Every finding on record at Falcon Lake Nursing Home, LLC

Based on interview and record review the facility failed to ensure each resident was permitted to remain in the facility and not transfer or discharge the resident from the facility for 1 of 5 residents (Resident #1) reviewed for discharge requirements.The facility failed to ensure Resident #1 was given a discharge date 30 days after being given a 30-day discharge notice on 03/06/26.The facility failed to readmit Resident #1 after he was discharged from the hospital prior to the 30th day after his 30-day discharge notice. This failure could place discharged residents and residents residing in the facility at risk of being discharged and not allowed to return to the facility causing a disruption in their care and/or services.Findings included:Record review of Resident #1's admission record reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included type 2 diabetes (chronic condition that happens when blood sugar levels are persistently high which can lead to heart disease, kidney disease, and stroke) with diabetic neuropathy (damage to nerves outside of the brain and spinal cord that leads to pain, weakness, numbness or tingling in one or more parts of the body) and foot ulcer (wound on the foot arising from neuropathy, peripheral arterial disease, and impaired wound healing caused by diabetes), end stage renal disease (when the kidneys lose the ability to remove waste and balance fluids), dependence on renal dialysis (process of filtering blood through a machine to remove excess water and toxins in the blood when the kidneys no longer function), essential (primary) hypertension (high blood pressure), heart failure (when the heart does not pump blood as well as it should causing fluid to build up in the lungs), major depressive disorder, recurrent (persistently low or depressed mood and a loss of interest in activities that creates significant difficulty in daily life, work, and social functioning), and 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) with atherosclerosis of coronary artery bypass graft(s).Record review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 13 which indicated he had no cognitive impairment. This MDS reflected he used a walker and an electric wheelchair for mobility, and he was independent with all of his self-care. The MDS reflected he had diabetic foot ulcer(s) upon admission. Record review of Resident #1's discharge-return anticipated MDS dated [DATE] reflected active discharge planning was already occurring for the resident to return to the community and a referral to the local contact agency was not wanted by the resident.Record review of Resident #1's progress notes reflected the following notes:A Social Service Note dated 01/28/26 at 11:42 am by the SW, Resident approached me to request assistance for possible future discharge. He wants to live alone and will need a wide range of services since he is wheelchair bound. I told him I would look into it and have some form of response when I returned to this facility on 02/08/26.General Note dated 01/28/26 at 4:20 pm by the DON, Meeting held with resident and administrator. Ombudsman present via telephone. Resident was issued a 30-day discharge notice. Resident refused to receive copy of notice. DON read notice out loud to resident. Resident did not ask any questions. Ombudsman stated she would try to come to the facility on Monday. Social worker [name] was made aware of resident's discharge notice. General Note dated 01/29/26 at 3:40 pm by the DON, Resident requested a meeting with the DON and ADON. Resident stated he would be audio recording the meeting. DON asked resident if she could call the ombudsman [name] to be present over the phone. Resident agreed. Resident expressed concerns with discharge notice. DON reminded resident of his rights and staff available to assist him with the transition. Resident apologized for his behaviors following the notice. DON and ADON assured the resident he would be safely discharged . Ombudsman asked to set up an in person meeting tomorrow 01/30/26 at 2:00 pm. Resident and staff agreed. DON asked resident if he would like to include any family or friends in which he declined.Behavior Note dated 02/01/26 at 5:30 am by LVN F, Resident became verbally agitated after asking CNA about another resident's blood glucose level and was informed by the CNA that another resident's information did not concern him. Resident responded with escalated statements including, If you want to start, I can start, and stated he would begin recording, monitoring, and taking pictures of staff. CNA asked resident if he was threatening her and resident replied, yes. Nurse was nearby and addressed the situation. Resident approached nurse and stated he felt targeted by staff. Nurse listened to resident's concerns and provided redirection, explaining appropriate boundaries and communication. Resident stated he did not want to act this way and stated, This is my house, you don't scare me, I'm not afraid of the office or the owners. Why would I be scared of you all? Resident was advised on facility policies regarding privacy and interactions. Conversation was left at that.Nurse's Note dated 02/01/26 at 6:19 pm by RN G, As reported by CNAs [Resident #1] has been requesting money from residents.Nurse's Note dated 02/02/26 at 9:38 am by the ADON, Resident came into office and voiced he felt very overwhelmed and has been unable to sleep. He voiced his family came over the weekend and told him he needed to pay his taxes on a property he has out in the community and he states he only gets $75 a month and is unable to pay that and stresses on how he is going to pay it. In addition, he was issued a 30 day notice here at this facility and he voiced he is also stressed about that. ADON assured resident he would be ok and we were here to help and care for his needs. ADON voiced to him that we would set up an appt with [psychiatrist]. Appt scheduled for tomorrow 02/03/26. Resident voiced understanding and expressed how grateful he is.Behavior Note dated 02/04/26 at 6:08 am by RN H, At this time staff reported to SN that resident was noted going into another resident's room without his whereabouts as per resident sleeping during this time and hx of being blind. Resident was redirected and told not to be entering other residents' rooms with them knowing.Behavior Note dated 02/04/26 at 7:03 am by RN H, At this time med nurse was preparing medications when resident attempted to enter medication room, knowing that it is a restricted area due to HIPAA violation. Resident was redirected out of room with teaching and education done and resident joking and making remarks to nurse.Behavior Note dated 02/04/26 at 9:28 pm by LVN F, At this time the owner [CO] was present and informed the resident that he is not permitted to be around the medication room due to previous activity involving attempts to open the medication room door. Upon being informed of this, the resident became verbally agitated and stated that the owner was bullying him. The resident raised his voice and made inappropriate remarks toward the owner. Administrator was notified and came to the area; the situation was de-escalated without further incident. However following de-escalation, the resident continued to make joking remarks and provocative comments in an apparent attempt to upset the owner. Resident was redirected as needed.No Type Specified on 02/05/26 at 5:35 pm by the AD, Resident had told another resident that if he leaves [facility] he will [NAME] the nursing home and take all the laptops, iPads, and etc. He also stated to the resident if he leaves he's not leaving till the nursing home goes down.Nurse's Note dated 02/12/26 at 1:00 pm by the DON, Care plan meeting held with resident. Discussed resident's plan of care. Resident had no concerns or special requests. Resident had a question regarding his Medicaid in the nursing home and how he would be able to continue with coverage in the community. BOM provided the resident with information. As per resident, continue with plan of care and full code status.Behavior Note dated 02/18/26 at 12:24 pm by LVN K, During mealtime, CNAs reported that resident was saying inappropriate words stating [translated from Spanish to English] I wish you would give me the breast so I could finish growing up. CNAs redirected resident and informed him that comment was inappropriate. CNAs then reported to me stating they felt uncomfortable with resident. I spoke to resident and reminded him of expected respectful behavior towards staff members. Will continue to monitor behavior and reinforce boundaries as needed. DON and MD notified.Nurse's note dated 02/22/26 at 3:45 pm by RN G, At this time resident arrived back to facility. Resident arrived with 4 packs of sodas, 4 packs of cigarettes, 1 pack of [energy drink], and 1 box of chips. Resident was educated on the importance of following diabetic diet as per his medical history. Resident verbalized understanding. Behavior Note dated 02/26/26 at 7:07 am by RN H, At this time CNA staff reported resident talking back to staff and using vulgar language, making them uncomfortable. Resident was addressed about CNA staff feeling uncomfortable with remarks and vulgar language. Resident rolled his eyes.Behavior note dated 02/26/26 at 5:09 pm by RN H, At this time staff reported resident blocking staff from rooms and feeling like resident is taunting them and talking back to them saying comments like, [translated Spanish to English] I don't give a s**t [expletive], and I don't give a f**k [expletive]. Again, SN addressed this to resident and office was made aware.Behavior note dated 02/28/26 at 6:58 am by LVN L, At this time I provided resident with an unlit cigarette and asked how he intended to light it. The resident responded, That's none of your business. I informed him that it was my business, as residents are not permitted to possess lighters per facility policy. The resident then stated that he only has a problem with me. His tone appeared dismissive and mildly confrontational. No further escalation occurred at that time.MD/DON/ADON made aware.Social Service Note dated 03/06/26 at 11:22 am by the SW, Spoke with [Resident #1] this morning regarding the 30 day letter and the facility's commitment to making his transition the most fair given his health needs and mindset. Resident states he has spoken to [apartment complex] which I will investigate and to provide to him the services necessary to lead a normal life possible once he is discharged .Social Service note dated 03/06/26 at 11:36 am by the SW, I mentioned to [Resident #1] that in addition to report from nurses and staff about his behavior patterns, he has refused to meet his obligation regarding his applied income. I mentioned to him that he has failed to pay for the month of February and that March was becoming due. He added he did not have any money, but I mentioned to him that his birthday is on the 14th and SS would send him his $1200 check on the second week of the month, but he continued insisting he did not have any money because he had spent it already, without explaining how he could possibly do this being that all food and services are provided in the nursing home. He attempts to redirect the conversation, but I decided to just move on to other topics because he has a habit of manipulation and the conversation would turn to a [NAME] endless loop of subjects.Social Service Note dated 03/06/26 at 12:19 pm by the SW, spoke with [name of person at apartment complex] who told me the apt for the resident will be available on March 11 or 12. I also spoke with [person] from [home health care]. I will be providing them with necessary information later today.General Note dated 03/06/26 at 12:23 pm by the BOM, BOM and Administrator held a meeting with resident regarding unpaid Medicaid applied income for February and March totaling $2,261.80. Resident reminded of Medicaid patient pay obligation. Resident stated that he needed the money to get ready to live out in the community and that he did not have the money to pay. He also stated that the facility got paid my Medicaid and that they could afford it.Social Service Note dated 03/06/26 at 5:05 pm by the SW, I sat with [Resident #1] to go over what we had done for the day. I called [person at apartment complex] who explained to us that she would need a down pay of $50.00, rent would be $249 a month and that there would be a $350 deposit which could be paid in small portions monthly. I also spoke with [person at home health agency] and provided their business card to [Resident #1] who would work with him regarding his need for caregiver, home health and PT services. That I personally took him to the local DHHS office to change his Medicaid from nursing home to community Medicaid, filled out his papers which he signed, and added that the staff would take him to [name of Community Health Center] to make an appointment for medical services once he was discharged . He added that he had never received medical services before and I added they would help him in getting the medical services he needed. I also called [dialysis center] and informed them that after the 12th, [Resident #1] would have a new address, I reminded him that I would call [name of ambulance company] to ensure that he would be picked up at his new address after the 12th for his 3x weekly dialysis, as well as contact [community meal provider] to see whether they could provide services for him. He again went into circular arguments about not having money, wanting to leave, but wanting to stay and wanted guarantees from me that he would be well, and threatened to call the ombudsman. I told him he is welcome to call but she would find that we had done everything possible and that he was of sound mind and capable of making decisions. I added that we would seek the advice of the medical director as to whether he could function. Again he brought up his argument that he did not have any money and what would happen if he did not have a safe discharge. I reminded him of the services we had provided but he had to do his share. He agreed with me that he is intelligent and can make his own decisions. He added that what would happen if he wanted to just leave the facility and live in the park. I told him that if the medical director determined he had the mental capacity to make those decisions, there was nothing we could do to prevent it. I told him that we could take him back to FM's home and he immediately turned that idea down saying he did not get along with her. He continued in an endless loop of excuses, unwilling to make decisions for himself and unwilling to accept responsibility for actions and behavior, but wanting the Nursing Home to continue providing services yet not acknowledging his responsibilities in return.Incident Note dated 03/17/26 at 2:00 pm by the DON, At this time, the rehab director and BOM/HR notified DON of finding a vape device with strong odor while gathering discharged [Resident #1's] belongings. DON notified the Admin and CEO. CEO called the sheriff's office. [Officer's names] arrived at facility, assumed possession, and identified drug paraphernalia as THC. Case number:[case number].Record review of Resident #1's nursing facility account reflected he owed the facility a total amount of $4555.75 for his unpaid Medicaid applied income; $99.95 from October 2025, $1,099 from November 2025, $1099 from December 2025, $1130.90 from January 2026, and $1130.90 from February 2026. In a telephone interview on 3/17/26 at 3:42 pm, Resident #1 stated he was going to be released from the hospital on [DATE] or 03/18/26 and he did not want to go to a facility in [name of current city] because he, did not know the city, and he wanted a little more time to get his apartment in [name of original city]. Resident #1 stated, the facility did not like that he spoke out and that made him an enemy of them. Resident #1 stated his behavior while at the facility was because, he just got emotional sometimes. He stated he would record staff on his cell phone, to prove they were not doing their job right to the state because he felt the facility was not afraid of the state. He stated he was already approved for an apartment that was going to be ready on 03/12/26, but he was in the hospital, so he had to wait for another apartment to be ready. He stated he called the apartment complex and was told they were waiting for a stove to arrive for another apartment. He stated, it probably would not take more than next month, but it should not take too long because she (the person from the apartment complex) knew he had been waiting for a long time already. Resident #1 stated he could go to another nursing home, but he had already, paid everything to get into that housing and really wants to go to those apartments. He then stated, technically, the apartment complex had not told him yes because he had not paid the deposit. He stated he did not make any payments on the apartment because it was not ready yet. He stated he had the money to pay the deposit and all that. He stated when the facility gave him the first 30-day notice (on 01/28/26) he did not give them the monthly payment and he knew it was not right, but when he got emotional, it did not let him think right. He stated he did not pay the facility because he needed the money to pay the deposit and get electricity at the apartment. He stated he had not followed through and made phone calls and such (to arrange transportation and help with his medical issues) but he hoped to move to the next step after he got the apartment. He then stated he did not have the Medicaid and the transportation to be able to move into the apartment. He stated the facility already knew he was going to leave, but they were making it harder and that was why he was sent to the hospital. He then stated he wanted to go to the hospital but, they were using the hospital to make it harder on me, and he kept calling in complaints because he did not know the laws. He stated he did call the Ombudsman, and she told him that she had already called the state. Resident #1 stated the facility gave him a 30-day notice, but they put a 3 day date on the notice. Then he said they gave it to him on 03/06/26 and the final day was 03/12/26. He stated he knew his apartment was supposed to be ready on 03/12/26. He stated the facility told him if he wanted to go back (to the facility), he would have to sign his money over to the facility so they could get paid. He stated it was 2 months, then said no, it was 1 1/2 months that he did not pay the facility. Resident #1 stated the hospital case worker said he was accepted in [current city] (where the hospital is), but he did not want to go there because he wanted to be in [original city (original facility)] to get the apartment, but the apartment was going to take a few weeks. He stated he appealed the discharge, and the Ombudsman took the paperwork to the facility. He said he just wanted to be able to move out and do the right thing, but the facility was making it hard on him. In a telephone interview on 3/17/26 at 4:20 pm, the Ombudsman stated she just got off the phone with the administrator at the facility and the state Ombudsman. The Ombudsman stated the facility gave him a 30-day discharge notice, but it was dated 03/06/26 and the discharge date was 03/12/26. She stated the facility documented he was supposed to be discharged to the apartment. The Ombudsman stated the administrator told her the owner of the nursing facility did not want to take Resident #1 back and did not want to honor the 30-day notice. The Ombudsman stated Resident #1 did not want to pay the facility because he wanted to go into the community. The Ombudsman stated she was not concerned about an unsafe discharge but only that the facility did not want to honor the 30-day discharge notice. The Ombudsman stated the ADON was on the phone call also and asked what were they (the facility) going to do when 04/06/26 came around? She stated she told the facility to push the apartments to get him an apartment. The Ombudsman stated she told Resident #1 she could only represent him for the 30-day discharge notice, but not anything else or anything after the 30 days because he would not pay the facility the money he owed them. In an interview with the facility owners on 03/17/26 at 5:40pm, the CO stated she felt threatened by Resident #1 and was a little afraid of him but did not let him know that. She stated she came up to the facility frequently during the evenings to sit at the nurse's station so there was someone to keep an eye on things while the nurses assessed and medicated residents and the CNAs helped with ADLs and such. She stated Resident #1 had been in the facility long enough to learn their routines and knew when no one was out in the halls. She stated he used that time to go into the breakroom, the nurse's station, and the kitchen/dining area to steal food and drinks, so she started sitting at the nurse's station to help prevent that behavior. She stated one evening the nurses were trying to get medications and he kept zooming around the nurse's station and through it in front of the medication room in his motorized wheelchair. The CO stated she told Resident #1 he could not cut through the nurse's station due to his previous attempts to get into the medication room. She stated Resident #1 started yelling at her and making threats toward her, but stopped yelling once the admin came and talked to him. The CO stated though Resident #1 had stopped yelling, he was still making comments toward her that made her feel unsafe, so she called the CEO to come in. The CEO stated he felt unsafe due to Resident #1's threats against the facility and staff and because he signed himself out to go across the street to the park to smoke several times a day. He stated this was a small town and he was aware of Resident #1's previous drug use and criminal history as well as his ability to get a gun or a knife from a friend. The CEO stated he was concerned Resident #1 would act on his threats one day and the staff had no way to know if he managed to acquire a gun or knife and no way to protect themselves if he did. In an interview on 03/17/26 at 6:41 pm, CNA A stated she had been a CNA since 09/2025. She stated she worked night shift and around September or October 2025 at about 12:00 am or 12:30 am, she asked Resident #1 to please turn his music down because he was disturbing other residents and he got mad and refused to turn his music down. She stated once the nurse talked to him, he finally turned it down. She stated around January or February 2026, he was upset because he got moved to another hall and he started recording staff members with other residents and making comments such as, Make sure you do it right or it is going to go bad (but in Spanish). She stated he used a motorized wheelchair to get around and had a phone holder attached to the arm of the wheelchair where he put his cell phone and record as he drove the wheelchair around the facility. CNA A stated Resident #1 followed her around in early February 2026 on several occasions and made sexual comments about her body parts (in spanish) to other staff members. She stated one day she was feeding another resident in the dining room, and he stated (in Spanish) he, wanted to get fed (from her breasts) so he could continue growing from that (referring to her breasts). She stated she reported it to the nurse, and the nurse told him he made her feel uncomfortable. She stated he had not said anything like that to her again. She stated Resident #1 was also disrespectful to other co-workers, but she did not have any details.In an interview on 03/17/26 at 7:05 pm, LVN B stated she worked 2-3 days a week and Resident #1 sometimes refused wound care, refused insulin and medications frequently and it was rare for him to take his medications as scheduled. LVN B stated she had witnessed Resident #1 videoing another resident who was yelling about being in the wheelchair. She stated he was recording the resident and her and said , it was for his safety because he was calling state. LVN B stated another morning he was recording the kitchen staff and residents that were in the dining room because breakfast was 15 minutes late. She stated before he started recording the kitchen/dining room area, he had been offered a snack because he was already complaining that breakfast was late, but he stated he would wait for breakfast then started recording on his phone. LVN B stated she could not recall any other incidents of him recording.In an interview on 03/17/26 at 7:20 pm, CNA C stated Resident #1 always made sexual comments such as, don't wear that because it makes me want you. She stated he would wheel up to her from behind in his motorized wheelchair and try to put his legs up around her so that it would trap her between his feet and the wheelchair. She stated he did not touch her but made her feel uncomfortable. CNA C stated she never heard him say anything to or about other residents, but he often made comments toward (female) staff about their clothing or their body and how it turned him on. She stated Resident #1 told her that he was going to record her, to show it to state and always said he was going to report them to state. She stated approximately a month ago another CNA was showering a female resident who frequently yelled when she was showered and Resident #1 was sitting in his wheelchair right outside the closed shower room door recording. CNA C stated when she asked him what he was doing, he stated, If I go down, everybody goes down. She stated she asked him what he was talking about, but he did not give her an answer. She stated he followed staff around all the time when they tried to work and disrupted them or got in the way. CNA C stated Resident #1 followed them to resident's rooms and would offer to help even though he had been told numerous times that it was a HIPAA violation and a violation of other resident's privacy for him to keep trying to help. CNA C stated even when he offered to help, he was really recording staff and trying to, catch them doing something wrong, so he would have something to show to state. She stated the last time state was in the building, Resident #1 would taunt staff by trying to record them and saying things like, What are you scared of? and you better be doing it right. In an interview on 03/17/26 at 7:44 pm, the ADON stated a lot of Resident #1's behaviors were at night when administration and office staff were not at the facility to monitor his behavior. She stated he tried to make it seem like he was helping someone, but he told the staff things like, You are not giving me my medicine, and you are not treating me right, when he is last to be medicated in the morning, even though he wanted to get his medication after everyone else. The ADON stated Resident #1 would go to the medication room and try to open the door or a medication cart and try to open it. She stated if staff had non-opened food/drinks at the nurse's station, he would take it because, he was paying here so he was entitled to it. The ADON stated Resident #1 would go into the kitchen and take snacks and drinks that were for all residents, he would say that he was entitled to it. She stated he took a rolling chair out of the nurse's station and put it in his room and told staff that he was entitled to it. He told the CNAs they had to do what he wanted or said because, he was paying them. The ADON stated Resident #1 would go ask a nurse about another resident's medical care and would get mad when he was told he was not allowed to have that information. The ADON stated he refused dialysis often and was non-compliant with insulin, medications, and fluid restrictions. She stated he was able to sign himself out and went to the store and brought back sodas, energy drinks, etc. She stated they had to put coded door locks on staff doors (breakroom, nutrition room, kitchen) because he would go in and take stuff especially from the lounge/ break room; he would take staff's food that was brought in for meal breaks. The ADON stated Resident #1 frequently told staff that he was recording them for his safety while they did their daily tasks. She stated there was an instance when he video recorded a resident who was yelling about being in her wheelchair. The ADON stated it was unknown if he purposely or inadvertently video or voice recorded other residents, but he often sat in the recliner in the corner near the nurse's station and just had his phone up and appeared to be recording, however he refused to show staff what he was doing. The ADON stated several staff have told her they felt uncomfortable and threatened by Resident #1 due to his sexual comments and aggressive behavior. In an interview on 03/17/26 at 8:10 pm, the DON stated Resident #1 had been at the facility for almost a year and since the beginning he was non-compliant with his insulin, medications, dialysis, fluid restrictions, diet recommendations, and wound care. The DON stated he had a roommate when he arrived and requested a room by himself, and the admin was able to grant that request at the time. She stated Resident #1 bought a lot of things and put them in the room. She stated when the census began to grow in the last couple of months, the admin told him that he had to move to another room because they needed to make that hall a skilled hall She said Resident #1 agreed to the move, but that night he played his music very loudly disrupting other residents sleep. She stated the resident had headphones but did not want to use them when asked to turn his music down so other residents could sleep. The DON stated the morning after he was moved was when he started recording staff and threatening to call state on them. She stated most of the female staff had come to her and reported he was making sexual comments and gestures toward them and making them uncomfortable. She stated he had a phone holder on his wheelchair and would go around and record staff and say he was, recording for his safety. The DON stated Resident #1 was issued a 30-day notice on 01/28/26 because he was already behind on his room and board payments to the facility, but he appealed and won, due to a technicality, however he did not pay the facility the money he owed. She stated he was issued another 30-day notice on 03/06/26 effective 03/12/26 because he was still behind on his payments. The DON stated the SW explained to Resident #1 his apartment would be ready on 03/12/26 but he was still obligated to pay the facility. The DON stated she and the ADON spoke to Resident #1 about refusing his wound care, smoking, and being non-compliant with his medications, insulin, and diet recommendations and gave him in depth information/education about what could happen. She stated Resident #1 started getting worried and told them he did not want to have any amputations. On Saturday, 03/07/26, Resident #1 agreed to go to the hospital per the physician's recommendation. The DON stated the administrator was very transparent about Resident #1's behaviors to the facility that accepted him when he got discharged from the hospital. The DON stated she was very involved with the discharge process because the SW came to the facility once a month. She stated the facility owners were concerned about staff wanting to quit due to Resident #1's behavior. In an interview on 03/17/26 at 8:40 pm, the Admin stated the facility originally issued Resident #1 a 30-day discharge notice on 01/28/26. He stated Resident #1 refused a copy of the notice, then appealed it and won. The Admin stated he was not aware until 03/03/26 Resident #1 had not paid the facility for February and March 2026. The Admin stated the DON was with him when he gave Resident #1 both of the 30-day notices. The Admin stated on 03/06/26 he asked Resident #1 why he had not paid and Resident #1 told him he wanted to move to an apartment. The Admin stated he told Resident #1 that he had to pay what he owed the facility by 03/06/26 and if he did not pay the money owed, he had to issue a discharge notice. The Admin stated the SW was at the facility that day and made Resident #1's Medicaid appointment for him. The Admin stated when the discharg

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 needs, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 (Resident #1) of 3 residents reviewed for care plans. The facility failed to ensure Resident #1's care plan reflected inappropriate behaviors such as inappropriate comments, taking facility/staff items, playing music loudly, and recording with his phone. This failure could place residents at risk of not receiving appropriate interventions and care to meet their needs.Findings included:Record review of Resident #1's face sheet, dated 01/30/26, reflected the resident was a [AGE] year-old male, admitted [DATE], with diagnoses that included type 2 diabetes (high levels of sugar in blood), major depressive disorder, heart disease, end stage renal disease (kidney failure), and dependence on renal dialysis (treatment to manage kidney function). Record review of Resident #1's MDS assessment, dated 01/01/26, reflected Resident #1 had a BIMS score of 13, indicating intact cognition. Record review of Resident #1's care plan, dated 01/30/26, reflected Resident #1 had no inappropriate behaviors such as making rude/inappropriate comments, taking facility/staff items, playing music loudly, and recording with his phone. Record review of Resident #1's progress notes dated 08/29/25-01/30/26 revealed progress notes related to Resident #1's behaviors:On 10/16/25 at 11:24 AM - Resident was being inappropriate and using vulgar language with staff. Resident stated that he could see the staff's private area through her pants. Staff expressed that they felt very uncomfortable with the resident and language being used.On 12/20/25 at 2:18 PM - Staff reported that resident was seen taking furniture out of other rooms and placing them in his room. Staff educated resident on the dangers of moving furniture that could cause potential injuries.Resident #1's progress notes did not reflect other progress notes related to Resident #1's behaviors or interventions implemented to address behaviors. In an interview on 01/30/26 at 11:15 AM, with the ADON, she said Resident #1 made inappropriate comments to the staff such as talking about their bodies. The ADON said Resident #1 took belongings from the staff's lounge such as the staff's meals and took facility belongings to his room like the nurse station's chair. The ADON said they redirected Resident #1 to stop these behaviors. The ADON said Resident #1 started recording staff with his phone which she was not sure if he was allowed to do. The ADON said Resident #1 played his music loudly which did not allow others to sleep. The ADON said they verbally redirected Resident #1 to stop recording and to use his headphones when listening to music at night so residents could sleep. The ADON said she was not sure if these behaviors were care planned. The ADON said the DON updated care plans. In an interview and observation on 01/30/26 at 12:25 PM, with Resident #1, he said he was given a 30-day discharge notice by the ADM because of his behaviors. Resident #1 said he did not agree with the notice as he did not behave or do the things the facility said he was doing. Resident was not injured or in distress. In an interview with on 01/30/26 at 3:15 PM, with the DON, she said Resident #1 had inappropriate behaviors such as making rude/sarcastic comments towards the staff. The DON said other residents complained that they could not sleep because of Resident #1 playing his music loudly. The DON said most recently, Resident #1 started recording the staff and tried to catch them doing something wrong. The DON said she reviewed the residents' chart and updated the care plans as needed. The DON said Resident #1's behaviors were not care planned but should have been. The DON said the staff verbally redirected Resident #1 to stop the behaviors, but there were no other interventions implemented for the behaviors. The DON said there was no negative outcome for Resident #1. The DON said it was important for the care plan to be individualized and developed accurately so staff knew how to care for the residents. Record review of the facility's Care Plans, Comprehensive Person-Centered policy dated December 2016 reflected - Policy: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition changes.

Based on interview and record review, the facility failed to ensure the contents of the discharge notice included the reason for transfer or discharge, the effective date of transfer or discharge, the location to which the resident was transferred or discharged , a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman for 1 (Resident #1) of 3 residents reviewed for discharge notices. The facility failed to include the location to which the resident was to be discharged and the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. This failure could place residents at risk of not receiving appropriate information regarding their discharge and violating their right to appeal. Findings included: Record review of Resident #1's face sheet, dated 01/30/26, reflected the resident was a [AGE] year-old male, admitted [DATE], with diagnoses that included type 2 diabetes (high levels of sugar in blood), major depressive disorder, heart disease, end stage renal disease (kidney failure), and dependence on renal dialysis (treatment to manage kidney function). Record review of Resident #1's MDS assessment, dated 01/01/26, reflected Resident #1 had a BIMS score of 13, indicating intact cognition. Record review of Resident #1's 30-day discharge notice, undated, reflected the reason for discharge was, Cannot provide the appropriate care for your specific needs, effective date of discharge: [DATE], a statement of the resident's appeal rights, Should you wish to appeal this decision, you have the right to do so. Please contact the ADM at (phone) or (email) to initiate the appeal process. We will provide you with the necessary information and support throughout the appeals procedure. The notice had no specific location to which the resident was to be discharged and no information regarding the Ombudsman. In an interview on 01/30/26 at 12:00 PM, with the OMB, she said the facility emailed her the 30-day discharge notice for Resident #1 on 01/28/26. The OMB said she was scheduled to visit Resident #1 today (01/30/26) to explain the appeals process because Resident #1 wanted to appeal. The OMB said part of the rule for the notice was for the OMB's information to be on the 30-day notice, in case the resident wanted to appeal. The OMB said the notice that was given to Resident #1 did not have the OMB's information. In an interview and observation on 01/30/26 at 12:25 PM, with Resident #1, he said he was given a 30-day discharge notice by the ADM and the DON. Resident #1 said the staff explained why he was given the notice, but he did not agree. Resident #1 said he had spoken to the OMB and was going to appeal. Resident was not injured or in distress. In an interview on 01/30/26 at 3:55 PM, with the ADM, he said the 30-day discharge notice was given to Resident #1 on 01/28/26. The ADM said he did not know if the discharge notice should have indicated where the resident would be discharged . The ADM said the facility would have planned the discharge within the 30 days. The ADM said the notice should have had the OMB's information. The ADM said he was not sure if the notice provided to Resident #1 had the OMB's information. The ADM said he just followed the notice letter template. The ADM said he was not sure where the template was from, but the DON provided the template to him. In an interview on 01/30/26 at 5:25 PM, with the DON, she said the ADM asked her for the 30-day discharge notice template. The DON said she was not sure what the notice information was supposed to consist of. The DON said she did a web search for examples, obtained a template, and provided the template to the ADM. Record review of the facility's Transfer and Discharge Notice policy dated December 2016 reflected - Policy: Our facility shall provide a resident and/or the resident's representative with a 30-day written notice of an impending transfer or discharge.3. The resident and/or representative will be notified in writing of the following information: c. The location to which the resident is being transferred or discharged ;f. The name, address, and telephone number of the Office of the State Long-term Care Ombudsman.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments for 1 of 1 wound care cart and 1 of 2 (400 hall) medication carts reviewed for storage of drugs. The facility failed to ensure LVN A's 400 hall medication cart and the wound care cart located by the nurse station were locked when not in use. This deficient practice could affect residents who have medications on the nurse's medication cart and could result in lost medications, drug diversion, or harm due to accidental ingestion of unprescribed medications. Findings include: During an observation on 01/07/26 at 10:11 AM, revealed a medication cart and the wound care cart by the nurse station was unlocked and unattended. This surveyor was able to open the top drawers, recognizing the medication cart and the wound care cart were unlocked while not in use. Multiple medications in bulk bottles, supplies, and blister packs were easily assessable for removal. One resident was observed sitting in front of the medication cart in a wheelchair approximately one foot away. LVN A came from behind the nurse's station and identified himself as being responsible for the unlocked 400 hall medication cart and the wound care cart.In an interview on 01/07/26 at 10:12 AM, LVN A stated he forgot to the lock the medication and wound care cart when he stepped away for just a moment to get something. LVN A stated it was important to lock the carts to prevent any residents from having access to the medications inside as well as wound care supplies. LVN A stated if a resident were to get into the medications, they could take something they are not supposed to and could get sick. LVN A stated he was a new nurse, but administration was constantly reminding staff to always lock the carts when not in use or when you walk away. In an interview on 01/07/26 at 10:38 AM, the ADON stated all medication and wound care carts should be locked when not in use. The ADON stated if a medication or wound care cart was left unlocked and unattended, anyone who was not authorized to have access to the contents inside, could cause a drug diversion or possible accidental ingestion. The ADON stated staff were constantly reminded to always lock the carts when not in use. In an interview on 01/07/26 at 10:48 AM, the DON stated staff were aware all carts should be locked even when they need to walk away for a moment. The DON stated if the carts were unlocked, residents and anyone who walked by could possibly take medications they should not be taking. Record review of the facility's Storage of Medications policy dated April 2007 reflected: Policy StatementThe facility shall store all drugs and biologicals in a safe, secure, and orderly manner.Policy Interpretation and Implementation7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerator, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on observation, interview, and record review, the facility failed to ensure the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 2 of 5 residents (Resident #2 and Resident #3) reviewed for resident rights. 1. The facility failed to place a privacy cover over Resident #2's catheter bag while she was in bed at 10:30 AM on 08/26/25. 2. The facility failed to place a privacy cover over Resident #3's catheter bag while she was in bed at 11:20 AM on 08/26/25. These failures could result in psychosocial harm to the residents, including feelings of shame and embarrassment and a loss of dignity. Findings included: 1. Record review of Resident #2's admission record reflected a [AGE] year-old female resident initially admitted to the facility on [DATE] with most recent admission on [DATE]. Her diagnoses included unspecified protein calorie malnutrition (a state of inadequate nutrient intake), osteomyelitis (infection of the bone) of vertebra (spinal column), sacral (the triangular bone at the base of the spine), and sacrococcygeal region (the junction between the sacrum and the coccyx, or tailbone), local infection of the skin and subcutaneous tissue (tissue under the skin), dehydration, urinary tract infection, sepsis (damage to vital organs caused by an infection), pressure ulcer of sacral region, dementia (loss of memory, language, problem solving and other thinking abilities which significantly impairs a person's ability to perform daily activities), and metabolic encephalopathy (when the brain has trouble working because of a chemical, or metabolic, problem in the body). Record review of Resident #2's quarterly MDS assessment dated [DATE] and significant change MDS assessment dated [DATE] reflected BIMS scores of 0 and 1 respectively, which indicated Resident #2 had severe cognitive impairment.Record review of Resident #2's order summary report on 08/26/25 reflected an active order for Resident #2 to have a foley catheter (urinary catheter) for urinary retention (inability to empty the bladder) and for foley catheter care every shift initiated on 06/25/25.Record review of Resident #2's comprehensive care plan dated 06/25/24 reflected the focus I have a foley for urinary retention initiated on 06/25/24. Interventions listed for the focus included:- My nurse changes my catheter sterile method as ordered by my MD and as needed for infection/ occlusion initiated 06/25/25.- My nurse irrigates my foley catheter with 30ml of NS sterile method as needed for patency initiated 06/25/25.- My nurse monitors me for s/s of UTI including cloudy urine, sediment, odor to urine, dysuria, abdominal distention, pain, fever, chills, change in LOC initiated on 06/25/25.- my staff perform foley catheter care Qshift initiated 06/25/25.During an observation of Resident #2 in her room in bed at 10:30 AM on 08/26/25, Resident #2's catheter bag did not have a privacy cover over it. The privacy cover was located on the opposite side of the bed attached to the lower bed rail. An interview was attempted with Resident #2, but she was not interviewable.In an interview on 08/26/25 at 10:35 AM, Resident #2's FM stated Resident #2 had a bag that the staff put the foley drainage bag into sometimes but not all the time. 2. Record review of Resident #3's face sheet dated 08/26/25 revealed an [AGE] year-old female with an initial admission date of 04/30/24 and a current admission date of 06/29/24. Pertinent diagnoses included depression (mood disorder, characterized by persistent low mood, loss of interest, and difficulty with daily activities for at least two weeks) and retention of urine (inability to empty the bladder completely). Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 2 (severe impairment). Record review of Resident #3's comprehensive care plan dated 08/26/25 revealed the focus 6/20/25 I was noted with severe excoriation and irritation to perineal area. My [doctor] ordered to place foley catheter initiated on 06/20/25. Interventions listed for the focus included:- My nurse inserts foley catheter using sterile technique as ordered by my doctor initiated 06/23/25- My nurse monitors my urine output every shift as ordered by my doctor initiated 06/23/25.- My nurse provides foley catheter care every shift as ordered by my doctor initiated 06/23/25.- My nurses remind me on the importance of drinking water initiated 07/18/25. Record review of Resident #3's order summary revealed an active order for Foley Catheter Care every shift initiated on 06/20/25. During an observation of Resident #3 in her room in bed at 11:20 AM on 08/26/25, Resident #3's catheter bag did not have a privacy cover over it. An interview was attempted with Resident #3, but she was not interviewable. In an interview with CNA B at 9:43 AM on 08/28/25, CNA B stated residents were supposed to have privacy covers over their catheter bags. CNA B stated if she saw a catheter bag without a privacy cover, she would immediately grab a privacy cover and place it over the catheter bag. CNA B stated she did that to protect the privacy and dignity of the residents because they may otherwise feel embarrassed. In an interview with RN A at 9:51 AM on 08/28/25, RN A stated if she saw a resident with a catheter bag without the privacy cover, she would locate a privacy cover and place it over the catheter bag. RN A stated she did that to protect the privacy and dignity of the resident. RN A stated the privacy covers helped residents feel less embarrassed and ashamed of the medical care they received. In an interview with the DON at 10:08 AM on 08/28/25, the DON stated catheter bags should have privacy covers on them at all times except when a nurse was actively adjusting something with the catheter bag. The DON stated privacy covers were important to protect the resident's privacy and dignity. Record review of the undated facility policy titled Resident Rights revealed the following: Employees shall treat all residents with kindness, respect, and dignity.These rights include a resident's right to a dignified existence.

Based on observation, interviews and record reviews the facility failed to ensure each resident received an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and were knowledgeable about the resident's status, needs, strengths, and areas of decline for 1 (Resident #2) of 6 residents reviewed for assessments.The facility failed to include Resident #2's use of bed rails in both her quarterly MDS dated [DATE] and her significant change MDS assessment dated [DATE].These failures could result in residents in the facility not being provided with the necessary care or services or implementation of personalized care plans developed to address their specific needs. Findings included:Record review of Resident #2's admission record reflected a [AGE] year-old female resident initially admitted to the facility on [DATE] with most recent admission on [DATE]. Her diagnoses included unspecified protein calorie malnutrition (a state of inadequate nutrient intake), osteomyelitis (infection of the bone) of vertebra (spinal column), sacral (the triangular bone at the base of the spine), and sacrococcygeal region (the junction between the sacrum and the coccyx, or tailbone), local infection of the skin and subcutaneous tissue (tissue under the skin), dehydration, urinary tract infection, sepsis (damage to vital organs caused by an infection), pressure ulcer of sacral region, dementia (loss of memory, language, problem solving and other thinking abilities which significantly impairs a person's ability to perform daily activities), and metabolic encephalopathy (when the brain has trouble working because of a chemical, or metabolic, problem in the body). Record review of Resident #2's quarterly MDS assessment dated [DATE] and significant change MDS assessment dated [DATE] reflected BIMS scores of 0 and 1 respectively, which indicated Resident #2 had severe cognitive impairment. Record review of section P of the same MDS assessments reflected, Physical restraints are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. The code entered for both assessments was 0- Bed rails not used. Record review of Resident #2's order summary report reflected an active order for Resident #2 to have bilateral full side rails in place every shift dated 07/24/25.Record review of Resident #2's Side Rail Use Assessment Form signed by the DON and Resident #2's FM on 07/24/25 reflected in part: 10. Has the RP expressed a desire to have side rails raised while in bed for safety and/or comfort? Yes11. Has the RP requested that the side rails not be released while sleeping? Yes Recommendations: Bilateral (both sides)Observation on 08/26/25 at 9:30 AM reflected Resident #2 had full side rails in the up position on both sides of her bed while she was in bed.In an interview on 08/28/25 at 9:30 AM, Resident #2's three FMs stated they were all aware of the risks associated with bed rails, however they felt better with her having side rails because they were concerned that she would try to get out of bed and fall if no one was there to stop her. Resident #2's FMs stated she was frequently confused and forgot that she did not have the strength to get out of bed. In an interview on 08/28/25 at 12:18 PM, the ADON stated she had been doing the MDS job for about seven or eight months after the previous MDS nurse left. The ADON stated on Resident #2's quarterly MDS assessment dated [DATE] and significant change MDS assessment dated [DATE], the bed rails were not being used as a restraint, so she answered the question as no. She stated she did not code it as a physical restraint because it was for family's peace of mind. She stated the family stated they knew she was bed bound and that she did not really move, but they still wanted the rails. The ADON stated, If it was a patient that we had put rails on because they were trying to get out of bed or something, then it would be coded as a physical restraint. The ADON stated it was important to code things correctly because it was submitted to CMS and that was how they figured reimbursement and quality measures. The ADON stated if the MDS was not accurate, the facility could get cited or have to repay money paid to the facility based on resident assessments. In an interview on 08/28/25 at 12:30 pm, the DON stated the newer beds the facility received, which Resident #2 was using, came with side rails on them. The side rails were not initially up on the bed, however Resident #2's family requested the side rails up all the time because they were concerned that she would try to get out of bed. The DON stated Resident #2 had minimal movement on her own and she required complete assistance for turning, repositioning, and all other things. The DON stated the family was educated about the risks of side rails and decided they wanted them anyway. The Side Rail assessment form was signed by one of the family members and the DON on 07/24/25. The DON stated side rail assessments were done quarterly. The risks of side rails included broken bones, strangulation, bruises/skin tears, falls, and even death. She stated there was not a medical rationale for the bed rails, but the family requested the bed rails for their peace of mind. The DON stated the MDS assessments were being done by the ADON, and it was important for the MDS to be coded correctly so the facility was paid correctly by CMS. Record review of the facility's Proper Use of Side Rails policy dated 2001 and revised 12/2016 reflected in part: Purpose The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms.Definition Physical restraints are defined by the Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. (Note: The definition of restraints is based on the functional status of the resident and not on the device, therefore any device that has the effect on the resident of restricting freedom of movement or normal access to one's body could be considered a restraint.)General GuidelinesI. Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). (Note: The side rails may have the effect of restraining one individual but not another, depending on the individual resident's condition and circumstances.)

Based on observation, interviews and record reviews, the facility failed to ensure residents comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including the comprehensive, quarterly, and significant change assessments.The facility failed to update Resident #2's care plan to include the use of full bed rails on 07/30/25 when her quarterly MDS assessment was completed and on 08/20/25 when a significant change MDS assessment was completed.These failures could place residents in the facility at risk of not being provided with the necessary care or services or implementation of personalized care plans developed to address their specific needs. Record review of Resident #2's admission record reflected a [AGE] year-old female resident initially admitted to the facility on [DATE] with most recent admission on [DATE]. Her diagnoses included unspecified protein calorie malnutrition (a state of inadequate nutrient intake), osteomyelitis (infection of the bone) of vertebra (spinal column), sacral (the triangular bone at the base of the spine), and sacrococcygeal region (the junction between the sacrum and the coccyx, or tailbone), local infection of the skin and subcutaneous tissue (tissue under the skin), dehydration, urinary tract infection, sepsis (damage to vital organs caused by an infection), pressure ulcer of sacral region, dementia (loss of memory, language, problem solving and other thinking abilities which significantly impairs a person's ability to perform daily activities), and metabolic encephalopathy (when the brain has trouble working because of a chemical, or metabolic, problem in the body). Record review of Resident #2's quarterly MDS assessment dated [DATE] and significant change MDS assessment dated [DATE] reflected BIMS scores of 0 and 1 respectively, which indicated Resident #2 had severe cognitive impairment. Record review of Resident #2's order summary report reflected an active order for Resident #2 to have bilateral full side rails in place every shift dated 07/24/25.Record review of Resident #2's care plan did not reflect the use of side rails.Record review of Resident #2's Side Rail Use Assessment Form signed by the DON and Resident #2's FM on 07/24/25 reflected in part: 10. Has the RP expressed a desire to have side rails raised while in bed for safety and/or comfort? Yes11. Has the RP requested that the side rails not be released while sleeping? Yes Recommendations: Bilateral (both sides)Observation on 08/26/25 at 9:30 AM reflected Resident #2 had full side rails in the up position on both sides of her bed while she was in bed. In an interview on 08/28/25 at 9:30 AM, Resident #2's three FMs stated they were all aware of the risks associated with bed rails, however they felt better with her having side rails because they were concerned that she would try to get out of bed and fall if no one was there to stop her. Resident #2's FMs stated she was frequently confused and forgot that she did not have the strength to get out of bed.In an interview on 08/28/25 at 12:42 PM, the DON stated care plans were completed by the DON, the ADON, and RN A. She stated Resident #2's care plan review was started on 07/09/25 so it would have been added by the end of the review period, which was 10/09/25. The DON stated it was important for the care plan to be accurate because it was her plan of care, an overall view of what was going on with the resident and if the care plan was not accurate it would not show accurate information. The DON stated the care plan was updated every three months, but if there were any new orders or issues, they were put into the care plan right away. The DON stated Resident #2's side rails were not care planned because it was overlooked. Record review of the facility's Care Plans, Comprehensive Person-Centered policy dated 2001 and revised 12/2016 reflected in part: Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Policy Interpretation and Implementationl. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.7. The care planning process will:b. Include an assessment of the resident's strengths and needs.8. The comprehensive, person-centered care plan will:g. Incorporate identified problem areas.h. Incorporate risk factors associated with identified problems.j. Reflect the resident's expressed wishes regarding care and treatment goals.k. Reflect treatment goals, timetables and objectives in measurable outcomes.12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS).13. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.14. The Interdisciplinary Team must review and update the care plan:a. When there has been a significant change in the resident's condition;b. When the desired outcome is not met;c. When the resident has been readmitted to the facility from a hospital stay; andd. At least quarterly, in conjunction with the required quarterly MDS assessment. Record review of the facility's Proper Use of Side Rails policy dated 2001 and revised 12/2016 reflected in part: 4. The use of side rails as an assistive device will be addressed in the resident care plan.

Based on observations, interviews, and record reviews the facility failed to ensure residents received appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #2) of three residents reviewed for urinary catheters. Resident #2's urinary catheter tubing did not have an unobstructed urine flow, and the collection bag was not below Resident #2's bladder at all times.This failure places residents with urinary catheters at risk for urinary tract infections. Record review of Resident #2's admission record reflected a [AGE] year-old female resident initially admitted to the facility on [DATE] with most recent admission on [DATE]. Pertinent diagnoses included unspecified protein calorie malnutrition (a state of inadequate nutrient intake), urinary tract infection, osteomyelitis (infection of the bone) of vertebra (spinal column), sacral (the triangular bone at the base of the spine), and sacrococcygeal region (the junction between the sacrum and the coccyx, or tailbone), local infection of the skin and subcutaneous tissue (tissue under the skin), dehydration, sepsis (damage to vital organs caused by an infection), pressure ulcer of sacral region, dementia (loss of memory, language, problem solving and other thinking abilities which significantly impairs a person's ability to perform daily activities), and metabolic encephalopathy (when the brain has trouble working because of a chemical, or metabolic, problem in the body).Record review of Resident #2's quarterly MDS assessment dated [DATE] and significant change MDS assessment dated [DATE] reflected BIMS scores of 0 and 1 respectively, which indicated Resident #2 had severe cognitive impairment.Record review of Resident #2's order summary report on 08/26/25 reflected an active order for Resident #2 to have a foley catheter (urinary catheter) for urinary retention (inability to empty the bladder) and for foley catheter care every shift initiated on 06/25/25.Record review of Resident #2's comprehensive care plan dated 06/25/24 reflected the focus I have a foley for urinary retention initiated on 06/25/24. Interventions listed for the focus included:- My nurse changes my catheter sterile method as ordered by my MD and as needed for infection/ occlusion initiated 06/25/25.- My nurse irrigates my foley catheter with 30ml of NS sterile method as needed for patency initiated 06/25/25.- My nurse monitors me for s/s of UTI including cloudy urine, sediment, odor to urine, dysuria, abdominal distention, pain, fever, chills, change in LOC initiated on 06/25/25.- my staff perform foley catheter care Qshift initiated 06/25/25.During an observation of Resident #2 in her room in bed at 10:30 AM on 08/26/25, Resident #2's urinary catheter drainage bag was attached to the right side of her bed on the rail just below the mattress. The catheter drainage bag was not below Resident #2's bladder.During an observation of Resident #2 in her room in bed at 9:23 AM on 08/28/25, Resident #2's urinary catheter drainage bag was attached to the right side of her bed on the rail just below the mattress. The urinary catheter tubing was routed up over the top of the side rail and the drainage bag was not below the level of her bladder. There was urine backed up in the tubing that was unable to drain into the bag, as it was not able to travel against gravity to drain.An interview was attempted with Resident #2, but she was not interviewable.In an interview on 08/28/25 at 9:43 AM, CNA B stated the catheter tubing and drainage bag were supposed to be below the bladder and off the floor. CNA B stated if she saw urinary catheter tubing that was not able to flow freely she would immediately wash her hands, put her gloves on, then fix the tubing so it was below the bladder.In an interview on 08/28/25 at 9:51 AM, RN A stated the catheter tubing an drainage bag were supposed to be below the bladder and on the opposite side of the bed from the door and off the floor. RN A stated if she saw the tubing was above the bladder, she would reposition it so it was below the bladder but still not touching the floor. RN A stated she would reposition it because it caused the urine to be retained in the bladder, and it needed to flow to minimize the risk of infection, pain, and bladder spasms. Record review of the facility's undated Foley Catheter Care Policy reflected in part: PurposeTo ensure safe and effective management of indwelling urinary catheters and to reduce the risk of catheter-associated urinary tract infections (CAUTIs).Policy StatementAll staff involved in catheter care must follow aseptic technique, adhere to infection control standards, and provide routine assessment and hygiene to minimize complications.2. MaintenanceKeep catheter tubing free from kinks and secured to patient's thigh.Position drainage bag below bladder level, off the floor.

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, physicians orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 residents (Resident #14) reviewed for respiratory care. The facility failed to ensure Resident #14's oxygen tubing was stored off the floor and in a bag when not in use at 11:09 AM on 08/26/25. This failure placed residents at an increased risk of infection leading to a decline in health.The findings included:Record review of Resident #14's face sheet dated 08/26/25 revealed an [AGE] year-old female with an initial admission date of 03/26/02 and a current admission date of 07/29/13. Pertinent diagnoses included vascular dementia (cognitive decline caused by damage to the blood vessels in the brain) and chronic obstructive pulmonary disease (chronic lung disease that causes inflammation and narrowing of the airways, leading to airflow obstruction). Record review of Resident #14's Quarterly MDS assessment dated [DATE] revealed a BIMS of 5 (severe impairment). Further review revealed Resident #14 received oxygen therapy in the last 14 days while a resident at the facility. Record review of Resident #14's comprehensive care plan dated 08/26/25 revealed the focus I have a diagnosis of COPD initiated on 05/01/24. Interventions listed for the focus included:- I have follow ups with my pulmonologist as appropriate initiated on 05/01/24.- I receive oxygen as ordered by my doctor initiated on 05/01/24 and revised on 05/01/25. Record review of Resident #14's order summary revealed an active order for 02 @ 3L NC every shift for SOB initiated on 05/06/25. During an observation of Resident #14's room at 11:09 AM on 08/26/25, Resident #14 was not in the room, oxygen tubing and nasal canula were on the floor beside the bed not in a bag. In an interview with CNA B at 9:43 AM on 08/28/25 CNA B stated if she saw a nasal canula with oxygen tubing on the floor she would inform the nurse and then discard of the tubing. CNA B stated she would discard the tubing because after it was on the floor it became contaminated. CNA B stated if a resident used a contaminated nasal canula for oxygen they would be exposed to more germs and bacteria. In an interview with RN A at 9:51 AM on 08/28/25, RN A stated if she saw oxygen tubing on the ground, she would put it in the trash and get new tubing for the resident. RN A stated she would discard of the tubing due to an increased risk of infection if the resident used dirty oxygen tubing. In an interview with the DON at 10:08 AM on 08/28/25, the DON stated oxygen tubing should not be left on the floor. The DON stated the tubing should have been in a bag because it was not in use at the time it was on the floor. The DON stated if a staff member came across oxygen tubing on the floor, they should discard it and get new tubing. The DON stated once the tubing was on the floor it became contaminated and increased the risk of infections for residents if they continued to use the same tubing. Record review of the facility policy titled Oxygen Administration dated 07/15 revealed the following policy: .Check the tubing connected to the oxygen cylinder to assure that it is free of kinks.a. Date and initial tubing.b. Change equipment every (7) seven days.c. Store equipment in a bag when not in use.d. Change or clean O2 filter weekly.

Based on observation, interviews and record review, the facility failed to store food in accordance with professional standards for food service safety for 1 of 1unit refrigerators reviewed for storage, preparation and sanitation. -The facility failed to ensure food items in the facility kitchen refrigerator were labeled and dated. -These failures could place residents at risk for complications from food contamination. Findings included: Observations during the initial tour of the kitchen on 08/26/25 at 8:00 AM, revealed one bag with four green peppers had black mold and did not have a use by date. In an interview with DA H on 08/26/25 at 9:32 AM, she said all kitchen staff was responsible for cleaning the refrigerator and made sure that all food was labeled, had not expired and had a use by date. DA H stated the fridge was cleaned and all expired food was thrown out daily. DA H could not explain why the green peppers did not have a date of when they were placed in refrigerator. In an interview with DA I on 08/26/25 at 9:46 AM, she stated she could not recall when the green peppers were placed in the refrigerator but knew that all items put in the refrigerator was to have a use by date. DA I stated the staff throws away all expired food daily and cleans refrigerator weekly. DA I stated last week she did not have a need for the green peppers for cooking, so she had not been in the refrigerator drawer where they were stored. In an interview with the DM on 08/26/25 at 9:43 AM, stated she and the staff clean out the refrigerator daily and the green peppers looked ok on the top but when you lifted the bag the bottom of the green peppers were rotten. The DM said they had not been used for cooking in a while and that could be why the green peppers were not noticed with no use by date and had spoiled. The DM stated she did not know why they did not have a date on them of when the green peppers were put in the refrigerator as all other items had a date. The DM stated she will do retraining on dating items and making sure they are all covered and throwing out expired foods for all forms of storage. Record review of the facility's policy dated 07/2014, titled, Food Receiving and Storing revealed Food Services, or other designated staff, will maintain clean food storage areas at all times. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) FDA Food Code 2022 Ch. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. to (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETYFOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

Based on observation and interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #3 and Resident #27) of 5 residents reviewed for infection control.1. The DON, LVN C, and CNA D did not wash their hands before and after performing wound care for Resident #3.2. The DON did not pat dry wound while performing wound care for Resident #3.3. LVN C and CNA D did not wash their hands after performing incontinent care for Resident #3.4. The facility failed to ensure CNA D did not grab Resident #27's cup and bowl by the rim with her bare hands, contaminating the tops of the rims, during the lunch meal serving process. These failures could place residents at risk for infection through cross contamination of pathogens and infectious diseases. 2. and 3. Record review of Resident #3's admission record reflected an [AGE] year-old female initially admitted to the facility on [DATE] with most recent admission on [DATE]. Pertinent diagnoses included infection of amputation stump, left lower extremity, pressure ulcer of unspecified part of back, pressure ulcer of sacral region- unstageable, pressure ulcer of right ankle- unstageable, open wound of right foot, depression (mood disorder, characterized by persistent low mood, loss of interest, and difficulty with daily activities for at least two weeks) and retention of urine (inability to empty the bladder completely). Record review of Resident #3's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 2 which indicated severe cognitive impairment. Record review of Resident #3's care plan dated 05/01/24 reflected the focus 06/17/25 I returned from hospital stay with a stage 3 sacral pressure wound. 08/04/25 My sacral wound is now unstageable, initiated on 06/17/25, revised on 08/26/25, 08/04/25 I returned back from the hospital with a dx of sepsis. My sacral ulcer is positive for MRSA and E. coli. 08/24/25 My MD ordered to begin Augmentin 500mg BID for 10 days for sacral wound infection, initiated on 08/05/25, revised on 08/26/25, and I have a stage 2 wound to my right middle back, initiated on 08/24/25. Interventions for these focuses included: - My nurse monitors my wound for s/s of infection such as fever, heat to site, swelling, redness, purulent drainage, chills, tachycardia (no initiated date). - My nurse performs wound care as ordered by my MD initiated 06/17/25. Record review of Resident #3's order summary report reflected an active order for Resident #3's wound care on her sacrum that read, Unstageable sacral ulcer: cleanse with wound cleanser or wound solution, pat dry with gauze, apply calcium alginate, pack with dry gauze, apply skin prep to peri wound, let dry, then cover with dry dressing daily and as needed for loose/soiled dressing one time a day, dated 08/28/25. Observation of wound care for Resident #3's sacral wound on 08/28/25 at 11:40 AM reflected the DON, LVN C, and CNA D used hand sanitizer then donned PPE before entering Resident #3's room. The DON, LVN C, and CNA D did not wash their hands prior to initiating wound care on Resident #3. The DON did not pat dry as stated in physician orders after cleansing Resident #3's unstageable pressure ulcer to her sacrum. The DON, LVN C and CNA D did not wash their hands after performing (or assisting with) wound care for Resident #3. LVN C and CNA D did not wash their hands after performing incontinent care for Resident #3. In an interview on 08/28/25 at 12:07 PM, the DON stated they had all sanitized before putting on PPE and she thought that was acceptable. She stated it was important to wash hands before doing wound care for infection control. The DON stated scrub time with hand washing was at least 20 second and it was important to wash hands before exiting the room after wound care or incontinent care to prevent the spread of infection. She stated it was important to follow the physician orders and pat the wound dry to decrease the chance if contamination of the wound after it was cleaned. The DON stated the last in-service on infection control and hand washing was on 08/15/25 and they were usually done every three months and as needed. In an interview on 08/28/25 at 12:10 PM, LVN C stated she did not wash her hands before assisting with wound care because she sanitized her hands before putting on her PPE. LVN C stated it was important to wash hands to prevent the spread of infection between residents. LVN C stated she did not wash her hands when she exited the room because she did not touch the resident's wound and her hands were not visibly soiled, so she used hand sanitizer. In an interview on 08/28/25 at 12:15 PM, CNA D stated handwashing was to be done if hands were visibly soiled, otherwise hand sanitizer was appropriate to use. CNA D stated it was important to cleanse hands between residents to ensure she did not spread infection to other residents. In an interview on 08/28/25 at 1:06 PM, the ADON stated hand washing was important to prevent the spread of germs. Hand washing was done anytime the hands were visibly soiled, before and after wound care was done, and when contact was made with indwelling devices. The ADON stated if hands were not washed it could cause cross contamination. Record review of the facility's Infection Control In-Service dated 08/15/25 reflected an Infection Control Quiz with the following: 1. The most important way to prevent infection is: [The correct answer was b) Hand hygiene] a) Wearing gloves b) Hand hygiene c) Wearing a mask 2. When must you wash your hands: [The correct answer was f) All of the above] a) Before/after resident contact b) After glove removal c) Before eating d) After using restroom e) After coughing/sneezing f) All of the above 4. Record review of Resident #27's face sheet revealed a [AGE] year-old female initially admitted on [DATE], and diagnosis of Paranoid Schizophrenia (Persistent delusions and hallucinations), Dementia (A group of thinking and social symptoms that interfere with daily functioning), Anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Record review of Resident #27's MDS Quarterly Assessment date 05/28/2025 revealed Resident #27 had a BIMS Score of 08 -moderate cognitive impairment. The assessment indicated Resident #27 needed some assistance with all ADLs. During a lunch dining observation on 05/28/25 at 12:30, PM CNA D was observed touching the rims of Resident # 27's cups and bowls with bare hands during the meal serving process. In an interview on 08/26/25 at 12:50 PM with Resident #27, she stated she had never felt ill after eating. Resident #27 also stated she had not experienced any gas, nausea, diarrhea from the food served at the facility. Resident #27 stated she had not noticed her bowl and cup were touched at the rim by CNA D. In an interview on 08/26/25 at 1:07 PM, CNA D stated training regarding how to serve the meal and how to properly handle the items while serving meals to residents approximately 3 months ago. CNA D stated she should have grabbed Resident's #27's bowls on the outside instead of grabbing the items from the rim. CNA D stated she knew how to properly serve drinks or bowls but was nervous and stated grabbing the rim of the resident's cups and bowls could lead to germs and cross contamination. In an interview on 08/26/25 at 1:14 PM, ADON stated she received training for infection control and how not to touch rims of the cups. The cups should be grabbed on the side and offered to the resident as the rim of the cups should not be touched by staff bare hands as it could lead to cross contamination when the resident goes to drink out of it. In an interview on 08/26/25 at 1:32 PM, the DM stated the ADON, and the DON were responsible for infection control and teaching the staff about proper hand sanitation and serving the resident's food correctly. Record review of the facility policy titled; Handwashing/Hand Hygiene revised August 2015 revealed in the Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Procedure Washing Hands 1. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds or longer under a moderate stream of running water at a comfortable temperature.

Based on interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 5 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded in the MDS for falls on 6/1/25 and 6/18/25.This failure could place residents at risk of receiving care and services to meet their needs. The findings included:Record review of Resident #1's face sheet dated 07/26/25 reflected Resident #1 was admitted on [DATE] and was [AGE] years old. Resident #1 had diagnoses of dementia (a progressive decline in cognitive abilities, such as memory, thinking, language, and judgement that interferes with daily functioning and social interactions), muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue), repeated falls, muscle weakness, and abnormalities of gait (the manner or pattern of walking) and mobility. Record review of Resident #1's undated comprehensive care plan reflected: Resident #1 was at high risk for falls and had an unwitnessed fall on the following dates:6/1/25 I had an unwitnessed fall. Date Initiated: 04/29/2024 Revision on: 06/02/2025. 6/18/25 I had an unwitnessed fall. Date Initiated: 06/18/2025.Record review of Resident #1's Discharge MDS dated [DATE] revealed: Short-term memory problem and severely impaired cognitive skill.Dependent on assistance for all self-care and mobility.No falls since Admission/Entry or Reentry or Prior MDS Assessment.Record review of the facility's incident log dated 7/25/25 revealed that Resident #1 had un-witnessed falls on 6/1/25 and 6/18/25. No other information regarding the fall was noted on the facility log.During an interview on 7/26/25 at 1:15 p.m., ADON said she oversaw completing the MDS at discharge. She said the falls on 6/1/25 and 6/18/25 were not captured on Resident #1's discharge MDS. She said it was her fault. She said she must had overlooked the question and placed no. She said Resident #1 did have those falls and the falls should have been captured on the discharge MDS. She said she started doing MDS approximately 8 months ago, so she was still learning. She said she was not sure why the fall must be captured on the discharge MDS. She said that she would imagine due to quality measures, so it would show the fall occurred. She said a negative outcome for not capturing the falls on the discharge MDS, would have had more of an effect if the fall was a major fall and Resident #1 entered the facility. She said the ambulance staff and hospitals usually obtain the information during report not from the MDS. She said to her understanding, if a fall required sending out the resident to the hospital, the hospital did not receive the MDS information. She said the hospital received order summaries, MARs, MD orders, and transfer orders all in paper forms.During an interview on 7/26/25 at 2:08 p.m., DON said that the falls on June 1st and June 18th of this year (2025) for Resident #1 were not captured on the discharge MDS because the RAI questions had a look back period, but she was not sure when the look back time was. The DON researched and got back with surveyor then she said there was not a look back period for the falls that Resident #1 had in June 2025. The DON said the negative outcome for the falls if not captured on the MDS would be incorrect documentation. She said she was not sure how it would affect the RUG (a classification system used in skilled nursing facilities, to categorize residents based on their care needs and resource intensity which helps determine the level of care and associated costs for reimbursement purposes). Record review of CMS's RAI Version 3.0 Manual dated 10/2024, reflected section:J1800: Any falls since admission/entry or reentry or prior to Assessment.Coding instructions:Code 0, no: if the resident has not had any fall since the last assessment.Code 1, yes if the resident has fallen since the last assessment. Continue to number of falls since admission/entry or reentry or prior assessment.(J1900), whichever is more recent.

Based on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 Residents (Resident #2) reviewed for medical records accuracy, in that: Resident #2's February 2025 Monitoring Administration Records documentation was incomplete and inaccurate. Staff inaccurately documented and did not sign off on the monitoring of Resident #2's wander guard. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment. The findings included: 1. Record review of Resident #2's face sheet, dated 02/13/25, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease (memory loss, cognitive decline, language problems, behavioral changes and difficulty with daily tasks) with late onset (typically after age 65), Anxiety disorder, unspecified (intense, excessive, and persistent worry and fear about everyday situations), and heart failure, unspecified (when the heart doesn't pump blood as well as it should). Record review of Resident #2's quarterly Minimum Data Set assessment, dated 01/09/25, revealed Resident #2 had a BIMS score of 00, indicating her cognition was severely impaired. Resident #2's MDS indicated she used a walker as her mobility device. Record review of Resident #2's physician's orders, retrieved on 02/14/25, revealed orders for 1. Wander guard placement due to high risk for elopement and wandering. with frequency of every shift and a start date of 12/23/24. Record review of Resident #2's Monitor Administration Record for February 2025 revealed 2 unsigned sections on the 6pm-6am shift on 02/09/25 and the 6am-6pm shift on 02/10/25, and RN A documented Y (yes) on 02/12/25 during the 6AM-6PM shift for the following physician orders: 1. Wander guard placement due to high risk for elopement and wandering every shift. Record review of Resident #2's nursing note written by the DON on 02/12/25 at 6:49pm stated Resident's wander guard found in pocket of her walker. Bracelet replaced and now in place on resident's left wrist. SN (staff nurse) to continue to monitor for wander guard placement and function. Observation and interview on 02/12/25 at 5:31 pm with RN A in the dining room revealed Resident #2 did not have her wander guard on her person and was located in her bag attached to her walker. RN A was not aware of the last time Resident #2 had her wander guard on. Observation on 02/12/25 at 6:30 pm with the DON revealed Resident #2 did not have her wander guard on her and was in the bag attached to her walker. During an interview with the DON on 02/12/25 at around 6:45 pm, she stated if Resident #2 had a behavior of removing her wander guard, and it would have to be care planned. She stated, at that time, she was not sure if it was already care planned or not. During an interview with the DON on 02/14/25 at 11:19 am, she stated after Surveyor D notified her of Resident #2's wander guard not being in place on 02/12/25, she added Resident #2's removal of the wander guard to her care plan. Record review of Resident #2's care plan, retrieved on 02/14/25 revealed Resident #2 had a focus of, I have been noted wandering. I am at risk for elopement. I have a wander guard in place for my safety. I do not like my wander guard bracelet and remove it at times. When my [SIC] staff are unable to redirect to keep my bracelet on, it is placed in my walker that is with me at all times. with an initiation date of 10/15/24 and a revision date of 02/13/25. Interventions included, My [SIC] staff redirect me when I am found trying to remove my wander guard. with an initiation date of 02/12/24 and My [SIC] staff respect my wishes of not wanting to wear my wander guard bracelet at times when they are unable to redirect me, with an initiation date of 11/16/24 and revision date of 02/13/25. During record review and interview with RN A on 02/13/25 at 5:51 pm, she stated she worked with Resident #2 on 02/12/25 during the 6am-6pm shift. RN A stated Resident #2's wander guard should be placed on her wrist. RN A stated during observation of Resident #2's wander guard on 02/12/25 during dinner in the dining room, she did not have her wander guard properly placed and was located in her bag of the walker. RN A reviewed Residents #2's monitoring administration record and stated on both of her shifts on 02/11/25 and 02/12/25, her documentation was inaccurate because she marked yes that the wander guard was in place for Resident #2 but stated she shouldn't have marked yes when it was not on her wrist. RN A stated she marked yes because Resident #2 always removed her wander guard and placed it in the walker. RN A stated they would check her bag that's attached to the walker to make sure the wander guard was in there and stated every time she walked by the door, the alarm was triggered. RN A stated it was important to ensure residents wander guards were in place to prevent them from eloping from the facility and for resident safety. RN A stated she had checked for wander guard placement every shift. RN A stated Resident #2 would remove her wander guard, and stated in response, staff would tell her not to remove it or replace it if it had been removed. RN A stated the facility policy for wander guard monitoring/supervision was to have the wander guard on at all times to prevent elopement, make sure the residents were in the facility, and know where they were depending on what alarm would ring. RN A stated, in this situation, she felt she had followed the facility policy. RN A stated she had been trained upon hire on ensuring wander guards were in place. RN A stated not checking wander guards to ensure proper placement could put residents at risk for leaving the facility, getting hurt or getting lost. During record review and interview on 02/14/25 at 11:09 am with the DON, she stated LVN B worked with Resident #2 on 02/10/25 from 6am-6pm, LVN C worked with Resident #2 on 02/09/25 from 6pm-6am, and RN A worked with Resident #2 on 02/12/25 during 6am-6pm shift and were each responsible for documentation during their shift. The DON stated Resident #2 did have an order to check wander guard placement and stated a blank on the administration record meant that it was not checked off. The DON confirmed there were blanks on 02/09/25 on the 6pm-6am shift and 02/10/25 during the 6am-6pm shift. The DON also confirmed RN A had checked off yes on the order regarding placement of Resident #2's wander guard on 02/12/24 during her 6am-6pm shift. The DON was not sure why LVN B and C had not documented Resident #2's wander guard placement on the monitoring administration record for Resident #2. The DON was informed of an observation on 02/12/25 when RN A observed Resident #2 without her wander guard in place. The DON was shown documentation completed by RN A that reflected the wander guard was in place. The DON was unable to say if the documentation completed by RN A was inaccurate and stated that was a question for RN A. The DON stated she did not know why RN A marked the wander guard in place, and stated she did not know how RN A monitored that. The DON stated when she observed Resident #2 on 02/12/25 at 6:30pm, she did not have her wander guard on her wrist, and it was in her bag. The DON stated they did not have a specific area for the wander guard to be placed and stated it just had to be on her. The DON stated she had previously trained staff over wander guards and had previously spoken to staff about not leaving until they had finished their documentation. The DON stated herself and the ADON were responsible for monitoring the records to ensure staff had completed accurate and complete documentation. The DON added that Medical Records would sometimes help when she was uploading document, and identified something was missed. The DON did not recall facility policy related to accurate and complete documentation, and stated they did not have a policy for wander guards. The DON stated it was important to complete documentation accurately and completely because it was physician orders, and the floor nurses were ultimately responsible for carrying out those orders. The DON stated incomplete, inaccurate documentation could negatively impact the residents because their orders were in place to benefit them, and if it was being documented, it needed to be for their benefit. She stated if it was not documented, then it went undone and that would be to a resident's disadvantage. During a telephone interview on 02/14/25 on 1:51 pm with LVN B, she stated she worked with Resident #2 on 02/10/25 from 6am-6pm, and was responsible for documentation. LVN B stated Resident #2 did have an order to check wander guard placement, and stated a blank on the administration record meant that the documentation was not there. LVN B stated on 02/10/25, she did check Resident #2's wander guard placement during her shift and stated it was on her right arm, LVN B stated she was unable to recall why she did not document, and she must have missed it. LVN B stated she had previously been trained on complete and accurate documentation by the ADON or DON and different nurses during her training days. LVN B stated the DON and ADON were responsible for monitoring and the records to ensure staff had completed accurate and complete documentation. LVN B stated according to facility policy, they had to complete documentation before the end of their shift. LVN B stated, in this situation, she did follow the facility policy but did not know why she had not documented for Resident #2's wander guard placement on Resident #2's administration record. LVN B stated it was important to complete documentation accurately and completely so that they could go back and see what was done or not. She stated incomplete, inaccurate documentation didn't let them know about the residents, and could impact follow up on residents' care and health. During a telephone interview on 02/14/25 on 2:15 pm with LVN C, she stated she worked with Resident #2 on 02/09/25 from 6pm-6am, and was responsible for documentation. LVN C stated Resident #2 did have an order to check wander guard placement, and a blank on the administration record meant that she did not check it off. LVN C stated on 02/09/25, she did check Resident #2's wander guard placement during her shift, and she checked yes it was in place because it was on her walker. LVN C stated Resident #2 had removed her wander guard 2 times that day, so LVN C left it on her walker. LVN C stated the wander guard should be placed on Resident #2's wrist and not the walker. LVN C stated she did not know why she did not document for Resident #2's wander guard placement on Resident #2's administration record. LVN C stated she had previously been trained on complete and accurate documentation by the nurse she trained under upon hire. LVN C stated the DON and ADON were responsible for monitoring the records to ensure staff had completed accurate and complete documentation. LVN C stated according to facility policy, if it wasn't documented, it wasn't done. LVN C stated, in this situation, she did not follow the facility policy because she left the documentation blank. LVN C stated it was important to complete documentation accurately and completely so that they could go back to it and check and stated incomplete, inaccurate documentation could impact resident's care. During an interview with the ADON on 02/14/25 at 4:40 pm, she stated they had trained RN A on how to use their documentation system and on leaving everything checked off, but she did not have anything in writing regarding RN A's training over documentation. During an interview with the DON on 02/14/25 at 11:19 am, she stated they did not have a wander guard policy. Record review of facility in-service dated 08/24/24 revealed the training covered documentation and was completed by LVN C. Record review of facility in-service dated 01/14/25 revealed the training covered documentation and was completed by LVN B. Record review of the facility's policy titled, Charting and Documentation with a revised date of July 2017 reflected, 3. Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate and 7. Documentation of procedures and treatments will include care specific details including .g. The signature and title of the individual documenting.

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 and 1of 2 unit (unit 1) nutrition refrigerators reviewed for sanitation. The facility failed to maintain the kitchen freezer that had a large section of ice build-up in it. The facility failed to provide clean coffee cups for the resident's use. The facility failed to ensure the nutrition room refrigerator had labeled and dated items in them. The facility failed to ensure the nutrition room did not have expired items. The facility failed to ensure the nutrition room snack tray items were labeled, dated, and refrigerated. The facility failed to ensure the freezer temperature logs for the unit refrigerator were documented. The facility failed to ensure there was a thermometer in the unit freezer. These failures could place residents at risk of living in an unsafe, unsanitary environment and place them at risk of foodborne illness. Findings were: Initial tour and observation of the kitchen on [DATE] at 9:45 am revealed a large section of ice build-up around the upper walls, over electrical conduit, around the fans and across the upper back ceiling of the freezer, potentially impeding airflow, water flow, and causing failure and/or potential fire. The freezer was approximately 8 feet long by 3 feet wide and 8 feet high inside. There were 14 of 14 coffee cups on a clean rack in the dining area near the coffee set-up that had heavy dark brown stains and scratches in them. In an interview with the cook on [DATE] at 9:50 am, she stated she worked at the facility for 7 years. She stated the ice build-up in the top back of the freezer and freezer walls had been doing that for a long time, since the end of last year (2023). She stated the MS would go in and remove the ice, but it always came back. She stated she thought the fans blowing up there were what caused the ice build-up. She stated the ice could cause the freezer to stop working, and they had nowhere to put everything from the freezer. She stated the residents might not get the food they were promised, and the food from the freezer would have to be thrown out. In an interview with the MS on [DATE] at 10:10 am, he stated he worked at the facility for [AGE] years. He stated the ice build-up in the freezer had been there for a couple of days on account of the ice needs to be defrosted. He stated the pipes could get clogged and cause the freezer to stop working. He stated he did most of the work on the equipment at the facility. He stated the last service that was done on the freezer was about a year ago when they repaired the fans but did not fix the fans. He stated he had not called the freezer service company. He stated he broke off the ice, but it would keep coming back. He would not say how many times he had to break the ice off inside the freezer, indicating the ice had been there longer than a couple of days. Maintenance service policy, the maintenance log, and invoices requested. In an interview with the DS on [DATE] at 10:15 am, she stated the ice build-up in the freezer was on-going, and she did not know what the MS was doing about it. She stated the cups on the clean rack by the coffee set-up were used by the residents to self-serve. She stated she would not want to use the dirty cups herself, and the residents could get sick. Observation of the nutrition room refrigerator (unit 1) on [DATE] at 3:09 pm revealed 3 small, 3-oz. lidded cups with cookies in them that were unlabeled and undated, a 1-gallon bag with the same type of cookies dated [DATE], but not labeled. There was a 6-oz. Styrofoam container opened to air with several slices of fruit that were shriveling and turning brown, a 3-oz unlidded container opened to air with what appeared to be slimy and shriveled watermelon, undated and unlabeled, an 18-oz. partially empty jar of what appeared to be red jam unlabeled and undated, a 35 ml container of sweet juice unlabeled and undated, a 20-oz. container of bacon, unlabeled and undated, and a 48-oz. container of cream cheese that was unlabeled and undated. There was a 16-oz. open, partially empty can of energy drink that was unlabeled and undated. There was a tray on the counter with 6, ,d+[DATE]-bananas and 8 small bundles of cookies that were wrapped in plastic, 4, 4-oz. small bags of cheese chips with expired use-by dates of [DATE], and 2, 6-oz. containers of pudding that were unlabeled and undated. There was a full pitcher of what appeared to be iced tea on the counter with condensation on the outside. All items on the tray and the pitcher were unlabeled and undated. There was an open quart-size bag of ice open to the air in the freezer, unlabeled and undated. There was no thermometer in the freezer. There was a printed 8 ,d+[DATE] x 11 green paper sign on the outside of the refrigerator stating in all capital letters, Resident items only! and in smaller capital letters, the sign stated, Any food or beverages must be labeled with the resident's name, date, time, and initials of who placed items in the refrigerator. In an interview with the ADON and DON on [DATE] at 3:10 pm revealed they were unaware of the unlabeled, undated items in the nutrition rooms. They both stated they were not sure who was responsible for the nutrition room refrigerators. Both stated they did not know why the freezer temperature was not being documented or why there was no thermometer in the freeezer. The ADON stated having exposed food in the nutrition refrigerator could make residents sick if they consumed any of it. They both stated the undated, unlabeled, uncovered and expired food was a danger to residents because of cross contamination and any decomposition of food was unsafe. Neither would say why there was no thermometer in the unit freezer. A food storage policy was requested. In an interview with the DS on [DATE] at 3:15 pm, she stated the kitchen forgot to date the items on the tray. She stated the tray of bananas and snacks that was on the counter should have been put in the refrigerator. She stated everyone was responsible for the nutrition room refrigerator and the kitchen was responsible for bringing the snack trays, but they should have been labeled, dated, and placed in the refrigerator. She stated if snack items were left unrefrigerated too long, bacteria could grow and make residents sick. In an interview with the ADM on [DATE] at 3:25 pm, she stated she was unaware the freezer in the kitchen was icing up. She stated she was also unaware the nutrition refrigerator was not being monitored. She stated the process for repairs to the facility was for staff to place requests in the hand-written maintenance log that was kept at the nurse's station. She stated she did not check the maintenance log because the MS assured her everything was fine and he was taking care of things. She stated she could not locate the maintenance log at the nurse's station. She stated she would in-service staff about the nutrition refrigerator. Record review of the refrigerator log dated [DATE]-[DATE] revealed 2 checks for the refrigerator: one in the mornings and one on nights for the refrigerator, and no checks for the freezer. There were no concerns identified with the refrigerator temperatures. Record review of the nutrition refrigerator revealed a printed 8 ,d+[DATE] x 11 green paper sign on the outside of the refrigerator stating in all capital letters, Resident items only! and in smaller capital letters, the sign stated, Any food or beverages must be labeled with the resident's name, date, time, and initials of who placed items in the refrigerator. Record review of the facility policy titled, Food Receiving and Storage revised [DATE] revealed under the policy statement, Foods shall be received and stored in a manner that complies with safe food handling practices. 7. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). 13. Food items and snacks kept on the nursing units must be maintained as indicated below: a. All food items to be kept below 41F must be placed in the refrigerator located at the nurse's station and labeled with a use by date. B. All foods belonging to residents must be labeled with the resident's name, the item, and the use by date. C. Refrigerators must have working thermometers and be monitored for temperature according to state specific guidelines. D. Beverages must be dated when opened and discarded after 24 hours. E. Other opened containers must be dated and sealed or covered during storage. F. Partially eaten food may not be kept in the refrigerator. Record review of the facility policy titled, Maintenance Service revised [DATE] revealed under Policy Statement Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. B. Maintaining the building in good repair and free from hazards. 3. The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 9. Records shall be maintained in the maintenance director's office. 10. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned. Record review of a copy of a facility check written for various services included invoice numbers 007141, 007142, and 007275. The date on the check was [DATE]. Invoice details for numbers 007141 and 007142 were not provided. Record review of invoice number 007275 revealed no date. The description of services noted Check freezer-found coil totally frozen, removed ice and bypass bad sensor. Replace sensor with new. Record review of invoice number 007831 dated [DATE] revealed the description of services noted Install evaporator motor in freezer and level out evaporator unit for water drainage. The maintenance log was not provided. References: U.S. Food and Drug Administration Food Code http://www.fda.gov/Food/GuidanceRegulation/RetailFoodProtection/FoodCode/ : Ch. ,d+[DATE] Pg. 96 Time-maximum up to 4 hours, (2) The food may have an initial temperture of 70F or less if; (a) It is a ready-to-eat fruit or vegetable that upon cutting is rendered a time/temperature control for safety .(c) The food temperature does not exceed 70F within a maximum time period of 4 hours from the time it is rendered a time/temperature control for safety food; and (d) The food is marked or otherwise identified to indicate the time that is 4 hours past the point in time when the food is rendered a time/temperature control for safety (3) The food shall be marked or otherwise identified to indicate the time that is 4 hours past the point in time when the food is removed from temperature control. (5) The food in unmarked containers or packages or marked to exceed a 4-hour limit shall be discarded. Ch. ,d+[DATE].112 Pg. 115 Temperature measuring devices. (A) in a mechanically refrigerated or hot food storage unit, the sensor of a temperature measuring device shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit and in the coolest part of a hot food storage unit. (B) .cold or hot holding equipment used for time/temperature control for safety food shall be designed to include and shall be equipped with at least one integral or permanently affixed temperature measuring device that is located to allow easy viewing of the device's temperature display. TAC 554.1111 (b) The facility must store, prepare, and serve food under sanitary conditions, as required by the Texas Department of State Health Service sanitation requirements.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 3 residents (Resident #3) reviewed for infection control, in that LVN A failed to wash her hands, change gloves, or sanitize her hands while providing peg tube care on Resident #3. LVN A failed to follow enhanced barrier precautions for an indwelling medical device (PEG tube). This failure could place residents at risk for infection due to improper care practices. Findings include: Record review of Resident #3's admission record revealed a Resident #3 was admitted on [DATE]. Diagnoses included she was non-verbal, blind, and spoke Spanish only. She had a stroke, a PEG tube, and was incontinent. Observation of PEG tube care for Resident #3 on 07/16/24 at 3:27 pm revealed LVN A did not exercise EBP (Enhanced Barrier Precautions-an approach of targeted gown and glove use set forth by the CDC {Centers for Disease Control} during high contact resident care activities with any wound(s), indwelling medical device(s), or infection or colonization with an MDRO (Multi Drug Resistent Organism) designed to reduce transmission of germs.) prior to care. LVN A did not wash hands or use hand sanitizer prior to care. LVN A donned gloves and supplies: sterile 4x4 gauze, 4x4 gauze, normal saline, a large medicine cup, tape & gloves. LVN A did not change gloves or sanitize her hands after collecting her supplies. LVN A touched the feeding pump to place it on hold and touched the bed control to position Resident #3. LVN A did not change gloves or sanitize after touching the feeding pump and bed control. LVN A poured the normal saline into the large medicine cup & soaked the 4x4 gauze with the normal saline. LVN A then repositioned Resident #3 with the same gloves. LVN A stated she was checking the PEG site for redness, odors, or swelling when she removed the dressing. LVN A changed her gloves and removed the soiled dressing. LVN A threw the soiled dressing into the trash. LVN A did not change her gloves or sanitize after discarding the soiled dressing. LVN A reported slight redness to the upper right side of the PEG site under the tape that secured the dressing. LVN A voiced she would tell the nurses. LVN A cleaned the PEG site in individual passes with the normal saline soaked gauze x3 with the same gloves. LVN A patted dry the PEG site with clean 4x4 gauze, with the same gloves. LVN A did not change gloves or sanitize before opening the sterile 4x4, then placed the sterile gauze on the site using the same gloves. LVN A did not change gloves or sanitize after placing the sterile 4x4 on the PEG site. LVN A stated her gloves were still clean and picked up the roll of tape. LVN A secured the dressing with the tape and restarted the tube feeding without changing gloves or sanitizing. LVN A did not wash her hands after the dressing change. In an interview with LVN A on 07/16/24 at 3:45 pm, she stated she took only 2 pair of gloves in the room. She stated the process for hand washing was to lather for 20 seconds, minimum. She stated not washing her hands was my mistake. She stated she had been sanitizing so much, she forgot to wash her hands. She stated she did not wash her hands or sanitize before or after the dressing change and she should have. She stated not washing hands or sanitizing could cause cross contamination and infection. She stated that was why they used contact precautions, and spreading germs was #1. She stated contact precautions was used when any bodily fluid could come out. She stated that was when staff should gown up and mask-the whole shabam. She stated the soiled dressing was considered contaminated with bodily fluid. She explained she thought EBP was PPE and she was confused. She stated the DON and ADON explained to the staff that they had to be extra cautious. She did not know what EBP was. LVN stated staff was supposed to use EBP before and after every patient, to protect them because they could be immunocompromised. She stated Resident # 3 did not have the EBP and that was why she did not use PPE. She stated the resident did not have Covid and was moved to this hall, but her EBP did not come with her. In an interview with the ADM on 07/16/24 at 4:15 pm, she stated staff were trained on handwashing and EBP regularly. The ADM stated she would be embarrassed to find out her staff were not following guidelines for infection control. The facility policy for hand hygiene was requested. Record review of the facility policy titled; Handwashing/Hand Hygiene revised August 2015 revealed in the Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 70% alcohol, or alternatively, soap and water for the following situations: b. before and after coming into direct contact with residents, d. before performing any non-surgical invasive procedures, e. before and after handling an invasive device, g. before handling clean or soiled dressings, gauze pads, etc., h. before moving from a contaminated body site during resident care, i. after contact with a resident's skin, j. after contact with blood or bodily fluids, k. after handling used dressings, contaminated equipment, etc., l, after contact with objects (e.g. medical equipment) in the immediate vicinity of the resident, m., after removing gloves, 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 10. Single use disposable gloves should be used a. before aseptic procedures, when anticipating contact with blood or body fluids. Procedure Washing Hands-1. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds or longer under a moderate stream of running water at a comfortable temperature . Applying and Removing Gloves-1. Perform hand hygiene before applying non-sterile gloves. 4.remove the gloves 5. Perform hand hygiene.

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for one of one laundry reviewed for environment. The facility failed to ensure the doors in the laundry would open and close safely and had functioning doorknobs. The facility failed to ensure the washing machine in the laundry was not leaking water into a basin and attracting mosquitoes. The facility failed to ensure the walls in the storeroom inside the laundry did not have dark patches showing through the paint. These failures could place residents at risk for diminished quality of life due to the lack of a well kept environment. Findings included: Initial tour and observation of the laundry room on 07/17/24 at 11:30 am revealed the entrance door (door #1) was difficult to open. Once unlatched, the door fell enough to stick badly on the floor when opening it. There were deep grooves through the tiles and into the concrete where the bottom corner of the door dragged when it was opened and closed. The heavy door had to be physically lifted back onto its jamb to close it. There was a hole approximately 6 inches x 4 inches in the wall in alignment where the handle of the heavy door would go through the hole. The other door (door #2) had no inner handle. There was a room inside the laundry that had dark patches on all the walls and missing an inner door handle. One of the washing machines was leaking water into a basin. A stray cat was observed coming into the laundry through door #1, as it would not shut completely. In an interview with HSK on 07/17/24 at 11:35 am she stated the doors were difficult to open and close since she started working in the laundry room going on 4 years. She stated sometimes, she could not get door #1 shut all the way and stray cats would enter the laundry room. She stated sometimes the wind would blow door #1 open when it did not get shut all the way and blow all kinds of things into the laundry. She stated the doors without the handles had to be closed from the inside and the doors were heavy. She stated the doors were not very safe and she was afraid she could hurt herself lifting door #1 all the time. She stated the MS was in the laundry room often and she had mentioned the doors and door handles problems multiple times. She stated when there was a problem for maintenance, she would go to the MS directly. She stated there was a handwritten maintenance log at the nurse's station, but she was not sure how often he checked it. She stated the room inside the laundry room was a restroom, but the toilet did not work, and they were not using the room because the MS was renovating it. She stated the dark patches on the walls in the room had been there since the beginning of this year and were worsening. She stated the room had what she thought was patches of mold all over the walls. She stated the washing machine had been leaking for a week and in the mornings, there was tons of mosquitos in the laundry. In an interview with the MS on 07/17/24 at 1:10 pm, he stated he was renovating the room inside the laundry, and he had not had time to get to the doors in the laundry. He stated he worked at the facility for [AGE] years. He stated he did most of the work on the equipment in, at, and on the facility. The Maintenance service policy and the maintenance log was requested. In an interview with the ADM on 07/18/24 at 3:25 pm, she stated she was unaware of the laundry room doors and washing machine. She stated the process for repairs to the facility was for staff to place requests in the hand-written maintenance log that was kept at the nurse's station. She stated she did not check the maintenance log because the MS assured her everything was fine and he was taking care of things. She stated she could not locate the maintenance log at the nurse's station. She stated she was working on getting an electronic maintenance log, so repairs could be tracked and monitored better. Record review of the facility policy titled, Maintenance Service revised December 2009 revealed under Policy Statement Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. B. Maintaining the building in good repair and free from hazards. 3. The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 9. Records shall be maintained in the maintenance director's office. 10. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned.

Based on interview and record review the facility failed to ensure all irregularities reviewed/identified by the licensed pharmacist were followed for 1 (Resident #12) of 6 residents reviewed for drug regimen review, in that: The facility failed to address Seroquel (antipsychotic) being given to a resident with diagnosis of dementia. The facility failed to follow the consultant pharmacist and physician's recommendation for the gradual dose reduction of Seroquel 25mg PO one time a day. This deficient practice could place residents at risk of receiving unnecessary medications and dosages. The findings were: Record review of Resident #12's face sheet dated 04/19/23 revealed an [AGE] year-old female admitted to the facility 11/11/16 with the diagnoses including Alzheimer's Disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment. Alzheimer's disease involves parts of the brain that control thought, memory, and language), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, psychosis, not due to a substance or known physiological condition, unsteadiness on feet, general anxiety disorder, anorexia, and bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs). Record review of Resident #12's Quarterly MDS revealed she had a BIMS score of 03, indicating she had severe cognitive impairment. Resident #12 had minimal difficulty hearing with clear speech, she was sometimes understood by others, and sometimes she understood others. Resident #12 required extensive assistance by 1 staff for bed mobility, transfers, locomotion on the unit, dressing, toilet use, and personal hygiene. Resident #12 was frequently incontinent of bowel and bladder. Record review of Resident #12's care plan dated 02/21/23 revealed Resident #12 had Dementia and also a diagnosis of bipolar disorder. I am forgetful & require frequent reorientation Date Initiated: 09/21/2022 Revision on: 03/13/2023. Resident #12 had the following interventions listed: -11/1/22 My Pharmacist recommended a GDR of my Seroquel. My (NP) reviewed and declined my GDR due to me not being stable and another medication of mine was increased. Date Initiated: 11/02/2022 LPN RN -12/21/22 my pharmacy recommended a GDR of my Seroquel. My (NP) LPN reviewed and approved the recommendation. Date Initiated: 12/21/2022 RN -4/5/23 my pharmacy recommended to attempt a GDR of Seroquel. My NP viewed the recommendation and approved it ordering to discontinue Seroquel. My RP was made aware but refuses a GDR at this time as I have been verbally aggressive at times, and she is concerned that it will worsen without my Seroquel. My Pharmacist and NP are aware. Date Initiated: 04/05/2023 -My nurse/CMA administers Seroquel as ordered by my doctor. My nurse monitors me for: Target behaviors: frightful distress, paranoia, and fearfulness. Side effects: dizziness, fatigue, drowsiness. My nurse reports to my doctor as appropriate. Monitor frequently, re-orientate as necessary, anticipate needs, provide incontinent care every 2 hours and prn Date Initiated: 09/21/2022 Revision on: 10/23/2022 Record review of Resident #12's Order Summary Report, dated 12/21/22 revealed, Seroquel Tablet 25 MG (Quetiapine Fumarate) Give 1 tablet by mouth one time a day related to unspecified dementia without behavioral disturbance. Start date of 12/21/22 ordered by (Medical Director). In an interview on 04/20/23 at 05:00 p.m., DON stated she is the one who gets the GDR (Graduated Dose Reduction) and acts on it (doctor notification). She stated that antipsychotics should not be given to a resident with the diagnosis of dementia or Alzheimer's. DON stated they need to consider a whole outlook of the resident (mental, physical, spiritual, etc.) and do not want any resident on unnecessary medications. DON stated the negative outcome of giving a resident who has the diagnosis of dementia or Alzheimer's an antipsychotic for dementia or Alzheimer's could be adverse side effects. DON stated Medical Director, does not order antipsychotics. DON stated NP (mental health) is the one who orders antipsychotics. DON stated Resident #12's family pushes back whenever there is a GDR. They think she is doing well on what she is getting. DON stated she tried to explain if the GDR does not work, they can always go back, but they needed to try. DON stated if they are adamant, then NP was notified, and they try to work with the family. Attempted telephone interview on 04/20/23 at 05:45 p.m., Medical Director, who wrote the order for Seroquel for dementia without behaviors for Resident #12. There was no answer. A voicemail left. No return call was placed by Medical Director. Attempted telephone interview on 04/20/22 at 05:50 p.m., with pharmacist for facility. There was no answer. A voicemail left. In a telephone interview on 04/20/23 at 05:55 p.m., the facility pharmacist stated when she sees an antipsychotic ordered with dementia diagnosis, without behaviors, she will ask for diagnosis to be verified. The facility pharmacist stated the GDR will have it on the paperwork. The facility pharmacist stated antipsychotics need to be tapered before they are discontinued. The facility pharmacist stated the facility sent her an email that the family (of Resident #12) declined the GDR of Seroquel. She stated her notes show the psychiatrist was aware of family declining the GDR. When the facility pharmacist was asked what the negative outcome of a resident with dementia without behaviors receiving Seroquel, an antipsychotic, could be, the facility pharmacist replied, The thing as with any antipsychotic, residents are on the lowest dose anyway. There are side effects with any medication. We just try to discontinue by tapering off first. The facility pharmacist stated she already has it on her schedule to send the GDR back to the doctor in July. The facility pharmacist stated it was all she could do. Record review of facility's policy on Antipsychotic Medication Use 2001 MED-PASS, INC (Revised December 2016), revealed: Policy Statement Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Policy Interpretation and Implementation 1.Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 7. Antipsychotic medications shall generally be used for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions): e. Mood disorders (e.g. bipolar disorder, depression with psychotic features, and treatment refractory major depression); f. Psychosis in the absence of dementia 8. Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: a. The behavioral symptoms prevent a danger to the resident or others; AND: 1. The symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity); or 2. Behavioral interventions have been attempted and included in the plan of care, except in an emergency .

Based on observation, interview, and record review the facility failed to store and prepare food in a sanitary manner, in that: 1) Undated and unlabeled food were in the refrigerator and freezer. 2) Frozen food items were stored on the floor in the freezer. These failures could place residents who were served meals from the facility's kitchen at risk for food borne illness. The findings were: Observation during the initial tour of the kitchen on 04/18/23 at 9:20 AM revealed in the refrigerator a container with an opened undated package of [NAME] in a plastic sandwich bag and an undated package of pepperoni slices. The DS took out the package of [NAME] and pepperoni and asked the Dietary Aide to throw it out. Observation on 04/18/23 at 9:23 AM of the freezer revealed an opened box of Premium Reserve Pork with three individual wrapped pork meat packages, 2 unopened packages of different flavored popsicles and an unknown large frozen package of meat wrapped in pink plastic were on the floor of the freezer. The DS said nothing should be placed on the floor. The DS said the unknown package of meat would be thrown out. The three pork meat packages were taken out of the box and placed on the shelf along with the popsicles. In an interview on 04/18/23 at 9:27 AM the DS said all food must be labeled and dated when it is received. If any food is opened it should be stored separately and labeled and dated when opened. All staff are responsible for labeling and dating food in the refrigerator or freezer. Opened items are stored in the refrigerator for three days and then thrown out. If there is no opened date, then that food would be thrown out. The Dietary Supervisor said nothing should be placed on the floor. DS asked the Dietary Aide if she knew why the items in the freezer were placed on the floor and if she knew what type of meat that was wrapped in the pink plastic and when was it received. The Dietary Aide said she did not know what it was nor when it was received. The DS said the unknown package of meat would be thrown out. The pork meat was taken out of the box and placed on the shelf along with the popsicles. The DS said they will not use food that is not labeled or dated. DS was asked twice what the consequences of not labeling and dating food when stored in the refrigerator would be and each time the DS just said, We will not use food that is unlabeled or undated, it will be thrown out. In an interview on 04/19/23 at 10:20 AM Dietary Aide A said the food must be labeled and dated when it is stored, and the food must never be on the floor. Dietary Aide A said the Cook and the Dietary Supervisor are responsible for putting the foods in the refrigerator or the freezer. Everything must be off the floor and when a package is opened, the date the package was opened must be written on the package. The Dietary Aide said anything not dated must be thrown out because they don't know how long it has been in the refrigerator or freezer and if it was contaminated. In an interview on 04/19/23 at 10:35 AM Cook B said all staff are responsible to put the food in the refrigerator or the freezer. Cook B said they must date and label all food items in the refrigerator or freezer. If a package is opened, they must put the date the package was opened before placing it in the refrigerator or freezer. Cook B said when their food order arrives, they must place all items on a cart and then they must be labeled and dated before putting them away six inches from the floor. Cook B said they would not use any item that was not labeled or dated. The Cook said they would not use it because they do not know if it was still good. In an interview on 04/19/23 at 3:43 PM the Dietary Consultant said she had not provided any in-services to the dietary staff but would do so since they had food that was unlabeled and undated in the refrigerator and food on the freezer floor. In an interview on 04/19/23 at 03:50 PM The Administrator said he and the Dietary Consultant oversee the kitchen. The Administrator said the Dietary Consultant has not physically been at the facility. The Administrator said the Dietary Consultant only does face time visits with the staff ever since the COVID-19 pandemic. The Administrator said he would call the Dietary Consultant and request she come to the facility and provide in-services to the staff and conduct an inspection and address any concerns found during the survey. Record review of facility's policy revised on 07/2014 regarding Food Receiving and Storage, revealed: Food shall be received and stored in a manner that complies with safe food handling practices. 7. All foods stored in the refrigerator or freezer shall be covered, labeled, and dated (use by date). 1) FDA (Food and Drug Administration) Food Code 2017, Preventing Contamination from the Premises 3-305.11, Food Storage, indicated: (A) Except as specified in - (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor.

Based on observation, interview, and record review, the facility failed to ensure RN coverage eight hours a day: [DATE] Nursing coverage schedule shows (4) weekend days without RN coverage January 2022 Nursing coverage schedule shows (9) days without RN coverage February 2022 Nursing coverage schedule shows (8) days without RN coverage This failure could place residents at risk for unmet nursing services. Findings included: Record review of Nursing schedule for [NAME] Lake indicated there was no RN scheduled to work on the weekends 2/5/2022, 2/6/2022, 2/12/2022, 2/13/2022, 2/19/2022, 2/20/2022, 2/26/2022, 2/27/2022 in February 2022. Nursing schedule for January 2022 indicated an RN worked one weekend day, 1/22/2022, out of ten weekend days for the month. Nursing schedule for December 2021 indicated an RN worked four out of eight weekend days out of the month . An RN worked on 12/4/2021, 12/11/2022, 12/18/2022 and 12/25/2021. In an interview on 2/4/2022 @ 8:45 AM with LVN C it was stated she worked weekends without an RN present . LVN works various schedules. She stated there was no RN on the weekends about 9 months ago and again recently. She stated a post fall assessment is done by the RN. If they fall on the weekend the RN does the assessment on Monday. She stated if there was an issue with a resident, she would send them out. In an interview on 2/4/2022 @ 9:25 AM with LVN D it was stated she worked weekends without an RN present. In an interview with the Director of Nurses (DON) on 2/3/2022 at 4:00 PM she stated she did not schedule an RN to work on the weekends. The DON indicated she did not have a waiver to omit RN coverage. The DON stated on 2/4/2022 @ 9:35 AM: RNs are used for PICC lines removals. We don't have any residents with PICC lines. We haven't had any residents with PICC lines since I've been here. If there is a fall, the RN is notified. Usually, the RNs do a fall assessment. Things like that. Skilled has different training that RNs. There haven't been any issues with us not having an RN. In an interview with the administrator on 2/3/2022 @ 5:10 PM, he stated he was aware of the requirement to have RN coverage 8 hours each day. He indicated he attempted to hire an RN but was unsuccessful. He indicated he would apply for a waiver. (Record review of fall policy indicates assessment must be done by a nurse and not specifically by an RN).

Based on interview, observation and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in that: Kitchen staff failed to maintain temperature logs of the dishwasher. Kitchen staff failed to ensure dishwasher temperatures were maintained for proper sanitization. Kitchen staff failed to keep the ice maker clean to prevent potential foodborne illness. Kitchen staff failed to keep the water wells of the steam table clean to prevent potential foodborne illness. These deficient practices could affect the 25 residents receiving their meals prepared from the kitchen by putting them at risk for foodborne illnesses. Findings included: Observation on 02/01/22 at 11:30 AM with DM and DSCI revealed the following: Ice machine found to be harboring a black/brown substance along the inside borders of the lid and inside the inner ice chute. Interview with DM and DSCI on 02/01/22 at 11:45 AM revealed the ice machine and all equipment was deep cleaned once a month. Observation on 02/02/22 at 08:45 AM of the water in the wells of the steam table revealed floating debris, a thick, whitish brown/yellow caked-on substance covering all inner sides and bottoms of all four pans. The washer was inspected and found to have a temperature below the minimum 120F. Observation revealed the dishwasher gauge was inspected and found to be 118 degrees. Record review of the temperature logs for the washer for the month of December 2021, and the first 2 days of February revealed they were all written as 130F. Record review of the cleaning schedule revealed all monthly cleaning had been done for the past 3 months. Interview with DM and DSCI on 02/02/22 at 8:50 AM revealed: They were all aware the water wells were in this condition and said they had told management, but nothing ever happened. DM said the steam table pans needed to be replaced. DM was asked about the logged washer temps and the discrepancy found; She explained that the temperature on the boiler was lowered 2 months ago after the thermostat overheated and blew off the relief valve. When asked about maintenance of the washer, she explained the representative from the washer company came out monthly and the machine always worked perfectly when he's there and acted up after he leaves. When asked if he was ever called back, she said no, they just wait for him to come again the next month. Observation on 02/02/22 at 09:15 AM revealed: ES attampted to verify temperature at the handwashing sink and reported it as 120F. When compared to this surveyor's calibrated thermometer, the temp read 118F. The ES then used his thermometer again at the same time and both thermometers read 118F when observed by this surveyor. Interview with DSC2 on 02/03/22 at 2:15 PM: he said the steamer table water well pans had looked like that since he first started working here [AGE] years ago and they have never been cleaned. He said we needed new ones since the beginning-[AGE] years, and the staff knew about, but never told anyone the pans were bad and no one from state ever mentioned it that he knew of. Interview with ES on 02/03/22 at 2:20 PM revealed that he was just now informed about the washer temperatures. When asked about the logs, he said they may be falsifying those records because he had just adjusted the water heater prior to this interview. The temperature reads 126F at that time. He said he was not informed of problems in the kitchen, nor does he independently check the logs in the kitchen. 02/04/22 8:40 AM: ADM shared some unsolicited photos of the steamer table wells, which were grinded last night to clean them-a grinder had to be used to get them clean Interview with ADM, DON and DS on 02/04/22 at 10:42 AM: When asked about cleaning schedules, DS said she personally cleans the stove and the washer 2 times a month and staff clean the ice machine 2 times a month. ADM explained that anything on the logs that are a problem are addressed in their morning meetings and maintenance or whoever needs to know to correct the problem is notified. If there's a problem with equipment, he said staff informs maintenance and maintenance follows up to see if the problem is corrected. DS said she reports any problems to maintenance. DS said maintenance on the washer is done monthly by the company and she calls them back for big issues. The last time she had to call them back was a year ago but at first could not recall which piece of equipment was shut down. When asked about the washer temperature log for the month of December 2021 being listed at 130F, she said it was hard to account for December 2021 because the sanitation could not be assured. ADM admitted to false information on the logs. DS said she will in-service the staff on the importance of writing the correct numbers on the logs instead of what the number is supposed to be. Record review of the Model A4 dishwasher manufacture instructions read, Water Supply Temp 120F Minimum