Every finding on record at Parklane West Healthcare Center

Based on observations, interviews and record reviews, the facility failed to ensure a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 8 (Residents #103 and #66) residents in the dining area in that:The facility failed to deliver and serve meals to Residents #103 and #66 on time as posted on 7/14/2026, 7/15/2026 and 7/16/2026. Residents #103 and #66 were upset they had to wait to eat their food for anywhere from 30 to 40 minutes late. This failure could place residents that eat by mouth and could result in residents, not wanting to eat due to long period of time waiting and the loss of weight. The Findings:Record review of Resident #103's admission Record dated 7/17/2026 was documented he was admitted on [DATE], re-admitted on [DATE] with diagnoses of Cerebral Palsy (is a group of neurological disorders that affect movement, muscle control, and posture, caused by damage to the developing brain).Record review of Resident #103's Quarterly MDS dated [DATE] was documented that his BIMs score was 15/15 (cognitively intact).Record review of Resident #103's care plan dated 7/15/2026 was documented as Resident had Cerebral Palsy and used assistance devices recommended by therapy for eating. ADL assistance with eating setup or clean up assistance. 2. Record review of Resident #66's face sheet, dated 07/17/2026 revealed the resident was a [AGE] year-old female with an admission date of 04/09/2026. Her diagnoses include: Type 2 diabetes mellitus (condition that develops with the way the body regulates and uses sugar), moderate protein-calorie malnutrition (condition caused by inadequate nutrient intake or absorption of protein resulting in muscle and fat loss and reduced physical function) and adult failure to thrive (condition of physical, mental and functional decline leading to weight loss, physical weakness and mental changes). Resident #66's most recent MDS was a comprehensive assessment dated [DATE] listing her with a BIMS of 5 out of 15 indicating that her cognitive function is considered severely impaired (severe problems with thinking and/or memory). Resident #66's care plan with initiation date of 04/10/2026 revealed the following: Focus: Has nutritional deficit problem r/t malnutrition, failure to thrive, T2DM (condition that develops with the way the body regulates and uses sugar), encephalopathy (disease affecting the function of the brain), BIMS eval score, Alzheimer's disease, depression (mood disorder causing feelings of sadness or loss of interest), HTN (high blood pressure), HLD (high level of fats in the blood), CKD (long term kidney disease), insomnia (issues with falling or staying asleep, constipation (difficulty with producing a bowel movement). Date initiated: 04/10/2026. Revision on 4/10/2026 Goal is Will maintain adequate nutritional status as evidenced by maintaining weight with no s/sx of malnutrition through review date. Date initiated: 04/10/2026. Target date: 8/20/2026 Record review of the posted Mealtimes: (no date)Breakfast-7:30 AMLunch-11:30 AMDinner 5:30 PM Observation on 7/14/2026 at 11:45 AM - 2 unknown male residents noted in dining area with 1 staff. 1 resident conversing with aide, others sitting at a table watching television. No lunch meal.Observation on 7/14/2026 at 12:15 PM in the dining area, there are 6 residents in the dining area, no lunch meal.Observation on 7/14/2026 at 12:17 pm: 2 staff now present with no lunch meal i dining room.Observations on 7/14/2026 at 12:19 PM, lunch cart arrived on the 3rd floor dining room.Observation on 7/15/2026 at 11:54 AM, lunch cart arrived on the 3rd floor dining room.Observation on 7/16/2026 at 12:10 PM, lunch cart arrived in the 3rd flood dining room.Observation on 7/16/2026 at 6:08 PM, dinner carts arrived on the 3rd floor dining room. Observation on 7/16/2026 from 5:57 PM to 6:30 PM, in the 3rd floor dining room, Resident #66 and family member seen sitting in the dining area, waiting for the meal to be served. Family of Resident #66 had been observed getting up and walking around the dining area several times before dinner tray was served at 6:22 PM.Interview on 7/15/2026 at 9:44 AM with Resident #103 stated that sometimes the food was cold and it was delivered late. Resident #103 stated he waits in the dining room for his meal, continuously looking at watch and staff until the meal is delivered. Resident #103 stated he did notify the nurse when the meal was late, and they told him they are working on it. Resident #103 stated he was upset. Interview on 7/15/2026 at 11:53 AM with ADON A stated the meals get served on the 3rd floor first. Interview on 7/17/2026 at 9:50 AM with [NAME] B stated he started serving the line, in the kitchen, at 11:30 AM. [NAME] B did not have any other comments.Interview on 7/17/2026 at 9:59 AM with the FSM stated lunch meals start at 11:30 AM. So, the first trays, on 3rd floor, were delivered after 11:30AM. Interview on 7/17/2026 at 10:12 AM with the ADM stated the mealtimes posting was wrong and they did not have time to approve the mealtimes before surveyor entered facility. ADM stated the residents would have no side effects.Interview on 7/17/2026 at 12:37 PM with the FSM stated the effects of meals being late, could affect residents by them getting frustrated and then not wanting to eat. Interview on 7/17/2026 at 2:18pm, Resident #66 and family members stated that he comes to the facility several days during the week to sit with resident during dinner. when asked if wait times for dinner service are long and he stated, Yeah. Sometimes we wait awhile - it's not good. Family was upset their loved one had to wait along time to eat. Record review of policy, Resident Rights and Responsibilities, Notice of dated 4/2025 was documented Policy, it is the policy of this facility to inform the resident both orally and in writing of their rights as a resident, as well as a rules and regulations governing the residents conduct and responsibilities during their stay in the facility.no other policy was provided.Record review of State Long-Term Care Ombudsman Program, Your Rights in a Nursing Facility, Brothers of Texas nursing facilities have all the rights, benefits, responsibilities, and privileges granted by the constitution and the laws of this state and the United States. They have the right to be free of interference, coercion, discrimination, and reprisal and exercising these rights as citizens of United States. Dignity and Respect, you have the right to; live in safe, decent and clean conditions, be free from abuse, neglect and exploitation. Be treated with dignity, courtesy, consideration and respect.Residents' Rights | State Long-Term Care Ombudsman, 7/21/2026 at 11:33 AM.

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 refrigeration units reviewed for food safety requirements.The facility failed to ensure the refrigeration area was free from spills and debris.The facility failed to ensure food stored in the refrigeration areas was labeled properly with the contents and dates prepared/opened.These failures could place residents at risk of cross contamination and foodborne illness. Findings include:During observation of community refrigerator located in the dining room and accessible to everyone and interview with DON on 07/16/2026 at 11:20 a.m., the refrigerator had spills and debris in the freezer and refrigerator sections. In the freezer there was a plastic bag of whipped cream, open on one end, and unlabeled and undated. In the refrigerator door was a tumbler cup with unknown liquid and a plastic cup of soda, unlabeled and undated. In the refrigerator was a plastic bag containing salad greens and a container of cooked chicken, unlabeled, and undated. The chicken had a use by date of 07/05/2026. There were 2 lunch boxes in the refrigerator, and the DON stated they probably belonged to staff but should not be stored in that refrigerator because it is designated for resident use. The DON stated housekeeping is responsible for cleaning the refrigerator, and staff are responsible for dating and labelling the food items. The DON stated that a resident could potentially become ill if they were to consume expired items from the refrigerator.During an interview with LVN F on 07/17/2026 at 9:45am stated if a resident had food that needed to be refrigerated, it would be labeled with the resident's name and date and placed in the refrigerator in the dining room if the resident did not have a personal refrigerator in their room. LVN F stated that nursing staff checks the refrigerator on Fridays and throws away any food that is expired. LVN F stated if a resident consumed items from the refrigerator that were not labeled, dated, or had expired, they could become ill or experience stomach upset. During an interview with the housekeeping supervisor on 07/17/2026 at 9:50 a.m., she stated that the nursing department is responsible for the resident refrigerator located in the dining room and housekeeping does not touch it, clean it out, or remove any food items. She stated she was never instructed that housekeeping staff clean the resident refrigerator.A record review of policy titled Resident Personal Food Storage dated 12/2023 revealed Food or beverage brought in from outside sources for storage in facility pantries, refrigeration units, or personal/resident room refrigeration units will be monitored by designated facility staff for food safety. Procedure: 1. Food storage areas shall be clean at all times. 5. Resident and individuals bringing food in from outside sources will be educated on safe food handling and storage techniques by designated facility staff as needed.

Based on interview and record review the facility failed to ensure that all residents had the right to formulate an advanced directive for 1 (Resident #5) out of 20 residents reviewed for advanced directives.The facility failed to ensure Resident #5's advance directive wishes were clearly identified and documented in the electronic health record. The resident was listed as full code, but had an active Out of Hospital Do not Resuscitate (OOH-DNR) form on file.This failure could place residents at risk for not receiving healthcare as per their or their legal representatives' wishes.The findings included: Record review of Resident #5's face sheet printed [DATE] revealed that he was a [AGE] year-old male resident admitted to the facility originally on [DATE] and readmitted on [DATE]. His diagnoses include recurrent enterocolitis (inflammation of the digestive tract) due to clostridium difficile (bacterial infection causing severe diarrhea), anemia (low number of red blood cells), metabolic encephalopathy (disease affecting brain function), congestive heart failure (progressive decrease in hearts ability to pump blood to the body), chronic kidney disease (loss of kidneys ability to filter waste from the blood) and type 2 diabetes mellitus (condition affecting the way the body regulates sugar in the blood). In the section Advance Directive Resident #5 is listed as Full Code: Use AED (Automated External Defibrillator) with CPR during sudden cardiac arrest.Record review of Resident #5's most recent MDS was a quarterly assessment dated [DATE], listing him with a BIMS of 04 out of 15 indicating that he was severely cognitively impaired. He was assessed to have exhibited verbal behavioral symptoms directed toward others for 1 to 3 days. He required partial/moderate assistance for most activities of daily living.Record review of Resident #5's care plan with initiation date of [DATE] revealed the following: Focus: Resident has elected DNR Code status (Date initiated: [DATE], Revision on: [DATE]) Goal: Code Status election will be honored through review date (Date initiated: [DATE]. Revision on: [DATE]. Target date: [DATE]. Interventions: Do Not Resuscitate in the event of cardiac arrest. Review code status quarterly and PRN with resident/RP. Update resident's chart to reflect elected code status, staff must be aware of code status election (Date initiated: [DATE])Record review of the electronic health record for Resident #5 revealed an order summary printed [DATE] with the following order: Full Code: Use AED (Automated External Defibrillator) with CPR during sudden cardiac arrest with an order date of [DATE]Record review of electronic health record progress notes section revealed an admission note dated and signed by the internal medicine nurse practitioner [DATE] that documents a code status of full code for Resident #5.Record review of the electronic health record for Resident #5 revealed an Out of Hospital Do-Not-Resuscitate Order signed and dated by resident's MPOA on [DATE].Record review of Resident #5's electronic health record revealed a social work note dated [DATE] that reveals that Resident #5's code status is DNR.During a telephone interview on [DATE] at 4:22 p.m., the facility social worker reviewed Resident #5's chart and reported that there is conflicting information in the electronic health record regarding Resident #5's code status. She clarified that Resident #5 is DNR status. She stated that the documentation needs to be updated because the facility runs the risk of not honoring Resident #5 wishes by potentially providing CPR to someone who does not want to be resuscitated. She stated that she is the person responsible for updating the residents' code status and will do so as soon as possible.During an interview on [DATE] at 4:55 p.m., the DON reported that the social worker is fully responsible for assuring that a resident's code status is accurately documented in the electronic health record. She stated that if the code status is not accurately documented, the facility risks not following the wishes of the resident and/or family.Record review of the facility provided policy titled Advance Directives and Associated Documentation dated 11/2016 with a last review/revised date of 4/2025 revealed the following: It is the policy of this facility that a resident's choice about advanced directives will be recognized and respected.The facility recognizes and respects the resident's right to choose their treatment and make decisions about care to be received at the end of their life. and Once the advance directive or information regarding resident preferences regarding treatment options is received by the facility, it will be confirmed in the resident medical record and communicated to members of the care plan team. The facility will also notify the attending physician of advance directives so that, if necessary, appropriate orders can be documented in the resident's medical record and plan of care.

Based on interviews and record review, the facility failed to ensure transmittal requirements within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System for 1 of 8 (Resident #6) residents reviewed for MDS assessments in that: MDS LVN C failed to transmit Resident #6's Quarterly MDS assessment within 14 days. Submitted on 7/13/2026.This failure could place residents at risk of not having their assessments transmitted timely and incomplete records. The Findings:Record review of Resident #6's admission Record dated 7/17/2026 was documented he was admitted on [DATE], re-admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease. Record review of Resident #6's Quarterly MDS was dated 6/9/2026 and the BIMS score 13/15 (cognitively intact). This was not submitted until 7/13/2026.In an interview on 07/17/2026 at 2:45 PM, MDS LVN C stated the MDS for Resident #6 was not transmitted within the 14 days due to changes in MDS staffing. No other comments. This MDS should have been transmitted on 6/9/2026, not 7/13/2026. MDS stated they follow the RAI policy. MDS stated she forgot to transmit with no other comments.In an interview on 7/17/2026 at 4:56 PM, the DON stated she was not aware that Resident #6's MDS was transmitted late. The DON stated this could affect the accuracy of documentation and billing. Record review of policy, Resident Assessments and Associated Processes, dated 12/2023 was documented It is the policy of the facility that residents will be assessed, and the findings documented in their clinical health record. These will be comprehensive, accurate, standardized reproductible assessments of each resident and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified. 9. A facility will electronically transmit encoded, accurate, and complete MDS data the CMS system. This was the facility policy.

Based on observation, interview and record review, the facility failed to ensure that the residents comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 (Resident #6) of 8 residents reviewed for care plans in that:The facility failed to ensure that Resident #6's care plan was reviewed and revised when the physician's order for oxygen was no longer active.This failure could place residents at risk of not receiving the care and services needed to meet their individualized needs.The findings include:Record review of Resident #6's face sheet, dated 7/14/2026 revealed the resident was a [AGE] year-old male with an initial admission date of 03/13/2019 with a readmission date of 07/13/2026. His diagnoses include chronic obstructive pulmonary disease unspecified (lung disease causing difficulty breathing), vascular dementia (impaired ability to think, remember or make decisions), cerebellar stroke syndrome (blood vessel is blocked or blood vessels burst in the brain causing dizziness and loss of coordination) and flaccid hemiplegia affecting left nondominant side (total paralysis with loss of muscle tone on one side of the body).Review of Resident #6's most recent MDS was a quarterly assessment dated [DATE] listing him with a BIMS of 13 out of 15 indicating that his cognitive function is considered intact with very little impairment. He was assessed to need partial/moderate assistance for a few activities of daily living and is dependent on staff for mobility and most activities of daily living. Under Section O entitled Special treatments, procedures and programs, there are no respiratory treatments or oxygen therapy documented.Record review of Resident #6's care plan with readmission date of 07/13/2026 revealed the following: Focus: . is on oxygen therapy as needed for SOB and respiratory distress and labored breathing. Date initiated 01/10/2025, Revision on 01/10/2025. Interventions include: Oxygen per MD orders Date initiated 01/10/2025, Revision on 04/16/2026 and O2 at 2L/Min via nasal cannula every 24 hours as need for SOB and Focus:.has emphysema, COPD (Chronic Obstructive Pulmonary Disease) Date initiated: 02/05/2024, Revision on: 10/16/2025. Interventions include: Change O2 tubing & humidifier Bottle Date initiated 2/19/2024, Give oxygen therapy as ordered by the physician Date initiated: 02/19/2024 and O2 at 2-4 L/min via nasal cannula prn Date initiated: 02/19/2024Record review of Resident #6's Order Summary, dated 7/14/2026 revealed that there were no current physician orders for oxygen.Observations of Resident #6's room on 7/14/2026 at 2:20 p.m., 7/15/2026 at 11:40 a.m., 7/16/2026 at 12:35 p.m., and 7/17/2026 at 9:43 a.m. revealed that there were no oxygen supplies visible in the room.During an interview with Resident #6 on 7/16/2026 at 11:28 a.m., he revealed that he had not been on oxygen since his recent hospital stay. Resident #6 was not able to state the date that he was last admitted to the hospital.During an interview with the MDS Nurse on 7/17/2026 at 4:50 p.m., Resident #6's current physician orders and care plan were reviewed. The MDS nurse verified that Resident #6 had no order for oxygen therapy, and the care plan should be updated to reflect this. She said the care plan should be updated otherwise it could read incorrectly and the resident could receive the wrong care. During an interview with the DON on 7/17/2026 at 4:55 p.m., she stated that the MDS nurse is responsible for making updates to the care plans. She stated that if the care plans are not updated then proper care is not given to the resident because the care plan is not accurateRecord review of facility policy titled Comprehensive Person-Centered Care Planning, originally dated 11/2016 with last revision/review date of 4/2025 revealed: The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the quarterly and comprehensive assessments.

Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 (Resident #88) of 2 residents reviewed for incontinence and catheter care.CNA failed to change gloves and perform hand hygiene after cleaning and removing soiled brief while providing perineal and catheter care. This failure could place residents at risk of urinary tract infections from cross contamination. The findings include:Record review of Resident #88's face sheet, dated 07/17/2026, reflected a [AGE] year-old male with current admission date of 09/29/2025. Diagnosis included obstructive and reflux uropathy (a blockage of urine flow causing urine to back up and exert pressure on the kidneys) and benign prostatic hyperplasia (enlargement of the prostate).A record review of Resident #88's MDS dated [DATE] revealed a BIMS score of 04 indicating severely impaired cognition and section H10100 revealed resident had an indwelling catheter.A record review of Resident #88's active physician orders revealed Catheter type: 16Fr/10ml to closed urinary drainage system with a start date of 09/30/2025 and Catheter care every shift. Monitor urethral site for s/s of skin breakdown, pain/discomfort, unusual odor, urine characteristics or secretions, catheter pulling causing tension with start date of 09/29/2025.Record review of Resident #88's comprehensive care plan dated 09/30/2025 revealed: indwelling catheter r/t obstructive uropathy with goals: will remain free from catheter-related trauma through review date, and intervention: provide catheter care every shift and as needed.Observation on 07/15/2026 at 10:20 a.m., of indwelling urinary catheter and perineal care for Resident #88 performed by CNA D and CNA E. CNA D performed catheter care, then cleaned residents' buttocks and removed soiled brief but did not remove gloves, perform hand hygiene and put on new gloves before applying clean brief.During an interview with CNA D on 07/15/2026 at 10:35 a.m., CNA D stated she forgot to change her gloves and sanitize her hands before applying a clean brief. CNA D stated this could cause contamination to the areas touched.During an interview with the DON on 07/17/2026 at 9:25 a.m., the DON stated her expectation is that after a soiled brief is removed, gloves should be removed, hand hygiene performed and new gloves donned before applying a clean brief to prevent infection. The DON stated that CNA D had received training on perineal and catheter care and provided training documentation.A record review of policy titled Incontinence Care, no date: Procedure, 7. Assist resident to turn and cleanse buttocks. 8. Sanitize and re-apply clean gloves. 9. Assist the resident with donning a clean disposable incontinent brief.

Based on observations, interviews, and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 (Resident #2) of 8 residents reviewed for accuracy of clinical records in that:The facility failed to ensure Staff LVNs accurately documented in the July 2026 medication administration record that Resident #2 had completed the order for up in dining room for all meals with 1:1 feeding assistance. Before meals. Order date 03/01/2026 1335 (1:35 p.m.) This failure could result in inaccurate information in the clinical record and could place the residents at risk for errors in their care.The findings included: Record review of Resident #2's face sheet, dated 7/14/2026, revealed the resident was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses include: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (severe weakness of right arm and leg due to brain tissue damage), unspecified protein-calorie malnutrition (inadequate intake of nutrients), speech and language deficits following cerebral infarction (difficulty speaking after a disruption in the brains blood flow), dysphagia (difficulty swallowing) and gastrostomy status (presence of a feeding tube in the stomach). Record review of Resident #2's quarterly MDS dated [DATE] revealed that the resident's BIMS score was 3 out of 15, which indicated the resident had severe cognitive impairment. He was assessed to have impairment on one side, was able to use a wheelchair and required set up or clean up assistance for meals. He was dependent on staff for all other activities of daily living. In regards to his nutritional status, Resident #2 was noted to hold food in mouth/cheeks or residual food in mouth after meals and had coughing or choking during meals or when swallowing medications.Record review of Resident #2's care plan with initiation date of 02/24/2026 revealed the following: Focus: .has ADL self care performance deficit r/t stroke Date initiated 09/15/2024, Revision 10/21/2025 with intervention of Eating: Dependent on staff participation to eat. Date initiated: 09/15/2024, Revision on 4/04/2026 and Focus: Resistive to care. Refused to get up for meals 6/4/26 and 6/8/2026 with Goal: Will participate in care through next review date. Date initiated: 06/04/2026, Target date: 07/26/2026 Record review of Resident #2's physician orders dated 04/03/2026, revealed the resident had the order of Regular diet Mechanical soft - Ground texture, Nectar thick consistency, 1:1 feeing assistance - rotate bite and sip, for nutrition and Up in dining room for all meals with 1:1 feeding assistance before meals dated 03/01/2026. Record review of Resident #2's medication administration record revealed that the resident was checked off on the order Up in dining room for all meals with 1:1 feeding assistance before meals dated 03/01/2026 on 7/14/26 at 1130 and 1630, 7/15/26 at 1130 and 1630, and 7/16/26 at 1630.Observations on 7/14/26 at 11:30 a.m. and 4:30 p.m., on 7/15/26 at 4:30 p.m., and 7/16/26 at 4:30 p.m., Resident #2 was not in the 3rd floor dining room. Observation on 7/16/26 at 6:30 p.m., during a visit with Resident #2, he was observed to be awake, sitting up in bed with his head elevated 45 degrees and scrolling on his cell phone with his left hand. Tray was on the overbed table, food uncovered and was untouched. His family member was sitting at the bedside encouraging him to eat.During an interview with Resident #2 and his family member on 7/17/2026 at 6:30 p.m., it was revealed that the resident has not wanted to go to the dining room for a meal since his hospitalization in February 2026 and has all meals served to him in his room each day.During an interview with the ADON on 7/17/2026 at 2:55 p.m., she reviewed the documentation and stated that a check mark near a medication or treatment means that a medication was given or a treatment was done. She is not sure why the dining tasks were documented as done. She was aware that the resident habitually refuses to go to the dining area and is not sure how oversight/monitoring is being done, as she is only aware of how she supervises this on her regular floor. She stated that if a resident has so many refusals, she would likely try and get the MD to update the order to best meet the needs of the client.During an interview with the DON on 7/17/2026 at 4:55 p.m., she reviewed the documentation and stated that the check mark could just be to acknowledge the order, not so much as to acknowledge whether it was done or not or if the resident refused. She stated that correct documentation is important to patient care.

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that were identified in the comprehensive assessment, and described services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 10 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan was updated to reflect Resident #1 had an incident of resident-to-resident verbal altercation on 04/17/2026. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included:Record review of Resident #1's face sheet, dated 06/02/2026, revealed the resident was a [AGE] year-old female, originally admitted to the facility on [DATE], and readmitted [DATE] with diagnoses of traumatic subdural hemorrhage with loss of consciousness (a bleed around the brain), dementia (loss of memory and thinking ability), and adjustment with mixed anxiety and depressed mood disorder. Record review of Resident #1's quarterly MDS assessment, dated 03/02/2026, revealed the resident's BIMS score was 4 out of 15 which indicated the resident had severe cognitive impairment and was receiving antianxiety and antidepressant as ordered in Section N (Medications). Record review of Resident #1's Incident and Accident Report, dated 04/17/2026, revealed LVN-A saw Resident #1 was yelling to her roommate and said that her roommate was her granddaughter and asked sitting down on the chair, but her granddaughter (Resident #1's roommate) did not listen to Resident #1. The facility staff immediately separated Resident #1 from her roommate and notified the resident's primary care physician and DON. Further record review of the Incident and Accident Report revealed the facility had IDT meeting, changed Resident #1's room, made Resident #1 to receive psychiatric evaluation and treatment as ordered, and conducted urinalysis. Record review of Resident #1's comprehensive care plan, dated 10/27/2025, revealed the resident had the care plan of [Resident #1] has a history of hallucinations of accusing related to confusion and dementia. For intervention - Administer medications as ordered. Monitor/document for side effects and effectiveness. Further record review of the comprehensive care plan revealed there was no updated care plans regarding resident-to-resident verbal altercation on 04/17/2026, room changed, urinalysis, and psychiatric evaluation and treatment. Interview on 06/04/2026 at 2:45 p.m. with MDS nurse LVN-B said that she had responsibility to update Resident #1's care plan regarding resident-to-resident verbal altercation on 04/17/2026 but did not update the resident's care plan because she started working on April 2026 so might have missed updating the incident. MDS nurse LVN-B said she should have updated Resident #1's care plan regarding the resident-to-resident verbal altercation on 04/17/2026 after the IDT meeting because updating the care plan played a leading role as a communication tool among staff and providers. Interview on 06/05/2026 at 1:00 p.m. with DON said Resident #1's comprehensive care plan should have been updated regarding the resident-to-resident verbal altercation on 04/17/2026 after the IDT meeting, and if the care plan was not updated, the resident might receive inappropriate care. Record review of the facility policy, titled Comprehensive person-centered care planning, undated, revealed . 5. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment and as needed. Interventions put in place are to follow as the plan of care for the resident. These interventions may be adjusted or resolved as needed to facilitate the resident needs.

Based on observation, interview, and record review, the facility failed to ensure resident who is incontinent of bladder receives appropriate treatment and service to prevent urinary tract infections for 1 (Resident #2) of 2 residents reviewed for incontinent care in that: CNA-C and CNA-D placed Resident #2's indwelling urinary catheter bag above the level of the resident's bladder during transferring the resident from the bed to the wheelchair mechanically on 06/03/2026. This failure placed resident at risk for urinary tract infection, unwanted antibiotic therapy, and decrease in quality of life. Findings:Record review of Resident #2's face sheet, dated 06/05/2026, revealed the resident was a [AGE] year-old male, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnoses of paraplegia (inability to voluntarily move the lower parts of the body), urinary tract infection (infection in any parts of the urinary system such as kidney, ureters, or bladder), and cystitis (inflammation of the bladder). Record review of Resident #2's quarterly MDS assessment, dated 04/23/2026, revealed the resident's BIMS score was 15 out of 15 which indicated the resident's cognition was intact and had an indwelling urinary catheter in the Section H (Bladder and Bowel). Record review of Resident #2's comprehensive care plan, dated 11/17/2025, revealed the resident had the care plan of [Resident #2] Has Suprapubic Catheter (urinary catheter that is inserted into the bladder from a small cut in the tummy, just above pubic bone) for Neurogenic bladder (the bladder does not empty, properly due to a neurological condition). For intervention - CATHETER: Position catheter bag and tubing below the level of the bladder and away from entrance room door. Observation on 06/03/2026 at 1:47 p.m. revealed that CNA-C and CNA-D put the sling under Resident #2 and attached the sling to the mechanical lift. When the mechanical lift raised the resident, CNA-C was holding the resident's catheter bag in the air above the level of the resident's bladder. Further observation revealed when Resident #2 was in the air and transferred from the bed to the wheelchair by the mechanical lift, and CNA-C was holding the resident in the air, CNA-D also was holding the resident's catheter bag in the air above the level of the resident's bladder. Interview on 06/03/2026 at 2:02 p.m. with CNA-C and CNA-D said they positioned Resident #2's catheter bag above the level of the resident's bladder during mechanical lift transfer because they were confused and nervous. CNA-C and CNA-D stated they should have positioned the catheter bag below the level of the resident's bladder all the time to prevent urine from flowing back to the bladder and possible infection. CNA-C and CNA-D said they received education and had skill check-off yearly regarding how to take care of the catheter bag during transfer. Interview on 06/03/2026 at 5:00 p.m. with DON said CNA-C and CNA-D should have positioned Resident #2's catheter bag below the level of the resident's bladder all the time during the mechanical lift transfer to prevent urine from flowing back to the bladder and possible infection. Record review of the facility policy, titled Catheter Drainage Bag, dated 12/2023, revealed . 14. Position the drainage bag below the level of the resident's bladder and without resting on the floor. Ensure tubing allows for unobstructed drainage of urine.

Based on observation, interview, and record review, the facility failed, in accordance with State and Federal laws, to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 (3rd floor medication aide cart and 2nd floor nursing cart) of 4 medication carts reviewed for medication storage. 1. The facility failed to ensure MA-E locked the 3rd floor medication aide cart when it was unattended on 06/03/2026. 2. The facility failed to ensure LVN-F locked the 2nd floor nursing cart when it was unattended on 06/04/2026. These failures could place residents at risk of not receiving prescribed medications as ordered and drug diversions. Findings Included:1. Observation on 06/03/2026 at 11:44 a.m. revealed there was one medication aide cart in front of the 3rd floor nursing station, and the cart was observed unlocked, unattended, and no staff were around the cart. Interview on 06/03/2026 at 11:57 a.m. with MA-E said she forgot to lock her cart when she left the cart for break, and it was her mistake. MA-E said she should have locked her cart all the time to prevent possible drug diversions. 2. Observation on 06/04/2026 at 3:00 p.m. revealed there was one nursing cart in front of the 2nd floor nursing station, and the cart was observed unlocked, unattended, and no staff were around the cart. Interview on 06/04/2026 at 3:04 p.m. with LVN-F said she forgot to lock her cart when she went to some resident's room for care, and it was her mistake. LVN-F said she should have locked her cart all the time to prevent possible drug diversions and somebody taking some medication. Interview on 06/04/2026 at 5:00 p.m. with DON said the facility Nurses and Medication Aides should have locked their carts all the time to prevent somebody from taking medications and possible drug diversions, and locking medication carts were their responsibilities Record review of the facility policy, titled Medication access and storage, undated, revealed . 2. Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (e.g. medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of infections for 2 of 2 residents (Residents #1 and #2) reviewed for infection control. The facility failed to ensure MA A cleaned the blood pressure cuff between Resident #1 and Resident #2 on 03/17/2026. This deficient practice could place residents at risk for infections. The findings included: 1.Record review of Resident #1's admission Record, dated 03/18/2026, reflected a [AGE] year-old male. He was initially admitted on [DATE] and re-admitted on [DATE]. Record review of Resident #1's Medical Diagnosis tab, undated and accessed on 03/18/2026 at 12:56 p.m., reflected diagnoses included pneumonitis (the swelling and irritation of the lung tissue), type 2 (two) diabetes mellitus (a condition that develops with the way the body regulates and uses sugar as fuel), and hypertension (condition of high pressure in the vessels that carry blood from the heart to the rest of the body). Record review of Resident #1's Quarterly MDS Assessment, dated 12/18/2025, reflected the resident had a BIMS score of 09, which indicated he had moderate cognitive impairment. He had an active diagnosis of hypertension and no infections in the last seven (7) days of the assessment. He had not received antibiotic (a medication prescribed to treat bacterial infections) medications during the last seven (7) days or since admission/entry. 2.Record review of Resident #2's admission Record, dated 03/18/2026, reflected a [AGE] year-old female. She was initially admitted on [DATE] and re-admitted on [DATE]. Record review of Resident #2's Medical Diagnosis tab, undated and accessed 03/18/2026 at 12:49 p.m., reflected diagnoses included cerebral infarction (a disruption in the brain's blood flow), chronic obstructive pulmonary disease (a type of progressive lung disease), and hypertension. Record review of Resident #2's admission MDS Assessment, dated 01/05/2026, reflected the resident had a BIMS score of 00, which indicated she was severely cognitively impaired. She had an active diagnosis of hypertension and no infections in the last seven (7) days of the assessment. She had not received antibiotic medications during the last seven (7) days or since admission/entry. During an observation on 03/17/2026 at 03:38 p.m., MA A was observed taking Resident #1's blood pressure prior to administering medications to the resident. MA A returned to her medication cart and placed the blood pressure cuff on the cart. MA A did not sanitize the blood pressure cuff. MA A then administered Resident #1 his medications. At 05:10 p.m., MA A then went and took Resident #2's blood pressure with the same cuff. MA A again returned to her medication cart and placed the blood pressure cuff on top of her cart. MA A again did not sanitize the blood pressure cuff. MA A stated she received side-by-side training on medication administration protocols during her facility orientation, started June 11, 2025, and had since completed her re-certification for medication aide and on-line continuing education. During an interview on 03/17/2026 at 05:51 p.m., MA A revealed she did not sanitize the blood pressure cuff between residents because she was trying to find the residents and administer their medications on time. She stated she used to use the sanitizing wipes, but they were not on her cart today, 03/17/2026. She stated, when she did not have the sanitizing wipes, she would use hand sanitizer on paper towels to clean her blood pressure cuff. She stated it was important to sanitize the blood pressure cuff between residents because there were bacteria on the cuff that could carry from one (1) resident to another. During an attempted interview on 03/19/2026 at 03:50 p.m., Resident #1 was not available for interview. During observation an attempted interview on 03/19/2026 at 04:15 p.m., Resident #2 was observed to not be interviewable. During an interview on 03/19/2026 at 05:13 p.m., the DON revealed the infection control nurse and nurse managers were expected to do skill checks, observations, and provide in-services to staff administering medications. She stated the ADONs were responsible for monitoring medication administration procedures daily. She stated the nurses and medication aides were responsible for restocking the medication carts every shift with the sanitizer wipes, which were available in each facility floor medication room and storage room. She stated she expected staff to use the sanitation wipes to sanitize the blood pressure cuff. She stated the impact of the blood pressure cuff not being sanitized between residents was the residents would be at risk for infections. During an interview on 03/19/2026 at 05:42 p.m., the ADMIN revealed her expectation was for staff to follow the facility protocol, to use the sanitation wipes. She stated the impact of not following the protocol was infection control. She stated the protocol was to ensure the staff do not spread germs. She stated the facility completed skill checks as needed on staff and on an annual basis. Record review of facility policy IPCP Standard and Transmission-Based Precautions, dated last revision/review date 03/2024, reflected: PolicyIt is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions.Procedure.2. Contact Precautions (Transmission-Based Precautions of TBP) are used with a known infection that is spread by direct or indirect contact with the resident or the resident's environment (e.g. MDROs). c. Patient-care equipment (e.g., blood pressure cuffs). It is preferred dedicated or disposable patient-care equipment be used. If common use equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient.

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 fire panels reviewed for essential equipment. The facility failed to ensure fire watch was adequately performed according to regulations and facility policy in January 2026-March 2026 when the facilities fire panel malfunctioned in January 2026 and was red tagged on 2/13/2026 and was ongoing. This failure could place residents at risk of injury from undetected fire and patient care equipment not in safe operating condition. The findings were: Record review of the Fire Watch Log Sheet, dated 02/13/2026 to 03/12/2026, revealed it differed from the log sheet that was attached to the facility policy. A review of the documentation revealed: The location of area observed was not documented and there was inconsistent time from for the fire watch. from every 20 minutes to several hours without documentation throughout on evening and night shift provided by the security company. The documentation provided by the nursing facility was from 7:00 to 10:00 am as a start time ending at 5:00-6:00 pm and was documented every 30 minutes but without a location of the observation. During an observation on 03/12/2026 at 3:58 pm revealed the fire alarm control panel had a red tag indicating it was out of service. Further observation revealed the tag affixed to the panel was dated 2/13/2026 and had a note stating the Card 7 was Missing. During an interview on 3/12/2026 at 4:33 p.m., the Maintenance Director stated confirmation that the fire panel had been red tagged during a fire inspection. He stated he did not remember when this occurred. He stated the inspection company stated some cartridges used in the panel needed to be replaced, and a battery needed to be replaced. He stated the fire panel had been giving them a lot of trouble and there was a consistent beeping noise. He stated the facility had been doing fire watch because of the red tag. He stated it was him or his assistant doing fire watch. The Maintenance Director stated they would walk around the facility every 30 minutes where the sprinklers were in all the hallways and on all three floors, including the kitchen and laundry areas. During an interview on 3/12/2026 at 5:09 p.m., the Administrator stated she was a new Administrator as of 2/12/2026 but had worked as an AIT in the facility since October 2026. She stated they had been doing fire watch since 1/23/2026. She stated she was notified of the red tag in February when the sticker was placed on the fire panel. She stated her understanding was there was a ground fault error code and because it could not be fixed, they had to leave the red tag. The Administrator stated she did not know why it could not be repaired. She stated when fire watch was initiated someone should walk the entire premises every 30 minutes. She stated this was done during business hours. She stated they had a contract with a security company in the building next door to provide security and they had been conducting fire watch after hours. She stated the repair company had replaced a cartridge on the fire panel, but it did not fix the issues. She stated they were getting another card, but it was an interim repair. She stated the facility would be getting a whole new fire panel. She stated the new fire panel was a process. She stated it required a bid with three companies. The Administrator stated then her and the Market Leader would agree and then another person from Corporate would coordinate getting the repair done. She stated as of this date, she had improved the new card (cartridge) [a replaceable circuit board card] which was a $1300 repair. She stated the repair had not yet been scheduled. During an interview on 3/12/2026 at 5:45 p.m., the Security Office at the building next door responsible for afterhours security of the facility stated they were aware the nursing facility fire alarms were not functioning normally. He stated they were providing hourly fire watch on the patient floors in the evenings. He stated once every hour, the security guard would come to the facility and look on the patient floors. He stated the security guard had other duties which included security for both buildings, assisting residents in the main building, and assisting with lockouts as needed. During an interview on 3/12/2026 at 5:56 p.m., the Maintenance Director stated he had communicated with the Administrator that the fire panel was in need of repairs. He stated the Administrator was responsible for approval of the repairs. In an interview on 03/13/2026 at 11:47 a.m., the Regional Maintenance Director confirmed that the Fire Alarm Control Panel in the Nursing Facility was red tagged indicating it was out of service. He stated the system was also red tagged previously on 1/23/2026 due to a ground fault on the door. He stated there was a relay disconnect with the fire doors on the second floor. He stated the facility was conducting fire watches and had been doing so since 1/23/2026 when the system was initially red tagged. He stated he has contacted vendors and ordered parts for the repairs. He stated he would get the system repaired as soon as possible. When asked how this could affect the residents, he said it could place residents that live in the facility at risk due to the fire alarm system failing during an emergency in the event of a fire or other emergency. This could expose residents to smoke inhalation and bodily injuries. When asked how many residents could be affected, he said all residents could be affected. Record review of the Fire Alarm Proposal, dated 3/12/2026 at 6:18 PM, revealed the equipment was ordered and was scheduled to arrive on 3/16/2026. Further Review revealed the repair was scheduled for 3/17/2026. Record review of the facility policy titled Fire Watch Procedure undated revealed: The purpose of a fire watch procedure is to establish a monitoring system in case of a fire protection system failure. In case the facility fire system (alarm/sprinklers) become disabled for any reason .if the fire alarm system becomes disabled for more than 4 hours in a 24 hour period, a fire watch monitoring system shall be implemented. 3. The person in charge will implement fire watch rounds at intervals of 30-60 minutes. All affected areas shall include inside and out of the main building including the kitchen. Complete and sign the fire watch log. 4. The person performing fire watch is only to conduct fire watch. No other duties shall be assigned. Fire watch is continuous (fire watch shall be continuous and all portions of the facility will be checked at least once every 30--60 minutes).

Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect or exploitation were reported no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency for 1 of 1 fire alarm/panels reviewed for freedom from abuse, neglect, and exploitation. The facility failed to report to the State Survey Agency (HHSC) when the facilities fire alarm system and fire panel malfunctioned on 1/23/2026 and on 2/13/2026 when the fire alarm system panel was red tagged and in need of repairs and the facility continued on fire watch and was ongoing. This failure could place residents at risk for neglect from fire and physical harm from a malfunctioning fire alarm system. The findings were: Record review of TULIP from December 2025 to March 2026 revealed there were no facility self-reported incidents for fire watch or for the fire panel receiving a red tag. Record Review of the Fire Watch Log Sheet revealed fire watch was documented from 1/23/2026 to current (3/12/2026). During an observation on 03/12/2026 at 3:58 pm revealed the fire alarm control panel had a red tag indicating it was out of service. Further observation revealed the tag affixed to the panel was dated 2/13/2026 and had a note stating the Card 7 was Missing. During an interview on 3/12/2026 at 4:33 p.m., the Maintenance Director stated confirmation that the fire panel had been red tagged during a fire inspection. He stated he did not remember when this occurred. He stated the inspection company stated some cartridges used in the panel needed to be replaced, a battery needed to be replaced. He stated the fire panel had been giving them a lot of trouble and there was a consistent beeping noise. He stated the facility had been doing fire watch because of the red tag. He stated it was him [NAME] his assistant doing fire watch. He stated he had reported the issue to the Administrator when it occurred. During an interview on 3/12/2026 at 5:09 p.m., the Administrator stated she was a new Administrator as of 2/12/2026 but had worked as an AIT in the facility since October 2026. She stated they had been doing fire watch since 1/23/2026. She stated she was notified of the red tag in February when the sticker was placed on the fire panel. The Administrator stated her understanding was there was a ground fault error code and because it could not be fixed, they had to leave the red tag. The Administrator stated she did not know why it could not be repaired. She stated when fire watch was initiated someone should walk the entire premises every 30 minutes. She stated the repair company had replaced a cartridge on the fire panel, but it did not fix the issues. She stated they were getting another card, but it was an interim repair. She stated the facility would be getting a whole new fire panel. She stated the new fire panel was a process. She stated as of this date, she had improved the new card (cartridge) [a replaceable circuit board card] which was a $1300 repair. She stated the repair had not yet been scheduled and the facility remained on fire watch. The Administrator stated the did not report the facility's need for fire watch in January 2026 or the red tag on the fire panel and continued fire watch on 2/13/2026. She stated she consulted with her Corporate leadership who informed her reporting was not necessary and instead instructed her to email a program manager. The Administrator stated she notified two program managers on 1/23/2026 via email. The Administrator stated she normally self-reported things that might cause harm to a resident within two hours. She stated she did not self-report the fire alarm panel receiving a red tag because corporate told her to send the email and not formally self-report. Record review of the facility policy titled Abuse Prevention dated 01/17/2020 revealed: Reporting/Response: All alleged violations will be reported vial phone or in withing 24 hours to the State Licensing Agency.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 2 of 2 floors (2nd and 3rd floors) reviewed for physical environment, in that: The facility failed to ensure hot water temperatures were maintained between 100-110 degrees. This failure could place residents at-risk for uncomfortable water temperatures. The findings included: During an observation on 2/18/2026 at 2:54 p.m. of water temperatures measurements by the Maintenance Director revealed the following temperatures out of range for occupied resident rooms: room [ROOM NUMBER] - shower 118, sink 118 F. room [ROOM NUMBER] - sink 118 F.room [ROOM NUMBER] - sink 118 F.room [ROOM NUMBER] - shower 80, sink 80 F.room [ROOM NUMBER] - shower 91, sink 77 F. room [ROOM NUMBER] - shower 94 F.room [ROOM NUMBER] - shower 77, sink 77.room [ROOM NUMBER] - shower 80, sink 77 F.room [ROOM NUMBER] - shower 80, sink 80 F.room [ROOM NUMBER] - shower 88, sink 80 During an interview on 2/18/2026 at 4:14 p.m., LVN D stated there had not been any complaints of water being too hot. LVN D stated she had instructed the CNAs if water was too hot or too cold to use a basin to mix the water. LVN D stated some residents refused to go without a shower regardless of water temperature. LVN D stated they also tried to find an alternative room with hot water, if available, for a shower. LVN D stated she was not certain if anyone reported the water temperatures either too hot or too cold. LVN D stated they were supposed to report maintenance concerns via the computer but most of the time they just told the Maintenance Director in person. LVN D stated most of the time the Maintenance Director responded to let the water run for a few minutes or find an alternative. During an interview on 2/18/2026 at 4:27 p.m., the Maintenance Director stated since the end of December 2025 to present the facility had fluctuating water temperatures. The Maintenance Director stated he was uncertain what the regulations were for the exact temperature range he was supposed to maintain water temps between. The Maintenance Director stated he had plumbers fix certain issues, although he was unable to state what issues were repaired. The Maintenance Director stated he was unable to provide information to contact any of the plumbers when requested. The Maintenance Director did not respond when asked directly what was on the list of things that needed to be fixed. The Maintenance Director stated facility management, including the Administrator was aware of the water temperature issues in the facility. During an interview on 2/19/2026 at 10:12 a.m., the Administrator stated she was aware that some residents were complaining of lack of hot water. The Administrator stated reviewed and signed off on grievances including the one on 2/2/2026 made by Resident #1's family member. The Administrator stated the water temperature issue had been a known facility issue since the end of December 2025, and the facility had plumbers come to the facility several times. The Administrator stated they educated the CNA's that if they did not have hot water in the area where they were working to utilize other areas of the facility, such as another resident room or another method of bathing such as a bed bath with warm water. The Administrator stated the staff could get warm water because it was not a consistent problem. The Administrator stated her expectation of the Maintenance Director was to check water temperatures daily on random rooms, at random times and problem solve, notify/communicate to the department heads and to let the nurses know of the situation. The Administrator stated the Maintenance Director should respond to complaints of irregular water temperatures. The Administrator stated she was unsure what the regulations indicated for range of hot water temperatures. The Administrator stated having water temperatures within regulatory limits was important for the comfort of the residents because it was their home. During an interview on 2/19/2026 at 4:59 p.m., the DON stated the facility did not have a policy for water temperatures or physical environment. Record review on 03/05/2026 of the Facility Maintenance Water Temperature log dated 01/12/2026 revealed the following:Resident room [ROOM NUMBER] measured 80 degrees FahrenheitResident room [ROOM NUMBER] measured 94 degrees FahrenheitResident room [ROOM NUMBER] Measured 82 degrees FahrenheitResident room [ROOM NUMBER] Measured 80 degrees FahrenheitResident room [ROOM NUMBER] Measured 82 degrees FahrenheitResident room [ROOM NUMBER] Measured 80 degrees FahrenheitResident room [ROOM NUMBER] Measured 80 degrees FahrenheitResident room [ROOM NUMBER] Measured 82 degrees FahrenheitResident room [ROOM NUMBER] Measured 81 degrees FahrenheitResident room [ROOM NUMBER] Measured 81 degrees Fahrenheit Record review on 03/05/2026 of the Facility Maintenance log reflected an active repair floor plan of all the resident rooms affected by the fluctuating water temperatures.Findings included:Resident room [ROOM NUMBER]Resident room [ROOM NUMBER]Resident room [ROOM NUMBER]Resident room [ROOM NUMBER]Resident room [ROOM NUMBER]Resident room [ROOM NUMBER]Resident room [ROOM NUMBER]Resident room [ROOM NUMBER]Resident room [ROOM NUMBER]Resident room [ROOM NUMBER]Resident room [ROOM NUMBER]Resident room [ROOM NUMBER]Resident room [ROOM NUMBER]Resident room [ROOM NUMBER]Resident room [ROOM NUMBER]Resident room [ROOM NUMBER]Resident room [ROOM NUMBER]Resident room [ROOM NUMBER] During an interview with the Administrator on 03/05/206 at 11:35 a.m., the Administrator stated the facility's water problems had been an ongoing issue for several months. The Administrator stated only the resident rooms are affected as the kitchen and laundry are on a separate boiler. The Administrator stated there had been several repairs done over the last several months, and the facility was in the process to get bids to replace the whole boiler so their water system would be independent of the building they were currently connected to. During an interview on 03/05/2026 at 3:45 p.m., the Facility Maintenance Director confirmed and stated the resident rooms located on the first and second floors were recording fluctuating water temperatures. Additionally, he stated he was actively replacing the cartridges in all the water fixtures throughout the first and second floor to alleviate the rising and dropping water temperatures. When asked how long the facility had been having issues with the water temperatures, he stated that back in January of 2026 was when they first started experiencing the changes in temperatures. When asked who was responsible for maintaining the water temperatures throughout the facility he stated he was responsible. Additionally, he stated the facility had ordered a large amount of replacement pressure balance cartridges for the water fixtures located inside resident rooms and the Maintenance Department was actively replacing them with the new ones. He stated that replacing the cartridges in the rooms has drastically improved the water temperatures and is helping meet compliance throughout the facility. After further discussion it was agreed that not maintaining the water temperatures in resident rooms throughout the facility could cause scalding or other physical injuries to residents and staff. During an interview on 03/05/2026 at 4:30 p.m., the Regional Maintenance Director stated the facility had been struggling with maintaining water temperatures throughout the facility. When asked how long the facility had undergoing fluctuating water temperatures, he stated since January of 2026. Additionally, he stated the water towers, and boilers for the facility were in a mechanical room located in the neighboring independent living facility. He stated maintaining proper water temperatures has been a struggle since the independent living facility staff members are always adjusting the boilers without their discretion. When asked who was responsible for maintaining the water temperatures throughout the facility, he stated the facility maintenance department was responsible. When asked what plan the facility had created to correct the issue he stated the facility was actively checking water temperatures daily while bids for installing a new boiler and water tower connected to the Nursing Home branched away from the independent living with their own water meter were under review. He stated the facility had an additional bid for replacing the boilers. Additionally, he stated the process to get the bid approved from admission staff is a lengthy process but has plans to resolve the issue as soon as possible. He stated the facility had ordered a large amount of replacement pressure balance cartridges for the water fixtures located inside resident rooms and the Maintenance Department was actively replacing them with the new ones. He stated that replacing the cartridges in the rooms has drastically improved the water temperatures and is helping meet compliance throughout the facility. After further discussion it was agreed that not maintaining the water temperatures in resident rooms throughout the facility could cause scalding or other physical injuries to residents and staff. Record review of invoice from plumbing company, dated 01/07/2026, for repair to a recirculation line on the facility's hot water system. Record review of invoice from plumbing company, dated 01/22/2026, revealed plumbers came to the facility for, an estimate to install a whole new boiler system for domestic hot water. Record review of invoice from plumbing company, dated 01/27/2026, for a quote to replace mixing valves. Record review of invoice from plumbing company, dated 01/27/2026, for adjustment of mixing valve in the boiler room. Record review of invoice from plumbing company, dated 02/05/2026, for adjustment of mixing valve in boiler room. Record review of invoice from parts company, dated 02/18/2026, for plumbing parts to include: 71 pressure balance cartridges, four faucets, and an adjustable wrench.

Based on observation, interview and record review, the facility failed to provide residents with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 3 of 3 residents (Resident #1, #2, and #3) reviewed for quality of life. The facility failed to ensure Residents #1, #2, and #3 had hot water in their own showers for showering for a warm and comfortable experience. This failure could place residents at risk for a decline in quality of life and health status. The findings included:1.Record review of Resident #1's face sheet, dated 2/19/2026, revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: sequelae of cerebral infarction (stroke), vascular dementia without behavioral disturbance (a common form of dementia caused by an impaired supply of blood to the brain, such as may be caused by a series of small strokes), and need for assistance with personal care. Record review of Resident #1's quarterly MDS assessment, dated 11/21/2025, revealed a BIMS score of 00 which indicated the resident's cognition could not be scored and the resident could not be understood. Her functional abilities were maximal assistance with bathing and total dependance on staff for personal hygiene/toileting. Record review of Resident #1's ADL self-care performance deficit care plan, dated 2/22/2023, and last revised on 11/26/2025 revealed shower/baths was listed as: N/A (not applicable). Record review of Resident #1's ADL completed bath activity for the last 30 days revealed the resident was on a Monday, Wednesday, and Friday bathing schedule. There were no showers, baths, or sponge baths documented in the resident's medical record from 1/22/2026-2/19/2026. Record review of Resident #1's shower sheets revealed the following from 1/22/2026-2/19/2026: - shower provided on 1/23/2026- bed bath provided on 1/26/2026- shower provided on 1/28/2026, 1/30/2026. 2/2/2026. 2/04/2026, 2/06/2026, 2/09/26, 2/11/26, 2/13/26, 2/16/26, 2/18/26 Record review of a facility grievance, dated 2/02/2025, by Resident #1's family member revealed No hot water to provide a shower or bath . The grievance indicated it was resolved on 2/02/2026 without indications on how it was resolved. During an observation on 2/18/2026 at 2:54 p.m., with the Maintenance Director obtained water temperatures and revealed the water temperature in the shower inside Resident #1's room was 94 degrees F and the sink temperature was 77 degrees F after running for a full three minutes. During an interview on 2/18/2026 at 3:00 p.m., Resident #1 was unable to answer any interview questions due to her cognitive status. During attempted interviews on 2/18/2026 and 2/19/2026 with Resident #1's family members were unsuccessful. 2.Record review of Resident #2 face sheet, dated 2/19/2026, revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: paraplegia (paralysis of legs), type 2 diabetes mellitus, and need for assistance with personal care. Record review of Resident #2's 5-day Medicare MDS assessment, dated 1/21/2026, revealed a BIMS score of 15 which indicated he was cognitively intact. His functional status was maximal assistance with shower/bathing. Record review of Resident #2's ADL self-care performance deficit, dated 1/20/2026, revealed the plan of care did not identify the resident's showering/bathing needs. Record review of Resident #2's ADL completed bath activity for the last 30 days from 1/21/2026 to 2/19/2026 revealed:- Refusal of bathing on: 1/23/2026 and 1/30/2026- Full body bath on: 1/23/2026, 1/26/2026, 1/28/2025, 2/05/2026, 2/11/26, 2/13/26, 2/17/26 and 2/18/26- Shower on: 2/13/2026 During an observation on 2/18/2026 at 2:54 p.m., water temperatures were taken by the Maintenance Director and revealed the water temperatures in Resident #2's room shower were 80 degrees F at both the shower and sink after letting the water run for a full three minutes. During an interview on 2/18/2026 at 5:35 p.m., Resident #2 stated there was no hot water in his room for at least 2-3 weeks. The resident stated if the staff was unable to find hot water for him, he refused the shower. The resident stated staff had suggested he could take a shower in another resident's room, but he refused. The resident stated he wanted to shower in his room, not go into other people's room to shower and change. The resident stated he accepted sponge baths multiple times, if the staff found hot water. The resident stated he preferred to take a shower to feel clean. He stated he would like to have clean hot water in his own room. 3.Record review of Resident #3's face sheet, dated 2/19/2026, revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: cirrhosis of liver (an advanced, irreversible scarring (fibrosis) of the liver caused by chronic diseases), type 2 diabetes mellitus, and need for assistance with personal care. Record Review of Resident #3's 5-day Medicare MDS assessment, dated 1/14/2026, revealed a BIMS score of 15 which indicated he was cognitively intact. His functional status for showering/bathing was sept-up assistance. Record review of Resident #3's ADL self-care performance deficit care plan, dated 10/10/2025, last revised on 2/12/2026, revealed the resident was dependent on two staff members for bathing/showering. Record review of Resident #3's ADL completed bath activity for the last 30 days, 1/21/2026 to 2/19/2026, revealed:- Shower on: 1/22/2026, 1/24/2026, 1/26/2026, 1/27/2026, 1/29/2026, 1/31/2026, 2/05/2026 and 2/07/2026- Full Body bath on: 2/16/2026 During an observation on 2/18/2026 at 2:54 p.m., water temperatures inside Resident #3's room, taken by the Maintenance Director, revealed shower water temperature of 80 degrees F and sink water temperature of 77 degrees after running for a full three minutes. During an interview on 2/18/2026 at 5:30 p.m., Resident #3 stated he was only taking showers once a week because the water was too cold. The resident stated the staff were aware of the cold water temperatures. Resident #3 stated if he refused a shower the staff just said okay. The resident stated he sometimes accepted a bed bath because it was warmer. The resident stated sometimes, he just cannot stand it and will take a shower even if it was cold. The resident stated he wanted to take warm showers. During an interview on 2/18/2026 at 4:27 p.m., the Maintenance Director stated the facility had an issue with fluctuating water temperatures for the past couple of months. The Maintenance Director stated the hot water problem had stated at the end of December 2025 to the present. The Maintenance Director stated they made repairs to a mixing valve and were in the process of trouble shooting and working on additional solutions. The Maintenance Director stated it was his belief the showers were mixing hot and cold water and replacement cartridges were ordered to hopefully fix the shower concern. The Maintenance Director stated it could take a couple more weeks for the repairs to be completed. The Maintenance Director stated the majority of the rooms affected were on one wing of the facility which included Resident #1, #2 and #3's rooms. The Maintenance Director stated he told staff to let water run. The Maintenance Director stated all facility management was aware of the lack of hot water, including the Administrator. During an interview on 2/18/2026 at 5:40 p.m. CNA A stated some rooms had hot water and some rooms did not. CNA A stated they were taking residents who did not have hot water in their rooms to other residents' rooms of the same gender for showers or finding an empty room with hot water, if available. CNA A stated some residents would refuse to go into other residents' rooms to shower. She stated the sink in the dining room typically had hot water for a bed bath, or they could get hot water from the coffee machine to mix with cold water for a bed bath, or basin/bucket bath. CNA A stated a total body bath was another name for a basin bath, not an actual tub bath. CNA A stated there were some residents who would refuse bed baths if they were not able to obtain hot water. CNA A stated the staff had been instructed to offer alternatives to showers, but some residents refused the alternatives that were offered. CNA A stated they reported the shower refusals to the nurses, and the staff reported maintenance concerns, including water temperature concerns directly to the Maintenance Director. During an interview on 2/19/2026 at 4:50 p.m., LVN B stated there have been multiple resident complaints of hot water brought up by multiple people. LVN B stated Resident #1's family had concerns and others she could not remember. LVN B stated on most days, they exhausted the showers and hot water that were actually working for the day. LVN B stated the CNAs and staff tried to balance it out the best they could. LVN B stated all management staff were aware and the situation was never fully fixed. LVN B stated the staff had been trying to fill up basins with warm water, offer bed baths and find alternative rooms, but once the hot water was out, it was out. LVN B stated there was not enough hot water to go around for all the residents. LVN B stated the Maintenance Director told them to turn on all the water on the hallway, which she did, and the water was lukewarm at best. During an interview on 2/29/2026 at 4:55 p.m., CNA C stated staff documented showers in the POC (computer). CNA C stated some of the resident rooms did not have any hot water. CNA C stated she handled the lack of hot water by going to a room with hot water and filling containers of hot water. CNA C stated she then takes the resident into their own shower and pours basins of hot water/warm water over the resident, so they feel like they are getting an actual shower. CNA C stated she has reported the lack of hot water to the nurses, the management, and to maintenance. During an interview on 2/19/2026 at 2:54 p.m., the DON stated she was new to the facility by four weeks and was not really sure what the facility was doing or what their process were. The DON stated residents should be showered every other day. The DON stated the facility did not have a bathtub, but the facility had showers and could give a sponge bath or a bed bath as an alternative. The DON stated one used a washcloth to wash the whole body (sponge bath) and one used a bucket of water (head to toe bath) or basin but did not involve running water. The DON stated Resident #1's family had complained about the hot water/showers, however she had not heard of any other complaints. The DON stated she had instructed staff to use an empty room if the hot water in that room was working, to offer a bed bath, and if the resident refused, to notify the nurse and the family. The DON stated she acknowledged that not everyone would be comfortable with a bed bath. The DON stated when talking to Resident #1's family she did not discuss when the hot water issue would be resolved, and only stated, hopefully soon. The DON stated it was her understanding that hot water varied by day and by room. The The DON stated a room with hot water one day might not have it the next day. The DON stated she understood that having to move the location in which a resident showered daily could be confusing to the residents, especially those who had dementia. Record review of the facilities policy, titled Routine Procedures/Bath, Shower dated 05/2007 revealed: It is the policy of this facility to promote cleanliness, stimulate circulation and assist in relation. Dependent Residents: 1. Assist resident to shower room. 2. Adjust water to a comfortable temperature before turning stream toward resident.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for medical records accuracy, in that: The facility failed to ensure Resident #1 Nursing Assistant ADL Flow Sheet was accurately documented from 1/21/2026 to 2/19/2026. This failure could place residents at risk for an incomplete clinical picture and errors in care and treatment. The findings included: Record review of Resident #1's face sheet, dated 2/19/2026, revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: sequelae of cerebral infarction (stroke), vascular dementia without behavioral disturbance (a common form of dementia caused by an impaired supply of blood to the brain, such as may be caused by a series of small strokes), and need for assistance with personal care. Record review of Resident #1's quarterly MDS assessment, dated 11/21/2026, revealed a BIMS score of 00 which indicated the resident's cognition could not be scored and the resident could not be understood. Her functional abilities were maximal assistance with bathing and total dependance on staff for personal hygiene/toileting. Record review of Resident #1's ADL self-care performance deficit care plan, dated 2/22/2023 and last revised on 11/26/2025, revealed shower/baths was listed as: N/A (not applicable). Record review of Resident #1's ADL completed bath activity for the last 30 days revealed the resident was on a Monday, Wednesday, and Friday bathing schedule. There were no showers, baths, or sponge baths documented in the medical record in the last 30 days from 1/22/2026-2/19/2026. Record review of Resident #1's shower sheets, dated 1/22/2026-2/19/2026, revealed the following:-Shower provided on 1/23/2026-Bed bath provided on 1/26/2026-Shower provided on 1/28/2026, 1/30/2026. 2/2/2026. 2/04/2026, 2/06/2026, 2/09/26, 2/11/26, 2/13/26, 2/16/26, 2/18/26 During an interview on 2/19/2026 at 4:07 p.m., the DON stated she did not know if the shower sheets were part of the resident's medical records. The DON stated Medical Records was responsible for documentation uploads. The DON stated it was important to have a complete and accurate medical record so the facility could accurately account for all care the resident received while at the facility. During an interview on 2/19/2026 at 4:16 p.m., Medical Records stated she did not upload shower sheets as part of the resident's medical record. Medical Records stated shower sheets were for facility information only, however she stated she gathered residents' shower sheets and stored them for five years, but they were never uploaded into the medical record. Record review of the facilities policy titled Administration, Content of Medical Record dated 8/2007 revealed: All physicians, nursing staff and other health care professionals involved in the resident's care will be responsible for making prompt, appropriate entries in the record. 6. List of contents of the medical record: Nursing Assistants ADL Flow Sheets.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 3 residents (Residents #1 and #2) reviewed for care plans: 1.The facility failed to ensure Resident #1 comprehensive care plan included a plan with interventions to address her bathing and showering requirements. 2.The facility failed to ensure Resident #2's comprehensive care plan was developed to include interventions to address his ADL needs and requirements. These failures could place residents at risk of receiving improper care and services. The findings included: 1.Record review of Resident #1's face sheet, dated 2/19/2026, revealed a [AGE] year-old female admitted on [DATE] with diagnoses which included: sequelae of cerebral infarction (stroke), vascular dementia without behavioral disturbance (a common form of dementia caused by an impaired supply of blood to the brain, such as may be caused by a series of small strokes), and need for assistance with personal care. Record review of Resident #1's quarterly MDS assessment, dated 11/21/2026, revealed a BIMS score of 00 which indicated the resident's cognition could not be scored and the resident could not be understood. Her functional abilities were maximal assistance with bathing and total dependance on staff for personal hygiene/toileting. Record review of Resident #1's Care Plan for ADL self-care performance deficit care plan, dated 2/22/2023 and last revised on 11/26/2025, revealed shower/baths was listed as: N/A (not applicable). 2.Record review of Resident #2 face sheet, dated 2/19/2026, revealed a [AGE] year-old male admitted on [DATE] with diagnoses which included: paraplegia (paralysis of legs), type 2 diabetes mellitus, and need for assistance with personal care. Record review of Resident #2's 5-day Medicare MDS assessment, dated 1/21/2026, revealed a BIMS score of 15 which indicated he was cognitively intact. His functional status was maximal assistance with shower/bathing and transfers, total dependance on staff for toileting, dressing and use of the wheelchair/movement, moderate assistance for sit to stand and from lying to sitting, and supervision for rolling. Record review of Resident #2's Care Plan for ADL self-care performance deficit, dated 1/20/2026, revealed the plan of care did not identify the resident's ADL needs. The care plan read, encourage to participate to the fullest extent possible with each interaction. During an interview on 2/19/2026 at 3:46 p.m., the MDS Coordinator stated she was new to the facility as of 02/01/2026. The MDS Coordinator stated she was in training and had no prior experience as an MDS Coordinator. The MDS Coordinator stated she was responsible for the care plans. The MDS Coordinator stated her focus was on the skilled residents and not the long-term care residents. The MDS Coordinator stated she was still in training for the long-term care resident care plans. The MDS Coordinator stated she was being trained by someone who came to the facility, but she was unable to identify the person. The MDS Coordinator stated the charge nurses, herself and both the ADON and DON had the ability to alter or adjust the care plans, although the management team wanted to be the ones adjusting them. The MDS Coordinator stated they communicated during morning meetings to review changes. During an interview on 2/19/2026 at 3:58 p.m., the DON stated residents' care plans were usually updated with the MDS assessment but was not sure within what time frame. The DON stated Resident #1's care plan indicated not applicable for showering and bathing but should reflect the resident's actual care needs, or what was on the MDS assessment which was maximal assistance. The DON stated Resident #2's care plan was never fully developed but should indicate substantial or maximal assistance for bathing/showering and should also match his MDS assessment and actual care needs. The DON stated both care plans were missing information. The DON stated she did not recognize the names of the staff on either care plan, and was not sure why they were missing information. The DON stated an accurate comprehensive care plan was important to the nurses and aides had a baseline of care for the resident so any changes of condition could be identified and interventions put in place. Record review of the facilities policy, titled Comprehensive Person-Centered Care Planning dated12/2023 revealed: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. 4. The facility IDT will develop and implement a comprehensive person-centered, culturally competent, and trauma-informed care plan for each resident within seven (7) days of completion of the Resident Minimum Data Set (MDS) and will include resident's needs identified in the comprehensive assessment .and resident's goals and desired outcomes .

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 5 Resident's room (Resident #2, 3, 4, 5, 6) reviewed for environmental concerns. Water temperatures were less than 100 degrees Fahrenheit in Resident #2, 3, 4, 6's room. Water temperature was more than 110 degrees Fahrenheit in Resident #5's room. This failure could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe. The findings were: Record review of Resident #3's admission Record, dated 01/06/26, reflected an admission date of 04/25/25, with diagnoses that included weakness and need for personal assistance. Record review of Resident #3's Quarterly MDS assessment, dated 09/26/25, revealed a BIMS score of 15 out of 15, indicating intact cognition. Record review of Resident #4's admission Record, dated 01/06/26, reflected an initial admission date of 01/19/23 and re-admission date of 11/13/23, with diagnoses that included other speech and language deficits following cerebral infarction (when blood flow to a part of the brain is obstructed), cognitive communication deficit, and dementia (loss of cognitive functioning that interferes with daily life and activities). Record review of Resident #4's Quarterly MDS assessment, dated 09/01/25, revealed a BIMS score of 01 out of 15, indicating severe cognitive impairment. Record review of Resident #5's admission Record, dated 01/06/26, reflected an initial admission date of 03/18/23 and re-admission date of 02/11/24, with diagnoses that included cerebral infarction (when blood flow to a part of the brain is obstructed), weakness, cognitive communication deficit, and dementia (loss of cognitive functioning that interferes with daily life and activities). Record review of Resident #5's Quarterly MDS assessment, dated 09/30/25, revealed a BIMS score of 09 out of 15, indicating moderate cognitive impairment. Record review of Resident #2's admission Record, dated 01/06/26, reflected an initial admission date of 10/03/22 and re-admitted [DATE], with diagnoses that included depression. Record review of Resident #2's Annual MDS assessment, dated 10/29/25, revealed a BIMS score of 01 out of 15, indicating severe cognitive impairment. Record review of Resident #6's admission Record, dated 01/07/26, reflected an admission date of 01/02/26 with diagnoses that included sepsis (life-threatening medical emergency caused by the body's overwhelming response to an infection). Record review of Resident #6's MDS assessment, type unknown, dated 01/07/26, revealed a BIMS score of 04 out of 15, indicating severe cognitive impairment. Observation on 01/08/26 at 03:27PM revealed the Maintenance Director placed a dial instant read thermometer through a stream of water from Resident #3's sink in room [ROOM NUMBER]. It revealed the temperature was 78.1 degrees Fahrenheit. Resident #3 revealed that when the water was not hot enough he was told to use wipes or hand sanitizer to ensure his hands were clean. Observation on 01/08/26 at 03:38PM revealed the Maintenance Director placed a dial instant read thermometer through a stream of water from Resident #4's sink in room [ROOM NUMBER]. It revealed the temperature was 78.4 degrees Fahrenheit. Resident #4 was unavailable for an interview. Observation and interview on 01/08/26 at 03:45PM revealed the Maintenance Director placed a dial instant read thermometer through a stream of water from Resident #5's sink in room [ROOM NUMBER]. It revealed the temperature was 118 degrees Fahrenheit. Resident #5 revealed there was hot water available to her and it had not affected her daily life. Observation and interview on 01/08/26 at 03:57PM revealed the Maintenance Director placed a dial instant read thermometer through a stream of water from Resident #2's sink in room [ROOM NUMBER]. The temperature was 80 degrees Fahrenheit. Resident #2 was asleep and did not wake up during observation and interview. Resident #2's RP revealed the water had been too cold for Resident #2's bed baths so nursing staff had to get hot water somewhere else before Resident #2 could receive a bath. Observation and interview on 01/08/26 at 04:03PM revealed the Maintenance Director placed a dial instant read thermometer through a stream of water from Resident #6's sink in room [ROOM NUMBER]. It revealed the temperature was 79.5 degrees Fahrenheit. Resident #6 was unavailable for interview but Resident #6's family member revealed they had not been aware of the temperature of the water from the sink as they were newly admitted and had not gotten the opportunity to notice. Interview on 01/07/25 at 10:05AM, the Maintenance Director revealed there was work being done at a connecting facility and they had to shut off the water for work. He revealed this happened in December 2025 and since then some rooms did not have hot water and they had been moving residents around or supplying hot water from somewhere else. Interview on 01/08/26 at 04:56 PM, the Interim ADM and Operations Manager revealed they scheduled for mechanic to come and fix the hot water on 01/09/26. They revealed they shared utilities with another facility and the other facility had construction that messed up their building's water temperature. They revealed the water temperature had been messed up for 2 to 3 weeks. Interview on 01/09/26 at 11:21 AM, the DON revealed the hot water had been out intermittently since December 2025. She revealed the hot water had worked on and off. She revealed residents were made aware if their hot water was working or not. She revealed residents were educated to use hand sanitizer or offered wipes to ensure their hands were cleaned. She revealed it was important to have hot water for sinks so residents could have a homelike environment. A policy for water temperatures was requested on 01/09/26 at 01:48PM and the Operations Manager revealed they did not have a policy that was specific for water. Record review of the facility's policy Environmental Safety, dated 09/2024, reflected The facility provides a safe, functional, sanitary, and comfortable environment for the residents.

Based on interview and record review, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of medications for 2 of 8 residents (Residents #1 and #2) reviewed for pharmacy services. On 01/06/25, Resident #1 received the following medications late: Apixaban Oral Tablet 2.5 MG, Polyethylene Glycol 3350 Powder, Thiamine HCl Oral Tablet 100 MG, Multivitamin-Minerals Oral Tablet, Megestrol Acetate Oral Suspension 40 MG/ML, levETIRAcetam Oral Solution 500MG/5ML, Ascorbic Acid Oral Tablet 500 MG, Metoprolol Tartrate Oral Tablet 25 MG, and Lidocan External Patch 5%. On 01/07/25, Resident #1 received the following medications late: Ascorbic Acid Oral Tablet 500 MG, Megestrol Acetate Oral Suspension 40 MG/ML, Polyethylene Glycol 3350 Powder, Thiamine HCl Oral Tablet 100 MG, levETIRAcetam Oral Solution 500MG/5ML, Multivitamin-Minerals Oral Tablet, Lidocan External Patch 5%, and Metoprolol Tartrate Oral Tablet 25 MG. On 01/08/25, Resident #1 received the following medications late: Lidocan External Patch 5%, Ascorbic Acid Oral Tablet 500 MG, levETIRAcetam Oral Solution 500MG/5ML, Megestrol Acetate Oral Suspension 40 MG/ML, Multivitamin-Minerals Oral Tablet, Thiamine HCl Oral Tablet 100 MG, Apixaban Oral Tablet 2.5 MG, and Metoprolol Tartrate Oral Tablet 25 MG. On 01/08/25, Resident #2 received the following medications late: Lexapro Oral Tablet 5 MG, Artificial Tears Ophthalmic Solution 1%, Aspirin Oral Tablet Delayed Release 81 MG, Calcium 600 Oral Tablet 600 MG, Namenda Oral Tablet 10 MG, Aldactone Oral Table 25 MG, Ferrous Sulfate Oral Tablet 325 MG, Carvedilol Oral Tablet 6.25 MG, and Bumex Oral Tablet 1 MG This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medication, could result in worsening or exacerbation of chronic medical conditions.The findings were: 1. Record review of Resident #1's admission Record, dated 01/07/26, reflected an initial admission date of 09/27/25 and re-admitted [DATE], with diagnoses that included hypertension (high blood pressure), low back pain, and atrial fibrillation (irregular and often rapid heart rhythm that can lead to blood clots). Record review of Resident #1's admission MDS assessment, dated 10/04/25, revealed a BIMS score of 05 out of 15, which indicated severe cognitive impairment. Record review of Resident #1's order summary report, dated 01/09/26, revealed the following orders:- Apixaban Oral Tablet 2.5 MG. Give 1 tablet by mouth two times a day for anticoagulant, with start date 12/30/2025- Polyethylene Glycol 3350 Powder. Give 17 gram by mouth one time a day for bowel care mix with 4 oz of water, with start date 10/13/2025- Thiamine HCl Oral Tablet 100 MG. Give 1 tablet by mouth one time a day for supplement, with start date 10/13/2025- Multivitamin-Minerals Oral Tablet. Give 1 tablet by mouth one time a day for supplement, with start date 12/31/2025- Megestrol Acetate Oral Suspension 40 MG/ML. Give 20 ml by mouth one time a day for appetite, with start date 10/13/2025- levETIRAcetam Oral Solution 500MG/5ML. Give 7.5 ml by mouth two times a day for seizures, with start date 12/11/2025- Ascorbic Acid Oral Tablet 500 MG. Giive 1 tablet by mouth one time a day for supplement, with start date 12/31/2025- Metoprolol Tartrate Oral Tablet 25 MG. Give 2 tablet by mouth one time a day for HTN HOLD FOR SBP110 DBP 60 OR HR 60bpm, with start date 01/01/2026- Lidocan External Patch 5%. Apply to lower back topically one time a day for pain management, with start date 12/31/2025 Record review of the facility's Medication Admin Audit Report for 01/06/26, dated 01/08/26, revealed:the following medication was administered on 01/06/26 at 10:02AM instead of 07:00AM by MA A:- Apixaban Oral Tablet 2.5 MGthe following medications for Resident #1 were administered on 01/06/26 at 10:36AM instead of at 07:00 AM by MA A:- Polyethylene Glycol 3350 Powder - Thiamine HCl Oral Tablet 100 MG- Multivitamin-Minerals Oral Tablet- Megestrol Acetate Oral Suspension 40 MG/ML- levETIRAcetam Oral Solution 500MG/5ML- Ascorbic Acid Oral Tablet 500 MGthe following medication was administered on 01/06/26 at 10:37AM instead of 07:00AM by MA A:- Metoprolol Tartrate Oral Tablet 25 MGthe following medication was administered on 01/06/26 at 10:37AM instead of 07:00AM by MA A:- Lidocan External Patch 5% Record review of the facility's Medication Admin Audit Report for 01/07/26, dated 01/08/26, revealed:the following medications were administered on 01/07/26 at 10:21AM instead of 07:00AM by MA A:- Ascorbic Acid Oral Tablet 500 MG- Megestrol Acetate Oral Suspension 40 MG/ML- Polyethylene Glycol 3350 Powder - Thiamine HCl Oral Tablet 100 MG- levETIRAcetam Oral Solution 500MG/5ML- Multivitamin-Minerals Oral Tabletthe following medication were administered on 01/07/26 at 10:27AM instead of 07:00AM by MA A:- Lidocan External Patch 5%- Metoprolol Tartrate Oral Tablet 25 MG Record review of the facility's Medication Admin Audit Report for 01/08/26, dated 01/08/26, revealed:the following medication was administered on 01/08/26 at 10:14AM instead of 07:00AM by MA A:- Lidocan External Patch 5%the following medications were administered on 01/08/26 at 10:16AM instead of 07:00AM by MA A:- Ascorbic Acid Oral Tablet 500 MG- levETIRAcetam Oral Solution 500MG/5ML- Megestrol Acetate Oral Suspension 40 MG/ML- Multivitamin-Minerals Oral Tabletthe following medication was administered on 01/08/26 at 10:17AM instead of 07:00AM by MA A:- Thiamine HCl Oral Tablet 100 MGthe following medication was administered on 01/08/26 at 10:33AM instead of 07:00AM by MA A:- Apixaban Oral Tablet 2.5 MGthe following medication was administered on 01/08/26 at 10:43AM instead of 07:00AM by MA A:- Metoprolol Tartrate Oral Tablet 25 MG 2. Record review of Resident #2's admission Record, dated 01/06/26, reflected an initial admission date of 10/03/22 and re-admitted [DATE], with diagnoses that included depression, acute (developed suddenly) on chronic right heart failure (long-term condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), hypertension, and Non-ST elevation myocardial infarction (type of heart attack that occurs when there is a partial blockage of an artery). Record review of Resident #2's Annual MDS assessment, dated 10/29/25, revealed a BIMS score of 01 out of 15, which indicated severe cognitive impairment. Record review of Resident #2's order summary report, dated 01/09/26, revealed the following orders:- Lexapro Oral Tablet 5 MG. Give 1 tablet by mouth one time a day for depression, with start date 02/01/2025- Artificial Tears Ophthalmic Solution 1%. Instill 1 application in both eyes two times a day for dry eyes, with start date 05/14/2025- Aspirin Oral Tablet Delayed Release 81 MG. Give 1 tablet by mouth one time a day for heart health, with start date 05/15/2025- Calcium 600 Oral Tablet 600 MG. Give 1 tablet by mouth one time a day for supplement, with start date 09/07/2024- Namenda Oral Tablet 10 MG. Give 1 tablet by mouth one time a day for blood clots, with start date 03/26/2024- Aldactone Oral Table 25 MG. Give 1 tablet by mouth one time a day for CHF, with start date 03/27/2024- Ferrous Sulfate Oral Tablet 325 MG. Give 1 tablet by mouth one time a day for supplement, with start date 09/07/2024- Carvedilol Oral Tablet 6.25 MG. Give 1 tablet by mouth two times a day for High BP Give at breakfast and dinner Hold for SBP less than 110 or HR less than 60, with start date 03/26/2024- Bumex Oral Tablet 1 MG. Give 1 tablet by mouth one time a day for fluid overload, with start date 03/26/2024 Record review of the facility's Medication Admin Audit Report for 01/08/26, dated 01/08/26, revealed:the following medications were administered on 01/08/26 at 10:57AM instead of 07:00AM by MA A:- Lexapro Oral Tablet 5 MG- Artificial Tears Ophthalmic Solution 1%- Aspirin Oral Tablet Delayed Release 81 MG- Calcium 600 Oral Tablet 600 MG- Namenda Oral Tablet 10 MG- Aldactone Oral Table 25 MG- Ferrous Sulfate Oral Tablet 325 MG- Carvedilol Oral Tablet 6.25 MG- Bumex Oral Tablet 1 MG Interview on 01/08/26 at 05:08PM, MA A revealed medications were given late for Residents #1 and #2. She revealed she had been trying to work with the therapy department to be able to work with them and give medications before or after their respective therapy sessions. She also revealed sometimes residents had appointments, so she had to give the residents' medications before they left for their appointments. She further revealed that did not happen often, but that was no excuse. MA A revealed it was important to administer medications on time to follow doctor's orders and to make sure medications were given before there was a second dosage due for certain medications. Interview on 01/09/26 at 06:49 AM, the DON revealed it was not a pattern for residents to be given their medications late. She revealed if medications were late, they would call doctor. She revealed Residents #1 and #2 were in therapy and family visited so that would affect medication administration times. She revealed it was important to administer medications on time to follow the medication regimen and to prevent double dosing. She revealed the residents' doctor and NP were notified about these medications being administered late. Interview on 01/08/26 at 01:15PM. the Interim ADM revealed they did not have a policy that stated the time frame for when medication should be given to a resident. He revealed the facility followed the facility's medication times that were printed on a sheet titled Medication Times for reference, undated, which reflected Medication Times: Day Shift was between 7AM and 10AM and between 12PM and 2PM.

Based on observation, interview, and record review the facility failed to ensure personal privacy for 1 of 2 residents (Resident #11) reviewed for privacy, in that: Resident #11 was observed in the hallway on 12/07/2025 with his foley bag attached to right calf without a privacy cover, exposing his foley bag contents to anyone in the hallway. This deficient practice could affect residents by resulting in loss of dignity and low self-esteem. The findings were: Record review of Resident #11's undated face sheet revealed Resident #11 was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a chemical imbalance in the blood that causes problems in the brain), acute kidney failure (a condition where the kidneys stop working), Alzheimer's disease (a progressive disease that affects memory and other important mental functions) and legal blindness (a definition used to assess the severity of visual impairment). Record review of Resident #11's undated comprehensive care plan revealed a care plan, date initiated 09/30/2025, has indwelling catheter and an intervention that revealed, position catheter bag and tubing below the level of the bladder and away from entrance room door. Record review of Resident #11's annual MDS assessment, dated 09/30/2025, revealed a BIMS score of 4, indicating severe cognitive impairment. Section B - Hearing, Speech and Vision revealed Resident #11 had severely impaired vision. Section GG - Functional Abilities revealed Resident #11 required partial assistance with transfers and ambulation. Record review of Resident #11's December 2025 MAR revealed an order, position privacy bag and tubing below the level of the bladder every shift, order date 09/29/2025. The MAR was initialed by LVN F on 12/07/2025 with a U. The chart code on the MAR revealed, U=Unknown. During an observation, 12/07/2025 at 1:12 p.m., Resident #11 was observed walking in the hallway with CNA A leading Resident #11 by the hands to an armchair and assisted Resident #11 to sit in the chair. Resident #11 was observed to be wearing knee length shorts. Resident #11 had a foley catheter bag attached by a leg strap at the top of Resident #11's right calf. The foley catheter bag did not have a privacy cover and the bag was observed to be over half full of yellow urine. During an interview with CNA A, 12/07/2025 at 1:14 p.m., CNA A stated Resident #11 had a foley catheter bag and said she had not observed a privacy cover for Resident #11 foley bag. CNA A stated the bag was attached to his upper calf when she came on shift at 6 a.m. and stated she did not think she had access to foley catheter bags. CNA A stated it was important for a resident to have a foley privacy bag, because it is privacy for the residents. CNA A stated she was not sure who was responsible for ensuring privacy bags were in place and stated she received education about ensuring privacy bags were in place when she was in CNA school. During an interview with Resident #11, 12/07/2025 at 1:18 p.m., Resident #11 stated the staff assist with his foley catheter bag and stated he was blind and did not know if he had a privacy cover on the bag. Resident #11 stated he did not care if he had a privacy cover or not and it did not bother him to not have a privacy cover. During an interview with the Operations Manager, 12/07/2025 at 3:08 p.m., The Operations Manager said a resident with a foley catheter bag should have had a privacy cover on the foley bag and said the nurse and the aides were responsible for ensuring the placement of privacy covers. The Operations Manager stated she was not sure if staff had received training on privacy covers and stated it was important for foley catheter bags to have privacy covers, for the resident's dignity. During an interview with LVN F, 12/07/2025 at 3:22 p.m., LVN F said he was assigned to Resident #11 and said residents with foley catheter bags should have had privacy covers on their bags. LVN F stated the nurse managers were responsible for ensuring privacy bags were in place and stated he only worked on the weekends and the nurse managers, should be more diligent on that. LVN F said he had access to foley privacy bags and said the bags were located in the supply room. LVN F stated he had received training on keeping privacy bags on foley catheter bags and stated he did not place a privacy bag on Resident #11's foley catheter bag on his shift on 12/07/2025. LVN F stated he observed Resident #11 in the hallway without a privacy cover and stated it was important for residents to have privacy covers, so it gives them privacy for their bag and protect their privacy and to give them respect and dignity. During an interview with the DON, 12/07/2025 at 3:30 p.m., the DON stated residents with foley catheter bags should have had a privacy cover over the bag and stated the charge nurses were responsible for ensuring a resident had a privacy cover. The DON stated staff had received training on privacy covers and stated privacy covers were available to staff in the supply room on each floor. The DON stated it was important to keep privacy bags on a resident's foley catheter bag, for patient privacy. Record review of a facility policy titled, Indwelling Urinary Catheter Care (original date 05.2007 and revision/review date: 7.2012, 7.2013, 7.2015, 8.2017, 12.2019, 1.2022, 12.2023 and 4.2025), revealed, Procedure: 14. Cover the drainage bag with a privacy bag to maintain dignity. Record review of an undated facility in-service education record titled, Foley catheter orders revealed, position privacy bag & tubing below the level of the bladder and revealed LVN F received verbal education and signed the education roster.

Based on observation, record review, and interview, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for 1 of 6 residents (Resident #1) reviewed for pain management. The facility failed to administer PRN pain medication to Resident #1 prior to providing wound care to the resident's groin area. This failure could place residents at risk for unnecessary pain, discomfort, and decreased quality of life. The findings were: Record review of Resident #1's face sheet dated 4/13/2022 revealed a [AGE] year-old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's 5-day admission MDS dated [DATE] revealed a BIM's score of 15 (score 00-15) which indicated the resident was completely cognitively intact. The MDS assessment revealed Resident #1 was having frequent pain of 7 out of 10 on pain scale (1-10) which had limited his day-to-day activities. Resident #1 required extensive assistance from 2 staff members for moving and turning and was not able to ambulate (walk). Record review of Resident #1's Baseline Care Plan dated 3/30/2022 revealed the resident received skin and wound treatments with no interventions listed with pharmacological plan regime to include [MEDICATION(S)] for pain, with a review of the pain scale every shift for the presence of pain to wounds. Record review of Resident #1's Comprehensive Care Plan dated 4/12/2022 revealed he had an impairment to skin integrity of a surgical wound with interventions which included: Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's weekly skin assessment dated [DATE] revealed skin graft site to groin/scrotum: most of graft healed. Remaining areas with granulation (new skin cell growth) .no complaints of pain . Record review of Resident #1's physician orders for wound care dated 3/31/2022 revealed wound care to scrotal/groin: cleanse with wound cleaner, pat, cover wound and grafted areas with silver alginate and abdominal pads and secure with tape. Record review of Resident #1's physician orders for pain medication (date not legible) revealed orders for the administration of [MEDICATION(S)] 5/325 ([MEDICATION(S)]-Acetaminophen a narcotic pain reliever) give one tablet every 4 hours as needed for pain scale 5-10. Record review of Resident #1 TARS (treatment administration record) for April 2022 revealed the Wound Care Nurse documented wound care was provided on 4/12/2022 at 5:33 p.m. Record review of Resident #1's MARS (medication administration record) for April 2022 revealed there was no documentation that [MEDICATION(S)] had been administered for pain. During an interview on 4/12/2022 at 4:51 p.m., the Wound Care Nurse stated she provided wound care for the facility with exceptions of some evenings and weekends, at which time the Charge Nurses provided wound care. The Wound Care Nurse stated she was responsible for weekly skin assessments on all residents. She stated she documented wound details on the weekly skin assessment. The Wound Care Nurse stated she made rounds with the Wound Care Nurse Practitioner on Wednesdays and had learned to provide wound care from the Nurse Practitioner. The Wound Care Nurse stated she started the wound care position in January 2022. She stated Resident #1 received daily wound care which she provided Monday thru Friday. During an observation of wound care for Resident #1 on 4/12/2022 at 5:14 p.m., the Wound Care Nurse approached the resident and informed him she would be providing wound care, she did not assess the residents pain prior to the procedure. During the procedure while pulling off the old bandage to the groin area, Resident #1 winced when the dressing was removed. The Wound Care Nurse continued to provide wound care to Resident #1's groin including testicles, perineum, inguinal folds and penis. During the procedure particularly towards the end when the Wound Care Nurse was cleaning the inguinal folds (leg folds) and around base of the penis the resident winced, flinched briefly, held on to both handrails on the bed, closed his eyes, with his head back and grimaced. He did not make any vocalizations or request that the procedure stop. The Wound Care Nurse asked the resident are you okay on two occasions during the procedure to which the resident nodded his head yes. She did not ask the resident if he had pain. The Wound Care Nurse did not do a pain assessment during any part of the procedure. During an interview on 4/12/2022 at 5:30 p.m. Resident #1 stated during the wound care procedure his pain was 8 out of 10 on a pain scale (1-10 scale with 10 indicating the worst pain). Resident #1 stated the Wound Care Nurse had not asked about his pain prior to the wound care procedure and had never asked since he began receiving wound care treatments at the facility. Resident #1 stated when he was at the hospital, he would get [MEDICATION(S)] before they started the procedure but since arriving at the facility no one had asked him. He stated he just thought that was the way things were at the nursing home facility. Resident #1 stated he sometimes asked for [MEDICATION(S)] (narcotic pain medication) after the wound care procedure was complete from the nursing staff which was provided. Resident #1 stated he had not told anyone at the facility about the pain he experienced during wound care because he just dealt with it. He stated, I thought I had to deal with it, and I can tolerate pain for a short amount of time. Resident #1 stated most of the pain ended when the wound care procedure ended. He stated he would like to have pain medication before the wound care procedure started. During an interview on 4/12/2022 at 5:36 p.m., the Wound Care Nurse stated she did not assess Resident #1's pain prior to beginning wound care or during wound care because she was nervous, and she forgot. The Wound Care Nurse stated she knew she should have stopped the dressing change and asked about Resident #1's pain. She stated she did ask him if he was okay several times and he said he was okay. The Wound Care Nurse stated Resident #1 had pain during the procedure which she described as typical for the resident. The Wound Care Nurse stated as Resident #1's skin grafts and wounds were healing; the nerves were also healing which made them more sensitive to pain. The Wound Care Nurse stated Resident #1 flinches and that was normal, because the wound was healing more. She stated she had asked Resident #1 on other occasions if he wanted pain medication and he had refused pain medication. The Wound Care Nurse stated she could not remember with accuracy the last time she had asked him about pain or assessed him for pain or had administered pain medication to the resident. During an interview on 4/13/2022 at 4:37 p.m., the DON stated the Wound Care Nurse had been providing wound care at the facility for a little over a month. The DON stated the Wound Care Nurse had assisted her with wound care and vice versa but she (the DON) had not observed the Wound Care Nurse providing wound care without assistance to evaluate her abilities. The DON stated while assisting the Wound Care Nurse with wound care she did not have any concerns. The DON stated the Wound Care Nurse had been provided online training resources by the Wound Care NP (Nurse Practitioner), had completed new hire competencies but had not been provided with any addition wound care or pain related in-service training. The DON stated the Wound Care Nurse was the person responsible for wound care in the facility Monday-Friday. The DON stated her expectations of the wound care nurse was to ask the resident if they had pain and to get them medicated. The DON stated if the resident was receiving wound care every day, wound care should be scheduled to ensure they were getting medicated (for pain) during wound care. The DON stated she would expect the Wound Care Nurse and/or staff to ask the resident if they needed pain medication and stop the procedure to wait for pain medication before continuing. During an interview on 4/14/2022 at 10:39 a.m. the Wound Care NP (Nurse Practitioner) stated she had not observed any concerns for pain with Resident #1 when she provided wound care on Wednesday's when she rounded. During an interview on 4/14/2022 at 12:41 p.m., the Administrator stated he was new to the facility as of 4/11/2022 and was the acting Administrator for the facility. He stated to the best of his knowledge the DON and the NP for Wound Care provided oversite to the Wound Care Nurse because they are the boots on the ground for clinical/nursing procedures. The Administrator stated the DON had gone over some skills with the Wound Care Nurse (unknown date/time). He further stated he was in the process of getting to know the facility by observing clinical care and how nursing care was provided to residents at the facility and getting to know how the facility was currently operating. Record review of the Wound Care Nurse's computerized training transcript revealed she completed a training titled Assessing and Managing Pain on 3/27/2022 with a final score of 80 out of 100. Record review of the Wound Care Nurse's Wound Care Skills Competency (undated) revealed the skills check off did not mention pain or pain management as part of the skill. Record review of a facility policy, titled Resident Care - Recognition and Management of Pain dated 5/2007 and last revised on 7/2017 revealed: It is the policy of this facility to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The facility assists each resident with pain management to maintain or achieve the highest practicable level of well-being and functioning by: interview or observing the resident to determine if pain is present; identifying circumstances when pain can be anticipated; evaluating pain and working with the resident to develop a plan of care that considers their needs preferences and goals; developing and implementing a plan, using non-pharmacological and/or pharmacological interventions to manage and/or prevent pain. 3. For the resident will be documented in the electronic health record using a scale of 1-10. Management: 2. Medications received, refused and response to medication will be documented on the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER]