Every finding on record at North Star Ranch Rehabilitation and Healthcare Cen

Based on observation, interview, and record review, the facility failed to ensure the meals served met the nutritional needs of residents for 1 of 1 meal (the lunch meal), as reviewed 1.The facility failed to ensure [NAME] E followed the recipe for preparing mechanical diets for Resident #2 on 06/29/26.2.The facility failed to ensure Dietary Manager C followed the recipe by using the correct scoop size when for preparing pinto beans and sausage for the puree lunch on 06/30/26.These failures could place residents at risk for choking, weight loss, not having their nutritional needs met, and a decreased quality of life. 1. Record review of Resident #2's face sheet, dated 07/02/26, reflected Resident #2 was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included morbid (a chronic disease characterized by a body mass index of 40 or higher accompanied by severe weight-related health complications) (severe) obesity due to excess calories and unspecified protein-calorie malnutrition. Record review of Resident #2's quarterly MDS assessment, dated 04/03/26, reflected Resident #2 made himself understood, and understood others. Resident #2's BIMS score was 9, which reflected his cognition was moderately impaired. Resident #2 required setup or clean-up assistance with eating. Record review of Resident #2's comprehensive care plan, revised on 04/08/26, reflected Resident #2 had an ADL self-care performance deficit related to generalized weakness. The care plan interventions included required setup or clean-up assistance with eating. Record review of Resident #2's physician order dated 04/22/26, reflected: Regular diet Mechanical soft texture, and thin consistency, related to dysphagia. During an observation on 06/29/26 at 12:20 p.m., Resident #2 was sitting at the table and had a mechanical diet which consisted of stuffed bell peppers, and okra. He did not have gravy on his meats.During an interview on 06/29/26 at 12:23 p.m., [NAME] E said Resident #2 should have had gravy on his mechanical bell pepper. During an interview and observation on 06/29/26 at 12:30 p.m., Dietary Manager C said Resident #2 should have had gravy on his mechanical bell pepper. She looked at the policy, and it indicated mech soft meats should have some type of liquid consistency on it.During an interview on 06/29/26 at 12:58 p.m., [NAME] E said she was not sure where the menu was for lunch or what scoop size she should use. She said she had been the cook about a month and no one, even the dietitian, had said anything to her about the scoop size. She said she used a large spoon for the puree and the green scoop for the regular and mech soft. She said she did not know the scoop size of either spoon. She said she just served whatever scoop she had.During an interview on 06/29/26 at 12:59 p.m., Dietary Manager C said she was not sure where the extended menus were. She said she was not sure of the serving size that should have been served for the regular, mech soft or puree lunch served which consisted of stuffed bell pepper and okra. Dietary Manager C called a sister facility or the dietitian and was told the scoop size should have been 4 oz for the mech soft of bell pepper and okra. She said the regular should have received 1 stuffed bell pepper and 4 ounces of okra.During an interview and observation on 06/29/26 at 1:17 p.m., [NAME] E and the surveyor took the correct size scoop which was a 4 ounce and measured the mech soft bell pepper and compared it to the utensils used and it measured 3 ounces. The okra was measured and it measured 4 ounces, which was the correct serving size. She said not serving the correct size could lead to weight loss2. During an observation on 06/30/26 at 12:12 p.m., the Dietary Manager gave 2 scoops of pinto beans and sausage combination using a 4-ounce scoop for 2 residents who required a puree diet.During an interview on 06/30/26 at 12:56 p.m., Dietary manager C said she gave 2 scoops of pinto beans and sausage using the 4-ounce scoop. She said she was supposed to give 6 ounces The surveyor asked about the dietary spreadsheet to verify the serving size and the Dietary Manager could not locate the spreadsheet.During an interview on 07/02/26 at 9:21 a.m., the Registered Dietitian said the correct serving size should be used with all meals. She said kitchen staff should be using the spread sheet when serving to ensure they were following the recipe and serving size. The Registered Dietitian said the spreadsheet indicated what size serving of pinto beans and sausage was supposed to be used. She said the spread sheet also indicated that mechanical diets required gravy on their meat. The Registered Dietitian said she had made a visit on 06/26/26 at the facility and the staff were not using the menu spreadsheet and she did a verbal educated with Dietary Manager C. The Registered Dietitian said the Dietary Manager was responsible for ensuring the cooks and Dietary Manager followed the menu serving size. The registered Dietitian said mechanical diets required some type of liquid on their meats such as gravy to help with swallowing. The Registered Dietitian said it was important to follow the recipe and serve the correct serving size to ensure the residents did not have any swallowing or weight loss issues. During an interview on 07/01/26 at 1:29 p.m., Dietary Manager F said the Dietary Manager C was supposed to serve 6 ounces of pinto beans and sausage for the lunch menu on 06/30/26. He presented the dietary spread sheet, and it revealed 6 ounces of pinto beans and sausage were supposed to be served to the puree residents. He said if Dietary Manager C served 2 scoops of 4- ounces, she did not serve enough. Dietary Manager F said all mech soft should have some type of liquid added to their meats. He said it was part of the menu. Dietary Manager F said not following the serving size or providing enough protein could cause weight loss. He said if the mech soft did not have some type of liquid such gravy it could cause swallowing or choking problems.During an interview on 07/02/26 at 5:05 p.m., the DON said she expected the dietary staff to use the correct serving size so residents could receive the correct portions. She said if mechanical soft diets required some type of gravy or sauce on their food, she expected it to be on the food. The DON said failure to use the correct serving size placed residents at risk for not receiving the nutrition intended. She said failure to have gravy or sauce on mechanical soft diets could cause choking or swallowing issues. The DON said the Dietary Manager was responsible for following the recipe and ensuring the correct serving size and was being used to serve the residents' meals. During an interview on 07/02/26 at 5:52 p.m., the Administrator said she expected the dietary staff to read the menu and use the correct serving size. She said if the menu called for gravy or sauce on residents who required a mechanical soft diet then she expected it to be on the trays. The Administrator said the Dietary Manager was responsible for ensuring the correct serving size was being used when serving the meals. The Administrator said failure to serve the correct serving size or food that required gravy could affect the resident's overall health and well-being.Record review of the facility's policy titled, Menu Planning, revised 08/2017, indicated, Policy: Menu shall be preplanned to include a variety of foods that are nutritionally adequate, attractively prepared, and appetizing. Procedure: The Dietary Manager is responsible for using approved standardized menus to meet the resident nutritional needs and to sustain product consistency and portion control.Record review of the facility's policy titled, Food and Nutrition Services, revised 06/23/25, indicated, Policy Statement: Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. #7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident. The food appears palatable and attractive, and it is served at a safe and appetizing temperature.

Based on observation, interview, and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 1 medication storage area (The Facility Medication Room) reviewed for pharmacy services. The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. Findings included:During an observation and interview on 07/01/2026 at 08:56 AM, the following medications were observed in the facility medication room underneath a counter in a locked cabinet, that all nurses had a key to, awaiting to be disposed:*Pregabalin 25mg- 24 tablets*Lorazepam 0.5mg- 2 tablets*Tramadol 50mg- 16 tablets * Lorazepam 0.5mg- 56 tablets*Fentanyl 50mcg- 4 patches*Morphine 100mg/5ml -20.75 milliliters*Morphine 100mg/5ml -30 milliliters LVN B said the controlled medications had been under the cabinet for about a week that she could remember. LVN B said all narcotics that were discontinued were supposed to be taken to the DON Immediately to be logged and locked in the DON's office. LVN B said the failure placed a risk for the nurses nor the DON being able to account for the narcotic medications that were discontinued. LVN B said no one counted the medications once they were placed in the medication room in the locked cabinet. LVN B said the cabinet was missing a count sheet for the 30ml bottle of Morphine. She found the count sheet in the narcotic count sheet book folded. During an observation and interview on 07/01/2026 9:20 AM, the DON said her locked area for discontinued narcotic medications was in the ADON's office, and she was the only one who had keys. The DON said she meant to get the discontinued narcotic medications on Monday 06/29/2026, but she forgot. During an observation and interview on 07/01/2026 at 9:26 AM, the DON said her expectation was for the nurses to bring the discontinued medications to her immediately after the medications were removed from the medication cart so that she could reconcile the medications and lock the medications in her double locked area in the ADON office immediately. The DON said she normally checked with the nurses on Monday, Wednesday, and Friday mornings to ensure the narcotic medications were reconciled properly. The DON said the failure placed a risk for drug diversion. During an interview on 07/02/2026 at 5:46 PM, the Administrator said when the narcotic medications were discontinued and removed from the medication cart, they should be taken to the DON immediately. The Administrator said the DON was responsible for making sure there were no controlled medications stored in the medication room. The Administrator said the failure placed a risk for the medications not being discarded properly and the DON not having an account for the controlled medication and how many there were. Record review of the facility's policy, revised 06/24/2026, Controlled Substance: Policy Statement: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications.1. Only authorized licensed nursing and/or pharmacy personnel have access 10 Schedule 11 controlled substances maintained on premises.13. Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are securely locked in an area with restricted access until destroyed. 14. Accountability records for discontinued controlled substances are kept with the unused supply until it is destroyed or disposed of as required by applicable law or regulation.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 3 of 4 residents (Residents #12, Resident #27 and Resident #9) reviewed for quality of care. 1.The facility failed to ensure Resident #12's oxygen was set at 2 liters per nasal cannula as ordered on 04/23/26. 2. The facility failed to ensure Resident #27's oxygen concentrator filter was clean. 3.The facility failed to ensure Resident #27's oxygen tubing and water bottle were changed and dated. 4. The facility failed to ensure Resident #9's oxygen tubing was changed when it was dirty. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care. Findings included: 1.Record review of Resident #12's face sheet, dated 07/02/26, reflected Resident #12 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included shortness of breath (feeling that you can't get enough air into your lungs), dementia (a decline in mental ability that interferes with daily life), anxiety (a feeling of unease, worry, or fear, often experienced as a normal reaction to stress), and depression (a common mental health condition characterized by persistent sadness and a loss of interest in activities, significantly impacting daily life). Record review of Resident #12's admission MDS assessment, dated 04/27/26, reflected Resident #12 made herself understood, and was understood by others. Resident #12 BIMs score was an 11 which indicated she had a moderate cognitive impairment. The MDS indicated Resident #12 received oxygen during the 7-day look back period. Record review of Resident #12's comprehensive care plan dated 05/04/26 indicated Resident #12 had oxygen. The intervention was to apply oxygen at 2 liters via nasal cannula and may titrate up to 4 liters. Record review of Resident #12's physician orders dated 04/23/26 indicated an order for Oxygen at 2 liters per minute via nasal cannula continuously. May titrate up to 4 liters to keep oxygen saturations above 90% every shift. During an observation and interview on 06/29/26 at 12:27 p.m., Resident #12 was up in her chair with no oxygen. No distress noted. Resident #12 said she was wearing oxygen but was not sure when or why they stopped applying it. During an interview on 07/01/26 at 11:24 a.m., LVN H said she was Resident #12 nurse. She said Resident #12 did not wear oxygen. She looked at her physician orders and saw she had an order for oxygen at 2 liters continuously. She said she misread the order as may apply oxygen if oxygen saturations fall below 90%. She said she would apply oxygen and call the physician. She checked her oxygen saturations, and it was at 91%. She said failure to apply oxygen as ordered could lead to respiratory issues. During an interview on 07/02/26 at 5:02 p.m., the DON said the nurses were responsible for ensuring oxygen orders were being followed. She said the clinical nurses were the overseers of oxygen. She said failure to apply oxygen as ordered could lead to low oxygen levels which could cause respiratory distress. During an interview on 07/02/26 at 5:50 p.m., the Administrator said if a resident had an order for oxygen, it should be applied. She said the nurses were responsible for ensuring the oxygen was set at the ordered rate, and the DON was the overseers. She said failure to apply oxygen could lead to difficulty breathing. 2. Record review of Resident #27's face sheet dated 7/2/26 indicated she was an [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses which included dementia (decline in memory and thinking skills that interferes with daily life), chronic obstructive pulmonary disease (progressive lung condition that causes difficulty breathing due to damage to the airways), general anxiety (persistent, excessive worrying about everyday matters like health, finances, or family), and shortness of breath. Record review of Resident #27's quarterly MDS assessment dated [DATE] indicated she could make herself understood and she understood others. The MDS also indicated she had a BIMS score of 13 which meant she was cognitively intact. The MDS also indicated she was independent with toileting, dressing, bed mobility, and transfers, and she required set assistance with eating. The MDS also indicated Resident #27 required oxygen therapy while she was a resident. Record review of Resident #27's comprehensive care plan revised 06/24/2026 indicated she had oxygen therapy related to her diagnosis of chronic obstructive pulmonary disease with interventions in place to change oxygen tubing as needed and nebulizer tubing every week. Record review of Resident #27's order summary report dated as of 7/1/26 indicated she had an order for: 1. O2 at 2 liters per minute via nasal cannula. May titrate to 3-4 liters per minute to keep O2 sats >94% as needed for shortness of breath or O2 sats below 90%room air with a start date of 02/02/26 and no end date. 2. Change nebulizer treatment tubing Q week every night shifts every Sunday with a start date of 04/19/26 and no end date. 3. Change O2 tubing as needed with a start date of 04/17/26 and no end date. During an observation and interview on 06/29/26 at 11:06 a.m., Resident #27 was sitting on the side of her bed with oxygen on set at 3 liters per minute. Resident #27 said she wore her oxygen when she was in her room and used a small oxygen machine when she left her room. The oxygen concentrator filter was gray in color and dirty, and the tubing and empty water bottle was dated 5/24/26 as well as her nebulizer mask. During an observation and interview on 06/30/26 at 9:07 a.m., Resident #27 was sitting on her bed with oxygen on set at 3 liters per minute. She continued to have the same empty water bottle dated 5/24/26 and dirty gray filter on her oxygen concentrator. Resident #27 said the staff usually changed it, but it had not been changed that she could recall. During an observation on 07/01/26 at 11:45 a.m., Resident #27 was sitting in her room and her oxygen concentrator continued to have tubing and empty water bottle dated 5/24/26 and Resident #27 said oh I thought the nurse changed it. Resident #27 said she did not realize it had not been changed and did not want to use a dirty line and filter. Resident #27 said the graveyard shift normally changed it out every and was unsure what had happened for them not changing the oxygen tubing. During an observation and interview on 07/02/26 at 2:35 p.m. with LVN K, Resident #27's nasal canula continued to be dated 05/24/25, a new water bottle was in place dated 6/29/26, and oxygen concentrator filter still gray and dirty. LVN K said some of the oxygen nasal cannulas, water bottles, and respiratory masks were changed on the 2 PM-10 PM shift and some were changed out on the 10 PM to 6 AM so she was unsure of who was responsible. LVN K said the oxygen filter and tubing needed to be changed and the oxygen concentrator filter was dirty. LVN K said the failure placed Resident #27 at risk for infection and LVN K said she would clean the filter and replace the tubing. During an interview on 07/02/26 at 2:51 p.m., the ADON said the nebulizer should be changed out weekly and the oxygen should be changed out when compromised (if it falls on the floor, dirty, or water coming through tubing). The ADON said the oxygen concentrator filters should be changed and cleaned weekly. The ADON said she would have expected Resident #27's tubing and water bottle, dated 5/24/26, to be changed out by 07/02/26, but the oxygen tubing should not have been dated. The ADON said the failure placed Resident #27 at risk for respiratory infection or pneumonia. During an interview on 07/02/26 at 5:11 P.M., the DON said maintenance was responsible for cleaning oxygen concentrator filters, but the nurses could and should clean the oxygen concentrator filters. The DON said the oxygen tubing did not have to be changed out. The DON said the nebulizer mask and tubing should be changed every week. The DON said the failure of the dirty oxygen concentrator filter, and old nebulizer mask placed a risk of for compromising the function of the oxygen concentrator and placed Resident #27 at risk for respiratory infection. During an interview on 07/02/26 at 5:41 p.m., the Administrator said her expectation was for the cleanliness of the oxygen concentrator and tubing to be checked and cleaned as needed. The Administrator said she was unsure about a certain day for the change of the tubing or the filters. The Administrator said the DON was responsible for ensuring the oxygen concentrator tubing and filter were changed and cleaned. The Administrator said the failure placed a risk for Resident #27 breathing in dirty germs. 3. Record review of Resident #9's face sheet dated 07/02/2026 revealed a [AGE] year-old female admitted [DATE] with diagnoses which included COPD (Chronic Obstructive Pulmonary Disease, a progressive, irreversible lung disease that restricts airflow and makes breathing difficult), seizures (sudden, uncontrolled bursts of electrical activity in that brain that affects movement and consciousness), dysphagia (difficulty swallowing), hypotension (abnormally low blood pressure), major depressive disorder (a mental health condition characterized by a persistent feeling of sadness and loss of interest in normally enjoyable activities). Record review of Resident #9's Quarterly MDS dated [DATE] revealed Resident #9 had unclear speech, was usually understood by others and usually understood what was said to her with a BIMS score of 8 which indicated moderate cognitive impairment. The MDS indicated Resident #9 required a wheelchair for mobility, set-up assistance with eating, moderate assistance in upper body dressing, transfers, and bed mobility, total assistance in toileting and lower body dressing. Record review of Resident #9's physician order dated 08/29/25 indicated O2 at 2 to 4 liters per nasal cannula to maintain PO2 greater than 90% every shift related to Chronic Obstructive Pulmonary Disease, unspecified (J44.9). Resident #9's physicians' orders accessed 06/30/2026 did not reveal an active order to change oxygen tubing as needed. On 07/01/26, the oxygen order was updated to reflect, Change oxygen tubing prn as needed. Record review of Resident #9's care plan with target completion date of 7/1/26 revealed a focus area of COPD and interventions to include Oxygen at 2 to 4 liters per nasal cannula to maintain PO2 (partial pressure of oxygen levels in the blood) greater than 90% with no parameters to monitor or change oxygen tubing. Record review of Resident #9's June MAR revealed an order that read, Change O2 tubing prn as needed dated 05/01/26 and the oxygen tubing was changed on 06/01/26. Observation and attempted interview of Resident #9 on 06/29/26 in the dining room at 1:12 p.m. revealed the resident received oxygen at 2.5 liters per nasal cannula and the oxygen tubing attached to the oxygen concentrator was laying on the floor, and the tubing had a piece of tape that was brown and curled up at the edges and dated 06/22/26. Additional observation of Resident #9 on 07/02/26 at 2:30 p.m. while the resident was in bed revealed the resident received oxygen at 2.5 liters per nasal cannula and the tubing was lying on the floor and observed brown dust in the pattern of wheel markings on the tubing. The oxygen tubing was dated with a piece of tape that was curled up at the edges and dated 06/22/2026. Resident #9 presented with difficult speech and was unable to state when the tubing was last changed or how often it was changed. During an interview on 07/01/26 at 7:50 a.m., LVN H stated that she was not sure who is responsible for monitoring and changing the oxygen tubing. The LVN H stated that everywhere she has worked, the oxygen tubing and masks are changed weekly on the night shift. LVN H stated that the care plan should reflect the use of oxygen and appropriate interventions to ensure adequate infection control. During an interview on 07/02/26 at 10:20 a.m., LVN B stated that the oxygen tubing is changed weekly, when it is dirty, or observed to be hanging on the ground. LVN B stated the staff would date the tubing by putting a piece of tape on the tubing with the date. LVN B stated that residents who are on continuous oxygen should have the tubing changed more frequently, and that the nurse should document when the tubing is changed. LVN B could not recall when she last changed the tubing for Resident #9. During an interview on 07/02/26 at 12;44 p.m., LVN K stated that the oxygen tubing should be changed weekly to prevent condensation build up in the tubing and respiratory distress. LVN K did not know which nurse was assigned to change the tubing. During an interview on 07/02/26 at 3:00 p.m., the DON stated she had been advised, per corporate nursing, to not date the oxygen tubing. She stated that she advised her staff to change the tubing when it is visibly soiled. The DON stated that it is her responsibility to ensure residents have clean oxygen tubing and that the tubing is monitored and changed as needed when visibly soiled. The DON stated that risks to the residents is illness related to inhaling harmful bacteria or mold. The DON stated she would review the current policy with the corporate nurse and complete spot checks to ensure oxygen tubing is clean. During an interview on 07/02/26 at 4:08 p.m., the Administrator stated that nursing staff are ultimately responsible for ensuring the resident oxygen equipment is clean and serviceable. The Administrator stated the residents are at risk for respiratory infection due to unclean tubing. Record review of the facility's policy titled Oxygen Administration and Oxygen Safety, reviewed 03/03/2026, revealed Steps in the Procedure, 11. Cannula / Mask need changed if it malfunctions or becomes visibly contaminated. The Centers for disease Control and Prevention recommends oxygen concentrators be maintained according to the manufacturer's instructions, with special attention to the air intake filters to prevent contamination and ensure safe oxygen delivery. The air intake filter should be inspected and cleaned 1-2 times per week and replaced every 6-12 months or sooner if visibly clogged. The facility policy does not provide guidance for the cleaning of the oxygen concentrator filter.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs, for 3 of 4 (Resident #12, Resident #3, and Resident #2) residents reviewed for comprehensive resident centered care plan .1.The facility failed to care plan medication for Resident #12 on 04/23/26 which included Eszopiclone (for insomnia), Lexapro (for depression), and Mirtazapine (for appetite and depression).2. The facility failed to care plan medication for Resident #3's on 06/01/26 which included Zolpidem (medication for insomnia).3. The facility did not ensure Resident #2 was measured for diabetic shoes and diabetic insoles per the physician order.These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.The findings included:1.Record review of Resident #12's face sheet, dated 07/02/26, reflected Resident #12 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included dementia (a decline in mental ability that interferes with daily life), anxiety (a feeling of unease, worry, or fear, often experienced as a normal reaction to stress), malnutrition (your body isn't getting enough calories or the right balance of nutrients to stay healthy), and depression (a common mental health condition characterized by persistent sadness and a loss of interest in activities, significantly impacting daily life).Record review of Resident #12's admission MDS assessment, dated 04/27/26, reflected Resident #12 made herself understood, and was understood by others. Resident #12's BIMS score was an 11 which indicated she had a moderate cognitive impairment. The MDS indicated she received an antidepressant and hypnotic medication during the 7-day look-back period.Record review of Resident #12's comprehensive care plan, dated 04/23/26, did not indicate medication of Eszopiclone for insomnia(hypnotic), Lexapro, and Mirtazapine for depression.Record review of Resident #12's physician orders dated 04/23/26 indicated Eszopiclone Oral Tablet 2 MG (Eszopiclone), give 1 tablet by mouth at bedtime related to insomnia.Record review of Resident #12's physician orders dated 04/23/26 indicated Lexapro Oral Tablet 20 MG (Escitalopram Oxalate), give 1 tablet by mouth one time a day related to depression.Record review of Resident #12's physician orders dated 04/23/26 indicated Mirtazapine Oral Tablet 15 MG (Remeron), give 1 tablet by mouth at bedtime related to protein-calorie malnutrition. Record review of Resident #12 's medication administration record dated 06/01/26 through 06/30/26 revealed Resident #12 received: Eszopiclone Oral Tablet 2 MG (Eszopiclone), give 1 tablet by mouth at bedtime related to insomnia , Lexapro Oral Tablet 20 MG (Escitalopram Oxalate), give 1 tablet by mouth one time a day related to depression, and Mirtazapine Oral Tablet 15 MG (Remeron), give 1 tablet by mouth at bedtime related to protein-calorie malnutrition.2. Record review of Resident #3's face sheet, dated 07/02/26 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included Post-traumatic stress disorder also known as PTSD (is a mental health condition triggered by experiencing or witnessing a terrifying event), depression (sadness), and stroke.Record review of Resident #3's admission MDS assessment, dated 06/08/26, indicated Resident #3 understood and was understood by others. Resident #3's BIMS score was 08, which indicated his cognition was severely impaired. The MDS indicated Resident #3 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and eating. The MDS indicated she received hypnotic medication during the 7-day look-back period.Record review of Resident #3's physician orders dated 06/01/26 indicated Zolpidem Tartrate Tablet 5 MG Give 1 tablet by mouth at bedtime related to insomnia. Record review of Resident #12's comprehensive care plan, dated 04/23/26, did not indicate medication of Zolpidem.During an observation and interview on 07/01/26 at 4:22 p.m., the MDS Coordinator said they worked on care plans as a team, but she was ultimately responsible. She looked in Resident #12's medical records and did not see a care plan for her Eszopiclone (for insomnia), Lexapro (for depression), or Mirtazapine (for appetite and depression). She looked at Resident #3's care plan and did not see Zolpidem care planned. She said it was an oversight as to why she missed care planning those medications for Resident #12 and Resident #3. She said care plans were done so the staff would know how to care for the residents. She said the risk could have been that the staff would not know she was on the medication and for what to monitor.During an interview on 07/02/26 at 4:31 p.m., the DON said care plans were a team effort with the IDT. She said she and the MDS Coordinator were the overseers. She said they were made aware of any new orders or changes in the morning meetings and the electronic health records dashboard. She said care plans were done to direct and guide care of the residents. She said if care plans were not done properly, care could be missed.During an interview on 07/02/26 at 4:44 p.m., the Administrator said all disciplines should work together to complete a resident's care plan, but the MDS Coordinator was the overseer. She said care plans were the blueprint of residents' care. She said it was used so staff would know the care the residents needed.Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 06/05/25, indicated, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. #13. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.

Based on interview and record review, the facility failed to coordinate with the appropriate, State-designated authority, to ensure that individuals with a mental disorder, intellectual disability or a related condition received care and services in the most integrated setting appropriate to their needs for 3 of 6 residents (Resident #6, Resident # 31, and Resident #5) reviewed for resident assessments. 1.The facility failed to coordinate with the appropriate state authority to ensure Resident #6 had PASRR Comprehensive Service Plan (PSCP) meetings annually. 2. The facility failed to provide documentation of Resident #31's PASRR PCSP meetings held quarterly in the year 2025.3. The facility failed to provide documentation of Resident #5's habilitation coordination and independent living skills services as requested in the PCSP Form.These failures could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: 1.Record review of Resident #6's face sheet, dated 07/02/26 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with no discharges and included diagnoses of spina bifida (Intellectual and Developmental Disabilities also known as IDD). Record review of Resident #6's admission MDS assessment, dated 03/26/26, indicated Resident #6 understood and was understood by others. Resident #6's BIMS score was 12, which indicated his cognition was moderately impaired. The MDS indicated Resident #6 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and eating. The MDS reflected Resident #6 had an active diagnosis of Spina Bifida. Record review of Resident #6's comprehensive care plan, revised 05/11/26, indicated, Resident #6 had a positive diagnosis of Spina bifida. The intervention was for staff to have specialized services as requested by resident and staff of habilitation coordination, independent living skills training, behavioral support and specialized OT. Record review of the PASRR Level 1 Screening form, dated 05/01/26, reflected Resident #6 had Intellectual and Developmental Disabilities. Record review of the PASRR Evaluation Screening form, dated 05/04/26, reflected Resident #6 had Intellectual and Developmental Disabilities. Record review of Resident #6's medical record did not indicate an annual PCSP meeting occurred in 2025. The last meeting was held 10/23/24. 2. Record review of Resident #31's face sheet dated 7/2/26 indicated she was a [AGE] year-old female who originally admitted on [DATE] with diagnoses which included mild intellectual disabilities (typically characterized by an IQ between 50 and 70, delayed academic learning, and minor deficits in everyday functioning), major depressive disorder (a severe mood disorder characterized by persistent sadness, emptiness, and a loss of interest in daily activities), anxiety (excessive, persistent fear that interferes with daily life), and mixed obsessional thoughts and acts. Record review of Resident #31's annual MDS assessment dated [DATE] indicated she made herself understood and she understood others. The MDS also indicated she had a BIMS score of 12 which indicated she had moderate cognitive loss. The MDS also indicated was considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Record review of Resident #31's comprehensive care plan dated 3/30/26 indicated she was PASRR positive for intellectual disabilities with the interventions for PASRR PCSP meetings to be held with the LMHA and RP at least quarterly. Record review of Resident #31's EMR on 7/2/26 indicated there were no PASRR PCSP meetings held quarterly in the year 2025. 3. Record review of Resident #5's face sheet, dated 07/02/26, reflected Resident #5 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnosis which included intellectual disability (a condition that limits intelligence and disrupts ability necessary for living independently) and developmental disorder of scholastic skills (neurological condition that caused significant, unexpected difficulty in acquiring basic academic skills). Record review of Resident #5's significant change in status MDS assessment, dated 05/8/26, reflected Resident #5 understood others, and made himself understood. Resident #5's BIMS score was 9, which reflected his cognition was moderately impaired. Record review of Resident #5's comprehensive care plan, revised 05/22/26, reflected Resident #5 was PASRR positive for IDD for diagnosis of intellectual disability and developmental disorder of scholastic skills. The care plan interventions included: habilitation and specialized services as requested by resident and staff. habilitation coordination. Record review of Resident #5's PCSP meeting dated 05/13/26 reflected that habilitation coordination and independent living skills services were recommended for Resident #5. Record review of Resident #5's EMR dated 07/01/26 reflected no documentation of habilitation coordination or independent living skills training notes. During a telephone interview on 07/01/26 at 9:01 a.m., the Habilitation Coordinator stated she came to the facility monthly to ensure Resident #5's needs were met. The Habilitation Coordinator stated she had never been told to leave any documentation for the monthly visits. The Habilitation Coordinator stated she particularly did not speak to staff during the visits. During an interview on 07/02/26 at 3:55 p.m., the MDS Coordinator stated she was responsible for ensuring visits were conducted by the Habilitation Coordinator. The MDS Coordinator stated she was not aware when the habilitation coordinator came to visit. The MDS Coordinator stated she did not make a point of contact with the habilitation coordinator because she went straight to the resident. The MDS Coordinator stated the previous MDS Coordinator should have notified the family, LIDDA, and DON 7-10 days prior to give the date and time of the initial and annual meetings. The MDS Coordinator stated she did not know why there were no annual and quarterly meetings held in 2025. The MDS Coordinator stated it was important that documentation was received after every visit for continuity of care, and to ensure the residents received services their entitled too. During a telephone interview on 07/02/26 at 2:23 p.m., the Director of IDD Service stated the habilitation coordinator that was responsible for ensuring quarterly meetings were held was no longer with the company. The Director of IDD Service stated the nursing facility was responsible for conducting the annual/initial meetings and LIDDA was responsible for conducting the quarterly meetings. The Director of IDD Service stated when the facility became aware that there were no quarterly meetings, they should have notified LIDDA. The Director of IDD Service stated she could not state why the quarterly meetings were not held. The Director of IDD Service stated it was important to ensure meetings were held to ensure the residents' needs were met. During an interview on 07/02/26 at 4:08 p.m., the DON stated she could not recall the exact services Resident #5, should be receiving but she expected some type of documentation to be provided after every visit to show the Habilitation Coordinator was in the building. The DON stated she remembered having trouble with the provider's number during the change of ownership in 2025, but she was not familiar with all the PASRR information and the frequency of meetings. The DON stated she did attend the quarterly and annual meetings. The DON stated the previous MDS Coordinator was responsible for ensuring meetings were held in 2025. The DON stated it was important to ensure documentation was provided during each monthly visit and meetings were held quarterly/annually as required to ensure needs were being met. During an interview on 07/02/26 at 4:40 p.m., the Administrator stated she did not know how often the habilitation coordinator came to the facility. The Administrator stated there was not a system in place to monitor the MDS Coordinator oversight of needs. The Administrator stated the MDS Coordinator was responsible for ensuring quarterly and annual meetings were held. The MDS Coordinator stated she did not know why the meetings were not held. The Administrator stated it was important to ensure documentation was provided, and meetings were held annually and quarterly for continuity of care for their services. Record review of the facility's policy titled Preadmission Screening and Resident Review, revised 06/02/26, reflected. The services to be provide by the nursing home and/or specialized services provided by the State that are specified in the Level II PASRR determination, and the evaluation report should be addressed in the plan of care.

Based on interviews and record review, the facility failed to ensure residents had a right to personal privacy for 3 of 3 confidential residents reviewed for resident rights to receive personal mail. The facility did not ensure residents promptly receive mail on Saturdays.This failure could place residents at risk with a decline in a resident's psychosocial well-being and quality of life.Findings include: During a confidential group interview at an undisclosed date and time, 3 residents stated they did not always receive their mail on Saturdays. The residents stated they had to wait until Monday when the Activity Director passed it out. During an interview on 07/01/26 at 9:14 a.m., the Activity Director stated mail should be delivered to residents on Saturdays. The Activity Director stated the facility had gotten cited for not delivering mail to residents on Saturdays previously, and the solution was for the RN Supervisor to deliver the mail to the residents on Saturday. The Activity Director stated there were times she delivered mail to residents from Saturday on Monday that was given to her by the Business Office Manager. The Activity Director stated it was important residents received their mail because it was their right. During an interview on 07/01/26 at 9:20 a.m., the Business Office Manager stated the mail that was delivered on Saturday was placed in a locked box outside her door from the weekend staff. The Business Office Manager stated she was the only one that had a key to the locked box. The Business Office Manager stated there were times she gave the mail from Saturday to the Activity Director to distribute to residents. The Business Office Manager stated either the RN Supervisor, or the nurses were responsible for checking the mailbox and distributing mail on the weekends. The Business Office Manager stated it was important for residents to receive their mail because it was their right. During an interview on 07/02/26 at 4:08 p.m., the DON stated she was unaware residents were not receiving their mail on Saturdays. The DON stated she expected mail to be delivered on Saturdays. The DON stated the RN Supervisor was responsible for checking the mailbox and distributing mail on the weekends. The DON stated it was important for residents to receive their mail because it was their right. During an interview on 07/02/26 at 4:40 p.m., the Administrator stated she expected mail to be delivered to residents on Saturdays. The Administrator stated she did not know who was responsible for distributing mail on the weekends. The Administrator stated there was no system in place to ensure residents receive their mail on Saturdays. The Administrator stated this failure could affect resident's rights. An attempted telephone interview on 07/02/26 at 5:01 p.m. with RN A, the RN supervisor for the weekends was unsuccessful, voicemail left. The policy provided by the facility gave no relevant reference regarding resident's promptly receiving mail.

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 4 of 18 residents (Resident #28, and 3 anonymous) and 1 of 1 lunch meals reviewed for palatability. The facility failed to provide palatable food served at an appetizing temperature or taste for Resident #28, and 3 anonymous residents, who complained the food served was mushy, cold, and hard.The dietary staff failed to provide food that was palatable for the lunch meal observed on 06/30/26.These failures could place residents at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included:During an interview on 06/30/26 at 11:28 a.m., Resident #28 said the vegetables were mushy and the food was cold.During an observation and interview on 06/30/26 at 1:30 p.m., the DON and six surveyors sampled a lunch tray. The sample tray consisted of Pinto beans with sausage, rice, and mixed vegetables. The DON said the sampled regular and puree diet did not meet her expectations with flavor or temperature. She said the Pinto beans with sausage and mixed vegetables could be warmer, and the rice and mixed vegetables were bland. She sampled the puree Pinto beans with sausage and rice, and mixed vegetables and said they were cold. During a confidential resident group meeting 3 residents stated the food was cooked hard. They said they could tell when the Dietary Manager cooked.During an interview on 06/30/26 at 4:36 p.m., Dietary Manager C said she had not had complaints about food but had only been employed for about 3 weeks. She said if the residents did not like the food, they may not eat it, which could cause weight loss.During an interview on 07/02/26 at 9:06 a.m., the Dietitian said she was not aware of any food concerns. She said she did talk to residents when she visited the facility. She said if residents did not like the food it could potentially cause weight loss.During an interview on 07/02/26 at 5:05 p.m., the DON said she expected the temperature to be within parameters and taste should be palatably. She said it was the Dietary Manager's responsibility to ensure the food was palatable. She said if the residents thought the food was too cold, bland, or hard they may not consume enough which could lead to weight loss.During an interview on 07/02/26 at 5:52 p.m., the Administrator said she expected the food to be palatable. She said the Dietary Manager was responsible for ensuring the food served was palatable and served at an appetizing temperature. She said failure to serve palatable food could cause weight loss. Record review of the facility's policy titled, Food Preparation and Service, revised 03/05/26, indicated, Policy: Food and nutrition service employees prepare and serve food in a manner that complies with food handling practices. #4 Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Food Service/Distribution: #4 Food and nutrition service staff, including nursing service personnel, wash hands before serving food to residents. #6 Bare hand contact with food is prohibited. Gloves are worn when handling food directly and change between tasks. #7. Food and nutrition service staff wear hair nets (hair net, hat, restraints, etc.) so that hair does not contact food.Record review of the facility's policy titled, Menu Planning, revised 08/2017, indicated, Policy: Menu shall be preplanned to include a variety of foods that are nutritionally adequate, attractively prepared, and appetizing. Procedure: The Dietary Manager is responsible for using approved standardized menus to meet the resident nutritional needs and to sustain product consistency and portion control.Record review of the facility's policy titled, Food and Nutrition Services, revised 06/23/25, indicated, Policy Statement: Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. #7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident. The food appears palatable and attractive, and it is served at a safe and appetizing temperature.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. The facility did not ensure:1. Food items were labeled and dated.2. Hair restraints were worn correctly. 3. Hand washing was always performed. 4. The floors, bowls, saucers, pots/pans, and stove were cleaned.5. The microwave was clean and free of food debrisThese failures could place residents at risk for foodborne illness.Findings included: During the initial tour observation and interview with the Dietary Manager on 06/29/26 beginning at 10:35 a.m., revealed the following: 1.1 container of melons and 2 juice containers were undated in the refrigerator. 2. Dietary aide L and Dietary Manager C had hair sticking out of their hairnets.3. [NAME] F and Dietary aide N came into the kitchen and did not wash their hands, and no pedal trash can was next to the sink.4. Dirty bowls and saucers were stacked in the clean area but were dirty, pots/pans and stove were dirty with black buildup, and floors in the storage room were dirty and had an ice cream cup and a prefilled juice cup under the bottom shelves.5. The microwave was dirty and had food in it.During an observation on 06/29/26 at 10:35 a.m., Dietary Aide N and the Dietary Manager C hairnets were not covering their entire head. There was loose hair sticking out. During an observation and interview on 06/30/26 at 12:56 p.m., Dietary Aide N said she should have all her hair in the hair net. She said she did not know it was sticking out. Dietary aide L fixed her hairnet. She said all her hair should be completely covered with the hairnet to prevent food from getting into the food. Dietary Aide N said she did go out of the kitchen and returned without washing her hands. She said she knew she was supposed to wash her hand to prevent cross contamination.During an interview on 06/30/26 at 1:36 p.m., Dietary Manger C said hairnet should be worn while in the kitchen. She said all hair should be always covered. She said her hair should be in a hairnet to prevent food from getting into food. She said staff should be washing their hands when they enter the kitchen. She said she took the pedal trash can outside to clean it and had not brought it back inside. She said she knew they should have had the pedal trash can next to the sink to prevent cross contamination.During an interview on 06/30/26 at 3:56 p.m., [NAME] F said all staff were responsible for dating food products. [NAME] F said hair nets should always be worn while in the kitchen and covered the entire head without loose hair sticking out. [NAME] F said she should have washed her hands when she entered the kitchen and as needed between different work areas while in the kitchen. She said these failures could potentially put residents at risk for foodborne illness and cross contamination. During an interview on 07/01/26 at 8:54 a.m., Dietary Manager D said handwashing should be done every time staff leave or enter the kitchen, between every task, and after washing dishes. He said this was done for sanitization and to prevent the spread of germs. He said hairnet should be worn in the kitchen and should not have any hair out the hairnet to prevent hair from getting into the food. He said staff should have a foot pedal trash can to dispose of trash without having to lift the lid to prevent contamination. He said dirty dishes should not be stored with clean dishes, the microwave should be clean, and the floors should be clean and without debris. Dietary Manager D said the kitchen and staff should be clean to prevent foodborne illness and cross contamination.During a telephone interview on 07/02/26 at 9:23 a.m., the Dietitian said the kitchen should be clean and organized. She said staff should be sweeping and mopping each shift and as needed The Dietitian said the dirty dishes should not be stored with clean dishes and the microwave should be cleaned after each use. She said pot/pans and the stove should not have black buildup on them. She said this could prevent the food from cooking evenly. The Dietician said staff who entered the kitchen should wash their hands and use a step trash can to discard their paper towels. She said they should have a step lid to prevent contamination. She said whoever put the food or items up in the refrigerator was responsible for dating them. She said this was done to prevent residents from eating or receiving expired food or items. The Dietician said hair nets should always be worn while in the kitchen and covered the entire head without loose hair sticking out. The Dietician said these failures could potentially put residents at risk for foodborne illness and cross contamination.During an interview on 07/02/26 at 5:05 p.m., the DON said cleanliness was important in the kitchen, so the staff were not spreading germs or contaminating anything. The DON said the Dietary Manager was responsible for making sure the kitchen was cleaned appropriately. The DON said all food should be dated by the date received. The DON said hair nets should be worn while in the kitchen and covering the entire head without loose hair sticking out. The DON said dirty dishes should not be stored with clean dishes. The DON said these failures could potentially put residents at risk for cross contamination and food borne illness. During an interview on 07/02/26 at 5:50 p.m., the Administrator said she expected staff to wash their hands when entering the kitchen and in between as needed, food to be dated, and hair nets to be worn without loose hair sticking out. The Administrator said she expected the kitchen to always be clean. She said clean bowls and dishes should be stored with clean dishes. She said pots/pans and the stove should not have black buildup on them. The Administrator said they should have a pedal trash can to prevent cross contamination. The Administrator said the Dietary Manager was responsible for monitoring and overseeing the kitchen. The Administrator said these failures could potentially put residents at risk for cross contamination, and food borne illness. Record review of the facility's policy titled, Food Preparation and Service, revised 03/05/26, indicated, Policy: Food and nutrition service employees prepare and serve food in a manner that complies with food handling practices. #4 Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Food Service/Distribution: #4 Food and nutrition service staff, including nursing service personnel, wash hands before serving food to residents. #6 Bare hand contact with food is prohibited. Gloves are worn when handling food directly and change between tasks. #7. Food and nutrition service staff wear hair nets (hair net, hat, restraints, etc.) so that hair does not contact food.

Based on record review, observations and interviews, the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 2 of 2 residents (Resident #19 and Resident #37) reviewed in that: The personal refrigerators of Resident #19 and Resident #37 revealed temperatures were outside of the recommended guidelines and Resident #37 did not have a thermometer in his freezer. This failure could place residents at risk of foodborne illness due to consuming spoiled foods. The finding included: Record review of Resident #19's face sheet dated 07/02/2026 revealed an [AGE] year-old male admitted [DATE] and readmitted [DATE]. His diagnoses included Schizoaffective disorder bipolar type (a chronic mental health condition that combines the severe, reality-distorting symptoms such as hallucinations and delusions with mood swings of mania and depression), Benign Prostatic Hyperplasia (non-cancerous enlargement of the prostate gland), and protein calorie malnutrition (a severe condition caused by the inadequate intake of protein, calories or both). Record review of Resident #19's Comprehensive MDS dated [DATE] revealed adequate speech, hearing and communication skills and a BIMS Score of 11 which indicated moderate cognitive impairment with fluctuating inattention and disorganized thinking. The MDS indicated Resident #19 required the use of a walker for mobility, was independent in eating, toileting, dressing, bed mobility and transfers and required setup assistance with bathing. Record review of Resident #19's care plan with target completion date of 08/25/2026 revealed a focus area of Obsessive-Compulsive Disorder (a mental health condition characterized by uncontrollable, recurring thoughts and repetitive behaviors) that indicated Resident #19 will save food for 203 days and then say it is too hard. Interventions do not indicate that the personal refrigerator was monitored for expired foods, dated foods or temperatures within acceptable parameters. Record review of physician's orders revealed a regular diet with no restrictions. During an interview with Resident #19 and observation of personal refrigerator on 06/29/2026 at 11:10 a.m., Resident #19 stated that the girl checks my refrigerator every day. Observation of the personal refrigerator revealed that the refrigerator was clean, contained 3 unsealed and undated clear cups with approximately 4 ounces of milk, 7 closed bottles of grape juice with manufactures expiration of June 2028 and thermometer gauge revealed 50 degrees. Interview and observation with Resident #19 on 07/01/2026 at 10:15 a.m. revealed 2 undated and unsealed clear cups containing approximately 4 ounces of milk, 6 closed bottles of grape juice with manufactures expiration of June 2028 and thermometer gauge at 52 degrees. Resident #19 pointed to the cups of milk and stated, these will be gone by tonight. Interview and observation with Resident #19 on 07/02/2026 at 10:10 a.m., Resident #19 stated, I think she already checked my refrigerator today. Observation of refrigerator contents revealed 2 unsealed and undated clear cups with approximately 4 ounces of milk, 5 bottles of grape juice with manufactures expiration of June 2029 and thermometer gauge revealed 50 degrees. Record review of the temperature log for Resident #19's personal refrigerator from 05/01/2026 - 05/31/2026 revealed temperatures outside of recommended parameters ranging from 42-52 degrees for 20 days, 11 days with no temperature documented. The temperature log was completed by the Activity Director. Record review of the temperature log for Resident #19's personal refrigerator from 06/01/2026 - 06/30/2026 revealed temperatures outside of recommended parameters ranging from 41-53 degrees for 18 days, acceptable parameters ranging from 38-41 degrees for 4 days and 9 days with no temperature documented. The temperature log was completed by the Activity Director. Record review of Resident #37's face sheet dated 07/02/2026 revealed a [AGE] year-old male admitted [DATE] and readmitted [DATE]. His diagnoses included multiple sclerosis (an autoimmune disease that affects the central nervous system, leading to damage of the nerve fibers), paraplegia (paralysis of the legs and lower body), atrial fibrillation (irregular heart rhythm), major depressive disorder (a mental health condition characterized by persistent feelings of sadness, loss of interest that intrudes upon daily life), hypertension (high blood pressure) and neurogenic bowel (a condition in which nerve problems prevent normal bladder control, affecting the ability to store or release urine properly). Record review of Resident #37's Quarterly MDS dated [DATE] revealed adequate speech, hearing and communication skills and a BIMS Score of 12 indicating moderate cognitive impairment. The MDS indicated Resident #37 had upper and lower extremity impairment and required the use of a wheelchair for mobility, was dependent in eating, toileting, bathing, dressing, bed mobility and transfers. Record review of Resident #37's care plan with target completion date of 07/01/2026 revealed no preference for personal food items or use of personal refrigerator. Record review of Resident 337's physician's orders revealed a regular diet with double portions. During an observation of room [ROOM NUMBER]A, observation of refrigerator #1 on 06/29/2026 at 11:18 a.m. revealed a box of corn dogs (unopened with manufactures expiration date of May 2028), a box of tacos (opened with 4 tacos remaining with a manufactures expiration date of August 2028) and refrigerator items that included condiments of miracle whip, mustard and jelly with current manufactures expiration dates. The freezer in refrigerator #1 did not have a thermometer. The thermometer gauge in refrigerator #1 revealed 51 degrees. Observation of refrigerator #2 revealed contents to include a store-bought cake with expiration date that was illegible and a thermometer gauge revealed 62 degrees. Observation and interview on 07/01/2026 at 10:42 a.m. revealed the same food items in refrigerator #1 and refrigerator #2. Refrigerator #1 temperature gauge revealed 60 degrees and refrigerator #2 temperature gauge revealed 52 degrees. Resident #37 stated that both refrigerators belonged to him, that his family provided the food items and that he had never been ill because of spoiled food items. Record review of the temperature log for Resident #37's personal refrigerator from 05/01/2026 - 05/31/2026 revealed temperatures outside of recommended parameters ranging from 42-52 degrees for 9 days, acceptable parameters ranging from 36-41 degrees for 11 days, and 11 days with no temperature documented. Record review of the temperature log for Resident #37's personal refrigerator from 06/01/2026 - 06/30/2026 revealed temperatures of 32-42 degrees for 22 days and 8 days with no temperature documented. The temperature log for Resident #37 reflected only one refrigerator although there were two refrigerators in his room and did not reflect the temperature log for the freezer. The temperature log was completed by the Activity Director. During an interview on 07/01/2026 at 8:07 a.m., the Activity Director stated that she checks the personal refrigerators every day for cleanliness and temperature check and that she checks to ensure the temperature gauge range was between 32-40 degrees. The Activity Director stated she checks some of the food for dates and will ask the resident when the food was received if there was no date and throw it away if it was too long. She stated she was not aware of any resident getting sick because their food was spoiled. The Activity Director could not say why she did not report the temperatures obtained were outside of the recommended parameters. During an interview on 07/01/2026 at 9:05 a.m., CNA G stated that she was not sure who monitored the residents' personal refrigerators and that she was not aware of any time when the residents were sick because of spoiled food. During an interview on 07/01/2026 at 9:10 a.m., CNA L stated that the Activity Director checks the refrigerators for expiration dates of food items and that she did not know what a recommended temperature for the refrigerator was. During an interview on 07/02/2026 at 10:20 a.m., LVN B stated that the night shift nurse and the Activity Director check the refrigerators for acceptable temperatures. LVN B stated she was not sure what an acceptable temperature for the refrigerator or freezer was and that risks to residents would be food poisoning if the food was not properly stored. During an interview on 07/02/2026 at 3:00 p.m., the DON stated that the Activity Director was responsible for ensuring and logging the temperature logs of the resident's personal refrigerators. The DON stated the risk for of not following the policy guidelines for acceptable temperatures would be the residents could consume spoiled food items. During an interview on 07/02/2026 at 4:08 p.m., the Administrator stated that she expected the facility staff to follow the recommended temperature guidelines as designated in the personal refrigerator policy. The Administrator stated the risk would be residents consuming spoiled food items that could make them ill. The Administrator stated she was not aware that the personal refrigerator temperature logs did not reflect acceptable parameters or that one of the freezers did not have a thermometer and that she would review the policy with the Activity Director. Record review of the facility Personal Refrigerator Policy, reviewed 03/03/2026, revealed Temperature Control, the refrigerator compartment should be maintained at temperature of 35-41 degrees, and the freezer compartment should be maintained at zero degrees or less; and Cold Food Storage revealed food products should be stored by Commonly Used Dates such as Sell by and Best Buy. The refrigerator policy does not reflect the need to date or label items that are not stored in the original container. Additionally, the refrigerator policy revealed that the housekeeping staff can assist the resident or family member by inspecting the refrigerators at least weekly and assist with the removal of outdated food items and cleanliness.

Based on record reviews and interviews the facility failed to maintain medical records in accordance with the accepted professional standards and practices that are complete and accurately documented for 2 of 2 (Resident #9 and Resident #24) residents reviewed for documentation. Resident #9 and Resident #24's electronic medical record did not contain complete and accurate documentation that reflected that the resident or the responsible party were informed of and attended or declined to attend the quarterly care conference meeting. This failure could result in the residents' records not accurately documenting participation in the plan of care.The findings included: Record review of Resident #9's face sheet dated 07/02/2026 revealed a [AGE] year-old female admitted on [DATE]. Her diagnoses included COPD (Chronic Obstructive Pulmonary Disease, a progressive, irreversible lung disease that restricts airflow and makes breathing difficult), seizures (sudden, uncontrolled bursts of electrical activity in that brain that affects movement and consciousness), dysphagia (difficulty swallowing), hypotension (abnormally low blood pressure), major depressive disorder (a mental health condition characterized by a persistent feeling of sadness and loss of interest in normally enjoyable activities). The face sheet indicated that Resident #9's family member was her Responsible Party. Record review of Resident #9's Quarterly MDS dated [DATE] revealed Resident #9 had unclear speech, was usually understood by others and usually understood what was said to her with a BIMS score of 8 which indicated moderate cognitive impairment. The MDS indicated Resident #9 required a wheelchair for mobility, set-up assistance with eating, moderate assistance in upper body dressing, transfers, and bed mobility, and total assistance in toileting and lower body dressing. Record review of Resident #9's care plan with target completion date of 07/1/26 revealed a focus area that reflected impaired cognitive function, dementia or impaired thought processes related to history of traumatic brain injury initiated 09/21/2021 and a psychosocial well-being focus potential related to social isolation initiated 06/03/2025 with interventions that included to provide opportunities for the resident and family to participate in care. Review of the Care Conference & DC Case Management Evaluations for Resident #9 dated 07/03/2025, 10/15/2025 and 06/24/2026 revealed the conferences were conducted in person and attended by therapy, nursing staff, the activity department and the social worker. Section 1c. Care Plan Conference Attendees did not indicate that the resident or responsible party attended the care plan conference, refused to attend the care plan conference, were invited and were a no show for the care plan conference, refused to attend the conference or was too ill to attend the care plan conference. No Care Conference & DC Management Evaluation was available for January 2026 or March 2026. Attempted interview with Resident #9 on 06/29/26 at 11:48 a.m. was unsuccessful due to speech communication deficits as well as cognitive comprehension deficits. Attempted interview with Resident #9's family member who was identified as the responsible party on 06/29/2026 at 6:44 p.m. was unsuccessful. Message was left for responsible party with no return contact during survey. Record review of Resident #24's face sheet dated 06/20/2026 revealed an [AGE] year-old female admitted [DATE] and readmitted [DATE]. Her diagnoses included atrial fibrillation (irregular heart rhythm), heart failure (a chronic condition where the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), hypertension (high blood pressure), hypothyroidism (a condition where the thyroid gland does not produce enough thyroid hormone leading to a slowdown of metabolism), hyperlipidemia (high levels of fat in the blood), dementia (a decline in cognitive function severe enough to interfere with daily life), major depressive disorder (a mental health condition characterized by persistent feelings of sadness and loss of interest that impacts daily life). The face sheet indicated that Resident #24's family member was her Responsible Party, Power of Attorney for Care and Finances and Emergency Contact #1. Record review of Resident #24's Quarterly MDS dates 05/14/2026 revealed no vision, hearing or communications deficits and a BIMS Score of 15 which indicated intact cognition. The MDS indicated Resident #24 required the use of a wheelchair for mobility, setup assistance in eating, supervision with upper body dressing, moderate assistance with lower body dressing, and bed mobility, maximum assistance with transfers and total assistance in toileting and bathing. Record review of Resident #24's care plan with target completion date of 04/22/2026 identified focus areas of falls with intervention to educate the resident or family about safety reminders; a focus area of altered cardiovascular status with interventions to provide disease management teaching to resident or family; discharge planning with intervention to evaluate and discuss with resident or family; and activity involvement with interventions to invite and encourage family to attend events to support participation. Record review of the Care Conference & DC Case Management Evaluations for Resident #24 dated 08/25/2025, 11/12/2025, 02/11/2026, 04/15/2026 revealed the conferences were conducted in person and attended by members of the nursing, therapy, activity and social services staff. Section 1c. Care Plan Conference Attendees did not indicate that the resident or responsible party attended the care plan conference, refused to attend the care plan conference, were invited and were a no show for the care plan conference, refused to attend the conference or was too ill to attend the care plan conference. During an interview on 07/01/2026 at 7:14 a.m., Resident #24 stated that she was aware of the care plan meetings but could not recall if she was invited of the meeting every 90 days. Resident #24 stated she chose not to attend the meeting because in the past, a lot is talked about, but nothing happens. Resident #24 did not provide any specific concern that had not been addressed. Resident #24 stated that she did not know if her family member was informed of and invited to the care plan meeting. An attempted interview with Resident #24's family member on 07/01/2026 at 9:00 a.m. and 07/06/2026 at 3:25 p.m. were unsuccessful and voice mail had not been returned. During an interview of 07/01/2026 at 7:50 a.m., LVN H stated that she personally invites the resident to the Care Plan meeting and that she sends an invitation to the responsible party. LVN H stated she does not place a copy of the invitation as validation they were sent in the EMR. LVN H stated that she was responsible for completing the Care Conference & DC Case Management Evaluation forms and acknowledged that she failed to indicate that the resident or responsible party had been informed of the meeting, attended the meeting or refused to attend the meeting. LVN H stated she did not document resident or family participation and that the evaluation did not accurately reflect the meeting attendance. During an interview on 07/01/2026 at 8:07 a.m., the Activity Director stated she only completes the activity section of the Care Conference & DC Case Management Evaluation form and has nothing to do with inviting the resident or family. During an interview on 07/02/2026 at 3:00 p.m., the DON stated that she expects the Care Conference & DC Case Management Evaluation form to be completed in its entirety and that the presence or absence of the resident or the responsible party was indicated on the form. The DON stated she expects all the team members to assist with the form completion, that the MDS Nurse has been assigned the task of inviting the resident or responsible party and that she will monitor the care plan meetings sporadically to ensure the form is completed. The DON stated that failure to accurately document on the designated form could result in inadequate documentation that does not reflect the resident or family who were invited to participate in the plan of care. During an interview on 07/06/2026 at 4:08 p.m., the Administrator stated that accurate documentation was important to ensure all steps taken by staff members were captured. The Administrator stated that she will spot check the Care Conference & DC Case Management Evaluation form based on the care plan schedule to ensure the form was properly completed. The Administrator stated that risks of inaccurate documentation does not directly affect the residents, but cold overall reflect on the competency of the staff. A request for facility policy on accuracy of documentation was requested on 07/02/2026 at 2:00 p.m. The DON stated they did not have a policy for documentation.

Based on interviews and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 3 residents (Resident #12, and Resident #27) reviewed for hospice services.1.The facility failed to maintain Resident #12's hospice binder containing information related to hospice services provided for the resident such as the most recent medication profile, last two months of IDG also known as Interdisciplinary Group meetings (a regular, collaborative team review of a patient's care meetings), or updated recertification form.2.The facility failed to ensure Resident #27's Hospice binder included an up to date and accurate medication profile.These failures could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. Findings included: 1. Record review of Resident #12's face sheet, dated 07/02/26, reflected Resident #12 was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included dementia (a decline in mental ability that interferes with daily life), anxiety (a feeling of unease, worry, or fear, often experienced as a normal reaction to stress), and depression (a common mental health condition characterized by persistent sadness and a loss of interest in activities, significantly impacting daily life). Record review of Resident #12's admission MDS assessment, dated 04/27/26, reflected Resident #12 made herself understood, and was understood by others. Resident #12 BIMs score was an 11 which indicated she had a moderate cognitive impairment. The MDS indicated Resident #12 was on hospice services. Record review of Resident #12's comprehensive care plan revised 04/23/26 indicated Resident #12 had a terminal prognosis and was on hospice services. The intervention was to work cooperatively with the hospice team to ensure the residents' spiritual, emotional, intellectual, physical, and social needs were met, and for the nursing staff to provide maximum comfort for the resident. Record review of Resident #12's physician orders dated 04/23/26 indicated an order for {name} hospice. Record review of Resident #12's physician orders dated 05/22/26 indicated an order for Fentanyl Transdermal Patch 72 Hour 12 MCG/HR (Fentanyl) Apply 1 patch transdermal every 72 hours related to pain. Record review of Resident #12's physician orders dated 06/10/26 indicated an order for Zyprexa Oral Tablet 7.5 MG (Olanzapine) Give 1 tablet by mouth at bedtime related to schizoaffective disorder. Record review of Resident #12's hospice binder on 07/02/26 at 11:09 a.m., revealed it did not have the last medication profile (last updated 05/05/26), the last two months of IDG (Interdisciplinary Group) meetings or updated recertification form. The last recertification was dated 04/19/26-06/19/26. Record review of Resident #12's hospice binder on 07/02/26 at 11:09 a.m., did not reveal an order for Fentanyl Transdermal Patch or Zyprexa. During a phone interview on 07/01/26 at 3:48 p.m., the hospice RN K said the binders at the facility should contain any supporting notes or documentation needed for Resident #12. She said the binder should at least have the face sheet, election form, code status, certification of terminal illness, plan of care, and medications. She said they meet every two weeks on Friday for the IDG meetings and said the documentation should be updated at least the following week after the IDG meetings. She looked at the office's records and said Resident #12's last IDG meeting was 06/26/26 and prior meeting was 06/12/26 and had not been delivered to the facility. She said she was responsible for bringing over any updated information after the meetings on the following week. She said she did not have a reason why she had not brought the updated information, except she had forgotten. She said she would bring her recertification which started on 06/18/26 and would end on 08/16/26. She said the recertification should also be in the facility's chart the week of the termination of the recertification period. She said she would bring over the information to the facility and place it in the resident's binder. She said it was important to have the binders at the facility updated to help the facility know the care and services they were providing. During an interview on 07/02/26 at 10:39 a.m., LVN H said she was not sure of all the information that needed to be included in the hospice binder. She said she thought the hospice binder should include the name of the hospice, diagnosis, face sheet, and code status. She said management was responsible for ensuring the hospice binders were updated. She said any information the hospice company had for Resident #12 should be at the facility for effective communication because their care was combined. During an interview on 07/02/26 at 5:02 p.m., the DON said she expected the hospice binders to be updated on all material required in the book. She said the recertification and IDG meetings should be in the folder. She said hospice should correlate with the facility nurses to see about any medication changes. She said she the ADON was responsible for ensuring the hospice binder was updated. She said the risk of the binders not being updated was not knowing all of Resident #12's plan of care. During an interview on 07/02/26 at 5:50 p.m., the Administrator said any information the hospice had should be updated in the facility's hospice binder. She said she expected the recertification and IDG meeting to be in the facility's binder. She said the DON was responsible for ensuring all hospice documents were up to date. She said the binder should be updated for effective communication between hospice and the facility for the care of the residents. 2. Record review of Resident #27's face sheet dated 7/2/26 indicated she was an [AGE] year-old female who re-admitted to the facility on [DATE]. Her diagnoses included dementia (decline in memory and thinking skills that interferes with daily life), chronic obstructive pulmonary disease (progressive lung condition that causes difficulty breathing due to damage to the airways), general anxiety (persistent, excessive worrying about everyday matters like health, finances, or family), and shortness of breath. Record review of Resident #27's quarterly MDS assessment dated [DATE] indicated she could make herself understood and she understood others. The MDS also indicated she had a BIMS score of 13 which meant she was cognitively intact. The MDS also indicated she was independent with toileting, dressing, bed mobility, and transfers, and she required set assistance with eating. The MDS also indicated Resident #27 required oxygen therapy while she was a resident. The MDS also indicated she received hospice care while she was a resident. Record review of Resident #27's comprehensive care plan dated 12/31/25 indicated she had a terminal diagnosis of chronic obstructive pulmonary disease and was admitted to hospice care with interventions in place to work cooperatively with hospice team to ensure the Resident 27's spiritual, emotional, intellectual, physical and social needs were met. Record review of Resident #27's hospice binder on 06/30/26 indicated Resident #27's medication profile, last completed 3/30/26, did not match the facility orders. Record review of Resident #27's hospice medication profile dated 3/30/26 indicated Resident #27 had an order for: 1)Zoloft 25mg tab -Oral 1 tablet at bedtime for insomnia 2)Cyclobenzaprine 10 Mg tablet - Oral 1 tablet 2 times daily muscle spasms The hospice medication profile did not indicate Zoloft 50mg tablet or a as needed dose for cyclobenzaprine 10mg tablet. Record review of Resident #27's order summary report dated as of 07/01/26 indicated Resident had an order for: 1) Cyclobenzaprine HCl Oral Tablet 10 MG (Cyclobenzaprine HCl) Give 1 tablet by mouth every 24 hours as needed for Leg Cramps Cyclobenzaprine 10 mg PRN every 24 hours for leg cramps with a start date of 06/20/2026 and no end date. 2)Cyclobenzaprine HCl Tablet 10 MG Give 1 tablet by mouth two times a day related to pain in unspecified joint May cause dizziness, drowsiness with a start date of 02/15/2026 and no end date. 3) Sertraline HCl Tablet (Zoloft) 50 MG Give 1 tablet by mouth at bedtime for Depression related to generalized anxiety disorder with a start date of 04/15/26and no end date. During an interview on 07/02/26 at 11:30 a.m., the hospice receptionist said she would have Resident #27's RN case manager return a call to discuss the information about the Resident #27's medication profile but no return called was received. During an interview on 07/02/26 at 2:54 p.m., the ADON said the hospice company should have provided an updated medication profile. The ADON said the IDG meeting with medications should have matched the orders the facility had ordered. The ADON said herself and the DON were responsible and the failure placed Resident #27 at risk for medication errors. During an interview on 07/02/26 at 5:05 p.m., the DON said her expectation was for the hospice nurse to communicate with the facility nurse to ensure there were no new orders for each visit to ensure the IDG meeting paperwork and the hospice medication profile matched the facility orders. The DON said the ADON was responsible for checking the hospice binders and ensuring the hospice binders were up to date and accurate. The DON said the failure placed a risk for medication errors. During an interview on 07/02/26 at 5:39 p.m., the Administrator said her expectation was for the hospice to have the same orders as the facility to ensure proper continuity of care. The ADON and DON were responsible for ensuring the hospice books up to date. The Administrator said the failure placed a risk for ineffective communication for Resident #27's orders. During an interview on 07/02/26 at 6:04 PM the DON said the facility did not have a hospice policy.

Based on observations, interviews, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 1 of 18 residents (Resident #28) reviewed for storage and labeling of medications and 1 of 2 (East Hall nurse) medication carts reviewed for storage of medications. 1. The facility did not ensure Resident #28's Triamcinolone Acetonide cream (corticosteroid used to reduce inflammation, redness, and itching) was properly secured.2. The facility failed to ensure LVN M locked the east hall nurse's cart when left unattended in the hallway. These failures could place residents at risk for misuse of medication, overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications. Findings included: 1. Record review of Resident #28's face sheet, dated 07/02/26, reflected Resident #28 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #28's annual MDS assessment, dated 06/17/26, reflected Resident #28's made himself understood, and understood others. Resident #28's BIMS score was 11, which reflected his cognition was moderately impaired. Record review of Resident #28's comprehensive care plan, initiated 02/26/26, reflected Resident #28 had discoloration to his bilateral lower extremities. The care plan interventions included: monitor for breaks in the skin and report to MD if noted and monitor for edema and increased redness. Record review of Resident #28's order summary report, dated 07/02/26, reflected there was no order for Triamcinolone Acetonide cream 0.5%. During an interview and observation on 06/29/26 at 11:38 a.m., a tube that was labeled Triamcinolone Acetonide cream 0.5%, was observed on Resident #28's bedside table. Resident #28 stated a nurse gave him the cream to put on his legs for the rash. Resident #28 was unable to recall the nurse's name. During an interview and observation on 07/02/26 at 9:28 a.m., the Triamcinolone Acetonide 0.5% was observed on Resident #28's bedside table with CNA G. CNA G stated during her rounds, she did not see the cream on his bedside table. CNA G stated all staff were responsible for ensuring items were stored properly and securely. CNA G stated creams should be stored in the medication cart. CNA G stated it was important to ensure medications were not left on the bedside table for residents' safety. During an interview and observation on 07/02/26 at 9:35 a.m., LVN B stated she did not see the cream on Resident #28's bedside table. LVN B stated Resident #28 could not apply the cream to his legs. LVN B stated all staff were responsible for ensuring medications were not stored at bedside. After reviewing Resident #28's electronic medical records, LVN B stated Resident #28 did not have an order for the cream and she did not know who gave it to him. LVN B stated an order must be obtained first, and the medication should be stored in the treatment cart. LVN B stated it was important to ensure medications were not left on the bedside table for residents' safety. During an interview on 07/02/26 at 4:08 a.m., the DON stated she did not know where Resident #28 got the cream from, because he did not have an order for the cream. The DON stated she expected medications to be stored on the medication cart. The DON stated nursing staff were responsible for ensuring medications were not stored at bedside by observing during rounds. The DON stated she was responsible for monitoring and overseeing by entering random residents' rooms and making observations. The DON stated it was important to ensure medications were not on the bedside table for residents' safety. During an interview on 07/02/26 at 4:40 p.m., the Administrator stated she expected an order for the cream. The Administrator stated medications should be locked/secured on the medication cart. The Administrator stated nursing staff should be ensuring medications were not left at bedside. The Administrator stated she monitored medications at bedside by random spot checks. The Administrator stated it was important to ensure medications were not left at bedside for resident safety. 2. During an observation and interview on 06/30/2026 at 11:45 AM, LVN M gathered supplies to check a resident's blood sugar, closed the east hall nurse's cart while it was facing the room, but left cart open in the hallway with the privacy curtain in the resident's room pulled where she could not see the cart. LVN M returned to the east hall nurse's cart and gathered items for insulin administration and closed the east hall while it was facing the room, but left the east hall nurse's cart open in the hallway with the privacy curtain in the resident's room pulled where she could not see the east hall nurse's cart while administering insulin. LVN M said she understood that she could leave her nurse cart open if it was facing toward the resident's door. LVN M said she left the nurse carts open her entire career that way, but she said she understood the risk of a resident or staff getting into the east hall nurse cart with it being unlocked. During an interview on 07/02/2026 at 5:14 PM, the DON said her expectation was for the nurses' and medication carts to always be locked when the cart was unattended and not in view. The DON said the nurses or medication aides were responsible for ensuring the carts were locked if unattended. The DON said the failure placed a risk for residents getting into the carts and getting medications. During an interview 07/02/2026 at 5:44 PM, the Administrator said her expectation was anytime the nurse stepped away from the cart, the nurse should be locking the nurses' and medication carts. The Administrator said the failure placed a risk for residents getting into the cart and accessing medications. Record review of the facility's policy, dated 06/24/2025, Storage of Medications: Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls.3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observation and interview, the facility failed to ensure the environment was as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for 2 of 2 halls (east hall and west hall) reviewed for quality of care. The facility failed to ensure the shelves located on the east hall and west hall were free from rough edges. These failures could place residents at risk of accidents that could result in injury or harm.Findings included: During an observation on 06/30/2026 at 11:15 AM, the east hall had shelving attached directly to the hall wall that had jagged, rough edges. During an observation on 06/30/2026 at 11:22 AM, the west hall had shelving attached directly to the hall wall that had jagged, rough edges. During an interview on 06/30/2026 at 11:28 AM, the Maintenance Supervisor said he was aware that the shelves on the east and west halls had jagged, rough edges, but it was because he did not have time to sand the edges of the shelves. The Maintenance Supervisor said he placed the shelves on the east and west halls, and had planned to place doors on the outside of the shelves. The Maintenance Supervisor said he had been busy doing other things around the facility, but the Administrator did instruct him to remove the shelves after the surveyor's intervention until he was able to sand the shelves. The Maintenance Supervisor said the failure placed a risk for staff, residents, and visitors to get skin tears. During an interview on 07/01/2026 at 5:19 PM, the ADON said she was aware that the shelving on east and west wings were painted and replaced but she did not realize the edges were rough and jagged. The ADON said the failure of replacing the shelving without sanding the edges could have caused skin tears for staff, visitors, or residents. During an interview on 07/02/2026 at 5:03 PM the DON said she was made aware after the surveyors found the shelves on the east and west halls and she noted the shelves had jagged rough edges on them. The DON said she immediately went and reported the problem to the Administrator. The DON said she was unsure how long the shelves on the east and west wings had been replaced, but the failure placed a risk for residents and staff to get splinters as well as skin tears or cuts. The DON said the Maintenance Supervisor was responsible for ensuring the shelves were sanded prior to painting so that there were no sharp or splintered edges on either shelf. During an interview on 07/02/2026 at 5:36 PM, the Administrator said the areas on the east and west halls were cubby holes (open storage areas in the wall) where the facility was looking to store resident items. The Administrator said she expected the shelves on the east and west halls to be sanded prior to painting and then covered. The Administrator said the Maintenance Supervisor had steps left to sand the shelves jagged, rough edges down, and then to place doors over the storage area. The Administrator said the failure placed a risk for staff, visitors, and residents to acquire cuts or scratches. Record review of the undated facility policy Safety Guidelines indicated Policy: Staff shall follow procedures to ensure safe working environment while performing maintenance-related tasks.

Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #4) reviewed for quality of care. The facility failed to ensure Resident #4's physician's order for his enteral feedings (a form of nutrition that is delivered into the digestive system as a liquid form via the feeding tube) indicated the strength of the enteral feed and the specific administration method.This failure could affect residents receiving enteral nutrition and hydration and place them at risk of dehydration, weakness and malnutrition.Findings included:Record review of Resident #4's face sheet, dated 07/02/26, reflected Resident #4 was a [AGE] year old male, admitted to the facility on [DATE] with diagnose which included gastrostomy status (the presence of a surgically placed feeding tube through the abdomen), unspecified protein-calorie malnutrition and sequelae of protein-calorie malnutrition (long-term physical complications resulting from severe past malnutrition). Record review of Resident #4's significant change in status MDS assessment, dated 06/03/26, reflected Resident #4 rarely/never made himself understood, and sometimes understood others. The assessment did not address Resident #4's BIMS score but reflected he had long term and short-term memory problems. Resident #4 had a feeding tube and had not had any weight loss/gain of 5% or more in the last month or 10% or more in the last 6 months. Record review of Resident #4's comprehensive care plan, revised 05/11/26, reflected Resident#4 required tube feeding related to dysphagia (difficulty swallowing). The care plan interventions indicated the administration of tube feeding per physician orders. The order changed on 6/19/2026 to Isosource (nutrition supplement) 1.5 cal, 300 mL four times daily (providing 425 kcals and 20.4 g of protein per feeding), with a revision to the care plan on 06/30/2026 and water flushes per MD order. Record review of Resident #4's physician order summary report, dated 06/30/26 reflected an active physician order for enteral feed four times a day; give IsoSource 300ml 4 times a day via g-tube. This order omitted the required formula strength of Isosource and the specific administration method (bolus or pump). Record review of the hospice physician orders dated 6/19/2026 revealed a more specific directive: Isosource 1.5; 4 x day. The facility failed to transcribe the 1.5 strength or clarify the delivery method onto the current eMAR. During an interview on 6/30/2026 at 11:04 a.m., the MDS Coordinator stated nursing staff had been administering Isosource 1.5 cal bolus feeding via g-tube. During an interview and record review on 07/02/26 at 9:35 a.m., after reviewing Resident #4's electronic medical record, LVN B stated the order was missing the strength and administration method. LVN B stated the DON was responsible for ensuring the strength and administration method was in the order when she put the order in and the nurses that provided care to him were also responsible. LVN B stated the order should have specified 1.5 Cal for the strength and bolus for the administration method. LVN B stated it was important the five rights were followed through to prevent harm to the residents, medication error as well as aspiration. During an interview on 06/30/26 at 4:25 p.m., after reviewing Resident #4's electronic medical record, the DON stated the order was missing the strength and administration method. The DON stated when she updated the original order to add the nurse could use another brand if the Isosource was not available she specifically remembered adding the strength of 1.5 Cal, but could not recall if she added the administration method. The DON stated she reviewed the orders in clinical morning meetings, but could not recall specifics. The DON stated it was important the strength and administration methods were noted in the order to prevent potential adverse effects. During an interview on 07/02/26 at 4:40 p.m., the Administrator stated she expected strength and administration method to be stated on the order. The Administrator stated the person that put in the order was responsible. The Administrator stated the DON, or designee, was responsible for monitoring and overseeing physician orders to ensure accuracy. The Administrator stated she was not clinical, and did not know what could happen medically. Record review of the facility's policy Enteral Nutrition reviewed 03/03/2026, reflected . Adequate nutritional support through enteral nutrition is provided to residents as ordered . 11. The Nurse confirms that orders for enteral nutrition are complete. Complete orders include: the enteral nutrition product; Administration method (continuous, bolus, intermittent) .

Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food that accommodated resident allergies, intolerances, and preferences for 2 of 2 residents (Residents #2 and #28) reviewed for food preferences and the accommodation of resident's meal choices. 1. The facility failed to ensure Resident #2's preference for large portions was honored on 06/29/26 and 06/30/26. 2. The facility did not ensure Resident #28's preference for over easy eggs was honored on 06/29/26 and 06/30/26. These failures could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings include: 1. Record review of Resident #2's face sheet, dated 07/02/26, reflected Resident #2 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included morbid (a chronic disease characterized by a body mass index of 40 or higher accompanied by severe weight-related health complications) (severe) obesity due to excess calories and unspecified protein-calorie malnutrition. Record review of Resident #2's quarterly MDS assessment, dated 04/03/26, reflected Resident #2 made himself understood, and understood others. Resident #2's BIMS score was 9, which reflected his cognition was moderately impaired. Resident #2 required setup or clean-up assistance with eating. Record review of Resident #2 comprehensive care plan, revised on 04/08/26, reflected Resident #2 had an ADL self-care performance deficit related to generalized weakness. The care plan interventions included required setup or clean-up assistance with eating. Record review of Resident #2's order summary report, dated 06/30/26, reflected: give large portions of food for every meal per resident with a start date 09/22/23. Record review of Resident #2's lunch meal ticket dated 06/29/26 did not reflect large portions. During an observation on 06/29/26 at 12:50 p.m., Resident #2 received one serving of ground stuff bell pepper, and one serving of fried okra. During an interview on 06/30/26 at 8:29 a.m., Resident #2 stated he wanted to have large portions with every meal. During an observation and interview on 06/30/26 at 1:22 p.m., Resident #2 received one serving of pinto beans, chopped sausage, steamed rice and capri vegetable blend. The DON stated by the look of Resident #2's servings looked average. After reviewing Resident #2's lunch meal ticket the DON stated he did not have to have large portions. During an interview and record review on 07/02/26 at 9:35 a.m., LVN B stated she was responsible for ensuring Resident #2 received large portions with his lunch meal on 06/30/26. LVN B stated she unaware Resident #2 preferred large portions. After reviewing Resident #2's electronic medical records, LVN B stated he should be receiving large portions with every meal. LVN B stated she usually goes with what was on the ticket and compared it to the tray. LVN B stated it was important for their food preferences to be honored because it was their right and prevent weight loss. During an interview on 07/02/26 at 11:00 a.m., the ADON stated she was responsible for ensuring Resident #2 received large portions with his lunch meal on 06/29/26. The ADON stated she compared the ticket with the tray and if large portions were not on there, she would not have known. The ADON stated it was important for their food preferences to be honored because it was their right. 2. Record review of Resident #28's face sheet, dated 07/02/26, reflected Resident #28 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs) and morbid (a chronic disease characterized by a body mass index of 40 or higher accompanied by severe weight-related health complications) (severe) obesity due to excess calories. Record review of Resident #28's annual MDS assessment, dated 06/17/26, reflected Resident #28 made himself understood, and understood others. Resident #28's BIMS score was 11, which reflected his cognition was moderately impaired. Record review of Resident #28's comprehensive care plan, revised 03/20/26, reflected Resident #28 had an ADL self-care performance deficit related to impaired balance and limited mobility. The care plan interventions included required setup or clean-up assistance with eating. Record review of Resident #28's order summary report, dated 07/02/26, reflected there was no order for Resident #28 dislikes. During an interview on 06/29/26 at 11:38 a.m., Resident #28 stated he was told by the dietary staff that he could not have over easy eggs. Resident #28 stated the eggs were fried so hard, he could cut with a butter knife.During an interview on 06/30/26 at 9:00 a.m., Resident #28 stated I wish you seen my eggs this morning. Resident #28 stated those eggs were fried so hard you could have knocked someone out with them. During an interview on 06/30/26 at 3:37 p.m., Dietary Manager C stated she told her cooks to cook the eggs hard to prevent salmonella (foodborne illness) poisoning. Dietary Manager C stated she did have complaints and they just told the residents they could not do runny eggs. The Dietary Manager stated she was not aware that eggs could be runny if the eggs were pasteurized (raw eggs that have been gently heated their shells to a specific temperature to destroy harmful bacteria). During a telephone interview on 07/02/26 at 8:56 a.m., The Dietician stated Dietary Manager C had never mentioned not being able to cook over easy eggs. The Dietician stated to her knowledge she had never heard a resident preferred over easy eggs. The Dietician stated if the facility had pasteurized eggs over easy eggs could be provided. The Dietician stated Resident #2's entire plate should be large portions per his request. The Dietician stated Resident #2's meal tickets should reflect large portions. The Dietician stated the Dietary Manager was responsible for ensuring the meal tickets reflect the order. The Dietician stated it was important for residents' preference to be followed to meet the residents' needs.During an interview on 07/02/26 at 10:03 a.m., [NAME] E stated she was cooking Resident #28's eggs like he preferred until Dietary Manager C told her to fry the eggs hard. [NAME] E stated Resident #28 complained about his eggs and when she told Dietary Manager C, she would tell her to fry them extra hard on purpose so he would not come back. [NAME] E stated she was aware that eggs could be made over easy if the eggs were pasteurized. [NAME] E stated Dietary Manager C was responsible for ensuring the meal tickets state residents' preferences. [NAME] E stated she was unaware Resident #2 was supposed to receive large portions with every meal. [NAME] E stated it was important for residents' food preferences were followed to prevent the potential of weight loss. During an interview on 07/02/26 at 10:36 a.m., Dietary Manager D stated over easy eggs could be prepared if the eggs were pasteurized. Dietary Manager D stated Dietary Manager C was responsible for ensuring the tickets reflected residents' preference. Dietary Manager D stated that when she received the order from the nurse she should go into the system to make the change to reflect on the meal ticket. Dietary Manager D stated Resident #2 should have received one and half serving of protein, vegetables and starch. Dietary Manager D stated it was important for residents' food preferences to be honored because it was their right. An attempted telephone interview on 07/02/26 at 10:55 a.m. with [NAME] F, the cook that prepared breakfast and lunch on 06/30/26, voicemail left. During an interview on 07/02/26 at 4:08 p.m., the DON stated she expected food preferences to be followed. The DON stated after she reviewed Resident #2's orders he should have received large portions with every meal. The DON stated she was unaware Resident #28 was told that he could not have over easy eggs. The DON stated if the eggs were pasteurized over easy eggs could be prepared. The DON stated the Dietary Manager was responsible for ensuring the residents' preferences reflected on the ticket. The DON stated it was important for their food preferences to be followed to prevent weight loss. During an interview on 07/02/26 at 4:40 p.m., the Administrator stated she expected food preferences to be followed. The Dietary Manager stated she expected Resident #2 to receive large portion with every meal. The Administrator stated after education with corporate she in serviced the Dietary Manager and cooks that eggs could be cooked in the preference of Resident #28. The Administrator stated there was no system to monitor and oversee meal service. The Administrator stated it was important for residents' food preferences to be followed because it was their right. Record review of the facility's policy titled Food and Nutrition Service Menus revised 06/23/25 reflected. Each resident is provided with a nourishing, palatable, well-balanced diet that meet his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident. 7 (a) if an incorrect meal is provided to a resident, or a meal. nursing staff will report it to the Food Service Manager so that a new food tray can be issued.

Based on observation, interview, and record review, the facility failed to ensure residents received proper treatment and care to maintain good foot health by providing foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 1 of 18 residents (Resident #2) reviewed for foot care. The facility did not ensure Resident #2 was measured for diabetic shoes and diabetic insoles per the physician order. This failure could result in residents developing fungal infections or other podiatric problems. Findings included: Record review of Resident #2's face sheet, dated 07/02/26, reflected Resident #2 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar) Record review of Resident #2's quarterly MDS assessment, dated 04/03/26, reflected Resident #2 made himself understood, and understood others. Resident #2's BIMS score was 9, which reflected his cognition was moderately impaired. Record review of Resident #2 comprehensive care plan, revised on 04/08/26, reflected Resident #2 had diabetes mellitus. The care plan interventions included: check all of body for breaks in skin and treat promptly as ordered by the doctor. Record review of Resident #2's order summary report, dated 06/09/26, reflected: physical therapy to measure, order, and dispense diabetic shoes, three pairs of heat molded/custom molded diabetic insoles. During an interview on 06/30/26 at 8:29 a.m., Residet #2 stated he did not recall someone from therapy talking to him about diabetic shoes. During an interview on 07/01/26 at 9:35 a.m., LVN B stated the podiatrist (a medical professional who helped with problems that affect the feet or lower legs) had come to the facility on [DATE] to see Resident #2 and wrote an order for physical therapy to measure and order diabetic shoes and insoles. LVN B stated she gave the order to the Director of Rehabilitation on 06/09/26. LVN B stated the ADON was responsible for following up on the order to ensure the order was followed through. LVN B stated it was important that Resident #2 was measured for diabetic shoes to prevent open areas. During an interview on 07/01/26 at 10:52 a.m., the Director of Rehab stated there was a miscommunication between her and the podiatrist. The Director of Rehab stated LVN B had notified her around 06/17/26 that there was a new order for a physical therapy eval for diabetic shoes. The Director of Rehab stated she should have called the podiatrist office right away to collaborate on how to go about getting the custom fit diabetic shoes. The Director of Rehab stated she was not aware the resident had not been seen until the state surveyor intervention. The Director of Rehab stated it was important Resident #2 was measured for diabetic shoes to protect his feet from any chances of skin tears. During an interview on 07/01/26 at 11:00 a.m., the ADON stated the podiatrist completed the order form and gave it to her on 06/09/26. The ADON stated she gave the order to LVN B, and LVN B gave it to the Director of Rehab. The ADON stated her, LVN B, and the Director of Rehab discussed on 06/09/26, that therapy did not evaluate residents for diabetic shoes. The ADON stated the Director of Rehab should have reached out to the podiatrist office to see what the next was. The ADON stated she should have followed up to see what needed to be done to get Resident #2 to be evaluated for diabetic shoes. The ADON stated it was important Resident #2 was measured for diabetic shoes to prevent foot ulcers. During an interview on 07/02/26 at 4:08 p.m., the DON stated the Director of Rehab should have contacted the podiatrist office and found a solution, and the ADON should have followed up with the Director of Rehab since she had the original order. The DON stated she monitored orders by clinical morning meeting, and from her understanding, the podiatrist was contacted and they were waiting for further instruction. The DON stated it was important Resident #2 was measured for diabetic shoes to prevent any foot problems. During an interview on 07/02/26 at 4:40 p.m., the Administrator stated she expected orders to be followed. The Administrator stated therapy was responsible for ensuring Resident #3 received diabetic shoes. The Administrator stated if the Director of Rehab was unable to do the evaluation, he/she should have notified the podiatrist office to see what steps should have been taken. The Administrator stated there was no system for monitoring therapy eval to ensure orders were being followed through. The Administrator stated it was important Resident #2 was measured for diabetic shoes to prevent open sores. During an interview on 07/02/26 at 6:04 p.m., the DON stated there was not a policy and procedure regarding following physician orders.

Based on interview and record review, the facility failed to ensure the discharge information was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider for 1 of 6 (Resident #1) residents reviewed for transfer and discharge process. The facility failed to ensure the necessary information, including a discharge summary was included in Resident #1's discharge with applicable information to include contact information of the practitioner responsible for the care of the resident, Advance Directive information, special instructions or precautions for ongoing care, and comprehensive care plan goals, was completed. This failure could result in poor continuity of care and harm or injury to resident during transition of care. Findings included: Record review of Resident #1's face sheet dated 03/06/2026 revealed a [AGE] year-old female admitted [DATE] and discharged [DATE] with diagnoses that included cerebral infarction with right sided hemiplegia (interrupted blood flow in the brain resulting in right sided paralysis), dysphagia (swallowing difficulty), hyperlipidemia (high cholesterol), Buerger's disease (a rare disorder where veins in the hands and feet become clogged with clots), psychotic disorder (severe mental illness causing a loss of contact with reality), and major depressive disorder (mood disorder defined by persistent sadness or loss of interest that impairs daily life). Record review of Resident #1's discharge MDS assessment dated [DATE] revealed the resident presented with short-term and long-term memory deficits, required modified independence in daily decision making, and presented with inattention and disorganized thinking. Resident #1 was verbal and exhibited other behavioral symptoms that occurred 4-6 days. The activities of daily living and nutritional approaches revealed the resident was independent in eating, and totally dependent in toileting, bathing, dressing and bed mobility and required a mechanically altered diet. Record review of Resident #1's care plan closing date 11/14/25 revealed Resident #1 had a history of poor safety choices, DNR (Do Not Resuscitate in the event of cardiac arrest) status, refusal of housekeeping assistance in room, refusal of psychiatric treatment with active behavior management focus areas to include yelling out, cursing at staff, derogatory comments, false accusations and refusing to allow staff to remove meal trays, required use of bedside loops to assist in bed mobility, anticoagulant-use. Resident #1 had contractures of her left hand and foot drop (the inability to lift the front part of the foot) to left foot, refusal of incontinent care and actual impairment to skin integrity as evidenced by wound (abrasion) to right foot. Record review of Resident #1's EMR revealed there was no physician's order to discharge, no Interdisciplinary Team Discharge plan and no completed discharge summary. During an interview on 03/06/2026 at 11:50 a.m., LVN A stated that for all discharges, she would include the resident's face sheet, medication list, call the accepting facility or hospital and provide a verbal report, notify the responsible party, and obtain a discharge order from the physician. LVN A stated that if the discharge was planned, the IDT members usually initiate a discharge assessment, but if it is unplanned, such as a hospital or emergency room visit, the discharging nurse would complete the transfer documents. During an interview on 03/06/2026 at 12:10 p.m., LVN B stated that she worked at the facility for 3 weeks as the MDS Nurse. LVN B stated that there was a difference in the discharge documents for residents with a planned or unplanned discharge. LVN B stated that the discharging nurse should complete a packet with documents to include a face sheet, medication list, laboratory results, if pertinent, and physician's recent progress note or H & P to reflect resident's care. LVN B stated, additionally, if transfer was to a hospital or alternate facility, the nurse should call a report with pertinent information about the resident. LVN B stated that the resident MDS should reflect a planned or unplanned discharge and if services were coordinated. During an interview on 03/06/2026 at 12:25 p.m., LVN C stated she had been working at the facility for less than three weeks but was aware that a resident discharge would require a physician's order and progress note reflecting the purpose of the discharge, responsible party notification and any pertinent information pertaining to the resident's care. LVN C stated that normally a Discharge Assessment form is completed and sent with the resident along with a face sheet. During an interview on 03/06/2026 at 1:00 p.m., the DON stated that the discharge nurse completed a progress note on the day of discharge that indicated Resident #1was transferred to the accepting facility via ambulance, provided medications and was transferred with her personal belongings. The DON stated that neither a transfer form or discharge assessment and discharge summary were completed to reflect what location the resident was transferred to, whether a nurses' report was provided and clinical records were sent to the accepting facility to include current physician's orders, care plan, psychiatric progress notes and a physician's history and physical. The DON stated that she would provide an in-service for nursing staff regarding the discharge process for planned and unplanned discharges. The DON stated she expected the nurses to complete the appropriate assessments for discharged residents. The DON confirmed that Resident #1 discharged to an alternate nursing facility of her choice with her medications and personal belongings. The DON stated that the discharge was initiated by Resident #1, that referrals were sent to multiple locations and facility was notified of bed availability at the accepting location on the date of discharge. The DON stated the physician was aware of the anticipated discharge pending acceptance at a nursing facility. Attempted interview with discharge nurse LVN D on 03/06/2026 at 1:05 p.m. was unsuccessful. During an interview on 03/06/2026 at 1:10 p.m., the Administrator stated that she expected the nursing staff to complete the appropriate assessments and documentation for all discharge residents, and the DON was responsible for overseeing this process and ensuring accuracy. The Administrator stated that a poor or inaccurate discharge system could result in harm to residents because the accepting agency would not have a full picture of the resident's needs. Record review of the facility's policy titled Discharge or Transfer to another facility, dated 12/14/2027, reflected: Information conveyed to receiving provider.the following information must be conveyed to the receiving provider: Contact information of the practitioner responsible for the care of the resident;Resident representation information including contact information;Advance Directive information;All special instructions or precautions for ongoing care, as appropriate;Comprehensive care plan goals;All information necessary to meet the resident's needs, which includes, but may not be limited to:Resident status, including baseline and current mental, behavioral and functional status, reason for transfer, recent vital signs;Diagnoses and allergies;Mediations (including when last received; andMost recent relevant labs, other diagnostic tests and recent immunizations.

Based on observation, interview and record review the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that it was not possible or the resident preferences indicated otherwise for 4 of 4 residents (Resident #1, Resident #2, Resident #3, Resident #4) reviewed for nutrition status. 1.The facility failed to follow dietary recommendations for Resident #1. Resident # 1 lost 8.2 lbs. from 12/03/2025 to 01/12/2026 which was a significant weight loss of 5.0%. 2. The facility failed to follow dietary recommendations for Resident #2. Resident #2 lost 16.9 lbs. from 12/04/2025 to 01/12/2026 which was a significant weight loss of 5.5% in 1 month. 3. The facility failed to follow dietary recommendations for Resident #3. Resident #3 had a re-opened left dorsal foot graft site with a low albumin level. 4. The facility failed to follow dietary recommendations for Resident #4. Resident #4 lost 11.6 lbs. from 07/10/2025 to 01/12/2026which was a non-significant weight loss of 7.9% in 6 months. These failures could place residents at-risk for loss of weight, inadequate nutrition and delayed wound healing.Findings include: 1. Record review of Resident #1's face sheet, dated 02/20/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #1 had diagnoses which included atrial fibrillation (a heart rhythm disorder), heart failure (impairment of the heart's ability to fill with and pump blood), hypertension, (high blood pressure) hyperlipidemia (high levels of fats in the blood), celiac disease (an autoimmune disorder that leads to malnutrition) and cystic fibrosis with intestinal manifestations (occurs when dehydrated mucous results in chronic constipation and malabsorption). Record review of Resident #1's Annual comprehensive MDS, dated [DATE], revealed BIMS score of 15, which indicated no cognitive impairment. Section K: Nutritional Approaches revealed no dietary modifications required. Record review of Resident #1's EMR, accessed 02/20/2026, revealed a height of 63 inches and weight of 138.1 lbs. on 12/03/2025 and 129/9 lbs. on 01/12/2026. Record review of Resident #1's Nutrition/Dietary, dated 01/30/2026 at 10:31 p.m. by the Registered Dietician, revealed recommendation for ice cream BID (twice daily) with lunch and dinner. Record review of Resident #1's physician's orders, reviewed 02/20/2026, revealed: Diet: No Fried foods, Regular texture, thin consistency, Gluten free diet. Breakfast with Oatmeal, bacon or sausage links. No beans or cabbage, dated 07/23/2026, with no changes or reviews since. Resident #1's EMR revealed no order for ice cream BID with lunch and dinner and no documentation that the physician was notified to accept or decline the recommendation. Record review of Resident #1's care plan, with target date of 05/12/2026, revealed Focus area: The resident has a potential nutritional problem and is at risk for Malnutrition related to celiac disease. Goal: The resident will comply with recommended diet through review date. Interventions: Registered Dietician to evaluate and make diet change recommendations PRN, Monitor/record/report to MD PRN signs and symptoms of malnutrition, Provide, serve diet as ordered. During an interview on 02/20/2026 at 10;40 a.m., Resident #1 stated she had never received ice cream with lunch or dinner or at any other time that she recalled. The resident stated she was aware of weight fluctuations and noted she received diuretics. During an observation of the lunch meal on 02/20/2026 from 12:16 p.m. - 1:20 p.m., revealed Resident #1 did not have an ice cream with her lunch and tray ticket showed no evidence of an ice cream with lunch. 2. Record review of Resident #2's face sheet, dated 02/20/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Chronic Obstructive Pulmonary Disease (a progressive lung disease causing severe breathing issues), hypertension (high blood pressure), Diabetes Type II (a chronic metabolic disorder where the body develops insulin resistance causing high blood sugar levels), heart failure (impairment of the heart's ability to fill with and pump blood), and Benign Prostatic Hyperplasia (enlargement of the prostate gland caused by age-related hormone changes). Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score 15, which indicated no cognitive impairment. Section K: Nutritional Approaches revealed unable to complete interview. Further review Section K: Nutritional Approaches: no dietary modifications required. Record review of Resident #2's EMR, accessed 02/20/2026, revealed a height of 61 inches and weight of 308.7 lbs. on 12/03/2025 and 291.8 lbs. on 01/12/2026. Record review of Resident #2's physicians orders, reviewed 02/20/2026, revealed: Diet: Regular texture, thin consistency, Double meat portions, dated 07/16/2025, with no changes or reviews since that date. Record review of Resident #2's Nutrition/Dietary note, dated 01/30/2026 at 10:33 p.m., revealed recommendation for sugar free health shake 1 can QD (daily) between meals. Resident #2's EMR revealed no order for sugar free health shake 1 can QD (daily) between meals and no documentation the physician was notified to accept or decline the recommendation. Record review of Resident #2's care plan, with target date of 04/21/2026, revealed Focus area: The resident has a nutritional problem or potential nutritional problem and is at risk for malnutrition related to diabetes diagnosis, malnutrition risk. goal: The resident will not develop complications related to obesity, including skin breakdown, ineffective breathing patters, altered cardiac output, diabetes, impaired mobility through review date. Interventions: Provide and serve diet as ordered, Registered Dietician to evaluate and make diet change recommendations PRN. During an interview on 02/20/2026 at 12:16 p.m., Resident #2 stated he had not received a health shake between meals and has never received a health shake that he recalled. 3. Record review of Resident #3's face sheet, dated 02/20/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #3 had diagnoses which included peripheral vascular disease (a slow-progressing condition involving the narrowing or blockage of blood vessels outside of the heart), chronic ulcer of left foot, protein-calorie malnutrition (a severe nutrient deficiency leading to reduced body mass and poor immune function), anemia (a condition marked by lack of healthy red blood cells causing reduced oxygen transport) and hypertension (high blood pressure). Record review of Resident #3's Annual comprehensive MDS, dated [DATE], revealed a BIMS Score of 5, which indicated severe problems with thinking and memory. Section K: Nutritional Approaches revealed the resident received a therapeutic diet. Record review of Resident #3's EMR, accessed 02/20/2026, revealed a height of 64 inches and weight of 175.1 lbs. on 12/04/2025 and 168 lbs. on 01/08/2026 Record review of Resident #3's physicians orders, reviewed 02/20/2026, revealed Diet: No added salt, regular texture, thin consistency, no shrimp, lobster or mango fruit, dated 04/21/2025, with no changes or reviews since that date. Record review of Resident #3's Nutrition/Dietary note, dated 01/30/2026 at 10:36 p.m., revealed recommendations for ice cream with lunch and Prostat (a concentrated liquid protein drink designed to treat wounds) 30 cc BID for low albumin. Resident #3's physicians orders revealed no order for ice cream with lunch or Prostat 30 cc's BID for low albumin. Record review of Resident #3's care plan, with target date of 04/16/2026, revealed Focus area: Receives regular diet. Goal: Will maintain stable weight without significant change through next review period. Interventions: House shake (with sugar) one time a day for weight maintenance, med pass two time a day for weight stability 90cc, Fortified cereal with breakfast, provide diet as ordered, provide nutritional supplement as recommended/ordered, RD to evaluate and follow as appropriate. During an interview on 02/20/2026 at 9:45 a.m., Resident #3 stated she had not received ice cream with her lunch and had not received a protein drink twice a day. During an observation of the lunch meal on 02/20/2026 from 12:16 p.m. - 1:20 p.m., revealed Resident #3 did not have an ice cream with her lunch and diet ticket showed no evidence of ice cream with lunch meal. 4. Record review of Resident #4's face sheet, dated 02/20/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #4 had diagnoses which included metabolic encephalopathy (a brain dysfunction caused by systemic imbalances), cerebral infarction (blocked blood flow to the brain leading to tissue death), Parkinsonism (a progressive nervous system disorder that affects movement), and dysphagia with gastrostomy status (difficulty swallowing with a feeding tube). Record review of Resident #4's quarterly MDS, dated [DATE], revealed short-term and long-term memory deficit and severe impairment for daily decision making. Section K: Nutritional Approaches revealed resident received a mechanically altered diet and had a feeding tube. Record review of Resident #4's EMR, accessed 02/20/2026, revealed a height of 66 inches and a non-significant weight loss of 11.6 lbs. (7.9%) over 6 months with a weight of 156.6 lbs. on 07/10/2025 and 145 lbs. on 1/12/26. Record review of Resident #4's physicians orders, reviewed 02/20/2026, revealed Diet: Pureed texture, thin consistency, cue as needed for small bits and sips for pleasure feeding related to metabolic encephalopathy, Parkinsonism, dated 09/26/2025, with no changes or reviews since that date. Record review of Resident #4's Nutrition/dietary note, dated 01/30/2026 at 10:42 p.m., revealed recommendation included Med pass 2.0 (a high calorie, high protein nutritional supplements) 120cc BID to prevent any further weight loss. Record review of Resident #4's care plan, with target date 05/19/2026, revealed Focus area: Requires tube feeding related to dysphagia, Jevity 1.5 - 300cc every 6 hours to provide 1800 kilocalories every 24 hours, pleasure feedings-pureed texture. Goal: Will maintain adequate nutritional and hydration status as evidenced by weight stable, no signs or symptoms of malnutrition or dehydration through review date. Interventions: Provide pleasure feedings encouraging small bites and sips of fluid, RD to evaluate quarterly and PRN, monitor caloric intake, estimate needs, make recommendations for changes to tube feeding as needed. An interview with Resident #4 was attempted on 02/20/2026 at 10:50 a.m., Resident # 4 was not cognitively able to respond to interview questions pertaining to oral intake. During an interview on 02/20/2026 at 12:08 p.m., LVN A stated Resident #1 did not receive an ice cream with her lunch meal, Resident #2 did not receive a health shake between his meals, Resident # 3 did not receive ice cream with her lunch meal and Resident #4 did not have an order for Med pass 2.0 twice daily. During an interview on 02/20/2026 at 12:28 p.m., the Food Service Supervisor revealed the RD provided the dietary recommendations to the DON for review with the MD and obtained orders as approved. The Food Service Supervisor stated the nursing department was responsible for putting the order into the EMR and once the order was placed, the FSS was notified by the nursing department and would apply to the ticket. The Food Service Supervisor stated she had not received any dietary recommendations for Resident #1, Resident #2, Resident #3 or Resident #4 for the January 2026 recommendations. During a phone interview on 02/20/26 at 12:51 p.m., the Registered Dietician stated she provided the facility with her recommendations within 24 hours of her visit and expected recommendations to be acted upon with the physician within 72 hours. The RD stated her next scheduled visit was 02/23/26 and she would review all recommendations with the DON. The Registered Dietician stated that is important for recommendations to be addressed with the physician to avoid any weight loss or wound healing concerns. During an interview on 02/20/2026 at 1:00 p.m., the ADON stated she had been assigned to ensure the dietary recommendations were acted upon, and she was still working on them. The ADON stated she was fairly new at the facility and was still learning the processes. During an interview on 02/20/2026 at 1:25 p.m., the DON stated the dietary recommendations should be provided to the physician as soon as possible and stated the physician had a folder at the nurse's station that recommendations were placed if not immediate and were faxed to his office if quicker attention was required. The DON stated that she had assigned the dietary recommendations to her new ADON but failed to provide sufficient monitoring to ensure the recommendations were addressed with the physician. The DON stated the physician rounds weekly and reviewed the folders at each visit. The DON stated it was her responsibility to ensure the physician was notified of the dietary recommendations and completed timely. The DON stated failure to act on recommendations could result in compromised nutrition and weight loss. The DON stated Resident #1, Resident #2, Resident #3 and Resident #4 had no adverse effects due to the delay in processing the dietician's recommendations and noted that all residents with dietary recommendations could be adversely affected by weight loss or delayed wound healing. During an interview on 02/20/2026 at 1:35 p.m., the Administrator stated she expected the nursing staff to act on the dietary recommendations as soon as possible to prevent weight loss. The Administrator stated she had been working at this facility for approximately 3 months and would follow up with the DON regarding the dietary recommendations. During an interview on 02/23/2026 at 12:08 p.m., the physician for Resident #1, Resident #2, Resident #3 and Resident #4 stated he was not notified of the dietary recommendations completed by the RD on 01/30/2026. The physician stated the nursing staff placed recommendations in his folder that was left at the nurse's stations for his review or sometimes would fax them to his office if the recommendation pertained to a significant weight loss or gain. In review of the recommendations for the identified residents, the physician stated no adverse effects were identified for these residents, noting Resident #1's weight was within normal limits and resident was on diuretic therapy and weight fluctuations would be expected; Resident # 2 was morbidly obese and was on diuretic therapy, with expected weight fluctuations; Resident #3 was already receiving a nutritional supplement twice daily and the foot wound was a chronic condition, noting delay in starting Prostat would not significantly affect the wound healing process; and Resident #4 received his primary nutrition via a feeding tube and the Med pass twice daily was a supplement due to poor oral intake. Record review of the facility's policy titled Consultant Recommendations and Follow Up, reviewed 06/23/2025, revealed 4. The recommendations will be followed up on within 72 hours, and 6. If a physician does not respond or choose to follow the recommendations, this must be documents in the nurse's notes and on the recommendation sheet.

Based on observation, interview and record review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and the facility assessment for 1 of 1 facility reviewed and 3 of 20 residents (Resident #2, Resident #4, and Resident #5) for care and services. 1. The facility failed to ensure Resident #2 medications were administered during the scheduled time. 2. The facility failed to ensure sufficient staff was provided to ensure Resident #4 received her showers on Saturdays. 3. The facility failed to ensure sufficient staff was provided to ensure Resident #5 was able to get out of bed when requested. 4. The facility failed to provide sufficient nursing staff according to the facility assessment on 05/03/2025, 05/04/2025, 05/10/2025, 05/11/2025, 06/20/2025, 06/21/2025, 06/28/2025, 07/01/2025, 07/05/2025, 07/06/2025, 07/12/2025, 08/02/2025, 08/03/2025, 09/01/2025, 09/20/2025, 09/21/2025, 10/5/2025, 10/12/2025, and 10/18/2025. These failures placed residents at risk of not having sufficient staff to provide for their care/treatment needs.Findings included: 1. Record review of Resident #2's face sheet, dated 10/23/25, reflected Resident #2 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included Parkinson's (a disorder that affects movement, balance, and coordination) with dyskinesia (involuntary, uncontrolled, and abnormal muscle movements). Record review of the order summary report dated 10/23/25 indicated Resident #2 was ordered: Carbidopa-Levodopa 25-100mg 1 tablet by mouth three times a day. Buspirone 5 mg 1 tablet by mouth three times a day. Record review of the Medication Administration Audit Report dated 10/23/25 reflected Resident #2 received her medications on 10/05/25 by MA B as listed: Carbidopa-Levodopa 25-100mg 1 tablet given at 11:06 a.m. instead of the scheduled medication pass 7:00 a.m.-10:00 a.m. Buspirone 5 mg 1 tablet given at 11:06 a.m. instead of the scheduled medication pass 7:00 a.m.-10:00 a.m. Carbidopa-Levodopa 25-100mg 1 tablet given at 11:46 a.m. of the scheduled medication pass 12:00 p.m. Buspirone 5 mg 1 tablet given at 11:46 a.m. of the scheduled medication pass 12:00 p.m. During an interview on 10/23/25 at 10:39 a.m., MA B stated medications should be administered one hour before or one hour after the scheduled time. MA B stated medications were given late due to short staff and her being the only MA that worked that day. MA B stated she did not remember given Resident #2 the second dose of Buspirone and Carbidopa-Levodopa that was scheduled at 12:00 p.m. MA B stated she probably just clicked it off on the MAR as given to show the task was completed. MA B stated she did not notify the physician or the DON about the second dose not given, or medications given late. MA B stated it was important medications were given on time to ensure the dose was effective and prevent an overdose. Record review of the Medication Administration Audit Report dated 10/23/25 reflected Resident #2 received her medications on 10/18/25 by the ADON as listed: Buspirone 5 mg 1 tablet given at 11:25 a.m. instead of the scheduled medication pass 7:00 a.m.-10:00 a.m. Carbidopa-Levodopa 25-100mg 1 tablet given at 11:25 a.m. instead of the scheduled medication pass 7:00 a.m.-10:00 a.m. Carbidopa-Levodopa 25-100mg 1 tablet given at 11:26 a.m. of the scheduled medication pass 12:00 p.m. Buspirone 5 mg 1 tablet given at 11:26 a.m. of the scheduled medication pass 12:00 p.m. During an interview on 10/23/25 at 11:27 a.m., the ADON stated medications should be given within the scheduled time. The ADON stated she rarely passed medications, and she did not know the medications like the staff that normally administered the medications. The ADON stated she did not notify the MD that the medications were given late nor the 12:00 p.m. dose of Buspirone or Carbidopa-Levodopa were not given. The ADON stated she guessed when she was clicking off the medications on the MAR, she did not realize it was duplicate. The ADON stated it was important medications were given as scheduled to prevent overmedication and a medication error. During a telephone interview on 10/23/25 at 12:24 p.m., the MD stated staff should have notified him if the medications were given late or if the second dose was close to the first dose that was administered. The MD stated he had received text messages about medications been administered late but not frequently. The MD stated he did not know anything about culture time window just the one hour before and one hour after. The MD stated the risk of not administering medications on time was if the resident received a blood pressure medication it could affect their blood pressure. During an interview on 10/23/25 at 12:54 p.m., the DON stated medications can be given one hour before or one hour after. The DON stated the facility did have a culture time which means a window for medication administration. The DON stated if the first dose was given close to when the second dose should be given, the second dose should be held and the MD notified. The DON stated she was responsible for monitoring and overseeing by pulling the medication administration audit report in PCC randomly. The DON stated there have been issues in the past and when she investigated it the staff stated it was given on time just documented late. The DON stated it was important medications were given on time to ensure the residents received the accurate dose and decrease their risk of complications. During an interview on 10/23/25 at 2:08 p.m., the Administrator stated she expected the medications to be administered according to the schedule to ensure effectiveness. The Administrator stated the DON and the ADON were responsible for monitoring and overseeing medication administration. The Administrator stated it was important to ensure medications were given on time to prevent an adverse reaction.2. Record review of a face sheet dated 10/23/2025 indicated Resident #4 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included unspecified combined systolic and diastolic congestive heart failure (heart is unable to pump enough force to push enough blood into circulation) and schizoaffective disorder bipolar type (mood disorder that can include depression, delusions, hallucinations, disorganized thoughts, speech and behavior). Record review of Resident #4's Comprehensive MDS assessment dated [DATE] indicated Resident #4 was understood by others and understood others. Resident #4 had a BIMS score of 15, which indicated her cognition was intact. Resident #4 required substantial/maximal assistance with showering/bathing herself. Record review of Resident #4's care plan dated 08/28/2024, indicated she had an ADL self-care performance deficit related to impaired balance. Resident #4's care plan indicated she was able to wash the upper front and lower front of her body and staff was to wash her back areas. Record review of Resident #4's Shower/Bathe Task Record for October 2025 indicated she received showers on Tuesday, Thursday, and Saturday on the 2 PM-10 PM shift. Resident #4's Shower/Bathe Task Record did not indicate she missed any showers. During an interview on 10/21/2025 at 4:04 PM, Resident #4 said she was not getting showers sometimes on Saturdays. Resident #4 said the staff told her they were short-handed, so they could not give her a shower. During an interview on 10/22/2025 at 12:33 PM, the Executive Director said the facility assessment direct care staff hours per resident day indicated the number of staff required per shift, which indicated 4 CNAs for days (6 AM-2 PM) and evenings (2 PM-10 PM), 3 CNAs for nights (10 PM-6 AM), and 1 MA for days and evenings. During an interview on 10/22/2025 at 1:42 PM, LVN F said she worked the weekends (6 AM- 10PM) and a lot of times they were short staffed. LVN F said usually they had 1 CNA on each side of the building and 2 nurses. LVN F said the past weekend the ADON worked because they were short staffed. LVN F said when they were short staffed it was not possible to provide the required care, and if they were not able to provide the required care due to being short staffed, this could be considered neglect. During an attempted phone interview on 10/22/2025 at 1:51 PM, LVN D did not answer the phone. During an interview on 10/23/2025 at 10:38 AM, MA H said she worked Saturday, 10/18/2025. MA H said they were short, and she worked all over the building, and she did not know if the residents' received showers. MA H said they were short staffed frequently, and sometimes they missed the showers. MA H said Saturdays were awful. MA H said she did not give any showers on 10/18/2025. MA H said not having sufficient staff to care for the residents could affect them emotionally and physically because the residents deserved the care they required while in the facility. During an interview on 10/23/2025 at 11:39 AM, the ADON said the DON and herself were responsible for scheduling the staff. The ADON said she was not aware the facility required a set number of CNAs for each shift. The ADON said they would like to have 4 CNAs for the 6 AM-2 PM shift and 2 PM-10 PM shift and 3 CNAs for the night shift. The ADON said MA H and herself covered the call-ins. The ADON said Saturday, 10/18/2025, she worked and gave medications to the residents for 12 hours and then worked as a CNA the last 4 hours of her shift, due to being short staffed. The ADON said the staff had not told her they were unable to complete their tasks due to insufficient staff. The ADON said if there were not enough CNAs the nurses should be helping the CNAs. The ADON said she did not see there could be a potential negative outcome for being short staffed.3. Record review of Resident #5's face sheet, dated 10/23/25, indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Atrial Fibrillation (an irregular heartbeat, or arrhythmia), muscle weakness, unsteadiness on her feet, and cognitive communication deficit. Record review of Resident #5's OBRA (Omnibus Budget Reconciliation Act) MDS dated [DATE] indicated a BIMS score of 15 which meant she was cognitively intact. The MDS also indicated she required total assistance with toileting, transfers, bathing, and bed mobility, and required setup assistance for eating. Record review of Resident #5's care plan dated 02/25/25 indicated she had an ADL self-care performance deficit related to impaired mobility, cellulitis, and a history of a fracture. The interventions were for staff to help with toileting, transfers, bed mobility, bathing, and personal hygiene. During an observation and interview on 10/21/25 at 10:35 a.m., Resident #5 was observed to be lying in bed. The resident said she had a problem with staff getting her up over the weekend, some months back. She said at times it still occurs if she does not remind them, but it has been much better. She said the staff would tell her they were short-handed; therefore, they could not get her up. She said she wanted to be up for lunch and supper meals. During an interview on 10/21/25 at 10:50 p.m., CNA I said she worked a 10 pm - 6 am shift and most times it was 2 aides, but sometimes it was only 1 aide for the entire building. She said she was working double weekends (6 am-10 pm), but she came tonight because most of the time they only had 3 aides and sometimes 2 aides until they could get someone to come in to work the shift. She said it was very hard to complete the task that needed to be done, but they worked together as much as they could to get things done. She said not having enough staff placed the residents at risk of not receiving the care they needed. She said management was aware that they were short over the weekend and at night, and it was difficult to provide timely care to the residents. During an interview on 10/23/25 at 11:55 a.m., the ADON said she knew Resident #5 had mentioned she was not getting up, but she had asked the staff, and they said they were getting her up. She said staff should never tell a resident that they were shorthanded, but they might have. She said she agreed they were short-handed during the period Resident #5 said she was not getting up, according to the facility assessment. She said she was not aware of the requirements of how many staff they should have. She said she would like them to have 4 aides on days (6 am -2 pm) and evenings (2 pm-10 pm), and 2 aides on nights (10 pm- 6 am), but they mostly had 3 aides on the day and evening shifts. During an interview on 10/23/2025 at 12:28 PM, the Medical Director said he was not aware of staffing shortages at the facility. The Medical Director said he had been notified occasionally of medications being administered late, but it had not been frequently. The Medical Director said staffing shortages could affect the residents' care and the care they received. During an interview on 10/23/2025 at 1:29 PM, the DON said nobody had reported to her not being able to complete their tasks due to not having enough staff. The DON said the ADON was responsible for scheduling the staff, and she was not aware of the facilities staffing requirements. The DON said she had requested the facility assessment from the previous administrator, and he never provided it. Therefore, she had not seen it. The DON said insufficient staffing could result in delays in the care the residents received. During an interview on 10/23/2025 at 2:21 PM, the Interim Administrator said she was not aware of there being staff shortages in the facility. The Interim Administrator said based on their facility assessment they were adequately staffed. The Interim Administrator said not having enough staff could result in a delay in care. Record review of the Facility Assessment updated, 04/22/2025, indicated Direct Care Staff Hours Per Resident Day: Days: 1 RN, 1 LVN, 4 CNAs/Hospitality, and 1 Med Aide. Evenings: 2 LVNs, 4 CNAs/Hospitality, and 1 Med Aide. Nights: 2 LVNs, 3 CNAs/Hospitality. Record review of the Punch Detail for 05/03/2025 indicated 2 CNAs worked on the 6 AM-2 PM shift, 3 CNAs worked on the 2 PM-10 PM shift, and 2 CNAs worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 05/04/2025 indicated 3 CNAs worked on the 6 AM-2 PM shift, 3 CNAs worked on the 2 PM-10 PM shift, and 2 CNAs worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 05/10/2025 indicated 3 CNAs worked on the 6 AM-2 PM shift, 3 CNAs worked on the 2 PM-10 PM shift, and 2 CNAs worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 05/11/2025 indicated 2 CNAs worked on the 2 PM-10 PM shift. Record review of the Punch Detail for 06/20/2025 indicated 2 CNAs worked on the 2 PM-10 PM shift and 2 CNAs worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 06/21/2025 indicated 3 CNAs worked on the 2 PM-10 PM shift and 1 CNA worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 06/28/2025 indicated 2 CNAs worked on the 6 AM-2 PM shift, 3 CNAs worked on the 2 PM-10 PM shift, and 2 CNAs worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 07/01/2025 indicated 2 CNAs worked on the 2 PM-10 PM shift and 1 CNA worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 07/05/2025 indicated 3 CNAs worked on the 2 PM-10 PM shift and 2 CNAs worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 07/06/2025 indicated 3 CNAs worked on the 2 PM-10 PM shift and 2 CNAs worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 07/12/2025 indicated 3 CNAs worked on the 6 AM-2 PM shift, 3 CNAs worked on the 2 PM-10 PM shift, and 2 CNAs worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 08/02/2025 indicated 3 CNAs worked on the 2 PM-10 PM shift and 1 CNA worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 08/03/2025 indicated 2 CNAs worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 09/01/2025 indicated 3 CNAs worked on the 2 PM-10 PM shift. Record review of the Punch Detail for 09/20/2025 indicated 3 CNAs worked on the 6 AM-2 PM shift, 3 CNAs worked on the 2 PM-10 PM shift. The punch detail did not indicate an MA for the 6 AM-2 PM or 2 PM-10 PM shift. Record review of the Punch Detail for 09/21/2025 indicated 2 CNAs worked on the 10 PM-6 AM shift. Record review of the Punch Detail for 10/5/2025 indicated 1 CNA worked on the 10 PM-6 AM shift. The punch detail did not indicate an MA for the 6 AM-2 PM shift. Record review of the Punch Detail for 10/12/2025 indicated 2 CNAs worked on the 6 AM-2 PM shift, 2 CNAs worked on the 2 PM-10 PM shift, and 2 CNAs worked on the 10 PM-6 AM shift. The punch detail did not indicate an MA for the 6 AM-2 PM shift. Record review of the Punch Detail for 10/18/2025 indicated 3 CNAs worked on the 6 AM-2 PM shift and 2 CNAs worked on the 10 PM-6 AM shift. During an interview on 10/23/2025 at 2:33 PM, the Interim Administrator said the facility did not have a policy for staffing. Record review of the facility's policy titled, Activities of Daily Living (ADL), Supporting, revised March 2018, indicated, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing .). Record review of the facility's policy titled, Medication Administration, revised June 2025 reflected, . Medications are administered in a safe and timely manner, and as prescribed.3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observations, interviews, and record review the facility failed provide pharmaceutical services, which included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 3 residents (Resident #2) reviewed for pharmacy services. The facility failed to ensure Resident #2 medications were administered during the scheduled time. This failure could place residents at risk of medical complications and not receiving the therapeutic effects of their medications.Findings included: 1. Record review of Resident #2's face sheet, dated 10/23/25, reflected Resident #2 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included Parkinson's (a disorder that affects movement, balance, and coordination) with dyskinesia (involuntary, uncontrolled, and abnormal muscle movements). Record review of the order summary report dated 10/23/25 indicated Resident #2 was ordered:Carbidopa-Levodopa 25-100mg 1 tablet by mouth three times a day. Buspirone 5 mg 1 tablet by mouth three times a day. Record review of the Medication Administration Audit Report dated 10/23/25 reflected Resident #2 received her medications on 10/05/25 by MA B as listed: Carbidopa-Levodopa 25-100mg 1 tablet given at 11:06 a.m. instead of the scheduled medication pass 7:00 a.m.-10:00 a.m. Buspirone 5 mg 1 tablet given at 11:06 a.m. instead of the scheduled medication pass 7:00 a.m.-10:00 a.m. Carbidopa-Levodopa 25-100mg 1 tablet given at 11:46 a.m. of the scheduled medication pass 12:00 p.m.Buspirone 5 mg 1 tablet given at 11:46 a.m. of the scheduled medication pass 12:00 p.m. During an interview on 10/23/25 at 10:39 a.m., MA B stated medications should be administered one hour before or one hour after the scheduled time. MA B stated medications were given late due to short staff and her being the only MA that worked that day. MA B stated she did not remember given Resident #2 the second dose of Buspirone and Carbidopa-Levodopa that was scheduled at 12:00 p.m. MA B stated she probably just clicked it off on the MAR as given to show the task was completed. MA B stated she did not notify the physician or the DON about the second dose not given, or medications given late. MA B stated it was important medications were given on time to ensure the dose was effective and prevent an overdose. Record review of the Medication Administration Audit Report dated 10/23/25 reflected Resident #2 received her medications on 10/18/25 by the ADON as listed: Buspirone 5 mg 1 tablet given at 11:25 a.m. instead of the scheduled medication pass 7:00 a.m.-10:00 a.m.Carbidopa-Levodopa 25-100mg 1 tablet given at 11:25 a.m. instead of the scheduled medication pass 7:00 a.m.-10:00 a.m. Carbidopa-Levodopa 25-100mg 1 tablet given at 11:26 a.m. of the scheduled medication pass 12:00 p.m.Buspirone 5 mg 1 tablet given at 11:26 a.m. of the scheduled medication pass 12:00 p.m. During an interview on 10/23/25 at 11:27 a.m., the ADON stated medications should be given within the scheduled time. The ADON stated she rarely passed medications, and she did not know the medications like the staff that normally administered the medications. The ADON stated she did not notify the MD that the medications were given late nor the 12:00 p.m. dose of Buspirone or Carbidopa-Levodopa were not given. The ADON stated she guessed when she was clicking off the medications on the MAR, she did not realize it was duplicate. The ADON stated it was important medications were given as scheduled to prevent overmedication and a medication error. During a telephone interview on 10/23/25 at 12:24 p.m., the MD stated staff should have notified him if the medications were given late or if the second dose was close to the first dose that was administered. The MD stated he had received text messages about medications been administered late but not frequently. The MD stated he did not know anything about culture time window just the one hour before and one hour after. The MD stated the risk of not administering medications on time was if the resident received a blood pressure medication it could affect their blood pressure. During an interview on 10/23/25 at 12:54 p.m., the DON stated medications can be given one hour before or one hour after. The DON stated the facility did have a culture time which means a window for medication administration. The DON stated if the first dose was given close to when the second dose should be given, the second dose should be held and the MD notified. The DON stated she was responsible for monitoring and overseeing by pulling the medication administration audit report in PCC randomly. The DON stated there have been issues in the past and when she investigated it the staff stated it was given on time just documented late. The DON stated it was important medications were given on time to ensure the residents received the accurate dose and decrease their risk of complications. During an interview on 10/23/25 at 2:08 p.m., the Administrator stated she expected the medications to be administered according to the schedule to ensure effectiveness. The Administrator stated the DON and the ADON were responsible for monitoring and overseeing medication administration. The Administrator stated it was important to ensure medications were given on time to prevent an adverse reaction. Record review of the facility's policy titled, Medication Administration, revised June 2025 reflected, . Medications are administered in a safe and timely manner, and as prescribed.3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 5 (Resident #25, Resident #22, Resident #48, Resident #32, and Resident #15) of 53 residents reviewed for accidents and hazards. 1.The facility failed to ensure Resident #25 did not receive a cigarette burn on 08/24/24. 2.The facility did not ensure Resident #22, who was assessed as an unsafe smoker, signed out to smoke in an unsafe area on 04/21/25 and kept his cigarettes, vapor and lighter in his possession. 3.The facility did not ensure that Resident #48, who was assessed as a safe smoker, did not sign out of the facility to smoke on the side of a residential street on 04/22/25. 4.The facility did not ensure Resident #32, who was assessed as an unsafe smoker, signed herself out to smoke in an unsafe area on 03/31/25. 5. The facility failed to ensure Resident #15 did not have 7 razors stored insecurely in a light blue stainless-steel cup in his room on the mini refrigerator. An Immediate Jeopardy (IJ) situation was identified on 04/22/25. The IJ template was provided to the facility on [DATE] at 4:34 pm, and an amendment IJ template was provided on 04/23/25 at 11:54 a.m. While the IJ was lowered on 04/24/25 at 2:45 p.m., the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, with a scope of pattern due to the facility's need to evaluate the effectiveness of its corrective actions. These failures could put residents at risk of accidents and could result in burn injuries related to smoking paraphernalia that was not monitored/secured by the facility, harm, impairment, and death. Findings included: 1.Record review of Resident #25's face sheet, dated 04/24/25, indicated an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included seizures, anemia (a condition where the blood doesn't have enough healthy red blood cells or hemoglobin to carry oxygen to the body's organs and tissues), glaucoma (a group of eye conditions that damage the optic nerve, potentially leading to vision loss or blindness), and high blood pressure. Record review of Resident #25's quarterly MDS assessment dated [DATE] indicated Resident #25 understood others and was understood by others. The MDS assessment indicated he required assistance with bathing, toileting, dressing, bed mobility, personal hygiene, and eating independently. Record review of Resident #25's comprehensive care plan, dated on 8/26/24, indicated he had a cigarette burn on 08/24/24. The intervention dated 11/22/24 was for staff to provide a smoking apron. Record review of Resident #25's comprehensive care plan, dated on 04/23/25, indicated he was an unsafe smoker. The interventions were to evaluate his smoking safety ability and provide appropriate interventions as indicated by the smoking apron. Record review of Resident #25's smoking assessment dated [DATE] indicated that he required supervision while smoking. Record review of Resident #25 's progress note dated 08/24/24 by LVN CC indicated she was alerted by a laundry staff member that Resident #25 dropped his cigarette and burned himself. LVN CC assessed Resident #25 and noted a small burn to his right bilateral thigh. The area was cleaned, and Triple Antibiotic Ointment was applied. The physician was notified. LVN CC attempted to notify a family member, but there was no answer, so she left a message. Record review of Resident #25 's incident report dated 08/24/24 by LVN CC indicated Resident #25 said he burned his thigh when his cigarette dropped. Record review of Resident #25's skin assessment done on 08/24/24 indicated he had a burn to his bilateral right thigh measuring 1.5 x 1.3. Record review of Resident #25's smoking assessment dated [DATE] indicated that he required supervision and the use of an apron. Record review of Resident #25 's progress note dated 08/26/24 by LVN DD indicated she looked at the burned area on Resident #25's distal back of his right thigh. The area had a small intact blister with no redness or swelling. Record review of Resident #25's skin assessment done on 08/27/24 indicated he had no skin issues. Record review of Resident #25's physician orders dated 8/01/24 through 08/30/24 did not indicate any treatment orders for the right thigh. Record review of the Texas Unified Licensure Information Portal, also known as TULIP (It is an online system used by the Texas Health and Human Services Commission (HHSC) for managing long-term care licensure applications and other related activities) did not reveal an intake on Resident #25's related to a burn. During an observation on 04/22/25 at 11:00 a.m., Resident #25 was supervised while smoking outside. Resident #25 did not have on an apron. During an interview on 04/23/25 at 10:00 a.m., Resident #25 said he could not remember anything about a cigarette burn. During an interview on 04/23/25 at 3:27 p.m., the ADON said she vaguely remembered that incident. She said she was the MDS nurse back in August 2024, so she was unaware of what happened during the investigation process. The ADON said she was unaware if Resident #25's cigarette burn was reported to the state of Texas. She said if someone reported a cigarette burn to her, she would do an assessment and check for any injuries. She would apply treatment and notify the doctor and the responsible party if injuries were noted. She said she would do another smoking assessment and then call her corporate nurse to see what else she needed to do. During an interview on 04/23/25 at 3:32 p.m., the Administrator said he was not aware of Resident #25's burn. He said he was not employed at the facility at the time of that incident. He said he was not aware of any investigation into Resident #25's burn. The Administrator and the surveyor went over the notes in the chart, and he said he was not sure what steps he would have taken but said he would have investigated and gone from there. During an interview on 04/23/25 at 3:37 p.m., LVN DD said she remembered Resident #25 had a small burn to his pants. She said she received in report that he had obtained a burn, therefore she went to assess the area. She said she did not remember what the area looked like, but said she charted what she saw. She said she did not know if the injury was reported to the state of Texas, or if an in-service was conducted about the cigarette burns. During an attempted phone interview on 04/23/25 at 4:12 p.m., LVN FF (nurse that worked on 08-24 and 08-25-24) did not answer; a message was left. During an attempted phone interview on 04/23/25 at 4:14 p.m., LVN BB (nurse that worked on 08-24 and 08-25-24) did not answer; a message was left. During an attempted phone interview on 04/23/25 04:16 p.m., LVN GG (nurse that worked on 08-24 and 08-25-24) did not answer; a message was left. During an attempted phone interview on 04/23/25 at 10:05 a.m., LVN CC had no number listed. LVN CC was the nurse who completed Resident #25's skin assessment and incident report. The ADON said LVN CC had moved out of state, and they did not have her number. During an interview on 04/24/25 at 11:59 a.m., Housekeeper HH said she was on duty on 08/24/24 but did not recall a cigarette burn for Resident #25. She said Laundry Aide EE, usually smoked the residents at the 1:30 pm smoke break. During a phone interview on 04/23/25 at 12:15 p.m., the previous Administrator said she was the Administrator in August 2024. She said she did not recall Resident #25's cigarette burns. She said if it was reported to her, then she would have investigated to see why Resident #25 dropped his cigarette. She said she would have talked to the resident and staff to see what happened to cause Resident #25 to burn himself. She said since she did not recall Resident #25's burn, she could not say what she would have done or what she had done related to his investigation for the cigarette burn. During a phone interview on 04/24/25 at 1:30 p.m., Laundry aide EE said she did not remember a cigarette burn for Resident #25. She said she was usually the person who took them out to smoke but did not recall reporting his burn. She said she did not recall if he was required to wear a smoking apron during that time. She said if a resident received a burn while she was smoking them, she would have reported it to the nurse. 43047 2.Record review of Resident #22's face sheet, dated 04/23/25, reflected Resident #22 was a [AGE] year-old male, readmitted to the facility on [DATE] with a diagnosis which included multiple sclerosis (chronic, progressive disease involving damage to the sheaths of nerves cells in the brain and spinal cord causing numbness, impairment of speech, and of muscular coordination, blurred vison and sever fatigue). Record review of Resident #22's significant change in status MDS, dated [DATE], reflected Resident #22 made himself understood, and understood others. Resident #22's BIMS score was 15, which indicated his cognition was intact. Resident #22 required substantial/maximum assistance with eating, oral hygiene, upper body dressing, personal hygiene and dependent with toileting, shower/bath, and lower body dressing. Record review of the comprehensive care plan, revised 04/23/25, reflected Resident #22 was at risk for injury due to his smoking preference. The care plan interventions included to educate Resident #22 and encourage him to follow facility smoking times, designated smoking areas as needed. The care plan initiated on 03/31/25, reflected Resident #22 had a history of being signed out of facility in parking lot in electric wheelchair using his chair to block staff from parking their cars. The care plan interventions included staff to call into facility for assistance if they could not park their vehicle due to Resident #22 blocking parking spaces or entrances to parking lot. Record review of a quarterly smoking/vaping safety evaluation dated 03/31/25 reflected Resident #22 had a DX of multiple sclerosis and had burned himself during previous admission when he dropped a cigarette on himself while signed out to smoke. The evaluation reflected Resident #22 was confirmed not to be a safe smoker/vaper. Record review of a resident sign out/in log reflected on 04/21/25 Resident #22 signed out at 10:00 a.m. and did not sign back in until 12:02 p.m. During an observation on 04/21/25 at 10:15 a.m., Resident #22 and Resident #32 was observed in the wheelchairs sitting directly on a public roadway, near a residential home while they smoked without supervision. There were no sidewalks provided off the roadway. During an interview and observation on 04/22/25 at 10:21 a.m., Resident #22 was sitting outside in front of the facility vaping without supervision. Resident #22 stated he was told by the facility if he wanted to smoke a cigarette, outside the smoking times, he must sign out and go across the road. Resident #22 was unsure why he was made to do that. Resident #22 stated if he vaped, he could just come outside the facility to do that. Resident #22 stated he did not require supervision unless he went to smoke during the smoke breaks. Resident #22 stated he kept 1 vape on him and the facility kept the other one. Resident #22 stated his lighter was battery operated and was able to light his own cigarette unless the battery was dead. Resident #22 stated if the battery was dead, he would stop and ask someone that was driving by or walking to light his cigarette. During an observation on 04/22/25 at 2:00 p.m., Resident #22 was sitting in his electric wheelchair visiting with another resident. A vape was noted on top of his dresser. During an interview and observation on 04/22/25 at 2:15 p.m., Resident #22 was observed sitting outside in front of the facility vaping with cigarettes noted in the black pouch. Resident #22 stated he was not signed out at the moment, but he knew if he went across the street to smoke, he must go in and sign out. During an interview on 04/22/25 at 2:36 p.m., the ADON stated Resident #22 had to sign out if he wanted to smoke outside the smoke breaks. The ADON stated there was an incident, prior to him been readmitted to the facility, where he was signed out and when he came back, burn holes were noted to the hoyer sling and his shorts. The ADON stated if Resident #22 vapes, he did not have to sign out, but he must go outside in the front of the facility to vape. The ADON stated he was not considered a safe smoker, but he was alert and oriented x3, so he was able to make decisions on his own. The ADON stated Resident #22 did keep a few cigarettes in his pouch that he keeps on him, but he was aware that he must sign out to smoke the cigarettes he had in the pouch. The ADON stated Resident #22 did not require supervision unless during smoke breaks. After reviewing Resident #22's smoking evaluation with the state surveyor, the ADON stated he should not have the cigarettes or vapes on him because he was deemed not a safe smoker/vaper. The ADON stated she was not aware the policy stated, when deemed not a safe smoker/vaper, the resident required supervision. During an interview on 04/22/25 at 2:31 p.m., LVN A said Resident #22 had the right to smoke if he wanted to. She said Resident #22 was not a safe smoker. She said Resident #22 had to sign himself out if he wanted to go across the street to smoke. She said Resident #22 always kept a small bag with cigarettes in it with him. She said she was not aware of any vapes he had. She said Resident #22 did not always comply with the rules, and it was his right to keep his cigarettes if he wanted them. During an interview on 04/22/25 at 2:40 p.m., LVN E said residents could sign out independently. She said Resident #22 had a little pouch that he always kept his cigarettes in. She said he would sign himself out and go smoke. She said she had never gave him a vape but only his cigarettes when he asked for them. She said she was aware he had a special lighter that he used to light his cigarettes but felt he was an unsafe smoker because of his hand dexterity. She said he kept his cigarette in his mouth, which put him at risk of burning his lips or dropping his ashes. She said when he signed out to go smoke, he was supposed to return his cigarettes when he came in, but sometimes he did not. She said that because he would go in and out so much, he would keep his cigarettes until the next time he wanted to smoke. During an interview on 04/22/25 at 3:19 p.m., the Administrator stated he was told by the Regional Director of Operations that Resident #22 was allowed to vape outside the facility without supervision. The Administrator stated Resident #22 should be signing himself out to smoke when he was off the property. The Administrator stated he did not know why Resident #22 had to sign himself to go across the street to smoke. The Administrator stated he was unaware Resident #22 was deemed as not a safe smoker/vaper. The Administrator stated if that was the case, he should always be supervised per the policy. The Administrator stated for as he knew, Resident #22 could not light his cigarette himself and he did not know who did it for him. The Administrator stated he was not aware Resident #22 had a battery-operated lighter he could use for himself. The Administrator stated he was unaware that he kept a vape and cigarettes on him. 3.Record review of Resident #48's face sheet, dated 04/24/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included urinary tract infection, also known as a UTI (is an infection in any part of the urinary system), stroke, diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), chronic obstructive pulmonary disease also known as COPD (a common lung disease causing restricted airflow and breathing problems), and high blood pressure. Record review of Resident #48's admission MDS assessment, dated 03/10/25, indicated Resident #48 understood others and was understood by others. The MDS assessment indicated she had a BIMS score of 15, indicating she was cognitively intact. Resident #48 required assistance with bathing and dressing, and was independent with toileting, bed mobility, personal hygiene, and eating. Record review of Resident #48's smoking assessment dated [DATE] indicated she was safe to smoke independently. Record review of Resident #48's care plan dated 3/31/25 indicated she was a safe smoker. The interventions were for staff to educate her and encourage her to follow the facility's smoking times, designated smoking areas, and policy as needed. During an observation on 04/22/25 at 7:58 a.m., Resident #48 was across the street, sitting on her rolling walker, smoking on the side of the road. During an observation on 04/22/25 at 2:02 p.m., Resident #48 was sitting on the front porch smoking. Resident #48 said she had signed out, so she could smoke. Review of the sign-out book, revealed on (date) Resident #48 had signed out at 1:50 pm. During an interview on 04/23/25 at 8:52 a.m., Resident #48 said she was told that if she wanted to smoke outside of the designated smoking times, she had to go across the street to smoke. She said she was told to sign out and go across the street. She said today (04/23/25), she was told she no longer had to sign out and smoke across the street. She said she could smoke on the premises if someone was smoking with her. 4.Record review of Resident #32's face sheet, dated 04/24/25, indicated an [AGE] year-old female who was admitted to the facility on ,d+[DATE] /25 with diagnoses which included urinary tract infection, also known as a UTI (is an infection in any part of the urinary system), stroke, diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), chronic obstructive pulmonary disease also known as COPD (a common lung disease causing restricted airflow and breathing problems), and high blood pressure. Record review of Resident #32's admission MDS assessment, dated 04/03/25, indicated Resident #32 understood others and was understood by others. The MDS assessment indicated she had a BIMS score of 0, indicating she was severely cognitively impaired. Resident #32 required assistance with bathing, toileting, dressing, bed mobility, personal hygiene, and eating. The MDS did not indicate she required oxygen. Record review of Resident #32's smoking assessment dated [DATE] indicated she was not a safe smoker/vaper related to contractures. Record review of Resident #32's smoking assessment dated [DATE] indicated she was safe to smoke/vape independently. Record review of Resident #32's care plan revised on 1/07/25, indicated Resident #32 was a safe smoker. The interventions were for staff to educate her and encourage her to follow the facility's smoking times, designated smoking areas, and policy as needed. During an interview on 04/23/25 at 8:30 a.m., Resident #32 said she was told that if she wanted to smoke outside of the designated smoking times, she had to go across the street to smoke. She said today (04/23/25) she was informed she no longer had to sign out to go across the street to smoke. She said she was able to smoke on the premises. During an interview on 04/22/25 at 2:40 p.m., LVN E said residents could sign out independently. She said Resident #32 often signed out and went across the street with Resident #22 to smoke. She was not sure of Resident #22's smoking assessment. During an interview on 04/24/25 at 3:27 p.m., LVN U said before the in-service today (04/24/25), she was under the impression that the resident who wished to smoke outside of designated smoking times had to sign out to go across the street. During an interview on 04/22/25 at 2:36 p.m., the ADON said the residents signed themselves out to smoke. She said Resident #48 and Resident #32 were safe smokers. She said she thought they wanted to go smoke across the street. During an interview on 04/22/25 at 3:20 p.m., the Administrator said residents were supposed to smoke in the back courtyard, and if it were raining, they could smoke on the front porch. He said they had the proper disposal out back and on the front porch. He said if a resident had been deemed a safe smoker, then they could smoke on the premises on the back or the front porch. He said he was not aware why Resident #48 and 32 signed out to go smoke. He said he thought Resident #48 and Resident #32 were safe smokers. 45810 5.Record review of Resident #15's face sheet dated 04/30/25 indicated he was an [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses atherosclerotic heart disease (disease in which the build up of fat and cholesterol cause decreased blood flow), diabetes mellitus (disease that causes too much sugar in the blood stream), parkinsonism (neurogenerative disease that causes motor symptoms like tremors and slow movements), and anxiety (characterized by emotions involving increased fear or worry). Record review of Resident #15's quarterly MDS dated [DATE] indicated he understood others and could make himself understood. The MDS also indicated he had a BIMS score of 8 which meant he had moderate cognitive impairment. The MDS also indicated Resident #15 was dependent on staff for personal hygiene. Record review of Resident #15's care plan dated 2/14/23 indicated he had impaired cognitive function and an ADL self-care performance deficit and was dependent on staff for personal hygiene and required extensive assistance from the staff for personal hygiene. During an observation on 04/22/25 at 05:08 PM, Resident #15 had a light blue stainless-steel cup on his mini refrigerator with 7 disposable razors in it. During an observation on 04/23/25 at 07:53 AM, CNA X was in the room feeding Resident #15 and the light blue cup with 7 disposable razors were still sitting on the mini refrigerator in Resident #15's room. During an observation and interview on 04/23/25 at 09:30 AM, Resident #15 was in bed and continued to have the 7 disposable razors on the fridge in the blue cup. CNA X came in to Resident #15's room and said the facility CNAs shaved him but the disposable razors should not have been left there on Resident #15's refrigerator. CNA X said the disposable razors were not to be kept in the residents' rooms She said the disposable razors were kept in the locked bin for the CNAs to use and placed in the sharp's container after use. CNA X said Resident #15's family member would bring things into the facility at times. CNA X said the failure of the disposable razors being left out placed a risk for danger of the resident or other residents cutting themselves, but the facility did not have residents who wander. During an observation and interview on 04/23/25 at 09:41 AM, LPN A said the CNAs should keep the disposable razors stored in the sharp's containers in the bathroom after use. She said no disposable razors should have been left in any resident's room and in reach. LPN A said the failure placed a risk for residents to be injured or cut someone else. LPN A said all the staff were responsible for ensuring the razors were not left in resident's as she went and removed the disposable razors from the room and discarded them in the sharp's container. During an interview on 04/23/25 at 01:52 PM, the ADON said her expectation was for the disposable razors to be used and then disposed of properly in a sharp's container immediately after use. The ADON said the failure placed a risk for other residents getting the disposable razors and cutting themselves. She said all staff were responsible for ensuring no disposable razors or sharp objects were left out in reach of residents. During an interview on 04/23/25 at 02:04 PM, the Administrator said his expectation was for the CNAs to dispose of the disposable razors in the sharp's containers when they complete the residents' ADL care. He said the CNA assigned to the Resident #15 was responsible for ensuring the disposable razors were not left out in the room. The Administrator said the failure placed a risk for the resident or other resident to cut themselves. This was determined to be an Immediate Jeopardy (IJ) on 04/22/25 at 4:34 PM. The Administration was informed of the IJ. The Administrator was provided with the IJ template amendment on 04/23/25 at 11:54, and a plan of removal was requested. Record review of the facility's policy titled, Smoking Policy-Supervised and Unsupervised, revised 07/21/18 , indicated Safe Smoking Environment: it is the responsibility of the facility to provide a safe and hazard-free environment for those residents who have been assessed as being safe for facility smoking privileges. The facility is responsible for informing residents, staff, visitors, and other affected parties of the smoking policies through verbal means, distribution, and posting. This facility is intended to minimize the risk to residents: residents who smoke, including possible adverse effects on treatment; Passive smoke to others; and fire. Smoking accommodation: E cigarettes will be treated like cigarettes per policy at no time will E cigarettes be permitted for inside use of the facility. The facility is responsible for the enforcement of the smoking policy. Smoking is prohibited in any room or area within the facility. All residents who wish to smoke must provide funds to purchase their own smoking paraphernalia. Smoking Evaluation: Residents wishing to smoke while at the facility will have a smoking safety evaluation completed by the interdisciplinary team to determine the resident's ability to follow the smoking policy safely. If a resident is determined to be a safe smoker, the resident can smoke unsupervised, resident can keep their smoking supplies and smoke in a designated area at their leisure. Or a resident can smoke unsupervised, the facility will keep all smoking supplies, and the resident can smoke in designated areas at their leisure. If a resident is determined to be unsafe smoker then they must be supervised at all times when smoking facility staff will keep all smoking supplies and smoking times will be established by the facility and adhered to by the resident a supervised smoking schedule will be posted and residents will be required to smoke with supervision only according to the schedule. Record review of Plan of Removal accepted on 04/23/25 at 8:19 p.m. reflected the following: Plan of Removal Starting on 4/23/2025, resident #22, #48, and #32 will be supervised when in an unsafe area. The physician was notified of both the smoking and residents leaving safe supervised area. Immediately on 4/22/2025, all smoking assessments were audited for accuracy and care plan updated as indicated. Residents #22, #48, and #32 were reassessed and evaluation determined they are safe smokers and able to vape safely. Resident #25 was reassessed and evaluation determined he is an unsafe smoker. All smokers were reassessed, and changes made to safe or unsafe smoking, including vaping as indicated. Assessments completed by Corporate Clinical Specialist and Corporate Case Mix. Residents assessed to be unsafe will be supervised and smoking supplies will be held at the nurse's station. Residents assessed to be a safe smoker will be able to smoke unsupervised at their leisure in the designated smoking area. On 4/23/2025, an emergency care plan meeting was conducted with residents (#22, #48, #32, and #25) regarding safe supervision and smoking policy, to include vaping. Residents #22, #48 and #32 were informed they can smoke only in the smoking area of the facility. Resident #25 was informed that he remains and unsafe smoker and must be supervised. All smoking residents were educated in regards to the smoking area of the facility and informed that location is the only place they can smoke. Care plans updated as indicated to include education regarding safety plan and pedestrian safety. On 4/23/2025, Ombudsman notified of the incident with Resident #22, #48, and #32 smoking unsupervised in an unsafe area. Informed of Resident #25 incident of cigarette burn from 8/24/2024. On 4/23/2025, Medical Director notified of the incident with Resident #22, #48, and #32 smoking unsupervised in an unsafe area. Informed of Resident #25 incident of cigarette burn from 8/24/2024. On 4/22/2025, Corporate Clinical Specialist in-serviced Administrator and ADON regarding Accident/Hazard Supervision, specifically in regard to safe smoking policy, smoking assessment accuracy, designated smoking areas, and remaining in safe supervised area. Competency verified by quiz. Completed 4/22/2025. On 4/22/2025, facility Administrator and ADON in-serviced all staff regarding Accident/Hazard Supervision, specifically in regard to safe smoking policy, designated smoking areas, and remaining in safe supervised area. Competency verified by quiz. Staff will not be allowed to work until completion. Completed on 4/22/2025. On 4/23/2025, Corporate Clinical Specialist in-serviced staff on residents that are safe smokers and those that are not, and how to find that information. Completed 4/23/2025 On 4/23/2025, Corporate Clinical Specialist, or designee, in-serviced licensed nurses on completing smoking risk assessment accurately as related to current health concerns/conditions, resident capabilities, and resident smoking material preference (cigarettes and/or electronic cigarettes). In-service included that Licensed Nurses are responsible for completing the smoking assessments upon admission, change of condition, and quarterly. The above training regarding Accident/Hazard Supervision, specifically in regard to safe smoking and safe supervision will be implemented into new hire orientation effective 4/22/2025. To monitor compliance, residents will be monitored by the DON/designee through observations and communication with staff daily x4 weeks and monthly x3 months. DON/designee will review smoking assessments weekly x4weeks monthly x3 months. The QA committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, the facility will continue to be monitored as per the routine facility QA committee. On 04/24/2025 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an observation on 04/24/2025 at 01:35 PM, Resident #22 was in the designated smoking area with supervision while smoking. Record review of an in-service dated 4/22/2025 provided by Corporate Clinical Specialist to the Administrator and ADON regarding Accident/Hazard Supervision, specifically in regard to safe smoking policy, smoking assessment accuracy, designated smoking areas, and remaining in safe supervised area. Record review of competency verified by quiz, including all unsafe smokers to be supervised, encourage and educate on safe supervision areas, storage of paraphernalia, smoking assessments, and smoking violations were dated 4/22/2025 completed by the Administrator and ADON. Record review of an in-service dated 4/22/2025 provided by the facility Administrator and ADON was initiated to all staff regarding Accident/Hazard Supervision, specifically in regard to safe smoking policy, designated smoking areas, and remaining in a safe supervised area. Record review of 51 employees with a total of 51 competencies included questions regarding Accident/Hazard Supervision, specifically in regard to safe smoking policy, designated smoking areas, and remaining in safe supervised areas were verified by a quiz completed on 4/22/2025. Record review of in-service dated 04/23/2025, Corporate Clinical Specialist in-serviced staff on residents who were safe smokers and those who were not, and how to find that information. Re [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure that the resident environment remained free of accident hazards and each resident was provided adequate supervision to prevent injuries for 1 of 6 residents (Resident #1) reviewed for accident hazards. The facility failed to ensure Resident #1's bed was locked while providing care resulting in a fall with fractures to the orbital floor (a break to the thin, bony plate that forms the bottom of the eye socket) and cervical spine on 1/30/25. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 2/26/25 at 12:00 p.m. While the IJ was removed on 2/27/25, the facility remained out of compliance at no actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for serious harm, impairment, or death. Findings include: 1. Record review of the face sheet dated 2/26/25 indicated Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including heart failure, hypertension (elevated blood pressure), diabetes, anxiety, and COPD. Record review of the Admission MDS dated [DATE] indicated Resident #1 admitted to the facility from a short-term general hospital on 1/30/25. Record review of the Discharge MDS dated [DATE] indicated Resident #1 discharged from the facility with return anticipated to a short-term general hospital on 1/30/25. Record review of Resident #1's medical records indicated Resident #1 did not have a care plan or physician orders at the time of her discharge from the facility. Record review of the progress note dated 1/30/25 written by RN A indicated, [Resident #1] admitted facility, while doing assessment and applying wound Vac. [CNA B was] on left side of bed, bed did not lock as was thought, bed moved causing resident to fall to floor bed in semi high position. [CNA B] was unable to keep [Resident #1] from falling to floor. [Resident #1] hit her head causing a laceration to top of left forehead and also hit her left eye causing a hematoma (a localized collection of blood outside of the blood vessel) to eye. Due to nature of fall [Resident #1] was sent to local ER for sutures and evaluation. [Family] and MD made aware of incident. Record review of the incident report dated 1/30/25 written by RN A indicated, While doing assessment on [Resident #1] and wound measurements and to apply wound vac [CNA B] on other side [of bed] to hold [Resident #1], bed moved causing [CNA B] to lose her hold on [Resident #1]. The incident report indicated immediate action taken by the facility was Resident #1 was sent out to the ER. Record review of the hospital records for Resident #1's admission starting 1/30/25 indicated, [Resident #1] arrived by EMS due to fall/AMS from [nursing facility], [Resident #1] just arrived to the facility from the hospital for unknown reasons. staff was working on patients wound vacs, the bed was not locked, and patient fell out onto face, swelling, bruising to [left] eye, [laceration] to [left] side of forehead. The hospital records indicated Resident #1 had a notable orbital fracture and nondisplaced fractures (a type of fracture where the bone fragments remain in their original position without shifting) on C-spine (cervical spine) osteophytes (a bony growth that develops on the edge of a bone). The hospital records discharge summary indicated Resident #1 was status post fall from the bed with an orbital wall fracture with possible muscle entrapment and equivocal (a situation where the muscle gets trapped within a fractured bone or other tissue, often causing limitation in movement, while equivocal means uncertain or ambiguous), tiny acute or subacute fractures (stress fracture) of the anterior (nearer to the front) osteophytes along the inferior endplate of C6 bilaterally (a flat, bilayer cartilage that helps stabilize the vertebral column). During an interview on 2/20/25 at 10:03 a.m. the MDS Coordinator/ADON said Resident #1 was only in the facility for approximately an hour before she was sent to the ER, and they did not have time to complete a baseline care plan or any of her stuff in their computer system. During an interview on 2/26/25 at 9:38 a.m. RN A said Resident #1 entered the facility at the end of her shift on 1/30/25. RN A said she went to Resident #1's room to perform a skin assessment and apply the wound vac to the wound on her bottom. RN A said she had her head down when CNA B said, Oh no. RN A said Resident #1 fell to the floor. RN A said she thought she locked the bed but could not say for sure if it was locked. During an interview on 2/26/25 at 9:46 a.m. CNA B said on 1/30/25 she was assisting RN A with wound care on Resident #1. CNA B said Resident #1 was rolled up on her side. CNA B said she and RN A had thought the bed was locked but it was not, and the bed moved. CNA B said she attempted to hold Resident #1 up from falling but was unable to. CNA B said Resident #1 fell to the floor. Record review of the facility's Fall Prevention Program policy revised 6/10/24 indicate, All resident will be assessed for the risk for falls at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Based on the results of this assessment, specific interventions will be implemented to minimize falls, avoid repeat falls, and minimize falls resulting in significant injury . The Administrator was notified on 2/26/25 at 12:06 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 2/26/25 at 12:11 p.m. The facility's Plan of Removal was accepted on 2/26/25 at 6:30 p.m. and included: Immediately on 2/26/25, Regional Nurse in-serviced Administrator and ADON regarding Accident Hazards/Supervision/Devices, making sure all beds are properly locked prior to providing care to resident. If not working, ensure resident safety, remove equipment from use and notify maintenance director immediately. Competency verified via quiz. Licensed nurse was in-serviced by ADON on 2/26/25 with competency validation. On 2/26/25, the ADON/Designee initiated in-services with all facility staff regarding Accident Hazards/Supervision/Devices, making sure all beds are properly locked prior to providing care to resident. If not working, ensure resident safety, remove equipment from use and notify maintenance director immediately. Competency was verified via quiz. Staff will not be allowed to work until in-servicing has been completed on 2/26/25. The above content was incorporated into new hire orientation by Administrator effective 2/26/25. On 2/26/25, the Maintenance Director checked all beds and mobility devices to ensure safe working order. Any concerns were immediately repaired or replaced. The Medical Director was notified on 2/26/25. In order to monitor compliance, the Maintenance Director will check beds and mobility equipment weekly x4 weeks and monthly thereafter x 3 months. The ADON/designee will do periodic checks during resident care to ensure compliance daily x4 weeks than monthly thereafter x 3 months. Any negative findings will be corrected and reported to the QAPI committee to ensure continued compliance. The facility will meet weekly for the next eight weeks to review compliance with the plan of action. No further concerns are noted, will continue to monitor as per routine facility QA Committee. On 2/27/25 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the monitoring sheets indicated on 2/26/25 all beds and wheelchairs in the facility were checked to ensure they locked and working properly. Observations on 2/27/25 of randomly selected beds in the facility indicated 10 out of 10 beds checked locked properly and did not move when locked. Record review of in-services dated 2/26/25 indicated the Administrator, MDS Coordinator/ADON, and facility staff had been in-serviced regarding accidents hazards/supervision/devices, making sure all equipment (beds and wheelchairs) were in proper working order and the locks were working, and if equipment locks were not working properly notify maintenance. Record review of competency quizzes dated 2/26/25 indicated all staff interviewed by the surveyor as listed below had completed the competency quiz with questions including do you check to confirm bed is locked each time before providing care; if you are providing care for a resident and lock the bed, how do you confirm it is locked; what do you do if you test the bed and the lock is not working; and if you noticed equipment is not working, you should immediately ensure resident safety, remove equipment form you, and report to the Administrator/Maintenance Director with 100% accuracy. During an interview on 2/27/25 at 9:20 a.m. the Adminsitrator said he had been in-serviced by the Regional Nurse regarding ensuring locks on beds and wheelchairs were routinely checked and in working order, ensuring beds were locked prior to staff providing care for a resident, and staff's responsibility for reporting to management and the Maintenance Director of locks not working properly on beds or whellchairs. Staff interviewed (MA C, CNA B, CNA D, CNA E, LVN F, RN G, LVN H, CNA J, CNA K, Housekeeper L, CNA M, the AD, LVN N, and the MDS Coordinator/ADON) who worked across all shifts on 2/27/25 between 9:23 a.m. and 10:22 a.m. were able to verbalize when locks should be checked on beds and wheelchairs, the importance of ensuring locks were properly locked and working prior to providing care for a resident, and what to do if a lock was not working properly. During an interview on 2/27/25 at 10:24 a.m. the Maintenance Director said he had checked to ensure all beds in the facility had proper working locks and logged the results. The Maintenance Director said he would be checking the locks weekly for a few weeks and then monthly thereafter. On 2/27/25 at 10:29 a.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure each resident received necessary behavioral health care services to maintain the highest practicable mental and psychosocial wellbeing for 1 of 6 residents (Resident #1) reviewed for behavioral services. The facility failed to have Resident #1 evaluated for decision making capacity. The facility failed to provide a psychological evaluation to determine if Resident #1 was a harm to herself. The facility failed to re-offer psychiatric services since 8/2023 for Resident #1. The facility failed to develop interventions to address the resident's acute schizophrenic behaviors. The facility failed to implement licensed social services to provide crises support, and coordination with the healthcare team. The facility failed to recognize and obtain Resident #1's schizophrenia diagnosis from behavioral health care. An IJ was identified on 1/11/2024 at 12:56 p.m. The IJ template was provided to the facility on [DATE] at 1:11 p.m. While the IJ was removed on 1/12/2024, the facility remained out of compliance at a scope of isolated and a severity level of potential for [NAME] than minimal harm because all staff had not been trained on neglect. These failures could placed residents at risk for the lack of behavioral health services with the potential for serious injury and death. Findings included: Record review of an undated face sheet indicated Resident #1 was a [AGE] year-old female, who admitted on [DATE] with the diagnosis of unspecified psychosis (Psychosis is when people lose some contact with reality. This might involve seeing or hearing things that other people cannot see or hear (hallucinations) and believing things that are not actually true (delusions), motivational impairment, social withdrawal, flat emotions, negative symptoms worsen a person's quality of life and functioning (negative symptoms). It may also involve confused (disordered) thinking and speaking) not due to a substance or known physiological condition, Buerger's disease (also known as thromboangitis obliterans) affects blood vessels in the body, most commonly in the arms and legs. Blood vessels swell, which can prevent blood flow, causing clots to form. This can lead to pain, tissue damage, and even gangrene (the death or decay of body tissues), and major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.) Record review of the consolidated physician's orders dated 1/09/2024 indicated Resident #1 had an ordered referral for psychiatric services on 4/14/2022, and on 8/29/2023. There were no antipsychotic or antidepressant medications ordered on Resident #1's consolidated physician's orders. Record review of Quarterly MDS dated [DATE] indicated Resident #1 understood and was understood by others. The MDS in the section of Cognition Pattern C0100 had a (-) meaning unable to determine the response, in the section for the BIMS (Brief Interview Mental Status) assessment C0200 also had a (-), in the section Recall C0400 there was also a (-). The MDS in section C0700 indicated Resident #1's memory short-term and long-term both indicated her memory was intact. The MDS in the section C1310 indicated there was no evidence of an acute change in mental status, and no behaviors of inattention, or disorganized thinking. The MDS in the section Mood D0100 indicated a (-). The MDS section D0150 Resident Mood Interview indicated (-) in column 1 and blank in column 2. The MDS in section D0160 a (-) was documented. The MDS section D Mood the staff assessment of Resident #1's mood indicated she had no symptoms of little interest or pleasures, feeling down or depressed, feeling tired, poo appetite, indicating they feel bad about self, trouble concentrating, moving, or speaking slowly or fast, stating life not worth living. The MDS reflected in Mood J being short-tempered, easily annoyed marked yes and 12-14 days in column 2. Section E Behaviors of the MDS indicated Resident #1 had no hallucinations or delusions. The MDS indicated in E0200 Behavioral Symptoms indicated physical behaviors directed toward others occurred 1-3 days, verbal behavior symptoms directed at others occurred 4-6 days, and other behavioral symptoms not directed at others (such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, or disruptive sounds). The MDS in section E0800 Rejection of care indicated Resident #1 displayed this behavior 4-6 days but less than daily. The MDS indicated in Section GG Resident #1 was independent with eating, dependent with toileting and personal hygiene, and refused bathing, dressing. The MDS in section I Active Diagnosis indicated Resident #1 had depression other than bipolar, and psychotic disorder other than schizophrenia. The MDS assessment did not indicate Resident #1 had a diagnosis of schizophrenia. The MDS in section M indicated Resident #1 had no skin conditions. Section M of the MDS indicated Resident #1 was not receiving any antipsychotic or antidepressant medications. Record review of a PHQ-9 (an objective assessment of the severity of depression) dated 2/21/2023 indicated Resident #1 scored a 0 due to not being assessed. Resident #1 refused to participate in the assessment and the assessment indicated Resident #1 said close the door when you leave. Record review of a BIMS (Brief Interview for Mental Status) assessment dated [DATE] indicated Resident #1 score was a 10 indicating moderately impairment. Record review of the care plan dated 9/21/2021 and revised on 9/25/2023 indicated Resident #1 makes poor safety choices as evidenced by refusal of wound care to foot, hospitalization , and hospice. The goal of the care plan was Resident #1 wound not have adverse effects related to the refusal of care. The interventions of the care plan were to attempt to monitor resident in regard to safety choices; notify the doctor, administrator, DON, and supervisor in regard to poor safety choices that place resident at risk implemented on 8/19/2021 and educated Resident on risks associated with poor safety choices implemented on 8/19/2021 this care plan failed to implement any current interventions. The care plan indicated Resident #1 was at risk for infections related to refusal to allow her room to be cleaned. The goal of the care plan was Resident #1 would not have any adverse effects related to her refusal. The interventions included attempt to clean the room throughout the day by housekeeping and nursing dated 10/28/2022, attempt to tidy the room when care provided dated 10/28/2022, and educate Resident #1 on the risks of living in unclean environment dated 10/28/2022 there care plan failed to implement current interventions. The care plan dated 8/19/2021 and revised on 11/30/2022 indicated Resident #1 had a behavior problem as evidenced by yelling and cursing at staff, demeaning and derogatory comments to staff, allowing only limited staff members to provide care, calling 911, refuse to allow trays to be removed from room, making false accusations, refusing to allow call light to be turned off; the goal of the care plan was Resident #1 would have fewer episodes of outbursts. Resident #1's care plan interventions included 2 persons to offer and provide care at all times, anticipate and meet the resident needs allowed reviewed on 8/31/2023, anticipate and meet the resident's needs as allowed revised on 8/31/2023, assist the resident to develop more appropriate methods of coping and interacting and encouraged Resident #1 to express feeling appropriately revised on 8/19/2021. Resident #1's care plan interventions indicated she would have all procedure explained before starting and allow time for adjustment to change dated 8/19/2021. Resident #1's care plan intervention included to monitor behavior episodes and attempt to determine underlying cause and document dated 8/19/2021. Resident #1's care plan interventions indicated to refer Resident #1 to psychological services dated 8/30/2023. Resident #1's care plan failed to address her behaviors with new interventions and revise with interventions that promoted stability with her mental illness. Record review of a PHQ-9 (an objective assessment of the severity of depression) dated 8/03/2023 indicated Resident #1 scored an 8 indicating she was mildly depressed. Record review of a Comprehensive Care Plan Conference Summary dated 8/30/2023 indicated Resident #1 refused environmental care, refuses care, yells, curses, calls 911, verbal outbursts, and was at high risk for impaired skin. The care plan conference was signed by the AD, occupational therapist, the social services staff person, dietary manager, and the DON. The care plan conference was not signed by Resident #1 or the responsible party. Record review of a PHQ-9 (an objective assessment of the severity of depression) dated 10/23/2023 indicated Resident #1 was not assessed for depression due to her refusal to participate. Record review of an undated Comprehensive Care Plan Conference Summary indicated Resident #1 had multiple behaviors, unavoidable skin issues, and Buerger's disease. The conference was signed by the MDS nurse, the activity director, and social services staff person. Resident #1 or the responsible party signature area was left blank. Record review of a BIMS assessment dated [DATE] indicated Resident #1's score was 0 with the category of severe impairment. Record review of a Psychotherapy Intake Note dated 4/20/2022 indicated Resident #1 was seen by a therapist for 1 hour. The therapist indicated Resident #1 was referred due to a history of depression and psychosis. The note indicated Resident #1 was oriented to person, place, and time. The note indicated Resident #1's mood was euthymic (normal display of emotion), affect was congruent with Resident #1's mood, Resident #1 had good attention, and appropriate thought content. The note indicated Resident #1 denied any mental health issues and indicated her health records were falsified to keep her in the facility against her will. The note indicated she believed the staff were trying to murder her and the only way to get help was to meet her fiance. The note indicated Resident #1 believed the business office had stolen money and the claim was validated by the state agency even though she had not found a letter stating so. Resident #1 discussed previous traumas at other nursing facilities and alluded to some abuse when growing up. The note indicated Resident #1 believed she was in a relationship with a famous musician. The note indicated Resident #1 hoped to buy a gift card to purchase a fan club membership in so that she could spend time with the musician in person. The therapist documented the diagnosis of Major depressive disorder, single episode severe, and schizophrenia spectrum and other psychotic disorders. The note indicated Resident #1's presented with depression and psychosis. The goal of Resident #1's treatment was to reduce depression, psychosis, and improve sense of well-being in the facility. The estimated completion was 12 months for Resident #1. The note indicated Resident #1 would be seen weekly. Record review of a Psychotherapy Progress Note dated 5/04/2022 indicated the session lasted 53 minutes with Resident #1. The note indicated Resident #1 had the diagnosis of Major Depressive Disorder, single episode severe, and Schizophrenia Spectrum and other psychotic disorder. The note indicated Resident #1 was alert oriented to person, place, and time. The note indicated her mood was normal, and her affect was congruent with her mood. The note indicated Resident #1 was not having a good week. The note indicated Resident #1 continued to believe she was held against her will and they were still trying to kill her. The note indicated Resident #1 continues to hope to see her fiance soon and believed he was trying to come and visit with her. The note indicated Resident #1 was unable to call the person because he was in Europe and her phone does not call Internationally. The note indicated Resident #1 continues to be upset no one will purchase her a $2000 gift cared for her. Resident #1 said she could not notify the ombudsman or the state agency as they hang up on her. The note indicated Resident #1's interventions included rapport building, exploration of coping patterns, exploration of emotion, exploration of relationship patters, supportive reflection and symptom management. The note indicated there was no progress in the reduction of symptoms of depression, symptoms of psychosis, or an improved sense of well-being. The note indicated Resident #1 would be treated weekly. Record review of a Psychotherapy Progress Note dated 5/11/2022 indicated the therapist was with Resident #1 53 minutes. The note indicated Resident #1 oriented to person, place, and time. The note indicated Resident #1's mood and affect were congruent, attention was good, thought content appropriate. The resident reported she is not having a good week. The note indicated Resident #1 continues to believe she is held against her will and they were trying to kill her. The note indicated Resident #1 believes her fiance would be able to visit. Resident #1 said she had been able to speak with her fiance some this week but had not mentioned to issues of international calling. According to the note Resident #1 continued to be upset with not being able to purchase the $2000 gift card. The note indicated Resident #1 was hoping to see the orthopedic surgeon to strengthen her leg. The note indicated Resident #1 believed she needed someone in Dallas as they provide better care. Resident #1 was noted as indicating she would need physical therapy after the surgery. The note indicated Resident #1 does not want to stay in any nursing facility. Staff had reported Resident #1 called 911 twice last week and left the line open. Resident #1 reported a police officer had come to the facility and called her crazy in front of the staff. The note indicated Resident #1 indicated the police officer threatened to take her to court and make the facility her guardian. The note indicated Resident #1 believed this was a violation of her rights. The notes indicated the progress in reduction of symptoms of depression, reduction of symptoms of psychosis, and the reduction of sense of well-being was maintained. The note indicated Resident #1 called the therapist's office on 5/13/2022. The note indicated Resident #1 wanted to inform the therapist of her big toe on her bad foot was infected. The note indicated Resident #1 indicated the staff were not helping or treating her foot. The note indicated Resident #1 would be seen weekly. Record review of a Psychotherapy Progress note dated 6/01/2022 indicated the therapist was with Resident #1 60 minutes. The note indicated Resident #1's diagnoses were Major Depressive Disorder, single episode, severe, and Schizophrenia Spectrum and other Psychotic Disorder. The note indicted Resident #1 was oriented to person, place and time. The note indicated Resident #1 continued to report not having a good week, as indicated by expressing she believed she was held against her will, and they were trying to kill her. Resident #1 indicated to the therapist had found some new orthopedic surgeons in a hospital in Dallas. The note indicated Resident #1 hoped the therapist called all the physician's and to explain her emergency situation so they will quickly take her. The note indicated Resident #1 attempted to message one of the surgeons on an App, but never received a response. The note indicated Resident #1 hoped the FBI would find her friends in Arizona who would loan her some money so she could leave with her fiance's manager. The note indicated Resident #1 had spoken of suicide attempts but had promised God she would never try gain. The note indicated Resident #1 denied any current suicidal ideation, plan, means, or intent. The note indicated the treatment progress for Resident #1 continued to be maintained. The note indicated Resident #1 called the therapist's office indicating she had something urgent to discuss. The therapist indicated Resident #1 had not mentioned this concern during the therapy session. The note indicated Resident #1 would continue to be seen weekly. Record review of a Psychotherapy Progress Note dated 6/22/2022 indicated Resident #1 was seen by the therapists for 46 minutes. The therapist indicated Resident #1 was angry this week. The note indicated Resident #1 was upset with the therapist since the therapist had not provided an envelope and stamps for Resident #1 to mail money to her fiance. The note indicated the therapist indicated the dangers of mailing cash as well as the therapeutic boundaries. The note indicated Resident #1 attempted to switch places and tried to provide therapy to the therapist and become frustrated when the therapist would not allow this to occur. The note indicated Resident #1 believed the therapist was there to get easy blood money from Medicare and does not believe the therapeutic relationship was what she needed at present. The note indicated Resident #1 was placed on an as needed status. The note indicated Resident #1 had no progress in the reduction of depressive symptoms, psychosis symptoms or in the sense of well-being. Record review of Resident #1's clinical record revealed there were no further treatments noted from a psychotherapist after 6/22/2022. Record review of a Unavoidable Wound Documentation assessment dated [DATE] indicated Resident #1 had peripheral vascular disease, chronic bowel incontinence, thyroid disease, impaired mobility, and cognitive impairment. The assessment indicated Resident #1 had the head of her bed elevated the majority of the day. The assessment in Resident Compliance indicated Resident #1 refuses care and has psychosis this form was signed by the physician on 9/21/2023. Record review of a BIMS assessment dated [DATE] indicated Resident #1's score was 0 with the category of severe impairment. Record review of the electronic medication administration record dated December 2023 indicated Resident #1 accepted her medications. The medication administration record indicated Resident #1 was not treated pharmacologically for her depression or psychosis. Record review of a physician's progress note dated 12/20/2023 completed by the nurse practitioner indicated Resident #1 was seen for her high blood pressure, and reflux disease (stomach acid or bile irritates the food pipe lining). The physician's progress note indicated the past medical history of psychosis and major depressive disorder (recurrent and moderate). The physician's progress note failed to address a psychological examination and indicated Resident #1's skin was warm, dry, no rashes, and no suspicious lesions. The note failed to mention the stability of Resident #1's psychosis and depression. Record review of the electronic medication administration record dated January 2024 indicated Resident #1 accepted her medications. The medication administration record indicated Resident #1 was not treated pharmacologically for her depression or psychosis. Record review of a physician's progress note dated 7/20/2023 completed by the nurse practitioner indicated Resident #1 was seen for coronary artery disease (damage or disease in the heart's major blood vessels) and weakness. Resident #1's past medical history included psychosis and major depressive disorder. The assessment indicated Resident #1 had warm and dry skin with no suspicious lesions. The neurological assessment indicated non-focal (not specific to a certain area of the brain. It may be a general loss of consciousness or emotional problem). The note failed to mention the stability of Resident #1's psychosis and depression. Record review of a physician's progress note dated 8/09/2023 completed by the nurse practitioner indicated Resident #1 was seen for neuropathy (weakness, numbness, and pain from nerve damage usually in the hands and feet) and reflux disease. The note indicated the nature of the neuralgia was general neuralgia affecting both legs with a moderate severity. The note indicated Resident #1's skin was warm, dry, no suspicious lesions, and no rashes. The note failed to mention Resident #1's left foot condition, and the neurological exam indicated non-focal (not specific to a certain area of the brain. It may be a general loss of consciousness or emotional problem). The note failed to mention the stability of Resident #1's psychosis and depression. Record review of a Social Determinants of Health assessment dated [DATE] completed by the social worker designee indicated Resident #1's assessment included her ethnicity, race, language, need of interpreter to communicate with a doctor or health team, lack of transportation, how often does she require assistance with reading, and how often does she feel lonely or isolated. The social health assessment failed to ascertain information regarding Resident #1's current or past behavioral health needs, assess the on-going behaviors and identify triggers and interventions, provide in-sight on the need of outside resources. Record review of Resident #1's progress notes dated 9/12/2023 to 1/11/2024 indicated: Progress note dated 9/12/2023 at 2:57 p.m., LVN G documented the psychiatric nurse practitioner was present for a psychological exam and Resident #1 refused. The progress note failed to reflect Resident #1's physician was notified of the refusal for psychiatric services. Progress note dated 9/23/2023 at 11:21 p.m., LVN C documented he offered incontinent care and Resident #1 started yelling get out, get out, you murderers! The progress note failed to denote Resident #1's physician was notified of the delusions. Progress note dated 9/26/2023 at 4:00 a.m., LVN C documented Resident #1 cursed loudly and yelled obscenities at the nursing staff when offering incontinent care. The note failed to indicate LVN C notified the physician of the verbal aggressive behaviors. Progress note dated 9/26/2023 at 7:30 a.m., LVN A documented Resident #1 indicated she needed a brief change. LVN A indicated she offered a total bed bath. LVN A indicated Resident #1 refused and stated, I don't want you tearing my flesh apart more than you already have. LVN A documented Resident #1 stated during repositioning , you both are going to hell, [NAME]. God does me justice and you will both rot in hell and burn for eternity. The note failed to indicate LVN A notified Resident #1's physician of the delusions (of being harmed) and religiosity thoughts. Progress note dated 10/02/2023 at 9:17 a.m., LVN A indicated, Resident #1 continued to refuse care and left foot continued to decline related to Buerger's Syndrome. The note indicated Resident #1 refused to allow staff to touch her foot, clean or treat. The note indicated staff had made multiple attempts. The note indicated the foot appeared to be black on the toes with crusty like covering up to ankles. The note indicated multiple attempts were made to send Resident #1 to the hospital as the foot had no circulation and become necrotic. The note failed to indicate Resident #1's physician was notified of the negative symptoms of psychosis/schizophrenia. Progress note dated 10/02/2023 at 1:14 p.m., LVN A indicated the wound care specialist visited and Resident #1 refused care and treatment. The progress note indicated Resident #1 commenced to yelling and screaming at staff. The note failed to indicate Resident #1's physician was notified of her refusal of care and verbally aggressive behaviors. Progress note dated 10/03/2023 at 5:05 a.m., LVN B documented Resident #1 refused incontinent care this shift. Progress note dated 10/13/2023 at 8:55 a.m., LVN A documented Resident #1 requested to have incontinent care performed. LVN A documented after Resident #1's medication administration, and a sip of water Resident #1 threw the remaining water on LVN A and said, cool off bitch and burn in hell. The note indicated the Administrator was informed. LVN A failed to document the notification of the physician related to the aggressive physical behaviors. Progress note dated 10/30/2023 at 10:25 a.m., LVN A documented Resident #1 continue to refuse care and her left foot continued to decline. The progress noted indicated Resident #1 refused to allow staff to touch foot, clean, or treat. The progress note indicated LVN A documented the foot has black toes with crusty like covering up to Resident #1's ankles. LVN A documented Resident #1's left foot had no circulation and was necrotic. LVN A failed to document to notify Resident #1's physician. Progress note dated 11/03/2023 at 10:21 a.m., the DON documented during the weekly skin check Resident #1 refused care. The DON documented the Resident #1's left foot was withering and changing to a dark color with dry skin flaking off related to the diagnosis of Buerger's Syndrome. The DON documented the Resident #1's refusal of staff to touch the foot, clean or treat the foot. The DON documented Resident #1's left foot had black toes with a crusty like covering up to sock line. The DON documented Resident #1's fingertips had discolored areas on the middle of the fingers. The DON documented the physician was notified and the nurse practitioner was present for the offering of treatment, hospitalization , or hospice. The DON documented after extensive attempts Resident #1 was screaming get out of my room. The progress note failed to indicate any behavioral health care was offered. Progress note dated 11/05/2023 at 2:21 a.m., LVN C documented Resident #1 refused peri-care during each round and said, you all are bothering me so much on purpose. The note failed to indicate Resident #1's physician was notified on the negative symptoms, and paranoid thoughts. Progress note dated 11/06/2023 at 8:52 a.m., LVN A documented the weekly skin assessment was performed and Resident #1 has withering and callus with discoloration to the left great toe. LVN A documented Resident #1 refused care to the toe. LVN A documented Resident #1 stated it is a science project and staff shouldn't worry themselves about it. LVN A documented the physician has been notified. The note failed to reflect Resident #1 was disconnected from reality related to her left toe condition and seek psychological care. Progress note dated 11/09/2023 at 9:28 a.m., LVN B documented Resident #1 refused staff to assist with reposition or incontinent care. The note failed to reflect acknowledgement of this behavior as a negative symptom of schizophrenia and seek psychological care. Progress note dated 11/11/2023 at 5:43 a.m., LVN C documented Resident #1 refused peri-care throughout the shift. The note failed to reflect acknowledgement of this behavior as a negative symptom of schizophrenia and seek psychological care. Progress note dated 11/27/2023 at 3:37 p.m., LVN G documented Resident #1 asked to be changed. LVN G said Resident #1 had a strong body odor and a brown drainage coming from Resident #1's left foot. The note indicated LVN G documented Resident #1 refused the bath and refused a shower. LVN G documented Resident #1 stated I don't refuse care as they say, I refuse abuse, and no one has ever offered me a bath. LVN G documented she heard Resident #1 shouting and cursing a nurse aide. LVN G documented Resident #1 said nobody had ever tried to take care of her foot. LVN G indicated she advised Resident #1 the drainage from her foot was a sign of infection. LVN G documented Resident #1 said yes I know its infected, what do you expect? LVN G documented Resident #1 said, all of you are going to hell, you falsify my records, you abuse me if you touch me, it will be too late for you, and no one touches my flesh. LVN G said Resident #1 gets louder, cursing the nurse. LVN G documented she left the room to allow Resident #1 to calm down. The note failed to indicate LVN G notified the physician of these behaviors including grandiose behavior, insight not appropriate for the situation, fabrication, and the condition of the left foot and seek psychological care. Progress note dated 11/30/2023 at 1:10 a.m., LVN C documented Resident #1 refused peri-care during rounds. LVN C documented Resident #1 said just get out and leave me alone. The note failed to reflect acknowledgement of this behavior as a negative symptom of schizophrenia and seek psychological care. Record review of a skin check dated 12/07/2023 indicated Resident #1 had no skin issues, and a wound observation assessment was not started. Record review of a skin check dated 12/14/2023 indicated Resident #1 had no skin issues, and a wound observation assessment was not started. Progress note dated 12/14/2023 at 9:00 a.m., LVN A documented performed care for Resident #1 when apple juice accidently spilled. The note indicated Resident #1 indicated the nurse spilled the juice on purpose and then threw the apple juice on the nurse. LVN A failed to document the physician was notified on the aggressive behavior. Progress note dated 12/17/2023 at 11:00 p.m., LVN C documented Resident #1 refused routine rounds from this nurse and attempts to ignore nursing staff. Resident #1 stated the only way for you to leave me alone is to answer your questions? LVN C documented Resident #1 refused repositioning. Progress note dated 12/28/2023 at 1:35 a.m., LVN C documented Resident #1 refused routine peri-care and began yelling go to hell and just go to hell. LVN C documented Resident #1 was upset concerning not having a phone cord. The note failed to indicate LVN C notified the physician of the behavior refusing care and having verbal aggressive behaviors. Record review of a skin check dated 12/28/2023 indicated Resident #1 had no skin issues, and a wound observation assessment was not started. Progress note dated 12/29/2023 at 5:05 a.m., LVN C documented Resident #1 refused incontinent care all shift Progress note dated 12/29/2023 at 9:38 p.m., LVN G documented Resident #1 refused foot care from this nurse but allowed the nurse to trim her fingernails. LVN G documented Resident #1's left foot was withered with dead skin on the foot but Resident #1 refused care from the staff. Progress note dated 12/30/2023 at 11:22 p.m., LVN C indicated Resident #1 with the complaint her room was too hot and requested personal fan be turned on. The note indicated LVN C offered incontinent care and Resident #1 refused stating you can go now; you did all I needed you to do. The note indicated Resident #1 refused to allow the dinner tray to be removed from bedside. The progress note failed to reflect the physician was notified of the behaviors and to seek psychological care. Progress note dated 1/01/2024 at 3:04 a.m., LVN B documented Resident #1 refused incontinent care. Progress note dated 1/04/2024 at 1:37 a.m., LVN C documented Resident #1 refused incontinent care by CNA F, and LVN C. The note indicated Resident #1 refused oral fluids and snacks offered. LVN C documented Resident #1 refused the removal of the dinner tray. Record review of a skin check dated 1/04/2024 indicated Resident #1 had no skin issues, and a wound observation assessment was not started. Progress note dated 1/06/2024 at 8:30 p.m., LVN D documented she and CNA E were changing Resident #1. LVN D documented after providing peri-care she looked for barrier cream to apply in Resident #1's drawers. Resident #1 was noted to have said there was cream in the drawer. The note indicated LVN D obtained barrier cream returned to Resident #1. The note indicated LVN D rolled Resident #1 using the draw sheet when Resident #1 began screaming at the top of her lungs, Oh, my finger, you all hurt my finger. You are murdering me, and you are abusing me. LVN D said she left the room and obtained another CNA to assist with care. LVN D documented she notified the Administra [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 of 6 residents reviewed for quality of care. (Resident #1) The facility failed to provide an in-house wound evaluation for treatment of Resident #1's left foot declining condition. The facility failed to provide an evaluation to ensure Resident #1's mental health did not complicate her physical health. The facility failed to provide a recent to provide psychiatric services when Resident #1's behaviors continued. The facility failed to accurately assess Resident #1's left foot wound. The facility failed to inform the physician of continued refusals of medical care and psychiatric care . An IJ was identified on 1/11/2024 at 12:56 p.m. The IJ template was provided to the facility on [DATE] at 1:11 p.m. While the IJ was removed on 1/12/2024, the facility remained out of compliance at a scope of isolated and a severity level of actual harm because all staff had not been trained on neglect. These failures could place residents at risk for further neglect, lack of services, and a decreased quality of life. Findings included: Record review of an undated face sheet indicated Resident #1 was a [AGE] year-old female, who admitted on [DATE] with the diagnosis of unspecified psychosis (Psychosis is when people lose some contact with reality. This might involve seeing or hearing things that other people cannot see or hear (hallucinations) and believing things that are not actually true (delusions), motivational impairment, social withdrawal, flat emotions, negative symptoms worsen a person's quality of life and functioning (negative symptoms). It may also involve confused (disordered) thinking and speaking) not due to a substance or known physiological condition, Buerger's disease (also known as thromboangitis obliterans) affects blood vessels in the body, most commonly in the arms and legs. Blood vessels swell, which can prevent blood flow, causing clots to form. This can lead to pain, tissue damage, and even gangrene (the death or decay of body tissues), and major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.) Record review of the consolidated physician's orders dated 1/09/2024 indicated Resident #1 had an ordered referral for psychiatric services on 4/14/2022, and on 8/29/2023. There were no antipsychotic or antidepressant medications ordered on Resident #1's consolidated physician's orders. Record review of Quarterly MDS dated [DATE] indicated Resident #1 understood and was understood by others. The MDS in the section of Cognition Pattern C0100 had a (-) meaning unable to determine the response, in the section for the BIMS assessment C0200 also had a (-), in the section Recall C0400 there was also a (-). The MDS in section C0700 indicated Resident #1's memory short-term and long-term both indicated her memory was intact. The MDS in the section C1310 indicated there was no evidence of an acute change in mental status, and no behaviors of inattention, or disorganized thinking. The MDS in the section Mood D0100 indicated a (-). The MDS section D0150 Resident Mood Interview indicated (-) in column 1 and blank in column 2. The MDS in section D0160 a (-) was documented. The MDS section D Mood the staff assessment of Resident #1's mood indicated she had no symptoms of little interest or pleasures, feeling down or depressed, feeling tired, poo appetite, indicating they feel bad about self, trouble concentrating, moving, or speaking slowly or fast, stating life not worth living. The MDS reflected in Mood J being short-tempered, easily annoyed marked yes and 12-14 days in column 2. Section E Behaviors of the MDS indicated Resident #1 had no hallucinations or delusions. The MDS indicated in E0200 Behavioral Symptoms indicated physical behaviors directed toward others occurred 1-3 days, verbal behavior symptoms directed at others occurred 4-6 days, and other behavioral symptoms not directed at others (such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, or disruptive sounds). The MDS in section E0800 Rejection of care indicated Resident #1 displayed this behavior 4-6 days but less than daily. The MDS indicated in Section GG Resident #1 was independent with eating, dependent with toileting and personal hygiene, and refused bathing, dressing. The MDS in section I Active Diagnosis indicated Resident #1 had depression other than bipolar, and psychotic disorder other than schizophrenia. The MDS assessment did not indicate Resident #1 had a diagnosis of schizophrenia. The MDS in section M indicated Resident #1 had no skin conditions. Section M of the MDS indicated Resident #1 was not receiving any antipsychotic or antidepressant medications. The MDS indicated in Section Q the family, significant other, legal guardian, and other legally authorized representative participated in the assessment and goal setting. The MDS indicated Resident #1's assessments in sections B, C, E, and Q were completed by the social service staff. Record review of the care plan dated 9/21/2021 and revised on 9/25/2023 indicated Resident #1 makes poor safety choices as evidenced by refusal of wound care to foot, hospitalization , and hospice. The goal of the care plan was Resident #1 wound not have adverse effects related to the refusal of care. The interventions of the care plan were to attempt to monitor resident in regard to safety choices; notify the doctor, administrator, DON, and supervisor in regard to poor safety choices that place resident at risk implemented on 8/19/2021 and educated Resident on risks associated with poor safety choices implemented on 8/19/2021 this care plan failed to implement any current interventions. The care plan indicated Resident #1 was at risk for infections related to refusal to allow her room to be cleaned. The goal of the care plan was Resident #1 would not have any adverse effects related to her refusal. The interventions included attempt to clean the room throughout the day by housekeeping and nursing dated 10/28/2022, attempt to tidy the room when care provided dated 10/28/2022, and educate Resident #1 on the risks of living in unclean environment dated 10/28/2022 there care plan failed to implement current interventions. The care plan dated 8/19/2021 and revised on 11/30/2022 indicated Resident #1 had a behavior problem as evidenced by yelling and cursing at staff, demeaning and derogatory comments to staff, allowing only limited staff members to provide care, calling 911, refuse to allow trays to be removed from room, making false accusations, refusing to allow call light to be turned off the goal of the care plan was Resident #1 would have fewer episodes of outbursts. Resident #1's care plan interventions included 2 persons to offer and provide care at all times, anticipate and meet the resident needs allowed reviewed on 8/31/2023, anticipate and meet the resident's needs as allowed revised on 8/31/2023, assist the resident to develop more appropriate methods of coping and interacting and encouraged Resident #1 to express feeling appropriately revised on 8/19/2021. Resident #1's care plan interventions indicated she would have all procedure explained before starting and allow time for adjustment to change dated 8/19/2021. Resident #1's care plan intervention included to monitor behavior episodes and attempt to determine underlying cause and document dated 8/19/2021. Resident #1's care plan interventions indicated to refer Resident #1 to psychological services dated 8/30/2023. Resident #1's care plan failed to address her behaviors with new interventions and revise with interventions that promoted stability with her mental illness. Record review of a Comprehensive Care Plan Conference Summary dated 8/30/2023 indicated Resident #1 refused environmental care, refuses care, yells, curses, calls 911, verbal outbursts, and was at high risk for impaired skin. The care plan conference was signed by the AD, occupational therapist, the social services staff person, dietary manager, and the DON. The care plan conference was not signed by Resident #1 or the responsible party. Record review of an undated Comprehensive Care Plan Conference Summary indicated Resident #1 had multiple behaviors, unavoidable skin issues, and Buerger's disease. The conference was signed by the MDS nurse, the activity director, and social services staff person. Resident #1 or the responsible party signature area was left blank. Record review of a Wound-Weekly Observation Tool dated 2/16/2023 indicated Resident #1's left toes wound site was acquired since admission with a date of 11/21/2022. Resident #1's wound measured 0x0x0, with no undermining, no tunneling, 100 % skin intact, no eschar, no drainage, an odor was present, but the wound was determined to be healed . Record review of a PHQ-9 (an objective assessment of the severity of depression) dated 2/21/2023 indicated Resident #1 scored a 0 due to not being assessed. Resident #1 refused to participate in the assessment and the assessment indicated Resident #1 said close the door when you leave. Record review of a BIMS (Brief Interview for Mental Status) assessment dated [DATE] indicated Resident #1 score was a 10 indicating moderately impairment. Record review of a BIMS assessment dated [DATE] indicated Resident #1's score was 0 with the category of severe impairment. Record review of a Psychotherapy Intake Note dated 4/20/2022 indicated Resident #1 was seen by a therapist for 1 hour. The therapist indicated Resident #1 was referred due to a history of depression and psychosis. The note indicated Resident #1 was oriented to person, place, and time. The note indicated Resident #1's mood was euthymic (normal display of emotion), affect was congruent with Resident #1's mood, Resident #1 had good attention, and appropriate thought content. The note indicated Resident #1 denied any mental health issues and indicated her health records were falsified to keep her in the facility against her will. The note indicated she believed the staff were trying to murder her and the only way to get help was to meet her fiance. The note indicated Resident #1 believed the business office had stolen money and the claim was validated by the state agency even though she had not found a letter stating so. Resident #1 discussed previous traumas at other nursing facilities and alluded to some abuse when growing up. The note indicated Resident #1 believed she was in a relationship with a famous musician. The note indicated Resident #1 hoped to buy a gift card to purchase a fan club membership in so that she could spend time with the musician in person. The therapist documented the diagnosis of Major depressive disorder, single episode severe, and schizophrenia spectrum and other psychotic disorders. The note indicated Resident #1's presented with depression and psychosis. The goal of Resident #1's treatment was to reduce depression, psychosis, and improve sense of well-being in the facility. The estimated completion was 12 months for Resident #1. The note indicated Resident #1 would be seen weekly. Record review of a Psychotherapy Progress Note dated 5/04/2022 indicated the session lasted 53 minutes with Resident #1. The note indicated Resident #1 had the diagnosis of Major Depressive Disorder, single episode severe, and Schizophrenia Spectrum and other psychotic disorder. The note indicated Resident #1 was alert oriented to person, place, and time. The note indicated her mood was normal, and her affect was congruent with her mood. The note indicated Resident #1 was not having a good week. The note indicated Resident #1 continued to believe she was held against her will and they were still trying to kill her. The note indicated Resident #1 continues to hope to see her fiance soon and believed he was trying to come and visit with her. The note indicated Resident #1 was unable to call the person because he was in Europe and her phone does not call Internationally. The note indicated Resident #1 continues to be upset no one will purchase her a $2000 gift cared for her. Resident #1 said she could not notify the ombudsman or the state agency as they hang up on her. The note indicated Resident #1's interventions included rapport building, exploration of coping patterns, exploration of emotion, exploration of relationship patters, supportive reflection and symptom management. The note indicated there was no progress in the reduction of symptoms of depression, symptoms of psychosis, or an improved sense of well-being. The note indicated Resident #1 would be treated weekly. Record review of a Psychotherapy Progress Note dated 5/11/2022 indicated the therapist was with Resident #1 53 minutes. The note indicated Resident #1 oriented to person, place, and time. The note indicated Resident #1's mood and affect were congruent, attention was good, thought content appropriate. The resident reported she is not having a good week. The note indicated Resident #1 continues to believe she is held against her will and they were trying to kill her. The note indicated Resident #1 believes her fiance would be able to visit. Resident #1 said she had been able to speak with her fiance some this week but had not mentioned to issues of international calling. According to the note Resident #1 continued to be upset with not being able to purchase the $2000 gift card. The note indicated Resident #1 was hoping to see the orthopedic surgeon to strengthen her leg. The note indicated Resident #1 believed she needed someone in Dallas as they provide better care. Resident #1 was noted as indicating she would need physical therapy after the surgery. The note indicated Resident #1 does not want to stay in any nursing facility. Staff had reported Resident #1 called 911 twice last week and left the line open. Resident #1 reported a police officer had come to the facility and called her crazy in front of the staff. The note indicated Resident #1 indicated the police officer threatened to take her to court and make the facility her guardian. The note indicated Resident #1 believed this was a violation of her rights. The notes indicated the progress in reduction of symptoms of depression, reduction of symptoms of psychosis, and the reduction of sense of well-being was maintained. The note indicated Resident #1 called the therapist's office on 5/13/2022. The note indicated Resident #1 wanted to inform the therapist of her big toe on her bad foot was infected. The note indicated Resident #1 indicated the staff were not helping or treating her foot. The note indicated Resident #1 would be seen weekly. Record review of a Psychotherapy Progress note dated 6/01/2022 indicated the therapist was with Resident #1 60 minutes. The note indicated Resident #1's diagnoses were Major Depressive Disorder, single episode, severe, and Schizophrenia Spectrum and other Psychotic Disorder. The note indicted Resident #1 was oriented to person, place and time. The note indicated Resident #1 continued to report not having a good week, as indicated by expressing she believed she was held against her will, and they were trying to kill her. Resident #1 indicated to the therapist had found some new orthopedic surgeons in a hospital in Dallas. The note indicated Resident #1 hoped the therapist called all the physician's and to explain her emergency situation so they will quickly take her. The note indicated Resident #1 attempted to message one of the surgeons on an App, but never received a response. The note indicated Resident #1 hoped the FBI would find her friends in Arizona who would loan her some money so she could leave with her fiance's manager. The note indicated Resident #1 had spoken of suicide attempts but had promised God she would never try gain. The note indicated Resident #1 denied any current suicidal ideation, plan, means, or intent. The note indicated the treatment progress for Resident #1 continued to be maintained. The note indicated Resident #1 called the therapist's office indicating she had something urgent to discuss. The therapist indicated Resident #1 had not mentioned this concern during the therapy session. The note indicated Resident #1 would continue to be seen weekly. Record review of a Psychotherapy Progress Note dated 6/22/2022 indicated Resident #1 was seen by the therapists for 46 minutes. The therapist indicated Resident #1 was angry this week. The note indicated Resident #1 was upset with the therapist since the therapist had not provided an envelope and stamps for Resident #1 to mail money to her fiance. The note indicated the therapist indicated the dangers of mailing cash as well as the therapeutic boundaries. The note indicated Resident #1 attempted to switch places and tried to provide therapy to the therapist and become frustrated when the therapist would not allow this to occur. The note indicated Resident #1 believed the therapist was there to get easy blood money from Medicare and does not believe the therapeutic relationship was what she needed at present. The note indicated Resident #1 was placed on an as needed status. The note indicated Resident #1 had no progress in the reduction of depressive symptoms, psychosis symptoms or in the sense of well-being . Record review of Resident #1's clinical record revealed there were no further treatments noted from a psychotherapist after 6/22/2022. Record review of a PHQ-9 (an objective assessment of the severity of depression) dated 8/03/2023 indicated Resident #1 scored an 8 indicating she was mildly depressed. Record review of a Unavoidable Wound Documentation assessment dated [DATE] indicated Resident #1 had peripheral vascular disease, chronic bowel incontinence, thyroid disease, impaired mobility, and cognitive impairment. The assessment indicated Resident #1 had the head of her bed elevated the majority of the day. The assessment in Resident Compliance indicated Resident #1 refuses care and has psychosis this form was signed by the physician on 9/21/2023. Record review of a PHQ-9 (an objective assessment of the severity of depression) dated 10/23/2023 indicated Resident #1 was not assessed for depression due to her refusal to participate. Record review of a BIMS assessment dated [DATE] indicated Resident #1's score was 0 with the category of severe impairment. Record review of the medication administration record dated December 2023 (a seperate treatment administration record was not avaiable) indicated Resident #1 had an order dated 9/22/2022 for the application of Betadine to the left great toe redness three times daily as needed. The medicaton administration had no indications this treatment was offered, refused, or performed. Record review of the electronic medication administration record dated December 2023 indicated Resident #1 accepted her medications. The medication administration record indicated Resident #1 was not treated pharmacologically for her depression or psychosis. Record review of the electronic medication administration record dated January 2024 indicated Resident #1 accepted her medications. The medication administration record indicated Resident #1 was not treated pharmacologically for her depression or psychosis. Record review of a physician's progress note dated 12/20/2023 completed by the nurse practitioner indicated Resident #1 was seen for her high blood pressure, and reflux disease (stomach acid or bile irritates the food pipe lining). The physician's progress note indicated the past medical history of psychosis and major depressive disorder (recurrent and moderate). The physician's progress note failed to address a psychological examination and indicated Resident #1's skin was warm, dry, no rashes, and no suspicious lesions. The note failed to mention the stability of Resident #1's psychosis and depression. Record review of a physician's progress note dated 7/20/2023 completed by the nurse practitioner indicated Resident #1 was seen for coronary artery disease (damage or disease in the heart's major blood vessels) and weakness. Resident #1's past medical history included psychosis and major depressive disorder. The assessment indicated Resident #1 had warm and dry skin with no suspicious lesions. The neurological assessment indicated non-focal (not specific to a certain area of the brain. It may be a general loss of consciousness or emotional problem). The note failed to mention the stability of Resident #1's psychosis and depression. Record review of a physician's progress note dated 8/09/2023 completed by the nurse practitioner indicated Resident #1 was seen for neuropathy (weakness, numbness, and pain from nerve damage usually in the hands and feet) and reflux disease. The note indicated the nature of the neuralgia was general neuralgia affecting both legs with a moderate severity. The note indicated Resident #1's skin was warm, dry, no suspicious lesions, and no rashes. The note failed to mention Resident #1's left foot condition, and the neurological exam indicated non-focal (not specific to a certain area of the brain. It may be a general loss of consciousness or emotional problem). The note failed to mention the stability of Resident #1's psychosis and depression . Record review of a Social Determinants of Health assessment dated [DATE] completed by the social worker designee/marketer indicated Resident #1's assessment included her ethnicity, race, language, need of interpreter to communicate with a doctor or health team, lack of transportation, how often does she require assistance with reading, and how often does she feel lonely or isolated. The social health assessment failed to ascertain information regarding Resident #1's current or past behavioral health needs, assess the on-going behaviors and identify triggers and interventions, provide in-sight on the need of outside resources. Record review of Resident #1's progress notes dated 9/12/2023 to 1/11/2024 indicated: Progress note dated 9/12/2023 at 2:57 p.m., LVN G documented the psychiatric nurse practitioner was present for a psychological exam and Resident #1 refused. The progress note failed to reflect Resident #1's physician was notified of the refusal for psychiatric services. Progress note dated 9/23/2023 at 11:21 p.m., LVN C documented he offered incontinent care and Resident #1 started yelling get out, get out, you murderers! The progress note failed to denote Resident #1's physician was notified of the delusions. Progress note dated 9/26/2023 at 4:00 a.m., LVN C documented Resident #1 cursed loudly and yelled obscenities at the nursing staff when offering incontinent care. The note failed to indicate LVN C notified the physician of the verbal aggressive behaviors. Progress note dated 9/26/2023 at 7:30 a.m., LVN A documented Resident #1 indicated she need a brief change. LVN A indicated she offered a total bed bath. LVN A indicated Resident #1 refused and stated, I don't want you tearing my flesh apart more than you already have. LVN A documented Resident #1 stated during repositioning stating, you both are going to hell, [NAME]. God does me justice and you will both rot in hell and burn for eternity. The note failed to indicate LVN A notified Resident #1's physician of the delusions (of being harmed) and religiosity thoughts. Progress note dated 10/02/2023 at 9:17 a.m., LVN A indicated, Resident #1 continued to refuse care and left foot continued to decline related to Bueger's Syndrome. The note indicated Resident #1 refused to allow staff to touch her foot, clean or treat. The note indicated staff had made multiple attempts. The note indicated the foot appeared to be black on the toes with crusty like covering up to ankles. The note indicated multiple attempts were made to send Resident #1 to the hospital as the foot had no circulation and become necrotic. Progress note dated 10/02/2023 at 1:14 p.m., LVN A indicated the wound care specialist visited and Resident #1 refused care and treatment. The progress note indicated Resident #1 commenced to yelling and screaming at staff. The note failed to indicate Resident #1's physician was notified of her refusal of care and verbally aggressive behaviors. Progress note dated 10/03/2023 at 5:05 a.m., LVN B documented Resident #1 refused incontinent care this shift. The progress noted failed to reflect the acknowledgement of this behavior as a negative symptom of schizophrenia and seek psychological care. Progress note dated 10/13/2023 at 8:55 a.m., LVN A documented Resident #1 requested to have incontinent care performed. LVN A documented after Resident #1's medication administration, and a sip of water Resident #1 threw the remaining water on LVN A and said, cool off bitch and burn in hell. The note indicated the Administrator was informed. LVN A failed to document the notification of the physician related to the aggressive physical behaviors. Progress note dated 10/30/2023 at 10:25 a.m., LVN A documented Resident #1 continue to refuse care and her left foot continued to decline. The progress noted indicated Resident #1 refused to allow staff to touch foot, clean, or treat. The progress note indicated LVN A documented the foot has black toes with crusty like covering up to Resident #1's ankles. LVN A documented Resident #1's left foot had no circulation and was necrotic. LVN A failed to document to notify Resident #1's physician. Progress note dated 11/03/2023 at 10:21 a.m., the DON documented during the weekly skin check Resident #1 refused care. The DON documented the Resident #1's left foot was withering and changing to a dark color with dry skin flaking off related to the diagnosis of Buerger's Syndrome. The DON documented the Resident #1's refusal of staff to touch the foot, clean or treat the foot. The DON documented Resident #1's left foot had black toes with a crusty like covering up to sock line. The DON documented Resident #1's fingertips had discolored areas on the middle of the fingers. The DON documented the physician was notified and the nurse practitioner was present for the offering of treatment, hospitalization , or hospice. The DON documented after extensive attempts Resident #1 was screaming get out of my room. The progress note failed to indicate any behavioral health care was offered. Progress note dated 11/05/2023 at 2:21 a.m., LVN C documented Resident #1 refused peri-care during each round and said, you all are bothering me so much on purpose. Progress note dated 11/06/2023 at 8:52 a.m., LVN A documented the weekly skin assessment was performed and Resident #1 has withering and callus with discoloration to the left great toe. LVN A documented Resident #1 refused care to the toe. LVN A documented Resident #1 stated it is a science project and staff shouldn't worry themselves about it. LVN A documented the physician had been notified. Progress note dated 11/09/2023 at 9:28 a.m., LVN B documented Resident #1 refused staff to assist with reposition or incontinent care. Progress note dated 11/11/2023 at 5:43 a.m., LVN C documented Resident #1 refused peri-care throughout the shift. Progress note dated 11/27/2023 at 3:37 p.m., LVN G documented Resident #1 asked to be changed. LVN G said Resident #1 had a strong body odor and a brown drainage coming from Resident #1's left foot. The note indicated LVN G documented Resident #1 refused the bath and refused a shower. LVN G documented Resident #1 stated I don't refuse care as they say, I refuse abuse, and no one has ever offered me a bath. LVN G documented she heard Resident #1 shouting and cursing a nurse aide. LVN G documented Resident #1 said nobody had ever tried to take care of her foot. LVN G indicated she advised Resident #1 the drainage from her foot was a sign of infection. LVN G documented Resident #1 said yes I know its infected, what do you expect? LVN G documented Resident #1 said, all of you are going to hell, you falsify my records, you abuse me if you touch me, it will be too late for you, and no one touches my flesh. LVN G said Resident #1 gets louder, cursing the nurse. LVN G documented she left the room to allow Resident #1 to calm down. The note failed to indicate LVN G notified the physician of these behaviors and the condition of the left foot and seek psychological care. Progress note dated 11/30/2023 at 1:10 a.m., LVN C documented Resident #1 refused peri-care during rounds. LVN C documented Resident #1 said just get out and leave me alone. Progress note dated 12/14/2023 at 9:00 a.m., LVN A documented performed care for Resident #1 when apple juice accidently spilled. The note indicated Resident #1 indicated the nurse spilled the juice on purpose and then threw the apple juice on the nurse. LVN A failed to document the physician was notified on the aggressive behavior. Progress note dated 12/17/2023 at 11:00 p.m., LVN C documented Resident #1 refused routine rounds from this nurse and attempts to ignore nursing staff. Resident #1 stated the only way for you to leave me alone is to answer your questions? LVN C documented Resident #1 refused repositioning. Progress note dated 12/28/2023 at 1:35 a.m., LVN C documented Resident #1 refused routine peri-care and began yelling go to hell and just go to hell. LVN C documented Resident #1 was upset concerning not having a phone cord. The note failed to indicate LVN C notified the physician of the behavior refusing care and having verbal aggressive behaviors. Progress note dated 12/29/2023 at 5:05 a.m., LVN C documented Resident #1 refused incontinent care all shift. Progress note dated 12/29/2023 at 9:38 p.m., LVN G documented Resident #1 refused foot care from this nurse but allowed the nurse to trim her fingernails. LVN G documented Resident #1's left foot was withered with dead skin on the foot but Resident #1 refused care from the staff. Progress note dated 12/30/2023 at 11:22 p.m., LVN C indicated Resident #1 with the complaint her room was too hot and requested personal fan be turned on. The note indicated LVN C offered incontinent care and Resident #1 refused stating you can go now; you did all I needed you to do. The note indicated Resident #1 refused to allow the dinner tray to be removed from bedside. Progress note dated 1/01/2024 at 3:04 a.m., LVN B documented Resident #1 refused incontinent care. The progress note failed to reflect the physician was notified negative symptom of schizophrenia and seek psychological care. Progress note dated 1/04/2024 at 1:37 a.m., LVN C documented Resident #1 refused incontinent care by CNA F, and LVN C. The note indicated Resident #1 refused oral fluids and snacks offered. LVN C documented Resident #1 refused the removal of the dinner tray. Progress note dated 1/06/2024 at 8:30 p.m., LVN D documented she and CNA E were changing Resident #1. LVN D documented after providing peri-care she looked for barrier cream to apply in Resident #1's drawers. Resident #1 was noted to have said there was cream in the drawer. The note indicated LVN D obtained barrier cream returned to Resident #1. The note indicated LVN D rolled Resident #1 using the draw sheet when Resident #1 began screaming at the top of her lungs, Oh, my finger, you all hurt my finger. You are murdering me, and you are abusing me. LVN D said she left the room and obtained another CNA to assist with care. LVN D documented she notified the Administrator of Resident #1 accused LVN D of hurting her finger. Resident #1 was provided a phone and the Administrator spoke to Resident #1 where she alleged they're abusing me tonight. The note failed to indicate Resident #1's physician was notified of the displayed behaviors. Progress note dated 1/07/2024 at 5:21 a.m., LVN B documented R [TRUNCATED]

Based on interview and record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for 1 of 3 (Resident #2) residents reviewed for accidents. The facility failed to ensure CNA F used two-person assistance to provide incontinent care for Resident #2 which resulted in a fall with injury. This failure could place residents at risk of injuries, falls and hospitalization s. Findings include: Record review of Order Summary Report dated 01/12/2024 indicated Resident #2 was a [AGE] year-old male, with an admission to the facility on [DATE] with diagnoses including dementia (decline in cognitive abilities that impacts a person's abilities to perform everyday activities), myocardial infarction (a blockage of blood flow to the heart muscle), hypertension (high blood pressure), cognitive communication deficit, abnormal posture, heart failure, chronic respiratory failure, diabetes mellitus type I (a chronic condition where the pancreas produces little to no insulin), diabetes insipidus (a disorder of salt and water metabolism marked by intense thirst and urination), stiffness of left knee. Record review of the care plan last revised 04/20/2023 indicated Resident #2 had an ADL (Activities of Daily Living) self-care performance deficit related to activity intolerance. The care plan indicated interventions included two - person staff assist for toileting. Record review of the quarterly MDS dated [DATE] indicated Resident #2 was able to understand and make himself understood. The MDS showed BIMS of 15 which indicated Resident #2 was cognitively intact. The MDS indicated that Resident #2 required extensive assistance by two-person staff for toileting, bed mobility, transferring, and personal hygiene. The MDS indicated Resident #2 had not sustained any falls. Record review of the provider investigation report, dated 11/04/2023, indicated Resident #2 fell from the bed during peri care provided by CNA F. The provider investigation report indicated CNA F yelled from Resident #2's bedside for help from LVN D. The provider investigation report revealed LVN D found Resident #2 on his knees on the floor. LVN D requested assistance from 911 to place Resident #2 back into the bed. LVN D assessed Resident #2's injuries of an abrasion 2cm x 2cm noted to the left knee, open area to the right groin and superficial skin tear noted to right posterio r forearm. Other information noted on the provider's investigation report was a bariatric (obesity) mattress on regular size bed and hangs off bedframe and CNA F changed resident by herself. The provider's investigation report indicated Resident #2 denied the need to go to the hospital. Record review of the Visual/IPAD Kardex (a system that gives a brief overview of the resident's care with pictures) on 01/10/2023 used by the CNAs indicated Resident #2 required 2-person staff assist for toileting. During an interview on 01/09/2024 at 10:10 a.m. Resident #2 said CNA F entered his room on 11/05/2023 to change his brief alone . Resident #2 said CNA F instructed him to roll over to his left side. Resident #2 said I knew I was falling when my right leg came over and I yelled out to CNA F that I was going to fall. Resident #2 said his knees hit the floor and his neck was caught on the small grab bar on side of the bed. Resident #2 said sometimes two of the staff assisted him with toileting prior to the fall but most of the time it is just one. Resident #2 said LVN D and CNA F told him to attempt to get back into the bed, but he was not able to do that. Resident #2 said the LVN D finally called 911 for assistance to get him back into the bed. Resident #2 said I am a large man and weigh over 400 lbs. The weight of my leg due to gravity took me down into the floor because there was no one on the opposite side to catch my leg and I was too close to the edge of the bed. Attempted telephone call on 01/09/2024 at 11:30 a.m. to CNA F - not accepting calls and unable to leave a message. During an interview on 01/09/2024 at 02:19 p.m., CNA N said she recalled the incident involving Resident #2. CNA N said she was aware of how to take care of residents by the report the charge nurse gave to her or by the CNA that was on the previous shift would tell her what the resident required. CNA N said she did not look at the Kardex on the electronic charting system to verify how to take care of the residents. CNA N said she did not recall before the incident any staff member telling her Resident #2 was a two person assist for toileting. CNA N said it was important for Resident #2 to have a two person staff assistance to prevent falls and injuries. During an interview on 01/09/2024 at 02:31 p.m., CNA O said she was aware of how to take care of residents by the report the charge nurse gave to her or by the CNA that was on the previous shift that would tell her what the resident required. CNA O said she did not look at the Kardex on the electronic charting system to verify how to take care of the residents. CNA O said she did not recall before the incident any staff member telling her Resident #2 was a two person assist for toileting, but he can't help much with turning so she used another staff member to assist since the incident. CNA O said it was important for Resident #2 to have a two person staff assistance with toileting to prevent falls and injuries due to the Resident #2's weight and his inability to help turn. During an interview on 01/09/2024 at 03:03 p.m., LVN G said the CNA's got the information of how to take care of the resident from the charge nurse. LVN G said she gave the CNA's the information to take care of the residents during report prior to the start of the shift. LVN G said the CNAs should ask her what level of assistance a resident requires. LVN G said the CNA's can look at the Kardex for the resident's plan of care located in the electronic charting system on their iPad but mainly the CNA's get all information from the charge nurse. LVN G said it was important to follow the resident's plan of care to prevent injuries and take care of the residents safely. During an interview on 01/09/2024 at 03:08 p.m., CNA P said she received all information on how to take care of the resident from the CNA on the previous shift. CNA P said if she had other questions regarding the resident's care, she asked the charge nurse. CNA P said she used the iPad to chart the residents' showers but had not ever got that far into the system to see any information on how to take care of the residents such as the required staff needed for performing an ADLs. CNA P said it was important to know how to toilet and transfer a resident to prevent falls. Attempted telephone call on 01/10/2023 at 2:29 p.m. to CNA F - not accepting calls and unable to leave a message. During an interview on 01/10/2024 at 03:40 p.m., LVN D said she was the charge nurse working with CNA F who had attempted to provide toileting care when Resident #2 fell out of the bed. LVN D said she was aware that Resident #2 was a two person assist but some of the staff provided the care alone especially on night shift when no extra staff were available. LVN D stated that she educated all the CNA's to ask for assistance from her and not to move the residents by themselves after the incident with Resident #2. LVN D said the CNAs do have access to the Kardex on the iPad but prefer to ask the charge nurse most of the time. LVN D said if a resident was newly admitted CNAs should check the Kardex, ask the nurse, or consult with therapy regarding the residents' status. LVN D said it was important to utilize the Kardex for resident safety and prevent injuries and falls. Attempted telephone call on 01/10/2024 at 04:30 p.m. to CNA F - not accepting calls and unable to leave a message. During an interview and observation on 01/11/2024 at 03:30 p.m., the DON said the CNAs should have used the Kardex which was located on the iPad for necessary information on how to take care of the residents. The DON said the ADON was responsible upon hiring to train the CNAs to use the electronic charting system which contained the Kardex with the residents' plan of care. The DON said the new hire CNAs were placed with another trained CNA for further training after being educated on the electronic system. The DON demonstrated to surveyor how to utilize the Kardex on the CNAs' iPad. The DON said it was important for the Kardex to be used by all staff to prevent injuries and harm to the staff and residents while care was provided. During an interview on 01/11/2024 at 03:30 p.m., the ADON said the residents' status of a newly admitted resident was relayed in report from the discharging facility, found in the discharge paperwork, or relayed by the physician. The ADON said the status of a resident should be entered into the plan of care which populates into the iPad for the CNAs to access. The ADON said the CNAs were able to look in the iPad, ask the nurse, or should have been given report by the nurse to know how to take care of the resident. The ADON said she was responsible of hiring and training the CNAs. The ADON said the CNAs should use the Kardex on the iPad to access the resident information to know how to take care of the resident properly. The ADON said she was shown today by the DON how to access the information from the CNA iPad, and she had not shown the newly hired CNA's how to utilize the system for resident information because she did not know how to access the Kardex from the iPad herself before today's date. The ADON said there was not a process in place to monitor the CNA's knowledge to access the information on the iPad/Kardex. The ADON said it was important to follow the plan of care which is listed on the Kardex on the CNA's iPad to prevent injuries from occurring and ensure the residents were getting the proper care per their needs. During an interview on 01/11/2024 at 03:40 p.m., the Administrator said it was the responsibility of the DON to train the CNA staff which included the Kardex on the iPad. The Administrator said the DON was good to know the needs of the residents and was good to verbally communicate the needs of the residents to the staff. The Administrator said the importance of staff knowing how to take care of the residents appropriately was to prevent falls and injuries. Record review of the facility's Fall Prevention Program revised 07/20/2021 indicated, The goal of fall prevention strategies is to design interventions that minimize fall risk by elimination or managing contributing factors while maintaining or improving the resident's mobility. After risk is assessed, individualized nursing care plans will be implemented to prevent falls .

Based on observation, interview, and record review the facility failed to ensure residents received adequate assistance devices to prevent accidents for one (Resident #186) of four residents reviewed for accidents. CNA B and LVN C failed to transfer Resident #186 safely when they failed to use a gait belt to transfer Resident #186 from wheelchair to bedside commode, resident fell suffering swelling and pain in her right leg stump. As a result, the resident experienced weakness during transfer in her primary weight-bearing leg (left), fell , and suffered a swelling and pain in her right stump with a corresponding femoral fracture. This failure could affect the residents by placing them at risk for discomfort, pain and/or injury. Findings included: Review of Resident #186's admission record dated 07/12/18 reflected the resident was a [AGE] year-old female admitted on [DATE]. Review of Resident #186's MDS assessment dated [DATE] reflected the resident was diagnosed with [REDACTED]., Depression and [MEDICAL CONDITION]. The MDS reflected the resident required extensive assistance of one with transfers . Review of Resident #186's Care Plan dated 12/13/18 reflected the resident required total assistance of 2 people with transfers, and on 04/16/19 the care plan reflected the resident required extensive assistance with transfers. Review of Resident #186's Comprehensive Care Plan Conference dated 04/17/19 reflected the resident required extensive assistance with all activities of daily living. A review of the Nurse Assistant Care Plan dated 04/01/19 reflected that Resident #186 required 2 person assistance with transfers. Review of an incident report dated 06/02/19 reflected, Resident #186 became weak while being assisted to BSC by 2 staff. Assisted resident to floor. Resident complained of pain in right stump with swelling to area. Resident was assessed with [REDACTED]. Review of nurse's notes dated 06/02/19 reflected resident complained of pain of bilateral hips after the fall, the physician was notified, and an x-ray was completed which was negative for fracture. Review of SBAR for Resident #186 dated 06/02/19 8:10 am reflected the resident had pain in her right stump and staff were to monitor resident. The report indicated resident's right stump was swollen. Review of the nurse's notes dated 06/03/19 reflected Resident #186 complained of pain to her right femur and knee and secondary x-rays were completed which revealed a fracture of her right femur. Review of a radiology report for Resident #186 dated 06/03/19 reflected an acute femoral fracture. Interview on 09/10/19 at 1:15 PM with CNA B revealed she and LVN C attempted to transfer Resident #186 to the bedside commode without the use of a gait belt. She stated the resident was ready to go to bed, and she and the nurse helped the resident to standup onto her leg. The resident stated, I'm about to fall, and the nurse said, I got you, but the resident fell before she was on the commode . She stated since the incident, staff had been in-serviced on falls and transfers. She stated the resident did not complain of pain after the fall that day . Observation on 09/10/19 at 1:40 PM observed CNA B transfer Resident #31 used a gait belt without problems. Interview on 09/11/19 at 2:27 PM with LVN C revealed she and CNA B attempted to transfer Resident #186 to her bedside commode when the resident started falling and they had assisted her to floor she stated resident told staff she felt weak and was about to fall. She stated the resident had a prosthesis in place while being transferred. She stated she did not remember the resident having a gait belt in place during the transfer . She stated resident complained of pain to stump prior to fall. Interview on 09/11/19 at 8:10 AM with PTA F revealed all staff were in-serviced to use a gait belt for resident transfers for the residents' safety during orientation and as needed. She stated Resident #186 required a Hoyer lift transfer at one time but had progressed to the point that she could stand and pivot with staff assistance when transferred . Interview on 09/12/19 at 10:20 AM with COTA G revealed when she in-serviced staff in orientation and as needed, they were educated to always use a gait belt with all resident transfers . Review of the Provider Incident Report dated 06/03/19 reflected Resident #186 fell on [DATE] and sustained a femoral fracture and staff were in-serviced on falls, transfers, abuse and resident change of condition. Review of CNA B's personal file reflected a hire date of 04/05/18 and she was trained to use a gait belt with transfers in orientation training and after the incident. Review of LVN C's personal file reflected a hire date of 04/05/18 and she was trained to use a gait belt with transfers in orientation training . Review of in-service training on resident transfers was completed 06/03/29 and signed by staff. A review of the facility policy entitled, Gait Belt-Correct Use of revealed, . 4. Apply the Gait Belt: Always use the gait belt when the resident requires 'hands on' assistance to ambulate or transfer.