Every finding on record at Las Alturas Nursing & Transitional Care Brownsvill

Based on observation, record review and interviews the facility failed to store, prepare and serve food in accordance with professional standards for food service safety for 1 of 1 unit refrigerators, 1 of 1 dry pantry storage unit refrigerator and 1 of 1 kitchen walk in pantry walk in pantry WP# 1 and maintain equipment in proper condition reviewed for storage, preparation, and sanitation. The facility failed to utilize proper personal hygiene practices the appropriate use of gloves to prevent contamination of food while preparing pureed food and plating food to be served to residents.The facility failed to ensure kitchen staff were educated on calibrating thermometers.The facility failed to ensure items in the refrigerators and freezers were labeled and dated.The facility failed to ensure food stored in the facility refrigerator was sealed properly.The facility failed to ensure the dry storage room was restocked with the first in first out method.The facility failed to keep kitchen equipment clean for proper operating function. These failures could place residents at risk of foodborne illnesses. Findings included: Observation and Initial tour of the kitchen on 08/25/26 at 8:20 AM revealed the refrigerator had two trays with beverages that had not been label with a date, a try with cups of pudding with no date, and a bag of grapes opened exposed to air. In observation of the dry pantry, it revealed a canister of coffee undated, boxes of pasta and bags of gelatin not using in first in first out method. In observation of the facility stove revealed the oven had black crusty substance all on the bottom of the oven and a grey colored stains on the oven doors. In observation of the deep fryer revealed brown substance that covered the back panel and the front basket resting panel. In observation of the microwave revealed the top panel coved with a brown substance, the rotation glass plate had white food crumbs on covering the plate. In a second observation of the kitchen revealed during the making of the puree foods of the menu the cook did not wear gloves and was wearing a ring with small stones and carved groves. In observation of the cook taking the temperatures of the all the prepared food the thermometers were not correctly calibrated with ice cold water before attempting to take the temperatures. In an interview on 08/26/26 at 11:21 AM with Dietary Aide B she stated all items stored in the refrigerator or dry pantry should be sealed correctly and not exposed to the air which can cause the food to become contaminated. DA B stated all food was to be dated and labeled with the open or entry date so that expired food can be thrown away and not served to residents which could make them ill. DA B stated it was all the kitchen staff were responsible in making sure that all items that are received are dated with the receive date and stored with the first in first out method to prevent serving expired food to the residents and possibly making them sick. DA B stated it was all the kitchen staff's responsibility to make sure that all kitchen equipment is clean and in proper working condition. DA B state gloves must be worn any time food for residents to eat is handle or being prepared. DA B stated she just received her training and in services on preparing, storing, and handling food last week she just started in the kitchen on the 08/24/2026. In an interview on 08/26/26 at 11:31 am DA C stated all items stored in the refrigerator, freezer, and dry pantry should be dated with the received date and put in the first in first out way so that no expired food is used for cooking or served to residents and possibly making them sick. DA C stated food items must be sealed or covered to prevent exposure to air and contamination of the food that could possibly make the residents sick and be sent to the hospital. DA C stated the kitchen equipment was to be cleaned after every use and all the kitchen staff were responsible for keeping all the equipment clean and in working condition. DA C stated the equipment was to be clean so that they are used with no old food residue that could be with contaminated harmful bacteria that can transfer to food being prepared for residents. DA C stated food is not to be touched with bare hands that is being prepared for the residents. In an interview on 08/26/26 at 11:45 AM with the [NAME] she stated she forgot she had the ring on and took it off. The [NAME] was not aware she was to put on gloves when preparing the puree food on the menu. The cook stated she forgot to calibrate the thermometers in ice cold water because she was nervous. The cook stated she knew that the thermometers used for taking temperatures of cooked food were to be calibrated in ice cold water to ensure the food was at the proper temperature so that it does not contain harmful microorganisms while plating food so the residents do not eat contaminated food making them ill. The cook stated she knew to wear gloves while handling raw foods but forgot about wearing gloves during the preparation of the puree and plating the food. The cook stated she knew that all food that is put in the refrigerator, dry pantry, and freezer need a received date or a use by date. The cook stated she knew that all food items must be sealed to keep the food from being exposed to air and possibly becoming contaminated. The cook stated she will be wearing gloves any time she prepares and handles food to be served so that the residents do not become ill especially those who have a weak immune system.In an interview on 08/26/2026 12:05 PM the Dietary Manager stated that all food items stored in the dry pantry should be dated with a received by date and any open items sealed in a resealable bag or container. The DM stated all the items in the refrigerator are to be sealed correctly, dated with the received date, leftovers are to be dated with the date and time entered and thrown away after 3 days. The DM stated All the kitchen equipment is the be cleaned when needed and at the scheduled time. The DM stated the staff had recently had an in-service on food handling and preparation and knew to wear gloves and not touch ready to eat food with bare hands but were nervous and forgot to put them on. The DM stated the cook wores gloves when preparing food, did not normally wear the ring she was wearing, and will wear gloves while preparing the puree and plating food for the residents. The DM stated she will have an in-service on storing, handling, and preparing foods for the residents and on how to correctly calibrate thermometers. The DM stated she will be inspecting the freezer, refrigerator, and dry pantry to make sure all the policy and procedures are being followed and implemented correctly. In record review of the facility kitchen policies titled Food Preparation and Handling Policy and was undated revealed To ensure that all food served by the facility is of good quality and safe for consumption, all food will be prepared and handled according to the state and US Food Codes and HACCP guidelines. e. Take temperatures throughout the preparation process to ensure that food is safe. In record review of the facility kitchen policies titled Employee Sanitation Dated 10/01/2018 revealed The Nutrition & Foodservice employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness.f. No jewelry can be worn on the arms and hands while preparing food, except for a single plain ring such as a wedding band. In record review of the facility kitchen policies titled Food Storage revealed To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. 1. Dry storage roomsd. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. f. Where possible, leave items in the original cartons placed with the date visible. g. Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that the older items are used first. 2. Refrigerators d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.

Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5% for 28 medication administration opportunities with 2 errors resulting in a 7.14% medication error rate, for 1 of 7 residents (Resident #72) reviewed for medication administration. The facility failed to ensure Resident #72 received the complete doses of medications Gabapentin (used to control seizures) and Docusate Sodium (used to relieve constipation) as ordered by the physician during medication pass observation on 08/26/2026 at 2:30 p.m. This failure could place residents at risk for potential recurrence of seizure activity, worsening nerve pain, and constipation if not receiving the intended therapeutic benefits of the medications.Record review of Resident #72's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included Seizures, Neuropathy (nerve pain), Diverticulitis (a painful condition where tiny bulging pouches in your large intestine become inflamed or infected), and Hemiplegia/Hemiparesis (weakness or loss of movement on one entire side of the body, caused by damage to the opposite side of the brain). Record review of Resident #72's comprehensive MDS dated [DATE] reflected he had a BIMS score of 03 which indicated severe cognitive impaired. Record review of Resident #72's care plan dated 06/23/2026 reflected a focus of at risk for pain. Interventions included administer medications, care, and treatment as per MD recommendations.Review of Resident #72's physician order summary reflected an order dated 08/27/2026 for Gabapentin oral tablet 100mg give 1 tablet via PEG tube three times a day for Neuropathy, start date 08/14/2026. The physician orders indicated an order for Docusate Sodium oral tablet 100mg give 1 tablet via G-Tube every day and evening shift for Constipation, start date 01/29/2026.During an observation on 08/26/2026 at 3:05 p.m., LVN H crushed Gabapentin (used to control seizures) and Docusate Sodium (used to relieve constipation) individually. He then put them individually in a cup and poured water in each cup. He proceeded to mix each medication using a long wooden stick for each one. Upon transferring the medication tray with medications from medication cart to the bedside table, both medication cups tipped over. The mixed medications spilled onto the tray. He picked them back up and poured more water in each cup. He then proceeded to administer both medications via g-tube.In an interview on 08/26/2026 at 3:20 p.m., LVN H stated that he poured more water into the medication cups because he saw residual medication and only saw water spill. He stated that the correct action would have been to dispose of the spilled medication and prepare the medication again from the beginning. LVN H stated that he could not be certain of how much medication was lost after the spill because he had mixed the medications with water using the wooden stick. He stated that the negative outcome was that the Resident#72 did not receive the full prescribed dose. In an interview on 08/26/2026 at 1:04 p.m., the DON stated that the expected procedure when a medication mixture was accidentally spilled was to start over and prepare the medication again. She stated that she ensured medications were completely administered through annual medication administration skill check offs. The DON also stated that staff received training on medication administration via G-tube upon hire. She stated that the negative outcome was that the resident would not receive the full prescribed dose. Record Review of LVN H Competencies Checklist dated 02/10/2026, revealed:LVN H Demonstrates understanding and competency of Enteral Feeding Tube. was MET. Record Review of the facility policy and procedure titled Medication Administration via Enteral Tube with a revised date January 2023 revealed: Compliance Guidelines: To administer medications through a enteral tube in an accurate, safe, timely and sanitary manner.Guidelines:2.Prepare medication12. Prepare medications to be administered.

Based on interviews and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete, accurately documented, readily accessible, and systematically organized for 4 of 4 residents (Resident #2, Resident #76, Resident #83 and Resident#30) reviewed for resident records. The facility failed to ensure Resident #2, Resident #76, Resident #83 and Resident#30's low air loss mattress order was in the electronic chart. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information records. Findings included: 1. Record review of Resident #2's face sheet 08/27/26 revealed a [AGE] year old female admitted to the facility on [DATE] diagnoses included pressure ulcer of sacral region, muscle weakness, need for assistance with personal care. Record review of Resident #2's MDS assessment dated [DATE] reflected Resident had a BIMS score of 00 which indicated severe cognitive impairment. Resident #2 had one Stage 2 Pressure injury to sacral region. Skin and Ulcer treatments included a pressure-reducing device for the bed. Record review of Resident #2's care plan reflected resident had an actual or at risk for skin impairment due to incontinence, impaired mobility. Interventions: skin risk: therapeutic air pressure reducing mattress. Review of Resident #2's August 2026 Consolidated Physician Orders did not reflect an order for low air loss mattresses. During an observation of Resident #2 on 08/27/26 at 10:30 a.m. revealed the resident was laying on bed, bed had a low air loss mattress. 2. Record review of Resident #83's face sheet 08/26/26 revealed she was a [AGE] year old female who was admitted to the facility on [DATE] and her diagnoses included muscle weakness, need for assistance with personal care Type 2 diabetes (is a chronic condition where your body either resists the effects of insulin or doesn't produce enough of it to regulate blood sugar properly).Record review of Resident #83's MDS assessment dated [DATE] reflected Resident had a BIMS score of 03 which means resident had a severe cognitive impairment. Resident #83 had risk of pressure ulcers. Skin and Ulcer treatments included a pressure-reducing device for the bed.Record review of Resident #83's care plan reflected resident had an actual or at risk for skin impairment due to incontinence, impaired mobility. Interventions: skin risk: therapeutic air pressure reducing mattress.Review of Resident #83's August 2026 Consolidated Physician Orders did not reflect an order for low air loss mattresses.During an observation of Resident #83 on 08/27/26 at 10:40 a.m. revealed the resident was laying on bed, bed had a low air loss mattress.3. Record review of Resident #76's face sheet 08/25/26 revealed he was a [AGE] year old male who was admitted to the facility on [DATE] and his diagnosis included Type 2 diabetes (is a chronic condition where your body either resists the effects of insulin or doesn't produce enough of it to regulate blood sugar properly).Record review of Resident #76's MDS assessment dated [DATE] reflected Resident had a BIMS score of 10 which means resident had a moderate cognitive impairment. Resident #76 had a pressure ulcer. Skin and Ulcer treatments included a pressure-reducing device for the bed.Record review of Resident #76's care plan reflected resident had an actual or at risk for skin impairment. Interventions: skin risk: therapeutic air pressure reducing mattress.Review of Resident #76's August 2026 Consolidated Physician Orders did not reflect an order for low air loss mattresses.During an observation of Resident #76 on 08/25/26 at 10:40 a.m. revealed the resident was laying on bed, bed had a low air loss mattress.4. Record review of Resident #30's face sheet 08/26/26 revealed she was a [AGE] year old female who was admitted to the facility on [DATE] and her diagnoses included muscle weakness, need for assistance with personal care Alzheimer Disease (a progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks). Record review of Resident #30's MDS assessment dated 06 /30/26 reflected Resident had a BIMS score of 00 which means resident had a severe cognitive impairment. Resident #30 had a pressure ulcers. Skin and Ulcer treatments included a pressure-reducing device for the bed.Record review of Resident #30's care plan reflected resident had an actual or at risk for skin impairment due to incontinence, impaired mobility. Interventions: skin risk: therapeutic air pressure reducing mattress.Review of Resident #30's August 2026 Consolidated Physician Orders did not reflect an order for low air loss mattresses.During an observation of Resident #30 on 08/27/26 at 11:45 a.m. revealed the resident was lying on the bed with a low air loss mattress in place.During an interview on 08/27/26 at 04:05 p.m., the WCN stated that she was responsible and that she decided when a resident needed a low air loss mattress for residents that were at risk for skin integrity or when a resident had a pressure ulcer. The WCN stated that the mattress was in the care plan and that the order was not necessary because it was like a nursing intervention. The WCN stated that the resident would tell her when its comfortable and if the resident was not able to verbalize she would set it up. The WCN stated that the correct way was to place two fingers under the mattress and if the fingers were able to fit that meant that it was ready to use. The WCN stated that she did not think there was a negative outcome.During an interview on 08/27/26 at 04:15 p.m., the DON stated that staff did not need orders to place an air mattress because it was use as a nursing intervention. DON stated that the WCN did the assessments and as long as the resident was comfortable.Record review of facility's policy titled Skin and Wound Prevention and Management with an implemented date 03/14/19 reflected skin prevention program will: identify associated risk for alteration in skin or development of pressure ulcers injuries, identify early onset skin breakdown so that the IDT may implement appropriate interventions as clinically indicated, implement interventions designed to stabilize, reduce, or remove underlying risk factors.

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 8 (Resident #109 and Resident #76) residents reviewed for respiratory care. 1.The facility failed to post an Oxygen sign indicating Resident #109 received oxygen on 8/25/2026. 2.The facility failed to post an Oxygen sign indicating Resident #76 received oxygen on 8/25/2026. These deficient practices could place residents who receive respiratory care at an increased risk of fire hazards by not posting oxygen signs outside the residents' rooms. 1. Record review of Resident #109's face sheet, dated 08/26/2026, revealed a [AGE] year-old male with an admission date of 01/23/2026. Pertinent diagnoses included Lobar Pneumonia (a type of lung infection that affects a whole section, or lobe, of a lung). Record review of Resident #109's Quarterly MDS assessment, dated 07/28/2026, revealed a BIMS score of 00 which indicated he had severe cognitive impairment. Record review of Resident #109's physician order summary, start date 08/23/2026, revealed an order for Oxygen at 5 liters per minute per nasal cannula continuous every shift. An observation on 08/25/2026 at 10:05 a.m., revealed Resident #109 was in his room lying on his bed. He was wearing a nasal canula and was receiving oxygen at 5 liters per minute. There was no oxygen sign posted outside of his room. In an interview on 08/25/2026 at 10:10 a.m., LVN G stated that she was the nurse for Resident #109. She stated that the nurse was responsible for posting the oxygen sign outside the residents' rooms. LVN G verified that Resident #109 did not have an oxygen sign posted outside his room. She stated that all residents who were on oxygen need a sign. LVN G stated that it was important for an oxygen sign to be posted outside the residents' rooms, to alert everyone that oxygen was in use due to the increased flammable risk. 2. Record review of Resident #76's face sheet, dated 08/25/2026, revealed a [AGE] year-old male with an admission date of 06/30/2026. Pertinent diagnosis included End Stage Heart Failure (the most severe and advanced stage where the heart can no longer pump enough blood to meet the body's needs, causing constant symptoms even at rest), shortness of breath. Record review of Resident #76's Quarterly MDS assessment, dated 07/02/2026, revealed a BIMS score of 10 which indicated he had moderate cognitive impairment. Record review of Resident #76's physician order summary, start date 08/25/2026, revealed an order for Oxygen at 2-3 liters per minute per nasal cannula as needed. During an observation on 08/25/2026 at 11:05 a.m. revealed Resident #76 was in his room lying on his bed. He was wearing a nasal canula and was receiving oxygen at 2 liters per minute. There was no oxygen sign posted outside of his room. During an interview on 08/25/26 at 11:10 a.m. LVN J stated that all staff was responsible to place the sign of no smoking outside the door. LVN J stated that it was important for sign to be posted because smoking should not occur near the oxygen concentrator because it could cause a fire. In an interview on 08/26/2026 at 1:04 p.m., the DON stated the policy regarding oxygen usage outside the resident's room was to place a no smoking oxygen sign outside the room when oxygen was in use. She stated the nurse or Infection Preventionist was responsible for posting the oxygen sign. The DON stated the sign was required to be posted anywhere on the door frame. She stated that it was important for the O2 sign to be posted because smoking should not occur around the oxygen tank. The DON stated the staff had been educated on the requirement to post the O2 sign whenever oxygen was in use. Record Review of the facility's Oxygen Administration policy, revised January 2023, revealed Compliance Guidelines: A resident receives oxygen therapy when there is an order by a physician. The residents disease physical condition, and age will help determine the most appropriate method of administration and should be reflected in the physician order. Procedure: 1.Assess the residents room to determine if the environment is safe for oxygen administration. 2. Signage on entrance of community should indicate that facility does not allow smoking. 3. Obtain physician orders for oxygen administration. Order should include the following: a. oxygen source to be used (concentrator, tank, etc.) b. method of delivery (cannula, mask, etc.) c. flow rate of delivery.

Based on observation, interviews and record review the facility failed to ensure an alleged violation involving abuse was reported immediately within two hours after the allegation was made to the State Agency in accordance with State Law and failed to report to the local law enforcement agency for 2 (Resident #14 and Resident #29) out of 5 residents reviewed for abuse. 1.The facility failed to report an abuse incident involving Resident #14 that occurred on 08/15/25 to the state agency. 2.The facility failed to report an abuse incident involving Resident #29 that occurred on 08/22/25 to the state agency within 2 hours after resident stated he had a fall. 3.The facility failed to report an incident involving Resident #14 and that occurred on 08/15/2026 to the local law enforcement agency. Record review of Resident #29's face sheet dated 08/27/2026 indicated a [AGE] year-old male who was initially admitted to the facility on [DATE]. Resident #29 had diagnoses which included Type 2 diabetes (is a chronic condition where your body either resists the effects of insulin or doesn't produce enough of it to regulate blood sugar properly), muscle weakness, personal history of traumatic brain injury (sudden damage to the brain caused by an external physical force, such as a forceful bump, blow, or jolt to the head or body). Record review of Resident #29's Care Plan with a date 06/08/2026 indicated Resident #29 was at risk for falls related to comorbid conditions, obesity, history of traumatic brain injury. Resident #29 needed set up and supervision assist with transfers. Record review of Resident #14's Quarterly MDS assessment dated [DATE] revealed Resident #29's had a BIMS Score of 00 which indicated severe cognitive impairment. Resident #29 Functional abilities was independent and needed set up and supervision help with all ADLs. During an interview on 08/26/26 at 03:40 p.m., CMA K stated that she was working on 08/22/26 and she went into Resident #29's room to check his blood pressure and saw that his left hand and arm looked swollen. CMA K stated that she immediately went to notify LVN F. CMA K stated that LVN F went to assess resident and she saw a yellowish discoloration in the left elbow area. CMA K stated that after the nurse went to the room she left. During an interview on 8/26/26 at 4:00p.m., Resident #29 refused to the interview. During an interview on 08/27/26 at 10:08 a.m., LVN F stated that CMA K and informed her that Resident #29 had swelling to his left arm on 08/22/26. LVN F stated that she went to assess the resident and saw yellow/purplish discoloration to Resident #29's left shoulder area and down towards the left elbow. LVN F stated that she asked Resident #29 what had happened, and the resident told her that he had fallen. LVN F stated that she asked the resident to elevate his arm and the resident complained of pain. LVN F stated that she gave pain medication to Resident #29. LVN F stated she called the doctor and got orders for an X- rays to left shoulder and she carried out the orders. LVN F stated that she called the responsible party to notify the swelling to the left arm. LVN F stated that she informed the DON about the swelling to the left arm. During an interview on 08/27/26 at 04:15 p.m., the DON stated that she was called by LVN F to informed her that Resident #29 had swelling to his left arm. The DON stated that LVN F told her that she assessed resident and that she got orders from the doctor for X-rays. The DON stated that the X-ray results were report it to the doctor a little after mid night and resident was sent out to the hospital for further evaluation. The DON stated that resident came back from the hospital and it confirmed that Resident #29 had a fracture to left humerus. The DON stated that the incident was reported to the HHSC agency after the X- rays results. The DON stated that she did not think that the discoloration and swelling to left arm were a significant change. During an interview on 08/27/26 at 4:30 p.m., Administrator stated that he was notified after the nurse received the x ray results and that he report it to HHSC agency within 2 hours after he was informed. The findings include: 1.Record review of Resident #14's face sheet dated 08/15/2026 indicated a[AGE] year-old female who was initially admitted to the facility on [DATE].Resident #14 had diagnoses which included Alzheimer's Disease with late onset (a progressive disease that destroys memory and other important mental functions), cognitive communication deficit is a condition were Communication is impaired due to underlying cognitive dysfunction rather than a primary language or speech problem, dementia (A group of thinking a social symptom that interfere with daily functioning), Mixed receptive-expressive language disorder (a communication condition where a person struggles to with both understanding language to express themselves. Resident #14's care plan indicated she had a behavior problem r/t push call light out of bed, yelling, pulls dry skin from lips, refuses care and showers, episodes of aggression towards staff, foul language/name calling towards staff, sudden mood changes. Record review of Resident #14's admission MDS assessment dated [DATE] revealed Resident #14's had a BIMS Score of 03 which indicated Severe cognitive impairment Resident #14 exhibited Verbal behaviors directed towards others like hitting, kicking pushing scratching grabbing, abusing others along with wondering. Resident #14 Functional abilities need moderate to substantial help with all ADLs. Record review of Resident #14's Care Plan initiated date 08/10/2026 indicated Resident #14 had impaired cognition and was at risk for a further decline in cognitive and functional abilities related to dementia and pain. Resident #14 had an ADL self-care performance deficit, had Impaired cognitive function, dementia, or impaired thought process related to Alzheimer's. Resident #44 had problems communicating needs and wants related to cognitive impairment. In observation and interview on 08/25/2026 of Resident #14 she was in the dining room of the one hundred locked unit hall she was sitting at the table with other residents as they eat a snack and had a beverage. Resident #14 was engaged in coloring a page of flowers. Resident # 14 could not recall all that had happened just remembered she was angry and did not want the CNA helping her or touching her. In an interview on 08/26/2026 at 5:30 PM with a family member she stated that Resident #14 can exaggerate things at times. The FM stated that CNA E was very kind and did not think she could do what Resident #14 stated. The FM stated CNA E was kind and respectful. The FM stated that due to dementia and Alzheimer's Resident #14 has she can be defensive and aggressive at times combative. The FM stated the DON called her and explained to her what occurred the next evening after the incident occurred. The FM is at the facility every day and helps with Resident #14 care when she is the facility. The FM stated when she was at the facility she never saw CNA mistreat Resident #14 and always provide good care did have any issues with her care. In a second observation on 08/27/2026 at 11:01 am the resident was seen at the door of the locked unit asking to see her sister and trying to get out as the staff tried to redirect her back to the activities area in the dining room away from the door. In an interview on 08/27/2026 at 10:31 AM with social services director she stated she had not visited Resident #14 because she was not told an incident had occurred. The SSD stated she visited the unit three times a week and talks to Resident #14 as she is one of the residents that is very verbal. The SSD stated she talked to her every time she enters the unit as she is a more active resident and can carry a conversation well at times. The SSD stated the resident had not mentioned the incident to her and does not think she remembered what occurred with the CNA. The SSD stated she could not recall if she was told to do follow up with Resident #14, but when she did talk to her she did not seem to be under any distress or fearful of anyone in the unit. The SSD stated she saw the FM often when she visits Resident #14 and often advocates for Resident #14 if there is a need. The SSD stated the daughter did not bring up any concerns about Resident #14. The SDD stated the normal protocol is to follow up three days with the resident to ensure the resident is not under any distress or in need of other medical or psychiatric services. The SSD monitors the care of the resident after an allegation of abuse by following up with the resident for 3 days, making any referrals to other services for the resident if needed, and does an admission, quarterly and as needed assessment for depression. The SSD stated the last in-service about abuse was at the beginning of this week. The SSD could verbalize the types of abuse, and the abuse coordinator is the administrator. In an interview on 08/27/2026 at 11:25 AM the CNA E stated she was getting Resident #14 ready for a shower she was sitting on the toilet and the as the resident was using the toilet she was getting Resident #14's clothes ready. CNA E stated when she went back to help Resident #14 to the shower and began to undress her, she grabbed her while she was taking her sweater off, she started saying she did not want to shower. CNA E stated she was trying to free herself from the resident's grasp and then the resident hit her and knocked the glasses off her head. CNA E stated at that point she pulled the emergency light to get help with Resident #14 aggressive behavior and the resident was saying she did not want to see her and did not want to take a bath. CNA E stated the incident happened around 6 after they ate and at 8:00 she was told to leave for the day. CNA E stated CNA D stated she needed to leave the Resident# 14's room, so she went to the charge nurse and explained what occurred. CNA E remained in the building until the administrator got there at 8 :000 PM. CNA E stated the charge nurse escorted out of the building but did not know why she was asked to leave. CNA E stated did have some disagreements with Resident#14 because she was always reluctant to shower. CNA E stated shower time was always a difficult time for the Resident #14 and had to be told she had a doctor's appointment and then she would agree to bathe. CNA E stated Resident #14 was reluctant to shower with all staff, but when she was arguing she would come at a later time and try again. T CNA E stated his was the first time Residnet #14 had struck her or any other staff member. In an interview on 08/27/2026 at 1:42 PM with CNA D stated she heard the resident screaming and entered the bathroom in Resident #14's room. CNA D stated this happened right at around 6:00 Pm right after dinner while picking up the trays from dinner. CNA D stated when she opened the door she saw Resident #14 and CNA E both were discussing the resident talking a shower. CNA D stated CNA E was in front of Resident #14 and was trying to calm her down and had her hands in front of the resident trying to calm her down. CNA D stated CNA E was trying to convince resident #14 to take a bath and CNA D stated she did not like how the conversation was going so she stepped in to stop the discussion and calm the resident down. CNA D stated she did not see CNA E without eyeglasses as CNA E claimed the resident knocked her glasses off. CNA E did not have any markings of any kind anywhere on CNA E's face. CNA D stated she did not see any markings or indications that CNA E hurt Resident#14. CNA D had called the nurse in charge LVN F, and she began to talk to the resident to assess her. CNA D stated the charge nurse removed CNA E out of the unit and CNA E did not return. CNA D stated they took her statement immediately after the incident happened. CNA D stated that Resident #14 has never had any incident or other incidents with other residents and the residents with other staff or residents. CNA D stated the last time she received an in-service on abuse was on 08/24/2026. CNA D could not verbalize different types of abuse, and the administrator was the abuse coordinator. In an interview on 08/27/2026 at 2:13 PM with LVN F, charge nurse, she stated she was in dining area in the lock unit right after diner and the CNAs were busy with residents taking them back to their rooms. CNA D stated she had taken Resident #14's roommate to the bathroom and as she entered Resident #14 she heard Resident #14 talking with CNA sounded agitated. LVN F stated CNA D decided to switch residents and began trying to calm Resident #14 by talking to her because she was talking very loudly. LVN F stated the incident happened after dinner but could not say for sure the exact time. LVN F called the DON about the incident and was told by the DON to escort the CNA E out of the building. LVN F stated she did not know exactly what occurred with Resident #14 only that the resident was very upset and agitated and she only did what she was told to do and removed CNA E. LVN F stated Resident #14 could be very verbal and throws her hands around when she talks but nothing to this extent. LVN F stated Resident #14 had not been in any other incidents with either residents or staff. LVN F stated the last in-service was done last week on abuse and neglect. The LVN was able to verbalize different Abuse. The Abuse Coordinator was the administrator. In any incident would report regardless of mental cognition. In an interview on 08/27/2026 at 3:37 PM with DON she stated LVN F called her stated the CNA D was uncomfortable with what she saw with the CNA E and Resident #14 while toileting and getting the resident ready for a shower. The DON stated CNA D stated CNA F pushed the resident on to the toilet seat and the resident was yelling to leave her alone, but this was something that she normally screams. The DON stated CNA E stated to her Resident #14 was being combative with her. The DON stated the incident was at around 6:00 pm after dinner. The DON stated she told LVN F to keep an eye on the CNA E and took CNA E's statement and was then walked out of the facility. The DON stated she did not come in made all the phone calls from home and took all witness statements over the phone. The DON stated the abuse coordinator was notified immediately that same day. The DON stated last abuse in-service was 1 week ago and the abuse coordinator was the administrator. The abuse coordinator is the one in charge of notifying the local authorities. The DON stated if abuse coordinator/ Administrator is not available the corporate consultant would be back up for the administrator. TheDON stated the DON and ADON are responsible for in-services, routine rounds, and randomly ask staff questions about who, when, and how to report abuse and neglect. The DON stated the facility monitors the grievance binder and that would show any trends of abuse. In an interview on08/27/2026 at 4:00PM with the Administrator/Abuse Coordinator, he stated he was notified at around 8:00 PM about the incident with Resident #14 and CNA # E earlier that evening. The Administrator stated he was informed by the DON that an incident occurred with CNA E and Resident #14. The Administrator stated he was informed that the incident of verbal abuse had occurred in the Resident # 14's bathroom that involved her refusing to bathe and CNA E being overheard by CNA D as she enter the room described as aggressive language towards the resident and possible physical abuse as she had her hands on the shoulder of Resident #14. The Administrator stated after the statements were from CNA E she was escorted out of the building until the investigation was completed. The Administrator stated it was determined that it was in the best interest of the facility to terminate CNA E as she had other incidents that had occurred regarding resident care. The Administrator stated the investigation began over the phone with the DON, and she took all the witness statements. The Administrator stated he made sure all statements were taken, and the perpetrator was removed from the facility. The Administrator stated he notified the State at 9:16 PM but did not feel the local authorities need to be notified because the family was satisfied with all the facility had done to protect the residents. The Administrator stated the incident occurred around 8:00 PM and reported it at 9:16 PM and provided a copy of the email to state. The Administrator stated he did not take into consideration the family did not want it reported but did get with the regional team, and they did not instruct him to not make a report to the local authorities. The Administrator stated it was the abuse coordinator job to oversee the abuse investigation and in-services to staff to ensure that all staff are aware of when and how to report abuse. The Administrator stated he monitors the staff's knowledge of abuse/ neglect policy and procedure and goes around randomly asking staff questions about abuse and neglect. The Administrator stated reporting abuse is on a case-by-case basis as it depends on scenarios like date, time, and persons involved. The administrator stated the facility ensures the policy and procedure are implemented correctly is to constantly, educate abuse and neglect policy and procedures. Record review of the facility's Abuse and Neglect and Exploitation Policy and Procedure dated 01/2025 indicated Every resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents should not be subjected to abuse by anyone, including, but not limited to, community team members, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. It is the respons1b1hty of our team members, Community consultants, attending physicians, family members, visitors, etc. to promptly report any incident of suspected neglect or resident abuse, including injuries of an unknown source, and theft or misappropriation of resident property to Community management. Reporting/Response-All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities are individuals as may be required by law and per the current state/federal reporting requirements.

Based on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for one of four residents (Resident #37) reviewed for accuracy and completeness of clinical records.The facility failed to ensure LVN A documented Resident #37's information on her nursing progress notes after completing an IV catheter (small, flexible plastic tube inserted into a vein to deliver fluids, blood, or medication directly into a person's bloodstream) insertion. This failure could place residents at risk of not recording a proper account of medical interventions, treatments, and outcomes during a resident's stay.The findings included:Record review of Resident #37's face sheet dated 8/27/26 revealed an [AGE] year-old female with an admission date oof 6/26/26. Her pertinent diagnoses included type 2 diabetes mellitus (chronic disease where the body becomes resistant to insulin, leading to high blood sugar levels) and congestive heart failure (chronic condition where the heart cannot pump blood well enough to meet the body's needs, causing fluid to back up and build up in the body).Record review of Resident #37's comprehensive MDS assessment, dated 8/25/26, revealed a BIMS score of 6 which indicated severe cognitive impairment.Record review of Resident #37's comprehensive care plan, dated 8/27/26, revealed the focus I am at risk for complications associated with my intravenous therapy r/t: Peripheral Line. Date initiated: 8/18/26. Interventions included administer medications and/or flushes as ordered by MD. Date initiated: 8/18/26.Record review of Resident #37's order summary revealed an order for ceftriaxone 2 gram intravenously for pneumonia for 7 days in the evenings- Start date: 8/18/26.Record review of Resident #37's MAR revealed the order for ceftriaxone was administered on 8/18/26-8/24/26.During an interview on 8/25/26 at 3:33 p.m., LVN A said she was supposed to document when she inserted the peripheral IV. She said she tried to document the IV catheter insertion in the Resident's EMR at that moment, but she got busy with other tasks and did not go back to document the IV insertion. LVN A said she inserted the IV catheter on 8/18/26 at 6 p.m. and started the medication as ordered. She said there were no negative outcomes for Resident #37 from not documenting. LVN A said had in-services on documentation but did not remember the date.During an interview on 8/25/26 at 3:49 p.m., the DON said the nurse should have documented when she initially inserted the IV catheter in the resident's EMR. She said in-services were on IV medication and documentation were assigned through a web-based training site and yearly skilled check lists were completed for the nurses.Record review of the undated facility policy titled, IV Policies and Procedure [NAME], Peripheral revealed the following: Procedure: To safely insert and start peripheral IV 3 inches in length or less, the following procedure will be performed.15. Document the procedure.

Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 16 (Resident #37, Resident #66 and Resident#83) residents reviewed for infection control, 1. The facility failed to ensure Resident #37's IV dressing was labeled on 8/18/26. 2. The facility failed to ensure that an Enhanced Barrier Precaution (EBP) sign was displayed outside the room of Resident #66 on 08/25/26. 3. CNA D failed to follow Enhanced Barrier Precautions for an indwelling medical device (indwelling catheter) for Resident #83 on 08/26/26. These failures could place residents at risk for healthcare associated cross-contamination and the spread of infection. 1. Record review of Resident #37's face sheet dated 8/27/26 revealed an [AGE] year-old female with an admission date of 6/26/26. Her pertinent diagnoses included type 2 diabetes mellitus (chronic disease where the body becomes resistant to insulin, leading to high blood sugar levels) and congestive heart failure (chronic condition where the heart cannot pump blood well enough to meet the body's needs, causing fluid to back up and build up in the body). Record review of Resident #37's comprehensive MDS assessment, dated 8/25/26, revealed a BIMS score of 6 which indicated severe cognitive impairment. Record review of Resident #37's comprehensive care plan, dated 8/27/26, revealed the focus I am at risk for complications associated with my intravenous therapy r/t: Peripheral Line. Date initiated: 8/18/26. Interventions included administer medications and/or flushes (injection of sterile salt water through an IV tube to clean it out) as ordered by MD. Date initiated: 8/18/26 and Infection Risk: Change dressing to IV access as ordered. Initiated on 8/18/26. Record review of Resident #37's order summary revealed an order for ceftriaxone (antibiotic used to treat bacterial infections) 2 gram intravenously for pneumonia for 7 days in the evenings- Start date: 8/18/26 and Monitor IV site for s/s of infiltration (fluid or medicine from an IV line leaks into the soft tissue under the skin instead of staying in the vein) or infection every shift-Start date: 8/2026. During an interview on 8/25/26 at 3:33 p.m., LVN A said she changed the resident's transparent film dressing on 8/24/26 because it was leaking and labeled it, but she did not know how it fell off. She said part of the procedure when inserting an IV catheter or changing the dressing, was to label the dressing, which included the date. LVN A said not having an IV dressing labeled could place the residents at risk of infection as the nurses would not know the last time it was changed. She said in-services on IV medication, which includes dressing changes, were done yearly. She said she could not remember the date of the last in-service on IV medication that was done. During an interview on 8/25/26 at 3:49 p.m., the DON said during morning meetings, residents that have IV catheters in place are discussed. She said the clinical team performed daily rounds and checked IV dressings and IV sites. The DON said there was no negative outcome for Resident #37 from not having had the IV dressing labeled. She said the staff have eyes on the IV sites every day to ensure they are patent and there are no signs of infection. She said the nurses checked the IV site every shift and documented on the resident's MAR. The DON said in-services on IV medication were assigned to the nurses through the facility's web-based training and yearly nurse skilled check list were completed. 2. Record review of Resident #66's face sheet, dated 02026, reflected a [AGE] year-old male admitted on [DATE]. His pertinent diagnoses included Endocarditis (a serious infection and inflammation of the inner lining of the heart's chambers and valves) and Type 2 Diabetes Mellitus (high blood sugar levels). Record review of Resident #66's MDS assessment in process. Record review of Resident #66's care plan not dated, reflected at risk for infection or recurrent/chronic infection r/t compromised medical condition: Aortic valve endocarditis. Interventions were Enhanced Barrier Precautions practices as clinically indicated. Record review of Resident #66's Physician's Order Summary dated 08/25/2026 reflected EBP (Enhanced Barrier Precautions): Practice EBP as indicated in contact with PICC line. Order Date 08/13/2026. During an Observation on 08/25/2026 at 11:05 a.m., revealed there was no EBP sign displayed outside Resident #66's room. In an interview on 08/25/2026 at 11:15 a.m., LVN G stated that she was Resident #66's nurse. She stated that residents requiring an EBP sign were identified if they have an indwelling catheter, feeding tube and PICC lines. She stated that the infection control nurse was responsible for posting the EBP sign immediately once the need for EBP was identified. LVN G stated that it was important to have the EBP signs posted to alert all staff that the residents had an invasive device or an open wound requiring EBP. She stated Resident # had a PICC LINE and was transferred from another hall yesterday. LVN G confirmed there was no EBP sign outside Resident #66's room. She stated that the negative outcome was the spread of infection. In an interview on 08/25/2026 at 1:04 p.m., the DON stated that the residents who require an EBP sign were those who had a PICC line, catheter, or any draining wounds. She stated that it was important to post the EBP sign to prevent the spread of infection. The DON stated the infection preventionist and the nurse were responsible for posting the EBP sign. She stated that the sign should have been posted as soon as possible upon the resident's arrival. The DON stated that the EBP sign alerts staff to wear gowns and gloves when coming into close contact with the residents. She stated that the negative outcome for not posting the EBP sign was that staff providing care might wear the appropriate PPE. 3. Record review of Resident #83's face sheet, dated 08/26/2026, revealed a [AGE] year-old female with an admission date of 10/07/2024. Pertinent diagnoses included Obstructive and Reflux Uropathy (a condition in which the flow of urine was blocked), Muscle wasting and atrophy (the shrinking and loss of muscle tissue). Record review of Resident #83's Care Plan, dated 01/22/2019, revealed Resident #83 had a indwelling catheter. Interventions: Enhanced Barrier Precautions practices as clinically indicated. Record review of Resident #83's Quarterly MDS assessment, dated 06/30/2026, revealed Section H-Bladder and Bowel indicated Resident had an indwelling catheter while a resident. During an incontinent care observation on 08/26/26 at 09:10 a.m., CNA D and CNA I commenced incontinent care and indwelling catheter care of Resident #83. CNA D and CNA I entered Resident #83's room after knocking. CNA D and CNA I began with washing hands for 30seconds, gloved up, and prepared table of needed supplies. CNA D and CNA I continued by raising bed and then discarded gloves. After discarding the gloves, CNA D and CNA I continued with applying hand sanitizer and applied new gloves. CNA D proceeded with catheter care and proceeded to clean the back area., removed brief, applied new brief. CNA D and CNA I did not use gown during incontinent care. During an interview on 08/26/26 at 09:30 a.m., CNA D stated any resident with a indwelling catheter was required to be in enhanced barrier precautions. She stated she should have worn a gown and just overlooked it when she entered the room. She stated the risk of not following Enhanced Barrier Precautions was the spread of infection. During an interview on 08/26/26 at 9:35 a.m., CNA I said that she forgot to use the gown. CNA I said it was important to use the EBP to protect residents from whatever microorganisms that she could carry and to protect other residents. CNA I said residents could be at risk of infection. During an interview on 08/27/26 at 4:15 p.m., DON stated EBP was needed, staff needed to wear gown and gloves for individuals with a catheter, feeding tube, or wounds. DON said that it was important to use PPE to prevent introducing any kind of infection to residents, DON said that staff was doing the handwashing properly and that did not have any effect to Resident #83. Record review of the undated facility policy titled, IV Policies and Procedure [NAME], Peripheral revealed the following: Procedure: To safely insert and start peripheral IV 3 inches in length or less, the following procedure will be performed.13. With sterile tape, secure the catheter and apply dressing. Label appropriately. Record review of the facility's policy titled Infection Prevention and Control, date revised April 2024, stated Compliance Guidelines: The infection prevention and control program is a facility wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/oversight, guidance/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. Prevention of Infection: Important facets of infection prevention include: Instituting measures to avoid complications or dissemination; Educating staff and ensuring that they adhere to proper techniques and procedures; In addition to isolation practices, Enhanced Barrier Precautions (EBP) maybe implemented as an infection control intervention designed to reduce transmission of resistant organisms. The use of PPE, such as gown and glove use during high contact resident care activities. EBP may be indicated as a recommendation by the CDC (when Contact Precautions do not otherwise apply) for residents with the following: Wounds or indwelling medical devices, regardless of MDRO colonization status EBP requires the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Residents/Patients with the following clinical indication should be under EBP: .Indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. EBP should be utilized during high contact resident care activities: Dressing Bathing/shower Transferring. Providing hygiene. Changing linens Device care or use. 12. Implementation of Isolation and/or Precautions: Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves) For Enhanced Barrier Precautions, signage should also clearly indicate the high contact resident care activities that require the use of gown and gloves.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure acquiring, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident#1) of 4 residents, reviewed for pharmaceutical services, in that:The facility failed to ensure Resident #1's physician ordered Midodrine (medication used to raise blood pressure) was held when her blood pressure was found to be out of parameters for administration.This failure could place residents at risk of not receiving the therapeutic effect of their medication as ordered by the physician.Findings included:Record review of Resident #1's face sheet, dated 6/24/26, reflected an [AGE] year-old female with an admission date of 5/06/26. Her relevant diagnoses included end stage renal disease (most severe stage of kidney disease) and hypertension (high blood pressure).Record review of Resident #1's Nursing Home PPS MDS assessment, dated 5/24/26, reflected her BIMS score of 15, which indicated her cognition was intact.Record review of Resident #1's care plan, dated 6/19/26, reflected Resident #1 has heart disease. I am at risk for associated cardiac complications such as chest pain, SOB, fatigue, dizziness, poor endurance/activity intolerance and edema. Date initiated:5/06/26. GOAL: I will tolerate my medication and treatment regimen to manage my heart disease without any adverse effects or associated complications through my next due date. INTERVENTIONS: Administer my medications as ordered by my physician.Record review of Resident #1's order summary, dated 6/24/26, reflected orders for Midodrine HCl oral tablet 10 mg give one tablet by mouth three times a day for hypotension, hold for SBP >130 with a start date of 5/21/26.Record review of Resident #1's June 2026 MAR indicated, Resident #1's physician order for Midodrine HCl oral tablet 10 mg (Midodrine HCl) give 1 tablet by mouth three times a day for hypotension HOLD FOR SBP >130 was administered on 6/4/26 and 6/13/26 based on check offs and signatures completed by MA A and MA B. On 6/04/26 Resident #1 had a blood pressure of 133/60 and on 6/13/26 had a blood pressure of 134/75.During an interview on 6/24/26 at 11:06 a.m., MA B said he worked with Resident #1 and checked her blood pressure before administering the medication. He said the medication would be held if her blood pressure was greater than 130. He said he had administered the medication instead of holding it. MA B said a negative outcome from administering Midodrine to Resident #1 with a blood pressure greater than 130, could cause the resident to have high blood pressure. He said the last in-service on medication administration was on 6/23/26.During an interview on 6/24/26 at 2:10 p.m., MA A said she knew to hold the Midodrine if Resident #1's blood pressure was greater than 130. She said she always checked the resident's blood pressure before administering a blood pressure medication and checked the MARs against the doctor's orders. She said the last in-service on medication administration was in May 2026.During an interview on 6/24/26 at 5:11 p.m., the DON said she performed random checks on MARs and TARs, and chart audits were done every morning. She said MA B had an in-service on 6/23/26 and MA A had an in-service on 6/9/26 for medication administration. The DON said that Midodrine administered with a blood pressure greater than 130 could cause a resident's blood pressure to increase. She said Resident #1 did not have adverse reactions from the Midodrine that was administered on 6/4/26 and 6/13/26. She said in-services on medication administration and management were done twice in June 2026.Record review of facility policy titled Medication Administration, dated 3/15/19, stated GUIDELINES: 2. a. The nurse/medication aide shall be responsible to read and follow precautionary or instruction on prescription labels.

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 (200 hallway) of 4 medication carts. The facility failed to ensure the nurses medication cart for 200 hall was secured by a lock when it was left unattended by LVN A. This failure could place residents at risk of injury to other residents if medication left unsecured were consumed. Findings included: During an observation on 3/3/2026 at 03:40 p.m., revealed the 200 Hall nurse's medication cart was left unlocked and unattended in the 200 hallway. During the observation LVN A was called by surveyor and informed her that the medication cart was unlocked. LVN A secured the cart by locking it. During an interview on 3/3/2026 at 03:40 p.m., LVN A revealed she was responsible for the nurse's medication cart that was left unlocked. She stated he was expected to lock the nurse's medication cart when he walked away from it. She said that inside the cart there were medications of the residents for 200 hallway. She stated if it was left unlocked then a resident could open a drawer and take a medication that was not for them. During an interview on 3/3/2026 at 04:00 p.m., the DON revealed numerous staff, including she and the ADON, were responsible for ensuring medications carts were locked. The DON stated his expectation of staff when they walked away from the medication cart was to lock it. The DON stated the negative outcome for leaving the cart unlocked was a resident or visitor could grab the medication from the cart, and it could harm them.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 (Resident # 1) of 2 residents reviewed for parenteral fluids.The facility failed to ensure on 8/15/2025 that Resident # 1's intravenous medication bag was correctly labeled with the resident's name.This failure could place residents at risk for medication error and delay in medication administration.The findings included: Record review of Resident # 1's MDS assessment, dated 8/01/2025, reflected the resident was an [AGE] year-old-resident who was admitted to the facility on [DATE]. The resident had a diagnoses which included: Atrial Fibrillation (an irregular and often rapid heart rhythm in the upper chambers of the heart, called the atria), Coronary Artery Disease (a condition where the heart's blood vessels narrow or become blocked, usually due to a buildup of plaque made of fat, cholesterol, and other substances), Hypertension (high blood pressure), Wound Infection, Diabetes Mellitus (a condition where the body cannot properly use glucose, a type of sugar, for energy), Non-Alzheimer's dementia (brain conditions that cause a decline in thinking, memory, or other cognitive abilities but are not caused by Alzheimer's disease. Resident # 1's BIMS score was 03 which indicated severe cognitive impairment. Record review of Resident # 1's physician's order dated 7/29/2025 reflected an order for Meropenem intravenous Solution Reconstituted 500 MG. Use 500 MG intravenously every 6 hours for Sacral Wound Infection for 5 weeks. Start date 7/30/2025, End date 9/02/2025. Record Review of Grievance Binder reflected Grievance/Concern Report dated 8/15/2025 Name and contact information of person expressing concern: LVN A and Family member. Department concern is related to: Nursing, Description of concern: Care concern, Other: Family member had concerns regarding medication concern. Date assigned: 8/15/25, Action Taken: 1:1 Inservice completed by DNS. Was the person expressing the concern notified of the results or concern resolution: Yes, In Person. Outcome: Person/Resident satisfied with community's response to concern. Administrator's signature and dated 8/16/25. Training/Retraining form dated 8/15/2025, Topic: 5 Rights of medication administration and Utilizing the StatSafe (automated medication management system) when medications are not available, for Employee: LVN A 2-10 shift. In a phone interview on 11/17/2025 at 4:11 PM with LVN A she said Resident # 1 was on an IV antibiotic, Meropenem. She said it was a very busy day and when she picked up the medication, she only saw the name of the medicine and the dosage but did not see the resident's name. She said that the Family member was rushing me and brought it to my attention that the resident's name was different. LVN A said that at that moment she stopped the machine and notified the DON and the physician. She said there were no new orders given by the doctor. She said she also called the pharmacy to order more medication. She said, I saw that it was the right dose and the right medication, but I didn't check the label for the name. Everybody was talking to me and asking questions. She said there was medication on hand for the resident and restarted the medication with the resident's own medication. She said the medication that was hung the first time had infused for less than five minutes. She said she had a 1:1 in-service on the 5 rights of medication administration. She said not following the 5 rights can cause a resident to have reaction and depending on the medication, could worsen an infection or could cause an interaction and have consequences.In an interview on 11/18/2025 2:10 PM with the DNS said, she received a phone call from LVN A at 3 AM that she had an issue grabbing the wrong IV. The DNS said she spoke to the family the following day and informed them that there was no harm to the resident as it was the same medication and dosage. She said she informed the family of the plan of correction regarding the incident, and they agreed. The DNS said she had a 1:1 in-service on the 5 rights of medication administration and what to do if medication is not available. She said she also informed the NP, and no new orders were given. The DNS said she held an in-service on medication administration in July for all staff and in-service on medication administration was done in September. She said by not following the 5 rights of medication administration would be based on a case-by-case scenario, and in this case, there was no potential harm to the resident because it was the same medication. She said LVN A is a good nurse and compassionate, there have been no customer complaints about her. The DNS said she frequently provides re-education on medication administration and reminders on the 5 rights of medication administration (The five fundamental rights are simple checks healthcare providers use to ensure patient safety, making sure you're giving the right person, right medicine, right amount, right method, and right time) to the staff. Record review of Training/Retraining dated: July 11, 2025, Topic: Safe Medication Administration, Following MD orders, Reporting, reflected 18 employee signatures which included LVN A.Record review of September 2025 Meeting Agenda dated September 30, 2025, at 2:30 PM reflected Clinical Care, Topics: Feedings, Residents' Appearances, Notifications RP/MD/DNS, 5 Rights of Medication Administration. Customer Service, Topics: Call lights, Abuse and Neglect, Patients served. Sign-in sheet revealed 23 employee signatures which included LVN A. Record review of the facility's Medication Administration Policy and procedure dated January 2024 reflected Compliance Guidelines: Resident medications are administered in an accurate, safe, timely, and sanitary manner. 2. Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route. 4. Follow safe preparation practices.

Based on interview and record review, the facility failed to ensure residents had the right to formulate an advance directive for 1 (Resident #173) of 8 residents reviewed for Advance Directives. The facility failed to ensure Resident #173's OOH-DNR was completed. The OOH-DNR form did not have the physician's signature. This failure could affect all residents who have implemented Advance Directives and established their choice not to be resuscitated at risk of receiving CPR against their wishes. The findings were: Record review of Resident #173's electronic face sheet dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Respiratory Failure, Metabolic Encephalopathy (any disease or disorder of the brain, characterized by changes in brain function or structure), Heart Failure, Chronic Obstructive Pulmonary Disease (a chronic lung disease that causes air flow limitation), Type 2 Diabetes Mellitus, Hypertension (high blood pressure), Acute Kidney Failure.Resident #173's electronic face sheet reflected Code Status: DNR. Record review of Resident #173's MDS assessment dated [DATE] reflected he scored a 0 on his BIMS which reflected he was severely cognitively impaired. Record review of Resident #173's undated comprehensive care plan reflected, Resident #173's Advanced Directives: Code Status: (DNR) Do Not Resuscitate Date Initiated: [DATE]. Honor my Advance Directives, care wishes, and Code Status will be respected and honored as indicated. Date Initiated: [DATE]. Refer to Social Services as indicated. Date Initiated: [DATE]. Record review of Resident #173's physician order dated [DATE] reflected ***Code Status: ***DNR*** Record review of Resident #173's OOH-DNR form dated [DATE] reflected the form was signed in section C. Declaration by a qualified relative of the adult person who is incompetent or otherwise incapable of communication: I am the above person's: spouse. The OOH-DNR revealed the form was not signed by the attending physician below section E, Physician's Statement: I am the attending physician of the above noted person and have noted the existence of this order in the person's medical records. I direct health care professionals acting in our-of- hospital settings, including a hospital emergency department, not to initiate or continue for the person: cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, artificial ventilation. It also revealed the physician did not sign section F, All persons who have signed above must sign below, acknowledging that this document has been properly completed. In an interview on [DATE] at 11:15 a.m., Social Services stated that she was the one responsible for completing the OOH DNR form. She stated that upon admission, she informed the resident and/or family of their rights regarding the DNR status. If it was confirmed for the resident to be DNR, she provided them with the form, and obtained their signatures, and the doctor's signature. She stated that the OOH DNR form should be signed by the doctor as soon as possible. She called the doctor's office to notify her of needing a signature. She stated that it was important for the OOH DNR form to be signed by the doctor because it made the document official, a legal document that all parties signed. The Social Services stated the DNR was not official until the doctor signed it. She stated Resident #173's OOH DNR form was not signed because his doctor's NP had not come to the facility yet. In an interview on [DATE] at 1:05 p.m., LVN A stated that the DNR form was discussed upon admission. She stated residents who were DNR should have a completed and signed by all parties, the OOH DNR. She stated all parties were residents or family, witnesses, and the doctor. LVN A stated that until they have a completed signed OOH DNR, the resident was considered a full code (provide cardiopulmonary resuscitation) . They would have to provide CPR causing the resident harm. She stated that the DNR status of a resident was located on PCC (it serves as an electronic health record system). LVN A stated if it showed DNR on PCC that meant the OOH DNR form had been verified and completed. In an interview on [DATE] at 1:35 p.m., the DON stated that the social worker was responsible for completing the OOH DNR form. She stated the facility explains the document and if they say yes that they want to be DNR, the facility would obtain the resident/RP and witnesses signatures. They then called the MD for an order and changed the DNR status in PCC. The DON stated that it was important for the MD to sign the OOH DNR form to verify that they agreed to the process. She stated that it was an official legal form. She stated that they got the MD signature fast. Record review of the facility's Advance Directives policy date reviewed/revised 2017, revealed theCompliance Guidelines:Every resident has the right to formulate an advance directive and to refuse treatment. The community will determine the existence of an advance directive at the time of admission.A copy of the advance directive and subsequent revisions will be included in the resident's medical record.The IDT should honor the care decision expressed and initiate the advance directive by initiating the Out of Hospital Do Not Resuscitate (OOH DNR) form and should obtain the medical provider/physician's signature as per the OOH DNR instructions. The medical record and resident plan of care should reflect the residents wishes as well as the physician orders in order to meet the directives described. Record review of the OOH DNR Order instructions for issuing an OOH-DNR Order revealed thePurpose: The Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Order on reverse side complies with Health and Safety Code (HSC), Chapter 166 for use by qualified persons or their authorized representatives to direct health care professionals to forgo resuscitation attempts and to permit the person to have a natural death with peace and dignity. Applicability: This OOH-DNR Order applies to health care professions in out-of-hospital settings, including physicians' offices, hospital clinics and emergency departments. Implementation: A competent adult person at least [AGE] years of age, or the person's authorized representative or qualified relative may execute or issue an OOH-DNR Order. The person attending physician will document the existence of the Order in the person's permanent medical record. The OOH-DNR Order may be executed as follows: . In addition: the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if applicable, have witnessed a competent adult person making and OOH-DNR Order by nonwritten communication to the attending physician, who must sign in Section D and also the physician's statement section.

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 (Resident #61) residents reviewed for respiratory care. 1. The facility failed to ensure Resident #61's oxygen was administered at the correct setting of 2 liters per minute on 06/29/2025 as ordered by the physician. These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. The findings included: 1.Record review of Resident #61's admission record dated 06/29/2025 reflected a [AGE] year-old female with an admission date of 01/16/2025. Pertinent diagnoses included Pulmonary Fibrosis (a lung disease characterized by the scarring and thickening of lung tissue, specifically the interstitium, which is the area between the air sacs), Muscle weakness, shortness of breath, and Need for assistance with personal care. Record review of Resident #61's person-centered care plan, initiated date 1/16/2025 reflected Resident #61 used oxygen therapy related to shortness of breath. Intervention included oxygen settings: Provide oxygen as ordered/recommended by my physician. Record review of Resident #61's physician order dated 06/29/2025, revealed oxygen at 2 liters per minute via nasal cannula every shift. Record review of Resident #61's Quarterly MDS assessment, dated 03/15/2025 revealed oxygen therapy while a resident. During an observation of Resident #61 on 06/29/2025 at 11:15 a.m. the oxygen level on the oxygen concentration machine was at 1.5Liters Per Minute via nasal cannula. Observed Resident #61 in bed with the head of the bed slightly elevated. No signs of respiratory distress were noted. In an interview on 06/29/2025 at 11:20 a.m. LVN B, stated she was the nurse for Resident #61. LVN B agreed that the Oxygen setting was set at 1.5 Liters Per Minute. She stated the oxygen setting was supposed to be at 2 Liters Per Minute per physician orders. She stated that she checked the settings at the beginning of her shift. She was not sure who might have moved it. LVN B stated that she checked Resident #61's oxygen tubing and saturation this morning. She stated that she usually checks the oxygen once a day and as needed. LVN B stated that the negative outcome to keeping Resident# 61's oxygen setting at 1.5 Liters Per Minute was that the resident could go into respiratory distress or her oxygen level might drop. In an interview on 07/1/2025 at 10:45 a.m. with the DON, she stated that the nurses assigned to that hall were responsible for checking the Oxygen settings. She stated that the nurses were to check the setting once per shift. The DON stated they were to follow oxygen settings on physician orders. The DON stated that the negative outcome could be the resident could have a respiratory distress and hypoxia (low oxygen levels). Record review of the facility policy named Oxygen Administration with an implemented date 2/14/19 and revised date January 2023, revealed: a resident receives oxygen therapy when there is an order by a physician. the resident's disease, physical condition, and age will help determine the most appropriate method of administration and should be reflected in the physician order.

Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 5 residents (Resident #29) reviewed for tube feeding management. The facility failed to ensure there were labels or instructions on Resident #29' s enteral nutrition supplemental feeding bottle on 06/29/25. These failures could place residents at risk for non-therapeutic responses to enteral feeding, as well as receiving the wrong feeding or receiving a feeding at the wrong rate. Findings included: Record review of Resident #29's face sheet, dated 06/29/25, revealed a [AGE] year-old female with an original admission date of 08/20/24 and a current admission date of 12/25/24. Diagnoses included Gastrostomy Status (a surgical procedure that creates an opening into the stomach, allowing for access to the stomach for feeding). Record review of Resident #29's Significant Change MDS Assessment, dated 03/26/25, revealed a BIMS score of 1 as the resident was severely cognitively impaired. The MDS assessment also revealed Resident #29 had a feeding tube. Record review of Resident #29's care plan, initiated 08/20/24 and revised 6/25/25, revealed a care plan for tube feeding with a goal I will not experience any complication associated with my feeding tube or enteral nutrition/hydration through my next review date. Record review of Resident #29's physician orders, dated 06/29/25, revealed an order for Nepro (therapeutic nutrition) at 1.8 milliliters per hour for 18 hours via G-tube stationary pump. During an observation on 06/29/25 at 11:50 a.m. it was revealed Resident #29's enteral feeding bottle was not labeled, and there was no label on the ground. In an interview on 06/29/25 at 11:55 a.m. with LVN B, she stated the feeding bags were supposed to be labeled with the resident's name, the feeding type, the feeding rate, and the time and date the feeding was initiated. She stated sometimes the labels fell off because they did not stick very well. She stated if this information was not listed, then the nurse would not be able to verify if the feeding was correct, and this could cause the resident harm. In an interview on 07/01/25 at 10:45 a.m. with LVN C, she stated the feeding bottles should always be labeled so the nurses were aware the resident was receiving the correct feeding at the correct rate. She stated the bottle could not be checked with another nurse or verified against the order without a proper label on it, and this could cause the resident harm or the resident could not get the proper nutrition. In an interview on 07/01/25 at 11:35 a.m. with the DON, she stated the labels needed to be on the enteral feeding bottles so that nurses were aware the resident received the correct feeding because if it was not labeled appropriately, a resident could receive the wrong feeding., She said there was not a negative outcome but nurses needed to know when the feeding bottle was opened. Record review of the facility policy titled Medication Administration via Enteral Tube implemented on 3/15/19 stated the following: to administer medications through a enteral tube in an accurate, safe, timely and sanitary manner.

Based on interview, and record review, the facility failed to implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for 1 of 22 residents (Resident #20) reviewed for care plans. The facility did not develop Resident #20's care plan related to diagnosis Post-Traumatic Stress Disorder. These failures could place residents at risk for unmet care needs and decreased quality of care. Findings included: Record review of face sheet dated 06/30/25 indicated Resident #20 was a [AGE] year-old male admitted on [DATE]. His diagnoses included post-traumatic stress disorder, need for assistance with personal care, cognitive communication deficit. Record review of Resident #20's admission MDS assessment dated [DATE] indicated his BIMS score was 8 out of 15 showing moderate cognitive impairment. He was coded as having post-traumatic stress disorder. Observation and interview with Resident #20 on 06/29/25 at 2:28 PM, indicated he was lying in bed watching television. Resident #20 said that he felt safe in this facility, and he was treated with respect and dignity. Record review of Resident #20's care plan, initiated on 5/25/2025, indicated Resident #20 did not have Post traumatic stress disorder in the care plan. During an interview on 6/30/25 at 1:40 p.m., MDS D said it was important to have Post traumatic stress disorder in the care plan to communicate with the floor nurses. MDS D said she was not sure what was the negative outcome because the resident was stable. MDS D said that she was not aware that Resident #20 had PTSD. During an interview on 7/1/25 at 2:30 p.m. the DON said she was not sure if post-traumatic stress disorder was supposed to be care planned. The DON said that staff followed the care plan. The DON said that the negative outcome was not giving the proper care to Resident #20. Record review of the facility's policy titled Care Plans implemented 02/2017, indicated, The community develops a comprehensive care plan for each resident that includes measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan should be reflective of the identified problem or risk, a measurable outcome objective and appropriate intervention in relation to the identified problem or risk, outcome objective and resident's ability, needs, medical condition, preventative measures. The care plan may also include the expressed preferences. The care plan in conjunction with the plan of care throughout the medical record is developed and or recommended to attain or maintain the resident's highest practicable physical mental, and psychosocial well-being.

Based on interview and record review, the facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort for 2 of 8 residents reviewed for PASRR. (Resident #20, Resident #22)1. The facility failed to refer Resident #20 for PASRR Level II assessment when the facility incorrectly coded her PASRR Level I assessment.2. The facility failed to refer Resident #22 for PASRR review following new mental illness diagnosis of Major Depressive Disorder, added on 04/30/2025.These failures could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.Findings include:1. Record review of face sheet dated 06/30/25 indicated Resident #20 was a [AGE] year-old male admitted on [DATE]. His diagnoses included post-traumatic stress disorder, need for assistance with personal care, cognitive communication deficit.Resident #20's admission Minimum Data Set (MDS) assessment dated [DATE] indicated her Brief Interview for Mental Status (BIMS) score was 8 out of 15 showing moderate cognitive impairment. She was coded as having post-traumatic stress disorder.Observation and interview with Resident #20 on 06/29/25 at 2:28 PM, indicated he was lying in bed watching television.During an interview on 06/30/25 at 9:15 a.m., MDS D said she completed the PASRR assessments for the facility. When MDS D was asked if bipolar disorder was a qualifying diagnosis for a positive PASRR Level 1, she stated, yes. MDS D said that she missed the diagnosis for this resident. MDS there was not a negative outcome because she submitted the form 1012 for the resident to be evaluated on 6/30/25 after surveyor asked for PASRR Level 2.During an interview on 7/1/25 at 11:40 a.m. with the Director of Nursing (DON) confirmed post-traumatic stress disorder was a qualifying diagnosis for PASRR and there should have been a Level 2 evaluation conducted. The DON said the MDS nurse should not have entered it in as negative and should have requested the Level 1 be recompleted. The DON said that PASRR was just extra help that the resident could benefit from. The DON said that the negative outcome was that the resident was not receiving the extra help.2. Record review of Resident #22's electronic face sheet dated 06/30/2025 reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] and with an original admission date of 10/08/2024. Her diagnoses included Major Depressive Disorder, Metabolic Encephalopathy (any disease or disorder of the brain, characterized by changes in brain function or structure), Acute Respiratory Failure with Hypoxia (a low level of oxygen in the blood), Type 2 Diabetes Mellitus, Heart Failure, Muscle Wasting and Atrophy (the decrease in size and wasting of muscle tissue), and Hypertension (high blood pressure).Record review of Resident #22's quarterly MDS assessment dated completed on 04/18/2025, Section C, revealed a BIMS score of 14, indicating intact cognition. Section I (Active Diagnoses) indicated Resident #22 had diagnoses included Depression (other than bipolar). Section N (Medications) indicated Resident #22 was on antidepressant medications.Record review of Resident #22's comprehensive care plan, dated 05/22/2025, reflected Resident #22 requires antidepressant medication. Interventions: administer medication per MD orders, educate me and/or my family regarding all potential side effects, and risks associated with psychotropic medications and obtain consent for medication use, Monitor for target behaviors/symptoms, monitor/document/report to MD prn ongoing s/s of depression unaltered by antidepressant meds .In an interview on 06/30/2025 at 3:43 p.m. with MDS D, she was responsible for completing the PASRR assessments for the facility. She confirmed Resident #22 had a diagnosis of Major Depressive Disorder and was a qualifying diagnosis for PASRR Level 1. She stated that she submitted form 1012 for Resident #22. She stated she spoke to a staff member from LIDDA this morning and was informed that they would notify her of when they can come to get it done. MDS D stated that it was important for the PASARR level 1 screening to be completed so they can get the LIDDA to do the evaluation to see if they were a true positive.In an interview on 07/01/2025 at 1:35 p.m. with the DON stated, the MDS D nurse was responsible for completing the PASSR assessments. She stated that Major Depressive Disorder was a qualifying diagnosis for PASRR. The DON stated that she was not aware that Resident #22 had a new diagnosis of Major Depressive Disorder. She stated that it was important for the residents to be screened again with new added diagnosis because they can render services if, they were positive.Record review of facility policy titled comprehensive assessments with an implemented date February 2017 and a revised date January 2014 reflected: Pre-admission screening and resident review (PASRR) screen was required of all individuals with mental illness or mental retardation regardless of the applicant ' s source of payment. These screenings were provided when there had been a significant change in the residents ' condition. The community coordinates resident assessment with pre-admission screening to maximize the resident assessment process.

Based on observation, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 1 of 4 Residents (Resident #39) that were observed for infection control in that: The facility failed to ensure CNA E performed proper hand hygiene during pericare (incontinent care) for Resident #39.The facility failed to ensure CNA F performed proper Foley catheter care for Resident #39. These deficient practices could place residents at risk for infections, healthcare associated cross contamination, and the spread of infection. Findings included: Record review of Resident #39's electronic face sheet dated 07/01/2025 reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Personal History of Urinary Tract Infections, Acute Kidney Failure, Unspecified Hydronephrosis (a condition that occurs when a kidney swells and cannot get rid of urine), Obstructive and Reflux Uropathy (a condition in which the flow of urine was blocked), Type 2 Diabetes Mellitus, Unspecified Dementia. Record review of Resident #39's quarterly MDS assessment, dated 04/18/2025, reflected a BIMS score of 00, indicating Resident #39 was severely cognitively impaired. Resident #39 had an indwelling foley catheter. Record review of Resident #39's comprehensive person-centered care plan, dated on 05/22/2025 reflected Focus Resident #39 at risk for infection or recurrent/chronic infection r/t compromised medical condition: Foley Catheter. Interventions: Report changes in condition to MD as clinically indicated. Monitor vital signs as indicated. Enhanced Barrier Precautions practices as clinically indicated. Observation on 06/30/2025 at 1:38 p.m. revealed CNA E grabbed the bed remote, while wearing gloves, to adjust the height of the bed to working level and with the same pair of gloves she proceeded to touch the clean wipe. CNA E handed the wipe to CNA F and used it to clean Resident #39's inner thigh. Throughout the entire pericare process, CNA E handed the clean wipes to CNA F with the same pair of dirty gloves that touched the bed remote. During catheter care, CNA F cleansed the catheter tubing line going upwards towards the vaginal opening instead of downwards. In an interview on 06/30/2025 at 1:55 p.m., CNA E stated that she should have changed her gloves and sanitized after touching the bed remote. She stated that she did not change them due to being nervous. CNA E stated the potential negative outcome was infection. She stated that they were to clean the foley catheter tube downward, away from the vaginal opening to prevent infection. CNA E stated that pericare and foley catheter care skill checks off were done about a month ago and skills were met. She stated infection control in-services were done frequently, but she could not remember the exact date that it was done. In an interview on 06/30/2025 at 2:02 p.m., CNA F stated that she cleansed the foley catheter tubing upward towards the vaginal opening instead of downward. She made this error because she got nervous and was standing on the opposite side of the bed so that threw her off. CNA F stated that proper cleansing of the foley catheter tubing was to prevent infection. She stated that CNA E should have changed her gloves after touching the bed remote to prevent infection. CNA F stated that pericare and foley catheter care skill checks off were done randomly and skills were met. She stated infection control in services were done monthly. In an interview on 07/01/2025 at 1:35 p.m., the DON stated CNA E should have changed her gloves prior to touching the clean wipes. This was important to prevent germs from spreading onto the wipes. The DON stated the proper way to cleanse foley catheter tubing was to start from the vaginal opening and go downwards. This was important to keep infections away from the site. The DON stated that they have monthly infection control in-services. She stated that they conduct sporadic skill check offs. Record review of CNA E's Competency Skills Checklist dated 06/09/2025 reflected skills for Pericare and Foley Catheter Care for both males and females were all met in accordance with the facility's standard of practice. Record review of CNA F's Competency Skills Checklist dated 02/11/2025 reflected skills for Pericare and Foley Catheter Care for both males and females were all met in accordance with the facility's standard of practice. Record review of the facility's Infection Prevention and Control Program Policy date revised 04/2024 reflected: Compliance Guidelines: The infection prevention and control program is a facility wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program.The elements of the infection prevention and control program consist of coordination/oversight, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. Prevention of Infection:Important facets of infection prevention include:(3) educating staff and ensuring that they adhere to proper techniques and procedures;(6) educating staff and ensuring that they adhere to proper infection prevention and control practices when performing resident care activities as it pertains to his/her role, responsibilities and situation.

Based on record reviews and interviews, the facility failed to send a copy of the residents' discharge notice, prior to discharge, to the representative of the Office of State Long-Term Care (LTC) Ombudsman of the residents' transfer or discharge and the reasons for the move for 2 of 3 (Resident #1, Resident #41) reviewed for notifying the LTC Ombudsman of the residents' discharge. 1.Resident #1 was discharged to the hospital on [DATE] without a notice to the LTC state ombudsman. 2.Resident #41 was discharged home on [DATE] without a notice to the LTC state ombudsman. These failures could place residents at risk of not knowing their rights and receiving the services of the state LTC Ombudsman. Findings were: 1. Record review of Resident #1’s admission record dated 07/01/25 revealed Resident #1 was a [AGE] year-old female with diagnoses of Acute Respiratory Failure with Hypoxia (lungs cannot supply oxygen to blood), Type 2 Diabetes Mellitus without Complications (high blood sugar levels), Chronic Obstructive Pulmonary Disease (lung disease that causes obstructed airflow from lungs), Essential (Primary) Hypertension (high blood pressure), Shortness of Breath, Muscle Weakness (Generalized). Record review of Resident #1’s latest MDS dated [DATE] revealed a BIM score of 13 indicating intact cognition. Record review of Resident #1’s electronic medical record revealed a progress note dated 04/09/25 stating Resident #1 had been discharged to the hospital. Record review of Resident #1’s electronic medical record from 03/29/25 to 04/09/25 revealed no evidence of notice given to the LTC Ombudsman pertaining to Resident #1’s discharge to the hospital. 2.Record review of Resident #41's electronic face sheet dated 07/01/2025 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with a discharge date of 06/11/2025. His diagnoses included Chronic Obstructive Pulmonary Disease (a sudden worsening in a chronic lung disease that causes air flow limitation), Peripheral Vascular Disease (reduced circulation of blood to a body part, other than the brain or heart), Acute Respiratory Failure with Hypoxia (a condition where you don’t have enough oxygen in your body), Dementia, Hypertension (high blood pressure), Gastrostomy Status (a surgical procedure used to insert a tube through the abdomen and into the stomach), Dysphagia (difficulty swallowing), Anxiety Disorder. Record review of Resident #41’s comprehensive MDS dated [DATE] revealed a BIMS score of 13 indicating intact cognition. Record review of Resident #41’s electronic medical record revealed a progress note dated 06/11/2025 stating Resident #41 had been discharged home with family. Record review of Resident #41’s electronic medical record from 06/02/2025 to 06/13/2025 revealed no evidence of notice given to the LTC Ombudsman pertaining to Resident #41’s discharge home. During an interview on 07/01/25 at 4:43 p.m. the SSD said she had been working at the facility for a year. She said she wasn’t aware that she needed to notify the ombudsman whenever a resident was discharged from the facility. She said she had not notified the ombudsman of any residents that had been discharged since she has been working at the facility. During an interview on 07/01/25 at 11:03 a.m. the state LTC Ombudsman representative for the facility stated he had not received any discharge notices from the facility for the past year. During an interview on 07/01/25 at 4:55 p.m. the Administrator, said he had contacted the ombudsman on recent discharges for the current month. Record review of the facility’s policy titled “Admission, transfer, and Discharge”, date revised: September 2022 stated: “Notification before transfer Before a transfer or discharge occurs, the community notifies the resident and, if known, the family member, surrogate, or representative of the transfer and the reasons for it. A copy or documentation of the notice is kept in the clinical record and a copy is sent to a representative of the Office of the State Long Term Care Ombudsman.”

Based on observations, interview and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preference for 2 (Resident #34 and Resident #60) of 25 residents reviewed for call lights. The facility failed to ensure Resident #34 and Resident #60 had the call light within reach while in bed in their room. This failure could place residents at risk of being unable to obtain assistance or help when needed and in the event of an emergency. Findings were: 1.Record review of Resident #34's admission record dated 06/29/25 reflected a [AGE] year-old male with diagnoses of Unspecified Dementia (decline in thinking, learning and reasoning), Muscle Wasting And Atrophy Multiple Sites, Need for assistance with personal care, Difficulty in Walking. Record Review of Resident #34's Annual MDS dated [DATE] reflected a BIMS score of 14 indicating no cognitive impairment. Resident #34 used a wheelchair. 2. Record review of Resident #60's admission record dated 06/29/25 reflected a [AGE] year-old male with diagnoses of Unspecified Dementia (decline in thinking, learning and reasoning), Muscle weakness, Need for assistance with personal care, Difficulty in Walking and History of falling. Record Review of Resident #60's Annual MDS dated [DATE] reflected a BIMS score of 9 indicating moderate cognitive impairment. Resident #34 used a wheelchair. During an observation and interview on 6/29/25 at 10:25 a.m. revealed Resident #34's and Resident #60's call light devices were on the floor, and Resident #34 and Resident #60 were not able to reach them. Resident #34 and Resident #60 said that they were not able to reach the call light. During an interview on 6/29/25 at 10:30 a.m. LVN B observed Resident #34's and Resident #60's call light devices were on the floor, and Resident #34 [and Resident #60 were not able to reach them. LVN B said Resident #34 and Resident #60 were supposed to have their call lights near so residents can call for help if they need to. LVN B said Resident #34 and Resident #60 usually used the call light on and off. LVN B said she checks all residents to make sure their call lights are within reach, and they are not in need of any other assistance. She said she does this at the beginning when she first begins working and throughout her shift. LVN B said a negative outcome of not having the call light within reach was that Residents could fall and Residents could not be able to call for help. During an interview on 6/29/25 at 11:35 a.m. LVN A said that Resident #34 and Resident #60 usually used the call light when they needed something. She said she always makes sure residents had it within their reach and reminds them to use it. LVN A said that if a resident cannot reach the call light, then they cannot get help, they may have a fall and be at risk of getting hurt. During an interview on 7/1/25 at 11:00 a.m. the DON said that if call lights were not within reach, residents might need help. The DON said that she did not think there was a negative outcome due to residents were able to get up by themselves. Record review of facility's policy titled Routine Resident Care with date implemented: 3/14/19 stated; Policy: Residents should receive the necessary assistance to maintain good grooming, personal/oral hygiene and safety. Steps are taken to provide that a resident's capacity for self-performance of these activities does not diminish unless circumstances of the resident's clinical condition demonstrate the decline is unavoidable. Care is taken to maintain resident safety at all times.Guidelines: 9. resident call lights should be answered timely and resident requests are addressed, if permitted. Call lights should be placed within easy reach of the resident. Specific types of call lights, i.e. call light pads etc. should be added to the resident plan of care based upon residents abilities and limitations.

Based on interviews and record review, the facility failed to ensure adequate supervision was provided for 1 of 3 residents reviewed for accidents and supervision. (Resident #1) The facility failed to ensure Resident#1 received adequate supervision to prevent elopement. Resident #1 eloped from the facility on 02/12/2025 and was found by the police department approximately 2700 feet (0.5 mile) away from the facility. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 02/12/2025 and ended on 02/13/2025. The facility had corrected the noncompliance before the survey began. This failure could prevent residents from receiving appropriate supervision which could lead to residents sustaining serious injury, harm, or death. Findings included: Record Review of Resident #1's electronic facility face sheet dated 06/11/2025, revealed she was an [AGE] year-old male admitted to the facility on [DATE]. Her diagnoses included Unspecified Dementia, Hypertension (high blood pressure), Insomnia (sleep disorder in which you have trouble falling asleep), Unspecified Mood Disorder, and Hyperlipidemia (high cholesterol). Record Review of Resident #1's quarterly MDS assessment, dated 03/24/2025 revealed a BIMS score of 01 indicating Resident #1 was severely cognitive impaired and ambulated independently with a walker. Record Review of Resident #1's admission assessment dated [DATE] revealed the resident had a wandering history, and she had a wander guard in place. Record review of an incident report dated 02/13/2025, revealed on 02/12/2025 at around 9:00 p.m. the Administrator was notified by the DON, that Resident #1 had left the facility unattended and was returned to the facility without incident by the PD. The PD indicated they had located the resident around 8:19 p.m. after receiving a call from a civilian. Resident #1 was safely dropped off at the facility around 8:50 p.m. Surveillance footage revealed that the resident left from the facility at 7:00 p.m. A head-to-toe assessment was completed with no findings. Record review of LVN A's written statement on 02/12/2025 regarding Resident #1's incident indicated that she last saw Resident #1 in front of the nurse's station around 6:30 p.m.-6:40 p.m. She did not understand what the resident was asking and when asked again the resident was not able to answer. LVN A redirected Resident #1 to sit in the common area. Resident #1 walked away from nurse station as LVN A used desktop. In an interview on 06/11/2025 at 1:58 p.m., the DON stated she received a call from LVN A notifying her Resident #1 had returned to the facility and was brought in by the PD. She notified the Administrator. She stated that CNA B was doing her round in Resident #1's room when she realized Resident #1 was not there. She then walked out to notify the nurse and at that time LVN A had called her and told her the PD had just brought in Resident #1. She stated a head-to-toe assessment was done; no injuries were noted. The facility's secured unit was not open at that time. She stated the interventions prior to the elopement were a wander guard, redirection, and activities. The DON stated interventions after the elopement were Resident #1 was monitored every 30 minutes, the code was changed to the front door, residents were assessed for exit seeking tendencies with the need for additional personalized interventions. The DON stated that staff were trained and had drills on elopement and exit seeking management procedures. The DON stated there have been no elopements since the incident on 02/12/2025. In an interview on 06/11/2025 at 2:19 p.m., the Administrator stated the DON notified him of the incident. He reviewed the facility's surveillance cameras and was able to identify that a visitor had opened the door for Resident #1. The visitor was not aware Resident #1 was a resident, allowing her to leave the facility. The Administrator was able to identify the visitor and was called in for an interview. The visitor did confirm that she had opened the door for Resident #1 when she visited but did not know that that person was a resident. She stated that the individual had told her to hold the door open and not to close it. The Administrator educated the visitor regarding not to hold the door open for anyone and ensuring the door closes behind her anytime she was visiting. She was reminded to be aware of her surroundings and other individuals to help prevent future incidents. The Administrator also sent out a mass message via text and email, depending on families' preferred method of communication on file, to not hold the door open. Record Review of an Elopement Response & Exit Seeking Management Policy with date revised of January 2023, revealed Guideline: A. Elopement Response: Unable to locate resident: 1. If a resident is unable to be located or the alarms have sounded, immediately initiate a search of the entire community both inside and outside premises. B. Response following the location of the resident: 1. Once located and safety confirmed, conduct an assessment. Record Review of Routine Resident Care Policy with date revised of January 2024, revealed Compliance Guidelines: Care is taken to maintain resident safety at all times. Responsible Disciplines License nurses and non-licensed direct care team members. The facility had implemented the following interventions: Resident was placed on a 1:1. Vitals monitored every 4 hours for 24 hours The RP and physician notified. Head count. All other residents were assessed for exit seeking tendencies with a need for additional personalized interventions. Educated visitor regarding not opening the door for anyone and being aware of her surroundings and other individuals. Staff were trained in elopement/supervision procedures on 02/12/2025. Interviews with staff revealed that they were aware of the policy and procedures of elopement. The code changed to the front door. Reminder sent out to all families regarding entering/exiting the facility. Posted sign on the front entrance reminding visitors to exercise caution when entering/exiting the community to ensure residents do not follow them out. No additional elopement events had been identified since 02/12/2025. Resident placed in the new secured care unit for increased supervision on 02/26/2025. During an observation on 06/11/2025 at 8:30 a.m. revealed a posted sign on the front entrance which reflected, Please refrain from providing assistance to anyone out of the community without checking with a team member. During an observation on 06/11/2025 at 9:16 a.m. revealed Resident #1 was sitting in a chair in her room that was located in the secured unit. She was well dressed and appeared with good personal hygiene. The resident was observed without injury. Record review of Resident #1 revealed that she was placed on a 1:1, vitals were monitored every 4 hours for 24 hours, the RP and physician were notified. Record review of Resident #1 revealed that all other residents were assessed for exit seeking tendencies with a need for additional personalized interventions. Record review of Resident #1 revealed that visitors were educated regarding not opening the door for anyone and being aware of her surroundings and other individuals. Record review of an in-service attendance record with topic of Elopement and subject Missing person response & Elopement/exit seeking risk & response/Identifying & responding to triggers to prevent elopement drill and procedure, dated 02/12/2025, indicated that staff signed the in-service record. Record review of Resident #1 revealed the code was changed to the front door and a reminder was sent out to all families regarding entering/exiting the facility. Record review revealed no additional elopement events had been identified since 02/12/2025. In interviews on 06/11/2025 at 10:28 a.m. - 06/12/2025 at 2:20 p.m., 4 CNAs from different shifts were able to identify residents at risk for elopement; all were knowledgeable of the elopement policy and procedure. In interviews on 06/11/2025 from 4:05 p.m. - 06/12/2025 2:40 p.m., 3 LVNs from different shifts were able to identify residents at risk for elopement, all were knowledgeable of the elopement policy and procedure. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 02/12/2025 and ended on 02/13/2025. The facility had corrected the noncompliance before the survey began.

Based on interviews and record reviews, the facility failed to develop and implement baseline care plans that included the instructions needed to provide effective and person-centered care within 48 hours of admission for 2 of 4 residents (Resident #3 and Resident #2) reviewed for baseline care plans: 1. The facility failed to complete Resident #3's baseline care plan within 48 hours. 2. The facility failed to include in her baseline care plan that Resident #2's was admitted with a PICC line to upper right arm. These deficient practices could affect residents who receive care at the facility and could result in missed or inadequate care. The findings included: 1.Record review of Resident #3's face sheet dated 6/12/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a progressive, irreversible brain disorder that primarily affects memory, thinking and reasoning eventually leading to difficulty with everyday tasks), dementia (a decline in cognitive function that is severe enough to interfere with daily life and activities) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Record review of Resident #3's admission MDS dated [DATE] revealed the resident had a BIMS score of 00 which indicated severe cognitive impairment. It also revealed Resident #3 was dependent on assistance with toileting hygiene, required substantial/maximal assistance with shower/bathe self, upper and lower body dressing, putting on/taking off footwear and personal hygiene, and partial/moderate assistance with eating and oral hygiene. Record review of Resident #3's Admission/readmission assessment revealed he was admitted on [DATE] and assessed by LVN A. Record review of Resident #3's undated Comprehensive Care Plan revealed the following: Baseline / Initial Care Plan: I may be at risk for: self-care deficit, falls, skin concerns, pain, infection & nutritional/hydration concerns and emotional distress. Date Initiated: 05/19/2025. During an interview on 6/12/25 at 9:20 a.m., LVN A stated she had performed the admission assessment on Resident #3 on 5/15/25. LVN A said when she completed an admission, she reviewed medications, received/clarified orders, completed head-to-toe assessment, completed inventory, completed Braden scale for the skin, received consents for psychotropic medications, and the look back period for the past 3 days. LVN A said she believed the RNs completed the baseline care plans, but she would have to check with the DON to ensure that it was accurate. LVN A said it is important for the baseline to be completed and accurate because if not, a resident who could be at risk for falls for example could have a fall especially if he attempted to get out of bed and staff were not aware of his fall risks. During an interview on 6/12/25 at 10:36 am, the MDS Coordinator said when the admitting nurse completed the initial admission assessment, that initial assessment triggered and created the baseline care plan. She said the baseline care plan was usually completed withing 24 hours. She said she was the only MDS staff, so she oversaw the care plans. She said at times the regional MDS and the DON helped with the care plans, so an RN usually completed the care plans. She said the LVNs don't really understood that their initial/admission assessment was the baseline care plan. The surveyor asked the MDS if Resident #3 could be at risk for falls since the baseline care plan was not added until 5/19/25, 4 days later. She said any resident was at risk of falls due to age and co-morbidities. The MDS coordinator said when she worked on the assessment, she placed a fall risk on every resident. During an interview on 6/12/25 at 4:10 pm the DON said most of the time the baseline care plan was triggered off the admission and readmission assessment. The Surveyor asked the DON if the baseline care plan was not completed within their policy time frame, could it cause a resident to fall if they were a fall risk. The DON said they tried and treated most residents as they were a fall risk. The DON said for Resident #3, his bed had always been set to the lowest position. The DON said any resident could fall. She said even after the fall risk was added on 5/19/25, the resident sustained a fall after. 2. Record review of Resident #2's admission record dated 06/12/25 reflected she was an [AGE] year-old female admitted on [DATE], an original admit date of 10/03/24 and a discharge date of 11/14/24. Her relevant diagnoses included sepsis (a life-threatening complication of an infection) , cerebral infarction (occurs when blood flow to the brain is blocked, causing brain tissue to die), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and seizures (uncontrolled jerking, loss of consciousness, blank stares, or other symptoms by abnormal activity in the brain). Record review on 060/11/25 of Resident #2's progress notes dated 10/03/24 at 3:00 p.m. authored by RN D reflected in part .Resident arrived at facility via facility .head to toe assessment done midline (PICC) to right upper arm. Record review on 06/11/25 of Resident #2's quarterly MDS assessment dated [DATE] reflected a BIMS score of 99, which indicated her cognition was severely impaired. Further review reflected that she had an IV access: central (picc line) when she had been admitted . Record review on 06/11/25 of Resident #2's baseline care plan dated 10/03/24, Section D: Special Care/Needs reflected an answer of no to having a PICC/Central Line/Implanted Catheter-Access Port. In an interview on 06/11/25 at 1:54 pm, LVN C said Resident #2 had been admitted with a PICC line to her right upper arm and which was required to be flushed before and after medication and the dressing to be changed/cleaned at least once a week. LVN C said if a resident had a physician's order for monitoring and flushing their PICC line, it would automatically populate on their electronic medical administration record and that was what she followed. An interview on 06/11/25 at 2:00 p.m., The MDS Coordinator said when a resident was admitted with a PICC line it needed to be included in their baseline care plan. She said Resident #2 had been admitted with a PICC line to her upper right arm on 10/03/24. She said RN D had completed the baseline care plan and had failed to answer yes to Section D, which asked if the resident had a PICC/central/implanted catheter access port. She said by answering no to that question, it did not trigger any interventions. She said there were no negative outcome to Resident #2 because Resident #2 had not started her IV therapy until 10/22/24. She said Resident #2 had a physician's order to monitor PICC line and to flush the PICC line before and after medication effective 10/22/24. The MDS Coordinator said nurse's really just look at the orders and not at the care plans. An interview on 06/11/25 at 2:35 p.m., the DON said Resident #2 had been admitted on [DATE] with a PICC line to her upper right arm. She said RN D had completed the baseline assessment which triggered off the admission and readmission assessment. She said RN D had not indicated that Resident #2's had a PICC line on her baseline assessment. The DON said Resident #2 had not sustained any negative outcome due to her baseline care plan not indicating she had a PICC line because it wasn't until 10/22/24, that Resident #2 had started on IV therapy. In a telephone interview on 06/12/25 at 12:45 p.m., RN D (former employee) said she had been the admitting nurse for Resident #2. She said she did not remember if Resident #2 had a PICC line. She said if Resident #2 did have a picc line, she should have answered yes to the question asking if resident had a picc line. She said after she completed the base line assessment the facility's MDS Coordinator should have revised it and make any corrections or additions that she might have missed. RN D said there were no negative outcome to Resident #2 baseline care plan not indicating she had a PICC line when admitted . On 6/12/25 at 4:30 pm, a baseline care plan policy was requested from the Administrator. The Administrator provided a Care Plans policy, dated February 2017 and revised January 2024, and stated they did not have a policy specific to baseline care plans. He said the Care Plans policy was the only policy they had regarding care plans. Record review of the facility's Care Plan's policy dated February 2017 and revised January 2024 reflected, . The care plan should be initiated upon admission, continued to be developed during the initial 48-72 hrs., throughout the completion of the admission comprehensive assessment.The care plan should be considered part of the medical record and should be utilized in conjunction with the complete medical record. The care plan should serve as a guide, which should direct care needs, care choices and care preferences .the care plan should serve as a guide, that identified risks, direct care needs, care choices and care preferences.