Every finding on record at Del Rio Nursing and Rehabilitation Center

Based on observations, interviews, and record reviews the facility failed to ensure the residents right to be free from neglect for 1 of 4 residents (Resident #1) reviewed for freedom from abuse, neglect, and exploitation. The facility VD failed to call 911 after Resident #1 slid out of her wheelchair to the van floor after the brakes of the van were applied quickly to avoid an accident on 8/4/26. The VD stopped to check on Resident #1 then continued to drop another resident off at an appointment before driving Resident #1 back to the facility where EMS was called. Resident #1 was sent by EMS to the hospital and sent back to the facility the same day with diagnoses of lower extremity fractures. Resident #1 was on the van floor for approximately 45 minutes. The noncompliance was identified as PNC. The IJ began on 8/4/26 and ended on 8/4/26. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of injury, pain, mental anguish, and delays in assessment and needed emergency services.The findings were:Record review of Resident #1's admission record dated 8/5/26 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with readmission on [DATE]. Resident #1's diagnoses included rheumatoid arthritis unspecified (autoimmune disease where the immune system attacks its own body's tissues, and the joints causing pain, inflammation, and swelling. It affects the lining of the joints and eats away at the bone under them. This causes a painful swelling that can cause joints to bend out of shape over time), Type 2 diabetes mellitus with hyperglycemia (medical condition where the body does not use insulin properly or cannot produce enough insulin, leading to high blood glucose levels.), morbid (severe) obesity due to excess calories (a body mass index (BMI) of 40 or higher due to an intake of calories greater than expenditure), muscle wasting and atrophy not elsewhere classified, unspecified site (wasting or loss of muscle tissue), and muscle weakness generalized.Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed the resident had minimal difficulty hearing, clear speech, was able to understand others, and make herself understood. The resident had a BIMS score of 15 out of 15 indicating she was cognitively intact. The resident had impairment to both lower extremities and used a manual wheelchair. The resident was Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity for chair to bed and bed to chair transfers, sit to lying and lying to sitting, and rolling left and right in bed. The resident was unable to attempt sit to stand or walking. The resident was always incontinent of urine and bowel. Record review of Resident #1's undated care plan revealed a focus initiated on 2/21/22 and revised on 6/15/26 for a self-care deficit related to activity intolerance, obesity, and weakness. Interventions included mechanical lift with 2 staff members. And a focus initiated on 2/21/22 and revised on 8/4/26 for the resident being a risk for falls with an actual fall on 8/4/26. Interventions included to anticipate and meet the resident's needs.Record review of Resident #2's admission record dated 8/5/26 revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with readmission on [DATE]. Resident #2's diagnoses included end stage renal disease (ESRD - medical condition in which the kidneys cease functioning on a permanent basis leading to the need for long-term dialysis or a kidney transplant to maintain life), and dementia in other diseases classified elsewhere, mild, without behavioral, psychotic, mood disturbances, or anxiety (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life without behavioral changes).Record review of Resident #2's MDS and care plan were not relevant to the incident. Record review of the facility incident intake #1109513 dated 8/4/26 revealed the facility first learned of the incident on 8/4/26 at 11:00 a.m. and the incident occurred on 8/4/26 at 10:45 a.m. resulting in a lower extremity fracture. It was further documented under narrative of the incident During transportation in the facility van, the driver applied the brakes suddenly in an effort to avoid a potential motor vehicle accident. During the abrupt stop, the resident moved from the wheelchair and fell. The driver immediately stopped the vehicle and assessed the resident. Upon return to the facility, the resident was assessed by licensed nursing staff, including evaluation for injury, pain, and change in condition. The attending physician and responsible party were notified, and the resident was monitored in accordance with facility protocols. Resident was sent to the ER for evaluation and treatment. And under actions and notifications was documented An investigation was initiated immediately following the incident. Identified van driver was immediately suspended from assignment. Van was placed out of use pending validation of safety and proper functioning. Education and training commenced for all staff members responsible for transportations regarding ANE, expectations for proper securement and safety requirements, validation of transportation equipment functionality, and implementation of enhanced transportation safety monitoring to prevent recurrence.Record review of Resident #1's hospital x-ray report to her left knee dated 8/4/26 revealed Findings: There is an acute transversely oriented fracture at the proximal tibial metaphysis without significant displacement or impaction. No definite involvement of the tibial plateau articular surfaces. Similar nondisplaced transverse fracture at the proximal fibular metaphysis. Bones are markedly demineralized. Moderate osteoarthritis (. It happens when the slippery cushion (cartilage) at the ends of bones wears down over time. This causes bones to rub together, leading to pain, stiffness, and swelling in places like the hands, knees, and hips) at the knee. Suprapatellar lipohemarthrosis (medical condition where fat and blood from inside a broken bone leak into the knee joint space, gathering in the upper pouch above the kneecap) with layering fat fluid level suggests an acute occult intra-articular component to the fracture. Diffuse subcutaneous edema. Impression: 1. Nondisplaced transversely oriented proximal tibial and fibular metaphyseal fractures. 2. Suprapatellar lipohemarthrosis suggesting occult intra-articular component to the fracture.Record review of the facility incidents and accidents from 5/1/26 to 8/5/26 revealed Resident #1 had one fall during this time frame and it was on 8/4/26 at 10:29 a.m Record review of Resident #1's progress notes revealed an EMAR progress note with an effective date of 8/4/26 at 10:55 a.m. by LVN A that Resident #1 received acetaminophen 325mg for pain (a level for her pain was not documented). Record review of the facility van vehicle safety inspection checklist included Wheelchair Tie-Down Inspection - Check that tie-downs are secure to floor, not frayed, and in good working condition. Check fluid levels in lift, Inspect lift for fluid leaks, Seat belts not frayed, cut or torn and are in good working order. The van was inspected and signed by the MD on 7/27/26 and 8/4/26.Record review of the VD's employee file revealed he was educated on vehicle transportation and safety of residents on 1/27/26 and again on 8/4/26.In an observation and interview on 8/5/26 at 1:58 p.m. Resident #1 was sitting up in her bed with the HOB elevated and her spouse was in the room with her. The resident had a leg immobilizer to her left leg. The resident stated she had been going to a physician's appointment and the VD stepped on the van brakes hard and her wheelchair tilted forward and she fell to the van floor landing on her back with her left knee stuck between the front driver's seat and the front passenger seat and her head on the wheelchair seat. Resident #1 stated the VD had not secured her wheelchair and had not put her seatbelt on. Resident #1 stated the VD stopped near the (name) fast food restaurant and tried to get her up and she told him it was not possible. Resident #1 stated the VD told her they could not go back to the facility because the other resident with them had to go to dialysis and the VD got back in the van and drove to dialysis and dropped the other resident off and then returned to the facility. Resident #1 stated the VD did move her wheelchair out from behind her after dropping the other resident off so she could lay down completely. The resident stated she felt the pain at a 10 of 10 in her left leg as soon as she fell and she had told the driver she was in pain. In an observation and interview on 8/5/26 at 2:09 p.m. Resident #2 was sitting up in his bed eating his lunch. The resident stated he did not know anything about the incident as he had fallen asleep during the transport and stated he was sorry but he could not remember what happened. The resident stated the VD had secured his wheelchair and put his seatbelt on but he does not know if Resident #1's wheelchair was secured or if she was wearing her seatbelt. Resident #2 stated the VD always secures his wheelchair and puts his seatbelt on while transporting him in the facility van and he felt safe with him.In an observation and interview on 8/6/26 at 1:30 p.m. in the facility van, the MD secured the DM in a wheelchair in the facility van by first locking the wheelchair, attaching the floor straps securely to the frame in the front and back of the wheelchair and then properly applied the seat belt securing the DM for transport. The MD then reversed the process for unloading. The DM then secured the MD in a wheelchair by first locking the wheelchair then attaching the floor straps to the frame and properly securing the DM with the seat belt. The DM went further to demonstrate how attempting to move the wheelchair would cause the straps to auto tighten so the wheelchair was unable to tilt forward or backward while he explained it. The van was observed to be clean and free of rust and wear. There were 2 floor anchors for the front wheelchair and 4 floor anchors behind the wheelchair (2 of those rear floor anchors were for the wheelchair behind the first one) and all were in good working order.In interviews on 8/5/26 from 2:11 p.m. to 2:14 p.m. with 3 other unidentified residents that utilize the facility van for transportation, all the residents stated the VD always secures their wheelchairs and puts their seatbelts on during transportation and they felt safe with the VD. In a telephone interview on 8/5/26 at 2:31 p.m. the VD stated on 8/4/26 he was transporting Resident #1 to a doctor's appointment and Resident #2 to dialysis. The VD stated he had been the facility's van driver for many years (unsure of how many). The VD stated he loaded Resident #1 in the van first, secured her wheelchair and put her seatbelt on and then loaded Resident #2 and did the same with his chair and seatbelt. The VD stated he then double checked that both residents were secured properly prior to leaving the facility. The VD stated he secured Resident #1 and Resident #2 was directly behind Resident #1 as only 2 wheelchairs fit in the van at a time and Resident #2 would be dropped off first so he was closet to the lift ramp at the back to the van. The VD stated as he was driving another driver ran a red light and he had to step on the brakes hard to avoid a collision. The VD stated he did not hear or see Resident #1 fall but he heard her say hey, I fell and he pulled over immediately in a gas station parking lot and he was unable to assist the resident due to her size and he attempted to reposition her. The VD stated Resident #1 denied pain and told him he needed to take her to the hospital or back to the facility to get her up. The VD stated he called the facility and LVN A told him to bring the resident back to the facility. The VD stated he took it upon himself to decide to take Resident #2 to his dialysis appointment prior to returning to the facility with Resident #1. The VD stated once Resident #2's wheelchair was out of the way, he unlocked, unsecured and removed Resident #1's wheelchair out of the way so she could lay flat and that was when he noticed the seatbelt was not connected and stated it had been previously and he stated he was unsure how the seat belt had come off. The VD stated he had positioned the resident for comfort and she had stated she was fine. The VD stated initially it was not more than an hour Resident #1 was on the floor and then stated an hour would be an exaggeration and it was less than an hour, maybe 45 minutes. The VD stated he panicked and did not know what to do at that moment and the facility nurse had told him to bring the resident back to the facility. The VD stated Resident #1 complained of pain as theyre were almost back to the facility but had denied pain prior to returning to the facility. The VD driver stated he had been trained on how to respond to an incident or accident when transporting residents in the facility van and that he panicked and was not thinking clearly. The VD further stated per his training, he should have called 911 when he pulled over and waited for them to assist the resident instead of continuing on to dialysis but his mind blanked in the moment.In a telephone interview on 8/5/26 at 3:40 p.m. LVN A stated she did answer a call from the VD on 8/4/26 and she was unsure of the time of the call but it was regarding Resident #1 but stated the VD told her the resident was sliding out of her wheelchair and he was headed back to the facility. LVN A denied she gave the VD any instruction to return to the facility and she would have told him to stop, call 911, and wait for an ambulance if she had known the resident had already fallen and was on the floor of the van. LVN A stated when they returned to the facility they discovered the resident had already fallen and the DNS and herself assessed the resident and 911 was called. LVN A stated the resident complained of pain to her left leg 5 out of 10 and she was medicated prior to leaving with EMS. In an interview on 8/5/26 at 4:10 p.m. the DNS stated Resident #1 was not admitted to the hospital and returned the same day after evaluation in the ER with a left leg knee immobilizer and recommendations to follow up with the orthopedic surgeon and her appointment was scheduled for 8/6/26 in the afternoon but unsure of the exact time. The DNS stated the resident will be transported by an ambulance transport service by stretcher. In an interview on 8/6/26 at 1:05 p.m. the Administrator stated her expectation for any accident or incident in the facility van regarding the residents would be for staff to stop immediately and call 911 first then notify facility staff and herself. The Administrator stated the possible consequences of not stopping and calling 911 first for the residents could possibly be a delay in assessment and care. The Administrator stated in-services and training were completed for all facility staff approved to drive the facility van and an adhoc QAPI meeting was held on 8/4/26 (the same day as the incident), a new form for a second staff signature was created and will be kept in a binder in the van when it is back in service for a two-staff verification of the residents being secured properly in the van and going forward Resident #1 will have a staff companion for all transportations in the facility van.Review of the facility policy on safe vehicle transportation revised January 2023 indicated . 7. After all residents are loaded, make sure that all residents have seat belts properly secured. 8. Securing wheelchairs and other equipment: a. Secure down all wheelchairs using the secure strap equipment. b. Always secure the strap to the frame of the wheelchair not the armrest or wheels. c. Place seat belt around all residents including those in wheelchairs. 10. What to do in the event of an accident? Driver shall immediately report to local authorities and emergency services (911) as indicated. Then promptly notify the Administrator or Director of Nurses Services for additional instructions. 11. What to do in the event a medical emergency during a transport? Driver shall immediately notify the emergency services by calling 911. Then the driver shall immediately notify the community nurse/DNS of the emergency event.Review of the facility policy on abuse guidance preventing, identifying, and reporting revised January 2024, indicated . Every resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.Any violation of these rights is against the law. Neglect occurs when the facility is aware of or should have been aware of goods or services that a resident requires but the facility fails to revive them to the resident that has resulted in or may result in physical harm pain mental anguish or emotional distress. Neglect includes cases where the facilities indifference or disregard for resident care comfort or safety resulted in or could have resulted in physical harm pain mental anguish or emotional distress.The Administrator was notified on 8/6/26 at 4:45 p.m. that a past non-compliance IJ had been identified due to the above failure and an IJ Template was provided to the Administrator. The facility implemented the following interventions prior to the survey entrance on 8/5/26.The VD was immediately re-educated on safe vehicle transportation and resident rights and suspended pending the facility investigation on 8/4/26. The facility van was immediately taken out of service on 8/4/26 pending inspection by the maintenance director.Adhoc QAPI meeting was held on 8/4/26.All residents needing transportation would be through a transportation service until the facility van was cleared for transportation and facility driver re-education.All facility staff approved for transporting residents (8) in the facility van were re-educated on safe vehicle transportation, resident rights, and the 2-person verification check off sheet on 8/4/26.Record review of transportation staff training revealed training on safe vehicle transportation, resident rights, and the pre-transport 2-person check-off was completed on 8/4/26 for the DNS, ADNS, MD, VD, MDS RN, WD, DM, and CNA B.In interviews on 8/5/26 the following facility approved drivers stated they had been trained on safe vehicle transportation, resident rights, and the pre-transport 2-person check-off and stated they would stop and call 911 for any resident incidents or accidents. 4:55 p.m. DNS, 4:58 p.m. ADNS, 5:00 p.m. MDS RN, 5:55 p.m. WD, 5:56p.m. DM, 5:57 p.m. MD, 9:00 p.m. CNA B.

Based on observations, interviews and record reviews, the facility failed to ensure assessments accurately reflected thestatus of the residents for 1 of 5 residents (Resident #1) reviewed for MDS assessments. The facility failed to ensure Resident #1s falls were reflected on the quarterly MDS assessment dated [DATE]. This deficient practice could place residents at risk of inadequate care.The findings include: Record review of Resident #1's electronic face sheet dated 07/21/2026 reflected an [AGE] year-old male admitted on [DATE]. His diagnoses included: paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease) heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen) and dementia (loss of cognitive functioning that interferes with daily life and activities). Record review of Resident #1's admission MDS assessment dated [DATE] reflected he could understand others and be understood. He scored a 4 of 15 on his BIMS which signified his cognitive status was severely impaired. Section J1800, Fall History on Admission/Entry or Reentry or Prior Assessment reflected he had no falls. Further review of Resident #1's quarterly MDS assessment dated [DATE] reflected he had no falls. Record review of Resident #1's comprehensive care plan dated 02/21/2026 reflected Focus, at risk for falls r/t: chronic health problems, debility and weakness, Interventions, routine rounds to help with safety checks. Record review of the facility's Incident and Accident log dated 04/01/2026 to 06/30/2026 reflected Resident #1 had falls on 04/04/2026, 05/12/2026 and 06/13/2026, after his admission MDS assessment and prior to his quarterly MDS assessment. Record review of Resident #1's Post Fall Reviews dated 04/04/2026, 05/12/2026 and 06/13/2026 reflected he had unwitnessed falls and was assessed. Record review of Resident #1's Progress Notes dated 04/04/2026, 05/13/2026 and 06/13/2026 reflected he had unwitnessed falls on these dates. Observation on 07/21/2026 at 10:00 a.m. revealed he was sitting in a tall wheelchair in his room. His bed was in a low position with a scoop mattress. During an interview on 07/21/2026 at 10:03 a.m., Resident #1 stated he had fallen because he tried to get up and he knew he needed to call for someone to help him. Resident #1 stated his sensor pad was within reach. During an interview on 07/21/2026 at 3:49 p.m., the MDS nurse stated she did not know why she missed coding Resident #1's falls. She stated an inaccurate MDS assessment could affect the facility quality rating and care could be missed. During an interview on 07/21/2026 at 4:16 p.m., the DON stated the MDS needed to be accurate to show what care a resident needed and it could be miscommunicated and not communicated if it was wrong. During an interview on 07/21/2026 at 4:30 p.m., the ADM stated the accountability of the MDS was a team effort. She stated it was important for the MDS to be accurate to reflect and communicate care needed or it could be missed. Record review of the facility's policy and procedure titled Comprehensive Assessments dated January 2024 reflected, Accuracy of Assessment, each resident receives an accurate team assessment of relevant care areas that provide team members with knowledge of each resident's status, needs, strengths, and areas of decline. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, dated October 2025 reflected The RAI process has multiple regulatory requirements. Federal regulation required the assessment accurately reflects the resident's status.

Based on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensiveperson-centered care plan for each resident, consistent with the resident rights, which includes measurable objective andtimes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #1 and #2) of 5 residents reviewed for care plans. 1.The facility failed to accurately reflect Resident #1's prevention intervention of a scoop mattress (specialized medical mattress designed with raised, contoured sides or edges that create a concave sleeping surface. The scoop shape gently cradles the user, forming a soft barrier that helps prevent them from rolling out of bed) in the care plan. 2. The facility failed to accurately reflect Resident #2's fall prevention intervention of anti-slip strip (traction-enhancing safety product applied to a surface to reduce slips and falls) in the care plan. These deficient practices place residents at risk of missed or miscommunicated care.The findings include: 1.Record review of Resident #1's electronic face sheet dated 07/21/2026 reflected an [AGE] year-old male admitted on [DATE]. His diagnoses included: paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease) heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen) and dementia (loss of cognitive functioning that interferes with daily life and activities). Record review of Resident #1's admission MDS dated [DATE] reflected he could understand others and be understood. He scored a 4 of 15 on his BIMS which signified his cognitive status was severely impaired. Section J1800, Fall History on Admission/Entry or Reentry or Prior Assessment reflected he had no falls. Further review of Resident #1's quarterly MDS assessment dated [DATE] reflected he had no falls. Record review of Resident #1's comprehensive care plan dated 02/21/2026 reflected Focus, at risk for falls r/t: chronic health problems, debility and weakness, Interventions, routine rounds to help with safety checks, remind resident to keep bed in low position, call light within reach, and did not reflect the bed had a scoop mattress. Record review of the facility's Incident and Accident log dated 04/01/2026 to 06/30/2026 reflected Resident #1 had falls on 04/04/2026, 05/12/2026 and 06/13/2026, after his admission MDS assessment and prior to his quarterly MDS assessment. Observation on 07/21/2026 at 10:00 a.m. revealed he was sitting in a tall wheelchair in his room. His bed was in a low position with a scoop mattress. During an interview on 07/21/2026 at 10:03 a.m., Resident #1 stated he had fallen because he tried to get up and he knew he needed to call for someone to help him. He stated his sensor pad was within reach. During an interview on 07/21/2026 at 04:39 p.m., LVN A stated Resident #1 had a low bed with a scoop mattress as fall prevention interventions. During an interview on 07/21/2026 at 04:49 p.m., CNA B stated Resident #1 had a low bed with a scoop mattress as fall prevention interventions. 2.Record review of Resident #2's electronic face sheet dated 07/21/2026 reflected a [AGE] year-old female admitted on [DATE]. Her diagnoses included: displaced fracture of base of neck of right femur (when the bones break in the upper part of the thigh bone near the hip and are not aligned), depression (common and serious mood disorder characterized by persistent feelings of sadness, loss of interest and other emotional and physical problems), cognitive communication deficit (breakdown in the mental processes that support effective communication), and cerebral infarction (when a blood vessel in the brain becomes blocked, leading in a sudden reduction of cessation of blood flow and oxygen delivery to brain tissue causing cell death). Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected that she could usually understand and sometimes be understood. She scored 6 of 15 on her BIMS which signified her cognitive status was severely impaired. She was coded to have fallen. Record review of Resident #2' comprehensive care plan dated 02/10/2026 reflected Focus, at risk for falls r/t: right sided weakness, impaired balance, Interventions, anticipate and meet resident needs, keep call bell within reach, scoop mattress on bed, bed in low position. The comprehensive care plan did not reflect that she had an anti-slip strip on the floor beside her bed. During an interview on 07/21/2026 at 1:46 p.m., LVN C stated Resident #2 had anti-skid tape on the floor near her bed to help prevent her from slipping and falling. Observation on 07/21/2026 at 3:20 p.m. of Resident #2 revealed she was lying in her bed at the low position. She had a scoop mattress on her bed, and an anti-slip strip on the floor next to her bed. During an interview on 07/21/2026, at 3:25 p.m., Resident #2 acknowledged the fall interventions were to keep her safe. During an interview on 07/21/2026 at 3:49 p.m., the MDS nurse stated she did not know why Resident #1's scoop mattress or Resident #2's anti-slip strip was not in their care plans. She stated it was important to show what the residents needed to try and keep them from falling. During an interview on 07/21/2026 at 4:16 p.m., the DON stated the care plan needed to show what residents required to be cared for and to reflect what interventions were necessary to keep them safe. During an interview on 07/21/2026 at 4:30 p.m., the ADM stated the accountability of the care plan was a team effort. She stated it was important for the care plan to be accurate to reflect and communicate care needed. Record review of the facility's policy and procedure titled Care Plans dated January 2024 reflected The community develops a comprehensive care plan for each resident that includes measurable objectives to meet a resident's medical, nursing, mental, and psychological needs that are identified in the comprehensive assessment.

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 and 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 February 2026 - May 2026. This failure placed residents at risk of not having their preferences honored.The findings included: Review of Resident Council minutes reflected failure to follow up with group grievances: 05/04/2026 Dietary: Why is coffee prepared late, especially in the morning? We want coffee earlier, at least by 7 AM. We want coffee during meals, not after.04/07/2026 Dietary: Sometimes our meat is hard and gravy is too strong. Can something be done to better it? The coffee times feel off, there are no coffee or cups at some moments that we expect it to be. Aside from one dietary aide, do the other dietary aide know the coffee times?03/06/2026 Why are the utensils dirty at times? They have white residues. Why are there some items missing, at times? Can dietary be more careful and double check their work?02/03/2026 Dietary: Dinner has been getting there cold at times. Are they still using plate warmers? During a confidential interview on an undisclosed date and time 12 anonymous residents stated that meals were usually late. They stated there have been issues with the dietary department and most recently more than three dietary staff members left and the department had been short, which had caused issues with meals. They stated the Administration was constantly telling them there would be changes to the dietary department, but that it had been more than three months with these issues. They stated less than two weeks back the Activity Director became the Dietary Manager and he was also learning. He was trying to make changes, but there were too many to make. They stated the grievances would be addressed by the management team, but actions were not being taken to make real change.During an interview on 06/15/2026 at 7:52 p.m., the Regional Nurse stated the Activity Director was responsible for grievances and follow-up. She stated grievances are assigned to the department heads to address; however, the ADMIN was responsible for the overall function of the grievance process.During an interview on 06/16/2026 at 4:01 p.m., the DS stated as the former Activity Director he was responsible for helping facilitate grievances submitted by the residents. He stated the ADMIN is the grievance officer, and he would help residents with the grievance process. He stated he would help residents write individual and group grievances and would deliver it directly to the ADMIN for follow-up. He stated that not resolving grievances could cause a resident to feel unheard. He stated he did not recall the group grievances submitted for months of February 2026 - May 2026 and was not sure they were fully addressed or resolved. He stated that with no Dietary Manager in the role for about two months the food complaints would go up and down and he was unsure if the grievances regarding dietary concerns were addressed. The DS stated that he believed dietary concerns had improved. He stated he was working on improving the group and individual grievances about coffee and late meals that had been submitted to the ADMIN. He stated that he was aware that this was an issue and with no Dietary Manager overseeing the dietary department for some time it was not being addressed. He stated now that he was the Dietary Manager he would be implementing changes to improve the dietary program which will also address resident and group grievances.During an interview on 06/16/2026 at 6:31 p.m., CNA E was knowledgeable of resident rights and provided examples. She stated that the impact on a resident for violation of their rights could cause them to become angry. She stated that if a resident were to notify her of a grievance, she would immediately notify the charge nurse. She stated she was not sure who managed grievances. She stated not responding to grievances could make residents angry.During an interview on 06/16/2026 at 6:45 p.m., CNA F stated all grievances are directed to the charge nurse to manage.During an interview on 06/15/2026 at 7:36 p.m., the ADMIN stated that she was the grievance official, and the NF is constantly trying to accommodate all residents and their grievances. She stated that the resignation of several dietary staff from the dietary department had setback the dietary program significantly. She stated the individual and group grievances from February 2026 - May 2026 were addressed with the dietary staff, and they were being in-serviced, and were counseled on their duties, but efforts were not correcting the issues. She stated that she believed NF staff were trying to address grievances, but because of the previous dietary team the grievances did not receive the proper response or actions.Record review of policy titled, Activities Program, date revised January 2023, revealed .When a resident or family group exists, the community listens to the views and acts upon the grievances and recommendations concerning proposed policy and operational decisions affecting resident care and life in the community. Acting upon these issues does not mean that the community must accede to all group recommendations. However, the community will seriously consider the group's recommendations and must attempt to accommodate those recommendations, to the extent practicable, in developing and changing community policies affecting resident care and life in the community. The community communicates its decisions regarding proposals to the resident or family group.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens reviewed for food safety requirements. The facility failed to store food in accordance with professional standards for food service safety by not labeling, dating, sealing, or thawing meat per recommended guidelines. This failure could place residents who eat meals from the kitchen at risk for the spread of food borne illness. The findings include:Observation on 06/14/2026 at 11:06am, revealed two milk containers were in fridge that did not have lids to close them. A small dessert was not labeled or dated, half of a cut onion in a plastic bag had no date, half used roll of ground meat with no date was in a plastic bag, and a container of what was referred to as soup by the cook did not have a date in the refrigerator. Observation on 06/14/2026 at 11:06am, of standing freezers contained multiple items that were not labeled and/or dated; waffles, ice cream, French toast, and cups with plastic coffee lids placed on them with frozen pink substance in them. The bottom of one of the standing freezers had several packages of butterball meat sitting on the actual bottom of freezer that were surrounded with reddish-brown frozen slush.Observation on 06/14/2026 at 11:06am, of the pantry revealed a bin of bananas and a bin of apples were not dated. Observation of the kitchen area revealed 3 bottles of spaghetti sauce without label or dates. Floors and countertops of kitchen had scattered egg, bread crumbs, onion and were splattered with varying colors of substances that could be easily wiped off. Multiple flies were seen in kitchen area, landing on countertops, dishes, and covered food items. Observation, on 06/14/2026 at 11:06am, of the kitchen revealed [NAME] A had frozen chicken in a container in the sink with hot water running over it to thaw the chicken for lunch. During observation it was noticed that steam from chicken where water was running over it and tapped the faucet slightly to move the stream of water away from the chicken to test temperature. During observation it was revealed that an individual could not keep fingers on faucet due to temperature of the metal faucet against skin, when water was tested by placing finger into stream of running water, it revealed that finger could not stay in stream of water due to temperature of water. Noted the water to be too hot to leave finger in stream.During an interview on 06/14/2026 at 11:20am with [NAME] A it was revealed that the evening staff did not pull the chicken out to thaw the day before so [NAME] A stated he was having to thaw it quickly for meal service. [NAME] A acknowledged that this was not the appropriate way to thaw the meat, but he had to get lunch ready and would now be behind. [NAME] A stated that the meat should be brought to temp with cool water and that he could not reuse the chicken once heated and cooked after thawing from frozen this way, due to potential foodborne illness. [NAME] A stated that thawing the chicken this way should be okay because he was cooking the chicken right away. During an interview on 06/15/2026 at 10:30am Dietary Supervisor revealed that he had been in the position for about two weeks so far and recognized that the kitchen needed work. Dietary Supervisor stated that he had been in kitchen cleaning until midnight to get everything up to code. Dietary Supervisor stated that he was implementing things to make the kitchen better. Dietary Supervisor revealed that the Administrator was covering the kitchen during the lapse of dietary management. Dietary Supervisor also stated that the kitchen team was all new. During an interview on 06/15/2026 at 1:15pm, the Administrator stated that they had to replace the kitchen staff and that the Dietary Supervisor had just started. The Administrator also revealed that she was the one managing the kitchen in the interim and she did do some in-services with the kitchen staff, but that it was hard to find the time to spend in the kitchen to cover all the issues. The administrator admitted that the kitchen did have some concerns and she was aware of them. During an interview on 06/16/2026 at 11:55am, Dietician shared that she sends her reports up and that the Administrator is aware of what is found, good or bad. The last report did cover kitchen cleanliness, labeling, temperature checks and storage. During an interview on 06/17/2026 at 8:54am, the Dietary Supervisor stated that he was not sure what the frozen reddish-brown substance at the bottom of the freezer surrounding the meat could be. The Dietary Supervisor also stated that the policy for food is that it is to be labeled and dated when opened, arrives to facility, or placed into appropriate area with dates and labels. Dietary Supervisor stated that the kitchen needs to be cleaned and items labeled and dated to prevent the residents from becoming sick.During an interview on 06/17/2026 at 9:40am the DCS revealed that she oversaw 28 communities within the company and that she had been to this particular community twice in the last eight months. The DCS also stated that she works closely with the dietician and will facetime into the facility for observations and walk-throughs. The DCS was aware of the Dieticians last report where the facility scored and 83 and it was shared that the report covered that the kitchen was dirty, items were not labeled, and that the staff were not temping foods correctly. The DCS shared that the Administrator was also aware of the concerns in the kitchen. Record review of facility Dietary Services Compliance Guidelines, dated 01/2023, revealed that the facility expectation is that the facility stores, prepares, distributes, and serves food under sanitary conditions. The policy also revealed that the purpose of the policy is to prevent the spread of foodborne illness and reduce practices that result in food contamination and compromised food safety. The policy defines sanitary conditions as the proper storage, preparation, distribution, and serving of food to prevent food borne illness. The policy also covered the correct processes for thawing foods.

Based on interview and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the State for 1 of 1 facility reviewed for qualifications of activity professionals. The facility failed to have a qualified Activities Professional to direct their activities program. This deficient practice could place residents at risk of not receiving approaches that were individualized to match the skills, abilities, and interests/preferences of each resident for activities.The findings included: During an interview on 06/15/2026 at 1:49 p.m., the ADNS revealed the former Activity Director transitioned to a role with the dietary department recently and the Activity Director position was currently vacant and was not filled.During an interview on 06/15/2026 at 1:50 p.m., CNA D revealed that the former Activity Director transitioned to the dietary department at the beginning of June and the facility was actively recruiting an Activity Director. He stated he was the former Activity Director more than a year back and was familiar with activities department, but his certification lapsed. He stated he had agreed to provide activities on a part-time basis, roughly 20-25 hours per week during the afternoons.During an interview on 06/15/2026 at 5:14 p.m. the ADMIN revealed that the former Activity Director was transitioned to the dietary department as of 06/04/2026. She stated that CNA D was an assistant Activity Director who was previously certified as an Activity Director a year back and returned on a part-time basis but was not sure if his certification was active or lapsed. She stated that CNA D is scheduled at 12:00 p.m. and he provided activities for residents on a part-time basis.During an interview on 06/15/2026 at 6:25 p.m., CNA D revealed that his Activity Director certification lapsed one year back after he left the position. He returned to employment two weeks back to help with the activities program on a part-time basis until the position was filled. CNA D revealed that he provided group activities in the afternoon. He stated at this time he had not provided in-room activities for residents but was working on implementing. He stated the former Activity Director had implemented a sensory cart to use during in-room activities.During an interview on 06/15/2026 at 8:00 p.m., the ADMIN revealed the NF did not have a certified Activity Director on staff, but that the management staff were actively recruiting.During an interview on 06/16/2026 at 4:01 p.m., the DS revealed he was the former Activity Director, and he transitioned into his current role with dietary department 10 days ago. He stated as the former Activity Director he provided group and in-room activities for the residents. He stated he would visit residents throughout the week, some residents were visited once a week if they participated in group activities and others were daily as they were bedbound. He stated he documented group and individual in-room activities in the residents' electronic medical record. He stated activities are necessary to promote the residents' physical and emotional well-being. He stated if residents were not provided with activities, it could affect their emotional and physical well-being. He stated CNA D is volunteering part-time as the wellness staff, but he was not the Activity Director. He stated the Activity Director position was currently vacant and the facility was actively recruiting staff to fill the position.Record review of policy titled, Activities Program, date revised January 2023, revealed .The community provides an ongoing, organized program of activities designed, in accordance with the comprehensive assessment, to meet the interests and to maintain the physical, mental, and psychosocial well-being of each resident. The activities program is an essential component of the community's fulfillment of its obligation to care for its residents in a manner and environment that maintain or enhance each resident's quality of life. The activity program is designed to encourage restoration of self-care and maintenance of normal activity and is geared to meet the individual resident's needs. The community provides adequate team members with appropriate training and experience to meet the varied needs and multiple interests of each resident. The activities program is directed by a qualified professional.

Based on observation, interview, and record review the facility failed to provide drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration, for 2 of 2 dining rooms (Dining Room A and Dining Room B) at meal services.The facility failed to ensure facility residents in both dining rooms received drinks while they waited for their late meals (lunch) on 06/14/2026.The facility failed to ensure facility residents in both dining rooms received drinks while they waited for their late meals (breakfast and lunch) on 06/15/2026 and 06/16/2026.This failure could place residents at risk of discomfort, dehydration, and/or a diminished quality of life.Findings included:During an observation on 06/14/2026 at 12:02pm in dining room A (meal service at 11:45am) the meal had not arrived to the dining room. Eight unknown residents were seated around the dining room at the tables without any drinks in front of them. The meals did not arrive to the dining room and tray pass did not begin until 12:19pm. The residents did ask about coffee while they wait. Staff stated that there was no coffee yet.During an observation on 06/14/2026 at 12:22pm in dining room B (meal service at 12:15) 12 unknown residents were seated around dining room at the tables without any drinks in front of them. The meal did not arrive to dining room and tray pass did not begin until 12:33pm. During an observation on 06/15/2026 at 12:50pm in dining room A (meal service at 11:45am) meal trays did not arrive and were not passed until 1:00pm. Seven unknown residents were seated at the table with no drinks in front of them. Residents did ask for coffee while they wait and were told by staff that there was not any coffee.During an observation on 06/15/2026 at 1:25pm in dining room B (meal service at 12:15pm) 14 unknown residents were seated at tables without and drinks in front of them. Trays were not passed until 1:30pm. Residents did ask for coffee or a snack and were told by staff that there were no drinks yet, they would come on the tray.During an observation on 06/16/2026 at 12:25pm in dining room B (meal service at 11:45) the meal trays did not leave kitchen until 12:25pm. Observation revealed no drinks on the tables. Residents did ask for coffee.During an observation on 06/16/2026 at 12:44pm in dining A (meal service at 12:15pm) half of the meal trays did not leave kitchen until 12:44pm. Observation revealed out of 13 in dining room B only 4 or 5 had coffee in front of them. The remaining trays left the kitchen at 1:15pm to dining room A. The residents who did not receive their trays on the first tray run were still sitting with no drinks in front of them. Residents did ask for coffee but were told by staff that the kitchen had run out and they would have drinks on their trays.During an interview on 06/14/2026 at 12:04pm, CNA B stated that meals were normally late. Especially depending on who was cooking in the kitchen. CNA B stated that drinks came out on the resident trays.During interviews on 06/15/2026 at 4:22pm with Resident Council, council members shared that the food is always late and sometimes cold. Resident Council members also stated that there are never any drinks while they wait, especially coffee. If a drink and a soup or salad could be given then that would help them while they wait so long for their food.During an interview on 06/16/2026 at 9:45am, DS stated that he knows the meals are running behind and that he is working on getting the meals out on time.During an interview on 06/17/2026 at 9:40am, DCS stated that getting the meals out on time is one of the issues they are working on.Record review of facility grievances on 06/16/2026 revealed complaints regarding meals being late and it affecting food temperatures.

Based on observations, interviews and record reviews the facility failed to provide each resident with at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care for 2 of 2 (Dining Room A and Dining Room B)dining rooms reviewed for designated meal service times.The facility failed to provide breakfast and lunch according to the designated meal service schedules for dates 06/14/2026, 06/15/2026, 06/16/2026, 06/17/2026.This deficient practice could place residents at risk of low blood sugar levels, increased stress levels, slowed metabolism rates, weakened immune systems, malnutrition, and organ failure. Findings include: During an observation on 06/14/2026 at 12:02pm, in the facility's dining room A, residents sat at tables for the lunch meal service with no drinks or food in front of them. Observation revealed food trays arrived by staff at 12:19pm for distribution. During an observation on 06/14/2026 at 12:22pm, in the facility's dining room B, residents sat at tables for lunch meal service with no drinks or food in front of them. Observation revealed food trays arrived by staff at 12:33pm for distribution. During an observation on 06/15/2026 at 7:15am, in facility's dining room A, residents sat at tables with no food or drinks in front of them. Observation revealed food trays arrived by staff at 8:05am. During an observation on 06/15/2026 at 8:15am, in facility's dining room B, residents sat at tables for breakfast meal service with no food or drinks in front of them. Observation revealed food trays arrived by staff at 8:30am for distribution. During an observation on 06/15/2026 at 12:50pm, in the facility's dining room A, residents sat at tables for lunch meal service with no drinks or food in front of them. Observation revealed food trays arrived by staff at 1:00pm for distribution. During an observation on 06/15/2026 at 1:05pm, in the facility's dining room B, residents sat at tables for lunch meal service with no drinks or food in front of them. Observation revealed food trays arrived by staff at 1:10 pm for distribution. During an observation on 06/16/2026 at 12:25pm, for facility's dining room A, meal trays left kitchen at 12:25pm for lunch meal service. During an observation on 06/16/2026 at 12:44pm, for facility's dining room B, meal trays left kitchen at 12:44pm to start meal service. The surveyor observed not all of the food for lunch was temping at appropriate temperatures, so close to half of the trays for dining room B's lunch service were sent to dining room. Observation revealed remaining trays leaving kitchen for dining room B at 1:15pm. During an interview on 06/14/2026 at 12:04pm, CNA B revealed that meals were frequently late and depending on who was cooking changed how late the trays arrived. During an interview on 06/15/2026 at 10:30am, DS revealed that he had just taken over as the manager for the kitchen and was still adjusting. DS also revealed that most of staff were new. During an interview on 06/15/2026 at 1:00pm, ADMIN revealed that she was aware of concerns for dining and mealtimes and that they had hired almost all new staff for the kitchen and they were training and adjusting. ADMIN also stated she was assisting to cover oversight of kitchen due to no Dietary Supervisor for several weeks to a couple of months. During resident council interview on 06/15/2026 at 4:22pm, resident council stated that meals were always late, all three of them. During an interview on 06/17/2026 at 9:40am, DCS revealed that the staff at facility were working with the dietician to address the concerns. DCS also revealed that all findings are shared with ADMIN. DCS revealed that not only had they changed over personnel, but they were also working to distribute kitchen tasks a little more fairly and remove time constraint issues. Record review of the facility's updated posted meal service reflected breakfast mealtime was 7:30am for dining room A and 8:00am for dining room B, lunch mealtime was 11:45am for dining room A and 12:15pm for dining room B, and dinner mealtime was 5:30pm for dining room A and 6:00pm for dining room B. Record review of policy titled, Dietary Services, date revised January 2023, revealed . The community provides each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident. The community employs sufficient support personnel competent to carry out the functions of the dietary service. Sufficient support personnel is defined as enough team members to prepare and serve palatable, attractive, nutritionally adequate meals at proper temperatures and appropriate times. Frequency of meals. The community provides three daily meals at times comparable to normal mealtimes in the community. Review of Resident #51's Annual MDS assessment dated [DATE] reflected Resident #51 had a BIMS of 14 indicating he was cognitively intact. Review of Resident #60's admission record dated 06/16/2026 reflected Resident #60 was a new admission on [DATE]. During an observation on 06/14/2026 at 12:30 p.m., in the main dining room of meal times posting revealed SCHEDULED MEAL TIMES STATIONS: (A) & (B) undated revealed Lunch: . 11:45 AM (A); 12:15 PM (B). During an observation on 06/14/2026 at 12:50 p.m., numerous residents were sitting in dining room B waiting for lunch meals to arrive. During an interview on 06/14/2026 at 12:52 p.m., Resident #51 revealed he preferred to eat meals in his room. Resident #51 revealed lunch is usually late. During an interview on 06/14/2026 at 1:20 p.m. Resident #60 revealed lunch trays were late most times. He preferred to eat in his room. Resident #60 was orientated to person, place, and time. He was cognitively intact. During an observation on 06/14/2026 at 1:15 p.m. revealed the lunch cart arrive to dining room B and meal trays were passed out to residents. During a confidential group interview at an undisclosed date and time with 12 residents revealed resident meal trays were served late often. During an interview on 06/15/2026 at 7:36 p.m., the ADMIN stated that the resignation of dietary staff and non-vested or committed staff in the dietary department had setback the dietary program significantly. ADMIN stated the change of Dietary Manager and cooks had setback the program, dietary staff were being in-serviced, were counseled on their duties, but efforts were falling on deaf ears. She stated within the last two weeks significant changes have started occurring with the dietary department with the new hire of cooks, committed and caring staff who want to see the dietary program succeed had joined the team. She stated that she believed staff were trying to address grievances regarding meal service, but because of the previous dietary team the grievances did not receive the proper response or actions. She stated the dietary team was constantly doing their best to get meals out on time and on schedule. She stated these concerns are being addressed at this time. During an observation on 06/16/2026 at 1:04 p.m., it revealed five residents sitting in dining room B without lunch trays. Residents were sitting patiently without drinks, staff did not communicate reason for late meals, and all other residents were finishing their meals. During an observation on 06/16/2026 at 1:16 p.m., revealed the remaining five lunch trays arrived for residents in dining room B. During an interview on 06/16/2026 at 1:53 p.m., CNA A revealed lunch mealtimes were posted at 11:45 a.m. and 12:15 p.m., but dining room trays are sometimes delivered 15-45 minutes late. There have been delays recently because of the transition of the dietary staff. During an interview on 06/16/2026 at 4:01 p.m., the DS revealed that with no dietary manager in the role for months the food complaints would go up and down. The DS stated that he believed dietary concerns have improved and the dietary team is now actively trying to improve the concerns with the dietary program. He stated he was improving the group and individual grievances about meals being late that had been submitted to the ADMIN. He stated that he was aware that this was an issue and due to no dietary manager overseeing the dietary department it was not being addressed. He stated now that he is the dietary manager he would be implementing changes to address resident grievances and to improve the dietary program. During an interview on 06/16/2026 at 6:31 p.m., CNA E stated that residents' meals are usually running behind. She stated when meals are late the residents become upset and are constantly asking when meals will be ready. During an interview on 06/16/2026 at 6:45 p.m., CNA F stated lately meals have been a bit late due to the change of dietary staff. She stated meals are extremely late after 45 minutes and they become upset, edgy and they feel it physically. She stated residents are used to their routine, they want to eat early, let food go down, and lay down and late meals upset them. Record review of policy titled, Dietary Services, date revised January 2023, revealed . The community provides each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident. The community employs sufficient support personnel competent to carry out the functions of the dietary service. Sufficient support personnel is defined as enough team members to prepare and serve palatable, attractive, nutritionally adequate meals at proper temperatures and appropriate times. Frequency of meals. The community provides three daily meals at times comparable to normal mealtimes in the community.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs for 1 of 8 residents (Resident #4) reviewed for comprehensive care planning. The facility failed to develop a comprehensive person-centered care plan for Resident #4 following admission on [DATE]. This failure could result in decreased quality of life. The findings included: Record review of Resident #4's admission Record, dated 06/17/2026, revealed a [AGE] year-old female admitted [DATE].Record review of Resident #4's Medical Diagnoses, undated and accessed on 06/17/2026 at 11:50 a.m., revealed diagnoses including cerebral infarction due to unspecified occlusion or stenosis (condition is an ischemic stroke caused by a blockage or narrowing in the left middle cerebral artery), hemiplegia (severe or complete paralysis on one side of the body, where muscles cannot respond voluntarily) and hemiparesis (mild to moderate weakness on one side of the body).Record review of Resident #4's baseline care plan, undated, revealed resident had a Self-Care deficit *Hemiparesis, *Cognitive Impairment, *Weakness & Debility., Incontinent of bladder (total loss of control), *Paralysis, *Requires colostomy with interventions including, Ostomy care / empty collection bag & ensure appliance is intact Date Initiated: 06/08/2026. Resident #4's care plan did not reveal mention of individual activities for individual with paralysis.Record review of Resident #4's MDS tab on 06/17/2026 did not reveal documentation of completed assessment.Record review of Resident #4's Activity Assessment progress note, dated 05/22/2026 reflected Resident #4 enjoys doing things with groups of people and it is important to them. Resident stated doing their favorite activities is somewhat important to them. Resident stated it is very important and enjoys getting out in the fresh air when the weather is good. religious services and practices is very important to them. Resident's preference for scheduled activities is in the morning. Resident choice is to have activities in the Day/Activity room. By review and assessment, the resident will need assistance getting to and from activity functions. Overall attitude toward life and activities is showing an interest. Resident not able to comprehend instructions for cognition/communication.During an observation of Resident #4 on 06/15/2026 at 1:18 p.m., she was noted to be lying in bed, watching television. She was dressed well, groomed appropriately, with no odors, colostomy bag clipped to bed, and the call light pad was within reach. Attempted interview with Resident #4 revealed she was not interviewable.During an interview on 06/16/2026 at 1:53 p.m., CNA A revealed former AD would visit bedbound residents with cart of activities. She stated since the former AD transitioned over to the dietary program two weeks back, she had not seen activities for bedbound residents occurring. She stated that residents who do not receive activities could be made to feel isolated. She stated she provides Resident #4 with direct care and she was unsure if in-room activities had been provided to her during the last two weeks.During an interview on 06/15/2026 at 6:25 p.m., CNA D revealed that he provided group activities in the afternoon. He stated at this time he had not provided in-room activities for residents but was working on implementing.During an interview on 06/16/2026 at 4:01 p.m., the DS revealed he was the former Activity Director, and he transitioned into his current role with dietary department on 06/04/2026 and he was unsure if resident activities were being offered or provided to Resident #4.During an interview on 06/17/2026 at 12:29 p.m., RNAC revealed care plans are updated at admission, during quarterly reviews and for a change of condition. She stated the care plan lists different areas pertaining to resident care, level of assistance, activities, and preferences. RNAC stated the impact to not updating care plans could be missed information. She stated care plan was not created for Resident #4 as she was a new resident. She stated preferences and activities should have been captured on the baseline care plan upon admission. She stated that she was responsible for ensuring care plans were comprehensive and person centered and she was responsible for ensuring Resident #4's care plan was comprehensive, and person centered and including activities and preferences. She stated while working on the MDS assessment that it normally will transfer information onto the baseline and comprehensive care plans and she was not sure why the software had not performed this function. She stated she would generate the baseline care plan immediately.Record review of policy titled, Care Plan Development, Review, and Update Policy date revised January 2026, revealed .To ensure that each resident receives an individualized, person-centered care plan that reflects their assessed needs, goals, preferences, risks, and strengths, and that the care plan is developed, implemented, and updated in accordance with federal regulations. The community will develop and maintain a comprehensive, interdisciplinary, person-centered care plan for each resident. The care plan will include measurable objectives, appropriateinterventions, and resident-directed goals designed to support the resident's highest practicable physical, mental, and psychosocial well-being. A Baseline Care Pian should be initiated upon admission and completed within 48-72 hours of admission. The baseline care plan should: Reflect the residents' assessed needs. Include essential health information as indicated. Identify risks, safety needs, and initial interventions-pending the completion of the comprehensive care plan. Guide staff until the comprehensive care plan is completed. The baseline care plan should be accessible to all staff and used in conjunction with the medical record. Developed within 21 days of admission per federal timelines. The comprehensive care plan should include: Interventions appropriate to the resident's needs, abilities, medical condition, and preferences. Resident's expressed choices and preferences. The care plan should also allow for appropriate variability in care approaches when the resident's needs fluctuate, and within the scope of the resident's assessed needs and abilities. Record review of policy titled, Statement of Resident Rights, date revised January 2023, revealed . The community should educate, encourage, and honor the rights of those we serve. Resident/Patient Rights Include: 10. To participate in developing a plan of care. The community will promote the exercise of rights for each resident, including any who face barriers a (such as communication problems, hearing problems, and cognition limits) in the exercise of these right.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 1 halls (B hall) reviewed for infection control. The facility failed to ensure CNA B sanitized their hands between resident meal trays while passing out trays for 8 of 8 residents and 1 of 1 halls (B hall) reviewed for infection control.This failure could place residents at risk of cross-contamination and the spread of infection. The findings include:During an observation on 06/14/2026 at 1:15pm, CNA B was observed passing meal trays out on B halls. CNA B was observed not sanitizing or washing hands before beginning meal tray pass. CNA B was observed not sanitizing hands between passing out meal trays. CNA B passed meal trays to 8 different residents on B halls. During an interview on 06/14/2026 at 2:15pm, CNA B stated that not washing hands or sanitizing between residents and tasks could put residents at risk for infection. CNA B stated they have held training for it. CNA B stated they were not sure why they did not sanitize hands, stated they may have been nervous.During an interview on 06/15/2026 at 1:15 pm, the ADMIN stated that the expectation for staff is that they wash or sanitize hands according to policy.During an interview on 06/16/2026 at 9:45am CMA E stated that washing or sanitizing hands between the residents is important and she makes sure to clean her hands between residents when passing medication. They have in-servicing for it.During an interview on 06/16/2026 at 1:25pm LVN G stated that cleaning hands between care and residents was important and must be done. LVN G stated that they have had training on it.Record review of facility Handwashing/Hand Hygiene policy, dated 01/2023, revealed that the company considers hand hygiene the primary means to prevent the spread of infections. Policy also revealed that all personnel should follow the handwashing/hand hygiene procedures to help prevent the spread of infections and that washing or utilizing hand sanitizer is used for the following situations (including but not limited to) Before and after direct contact with residents, before and after handling food, and before and after assisting residents with meals.

Based on interview and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every three months for 1 (Resident #37) of 2 residents reviewed for MDS assessments. The facility failed to complete Resident #35's Quarterly MDS Assessment within three months of their most recent comprehensive assessment.This failure could lead to residents not receiving necessary, complete, or correct care due to lack of current information for their care plans.Findings include:Record review of Resident #35's admission Record, dated 06/17/2026, revealed resident admitted on [DATE] with diagnoses including Type 2 Diabetes Mellitus (chronic condition where your body does not use insulin properly or cannot make enough of it), Dysphagia (difficulty swallowing), and Occlusion and Stenosis of Bilateral Carotid Arteries (severe condition where both major neck arteries that supply blood to the brain become narrowed (stenosis) or completely blocker (occlusion) by fatty plaque).Record review of Resident #35's Quarterly MDS, dated [DATE], revealed that it was not completed, signed and uploaded. The previous Quarterly MDS was completed, signed and uploaded 02/05/2026. The current MDS was due to be completed by 06/05/2026.Record review of Resident # 35's electronic health record under the MDS tab revealed that there was not a more recent MDS Assessment Submitted since 02/05/2026. Per PCC, the Quarterly Assessment was 12 days overdue.During an interview on 06/17/2026 at 10:19am, the RNAC revealed there was not an RN on staff that could sign the MDS Assessments and she was having to wait for it as the Director of Nursing had resigned. RNAC stated that when they had a Director of Nursing it was not a problem. RNAC revealed that she is aware of the three-month guidelines and that she would have the assessment signed as soon as possible.During an interview on 06/17/2026 at 11:35am, the ADMIN revealed that she does not really get into clinical as that is not her specialty, but the company would hold the staff to the highest standards per guidelines.Record review of the facility Care Plan Development, Review, and Update Policy, revised 01/2026, revealed that the assessments should be updated and reviewed at least quarterly as defined in the RAI manual.

Based on observation, interviews and record reviews, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for one resident (Resident #8) reviewed for care plans. The facility failed to update or add interventions to Resident #8's care plan regarding the use of an indwelling urinary catheter. This failure could place residents at risk of not receiving the necessary services or having the appropriate interventions to meet their current needs. The findings included: Record review of Resident #8's face sheet, dated 06/17/2026 revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included: neuromuscular dysfunction of bladder (when a person does not have bladder control because of brain, spinal cord, or nerve problems). Record review of Resident #8's Quarterly MDS assessment, dated 05/28/2026, revealed Resident #8's BIMS score was 13 indicating cognition was intact and Section H-Bladder and Bowel H0100 Appliances A. Indwelling catheter (including suprapubic catheter and nephrostomy tube) was coded as Yes. Record review of Resident #8's care plan, dated 06/17/2026, revealed Resident #8 did not have a care plan for an indwelling urinary catheter. Record review of Resident #8's physician order summary dated 06/17/2026, revealed, Foley Catheter 16Fr 10cc, change monthly and PRN every night shift starting on the 15th of every month and as needed, start date 05/25/2026, Foley catheter care with perineal wipes and/or soap and water as needed, start date 05/25/2026, and Foley Output every shift, start date 06/10/2026. Observation of peri-care and catheter care on 06/15/2026 at 10:45am revealed Resident #8 had an indwelling urinary catheter. During an interview on 06/17/2026 at 8:33am, the Registered Nurse Assessment Coordinator stated she was responsible for updating care plans. On 06/17/2026 at 8:45 am the RNAC stated there was no care plan for Resident #8's Foley catheter and did not know why the care plan was not updated, and it was an oversight that she would correct immediately. The RNAC stated Resident #8 returned from the hospital with the catheter in place and presence of the Foley catheter should have been added to the care plan upon completion of the MDS dated [DATE]. The RNAC stated the consequences of not having an accurate care plan causes a breakdown of communication with nursing staff regarding the care needs of Resident #8. During an interview on 06/17/2026 at 10:28am, the ADNS stated she was aware that the care plan for Resident #8 had not been updated to include use of Foley catheter. The ADNS stated the RNAC is responsible for updating the care plans in PCC. The ADNS stated the importance of care plans is to reflect the needed care of the residents to the nursing staff including the Kardex and they should be updated when changes occur. Record review of facility policy titled, Care Plan Development, Review, and Update Policy, dated 01/2026 read: II. Policy Statement. The community will develop and maintain a comprehensive, interdisciplinary, person-centered care plan for each resident. The care plan will include measurable objectives, appropriate interventions, and resident-directed goals designed to support the resident's highest practicable physical, mental, and psychosocial well-being. IV. A Comprehensive Care Plan should be: Completed no later than 7 days after completion of the comprehensive MDS assessment.

Based on interview and record review, the facility failed to ensure residents received an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 of 8 residents (Resident #4 and Resident #31) reviewed for activities. The facility failed to ensure Resident #4, and Resident #31 had the option of participating in daily, organized activities to meet the residents' psychosocial needs and preferences during June 2026. This failure could result in decreased psychosocial well-being or decreased quality of life. The findings included: 1. Record review of Resident #4's admission Record, dated 06/17/2026, revealed a [AGE] year-old female admitted [DATE].Record review of Resident #4's Medical Diagnoses, undated and accessed on 06/17/2026 at 11:50 a.m., revealed diagnoses including cerebral infarction due to unspecified occlusion or stenosis (condition is an ischemic stroke caused by a blockage or narrowing in the left middle cerebral artery), hemiplegia (severe or complete paralysis on one side of the body, where muscles cannot respond voluntarily) and hemiparesis (mild to moderate weakness on one side of the body).Record review of Resident #4's care plan, undated, revealed resident had a Self-Care deficit *Hemiparesis, *Cognitive Impairment, *Weakness & Debility., Incontinent of bladder (total loss of control), *Paralysis, *Requires colostomy with interventions including, Ostomy care / empty collection bag & ensure appliance is intact Date Initiated: 06/08/2026. Resident #4's care plan did not reveal mention of individual activities for individual with paralysis.Record review of Resident #4's MDS tab on 06/17/2026 did not reveal documentation of completed assessment capturing Section F: Preferences for Customary Routine and Activities. Record review of Resident #4's Activity Assessment, dated 05/22/2026 conducted by the former AD now the DS, revealed Resident stated it is very important and enjoys getting out in the fresh air when the weather is good. During interview, resident stated that religious services and practices is very important to them. Resident's preference for scheduled activities is in the morning. Resident's preference for scheduled activities is in the afternoon. Resident's preferences for scheduled activities is in the evening. Resident choice is to have activities in the Day/Activity room. Resident does not require adaptive activities. By review and assessment, the resident will need assistance getting to and from activity functions. Overall attitude toward life and activities is showing an interest. Resident not able to comprehend instructions for cognition/communication.Record review of Resident #4's Documentation Survey Report, dated May 2026, revealed Individual Activity entries of (1), 'Resident Council entries of (0), and In Room Visits entries of (1) for the month were recorded. Record review of Resident #4's Life Works Daily Activity Participation, dated June 2026, revealed in-room activities were inaccurately documented for the month for this resident . Reviewing 22 other unidentified residents' Life Works Daily Activity Participation logs for June against Resident #4's activity log reflected no other residents received more than 3 entries for the month of June while Resident #4's activity log reflected 23 entries for the month. Staff interviews did not line up with activity entries for Resident #4.During an observation of Resident #4 on 06/15/2026 at 1:18 p.m., she was noted to be lying down in bed, watching television. She was dressed well, groomed appropriately, with no odors, colostomy bag clipped to bed, and the call light pad was within reach. Attempted interview with Resident #4 revealed she was not interviewable. 2. Record review of Resident #31's admission Record, dated 06/17/2026, revealed a [AGE] year-old female admitted [DATE] and re-admitted on [DATE].Record review of Resident #31's Medical Diagnoses, undated and accessed on 06/17/2026 at 11:30 a.m., revealed diagnoses including Cerebrovascular Accident (CVA) (sudden interruption of blood flow to the brain), Non-Alzheimer's Dementia (refers to any form of dementia that is not caused by Alzheimer's disease, encompassing a variety of neurological conditions that impair memory, cognition, and daily functioning) and Hemiplegia (complete or near-complete paralysis on one side) and Hemiparesis (partial weakness on one side of the body). Record review of Resident #31's quarterly MDS assessment, dated 05/01/2026 and signed 05/1/2026 as completed, reflected a BIMS of score of 00, indicating severe cognitive impairment. Resident #31's functional abilities were documented as being dependent. MDS assessment reflected that it did not document Section F: Preferences for Customary Routine and Activities for Resident #31.Record review of Resident #31's care plan undated, did not reveal mention of individual activities for individual with paralysis.Record review of Resident #31's Life Works Daily Activity Participation, dated June 2026, revealed in-room activities were inaccurately documented for the month for this resident . Reviewing 22 other unidentified residents' Life Works Daily Activity Participation logs for June against Resident #31's activity log reflected no other residents received more than 3 entries for the month of June while Resident #31's activity log reflected 26 entries for the month. Staff interviews did not line up with activity entries for Resident #31.During an observation of Resident #31 on 06/16/2026 at 2:02 p.m., she was noted to be lying down in bed. She was dressed well, groomed appropriately, with no odors, and the call light pad was within reach. Attempted interview with Resident #31 revealed she was not interviewable.During an interview on 06/15/2026 at 1:49 p.m., the ADNS revealed the former Activity Director transitioned to a role with the dietary department recently and the Activity Director position was currently vacant.During an interview on 06/15/2026 at 5:14 p.m. the ADMIN revealed that the former Activity Director was transitioned to the dietary department as of 06/04/2026. She stated that CNA D was an Assistant Activity Director who was previously certified as an Activity Director a year back and returned on a part-time basis but was not sure if his certification was active or lapsed. She stated that CNA D is scheduled at 12:00 p.m. and he provided activities for residents on a part-time basis.During an interview on 06/15/2026 at 6:25 p.m., CNA D revealed that his Activity Director certification lapsed one year back after he left the position. He returned to employment two weeks back to help with the activities program on a part-time basis until the position was filled. CNA D revealed that he provided group activities in the afternoon. He stated at this time he had not provided in-room activities for residents but was working on implementing. He stated the former Activity Director had implemented a sensory cart to use during in-room activities.During an interview on 06/15/2026 at 8:00 p.m., the ADMIN revealed the NF did not have a certified Activity Director on staff, but that the management staff were actively recruiting.During an interview on 06/16/2026 at 1:53 p.m., CNA A revealed former AD would visit bedbound residents with cart of activities. She stated since the former AD transitioned over to the dietary program two weeks back, she had not seen activities for bedbound residents occurring. She stated that residents who do not receive activities could be made to feel isolated. She stated she provides Resident #4 with direct care, and she was unsure if in-room activities had been provided for her during the last two weeks. During an interview on 06/16/2026 at 4:01 p.m., the DS revealed he was the former Activity Director, and he transitioned into his current role with dietary department on 06/04/2026. He stated activities are necessary to promote the residents' physical and emotional well-being. He stated if residents were not provided with activities, it could affect their emotional and physical well-being. He stated CNA D is volunteering part-time as the wellness staff, but he was not the Activity Director. He stated the Activity Director position was currently vacant, and the facility was actively recruiting to fill the position, and he was unsure if resident activities were being offered or provided to Resident #4 and Resident #31.During an interview on 06/16/2026 at 6:31 p.m., CNA E stated group activities are provided daily. She stated she does not recall if Resident #4 and Resident #31were provided with in-room activities.During an interview on 06/16/2026 at 6:45 p.m., CNA F stated she had not seen Resident #31 provided with in-room activities. She stated she could not recall the last in-room activities provided to Resident #31.Record review of policy titled, Activities Program, date revised January 2023, revealed .The community provides an ongoing, organized program of activities designed, in accordance with the comprehensive assessment, to meet the interests and to maintain the physical, mental, and psychosocial well-being of each resident. The activities program is an essential component of the community's fulfillment of its obligation to care for its residents in a manner and environment that maintain or enhance each resident's quality of life. The activity program is designed to encourage restoration of self-care and maintenance of normal activity and is geared to meet the individual resident's needs. the community provides adequate team members with appropriate training and experience to meet the varied needs and multiple interests of each resident.The activities program is directed by a qualified professional. The activities program consists of individualized and group sessions and: reflects the schedules, choices, and rights of the resident. The activity program consists of individual and small and large group activities that are designed to meet the needs and interests of each resident and includes, at minimum: individualized activities in-room activities. When residents refuse to participate in activities, however, document in the clinical record the reason for the refusal. Also document efforts to encourage resident participation. Each resident must have an individualized care plan, and the community is obligated to provide activities that meet each resident's individual needs. When there is a limitation on their ability to participate, the community should find alternative means of addressing the interest. The activity director is responsible for keeping appropriate departmental records in order to maintain, plan, and develop the activity programs. The following records, at minimum, are maintained by activity department personnel: Attendance records Activity progress notes Individualized activity plan. Residents who are confined or who choose to remain in their rooms are provided with in-room activities and in-room projects they can work on independently.

Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Resident #8) reviewed for incontinent care and catheter care, in that: While providing catheter/incontinent care for Resident #8, CNA C cleaned resident buttocks and then turned resident back onto soiled draw sheet.These deficient practices could place residents at-risk for infection and skin break down due to improper care practices.The findings were: Record review of Resident #8's face sheet, dated 06/17/2026 revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included: neuromuscular dysfunction of bladder (when a person does not have bladder control because of brain, spinal cord, or nerve problems). Record review of Resident #8's Quarterly MDS assessment, dated 05/28/2026, revealed Resident #8's BIMS score was 13 indicating cognition was intact and was indicated to always be incontinent of bowel and had an indwelling catheter. Record review of Resident #8's care plan, dated 05/25/2026, reflected a problem of I have a Self-Care deficit: Limited Physical Functioning r/t stiff or limited joint ROM. Poor physical functioning, Recently in hospital that resulted in weakness and debility, Incontinent of bowel and bladder, and an intervention of Incontinent Care: Check and change upon rounds and as indicated. Observation on 06/15/2026 at 10:45am revealed CNA A and CNA C provided catheter/incontinent care for Resident #8. During care CNA C removed Resident #8's soiled brief and left the draw sheet under the resident. CNA C turned resident to right side, cleaned buttocks, then turned resident back onto the same draw sheet. CNA C then turned resident back to right side and applied clean brief. During an interview with CNA C on 06/15/2026 at 11:05am, CNA C stated the proper procedure was to remove the soiled draw sheet with the soiled brief, clean the resident, and apply a clean brief before turning the resident onto her back. CNA C stated she was nervous. She stated she has received training in incontinent care and catheter care annually. During an interview with the ADNS on 06/17/2026 at 7:52am, the ADNS stated she assists with conducting staff training including peri-care/catheter care and skills checks for CNAs on an annual basis and as needed. The ADNS stated her expectation for peri-care is to apply a clean brief to the residents after they have been cleaned to prevent cross-contamination and potential infection. Record review of facility's policy titled, Incontinence and Catheterization Assessment and Evaluation, dated 01/2023, revealed: The community employs standard infection control practices in managing catheters and associated drainage system. There were no policies or procedures provided as requested for incontinence/catheter care.

Based on interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 kitchen reviewed.The facility failed to employ a qualified dietician who designates a person to serve as a full-time director of food and nutrition services for the facility. The person designated to serve as a director of food and nutrition services did not have the qualifications to serve as the director of food and nutrition.These failures could place residents at risk of not having their nutritional needs met.The findings include:Based on observation on 06/14/2026 at 11:06am the surveyor found the kitchen to be unclean, haphazardly organized, staff unsure of what to do and multiple tasks unfinished.During an interview on 06/14/2026 at 11:06am [NAME] A stated that he had just been promoted to cook and that the DS was also new. [NAME] A stated he was running behind in the kitchen and was trying to get caught up but that lunch would be late again.During an interview on 06/14/2026 at 3:00pm, ADMIN revealed that the DS is new and that the last one left around mid-April. ADMIN also stated that the facility contracts their dietician with Nutritious Lifestyles. During an interview on 06/17/2026 at 8:54am, DS stated that he had not previously been in the kitchen before taking the job to see what needed to be done. DS stated that he had been in the job a few weeks and was the activity director previously. DS could not remember exact date he took over kitchen duties but did share that he did take the food manager course.During an interview on 06/17/2026 at 2:45pm, BOM revealed that the DS signed his job description on 06/03/2026 to start as the DS for the kitchen.Record review of facility policy Dietary Services, dated 01/2023, revealed that Food services are managed by either a qualified dietician or an experienced or qualified food service director. If a qualified dietician is not employed full-time, the community has designated a person to serve as the director of food service who receives frequently scheduled consultation from a qualified dietician. Policy for Dietary Services also revealed that The director of food service must be at least:. d) A person who has completed a state-agency-approved 90-hour course in food service supervision.Record review of facility kitchen staff training revealed that DS completed a state-approved food manager course on 06/15/2026.

Based on observation, interview and record review, the facility failed to ensure residents have a right to a dignified existence and treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident #4) of 8 residents and 1 (Dining Room A) of 2 dining rooms reviewed for dignity. The facility failed to provide Resident #4 privacy during ostomy care on 06/14/2026 when RN G kept resident door open and privacy curtain was not drawn exposing resident to other residents, staff, and visitors walking by the room.The facility failed to ensure residents receiving meals in Dining Room A were treated with dignity on 06/16/2026 when CNA A provided residents with feeding assistance while on personal cell phone making a personal phone call. These failures could lead to psychosocial harm due to feelings of low self-esteem and/or embarrassment regardless of resident cognition. The findings included: Record review of Resident #4's admission Record, dated 06/17/2026, revealed a [AGE] year-old female admitted [DATE]. Record review of Resident #4's Medical Diagnoses, undated and accessed on 06/17/2026 at 11:50 a.m., revealed diagnoses including cerebral infarction due to unspecified occlusion or stenosis (condition is an ischemic stroke caused by a blockage or narrowing in the left middle cerebral artery), hemiplegia (severe or complete paralysis on one side of the body, where muscles cannot respond voluntarily) and hemiparesis (mild to moderate weakness on one side of the body). Record review of Resident #4's care plan, undated, revealed resident had a Self-Care deficit *Hemiparesis, *Cognitive Impairment, *Weakness & Debility., Incontinent of bladder (total loss of control), *Paralysis, *Requires colostomy (is an opening in the colon that lets stools pass from the body without going through the anus) with interventions including, Ostomy (a surgical procedure that creates an opening in the body for the discharge of body wastes) care / empty collection bag & ensure appliance is intact Date Initiated: 06/08/2026. During an observation on 06/14/2026 at 1:01 p.m., RN G was observed providing ostomy care to Resident #4 with the privacy curtain open and door open. Residents, visitors, and staff were observed passing by Resident #4's room when she was being provided with ostomy care. ADNS observed RN G providing ostomy care and she intervened by helping with care and closing the door immediately. During an observation of Resident #4 on 06/15/2026 at 1:18 p.m., she was noted to be lying in bed, watching television. She was dressed well, groomed appropriately, with no odors, colostomy bag clipped to bed, and the call light pad was within reach. Attempted interview with Resident #4 revealed she was not interviewable. During an observation on 06/16/2026 at 12:40 p.m. in Dining Room A, CNA A was observed on personal call while on her personal cell phone while at the table providing feeding assistance to an unidentified male resident. During an interview on 06/16/2026 at 1:53 p.m., CNA A revealed she was knowledgeable of resident rights and provided examples. She stated that not closing doors and not closing privacy curtain while providing resident care or medical care could expose the residents and cause them anger and could cause them to feel uncomfortable. She stated staff should not have cell phones out during shifts and that using cell phones when providing direct care services to residents does not make them feel good. She stated she was on a personal call on her cell phone earlier during lunch while providing unidentified male resident with feeding assistance and she should not have been. She stated she was in-serviced on cell phone use in the workplace and was aware it was not allowed. During an interview on 06/16/2026 at 6:31 p.m., CNA E revealed she was knowledgeable of resident rights and provided examples. She stated that the impact on a resident for violation of their rights could cause them to become angry. She stated she had received education on privacy and dignity. She stated if a resident's privacy and dignity were violated it could cause them to become disappointed. She stated when providing care to a resident the door and privacy curtain should be closed. If privacy and dignity procedures were not followed it could cause a resident to believe the NF staff to not care about them. She stated that when helping a resident with eating staff were expected to be present and not on their phones. She stated she had been in-serviced on this topic. During an interview on 06/16/2026 at 6:45 p.m., CNA F revealed she was knowledgeable of resident rights and provided examples. She stated privacy curtain and door should be closed when providing a resident with personal care. She stated if a resident's privacy was violated, they would feel uncomfortable. She stated staff are not to be on personal cell phones during resident care, including helping residents with eating their meals. She stated this violation could cause residents to not feel important. During an interview on 06/17/2026 at 10:15 a.m., BOM revealed she provided NF staff with resident rights education, NF staff were expected to provide residents with privacy and dignity during ostomy care. She stated NF staff should be closing the privacy curtain and closing doors when providing residents with any personal care. She stated failure to do so would make residents not feel safe and feel their privacy was being violated. BOM stated NF staff should not have personal cell phone out, this is the resident's home, and they need to feel comfortable. She stated that the NF staff are provided with cell phone policy during new hire orientation and have received periodic in-services. During an interview on 06/17/2026 at 12:04 p.m., LVN H revealed she was provided with resident rights training during orientation and periodically. She stated NF staff were expected to use privacy curtain and close door when providing resident personal care, including ostomy care. She stated it would be a dignity and privacy violation to expose the residents, and it could affect them emotionally. She stated NF staff should not be on personal phone calls while providing personal care to residents and this would include during dining room feeding assistance. Violations could impact residents and cause them physical anxiety, feelings of not being seen and not being a priority. During an interview on 06/17/2026 at 12:17 p.m., LVN J revealed she was knowledgeable of resident rights and provided examples. She stated privacy curtain and door should be closed when providing a resident with personal care. She stated not using privacy curtains or closing door while providing resident with personal care could be a violation of one's privacy. She stated it could cause a resident to not feel good, cause them to become sad or upset. She stated NF staff should not be using personal phones on their shift unless they were calling 911. She stated NF staff should be focused and pay attention to the residents. She stated using personal cell phones in the dining room in front of residents could make them believe they were taking pictures of them or talking about them. During an interview on 06/17/2026 at 12:29 p.m., the RNAC revealed that she will help with direct care services and meals. She stated privacy should be maintained when providing residents with personal care including ostomy care. She stated violations could affect a resident's social and emotional state. She stated cell phones should not be used when providing residents with personal care as it could make them feel embarrassed and uncomfortable. During an interview on 06/17/2026 at 12:43 p.m., the ADNS stated that residents have the right to privacy and this would include when personal care or ostomy care was being provided. She stated NF staff should close the privacy curtains and close the door when providing patient care. She stated residents could be made to feel uncomfortable and exposed when privacy and dignity were violated. She stated she did recall the incident with RN G and her failure to close the door and privacy curtain exposing Resident #4 when providing her with ostomy care. She stated she counseled RN G on privacy immediately following the incident. She stated NF staff should not be using cell phones when providing care, including feeding assistance during meals. She stated the residents could feel like NF staff were not paying attention to them. Attempted interview with RN G, on 06/16/2026 at 5:00 p.m., no return call received. Requested a policy for Cell Phone In the Workplace on 06/17/2026 and it was not provided. Record review of facility In-Service, dated 05/15/2026, revealed NF staff were educated on Phone Use/Cell Phone use while on the clock and air pods. Record review of facility In-Service, dated 05/14/2026, revealed NF staff were educated on No Cell Phone use while on the clock or with resident care. Record review of facility In-Service, dated 12/22/2025, revealed NF staff were educated on cell phone policy. Record review of facility In-Service, dated 07/30/2025, revealed NF staff were educated on Patient care rounds should be done in a manner that is respectful, professional and compassionate. It is our expectation that residents receive compassionate care and services that are necessary to promote quality of life. Record review of policy titled, Statement of Resident Rights, date revised January 2023, revealed .the community should educate, encourage, and honor the rights of those we serve. Resident/Patient Rights Include: 4. To be treated with courtesy, consideration and respect; 6. To privacy, including privacy during visits.The community will promote the exercise of rights for each resident, including any who face barriers a (such as communication problems, hearing problems, and cognition limits) in the exercise of these right. Residents have the right to personal privacy and confidentiality. Personal privacy includes accommodations, medical treatment. personal care. Residents' right to privacy includes full visual and, to the extent desired for visits or other activities, auditory privacy. This is in addition to the explicit requirement for privacy curtains in all initially certified communities'. Residents will be examined and treated in a manner that maintains the privacy of their bodies. In situations where a resident requires assistance, authorized team members are required to respect the individual's need for privacy. Team members will ensure that privacy curtains are pulled, doors are closed, or residents are otherwise removed from public view or covered or draped to prevent unnecessary exposure of body parts during the provision of personal care and services.

Based on observations, interviews, and record reviews the facility failed to ensure residents had the right to exercise their rights as a resident of the facility and as a citizen or resident of the United States for 2 of 40 residents (Residents #93 and #94) reviewed for freedom of their rights. 1. On 4/17/2025 Resident #93 was admitted to the facility in the custody of the United States Marshal Service under armed guard supervision and shackled at the wrists, abdomen, and ankles. 2. On 4/28/2025 Resident #94 was admitted to the facility in the custody of the United States Marshal Service under armed guard supervision and shackled at the wrists, abdomen, and ankles. These failures could place residents at risk for physical restraints not required to treat medical symptoms. The findings included: 1. A record review of Resident #93's administration record dated 5/2/2025 revealed Resident #93 was a [AGE] year-old male admitted on [DATE] with diagnoses which included cerebral infarction (stroke) and epilepsy (seizures). A record review of Resident #93's care plan dated 4/18/2025 revealed, actual or at risk for skin impairment: cuffs to bilateral (left and right) wrists, ankles, and abdominal back area, . other: US Marshal's supervisory needs in Rome [SIC(ROOM)] at all times . resident is detained under the direct supervision of a United States marshals as per state and federal law enforcement court orders. Therefore, the resident must remain secured via law enforcement requirements such as the use of cuffs / shackle like device. Nursing to monitor for seeing this especially at the ankles, wrists, etcetera. Regarding the cuffs shackles in place. Nurse should notify the US Marshal's nurse case manager and assigned physician for any skin related condition. During an observation and interview on 4/29/25 at 3:44 PM revealed Resident #93 in his room lying in bed covered in blankets with 2 armed guards supervising him. Resident #93 pulled back his covers and demonstrated his cuffed hands, and ankles as well as an abdominal chain. Resident #93 refused to comment on his wishes for restraints and or medical needs for restraints. 2. A record review of Resident #94's administration record dated 5/2/2025 revealed Resident #94 was a [AGE] year-old male admitted on [DATE] with diagnoses which included chronic pulmonary disease and heart failure. A record review of Resident #94's care plan dated 4/29/2025 revealed, actual or at risk for skin impairment: cuffs to bilateral wrists, ankles, and abdominal back area, . other: US Marshall's supervisory needs in Rome [sic(room)] at all times . resident is detained under the direct supervision of a United States marshals as per state and federal law enforcement court orders. Therefore, the resident must remain secured via law enforcement requirements such as the use of cuffs / shackle like device. Nursing to monitor for seeing this especially at the ankles, wrists, etcetera. Regarding the cuffs shackles in place. Nurse should notify the US Marshal's nurse case manager and assigned physician for any skin related condition. During an observation and interview on 4/29/25 at 3:48 PM revealed Resident #94 in his room lying in bed with 2 armed guards supervising him. Resident #94 demonstrated his cuffed hands, and ankles as well as an abdominal chain. Resident #94 refused to comment on his wishes for restraints and or medical needs for restraints. During an interview on 4/29/25 at 3:50 PM LVN B stated she was the charge nurse for Residents #93 and #94. LVN B stated Residents #93 and #94 were prisoners under custody of the Marshals service and each one was guarded by 2 armed guards and each prisoner was restrained by hand cuffs, ankle cuffs and an abdominal chain. LVN B stated each one was admitted with the restraints and each one did not have any consents nor physician's orders for the restraints. LVN B believed the resident prisoners were restrained by the Marshals and not the facility. LVN B stated, [Resident #94] just arrived yesterday, and [Resident #93] has been here since 4/17/2025. LVN B stated she and other nurses checked on resident prisoners' skin under and around the restraints for skin integrity. LVN B stated, They never leave their rooms, except for showers which are provided late evenings when other residents are in their rooms. During an interview on 4/29/25 at 4:50 PM the Health Services Administrator for the (Local) Detention Facility stated Resident # 94 and Resident #93 were current prisoners under the custody of the U.S. Federal Marshal Service. The Health Services Administrator stated the prisoners had medical needs for health care and security and the facility accepted the prisoners for care with the armed guards and the prisoners restrained. The Health Services Administrator stated per the Department of Justice the prisoners were to be always shackled at the wrists and ankles and guarded by 2 guards armed with firearms. During an interview on 4/30/25 at 5:10 PM the Deputy U.S Marshal Detention Management Investigator stated Resident #94 and Resident #93 were current prisoners under the custody of the U.S. Federal Marshal Service. The Deputy Marshal stated the prisoners had medical needs for health care and security which the facility accepted the prisoners. The Deputy Marshal stated the prisoners were to be always shackled at the wrists and ankles and guarded by 2 guards armed with firearms. During an observation and interview on 4/30/25 at 7:01 AM revealed Detention Guard C and Detention Guard D were in Resident #93's room guarding Resident #93. The detention guards stated Resident #93 was a prisoner of the U.S. Marshals Service and were to be always shackled and in certain situations like mealtime they would call the Marshal and request permission to undo 1 of the hand cuffs temporarily for the meal. During an observation and interview on 4/30/25 at 7:10 AM revealed Detention Guard E and Detention Guard F were in Resident #94's room guarding Resident #94. The detention guards stated Resident #94 was a prisoner of the U.S. Marshals Service and were to be always shackled and in certain situations like mealtime they would call the Marshal and request permission to undo 1 of the hand cuffs temporarily for the meal. During an interview on 5/2/2025 at 4:40 PM the Administrator and the DON stated Residents #93 and #94 were admitted for rehabilitation healthcare under the supervision of the U.S. Marshals Service and had the need to be restrained. The Administrator and the DON stated they believed the restraints were applied by the Marshals and not the facility. The Administrator and the DON stated the risks for residents was for residents to be restrained. The Administrator stated she would partner with the Marshal Service to safely discharge Residents #93 and #94. A record review of the facility's Restraint Management policy dated January 2024, revealed, Compliance Guidelines: The standard of practice at the community is to attain a home like environment; therefore, the community strives to be a restraint free environment. Physical or chemical restraints are not used for purpose of discipline or convenience, but only as required/ordered to treat the resident's medical symptoms. Resident Rights - Each resident has the right to be free from restraint or seclusion, of any form, used as a means of coercion, discipline, convenience, or retaliation.

Based on interviews and record reviews the facility failed to ensure residents had the right to be informed of, and participate in, their treatments, for 1 of 8 residents (Resident #24) reviewed for antipsychotic medication administration. 1. Resident #24 was administered ziprasidone, an antipsychotic medication, in April 2025 without the resident's informed consent and understanding the medications potential side effects. The deficient practices could place residents at risk for side effects for which they did not consent. The findings included: A record review of Resident #24's admission record dated 5/2/2025 revealed an admitted [DATE] with diagnoses which included dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities which can interfere with activities of daily life) and anxiety. A record review of Resident #24's admission MDS assessment dated [DATE] revealed Resident #24 was an [AGE] year-old female admitted for long term care and was assessed with a BIMS score of 0 out of a possible 15 which indicated severe cognitive impairment. Resident #24 was assessed with trouble sleeping and difficulty concentrating on tasks. Resident #24 needed total assistance with most ADL's and could use a wheelchair. Further review revealed Resident #24 was documented as receiving high-Risk Drugs. Resident #24 was documented as receiving antipsychotic medication. A record review of Resident #24's care plan dated 2/1/2025 revealed, I have a self-care deficit - dementia . with psychotic disturbance . I use my wheelchair as a walker and refuse to use a regular walker, I ambulate without requesting assistance and refuse to be assisted by staff, I tend to refuse care at times such as brief changes, showers, and clothing changes from staff . I require psychotropic medications and I am at potential risk for side effects related to my medication regiment . my targeted behavior for the antipsychotic is: aggressive [sic(aggression)] towards others . monitor, document, report, to medical doctor as needed signs and symptoms of psychotropic drug complications; altered mental status, decline in mood or behavior, hallucinations, delusions, social isolation, A record review of Resident #24's physician's orders dated 4/29/2025 revealed the physician prescribed for Resident #24 to receive ziprasidone (an antipsychotic medication) 10 mg injections as needed every 8 hours . A record review of Resident #24's Consent for Antipsychotic or Neuroleptic Medication Treatment form dated 4/18/2025, revealed the form was signed by Resident #24's representative however the form lacked any information for risks and benefits. The form instructed, you may attach prepared documents that state the risks and benefits of the proposed major medical treatment, procedure, specified. however, all questions must be addressed on this forum. the probable clinically significant side effects and risks of the proposed treatment with antipsychotic or neuroleptic medications are indicated: . the need for, and benefits of, the proposed treatment with antipsychotic or neuroleptic medications is indicated: During an interview on 4/30/2025 at 1:19 PM Resident #24's representative stated she recalled receiving reports shortly after Resident #24's admission concerning Resident #24's aggressive behaviors towards peer residents and staff along with Resident #24's confused anxiety and refusals for medication and hygiene care which led to the physician's recommendation for a drug that could calm Resident #24. Resident #24's representative stated she signed a permission slip for Resident #24 to receive the drug but was unaware of any risks for side effects and believed the drug would be a pill and not an injection. Resident #24's representative stated she learned Resident #24 had received the drug multiple times since the end of April 2025 and believed the drug had helped Resident #24 but she now had concerns about the injection and the potential risks for side effects. During an interview on 5/1/2025 at 1:40 PM the ADON stated Resident #24 had a history of aggression towards peers and staff and had been prescribed ziprasidone on 4/29/2025 and had been administered the medication via an injection several times in April 2025. The ADON stated Resident #24's representative had consented for the medication administration and was documented on the Consent for Antipsychotic or Neuroleptic Medication Treatment form dated 4/18/2025. The ADON stated upon inspection of the document the form lacked any information for risks and benefits. The ADON stated the resident should be informed of the proposed medication's potential risks versus the intended benefits prior to the administration. The ADON stated she was unaware of how the information was not documented. During an interview on 5/2/2025 at 5:02 PM the Administrator and the DON stated the expectation for anti-psychotic medication administration was for the resident and or the resident's representative to receive informed consent prior to the drugs administration. The DON stated the risk to residents who did not receive informed consent could be receiving the medications without understanding the potential benefits versus the potential risks of the medications administered. The DON stated the system in place to ensure informed consents prior to medication administration was for the IDT to meet daily and review the medication orders and follow up with consents. A record review of the facility's Psychotropic Medications & Gradual Dose Reduction policy dated January 2023 revealed, The community is expected to make every effort to comply with state and federal regulations related to the use of psychotropic medications in the community to include diagnosis, targeted behavior or clinical indications for use, prescriber's specified dosage frequency and duration of therapy, consent must be received and noted in the medical record for any use of psychotropic medications. Additionally, the prescriber must provide specific rational for use, clinical indications for use, risks and/or benefits of therapy and informed consent as per defined content in the Texas 3713 form for all antipsychotic or neuroleptic drug therapy

Based on observations, interviews, and record review the facility failed to ensure that each resident was free from physical or chemical restraints imposed for purposes of discipline or convenience and that were not required to treat the resident's medical symptoms, for 2 0f 40 residents (Residents #93 and #94) reviewed for physical restraints. 1. On 4/17/2025 Resident #93 was admitted to the facility in the custody of the United States Marshal Service under armed guard supervision and shackled at the wrists, abdomen, and ankles. 2. On 4/28/2025 Resident #94 was admitted to the facility in the custody of the United States Marshal Service under armed guard supervision and shackled at the wrists, abdomen, and ankles. These failures could place residents at risk for physical restraints not required to treat medical symptoms. The findings included: 1. A record review of Resident #93's administration record dated 5/2/2025 revealed Resident #93 was a [AGE] year-old male admitted on [DATE] with diagnoses which included cerebral infarction (stroke) and epilepsy (seizures). A record review of Resident #93's care plan dated 4/18/2025 revealed, actual or at risk for skin impairment: cuffs to bilateral (left and right) wrists, ankles, and abdominal back area, . other: US Marshal's supervisory needs in Rome [SIC(ROOM)] at all times . resident is detained under the direct supervision of a United States marshals as per state and federal law enforcement court orders. Therefore, the resident must remain secured via law enforcement requirements such as the use of cuffs / shackle like device. Nursing to monitor for seeing this especially at the ankles, wrists, etcetera. Regarding the cuffs shackles in place. Nurse should notify the US Marshal's nurse case manager and assigned physician for any skin related condition. During an observation and interview on 4/29/25 at 3:44 PM revealed Resident #93 in his room lying in bed covered in blankets with 2 armed guards supervising him. Resident #93 pulled back his covers and demonstrated his cuffed hands, and ankles as well as an abdominal chain. Resident #93 refused to comment on his wishes for restraints and or medical needs for restraints. 2. A record review of Resident #94's administration record dated 5/2/2025 revealed Resident #94 was a [AGE] year-old male admitted on [DATE] with diagnoses which included chronic pulmonary disease and heart failure. A record review of Resident #94's care plan dated 4/29/2025 revealed, actual or at risk for skin impairment: cuffs to bilateral wrists, ankles, and abdominal back area, . other: US Marshal's supervisory needs in Rome [sic(room)] at all times . resident is detained under the direct supervision of a United States marshals as per state and federal law enforcement court orders. Therefore, the resident must remain secured via law enforcement requirements such as the use of cuffs / shackle like device. Nursing to monitor for seeing this especially at the ankles, wrists, etcetera. Regarding the cuffs shackles in place. Nurse should notify the US Marshal's nurse case manager and assigned physician for any skin related condition. During an observation and interview on 4/29/25 at 3:48 PM revealed Resident #94 in his room lying in bed with 2 armed guards supervising him. Resident #94 demonstrated his cuffed hands, and ankles as well as an abdominal chain. Resident #94 refused to comment on his wishes for restraints and or medical needs for restraints. During an interview on 4/29/25 at 3:50 PM LVN B stated she was the charge nurse for Residents #93 and #94. LVN B stated Residents #93 and #94 were prisoners under custody of the Marshals service and each one was guarded by 2 armed guards and each prisoner was restrained by hand cuffs, ankle cuffs and an abdominal chain. LVN B stated each one was admitted with the restraints and each one did not have any consents nor physician's orders for the restraints. LVN B believed the resident prisoners were restrained by the Marshals and not the facility. LVN B stated, [Resident #94] just arrived yesterday, and [Resident #93] has been here since 4/17/2025. LVN B stated she and other nurses checked on resident prisoners' skin under and around the restraints for skin integrity. LVN B stated, They never leave their rooms, except for showers which are provided late evenings when other residents are in their rooms. During an interview on 4/29/25 at 4:50 PM the Health Services Administrator for the (Local) Detention Facility stated Resident # 94 and Resident #93 were current prisoners under the custody of the U.S. Federal Marshal Service. The Health Services Administrator stated the prisoners had medical needs for health care and security and the facility accepted the prisoners for care with the armed guards and the prisoners restrained. The Health Services Administrator stated per the Department of Justice the prisoners were to be always shackled at the wrists and ankles and guarded by 2 guards armed with firearms. During an interview on 4/30/25 at 5:10 PM the Deputy U.S Marshal Detention Management Investigator stated Resident #94 and Resident #93 were current prisoners under the custody of the U.S. Federal Marshal Service. The Deputy Marshal stated the prisoners had medical needs for health care and security which the facility accepted the prisoners. The Deputy Marshal stated the prisoners were to be always shackled at the wrists and ankles and guarded by 2 guards armed with firearms. During an observation and interview on 4/30/25 at 7:01 AM revealed Detention Guard C and Detention Guard D were in Resident #93's room guarding Resident #93. The detention guards stated Resident #93 was a prisoner of the U.S. Marshals Service and were to be always shackled and in certain situations like mealtime they would call the Marshal and request permission to undo 1 of the hand cuffs temporarily for the meal. During an observation and interview on 4/30/25 at 7:10 AM revealed Detention Guard E and Detention Guard F were in Resident #94's room guarding Resident #94. The detention guards stated Resident #94 was a prisoner of the U.S. Marshals Service and were to be always shackled and in certain situations like mealtime they would call the Marshal and request permission to undo 1 of the hand cuffs temporarily for the meal. During an interview on 5/2/2025 at 4:40 PM the Administrator and the DON stated Residents #93 and #94 were admitted for rehabilitation healthcare under the supervision of the U.S. Marshals Service and had the need to be restrained. The Administrator and the DON stated they believed the restraints were applied by the Marshals and not the facility. The Administrator and the DON stated the risks for residents was for residents to be restrained. The Administrator stated she would partner with the Marshal Service to safely discharge Residents #93 and #94. A record review of the facility's Restraint Management policy dated January 2024, revealed, Compliance Guidelines: The standard of practice at the community is to attain a home like environment; therefore, the community strives to be a restraint free environment. Physical or chemical restraints are not used for purpose of discipline or convenience, but only as required/ordered to treat the resident's medical symptoms. Resident Rights - Each resident has the right to be free from restraint or seclusion, of any form, used as a means of coercion, discipline, convenience, or retaliation.

Based on interviews and record reviews the facility failed to ensure residents did not receive antipsychotic medications ordered as needed for longer than 14 days for 1 of 8 residents (Resident #24) reviewed for antipsychotic medication administration. 1. Resident #24 was prescribed ziprasidone, an antipsychotic medication, as needed without an end date. The deficient practices could place residents at risk for indefinitely receiving an antipsychotic medication. The findings included: A record review of Resident #24's admission record dated 5/2/2025 revealed an admission date of 1/31/2025 with diagnoses which included dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities which can interfere with activities of daily life) and anxiety. A record review of Resident #24's admission MDS assessment dated [DATE] revealed Resident #24 was an [AGE] year-old female admitted for long term care and was assessed with a BIMS score of 0 out of a possible 15 which indicated severe cognitive impairment. Resident #24 was assessed with trouble sleeping and difficulty concentrating on tasks. Resident #24 needed total assistance with most ADL's and could use a wheelchair. Further review revealed Resident #24 was documented as receiving high-Risk Drugs. Resident #24 was documented as receiving antipsychotic medication. A record review of Resident #24's care plan dated 2/1/2025 revealed, I have a self-care deficit - dementia . with psychotic disturbance . I use my wheelchair as a walker and refuse to use a regular walker, I ambulate without requesting assistance and refuse to be assisted by staff, I tend to refuse care at times such as brief changes, showers, and clothing changes from staff . I require psychotropic medications and I am at potential risk for side effects related to my medication regiment . my targeted behavior for the antipsychotic is: aggressive [sic(aggression)] towards others . monitor, document, report, to medical doctor as needed signs and symptoms of psychotropic drug complications; altered mental status, decline in mood or behavior, hallucinations, delusions, social isolation, A record review of Resident #24's physician's orders dated 4/29/2025 revealed the physician prescribed for Resident #24 to receive ziprasidone (an antipsychotic medication) 10 mg injections as needed every 8 hours. Further review revealed no end date for the medication. During an interview on 4/30/2025 at 1:19 PM Resident #24's representative stated she recalled receiving reports shortly after Resident #24's admission concerning Resident #24's aggressive behaviors towards peer residents and staff along with Resident #24's confused anxiety and refusals for medication and hygiene care which led to the physician's recommendation for a drug that could calm Resident #24. Resident #24's representative stated she signed a permission slip for Resident #24 to receive the drug but was unaware of any risks for side effects and believed the drug would be a pill and not an injection. Resident #24's representative stated she learned Resident #24 had received the drug multiple times since the end of April 2025 and believed the drug was prescribed indefinitely. During an interview on 5/1/2025 at 1:40 PM the ADON stated Resident #24 had a history of aggression towards peers and staff and had been prescribed ziprasidone on 4/29/2025 and had been administered the medication via an injection several times in April 2025. The ADON stated Resident #24's medication order for ziprasidone had no end date. The ADON stated she could not opine on whether the order needed an end date and would review the order with the DON. During an interview on 5/2/2025 at 5:02 PM the Administrator and the DON stated the expectation for anti-psychotic medication administration was for the order not to exceed 14 days at which time the order would be reviewed with the physician. The DON stated the risk to residents would be potentially receiving the medication longer than 14 days. The DON stated the system in place to ensure antipsychotic medications were not prescribed longer than 14 days was for the IDT to meet daily and review the medication orders for end dates and follow up with the prescriber for order clarifications. A record review of the facility's Psychotropic Medications & Gradual Dose Reduction policy dated January 2023 revealed, The community is expected to make every effort to comply with state and federal regulations related to the use of psychotropic medications in the community to include diagnosis, targeted behavior or clinical indications for use, prescriber's specified dosage frequency and duration of therapy, consent must be received and noted in the medical record for any use of psychotropic medications. The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long-term care facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits

Based on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for adequate supervision. On 01/30/24, Resident #1 was left unsupervised and suffered an injury, bilateral nasal bone fracture and ten sutures to the forehead, from an unwitnessed fall from a wheelchair to the floor. The facility did not provide adequate supervision. The noncompliance was identified as PNC. The noncompliance began on 01/30/24 and ended on 02/06/24. The facility had corrected the noncompliance before the survey began. This failure could result in residents experiencing accidents, injuries and/or a diminished quality of life. The findings were: Record review of Resident#1's face sheet, dated 3/26/24, revealed the resident was admitted on [DATE] and readmitted [DATE] and 5/27/22 with diagnoses that included: Parkinson's disease (neurological disease), dementia, anticoagulants (blood thinners) , UTI (urinary tract infection), and lack of coordination. Resident was a female age 80. The RP was listed as: a family member. Record review of Resident#1's quarterly MDS assessment, dated 2/11/24 revealed: o BIMS Score was Zero (severe impairment ) o ADLs were: bowel and bladder: incontinent of both. Transfer was listed as resident being dependent and mechanical lift. Bed mobility was dependent. ROM was listed as impairment to lower extremity. Assistive devises included a customized innovative W/C. Record review of Resident #1's CP reflected: the resident's assistive devise was a wheelchair, and the goal was Resident will experience safe transfers . through use of mechanical lift. The transfer required Total Lift X 2 Team Members. The CP also reflected that the resident was at risk for falls due to the diagnosis of Parkinson's and interventions included: avoid leaving resident unattended for excessive periods. Likewise, staff was to observe to ensure appropriate use of safety/assistive devices. Preventive fall measures included: low bed, call light, beside mat, room next to nurse station, routine rounds, scoop mattress, and a customized innovative wheelchair. Record review of resident #1's physician's orders dated February 2024 revealed order for a UTI: order was as follows [initiated 2/1/24 and completed 2/6/24] Ceftriaxone( Sodium) Solution Reconstituted 1 GM . Use 1 gram intravenously every 24 hours for Empiric Treatment for 5 Days. Record review of Resident#1's Physician' Orders, dated March 2024, reflected: monitor the resident's forehead every shift. Monitoring also included monitoring for Anxious/Restless/Panic. The Physician's order included resident prescribed an Anti-coagulant (Xarelto 20 mgs once per day). Record review of Resident#1's MAR dated January 2024 reflected the following anticoagulant: Xarelto 20 mgs once per day. Record review of Resident#1's Skin Assessments reflected : (dated 1/31/24 ) laceration to forehead: 2.9 cm X 0.9 cm (10 sutures) and 3 bruises to face and left finger . Current skin assessment (dated 3/20/24) reflected skin intact with a bruise to the forehead. Record review of Resident #1's SBAR dated 1/30/24 revealed: Laceration to the forehead; sent to ER. Record review of Resident #1's fall risk assessment dated [DATE] revealed a description of High risk. Record review of Resident#1's TAR (dated February 2024) revealed, the resident received treatment for laceration to forehead. Treatment was to cleanse with normal salient, pad dry, leave open to air twice per day. Also, monitor the sutures to facial area, and discoloration every shift. Record review of Resident#1's hospital record, dated 1/30/24, reflected: unwitnessed fall with possible nose fracture on blood thinners. CT dated 1/31/24 revealed: bilateral nasal bone fracture. Ten sutures to the forehead. Record review of Resident #1's hospital labs dated 1/30/24 revealed the resident had a UTI at the time of fall. Record review of Resident #1's rehab assessment dated [DATE] revealed: resident was an 80- year- old female patient who was referred for skilled PT Evaluation and Treatment for range of motion, mobility, to enhance balance, and coordination. Resident #1's assessment reflected she had limitations in bed mobility, balance, and positioning. Record review of Resident #1's Rehab note at discharge, dated 1/14/23 authored by PT C reflected: improved to partial and minimal assistance with rolling. But the resident required maximum assistance with transfer from W/C to bed. Record review of Resident #1's assessment on 2/6/24 and nurse note on 2/6/24 revealed: RP refused rehab services. RP wanted to wait until resident was better from fall on 01/30/24. Record review of Resident #1's rehab note dated 01/30/24 by Rehab Director reflected: RP was called but refused referral for skilled therapy services and W/C management. Record review of Resident #1' Nurse note dated 01/31/23 at 3:18 PM by the DON reflected: resident returned from hospital (one day stay) with nasal fracture and laceration to center of forehead with sutures. CT scan was negative. MD notified and Eliquis (anticoagulant medication) was withheld for 7 days. Record review of Resident#1's Nurse Note, dated 01/30/24 at 6:50 PM authored by LVN B reflected: CNA A came running out of Resident #1's room telling LVN B that the resident had fallen out of the W/C. LVN B found Resident #1 faced down with blood on the floor. First aid was administered and another nurse arrived to assist. MD was notified and the resident was sent to the ER. The DON and RP were also notified. During an observation and interview on 3/26/24 at 11:31 AM, Resident #1 was in an innovative customized W/C [ chair made to fit a resident for posture and comfort; not a restraint] and was alert and not oriented. Resident's room had a pressure release mattress, call light was present, scoop mattress, clutter free room, and bed was at lowest position. Resident had impairment to lower limbs. The resident's specialized W/C had working breaks and was tilted at a 20-degree angle. Resident #1's Hoyer sling was on the chair and the resident wore skid proof soaks. The resident had a bruise to the right of the forehead. The bruise color was yellow and blue. There was no fracture to the nose and sutures were not present to the forehead. The resident could not answer any direct questions. The resident was unable to lift herself out of the specialized wheelchair. During an interview on 3/16/24 at 11:35 AM, the DON stated: CNA A informed her that resident was taken to her room on 01/30/24 for a mechanical transfer from wheelchair to bed. The DON stated CNA A responded to a call light and left the resident unsupervised for about 5 minutes. The DON stated that when CNA A returned to the resident's room she found her on the floor. The specialized wheel chair had not fallen with the resident. The DON stated: Resident #1 used her upper strength to pull out of the wheelchair and suffered a fall with an injury. The hospital x-ray revealed a fracture to the nose and an injury to the head requiring sutures. We conducted training on fall prevention for the nursing staff. The DON stated that 100% of nursing staff was in-serviced on date range of 1/31/24 (nursing staff on 1/31/24 equaled thirty paid staff). The DON stated the in-service was on fall prevention, monitoring, and abuse and neglect. The DON stated the resident likely pulled her weight forward and fell to the floor. The DON stated the roommate did not witness the fall. Instead, the roommate entered the room after CNA A left and found Resident #1 on the floor and triggered the call light. The DON's expectation was that the CAN sought assistance from another nurse aide for the answering of the call light and not leave a resident unsupervised that was pending a mechanical lift; and could pull herself forward on a specialized wheelchair. During an interview on 3/26/24 at 11:44 AM, CNA A stated: she had provided ADL assistance to Resident #1 for about six months which included transfer with the use of a mechanical lift. CNA A stated that after dinner on 01/30/24, she took the resident to her room, put on the breaks to the special W/C and responded to a call light. The CNA A stated the resident was in a reclined position, she was calm, and not agitated in the W/C when taken to the room. The CNA A stated, I left the resident unsupervised for about five minutes. The roommate [Resident #2] triggered the call light. I found the resident on the floor with blood on the floor. I went to get help from the charge nurse [LVN B]. The resident was unable to explain the fall. The special w/c was stationary with the breaks on. CNA A stated that two staff were needed for a Hoyer lift and she did not bring the Hoyer lift with her. CNA A stated she did not take another staff with her in anticipation to transfer her from bed to W/C. CNA A stated her plan was to get the Hoyer lift and another staff member when she was ready to do the mechanical lift. CNA A stated that she was trained that a mechanical lift required two staff members and a resident had to be monitored during the performance of a mechanical lift. The CNA denied she was planning a one- person transfer, given there was no mechanical lift in the room. CAN A stated after receiving an in-service training from LVN B she should not have left to answer a call light; and should have requested assistance from another nurse aide in the answering of the call light. During telephone interview on 3/26/24 at 12:27 PM, the MD stated: he did not know whether the specialized wheelchair was a restraint. He had no orders for the 24- hour monitoring of the resident (Resident #1). The MD did not want to express an opinion as to whether nursing staff needed to have a staff present when anticipating a mechanical lift. The MD stated he saw Resident #1 in the ER and she was treated and returned to the facility the next day. The MD stated that Resident #1 was on blood thinners which could lead to quick bleeding if the resident had a fall. Attempted telephone call on 3/26/24 at 2:25 PM, message left for family member to call the state surveyor. During an observation and interview on 3/26/24 at 2:40 PM, Resident #2 was in bed trying to sleep, pressure release call light was present. The resident stated that on the day of the incident [1/30/24] she returned to her room and found Resident #1 on the floor in the room crying and blood present on the floor. Resident #2 could not remember pushing the call light to request nursing assistance during the incident. [Record review of Resident 2's face sheet, dated 3/26/24 revealed, the resident was admitted on [DATE] with diagnoses that included: stroke, diabetes type 2, and dementia. The resident was a female; age 77. RP was listed as: a family member. BIMs score of 10 dated 1/11/24.[score of 10 means moderately impaired in cognition] During an interview on 3/26/24 at 2:45 PM, LVN B stated, she was at the nurse station on 1/30/24 and after the dinner meal CNA A came out screaming saying Resident #1 was on the floor bleeding from a fall. LVN B stated she was accompanied by LVN D and assessed the resident and called 911. LVN B's assessment revealed the resident was on the floor with a puddle of blood, she was crying. LVN B stated first aid was applied, pressure to the forehead, until EMS arrived. The resident returned the next day. LVN B notified the MD and tried to notify the RP. LVN B stated, I have no clue how the fall happened. LVN B stated, if a Hoyer lift is anticipated, the nurse aides should arrive together to assess and assist each other .also the nurse aide should stay with the resident until the Hoyer lift is brought to the room by another nurse aide. LVN B stated, I have no idea why nurse practice was not followed when a Hoyer lift was anticipated for Resident (#1) by CNA A. I told her (CNA A) after the incident not to leave a resident by themselves when a Hoyer lift was anticipated. CNA A did not provide an explanation for failure to follow nursing practice. LVN B stated that she received training on abuse and neglect and fall prevention; which included monitoring of residents when a mechanical lift was anticipated and done. During an interview on 3/26/24 at 3:07 PM, the Rehab Director stated, Resident #1 was fitted for a customized innovative W/C which was not a restraint about 2-3 years ago. The Rehab Director stated, the said chair had a cushion and was usually angled at 20 degrees. The Rehab Director stated that Resident #1 has the freedom to move forward and has core strength to fall from the chair forward. The Rehab Director stated that I have always seen two nurse aides when anticipating or initiating a Hoyer lift. When Resident #1 was in therapy we never left her alone because we have seen her in therapy sessions moving forward with her core strength which shows the chair is not a restraint. The Rehab Director stated that at the time of the incident the resident was not getting therapy. The Rehab Director stated, after the incident (01/30/24) the RP was notified to initiate PT or OT but the RP refused. The Rehab Director stated the RP's latter refusal could prevent Resident #1 receiving therapy to improve mobility and transfer. During an interview on 3/27/24 at 10:15 AM, the Administrator stated: the fall was unwitnessed and the findings were unfounded. The Administrator stated her investigation revealed that CNA A left Resident #1 in her room to attend to a call light. The W/C was secured, and the resident was calm. The Administrator stated, CNA A felt the resident was safe to be left in the room unsupervised. The Administrator stated there was no neglect because CNA A ensured the resident was safe before answering the call light. The Administrator stated the incident was a past event because: the facility initiated an in-service on fall prevention before the entrance of the state surveyors for the reported incident to the state. The in-service included, per the Administrator, the topic of Do not leave residents in room in W/C unattended. The Administrator stated, the resident has had no falls since the incident and the CP was reviewed and updated. The Administrator stated, interventions put in place for Resident #1 included: floor mat, monitoring more often, low bed, scoop mattress, and specialized wheelchair, antibiotics for a UTI, and referral to rehab services declined by the RP. The Administrator stated a resident should not be left alone when a mechanical lift was anticipated or done; and nursing aides could assist each other in answering call lights. Observation on 3/27/24 at 11:24 AM, Resident #1 was sitting in the innovative customized W/C and attempting to lean forward by grabbing the handle bars. Nursing staff were present. During an interview on 3/27/24 at 11:25 AM, the DON stated, Resident #1 has the upper body strength to lean forward and attempt to push herself forward to get out of the chair. The DON stated, nursing staff closely monitor Resident #1 so that she does not fall again from the W/C by thrusting herself forward. Record review of facility's in-service training on 1/31/24 on the topics of fall prevention and abuse and neglect revealed: 30 signatures for 100 % completion rate. Record review of facility's incident fall list for the past 90 days (January, February, and March 2024) revealed: Resident #1 only had one fall on 1/30/24. Record review of facility's Fall Prevention policy dated 10/2022 reflected: Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision .to minimize the risk of falls .