Every finding on record at Edinburg Nursing and Rehabilitation Center

Based on interview and record review, the facility failed to review and revise the comprehensive Care Plan for 1 of 4 (Resident #1) residents reviewed for comprehensive Care Plan revisions. The facility failed to ensure Resident #1's Care Plan was updated to reflect his preference to use a lock box to store his money and valuables. This failure could place residents at risk of not receiving the appropriate care, service, and preferences. Findings included: Record review of Resident #1's face sheet, dated 08/27/2026, revealed a [AGE] year-old male who admitted to the facility on [DATE] diagnoses included unspecified fracture of left femur, subsequent encounter for closed fracture with routine healing, muscle wasting and atrophy not elsewhere classified, multiple sites, other abnormalities of gait and mobility (break in thighbone, broken bone that did not piece skin, resident is receiving follow up medical care, bone is mending normally without delays or other issues, loss of muscle mass and strength across more than one part of the body, muscle loss affects multiple areas, changes in how a person walks or moves). Record review of Resident #1's admission MDS assessment, dated 08/07/2026, revealed he had clear speech and was understood by staff. The MDS revealed Resident #1 was able to understand others. The MDS revealed Resident #1 had a BIMS score of 10, which indicated moderate cognitive impairment (moderate problems with thinking and memory). The MDS revealed Resident #1 felt like it was somewhat important to take care of personal belongings.Record review of Resident #1's quarterly Care Plan, revised on 08/25/2026, revealed had a history of mild cognitive impairment.Record review of Resident #1's quarterly Care Plan, revised on 08/25/2026, Resident #1's Care plan did not indicate that resident keeps large amounts of money in his room for which a lock box was provided as an intervention so resident #1 can store his money. During interview and observation on 08/25/2026 at 4:09p.m., Resident #1 revealed a lock box in the dresser in his room. Resident #1 stated that the Social Worker told him that only he has keys to the lock box. Resident #1 stated he does not want the facility's Business Office to hold his money and stated he does not like to inform the facility when he has money. Resident #1 stated that the lock box was provided to him after he reported $200.00 was stolen from his room.During an interview on 08/26/2026 at 3:30p.m., Social Worker stated that on 08/08/2026, she was informed Resident #1 was missing $200.00. Social Worker stated the facility offered Resident #1 a lock box so he could store his money, to which only he had keys. Social Worker stated that the case management nurses in the MDS office were responsible for updating the Care Plan. Social Worker stated that the Care Plan should have been updated to include the lock box provided to Resident #1 because it was used as an intervention. Social Worker stated that Resident #1 does not like to keep his money in the Business Office vault. Social Worker stated a negative consequence of not having the Care Plan updated was that the incident might have repeat itself leading to the resident being upset at the facility.During an interview on 08/26/2026 at 4:05p.m., ADON B stated that the Social Worker had given a lock box to Resident #1 so that he can keep his money and valuables secure. ADON B stated the case management nurses in MDS office staff were responsible for updating the Care Plan anytime an intervention was done. ADON B stated a negative consequence of an intervention such as the use of a lock box not being documented on a care planned was that a resident might have said that money was lost again.During an interview on 08/26/2026, at 4:15p.m., The MDS nurse stated she was responsible for initial assessments, MDS forms, and revisions on Care Plans. The MDS nurse stated she updates Care Plans within 72 hours of an intervention update. The MDS nurse stated that the Care Plan for Resident #1 should have been updated when he was provided with a lock box as an intervention. The MDS nurse stated updates were usually given to the MDS nurses so that Care Plans could be updated, but she was not told about the intervention during morning meetings. The MDS nurse stated a negative consequence of the update not being done to the Care Plan, can be that the resident can make another allegation that his money was taken again.During an interview, on 08/27/2026 at 11:33a.m., the DON stated she was aware that the lock box provided to Resident #1 was provided with a lock box to keep his money safe. DON stated that only Resident #1 has a key to the lock box. The DON stated that the lock box intervention was not revised in the Care Plan. The DON stated that a negative consequence of the intervention not being revised was that the resident might say he lost money in the future.During an interview on 08/27/2026 at 12:20p.m., Administrator stated he was made aware that Resident #1 was provided with a lock box by the facility. Administrator stated that the incident with the lock box was not revised in the Care Plan, he stated that the Care Plan was normally updated by MDS and by the Social Worker. Th Administrator stated that he and the Social Worker inadvertently forgot to inform MDS that Resident #1 was provided with a lock box. The Administrator stated that a negative consequence of the Care Plan not being revised was that allegations of missing money could occur again.Record review of the facility's Comprehensive Care Plans policy revised 10/24/2022, reflected:Policy: It is a policy of this facility that the interdisciplinary team shall develop a comprehensive person centered Care Plan for each resident that includes measurable objectives and time frames to meet residents medical and nursing home and cycle needs were identified in the assessment.Policy Explanation and Compliance Guidelines: 6.The comprehensive plan of care will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

Based on interview and record review, the facility failed to ensure all written grievance decisions included the date the grievance was received, a statement of the resident's grievance, the steps taken to investigate the grievance and a summary of the pertinent findings or conclusions for 1 of 4 (Resident #1) of reviewed grievances.The facility did not ensure a complaint and grievance form was filled out and followed up with after Resident #1 reported he was missing $200.00 on 08/08/2026. 2. The facility did not ensure resident's grievance was documented on the grievance log for the month of August after Resident #1 reported he was missing $200.00 on 08/08/2026. These deficient practices could place the residents at risk for decreased quality of life and feelings of neglect. Findings included: Record review of Resident #1's face sheet, dated 08/27/2026, revealed a [AGE] year-old male who admitted to the facility on [DATE] diagnoses included unspecified fracture of left femur, subsequent encounter for closed fracture with routine healing, muscle wasting and atrophy not elsewhere classified, multiple sites, other abnormalities of gait and mobility (break in thighbone, broken bone that did not piece skin, resident is receiving follow up medical care, bone is mending normally without delays or other issues, loss of muscle mass and strength across more than one part of the body, muscle loss affects multiple areas, changes in how a person walks or moves). Record review of Resident #1's admission MDS assessment, dated 08/07/2026, revealed he had clear speech and was understood by staff. The MDS revealed Resident #1 was able to understand others. The MDS revealed Resident #1 had a BIMS score of 10, which indicated moderate cognitive impairment (moderate problems with thinking and memory). The MDS revealed Resident #1 felt like it was somewhat important to take care of personal belongings. Record review of Resident #1's quarterly Care Plan, revised on 08/25/2026, revealed he has a history of mild cognitive impairment. Record review of Resident #1's progress notes, on 08/08/2026, revealed he reported he was missing $200.00.Record review of the facility's Grievance Logs dated 08/27/2026, revealed that Resident #1's 08/08/2026 grievance was not documented. During an interview on 08/25/2026 at 10:08a.m., Resident #1 stated that on 08/07/2026 he left $200.00 in his dresser drawer. Resident #1 reported that on 08/07/2026 he went to the designated smoking area to smoke, and when he returned to his room the $200.00 was missing from his drawer. Resident #1 stated he reported incident of the missing $200.00, on 08/08/2026. During an interview on 08/27/2026 at 9:20a.m., the Social Worker stated she did not have a complaint/grievance or follow up report form for Resident #1. The Social Worker said she did not know why the incident was not added to the grievance log. The Social worker indicated that residents usually fill out the form with the assistance of staff. The Social Worker stated a negative consequence for not having the complaint or grievance report or not having the information on the grievance log was that Resident #1's concerns may go unresolved. During an interview on 08/27/2026 at 9:48a.m., ADON A stated that the nursing facility normally did not put self-reported allegations to law enforcement or state offices, on the grievance log. ADON A stated a complaint and grievance follow up report was not completed for self-reported allegations to law enforcement or state offices. ADON A stated he was not aware what negative consequences could have resulted if the incident was not on the grievance log. ADON A stated he was not aware what negative consequence could have resulted if a complaint and grievance follow up report was not completed. During an interview on 08/27/2026 at 11:33a.m., the DON stated that if an incident was reportable to state or to law enforcement it was not logged on the grievance log. The DON stated a grievance form was also not completed since the item had been reported to state and to law enforcement. The DON stated she could not think of a negative consequence of Resident #1's grievance not being listed on the grievance log. DON also stated she could not think of a negative consequence to Resident #1 not having Complaint and Grievance form completed.During an interview on 08/27/2026 at 12:20p.m., Administrator stated that self-reported allegations were not entered on the grievance log, if the allegation needs to be elevated to the state and to law enforcement. The Administrator also stated that the Complaint and Grievance follow up form was not completed, he produced a form that he stated was just completed on 08/27/2026, because he was not aware it had to be completed. The Administrator stated that the allegation was reported to state office and law enforcement and that, We don't complete a Complaint and Grievance form when we report an allegation to state or law enforcement. The Administrator stated he did not know a negative consequence that could occur to not having the incident on the log or having a complaint and grievance follow up report completed but stated he would ensure to complete them in the future. Record review of the Policy, Resident and Family Grievances, implemented 10/04/2025, revealed: g. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to resident or representative at the conclusion of the investigation. The written decision will include at a minimum: i. The date the grievance was received.ii. The steps taken to investigate the grievance.iii. A summary of the pertinent findings or conclusions regarding the resident's concern(s).iv. A statement to whether the grievance was confirmed or not confirmed.v. Any corrective action taken or to be taken by the facility as a result of the grievance.vi. The date the written decision was issued.

Based on interviews and record review, the facility failed to maintain clinical records that were accurately documented for four of six residents (Resident #42, Resident #99, Resident #100, and Resident #97) reviewed for medical records. 1. The facility failed to ensure Resident #42's blood pressures were not duplicated for the month of May of 2026 by RN A and LVN B. 2. The facility failed to ensure Resident #99's blood pressures were not duplicated for the month of May of 2026 by RN A and LVN B. 3. The facility failed to ensure Resident #100's blood pressures were not duplicated for the month of May of 2026 by RN A and LVN B. 4. The facility failed to document Resident #97's physician order for a one-time dose of haloperidol injected on 04/02/2026. These failures could place residents at risk for errors in care and treatment. The findings include: Record review of Resident #42's face sheet dated 5/18/26 reflected a [AGE] year-old-female with an admission date of 04/06/26. Diagnoses included high blood pressure and stroke. Record review of Resident #42's care plan created on 04/22/26 reflected: Resident #42 had hypertension, due to lifestyle choices and stroke. Interventions included: Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (sudden drop in blood pressure when standing up often causing dizziness, lightheadedness and or fainting) and increased heart rate and effectiveness. Medications: -Losartan (blood pressure altering medication) -Metoprolol (blood pressure altering medication) The resident will remain free of complications related to hypertension through review date. Record review of Resident #42's May 2026 blood pressure log reflected: 5/17/2026 22:36 (10:36pm) 122 / 68 mmHg (RN A) 5/17/2026 15:38 (3:38pm) 122 / 68 mmHg 5/17/2026 15:26 (3:26pm) 118 / 62 mmHg (LVN B) 5/17/2026 08:44 (8:44am) 118 / 62 mmHg 5/16/2026 20:07 (8:07pm) 128 / 64 mmHg (RN A) 5/16/2026 16:40 (4:40pm) 128 / 64 mmHg 5/16/2026 15:12 (3:12pm) 120 / 62 mmHg (LVN B) 5/16/2026 07:39 (7:39am) 120 / 62 mmHg 5/15/2026 22:45 (10:45pm) 130 / 80 mmHg (RN A) 5/15/2026 19:05 (7:05pm) 130 / 80 mmHg 5/15/2026 13:57 (1:57pm) 120 / 70 mmHg (LVN B)5/15/2026 07:09 (7:09am) 120 / 70 mmHg 5/14/2026 19:31 (7:31pm) 120 / 60 mmHg (RN A) 5/14/2026 18:02 (6:02pm) 120 / 60 mmHg 5/14/2026 14:36 (2:36pm) 110 / 62 mmHg (LVN B) 5/14/2026 08:10 (8:10am) 110 / 62 mmHg 5/11/2026 11:07 (11:07am) 120 / 68 mmHg (LVN B)5/11/2026 07:12 (7:12am) 120 / 68 mmHg 5/10/2026 11:20 (11:20am) 124 / 68 mmHg (LVN B)5/10/2026 07:43 (7:43am) 124 / 68 mmHg 5/9/2026 14:18 (2:18pm) 128 / 73 mmHg (LVN B)5/9/2026 07:18 (7:18am) 128 / 73 mmHg 5/8/2026 14:16 (2:16pm) 112 / 64 mmHg (LVN B)5/8/2026 08:28 (8:28am) 112 / 64 mmHg 5/4/2026 13:03 (1:03pm) 122 / 64 mmHg (LVN B)5/4/2026 07:33 (7:33am) 122 / 64 mmHg 5/3/2026 13:42 (1:42pm) 118 / 64 mmHg (LVN B)5/3/2026 07:13 (7:13am) 118 / 64 mmHg 5/2/2026 13:21 (1:21pm) 112 / 62 mmHg (LVN B)5/2/2026 08:10 (8:10am) 112 / 62 mmHg 2. Record review of Resident #99's face sheet dated 05/18/26 reflected a [AGE] year-old-female with an original admission date of 05/12/26. Diagnoses included high blood pressure, heart disease, and old myocardial infarction (heart attack). Record review of Resident #99's care plan initiated on 05/17/26 reflected: Resident #99 had coronary artery disease (narrowing or blockage of the coronary arteries due to plaque buildup) r/t Atherosclerosis (buildup of plaque in the arteries), hypercholesterolemia (elevated levels of cholesterol), high blood pressure, due to lifestyle choices and myocardial infarction. Interventions included: Avoid taking the blood pressure reading after physical activity or emotion distress. Give anti-hypertensive (high blood pressure) medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate and effectiveness. Medications: - Losartan -Hydralazine (blood pressure altering medication) -Clonidine (blood pressure altering medication) Record review of Resident #99's May 2026 blood pressure log reflected: 5/17/2026 22:34 (10:34pm) 187 / 100 mmHg (RN A) 5/17/2026 15:26 (3:26pm) 187 / 100 mmHg (RN A) 5/17/2026 11:53 (11:53am) 187 / 100 mmHg (LVN B)5/17/2026 08:34 (8:34am) 187 / 100 mmHg (LVN B)5/16/2026 20:01 (8:01pm) 164 / 73 mmHg (RN A) 5/16/2026 16:02 (4:02pm) 164 / 73 mmHg (RN A) 5/16/2026 09:41 (9:41am) 180 / 94 mmHg (LVN B)5/16/2026 08:12 (8:41am) 180 / 94 mmHg (LVN B)5/15/2026 22:33 (10:33pm) 188 / 100 mmHg (RN A) 5/15/2026 16:13 (4:13pm) 188 / 100 mmHg (RN A) 5/15/2026 13:42 (1:42pm) 188 / 100 mmHg (LVN B)5/15/2026 08:13 (8:13am) 188 / 100 mmHg (LVN B)5/14/2026 19:28 (7:28pm) 189 / 100 mmHg (RN A) 5/14/2026 18:40 (6:40pm) 189 / 100 mmHg (RN A) 5/14/2026 14:29 (2:29pm) 189 / 100 mmHg (LVN B) 3. Record review of Resident #100's face sheet dated 05/18/26 reflected a [AGE] year-old-femalewith an original admission date of 05/11/26. Diagnosis included high blood pressure. Record review of Resident #100's care plan initiated on 05/17/26 reflected: Resident #100 had high blood pressure r/t heart problems. Interventions included: Avoid taking the blood pressure reading after physical activity or emotion distress. Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate and effectiveness. Medications: -Lisinopril -Metoprolol. Monitor/document/report PRN any signs and symptoms of malignant hypertension: Headache, visual problems, confusion, disorientation, lethargy (significant decrease in energy, mental capacity and alertness), nausea and vomiting, irritability, seizure activity, difficulty breathing. Record review of Resident #100's May 2026 blood pressure log reflected: 5/17/2026 22:37 (10:37pm) 122 / 66 mmHg (RN A) 5/17/2026 20:49 (8:49pm) 122 / 66 mmHg 5/17/2026 15:24 (3:24pm) 128 / 68 mmHg (LVN B)5/17/2026 13:26 (1:26pm) 128 / 68 mmHg 5/16/2026 15:04 (3:04pm) 120 / 70 mmHg (LVN B)5/16/2026 08:28 (8:28am) 120 / 70 mmHg 5/15/2026 22:46 (10:46pm) 110 / 66 mmHg (RN A) 5/15/2026 20:46 (8:46pm) 110 / 66 mmHg 5/15/2026 14:06 (2:06pm) 108 / 68 mmHg (LVN B)5/15/2026 08:40 (8:40am) 108 / 68 mmHg 5/14/2026 19:06 (7:06pm) 118 / 62 mmHg (RN A) 5/14/2026 14:37 (2:37pm) 118 / 62 mmHg (LVN B)5/14/2026 08:13 (8:13am) 118 / 62 mmHg In a phone interview on 05/18/26 at 2:42 pm, RN A who worked the evening shifts and had been employed at the facility for approximately four weeks, stated that the PCC (cloud-based healthcare software platform designed to streamline long-term and post-acute care management) system included a recall feature that displays previously entered vital signs when new vitals were documented. RN A stated staff may review prior vital signs before documenting and entering updated values. RN A further stated that if the vital signs were the same or very close, he would enter the previously documented value, particularly if the difference was not considered significant and only varied by one number. RN A stated that accurate blood pressure documentation was important since blood pressures can fluctuate throughout the day. RN A explained that elevated blood pressures could lead to cardiac complications, while low blood pressure could result in a resident being difficult to arouse. RN A stated it would be unlikely for a resident's blood pressure to remain the same throughout the entire day. In a phone interview on 05/18/26 at 2:47pm, LVN B, employed at the facility for approximately seven years, stated she was unsure whether the PCC system contained a recall feature. LVN B stated she would personally document the blood pressure values she obtained at that time. LVN B stated that during the evening shift, if a resident had a blood pressure reading monitoring ordered twice a day, or three times a day, staff were expected to obtain and document a current blood pressure reading for those ordered times. LVN B stated if a resident had an order to obtain vital signs every shift, she would reuse the previous blood pressure reading she took earlier that day since the order was only once per shift. LVN B also stated that when administering blood pressure altering medications, she would document the resident's actual blood pressure reading. LVN B further stated there could be potential complications if a staff member documented blood pressure readings that were not personally obtained at that time. LVN B stated she was unsure how duplicate blood pressure documentation could occur, specifically referencing her duplicated documentation of blood pressures. LVN B stated she was not certain what the facility's policy regarding reusing previously documented blood pressures stated. She explained that nurses were expected to obtain and document blood pressure readings at the time assessments were completed and she had never been informed that blood pressure documentation was required to reflect a reading obtained at that exact documented time. In an interview on 05/19/26 at 10:01am, the DON stated that the recall button was removed from the PCC system. The DON stated it was not very likely that a resident's blood pressure could remain the same throughout the day. The DON stated staff were aware that when a blood pressure was documented, it should reflect the actual reading at that time. The DON stated the system does alert staff when a blood pressure is out of parameters and for Resident #99, they were made aware by LVN B sometime last week, that her blood pressure was out of parameters, but the system does not notify staff if blood pressures were being duplicated. The DON stated if a resident's blood pressure reading was duplicated throughout the day, the facility would not be able to track and trend any possible concerns and the resident could have a low or high blood pressure and staff would be unaware. The DON stated an in-service on blood pressure and documentation was conducted on 05/18/26. 4. Record review of Resident #97's face sheet, dated 05/18/20256, revealed the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: Cerebral edema (swelling of the brain), chronic obstructive pulmonary disease with sudden exacerbation (a sudden worsening of chronic obstructive pulmonary disease symptoms, such as increased shortness of breath, chest tightness, and a change in mucus), respiratory failure (occurs when the lungs cannot get enough oxygen into the blood or fail to remove enough carbon dioxide the blood), and heart disease (a general term that refers to several types of conditions affecting the heart's structure and function). Record review of Resident #97's quarterly MDS assessment, dated 02/12/2026, revealed Resident #97 had a BIMS assessment score of 12, indicating she had moderate cognitive impairment. Record review of Resident #97's Change of Condition Progress Note written by LVN C, dated 04/02/2026 at 10:08 a.m., revealed The change in condition, symptoms, or signs to report: agitation/increased anxiety/ increased confusion; Long-Term Care Primary Diagnosis: copd Allergies: Zantac Vitals : Blood Pressure: 110/62 Sitting 04/03/2026 Pulse:70 Regular 04/02/2026 Respiration: 18 04/02/2026 Temp: 97.6 04/02/2026 Weight: NA 04/02/2026 O2: 96 04/02/2026 O2 L/M; Mentals Status : Mental Status Change: Increased confusion; Notifications : Name of Family/Health Care Agent Notified: [NP D]. Record review of Resident #97's April 2026 MAR revealed on 04/02/2026 at 11:33 a.m., LVN C injected Haloperidol Lactate Injection Solution 5 MG/ML (Haloperidol Lactate) Inject 1 ml intramuscularly one time only for mood disorder; agitation until 04/02/2026 12:59 p.m. Record review of Resident #97's Progress Note dated 04/02/2026 at 01:10 p.m., written by LVN C revealed, sn and resident on a tele visit with [NP E palliative care] as per her she would consult with medical doctor and get back to us if any changes would be made to resident's medication regimen. [sic]Record review of Resident #97's Doctor - MD Progress Note written by NP D on 04/02/2026 at 01:14 p.m., revealed Face to face consult done with resident and [NP E palliative care] due to patient's progressive decline, SOB and worsening anxiety. Record review of Resident #97's NP D's order dated 04/02/2026 revealed Haloperidol Lactate Injection Solution 5 MG/ML (Haloperidol Lactate) Inject 1 ml intramuscularly one time only for mood disorder; agitation until 04/02/2026 12:59 p.m. Record review of Resident #97's consent form dated 04/02/2026 revealed Resident #97 signed the consent form for the injection of haloperidol 1 ml intramuscularly one time only for mood disorder; agitation. During an interview on 05/19/2026 at 10:47 a.m., the DON stated the NP or doctor would write their notes in the Progress Notes when they visited a resident or wrote an order. The DON stated the nurse who took the order was supposed to remind the NP or doctor to document on a Progress Note when they visited a resident and/or wrote an order. The DON stated if the NP or doctor would not write a Progress Note showing they wrote an order for a one time dose of a medication (haloperidol), they (the facility) would not be able to track the medication or who ordered it. The DON stated for any new order of an antipsychotic even a one-time dose, the order would be on the 24-hour report. The DON stated she reviewed the 24-hour report daily. During an interview on 05/19/2026 at 10:56 a.m., LVN C stated when she was given an order by an NP or doctor whether verbally or on the telephone, she would carry out the order. She said she would notify the family. She said she would get consent from the family and have them sign a consent form for the antipsychotic. LVN C stated the NP, or the doctor would write their note for the visit and order and it went into the electronic medical record's Progress Notes. LVN C stated she would not check to ensure the NP or doctor had written their notes in the Progress Notes. LVN C stated after she received the signed consent for an antipsychotic, she would put the order in and administered the antipsychotic. LVN C stated she would not write an order if one were not given. She said she did not remember who gave the order for haloperidol one time dose for Resident #97, but if she had put NP D's name on the order, NP D would have given the order. LVN C stated she did not know why she did not document the order in her notes. During an interview on 05/19/2026 at 12:46 p.m., NP D stated the day (04/02/26) the facility did a face-to-face with NP E palliative care concerning the decline of Resident #97, she said she thought they had increased two medications. NP D stated it was her practice to document an order for an antipsychotic but could not remember if she ordered Haldol for Resident #97 on 04/02/26 and she had forgotten to document if she had. NP D stated all she remembered was how Resident #97 was that day (04/02/2026). NP D stated Resident #97 had been very agitated. NP D stated she had been there for the face-to-face with the [LVN C} and NP E palliative care. NP D stated her name was on the consent for the haloperidol for Resident #97. NP D stated, So it probably was me who ordered the one-time dose of Haldol for [Resident #97]. She said Resident #97 was very agitated that day and she (NP D) had been concerned about exacerbating her respiratory issues. NP D stated she was supposed to document (in the electronic medical record) when an order was given. NP D stated anything could happen or nothing could happen when documentation was not completed and conclusions could be jumped into. Record review of the facility's Documentation in Medical Record policy dated 10/24/22 reflected: Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. 3. Principles of documentation include, but are not limited to: a. Documentation shall be factual, objective, and resident centered. i. False information shall not be documented ii. Record descriptive and objective information based on first-hand knowledge of the assessment, observation, or service provided. b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. Record review of the facility's policy Physician Visits and Physician Delegation dated 10/24/2022, revealed, Policy: It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents. Policy Explanation and Compliance Guidelines: 1. The Licensed Nurse should: f. Remind the physician to date and sign all orders and write a progress note. g. When possible, review the medical record for completeness, prior to the physician leaving the facility. h. Write a note to reflect the date and time of the physician visit, and indication as to whether new orders were written or no new orders were received and any special discussions between the resident and/or family and physician during the visit. 1. The physician should: d. Date, write and sign a progress note for each visit.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for storage, preparation, and sanitation. The facility failed to ensure coffee cups and bowls were clean. The facility failed to ensure clean racks/trays of coffee cups and bowls had drying mats. The facility failed to ensure the dishwasher was in good working order. The facility failed to ensure the vent above the dishwasher was clean and without corrosion and rust. The facility failed to ensure the freezers did not have worn seals and ice accumulation inside of them. The facility failed to ensure the refrigerators did not have worn seals, bulging seals, and condensation inside of them. The facility failed to ensure the steam table wells were clean and free of rust. These failures could place residents who received meals and/or snacks from the kitchen at risk for food contamination and food-borne illness. Findings included: Observation and initial tour of the kitchen on 05/17/26 beginning at 10:45 am revealed 18 of 20 plastic coffee cups on a clean rack had white residue and/or brown stains and scratches inside them. The clean racks did not have any kind of drying mats. The dirty and clean cups were rim-side down together on the clean racks (trays), sitting in water. The low temp dishwasher machine required 4 run times to reach a minimum temperature of 120F. The vent above the dishwasher was rusted and crusted with a thick dark brown/black substance. A chest type milk refrigerator had bulging, separating seams inside of it, on the lid and a black substance around the seals on the lid. A chest type freezer had a black substance around the seals on the lid. Two standing freezers had ice build-up on the inside doors near the seal. One of them had condensation dripping on the inside. The 5 of 5 steam wells in the steamer table had thin whitish yellow scaling around the insides and a dark brown ring at the water line inside all five wells. In an interview with the DM during the initial tour of the kitchen on 05/17/26 beginning at 10:45 am, he said all of the equipment in the kitchen was in good working order. The DM said the facility needed a new dishwasher machine. He said the washer worked, but it had to be run several times to reach a minimal temperature of 120F. He said the DW was responsible for checking the dishes for cleanliness before placing them on a clean rack. He said there were no drying mats on the clean rack trays and cross contamination could occur with the clean and dirty cups draining into the same water on the trays. The DM said he had a work order for the vent to be replaced. The DM said the facility needed new freezers, such as a walk-in. He said the seals were bad on the freezers and refrigerators. He said the steam table wells were cleaned daily and every 2 months. Observations during a return visit to the kitchen on 05/19/2026 at 8:00 am revealed 6 of 10 plastic desert bowls on a clean rack had a creamy yellow substance on the insides, in addition to the same observations made on 05/17/26 beginning at 10:45 am. In an interview with the DM on 05/19/2026 at 8:05 am, he said he did not know what was going on with the dirty dishes on the clean racks. He said the DW was responsible for making sure dishes were clean before being put on a clean tray. In an interview with the [NAME] on 05/19/2026 at 8:10 am, she said the steam table wells were supposed to be cleaned every night, and every 2 months with the chemicals to descale them. She said they had been rusted for years. In an interview with the RD on 05/19/2026 at 10:00 am, she said there had been no outbreaks of foodborne illnesses at the facility. She said she visited the facility at least monthly to check cleanliness, temperatures, and the quality of the food. She said when she was not at the facility, she checked trends and messages on her computer. She said she made rounds in the kitchen and spoke to residents regarding the quality of the food and checked on anyone with weight gain or loss. She said she collaborated with the DM if there were any food preferences that needed updates.In an interview with the ADM on 05/19/2026 at 12:40 pm, he said he was aware of the vent above the dishwasher and that he was in the process of getting it replaced. He said the invoice the DM had was only a quote. He said he was unaware of the seals on the freezers and refrigerators in the kitchen. He said he was unaware the dishes needed a drying mat on the clean rack trays. He said it made sense for the dishes not to be sitting in water upside down to dry. In an interview with the DW on 05/19/2026 at 1:45 pm, she said the dishwasher person was responsible for making sure the dishes were clean. She said she wiped them out before she put them through the washer and looked at them again after the trays came out of the washer. She said if she saw any dishes that were still dirty, she would put them back through the washer. She said there were no drying mats on the clean rack trays. She said she did not know what a dry mat was. Record review of the daily and weekly cleaning schedules for the last three months revealed all cleaning had been marked done. Record review of work order # 700105 for Replacement for range cabinet under dish room. Remove and replace with new. The amount shown was $3500.00 for materials and labor. Record review of the facility policy dated 10/01/18 titled, General Kitchen Sanitation under policy; The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition & Foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and foodborne illness. 1. After each use, clean and sanitize all tableware, kitchenware and food-contact surfaces of equipment 3. Keep food-contact surfaces of all cooking equipment free of encrusted grease deposits and other accumulated soil. 4. Clean and sanitize all multi-use utensils and food-contact surfaces of equipment used in the preparation or storage of potentially hazardous food prior to each use. Clean and sanitize food-contact surfaces of equipment and multi-use utensils used for preparation of potentially hazardous foods on a continuous or production line basis at scheduled intervals throughout the preparation period based on food temperature, type of food and amount of food particle accumulation. 5. After cleaning and until use, store and handle all food-contact surfaces of equipment and multi-use utensils in a manner that protects the surfaces from manual contact ' splash, dust, dirt, insects and other contaminants. Record review of the facility policy dated 10/01/18 titled, Mechanical Cleaning and Sanitizing of Utensils and Portable Equipment under policy; The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for mechanical cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. 3.Rinse or scrape equipment and utensils and, when necessary, soak to remove gross food particles and soil prior to being washed. 4. Place equipment and utensils on racks, trays, or baskets, or on conveyors, so that all food-contact surfaces are exposed to the detergent wash and clean rinse water and the equipment and utensils can freely drain.References: FDA Food Code 2022 Ch. 3-305 Preventing contamination from the premises Ch. 4-1-101.11 Characteristics. Materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: (A) Safe; (B) Durable, corrosion- resistant, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated warewashings; (D) finished to have a smooth, easily cleanable surface; and Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. Ch. 4-202 Cleanability 4-202.11 Food-Contact Surfaces. (A)Multiuse FOOD-CONTACT SURFACES shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; (3) Free of sharp internal angles, corners, and crevices; (4) Finished to have smooth welds and joints 4-5 Maintenance and Operation 4-501 Equipment 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. 4-602 Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) Equipment food-contact surfaces and utensils shall be cleaned: (5) At any time during the operation when contamination may have occurred. EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned throughout the day at least every 4 hours. All refrigerator units are kept clean and in good working condition at all times.

Number of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption for 1 (Resident #34) of 3 resident refrigerators reviewed for refrigerator sanitation. The facility failed to ensure Resident #34's personal refrigerator was maintained. Resident #34's personal refrigerator had 4 small individual cups of pudding, 5 small individual pies and a slice of bologna that all had best by dates that were expired. There was not a temperature thermometer inside her refrigerator.This failure could place residents who store food items in resident refrigerators, at risk of cross-contamination and food-borne illnesses if consumed.Findings included:Record review of Resident #34's admission Record dated 05/19/26 reflected a [AGE] year-old female, admitted on [DATE], diagnoses included, Type 2 Diabetes Mellitus without Complications (body does not use insulin properly and leads to high blood sugar), Essential (Primary) Hypertension (high blood pressure), and Hypothyroidism Unspecified (insufficient hormones are produced causing body to slow down).Record review of Resident #34's Annual MDS assessment dated [DATE] reflected a BIMS score of 11 indicating moderate cognitive impairment. Section GG, - Functional Abilities and Goals, indicated Resident #34 used a manual wheelchair and required partial/moderate assistance when eating.During observation and interview on 05/17/26 at 3:31 p.m., Resident #34 was observed in her room sitting upright on her bed and was alert. Resident #34 gave consent to observe her personal refrigerator. Inside the refrigerator there were 4 individual pudding cups, 5 small individual pies and a slice of bologna. All the items found had an expired date. Also observed was no thermometer inside, and no refrigerator temperature log on or near the refrigerator. Resident #34 said she did not know the items were expired. She said she sometimes allowed staff to check the refrigerator, but no one had told her there was expired food in it. During an interview on 05/18/26 at 10:17 a.m., Supervisor E said she was responsible for checking Resident #34's personal refrigerator. She said she had not been able to check it because Resident #34 had not allowed her to. Supervisor E said she did not know there was not a thermometer in Resident #34's refrigerator. She said nurses on duty checked the refrigerator temperature. Supervisor E said she did not know if anything could have happened to Resident #34 if she had eaten expired food. She said she had thought whoever gave her food from the refrigerator would have probably checked the dates before giving it to her. During an interview on 05/19/26 at 10:38 a.m., the DON said a staff member was assigned to each resident's room. They were responsible for making sure the residents were comfortable, call lights were within reach, the rooms cleaned and if there was a refrigerator in the room, they were to check it to make sure that it was clean and no food had expired. She said rooms were checked every morning. The DON said that Resident #34 had refused to let staff check her refrigerator. She said sometimes she had let them check it but it had not been very often. The DON said there should have been a temperature thermometer in Resident #34's refrigerator. She said she did not know why there had not been one in there. The DON said had Resident #34 eaten the expired food that was found in her refrigerator she could have gotten sick, gotten nausea or vomiting.During an interview on 05/19/26 at 3:23 p.m., LVN F said he only checked the temperature in Resident #34's room on 05/17/26. He said he did not check for expired food or if there was a thermometer in there. LVN F said he checked for the temperature with a temperature gun and logged it on the Temperature Log binder located in the nurse's station.Record review of the facility's policy titled Resident Refrigerators dated 07/03/23 revealed; Policy; This facility does not provide a refrigerator in a resident's room. However, it is the policy of this facility to ensure safe and sanitary use of any resident-owned refrigerators. Policy Explanation and Compliance Guidelines:Dormitory-sized refrigerators are allowed in resident's room under the following conditions:1 e. The resident complies with the facility's policy for use of the refrigerator.2. Staff shall record refrigerator temperatures weekly on a temperature log attached to the refrigerator.a. A thermometer shall remain in the refrigerator.3. Staff shall clean the refrigerator weekly and discard any foods that are out of compliance. 4. Residents and staff shall comply with safe food handling and storage principles: c. Foods with use-by dates shall be discarded accordingly.

Based on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 2 of 5 residents (Resident #1 and Resident #2) reviewed for medical records. 1. The facility failed to ensure LVN A documented accurate medication administration records for Resident #1 after medications and treatments were administered. 2. The facility failed to ensure LVN B documented accurate physician orders for Resident #2 after receiving telephone orders. This failure could place residents at risk for errors in care and treatment.Findings included: 1. Record review of Resident #1's admission record, dated 5/13/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses included quadriplegia (a form of paralysis, resulting in the loss of movement and feeling to both arms and legs and torso), dysuria (pain when urinating), neuromuscular dysfunction of bladder (damage to the brain, spinal cord, or nerves disrupts the signals needed to store or empty urine properly), urinary catheterization (insertion of a hollow tube and into the bladder to drain urine), and hypertension (high blood pressure). Record review of Resident #1's annual MDS assessment, dated 3/17/2026, reflected a BIMS score of 15 which indicated cognitively intact. Record review of Resident #1's medication administration record, dated 5/13/2026, indicated no nurse's signature was entered for medications and treatments administered on 5/7/2026 at 7:00 p.m., 5/8/2026 at 9:00 a.m., and 5/8/26 at 7:00 p.m. During an interview on 5/12/2026 at 1:56 p.m., Resident #1 said a few nights ago the nurse administered his medications and treatments, but he felt the nurse took too long. He said he takes medications and treatments at 7:00 p.m. everyday. Resident #1 said he liked to have his medications and treatments at specific times because the CNAs repositioned him in bed afterwards. During an interview on 5/13/2026 at 3:03 p.m., LVN A said she had given medications and treatments to Resident # 1 on 5/7/26 and 5/8/26 during the second shift and 5/8/26, during the day shift, but did not sign off on the MAR. She said it was overlooked. LVN A said she ensured the MARs were signed off but Resident #1 resided in a different hall and it was missed. She said if the MAR was not signed off, there would be a possibility of overmedicating the resident. She said the last in-service on medication administration and documentation she had was less than six months ago. During an interview on 5/14/2026 at 11:08 a.m., the DON said she reviewed MARs every morning to ensure staff were signing appropriately. She said she was not sure if she missed checking on Friday (5/8/26) for Thursday (5/7/26) and Monday (5/11/26) for Friday (5/8/26). She said she provided reminders/training on documentation to the staff three to four weeks ago. The DON said a negative outcome of not signing the MAR was that the resident could have received a double dose of medication. She said she did not receive concerns from the resident about not received his medications and treatments. Record review of the facility's policy titled, Medication Administration, dated 10/24/22, reflected Policy Explanation and Compliance Guidelines: .17. Sign MAR after administered. Record review of the facility's policy titled, Documentation in Medical Record, dated 10/24/22, reflected Policy Explanation and Compliance Guidelines: .2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. 2. Record review of Resident #2's admission record, dated 5/14/2026, reflected a [AGE] year-old male admitted [DATE]. Resident #1's diagnoses included left side hemiplegia/hemiparesis (conditions involving weakness or paralysis on one side of the body caused by brain or spinal cord injury), benign prostatic hyperplasia (enlargement of the prostate gland), neuromuscular dysfunction of bladder (damage to the brain, spinal cord, or nerves disrupts the signals needed to store or empty urine properly), diabetes mellitus (chronic condition where blood sugar levels are too high because the body either does not produce enough insulin or cannot effectively use the insulin it makes), and hypertension (high blood pressure). Record review of Resident #2's quarterly MDS assessment, dated 4/15/2026, reflected a BIMS score of 07 which indicated severe cognitive impairment. Record review of Resident #2's nursing progress notes, dated 5/11/2026, indicated a telephone order, obtained by LVN B, for antibiotics and to place the resident on contact precaution due to ESBL (urinary tract infection caused by bacteria that are resistant to common antibiotics) in the urine. Record review of Resident #2's physician order summary, dated 5/12/2026, did not include an order for contact precautions. In an observation on 5/12/2026 at 2:29 p.m., a contact precautions sign was posted on Resident #2's door which included PPE supplies. During an interview on 5/14/2026 at 10:58 a.m., the DON said the nurse received the order for isolation precautions due to positive ESBL in the urine of Resident #2. She said it was the nurse's responsibility to enter the order into the EMR. She said there was a change of condition noted by the nurse which was then reviewed by the infection preventionist. She said she and the ADON were responsible for ensuring all orders were placed in the EMR. She said a negative outcome from not having the order in the EMR was that there could be miscommunication between the nurses. She said PPE and a sign was on the door indicating contact precautions for Resident #2. During an interview on 5/14/2026 at 11:26 a.m., LVN B said she received an order from the physician to start antibiotics and to place the resident under contact precautions due to ESBL in the urine. She said she documented a change of condition and completed an infection control form. She said the telephone order she received was supposed to be added to the order summary section in the EMR. She said she missed adding the order in the order summary section of the EMR because she had other paperwork she had filled out. LVN B said that upon receiving the telephone order by the physician, Resident #2 and his RP were notified of moving to a different room and of the orders received regarding the infection. She said the PPE and contact precautions sign were added to the resident's door. LVN B said not having an order included in the EMR for contact precautions did not affect Resident #2 because there was a sign posted on his door indicating he was under contact precautions. She said she had received a reminder/training on documentation one week ago. Record review of the facility's policy titled, Documentation in Medical Record, dated 10/24/22, reflected Policy Explanation and Compliance Guidelines: .2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.

Based on interview and record review, the facility failed to have the interdisciplinary team review and revise the comprehensive care plan after the completion of the quarterly review assessments for 1 (Resident #1) of 5 residents reviewed for care plan revision.The facility failed to complete a quarterly care plan for Resident #1.This failure could place the residents at risk of care and needs not being met.Findings included:Record review of Resident #1's admission record, dated 5/13/2026, reflected a [AGE] year-old male admitted [DATE]. Resident #1's diagnoses included quadriplegia (a form of paralysis, resulting in the loss of movement and feeling to both arms and legs and torso), dysuria (pain when urinating), neuromuscular dysfunction of bladder (damage to the brain, spinal cord, or nerves disrupts the signals needed to store or empty urine properly), urinary catheterization (insertion of a hollow tube and into the bladder to drain urine), and hypertension (high blood pressure).Record review of Resident #1's MDS assessment, dated 3/17/2026, reflected a BIMS score of 15 which indicated cognitively intactRecord review of Resident #1's care plan, on 5/14/2026, reflected the last quarterly care plan was made on 8/26/2025.During an interview on 5/14/2026 at 4:51 p.m., the MDS Coordinator said the last care plan for Resident #1 was done on 8/26/2025. She said the care plans were updated every three months (quarterly). She said Resident #1's care plan was not updated because it was overlooked and there were no changes to his care plan. She said the last assessment (MDS) was done on 3/27/2026 and his care plan would have been due at the beginning of April 2026. She said the MDS coordinators were responsible for updating the care plans quarterly and the ADONs were responsible for any acute (sudden or short-term) changes to the care plans. She said Resident #1 was not negatively affected from not having an updated care plan because the assessments were being completed in a timely manner. She said the MDS coordinators received training from the facility's corporate office on MDS assessments and care planning. The MDS coordinator said the last training was done in April 2026.During an interview on 5/14/2026 at 5:17 p.m., the DON said the care plans were updated quarterly and as needed. She said the MDS coordinators were responsible for updating the quarterly care plans and the ADONs and DON were responsible for updating the acute care plans. She said she was not sure why the care plan was not updated and said it might have been overlooked. She said the Administrator and the DON were responsible for ensuring the care plans were updated in a timely manner. She said the facility's regional MDS coordinator was also responsible for ensuring the care plans were updated in a timely manner. She said the MDS coordinators attended quarterly in-services regarding care plans and MDS assessments. She said there was no negative effect for Resident #1 by not having an updated care plan.Record review of the facility's policy titled, Comprehensive Care Plans, dated 10/24/2022, reflected Policy Explanation and Compliance Guidelines: .2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment.5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 (Resident #5) of 6 residents reviewed for care plans.The facility failed to ensure Resident #5's care plan reflected his diet was no added salt, pureed texture, with nectar thickened liquids consistency.This failure could place the residents at risk of not receiving appropriate care to meet their needs.Findings included:Record review of Resident #5's face sheet, dated 03/11/26, reflected a [AGE] year-old male, admitted on [DATE] with diagnoses that included: cerebral infarction (stroke), chronic heart failure, type 2 diabetes (high levels of blood sugar levels), dementia (decline in cognitive function, affecting memory, thinking, and behavior), urinary tract infection, hypertension (high blood pressure), muscle wasting and atrophy (decreased muscle mass and strength), dysphagia (trouble swallowing), and other lack of coordination. Resident #5 was discharged to the hospital on [DATE]. Record review of Resident #5's MDS assessment, dated 02/09/25, reflected Resident #5 had a BIMS score of 1, indicating severe cognitive impairment. Resident #5 required a mechanically altered and therapeutic diet. Record review of Resident #5's care plan, dated 03/11/26, reflected [Resident #5] had potential nutritional problem related to diet restrictions. Date initiated: 01/11/26. Interventions included: No added salt, mechanical soft texture, regular liquids consistency diet. Date initiated: 01/11/26. Resident #5's care plan was not updated to Resident #5's current diet of no added salt, pureed texture, with nectar thickened liquids consistency. Record review of Resident #5's order summary report, dated 03/11/26 at 2:45 PM, reflected Resident #5 had an order for a diet of no added salt, pureed texture, with nectar thickened liquids consistency with start date: 02/03/26. In an interview with MDS Nurse B, on 03/13/2026 at 9:30 AM, she said the team reviewed orders and ensured everything was care planned accordingly including the resident's diet. MDS Nurse B said Resident #5's diet was changed from mechanical soft with regular liquids to pureed texture with nectar thickened liquids on 02/03/26, but the care plan was not updated with the current diet. MDS Nurse B said Resident #5 was not affected by not having the correct diet on his care plan as the kitchen and the staff followed the diet orders, not the care plan. MDS Nurse B said Resident #5 had no negative outcome, however, it was important for the current diet to be care planned so everyone was aware of how to care for Resident #5. In an interview with ADON A, on 03/13/26 at 10:00 AM, he said care plans, including diets, were updated by the ADONs. ADON A said if the resident's diet changed from mechanical soft with regular liquids to pureed with nectar liquids, that was care planned. ADON A said Resident #5 was assigned to ADON B so he was not very familiar with him. ADON A said the meal trays were prepared following the diet orders, not the care plan. ADON A said it was important to have the resident's current diet care planned so that everyone knew how to care for the resident. In an interview with ADON B, on 03/13/26 at 10:15 AM, he said Resident #5's diet was changed from mechanical soft with regular liquids to pureed with nectar thickened liquids on 02/03/26 because it was safer for him. ADON B said the team, including the ADONs, updated the care plans as needed and the diet should have been updated on the care plan. ADON B said he reviewed Resident #5's care plan and his diet did not reflect a pureed texture with nectar thickened liquids. ADON B said Resident #5 received his diet as ordered and had no negative outcome. ADON B said the care plan should have been updated because it reflected the resident's needs. In an interview with the DON, on 03/13/26 at 11:00 AM, she said Resident #5's diet was changed from mechanical soft with regular liquids to pureed with nectar thickened liquids on 02/03/26, following a speech evaluation. The DON said when the diet was changed, the care plan should have been updated. The DON said the care plan was updated by the ADONs, MDS nurses, or herself as it was a team effort. The DON said the kitchen followed the orders, not the care plan, and Resident #5 received his correct diet, so there was no negative outcome for him. The DON said it was important for the care plan to be updated because the care plan communicated to the staff what the resident needed and how to care for him. In an interview with the ADM, on 03/13/26 at 11:50 AM, he said diets and changes were care planned by the team. The ADM said he was not aware of any negative outcome for Resident #5. The ADM said it was important for care plans to be updated to current information so the staff can follow the care specific to the resident. Record review of the facility's Comprehensive Care Plans policy dated 10/24/22 reflected - Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs.6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

Based on observation, interview, and record review the facility failed to conduct a comprehensive and accurate assessment of each resident using the resident assessment instrument (RAI) specified by CMS for 1 of 3 residents (Resident #1) whose records were reviewed for assessments. Resident #1's MDS erroneously indicated her ADLs of sit to stand or chair/bed-to-chair transfer were not attempted due to medical condition or safety concerns. This failure to ensure comprehensive and accurate assessments could affect residents by placing them at risk for not receiving correct care and services.Findings include:Record review of Resident #1's admission record, dated 03/11/26, reflected a [AGE] year-old female with an admit date of 04/19/24 with diagnoses that included cerebral infarction due to embolism (blood clot or debris forms elsewhere (often the heart or neck arteries), travel to the brain and locks blood flow), osteoarthritis-left shoulder (a chronic degenerative joint disease where cartilage breaks down, causing pain, swelling, and reduced motion), and flaccid hemiplegia (a severe neurological condition characterized by limp, weak, and paralyzed muscles on one side of the body) affecting left nondominant side. Record review of Resident #1's significant change MDS assessment, dated 02/26/26 reflected a BIMS score of 6, which indicated her cognition was severely impaired. Resident #1's level of assistance for her ADL for chair/bed-to-chair transfer (the ability to transfer to and from a bed to a chair (or wheelchair) had a code of 88 which indicated not attempted due to medical condition or safety concerns, for sit to lying and lying to sitting on side of bed she was coded a 2 which indicated she required substantial/maximal assistance (helper does more than half the effort. Helper lifts or hold truck or limbs and provides more than half the effort.Record review of Resident #1's quarterly care plan, dated 02/22/26 reflected a problem: Functional performance: chair/bed-to-chair transfer: [Resident #1] requires (x2 staff) to transfer to and from a bed to a chair (or wheelchair), date initiated 04/29/24 and revised on 08/29/25. Functional performance: lying to sitting on the side of bed: lying to sitting on side of bed: [Resident #1] requires (substantial/maximal assistance) to move from lying on the back to sitting on the side of the bed and with no back support x2, date initiated 12/31/24 and revised 08/29/25. Functional performance: sit to lying [Resident #1] requires (substantial/maximal assistance required) to come to a standing and side of bed to lying flat on the bed. X2 staff, date initiated 04/29/24 and revised on 08/29/25.In an interview and observation on 03/11/26 at 4:26 p.m., MDS nurse was observed as she reviewed Resident #1's electronic medical record/MDS change in condition assessment, dated 02/26/26 and said the code 88 entered for her ADL of sit to stand and chair/bed-to-chair transfer had been entered in error. She said the correct code for Resident #1 for her ADLs of sit to stand and chair/bed-to-chair transfer should have been 01 which indicated she was dependent (helper does all the effort). She said code 88 was for residents who were bedridden and Resident #1 was not. MDS nurse said there were no negative outcomes to Resident #1 not having her MDS assessment indicate she was dependent for her ADLs of sit to stand and chair/bed-to-chair transfer because her plan of care indicated she required a mechanical lift for transfers.In an interview and observation on 03/12/26 at 2:39 p.m., the DON said Resident #1 liked to sit in her wheelchair during the day. She said Resident #1 was not bedbound. The DON was observed as she reviewed Resident #1's electronic medical record/MDS assessment, dated 02/26/26 and said the code of 88 was not correct. She said it was the responsibility of the MDS nurse to ensure a resident's ADL codes were correct to ensure staff would know their level of care. The DON said even though, Resident #1's ADL code for sit to stand and char/bed-to-chair-transfer had been miscoded, there were no negative outcomes because her plan of care indicated she required the assistance of 2 persons and a mechanical lift.Record review of the facility's RAI version 3.0 revised on 10/2025 reflected:GG 170: MobilityCoding GG170D Sit to Stand would be coded 01, dependent with the following rationale: Resident requires the assistance of two helpers to complete activity. Coding GG 170E Chair/bed-to-chair-transfer would be coded 01, dependent with the following rationale: the two helpers completed all the effort for the activity of chair/bed-to-chair-transfer.

Based on observations, interviews and record reviews, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 3 residents reviewed for accuracy and completeness of clinical records. The facility failed to ensure Resident #1 had an order for EBP (refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloved use during high contact resident care activities). This failure could place residents at risk of not receiving nursing services by adequately trained nurses and could result in a decline in health.The findings included:Record review of Resident #1's admission record dated 02/04/26 reflected a [AGE] year-old female with an admit date of 01/14/26 an original admission date of 01/14/2021. Her relevant diagnoses included Alzheimer's disease (a progressive neurodegenerative disorder, causing dementia symptoms that worsen over time), chronic kidney disease (a long-term condition characterized by a gradual loss of kidney function over months or years), and heart failure (the heart can't pump enough blood). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 4, which indicated her cognition was severely impaired. MDS did not address any care issues that would require EBP. Record review of Resident #1's quarterly care plan dated 01/18/26 reflected a problem resident has the need for Enhanced Barrier Precautions due to history of ESBL (extended-spectrum beta-lactamase-E. coli (a common bacterium found in the intestines of humans and animals) or Klebsiella (a bacteria found in the human gut and stool that can cause serious infections like pneumonia, urinary tract infections, bloodstream infections, and meningitis), cause serious infections in the bloodstream, urinary tract, or abdomen) to urine, MRSA (methicillin-resistant staphylococcus-a type of staph bacteria resistant to several common antibiotics, making infections harder to treat) to sacral wound. Her interventions in part included place on Enhanced Barrier Precautions, ensure a sign is placed on the door to notify staff and visitors of the precautionary measures: Gown and gloves only for high- contact resident care activities (dressing, bathing/showering, personal hygiene, changing linens, assisting with toileting, perineal/incontinent care, medical device care or use, wound care), no room restriction and may participate in communal activities. Use a mask, goggles/eye shield as indicated, date Initiated 01/23/2025.An interview and observation on 02/04/26 at 11:20 a.m., MDS-RN said Resident #1 was under EBP due to a history of due to history of ESBL to her urine and MRSA to a sacral wound. She said Resident #1 would aways need to be on EBP. MDS-RN was observed as she reviewed Resident #1's electronic medical record and said she did not see an active order for EBP. She said she found an EBP order that was discontinued on 01/23/26. She said a negative outcome for Resident #1 not having an order for EBP was that the CNAs and nursing staff would not know to take precautions.An interview on 02/04/26 at 11:27 a.m., the IP said Resident #1 had a history of ESBL to her urine and MRSA to a sacral wound she had and would need to remain under EBP indefinitely. He was observed as he reviewed Resident #1 medical electronic record and said he could not find an active order for EBP. He said Resident #1 had an EBP order that was discontinued on 01/23/26. The IP said he did not know why Resident #1's ESP order was discontinued, he said it might have been in error. The IP said it was his responsibility to ensure all resident who were under EBP had an order. He said he would conduct weekly reviews, but he must have missed Resident #1 did not have one. The IP as not able to say if there was a negative outcome to Resident #1 not having an order for EBP, he said her room had the required signage, supplied were readily available to CNAs and nursing staff who performed high-contact care. An interview on 02/04/26 at 11:37 a.m., the DON said if a resident had a history of ESBL infection they remained under EBP. She said Resident #1 had an EBP order but had been discontinued on 01/23/26. The DON said Resident #1 had the EBP signage on her door, supplies were readily available to CNAs and nursing staff who performed high-contact care. She said it was the responsibility of the facility's IP to ensure all residents who were on EBP had an order. She was not able to say if there was a negative outcome to Resident #1 for not having an order for EBP because the precautions were being taken. Record review of the facility's Documentation in Medical Record policy dated 10/24/22 reflected:Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.

Based on observation, interview and record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for 1 of 4 resident (Resident #1) reviewed for accidents and supervision who had a vehicle on the facility premises. The facility failed to evaluate R#1s safety awareness and risks for elopement after multiple incidents of R#1 leaving the facility without staff awareness or supervision. On 10/27/2025 R#1 left the facility and returned driving a vehicle he had purchased in another city. On 11/27/2025, R#1 left the facility and was returned by police due to driving around lost. On 12/06/2025, R#1 left the facility without being signed out on pass and was found at a nearby facility. The noncompliance was identified as PNC. The Immediate Jeopardy was identified on 12/06/2025 and ended on 12/06/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of sustaining accidents, injuries, and/or death.Findings include: Record review of Resident #1's face sheet dated 12/29/2025, revealed a [AGE] year old male admitted into the facility on [DATE] with diagnosis of Alzheimer's disease (a progressive brain disorder and the most common cause of dementia, characterized by gradual memory loss, impaired thinking, and behavioral changes that worsen over time, eventually affecting daily activities), Type 2 diabetes (a chronic condition where the body either doesn't make enough insulin or doesn't use insulin effectively leading to high blood sugar levels), unspecified protein calorie malnutrition (a nutritional deficiency from not getting enough protein and calories), and hypertension (a common condition where the force of blood against your artery walls is consistently too high, making your heart work harder and increasing the risk of heart attack, stroke, and other serious problems). Record review of Resident #1's BIMS assessment dated [DATE] revealed a score of 8 which indicated moderately impaired cognition. Record review of Resident #1's baseline care plan dated 09/13/2024 revealed the resident had impaired cognitive function or impaired thought process related to Alzheimer's; included cue, reorient, and supervise as needed. The same care plan also revealed, The resident is (dependent on staff) for meeting emotional, intellectual, physical, and social needs related to cognitive deficits; The resident needs assistance with ADLs as required. Record review of Resident #1's Release of Responsibility for Leave of Absence log revealed, Resident #1's Relative V had signed Resident #1 out on 10/26/25 with anticipated date of return as PM. There was no sign-in date, time, or facility representative initials to confirm Resident #1 had returned. Record review of LVN A's progress note dated 10/27/2025 time stamped 9:00 a.m. revealed Received call from [family member] to resident stating resident was stranded in City W, SN informed him resident had signed out for out on pass and taken medication with him. SN informed to let us know if any changes with resident. City W is approximately 233 miles away from the facility. Record review of Resident #1's care plan initiated on 09/05/2024 did not reveal any new interventions regarding the 10/27/2025 incident. Record review of Resident #1's Release of Responsibility for Leave of Absence log revealed, Resident #1's Relative V had signed Resident #1 out on 11/27/2025 with anticipated date of return as PM. There was no Sign-in date, time, or facility representative initials to confirm Resident #1 had returned. Record review of LVN B's progress note dated 11/27/2025 time stamped 7:45 p.m., revealed Resident back at facility from out on pass, arrived via wheelchair accompanied by City X Police Department. Per Officer, resident was driving in his GMC truck around City X and got lost. Per resident, he did not know his way back to facility. RP made aware. Informed RP that resident's truck was left at City X. Resident's car keys and driver's license kept under lock and key in 300-Hall Nurse cart. DON and ADON made aware of situation. City X is approximately 5 miles from the facility. Record review of Resident #1's care plan revised on 11/27/2025, revealed Resident #1 was unable to return to facility without assistance due to forgetfulness and intermittent cognition; removed keys and kept with nurse, administer medications as ordered, monitor behavior episodes and attempt to determine underlining cause, and provide a program of activities. Record review of Resident #1's Release of Responsibility for Leave of Absence log revealed, Resident #1's Relative V had signed Resident #1 out on 12/06/2025. Resident #1 was signed back in by his brother on 12/06/2025 at 11:00 a.m. There were no facility representative initials on the form to confirm Resident #1 had returned. Record review of LVN C's progress noted dated 12/06/2025 time stamped 1:41 p.m. revealed: Facility receptionist saw patient leaving facility & HRC questioned if patient had signed out to go out on pass. I checked the sign out book and noted that the patient did not sign out. I then notified Administrator, DON and ADONs that patient was seen leaving the facility in a vehicle. I attempted to call patient on his cell phone multi times, but he did not answer. I also notified RP. City Y police is notified by HRC. Record review of LVN B's progress note dated 12/06/2025 time stamped 7:00 p.m. revealed: At 7:00 p.m., resident safely returned to facility. DON, ADON, and Administrator present during resident's return. Assisted resident to room. Performed head-to-toe assessment and obtained vital signs. When asked where resident left to, resident states he was driving around town in his truck. Administrator requesting resident's car keys for safekeeping, resident cooperative and in agreement. MD notified of resident's return. RP notified of resident's safe return. Safety plan reviewed with staff and team. Continuing to monitor for exit-seeking behavior. Staff present at bedside for 1:1 monitoring. Record review of Resident #1's care plan revised on 12/06/25, revealed Resident #1 was at risk for elopement; 1:1 staff member monitoring, monitor exit seeking behavior, labs, Allow the resident to make decisions about treatment regime, to provide sense of control, Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care, and Encourage as much participation/interaction by the resident as possible during care activities. Record review of Resident #1's care plan initiated on 09/05/2024 did not reveal any interventions regarding Resident #1 having a vehicle on premises or having the capability to drive. During an interview on 12/29/2025 at 9:24 a.m. Resident #1 could not recall the incident on 12/06/2025. Resident #1 stated he remembered a time when he had left in his van to City W. Resident #1 stated the van he had been driving broke down and left him stranded. Resident #1 was redirected to the incident of 12/06/2025 but he reverted to talking about the other incident. During an interview on 12/29/2025 at 10:49 a.m., the HRC stated DA had informed her that he had witnessed Resident #1 drive off in his car. The HRC stated she called the nurse's station and had asked the nurse if Resident #1 was allowed to drive in which the nurse responded, No. The HRC stated she called the Administrator to notify her that Resident #1 had left. The HRC stated she was aware Resident #1 had a truck at the facility. During an interview on 12/29/2025 at 11:02 a.m., the DA stated he was covering for the receptionist on the day of 12/06/2025. The DA stated that on the day of the incident, Resident #1's Relative V had signed him out on pass in the morning but had returned soon after. The DA stated that when he saw Resident #1 leaving for the last time, he questioned the resident if he had been signed out. Resident #1 responded by saying that Relative V had signed him out. The DA stated he then saw Resident #1 wheel himself to his truck, place the wheelchair in the back seat and drive off. The DA then notified HRC what he had witnessed. The DA stated he knew he was supposed to call the nurse's station to verify if Resident #1 had been signed out but stated he did not.During an interview on 12/29/2025 at 11:44 a.m. Resident #1's RP stated on that on 10/26/2025, Resident #1's Relative V had signed him out for an outing. Somehow, Resident #1 then drove his own van to City W. Resident #1's van broke down and left him stranded on the side of the road. RP stated that Resident #1 was picked up by a passerby and drove him into the city. The following day, Resident #1 was able to purchase a truck at a dealership. Resident #1 then drove the new truck back to the facility. RP stated she was able to locate the dealership and informed the general manager that Resident had a diagnosis of Alzheimer's and was not able to make decisions on his own. RP stated that on 11/27/2025, she received a call from a police officer stating Resident #1 had been stopped due to being lost and driving around. RP stated the officer had said Resident #1 was confused and did not know how to get back to the facility. RP stated that on 12/06/2025, Resident #1 had left the faciity on his own. RP stated that a staff member had seen Resident #1 drive off in his truck. RP stated that Resident #1 should not have been driving due to forgetfulness. RP stated she had Resident #1's truck picked up by family so Resident #1 would not leave in it. RP stated she was afraid he could hurt himself or others while driving. During an interview on 12/29/2025 at 5:10 p.m., the DON said she received a call on 12/06/25 from the Administrator notifying her that Resident #1 had left the facility. The DON assisted with making calls to local authorities and family. The DON said that on 10/06/2025, Resident #1 was out on pass with his family member and returned with no injuries. The DON said that on 11/27/2025, Resident #1 was signed out by his family member and was dropped off by the PD because he was confused. The DON stated that the officer had said Resident #1 did not know how to get back to the facility because he was confused. The DON stated she was unaware that Resident #1 was able to drive. The DON stated she did not know if Resident #1 was capable of driving even thought he had the diagnosis of Alzheimer's. During an interview on 12/29/2025 at 5:30 p.m., the Administrator said that on 12/06/2025, the HRC notified her that the resident had left the building in his own vehicle. The Administrator initiated a code purple, the code used to notify staff there was a resident missing. The Administrator said that at 6:45 p.m., she received a call from a nearby nursing facility reporting they had Resident #1. The nearby facility was approximately 0.6 miles away. The Administrator said she sent three staff members to bring Resident #1 back to the facility. One of the three staff members drove Resident's truck back to the facility. The Administrator stated that Resident #1 had arrived at that other facility because he was confused as to which facility he was a resident of. The Administrator stated that Resident #1's RP had his truck picked up after the incident. The administrator stated that it was best that Resident #1 did not have a vehicle on premises because Resident #1 could hurt himself or others while driving. Resident #1 could become confused and cause an accident. During an interview on 12/30/2025 at 2:22 p.m., ADON said he was one of three staff members who picked up Resident #1 at a nearby facility. ADON stated when he saw Resident #1, the resident appeared fine. Resident #1 had no visible injuries. ADON said Resident #1 might have been a bit confused due to Resident #1 ending up at the wrong facility. ADON stated that he drove Resident #1 back to the facility in the resident's own truck. ADON stated that he did not feel it was safe for Resident #1 to drive his own truck back to the facility because Resident # 1 had been confused to which facility he belonged to. During an interview on 12/31/2025 at 9:28 a.m., NP stated that every patient with Alzheimer's is different. Generally, a patient with Alzheimer's should not be driving. NP stated it is unknown the state of mind that the patient can have while driving. NP stated, I would not recommend for a patient with Alzheimer's to drive. The patient could have caused an accident in which he could have gotten hurt or could have hurt others. Record review of facility's Elopements and Wandering Residents policy dated 11/21/22 revealed:Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. F689 Quality of Care Immediate Action Taken:Upon return to the facility on [DATE] Resident #1 received a head-to-toe assessment no issues noted. Resident #1 was placed on 1:1 monitoring. The physician was notified and lab orders were obtained on December 6, 2025 with no abnormalities noted. The care plan was updated on December 6, 2025, with updated interventions of 1:1 monitoring, documenting exit seeking behaviors, and laboratory studies were completed. The vehicle belonging to Resident #1 which was on the premises was removed on December 7, 2025, by resident's Relative Z and moved to her premises. R#1 has not driven a vehicle since December 6, 2025. The employee monitoring the reception desk on December 6, 2025, was suspended on 12/6/25 and returned to work on 12/7/25. Staff member was provided with 1:1 education on following proper out on pass process. On 12/6/25 nursing administration conducted a facility wide audit of all current residents to determine if any residents were operating personal vehicles that ere on the facility's premises. The facility completed an audit of all residents wandering evaluations. No new residents found at risk for wandering/elopement. The center developed and implemented a process to ensure safe and proper leaves of absence for residents: On December 7, 2025, the center developed and implemented a Front Door Safety & Sign-Out Procedure, staff members who assist with front desk reception duties were educated on the new process of Front Door Safety & Sign-Out Procedure to include competency check off. The facility initiated 100% reeducation on Elopement Protocols and the supervision of residents and ANE with completion date of 12/08/25. The facility initiated 100% reeducation with the Charge Nurses on the process of Front Door Safety & Sign-Out Procedure. The training of direct care staff was completed on December 7, 2025, in person or via telephone. Those that were not scheduled on 12/7/25 completed reeducation prior to accepting assignment for the next scheduled work. Verification of 100% of direct care staff education was verified by the Director of Nursing/ designee. Employee roster was utilized to validate completion. Verification: Started on 01/01/2026 at 11:00 a.m. and included:The following observations, record reviews and interviews were conducted by the survey team to ensure the staff's understanding of in-service training received between 12/06/2025 and 12/07/2025:Observation on 01/01/2025 at 12:05 p.m., the Receptionist was observed verifying a resident leaving with family. The Receptionist called the nurse's station via a 2-way radio, and the nurse confirmed the resident had been signed out.Record review of progress notes dated 12/06/2025 - 12/18/2025 on Resident #1's 1:1 supervision.Record review of Resident #1 neuro checks dated from 12/06/2025 - 12/09/2025. Record review of Resident #1's head to toe assessment completed on 12/06/2025.Record Review of Resident #1's RP and physician notification on incident dated 12/06/2025.Record review of DA's suspension and 1:1 counseling.Record review of Resident #1's care plan revision on Risk of elopement for 12/06/2025.Record review of an In-Service Attendance Record with the topic of Out on Pass Protocol and Elopement Protocol, revealed that all staff was in-serviced on 12/06/2025.Record review of an In-Service Attendance Record with the topic of Receptionist Competency-Front Door Safety and Resident Sign-Out Verification, revealed that staff who are assigned to assist with covering for receptionist duties were in-serviced on 12/07/2025.During interviews on 01/01/2026 from 11:05 a.m. to 5:55 p.m., CNA F, CNA G, CNA I, CNA L, CNA M, CNA N, CNA O, CNA P, CNA T, LVN A, LVN, B, LVN C, LVN D, LVN E, LVN H LVN J, LVN K, LVN Q, LVN R, LVN S, LVN U, Social Worker, and Human Resource Coordinator revealed the staff were all knowledgeable of the out on pass protocol and elopement protocol. The CNAs interviewed stated they were to report to their nurse immediately if and when a resident voiced, they wanted to go out on pass. The nurses interviewed stated they would verify that the family member that signed out the resident was approved to sign the resident out. They were aware and voiced understanding of the new expectations to verify all residents were signed out through the nurse's station and ensure all residents were signed back in. During an interview via telephone on 01/01/2026 at 4:02 p.m., the DA was able to verbalize understanding of the following in services received: Out on Pass Protocol and Elopement Protocol and Receptionist Competency-Front Door Safety and Resident Sign-Out Verification.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect or exploitation were reported no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency where state law provides for jurisdiction in long-term care facilities in accordance with State law through established procedures for 1 of 2 residents (Resident #1), reviewed for freedom from abuse, neglect, and exploitation.The facility failed to report to the State Survey Agency (HHSC) an incident that occurred on 11/27/25 in which Resident #1 was returned to the facility by a police officer. Resident #1 had been driving around town in his own vehicle and did not know his way back to the facility. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and physical harm. Record review of Resident #1's face sheet dated 12/29/2025, revealed a [AGE] year old male admitted into the facility on [DATE] with diagnosis of Alzheimer's disease (a progressive brain disorder and the most common cause of dementia, characterized by gradual memory loss, impaired thinking, and behavioral changes that worsen over time, eventually affecting daily activities), Type 2 diabetes (a chronic condition where the body either doesn't make enough insulin or doesn't use insulin effectively leading to high blood sugar levels), unspecified protein calorie malnutrition (a nutritional deficiency from not getting enough protein and calories), and hypertension (a common condition where the force of blood against your artery walls is consistently too high, making your heart work harder and increasing the risk of heart attack, stroke, and other serious problems). Record review of Resident #1's BIMS assessment dated [DATE] revealed a score of 8 which indicated moderately impaired cognition. Record review of progress note dated 11/27/2025 time stamped 7:45 p.m., revealed Resident #1 returned to the facility from being out on pass. Resident #1 arrived via wheelchair accompanied by an officer from a local police department. Per the police officer, Resident #1 was driving his truck around and got lost. Per Resident #1, he did not know his way back to facility. Resident #1's RP was made aware of the incident and was informed the resident's truck needed to be picked up from the location where Resident #1 was picked up from by the officer. Record review of Resident #1's care plan revised on 11/27/2025, revealed Resident #1 was unable to return to facility without assistance due to forgetfulness and intermittent cognition; removed keys and kept with nurse, administer medications as ordered, monitor behavior episodes and attempt to determine underlining cause, and provide a program of activities. During an interview on 12/29/2025 at 9:24 a.m., Resident #1 did not recall the incident of driving and being returned to the facility by a police officer. During an interview on 12/29/2025 at 11:44 a.m., Resident #1's RP stated she received a call on 11/27/2025 from a police officer. The police officer said he had Resident #1. Resident #1 had been driving his truck around and was lost. Resident #1 could not remember how to return to the facility. The RP stated she provided the police officer the phone number and address to the facility. The police officer said he was going to contact the facility to verify Resident #1 was a resident at the facility and take the resident back. During an interview on 12/30/2025 at 8:50 a.m. the DON stated she did not notify the Administrator that Resident #1 was brought back to the facility by a police officer. The DON stated the Administrator was out on vacation and did not want to bother her. The DON stated that since Resident #1 was returned safe and with no injuries, she felt there was no need to notify the Administrator. During an interview on 01/01/2026 at 3:00 p.m., the Administrator stated that on 11/17/2025, she was not notified Resident #1 had been returned to the facility for being lost. The Administrator stated it was not until days later that the DON mentioned the incident. The Administrator stated she felt she did not report the incident to HHSC for the same reasons the DON did not notify her; Resident #1 had returned to the facility safely. The Administrator said that on 12/06/2025, the HRC notified her that the resident had left the building in his own vehicle. The Administrator initiated a code purple, the code used to notify staff there was a resident missing. The Administrator said that at 6:45 p.m., she received a call from a nearby nursing facility reporting they had Resident #1. The nearby facility was approximately 0.6 miles away. The Administrator said she sent three staff members to bring Resident #1 back to the facility. One of the three staff members drove Resident's truck back to the facility. The Administrator stated that Resident #1 had arrived at that other facility because he was confused as to which facility he was a resident of. The Administrator stated that Resident #1's RP had his truck picked up after the incident. The administrator stated that it was best that Resident #1 did not have a vehicle on premises because Resident #1 could hurt himself or others while driving. Resident #1 could become confused and cause an accident. Record review of TULIP (Texas Unified Licensure Information Portal) did not reflect a facility reported incident that corresponded to the allegations in the incident described above. TULIP is a web-based program used by facilities to report incidents involving residents. HHSC then takes that information and performs an investigation into those incidents reported. Record review of facility policy titled, Abuse, Neglect, and Exploitation dated 8/15/22, revealed:VII. Reporting/Response1. Reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:b. Not later 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs for 3 of 5 residents (Resident #6, Resident #2, and Resident #5) reviewed for care plans. The facility failed to develop care plans for Resident #6 and Resident #2 to include previous verbal altercations in the months leading up to when the physical altercations began between Resident #6 and Resident #2. The facility failed to include wound care for Resident #5's care plan for her surgical wound. These failures could place residents at risk of not receiving person-centered care and/or services to meet their physical and/or psychosocial needs. Findings included: 1. Record review of Resident #6's face sheet, dated 10/08/2025, revealed a [AGE] year-old-female with an admission date of 01/15/2023. Pertinent diagnoses included Cerebral Infarction (most common form of stroke) and Altered Mental Status (a change in cognitive function). Record review of Resident #6's Quarterly MDS Assessment, dated 04/17/2025, revealed a BIMS score of 15, intact cognition. Record review of Resident #6's care plan, initiated 06/02/2025, revealed Resident #6 had a potential to be physically aggressive as evidenced by striking another resident in the arm related to poor impulse control. Interventions included assessing for contributing sensory deficits, assessing Resident #6's needs, and lab work. This care plan was revised on 06/11/2025 to include Resident #6 was involved in a physical altercation with another female resident. There was no care plan which addressed Resident #6's verbal altercations with Resident #2 which began in April 2025 (according to interviews and incident and accident reports). Record review of Resident #6's progress note, dated 04/06/2025, revealed resident to resident verbal altercation. Both residents became increasingly verbally aggressive. Residents were separated and no physical altercation occurred. Record review of the provider investigation report, dated 06/02/2025, in a narrative given by LVN-F, revealed Resident #2 and Resident #6 were involved in a physical altercation in which Resident #2 looked at Resident #6 ugly, so in response, Resident #6 made a noise to scare her away. Then, Resident #2 grabbed Resident #6 by the arms causing a small skin tear to Resident #6's hand. The Provider Investigation report revealed the Administrator confirmed the incident with both residents, however, both residents blame the other for instigating the altercation. Record review of Resident #6's progress note, dated 04/06/2025, revealed resident to resident verbal altercation. Both residents became increasingly verbally aggressive. Residents were separated and no physical altercation occurred. Record review of Resident #6's progress note, dated 06/02/2025, revealed Resident #6 was heard arguing with another resident. Upon visualization of Resident #6 and Resident #2, LVN-F saw both residents throwing their hands up in the air and on their arms. LVN-F got in the middle of the altercation and separated both residents. This incident occurred in the hallway outside of the dining room. Only a small nail imprint, 0.25 cm, on the right wrist visualized on Resident #6. A progress note dated 06/11/2025 revealed Resident #6 was seen with her hands on another resident in a physically aggressive manner. Resident #6 stated the other resident started it. Record review or Resident #6's care plan note, dated 06/12/2025, revealed it was discussed with Resident #6 the other resident had intellectual disabilities, and these altercations could be considered mental abuse. It was recommended for Resident #6 to try and avoid the other resident, and if Resident #6 felt she was being bothered by the other resident, to notify a staff member so they could intervene. 2. Record review of Resident #2's face sheet, dated 10/07/2025, revealed a [AGE] year-old-female with an admission date of 02/09/2025, and a discharge date of 06/19/2025. Relevant diagnoses included Senile Degeneration of the Brain (progressive deterioration of brain tissue and function), bipolar disorder (a mental health condition characterized by extreme mood swings, including emotional highs and lows), Genetic Related Intellectual Disability (a learning disability significantly influenced by genetic factors), and Severe Intellectual Disabilities (significant limitations in cognitive functioning and adaptive behavior). Record review of Resident #2's Quarterly MDS Assessment, dated 05/17/2025, revealed a BIMS score of 09, moderately impaired cognition. Record review of Resident #2's care plan, initiated 05/19/2025, revealed Resident #2 had a potential to be verbally aggressive (she yelled at other residents and staff). Interventions included: medication review was done by the hospice doctor; urinalysis was done; administer medications as ordered; assess Resident #2's understanding of the situation; allow time for Resident #2 to express self and feelings toward the situation. Another care plan, initiated 06/02/2025, revealed Resident #2 had the potential to be physically aggressive. Interventions included: labs obtained, modify environment (to include adjust room temperature to comfortable level, reduce noise, dim lights, place familiar objects in room, keep door closed), started on an antibiotic for a urinary tract infection. This care plan was revised on 06/11/2025 to include Resident #2 was involved in a resident-to-resident altercation with a skin tear to Resident #2's left forearm. There was no care plan which addressed Resident #2's verbal altercations with Resident #6 which began in April 2025. Record review of Resident #2's progress note, dated 04/06/2025, revealed resident to resident verbal altercation. Resident #2 stated the other resident was being mean and dismissive to her. Anxiety medication was offered, and labs were ordered. Resident #2's room assignment was changed in an effort to avoid further altercations. Record review of Resident #2's progress note, dated 05/11/2025, revealed a resident-to-resident verbal altercation in the dining room with Resident #6. Resident #2 stated gave her the middle finger. Record review of Resident #2's progress note, dated 06/02/2025, revealed a resident-to-resident verbal and physical altercation in which both residents were witnessed throwing their hands up in the air, and Resident #2 then hit Resident #6, and dug her nails into the back of Resident #6's hand. Record review of the provider investigation report, dated 06/11/2025, in a narrative given by ADON-B, revealed Resident #2 and Resident #6 were involved in a physical altercation in the dining room in which ADON-B stated he observed both residents physically engaging, and both residents were immediately separated by LVN-G. The assessment, completed by LVN-D, revealed Resident #2 was noted to have had a skin tear to the left forearm. Record review of Resident #2's progress note, dated 06/11/2025, revealed a resident-to-resident verbal and physical altercation. Resident #2 voiced Resident #6 was verbally aggressive toward her and grabbed her by her left forearm and pressed her nails into her. A skin tear was noted to the left forearm. Resident #2 was upset and crying. Record review of the facility's incidents and accidents from 04/01/2025 - 06/23/2025 revealed a resident-to-resident altercation between Resident #6 and Resident #2 on 04/06/2025 (verbal), 05/11/2025 (verbal), 06/02/2025 (physical), and 06/11/2025 (physical). 3. Record review of Resident #5's admission assessment reflected an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included displaced intertrochanteric fracture of left femur (a break in the top of the thigh bone), history of falling, cognitive communication deficit (difficulty with communication), vascular dementia (problems with thought processes and memory caused by brain damage from impaired blood flow), and unspecified osteoarthritis (degenerative joint disease that results from breakdown of joint cartilage and underlying bone).Record review of Resident #5's admission MDS dated [DATE] and electronically signed by the MDS nurse on 07/17/25 reflected it was a reentry into the facility on [DATE] from a short-term general hospital and a BIMS score of 5 which indicated severe cognitive impairment. Section I- Active Diagnoses reflected Resident #5 had a hip fracture. Section J 2100- Recent Surgery Requiring Active SNF Care reflected Resident #5 had a major surgical procedure (repair of a fracture of the pelvis, hip, leg, knee, or ankle) during the prior inpatient hospital stay that required active care during the SNF stay. Section M 1040- Other Ulcers, Wounds, and Skin Problems reflected Resident #5 had a surgical wound that required surgical wound care. Record review of Resident #5's order summary report as of 07/12/25 reflected the order, Cleanse left hip surgical incision with wound cleanser, pat dry, paint with povidone iodine, leave open to air QD and PRN every day shift for surgical incision with staples in place. Record review of Resident #5's care plan dated 05/11/25 reflected the problem, alteration in musculoskeletal status r/t fracture of the left hip s/p ORIF initiated 07/17/25 with goal, the resident's wound will heal and progress without complications through the review date. Interventions included, Follow MD orders for weight bearing status; see MD orders and/or PT treatment plan, give analgesics as ordered by the physician, monitor for fatigue, monitor/ document for risk for falls, monitor/ document/ report PRN s/sx or complications related to arthritis. This care plan also reflected the problem, [Resident #5] has surgical incision to left hip r/t s/p surgery, initiated on 07/10/25 with goal, resident will have no complications from left hip surgical incision through the review date. Interventions included, Administer medication as ordered, avoid scratching and keep hands and body parts from excessive moisture, do not use harsh detergents, soaps, fragrances, or other irritating substances, and increase out of bed activity as tolerated. Interventions for wound care and monitor/ document/ report signs and symptoms of infection were not included. In an interview on 10/08/25 at 2:44pm, the MDS nurse stated wound care should have been an intervention on the care plan for either the musculoskeletal or the surgical site problems. She stated the care plan started with the admission nurse then she finished it when she did the assessment. She stated she did not know why wound care was not on the care plan. In an interview on 10/08/25 at 3:09 pm, the DON stated if things were not care planned, it could cause a break in communication regarding the care of the resident and wound care should have been in the interventions for the surgical wound. The DON stated the goal for the problem, alteration in musculoskeletal status should not have been about the wound. She stated it was everyone's responsibility to ensure the care plan was correct. In an interview on 10/08/25 at 4:47pm, the WCN stated it was important that wound care was on the care plan because everything should match. She stated wound care would be on the interventions for whichever wound was being addressed and if wound care was not on the care plan for a resident that received wound care, she would add it. The WCN stated the MDS nurse was ultimately responsible for making sure that interventions were added to the care plan and if something was not on a care plan it could cause the residents to not receive the best quality of care. She stated care plans were to be reviewed daily in case there were changes in residents' conditions and she found out about new residents/ changes in care in morning report. The WCN stated she was involved in care plan meetings if wound care was addressed. Record review of the facility's policy Comprehensive Care Plans, implemented 10/24/2022, revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 3. The comprehensive care plan will describe, at minimum, the following: A. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. F. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated.

Based on observation, interview, and record review, the facility failed to protect the residents' rights to be free from abuse, neglect, and exploitation for four residents (Resident #2, Resident #6, Resident #9, and Resident #10) out of 5 residents reviewed for abuse. 1. The facility failed to protect Resident #6 and Resident #2 from both verbally and physically harming each other on [DATE]. Resident #6 and Resident #2 had a verbal altercation which turned physical on [DATE] in which Resident #6 ended up with a small skin tear to her hand. 2. The facility failed to protect Resident #2 and Resident #6 from both verbally and physically harming each other on [DATE]. Resident #2 and Resident #6 had a verbal altercation which turned physical on [DATE] in which Resident #2 ended up with a small scratch to her left arm. 3. The facility failed to protect Resident #9 when Resident #10 hit her with an electric wheelchair on [DATE], causing her to move backward, and creating a skin tear to her left calf. These failures could place residents at risk for serious physical or psychological harm.The findings included: 1. Record review of Resident #6's face sheet, dated [DATE], revealed a [AGE] year-old-female with an admission date of [DATE]. Pertinent diagnoses included Cerebral Infarction (most common form of stroke) and Altered Mental Status (a change in cognitive function). Record review of Resident #6's Quarterly MDS Assessment, dated [DATE], revealed a BIMS score of 15, intact cognition. Record review of Resident #6's care plan, initiated [DATE], revealed Resident #6 had a potential to be physically aggressive as evidenced by striking another resident in the arm related to poor impulse control. Interventions included assessing for contributing sensory deficits, assessing Resident #6's needs, and lab work. This care plan was revised on [DATE] to include Resident #6 was involved in a physical altercation with another female resident. Record review of the provider investigation report, dated [DATE], in a narrative given by LVN-F, revealed Resident #2 and Resident #6 were involved in a physical altercation in which Resident #2 looked at Resident #6 ugly, so in response, Resident #6 made a noise to scare her away. Then, Resident #2 grabbed Resident #6 by the arms causing a small skin tear to Resident #6's hand. The Provider Investigation report revealed the Administrator confirmed the incident with both residents, however, both residents blame the other for instigating the altercation. Record review of Resident #6's progress note, dated [DATE], revealed Resident #6 was heard arguing with another resident. Upon visualization of Resident #6 and Resident #2, LVN-F saw both residents throwing their hands up in the air and on their arms. LVN-F got in the middle of the altercation and separated both residents. This incident occurred in the hallway outside of the dining room. Only a small nail imprint, 0.25 cm, on the right wrist visualized on Resident #6. A progress note dated [DATE] revealed Resident #6 was seen with her hands on another resident in a physically aggressive manner. Resident #6 stated the other resident started it. Record review or Resident #6's care plan note, dated [DATE], revealed it was discussed with Resident #6 the other resident had intellectual disabilities, and these altercations could be considered mental abuse. It was recommended for Resident #6 to try and avoid the other resident, and if Resident #6 felt she was being bothered by the other resident, to notify a staff member so they could intervene. 2. Record review of Resident #2's face sheet, dated [DATE], revealed a [AGE] year-old-female with an admission date of [DATE], and a discharge date of [DATE]. Relevant diagnoses included Senile Degeneration of the Brain (progressive deterioration of brain tissue and function), bipolar disorder (a mental health condition characterized by extreme mood swings, including emotional highs and lows), Genetic Related Intellectual Disability (a learning disability significantly influenced by genetic factors), and Severe Intellectual Disabilities (significant limitations in cognitive functioning and adaptive behavior). Record review of Resident #2's Quarterly MDS Assessment, dated [DATE], revealed a BIMS score of 09, moderately impaired cognition. Record review of Resident #2's care plan, initiated [DATE], revealed Resident #2 had a potential to be verbally aggressive (she yelled at other residents and staff). Interventions included: medication review was done by the hospice doctor; urinalysis was done; administer medications as ordered; assess Resident #2's understanding of the situation; allow time for Resident #2 to express self and feelings toward the situation. Another care plan, initiated [DATE], revealed Resident #2 had the potential to be physically aggressive. Interventions included: labs obtained, modify environment (to include adjust room temperature to comfortable level, reduce noise, dim lights, place familiar objects in room, keep door closed), started on antibiotic for urinary tract infection. This care plan was revised on [DATE] to include Resident #2 was involved in a resident-to-resident altercation with a skin tear to Resident #2's left forearm. Record review of the provider investigation report, dated [DATE], in a narrative given by ADON-B, revealed Resident #2 and Resident #6 were involved in a physical altercation in the dining room in which ADON-B stated he observed both residents physically engaging, and both residents were immediately separated by LVN-G. The assessment, completed by LVN-D, revealed Resident #2 was noted to have had a skin tear to the left forearm. Record review of Resident #2's progress note, dated [DATE], revealed resident to resident verbal and physical altercation. Resident #2 voiced Resident #6 was verbally aggressive toward her and grabbed her by her left forearm and pressed her nails into her. A skin tear was noted to left forearm. Resident #2 was upset and crying. 3. Record review of Resident #9's face sheet revealed a [AGE] year-old female initially admitted on [DATE], with diagnoses of Cerebral Infarction due to Embolism of Right Middle Cerebral Artery( a condition were a blood clot travels through the blood to the brain and blocks oxygen and blood flow to blood vessels in the brain, causing tissue damage.), anxiety disorder(a mental health condition characterized by excessive and persistent worry, fear, and nervousness which could interfere with daily life), Post Traumatic Stress Disorder (a mental health condition which could develop after experiencing or witnessing a traumatic event such as a natural disaster, war, violent crime, or serious accident), Schizophrenia (A Chronic mental health condition which affects a person's thoughts, feelings, and behaviors), Major Depressive Disorder (A common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in previously enjoyable activities). Record review of Resident #9's MDS Quarterly dated [DATE] revealed Resident #9 had a BIMS Score of 02-severe problems with thinking and memory classified as severely impaired cognition, suggesting significant cognitive impairment. MDS functional status revealed the resident needed extensive assistance with ADLs. Record review of Resident #9's care plan dated [DATE] revealed Resident #9 used antidepressant medication Vilazodone for depression and her behavior was to be monitored, documented, and reported for adverse reactions to antidepressant therapy. Resident#9 was to be monitored also for changed behavior in mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, withdrawal and decline in ADL ability. Resident#9 was dependent on staff for meeting emotional, intellectual, physical, and social needs due to physical limitations. Resident#9 had an ADL self-care performance deficit related to weakness, poor mobility related to hemiplegia affecting the left side. Resident #9 was at risk for a behavior problem related to Major Depressive Disorder, Post-Traumatic Stress Disorder, Anxiety Disorder, Bipolar Disorder, and Insomnia. Resident #9 had potential to be verbally aggressive yells at staff, verbally inappropriate, uses foul language towards staff related to mental and emotional illness, poor impulse control, anxiety, bipolar disorder, Post Traumatic Stress Disorder, major depressive disorder, and insomnia. Resident #9 had impaired cognitive function or impaired thought processes related to difficulty making decisions. Record review of Resident #9's progress notes dated [DATE] to [DATE] revealed on [DATE] Resident #9 went to the nurses station and stated another resident had hit her with his electric wheelchair. Resident #9 stated she got lost and went into Resident #10's room where the incident occurred. Resident #9 stated Resident #10 hit her on the right shin with his electric wheelchair attempting to push her out of his room at the same time resident attempted to move back causing a skin tear to her left calf. A complete head to toe assessment was done, head clear of bumps, abrasion or pain, face asymmetrical due to Cerebrovascular accident (stroke) and missing dentition. Skin tear to left shin measured 1.5cm X 0.3cm according to the nurse's head to toe assessment. 4. Record review of Resident#10 face sheet revealed an [AGE] year-old male initially admitted on [DATE], with diagnosis of Quadriplegia (A medical condition characterized by the partial or complete loss of movement and sensation in all four limbs), muscle wasting atrophy (a condition which causes a progressive loss of muscle mass, strength and power), acute embolism(an obstructions of an artery typically by a blood clot or other material) and thrombosis (the formation of a blood clot inside a blood vessel obstructing the flow of blood through the circulatory system), Bradycardia(a slow heart rate, where the heart beats at a rate below the normal range). Record review of Resident #10's MDS Quarterly dated [DATE] revealed Resident #10 had a BIMS Score of 15 which indicated a resident's cognition was intact, meaning they had very little mental impairment. The MDS revealed functional limitations in range of motion on both sides. The MDS indicated Resident #10 used a motorized wheelchair and was dependent on staff to help in all daily activities. Record review of Resident #10's Care Plan date [DATE] revealed Resident #10 was independent for meeting emotional, intellectual, and social needs related to activities. Resident #10 could decide whether he wanted to participate in an activity. Resident #10 enjoys spending social time on the patio in the mornings, chatting and smoking with other residents. Resident #10 enjoyed participating in group activities such as recreational bingo in the afternoons, celebrations with music and snacks and only when he preferred, the outings for Walmart. Resident #10 was alert and independent and able to move around in his power wheelchair but due to the limitations of his hands, he required activities without much physical or cognitive effort. Resident #10 had an ADL self-care performance deficit related to functional quadriplegia and bilateral hand contractures. Resident #10 had limited physical mobility related to quadriplegia. Resident #10 required supervision by staff for locomotion when he used his personal motorized wheelchair. Resident #10 had potential to be physically aggressively related to poor impulse control and was triggered for physical aggression with poor impulse control. Resident #10's behaviors were de-escalated by redirection. Record review of Resident #10's progress notes dated [DATE] to [DATE] revealed on [DATE] at 12:00 AM Resident #10 stated to LVN Resident #9 went inside his room and as he used his electric wheelchair to push Resident #9 out of his room it caused a skin tear to Resident #9's lower leg. Resident #10 was checked for injuries, denied pain or discomforts. Administrator, DON, MD, and family notified of incident occurrence between both residents. In an observation and interview on [DATE] at 3:17 PM with Resident #9 revealed the resident was sitting in her wheelchair in her room talking with the CNA who had just brought her into the room. Resident #9 was upset as she spoke to CNA-A about her mother and how her visit was with her mother. The State Surveyor asked Resident #9 about the incident with Resident #10, and she stated she could not remember the incident or having received a wound from the wheelchair of Resident #10. Resident #9 then began to state her home had been robbed by someone named [NAME] and she needed help to find her stuff. The Surveyor discontinued the interview as the resident became upset while she spoke of the robbery. CNA-A stated she gets confused often. In an observation and interview on [DATE] 3:43 PM with Resident #10 revealed the resident was in bed watching television. Resident #10 was alert and agreed to discuss the incident between Resident #9 and himself. Resident # 10 stated he was in his chair watching TV when suddenly Resident #9 rolled in on her wheelchair and said she thought it was her room and for him to leave. Resident #10 stated she was confused and was in the wrong room, so she tried to wheel herself out and she got caught up between the bed and wall. Resident #10 stated he then rolled over to her to help her and accidentally scratched her leg. Resident #10 stated he was only trying to help her get unstuck, and he did not intend to harm her leg. In an interview on [DATE] at 3:30 PM, LVN-D stated Resident #2, had an issue with maybe 1 or 2 residents which were on the 100 and 300 hall, but it was mostly the other residents picking on Resident #2. She stated Resident #6 used to pick on Resident #2 because she was jealous of Resident #2 talking to her boyfriend. Resident #6 would call Resident #2 names. LVN-D stated she did not recall a specific incident in which she did a skin assessment on Resident #2 or Resident #6, but she could have. She also did not recall having to intervene between Resident #2 and Resident #6 during any of their physical altercations, but she did remember one of the physical altercations because she was at the nurses' station getting report and heard both Resident #2 and Resident #6 yelling at each other. LVN-D did not go into the dining room to assist because she was counting narcotics, and the other staff had already assisted and separated the residents. She stated Resident #2 had scratches on her arm from the physical altercation. LVN-D stated after the incident, Resident #2 was moved to the 300 hall first, then Resident #2 was moved to the 200 hall after another incident. LVN-D stated Resident #2 was moved multiple times in the facility's attempt to keep her and Resident #6 from having any verbal or physical altercations. In an interview on [DATE] at 3:55 PM, MA-E stated Resident #2 was moved to multiple rooms while she was here. MA-E stated Resident #2 would yell at everyone. It was not that she was yelling, but it was Resident #2's way of communicating because she talked very loudly. MA-E stated most of the incidents were in the dining room because Resident #2 followed Resident #6 and her boyfriend because she liked Resident #6's boyfriend. Resident #6 would get jealous and get verbally aggressive with Resident #2. MA-E stated she was there when one of the physical altercations occurred but did not remember the exact date. MA-E stated by the time she had gotten to the dining room, both residents had already been pulled apart. Resident #6 stated her hair was pulled, but MA-E had not seen any redness to the area or missing hair, and Resident #2 had a scratch to one of her arms. MA-E stated both residents used to taunt each other. In an interview on [DATE] at 4:53 PM, the DON stated Resident #2 was pleasant, not aggressive. She was loud sometimes, but it was normal for Resident #2 to be loud. Other residents may have taken it the wrong way if they had not known or understood Resident #2, but she was not the type to have gone up to anyone and started an argument or started an altercation. The DON stated Resident #2 had an intellectual disability, but she was able to answer simple questions and give simple answers, but she would get confused very easily. The DON stated Resident #6 could be very disrespectful and call other residents names and make fun of them or make faces at them. She stated they tried to explain to Resident #6 about Resident #2's cognitive status, but she still instigated things, made noises at her, and called her names, and it would upset Resident #2 who then lashed out. The DON stated staff tried to always keep the two residents separated from each other, but it did not always work because when Resident #6 would say something, Resident #2 would turn around to make a face at her or went back to her. The DON stated Resident #2 had lorazepam (a medication used to treat anxiety) ordered because she was under hospice services, and it would sometimes help with her anxiety or agitation. Then, hospice ordered the Ativan/Benadryl/Haldol (ABH) Gel (a medication used for agitation, anxiety, and hospice patients) after the second incident, and it seemed to help as well. The DON stated Resident #2 was moved from the facility and transferred to a different facility, even though Resident #6 was the one who instigated things. In an interview on [DATE] at 5:05 PM, CNA-I stated she had taken care of Resident #9 and said Resident #9 was always lost and went into other residents' rooms. CNA-I stated Resident #9 was always confused and made-up stories about residents or staff members in the facility. CNA-I stated Resident #9 had made phone calls to police claiming she had been hurt and robbed by other residents and that did not occur. CNA-I stated earlier today Resident #9 told her about visiting her mother and the resident's mother had been deceased for several years. CNA-I stated every incident Resident #9 had been a part of had been investigated by the facility. CNA-I stated the resident was removed from the same hall as Resident #10, so the incident did not occur again. CNA-I stated last Abuse and Neglect training was about 2 weeks ago and was able to state the steps for reporting physical/sexual, mental and verbal abuse seen in the facility. In an interview on [DATE] 5:30 PM, LVN-C stated she had completed a head-to-toe assessment on Resident #9 but could not remember the location or describe how the scratch looked. LVN-C stated she remembered the incident and remembered the resident crying and trying to calm her down. LVN-C stated Resident #9 was an emotional person and was very sensitive and always thought other residents and staff members would talk badly about her. The LVN stated Resident #9 had made accusations against the facility even by calling police and when police showed up she would tell them to leave. The LVN stated Resident #10 was found to have had no injuries when assessed. Resident #9 was moved to another hall away from Resident #10 so future incidents do not occur between them. In an interview on [DATE] at 9:38 AM, CNA-F stated he heard a female scream and quickly went toward the room of Resident #10's room and found Resident #9 near the doorway making her way out of Resident 10's room. CNA-F called the charge nurse, and a head-to-toe assessment was administered and the only injury found was the scratch to her lower leg. The CNA stated Resident #9 wanders into other residents' rooms and the staff monitored her when she scooted around the halls in her wheelchair. Record review of the facility's policy Abuse, Neglect and Exploitation, implemented [DATE], it revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. 1. B. Prospective residents will be screened to determine whether the facility has the capability and capacity to provide necessary care and service for each resident admitted to the facility.

Based on observation, record review, and interview, the facility failed to maintain clinical records in accordance with accepted professional standards and practices complete and accurately documented medical records for 1 (Resident #7) of 10 residents whose records were reviewed. Clinical medical staff failed to ensure that Resident #7 suprapubic catheter output log was accurately documented as order by her physician. This failure could place residents of having incomplete and inaccurate records which could impact their treatment and health when receiving suprapubic catheter care. The findings include: Record review of Resident #7's face sheet revealed a [AGE] year-old-female initially admitted on [DATE] with diagnoses of Neuromuscular dysfunction of bladder (the nerves that carry messages back and forth between the bladder and the spinal cord and brain don't work the way they should.), chronic combined systolic and diastolic congestive heart failure (Systolic heart failure, heart isn't contracting well during heartbeats. While diastolic heart failure, by contrast, is when heart can't relax normally between beats), Type 2 diabetes mellitus without complications (body does not use insulin properly with, but it has not resulted in further health problems, such as nerve damage or stroke). Record review of Resident #7's MDS readmit date d 05/19/25 revealed BIMS score 11 indicated moderate cognitive impairment and requires prompt care plan modification. Functional abilities revealed Resident #7 needed substantial maximal assistance with activities of daily living. The MDS revealed Resident #7 has and suprapubic catheter and colostomy bag due to bowel and urine incontinence. Record review of Resident#7's care plan dated 04/04/25 revealed Resident #7 had a suprapubic Catheter related to Neuromuscular dysfunction of bladder. Interventions included administer medication Oxybutynin Chloride as ordered by MD. Monitor for effectiveness and side effects initiated 04/04/2025. Change catheter monthly 20 French catheter(a catheter sized using the French scale) 30ml foley initiated 04/04/25. Check the foley catheter and document urine output every shift. Use leg strap to secure foley in place initiated 05/07/2025. Check tubing for kinks each shift date initiated 04/04/2025. Record review of Resident #7's physician orders dated 04/26/25 indicated Check Foley catheter and document output every shift. The physician orders indicated suprapubic cath. Care every shift and as needed. The physician orders indicated monitor that collection bag is off the floor and hung below bladder level. The physician orders indicated Check suprapubic catheter every shift. Record Review of Resident #7's MAR for the month of May 2025 indicated no documentation of urine output for 4 days, May 1st through 4th, while Resident #7 stayed in the facility. In an interview and observation on 10/07/25 at 3:36 of Resident #7 she stated she has a huge hernia in her lower abdominal area which presses down on her bladder make it difficult to urinate, so she now has a suprapubic catheter to help her void her bladder. She stated that the catheter needed to be changed often but at times it can last for a couple of weeks. Resident #7 stated she still leaks at times from her urethra, so she had a pad to collect any leaked urine. Resident #7 stated her urine output was different everyday but usually voids frequently and a lot. The resident stated that when there was not a lot of output, she knows the catheter is blocked or migrated and needs to be changed. In an interview on 10/08/25 4:35PM with ADON B he stated all staff was responsible for documenting the output of urine if the bag is emptied by he or she. ADON B stated if the hospice nurse empties the urine bag the amount of urine was to be reported to a CNA or nurse. The ADON stated the amount of urine voided is to be documented both in the progress notes and MAR. ADON B could not explain why the amount were not documented on the days in question. In an interview 10/09/25 at 4:40 PM with the DON she stated no documentation could be found in either progress notes or MAR for the urine output for Resident#7. The DON could not explain why no documentation was not done for the 4 days in question. The DON stated not having accurate documentation of urine output could put the resident at risk for the bladder to rupture or urosepsis. The DON stated the facility did not have its own policy and procedure but followed the Lippincott Manual of Nursing Practice 11th Edition for procedure and treatment of residents with catheters and suprapubic catheters. In an interview on 10/0925 at 6:18pm CNA J stated she could not say why the amounts of urine voided was not documented. CNA J stated she could not remember that far back to explain why the amounts were not documented. CNA J stated she takes care of Resident #7 frequently and knows Resident #7 has large amounts of urine output about 700ml to 1000ml in her bag. CNA stated she knew to report to the nurse if Resident #7 amounts of urine during were smaller or different in color and clearness. Record of an In-Service dated 05/05/25 revealed an in-service was completed with the objective of: Suprapubic catheter change and personal protective equipment. The training did not mention any discussion or training on the importance of documentation of urine voided by residents each time the urine bag is emptied.

Based on interviews and record reviews the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #5) of 5 residents reviewed for MDS assessment. Resident #5's MDS admission assessment dated [DATE] failed to indicate Resident #5 had a fall that resulted in major injury. This deficient practice could place residents at risk for inadequate care and services to meet their needs based on inaccurate MDS assessments. Findings included:Record review of Resident #5's admission assessment reflected an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included displaced intertrochanteric fracture of left femur (a break in the top of the thigh bone), history of falling, cognitive communication deficit (difficulty with communication), vascular dementia (problems with thought processes and memory caused by brain damage from impaired blood flow), hyperlipidemia (high cholesterol), atherosclerotic heart disease (buildup of fats and other substances in and on the artery walls of the heart causing decreased blood flow and/or clots), non-ST elevation myocardial infarction (a type of heart attack characterized by a partial artery blockage in the heart), hypertension (high blood pressure), and unspecified osteoarthritis (degenerative joint disease that results from breakdown of joint cartilage and underlying bone). Record review of Resident #5's previous hospital records dated 04/29/25 to 05/10/25 reflected an orthopedic consultation dated 05/02/25 which stated in part: History of Present Illness: [AGE] year-old female who was admitted after sustaining a ground level fall. Resident #5 was complaining of knee pain but did not require surgery during that hospital stay. Record review of the facility's provider investigation report dated 07/03/25 reflected Resident #5 had an unwitnessed fall in her room on 06/27/25 that resulted in a cut to the back of her head and complaints of left hip and leg pain. Resident #5 was transferred to the hospital and underwent surgery on 06/28/25 to repair her left hip fracture that was sustained as a result of the fall. Record review of Resident #5's admission MDS dated [DATE] and electronically signed by the MDS nurse on 07/17/25 reflected it was a reentry into the facility on [DATE] from a short-term general hospital and a BIMS score of 5 which indicated severe cognitive impairment. Section I- Active Diagnoses reflected Resident #5 had a hip fracture. Section J 1700- Fall History on Admission/Entry or Reentry reflected the MDS nurse answered, No, Resident #5 did not have a fall any time in the last month or in the last 2 to 6 months, and Resident #5 did not have any fracture related to a fall in the 6 months prior to admission/entry or reentry. Section J 2100- Recent Surgery Requiring Active SNF Care reflected Resident #5 had a major surgical procedure (repair of a fracture of the pelvis, hip, leg, knee, or ankle) during the prior inpatient hospital stay that required active care during the SNF stay. Section M 1040- Other Ulcers, Wounds, and Skin Problems reflected Resident #5 had a surgical wound that required surgical wound care. In an interview on 10/08/25 at 2:44pm, the MDS nurse stated she coded the fall with major injury on the resident's discharge MDS dated [DATE], so she did not answer yes to those questions on the reentry MDS. She stated the questions about the falls should have been answered yes instead of no. The MDS nurse stated Resident #5's falls were on the care plan even though they were not on the MDS but if falls were not triggered on the MDS for a new resident, it did not show up on the care plan as high risk. The MDS nurse stated it was the responsibility of the MDS nurses to ensure resident assessments were accurate. A policy for accuracy of MDS assessments was requested from the facility, however they did not have one and stated they referred to the RAI for whichever section is being answered. Record review of CMS's RAI Version 3.0 Manual, CH 3: MDS Items J effective 10/01/25 reflected in part: Steps for Assessment The period of review is 180 days (6 months) prior to admission, looking back from the resident's entry date (A1600). 1. Ask the resident and family or significant other about a history of falls in the month prior to admission and in the 6 months prior to admission. This would include any fall, no matter where it occurred. 2. Review inter-facility transfer information (if the resident is being admitted from another facility) for evidence of falls. 3. Review all relevant medical records received from facilities where the resident resided during the previous 6 months; also review any other medical records received for evidence of one or more falls. Coding Instructions for J1700A, Did the Resident Have a Fall Any Time in the Last Month Prior to Admission/Entry or Reentry? Code 0, no: if resident and family report no falls and transfer records and medical records do not document a fall in the month preceding the resident's entry date item (A1600). Code 1, yes: if resident or family report or transfer records or medical records document a fall in the month preceding the resident's entry date item (A1600). Coding Instructions for J1700B, Did the Resident Have a Fall Any Time in the Last 2-6 Months prior to Admission/Entry or Reentry? Code 0, no: if resident and family report no falls and transfer records and medical records do not document a fall in the 2-6 months prior to the resident's entry date item (A1600). Code 1, yes: if resident or family report or transfer records or medical records document a fall in the 2-6 months prior to the resident's entry date item (A1600). Coding Instructions for J1700C. Did the Resident Have Any Fracture Related to a Fall in the 6 Months prior to Admission/Entry or Reentry? Code 0, no: if resident and family report no fractures related to falls and transfer records and medical records do not document a fracture related to fall in the 6 months (0-180 days) preceding the resident's entry date item (A1600). Code 1, yes: if resident or family report or transfer records or medical records document a fracture related to fall in the 6 months (0-180 days) preceding the resident's entry date item (A1600).

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for one of three residents (Resident #1) reviewed for medication errors. The facility failed to ensure Resident #1's blood pressure/pulse altering medications (Midodrine) was not given outside of the scheduled time parameters for the month of November 2025 per the physician's orders. This failure could place residents at an increased risk for complications such as decreased blood pressure, decreased pulse, exacerbation of symptoms and disease process, and potential hospitalization.The findings include:Record review of Resident #1's face sheet dated 11/18/25 reflected an [AGE] year-old-female with an original admission date of 12/06/23. Resident #1 had diagnoses which included Type 2 diabetes (insufficient insulin production in the body), Dementia (the loss of cognitive functioning that interferes with daily life and activities), high blood pressure, coronary artery disease (narrowing or blockage of your coronary arteries) and acute kidney failure. Record review of Resident #1's care plan with an initial date of 01/15/24, and a revision on 07/18/25 reflected:Resident #1 has coronary artery disease r/t lifestyle choices and high blood pressure. Interventions included:Administer hypotension medications as ordered by MD. Monitor for side effects and effectiveness.Record review of Resident #1's physician orders dated 09/04/25 reflected:Midodrine Tablet 10 MGGive 1 tablet by mouth three times a day for Hypotension. Hold if SPB 130 or above. No doses should be given after evening meal or within 4 hours of bedtime. Record review of Resident #1's annual MDS dated [DATE] reflected a BIMS score of 5 which indicated (severe cognitive impairment). Record review of Resident #1's blood pressure log reflected Midodrine was given on the following dates and times: the blood pressures reflected Resident #1's reading prior to medication administration. Dinner was noted to be served beginning at 5:00pm. 11/02/25 at 9:09pm11/05/25 at 8:43pm11/06/25 at 8:40pm11/07/25 at 8:50pm11/08/25 at 9:21pm11/12/25 at 8:29pm11/13/25 at 8:57pm11/14/25 at 8:33pm11/17/25 at 8:31pmAttempted interview on 11/18/25 at 11:36am, Resident #1 was non-interviewable. In an interview on 11/18/25 at 12:14pm, MA A stated dinner was served around 5:00pm. MA A stated Resident #1's Midodrine could be given an hour before or after 5:00pm. MA A stated if the orders stated do not give after the evening meal, then it should not be administered after 6:00pm since the medication was scheduled for 5:00pm. MA A stated if the medication was not given as prescribed, Resident #1's blood pressure could drop or become too high. MA A stated sometimes when logging blood pressures, the system did not allow MA's to input the blood pressure reading and the nurse must be informed so the blood pressure could be documented. MA A stated it was important to document accurate times and blood pressure readings to see if there was a pattern and if medication needed to be adjusted. MA A stated she did not know why Resident #1's Midodrine medication was given outside of prescribed parameters. In an interview on 11/18/2025 at 12:54pm, the DON stated dinner was served between 5:00pm and 5:45pm. The DON stated the medication Midodrine was scheduled for 5:00pm and could be given an hour before or an hour after. The DON stated the medication should not have been given after 6:00pm per physician orders. The DON stated she did not know if staff were signing out the medication late or if it was being given at the time documented. The DON stated it was important to accurately document the times of medication administration so Resident #1's blood pressure could be tracked and trended and to see if medication needed to be held. The DON stated all MA's and nurses should be following the physician orders. The DON stated if the medication was not given as prescribed, Resident #1 could become hypotensive (low blood pressure) or hypertensive (high blood pressure). The DON stated audits were conducted daily and monthly, but the system did not alert them if the medication was given late. The DON stated staff were checked off on administering medication randomly and annually to make sure they knew the Rights of Administration.Record review of the facility's Medication Administration policy dated 10/24/22 reflected: PolicyMedications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy of Explanation and Compliance Guidelines:8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. Record review of the facility's Documentation in Medical Record policy dated 10/24/22 reflected: Policy:Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines:3. Principles of documentation include, but are not limited to:a. Documentation shall be factual, objective, and resident centered. i. False information shall not be documented.b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.c. Documentation shall be timely and in chronological order. e. Record date and time of entry.4. When documentation occurs after the fact, outside acceptable time limits, the entry shall be clearly indicated as late entry.

Based on interviews and record review, the facility failed to, in accordance with accepted professional standards and practices, maintain clinical medical records on each resident that were complete and accurately documented for one of three residents (Resident #1) reviewed for medical records.The facility failed to ensure Resident #1's vital signs were documented in the MAR from 10/01/25 to 10/24/25.This failure could place residents at risk for errors in care and treatment.The findings include:Record review of Resident #1's face sheet dated 11/18/25 reflected an [AGE] year-old-female with an original admission date of 12/06/23. Resident #1 had diagnoses which included Type 2 diabetes (insufficient insulin production in the body), Dementia (the loss of cognitive functioning that interferes with daily life and activities), high blood pressure, coronary artery disease (narrowing or blockage of your coronary arteries) and acute kidney failure. Record review of Resident #1's care plan with an initial date of 01/15/24 and a revision on 07/18/25 reflected:Resident #1 has coronary artery disease r/t lifestyle choices and high blood pressure. Interventions included:Administer hypotension (low blood pressure) medications as ordered by MD. Monitor for side effects and effectiveness.Record review of Resident #1's physician orders dated 09/04/25 reflected:Midodrine Tablet 10 MGGive 1 tablet by mouth three times a day for high blood pressure. Hold if SPB 130 or above. No doses should be given after evening meal or within 4 hours of bedtime. Record review of Resident #1's annual MDS, dated [DATE], reflected a BIMS score of 5 which indicated (severe cognitive impairment). Record review of Resident #1's MAR reflected vital signs were not documented from 10/01/25 to 10/24/25.In an interview on 11/18/25 at 12:14pm, MA A stated sometimes when logging blood pressures, the system did not allow MA's to input the blood pressure readings and the nurse must be informed so the blood pressure could be documented. MA A stated it was important to document accurate times and blood pressure readings to see if there was a pattern and if medication needed to be adjusted. In an interview on 11/18/2025 at 12:54pm the DON stated it was important to accurately document vitals were taken so Resident #1's blood pressure could be tracked and trended and to see if medication needed to be held. The DON stated all MA's and Nurses should be following physician orders and documenting vital signs when they were taken to ensure accuracy. The DON stated staff were checked off on administering medication randomly and annually to make sure they knew the Rights of Administration. Record review of facility's Documentation in Medical Record policy, dated 10/24/22, reflected: Policy:Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines:3. Principles of documentation include, but are not limited to:a. Documentation shall be factual, objective, and resident centered.i. False information shall not be documented.b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.c. Documentation shall be timely and in chronological order. e. Record date and time of entry.4. When documentation occurs after the fact, outside acceptable time limits, the entry shall be clearly indicated as late entry.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: The facility failed to ensure the juice nozzle was clean. The facility failed to ensure food in the refrigerator was not expired. These failures could place residents at risk of foodborne illnesses. The findings included: During the initial observation of the kitchen on [DATE] at 10:30 a.m., revealed the juicer ' s nozzle dispenser had red and yellow slimy substance in the middle and a white slimy substance on the outer part. The vegetable refrigerator contained an uncovered clear plastic box with a label dated ,d+[DATE] that had 12 cucumbers that had brown, white, and black spots on them. Some of the cucumbers had soft spots that made it difficult to pick up. In an interview on [DATE] at 10:35 a.m., the DM said his staff had a hard time removing the juicer nozzle but ensured it was cleaned daily. He said he did not know what the slimy substances were. He said he kept a weekly cleaning schedule which included the juice machine. He said he would check the logs daily to ensure the cleaning had been done. The DM said he had not noticed the cucumbers in the vegetable refrigerator had brown, white, and black spots or being soft to the touch. He said he would discard the cucumbers immediately. He said the clear plastic box did not have a lid. The DM was not able to say what negative outcome to the residents for having the juicer ' s nozzle with slimy substances and cucumbers that were soft to the touch with colored spots. The DM said the facility did not have a policy addressinng cleaning kitchen appliances. Record review of the kitchen ' s weekly cleaning schedule from [DATE] to [DATE] reflected the juice machine and refrigerators had been cleaned. Record review of the Food Storage policy from the Nutrition & Foodservice Policies & Procedures Manual dated 2018 reflected: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal, and US Food Codes and HACCP guidelines. 2.Refrigerators: d. date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.

Based on interview and record review the facility failed to conduct an assessment of each resident's functional capacity for 1 (Resident # 1) of 8 residents reviewed for resident assessments. The facility failed to complete the MDS discharge assessment for Resident #1. This failure could place residents at risk of receiving care and services to meet their needs. The findings include: Record review of Resident #1's face sheet dated 04/02/25 reflected Resident #1 was a [AGE] year-old female admitted on [DATE]. Resident #1 had diagnoses of hypertension (high blood pressure), dementia (cognitive disorders characterized by progressive decline in memory, thinking, reasoning, and other mental abilities that interfere with daily life and activities), aphasia (neurological disorder that impairs the ability to comprehend or formulate language), epilepsy (neurological disorder characterized by recurrent, unprovoked seizures), myocardial infarction (commonly known as a heart attack where blood flow to the heart muscle was significantly reduces or blocked), and contracture (muscles, tendons, or ligaments become permanently shortened and tight, limiting range of motion in a joint or body part) of muscle. Record review of Resident #1's most recent MDS assessment dates on PCC revealed: No Discharge MDS was completed. Last MDS completed was Resident #1's annual MDS on 09/10/2024. Record review of Resident #1's most recent annual MDS dated [DATE] revealed: BIMS Summary Score was a 02, which indicated Resident #1's cognition was severely impaired. Record review of Resident #1's progress notes dated 10/24/2024 at 5:44 p.m. reflected, Resident will be leaving to ., report has been given to nurse ., medications and belonging have been transported with resident RP. During an interview on 4/2/25 at 11:20 am, MDS A said, anytime a resident was discharged there must be a DC MDS. She said a negative effect could be the resident still shows as active, but Resident #1 was already in another facility. She said she does not think it will affect the other facility because they provide clinical information during report, and the receiving facility can request any information they need. She was asked if this would affect billing for this facility and she said it would not. She said she oversees the short-term care residents and Resident #1 was in Long-Term care. She said MDS B oversaw LTC residents. During an interview on 4/2/25 at 11:30 am, MDS B said the DC MDS was not done. She said a DC MDS should have been done. She said not completing a DC MDS does not have a negative effect, because they send over resident records and the nurses give report. She said the receiving facility can request records. She said it does not affect billing because once Resident #1 was admitted to another facility, she automatically got dropped from the facility's billing and gets picked up by the receiving facility's billing. She said Resident #1 automatically got cancelled from the ADT at this facility on the exact discharge date . She said she does not believe the receiving facility requests the MDS. She said they must complete an entry and DC MDS on all residents. She said it was more as a record. She said she was sure there was a reason for it being required, she just could not recall why. During an interview on 4/2/25 at 1:30 pm, ADON C said he was not familiar with MDS, but he felt the facility provides the receiving facility all the information they need regarding a resident's current health and care required. He said if a DC MDS were not completed, he does not feel it would affect the resident's care. He said upon DC the floor nurse gets medications ready and goes over with family. They provide final assessment of resident prior to DC. He said they provided receiving facility resident's status, vitals, medication, any abnormalities, follow up appointments, and last BM. He said they also provided receiving facility information on any recent falls, any current therapies, and all the care the resident was receiving. During an interview on 4/2/25 at 2:00 pm DON said if MDS did not complete a DC MDS, that would not have any effect on the care a resident received from the receiving facility. She said she could not think of any negative effect in care a resident would have by not completing a DC MDS. During an interview on 4/2/25 at 2:37 pm Administrator said she knows some about MDS but not in depth. She said they should complete a DC MDS on all residents that have been discharged . She said she does not know exactly why a DC MDS was needed. She said she did not think it had a negative effect for the care Resident #1 received at the receiving facility, because she would have already been informed of it since it was a sister facility. Record review of CMS's RAI Version 3.0 Manual dated October 2025 reflected, CH2: Assessments for the RAI: RAI OBRA-required Assessment Summary (cont.) . Discharge Assessment - return not anticipated (Non-Comprehensive) . MDS Completion Date .No Later Than discharge date + 14 calendar days.

47573 Based on interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 1 of 1 resident (Resident # 30) reviewed for accidents. The facility failed to develop and implement interventions to prevent Resident #11 's elopement from the facility. Resident #11 eloped from the facility and was found according to the police report by the road approximately five (5) miles from the facility. The non-compliance was identified as Past Non Compliance. The Immediate Jeopardy (IJ) began on 09/19/23 and ended on 09/19/23. The facility corrected the non-compliance before the survey began. This failure could lead to residents at risk of accidental exposure or death due to lack of supervision. The findings included: 47828 Record review of Resident #11's admission record dated 10/25/23 documented a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE]. The form further documented Resident #11 with diagnoses including, unspecified dementia (a group of thinking and social symptoms that interfere with daily functioning), muscle wasting and atrophy (a decrease of muscle mass and strength), age-related physical debility (group of symptoms related to age that cause frailty), lack of coordination (group of symptoms that cause impaired direction) , and unspecified hearing loss (inability to hear). Resident #11 was not identified as her own responsible party. Record review of Resident #11's quarterly minimum data set (MDS) revealed a BIMS score of 99 indicating severe cognitive impairment. It further documented Resident #11 required a walker for mobility and required supervision when walking up to 10 feet. The MDS documented, Resident #11 did not use a wander/elopement alarm. Furthermore, the form documented a 0 when asked Has the resident wandered?, indicating the behavior had not been exhibited. Record review of Resident #11's comprehensive care plan documented Resident #11 was an elopement risk/wanderer related to attempts to leave facility unattended with an initiated date of 09/19/23. Resident #11's care plan stated The resident's safety will be maintained through the review date and the resident will not leave the facility unattended through the review date with a revision date of 09/26/23. Interventions included, 09/19/23 elope from facility, door codes changed, 1:1 monitoring, moved to room closer to nurse station, wander guard, alarms checked and functional, critical behavior monitoring, will be transferred to secured unit upon bed availability .complete wandering evaluation tool .identify pattern of wandering . All with initiation date of 09/19/23. Record review of Resident #11 physician order revealed an order to verify function of wander guard daily and wander guard in place .verify placement every shift for elopement with a start date of 09/20/23 and that was discontinued with no end date noted. Record review of Resident #11 September 2023 licensed nurse administration record dated 10/26/23 revealed order had been completed and documented for every shift on 09/20/23 as ordered. Record review of Resident #11 Wandering Evaluation completed upon admission on 08/09/23 at 08:23 a.m., documented a summary of finding score of four (4) indicating resident was a low risk for wandering. Resident #11 was not a wandering risk at that time. Record review of Resident #11 wandering re-evaluation completed on 09/19/23 at 10:30 a.m. documented a summary of findings score of five (5) indicating resident was a low risk for wandering. Furthermore, document recorded Resident #11 was a wandering risk and interventions and care plans had been re-evaluated Record review of Resident #11 progress notes with an effective date 09/19/23 at 12:24 p.m. and written by Staff M revealed a CNA last saw Resident #11 at approximately 09:00 a.m. Record review of Resident #11's progress notes signed and dated 09/19/23 at 12:50 p.m. by Staff J quoted in part, family in to see Resident #11 at 10:30 a.m., Staff E assisted family with locating resident. Resident #11 not found in facility. Facility conducted 100% of room search in the facility. Resident was last seen in facility by Staff L at around 09:00 a.m. Staff began to search for Resident #11inside and outside facility, restaurants, gas stations, stores, and surrounding neighborhoods; however Resident #11 was not located anywhere. Local police department notified at approximately 11:00 a.m. DON spoke to Officer regarding details describing Resident #11's last whereabouts and clothing worn. At approximately 11:30 a.m., Resident #11 was located by local police department walking on a street. Resident #11 was brought back to facility. Physician and family were made aware. Record review of Resident #11 Change of condition communication form dated 09/23 at 12:47 p.m. revealed the change in conditions, symptoms or signs to report: Pt (patient) had incident of elopement .this started on 09/19/23 . Nurse suggestion .Transfer to the hospital. Record review of Resident #11's weekly skin evaluation signed and dated 09/19/23 at 12:59 p.m. revealed resident did not have any abnormal skin areas i.e., bruises, skin tears, pressure ulcers, non-pressure wounds etc. Record review of Resident #11's pain evaluation signed and dated 09/19/23 at 12:59 p.m. revealed resident had no pain upon return to facility on 09/19/23. Record review of Resident #11 progress notes with an effective date of 09/19/23 at 13:20 p.m. and written by Staff J quoted in part, Resident was returned to facility by PD at approximately 1200 p.m. Resident is alert and oriented x 2. Patient denies pain at this time. Head to toe assessment conducted, no bumps or lesions noted to head .doctor, new order received: transfer resident to DHR ER for evaluate and treat. FM A in facility and aware and in agreement. Record review of Resident #11 progress notes with an effective date of 09/19/23 at 13:35 p.m. and written by Staff J, quoted in part, EMS in facility to transport resident to ER, family at bedside. Resident is calm and cooperative. Resident exited the facility at approximately 1330. Report called in by Staff E to ER staff. Record review of Resident #11 progress notes with an effective date of 09/19/23 at 20:42 p.m., quoted in part, Resident arrived from [hospital] awake, alert and VWNL (vital signs within normal limits) denies any pain or discomfort N/O (new orders) Keflex (antibiotic) 500 (milligram) capsule give 1 cap (capsule) QID (four times a day) x 5 (times five) days. Order carried out. Initial dose given no adverse reactions noted. Record review of Resident #11 progress notes with an effective date of 09/19/23 at 06:03 a.m., quoted in part, Resident slept well during the night continues. 1:1. Record review of Resident #11 progress notes with an effective date of 09/20/23 at 10:46 a.m., quoted in part, Resident in room talking on the phone with a family member. 1:1 aide at bedside. Patient calm and cooperative. Wander guard in place to left wrist. Will continue to monitor. Record review of TULIP (HHSC online incident reporting application on 10/24/23 at 09:00 a.m. revealed the facility made a self-reported incident on 09/19/23 at 10:30 a.m. regarding Resident #11's elopement. Record review of the facility map and evacuation routes, revealed a total of nine (9) exits were identified as exit doors. Initial rounds were conducted on 10/24/23 beginning at 11:00 a.m. throughout the facility. The facility was well lit, temperature was comfortable, and staff were seen appropriately interacting and assisting residents in their rooms and in the hallways. The facility was clean, well-lit, the ambient was comfortable with comfortable temperature and noise level. Resident rooms were clean, orderly, without any noted hazards or clutter. There were no sounds of yelling, screaming, or moaning. Residents in bed had their call lights within their reach. Call lights were observed activated and timely answered. Nurses were administering care and medications in a timely manner. Water and belongings were observed at the bedside of the residents and within their reach. No resident was observed to display any disrupting or aggressive behaviors. No injuries or bruising was noted on any resident that would raise suspicion of abuse or neglect. There were no active cases of COVID-19 positive residents in the building. Visitors were observed entering and exiting through the main entrance after being allowed entrance. Residents in designated smoking area being observed monitored. Other exit doors locked and secured with codes and screech alarm. Observation on 10/24/23 at 11:00 a.m. of the surrounding streets revealed a highly trafficked four lane road with a center lane and a speed limit of 40 miles per hour. In a telephone interview with FM A on 10/26/23 at 08:10 a.m. revealed she and an unnamed family member came to visit Resident #11 on 09/19/23. FM A stated she arrived at the facility at 09:55 a.m. and went straight to Resident #11's room. FM A stated after she did not find Resident #11 in her room, she decided to look in the room she was previously assigned to because she had been moved the day before. FM A stated again she could not find Resident #11. FM A stated she then decided to look in other areas of the facility including the activities area, designated smoking area, therapy, and the lounge. FM A stated that once she eliminated the areas where she believed Resident #11 could be, she then asked the staff for the whereabouts of Resident #11. FM A stated a staff member stated she was in the shower. FM A stated she decided to wait until Resident #11 came out from the shower, but after 20 minutes had gone by and Resident #11 did not come out from the shower, she inquired again to staff about the whereabouts of Resident #11. FM A stated staff then became involved in searching for Resident #11 all around the facility and police were called to assist in the search. FM A stated Resident #11 was found approximately two (2) hours after she initially arrived at the facility. FM A stated Resident #11 was brought back to the facility and then transferred to the emergency room for further evaluation. FM A stated Resident #11 mentioned she was upset about the room change the previous night, not being able to sleep and walking out the front door because she wanted to leave. FM A stated after she came back to the facility from the hospital, staff informed her Resident #11 would be transferred to a different nursing facility for safety. In an interview on 10/26/23 at 11:15 am, with CNA L stated exit doors were secured with codes and alarms. CNA L stated residents and visitors did not have codes to the exit doors. CNA L stated the facility did have a designated smoking area where residents are able to go outside supervised. CNA L stated she last saw Resident #11 in her room after breakfast. CNA L stated Resident #11 went to restroom in her room and after briefly sitting on her bed she laid down. CNA L stated Resident #11 had mentioned to her that she had not slept the night before. CNA L stated Resident #11 was last seen at approximately 09:30 a.m. that morning wearing a pink sweater, brown blouse, and beige pants CNA L stated she did not see Resident #11 anymore and did not know her whereabouts until family came to ask for her at approximately 09:45 a.m. CNA L stated all staff went to look in every room, outside, rehab, activities room, parking area, and in the surrounding areas. Staff L stated she did not know what time, the location, who found Resident #11 and how she was brought back to the facility. In an interview on 10/26/23 at 11:25 a.m., CNA J stated exit doors were secured with alarms that could be turned off by punching in a code. CNA J stated residents were allowed to go outside of the facility supervised to designated areas such as the smoking area. CNA J stated she was assigned to work shower duties the day Resident #11 was missing. CNA J stated Resident #11 had not showered and that Resident #11 had just been transferred from hall 200 to room [ROOM NUMBER]-A in hall 300. CNA J stated she was on break when FM A arrived at facility and search for Resident #11 was initiated. CN J stated residents were accounted for when doing walking rounds in the morning, as they are passing breakfast trays, when they round every two (2) hours. CNA J stated she does not know where Resident #11 was found or when. Staff J stated Resident #11 was brought back to the facility by police, she was taken to the hospital and when she came back she was put on 1:1 observation. In an interview on 10/26/23 at 11:35 a.m. with LVN K stated he worked on hall 300 for approximately twelve (12) years as a floor nurse. LVN K stated he was not working the day of the incident; however, exit doors are secured by a code and an alarm with a 15 second delayed egress and a stop alarm (screech annunciator). LVN K stated that residents must ask staff for assistance to go outside in the assigned patio area. In an interview on 10/26/23 at 12:10 p.m. with LVN E stated she had worked at facility for approximately three (3) yeaars as a floor nurse. LVN E stated exit doors are secured with a code and an alarm with a 10 second delay and stop alarm. LVN E stated residents were not allowed to go outside unsupervised unless with staff or family member and depending on the resident's independent need. LVN E stated her shift on 09/19/23 started at 02:30 a.m. to assist a co-worker and was assigned to hall 300 including, Resident #11. LVN E stated Resident #11 was moved from 200 to hall 300 the day before. LVN E stated Resident #11 was not completely comfortable in her room and that Resident #11 spend her time at the nurse's station. LVN E stated Resident #11 was a smoker and had wanted to go outside. Staff E stated Resident #11 needed to wait for someone to assist her. LVN E stated her shift changed at 06:00 a.m. and her assignment changed to a different hall including the resident she was taking care of. LVN E stated she observed Resident #11 sitting at the nurse's station at approximately 08:40 a.m. LVN E stated Resident E went to her room to change her shirt because it was stained and returned to the bistro area around 08:50 a.m. wearing a blue shirt. LVN E stated family came to visit Resident #11 close to 10:00 a.m. LVN E stated she was approached by her supervisor and was asked the whereabouts of Resident #11. LVN E stated she assisted in searching for Resident #11 in the activities area, bistro, and smoking area. LVN E stated she knew Resident #11 was missing when Resident #11 could not be located in those areas. LVN E stated after code elopement was announced, she and other staff were assigned to look in all halls, restrooms, closets, locked and unlocked doors, in halls, outside parking lots, staff searched in each direction of the facility, drove in the surrounding areas of the facility. LVN E stated family and staff called Resident #11's cell phone multiple times and went unanswered or went to voicemail. LVN E stated Resident was found at approximately 11:30 a.m. on [NAME] Rd. in Edinburg and brought back to the facility by police. LVN E stated she performed a head-to-toe assessment immediately. LVN E mentioned no injuries were noted. LVN E stated Resident #11 was sent to hospital for further evaluation and treatment, an incident report was made, and in-service of staff was performed. In an interview on 10/26/23 at 04:45 p.m., LVN D mentioned she has been employed at the facility for seventeen (17) years. LVN D stated she makes sure all residents are accounted for in the facility by performing a walking round on the hall she is assigned and count the residents to assure they are in the facility. LVN D stated staff should round on residents every two (2) hours or more often if needed. LVN D stated exit doors have a code. LVN D also mentioned residents should not know the code, and that if administration finds out residents know the codes, administration will change the codes frequently. She stated the exit codes were changed within the last week. In an interview on 10/27/23 at 08:45 a.m., BOM U stated she had been employed at facility for approximately twenty-four (24) years. BOM U stated she was assigned to the reception area and her responsibilities included allowing entry and exit to visitors, staff and/or residents to the facility. BOM U stated visitors no longer have to sign in or out. BOM U stated visitors nor residents have entrance or exit codes. BOM U stated some residents were able to obtain codes because they watched staff punch the codes on the access keypad of the exit doors as they exited or entered the facility. BOM U stated exit doors have a code that must be punched in a keypad in order for the door to unlock and allow the person to enter or exit. BOM U stated emergency exit doors have a push bar that is equipped with a 15 second delayed egress and a stop alarm (screech annunciator). BOM U stated she accounts for residents by obtaining a printed report from admissions department. She stated she looked at the schedule to make sure all residents are in the facility and checks with the nurses if they are not. BOM U stated if she found a missing resident she would inform admissions and checked to see if the resident was at the facility. BOM U stated she has access to the computer where she could see resident pictures to identify the residents. BOM U stated the facility discouraged staff from sharing codes with other employees, staff, and visitors. In an interview on 10/27/23 at 11:05 a.m., Resident #12 stated staff treated him well. Resident #12 stated he was happy with the services he was receiving at facility. Resident #12 denied pain or discomfort. Resident #12 stated staff brought him his medication on time. Resident #12 stated the doors have alarms and he cannot go out the exit doors. Resident #12 stated he needed to ask staff for assistance to go outside. In an interview on 10/27/23 at 11:15 a.m.Resident #13 stated staff treated her well. Resident #13 stated she was happy with the services provided by the facility. Resident #13 stated she was comfortable and denied pain. Resident #13 stated staff brought her medication on time. Resident #13 stated she knows how to make complaints and to who in the facility to make them to. Resident #13 stated she is mostly in bed and does not usually go outside. In an interview on 10/27/23 at 11:30 a.m., Resident #14 stated he was happy with the services he was receiving at the facility. Resident #14 stated he did not feel threatened and had not been hurt by staff. Resident #14 denied pain and stated he was comfortable. Resident #14 stated he went outside with the assistance of staff and did not know the codes to the doors. In a telephone interview on 10/27/23 at 02:00 p.m., ADON C stated he had been employed with the facility for approximately 2 years. Staff C stated he accounted for residents by rounding in the morning. ADON C stated if a resident was out on pass, on an appointment or not in his/her room he would communicate with other staff to find out the whereabouts of the resident. ADON C stated medical records took a picture of the resident and uploaded it into the resident profile. ADON C stated everyone who had access to resident records had access to view the resident profile and was able to identify residents. ADON C stated the front door was always locked and staff did not allow residents to go through the front door unsupervised. ADON C stated only employees know the codes in order to deactivate the alarms to the doors. ADON C stated doors are secured by a magnet punch code to be unlocked and codes are not shared with visitors and residents. ADON C stated only management had access to door codes. ADON C mentioned employees, nurses and charge nurses do not have access to door codes. ADON C stated staff would notify management when door is opened without an alarm going off. ADON C stated there is one code for all staff members. ADON C stated if a resident is missing he would notify the charge nurse immediately and ask other staff including CNA and LVN about the whereabouts of the resident. ADON C stated that the process is usually immediately, but following the identification of a missing resident, the charge nurse and management team including the DON and the administrator would be notified. ADON C stated an onsite search would be conducted for the resident. ADON C stated an emergency code purple to all staff would be announced to indicate a missing resident. ADON C stated staff would search every door, closet, room, parking area would be searched, and the police would be called. ADON C stated this process usually is less than ten (10) minutes because all staff is assigned to a hall and the facility would know immediately whether the resident was within the facility. ADON C stated facility would then designate a staff member as the point of contact who would communicate to others of all updates. ADON C stated that meanwhile, the remaining facility staff would continue with the search on the outside of the facility. ADON C stated after code purple was initiated, the police department was called immediately, the family of the resident would be updated, and the physician would be notified within one (1) hour. ADON C stated that once the resident was found, code purple would be called off, a head-to-toe assessment would be performed, the physician and family would be updated. ADON C mentioned code purple or elopement incidents are self-reported incidents. He stated the facility would perform an in-service for the staff on elopement and the exit door codes would be changed. ADON C stated that facility staff performed an elopement risk assessment on admission to assess residents for risk of eloping. He stated that those residents who were high risk of elopement are moved closer to the nurse's station and the staff would maintain a closer observation to those residents. ADON C stated the facility was not a lockdown facility meaning the facility did not have a secure memory care unit. ADON C stated staff increased rounding on residents with high-risk elopement risk. He stated he had not observed cameras on the inside of the facility premises and only had observed a few on the outside. ADON C stated facility offers in-services weekly on different topics including abuse, neglect, and exploitation. In an interview on 10/27/23 at 02:00 p.m., DON stated she had worked at the facility for four (4 years) and was responsible for in-servicing staff, oversight of floor staff and reporting to the administrator. DON stated certified nurse assistants (CNAs) round every two (2) to three (3) hours and as needed. She stated nurse's round at the beginning of their shift, during medication pass and at the end of their shift. DON stated that information is passed on report when a resident is out on pass and that a resident must be signed out if they do go on pass. DON stated if a resident is missing staff must go room to room, in the activity's areas, or in rehab to ensure residents are not in the facility. DON stated the resident roster is compared to each hallway to make sure all residents are accounted for. Staff A stated that if a resident is identified as missing, a code is announced to alert all staff of the missing resident. DON continued by stating that staff then are assigned to search in all areas of the facility. DON stated if the resident is not located within the facility, staff are assigned to go out of the premises in teams to search for the resident within a 3-mile radius in all directions. DON stated the police department, family and physician is then notified of the resident's elopement. DON stated that no more than 10 minutes of identifying a missing resident is a code for elopement activated and police are notified. DON stated facility exit doors are secured by alarms that must be deactivated with a code that was entered on a punch keypad. DON stated those codes are not shared with residents or visitors. DON stated the facility has identified residents who figure the codes out by observing staff members while entering the code on the keypad. DON stated that the facility prevents residents from accessing the codes by frequently changing the codes, changing them once the code has been breached or as often as needed. DON stated the facility prevents residents from entering/leaving the facility by assigning two receptionists between the hours of 08:00 a.m. and 08:00 p.m. DON stated after these hours, visitors must ring the doorbell, so the door is opened by a staff member at the nurse's station. DON stated the receptionists have access to the resident pictures that are on the resident profile and receptionists can identify residents who attempt to exit the front door unsupervised. DON stated Resident #11's family members arrived to visit with Resident on 09/19/23 and at approximately 10:30 a.m. approached LVN E to assist in locating resident within the facility. Staff A stated family and LVN E were not able to locate Resident #11 after searching on the premises themselves and delayed informing other staff of the resident's status because Resident #11 had not ever voiced desires to go home and had never had exit seeking behaviors. DON stated FM A and Staff E notified other staff members of the management at approximately 10:45. DON stated the facility activated the code for elopement at approximately 11:00 a.m. when police were notified. DON stated Resident #11 was located by local police department at 11:30 a.m., approximately two (2) miles from the facility. DON stated Resident #11 walked to a nearby hospital where she asked a woman (unknown name) for a ride to a local restaurant. DON stated Resident #11 stayed to have a drink at the restaurant and then walked home. DON stated Resident #11 knows the address to her apartment. DON stated Resident #11 was found walking with herself using her walker on [NAME] Road in the direction of her apartment. DON stated local police department brought Resident #11 back to the facility. DON stated staff performed a head-to-toe assessment, food and water was offered, and the physician was notified. DON stated Resident #11 was interviewed, and it was revealed she left through the front exit. DON stated she was unaware if Resident #11 piggybacked (walked out) with a group of other visitors or if Resident #11 held the door for 15 seconds so the alarm would not sound. DON stated that the facility was in-servicing staff and performing routine mock drills in order to better prepare staff and prevent a future elopement. DON stated the facility was also changing exit door codes frequently and incoming residents were screened to make sure their needs could be properly addressed. DON stated incoming residents with high score risk elopement risks would be placed on 1:1 until the facility was able to transfer them to a facility that could accommodate their needs. In an interview on 10/30/23 at 09:55 a.m., Resident #15 in room stated she was happy with the services received at the facility. Resident #15 stated she does not feel threatened and was not hurt by facility staff. Resident #15 stated she did not always like the food; however, she knew how to file a complaint to the Administrator regarding her concerns. Resident #15 stated staff brought her medication on time. Resident #15 stated she did not know the codes to the exit doors, staff did want to share the codes with her, and that the doors had alarms. Resident #15 stated staff assist her if needing to go outside. In an interview on 10/30/23 at 10:05 am, Administrator stated she had been employed by the facility for two (2) years and was responsible for the administrative duties of the facility. Stated she was also responsible for performing in-services on staff as well as DON and ADON C. Administrator stated topics of in-services provided to staff resident supervision, Stated best practice is for CNAs and nurses to round the assigned hallways when they start their shift, every two (2) hours and as needed. Nurses round when they start their shift, every two (2) hours and as needed on their assigned hallways. Administrator stated residents are accounted for in the facility by staff communicating during report and walking rounds. Stated exit doors are secured by maglocks (magnetic lock which is a locking mechanism that uses an electromagnetic field controlled by an electrical system that can be configured with a switch, keycard reader or biometric scanner) and a code that releases the maglock. Administrator stated the exit doors are also secured with a fifteen (15) second delayed egress and a stop alarm (screech annunciator). Stated exit door codes are changed monthly or as needed and are not shared with visitors or residents. Administrator stated the facility prevented visitors and residents from accessing the codes by offering in-services to staff on not sharing codes. Stated residents have accessed the codes before by watching staff members input the code as they are entering or exiting the facility. Administrator stated facility changed exit door codes as soon as facility identified a code had been breached and resident or visitor had learned or accessed a code. Stated facility had no working cameras at the exit doors. Administrator stated on 09/19/23 Resident #11's family member came to visit her. Stated floor staff notified her that Resident #11 was missing. Administrator stated the facility initiated their code purple (elopement protocol) immediately and followed their procedures. Adiminstrator stated they assigned a point of contact and assigned teams to search within the facility and outside of the facility. Stated that staff searched a radius of 1 mile in each direction of the facility. Staff B stated the police and physician were notified. Stated Resident #11 had been previously assessed and was not an exit seeker and never verbalized or gave any indication of wanting to leave. Administrator stated Resident #11 was found by local police department and returned to the facility unharmed. Stated a head-to-toe, pain, and skin assessment was performed upon Resident #11's return. Administrator stated family was at the facility, but physician was informed. Stated upon Resident #11's return, staff were in-serviced on elopement, a head count was performed on all residents, a secured clear box was placed over alarm over front door to prevent people from unplugging the maglock and deactivating it. Administrator stated facility prevented a reoccurrence of this incident by performing mock drills, changing exit door codes frequently, maintaining communication with staff regarding whereabouts of residents, and in-servicing staff on elopement. Interview on 11/01/2023 at 2:00 p.m., The Administrator said they change the code monthly or as needed. She said if they find out the codes have been compromised, they will change it immediately. Record review of maintenance logbook documentation stating Year 2023 Codes doors marked each exit tested for months April through October. Record review of facility in-service training report revealed facility had a training with staff including nursing staff, social worker, administrative/office, food service and maintenance personnel over Elopement and Wandering Residents on 09/19/23. Record review of facility in-service training report revealed facility had a training with staff including nursing staff, social worker, administrative/office, food service and maintenance personnel over Abuse and Neglect/Resident Supervision, Answer Call lights in a timely manner on 09/19/23 with the following evaluations, comments, suggestions: Elopement process: follow proper protocol for elopement events: Meet nurses' station, search all areas of facility, search all areas outside, search does not end until patient is found, ensure codes are changed, monitor as needed for safety of residents. Record review of facility in-service training report revealed facility had an elopement mock drill with staff including nursing staff, social worker, administrative/office, food service and maintenance personnel on 09/22/23 with the following content [TRUNCATED]