Every finding on record at Greenview Nursing and Rehabilitation

Based on interview and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASARR) Level I residents with a mental illness was completed correctly and were provided with a PASARR Level II assessment for one (Resident #1) of four residents reviewed for resident assessments. The facility failed to ensure the PASARR Level 1 screening for Resident #1 was completed accurately and timely. This failure could place residents at risk of not receiving the appropriate care and services to meet their needs. Findings included: Record review of Resident #1's admission sheet, dated 05/11/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included unspecified intracranial injury with loss of consciousness of unspecified duration, subsequent encounter (a condition that develops after an initial injury and could lead to long-term effects or complications was often referred to as a secondary or chronic complication of that injury) flaccid hemiplegia affecting left nondominant side (a type of one-sided paralysis where the affected muscles are limp and lack voluntary control, in contrast to spastic hemiplegia where muscles were stiff or contracted uncontrollably) major depressive disorder, recurrent, unspecified (a severe form of depression characterized by persistent feelings of sadness, hopelessness, and a loss of interest in activities once enjoyed), and personal history of traumatic brain injury (an individual previously experienced a head injury caused by external force, regardless of current symptoms or ongoing illness.) Record review of Resident #1's annual MDS assessment, dated 04/08/2026, reflected that he was assessed to have a BIMS score of 14 indicating moderate cognitive impairment. Resident #1 was assessed to have Non-traumatic Dysfunction. Record review of Resident #1's care plan, dated 7/22/2026 reflected a Focus Area: PASARR DME: CMWC- Delivered: N/A Serial #: N/A. In Progress: Requested during initial IDT meeting on 3/26/2026. Goal: CMWC (will be) purchased through PASARR. Interventions: If Resident #1 leaves the facility, CMWC will go with her (once received). Record review of Resident #1's PASARR Comprehensive Service Plan (PCSP) Form, dated 3/26/2026, indicated an IDT meeting took place and Resident #1 was approved for PT, OT, ST and DME. Record review of an email sent to the facility from PASRR NFSS Compliance Department, dated 5/19/2026, indicated: The reason for this email is to notify you that according to our records, an Interdisciplinary Team meeting (IDT) was held and entered the Long-Term Care Online Portal for one or more of your residents. During the IDT meeting nursing facility specialized services were recommended and agreed upon for the resident in your facility. For your facility to be compliant with the 26 Texas Administrative Code (TAC), Chapter 554, Subchapter BB, section S554.2704(i)(7), a nursing facility must initiate nursing facility specialized services within 20 business days following the date that the services are agreed to in the IDT meeting. Currently, your nursing facility is out of compliance as per this TAC Rule. As of today (5/19/2026 date of the email), our records show that the HHSC PASARR unit has not received a request for specialized services for the following residents: Resident#1. In an interview on 07/22/2026 at 10:25 AM, the MDS Coordinator stated she oversaw doing PASRR assessments. She received the PL1. The MDS Coordinator stated if she a resident transferred from their facility to another facility, she filled out the PL1. The MDS Coordinator stated if a resident admitted another facility, she looked at them to ensure they were accurate. She stated a PASARR should be completed within 72 hours of the resident entering the facility. MDS Coordinator stated a diagnosis of mental-major depressive disorder would indicate a positive level 1 on the PASRR. They would place a 1 on the form and it would trigger the LIDDA, which was the local authority, to come out and assess the resident. She stated if the resident had a positive PASARR, they would have a PE completed and an IDT meeting set up within 14 days with the LIDDA. The MDS Coordinator stated if residents were in the facility, and newly diagnosed with mental illness, a new PL1 was needed. She stated a PASARR would not be done if the resident was not suspected to have a diagnosis that would fall under those categories or IS, MD, DD. She stated everyone who admitted into the facility must have a PL1. The MDS Coordinator stated if there was no diagnosis that trigger any of the boxes, it was a negative PL1; However, if the PASARR was inaccurate, the resident would not receive the services they were eligible for. The MDS Coordinator stated Resident #1 had a diagnosis of major depressive disorder, but her Level 1 was completed on 3/14/2026. She stated a new PASARR was generated, which updated her PL1 PASARR to reveal the new diagnosis. The MDS Coordinator stated Resident #1's PASARR received from the previous facility was not correct, which a new PL1 was updated and revealed her diagnosis. In an interview on 07/22/2026 at 1:13 PM, the DOR stated the MDS Coordinator oversees the PASARR screening. She would double check the PASARR when they come in. He stated he was not sure of the process or any other parts of the PASARR process. DOR stated he did assessments and therapies with the residents. He stated Resident #1 was approved for a DME. He stated it takes between 2 weeks to a month to receive the equipment. He stated the process begins when he does the assessments on the residents, he will then reach out to the wheelchair providers and see who is available and reliable to provide the services. The provider will schedule a day to come out and do the measurements and customization for the wheelchair for the residents. The provider will get bids from different companies for different parts to put the wheelchair together. The provider will write up the estimate and send a copy back to him. The DOR stated once all the bid data from the providers was collected, he will get the signature from the doctor. He stated he believed he reached out to the doctor to get the signature, but the doctor was unavailable for an extended time, and that was the hold up. The DOR stated he upload all the documentation and once PASARR approved it, he would capture the PASARR approve section. He will give it to the system technician with the provider, and she will bill from there and they will begin to build the wheelchair. The DOR stated once the customized wheelchair was built, they will deliver the wheelchair to the facility. The DOR stated the provider was not available which delayed the process of Resident #1 getting her wheelchair in a timely manner. In an interview on 07/22/2026 at 3:06 PM, the ADM stated the MDS Coordinator was responsible for the PASARR. He stated a PASARR should be completed prior to the resident entering the building. The ADM stated a diagnosis that would indicate a Positive Level 1 PASARR would be a traumatic brain injury. The ADM stated if a resident had a positive PASARR 1, they would go through the DOR and a screening to see what services they would be put on or was eligible for. The ADM stated a new PASARR screening would be due to a different diagnosis from when the resident first entered the facility and a change from their original diagnosis. The ADM stated a new ID, MD, or DD would warrant a new Level 1 screening. He stated if the PASARR was inaccurate, the resident would not receive the services, or they were offered the wrong services. In an interview on 07/22/2026 at 3:30 PM, the DON stated LIDDA and the MDS Coordinator was responsible for the PASRR. She stated the PASARR should be completed before the resident entered the facility and based on the answers, LIDDA will come out and see the resident. The DON stated a diagnosis that would indicate a positive level 1 was ID - congenital illness, ataxia. She stated if a resident had a positive PASARR 1, they would notify LIDDA and they would come out and assess the resident. The DON stated the need for a new PASARR screening would be if the information is incorrect or LIDDA sees something incorrect when they come out. She stated a new ID, MD, or DD diagnosis would warrant a new level 1 screening. She stated a new PASARR was not warranted for Resident #1 because the documentation was correct and it was just delayed due to a missing signature from the doctor. She stated if the PASARR was inaccurate, it could delay services. Record review of the facility's, Resident Assessment - Coordination with PASARR Program Policy, dated October 2025, revealed The facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. 7. Recommendations, such as any specialized services, from a PASARR level II determination and/ or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transition or care.

Based on interview, and record review, the facility failed to implement a comprehensive care plan that describes the services to be furnished to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents(Resident #1) reviewed for care plans.The facility failed to revise Resident #1's care plan to reflect behavior and intervention when he urinated on the floor in the commons area due to dementia on 07-07-2026.This deficient practice placed residents at risk of not having their individualized needs met and communicated to providers that could result in a decline in physical well-being. Findings included:2. Record review of Resident #1's admission record, dated 07/12/2026, revealed a [AGE] year-old male was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Alzheimer's disease(memory loss), cognitive communication deficit (difficulty with speech, listening, reading, or writing caused by an underlying problem with brain function),mental disorder (significant disturbance in an individual's cognition, emotional regulation or behavior), and ADHD (a psychiatric condition marked by persistent patterns of inattention, hyperactivity, and impulsivity that interfere with daily functioning and development).Record review of Resident #1's Quarterly MDS assessment, dated 04/29/2026, revealed the resident had a BIMS score of 0, which indicated Resident #1 cognition was severely impaired. Resident #1's behavioral symptoms on the Quarterly MDS revealed no behaviors were exhibited.Record review of Resident #1's care plan, dated 05/27/2026, revealed Resident #1's was care planned on 05/23/2026 for resident to resident behaviors associated with ADHD with intervention to document target behavior in clinical records. There was no care plan update for when Resident #1 urinated on the floor in the commons area due to dementia on 07-07-2026.Review of Resident #1's progress note dated 07/07/2026 reflected Resident #1 had urinated on the floor.During an attempted interview on 07/12/2026 at 11:30 AM with Resident # 1, he was not competent enough to participate in the interview. Resident # 1 did not respond or look at the surveyor when he was addressed.During an interview on 07/12/2026 at 2:32 PM, the MDS Coordinator stated she was responsible for updating the care plan and interventions for Resident #1 on 07/07/2026. The MDS Coordinator stated it was expected for her to update the care plan along with the interventions, and she had overlooked and failed to update the behaviors and interventions. The MDS Coordinator stated that she would have seen the behavior note to indicate the behavior but overlooked them. The MDS Coordinator did not provide risks of updates not being done.During an interview on 07/12/2026 at 2:54 PM, the ADON stated it was expected for the MDS Coordinator to have updated the care plan and interventions for behaviors for Resident #1 on 07/07/2026. The ADON stated it was important for the MDS Coordinator to have updated care plan to meet the residents' needs. The ADON stated when care plans were not updated, the needs of the residents may not be met.During an interview on 07/12/2026 at 3:09 PM , the ADM stated it was expected for the MDS Coordinator to update Resident #1's behavior and interventions on the care plan on 07/07/2026. The ADM stated the MDS Coordinator was responsible for making sure the behavior and interventions were updated so the residents could be cared for to the best of the facility's ability.Record review of the facility's undated policy titled, Care Plan Revisions Upon Status Change revealed , The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status changeThe comprehensive care plan will be reviewed , and revised as necessary, when a resident experiences a status change.

Based on interviews and record review, the facility failed to ensure residents had the right to retain and use personal possessions, including clothing, as space permits, unless to do so would infringe upon the rights of others for 3 of 10 residents (Resident #11, Resident #31, and Resident #106) reviewed for respect and dignity. The facility failed, for an undetermined period, to return residents' clothing to them after they had been laundered causing Residents #11, #31, and #106 to be mad. This failure could place residents at risk of their clothing not being returned, lost, stolen, and not having adequate clothing options.Based on interviews and record review, the facility failed to ensure residents had the right to retain and use personal possessions, including clothing, as space permits, unless to do so would infringe upon the rights of others for 3 of 10 residents (Resident #11, Resident #31, and Resident #106) reviewed for respect and dignity. The facility failed, for an undetermined period, to return residents' clothing to them after they had been laundered causing Residents #11, #31, and #106 to be mad. This failure could place residents at risk of their clothing not being returned, lost, stolen, and not having adequate clothing options. Findings included: Record review of Resident #11's face sheet, dated 05/29/2026, revealed a seventy six year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] and 04/12/2026 with a diagnosis that included type 2 diabetes mellitus with diabetic polyneuropathy (nerve damage caused by long-term high blood sugar and metabolic dysfunction), gastrointestinal hemorrhage (blood loss originating anywhere in the digestive tract), and non-st elevation (NSTEMI) myocardial infarction (a common, life-threatening heart attack caused by a partial (or temporary) blockage of a coronary artery). Record review of Resident #11's MDS (clinical assessment to determine resident's strength and needs) dated 03/28/2026 Nursing Home Comprehensive Section C - Cognitive Patterns revealed a score of 15 indicating no cognitive issues. Record review of Resident #11's care plan revealed Resident #11 had a focus dated 09/16/2014 of impaired physical functioning related to debility, cognitive impairment with a goal dated 05/19/2026 of Resident #11 will remain well groomed, dressed, and assisted by staff as needed. Record review of Resident #31's face sheet, dated 05/29/2026, revealed a fifty six year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis that included hypotension (low blood pressure), hypokalemia (a potentially dangerous electrolyte imbalance characterized by lower-than-normal potassium levels in the blood), and epileptic spasms (sudden contractions of the arms, legs, and trunk). Record review of Resident #31's MDS (clinical assessment to determine resident's strength and needs) dated 03/30/2026 Nursing Home Comprehensive Section C - Cognitive Patterns revealed a score of 15 indicating no cognitive issues. Record review of Resident #31's care plan revealed Resident #31 had a focus dated 03/01/2025 of impaired physical functioning and cognitive impairment with a goal dated 06/30/2026 of Resident #31 will remain well groomed, dressed, and assisted by staff as needed. Record review of Resident #106's face sheet, dated 05/29/2026, revealed a seventy-year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis that included type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema (indicates that the patient has eye damage (retinopathy) caused by Type 2 diabetes, but the retinopathy's severity is not specified), polyneuropathy (a neurological condition characterized by the simultaneous damage or malfunction of multiple peripheral nerves throughout the body), and gout (intensely painful form of inflammatory arthritis caused by a buildup of uric acid crystals in the joints). Record review of Resident #106's MDS (clinical assessment to determine resident's strength and needs) dated 04/15/2026 Nursing Home Comprehensive Section C - Cognitive Patterns revealed a score of 15 indicating no cognitive issues. Record review of Resident #106's care plan revealed Resident #106 had a focus dated 01/22/2025 of impaired physical functioning related to debility with a goal dated 05/13/2026 of Resident #106 will remain well groomed, dressed, and assisted by staff as needed. During an interview on 05/28/2026 at 7:40 AM with Resident #106, he said he was missing socks and underwear. Resident #106 said he put his name on all his clothing. Resident #106 said he discussed the problem of not getting clothing back from the laundry with the AD and it had been discussed at resident council meetings. Resident #106 said he received 6 new pairs of socks from the AD, and the AD put his name on the socks, and he never received the socks back after they went to the laundry. Resident #106 said it made him mad that he did not receive his clothing back from the laundry. During an interview on 05/28/2026 at 12:01 PM with the AD, she said residents had a lot of concerns about clothing not coming back to them from the laundry. The AD said residents had lost socks, bras, underwear, and pants. The AD said the facility received donations for socks and she wrote Resident #106's name, using a permanent marker, on his donated socks. The AD said Resident #106 did not receive his socks with his name on them from the laundry after they were sent to be washed. The AD said she had written residents' names on a lot of clothing, and the residents said they did not receive their clothing back after it had been laundered. The AD said residents not receiving clothing back from the laundry was a continuing problem. During an interview on 05/29/2026 at 8:40 AM with the PTM, he said it was hit or miss whether residents had their names on their clothing. The PTM said the CNAs were to make sure that the residents' name was on their clothing. The PTM said the CNAs took the clothing from the residents' rooms and put them into laundry bags then brought them to the laundry room. The PTM said the clothing was separated into colors, whites, [NAME], and washed. The PTM said all the residents' clothing was mixed. The PTM said he got a lot of complaints from residents about missing laundry. The PTM said he spoke with the Administrator and tried to get him to purchase a laundry bag for each resident. The PTM said there were laundry bags that held dirty clothing and could be put into the washer then into the dryer and the clothing would stay together. The PTM said the Administrator said that was too much money. The PTM said the Administrator supported him on making changes so that residents received their clothing back from laundry. The PTM said the nurses and the CNAs needed to be on board to get the residents' laundry returned to them. The PTM said he spoke with the DON about working together to come up with a solution to the resident laundry issue. The PTM said the DON told him to do what he needed to do, but she had bigger fish to fry. During an interview on 05/29/2026 at 12:12 PM with the Administrator he said laundry was a problem. The Administrator said he had not heard from the residents that their clothing had been lost in the laundry, but he had heard from staff members, but he could not remember all the names of the staff who told him. The Administrator said he did hear from the PTM that residents were not getting their clothing back from the laundry. The Administrator said he met with an Administrator at a sister facility for suggestions on how to solve the laundry issue. The Administrator said he had discussed getting separate laundry bags for each resident so their clothing could be in a bag all together and the bag would be placed in the washer then the dryer. The Administrator said when residents arrived at the facility their personal items should be inventoried and the resident's name be written on their clothing, but he did not think that was happening. The Administrator said it was the responsibility of the laundry department to make sure residents received their clothing and the CNAs needed to work with the laundry department. The Administrator said the negative effect of residents not getting their clothing from the laundry was that the residents could be upset because they did not receive their clothing. The Administrator said some of the residents did not have a lot of clothing and might not have available clothing to wear if they did not receive their clothing back from the laundry. During an interview on 05/29/2026 at 2:36 PM the DON said residents have told her there was a problem with receiving clothing back from the laundry. The DON said she discussed the laundry with the PTM, and he did not tell her it was a large problem. The DON said when residents came into the facility their names should be put on their clothing. The DON said many of the residents were homeless when they came to the facility and their clothing was dirty. She said their dirty clothing was taken straight to laundry because staff did not want to touch dirty clothing. The DON said the laundry department would be responsible for putting the resident's name on the clothing after it was washed and dried. The DON said there was an inventory taken of residents' belongings when they entered the facility. The DON was not sure if it was a paper inventory or if it was included in the resident eMAR. The DON said the inventory of residents' belongings was not something she spent too much time on. During an interview on 05/29/2026 at 4:31 PM with Resident #11, she said she had 4 pairs of pants and two of them always seemed to be misplaced. Resident #11 said she always put her name on her clothing before her clothing went to the laundry. She said she had talked to the Administrator about it and staff tried to find her clothing and sometimes her clothing was found in the laundry. She said there had been times when she did not have clean clothing to wear because her clothing was missing. Resident #11 said she did not know if another resident was wearing her clothing and then they were returned to her. Resident #11 said she had seen her clothing on other residents and that made her mad and it made her mad that her clothing was missing. During an interview on 05/29/2026 at 5:01 PM with Resident #31, she said she put her name on her clothing and sometimes she did not get her clothing back from the laundry. Resident #31 said she had talked to the AD about it, and it did not do any good. Resident #31 said she had seen one of her shirts on another resident and the AD told the other resident to take it off. When the resident took it off, it had Resident #31's name on it. Resident #31 said she saw a male resident wearing her pajama bottoms and another man wearing her jacket. Resident #31 said she told the Administrator about it. Resident #31 said it made her mad because she as not getting her laundry back and other residents were wearing her stuff. During an interview on 05/29/2026 at 5:35 pm CNA D said residents complained to her about not getting clothing back from the laundry. CNA D said when residents ere admitted to the facility, she wrote the resident's name on their clothing. CNA D said when residents could not locate their clothing, she checked for them in laundry or in the resident's rooms. CNA D said the residents were upset big time because they did not get their clothes back from the laundry. CNA D said some of residents did not have any clothing because all of their clothing was long in the laundry. CNA D said she told the Administrator that residents need clothing because laundry lost their clothing. Record review of facility policy Resident Personal Belongings, undated, reflected was is the policy of the facility to protect the resident's right to possess personal belongings, such as clothing and furnishings, for their use while in the facility. Policy Explanation and Compliance Guidelines:1. All resident possessions, regardless of their apparent value to others, will be treated with respect.2. The facility will support the resident's right to retain and use personal possessions to promote ahomelike environment and maintain their independence.3. All resident personal items will be inventoried at the time of admission by the social services designee,or another designated staff member and documentation shall be retained in the medical record.4. Additional possessions brought in during the duration of the individual's stay shall be added to theexisting personal belongings inventory listing.5. The facility may refuse to allow a resident to retain his or her personal possession(s) due to thefollowing reasons- insufficient space in resident's room6. The facility will ensure resident belongings are kept in a neat and orderly fashion and maintained ineach resident's room.7. The facility will exercise reasonable care for the protection of the resident's property from loss ortheft.

Based on observations, interviews, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 3 of 6 residents (Residents #28, #72, and #87) reviewed for resident rights. The facility failed to ensure Resident's #87's and Resident #72's call light was within reach on 05/27/26. The facility failed to ensure Resident's #28's and Resident #72's call light was within reach on 05/28/26. This failure could place residents at risk of needs not being met. Findings included:Record review of Resident #87's face sheet dated 05/29/26 reflected a [AGE] year-old-male admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD) (a lung disease characterized by chronic respiratory symptoms and airflow limitation), multiple sclerosis (a chronic, autoimmune disorder of the central nervous system), hemiplegia-right dominant side (refers to total paralysis or the complete loss of voluntary movement on one side of the body), and hemiparesis-right dominant side(partial weakness or a mild loss of strength on one side of the body), traumatic brain injury (is a sudden physical assault that causes damage to the brain). Record review of Resident #87's quarterly MDS assessment dated [DATE] reflected a BIMS score of 15 which indicated Resident #87 was cognitively intact. The MDS reflected Resident #87 had no impairment in functional limitation in range in motion for upper extremity (shoulder, elbow, wrist, hand). Resident #87 required setup or clean-up assistance for eating, supervision or touching assistance for toileting, showering and personal hygiene. Review of Resident #87's care plan dated 03/11/26 reflected: Resident was risk for falls/injuries r/t debility/generalized weakness, poor safety awareness, potential medication side effects. Goals: Resident # 87 would be free from injury r/t falls with target date: 06/16/26 Interventions included: Call don't fall sign in room [ROOM NUMBER]/10/26, Call light within easy reach. Encourage him/her to use call light for staff assistance and encourage the use of his call light. 04/13/2026. During an interview/observation on 05/27/26 at 1:35 PM, Resident #87 was seated in his wheelchair in his room. He stated he used his call light when assistance was needed. Resident #87's call light was lodged between the bed rail and mattress at the head of bed, preventing him from reaching and accessing the call light. Resident #87 attempted to retrieve the call light but was unable to free or access the call light due to its position. Record review of Resident #72's face sheet dated 05/29/26 reflected a [AGE] year-old-male admitted on [DATE] with diagnoses of chronic kidney disease, stage 3, (a condition where your kidneys are damaged and gradually lose their ability to properly filter waste and excess fluids from your blood), vascular dementia (a decline in thinking and memory skills caused by restricted or blocked blood flow to the brain), hypothyroidism (occurs when your butterfly-shaped thyroid gland fails to produce enough essential hormones), hypertension (a common condition where the force of your blood pushing against your artery walls is consistently too high). Record review of Resident #72's quarterly MDS assessment dated [DATE] reflected a BIMS score of 00 which indicated severely impaired cognition. The MDS reflected Resident #72 had no impairment in functional limitation in range in motion for upper extremity (shoulder, elbow, wrist, hand). Resident #72 required setup or clean-up assistance for eating, supervision or touching assistance for toileting, showering and personal hygiene. Record review of Resident #72's care plan dated 03/25/26 reflected: Resident was at risk for falls r/t impaired mobility/balance, impaired cognition, psychoactive medications, incontinence, wandering, chronic kidney disease (long standing disease of the kidneys leading to renal failure), history of myocardial infarction (commonly known as a heart attack, occurs when blood flow to a part of the heart is blocked or severely reduced), hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated), coronary artery disease (the most common type of heart disease. It occurs when plaque-a buildup of cholesterol, fat, and calcium-narrows the arteries that supply oxygen-rich blood to your heart). Goals: Resident #72 would be free of falls with target date: 06/09/2026. Interventions included: Be sure [Resident #72]'s call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Resident was incontinent of bowel and bladder r/t impaired mobility, incontinence. Goals: Resident #72 would remain free from skin breakdown due to incontinence and brief use with target date: 06/09/26. Interventions included: have call light within easy reach. During an interview/observation on 05/27/26 at 1:22 PM, Resident #72 was in bed with his blanket pulled up to his chest. Resident #72's eyes were closed and he was showing no signs of pain or distress. Resident #72 did not respond when his name was called. Resident #72's call light was observed hanging near the wall outlet from a string attached to the over-bed light fixture and not readily accessible to Resident #72. A sign posted on the wall stated, ENSURE CALL LIGHT IS WITH IN REACH. During an interview/observation on 05/28/26 at 9:49 AM, Resident #72 did not know about his call light. Resident #72 appeared pleasantly confused and did not answer for how he would call for help if needed. Resident #72's call light was observed hanging near the wall outlet from a string attached to the over-bed light fixture and not readily accessible to Resident #72. Record Review of Resident #28's admission record dated 05/28/26 reflected the resident was a [AGE] year-old male admitted on [DATE]. His diagnoses included cerebral infarction (a pathologic process that results in an area of necrotic tissue in the brain), diabetes (a group of diseases that result in too much sugar in the blood), hemiplegia/hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), and muscle wasting and atrophy (the loss of muscle tissue and strength, typically caused by inactivity, malnutrition, aging (sarcopenia), or diseases affecting nerves or muscles). Record Review of Resident #28's Quarterly MDS assessment dated [DATE] reflected Resident #28 had a BIMS score of 00 which indicated Resident #28 was severely cognitively impaired. The MDS reflected Resident #28 required setup or clean-up assistance for eating and toileting, partial to moderate assistance for showers, supervision or touching assistance for personal hygiene. Record review of Resident #28's care plan dated 06/25/20 and revised 06/22/21 reflected: Resident was at risk for falls r/t age, and limited mobility r/t history of CVA (commonly known as a stroke, occurs when blood flow to an area of the brain is interrupted or reduced, depriving brain tissue of oxygen and nutrients) with hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles).Goal: Resident #28's risks and injury potential will be minimized through the next review date Interventions included: Be sure resident's call light is within reach and encourage resident to use it for assistance as needed. Resident needs prompt response to all requests for assistance During an interview and observation on 05/28/26 at 12:35 PM, Resident #28 stated he did not know where his call light was placed at that time and he could not reach it wherever it was. He stated he got up out of bed on his own but if he was not able to get out of bed and he needed help for something, he would not have had a way to call for help and he would not have known what to do. Observed Resident #28's call light on the floor at the foot of the bed and not within resident's reach. Observed signage posted on Resident #28's wall beside Resident #28's bed that stated, Ensure Call Light Is Within Reach. During an interview on 05/28/26 at 12:48 PM, CNA D stated she usually put Resident #28's call light within his reach and he always moved it to the bottom corner of his bed. She stated the call light must have fallen off onto the floor. She stated resident would not have been able to call for help where the call light was located. She stated she had been trained on call light placement being within residents' reach and if a call light was not in a resident's reach, it could have caused a fall or accident and resident would not have had a way to call for help. During an interview on 05/28/26 at 4:41 PM, CNA A stated it was the third day she had worked at the facility. She stated Resident #72's call light was not in a place where he could reach it. She stated the call light should have always been within residents' reach and he had liked to move his call light and stuff. She stated she was trained on call lights having to be within residents' reach. She stated if a call light was not in reach, a resident could have fallen or needed to be changed and could not call for help. She stated residents are rounded on every two hours. During interview on 05/28/2026 at 4:45 PM, CNA B stated she had worked at the facility for 8 months. She stated she had been in-serviced on call light placement and resident rights. She stated residents' call lights should have always been within their reach. She stated if a resident's call light was not within their reach, it could have resulted in a resident falling trying to reach their light or they may have needed emergency help, and staff would not have known. During interview on 05/28/2026 at 4:49 PM, LVN C stated she had worked at the facility for 16 months, She stated she had been in-serviced on call light placement and resident rights. She stated residents' call lights should have always been within their reach. She stated if a resident's call light was not within their reach, it could have resulted in injury to the resident. During an interview on 05/29/26 at 11:37 AM, LVN E stated all residents' call lights should have been within the residents' reach at all times and she had been trained on this. She stated if a resident's call light had not been within the resident's reach it could have caused falls, distress, or numerous other things for the resident because they may not have been able to get ahold of staff. During an interview on 05/29/26 at 11:55 AM, the ADM stated it was his expectation that all residents' call lights be within the residents' reach at all times. He stated staff had been trained on call lights being within residents' reach at all times. He stated if a resident's call light had not been within the resident's reach, it could have caused a resident to have fallen and gotten hurt. During an interview on 05/29/26 at 11:38 AM, the DON stated it was her expectation that all residents' call lights be within the residents' reach at all times. She stated staff had been trained on call lights being within residents' reach at all times. She stated if a resident's call light had not been within the resident's reach, it could have caused a fall or injury. Record review of facility policy titled Call Lights: Accessibility and Timely Response dated 05/16/25 reflected Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines: 1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. 5. Staff will ensure the call light is within reach of resident and secured, as needed.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. The facility failed to date all items after they were opened. The facility failed to properly label and date all items in the freezer.The facility failed to maintain clean cooking equipment. These failures could place residents at risk for foodborne illness. Findings included: An observation on 05/27/2026 at 9:08 AM of the stand-up freezer revealed the following: An undated and opened to air bag of chicken stripsAn undated and opened to air bag of fries2-freezer bags of undated and unknown substances4-sealed bags of undated and unlabeled substances that appeared to be frozen saucesAn undated opened bottle of blackberry lemonade An observation on 5/27/2026 at 9:14 AM revealed the following areas to be uncleaned:The side of the fryer was dirtyUnder the counter where the tea maker was located was dirtyThe floors and walls were dirty and had food and dripping from food on them.The sanitation bucket had dirty towels in it and hanging out of itThere was a container with kitchen equipment (a skillet, containers, container tops, tongs) that was unclean that sat under the counterThe steam table was observed with particles of food on it. During an interview on 5/28/2026 at 5:17 PM, DM stated he has been working at the facility as the Dietary Manager since 12/2025 but has been in the culinary business as a chef for 20 years. DM stated he, along with his staff, is responsible for making sure the opening and used by dates are placed on items in the coolers and the freezers, but ultimately it all falls on him. DM stated it is the responsibility of everyone to check the dates on the items before using them and it should be done daily on every shift. He stated if the food is not dated and the resident is served that food; the resident could get food poisoned. He stated food left opened in the freezer is thrown away. DM stated the kitchen is swept and mopped daily and decked brush the floors and walls weekly, and the trash cans are washed nightly, the cutting board and the counters are cleaned in between the shift, the juice machine is done each time they change the bags, the juice lines are flushed weekly, the nozzles to the juice machine are done nightly, the shelves are put through the machine to be cleaned monthly. DM stated it is the responsibility of the kitchen staff to keep the kitchen cleaned. During an interview on 5/29/2026 at 11:01 AM, CK K stated she has worked at the facility a little over a month. She stated it is everyone's responsibility to make sure all items are labeled and dated. CK K stated it is everyone's responsibility to check the dates on the food before using it. She stated if the food is not dated, it is supposed to be thrown away. She stated if the food is in the freezer left opened, it could get freezer burnt and thrown away. CK K stated it is everyone's job to make sure the kitchen is thoroughly cleaned and disinfected daily; but the kitchen is thoroughly cleaned every 2 days. During an interview on 5/29/2026 at 11:12 AM, CK J stated she has worked at the facility since February 2026. She stated she mainly prepares the desserts. She stated when the truck comes in, everyone is supposed to put up the items and place the dates on the items. CK J stated everyone is responsible for checking dates on food daily. CK J stated if the food in the freezer is left open, it can get freezer burnt and the DM will have them to throw it away. She stated they are supposed to put the food in a zip lock bag once the item is opened, seal it, then label it and date it. CK J stated it is the kitchen staff's responsibility to make sure the kitchen is clean daily. She stated when she comes in, she grabbed a bucket and wiped the areas down. During an interview on 5/29/2026 at 11:40 AM, ATDM stated she has worked at the facility since January 2026, but she became the ATDM within the last 2 months. She stated it is everyone's responsibility to make sure the items in the coolers and freezers are labeled and dated. She stated it is her responsibility to make sure it is checked. She stated she worked 4 days out of the week (4 days on and 2 days off). ATDM stated the food is supposed to be discarded if there is no date on it and it is found in the refrigerator or the freezer opened. She stated it is everyone's responsibility to ensure the kitchen is cleaned daily. Review of facility policy titled Sanitation Inspection date implemented June 23, 2025, reflected It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations.Policy Explanation and Compliance Guidelines:1. All food service areas should be kept clean, sanitary, free from litter and rubbish and protected from rodents, roaches, flies and other insects. 2. The department shall establish a sanitation program for food services based on applicable state and federal requirements.3. The sanitation program will provide for inspections to be conducted of the food service areas. 4. Sanitation inspections will be conducted in the following manner:a. Daily: Food service staff shall inspect refrigerators/coolers, freezers, storage area temperatures, and dishwasher temperatures daily.b. Weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations.5. Inspections will be conducted but not limited to the following areas:a. Dry storageb. Freezerc. Refrigeratord. Dish [NAME]. Pot washf. Main production areag. Food preparation areah. General dietary observations

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 kitchen reviewed for pests. The facility failed to ensure the kitchen was free of flies on 5/27/2026, 5/28/2026 and 5/29/2026. These failures could place residents at risk for insect borne illness, infection and diminished quality of life. Findings included: Observation on 5/27/2026 at 9:08 AM, 11:25 AM, and 5:20 PM, 5/28/2026 at 12:15 PM and 5/29/2026 at 11:45 AM, revealed there were about 4 to 6 flies observed flying around in the kitchen, and flies landing on cake while the staff were trying to prepare the trays to be placed on the cart. Staff shooed the flies as they worked. Observation on 5/28/2026 at 4:15 PM reflected the facility pest control comes in a spray monthly for all insects and any rodents. During an interview and observation on 5/28/2026 at 5:17 PM, DM stated he has been working at the facility as the Dietary Manager since 12/2025 but has been in the culinary business as a chef for 20 years. DM stated he has spoken with the ADM regarding the flies and they are getting an air curtain, they are going to upgrade the light which will attract the flies to assist with getting rid of them. He said they have had an issue with the flies within the last 2 weeks. DM stated if the flies are touching the food, it needs to be thrown away. Observed a can of Aerosol Contact Insecticide in which the DM stated the staff cleaned the kitchen at night and they are to spray the insecticide once they leave. He stated he has asked the staff to make sure to dump the water bucket. DM stated it does not help with staff leaving the door open and the flies fly in also. During an interview on 5/29/2026 at 10:30 AM, ADM stated he was just informed of the fly's issue in the kitchen. He stated they are going to get the Eco-machine ( a machine used to attract flies) fixed to assist with getting rid of the flies. ADM stated if any flies touch the food, they can lay eggs and multiply and make more flies, and residents will get sick. ADM stated his expectation of the DM and the kitchen staff is to make sure they are keeping the kitchen as clean and sanitary as possible. During an interview on 5/29/2026 at 11:01 AM, CK K stated she has worked at the facility a little over a month. She stated there had been an issue with the flies since she has been there. She stated if the flies landed on the food, it needs to be thrown away because the resident can get sick if they are served the food the flies landed on. During an interview on 5/29/2026 at 11:12 AM, CK J stated she has worked at the facility since February 2026. She stated there has been an issue with the flies since she has been here. CK J stated if the flies land on the food it is thrown away. She stated the residents could get sick if the food is eaten and the flies or any bug touched it. During an interview on 5/29/2026 at 11:40 AM, ATDM stated she has worked at the facility since January 2026, but she became the ATDM within the last 2 months. She stated they have a pesticide they spray every night before they leave. ATDM stated they try to spray in the morning to keep the flies away also. She stated they also keep the trash cans away from the door to keep the flies down. ATDM stated the flies recently started getting bad since they have gotten warmer outside. She stated it is worse when the delivery truck comes and the door is left open and if the trash is closed by the door. Review of facility policy titled Pest Control Program date implemented June 15, 2025, reflected It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. 4. Facility will utilize a variety of methods in controlling certain seasonal pests, i.e. flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations.

Based on observation, interview, and record review, the facility failed to follow the menu for three of three days reviewed for menu adherence. The facility failed to follow the lunch menu on 5/27/2026, 5/28/2026, and 5/29/2026. The facility failed to post menus visible for residents to see what is being served daily. These failures placed residents at risk for decreased intake, dissatisfaction with their meals, weight loss, and nutritional inadequacy.Findings included:A record review of the facility's menu for 5/27/2026 reflected the following items that were to be served for lunch: spaghetti and meat sauce, garlic bread, mixed vegetables, fruit cup, tea or punch. A record review of Resident #116's face sheet dated 05/28/2026 reflected a [AGE] year-old male admitted on [DATE] and with diagnoses of Spastic Quadriplegic Cerebral Palsy (impacts all four limbs, the trunk, and the face. Caused by early brain damage, it commonly causes muscle stiffness, limited mobility, and challenges with speech, feeding, and seizures), acute Pyelonephritis (a sudden, severe bacterial infection of the kidneys), and bipolar disorder II (a mental health condition defined by recurring patterns of major depressive episodes and at least one hypomanic episode, without ever experiencing a full-blown manic episode). A record review of Resident #116's MDS assessment dated [DATE] reflected a BIMS of 15, which indicated no cognition impairment. A record review of Resident #116's care plan last revised 04/15/2026 reflected a focus of Resident #116 was risk for nutritional related to weight loss, refusals to eat. During an observation on 05/27/2026 at 12:12 PM Resident #116 was brought his lunch meal tray. The meal consisted of noodles topped with red meat sauce and spaghetti. Record review of Resident #116's lunch meal tray meal ticket reflected Food Dislikes: spaghetti. During an interview on 05/27/2026 at 12:12 PM Resident #116 said he hated spaghetti. During an interview on 5/28/2026 at 5:17 PM, DM stated there is always an alternate meal for the resident if they do not want what is being served. He stated but sometimes the resident changed their mind. DM was advised resident ticket reflected he disliked spaghetti and he was served a mechanical diet which included noodles and meat sauce. DM stated the staff did not pay attention to the ticket. DM stated it is his responsibility along with the nursing staff to make sure the resident received the correct food items. DM stated if the resident isn't served the proper diets and they received food they did not like; they can lose weight. His expectations are to make sure the residents received the meals they are supposed to be served and if they do want what is being served, he will accommodate the residents with an alternative meal. During an interview on 5/29/2026 at 11:01 AM, CK K stated she has worked at the facility a little over a month. She stated she does not read or touch the residents' tickets. She prepares the food according to what is to be served for the day, and she places the food on the trays. The other staff members call out what type of diet is needed per plate, and she fixed it according to what is prepared per that diet. CK K stated it is the job of the nurses, and the aides to make sure once the plates are prepared and sent out on the cart, the resident received the correct diet. During an interview on 5/29/2026 at 11:12 AM, CK J stated she has worked at the facility since February 2026. She stated the cook is responsible for making sure the resident received the correct food on their tray. She stated the aides in the kitchen are responsible for calling out the ticket to the cook so that she knows what type of tray to prepare. CK J stated the reason the resident is asked their likes and dislikes is because they may have allergies to certain types of food and they may not like certain foods. She stated if the resident does not get the correct food, they will get mad and not eat the food, they can get sick and start losing weight. She stated she will offer something else, but she will not allow the resident to be hungry. During an interview on 5/29/2026 at 11:40 AM, ATDM stated she has worked at the facility since January 2026, but she became the ATDM within the last 2 months. She stated she takes notice they are putting the right items on the trays. ATDM stated the kitchen aides are supposed to check the trays and make sure they have their mighty shakes on the trays. The nurse and the nurse aides are supposed to read the tickets to make sure they have what is supposed to be on their trays before serving them to the residents. ATDM stated she went around and asked the resident what they liked and disliked. She stated so they can make sure the residents are getting the proper diet, they are getting what they like, and they will eat it and you do not have to worry about them losing weight or writing up a grievance. She stated she tried to make sure the resident likes and dislikes are honored. Review of facility policy titled: Menus and Adequate Nutrition revision date 2025 reflected the following:Policy: The purpose of this policy is to assure menus are developed and prepared to meet resident choices including their nutritional, religious, cultural, and ethnic needs, while using established guidelines. 3. Menus shall be prepared at least two weeks in advance for timely approval and ordering of food. Menus will be posted in the kitchen and in areas accessible by residents at least one week in advance. 4. Menus will be followed as posted. Notification of any deviations from the menu shall be made as soon as practicable. Substitutions shall comprise of foods with comparable nutritive value. 5. Menus shall reflect, based on a facility's reasonable efforts, the religious, cultural, and ethnic needs of the resident population.a. Religious, cultural, and ethnic needs shall be determined through the facility assessment and individual assessments.b. The facility should review the availability of preferred food items, identify preparation methods and approaches, and determine whether purchasing and serving preferred food items can occur.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for one (room [ROOM NUMBER]) of six resident rooms reviewed for a clean and homelike environment. The facility failed to ensure room [ROOM NUMBER] did not have spattered and smeared yellowish-brown, chunky substance appearing consistent with vomit on the floor beneath and beside the bed and the room was free of a bitter foul odor. The failure could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. Findings included: During observation on 05/27/2026 at 1:22 PM revealed room [ROOM NUMBER] to have spattered and smeared yellow-brown, chunky substance appearing consistent with vomit on the floor beneath and beside the bed and the room was free of a bitter foul odor.During observation on 05/28/2026 at 9:49 AM revealed room [ROOM NUMBER] to have spattered and smeared yellowish-brown, chunky substance appearing consistent with vomit on the floor beneath and beside the bed and the room was free of a bitter foul odor.During an interview on 05/28/26 at 4:41 PM, CNA A stated that residents are rounded every two hours and that resident rooms should be cleaned daily. She stated housekeeping is responsible for cleaning the residents room's. She stated that nursing staff (nurses and CNA's) were responsible for cleaning up bodily fluids, including vomit, and that housekeeping would be notified afterward to sanitize the affected area. She stated that a resident could slip and fall if a substance was present on the floor. During interview on 05/28/2026 at 4:45 PM, CNA B stated that residents are rounded every two hours and that housekeeping are responsible for cleaning the resident rooms daily. She stated that nursing staff and CNA's were responsible for cleaning up bodily fluids, including vomit, and that housekeeping would be notified afterward to clean and sanitize the affected area. She stated if a resident stood up and there was yellowish-brown, chunky substance appearing consistent with vomit on the floor, the resident could slip or fall and sustain an injury. During interview on 05/28/2026 at 4:49 PM, LVN C stated that residents are rounded every two hours and that housekeeping are responsible for cleaning the resident rooms daily. She stated that nursing staff, CNA's should be checking the resident rooms during rounds and throughout their shift to ensure the rooms remained clean, safe, and free of hazards. She stated that the nurses and CNA's were responsible for cleaning up bodily fluids, including vomit and that after the substance was removed, housekeeping would be notified to clean and sanitize the floor. She stated that substance left on a resident floor could create a fall hazard and could result in injuries, including a fractured hip. During an interview on 05/29/2026 at 11:33 AM, the ADM stated that it was his expectation that the facility maintain a home-like environment and that all resident rooms be cleaned daily. He stated that housekeeping staff were responsible for cleaning resident rooms. He stated that housekeeping and nursing staff were responsible for cleaning up bodily fluids, including vomit. He stated that residents are round every two hours and that management also conducted rounds throughout the facility. He stated that if a substance was present on a residents floor, it could cause a resident to slip, fall, and experience a serious injury. During an interview on 05/29/2026 at 12:12 PM, the PTM stated that housekeeping staff were responsible for cleaning resident rooms daily and as needed to maintain a clean environment. He stated that nurses and CNA's were responsible for cleaning bodily fluids, including vomit, and that housekeeping staff would be notified to clean and sanitize the affected area following the initial cleanup. He stated that he conducted daily rounds throughout the facility, including resident rooms and bathrooms to monitor cleanliness and sanitation. He stated substances should not be left on resident room floors, as they could create an unsafe environment for residents. During an interview on 05/29/2026 at 1:00 PM, the DON stated that housekeeping staff were responsible for cleaning resident rooms. She stated that nurses and CNA's were responsible for cleaning bodily fluids, including vomit, and would notify housekeeping to clean and sanitize the affected area following removal of the substance. She stated that staff were expected to report housekeeping concerns to the PTM. She stated that if a substance was left on the floor, it could create a safety hazard and place residents at risk for injury. Review of the facility's Safe and Homelike Environment policy, revised 06/10/2025, reflected the following:Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.Definitions: Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas.A homelike environment is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A determination of homelike should include the resident's opinion of the living environment. Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living.Policy Explanation and Compliance Guidelines:3.Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.Review of the facility's Routine Cleaning and Disinfection policy, revised 06/15/2025, reflected the following:Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible.Definitions: Cleaning refers to the removal of visible soil from objects and surfaces and is normally accomplished manually or mechanically using water or detergents or enzymatic products.Policy Explanation and Compliance Guidelines:1. Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge.4. Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include, but not limited to:a. Toilet flush handlesb. Bed railsc. Tray tablesd. Call buttonse. [NAME] remotef. Telephonesg. Toilet seatsh. Monitor control panels, touch screens and cables1. Resident chairsJ. IV polesk. Blood pressure cuffsl. Sinks and faucetsm. Light switchesn. Doorknobs and levers5.Standard precautions will be adhered to when cleaning any blood or body fluid spills, or soiled material that have the potential to contain these or other potentially contaminated substances:a. Hand hygieneb. Use of gloves, gown, mask, eye protection or face shield12. Horizontal surfaces with infrequent hand contact (windowsills and hard surface flooring) in routine resident-care areas should be cleaned:a. On a regular basisb. When soiling and spills occurc. When a resident is discharged from the facilityReview of the facility's Cycle Cleaning policy, revised 06/15/2025, reflected the following:Policy: It is the policy of this facility to identify the functional areas in the facility that require cleaning and to use cycle cleaning schedules to outline the frequencies and maintain regularly scheduled environmental service tasks.Policy Explanation and Compliance Guidelines:1. Routine cleaning of environmental surfaces and non-critical resident care items shall be performed according to a predetermined schedule and shall be sufficient enough to keep surfaces clean and dust free.2. Surfaces that are frequently touched by hands of health care personnel and residents, may require more frequent cleaning.3. Cycle cleaning will be completed according to the Facility Cycle Cleaning form.4. All specific areas have a form that has a designated legend and cycle related to specific areas.5. Specific areas include:a. Hallways/Dayrooms/Dining Roomsb. Offices/Support Rooms/Exteriorc. Showers/Utility/Bathroomsd. Resident Rooms6.The frequency of cleaning and disinfection of the facility environment may vary according to the:a. Type of surface to be cleanedb. The number of individuals in the areac. Amount of activity in the aread. Risk to residentsc. Amount of soiling7. The Environmental Services Manager is responsible to ensure that cycle cleaning is maintained.

Based on observation and interview, the facility failed to provide IV maintenance in accordance with standards of practice for one of one residents (Resident #22) reviewed for IV maintenance care. On 5/29/2026, Nurse G failed to adhere to sterile technique during maintenance of IV therapy port for Resident #22 This failure could cause residents infection, pain and decreased quality of life.Findings include:Review of Resident #22's face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included hypokalemia (low levels of potassium in the blood), Liver cancer, colostomy opening created allowing access to the colon), alcoholic cirrhosis of the liver (long term scarring of the liver due to heavy alcohol consumption), hypertension (high blood pressure) atrial fibrillation (irregular heart rhythm), hyperlipidemia (high cholesterol) and acute kidney failure. Review of Resident #22's quarterly MDS dated [DATE] reflected a BIMS of 15 suggesting she was cognitively intact. Review of the MDS section Special Treatments, Procedures, and Programs reflected resident #22 had IV access performed while a resident of this facility and within the last 14 days. Review of Resident #22's care plan dated 5/29/2026 reflected the problem: Potential for complications r/t peripheral IV access, PICC to Right ARMWith interventions: Assess peripheral IV site q shift for s/s of complicationsa) rednessb) painc) swellingd) infiltration Change PICC line dressing per order Review of Resident #22's physician's orders dated 5/29/2026 reflected an order: PICC LINE RT. ARM. Change PICC/Midline dressing every 7 days. every day shift every Thu-Start Date- 05/14/2026 [6:00 am]. During an observation on 5/29/2026 at 10:06 am Nurse G was observed emptying the contents of a sterile PICC dressing change kit onto a table covered with a clean, disposable absorbent pad. Nurse G then donned [put on] clean gloves and removed the existing PICC line dressing from Resident #22'S right arm. Nurse I was in the room observing Nurse G. During an interview on 5/29/2026 at 10:45 am, Nurse I stated she observed Nurse G put the sterile dressing change supplies on the clean disposable pad instead of setting up the sterile field. She stated that could cause an increase in infection risk for the resident. During an interview on 5/29/2026 at 12:00 pm, Nurse G stated she had put the sterile supplies for changing the PICC line dressing right on the disposable pad instead of on the sterile drape. She stated she got nervous during the procedure and then lost her concentration. She stated not using a sterile drape for the supplies could pose an infection risk to the resident. During an interview on 5/29/2026 at 11:45 am, the ADM stated that PICC line dressing changes were a nursing area, and he really didn't know much about the procedure. He stated the DON would know about nursing procedures. During an interview on 5/29/2026 at 12:45 am, the DON stated it was her expectation that staff would use a sterile drape for putting PICC line dressing change on instead of a disposable pad. She stated using a disposable pad instead of the sterile drape meant it was no longer sterile and there was a risk of bringing bacteria into a sterile site. She stated that could increase the risk of infections. She stated they rarely got a resident admitted to the facility that has a PICC line, but staff was recently certified for IV skills and knew what to do. Review of the facility policy dated 5/2/2025 PICC/Midline/CVAD Dressing Change revealed: It is the policy of this facility to change peripherally inserted central catheter to decrease (PICC), potential midline or for central venous access device (CVAD) dressing weekly or if soiled, in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. Policy Explanation and Compliance Guidelines:4 Perform hand hygiene.a. Put on mask.b. Place mask on resident if they cannot keep their head turned away.c. Perform hand hygiene.d. Set up clean field on the overbed table (wipe tabletop with sanitizing wipe) with needed supplies for the dressing change.e. Place a disposable cloth on the overbed table.f. Perform hand hygieneg. Open the sterile dressing change kit, lay out the sterile drape and place supplies on the sterile field being careful not to contaminate them.

Based on observation, interview, and records review, the facility failed to ensure proper labeling, storage and disposal of the drugs and biologicals in a safe manner for two of six medication carts (Medication Cart #1 and Medication Cart #2) inspected on 5/28/2026. The facility failed to dispose of:- One bottle of concentrated liquid protein with expiration date of 15 May 2026.- one bottle of Rapid Dry skin protectant with expiration date of 10-03-2025.- one tube of Extra Strength Anti-Itch Cream with expiration date of 06/2024. These failures could prevent residents illnesses from being addressed by not getting the therapeutic benefit of their medications. Findings include: During a med pass observation and interview on 5/28/2026 at 8:11 am with CMA F of Medication Cart #1, it revealed a bottle of concentrated liquid protein was discovered with an expiration date of 15 May 2026. CMA F stated expired medications should be removed from the cart and that she checked her cart every other month. She stated it was her responsibility to check the cart for expired medications and remove them from the cart. She stated expired meds should not be given to residents because it could make them sick or not have the intended effect. During an observation audit of Medication Cart #2 on 5/28/2025 at 2:35 pm with Nurse M, revealed a bottle of Rapid Dry skin protectant with expiration date of 10-03-2025 and one tube of Extra Strength Anti-Itch Cream with expiration date of 06/2024 were observed. During an interview on 5/28/2026 at 2:40 pm, Nurse M stated she was not aware that the two medications in the bottom drawer were expired. She stated she checked her cart monthly and removed any expired medications and was not sure how they were overlooked. She stated it was her responsibility to check the cart for expired medications and remove them from the cart. Nurse M stated residents should not be given expired medications because they may not have the desired effect or it could cause them to feel worse. During an interview on 5/29/2026 at 12:45 pm, the DON stated expired medications should be removed from the cart by the medication aide or nurse; whomever was assigned to the cart. She stated she was not aware of the expired medication on the cart but noted that the pharmacist came in monthly to complete cart audits. The DON stated expired medications given to residents could potentially not have the desired therapeutic effect or could make them sick. She stated they would be in-servicing staff on checking their medication carts for expired meds. During an interview on 5/29/2026 at 11:30 am the ADM stated he was aware that expired medications had been found on the medication carts. He stated the nursing staff was responsible for checking the medications carts and removing expired medications. The ADM stated expired medications could cause residents to not get their symptoms treated but that he was not aware of any adverse effects to residents from expired medications. Review of Facility Policy Medication Administration dated 5/9/2025 reflected: Policy:Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines:13. Identify expiration date. If expired, do not administer and notify pharmacy for replacement.

Based on observation and interview, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections when 1 of 5 staff observed for infection control failed to perform proper hand hygiene. CNA L failed to perform hand hygiene while passing meal trays from the hall cart to residents in their rooms. These deficient practices placed residents at risk for cross contamination and/or spread of infection. Findings include:During an observation in the 100 hall on 5/29/2025 at 11:55 am, CNA L was observed passing meal trays to room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]. CNA L picked up each tray after handling the tray cart with his bare hands, then took the trays in the room and set it up for each resident., handling items on the trays. Further observations revealed CNA L did not perform hand hygiene before and after entering each of these rooms. During an interview on 5/29/2025 at 12:05 pm CNA L stated he had passed trays to rooms room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER] without performing hand hygiene and stated he had missed using hand sanitizer between some of the rooms. CNA L stated he had been trained on passing meal trays and that hand hygiene was to be performed before entering and after leaving the resident's rooms. He stated he should be sanitizing his hands before delivering meal trays and if he did not it could cause cross contamination, and the residents could get sick. He stated residents could get sick because they are older and they are more susceptible to getting sick. During an interview on 5/29/2026 at 12:45 pm, the DON Stated her expectation was that staff would perform hand hygiene while passing meal trays to residents. She stated that not performing hand hygiene could have been an infection control issue and staff could have brought something in the room to the residents and made them sick. During an interview on 5/29/2026 at 11:45 am, the ADM stated his expectation was that hand hygiene would be done by staff between passing meal trays to residents. He stated by not doing so the staff could spread germs to residents that could cause them to get sick. Review of facility policy Hand Hygiene dated 4/11/2025 reflected: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.Policy Explanation and Compliance Guidelines:Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table.Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom.Review of Hand Hygiene table attached to the policy reflected that staff could use Either Soap and Water or Alcohol Based Hand Rub (ABHR is preferred), between resident contacts

Based on interviews and record review the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 6 (Resident #1) reviewed for accident hazards and supervision.The facility failed to ensure Resident #1 was properly secured in her wheelchair on 4/20/2026, which resulted in the resident slipping out of her wheelchair onto the floor of the vehicle and suffering a fractured toe and shoulder pain.This failure placed the residents at risk of serious harm and a diminished quality of life.Findings included:Record review on 4/23/2026 of Resident #1's admission record reflected a [AGE] year-old female, originally admitted to the facility on [DATE]. Record review on 4/23/2026 of Resident #1's diagnoses report reflected the following diagnoses in part: End Stage Renal Disease (kidney failure), Other Specified Disorders of Bone Density and Structure, Unspecified Site (abnormal bone density), Nondisplaced Fracture of Third Metatarsal Bone, Right Foot, Subsequent Encounter for Fracture with Routine Healing (less severe bone crack of the right toe closest to the little toe which remained in its normal position healing normally), Systematic Involvement of Connective Tissue (group of disorders that affect the connective tissues, which provide support and structure to various organs, joints, and other body systems), Unspecified Dislocation of Left Shoulder Joint, Sequela (abnormal bone density or structure localized to the left shoulder that is a residual effect of a prior injury, surgery or disease) onset 5/19/2025, Other Chronic Pain onset 5/28/2025, and Unspecified Osteoarthritis (breakdown of cartilage leading to pain, stiffness, and loss of mobility).Record review of Resident #1's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 13, indicating intact cognitive functioning. Resident #1 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts,holds, or supports trunk or limbs, but provides less than half the effort) rolling left to right and moving from sitting to lying. Resident #1 was dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for transfers.Record review of Resident #1's Order Summary Report on 4/23/2026 revealed active orders for: renal dialysis dated 6/4/2025 to be conducted on Monday, Wednesday, and Friday, with chair times at 6:15 am-11:25 am per facility staff; Monitor circulation sensation and movement. [Insure] boot to the Right foot is not [to] tight. [Notified] provider immediately for signs of impaired circulation or increased pain. every shift for Fractures toes, dated 4/23/2026; place gauze or padding between 2nd and 3rd digit on right foot secure with medical tape, ensure circulation is not impaired, reapply daily monitor for pain discoloration swelling or numbness and report changes every shift for fracture stabilization, dated 4/21/2026. Record review of Resident #1's care plan on 4/23/2026 reflected the following focus items and interventions in part: Resident #1 has Impaired physical functioning r/t debility/weakness, fatigue, limited ROM, musculoskeletal impairment; UNSPECIFIED OSTEOARTHRITIS, UNSPECIFIED SITE; CONTRACTURE, LEFT HAND; POLYNEUROPATHY, UNSPECIFIED; UNSPECIFIED DISLOCATION OF LEFT SHOULDER JOINT, SEQUELA, initiated 11/24/2025 and revised 04/23/2026. Utilizes Hoyer lift and 2 staff for transfers, initiated 03/03/2026, revised on 03/03/2026. Utilizes the following for mobility: Motorized Wheelchair Sometimes Manual wheelchair (Dependent) with certain transport, initiated on 3/03/2026, revised on 03/03/2026. Resident #1is at risk for complications r/t Boot/Shoe to the right foot, initiated on 4/23/2026, revised on 4/23/2026. Resident #1 is at risk for pain r/t chronic disease processes, musculoskeletal abnormalities/diseases AEB DX: UNSPECIFIED DISLOCATION OF LEFT SHOULDER JOINT, SEQUELA SYSTEMIC INVOLVEMENT OF CONNECTIVE TISSUE, UNSPECIFIED NONDISPLACED FRACTURE OF THIRD METATARSAL BONE, RIGHT FOOT, SUBSEQUENT ENCOUNTER FOR FRACTURE WITH ROUTINE HEALING, initiated on 9/22/2025, revised 4/23/2026. Potential for complication r/t fracture of right third toe AEB DX: NONDISPLACED FRACTURE OF THIRD METATARSAL BONE, RIGHT FOOT, SUBSEQUENT ENCOUNTER FOR FRACTURE WITH ROUTINE HEALING, initiated 4/23/2026 revised 4/23/2026.Record review conducted on 4/23/2026 of Resident #1's progress notes reflected the following: 4/20/2026 07:24 eMAR Note Resident went to dialysis at this time. 4/20/2026 11:50 eMAR Note Resident is complaining right lower leg. Hydromorphone administered per order for pain.4/20/2022 12:00 Post Fall Evaluation Fall Details: Date/Time of Fall: 04/20/2026 1:19 PM Fall was not witnessed. Fall occurred elsewhere. Other fall location: Facility Van while back [form] facility. The reason for the fall was not evident. Did an injury occur as a result of the fall: No. Did fall result in an ER visit/hospitalization: No. Provider: (NP A)Notified of: Unwitnessed fall new orders received; See Provider order sheet. Resident's responsible party notified: Yes.Sister.Details of notification: No [answers] Date of Resident's responsible party notification: 04/20/2026 12:29 PM Contributing Factors.Wheelchair was involved in fall. Wheelchair was not unlocked at time of fall. Wheelchair footrest(s) were not in the way at the time of fall. Footwear at time of fall: Shoes. Resident was not using cane/walker as instructed.Contributing factors note: IT [was happened] outside facility. it [was happened] in facility van.Vitals note: WITHIN NORMAL RANGES.Indicators of pain: Vocal complaints of pain. Pain Issue: #001: New. Location: Generalized. Pain score: 6. Aching. PRN medication provided.4/20/2026 1:17 Nurses Note Facility Van Driver stated that while she back from dialysis center. When she pressed [break], resident [slide] from wheelchair and [fall down]. This nurse went [front] after van arrived. Resident was found sitting on van floor with wheelchair on back. No visible injuries while [do] assessment on van. Resident is [complaining] right leg pain. We transferred back to wheelchair with help of staff and [bring] back to bed. Did assessment again. Vital signs were taken. [Vital s] signs within normal ranges. No injuries noted. Pain pills [given] as order. Notified (NP A) while she is in facility. (NP A) evaluated resident. [Give] x-ray order right femur, foot and knee 2 Views. Administrator. and ADON.aware. Contact Sister.no answered. Resident stated that she will contact sister. Resident is responsible party [self]. Resident aware situation.4/20/2026 1:44 eMAR Note X-ray tech aware. They will come to do later. FEMUR RT 2V* | FOOT RT 2V | KNEE RT 2V** SENT for Imaging 4/21/2026 7:27 AM CT ** one time only.4/21/2026 1:57 Nurses Note This nurse received x-ray right foot x-ray. This nurse [send] to (NP B) to review while she is in facility. NP Reviewed result. Result [show] acute fracture may be present in the neck of the third metatarsal. NP [order] boot and follow up with Podiatry. [Advice] resident not to put [press and] weight [bearing] on that foot. Podiatry will be coming facility to see resident.4/21/2026 2:32 Nurses Note spoke with (NP B), received order to buddy wrap 2nd and 3rd digit on right foot to provide stability to fracture.4/21/2026 3:30 eMAR Note They will come to do x-ray. X-ray tech aware. SHOULDER LT 2V** SENT for Imaging 4/21/2026 2:28 PM CT ** one time only related to OTHER CHRONIC PAIN.4/21/2026 6:11 Nurses Note Unwitnessed fall 1/3 days. Resident is alert and oriented x3. Resident had no visible injuries noted post fall. Resident x-ray done post fall. X-ray report collected and acute fracture noted on third metatarsal. (NP B) [Give] order to fix boot and follow up with Podiatry. Podiatry saw her this shift. Resident is in electric wheelchair all day. Resident is complaining left shoulder pain and NP [give] me order for x-ray. X-ray order put in PCC. This nurse will pass to next shift nurse. nurse to follow up on x-ray.4/22/2026 3:49 Nurses Note (MD B) looked over rsd XR of shoulder advised dislocation and to let (MD A) know to see plan for shoulder. Also advised to send to (NP A). (NP A) approved to send out to ER. Prior hx of dislocation on L shoulder. (NP A) okayed to be sent to hospital. Pain med given and sent to (hospital). Sister has been notified, MD and NPs notified4/22/2026 10:26 Nurses Note pt arrived to facility with a new order of Hydrocodone 5-325 mg every 8 hrs. First dose given by ER nurse at 622 pm. [Sated] patient left shoulder chronic dislocation. Boot shoe for the right foot 3rd toe, due to fracture. patient arrived to facility via transport staff from facility. Call light in reach. 4/23/2026 10:29 Skin Check Foot evaluation completed.Record review on 4/23/20256 of Resident #1's neurological evaluation report dated 4/20/2026 revealed neurological checks were started on 4/20/2026 at 12:00 PM and continued every 15 minutes through 4/21/2026 at 16:45 PM. No concerns, changes, or deviations from the resident's baseline noted.Record review on 4/23/2026 of Resident #1's Post Fall Evaluation conducted on 4/20/2026 reflected Resident #1 fell on 4/20/2026 at 13:19 PM with no witnesses to the fall. The fall was shown to have occurred in the facility's van with no injuries and no hospital visit necessary. The NP was notified. Notification contact with the resident's sister was attempted on 4/20/2026 at 12:29 PM. The contributing factor listed was the resident's wheelchair. At 14:26 PM the resident vocalized generalized complaints of moderate pain. PRN medication provided.Record review on 4/23/2026 of Resident #1's hospital discharge paperwork dated 4/22/2026 (printed at 9:52 PM) indicated the resident was given a new prescription for pain medication, recommendations for exercises to relieve should pain, and a fall prevention guide. Imaging tests conducted during the hospital visit included XR Shoulder 2 or More Views Left, and XR Toe 2 or More Views Right. The resident's diagnoses during her hospital visit were chronic dislocation of left shoulder and toe pain, right.Record review on 4/23/2026 of Resident #1's Skin Assessment conducted 4/23/2026 at10:30 AM indicated the resident's right lateral foot was evaluated with no concerns noted.Record review on 4/23/2026 of the facility's in-service records from January 2026 through April 2026 reflected education provided on various topics including Resident Rights, Safe and Homelike Environment, and Transporting a Resident (Facility Van or Vehicle). The in-service on transporting a resident was provided to TR A and TR B only on 4/21/2026 per the staff sign-in sheet.Record review of TR A's personnel file on 4/23/2026 at 1:38 PM revealed the duties and responsibilities of TR A's position as a driver, which was signed by TR A on 4/1/2024. Those duties and responsibilities included immediately reporting to the Program Director any problems observed or encountered while transporting participants.TR A's personnel file also included a Transportation Safety Checklist dated 6/26/2025 in which the former maintenance director verified and signed off on TR A's Wheelchair Transport Driver requirements and skills, visually checking equipment for proper working conditions, fastening restraints, and not starting the vehicle until passengers were properly seated and secured.Record Review conducted on 4/23/2026 at 1:39PM of the written statement of TR A dated 4/22/2026, revealed TR A's account of the incident/accident involving Resident #1 on 4/20/2026. TR A stated she received a call from Resident #1 on 4/20/2026 informing TR A that the resident was finished with dialysis and requested to be picked up. TR A stated when she got to the dialysis center, she proceeded to push the resident up into the van and strap all 4 of the buckles to the wheelchair. She stated she then proceeded back to the facility. TR A stated when she approached the 4-way intersection she began to slow as the light quickly started to change. TR A reported it was then that she heard Resident #1 say she was slipping. TR A stated that she immediately reached back with her arm to try to prevent the resident from further slipping. TR A reported, the next thing she knew was that the resident slipped off of her mechanical lift pad and landed on her bottom. TR A said she immediately asked the resident if she was okay and the resident said yes but told TR A to get her off this floor. TR A stated because the resident required a mechanical lift, she told Resident #1 there was nothing she could do. TR A said she called the facility and told the resident's nurse what happened. TR A stated she asked the nurse to have people waiting when she arrived back at the facility to assist. TR A stated when they arrived staff were waiting and they quickly got the resident back into her wheelchair. The resident was then taken inside to be assessed by her nurse. Record review conducted on 4/23/2026 at 3:53 PM of TR B's personnel file. TR B was the back-up van driver for the facility. TR B's primary position at the facility was a CNA. Included in the file were copies of TR B's orientation and training conducted on 7/4/2025. There was no evidence of a transportation skills checklist in TR B's file.Record review conducted on 4/23/2026 at 3:53 PM of AD's personnel file. AD was not the facility's primary or secondary driver, but was trained and authorized to transport residents, if necessary. AD signed her orientation for the AD position 2/9/2023. AD's file contained a Motor Vehicle Record Questionnaire completed by AD on 11/17/2021 in which she denied committing any major driving infractions or committing motor vehicle crimes. A driving record was requested for AD on 11/18/2021 by the administrator at that time. The form shows the submission was accepted. The instructions on the form stated that the form was to be completed annually to obtain/maintain driving privileges. There was no additional evidence in the file that suggested any further driving record checks were completed.Record review conducted on 4/23/2026 at 4:42 PM of the facility's new transportation/driver safety checklist provided by FD. The form was not completed but was provided as evidence of the facility's intention and plan moving forward. The checklist included running driving record and license verifications, verbalization and demonstration of the safe and proper use of vehicle equipment.During an observation and interview of Resident #1 on 4/23/2026 at 10:58 AM, the resident was observed in the lobby area of the facility in her motorized wheelchair. She was casually speaking and interacting with staff and others. Resident #1 was observed to be dressed in her own clothing that was appropriate for the weather and time of day. Her hair was neatly braided. Her hygiene appeared good. The resident was wearing soft open-toe medical shoe or boot on her right foot and her toes were visible. The resident was not wearing a sock on her right foot. No discoloration or swelling was noted, and the resident did not exhibit obvious signs of pain or discomfort and denied such. The resident's mobility within her motorized chair did not appear to be restricted. Resident #1 said she attended dialysis several days a week. Resident #1 confirmed she was transported to those appointments and back by facility staff in the facility's transportation vehicle. The resident said she was not good when asked how she was doing. I advised the Resident that I would check back with her in her room privately and she agreed.In an interview on 4/23/2026 at 11:28 AM, Resident #1 stated that TR A picked her up from dialysis on 4/20/2026 in the facility's van. She stated TR A was the only person in the vehicle. Resident #1 said while returning to the facility in the van, she slid out of her wheelchair onto the floor of the van. Resident #1 said TR A anchored her wheelchair into the van, but TR A stated she was not secured in her wheelchair with a seat belt of any kind. Resident #1 said she was using a manual wheelchair at that time. Resident #1 said she preferred to use her motorized wheelchair, but she is not allowed to when being transported in the facility van due to her motorized wheelchair's size. Resident #1 said she slid all the way out of her chair onto the floor. She said TR A said she couldn't pick her up off the floor because no one was there to assist. Resident #1 said she was on the floor until they arrived back at the facility. She estimated this to be approximately 30 minutes. Resident #1 said she was attending dialysis when TR A picked her up. Resident #1 said she broke her toe and dislocated her shoulder as a result. Resident #1 said her toes were x-rayed the same day as the incident. She said her shoulder was x-rayed on 4/22/2026 after she started experiencing shoulder pain. She said she wasn't in serious or uncontrolled pain now. She said overall she was okay. She was just upset that the incident happened. Resident #1 stated overall the staff were attentive and caring, including TR A. In an interview on 4/23/2026 at 11:34 AM, the ADM stated he had been employed with the facility for over 1 year. The ADM stated TR A had been employed as a driver with the facility for more than 3 years. The ADM stated TR A did not report the incident involving Resident #1 to him or a supervisor. He said he was not made aware of the incident until the day after the incident because he had been out of the office. ADM stated TR A was suspended when he learned of the incident and while he investigated. ADM stated that he obtained a written statement from TR A. ADM stated TR A picked up the resident from the dialysis center and she was in a hurry. ADM said TR A didn't strap the resident into her chair properly and she slid out of the chair. ADM said TR A stated she hit the brakes as she approached a traffic light, causing Resident #1 to slide out of her chair. ADM said TR A stated that she utilized the manual floor anchors to secure the wheelchair to the floor of the van but didn't use the cross belt to secure the resident in the chair. ADM stated that TR A said she attempted to fasten the cross belt, but it didn't fit. ADM said the incident happened nearby, so the resident was not on the floor long. He said the incident happened around the corner. ADM stated that TR A was alone with the resident when she slid out of her chair, so she called ahead to facility staff to inform them of their need for help. ADM stated that all necessary staff were outside waiting when they arrived. ADM stated that the resident was reportedly crying when they arrived and told staff to get her up. ADM said he implemented an employee plan with TR A and he will be terminating her employment. ADM stated that TR A had never been accused or abuse, neglect, or mistreatment of any resident. ADM stated that TR A had not been involved in an incident such as this while employed with this facility, but she was involved in a similar incident while employed at another facility. He said documentation regarding the prior incident was maintained in TR A's personnel file because the incident was at a sister facility. ADM stated he had the maintenance director conduct a maintenance evaluation of the vehicle to ensure the safety equipment was functioning properly. He said the maintenance director reported the vehicle and its safety equipment were functioning properly and not in need of replacement or repair.In an interview on 4/23/2026 at 11:53 AM, DON stated she was not made aware of the incident involving Resident #1 at the time it occurred. The DON said she learned of the incident when she pulled her daily reports and read about it the next day. DON said she made the ADM aware of the incident upon learning of it. She said the ADM had been out of the facility at the time. DON said the notes she reviewed weren't immediately alarming, but she did question what happened and how it happened. DON said she began investigating the incident by talking to Resident #1. DON said Resident #1 told her that she was asleep and slid out of her chair. DON said the appropriate nursing actions were taken in response to the incident. DON said the resident was assessed, notifications were made, and orders were obtained for an x-ray of the resident's foot, as that was the resident's only complaint at the time. DON said there was no reason for an orthopedic consultation, and the podiatry service provider was already scheduled to see Resident #1 the following day. She said the NP was onsite when the x-ray results were received. The NP reviewed the results and advised staff to buddy wrap the toe, which was common with the type of injury the resident sustained. A medical boot was also recommended but the resident refused. She said after speaking to Resident #1, she interviewed TR A. The DON stated TR A said Resident #1 slipped out of her wheelchair during transport when TR A came to an abrupt stop. She said she was unable to lift the resident back into her chair because the resident required a mechanical lift. DON said TR A and the resident were the only ones in the vehicle. DON said she told TR A not to transport any resident until further notice and to have no contact with Resident #1. DON said she provided an in-service to both facility drivers and instructed the assistant driver to conduct resident transports. The DON stated TR A was suspended pending ADM's investigation. DON also instructed TR A to write a statement of the events. The DON said the resident expressed no out of the ordinary pain or distress, but she did complain of shoulder pain to DON. DON said x-rays were ordered and PRN pain medication was administered in response to the resident's complaint. DON said Resident #1 had a prior diagnosis of a right shoulder dislocation in 2025, so her complaint of shoulder pain was not new. DON said the results of Resident #1's shoulder x-rays were sent to the doctor, but the doctor did not immediately respond. Because of the delay, DON said she sent Resident #1's x-rays to radiology too and asked for a comparison between last year's results and the current results. They were unsure they could access the former results but said they would attempt to gain access and let DON know. While DON was at the nurses station handling the situation, Resident #1 came up to the desk and again asked what they were going to do about her shoulder pain. DON said she explained to the resident they were waiting for the doctor's review of the x-rays. The nurse stated that no fracture or new injury to the resident's shoulder was identified. In an interview on 4/23/2026 at 12:29 PM, the FD stated that he had been employed with the facility since September 2025 but had almost 10 years of prior similar experience. The FD stated that he was made aware of the incident with Resident #1 by ADM and was asked to conduct a maintenance inspection on the facility vehicle. The FD said he completed a full check of the vehicle and it's equipment immediately and found everything to be safe and in working order. FD said he made an appointment with a certified mechanic for next week to do a full vehicle systems check as a precaution. FD said he was responsible for vehicle inspections and ensuring staff who operate the vehicle are doing so safely and that they can operate the vehicle's equipment. FD said he was not responsible for training or supervision of the drivers. FD said about 2 weeks ago ADM asked FD to create a skills check list for the drivers because the person who occupied FD's position previously had taken or destroyed those records when he was terminated. FD stated that he did a ride along with the drivers when he started to observe their operation of the vehicle and it's equipment. FD said he did this several times with TR A and TR B. FD said both appeared to be safe drivers, but TR A was distracted and scattered. FD said TR A didn't drive too fast and wasn't reckless, but she could lack focus. FD said he didn't speak to TR A following the incident, but he suspected TR A failed to engage the resident's safety belt. FD said Resident #1 is required to use a manual wheelchair when being transported due to the electric wheelchair's size. FD said that there are safety straps and anchors installed in the vehicle. FD said it was likely that TR A didn't use the safety belt or used it incorrectly. FD said the safety belt required tightening following placement to engage the latch and he felt that likely didn't happen. In an email response/interview on 4/23/2026 at 1:31 PM, ADM stated TR A did not transport any other resident following Resident #1's incident on 4/20/2026. ADM stated the motor vehicle questionnaire found in AD's personnel file was a form used by their former owner. AD was employed by the former owner when the company was sold and bought. ADM stated that he wasn't sure if any such form or checklist existed for personnel after the change in ownership. He stated this was something HR would have to investigate. Interview conducted on 4/23/2026 at 4:28 PM., the SW stated he had been employed at the facility since July 2025. The SW stated that he was familiar with Resident #1 as staff were informed during their morning meeting of the seatbelt incident involving Resident #1. The SW stated that he was able to speak with Resident #1 about the incident today and she was doing okay. The SW stated that Resident #1 told him that TR A didn't secure her in her wheelchair. Resident #1 told the SW that TR B always operated the facility vehicle safely and strapped the resident in securely. SW stated that he had not ever observed TR A or TR B operating the facility vehicle unsafely, or interacting with residents in a negative way. SW stated that he interviewed other residents who had recently been transported by TR A and TR B. SW stated that neither resident reported experiencing any harm or injury during transport and neither reported being mistreated or their safety being compromised. Interview conducted at 4:30 PM.at 4:30 PM, the ADM stated the Transportation Driver Safety Checklist form provided for reference was used as a part of their inspection and safety checklist process. The ADM stated he had not used the form personally because he had not had to do a skills check-off since accepting his position. ADM stated the former maintenance director was responsible for those inspections and checkoffs and maintaining those records, but the ADM believed he removed or destroyed the records when he was terminated. The ADM also informed me that he would be terminating TR A's employment and she would no longer be employed or providing services to the residents at the facility.Record review of the facility's policy and procedures regarding Transporting a Resident (Facility Van or Vehicle) implemented and reviewed/revised on 6/10/2025, reflected that it was the policy of the facility to provide residents safe, non-emergency transportation to doctor's appointments, activity outings, and any other trips the facility deems necessary. It also stated:6. The van will be well-maintained and equipped with safety features. Each resident will be secured in a seat with a seatbelt or in their wheelchair secured with wheelchair tie-downs.8. Staff authorized to drive the van will have necessary training and licensure to operate the vehicle [NAME] as knowledge on van safety features. Copies of any necessary documentation will be kept in eachemployee's personnel file.Record review of the facility's policy and procedures regarding Incidents and Accidents implemented and reviewed/revised on 5/16/2025, reflected it was the policy of the facility for staff to utilize the risk management section of PCC to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Those included equipment malfunction, falls, observed accidents/incidents, resident injuries due to staff handling, and injuries of an unknown origin. The policy also reflected steps staff were to take in the event of an accident and/or incident as follows: o In the event of an incident or accident, immediate assistance will be provided to ensure resident safety. o Any injuries will be assessed by the licensed nurse or practitioner. First aid will be given for minor injuries such as cuts or abrasions.o The supervisor or other designee will be notified of the incident/accident. If necessary, law enforcement may be contacted for specific events.o In the event of an unwitnessed fall or head trauma, the nurse will initiate neurological checks as per protocol and document on the neurological flow sheet. Abnormal findings will be reported to the practitioner. Online record review conducted on 4/23/2026 of the eCFR Title 49, Transportation, Subtitle A, Office of the Secretary of Transportation, Part 38, ADA Accessibility Specifications for Transportation Vehicles, Subpart B, Buses, Vans and Systems, Section 38.23, Mobility aid accessibility, (d) Securement devices, (7) Seat belt and shoulder harness, reflected the following: For each wheelchair or mobility aid securement device provided, a passenger seat belt and shoulder harness, complying with all applicable provisions of part 571 of this title, shall also be provided for use by wheelchair or mobility aid users. Such seat belts and shoulder harnesses shall not be used in lieu of a device which secures the wheelchair or mobility aid itself.

Based on interviews, observation, and record review, the facility failed to allow immediate access to residents by a state representative of HHSC in that:The facility's Administrator refused to allow a HHSC Employee to enter the facility to conduct a Priority One investigation; with a resulting outcome of delaying entrance on 3/3/2026 from 10:05 am through til 2:00 pm, a delay of 4 hours.This failure placed all 93 residents at risk of potential harm due to a priority investigation not being conducted to rule out immediacy. Findings included: On 03/03/2026 at 10:05 am, through direct observation the HHSC Surveyor entered the facility and checked in with the reception desk. The HHSC Surveyor was led to the conference room behind the reception desk. On 3/3/2026 at 10:11 am, the ADM entered the conference room and informed the Surveyor she would not be allowed in the building to conduct the P1 investigation. The ADM was advised it was a P1 investigation. On 3/3/2026 at 10:43 am, the Surveyor was instructed by phone from the PM to leave the facility. The PM then contacted the ARD and was briefed on the incident and indicated she would get the appropriate parties involved. On 3/3/2026 at 2:00 pm, the Surveyor re-entered the building and conducted the entrance conference with the ADM and the P1 investigation commenced. During an interview on 3/3/2026 at 2:00 pm, the ADM apologized for the situation and stated he was just a ping pong ball going back and forth between corporate staff and HHSC During an interview on 3/5/2026 at 12:30 pm, the ADM stated they did not have a policy on impeding a survey or access to medical records. Review of facility census document revealed their current census was 93 residents. Review of the facility's policy Governing Body dated 7/23/2025 revealed:The facility will have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility. Review of Health and Safety Code revealed under Ch 242: Sec. 242.043. INSPECTIONS. (a) The commission or the commission's representative may make any inspection, including an unannounced inspection or follow-up inspection, survey, or investigation that it considers necessary and may enter the premises of an institution at reasonable times to make an inspection, survey, or investigation in accordance with department rules Review of Texas Health and Human Services Commission Provider Letter PL18-26, dated December 10, 2018, entitled Providing Access to Electronic Health Records revealed: The Texas Health and Human Services Commission (HHSC) is issuing this letter as a replacement of PL 18-10 to inform provider of the following updated information as it applies to all provider types. Providers must grant access to all electronic health records when re

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for one of one kitchen reviewed for kitchen sanitation, in that: The facility failed to label, date and seal food items in the pantry, refrigerator and chest freezer on 3/3/2026. The deficient practice placed residents who were served from the kitchen at risk for health complications and foodborne illnesses.Findings included: During an observation on 3/3/2026 between 3:27 pm and 3:47 pm the following observations were made in the kitchen area: 1) a clear, plastic, square container with a white granulated substance in it was found on the floor, lying on its side with the lid off and the white granulated substance on the pantry floor.2) an unsealed zip bag of pasta was on the pantry shelf.3) an unsealed bag of tortilla chips was on the pantry shelf.4) an open box, containing a blue unsealed bag of rice was on the pantry shelf.5) an unsealed plastic tote, not dated or labeled, of a while granulated substance was on the pantry shelf.6) an unsealed zip bag of yellow shredded cheese was on the refrigerator shelf7) more than a dozen, uncovered, not labeled or dated, white Styrofoam cups with a fruit substance in them were on the refrigerator shelf.8) an opened box, with an unsealed bag of frozen cookie dough was in the bottom of a chest freezer. During an interview on 3/3/2026 at 3:29 pm the DM acknowledged the opened items in the pantry area and stated he was the Dietary Manager, but all staff were responsible for ensuring food was stored correctly. During an interview on 3/3/2026 at 3:41 pm, the [NAME] acknowledged the open bag of shredded cheese and stated the bag was supposed to be sealed before being put away. She stated all dietary staff were supposed to store food properly and acknowledged she has been trained on how to properly store food in the kitchen. She stated food that was not stored right could go bad and make the residents sick. During an interview on 3/4/2026 at 10:53 am, the DM stated all staff have been trained on how to store food. The Dry pantry items should be put in a zip bag, labeled and dated; opened refrigerated items should be stored in a zip bag and labeled and dated, and freezer items should also be in sealed bags, labeled and dated - if not in the original packaging. He stated he has seen food items not stored properly and he will go back and seal packages, label and date them when he finds them. He stated it was important to store food properly, so residents do not get sick. He stated to his knowledge all residents were served food from the facility kitchen. During an interview on 3/4/2026 at 10:59 am, Dietary Staff A stated he had been trained on how to properly store food and to rotate food - first in, first out. He stated they should be using zip bags and labeling and dating food when it was stored. He stated the sugar was stored in a plastic tub in the dry pantry area and he has seen the tub with the lid off, and he will close it back up. He stated when he finds items not stored properly, he will try and fix it himself or let the DM know. He stated that when food was not stored correctly, it could make the residents sick. During an interview on 3/4/2026 at 11:18 am, the DM stated ultimately it was he, the DM, that was responsible for making sure food was stored correctly. He stated he doesn't always go back to the staff that were responsible for the improperly stored food; he will just fix it himself. He stated the facility conducted a mock survey last month and he talked to all the kitchen shifts about food storage, and he thought it had been addressed at that time. He stated any food that was identified as not being stored properly on 3/3/2026 had been thrown out and not served to residents. During an interview on 3/4/2026 at 1:32 pm, the ADM stated his expectation was that all food in the kitchen is stored properly. He stated it was the DM's responsibility to ensure all staff know how to store food and ensure the process was followed. He stated that improper food storage could lead to food borne illnesses and potentially make residents sick. Review of the facility policy Food Receiving and Storage, revised October 2017, revealed: Foods shall be received and stored in a manner that complies with safe food handling practices. Additionally, 7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated ( use by date). Such foods will be rotated using a first in - first out system.8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date). Review of the facility policy Date Marking for Food Safety, copyright 2025, revealed: The facility adheres to a date marking system to ensure the safety of ready to eat, time/temperature control for safety food.Further review revealed: 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded.3. The individual opening or preparing the food shall be responsible for date marking the food at the time the food is opened or prepared.

Based on observations, interviews and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for two (Resident #2 and Resident #3) of six residents reviewed for resident call system in that: Resident #2 and Resident #3 did not have a properly functioning call system in their room from 11/18/2025 to 01/29/2026. This failure placed residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency.Findings included Observation on 01/29/2026 at about 09:40 am with the Maintenance Director, in Resident #2 and Resident #3's room revealed their call light system was not functioning, and the entire box was out of the wall. It was observed Resident #2's call button was placed on the bed within reach even though it was non-functioning and a bell on top of Resident #2's nightstand was out of reach. Observation also revealed Resident #3's call light was placed within reach even though it was non-functioning.During an interview on 01/29/2026 at 09:43 am the Maintenance Director stated the call system in Resident #2 and Resident #3's room broke sometimes last week and he had ordered a replacement part. The Maintenance Director stated he gave both residents bells to use until the call system was replaced. The Maintenance Director stated he verbally told staff of the broken call system. The Maintenance Director stated the nursing staff put in maintenance requests in the facility's TELS system (Streamlines maintenance, housekeeping, and repairs, allowing staff to track, manage, and complete tasks efficiently.). The Maintenance Director stated he checked the TELS system daily in addition to his daily routines. The Maintenance Director stated he tried to address concerns within a day or at most 72 hours based on the priority of the concern.During an interview on 01/29/2026 at 09:47 am Resident #2 stated her call system had been broken for about 6 months. Resident #2 stated she was not able to reach the bell on the nightstand. Resident #2 stated whenever she needed help, she would go to the restroom and use the call button in the restroom.During an interview on 01/29/2026 at 1:05 pm the DON stated she was aware of the call system problem in Resident #2 and Resident #3's room. The DON stated she was not sure how long the call system in their room had been broken but the Maintenance Director was working on it. The DON stated the Maintenance Director had given Resident #2 a bell to call for help.During an interview on 01/29/2026 at 1:49 pm the Administrator stated he was aware Resident #2, and Resident #3's room call system was broken and they were given a bell. The Administrator stated the call system had been broken for a couple of months, maybe 2 months. The Administrator stated any damage to the facility should be fixed immediately.Review of facility's TELS documentation reflected:Order # 2891-- Call light malfunctioning. Unscrewed and unplugged from wall-undated -medium priority-room [Resident #2 and Resident #3's room number]Order # 3053- Call light completely broken out of wall, separated from wiring-dated 12/12/2025-medium priority-room [Resident #2 and Resident #3's room number]. Review of facility's invoice completed by the Maintenance Director dated 11/18/2025 reflected: Patient Station, Bedside: 0.25 Dual 2-Jack 2-Gang Replacement Patient Station Review of facility's policy titled Accommodation of Needs revised 06/06/2025 reflected: Policy:The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodation for the individual needs and preferences of a resident, except when the health and safety of the individual or other resident would be endangered.Policy Explanation and Compliance Guidelines:1. The facility will make reasonable accommodations to individualize the resident's physical environment including their personal bathroom and bedroom and the common living areas within the facility.2.The facility will ensure that common areas frequented by residents are accommodating physical limitations and enhance their abilities to maintain independence.3.Facility staff shall make efforts to reasonably accommodate the needs and preference of the resident as they make use of their physical environment.4.Based on individual needs and preferences, the facility will assist the resident in maintaining and/or achieving independent functioning, dignity, and wellbeing to the extent possible. Review of facility's policy titled Safe and Homelike Environment dated 06/15/2025 reflected: Policy:In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility, both inside and outside, maximizes resident independence and does not pose a safety risk.Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas.

Based on observation, interview and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #2 and Resident #3) of six residents review for resident rights. The facility failed to keep Resident #2's bell within reach to call for assistance. The facility failed to provide an alternative way for Resident #3 to call for staff assistance. These failures place residents at risk of not getting their needs met timely.Findings included:Review of Resident #2's face sheet printed 01/29/2026 reflected a [AGE] year-old female who was admitted on [DATE] with remission date of 12/15/2022 with the following dx: Osteoarthritis to the right shoulder (a degenerative condition where cartilage wears down, causing pain, stiffness, grinding (crepitus), and reduced range of motion, often affecting sleep), Osteoarthritis of the knee, Chronic Obstructive Pulmonary Disease (a progressive, incurable lung disease-primarily caused by smoking-that causes airflow obstruction, making it difficult to breathe.), Muscle weakness, pain specific joints, history of falling. Review of Resident#2's admission MDS assessment dated [DATE] reflected a BIMS score 15, indicating no cognitive impairment. Section GG functional Abilities reflected 3 for Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) which indicated Resident #2 required Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunks or limbs, but provides less than half the effort. Toilet transfer 1- The ability to get on and off a toilet or commode. Dependent - Helper does ALL of the effort. Residents do none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the residents to complete the activity. Review of Resident #2's care plan initiated 03/24/2025 reflected Resident #2 had pain r/t impaired mobility, neuropathy (nerve damage or dysfunction that causes symptoms like numbness, tingling, pain, muscle weakness, and loss of coordination, and can also affect body functions like digestion and blood pressure.), right shoulder pain, joint pain, had an actual fall with Poor Balance, Unsteady gait, impaired physical functioning r/t debility, cognitive impairment. Review of Resident #3's face sheet printed 01/29/2026 reflected a [AGE] year-old female who was admitted on [DATE] with readmission date of 12/06/2023 with the following dx: Repeated falls, Muscle weakness, lack of coordination, other abnormality of the gait and mobility, need for assistance with personal care. Review of Resident#3's admission MDS assessment dated [DATE] reflected a BIMS score 10, indicating moderate cognitive impairment. Review of Resident #3 's care plan initiated 10/27/2024 reflected Resident #3 had impaired cognitive function/dementia or impaired thought processes r/t Dementia, Difficulty making decisions, impaired decision making, psychotropic drug use, impaired physical functioning r/t debility, cognitive impairment. Observation on 01/29/2026 at about 09:40 am with the Maintenance Director, in Resident #2 and Resident #3's room revealed their call light system was not functioning, and the entire box was out of the wall. It was observed Resident #2's call button was placed on the bed within reach even though it was non-functioning and a bell on top of Resident #2's nightstand was out of reach. Observation also revealed Resident #3's call light was placed within reach even though it was non-functioning. There was no visible bell for Resident #3.During an interview on 01/29/2026 at 09:43 am the Maintenance Director stated the call system in Resident #2 and Resident #3's room broke sometimes last week and he had ordered a replacement part. The Maintenance Director stated he gave both residents bells to use until the call system was replaced. The Maintenance Director stated he verbally told staff of the broken call system. The Maintenance Director stated the nursing staff put in maintenance requests in the facility's TELS system (Streamlines maintenance, housekeeping, and repairs, allowing staff to track, manage, and complete tasks efficiently.). The Maintenance Director stated he checked the TELS system daily in addition to his daily routines. The Maintenance Director stated he tried to address concerns within a day or at most 72 hours based on the priority of the concern.During an interview on 01/29/2026 at 09:47 am Resident #2 stated her call system had been broken for about 6 months. Resident #2 stated she was not able to reach the bell on the nightstand. Resident #2 stated whenever she needed help, she would go to the restroom and use the call button in the restroom. Resident #2 stated she was not able to use the toilet in the restroom, she only goes to the toilet to use the call button to call for help.During an interview on 01/29/2026 at 09:51 am Resident #3 stated she did have a bell to call for help as needed. Resident #3 stated she sometimes yells to call for help.During an interview on 01/29/2026 at 1:05 pm the DON stated she was aware of the call system problem in Resident #2 and Resident #3's room. The DON stated she was not sure of how long the call system in their room had been broken but the Maintenance Director was working on it. The DON stated the Maintenance Director had given Resident #2 a bell to call for help. The DON stated the bell was supposed to be positioned within Resident #2's reach, where she could be able to use it, and if she was not able to reach the bell, it was a safety issue.During an interview on 01/29/2026 at 1:49 pm the Administrator stated he was aware Resident #2, and Resident #3's room call system was broken and they were given a bell. The Administrator stated the call system had been broken for a couple of months, maybe 2 months. The Administrator stated he expected the staff to make frequent rounds to Resident #2 and Resident #3's room and place the bell within Resident's reach as if it was the call light, and if not there was a problem. The Administrator stated any damage to the facility should be fixed immediately.Review of facility's TELS documentation reflected:Order # 2891-- Call light malfunctioning. Unscrewed and unplugged from wall-undated -medium priority-room [Resident #2 and Resident #3's room number]Order # 3053- Call light completely broken out of wall, separated from wiring-dated 12/12/2025-medium priority-room [Resident #2 and Resident #3's room number]. Review of facility's invoice completed by the Maintenance Director dated 11/18/2025 reflected: Patient Station, Bedside: 0.25 Dual 2-Jack 2-Gang Replacement Patient Station Review of facility's policy titled Accommodation of Needs revised 06/06/2025 reflected: Policy:The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodation for the individual needs and preferences of a resident, except when the health and safety of the individual or other resident would be endangered.Policy Explanation and Compliance Guidelines:1. The facility will make reasonable accommodations to individualize the resident's physical environment including their personal bathroom and bedroom and the common living areas within the facility.2.The facility will ensure that common areas frequented by residents are accommodating physical limitations and enhance their abilities to maintain independence.3.Facility staff shall make efforts to reasonably accommodate the needs and preference of the resident as they make use of their physical environment.4.Based on individual needs and preferences, the facility will assist the resident in maintaining and/or achieving independent functioning, dignity, and wellbeing to the extent possible. Review of facility's policy titled Resident Rights dated 2018 reflected: Policy statement:Employees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and ImplementationI. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to:a. a dignified existence.b. be treated with respect, kindness, and dignity.

Based on observation, interviews, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for mechanical lift transfer. The facility failed to ensure Resident #1 was transferred safely when CNA A transferred her by mechanical lift by herself on 01/29/2026. This failure placed residents at risk of injury.Review of Resident #1's face sheet printed 01/29/2026 reflected a [AGE] year-old female who was admitted on [DATE] with the following dx: Chronic Obstructive Pulmonary Disease (a progressive, incurable lung disease-primarily caused by smoking-that causes airflow obstruction, making it difficult to breathe.), Muscle weakness, pain unspecified, Type 2 Diabetes Mellitus with unspecific complications (is a chronic metabolic condition where the body resists insulin or fails to produce enough, causing high blood sugar.), cerebral infarction (a critical medical condition where restricted blood flow causes tissue death (necrosis) in the brain.). Review of Resident #1's admission MDS assessment dated [DATE] reflected a BIMS score 11, indicating moderate cognitive impairment. Section GG - functional Abilities and goal reflected 1 for Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) which indicated Resident #1 was Dependent - Helper does ALL of the effort. Residents do none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Review of Resident #1's care plan initiated 10/25/2025 reflected Resident #1 was at risk for pressure injury r/t (specify) decreased bed mobility/transfers, incontinence, poor nutrition, hx of skin breakdown, fragile skin, braden risk score [a tool used by healthcare professionals to assess a patient's risk of developing pressure ulcers (bedsores), with lower scores indicating higher risk and scores ranging from 6 (highest risk) to 23 (no risk)], sensory perception). Resident #1's care plan did not address ADLs and means of transfers. Review of Resident #1's mode of transfer printed on 01/29/2026 from the CNA Kardex ((is a centralized, frequently updated, and easy-to-reference paper or electronic system that provides a concise summary of essential patient information, including daily care plans, medication, and, allergies) reflected: GG-CHAIR/BED-TO-CHAIR TRANSFER: The ability to transfer to and from a bed to a chair (or wheelchair) 2 person.During an observation on 01/29/2026 at about 10:10 am, CNA A was observed transferring Resident #1 all by herself without another staff present from Resident#1's bed to the chair via mechanical lift. The DON then walked to the scene and stated 2 people were needed for mechanical transfers.During an interview on 1/29/2026 at 10:12 am CNA A stated she had been trained on mechanical transfers and 2 people were required for mechanical transfers. CNA A stated 2 people were needed for the safety of the residents and staff. CNA A stated Resident #1 was her family member, and Resident #1 kept telling her (CNA) to get her (Resident #1) up quickly. CNA A stated the other CNA on the hall was busy and she did not have anyone else to help her that is why she transferred Resident #1 via mechanical lift all by herself. During an interview on 01/29/2026 at 1:05 pm the DON stated 2 people needed to transfer a resident via mechanical lift, and this was done for safety, spotting, and making sure the transfer was done safely. The DON also stated the staff would know a resident required a mechanical lift transfer from daily shift change report. The DON stated the CNAs would know a resident required a mechanical lift transfer from the Kardex. The DON stated she initiated an in-service on mechanical transfers. During an interview on 01/29/2026 at 2:27 pm the MDS nurse stated she was responsible for completing care plans. The MDS Nurse stated Resident #1's mechanical lift transfer was supposed to be care planned and she must have overlooked it. The MDS Nurse stated the CNAs always look in the Kardex to provide care for Residents and Resident #1's mode of transfer was in Kardex. The MDS Nurse stated she just updated Resident #1's care plan when it was brought to her attention by the DON. The MDS Nurse stated every care area of a Resident was supposed to be care planned. The MDS Nurse stated it was noted in Resident #1's MDS that she was dependent for transfers. Review of facility's in-services reflected the following:Safe lifting and movement to Residents and Lifting Machine /Mechanical lift dated 05/07/2025-CNA A signedReview of facility's policy titled Lifting Machine, using a Mechanical dated 2018 reflected: Purpose -The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions.GuidelinesAt least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. (Note: Review Manufacturer guidelines for specific machine use/directions)Review of facility's policy titled Safe Resident Handling/Transfers revised 05/05/2025 reflected: Policy:It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the residents while keeping the employees safe in accordance with current standards and guidelines.Policy Explanation:All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used. Compliance Guidelines:3. Mechanical lifting equipment or other approved transferring aids will be used based on the resident's needs to prevent manual lifting except in medical emergencies.4. Mechanical lifts may include equipment such as full body lifts, sit-to-stand lifts, or ceiling track mounted liftsTwo staff members must be utilized when transferring residents with a mechanical lift.11. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical liftdevices upon hire, annually and as the need arises or changes in equipment occur.12. The staff must demonstrate competency in the use of mechanical lifts prior to use and annually withdocumentation of that competency placed in their education file.13. Staff members are expected to maintain compliance with safe handling/transfer practices. Failure tomaintain compliance may lead to disciplinary action up to and including termination of employment.14. Resident lifting and transferring will be performed according to the resident's individual plan of care.15. Staff will perform mechanical lifts/transfers according to the manufacturer's instructions for use of the device. Review of facility's policy titled Accident and Supervision revised 05/16/2025 reflected: Policy:The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes:1. Identifying hazard(s) and risk(s).2. Evaluating and analyzing hazard(s) and risk(s).3. Implementing interventions to reduce hazard(s) and risk(s).4. Monitoring for effectiveness and modifying interventions when necessary. Definitions:Accident refers to any unexpected or unintentional incident, which results in injury or illness to a resident.Hazards refers to elements of the resident environment that have the potential to cause injury or illness.Supervision/Adequate Supervision refers to intervention and means of mitigating risk of an accident. Policy Explanation and Compliance Guidelines:The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 5- Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision:a. Defined by type and frequencyb. Based on the individual resident's assessed needs and identified hazards in the resident environment.

Based on interviews and records review the facility failed to develop and implement a person-centered comprehensive care plan for each resident consistent with resident rights set forth that include measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. for one (Resident #1) of six residents reviewed for care plan. The Facility failed to include in Resident #1's care plan that she needed 2-person physical assist with transfer via mechanical lift.The facility failed to have an order for Resident #1 to be transferred via mechanical lift. This deficient practice placed Residents at risk for not getting the right interventions, risk for harm and hospitalization. Findings included:Review of Resident #1's face sheet printed 01/29/2026 reflected a [AGE] year-old female who was admitted on [DATE] with the following dx: Chronic Obstructive Pulmonary Disease (a progressive, incurable lung disease-primarily caused by smoking-that causes airflow obstruction, making it difficult to breathe.), Muscle weakness, pain unspecified, Type 2 Diabetes Mellitus with unspecific complications (is a chronic metabolic condition where the body resists insulin or fails to produce enough, causing high blood sugar.), cerebral infarction (a critical medical condition where restricted blood flow causes tissue death (necrosis) in the brain.). Review of Resident #1's admission MDS assessment dated [DATE] reflected a BIMS score 11, indicating moderate cognitive impairment. Section GG functional Abilities reflected 1 for Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) which indicated Resident #1 was Dependent - Helper does ALL of the effort. Residents do none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Review of Resident #1's care plan initiated 10/25/2025 reflected Resident #1 was at risk for pressure injury r/t (specify)decreased bed mobility/transfers, incontinence, poor nutrition, hx of skin breakdown, fragile skin, Braden risk score [a tool used by healthcare professionals to assess a patient's risk of developing pressure ulcers (bedsores), with lower scores indicating higher risk and scores ranging from 6 (highest risk) to 23 (no risk)], sensory perception). Resident #1's care plan did not address ADLs and means of transfers. Review of Resident #1's mode of transfer printed on 01/29/2026 from the CNA Kardex (is a centralized, frequently updated, and easy-to-reference paper or electronic system that provides a concise summary of essential patient information, including daily care plans, medication, and, allergies) reflected: GG-CHAIR/BED-TO-CHAIR TRANSFER: The ability to transfer to and from a bed to a chair (or wheelchair) 2 person.Review of Resident #1's physician orders reflected no order for mechanical lift transfer.During an interview on 01/29/2026 at 1:05 pm the DON stated if a resident required a mechanical lift transfer, there would be a physician order. The DON also stated the staff would know a resident required a mechanical lift transfer from daily shift change report. The DON stated the CNAs would know a resident required a mechanical lift transfer from the Kardex. The DON stated there was safety issue if there was no order for mechanical lift transfer and the Resident was not care planned for mechanical lift transfer. The DON stated she initiated an in-service on mechanical transfers. During an interview on 01/29/2026 at 2:27 pm the MDS nurse stated she was responsible for completing care plans. The MDS Nurse stated Resident #1's mechanical lift transfer was supposed to be care planned and she must have overlooked it. The MDS Nurse stated the CNAs always look in the Kardex to provide care for Residents and Resident #1's mode of transfer was in Kardex. The MDS Nurse stated she just updated Resident #1's care plan when it was brought to her attention by the DON. The MDS Nurse stated every care area of a Resident was supposed to be care planned. The MDS Nurse stated it was noted in Resident #1's MDS that she was dependent on staff for transfers. Review of facility's policy titled Comprehensive Care plan revised 05/05/2025 reflected: Policy:It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and services that are identified in the resident's comprehensive assessment and meet professional standards of quality.Definitions:Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives.Professional standards of quality means that care and all services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. Policy Explanation and Compliance Guidelines:The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. All services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality, and incorporate culturally competent and trauma-informed care as indicated.2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the residents' preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record.3. The comprehensive care plan will describe, at a minimum, the following:a. The services that are to be furnished to attain or maintain the resident's highest practicablephysical, mental, and psychosocial well-being.b. Any services that would otherwise be furnished, but are not provided due to the resident 'sexercise or his or her right to refuse treatment5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive, quarterly MDS assessment and when a resident experiences a status change.6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services in that: The facility's dietary staff failed to effectively label and date items in the walk-in refrigerator. The facility failed to address the kitchen's air conditioning vents that were visibly soiled with a black substance. These failures could place residents at risk for food contamination and foodborne illness.The findings include:During a tour of the kitchen on 10/17/2025 at 09:27am the following was observed:The walk-in refrigerator contained what appeared to be ravioli in a clear plastic bag that was not labeled or dated.The freezer contained what appeared to be hash browns in a clear plastic bag with no label or date.The freezer contained what appeared to be pancakes in a clear plastic bag with no label or date.The air condition system in the ceiling of the kitchen had a black substance on the vents. No interview could be conducted with the DM due to her being in the hospital with an illness. During an interview with DA on 10/17/2025 at 9:30am, DA stated the air condition unit's vents have had the black substance on them for a while. The DA stated that the black substance appeared to be mold. The DA stated that he was not aware if anyone had notified the maintenance director or ADM of the issues. The DA stated he did not know who was responsible for cleaning the vents but assumed it would be maintenance since it was on the air condition unit. The DA stated that a negative outcome would be someone could get sick from the black substance on the air condition unit's vents. During an interview with the [NAME] on 10/17/2025 at 9:35am, the [NAME] stated all items in the refrigerators and freezers should be sealed, labeled, and dated. The [NAME] stated she was new and was not sure who was responsible for labeling and dating items in the freezer. The [NAME] stated if an item in the freezer was not labeled or dated then you would not know if the items were usable or what the item was. During an interview with the Maintenance Director on 10/17/2025 at 11:45am, the Maintenance Director stated that he was new to the facility and was not aware of the black substance on the kitchen air condition unit's vents. The Maintenance Director stated he was not sure who was responsible for cleaning the air conditioning vents in the kitchen. The Maintenance Director stated that someone could get sick from the black substance. During an interview with the CO on 10/17/2025 at 3:15pm, the CO stated every item in the freezer should be labeled and dated. The CO stated it was whomever received the items responsibility to ensure the items were labeled and dated. The CO stated she was not aware that the air condition unit vents had a black substance on them. The CO stated the kitchen staff were responsible for cleaning the air condition unit's vent routinely. The CO stated the black substance appeared to be grime. The CO stated the black substance could possibly fall into the food being served or on the utensil being used in the kitchen. During an interview with the ADM on 10/17/2025 at 3:45pm, the ADM stated all items should be sealed, labeled, and dated. The ADM stated if an item was not labeled then it may not be identified correctly. The ADM stated whoever received the item would be responsible for ensuring it was sealed, labeled and dated properly. The ADM stated he was not aware of any black substance on the kitchen air condition unit's vents. The ADM stated the black substance appeared to be dust build up. The ADM stated a negative outcome would be someone could get sick from the dust build up on the vents. Record review of the facility's Food Receiving and Storage policy, dated 2001, reflected:Policy StatementFoods shall be received and stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date). Review of the facility's Sanitization policy, revised dated 2008, reflected: Policy StatementThe food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation15. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime.

Based on observation, interview and record review the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 1 of 5 residents (Residents #1) reviewed for food and nutrition services.1. The facility failed to ensure Resident #1's personal refrigerator did not have a brown substance stuck to the bottom of the refrigerator and freezer along with a food encrusted butter knife. 2. The facility failed to ensure Resident #1's personal refrigerator had a temperature log.These deficient practices could place residents at risk of foodborne illness due to consuming foods which might be spoiled. The findings include: Record review of Resident #1's admission Record reflected Resident #1 was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Alzheimer's disease (a progressive brain disorder that affects memory, thinking, and behavior), elevated blood pressure, muscle weakness and chronic pain. Record review of Resident #1's admission MDS, dated [DATE], reflected Resident #1 had a BIMS score of 15, which indicated she was cognitively intact. Resident #1 required Substantial/Maximal assistance with personal hygiene, upper and lower body dressing. During an observation and interview on 09/12/25 at 10:25 a.m. revealed Resident #1 had a personal refrigerator. There was a brown substance stuck to the bottom of the refrigerator and freezer along with a food encrusted butter knife. There was no temperature log for the refrigerator. Resident #1 stated she did not have anything in the refrigerator at this time, but she did occasionally store food in it. Resident #1 stated staff did not clean her refrigerator. In an interview on 09/12/25 at 1:05 p.m., the Maintenance Director stated it was his first week working at the facility. He stated all refrigerators should have a temperature log and be clean. He stated he was not sure why it had not been done in the past. He stated housekeeping and maintenance were responsible for checking the cleanliness of the refrigerators and temperatures. He stated not keeping the residents' room refrigerators clean and within a proper temperature, could lead to mold, antifreeze could be leaking, spoiled food not at the right temperature that could cause residents to become sick. In an interview on 09/12/25 at 1:10 p.m., the ADM stated the facility staff should have been checking the residents' refrigerators in the rooms for cleanliness and temperatures. He stated moving forward the facility would have a temperature log taped to each refrigerator. He stated he was not sure why it was not completed before now. He stated the negative effects could be spoiled food, which could cause illness Record review of the facility's policy titled Resident Refrigerators, dated 06/15/2025, reflected, Maintenance staff shall record refrigerator temperatures weekly on a temperature log attached to the refrigerator. a. A thermometer shall remain in the refrigerator. It shall be calibrated prior to use and periodically thereafter.b. Temperatures will be at or below 41 0 F, and freezers will be cold enough to keep foods frozen solid to the touch (or in accordance with state regulations).c. If temperatures are out of range, maintenance staff shall notify nursing department to discard any foods that require refrigeration and take measures to remedy the problem.d. If problems persist with maintaining proper temperatures, the refrigerator shall be removed from use and the resident/family notified.(Nursing/housekeeping) staff shall clean the refrigerator weekly and discard any foods that are out of compliance. Nursing staff shall clean up spills as needed or refer to housekeeping staff.

Based on interview, observation, and record review, the facility failed to ensure the residents had the right to be free from physical abuse and neglect for 3 (Resident #1, Resident #2, and Resident #3) of 9 residents reviewed for abuse and neglect. 1.The facility failed to provide continuous one to one monitoring for Resident #1 after repeated targeted aggressive behavior against Resident #2. An Immediate Jeopardy (IJ) situation was identified on 07/01/25 at 6:55 pm for failure #1.While the IJ was removed on 07/02/25 a 6:42 pm the facility remained out of compliance at a scope of isolated that with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. 2.The facility failed to ensure Resident #3 was not physically abused by MA F on 06/25/2025 when MA F grabbed Resident #3's wrist. These failures could affect the residents by placing them in mental anguish or emotional distress, pain, and physical harm. Findings included: 1.Resident #1 Review of Resident #1's face sheet dated 07/01/25 reflected an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including other frontotemporal neurocognitive disorder (degeneration of the frontal and temporal lobes of the brain, leading to a range of behavioral, language, and movement difficulties) vascular dementia (a decline in thinking skills caused by conditions that reduce or block blood flow to the brain, leading to brain damage), with other behavioral disturbance, and major depressive disorder (a serious mental illness characterized by persistent sadness, loss of interest in activities, and other symptoms that significantly interfere with daily life). Review of Resident #1's quarterly MDS assessment, dated 05/23/25, reflected a BIMS score of 9, indicating moderate cognitiveimpairmentSection E Behavior reflected physical behavior directed towards others (example hitting, kicking, pushing, scratching, grabbing, abusing others sexually) – behavior of this type occurred every 1 – 3 days. Verbal behaviors directed towards others (example threatening others, screaming at other, cursing at others) – behavior of this type occurred every 1 – 3 days. Review of Resident #1's care plan reflected focus – noted behaviors of physical aggression: 1.05/13/15 resident to resident – Resident #1 was seen holding a fork/spoon like object and was on the verge of trying to stab another resident 2.05/19/25 resident to resident - Resident #1 grazed the other resident in the back of head with remote 3.05/28/25 resident to resident – Resident #1 hit another resident with a broom while sitting in the secure dining room 4.06/01/25 resident was destroying dining room area by overturning table and chair Review of Resident #1's care plan reflected interventions for noted behaviors of physical aggression: 1.05/13/25 document behaviors in the clinical record. 2.05/13/25 let physician know if behaviors are interfering with daily living. 3.05/13/25 refer to psychologist/psychiatrist as needed. Review of Resident #1's care plan reflected focus revised on 05/29/25 indicated Resident #1 had potential to demonstrate verbally abusive behaviors related to vascular dementia, with other behavioral disturbance.Review of Resident #1's care plan reflected focus revised on 05/26/25 indicated Resident #1residedon the facility secured unit related to deemed at risk for elopement. Review of Resident #1's care plan reflected focus revised on 06/30/25 indicated Resident #1 demonstrated behavior symptoms/risk at times such as cursing at other residents who are in the way and following other resident (Resident #2) around telling him to get out from his property. Review of Resident #1's care plan reflected focus revised on 05/26/25 indicated Resident #1 was at risk for behaviors related to demonstrates physically abusive behaviors 05/26/25 – resident to resident, Resident #1 ambulating on hallway with staff member when he hit another resident in the face. Review of Resident #1's care plan reflected interventions dated 05/26/25 indicated psychiatric referral as needed to evaluate and follow in house or outpatient. Observation of the facility secured unit on 07/01/25 at 12:10 p.m., revealed Resident #1 wassitting quietly at a dining table.Residents had finished eating. Two staff members were observed in the diningareaperforming normal work duties. Observation in facility secured unit on 07/01/25 at 2:56 p.m., Resident #1 reflected the door was closed to Resident #1’s room. When surveyor entered with the assistance of RN D, Resident #1 was sitting on his bed. His roommate was laying in his own bed sleeping. Observed no 1:1 monitoring of Resident #1. Review of Resident #1’s Nurses Notedated 05/09/25 written by the ADON reflected Resident #1 was placed on the secure unit due to elopement risk. Review of Resident #1’s Nurses Note dated 05/13/25 written by LPN A reflected aide (name of aide not stated) reported to LPN A that Resident #1, who was the roommate of Resident #2, was seen holding a fork/spoon like object and was on the verge of trying to [stab] Resident #2.The aide was unable to remove the fork/spoon out of Resident #1’s hands.LPN A was called and able to remove the fork/spoon from Resident #1. Both residents were assessed for injury, none at the time will continue to monitor both residents for any complications. Review of Resident #1’s Nurses Note dated 05/20/25 written by RN C reflected Resident #1 was holding a remote in hand and refused to put remote down.Resident #1 picked up broom in the dining room hallway and attempted to hit another Resident #2. CNA (name of CNA not stated) able to redirect and remove broom from Resident #1.Resident #1 was holding remote that he refused to put down. Resident #1 “grazed” Resident #2 in the back of the head with remote. Residents separated for safety. Resident #1 closely monitored post incident. Review of Resident #1’s Progress Note Psychiatric Initial Evaluation dated 05/20/25 by PNP reflected dementia with behavioral disturbances. Patient #1 currently on 1:1 observation, continue current medication regimen. Continue to assess for adverse effects and let medication management associates know. Patient has significant cognitive impairment consistent with Alzheimer’s disease (a progressive neurodegenerative disorder that gradually destroys memory and thinking skills, eventually impacting the ability to carry out even the simplest tasks). Patient with history of becoming easily agitated. Staff report patient was physically aggressive towards another resident with difficulty redirecting over the weekend. No aggressive behaviors noted during evaluation. Seen for initial psychiatric evaluation by request of facility. Consider sending to psychiatric hospital or emergency room if patient is a danger to self or others. Review of Resident #1’s Nurses Note dated 05/20/25 writtenbyRN D reflected PNP saw Resident #1.PNP said she hoped the medications will help calm him down and he will have less behaviors. Review of Resident #1’s Nurses Note dated 05/26/25 written by LVN E reflected Resident #1 walked down the hallway of the secured unit when he hit Resident #2 on the face. Both Resident #1 and Resident #2 grabbed each other’s arms. Residents separated by two staff members (names of staff members no listed).No acute injuries noted. Resident #1 was easily redirected and was calm after being separated from Resident #2. Will continue to monitor. Review of Resident #1 Psychiatry Follow Up from PNP dated 05/27/25 reflected Resident #1 was involved in an altercation with another resident over the weekend, where he was the aggressor. Resident #1 with vascular dementia with behavioral disturbances, currently 1:1 (indicates that one staff member is assigned to continuously observe a single patient. This was often necessary for patients with certain behavioral conditions). Consider sending to emergency room or psychiatric hospital. Dementia in other diseases classified elsewhere, moderate with other behavioral disturbance – Resident #1 with history of becoming easily agitated. Was involved in an altercation with another resident [Resident #2] over the weekend. Resident #1 was the aggressor.Resident #1 continued to be on 1:1, required close monitoring. He appeared to dislike one particular resident (Resident #2). Resident #1 seen in room on 1:1 observation, did not engage much, oriented to self only, significant cognitive impairment consistent with dementia. Resident #1 required 1:1 observation and required close monitoring. Staff were to monitor, redirect, and ensure Resident #1’s safety.It was recommended to keep Resident #1 and Resident #2 in separate locations. Resident #2 Review of Resident #2’s face sheet dated 07/01/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including senile degeneration of brain (decline in cognitive abilities, memory, and behavior associated with old age), Major depressive disorder, wandering in diseases (repetitive, aimless movement from place to place, often without a clear purpose or destination, especially in individuals with dementia or other cognitive impairments). Review of Resident #2's quarterly MDS assessment, dated 04/18/25, reflected a BIMS score of 3, indicating severe cognitiveimpairment. Review of Resident #2's care plan reflected focus revised on 04/12/25, indicated Resident #2 had a behavior problem related to taking other residents’ food off their tray during meals. Review of Resident #2’s Nurses Note dated 05/13/25 written by LPN A reflected Resident #1, who was a roommate with Resident #2, was seen holding a folk/spoon like object and was on the verge of trying to stab Resident #2. The aide (name of aide not stated) tried to get the folk out of Resident #1’s hands but Resident #1 was unable to give up the folk. LPN A was called to the scene and was able to remove the folk from Resident #1. Both residents were assessing for any injury, no injuries. Review of Resident #2’s Nurses Note dated 05/26/25 written by LVN E reflected Resident #2’s was walking down the hallway when he was hit on left side of jaw by another resident (Resident #1). Both residents grabbed each other's arms. Resident separated from the other resident by staff x2. No visible injuries noted. Attempted to initiate neurological assessment and vitals, Resident #2 refused at this time. Will continue to monitor. Review of Resident #2’s Nurses Note dated 05/20/25 written by RN C reflected Resident #2 was sitting in chair in dining room. Another resident (Resident #1) attempted to hit Resident #2 with broom and hit the chair. Resident #2 remained seated in dining room chair. Resident #1 grazed Resident #2’s hair on the back of the head with the remote. Resident #2 remained seated, no signs of agitation or aggressive behavior noted. Residents separated for safety. Review of Resident #2’s Progress Note Psychiatric Follow Up Evaluation dated 05/20/25 by PNP reflected Resident #2 was involved in an altercation where he was hit by another resident (Resident #1). Plan was to redirect and keep him safe. Review of Resident #2 Progress Note from PNP dated 05/27/25 reflected Resident #2 was involved in an altercation where another resident (Resident #1) hit him; Resident #2 did not retaliate. Resident #1 required redirection and safety measures. Staff were advised to try to keep Resident #2 and Resident #1 in different locations to prevent further incidents. Review of facility complaint incident report dated 06/01/25 revealed Resident #1 had a problem with Resident #2. Resident #1 is fixated on Resident #2.Resident #1 said, “he thinks resident two broke his family up.” Review of Psychiatry Follow Up from PNP dated 06/10/25 reflected Resident #1 with history of becoming easily agitated and continued to be 1:1 observation, required close monitoring. On and off agitation and aggressive behavior towards one particular resident (Resident #2). Social support – Resident #1 received 1:1 observation and required close monitoring due to aggressive behavior. Follow up – staff to monitor, re-direct and keep safe, continue 1:1 observation due to behavioral issues. Keep Resident #1 and Resident #1 at different locations was encouraged. Continue secure unit placement. Consider sending to the emergency room if identified harm to self or other. Review of Resident #2’s Nurses Note dated 06/17/25 written by RN D revealed Resident #2 would take food when he walked by. Review of IDT (team is composed of various healthcare professionals who collaborate to provide comprehensive care and support for residents) meeting note dated 06/19/25 and attended by the Administrator, ADON, MDS Coordinator and therapy reflected, “Team decided that with information that we reviewed [Resident #1] would be OK off 1:1 monitoring.”No MD or PNP listed as attending meeting and no documentation of information reviewed. Review of Resident #2’s Nurses Note dated 06/20/25 written by RN D revealed Resident #2 seen walking around eating and stealing food from others. Was able to redirect him but he kept walking towards other and grabbing at food or drinks. Other patients are very upset and stating they might hit him if he kept doing it. Review of Resident #2’s Nurses Note dated 06/21/25 written by RN D revealed was going in other rooms and standing over patients while sleeping. Other patients getting upset. Review of Resident #2’s Nurses Note dated 06/26/25 written by RN D revealed continues to take other's food at times. Review of Resident #2’s Progress Note dated 07/02/25 written by MD reflected Resident #2 was the target of another resident’s (Resident #1’s) erratic behavior on 06/28/25, though staff preventedaltercation. Interview on 07/01/25 at 2:42 p.m., with the PNP revealed Resident #1 was a safety concern because he was aggressive. She was concerned about his safety and the safety of the other residents if Resident #1 was not provided 1:1 monitoring.She said he was on the correct medications and if he was not given 1:1 monitoring, the facility needed to find alternative placement for Resident #1. Interview on 07/01/25 at 12:10 p.m., with RN D revealed Resident #1 “targets” Resident #2, but Resident #1 instigates things by taking food and items from residents’ trays (including Resident #1’s tray). RN D said he was not concerned Resident #1 would harm other residents and Resident #1 was currently not 1:1. RN D felt they had enough staff and Resident #1 could be watched. He said some incidents between Resident #1 and Resident #2 have occurred in the past even when Resident #1 was on 1:1 monitoring because staff was not watching.An example was when Resident #1 attempted to hit Resident #2 with a broom. Interview on 07/01/25 at 2:56 p.m., with RN D revealed Resident #1 said he was taken off 1:1 monitoring last Wednesday(06/25/25) and when RN D came to work on the followingThursday (06/26/25), Resident #1 was off 1:1 monitoring and had been off 1:1 monitoring since. Interview on 07/02/25 at 11:29 p.m., CNA G revealed she had not witnessed any physical aggression towards Resident #2 by Resident #1. She said Resident #2 would go around Resident #1’s food tray and take things from his tray. CNA G example gave the example of when Resident #2 took Resident #1’s food cover. CNA G said this would aggravate Resident #1 and said Resident #1 would say something to the affect that Resident #2 was messing with his wife.Resident #1 thought that Resident #2 was in Resident #1’s home. She said Resident #1 would threaten Resident #2 when Resident #2 moved things around and said, “I’m going to kick your ass.”CNA G did not think that 1:1 monitoring was necessary because there were 2 aides in the secured unit she said when staff was there they could re-direct Resident #1.She said that Resident #1 listened to her, but she was not sure if he listened to the staff on othershifts. Interview on 07/02 25 at 2:50 p.m., LVN E revealed she had worked in the secured unit and was familiar with the relationship between Resident #1 and Resident #2. She said that Resident #1 seemed like he would get agitated when he saw Resident #2. She said Resident #1 would get upset and start walking towards Resident #2 getting verbally aggressive and cursing. She said there was an altercation between Resident #1 and Resident #2 with a broom when she was on duty, but she did not see what happened. She said a CNA got in between the residents. She said she was not concerned about resident safety because Resident #1 always received 1:1 monitoring when she was working the secured unit. She said as long as Resident #1 was 1:1 she was not concerned about safety. She said it was the responsibility of the DON and Administrator to decide if a resident received 1:1 monitoring. She said the negative effect of a resident who does not have 1:1 monitoring and needs 1:1 monitoring was that a resident could get hurt. Interview on 07/02/25 at 2:17 p.m., RN C revealed she used to work in the secured unit at night and was familiar with Resident #1 and Resident #2. She said they are physically independent in that they are not in wheelchairs and are able to walk. She said Resident #1 and Resident #2 do not like each other. Resident #1 would say, “it is my house.” She said the residents should be separated. She said Resident #1 should definitely be monitored 1:1. She said if Resident #1 was not monitored 1:1, Resident #2 can get close to him and that irritated Resident #1. She said if Resident #1 is monitored 1:1, he can be re-directed quickly. She said when he received 1:1 monitoring, he was fine but as soon as he was taken off his behaviors go back to what they were previously.She thinks that Resident #1’s behavior could cause harm to Resident #2 or himself if Resident #1 did not receive 1:1 monitoring. Interview on 07/02/25 at 12:46 p.m., with the DON revealed she had not witnessed any disturbances between Resident #1 and Resident #2, but it was reported to her by the overnight nurse (could not remember the name of the nurse) by phone that Resident #1 attempted to hit Resident #2 with a broom. The ADON had heard that Resident #1 thinks that Resident #2 was trying to “break up his family.” She said that Resident #1 found Resident #2 sitting on Resident #1’s bed and Resident #2 had an incontinent episode and Resident #1 had been “fixated” on Resident #2 since this episode. The ADON said the IDT team decided if a resident was going to come off 1:1 monitoring.She said the IDT team consists of the Administrator, the DON, Social Worker, and psychologist. She said she felt like the PNP should have been included in the decision whether to remove Resident #1 from 1:1monitoring. Interview on 07/01/25 at 5:13 p.m., CNR #1 revealed Resident #1 was fixated on Resident #2 and they were both in the secured unit, so it was not like you could keep them separate. She said the facility held an IDT meeting on 06/19/25 and the team reviewed Resident #1’s behaviors and progress note charting and found 1:1 monitoring for Resident #1 was not warranted any longer. She said the facility needed to make sure the provider was consulted and updated. She said if the PNP said Resident #1 needed to have 1:1 monitoring, then Resident #1 needed to be on 1:1 monitoring. She said if you don’t get the approval from the provider, the PNP, you run the risk of more resident-to-resident altercations. Interview on 07/02/25 at 3:15 p.m., CNR #2 revealed that during the IDT meeting on 06/19/25 that concluded that was okay to end Resident #1’s 1:1 a critical component that was missing because the PNP was not included and consulted. He said it was the responsibility of the Administrator make sure that all relevant people are present during an IDT meeting. He said the possible negative outcome of not including the PNP provider at the IDT meeting to provide input regarding the possibility of removing Resident #1 from 1:1 monitoring would be continuing issues with resident-to-resident altercations. Interview on 07/02/25 at 3:06 p.m., the Administrator revealed the PNP should have been kept in the loop when the IDT team made the decision on 06/19/25 to removed Resident #1 from 1:1 monitoring. He said he thought Resident #1 was doing better because Resident #1 did not have any incidents of altercations with Resident #1.He said that the IDT meeting participants should have included a mental health provider to discuss Resident #1’s 1:1 status. He said that Resident #1’s 1:1 monitoring should have remained intact, and he should not have been removed from 1:1 monitoring. He said the negative affect of not having a resident on 1:1 monitoring who should be on 1:1 monitoring would be that it could be unsafe for residents. The Administrator said it was his understanding that Resident #1 only had problems with Resident #2, and Resident #1 was focused on Resident #2.Resident #1 thought that Resident #2 stole his family. He also heard that Resident #2 had an incontinent incident on Resident #1’s bed and Resident #1 had not forgotten about the incident and Resident #1 was still upset about it.The Administrator said the facility was working on getting Resident #1 transferred to another facility because of his fixation on Resident #2 and concerns for Resident #1’s safety and other safety of the other residents in the secured unit. It is the responsibility of the Administrator and the IDT team to make sure that the physical and mental providers are included in the IDT meeting when making decisions about 1:1 monitoring status. Review of facility policy Resident to Resident Altercations dated December 2016 reflected the facility staff will monitor residents for aggressive/inappropriate behavior towards other residents. Occurrences of such incidents shall be promptly reported to the nurse supervisor, director of nursing services, and the administrator. If two residents are involved in an altercation staff will notify each resident's attending physician of the incident, review the events with the nursing supervisor, director of nursing and possible measures to try to prevent additional incidents, make any necessary changes to the care plan approaches to any or all of the involved individuals, document in the resident’s clinical record all interventions and their effectiveness, contract psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for interventions and management as necessary or as may be recommended by the attending physician or interdisciplinary care planning team. If after carefully evaluating the situation, it is determined that care cannot be readily given within the facility to transfer the resident. This was determined to be an Immediate Jeopardy (IJ) on 07/01/25 at 5:27 pm.The Administrator was notified at 6:55 p.m.The ADM was provided with the IJ template on 07/01/25 at 6:55 p.m. The following Plan of Removal submitted by the facility was accepted on 07/02/25 at 1:01 p.m. PLAN OF REMOVAL On 07/01/2025 an abbreviated survey was initiated at the facility.On 07/01/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to continuously monitor Resident #1 1:1 for multiple altercations of aggressive behavior targeted against Resident #2. IMMEDIATE JEOPARDY PLAN OF REMOVAL for F600 – Failure to Protect Residents from Abuse Tag Number: F600 Regulation: The resident has the right to be free from abuse. Deficient Practice: The facility failed to ensure that Resident #1 was continuously monitored as ordered for 1:1 supervision following multiple episodes of physical aggression toward Resident #2, placing Resident #2 at risk for harm. 1. Corrective action(s) taken for resident(s) found to be affected: Who: The Administrator/Designee and Secure Unit Charge Nurse. What: Immediately reinstated 1:1 monitoring for Resident #1 to ensure Resident #1 and Resident #2 are separated. 1:1 monitoring to include direct 24-hour eyes on supervision by dedicated/assigned staff member. In-service education provided clarification to staff to ensure Resident #1 is not left alone at any time and the protocol for providing breaks and adequate replacement for assigned staff member. When: Initiated on 07/01/2025, following incident review. Where: On the secured memory care unit, where both residents reside. Additionally: Resident #2 was assessed by the ADON/Designee for injury and psychosocial impact—no acute injury found, no acute psychosocial impact. Referral was made to [MD]on 07/01/25 to conduct follow up visit on 7/2/2025. No other residents identified during review of R-to-R altercations with Resident #1 Psychiatric Nurse Practitioner (NP) re-evaluated Resident #1 on 07/01/2025, recommending need to reinstate 1:1 due to continued aggression. The interdisciplinary team (IDT) met on 07/01/2025 and updated Resident #1’s care plan to reflect behavior management strategies, permanent 1:1 status, and physical separation plan from Resident #2 through direct 1:1 supervision. Finding alternate placement. 2. How the facility will identify other residents who could be affected: Who: ADON/Designee. What: Conducted a review of all residents on the secured unit with active or recent aggressive behavior or R-to-R altercations within the last 30 days. Facility wide incidents were reviewed and are currently ongoing starting on 7/1/25 When: Audit began 07/01/2025 and will be completed by 07/02/25. Where: Secured unit. The audit includes: Review of behavior monitoring orders. Validation of 1:1 interventions being documented and implemented. Documentation is assigned to the Charge Nurse on the MAR/TAR every shift and paper monitoring, which includes location, behavior/activity and supervising staff initials, is ongoing with 1 hour frequency. Confirmation of care plan updates for any additionally identified resident and interdisciplinary review of any behavior incidents in the last 30 days. 3. Systemic changes made to ensure the deficient practice does not recur: Who: Staff Development Nurse, in coordination with Administrator/Designee and Regional Nurse Consultant. What: Regional Nurse provided education to the Assistant Director of Nursing and Administrator on 07/01/2025 by in-service education. Assistant Director of Nursing and Administrator will conduct Facility-wide in-service education and posttest for all licensed nurses, CNAs, agency and direct care staff prior to the start of assigned shift. New staff will receive training during orientation: Abuse prevention Resident to Resident altercation policy Requirements for initiating, documenting, and discontinuing 1:1 supervision. In-service provided clarification to staff outlining the expectations of 1:1 supervision, including, 24-hour eyes on supervision; not leaving Resident unsupervised at any time; providing adequate coverage of assigned staff member. Importance of timely IDT reviews and documentation in the MAR/TAR and care plan. When: Initiated on 07/01/2025 and completed by 07/02/2025 with all current and oncoming staff/agency prior to start of shift worked; new staff will receive this training during orientation. Where: In-person training held in facility and documented with sign-in sheets. Additional changes: Continue 1:1 Supervision Monitoring Log, to be maintained at the point of care (resident’s room or nearby nurse station), requiring hourly initials by assigned staff. Verification of completion of monitoring log will be done by ADON/designee daily. 1:1 supervision will be reviewed by IDT within 24 hours of initiation and will be reviewed daily for continued appropriateness of 1:1. 4. How the facility will monitor to ensure compliance and prevent recurrence: Who: Administrator/designee. What: Weekly audits of 100% of residents with 1:1 orders for compliance with documentation, monitoring logs, and MAR/TAR entries. Monthly reviews of incident reports involving R-to-R contact, focusing on behavioral care planning and response follow-through. When: Weekly audits for 8 weeks starting 07/02/25, followed by monthly audits for 4 months. Where: Monitoring will occur facility wide for any identified R-to-R altercations. Audit results will be reported to the QAPI Committee monthly, and immediate corrective action will be taken for any missed 1:1 interventions or breakdowns in IDT communication. 5. Date of completion: All corrective actions and training will be fully implemented by: July 02, 2025 Monitoring: Review of Resident #1’s MAR and TAR reflected 1:1 supervision continuous 24hr monitoring with every hour checks every hour for physical behaviors every shift documented every hour with no behavioral issues reflected. Observation 07/02/25 at11:25 a.m. of Resident #1 with 1:1 monitoringdedicated/assigned staff member. Observation 07/02/25 at 1:00 p.m. of Resident #1 with 1:1 monitoringdedicated/assigned staff member. Observation on 07/03/25 at 11:40 am of Resident #1 with 1:1 monitoringdedicated/assigned staff member. Interview on 07/02/25 with CRN #1 stated she assessed Resident #2 for any psychosocial impact and no acute injury found. Review of PNP documentation dated 07/01/25 re-evaluation of Resident #1 recommended need to reinstate 1:1 monitoring due to continued aggression. Review ofinterdisciplinary team (IDT) meeting document dated 07/01/2025 and review of updated Resident #1&rsqu[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 3 residents reviewed for accidents and hazards. The facility failed to ensure there was appropriate supervision on [DATE] when Resident #1, who resided on the secure unit, exited the secure unit, after RN A left the unit (to respond to a code after not being familiar with the CPR policy), and then one of the facility's side exits and got into the passenger seat of a parked fire truck in the parking lot. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:28pm. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of elopement, falls, or injuries and not having their end-of-life wishes followed. Findings included: Review of Resident #1's quarterly MDS assessment dated [DATE] reflected he was an [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses including dementia (memory loss), major depressive disorder with severe psychotic symptoms (loss of contact with reality) (extreme sadness), anxiety (extreme worry), unsteadiness on feet, and frontotemporal neurocognitive disorder (when nerve cells in the brain are lost). Section E - Behavior, revealed that he had physical and verbal behavior directed toward others in the last 1-3 days, and wandering had occurred in the last 4-6 days in the last week. His BIMS score was a 9, indicating he was moderately cognitively impaired. Review of Resident #1's elopement risk assessment dated [DATE] revealed a score of 6, which indicated he was a high risk of elopement. Review of Resident #1's care plan dated [DATE] revealed that he was to reside in the secure unit due to risk of elopement and to have elopement risk assessments per facility protocol. Review of progress note dated [DATE] at 10:00am by RN A reflected, Patient was brought back to unit by staff up front. Stated he was seen at the front door. Patient came back very calm and was even pushing another patient with him. Patient stated, I was just wanting to look at the fire truck. He was unable to state how he exited. All areas were checked. Side and back door are locked. All windows are secured shut and unable to open. Management informed and looked at cameras and noted he went out secure main door when it did not secure properly behind me as I was exiting to respond to a code on the other side of the building. DON contacted family. Patient was put on 1:1 (monitoring where a staff member is directly responsible for one resident) And q15 minute checks was started also immediately. Reminded all staff to ensure door is locked when going out. Review of progress note dated [DATE] at 10:00am by the DON reflected, at 0939, this nurse received a phone call from charge nurse {RN A}, stating that this resident was found at the front door of facility during a time of a code on another resident on one side of the building, and an emergency on the other. {RN A} verbally stated as he was exiting the doors of the secure unit to go assist, he stated that, the resident must have followed me out of the secure unit and that is how he ended up in the mix of the facility due to the nature of the emergency and situation. Admissions coordinator was at the front of the building and seen resident as he was at the front door of the building holding his remote and was with the EMS staff and firemen and immediately redirected resident back to the secure unit. Resident was approachable and easily willing to go back to the secure unit. He pushed another resident in his wheelchair to the south station of the building, in good spirits, hugging everyone and, glad to be a help to others. No injuries were reported on resident. This nurse instructed charge nurse, {RN A} to immediately initiate one on one monitoring on this resident to indefinite timing, 24 hours a day, as resident is a high elopement risk with good understanding verbalized. {The DON} instructed {RN A} to ensure that anytime the secure doors are opened by any staff member or at any time, that they need to make sure they are completely closed and locked to where no resident in a secure unit can exit. There are two other doors on secure unit that have been tested and do work; alarms will sound and go off if they are pushed. This nurse spoke with daughter, and explained to her the situation and she thanked nurse for the phone call and update and stated she was at a funeral and wouldn't be back up to the facility for the rest of the day. This nurse and {daughter} discussed this residents' disease process, and she expressed her feelings about it and how she is sad seeing the rapid decline in her father, cognitively, and she and her brother are coming to realization to acceptance about it. She stated that resident used to be a Life support educator, and that in his mind, he probably really did think he was a part of the emergency he seen happening and followed the nurse/EMS staff, thinking he was helping save someone's life. I informed {daughter} that I had re-initiated one on one monitoring on her dad due to safety measures, and it would be a 24-hour monitoring, and she tearfully expressed her appreciation. I told her to contact this nurse at any time with any questions, concerns, or needs and she verbalized understanding. In an attempted interview on [DATE] at 9:10am with Resident #1, the HHSC surveyor attempted to ask him about recent events, but he stated he did not remember the events in question. During an interview on [DATE] at 11:16am with RN A he stated that on [DATE] he was the RN assigned to the secure unit and was assisted by CNA B. He was aware that CNA B was off the unit for lunch at the time a code (indicating a resident had stopped breathing and needed CPR) was called, but he thought it was just him and 1 other nurse working in the building during that time, so he said he had to respond to the code. He stated that he was only off the unit for a couple of minutes. He stated that when he left the unit the door did not lock behind him and that the door got stuck unless it was pushed shut. He stated that a code was never called over the loudspeaker, and he had heard through word of mouth from another CNA there was a code. When he arrived to the code, the RN told him the resident collapsed, so she started CPR and never had a chance to call the code. He stated they (EMS/Nurse) were already working on the resident and didn't need any help, so he went back to the secure unit. He stated he knew his CNA was off the unit and he knew he was leaving the residents unattended/unsupervised. His stated his priority was the emergency when he found out about it. He could not recall who told him about the code. He stated that he received no notification other than CNA word of mouth. He stated that based on experience as a nurse he was to respond to all codes, and he had no direction from the facility on responding to codes. He stated he did not see Resident #1 was by the doors when he went off the unit and didn't know he was followed. He stated he had received no training on CPR response teams and no training on the team or identifying who responded or not. During an interview on [DATE] at 11:36am with the DON she stated that she was not aware CNA B was off the unit when RN A responded to the code. She thought there was an additional agency staff present on the secure unit that day. She later confirmed there was no agency staff present on the secure unit on [DATE] and just RN A and CNA B were working on the secure unit. She stated 2 other nurses were working on the other side of the building and there was no reason for RN A to leave the secure unit. During an interview on [DATE] at 1:19pm with the AC, she stated that RN A never attended the code. She also stated that she was at the front door of the facility when Resident #1 had made his way to the door, and that she had redirected him back to the secured unit. She was unable to verify if Resident #1 had made it outside the front door or just to the front door of the building. During an interview on [DATE] at 3:22pm with the RNC he stated that if a code happened on a certain hall, the staff that worked that hall should respond, and that all direct care staff were CPR trained and certified. During an interview on [DATE] at 6:30pm with RN A, he stated that based on experience as a nurse he was to respond to all codes, and he had no direction from the facility on responding to codes. He stated he had received no training on CPR response teams and no training on the team or identifying who responds or not. He stated that for that incident there was no code called over the loudspeaker, he was just notified through CNA word of mouth. During an interview on [DATE] at 8:36am with MA C, she stated that she did not recall any recent in-services on elopement or resident supervision. During an interview on [DATE] at 8:43 am with RN B, she stated they had not received in-serving on elopement since the incident on [DATE]. During an interview with the MD on [DATE] at 10:30am she stated that her expectation for staffing in the secure unit was that there would be somebody working in the unit to make sure residents could not harm themselves or others, to provide medications and help during meals. For staffing, she stated that there were times when the residents were stable, and the environment varied based on the patients' behaviors. She said if they were poorly staffed or things happened, more staff could be needed, but in general somebody needed to be always back there with the residents. She stated she had concerns if all staff left the secure unit for an extended amount of time, but if someone was stepping out to get help or something quick, that should be allowed. In the situation on [DATE] she stated that RN A was a very well-trained nurse, and she thought it was appropriate that he stepped out to check on things and then returned. She stated that a resident would be ordered to live on the secure unit due to Alzheimer's disease, not being aware of his surroundings, and not being aware of potentially dangerous situations. The MD stated she had no more concerns with Resident #1 getting around the fire truck than any other residents. She stated she did not think Resident #1 had the capacity to drive, pick up heavy things, or move equipment anymore. The MD stated there was potential for injury, but she didn't know that the fire truck would sit much higher than the bed in his room or a table in the secure unit, so the MD did not know that it would be more of a fall risk. She stated it wouldn't be good if Resident #1 got into any hoses and the MD did not know if Resident #1 had any strength to pull heavy equipment. In an interview with the RNC on [DATE] at 11:17am he stated that the facility did not have any policies specific to the secure unit. In an interview on [DATE] at 12:20 pm with the DON, she stated that every staff member had a code legend on their badge, and that if there was a resident coding, someone would get on the loudspeaker/intercom and call a code blue, which would alert everybody, so staff could respond. She stated they did not designate teams; the nurses would just respond. The expectation of responding nurses would be that they call 911 and get crash cart to help out. In an interview with MA C on [DATE] at 12:31pm she stated that she was working on the south hall on [DATE] as a medication aide. She stated that the south side entrance door alarm went off (meaning that the exit door had been opened) so she responded to the door. She looked outside and did not see any residents outside. She stated she was able to see out into the driveway where the fire truck was parked. She stated that she thought the door alarm may have been triggered by the in and out of the emergency personnel on the other side of the building, and that the emergency personnel took the coded resident out of the facility's main front door. She stated she worked until 2:00pm on [DATE] and was never informed of Resident #1's elopement, and that she did not receive in-service for elopement until [DATE], even though she had worked another shift on [DATE]. She stated that a negative outcome of a resident leaving out of the south door unsupervised was that they could potentially walk into traffic, get lost, get injured, or die. Review of video footage provided by the facility revealed RN A leaving the secure unit on [DATE] at 9:22:37am and returning at 9:24:18am. Resident #1 could be seen on camera peeking out from his bedroom door and watching RN A leave the unit, and then Resident #1 ambulated to the secure unit door and pushed it open at 9:22:42 and began walking down the south hallway. Resident #1 was then seen through a different camera view, pushing open and walking out of the building's south side entrance and walking into the driveway and ambulating into the passenger side of the fire truck with its lights on, that was parked there. There were no facility staff or emergency personnel in view of the camera. Review of a different camera view of the facility outside the front main entrance revealed Resident #1 approaching the ambulance that was parked in the driveway in front of the main entrance. Resident #1 was seen observing the ambulance but did not open any of the doors, and no facility staff or emergency personnel were in view of the camera. Resident #1 was observed making his way to the facility front door on his own. In a different camera view of the facility inside the main entrance at 9:25:27 the AC can be seen making her way from the entrance, down the hallway toward the dining area at 9:25:57., At this time her back was toward the main entrance, and she went out of the camera's view until she reappeared at 9:28:01 and began her way back toward the front entrance doors. At 9:28:40 she came back into the camera view and was observed guiding Resident #1 down the hallway with their hands intertwined. Resident #1 was returned to the secure unit at 9:30:52am. Review of the facility's Safety and Supervision of Residents policy dated 2018 revealed, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified needs and identified hazards in the environment. Review of the facility's policy titled 'Emergency Procedure - Cardiopulmonary Resuscitation' last revised February 2028 reflected, Select and identify a CPR Team for each shift in the case of an actual cardiac arrest. To the extent possible, designate a team leader on each shift who is responsible for coordinating the rescue effort and directing other team members during the rescue effort. The ADM, DON, and RNC were notified on [DATE] at 4:18pm that an Immediate Jeopardy had been identified due to the above failure and an IJ template was provided. The following POR was accepted on [DATE] at 11:43am: On [DATE] an abbreviated survey was initiated at the facility. On 5-30-25 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate Jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to ensure there was appropriate supervision on [DATE] when Resident #1, who resides on the secure unit, exited the secure unit, after RN A left the unit, and then one of the facility's side exits (approximately 160 feet from the secure unit) and got into the passenger seat of a parked fire truck (approximately an additional 220 feet from the exit door) in the parking lot. Immediate Jeopardy Plan of Removal - F689 (Supervision to Prevent Accidents) 1. Resident #1 (Affected Resident): Resident #1 was safely returned to the secure unit by the medication aide on [DATE] after exiting the unit unsupervised. The elopement was self-reported to HHSC on [DATE] by the Administrator. Immediate actions taken included: o Initiation of 1:1 supervision by the CNA on 5-24-25 for 24 hours from the time of the incident. o The charge nurse updated the elopement risk assessment on 5-25-25, reviewed and updated the care plan as needed. o The interdisciplinary team review was initiated by the Administrator and the interdisciplinary team on 5-25-25. o CNA B and RN A were instructed on 5-24-25 by the DON to not leave residents unattended, especially those on secure unit, even for a moment. o Door hardware on the secure unit was repaired by the maintenance director to ensure door latched when closing and signage placed (Please make sure the door is closed and latched behind you!) on 5-26-25. All staff were in-serviced by the DON/designee on 5-30-25 to ensure that the door is closed and latches when exiting. New hire employees will be in serviced during orientation and prior to the start of their first shift. PRN employees and agency staff will be in-serviced prior to the start of their next assigned shift. 2. Identification of At-Risk Residents (Facility-Wide Review): On [DATE], the MDS coordinator initiated a full audit of all the residents on the secure unit to identify additional elopement risks. All current elopement risk assessments were reviewed and updated as needed on 5-30-25 by the MDS coordinator. Care plans were reviewed by the MDS coordinator on 5-30-25 to ensure they reflect current interventions. All staff were in-serviced by the DON/designee on 5-30-25 to immediately notify administration by phone of any breaks or coverage issues. Door alarm systems and locking mechanisms for all exit doors were checked by maintenance on 5-26-25 and documented on a log and will be reviewed by the administrator daily. 3. System Correction: o The DON/designee in-serviced all staff on elopement protocol, and supervision protocols, on [DATE] and are ongoing until all staff have completed training on 5-31-25. Mandatory in-services will be completed on 5-31-25 with all current and oncoming staff prior to the start of shift worked. The regional nurse provided education to the director of nursing and the administrator on 5-30-25 regarding supervision protocols, elopement prevention, and response expectations for secure unit. Agency staff and PRN staff will not be assigned to the secure unit unless they have completed the facility's elopement prevention and supervision in-service. This will be verified through the human resources and staffing coordinator prior to working their shift. This will be validated by the DON/designee. o A revised policy on code response was implemented by the regional nurse on [DATE] to require designated responders to any emergency or code being called, ensuring secure unit staff do not leave residents unattended. o Daily door audits were implemented on 5-30-25 by the maintenance director for all secure unit exits for 14 days and then weekly thereafter. This will be documented by the maintenance director on a daily audit form and reported to the Administrator daily. o The DON/designee in-serviced staff on 5-30-25 when assigned to the secure unit staff are now required to formally sign out when taking a break or leaving the unit to verify designated coverage is in place prior to leaving the unit ensuring continuous supervision of residents in accordance with facility protocols. Agency staff and PRN staff will not be assigned to the secure unit unless they have completed the facility's elopement prevention and supervision in-service. This will be verified through the human resources and staffing coordinator. This will be validated by the DON/designee. o Each staff member attending the in-service will complete a verbal return demonstration to confirm comprehension of the content presented, and once the staff verbalizes understanding by repeating back the information then the in-service will be signed at that time. o Verbal return demonstrations will include scenario-based questions, policy clarification, and role-specific expectations (e.g., code response protocol, secure unit coverage requirements). o Competency will be assessed in real time by a licensed nurse, department manager, or clinical educator. o Staff who do not successfully complete the verbal return demonstration will receive immediate re-education and follow-up assessment to ensure understanding. 4. Administrative Oversight/Monitoring: oThe DON/designee is completing daily visual checks on secure unit supervision and door status for 14 days starting [DATE]. o The Maintenance Director will check the secure unit door latch and magnetic locking mechanism daily starting 5-30-25 for 14 days, then weekly thereafter, to ensure the door closes and secures properly. If there is a malfunction to the door the maintenance will fix it and if unable the location will be monitored directly by designated staff member until repaired. o QAA Committee will review supervision compliance and elopement documentation monthly for 3 months. ADHOC QAPI meeting was held on 5-30-25 by the Administrator and IDT team to review the deficiency and the process of when the POR will be completed. 5. Completion Date: [DATE] The surveyor monitored the POR on [DATE], [DATE], and [DATE] as follows: During observation on [DATE] between 9:00am-9:50am revealed the south side entrance door working properly, it had a delayed egress mechanism, signage that stated Emergency Exit Only Push Until Alarm Sounds. Door Can Be Opened in 15 Seconds. When tested, the door did not immediately open, and after 15 seconds a loud alarm sounded and the door opened to the outside. An exit door in the secure unit revealed a sign that read Do not use door. An alarm code was used by facility staff to enter/exit the secure unit main entrance as well as the back exit door, the back exit door also had a delayed egress mechanism and sounded a loud alarm when opened without the door code. During an observation on [DATE] at 9:47am revealed signage placed on secure unit doors advising staff to ensure door closure and latching. The surveyor tested the secure unit door to ensure its latching. Review of Resident #1's progress note dated [DATE] reflected, One on one monitoring, indefinite timing, 24 hours a day, on this resident continues due to resident being a high elopement risk. Resident sitting up in bed. Resident attempting to wake up roommate and easily redirected back to bed. Resident alert and oriented to self. Review of Resident #1's elopement risk assessment dated [DATE] revealed he was scored at a 13, indicating high risk for wandering. Review of secure unit resident list revealed 2 additional residents whose elopement risk assessments were updated on [DATE] and the other 13 were done prior to [DATE]. Review of Resident #1's care plan updated [DATE] reflected he was a high risk for elopement, was to maintain 1:1 supervision until behavior stabilized and IDT determined it was safe to discontinue. Review of a document titled Systemic Issues No real-time staff assignment to monitor unit during dual emergencies revealed the regional nurse provided education on the following topics, 1:1 supervision maintained, door security protocol re-education completed with staff on secure unit, mock drill to assess emergency-response door security codes, secure unit alarms re-tested and validated, resident's care plan and elopement risk assessment updated, QAPI follow-up scheduled in 30 days for reassessment and was signed by the DON, ADM and the RNC. Review of 15 residents who resided on the secure unit revealed updated elopement risk assessments and care plans with assessment and/or updated dates of [DATE]. Review of a log titled Daily Secure Doors Door Monitoring Log reflected dates of: [DATE]-10am Checked Door Functions [DATE]-10am Checked Door Functions [DATE]-10am Checked Door Functions [DATE]-10am Checked Door Functions [DATE]-10am Checked Door Functions [DATE]-10am Checked Door Functions Review of the facility's QAPI meeting agenda, dated [DATE], titled Unauthorized Exit from Secured Memory Care Unit revealed the MD, MS, MDS, DOR, ADON, DON, RNC, and ADM were all in attendance. Review of the facility's in-service dated [DATE] and [DATE], and conducted by the RNC, ADON, and DON titled Elopement Prevention and Supervision In-Service Packet revealed all staff (CNA B, MA C, and RN A's signatures were visible) were in-serviced on the following: 1. Supervision Protocols for Residents on Secure Units -Never leave residents on a secure unit unsupervised. -Ensure coverage is confirmed before leaving for any reason. -Document any staff hand-offs. -Notify supervisor immediately if understaffed. 2. Elopement Prevention Strategies -Know which residents are at risk (review care plans and risk assessments). -Ensure resident doors and alarms are operational at the beginning of each shift. -Report and document any unsafe conditions immediately. 3. Door Security and Exit Door Monitoring -Check that doors latch and alarms sound properly at the start and end of each shift. -Ensure signage remains visible on all secure exits. -Never prop open doors to the secure unit. -Report door malfunctions to maintenance immediately. 4. Code Response Expectations and Designated Response Team Procedures - Secure unit staff must not respond to codes unless alternate staff has assumed coverage. -Follow the designated code response team assignments. -If you're not assigned to respond, remain at your post. -Call for assistance if help is needed, but do not leave residents unattended. 5. Reporting and Documentation of Coverage Breaks -Notify supervisor or nurse manager prior to leaving your post for break or emergency. -Ensure a staff handoff is documented. -Use the assignment sheet or staff coverage log. -Report and document any observed lapses in supervision. Review of 2 sign out sheets titled Secure Unit Staff Break Sign Out revealed 1 sheet dated [DATE] with 3 staff members clock in times and clock out times handwritten. A sheet dated [DATE] with 5 staff members clock in times and clock out times handwritten. Review of in-servicing post tests in employee files in the HR office reflected staff completed question/answer tests to verify their comprehension of the in-services provided with dates observed of 5/30 and 6/1. Review of a log titled Daily Administrative Oversight Log reflected columns titled Observer (DON/Designee), Supervision in place on secure unit? (Yes/No), Any gaps in coverage (yes/no), Door functional and locked? (Yes/No), Corrective actions taken if issues found. The logs had dates of [DATE]-[DATE] with yes and no answers and the ADON's signatures next to each date. Review of the revised CPR Policy dated [DATE] reflected, It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance with these rights, the facility will implement guidelines regarding cardiopulmonary resuscitation (CPR) in accordance with accepted clinical standards and federal regulations. Emergency Preparedness and Code Response (Added [DATE]) - A revised Code Response Protocol was implemented by the Regional Nurse on [DATE] to ensure resident safety during emergency situations. - Designated emergency responders will be pre-identified for each shift and are responsible for responding to codes and medical emergencies. - Staff assigned to the secure unit are prohibited from leaving the unit unattended under any circumstance, including to respond to a code, unless relieved by appropriate coverage. - This measure ensures continuous supervision of high-risk residents and aligns with regulatory requirements under F689 (Supervision to Prevent Accidents) and F678 (CPR). - Staff have been educated and a log of designated code responders is maintained at each nurse's station for reference. Review of handwritten staff unit assignments dated 6/12 and 6/13 revealed a CR next to 2 nurses per shift indicating they were the code responders for their shift. During an interview on [DATE] at 9:47am with the MS, he stated that he was notified of the elopement on [DATE] and went to the facility at 10am that day to begin door checks on all facility doors to ensure latching/security. He stated that he was to be responsible for secure unit door checks for 2 weeks from [DATE], and then weekly. He stated the protocol was to check the doors behind him and ensure proper latching/locking. During an interview on [DATE] at 5:24pm with CNA C, she stated that she was providing 1:1 supervision to Resident #1 due to his elopement that occurred on [DATE]. She stated that she received in-service training on elopement, door safety and security, supervision instructions specific to Resident #1, and keeping the door code private. During interviews on [DATE] from 5:13pm-5:40pm with 1 MA, 4 CNA's, 1 LVN, and 1 SC from multiple shifts revealed they were all in-serviced between [DATE]-[DATE] on elopement, ensuring door safety/security, visual checks if doors alarm, supervision of residents, keeping door codes private, not leaving residents alone in the secure unit, and who the abuse coordinator is. They stated they were to immediately go to the door that alarmed to see who exited, and ensure they see the person that exited before leaving the door to ensure it was not a resident. During an interview on [DATE] at 10:47am with the MS, he stated that he repaired the secure unit doors so they would close without rubbing on [DATE]. He also stated that he adjusted the timing on the doors so they have 3 seconds, from the time the code is input on the keypad, meaning whoever is trying to gain entry, would have 3 seconds to open the door after inputting the code on the keypad, and if they don't open it within the 3 seconds it would re-engage the magnetic lock. He confirmed he conducts daily audits of all secured exit doors and turns them into the ADM. During an interview on [DATE] at 11:25am with the MDSC she stated that she was given instructions to update/view all care plans and ensure elopement risk assessments were completed. She stated that the secure unit RN completed the elopement risk assessments, but she verified all assessments were done on [DATE]. She also went into each care plan and made sure they all had problem/focus areas for elopement risk. During an interview on [DATE] at 11:37am with RN A he stated he got in-serviced after the elopement on needing to make sure there was always staff on the secure unit. He stated that during his shifts he made sure all doors were working properly and alarms were working, if they were not, he was to notify the DON or the ADM immediately. He stated that Resident #1 was still residing at the facility and on 1:1 monitoring. He stated he had not had any issues with the secured unit door not closing or latching. He stated if a code were called or something else happened, he was to stay on the unit. If there was a code, he was to page the code and start CPR. He confirmed he had to take a posttest to confirm his comprehension of the topics presented.

Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable, and a resident with pressure ulcers received necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for one 1 (Resident #3) of six residents reviewed for quality of care. The facility failed to complete weekly skin assessments, obtain wound care orders and a therapy consult for Resident #3, causing his wound to deteriorate. These failures placed the resident at risk of not receiving adequate care and services, pain, and decreased quality of life. Findings included: Review of Resident #3's face sheet dated 5/29/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: Spastic Quadriplegic Cerebral Palsy (congenital disorder of movement, muscle tone or posture), other mixed anxiety disorders, urine retention, chronic pain, Hypertension (high blood pressure) and cramps and spasm. Review of Resident #3's quarterly MDS dated [DATE] reflected a BIMS score of 13 suggesting resident was cognitively intact. Further review of MDS, section M, Skin Conditions reflected a clinical assessment was competed to determine risk of pressure ulcer/injury and that Resident #3 was at risk of developing pressure ulcers/injuries. The MDS , Section M, reflected Resident #3 did not have any pressure ulcers/injuries at that time. Review of Resident orders from 4/1/2025 until 5/29/2025 reflected no treatment orders for wound care or medications for wound healing. Review of Resident #3's progress notes dated 4/28/2025 at 11:30 pm revealed Resident c/o burning sensation to abrasion on right calf. Redness to abrasion noted on assessment. This nurse cleaned 5x5x0.1cm abrasion to back of right calf with normal saline and applied TAO and a dry dressing. Review of Resident #3's progress notes dated 4/29/2025 at 11:55 pm reflected F/U skin injury. This nurse cleaned 5x5x0.1cm abrasion to back of right calf with normal saline and applied TAO and a dry dressing. On assessment this nurse noted slight redness on border of skin injury. No c/o of increased pain/discomfort. Review of Resident #3's progress notes dated 5/2/2025 to 5/28/2025 reflected no notes about wound on right rear calf and no notes about therapy consult . Review of Resident #3's progress notes dated 5/29/2025 at 1:08 pm by LVN-A reflected Partial thickness wound with etiology of trauma to right posterior superior calf. 80% granulation tissue noted and 20% slough. Dried serous drainage noted to peri wound. Peri wound with no abnormality noted. New wound care order of Partial thickness wound with etiology of trauma to right posterior superior calf. Cleanse with wound cleanser or normal saline. Pat dry. Apply TAO to wound bed. Apply calcium alginate. Cover with silicone border dressing to promote autolytic debridement daily and PRN. RP, [name] notified of area and of new wound treatment. RP also verbalized consent for resident to be seen by [name] Wound care. No concerns or questions voiced at this time. Review of Resident #3's weekly skin assessments revealed he received a skin assessment on 4/10/2025 and not again until 5/29/2025. During an interview on 5/29/2025 at 11:04 am, Resident #3 stated he had had the wound on the back of his calf for a couple weeks. He stated they were cleaning it and putting some stuff on it but hadn't done that in while. He stated the wound was from the back of his calf rubbing on his wheelchair because of the way his lower leg hangs. He stated one of the staff gave him a towel to sit on to cover the edge of the wheelchair seat but it was still rubbing and hurt. He stated a nurse told him to leave it open so it would heal, but it kept rubbing on his chair and had gotten worse. He stated a staff person also told him they would have therapy look at his chair to see if they could help. He said he supposedly had a custom wheelchair on order but did not know the status on that. Resident #3 stated the wound was burning but the pain medications he was already on helped some. During an interview on 5/29/2025 at 11:15 am, LVN A said she had just started as wound care nurse and was not sure how long the facility was without a wound care nurse before she started. She stated she would be reaching out to the wound care doctor for orders and follow up for Resident #3. LVN A stated she checked the EMR and the last weekly skin assessment was competed on 4/10/2025 for Resident #3. During an observation conducted with LVN-A present, on 5/29/2025 at 11:04 am, Resident #3 was noted to have a wound approximately (investigator did not have a ruler to measure but wound care nurse took measurements afterwards) 1cm wide by 2cm long on his right rear calf. The wound area was oval, red around the edges, open and not covered. The top layer of the skin had been rubbed away exposing raw skin. Observation also revealed that Resident #3 was sitting on a towel that was draped over the front edge of his wheelchair seat. During an interview on 5/29/2025 at 9:43 am, WCMD stated he had taken over wound care of this facility about 5 weeks ago. He stated when he first started coming the facility had 13-14 wounds and now they were down to 5-6. He stated he has observed residents being offloaded using wedges or other cushions and heels being floated and wounds were improving and healing. During an interview on 5/30/2025 at 5:12 pm, DON stated skin assessments are supposed to be completed weekly. She stated they had a problem back in April where the skin assessments were not being generated as expected in the electronic medical records, but the nurses still knew to complete the skin assessments and chart in the progress notes. DON stated the prior wound care nurse was responsible for making sure the skin assessments were being done, but she had been terminated. She stated the facility had just hired a new wound care nurse, but the charge nurses were responsible for completing weekly skin assessments in the interim, until the wound care nurse had been replaced. Review of undated facility policy skin Assessment reflected: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. 7. Documentation of skin assessment: a. Include date and time of the assessment, your name, and position title. b. Document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.). c. Document type of wound. d. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). e. Document if resident refused assessment and why. f. Document other information as indicated or appropriate.

Based on interviews and record review, the facility failed to develop and implement a CCP for 1 or 3 residents (Resident #1) reviewed for CCP. 1. The facility failed to implement care plan interventions for Resident #1, after Resident #1's physically abused Resident #2 on 8/18/2024, to protect other facility residents. This failure could have placed the facility residents at risk of physical harm and mental anguish. Findings included: Resident #1 Record review or Resident #1's AR, dated 10/29/2024, reflected a [AGE] year-old male who admitted to the facility on [DATE]. He was diagnosed with Dementia (which was a disease that affected memory, thought, and interfered with daily life.) Record review of Resident #1's Discharge MDS (unplanned), dated 10/10/2024, reflected the resident had a BIMS Score of 1. A BIMS Score of 1 indicated the resident had severe cognitive impairment. Record review of Resident #1's CCP reflected a focus area, initiated on 8/22/2024/ revised on 8/22/2024, for potential to demonstrate physical behaviors related to dementia and poor impulse control. The CCP indicated on: 8/18/2024-he hit his roommate for messing with him while he was sleeping; 8/22/2024-resident to resident incident noted, resident held the arms of roommate's wheelchair slamming his wheelchair into his roommate's legs, yelling, cursing towards roommate. The Goal, initiated on 8/22/2024, revised on 8/22/2024, revealed a goal of fewer than 3 episodes per week of physical behavior. The interventions for nursing staff, initiated and revised both on 8/22/2024, revealed nursing staff was supposed to analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess and address for contributing sensory deficits. Assess and anticipate Resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain. Cognitive assessment. Communication: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Evaluate for side effects of medications. Give resident as many choices as possible about care and activities. Modify environment; adjust room temperature to comfortable level, reduce noise, dim lights, place familiar objects in room, keep door closed. Document observed behavior and attempted interventions in behavior log. Monitor/document/report to MD of danger to self and others. Psychiatric/Psychogeriatric consult as indicated. Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff walk calmly away, and approach later. Record review of Resident #1's PN, dated 8/18/2024 at 8:12 AM, reflected: Was reported that Resident #1 had hit his roommate, Resident #2, for messing with him while he was sleeping. Resident #1 says his roommate, Resident #2, was grabbing him while he was sleeping. Resident #1 said he warned Resident #2 the first time to get away. Resident #1 said Resident #2 grabbed him, so Resident #1 hit Resident #2 to get him away. Resident #1 did not remember where he hit Resident #2. Administrator and NP was informed. No new orders received. Resident #1 has been calm so far this morning and has not made complaints towards his roommate, Resident #2. Record review of self-reported incidents, did not reflect a facility self-report for Resident #1 and Resident #2's altercation on 8/18/2024. Record review of historical census information from 8/17/2024 to 8/22/2024, dated 10/29/2024, indicated Resident #1 changed rooms on 8/20/2024 to reside with Resident #3. Record review of Resident #1's PN, dated 8/20/2024 at 11:36 AM revealed the presence of a UTI (which was the presence of bacteria in the urethra and bladder.) Resident was alert and mildly confused. Record review of Resident #1's PN, dated 8/22/2024 at 6:15 AM, reflected: This nurse was sitting at the desk and heard yelling coming from Resident #1 and Resident #3's room. Upon entering room, Resident #1 was found with his Resident #3's wheelchair and Resident #3 sitting on the side of Resident #1's bed. Resident #1 was holding the arms of the wheelchair slamming it into Resident #3's legs yelling I'm going to kill you shut your mouth Resident #3 was yelling Mother F***** Record review of an intake, dated 8/22/2024, reflected a resident-on-resident abuse between Resident #1 and Resident #3 on 8/22/2024. Record review of Resident #1's PN, dated 8/22/2024 at 1:39 PM reflected Resident #1 moved to his private room in the memory Care Unit. Record review of historical census information from 8/17/2024 to 8/22/2024, dated 10/29/2024, indicated Resident #1 changed rooms on 8/22/2024 with no assigned roommate. Record review of Resident #1's PN, dated 8/22/2024 at 7:31 PM reflected an order for 50 Milligrams of Seroquel (mood regulator) at bedtime. Record review of Resident to Resident incident in Resident #1's PN, dated 8/22/2024 at 9:10 AM, reflected Resident #1 did not have any injuries. Breathing-normal; facial expression-sad; frightened; frown; body language-tensed; console needed-distracted/reassured by voice or touch. Resident alert. Predisposing psychological factors-confusion; dementia; impaired memory. Predisposing situational factor-recent room change. Record review of Resident #1's PN, dated 8/23/2024 at 9:46 AM, reflected: IDT Event Review Name of IDT participating in review: Administrator, DON, ADON, MDS (C) *Event Being Reviewed: Resident #1 to Resident #3 incident on 8/22/2024. *Root Cause Analysis for event: Resident #3 was cursing at Resident #1 because he was getting into the Resident #3's snacks and ate all of them. Per responsible party, it was noted that Resident #1 got aggressive when consuming sugary items. Resident #1, confused and aggressive, pushed a wheelchair into his roommate's legs to get him to stop cursing at him. *Interventions initiated and residents' response / compliance with Intervention: Resident #1 and Resident #3 separated and assessed for injury. *New Interventions suggested following current IDT review: Resident #1 room changed. Record review of Resident #1's post event head to toe skin check PN, dated 8/23/2024 at 12:32 PM, reflected no new skin issues, no apparent injuries. Recorded review of Resident #1's PN, dated 10/10/2024 at 2:54 PM, reflected the resident was DC to hospital. (Return not anticipated.) Record review of the facility's incidents report from 8/22/2024 to 10/30/2024 did not reflect any resident-on-resident altercations involving Resident #1, Resident #2, Resident #3. Interview on 10/29/2024 at 3:00 PM with NP H revealed no recall of any information having pertained to Resident #1 and Resident #2's altercation, which occurred on 8/18/2024. When asked how she was mentioned in a PN of Resident #1, she stated, I do not work on the weekends and did not take any calls, 8/18/2024 was a Sunday. Interview on 10/29/2024 at 4:00 PM with the ADM revealed the resident-on-resident incident, which occurred on 8/18/2024, between Resident #1 and Resident #2 was not reported to the state office because there were no injuries. The incident on 8/18/2024 did not make the ADM, or the staff, feel that Resident #1 was the aggressor towards Resident #2, nor did they feel that Resident #1 was a threat to other residents. On 8/22/2024, Resident #1 engaged in a resident-on-resident altercation with Resident #3. The incident with Resident #1 and Resident #3 was reported to the state office because the situation was discovered quickly by staff, was reported as possible physical contact, but resulted with no injuries. The ADM did not feel that Resident #1 was the aggressor in the incident with Resident #3. After the incident with Resident #1 and Resident #3, Resident #1 was moved to a private room on the Memory Care Unit. The ADM did not think a lack of any action, such as updating Resident #1's CCP after the incident on 8/18/2024, would have stopped the incident on 8/22/2024. Resident #2 Record review or Resident #2's AR, dated 10/29/2024, reflected an [AGE] year-old male who admitted to the facility on [DATE]. He was diagnosed with Legal Blindness and Schizoaffective Disorder (which was a mental illness with both psychotic, and mood, fluctuations.) Record review of Resident #2's Quarterly MDS, dated [DATE], reflected the resident had a BIMS Score of 4. A BIMS Score of 4 indicated the resident had severe cognitive impairment. Record review of Resident #2's CCP reflected a focus area, initiated 7/27/2024 / revised 9/1/2024, for behavior problems evidenced by Alzheimer's Disease: up late at night, entering other people's rooms, grabbing at roommate, and taking things down from the walls. The goal, initiated on 7/27/2024, was for Resident #2 to have fewer episodes of restlessness. The intervention, revised on 9/1/2024, for nursing staff was to administer medications as ordered; anticipate and meet needs; create opportunity for positive interaction; explain procedures; monitor episodes and attempt to determine underlying cause; and provide a program of activities. Record review of Resident #2's PN, dated 8/18/2024 at 8:36 AM, reflected: Last night, reported this morning, Resident #2 was messing with his roommate, Resident #1, and grabbing on him while he was trying to sleep. Resident #1 reported Resident #2 would not leave him alone after he told him to go away. Resident #1 resorted to hitting Resident #2 on his body. Record review of Resident #2's PN, dated 8/18/2024 at 9:16 AM, reflected a skin assessment, with no new injuries from last night. On fading bruise to left upper arm. Skin discoloration to left elbow/forearm. Record review of Resident #2's PN, dated 8/18/2024 at 10:57 AM, reflected hospice and RP #12 were at the facility and order received, from hospice, for 50 Milligrams of Seroquel (mood regulator) at bedtime. RP #12 saw Resident #2's bruise on left upper arm. Requested to speak to management. Record review of Resident #2's PN, dated 8/20/2024 at 10:56 AM reflected Resident #2 was more confused and agitated than normal. Resident stated, [my roommate beat me up last night and gave me a concussion.] Record review of Resident #2's PN, dated 8/20/2024 at 2:19 PM reflected Resident #2 received an order, from hospice, for 50 milligrams of Trazadone (a treatment for insomnia) at bedtime to ease resident's restlessness. Observation and interview on 10/29/2024 at 10:10 AM with Resident #2 revealed him in his wheelchair in the memory care unit having just came from an activity. He was unable to recall any injuries or harm from another resident. No distress noted. He felt safe at the facility. Interview and record review on 10/29/2024 at 6:00 PM with Resident #2's RP, RP #11, revealed he was made aware, by staff, about the incident with Resident #1 and Resident #2 on 8/18/2024. He did not know many details, but he did learn of a bruise on Resident #2's left upper arm from another one of Resident #2's RP, RP #12. RP #11 stated he went to the facility on [DATE] to look at Resident #2's arm and take a photo. Record review of a photo, provided by a RP #11 on 10/29/2024 at 6:17 PM, reflected a baseball sized bruise on Resident #2's left upper arm. Interview on 10/29/2024 at 6:34 PM with RP #12 revealed RP #12 went to the facility on [DATE] between 8-9 AM. She stated she was told, from staff, about an incident between Resident #1 and Resident #2 when she arrived. She was not informed it was of a physical nature. While there, she noticed a bruise on Resident #2's left upper arm. The bruise was about a quarter in diameter and was purple. She reported Resident #2 told her, My roommate hit me because I was in his bed. She stated Resident #2 pointed to his left arm and to his lower abdomen area. RP #12 had visited Resident #2 the day before, 8/17/2024, and did not notice a bruise on Resident #2's arm because of long sleeves, but Resident #2 did not mention his arm being hurt. Resident #3 Record review or Resident #3's AR, dated 10/29/2024, reflected a [AGE] year-old male who admitted to the facility on [DATE]. He was diagnosed with Hemiplegia (which was one-sided paralysis,) Hemiparesis (which was one-sided muscle weakness,) and Speech and Language deficits. Record review of Resident #3's Quarterly MDS, dated [DATE], reflected the resident did not receive a BIMS Assessment, due to rarely/never understood. By staff assessment, cognitive skills for daily decision making were consistent and reasonable. Record review of Resident #3's CCP reflected a focus area, initiated on 3/29/2021, evidenced by physical aggression towards other residents. The goal, revised on 11/23/2022, was for resident to demonstrate effective coping skills and not harm self or others. The intervention, initiated on 3/29/2021, was for nursing staff to administer medications as ordered; analyze times of day and location; assess and address sensory deficits; anticipate needs; communication; provide choices; observe and document; and intervene before agitation escalates. A focus area, initiated on 4/19/2024, for potential to demonstrate physical behaviors R/T anger, history of harm to others, and poor impulse control: pushed his rollator walker into his roommate's leg on 6/28/2024. The goal, revised on 6/23/2024, was for resident to verbalize understanding of need to control physical aggressive behavior. The intervention, initiated 6/28/2024, was for nursing staff to analyze times of day and location; assess and address sensory deficits; anticipate needs; observe and document; evaluate side effects of medication; and psychiatric consult, as necessary. A focus, initiated on 8/22/2022, for potential behavior problems R/T heart conditions and anxiety: Resident to Resident incident-resident held arms of roommate's wheelchair slamming his wheelchair into his roommate's legs-yelling and cursing. The goal, initiated on 8/22/2024, was that resident would have fewer episodes of physical behavior. The intervention, initiated on 8/22/2024, for nursing staff was to administer medications as ordered; develop appropriate methods to cope; create opportunity for positive interaction; intervene as necessary to protect others; monitor episodes and attempt to determine underlying cause; and provide a program of activities. Record review of Resident to Resident incident in Resident #3's PN, dated 8/22/2024 at 9:10 AM, reflected Resident #3 did not have any injuries. Breathing-normal; facial expression-smiling, or inexpressive; body language-relaxed; console needed-no need to console. Oriented to person, place, situation. Predisposing situational factor-dislikes roommate/exhibiting behaviors. Record review of Resident #3's PN, dated 8/23/2024 at 9:58 AM, reflected: IDT Event Review Name of IDT participating in review: Administrator, DON, DOR, ADON, MDS *Event Being Reviewed: Resident to resident 8/22/2024 *Root Cause Analysis for event: Resident #3 started cussing at his roommate, Resident #1, because was taking and consuming all his snacks. The roommate, Resident #1, became aggressive and started pushing Resident #3's wheelchair into his legs while yelling at him. *Interventions initiated and residents' response/compliance with Intervention: Residents were separated and assessed. *New Interventions suggested following current IDT review: Resident #1 moved to alternate room. Record review of Resident #3's post event head to toe skin check PN, dated 8/23/2024 at 12:25 PM, reflected no new skin issues, no apparent injuries, Range of motion within normal limits, denied pain or injury to head. Observations on 10/29/2024 at 10:39 AM with Resident #3 revealed him receiving assistance with personal hygiene. No distress noted. Interview on 10/29/2024 at 10:45 PM with Resident #3 revealed he could not remember and details about the resident-on-resident altercation on 8/22/2024. He did verbalize with tones and facial expressions that he was not hurt; he confirmed with tones and facial expressions that he was not harmed; they were just yelling. He confirmed with tones and facial expressions that he felt safe at the facility. Interview on 10/30/2024 at 10:26 AM with Resident #3's RP, RP #13, revealed she was informed about the resident-on-resident altercation on 8/22/2024. RP #13 did not have concerns for Resident #3's safety. She felt Resident #3 was safe at the facility. Observations on 10/30/2024 at 2:21 PM of a resident group activity, in the facility dining room, revealed a peaceful atmosphere with staff and resident participation. Adequate staff were present. No disturbances: residents were calm. Interview on 10/30/2024 at 3:01 PM with RN D revealed he responded to Resident #1 and Resident #2's resident to resident altercation on the morning on 8/18/2024. He stated he separated the two residents, after learning of the incident, and then told the ADM. RN D thought the incident was abuse and should have been reported in the 2 hours requirement. RN D stated, abuse was supposed to be reported within two hours to start a timely investigation. Timely responses help people remember details and the facts of the incidents stay fresh. If reporting was not timely, residents risked the abuse continuing or lead to other medical or psychosocial problems. He had attended training on ANE, ANE reporting, and Resident-on-Resident Altercations. Interview on 10/30/2024 at 3:49 PM with the LVN C revealed she had not attended an IDT team meeting to discuss the Resident #1 and Resident #2 incident that occurred on 8/18/2024. She stated she learned about the Resident #1 and Resident #2 incident the next day, which was Monday 8/19/2024. The incident on 8/18/2024 was a form of abuse and should have been reported to the state agency. Resident #1's CCP should have been updated as soon as possible to address negative outcomes and to keep residents safe. If the incident on 8/18/2024 had been addressed in Resident #1's CCP, the incident on 8/22/2024 could have been avoided. It could have been avoided by having Resident #1 in a private room or having chosen a better roommate. Interview on 10/30/2024 at 4:10 PM with the ADM revealed the decision not to report the incident on 8/18/2024 with Resident #1 and Resident #2 was the ADM's choice, not of the other leadership staff. He reiterated he did not feel any intervention for Resident #1, stemming from the incident on 8/18/2024, would have had any positive effect on, or stop, the incident with Resident #1 and Resident #3 on 8/22/2024; therefore, there was no CCP update for Resident #1, post the resident-on-resident incident on 8/18/2024. CCP updates were made after Resident #1 and Resident #3's resident altercation on 8/22/2024. There was no direction in the facility's Comprehensive Care Plan to address timeliness of updates. He did not feel there was any failure on his staff to have not updated Resident #1's CCP with a behavior intervention after 8/18/2024. Record review of the facility's CCP Policy, dated December 2016, reflected the CCP will contain measurable objectives and timeframes; describe these services that are being furnished to attain or maintain their residence highest practical physical, mental, and psychosocial well-being; and incorporate risk factors associated with identified problems, such as identify the professional services that are responsible for each element of care. The IDT must review and update the CCP when the desired outcome has not been met.

Based on observations, interviews, and record review, the facility failed to ensure its residents were free from abuse for 2 of 10 Residents (Resident #2 and Resident #3) reviewed for resident-on-resident abuse. 1. The facility failed to prevent Resident #1 from punching Resident #2, on his body, on 8/18/2024. 2. The facility failed to prevent Resident #1 from physically abusing Resident #3, with a wheelchair, on 8/22/2024. This failure could have placed the facility residents at risk of physical harm and mental anguish. Findings included: Resident #1 Record review or Resident #1's AR, dated 10/29/2024, reflected a [AGE] year-old male who admitted to the facility on [DATE]. He was diagnosed with Dementia (which was a disease that affected memory, thought, and interfered with daily life). Record review of Resident #1's Discharge MDS (unplanned), dated 10/10/2024, reflected the resident had a BIMS Score of 1. A BIMS Score of 1 indicated the resident had severe cognitive impairment. Record review of Resident #1's CCP reflected a focus area, initiated on 8/22/2024, revised on 8/22/2024, for potential to demonstrate physical behaviors related to dementia and poor impulse control. The CCP indicated on: 8/18/2024-he hit his roommate for messing with him while he was sleeping; 8/22/2024-resident to resident incident noted, resident held the arms of roommate's wheelchair slamming his wheelchair into his roommate's legs, yelling, cursing towards roommate. The Goal, initiated on 8/22/2024, revised on 8/22/2024, revealed a goal of fewer than 3 episodes per week of physical behavior. The interventions for nursing staff, initiated and revised both on 8/22/2024, revealed nursing staff was supposed to analyze key times, places, circumstances, triggers, and what de-escalated behavior and document. Assess and address for contributing sensory deficits. Assess and anticipate Resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain. Cognitive assessment. Communication: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Evaluate for side effects of medications. Give resident as many choices as possible about care and activities. Modify environment; adjust room temperature to comfortable level, reduce noise, dim lights, place familiar objects in room, keep door closed. Document observed behavior and attempted interventions in behavior log. Monitor/document/report to MD of danger to self and others. Psychiatric/Psychogeriatric consult as indicated. Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff walk calmly away, and approach later. Record review of Resident #1's PN, dated 8/18/2024 at 8:12 AM, reflected: Was reported that Resident #1 had hit his roommate, Resident #2, for messing with him while he was sleeping. Resident #1 said his roommate, Resident #2, was grabbing him while he was sleeping. Resident #1 said he warned Resident #2 the first time to get away. Resident #1 said Resident #2 grabbed him, so Resident #1 hit Resident #2 to get him away. Resident #1 did not remember where he hit Resident #2. The Administrator and the NP was informed. No new orders received. Resident #1 has been calm so far this morning and has not made complaints towards his roommate, Resident #2. Record review of self-reported incidents did not reflect a facility self-report for Resident #1 and Resident #2's altercation on 8/18/2024. Record review of historical census information from 8/17/2024 to 8/22/2024, dated 10/29/2024, indicated Resident #1 changed rooms on 8/20/2024 to reside with Resident #3. Record review of Resident #1's PN, dated 8/20/2024 at 11:36 AM revealed the presence of a UTI (which was the presence of bacteria in the urethra and bladder). Resident was alert and mildly confused. Record review of Resident #1's PN, dated 8/22/2024 at 6:15 AM, reflected: This nurse was sitting at the desk and heard yelling coming from Resident #1 and Resident #3's room. Upon entering room, Resident #1 was found with Resident #3's wheelchair and Resident #3 sitting on the side of Resident #1's bed. Resident #1 was holding the arms of the wheelchair slamming it into Resident #3's legs yelling, I'm going to kill you shut your mouth. Resident #3 was yelling Mother F***** . Record review of an intake, dated 8/22/2024, reflected a resident-on-resident abuse between Resident #1 and Resident #3 on 8/22/2024. Record review of Resident #1's PN, dated 8/22/2024 at 1:39 PM reflected Resident #1 moved to his private room in the Memory Care Unit. Record review of Resident #1's PN, dated 8/22/2024 at 7:31 PM reflected an order for 50 Milligrams of Seroquel (mood regulator) at bedtime. Record review of historical census information from 8/17/2024 to 8/22/2024, dated 10/29/2024, indicated Resident #1 changed rooms on 8/22/2024 with no assigned roommate. Record review of Resident-to-Resident incident in Resident #1's PN, dated 8/22/2024 at 9:10 AM, reflected Resident #1 did not have any injuries. Breathing-normal; facial expression-sad; frightened; frown; body language-tensed; console needed-distracted/reassured by voice or touch. Resident alert. Predisposing psychological factors-confusion; dementia; impaired memory. Predisposing situational factor-recent room change. Record review of Resident #1's PN, dated 8/23/2024 at 9:46 AM, reflected: IDT Event Review Name of IDT participating in review: Administrator, DON, ADON, MDS (C) *Event Being Reviewed: Resident #1 to Resident #3 incident on 8/22/2024. *Root Cause Analysis for event: Resident #3 was cursing at Resident #1 because he was getting into the Resident #3's snacks and ate all of them. Per responsible party, it was noted that Resident #1 got aggressive when consuming sugary items. Resident #1, confused and aggressive, pushed a wheelchair into his roommate's legs to get him to stop cursing at him. *Interventions initiated and residents' response / compliance with Intervention: Resident #1 and Resident #3 separated and assessed for injury. *New Interventions suggested following current IDT review: Resident #1 room changed. Record review of Resident #1's post event head to toe skin check PN, dated 8/23/2024 at 12:32 PM, reflected no new skin issues, no apparent injuries. Recorded review of Resident #1's PN, dated 10/10/2024 at 2:54 PM, reflected the resident was DC to hospital. (Return not anticipated.) Record review of the facility's incident reports from 8/22/2024 to 10/30/2024 did not reflect any resident-on-resident altercations involving Resident #1, Resident #2, and Resident #3. Interview on 10/29/2024 at 2:39 PM with LVN A revealed she did not have an answer to why the Resident upon Resident interaction on 8/18/2024 between Resident #1 and Resident #2 was not reported to the state office. Interview on 10/29/2024 at 2:43 PM with LVN B revealed she did not have an answer to why the Resident upon Resident interaction on 8/18/2024 between Resident #1 and Resident #2 was not reported to the state office. Interview on 10/29/2024 at 2:45 PM with LVN C revealed she did not have an answer to why the Resident upon Resident interaction on 8/18/2024 between Resident #1 and Resident #2 was not reported to the state office. Interview on 10/29/2024 at 3:00 PM with NP H revealed no recall of any information having pertained to Resident #1 and Resident #2's altercation, which occurred on 8/18/2024. When asked why she was mentioned in a PN of Resident #1, she stated, I do not work on the weekends and did not take any calls, 8/18/2024 was a Sunday . Interview on 10/29/2024 at 4:00 PM with the ADM revealed the resident-on-resident incident, which occurred on 8/18/2024, between Resident #1 and Resident #2 was not reported to the state office because there were no injuries. The incident on 8/18/2024 did not make the ADM, or the staff, feel that Resident #1 was the aggressor towards Resident #2, nor did they feel that Resident #1 was a threat to other residents. On 8/22/2024, Resident #1 engaged in a resident-on-resident altercation with Resident #3. The incident with Resident #1 and Resident #3 was reported to the state office because the situation was discovered by staff, was reported to him as possible physical contact, and resulted with no injuries. The ADM did not feel that Resident #1 was the aggressor in the incident with Resident #3. After the incident with Resident #1 and Resident #3, Resident #1 was moved to a private room on the Memory Care Unit. The ADM did not think a lack of any action, such as updating Resident #1's CCP after the incident on 8/18/2024, would have stopped the incident on 8/22/2024 . Resident #2 Record review or Resident #2's AR, dated 10/29/2024, reflected an [AGE] year-old male who admitted to the facility on [DATE]. He was diagnosed with legal blindness and schizoaffective disorder (which was a mental illness with both psychotic and mood fluctuations.) Record review of Resident #2's Quarterly MDS, dated [DATE], reflected the resident had a BIMS Score of 4. A BIMS Score of 4 indicated the resident had severe cognitive impairment. Record review of Resident #2's CCP reflected a focus area, initiated 7/27/2024, revised 9/1/2024, for behavior problems evidenced by Alzheimer's Disease: up late at night, entering other people's rooms, grabbing at roommate, and taking things down from the walls. The goal, initiated on 7/27/2024, was for Resident #2 to have fewer episodes of restlessness. The intervention, revised on 9/1/2024, for nursing staff was to administer medications as ordered; anticipate and meet needs; create opportunity for positive interaction; explain procedures; monitor episodes and attempt to determine underlying cause; and provide a program of activities. Record review of Resident #2's PN, dated 8/18/2024 at 8:36 AM, reflected: Last night, reported this morning, Resident #2 was messing with his roommate, Resident #1, and grabbing on him while he was trying to sleep. Resident #1 reported Resident #2 would not leave him alone after he told him to go away. Resident #1 resorted to hitting Resident #2 on his body. Record review of Resident #2's PN, dated 8/18/2024 at 9:16 AM, reflected a skin assessment, with no new injuries from last night. Fading bruise to left upper arm. Skin discoloration to left elbow/forearm. Record review of Resident #2's PN, dated 8/18/2024 at 10:57 AM, reflected hospice and RP #12 were at the facility and order received, from hospice, for 50 Milligrams of Seroquel (mood regulator) at bedtime. RP #12 saw Resident #2's bruise on left upper arm. Requested to speak to management. Record review of Resident #2's PN, dated 8/20/2024 at 10:56 AM reflected Resident #2 was more confused and agitated than normal. Resident stated, [my roommate beat me up last night and gave me a concussion.] Record review of Resident #2's PN, dated 8/20/2024 at 2:19 PM reflected Resident #2 received an order, from hospice, for 50 milligrams of Trazadone (a treatment for insomnia) at bedtime to ease resident's restlessness. Observation and interview on 10/29/2024 at 10:10 AM with Resident #2 revealed him in his wheelchair in the memory care unit having just came from an activity. He was unable to recall any injuries or harm from another resident. No distress noted. He felt safe at the facility. Interview and record review on 10/29/2024 at 6:00 PM with Resident #2's RP, RP #11, revealed he was made aware, by staff, about the incident with Resident #1 and Resident #2 on 8/18/2024. He did not know many details, but he did learn of a bruise on Resident #2's left upper arm from another one of Resident #2's RP, RP #12. RP #11 stated he went to the facility on [DATE] to look at Resident #2's arm and take a photo. Record review of a photo, provided by a RP #11 on 10/29/2024 at 6:17 PM, reflected a baseball sized bruise on Resident #2's left upper arm. Interview on 10/29/2024 at 6:34 PM with RP #12 revealed RP #12 went to the facility on [DATE] between 8-9 AM. She stated she was told, from staff, about an incident between Resident #1 and Resident #2 when she arrived. She was not informed it was of a physical nature. While there, she noticed a bruise on Resident #2's left upper arm. The bruise was about a quarter in diameter and was purple. She stated Resident #2 told her, My roommate hit me because I was in his bed. She stated Resident #2 pointed to his left upper arm and to his lower abdomen area. RP #12 had visited Resident #2 the day before, 8/17/2024, and did not notice a bruise on Resident #2's arm because of long sleeves, but Resident #2 did not mention, to RP #12, his arm being hurt. Resident #3 Record review or Resident #3's AR, dated 10/29/2024, reflected a [AGE] year-old male who admitted to the facility on [DATE]. He was diagnosed with hemiplegia (which was one-sided paralysis), hemiparesis (which was one-sided muscle weakness), and speech and language deficits. Record review of Resident #3's Quarterly MDS, dated [DATE], reflected the resident did not receive a BIMS Assessment, due to rarely/never understood. By staff assessment, cognitive skills for daily decision making were consistent and reasonable. Record review of Resident #3's CCP reflected a focus area, initiated on 3/29/2021, evidenced by physical aggression towards other residents. The goal, revised on 11/23/2022, was for resident to demonstrate effective coping skills and not harm self or others. The intervention, initiated on 3/29/2021, was for nursing staff to administer medications as ordered; analyze times of day and location; assess and address sensory deficits; anticipate needs; communication; provide choices; observe and document; and intervene before agitation escalates. A focus area, initiated on 4/19/2024, for potential to demonstrate physical behaviors R/T anger, history of harm to others, and poor impulse control: pushed his rollator walker into his roommate's leg on 6/28/2024. The goal, revised on 6/23/2024, was for resident to verbalize understanding of need to control physical aggressive behavior. The intervention, initiated 6/28/2024, was for nursing staff to analyze times of day and location; assess and address sensory deficits; anticipate needs; observe and document; evaluate side effects of medication; and psychiatric consult, as necessary. A focus area for potential behavior problems, initiated on 8/22/2022, R/T heart conditions and anxiety: Resident to Resident incident-resident held arms of roommate's wheelchair slamming his wheelchair into his roommate's legs-yelling and cursing. The goal, initiated on 8/22/2024, was that resident would have fewer episodes of physical behavior. The intervention, initiated on 8/22/2024, for nursing staff was to administer medications as ordered; develop appropriate methods to cope; create opportunity for positive interaction; intervene as necessary to protect others; monitor episodes and attempt to determine underlying cause; and provide a program of activities. Record review of Resident-to-Resident incident in Resident #3's PN, dated 8/22/2024 at 9:10 AM, reflected Resident #3 did not have any injuries. Breathing-normal; facial expression-smiling, or inexpressive; body language-relaxed; console needed-no need to console. Oriented to person, place, situation. Predisposing situational factor-dislikes roommate/exhibiting behaviors. Record review of Resident #3's PN, dated 8/23/2024 at 9:58 AM, reflected: IDT Event Review Name of IDT participating in review: Administrator, DON, DOR, ADON, MDS (C) *Event Being Reviewed: Resident to resident 8/22/2024 *Root Cause Analysis for event: Resident #3 started cussing at his roommate, Resident #1, because was taking and consuming all his snacks. The roommate, Resident #1, became aggressive and started pushing Resident #3's wheelchair into his legs while yelling at him. *Interventions initiated and residents' response/compliance with Intervention: Residents were separated and assessed. *New Interventions suggested following current IDT review: Resident #1 moved to alternate room. Record review of Resident #3's post event head to toe skin check PN, dated 8/23/2024 at 12:25 PM, reflected no new skin issues, no apparent injuries, range of motion within normal limits, denied pain or injury to head. Observations on 10/29/2024 at 10:39 AM with Resident #3 revealed him receiving assistance with personal hygiene. No distress noted. Interview on 10/29/2024 at 10:45 AM with Resident #3 revealed he could not remember any details about the resident-on-resident altercation on 8/22/2024. He did verbalize with tones and facial expressions that he was not hurt; he confirmed with tones and facial expressions that he was not harmed; they were just yelling. He confirmed with tones and facial expressions that he felt safe at the facility. Interview on 10/30/2024 at 10:26 AM with Resident #3's RP, RP #13, revealed she was informed about the resident-on-resident altercation on 8/22/2024. RP #13 did not have concerns for Resident #3's safety. She felt Resident #3 was safe at the facility. Interview on 10/30/2024 at 3:01 PM with RN D revealed he responded to Resident #1 and Resident #2's resident to resident altercation on the morning on 8/18/2024. He stated he separated the two residents, after learning of the incident, and then told the ADM. RN D thought the incident was abuse and should have been reported in the 2 hours requirement. RN D stated, abuse was supposed to be reported within two hours to start a timely investigation. Timely responses help people remember details and the facts of the incidents stay fresh. If reporting was not timely, residents risked the abuse continuing or lead to other medical or psychosocial problems. He had attended training on ANE, ANE reporting, and Resident-on-Resident Altercations. Interview on 10/30/2024 at 3:21 PM with LVN E revealed she was a charge nurse at the facility. The immediate response for resident-on-resident abuse was to separate the residents, calm the residents, make sure they were safe, and perform an assessment for injuries. Staff were trained to report allegations of abuse, or actual incidents of, to the ADM as soon as possible. The ADM had a 2-hour window to report incidents of abuse. LVN E had attended training on ANE, ANE reporting, Resident-on-Resident Altercations . Interview on 10/30/2024 at 3:32 PM with CNA F revealed she had just started work at the facility. CNA F stated, the first thing to do when witnessing a resident-on-resident altercation is to separate the resident and make sure they were safe. The altercation was supposed to be reported immediately to the charge nurse and to the ADM. She just attended an in-service training where she learned incidents of abuse needed to be reported to the state within 2 hours. She had taken training on dementia care and resident upon resident abuse. She had not witnessed any resident-on-resident altercations while at the facility . Interview on 10/30/2024 at 3:38 PM with CNA G revealed he had been working at the facility for 3 years. He stated he had participated in in-service trainings for Abuse, Neglect, and Resident-on-Resident Altercations. Allegations of ANE, or resident harm, were supposed to be reported to the charge nurse and the ADM immediately. Interview on 10/30/2024 at 3:49 PM with the LVN C revealed she had not attended an IDT team meeting to discuss the Resident #1 and Resident #2 incident that occurred on 8/18/2024. She stated she learned about the Resident #1 and Resident #2's incident the next day, which was Monday 8/19/2024. The incident on 8/18/2024 was a form of abuse and should have been reported to the state agency. Resident #1's CCP should have been updated as soon as possible to address negative outcomes and to keep other residents safe. If the incident on 8/18/2024 had been addressed by the IDT members and addressed Resident #1's CCP, the incident on 8/22/2024 might have been avoided. It could have been avoided by having Resident #1 already in a private room or having chosen a better roommate. Interview on 10/30/2024 at 4:10 PM with the ADM revealed the decision not to report the incident on 8/18/2024 with Resident #1 and Resident #2 was the ADM's choice, not of the other leadership staff. He reiterated he did not feel any intervention for Resident #1, stemming from the incident on 8/18/2024, would have had any positive effect on, or stop, the incident with Resident #1 and Resident #3 on 8/22/2024; therefore, there was no CCP update for Resident #1, post the resident-on-resident incident on 8/18/2024. CCP updates were made after Resident #1 and Resident #3's resident altercation on 8/22/2024; Resident #1 moved rooms too. There was no direction in the facility's Comprehensive Care Plan to address timeliness of updates. He did not feel there was any failure on his staff's duties to update Resident #1's CCP after the incident on 8/18/2024. He had seen to his staff's completion of in-service trainings on 8/22/2024 on ANE, Resident-on-Resident Altercations, ANE Reporting, Protecting Residents during an Abuse Investigation, and Resident Rights. Record review of 10 resident safe surveys, dated 8/23/2024, reflected positive answers, yes, for 1. Are you happy with nursing staff. 2. Are you happy with the therapy department. 3. Do you feel safe at the facility. 4. If you did not feel safe would you tell the Administrator or the Director of Nursing. Record review of the facility's in-service trainings, from 8/23/2024 to 8/29/2024, indicated 80 employees attended training for Coordinating/Implementing Abuse, Neglect, and Exploitation Policies and Procedures, Resident Rights, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, Identifying Types of Abuse, Abuse and Neglect- Clinical Protocol, Recognizing Signs and Symptoms of Abuse, QAPI Review of Abuse, Neglect, Exploitation or Misappropriation, Protection of Residents During Abuse Investigations, Compliance and Ethics-Risk Areas for Fraud and Abuse, and Resident to Resident Altercations. Record review of the facility's Coordinating/Implementing Abuse, Neglect, and Exploitation Policies and Procedures, dated April 2021, reflected policies were in place to prohibit and prevent resident abuse, neglect, exploitation, or misappropriation of resident property, reporting and response to investigations, the administrator having the overall responsibility for the coordination and implementation of facility policy. Record review of the facility's Resident Right's Policy, dated February 2021, reflected residents had the right to be free from abuse, neglect, exploitation, or misappropriation of resident property. Record review of the facility's Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating Policy, dated September 2022, reflected if resident abuse, neglect, exploitation, misappropriation of resident property or injury of an unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Within 5 business days of the incident, the administrator will provide a follow-up investigation report. Record review of the facility's Identifying Types of Abuse Policy, dated September 2022, reflected Physical Abuse of any kind against residents is strictly prohibited. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse toward a resident can occur as resident-to-resident abuse, staff to resident abuse, or visitor to resident abuse. Physical abuse included, but was not limited to hitting, slapping, biting, punching, or kicking. Some situations of abuse do not result in an observable physical injury, but psychosocial effects of abuse may not be immediately apparent. Record review of the facility's Abuse and Neglect- Clinical Protocol Policy, dated March 2018, reflected abuse defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful defined as acting deliberately, not that the individual must have intended to inflict injury or harm. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. Record review of the facility's Recognizing Signs and Symptoms of Abuse, dated April 2021, reflected all personnel are expected to report any signs and symptoms of abuse or neglect to their superior or to the director of nursing services immediately. Signs of physical abuse can be injuries that are non- accidental or unexplained. Record review of the facility's QAPI Review of Abuse, Neglect, Exploitation or Misappropriation, dated September 2022, reflected the QAPI Team was responsible for integrating the findings of a confirmed allegation of abuse into a performance improvement initiative. Record review of the facility's Resident-to-Resident Altercation Policy, dated September 2022, reflected occurrences of such incidents were reported to the ADM. If two residents engaged in an altercation, staff were to review the events with nursing supervisor and DON and evaluate the effectiveness of interventions meant to address distressed behaviors for one, or both, residents. The ADM, who would report in accordance with the reporting criteria, would do so within two hours of the allegation involving abuse. Record review of the facility's CCP Policy, dated December 2016, reflected the CCP will contain measurable objectives and timeframes; describe these services that are being furnished to attain or maintain their residence highest practical physical, mental, and psychosocial well-being; and incorporate risk factors associated with identified problems, such as identify the professional services that are responsible for each element of care. The IDT must review and update the CCP when the desired outcome has not been met.

Based on interview and record review the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that was not possible or the resident preferences indicated otherwise for 1 of 13 residents (Resident #1) reviewed for nutrition and hydration. On 5/11/2024 Resident #1 was admitted into the hospital due to a decline in health. Resident #1 was lethargic, unable to stand, skin was pale in color and fingertips were turning purple. Resident #1 was diagnosed with severe dehydration and non-traumatic rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood). The facility failed to identify there was a decrease in Resident #1's meal intake and notify the nutritionist, NP, or PCP to address nutritional or hydration concerns for Resident #1. This failure could place residents at risk of nutritional deficit, dehydration, and other adverse health consequences. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old male with an admitted [DATE]. Diagnoses included: UNSPECIFIED DEMENTIA (a group of thinking and social symptoms that interfere with daily functioning), Parkinson's disease (a disorder of central nervous system that affects movement, often including tremors), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and depression (a group of conditions associated with the elevation or lowering of a person's mood). Review of Resident #1's admissions MDS assessment dated [DATE] reflected incomplete. Only the identification page of the assessment had been completed no other sections of the assessment were completed. Review of Resident #1's care plan dated 5/2/2024 reflected Resident # 1 was an elopement risk and was placed on the secure unit at the facility when he admitted to the facility. Resident # 1 was at risk for falls and had previous falls in the home prior to admitting to the facility. The care plan did not reflect any interventions to address the nutritional or fluid intake needs for Resident #1. Review of Resident #1's physician orders for Resident #1 reflected, the facility did not have a physician's order for Resident #1's diet or fluid intake. Record review of meal intake records dated 5/2/2024- 5/11/2024 reflected on 5/6/2024 ,5/7/2024, 5/8/2024, and 5/10/2024 Resident #1 consumed less than 25% of his dinner on the days listed. On 5/2/2024 reflected no record of dinner eaten. Record review of progress note dated 5/2/2024 at 5:27 pm by LVN A reflected, Resident #1 refused to eat dinner because he had anxiety and was worried about being at the facility. The note reflected LVN A redirected Resident #1, however does not indicate if he ate his dinner. Record review of progress note dated 5/6/2024 at 2:18 pm by LVN A, reflected he contacted the RP regarding Resident #1 observed coughing and after eating and drinking. The RP stated Resident #1 had swallowing problems due to his Parkinson's disease. The RP stated Resident #1 had a swallow study in January 2024, she advised for the resident to take small bites and to encourage to swallow in between bites. Record review of hospital medical records dated 5/11/2024 reflected Resident #1 was admitted to the hospital on 5/11/2024 from the nursing facility. Resident # 1 was diagnosed with non-traumatic rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood) and severe dehydration. Resident #1 was currently in the hospital receiving fluids and has suffered acute kidney injury. In an interview via phone on 5/14/2024 at 7:40 am with Resident #1's RP, revealed when she showed up on 5/11/2024 to take Resident #1 home she stated he was very weak, pale in the face, fingers were turning purple, and he could not get up out of the wheelchair into the car. She stated she had them call 911 and he was taken to the hospital where he was diagnosed as being severely dehydrated and having rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood). The RP stated she was not aware of what could have happened in this short period of time to cause this decline in his health. She stated when he admitted to the facility, he was using his walker to walk, eating, and talking. The RP stated she admitted Resident #1 to the facility on [DATE] because they were having some renovations completed at their home. She stated he was previously at another facility closer to their home but had continued to have elopement issues so that was the reason he was transferred to this facility. The RP stated Resident #1 was on the secure unit at this facility, but stated she just does not understand the decline in his health from the time he admitted to the time he discharged . In an interview on 5/14/2024 at 10:00 am with hospital RN staff reported Resident #1 stated that he had not had anything to eat or drink for the past three days. Hospital RN staff reported the resident admitted to the hospital with severe dehydration and rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood) she stated this could cause the dehydration. In an interview on 5/14/2024 at 11:15 am with PCP, revealed he never saw Resident #1 while at facility he stated the NP met with the resident. He stated he was never contacted or made aware of any issues related to this resident. The PCP stated there were no additional treatment services for this resident and there were no medication changes ordered for this resident. In an interview on 5/14/2024 at 12:38 pm with the DON she reported they did keep fluid intake records for Resident #1 she stated when the resident had some coughing issues when eating and drinking, they contacted the RP on 5/6/2024 who advised that Resident #1 had a swallowing problem. She stated they were advised to cut his food smaller and encourage smaller bites, drink and swallow slowly, and monitor the resident. The DON stated they do not track fluid intake for residents unless there was an order. However, she stated if the resident was eating below 50% of their meals, they were provided with a supplemental shake with each meal. She stated it was standard facility protocol, however reported they do not document if the shake supplement was provided or if the resident consumed the shake. She stated they did not add this intervention to the care plan because it was standard to do and not an order. She stated she did not address the eating or drinking issues with the NP or PCP because they spoke with the RP and were doing what the RP advised them to do for the resident. The DON stated she did send the resident out to the hospital because she stated he did not look right. She stated the resident was assessed at the hospital and returned to the facility the same day. She stated the hospital called and stated the resident was stable and ready to be picked up. The DON stated they never received any discharge paperwork from the hospital from the 5/9/2024 visit due to a breach in their system. The DON stated she did contact the director of OT/PT to have a swallow assessment completed for the resident. The DON stated all staff had been trained on abuse/neglect and the protocol. She stated all CNA staff had been trained to report any changes in condition to their nurse and they would discuss in their morning meeting for steps to take and treatment. The DON stated the facility did not have a hydration policy. In an interview on 5/14/2024 at 3:17pm with the NP revealed, Resident #1 admitted to the facility on [DATE] for respite care. She stated she normally did not see the residents if they were at the facility for respite care. She stated she did not know how long Resident #1 was going to be at the facility, so she saw Resident #1 on 5/6/2024. The NP stated Resident #1 was not getting any additional treatment and, stated no medications were changed. She stated the resident was confused and appeared to have already had a cognitive decline requiring to be on a secure unit. She stated she was contacted by the facility indicating that Resident #1 was having some hip pain. She advised the facility to check with the RP about getting some x-rays and stated she was advised that Resident #1 would be discharging on 5/10/2024 to return home. She stated she was not aware of any other issues regarding Resident #1. In an interview on 5/14/2024 at 4:26 pm with LVN A revealed, the CNAs were trained to let their nurse know if there was any change in condition for any resident. LVN A stated the CNA staff are trained to pay attention to the resident's trays if they are not eating or drinking when the get their meals, their urine color, or if they are changing the resident and they are fairly dry they are not getting enough hydration and they would need to push fluids. LVN A stated the resident admitted for respite care and had a decline while at the facility. He stated all staff had been trained on abuse/neglect and the administrator was the abuse/ neglect coordinator he stated he had never seen or suspected abuse/neglect at this facility. In an interview on 5/15/2024 at 7:08 am with RN revealed, he worked with Resident #1 on the secure unit. He stated when the resident admitted to the facility he was doing more. He stated he was using his walker to get around and able to feed himself with some assistance as needed. He stated the resident took water and other hydration with meals and stated his appetite continued to decrease. RN stated he contacted the RP on 5/6/2024 and reported swallowing problems but was told he was still on a regular diet and needed to take small bites. He stated the resident was a 2x person assist for the week that he was at the facility. RN stated he contacted the hospital Resident #1 went to on 5/9/2024 to try to obtain those records however, due to the hospital breach in their system they did not have any records available they could provide. RN stated he let the DON know about the issues Resident #1 was having and they contacted the therapy department to try to get another swallow study for the resident. RN stated they helped with eating and drinking for Resident #1 he stated the resident continued to decline. The RN stated the CNAs are trained to report any changes in a resident's condition to the nurse on duty. He stated they would report to the DON or contact the NP for concerns with a resident. In an interview on 5/15/2024 at 7:32 am with RP, revealed Resident #1 saw two doctors on yesterday and stated they came up with a plan for him to go home on hospice care. She stated the doctor of the supportive and palliative care department attributed his condition to his current diagnosis and progression of the Parkinson's disease and Dementia. She stated she just did not expect this, and stated she wanted someone to blame. The RP stated she felt the hospital did not do what they needed to do on 5/9/2024 before releasing him back to the facility. She stated she did speak with the hospital staff on 5/9/2024, but stated she could not remember what was said regarding Resident #1's condition. The RP stated she would be taking Resident #1 back home to are for him and that he would not be returning to the facility. The RP stated palliative care has been put into place and they will come into the home and provide these services. In an interview on 5/15/2024 at 12:15 pm with the hospital treating physician reported that rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood) could be caused from a fall and being left in that spot for a prolonged period of time or it can be caused by not getting the nutrition and hydration needed. She stated the resident reported lying in the bed and not having anything to eat or drink for three days. She stated the cause of rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood) would be consistent with lying in a bed and not having anything to eat or drink for three days. The physician reported there was no other way that the rhabdomyolysis could be caused except for one of these two ways. In an interview on 5/15/2024 at 2:15pm with director of OT/PT revealed, she was advised that Resident #1 was coughing and had problems swallowing during meals. She stated since Resident #1 was a Veteran, and his services were being covered by the Veteran Administrator she contacted the VA to get approval for another swallow study to be completed on Resident #1. She stated she was advised by the VA that this condition was not a new condition for Resident #1 and that a swallow assessment was completed in January 2024 and another one would not be approved at this time. In an interview on 5/15/2024 at 2:30 pm with LVN B revealed, she worked through an employment agency. She stated she worked the night of 5/9/2024 when Resident #1 was sent out the hospital. She stated she was advised by other staff that he was sent out due a decline, stated the resident was struggling breathing and his blood pressure was low. LVN B stated she received a call that night from the RP. She stated the RP reported that the hospital advised her to put a DNR in place for Resident #1. She stated the RP blamed herself for his decline and stated he had been declining ever since going to the first facility. She stated the RP reported that she felt the resident was declining to due being in unfamiliar surroundings and places. LVN B stated the administrator was the abuse/neglect coordinator and they needed to report any suspected abuse/neglect to the administrator immediately, she stated she had never seen or suspected abuse/neglect at this facility. In an interview on 5/15/2024 at 4:07pm with CNA B, revealed she worked on the MC unit with Resident #1. Stated she was not aware that the resident had any eating issues. She stated she was not aware of why the resident was on the secure unit and thought it was odd. She stated she gave the best care that she could to the resident with the information she was provided. CNA B stated the nurses usually would let them know what was going on with a resident. CNA B stated the RP advised them to cut Resident #1's food up so he could take smaller bites, but stated he should have been on a puree' textured diet. She stated there were a lot of things that the RP stated Resident #1 could do when he admitted but he could not, she stated they had to provide a lot of assistance to Resident #1. CNA B stated she let the nurse on duty LVN A know about the amount of assistance Resident #1 required. She stated when the resident was in the wheelchair, he required two people assist because he was a tall man and required two people to assist him. CNA B stated she had been trained on change in condition, she stated it could be loss of appetite, not participating in activities, or wanting to stay in bed. She stated she was trained to let her nurse know if there were any changes with the residents. She stated if a resident had hydration problems, they were trained to push hydration throughout the day and encourage the resident drink throughout the day. CNA B stated the administrator was the abuse/neglect coordinator and they were required to report immediately if they see or suspected abuse/ neglect to the administrator or their nurse. She stated she had never seen of suspected abuse/neglect at this facility. In an interview on 5/15/2024 at 4:18 pm with CNA C, revealed she worked the 6pm to 6am shift with Resident #1 on the secure unit. She stated when she noticed the resident had a change in condition and was in the bed more, she stated she let the nurse know. She stated she did not assist with any meals, she stated when she arrived, she just turned the resident every two hours to prevent skin breakdown. CNA C stated they were trained to let the nurse know if there were any changes with the residents. She stated she had also been trained on abuse/ and stated the administrator was the abuse/neglect coordinator and they needed to report immediately if they seen or suspected abuse/neglect. She stated she had never seen or suspected abuse/neglect at this facility. CNA C stated if a resident hydration concerns, they would push fluids and monitor the intake throughout the day. Record review of 10 resident's charts who were identified to have fluid restriction/ monitoring, special diet. Each resident's chart reviewed had a care plan to address nutritional needs, an order to monitor hydration intake, meal intake records to monitor the amount of their meal they consumed throughout each day. The records reflected they were monitored and evaluated by the primary care physician and nutritionist regularly. The charts reflected weekly weight monitoring to track any significant weight loss of the residents. Record review of facility in-service on abuse/neglect dated 3/25/2024 reflected staff had been in-serviced on abuse/neglect. Record review of facility in-service on Standard of Care dated 1/11/2024 reflected staff had been in-serviced on standards of care. Record review of facility abuse/neglect policy dated March 2018 reflected the following: All residents will be free from abuse/neglect. Record review of facility Intake, Measuring and Recording policy dated October 2010 reflected the following: Review the resident care plan to assess for any special needs of the resident. Verify there is a physician's order for this process. In an interview with the DON on 5/14/2024, she stated the facility did not have a dehydration/ hydration policy.

Based on observation, interview and record review that facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is (A) significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). On 5/11/2024 Resident #1 was admitted into the hospital due to a decline in health. Resident #1 was lethargic, unable to stand, skin was pale in color and fingertips were turning purple. Resident #1 was diagnosed with severe dehydration and non-traumatic rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood). The facility failed to identify there was a decrease in Resident #1's meal intake and notify the nutritionist, NP, or PCP to address nutritional or hydration concerns for Resident #1 This failure could place residents at risk of not getting the medical treatment required that could lead to other adverse health consequences. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old male with an admitted [DATE]. Diagnoses included: UNSPECIFIED DEMENTIA (a group of thinking and social symptoms that interfere with daily functioning), Parkinson's disease (a disorder of central nervous system that affects movement, often including tremors), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and depression (a group of conditions associated with the elevation or lowering of a person's mood). Review of Resident #1's admissions MDS assessment dated [DATE] reflected incomplete. Only the identification page of the assessment had been completed no other sections of the assessment were completed. Review of Resident #1's care plan dated 5/2/2024 reflected Resident # 1 was an elopement risk and was placed on the secure unit at the facility when he admitted to the facility. Resident # 1 was at risk for falls and had previous falls in the home prior to admitting to the facility. The care plan did not reflect any interventions to address the nutritional or fluid intake needs for Resident #1. Review of Resident #1's physician orders for Resident #1 reflected, the facility did not have a physician's order for Resident #1's diet or fluid intake. Record review of hospital medical records dated 5/11/2024 reflected Resident #1 was admitted to the hospital on 5/11/2024 from the nursing facility. Resident # 1 was diagnosed with non-traumatic rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood) and severe dehydration. Resident #1 was currently in the hospital receiving fluids and has suffered acute kidney injury. In an interview via phone on 5/14/2024 at 7:40 am with Resident #1's RP, revealed when she showed up on 5/11/2024 to take Resident #1 home she stated he was very weak, pale in the face, fingers were turning purple, and he could not get up out of the wheelchair into the car. She stated she had them call 911 and he was taken to the hospital where he was diagnosed as being severely dehydrated and having rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood). The RP stated she was not aware of what could have happened in this short period of time to cause this decline in his health. She stated when he admitted to the facility, he was using his walker to walk, eating, and talking. The RP stated she admitted Resident #1 to the facility on [DATE] because they were having some renovations completed at their home. She stated he was previously at another facility closer to their home but had continued to have elopement issues so that was the reason he was transferred to this facility. The RP stated Resident #1 was on the secure unit at this facility, but stated she just does not understand the decline in his health from the time he admitted to the time he discharged . In an interview on 5/14/2024 at 10:00 am with hospital RN staff reported Resident #1 stated that he had not had anything to eat or drink for the past three days. Hospital RN staff reported the resident admitted to the hospital with severe dehydration and rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood) she stated this could cause the dehydration. In an interview on 5/14/2024 at 11:15 am with PCP, revealed he never saw Resident #1 while at facility he stated the NP met with the resident. He stated he was never contacted or made aware of any issues related to this resident. The PCP stated there were no additional treatment services for this resident and there were no medication changes ordered for this resident. In an interview on 5/14/2024 at 12:38 pm with the DON she reported they did keep fluid intake records for Resident #1 she stated when the resident had some coughing issues when eating and drinking, they contacted the RP on 5/6/2024 who advised that Resident #1 had a swallowing problem. She stated they were advised to cut his food smaller and encourage smaller bites, drink and swallow slowly, and monitor the resident. The DON stated they do not track fluid intake for residents unless there was an order. However, she stated if the resident was eating below 50% of their meals, they were provided with a supplemental shake with each meal. She stated it was standard facility protocol, however reported they do not document if the shake supplement was provided or if the resident consumed the shake. She stated they did not add this intervention to the care plan because it was standard to do and not an order. She stated she did not address the eating or drinking issues with the NP or PCP because they spoke with the RP and were doing what the RP advised them to do for the resident. The DON stated she did send the resident out to the hospital because she stated he did not look right. She stated the resident was assessed at the hospital and returned to the facility the same day. She stated the hospital called and stated the resident was stable and ready to be picked up. The DON stated they never received any discharge paperwork from the hospital from the 5/9/2024 visit due to a breach in their system. The DON stated she did contact the director of OT/PT to have a swallow assessment completed for the resident. The DON stated all staff had been trained on abuse/neglect and the protocol. She stated all CNA staff had been trained to report any changes in condition to their nurse and they would discuss in their morning meeting for steps to take and treatment. The DON stated the facility did not have a hydration policy. In an interview on 5/14/2024 at 3:17pm with the NP revealed, Resident #1 admitted to the facility on [DATE] for respite care. She stated she normally did not see the residents if they were at the facility for respite care. She stated she did not know how long Resident #1 was going to be at the facility, so she saw Resident #1 on 5/6/2024. The NP stated Resident #1 was not getting any additional treatment and, stated no medications were changed. She stated the resident was confused and appeared to have already had a cognitive decline requiring to be on a secure unit. She stated she was contacted by the facility indicating that Resident #1 was having some hip pain. She advised the facility to check with the RP about getting some x-rays and stated she was advised that Resident #1 would be discharging on 5/10/2024 to return home. She stated she was not aware of any other issues regarding Resident #1. In an interview on 5/15/2024 at 12:15 pm with the hospital treating physician reported that rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood) could be caused from a fall and being left in that spot for a prolonged period of time or it can be caused by not getting the nutrition and hydration needed. She stated the resident reported lying in the bed and not having anything to eat or drink for three days. She stated the cause of rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood) would be consistent with lying in a bed and not having anything to eat or drink for three days. The physician reported there was no other way that the rhabdomyolysis could be caused except for one of these two ways. Record review of facility abuse/neglect policy dated March 2018 reflected the following: All residents will be free from abuse/neglect. Record review of facility Intake, Measuring and Recording policy dated October 2010 reflected the following: Review the resident care plan to assess for any special needs of the resident. Verify there is a physician's order for this process. In an interview with the DON on 5/14/2024, she stated the facility did not have a dehydration/ hydration policy.

Based on interviews, observations, and record review the facility failed to ensure each resident receives adequate supervision and assistive devices for one of twenty residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1's coffee cup was positioned properly at the upper right of his plate which led to him knocking it over. Resident #1 sustained 2nd degree burns to his bilateral inner thighs from the hot coffee. An IJ was identified on 01/11/2024 at 4:10 PM. While the IJ was removed on 01/12/2024, the facility remained out of compliance at a severity level of actual harm and a scope of isolated harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures placed all residents at risk for injuries, pain, and mental anguish. Findings include: Record review of Resident #1's face sheet dated 01/11/2024, reflected Resident #1 was a [AGE] year-old man admitted on [DATE] with diagnoses of unspecified glaucoma (build-up of fluid in the eye, which presses on the retina and optic nerve), unspecified cataract (a condition in which the lens of the eye becomes cloudy), muscle weakness (lack of physical or muscle strength), and type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye (central part of the retina, swells from the leaking fluid and causes blurred vision). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 09, which indicated moderate cognitive impairment. Section B (Hearing, Speech, and Vision) reflected Resident #1's vision was highly impaired. Section GG (Functional Abilities and Goals) reflected Resident #1 required setup or clean-up assistance for eating. Record review of Resident #1's care plan dated 01/11/ 2024 reflected Resident #1 was care planned for impaired visual function related to cataracts, glaucoma, and diabetic retinopathy. Resident #1 was care planned for ADL self-care performance deficit related to confusion, impaired balance, and limited mobility with interventions of eating self-performance (limited assist) support provided (x1 assist). Resident #1 was also care planned for blisters to medial thighs bilaterally related to coffee spillage in his lap. Record review of the facility nursing progress note dated 12/29/23 reflected, At approximately. 10:00 am the nurse was called to the dining room; the nurse notified the resident was yelling. Resident reported he had spilled coffee on himself, the nurse returned to his room to assess injury. I wasted coffee in my lap Record review of the facility nursing progress note dated 01/02/24 reflected, Nurse practitioner there to see resident today and assess blisters to inner thighs bilaterally. New orders noted by the charged nurse and entered into the computer. Care plan updated to reflect the following: Focus: Resident #1 had blisters to medial thighs bilaterally related to coffee spillage in his lap. Goal: Resident #1's blisters would heal without complications in the next 30 days. Interventions: Administer treatment as ordered by the physician, assist Resident #1 with his coffee and provide Kennedy cup (non-spill cup) as needed while drinking his coffee, for closed blister on left inner thigh: spray with skin prep or betadine and cover with foam dressing daily, for opened blister on inner right thigh: clean with NS, apply Silvadene to red base wound, calcium alginate to the slough are and cover with foam dressing, change daily, monitor blisters to legs bilaterally for signs of infections or swelling, and notify physician with any concerns. Record review of the facility nursing progress note dated 01/02/24 reflected, received new order for wound care to change orders for care of burns to residents bilateral thighs, New order to clean open blisters to bilateral thighs with NS/WC, pat dry, apply petrolatum gauze to wound beds, and cover with dry gauze type dressing daily and PRN. Resident advised of new orders to start 01/11/2024. Record review of the wound care progress note dated 01/03/24 reflected, Resident #1's wound #1 status was Open. The date acquired was: 1/1/2024. The wound was classified as a Partial Thickness wound with etiology (the cause or cause of a disease) of 2nd degree Burn and was located on the right, Anterior Upper Leg. The wound measured 8cm length x 8.5cm width x 0.1cm depth; 53.407cm2 area and S.341cm3 volume. There was no tunneling or undermining noted. There was a non-present amount of drainage noted. There was no necrotic tissue within the wound bed. The periwound skin appearance did not exhibit: Callus (a region of thickened skin that develops from increased friction), Crepitus (popping, clicking or cracking sound in joints), Excoriation (health condition where you compulsively pick at your skin), Induration (thickening or hardening of soft tissues of the body), Rash (irritated or swollen skin), Scarring (the body's natural way of healing and replacing lost or damage skin), Dry/Scaly (small, hard, dry area that fall of in small pieces), Maceration (skin softening and breaking down due to prolonged contact with moisture that is usually not present on the skin), Atrophie Blanche (a chronic condition that presents as recurrent, painful, ulcers of the lower leg, ankle, or dorsal foot), Cyanosis (bluish color in the skin, lips, and nail beds caused by a shortage of oxygen in the blood), Ecchymosis (bruises), Hemosiderin Staining (areas of discolored skin that usually affect the lower leg, typically on the ankle and the top of the foot), Mottled (marked with spots of different colors), Pallor (skin paleness), Rubor (redness to skin), Erythema (skin rash). Periwound temperature was noted as No Abnormality. Wound #2 status was Open. The date acquired was: 1/1/2024. The wound was classified as a Partial Thickness wound with etiology (the cause or cause of a disease) of 2nd degree Bum and was located on the left,Medial Upper Leg. The wound measures 0.5cm length x 3cm width x 0.1cm depth; 1.178cm2 area and 0.118cm3 volume. There was no tunneling or undermining noted. There was a non-present amount of drainage noted. The wound margin was flat and intact. There was no necrotic tissue within the wound bed. The periwound skin appearance did not exhibit: Callus (a region of thickened skin that develops from increased friction), Crepitus (popping, clicking or cracking sound in joints), Excoriation (health condition where you compulsively pick at your skin), Induration (thickening or hardening of soft tissues of the body), Rash (irritated or swollen skin), Scarring (the body's natural way of healing and replacing lost or damage skin), Dry/Scaly (small, hard, dry area that fall of in small pieces), Maceration (skin softening and breaking down due to prolonged contact with moisture that is usually not present on the skin), Atrophie Blanche (a chronic condition that presents as recurrent, painful, ulcers of the lower leg, ankle, or dorsal foot), Cyanosis (bluish color in the skin, lips, and nail beds caused by a shortage of oxygen in the blood), Ecchymosis (bruises), Hemosiderin Staining (areas of discolored skin that usually affect the lower leg, typically on the ankle and the top of the foot), Mottled (marked with spots of different colors), Pallor (skin paleness), Rubor (redness to skin), Erythema (skin rash). Periwound temperature was noted as No Abnormality. A Record Review of Coffee temp log reflected there was no documentation of coffee temperatures before January 2024. There were missing coffee temperatures for the PM shift on 01/07/24, 01/08/24, and 01/09/24. The coffee temperature log only has one AM and one PM column for documentation. During an observation on 01/10/24 at 1:15 pm of Resident #1's injuries, it was observed Resident #1 had two bandaged areas on both his right and left inner thighs. Observation of the upper right inner thigh area was observed to be pink in color, skin missing. No observation of Resident's #1 left thigh due to Resident #1 yelling out in pain. During an interview on 01/10/24 at 10:30am with Resident #1 stated his plate was placed in front of him and his cup of coffee placed beside the plate (right side), but near the edge of the table. Resident #1 states that his vision was impaired, and he can see objects, shadows, and movement, but not clearly. Resident #1 stated that typically his cup of coffee would have been placed near to the center of the table. Resident #1 stated that his cup was usually at the upper right of his plate with the handle turned out so that he could easily manage his grip on the cup. Resident #1 stated that while he was attempting to take a bite of his food, his hand/arm knocked over his cup of hot coffee directly into his lap. Resident #1 stated he yelled out in pain when he spilled the hot coffee. Resident #1 states that he was wearing sweatpants at the time. During an interview on 01/10/24 at 11:45 am with the CNA, he stated that Resident #1 needs his food and drink positioned to his liking, so he doesn't knock it over. CNA stated that Resident #1 liked his coffee positioned near the center of the table so could see it. Attempted an interview on 01/10/24 at 1:20 pm with LVN #1. No answer but voicemail was left. No return call was made from LVN #1. During an interview on 01/10/24 at 2:45 pm with the DON, she stated she was notified of Resident #1 injuries but there was no redness or blistering at the time. Resident #1 was given a cold towel to place in his lap and the MD was notified. The DON stated LVN #1 and NA #1 gave Resident #1 a shower after the incident and no redness or blistering was observed at that time. DON stated that Resident #1 sustained 2nd degree burns to his left and right thigh because of the incident. During an interview with Dietary Supervisor on 01/10/24 at 3:15pm, a request was made for the coffee/hot liquid temperatures for the calendar year of 2023. Dietary Supervisor stated the facility had not taken any coffee/hot liquid temps prior to January 2024. During an interview on 01/10/24 at 4:15 pm with the ADM, he stated hot liquid temps should be taken after batch of coffee was made. The ADM stated if no temperatures are taken then there would be potential for the coffee/hot liquid to be too hot for the residents. If the coffee/hot liquid was too hot, then there would be risks for resident to sustain injuries from the coffee/hot liquid. During an interview on 01/10/24 at 4:30 pm with the Dietary supervisor, she stated coffee was made 7 times a day. There was a coffee pot for both halls and one for the dining area. The Dietary supervisor stated that the dishwashing staff was responsible for checking the temperature of the coffee. The Dietary supervisor stated she was not aware the temperature of the coffee needed to be checked after each batch was made. During an interview on 01/11/24 at 9:45 am with dishwashing staff #1, he stated he checked the temperature of each coffee pot before each meal. Dishwashing staff #1 stated he only checked the temperature for breakfast and before lunch. The dishwashing #1 stated he did not remember when he was in-services on hot liquids. Attempted an interview on 01/11/24 at 10:15 am with NA #1. No answer but voicemail was left. No return call was made from NA #1. Attempted an interview on 01/11/24 at 2:15 pm with LVN #1. No answer but voicemail was left. No return call was made from LVN #1. Attempted an interview on 01/11/24 at 12:55 pm with NA #1. No answer but voicemail was left. No return call was made from NA #1. Review of the facility's Safety of Hot Liquids Policy dated 2001 reflected Residents will be evaluated for safety concerns and potential of injury from hot liquids up admission, readmission and on change of condition. Appropriate precautions will be implemented to maximize choice of beverage while minimizing the potential of injury. Policy interpretation and implementation 1. The potential for burns from hot liquids is considered an ongoing concern among residents with weakened motor skills, balance issues, impaired cognition, and nerve or musculoskeletal condition. 2. Residents with these or other conditions may suffer from accidental burns and related complications stemming from thinner, more fragile skin that may burn quickly and severely and take longer to heal. 3. Residents who prefer hot beverages with meals (i.e. coffee, tea, soups, etc.) will not be restricted from these options. Instead, staff will conduct regular Hot Liquid Safety Evaluations as indicated, and document the risk factors for scalding and burns in the care plan. 4. Once risk factors for injury from hot liquids are identified, appropriate intervention will be implemented to minimize the risk from buns, such interventions may include: A. Maintaining a hot liquid serving temperature of not more than 155 degrees Fahrenheit: B. Serving hot beverages in a cup with a lid: C. Encouraging residents to sit at the table while drinking or eating hot liquids: D. Providing protective lap coverage or clothing to protect skin from accidental spills, and E. Staff supervision or assistance with hot beverages. 5. Food service staff will monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. This was determined to be an Immediate Jeopardy on 01/11/24 at 4:10 pm. The ADM was notified. The ADM was provided with the IJ template on 01/11/24 at 4:10 pm. The Plan of Removal was accepted on 01/12/2024 at 10:20 AM and included the following: All listed items will be completed by 01/12/24 with continued follow-up: 1. On 1/11/2024, Resident #1 was assessed by the Director of Nursing/Designee to validate that the resident was not exhibiting signs or symptoms of physical or psychosocial distress related to the deficient practice and to ensure that measures were in place to minimize the risk of future burns related to hot liquids. Care Plan was reviewed to validate all current interventions in place. On 1/11/2024 The Director of Nursing/Designee notified resident #1's responsible party and physician of the identified deficient practice. 2. On 1/11/2024, dietary log was initiated to monitor and temp all brewed batches of coffee throughout the day. Total of 13 dietary staff, 9 of which have received education, the remaining 4 will be completed on 1/12/2024, prior to start of shift, on the process to monitor and temp all batches and requirement to be 155 degrees or less prior to making available for residents consumption. 3. The Director of Nursing/Designee completed a sweep of all facility residents' hot liquid assessment, validated they were current and applicable for all residents on 1/11/2024. Director of nursing/designee then validated for appropriate interventions to be in place and that care plans are updated as applicable related to risk assessment. 3 residents with visual deficit/legally blind were identified including Rresident #1 All 3 identified were supplied with specialty mugs with handles, non-slip bases and lids on January 4, 2024. 4 residents identified as needing assist with all hot liquids, these care plans were updated to reflect necessary need. 5 residents identified with need to be seated at table to securely place hot liquids while drinking. Those care plans updated to reflect the need for this intervention on 1/11/2024. 4. Director of Nursing completed education with all dietary staff on requirements to monitor and log temperature of all batches of coffee, and requirement that temperature before serving or making available to resident be 155 degrees or less 5. The Director of Nursing/Designee provided education to all facility staff on policy for hot liquids and list of specific residents that require additional interventions for hot liquid safety. This education included the requirement to implement appropriate interventions to prevent burns for residents consuming hot liquids. To monitor for compliance: Director of Nursing/Designee will review residents identified with safety concerns from hot liquid assessment daily x 7 days, beginning 1/12/2024, to validate all implemented interventions are in place and any newly identified residents at risk are addressed accordingly with appropriate interventions. Any identified concerns will be corrected with applicable education completed as identified, Director of Nursing/Designee will then continue to monitor daily in clinical meeting ongoing. Monitoring will continue daily in kitchen with temperature log completed on each new batch. Administrator/designee will audit logs daily Monday through Friday to validate hot liquids are temped prior to serving and will review in QAPI for compliance. Any trends or concerns were/will be addressed with the Quality Assurance Performance Committee and continue until a lessor frequency deemed appropriate through QAPI review. Plan of Removal completion date is 01/12/2024. Monitoring for Plan of Removal was completed on 01/12/2024 as follows: The Director of Nursing/Designee provided education to all facility staff on policy for hot liquids and list of specific residents that require additional interventions for hot liquid safety. This education included the requirement to implement appropriate interventions to prevent burns for residents consuming hot liquids. In an interview on 01/12/2024 at 9:05 am with Regional RN, stated Resident #1 was assessed and not exhibiting and signs or symptoms of physical or psychological distress related to recent deficient practice in regard to the coffee burn. Measure have been put in in place to prevent further coffee burns including a cup with a lid, the kitchen staff will ensure coffee remains 155 or less prior to serving coffee to the resident. Resident #1 was in a great mood. He stated, I'm getting better every day. Wounds are improving. Noted inner left thigh was healed, and 2 of the wounds to the right inner thigh are pink, and dry, without any scabs. The wound to the top of the right thigh was approximately 1cm x 1cm, skin pink, blister has popped and without any signs of infection. Resident #1 stated, it does itch a bit. Resident #1 denies any pain. Family and physician were notified of the deficient practice. The physician agrees with current wound care orders and interventions. Regional RN also stated that the facility identified Resident #1, Resident #2, and Resident #3 will use a Kennedy cup (non-spill cup). Resident #4, Resident #5, Resident #6, and Resident #7 will need physical assistance at the table during meals. Resident #8 Resident #9 Resident #10, and Resident #11 will need to be sitting at a table when receiving hot liquids. During interviews on 01/12/24 from 9:50 am - 10:45 am with six dietary staff members (1 dietary supervisor, 3 dietary aides and 2 dietary cooks), who were able to articulate information from the hot liquid in-service. Observation on 01/12/2024 at 9:30am, Kennedy cups for Resident #1, Resident #2, and Resident #3. Each cup had the resident's name on it. Record review on 01/12/2024 at 9:45am, reflected a new hot liquid temperature sheet with columns for documentation for date, time, batch, temp, staff name, and correction/retemp. Record review of the facility's Procedure for monitoring temperature of Coffee 1. All batches of coffee to have temperature taken prior to being allowed for resident consumption. 2. Log each temperature, date/time, batch number, your initials, and time temperature taken. 3. If temperature too high - above 135 degrees, correction taken and what temperature was on recheck. An IJ was identified on 01/11/2024. The IJ template was provided to the facility on [DATE] at 4:10 PM. While the IJ was removed on 01/12/2024, the facility remained out of compliance at a severity level of actual harm and a scope of isolated harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.