Every finding on record at Pecan Creek Healthcare Center

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 1 facility observed in that:1. Throughout the facility, the wall base strips were loose and peeling off the wall. 2. The exit door in Hall 5 was soft and unstable.These failures could affect resident safety and environmental cleanliness.Findings included:Observation on 06/09/2026 at 10:13 a.m. revealed that the wall baseboard strips in room [ROOM NUMBER], Hall 6, had come off on the side of the resident's bed and were dusty. There was no wall base strip (plastic trim to the baseboard) on one side of room [ROOM NUMBER], Hall 5. Hall 1, next to room [ROOM NUMBER]'s wall base strips, were coming off the wall. Throughout the facility, the wall base strips (baseboard trim) was loose and peeling off the wall. The exit door in Hall 5 was observed to be soft and unstable appearing to have severe water damage. The condition of the door could allow unauthorized entry or exit due to its potential for easy breach. Interview on 6/11/26 at 11:00 a.m., the MS stated he had been working in the facility since August 2025. The MS stated he fixed room [ROOM NUMBER]'s wall base strips. The MS stated he submitted a work order to fix the exit door in Hall 5. The MS stated that the exit door should not be soft, as it can cause someone to break in. The MS stated that no residents should live in a dusty environment, such as room [ROOM NUMBER]. The MS stated he did not know about the wall base strips in room [ROOM NUMBER] coming off like that; otherwise, he would have fixed it. The MS stated that he will put a new wall base strips in the missing pieces of room [ROOM NUMBER].Interview on 6/11/26 at 12:45 p.m. The ADM stated that she had been working in the facility for almost a month. The ADM stated that the soft, unrigid door could be potentially forced open, and the maintenance director submitted a work order to repair it. The ADM stated that she saw the wall bases strips come off in rooms [ROOM NUMBERS], and the maintenance director had already fixed them. The ADM stated that if the wall base strips were coming off from multiple places, she would look into it. The ADM stated that potentially no resident should live in a room where wall base strips came off, and the area was dusty. The ADM stated that she was conducting in-services on creating a work order in PCC for all staff to address maintenance concerns. Review of the facility policy titled Homelike Environment, revised in February 2021, revealed: 1. Staff provides person-centered care that emphasizes the resident's comfort, independence, and personal needs and preferences. 2. The facility staff and management maximizes to the extent possible, the characteristics of the facility that reflect personalized, home-like settings. These characteristics include: a. clean, sanitary and orderly environment.In-Service training on maintaining a homelike environment and timely completion of work orders started on 06/11/2026 stated that under the purpose section:The purpose of this in-service is to educate staff on maintaining a safe, clean, comfortable, and home-like environment for residents while ensuring environmental concerns are reported promptly through the TELS (Connected software in PCC for maintenance workflows) work order system in PCC and addressed in a timely manner.

Based on interview, and record review, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility for the resident through the means other than a postal service for 9 of 13 confidential residents reviewed for weekend mail delivery.The facility failed to ensure residents received their mail on the weekend.This failure could place residents at risk for not receiving mail in a timely manner that could result in a decline in residents' psychosocial well-being and quality of life.Findings included:During a confidential group interview on 06/10/26 at 10:30 AM, 9 of 13 residents stated mail was not distributed on Saturdays. They stated the mail did not get delivered until Monday or even picked up until Monday.During an interview on 06/10/26 at 12:13 PM, the AD stated mail delivered on the weekend would stay in the mailbox and staff had been instructed by the BOM/HR not to touch it. She stated the mail would get picked up by BOM/HR on Monday or she would get it. The AD stated she was not aware it was a requirement that mail had to be delivered to residents on the weekend. She stated that on Mondays they would go through the mail and disperse what needs to go to the residents. She stated a negative outcome of mail not being delivered to residents on the weekend would be residents would not get something they were expecting. During an interview on 06/10/26 at 12:27 PM, the BOM/HR stated mail was delivered to residents Monday through Friday. She stated she goes through the mail and keeps what is addressed to the facility and then give the residents their mail along with the help of the AD. She stated she was not at the facility on weekends and there was no one designated to pass mail on the weekend. The BOM/HR stated she was aware it was a resident right to receive mail on the weekend. She stated a potential negative outcome to residents not getting their weekend mail would be it would not make them feel very happy. During an interview on 06/11/26 at 12:35 PM, the ADM stated that prior to the survey there was nobody designated to deliver mail to residents on the weekend. She stated it was the expectation that mail was delivered to residents unopened on the weekend. She stated getting mail on the weekend was a resident right. She stated a negative outcome of residents not getting weekend mail was the potential for residents to miss something time sensitive. Review of the facility Resident Rights policy revised February 2021 reflected:Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to:-Access to mail-Communicate by mail Review of a separate Nursing Facility Resident Rights policy dated 3/6/26 reflected:The following rights are guaranteed to residents of Texas nursing facilities under federal law and Texas law. Facilities are required to protect and promote these rights for every resident. -To send and receive unopened mail.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in according with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to ensure a dedicated hand-washing sink was placed in the kitchen.2. The facility failed to ensure the kitchen ceiling vents were dust-free and clean. 3. The facility failed to ensure milk was assessed for appropriate temperature of 40 degrees Fahrenheit or below prior to being served. These failures could place residents at risk of foodborne illness and decreased quality of life.Findings included:Observation and interview on 06/09/2026 at 11:30 a.m. revealed that the handwashing sink was missing in the kitchen. Surveyor observed that kitchen staff washes their hand at the three-cabinet sink faucet. One of the kitchen ceiling vents next to the preparation area was dusty. The soap and paper towel dispensers were far apart, the soap dispenser was on the right side, and the towel dispenser was on the left side of the three-part sink . The trash can was on the opposite side of the kitchen from the Three-cabinet sink, next to the dry, cold storage area. The DM said the handwashing sink was missing in the kitchen about 2 years ago; however, the facility removed it due to plumbing issues, and it was never reinstated. Just before serving lunch, there was milk in the glass container for residents. No temperature had been taken for the milk before serving. When asked to take the temperature, it was 48 degrees Fahrenheit. The kitchen Aide immediately discarded the milk and made new milk to serve at 39.5 degrees Fahrenheit.Interview on 6/10/26 at 09:47 a.m.,DM stated she had been working in the facility for about 5 years. DM stated she handles everything in the kitchen, including budgeting, ordering food, training current and new staff, hiring kitchen staff, labeling food products, assisting with cooking to ensure it was properly prepared, and following menus and recipes. DM stated she reports maintenance issues in the kitchen to the maintenance man through PCC. DM stated that, according to her knowledge, the current administrator, DON, and maintenance personnel were aware that the hand-washing sink was missing. DM stated that not having a handwashing sink made her daily tasks difficult. DM stated the hand-washing sink had been missing for at least two years. DM stated washing hands in the middle section of the three-part sink was incorrect. DM stated the trash should be placed next to the hand-washing sink. DM stated that she was trained on properly taking the food temperature, including hot and cold, before serving. DM stated that in-service training was conducted after the surveyor found the milk temperature above 48 degrees while serving it during lunch. DM stated cold items should be below 41 and hot items should be above 135 degrees Fahrenheit. DM stated that any food not being served at the proper temperature could make residents sick. DM stated that dusting vents directly over food preparation can cause particles from that dust to fall onto the food. Interview on 6/10/26 at 10:12 a.m.,Cook A stated she had been working in the facility for about little over a year. [NAME] A stated she prepares breakfast and lunch. [NAME] A stated she measures and documents the temperature needed for the entire kitchen and checks it before serving food. [NAME] A stated she reports maintenance concerns to the maintenance director and the DM. [NAME] A stated she had been told that the hand-washing sink was not there when she first started. [NAME] A stated she knew it had been reported, but she did not report it to anyone. [NAME] A stated that not having a handwashing sink made tasks difficult, but she adopted the way it is. [NAME] A stated washing hands in the middle section of the three-part sink was incorrect. [NAME] A stated the trash should be placed next to the hand-washing sink. [NAME] A stated that her training included properly taking the food temperature, including hot and cold, before serving. [NAME] A stated that in-service training was conducted after the surveyor found the milk temperature above 48 degrees while serving it during lunch. [NAME] A stated that interventions were taken to ensure that food items were at the proper temperature, that they were discarded if necessary, and that all food items' temperatures were properly measured. [NAME] A stated cold items should be below 41 and hot items should be above 135 degrees Fahrenheit. [NAME] A stated that any food not being served at the proper temperature could make residents very sick. [NAME] A stated that dusting vents directly over food preparation can cause particles from the dust to fall onto the food, and she may need to throw it out. Interview on 6/10/26 at 10:35 a.m.,DA B stated she had been working in the facility for over a year. DA B stated she makes drinks, washes dishes, and takes the temperature of the milk and coffee.DA B stated she reports maintenance concerns to the maintenance director and the DM. DA B stated she was told the hand-washing sink was not there when she first started. DA B stated she did not know whether it had been reported, but she did not report it to anyone. DA B stated that not having a handwashing sink did not make much difference for her duties. DA B stated washing hands in the middle section of the three-part sink was probably incorrect. DA B stated the trash shouldn't be placed next to the hand-washing sink, but it was not necessarily so. DA B stated that her training included properly taking the food temperature, including hot and cold, before serving. DA B stated that in-service training was conducted after the surveyor found the milk temperature above 48 degrees while serving it during lunch. DA B stated that interventions were taken to ensure that food items were at the proper temperature, that they were discarded if necessary, and that all food items' temperatures were properly measured. DA B stated cold items should be below 41 and hot items should be above 140 degrees Fahrenheit. DA B stated that any food not being served at the proper temperature could make residents sick. DA B stated that dusting vents directly over food preparation can cause dust particles to fall onto the food, and she may need to throw it out. Interview on 6/10/26 at 10:53 a.m.,The DON stated she had been working in the facility since December 2024.The DON stated that kitchen staff reports maintenance issues to the administrator. The DON stated she was not aware that the hand-washing sink was missing in the kitchen. The DON stated she had to refer back to the facility policy on the proper temperature. The DON stated that any food not being served at the proper temperature could make residents sick and could cause infection issues.Interview on 6/11/26 at 11:00 a.m., The MS stated he had been working in the facility since August 2025. The MS stated he cleaned the vent in the kitchen area and replaced the filter. The MS stated that dust particles could fall into the food if cooked and prepared food was directly underneath the dusty vents. The MS stated he was not aware that the hand-washing sink was missing in the kitchen area until 6/9/2026. The MS stated he was getting two quotes from two different plumbers, then he would send the quotes to the corporate with a repair and installation request, and then he would go from there. The MS stated that the administrator ordered a temporary sink on 6/9/2026 for the kitchen for hand washing. Interview on 6/10/26 at 11:32 a.m.,The CD stated that she had been working in the facility for about 10 months.The CD stated she audits the kitchen monthly.The CD stated that it was not in the policy to wash hands in the three-compartment sink.The CD stated she was a third-party consultant but didn't know how to add a hand-washing sink for them in the kitchen area, given the condition of the facility's building, area, and space. The CD-stated staff can wash their hands in the dishwashing room and work in the kitchen. The dishwashing room was a separate room from the kitchen, with a hand-washing sink. The CD stated that there was an expectation to have a trash can next to or close to the paper towel dispensing machine.Interview on 6/11/26 at 12:45 p.m., The ADM stated that she had been working in the facility for almost a month. The ADM stated that not having a sink in the kitchen area can make handwashing difficult for kitchen staff.The ADM stated she ordered a portable sink as a temporary sink, and the maintenance director will install it. The ADM stated that having a dusty vent on the ceiling of the food preparation area can cause potentially dusty particles to fall into the food.The ADM stated that serving food at an inaccurate temperature question will be directed to the facility DON and DM. Record review of the policy on Food Preparation and Service dated October 2022 and reviewed and revised 3/5/2026 under the Food Preparation section 5. Stated Handwashing sinks are located near food preparation and clean dish areas and are separate from ware washing sinks. Under the Food Preparation, Cooking, and Holding Time/Temperature Food Preparation, Cooking, and Holding Time/Temperatures 1. The Dander zone for food temperatures is between 41 F and 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness.2. Potentially hazardous foods (HF) include meats, poultry, seafood, cut melon, eggs, milk, yogurt, and cottage cheese.3. The longer foods remain in the Danger zone, the greater the risk of growth of harmful pathogens. Therefore, HF must be maintained below 41 F or above 135 F.4. Potentially hazardous foods held in the danger zone for more than 4 hours (if being prepared from ingredients at room temperature) or 6 hours (if Cooked and then cooled) may cause food borne illness.

Based on observation, interview, and record review, the facility failed to provide a private meeting space for residents' monthly council meetings for 13 of 13 confidential residents who were reviewed for resident council. The facility failed to provide a private space for resident council meetings.This failure could place residents at risk of not being able to voice concerns due to a lack of privacy. Findings included: Observation and interview during a confidential group interview on 06/10/26 at 10:30 AM, revealed multiple staff in and out of the dining room which included MS and DA B (multiple times). The ombudsman who was present in the meeting stated, this has got to stop. The Ombudsman stated there were too many staff causing too many distractions and interruptions to what was supposed to be a confidential, uninterrupted meeting. 13 of 13 confidential residents stated that this was typical and their meetings were regularly interrupted as they were held in the dining room.During an interview on 06/10/26 at 11:36 AM, DA B stated she did not know the purpose of resident council meetings, and she was not aware they were confidential. She stated she needed silverware and to go to the dish room (next to the kitchen, separate, but still located in the dining room) and that's why she had gone in and out. She stated the AD would usually let them know when resident council would be taking place, but they would still go out if they needed items. She stated a negative outcome to disruptions of a confidential meeting would be residents are not able to talk about what they need to talk about.During an interview on 06/10/26 at 12:13 PM, the AD stated she is responsible for setting up the resident council meetings which occur in the main dining room on the first Thursday of every month. She stated during meetings they shut both of the doors on each side of the dining room and that staff are notified in advance of the meeting taking place by her. She stated they did not have signs implemented that indicated that there was a confidential meeting in progress. The AD stated the purpose of resident council is for residents to discuss their concerns. She stated a negative outcome of the council meeting, not being private or having staff interruptions had the potential to result in residents not being able to have a discussion and say what they want to say in a safe space because someone else could hear it. She stated the expectation was for the meeting to be private and confidential. During an interview on 06/10/26 at 12:27 PM, the BOM/HR stated she does not know the purpose of the resident council meeting. She stated however resident's privacy is crucial. She stated she was responsible for managing staff training records and did not believe staff were specifically trained on resident council being a private meeting. She stated she was aware that it was supposed to be a confidential private meeting and interruptions could affect the residents in that staff could hear something the residents don't want them to hear especially if they had a complaint about the person who went in there. During an interview on 06/10/26 at 12:30 PM, the MS stated the purpose of resident council was for residents to voice grievances or give input over concerns they may have. The MS stated that the ADM would usually notify them when resident council was taking place. He stated he was aware nobody was allowed in the kitchen during resident council, but he was in the kitchen fixing items and needed to walk through to get back out. He stated a negative outcome of resident council having staff walking through was it would cause a disruption to residents.During an interview on 06/11/26 at 12:35 PM, the ADM stated the purpose of resident council meeting was to allow the residents an opportunity to voice their opinion, concerns, or their complaints and/or anything positive so they have a protected time where they feel safe and comfortable doing so. She stated the expectation was for no staff members to enter into the meeting unless invited by the residents. She stated she was unsure if prior to her staff were trained on the purpose of resident council and privacy as she is new to the facility (3 weeks in). She stated the AD is responsible for setting up the meeting and notifying staff that there is one taking place. She stated a negative outcome to the confidential meeting being interrupted was they [confidential residents] may feel they cannot voice everything on their mind.Review of the facility Resident Rights policy revised February 2021 reflected:Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to:-Privacy and confidentiality.-Communicate in person and by mail, email, telephone with privacy.

Based on interview and record review, the facility failed to ensure that the resident has the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 1 (Resident #4) of 6 residents reviewed for resident rights. The facility failed to obtain an informed consent for the use of Brexpiprazole (an antipsychotic medication) used for Resident #4.This failure could place residents at risk of receiving medications without prior consent and without the option to choose alternative treatment or decline based on awareness of risk and benefits of the medications.Findings included:Record review of Resident #4's quarterly MDS assessment, dated 04/01/26, reflected that she was admitted on [DATE]. Her diagnoses included anxiety, depression, schizoaffective disorder (a mental disorder causing hallucinations and delusions), and chronic obstructive pulmonary disease (a disease affecting the lung that makes it difficult to breathe). Resident #4 was coded as being partial moderate assistance on staff for shower/bathing. Resident #4 had a BIMS score of 15, which indicated she was cognitively intact.Record review of Resident #4's care plan dated 09/24/25 reflected The resident uses psychotropic medications brexpiprazole related to behavior management interventions included Monitor/document/report as needed any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person.Record review of Resident #4's form 3713 Consent for antipsychotic or neuroleptic medication treatment dated 02/16/26 for Rexulti (brexpiprazole) reflected a diagnosis of schizoaffective disorder. The diagnosis criteria, significant side effects and risks for the proposed treatment and the need and benefits were left blank. The form was signed by Resident #4 and the prescribing persons dated 02/16/26. Record review of Resident #4's Physician Order Summary dated 06/09/26 reflected an order for Brexpiprazole Oral Tablet 2 (two) milligrams give one tablet by mouth one time a day related to schizoaffective disorder.In an interview on 06/09/26 at 10:00 a.m. Resident #4 stated she felt her needs were being met. She had no complaints of neglect and stated staff answer her call light promptly. She had no complaints related to facility or care from staff . In an interview on 06/11/2026 1:14 p.m., the DON stated the 3713 consent for antipsychotic or neuroleptic medication treatment form should have been completed for Resident #4. The ADON and DON were responsible for monitoring all consents to ensure they were completed. She stated with this drug negative effects for the resident having incomplete consent would be lack of knowledge of the risk verses benefits and side effects. Record review of facility policy dated 03/06/26 titled Residents Rights reflected: The following rights are guaranteed to residents of Texas nursing facilities under federal law and Texas law. Facilities are required to protect and promote these rights for every resident. To be fully informed of one's medical condition and treatment options in a language the resident understands. To receive information about prescribed medications, including psychoactive medications

Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) and refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for 1 (Resident #4) of 6 residents reviewed for PASARR screenings.The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #4. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (schizoaffective disorder) was present upon Resident #4's admission date on 09/20/25. This failure could place residents at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs.Findings included:Record review of Resident #4's quarterly MDS assessment, dated 04/01/26, reflected that she was admitted on [DATE]. Diagnoses included anxiety, depression, schizoaffective disorder (a mental disorder causing hallucinations and delusions), and chronic obstructive pulmonary disease (a disease affecting the lung that makes it difficult to breathe). Resident #4 was coded as being partial moderate assistance on staff for shower/bathing. Resident #4 had a BIMS score of 15, which indicated she was cognitively intact.Record review of Resident #4's PASRR Level 1 Screening, dated 09/20/25, reflected that Section C Mental Illness was marked as no, which indicated Resident #4 did not have a mental illness.Record review of Resident #4's care plan, dated 09/24/25, reflected Resident #4 was care planned for a mood problem r/t bipolar disorder and The resident uses psychotropic medications brexpiprazole (an antipsychotic medication used to treat schizophrenia) related to behavior management.During an interview on 06/11/26 at 1:10 p.m., MDS C stated Resident #4 had a diagnosis of schizoaffective disorder and the original PASRR was incorrect. MDS C stated Resident #4 should have had a PASSR Level 2 assessment completed due to her diagnosis. MDS C stated a negative outcome would be Resident #4 would not receive the proper services she needed. During an interview on 06/11/26 at 1:26 p.m., the DON stated Resident #4's PASRR should have been corrected immediately and resubmitted when it came from the hospital incorrect due to her diagnosis of schizoaffective disorder. She stated it was the MDS Coordinator's responsibility to ensure the PASRR level 1 was completed correctly. The DON stated a negative outcome would be Resident #4 would not receive the proper services she needed. Record review of the facility's policy, Preadmission Screening and Resident Review (PASRR) revised 07/18/18 reflected: Health-related Quality of Life Individuals who have or are suspected to have MI, ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the state.Planning of Care The Level II PASRR determination and the evaluation report specify services to be provided by the nursing home and/or specialized services defined by the state. The services to be provided by the nursing home and/or specialized services provided by the State that are specified in the Level II PASRR determination, and the evaluation report should be addressed in the plan of care .

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 6 residents reviewed (Resident #15) for infection control.CNA D failed to change her gloves or clean her hands when moving from a dirty to clean site while performing peri care for Resident #15 on 06/10/26 at 11:01 a.m. This failure could place residents at risk for cross contamination and the spread of infection.Findings included:Record review of Resident #15's admission MDS, dated [DATE], reflected an admission date of 04/17/26 with diagnoses of atrial fibrillation (an irregular heart rate), heart failure, high blood pressure, and age-related cognitive decline. Resident #15 required a wheelchair for mobility, partial moderate assistance for personal hygiene. The MDS reflected Resident #15 was always incontinent with urine and frequently incontinent with bowel. Record review of Resident #15's care plan dated 04/21/26 reflected The resident has mixed bladder incontinence related to impaired mobility, loss of peritoneal tone, and physical limitations. Interventions included Staff to perform/assist with incontinent care during daily care and as needed. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes.In an observation on 06/10/26 at 11:01 a.m. CNA D provided perineal care for Resident #15. CNA D was cleansing from front to back. She removed the soiled brief and discarded it. CNA D then applied a clean brief and did not change her gloves or wash her hands when moving from a dirty surface to clean surface. In an interview on 06/10/26 at 11:36 a.m. CNA D stated she should have washed her hands and changed her gloves after removing the dirty brief and before applying the clean brief during perineal care for Resident #15. CNA D stated she just forgot. She stated she had been trained by the ADON and the DON on infection control and handwashing. She stated that not washing her hands could spread infection from one resident to another. In an interview on 06/11/26 at 1:20 p.m., the DON stated CNA D absolutely needed to wash her hands and to remove gloves when going from dirty to clean surface area. She stated Nursing staff were educated by the ADON and the DON, upon hire, quarterly and as needed on infection control and handwashing. She stated the nursing staff were visually checked off on handwashing yearly at least by the ADON. She stated the negative impact to the residents for not washing hands between dirty and clean surfaces would be the spread of infection.Record review of facility policy titled Handwashing-Hand Hygiene Policy and Procedures, dated March 2020 and revised October 2020, reflected hand hygiene was indicated before handling clean or soiled dressings/gauze pads, moving from work on a contaminated body site to a clean body site on the same resident and after glove removal.

Based on observation, interview, and record review the facility failed to have the results of the most recent survey of the facility posted in a place readily available to residents, family members, and legal representatives for 1 of 1 survey results books.The facility failed to ensure a binder placed in a bin at the entrance of the facility and titled Survey Results contained the results of the most recent health recertification survey.This failure placed residents at risk of not having all the information necessary to make decisions about living at the facility. Findings included:Observation on 06/10/26 at 10:11 AM revealed, a white three-ring binder connected by a silver chain to a bin next to the entrance door. The binder had Survey Results printed on the front as well as the bin. Within the binder results from the most recent full recertification survey, held from 04/28/25 to 04/30/25, were not present anywhere in the binder. Additional 2567 reports from visits on 10/07/25, 10/15/25, and 06/03/26 were not included. The binder only contained results from an LSC visit dated 07/07/25 and a health follow-up visit dated 06/03/25. During a confidential group interview on 06/10/26 at 10:30 AM, 13 of 13 residents stated they did not know where the results of the recent health inspections/ investigations were located and did not believe they were made available to them. During an interview on 06/11/26 at 12:35 PM, the ADM stated it was the Administrators responsibility to ensure the results of the previous surveys and investigations were available for residents and the public to view without having to ask. She stated the expectation was that it is always up to date and accessible to everyone including those residents in a wc. She stated the location and book itself should be easily identified. She stated a negative outcome of previous health visit results not being available to view would be that it would leave visitors/ residents not being aware of issues the facility has had in the past and to know that they have been corrected. The ADM stated she had been at the facility 3 weeks and did not know why the binder was not up to date but was working on correcting the deficiencies being addressed by the survey team. Review of the facility Resident Rights policy revised February 2021 reflected:Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to:-Examine survey results

Based on observation, interviews, and record review, the facility failed to store food following professional standards for food service safety for one of one kitchen reviewed in that: - Food items were not labeled and/or dated correctly in the walk-in fridge. - Out of date food in the walk-in fridge These failures could place residents who received meals from the main kitchen at risk for food-borne illness. Findings included: Observation on 4/28/2025 at 8:15 am of the walk-in refrigerator reflected the following: - Refrigerated cornbread for stuffing dated 4/22/2025 with no expiration date. - Refrigerated tortillas dated 4/12/2025 with no expiration date. - Refrigerated lunch Meat dated 4/25/2025 with no expiration date. - Refrigerated milk and juice on a tray that was not dated. - Refrigerated tamale pie dated 4/19/2025 with an expiration date of 4/26/2025. - Refrigerated scrambled eggs dated 4/27/2025 with no expiration date. - Refrigerated sausage dated 4/27/2025 with no expiration date. - Refrigerated pancakes dated 4/22/2025 with no expiration date. - Refrigerated gelatine dated 4/20/2025 with an expiration date of 4/26/2025. - Refrigerated coleslaw dated 4/25/2025 with no expiration date. Observation on 4/28/2025 at 8:30 am of the freezer reflected the following: - Frozen beef and chili Burritos red burritos in a bag with a date of 2/25/2025 with no expiration date. - Frozen chicken Breast Fillets in a bag that was dated 4/10/25 with no expiration date. - Froze Hush Puppies in a bag dated 4/25/2025 with no expiration date. - Frozen chicken pieces in a bag dated 4/03/2025 with no expiration date. - Frozen Salisbury steak in a bag dated 3/12/2025 with no expiration date. - Frozen corn dogs in a bag dated 1/31 with no year and no expiration date. During an interview on 4/30/2025 at 9:31 AM DA stated that she tried to check for out of date products in the kitchen daily, DA said that sometimes items get missed. DA stated if she found an item out of date, then she told the DM, and the food was thrown in the trash. DA stated when labeling items in bags the name of the product should be on the bag, the date the item was placed in the bag, and the expiration date put on the bag. DA stated if the bag was not labeled correctly, you would not know what was in the bag. Also, if the date on the bag was not there, the food in the bag could be expired. During an interview on 4/30/2025 at 9:38 AM KC stated she tried to check the kitchen daily for out-of-date product. KC stated if she found food was out of date, she threw the food in the trash. KC stated when labeling items in bag the name of the item should be on the bag, the date it was put on the bag, and the expiration date should be on the bag. KC stated if bags were not labeled and outdated food was served, residents could have gotten get sick from eating the food. During an interview on 4/30/2025 at 9:37 AM DM stated the kitchen should be check daily for out-of-date items. If out of date items in the kitchen are found the item should be discarded. DM stated when Items are placed in a bag the bag should be labeled with the name of the food, the date that the food was put in the bag, and the expiration date of the food in the bag which was three days. DM stated that if items are not labeled or dated correctly then the food could be bad without knowing it. DM said that if out of date food was served to the residents, then the residents for get sick from eating food that was out of date. DM said that she had in-serviced staff on the procedure labeling and checking for food that was out of date. During an interview on 4/30/2025 at 9:55 AM with ADM stated food in the kitchen should be checked regularly for out-of-date products. ADM stated items in the walk-in fridge should be labeled and dated correctly. ADM stated residents could get sick if food was not labeled or dated correctly. Record Review of the facility's undated Food Storage Policy: -All foods shall be dated with the month and year received and shall be rotated on the first in/first out basis upon receipt. Oldest items are to be moved to the front to be used first. -Food shall be purchased in quantities which can be stored properly. Frozen products purchased in larger quantities than needed are divided into appropriate quantities, wrapped, and labeled with the description of the product, the date it was wrapped and placed in the freezer.

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 communicable diseases and infections for 1 of 3 residents (Resident #4) observed for infection prevention. The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when RNA provided wound care for Resident #4. This deficient practice could place residents at-risk for spread of infection. Findings included: Record review of Resident #4's Face sheet dated 02/07/2025 revealed she was a [AGE] year-old woman, with an initial admission date of 02/08/03/2018, with re-admission on [DATE] and with diagnoses which included: Chronic Embolism (a blockage in a blood vessel) and Thrombosis (formation of a blood clot inside a blood vessel, obstructing blood flow) of Unspecified Deep Veins of Left Lower Extremity. Record review of Resident #4's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating intact cognition. Further review revealed Resident #4 was assessed as having an indwelling urinary catheter, a colostomy, three stage 2 pressure ulcers, four unstageable pressure injuries and one venous/arterial ulcer. Record review of Resident #4's Care Plan dated last reviewed 04/07/2025 revealed a Problem which included Resident requires Enhanced Barrier Precautions related to wounds, initiated 01/16/2025 and revised 04/07/2025. This problem area included the following interventions: Apply signage outside resident room; initiated 01/16/2025 and EBP used during high-contact resident care activities as applicable, such as: -Dressing -Bathing/Showering -Transferring -Providing hygiene -Changing linens -Changing briefs or assisting with toileting -Device care or use -Wound Care -Other areas determined to require EBP; Initiated 01/16/2025 Observation on 04/28/2025 at 11:07 AM, revealed there was a sign indicating Enhanced Barrier Precautions outside the door to Resident #4's room, and there was a supply of PPE available outside the door/room. Further observation revealed the contracted wound care nurse donned gloves but did not wear a gown while performing wound care for Resident #4. During an interview on 04/28/2025 at 11:30 AM, after the wound care observation, the DON and the Corporate Nurse both agreed that it was their expectation that the contracted wound care nurse wear a gown during the process of wound care. During an interview on 04/28/2025 at 1:00 PM, the DON stated she had called the wound care nurse and educated regarding EBPs. The DON presented written documentation of the education. During a telephone interview with the contracted wound care nurse on 04/30/2025 at 9:45 AM she stated she had received education from the DON regarding the need to wear a gown when providing wound care to a resident who had been placed on Enhanced Barrier Precautions. She also stated: Now that we have been educated, we will follow the protocol. Record review of facility policy titled Enhanced Barrier Precautions, reviewed 03/19/2025 states: Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multi-drug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and glove during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for resident with any of the following: -Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.

Based on observation, interview, and record review, the facility failed to provide a resident, who was incontinent of bladder, the appropriate treatment, and services to prevent urinary tract infections, to the extent possible, for 1 of 7 residents (Resident #71) reviewed for catheter care. Resident #71's urinary catheter bag with urine was not anchored to his bed frame and was lying directly on the floor. This failure could place residents at risk of infection. Findings included: Record review of Resident #71's Annual MDS, dated [DATE], reflected Resident #71 was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with renal insufficiency (which was a disease that caused poor function of the kidneys,) atrial fibrillation (which was a disease of the heart characterized by irregular and often faster heartbeat,) and coronary artery disease (which was a disease where major blood vessels struggled to send blood, oxygen, and nutrients to the heart muscle.) Section C., Cognitive Patterns reflected Resident #71 had a BIMS Score of 12. A BIMS Score of 12 indicated Resident #71 had moderate cognitive impairment. Section H., Bladder and Bowel reflected Resident #71 utilized an indwelling catheter. Record review of Resident #71's CP reflected a focus area for the resident having utilized an indwelling catheter. This resident was a new admission, 3/11/2024 and the goals and interventions were not yet complete. Record review of Resident #71's order summary report reflected an order, dated 03/14/2024, to provide catheter care each shift, and as needed. Record review of Resident #71's progress notes, dated 3/11/2024, reflected Resident #71's arrival to the facility. Resident arrived with the catheter, which was free from obstruction and draining yellow clear urine. Observation and interview on 03/18/2024 at 10:10 AM revealed Resident #71 lying in bed comfortably watching television. He utilized an indwelling catheter, and the catheter bag was located on the floor next to his bed. The tubing had sufficient slack to reach the resident and there was no visual evidence of urine spilled on the floor or an odor of urine in the room. Resident #71 stated he felt good and that he did not have any concerns with the care he had received since he arrived at the facility on 3/11/2024. He was not aware that his catheter bag was located directly on the floor, and he denied any pain or discomfort in the area of his urinary track system. Interview on 03/20/2024 at 9:10 AM with CNA A revealed she had been a CNA for the last [AGE] years and had been at the facility for the last two. She stated catheter bag placement was within the scope of practice for the CNAs and that the correct placement of the catheter bag was on the side of the bed, or chair, and lower than the level of the resident's bladder. The catheter bag was placed lower than the level of the resident's bladder, so gravity drained the resident's urine into the catheter bag. The catheter bag was not supposed to be on the floor to protect the catheter bag, and the tubing, from contamination. Contamination of the catheter bag, or tubing, risked spreading to the resident and risked a urinary tract infection. She stated the failure associated with the catheter bag on the floor fell on the last person to provide the resident care or the clip that held the catheter bag to the bed. Interview on 03/20/2024 at 9:26 AM with LVN B revealed she had been an LVN for the last [AGE] years and had been at the facility for the last 6 months. She stated that CNAs usually emptied the resident's catheter bags during their shifts and reported the urinary output to the nursing staff for documentation. CNA staff was trained to affix the catheter bag to the resident's bed, or chair, lower than the level of the bladder. The catheter bag was not supposed to be positioned on the floor. If the catheter bag was on the floor, the catheter bag, and the tubing, risked contamination. If the contamination reached the resident's body, the resident risked a urinary tract infection. She stated that nursing staff periodically conducted rounds and any observations as such would have been corrected on the spot. Interview on 03/20/2024 at 10:57 AM with the DON revealed she had been an LVN for the previous [AGE] years and had been an RN for the last 6 months. She recently started working at the facility and she had been the DON for the last 9 days. She stated the correct placement for a catheter bag was on the side of the resident's bed, or chair, lower than the level of the resident's bladder. The bag was not supposed to be on the floor. If a catheter bag was on the floor, the catheter bag was exposed to contamination. If the bag was contaminated, and the contamination reached the resident, the resident risked a urinary tract infection. The failure to keep the resident's catheter bag off the floor was the resident's movements or the clip that affixed the bag to the bed. She did not believe that staff saw the bag on the floor and intentionally left it on the floor. Interview on 03/20/2024 at 11:53 AM with the ADM revealed facility policy for catheter care, specifically stated that the catheter bag was supposed to be kept off the floor for infection control. If the catheter bag was contaminated, it posed a risk of infection to the resident. The ADM stated the failure to keep the bag off the floor rested with staff did not ensure the catheter bag was in its proper location. Record review of the facility's Catheter Care Policy, dated January 2023, reflected a section for infection control. The infection control section indicated staff were to maintain clean techniques when handling or manipulating the catheter, tubing, or drainage bag. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, interview, and record review the facility failed to ensure that a resident had appropriate treatment and services to prevent complications of enteral feeding for 1 of 7 resident (Resident #72) reviewed for enteral feeding. Resident #72's peg tube gauze was not changed for 9 days. This failure placed the resident at risk of feeding tube complications and infections. Findings included: Record review of Resident #72's Admission MDS, dated [DATE], reflected Resident #72 was an [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with benign prostatic hyperplasia (which was a disease having caused an enlarged prostate,) anemia (which was a health condition having caused fewer red blood cells to carry oxygen throughout the body,) and hypertension (which was a disease effecting the outward pressure on arteries and blood vessel walls.) Section C., Cognitive Patterns, revealed Resident #72 had a BIMS Score of 1. A BIMS Score of 1 indicated Resident #72 had severe cognitive impairment. Section K, Swallowing and Nutritional Status, revealed Resident # 72 had a feeding tube and consumed 51% or more calories and 501 CCs or more fluid each day through tube feeding. Record review of Resident # 72's CP revealed a focus area for tube feeding care, evidenced by Resident #72 having been admitted to the facility on tube feedings, revised on 3/15/2024. The goal, initiated on 3/15/2024, was for the resident's insertion site to be free from signs and symptoms of infection. The intervention for nursing staff, initiated on 3/15/2024, revealed nursing staff was supposed to cleanse tube site with normal saline, place split gauze dressing daily, and monitor for infection at tube site. Record review of Resident #72's Order Summary Reports revealed an order, dated 2/29/2024, to cleanse peg tube site with normal saline and place split gauze dressing daily. Resident #72's Order Summary Reports revealed an order, dated 03/16/2024, to cleanse peg tube site with normal saline and place split gauze dressing daily. Resident #72's Order Summary Reports revealed an order, dated 03/19/2024, to cleanse peg tube site with normal saline and place split gauze dressing daily. Record review of Resident #72's progress note dated 2/26/2024 revealed Resident #72 admitted to the facility with peg tube in place. Interview and observation on 3/19/2024 at 8:03 AM with Resident #72 revealed he had a peg tube insertion on his abdomen and had received nutrition through his peg tube since admission to the facility. The tube insertion site was covered by a split gauze pad to protect the insertion site. The date on the split gauze pad, written in black ink, was 3-10-2024. Resident #72 could not remember the last time staff cleansed, or changed the split gauze pad, at his tube insertion site. With the assistance of an Investigator VI, RN, there was observable pink coloration around the tube insertion site, but no signs of infection. Resident # 72 denied pain or discomfort at the insertion site. Interview and observation on 03/20/2024 at 9:51 AM with LVN C and Resident #72 revealed she had been an LVN for the last [AGE] years and had been working at the facility for the last 6 months. She stated she had cleansed the tube insertion site for Resident #72 at the beginning of her shift on 3-20-2024 and each new dressing was supposed to be marked with the date it was changed. Observation revealed the date on the split gauze pad was 3-20-2024. She stated the date on the split gauze pad she replaced was dated 3-19-2024. The importance of cleansing the insertion site, and changing the split gauze pad, was to prevent infection. An infection, at a tube insertion site, risked skin breakdown, loss of nutrition, and weight loss. The order to cleanse the insertion site and change the split gauze pad was not entered into the TAR. Interview on 03/20/2024 at 11:13 AM with the DON revealed she had been an LVN for the previous [AGE] years and had been an RN for the last 6 months. She recently started working at the facility and she had been the DON for the last 9 days. The DON did not speculate on why, or how, Resident #72's dressing was not changed as ordered, but stated the gauze should have been changed daily per the order to prevent the spread of infection. Interview on 03/20/2024 at 11:20 AM with LVN B revealed she cleansed the tube insertion site for Resident #72 and changed the split gauze pad yesterday, 3-19-2024. She stated the date on the gauze pad she changed yesterday, on 3-19-2024, was previously dated as 3-10-2024. She could not explain why the gauze pad had gone 9 days without being changed. She stated the failure to cleanse and change the dressing on the tube insertion site fell on the nursing staff. Interview on 03/20/2024 at 11:41 AM with the ADM revealed the facility had a policy in place to address enteral feedings and skin break down precautions. The ADM stated the failure of the dressing not being changed as ordered fell either on the order not being reviewed, not entered on the TAR, or due to leadership. Resident #72 risked infection and skin breakdown. Record review of the facility's Enteral Feedings Policy, dated January 2023, reflected a section that addressed preventing skin breakdown. The policy stated to keep the skin around the site clean, dry, and lubricated and observe for signs of skin breakdown, infection, and irritation.

Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for one (Resident #17) of eight residents reviewed for nutrition. The facility failed to ensure Resident #17 received all items on her meal ticket as ordered by a regular diet which resulted in inadequate oral intake and weight loss. The facility failed to provide Resident #17 effective interventions to prevent further weight loss. This failure could place residents at risk of further weight loss, malnutrition, and decreased quality of life. Findings included: Record review of Resident #17's face sheet dated 01/30/2023 revealed Resident #17 was an [AGE] year old female admitted to the facility on [DATE] with a diagnoses of Alzheimer's disease (disease that effects the brain and nervous system and results in confusion, memory problems and behavioral issues), congestive heart failure (weakening of heart muscle resulting in the heart not pumping blood as effectively), GERD (condition that causes heart burn), high blood pressure, major depressive disorder (mental disorder characterized by low mood, low self-esteem, loss of interest or pleasure in normally enjoyable activities for at least two weeks) and anxiety disorder with history of hallucinations. Record review of Resident #17's quarterly MDS assessment dated [DATE] revealed Resident #17 had a BIMS score of 11 to indicate moderately impaired cognition. Resident #17 was not noted to have recent weight loss or require a mechanically altered or therapeutic diet. Resident #17 was independent and only required setup help for eating. Record review of Resident #17's care plan dated 11/12/2022 revealed Resident #17 was at risk for weight changes due to depression with fluctuating appetite, diuretic use and GERD. Resident #17 had the goal to maintain stable weight and will exhibit no signs or symptoms of dehydration over the next 90 days. Interventions included: -Labs as ordered. -Monitor for signs and symptoms of dehydration (poor skin turgor, chapped lips, dry skin, dry oral mucosa) Notify MD PRN. -Administer meds as ordered. -Diet as ordered. -Monitor meal percentages. Notify nursing PRN poor intake. -Offer choices of food/drink with each meal as able. -Quarterly drug review. -Weigh monthly. Review of Resident #17's weight record dated 01/29/2023 revealed: 01/20/2023 143.6 lbs -6.1% change in 30 days, -8.1% in 3 months, -10.25% in 6 months 12/01/2022 152.8 lbs 10/06/2022 156.2 lbs 07/06/2022 160.0 lbs In an interview on 01/29/2023 at 8:45 AM, Resident #17 stated the food at the facility was okay and that she was picky eater. She stated she felt like she lost weight recently because she had not been eating as much. She said she was unsure of how much weight she lost, but her clothes were looser. In an observation on 01/30/2023 at 7:23 AM, Resident #17's breakfast tray contained one piece of toast, a cup of coffee, a cup of milk, a cup of orange juice and a bowl of hot cereal. Record review of Resident #17's tray card dated 01/30/2023 revealed the following regular diet/regular texture and the menu included choice of juice, choice of cereal, scrambled eggs, sausage patty, toast, margarine, jelly, milk, coffee and water. In an interview on 01/30/2023 at 7:30 AM, CNA B stated Resident #17 will not eat much for breakfast and prefers a light breakfast. She stated Resident #17 preferred only a piece of toast or two biscuits for breakfast. She stated Resident #17 was offered the additional food including eggs and sausage in the past and refused to eat it. She stated Resident #17 was particular about the food she ate and would only eat a salad for lunch and then ate a bigger dinner. In an interview on 01/30/2023 at 7:50 AM, Resident #17 stated she only wanted to eat toast and coffee for breakfast. She did not like to eat a big breakfast and would not eat the eggs or sausage if it was brought to her. She liked eating a salad for lunch and then she would eat dinner. She said she was particular about food and had always watched what she ate closely and like to eat healthy. When asked what she thought caused the weight loss, she did not know but maybe she had been eating less. She said the facility did offer other food to her if she did not like what was served. She said she was not offered a health shake or other supplement to stabilize her weight. She said before she was admitted to the facility, she would drink a [NUTRITION SUPPLEMENT] shake every day. She said she would drink a health shake/supplement if offered one by the facility. In an interview on 01/30/2023 at 7:58 AM, CNA C stated Resident #17 ate only what she wanted to eat and had her preferences. He stated she was offered more food or different food by the kitchen to encourage intake but she would not eat it . He stated she had been very depressed over the holidays and would not come out of her room. He said they tried to encourage her to eat whatever she wanted and she would not eat much. He said he was not sure if her doctor was notified. In an observation on 01/30/2023 at 8:15 AM, Resident #17 was weighed standing up on the scale and her weight was 138.8 pounds. From 01/20/2023 her weight decreased another 4.8 pounds. Record review of Resident #17's RD Weight Variance Note dated 01/20/2023 revealed Resident #17 had a 6% decrease in her weight in 30 days and 8.1% decrease in 90 days. Her intake was noted at 76-100% some and <50% on occasion. Her estimated needs were 1488 kcal , 65-79 g protein, 1964 cc fluid. The summary noted: Resident with no real changes to eating behaviors and no skin issues presents with weight loss this month. Staff noted that had a very rough few weeks over the holiday season with increased depression. She did not come out to the dining room for two weeks during that time, but intake only marginally changed. Resident is not a big breakfast eater and has a chef salad every day at lunch and then the menued dinner. Resident also does not drink milk or consume ice cream type foods. Resident also is not a snacker. At this time continue nutrition POC (Plan of Care) as resident declines other intervention. Goal: Adequate oral intake to support stable weight during admission. RD will monitor and follow up as needed. In an interview on 01/30/2023 at 8:30 AM, the DON stated she and other staff routinely offer Resident #17 snacks, alternate foods and supplements to increase her intake and Resident #17 refused all of them. When asked if there was documentation to prove the offering of supplements or additional food, she said she would have to check. When asked if Resident #17's doctor was notified of her weight loss she said she would have to check because it was not documented in Resident #17's clinical record . When asked if any interventions were put into place by the RD after she was evaluated on 01/20/2023, she said no because Resident #17 refused previous interventions including supplements. She said the RD saw every resident quarterly or if there was a significant change and the RD would then make recommendations. She said the physician would be notified of a significant change and any additional orders would be implemented. She said she was not aware of any new orders for Resident #17 in regards to her recent weight loss. In an interview on 01/30/2023 at 8:45 AM, the DM stated Resident #17's food preferences were for a light breakfast of either two biscuits or a piece of toast. She said Resident #17 wanted a salad for lunch and then ate a regular dinner. She stated they offer her additional food and snacks and she declines them. She stated when Resident #17 was depressed over the holidays they offered any food that she would eat. She said she offered to run to any restaurant to pick up her favorite food and Resident #17 declined outside food as well. She stated Resident #17 did not like milk drinks and therefore did not like health shakes so they did not offer health shakes when her intake was low. In an interview on 01/30/2023 at 9:00 AM, Resident #17's RP stated Resident #17 suffered from depression every year this time of year like clockwork and had a history of losing weight when depressed. She stated Resident #17 also stopped eating sweets in the last few months and told Resident #17's RP that she did not like sweet food or desserts anymore. She said they used to bring Resident #17 pastries when they visited and now Resident #17 will not eat them anymore. She stated she thought Resident #17's tastes had changed. She said she was not notified by the facility about the weight loss. She said she was not aware of any changes the facility made for Resident #17 to stabilize her weight. She said she did not know if Resident #17 was offered a supplement and refused it. She said Resident #17 drank [NUTRITION SUPPLEMENT] daily when she lived independently, so she would assume Resident #17 would drink one now. In an interview on 01/30/2023 at 9:17 AM, the RD for the facility stated she believed Resident #17 had the weight loss due to depression over the holiday period. She said the staff reported to her Resident #17 stopped coming out of her room for two weeks over the holidays and stopped eating in the dining room. She said Resident #17 had improved since that time and the RD said she thought Resident #17's intake improved with her eating in the dining room now. She stated Resident #17 was health conscious with what she ate and chose to eat a salad every day for lunch and liked a lighter breakfast of biscuits or toast . She stated she did not ask for weekly weights after the significant weight loss was noted on 01/20/2023. She stated she only had residents who were underweight and continuing to lose weight weighed weekly or residents under 100 pounds. She said they did not have a specific protocol or policy for weight loss that would include weekly weights. When asked about interventions put into place after the significant weight loss was noted, she said no specific intervention was put into place because Resident #17 would refuse the interventions including a health shake, med pass supplement, fortified food or snacks. She said she knew staff at the facility had offered snacks and health shakes and Resident #17 refused them. When asked if there was documentation of what was offered or if the information was in Resident #17's care plan she said she did not know. She said information on what was offered to Resident #17 for weight loss would be in the EMR. She said she did not update a resident's care plan when weight loss occurred, the MDS Coordinator was in charge of updating a resident's care plan with interventions. She did not notify the doctor of Resident #17's weight loss and said the nurse would be in charge of notifying the doctor. She did not ask about or recommend an appetite stimulant for Resident #17. In an interview on 01/30/2023 at 9:43 AM, LVN A stated Resident #17 was particular about the food she ate and did not eat junk food. She said she liked her breakfast to only be two biscuits or a piece of toast. She said they could offer more food and she would refuse additional food. She stated Resident #17 only ate a salad for lunch because it was preference and then ate a regular dinner. She stated Resident #17 was depressed over the holidays which likely caused her intake to decrease. She stated she felt like Resident #17 was eating more now because she ate in the dining room again. She said for two weeks over the holidays Resident #17 refused to leave her room. She said they would offer her snacks or more food and Resident #17 would decline. She said she was not sure if a health shake or other supplement had been offered to Resident #17. In an interview on 01/30/2023 at 11:04 AM, the ADMIN stated Resident #17 was very particular about what she ate and how she dressed. She stated Resident #17 liked to take good care of herself including eating a healthy diet. She said Resident #17 eats what she wants when she wants. In a follow-up interview on 01/30/2023 at 11:42 AM, the DON stated she spoke with Resident #17's PCP and he ordered an appetite stimulant to prevent further weight loss. She said they would offer Resident #17 a health shake and if she drank it, she would have the PCP order health shakes twice per day for Resident #17. In an interview on 01/30/2023 at 11:58 AM, the PCP for Resident #17 stated he rounded on Resident #17 last week and was given Resident #17's current weight, but he was not notified of the significant change for her previous weight in December 2022. He stated he ordered an appetite stimulant today and will monitor her weight closely for the next 60 days. He stated he requested the RD re-evaluate her as well. He said Resident #17 did not suffer a decline as a result of the weight loss or develop skin breakdown. The PCP thought the weight loss was related to depression over the holidays which resulted in decreased appetite. Record review Resident #17's EMR dated 07/01/2022 - 01/30/2023 did not reveal additional documentation regarding Resident #17's weight loss or interventions that were tried by the facility. Record review of Resident #17's Dietary Progress notes written by the DM dated 08/04/2022 revealed CDM (Certified Dietary Manager) spoke with resident about her likes and dislikes. She is on a regular diet, regular texture and thin liquids at this time. No concerns voiced. She enjoys two biscuits or toast for breakfast and a bowl of cream of wheat. Review of Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol Policy dated September 2017 revealed the staff will report to the physician significant weight gain, anorexia and weight loss before ordering interventions . The physician will review for medical causes of weight gain, anorexia and weight loss before ordering interventions . the staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes . The physician will authorize appropriate interventions, as indicated.

Based on observation, interview and record review, the facility failed to ensure expired/discontinued medications were removed and destroyed for 1 of 1 medication storage rooms reviewed for medications. The facility failed to remove two bottles of expired Famotidine from the medication storage room. This failure could place all residents at an increased risk of receiving expired medications resulting in adverse health consequences. Findings include: Observation on 01/29/2023 at 10:00 AM of the medication storage room with the DON in attendance revealed two bottles of Famotidine (used to treat stomach ulcers) 20 mg with expiration dates of 12/2022. Interview on 01/29/2023 at 10:05 AM the DON stated, I don't know for sure if the potency of the drug is affected. She further stated she had recently looked at all the medications in the storage room and wasn't sure how those were missed. Interview on 1/30/2023 at 11:19 AM the ADMIN stated it was a requirement to not have expired medications available to give to the residents. Review of the facility policy dated 2007 and titled Disposal of Medications reflected Outdated medications shall be destroyed. The director of nursing and consultant pharmacist will monitor for compliance with federal and state laws and regulations regarding the disposal of medications.

Based on interview and record review the facility failed to ensure Resident # 1 received adequate supervision and assistance to prevent a fall for 1 of 5 residents reviewed for accidents and supervision. (Resident #1) The facility failed to ensure Resident #1 remained free of falls to prevent an accident. The facility failed to ensure Resident #1's assistance with toileting routinely was followed. These failures could place residents at risk for falls for possible injuries due to lack of supervision. Findings Include: Review of Resident #1's undated face sheet reflected an [AGE] year-old female was admitted to the facility on [DATE] with a diagnosis of dementia (memory loss), Cognitive communication deficit (difficulty thinking), Insomnia (difficulty falling asleep), hypothyroidism (under production of hormone), hyperlipemia (increased cholesterol), and hypertension (high blood pressure). A review of Resident #1's MDS dated [DATE] revealed Resident#1's BIMS Summary score of 5 indicated severe cognitive impairment. Review of Resident #1's care plan dated 11-30-2022 revealed Resident #1 is at risk for falls, impaired mobility, impaired cognition with impaired safety awareness, and impaired judgment. Review of Resident # 1's care plan dated 11-30-2022 revealed Resident #1 ADLs revealed Resident #1 has self-care deficits, impaired cognition, and impaired mobility. Ambulation/Transfers amount 1 staff assist able to walk with a walker and use a wheelchair. Review of Resident #1's care plan dated 11-30-2022 revealed that Resident #1 is incontinent of bowel and bladder and needs assistance with toileting routinely. Review of Resident #1's progress notes dated 12-7-2022 revealed Resident #1 noted an unwitnessed fall. Review of Resident #1's progress notes dated 12-07-2022 revealed Resident #1 hollered out I'm in here on the floor. when LVN tried to open Resident #1's door. Review of Resident # 1's investigation summary dated 12-07-2022 revealed the Administrator interviewed Resident #1. Resident # 1 stated she asked the LVN to step out of the room and give her some privacy. Resident #1 began to holler that she fell and hurt her back. The DON and the LVN attempted to access Resident # 1 through the door but the door was blocked by Resident # 1. Maintenance assisted the DON to access Resident #1's room through the window. Resident #1 stated that she had fallen and hurt her back. Review of Resident #1's physician documentation dated 12-07-2022 revealed Resident #1 presented to the emergency room with complaints from a fall injury. The fall was unwitnessed, but staff (not named) heard it occur. Resident #1 fell against the door and nursing home staff had to rescue her by going through a window. Review of Resident # 1's hospital notes dated 12-07-2022 revealed Resident # 1 was found to have a right femoral neck fracture. Hip fracture of the thigh bone (femur) just below the ball and socket hip joint that would need surgical intervention. Resident #1 was transferred to a local hospital and admitted to Internal Medicine. Interview on 12-18-2022 at 3:33 PM with CNA A stated LVN told Resident #1 that a urinalysis was needed on 12-07-2022. LVN took Resident #1 from the nurse's station to Resident #1's room. LVN put Resident #1 on the toilet and she left. CNA A could not recall the length of time Resident #1 was left alone. CNA A stated Resident #1 should not have been left alone. CNA A was alerted by LVN that Resident # 1 was on the floor. CNA A stated she went to the door and was not able to open it. DON notified maintenance and they both went to Resident #1's outside window and the DON crawled through Resident # 1 window. CNA A stated she witnessed from outside of Resident # 1's door. When the door was opened CNA A saw Resident #1 laying on the floor up against the door and the wheelchair laying on it's side, beside Resident # 1. Interview on 12-18-2022 at 4:30 PM with maintenance stated he was en route when he heard that Resident # 1 had fallen. When it was determined that Resident #1 had the door blocked, he went to the outside window and jimmied the window lock with a pocketknife to flip the locks back. Maintenance stated Resident #1's windows were not open. The DON went through the window and the only thing he saw was Resident # 1 laying up against the door with her wheelchair beside her. Interview on 12-18-2022 at 4:41 PM with DON stated LVN came and told her that Resident #1 had fallen and LVN could not get the door open. DON spoke with Resident #1 through the door making sure Resident # 1 was competent. Resident # 1 advised the DON she was not able to get up. DON notified maintenance at the nurse station for assistance. DON and maintenance went outside to Resident # 1's window and maintenance popped the window locks and DON climbed in to assist Resident # 1. DON assessed Resident #1 and Resident # 1 stated her lower back was hurting. DON made the judgment to send Resident # 1 out for further evaluation. The DON stated she does not suspect any neglect with the incident of LVN and Resident #1. Interview on 12-18-2022 at 5:00 PM with the Administrator stated that the self-report summary was based on the interview of Resident # 1 and the LVN. No neglect was suspected with LVN and if any neglect had been suspected the LVN would not still be at the facility. Interview on 12-19-2022 at 11:05 AM with LVN stated CNA A and CNA B brought Resident #1 down the hall from the nurses station on 12-07-2022. LVN stated to CNA B that a urinalysis would need to be conducted. LVN stated she asked specifically to CNA B if Resident # 1 could go to the toilet and CNA B stated yes. LVN stated she asked CNA B to get a hat so she could collect specimens on Resident # 1. CNA B put the hat in the toilet and the LVN followed Resident # 1 in a wheelchair to her room into the restroom. Resident #1 was in the restroom and pulled up to the toilet in front of LVN. Resident # 1 grabbed the bar and pulled herself to a standing position and LVN held onto the back of Resident #1's pants while Resident #1 was standing. Resident #1 was sitting on the toilet and LVN left the faucet water running to encourage Resident #1 to urinate. LVN advised and confirmed with Resident #1 that she was going to step out and for Resident #1 to pull the call light when she finished. Resident #1 acknowledged LVN by saying okay. LVN left Resident #1's bathroom door open and the room door slightly open for privacy and LVN went to the medication cart just outside Resident # 1 's room. LVN stated when she was popping pills Resident #1 had closed the door. LVN knocked on the door and attempted to open it and Resident #1 stated she was on the floor. LVN hollered to an employee (could not recall a name) that Resident # 1 was on the floor and to get the DON. Maintenance and DON came to the door. LVN told DON Resident #1 was on the floor right in front of the door. DON asked Maintenance if he could get into Resident #1s room from the outside window. The DON and maintenance took off to the backdoor and within minutes the DON was inside. LVN heard DON call out to Resident #1 that she was coming into the room. LVN did not witness what took place once the DON entered the room. Resident #1 was sitting in her wheelchair when the door opened. LVN asked Resident #1 if she was having any pain and Resident # 1 stated her back was hurting. Resident # 1's vitals were taken, and she became nauseous. Resident #1 vomited and 911 was called. LVN called the emergency room to give nurse to nurse report while Resident # 1 was en route to the hospital. LVN stated she would not have left Resident #1 on the toilet if she was not physically or mentally competent. LVN stated she did not neglect Resident#1 she gave Resident #1 privacy and left both doors open. LVN instructed Resident#1 to pull the call light when she was finished. LVN stated to Resident#1 that she would be right outside the door. LVN stated that she believe Resident #1's fall was an accident and not neglect. Interview on 12-19-2022 at 12:50 PM with CNA B stated the LVN took Resident #1 to her room for a urine specimen on 12-07-2022. CNA B states she did not know LVN left Resident #1 in her room. CNA B stated she retrieved the hat for LVN. CNA B stated Resident #1 is to be assisted with toileting. CNA B states Resident # 1 should not have left as she is to be assisted with toileting. CNA B stated Resident #1 incident was an accident and not neglect. Interview with DON 12-19-2022 at 1:16 PM stated Resident #1's incident was more of an accident. DON stated if she felt Resident # 1 incident was neglect there would be a suspension. DON stated Resident #1's wheelchair potentially may have gotten caught by her dresser. Resident #1's wheelchair never folded and was on the right side along with Resident #1. DON stated wheelchair wheels tend to turn in different ways and she did not suspect any neglect. Record review of the facility's fall risk managing dated July 2019 policy revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on interview and record review the facility failed to ensure Resident # 1 received adequate supervision and assistance to prevent a fall for 1 of 5 residents reviewed for accidents and supervision. (Resident #1) The facility failed to ensure Resident #1 remained free of falls to prevent an accident. The facility failed to ensure Resident #1's assistance with toileting routinely was followed. These failures could place residents at risk for falls for possible injuries due to lack of supervision. Findings Include: Review of Resident #1's undated face sheet reflected an [AGE] year-old female was admitted to the facility on [DATE] with a diagnosis of dementia (memory loss), Cognitive communication deficit (difficulty thinking), [CONDITION(S)] (difficulty falling asleep), [CONDITION(S)] (under production of hormone), hyperlipemia (increased cholesterol), and hypertension (high blood pressure). A review of Resident #1's MDS dated [DATE] revealed Resident#1's BIMS Summary score of 5 indicated severe cognitive impairment. Review of Resident #1's care plan dated 11-30-2022 revealed Resident #1 is at risk for falls, impaired mobility, impaired cognition with impaired safety awareness, and impaired judgment. Review of Resident # 1's care plan dated 11-30-2022 revealed Resident #1 ADLs revealed Resident #1 has self-care deficits, impaired cognition, and impaired mobility. Ambulation/Transfers amount 1 staff assist able to walk with a walker and use a wheelchair. Review of Resident #1's care plan dated 11-30-2022 revealed that Resident #1 is incontinent of bowel and bladder and needs assistance with toileting routinely. Review of Resident #1's progress notes dated 12-7-2022 revealed Resident #1 noted an unwitnessed fall. Review of Resident #1's progress notes dated 12-07-2022 revealed Resident #1 hollered out I'm in here on the floor. when LVN tried to open Resident #1's door. Review of Resident # 1's investigation summary dated 12-07-2022 revealed the Administrator interviewed Resident #1. Resident # 1 stated she asked the LVN to step out of the room and give her some privacy. Resident #1 began to holler that she fell and hurt her back. The DON and the LVN attempted to access Resident # 1 through the door but the door was blocked by Resident # 1. Maintenance assisted the DON to access Resident #1's room through the window. Resident #1 stated that she had fallen and hurt her back. Review of Resident #1's physician documentation dated 12-07-2022 revealed Resident #1 presented to the emergency room with complaints from a fall injury. The fall was unwitnessed, but staff (not named) heard it occur. Resident #1 fell against the door and nursing home staff had to rescue her by going through a window. Review of Resident # 1's hospital notes dated 12-07-2022 revealed Resident # 1 was found to have a right femoral neck fracture. Hip fracture of the thigh bone (femur) just below the ball and socket hip joint that would need surgical intervention. Resident #1 was transferred to a local hospital and admitted to Internal Medicine. Interview on 12-18-2022 at 3:33 PM with CNA A stated LVN told Resident #1 that a urinalysis was needed on 12-07-2022. LVN took Resident #1 from the nurse's station to Resident #1's room. LVN put Resident #1 on the toilet and she left. CNA A could not recall the length of time Resident #1 was left alone. CNA A stated Resident #1 should not have been left alone. CNA A was alerted by LVN that Resident # 1 was on the floor. CNA A stated she went to the door and was not able to open it. DON notified maintenance and they both went to Resident #1's outside window and the DON crawled through Resident # 1 window. CNA A stated she witnessed from outside of Resident # 1's door. When the door was opened CNA A saw Resident #1 laying on the floor up against the door and the wheelchair laying on it's side, beside Resident # 1. Interview on 12-18-2022 at 4:30 PM with maintenance stated he was en route when he heard that Resident # 1 had fallen. When it was determined that Resident #1 had the door blocked, he went to the outside window and jimmied the window lock with a pocketknife to flip the locks back. Maintenance stated Resident #1's windows were not open. The DON went through the window and the only thing he saw was Resident # 1 laying up against the door with her wheelchair beside her. Interview on 12-18-2022 at 4:41 PM with DON stated LVN came and told her that Resident #1 had fallen and LVN could not get the door open. DON spoke with Resident #1 through the door making sure Resident # 1 was competent. Resident # 1 advised the DON she was not able to get up. DON notified maintenance at the nurse station for assistance. DON and maintenance went outside to Resident # 1's window and maintenance popped the window locks and DON climbed in to assist Resident # 1. DON assessed Resident #1 and Resident # 1 stated her lower back was hurting. DON made the judgment to send Resident # 1 out for further evaluation. The DON stated she does not suspect any neglect with the incident of LVN and Resident #1. Interview on 12-18-2022 at 5:00 PM with the Administrator stated that the self-report summary was based on the interview of Resident # 1 and the LVN. No neglect was suspected with LVN and if any neglect had been suspected the LVN would not still be at the facility. Interview on 12-19-2022 at 11:05 AM with LVN stated CNA A and CNA B brought Resident #1 down the hall from the nurses station on 12-07-2022. LVN stated to CNA B that a urinalysis would need to be conducted. LVN stated she asked specifically to CNA B if Resident # 1 could go to the toilet and CNA B stated yes. LVN stated she asked CNA B to get a hat so she could collect specimens on Resident # 1. CNA B put the hat in the toilet and the LVN followed Resident # 1 in a wheelchair to her room into the restroom. Resident #1 was in the restroom and pulled up to the toilet in front of LVN. Resident # 1 grabbed the bar and pulled herself to a standing position and LVN held onto the back of Resident #1's pants while Resident #1 was standing. Resident #1 was sitting on the toilet and LVN left the faucet water running to encourage Resident #1 to urinate. LVN advised and confirmed with Resident #1 that she was going to step out and for Resident #1 to pull the call light when she finished. Resident #1 acknowledged LVN by saying okay. LVN left Resident #1's bathroom door open and the room door slightly open for privacy and LVN went to the medication cart just outside Resident # 1 's room. LVN stated when she was popping pills Resident #1 had closed the door. LVN knocked on the door and attempted to open it and Resident #1 stated she was on the floor. LVN hollered to an employee (could not recall a name) that Resident # 1 was on the floor and to get the DON. Maintenance and DON came to the door. LVN told DON Resident #1 was on the floor right in front of the door. DON asked Maintenance if he could get into Resident #1s room from the outside window. The DON and maintenance took off to the backdoor and within minutes the DON was inside. LVN heard DON call out to Resident #1 that she was coming into the room. LVN did not witness what took place once the DON entered the room. Resident #1 was sitting in her wheelchair when the door opened. LVN asked Resident #1 if she was having any pain and Resident # 1 stated her back was hurting. Resident # 1's vitals were taken, and she became nauseous. Resident #1 vomited and 911 was called. LVN called the emergency room to give nurse to nurse report while Resident # 1 was en route to the hospital. LVN stated she would not have left Resident #1 on the toilet if she was not physically or mentally competent. LVN stated she did not neglect Resident#1 she gave Resident #1 privacy and left both doors open. LVN instructed Resident#1 to pull the call light when she was finished. LVN stated to Resident#1 that she would be right outside the door. LVN stated that she believe Resident #1's fall was an accident and not neglect. Interview on 12-19-2022 at 12:50 PM with CNA B stated the LVN took Resident #1 to her room for a urine specimen on 12-07-2022. CNA B states she did not know LVN left Resident #1 in her room. CNA B stated she retrieved the hat for LVN. CNA B stated Resident #1 is to be assisted with toileting. CNA B states Resident # 1 should not have left as she is to be assisted with toileting. CNA B stated Resident #1 incident was an accident and not neglect. Interview with DON 12-19-2022 at 1:16 PM stated Resident #1's incident was more of an accident. DON stated if she felt Resident # 1 incident was neglect there would be a suspension. DON stated Resident #1's wheelchair potentially may have gotten caught by her dresser. Resident #1's wheelchair never folded and was on the right side along with Resident #1. DON stated wheelchair wheels tend to turn in different ways and she did not suspect any neglect. Record review of the facility's fall risk managing dated July 2019 policy revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on observations, interviews, and record review the facility failed to ensure that the resident was free from misappropriation of resident property and exploitation for 1 of 5 (Res # 1) reviewed. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This deficient practice could place residents at risk of being exploited by staff. Findings included: Res# 1 is a [AGE] year-old, Caucasian female admitted to the facility on [DATE]. Res. # 1 has the current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 5/10/2022 at 1:47pm with Res# 1 revealed, that the resident has been required to pay a daily fee to staff for keeping and caring for her dog in her home. Res#1 stated she was not in agreement for paying this fee to staff. Res#1 stated having to pay the staff made her angry, sad, frustrated, agitated and has caused her anxiety to increase Res #1 began to cry. Res #1 stated she was informed by the ADM that she would no longer be able to keep the dog at the facility due to her not being able to care for the dog appropriately. Res#1 indicated that she was advised that there were several complaints made about the dog from other residents and family members. Res#1 stated she was told by the ADM that the BOM would be taking the dog and caring for the dog. Res. # 1 stated the BOM never said anything about charging Res#1 for keeping the dog. Res#1 stated there was never any agreement written or verbal about the charges she would be required to pay. Res#1 stated she was given a bill from the BOM with the amount she was charging Res#1 for keeping the dog. Res#1 stated she paid the BOM $460 in cash. In an interview on 5/11/2022 at 10:30a.m, the BOM revealed, had been in this position since Oct. 2021. She stated the expectation and policy was no employee accepted money or gifts from the residents. She stated, she took the dog because Res#1 had nowhere for the dog to go when she was advised she could no longer have the dog at the facility. The BOM stated she thought it was only going to be for a few days when Res#1 was a scheduled to move but the resident has yet to move. The BOM stated she prepared and presented RES#1 with an invoice in the amount of $420, outlining the dates and the amount charged for feeding and caring for the dog from 3/11/2022-3/31/2022. She stated Res#1was being charged $20 dollars per day for boarding the dog. The BOM stated she has tried to take the dog to two different animal shelters; however, they have refused to take the dog. She stated she was suspended from her job until she had returned Res#1 her money and gotten rid of the dog. The BOM stated she still has Res#1s' dog in her possession waiting to hear back from the sheriff department today. In an interview on 5/10/2022 at 4:30p.m., the ADON revealed, that was the expectation and policy of the facility that staff are not to accept money and or gifts under no circumstances from the residents. The ADON stated this was Misappropriation / Exploitation of the resident and must be reported immediately to the ADM who was the abuse/neglect coordinator. The ADON stated the BOM did keep the resident's dog in her home and the BOM had had the dog since March 2022. The ADON stated, Res#1 told her she paid the BOM $460 for keeping her dog. The ADON stated the BOM had a contract with Res#1 regarding the terms and the payment, she stated she was not sure if Res#1 signed the agreement. In an interview on 5/10/2022 at 5:07p.m., the DON revealed, that it was the expectation of the facility and policy that no employee shall accept any money or gifts from the residents for any reason. The DON stated this would be considered exploiting the resident to get money from a resident. The DON stated when he learned of the situation that took place he suspended the employee pending an investigation. The DON stated he believed the BOM accepted a total of around $400 dollars from Res#1. The DON stated the BOM was willing to keep Res#1 dog for money is not ok. He stated the BOM would be paying Res#1 back all the money she accepted, he stated she will be trained on Abuse, Neglect, and Misappropriation /Exploitation of a resident. The DON stated he was not aware if the money has been returned to Res#1 as the BOM reported directly to the ADM. In an interview on 5/11/2022 at 9:30a.m., the ADM revealed, it was the expectation and policy that no employee shall accept money or gifts from the residents. The ADM stated the BOM already was in possession of Res#1 dog when she started in this position February 2022. She stated the previous ARD from the corporate office went over the pet policy with Res#1 explaining that she would be 100% responsible for caring for the dog. The ADM stated Res#1 was not able to care for the dog and was advised that she could no longer have the dog at the facility. The ADM stated the BOM stated she would take the dog for a few days which turned into now a couple of months. The ADM stated on 05/05/22 she became aware the BOM charged Resident #1 at total of $460.00 for the care of the dog. The ADM stated the BOM had provided her a written agreement between the BOM and Res #1. The ADM stated Res #1 had not signed the agreement. The ADM contacted the facilities legal department and the BOM was suspended pending the internal investigation. The ADM stated she contacted the shelter where Res #1 originally adopted the dog so the dog could be returned. The BOM attempted to return the dog back to the shelter, however they would not accept the dog back. The ADM stated the BOM will be in-serviced on abuse, neglect, and exploitation of residents. She stated a safe survey would be completed with all residents at the facility. Review of BOM's invoice provided to Res#1, dated 3/31/2022 revealed the following: The invoice was dated 3/31/2022 and stated: Keeping [NAME] for Res #1 until she moves out of [NAME] Healthcare Center. 3/11/2022-3/31/2022= 21 days @ $20.00 a day for boarding and care = $420.00. If [NAME] remains in the care of BOM after 4/1/2022 fees will continue at $20.00 a day until pet is picked up or signed over to BOM. Please remit payment to BOM in cash. Review of the facility's Pet, Animals, and Plants policy dated August 2021 revealed, Policy Statement: The administrator has the authority to allow or prohibit Residents to have pets live at the center. Resident Pets are restricted to dogs and cats. Fulltime live- in residents: 2. The resident and or resident's responsible representative accepts all responsibility for the care of the pet, cost of foods and supplies, veterinary visits and maintaining current vaccinations. 3. Current pet vaccination records for the per are provided to the center administrator before admission and kept on file for survey and infection control audits. 10. Pets that are disruptive, destructive. Loud, aggressive, unable ability to contain urine or feces or vomiting will be immediately removed from the center. If the resident or family is unable to immediately remove the pet, animal control may be contacted. Safety Precautions: 3. Any dog that shows aggressive or inappropriate behavior, including lunging, growling, or biting will be immediately removed from the center and visiting privileges will be revoked. Review of facility's policy, Abuse Prevention Program dated May 2020 revealed, 2. Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. 4. Our facility will implement and permanently maintain an effective training program for all staff which includes at a minimum abuse, neglect, exploitation, misappropriation of resident property that is appropriate an effective. 7. All reports of resident abuse, neglect, exploitation, misappropriation of resident property shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. 8. Our facility will provide protection for the health, welfare and rights of each resident residing in the facility 9. All occurrences of abuse, neglect, misappropriation of resident property will be analyzed by the Quality Assurance and Performance Improvement (QAPI) committee to determine system changes need to be made. In-Services reviewed revealed: 5/3/2022- Abuse, Neglect, Exploitation training was conducted with staff

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and support the physical, mental and psychosocial well-being for twelve (CR #1 - CR #9, Resident #16, Resident #19, and Resident #22) of twenty-one residents reviewed for activities, in that: The facility failed to provide an activity program designed to meet the interests or needs for CR #1 - CR #9, Resident #16, Resident #19, and Resident #22. This deficient practice placed residents at risk for a diminished quality of life, isolation, lack of stimulation, and a decline in mental status. The findings included: Review of the facility's activity calendars for August, September, October, and November of 2021 reflected no scheduled activities after 11:00 AM. During an interview on 10/8/21 at 10:12 AM with the AD, she stated she only worked until noon Monday - Friday. She stated she wished she was allowed to work more hours, but the ADM would not allow it. She stated she tried to cram a lot of activities in the morning to ensure several activities were conducted daily. When asked what the residents had planned for the afternoons and weekends, she stated she hoped the staff were doing something with them. She stated a church volunteered once a month on a Sunday to provide a small church service. She stated the residents complained about not having more activities, but she could only do what she was allowed to do. She stated the importance of activities was to give the residents socialization, stimulation, and things to look forward to. During a confidential interview on 11/9/21 with nine alert and oriented residents , they stated it was not fair they did not have any activities after lunch time. They stated they loved the AD and she did everything she could and she should be allowed to work more hours. They stated they were bored in the afternoons and on weekends, they just sleep or watch TV. They stated they look forward to mealtimes because at least that provided some kind of socialization. They stated they never got to go on outings unless it was to a doctor's appointment. They stated the lack of stimulation and socialization had caused them to be more reclused and depressed. Review of Resident #16's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #16's most recent MDS, dated [DATE], reflected a BIMS of 15, indicating no cognitive impairment. Review of Resident #16's care plan, dated 10/27/21, reflected she had the potential for lack of participation in activities due to physical limitations with interventions of inviting her to activities daily and to include her in the discussion of what activities and games to plan for the month. Review of Resident #22's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #22's most recent MDS, dated [DATE], reflected a BIMS of 11, indicating a moderate cognitive impairment. Review of #22's care plan, dated 10/25/21, reflected she had the potential for lack of participation due to physical limitations with interventions of inviting her to activities daily and including her in the discussion of what activities and games to plan for the month. During an interview on 11/9/21 at 1:40 PM with Resident #16 and Resident #22, they stated the lack of activities has made them feel depressed and feel like their personality has changed. Resident #16 stated she used to be social and would be out of her room all day. She stated she has found that she stays in her room all the time now. She stated there was nothing to do but sleep. They stated they felt like their quality of life had diminished and were more anxious. They stated they needed more activities for brain stimulation. They stated they could not even go on outings because the facility van was used for transfers to doctor appointments. They stated they would enjoy just going for a drive, having a dance or party, a cooking class, movie night, arts and crafts. They stated they just needed something to look forward to, every day was the same mundane thing, and it was hard to get up in the morning. They stated all they had to look forward to was watching TV and smoke breaks. Review of Resident # 19's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's most recent MDS, dated [DATE], reflected a BIMS of 15, indicating no cognitive impairment. Review of Resident #19's care plan, dated 10/12/21, reflected the goal was for her to attend/participate in one activity per week with the intervention of evaluating time awake and readiness for activity. Review of Resident #19's care plan, dated 10/12/21, reflected she had a problem regarding the state of her mood with interventions of encouraging her to be involved in group activities. During an interview on 11/9/21 at 3:55 PM with Resident #19, she stated there needed to be activities in the afternoon and on weekends. She stated with nothing to do, she just goes to sleep and wakes up for dinner. It made her extremely sad, as evident as she was tearful through the entire interview. She stated she was an introvert, so it took a lot of energy to just go up and talk to people in general if there was nothing going on. She stated her depression had worsened to the point that it hurt her tummy. During an interview on 11/9/21 at 2:47 PM with LVN C, she stated she noticed that the residents are more irritable and reclused in their rooms in the afternoons and weekends because there was absolutely nothing going on and they had nothing to do. During an interview on 11/10/21 at 12:31 PM with the RegNM, she stated if the AD was not working in the afternoon, the staff should be running the scheduled activities. She was unaware no activities were scheduled in the afternoons or weekends. She stated it was unacceptable. She stated her expectations for an activity program was to help stimulate the residents, provide socialization and excitement. She stated without a structured program, it could lead to the residents becoming depressed, developing behaviors, and a decreased quality of life. During an interview on 11/10/21 at 1:35 PM with the ADM, he stated their activity program had room for improvement. He stated they should be offering more activities and activities that were based on each residents' needs and function. Review of Resident Council minutes, dated 11/4/21, reflected the residents wanted the AD to work more hours and there needed to be more activities. One resident expressed she did not want to do activities in the morning because she liked to sleep late. A facility policy regarding activities was requested on 11/10/21 at 8:02 AM from the RCSN but was not provided prior to exit.

Based on observation and interview, the facility failed to have the results of the most recent survey of the facility posted in a place readily available to residents, family members and legal representatives, in that: The facility failed to post the results of the past surveys by the State Agency. This failure could affect residents, potential residents, and family members by denying them information about the practices and level of regulatory compliance demonstrated by the facility. The findings included: Observation on 11/8/21 at 7:22 AM revealed no State Survey results binder or sign stating that the results were available visible in the lobby. During an interview on 11/9/21 at 8:50 AM with the SW, she stated she only worked at the facility one day a week. She stated she was not entirely sure what a State Survey results binder was, but perhaps it was at the nurse's station. During an observation and interview on 11/9/21 at 8:53 AM with the DON, she stated the binder with the past state surveys was in the lobby on the bookshelf. She went into the lobby and looked everywhere but could not find it. She stated it was chained to a table in the lobby, but it must have walked off as some of their residents had sticky fingers. During an interview on 11/9/21 at 8:56 AM with the AD, she stated she had never seen a binder of any kind that was labeled with State Survey Results, nor did she know what that was. During an interview on 11/9/21 at 10:21 AM with the MAINTD, he stated he had worked at the facility for two years and had never seen a State Survey binder. During a confidential interview on 11/9/21 at 10:30 with nine confidential residents, none of them knew what a state survey binder was. They stated they did not know it was their right to be able to read past State surveys. During an interview on 11/10/21 at 12:31 PM with the Reg NM, she stated the survey results binder should be visibly posted up front. She stated it was important because any visitor, family member, or resident had the right to review it at any time. During an interview on 11/10/21 at 1:35 PM with the ADM, he stated the survey result binder should be on a bookshelf in the lobby. He stated he was not aware it was not there. A facility policy was requested from the RCSN for the requirement of having the State Survey results readily available on 11/10/21 at 8:02 AM but was not provided prior to exit.

Based on interview and record review, the facility failed to implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. The facility's infection prevention and control program did not implement a facility-wide system to monitor the use of antibiotics and did not develop and implement protocols to optimize the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings included: During an interview on 11/8/21 at 11:13 AM the DON stated HSK F was the facility IP as she had completed the CDC training and had the certificate. The DON stated that she was working on the training and so far, had completed nine of the modules. She stated she had given training on infection control. During an interview on 11/9/21 at 11:40 AM HSK F stated she had completed the training but she was not the facility IP, she only helped with infection control within the housekeeping department. She stated she was not a nurse and did not have a degree in any related field. Review of the facility infection control documents reflected a facility map highlighting the location of the infections. During an interview on 11/10/21 at 12:24 PM the RegNM explained the role of the Infection Preventionist to the DON. The DON stated she did not know there were so many different aspects to the IP duties. She stated there was no antibiotic tracking, no person acting as the IP, and no meetings regarding the program. She stated not having an Infection Preventionist in the building could lead to clusters not being found or using the wrong antibiotic. During an interview on 11/10/21 at 1:35 PM the ADM stated since the DON was not certified, the facility had not had anyone in the Infection Preventionist role since July. Not having someone in that role could increase the chances of infections. The facility would have to find someone to fill that role. Review of the facility Infection Prevention and Control Program policy dated October 2020, reflected in part, Coordination and oversight A. The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist). Antibiotic Stewardship A. Culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activities. B. Medical criteria and standardized definitions of infections are used to help recognize and manage infections. C. Antibiotic usage is evaluated, and practitioners are provided feedback on reviews.