Every finding on record at Hampton Place Healthcare, LLC

Number of residents sampled: Number of residents cited: Based on observations, interviews, record review, and facility policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen. Specifically, the facility failed to ensure dietary staff properly restrained hair in the kitchen; and dietary staff washed their hands and used gloves properly. The findings included: During an observation in the kitchen on 07/29/2026 at 11:00 AM, [NAME] #13, Dietary Aide (DA) #14, DA #15, DA #16, [NAME] #17 and [NAME] # 18 did not have their hair fully restrained by a hair net. During an interview on 07/30/2026 at 9:34 AM, [NAME] #13 stated as soon as staff walked into the kitchen, they should cover the nape of their neck to the crown of their head, making sure all hair was contained with no strays sticking out. [NAME] #13 stated, I did not realize my hair was out.During an interview on 07/30/2026 at 9:34 AM, DA #14 stated, I put on my hair net when I get into the kitchen, when I leave the kitchen I take the hair net off and replace it with a new one. I need to make sure my your hair is completely covered up. I did not realize my hair was out.During an interview on 07/29/26 at 1:26 PM, DA #15 stated I put my hair net on before entering the kitchen and check myself in the mirror. I did not realize my hair was out during the day. During an interview on 07/29/2026 at 1:30 PM, [NAME] #17 stated, I put on my hair net before entering the kitchen, I looked in the mirror to ensure my hair was contained. I did not realize my hair was out.During an observation on 07/29/2026 at 11:10 AM, [NAME] #18 took their gloves off and opened a bread package then put back on the previously used gloves without performing hand hygiene. [NAME] #18 then took bread out of the bag and put it on a plate, opened a plastic container with cheese in it with gloved hands and placed cheese on the bread with contaminated gloves. [NAME] #18 then cooked grilled cheese in a pan, flipped the grilled cheese with a spatula and then plated the grilled cheese with contaminated gloved hands. After plating the grilled cheese, [NAME] #18 put on new gloves, without performing hand hygiene then took off one glove to grab a knife on the wall and put the same contaminated glove back on before using the knife. During an interview on 07/30/2026 at 9:47 AM , [NAME] #18 stated, [you should] wash hands every time you touch something, and when you change gloves. Wash hands before putting on gloves and after taking them off. [NAME] #18 stated I did not realize I did not wash my hands correctly. During an observation on 07/29/2026 at 11:13 AM, DA #15 dropped a small individual sized serving of ice cream on the floor contaminating the ice cream, picked it up and put it on the serving line with the other ice cream. During an interview on 07/29/2026 at 1:26 PM, DA #15 stated, I should wash my hands after I picked something up from the floor, I did not do that when I picked up the item from the floor. I should not have put that item on the serving line. During an interview on 07/30/2026 at 10:27 AM, the Dietary Manager stated, I expect staff to wash their hands before during and after food prep, wash hands before putting on gloves, after taking them off and putting on a new pair. Staff should not reuse gloves because they are not sanitary. Hair nets need to cover all hair. Hair needs to be in hair nets to ensure it is not contaminating food. A review of a facility policy titled Hand Washing dated 03/27/2012, revealed the purpose of handwashing was to remove contamination during food preparation before donning gloves for working with food. A review of a facility policy titled Dress Code dated 01/22/2024, revealed food service employees will wear a hair covering that completely covers all hair. [NAME] guards will be used for employees with facial hair.

Number of residents sampled: Number of residents cited: Based on review of video footage, interviews, record review, and facility policy review, it was determined that the facility failed to ensure a resident was free from physical abuse. Specifically, the facility failed to ensure one (Resident #57) of three residents were free from physical abuse and mental anguish. The findings included: Review of Resident #57's annual Minimum Data Set (MDS) with an Assessment Reference Date of 05/15/2026, revealed the resident had a Brief Interview for Mental Status score of 06 which indicated the resident had severe cognitive impairment. The MDS also indicated Resident #57 was independent for all mobility, personal care and dressing needs, and refused showers/baths. The MDS indicated Resident #57 had active diagnoses that included Alzheimer's disease, anxiety, bipolar and psychotic disorder. Review of Resident #57's Care Plan indicated Resident #57 was in the secure unit with an Activities of Daily Living (ADL) self-care deficient due to Alzheimer's/Dementia. Resident #57 exhibited a history of behaviors related to confusion, verbal aggression, yelling, physical aggression, and the resident refused to allow staff to shower, but will do a sink bath. interventions included re-direction, offer snacks, and call family for a 1:1 conversation. If resident refuses and /or becomes agitated try a different approach such as having another staff member attempt care, postpone care and try again later. Review of Resident #57's Physician Orders Summary indicated Resident #57 was admitted to Long Term Care Secure Unit on 05/21/2025, no behaviors were noted on the Physician Orders Summary. Review of the Reportable dated 07/06/2026, revealed a description of the incident as such: Resident #57 threw water on the Licensed Practical Nurse (LPN#4), LPN#4 told the resident that they could not do that and that they were going to clean their room. Certified Nursing Aide (CNA) # 6 took a linen/trash caddy to the hallway in front of Resident #57 room and removed items from Resident #57 room, such as soiled linens and dishes in front of Resident #57. Later, on 07/06/2026 at 12:59 PM, LPN #4 followed Resident#57 down the hall telling them they could not take cups into the room, Resident #57 turned and threw the fluid from the cup on LPN#4. LPN#4 continued to follow Resident #57 and forcibly took the cup from Resident #57's hand. Resident #57 and LPN #4 turned to walk back down the hallway, LPN#4 dumped the remaining contents from the cup on the Resident #57's head. The Administrator included the complaint submitted to the Arkansas State Board of Nursing regarding LPN #4. Review of video footage with the Administrator on 07/30/2026 at 2:55 PM, revealed on 07/06/2026 Resident #57 threw a cup of liquid at LPN #4 who then followed Resident #57 from the table, stepped extremely close to Resident #57 and was seen on camera waving her hands at Resident #57. The sound was not audible. CNA #5 and CNA #6 witnessed the incident. A different camera view showed LPN #4 followed Resident #57 down the hall toward their room. LPN #4 touched the resident on the left arm in two places. Resident #57 turned and threw a cup of liquid at LPN #4, who then took the cup from Resident #57's hands. Medication Aid-Certified (MAC) # 9 came out of another resident's room and turned towards Resident #57 and LPN #4. LPN #4 took her right hand and poured the contents of the cup on Resident #57's head. Resident #57 immediately turned toward LPN #4 and raised their hand toward LPN #4; MAC #9 immediately stepped in between LPN #4 and Resident #57. At the end of the hallway in line-of-sight CNA #7 and CNA #8 can be seen watching the incident. LPN #4 walked toward CNA #7 and CNA #8 and could be seen speaking with them. During an interview on 07/29/2026 at 9:18 AM, CNA #19 stated Resident #57 would take everything to their room, cups or anything laying around. Staff wait to remove the items from the room when they are not around, to prevent them from getting upset. During an interview on 07/29/2026 at 9:34 AM, CNA #20 stated, Resident #57 did have a hoarding behavior, we [staff] go in the room to remove the items with the resident is not around, if Resident #57 sees us taking items out of the room they become upset. During an interview on 07/30/2026 at 10:05 AM, CNA #11 stated, The only time I go into [Resident #57's] room to clean it out is when they are not around, or Resident #57 will become upset. I coordinate with housekeeping to clean the room when the resident will not see them. During an interview on 07/30/226 at 12:52 PM, CNA #5 stated I saw Resident #57 throw the water into the face of LPN #4, and then LPN #4 got into Resident #57's face and stated, let's go clean out your room. CNA #5 stated, I did not report this because I was not sure it was something that needed to be reported. This surveyor attempted to contact MA-C #9 for an interview with no success. During an interview on 07/30/2026 at 1:05 PM, LPN #4 stated, I did not pour water on Resident #57 at any time, I did gesture like I was going to dump tea on them. Earlier in the day I explained to Resident #57 that the room needed cleaned out. I was irritated at this time and took the cups from the resident. During an interview on 07/30/26 at 11:57 AM, the Director of Nursing (DON) stated, we usually let [Resident #57] take cups to the room, and retrieve them later, it is not a big deal. I never would have expected to see what was on the video. After I saw the video, I knew we had to do something. I spoke with LPN #4 on 07/06/2026 regarding Resident #57's behaviors and let her know handling behaviors like this was expected on a dementia unit. The next day LPN # 4 requested to change assignments. During an interview on 07/30/2026 at 3:10 PM, the Administrator stated he believed LPN #4 went to clean out Resident #57's room to cause frustration. After the incident was discovered he immediately suspended LPN #4, CNA #5, #6, #7, #8 and MA-C #9 and terminated them after the investigation. The Administrator also stated that after the incident, the facility conducted education and training on Abuse and Neglect with posttest for staff to ensure understanding. Review of a facility policy titled Abuse, Neglect, Misappropriation and Exploitation Investigation and Reporting with a revised date of 10/18/22, revealed The facility will endeavor to protect residents from Maltreatment, which means adult abuse, sexual abuse, neglect, misappropriation of resident property, and exploitation of residents. It recognizes resident rights to be free from physical, verbal or mental abuse, corporal punishment, involuntary seclusion, and any chemical and physical restraints as defined by federal regulation. The facility has implemented the following actions prior to surveyor entry to the facility to correct the deficient practice effective 07/21/2026: Termination of involved staff, Abuse in-service with posttest, seven days of behavioral monitoring for residents with a BIMS less than 12 in the facility, and the Administrator instituted a Behavioral Care Plan in the secure unit for baseline behaviors and likes. The DON reviews the progress notes every day to monitor for any new behaviors.

Number of residents sampled: Number of residents cited: Based on observation, interview, record review and facility policy review, the facility failed to ensure that medications were stored and labeled in accordance with professional standards. Specifically, the facility failed to ensure an insulin pen was properly dated upon removal from refrigeration for one (Resident #86) of one resident reviewed. The findings include: Review of an admission Record revealed Resident #86 was admitted to the facility with diagnoses that included type two diabetes mellitus with hyperglycemia.Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Data (ARD) date of 05/15/2026 revealed Resident #86 had Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident had severe cognitive impairment. The MDS revealed active diagnoses that included diabetes mellitus and that Resident #86 received an insulin injection seven out of seven days during the look back period. Review of Resident #86's Physician Orders revealed an order start date of 07/09/2026 for insulin [brand name] subcutaneous solution pen injector 100 unit/milliliter (ml). Inject 40 units subcutaneously one time a day for DM [diabetes mellitus]. Review of Resident #86's Care Plan Report revealed Resident #86 had diabetes mellitus that was initiated on 08/21/2025 with interventions that included medications to be administered as ordered by the provider. During an observation and concurrent interview with Licensed Practical Nurse (LPN) #1 of the 600/700/800 Hall medication cart on 07/28/2026 at 2:45 PM, an insulin [brand name] 100 units/3 ml was observed opened without the required opened date or initial use by date indicated on the medication. The insulin pen was observed in a plastic bag, in the top drawer of the medication cart with Resident #86's name on the label. The prescription tag on the pen was without an initial use by date. The prescription label on the plastic bag was dated 07/13/2026. LPN #1 verified the finding and reported that the insulin pen should have been formally dated immediately when it was opened for Resident #86's use. Review of a Medication Administration Record dated 07/01/2026-07/31/2026 revealed Resident #86 received an injection from the insulin pen injector on 07/28/2026 during the 8:00 AM medication pass with Medication Assistant Certified (MA-C) #3 initials. During an interview on 07/28/2026 at 2:47 PM, Registered Nurse (RN) #2 reported that Resident #86 received their daily insulin injection from the undated multi-dose insulin pen despite RN #2's confirmation of facility protocol that indicated undated insulin pens had to be discarded. RN #2 was unable to confirm or verify the exact date the insulin pen was removed from refrigeration. RN #2 confirmed receipt of facility training regarding insulin pens, explicitly acknowledging a rule to date them when opened. RN #2 reported the rational for dating the pen upon removal from refrigeration to the medication cart was to ensure it was not used past its room-temperature expiration date. RN #2 admitted that the opened date should have been confirmed prior to administrating the medication to Resident #86. During an interview on 07/28/2026 at 3:26 PM, the Director of Nursing (DON) reported that staff who removed an insulin pen from refrigeration should date the pen at that time. The DON reported that the subject insulin pen had just been removed from the facility refrigerator yesterday on 07/27/2026. The DON reported they could verify the removal timing based on a joint medication cart inspection conducted yesterday with the Consultant Pharmacist. The DON stated that all insulin pens were checked specifically during the pharmacy audit and all were marked at that time. The DON confirmed that MA-Cs was authorized by the facility to administer insulin and stated that both the specific dose and the resident identity were first verified by a Licensed Nurse. The DON verified that all nursing staff had received formal training regarding the mandatory policy to date insulin pens immediately upon removal from refrigeration. During an interview 07/28/2026 at 3:44 PM, the Pharmacy Consultant reported that all facility medication carts were audited monthly. This review included a physical check of all insulin vials, pens, and other injectable medications. The Pharmacy Consultant verified all insulin formulations were audited for expiration dates during the 07/27/2026 inspection. The Pharmacy Consultant reported that when the 600/700/800 halls medication cart was observed during the inspection on 07/27/2026, there were not any multi-use vials or insulin pens that were undated.During an interview on 07/29/2026 at 10:45 AM, MA-C #3 reported that RN #2 removed Resident #86's insulin pen from refrigeration for administration on 07/28/2026. MA-C #3 confirmed the first use for the insulin pen was 07/28/2026 during the morning medication pass. MA-C #3 was unable to confirm if anyone checked the insulin pen's attached tag for an expiration or opened date prior to administration of the insulin to Resident #86.Review of the manufacturer's specification label on Resident #86's insulin pen indicated that the product must be discarded or used within 28 days after initial opening or removal from refrigeration. Observation and review of the insulin pen cylinder revealed that the remaining medication level had decreased from its original 300 units down to approximately 240 units, confirming previous medication administration. Review of a facility policy titled, Medication Storage in the Facility policy with an effective date of 01/01/15, revealed that medications were stored safely, securely, and properly. Storage protocols must align with manufacturers' recommendations or supplier guidelines.

Based on interview and record review the facility failed to ensure a baseline Care Plan included instructions needed to provide effective and person-centered care for one (Resident #153) of 26 residents reviewed. The findings included:Review of Resident #153's admission Record revealed the facility admitted the resident on 07/22/2026 after an original admission date of 10/04/2024 with a diagnosis that included unspecified dementia with an onset date of 06/27/2025. Review of Resident #153's 5-Day Minimum Data Set with an Assessment Reference Date of 07/29/2026, revealed that Non-Alzheimer's dementia was one of Resident #153's active diagnoses. Review of Resident #153's Care Plan on 07/29/2026 at 10:33 AM, revealed the Care Plan did not identify needs for supervision, behavioral interventions or assistance with activities of daily living as it was related to the resident's diagnosis of dementia. During an interview on 07/30/2026 at 2:51 PM, the MDS Coordinator indicated that it was an oversite that he had not care planned Resident #153's dementia. The MDS Coordinator indicated that he would care plan dementia immediately for Resident #153. During a follow-up review of Resident #153's Care Plan on 07/30/2026 at 3:15 PM, revealed that the MDS Coordinator had care planned Resident #153's dementia with an initiated date of 07/30/2026. The Care Plan did not identify needs for behavioral interventions or assistance with activities of daily living as related to the residents' diagnosis of dementia.

Number of residents sampled: Number of residents cited: Based on interview, record review, and facility policy review, the facility failed to ensure staff reported a witnessed incident of abuse which occurred on 07/06/2026, affecting one (Resident #57) of three residents reviewed. Specifically, staff that witnessed the incident of abuse did not report the incident to the Administrator. The findings include: Review of an annual Minimum Data Set (MDS) with an Assessment Reference Date of 05/15/2026, revealed Resident #57 had a Brief Interview for Mental Status score of 6, which indicated the resident had severe cognitive impairment. The MDS also revealed Resident #57 was independent for all mobility, personal care, and dressing needs, and refused showers/baths. Diagnoses included Alzheimer's disease, anxiety, bipolar and psychotic disorder. Review of the Care Plan revealed Resident #57 resided in the secured unit with an Activities of Daily Living (ADL) self-care deficient due to Alzheimer's/Dementia. Resident #57 exhibited a history of behaviors related to confusion, verbal aggression, yelling, physical aggression, and refusals to allow staff to provide showers. Interventions included for staff to attempt re-direction, offer snacks, and to call the resident's family for a 1:1 conversation. Review of Physician Orders Summary for Resident #57 indicated the resident was admitted to the Long-Term Care Secure Unit on 05/21/2025, no behaviors noted on the Physician Orders Summary. Review of the Reportable, dated 07/06/2026, revealed Resident #57 threw water on Licensed Practical Nurse (LPN) #4. LPN #4 told the resident they could not do that and that staff were going to clean their [Resident #57's] room. Certified Nurses Aid (CNA) #6 took a linen/trash caddy to the hallway in front of Resident #57 room and removed items from Resident #57 room, such as soiled linens and dishes, in front of Resident #57. LPN #4 was described as following Resident #57 down the hall, telling them they could not take cups into [the resident's] room. Resident #57 turned and threw the fluid from the cup on LPN #4. LPN #4 continued to follow Resident #57 and forcibly took the cups from Resident #57's hand. Resident #57 and LPN #4 turned to walk back down the hallway, LPN #4 dumped the remaining contents from the cup on the Resident #57's head. Review of video footage dated 07/06/2026, with the Administrator on 07/30/2026 at 2:55 PM, revealed Resident #57 threw a cup of liquid at LPN #4, who then followed the Resident #57 from the table, stopped extremely close to Resident #57 and was seen on camera waving her hands at Resident #57, the sound was not audible. CNA #5 and CNA #6 were seen in frame, witnessing the incident. LPN #4 followed Resident #57 down the hall toward their room. LPN #4 touched the resident on the left arm in two places. Resident #57 turned and threw a cup of liquid at LPN #4, who then took the cups from Resident #57's hands. Medication Aid-Certified (MAC) # 9 came out of another resident's room and turned towards Resident #57 and LPN #4. LPN #4 took her right hand and poured the contents of the cup on Resident #57's head. Resident #57 immediately turned toward LPN #4 and raised their hand toward LPN #4; MA-C #9 stepped in between LPN #4 and Resident #57 to intervene. At the end of the hallway in line-of-sight CNA #7 and CNA #8 can be seen watching the incident. LPN #4 walked toward CNA #7 and CNA #8 and could be seen speaking with them. During an interview on 07/30/2026 at 11:57 AM, the Director of Nursing (DON) stated she was following up with a request from mental health services to find the triggers for increased behaviors for Resident #57. While reviewing video footage on 07/08/2026 she found the incident from 07/06/2026 involving Resident #57 and LPN #4. The DON noted which staff had witnessed the incident and reported the findings to the Administrator, who started an investigation. During an interview on 07/30/2026 at 12:50 PM, CNA #5 stated, I did not report this because I was not sure if this was something I needed to report. I should have reported it and know now I was in the wrong. During an interview on 07/30/2026 at 1:50 PM, CNA #6 stated, I did not know it was not a reported incident by another staff. During an interview on 07/30/2026 at 3:15 PM, the Administrator stated upon learning of the allegation on 07/08/2026 from the DON, they immediately started an investigation, notifying the Office of Long-Term Care, Police Department, Medical Provider, and the family. All staff that were involved in the incident and who witnessed the incidents without reporting were immediately suspended and later terminated. Review of the facility policy, Abuse, Neglect, Misappropriation and Exploitation Investigation and Reporting Policy, with a revised date of 10/18/2022, revealed alleged, witnessed, or suspected resident maltreatment, including abuse, sexual abuse, neglect, misappropriation of resident property and exploitation of residents, shall be immediately reported to Administrator or immediate supervisor and investigated by Facility management.

Number of residents sampled: Number of residents cited: Based on interview and record review the facility failed to ensure a resident's Power of Attorney (POA) was notified of a medication change for one (Resident #45) of one resident reviewed.The findings include: Review of Resident #45's admission Record revealed the facility admitted Resident #45 on 06/29/2026 with diagnoses which included Parkinson's Disease. Resident #45's family member was listed as the POA for care and emergency contact #1. Review of Resident #45's admission Minimum Data Set with an Assessment Reference Date of 07/06/2026 revealed the resident had a Brief interview of Mental Status score of 9 which indicated that Resident #45 had moderate cognitive impairment. Review of a July 2026 Medication Administration Record revealed Resident #45 was administered Sertraline HCI 25mg at 8:00 AM on 07/15/2026, 07/16/2026/, 07/17/2026, 07/18/2026, 07/19/2026, and 07/20/2026. Review of Resident #45's Electronic Medical Record revealed there was not a consent for administration of Sertraline HCI 25mg approved by the POA. During an interview on 07/27/2026 at 2:52 PM, Resident #45's POA indicated that they were out of town when the facility started Resident #45 on another antidepressant. They indicated that Resident #45 was already on one antidepressant and did not need another one. The POA indicated that Resident #45's spouse had dementia and the spouse approved the antidepressant. The POA indicated that they were not sure if the facility called them, as they had been out of the country at that time. During an interview on 07/29/2026 at 3:28 PM, the Director of Nursing (DON) indicated that Resident #45 was admitted by the facility on 06/29/2026 for therapy. The DON indicated that on 07/13/2026 Resident #45 reported that they were depressed. The DON reviewed the electronic records. The DON indicated that she did not see a note acknowledging the POA consented to start Sertraline. The DON indicated that whoever took the order was responsible for notifying the family. The DON indicated that when Resident #45's POA found out the resident was on Sertraline and Seroquel the POA wanted both medications discontinued. During an interview on 07/30/2026 at 2:40 PM, Licensed Practical Nurse (LPN) #10 indicated that she called Resident #45's family and left a voicemail since they were out of the country. LPN #10 indicated she then called Resident #45's second emergency contact and informed them that Resident #45 was starting some new medications. LPN # 10 indicated that she did not get Resident #45's family member to sign a consent form. LPN #10 indicated that she did not document that she talked to Resident #45's emergency contact #2, or that consent was given. During a follow-up interview on 07/30/2026 at 3:03 PM, the DON indicated that Resident #45's POA was out of the country and was the only one authorized to consent to Resident #45's medication changes. The DON indicated that LPN #10 talked to Resident #45's second emergency contact who was not authorized to give consent. During an interview on 07/30/2026 at 3:10 PM, the Physician Assistant (PA) indicated that family should be called for new medications. The PA indicated that orders have a pending confirmation and should not be started until family was notified. The Physician Assistant indicated that Resident #45 was on Seroquel when admitted and it was decreased. Sertraline was a new medication. The PA indicated that the staff informed her that Resident #45 may be depressed, and had made some comments to the nurse, don't remember their exact words. During an interview on 07/30/2026 at 4:15 PM, the Administrator indicated that the staff should have contacted the POA if medication changes were needed. The administrator indicated that if there was another contact that was authorized to consent to medication changes then they should be contacted. The administrator indicated that the floor nurse that took the medication order should be the one to contact the family with medication changes. The administrator indicated that the facility does not have a policy on notification of medication changes.

Number of residents sampled: Number of residents cited: Based on facility record review and interview, the facility failed to ensure the Ombudsman was notified of an emergency transfer or discharge for two (Resident #143 and #145) of two residents reviewed for hospitalization or discharge. The findings included: Resident #143Review of an admission Record revealed Resident #143 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, congestive heart failure, hypoxemia, acute kidney failure and atherosclerotic heart disease.Review of a discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/21/2026 revealed Resident #143 was coded as, discharge return not anticipated. Review of a facility Hospital Transfer Form revealed Resident #143's date of transfer to an acute care hospital, was 05/21/2026 at 7:00 AM. Review of Resident #143's Order Summary Report revealed an order dated 05/21/2026 that indicated may send to [Local] ER (Emergency Room).Review of Progress Notes dated 05/21/2026 revealed Resident #143 had been assessed by telemedicine for a decline in condition, and after reviewing the diagnostic results and family conference, it was decided to transfer the resident to acute care. Resident #145 Review of an admission MDS with an ARD of 05/14/2026, revealed the facility admitted Resident #145 on 05/07/2026 with diagnoses that included myocardial infraction, muscle weakness, peripheral vascular disease, and acute respiratory failure. Review of Progress Notes dated 05/15/2026 revealed Resident #145 was discharged to acute care for shortness of breath. A review of the facility's Emergency Transfers from Facility dated May 2026 and June 2026 revealed Residents #143 and #145 had not been added to the monthly ombudsman discharge notification list. Further review of the medical records and communication logs failed to reveal any documented evidence that the facility provided timely notification of these emergency transfers or discharges to the regional ombudsman. During an interview on 07/29/2026 at 3:55 PM, the Administrator reported that he sends out a report on or around the 15th of every month to the ombudsman. The Administer reported that the Business Office Manager (BOM) was ultimately responsible for sending the Emergency Transfers List report monthly to the ombudsman and updating the form. During an interview on 07/30/2026 at 12:55 PM, the BOM confirmed it was their responsibility to update and report monthly emergency transfers to the ombudsman via email. After the BOM reviewed the Emergency Transfers List dated May 2026 and June 2026, the BOM confirmed that it was the correct form for notification of the ombudsman and verified they did not report to the ombudsman in any other form. The BOM confirmed the regional ombudsman had not been notified of the emergency transfer or discharge for Residents #143 or #145. The BOM reported they were not aware of the facility having an ombudsman notification policy. During a phone conversation on 07/31/2026 at 1:18 PM, the regional ombudsman reviewed their documents and confirmed that they had not been notified of the emergent transfers of Resident #143 and #145 in May or June 2026.

Based on observation, interview, and record review, the facility failed to ensure foods stored in the freezer were covered and sealed; 1 of 2 ice machines were maintained in clean and sanitary condition; expired food items were promptly removed, and dietary staff washed their hands before handling clean equipment or food items for 2 of 2 meals observed. The findings are: 1. On [DATE] at 1:22 PM, the following observations were made in the walk-in freezer. a. An opened box of fish. The box was not covered or sealed. b. An opened box of breaded chicken. The box was not cover or sealed. 2. On [DATE] at 1:27 PM, the following observations were made in the kitchen area. a. An opened bottle of lemon juice was on a shelf above the food preparation counter with an expiration date of [DATE]. The Dietary Manager (DM) was interviewed and was asked what she used lemon juice for. The DM stated the staff used it when they had a recipe that called for it, but they have not used it to bake anything in a long time. b. A bottle of lemon juice was on a shelf in the storage room with an expiration date of [DATE]. 3. On [DATE] at 1:49 PM, inside the back wall of the ice machine in a hall opposite the kitchen had buildup of wet black residue on it. This surveyor asked the DM if she could wipe the area where the wet black residue was observed. She did. Solid black residue easily transferred to the tissue. This surveyor asked the DM if she could describe what she saw on the back wall of the ice machine, where ice cubes were resting. She stated it was wet black residue. The DM was interviewed and was asked how often the ice machine was cleaned and who used the ice from the ice machine. She stated it was cleaned once a week, then sanitized every six (6) months. The kitchen staff used it to fill beverages served to the residents at mealtimes, and the Certified Nursing Assistants (CNA) also used it for the water pitchers in the residents' rooms. 4. On [DATE] at 1:52 PM, the scoop holder attached to the body of the ice machine had wet brown residue at the bottom of it and the ice scoop was resting directly on it. This surveyor asked the DM if she could wipe the wet brown residue. She did so, and the wet brown residue easily transferred to the tissue. This surveyor asked the DM if she could describe what she saw at the bottom of the scoop holder and how often the scoop holder got cleaned. She stated it was cleaned every week, and there was a brown residue. 5. On [DATE] at 2:03 PM, Dietary Aide (DA) #1 pushed a cart with an empty glass toward the refrigerator. DA #1 opened the refrigerator, removed pitchers of tea, punch, orange juice, and cartons of milk and placed them on the counter. DA #1 did not wash her hands when she picked up glasses by their rims and poured beverages to be served to the residents who requested juice with their supper meal. DA #1 was interviewed and was asked what she should have done after touching and before handling food items. DA #1 confirmed she should have washed her hands. 6. On [DATE] 02:12 PM, Dietary [NAME] (DC) #2 turned on the sink faucet and washed his hands. He used his bare hands to turn off the faucet, contaminating his hands. DC #2 picked up scissors from the counter and placed in a cup on a shelf above the food preparation counter. DC #2 did not wash his hands when he removed the gloves from the glove box and put them on, contaminating the gloves. DC #2 then used his contaminated gloved hand to remove slices of bread from the bread bag and placed them on a pan liner to be used for making pimento cheese sandwiches for the supper meal. DC #2 was interviewed, and based on current observations, he was asked what he should have done after touching dirty objects and before handling food items. He stated he should have washed his hands before putting on gloves and handling food. 7. On [DATE] at 2:15 PM, DA #3 turned the sink on and washed her hands. She used her bare hands to turn off the faucet, contaminating her hands. Without washing her hands, she picked up plates and placed them on a clean cart to be used in portioning food items to the residents for the supper meal with her fingers inside of the plates. DA#3 was interviewed and was asked what she should have done after touching and before handling food items. DA #3 confirmed she should have washed her hands. 8. On [DATE] at 4:00 PM, DA #1 turned on the hand washing sink and washed her hands. She turned off the faucet with her bare hands, contaminating her hands. Without washing her hands, she picked up picked up glasses by their rims and placed them on a cart to be used in serving beverages to the residents for the supper meal. On [DATE] at 04:02 PM, DA #1 opened the refrigerator, removed a carton of silk milk, a pitcher tomato juice, and orange juice. Without washing her hands, DA #1 picked up glasses by their rims and poured beverages to be served to the resident for the supper meal. 9. On [DATE] at 4:14 PM, DA #1 pulled her blouse down, then pushed her sleeves back, contaminating her hands. Without washing her hands, DA #1 picked up glasses that contained beverages from the cart by their rims and placed them in the cooler by the steam table to be served to the residents for the supper meal. 10. On [DATE] at 7:34 AM, DC #4 was on the tray line serving the breakfast meal. She picked up tray cards and placed them on the trays. Without washing her hands, DC #4 picked up plates and placed them on the trays to be used in portioning food items to be served to the residents for lunch with her fingers inside the plates. DC #4 was interviewed and was asked what she should have done after touching and before handling food items. DC #4 stated she should have washed her hands, 11. A review of facility policy titled, Food Safety-Infection Control and Hand washing initiated [DATE] and provided by the DM indicated hands should be washed entering the kitchen and before, during and after food preparation.

50923 Based on observation, interviews, record review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for 2 (Resident #56 and Resident #61) of 2 residents reviewed for MDS accuracy. Specifically, the facility failed to ensure information regarding the resident's hearing was accurately completed for Resident #56, and Resident # 61 was inaccurately coded for hospice services. The findings are: A review of the Order Summary dated December 2024, indicated the facility admitted Resident #56 with diagnoses of fracture of left femur, urinary tract infection (UTI), and history of falls. The admission Minimal Data Set (MDS), with Assessment Reference Date (ARD) of 10-31-2024, revealed that Resident #56 ' s hearing was adequate. Resident #56 ' s Brief Interview for Mental Status (BIMS) was a 9 and indicated moderately impaired cognitive impairment. A review of Resident #56 ' s care plan, with initiation date of 10-28-2024, did not reveal that Resident #56 was hard of hearing or required use of a hearing aid. A review of the Admission Record indicated that Resident #56 was hard of hearing and had a left hearing aid in ear. On 12/11/24 at 04:02 PM, the surveyor visited Resident #56. The resident was unable to hear the surveyor. A Certified Nursing Assistant (CNA) in the room leaned into resident ' s ear and spoke loudly. The resident heard and responded to the surveyor. The surveyor observed Resident #56 wearing a hearing aid in the left ear. During an interview with Restorative Nursing Aide (RNA) #5, on 12/11/24 at 04:04 PM, she stated that resident was hard of hearing. She was unsure if the resident had hearing aids or not. RNA #5 reviewed the closet care plan and verified that hard of hearing and hearing aid neither one was on there for review. During an interview with the MDS Coordinator, it was revealed that Resident #56 was hard of hearing. She had no knowledge that Resident #56 had a hearing aid. It was also revealed that hearing was coded as adequate on the MDS and in fact it was coded incorrectly. Review of the Admission Record revealed Resident #61 was admitted on [DATE] with a diagnosis of type II diabetes mellitus with diabetic polyneuropathy. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/2024, revealed Resident #61 had a Brief Interview for Mental Status (BIMS) score of 11 (8-12 suggest moderate cognitive impairment). Per section GG of the MDS, Resident #61 required partial to moderate assistance with Activities of Daily Living (ADLs) and ambulated with the assistance of a walker or manual wheelchair. In section O, sub-section K1, it was noted that Resident #61 was under hospice care. During an interview on 12/09/2024 at 1:30 PM, Resident #61 confirmed the resident did not receive hospice care. Upon review of the physician orders, Resident #61 did not have an order for hospice care. During an interview on 12/09/2024 at 1:45 PM, Licensed Practical Nurse (LPN) # 6 confirmed Resident #61 was not ordered or received hospice care. During an interview on 12/12/2024 at 9:30 AM, the MDS Coordinator-LTC confirmed Resident #61 was not receiving hospice care and confirmed hospice was selected in section O, sub-section K1. The MDS Coordinator -LTC was asked why it was important to have accurate assessments of the residents within the MDS. The MDS Coordinator -LTC stated, Because the MDS is what helps create the care plan. The care plan is what the staff use to care for the residents. A facility policy titled Resident Assessment with no date was reviewed. The review revealed that comprehensive assessments will describe significant impairment in functional capacity. Therefore, to develop a care plan to be able to provide appropriate care and services for the resident.

Based on facility policy review, record review, and interviews, the facility failed to develop a person centered, comprehensive care plan for hearing loss or use of hearing aid for 1 (Resident #56) of 1 sampled resident reviewed for hearing loss. The findings are: A review of the facility policy titled Resident Assessment revealed that comprehensive assessments will describe significant impairment in functional capacity. Therefore, to develop a care plan to be able to provide appropriate care and services for the resident. A review of the December 2024 order summary indicated the facility admitted Resident #56 with diagnoses of fracture of left femur, urinary tract infection (UTI), and history of falls. The admission Minimal Data Set (MDS), with Assessment Reference Date (ARD) of 10-31-2024, revealed Resident #56 ' s hearing was adequate. Resident #56 ' s Brief Interview for Mental Status (BIMS) was a 9 and indicated moderately impaired cognitive impairment. A review of Resident #56 ' s care plan, with initiation date of 10-28-2024, did not reveal that Resident #56 was hard of hearing and required use of a hearing aid. A review of previous Admission Record, dated 8-7-2024, indicated that Resident #56 was hard of hearing and had a left hearing aid in ear. On 12/11/24 at 04:02 PM, the surveyor visited Resident #56, and the resident was unable to hear the surveyor. A Certified Nursing Assistant (CNA) in room leaned into resident ' s ear and spoke loudly. The resident heard and responded to the surveyor. The Surveyor observed the resident wearing a hearing aid in the left ear. During an interview with Restorative Nursing Aide (RNA) #5, on 12/11/24 at 04:04 PM, she revealed that the resident was hard of hearing. RNA #5 was unsure if the resident had hearing aids or not. She reviewed the closet care plan and stated hard of hearing and hearing aid neither one was on there for review. During an interview with the MDS Coordinator-Skilled it was revealed that Resident #56 was hard of hearing. The MDS Coordinator-Skilled had no knowledge that Resident #56 had a hearing aid. The MDS Coordinator-Skilled stated she did not add hearing loss or hearing aid usage to the care plan. The MDS Coordinator-Skilled revealed it was important to add these types of things to care plan because it was the guidance of how care was given to the resident.