Every finding on record at McAllen Nursing Center

Based on interviews and record review, the facility failed to ensure that one of five residents (Resident #1) reviewed for transfer or discharge were allowed to return to the facility after their hospitalization. The facility discharged Resident #1 on 06/19/26 to a local behavioral hospital, received notice that he was ready to return to the facility on [DATE] but denied his re-entry. This failure could put residents at risk for psychosocial harm by keeping them from their home and belongings.The findings included:Record review of Resident #1's face sheet dated 08/04/26 revealed a [AGE] year-old male with an original admission date of 08/18/25, a current admission date of 04/03/26, and a discharge date of 06/19/26. Resident #1's pertinent diagnoses included unspecified sequelae of cerebral infarction (long-term aftereffects or residual complications remaining after an ischemic stroke) and mood disorder (mental health condition that long-term affects your everyday emotional state). Record review of Resident #1's Change of Condition MDS dated [DATE] revealed a BIMS score of 6 which indicated severe cognitive impairment. Record review of Resident #1's Comprehensive Care Plan dated 08/04/26 revealed the focuses Behavioral Problem:[Resident #1] has a behavior problem as evidenced by:Hitting staff membersHitting other patients6/18/26-striked another patient in left shoulderKicking other patient's wheelchairRams wheelchair into staffKicks at door when wanting to go out; when educated he can not go out unsupervised he attempts to hit staffSelf transfers self when therapy has not cleared him to do so initiated on 10/31/25 and revised on 06/18/26.An intervention listed for these focuses included 6/18/26 - 1:1 supervision immediately placed. Sent out to [behavioral hospital] for behaviors for possible section initiated on 06/18/26 and revised on 06/29/26. Record review of the discharge summary of Resident #1 from the behavioral hospital dated 06/24/26 at 9:21 AM revealed Resident #1 was ready for discharge and signed by a medical doctor. Record review of an email sent by the SWPS from the behavioral hospital to the ADM dated 06/25/26 at 10:54 AM revealed I am writing regarding a mutual patient [Resident #1] who is a long-term resident of your facility and is currently admitted to our hospital. Our team has made multiple attempts to coordinate the patient's return; however, we have been unable to connect with the appropriate facility representative to finalize discharge arrangements.At this time, [Resident #1] is medically stable and ready for discharge. As the patient's long-term care facility, we are requesting your assistance in facilitating a timely return and identifying the appropriate contact person who can coordinate acceptance and transportation arrangements . Record review of the letter sent by the ADM to the SWPS at the behavioral hospital dated 06/25/26 at 5:03 PM revealed After careful review, we regret to inform you that we are unable to accept this patient for admission at this time, as we are not able to safely meet the patient's current care needs within our facility.This case has undergone a comprehensive review by our interdisciplinary clinical team, including our Clinical Psychiatrist and Medical Director. Based on their assessments, the team agrees that there have not been sufficient changes in the patient's clinical condition or care needs to support a safe readmission to our skilled nursing facility community.At this time, however, we must respectfully decline admission until the patient's needs can be safely and appropriately met within our level of care.Thank you for your understanding. Please feel free to contact me if you have any questions or if additional clinical information becomes available for future review. During an interview with the ADM at 4:07 PM on 08/04/26, the ADM stated Resident #1 was sent out to a behavioral hospital on [DATE] due to his aggressive behaviors with staff and residents. The ADM stated Resident #1 had not been discharged from the facility because they anticipated his return. The ADM stated they would be happy to take him back if the behavioral hospital provided the necessary updated information on any interventions they put in place to prevent Resident #1 from continuing to harm others. The ADM stated they would have to put Resident #1 on a 1:1 indefinitely once he got back and they did not have the resources to do that. The ADM stated the facility was unable to clinically meet his needs at that time. The ADM stated she had not contacted the behavioral hospital since she sent the letter to them on 06/25/26 stating the facility could not accept him back at that time. The ADM stated not allowing residents back into the facility after a hospitalization may lead to psychosocial harm. During an interview with the SW at 9:04 AM on 08/05/26, the SW stated Resident #1 had a history of aggressive behaviors at the facility. The SW stated residents had a right to return to the facility after they were hospitalized . The SW stated not allowing a resident to return to the facility could make them feel discriminated against. The SW stated they had reached out to several other nursing facilities about accepting Resident #1 but were unable to find another facility that would take him. During an interview with the BSW at the behavioral hospital at 11:30 AM on 08/05/26, the BSW stated Resident #1 had been at their facility since 06/19/26. The BSW stated Resident #1 felt stuck at their facility because he saw other residents come and go while he had been there for 47 days at this point. The BSW stated the physician cleared him for discharge on [DATE]. The BSW stated she spoke with the ADM on 06/24/26 when the ADM told her they were going to take him back but they still had some concerns about him clinically. The BSW stated she tried to contact the ADM on the 25th, but there was no answer so she informed her boss so she could help get Resident #1 discharged back to the facility. The BSW stated after they received the letter from the facility on 06/25/26 they contacted the local ombudsman for assistance. The BSW stated any time she had tried to communicate with the facility but her phone calls were not returned. During a re-interview with the ADM on 08/05/26 at 2:50 PM, the ADM stated Resident #1 did not receive his PASRR evaluation at the behavioral hospital until 06/26/26. The ADM stated even if they had wanted to accept him back into the facility before 06/26/26 they would not have been able to until his PASRR evaluation was completed at the behavioral hospital. The ADM stated she was not aware of Resident #1's PASRR status when they originally told the behavioral hospital they could not accept him. During an interview with the PASRR Supervisor at a local mental health authority on 08/05/26 at 3:05 PM, the PASRR Supervisor stated every resident that attended a behavioral hospital needed a PASRR evaluation if their primary diagnosis was not dementia. The PASRR Supervisor stated the evaluation for Resident #1 started on 06/26/26 and was not completed until a few days later. The PASRR Supervisor stated Resident #1 met medical necessity (determination of an individual's need for its services is supported by clear, documented evidence that those services are required to meet the person's medical, psychiatric, or functional needs) over a month ago. The PASRR Supervisor stated once Resident #1 met medical necessity he was free to be discharged back to the nursing facility. Record review of the facility policy Transfer or Discharge, Facility-Initiated last updated May 2026 revealed the following: Notice of Transfer or Discharge (Emergent or Therapeutic Leave)22. When residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, NOT discharges, because the resident's return is generally expected.23. Residents who are sent emergently to an acute care setting, such as a hospital, are permitted to return to the facility. Residents who are sent to the acute care setting for routine treatment/planned procedures are also allowed to return to the facility.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. On 06/22/26, the facility failed to ensure bread and fresh vegetables were properly labeled and dated. This failure placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings include: Observation of the dry pantry room on 06/22/26 at 8:26 AM revealed an open bag of bread was not labeled or dated when opened. Observation of the dry pantry room on 06/22/26 at 8:26 AM revealed approximately 5 trays of unopened loaves of breath not labeled or dated when received. Observation of the refrigerator on 06/22/26 at 8:29 AM revealed an open box of fresh vegetables not labeled or dated when received. In an interview on 06/22/26 at 8:34 AM, the [NAME] stated he did not know why the food items had not been labeled. He stated it was important to label food with dates because it could prevent residents from being severed with old food, which could cause them to get sick. In an interview on 06/24/26 at 10:26 AM, the DON stated that the SOM would make rounds of the kitchen whenever there were food deliveries. The DON stated that anytime new merchandise arrived, the kitchen staff knew it had to be labeled and dated. He stated that he didn't know why the food items got missed, but they should have been labeled and dated. In an interview on 06/24/26 at 1:05 PM, the SOM stated that all staff were responsible for ensuring items were stored, labeled, and dated. The SOM stated that when there was a food delivery, whoever was on shift, was responsible for labeling the food. The SOM stated that every item open should have an open date in the refrigerator, freezer, and dry storage. The SOM stated that if food items were not properly labeled and dated, staff may be unaware of when the items were opened, increasing the risk of food spoilage and potential illness for residents. The SOM stated dates should have been legible to read to make it easy for staff to discard when needed. The SOM stated that if food items were not properly labeled, it would have increased the risk of food getting spoiled, or it would cause potential illness for the residents. In an interview on 06/24/26 at 7:25 PM, the Administrator stated that she did weekly rounds in the kitchen. She stated she had not seen any issues with labeling. The administrator stated it was important to label and date food because it was a way to monitor the quality of food and ensure the food was appropriate for consumption. Record review of the Dry Food and Supplies Storage Policy with a review date of 07/22/22 revealed the following: 9. All opened products must be resealed effectively and properly labeled, dated and rotated for use. Record review of the Frozen and Refrigerated Foods Storage with a review date of 07/22/22 revealed the following: 9. Items stored in the refrigerator must be dated upon receipt. 11. All refrigerated and frozen items in storage will contain a minimum label of common name of product and dated as noted above.

Based on observation, interview, and record review, the facility failed to ensure each resident had a right to a dignified existence and to treat each resident with respect and dignity for 1 of 16 residents (Resident #19) reviewed for resident rights. The facility failed to ensure Resident #19's foley catheter bag (a drainage bag that collects urine) had a privacy cover on it to provide respect and dignity. This failure could lead to residents at risk of experiencing feelings of shame and/or embarrassment as well as having their right to privacy violated. Findings include: Record review of Resident #19's face sheet dated 06/23/26 revealed a [AGE] year-old female originally admitted to the facility on [DATE] and then a re-admission date of 06/17/26. Her diagnoses included but not limited to, acute panmyelosis with myelofibrosis (a very rare and aggressive type of leukemia), malignant melanoma of skin (the most serious type of skin cancer), neutropenia (having low levels of white blood cells), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), generalized anxiety (a group of mental illnesses that cause constant fear and worry), and schizophrenia (mental health condition that affects how people think, feel and behave). Record review of Resident #19's care plan dated 04/17/26 revealed the foley catheter (a device that drains urine from your urinary bladder into a collection bag outside of your body) was not added as part of the care plan. Record review of Resident #19's Order Summary of active orders dated 06/22/26 revealed an order with a date of 06/17/26: Flush foley catheter (sending a liquid gently through the tube to clear out any blockages) with 60ml of sterile water or normal saline as needed for non-patency (blockage). During an observation on 06/22/26 at 10:21 AM, Resident #19 was lying in her bed. Resident #19's foley catheter bag was hung from the side of the bed with no privacy cover over it. The foley catheter bag had urine in it that was visible to anyone in the room. In an interview on 06/22/26 at 10:21 AM, Resident #19 stated the foley catheter had been placed during a recent hospital stay. She stated she returned to the facility with the foley catheter in place. Resident #19 stated she could not remember the exact date the foley had been placed, but it was a few days ago. She stated she did not realize there was not a cover on the foley bag because since her return to the facility, she had been just in bed due to her health restrictions. Resident #19 stated she could not see the foley drainage bag from the position she was in. She stated she didn't know it had to be covered but knowing that the bag had urine, she did not want other people to see it. In an interview on 06/22/2026 at 10:27 AM, LVN A stated Resident #19 had returned from the hospital a week ago. LVN A stated Resident #19 already had the foley in place when she returned. LVN A stated the foley catheter bag had to be covered for dignity purposes and so Resident #19 would not feel embarrassed. LVN A stated that the foley catheter bag should also be covered for infection control. In an interview on 06/24/26 at 10:26 AM, the DON stated Resident #19 had returned from the hospital with a foley. The DON stated that a foley catheter bag cover should have been placed right away upon her return. He stated ultimately the admitting nurse should have placed the privacy bag, but all nurses were responsible too. It was important to have the privacy cover on the foley catheter bag because it maintained Resident #19's dignity. In an interview on 06/24/26 at 7:25 PM, the Administrator stated that as soon as the nurse realized Resident #19 did not have a cover on the foley catheter bag, one was placed and everyone received an in-service (teaching) on placing privacy bags over foley catheter bags. Record review of the facility's Resident Rights policy reviewed on 02/20/21, revealed, Resident Rights. The resident has the right to a dignified existence. 4. Respect and dignity. The resident has a right to be treated with respect and dignity.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #19) of 13 residents reviewed for comprehensive care plans. The facility failed to include Resident #19's use of a foley catheter (a device that drains urine from your urinary bladder into a collection bag outside of your body) in her care plan. These failures could place residents at risk of not receiving adequate care for a foley catheter device which could potentially lead to infection and deterioration of health. The findings were: Record review of Resident #19's face sheet dated 06/23/26 revealed a [AGE] year-old female originally admitted to the facility on [DATE] and then a re-admission date of 06/17/26. Her diagnoses included but not limited to, acute panmyelosis with myelofibrosis (a very rare and aggressive type of leukemia), malignant melanoma of skin (the most serious type of skin cancer), neutropenia (having low levels of white blood cells), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), generalized anxiety (a group of mental illnesses that cause constant fear and worry), and schizophrenia (mental health condition that affects how people think, feel and behave). Record review of Resident #19's care plan dated 04/17/26 revealed no mention of the foley catheter. Record review of Resident #19's Order Summary of active orders dated 06/22/26 revealed an order with a date of 06/17/26: Flush foley catheter (sending a liquid gently through the tube to clear out any blockages) with 60ml of sterile water or normal saline as needed for non-patency (blockage). During an observation on 06/22/26 at 10:21 AM, Resident #19 was lying in her bed. Resident #19's foley catheter bag was hung from the side of the bed. In an interview on 06/22/26 at 10:21 AM, Resident #19 stated the foley catheter had been placed during a recent hospital stay. She stated she returned to the facility with the foley catheter in place. Resident #19 stated she could not remember the exact date the foley had been placed, but it was a few days ago. In an interview on 06/22/2026 at 10:27 AM, LVN A stated she was the nurse caring for Resident #19. She stated Resident #19 had returned from the hospital a week ago with the foley catheter in place. LVN A stated she had not looked at Resident #19's care plan to verify if the foley catheter had been added. She stated that the MDS coordinator was in charge of updating all care plans. LVN A stated the MDS coordinator usually informed her of changes with residents but had not updated her on Resident #19's foley catheter care plan updates. In an interview on 06/24/26 at 9:44 AM, the MDS coordinator stated she was in charge of updating care plans. She stated that when a resident had a change, she would update the care plan that same day or the following day, at the latest. The MDS coordinator stated she was aware Resident #19 was returning to the facility with a foley catheter due to having reviewed the hospital paperwork. The MDS coordinator stated that she immediately updated the MDS form and the care plan. She stated that since the facility was going through company changes and computer system changes, the addition of the foley catheter in the care plan must not have been updated. The MDS coordinator stated that if there was a change on any resident, she notified the nurses in the daily morning meeting. The MDS coordinator stated it was important to update the care plans because if changes were not updated, the proper care would not be rendered. In an interview on 06/24/26 at 10:26 AM, the DON stated Resident #19 had returned from the hospital with a foley about a week ago. He stated that the MDS coordinator was responsible for updating the changes in Resident #19's care plan. The DON stated the computer system was having issues with the transition of the new company, and that might have caused the care plan not to be updated. Record review of the facility's policy titled Care Plans and CAAs (Care Area Assessments) with a revision date of 05/06/2016 revealed: Purpose The purpose of this guide is to ensure that an interdisciplinary (IDT) approach is utilized in addressing the Care Area Triggers that were generated by the completion of the MDS in order to effectively address the CAA and ultimately achieve the completion of an effective comprehensive plan of care for each resident. Procedure .Manager or designee will be responsible for: 3. Urinary Incontinence / Foley Catheter Care Plan Updates The IDT will review the care plan. as needed to ensure all goals and approaches are appropriate. Acute Care Plans As acute problems or changes to interventions or goals are identified, an appropriate care plan will be developed or modified.

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 16 residents' rooms (Resident #17's room) reviewed for food safety.The facility failed to place a thermometer in the refrigerator located in Resident #17's room; therefore, the staff did not monitor the internal temperature and expiration/used by dates of food items.These failures could place residents at risk of foodborne illnesses.Findings include: Record review of Resident #17's face sheet dated 06/24/26 revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Alzheimer's' disease (a brain disorder that slowly destroys a person's memory and thinking skills), Type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), protein-calorie malnutrition (a condition resulting from inadequate intake of protein and calories, often due to decreased oral intake), diverticulosis of intestine (small, bulging pouches (diverticula) form in the walls of the large intestine), age related physical debility, and need for assistance with personal care. During an observation on 06/22/26 at 11:22 AM, Resident #17's room was noted to have a personal refrigerator. The refrigerator contained perishable food items such as bottled water and canned drinks. The refrigerator did not contain a thermometer inside. There was not a log present indicating the refrigerator's daily temperatures. During an interview on 06/22/26 at 11:23 AM, Resident #17 stated no one had ever placed a thermometer in the refrigerator. He stated that no one would review the items in the refrigerator either. Resident #17 stated he assumed that since the refrigerator was his personal item, the facility staff did not have to maintain it. He stated that in the time he had the refrigerator, no staff member had checked the temperature of the refrigerator or cleaned it.During an interview on 06/22/26 at 3:57 PM, the MM stated he was not in charge of checking the refrigerator temperature. He stated that housekeeping oversaw that task.During an interview on 06/22/26 at 4:02 PM, the SOM stated that the refrigerator temperatures were checked by the CNAs. The SOM stated that resident refrigerators should have a paper on the side of the refrigerator where the temperatures were logged. She stated that if there was no paper on the refrigerator, then nursing should be questioned because it was a duty for the CNAs.During an interview on 06/22/26 at 4:27 PM, LVN B stated she was the nurse for Resident #17. LVN B stated she was unaware that personal refrigerators had to be checked. She stated she would have to speak to a CNA to confirm that. LVN B stated that it was important to check the temperature of the refrigerators because food could be spoiled and could have caused the residents to get sick.During an interview on 06/22/26 at 4:30 PM, CNA C stated he had not checked Resident #17's fridge. He stated that if it was a personal fridge, the resident's family would oversee its upkeep. CNA C stated it was important to check the fridge daily because if the refrigerator did not work properly, the food could go bad, and the resident could get sick.During an interview on 06/22/26 at 4:33 PM, the Administrator stated that because of the facility's transition into a different company, she was waiting on the new forms to log in Resident #17's refrigerator temperatures. The administrator stated she could not confirm that staff were not checking the refrigerator's temperatures. The Administrator stated she did not have the old forms with Resident #17's refrigerator temperature logs. The Administrator stated it was important to do temperature checks on Resident #17's refrigerator because it was a way to monitor the quality of the food and ensure the food was appropriate for consumption. Record review of the facility's Resident Refrigerators policy revised 08/28/23 revealed: 1. Dormitory-sized refrigerators are allowed in a resident's room under the following conditions:The refrigerator is inspected by maintenance personnel and deemed safe prior to use.The refrigerator maintains proper temperatures.2. Staff shall record refrigerator temperatures weekly on a temperature log attached to the refrigerator. a. A thermometer shall remain in the refrigerator.3. Staff shall inspect the refrigerator weekly.

Based on observation, interview and record review, the facility failed to respect the residents' right to personal privacy and confidentiality, for 3 of 11 residents (Resident #1, Resident #4, and Resident #7) reviewed for personal privacy and confidentiality. The facility failed to provide personal privacy and confidentiality for Resident #1, Resident #4, and Resident #7 when the residents and their private space were recorded without the resident's or designated representative's consent; and the video was posted on social media on 05/10/26. This failure could place residents at risk of their right to privacy and confidentiality not being honored or respected. Findings included:1. Record review of Resident #1's face sheet, dated 05/13/26, reflected a [AGE] year-old female, admitted on [DATE], diagnoses included: Alzheimer's disease (progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia), mood disorder due to physiological condition (mental health disorder where depressive or manic symptoms arise directly from a medical or neurological condition affecting brain function), and cognitive communication deficit (communication is impaired due to underlying cognitive dysfunction rather than a primary language or speech problem). Record review of Resident #1's MDS assessment, dated 04/29/26, reflected a BIMS score of 6, indicating severe cognitive impairment. Record review of Resident #1's care plan, dated 05/13/26, reflected [Resident #1] had impaired cognition and was at risk for a further decline in cognitive and functional abilities related to diagnosis of Alzheimer's. Date initiated: 11/19/25. [Resident #1] had a potential psychosocial well-being problem related to improper social media exposure. Date initiated: 05/12/26. Interventions included: allow resident time to answer questions, verbalize feelings, perceptions, and fears; and monitor/document resident's feelings relative to situation such as isolation, unhappiness, or anger. 2. Record review of Resident #4's face sheet, dated 05/13/26, reflected a [AGE] year-old female, admitted on [DATE], diagnoses included: Parkinson's disease (progressive neurological disorder that primarily affects movement), chronic kidney disease (condition that affects the kidneys' ability to filter waste from the blood), muscle wasting and atrophy (reduction in muscle mass and strength), mood disorder due to physiological condition (mental health disorder where depressive or manic symptoms arise directly from a medical or neurological condition affecting brain function), cognitive communication deficit (communication is impaired due to underlying cognitive dysfunction rather than a primary language or speech problem) and unspecified psychosis (presence of symptoms, like hallucinations or delusions). Record review of Resident #4's MDS assessment, dated 04/16/26, reflected a BIMS score of 6, indicating severe cognitive impairment. Record review of Resident #4's care plan, dated 05/13/26, reflected [Resident #4] had impaired cognition and was at risk for a further decline in cognitive and functional abilities related to history of psychosis and mood disturbances. Date initiated: 03/15/24. [Resident #4] had a potential psychosocial well-being problem related to improper social media exposure. Date initiated: 05/12/26. Interventions included: allow resident time to answer questions, verbalize feelings, perceptions, and fears; and monitor/document resident's feelings relative to situation such as isolation, unhappiness, or anger. 3. Record review of Resident #7's face sheet, dated 05/13/26, reflected an [AGE] year-old female, admitted on [DATE], diagnoses included: Alzheimer's disease (progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia), chronic kidney disease (condition that affects the kidneys' ability to filter waste from the blood), muscle wasting and atrophy (reduction in muscle mass and strength), mood disorder due to physiological condition (mental health disorder where depressive or manic symptoms arise directly from a medical or neurological condition affecting brain function), cognitive communication deficit (communication is impaired due to underlying cognitive dysfunction rather than a primary language or speech problem), and major depressive disorder (mental health condition with persistent feelings of sadness, loss of interest, various emotional/physical problems). Record review of Resident #7's MDS, dated [DATE], reflected a BIMS score of 00, indicating severe cognitive impairment. Record review of Resident #7's care plan, dated 05/13/26, reflected [Resident #7] had impaired cognition and was at risk for a further decline in cognitive and functional abilities related to diagnosis of Alzheimer's. Date initiated: 02/27/24. [Resident #7] had a potential psychosocial well-being problem related to improper social media exposure. Date initiated: 05/12/26. Interventions included: allow resident time to answer questions, verbalize feelings, perceptions, and fears; and monitor/document resident's feelings relative to situation such as isolation, unhappiness, or anger. Observation of video recording on social media on surveyor's phone from a link on TULIP (undated), on 05/13/26 at 8:40 AM, revealed a visitor at the facility. At 0:32, showed Resident #1 received a rose and got a hug from the visitor while in Resident #1's room. At 0:43, showed Resident #4 received a rose and got a hug from the visitor while in the hallway. At 0:47, showed Resident #7 received a rose from the visitor while in the hallway. During an interview and observation, on 05/13/26 at 10:45 AM, Resident #1 stated a lady gave her a rose but she did not know who it was. Resident #1 stated she did not remember if the lady asked her to take a photo or video and she did not know if the lady took a photo or video of her. Resident #1 was not injured or in distress. During an interview and observation, on 05/13/26 at 11:30 AM, Resident #4 stated she did not remember if she got a rose or if anyone visited her. Resident #4 stated she did not remember if anyone asked to take a photo or video of her. Resident #4 was not able to provide information regarding alleged incident. Resident #4 was not injured or in distress. During an interview and observation, on 05/13/26 at 11:45 AM, Resident #7 was asked basic questions and she did not respond. Resident #7 was not interviewable. Resident #7 was not injured or in distress. During an interview, on 05/13/26 at 12:10 PM, RP A stated Resident #4 should not have been posted on social media by a random person as Resident #4 would not have appreciated her photos or videos to be taken or posted without her permission. RP A stated Resident #4 was reserved and although she might have agreed to take a photo or video at the time, Resident #4 was not cognizant or aware of what that meant. RP A stated Resident #4 would not have wanted her medical condition to be on social media for anyone to see. During an interview, on 05/13/26 at 12:30 PM, the SW stated Resident #1 and Resident #4 were able to recall past events sometimes, but not always. The SW stated Resident #7 was not able to answer questions or recall past events. During an interview, on 05/13/26 at 12:40 PM, RP B stated Resident #1 should not have been photographed or recorded by a random person. RP B stated Resident #1 might have agreed to a photo at the time, but she would have forgotten moments later. RP B stated Resident #1 did not mind photos but she never liked videos even when she was fully cognizant and she respected Resident #1's wishes. RP B stated Resident #1 was not of sound mind or fully aware of what was being asked or what she agreed to. During an attempted interview, on 05/13/26 at 12:50 PM, RP C did not answer. A voicemail was left requesting a callback. RP C did not respond. During an interview, on 05/13/26 at 1:15 PM, the AD stated a visitor, a civilian, arrived to donate [NAME] to the residents on 05/10/26 for Mother's Day. The AD stated she notified the residents, including Resident #1, Resident #4, and Resident #7, and asked them if they wanted to accept the rose. The AD stated she was not aware that the visitor was video recording. The AD stated she knew the rules and they were not allowed to take videos of the residents. The AD stated the facility was able to take photos of the residents, but the facility had consent from the resident or their RP. The AD stated she was in-serviced on abuse, neglect, HIPAA, privacy, and resident rights before and after this incident. The AD stated she knew the residents' rights included the right to privacy. The AD stated she was the weekend manager and if there was an incident or issue, the staff reported to her, and she would have reported to the ADM, if needed. The AD stated she notified the ADM about the rose donation, but she did not report about a recording because she was not aware of the video. The AD stated if she had known the visitor was recording, she would have taken away the device. The AD stated she knew she had to protect the residents and their privacy. During an interview, on 05/13/26 at 2:00 PM, the DON stated he spoke to the residents' families and Resident #1's RP was upset. The DON stated Resident #1's RP said that Resident #1 was not able consent to a photo or video. The DON stated Resident #4's RP was upset and said she did not want Resident #4 posted in a video with her medical condition and for other people to see her. During an interview, on 05/13/26 at 2:35 PM, the ADM stated she became aware of the video when she was tagged on the video on her social media by a friend on 05/10/26. The ADM stated she immediately questioned the AD and the AD was not aware of the visitor recording the residents. The ADM stated they suspended the AD because the AD was the manager on duty and was responsible for ensuring the residents were well. The ADM stated the residents, or their representatives signed a consent form during the admissions process for the facility to take/post photos, but not for a visitor to take photos/video. The ADM stated the AD was aware of the rules. The ADM stated they in-serviced staff on HIPAA, privacy, rights, abuse, neglect, and exploitation. The ADM stated they posted signs of no video or photos allowed at the entrance and in the common areas. The ADM stated Resident #1, Resident #4, and Resident #7 were not injured, in distress, or negatively impacted, but it was the facility's responsibility to respect and protect the resident's right to privacy. The ADM stated there was no specific policy for HIPAA or for taking photos/videos of residents. During an interview, on 05/13/26 at 4:15 PM, the DON stated there were no negative outcomes for Resident #1, Resident #4, or Resident #7. The DON stated it was important to respect the residents' right to privacy as this was their home and to ensure their well-being. Record review of the facility's Resident Rights policy, dated 02/20/21, reflected - Policy: The facility will inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility.The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.7. Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records.a. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits.

Based on interview and record review, the facility failed to ensure that the comprehensive care plans were periodically reviewed and revised by a team of qualified persons after each assessment, including both the comprehensive and quarterly review assessments for 2 of 3 residents (Resident #1 and Resident #2) reviewed for care plans, in that:1. The facility failed to ensure Resident #1's care plan reflected an unwitnessed fall on 11/27/2025.2. The facility failed to ensure Resident #2's care plan reflected witnessed falls on 11/14/2025, 12/16/2025, and 12/30/2025.This failure could place residents at risk of not being provided the necessary care or services and not having personalized care plans updated to address their specific needs. The Findings included:1. Record review of Resident #1's face sheet dated 2/3/26 reflected Resident #1 was admitted on [DATE] with an original admission date of 7/3/24. Resident # 1 was an [AGE] year old with diagnosis of muscle weakness, reduced mobility, stiffness of unspecified joint, disorder of bone density (measurement of amount of minerals contained within a certain volume of bone) and structure, dementia (severe loss of cognitive functions including memory, language, reasoning, and behavior that was significant enough to interfere with a person's daily life and functional independence) and Alzheimer's disease (progressive, irreversible brain disorder characterized by the gradual destruction of brain cells leading to severe impairment in memory, thinking, language, judgment, and behavior). Record review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS score of 03 which indicated Resident #1's cognition was severely impaired. Resident #1 required substantial/maximal assistance for self-care of toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear. Resident #1 required supervision or touching assistance for self-care of eating and oral hygiene and required setup or clean-up assistance for personal hygiene. Record review of Resident #1's comprehensive care plan reflected Resident #1 had the potential for falls related to Alzheimer's Disease. Date Initiated: 07/04/2024 Revision on: 12/16/2025. Interventions: Floor mat to side of the bed. Date Initiated: 12/16/2025 May be up to high back wheelchair with bilateral leg rests and anti-tippers as tolerated.Date Initiated: 12/16/2025 Anticipate and meet the resident's needs. Place items frequently used by the resident within easy reach when in the room. Date Initiated: 01/14/2026 Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Date Initiated: 07/04/2024 Fall Risk Screening upon admission and quarterly to identify risk factors. Date Initiated: 07/04/2024 Floor Mat Date Initiated: 01/14/2026 Low bed Date Initiated: 01/14/2026 Place the resident's call light was within reach and encourage the resident to use it for assistance as needed. Date Initiated: 07/04/2024Record review of the facility's incident/accident report from dates 11/2/2025 to 1/22/2026 revealed Resident #1 had an unwitnessed fall on 11/27/25 that was not reflected on Resident #1's care plan. 2. Record review of Resident #2's face sheet dated 2/3/26 indicated Resident #2 was admitted on [DATE]. Resident #2 was an [AGE] year old with diagnoses of hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness or reduced motor function on one side of the body) following cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting the right dominant side, contracture (permanent tightening and shortening of muscles, tendons, skin, or other tissues that restricts normal movement of a body part), muscle weakness, lack of coordination, dementia (severe loss of cognitive functions including memory, language, reasoning, and behavior that was significant enough to interfere with a person's daily life and functional independence), and mood disorder. Record review of Resident #2's Quarterly MDS dated [DATE] reflected a BIMS score of 14 which indicated Resident #2's cognition was intact. Resident #2 required substantial/maximal assistance for self-care of lower body dressing and putting on/taking off footwear. Resident #2 required partial/moderate assistance for toileting hygiene, shower/bathe self, and upper body dressing and required setup or clean-up assistance with eating and oral hygiene. Record review of Resident #2's comprehensive care plan reflected Resident #2 had the potential for falls related to CVA, dementia, and R sided weakness in UE/[NAME] Date Initiated: 08/12/2025 Revision on: 08/25/2025. Interventions: Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs.Date Initiated: 08/12/2025 Encourage socialization and activity attendance as tolerated. Date Initiated: 08/12/2025 Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Date Initiated: 08/12/2025 Fall Risk Screening upon admission and quarterly to identify risk factors. Date Initiated: 08/12/2025 Place the resident's call light was within reach and encourage the resident to use it forassistance as needed. Date Initiated: 08/12/2025Record review of the facility's incident/accident report from dates 11/2/2025 to 1/22/2026 revealed Resident #2 had witnessed falls on 11/14/2025, 12/16/2025, and 12/30/2025 that were not reflected on Resident #2's care plan. During an interview on 2/3/26 at 4:55 p.m., the MDS/RN said per the corporate consultant they no longer update care plans with dated interventions. The MDS/RN said staff used the information located on the incident reports, progress notes, post-fall evaluations, and neuro check forms to provide information on interventions done and any updates to interventions. The MDS/RN said after hearing the Fall Management System Policy, she feels the work was done but the facility just did not complete the dates in the care plan. The MDS/RN said she did care plan reviews quarterly, annually and when there was a significant change in condition. The MDS/RN said dated interventions were not added after each fall, especially if there was no injury or significant change in condition. The MDS/RN said she did not feel that not having the fall dates reflected in the residents' care plan would cause any adverse outcomes because staff had access to the care plans, but they choose to use the information they receive from the 24-hour report and previous progress notes.During an interview on 2/3/26 at 5:05 p.m., the DON said staff learn of changes to interventions during in-services provided after a fall or with the incident report. The DON said care plans were updated when an incident occurs or as needed by any IDT staff. He said after a resident had a fall, the MDS, ADON, or DON would usually updated the care plans. He said if new interventions were implemented, they would update the care plan. He said if care plans were reviewed and no updates were needed, the care plan was updated to reflect that. He said falls without injuries would be updated in the care plans if they needed interventions. The DON said after hearing the Fall Management System Policy, it meant each fall must be documented, reviewed, and interventions updated in the care plan. The DON said they should place a fall date on the care plan, it was in the policy that staff were supposed to. The DON said he did not recall the regional consultant ever mention the fall dates were not supposed to be documented on the care plans. Record review of facility's Fall Management System policy with revised date of 02/19/2021 reflected: Policy:It is the policy of this facility that each resident will be assessed to determine his/her risk for falls, and a plan of care implemented based on the resident's assessed needs.Procedure: .A. Identifying residents at risk for falls.3. A care plan is implemented for residents at risk for falls.5. Preventive interventions are reviewed, evaluated and implemented to reduce the reoccurrence of falls. D. Documentation requirements for residents sustaining a fall.4. Documentation in the nurse's notes and/or care plan will reflect interventions attempted.8. An Administrative nurse will ensure that the resident's plan of care is revised to reflect each fall and interventions that were implemented.

Based on observation, interviews and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 (Resident #1) of 3 residents reviewed for accuracy of records, in that:LVN A failed to document the administration of clonazepam and insulin on 10/11/25 and 10/17/25.LVN B failed to document the administration of clonazepam and insulin on 10/27/25 and 10/28/25. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care.The findings included:Record review of Resident #1's face sheet dated 11/21/25 reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: Parkinson's disease (movement disorder of the nervous system), type 2 diabetes (high levels of sugar in blood), unspecified intellectual disabilities, autistic disorder (developmental condition that affects communication, social interaction, and behavior), anxiety disorder, and depression. Record review of Resident #1's order summary dated 11/21/25 reflected Resident #1 had orders for clonazepam oral tablet 2 mg, give 1 tablet by mouth three times a day for anxiety with start date of 07/31/25, and insulin pen 100 unit/ml solution pen injector, inject as per sliding scale, subcutaneously before meals and at bedtime related to type 2 diabetes with start date of 08/04/25.Record review of Resident #1's MAR dated October 2025 reflected clonazepam oral tablet 2 mg was not checked off as administered on 10/11/25 at 800 and 1200, on 10/17/25 at 1200, on 10/27/25 at 1200, and on 10/28/25 at 1200. Insulin pen 100 unit/ml solution pen injector was not checked off as administered on 10/11/25 at 700 and 1100, on 10/17/25 at 700 and 1100, on 10/27/25 at 700 and 1100, and on 10/28/25 at 700 and 1100. Record review of Resident #1's progress notes dated October 2025 reflected no documentation for the missing check offs on 10/11/25, 10/17/25, 10/27/25, or 10/28/25 to indicate the medication was administered, held for any reason, or refused. Record review of the facility's sign in sheets dated 10/11/25, 10/17/25, 10/27/25, and 10/28/25 reflected LVN A worked on 10/11/25 and 10/17/25 from 6 AM-2 PM, and LVN B worked on 10/27/25 and 10/28/25 from 6 AM-2 PM. On 11/21/25 at 10:15 AM, an attempted interview and observation with Resident #1, revealed he was not interviewable. Resident #1 did not answer baseline questions or questions related to the incident. Resident #1 laid in bed with the call light within reach. Resident #1 appeared with good personal hygiene, no injury, and not in distress. The bed was at its lowest position. A fall mat was in place next to the bed.On 11/21/25 at 11:30 AM, in an interview with LVN A, she said she worked on 10/11/25 and 10/17/25 with Resident #1. LVN A said Resident #1 had not been out to the hospital and did not refuse his medications. LVN A said she administered all medications, including the antianxiety medication, and followed orders for the insulin as she checked his blood sugar and administered insulin based on the sliding scale. LVN A said Resident #1 showed no indications that his medications were not administered as ordered such as episodes of hypo/hyperglycemia or significant increase in behaviors. LVN A said she administered all medications as ordered, just did not document or check off the medications on the MAR. LVN A said she did not know why, maybe she forgot to check off the MAR. LVN A said the facility instructed them in the past that it was her responsibility to ensure all the documentation was done. LVN A said it was important for documentation to be accurate to show if the resident was compliant with medications and to show the staff followed the orders. On 11/21/25 at 12:30 PM, in an interview with LVN B, she said she worked on 10/27/25 and 10/28/25 with Resident #1. LVN B said Resident #1 did not refuse his medications when she worked with him and he allowed her to do the blood sugar checks. LVN B said she did not have to notify the doctor of any abnormal findings and there were no other indications that Resident #1 had not been administered his medications as ordered. LVN B said she administered Resident #1's medications on 10/27/25 and 10/28/25, including the antianxiety medication and insulin, but possibly forgot to check off the MAR. LVN B said she was in-serviced on medication administration and documentation a few weeks ago. LVN B said she was told it was her responsibility to ensure documentation was completed before leaving for the day. LVN B said it was important for the MAR to be accurate, to ensure they gave Resident #1's medications appropriately, to not give double medications and to prevent medication errors. On 11/21/25 at 3:00 PM, in an interview with the DON, he said he reviewed the documentation and did not find the MARs to be checked off correctly for Resident #1. The DON said he spoke to the nurses and they all ensured that they administered the medication. The DON said he will be re-educating staff to ensure they check their MARs before leaving at the end of their shift. The DON said documentation was important to show whether the medications were given or not and why not. The DON said the expectation for staff was to ensure all documentation was accurate and completed. The DON said there were no negative outcomes for Resident #1 or indications that his medications were not administered as ordered, just not documented properly. Record review of the facility's Medication Administration policy dated 02/10/20 reflected - Purpose: to safely and accurately prepare and administer medication according to physician orders and patient needs. 9. Administration - document initials on MAR for each medication administered. 10. Patient refusal - circle initials on MAR and document refusal on back side of MAR. Record review of the facility's Clinical Document Guidelines policy dated 02/14/20 reflected - Policy: the patient's clinical record provides a record of the health status, including observations, measurements, history and prognosis and serves as the primary document describing healthcare services provided to the patient.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 (Resident #1 and Resident #2) of 4 residents reviewed for medical records accuracy, in that: The facility failed to provide any documentation in the Progress Notes for Resident #1 and Resident #2 for the resident-to-resident altercation on 07/13/2025. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment. The findings included: 1.Record review of Resident #1's admission record dated 08/16/2025, revealed a [AGE] year-old male with an initial admission date of 08/30/2024 and a re-admission on [DATE]. Resident #1's diagnoses included cerebral infarction (stroke), paranoid personality disorder (a personality disorder characterized by paranoia, and a pervasive, long-standing suspiciousness and generalized mistrust of others), chronic Hepatitis C (a virus that attacks the liver and leads to inflammation that is spread by contact with contaminated blood, for example, from sharing needles or from unsterile tattoo equipment), bipolar disorder (mood swings ranging from depressive lows to manic highs), chronic obstructive pulmonary disease (a lung disease characterized by persistent airflow limitation and chronic inflammation of the airways and lungs), alcohol use disorder, and homelessness. Record review of Resident #1's Annual MDS, dated [DATE], revealed a BIMS score of 13, indicating he was cognitively intact. Resident #1 had moderate difficulty hearing. He could understand others and others could understand him. Resident #1 was always incontinent of bowel and bladder. There were no potential indicators of psychosis. No behavioral symptoms were exhibited. There was no overall presence of behavioral symptoms. Antipsychotics were received on a routine basis. Record review of Resident #1's Care Plan dated 07/07/2025 revealed:FOCUS: Resident put his hands on other male resident and hit nurses left hand away from phone Date Initiated: 07/13/2025 Revision on: 07/13/2025.GOALS: Safety will be provided to self and others during review period Date Initiated: 07/13/2025 Target Date: 08/18/2025.INTERVENTIONS/TASKS: 7/14/25 order attained for section pending to be placed Date Initiated: 07/14/2025 CN Called pd and received a case number Date Initiated: 07/13/2025 Revision on: 07/13/2025 CN Care plan with ombudsman to be held Date Initiated: 07/13/2025 SW MD notified Date Initiated: 07/13/2025 CN Pending section order Date Initiated: 07/13/2025 CN SW Placed on one to one Date Initiated: 07/13/2025 CN social worker to meet with resident for psychosocial needs till section Date Initiated: 07/18/2025 CN. Record review of facility's Incidents by Incident Type dated 07/13/2025 revealed a resident-to-resident between Resident #1 (aggressor) and Resident #2 (victim). Record review of Resident #1's Progress Notes dated 07/13/2025 revealed there were no notes concerning the resident-to-resident altercation between Resident #1 and Resident #2 (victim). Record review of Resident #1's Progress Notes written on 07/14/2025 at 07:40 am written by DON revealed, Notified doctor of incident of yesterday and new orders given to section resident. Record review of Resident #1's Progress Notes dated 07/14/2025 at 03:41 pm written by SW revealed, SOCIAL WORKER FOLLOW UP VISIT: Met with resident with DON present in privacy of room to follow up on altercation situation; resident voiced not feeling good due to behavior of other resident and staff and reported being bullied by other resident. Administrator aware, will continue to follow up as needed. Record review of facility's incident report (#1203623) revealed the report of the resident-to-resident altercation was sent to the State reporting system on 07/14/2025 at 04:24 pm. Record review of Resident #1's Progress Notes dated 07/14/2025 at 04:30 pm written by DON revealed, Resident speaking with administrator acknowledged that he was disrespectful yesterday. he admitted he was drunk and had supper at (restaurant) and had beer. Record review of Resident #1's Progress Notes dated 07/15/2025 at 12:29 pm written by PA revealed, Upon evaluation today, the patient is resting in bed. Nursing team reported the patient got physically aggressive with a patient and physical contact was made. He is also reported coming back to facility intoxicated with alcohol in his hands. Behavioral team was contacted and patient has been accepted, sectioned for transfer to their facility. He is also noted with physical altercation with nursing staff. Report made by police. No acute issues per nursing team. 2. Record review of Resident #2's admission record dated 08/16/2025, revealed a [AGE] year-old male with an admission date of 05/16/2024. Resident #2's diagnoses included bipolar disorder (mood swings ranging from depressive lows to manic highs), peripheral vascular disease (a condition where the blood vessels in the arms, legs, feet or hands become narrowed or blocked), Type 2 Diabetes Mellitus (a chronic metabolic disorder characterized by the body's inability to properly use insulin, a hormone that regulates blood sugar levels), hypertension (high blood pressure), and heart disease (a disease that include diseased vessels, structural problems, and blood clots). Record review of Resident #2's 05/23/2025 Annual MDS dated [DATE] revealed Resident #2 had a BIMS score of 15 indicating he was cognitively intact. He could understand others and others could understand him. Resident #1 was frequently incontinent of bowel and bladder. There were no potential indicators of psychosis. No behavioral symptoms were exhibited. There was no overall presence of behavioral symptoms. An antidepressant was received on a routine basis. Record review of Resident #2's Care plan dated 06/06/2025 revealed the altercation between Resident #1 (aggressor) and Resident #2 (victim) had not been care planned. Record review of Resident #2's Progress Notes dated 07/13/2025 revealed there were no notes concerning the resident-to-resident altercation between Resident #1 (aggressor) and Resident #2 (victim). Record review of Resident #2's Progress Notes dated 07/14/2025 at 06:09 am written by LVN C revealed DAY 1- ALTERCATION (VICTIM), PT UP TO WC AT THIS MOMENT BY NURSES STATION, VOICES HE RESTED WELL. RESPIRATIONS EVEN AND UNLABOREDRED, 0 DISTRESS NOTED. CALL LIGHT AND HYDRATION WITHIN REACH. Record review of Resident #2's Progress Notes dated 07/14/2025 at 08:27 am written by SW revealed, SOCIAL WORKER FOLLOW UP VISIT: Met with resident in privacy of room to follow up on altercation situation; resident voiced feeling good and reported no physical pain or discomfort. Resident proceeded to state that he is not okay with staff being physically at risk by other residents. Administrator and DON aware, will continue to follow up as needed. Record review of facility's incident report (#1203623) revealed the report of the resident-to-resident altercation was sent to the State reporting system on 07/14/2025 at 04:24 pm. During an interview on 08/16/2025 at 04:15 pm, the Administrator stated the Resident-to-Resident incident she reported to State on 07/14/2025 was thoroughly documented in her report. She said her nurses were usually very good at documenting so she could not understand why there was no documentation in the Progress Notes for either resident concerning the resident-to-resident altercation on 07/13/2025. During an interview on 08/17/25 at 04:05 pm, Resident #2 stated the day when the other resident pushed the nurse at the nurse's station (07/1/2025), he had not liked that Resident #1 had done that especially to a nurse. He said he stood up and was between the other resident (Resident #1) and the nurse when Resident #1 pushed him. He said the nurses stopped it. He said he would never start a fight, but if the other resident had hit him, he would have finished it. Resident #2 stated he was not at the facility to fight, but Resident #1 pushed a woman and he had not liked it. During an interview on 08/17/2025 at 04:30 pm, RN A stated if a resident would be aggressive verbally or physically with her, she would step back and try to calm the resident down. She said if the resident would not calm down, she would give the resident more space to try to calm him down. RN A stated she was not afraid of Resident #1, but she was sure some of the other residents were. She said he was difficult to deal with when he would get upset about things like not getting a cigarette whenever he wanted one. RN A stated Resident #2 was easy going and she never had any problems with him. During an interview on 08/17/2025 at 04:50 pm, The SW stated when she was notified of a resident-to-resident altercation, she would notify the administrator, would interview the residents involved once a day for 72 hours, and document the altercation and the interviews in PCC (electronic health record). The SW stated the administrator notified her of the altercation between Resident #1 and Resident #2. She said she followed protocol. During an interview on 08/17/2025 at 05:13 pm, the DON stated LVN B no longer worked at the facility. LVN B was one of the nurses working when the resident-to-resident occurred. In an attempted interview on 08/17/2025 at 05:15 pm, LVN C was not reachable. Her voice mailbox was full. No voicemail left. LVN C was the nurse who was involved with the resident-to-resident altercation. In an attempted interview on 08/17/2025 at 05:21 pm, LVN D was not reachable. A voicemail was left. There was no return call. In an attempted interview on 08/17/2025 at 05:22 pm, LVN E was not reachable. A voicemail was left. There was no return call. During an interview on 08/17/2025 at 05:30 pm, the DON stated for a resident-to-resident altercation, skin, vital signs, what the nurse did, how it happened, residents involved, that the residents were separated, etc., were to be documented on. The DON stated she could guess what happened and why there were no notes in Progress Notes about the resident-to-resident altercation between Resident #1 and Resident #2. She said the nurse's notes had not transferred over from the Incident Report the nurse completed for the resident-to resident altercation. The DON could not produce the incident report written by LVN C. Record review of facility's policy Clinical Document Guideline dated original date 03/14/2022, revised dated 03/25/2014, and reviewed date of 02/14/2020 revealed: PolicyThe patient's clinical record provides a record of the health status, including observations, measurements, history, and prognosis which serves as the primary document describing healthcare services provided to the patient.Fundamental InformationThe clinical record is used by the healthcare team to record, preserve, and to communicate the patient's progress and current treatment.DocumentationClinical record progress notes, physician orders, flow records.

Based on interviews and record reviews, the facility failed to ensure each resident and/ or their representative and the IDT were invited to attend/participate in the care plan meetings including both the comprehensive and quarterly review assessments for the resident for 2 of 6 residents (Resident #1 and Resident 2) reviewed for care plan timing and revision. The facility failed to ensure Resident #1 and Resident #2's care plan was revised to accurately reflect current smoking status. The facility failed to develop a care plan for Resident #2 to address his discharge plan. These failures could place the residents at risk of not receiving appropriate interventions and care to meet their needs as indicated on the comprehensive care plans. The findings included: Record review of Resident #1's face sheet dated 05/20/25 reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: bipolar disorder (mental health condition with mood swings), type 2 diabetes (high levels of sugar in blood), depression, anxiety disorder, heart disease, and peripheral vascular disease (narrowing/blocking of the blood vessels outside of the heart). Record review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 15, indicating intact cognition. MDS assessment did not reflect tobacco use or smoking for Resident #1. Record review of Resident #1's care plan dated 05/20/25 reflected Resident #1 had an ADL self-care performance deficit and was at risk for not having his needs met in a timely manner. Date initiated: 05/17/24. Resident #1's care plan did not reflect that he smoked. Record review of Resident #1's smoking evaluation dated 04/07/25 reflected Resident #1 was independent and required no supervision to smoke. Resident #1 demonstrated safe techniques for smoking. Resident #1 understood that smoking may only take place at designated times and in designated smoking areas. Record review of Resident #2's face sheet dated 05/20/25 reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: nontraumatic subdural hemorrhage (brain bleed), mood disorder, type 2 diabetes (high levels of sugar in blood), and heart disease. Record review of Resident #2's MDS assessment dated [DATE] reflected Resident #2 had a BIMS score of 9, indicating moderately impaired cognition. MDS assessment did not reflect tobacco use or smoking for Resident #2. Record review of Resident #2's care plan dated 05/20/25 reflected Resident #2 had an ADL self-care performance deficit and was at risk for not having his needs met in a timely manner. Date initiated: 01/08/25. Resident #2's care plan did not reflect that he smoked or his discharge plan. Record review of Resident #2's smoking evaluation dated 02/12/25 reflected Resident #2 was independent and required no supervision to smoke. Resident #2 demonstrated safe techniques for smoking. Resident #2 understood that smoking may only take place at designated times and in designated smoking areas. On 05/22/25 at 10:30 AM, in an interview with MDS E, she said she completed the MDS assessment and developed the care plan based on the triggered areas and initial assessments. MDS E said they completed the smoking assessment upon admission, if the resident told them they smoked or if based on their history they smoked. MDS E said if the resident did not voice that they smoked or wanted to smoke, they did not complete the assessment. MDS E said Resident #1 did not smoke when he was first admitted and he started smoking recently in April 2025. MDS E said Resident #2 did not smoke when he was first admitted and they did the smoking assessment for him in February 2025. MDS E said she was unsure of when the care plans were implemented regarding smoking for Resident #1 and Resident #2. MDS E said whoever completed the smoking assessments could have developed the care plan for smoking, however, the team should have followed up to ensure smoking was properly care planned. On 05/22/25 at 12:00 PM, in an interview with the DON, she said Resident #1 just started smoking a month ago, but when he was first admitted , he did not smoke. The DON said Resident #2 was also a smoker but she was unsure of when he started smoking. The DON said for the residents that smoke, they should have the smoking care planned. The DON said Resident #1 and Resident #2 have smoking care planned. The DON said Resident #1 and Resident #2 did not have the smoking care planned until 05/20/25. The DON said discharge plans should have been care planned. The DON said Resident #2 had been admitted since January 2025 and discharge plans were not care planned. The DON said she would conduct an audit on all the care plans regarding discharge plans. The DON said the team would have ensured to implement the smoking care plan and the discharge care plan. The DON said it was important for the care plan to be developed and implemented accurately so staff knew how to care for the residents. The DON said there was no negative outcomes for Resident #1 and Resident #2 as staff were aware that they were smokers. On 05/22/25 at 12:45 PM, in an interview with the ADM, she said the team discussed things for a resident that wanted to smoke, they completed the smoking assessment, ensured they were a safe smoker, and implemented the care plan. The ADM said Resident #1 and Resident #2 did not have care plans for smoking until 05/20/25. The ADM said she was going to have the social worker develop a binder with the smoking policy, guidelines, and information for the residents that smoked. The ADM said discharge planning was care planned. The ADM said Resident #2 was admitted since January 2025 and had a care plan meeting regarding his discharge. The ADM said Resident #2 was going to be at the facility long term. The ADM said she was unsure of why Resident #2 did not have discharge plans on his care plan. The ADM said there were no negative outcomes for Resident #1 and Resident #2 as staff were aware that they were smokers and they completed the smoking evaluations to determine they were safe smokers. Record review of the facility's Comprehensive Care Plans policy dated 02/10/21 reflected - Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 3. The comprehensive care plan will describe at a minimum: a. The services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being. 6. Alternative interventions will be documented, as needed.

Based on observation, interview and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 4 (B-hall and D/E-halls) medication carts reviewed for medication storage. 1. The facility failed to store 17 loose tablets/capsules in their appropriate blister packs in the medication cart for B-hall. 2. The facility failed to store 17 loose tablets/capsules in their appropriate blister packs in the medication cart for D/E-halls. These deficient practices could place residents at risk of losing medications leading to medication shortage. The findings included: An observation of the B-hall medication cart on 04/23/25 at 12:25 PM revealed 17 assorted tablets and capsules loose in the 2nd drawer from the top. The drawer contained blister packs of medications for residents living on the B-hall along with the loose medications. An observation of the D/E-hall medication cart on 04/23/25 at 12:35 PM revealed 17 assorted tablets and capsules loose in the 2nd drawer from the top. The drawer contained blister packs of medications for residents living on the D/E-hall along with the loose medications. In an interview with LVN A at 1:34 PM on 04/23/25, LVN A stated she was the current charge nurse for B hall and E hall. LVN A stated she had never seen loose medications in any of the medication carts. LVN A stated she would dispose of any loose medications properly if she saw any inside the carts. LVN A stated the proper way to dispose of medications was to crush it and put it in the biohazard box on the medication cart or a sharps container. LVN A stated she cleaned out her carts at the end of each month and as needed if she had free time during the day. LVN A stated she was not aware of any official policy on cleaning out medication carts. LVN A stated wasting pills unnecessarily was not good because they were the residents' property. LVN A stated if they ran out of medications on a resident early, they would have to order more before they could administer them to the resident. LVN A stated medications should not be loose in the cart because it meant residents were losing some of their medications unnecessarily. LVN A stated she did not think the medications were loose in the cart for over a month. LVN A stated she did not know what medications they were and there was no way of determining who the medications belonged to. In an interview with the ADON at 2:49 PM on 04/23/25, the ADON stated nurses went through medication carts weekly to clean them out. The ADON stated he did not believe there was a policy that covered how to properly clean out a medication cart. The ADON stated each nurse was responsible for cleaning out their own cart. The ADON stated he could not determine how long the medications had been loose in the medication carts or which resident they belonged to. The ADON stated if a nurse found a loose tablet or capsule in a cart, they were to notify a supervisor and destroy the medication appropriately. The ADON stated it was important to keep medication carts free of loose medications to prevent cross contamination and from medications potentially falling out of the cart as drawers were opened and closed. In an interview with the DON at 7:51 AM on 04/24/25, the DON stated loose medications should not be in the medication carts, and they should be properly disposed of whenever spotted. The DON stated nurses were responsible for keeping their medication carts clean. The DON stated there was not an official policy on how often medication carts were to be cleaned, but it was to be done whenever necessary. The DON stated the loss of medications resulted in residents losing their property. The DON stated there was no way to determine how long the loose medications had been in the cart or which resident they belonged to. The DON stated the facility would pay for new medications if they ran out of them before they were due for a refill. Record review of the facility's policy titled Medication Storage, dated 01/20/21, revealed the following: .8. Medication Carts are routinely inspected for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are removed and destroyed in accordance with the facility policy.

Based on interviews and record reviews, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 2 (Resident #2 and Resident #11) of 6 residents reviewed for accuracy and completeness of clinical records. 1. The facility failed to ensure LVN A correctly documented Resident #2's blood pressure 59 times when she administered blood pressure altering medications (amiodarone, hydralazine, metoprolol, and midodrine) between 04/01/25 and 04/23/25. 2. The facility failed to ensure LVN I correctly documented Resident #2's blood pressure 10 times when she administered blood pressure altering medications (amiodarone, hydralazine, metoprolol, and midodrine) between 04/01/25 and 04/23/25. 3. The facility failed to ensure LVN D correctly documented Resident #2's blood pressure 4 times when she administered blood pressure altering medications (amiodarone, hydralazine, metoprolol, and midodrine) between 04/01/25 and 04/23/25. 4. The facility failed to ensure LVN A correctly documented Resident #11's blood pressure 16 times when she administered blood pressure altering medications (amlodipine) between 04/01/25 and 04/23/25. These deficient practices could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment due to documentation of inaccurate information. The findings included: 1. Record review of Resident #2's admission record reflected an [AGE] year-old female originally admitted to the facility on [DATE] with most recent admission on 04/10/24. Resident #2's diagnoses included chronic combined systolic and diastolic heart failure (aka congestive heart failure- a condition in which the heart does not pump blood as well as it should and can cause fluid to build up in the lungs), essential hypertension (high blood pressure), hypotension (low blood pressure), end stage renal disease (a condition in which the kidneys have permanently lost the ability to function effectively), and dependence on renal dialysis (a process that replaces the function of the kidneys by removing blood from the body, filtering it through a machine, then returning the blood to the body). Record review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 15 which indicated Resident #2 was cognitively intact. Record review of Resident #2's order summary report dated 04/22/25 reflected the following orders dated 04/10/24: Amiodarone HCl tablet 200mg. Give 1 tablet by mouth two times a day (8:00am and 4:00pm) related to paroxysmal atrial fibrillation (when the top part of the heart does not contract correctly sometimes). Hold if SBP less than 110 or HR under 60. (This medication did not require the blood pressure to be documented on the eMAR when it was administered, however it did have hold parameters). Hydralazine HCl oral tablet 50mg. Give 1 tablet my mouth four times a day (8:00am, 12:00pm, 4:00pm, and 8:00pm) related to essential hypertension. Hold if SBP less than 110 or HR under 60. (This medication required the blood pressure to be documented on the eMAR when it was administered.) Metoprolol Succinate ER tablet Extend Release 24 Hour 25mg. Give 1 tablet by mouth at bedtime (8:00pm) related to essential hypertension. Hold if SBP less than 110 or HR under 60. (This medication required the blood pressure to be documented on the eMAR when it was administered.) Midodrine HCl tablet 10mg. Give 1 tablet by mouth three times a day 8:00am, 12:00pm, 4:00pm) related to hypotension. (This medication required the blood pressure to be documented on the eMAR when it was administered.) Record review of Resident #2's eMAR and blood pressure summary both dated 04/01/25 to 04/23/25 reflected the following: On 04/01/25 at 8:18pm, Resident #2's blood pressure was documented as 102/56 on the blood pressure summary by LVN J. On 04/02/25, LVN A documented she administered Resident #2's 8:00am dose of Amiodarone, Resident #2's 8:00am and 12:00pm doses of Hydralazine (BP documented on the eMAR as 102/56 for both administrations), and Resident #2's 8:00am and 12:00pm doses of Midodrine (BP documented on the eMAR as 102/56 for both administrations). On 04/02/25, LVN I documented she administered Resident #2's 8:00pm doses of Hydralazine (BP documented on the eMAR as 122/66) and Metoprolol (BP documented on the eMAR as 122/66). On 04/02/25, the only blood pressure documented on Resident #2's blood pressure summary was 122/66 which was done at 5:57pm by LVN I. On 04/03/25, LVN A documented she administered Resident #2's 8:00am dose of Amiodarone, Resident #2's 8:00am and 12:00pm doses of Hydralazine (BP documented on the eMAR as 122/66 for both administrations) and Resident #2's 8:00am and 12:00pm doses of Midodrine (BP documented on the eMAR as 122/66 for both administrations). On 04/03/25, LVN I documented she administered Resident #2's 8:00pm doses of Hydralazine (BP documented on the eMAR as 114/67) and Metoprolol (BP documented on the eMAR as 114/67). On 04/03/25, the only blood pressure documented on Resident #2's blood pressure summary was 114/67 which was done at 5:53pm by LVN I. On 04/04/25, LVN A documented she administered Resident #2's 8:00am doses of Amiodarone, Hydralazine (BP documented on the eMAR as 114/67) and Midodrine (BP documented on the eMAR as 114/67). On 04/04/25, the only blood pressures documented on Resident #2's blood pressure summary were 106/48 at 4:19pm and 114/56 at 8:21pm, both documented by LVN J. On 04/07/25 at 8:59pm, Resident #2's blood pressure was documented as 114/46 on the blood pressure summary by LVN J. On 04/08/25, LVN A documented she administered Resident #2's 8:00am dose of Amiodarone, Resident #2's 8:00am and 12:00pm doses of Hydralazine (BP documented on the eMAR as 114/46 for both administrations) and Resident #2's 8:00am and 12:00pm doses of Midodrine (BP documented on the eMAR as 114/46 for both administrations). On 04/08/25, LVN I documented she administered Resident #2's 8:00pm doses of Hydralazine (BP documented on the eMAR as 115/62) and Metoprolol (BP documented on the eMAR as 115/62). On 04/08/25, the only blood pressure documented on Resident #2's blood pressure summary was 115/62 at 6:13pm by LVN I. On 04/09/25, LVN A documented she administered Resident #2's 8:00am dose of Amiodarone, Resident #2's 8:00am and 12:00pm doses of Hydralazine (BP documented on the eMAR as 115/62 for both administrations) and Resident #2's 8:00am and 12:00pm doses of Midodrine (BP documented on the eMAR as 115/62 for both administrations). On 04/09/25, LVN I documented she administered Resident #2's 4:00pm dose of Amiodarone, Resident #2's 4:00pm and 8:00pm doses of Hydralazine (BP documented on the eMAR as 115/62 for both administrations), Resident #2's 4:00pm dose of Midodrine (BP documented on the eMAR as 115/62), and Resident #2's 8:00pm dose of Metoprolol (BP documented on the eMAR as 115/62). On 04/09/25, there were no blood pressures documented on Resident #2's blood pressure summary. On 04/10/25, LVN A documented she administered Resident #2's 8:00am dose of Amiodarone, Resident #2's 8:00am and 12:00pm doses of Hydralazine (BP documented on the eMAR as 115/62 for both administrations) and Resident #2's 8:00am and 12:00pm doses of Midodrine (BP documented on the eMAR as 115/62 for both administrations). On 04/10/25, the only blood pressures documented on Resident #2's blood pressure summary were 132/68 at 4:33pm and 96/54 at 8:40pm, both documented by LVN J. On 04/11/25, LVN A documented she administered Resident #2's 8:00am dose of Amiodarone, Resident #2's 8:00am and 12:00pm doses of Hydralazine (BP documented on the eMAR as 96/54 for both administrations), and Resident #2's 8:00am and 12:00pm doses of Midodrine (BP documented on the eMAR as 96/54 for both administrations). On 04/11/25, the only blood pressures documented on Resident #2's blood pressure summary were 100/56 at 4:33pm and 108/56 at 8:10pm, both documented by LVN J. On 04/13/25, at 7:53pm, Resident #2's blood pressure was documented as 108/56 on the blood pressure summary by LVN J. On 04/14/25, LVN A documented she administered Resident #2's 8:00am and 4:00pm doses of Amiodarone, Resident #2's 8:00am, 12:00pm, 4:00pm, and 8:00pm doses of Hydralazine (BP documented on the eMAR as 108/56 for all 4 administrations), Resident #2's 8:00am, 12:00pm, and 4:00pm doses of Midodrine (BP documented on the eMAR as 108/56 for all 3 administrations), and Resident #2's 8:00pm dose of Metoprolol (BP documented on the eMAR as 108/56). On 04/14/25, there were no blood pressures documented on Resident #2's blood pressure summary. On 04/15/25, LVN A documented she administered Resident #2's 8:00am dose of Amiodarone, Resident #2's 8:00am and 12:00pm doses of Hydralazine (BP documented on the eMAR as 108/56 for both administrations) and Resident #2's 8:00am ad 12:00pm doses of Midodrine (BP documented on the eMAR as 108/56 for both administrations). On 04/15/25, LVN D documented she administered Resident #2's 4:00pm dose of Amiodarone and Resident #2's 4:00pm dose of Hydralazine (BP documented on the eMAR as 108/56). On 04/15/25, the only blood pressure documented on Resident #2's blood pressure summary was 124/60 at 7:29pm by LVN D. On 04/16/25, LVN A documented she administered Resident #2's 8:00am dose of Amiodarone, Resident #2's 8:00am and 12:00pm doses of Hydralazine (BP documented on the eMAR as 124/60 for both administrations), and Resident #2's 8:00am and 12:00pm doses of Midodrine (BP documented on the eMAR as 124/60 for both administrations). On 04/16/25, the only blood pressures documented on Resident #2's blood pressure summary were 98/62 at 4:06pm and 108/56 at 8:50pm, both by LVN J. On 04/17/25, LVN A documented she administered Resident #2's 8:00am dose of Amiodarone, Resident #2's 8:00am and 12:00pm doses of Hydralazine (BP documented on the eMAR as 108/56 for both administrations) and Resident #2's 8:00am and 12:00pm doses of Midodrine (BP documented on the eMAR as 108/56 for both administrations). On 04/17/25, the only blood pressures documented on Resident #2's blood pressure summary were 132/76 at 4:10pm and 128/76 at 8:50pm, both by LVN J. On 04/19/25, LVN A documented she administered Resident #2's 12:00pm doses of Hydralazine and Midodrine (BP documented on the eMAR as 102/62 for both administrations). On 04/19/25, the only blood pressures documented on Resident #2's blood pressure summary were 102/62 at 9:46am by LVN C, 98/56 at 4:44pm by LVN J, and 108/52 at 7:58pm, also by LVN J. On 04/20/25, LVN A documented she administered Resident #2's 8:00am dose of Amiodarone, Resident #2's 8:00am and 12:00pm doses of Hydralazine (BP documented on the eMAR as 108/52 for both administrations), and Resident #2's 8:00am and 12:00pm doses of Midodrine (BP documented on the eMAR as 108/52 for both administrations). On 04/20/25, the only blood pressures documented on Resident #2's blood pressure summary were 124/74 at 4:48pm and 136/70 at 7:24pm by LVN K. On 04/21/25, LVN A documented she administered Resident #2's 8:00am dose of Amiodarone, Resident #2's 8:00am and 12:00pm doses of Hydralazine (BP documented on the eMAR as 136/70 for both administrations), and Resident #2's 8:00am and 12:00pm doses of Midodrine (BP documented on the eMAR as 136/70 for both administrations). On 04/21/25, LVN D documented she administered Resident #2's 4:00pm doses of Hydralazine and Midodrine (BP documented on the eMAR as 136/70 for both administrations). On 04/21/25, the only blood pressure documented on Resident #2's blood pressure summary was 128/76 at 7:55pm by LVN D. On 04/22/25 at 11:11pm, LVN K documented Resident #2's blood pressure as 122/66 on the blood pressure summary. On 04/23/25, LVN A documented she administered Resident #2's 8:00am dose of Amiodarone and Resident #2's 12:00pm doses of Hydralazine and Midodrine (BP documented as 122/66 for both administrations). On 04/23/25, there were no blood pressures documented on Resident #2's blood pressure summary. 2. Record review of Resident #11's admission record reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #11's diagnoses included essential hypertension (high blood pressure) and chronic kidney disease (a condition where the kidneys do not function as they should). Record review of Resident #11's quarterly MDS dated [DATE] reflected a BIMS of 15 which indicated Resident #11 was cognitively intact. Record review of Resident #11's order summary report reflected an order for Amlodipine Besylate oral tablet 5mg. Give 1 tablet by mouth in the morning related to essential hypertension. Hold if SBP <100 dated 02/14/25. Record review of Resident #11's eMAR and blood pressure summary both dated 04/01/25 to 04/23/25 reflected the following: On 04/01/25, LVN C documented Resident #11's blood pressure as 112/65 at 12:07pm on the blood pressure summary. On 04/02/25, LVN A documented she administered Resident #11's 8:00am dose of Amlodipine (BP documented as 112/65 on the eMAR). On 04/02/25, there were no blood pressures documented on Resident #11's blood pressure summary. On 04/03/25, LVN A documented she administered Resident #11's 8:00am dose of Amlodipine (BP documented as 112/65 on the eMAR). On 04/03/25, the only blood pressure documented on Resident #11's blood pressure summary was 123/72 at 3:23pm by LVN I. On 04/04/25, LVN A documented she administered Resident #11's 8:00am dose of Amlodipine (BP documented as 123/72 on the eMAR). On 04/04/25, there were no blood pressures documented on Resident #11's blood pressure summary. On 04/07/25, LVN C documented Resident #11's blood pressure as 128/72 at 11:54am on the blood pressure summary. On 04/08/25, 04/09/25, and 04/10/25, LVN A documented she administered Resident #11's 8:00am dose of Amlodipine (BP documented as 128/72 on the eMAR for all 3 days). On 04/08/25 and 04/09/25, there were no blood pressures documented on Resident #11's blood pressure summary. On 04/10/25, the only blood pressure documented on Resident #11's blood pressure summary was 126/74 at 5:12pm by LVN J. On 04/11/25, LVN A documented she administered Resident #11's 8:00am dose of Amlodipine (BP documented as 126/74 on the eMAR). On 04/11/25, there were no blood pressures documented on Resident #11's blood pressure summary. On 04/13/25, LVN C documented Resident #11's blood pressure as 124/72 at 8:19am on the blood pressure summary. On 04/14/25, LVN A documented she administered Resident #11's 8:00am dose of Amlodipine (BP documented as 124/72 on the eMAR). On 04/14/25, the only blood pressure documented on Resident #11's blood pressure summary was 120/66 at 10:53pm by LVN L. On 04/15/25, LVN A documented she administered Resident #11's 8:00am dose of Amlodipine (BP documented as 120/66 on the eMAR). On 04/15/25, there were no blood pressures documented on Resident #11's blood pressure summary. On 04/16/25, LVN A documented she administered Resident #11's 8:00am dose of Amlodipine (BP documented as 133/72 on the eMAR). On 04/16/25, the only blood pressures documented on Resident #11's blood pressure summary were 133/72 at 3:16am by LVN L and 126/74 at 4:59pm by LVN J. On 04/17/25, LVN A documented she administered Resident #11's 8:00am dose of Amlodipine (BP documented as 120/66 on the eMAR). On 04/17/25, the only blood pressures documented on Resident #11's blood pressure summary were 120/66 at 1:24am by LVN K, 118/78 at 4:12pm by the ADON, and 112/62 at 9:48pm by LVN J. On 04/19/25, LVN A documented she administered Resident #11's 8:00am dose of Amlodipine (BP documented as 110/66 on the eMAR). On 04/19/25, the only blood pressures documented on Resident #11's blood pressure summary were 110/66 at 12:03am by LVN K, 114/62 at 4:43pm by LVN J, and 126/76 at 10:29pm by LVN K. On 04/20/25, 04/21/25, 04/22/25, and 04/23/25, LVN A documented she administered Resident #11's 8:00am dose of Amlodipine (BP documented as 126/76 on the eMAR on all 4 days). On 04/20/25, 04/21/25, 04/22/25, and 04/23/25, there were no blood pressures documented on Resident #11's blood pressure summary. In an interview on 04/23/25 at 3:04pm, LVN A stated when a resident got medications that affected blood pressure, she checked vital signs 5-10 minutes prior to administration of the medications. LVN A stated there were not any times she did not check vital signs prior to medication administration. LVN A stated the blood pressure was documented on the eMAR when the medication was administered because it would not let you click that it was administered without that documentation. LVN A stated the windows that came up for vital sign documentation were new, view prior, and n/a. LVN A stated she always put in new vital signs with medication administration. LVN A stated if a resident did not have much activity or did not move around much, they could have the same blood pressure 2 times in a row, but a resident having the same blood pressure 4 times in a row would not be normal. LVN A stated if a medication that altered blood pressure was given without checking vital signs, it could lower or raise the blood pressure to a dangerous level. LVN A stated if the blood pressure went too low, it could put the resident into cardiac arrest and they could pass away and if the blood pressure was raised too high, it could cause a stroke and cause hospitalization or death. LVN A stated when Resident #2 got back from dialysis at about 10:30am or 11:00am on 04/23/25 she checked Resident #2's blood pressure, and she did not know why the blood pressure did not show up on the blood pressure documentation page. LVN A stated she did not know why the blood pressure when she got back from dialysis was the same as the blood pressure from 11:11pm on 04/22/25. When asked about Resident #2's Midodrine administration on 04/14/25 and 04/15/25, (6 administrations) and how Resident #2's BP was exactly the same for all 6 medication administrations, LVN A stated it was not documented properly. LVN A stated she checked the blood pressure each time but if she misplaced the paper she wrote it on, she would go back and use the blood pressure she had previously documented. LVN A stated if vital signs were not documented correctly, the provider could increase or decrease a medication unnecessarily which could cause the resident's blood pressure to be unstable. LVN A stated she had not seen or heard of anyone else not checking a resident's blood pressure before blood pressure altering medications were given. LVN A stated they were in-serviced on mediation administration/documentation anytime there was a problem or a change in staff and the last one was about a month ago. In an interview on 04/23/25 at 5:48pm, the ADON stated when medications that could affect blood pressure were administered, the nurse checked the blood pressure right before giving the medication and documented in the eMAR right after administration. The ADON stated it was not acceptable to write it down on a piece of paper to document later, it was not acceptable for the nurse to not check a blood pressure prior to administration/documentation nor was it acceptable for the nurse to use prior blood pressure documentation. The ADON stated it was not normal for a resident to have the same blood pressure 2 or more times in a row. When asked about Resident #11's blood pressure documentation on the eMAR on 04/20/25, 04/21/25, 04/22/25, and 04/23/25, the ADON stated that it did not look right for his blood pressure to be the same 4 days in a row when there were no blood pressures documented on the blood pressure summary page. The ADON stated if blood pressures were not checked prior to administration of blood pressure altering medications, it could cause a dangerous drop or elevation in the resident's blood pressure which could lead to hospitalization . The ADON stated if a provider was to look at inaccurately documented vital signs, they could stop, decrease, or increase a medication unnecessarily. The ADON stated in-services on medication administration and documentation were done annually and as needed, however he did not recall when the last in- service was completed. The ADON stated his expectation was for the nurses to document accurately and timely. In an interview on 04/24/25 at 10:35am the DON stated when nurses were giving medications that could affect blood pressure, they were to check the resident's blood pressure within 5-10 minutes prior to administration of the medication. The DON stated the nurses were to document the blood pressure on the eMAR at the time the medication was given or held, and it was important to check the blood pressure before medication administration to ensure the medication did not adversely affect the resident. The DON stated it was important to document vital signs on the eMAR so the provider did not make any unnecessary adjustments to the medication. The DON stated if a resident had a low blood pressure and a medication was given that further lowered it, or if a resident had a high blood pressure and a medication was given that would further increase it, it could lead to hospitalization or possibly death. The DON stated she expected the nurses to check vital signs within 5-10 minutes before medication administration and to document accurately at the time the medication was given. The DON stated in-services on medication administration and documentation were done at least annually and as needed and nurse skills check offs, and an in-services were done either late February or early March. The DON stated the ADON did the check offs. The DON stated this would become part of the QAPI plan and a PIP was put into place. In an interview on 04/24/25 at 11:05am, Resident #2 stated the nurses sometimes only checked her blood pressure once a day and sometimes checked it a lot. Resident #2 stated she sometimes felt tired after dialysis, but in general she felt ok. In an interview on 04/24/25 at 11:27am, the MD stated he expected the nurses to follow physician orders and check blood pressures prior to administering medications that had an effect on blood pressures. The MD stated if a resident had a low blood pressure and a medication was given that could lower it more, it could cause a precipitous drop and lead to hospitalization and if a medication to raise the blood pressure was given to a resident who already had a high blood pressure, it could lead to a hypertensive emergency, a stroke, hospitalization , or death. Record review of LVN A's Medication Pass Validation Checklist, dated 01/06/25 and signed by the ADON, reflected the following procedures were observed and no corrective actions were required: .3. Obtained necessary information to administer medications safely (BP, pulse, glucose, lab values). 9. Documented medications administered on MAR. Record review of the facility's Medication-Treatment Administration and Documentation Guidelines, dated 01/09/14 and revised 04/06/23, reflected in part: Anticipated Outcome: To provide a process for accurate, timely administration and documentation of medication and treatments. Fundamental Information: The Medication-Treatment Administration Documentation Guideline applies to licensed nurses and certified medication aides according to licensure or certification scope of practice. Process: 3. Verify and provide medication or treatment focused assessment i.e. BP . as indicated by manufacturers guidelines or physician orders. 4. Administer the medication according to the physician order. 5. Document e-signature for medications and treatments administered on the EMAR or ETAR immediately following administration. 12. Review the EMAR after each medication and treatment administration is completed and prior to end of the shift to validate documentation is completed and supports services provided according to physician orders.

Based on observation, interview, and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriaton of resident property, and exploitation for two out of 10 residents (Resident #59 and Resident # 100) reviewed for abuse/neglect. The facility failed to ensure Resident #59 was free of abuse. Resident #59 was hit on the head twice by Resident #100 on 02/22/25. This failure could place residents at risk of serious injury or death. The findings include: 1.Record review of Resident #59's face sheet dated 04/23/2025 indicated a [AGE] year-old male who was initially admitted to the facility on [DATE]. Resident #59 had a diagnoses which included nontraumatic subdural hemorrhage (rare condition where a blood clot forms in the space between the brain and its outer lining) , dysphagia( difficulty swallowing), difficulty in walking, other lack of coordination, muscle weakness, cognitive communication deficit (problems in communicating in conversations) , dementia (loss in cognitive functioning) and muscle wasting and atrophy (wasting and shrinking of the muscles). Record review of Resident #59's Admission MDS Assessment, dated 02/20/2025, revealed Resident #59 had a BIMS Score of 09, which indicated-Moderate cognitive impairment needed some assistance with all ADLs. Record review of Resident #59's Care Plan, date initiated 01/04/2025, indicated Resident #59 had impaired cognition and was at risk for a further decline in cognitive and functional abilities related to dementia and pain. The resident had an ADL self-care performance deficit. 2.Record review of Resident #100's face sheet, dated 04/23/25, indicated a [AGE] year-old female who was initially admitted to the facility on [DATE]. Resident #100 had diagnoses which included Rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), muscle weakness (generalized) unsteadiness on feet, lack of coordination, need for assistance with personal care. Major depressive disorder(a mental disorder characterized by persistent feelings of sadness, loss of interest or pleasure in activities, and other symptoms that interfere with daily life), anxiety(a natural human emotion characterized by feelings of worry tension and apprehension about the future), cerebral palsy (congenital disorder of movement muscle tone or posture) . Record review of Resident #100's Admission MDS Assessment, dated 02/23/2025, indicated a BIMS score of 00 which indicated -severe cognitive impairment. Resident #100 needed extensive assistance with all ADLs. The assessment indicated Resident #100 had hallucinations and delusions. Resident #100 had physical and verbal behavioral symptoms directed toward others within 1 to 3 days. Record review of Resident #100's Care Plan, dated 02/19/25, indicated Resident #100 had impaired cognition and was at risk for a further decline in cognitive and functional abilities related to cerebral palsy, insomnia, depression, and violence. Resident#100 had a behavior problem as evidenced created an emotional attachment towards male staff. The resident preferred male staff to give care and refused care from female staff (on occasion). Resident #100 had a behavior problem as evidenced by aggressive behavior such as yelling, screaming, and throwing herself on floor. Intervention included monitoring behavior episodes and attempted to determine the underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and interventions in behavior log. Approach the resident in a calm manner, call by name, speak slowly, and maintain eye contact. Talk to the resident while providing care, allow time for a response, and do not rush. Record review of Resident #100's progress notes indicated: -02/21/25 at 7:56 PM Resident received 1:1 monitoring until a bed becomes available at psychiatric behavior hospital in the morning 2-22-25. Will continue to monitor resident. -On 02/22/25 at 4:25 PM Resident #100 was in the front lobby being verbally abusive to residents, residents' family members, and staff shouting curse words. -02/22/25 at 6:42 PM Haloperidol Lactate injection Solution (an antipsychotic used to treat mental disorders) 5 MG/ML injection 2 mg intramuscularly as needed for psychosis delusions 03/05/2025 daily as needed was effective. -02/22/25 at 8:13 PM Resident continues to be verbally and physically abusive to staff and resident she is banging on other residents' doors, also put an object into a female resident's lap nudging the resident. resident is very non redirectable at this point. This nurse notified [local] police and ambulance resident is being sectioned to a psychiatric behavior hospital DON is aware. 02/22/2025 at 8:13 pm Resident #100 refused all medication she stated F K off. 02/22/2025 at 8:50 PM Resident transported to psychiatric hospital via ambulance escorted by [local] police department. Resident to be sectioned to psychiatric hospital. Record review of the facility's Provider Investigation Report Indicated: Date reported to HHSC: 02/24/25 8:45 PM. Incident date:02/22/25 7:00PM in the dining room. Description of allegation: During morning round, alleged witness notified me of incident where female resident [Resident #100] hit male [Resident #59] twice on the head. Male resident interview stated was not hit . Assessment: 02/24/25 11:05 AM-no injuries noted upon skin assessment. Investigation summary . resident initially denied being hit, but during our investigation admitted being hit but did not want to report it. Investigation findings: confirmed. No witness statement was observed to have been taken from any residents. Record review of Resident #59's Progress Notes dated 02/25/2025 indicated Resident #59 was Hit by a female resident twice. Resident stated it did not occur. No complaints of pain or discomforts, able to move all extremities with no difficulty. Able to voice needs. All due care rendered, call light within reach. Record Review of the facility's incident and accident log, dated January 2025 - April 22, 2025, indicated there were no prior incidents involving Resident #59 and Resident #100. In an observation and interview on 04/23/25 at 09:14 AM with Resident #59 revealed he was alert, verbal, and appropriately engaged in conversation. Resident #59 stated Resident #100 was verbally abusing him for some time but never reported it to staff because he did not want the situation to get worse between them. Resident #59 said he also did not want to report any incident because he did not want police involved because he was afraid his probation would be revoked. Resident #59 stated on the day of the incident the verbal abuse escalated to Resident #100 assaulting him in the dining room. Resident #59 stated as Resident #100 was wheeled past him in her wheelchair Resident #100 started swinging her arms towards him and hit him twice on the head. Resident #59 stated HA K who was wheeling Resident #100 asked him if he was ok and if she had hit him. Resident #59 told HA K was ok and she did not touch him, but she had made contact and hit him twice. Resident #59 stated he also told CNA H during the head-to-toe assessment he stated to her he had not pain or discomfort. Resident #59 stated the physical abuse was a one-time incident, but arguments would occur frequently between Resident #100 and him. Resident #59 stated he had no fear of retaliation from staff or other residents, just from Resident #100. Resident #100 was no longer a resident at the facility at the time of the investigation. On 2/24/25 Resident #100 left against medical advice and has not been readmitted . In an interview on 04/23/25 at 03:46 PM with the DON revealed the administrator was conducting rounds on 02/24/25 when she was told by former Resident #101 the witnessed Resident #59 got hit by Resident #100. The DON said it was reported Resident #59 was hit by Resident #100 twice on the head as the residents were walking past each other in the dining room. The DON said Resident #59 and Resident #100 had not had any previous altercations with each other or other residents. The [NAME] Stated Resident #100 was put on a one to one monitoring and was awaiting placement at a psychiatric hospital. All Staff were notified to redirect Resident #100 if she was being disruptive, verbally abusive or trying to enter the rooms of the other residents. In an interview on 04/23/25 at 04:49 PM with the Administrator she stated she was made aware of Resident #100 hitting Resident #59 after the incident occurred, and not until 02/24/25, two days later, was when she made aware of the incident. The Administrator said she immediately initiated an investigation and had both residents assessed for injuries, which no injuries were found on either resident. The Administrator said Resident #59 initially denied being hit by Resident #100 but then confirmed he was hit on the head, twice. The Administrator said Resident #100 was already on one-to-one supervision due to her behaviors and was awaiting a bed at the psychiatric hospital for evaluation and treatment. The Administrator said she reported this abuse incident to state officials but did not report it to law enforcement because Resident #59 did not want to involve law enforcement due to him being on probation and did not want to risk getting arrested for being involved in an altercation. The administrator stated it was policy and procedure to inform state and local law enforcement for abuse and neglect allegations. In an interview on 04/24/25 at 09:48 AM HA K said he was escorting Resident #100 to her room when they passed by Resident #59 and Resident #100 began swinging her arms to hit Resident #59. HA K said Resident #100 hit Resident #59 on the head twice. HA K stated Resident #100 proceeded to swing her arms while he was escorting her to her room. HA K said Resident #100 continued to display aggressive behavior in her room. HA K said he could not recall if he reported Resident #100 hitting Resident #59 since he was dealing with Resident #100 during her behavior. Record review of the facility's Abuse and Neglect and Exploitation Policy and Procedure dated 09/06/2024 indicated Policy: it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing a d implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident properties. 1. The facility provides resident protection that includes: Prevention/ prohibit resident abuse, neglect, and exploitation and misappropriation of resident property; Investigation of all allegations listed above and Training for new and existing staff on activities that constitute abuse, neglect and exploitation and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; .

Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries or unknown source and misappropriation of residents property, were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including to the State Agency, in accordance with State Law through established procedures for 1 out of 10 residents (Resident #59 that occurred on 02/24/25 to the local law enforcement agency, for 1 of 10 residents (Resident #59 ) reviewed for reporting of abuse/neglect. The facility failed to report an incident involving Resident #100 and Resident #59 that occurred on 02/24/25 to the local law enforcement agency. This failure could place residents at risk for potential abuse. The findings include: 1.Record review of Resident #59's face sheet dated 04/23/2025 indicated a [AGE] year-old male who was initially admitted to the facility on [DATE]. Resident #59 had diagnoses which included nontraumatic subdural hemorrhage (rare condition where a blood clot forms in the space between the brain and its outer lining) , dysphagia( difficulty swallowing), difficulty in walking, other lack of coordination, muscle weakness, cognitive communication deficit (problems in communicating in conversations) , dementia (loss in cognitive functioning) and muscle wasting and atrophy (wasting and shrinking of the muscles) . Record review of Resident #59's Admission MDS assessment dated [DATE] revealed Resident #59's had a BIMS Score of 09 which indicated -Moderate cognitive impairment Resident #59 needed some assistance with all ADLs. Record review of Resident #59's Care Plan initiated date 01/04/2025 indicated Resident #59 had impaired cognition and was at risk for a further decline in cognitive and functional abilities related to dementia and pain. The resident had an ADL self-care performance deficit. 2. Record review of Resident #100's face sheet dated 04/23/25 indicated a [AGE] year-old female who was initially admitted to the facility on [DATE]. Resident #100 had diagnoses which included Rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), muscle weakness (generalized) unsteadiness on feet, lack of coordination, need for assistance with personal care. Major depressive disorder Major depressive disorder(a mental disorder characterized by persistent feelings of sadness, loss of interest or pleasure in activities, and other symptoms that interfere with daily life), anxiety(a natural human emotion characterized by feelings of worry tension and apprehension about the future), cerebral palsy (congenital disorder of movement muscle tone or posture). Record review of Resident #100's Admission MDS assessment dated [DATE] indicated a BIMS score of 00-severe cognitive impairment and needed extensive assistance with all ADLs. The assessment revealed Resident #100 had hallucinations and delusions. Resident #100 had physical and verbal behavioral symptoms directed toward others within 1 to 3 days. Record review of Resident #100's Care Plan dated 02/19/25 indicated Resident #100 had impaired cognition and was at risk for a further decline in cognitive and functional abilities related to cerebral palsy, insomnia (a sleep disorder characterized by difficulty falling asleep, or experiencing non-restorative sleep), depression, and violence. Resident#100 had a behavior problem as evidenced created an emotional attachment towards male staff. The resident preferred male staff to give care and refused care from female staff (on occasion). Resident #100 had a behavior problem as evidenced by aggressive behavior such as yelling, screaming, and throwing herself on floor. Intervention included monitoring behavior episodes and attempted to determine the underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and interventions in behavior log. Approach the resident in a calm manner, call by name, speak slowly, and maintain eye contact. Talk to the resident while providing care, allow time for a response, and do not rush. Record review of Resident #100's progress notes indicated: -02/21/25 at 7:56 PM Resident received 1:1 monitoring until a bed becomes available at psychiatric behavior hospital in the morning 2-22-25. Will continue to monitor resident. -On 02/22/25at 4:25 PM Resident#100 was in front lobby being verbally abusive to residents, residents' family members, and staff shouting curse words. -02/22/2025 at 6:42PM Haloperidol Lactate injection Solution (an antipsychotic used to treat mental disorders) 5 MG/ML injection 2 mg intramuscularly as needed for psychosis delusions 03/05/2025 daily as needed was effective. -02/22/25 8:13 at PM Resident continues to be verbally and physically abusive to staff and resident she is banging on other residents' doors, also put an object into a female resident's lap nudging the resident. resident is very non redirectable at this point. This nurse notified [local] police and ambulance resident is being sectioned to a psychiatric behavior hospital DON is aware. 02/22/2025 at 8:13 pm Resident #100 refused all medication she stated F K off. 02/22/2025 at 8:50 PM Resident transported to psychiatric hospital via ambulance escorted by [local] police department. Resident to be sectioned to psychiatric hospital. Record review of the facility's Provider Investigation Report Indicated: Date reported to HHSC: 02/24/25 8:45 PM. Incident date:02/22/25 7:00PM in the dining room. Description of allegation: During morning round, alleged witness notified me of incident where female resident [Resident #100] hit male [Resident #59] twice on the head. Male resident interview stated was not hit Assessment: 02/24/25 11:05 AM-no injuries noted upon skin assessment. Investigation summary resident initially denied being hit, but during our investigation admitted being hit but did not want to report it. Investigation findings: confirmed. Record review of Resident #59's Progress Notes dated 02/25/2025 indicated Resident #59 was Hit by a female resident twice. Resident stated it did not occur. No complaints of pain or discomforts, able to move all extremities with no difficulty. Able to voice needs. All due care rendered, call light within reach. Record review of the facility's incident and accident log date January 2025 - April 22, 2025, indicated there were no prior incidents involving Resident #59 and Resident #100. In an observation and interview on 04/23/25 at 09:14 AM Resident #59 revealed he was alert, verbal, and appropriately engaged in conversation. Resident #59 stated he did not want to report the altercation between himself and #100 because he felt sorry for her and he did not want to get her in trouble. Resident #59 was afraid to get in trouble himself for arguing with resident #100 said he also did not want the incident reported to police because he was afraid that his probation would be revoked. Resident #59 stated he did not want to go back to jail and was afraid that the situation would be turned around and he would somehow be blamed of assault too and this would have revoked his probation and he ' d go back to jail. In an interview on 04/23/25 at 03:46 PM with the DON revealed she stated the administrator was responsible for reporting all incidents to the local authorities after she reports them to the state. The administrator was initially made aware of the incident two day after the altercation took place with resident #59 and Resident #100 in the dining room. As soon as she was made aware she began to investigate why it had not been reported to staff and what actually happened n 02/22/25 . the [NAME] stated that the resident was fearful of going back to jail and that was the reason local authorities were not notified of the abuse to Resident #59. In an interview on 04/23/25 at 04:49 PM with the Administrator she stated she was made aware of Resident #100 hitting Resident #59 two days after the time the incident occurred on 02/24/25. The Administrator said she immediately initiated an investigation and had both residents assessed for injuries, which no injuries were found on either resident. The Administrator said Resident #59 initially denied being hit on 02/22/25 by Resident #100 but then confirmed he was hit on the head twice. On 02/24/25. The Administrator said Resident #100 was already on one-to-one supervision due to previous behaviors and was awaiting a bed at the psychiatric hospital for evaluation and treatment. The Administrator said she reported this abuse incident to state officials but did not report it to law enforcement because Resident #59 did not want to involve law enforcement due to him being on probation and did not want to risk getting arrested for being involved in an altercation. The administrator stated it was policy and procedure to inform state and local law enforcement for abuse and neglect allegations. The administrator wrote in a letter dated 02/24/25 stating the reason she did not report to local police was because I explained that was not my protocol but since it was resident request/ family request I would honor. I still need to report to state. They understood. This administrator explained that he would be free of any abuse or harm in our facility and that if any Future incidents happen please call or text me. Both understood. DON present. In an interview on 04/24/25 at 09:48 AM with HA K said he was escorting resident#100 to her room when the incident occurred, and he did ask Resident# 59 if Resident #100 hit him and he said no. HA K could not remember if he reported it to anyone as he was trying to redirect Resident #100 to her room so that she could not hurt anyone while she was acting up as he took her to her room. He knew if he witnessed any abuse or neglect, he would report it to a nurse, DON, or Administrator. HA K also stated the facility had abuse and neglect training at least once a month if not more. Record review of the facility's Abuse and Neglect and Exploitation Policy and Procedure dated 09/06/2024 indicated Policy: it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing a d implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident properties. 1. The facility's Abuse Prevention Coordinator is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law .

Based on interview and record review, the facility failed to develop a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs, as well as describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 6 (Residents #42 and #53) residents reviewed for care plans. 1) The facility failed to ensure Resident #42 was weighed weekly as ordered by the physician. 2) The facility failed to ensure Resident #53 was weighed weekly as ordered by the physician. These failures could place residents at risk of unnoticed weight loss or weight gain resulting in exacerbation of symptoms and increased morbidity. The findings included: 1. Record review of Resident #42's face sheet, dated 04/22/25, revealed a [AGE] year-old male with an initial admitted [DATE] and a current admitted [DATE]. Resident #42's pertinent diagnoses included morbid obesity due to excess calories and chronic systolic heart failure (condition where the heart's left ventricle weakens and cannot pump blood effectively). Record review of Resident #42's Quarterly MDS assessment, dated 04/10/25, section C revealed a BIMS score of 15, which indicated the resident's cognition was intact. Record review of Resident #42's comprehensive care plan, dated 04/22/25, revealed the focus Nutritional Status: Resident is on a renal, regular, regular and at nutritional & hydration risk [sic] initiated on 09/10/24. The goal of the focus stated Resident will maintain adequate nutritional and hydration status as evidenced by weight being stable with no signs or symptoms of malnutrition or dehydration being present through the next review date initiated on 09/10/24. The intervention listed stated Provide and serve diet as ordered- renal, regular, regular initiated on 09/10/24. Record review of Resident #42's physician orders revealed an active order initiated on 02/28/25 for weekly weights: if has 5lb wt gain/loss report to MD for further orders. Every day shift every Thu. Record review of Resident #42's weight revealed Resident #42 was weighed on 04/17/25 with a result of 234.3lbs, and he was weighed on 03/14/25 with a result of 245.0lbs. No weights were documented between 04/17/25 and 03/14/25. In an interview with Resident #42 at 2:45 PM on 04/22/25, Resident #42 stated he was not sure if he was supposed to be weighed weekly or monthly. Resident #42 stated he knew they weighed him but was not sure exactly how often. 2. Record review of Resident #53's face sheet, dated 04/22/25, revealed a [AGE] year-old male with an initial admitted [DATE] and a current admitted [DATE]. Resident #53's pertinent diagnoses included mild protein-calorie malnutrition (body does not receive enough protein or calories), and dementia (loss of cognitive function including memory, thinking, and reasoning severe enough to interfere with daily life). Record review of Resident #53's Quarterly MDS assessment, dated 03/22/25, section C revealed a BIMS score was not gathered for this resident. Resident #53 was rarely/never understood. Record review of Resident #53's comprehensive care plan, dated 04/22/25, revealed the focus [Resident #53] has, unplanned/unexpected weight loss. 10/17/24 wt 125 has 10% wt loss since 04/24/24 initiated on 05/10/24 and revised on 10/17/24. Interventions listed included: - 10/17/24 weekly weights, speech therapy, diet testing for po intake initiated on 10/17/24. - Monitor and evaluate any weight loss. Determine percentage lose and follow facility protocol for weight loss initiated on 05/10/24 and revised on 05/10/24. Record review of Resident #53's physician orders revealed an active order initiated on 02/13/25 for weekly weights every day shift every Thu. Record review of Resident #53's weight revealed Resident #53 was weighed on 04/17/25 with a result of 154.3 lbs. He was weighed on 03/13/25 with a result of 159.1lbs. No weights were documented between 04/17/25 and 03/13/25. An interview was attempted with Resident #53 at 2:40 PM on 04/22/25, but Resident #53 was not interviewable. In an interview with CNA B at 2:08 PM on 04/23/25, CNA B stated she weighed residents before. CNA B stated the nurses gave the CNAs a list at the beginning of the shift with the residents who needed to be weighed that day. CNA B stated she always weighed all residents who needed to be weighed on her shifts. CNA B stated she had not heard of any CNAs not weighing their residents. CNA B stated they monitored the weight of residents to ensure they were not losing or gaining weight, and they were eating well. In an interview with CNA E at 2:16 PM on 04/23/25, CNA E stated they weigh residents on the first of every month. CNA E stated she had a list of residents who needed weekly weights. CNA E stated she had never missed weighing a resident when they needed it. CNA E stated if she did not get to a resident on a specific day, she informed the nurse so they could have the next CNA on shift weigh the resident. CNA E stated it was important to monitor the resident's weight to know if they were losing or gaining weight, which could lead to other problems. In an interview with LVN A at 2:34 PM on 04/23/25, LVN A stated the nurses gave a list of residents who needed to be weighed to the CNAs at the beginning of the shift. LVN A stated the list was pre-filled by the MAR. LVN A stated sometimes CNAs were not able to weigh all residents on the list every shift, so they passed the information to a nurse who then told the oncoming shift to weigh the necessary residents. LVN A stated it was important to monitor a resident's weight depending on what conditions they had. LVN A stated if a resident's weight was not monitored as frequently as ordered they might have underlying symptoms of diseases go unnoticed for extended periods of time. In an interview with the ADON at 2:49 PM on 04/23/25, the ADON stated at the beginning of the shift, the nurses gave the CNAs a list of all residents who needed to be weighed that day. The ADON stated the CNAs weighed the residents, recorded it on paper, and then handed the results to the nurse. The ADON stated the nurses pulled the list of residents who needed to be weighed from the MAR. The ADON stated if residents were not weighed as ordered they could experience exacerbations of their problems, ultimately causing them harm. In an interview with the DON at 7:51 AM on 4/24/25, the DON stated they discovered residents were not being weighed as ordered recently. The DON stated they implemented a new policy involving a weight team that would come in on Thursdays to weigh all residents who needed to be weighed on a weekly basis. The DON stated residents received orders for weekly weights if they had heart failure, a G-tube, severe weight loss, or they were a new resident. The DON stated those residents were more prone to weight changes. The DON stated if they did not weigh residents as ordered there was potential to miss a change in the resident's condition. Record review of the facility's policy titled Weight Management, written on 01/05 and last reviewed on 09/13/24 revealed the following: Resident weights will be recorded in each resident's medical record monthly, unless specifically ordered otherwise . All weights (admission, readmission, weekly and monthly) are to be entered into the Point Click Care (PCC) weight system . All residents should be weighed on admission, readmission and monthly unless more frequent weights are deemed necessary by the clinical team.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for one of 16 residents (Resident #40) reviewed for infection control practices. 1. The facility failed to ensure the WCN wore proper PPE (gown) during wound care for Resident #40 who required enhanced barrier precautions. 2. The facility failed to ensure CNA E wore proper PPE (gown) during wound care for Resident #40 who required enhanced barrier precautions. 3. The facility failed to ensure the WCN performed hand hygiene after removing a glove during wound care for Resident #40. 4. The facility failed to ensure CNA E performed hand hygiene after removing a glove while assisting during wound care for Resident #40. These failures could place residents at risk for healthcare associated cross-contamination and infections . The findings include: Record review of Resident #40's face sheet dated 04/23/25 reflected a [AGE] year-old-male who had an original admitted [DATE]. Resident #40 had diagnoses which included pressure ulcer (open wound on the skin caused by prolonged pressure to specific area of the body) of sacral (a bone in the lower back) region stage 4 (full thickness tissue loss extending below the subcutaneous fat into deep tissue, muscle, tendons and ligaments), hypertension (high blood pressure), and type 2 diabetes (insufficient insulin production in the body). Record Review of Resident #40's physician orders reflected the following: Dated 4/05/25: Enhanced barrier precautions: Must wear gloves and gown for the following high-contact resident care activities: Dressing, bathing/showering, transferring, changing linens, providing hygiene, assisting with toileting, wound care, feeding tube, trach care, central line care, urinary catheter care, every day for wounds and foley. Dated 04/09/25: Cleanse sacrum with NS wound cleanser, pat dry with 4x4 gauze, apply skin prep to peri (region of the body located between the thighs marking the lower boundary of the pelvis) wound, apply collagen sheet (promotes healing by stimulating new tissue growth) , apply calcium alginate sheet (highly absorbent wound dressing), cover with 4x4 gauze (bleached white cloth or fabric used in bandages and dressings) secure with tape every day. Record review of Resident #40 's care plan dated 03/27/2024 and revised on 02/11/2025 reflected: Resident requires enhanced barrier precautions related to catheter and wound. Enhanced barrier precautions: Must wear gloves and gown for the following high-contact resident care activities: Dressing, bathing/showering, transferring, changing linens, providing hygiene, assisting with toileting, wound care, feeding tube, trach care, central line care, urinary catheter care. During an observation of wound care on 04/23/25 at 08:57 AM revealed CNA E and the WCN did not put on the correct PPE (a gown) to perform wound care. An EBP sign was observed above Resident #40's bed which indicated a gown must be worn. During wound care, both CNA E and the WCN were observed removing a glove and placed another glove on without washing or sanitizing their hands. In an interview on 04/23/25 at 09:21 AM, the WCN stated when her glove tore, she should have taken off both gloves, washed or sanitized her hands, but instead, she took off only the torn glove and forgot. The WCN said it was important to wash or sanitize hands after removing gloves as it was a part of infection control practice and could cause cross contamination. The WCN stated infection control in-services happened frequently but could not recall the last in-service. The WCN nurse stated she should have worn a gown to prevent cross contamination since Resident #40 had a wound but just forgot. In an interview on 04/23/25 at 09:26 AM, CNA E stated she forgot to wash or sanitize her hands after removing gloves while helping during wound care. CNA E stated it was important to wash or sanitize hands to prevent resident cross contamination and infection. CNA E stated she should have worn a gown to prevent cross contamination. CNA E stated she usually did not work Resident #40's hall and just forgot. In an interview on 04/23/25 at 02:37 PM, the DON stated the WCN and CNA E should have washed or sanitized their hands to prevent infection and because it was good hygiene practice. The DON stated EBP should have been worn to prevent cross contamination since Resident #40 had a wound. The DON stated the last infection control in-service was about 3 weeks ago. Record Review of facility's Hand Hygiene policy dated 02/20/20 and revised on 02/11/22, reflected: Policy: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your tasks requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Based on observation, interview and record review, the facility failed to ensure adequate supervision was provided for 1 of 6 residents reviewed for accidents and supervision. (Resident #1) The facility failed to ensure Resident#1 received adequate supervision to prevent elopement. Resident #1 eloped from the facility and was found by the police department approximately 0.2 miles away from the facility. The Immediate Jeopardy template was provided to the facility on [DATE] at 4:38 p.m. While the Immediate Jeopardy was removed on 10/26/2024 at 1:33 p.m., the facility remained out of compliance at a scope of isolated and severity level of potential for more than minimal harm because all staff was not aware of and did not implement the facility's elopement procedures. This failure could prevent residents from receiving appropriate supervision which could lead to resident sustaining serious injury, harm, or death. Findings included: Record review of Resident #1's electronic facility face sheet dated 10/24/2024, revealed he was an [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses included Alzheimer's, Bipolar, Post Traumatic Stress Disorder, Major Depressive Disorder, and Unspecified Dementia. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed he scored a 10 on his BIMS which indicated he was moderately cognitively impaired. Resident #1 functional abilities indicated he was independent for everyday activities. Record review of Resident #1's Elopement/Wandering Risk assessment dated [DATE] revealed low elopement risk. Record review of a progress note dated 10/11/2023, revealed at 12:30 am Resident #1 was missing from room. Resident #1 was last seen in room at 11:15 pm. A silver alert activated. The staff was alerted in the facility and a surrounding search was initiated. At approximately 12:35 am Resident #1 was picked up at a convenience store. No injuries noted to Resident #1. As per Resident #1 voiced he exited through the front door, and he was wanting to go home. The MD and RP notified. A full body assessment was completed, vital signs were taken and within normal limits, and a wander guard bracelet was placed. One to One monitoring initiated. During an interview on 10/24/2024 at 11:10am Resident #1 stated he did not remember the incident. During an interview on 10/25/2024 at 10:30 a.m. CNA B stated he was assigned to work in the hall that Resident #1 was at. He did work the night of the incident. He stated that he was in the break room when LVN A and LVN D asked him where Resident #1 was at. CNA B stated that a code silver was activated by LVN A. He heard the front door alarm going off once he was out of the break room. He was not sure if it was him or LVN A who turned off the alarm because he was heading out the front door to go look around the outside perimeter. He stated that it wasn't the wander guard alarm that sounded, it was the front door alarm. CNA B stated that he saw the police at the nearby convenience store then he saw Resident #1. He stated they had an in-service for elopement done the following day. During an interview on 10/24/2024 at 3:37 p.m. LVN A stated she was Resident #1's nurse the night of the incident and she didn't hear the alarm. She was in the break room at the time when she was notified by LVN D that Resident #1 was not in his room. She stated CNA B was with her in the break room. They both got up and she initiated code silver alert. She called DON. At around 12:35 a.m. CNA B called her to notify her of Resident #1 being found at a nearby convenient store standing with a police officer. Resident #1 told LVN A that he was going home. She assessed him right away. LVN A stated he was last seen in the facility around 11:15 p.m. by LVN D. LVN A asked him how he got out of facility, and he said through the front door. A few minutes later she asked him again and he said he couldn't remember. Interventions that were put into place were a wander guard, 1:1 monitoring initiated, an in-service for a missing resident and an elopement drill completed. During an interview on 10/25/2024 at 9:12 a.m. LVN D stated that it was her second day on the job and she was being trained by LVN A the night of the incident. She stated she thought she heard an alarm earlier that night when she was at the vending machine. She was hearing something that did not sound like a call light but by the time she walked to the nurse's station, the sound was off. Then 30 minutes later, around 12:30 a.m. it was during that time that she walked by Resident #1's room and did not see him in his bed. She then went to get LVN A and CNA B, who were in the break room, and notified them that Resident #1 was not in his room. She was instructed to look inside the facility and then outside by LVN A. She did not recall hearing an alarm when going out of the facility to look on the outside perimeter. During an interview on 10/25/2024 at 9:42 a.m. LVN E stated she worked the night of the incident in another hall. She stated that she was in the room with a resident, and she did not hear an alarm. She did not know that Resident #1 was missing until a code silver alert was announced. She stated the only way they could leave facility was if they know the code. LVN E stated in-services were done on a missing resident and she thought an elopement drill as well. During an interview on 10/25/2024 at 11:15 am CNA F stated she worked the night of the incident in another hall. She stated she did not hear the alarm go off that night. During an interview on 10/24/2024 at 1:50 pm the DON stated Resident #1 was missing for about 35-45 minutes. The DON stated she was notified at 12:35 am Resident #1 was not in his room and a code silver was initiated. The DON stated that a head-to-toe assessment be done, hydration assessment, pain assessment, and elopement assessment. The DON confirmed with Staff A the MD and RP had been notified. The facilityinitiated posttest training and in serviced all staff on the missing resident policy. The facility also conducted a mock drill silver alertThe DON stated they did 100% elopement assessments on all residents. No additional elopement events had been identified since. During an interview on 09/20/2024 at 11:03a.m. the Administrator stated that he ensures that the staff were doing and following the elopement protocol by conducting periodic monthly elopement education and drills. He stated that the drills were unannounced. He stated that the front door code was changed monthly and as needed. Sometimes if they noticed the family member know the code then they change it right away. During an interview on 10/24/2024 at 2:28 p.m. the Administrator stated the staff took action immediately. She was notified and a code silver was initiated. A head to toe assessment was completed. The RP and medical director were notified. The interventions were discussed and put into place. The investigation was started right away. She stated the door codes are only given to staff. Door codes are changed monthly and on an as needed basis. The Administrator stated Resident #1 must have opened the door by holding it for 15 seconds but when they asked Resident #1 again how he left the facility, he states he cannot remember. She stated they had an elopement drill that evening and yesterday 10/23/2024. In-services were also done for a missing resident and pretest/posttest, so staff know code silver. Record review of where Resident #1 was found approximately 0.2 miles away from the facility and the street speed was 30 miles per hour. This information was gathered by using google maps. Record review of a policy with date implemented of 10/24/2022 titled Missing Resident Policy revealed Policy: The facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions: Elopement occurs when a resident leaves the premises or a safe area without the authorization (i.e. an order for discharge or leave of absence), and/or any necessary supervision to do so. Policy Explanation and Compliance Guidelines: 2. Staff are to be vigilant in responding to alarms in a timely manner. 3. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering including identification and assessment of risk evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. On 10/25/2024 at 4:38 p.m., the Administrator was informed of the Immediate Jeopardy and the plan of removal was requested The plan of removal was accepted on 10/26/2024 at 1:33pm. 1.Immediate Action Taken On 10/11/2024 The DON/ Designee completed a head-to-toe physical assessment with no negative findings noted On 10/11/2024 [Resident #1] was returned back to the facility and wander guard bracelet placed on resident On 10/11/24 [Resident #1] was returned back to the facility and placed on 1:1 observation. On 10/11/24 The DON/ Designee updated [Resident #1] care plan for wandering/exit seeking. On 10/11/24 The DON/ Designee completed elopement assessments on all facility residents with no changes noted. On 10/11/24 The maintenance director/ Designee completed environmental assessments to include checks on all door alarms and windows. On 10/11/24 The DON/ Designee completed in-service education with facility direct care staff on the missing resident policy which ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents. On 10/11/24 The DON/ Designee completed a Missing Resident Drill with facility direct care staff to ensure staff know the proper procedure for locating missing residents to include when a staff member hears the alarm sound they will initiate the code silver alert to notify all other staff members of the missing resident and to not turn the alarm sound off until all staff are notified of the missing resident and headcount guidelines which requires visual confirmation and documentation regarding the location of each resident in the center. On 10/25/24 The facility administrator spoke with tech support in regards to functioning door alarm who stated alarm volume could not be adjusted and is functioning at manufacture guidelines. Verification: Started on 10/26/2024 at 10:38 a.m. and included: The following observations, record reviews and interviews were conducted by the survey team to ensure the staff's understanding on in-service trainings received between 10/11/2024 and 10/25/2024: Observation on 10/23/2024 at 2:15 p.m. LVN G verified with surveyor that Resident #1's wander guard and window alarm was functioning properly. Observation on 10/24/24 on 9:30 a.m. ensured that all the door alarms were functioning properly. Observation on 10/26/2024 at 11:36 a.m. Resident #1 was observed lying down in bed in his room asleep. There was a wander guard on his right wrist. Record review of the completed head to toe assessment was done on 10/11/2024 and it had no negative findings. The 1:1 observation completed. The care plan was updated, and the elopement/wandering risk assessment was updated on 10/11/24. Resident was scored 8 at risk for elopement or unsafe wandering. The elopement assessments were done on all the residents. Record review of an In-Service Attendance Record with topic of Missing Person Alarm System, revealed that all staff was in-serviced on 10/25/2024. Record review of an In-Service Attendance Record with topic of Silver Alert, revealed that all staff was in-serviced and the elopement drill was done on 10/25/2024. During interviews on 10/27/2024 from 03:15 p.m. to 11:45 p.m., 3 CNAs, 4 LVNs, 2 Dietary/Kitchen staff, Receptionist, Central Supply Staff, Social Worker and Human Resource Staff were all knowledgeable of the missing resident policy and procedure. They were aware of the new expectations to not turn the alarm sound off until all staff were notified of the missing resident and headcount guidelines which required visual confirmation and documentation regarding the location of each resident in the center. During an interview via telephone on 10/27/2024 at 11:45 p.m., LVN A was able to verbalize understanding of the following in services received: Missing Person Alarm System and Silver Alert. During interviews on 10/28/2024 from 12:01 a.m. to 10:44 a.m., 2 RNs, 4 LVNs, 5 CNAs, Restorative Aide, Rehab Tech, Director of Rehab, 2 Housekeeping/Laundry, and Floor Technician were all were knowledgeable of the missing person policy and procedure, all were aware of the new expectations to not turn the alarm sound off until all staff are notified of the missing resident and headcount guidelines which requires visual confirmation and documentation regarding the location of each resident in the center. During an interview via telephone on 10/28/2024 at 10:44 a.m., CNA B was able to verbalize understanding of the following in services received: Missing Person Alarm System and Silver Alert. On 10/25/2024 at 4:38 p.m., the Administrator was informed of the Immediate Jeopardy. Verification of the plan of removal immediacy was completed prior to exit. The Immediate Jeopardy began on 10/25/2024 and ended on 10/26/2024.

Based on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 5 residents (R #1) reviewed for supervision. The facility failed to ensure R #1 received adequate supervision as R #1 eloped from the facility without anyone's knowledge on 07/19/24 between 7:30-7:40 PM and was found at an apartment complex approximately 0.2 mile away. R #1 was exit seeking, had increased behaviors, and staff placed R #1 in his room and failed to request additional interventions or increased supervision. R #1 was out of the facility for approximately 30 minutes before the facility became aware that he had eloped. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 07/19/24 and ended on 07/22/24. The facility corrected the non-compliance before the investigation began. This failure could lead to residents exiting the facility unattended which could result in injuries, hospitalization , or death. The findings included: Record review of R #1's face sheet dated 07/24/24 reflected an [AGE] year-old male, with an original admitted [DATE]. His diagnoses included type 2 diabetes, hepatic encephalopathy (brain dysfunction caused by liver dysfunction), mood disorder, unspecified psychosis, hypertension, dementia with other behavioral disturbance, alcohol abuse (in remission), muscle weakness, lack of coordination, and cognitive communication deficit. Record review of R #1's Minimum Data Set (MDS) assessment dated [DATE] reflected R #1 had a BIMS score of 8 (moderate cognitive impairment) and required supervision (oversight, encouragement, or cueing) for bed mobility and transfers. Record review of R #1's elopement assessment dated [DATE] (admission) reflected a score of 11 (a combined score of 6 or more triggered possible elopement risk). At risk to elope and should be placed on the Elopement Risk Protocol. A care plan for Elopement was indicated. Record review of R #1's Care Plan dated 07/24/24 reflected R #1 was independent for bed mobility, transfers and ambulation. Date Initiated: 05/24/24. R #1's care plan also reflected R #1 was at risk of Wandering/Exit Seeking: Resident wanders related to cognitive impairment and is at risk for injury related to: Mood Disorder due to known physiological condition. Date Initiated: 05/24/24. Attempt to determine any pattern or cause of wandering, reassure resident when distressed over placement, mark room door with a familiar object, photo, etc. to aid in remembering room location as indicated, redirect if resident enters a restricted area, notify the immediate supervisor if unable to locate the resident, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, etc. Date Initiated: 05/24/24. R #1's care plan reflected the elopement. Additional interventions after elopement: will find a secured unit for resident to transfer to upon acceptance, will place on one to one and place window alarm as soon as available, and window alarm placed on 07/19/24. Date Initiated: 07/19/24. Record review of the Provider Investigation Report dated 07/23/24 reflected an elopement incident involving R #1 on 07/19/24 at 8 PM and was reported on 07/20/24 at 8 PM to the State Survey Agency. Investigation summary : R #1 had a BIMS of 8, diagnosed with diabetes and mood disorder, and had no prior incidents of elopement. Staff were notified by LE that LE had R #1 when LE showed up to the facility with R #1. LVN A called the DON at 8:25 PM that LE had found R #1 at apartment complex nearby. The DON notified the ADM. Staff were immediately redirected and evaluated R #1, assessments completed, wander guard bracelet verified, R #1 on 1:1, risk call and interventions initiated and conducted. Staff interviews conducted revealed LVN A saw R #1 at around 7 PM, when LVN B assisted R #1 to the restroom. At approximately 7:30 PM, R #1 was at the hall door and pressed on the door, the alarm rang, and CNA F and RN G redirected R #1 to his room. RN G administered R #1's medications as ordered. CNA F and RN G placed R #1 in bed with his shoes on per his preference and he wanted his door closed. Staff continued to do their rounds down the hall. LE arrived at the facility with R #1 and LE went to R #1's room, room B-21, with staff. When they entered the room, the window was completely open and the window had not been open earlier. MD and RP were notified. R #1 was placed on a 1:1 at that time. MD orders labs and results were pending. Staff and resident interviews for abuse/neglect conducted. All staff in-serviced. Provider action taken post-investigation: wander guard list validated, wander guard bracelet rechecked, all staff in-serviced, 1:1 continued until placement at secured unit, care plan updated, 1:1 care plan meeting with family, chart review, staff in-serviced for code silver and abuse/neglect, MAR/TAR reviewed, environmental evaluation, incident report completed, post-test follow up audits on code silver will be reported to Quality Assurance for any negative findings, and 100 % of elopement assessments completed for all residents. Findings confirmed. Signed by the ADM on 07/23/24. Description of injury: none. Description of assessment: pain assessment, elopement assessment, head to toe assessment, hydration assessment, glucometer check, vitals checked, and placed on a 1:1 until they got further orders. Provider response: assessments, contacted the ADM/RP/DON, notified the doctor, in-service on elopement and code silver, wander guard bracelet rechecked and in place, binder updated, resident interview, updated care plan, orders for labs, labs taken, and window alarm placed. Attachments included: R #1's face sheet, assessments, notes, labs, order summary, elopement assessments for residents with wander guard, LE report, emergency response drill: missing resident on 07/19/24, worksheets, head count 100 %, elopement assessments completed 100 % from 07/19/24-07/20/24, in-services on elopement, door alarms, elopement drill, wandering residents, head count, code silver, and abuse/neglect, and policies on 07/19/24; doors, locks, gates, alarms and wander guard system checked, and staff post-tests from 07/19/24-07/22/24. Record review of R #1's progress notes dated 05/23/24-07/26/24 reflected R #1 continuously attempted to exit seek since his admission on 05/23/24. Staff redirected R #1 and the wander guard was placed on 05/24/24. Staff continued to redirect R #1 as he continued to attempt to exit seek. R #1 was placed on a 1:1 on 05/25/24. Staff continued to exit seek despite of the 1:1 staff and staff redirected R #1. R #1 at times became aggressive or upset due to the redirection as R #1 wanted to leave. Staff explained placement or distracted R #1 with other activities. Staff also reported behaviors to NPs and obtained orders for medications. Staff continuously monitored R #1. Record review of R #1's order summary dated 07/24/24 reflected a wander guard was initiated for R #1 on 05/24/24: wander guard on at all times for elopement prevention, licensed nurse to assess wander guard every shift to assure it is working properly every shift. R #1 was also placed on a 1:1 on 05/25/24 which was discontinued on 07/18/24 at 5:53 PM. R #1 was placed back on a 1:1 on 07/19/24 after the incident of elopement. Record review of R #1's MAR dated 05/24/24-07/25/24 reflected a licensed nurse checked the wander guard every shift to assure it was working properly. Record review of R #1's elopement assessment dated [DATE] (readmission from hospital visit on 07/01/24) reflected score of 4 and still indicated to place him on an elopement risk protocol. Record review of R #1's progress notes reflected: -On 07/18/24 at 12:00 AM, documented by LVN B: R #1 noted with exit seeking behaviors, attempted to open exit door from hall and other doors in the hall. Staff attempted to redirect, and redirection was unsuccessful. As R #1 began to show agitation, the RP was contacted to help speak to R #1 and he was redirected to room. Redirection was unsuccessful. R #1 only complied to sit in a chair by the hallway, voiced he was being kidnapped, and the nurse explained to R #1 that he was in a nursing home due to him needing daily care. R #1 voiced that he did not need care as he cared for himself. R #1 stayed sitting in the chair. Staff continued to monitor. -On 07/19/24 at 7:30 PM, documented by RN G: Was alerted by the hall door alarm. Noted R #1 attempted to exit the facility. R #1 required constant redirection with poor outcome and showed signs of irritability while he was assisted back to his room. Placed R #1 back to bed. All care met and provided for. -On 07/19/24 at 8:55 PM, documented by RN G: Provided skin assessment of R #1. R #1 had clean and intact skin with no scrapes, bruising, or discoloration noted. Skin turgor was normal, skin was cool to touch with normal pigmentation noted. Record review of R #1's SBAR communication form dated 07/19/24 reflected the resident with increased confusion, continues with exit seeking behaviors. Placed on a 1:1. Obtained orders for UA and labs related to increased confusion. Documented by RN G. Record review of R #1's elopement assessment dated [DATE] (elopement incident) reflected score of 11 and indicated to place him on an elopement risk protocol. Record review of R #1's progress notes reflected: -On 07/20/24 at 9:12 AM, documented by LVN D: Order given for window alarm. Window alarm placed. RP notified. -On 07/20/24 at 12:27 PM, documented by LVN D: Results received for labs and results relayed to NP. Pending orders. -On 07/20/24 at 2:50 PM, documented by LVN D: New order obtained by the NP for Haldol solution once a day for 14 days. Diagnosis: aggression/behaviors. Nurses to document every shift for 14 days any signs or symptoms of elopement, behaviors, aggression. Nurses to notify NP if behaviors continued. -On 07/20/24 at 2:55 PM, documented by LVN D: Consent obtained by SP to administer Haldol. -On 07/20/24 at 10:44 PM, documented by RN G: R #1 was seen by psych NP. Obtained orders for Haldol for the treatment of psychosis and agitation. Monitor sleep hours and call if condition worsened. Orders placed. Resident rested in bed and on 1:1 supervision for continued exit seeking behavior. -R #1 continued to be monitored by staff. Staff attempted to find placement for R #1 at a secured unit and worked with R #1's RP until placement was found and R #1 was transferred on 07/25/24. Interview with LE on 07/23/24 at 4:45 PM revealed LE was dispatched to an apartment complex nearby the facility. LE said on 07/19/24 at around 7:45 PM she contacted R #1 who was sitting on a bench, sweaty, and thirsty . LE said R #1 was confused and answered her questions with irrelevant answers. LE said R #1 had a phone which she used to call R #1's FM and the FM informed her that R #1 was a resident at the facility. LE said she went to the facility and spoke to the staff. LE said the staff did not know that R #1 was not in the facility. LE said the staff were able to identify R #1 and verified R #1 was a resident. LE said she went to R #1's room with the staff and saw R #1's window was open. LE said her partner brought R #1 to the front of the building and the staff took R #1 back into the facility. LE said R #1 was not injured. LE said the apartment complex where R #1 was found was about a block down the street. Interview with R #1 on 07/24/24 at 2:30 PM revealed R #1 did not answer basic questions appropriately. R #1 answered with irrelevant topics. R #1 appeared confused, stopped answering questions, and did not continue the interview. Observation of R #1 on 07/24/24 at 2:35 PM revealed R #1 was in the same room, 21, he was in when he eloped, and staff saw the window fully open on 07/19/24. R #1 was wearing a wander guard on his wrist. Window was observed locked with window alarm. Window was about a foot off the floor and large enough where R #1 had likely fit. Interview with CNA A on 07/24/24 at 3:00 PM revealed CNA A said she worked on the 6 AM-6 PM shift. CNA A said she was informed about R #1's elopement on 07/20/24. CNA A said she was not working at that time. CNA A said she did not work much with R #1 and was not familiar with him. CNA A said she was in-serviced on elopements and abuse/neglect after the incident of R #1 eloping. CNA A said during their rounds they ensured to see each resident and if they noticed someone was missing, she would report it to the nurse immediately, call a code silver, and start looking in all the rooms, restrooms, closets, etc. CNA A said they would search outside and continue to search until the resident was found and if not, then call the police as well. CNA A said she also knew to report any changes to the nurse for any resident. CNA A said she had been in-serviced on these topics before the incident of R #1 eloping . CNA A said there were other residents that wore the wander guard due to exit seeking behaviors or because they wandered, but none of the residents had eloped before as the wander guard and verbal redirection was normally successful. CNA A said she knew to redirect the residents when they tried to go towards the exits. Interview with CNA B on 07/24/24 at 3:55 PM revealed CNA B said she worked on the 6 AM-6 PM shift. CNA B said she worked on 07/19/24 with R #1 during the day and he did not have different behaviors out of the ordinary. CNA B said she worked with R #1 and there were days that he was more confused than others. CNA B said R #1 looked out through the exit door windows, but returned to the hall and did not try to leave. CNA B said R #1 walked slowly, but he walked. CNA B said R #1 wore the wander guard even before the elopement. CNA B said she was informed about R #1's elopement when she worked the next day, 07/20/24. CNA B said that next day, she was in-serviced on what to do when a resident was missing and abuse/neglect. CNA B said they were trained to notify the nurse immediately, call a code silver, and search every room. CNA B said they also did an elopement drill and practiced like if someone was missing. CNA B said she knew to check every resident during her rounds, every 2 hours, and if they were not in their rooms, she would check other areas where they could be. CNA B said she knew to report to the nurse immediately if she noticed any change to the resident such as a change to their skin, change to their health, or changes of behavior. CNA B said she was in-serviced on elopements before the incident happened with R #1. Interview with CNA C on 07/24/24 at 4:15 PM revealed CNA C said she worked 8 AM-5 PM and different hours as needed. CNA C said she supervised the CNAs, completed the schedule, and stocked supplies. CNA C said she worked during the day on 07/19/24 and was gone for the day when R #1 eloped. CNA C said she was informed about the incident the next day, 07/20/24. CNA C said R #1 was known to go towards the doors and was sometimes redirectable, sometimes not. CNA C said R #1 would get upset and would not want to come back away from the doors when being redirected. CNA C said they tried to distract him from going towards the exit doors. CNA C said R #1 had the wander guard in place and the door alarm rang if R #1 got too close to it the door. CNA C said the nurses ensured R #1 had the wander guard in place. CNA C said R #1 was confused at times and was able to walk steadier at times. CNA C said she was in-serviced on elopement and abuse/neglect after the incident of R #1 eloping. CNA C said she also participated in the elopement drills. CNA C said even before the incident, they had provided in-services for elopements and abuse/neglect. CNA C said the CNAs were also aware to report any changes to the nurses right away. CNA C said if the CNAs noticed the resident was acting different, had a new rash, or a new injury, the staff would have reported that to the nurses. Interview with CNA D on 07/24/24 at 4:40 PM revealed CNA D said she worked on the 6 AM-6 PM shift. CNA D said she did not work when R #1 eloped but was informed about the incident the next day, 07/20/24. CNA D said she had worked with R #1 in the past and knew R #1 could be confused at times and wore the wander guard. CNA D said if R #1 got too close to the doors, the alarms would sound as he wore the wander guard. CNA D said the CNAs and the nurses ensured R #1 had the wander guard on. CNA D said R #1 used the wander guard because he tried to go towards the doors and exit. CNA D said they redirected him and tried to get him to do something else. CNA D said the redirection would usually work but some days were harder than others. CNA D said the staff always monitored R #1 and checked where he was during their rounds. CNA D said the staff rounded every 2 hours and as needed and ensured to see each resident assigned in their hall. CNA D said if the residents were not in their rooms, they checked other areas until they accounted for each resident. CNA D said she was in-serviced on elopements the day after R #1 eloped. CNA D said she was in-serviced on 07/20/24. CNA D said if the staff could not find a resident during their round, they were trained to report it to the nurse, call a code silver, search everywhere inside/outside, and call the police if the resident was not found. CNA D said she was also in-serviced on abuse/neglect. CNA D said they also practiced elopement drills. CNA D said she had been in-serviced on these topics before the incident. Interview with HA A on 07/24/24 at 5:00 PM revealed HA A said she worked on the 6 AM-6 PM shift. HA A said she worked with R #1 on 07/19/24 during the day and was gone by the time R #1 eloped. HA A said she was informed about the incident the following time she worked, but she did not remember the exact date. HA A said R #1 tried to leave in the past and he tried to go exit the doors. HA A said she redirected R #1 constantly as he continued to try to exit seek. HA A said she was informed when R #1 was experiencing a change of condition and knew to report any changes to his behavior. HA A said R #1 exit seeking was not abnormal for him because he would do that all the time. HA A said R #1 knew what he was trying to do when he tried to exit seek and would say to let him go. HA A said she was in-serviced on elopements on 07/22/24. HA A said she was told to notify the nurse if she could not find someone during her rounds, call a code silver, check the rooms, closets, search inside/outside the building, and call the police if the resident was not found. HA A said she was also informed to ensure the residents were not trying leave through the window since R #1 left through the window. HA A said there were alarms installed on the windows so the alarms would sound off too. HA A said she was not sure if the window alarms were placed on all the windows. HA A said R #1 was placed on a 1:1 when he returned and had been on a 1:1 ever since then. HA A said she was assigned to R #1 today and supervised him. HA A said R #1 would remain on the 1:1 until they found another place for him. HA A said she was already trained and in-serviced on elopements even before the incident of R #1 eloping. Interview with LVN A on 07/24/24 at 5:25 PM revealed LVN A said she worked on the 2 PM-10 PM shift. LVN A said she worked on 07/19/24 when R #1 eloped. LVN A said she was in another hall and saw LVN B took R #1 to the restroom at around 7 PM. LVN A said LVN B assisted R #1 in the restroom and then LVN B redirected R #1 back to his hallway. LVN A said RN G was assigned to R #1 that evening. LVN A said she was not sure if R #1 had been exit seeking that day. LVN A said R #1 usually went towards the doors, but the alarms would always sound as he wore the wander guard. LVN A said if they saw R #1 going towards the doors, they redirected R #1 before the alarms went off or tried to. LVN A said she saw R #1 walked towards the end of the halls a couple times. LVN A said she redirected R #1, and he walked back towards the nurse's station and towards his hallway. LVN A said the last time she saw R #1 that evening was when LVN B assisted him to the restroom. LVN A said she saw LE at the front door and let LE in at around 8 PM. LVN A said LE asked if there was a resident missing. LVN A said LE verified it was R #1 that was in their custody. LVN A said she called RN G over since he was assigned to R #1's hallway. LVN A said RN G spoke to LE and LVN A called the DON. LVN A said LE and RN G went to R #1's room and when they opened the door, they saw the window was open. LVN A said LE said her partner would bring R #1 as R #1 had gotten a little aggressive with LE. LVN A said R #1 was sitting outside under the canopy with the other LE. LVN A said RN G ran out with CNA F to get R #1 back inside. LVN A said R #1 was not on a 1:1 before he eloped but was placed on a 1:1 when he returned. LVN A said R #1 was not injured and did not appear dehydrated but looked tired. LVN A said RN G took R #1 to his room and assessed R #1. LVN A said she continued with her rounds in her hallway. LVN A said the DON went to the facility that night and started in-services with all staff. LVN A said she was in-serviced on elopement and abuse/neglect. LVN A said they also completed elopement drills. LVN A said she was trained to call a code silver, staff would respond, assign everyone where to look, search, and notify the DON, ADM, doctor, RP, and LE if needed. LVN A said that protocol was followed for the incident. LVN A said they notified the RP, doctor, DON and ADM. LVN A said R #1 had tried to leave with his family in the past and would say he had to go, or he had to get out of the facility. LVN A said that was normal for him to say and do. LVN A said he wore the wander guard, and they redirected him, distracted him, and tried to offer him different things to keep him safe. LVN A said that was the first time R #1 was able to leave. LVN A said the nurses informed the staff of any changes to the resident and the staff knew to report any changes to the nurses as well. LVN A said she had been in-serviced on elopements before the incident happened with R #1. LVN A said she did not like that this happened to R #1 but sometimes there were not enough staff to monitor everything. LVN A said R #1 had been on a 1:1 since the incident and the residents with the wander guard also had a window alarm installed on their windows for added safety. Interview with SP on 07/24/24 at 7:27 PM revealed SP said she believed R #1 went out the window because R #1 had been saying see that window, I am going to go out that window. SP added that the window was low enough for R #1 to be able to get out. SP did not specify if she informed anyone about R #1's comments. Interview with RN A on 07/25/24 at 2:05 PM revealed RN A said she worked on the 6 AM-2 PM shift. RN A said she worked with R #1 in the past. RN A said R #1 had exit seeking behaviors since he was admitted and was on a 1:1 since he was admitted . RN A said R #1 was taken off the 1:1 because although he would verbalize that he was going to leave, he was easily redirectable. RN A said she assumed the facility thought R #1 would be fine if he was off the 1:1 but she guessed not since R #1 eloped. RN A said she did not know when exactly R #1 was taken off the 1:1. RN A said she believed it would be administration or the doctor that decided to add or remove the 1:1. RN A said R #1 had the wander guard in place and if he got too close to the doors, the alarms rang. RN A said R #1 usually wanted to call his family member and tried to go towards the doors. RN A said R #1 never mentioned he was going to go out the window. RN A said R #1 would also get aggressive towards staff at times. RN A said she did not work when R #1 eloped but was informed about the incident when she returned to work. RN A said she was provided with the in-service for elopements and abuse/neglect. RN A said even before the recent incident, they had given them in-services for elopements. RN A said they knew what to do in case someone was missing. RN A said during their rounds, they knew to make sure they saw every resident, and if they were not in their room, they looked for them in other areas and made sure they saw them. RN A said R #1 was confused at times. RN A said R #1 asked to speak to his family member, he knew the number by memory, but then he would say that he left his car outside or something that did not make sense. RN A said R #1 had moments of increased confusion but that was not uncommon. RN A said the CNAs knew to report any changes especially if the residents had a UTI. RN A said the CNAs were informed if the resident had a UTI and they knew to report any changes of behavior, or other changes. RN A said R #1 walked slowly. RN A said R #1 did not look very strong but when he had been aggressive, he had a surprising amount of strength. RN A said R #1 would get aggressive both physically and verbally. RN A said she was informed that R #1 was not injured from the elopement. RN A said if R #1 was out in the community, there were apartments around the facility, and if R #1 maybe had spoken to someone the wrong way or gotten aggressive with someone who did not know R #1 was demented or his disease, then she believed R #1 could have gotten hurt in that way. Interview with CNA E on 07/25/24 at 2:45 PM revealed CNA E said she worked on the 6 AM-6 PM shift. CNA E said she worked with R #1 often but did not work when R #1 eloped. CNA E said before R #1 was sent to the hospital he was on a 1:1 and she was not sure why R #1 was taken off the 1:1 or when. CNA E said R #1 wore the wander guard on his wrist. CNA E said if R #1 got too close to the doors, the door alarms rang. CNA E said she was not sure how R #1 had the strength to get out the window but that was how she was informed that he eloped. CNA E said R #1 walked, but more like shuffled his feet, to move around. CNA E said she had seen R #1 got aggressive with staff in the past and tried to hit. CNA E said R #1 also got verbally aggressive and yelled at staff to get away. CNA E said she worked with R #1 the days before he eloped, and R #1 was a bit slower than normal. CNA E said ever since R #1 returned from the hospital, he seemed a little more declined, and less ambulatory. CNA E said R #1 was more confused at times or he said things like that he was leaving or that he was going to get his car. CNA E said R #1 would say things that were not actually happening. CNA E said R #1 also asked where the exit was or tried to go towards the door, but they redirected him back. CNA E said R #1 never said he was going to escape or that he was going to go out the window. CNA E said the staff knew if a resident had any change and they would tell them, so they knew to report if there were any other changes or different behaviors. CNA E said she was informed about the incident, and they did an in-service for elopements, abuse/neglect, and what to do if someone was missing. CNA E said they also did elopement drills to practice. CNA E said if a resident was missing, if they heard the door alarm going off, check the area first, check the area outside to see if they got out, check the rooms nearby, report as soon as possible to the nurse, and the nurse would take over and give them further instructions. CNA E said if the resident was not found, maybe also call the police. CNA E said before the incident happened with R #1, she had been in-serviced for elopements and already knew what to do. Interview with LVN B on 07/25/24 at 3:50 PM revealed LVN B said she worked on the 10 PM-6 AM shift but also worked on the other shifts as needed. LVN B said there were several residents that wore the wander guard for their safety because they tried to exit seek so the door alarms rang if the residents got too close. LVN B said that included R #1. LVN B said on 07/19/24, R #1 needed to go to the restroom at around 6:30 PM-7 PM, so she assisted him in the men's shower restroom. LVN B said after R #1 finished, she redirected R #1 back to his hallway, but R #1 decided to sit in a chair by the nurse's station, which he would usually do. LVN B said she continued with her assignments. LVN B said she saw R #1 walk around and that was the last time she saw R #1. LVN B said she saw when LE arrived as she walked back to the nurse's station. LVN B said LE asked if she had an identification for R #1 and LVN B showed her the photo on his file. LVN B said LE verified R #1 was the individual LE had in their custody. LVN B said LE's partner brought R #1 to the front of the building and RN G went out to get him. LVN B said LVN A was on the phone with the DON. LVN B said R #1 had a shuffling gait and walked slowly so they brought his wheelchair outside to assist him. LVN B said RN G took R #1 to his room and assessed him. LVN B said she was not there during the assessments. LVN B said R #1 did not appear to be injured but he was a little sweaty. LVN B said it was humid that day. LVN B said she did not think R #1 looked dehydrated. LVN B said LE brought R #1 back around 8 PM. LVN B said R #1's usual questions were that how far his home was, where did the bus stop, and he would say that the facility was not his home and asked to call his family member. LVN B said those were not abnormal comments or behaviors for him. LVN B said that was the reason why R #1 had the wander guard in place, because he tried to go towards the exit doors. LVN B said R #1 was easily redirectable. LVN B said she had been assigned to him recently before this happened and he also tried to exit seek during the overnight shift. LVN B said she did not remember the exact date, but she documented in her notes. LVN B said she just redirected him. LVN B said R #1 never said he was going to go out the window or tried to get out the window. LVN B said R #1 had finished his antibiotics he was on because he had ESBL (bacterial infection) to the urine. LVN B said it had been like a week before the recent incident happened that he had finished his antibiotics. LVN B said R #1 was confused at times even if he did not have a UTI. LVN B said R #1 had good days with no behaviors and then other days he would be very forgetful and even aggressive. LVN B said she had seen R #1 be aggressive towards staff, cussing at staff, trying to punch them, so both physically and verbally aggressive. LVN B said the DON or administration and the doctor decided if they placed him on a 1:1 from what she knew. LVN B said R #1 was placed on a 1:1 after the incident. LVN B said they also notified the DON, doctor, and family, which was the protocol for an elopement. LVN B said she was provided with in-services starting that night and the following days. LVN B said the in-services were for elopements and they also did elopement drills. LVN B said even before this happened, she had been in-serviced for elopements and it was not something new they learned. LVN B said they were also informed that they placed window alarms for those residents that have the wander guard which included R #1. LVN B said R #1 walked, like shuffled, not walked like normal, but he was on a mission and wanted to leave all the time. LVN B said R #1 did not get hurt from eloping, but he could have gotten hurt since he was not always fully alert, and he was sometimes more confused. Interview with LVN C on 07/25/24 at 4:30 PM revealed LVN C said he worked on the 2 PM-10 PM shift. LVN C said he worked with R #1 and was familiar with him. LVN C said he did not work on the day R #1 eloped. LVN C said R #1 tried to exit seek multiple times since his admission. LVN C said R #1 was on a 1:1 basically since he was admitted . LVN C said R #1 was sent to the hospital on 07/01/24 and after he returned, R #1 was no longer on the 1:1. LVN C said R #1 was sent to the hospital for a fall, but he resulted with no serious injury. LVN C said R #1 was sent to the hospital more as a precaution. LVN C said R #1 was no longer on a 1:1 but he was not sure who decided the 1:1 or took him off it. LVN C said R #1 wore the wander guard since his admission and still currently wore it. LVN C said if R #1 got too close to the doors, the alarms rang. LVN C said the staff had to constantly redirect R #1 and he would sometimes get ups [TRUNCATED]

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 5 residents (R #1) reviewed for care plans. The facility failed to ensure R #1's care plan reflected the use of the wander guard, the antibiotics R #1 received for ESBL (bacterial infection) in the urine, and falls he experienced on 07/01/24, 07/10/24 and 07/14/24. This failure could place residents at risk of not receiving the care and services as indicated in the comprehensive care plans. The findings included: Record review of R #1's face sheet dated 07/24/24 reflected an [AGE] year-old male, with an original admitted [DATE]. Diagnoses included type 2 diabetes, hepatic encephalopathy (brain dysfunction caused by liver dysfunction), mood disorder, unspecified psychosis, hypertension, dementia with other behavioral disturbance, alcohol abuse (in remission), muscle weakness, lack of coordination, and cognitive communication deficit. Record review of R #1's Minimum Data Set (MDS) assessment dated [DATE] reflected R #1 had a BIMS score of 8 (moderate cognitive impairment) and required supervision (oversight, encouragement, or cueing) for bed mobility and transfers. Record review of R #1's incident reports dated 07/01/24, 07/10/14, and 07/14/24 reflected the fall protocol was followed and interventions were implemented for each fall. On 07/01/24 at 5:35 AM, as per 1:1, R #1 rolled out of bed, hitting head on bedside dresser, causing laceration/abrasion to upper forehead. R #1 was assessed and his vitals within normal limits. R #1 noted with continued aggressive behavior. MD ordered for R #1 to be sent to the hospital. RP notified. Hospital contacted and report was given. R #1 was transferred to the hospital at 5:40 AM. Resulted in no other injury besides abrasion to right side of forehead. Recommendations from the team: wound care for abrasion, rehab screen, re-educate to use call light for assistance, neuro checks, and send to hospital for evaluation. MD and RP notified. On 07/10/24 at 7:00 PM, nurse rounding noted R #1 laying on his right side next to his bed, awake, and able to respond. Head to toe assessment completed with no complaints of pain. Staff assisted R #1 and R #1 was in good spirits and joked. As per family members, R #1 was sitting himself down on the side of the bed, misjudged his placement and slid down to the floor/onto his right side. No injuries observed. MD was notified, RP at bedside aware, started neuro checks as per facility protocol, call light within reach, and bed to lowest position. Recommendations from the team: rehab screen, re-education on call light, fall prevention protocol and therapy, and therapy targeted strength, bed mobility, and walking. On 07/14/24 at 2:38 AM, staff reported to nurse that they found R #1 on the floor. Nurse assessed R #1 and R #1 was laying down on his left side with head above the floor. It appeared that R #1 slid off his chair in attempting to get up from chair. R #1 stated he was trying to go back to bed. R #1 denied pain or discomfort. No injuries observed. Reported fall to NP and was instructed to complete neuro checks. Fall precautions continued to be in place. Informed R #1 to use call light for assistance. Bed was at the lowest position and call light within reach. DON and RP notified. Recommendations from the team: rehab screen, re-educate on call light, neuro checks and rehab addressed safety awareness, transfers, gait, and balance. Record review of R #1's order summary dated 07/24/24 reflected the wander guard was initiated for R #1 on 05/24/24: wander guard on at all times for elopement prevention, licensed nurse to assess wander guard every shift to assure it is working properly every shift. Order summary reflected the order for the IV antibiotics: Use 1 gram every 12 hours for bacterial infection/ESBL to the urine until 07/14/24 with start date of 07/04/24. Record review of R #1's MAR dated 05/24/24-07/25/24 reflected a licensed nurse checked the wander guard every shift to assure it was working properly. MAR reflected R #1 received the antibiotics for ESBL in the urine as ordered. Record review of R #1's Care Plan dated 07/24/24 reflected R #1 was at risk of Wandering/Exit Seeking: Resident wanders related to cognitive impairment and is at risk for injury related to: Mood Disorder due to known physiological condition. Date Initiated: 05/24/24. Attempt to determine any pattern or cause of wandering, reassure resident when distressed over placement, mark room door with a familiar object, photo, etc. to aid in remembering room location as indicated, redirect if resident enters a restricted area, notify the immediate supervisor if unable to locate the resident, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, etc. Date Initiated: 05/24/24. R #1's care plan reflected the elopement. Additional interventions after elopement: will find a secured unit for resident to transfer to upon acceptance, will place on one to one and place window alarm as soon as available, and window alarm placed on 07/19/24. Date Initiated: 07/19/24. R #1's care plan reflected R #1 had the potential for falls related to. Date Initiated: 05/24/24. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, encourage socialization and activity attendance as tolerated, encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, fall risk screening upon admission and quarterly to identify risk factors, place the resident's call light is within reach and encourage the resident to use it for assistance as needed. Date Initiated: 05/24/24. Velcro shoes will be used instead of lace shoes. Date Initiated: 07/25/24. -R #1's care plan did not reflect the wander guard R #1 had placed since 05/24/24. R #1's care plan did not reflect the IV antibiotics R #1 received for ESBL to the urine from 07/04/24-07/14/24. R #1's care plan also did not reflect the falls R #1 experienced on 07/01/24, 07/10/24, and 07/14/24 or the interventions implemented for each fall. Interview with LVN A on 07/24/24 at 5:25 PM revealed LVN A said R #1 had been on IV antibiotics for ESBL to the urine about a week before R #1 eloped. Interview with RN A on 07/25/24 at 2:05 PM revealed RN A said R #1 had the wander guard in place and the nurses ensured he wore the wander guard and that it functioned properly. RN A said R #1 was on IV antibiotics for ESBL to the urine when he returned from the hospital on 07/04/24. RN A said she assisted LVN A for one of the falls R #1 experienced on 07/10/24. RN A said R #1's FM was in the room, and he was not injured. RN A said the fall protocol was followed and they continued to monitor him. RN A said they did implement different interventions for each fall, depending on the cause of the fall. RN A said the administration or the doctor, collaborated to try to implement something, but she was unsure of what was implemented for this fall. Interview with LVN A on 07/25/24 at 3:30 PM revealed LVN A said R #1 had been on IV antibiotics for ESBL to the urine. LVN A said R #1 finished the antibiotics on 07/14/24. LVN A said she worked with R #1 when he fell on [DATE]. LVN A said she was in the hall and heard a noise come from R #1's room. LVN A said she went to the room and checked on him. LVN A said R #1's FMs were in the room with him. LVN A said the FMs said that R #1 did not fall but slid off the bed when he went to sit down on the bed. LVN A said she assisted R #1 back into bed and assessed him. LVN A said R #1 had no injuries, but she followed the fall protocol and monitored him. LVN A said she completed the incident report which was part of the protocol. LVN A said R #1 wore the wander guard even before the incident of elopement and continued to have it in place. LVN A said it was part of the MAR to ensure R #1 was wearing the wander guard. Interview with LVN C on 07/25/24 at 4:30 PM revealed LVN C said he worked on 07/01/24 when R #1 had a change of condition as he fell /rolled out of bed. LVN C said it happened during the overnight shift at around 5-5:30 AM. LVN C said R #1 was on a 1:1 and had his bed low. LVN C said he did not recall which staff was assigned to him. LVN C said R #1 rolled out of the bed as he reached for some beans or some food he had on the dresser. LVN C said R #1 turned, rolled off the bed, and hit his head on the dresser next to his bed. LVN C said the 1:1 staff notified LVN C as he called out for help. LVN C said he assessed R #1 and assisted him back up. LVN C said R #1 had a small cut on his eyebrow, approximately 1 centimeter in size. LVN C said he applied pressure to the cut as it was bleeding minimally. LVN C said he notified the doctor and the doctor decided to send him out to the hospital as a precaution. LVN C said he also notified R #1's FM. LVN C said R #1 returned from the hospital and his tests were negative for head injury or other injury. LVN C said the small cut had been scabbed over and it did not require stitches or further medical attention. LVN C said he followed the protocol for the incident and completed the incident report. LVN C said R #1 returned from the hospital with orders for IV antibiotics for ESBL to the urine. LVN C said the orders were carried out. LVN C said R #1 had the wander guard in place because he tried to exit seek since he was admitted . LVN C said the nurses checked the wander guard every day on every shift to ensure R #1 had it on and it was working. Interview with LVN D/MDS Nurse on 07/25/24 at 5:15 PM revealed LVN D said the comprehensive care plan was broken down by departments and each department would add information as needed such add changes or implemented interventions. LVN D said the team discussed any changes or incidents during the morning meetings and throughout that day, the departments went in and adjusted the care plan as needed. LVN D said R #1 had the wander guard since he was admitted , start date on 05/24/24, but she did not know why the care plan did not reflect the wander guard. LVN D said there was a different MDS Nurse back then. LVN D said the wander guard was definitely something that should have been care planned. LVN D said even though it was not in the care plan, the nurses checked the wander guard every day on every shift. LVN D said she updated the care plan for R #1 today, 07/25/24, to reflect the wander guard. LVN D said for falls, the ADON updated the care plans as that was considered risk management and the ADON took care of those. LVN D said the ADON would also have care planned the interventions for the elopement, but she knew they implemented the window alarm, the 1:1, and to find him a secured unit. Interview with RN G on 07/26/24 at 10:10 AM revealed RN G said R #1 had received IV antibiotics therapy when he came back from the hospital for ESBL to the urine and he was on isolation precautions. Interview with ADON on 07/26/24 at 10:45 AM revealed the ADON said the MDS nurse was the staff that updated the care plans. The ADON said for R #1 and the other residents that had the wander guard, the wander guard was something that should have been care planned. The ADON said the MDS nurse was relatively new to the role. The ADON said R #1 was admitted in May 2024 and the other MDS Nurse that left would have been the one to ensure the wander guard was care planned. The ADON said he was unsure how often they reviewed the care plans, but they had meetings for the care plans. The ADON said they had a morning meeting and went over falls, change of conditions, any discharges, etc. The ADON said each department was in the morning meetings. The ADON said if there were falls, those were care planned or should have been care planned. The ADON said on 07/01/24, R #1 rolled off the bed and the interventions implemented were a rehab screen, re-educated to use the call light, neuro checks and he had a little scrape on top of his eyebrow, so they did wound care. The ADON said the cut/scrape R #1 was not a serious injury. The ADON said for the second fall, on 07/10/24, they did a rehab screen, re-educated to use the call light for assistance, therapy targeted upper body strength, bed mobility and walking. The ADON said those were the interventions implemented for that fall. The ADON said R #1's FMs were there when that fall happened, and R #1 was not injured. The ADON said R #1 sat on the bed and slid down. The ADON said it was witnessed and not a true fall, but more like he slid down. The ADON said on 07/14/24, R #1 was going back to his bed, laid down and slid off the bed. The ADON said R #1 was not injured. The ADON the interventions implemented were a rehab screen, re-educated on call light, neuro checks, and therapy addressed safety awareness, gait and balance. The ADON said for each fall they always completed rehab screen. The ADON said he filled out the paperwork for the incident reports and discussed it in the meetings if they needed further interventions. The ADON said the team usually followed the rehab recommendations. The ADON said for falls sometimes they added a visual aide, maybe changed in the room, or adjusted the wheelchair if the resident used one. The ADON said the interventions implemented would have been added to the care plans. The ADON said the interventions were not inputted into R #1's care plan for each fall. The ADON said he was not sure if they needed to update the care plan for each fall. The ADON said they usually had a meeting with himself, MDS nurse, and the DON for care plans. The ADON said he was not sure exactly who was responsible for the care plan being updated. The ADON said there were interventions for each incident for R #1. The ADON said R #1 was also on IV antibiotics when he came back from the hospital on 07/04/24. The ADON said the antibiotics were for ESBL to the urine. The ADON said the IV antibiotics should have also been care planned but it would come off the care plan once R #1 finished the antibiotics. The ADON said he was not sure if those antibiotics were care planned. The ADON said the importance of care planning different things was so that staff knew R #1's behaviors, knew how to care for him, and knew about him. The ADON said the care plans were individualized to each resident and it was important to keep the care plans updated and accurate. Interview with the DON on 07/26/24 at 11:40 AM revealed the DON said she worked at the facility for about a month and R #1 wore the wander guard already when she began. The DON said R #1 was on a 1:1 but then R #1 was sent to the hospital on 07/01/24 because he had a fall and had a small laceration to the eyebrow. The DON said the fall protocol was followed and he returned on 07/04/24. The DON said R #1 did not have an order for a 1:1 when he returned. The DON said R #1's cut was scabbed and treated by wound care. The DON said R #1 also returned with orders for IV antibiotics for ESBL to the urine and the isolation precautions. The DON said the orders were followed and carried out. The DON said R #1 had other falls on 07/10/24 and 07/14/24 which resulted without injury. The DON said the fall protocol was followed for those incidents and there were no concerns. The DON said there were interventions implemented for each fall on 07/01/24, 07/10/24 and 07/14/24. The DON said it was important for the care plans to be updated so staff knew how to care for the residents. The DON said antibiotics should have been care planned and it did not matter if it was through IV or oral. The DON said the wander guard should have been care planned. The DON said falls should have been care planned. The DON said if those things were not care planned, how were staff supposed to know. The DON said as far she knew the orders were still followed and interventions were implemented, but the care plan was not updated for R #1. The DON said she was already formulating her plan of correction and started providing training and re-education to staff. The DON said she did not know what happened before she arrived and started working at the facility, but she was going to try to fix the issues. Interview with the ADM on 07/26/24 at 1:40 PM revealed the ADM said R #1 had 3 falls this month, July 2024. The ADM said the fall protocol was followed for those falls. The ADM said everything was done appropriately and followed up on for the falls. The ADM said the staff notified the nurse, the nurse assessed, called the doctor, obtained/carried out orders, and notified the family. The ADM said there were no serious injuries that resulted from the falls and there was nothing that was reportable. The ADM said the care plan policy said for them to do an incident report for each fall and it said on the incident report what the interventions were. The ADM said she did not think that the care plan needed to reflect each fall. The ADM said she would review the policy and ensure they followed what they needed to do. The ADM said the DON had only worked here for about 4 weeks, so they were still adjusting, reviewing, and learning. The ADM said the DON was also implementing new information and ideas. The ADM said reviewed the care plan for R #1 and the care plan did not reflect the IV antibiotics, falls for July 2024, or the wander guard. The ADM said the current care plan reflected the wander guard but that was updated on 07/25/24, after the state entered. Record review of Fall Management System Policy Origination date: 09/01. Review date: 02/19/21. Revision date: 01/03/17. Policy: It is the policy of this facility that each resident will be assessed to determine his/her risk for falls, and a plan of care implemented based on the resident's assessed needs. A. 3. A care plan is implanted for residents at risk for falls. D. 1. A licensed nurse will complete an incident/accident report after each fall. D. 4. Documentation in the nurse's notes and/or care plan will reflect interventions attempted. D. 8. An administrative nurse will ensure that the resident's' care plan is revised to reflect each fall and interventions that were implemented. Record review of Comprehensive Care Plans Date implemented: 02/10/21. Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 3. The comprehensive care plan will describe at a minimum: a. The services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being. 6. Alternative interventions will be documented, as needed.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards or food service safety for 1 of 1 kitchen reviewed for sanitation in that: 1. The facility failed to ensure all food items were labeled and dated in refrigerator #1. 2. The facility failed to keep personal drinks out of refrigerator#1 3. The facility failed to ensure expired food in refrigerator #2 was discarded. These failures could place residents at risk of foodborne illnesses. The findings included: An observation of the kitchen on [DATE] beginning at 10:15 a.m., revealed there was a plastic container with beans that was not labeled in refrigerator #1, a personal 4 fl. Oz. bottle of water and an open 2-liter plastic bottle belonging to staff in refrigerator #1, and 2 gallons of milk that were expired in refrigerator #2. In an interview on [DATE] at 10:30 a.m., the Dietary Manager said she would immediately discard the 2 gallons of milk that were expired and the beans in the plastic container that was not labeled. The Dietary Manager said kitchen staff were not going to use the milk because they knew it was expired but failed to discard it. The Dietary Manager did not say what negative effects of not labeling the food would be. She said she would in-service and counsel her staff immediately. The Dietary Manager said she conducts quarterly or as needed in-services to her staff regarding labeling/dating. She said she was responsible for making sure policy was followed. In an interview on [DATE] at 4:00 p.m., the Administrator said the Dietary Manager had informed her of the expired milk, plastic container with bean not labeled, and personal food items in refrigerator meant for residents. She said the Dietary Manger had in-serviced and counseled her staff. The Administrator did not say what negative effects of not labeling food, expired food, and personal food in resident's refrigerator were. The Administrator said all food items had been discarded. Record review of facility's Frozen and Refrigerated Foods Storage policy revealed: Procedure: 7. Proper labeling of cooked foods includes the date placed in the refrigerator, and an expiration or use by date.

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 3 of 6 halls and 1 of 1 dining rooms reviewed for environment, in that: The facility failed ensure that 3 of 11 rooms (room [ROOM NUMBER], 21 and 22) in Hall B, 4 of 12 rooms (room [ROOM NUMBER], 47, 48, and 49) in Hall E, 5 of 11 rooms (room [ROOM NUMBER], 54, 55, 57 and 59) in Hall F received repair and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior that was free of environmental hazards. An IJ was identified on 07/21/23. The IJ template was provided to the facility on [DATE] at 4:52pm. While the IJ was removed on 08/09/23, the facility remained out of compliance at a scope of widespread and a severity level of no actual harm with potential for more than minimal harm because repair of damaged areas had not yet been completed. These failures could lead to residents living in an environment that was unsafe, unfunctional, and/or unsanitary, and could impact the president's ability to achieve or maintain their highest practicable physical, mental, and psychosocial well-being resulting in a diminished quality of life. Findings included: Review of Resident #3's face sheet dated 07/21/23 reflected a [AGE] year-old male who resided in Hall B was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, unspecified (kidney damage, and kidneys cannot filter blood as well as they should), delusional disorders (A belief or altered reality that is persistently held despite evidence or agreement to the contrary), vascular dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, an anxiety (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain) and dysphagia, oropharyngeal phase (difficulty swallowing). Review of Resident #3's quarterly MDS assessment dated [DATE], reflected a BIMS of 10, indicating a moderate cognitive impairment. Review of Resident #5's face sheet dated 07/21/23 reflected a [AGE] year-old male who resided in Hall F and was admitted to the facility on [DATE] with diagnoses including shortness of breath, type 2 diabetes mellitus with hyperglycemia (high blood sugar), unspecified fracture (break) of upper end of right tibia (shin), subsequent encounter for closed fracture with routine healing and dysphagia, oropharyngeal phase difficulty swallowing). Review of Resident #5's quarterly MDS, dated [DATE], reflected a BIMS of 12, indicating a moderate cognitive impairment. Review of Resident #6's face sheet dated 07/21/23 reflected a [AGE] year-old male who resided in Hall F and was admitted to the facility on [DATE] with diagnoses including myocardial infarction (A blockage of blood flow to the heart muscle )type 2, type 2 diabetes mellitus with hyperglycemia (high blood sugar), vascular dementia, moderate, with psychotic disturbance, (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain) and end stage renal disease (kidneys are no longer able to work at a level needed for day to day life). Review of Resident #6's quarterly MDS, dated [DATE], reflected a BIMS was not completed for Resident #6 due to the resident being rarely/never understood. Review of Resident #7's face sheet dated 07/21/23 reflected a [AGE] year-old male who resided in Hall E and was admitted to the facility on [DATE] with diagnoses including critical illness myopathy (group of disorders primarily affecting the skeletal muscle structure, metabolism, or channel function), essential (primary) hypertension (high blood pressure), acute diastolic (congestive) heart failure (develops when your heart doesn't pump enough blood for your body's needs) and hypothyroidism, unspecified (A condition in which the thyroid gland doesn't produce enough thyroid hormone). Review of Resident #7's quarterly MDS, dated [DATE], reflected a BIMS of 15, indicating Resident #7 was cognitively intact. Review of Resident #8's face sheet dated 07/21/23 reflected a [AGE] year-old female who resided in Hall E and was admitted to the facility on [DATE] with diagnoses bilateral (affecting both sides) primary osteoarthritis of knee (breakdown of cartilage between knee joints), chronic kidney disease, stage 3A (kidney damage, kidneys are less able to filter and work as well as they should), dementia in other disease classified elsewhere, mild, with other behavioral disturbance (A group of thinking and social symptoms that interferes with daily functioning.) and essential (primary) hypertension (high blood pressure). Review of Resident #8's quarterly MDS, dated [DATE], reflected a BIMS of 15, indicating Resident #8 was cognitively intact. Review of Resident #9's face sheet dated 07/21/23 reflected a [AGE] year-old male who resided in Hall E and was admitted to the facility on [DATE] with diagnoses including cerebral infarction, unspecified (disrupted blood flow to the brain due to problems with the blood vessels that supply it), type 2 diabetes mellitus with hyperglycemia (high blood sugar), vascular dementia, moderate, with behavioral disturbance (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), and dysphagia (swallowing difficulties) following cerebral infarction. Review of Resident #9's quarterly MDS, dated [DATE], reflected a BIMS of 09, indicating a moderate cognitive impairment. Review of Resident #10's face sheet dated 07/21/23 reflected a [AGE] year-old male who resided in Hall E and was admitted to the facility on [DATE] with diagnoses including cocaine abuse, uncomplicated, type 2 diabetes mellitus with hyperglycemia (high blood sugar), blindness (complete or partial loss of vision) left eye category 5, normal vision right eye, and essential (primary) hypertension (high blood pressure). Review of Resident #10's annual MDS, dated [DATE], reflected a BIMS of 15 indicating Resident #10 was cognitively intact. Observation of dining room on 07/19/23 at 1:50pm revealed an open area in the ceiling that was covered with a plastic sheet. No residents were directly under the open area however residents were still using the dining room. Observation of rooms in Hall E on 07/19/23 at 5:11pm revealed room [ROOM NUMBER] was locked and required a key for entrance, room [ROOM NUMBER] was not in use and had no resident staying in room. room [ROOM NUMBER] had water damage to ceiling with black colored bio growth on ceiling, approximately 6ft x 6ft and a trash can that was collecting brown colored liquid. Observation of rooms in Hall E on 07/19/23 at 5:15pm revealed room [ROOM NUMBER] was locked and required a key for entrance, room [ROOM NUMBER] was not in use and had no resident staying in room. room [ROOM NUMBER] had water damage to ceiling with torn areas of ceiling sheet rock, staining on ceiling, a trash can that had collected brown colored liquid, and a black colored bio growth surrounding the exhaust vent in the restroom. Observation of rooms in Hall E on 07/19/23 at 5:17pm revealed room [ROOM NUMBER] was locked and required a key for entrance, room [ROOM NUMBER] was not in use and had no resident staying in room. room [ROOM NUMBER] had water damage to ceiling with bubbling paint at tape joints and opened bubbling areas on ceiling. Observation of rooms in Hall E on 07/19/23 at 5:18pm revealed room [ROOM NUMBER] was locked and required a key for entrance, room [ROOM NUMBER] was not in use and had no resident staying in room. room [ROOM NUMBER] had water damage to ceiling and walls, staining on ceiling, bubbling paint at tape joints, torn areas of ceilings sheet rock, unsanitary linen on the floor and a black colored bio growth surrounding exhaust vent in the restroom. Observation of rooms in Hall F on 07/19/23 at 5:22pm revealed room [ROOM NUMBER] was locked and required a key for entrance, room [ROOM NUMBER] was not in use and had no resident staying in room. room [ROOM NUMBER] had water damage to ceiling with staining on ceiling and black colored spots of bio growth present on ceiling, and brown colored staining streaks on floor. Observation of rooms in Hall F on 07/19/23 at 5:23pm revealed room [ROOM NUMBER] was locked and required a key for entrance, room [ROOM NUMBER] was not in use and had no resident staying in room. room [ROOM NUMBER] had water damage to ceiling with staining on ceiling, torn and bubbling paint on ceiling with broken off pieces on the floor and spots of black colored bio growth on ceiling. Observation of rooms in Hall F on 07/19/23 at 5:24 pm revealed room [ROOM NUMBER] was locked and required a key for entrance, room [ROOM NUMBER] was not in use and had no resident staying in room. room [ROOM NUMBER] had water damage to ceiling with brown and black staining to ceiling. Observation of rooms in Hall F on 07/19/23 at 5:25pm revealed room [ROOM NUMBER] was locked and required a key for entrance, room [ROOM NUMBER] was not in use and had no resident staying in room. room [ROOM NUMBER] had water damage to ceiling with staining on ceiling, black colored bio growth on ceiling. The Floor in room [ROOM NUMBER] had brown water stains near window and in middle of room and edge of be frame. Observation of rooms in Hall F on 07/19/23 at 5:26pm revealed room [ROOM NUMBER] was locked and required a key for entrance, room [ROOM NUMBER] was not in use and had no resident staying in room. room [ROOM NUMBER] had a trash can that had collected brown liquid with other trash items such as a soda can floating in trash can. The trash can had 2 towels around its base. Observation of rooms in Hall B on 07/19/23 at 5:52pm revealed room [ROOM NUMBER] was locked and required a key for entrance, room [ROOM NUMBER] was not in use and had no resident staying in room. room [ROOM NUMBER] had brown water damage staining to ceiling with parts of ceiling sheet rock torn and bubbled. Observation of rooms in Hall B on 07/19/23 at 5:53pm revealed room [ROOM NUMBER] was locked and required a key for entrance, room [ROOM NUMBER] was not in use and had no resident staying in room. room [ROOM NUMBER] had water damage to ceiling with bubbling paint at tape joints on ceiling, torn areas of ceilings sheet rock. Observation of rooms in Hall E on 07/19/23 at 5:54pm revealed room [ROOM NUMBER] was locked and required a key for entrance, room [ROOM NUMBER] was not in use and had no resident staying in room. room [ROOM NUMBER] had water damage to ceiling with bubbling paint at tape joints on ceiling, torn areas of ceilings sheet rock. Record review of bids received by facility for roof repair revealed the facility had received 5 bids from roofing companies with the earliest dated 03/30/23. During an observation and interview with Resident #10 on 07/19/23 at 4:53PM revealed his room was in Hall E. Resident #10 stated he had been in his room in E Hall for 10 months and had not had any leaks of water in his room at any time or during a rainstorm. Resident #10 stated he had not seen any black substance growth in his room. During an observation and interview with Resident #9 on 07/19/23 at 6:43pm revealed his room was in Hall E. Resident #9 stated he has had no water leaking in his room and had not seen any black substance on the walls or ceiling. During an observation and interview with Resident #8 on 07/19/23 at 6:47pm revealed her room was in Hall E. Resident #8 stated she had not had any water leaks or black substance growth in her room. Resident #8 stated she had been in her room for 2 months. During an observation and interview with Resident #7 on 07/19/23 at 6:53pm revealed his room was in Hall E. Resident #7 stated his room had been fine and had no wet leaks or black substance growths. Resident #7 stated when it rained water had come out of rooms across the hall, but staff had cleaned it and stopped it from entering rooms. Resident #7 stated he had been in the same room for over a year. During an observation and interview with Resident #6 on 07/19/23 at 7:00PM revealed his room was in Hall F. Resident #6 stated no, when asked if he had seen any leaks in his room or any black substance growths in his room. During an observation and interview with Resident #5 on 07/19/23 at 7:08PM revealed his room was in Hall F. Resident #5 stated he had been in this hall for 8 months and had not noticed any water leaks or black substance growth. During an interview with Resident #9 on 07/20/23 at 2:24pm he stated he had a cough for the last 3 or 4 days, and he had received cough medication. Resident #9 stated being in his room in Hall E had not triggered any allergies or breathing issues stating he did not have concerns with air quality in his room and was comfortable. During an interview with Resident #8 on 07/20/23 at 2:25pm she stated she had not had any respiratory issues since being in her room in Hall E. Resident #8 stated being in her room had not triggered any allergies or breathing issues that she was aware of and stated she did not have any concerns with the air quality in her room and stated she was comfortable in her room. During an interview with Resident #5 on 07/20/23 at 2:30PM he was asked if he had any respiratory issues while being in his room in Hall F and stated he had a panic attack before but stated being in his current room had not triggered any allergies or breathing problems. When asked how he felt about the air quality in his room Resident #5 stated his room stunk of cleaning sprays and stated he wanted to go home. During an interview with Resident #10 on 07/20/23 at 2:40PM he stated he had not had any respiratory issues while being in his room in Hall E. Resident #10 stated he had no concerns with the air quality in his room stating he had been in that room for over 10 months and was comfortable. During an interview with Resident #3 on 08/09/23 at 12:50pm he stated when he was in Hall B he did not have any respiratory issues and stated being in Hall B had not triggered an allergies or breathing issues, Resident #3 stated he had no concerns with his room when he was in Hall B. During an interview with the Administrator on 07/20/23 at 4:54pm she stated her original bid for roof repair from March (03/30/23) had to be redone due to original bid not including roof tile repair that was needed due to the damaged sustained after the storm on 04/29/23. During an interview with the Administrator on 07/20/23 at 1:47pm she stated the hole in the dining room ceiling had been there since she began working at the facility in December of 2022, stating it had been covered and stable without leaking. The Administrator stated every time there was major rain they had taken out the rain water and re done the plastic covering on the hole in the dining room ceiling. The Administrator stated there had been constant roof issues, stating they had been previously fixed but had continued to happen. The Administrator stated the water leaking into resident rooms started since a storm they had on 04/29/23. The Administrator stated the areas that had been damaged were the dining room, E and F Hall and stated she had started seeing more rooms in Hall B damaged. The Administrator stated in order to fix the issues she had gotten bids for repairs and had placed air purifiers in effected halls. The Administrator stated she did not have a planned date for work to begin on roofing, sheet rock or bio growth removal. The Administrator stated they were pending to get quotes from abatement companies and stated they were pending a visit from a roofing company employee to see what areas of the roof could be fixed. The Administrator stated repairing roof leaks were not within the Maintenance directors' scope of practice and required a contractor. The Administrator state the roof had not been fixed because they had been waiting for the insurance to go to the facility and take pictures, stating an insurance adjuster had been to the facility to do a round on 06/19/23. The Administrator stated they were not able to remove the panels and sheet rock due to it being a hazmat issue and needing prior approval. When asked if the issues should have already been corrected The Administrator stated she did not make decisions on financials at that high of an amount. The Administrator stated she kept residents safe in the dining room by not allowing residents underneath the hole and stated if the ceiling hole in the dining room had leaked, they would apply yellow tape to secure the area. The Administrator stated based on her emergency management plan she would remove residents from the area, put wet floor signs and make sure residents did not get near the affected areas. The Administrator stated all residents in effected rooms were relocated to other rooms the night of the storm on 04/29/23. The Administrator stated she had followed her emergency plan in this case stating she made sure they kept the affected areas secured, locked and aware from residents. The Administrator stated they had also assessed residents clinically. The Administrator stated not maintaining the rooms, walls and resident environments could negatively affect the residents because it could harm their immune system if they had a weak immune system, The Administrator stated she would consider any resident in the facility to have an impaired immune system. During an interview with Maintenance director on 07/20/23 at 2:00pm he stated the issues with the roof and water leaking into resident rooms were in Hall E and Hall F and had started the night of a storm on 04/29/23 or 04/29/23. The Maintenance Director stated the dining room ceiling hole would leak when it rained and stated it had been that way for about 10 months. The Maintenance Director stated the ceiling hold in the dining room had been repaired but only lasted a little while, stating it had last been repaired 4 or 5 months before 07/20/23. The Maintenance Director stated Hall E and F had water damage along with some rooms in Hall B. The Maintenance Director stated the facility had gotten proposals for the roof repair before Hall E and F had gotten damaged, he state they were going to try and do a seal coat (a monolithic, fully adhered, fluid applied roofing membrane.) but after the storm on 04/29/23 the roof came off. The Maintenance Director state they did not have a planned date to start working on the roof, sheet rock or bio growth removal. The Maintenance Director stated they were still gathering proposals and stated it was up to the owner and insurance company or whoever makes that decisions, stating he was not sure what level it comes from. The Maintenance Director stated fixing the issues with the roof and rooms was a big job and required a contractor. The Maintenance Director stated the issues had not been fixed because they had not received approval from the owner, insurance or higher ups. When asked if the issues with the roof and rooms should had already been corrected The Maintenance Director stated it was going through a process. The Maintenance Director stated all residents who were in the effected rooms were moved out the same night as the storm. The Maintenance Director stated when the hole in the dining room ceiling leaks they would channel it to one area and if was currently leaking they would rope off the area to keep everyone away from that section. The Maintenance Director stated based on the facility's emergency management plan if the ceiling was leaking, they could evacuate the room and isolate the area, The Maintenance Director stated they followed their emergency plan because they evacuated the effected rooms in Hall E and F and isolated the rooms by locking the doors. The Maintenance Director stated he could not answer how not maintaining the roof, walls and resident environment could negatively affect the residents. During an interview with CNA A on 07/20/23 at 2:15pm he stated he had seen areas that had water damage in resident rooms but stated those rooms did not currently have residents in them. CNA A stated he had not seen any black substance growths in resident rooms and stated he had seen the hole in the dining room leaking but stated residents were seated away from the hole and stated no residents were injured. When asked what had been done about these issues CNA A stated he did not get into it stating they had tried to fix it but when it rained it would leak again. During an interview with LVN B on 07/20/23 at 3:33pm he stated he had only seen water damage in the rooms residents were relocated from but had not seen any black substance growths. LVN B stated after the last rain storm the area in the dining hall ceiling opened and they used emergency buckets to catch the water and rearranged furniture and closed that area off with signs to make sure residents would not have falls. LVN B stated corporate had been in and out of the facility and stated they were pending a follow up from them, he stated it was an on-going process, but they had been contacting various companies to get quotes. During an interview with the Medical Director on 08/28/23 at 9:55am he stated the black substance growth in the facility might result in increased respiratory infections, but stated he was not notified of any residents who had respiratory issues. The Medical Director stated the black substance growth can have other interactions such as exacerbation of COPD, asthma or other exacerbation. The Administrator was notified on 07/21/23 at 4:50 pm, that an Immediate Jeopardy (IJ) had been identified due to the above failures. The IJ template was provided to the Administrator on 07/21/23 at 4:52 PM. A Plan of Removal (POR) was first submitted by the Administrator on 07/21/23 at 8:00 PM with a revised POR accepted on 07/22/23 at 4:30 PM and read as follows: Preparation and/or execution of this plan do not constitute admission or agreement by the provider that immediate jeopardy exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents, or other individuals who draft or may be discussed in this response and immediate jeopardy removal plan. This immediate jeopardy removal plan is submitted as the facility's immediate actionable plan to remove the likelihood that serious harm to a resident will occur or recur. 1. Immediate Action: A. On 7/22/2023 all residents will be transferred from E Hall to a sister facility or alternative. The transfer will occur on 7/22/2023. Residents and RPs were notified of transfer on 7/21/2023 via telephone by Social Services/designee and notification was documented in resident's medical record. There will be one licensed nurse and one certified nurse assistance accompanying residents during transport. B. On 7/22/2023 all residents will be transferred from F Hall to a sister facility or alternative. This will be completed on 7/22/2023. Residents and their RPs were notified of transfer on 7/21/2023 via telephone by Social Services/designee and notification was documented in resident's medical record. There will be one licensed nurse and one certified nurse assistance accompanying residents during transport. C. On 7/22/2023 all residents will be transferred from B Hall to a sister facility or alternative. This will be completed on 7/22/2023. Residents and RPs were notified of transfer on 7/21/2023 via telephone by Social Services/designee and notification was documented in resident's medical record. There will be one licensed nurse and one certified nurse assistance accompanying residents during transport. D. Residents were provided options other than a sister facility. Four residents have elected to be transferred to a long-term care center in (City) E. On 7/21/2023 the facility Administrator scheduled (Asbestos Abatement/Mold Remediation Company) (Project Manager employee) to come on-site 7/22/2023 to test for Mold and Asbestos. Test results will be pending. F. There will be at least 1 licensed nurse, as well as at least 1 certified nurse assistant from the (City) facility, who will remain on-site at the receiving facilities for at least a week to ensure continuity of care. 2. Identification of Residents Affected or Likely to be Affected: A. On 7/22/2023 DON/Designee completed respiratory assessment of each resident to determine if any resident was experiencing any new or exacerbation of respiratory issues. No resident identified from assessments. 3. Actions to Prevent Occurrence/Recurrence: A. Once the environmental mold testing has been completed, and the findings identified, repair of the facility roof and other identified repairs will begin within 48 to 72 hours. B. Contingency plans if mold is identified, and levels above a safe threshold would be to remove all residents form the center. C. The facility has a Scope of Work ([NAME]) emergency services agreement signed on 7/22/2023 in their possession. 4. Monitoring A. Regional Director of Operations will complete a center visit weekly for the next 4 weeks to validate all repairs are progressing as scheduled. 5. The center's medical director was notified on 7/21/2023 at 8:00 pm of the Immediate Jeopardy. On 7/22/2023 the center will conduct an Ad Hoc QAPI meeting to review the citation, and sustaining compliance. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: ________7/24/2023_________ The Surveyor monitored the Plan of Removal on 08/09/23 as follows: Record review of sampled resident's (Resident #1, #3, #4, #5, #6, #7, #8, #9, #10) electronic medical records on 08/09/23 revealed all residents had respiratory assessments completed between 07/21/23 and 07/22/23 with no residents identified with respiratory issues. Record review of electronic medical records for sampled residents (Resident #3, #4, #5, #6, #7, #8, #9, #10) in Hall B, E and F on 08/09/23 revealed all residents had been removed from halls and had been moved to other parts of the building or to other facilities. All sampled residents had documentation in their chart regarding notification of transfer or room change to responsible party or resident. Record review of resident transfers revealed a total of 27 residents were transferred out of facility on 07/22/23 with accompanying transportation services staff or facility staff that would remain working at receiving facilities. During an interview with the Administrator on 08/09/23 at 11:40am confirmed 27 residents had been moved out of effected rooms and halls to other facilities. Observations on 08/09/23 at 11:45am revealed Halls B, E, and F were closed off with shut double doors, plastic sheet barriers and signage with verbiage stating not to enter. Halls B, E and F were not in use, and had no residents in rooms. Record review of facility documents revealed an emergency service agreement between the facility and an Asbestos Abatement/Mold Remediation Company was dated 07/22/23. Record review of facility documents revealed a scope of work dated 07/22/23 from an Asbestos Abatement/Mold Remediation Company. The Scope of work stated, emergency services to engage a 3rd Party consultant to test, assess damage, and to provide direction for corrective actions and protocol. Record review of facility documents revealed an emergency services work authorization from an Asbestos Abatement/Mold Remediation Company dated 07/22/23. Record review of environmental testing lab results dated 07/25/23 revealed samples were collected on 07/22/23 to test for fungal/mold identification and spore count via mycology (mold) spore trap air samples ( Fungal/Mold spore count by Air-O-Cell, Cyclex (d), Bio-Cell or other spore trap cassette/device.) and Mycology (mold) Bulk ID sampled (Fungal/Mold identification - bulk sample, tape lift, swab.) In a telephone interview on 07/28/23 at 9:30 a.m. with the testing lab manager, it was elaborated that testing consisted of a combination of air quality and tape lift procedure. One control sample from exterior environment was taken and a 60% threshold was set. Samples were taken throughout the facility. The rooms that failed was due Trichoderma spores being identified. This spore is not dangerous, however, it is a red flag as it primarily grows on building material and it is an indicator or water damage. If the test had identified any dangerous spores the lab would provide specific instruction on how to scrub the air. Additional review of environment testing of 3 rooms (49,52,57) were identified to have failed with asbestos fibers (2%-3% Chrysotile) identified on floor tile by the door way of room [ROOM NUMBER], the floor tile under the window in room [ROOM NUMBER], and 59, the restroom floor tile in room [ROOM NUMBER], the floor tile in the closet of room [ROOM NUMBER] and on the second layer of floor tile in room [ROOM NUMBER]. Record review of facility documents revealed a scope of work from a Roofing Company dated 07/25/23 that stated, Scope of Work: Roof is approximately 30,000 sq ft. Remove current roof. Install-fully adhered .5 ISO to decking Install -fully adhered .60 Mil TPO roofing system All HVAC curbs and roof penetration will be sealed with TPO products Install new perimeter metal Replace all pipes and roof Minor repairs to Mansards included 20-year NDL Firestone warranty Observation of outside of facility on 08/09/23 at 10:45am revealed multiple crew members were working on roof repairs and designated areas for material/supplies and dumpsters identified away from resident areas. Record review of facility documents received on 08/09/23 revealed the facility had a modified safety plan and had completed fire drill exercises with staff on 08/09/23 to utilize exit strategies while exits in Hall B, E and F were not available. Observation on 08/22/23 at 2:45 pm revealed the facility which at time was having roof repairs had been affected by the rains of a passing tropical storm. The interior of the facility primarily Hall A had suffered extensive damage and hours after the rain had passed was still draining on to buckets throughout the hall. Suspended ceiling tiles had collapsed in the hall ways due to the amounts of fluids absorbed. Dining area had an area where the ceiling had collapsed around a light fixture. The kitchen pantry/fry food storage ceiling had collapsed and was exposed to outside. Through out the building various light fixtures could be seen collecting fluid. During an interview on 08/22/23 at 4:05 pm with the DON revealed a tropical storm had affected the morning and caused water to leak into resident areas, such as rooms and common areas. The DON said they would be evacuating residents to other facilities and had already made calls to make arrangements with accepting facilities. Observation on 08/22/23 at 4:30-6:20 pm revealed the facility coordinating transferring of residents to other facilities. Email on 08/22/23 at 11:19 pm. received by the facility administrator revealed the facility had transferred all resident. Observation on 08/28/23 at 1:30pm revealed the facility had removed all residents and was under construction with crew members working on the roof and inside the facility . Record review of facility policy titled, Emergency Preparedness with an origination date of 01/27/18 and a review date of 08/08/23 stated, It is the policy of this facility to evacuate the building when deemed necessary to protect the life and safety of residents, employees and visitors. Evacuation decisions will be made by the Administrator or incident commander. The decision to evacuate may also be made by local/state authorities. Reasons to evacuate could include severe weather, fire or chemical/biological threats when sheltering in place is not feasible. An IJ was identified on 07/21/23. The IJ template was provided to the facility on [DATE] at 4:52pm. While the IJ was removed on 08/09/23, the facility remained out of compliance at a scope of widespread and a severity level of no actual harm with potential for more than minimal harm because repair of dam

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 3 of 6 halls and 1 of 1 dining rooms reviewed for environment, in that: The facility failed ensure that 3 of 11 rooms (room [ROOM NUMBER], 21 and 22) in Hall B, 4 of 12 rooms (room [ROOM NUMBER], 47, 48, and 49) in Hall E, 5 of 11 rooms (room [ROOM NUMBER], 54, 55, 57 and 59) in Hall F received repair and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior that was free of environmental hazards. An IJ was identified on 07/21/23. The IJ template was provided to the facility on [DATE] at 4:52pm. While the IJ was removed on 08/09/23, the facility remained out of compliance at a scope of widespread and a severity level of no actual harm with potential for more than minimal harm because repair of damaged areas had not yet been completed. These failures could lead to residents living in an environment that was unsafe, unfunctional, and/or unsanitary, and could impact the president's ability to achieve or maintain their highest practicable physical, mental, and psychosocial well-being resulting in a diminished quality of life. Findings included: Review of Resident #3's face sheet dated 07/21/23 reflected a [AGE] year-old male who resided in Hall B was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, unspecified (kidney damage, and kidneys cannot filter blood as well as they should), delusional disorders (A belief or altered reality that is persistently held despite evidence or agreement to the contrary), vascular dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, an anxiety (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain) and dysphagia, oropharyngeal phase (difficulty swallowing). Review of Resident #3's quarterly MDS assessment dated [DATE], reflected a BIMS of 10, indicating a moderate cognitive impairment. Review of Resident #5's face sheet dated 07/21/23 reflected a [AGE] year-old male who resided in Hall F and was admitted to the facility on [DATE] with diagnoses including shortness of breath, type 2 diabetes mellitus with hyperglycemia (high blood sugar), unspecified fracture (break) of upper end of right tibia (shin), subsequent encounter for closed fracture with routine healing and dysphagia, oropharyngeal phase difficulty swallowing). Review of Resident #5's quarterly MDS, dated [DATE], reflected a BIMS of 12, indicating a moderate cognitive impairment. Review of Resident #6's face sheet dated 07/21/23 reflected a [AGE] year-old male who resided in Hall F and was admitted to the facility on [DATE] with diagnoses including myocardial infarction (A blockage of blood flow to the heart muscle )type 2, type 2 diabetes mellitus with hyperglycemia (high blood sugar), vascular dementia, moderate, with psychotic disturbance, (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain) and end stage renal disease (kidneys are no longer able to work at a level needed for day to day life). Review of Resident #6's quarterly MDS, dated [DATE], reflected a BIMS was not completed for Resident #6 due to the resident being rarely/never understood. Review of Resident #7's face sheet dated 07/21/23 reflected a [AGE] year-old male who resided in Hall E and was admitted to the facility on [DATE] with diagnoses including critical illness myopathy (group of disorders primarily affecting the skeletal muscle structure, metabolism, or channel function), essential (primary) hypertension (high blood pressure), acute diastolic (congestive) heart failure (develops when your heart doesn't pump enough blood for your body's needs) and hypothyroidism, unspecified (A condition in which the thyroid gland doesn't produce enough thyroid hormone). Review of Resident #7's quarterly MDS, dated [DATE], reflected a BIMS of 15, indicating Resident #7 was cognitively intact. Review of Resident #8's face sheet dated 07/21/23 reflected a [AGE] year-old female who resided in Hall E and was admitted to the facility on [DATE] with diagnoses bilateral (affecting both sides) primary osteoarthritis of knee (breakdown of cartilage between knee joints), chronic kidney disease, stage 3A (kidney damage, kidneys are less able to filter and work as well as they should), dementia in other disease classified elsewhere, mild, with other behavioral disturbance (A group of thinking and social symptoms that interferes with daily functioning.) and essential (primary) hypertension (high blood pressure). Review of Resident #8's quarterly MDS, dated [DATE], reflected a BIMS of 15, indicating Resident #8 was cognitively intact. Review of Resident #9's face sheet dated 07/21/23 reflected a [AGE] year-old male who resided in Hall E and was admitted to the facility on [DATE] with diagnoses including cerebral infarction, unspecified (disrupted blood flow to the brain due to problems with the blood vessels that supply it), type 2 diabetes mellitus with hyperglycemia (high blood sugar), vascular dementia, moderate, with behavioral disturbance (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), and dysphagia (swallowing difficulties) following cerebral infarction. Review of Resident #9's quarterly MDS, dated [DATE], reflected a BIMS of 09, indicating a moderate cognitive impairment. Review of Resident #10's face sheet dated 07/21/23 reflected a [AGE] year-old male who resided in Hall E and was admitted to the facility on [DATE] with diagnoses including cocaine abuse, uncomplicated, type 2 diabetes mellitus with hyperglycemia (high blood sugar), blindness (complete or partial loss of vision) left eye category 5, normal vision right eye, and essential (primary) hypertension (high blood pressure). Review of Resident #10's annual MDS, dated [DATE], reflected a BIMS of 15 indicating Resident #10 was cognitively intact. Observation of dining room on 07/19/23 at 1:50pm revealed an open area in the ceiling that was covered with a plastic sheet. No residents were directly under the open area however residents were still using the dining room. Observation of rooms in Hall E on 07/19/23 at 5:11pm revealed room [ROOM NUMBER] was locked and required a key for entrance, room [ROOM NUMBER] was not in use and had no resident staying in room. room [ROOM NUMBER] had water damage to ceiling with black colored bio growth on ceiling, approximately 6ft x 6ft and a trash can that was collecting brown colored liquid. Observation of rooms in Hall E on 07/19/23 at 5:15pm revealed room [ROOM NUMBER] was locked and required a key for entrance, room [ROOM NUMBER] was not in use and had no resident staying in room. room [ROOM NUMBER] had water damage to ceiling with torn areas of ceiling sheet rock, staining on ceiling, a trash can that had collected brown colored liquid, and a black colored bio growth surrounding the exhaust vent in the restroom. Observation of rooms in Hall E on 07/19/23 at 5:17pm revealed room [ROOM NUMBER] was locked and required a key for entrance, room [ROOM NUMBER] was not in use and had no resident staying in room. room [ROOM NUMBER] had water damage to ceiling with bubbling paint at tape joints and opened bubbling areas on ceiling. Observation of rooms in Hall E on 07/19/23 at 5:18pm revealed room [ROOM NUMBER] was locked and required a key for entrance, room [ROOM NUMBER] was not in use and had no resident staying in room. room [ROOM NUMBER] had water damage to ceiling and walls, staining on ceiling, bubbling paint at tape joints, torn areas of ceilings sheet rock, unsanitary linen on the floor and a black colored bio growth surrounding exhaust vent in the restroom. Observation of rooms in Hall F on 07/19/23 at 5:22pm revealed room [ROOM NUMBER] was locked and required a key for entrance, room [ROOM NUMBER] was not in use and had no resident staying in room. room [ROOM NUMBER] had water damage to ceiling with staining on ceiling and black colored spots of bio growth present on ceiling, and brown colored staining streaks on floor. Observation of rooms in Hall F on 07/19/23 at 5:23pm revealed room [ROOM NUMBER] was locked and required a key for entrance, room [ROOM NUMBER] was not in use and had no resident staying in room. room [ROOM NUMBER] had water damage to ceiling with staining on ceiling, torn and bubbling paint on ceiling with broken off pieces on the floor and spots of black colored bio growth on ceiling. Observation of rooms in Hall F on 07/19/23 at 5:24 pm revealed room [ROOM NUMBER] was locked and required a key for entrance, room [ROOM NUMBER] was not in use and had no resident staying in room. room [ROOM NUMBER] had water damage to ceiling with brown and black staining to ceiling. Observation of rooms in Hall F on 07/19/23 at 5:25pm revealed room [ROOM NUMBER] was locked and required a key for entrance, room [ROOM NUMBER] was not in use and had no resident staying in room. room [ROOM NUMBER] had water damage to ceiling with staining on ceiling, black colored bio growth on ceiling. The Floor in room [ROOM NUMBER] had brown water stains near window and in middle of room and edge of be frame. Observation of rooms in Hall F on 07/19/23 at 5:26pm revealed room [ROOM NUMBER] was locked and required a key for entrance, room [ROOM NUMBER] was not in use and had no resident staying in room. room [ROOM NUMBER] had a trash can that had collected brown liquid with other trash items such as a soda can floating in trash can. The trash can had 2 towels around its base. Observation of rooms in Hall B on 07/19/23 at 5:52pm revealed room [ROOM NUMBER] was locked and required a key for entrance, room [ROOM NUMBER] was not in use and had no resident staying in room. room [ROOM NUMBER] had brown water damage staining to ceiling with parts of ceiling sheet rock torn and bubbled. Observation of rooms in Hall B on 07/19/23 at 5:53pm revealed room [ROOM NUMBER] was locked and required a key for entrance, room [ROOM NUMBER] was not in use and had no resident staying in room. room [ROOM NUMBER] had water damage to ceiling with bubbling paint at tape joints on ceiling, torn areas of ceilings sheet rock. Observation of rooms in Hall E on 07/19/23 at 5:54pm revealed room [ROOM NUMBER] was locked and required a key for entrance, room [ROOM NUMBER] was not in use and had no resident staying in room. room [ROOM NUMBER] had water damage to ceiling with bubbling paint at tape joints on ceiling, torn areas of ceilings sheet rock. Record review of bids received by facility for roof repair revealed the facility had received 5 bids from roofing companies with the earliest dated 03/30/23. During an observation and interview with Resident #10 on 07/19/23 at 4:53PM revealed his room was in Hall E. Resident #10 stated he had been in his room in E Hall for 10 months and had not had any leaks of water in his room at any time or during a rainstorm. Resident #10 stated he had not seen any black substance growth in his room. During an observation and interview with Resident #9 on 07/19/23 at 6:43pm revealed his room was in Hall E. Resident #9 stated he has had no water leaking in his room and had not seen any black substance on the walls or ceiling. During an observation and interview with Resident #8 on 07/19/23 at 6:47pm revealed her room was in Hall E. Resident #8 stated she had not had any water leaks or black substance growth in her room. Resident #8 stated she had been in her room for 2 months. During an observation and interview with Resident #7 on 07/19/23 at 6:53pm revealed his room was in Hall E. Resident #7 stated his room had been fine and had no wet leaks or black substance growths. Resident #7 stated when it rained water had come out of rooms across the hall, but staff had cleaned it and stopped it from entering rooms. Resident #7 stated he had been in the same room for over a year. During an observation and interview with Resident #6 on 07/19/23 at 7:00PM revealed his room was in Hall F. Resident #6 stated no, when asked if he had seen any leaks in his room or any black substance growths in his room. During an observation and interview with Resident #5 on 07/19/23 at 7:08PM revealed his room was in Hall F. Resident #5 stated he had been in this hall for 8 months and had not noticed any water leaks or black substance growth. During an interview with Resident #9 on 07/20/23 at 2:24pm he stated he had a cough for the last 3 or 4 days, and he had received cough medication. Resident #9 stated being in his room in Hall E had not triggered any allergies or breathing issues stating he did not have concerns with air quality in his room and was comfortable. During an interview with Resident #8 on 07/20/23 at 2:25pm she stated she had not had any respiratory issues since being in her room in Hall E. Resident #8 stated being in her room had not triggered any allergies or breathing issues that she was aware of and stated she did not have any concerns with the air quality in her room and stated she was comfortable in her room. During an interview with Resident #5 on 07/20/23 at 2:30PM he was asked if he had any respiratory issues while being in his room in Hall F and stated he had a panic attack before but stated being in his current room had not triggered any allergies or breathing problems. When asked how he felt about the air quality in his room Resident #5 stated his room stunk of cleaning sprays and stated he wanted to go home. During an interview with Resident #10 on 07/20/23 at 2:40PM he stated he had not had any respiratory issues while being in his room in Hall E. Resident #10 stated he had no concerns with the air quality in his room stating he had been in that room for over 10 months and was comfortable. During an interview with Resident #3 on 08/09/23 at 12:50pm he stated when he was in Hall B he did not have any respiratory issues and stated being in Hall B had not triggered an allergies or breathing issues, Resident #3 stated he had no concerns with his room when he was in Hall B. During an interview with the Administrator on 07/20/23 at 4:54pm she stated her original bid for roof repair from March (03/30/23) had to be redone due to original bid not including roof tile repair that was needed due to the damaged sustained after the storm on 04/29/23. During an interview with the Administrator on 07/20/23 at 1:47pm she stated the hole in the dining room ceiling had been there since she began working at the facility in December of 2022, stating it had been covered and stable without leaking. The Administrator stated every time there was major rain they had taken out the rain water and re done the plastic covering on the hole in the dining room ceiling. The Administrator stated there had been constant roof issues, stating they had been previously fixed but had continued to happen. The Administrator stated the water leaking into resident rooms started since a storm they had on 04/29/23. The Administrator stated the areas that had been damaged were the dining room, E and F Hall and stated she had started seeing more rooms in Hall B damaged. The Administrator stated in order to fix the issues she had gotten bids for repairs and had placed air purifiers in effected halls. The Administrator stated she did not have a planned date for work to begin on roofing, sheet rock or bio growth removal. The Administrator stated they were pending to get quotes from abatement companies and stated they were pending a visit from a roofing company employee to see what areas of the roof could be fixed. The Administrator stated repairing roof leaks were not within the Maintenance directors' scope of practice and required a contractor. The Administrator state the roof had not been fixed because they had been waiting for the insurance to go to the facility and take pictures, stating an insurance adjuster had been to the facility to do a round on 06/19/23. The Administrator stated they were not able to remove the panels and sheet rock due to it being a hazmat issue and needing prior approval. When asked if the issues should have already been corrected The Administrator stated she did not make decisions on financials at that high of an amount. The Administrator stated she kept residents safe in the dining room by not allowing residents underneath the hole and stated if the ceiling hole in the dining room had leaked, they would apply yellow tape to secure the area. The Administrator stated based on her emergency management plan she would remove residents from the area, put wet floor signs and make sure residents did not get near the affected areas. The Administrator stated all residents in effected rooms were relocated to other rooms the night of the storm on 04/29/23. The Administrator stated she had followed her emergency plan in this case stating she made sure they kept the affected areas secured, locked and aware from residents. The Administrator stated they had also assessed residents clinically. The Administrator stated not maintaining the rooms, walls and resident environments could negatively affect the residents because it could harm their immune system if they had a weak immune system, The Administrator stated she would consider any resident in the facility to have an impaired immune system. During an interview with Maintenance director on 07/20/23 at 2:00pm he stated the issues with the roof and water leaking into resident rooms were in Hall E and Hall F and had started the night of a storm on 04/29/23 or 04/29/23. The Maintenance Director stated the dining room ceiling hole would leak when it rained and stated it had been that way for about 10 months. The Maintenance Director stated the ceiling hold in the dining room had been repaired but only lasted a little while, stating it had last been repaired 4 or 5 months before 07/20/23. The Maintenance Director stated Hall E and F had water damage along with some rooms in Hall B. The Maintenance Director stated the facility had gotten proposals for the roof repair before Hall E and F had gotten damaged, he state they were going to try and do a seal coat (a monolithic, fully adhered, fluid applied roofing membrane.) but after the storm on 04/29/23 the roof came off. The Maintenance Director state they did not have a planned date to start working on the roof, sheet rock or bio growth removal. The Maintenance Director stated they were still gathering proposals and stated it was up to the owner and insurance company or whoever makes that decisions, stating he was not sure what level it comes from. The Maintenance Director stated fixing the issues with the roof and rooms was a big job and required a contractor. The Maintenance Director stated the issues had not been fixed because they had not received approval from the owner, insurance or higher ups. When asked if the issues with the roof and rooms should had already been corrected The Maintenance Director stated it was going through a process. The Maintenance Director stated all residents who were in the effected rooms were moved out the same night as the storm. The Maintenance Director stated when the hole in the dining room ceiling leaks they would channel it to one area and if was currently leaking they would rope off the area to keep everyone away from that section. The Maintenance Director stated based on the facility's emergency management plan if the ceiling was leaking, they could evacuate the room and isolate the area, The Maintenance Director stated they followed their emergency plan because they evacuated the effected rooms in Hall E and F and isolated the rooms by locking the doors. The Maintenance Director stated he could not answer how not maintaining the roof, walls and resident environment could negatively affect the residents. During an interview with CNA A on 07/20/23 at 2:15pm he stated he had seen areas that had water damage in resident rooms but stated those rooms did not currently have residents in them. CNA A stated he had not seen any black substance growths in resident rooms and stated he had seen the hole in the dining room leaking but stated residents were seated away from the hole and stated no residents were injured. When asked what had been done about these issues CNA A stated he did not get into it stating they had tried to fix it but when it rained it would leak again. During an interview with LVN B on 07/20/23 at 3:33pm he stated he had only seen water damage in the rooms residents were relocated from but had not seen any black substance growths. LVN B stated after the last rain storm the area in the dining hall ceiling opened and they used emergency buckets to catch the water and rearranged furniture and closed that area off with signs to make sure residents would not have falls. LVN B stated corporate had been in and out of the facility and stated they were pending a follow up from them, he stated it was an on-going process, but they had been contacting various companies to get quotes. During an interview with the Medical Director on 08/28/23 at 9:55am he stated the black substance growth in the facility might result in increased respiratory infections, but stated he was not notified of any residents who had respiratory issues. The Medical Director stated the black substance growth can have other interactions such as exacerbation of COPD, asthma or other exacerbation. The Administrator was notified on 07/21/23 at 4:50 pm, that an Immediate Jeopardy (IJ) had been identified due to the above failures. The IJ template was provided to the Administrator on 07/21/23 at 4:52 PM. A Plan of Removal (POR) was first submitted by the Administrator on 07/21/23 at 8:00 PM with a revised POR accepted on 07/22/23 at 4:30 PM and read as follows: Preparation and/or execution of this plan do not constitute admission or agreement by the provider that immediate jeopardy exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents, or other individuals who draft or may be discussed in this response and immediate jeopardy removal plan. This immediate jeopardy removal plan is submitted as the facility's immediate actionable plan to remove the likelihood that serious harm to a resident will occur or recur. 1. Immediate Action: A. On 7/22/2023 all residents will be transferred from E Hall to a sister facility or alternative. The transfer will occur on 7/22/2023. Residents and RPs were notified of transfer on 7/21/2023 via telephone by Social Services/designee and notification was documented in resident's medical record. There will be one licensed nurse and one certified nurse assistance accompanying residents during transport. B. On 7/22/2023 all residents will be transferred from F Hall to a sister facility or alternative. This will be completed on 7/22/2023. Residents and their RPs were notified of transfer on 7/21/2023 via telephone by Social Services/designee and notification was documented in resident's medical record. There will be one licensed nurse and one certified nurse assistance accompanying residents during transport. C. On 7/22/2023 all residents will be transferred from B Hall to a sister facility or alternative. This will be completed on 7/22/2023. Residents and RPs were notified of transfer on 7/21/2023 via telephone by Social Services/designee and notification was documented in resident's medical record. There will be one licensed nurse and one certified nurse assistance accompanying residents during transport. D. Residents were provided options other than a sister facility. Four residents have elected to be transferred to a long-term care center in (City) E. On 7/21/2023 the facility Administrator scheduled (Asbestos Abatement/Mold Remediation Company) (Project Manager employee) to come on-site 7/22/2023 to test for Mold and Asbestos. Test results will be pending. F. There will be at least 1 licensed nurse, as well as at least 1 certified nurse assistant from the (City) facility, who will remain on-site at the receiving facilities for at least a week to ensure continuity of care. 2. Identification of Residents Affected or Likely to be Affected: A. On 7/22/2023 DON/Designee completed respiratory assessment of each resident to determine if any resident was experiencing any new or exacerbation of respiratory issues. No resident identified from assessments. 3. Actions to Prevent Occurrence/Recurrence: A. Once the environmental mold testing has been completed, and the findings identified, repair of the facility roof and other identified repairs will begin within 48 to 72 hours. B. Contingency plans if mold is identified, and levels above a safe threshold would be to remove all residents form the center. C. The facility has a Scope of Work ([NAME]) emergency services agreement signed on 7/22/2023 in their possession. 4. Monitoring A. Regional Director of Operations will complete a center visit weekly for the next 4 weeks to validate all repairs are progressing as scheduled. 5. The center's medical director was notified on 7/21/2023 at 8:00 pm of the Immediate Jeopardy. On 7/22/2023 the center will conduct an Ad Hoc QAPI meeting to review the citation, and sustaining compliance. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: ________7/24/2023_________ The Surveyor monitored the Plan of Removal on 08/09/23 as follows: Record review of sampled resident's (Resident #1, #3, #4, #5, #6, #7, #8, #9, #10) electronic medical records on 08/09/23 revealed all residents had respiratory assessments completed between 07/21/23 and 07/22/23 with no residents identified with respiratory issues. Record review of electronic medical records for sampled residents (Resident #3, #4, #5, #6, #7, #8, #9, #10) in Hall B, E and F on 08/09/23 revealed all residents had been removed from halls and had been moved to other parts of the building or to other facilities. All sampled residents had documentation in their chart regarding notification of transfer or room change to responsible party or resident. Record review of resident transfers revealed a total of 27 residents were transferred out of facility on 07/22/23 with accompanying transportation services staff or facility staff that would remain working at receiving facilities. During an interview with the Administrator on 08/09/23 at 11:40am confirmed 27 residents had been moved out of effected rooms and halls to other facilities. Observations on 08/09/23 at 11:45am revealed Halls B, E, and F were closed off with shut double doors, plastic sheet barriers and signage with verbiage stating not to enter. Halls B, E and F were not in use, and had no residents in rooms. Record review of facility documents revealed an emergency service agreement between the facility and an Asbestos Abatement/Mold Remediation Company was dated 07/22/23. Record review of facility documents revealed a scope of work dated 07/22/23 from an Asbestos Abatement/Mold Remediation Company. The Scope of work stated, emergency services to engage a 3rd Party consultant to test, assess damage, and to provide direction for corrective actions and protocol. Record review of facility documents revealed an emergency services work authorization from an Asbestos Abatement/Mold Remediation Company dated 07/22/23. Record review of environmental testing lab results dated 07/25/23 revealed samples were collected on 07/22/23 to test for fungal/mold identification and spore count via mycology (mold) spore trap air samples ( Fungal/Mold spore count by Air-O-Cell, Cyclex (d), Bio-Cell or other spore trap cassette/device.) and Mycology (mold) Bulk ID sampled (Fungal/Mold identification - bulk sample, tape lift, swab.) In a telephone interview on 07/28/23 at 9:30 a.m. with the testing lab manager, it was elaborated that testing consisted of a combination of air quality and tape lift procedure. One control sample from exterior environment was taken and a 60% threshold was set. Samples were taken throughout the facility. The rooms that failed was due Trichoderma spores being identified. This spore is not dangerous, however, it is a red flag as it primarily grows on building material and it is an indicator or water damage. If the test had identified any dangerous spores the lab would provide specific instruction on how to scrub the air. Additional review of environment testing of 3 rooms (49,52,57) were identified to have failed with asbestos fibers (2%-3% Chrysotile) identified on floor tile by the door way of room [ROOM NUMBER], the floor tile under the window in room [ROOM NUMBER], and 59, the restroom floor tile in room [ROOM NUMBER], the floor tile in the closet of room [ROOM NUMBER] and on the second layer of floor tile in room [ROOM NUMBER]. Record review of facility documents revealed a scope of work from a Roofing Company dated 07/25/23 that stated, Scope of Work: Roof is approximately 30,000 sq ft. Remove current roof. Install-fully adhered .5 ISO to decking Install -fully adhered .60 Mil TPO roofing system All HVAC curbs and roof penetration will be sealed with TPO products Install new perimeter metal Replace all pipes and roof Minor repairs to Mansards included 20-year NDL Firestone warranty Observation of outside of facility on 08/09/23 at 10:45am revealed multiple crew members were working on roof repairs and designated areas for material/supplies and dumpsters identified away from resident areas. Record review of facility documents received on 08/09/23 revealed the facility had a modified safety plan and had completed fire drill exercises with staff on 08/09/23 to utilize exit strategies while exits in Hall B, E and F were not available. Observation on 08/22/23 at 2:45 pm revealed the facility which at time was having roof repairs had been affected by the rains of a passing tropical storm. The interior of the facility primarily Hall A had suffered extensive damage and hours after the rain had passed was still draining on to buckets throughout the hall. Suspended ceiling tiles had collapsed in the hall ways due to the amounts of fluids absorbed. Dining area had an area where the ceiling had collapsed around a light fixture. The kitchen pantry/fry food storage ceiling had collapsed and was exposed to outside. Through out the building various light fixtures could be seen collecting fluid. During an interview on 08/22/23 at 4:05 pm with the DON revealed a tropical storm had affected the morning and caused water to leak into resident areas, such as rooms and common areas. The DON said they would be evacuating residents to other facilities and had already made calls to make arrangements with accepting facilities. Observation on 08/22/23 at 4:30-6:20 pm revealed the facility coordinating transferring of residents to other facilities. Email on 08/22/23 at 11:19 pm. received by the facility administrator revealed the facility had transferred all resident. Observation on 08/28/23 at 1:30pm revealed the facility had removed all residents and was under construction with crew members working on the roof and inside the facility . Record review of facility policy titled, Emergency Preparedness with an origination date of 01/27/18 and a review date of 08/08/23 stated, It is the policy of this facility to evacuate the building when deemed necessary to protect the life and safety of residents, employees and visitors. Evacuation decisions will be made by the Administrator or incident commander. The decision to evacuate may also be made by local/state authorities. Reasons to evacuate could include severe weather, fire or chemical/biological threats when sheltering in place is not feasible. An IJ was identified on 07/21/23. The IJ template was provided to the facility on [DATE] at 4:52pm. While the IJ was removed on 08/09/23, the facility remained out of compliance at a scope of widespread and a severity level of no actual harm with potential for more than minimal harm because repair of dam