Every finding on record at Hidden Valley Center

Based on staff interview and observation, the facility failed to ensure a safe, clean home-like environment for residents by not providing clean linen and an adequate amount of linen available for resident use. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 76.a) Mary's Garden On 05/12/26 at 1:00 PM, a tour of the unit was completed. The linen storage room was observed. The observation found minimal linen available for residents. There were seven (7) towels found in the closet. One (1) of the seven (7) towels was noted with a dark brown stain. There were 11 wash cloths found in the closet. Eight (8) of the 11 wash clothes were noted with dark brown stains, white bleach stains as well as faded colors and frayed areas. There were no fitted sheets available, only four (4) flat sheets, and three (3) blankets were available at this time. An interview was held with the Administrator of Mary's Garden on 05/12/26 at approximately 1:20 PM. The Administrator was notified of the stained linen as well as the unavailability of all the linen. The Administrator stated, we can throw those away and laundry can bring us some more. On 05/12/26 at 1:30 PM, an interview was held with Housekeeper #41 in the facility linen storage area. An observation of multiple stacks and boxes of new linen were on the shelves around three walls of the storage room. Housekeeper #41 confirmed multiple stacks of linen in plastic and boxes of new linen were stored in the room. Housekeeper #41 stated, I'm not putting any of this out now, there is still available linen on the floor. On 05/12/26 at approximately 5:15 PM, an interview was held with the Facility Administrator as well as the Senior Administrator. The Facility Administrator as well as the Senior Administrator were notified of the unavailabilty of linen on Mary's Garden and throughout the facility. Both Administrators stated, we were unaware. The Senior Administrator stated, we need to go tell Housekeeper #41 that the new linen needs to be made available. The Facility Administrator stated, we order linen every month .this should not be an issue. B Hall On 05/12/26, the storage room where clean linens and towels are stored was investigated by the state surveyor. No blankets, top sheets, bottom sheets, or pillow cases were located on the linen shelves. Minimal towels and washcloths were observed At 1:05 PM, Nurse Aide #70 confirmed the lack of linens and stated, 'll tell laundry now.

Based on record review, observation and staff interview, the facility failed to ensure a safe environment from avoidable accidents/hazards over which the facility had control. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #29. Facility Census: 76.Findings included:a) On 05/12/26, the Hospice Nurse Aides reported frequent bruising and skin issues for Resident #29. The Hospice Nurse Aides reported they always made nursing aware, including the Hospice supervising Registered Nurse. On 05/07/26 at 9:59 AM, the Hospice Nurse Aides reported they observed a fresh bruise on the resident's at leg. No documentation of the bruise was documented by the facility on the skin checks.The Hospice Nurse's Note documented the following:02/03/26 - Bruising present to knees.02/10/26 - She has scabs to bilateral knees. She does hit the wall with her legs, at times.02/19/26 - Red abrasions noted to left hip. Slight discoloration to knee but resolves.02/24/26 - Scabbed area to back of right heel. Bruise to right upper arm.02/26/26 - Assisted CNA with bathing patient. Small bruised area to mid spine.02/26/26 - Small bruised area to mid spine. L hip with small open area noted.02/27/26 - Scabbed area to back of right heel. Bruise to right upper arm.03/03/26 - Facility managing skin breakdown to L hip.03/17/26 - Small bruised area to mid spine appears to be healing. 03/12/26 - Slight purple discoloration on feet and knees however patients cool to touch and her small blanket doesn't cover her whole body when she pulls it over her face.03/19/26 - Patient has discoloration to BLE, splotchy, purple color noted from knees down, multiple Blanchable areas to bilateral feet.04/13/26 - Scabbed area to left knee and foot.04/14/26 Scabs to left knee and left foot due to hitting legs against the wall.04/16/26: Small, scattered bruising noted on lower extremities and a small bruise present on the right upper arm (RUA).04/21/26 Bruise on the right upper arm (RUA). Small scabs to bilateral knees.04/23/26 She has multiple scabs on bilateral knees. Scratch on right abdomen.04/30/26 Scattered bruising noted on lower extremities. Patient kicking the wall frequently.04/28/26 Scattered bruising noted to lower extremities. Patient kicks the wall frequently.05/05/26 Scattered bruising noted to lower extremities. Patient kicks the wall frequently.The facility's Skin Checks documentation was reviewed for Resident #29. The documents stated the following: On 05/13/26 at 9:25 AM, the state surveyor observed a yellow bruise-like skin discoloration on Resident #29's right leg on the back of the leg below the bend of the right knee. Bruise-like discolorations were observed on the resident's feet On 05/13/26 at 3:00 PM, the Director of Nursing (DON) confirmed bruising on the resident's feet and legs. The state surveyor reviewed the most recent skin check completed on 05/12/26 with no skin issues documented. The DON confirmed the skin issues and stated, I will get a new skin assessment.During the observation of the resident in her bed, the State Surveyor and DON observed the resident's feet hitting the foot board at the end of the bed multiple times.On 05/12/26 at 5:09 PM, the Senior Administrator stated, She has Huntington's Disease and hits the wall.The resident's BIMS on 05/05/26 was 00. The resident was judged to be incapacitated on 07/12/23.The facility's policy and procedure for Accidents /Incidents stated, Take immediate action post-accident/incident measures as deemed appropriate. The purpose was stated to determine a root cause and contributing factors, identify measure to reduce further occurrences and adverse outcomes as part of the Quality /assurance Performance Improvement (QAPI) process.

Based on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. Additionally, the facility failed to follow the proper sanitation practices for the kitchen and the food preparation equipment. This practice had the potential to affect all of the residents. Facility census: 74. Findings include:a) Healthcare Services Group (HCSG) policy #28 titled Environment states:All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition.The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation.All food contact surfaces will be cleaned and sanitized after each use.The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces.The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces. b) The HCSG Policy #27 titled Equipment states: All foodservice equipment will be clean, sanitary, and in proper working order. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. All staff members will be properly trained in the cleaning and maintenance of all equipment. All food contact equipment will be cleaned and sanitized after every use. All non-food contact equipment will be cleaned and free of debris. The Dining Services Director will submit requests for maintenance or repair to the Administrator and / or Maintenance Director as needed. c) The HCSG policy #19 titled Food Storage: Cold Foods states: All Time / Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded. d) The HCSG policy #22 titled Ware washing states: All dishware, service ware, and utensils will be cleaned and sanitized after each use. All dishware will be air dried and properly stored. 04/13/26 at 10:36 AMe) Initial kitchen observationThe Healthcare Services Group (HCSG) District Manager (DM) accompanied me during this walkthrough and verified the findings.The reach-in refrigerator did not have a documented temperature for PM shift on 04/12/26 or for AM shift on 04/13/26.The can opener was soiled.The box of food thickener located in the dry storage room did not have an open or use by date.The steamer was broken down.The inside of the microwave was soiled.The toaster crumb tray was soiled.The ice scoop was in the ice machine stuck inside of the ice.There was one food cart soiled inside and out.There were three (3) ceiling vents that were soiled with debris.The HCSG DM stated that the temps for the reach-in refrigerator were missed. I will have the can opener based cleaned also. I will put a date on the food thickener. We are supposed to get a new steamer. He let the cook know about the toaster and microwave needing to be cleaned. He removed the ice scoop from the ice and had it sanitized and stored properly. He stated the food cart will be cleaned now, we were running behind today. He stated that I will put the ceiling vents needing to be cleaned in the maintenance system called TELS. 04/13/26 at 11:06 AM The microwave located in nourishment room [ROOM NUMBER] was soiled. 04/15/26 at 11:30 AM Follow up visit to the kitchen findings: There was a soiled latex glove sitting on the counter top beside the steamer.There was one (1) soiled cleaning cloth sitting on the counter top beside the food processor.The HCSG DM tested two (2) buckets with a sanitizer test strip, neither one registered any sanitizer. The were located on a shelf under the table beside the steam table.There was one (1) oven rack sitting directly on the floor.There was one (1) cold food container not stored correctly.There was no sanitizer bucket log available.The HCSG DM stated that the oven rack should be anywhere but there. He also stated that the sanitizer bucket log should be hanging up, but I cannot find it. He told the kitchen staff that you need to place the cleaning cloths in a bucket with sanitizer, when not in use. I asked the DM for a copy of the last six (6) months of the sanitizer bucket log. He could only provide me with half of November 2025 and all of December 2025 and January 2026. Nothing for February, March or April 2026. 04/15/26 at 12:07 PM The meal trays that were being used to serve the residents on Mary's Garden unit were wet nesting. The DM stated that the meal trays should have been air dried prior to the lunch meal service.

Based on observation, record review, resident interview, and staff interview, the facility failed to maintain an infection control program during medication administration and offering hand hygiene prior to the meal service. These were random opportunities for discovery. Resident identifiers: #45, #84, #41, #87 and #50. Facility Census: 74. Findings Include: a) Resident #45 On 04/21/26 at 8:15 AM, observations were made of Licensed Practical Nurse (LPN) #24 during medication administration. LPN #24 touched the pills while removing them from the bubble pack: -Norvasc 5mg (milligram) -Depakote DR (delayed release) 250mg -Oxybutyin ER (extended release) 10mg --Lasix 40mg --Prednisone 20mg On 04/21/26 at 9:01 AM, LPN #24 was asked, Do you normally touch the pills as you pop them out of the bubble packs? LPN #24 stated, oh did I? .I didn't realize I did, b) Resident #84 On 04/21/26 at 8:21 AM, observations were made of LPN #24 during medication administration. LPN #24 touched the pills while removing them from the bubble pack and administered insulin without donning gloves: -Norvasc 5mg -Doxycycline 100mg -Eliquis 2.5mg -Potassium Chloride 10meq (milliequivelant) -Lantus 15 units On 04/21/26 at 9:01 AM, LPN #24 was asked, Do you normally touch the pills as you pop them out of the bubble packs? Do you normally administer insulin without wearing gloves? LPN #24 stated, Oh, did I? . I didn't realize I did . You are right . I didn't wear gloves. c) Resident #41 On 04/21/26 at 8:49 AM, observations were made of LPN #24 during medication administration. LPN #24 touched the pills while removing them from the bubble pack: -Eliquis 5mg -Novantik 25mg -Protonix 40mg On 04/21/26 at 9:01 AM, LPN #24 was asked, Do you normally touch the pills as you pop them out of the bubble packs? LPN #24 stated, oh did I? .I didn't realize I did, On 04/21/26 at approximately 9:06 AM, the Corporate Registered Nurse (RN) #80 was notified regarding LPN #24 touching the pills and administering insulin without donning gloves. Corporate RN #80 stated, they know what to do . d) Resident #87 On 04/13/26 at 12:25 PM, nurse aides were observed passing lunch trays on A hallway. Resident #87 received her lunch tray at 12:27 PM. The resident was asked, Did the staff offer you a way to complete hand hygiene? Resident #87 stated, No . they didn't. On 04/13/26 at approximately 12:33 PM, the Director of Nursing (DON) was notified that residents were not offered a way to complete hand hygiene on A hallway. The DON stated, She hasn't been given a lunch tray yet. At this time, the DON observed the resident eating the food from her lunch tray. The DON stated, hand hygiene should be offered to the resident from the staff. On 04/13/26 at approximately 1:15 PM, Corporate RN #80 was advised Resident #87 was not offered a way to complete hand hygiene prior to the noon meal. The Corporate RN #80 stated, staff should be offering residents a way to complete hand hygiene. e) Resident #50 - On 04/13/26 at 11:50 AM, during the Main Dining Room Investigation, Resident #50 returned to the dining room for the lunch meal. The resident's lunch tray was set up by Activity Assistant #85. No hand hygiene was observed to be performed upon return to the main dining room. At 11:55 AM, Activity Assistant #85 confirmed the resident did not receive hand hygiene upon return to the dining room. The facility's policy and procedure for Patient Hand Hygiene stated, Staff should assist patient/residents (hereinafter patient) with hand hygiene after toileting and before meals, as needed.

Based on record review, staff interview and observation, the facility failed to provide a homelike dining environment for the resident's in the facility's main dining room. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 74.Findings included:a) On 04/13/26 at 11:20 AM, the Dining Room task was initiated in the facility's main dining room. The wallpaper beside the kitchen door was torn in multiple places and had separated at the seams. Holes where screws had been removed and multiple screws were observed in the wall. [NAME] glue was spread over the wall in places. The length of the damaged wall was approximately eight (8) feet in length.On 04/13/26 at 11:26 AM, Administrator #79 confirmed the wall damage and reported there was no maintenance director at this time, but the repair was on a list. At 11:30 AM, Administrator #79 reported the wall repair would be a priority this afternoon. The facility's Policy and Procedure for Meal Service stated, Meal service may occur in dining room, patient rooms, and other suitable locations that promote a homelike environment.

Based on observation, record review and staff interview, the facility failed to ensure the residents' environment remains as free, from accident hazards as possible, by leaving a medication cart unlocked. This was a random opportunity for discovery. Facility Census: 74.a) Medication Cart On 04/15/26 at 4:40 PM, staff observed an unlocked medication cart near the nurses' station. At this time, no staff members were near the medication cart. Assistant Administrator #83 was present during this observation. Assistant Administrator #83 entered the nurses' station and asked, Whose medication cart is this? Licensed Practical Nurse (LPN) #76 stated, It's mine . I usually always lock it. Assistant Administrator #83 confirmed the medication cart was unlocked while unattended. b) Facility Medication Administration Policy On 04/21/26 at 9:00 AM, Corporate Registered Nurse (RN) #80 was notified of the observation from 04/15/26. Corporate RN #80 provided the facility policy entitled Medication Administration General Guidelines, Number 17, which stateD, During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse . The cart must be visible to the personnel administering medications when unlocked.

Based on food tray temperatures, resident interviews and staff interviews, the facility failed to serve food that was palatable and at a safe and appetizing temperature to prevent foodborne illness. The facility failed to ensure hot foods were served hot. This failed practice was true for one (1) of one (1) meal trays tested throughout the survey process. Residents identified: #20 and #50. Facility census: 74.Findings include: a) Healthcare Services Group policy #16 titled Food: Preparation states: All foods are prepared in accordance with the FDA Food Code. b)This surveyor made a second visit to the kitchen and observed the lunch meal service. When the dietary staff started to make the meal trays for the residents located on Mary's Garden Memory Unit, I asked for a test tray to be made and sent. After all the residents were served at 12:39 PM, the Healthcare Services Group (HCSG) District Manager (DM) used a thermometer to take the temperatures of each food item served. The Administrator was present for this. The temperatures were as follows: Hotdog 110.7 degrees Fahrenheit (F)Baked beans 128.9 degrees FChicken noodle soup 146 degrees FVanilla ice cream 27.4 degrees FAt the time of receipt by the resident, foodsshall be at a temperature of no less than 120 F for hot foodsand no more than 50 F for cold foods. Per the Food Code.c) Resident #20 stated the food is terrible.d) Resident #50 stated some food is so bad, I have to spit it out.

Based on record review and staff interview the facility failed to ensure pharmacy recommendations were acted upon by the resident attending physician. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications. Resident Identifier: 72. Facility Census: 74. Findings Include: a) Resident #72 A review of Resident #72's medical record found a pharmacy recommendation dated 10?04/25 which read as follows: This resident is diagnosed with dementia and receiving the antipsychotic Zyprexa 5 mg twice daily. Please indicate the appropriate clinical situation the continued use of this medication: () Behavioral symptoms present a danger to the resident or other AND one or both of the following() Symptoms identified due to mania or psychosis (auditory, visual hallucinations, delusions (paranoia or grandiosity) or () Behavioral interventions have been attempted and included in the plan of care. Resident continues to benefit from continued therapy. Further review of this recommendation the attending physician placed a check mark in the parentheses in front of the following statement: () Behavioral symptoms present a danger to the resident or other AND one or both of the following However the last two statement both remained unchecked. The attending physician signed the recommendation on 10/29/25. An interview with the the Market Clinical Advisor in the afternoon of 04/20/26 confirmed the physician did not completely address the pharmacy recommendation. No NotesWOLFE, [NAME] (72) Lucas, [NAME] (31826) - RESIDENT NOTE No Notes

Based on a review of a facility reported incident (FRI) and staff interview it was determiend the facility failed to use the results of the investigation to determine the appropriate action to take regarding education of staff following a resident's fall with major injury. Resident identifier: #78. Facility census: 74. a) Resident #78 An investigation for a Facility Reported Incident (FRI) was initiated on 04/20/26. A random discovery was found pertaining to an additional FRI dated 06/13/25 that was reviewed during the investigation. It was determined the facility failed to implement corrective action for staff education following a fall with major injury for Resident #78 for FRI dated 06/13/25. The Initial Report of Allegations dated 06/13/25 stated the resident had a fall and was sent to the hospital. The hospital called the facility and stated the resident had a fracture of the right shoulder and collarbone on 06/14/26. The Five-Day Follow-Up Investigation Report, submitted 06/18/25, stated the nurse assessed the resident for injuries, noting a hematoma to the top right side of her scalp at the time of the incident. Resident complained of right knee pain on assessment. The resident's Medical Power of Attorney requested the resident be sent to the Emergency Room. A verbal report from the emergency room was received by the facility that the resident had sustained a right scapula fracture. The facility's actions to be taken as a result of the investigation or allegation stated, All staff are being educated on safe resident handling. Education provided to the state surveyor was completed on 06/18/25 for two (2) nurse aides only. No training was provided to additional staff members. Corporate Registered Nurse #80 confirmed two (2) staff members were educated for the FRI dated 06/13/25. \

Based on record review and staff interview, the facility failed to provide an accurate Minimum Data Set (MDS) assessment upon discharge for Resident #79. This was true for one (1) of four (4) residents reviewed under the care area of discharges. Resident Identifier: #79. Facility Census: 74.Findings Include: a) Resident #79 On 04/21/2026 at 1:20 PM, a record review was completed for Resident #79. The review found the resident was discharged from the facility on 08/27/24. The resident would not be returning to the facility. However, the MDS, dated [DATE], indicated the resident was discharged but return to the facility was anticipated. On 04/21/26 at 1:40 PM, Corporate Nurse #80 confirmed the resident was discharged from the facility and did not return.

Based on record review and staff interview, the facility failed to ensure a resident's Pre-admission Screening and Resident Review (PASARR) included a diagnosis of Post-Traumatic Stress Disorder (PTSD). This was true for one (1) of 28 residents reviewed during the survey process. Resident #13. Facility Census: 74. Findings Include: a) Resident #13 Resident #13 was admitted on [DATE]. A review of the resident's comprehensive minimum data set (MDS) with an assessment reference date (ARD) of 03/03/26 revealed a diagnosis of Post-Traumatic Stress Disorder (PTSD). A review of the PASARR dated 02/20/26 found that the diagnosis of Post-Traumatic Stress Disorder (PTSD) was not included in the PASARR. On 04/13/26 at 4:00 PM, Corporate Registered Nurse (RN) #80 confirmed the PTSD diagnosis was not included on the PASARR.

Based on record review and staff interview, the facilty failed to develop a care plan regarding a urinary catheter for Resident #5 and failed to implement a care plan for blood glucose monitoring for Resident #8. Resident Identifiers: #5 and #8. Facility Census: 74.a) Resident #8 Review of clinical documentation revealed a blood glucose (BG) result of 67 mg/dL on 04/1/26 at 08:07 AM The resident's care plan specified that the physician must be notified for blood glucose readings less than 70 mg/dL or greater than 450 mg/dL. However, the medical record contained no evidence that the physician was notified of the low blood glucose result as required by the care plan. This failure to implement the care plan interventions placed the resident at risk for delayed recognition and treatment of hypoglycemia. This was confirmed with Corporate Nurse #80 on 04/15/26 at approximately 9:00 AM. Findings Include: b) Resident #5 On 04/20/2026 at 11:40 AM, a record review was completed for Resident #5. The review found on the care plan, a incomplete focus area for a urinary catheter. The focus area states,Resident requires indwelling (supra-pubic or foley or urostomy) catheter due to other:_____. (Typed as written.) The resident did require an 18 french (FR) foley catheter for urinary retention and obstruction. On 04/21/2026 at 10:49 AM , the Corporate Registered Nurse (RN) #80 confirmed the focus area had not been developed to indicate the type of catheter or the reason for the catheter.

Based on record review and staff interview, the facility failed to ensure a resident's plan of care was updated for a Change in Condition (CIC). This failed practice had the potential to affect a limited number of residents. Resident Identifier: #46. Facility Census: 74.Findings included: a) Resident #46 A Change in Condition (CIC) was completed on 04/14/26 for Resident #46 for the following: Nursing observations, evaluation, and recommendations are: resident was scratching right cheek and left a scratch. Fingernails were checked and were short. Resident was educated not to scratch face. A scratch was observed on the resident's right cheek by the state surveyor on 04/13/26 and 04/14/26. The resident's care plan was reviewed and no update was found for the CIC.b) On 04/20/26 at 11:50 AM, Corporate Registered Nurse #80 confirmed that the Change of Condition for Resident #46 was not initially updated on the care plan and stated, I updated the care plan.

Based on record review and staff interview, the facility failed to ensure a Physician's Order for Scope of Treatment (POST) and eight (8) consents were signed and dated by Resident #13, who has capacity, and ensure a resident's code status was correctly documented in the medical record for Resident #48. This was true for two (2) of 28 residents reviewed during the survey process. Resident Identifiers: Resident #13 and #48. Findings Include: a) Resident #13 On 04/14/2026 at 1:12 PM, a record review was completed for Resident #13. The review found the resident had capacity to make medication decisions. The physician's determination of capacity was completed by the facility physician on 03/04/26. Upon further review, the following forms and consents were not signed by the resident: --POST form --Influenza Vaccine informed consent --Vaccination informed cosent/declination for varicella (chicken pox), shingles, respiratory syncytial virus (RSV), Measles, Mumps, Rubella, Varicella (MMRV) and Tetanus, Diptheria, Pertussis (Tdap) --Psychotropic Medication Administration Administration Disclosure --Patient Informed Consent or Declination COVID-19 Vaccine 2025-2026 --Consent and Authorization to Screen, Evaluate and Treat by MTC care --Pneumococcal Vaccine Informed Consent --Consent for Wound Photography The above listed consents were signed by the resident's spouse. On 04/14/26 at 2:30 PM, Corporate Registered Nurse (RN) #80 stated, he had a stroke and he cannot sign his name.Corporate RN #80 was asked, Is there any documentation to verify the resident wanted his spouse to sign the consents? The Corporate RN stated, no there is no documentation to verify this .I understand .the reason needed to be documented and the consent could have been taken verbally with 2 (two) witnesses. b) Resident # 48 On 04/13/26, Resident's #48's Advanced Directive was reviewed. The Resident's Advance Directive Acknowledgement Form was marked, Do not perform cardiopulmonary resuscitation. and was signed by the physician on 04/01/26. The resident's order stated , DO NOT RESUSCITATE (DNR). COMFORT MEASURES. NO ARTIFICIAL MEANS OF NUTRITION. During the documentation review, a physician progress note, dated 04/01/26, was initiated on 04/02/26 and signed on 04/06/26 stating that the resident was a Full Code. A physician's progress note dated 04/08/26 also stated that the resident was a Full Code. On 04/14/26 at 3:45 PM, the Director of Nursing confirmed the physician progress notes documenting Full Code. and stated, Okay.

The facility failed to follow physician orders regarding required notification parameters for abnormal blood glucose results. Resident #8.The physician order directed staff to notify the physician when blood glucose levels were less than 70 mg/dL or greater than 450 mg/dL. On 4/1/2026 at 08:07, a blood glucose reading of 67 mg/dL was obtained and documented; however, the physician was not notified of this abnormal result.During confirmation on 4/15/2026 at 4:30 PM with Corporate Nurse, it was acknowledged that physician notification did not occur as required. This failure to follow physician orders placed the resident at risk for delayed medical intervention and potential adverse outcomes related to hypoglycemia.

Based on record review, observation and staff interview, the facility failed to promote respect and dignity during care for a resident during mealtime. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #48. Facility Census: 74. Findings included: a) Resident #48 On 04/13/26, during the Dining Room observation on the unit (Mary's Garden), Nurse Aide #41 was observed feeding Resident #48 lunch. The nurse aide did not give the resident time to chew and swallow before repeatedly offering another bite during the lunch meal. The resident would shake her head 'no', move her head away from the presented food bolus and verbally state No! This occurred when feeding attempts were made before she was given adequate time to chew and swallow what was already in her mouth. Nurse Aide #41 repeatedly asked the resident, Wanna bite? and put the utensil to the resident's mouth before the resident swallowed. The resident spit the food out of her mouth once and Nurse Aide #41 stated, Don't spit .that's yucky. The resident attempted to feed herself with her fingers and a fork during the meal. Salt was put on the resident's food without asking, and no more food was consumed. Nurse Aide #41 fed the resident large bites, and the resident coughed once during the lunch meal. On 04/12/26 at 12:58 PM, Administrator #84 for Mary's Garden confirmed the issue and stated, Ok, I'll talk to her. The facility's Policy and Procedure for Meal Service stated, Staff will promote care for patients during meal service in a manner and environment that maintains or enhances patient dignity and honors the patient's right to make choices about meal preferences.

Based upon record review and staff interviews, the facility failed to refer one (1) of one (1) residents who had a newly evident serious mental health disorder diagnosis for a level II review. This was true for one (1) of one (1) records reviewed. Resident identifier: #20. Facility census: 74. a) Resident #20 On 04/14/26 During a record review for Resident #20, the surveyor could not find the level II PASARR. 04/15/26 9:22 AM Record review and interview revealed that on 03/27/26 a PASARR was completed on Resident #20. A level II was identified as needing to be completed and never was. At 8:58 AM, the surveyor asked the Administrator why the Level II was not completed as required. She stated, I will find out and get back to you. 04/15/26 11:08 AM On 04/15/26 at 11:08 AM Corporate nurse (CN) #80 stated, The level II PASARR has not been completed yet, but is scheduled for tomorrow (04/16/26). 4/15/26 09:45 AM a reivew of a General Note revealed, A phone call was made to Level II Evaluator (Name and phone #) regarding the completion of the Level II Evaluation. (Name) reported that she is coming to facility to complete the Level II Evaluation on 4/16/26 (tomorrow). IDT notified. Record review on 04/21/26 at 11:32 AM revealed, the level two (2) PASRR was completed on 04/16/26 for Resident #20 by Psychological Consultation & Assessment Inc.

Based on record review, staff interview, resident interview and observation, the facility failed to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests, and the physical, mental, and psychosocial well-being of the residents. This failed practice had the potential to affect a limited number of residents. Resident Identifiers: #68 and #69. Facility Census: 74.Findings included: a) Resident #68 On 04/13/26, during the initial interview process, Resident #68 stated, I don't get to go outside enough. I'm an outdoor person. The resident stated that the facility Need[s] to have more activities. The resident was waiting for his lunch and stated it was a long break before now and suppertime.The resident's care plan stated, It is important for me to go outside when the weather is good and enjoy eating/drinking, napping, sitting, talking/visiting, walking, sitting with wife. b) Resident #69 On 04/13/26, during the initial interview process, Resident # 69 stated, I'm putting on weight just sitting here. The resident reported she like it at the facility, but she was bored, she wanted/needed something to do and got tired of sitting. The resident stated, I tell them I'll help - tell me they don't need no help. The resident stated, I want something to do .pick up, clean up, put up . The residents care plan stated, That it is important that she has the opportunity to engage in daily routines that are meaningful and relative to her preferences. and the resident will have opportunities to make decisions/choices related to/for self-directed involvement in meaningful activities. c) On 04/15/2026 at 10:15 AM to 12:15 PM, activities provided for the residents were observed. Observation of Mary's Garden included: 10:15 AM - Residents were watching TV.10:30 AM - Named Capitols of US - cognitive activity and phrase completion activity Ex. Hit below the . with the Activity Director.10:50 AM to 11:30 AM - Watching TV - The [NAME] Hillbillies.11:19 AM - Administrator for Mary's Garden #84 was observed working with one resident on a puzzle.11:30 AM - Coloring sheets for three (3) residents in dining room.11:46 AM - Reminiscing about gardens in TV room with the Activity Director. Wednesday's Calendar for April 2026 stated: 10:00 AM Individual 1:1, 10:30 AM Outdoor Activity, 11:00 AM Social Activity and 11:30 AM Sensory Activity. On 04/15/26 at 11:50 AM, Administrator for Mary's Garden #84 confirmed the weather was appropriate for the residents to go outside and confirmed the activities were not provided as scheduled. d) The facility's policy and procedure for Therapeutic Program stated, the purpose was To provide therapeutic programming based on patients' interests, abilities, and disease stage. To optimize patients' existing skills, functional independence, and mental status. To maintain patients' dignity and self-esteem and promote success.

Based on interview and record review, the facility failed to ensure they implemented their policy on abuse to ensure allegations of abuse were properly identified, reported, and thoroughly investigated in accordance with the facility's abuse prevention policies. This deficient practice placed residents at risk for unrecognized and unaddressed abuse. Resident identifier: #25. Facility census: 74. Findings included:a) Resident #25On 04/20/26 at approximately 12:59 PM, the surveyor interviewed Administrator #18. During the interview, the Administrator acknowledged observing Resident #25 unclothed and confirmed the incident occurred. However, the Administrator stated the facility did not classify the incident as an allegation of sexual abuse. The Administrator reported, I think because she was fully clothed. There was no evidence of her being touched. The Administrator further indicated that the facility conducted interviews and completed a skin assessment as part of its review process.On 04/20/2026 at approximately 12:59 PM, the surveyor interviewed Administrator #18. During the interview, the Administrator acknowledged a resident was observed unclothed and confirmed the incident occurred within the facility. The Administrator stated the facility did not classify the incident as an allegation of sexual abuse, reporting, I think because she was fully clothed. There was no evidence of her being touched. The Administrator further indicated staff interviewed the individuals involved and completed skin assessments of the residents.A review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy revealed residents had the right to be free from abuse, including sexual and physical abuse. The policy further indicated that the facility maintained a facility-wide commitment and allocated resources to protect residents from abuse by anyone, including other residents. The policy required the facility to establish and implement a QAPI review and analysis process for reports, allegations, or findings of abuse.A review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy revealed all reports of resident abuse were to be reported and thoroughly investigated by facility management. The policy further directed that findings of all investigations were to be documented and reported.These findings were reviewed and confirmed with Corporate Nurse #80 on 04/21/2026 at approximately 10:00 AM.

Based on record review and staff interview the facility failed to report an allegation of physical abuse between residents within two (2) hours of the incident. This was discovered during an investigation into a Facility Reported Incident (FRI) and was true for Resident #28. Resident Identifier: #28. Facility Census: 74. Findings Include: a) Resident #28 A review of a Facility Reported Incident (FRI) dated 11/09/24 found the following: A co-resident punched the resident in the shoulder. An X-ray was completed, and the resident was not injured. The incident occurred on 11/09/24 at 12:40 PM. A further review of the initial report showed it was filed on 11/09/24 but no time was identified. A further review of the information provided by the facility found no fax confirmation sheet to identify when the facility submitted the report. The five-day follow-up was reviewed and showed the fax confirmation sheet was attached, indicating when the five-day follow-up was submitted. The nursing home administrator (NHA) was asked to provide the fax confirmation sheet for the initial report filed on 11/09/24. On the afternoon of 04/21/26 the NHA confirmed she could not find anything that would prove what time the initial report was filed.

Based on record review, observation, and staff interview, the facility failed to ensure Resident #21 received liquid at the appropriate thickness as ordered by the physician. Resident #21 would have been given regular consistency tea had the surveyor not intervened. Resident #21 physician's orders indicated she should only receive pudding/spoon thickened liquids. The State Agency (SA) found this failure rose to the level of an Immediate Jeopardy (IJ). The Nursing Home Administrator (NHA) and Director of Nursing (DON) was notified of the IJ on 09/25/24 at 3:45 PM. The SA accepted the plan of Correction (POC) at 6:40 PM on 09/25/24. After verification of the steps of the POC being Implemented the IJ was abated at 3:15 PM on 09/26/24. This failed practice was true for Resident #21 but had the potential to affect any resident receiving thickened liquids. At the time of the discovery only Resident #20 and Resident #75 received thickened liquids. Resident identifiers: #21. Facility Census: 77. Findings Included: a) Resident #21 A review of Resident #21's medical record found an order for spoon thick liquids. The order was put in place on 06/04/24. An observation of Resident #21's door found a circular sticker with the letter P on it to indicate the resident should receive Pudding Thickened liquids. The meaning of this sticker was confirmed with the Director of Nursing (DON) on 09/25/24 at 2:12 PM. Pudding and spoon thick liquids are interchangeable and refer to drinks which are pudding thick consistency. A review of the resident's speech therapist (ST) notes found the following, Summary of skilled interventions Provided: Patient has been seen for ST skilled services for dysphasia treatment for assessment of swallow function in order to determine safest diet level, decrease risk of aspiration, and educate staff on patient's diet level and risk of aspiration. Patient is consuming a puree diet level with pudding thick liquids. Education with return demonstration completed with staff to ensure accuracy and understanding of the patient's new liquid level, especially because it is not readily utilized in this facility. Patient continues to have occasional episodes of overt signs and symptoms of aspiration, despite the modifications. ST plans to discontinue services on 06/21/24 pending no further changes in function. A review of the resident's care plan found the following goal and interventions, Focus Statement: (First Name of Resident #21 First Name) is at nutritional risk related to Huntington's Disease which increases energy expenditure, Dysphasia with mechanically altered diet in place, Hypokalemia, and Significant Weight Loss. Goals: Resident will maintain weight and have no undesirable weight loss thru next review Interventions included: -- Regular/Liberalized Diet with Puree Texture and Thickened Liquids-Spoon Thick Consistency. Plastic silverware per order. This intervention was last revised on the care plan on 06/07/24. An observation on 09/25/24 at 1:05 PM found Licensed Practical Nurse (LPN) #47 was assisting Resident #21 with her lunch meal. LPN #47 stated, Would you like another drink? At which time she picked up Resident #21's drink which was sweet tea. When she picked up the drink it was obvious to the surveyor the tea was regular/thin. LPN #47 placed the cup to the resident's lips to give her a drink. The surveyor at this time intervened and stated, Please don't give her that. The LPN said, 'Why not. The surveyor stated, She is supposed to have pudding thickened liquids. LPN #47 sat her drink down and continued to feed the resident her meal. At the conclusion of the meal she cleared the tray and left the tea on the bedside table. She stated, I am going to get some thickener for that in case you are wondering. All the other items on the resident's tray were correct because they had come from the kitchen. Staff on the floor are responsible for all drinks served at meals. The kitchen does not send thickened drinks on the resident's tray. About five (5) minutes later LPN #47 returned with a bowl with some thickener in it. LPN #47 poured in a small amount of thickener and stirred the tea. The tea was still not pudding thick and could have easily been poured from the cup. She again placed the cup to the resident's lips to give her a drink. LPN #47 was asked, How do you know if it is the right consistency? She looked at the cup and put the spoon in and out of the tea a few times and stated, Is that not thick enough. The surveyor then stated she was on pudding thickened liquids, and no it was not thick enough. The LPN then abruptly poured in some more thickener from the bowl. She then stirred it up. The surveyor stated, If you're not sure you can ask someone. She looked at the liquid again and said, Well it looks like pudding to me, and proceeded to feed the resident the thickened tea. During an interview with the Director of Nursing (DON) on 09/25/24 at 2:12 PM the DON was asked how they determine something is proper consistency when the kitchen provides a bowl of unmeasured thickener opposed to the packet of thickener which tells you how many packets to use for each thickness. The DON stated, They just look at it and add it until it looks right. She made no mention of measuring the appropriate amount as directed by the manufacturer. After the notification of the IJ the facility obtained an order for a chest X-ray for Resident #21. This order was obtained on 09/25/24 at 3:51 PM. The results of the X-ray were reviewed by the surveyor in the afternoon of 10/01/24. The results read as follows: Examination demonstrates no mediastinal shift. There is left lower lobe atelectasis, but no acute alveolar/interstitial infiltrate, consolidation, CHF, Mass or pneumothorax b) Facility Plan of Correction The facility's accepted plan of correction read as follows, The licensed nurse conducted an evaluation on 9/25/24 with notification to the medical provider of the possible risk of aspiration for Resident #21. The Speech therapist provided education to the Director of Nursing (DON) on 9/25/24 regarding the process to mix thicken liquids per the manufacturer guidelines. The Director of Nursing (DON)/designee provided education to Licensed Nurse #47 on 9/25/24 regarding the process to mix thicken liquids per the manufacturer guidelines. All residents of the facility have the potential to be affected. The Director of Nursing (DON)/designee conducted an observation round on 9/25/24 to ensure residents receiving thickened liquids are mixed according to manufacturer's guidelines with any corrective action immediately upon discovery. Reeducation will be provided by the Director of Nurses(DON)/designee to nursing staff on 9/25/24 regarding residents receiving thickened liquids mixed according to manufacturer's guidelines with a posttest and return demonstration (per the attachment educational document) to validate understanding. Any nursing staff not available during this time frame will be provided reeducation, including posttest and returned demonstration by DON/designee prior to the beginning of their shift. New nursing staff will be provided education and return demonstration, including posttest during orientation by the DON/designee. Reeducation will be provided by the Dietary Manager (DM)/designee to dietary employees on 9/25/24 regarding not to send out thickening powder during meal service with a posttest to validate understanding. Any dietary staff not available during this time frame will be provided reeducation, including posttest by DM/designee prior to the beginning of their shift. New dietary employees will be provided education, including posttest during orientation by the DON/designee. The Unit Manager/designee will monitor during meal service starting on 9/25/24 for dinner to ensure residents receiving thickened liquids are mixed according to manufacturer's guidelines daily across all meal service for 2 weeks, including weekends and holidays, then 5 times a week for 4 weeks, then 3 times a week for 4 weeks, then randomly thereafter. The Unit Manager/designee will monitor during meal service starting on 9/25/24 for dinner to ensure dietary does not send out thickening powder during meal service daily across all meal service for 2 weeks, including weekends and holidays, then 5 times a week for 4 weeks, then 3 times a week for 4 weeks, then randomly thereafter. Results of monitors will be reported by the Director of Nursing (DON)/designee to the Quality Improvement Committee (QIC) monthly for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the Quality Improvement Committee. On 09/26/24 the education posttests were reviewed for all staff who had worked since the notification of the IJ with no issues identified. Nurse Aide #55 was observed assisting Resident #21 her noontime meal. She correctly thickened her drink and upon interview was able to describe the education she received and answered all questions appropriately. NA #18 was also interviewed and was able to answer all questions appropriately related to thickening the resident drinks. LPN #52 was interviewed and was able to describe her education and was able to provide details into how to thicken resident drinks. After implementation of the POC was completed the IJ was abated at 3:15 PM on 09/26/24.