scream. She added that Resident #7 will put her head down frequently with her eyes open, but just does not make eye contact. She stated that Resident #7 had two blisters that were flat and by the next day the blister were filled. RN "B" stated she talked to the cook about taking the temperature of the tea. RN " B " was not aware if the cook had implemented this. Observation on 6/13/11 at 10:30 a.m. of resident # 7 revealed a 4 cm x 1 cm reddened area on right, inner thigh. Interview with resident #7 on 6/13/11 at 10:30 a.m. revealed reddened area was caused by a spill of hot water in dining room, when attempting to fill cup for tea. Interview with CNA "N" on 6/13/11 at 10:30 a.m. revealed spillage of hot water occurred on 5/30/11. Interview with RN "B" on 6/13/11 at 10:45 a.m. revealed size of burn following spillage of hot water was 7cm x 8cm, Silvadene ointment was ordered to be applied daily with bandage to cover wound. RN " B " stated she was unsure of how they were monitoring the hot liquids. 3. Resident #3 Review of Resident #3 Incident/Accident Report dated 2/17/11 revealed "resident reports she spilled coffee onto abdomen -paraplegic waist down, no redness, no blistering." Review of nurses' notes dated 2/16/11 at 3:00 p.m. revealed Resident #3 to be very drowsy. Nurses' notes dated 2/17/11 12:00 a.m. revealed Resident #3 "opens eyes to voice command increase lethargy noted. Resident continues to nod and close eyes." Nurse ' s note on 2/17/11 at 7 a.m. revealed "complaint of spilling coffee on abdomen no redness or blistering. Coffee warm and tested at 150 degrees." Observation on 6/15/11 at 11:52 a.m. revealed 3 large urns in the dinning room, one held regular coffee, one held hot water, and one held decaffeinated coffee. Observation on 6/15/11 at 12:04 p.m. revealed 3 large urns containing coffee, decaffeinated coffee and hot water in the main dinning room area. During this observation an unidentified resident was observed reaching up to large canister from her wheel chair and filled her cup with coffee from one of the urns. As she filled her cup the cup was slightly tilted toward her. Observation on 6/15/11 at 12:09 p.m. an unidentified CNA was observed getting coffee for 2 residents from the urns of hot liquid in the main dinning room. Observation on 6/15/11 at 1:48 p.m. revealed the following temperatures from the urns that contained the hot beverages that were in the main dinning room area. Using the surveyor's thermometer the coffee temperature was measured at 129.6 degrees Fahrenheit, the hot water at 145 degrees Fahrenheit, and the decaffeinated coffee at 150.6 degrees Fahrenheit. During an interview with the Dietary Manager on 6/14/11 at 7:24 p.m. she stated the equipment the facility uses to brew the coffee is set at the lowest temperature of 180 degrees. The Dietary Manager stated she was told this is the lowest temperature the machine could go to, to brew the coffee right. The Dietary Manager stated once it is brewed the facility adds water or ice to bring the temperature of the coffee down. The Dietary Manager stated she thought that would drop the temperature of the coffee by about 5 to 10 degrees. The Dietary Manager stated they did not monitor the temperatures of the hot liquids after they were set out for resident use. During an interview on 6/15/11 at 12:00 PM, The Dietary Manager stated the Administrator determined on 6/15/11 to keep the temperature of the coffee around 140 degrees. The Dietary Manager also said that the temperature can be plus or minus 15 degrees based on the research she obtained. During an interview on 06/15/11 at 1:34 PM, the Dietary Manager stated she was not aware of any other burns beside Resident #7. The Dietary Manager stated she had never seen any policy and procedures from the management company regarding coffee. The Dietary Manager stated she found information from Ecolab (Food Service Management Company) that the temperature of coffee should be about 140 degrees plus or minus 15 degrees. The Dietary Manager stated she was not aware of any policy regarding resident self serving coffee. During an interview on 6/15/11 at 5:22 p.m. the DON stated there has not been any prior assessment forms completed to which residents were assessed to be at risk for burns from hot liquids. Review of list provided by facility on 6/15/11 at 5:25 p.m. there were 38 residents who are at risk of burns or scalds with hot liquid due to diagnosis, dementia, or tremors. Plan of Removal: (B) The ADON/DON reviewed all residents' history, [DIAGNOSES REDACTED]. This assessment was documented in the Nurses Notes. All residents determined at risk for burns/scalds from hot liquid spills related to the inability to safely hold a cup securely. The assessment was documented in the Nurse's Notes. Thirty-eight (38) residents were determined at risk for burns/scalds from hot liquid spills related to the inability to safely hold a coffee cup securely. The care plan and TAR for the residents will be updated with interventions to prevent injury. The DON/ADON will assess all resident for inability to safely hold a mug and document this assessment in the Nurse's Notes. All residents who are identified at risk will have interventions put in place to prevent injury. These interventions include covered mugs for hot beverages, staff to convey all beverages to resident ' s table, and supervision during consumption of hot beverages if indicated by cognitive impairment. The care plan and TAR will be updated with these interventions. The Dietary Manager/ Cook will monitor and record the temperature of hot beverage urns before beverage service and before placing hot beverages in the urn for distribution to residents. The temperatures must be 120 degrees Fahrenheit or below before it is acceptable for service to the residents. The Administrator/Registered Dietitian will review the logs to validate compliance and conduct a temperature test of the hot beverage urn weekly. In an observation on 06/15/11 at 6:10 PM, Residents were served hot liquids in covered mugs. During interviews on 06/15/11 at 6:12 PM, verified with multiple staff members that inservices on hot beverages were conducted. The IJ was removed on 06/15/11 at 6:15 PM and the Administrator was notified. However, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a pattern. The facility was continuing to monitor implementation of the plan of removal. The facility's CMS 672 dated 06/12/11 documented a resident census of 93. The facility staff identified 5 Wanderguard system devices on Hall 200 and 2 Wanderguard system devices on Hall 100. The facility's CMS 672 identified 38 residents at risk for injuries of burns with hot liquid.