Every finding on record at Five Points Nursing and Rehabilitation

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #6) out of 6 residents reviewed for accidents and supervision.The facility failed to ensure CNA-A used proper fall procedures on 3/2/26 when Resident #6 slid from her wheelchair while being loaded into the transportation van by not contacting a nurse to assess the resident immediately.The facility failed to ensure Resident #6's safety when CNA-A drove back to the facility with the resident sitting on the van floor unsecured.These failures could place residents at risk for falls, injuries, and a decline in health.Record Review of Resident #6's face sheet revealed she was a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included: Displaced Supracondylar Fracture without Intracondylar extension of lower end of left femur (lower thigh bone breaks just above the knee joint), Other Sequelae of Cerebral Infarction (long-term residual neurological and functional deficits persisting after a stroke), Muscle Weakness, Lack of Coordination, Sickle Cell Anemia (inherited blood disorder which causes pain, organ damage and infections), age related Osteoporosis (characterized by low bone mass, structural deterioration, and decreased density, making bones fragile and highly susceptible to fractures), and Cognitive Communication Deficit (caused by underlying cognitive impairments such as memory, attention or executive function deficits). Record Review of Resident #6's Admissions MDS dated [DATE] revealed a BIMS of 11 which meant moderate cognitive impairment. Resident #6's MDS revealed she used a wheelchair and a manual lift (a mechanical device used to lift a wheelchair for transportation). She needed some help with self-care, indoor mobility, and functional cognition. Resident #6 had impairment of her lower extremities on both sides. Record Review of Resident #6's Care Plan dated 3/3/26 revealed she was at risk for falls due to decreased mobility/unstable balance,, and had a potential for uncontrolled pain due to Sickle Cell Disease and history of fracture. Record Review of the PIR dated 3/6/26 revealed the incident occurred on 3/2/26 around 6:30 p.m. The Admin. notified and it was reported to HHSC on 3/3/26 at 8:22 a.m. The PIR stated Resident #6 was loaded into the facility van by CNA-A after an appointment. Resident #6 slid out of her wheelchair when the van was parked. CNA-A assisted Resident #6 to the van floor. Resident #6 stated she had dull pain to her left thigh. The facility notified Resident #6's family, and physician about the incident. The physician ordered x-rays be completed. The x-rays showed a possible fracture of the left thigh; the physician was notified and sent Resident #6 to the hospital for evaluation. The hospital found no new fractures in Resident #6's left leg and she returned to the facility the same day. The facility started in-service training for all staff on Abuse and Neglect, Fall Preventions/Fall Risk, Incident/Accident notification, and Notification of Change of Status. The facility conducted safe surveys with no concerning results. The facility interviewed and suspended CNA-A pending investigation. The facility in-serviced CNA-A on Employee Auto Training Handbook on 3/3/26. The facility removed the van from service until a full inspection could be completed using outside transportation companies until a trained and qualified driver was identified. Record Review of the facility's Incidents By Incident Type Log, dated 3/12/26 revealed Resident #6 had a Fall Incident on 3/2/26 at 5:36 p.m. Record Review of Resident #6's Progress Notes on 3/2/26 at 7:30 p.m. written by the LVN revealed Resident #6 slid out of wheelchair and assisted to the floor by staff. Resident was assisted back into the wheelchair by staff. Appears and/or states to be in pain. Describes the pain as: Dull, Location of pain: left thigh pain relieving intervention used at this time: prn pain medication.Resident statement: Resident stated she slid out of chair. Record Review of a Witness Statement dated 3/2/26 by CNA-A stated revealed, I loaded [Resident #6] in the van as I pulled her chair in [Resident #6] begin to slide out her chair and I guided her to floor. I then transported her back to the facility. Record Review of a Witness Statement dated 3/2/26 by the LVN stated revealed the van driver came into the building and said she needed help getting a resident up that slid out of her chair. The resident was assessed and was cleared to get put back into her wheelchair and returned to her room. I then performed a full head to toe assessment with no new injuries noted. The resident stated (sic) having a dull pain that was not a new pain for her. I place a pillow in the spot she asked me to and she said that felt better. Record Review of a Witness Statement dated 3/2/26 by the Admin stated revealed On 3/2 I was informed by nursing that a resident fell while out on a transport and was now back in her room. I was informed that the driver came in and asked for help getting the resident up due to her being on the floor of the van. I was informed that while loading a resident [#6] onto the transportation van the resident began sliding and the driver assisted her to the floor. She [CNA-A] then drove the van back to the facility with the resident in the floor of the van. The driver stated that the resident was a two person lift and she was not able to lift by herself. She stated that she knew that the resident was a two person lift and she was not able to lift by herself. She stated that she knew that she should have called for help and was trained on when to call for assistance. When I asked her why did she not call for assistance her response was, I am not sure. I knew I should have but chose the wrong decision. Record Review of Resident #6's Progress Notes on 3/3/26 at 6:45 a.m. written by the RN revealed Report received that resident slid out of wheelchair yesterday in the Transportation Van coming back from The Doctors [sic] appointment. Radiology report received this morning and sent to Doctor, Manager called in this morning to send resident to the hospital and a message came in from the Doctor as well to send resident to the hospital too. Paramedics called in and resident was transported to the Hospital. Record Review of Resident #6's discharge paperwork on 3/3/26 from the hospital findings revealed No acute fractures are present in this patient. Interview on 3/12/26 at 10:17 a.m. with the Admin. stated CNA-A was transporting Resident #6 from her appointment when she slid out of her wheelchair. He stated CNA-A got a nurse to assess and get Resident #6 back in her wheelchair. Interview on 3/12/26 at 12:19 p.m. with the RN stated if a CNA found a resident on the floor, they should get a nurse immediately. The nurse would assess the resident to see if they could get up or if they needed to call 911. The RN stated she would inform the MD and FM of the fall. The RN stated she was not working at the time but heard Resident #6 slid out of her wheelchair coming back from an appointment. She stated they did x-rays and they showed an old injury, but the MD still gave orders to have her sent to the hospital. The hospital confirmed there were no new fractures and Resident #6 returned to the facility the same day. Interview on 3/12/26 at 2:45 p.m. with Resident #6 stated she had an appointment, the driver used the lift to get her wheelchair in the van. Resident #6 stated she started to slip, while she was in the van and the driver helped her to the floor. She stated the driver left her on the floor and she drove back to the facility. Resident #6 stated she hurt her leg, but it was broken before the incident. She had not seen CNA-A since the incident. Interview on 3/13/26 at 10:30 a.m. with the Admin stated Resident #6 was going up into the van on her wheelchair when she slipped out and the aide helped her back into her wheelchair. He stated x-rays were done and they saw the old fracture from around November 2025. The Admin stated Resident #6 was sent out to the hospital, and they reported no new injuries, only the old break. The Admin stated he had terminated CNA-A due to the incident. Attempted interview on 3/13/26 at 11:49 a.m. to with CNA-A by telephone. A , a message was left requesting a return call. No return call was received to date. Interview on 3/13/26 at 11:53 a.m. with CNA-B stated she did transportation training on how to load and unload a resident. She stated you they must load the resident at the back of the ramp, push them up and hook the latch at the back of the wheelchair and put the seat belt on. CNA-B stated she heard about CNA-A reportedly loading Resident #6 into the van when she started sliding. She heard CNA-A kneeled Resident #6 to the ground. CNA-B stated she would have gone back into the doctor's office for help or would have called 911. She heard CNA-A called when she got back to the facility for the nurse to help get her back in her wheelchair. Record Review of the facility's Safe Patient Handling, undated revealed The facility has a program to promote and assure safe patient handling for both the resident and the employee. The policy includes identification, assessment, and interventions to provide a comfortable safe transfer, repositioning, and resident movement. 6. Facility staff will report to supervisor the inability to complete resident lifting, transfer, or repositioning if they feel it will either endanger the resident or cause injury to staff. Record Review of the facility's Fall Risk Assessment dated 2/1/2007 revealed under 13. In the instance where fall risk measures do not prevent a fall, the resident will be assessed immediately for injury. Vital signs and first aid measures will be completed immediately. The Charge Nurse will notify the attending physician and family member as soon as possible after the resident has been stabilized. Record Review of the facility's Employee Auto Training Handbook undated revealed under Safety 1. Safety must always be our priority. 2. Employees will comply with all safety laws. 3. It is the responsibility of each of us to ensure that our organization operates safe equipment on our highways. Additionally, we must carry out assigned duties in a safe manner.

Based on observations, interviews and record review, the facility failed to maintain medical records for 3 of 10 residents (Residents #2, #3 and #4) reviewed for accurate documentation. The facility failed to document wound care treatments for Residents #2, #3 and #4 as ordered by the physician This failure could place 3 residents with pressure injuries at risk of not receiving the care and services to meet their needs.Findings included: 1. Record Review of Resident #2's MDS dated [DATE] reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE]. Her cognitive skills for daily decision making are severely impaired. Her diagnoses include Dementia, Alzheimer's Disease, Stroke, and Malnutrition. The resident was dependent on staff for her repositioning to her back, left, and right side. Resident #2 was always urinary and bowel incontinent and dependent on staff for toileting hygiene. Record review of Resident #2's Care Plan dated reflected:Resident had pressure ulcers or potential for pressure ulcer development.Resident had a performance deficitFacility Interventions:Staff to ensure heels are floated with the use of pillowsStaff to turn/reposition at least every 2 hoursStaff to assist resident with bed mobility, dressing, and toileting. Record review of Resident #2's TAR dated February 2026 indicated Resident #2 did not receive her scheduled wound care on the following days:2/7; 2/8; 2/11; 2/12; 2/13; 2/14; 2/15; 2/16; 2/20; 2/23. 2. Record Review of Resident #3's MDS dated [DATE] reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His cognitive skills for daily decision were moderately impaired. His diagnoses included: Heart Failure, Malnutrition, Muscle Weakness, Difficulty walking, End Stage Renal Disease. Resident was always urinary and bowel incontinent and required maximal assistance with toileting hygiene. Record review of Resident #3s Care Plan dated08/30/2024 reflected:Resident had a pressure ulcer or potential for pressure ulcer developmentGoal was for the resident will have intact skin, free of redness, blisters or discolorationInterventions were as follows:Administer medications as ordered. Monitor/document for side effects andeffectiveness.Follow facility policies/protocols for the prevention/treatment of skin breakdown.Incontinent care after each episode and apply moisture barrierNotify nurse immediately of any new areas of skin breakdown: Open area, Reness, Blisters, Bruises, discoloration noted during bath or daily care. A TAR dated February 2026 indicated Resident #3 did not receive his schedule wound care on the following days: 2/7/2026; 2/8/2026; 2/9/2026; 2/11; 2/12; 2/13; 2/14; 2/15; 2/16 3. Record review of Resident #4's MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her cognitive skills for daily decision making are intact. Her diagnoses include Type 2 Diabetes, Difficulty Walking, Muscle Weakness, Heart failure, and Protein-Calorie Malnutrition. Resident #4 was always incontinent in urinary and bowel continence and dependent on staff for toileting. Record Review of Resident #1's care plan dated 12/18/2025 reflected:Resident #1 had potential for pressure ulcer development; decreased mobility.Goal:will have intact skin, free of redness, blisters or discoloration.Interventions:Follow facility police/protocols for the prevention of skin breakdownThe resident needs assistance to turn/reposition at least every two hours. A TAR dated February 2026 indicated Resident #1 did not receive her scheduled wound care on the following days:2/11; 2/12; 2/13; 2/15; 2/16; 2/23. During an interview on 02/19/26 at 11:44a.m., ADON A revealed that she was currently the treatment nurse for the facility and that the facility expectation was that staff were to chart a treatment was completed in a residents medical administration record. ADON A stated that if there were missed wound care treatment dates on the medical administration record it did not mean that the staff did not complete the task. ADON A stated that that it the staff member may have been forgotten, but as a nurse and according to the DON expectation if it is not documented it was not completed. ADON A stated one way to tell if the wound care was completed was by the date and initial on the bandage or you can tell by the wounds that have healed or resolved. During an interview on 02/19/26 at 12:43p.m., the DON revealed that her expectations of staff were to document that they completed the task at least once per shift. The DON stated that if the documentation was not in electronic health record it meant one of three things that they completed the task and forgot to chart, or that the staff member did not perform the task, or that the resident was independent and did not require our assistance. The DON stated that if it was not charted it did not happen. The DON stated that the risk to the resident when staff do not document wound care residents pressure sores can get larger, infected, or prevent healing. During an interview on 02/19/2026 at 4:35p.m., the Administrator stated that his expectations of clinical staff were document care that was provided once per shift. The Administrator stated that if dates were missed on wound care it meant the wound care did not happen.The Administrator stated that the harm and risk to the resident when staff do not document wound care for resident was that the resident could develop skin break down, pressure wounds, get an infection, or prevent healing. The Administrator stated the facility had in-serviced staff on documentation on 02/06/2026. Record review of in-service dated 02/06/2026 which included the following topics:DocumentationPrevention of Pressure UlcersRecognizing Change of ConditionRounding and RepositioningCall Light Response Time Record review of facility policy titled Pressure Injury: Prevention, Assessment and Treatment with revised date of 05/05/2025 revealed6. Nurse Action/Rationale. 1. Prevention: The nurse can assist in the prevention of pressure injuries by performing the following nursing interventions; 1. Determine resident's skin tolerance to pressure and develop a turning schedule; resident should be turned every two hours or more often if necessary and notify the Treatment Nurse/designee of any potential problems. 10. Treatment Nurse/designee of DON will assess site and evaluate for appropriate stage as listed in this procedure. Sign off on treatment sheet any treatment completed.

Based on interviews and record reviews the facility failed to ensure each resident was treated with respect, dignity, and care for four (Residents #1, #3, #4 and #8) of 10 reviewed for resident rights. The facility failed to ensure all residents #1, #3 #4 and #8's call lights were answered in a timely manner. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met.Findings included: Record review of Resident #1's MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her cognitive skills for daily decision making are severely impaired. Her diagnoses include Dementia, Senile Degeneration of Brain, Stroke, Paralysis of her left side, and Protein-Calorie Malnutrition. The resident was dependent on staff for repositioning to her back, left, and right side. The resident did not have any skin conditions listed on admission. Record review of Resident #3's MDS dated [DATE] reflected an [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Her cognitive skills for daily living decision making were intact. Her diagnoses included Type 2 Diabetes, Muscle wasting and Atrophy, Lack of Coordination, and Muscle weakness. Record Review of Resident #4's MDS dated [DATE] reflected a [AGE] year-old female admitted to the facility on [DATE]. Her cognitive skills for daily decision making are intact. Her diagnoses included Malnutrition, Difficulty walking, Lack of coordination, and kidney disease. Record review of Resident #8 MDS dated [DATE] reflected a [AGE] year-old male admitted to the facility on [DATE]. His cognitive skills for daily decision making were moderately impaired. Resident #8 was diagnosed with Cerebral Infarction, Type 2 Diabetes, Vascular Dementia, End Stage Renal Disease. Record Review of Resident's Council Meeting Minutes dated 12/30/25 revealed complaints were made regarding call light response times. Record Review of Resident's Council Meeting Minutes dated 01/30/26 revealed complaints were made regarding call light response from nursing staff. It stated that staff would come into the room to turn the call light off and not assist with their needs. During an Interview on 2/18/26 at 10:05 a.m., Resident #1's family member revealed that staff do not answer call lights within a timely manner. Resident #1 family member stated that it had taken 45 minutes for staff to answer call lights also on rounding it had taken over two hours for staff to attend to her mother. Resident #1's family member stated there were no negative outcomes to Resident #1 due to the long wait. Resident #1's family member stated she had reported this to the DON and Administrator on 02/09/2026. Resident #1's family member stated that both the Administrator and DON were new and they informed her they were actively trying to hire additional staff and have let go of staff that did not want to perform their duties. Record review of facility grievance log for month of January 2026 revealed on 01/04/2026 a concern related to call light response time. Resolution revealed staff in-service. Record review of facility grievance log for month of February revealed on 02/09/2026 a concern related to call light response time. Resolution revealed staff in-services on call light response and rounding. During an Interview on 02/19/26 at 10:30a.m., Resident #4 stated that it takes staff up to an hour to respond to her call bell. She stated that it had happened on all shifts, but not every day, it depended on who worked that shift. She could not provide names of staff who took long time to answer call lights, During an interview on 02/19/2026 at 1:25p.m., Resident #3 stated that the staff were slow at responding to call lights. Resident #3 stated that she had waited up to an hour before someone had come but could not state a date. Resident #3 stated that she had not reported this to anyone, just figured they would get to me when they could. She stated that the facility had recently gotten a new Administrator and DON and was told they were actively trying to hire new staff and get rid of staff who did not want to perform their duties properly. During an interview on 02/19/2026 CNA B revealed that he received inservice on documentation, call lights, when he first started working at facility approximately 3 weeks ago. He stated that he received complaints from residents regarding call light response. He stated that when he had received the complaint, he would take care of the resident request. He stated the expectation to respond to call lights was within 2-3 minutes. He stated that he does have to answer call lights on all hall. He could not state how long the light had been on for, just try to assist the resident. In an interview on 02/19/2026 at 12:43p.m., the DON stated she expected her staff to answer call lights timely. The DON stated that she wanted all staff to answer call lights and if they could not take care of the problem, they needed to get someone who could. The DON said the call light should never stay on longer than five to seven minutes and anything over that time was too long. The DON said there was no reason that the staff should not answer the call lights or go in and turn the light off without fulfilling the residents request. The DON stated that if a facility staff member could not fulfill resident request the resident light should remain on and that staff member was to go get someone who could assist. In an interview with Resident #8 on 03/04/26 at 1:10p.m., he stated he had just returned from dialysis. He stated CNAs were not available when he returned from dialysis. He stated it did no good if he pushed the call light, because the staff would not show up to see what he wanted. He stated he returned from dialysis around lunch time. He stated he was always told that they were passing out the trays on hall, and he would have to wait until all the lunch trays had been passed. He stated when he returned from dialysis, he was very tired and wanted to get into his bed. Observation on 03/04/26 at 1:30p.m., the Social Worker responded to the call light of Resident #8. The Social Worker was observed by investigator telling Resident #8 that the food trays were a priority for the staff and they would come to see what he needed once the last tray was passed. Observed Resident #8 inform the Social Worker he wanted his bed made so he could lay down. In an interview on 03/04/26 at 1:35p.m., the Social Worker stated on 03/03/26 Resident #8 had asked to change his room. She stated that later in the day he stated that he wanted to move back to the previous room. She stated that Resident #8's personal items were still in the room he moved from the second time. She stated she was explaining to Resident #8 that his personal items would be moved back to his room once the staff finished passing out the trays. She stated that his bed was made in the room that he left this morning, but it was not made in the room he moved back to yesterday. She stated that his family had requested to be present when his items were moved so that she could account for the items. She and a nurse got linen and made-up Resident #8's bed so that he could get into bed. In an interview on 03/04/26 at 2:40p.m., CNA G stated she was the only CNA working the hall on 03/04/2026 on the 6-2 shift. She stated if she saw the lights and she was busy she could ask someone to help her, she stated anyone could answer the call lights. She stated that she was assigned hall 600 and hall 400, the nurses were supposed to assist her with the residents. CNA G stated that when a call light was not answered in a timely manner it would place the residents at risk of not getting their needs met which could cause harm. Record review of facility In-service training attendance roster dated 02/6/26 reflected, Call Light Response time: Call lights should be answered promptly by any staff member. Call light is to stay on until need is met. Record review of facility In-service training attendance roster dated 02/6/26 reflected, Rounding and Repositioning: Changing [residents] position is imperative to the well being of the resident. It prevents skin breakdown and odors.Record review of the facility in-service on Rounding and Answering call lights dated 02/02/2026. Record review of facility policy titled Every 2 Hours Matters undated revealed the following:Rounding and Call light Responsiveness, why this is important.-Prevents falls, skin breakdown, and injuries-Reduces call light and resident complaints-improves resident comfort, dignity and safetyCall light Expectations-Answer call lights promptly-never ignore or silence a call light without checking-if you cannot meet the need right away: Acknowledge the resident; Communicate clearly when you will return

Based on observations, interviews, and record reviews, the facility 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 disease and infections for 1 (Resident #2) of 5 residents. The facility failed to ensure CNA A performed hand hygiene during incontinence care for Resident #2. This failure placed residents at risk for healthcare associated cross contamination and infections.Findings: Record Review of Resident #2's MDS dated [DATE] reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE]. Her cognitive skills for daily decision making are severely impaired. Her diagnoses include Dementia, Alzheimer's Disease, Stroke, and Malnutrition. The resident was dependent on staff for her repositioning to her back, left, and right side. Resident #2 was always urinary and bowel incontinent and dependent fir toileting hygiene. Review of Resident #2's Care Plan dated 12/04/2025 reflected:Resident had pressure ulcers or potential for pressure ulcer development.GoalPressure ulcer will show signs of healing and remain free from infection.Facility Interventions:Administer treatments as ordered and monitor for effectiveness.Follow facility policies/protocols for the prevention/treatment of skin breakdown. Record review of Resident #2's skin assessment dated [DATE] revealed that Resident #2's skin was intact. Resident #2 had a moderate/high risk for skin breakdown due to incontinence of urine and stool. On December 2, 2025 nurse practitioner was consulted for 3 new pressure ulcers discovered on resident's right heel and left toe. On January 20, 2026 new pressure ulcers were discovered on resident's left foot, right 4th toe, left big toe, and on right and left heels. On February 3, 2026, a new sacral pressure wound was discovered. During an observation on 2/18/26 at 1:30p.m. of Resident #2 revealed CNA B performed incontinent care. Resident #2 was lying on her left side with her eyes closed and non-verbal. Resident #2 responded to verbal stimulation. CNA B washed his hands and put on gloves. CNA B removed the brief, moved Resident #2 to her back and cleaned the perineal area. As CNA B cleaned Resident #2's perineal area he used the same soiled wipe to wipe her perineal area multiple times. Afterwards, CNA B used his soiled, gloved right hand to pull up his left sleeve before going back to incontinent care. During an interview on 02/19/2026 at 11:23a.m., CNA B revealed that he was not aware that he reused the same wipe when he performed incontinent care on Resident #2. He also stated that he did not realize he had adjusted his personal sleeve with soiled glove then continued to perform incontinent care without changing glove. CNA B stated that was not the facilities standard practice and was able to correctly state the correct way to perform incontinent care on residents. CNA B revealed he had received in-service on Infection Control prior to being able to work the floor three weeks ago. During an interview on 02/19/2026 at 12:43p.m., the DON, revealed staff were supposed to use one wipe then discard soiled wipe and get a new wipe to continue incontinent care and repeat until resident were clean. The DON stated they only used one clean wipe at a time to prevent infection. The DON stated that during incontinent care, staff should perform hand hygiene after they touch any part of their clothing, because there could be something on the staff's clothes. Record review of the facility policy Fundamentals of Infection Control Precautions undated revealed the following:A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility.Hand Hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene-After handling soiled or used linens, dressings

Based on observations, interviews and record reviews the facility failed to ensure each resident received and the facility provided with food that was palatable, attractive, and at a safe and appetizing temperatures for 3 (Residents #1, #2, and #3) of 8 residents reviewed for nutritional services. The facility failed to ensure the staff served hot meals to the residents, subsequently they had no interventions in place to address the delays in meal services. This facility could cause all residents to be at risk of not getting the nutrients needed for weight management and good health which could have led to weight loss and deteriorating health and decline resulting in decreased psychosocial well-being. Findings included: A)Record review of Resident #1's Quarterly MDS 11/20/25 revealed a [AGE] year old male who admitted [DATE]. He had a BIMS score of 08 (moderate cognitive impairment. For Eating: helper provided verbal cues and /or touching and contact guard assistance as resident completed activity, assistance may be provided throughout activity or intermittently. He had a diagnoses of coronary artery disease, hypertension, malnutrition, and protein calorie malnutrition and no checkmark for therapeutic diet and he had 7 days of insulin injections. Record review of Resident #1's Care plan dated 03/31/25, Resident has paraplegia, impaired cardiac functioning related to diagnoses of HTN and ASHD- Monitor/document/report to MD PRN any s/sx of malignant hypertension: Headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, difficulty breathing, diagnosis of diabetes mellitus - Diabetes medication as ordered by doctor, Resident #1 has anemia r/t abnormal lab - Encourage intake of foods high in iron, vitamin C, risk for weight fluctuations related to diagnoses of malnutrition and chronic kidney disease - Monitor and document meal intake per policy, monitor resident weights per facility policy. Record review of Resident #1's Diet order dated 10/20/25 revealed, Fortified/Enhanced Diet - diet Regular texture, Regularconsistency, DOUBLE MEAT/PROTEIN PORTIONS for diet. Interview on 12/05/25 at 10:32 am, Resident #1 stated he ate in his room and he did not like the food, You mean the slop that comes out the kitchen. He stated the food was always cold and stated he had not told the management staff but told the nurses about it. He stated he had not asked the staff to warm up his food and would just eat snacks in his room. He stated this facility needed to get some older people in the kitchen to cook the food so that it would stay hot longer and taste right. He stated he ate his meals in his room all the time and his hall was always served last. He stated the last time he received his food late was his lunch yesterday at 1:45 pm. B) Record review of Resident #2's Quarterly MDS dated [DATE] revealed a [AGE] year old male who admitted [DATE], he had a BIMS score of 04 (severe cognitive impairment). Eating: Helper sets up or cleans up; resident completes activity, helper assists only prior to or following the activity. He had a primary medical condition a stroke and diagnoses of anemia, hypertension, hyperlipidemia, CVA, Non -Alzheimer's dementia. He was on a therapeutic diet. Record review of Resident 2's Care plan revised 02/24/25 revealed, Resident #2 has a communication problem related to intellectual disabilities - Anticipate and meet needs, validate resident's message by repeating aloud. And for impaired cognitive function/dementia or impaired thought processes - Communicate with the resident/family/caregivers) regarding residents capabilities and needs. And for oral/dental health problems poor nutrition - coordinate arrangements for dental care, transportation as needed/as ordered, Monitor/document/report to Medical Doctor PRN s/sx of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth. And for diet order other than regular (NSOT, mechanically soft diet) - Monitor weight per facility protocol, offer substitute, if resident eats less than 50% or dislikes meal and offer supplement if resident continues to eat less than 50%, Registered Dietitian assess per facility protocol, the resident has mechanically altered diet. He was at risk for unplanned weight loss or gain - Monitor weight per facility protocol, offer substitute, if resident eats less than 50% or dislikes meal and offer supplement if resident continues to eat less than 50%, Registered Dietitian assess per facility protocol, the resident has mechanically altered diet. He had statuses related to hypertension and transient cerebral ischemic attack and hyperlipemia and osteoarthritis. Record review of Resident #2's Diet order dated 11/13/25 revealed, NSOT diet Regular texture, Regular consistency. Interview on 12/05/25 at 1:13 pm, interview was attempted with Resident #2 but he was not interviewable. Interview on 12/08/25 at 10:36 am, the FM stated Resident #2 complained about his meals being late and cold ever since he admitted to the facility. She stated he did not like the mechanically softened food either. B) Record review of Resident #3's Quarterly MDS Quarterly assessment dated [DATE] revealed a [AGE] year old female who admitted [DATE] with a BIMS score of 15 (no cognitive impairment). Eating: helper sets up clean up; resident completes activity helper assists only prior to or following the activity. She had diagnoses of cancer, anemia, coronary artery disease, heart failure, hypertension, peripheral artery disease, ulcerative colitis, renal insufficiency, diabetes mellitus, hyperlipidemia, malnutrition, gastro-esophageal reflux and diverticulitis of large intestine. There was no therapeutic diet checked. Record review of Resident #3' Care plan revised on 11/19/25 revealed, Resident #3 has potential/actual impairment to skin integrity related to edema, fragile skin - Avoid scratching and keep hands and body parts from excessive moisture. encourage good nutrition and hydration in order to promote healthier skin. And for heart failure and takes diuretics as ordered - Monitor/document/report to MD PRN any s/sx of Congestive Heart Failure: dependent edema of legs and feet, periorbital edema, .weight gain unrelated to intake, diabetes mellitus - Monitor/document/report to MD PRN for s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss And for hypertension - Monitor/document/report to MD PRN any s/sx of malignant hypertension, Headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting. And for impaired immunity related to: cancer, lupus and lymphedema - Encourage fluid intake and adequate rest to bolster the immune system, monitor /document/report to MD PRN any s/sx of infection: Fever; Redness; Drainage or swelling around wounds or catheter sites; Cough, respiratory symptoms; Dysuria, hematuria, flank pain and foul smelling urine. And for GERD, diverticulosis, and Crohn's disease- Avoid lying down for at least 1 hour after eating. Keep HOB elevated. Encourage to stand/sit upright after meals, avoid overeating. Provide small frequent meals rather than 3 large ones. Encourage the resident to take their time eating. Alternate food with sips of fluids. And for alteration in hematological status related to history of thrombosis - Obtain and monitor lab/ diagnostic work as ordered. Report results to MD and follow. Interview on 12/07/25 at 8:30 am, Resident #3 stated she preferred to eat in her room and said her food usually was too hard and spicy to eat. She stated the food was cold most of the time and she ate sandwiches at times. She stated the food was never on time and whatever she did not like they put on her tray anyway. She stated when HHSC staff was in the building she would get breakfast in the 8:00 am hour but when they were not at this facility she would usually get it at 9:30 am. She stated she received lunch around 1:00 pm or 1:15 pm. She stated she would usually get dinner at 6:00 pm and said she guessed they did not have enough dietary staff. She stated hearing they only had two dietary staff in the kitchen. She stated the last time her food was cold and late was yesterday 12/06/25 her oatmeal was normally cold and the staff would not take it back to warm up because they said it was cross contamination. She stated they used to warm up the food but they stated it was against state rules so she just ate something else. She stated she did not file a grievance because she complained to the staff about the food issues. Interview on 12/08/25 at 10:48 a.m., FM 4 stated this facility changed cooks two or three times that he was aware of. He stated a few times he was a the facility for breakfast or lunch and the food was not cooked right. He stated, a few weeks ago for lunch, he did not know what was on the plate it looked like hamburger helper but it was hard to say. He stated Resident #3 complained about it and got food from the alternate menu. In a confidential interview on 12/07/25, (Anonymous) stated the food was served cold most of the time and hopefully things would get better with the new Administrator. They stated at least one to two meals had to be reheated daily because they were cold. They stated the management people were aware of the food issues and with not having enough dietary staff. They stated management needed to pay the dietary staff more money so they would stay. They stated the food was served late for two or three months and was usually an hour and 15 minutes late every day. They stated they were not sure if the dietary staff got to work late or what. They stated they had an idea how breakfast was to determine how lunch and dinner would be. They stated there was new staff working in the kitchen but the last time food was late and cold was last night 12/06/25. Interview 12/05/25 at 1:25 pm, the Ombudsman stated for the past year many residents complained about the food quality and about the food being late and cold getting to them. She stated the residents said the food was nasty, not good and there were complaints about the facility being understaffed. She stated the last time she was there was this week and it was the same complaints. She stated she had spoken to the Administrator each time visited the facility and there was still no changes. She stated she spoke to the last administrator and he said he was working on getting more dietary staff. She stated nobody like the food and she was not sure if the delay was in passing the trays out or something else. She stated over the past year up to 16 residents complained about the food. Observation on 12/05/25 of the facility's dining room services revealed: 12:40 pm, 12 residents were eating their meals in the dining room. 12:50 pm, one staff passed out meals on the 100 hall and one staff passed out meals on the 200 hall to the residents who were in their rooms. 1:10 pm, most of the meal trays were sent to the halls but not the 600 hall. 1:35 pm, one staff passed out meals on the 600 hall. Interview on 12/05/25 at 2:39 p.m., LVN B stated Residents #1 and #2 complained about their food being late and cold often. She stated she spoke to the kitchen staff about warming up their meals and hot plates were made for them. She stated she was not sure why the resident's food came out late and was not sure why she had not spoken to management about the meal issues. Interview on 12/06/25 at 10:54 am, [NAME] C stated she heard about the food complaints. She stated she and DA D usually work together on the split shift schedule. She stated they needed one more DA for their shift and said they had not had a DA for two weeks or so. She stated the DD had been coming in to help at times with meal services which helped. She stated she heard the Morning [NAME] E ran late and did not start her shift on time and was not sure why. She stated yesterday (12/05/25) breakfast and lunch was late and said that DD was starting to make changes. She stated they were good with having enough cooks just short on a DA. She stated whenever she cooked the breakfast was on time. Interview on 12/06/25 at 11:05 am, DA stated he worked the split shift. He stated they used to have a full team but when the previous DD quit, one cook and two DA's left. He stated a Corporate lady was the temporary DD over the dietary department for a few weeks. He stated the new DD F started working here two or three weeks ago and said they needed 1 more DA for his shift. He stated he helped with setting up the meal trays with silverware and cooked as needed. He stated in the mornings the meals were getting out late because the dayshift dietary staff were not prepping early enough. He stated sometimes when he came to work at 1:00 pm the dayshift dietary staff were still making lunch plates so he would help. He stated sometimes it could take up to five minutes for a nurse to check the meal trays and sometimes they had to go get a nurse. He stated the morning shift had one cook and two DA's and for about a month the split shift only had one cook and himself. He stated not being sure why the Dayshift dietary staff was always running behind. He stated there was a new DA that work two times on the split shift, but she had not been back to work but still on the schedule. He stated the last time the new DA worked here was last Thursday 12/04/25 he believed. He stated [NAME] E did not have a since of urgency when food prepping and cooking but [NAME] C was great in getting the meals out on time and the food was never brought back for hot meals. He stated the split shit go the food out on time with just himself and one cook and did not understand why the Dayshift Dietary staff ran behind with more staff. Interview on 12/06/25 at 12:26 pm was attempted with [NAME] E but she did not answer and a message was left for a return call. Interview on 12/06/25 at 12:55 pm, CNA I stated she started her shift at 6:00 am. She stated almost all of the resident said their meals were late and cold. She stated Resident #1 mentioned his food came out late and cold since the end of October 2025. She stated for lunch Resident #1 complained about his breakfast and lunch being late. She stated DD F should know about these concerns. She stated 9 times out of 10 the meals came out late from the kitchen and it was not that the meal trays were sitting in the hallways that caused the meals to be late. She stated if meal trays were rolled out at 8:30 am the nursing staff could get the meals out to the residents in their rooms a lot earlier. She stated the latest time for lunch trays were served to the residents was 1:45 pm in the past month. She stated the meals were supposed to come out at 12:00 pm but the 600 hall residents did not get their meals until 1:30 pm or 1:45 pm. She stated the DON and ADON knew about the meal time issues. She stated they had Inservice trainings but had no open forum for them to discuss their concerns for getting feedback about the meal service delays. Observations on 12/06/25 revealed:*12:25 pm , there was 8 residents in the dining room watching TV and waiting for meals. *1:24 pm the meal carts rolled to the 600 hall and one staff passed out the meal trays to the room residents; the last tray was given to a resident was at 1:34 pm *1:37 pm - Test was tray given after last resident served their meal - the test tray food looked appetizing and was hot. (Chicken fried steak with gravy, baked potato with green beans and a roll). Interview on 12/06/25 at 1:58 pm, SW H stated some of the residents complained about the food being cold and one resident said he was served a burnt pancake three weeks ago. She stated the last time she received a complaint about cold food was in the past month. She stated she noticed the meal carts were served late on Saturday 11/08/25 when she was manager on duty, She stated on Sunday 11/09/25 the meal carts went out late for lunch around 1:45 pm. She stated the kitchen staff was short staff and they needed another DA and figured that was why they were late coming out of the kitchen. She stated in the last two weeks she has had to warm up a resident's food because it was cold, but did not write it down as grievances. She stated she talked in the standup/standdown meetings about the cold meals and they were told management staff would help with serving the residents their meals. She stated she was responsible for making sure the relevant department head resolved grievances then the grievance were given to the Administrator. She stated the late and cold meals was still a concern. Interview on 12/07/25 at 9:34 am was attempted with [NAME] E but she did not answer and a message was left for a return call. Interview on 12/07/25 at 10:55 am, DOR K stated sometimes get the residents food was late and cold. She stated they discussed the meal issues in their last standup meeting and how to resolve it. She stated they were not sure why the trays were not being moved fast enough and were told to tell the staff to move much faster and they were going to continue to monito the situation. She stated everyday Monday - Friday, the department heads did daily room rounds. She stated they were supposed to ask the residents how was their food before their standup meetings to be able to discuss in the meetings. Interview on 12/07/25 at 11:55 am, Staffing Coordinator L stated Resident #1 and #2 complained about their food being late and cold. She stated they were no longer about to use the microwave in the breakroom to warm them up. She stated they just ask the dietary department to make another plate and said the last time Residents #1 and #2 complained about the food and they had to get hot meals was last Friday 12/05/25. She stated HR M stated they were needing one DA the past Friday 12/05/25. Interview on 12/07/25 at 12:46 pm, HR M stated they needed one more cook and DA. He stated cook was hired was a no call not show two weeks ago. He stated DA N worked split shift who worked last Thursday 12/04/25 but she quit. He stated they had a pool of applicants about 30 something that DD F was interviewing. He stated this facility paid the cooks $14.00 per hour and DA $12.00 per hour and had asked corporate about increasing hourly pay rates they said they could not do. Observations of the dining service on 12/07/25 revealed the following: *1:00 pm - Residents were in the dining room eating and meal trays were being served to the residents in their rooms. *1:10 pm - There was six dietary staff (including DD) preparing the meal trays for the hall carts, they appeared to be moving fast. The food was being prepared from the steam table and the food appeared hot because steam was seen coming them. *1:29 pm - The 600 hall residents were not eating yet. *1:31 pm - A female staff rolled the meal cart to the 600 and started passing out meal trays. *1:36 pm - There was one female staff passing out meal trays to the 600 hall residents *1:37 pm - Resident #2 received his lunch tray and began eating his food and they said it was served hot. *1:38 pm - Resident #1 received his lunch tray and began eating his food and they said it was served hot. Interview on 12/07/25 at 1:53 pm was attempted with [NAME] E but she did not answer and a message was left for a return call. Interview on 12/07/25 at 2:05 pm, DA P stated there were still issues with dining room services. He stated sometimes once the dietary staff put the meal carts out, the nurses were not around to check them. He stated the meal carts sat for a while and sometimes he had to get a nurse to check the trays. He stated the last time there was a delay in getting a nurse to check the trays was last Wednesday 12/03/25 for breakfast. He stated they had enough dietary staff and as long as they worked together they were able to get the meals out. He states if someone was slacking they went to help that person in the kitchen. He stated to his knowledge there was no issue with the cooks not working as fast as they could or getting to work late . He stated the cooks had to be at the facility at 5:00 am and the DA had to arrive at 6:00 am. He stated there was no issues with the dietary staff arriving to work late. He stated one dietary stated was late to work due to the traffic being bad a month ago but normally that did not happen. He stated they had enough cooks but needed one DA since last month. He stated they needed another DA nightshift. Interview on 12/07/25 at 2:34 pm, ADON A stated there were no complaints about the residents' food being cold or late. She stated she may have seen meal trays going out late about two months ago. She stated they did not rewarm the residents meals per policy but would get them another hot plate of food, She stated the dining room residents meal trays were served first, then the hall trays went out. She stated never just seen the meal carts just sitting waiting for a nurse to check it. She stated the expectation was for meal to go out at 12:30 pm and if dietary had a delay they needed to let them know. She stated expectation for all of the hall room trays to be delivered around 1:00 pm or 1:15 pm. She stated she was not aware the meal trays being served to the residents at 1:40 pm or 1:45 pm. She stated if residents received their meals late and cold could cause them to get an infection, get sick, have weight loss and make them not want to eat. Interview on 12/07/25 at 3:09 pm, DD F stated on 11/05/25 one resident really pulled him in to talk to him about the food experience not being good. He stated he told that resident what he was he going to do to address the issues by working with and re-educating the staff. He stated this resident did not want his sausages being overcooked around the edges. He stated he had not checked with this resident yet and was not aware his sausage was overcooked this morning 12/07/25. He stated this resident was really good about letting him know about a meal issue. He stated he used to have enough staff but DA N did not show up for work last Friday 12/05/25. He stated DA N said she did not have a babysitter and on Saturday 12/06/25 she was a no call no show and did not work. He stated the DA position was vacate for a month but he was filling in for that position. He stated he had two staff coming in to interview for that position. He stated he was going to do a wage analysis of the DA position, maybe the facility needed to increase the pay rate. He stated he needed a PRN [NAME] for when staff called out. He stated currently he had one cook and two aides for the day and evening shifts but the DA was needed for the split shift. He stated meal services started at 7:30 am, 12:30 pm and 5:30 pm and the food came from the steam tables hot and temperature checked. He stated once the meals were ready to push out it should only take one hour to serve the whole facility. He stated he was not aware the meals were getting to the residents at 1:45 pm until he saw HHSC surveyor on the halls. He stated he noted one staff person was passing out the meal trays and knew that was slowing down that person if had to get some missing off the tray. He stated he needed to come up with a plan for more staff to help serve the meal trays to get them to the rooms faster. He stated when a resident complained about having a cold plate the staff needed to get them another hot meal tray. He stated he did not recommend warming up the residents' meal place in a microwave due to cross contamination and temperature control issues. He stated the dayshift [NAME] E needed more work on meal prep and time management because there was no time to relax in the kitchen. He stated after breakfast the cook needed to be prepping for lunch. He stated he had been trying to address the cold plate complaints and was thinking about asking for the enclosed meal enclosed carts. He stated he saw the meal cart on the hall last week and asked the aide did she need helped passing out the meal trays. He stated it looked like the CNA was answering the call lights to get condiments and he told her to ask for help. He stated meals being cold could affect the residents, they could get sick and if they did not eat and diabetic it could cause their blood sugar to drop. He stated he spoke to HR M about the DA and PRN [NAME] staff needed and preferred dependable staff. He stated [NAME] E lacked experience [NAME] he was addressing. He stated the previous Administrator said the biggest problem at this facility was getting the food out fast enough. He stated there were no problems with the morning staff coming to work late including [NAME] E. He stated [NAME] E needed to prep in advance and said he had been watching her closely. He stated [NAME] C was good with getting her tasks completed and helping the DA's. He stated he was in the process of getting [NAME] C to be the dayshift to cook for breakfast and lunch services. He stated [NAME] C needed to give other job notice before she could change shifts here. He stated he had enough of a budget to run his department. He stated he had not reviewed the November resident council minutes but the department heads went over grievances in the standup meeting and there was a few cold food complaints. He stated he was doing his best to address them. Interview on 12/07/25 at 4:16 pm, the DON stated none of the residents complained about the meal services being late, cold or that staff refused to warm food. She stated there was on occasion the meal trays were late getting the residents in their rooms. She stated they did not have that problem any longer with meal services and could say the lunch services rolled over to 1:00 pm. She stated they were good about resolving grievances. She stated the SW H was great about bringing the resident and RP complaints to the morning meetings. She stated SW _ would ask the department head did they resolves the complaints for their departments. She stated the SW received the grievances and kept a log of them and gave the grievances to the department head to resolve the issue. Interview on 12/07/25 at 5:06 pm, the Acting Administrator stated he was new to the facility and was not aware of any complaints about the meals being late and cold. He stated he had not noticed the meal carts going out late causing delays with meal service. He stated he was aware of the kitchen being short a DA and cook which were both being posted on job sites. He stated he was in the process of asking for a higher wage for their cooks. he's ask for higher wage for a cook. He stated he noticed only one member of staff was passing out the hall meal trays and that he was going to make sure the department head helped pass trays to get them out faster. He stated he was currently working on getting this facility where it needed to be. Record review of the facility's Mealtimes posting revealed. Breakfast 7:30 am, Lunch 12:30 pm and Dinner 5:30 pm. If you have any question regarding meal services or times, please feel free to contact Director of food and nutrition. Record review of the 07/21/25 Resident Advisory Council minutes revealed, Want to get meals on time, dinner getting later and later. (There was no follow-up documentation to address concerns). Record review of the 08/28/25 Resident Advisory Council minutes revealed, Meal out on time. (There was no follow-up documentation to address concerns). Record review of the November 2025 Resident Advisory Council meeting was requested but the DON stated there was no meeting for this month because they did not have an Activity Director. Record review of the September 2025 Grievances revealed the following: 09/02/25 Resident #5 reported the eggs were cold, 09/03/25 Resident #6 reported the breakfast was cold , pancakes burnt doesn't like eggs so don't put on tray, 09/04/25 Resident #7 reported the breakfast was cold, and09/09/25 Resident #8 reported she didn't like her meal. Record review of the facility's October 2025 Grievances were requested from the DON and Administrator on 12/05/25 but was told they did not have it in the binder. Record review of the facility's November 2025 Grievances revealed, On 11/10/25 Resident #9 reported his breakfast meal was burnt. Observations between 12/05/25 at 12:40 pm and 12/07/25 at 5:30 pm, revealed the facility used metal frame carts that were not insulated and the last hall served meals was the 600 hall and for each hall there was only one staff person passing out the meal trays to the residents. Record review of the facility Daily Food temperature control policy dated 2012 revealed, We will assure that food is served at a safe temperature. Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature log. This is done to help ensure that food is safe and is served within the acceptable ranges. Procedure: 1. There is a thermometer available for use in the department to test the temperature of foods which is sanitized between food testing. 2. Prior to meal services, the cook shall take the temperature of all hot and cold foods. 3. Temperatures are recorded on the Temperature log form. 4. All hot foods shall be cooked and held for service at temperature of 140 degrees F or above. 5. Any hot or cold food which does not meet minimum acceptable temperature shall be heated to a temperature of 165 degrees F and held at least 15 seconds. These instances should be recorded on the HAACP form.

Based on observations, interviews and record reviews the facility failed to ensure they provided, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two (Residents #1 and #2) of eight residents reviewed for activities. The facility failed to ensure the residents had scheduled activities since Former AD G stopped working 10/31/25. This failure could place residents at risk of not having routine activities to stimulate their minds and prevent boredom which could result in a decrease in the residents health and psycho-social well-being. Findings included: A)Record review of Resident #2's Quarterly MDS dated [DATE] revealed a [AGE] year old male who admitted [DATE], he had a BIMS score of 04 (severe cognitive impairment). He had a primary medical condition of a stroke and diagnoses of anemia, hypertension, hyperlipidemia, CVA, Non -Alzheimer's dementia. Record review of Resident #2's Care plan revised 02/24/25 revealed, Has a communication problem related to intellectual disabilities, impaired cognitive function/dementia or impaired thought processes, oral/dental health problems poor nutrition, diet order other than regular (no salt on tray, mechanically soft diet), and is at risk for unplanned weight loss or gain. Has status related to hypertension, transient cerebral ischemic attack and hyperlipemia and osteoarthritis. And The resident has little or no activity involvement revision on: 07/25/2024 Resident #2 will participate in activities of choice as tolerated per week by review date, establish and record the resident's prior level of activity involvement and interests by talking with the resident caregivers, and family on admission and as necessary. explain to the resident the importance of social interaction, leisure activity time. Encourage the resident's participation. Interview on 12/05/25 at 1:13 pm, interview was attempted with Resident #2 but he was not interviewable. He was lying in bed watching TV in his room. Interview on 12/08/25 at 10:36 am, Resident #2's FM stated the facility had a family Thanksgiving dinner but she had not seen any activities lately. She stated she was not sure if it was because of the holidays or what. She stated she had not spoken to any of the staff about it yet. She stated Resident #2 liked to play dominoes and bingo but she had not seen him playing them in the past month or so. B)Record review of Resident #3's Quarterly MDS Quarterly assessment dated [DATE] revealed a [AGE] year old female who admitted [DATE] with a BIMS score of 15 (no cognitive impairment). She had a primary diagnosis of medically complex conditions. She had diagnoses cancer, anemia, coronary artery disease, heart failure, hypertension, peripheral artery disease, ulcerative colitis, renal insufficiency, diabetes mellitus, hyperlipidemia, malnutrition, gastro-esophageal reflux and diverticulitis of large intestine. Record review of Resident #3' Care plan revised on 11/19/25 revealed, Has potential/actual impairment to skin integrity related to edema, fragile skin, heart failure and takes diuretics as ordered, diabetes mellitus, hypertension, impaired immunity related to: cancer, lupus and lymphedema, GERD, diverticulosis, and Crohn's disease, alteration in hematological status related to history of thrombosis. And Resident #3 has little or no activity involvement. Revision on: 11/19/2025 - Resident #3 will express satisfaction with type of activities and level of activity involvement when asked through the review date. Explain to resident the importance of social interaction, leisure activity time. Encourage Resident #3's participation. Interview on 12/07/25 at 8:30 a.m., Resident #3 was sitting up in bed watching TV in her room, she stated she was not sure who the AD was now and had not seen any activities going on or being offered in a while and was not sure why, so she just watched a lot of TV. Interview on 12/08/25 at 10:48 am, FM 4 of Resident #3 stated [This facility] has had activities in the past but had not seen them doing any lately. He stated he used to see the residents playing bingo and things like that and it had been about a month since seeing the residents doing activities. In a confidential interview on 12/07/25, (Anonymous) stated they had not had any activities for two months. They stated they were supposed to have $200.00 per month for activities and was not sure what that money was being used for now. They stated they complained to the staff about not having activities and was told to go to the Church activities but said they were not into church like that. They stated the therapy did have music therapy twice a week but they were not interested in that. They stated they had not had bingo, movie matinee and no monthly birthday party for the residents. They stated they watched a lot of TV and went out on pass with family and friends and talked on the phone a lot. They stated hopefully activities would be back again really soon. Interview on 12/06/25 at 12:43, the DON stated Former AD G quit working at this facility on 10/31/25 and the Therapy Department and SW H were doing activities with the residents. She stated they could not find the Resident council minutes form for November 2025 and was not sure where Former AD G put it. Interview on 12/06/25 at 1:58 pm, SW H stated they did not have an AD anymore because she stopped working here in October 2025. She stated since the AD she was not filling in as AD and doing activities with the residents. She stated some CNA's and nurses played music for the residents and the residents watched TV and had church services. Interview on 12/06/25 at 2:23 pm, PTA J stated they did not fill in for the facility not having an AD but they did group therapy for all the residents who wanted to participate. She stated usually around 15 to 20 residents participated for one hour on Wednesday and one hour on Fridays. She stated they did exercises and balloon tosses, [NAME] says and wheelchair races. Interview on 12/07/25 at 10:55 am, DOR K stated they had group therapy with the residents in the dining room on Wednesdays and Fridays at 10:30 am that was available for all residents to do. She stated usually about 15 residents participated in the dining room. She stated the therapy department did not follow the schedule on the activity's calendar board. She had not seen the residents playing bingo, live music but had seen them watching TV like family feud and western shows in the dining room. Interview on 12/07/25 at 11:55 am, Staffing Coordinator L stated they did not have an AD since the beginning of November 2025 and said the therapy department did group therapy with the residents. She stated they would put the residents in a circle and talk to them, introduce themselves and play music. She stated the residents had not had any bingo, pretty nails, birthday parties, since the Former AD G left. She stated in their standup meeting they discussed they were running an ad for a new AD. Interview on 12/07/25 at 12:46 pm, HR M stated the Former AD G stopped working at this facility 10/31/25. He stated she went to another facility paying more money. He stated they were looking for another AD and one AD he interviewed said the pay was too low at this facility. He stated other interviewees were not experienced. He stated the staff did activities at times with the residents whenever they had time and said their Transportation driver O helped with activities but was not sure when the last she did activities like bingo with them. He stated they had three potential AD's but the pay at this facility was too low. He stated one AD potential had 10 years AD experience, but told him if the payrate was below $27.00 per hour she would accept the position. She stated this facility starting rate for AD was $19.50 per hour. He stated he had spoken to Corporate and they said they were not able to increase the pay. He stated they had a potential housekeeper interested in the AD Role but would have to get her certified first. Interview on 12/07/25 at 2:05 pm, DA P stated for activities he saw the residents doing exercises last Friday 12/05/25 and said they listen to music sometimes in the dining room. He stated he had not seen the residents having activities like Bingo on a regular basis. Interview on 12/07/25 at 2:34 pm, ADON A stated they have had some changes in the staff and no longer had an AD and the facility was currently searching for another one. She stated their therapy department did some group activities with the residents twice per week. She stated last Friday 12/05/25 therapy played music with the residents and said the residents loved their activities around here. She stated she was not be able to say if therapy was doing all the activities listed on the activity calendar. She stated she had not seen SW H doing activities with the residents. She stated each department head did champion rounds to each of the residents and was not sure who did the champion rounds for the 600 hall. She stated they did there very best as a team to resolve grievances, by getting their departments heads involved and to follow/up with the complainant to see if the complaint was resolved. She stated the SW was responsible for ensuring the complaints were address and then the Administrator and DON reviewed them. Interview on 12/07/25 at 3:09 pm, DD F stated this facility did not have an AD and was not sure how long she had been gone. He stated he saw the therapy department doing workouts around 10:30 am, with a few of the residents in the dining room at times during the week. He stated he had not seen anyone doing the activities like bingo and was not sure about the residents having activities on the weekends. Interview on 12/07/25 at 4:16 pm, the DON stated Former AD G stopped working here 10/31/25 which was why they did not have a November 2025 resident council meeting. She stated they were going to have SW H do a resident council meeting this week. She stated from what she heard they were advertising online for a new AD. She stated she was aware it was a regulatory requirement to have an AD at this facility but they had been some churches came by for singing. She stated the residents also had snack activities. She stated hospice companies provided birthday cakes for the resident and [NAME] for them and called bingo. She stated therapy did some group therapy with ethe residents Monday - Friday and said she was not sure if they were doing activities on the activities calendar. She stated the van driver also helped with activities at times. She stated not having an AD could cause the residents to get bored. She stated they talked about the need for an AD in their standup meetings Interview on 12/07/25 at 5:06 pm, the Acting Administrator stated they had an AD job posting on jobsites and knew they were interviewing for a new AD. He stated as a team they were doing activities with the residents and the therapy department did activities with the residents last Friday (12/05/25). He stated therapy was playing music and said he saw one staff doing a residents nails last Wednesday. He stated he was not aware if anyone was going by the activities calendar and had not seen residents playing bingo. He stated he knew it was important for this facility to have an AD and they were doing their best to hire someone soon. Observation on 12/07/25 at a.m., the 200 hall wall revealed a large activity calendar for October 2025. Record review of the November 2025 Resident Advisory Council meeting was requested but the DON stated there was no meeting for this month because they did not have an Activity Director. Observations between 12/05/25 at 9:30 am and 12/07/25 at 5:30 pm, did not reveal the residents in daily activities, some residents were seen watching TV in the dining room or in the hallways interacting with other residents and the staff. (On Friday 12/05/25 around 11:00 am several of the resident participated in a group activity with music playing in the dining room. And Sunday 12/07/25 around 11:30 am, Church services with 7 residents seen participating in the dining room. Record review of the November and December activity calendars were requested from the Acting Administrator and DON on 12/08/25 at 8:09 am, but they did not respond. Record review of the facility's Activities Director Policy dated 2011 revealed, ACTIVITY PROGRAMMING: STANDARD: The Activity Director and staff will provide for ongoing Activity programs. PRACTICE GUIDELINES: 1. Recreation programs are based on the interests and needs of the residents expressed through the Activity assessment. 2. Residents or family's expressed needs and interests are included in the development of programs. Input from residents may be done individually or discussed at Resident Advisory Council meeting. 3. Activity programs are based on resident's leisure interests and implemented to meet the needs (physical, cognitive, creative, social, spiritual, independent, and sensory) of the residents. 4. Programs will be geared to maintain functional ADL's, provide social interaction and, at the same time, protect residents from environmental over stimulation. 5. Those who cannot participate in group settings are provided individual programming. Inability to participate could include those who refuse to participate in activities, those who are in isolation, or physician ordered bed rest. 6. Programming includes large groups, small groups, individual and independent opportunities. 7. Programs may take place in mornings, afternoons and/or evenings that span throughout the entire week. 8. Programs use various areas available in and out of the health care center. 9. The resident population is cognitively assessed routinely to determine the number of functional level programs needed. 10. The opportunity is provided for regular community outings/trips. 11. Programs are developed to include community resources and involvement within, and outside, the health care center.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen observed for sanitization and storage: 1. The facility failed to clean dishes and eating utensils in accordance with proper sanitization standards when the facility's only chemical dishwasher was broken. 2. The facility failed to ensure food items, stored facility's only dry storage room, were sealed and dented cans discarded. These failures could affect residents by placing them at risk for cross-contamination and/or food-borne illness. Findings included: Observations and interviews, during the initial tour of the kitchen, on 5-27-2025 at 9:00 AM, revealed the following: Dry Storage Pantry Area: 1. 1- bag of cornbread mix was torn open exposed to air 2. 1- 11 lb. container of chocolate icing was dented and punctured at the bottom exposing the contents to the air. 3. 1-7lb can of lemon pudding was severely dented from one side to the other 4. 1- 8lb can of Apple Jelly was dented 5. 2- 50 oz cans of soup were dented In an interview with the Dietary Manager on 5-27-2025 at 9:05 AM it was revealed he did not know there were dented cans, torn packages, and punctured containers in the dry storage pantry. The Dietary Manager said it was his responsibility to ensure proper storage of dry foods and that food was not served from these deficiencies. The Dietary Manager stated he expected staff to check items stored in the dry storage area for torn or ripped packages and dented cans and for them to make sure all items were sealed and dated properly. The Dietary Manager stated the risk to residents being served food from punctured containers and items exposed to air was the possibility of getting food-borne illness. Dishwashing Area: The facility's only dishwasher was observed not being used and broken. Kitchen staff were observed using a 3-sink system with no sanitization solution in the third sink. In the same room, a single sink was being used to wash dishes with a spray nozzle and a plastic container of dirty looking water by Dietary Aide A. In an interview with the Dietary Manager on 5-27-2025 at 9:05 AM, it was revealed that the Dietary Manager did not know what type of dishwasher the facility had. The Dietary Manger said he had been working at the facility for 4 days. The Dietary Manager acknowledged the facility's only dishwasher had been broken since Friday 5-23-2025. The Dietary Manger said he found out about the broken dishwasher on Monday 5-26-2025, as he had been off all weekend. The Dietary Manager stated that the facility's Maintenance Supervisor was responsible for getting the dishwasher fixed. In an interview on 5-27-2025 at 9:10 AM, Dietary Aide A said she was washing dishes in her sink and another person was using the 3-compartment sink to wash dishes. When Dietary Aide A was informed this was not a sanitary procedure, to hand wash dishes, she said oh, I am just rinsing them off for the 3-compartment sink. In an interview on 5-27-2025 at 9:15 AM the Maintenance Supervisor indicated the facility had one chemical dishwasher and it broke down on Thursday 5-22-2025 in the morning hours. The Maintenance Supervisor stated he contacted the repair company to get the dishwasher repaired and was informed the company would charge overtime pay if they came out over the weekend. The Maintenance Supervisor said the repair company would not be able to come to the facility until Wednesday (5-28-2025) or Thursday (5-29-2025) of the following week. The Maintenance Supervisor said, the responsibility of getting the dishwasher fixed was thrown on him. In an interview with the Administrator on 5-27-2025 at 9:53 AM it was conveyed that the repair company could not come to the facility until Wednesday or Thursday. The Administrator stated the facility is using a 3-compartment sink to wash dishes and doing hand washing. The Administrator said the facility was not going to use paper plates until the dishwasher was fixed but was going to keep using the same dishes. The Administrator said he did not know what the risk to residents could be if dishes and silverware were not cleaned properly. The Administrator said the Maintenance Supervisor was responsible to ensure the facility's only dishwasher worked properly. The Administrator said his expectations were for the kitchen staff to us the 3-compartment sink to wash dishes and to follow the proper protocols to keep dishes properly sanitized for the residents. In an interview on 5-27-2025 at 9:45 AM Dietary Aide A was asked if she was doing temperature checks while she was only using one sink to wash dishes. Dietary Aide A got angry and said what are you asking me for, I feel like I am being ganged up on! Dietary Aide did not answer the question. On 5-27-2025 at 10:15 AM an observation was made revealing a test strip, was dipped in the sanitizing sink of the 3-compartment sink, by Dietary Aide A. The test strip revealed a 0 rating of a 50-ppm test. Dietary Aide A was informed that this failed the sanitization test. Dietary Aide A did not respond to questions after that. In an interview on 5-27-2025 at 12:30 PM, the Administrator stated that the facility's only dishwasher had been repaired and was working. In an observation on 5-27-2025 at 1:30 PM, it was revealed that the facility's dishwasher was working, reached 120 F, and indicated 50 ppm sanitization. In an interview on 5-29-2025 at 9:50 AM it was revealed Dietary Aide A had worked at the facility for 1.5 years. Dietary Aide A said her kitchen duties included making sure residents had their proper diet, serving food, and washing dishes. Dietary Aide A said she first learned the chemical dishwasher was broke on Friday 5-23-2025. Dietary Aide A said she did not know who was responsible to ensure dishes were properly sanitized. Dietary Aide A said the last time she was trained, on the proper use of the chemical dishwasher and hand washing dishes, was when she was first hired. Dietary Aide A said the proper way to hand wash dishes was to use a 3-compartment sink where one sink was to wash, the 2nd sink was to rinse, and the 3rd sink was to sanitize dishes. Dietary Aide A said the risk to residents, if dishes were not properly sanitized, was the transference of bacteria and the potential of making them sick. In an interview on 5-29-2025 at 10:15 AM the Dietary Manager revealed he had been working at the facility for 1.5 weeks. The Dietary Manager stated he was responsible to ensure the kitchen's dishwasher was working properly. The Dietary Manager stated he was making the initial kitchen tour rounds with the surveyor and heard Dietary Aide A say she was washing dishes in the single sink and not the 3-compartment sink. The Dietary Manager stated Dietary Aide A was not doing any temperature checks when she was cleaning dishes in the single sink, and she was not following proper procedures. The Dietary Manager stated he gave in-services on sanitization procedures in washing dishes on Wednesday 5-21-2025 and was doing more because of what he witnessed today. The Dietary Manager said the risk to residents if dishes were not properly sanitized was that they could get sick. The Dietary Manger stated he did in-services with the kitchen staff on proper dishwashing and handwashing techniques. Record review of the kitchen's Dishwashing Machine Temperature Check Log, dated 5-2025, revealed the exact same temperatures were entered into the log for 5-18-2025 thru 5-27-2025 during breakfast times for wash, rinse, and ppm checks. However, observations and interviews indicated the dishwashing machine had been broken since 5-22-2025 and temperature checks would not have been possible. Record review of Kitchen Staff's in-service training on 6-5-2025, revealed proper dishwashing procedures for 3-compartment washing, dishwashing procedures, and proper storage and labeling were completed on 5-27-2025 and 5-28-2025. Record review of the facility's food storage policy titled Food Storage and Supplies dated 2012 stated: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects . 3. Dry bulk foods (e.g. flour, sugar) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized . 4. Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened . 8. On perishable foods, microorganisms such as molds, yeasts, and bacteria can multiply and cause food to spoil . Record review of the facility's Dishwashing Policy titled Dishwashing Preparation and Dishwashing dated 2012, stated: The facility will complete the dishwashing process in a sanitary manner to provide clean and sanitary dishes and utensils. Procedure: 1. Prior to washing, all eating utensils shall be pre-flushed or pre-scraped to remove gross particles. This area is separate from the clean dish processing area . 10. Manual dishwashing of eating utensils will be used only in the event of dish machine failure. a. Prior to washing, all utensils and equipment will be pre-scraped or pre-flushed, and when necessary, pre-soaked to remove gross waste. b. Effective concentration of detergent will be used. c. The detergent solution will be kept reasonably clean. d. All equipment and utensils will be thoroughly rinsed free of the detergent solution. e. All equipment and utensils shall be sanitized by one of the following methods: 1.) Immersion for at least one-half minute in clean, hot water at temperature of at least 180 degrees F, or 2.) Immersion for a period of at least one minute in a sanitizing solution containing: a. At least 50 ppm of available chlorine at a temperature of not less than 75 degrees F, mix 1 oz. chlorine compound per 12 gallons of water to equal 50 ppm, or b. At least 12.5 ppm of available iodine in a solution having a pH not higher that 5.0 and a temperature of not less than 75 degrees F (mix 2 oz. iodine compound per 5 gallons of water to equal 12.5 ppm), or c. At least 150-400 ppm of a quaternary ammonium compound a temperature of around 70 degrees F, (mix 1 oz. Quaternary ammonium compound per 4 gallons of water to equal 200 ppm.) d. Any other approved chemical sanitizing agency containing at least twice the minimum strength of solutions used for immersion sanitation .

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that ensured drugs and biologicals were accurately acquired, received, dispensed, and administered) to meet the needs of each resident for one (600 Hall medication supply room) of two medication rooms reviewed for pharmacy services. The facility failed to ensure expired medications were removed from the 600 Hall medication room. These failures could place residents receiving medications at risk for possible adverse medication effects. Findings included: In an interview and observation on 05/27/25 at 09:15 am the following expired medications were noted in the Hall 600 medication supply room: 1.) Pink Bismuth 236 ml bottle (3 unopened bottles) with manufacturer expiration date of 02/ 2025 . 2.) Good Sense Hemorrhoidal Ointment (2 unopened tubes), 2 ounces each, with manufacturer expiration dates of 08/2024 (one tube) and 09/2023 (one tube). 3.) Banatrol Plus with Bimuno Prebiotic for Diarrhea and Loose Stools (2 unopened boxes), .38 ounces per packet, 75 packets per box, with manufacturer expiration dated 03/10/2025 (1 box) and 12/22/2024 (1 box). 4.) Bisacodyl 10 mg laxative suppository (3 unopened boxes), 12 suppositories per box, with manufacturer expiration date of 01/2025 (1 box) and 07/2024 (2 boxes). 5.) Geri-Max Antacid and Antigas 355 ml unopened bottle with manufacturer expiration date of 03/2025. The DON declined to state the risk of expired medications but stated, for now, we go by the pharmacy policy and she removed the medications from the supply for immediate disposal. In an interview on 05/27/25 at 09:50 am, the ADM reported that expired medications were to be removed from supply and that the nurse or medication aide who found the expired medications or supplies were responsible for removing and disposing of them and that the clinical management team consisting of the DON and ADONs were also responsible. He declined to state the potential risks that expired medications may pose to residents. Record review of the facility policy titled, Expired Medications and Medications with Shortened Expiration Dates reflected the policy was to prevent having expired medications in the facility and that, All OTC (Over the Counter) medications may be used until manufacturer's expiration date is reached or per the individual State Board of Pharmacy and State Health Departments rules and regulations.

Based on interview and record review, the facility failed to ensure care plans were developed in consultation with the resident and the resident's representative for 5 of 8 residents (Resident #26, Resident #52, Resident #55, Resident #57, and Resident #61) reviewed for Comprehensive Care Plan in that: The facility failed to ensure Resident #26, Resident#52, Resident #55, Resident #57, and Resident #61 or the resident's representative were invited to participate in the resident's care plan meeting. This failure placed residents at risk for a loss of independence, psychosocial well-being, and the opportunity for them to participate in the planning of their care. Findings include: Resident #26 Record review of Resident # 26's face-sheet dated 05/29/2025, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Cardiomyopathy, Unspecified (a person has a disease of the heart muscle (myocardium) but the specific cause of the disease is not known); Cardiac Murmur, Unspecified (means a doctor heard an extra noise or sound while listening to the heart with a stethoscope, but specific cause or characteristic is unknown without further evaluation); Essential (Primary) Hypertension (a type of high blood pressure where no specific underlying cause, such as a medical condition, can be identified). Record review of Resident #26's, quarterly MDS dated [DATE], reflected Resident #26's BIMS score was noted to be 15/15, which indicated intact cognition. Resident #26 required partial to moderate assistance with care and was able to speak and voice her needs. In an interview on 05/30/2025 at 3:57 PM Resident #26's family member revealed that she had not been invited to a care plan meeting in about a year. Resident #26 and family member received an invitation to attend a meeting this past March 0f 2025. She had only attended two previous meetings in 2024. Family member revealed Resident #26 did not attend the meetings because she wanted family member to attend. Family member revealed she worked in health care and knows how important it was for the residents and family members to be kept informed of what was going on health wise and what care was being provided. Record review of Resident #26's file revealed documentation of care plan meetings with resident or resident representative on the following dates: 07/11/2024, 08/19/2024, and 03/05/2025. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. The facility will provide the resident and resident representative, if applicable with advance notice of care planning conferences to enable resident/resident representative participation. The facility has held three care planning conferenced since resident's admission on [DATE]. Resident #52 Record review of Resident #52's face-sheet dated 05/29/2025, revealed an [AGE] year-old female admitted to the facility on [DATE] with a readmission on [DATE]. Her diagnoses included Flaccid Hemiplegia affecting Left Dominant Side (a condition where the left side of the body, Including the arm, leg, face, experiences paralysis with limp, floppy muscles due to neurological Damage); Frontal Lobe and Executive Function Deficit Following Nontraumatic Intracerebral Hemorrhage (bleeding into the substance of the brain in the absence of trauma or surgery. Can damage the frontal lobe, leading to a range of executive function deficits such as planning, decision making, working memory, and impulse control.) Record review of Resident #52's quarterly MDS dated [DATE], reflected Resident #52's BIMS score was noted to be 0, which indicated severe cognitive impairment. Resident #26 required maximal assistance with care and could not speak and voice her needs. In an interview on 05/29/2025 at 1:50 PM Resident #52's family member revealed that he would like to meet with the staff to know what was going on with his loved one. Family member does not remember the last care plan meeting care plan meeting he attended. Family member received a letter to attend the care plan meetings. Resident #52 is not interviewable and would not understand the meeting. The Family member knew of only three meetings that he could remember and those occurred a long time ago. Record review of Resident #52's file revealed documentation of care plan meetings with resident or resident representative on the following dates: 02/22/2022, 05/24/2022, and 10/29/2024. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. The facility will provide the resident and resident representative, if applicable with advance notice of care planning conferences to enable resident/resident representative participation. The facility has held three care planning conferenced since resident's admission on [DATE]. Resident #55 Record review of Resident #55's face sheet dated 05/29/2025 revealed a [AGE] year-old female admitted to facility on 09/22/2022 with a readmission on [DATE]. Her diagnoses included Unspecified Diastolic Congestive Heart Failure (occurs when the heart's left ventricle can't relax properly between beats, preventing it from filling with enough blood, and thus pumping out less blood than it should); Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease (a serious complication of diabetes where the kidneys are damaged by high blood sugars); Cerebral Infarction due to Embolism of Left Middle Cerebral Artery (occurs when a blood clot travels to the brain and blocks the MCA, Middle Cerebral Artery, leading to tissue death and stroke. Embolism, a blood clot, embolus that travels from another part of the body, like the heart or another artery, to the brain. Record review of Resident #55's, quarterly MDS dated [DATE], reflected Resident #55's BIMS score was noted to be 14/15, which indicated intact cognition. Resident #55 required moderate to maximal assistance with care and was able speak and voice her needs. On 05/29/2025 at 2:04 PM attempted to contact Resident #55's family member. Left message r/t reason for call and a call back number. Before the end of the day family member had not returned call. In an interview on 05/31/2025 at 1:42 PM Resident #55's family member revealed that she resided in another state, but the facility kept her informed of any medication changes or other issues that may be occurring with her loved one. Family member revealed that she has been invited to the care plan meetings, but living out of state she is unable to attend. Family member revealed she visits her loved one every three months and will meet with the staff to discuss Resident #55. Resident is unable to attend the care plan meetings per family member. Record review of Resident #55's file revealed documentation of care plan meetings with resident or resident representative on the following dates: 12/01/2022, 02/08/2023, 03/01/2023, 06/26/2023, and 12/27/2023. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. The facility will provide the resident and resident representative, if applicable with advance notice of care planning conferences to enable resident/resident representative participation. The facility has held three care planning conferenced since resident's admission on [DATE]. Resident #57 Record review of Resident #57's face sheet dated 05/29/2025 revealed a [AGE] year-old female admitted to facility on 03/04/2022. Her diagnoses included Cerebral Infarction, Unspecified (refers to a stroke, a type of brain attack where blood flow to the brain is blocked, leading to Tissue damage); Essential (Primary) Hypertension (a type of high blood pressure where no specific underlying cause, such as a medical condition, can be identified); Unspecified Protein-Calorie Malnutrition (the lack of sufficient energy or protein to meet the body's metabolic demands). Record review of Resident #57's, quarterly MDS dated [DATE], reflected Resident #57's BIMS score was noted to be 14/15, which indicated intact cognition. Resident #57 required partial to moderate to maximal assistance with care and was able speak and voice her needs. In an interview on 05/29/2025 at 1:00 PM with Resident #57 revealed she did not know what a care plan meeting was. Resident #57 said that her friend would know. Asked Resident #57 who her friend was, and she revealed she is the person who comes to see her when she needs personal items or snacks. On 05/29/2025 at 2:13 PM attempted to contact Resident #57's family representative. Left message r/t reason for call and a call back number. Before the end of the day family representative had not returned call. In an interview on 05/30/2025 at 2:14 PM Resident #57's resident representative revealed the facility will contact her with updates r/t Resident #57. The Resident representative said that she had not attended a care plan conference in over a year because of her own personal problems. Resident representative has received care plan invitations to attend the meetings, but not in a while. Resident does not attend the meetings because she does not get out of bed often. Record review of Resident #57's file revealed documentation of care plan meetings held with resident or resident representative on the following dates: 03/10/2022, 02/08/2023, and 04/05/2023. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. The facility will provide the resident and resident representative, if applicable with advance notice of care planning conferences to enable resident/resident representative participation. The facility has held three care planning conferenced since resident's admission on [DATE]. Resident #61 Record review of Resident #61's face sheet dated 05/29/2025 revealed a [AGE] year-old female admitted to facility on 01/07/2023 with readmission on [DATE]. Her diagnosis included Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Mood Disturbance and Anxiety (unspecified dementia that does not present significant behavioral Disturbances, such as agitation, aggression, or psychosis); Chronic Kidney Disease, Unspecified (occurs when a disease or condition impairs kidney function, causing kidney damage to worsen over several months or years); Essential (Primary) Hypertension (a type of high blood pressure where no specific underlying cause, such as a medical condition, can be identified). Record review of Resident #61's, quarterly MDS dated [DATE], reflected Resident #61's BIMS score was noted to be 05/15, which indicated severe cognitive impairment. Resident #61 required maximal assistance with care and could not speak and voice her needs. In an interview on 05/29/2025 at 2:04 PM Resident #61's family member revealed that he had not been asked to attend a care plan meeting for quite a while. The Family member had to cut the conversation short. In an interview on 05/29/2025 at 2:10 PM Resident #61's second family member revealed that he had previously attended two care plan meetings and believed this was about two years ago. Both family members received invitations to attend the care plan meetings. Resident #61 is unable to attend due to her dementia. The Family member stated he had not been notified of any further care plan meetings since that time or asked to attend. The Family member revealed the facility had his phone number and he was concerned because attending care plan meetings was something he would like to do. Record review of Resident #61's file revealed documentation of care plan meetings held with resident and resident representative on the following dates: 01/18/2023, 03/15/2023, 04/26/2023, and 07/05/2023. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. The facility will provide the resident and resident representative, if applicable with advance notice of care planning conferences to enable resident/resident representative participation. The facility has held three care planning conferenced since resident's admission on [DATE]. In an interview on 05/29/2025 at 11:35 AM the SW revealed that she was new to the facility and was in the process of becoming organized within the social services department. The SW revealed that care plan conferences will be on her list to be scheduled monthly with the assistance from the MDS Coordinator. The SW was aware that the care plan conferences needed to be a priority. The SW could not show any documentation r/t care plan invitations sent to residents and resident's representatives. In an interview on 05/29/2025 at 11:55 AM the MDS Coordinator revealed that it was her responsibility to make the monthly MDS schedule for the departments responsible for completing the quarterly MDS for each resident. The quarterly care plans were scheduled in conjunction with the MDS schedule. The MDS Coordinator revealed that she will provide a monthly calendar with the scheduled MDSs due for the following month to the SW to send invites to the resident and resident representatives to scheduled care plan meetings. The MDS Coordinator was unaware of if there were any documentation r/t care plan invitations sent to residents and resident's representatives. The MDS Coordinator was new to the facility in the position. In an interview on 05/29/2025 at 2:45 PM the DON revealed that all residents and resident's family members had the right to participate in the care plan meetings. The DON said the SW set up the meetings with the resident and invited family members by sending a letter of invitation. Quarterly meetings were usually triggered along with the scheduled MDSs. The SW was new, and the plans were to bring family members together for a meeting first. The goals will be to ensure that the residents and resident representatives are invited to participate in care plan meetings. In an interview on 05/29/2025 at 5:06 PM the ADM revealed that his expectations r/t resident care plans were that all residents and resident representatives were invited to participate in the quarterly meetings according to the MDS schedule provided by the MDS Coordinator. The SW will mail out letters to invite the resident and resident representative to the scheduled care plan meetings as scheduled. Record review of the facility's policy on Comprehensive Care Planning in the of the Nursing Policy & Procedure Manual (no policy date) revealed in part, The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. Facility staff will assist residents to engage in the care planning process, e.g., helping residents and resident representatives, if applicable understand the assessment and care planning process; holding care planning meetings at the time of day when the resident is functioning best; planning enough time for information exchange and decision making; encouraging a resident's representative to participate in care planning and attend care planning conferences. The facility will provide the resident and resident representative, if applicable with advance notice of care planning conferences to enable resident/resident representative participation. Resident and resident representative participation in care planning can be accomplished in many forms such as holding care planning conferences at a time the resident representative is available to participate, holding conference calls or video conferencing.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the Comprehensive MDS Assessment for one (Resident #79) of six residents reviewed for comprehensive care plans. The facility failed to care plan chronic pain for Resident #79 when her Comprehensive MDS Assessment indicated she had constant pain. This failure placed residents at risk for not receiving pain medication causing them to not get pain relief and lowering their quality of life. The findings included: Record review of Resident #79's admission record dated 5-28-2025, revealed an [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of metabolic encephalopathy (a brain dysfunction resulting from underlying metabolic problems or organ dysfunction, rather than direct brain injury) and secondary diagnoses of type 2 diabetes mellitus (high blood sugar levels due to the body's inability to use insulin properly, known as insulin resistance), cognitive communication deficit (difficulty communicating due to problems with cognitive functions rather than problems with speech or language), thrombocytopenia (lower-than-normal number of platelets in the blood for proper clotting), and pain unspecified. Record review of Resident #79's Comprehensive MDS Assessment, dated 5-5-2025 revealed she had a BIMS score of 13 indicating being cognitively intact. In the Pain Assessment Interview of Resident #79's MDS, it was assessed that Resident #79 had pain almost constantly, pain frequently disturbed her sleep, pain frequently interfered with day-to-day activities, and showed a pain intensity of 5 on a Numeric Pain Rating Scale of (00-10). Record review of Resident #79's Comprehensive Care Plan dated 4-30-2025 and revised on 5-5-2025 indicated the facility failed to implement care planning for pain. Record review of Resident #79's Physician Orders dated 5-23-2025 indicated Resident #79 was prescribed one Tylenol Extra Strength Oral Tablet 500 MG to be given by mouth every 6 hours as needed for pain. Record review of Resident #79's MAR revealed Resident #79 was given 15 dosages of Tylenol Extra Strength Oral Tablet 500 MG from 5-23-2025 thru 5-28-2025 for pain. An Interview, on 5-27-2025 at 12:31 PM, revealed Resident #79 had ongoing pain from arthritis and was receiving pain medication from the facility. In an interview with the MDS Coordinator on 5-29-2025, at 11:45 AM, it was revealed she had worked at the facility for 5 months. The MDS Coordinator stated the MDS Coordinator completed the Comprehensive and Quarterly Care Plans and was responsible to ensure residents were care planned correctly. The MDS Coordinator said she did not know why Resident #79 was not care planned for pain. The MDS Coordinator said the potential risk to residents not being care planned completely was that a resident might not receive the care she needed. In an interview with the DON on 5-29-2025 at 2:35 PM, it was acknowledged she had worked at the facility for 5 months. The DON said the MDS Coordinator was responsible for retrieving the information from the MDS Assessments and putting it into Care Plans. The DON said she did not know why Resident # 79 was not care planned for pain. The DON said she expected resident's care plans to contain the information assessed on their MDS Assessments. The DON said the potential risk to a resident who was not care planned, with all the MDS Assessment information, was that residents and family members could fail to be educated on the care that was needed. Record review of the facility's policy on Care Plan Planning titled Comprehensive Care Planning stated: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment . Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services. If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing, or currently has a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. Documentation regarding these assessments and the facility's rationale for deciding whether or not to proceed with care planning for each area triggered will be recorded in the medical record.

Based upon interview and record review it was determined the facility failed to provide the required specialized rehabilitative services such as but not limited to physical therapy and occupational therapy for mental illness and intellectual disability as required in the resident's comprehensive plan of care for 1 of 3 resident (Resident #1) reviewed for PASRR coordination and rehabilitation services. The facility failed to submit a Day Habilitation application within 20 days for Resident #1 which prevented the resident from receiving skill development and social interaction in a community setting. This failure could place the residents with intellectual and developmental disabilities at risk for not receiving specialized services that would enhance their highest level of functioning. Findings included: Record review of Resident #1's face sheet dated 03/13/2025 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included transient cerebral ischemic attack (mini-stroke), protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition), dementia (decline in memory, thinking and reasonings abilities that are severe enough to interfere with daily living), adjustment disorder with mixed anxiety and depressed mood (a subtype of adjustment disorder characterized by both anxiety and depressive systems as a reaction to a specific stressor or life change), muscle weakness, lack of coordination, anemia (body does not have enough healthy red blood cells or hemoglobin), hyperlipidemia (high level of fat (lipids) in the blood, including cholesterol and triglycerides), mild intellectual disabilities (a range of cognitive abilities that fall below the average range, but are still within the functional limits of daily life), insomnia (sleep disorder characterized by difficulty falling asleep, staying asleep or waking up to early despite having adequate time and opportunity to sleep), hypertension (condition where the force of blood against artery walls is consistently too high), osteoarthritis (degenerative joint disease where cartilage breaks down causing pain, stiffness and reduced movement, particularly in the hands, knees, hips and spine), overactive bladder (frequent urge to urinate), repeated falls. Record review of Resident #1's Optional State Assessment MDS dated [DATE] revealed he had a BIMS score of 7, which indicated severe cognitive impairment. The MDS reflected Resident #1 was totally dependent upon staff for 1-person physical assist with bed mobility, transfers, and toilet use eating, dressing, personal hygiene, and 2-person physical assist with bed mobility, transfers, and toilet use. Record review of Resident #1's care plan revealed the care planned areas: Focus: Resident has been identified has having PASRR positive status related to Mental Illness, Intellectual Disability, or Development Disability. Goal: Resident will have the specialized services recommended by local authority per PASRR Specialized Services Program as needed. Intervention: The Local Authority will be invited to the care plan meetings for review of Specialized Services. Record review of the IDT meeting record dated 08/8/24 revealed that Resident #1 had selected to attend Day Habilitation. Record review of the Local intellectual and Developmental Disabilities Authorities Habilitation Service Plan dated 11/5/24 revealed Day Habilitation Services were pending. Record review of the Local intellectual and Developmental Disabilities Authorities Habilitation Service Plan dated 2/3/25 revealed Day Habilitation Services were still pending. In an interview with the Social Worker on 03/13/25 at 12:11 PM, she revealed there was only one resident who has inquired about day habilitation and that resident's family received the admissions paperwork to fill out but had not returned the admission paperwork back into the facility. The Social Worker could not recall how long the family had the paperwork but stated that the resident had a care plan meeting last month and the day habilitation admission paperwork was mentioned and that the MDS nurse would be the staff member to follow up with family to check the status. The Social Worker stated she was not aware if there was an allotted time frame that the paperwork had to be completed or if the member would lose out on that specialized service. In an interview with Resident #1 on 3/13/25 at 12:50 PM, he revealed that he had a meeting about day habilitation and his family member had selected a facility and he would still like to participate in activities to get him out of the facility for a while. In an interview with the Rehabilitation Director on 03/13/25 at 3:17 PM, he revealed Resident #1's interdisciplinary team meeting was last year date unknown. The Rehabilitation Director stated that Resident #1 was PASRR positive and requested a customized wheelchair, air mattress and day habilitation. The Rehabilitation Director stated that he had 20 days to complete for the durable medical equipment but was unsure of the process for day habilitation services. The Rehabilitation Director stated that he believed that the previous MDS nurse had provided Resident #1 family the admissions paperwork, but if the admission packet was sent to him, he would fill out everything that he could then have the resident representative come and sign, because It is the responsibility of the facility to get the residents services they require. Rehabilitation Director stated that if the resident missed out on services, they were willing to participate in, it would cause a decline in the residents quality of life. In an interview with the MDS nurse on 03/13/25 at 3:53 PM, she revealed that Resident #1 last PASRR meeting was held on 2/05/2025 and during the meeting Resident #1 was asked if they were still interested in participating in day habilitation and Resident #1 responded yes. The MDS nurse stated that she wasn't sure who was required to fill out the admissions paperwork but believed it should be the social worker, but between nursing, therapy and MDS they have the information required to fill the admission paperwork out and believed it was their responsibility to the resident to get them the services they need. All that should be required from the resident representative is if their signature is require. The MDS nurse stated they have 20 days to turn in the admission paperwork and to her knowledge there was no follow-up with the family prior to 2/25/2025 to ensure the 20-day deadline, which caused the resident to lose out on day habilitation services at least until the following quarterly meeting when they could reapply. In an interview with the Administrator on 03/13/25 at 4:36 PM, he revealed he had only been at the facility eight days and was made aware that Resident #1 was PASRR positive and had not received specialized services, but Resident #1's family member had been provided the admission packet for day habilitation, but not sure how long it had been since they received it. The Administrator stated that it would be his expectation that if a resident is agreeable to services that those services should be made available and that if the facility was made aware that the family representative had difficulty filling out the paperwork, the facility should be willing to assist filling out the paperwork except for the signature. In an interview with Resident #1 on 3/13/25 at 5:15PM, he acknowledged to the Administrator that he had heard about going to day habilitation to participate in activities and therapy. When the administrator asked if he wanted to participate in that, Resident #1 stated that he would like to attend. Requested the facility PASRR policy, but administrator stated he was not able to locate the policy.

Based on interview and record review, the facility failed to develop and implement an effective discharge planning process that focused on a resident's discharge goals, identified the resident's needs and how these needs would be met upon discharge, and ensure resident's comprehensive care plan to included the resident's individual discharge plan for five (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) of five residents reviewed for discharge planning. The facility failed to develop a discharge plan for Resident #1 that focused on their specific needs and goals. The facility failed to develop a discharge plan for Resident #2 that focused on their specific needs and goals. The facility failed to develop a discharge plan for Resident #3 that focused on their specific needs and goals. The facility failed to develop a discharge plan for Resident #4 that focused on their specific needs and goals. The facility failed to develop a discharge plan for Resident #5 that focused on their specific needs and goals. This failure could affect residents' ability to discharge from the facility in a safe and orderly manner to ensure all discharge needs were identified and addressed. Findings included: Record review of Resident #1's Optional State Assessment MDS dated [DATE] revealed Resident #1 was a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses of aphasia (disorder affecting the person's ability to communicate) and chronic obstructive pulmonary disease. BIMS score was not completed for this assessment. Record review of Resident #1's care plan with a revision date of 3/12/2024 revealed there was no discharge plan and no discharge interventions to meet the resident's needs and goals. Record review of Resident #2's Quarterly MDS dated [DATE] revealed Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia, malnutrition, and lack of coordination. Resident #2's BIMS was listed as 09 (indicated moderate cognitive impairment). Record review of Resident #2's care plan with a revision date of 8/14/2024 revealed there was no discharge plan and no discharge interventions to meet the resident's needs and goals. Record review of Resident #3's Optional State Assessment MDS dated [DATE] revealed Resident #3 was a [AGE] year-old female admitted to the facility on [DATE] and had a BIMS of 15 (suggested no cognitive impairment). Diagnoses were not selected on this assessment. Record review of Resident #3's care plan with a revision date of 3/12/2024 revealed there was no discharge plan and no discharge interventions to meet the resident's needs and goals. Record review of Resident #4's Quarterly MDS dated [DATE] revealed Resident #4 was an [AGE] year-old-female admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease (disease that causes progressive memory loss) and hypertension (high blood pressure). Resident #4's BIMS was not completed for this assessment. Record review of Resident #4's care plan with a revision date of 8/27/2024 revealed there was no discharge plan and no discharge interventions to meet the resident's needs and goals. Record review of Resident #5's Quarterly MDS dated [DATE] revealed Resident #5 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of a cerebrovascular accident (stroke) and dementia. Resident #5's BIMS was listed as 07 (suggested severe cognitive impairment). Record review of Resident #5's care plan with a revision date of 7/29/2024 revealed there was no discharge plan and no discharge interventions to meet the resident's needs and goals. In an interview on 1/16/2025 at 9:42 a.m., the SW reported she did not complete a discharge care plan for every admission because most residents were long-term and were not planning to discharge. The SW reported not all residents had discharge care plans, and Resident #4 was discharged without a discharge care plan because the family would not agree on the discharge plan. The SW reported discharges were discussed in the morning meetings and that was how the team would know what the plan was for discharge. The SW stated she did not feel like there was a risk to the residents because they had a plan for discharge, but it was not on the care plan. In an interview on 1/16/2025 at 10:55 a.m., the DON stated discharge planning was done for skilled residents but not for long-term residents because they were not going to discharge anywhere. The DON reported discharge planning was done by the SW and was unsure if there was a discharge care plan. In an interview on 1/16/2025 at 4:50 p.m., the DON stated she was not aware of the protocol for this company concerning discharge planning and care plans because it was her second day. The DON stated the risk to the resident would vary based on the scenario, but they would work with everyone involved in the resident's care concerning discharge. In an interview on 1/16/2025 at 11:12 a.m., the ADM stated discharge planning started when a resident arrived at the facility and there should be a discharge care plan. The ADM stated if the resident wanted to stay long-term then the care plan would state the resident's plan was to stay long-term. In an interview on 1/16/2025 at 5:06 p.m., the ADM stated the discharge plan should be included in the comprehensive care plan and the risks to the residents could be a delay in discharge. The ADM stated the social worker should have been including the discharge plan in the care plan, and she expected the SW to include the discharge plan in the care plan. Record review of the facility's policy titled Discharge Planning Process Policy, with a revision date of 11/28/2016, revealed Discharge Planning includes: . 4. Include regular re-evaluations of the resident to identify changes that require modification of the discharge plan and B) Developing an interdisciplinary team discharge plan designed to ensure that the resident's needs will be met after discharge from the facility.

Based on interview and record review, the facility failed to promptly notify the ordering physician of results which fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for one (Resident #2) of five residents reviewed for diagnostic services. The facility failed to promptly notify Resident #2's physician of her x-ray results for two days which revealed a left shoulder dislocation. This failure could place residents at risk for a delay in care, risk for pain and risk for suffering. Findings included: Record review of Resident #2's Quarterly MDS dated [DATE] revealed Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia, malnutrition, and lack of coordination. Resident #2's BIMS score was listed as 09 (indicated moderate cognitive impairment). Record review of Resident #2's care plan updated 10/18/2024 revealed Resident #2 had osteoarthritis which included interventions to report a decline in mobility, joint pain, or joint stiffness to the MD and had a history of falls with interventions updated after each fall. Record review of Resident #2's progress notes dated 10/04/2024 at 7:30 a.m., revealed Resident #2 was found on the floor in her bedroom, and Resident #2 stated she did not know how she fell . Resident #2 was assessed and pain medication was administered due to pain on the left side of the body. Pain level was not documented in progress notes. The notes also revealed hospice, the MD, and DON were notified. Record review of Resident #2's physician orders did not reveal an x-ray order for the fall on 10/04/2024. In an interview on 1/16/2025 at 12:35 p.m., LVN A reported she found Resident #2 on the floor next to her bed on 10/04/2024. LVN A reported Resident #2 was partially on a fall mat on the floor when found and had a little pain with movement of the left arm. LVN A stated Resident #2 appeared comfortable after she was given pain medicine. LVN A stated she received an order from the MD to obtain an x-ray on Resident #2's shoulder and entered the order into the computer system. LVN A was unsure why the order was no longer showing in the system, but the x-ray was ordered on 10/04/2024. LVN A stated she worked the next night and checked for the x-ray results by logging into the computer. LVN A reported x-ray results would be available on the computer system and would be faxed. LVN A stated she checked the fax machine and computer system for x-ray results at the beginning of every shift and more often if she was waiting for results. LVN A reported she did not remember seeing Resident #2's x-ray results faxed, but she saw the results on the computer system on 10/06/2024 around 3:00 a.m . LVN A stated she sent a message to the hospice nurse when she saw the results and spoke with the hospice nurse the next morning. LVN A reported Resident #2 was declining prior to the fall and was on hospice. Record review of morphine (pain medication) record revealed directions to administer morphine every hour as needed for pain. The record also revealed morphine was administered as needed on 10/04/2024 at 8:00am, 11:00 a.m., 1:30 p.m., 7:11 p.m., and 9:43 p.m. On 10/05/2024 morphine was administered at 1:00 a.m., 2:00 a.m., and 4:00 a.m. On 10/06/2024 morphine was administered at 2:00 p.m. Record review of the x-ray report log provided by the x-ray company for 10/04/2024 revealed the order was called in by LVN A and the order was created on 10/04/2024 at 11:56 a.m. The report log revealed x-rays were taken 10/04/2024 at 6:47 p.m. and results were faxed to the facility on [DATE] at 10:21 p.m. The report log revealed the x-ray report was viewed in the computer system by the facility on 10/06/2024 at 12:55 a.m. In an interview on 1/16/2025 at 12:35 p.m., LVN A reported pain medication was administered after the fall on 10/04/2024 and Resident #2 was comfortable after receiving pain medication. Record review of Resident #2's progress notes dated 10/05/2024 at 4:34 a.m. revealed Resident #2 complained of pain and received pain medications as needed. Record review of Resident #2's progress notes dated 10/06/2024 at 2:53 a.m. revealed x-ray results were received and revealed Resident #2 had a dislocated left shoulder. This note also revealed Resident #2 was sleeping with no facial grimacing. The note did not state if anyone was notified of the x-ray results at that time. Record review of Resident #2's progress notes dated 10/06/2024 at 1:40 p.m., revealed the MD and DON were notified of the dislocated left shoulder. This note revealed Resident #2 denied pain at that time. Record review of Resident #2's progress notes dated 10/06/2024 at 5:22 p.m., revealed Resident #2 was transferred to the hospital. Record review of Resident #2's progress notes dated 10/06/2024 at 9:50 p.m., revealed Resident #2 returned from the hospital and her left shoulder was put back into place. In an interview on 1/16/2025 at 11:50 a.m., the MD stated he was notified of the x-ray results for Resident #2 on 10/06/2024. The MD reported it could cause a delay in treatment if results were not reported timely, and he expected results to be reported to him as soon as the facility received them. In an interview on 1/16/2025 at 3:51 p.m., ADON B reported x-ray results were faxed to the facility and were available on the computer. ADON B reported there was no requirement concerning how often to check the computer or fax machine. ADON B stated if results were not checked in a timely manner then the dislocation could get worse and the resident could have pain. In an interview on 1/16/2025 at 4:50 p.m., the DON reported she was not aware how x-rays were checked in this facility because it was her second day. The DON stated she expected the nurses to use due diligence and call her about any x-rays that were after a fall. The DON stated not obtaining results in a timely manner could place the resident at risk for pain. In an interview on 1/16/2025 at 5:06 p.m., the ADM stated she expected the ADON and Unit Manager to ensure labs and x-rays were checked. The ADM stated her expectation was that staff checked for x-ray results every shift. The ADM stated that obtaining results more than 24 hours after they were sent was not timely and could place the residents at risk for delayed care. The ADM stated she was unsure of the process at this facility because she had been there for one week. In an interview on 1/16/2025 at 6:19 p.m., the ADM reported the facility did not have a policy for diagnostic testing.

Based on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan, activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 4 of 4 residents (#20, #26, #45, #49) reviewed for activities in that: Residents #20, #26, #45, and #49 were not provided activities since AD's last day of employment on 03/16/2024. The facility currently did not have an AD on staff. This deficient practice could affect all residents who required activities and could result in decline in social and mental psychosocial well-being . The findings were: Review of Resident #49's face sheet, dated 04/18/2024, revealed he was admitted on [DATE]. Resident #49's diagnoses included Unspecified Sequelae of Unspecified Cerebrovascular Disease (a condition that affects blood flow in the brain); Essential (Primary) Hypertension (High Blood Pressure); Hemiplegia and Hemiparesis Following Other Cerebrovascular Disease Affecting Unspecified Side (Paralysis of partial or total part of the body function on one side of the body). Review of Resident #49's Comprehensive Plan of Care, initiated 01/05/2022, revealed Resident #49 will express satisfaction with type of activities and level of activities. Review of the interventions revealed CNAs will modify resident's daily schedule, treatment plan prn to accommodate activity participation. Review of Resident #49's Quarterly MDS assessment, dated 03/19/2024, revealed he was cognitively intact and needs supervision to touching assistance with his activities of daily living. The facility Activity Assessment on file dated 08/02/2023, for Resident #49 indicated he enjoyed going to activities with groups and musical programs. Interview with Resident #49 on 04/18/24 at 10:43 AM revealed the last AD would have several activities scheduled everyday. Resident #49 mentioned he would like to have a birthday party. The residents missed their birthday parties. Resident #49 said he would like to see the facility have musical programs, birthday parties, corn hole, and arts and crafts. Resident #49 stated he was not aware of the musical program that was held yesterday afternoon with gospel music and preaching. Resident #49 revealed that the facility cannot keep an AD because of the budget or they do not pay them enough. Resident #49 admitted his family member takes him out on pass to eat and brings other family members by to see him. Resident #49 revealed that helps with the boredom of not having anything to do. Review of Resident #26's face sheet, dated 04/18/2024, revealed she was admitted on [DATE]. Resident #26's diagnoses included Personal History of Malignant Neoplasm of Brain (Cancerous brain tumors); Epilepsy, Unspecified, Intractable, With Status Epilepticus (Seizures that can't be completely controlled by medications); Essential (Primary) Hypertension (High Blood Pressure). Review of Resident #26's Comprehensive Plan of Care, initiated 02/02/2024 and revised 02/12/2024, revealed Resident #26 will attend/participate in activities of choice. Review of the interventions revealed activity director will provide a program of activities that is of interest. Review of Resident #26's Quarterly MDS assessment, dated 03/29/2024, revealed she was cognitively intact and needs moderate/substantial assistance with his activities of daily living. The facility Activity Assessment on file dated 02/16/2024, for Resident #26 indicated she enjoys going to activities with groups, musical programs, going outside for fresh air, reading, and attending church services. Interview with Resident #26 on 04/18/24 at 11:31 AM revealed that she would attend some of the activities when there was an Activity Director. Resident #26 would attend Church group that came twice a week, but then the group stopped coming. Resident #26 attended the Gospel Music and speaker on 04/17/2024 after Resident Council Meeting. Resident revealed that she stays in her room most of the time. She likes to play on her I-Pad most of the time because there have not been any activities to attend without an Activity Director. Review of Resident #20's face sheet, dated 04/18/2024, revealed he was admitted on [DATE]. Resident #20's diagnoses included Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris (Caused by plaque buildup in the wall of the arteries that supply blood to the heart) ; Parkinson's Disease (Disorder of the central nervous system that affects movement, often including tremors); and Schizoaffective Disorder, Bipolar Type (A mental illness or mental episodes of feelings of euphoria, racing thoughts, increased risky behavior and other symptoms of mania). Review of Resident #20's Comprehensive Plan of Care, updated 10/17/2022 and revised 03/15/2024, revealed Resident #20 will attend activities of choice. Review of the interventions revealed activity director will encourage and remind resident of activities. Review of Resident #20's Quarterly MDS assessment, dated 03/14/2024, revealed he was cognitively intact and needs supervision with his activities of daily living. The facility had no Activity Assessment on file in Resident #20's medical file to review. Interview with Resident #20 on 04/18/24 at 12:46 PM revealed that the activities were being held and there would be at least 15 - 17 residents to attend the programs. There had been several ADs in the last 2 years the facility has been opened. The AD left to have her baby back in March and she was not returning. Resident #20 had held bingo for the residents. He revealed that the store was taken away from the residents for the bingo prizes. Resident revealed that his family member bought the last prizes for bingo store, but resident states that the Administrator stopped having the store for the prizes. Playing bingo, attending church and musical programs are his favorite programs. All Resident #20 does most of the day is watch TV. Resident #20 said that no one likes to play Dominoes. Interview with SW on 04/18/2024 at 10:10 AM the SW revealed the AD last worked there 3/16/24. The facility has been without someone to lead activities. The SW revealed that no other department heads have held any activity programs for residents. The SW revealed that there is a Church group that comes in. An individual came in yesterday (4/17/24) from one of the churches to hold gospel music time and preaching. There were only about 5 or 6 residents in the activity. The SW revealed that there was a sister facility in another city, but not sure on groups who could come in from there to hold activities. Interview on 04/18/2024 at 11:40 AM with the Administrator confirmed that he has been without an AD since March and has interviewed for a new Activity Director and hoped to offer the job to the applicant today. The Administrator had hired a new AD that was to begin work on Monday, 04/15/2024 but did not show up for the job. The Administrator revealed prizes for bingo has not been stopped. The prizes will resume, but in a more efficient way to be fairer to all the residents who win. Review of Resident #45's admission record, dated 04/18/24, reflected she was a [AGE] year-old female, admitted [DATE], with diagnoses of stroke, broken femur, diabetes, Bell's palsy (a condition causing one side of the face to droop), major depressive disorder, heart failure, and dependence on renal dialysis. Review of Resident #45's quarterly MDS assessment, dated 02/28/24, reflected Resident #45 was sometimes understood by others, and was able to understand others and had severely impaired vision. Resident #45 had a BIMS of 14, indicating intact cognitive function. Resident #45 had no behaviors, and no indicators of psychosis or depression, and rarely felt socially isolated. She used a wheelchair and had one-sided impairment of her lower body. Resident #45 was incontinent of bowel and bladder, and required supervision or touching assistance with eating, and required substantial to complete assistance of staff for most other ADLs, like dressing, bathing, and hygiene. She was dependent on staff to move her in her wheelchair. Review of Resident #45's care plans reflected: The resident needs in room socialization and sensory stimulation; Date Initiated: 03/01/2023; Revision on: 03/01/2023: Resident will respond to one on one in room visits with sensory stimulation such as tactile, and visual in room activities. Date Initiated: 03/01/2023; Target Date: 06/02/2024. The activity director will provide the resident with one on one [sic] visits with sensory stimulation at least 3 times per week Date Initiated: 04/11/2023. Review of Resident #45's care plans reflected no care plans which addressed out of room activity options or preferences. Review of progress notes for 01/30/24 through 04/17/24 reflected no notes regarding Resident #45 attending activities. An interview and observation on 04/16/24 at 10:07 AM with Resident #45 revealed her to be fully dressed with her coat on, seated in her wheelchair, waiting for someone to take her to dialysis. She was friendly and talkative, and said that she liked the facility, and the staff, and had few complaints, but did not like her roommate at all. An interview on 04/17/24 at 4:17 PM with Resident #45 and Resident #45's family member revealed that when Resident #45 first got to the facility she used to be taken to meetings, and church services. Resident #45 said that someone used to come and get her, and take her to some activities, and though she did not want to go to all of them, because she was blind, and could not walk, she would like to go to church services, and maybe music activities sometimes. She said that when she became blind, and stopped being able to walk, she stopped doing some things she liked to do. Her family member said that the facility had two activity directors that she knew of, and that Resident #45 used to be taken to a lot of activities, but it suddenly stopped, and she did not know why, but she did not go to any of them anymore. Resident #45 said nobody asked her if she wanted to go to things anymore. On 04/19/2024 at 12:22 PM, requested policies and procedures for Activity Program from Administrator. Informed by the Administrator during a conference on 04/19/2024 at 1:00 PM the facility does not have an activity policy. The facility follows the CMS guidelines required for the activity program. 44894

49733 Based on observation, interview, and record review, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications from enteral feeding for 2 of 2 resident reviewed for enteral feeds (Residents #6 and #36). The facility failed to check for residual volume prior to medication administration for Resident #6 and Resident #36. The facility failed to flush G-tube between and after medication administration for Resident #36. The facility failed to ensure that Resident #36's head of bed was maintained at 30 degrees elevated during medication administration. The facility failed to ensure medications were administered through gravity method for Resident #6 and Resident #36. These deficient practices could place residents receiving enteral nutrition and medications at increased risk of aspiration, infection, bloating discomfort, tube occlusion (blocked fallopian tubes), and not receiving the full benefit of the medications administered. The findings included: Review of Resident #6's face sheet, dated 04/17/24, reflected the resident was an [AGE] year-old female who originally admitted to the facility on [DATE]. Her diagnoses included Gastrostomy status (an opening in the stomach at the abdominal wall made surgically to introduce food), dementia, Alzheimer's, dysphagia (difficult swallowing). Review of Resident #6's quarterly MDS Assessment, dated 04/17/24, revealed Resident #6's BIMS score was blank which indicated severe cognitive impairment. Resident # 6 required extensive to total assistance with activities of daily living with two persons assist. Further review revealed Resident #6 had a feeding tube. Record review of Resident #6's medication administration and treatment record revealed an order with a start date of 04/01/24 - 04/30/24 which indicated, Enteral Feed Order, every shift Check residual before medications and feedings; return contents after each check. Enteral Feed Order every shift Flush with at least 5mls of water between each medication via g/t. Observation on 04/17/24 at 09:20 AM revealed LVN E administering medication s to Resident # 6 via the feeding tube. LVN E crushed medication and placed in separate medication cups and then mixed with 5 - 10cc of water. LVN E informed Resident #6 she was going to administer her medication, then LVN E positioned the resident and paused the feeding pump and disconnected the resident from the feeding pump. LVN E then flushed the feeding tube with 30 cc of water by pushing with a syringe and she did not check for residual. LVN E then administered all the medication by pushing with the syringe and flushing in between with 5 cc of water. After medication administration LVN E flushed the feeding tube with 30 cc of water by pushing with the syringe. In an interview on 04/17/24 at 09:42 AM with LVN E she had initially stated she was not supposed to check for residual, but when she checked the orders, she then stated she was supposed to check for residual. LVN E stated she was supposed to check for residual to make sure the resident's feeding was being digested without any issues and she was not being overfed. She stated when the stomach had too much volume it could lead to the resident vomiting which could lead to aspiration. Regarding pushing fluids with the syringe, LVN E stated she was supposed push the water with the syringe and that there was no order not to push fluids or medication. LVN E stated she was not aware what the facility policy discussed about pushing medication and water flushes via a feeding tube. LVN E stated she had been in-serviced on medication administration via the feeding tube but did not remember when. Record review of Resident #36's Face Sheet, dated 4/16/24, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included unspecified Intracranial Injury without loss of consciousness (damage within the skull or brain that occurs without the affected person losing consciousness), unspecified Protein-Calorie malnutrition (imbalance of essential nutrients from your food and drinks, leading to inadequate protein and calorie intake), Aphasia (a comprehension and communication disorder resulting from damage or injury to the specific area in the brain), and encounter for attention to Gastrostomy (the creation of an artificial external opening into the stomach for nutritional support or gastric decompression). Record review of Resident #36's MDS assessment, dated 3/05/24, revealed the resident was non-verbal and had impaired cognitive and mental status. The BIMS score was blank. Record review of Resident #36's Care Plan, completed on 3/15/24, revealed: Resident G -tube came out and was sent to hospital for replacement. Date initiated: 5/15/23. Related interventions: The resident needs the HOB elevated 30 degrees during and thirty minutes after tube feed. Intervention initiated 3/17/23. The resident has potential fluid deficit related to feeding tube. Date initiated: 3/17/23. Revised on: 6/19/23. Related interventions: Administer enteral feeding and flushes/fluids per G-tube as ordered; Administer medications as ordered. The resident has an alteration in neurological status related to brain injury. Date initiated: 3/17/23; Revised on: 6/19/23. Related intervention: Give medications as ordered . The resident has GERD . Date initiated 3/17/23. Revised on 6/19/23. Related interventions: Give medications as ordered . The resident has potential nutritional problem related to dysphagia (difficulty in swallowing); feeding tube in place. Date initiated: 3/17/23. Revised on: 6/19/23 and 10/06/23. Related interventions: Administer medications as ordered . Record review of Resident #36's Order Summary Report, accessed on 4/16/24, revealed the following: Baclofen Oral Tablet 5 MG (Baclofen). Give 1 tablet via G-Tube two times a day. Order date: 12/27/23, no end date. Citalopram Hydrobromide Oral Solution 10 MG/5ML (Citalopram Hydrobromide). Give 5 ml via G-Tube one time a day. Order date 7/08/23, no end date. Famotidine Tablet 20 MG. Give 1 tablet via G-tube two times a day. Order date: 3/10/23, no end date. Gabapentin Oral Solution 300 MG/6ML (Gabapentin). Give 6 ml via G-tube two times a day. Order date: 4/03/24, no end date. Levetiracetam Oral Solution 100 MG/ML (Levetiracetam). Give 10 ml via G-tube two times day. Order date: 6/20/23, no end date. MiraLax Oral Powder 17 GM /SCOOP (Polyethylene Glycol 3350). Give 1 scoop via G-tube two times a day. Mix with at least 4-8 ounces of water. Order date: 9/23/23, no end date. Multivitamin Adult (Minerals) Oral Tablet (Multiple Vitamins with minerals). Give 1 tablet via G-tube one time a day. Order date: 3/04/24, no end date. Zyrtec Allergy Oral Tablet 10 MG (Cetirizine). Give 1 tablet via G-tube one time a day. Order date: 7/08/23, no end date. NPO diet. Start date 3/07/23, no end date. Enteral Feed Order every shift Check placement prior to feeding and medication administration. Start date 3/06/23, no end date. Enteral Feed Order every shift Check residual before medications and feedings; return contents after each check. Start date 3/06/23, no end date. Enteral Feed Order every shift Flush tube with 60ml water before and after medication and feedings. Start date: 3/06/24, no end date. Enteral Feed Order every shift Flush with at least 5mls of water between each medication. Start date: 3/06/23, no end date. Enteral Feed Order every shift Head of bed up at least 30 degrees during administration of enteral formula or water. Observation of medication pass on 4/17/24 at 9:47 AM revealed RN D at her medication cart preparing medications for Resident #36 to be administered via G-tube. RN D dispensed one of each of the following medications into a small paper cup for each tablet and liquid: Famotidine 20mg tablet Baclofen 5mg tablet Daily Vitamin tablet Cetrizine 10mg tablet Clear Lax 1 capful Gabapentin Solution 6ml Continued observation revealed RN D placed each medication into a plastic sleeve and crushed each medication separately then combined the medications in a cup. She put crushed medications into one cup, mixed them with 30 ml of water and she put each liquid medications into cups. RN D entered Resident #36's room and flushed his G-tube with 60 ml of water via push method (pushing medications with a syringe) without checking for residual. The nurse administered the crushed medications/water mixture through the G-tube via push. RN D administered the liquid medications via push then clamped the tubing without flushing after medication administration. Resident #36's head of bed was observed to be elevated approximately 10 degrees throughout the medication administration process. In an interview on 4/17/24 at 10:15 AM, RN D stated that during administration of medications through a G-tube, nurses were to check for residual. She stated she checked for residual. She stated the reason you check for residual is to make sure the resident does not have too much in their stomach. RN D stated that nurses should flush with water before, after, and in between medication administration. She stated she flushed the G-tube according to protocol. RN D stated it was important to flush during and after giving medications to ensure the medications are flushed completely and received by the resident. She stated the amount of water used for flushing the tubing depended on the resident's orders. RN D stated Resident #36's HOB should be elevated at 2 or 3 during nutrition and medication administration through G-tube. When asked to describe the HOB elevation in degrees, RN D stated she only knew that it should be at a 2 or 3. In an interview on 4/17/24 at 3:13 PM, the DON stated medications should not be mixed when giving medication through G-tube. She stated the combination of pills can have an ill effect on the resident and cause stomach issues. The DON stated that if medications were mixed, there was no way to determine which medications were given if the nurse was unable to complete the process of administering medications to the resident. The DON stated nurses were supposed to check for residual before giving any medications. She stated that if a resident's stomach was too full and medication was administered, it could lead to aspiration and vomiting. The DON stated nurses should flush before, between, and after administration of medications. She stated that medications were supposed to be given through gravity. If they are pushed, it can increase peristalsis (involuntary movements of the muscles in the digestive tract) in the stomach and cause diarrhea. The DON stated that residents who receive nutrition and medication through a G-tube should have their HOB elevated to at least 30 degrees during administration. Review of the facility's policy titled Enteral Medication Administration dated 1/25/13 revealed: 1. Check the placement of the tube by aspiration of contents or auscultation. Elevate the resident per facility policy. 2. Flush the tube with 30 ml water or according to physician order. 3. Administer one medication at time with a flush of 5-10 ml water or the amount ordered by the physician, between each medication and after the final medication is administered. 4. Once all medication has been administered, flush the tube with 30 ml water or according to physician order. 5. Do not force any medication or fluid into the tube. Allow gravity to work . Review of the facility's policy titled Gastrostomy Tube Care dated 3/02/21 revealed: 1. Unplug or unclamp the tube and check the placement by aspiration or injecting air and listening to the stomach for sounds. 2. Aspirate gastric contents with a 60 ml syringe and if the residual is less than 50% of last feeding or within guidelines of specific physician's order reinject aspirate and continue . 3. Maintain the resident in a semi (30 degrees) to high-Fowler's (60-90 degrees) position for 45-60 minutes following a feeding.

Based on observations, interviews, and record review, the facility failed to provide food that accommodated resident's preferences for two (Resident #45 and Resident #53) of six residents reviewed for food preferences and the accommodation of resident's meal choices. The facility failed to provide Resident #45 and Resident #53 with preferred foods when they failed to provide them information about alternate meals available to them. This failure could affect the residents who are provided daily meals by the facility, by placing them at risk for not enjoying meals, and weight loss. Findings included: Resident #45: Review of Resident #45's admission record, dated 04/18/24, reflected she was a [AGE] year-old female, admitted [DATE], with diagnoses of stroke, broken femur, diabetes, Bell's palsy (a condition causing one side of the face to droop), major depressive disorder, heart failure, and dependence on renal dialysis. Review of Resident #45's quarterly MDS assessment, dated 02/28/24, reflected Resident #45 was sometimes understood by others, and was able to understand others and had severely impaired vision. Resident #45 had a BIMS of 14, indicating intact cognitive function. Resident #45 had no behaviors, and no indicators of psychosis or depression. She used a wheelchair and had one-sided impairment of her lower body. Resident #45 required supervision or touching assistance with eating, and required substantial to complete assistance of staff for most other ADLs, like dressing, bathing, and hygiene. She was dependent on staff to move her in her wheelchair. Review of Resident #45's care plans reflected care plans for dysphasia (trouble swallowing) (dated 01/05/24), nausea/diarrhea (dated 01/05/24), dialysis (dated 09/27/22, including monitoring of weights), anemia (low level of iron in the blood) (dated 01/05/24), risk of unplanned weight loss or gain with a regular renal diet (09/27/22, and noting resident and family were not compliant with diet.) Review of Resident #45's weights from January of 2024 through 04/16/24 through 04/19/24 reflected her weights to be relatively stable, with fluctuations normal for a dialysis patient. An interview and observation on 04/16/24 at 10:07 AM with Resident #45 revealed her to be fully dressed with her coat on, seated in her wheelchair, waiting for someone to take her to dialysis. She said she was blind, so she had to wait right there for them. She was friendly and talkative, and said that she liked the facility, and the staff, and had few complaints. When asked about the food, Resident #45 hesitated and said she liked some of the food. An interview on 04/17/24 at 4:17 PM with Resident #45 and Resident #45's family member revealed that they were not happy with the food at the facility. Resident #45's family member said they were happy with the facility, for the most part, but they fail on the food. Resident #45 said the only alternate she was able to ever get was a grilled cheese sandwich. Her family member said that a staff member used to come into the room before meals and ask Resident #45 what she wanted that day, but they stopped doing that, and the resident said that nobody ever asked her if she wanted something that was different from what was on the menu, and if she asked for something, it was always the same grilled cheese sandwich. Resident #45 and her family member said neither of them knew the kitchen normally prepared an entire second alternate menu, besides the already available menu. When Resident #45 learned that they had fish while she was out at dialysis, she said she would rather have the option of fish than almost anything else they served her, any day, but she only knew they were having it when they brought it to her. Resident #53: Review of Resident #53's Admission Record, dated 04/19/24, reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included sepsis (an extreme reaction in the body to an infection), unspecified protein-calorie malnutrition, dysphagia (difficulty swallowing), aphasia following stroke (difficulty speaking after a stroke), and gastroesophageal reflux (stomach acid irritating the lining of the esophagus). Review of Resident #53's quarterly MDS assessment, dated 03/14/24, reflected she was usually able to understand others, and be understood. She had a BIMS score of six indicating severe cognitive impairment. Her Functional Status indicated she had one-sided impairment of her upper and lower body, and used a wheelchair. Resident #53 was dependent on staff for most ADLs, but was able to feed herself with only set-up/ clean-up assistance from staff. Resident #53's most recent weight taken in the past 30 days was 159 pounds, and the document reflected no significant weight loss. Review of Resident #53's weights reflected a significant weight loss (over 7.5% in a three month period) of 8.8%: Review of Resident #53's care plans reflected she had care plans for an antidepressant for depression and poor appetite (01/10/23), potential risk of malnutrition (01/05/24), regular diet (02/26/24), and significant, unplanned weight loss (04/17/24). Review of Resident #53's Order Summary, dated 04/19/24, reflected an active order from 01/04/24 for Mirtazapine 15mg, 1 tablet at bedtime as an appetite stimulant. An order was added on 04/17/24 for weekly weights one time a day every Wednesday until 05/15/24. The document reflected she was on a regular diet, regular consistency, may use a divided plate. Review of Resident #53's dietary note, dated 03/26/24, reflected RD Significant Wt Loss Note Current weight: 159.2# BMI: 26.5 Wt change: -5.4%/-9# within 30 days Diet order: Regular diet, regular texture, regular consistency; divided plates Supplement: NA; Meds: protonix, MVI/mins, mylanta, bowel meds, mirtazapine, ondansetron, gabapentin Skin: Intact; Resident seen d/t significant wt loss of -5.4%/-9# within 30 days. Res has fair average meal intake = 50-75%/meal. Res feeds self with supervision/setup help. Res often does not like the facility's food but will eat well when family brings outside food. Res also has her own snacks at bedside such as crackers. Res denies chewing/swallowing difficulty but reports nausea after eating for the past week and sometimes excess gas. Res has also had episodes of diarrhea. Res receives anti-nausea med which temporarily resolves symptoms, but symptoms are ongoing. Res reports that appetite stimulant has helped to increase her appetite, but she doesn't like several foods. She also c/o lactose intolerance and wants to avoid all dairy. Nutritional Intervention: 1) Please note that res c/o lactose intolerance; avoid all dairy. 2) Note that resident states the following food preferences: avoid salty and spicy foods, bacon instead of sausage, toast with jelly instead of biscuit, likes tuna sandwiches but not grilled cheese or deli sandwich. 3) Add jello and/or extra dessert (no cake) with lunches and dinners x30 days, end date 4/26/24. 4) Assess if med review and/or GI consult are appropriate d/t ongoing GI symptoms (diarrhea, gas, nausea).; Goals: 1. no further significant wt change 2. No s/s dehydration 3. Skin to remain intact An interview and observation on 04/16/24 at 10:32 AM with Resident #53 revealed her to be alert, and to be able to carry on a complex conversation with the surveyor. She could not remember the date, but was able to fully answer questions about her care, and other subjects. She said that they had talked with her about her weight loss, and put her on a medication to increase her appetite, because she had, at one point, gotten to where she could barely eat at all. She felt the medication was helping, but she still had problems eating enough sometimes, because she did not like the food. She said the food was her only complaint about the facility, and she was very happy there, aside from it. She said it was way too salty, and some was too spicy, and on occasion they would bring her tuna salad, or pasta salad with tuna in it, and she liked that a lot. She said she had talked to the dietician about her likes and dislikes, and they kept sending her food she did not like, and would not eat. She said she liked maybe 3-4 meals they served regularly. An interview and observation on 04/17/24 at 12:20 PM revealed Resident #53 eating lunch in her bed. She tasted the broccoli beef dish and said it was OK, and not too salty for her. She said that she did not really like beef very much, and had not eaten it for [AGE] years before she got to the facility, but if they brought her something she could stand to eat, she would eat it. She said that on 04/16/24 she had gotten the tamales for lunch, and had scraped off all of the sauce, and that made it less salty, and she was able to eat it. She did not like beans or rice, so she did not eat those. She was not aware that they had fish as an alternate. She said she really liked fish, and would have requested it, if she had known. She said did not ask for an alternate, because she did not want a grilled cheese sandwich. An interview on 04/17/24 at 1:05 PM with DM revealed nursing was supposed to ask residents if they want the meal or the alternate meal. She said sometimes she asked residents herself, like if she knew someone did not like some of the meal for that day, or they have not been eating well. Nursing staff came to the kitchen and gave her a list of people who wanted the alternate. She said the residents knew there was an always available alternative meal . An interview on 04/18/24 at 2:27 PM with the Dietician revealed she knew the dietary aides talked to the residents about preferences, but she did not know how often and was not involved in that part of the process. She said she was under the impression that the Dietary Manager was very up-to-date on what the residents wanted and were requesting, but if she was not, it could be an issue that the residents might not be getting choices to meet their preferences. She said if they do not get choices that met their preferences, they might have decreased intake of food, which could lead to weight loss. An interview on 04/18/24 at 8:59 AM- CNA F revealed she just started working at the facility on 04/17/24. She said she was a temporary worker, and nobody had told her to ask the residents what they wanted for meals before the meal. She said if someone did not like their meal, she would talk to them about getting something else from the kitchen. An interview on 04/17/24 at 1:55 PM with CNA G revealed the staff used to go around and ask the residents what they wanted for their meals, and tell them the alternate, but they did not do that anymore. She said now, when the resident gets their tray, if they do not want what is on it, they can ask for an alternate. The staff would go to the kitchen and request it. In an anonymous group interview on 04/17/24, at 2:04 PM, residents complained that they were often not told about the alternate meals, or that they were out of the alternate foods. An interview on 04/17/24 at 4:22 PM with CMA B said that they did not do rounds to ask residents what their preferences were, but if a resident asked her what was on the menu, she would go and find out and tell them. She said they took the trays to the residents, and if they did not like what was on them, they could ask staff, and they would get them something else. Review of the undated copy of the always available menu reflected the menu was formatted as three forms to a sheet, to allow resident names, room numbers, and dates to be written, and a choice of food items to be circled. It reflected Lunch deadline 9:00 AM and Supper deadline 2:00 PM. The form listed a selection of entrees and sides, and included a variety of salads, burgers, deli sandwiches, steak fingers or chicken strips, boiled egg, potato chips, French fries, buttered pasta, green beans, or corn, as well as a selection of condiments/ dressings and sandwich toppings. No policy regarding food preferences was provided during the duration of the survey.

Based on observation, interview, and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 22% based on 6 out of 27 opportunities, which involved 1 of 2 Residents (Resident #36) observed for medication administration, in that: The facility failed to ensure RN D administered medications to Resident #36 via G-tube according to the physician's orders and per standard of practice by crushing six different medications and combining them into one cocktail and pushing them through the G-tube instead of by gravity. These failures could place residents at risk for not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions. The findings included: Record review of Resident #36's Face Sheet, dated 4/16/24, revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included unspecified Intracranial Injury without loss of consciousness (damage within the skull or brain that occurs without the affected person losing consciousness), unspecified Protein-Calorie malnutrition (imbalance of essential nutrients from your food and drinks, leading to inadequate protein and calorie intake), Aphasia (a comprehension and communication disorder resulting from damage or injury to the specific area in the brain), and encounter for attention to Gastrostomy (the creation of an artificial external opening into the stomach for nutritional support or gastric decompression). Record review of Resident #36's MDS assessment, dated 3/05/24, revealed the resident was non-verbal and had impaired cognitive and mental status. No BIMS score was specified. Record review of Resident #36's Care Plan, completed on 3/15/24, revealed: The resident has potential fluid deficit related to feeding tube. Date initiated: 3/17/23. Revised on: 6/19/23. Related intervention: Administer medications as ordered . The resident has an alteration in neurological status related to brain injury. Date initiated: 3/17/23; Revised on: 6/19/23. Related intervention: Give medications as ordered . The resident has GERD (gastroesophageal reflux disease). Date initiated 3/17/23. Revised on 6/19/23. Related interventions: Give medications as ordered . The resident has potential nutritional problem related to dysphagia (difficulty in swallowing); feeding tube in place. Date initiated: 3/17/23. Revised on: 6/19/23 and 10/06/23. Related interventions: Administer medications as ordered . Record review of Resident #36's Order Summary Report, accessed on 4/16/24, revealed the following: Baclofen Oral Tablet 5 MG (Baclofen). Give 1 tablet via G-Tube two times a day. Order date: 12/27/23, no end date. Citalopram Hydrobromide Oral Solution 10 MG/5ML (Citalopram Hydrobromide). Give 5 ml via G-Tube one time a day. Order date 7/08/23, no end date. Famotidine Tablet 20 MG. Give 1 tablet via G-tube two times a day. Order date: 3/10/23, no end date. Gabapentin Oral Solution 300 MG/6ML (Gabapentin). Give 6 ml via G-tube two times a day. Order date: 4/03/24, no end date. Levetiracetam Oral Solution 100 MG/ML (Levetiracetam). Give 10 ml via G-tube two times day. Order date: 6/20/23, no end date. MiraLax Oral Powder 17 GM/SCOOP (Polyethylene Glycol 3350). Give 1 scoop via G-tube two times a day. Mix with at least 4-8 ounces of water. Order date: 9/23/23, no end date. Multivitamin Adult (Minerals) Oral Tablet (Multiple Vitamins with minerals). Give 1 tablet via G-tube one time a day. Order date: 3/04/24, no end date. Zyrtec Allergy Oral Tablet 10 MG (Cetirizine). Give 1 tablet via G-tube one time a day. Order date: 7/08/23, no end date. Enteral Feed Order every shift Check residual before medications and feedings; return contents after each check. Start date 3/06/23, no end date. Enteral Feed Order every shift Flush tube with 60ml water before and after medication and feedings. Start date: 3/06/24, no end date. Enteral Feed Order every shift Flush with at least 5mls of water between each medication . Start date: 3/06/23, no end date. Observation of medication pass on 4/17/24 at 9:47 AM revealed RN D at her medication cart preparing medications for Resident #36 to be administered via G-tube. RN D dispensed one of each of the following medications into a small paper cup for each tablet and liquid: Famotidine 20mg tablet Baclofen 5mg tablet Daily Vitamin tablet Cetrizine 10mg tablet Clear Lax 1 capful Gabapentin Solution 6ml Continued observation revealed RN D placed each medication into a plastic sleeve and crushed each medication separately then combined the medications in a cup. She put crushed medications into one cup, mixed them with 30 ml of water and she put each liquid medications into cups. RN D entered Resident #36's room and flushed his G-tube with 60 ml of water via push method (using a syringe to the g-tube port and slowly pushing medications into the g-tube). The nurse administered the crushed medications/water mixture through the G-tube via push. RN D administered the liquid medications via push then clamped the tubing. Per physician order, Enteral Feed Order every shift Flush with at least 5mls of water between each medication . Start date: 3/06/23, no end date, RN D did not flush with at least 5 ml between each medication and instead combined all the medications into one. In an interview on 4/17/24 at 10:15 AM, RN D stated medications should be crushed separately but it was okay to combine medications for administration. RN D stated that nurses should flush with water before, after, and in between medication administration. She stated she flushed the G-tube according to protocol. RN D stated it was important to flush during and after giving medications to ensure the medications are flushed completely and received by the resident. She stated the amount of water used for flushing the tubing depended on the resident's orders. In an interview on 4/17/24 at 3:13 PM, the DON stated medications should not be mixed when giving medication through G-tube. She stated the combination of pills can have an ill effect on the resident and cause stomach issues. The DON stated that if medications were mixed, there was no way to determine which medications were given if the nurse was unable to complete the process of administering medications to the resident. The DON stated nurses should flush before, between, and after administration of medications. She said that medications were supposed to be given through gravity. If they are pushed, it can increase peristalsis (involuntary movements of the muscles in the digestive tract) in the stomach and cause diarrhea. Review of the facility's policy titled Enteral Medication Administration dated 1/25/13 revealed: 6. Each medication is to be prepared for separate administration. 7. Check the placement of the tube by aspiration of contents or auscultation. 8. Flush the tube with 30 ml water or according to physician order. 9. Administer one medication at time with a flush of 5-10 ml water or the amount ordered by the physician, between each medication and after the final medication is administered. 10. Once all medication has been administered, flush the tube with 30 ml water or according to physician order. 11. Do not force any medication or fluid into the tube. Allow gravity to work.

Based on observation, interview, and record review, the facility failed to ensure each resident's environment remained as free of accident hazards as is possible, and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #16) of five residents reviewed for accidents. The facility failed to ensure the safety of Resident #16 by not assisting with the consumption of hot liquids and meals, which caused him to spill coffee over himself during the breakfast meal on 04/17/24. This could affect residents by placing them at risk for injuries that could be prevented. Findings included: Review of Resident #16's admission record, dated 4/16/24, revealed he was admitted to the facility on [DATE]. Diagnoses included cerebral infarction (stroke), multiple sclerosis, tremors, unspecified lack of coordination, muscle weakness and conversion disorder with seizures or convulsions. Review of Resident #16's quarterly Minimum Data Set (MDS) assessment, dated 3/1/2024, revealed resident was moderately cognitively impaired with a BIMS score of 09. His MDS revealed his functional abilities for eating required supervision or touching assistance. Helper provides verbal cues and or touching steadying and contact guard assistance as resident completes activity. Review of Resident #16's Comprehensive Care Plan, accessed on 4/16/24, revealed that alteration in musculoskeletal status r/t contracture (permanent shortening and tightening of muscle fibers that reduces flexibility and makes movement difficult) of left hand was initiated 3/6/2023. The resident has an ADL self-care performance deficit initiated 2/24/2023. eating required staff assistance. Review of Resident #16's Comprehensive Care Plan, accessed on 4/16/24 revealed that the resident has hemiplegia/hemiparesis (paralysis) r/t weakness on one side. Initiated on 02/24/2023. Interventions included assist with ADL/Mobility as needed. Reposition at least every two hours. Observation on 4/17/2024 at 8:14am of Resident #16 revealed he was in bed at this time with breakfast in front of him on the bedside table. Resident #16 was observed to have trouble connecting food to mouth. Resident #16 grabbed coffee cup off the bedside table to take a sip but when returning the cup to the bedside table, he spilled coffee over himself and table due to unsteady hand. Observation did not reveal steam rising from the coffee. The resident did not indicate pain. Observation revealed no staff in the room providing the resident assistance during the meal. Interview with DON on 4/17/2024 at 8:25am revealed there was supposed to be a lid over the coffee cup. DON stated that she would conduct a burn assessment as well as get resident cleaned up. The DON stated she was unaware that no one was in the room with Resident #16. Interview on 04/17/24 at 10:12am with Resident #16's family, she stated it was a common issue that she had with the facility. She stated on Monday (04/15/24) he spilled hot soup on himself, and she has asked over and over if he could have assistance, but she feels it was a staffing issue. She also stated before his stroke the resident was left-handed so now the resident was trying the best he could to use his right hand but was dealing with the MS which limited his ability. She stated that the resident did not want to be a bother, so he did not call for help. The family member stated he just will not eat or would keep trying to do so despite spilling it on himself. Surveyor came with her to assess and revealed he did not have any burns. Resident #16's family stated the resident stated that the coffee was not hot, it was only warm. He stated that it would be nice if he could get some assistance, but he knows everyone is not always available. Review of Resident #16's hot liquid assessment dated [DATE], revealed resident had weakness/paralysis to upper extremities. Resident could not consume hot liquids/foods without special interventions. Interventions to decrease potential burns with coffee or other hot liquid include lids on cups, staff provide observation and verbal assistance while handling hot liquids, should be seated in upright position with table or overbed table. Review of the facility's document titled Assisted with meals (600 hall) revealed Resident #16 was listed as a resident needing assistance with meals. Observation and interview on 4/17/2024 at 10:15am with RN D revealed Resident #16 lying in bed drinking a cup of coffee. Resident #16's shirt was open, revealing the top half of his chest. No burns or redness was observed. Resident denies any pain or discomfort currently. Asked resident, if the coffee had burned his skin he responded, No it was warm, not hot enough to burn me, thanks for asking. Interview with CNA A on 4/18/24 at 11:42 AM revealed the CNA stated that she fed Resident #16. She said he needed assistance and if left to himself, he will spill food. Interview on 4/18/2024 at 10:51am with COTA C stated that he did not do the assessment for determining feeding assistance. He stated he has worked with Resident #16 before on wheelchair tolerance, Geri chair and tolerance and range of motion to the left side. He stated he did speak with evaluator K yesterday (4/17/24) due to the left hand noticing a contraction, although he does have range of motion. COTA C said he would be ordering a sling for that. He stated therapy typically would come in when a resident needed help in eating. He stated he had observed Resident #16 eating and before the resident was able to pick up a cup and fork with no problem. From COTA C's observation the spill came from the resident not having a lid on the cup, because when he came in to observe Resident #16, the resident was able to pick the coffee cup up and down without an issue. If there was an issue, he would have recommended a universal cup. COTA C stated from a therapy standpoint therapy's goal was to keep the residents' independence as much as possible. Staff usually will let therapy know if the resident had declined. COTA C stated evaluator K did the assessment for feeding assistance. Observation on 4/19/2024 at 9:15am Surveyor tasted coffee served in the dining room which is always available for residents. Coffee was warm to the touch and able to sip from cup. The DM stated this coffee was put out at 7:00am. She said it was brewed in the back to 200 degrees but is not allowed to be served until it cools down and they temp it at 140 degrees Fahrenheit and serve it. Review of facility's policy, Daily Food Temperature Control ., undated, .We will assure that food is served at a safe temperature. Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log. This is done to help ensure that food is safe and is served within acceptable ranges .Hot Liquid / Food Spills .Residents are at risk of having any hot liquid/food spilled on their person causing burns. Examples of hot liquids/food are coffee, tea, hot soup, oatmeal, or any other hot food or liquid substance.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of five residents (Resident #57) observed for infection control. CNA A failed to perform hand hygiene while providing incontinence care to Resident # 57. This failure could place the residents at risk for infection. Findings include: Record review of Resident #57's face sheet dated 04/17/24 reflected she was [AGE] years old female. She was admitted to the facility on [DATE]. She was admitted with muscle weakness, difficult walking, hypertension (high blood pressure) history of falls and cognitive communication problem. Review of Resident #57 's care plan initiated 08/15/23 reflected Resident #57 had bladder incontinence and retention of urine. Intervention was to provide incontinent care at least every two hours and apply moisturizer after each episode. Observation on 04/17/24 at 11:34 AM revealed CNA A providing incontinent care to Resident #57. CNA A was observed completing hand hygiene and gloved before care, then she informed the resident she was providing incontinent care. CNA A positioned the resident and unfastened the brief and proceeded to clean Resident #57's front area, then positioned the resident on her side and cleaned her bottom area. Resident #57 was minimally soiled with urine and feces. After cleaning the resident CNA A did not complete hand hygiene or change gloves then she applied the clean brief, barrier cream and then fastened the brief and positioned the resident using the bed remote. With the same gloves CNA A touched the resident's clean linen and bedside table. After care CNA A completed hand hygiene and left the room with trash. In an interview on 04/17/24 at 12:02 PM with CNA A she stated she forgot to change gloves during care. CNA A stated she was expected to clean hands before and after care, but she was not required to wash hands after cleaning the resident. CNA A stated she was supposed to complete hand hygiene and change gloves during incontinent care to prevent cross contamination. She stated she had been in-serviced on infection control on 04/16/24. In an interview on 04/17/24 at 03:24 PM with the DON she stated during incontinent care the staff was to complete hand hygiene before and after care. DON also stated in between care CNA A was to complete hand hygiene and change gloves because her hands were considered dirty after cleaning the resident. The DON stated CNA A was to complete hand hygiene during care to prevent the spread on infection. The DON stated the nursing staff had been offered the in-service on hand hygiene/infection. The inservice was reviewed and reflected CNA A had been in-serviced. Review of the facility policy undated and titled, Fundamentals of Infection Control Precautions reflected, . Hand Hygiene. Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: o When coming on duty; o When hands are visibly soiled (hand washing with soap and water); Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice) . Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves. Failure to change gloves between resident contacts is an infection control hazard.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 3 of 7 residents (Residents #1, #2, and #3) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #1's care plan included Hypertensive Heart Failure. 2. The facility failed to ensure Resident #2's care plan included Hypertension. 3. The facility failed to ensure Resident #3's care plan included Hypertension. These failures could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of Resident #1's face sheet dated 01/04/24, revealed a [AGE] year-old female, with an initial admitted [DATE], and a readmitted [DATE], and a diagnosis of Alzheimer's Disease (disease in brain that controls thought, memory, and language), Dysphagia (difficulty swallowing), Hyperlipidemia (high level of fat particles in the blood), Hypertensive Heart Disease (problems with your heart due to untreated high blood pressure), Cerebral Infarction (disrupted blood flow to the brain), Persistent Mood (Affective) Disorder (depression that lasts for several years), Difficulty in Walking, Muscle Weakness, and Unspecified Lack of Coordination. Record review of Resident #1's care plan, dated 11/29/23, did not address her diagnosis of Hypertensive Heart Failure. Record review of Resident #2's face sheet dated 01/04/24, revealed a [AGE] year-old female, with an admitted [DATE], and a diagnosis of Malignant Neoplasm of Brain, Epilepsy, Other Symbolic Disfunctions, Hyperlipidemia, Essential Hypertension, and Long-Term use of Antithrombotic/Antiplatelets. Record review of Resident #2's care plan, dated 11/29/22, did not address her diagnosis of Essential Hypertension. Record review of Resident #3's face sheet dated 01/04/24, revealed an [AGE] year-old female, with an admitted [DATE], and a diagnosis of Lymphedema, Anemia, Hypothyroidism, Hyperlipidemia, Essential Hypertension, Cerebral Infarction, and History of other Venous Thrombosis and Embolism. Record review of Resident #3's care plan, dated 12/15/23, did not address her diagnosis of Essential Hypertension. In an interview on 01/04/24 at 4:14 PM, MDS Nurse stated she had only worked at the facility since September 2023. She stated her responsibilities included assessments and care plans. She stated she was the one that reviewed Resident #1's care plan around 11/28/23. She stated it was due for a review. MDS Nurse stated during the review one of her duties was to ensure there were no new issues that need to be care planned. She stated she was not sure why the hypertensive heart disease was not addressed on Resident #1's care plan. She stated that before the care plan was completed certain staff like the social worker, a nurse, and dietary review the care plan. MDS Nurse stated even though they review it, her signature is the only one seen on the care plan, and she cannot recall which nurse reviewed Resident #1's care plan before it was completed. MDS Nurse stated the risk of not addressing a diagnosis is a resident could go into heart failure or hypertensive mode if the care plan was not followed. In a follow-up interview on 01/04/24 at 5:35 PM, MDS Nurse stated she started working at the facility last September, and she was not sure why certain care plans did not address all diagnosis. She stated she had been trying to fix the care plans. She stated the facility started their own audit process for care plans. She stated hopefully it would take just one month to get the issue corrected. In an interview on 01/04/24 at 5:39 PM, DON stated she and the ADONs, two wound care nurses, and MDS Nurse started an audit to correct the care plans, to ensure they address all diagnoses. She stated she guaranteed the audit would be completed by close of business tomorrow, 01/05/24. She stated that several staff members signed off on the care plans, but all staff do not sign the care plan or document in the system who reviewed the care plans. DON stated she was not aware the care plans for Resident #2 and Resident #3 did not address hypertension until today. DON stated she started printing the diagnoses sheets to review for all residents. DON stated the risk of not addressing a diagnosis on a care plan is that diagnosis not being addressed, which could have affected a resident by mistreatment or missed interventions. In an interview on 01/04/24 at 5:47 PM, Administrator stated he understood the need to ensure all care plans were comprehensive. He stated all diagnosis should be addressed for the resident and for the best care. Record review of the facility's undated policy titled, Comprehensive Care Planning, revealed the following: Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.

Based on interviews and record reviews, the facility failed to ensure the residents received adequate supervision to prevent accidents for one (Resident #1) of seven residents reviewed for elopements. The facility failed to provide adequate supervision for Resident #1 for one hour and 20 minutes. He was last seen on 06/01/23 at 6:30 am and after that, the resident eloped from the facility and was observed by a concerned citizen who called Law Enforcement because Resident #1 was at a car wash located along a busy six lane street and four way cross intersection and 0.4 miles away from the facility. Resident #1 was returned to the facility on [DATE] at 7:52 am by Law Enforcement. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from 06/01/23 at 6:30 AM to 06/06/23. The Noncompliance was identified as PNC because the facility staff were unaware Resident #1 had eloped from the facility. The Immediate Jeopady was determined to have been removed on 06/06/23 due to the facility's implemented actions that corrected the non-compliance of re-educating staff about elopement prevention and response, elopement risks and alarm management of the access codes, prior to the beginning of the HHSC investigation on 08/16/23. The Staff confirmed when interviewed they were adequately trained about the prevention and response of resident elopements. This failure could place residents at risk for accidents, falls and serious injury resulting in a decreased psycho-social well-being, physical decline or death. Findings included: Record review of Resident #1's Order Summary Report dated 08/17/23 revealed a [AGE] year-old male who admitted to the facility 08/01/2022 with diagnoses other seizures, essential hypertension, cognitive communication deficit, cardiomegaly (enlarged heart), convulsions (seizures), need assistance for personal care, DM II, dementia, psychotic disturbance, mood disturbance and anxiety and took carvedilol (blood pressure), clonidine (Blood pressure), donepezil (Memory loss), insulin glargine solution (diabetes), levetiracetam (seizures), losartan (blood pressure), metformin (diabetes), spironolactone (blood pressure). Record Review of Resident #1's Admission MDS assessment dated [DATE] revealed he had a BIMS score of 06 (severe impaired cognition) and no wandering behavior exhibited, supervision with one person assistance with walking, balance not steady when walking, no upper extremity impairment and no lower extremity impairment and no mobility assist with walking. Record Review of Resident #1's Discharge MDS assessment dated [DATE] revealed he had a Staff Assessment score of 02 (moderate impaired cognition) no wandering behavior exhibited, supervision with one person assist with walking and he discharged to another nursing home. Record review of Resident #1's Care plans dated 08/09/23 revealed, care plans for: Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Oxygen dependent, Shortness of Breath, Hypertension, Diabetes Melilotus, Anti-psychotic monitoring, Impaired Vision, falls, communication problems, potential deficit due to memory loss/dementia, wander risk (Interventions: identify pattern of wandering, is wandering purposeful, aimless, or escapist, is resident looking for something, does it indicate a need for more exercise, intervene as appropriate .is the resident exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc.Monitor for fatigue and weight loss .provide structured activities, toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes) and hearing deficient . and on 06/01/23 care plan for actual elopement. Record review of Resident #1's Nurse Progress Notes from 08/09/22 to 05/31/23, revealed no documented evidence Resident #1 had eloped or attempted to elope, but at times wandered to the wrong hall from where his room was located and was easy to re-direct to right hall. Record review of Resident #1's Elopement Risk Assessment Version 2 dated 02/01/23 revealed a risk score of 12 (moderate risk) out of 15 points, for elopement risk, because he was not bedfast, and not on a secured unit and ambulated without assistance. Record review of the facility's Elopement Drills dated 03/24/23, 04/12/23 and 05/22/23 were conducted with RN's, CNA's, LVN's, Social Worker, Housekeepers, Laundry aides, Receptionist, Dietary, Therapists, Medical Records, Medication aides, Receptionist, Activities Director, Maintenance Director. Record review of the Facility's Provider Investigative Report dated 06/01/23 revealed Resident #1 had dementia without behavioral disturbance, mood disturbance and anxiety, cognitive communication deficit. Resident #1 said he went for a walk on the morning 06/01/23. At 7:40 am the resident was accompanied by LE. The incident occurred during shift change and Resident #1 had no adverse effects. In-service education on the elopement policy and prevention was initiated and completed. The resident was put on 1:1 observation until transferred to a facility with a secured unit. Completed an elopement audit on all residents and updated care plans. Had an outside provider come out to reassure all doors were functioning properly. Statement from CNA A revealed the resident was in bed all night and the last time Resident #1 was seen was at 6:00 am in bed. Findings: Confirmed. Record review of Resident #1's Police Report dated 06/01/23 revealed: Primary incident code: Welfare Check or concern 06/01/23 07:27:16 am Resident #1 IS THERE (at the Car Wash) AND IS GOING AROUND AND TRYING TO GET INTO THE BUILDING . 06/01/23 07:27:39 am Reporter IS CONCERNED ABOUT THIS GENTALMAN [sic] . 06/01/23 07:27:55 am LE Dispatch . 06/01/23 07:28:05 am B\M - 70'S - BLK SWEAT PANTS THIN JACKET . 06/01/23 07:28:14 am Reporter IS STILL THERE . 06/01/23 07:28:30 am Subject KEEPS SAYING HE LIVES THERE . 06/01/23 07:38:12 am Arrived .06/01/23 07:45:17 am Leaving Scene (Location: Healthcare Center) . 06/01/23 07:52:31 am Male was lost, possibly has dementia, lives at the Nursing Home . 06/01/23 07:52:47 am taken back to the nursing home. Record review of Resident #1's Progress Noted dated 06/01/23 by LVN F revealed, The patient had a head-to-toe assessment on Resident #1, the patient has no injury body anywhere .Vitals were taken (temperature 97.2, bp 138/89 .Sats 97 room air). Record review of Resident 1's Event Nurses Note 12 hr. - Elope or Attempt - Version 2 dated 06/02/23 at 11:56 am by the Former DON revealed, Resident #1 lying in bed with eyes closed and resting. CNA remained at bedside to provide 1:1 supervision .Elopement: Resident #1 exited front entrance, missing for approximately 2 hours and 20 minutes, resident observed .4 miles from the facility at the car wash, resident is independent with ambulation and expressed no desire to leave facility, no injures, vitals checked, and no new physician's orders. The resident stated he was just taking a walk. The Doctor was called on 06/01/23 at 8:10 am and the responsible party was notified on 06/01/23 at 8:10 am. Interventions included: 1:1 supervision and assisting family with placement in a secured unit. The resident was independent with all ADL's, no environment/equipment factors and yes to cognitive impairment. The facility took the following action to correct the non-compliance on 06/06/23: Record review of Resident #1's Progress Note dated 06/01/23 by DON revealed, Continue monitoring resident for exit seeking behaviors. 1:1 supervision until accepted at referred facility. Record review of Resident #1's Elopement Risk Assessment Version 3 dated 06/01/23 revealed a risk score of 22 (high risk) out of 23 points, for elopement risk, because he eloped on 06/01/23. Record review of the Schedule Sheets dated 06/01/23 and 06/02/23 revealed CNA's and nurses who completed the 1:1 monitoring of Resident #1. Record review of Resident #1's Former Social Worker progress note dated 06/02/23, revealed, SW followed up resident accepted to both facility's resident will be admitting to Nursing Facility per admissions coordinator. SW awaiting Admission follow up with the time the resident will arrive. Interview on 08/16/23 at 10:00 am, the Maintenance Director stated after Resident #1 eloped June 2023, the facility's doors were checked by their Outside Provider, and they said there were no issues with the doors, alarms, or keypads malfunctioning. He stated the facility requested the outside Provider change how the door alarms and keypads operated. He stated the staff used to be able to reset the door alarms remotely to stop the alarm from ringing, but now when the door alarms sounded off, they did not stop ringing after so many seconds. He stated the staff had to go to the door triggering the alarm by resetting it with the code and the staff also had to look around for any residents. Interview on 08/17/23 at 4:23 pm, the Maintenance Director stated the facility had 9 exit doors which had keypads and panic bars, but two of the doors were in the kitchen and the residents had no access to. He stated none of the visitors/family members had the pass codes to enter and exit and only the staff did. He stated he changed the keypad codes monthly and when needed and would continue to inspect the doors and alarms weekly. Interview on 08/16/23 at 10:50 am, LVN B stated Resident #1 eloped away from the facility June 2023 and he returned uninjured and shortly after he was transferred to another facility. She stated Resident #1's cognition was A/O (alert and oriented) x 2, very confused with short term memory loss and needed redirection at times because he forgot where his room was at times. She stated they were in-serviced on how to operate the door alarms because they used to stop sounding off after the alarm was triggered, but now they had to go to the door and press the keypad to get the alarm to reset. She stated they were also trained on monitoring the residents. She stated if a resident was suspected of being missing, they needed to do an immediate count of the residents. She stated the elopement protocol was for all staff to know about the facility's elopement procedures, not just nursing to alert nursing and pay attention to their surroundings to ensure the residents were not exit seeking. Interview on 08/16/23 at 5:37 pm, the Administrator stated Housekeeper/Floor Tech C was the last person who saw Resident #1 by the 600 Hall water fountain around 6:30 am, then an hour and half later he was returned by LE. She stated HSK D alerted Treatment Nurse E about LE being outside with Resident #1 around 7:50 am. She stated Treatment Nurse E spoke to LE and assessed Resident #1 after he returned to the facility, and he was fine and then they started the 1:1 monitoring with him until he discharged to a secured unit facility. She stated the former DON interviewed the staff and got all of their statements about his elopement. She stated they in-serviced the staff and had monthly elopement drills; the nurses did the elopement risk assessments for all the residents; weekly door checks were conducted, and they had a QA meeting about the incident. She stated the door alarm used to sound off after 15 seconds of the panic bar being pressed and stop ringing but now when the door alarm sounded off it did not stop until a staff physically went up to the keypad to put in the code to turn the alarm off and look around the area for residents. She stated they were not sure how Resident #1 eloped but suspected it may have been a visitor thinking he was a visitor but that was never confirmed. She stated Resident #1 had not been exit seeking or ever eloped from this facility or made statements of wanting to leave this facility in the past. She stated all of the facility's doors locked and had panic buttons that would allow the doors to open and the alarm to sound off for a few seconds and stop and they also had a remote way to reset the door locks. Interview on 08/16/23 at 6:07 pm, LVN F stated Resident #1 was not her resident, but she saw him in passing and he walked without assistance and wandered to the wrong hall at times. She stated he was never exit seeking or made statements of wanting to leave and added there were no problems with the door alarms and locks not working. She stated she heard about Resident #1 eloping this past June 2023. She stated they had a training on how to reset the door alarms and how to go to the door and press the code to the keypad and check outside to ensure no residents had exited from the facility. Interview on 08/16/23 at 6:22 pm, LVN G stated she was being trained by LVN B and was Resident #1's nurse working the night of 05/31/23. She stated she made rounds every two hours and did not know what time Resident #1 left the building and had made checks of the residents every two hours and there were not any issues with Resident #1 trying to elope. She stated there were no problems with the alarms going off on 05/31/23 and of 06/01/23. She stated she was not sure when Resident #1 returned to the facility because she got off work at 7:00 am. Interview on 08/17/23 at 9:00 am, Housekeeper/Floor Tech C stated on 06/01/23 she last saw Resident #1 around 6:30 am in the hallway by his room and the hall water fountain. She stated Resident #1 was not near an exit door and had on jogging pants and a shirt and Resident #1 said hello and she said hello back. She stated she went to get the floor cleaning supplies to start cleaning the floors and further in the day she heard Resident #1 eloped from the facility. She stated prior to 06/01/23, Resident #1 was not exit seeking and walked around without assist. She stated after Resident #1 eloped; the DON asked her what she knew about it, and she wrote a statement. She stated afterwards they had an elopement training by their supervisor about what the elopement code was and what to do if a resident was missing. She stated they now the door alarm would continue to sound off until they went to the door that triggered to press the keypad code. She stated the keypad code was changed once monthly. Interview on 08/17/23 at 11:09 am, LVN H stated Resident #1 was not exit seeking in the past and said worked the day he eloped 06/01/23 but did not hear the door alarms ringing and was unaware he eloped because she got off work at 7:30 am. She stated when she returned to work the next day, 06/02/23 at 7:00 pm, she heard Resident #1 had gotten out of the building and was brought back. She stated Resident #1 was getting 1:1 monitoring in rotation by the CNAs, and someone came to check the doors and locks. She stated on 06/02/23 Resident #1 was discharged to a secured unit facility. She stated after the incident she was trained on the new way they checked the doors and alarms. She stated they looked at the main panel and went to the door triggering the alarm codes labeled (1-7 doors), to make sure none of the residents were outside. She stated after she pressed the code on the keypad next to the exit door to stop the alarm, she then pressed the code to the keypad at the nurse's station. She stated before the incident the alarm would stop ringing after a few seconds but not any longer until the code was pressed. She stated they also did a couple of elopement in-services on the policy and procedures with how to proceed if they thought a resident eloped. She stated if a resident was to elope, they could fall or get injured. Interview on 08/17/23 at 12:30 pm LVN I stated Resident #1 used to be a resident at the facility, he had dementia and on occasion walked to the wrong hall from where his room was located, and he had to be redirected. She stated she started her shift on 06/01/23 at 7:00 am and was not aware he was missing and there were no alarms ringing when she arrived. She stated on 06/01/23 around 8:00 am he was dropped off by the police officers and that was when it was known that Resident #1 was gone. She stated Treatment Nurse E told them LE found Resident #1 down the street. She stated not too long after that he was transferred to secured unit. She stated Resident #1 was independent and confused about when church services were and where his room was and never exit seeking. She stated she was surprised he walked out and felt Resident #1 did not intentionally leave the facility. She stated Resident #1 had dementia and added after the incident they had in-service trainings about making sure the door alarms were reset and to go look to see what was going on to see what triggered the door alarm to go off, then reset it. She stated if a resident eloped, they could fall because the facility was right next to a busy street and a lot of things could happened, the resident could get lost or hit by a car. She stated the resident may not be found and could die, be in danger and could get dehydrated. Interview on 08/17/23 at 1:14 pm, LVN B stated she worked a few hours on 06/01/23 when Resident #1 eloped and the last time she saw Resident #1 was 10:00 pm and he his usual self, confused in his room and not exit seeking. She stated she got off work around 12:00 am because it was not her shift and there were three other nurses there that night. She stated after Resident #1's elopement the former DON came in on a Saturday 06/03/23 and spoke to all the staff; and explained to the entire staff it was everybody's responsibility to watch the doors. They went over the correct procedures of going to the door when the door alarm sounds off, to check to see if a resident was seen. She stated the DON said if a resident eloped they needed to do a count of the residents and to make a circle around the building, contact LE, the Administrator and DON. She stated after Resident #1 eloped she worked the 7:00 pm - 10:00 pm as a sitter and did 1:1 monitoring of Resident #1 who was mostly asleep and watched tv and was not exit seeking or made statements of wanting to leave. She stated CNA J did 1:1 monitoring of Resident #1 as well and later that day he was taken to another facility. She stated they made it clear they had to go to the door and press the code to let people out and could no longer reset the door alarm remotely. Interview 08/17/23 at 1:30 pm, CNA J stated she was not Resident #1's aide but saw him in passing the night of 05/31/23 he was in his room with the door open and in his bed asleep. She stated when she got off work 06/01/23 at 7:00 am she did not see him walking around anywhere and did not know he had eloped until she returned to work later that day, 06/01/23. She stated she heard Resident #1 had eloped and was getting 1:1 sitter monitoring. She stated Resident #1 was transferred to another facility with a secured unit. She stated after Resident #1's elopement she was trained on elopement and the new way to use the door system and by making sure residents were in their rooms and if there was a reason to believe the resident was missing they needed to check the rest room and outside, and do head counts. Interview on 08/17/23 at 1:44 pm CNA K stated Resident #1 eloped and LE found him close to the car wash. She stated Resident #1 did not show any signs of eloping or exit seeking but after he eloped, they had elopement trainings to prevent that from happening again. Interview 08/17/23 at 2:35 pm, the ADON stated they had no residents who were exit seeking or had eloped but heard about Resident #1 elopement and he was transferred to another facility. She stated if a resident was to be exiting seeking, they would have to be transferred to another facility with a secured unit. She stated they had a door alarm system and had to monitor the residents every two hours. She stated they had elopement trainings and was told if a resident was exit seeking or actually eloping, and they were not able to re-direct the resident she would stay with the resident and alert other staff to assist with getting the resident back into the facility. She stated personally she could not walk away from the resident and would just follow their elopement policy. She stated if a resident eloped they could get hit by a car or got lost. Interview on 08/17/23 at 3:37 pm, the Medical Director stated it was reported to him Resident #1 eloped and returned to the facility not injured, a few months ago and he did not need to go to the hospital. He stated Resident #1 was transferred to a secured unit and added after Resident #1 eloped they had a Quality Assurance meeting to further plan to prevent any other residents from eloping. He stated they were not sure how he got out and added the staff were pretty competent to keep an eye on the residents. He stated his expectation was for staff to ensure the doors were locked to prevent any further elopements and added all staff were responsible for ensuring the residents did not elope. Interview on 08/17/23 at 4:53 pm, the Administrator stated when Resident #1 eloped on 06/01/23, none of the staff were aware Resident #1 was missing until LE brought him back to the facility. She stated her expectations for preventing elopements was for the DON or designee to ensure the nurses completed the admission elopement risks. She stated the DON or designee needed to review the elopement assessments weekly and during the referral process, the staff needed to ensure the potential new residents were not considered wanderers. She stated additionally the Maintenance Director checked the doors and alarm system weekly. She stated they continued with the staff trainings on elopement prevention and response and monthly elopement drills. She stated they included the elopement trainings for all new hires during orientation and had Quality Assurance meetings to discuss the effectiveness and monitoring of their plan to prevent elopements. She stated if a resident eloped they could get dehydrated and require hospitalization , which could lead up to death. She stated it was the responsibility of all staff to ensure the residents did not elope but ultimately she was responsible for ensuring all staff followed their elopement policy. She stated approximately 95% of the staff had been re-trained on their new process to prevent residents from eloping. Record review of the facility's Missing Resident Action Plan dated 06/01/23 revealed, Action Taken: Head to Toe Assessment completed with no abnormal findings on 06/01/23 by charge nurse, Resident will continue with 1:1 monitoring for safety until transferred to secured unit at sister facility. Elopement risks assessments were completed for all residents in the building by the DON, ADON and Treatment Nurse. Elopement Risk Assessments will be reviewed and monitored weekly by the DON or designee. All exit doors were checked by the compliance nurse and Administrator for proper alarm functioning. No issues identified, completed 06/01/23,.Elopement drills were initiated by the Admin/DON/Designee for each shift including weekends, started 06/01/23. In-services: An in-service regarding resident elopement facility protocols were initiated 06/01/23 by the DON for all facility staff. The DON initiated an in-service on 06/01/23 for all staff that any resident that attempted to elope from the facility must be placed on 1:1 supervision immediately until transferred to secure unit. The Administrator and Director of Nursing will be notified immediately, start date 06/01/23 ongoing. In-services: All Nurses in-serviced by the DON that all residents must have an elopement risk assessment completed upon admission, quarterly, and as needed for changes in condition. All nurses not present will be in-serviced prior to performing work duties start date 06/01/23. Monitoring: The Administrator and DON will monitor for compliance and ensure all staff have been in-serviced on 06/01/23 and ongoing. Moving forward the Maintenance Director/designee would check all exit doors daily, start date 06/01/23 and ongoing. The Administrator would review the monitoring tool weekly for compliance, start date 06/01//23. Record review of the facility's Elopement Prevention and Response In-service Trainings from 06/01/23 to 06/03/23 reflected all staff from all shifts were trained, which included CNA's, LVN's , admissions, Dietary, therapists, housekeepers, clerical, receptionist, Medication Aides, Activities Director and other staff were trained on identifying the cause of wandering, intervention strategies and environmental modification. Record review of the facility's Elopement Posttests from 06/05/23 to 06/06/23 reflected all staff from all shifts were trained on what to do if the door alarms sounded off, if a resident eloped, resident exit seeking should redirect and report to nurse immediately, resident leaves without signing out was considered an elopement. Record review of all the facility residents Elopement Risk Assessments from 06/01/23 to 06/06/23 reflected, 53 Resident Elopement assessments were completed. Record review of the facility's Timesheet printed on 08/17/23 revealed they had one RN, and four CNA's working the night shift on 05/31/23 and they clocked out between 6:00 am and 7:00 am on 06/01/23. Record review of the Fire and Security invoice dated 06/02/23by an alarm company, After investigating I found that the buzzer at the doors would go off after the door went into its 15 second egress allowing the doors to be unlocked without anyone knowing. So, I re-wired the timer at every door so that when the door goes into egress the sounder will not go off until someone comes to the door and resets the keypad. Record review of the Fire and security's invoice dated 06/05/23 by the alarm company revealed, Customer wanted front door to lock as soon door is closed behind people entering building. Set keypad time to shorter open period. Door now locks when closed behind standard entry. Observations on 08/17/23 between 4:30 pm to 4:50 pm, with the Maintenance Director, The front entrance door and six exit hall doors (100, 200, 300, 400, 500 and 600) and one dining room door appeared to be in good working condition. They locked appropriately, and the alarms sounded off loudly and immediately after the panic bar was pressed to open the doors and it continued to sound off until the Maintenance Director pressed the code on the keypad to stop it. The front entrance door had a sign on it that read, Please Close Door Behind You. Observations from 08/16/23 and 08/17/23 did not reveal any residents who were exit seeking out of the facility. Record review of the facility's Elopement Prevention policy dated January 2023 revealed, Policy statement: Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopements. 1. The elopement risk assessment will be completed upon admission .identify the cause of wandering .Intervention strategies .Environmental modification .staff training . Record review of the facility's Elopement Response policy dated January 2023 revealed, Policy Statement: Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented .Policy and interpretation and implementation: It is the responsibility of all personnel to report any resident attempting to leave the premises determine missing resident .should an employee observe a resident leaving the premises .should an employee discover the resident missing from the facility (Code orange), Deployment procedures .If unable to locate resident in the building .post return resident evaluation and care and documentation . Record review of the facility's Incident/Accident policy was requested from the Administrator and Interim DON on 08/16/23 at 10:05 am and on 08/18/23 at 09:01 am, and the administrator said they did not have one.

Based on observation, interview and record review, the facility failed to ensure that a resident who was fed by enteral feeding received the appropriate treatment and services to prevent complications for one (Residents #30) of two residents reviewed for tube feedings. Observed at the bedside of Resident #30 was a de-clogger tool, it appeared to have residue on it. The de-cloggers were available in three locations on the medication cart, central supply room and treatment room; the de-cloggers were ordered to be restocked in January 2023. The facility failed to ensure the nurses were not using a de-clogger to unclog Resident #30's g-tube (Gastrostomy tube, tube inserted through the belly that brings nutrition directly to the stomach) without physician orders, without notifying the physician and without training. The Medical Director was not aware the nurses used a de-clogging device if there was an issue with a clogged g-tube. The use of the de-clogging device could cause serious harm to the resident, which could hospitalization . The nurse could have perforated the lining of the stomach or the intestine, and/or possible die from the use of the device. This failure placed residents at risk for perforation of the g-tube and/or intestinal wall, replacement of the g-tube, hospitalization , or even death. Findings included: An Immediate Jeopardy was identified on 02/21/23 at 08:11PM. The IJ template was provided to the facility on [DATE] at 08:11 PM. While the Immediate Jeopardy was removed on 02/23/22 at 05:35PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need of continuation of in-servicing and monitoring the plan of removal. Review of Residents #30's MDS assessment dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. Cognitive section of the MDS indicated Resident #30 severely impaired. The MDS reflected his functional status was dependent with ADLs and nutrition was via g-tube. The resident's diagnoses include cerebral vascular accident (stroke), gastroesophageal reflux disease (acid reflux), hypertension (high blood pressure) and hyperlipidemia (high cholesterol). Review of Resident #30's comprehensive care plan dated 12/09/2021 revealed the resident will be free of side effects or complications related to tube feeding, insertion site will be free of signs and symptoms of infection, will maintain adequate nutritional and hydration status, and resident will be free from aspiration (inhaling foreign substance into airway or lungs). The care plan reflected no goals or approaches related to appropriate protocol for de-clogging the g-tube or the use of a g-tube de-clogger. Review of Resident #30's order summary report dated 01/16/2023 reflected, enteral feeding order, flush tube with 30 ml water before and after medication and feedings. Flush with at least 5 ml's of water between each medication. Review of Resident #30s order summary report dated 01/16/2023 reflected an enteral feeding order, Isosource 1.5 55ml/hr for 1800 ml total volume, 2250Kcals/day. Feeding may be disconnected/stopped for repositioning, bathing, incontinent care, appointments, or per family/resident. (There was no order to use a de-clogging tool if the feeding tube was clogged.) Review of Resident #30's Nurses progress note dated 10/14/22 the resident was sent to Emergency Department for a split in the g-tube tubing. The resident returned on 10/15/2022 post g-tube replacement. Observation and interview on02/21/23 at 02:44 PM revealed Resident #30 lying in bed with pillows around him for positioning; he had contractures (limited range of motion due to immobility) of lower extremities. The resident did not respond when greeted. The resident's eyes were open, but he did not respond when his name was called and when he was asked what his name was. The resident was positioned in bed on a low air loss mattress, tube feed formula Isosource 1.5kcal was infusing at 55ml/hr. A suction at bedside, de-clogging tool (labeled Enteral Feeding Tube Clog Remover) at bedside, on shelf with other tube feeding supplies such as an extra syringe, extra formula, and personal care items. Record review on 02/21/23 at 03:30 reflected no order for de-clogger tool in Resident #30s physician order summary. Record review on 02/21/23 at 03:35 reflected Resident #30 did not have a care plan that included the use of the de-clogger tool. Observation on 02/21/23 at 04:30 PM revealed the de-clogging tool remained at bedside in Resident # 30's room. Interview and observation on 02/21/23 at 04:31PM with LVN C revealed she has worked at the facility for 1 year in March 2022. The nurse showed the surveyor the supplies in room Resident #30's room which included: a pump, tubing, feeding, and a syringe which was dated and timed. There was also a de-clogger tool that was approximately 2.5 ft in length. The package was open, and it remained in the same place as noted at 02:44 PM. LVNC was asked what the de-clogger tool was used for. She stated she was not sure and had not seen the tool before. She proceeded to read out loud the wording on the package which reflected Enteral Feeding Tube Clog Remover. LVN C stated she had not and would not know where to find a new one if it were needed. LVNC was asked if she has ever used the de-clogger tool and she stated she had not and would not know how to use it. LVN C was asked if tool appears to have been used and she confirmed that it appeared to have tan colored residue on it covering the entire tip and that since it appeared used, she will throw it away. Nurse removed de-clogger from the room. Record review on 2/21/23 at approximately 04:45 PM of undated manufacture directions on package reflected the following: 1. Determine the length of the feeding tube and choose the wand that corresponds with the size. Caution: confirm that the tube has not been modified 2. Stop feeding prior to use. Remove any accessories that are connected to the tube. Clamp off the feeding set and disconnect from feeding tube. 3. Insert the wand into the feeding tube until you've reached the blockage. Rotate the wand clockwise and counterclockwise to break up the clog. 4. Once the clog is clear, flush the feeding tube with at least 30cc of warm water. 5. Dispose of the wand. 6. Reconnect the feeding set to the feeding tube and resume feeding. After record review of physician's orders for Resident #30 there was no evidence of an order to use on g-tube residents. Interview on 02/21/23 at 04:50 PM with RN I revealed she is an agency nurse and today was her first day at the facility. RN I was asked what she would do if the tube was clogged, and she stated there was a de-clogger at the bedside that could be used. She stated she had not had any need for it but if she did, she knew that one was available at the beside of Resident #30's room. RN I stated she was not a facility staff member, so she was not sure what the facility policy was regarding the use of the de-clogger but the de-cloggers are available, so she thinks they are ok to use if a resident's g-tube becomes clogged. RN I stated the de-clogger could be found in the central supply room that had the treatment supplies on 300 hall or she would ask someone since she was new. When asked if she had training to use this tool and was there an order for the tool to be used she replied that she was agency and today (02/21/23) was her first day. Interview on 02/21/23 at 05:15 PM with LVN H revealed she has worked at the facility for 13 months. LVN H was asked if she passed medications for g-tube or PEG tube residents and she stated, Yes I have 8 residents who get medications this way. She stated if a g-tube/PEG tube was clogged she would use her fingers and a tongue blade (medical grade flat wooden stick) to milk the tubing to unclog the tubing. She stated that it usually works well and has no other issues. LVN H was asked what happens if it does not unclog the tubing and she stated she would ask for someone else to help unclog the tube. She was asked if someone was not available what would she do and she stated: the facility has these things (cannot recall the name) that are available, but I try not use them. I would try water and milking the tube first. When asked what thing she was referring to that facility has, she was observed to look in her medication cart and produced a tool in packaging that reflected Enteral Feeding Tube Clog Remover. She stated she had not used it but was trained on it 13 months prior by a nurse who no longer was employed by the facility. Interview on 02/21/23 at 05:54 PM with LVN H revealed none of her residents need the de-clogger tool but there was a resident on another hall (Resident #30) who had frequent issues with the tube clogging, and she was aware of him having one most of the time at his bedside. LVN H was asked if there was any order in the chart for the use of the de-clogger on any of her residents and she stated no, but there probably should be. She stated she would not use it without an order and would not use it at all because she was not comfortable using the de-clogger tool. She stated she used the de-clogger when she first started 13 months ago (cannot recall what resident) when she was trained by a peer. LVN H stated the training she received was when the orientating nurse showed her how to use the device. LVN H stated there was no classroom training provided. She stated she did not sign skills check off to use the de-clogger device. She stated de-clogger tools were on the medication carts, in the central supply room which was locked up in the back. LVN H was asked how many times the tool may be used, and she stated it should be used only for 24 hours and night shift throws them away. She also stated she had not been trained by the DON or ADON on how to use the tool or how long it could be used. During an interview and observation on 02/21/23 at 05:59 PM LVN C stated there would have to be an order for the staff to use the de-clogger and it would be found on the nurse's TAR so that the medication aides do not have access to the order. She stated she thought the de-clogger may be in the supply room but had never used one at this facility. LVN C had not come across a time she needed to find this tool. She stated she had never used a de-clogger. LVN C was asked if she had received any training on how to use the de-clogger tool and she replied no. LVN C opened the drawers of her medication cart and no de-clogger tools were found on the cart. LVN C was asked if she knew how long the de-clogger was good for and she stated she does not know and would throw it away if it looked used or night shift would throw them away during their shift. Interview and record review on 02/22/23 at 05:08 PM LVN C was asked if she recalled writing a note on 10/14/2022 that reflected: Resident [#30's] g-tube leaking, assessed g-tube noted a split on mid (middle) part of tubing. Informed DON informed to transfer resident to hospital, medical director called, sister called to inform of transfer to hospital. She stated she remembered the note and was not notified of any issues with the g-tube from previous shift. She stated she recognized issue upon rounds and immediately stopped the feeding so it would not cause any further issues and notified the DON and doctor. She stated she started the process of transferring him to the hospital after receiving the order. LVN C was asked if she knows how the g-tube became split and, she stated she was not sure and could not figure out how it occurred, but it caused her concern enough to notify her DON and the doctor. LVN C stated that when she wrote the note on 10/14/22, she had not received any training for de-cloggers. LVN C was asked if she had received any in-service regarding the de-cloggers and, she stated yes today (02/22/23), she knows not to use them and was given a competency and a short test after she was given the education by the DON; after the issue was brought to the facilities attention. LVN C was asked what she would do if g-tube becomes clogged and, she stated she would notify the DON and doctor right away. Interview on 02/22/23 at 06:13 PM the Admission Coordinator stated she has worked as the admissions coordinator for 2 months and was previously in medical records and central supply (which is one person for two roles) for about 2-3 months before that. She stated she also has her CNA certificate. She was asked what months she worked in central supply she stated in July 2022. She was asked if she had ever ordered any de-cloggers and she states she had not ordered any de-clogger tools while in the central supply/medical records position. The admissions Coordinator was asked if she ever saw them within the facility and she stated she saw them in the stock room in November 2022, there was about 5 individual devices within the treatment room. The Admissions Coordinator was asked if she had ever been asked to order them from the previous, or current DON or Administrator. She stated no and she didn't see any in central supply during her time in the position. The Admissions Coordinator was asked if she was aware of the risk of ordering them and she stated she was not familiar with what they are used for, so she was not sure the risks. The Admission Coordinator was asked if she has seen them being used on any residents she states she has never seen anyone use them on residents. Interview on 02/22/23 at 04:57 PM with Central Supply and Medical Record (which is one person with two job titles) started working at the facility in September 2021 but was in a different role until he took on central supply and medical records in September 2022. Central Supply/Medical Record was asked if he had been told not to order the de-cloggers. He stated he has never been told not to order them until yesterday (02/21/23). Central Supply/Medical Records was asked who asked him to put in a new order and, he stated the previous DON asked him to order them in January 2023 because they were running low on the supply that was already in the facility. Central Supply/Medical Records was asked if nurses had access to the de-cloggers and, he stated the nurses had access to them because they were kept in the treatment room and there were some in the central supply room. Central Supply/Medical Records was asked if he knew if the previous central supply employee ordered them before. He stated he was not sure and that all he is aware of is that they were present when he took over the job. He stated he did a search on the ordering system that covered his time within the position which was between September 2022 to February 2023 and the order was placed was on 1/4/2023. Central Supply/Medical Records was asked when the first time was, he saw the de-clogger and he stated the de-cloggers were already present when he started the position.(September 2022) Central Supply/Medical Records was asked if he knew where else they were present and he stated they were available on the nurses carts and they had a main supply in his office and in the treatment room. Record review of supply order receipt reflected that on 1/11/2023 at 12:57 PM a delivery was received that included 1 box of clog remover: yellow 16F FRX 39.5cm, SKU # ENT912. Record review of Medline.com revealed 10 de-cloggers were in each box. https://www.medline.com/sku/item/MDPENT912 A telephone interview was conducted on 02/21/23 at 06:10 PM with the Medical Director, who was also Resident #30's attending physician. The Medical Director was asked if he is aware facility staff was using a de-clogger tool to unclog g-tube/PEG tube. He stated he was not aware of what the tool was. Once explained to him what the tool looks like and how the facility was utilizing it, he stated he was not comfortable with it being used on his residents. When asked what harm could come, he stated it could cause harm to residents, which could damage stomach lining, perforate the bowels and lead to hospitalization or worse. An Interview on 02/21/23 at 06:25 PM with the DON, revealed she started working at the facility in October 2022, approximately 5 months. The DON was asked how nurses were trained when they were newly hired. The DON stated the nurses were trained from peer to peer, so they get placed on the floor with another nurse for orientation. She stated they also attend a SNF clinic where they get competencies checked off in accordance with the facility policies and procedures. The DON was asked who specifically checks off the competencies for g-tube feeding and management, and she stated that herself (DON) and or the ADON can check off on training with the new staff nurses. The DON was asked if there was any orders for the use of the de-clogger tools and she stated there was a list of standing orders which come from the Medical Director, and the order for use of the de-clogger was included on the list. She stated the de-clogger tool was used to unclog a g-tube when they cannot be cleared with any other way. The DON was asked if part of the nursing competencies included how to use the de-clogger. She stated they can use the de-clogger after the peer-to-peer training. The DON was asked if the care plan included the de-clogger as an intervention. She stated it should be in the resident's care plan if it is needed. She stated the Medical Director gives standing orders to the facility for newly admitted residents and they are transferred from the form to the electronic medical record and was only done on a case-by-case scenario specifically for g-tube residents. The DON was asked if she knew of any residents who currently needed the de-clogger and she stated she was aware of Resident #30 having increased issues with clogging of his tube and he needed the de-clogger tool. She could not recall how many times it had been used on Resident #30 or which nurses used it. The DON stated if the de-clogger tool was needed, it was available in the supply room. The DON was asked if she knew the risk of using the de-clogger tool without proper training, or without a doctor's order, and she stated yes, it could cause perforation of the abdomen. An interview on 02/21/23 at 6:50PM with the DON revealed there was no standing order for use of the de-clogging tool. She provided a copy of the standing orders titled Standing orders for Nursing Home Patient. The orders related to g-tube care and management reflected Patients with peg: head of bed should be at _ [greater than] 30 degrees, hold tube feedings during repositioning. Give water bolus 200 cc _ [per shift] unless ordered otherwise. (600 cc per 24 _ [hours]). Record review of the facility's nursing policy and procedure manual 2003 Gastrostomy Tube Care revealed it did not include a procedure for the use of the de-clogger. The policy did not reveal the procedure for care of a g-tube that becomes clogged. Record review of in-service trainings on 02/21/23 at 07:00 PM reflected the following in-service topics in-service training topic: De-clogger- do not use; g-tube policy, de-clogger- do not use, staff notifying management if g-tube is clogged or unable to flush following physician orders. Record review on 02/21/23 at 07:05 PM of enteral medication administration skills competency revealed the following statement do not force any medication or fluid into the tube. Allow gravity to work. If necessary, gentle pressure may be applied after repositioning the resident. There was no use of the de-clogger tool on the competency skills check off. Record review of Nursing 2023 The Peer-Reviewed Journal of Clinical Excellence titled Best Practices for unclogging feeding Tubes in Adults revealed: Follow your facility policy and procedure for unclogging [NAME] [enteral access device]. The American Society for Parenteral and Enteral Nutrition (ASPEN) recommends warm water as the best initial choice for trying to unclog a feeding tube. First, attach a 30- or 60-mL piston syringe to the feeding tube and pull back the plunger to help dislodge the clog. Next, fill the flush syringe with warm water, reattach it to the tube, and attempt a flush. If you continue to meet resistance, gently move the syringe plunger back and forth to help loosen the clog. You can then clamp the tube to allow the warm water to penetrate the clog for up to 20 minutes. If water fails to unclog the tube, ASPEN guidelines recommend using an activated pancreatic enzyme solution.1-4 However, use of a pancreatic enzyme solution requires a healthcare provider's prescription and should be attempted only by nurses familiar with the procedure according to facility policy and procedure.3 Additional second-line interventions include using a commercially available enzyme de-clogging kit or mechanical de-clogging device. These also must be used in accordance with facility policy and procedure and only by experienced clinicians. If the tube can't be unclogged by these methods, ASPEN recommends replacing it. [NAME], [NAME] BS, RN; [NAME], [NAME] MSN, RN, CRNP. Best practices for unclogging feeding tubes in adults. Nursing 48(6):p 66, June 2018. | DOI: 10.1097/01.NURSE.0000532744.80506.5e https://journals.lww.com/nursing/Fulltext/2018/06000/Best_practices_for_unclogging_feeding_tubes_in.16.aspx#:~:text=First%2C%20attach%20a%2030%2D%20or,to%20help%20loosen%20the%20clog. On 02/21/23 at 8:11 PM the Administrator, DON, Regional RN, Area Director of Operation was informed of the Immediate Jeopardy (IJ) and the facility was informed the POR requested. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 02/23/23 at PM and reflected the following: .The facility failed to ensure that nurses were not using a de-clogger to unclog resident g-tubes without physician orders, without notifying the physician and without training. Interventions: On 2/21/2023 Resident #30 was immediately assessed in the facility by the DON, Medical Director notified. Medical Director resident sent to ER for evaluation of stomach and g-tube site due to estimated wait time length of duration for Kidney, Ureter, Bladder abdominal XRAY by diagnostic imaging company. Results were negative, no issues found. (Completed assessment after immediate in-service/competency check by Regional Nurse) On 2/21/2023 G-tube residents were assessed via SBAR assessment, by DON, ADON, and Regional Nurse Consultant, for change of condition with the g-tube site or signs/symptoms of an infection, MD notified, new orders for KUB for the 7 residents with g-tubes. Residents will continue to be monitored by DON, ADON every shift until results of KUB are obtained. (Completed assessments after immediate in-service/competency check by Regional Nurse) Residents with G-Tubes: Resident #47, #51, #55, #58, #45, #42, #63 and #30 On 2/22/2023, 1:30pm Kidney, Ureter, and Bladder abdominal X-ray to be completed by diagnostic imaging company for 7 g-tube residents. Results for all 7 residents were negative for stomach perforation as of 2/22/2023 at 5:00pm. Residents with G-Tubes: Resident #47, #51, #55, #58, #45, #42, #63 On 2/21/2023 G-tube de-clogger was immediately removed from the resident room, Resident#30 On 2/21/2023 DON, ADON, and Regional Nurse Consultant searched g-tube resident rooms to ensure the absence of de-cloggers in the resident room and medication carts within the facility. During facility audit, there were zero de-cloggers found in resident rooms. One de-cloggers was located on nursing cart on 500 hall, immediately removed. An unopened box was located in the central supply office, immediately removed. No other de-cloggers found in facility audit. Upon reviewing the order history from medline the last time facility ordered the de-cloggers was on 1/12/2023 and was a quantity of 1 box. On 2/22/2023, Administrator contacted medline supplier and has since had the item removed from the facility formulary list which prevents facility from ordering de-cloggers in the future. Residents with G-Tubes: Resident #47, #51, #55, #58, #45, #42, #63 and #30 On 2/21/2023 The Regional Nurse Consultant 1:1 in-serviced the DON and ADON on the g-tube policy, and that no de-cloggers were to be used in the facility. On 2/21/2023 The Regional Nurse Consultant 1:1 in-serviced the DON and ADON on physician notification if g-tube is unable to be flushed. On 2/21/2023 DON, to immediately in-service during 2/10 shift on 2/21/23, then prior to the start of their shift the 10/6 shift coming in on 2/21/2023, ADON to in-service 6/2 shift prior to the start of their shift on 2/22/2023. On 2/21/2023 Regional Nurse Consultant, placed visual Alert regarding G-tube clogged? CALL THE DOCTOR immediately placed in each g-tube resident room, nurses' cart, and 24-hour report book. Residents with G-Tubes: Resident #47, #51, #55, #58, #45, #42, #63 and #30 Immediately starting 2/21/2023, The DON or ADON will complete g-tube competency with each staff nurse, completed 2/22/23. Immediately starting 2/21/2023 DON or ADON will complete g-tube competency with agency nurses or new nurse hires prior to start of their first shift. Immediately starting 2/21/2023, The DON or ADON will in-service oncoming staff and agency nurses prior to the start of their shift, to ensure that de-cloggers are not to be used in the facility. Immediately starting 2/21/2023, The DON or ADON will check competencies for G-tubes, for oncoming nurses and agency nurses, prior to the start of their shift, to ensure that de-cloggers are not to be used in the facility. *****The following in-services were initiated immediately by the DON, ADON and Regional Nurse Consultant on 02/21/2023: To be completed by Noon on 2/22/2023, Any licensed nurse does not present or in-serviced on 2/21/2023, will not be allowed to assume their duties until in-serviced. New Hire nurses or agency nurses will be in-serviced prior to start of shift by DON, ADON. o Nurse Staff will be Inservice on the following: Inservice staff on G-tube policy Inservice staff on following physician orders Inservice staff notifying physician if g-tube is unable to be flushed or clogged Inservice staff notifying DON/ADON/Nursing Supervisor if g-tube is unable to be flushed or clogged or other concerns related to the g-tube To be completed on 2/22/23, G-tube Protocol Test administered to all licensed nurse staff once g-tube competency check, education, and in-servicing are complete, to ensure understanding of the facility protocols related to g-tubes. The medical director was notified of the immediate jeopardy situation on 02/21/2023 at 8:30pm Policy reviewed with medical director, and he agreed with plan. Monitoring: Immediate monitoring started on 02/21/2023. DON, ADON, Treatment Nurse will monitor all rooms for residents with G-tubes every shift x 7 days per week to ensure de-cloggers are not present or in use. Immediate monitoring started on 02/21/2023. DON, ADON, Treatment Nurse will interview 2 nurses daily x 7 days per week. Charge nurses will be asked what to do if g-tube is clogged or unable to be flushed. In-servicing will be provided as needed. Immediate monitoring on 02/21/2023. DON, ADON, Treatment Nurse will interview 2 nurses daily x 7 days per week. Charge nurses will be asked if they have used or seen a de-clogger in use for residents with g-tubes. If present, the de-clogger will be removed from the facility. In-servicing will be provided. MD will be notified for additional orders to treat. Immediately on 2/22/23, the G-tube Protocol Test was administered to each licensed nursing staff once the G-tube competency check was completed to ensure understanding of the facility protocol. Administrator will review all monitoring tools 5 days per week. All findings will be reported monthly during the QAPI meeting x 3 months Monitoring of the facility's Plan of Removal to confirm the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) included the following: Observation on 02/21/23 at 09:00 PM revealed Resident # 30's room had no de-clogger tool at bedside. Observation on 02/21/23 at 09:05 PM revealed no de-clogger tools were on LVN H's medication cart. Observation and Interview on 02/21/23 at 09:12 PM DON accompanied to storage room named Clean Utility Room where tube feeding supplies were stored. Storage room no evidence of de-clogger tools. DON stated they did an immediate sweep of the building as part of the POR. Observation and Interview on 02/21/23 at 09:17 PM revealed no de-clogger tools on LVN C medication cart. Observation on 02/22/23 at 11:15 AM of Resident #30, TF was disconnected and paused. A sign was at the head of bead that reflected if clogged call MD! Do not use with a picture of de-clogger tool. Observation and record review on 02/23/23 at 09:40 AM revealed residents #55, #58, #47, #42, #63, #45, #51 and #30 with g-tubes/ tube feedings, there was signs observed at the heads of beds that reflected G-tube clogged? Call the doctor do not use these with a picture of the de-clogging tool. The signs were posted in the above listed resident rooms. Record review of KUB (kidney ureter bladder x-ray of abdomen) results on 02/23/23 at 12:45 PM was conducted for the following residents: Resident #55, Resident #47, Resident # 42, Resident #63, Resident #45, Resident #58, Resident # 51. Results did not indicate any injury. Exam was conducted per the POR. Interview on 02/22/23 at 10:26 AM with LVN K stated she worked the 6 AM to 2 PM shift and has worked here since November 2022. LVN K was asked if she had any medications she passed to residents with a g-tube and she stated yes, she passed medication through g-tube or PEG tube. LVN K was asked if the tube became clogged what she would do and she stated she would use warm water to try and flush the tubing and milk the tubing to see if she can free the clog. She stated if that did not work, they send resident out to the ER to be checked there. She stated she had not received any training on how to use the de-clogger tool. LVN K was asked how the training process was for her upon hire and she stated it was swift because they did not have a lot of staff. She stated she spent 3 days on the floor orientating with another nurse and she also attended a SNF clinic training that was one day of classroom. She stated the training included competencies and nursing skills check off. LVN K was asked what hands-on training was provided and she stated hands on training was done depending on what the topic was. She stated the ADON does most training and if the topic can only be taught by an RN, the DON does, the training. LVN K stated documentation training is provided by the MDS nurse E and skin treatments is taught by the treatment nurse LVN. LVN K was asked specifically who did skills check off for her including g-tube management and maintenance and she stated usually the ADON does the skills check off but for her the DON did her check off. She stated she did not receive hands on training for the use of the de-clogger tool. LVN K was asked if she received any education on what to do if the g-tube were to become clogged and she stated she will call the doctor. LVN K was asked if she received training on the use of de-clogger tool and she stated she would not use it without an order and will call the doctor and not use any tool she's not trained to use. She stated she received education this morning (02/22/23) on not using de-clogger tool and she verbalized understanding back to her ADON; after the issue was brought to the facilities attention. Interview on 02/22/23 at 11:22 AM RN D was asked if she had been trained on the use of the de-clogging tool and she stated she has not seen any in the building and was not trained on them upon hire. She stated she learned not to use

Based on interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of two residents reviewed for elopements. The facility failed to provide adequate supervision to Resident #1. As a result, she eloped from the facility and was located at the nearby police station on 12/07/21. It was determined a past non-compliance Immediate Jeopardy existed from 12/07/21 to 12/08/21. The Immediate Jeopardy was determined to have been removed on 12/08/21 due to the facility's implemented actions that corrected the non-compliance prior to the beginning of the investigation on 12/22/21. This failure could place residents at risk for injury related harm, accidents, falls, and lack of proper supervision. Findings included: Review of Resident #1's Face Sheet, dated 12/23/21, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] and discharged on [DATE]. Her diagnoses included dementia, [CONDITION(S)], and cerebral infarction. Review of Resident #1's Physician Orders for December 2021 revealed the following: May have wanderguard due to poor cognition and poor redirection located on lower leg and Check function of wanderguard bracelet one time per day [sic]. Review of Resident #1's Elopement Risk Assessment, dated 11/08/21 revealed Resident #1's Cognitive Skills for Daily Decision Making was Moderately impaired and had made Statements and/or threats to leave [the] facility. Review of Resident #1's Care Plan, dated 11/08/21, revealed Resident #1 was at risk for wandering . Interventions included Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book .Identify pattern of wandering and intervene as appropriate .If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system . Review of Resident #1's December 2021 MAR revealed staff had checked the function of wander guard bracelet on 12/06/21 on the evening/night shift. Review of Resident #1's Admission MDS Assessment, dated 11/09/21, revealed Resident #1 had a BIMS of 02 which indicated severe cognitive impairment. Further review revealed Resident #1 had wandering behavior within one to three days of completing the assessment. Review of an Event Nurses' Note dated 12/07/21 revealed Resident #1 eloped from the 500 hall and was missing for one and a half hours. Further review revealed Resident #1 was found at the [Local] Police Department as someone dropped resident off [sic]. Resident #1's vital signs were taken and she was ordered to be on one on one monitoring. A head to toe assessment was completed and there were no injuries noted. Review of Resident #1's Progress Notes revealed: - On 11/08/21: .res. has hx of wandering, wander guard checked and placed on rt. Lower ankle for safety. Redirection is required frequently and res. attempted to open door on 400 hall, staff responded to alarm immediately, and res. was monitored @ Nurses station.Resident up ad lib and require frequent redirection and monitoring for ambulating towards doors and stating 'I want to go out' and asking for her daughter. Wander guard intact and functioning .frequent monitoring remain in progress. Also informed nurse per RNC recommendation to continue to redirect resident as needed.Spoke to RNC and she is agreeance with Administrator to have the staff sit outside the room and observe resident for attempts to wander and exit seek.Message received from Administrator to have staff to frequently check on resident throughout the night.Phoned Medical Director in attempt to notify him of resident status and DON recommendation for Memory care for resident safety . - On 11/26/21: .res anxious, stating 'I need to get out of here to find my Mother and my sister is picking me up . - On 11/29/21: Resident stood up from table in activities, cna gave her the walker and she stated, 'I need to go, take me to the door so I can go home. In an interview on 12/23/21 at 9:02 AM with the DOR revealed she was with Resident #1 the morning of 12/07/21 before she eloped from the facility. The DOR said she took Resident #1 for her therapy session and then took Resident #1 back to her room, sat her down in a chair in her room, and then left the room. The DOR said she told the CNA (the DOR was unable to identify who the CNA was) in the hallway as a pass off and was told the CNA would check on her in a few minutes after the CNA took something to another resident in their room. The DOR said about five minutes later, she received a report that Resident #1 was missing. The DOR said staff began searching inside and outside of the building for Resident #1. The DOR said Resident #1 would often say [Resident #1] trying to go home although she was easily redirected. The DOR said the staff were cautious of Resident #1 trying to leave the building because she would wander in the facility at times but had never gone to an exit door. The DOR said when she hears the alarm going off, she was to go to the panel, look to see which door was opened and go to that door to ensure no resident left the building. The DOR said next staff were to complete a head count and ensure all residents were accounted for. The DOR said if a resident was missing, she was to activate the missing resident code which was orange and to start searching for them. In an interview on 12/23/21 at 10:16 AM with CNA B revealed she left early the morning of 12/07/21 when Resident #1 eloped. CNA B said she noticed Resident #1 had exit seeking behaviors and gave an example of Resident #1 waking up for the day and saying she wanted to go find her brother or daughter. CNA B said Resident #1 was kept engaged in an activity and busy throughout the day to keep her from wandering. CNA B said one day (CNA B could not recall what day this was) Resident #1 was walking and pushed her walker away and went to the exit door at the end of the 300 hallway and pushed on the door. CNA B said the alarms sounded when Resident #1 pushed on the door and was startled, but Resident #1 never opened the door. CNA B said she told the nurse at the time of Resident #1's exit seeking behaviors and was told to keep a closer eye on her. CNA B said Resident #1 also wore a wander guard on her ankle and she remembered seeing it on the morning of 12/07/21 when Resident #1 eloped. CNA B said when she hears the alarm going off, she was to go to the panel, look to see which door was opened and go to that door to ensure no resident left the building. CNA B said next staff were to complete a head count and ensure all residents were accounted for. CNA B said if a resident was missing, she was to activate the missing resident code which was orange and to start searching for them. In an interview on 12/23/21 at 10:55 AM with LVN A revealed she was at lunch in the break room when Resident #1 eloped on 12/07/21. LVN A said she was familiar with Resident #1 because her first day here, Resident #1 went to push on an exit door and set the alarms off one day (LVN A could not identify what date this occurred). LVN A said Resident #1 did not actually open the door though that day but continued to have exit seeking behaviors of saying she wanted to leave and go to [NAME], Texas. LVN A said staff were aware Resident #1 was at risk of wandering or eloping, so staff monitored her and kept her close to them or involved in an activity. LNV A said when she hears the alarm going off, she was to go to the panel, look to see which door was opened and go to that door to ensure no resident left the building. LVNA said next staff were to complete a head count and ensure all residents were accounted for. LVN A said if a resident was missing, she was to activate the missing resident code which was orange and to start searching for them. In an interview on 12/23/21 at 11:17 AM with LVN C revealed she was approached by a CNA (LVN C could not remember who) and was told that Resident #1 was missing from her room on 12/07/21. LVN C said staff began looking for Resident #1 and activated the missing resident code of orange. LVN C said Resident #1 was kept near the nurse's station or involved in an activity to keep her from wandering about the facility. LVN C said Resident #1 would verbalize wanting to go home or leave the facility often, and one day (LVN C could not remember the date) she saw Resident #1 walking towards the exit doors and had to redirect her. LVN C said when she hears the alarm going off, she was to go to the panel, look to see which door was opened and go to that door to ensure no resident left the building. LVN C said next staff were to complete a head count and ensure all residents were accounted for. LVN C said if a resident was missing, she was to activate the missing resident code which was orange and to start searching for them. In an interview via phone on 12/23/21 at 11:44 AM with CNA D revealed the DOR took Resident #1 to her room, but CNA D was not certain if Resident #1 was allowed to be in her room alone. CNA D said about five minutes or so went by and she went to check on Resident #1 in her room and only her walker was there. CNA D said she spoke with a nurse (CNA D was not sure who) at the nurse's station to report Resident #1 as missing. CNA D said staff began to search for her and mentioned she did not remember hearing an alarm go off at all around that time. CNA D said Resident #1 was constantly monitored by staff who kept her involved in an activity to keep her from wandering. CNA D said she did notice Resident #1 had exit seeking behaviors. CNA D said when she hears the alarm going off, she was to go to the panel, look to see which door was opened and go to that door to ensure no resident left the building. CNA D said next staff were to complete a head count and ensure all residents were accounted for. CNA D said if a resident was missing, she was to activate the missing resident code which was orange and to start searching for them. In an interview on 12/23/21 at 11:59 AM with the Maintenance Director revealed he had checked the exit doors of the facility the morning of 12/07/21, and they were all functioning properly. The Maintenance Director said he was out to lunch when Resident #1 eloped from the facility on 12/07/21. The Maintenance Director said he was told Resident #1 eloped from the exit door on the 500 hallway. The Maintenance Director said from his understanding of what occurred, the alarm panel was reading Fault 01 so when staff went to see which door was opened, they thought it was the front door they needed to check. The Maintenance Director explained that when the exit door on the 500 hallway was opened by Resident #1, it should have shown up on the alarm panel as Alarm 06 instead which would have directed staff to the exit door on the 500 hallway. The Maintenance Director said Resident #1 wore a wander guard which would alert staff that she was at risk of eloping/wandering from the facility . The Maintenance Director said after the elopement, he had someone come out to repair the issue and ensure that all the doors were alarming to the panel and the correct code was being displayed. The Maintenance Director said he was also checking all the exit doors each hour to ensure they were functioning properly. The Maintenance Director said he did this up until the alarm panel was in working order on 12/14/21. The Maintenance Director said he noticed the alarm panel displaying Fault 01 beginning in November to the Monday before Resident #1 eloped, but because the doors were still locking and appeared to be functioning properly he did not mention his concern to anyone. The Maintenance Director refused to say if he should have told someone about the alarm panel reading Fault 01 prior to the elopement. The Maintenance Director said when he hears the alarm going off, he was to go to the panel, look to see which door was opened and go to that door to ensure no resident left the building. The Maintenance Director said next staff were to complete a head count and ensure all residents were accounted for. The Maintenance Director said if a resident was missing, he was to activate the missing resident code which was orange and to start searching for them. In an interview on 12/23/21 at 12:36 PM with the ADON revealed he was with the DOR when she took Resident #1 to her room and told the CNA (the ADON could not remember who the CNA was) to keep an eye on Resident #1. The ADON said afterwards he went to a different hall and was then told a few minutes later that Resident #1 was missing. The ADON said the missing resident code orange was activated and all staff began to look for Resident #1. The ADON said Resident #1 had exhibited signs of exit seeking and there was documentation in her chart of a couple of times Resident #1 had said she wanted to leave, which was made worse when Resident #1's family member came to visit. The ADON said he knew of one or two times that Resident #1 went to the exit doors and pushed, although staff were able to redirect her easily. The ADON said her exit seeking behaviors were sporadic, but staff kept her involved in activities and kept a close eye on her. The ADON said he now knows that there was some sort of malfunction with the door and the alarm. The ADON said when he hears the alarm going off, he was to go to the panel, look to see which door was opened and go to that door to ensure no resident left the building. The ADON said next staff were to complete a head count and ensure all residents were accounted for. The ADON said if a resident was missing, he was to activate the missing resident code which was orange and to start searching for them. In an interview on 12/23/21 at 1:04 PM with the DON revealed she was not in the building at all on 12/07/21 when Resident #1 eloped as she was scheduled off. The DON said she understood there was a fault in the security alarm system and was not familiar with what events took place. The DON said Resident #1 did wear a wander guard because when Resident #1 first admitted , she liked to wander and get into cabinets or have behaviors similar to that. The DON said staff were supposed to keep an eye on her and were on guard about the exit seeking behaviors. The DON said Resident #1 had been talking about wanting to get out and was always on the move, which made the DON think Resident #1 might need to be in a memory care type setting instead. The DON said Resident #1 would go to exit doors but never pushed on them, Resident #1 would talk about going to see her sister or daughters or home. The DON said from what she was told of that day, Resident #1 was taken to her room from therapy and they handed her off to a CNA but the CNA was doing something. The DON said Resident #1 moves very fast and was gone while staff were attempting to figure out which door she went out of. The DON said staff began searching for her and activated the missing resident code of orange. The DON said once they found out it was the alarm panel that caused the confusion on which door Resident #1 eloped from, the alarm company came out to check and repair it. The DON said at the time of Resident #1's elopement, the alarm panel had shown Fault 01 which instructed staff to check the front door but that code was an actual fault instead of an alarm. The DON said none of the staff knew there was an issue with the alarm panel or that it had been displaying Fault 01. The DON said the facility decided to not accept any other residents who were at risk of wandering or eloping, ensured that all residents who were at risk of eloping or wandering were identified immediately , staff were in-serviced regarding what to do when a resident did elope, and had the alarm panel repaired. The DON said when staff hear the alarm going off, they were to go to the panel, look to see which door was opened and go to that door to ensure no resident left the building. The DON said next staff were to complete a head count and ensure all residents were accounted for. The DON said if a resident was missing, staff were to activate the missing resident code which was orange and to start searching for them. In an interview on 12/23/21 at 1:53 PM with the Administrator revealed Resident #1 was taken to her room by therapy and within five minutes the CNA (the Administrator was not sure who) checked on Resident #1 and noticed she was not in her room. The Administrator said staff activated the missing resident code of orange and began searching for Resident #1. The Administrator said she reviewed the camera footage and saw that Resident #1 eloped from the facility through the exit door on the 500 hallway. The Administrator said after searching the building, surrounding areas, and nearby business, she contacted the local police department to inform them of the missing resident. The Administrator said she received a call back from the local police department about fifteen minutes later saying Resident #1 had been found by a citizen walking along the sidewalk and they brought her to the local police station . The Administrator said Resident #1 was brought back to the facility by a police officer and was unharmed. The Administrator said Resident #1 made a lot of comments, but a lot of residents [did] that. The Administrator said staff had some concerns about Resident #1 at first because she was wandering in the facility, but they thought it was due to the adjustment of being in the facility after being admitted from home. The Administrator said after the elopement, they realized Resident #1 was no longer appropriate for their facility and made arrangements with Resident #1's RP to find an alternative placement. The Administrator said Resident #1 was discharged the next day 12/08/21. The Administrator said during her investigation of the elopement revealed a door alarm sounded, the nurse checked the alarm panel which said 01 and meant the front door was opened, so the nurse went to the front door and did not see any residents nearby, and went back to the nurse's station. The Administrator said at the time the nurse did not see that there was a fault at the alarm panel. The Administrator said she contacted the company responsible for the alarm and they repaired the fault on 12/14/21. The Administrator said she in-serviced staff regarding the alarm panel codes, and the elopement/wandering policy and procedure. The Administrator said before the elopement, the Maintenance Director was checking the alarm panel for functionality once per week but was now checking it every morning. The Administrator said the facility had decided to not admit anyone who had wandering or elopement tendencies or behaviors going forward. The Administrator said the Maintenance Director never informed her the alarm panel was showing a fault. The Administrator said when staff hear the alarm going off, they were to go to the panel, look to see which door was opened and go to that door to ensure no resident left the building. The Administrator said next staff were to complete a head count and ensure all residents were accounted for. The Administrator said if a resident was missing, staff were to activate the missing resident code which was orange and to start searching for them. Review of the facility's policy, revised 10/27/10, and titled Elopement Response reflected: 1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical. 2. Determination of missing resident either by routine nursing rounds or door alarms: A. Note: A resident is determined missing when he/she leaves the facility without the staff's knowledge 4. Should an employee discover the resident is missing from the facility, he/she should: A. Report to the charge nurse, B. Determine if the resident is out on authorized leave or pass. If not; C. Make a thorough search of the building(s) and premises. If not located; D. Notify the Administrator and Director of Nursing; E. Notify the resident's responsible party. F. Notify the attending physician; G. Notify VP of Risk Management, ADO, COO, and VP of Clinical Services.J. Make an extensive search of the surrounding area. 5. Deployment Procedure: A. Charge Nurse on each unit send staff down each hall to check each room, including bathroom, closet and bed for correct resident. B. Check all rooms on the hall including tub and bathrooms, linen closets and any recreation rooms. Check all common areas and offices. 6. If unable to locate resident in the building, proceed as follows: C. After 30 minutes, if the resident has not been found, the following call must be made: report missing resident to the police. The facility implemented the following interventions to address the non-compliance: Review of the facility's provider investigation report for Intake # 8 revealed the facility self-reported Resident #1's elopement from the facility on 12/07/21. The Provider Response revealed: [Resident #1] was placed on 1:1 supervision until discharged to alternate placement with secured facility or back home with daughter. [Resident #1]'s daughter [was] notified. Facility doors were checked; locking; implemented monitoring of doors until vendor [came] out to review door functions. Head counts monitor[ed] by facility staff. Physician notified and ordered Lab and UA. Facility staff re educat[ed] by DON and Administrator on elopement policy and wandering/exiting, abuse and neglect, doors and alarm functions. The Investigation Summary revealed: Based on [the facility's] investigation, it was determined the annunciator panel [had] a part that [had] failed; which contributed to the elopement of [Resident #1]. It was repaired by a licensed contractor on 12/14/21. The Provider Action Taken Post-Investigation revealed: .Elopement risk assessments reviewed and updated for [Resident #1] and other residents. Care plans reviewed. [Resident #1] discharged safely to her [RP] on 12/08/21. Head counts and door checks being completed until repaired. Education to facility staff on elopement policy/wandering/exit seeking/abuse and neglect/doors and alarms. Wander/elopement binder reviewed. Review of the Door Check for Locking and Unlocking on 12/07/21 revealed the doors were checked by the Maintenance Director each hour until 5:30 PM. Review of a sign-in sheet dated 12/13/21 revealed the facility held a Standards of Care Meeting Data Review related to Resident #1's elopement. Review of an in-service dated 12/07/21 and titled Elopement revealed staff were educated on the facility's elopement response policy and procedure. Review of an in-service dated 12/07/21 and titled Abuse/Neglect revealed staff were educated on the facility's abuse/neglect policy and procedure. Review of an in-service dated 12/07/21 and titled Elopement Risk- Exit Seekers revealed staff were educated on the behaviors to report when noted and the procedure for when a resident does exit seek or wander. Review of an undated in-service and titled Door Alarm [At] Nurse Desk revealed staff were educated on checking exit doors when the alarm sounds. Review of an in-service dated 12/09/21 and titled Locking Doors, Alarm, Nursing Panel Annunciator revealed staff were educated on the alarm system. Review of monitoring tools used for Resident #1 on 12/07/21 revealed staff monitored her until 12/08/21 every 30 minutes. Review of monitoring tools used for head counts completed revealed staff monitored all residents every 15 minutes until 12/08/21, and then every hour until 12/14/21. Review of monitoring tools used to check doors functionality of locking/unlocking revealed staff monitored the doors every hour until 12/14/21.