Every finding on record at Magnolia Haven Health and Rehabilitation Center

Based on interviews, record review, review of an anonymous complaint received by the State Agency, and review of the facility's investigative file, the facility failed to ensure Resident Identifier (RI) #43's left foot plantar wound was covered/dressed in a manner to prevent environmental contamination including flying insects, eggs, and larvae. On 08/04/2026, when RI #43 was brought back to his/her room from the shower, six live larvae (maggots) were observed in RI #43's left foot plantar wound bed. According to facility staff, when RI #43's left foot wound was dressed and wrapped with Kerlix, the toes were left exposed which could have been an entry point for flies to enter and lay eggs.This deficient practice affected RI #43, one of three residents sampled with wounds. Findings Include: On 08/07/2026 at 3:45 PM the State Agency received an anonymous complaint that six maggots were found in RI #43's heel wound on 08/04/2026. RI #43 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Type 2 Diabetes Mellitus without complications and Type 2 Diabetes Mellitus with Foot Ulcer. RI #43's Quarterly Minimum Data Set assessment with an Assessment Reference Date of 05/13/2026 revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15 which indicated intact cognition. RI #43's July 2026 Physician Orders revealed RI #43 had an order with state date of 05/26/2026 for treatment to his/her Left Posterior Foot Diabetic Ulcer to include: clean the wound with normal saline, pat dry, apply skin preparation the area around the wound, apply collagen, padding, and secure with kerlix every Tuesday, Thursday and Saturday.RI #43's Treatments Administration History: 08/01/2026 - 08/19/2026 documented wound care performed in RI #43's medical record. RI #43's left posterior foot diabetic ulcer wound care was not documented as completed on Saturday, 08/01/2026, which was blank.Review of RI #43's Progress Notes revealed a note dated 08/01/2026 at 3:19 PM that was documented by Licensed Practical Nurse (LPN) #28. The note included: Recorded as Late Entry on 08/06/2026 03:26 PM. Refused Treatment: Resident refused Treatment to (his/her) heel and foot, writer attempted to educate. on the need and value of changing. dressing unsuccessful after three attempts.On 08/20/2026 at 4:08 PM an interview was conducted with LPN #28 who said she worked at the facility every weekend. LPN #28 was asked, what days RI #43's wounds were scheduled to be treated. LPN #28 said it would have been on Saturdays and most of the time he/she would refuse.Further review of RI #43's Progress Notes revealed a note dated 08/04/2026 that was documented by the Interim Director of Nursing (IDON). The note documented the following: . Resident observed during routine wound care following a shower. Dressing to plantar surface of the left foot was removed for treatment. Upon removal of the dressing, approximately 6 live larvae were observed within the wound bed. No foul odor, purulent drainage, surrounding redness, warmth, exposed bone or other signs of acute infection were noted. Resident denied pain or discomfort. Wound was cleansed with normal saline, and all visible larvae was removed with a clean dressing applied. MD (Medical Director) made aware of findings . On 08/19/2026 at 11:38 AM an interview was conducted with RI #43. When asked about maggots being found in his/her foot wound, RI #43 said it happened about two or three weeks ago when Certified Nursing Assistant (CNA) #27 took him/her to the shower. RI #43 said when CNA #27 bought him/her back to the room and the Treatment Nurse (TXN) was getting ready to put a dressing on his/her foot was when the TXN saw the maggots. RI #43 said the head nurse talked to him/her about this and said they were larvae. RI #43 said he/she did go out and smoke and there were flies in the smoking area all the time and maybe that was when a fly got in his/her dressing. RI #43 said before, when treatments were done on his/her foot, his/her toes were not covered, and the fly may have entered that way. Contained within the facility's investigative file was a handwritten statement made by the TXN on 08/04/2026, which documented the following: . 1. How did you become aware of the alleged incident? I went (to) dress residents wound after (he/she) came from the shower .3. What did you observe concerning the alleged incident? I observed white maggots coming out of the wound under (his/her) left foot .4. What immediate action did you take? I went to get the DON .Q: How do you think the maggots got there? A: (His/Her) sock could have had a hole in it or (a fly) flew in where the toes were open . On 08/20/2026 at 8:55 AM an interview was conducted with the TXN. The TXN said prior to 08/04/2026 she had last performed wound care for RI #43 on Thursday 07/30/2026 and no maggots were observed. When asked about maggots being found in RI #43's left foot wound on 08/04/2026, the TXN said when she went in RI #43's room to do his/her treatment, RI #43 had just come back from the shower, and there was no dressing on RI #43's foot. The TXN said when she lifted RI #43's foot to clean it was when she saw two maggots in the wound bed. The TXN said she went and got the DON who came and assessed the wound and the doctor was called. The TXN said the maggots were observed on the wound under the bottom of RI #43's foot. When asked how maggots could have gotten in RI #43's wound, the TXN said RI #43 did not wear a sock all the time and when RI #43's foot was wrapped with the kerlix, RI #43's toes were exposed. The TXN said the fly could have entered through the opening by the toe. When asked if maggots should ever be in a residents wound, the TXN said never, unless ordered by the doctor. The TXN said what was now being done differently after the maggots were observed in RI #43's foot wound, was RI #43's entire foot was being covered when treatments were being done. Contained within the facility's investigative file was a handwritten statement made by the DON, dated 08/04/2026, which documented the following: . 1. How did you become aware of the alleged incident? The treatment nurse came to get me and asked that I come to the residents room .3. What did you observe concerning the alleged incident? Resident lying in bed with left foot wound uncovered. I observed about 6 larvae Removed from the wound bed by cleaning the area 4. What immediate action did you take? Explained to resident what was happening. Cleaned the wound and called the MD (Medical Doctor) .RI #43 is a smoker and enjoys (his/her) smoke breaks . Resident agreed to keep the left foot covered to ensure it's not exposed and open . On 08/20/2026 at 11:07 AM an interview was conducted with the DON and she said she was made aware RI #43 had maggots in his/her left foot wound on 08/04/2026, when the TXN informed her of this. The DON said she immediately went to RI #43's room, assessed the wound, and observed six maggots in the wound bed. The DON said, the wound bed was red, there was no pain to touch, no drainage, and no additional swelling. The DON said she proceeded to clean the wound with normal saline. The DON said the maggots were small and opaque in color. The DON said the maggots were put in a red biohazard bag and thrown away and the doctor was notified. The DON said prior to 08/04/2026 RI #43's wound care was last performed on 07/30/2026. The DON said RI #43 refused the wound care scheduled for 08/01/2026 and the next scheduled treatment was 08/04/2026. When asked if it was ever determined how the maggots got in RI #43's wound, the DON said there was speculation of how it could have occurred. The DON said RI #43 enjoyed smoke breaks and did not always have a sock on. The DON said maybe a fly landed on RI #43's foot during a smoke break. The DON said there had been times when she had seen RI #43 with the dressing on and RI #43's toes would be exposed and a fly could have entered that way. When asked should maggots ever be observed on a wound, the DON said only if they are ordered by the physician. The DON said these maggots were not ordered by RI #43's physician. The DON said RI #43's toes were now being covered when his/her dressing was applied. 08/20/2026 at 2:48 PM a telephone interview was conducted with the MD, RI #43's physician. The MD said he was made aware that RI #43 had maggots in his/her wound on 08/04/2026 by the DON. When asked what would prevent flies from laying eggs on a person's wound, the MD said keeping the wound clean dry and covered. The MD said he supposed a fly could possibly enter the dressing of a person when the foot was wrapped and the toes were left exposed. The MD said maggots should never be in a person's wound unless a doctor used them on purpose. During the interview on 08/20/2026 at 4:08 PM with LPN #28, a nurse providing wound care for RI #43 on the weekends. LPN #28 said when she provided wound care for RI #43, she would clean the wound, apply the treatment and wrap the foot with Kerlix. When asked how she wrapped the foot, LPN#28 said she wrapped the heel and the foot with Kerlix and the toes would be left exposed. When asked what could occur when a fly lays an egg on a wound, LPN #28 said it could produce larvae and that matures into a maggot. LPN #28 said what could possibly prevent flies from laying eggs in a wound would be if the wound is kept covered in a manner so nothing can get on the wound. Contained within the facility's investigative file was a form titled, Staff Development Attendance Record, dated 08/05/2026, which revealed the following: . Subject Presented: Wound Care Content: Wound Care, Dressing Integrity, and Prevention of Environmental Contamination Wounds must remain clean, dry, appropriately dressed, and completely covered .Residents with wounds who spend time outdoors should have wounds securely covered. Staff should be particularly alert to dressing displacement or exposure to flies/insects .RI #43's Care Plan for Problem. Problem Start Date: 05/26/2026. Lt (left) Plantar Foot Diabetic Ulcer. included . Approach Start Date: 08/04/2026 . Resident encouraged to wear socks during smoke breaks so that foot is covered.

Based on observation, record review, interviews, and a policy titled .Abuse, Neglect, and Exploitation the facility failed to ensure Resident Identifier (RI) # 90 was free from resident to resident physical abuse perpetrated by RI #57. The facility failed to implement timely and effective interventions to prevent resident to resident abuse on 04/15/2025 after RI #57 complained to staff about RI #90 entering his/her room without permission. On 04/16/2025, RI #57 pushed RI #90 from his/her room into the hallway, causing him/her to fall and sustain a laceration above the left eye and Contrast Tomography (CT) confirmed fractures of the left maxillary sinus wall and left orbital wall.This deficient practice affected RI #90, one of six sampled residents reviewed for abuse.This deficiency was cited as a result of the investigation of complaint/ report number #463612. Findings Include:Cross-Reference F740.On 04/16/2025 at 1:16 PM, the Alabama State Survey Agency received a Facility Reported Incident (FRI) which indicated RI #57 pushed RI #90 down on the floor in the hallway for entering his/her room. The roommate RI #8 witnessed the incident. RI #90 was noted to have a laceration above the left eye. RI #57 and RI #90 were separated and assessed for injuries. RI #57 and RI #90 were sent to a local hospital for additional evaluation and treatment. An X-ray for RI #90 documented: . 04/16/2025 21:05 (9:05 PM) . (#90) . IMPRESSION: Mildly displaced fractures of the left maxillary sinus wall and lateral border of the left orbit. Multiple sided facial fractures, partially visualized. A review of the facility's investigation dated 04/22/2025 revealed RI #57 admitted pushing RI #90 after he/she entered his/her room. The facility substantiated resident to resident physical abuse. The facility's Abuse Policy with a revised date of 11/2017, documented . SUBJECT: Abuse, Neglect and ExploitationPOLICY:Each resident of any facility. has the right to be free from verbal, sexual, physical or mental abuse, neglect, exploitation and misappropriation. Mistreatment, neglect or abuse of residents is prohibited by . facility . All residents will be free of mental and physical abuse and shall receive considerate care and treatment at all times . RI #90 was admitted to the facility on [DATE] with an admitting diagnoses of Unspecified Dementia, Mood Disorder, Anxiety, Cognitive Deficit and Adjustment Disorder. RI #90's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/04/2025, indicated RI #90 had a Brief Interview for Mental Status Score (BIMS) of 11 of 15 which indicated moderately impaired in cognitive skills for daily decision making, The MDS indicated RI #90 had long- and short-term memory problems. The MDS documented that RI #90 displayed no behaviors. A review of RI #90's care plan with a problem onset date of 05/04/2023 revealed the following . is having increased behaviors/cognitive loss related to dx of Dementia . Approach: encourage participation in . activities .refer to psych services as needed . A review of RI #90's care plan with a problem onset date of 01/15/2025 revealed the following .is at risk for elopement due to wandering. wanders into other residents' rooms. check code alert placement every shift. Consult with MD and psychologist as needed. encourage socialization and participation in activities. RI #57 was admitted to the facility on [DATE] with an admitting diagnoses of Dementia with Agitation (later with Psychotic Behaviors) Mood Disturbance, Anxiety Disorder and Memory Impairment. RI #57's Quarterly MDS with an assessment reference date of 03/11/2025, indicated RI #57 had a BIMS of 15/15 and was cognitively intact with skills for daily decision making, with long- and short-term memory problems. RI #57's Mood Interview indicated 0 and no behaviors. RI #57's Progress Note dated 04/16/2025 at 1:03 PM written by the Social Services Director (SSD) documented . Yesterday (RI #57) made the Assistant Director Of Nursing (ADON) and SSD aware of another resident coming into (his/her) room. (He/she) stated that (he/she) wanted them to leave (him/her) alone. SSD and ADON stated they would discuss this with the other resident and let them know not to come into (his/her) room. SSD and ADON stated to (RI #57) that when someone comes into (his/her) room (he/she) does not want to press the call light or get staff attention. (RI #57) stated that (he/she) understood. On 06/25/2026 at 4:44 PM during an interview the SSD said she became aware of RI #90 entering RI #57's room on 04/15/2025 when RI #57 notified her. When asked what interventions were put in place for RI #90 on 04/15/2025 the SSD stated that interventions began on 04/17/2025 to obtain placement for RI #90 in a memory care facility. The facility's investigation file included the following witness statements:A statement dated 04/16/2025 11:55 am handwritten by Interim Director of Nursing (DON) for RI #8, documented I saw (RI #57) push (RI #90) outside the door.A statement dated 04/16/2025 at 12:28 pm handwritten by Licensed Practical Nurse (LPN ) #15 documented I heard someone yell and I looked down the hall & (and) I saw (him/her) on the floor in the hall. laying in the hallway face down.A statement dated 04/16/2025 at 12:55 PM handwritten by Certified Nursing Assistant (CNA) #16, documented I heard a scream . found the resident on the floor in the hallway. (RI #90) was moaning and stating. shoulder and arm . hurting.A statement dated 04/16/2025 at 12:25 PM handwritten by the ADON documented . noted resident lying on floor face down with blood noted coming from left nostril. Laceration and bruising noted to left eye c (with) hematoma to eye (left) bruising noted to left shoulder. turn resident over to see where bleeding was coming from . On 06/24/2026 at 11:49 AM RI #8 was asked what happened on 04/16/2025 between RI #57 and RI #90. RI #8 stated RI #57 was fussing at RI #90 and told him/her to get out of the room. RI #57 pushed RI #90 by the shoulder and RI #90 hit the wall across the hall. RI #8 said he/she could hear RI #90 screaming. RI #8 said RI #57 would fuss at anyone that came near his/her room. On 06/25/2025 at 6:25 AM during a telephone interview LPN #15 was asked what she could tell the surveyor about the incident that occurred on 04/16/2025 involving RI #57 and RI #90. She stated she was on the opposite hall and saw something on the floor and it was RI #90. She said RI #90 was lying on his/her back in front of RI #57's room. She stated the staff was monitoring him/her, and RI #90 was not responsive for a few seconds then was blinking his/her eyes. She stated she saw blood but could not tell where the blood was coming from. On 06/29/2026 at 12:03 PM CNA #16 was asked what she could tell the surveyor about the incident that occurred on 04/16/2025 involving RI #57 and RI #90. She said she was passing trays on the North Hall and heard someone say Ugh and looked down the hallway and RI #90 was in the middle of the floor facedown. CNA #16 stated she observed a cut on RI #90's forehead, near the eye and in his/her hair. CNA #16 said she notified LPN #15 and other staff came to assist. CNA #16 said she asked RI #57's roommate RI #8 what he/she observed. RI #8 said RI #90 was sitting in the empty chair in their room then RI #57 shoved RI #90 out of the room. She stated RI #90 came out of the room and said I told him/ her to stay out of the room. CNA #16 said when RI #90 came back to the facility from the hospital his/her face was purple and his/her chest was very bruised. CNA #16 stated she would consider this incident physical and verbal abuse. On 06/24/2026 at 11:54 AM during an interview the ADON stated that on 04/16/2025 a staff member told her RI #57 pushed RI #90 down. She stated she went to the hall and RI #90 was lying on the floor with blood coming from his/her nose. She stated RI #57 told her that he/she told RI #90 not to come into his/her room and that he/she pushed RI #90 out the door. On 06/29/2026 at 12:52 PM during an interview CNA #17 stated that on 04/16/2025 she was working on the north hall and was in a room and heard a commotion in the hallway. She said she came out of the room and saw RI #90 lying face down on the floor and there was blood but she did not know where it was coming from. CNA #17 said RI #90 was crying and she could tell he/she was in pain. She stated this would be considered physical abuse. On 06/30/2026 at 10:27 AM during an interview the Director of Nursing (DON) stated RI #90 was identified as a wanderer on 01/15/2025 according to the care plans and a progress note. When asked what type of supervision was in place for RI # 90 at the time of the incident, the DON stated general supervision and RI #90 had a code alert monitor in use. The DON stated RI #90 had a diagnosis of dementia and he/she wandered all over the building. The DON stated the incident could have been prevented by moving RI #90. When asked how it would make a reasonable person feel being hit by another resident, the DON stated upset and in pain. The DON stated the facility substantiated abuse. On 06/30/2026 at 12:14 PM the Administrator (ADM) was asked what interventions were in place to protect RI #90, a known wanderer. The ADM stated RI #90 was identified as a wanderer on 01/15/2025 and staff were educated on interventions to assist with wandering. The ADM was asked the level of supervision RI #90 required and she stated he/she was redirected and staff checked the code alert for placement. The ADM asked what interventions were put in place by the ADON and SSD after being notified by RI #57 that he/she did not want RI #90 coming into his/her room to prevent the abuse from occurring. The ADM stated RI #57 was instructed to press the call device when RI #90 entered the room. The ADM stated moving RI #90 or placing him/her on 1 on 1 could have possibly prevented the abuse from occurring. The ADM stated being hit by RI #57 would make a reasonable person feel unhappy.

Based on interviews, the facility's CERTIFIED DIETARY MANAGER JOB DESCRIPTION, and a certificate of completion for Nutrition and Foodservice Professional Training Pathway III(b) from the University of Florida; the Dietary Supervisor in charge of the facility's Food Service Department/Dietary Department did not meet minimum qualifications as a director of food and nutrition services. This had the potential of affecting 84 of 84 residents receiving meals from the facility's Food Service Department/Dietary Department while it was under the direction of an unqualified individual. Findings Include: The facility's CERTIFIED DIETARY MANAGER JOB DESCRIPTION, dated 5/2003, included the following: . General Purpose: To assist in planning, organizing, developing and directing the overall operation of the Dietary Department in accordance with current federal, state and local standards governing the facility, and as may be directed by the Administrator, to ensure that quality nutritional services are provided on a daily basis and that the Dietary Department is maintained in a clean, safe and sanitary manner.Qualifications: Must be a Certified Dietary Manager in good standing with the State of Alabama or in training to satisfactorily complete the requirements to become a Certified Dietary Manager .A certificate of completion for Nutrition and Foodservice Professional Training Pathway III(b) from the University of Florida, dated September 17, 2025, naming the Dietary Supervisor as the recipient. On 06/22/2026 at 4:38 PM, the Dietary Supervisor was asked for her credentials. The Dietary Supervisor said she had not taken her CDM (Certified Dietary Manager) test yet. The Dietary Supervisor said she needed to take the CDM exam, The Dietary Supervisor further said she had not scheduled the exam yet, because she was studying for it still and because of the cost, $400. The Dietary Supervisor said she had completed the CDM course in September 2025. When asked about support management staff, the Dietary Supervisor said the RD (Registered Dietitian) Consultant came twice a month, the Corporate RD came once a month, and the Corporate CDM came once a month along with the Corporate RD.On 06/23/2026 at 2:17 PM, the Dietary Supervisor was asked if she had an Associate's Degree or Bachelor's Degree in Nutrition or Hospitality or Food Service. She said no, just the online CDM course from the University of Florida. On 06/25/2026 at 10:04 AM, the Dietary Supervisor said she had worked at the facility for eight years in her current position, managing the Food Service Department. On 06/25/2026 at 12:39 PM, the Administrator was interviewed. The Administrator said she had been the facility's Administrator since June 2023. Upon being asked why the Dietary Supervisor was hired to direct the facility's Food Service Department/Dietary Department eight years ago when she was not qualified, the Administrator said she was not here eight years ago. When asked if she followed up to see if the Dietary Supervisor became certified, the Administrator said she did. The Administrator further said the Dietary Supervisor was previously in training, but had not completed it, so she did follow up and encouraged her to complete the training, The Administrator said the goal was for everyone to meet the potential maximum requirement of the duty.

Based on observations, interviews, the facility's policies for DIET MANUAL and MENUS, the facility's menus for Spring/Summer 2026, and the facility's posted SCOOP AND DIPPER SIZES; the facility failed to ensure a #10 dipper/scoop was used for Chopped Meat (Hamburger Steak) for Lunch on Tues. 6/23/2026, a #6 dipper/scoop was used for Puree Lasagna for Dinner on Tues. 6/23/2026, and a #10 dipper/scoop was used for Chopped Fried Chicken and a #10 dipper/scoop was used for Puree Chicken when serving Lunch on Wed. 6/24/2026. This affected residents receiving chopped meats, Mechanical Soft diets, and Puree diets; 36 of 84 residents receiving meals at the facility and had the potential to result in weight loss. The facility's policy for DIET MANUAL, revised 8/2017, included the following: . PROCEDURE: . 4. The diet manual is the reference for regular, texture-modified and therapeutic diet orders.5. The diet manual is used as the basis for the planned menu and menu modifications. The facility's policy for MENUS, revised 12/2023, included the following: . POLICY:Menus are planned to meet the nutritional needs of the residents in accordance with the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences. The facility shall provide residents with a nourishing, palatable, well-balanced diet that meets daily nutritional needs as well as individual preferences and special dietary needs.PROCEDURE:1. Menus for regular and therapeutic diets are preplanned.3. The correct portion size for each menu item is listed for each diet included in the menu modifications. The facility's Spring/Summer 2026 Menu, Week 4 identified Hamburger Steak as the entree for lunch and Lasagna as the entree for dinner on Tuesday, 06/23/2026 and Fried Chicken was the entree for lunch on Wednesday, 06/24/2026. Portion sizes for the modified menu items of concern on these days were listed on the menu as follows:Tuesday, 06/23/2026Lunch - Mechanical Soft Diet - Chopped Hamburger Steak - 1 (one) #10 DipperDinner - Puree Diet - Puree Lasagna - 1 (one) #6 DipperWednesday, 06/24/2026Lunch - Mechanical Soft Diet - Chopped Fried Chicken - 1 (one) #10 DipperPuree Diet - Puree Fried Chicken - 1 (one) #10 Dipper The SCOOP AND DIPPER SIZES, undated, included the following information:#4 8 ounces (oz.) 1 cup#8 4 ounces 1/2 cup#10 3.2 ounces 2/5 cup#12 2.67 ounces 1/3 cup On 06/23/2026 at 10:40 AM, AM [NAME] EI (Employee Identifier) #9 was observed preparing the trayline for the residents' lunch meal. At 11:00 AM, a 3 oz. spoodle was used for serving Chopped Meat (chopped Hamburger Steak). On 06/23/2026 at 5:06 PM, the PM [NAME] was observed using a #8 dipper/scoop to serve the Puree Lasagna for the residents' dinner meal. On 06/24/2026 at 10:22 AM, AM [NAME] EI #10 was observed preparing the trayline for the residents' lunch meal. At 11:30 AM, a 3 oz. spoodle was used for serving Chopped Fried Chicken and a #12 dipper/scoop was used for serving the Puree Fried Chicken.Observations were made of seven trays being served 3 oz. spoodle of Chopped Fried Chicken and five trays being served a #12 dipper/scoop of Puree Fried Chicken. On 06/25/2026 at 9:38 AM, AM [NAME] #10 was interviewed about the lunch service on Wednesday, 06/24/2026. AM [NAME] #10 said the menu instructed her to use #10 dippers/scoops for serving the chopped Fried Chicken and the Puree Chicken. AM [NAME] #10 said the Dietary Supervisor was having a hard time getting dippers/scoops, so she had been instructed by the Dietary Supervisor to use the other utensils. AM [NAME] #10 said a 3 oz. spoodle was not equal to a #10 dipper/scoop and a #12 dipper/scoop was not equal to a #10 dipper/scoop. AM [NAME] #10 said they look at the dipper/scooper chart to know the difference. AM [NAME] #10 further said the problem with serving less than the menu instructs was, it could affect the resident's diet and cause weight loss over time. AM [NAME] #10 said they had been short of dippers/scoops for about a week because the dippers/scoops had broken. On 06/25/2026 at 10:04 AM, the Dietary Supervisor was interviewed. The Dietary Supervisor said there was a shortage of serving dippers/scoops in the facility. When asked about the service of lunch on Tuesday, 06/23/2026; the Dietary Supervisor said a 3 oz. spoodle of Chopped Meat (Hamburger Steak) was not equal to a #10 dipper/scoop and the menu was therefore not followed. The Dietary Supervisor said they could have given a bigger portion dipper/scoop or spoodle to get 3,2 oz. When asked about the service of dinner on Tuesday, 06/23/2026; the Dietary Supervisor said a #6 dipper/scoop should have been used to serve the Puree Lasagna, not a #8 dipper/scoop. The Dietary Supervisor said the menu was not followed for Tuesday dinner. When asked about the service of lunch on Wednesday, 06/24/2026; the Dietary Supervisor said the menu was not followed because a 3 oz. spoodle was used to serve Chopped Fried Chicken and a #12 dipper/scoop was used to serve Puree Fried Chicken. The Dietary Supervisor said the residents could potentially be affected by weight loss from the menu not being followed. The Dietary Supervisor further said the residents' preferences for larger servings might not be met.

Based on observation, interviews, a repair/service report, and the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code; the facility failed to ensure food was frozen solid in the Reach-in Bread Freezer on 6/22/2026 and further failed to ensure the internal temperature did not reach 45 (degrees) Fahrenheit (F). This had the potential to affect 84 of 84 residents receiving meals from the facility's Food Service Department and possibly exposing them to food borne illness.The 2022 U.S. FDA Food Code included the following: . Temperature and time Control3-501.11 Frozen Food.Stored frozen FOODS shall be maintained frozen.3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding.(A) . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: .(2) At 5 C (41 F) or less. FDA Food Code 2022 Annex 3. Public Health Reasons/Administrative Guidelines3-501.16 Time/Temperature Control for Safety Food [TCS], Hot and Cold Holding.Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone of 5 C to 57 C (41 F to 135 F) too long.Cold HoldingMaintaining TCS foods under the cold temperature control requirements prescribed in this code will limit the growth of pathogens that may be present in or on the food and may help prevent foodborne illness. During the initial kitchen tour on 06/22/2026 at 4:04 PM, an observation was made of the Two-door Reach-in Bread Freezer. The items in the freezer were not frozen solid. Items inside the freezer included Pancakes, French Fries, Onion Rings, and Hush Puppies, which were soft to touch. The internal thermometer reading was 45 degrees F. The external digital thermometer reading was 31 degrees F. Once notified of the situation, the Dietary Supervisor made a call for an outside service company to come and repair the freezer unit. On 06/23/2026 at 4:38 PM, the Dietary Supervisor said the service company representative fixed the freezer the night before on 06/22/2026. The facility provided the service invoice, dated 06/22/2026, that included the following: . Customer states that the freezer was up to 45 degrees. It is down to 0 degrees now. I pulled the cover and found the condenser coils completely clogged with dirt. I told (name of Dietary Supervisor) that the maintenance man needs to be cleaning the coils monthly. I cleaned the coils and checked the refrigerant pressures. All ok. On 06/25/2026 at 10:43 AM, the Maintenance Director was interviewed. When asked about routine maintenance provided for the refrigeration/freezer equipment in the Food Service Department; the Maintenance Director said the filters and coils were cleaned every 30 days or as needed. The Maintenance Director further said he drained the condenser line and made sure it was defrosting when it was supposed to defrost. When asked for the Maintenance policies, the Maintenance director said he had a monthly report, some have weekly, now he had a computer log. When asked for the Maintenance records, the Maintenance Director said he could try to print off six or seven months. When asked if he knew why the Two-door Reach-in Bread Freezer failed to operate properly on Monday, 6/22/2026; the Maintenance Director said the reason the freezer went down was because the A/C (air conditioning) was broken. The Maintenance Director further said the freezer blowers were pushing air through the freezer condenser coils and they were pushing hot air and humidity from the heat of the kitchen. The extra amount of time the blowers were working caused the condensers to be clogged up with dirt and that was what made the freezer go out. When asked if the other freezers and refrigerators could fail for the same reason, from dirty coils; the Maintenance Director said yes, that was why he was to clean the coils every 30 days and they were cleaned two to three weeks before. The Maintenance Director said, the A/C was out for 10 days and they were waiting for the part to come in. The Maintenance Director did not provide the requested maintenance records. On 06/25/2026 at 10:04 AM, the Dietary Supervisor was interviewed. When asked how often Maintenance performs routine checks and maintenance of the kitchen refrigeration/freezer equipment, the Dietary Supervisor said he looked at things every month.

Based on interview, the Resident Council, and the facility's policy for FOOD FROM OUTSIDE SOURCES, the facility failed to ensure there was a refrigerated area for storage of food brought in to the residents by family and friends. Eleven of eleven residents attending Resident Council on 6/24/2026 affirmed they wanted refrigeration space to be able to store personal food. This had the potential to affect all residents requiring safe storage for personal food requiring refrigeration, 84 of 84 residents eating meals in the facility. The facility's policy for FOOD FROM OUTSIDE SOURCES, revised 10/2017 and reviewed 11/2023, included the following:POLICY: . Food that is brought to residents from family, visitors or volunteers is handled in a safe and sanitary manner. PROCEDURE: . 4. Residents may accept precooked foods from family members or other visitors. Foods may be brought for a specific resident and shared with other residents. b. Food brought to a resident by a family member or visitor may be stored in the food service department. i. Foods brought to the food service department are stored in the refrigerator or freezer immediately. ii. Refrigerated cooked food that is not prepared in the facility is held no longer than 24 hours. iii. The label includes the resident's name and room number, the date it is received and stored, and the date it should be discarded. 7. Residents and family members are informed, orally and in writing, about the facility policy for bringing food. On 06/23/2026 at 5:30 PM, the Dietary Supervisor was asked which refrigerator they kept items brought in by friends and family for individual residents. The Dietary Supervisor said they did not keep them, the dietary staff stop it at the door, and dietary did not have room for food [NAME] in for residents. Resident Council met at 10:00 AM on 06/24/2026. The Resident Council members said there was no refrigerator for the residents to store their food when family members brought food to them. The Resident Council members further said the food had to be thrown away or eaten the same day. Additionally, they said the people in Dietary (Food Service Department) told them they did not have any place to put the food. Eleven of eleven Resident Council members said the residents would like to have a refrigerator to store their food.

Based on observation, interviews, Resident Council, the facility's policy for Daily Dumpster Monitoring, the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, and the facility's pest control service records; the facility failed to ensure there was not a build-up of greasy particles on the oil/grease refuse container, there was not a scattering of small particles of trash around the two dumpsters, and there was not a concentration of 30 to 40 flies in the dumpster area on 6/22/2026. This had the potential result of attracting rodents and flies, which could enter the facility to cause contamination and exposure to bites and maggots. This affected Resident Identifier (RI) #8, six of eleven residents in Resident Council, and had the potential to affect all residents in the facility, 88 of 88 residents. The facility's policy for Daily Dumpster Monitoring, dated 10/2006, included the following: . POLICY:Maintenance and Housekeeping staff will inspect all dumpsters each day to ensure that the surrounding area are free of debris and that the dumpster lids are closed . The 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code included the following: . 5-501.15 Outside Receptacles.(B) Receptacles and waste handling units for REFUSE . shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around . the unit. 5-501.110 Storing Refuse, Recyclables, and Returnables.REFUSE . shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents.5-501.115 Maintaining Refuse Areas and Enclosures.A storage area and enclosure for REFUSE, recyclables, or returnables shall be maintained free of unnecessary items, as specified under S 6-501.114, and clean.5-501.116 Cleaning Receptacles.(B) Soiled receptacles and waste handling units for REFUSE . shall be cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents.6-501.114 Maintaining Premises, Unnecessary Items and Litter.The PREMISES shall be free of: .(B) Litter. The provided facility pest control service records, dated 02/18/2026, 04/29/2026, and 06/08/2026, revealed the last treatment for flies, identified as F for the Target Pest per the Key Codes for IMP (Integrated Pest Management) Applications, was on 02/18/2026. During the initial kitchen tour on 06/22/2026 3:48 PM, one fly was observed in the kitchen seated on back of a plate in the plate lowerator. On 06/22/2026 at 4:43 PM the facility's Dumpster/Oil & Grease Refuse Area was observed with the Dietary Supervisor. There were small particles of trash around the two dumpsters, including a balled-up piece of aluminum foil, a piece of a clothes hanger, and a small bottle with an eye-dropper. In a small grassy section within the pavement near the dumpsters, there was a concentration of about 30 to 40 flies. The Dietary Supervisor said Maintenance was responsible for maintaining the area and said Maintenance rinsed the dumpster area daily. The Dietary Supervisor further said the flies could get into the Kitchen and cause contamination of resident food. In addition, there was a build-up of greasy particles on the outside of the oil/grease refuse container. The build-up of greasy particles was around the top opening of the container and reached up to the top of the opening's cover; approximately a two-inch build-up. The Dietary Supervisor said the build-up of greasy particles would attract flies and rodents that could potentially enter the kitchen and cause contamination. On 06/23/2026 at 10:50 AM, the Maintenance Director said he picks up the trash around the dumpsters and sprays down the pad around the dumpsters with water and either Pine Sol or beach or HDQ (an Ammonium Quat-based disinfectant). The Maintenance Director said he sprays down the dumpsters too. He further said either he or Housekeeping does it. The Maintenance Director said he was not here yesterday (Monday, 6/22/2026). When asked if he also sprayed down the oil/grease container, he said no, The Maintenance Director said it belonged to the commercial provider of the receptacle. On 06/23/2023 at 12:05 PM, RI #8 complained that there were some flies in his room. One fly was observed in the resident's room at this time. During the Resident Council meeting on 06/24/2026 at 10:00 AM with eleven participants attending, three residents said flies had landed on their food in their room and three residents said flies had awakened them while they were sleeping at night. On 06/24/2026 at 10:22 AM, a fly was observed flying in the kitchen while preparation for the residents' lunch meal was ongoing. On 06/24/2026 at 11:58 AM, one fly was observed flying around the kitchen while the residents' lunch trayline was ongoing. On 06/24/2026 at 4:56 PM, the Housekeeping Supervisor was interviewed. The Housekeeping Supervisor said the Housekeeping Department's responsibilities for maintaining the Dumpster/Oil & Grease Refuse Area were to daily make sure it was clean around the perimeter of the dumpsters and to make sure the dumpster lids were closed. The Housekeeping Supervisor said he personally checked those things daily and Maintenance checked it also. The Housekeeping Supervisor further said, if he saw any types of varmints or rodents, he reported them to Maintenance so Pest Control could be contacted. The Housekeeping Supervisor said HDQ (an Ammonium Quat-based disinfectant) or bleach or Pine Sol was sprayed in the area to keep the flies away. The Housekeeping Supervisor said flies were attracted to urine and feces, which were in the diapers and bed pads in the dumpsters. He further said HDQ worked best in the Summer. The Housekeeping Supervisor said Dietary (Food Service Department) and Maintenance did the cleaning to keep the exterior of the oil/grease refuse container free from a build-up of greasy particles. He further said that would be important to keep rodents from being attracted to it. The Housekeeping Supervisor said he had observed a concentration of flies by the Dumpster/Oil & Grease Refuse Area. The Housekeeping Supervisor said he thought the accumulation of flies was caused by the food, feces, and urine. He further said the shipment of HDQ was late, it just came Monday morning (6/22/2026) and it was supposed to arrive on Friday, 6/19/2026. When asked how the concentration of flies could affect the residents, the Housekeeping Supervisor said, if the concentration was massive enough, the flies could get inside the building and land on the residents, lay eggs, and create maggots. The Housekeeping Supervisor said the concentration of flies in the small grassy area in the pavement near the dumpsters could have been attracted to that area by liquid spilling from the dumpsters when they were emptied and the liquid accumulated in that grassy spot. On 06/25/2026 at 10:43 AM, the Maintenance Director was interviewed. The Maintenance Director said the Maintenance Department's responsibilities for maintaining the Dumpster/Oil & Grease Refuse Area included cleaning the slab and bleaching the surface of the slab and the dumpsters. He further said they clean everything on the concrete slab and spray the oil/grease refuse container as well. The Maintenance Director said they clean Monday through Friday and everything gets sprayed down with bleach or an alternate as needed. He explained that HDQ was a chemical for cleaning and sanitizing. When asked why HDQ or bleach or Pine Sol would be sprayed in the area, the Maintenance Director said they have an old trash truck that comes and picks up the dumpster with a hook and any liquid inside the dumpster leaked out. He further said that when the truck compresses the trash more liquid leaked out from the truck. The Maintenance Director said he was aware of the concentration of flies by the dumpsters. The Maintenance Director said he did not see them over by the grease refuse area, but there were flies there. The Maintenance Director said he uses fly bait Monday through Friday. The Maintenance Director said he thought the accumulation of flies was caused by contaminated liquid from the dumpster and the garbage truck that spills the liquid when the dumpsters are picked up by the truck. The Maintenance Director said residents could be affected by flies biting or by flies swarming on food or by flies getting in patient wounds and causing maggots. The Maintenance Director further said they had three different fly baits, a fly zone blower at the back door, and fly zappers and residents could use fly swatters if they wanted to. When asked about the build-up of grease in the Dumpster/Oil & Grease Refuse Area, the Maintenance Director said they needed to keep it clean. He said Dietary (Food Service Department) should clean the Dumpster/Oil & Grease Refuse Area after they empty the grease. The Maintenance Director also said he would be more mindful to clean/scrub the area after Friday's fish frying day. On 06/25/2026 at 10:04 AM, the Dietary Supervisor was interviewed. When asked if the Food Service Department cleaned the oil/grease refuse container, she said no, that should be washed down when the dumpsters were washed down, which should be daily or as needed. The Dietary Supervisor said it did not look like the oil/grease refuse container had been washed daily when observed on Monday, 6/22/2026.

Based on record review, interview, and Payroll Based Journal (PBJ) Report, the facility failed to report accurate staffing data from January 01, 2026 - March 31, 2026, to the Centers for Medicare & Medicaid Services (CMS).This failure affected one quarter of data reviewed during the survey. Findings Include: The PBJ report generated for the quarter of 01/01/2026 through 03/31/2026 documented: . This Staffing Data Report identifies areas of concern that will be triggered . Metric .Excessively Low Weekend Staffing . Triggered = Submitted Weekend Staffing data is excessively low .On 06/25/2026 at 3:45 PM, during an interview, the Administrator (ADM) stated she was responsible for submitting staffing data to CMS. The ADM said she did not know why low weekend staffing was triggered for the second quarter of 2026. She said she compiled the data for the report, sent the information to corporate and a third party company submitted the data to CMS. She said if incorrect data was submitted, CMS would not have accurate information concerning staffing.

Based on observation, interview and facility policies titled, . TELS Maintenance Services Work Order and . Standard Method of Cleaning Checklist the facility failed to ensure a clean, safe, and homelike environment. Specifically, the facility failed to maintain resident care areas were in good repair and in a sanitary condition as evidenced broken tiles behind the commode in the bathroom belonging to Resident Identifier (RI) #34, RI #26, RI #72, and RI #1. Additionally, the bathroom belonging to RI #8, RI #57, RI #5 and RI #36 had a water damaged wall and dirty floors with urine observed on the floor.These failures affected RI #34, #26, #72, #1, #8, #57, #5, and #36. These failures had the potential to affect residents by exposing them to an environment that was not maintained in a clean, safe and homelike condition.Findings Include: A facility policy titled, TELS Maintenance Services Work Order with an effective date of 08/01/2022 documented: . PROCEDURE: 1. Whenever a need for maintenance services is detected by an employee of the facility, it is their responsibility to report that need by completing an electronic work order in the device located at the nursing station, or other designated location. A facility policy titled, . Standard Method of Cleaning Checklist dated 11/2008 documented: . 5. CLEAN BATHROOMStart at the door and end with the toilet. Use a [NAME] mop inside the bowl and wipe the outside with a cleaning cloth. Do not use the clean cloth on any other surface after cleaning toilet. 7. INSPECT THE ROOMReport any needed repairsCorrect any deficiencies. RI #34 was admitted to the facility on [DATE]. RI #26 was admitted to the facility on [DATE]. RI #72 was admitted to the facility on [DATE]. RI #1 was admitted to the facility on [DATE]. RI #8 was admitted to the facility on [DATE]. RI #57 was admitted to the facility on [DATE]. RI #5 was admitted to the facility on [DATE]. RI #36 was admitted to the facility on [DATE]. On 06/22/2026 at 3:45 PM the surveyor observed brown spots on the floor on the main hallway and on the west unit.On 06/23/2026 at 10:39 AM the surveyor observed holes on the wall near the trim behind the commode belonging to RI #34, RI #26, RI #72, and RI #1. On 06/23/2026 at 10:52 AM the surveyor observed water damaged walls in the bathroom belonging to RI #8. An interview was completed with RI #8 who voiced his/her concern was flies inside the facility. On 06/24/2026 at 9:10 AM the surveyor observed a fly on the north hall flying near breakfast trays that were being removed from resident rooms.On 06/29/2026 at 5:45 PM, the surveyor made observations and concurrent interview with the Housekeeping Supervisor (HSUP) of the bathrooms belonging to RI #8, RI #57, RI #5, and RI #36. The HSUP indicated the bathrooms were cleaned daily during the daytime shift. When asked why the bathrooms were not clean, he said that the presence of urine on the floor contributed to the condition of the bathrooms. He said the fix would be a floor replacement. When asked if this was a homelike environment, he said his department attempted to keep the bathrooms clean; but it has continued to be a concern due to urine on the floor.

Based on record review, interview, and a policy titled, . Advance Directives and Refusal of Treatment the facility failed to ensure documentation regarding advance directives was complete and accurate. Specifically, the facility failed to maintain documentation that advance directives were discussed with Resident Identifier (RI) #81 and failed to ensure the advance directive documentation for RI #7 accurately reflected the resident's status. These failures had the potential to affect residents by preventing the facility from accurately identifying and honoring residents' advance directive decisions for 2 of 7 residents reviewed. Findings Include: A facility policy titled, . Advance Directives and Refusal of Treatment revised 11/2013 documented: PURPOSE:The resident has the right to refuse treatment, . to formulate an advance directive for management of his/her care.PROCESS:Prior to admission, the resident/sponsor will be provided information about the following:Advance Directives . Upon the resident's admission to the facility, the Social Services Designee will obtain from the resident or the resident's Family or significant other a copy of any existing Living Will, Health Care Proxy . Durable Power of Attorney for Health Care Decisions, or any previously recorded express written or oral (recorded in writing) declarations. This copy . should be placed in the front of the medical record. The Social Services designee should enter a progress note in the resident's record regarding the existence of an Advance Directive. RI #7 was admitted to the facility on [DATE] with diagnoses to include Hemiplegia and Hemiparesis follow Nontraumatic Intracerebral Hemorrhage Affecting Right Dominant Side. A document titled RESIDENT RIGHTS & ADVANCE DIRECTIVE ACKNOWLEDGEMENT dated 01/25/2025 signed by RI #7's representative indicated RI #7 had an advance directive. Further review of the form did not indicate the type of advance directive. RI #81 was admitted to the facility on [DATE] with a diagnosis to include End Stage Renal Disease. A review of RI #81's medical record revealed no signed acknowledgement that Advance directive was discussed with the resident or representative. On 06/26/2026 at 12:01 PM, the Social Services Director (SSD) stated she was responsible for advance directive within the facility, and that the documentation would be maintained in the resident's medical chart. When asked about the advance directive for RI #7, she said the electronically signed and dated form by the resident representative indicated the existence of an advance directive, but did not specify the type of advance directive. She said RI #7 did not have an advance directive and the form was filled out incorrectly and she should have followed up to correct the error. When asked about the advance directive for RI #7, she said she had been unable to find the paperwork. She said the concern of not having paperwork related to the advance directive for RI #81 would be not knowing if he/she had one which could cause a delay in treatment. The SSD said if a resident had an advance directive, it was important to have a copy to facilitate appropriate healthcare decisions and to prevent any delays in treatment.

Based on interviews and record review, the facility failed to ensure staff followed a physician's order to notify the medical provider when the Resident Identifier (RI) #89's blood glucose exceeded the ordered parameter of 250 mg/dL (milligrams/deciliter). Record review revealed a physician's order dated 03/07/2025 directing staff to check the resident's blood glucose four times daily before meals and at bedtime, document the results, and notify the medical provider for blood glucose readings below 70 mg/dL or above 250 mg/dL.Review of the Nurse Medication Administration History dated 03/01/2025 through 03/31/2025 revealed RI #89's had multiple blood glucose readings that exceeded the physician ordered notification and the medical provider was not notified. This deficient practice affected RI #89 one of four residents whose Medication Administration Record (MAR) was reviewed for physician notification during the survey. This citation was cited as a result of complaint/report number 463611. Findings include:A review of a facility policy titled, . ADMINISTRATIVE PROCEDURESUBJECT: Change in Medical Condition of ResidentsSTANDARD: Based on federal regulations, when there is a change in a resident's condition, notification of the physician, legal representative, or responsible relative, should occur promptly. Parties should be immediately notified. Abnormal blood glucose levels and blood glucose changes outside of physician parameters.RI #89 was admitted to the facility on [DATE] at 1:15 PM with a diagnosis of Type 2 Diabetes Mellitus without Complications.Review of RI #89's March 2025 Physician Order revealed: Check Blood Glucose four times daily before meals and bedtime, record blood glucose results, notify medical doctor if blood glucose is below 70 or above 250 mg/dl.Review of RI #89's Nurse Only Administration History revealed the following blood glucose levels which were above the 250 mg/dL parameter: On 03/08/2025 the blood glucose was 269 mg/dl. On 03/11/2025 the blood glucose was 309 mg/dl. On 03/12/2025 the blood glucose was 290 mg/dl, 316 mg/dl and 295 mg/dl. On 03/13/2025 the blood glucose was 278 mg/dl, 301 mg/dL and 279 mg/dl. On 03/14/2025 the blood glucose was 352 mg/dL and 300 mg/dl. On 03/15/2025 the blood glucose was 260 mg/dl and 281 mg/dl. On 03/18/2025 the blood glucose was 298 mg/dl. On 03/19/2025 the blood glucose was 259 mg/dl, 381 mg/dl and 301 mg/dl. On 03/20/2025 the blood glucose was 261 mg/dl. Record review revealed there was no evidence that the physician/medical doctor or other provider was notified of the above blood glucose levels. On 06/25/2026 at 11:57 AM an interview was conducted with Registered Nurse (RN) #11. She confirmed awareness of the physician's order requiring physician notification for blood glucose readings greater than 250 mg/dl. RN #11 stated no physician notification had been documented and no new physician orders had been received. RN #11 acknowledged the blood glucose readings exceeded the physician ordered notification parameter of greater than 250 mg/dl. On 06/25/2026 at 12:15 PM, an interview was conducted with the Medical Director (MD). The MD stated he had no recollection or documentation indicating of being notified of the RI #89's blood glucose readings that exceeded the ordered parameter of 250 mg/dL. MD stated no new orders were issued because there was no documentation that notification had occurred. The MD confirmed the notification parameters in the order were appropriate and clearly communicated. The MD further explained that persistent untreated hyperglycemia could result in urinary frequency and dehydration.On 06/25/2026 at 4:15 PM an interview was conducted with the Director of Nursing (DON). When asked what the facility policy and physician order required regarding physician notification for blood glucose readings greater than 250 mg/dl at the time of the event. The DON stated that it depended on the physician's order and that if the order directed staff to notify the physician, that was what we are supposed to do. During the interview, the DON stated the physician's order was present and that nursing staff were expected to follow the physician's order. The DON reported the facility verified physician notifications through daily medical record reviews. The surveyor and the DON reviewed RI #89's blood glucose readings ranging from 259 mg/dL to 381 mg/dl. The DON stated the blood glucose values would have been documented on the Medication Administration Record (MAR) and that physician notification should have been documented in the appropriate nursing note. The DON stated there was no evidence to validate that the physician had been notified in the absence of documentation in the medical record. The DON further stated the elevated blood glucose levels represented a potential change in the resident's condition, evidenced by hyperglycemia, and that the physician should have been notified and the notification documented in accordance with the prescribed order.

Based on interview, record review, and review of the Alabama Department of Mental Health Preadmission Screening and Resident Review ( PASRR) Level I Screening and Determination documentation, the facility failed to ensure compliance with PASRR requirements for Resident Identifier (RI) #5 by failing to ensure completion of the required PASRR Level II Evaluation. Record review revealed RI #5 had diagnoses including Generalized Anxiety Disorder and Post-Traumatic Stress Disorder (PTSD). Despite the Level I screening dated 11/07/2024 identifying the need for a Level II Evaluation, the required evaluation was not completed until 01/23/2026. This deficient practice placed RI #5 at risk for not being comprehensively evaluated to determine the need for specialized services and support to address RI #5 mental health needs, as required under PASRR regulations. The facility's failure to ensure completion of the required PASRR Level II Evaluation affected RI #5, one of three residents reviewed for PASRR compliance.Findings Include:RI #5 was admitted to the facility on [DATE] with diagnoses of Post-Traumatic Stress Disorder (PTSD) and Generalized Anxiety Disorder.The PASRR Level I Determination dated 11/07/2024 documented that, following a Quality Assurance (QA) review, the nursing facility applicant required a PASRR Level II Evaluation due to documented serious mental illness diagnoses, including PTSD and Generalized Anxiety Disorder. The determination further indicated the resident met the criteria for a Categorical Determination for Convalescent Care and could be admitted to the nursing facility while the required PASRR Level II Evaluation was completed. The PASRR Level I Determination, completed by the facility Social Services Director (SSD) further stated that, to comply with Federal and State PASRR regulations, the admitting nursing facility must report the resident's admission to the Omnibus Budget Reconciliation Act Of 1987 (OBRA) PASRR Office at the time of admission to initiate the PASRR Level II Evaluation process and determine eligibility for specialized services. On 06/26/2026 at 11:45 AM an interview was conducted with the SSD regarding RI #5's PASRR screening. The SSD stated the Level I PASRR screening had been completed prior to admission; however, the required Level II evaluation had not been completed at the time of admission. She stated she did not recall whether RI #5 had been admitted under emergency admission or exempted hospital discharge. The SSD stated RI #5 had diagnoses of Anxiety and PTSD, which required PASRR review, and acknowledged she had been responsible for ensuring the PASRR process was completed. She stated the omission was identified during a chart update on 01/23/2026, at that time the Level I PASRR screening was redone. She further stated the Level II PASRR evaluation was completed on 02/03/2026. She stated timely completion of a Level II evaluation was important to ensure residents with serious mental illness received appropriate recommendations, appropriate placement, and needed mental health services. She further stated failure to complete the required evaluation could result in inappropriate placement, inadequate mental health services, and a decline in the resident's mental health condition.

Based on interviews, observations, record review and review of a facility policy titled, Care Plans the facility failed to develop a comprehensive person-centered care plan to address the use of oxygen for Resident Identifier (RI) #1 and RI #35.This deficient practice affected RI #1 and RI #35 two of 30 residents whose care plans were reviewed. Findings Include:Review of a facility policy titled, Care Plans with a revised date of 09/2009 documented: . PURPOSE: Plans of Care are developed by the interdisciplinary team, to coordinate and communicate the plan of care for the resident. STANDARD: . the facility develops a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet a resident's medical needs, nursing and mental/psychological needs that are identified in the comprehensive assessment.PROCESS: . d) Comprehensive Plan of Care- within 7 days of the full assessments (admission, significant change, significant correction of prior full assessment and annual).1) RI #1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a diagnosis to include Pneumonia, Unspecified Organism.Review of RI #1's June 2026 physician orders revealed: . Administer oxygen at 2L (Liters) via (by way of) NC (nasal cannula) PRN (as needed) for SOB (shortness of breath). PRN for SOB (DX: Pneumonia, unspecified organism) Every shift-PRN: .On 06/23/2026 at 10:39 AM, an observation was made of RI #1 lying in bed, with oxygen on at 2L per nasal cannula.On 06/24/2026 at 9:03 AM, an observation was made of RI #1 lying in bed with oxygen on at 2L per nasal cannula.RI #1's care plans were reviewed and there was no documentation of a care plan developed for his/her oxygen use until 06/24/2026.2) RI #35 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a diagnosis of Heart Failure, Unspecified.Review of RI #35's June 2026 physician orders revealed: . OXYGEN AT 2 LITERS/MINUTE VIAL NASAL CANNUAL AS NEEDED FOR SOB .On 06/25/2026 at 11:19 AM, an observation was made of RI #35 sitting up in bed with oxygen on infusing at 2L per nasal cannula.RI #35's care plans were reviewed and there was no documentation of a care plan developed for his/her oxygen use until 06/25/2026.On 06/25/2026 at 3:43 PM an interview was conducted with the Minimum Data Set (MDS) Coordinator. The MDS Coordinator stated that she was responsible for developing and updating the care plan. The MDS Coordinator said residents who received oxygen should have a care plan for oxygen therapy. She further stated that if a resident did not have a care plan for oxygen, staff would not know the resident required oxygen use.On 06/30/2026 at 2:15 PM a follow up interview was conducted with the MDS Coordinator. The MDS Coordinator reviewed RI #1 and RI #35's care plans and stated she did not see a care plan for oxygen use prior to 06/24/2026. She stated RI #1 and RI #35 should have had a care plan for oxygen use. She further stated the importance of having a care plan for oxygen use was to alert staff to let them know what to look for related to oxygen and the reason for the oxygen use.

Based on interviews, record review, review of an anonymous complaint received by the State Agency, and review of the facility's investigative file, the facility failed to ensure Resident Identifier (RI) #43's left foot plantar wound was covered/dressed in a manner to prevent environmental contamination including flying insects, eggs, and larvae. On 08/04/2026, when RI #43 was brought back to his/her room from the shower, six live larvae (maggots) were observed in RI #43's left foot plantar wound bed. According to facility staff, when RI #43's left foot wound was dressed and wrapped with Kerlix, the toes were left exposed which could have been an entry point for flies to enter and lay eggs.This deficient practice affected RI #43, one of three residents sampled with wounds. Findings Include: On 08/07/2026 at 3:45 PM the State Agency received an anonymous complaint that six maggots were found in RI #43's heel wound on 08/04/2026. RI #43 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Type 2 Diabetes Mellitus without complications and Type 2 Diabetes Mellitus with Foot Ulcer. RI #43's Quarterly Minimum Data Set assessment with an Assessment Reference Date of 05/13/2026 revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15 which indicated intact cognition. RI #43's July 2026 Physician Orders revealed RI #43 had an order with start date of 05/26/2026 for treatment to his/her Left Posterior Foot Diabetic Ulcer to include: clean the wound with normal saline, pat dry, apply skin preparation the area around the wound, apply collagen, padding, and secure with kerlix every Tuesday, Thursday and Saturday.RI #43's Treatments Administration History: 08/01/2026 - 08/19/2026 documented wound care performed in RI #43's medical record. RI #43's left posterior foot diabetic ulcer wound care was not documented as completed on Saturday, 08/01/2026, which was blank.Review of RI #43's Progress Notes revealed a note dated 08/01/2026 at 3:19 PM that was documented by Licensed Practical Nurse (LPN) #28. The note included: Recorded as Late Entry on 08/06/2026 03:26 PM. Refused Treatment: Resident refused Treatment to (his/her) heel and foot, writer attempted to educate. on the need and value of changing. dressing unsuccessful after three attempts.On 08/20/2026 at 4:08 PM an interview was conducted with LPN #28 who said she worked at the facility every weekend. LPN #28 was asked, what days RI #43's wounds were scheduled to be treated. LPN #28 said it would have been on Saturdays and most of the time he/she would refuse.Further review of RI #43's Progress Notes revealed a note dated 08/04/2026 that was documented by the Interim Director of Nursing (IDON). The note documented the following: . Resident observed during routine wound care following a shower. Dressing to plantar surface of the left foot was removed for treatment. Upon removal of the dressing, approximately 6 live larvae were observed within the wound bed. No foul odor, purulent drainage, surrounding redness, warmth, exposed bone or other signs of acute infection were noted. Resident denied pain or discomfort. Wound was cleansed with normal saline, and all visible larvae was removed with a clean dressing applied. MD (Medical Director) made aware of findings . On 08/19/2026 at 11:38 AM an interview was conducted with RI #43. When asked about maggots being found in his/her foot wound, RI #43 said it happened about two or three weeks ago when Certified Nursing Assistant (CNA) #27 took him/her to the shower. RI #43 said when CNA #27 bought him/her back to the room and the Treatment Nurse (TXN) was getting ready to put a dressing on his/her foot was when the TXN saw the maggots. RI #43 said the head nurse talked to him/her about this and said they were larvae. RI #43 said he/she did go out and smoke and there were flies in the smoking area all the time and maybe that was when a fly got in his/her dressing. RI #43 said before, when treatments were done on his/her foot, his/her toes were not covered, and the fly may have entered that way. Contained within the facility's investigative file was a handwritten statement made by the TXN on 08/04/2026, which documented the following: . 1. How did you become aware of the alleged incident? I went (to) dress residents wound after (he/she) came from the shower .3. What did you observe concerning the alleged incident? I observed white maggots coming out of the wound under (his/her) left foot .4. What immediate action did you take? I went to get the DON .Q: How do you think the maggots got there? A: (His/Her) sock could have had a hole in it or (a fly) flew in where the toes were open . On 08/20/2026 at 8:55 AM an interview was conducted with the TXN. The TXN said prior to 08/04/2026 she had last performed wound care for RI #43 on Thursday 07/30/2026 and no maggots were observed. When asked about maggots being found in RI #43's left foot wound on 08/04/2026, the TXN said when she went in RI #43's room to do his/her treatment, RI #43 had just come back from the shower, and there was no dressing on RI #43's foot. The TXN said when she lifted RI #43's foot to clean it was when she saw two maggots in the wound bed. The TXN said she went and got the DON who came and assessed the wound and the doctor was called. The TXN said the maggots were observed on the wound under the bottom of RI #43's foot. When asked how maggots could have gotten in RI #43's wound, the TXN said RI #43 did not wear a sock all the time and when RI #43's foot was wrapped with the kerlix, RI #43's toes were exposed. The TXN said the fly could have entered through the opening by the toe. When asked if maggots should ever be in a residents wound, the TXN said never, unless ordered by the doctor. The TXN said what was now being done differently after the maggots were observed in RI #43's foot wound, was RI #43's entire foot was being covered when treatments were being done. Contained within the facility's investigative file was a handwritten statement made by the DON, dated 08/04/2026, which documented the following: . 1. How did you become aware of the alleged incident? The treatment nurse came to get me and asked that I come to the residents room .3. What did you observe concerning the alleged incident? Resident lying in bed with left foot wound uncovered. I observed about 6 larvae Removed from the wound bed by cleaning the area 4. What immediate action did you take? Explained to resident what was happening. Cleaned the wound and called the MD (Medical Doctor) .RI #43 is a smoker and enjoys (his/her) smoke breaks . Resident agreed to keep the left foot covered to ensure it's not exposed and open . On 08/20/2026 at 11:07 AM an interview was conducted with the DON and she said she was made aware RI #43 had maggots in his/her left foot wound on 08/04/2026, when the TXN informed her of this. The DON said she immediately went to RI #43's room, assessed the wound, and observed six maggots in the wound bed. The DON said, the wound bed was red, there was no pain to touch, no drainage, and no additional swelling. The DON said she proceeded to clean the wound with normal saline. The DON said the maggots were small and opaque in color. The DON said the maggots were put in a red biohazard bag and thrown away and the doctor was notified. The DON said prior to 08/04/2026 RI #43's wound care was last performed on 07/30/2026. The DON said RI #43 refused the wound care scheduled for 08/01/2026 and the next scheduled treatment was 08/04/2026. When asked if it was ever determined how the maggots got in RI #43's wound, the DON said there was speculation of how it could have occurred. The DON said RI #43 enjoyed smoke breaks and did not always have a sock on. The DON said maybe a fly landed on RI #43's foot during a smoke break. The DON said there had been times when she had seen RI #43 with the dressing on and RI #43's toes would be exposed and a fly could have entered that way. When asked should maggots ever be observed on a wound, the DON said only if they are ordered by the physician. The DON said these maggots were not ordered by RI #43's physician. The DON said RI #43's toes were now being covered when his/her dressing was applied. 08/20/2026 at 2:48 PM a telephone interview was conducted with the MD, RI #43's physician. The MD said he was made aware that RI #43 had maggots in his/her wound on 08/04/2026 by the DON. When asked what would prevent flies from laying eggs on a person's wound, the MD said keeping the wound clean dry and covered. The MD said he supposed a fly could possibly enter the dressing of a person when the foot was wrapped and the toes were left exposed. The MD said maggots should never be in a person's wound unless a doctor used them on purpose. During the interview on 08/20/2026 at 4:08 PM with LPN #28, a nurse providing wound care for RI #43 on the weekends. LPN #28 said when she provided wound care for RI #43, she would clean the wound, apply the treatment and wrap the foot with Kerlix. When asked how she wrapped the foot, LPN#28 said she wrapped the heel and the foot with Kerlix and the toes would be left exposed. When asked what could occur when a fly lays an egg on a wound, LPN #28 said it could produce larvae and that matures into a maggot. LPN #28 said what could possibly prevent flies from laying eggs in a wound would be if the wound is kept covered in a manner so nothing can get on the wound. Contained within the facility's investigative file was a form titled, Staff Development Attendance Record, dated 08/05/2026, which revealed the following: . Subject Presented: Wound Care Content: Wound Care, Dressing Integrity, and Prevention of Environmental Contamination Wounds must remain clean, dry, appropriately dressed, and completely covered .Residents with wounds who spend time outdoors should have wounds securely covered. Staff should be particularly alert to dressing displacement or exposure to flies/insects . RI #43's Care Plan for Problem. Problem Start Date: 05/26/2026. Lt (left) Plantar Foot Diabetic Ulcer. included . Approach Start Date: 08/04/2026 . Resident encouraged to wear socks during smoke breaks so that foot is covered.

Based on interviews, record review and review of a facility policy titled, Incident and Accidents, the facility failed to provide evidence how it was determined Resident Identifier (RI) #91 acquired skin tears to the right upper shin, left knee, right buttocks, right hip, right knee and right lower shin on 11/05/2025. This deficient practice affected RI #91, one of two residents sampled for accidents. Failure of the facility to investigate to determine how RI #91 acquired the skin tears placed RI #91 at risk of acquiring further skin tears due to no interventions being implemented to reduce the risk of RI #91 acquiring skin tears. When incidents are not investigated, underlying root causes remain unknown.F689 was cited as result of the investigation of complaint/report number 2653290.Findings Include: Review of a facility policy titled, Incidents and Accidents, with a revised date of 10/2008, revealed the following: . STANDARD: Incidents are categorized as:Incident Type I-an incident is an occurrence that may not be consistent with the routine operation of the facility or the routine care of a particular resident .Examples include . skin tears .PROCESS: .II. Documentation .b. An Incident/Accident report should be completed .c. Initiate an investigation .d. Witness Statements should be completed as follow:Employees having knowledge of, or who witnessed the incident, should be interviewed, .III. Tracking and TrendingEach incident will be entered into the incident tracking module . RI #91 was admitted to the facility on [DATE] with diagnoses to include Senile Degenerative of the Brain, Vascular Dementia, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side and History of Falling. A review of RI #91's Physician Order Report (Physician Orders) for 10/01/2025 - 06/24/2026 revealed RI #91 had treatment orders for the skin tears to his/her right upper shin, left knee, right buttocks, right hip, right knee and right lower shin. RI #91's Progress notes revealed the following: . 10/05/2025 11:28AM Sponsor (name of sponsor) made aware of new areas found on (RI # 91) . This progress note was made by the Treatment Nurse (TX nurse). On 06/24/2026 at 5:01 PM an interview was conducted with the TX nurse. When asked how RI #91 acquired the skin tears, the TX nurse said her notes were showing on 11/05/2025 she contacted the sponsor and made her aware of the new areas (skin tears) found on RI #91. The TX nurse said her documentation did not say who informed her of the skin tears or how the skin tears were acquired. The TX nurse said incident reports should be done for skin tears. The TX nurse said the incident report would tell how the skin tear occurred, but she did not recall if an incident report had been done or not.On 06/30/2026 at 8:41 AM an interview was conducted with the Administrator (ADM). The surveyor shared with the ADM when reviewing RI #91's Physician Orders and November Progress Notes, the surveyor saw where RI #91 acquired several new areas (skin tears) during the month of November 2025. When asked who would have initially identified the areas as skin tears, the ADM said it would be any staff providing care to RI #91. The ADM said she was not sure if it was ever investigated how RI #91 acquired the skin tears. The ADM said according to the facility's Incidents and Accidents policy, skin tears were considered incidents. When asked if according to the policy should an incident/accident report be completed when incidents occur, the ADM said yes. When asked why it would be important to complete incident reports, the ADM said to show what the facility did in the event of an incident or accident. Review of the facility's Event Summary Report (incident tracking module) dated 06/01/2025 to 02/01/2026 revealed no incident report or investigation had been completed related to RI #91's skin tears.

Based on observations, interviews, record review and review of a facility policy titled, DIET AND SUPPLEMENT ORDERS, the facility failed to ensure a water pitcher containing thin liquids was not at the bedside of Resident identifier (RI) #11, resident at risk for aspiration, who was to receive nectar-thick liquids per physician's orders. These observations were made on three of seven days of the survey. This deficient practice affected RI #11, one of four resident's reviewed for nutrition/hydration, and had the potential to result in the resident consuming liquids of an unsafe consistency, placing the resident at increased risk for aspiration and choking. Findings Include: Review of a facility policy titled, DIET AND SUPPLEMENT ORDERS, with a reviewed date of 12/2023 revealed the following:POLICY:The resident's diet is prescribed by the attending physician.PROCEDURE:1. The attending physician writes an order for regular or therapeutic diets . to be served to each resident, according to the resident's nutritional and medical requirements and/or limitations and preferences . RI #11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's Disease with Late Onset, Esophageal Obstruction, Senile Degeneration of the Brain and Gastro-Esophageal Reflux without Esophagitis. RI #11's care plan identified RI #11 to require thicken liquids related to his/her risk for aspiration. The care plan directed staff to not keep a water pitcher in the resident's room, to provide thickened liquids as ordered, and staff was to have a cooler containing thickened liquids at the bedside. This care plan was initiated on 12/03/2024. RI #11's COMMUNICATION FORM, to nursing from the therapy department, with an effective date of 02/09/2026 revealed a honey thick liquid consistency was changed to nectar thick liquids consistency. RI #11's Physician Order Report (Physician Orders) dated 05/2026 to 06/2026 revealed RI #11 was to have nectar-thick liquids. This order has a start date of 02/09/2026. A review of RI #11's RESIDENT PROFILE, dated 02/09/2026 revealed RI #11's diet was pureed diet with nectar-thick liquids. The profile sheet also revealed the nectar thicken liquids was a swallowing precaution. Documented on the profile was . cooler in room with nectar thicken liquids at bedside . RI #11's Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 05/26/2026, revealed RI #11 had a Brief Interview of Mental Status score of 3 of 15 which indicated severely impaired cognition. The assessment revealed RI #11 was to receive a mechanically altered diet, such as thicken liquids. On 06/22/2026 at 4:00 PM the surveyor observed a water pitcher at RI #11's bedside. On 06/23/2026 at 2:30 PM the surveyor again observed a water pitcher at RI #11's bedside. On 06/25/2026 at 4:41 PM the surveyor observed the water pitcher on top of the over-bed table in RI #11's room. At this time, Certified Nursing Assistant (CNA) #20 entered the room and checked the consistency of the water in the pitcher. CNA #20 said there was no thicken water in the pitcher. When asked the type of diet Resident #11 was receiving, CNA #20 stated, pureed with thickened liquids. When asked who was responsible for ensuring RI #11 had thickened water at his/her bedside, CNA #20 stated she was unsure. On 06/26/2026 at 10:43 AM an interview was conducted with the Registered Dietitian (RD). When asked whether water should also be nectar thickened for a resident prescribed a therapeutic diet with nectar thick liquids, the RD stated yes. The RD stated the reason for the nectar- thick liquids would be swallowing problems. When asked what could potentially occur if the water was not thicken and the resident received the water, the RD stated possibly chocking. When asked who was responsible for ensuring the resident received the correct water consistency at the bedside, the RD stated the nursing staff was responsible and could obtain thickened water from the kitchen. On 06/29/2026 at 12:56 PM an interview was conducted with the Registered Nurse Unit Manager (RN UMGR). When asked, according to RI #11's physician order what should be the fluid consistency of his/her fluids, the RN UMGR said nectar thick. The RN UMGR said she believed this was the consistency that speech recommended for RI #11. The RN UMGR said the consistency of the water should be nectar-thick liquid as well. The surveyor shared with the RN UMGR that from 06/22/2026 through 06/25/2026, RI #11 had a pitcher with regular water at his/her bedside. The RN UMGR stated RI #11 should not have had a pitcher of water at his/her bedside and she did not know why one was there. When asked how the CNAs providing care for RI #11 knew the required fluid consistency of RI #11's water, the RN UMGR stated they could review the resident's profile sheet in the closet or ask the nurse about the consistency of water RI #11 received. The RN UMGR stated that the CNAs or someone should have known that RI #11 should have had a cooler with thicken water in it at his/her bedside. When asked what could be an outcome if staff had given RI #11 water not in the ordered consistency, the RN UMGR said RI #11 could have strangled, chocked or aspirated.

Based on observations, interviews, record review, and review of a facility policy titled, Oxygen Administration, the facility failed to ensure Resident Identifier (RI) #1's oxygen tubing and RI #35's humidified water bottle was maintained in a manner to prevent contamination.Specifically: 1) RI #1's humidified water bottle was not dated when observed by the surveyor on 06/23/2026.2) RI #35's humidified water bottle was not dated when observed by the surveyor on 06/23/2026 and 6/24/2026. This deficient practice affected RI #1 and RI #35 two of four residents sampled for Respiratory Care. Findings Include:Review of a facility policy title, Oxygen Administration with an effective date of February 1, 2004, revealed the following: . PURPOSE: To administer high purity oxygen for the treatment of certain diseases or conditions. PROCESS: .11. Cannulas, masks and tubing should be changed weekly .1) RI #1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a diagnosis to include Pneumonia, Unspecified Organism.Review of RI #1's June 2026 physician orders revealed: . Administer oxygen at 2L (Liters) via (by way of) NC (nasal cannula) PRN (as needed) for SOB (shortness of breath). PRN for SOB (DX: Pneumonia, unspecified organism) Every shift-PRN: .On 06/24/2026 at 9:03 AM, an observation was made of RI #1 lying in bed with oxygen on at 2L per nasal cannula. The humidified water bottle did not have a date on it.On 06/24/2026 at 3:57 PM an interview was conducted with Licensed Practical Nurse (LPN) #18. The Surveyor accompanied LPN #18 to RI #1's room to observe the humidified water bottle. LPN #18 stated there was no date on the humidified water bottle. LPN #18 stated the humidified water bottles were change weekly. LPN #18 stated the concern of not dating the humidified water bottle was it could possibly lead to infection.On 06/24/2026 at 4:18 PM an interview was conducted with the Infection Preventionist (IP). The Surveyor accompanied the IP to observe RI #1's humidifier bottle. The IP stated there was no date on the humidifier bottle and it should be dated. On 06/26/2026 at 11:23 AM an interview was conducted with Registered Nurse, Unit Manager (RN UMGR). The RN UMGR stated she observed RI #1's humidified water bottle and did not see a date or any initials. When asked what should be written on the humidified water bottle, she stated the date it was changed and the nurse's initials. 2) RI #35 was admitted to the facility on 0913/2021 and readmitted to the facility on [DATE] with a diagnosis of Heart Failure, Unspecified.Review of RI #35's June 2026 physician orders revealed: . OXYGEN AT 2 LITERS/MINUTE VIAL NASAL CANNUAL AS NEEDED FOR SOB .On 06/23/2026 at 9:22AM, an observation was made of RI #35's oxygen and there was no date on the humified water bottle.On 06/24/2026 at 9:10 AM, an observation was made of RI #35's oxygen concentrator. The humidified water bottle was not dated.On 06/24/2026 at 5:32 PM an interview was conducted with LPN #21. LPN #21 was asked about the date on RI #35's humidified water bottle. She said the humidified water bottle did not have a date, but there should be a date on it.On 06/25/2026 at 3:43 PM an interview was conducted with the Minimum Data Set (MDS) Coordinator. The MDS Coordination stated the oxygen tubing, and humidified water bottles should be changed weekly, and the nurse on the unit was responsible for changing them. She said, she was not sure how the facility ensured the oxygen tubing and humified water bottle was changed. The MDS Coordinator said, the potential harm of oxygen tubing or humidifier water bottles not being changed was they could stop working and the tubing cloud get clogged or water get in it.

Based on record review, interview, and a policy titled . Behavior Management Program the facility failed to timely assess the behavior change and timely implement additional behavior interventions for Resident Identifier (RI) #90 a resident with a history of wandering behavior. Specifically: On 04/16/2025 RI #90 wandered into RI #57's room. RI #57 had a diagnoses of dementia with mood disturbance and staff had been made aware on 04/15/2025 that he/she did not want RI #90 in his/her room. Although staff were aware no interventions were in place to ensure RI #90 did not wander into RI #57's room. When RI #90 entered RI #57's room on 04/16/2025 RI #57 pushed RI #90 out of the room causing him/her to fall and sustain a fracture to the left maxillary sinus wall and lateral border of the left orbit. This deficient practice affected one of two residents reviewed for behavior health. This deficiency was cited as a result of complaint #463612. Findings include: On 04/16/2025 at 1:16 PM the Alabama State Survey Agency received a Facility Reported Incident (FRI) which indicated RI #57 pushed RI #90 down on the floor in the hallway after RI #90 entered RI #57's room. RI #90 was noted to have a laceration above the left eye.The facility's Behavior Management Program Policy with a revised date of 02/2013, documented .PURPOSE:To provide facilities with a standard process for identifying, assessing and managing residents who display mental or psychosocial adjustment difficulties.STANDARD:Residents who display mental or psychosocial adjustment difficulty should receive appropriate services, in an attempt to correct the problem. The social service department may assist with arrangements, for outside professional consultation services, such as psychologists or psychiatrists, when ordered by the attending physician.PROCESS: I. Assessment a) Mental adjustment disorders should be identified through the RAI process, completed after admission of a resident, and periodically throughout the resident's stay. b) The social services designee may conduct further assessments to identify and manage altered mental states, dementia, delirium, and depression.II. Behavior Management Programsa) The plan of care should be developed by the interdisciplinary team.Any resident not identified on the behavior list who exhibits a behavior will be immediately redirected and removed from the stimuli.The behavior will be reported to the unit manager and/ or charge nurse by the staff member who observed the behavior. The unit manager/charge nurse will evaluate the resident for possible causes or precipitating factors. The occurrence will be reported to the physician, if indicated and reported in the clinical record. The Social Service department, Director of Nursing and Administrator will be notified by documentation on a facility communication tool. The sponsor will also be informed of the occurrence by social services and/or nursing service. RI #90 was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Mood Disorder, and Adjustment Disorder with mixed Anxiety.RI #90's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/04/2025, indicated RI #90 had a Brief Interview for Mental Status (BIMS) Score of 11/15 indicating moderately impaired cognitive skills for daily decision making, with long- and short-term memory problems. According to the MDS RI #90 displayed no behaviors.A review of RI #90's care plan with a problem onset date of 05/04/2023 revealed the following . is having increased behaviors/cognitive loss related to dx of Dementia . Approach: encourage participation in . activities .refer to psych services as needed .A review of RI #90's care plan with a problem onset date of 01/15/2025 revealed the following . is at risk for elopement due to wandering . wanders into other residents' rooms . check code alert placement every shift . Consult with MD and psychologist as needed . encourage socialization and participation in activities . A review of RI #90's care plans did not indicate interventions were made on 04/15/2025 after RI #57 reported RI #90 wandering into his/her room.RI #57 was admitted to the facility on [DATE] with an admitting diagnosis of Dementia with Agitation. RI #57's Quarterly MDS with an ARD of 03/11/2025, indicated RI #57 had a BIMS Score of 15/15 and was cognitively intact with skills for daily decision making. RI #57's Mood Interview indicated a score of 0 and revealed no behaviors. RI #57's Progress Note dated 04/16/2025 at 1:03 PM written by the Social Services Director (SSD) documented . Yesterday (RI #57) made the Assistant Director Of Nursing (ADON) and SSD aware of another resident coming into (his/her) room. (He/she) stated that (he/she) wanted them to leave (him/her) alone. SSD and ADON stated they would discuss this with the other resident and let them know not to come into (his/her) room. SSD and ADON stated to (RI #57) that when someone comes into (his/her) room (he/she) does not want to press the call light or get staff attention. (RI #57) stated that (he/she) understood .On 06/25/2026 at 4:44 PM during an interview the SSD said she became aware of RI #90 entering RI #57's room on 04/15/2025 when RI #57 notified her. When asked what interventions were put in place for RI #90 on 04/15/2025 the SSD stated that interventions began on 04/17/2025 to obtain placement for RI #90 in a memory care facility. When asked were interventions put in place to provide adequate protection from foreseeable harm the SSD replied No.On 06/24/2026 at 11:21 AM with RI #57 was asked what happened on 04/16/2025 with RI #90. RI #57 stated RI #90 came up to his/her room about three times and he/she told the nurses that he/she kept coming to his/her room but they would not move him/her. RI #57 said the incident could have been avoided if the staff had removed the resident.On 06/24/2026 at 11:49 AM during an interview RI #8 stated that RI #57 would fuss at anyone who came close to his/her room. On 06/29/2026 at 12:03 PM during an interview Certified Nursing Assistant (CNA) # 16 stated that RI #90 wandered soon after being admitted to the facility and she observed him/her often going in and out of other resident's rooms. She stated she had observed RI #90 go into RI #57's room at least six times and she could hear RI #57 hollering at him/her. CNA #16 stated she told the nurses and suggested that RI #90 be moved to another hall. CNA #16 stated the incident could have been avoid if RI #90 had been moved.On 06/29/2026 at 12:52 PM during an interview CNA #17 stated RI #90 had a history of wandering in and out of other rooms and taking personal items. She stated RI #90 wandered daily and she had observed him/her going into RI #57's room about five times. She stated nothing could have prevented the incident because if they moved him/her RI #90 would continue to wander.On 06/30/2026 at 10:27 AM during an interview the Director of Nursing (DON) stated RI #90 was identified as a wanderer on 01/15/2025 according to the care plans and a progress note. When asked what type of supervision was in place for RI # 90 at the time of the incident, the DON stated general supervision and RI #90 had a code alert monitor in use. The DON stated RI #90 had a diagnosis of dementia and he/she wandered all over the building. The DON stated the incident could have been prevented by moving RI #90. When asked how it would make a reasonable person feel being hit by another resident, the DON stated upset and in pain. The DON stated the facility substantiated abuse.On 06/30/2026 at 12:14 PM the Administrator (ADM) was asked what interventions were in place to protect RI #90, a known wanderer. The ADM stated RI #90 was identified as a wanderer on 01/15/2025 and staff were educated on interventions to assist with wandering. The ADM was asked the level of supervision RI #90 required and she stated he/she was redirected and staff checked the code alert for placement. The ADM asked what interventions were put in place by the ADON and SSD after being notified by RI #57 that he/she did not want RI #90 coming into his/her room. The ADM stated RI #57 was instructed to press the call device when RI #90 entered the room.

Based on interviews, record review and review of a facility policy titled, Oral Medication Administration, the facility failed to ensure the medication nurses initialed on Resident Identifier (RI) #54's Medication Administration Record (MAR) that RI #54's Hydrocodone-Acetaminophen (Norco) 10/325 mg (milligram) and Pregabalin (Lyrica) 200 mg, both narcotic medications, had been administered to RI #54 on 05/02/2026 at 6:00 AM; and on 05/25/2026 at 6:00 PM.This deficient practice affected RI #54, one of four residents whose MARs was reviewed for medication administration. When nurses do not initial or document on the MAR immediately after administering a medication, another nurse may assume the resident did not receive the medication and administer a second dose, which could place the resident at risk of a dangerous overdose.Findings Include:Review of a facility policy titled, Oral Medication Administration, with an effective date of 02/01/2004 revealed the following: PURPOSE:To administer oral medications in an organized and safe manner . PROCESS: .18. Administer medication .21. Return to medication cart, . and document medication administration, with initials in appropriate space on Medication Record (MAR) . RI #54 was admitted to the facility on [DATE] with diagnoses to include Presence of Left Artificial Hip Joint, Polyneuropathy and Cellulitis. RI #54's May - June 2026 Physician Order Report (Physicians Orders) revealed RI #54 was to be administered Pregabalin 200 mg one capsule by mouth three times a day and Hydrocodone-Acetaminophen 10-325 mg by mouth twice daily for pain. A review of RI #54's May 2026 MAR revealed on 05/02/2026 there were no initials on the MAR indicating that RI #54 had been administered his/her Hydrocodone and Pregabalin at 6:00 AM; and on 05/25/2026 there were no initials on the MAR indicating that RI #54 had been administered his/her Hydrocodone and Pregabalin at 6:00 PM. On 06/29/2026 at 5:06 PM a telephone interview was conducted with Registered Nurse (RN) #23, the nurse administering medications to RI #54 on the 3rd shift on 05/02/2026. The surveyor shared with RN #23 that there were no initials on the MAR indicating she had administered RI #54 his/her Hydrocodone and Pregabalin at 6:00 AM. When asked why there were no initials on RI #54's MAR indicating she had administered the medications, RN #23 said she probably forgot to sign the MAR that she had administered them. When asked why it would be important to initial/document on the MAR after the nurse administered the medication to the resident, RN #23 said to show that the nurse had given the mediation and to keep good records. On 06/29/2026 at 4:43 PM a telephone interview was conducted with RN #24, the nurse administering medications to RI #54 on the 2nd shift on 05/25/2026. The surveyor shared with RN #24 that there were no initials on the MAR indicating she had administered RI #54 his/her Hydrocodone and Pregabalin at 6:00 PM. When asked why there were no initials on RI #54's MAR indicating she had administered the medications, RN #24 said she must have overlooked that and not signed the MAR. When asked why it would be important to initial/document on the MAR after the nurse administered the medication to the resident, RN #24 said because you have to keep track of when the medication was given. On 06/29/2026 at 1:22 PM an interview was conducted with the RN Unit Manager (RN UMGR). When asked, after the nurse had administered any medication to a resident what should they do next, the RN UMGR said sign off on the MAR the medication had been given. The RN UMGR said looking at RI #54's May 2026 eMAR (Electronic MAR), it was not signed off that RI #54 received his/her Hydrocodone and Pregabalin on 5/02/2026 at 6:00 AM and on 5/25/2026 at 6:00 PM. The RN UMGR said the facility's policy instructed nurses to initial and sign the MAR that medications had been administered. The RN UMGR said it would be important for the nurse to initial/document on the MAR after the nurse administered medications so that you know which nurse gave the medication and what medication had been given.

Based on observations, record review, interviews and review of a facility policy titled, DIET AND SUPPLEMENT ORDERS, the facility failed to ensure Resident Identifier (RI) #3 was served double portions of proteins as a part of the resident's therapeutic diet.This deficient practice affected RI #3, one of four residents that were reviewed for nutrition and was observed during the breakfast and lunch meals on 06/24/2026. RI #3 not receiving his/her double portions of protein placed RI #3 at risk of a decrease in his/her protein levels which may lead to malnutrition, weight loss and muscle wasting. Findings Include: Review of a facility policy titled, DIET AND SUPPLEMENT ORDERS, with a reviewed date of 12/2023 revealed the following:POLICY:The resident's diet is prescribed by the attending physician. PROCEDURE:1. The attending physician writes an order for regular or therapeutic diets . to be served to each resident, according to the resident's nutritional and medical requirements and/or limitations and preferences . RI #3 was admitted to the facility on [DATE] with the diagnoses of End Stage Renal Disease, Dependence on Renal Dialysis, and Muscle Weakness.RI #3's admission Minimum Data Set assessment with an Assessment Reference Date of 05/25/2026, revealed RI #3 had a Brief Interview of Mental Status score of 15 indicating the resident was cognitively intact. The MDS also coded RI #3 as receiving a Therapeutic diet.RI #3's Physician's Order, dated 05/26/2026, included a diet order with special instructions to add large portions to each meal tray, and add boiled eggs on breakfast tray and double meat on each tray for protein.On 06/24/2026 at 8:50 AM RI #3's breakfast tray was observed to contain one boiled egg and one thin turkey sausage patty. RI #3 stated, his/her protein was low and the doctor ordered more proteins a few days ago.On 06/24/2026 at 12:20 PM RI #3's lunch tray was observed to contain two chicken wings.On 06/24/2026 at 3:45 PM an interview was conducted with the Dietary Supervisor (DS). The DS said RI #3 was to receive two boiled eggs and two servings of meat with breakfast. The DS said the two wings were one serving and not a double portion. The DS said these were mistakes made by the kitchen.On 06/25/2026 9:06 AM during a follow up interview with the DS she stated the potential outcome that could occur if the resident's meal did not include double portion of proteins as prescribed would be, RI #3 would not get the nutrition that he/she needed and weight loss.On 06/26/2026 at 10:43 AM, the Registered Dietician (RD) was asked, when a resident was on a therapeutic diet and had an order for double portions and chicken wings were served, how many wings should be served to the resident. The RD said four should have been served. The RD said the dietary staff would be responsible to ensure the residents received double portions. When asked what was the potential when a resident was not served double portions as ordered, the RD said with RI #3, he/she was receiving dialysis and they were trying to double his/her portions to meet his/her protein needs after dialysis. The RD said the facility was trying to get RI #3 his/her additional proteins through diet. The RD said the outcome of RI #3 not receiving double portions would be that RI #3's protein needs would not be met.

Based on interviews, medical record review, review of the facility's policy titled Elopements and Wandering Residents, and review of a facility document summarizing the facility's investigation into Resident Identifier (RI) #1's elopement, facility staff failed to implement the elopement policy after a door alarmed on 08/11/2022, when RI #1 exited a facility door and left the premises. On 08/11/2022 at approximately 5:45 PM Employee Identifier (EI) #4, a Certified Nursing Assistant (CNA), heard the door alarm sound at the Rehab door. EI #4 proceeded to the Rehab door and looked out the window. When EI #4 did not see a resident outside the window, she turned off the door alarm and went back to work on the unit. EI #3, a Licensed Practical Nurse (LPN), also responded to the door alarm but took no further action upon finding EI #4 was turning off the alarm. EI #5, the off-duty Dietary Manager, was leaving work after her shift on 08/11/2022 and saw RI #1 walking down the sidewalk that runs beside the roadway approximately 0.3 miles from the facility. EI #5 returned RI #1 to the facility at approximately 5:59 PM. Staff members at the facility were not aware RI #1 had left the facility unsupervised. In addition, following RI #1's elopement from the facility, staff inaccurately re-assessed RI #1 using the facility's Elopement Assessment. This assessment was conducted on 08/11/2022 after RI #1 was returned to the facility, and staff indicated on the assessment RI #1 had not eloped from the facility within the last 120 days, had no attempted or successful elopements in the last 12 months, and was only on 1-2 medications (despite physician orders reflecting more than ten medication orders). As a result of this inaccurate information, RI #1 was not coded as being at risk for elopement, despite the known episode occurring earlier in the day. This deficient practice placed RI #1, one of four sampled residents, as well as any other residents in the facility at risk for elopement, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment or death. On 08/19/2022 at 1:50 PM, the facility's Administrator and the Director of Nursing (DON) were provided the immediate jeopardy template and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Quality of Care/Free of Accident Hazards/Supervision/Devices, F689. Findings include: On 08/11/2022 at 7:12 PM, the facility self-reported to the Alabama State Survey Agency an incident of elopement. According to the initial report, RI #1 was observed off the facility's campus and returned to the facility by EI #5, the off-duty Dietary Manager. An untitled document printed on facility letterhead dated 08/17/2022 outlined the facility's investigation into RI #1's elopement. Review of this document revealed the following: .Description of the incident: On 08/11/2022 at 5:53 pm (EI #2/DON), received a call from (EI #5/Dietary Manager) to report that she had observed (RI #1) on the sidewalk a short distance from the facility. (EI #5) brought (RI #1) back to the facility in her personal car. (RI#1) arrived back at the facility at 5:59 pm . Investigation Activities: . As part of the investigation the facility surveillance system was reviewed. We were able to determine from the video footage that (RI #1) exited the building from the Rehab ambulance exit at 5:47 pm. (EI #4/CNA) responded to exit door alarm, looked out of the window on the door and silenced the alarm after not seeing the resident. (EI #3/LPN) also reports that she heard the door alarm and observed (EI #4) at the door. (EI #3) took no further action. (EI #5) notified (EI #2) at 5:53 pm concerning (RI #1's) whereabouts and that she was picking (him/her) up . RI #1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Mood Disorder, Unspecified Dementia with Behavioral Disturbances, Adjustment Disorder with Mixed Anxiety and Depressed Mood, Unspecified [CONDITION(S)] and Anxiety Disorder. Review of RI #1's Comprehensive Care Plans revealed the facility identified and care planned RI #1 on 05/09/22 as a risk for elopement related to wandering. RI #1's Elopement assessment dated [DATE] revealed RI #1 scored a 12, indicating he/she was an elopement risk. Review of RI #1's most recent quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/28/2022 revealed RI #1 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. This assessment also indicated RI #1 used a wander/elopement alarm daily during the assessment period. Review of RI #1's Departmental Notes revealed the following: .7/28/2022 11:03 pm . alert, oriented to self with confusion . has been noted wandering in and out of other residents' room . 7/29/2022 2:06 AM . Resident is alert, with periods of confusion . 7/30/2022 9:42 PM . Set alarm off via pushing on door. Not easily redirected . 7/31/2022 3:14 AM . ambulating in hallway, going in other residents' room require much encouragement to return to room . Noted at back door attempting to open door and leave . 8/15/2022 3:20 PM . Late Entry for 8/11/2022 6:15 pm . ( RI #1) was escorted back into the facility by the dietary manager and the facility administrator. (RI #1) was picked up by the dietary manager walking on the sidewalk a short distance from the facility . Head to toe assessment was completed . No injuries noted . An updated Elopement Assessment was completed on RI #1 on 08/11/2022 at 7:05 PM after RI #1 was returned to the facility. This assessment was completed by EI #6, the MDS Coordinator. The assessment indicated RI #1 only took 1-2 medications (despite physician orders including more than ten medication orders) and had no history of elopement within the last 120 days. The section titled History of Elopement Episodes- Attempted or Successful- Prior 12 months also listed No History = 0. These answers resulted in an Elopement Assessment score of 9, not at risk. A total score of 10 or higher on the facility's Elopement Assessments indicate elopement risk. Review of a facility policy titled, Elopements and Wandering Residents, with a revision date of 4/2008, revealed: . PURPOSE . Unsupervised activity outside the facility could lead to serious injury of a resident due to the many hazards such as traffic, water, storms and hot/cold temperatures. STANDARD: Elopement means the unplanned, unauthorized leaving of the facility by a resident. Residents should be assessed for elopement risk on admission . then quarterly . The facility is equipped with door locks/alarms to help avoid elopements . PROCESS: . II. Procedure when alarm sounds/unconfirmed elopement a) In the event a door alarm sounds, the area outside of the door shall be searched immediately, even if a resident is observed near the door. The Charge Nurse should be made aware immediately. b) If no one is observed outside the door, an immediate head count of every Resident should be initiated by the Charge nurse of each unit. c) If a Resident has sounded the alarm by approaching an exit door, the incident should be communicated to the Director of Nursing to ensure appropriate review/revision of the Resident's care plan . EI #4, the CNA that responded to the door alarm on 08/11/2022, provided the facility with a signed STATEMENT FORM dated 08/11/2022 at 6:30 PM. On this form, EI #4 indicated she was unaware RI #1 had eloped from the facility until she was later called to the office for questions. EI #4 reported to the facility she had last seen RI #1 drinking a milkshake while staff were passing out the dinner meal trays. EI #4 further reported she heard the Rehab door alarm as she was finishing picking up dinner meal trays. She indicated she walked to the door and did not see anyone around, so she turned off the alarm. On 08/16/2022 at 3:28 PM, an interview was conducted with EI #4. When asked what she recalled about 08/11/2022 when RI #1 eloped from the facility, EI #4 said she heard the door alarm on the Rehab unit when she was picking up dinner trays. When asked what she did in response to the door alarm, EI #4 said she went to the door and looked out the window, and when she did not see anyone, she entered the code to turn off the alarm. EI #4 further stated she did not know RI #1 had left he building until she was called to the DON's office later in the day. On 08/17/2022 at 11:50 AM a follow-up interview was conducted with EI #4. EI #4 was asked what should have occurred when the alarm sounded on the door. EI #4 said she should have gone to the door and stepped out of the building to look around the premises. EI #4 was asked if she went outside to look around the premises when the door alarmed on 08/11/2022. EI #4 said no, but she should have. EI #4 was asked if she notified the charge nurse about the door alarm and if a resident head count was done. EI #4 said, no she did not notify the charge nurse and a resident head count was not done. EI #4 was asked if the facility's elopement policy was followed. EI #4 said no, the elopement policy was not followed. EI #3, the LPN that responded to the door alarm on 08/11/2022 provided the facility with a signed STATEMENT FORM dated 08/11/2022 at 6:30 PM. EI #3 reported to the facility that she was unaware RI #1 had eloped from the facility until she was informed by the DON. EI #3 further reported that when she heard the door alarm, she looked around and saw EI #4, the CNA, securing the door and alarm, but she took no further actions. On 08/16/2022 at 11:26 AM an interview was conducted with EI #3. EI #3 confirmed she heard the alarm sound on the Rehab unit. EI #3 said when she got to the Rehab unit, she saw EI #4 secure the door, put the code in the door and the alarm went off. When asked if she had followed up with EI #4 about why the alarm was sounding, EI #3 said no. On 08/17/2022 at 10:55 AM a follow-up interview was conducted with EI #3. EI #3 was asked what was the facility's protocol for when an alarm sounds on a door. EI #3 said secure the door and take a look around the door, go outside the facility, and the charge nurse should be made aware. She stated she should have gone out and looked outside the door, and if she did not see anyone (resident) a head count should have been done. EI #3 was asked if she went to the door, looked outside and did a head count. EI #3 said, no that was not done. EI #3 was asked, if the elopement policy was followed on 08/11/2022 when the alarm on the door sounded. EI #3 said no. EI #5, the off-duty Dietary Manager who observed RI #1 walking on the sidewalk beside the roadway on 08/11/2022, provided the facility with a signed STATEMENT FORM dated 08/11/2022 at 6:30 PM. EI #5 reported to the facility that as she was driving down the road after leaving work, and she noticed a person walking on the left side of the road. EI #5 further reported that when she realized the person walking was RI #1, she turned her car around, got RI #1 into her vehicle, and contacted the DON. EI #5 denied having any knowledge of the door alarm sounding prior to the end of her shift. On 08/16/2022 at 1:49 PM an interview was conducted with EI #5. EI #5 was asked if she saw RI #1 outside the facility on 08/11/2022. EI #5 said yes, she was driving down the road and spotted RI #1 walking on the sidewalk. She stated she stopped and asked the resident if he/she was okay, put him/her in her car, called the DON, and brought RI #1 back to the facility. She stated RI #1 was down the street from the facility at the medical center before the curve. On 08/16/2022 at 2:09 PM, EI #5 showed the surveyors where she found RI #1. Per EI #5, she observed RI #1 walking on the left side of street (indicating the resident would have had to cross the road way). The odometer readings at the time of this observation indicated RI #1 had traveled less than one mile from the facility. Google Maps indicated a distance of 0.3 miles from the facility to where RI #1 was found by EI #5. The website Weather.com documented a high temperature of 90 degrees Fahrenheit (F) and a low temperature of 71 degrees F in the Tuskegee area on 08/11/2022. On 08/17/2022 at 1:56 PM an interview was conducted with EI #2. EI #2 was asked how she became aware of RI #1 being outside of the building without staff knowledge. EI #2 said she got a call from EI #5 on 08/11/2022 at 5:53 PM. EI #2 said it was determined RI #1 went out the Rehab exit door, walked to the right and ended up on the left side of the street across from the medical center down the road. EI #2 further stated, the Rehab door alarm sounded and EI #4 acknowledged answering the alarm, but she did not go outside the door. EI #2 said EI #3 also heard the alarm, but did not report it. EI #2 was asked what process should have occurred when the alarm sounded on the door. EI #2 said when the alarm sounded, the staff should have approached the door, went outside to look for residents and then reported it to the nurse. The nurse should have immediately checked rooms for all residents, and called a code yellow to get all staff to one station for direction. EI #2 was asked if the facility's elopement protocol was followed. EI #2 said no, this process did not happen. An interview was conducted with EI # 6, Registered Nurse (RN)/MDS Coordinator, on 08/18/2022 at 12:08 PM. EI #6 stated she completed the elopement assessment for RI #1 on 08/11/2022 after he eloped from the facility. EI #6 was asked why RI #1's elopement was not included in the elopement assessment she completed on 08/11/2022. EI #6 stated, she misunderstood that the elopement episode for that day needed to be included. EI #6 was also asked about accuracy of medication coding. EI #6 stated she only included psychoactive medications, not all medications. Upon reviewing the Elopement Assessment form, EI #6 acknowledged her answers were not all accurate. An interview was conducted with EI #1, Administrator on 08/19/2022 at 10:31 PM. EI #1 admitted that the facility's Elopements and Wandering Resident policy was not followed on 08/11/2022 when the door alarm sounded and RI #1 eloped from the facility. EI #1 also admitted RI #1's elopement assessment completed on 08/11/2022 was inaccurate. EI #1 said the concern with an inaccurate elopement assessment is that an incorrect score could cause an inappropriate care plan to be put in place. This deficiency was cited as a result of the investigation of complaint/report number AL 998. ************************* On 08/19/2022 at 10:20 PM, the facility submitted an acceptable Removal Plan for F689 which documented: 1. The facility will ensure that the staff implement the elopement policy when a door alarm sound by completing routine education and elopement drills with facility staff. Elopement drills were completed on 08/17/2022, 5:45 pm and 08/18/2022 5:25 am and 7:45 am. Elopement drills are scheduled for each shift for the next week. Staff will immediately search the area outside the door and conduct an immediate head count of every resident in the facility. 2. On 08/11/2022 The Licensed Practical Nurse and Certified Nursing Assistant who failed to implement the elopement policy when the door alarm sounded received one on one education on 08/11/2022 and disciplinary actions on 08/15/2022. All Licensed and Non-licensed staff have been provided education on the Elopement Policy started 08/11/2022 - 08/19/2022. The education was provided by DON and Administrator. Attachments containing the elopement policy used for the education. Education was provided verbally in small groups and via phone. 3. The Director of Nursing will provide education to the Social Services Director and the Registered Nurse that completed the elopement assessment on 08/11/2022 for RI#1. Education is provided prior to the completion of elopement risk assessment of all residents on 08/19/2022. The Director of Nursing will visually monitor 100% of all elopement assessment completed on 08/19/2022 for accuracy and thereafter x 4 weeks. 4. The facility will ensure that all residents are accurately assessed for elopement risk, so that those identified as at risk can have interventions implemented completed by 08/19/2022. Assessments completed by Social Services Director and MDS Coordinator. Three residents had changes to elopement risk scores that placed them at a greater risk level than previously identified. 5. RI #1 was assessed head to toe on 08/11/2022 by RN. RI #1 had no noted injuries. Upon return to the facility, RI #1's wander bracelet was intact to his/her ankle. Proper function was verified upon reentry through the facility. RI #1 denied pain or discomfort. The occurrence was reported to the physician and RI #1's sponsor on 08/11/2022. RI #1 was immediately placed on every 15-minute checks after his assessment. RI #1 was given a snack after his assessment that included a beverage and food. QA for this occurrence started on 08/11/2022 via phone with the Administrator, DON, Corporate Nurse and Director of Operations. On the morning of 08/12/22, at the request of Administration, the resident's responsible relative provided 1:1 monitoring for the resident, pending his/her transfer to a facility with a secure unit. On 08/12/2022, RI #1 was transferred to another facility. ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F689 was lowered to a D level on 08/19/2022, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.