Every finding on record at San Antonio Wellness & Rehabilitation

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for nutrition services.The facility failed to ensure the commercial bar soda/juice gun dispenser was free from dirt and debris buildup.The facility failed to ensure that the DNS, Cook, and Dietary Aide were wearing hair restraints during food preparation during the initial brief tour of the kitchen.The facility failed to ensure that the DNS, Cook, and Dietary Aide were wearing hair restraints appropriately during follow-up visits to the kitchen. The facility failed to ensure the DNS was practicing hand hygiene when exiting and reentering the kitchen during follow-up visits to the kitchen. The facility failed to ensure LVN-L was using proper hygienic practices and serving food under sanitary conditions during observation of the first meal upon entrance into the facility. These failures could lead to contamination and foodborne illness. Findings included:On 02/17/2026 at 9:15 AM the following was observed in the facility's only kitchen:DNS and [NAME] were not wearing hair nets.DNS and [NAME] did not have beard guards covering their facial hair (beard). The facility's commercial bar soda/juice gun dispenser handle had buildup of dried juice and dark slime on the inside of the handle.On 02/17/2026 at 12:45 PM the following was observed in one of the three dining rooms during the initial lunch service:LVN-L was observed passing out silverware and didn't sanitize or wash hands first.LVN-L was also observed touching a resident while patting her on the back. LVN-L didn't wash or sanitize his hands and proceeded to continue passing out the silverware to residents.LVN-L was observed pulling down his mask and wiping his nose with bare hands and then began putting ice into water cups and passing them out to residents without washing or sanitizing his hands.On 02/19/2026 at 10:45 AM the following was observed:Dietary Aide was observed going into the kitchen and back out wearing the same plastic gloves and not sanitizing or washing hands or changing gloves.Dietary Aide was also observed going into the kitchen and back wearing a baseball cap on his head with hair showing visibly on the sides and back of his head from under the cap and not wearing a hair net.Dietary Aide went into the kitchen and back out wearing a face mask pulled down past his beard around his neck without covering his beard with it.On 2/19/2026 at 11:30 AM the DNS was observed exiting the kitchen and returning to the kitchen on three separate occasions and did not wash his hands after reentering each time. In an interview on 2/19/2026 at 11:15 AM, the DNS said the commercial juice gun dispenser used for nectar water and other juices was sanitized nightly and deep cleaned two times per month. He said all dietary aid staff are responsible for cleaning the juice dispenser, but he did not have a cleaning log and could not confirm who had cleaned it last. DNS said the commercial juice gun dispenser needs to be cleaned properly to prevent bacteria from building up, which could make residents ill. During an interview and observation on 02/19/2026 at 11:38 AM Dietary Aide was observed sitting in the dining room directly across from the kitchen rolling silverware for meal service. He was observed wearing his beard guard on his chin. He entered the kitchen to demonstrate use of the commercial dishwasher. He did not wash or sanitize his hands upon entering the kitchen nor when returning to the dining room to handle silverware.In an interview on 02/19/2026 at 1:00 PM, LVN-L stated he has had infection control training. He stated he had training in infection control and yes you must keep your hands clean the nurses [NAME]. LVN-L said he had training online and understood the importance of infection control. He said washing hands, using PPE, and practicing infection control protocol was important, for example if you had a person that had shingles, you don't want to spread. He said, you mask up, gloves the whole thing, and wash your hands before you leave. He stated he sometimes just gets busy and forgets to wash and sanitize his hands when he served the lunch trays on 02/19/2026. He said, wow when he was told what procedure he was observed not following. He stated he does understand the importance of infection control, washing and sanitizing and following proper procedure. He said O, man, I just do it so much I didn't pay attention. LVN-L said he appreciated what was being brought to his attention and thanked the surveyor.During observation and interview on 02/20/2026 at 11:20 AM, Dietary Aide was observed rolling cutlery in the dining room, wearing gloves, a baseball cap without a hair net and a face mask below his chin exposing his facial hair. He was observed leaving the area and going back and forth into the kitchen. He was observed returning to the dining room back to his activity without changing out his gloves or washing and sanitizing hands. The Dietary Aide said he has received training on infection control, specifically hand washing, hair nets, beard coverings and gloves. He said practicing proper infection control is important because people touch everything with their hands and could spread their germs to others especially those with a weak immune system especially in a place like this. When non-compliance of hair net and hand hygiene was brought to his attention he said, Wow yea, yea, I did have gloves on. He said it is cross contamination when you wear something into one area then another area without practicing proper hand hygiene and without wearing a hair net and beard guard.In an interview on 02/20/2026 at 11:38 AM, the [NAME] said he has received training on infection control and hygiene procedures. He said he has had lots training. He said it is important to practice hand hygiene to avoid cross contamination. He said not following procedures could make a resident sick. When brought to his attention that he was not practicing proper hand hygiene and wearing a hair net or beard guard during the initial observation of the kitchen he insisted he was wearing a hair net and beard guard. He said cross contamination can cause a resident to become sick and he understood the importance of hand hygiene and wearing hair net.In an interview on 02/20/2026 at 11:51 AM, the DNS said he has received training on infection control, food handling, food temperature danger zones, the use of proper vendors and measurements. He said he is aware of cross contamination and understands it could make a resident sick. When brought to his attention the observation of him not wearing a hair net or beard guard during the initial observation of the kitchen he denied it. He also said he would be reviewing the facility recordings to confirm this information. He also added that he hasn't been employed here at the facility long and expressed he didn't want to get fired or be in trouble for not following facility procedures on hand hygiene and wearing hair nets and beard guard. Record review of the facility policy titled, Kitchen Sanitation - Operation and Cleaning dated 1/1/2025, reflected the following: To maintain the highest standard of cleanliness and sanitation in the facility's kitchen and food service areas, ensuring the safety and well-being of our residents by preventing food borne illness and complying with all state, local, and federal regulations. This policy applies to all staff in the dietary department, including dietary managers, cooks, dietary aides, registered dietitians, and any other staff or contractors working in or around the kitchen area. I. Staff Hygiene All kitchen staff must: A. Wash hands thoroughly before starting work, after breaks, after restroom use, changing tasks, before meal service, and after handling raw food or waste. C. Hairnets while in the kitchens, beard guard when needed, may where a cap with a hair net under cap. II. Cleaning and Sanitizing A. Daily Cleaning Tasks: ii. Sanitize countertops, carts, meal carts, beverage dispensers. III. Equipment and Utensils A. All food prep equipment must be: i. Cleaned and sanitized after each use. ii. Stored in a sanitary manner.Record review of the facility policy titled, Nutrition Services Personnel Guidelines dated 1/1/2026, reflected the following: To describe important personnel guidelines followed by Food and Nutrition Services to promoteprofessionalism within the department. The dietary department employs sufficient employees, competent employees, and employees who practice good hygiene while carrying out the functions of the department. Dress Code:XXV. Hair must be fully covered with a hairnet or hair bonnet always within the department. Hairnet must be worn regardless of the amount of hair. XXVI. Facial hair is to be groomed, and mustache and beards are to be covered with hair restraint (Beard Guard).Record review of the facility policy titled, Hand Hygiene Infection Control Manual dated 6/2020, reflected the following: To ensure that all individuals use appropriate hand hygiene while at the facility. The Facility considers hand hygiene the primary means to prevent the spread of infections. I. Facility Staff are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. Ill. Facility Staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents, and visitors. IV. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policy. V. Facility Staff and volunteers must perform hand hygiene procedures in the following circumstances including but not limited to .A. Wash hands with soap and water: i. Before eating; ii. After using the bathroom; iii. When soiled with visible dirt or debris; iv. After unprotected (ungloved and damaged gloves) contact with blood, other body fluids, secretions, excretions, mucous membranes, non-intact skin, intact skin soiled with blood and other body fluids, wound drainage and soiled dressings; v. After contact with intact and non-intact skin, clothing and environmental surfaces of residents with active diarrhea even if gloves are worn; vi. Before and after food preparation.Record review of the facility policy titled, Nutrition Services Department - General dated 1/1/2025, reflected the following: To ensure that the nutrition services department has the requisite organization to meet the nutritional needs of residents. I. The primary objectives of the nutrition services department include: C. Maintenance of standards for sanitation and safety. IV. Training Program A. The Dietary manager and/or Registered Dietitian are responsible for planning and providing nutrition staff with in-service education. B. In-service topics may include: v. Infection Control/Food Safety v. Sanitation. C. The Dietary Manager and/or Registered Dietitian is also responsible for the day-to-day education of nutrition staff regarding topics such as sanitation, food preparation, etc.

Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles and stored in locked compartments for 2 of 3 residents (Residents #36 and #21) and 1 of 11 medication carts reviewed for storage. 1. Resident #36's insulin Glargine (Lantus) Solos Flex Pen for diabetes had no open date, found inside 500 and 600-hall nursing cart on 02/18/2026. 2. Resident #21's insulin Novolog 70/30 Flex Pen for diabetes had no open date, found inside 200-hall nursing cart on 02/18/2026. 3. The facility failed to ensure 1 of 11 medication carts was kept locked or under direct observation of authorized staff in an area where residents could access it on 2/19/2026. These failures could place residents at risk of clinically significant adverse consequences and not having therapeutic effects by using old insulins. The findings were: 1. Record review of Resident #36's face sheet, dated 02/20/2026, revealed Resident #36 was a [AGE] year-old male and admitted to the facility 05/05/2023 and re-admitted to the facility 02/11/2026 with diagnoses of influenza (an infection of the nose, throat, and lungs), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), and hypertension (high blood pressure). Record review of Resident #36's admission MDS, dated [DATE], revealed the resident's BIMS score was 14 out of 15, which indicated the resident's cognition was intact, and the resident was receiving insulin injections every day as ordered. Record review of Resident #36's physician's order, dated 02/11/2026, revealed the resident had the order of Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine-Lantus) Inject 10 unit subcutaneously in the morning related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. Record review of Resident #36's medication administration record, dated from 02/01/2026 to 02/28/2026, revealed the resident was receiving Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine-Lantus) Inject 10 unit subcutaneously in the morning for type 2 diabetes mellitus at 8:00 am as ordered. Observation on 02/18/2026 at 1:44 p.m. revealed Resident #36's Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine-Lantus) Inject 10 unit subcutaneously in the morning for diabetes with no open date was found inside the 500 and 600-hall nursing cart. Further observation revealed the insulin pen had a label, and the label said, discard after 28 days. Interview on 02/18/2026 at 1:56 p.m. with RN-E stated Resident #36's Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine-Lantus) Inject 10 unit subcutaneously in the morning for diabetes with no open date was found inside the 500 and 600-hall nursing cart, and the insulin pen should have been discarded 28 days after opening it per the label from the insulin pen. If the insulin pen did not have any open date, nurses did not know when they have to discard the insulin pen. Interview on 02/18/2026 at 1:57 p.m. with DON said the facility nurses should have written open date on Resident #36's Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine-Lantus) Inject Pen because the label from the insulin pen said, discard after 28 days, and using old insulin might affect Resident #36 to not reach therapeutic effects. 2. Record review of Resident #21's face sheet, dated 02/20/2026, revealed Resident #21 was a [AGE] year-old male and admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (progressive disease that destroy memories and other important mental functions), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), and hypertension (high blood pressures). Record review of Resident #21's quarterly MDS assessment, dated 02/18/2026, revealed the resident's BIMS score was 4 out of 15, which indicated the resident had severe cognitive impairment, and the resident was receiving insulin injections every day as ordered. Record review of Resident #21's physician's order, dated 09/27/2025, revealed the resident had the order of NovoLOG Mix 70/30 FlexPen Subcutaneous Suspension Pen-injector (70-30) 100 UNIT/ML (Insulin Aspart Protamine & Aspart (Human)) Inject 36 unit subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9) Hold for blood sugar less than 100. Record review of Resident #21's medication administration record, dated from 02/01/2026 to 02/28/2026, revealed the resident was receiving NovoLOG Mix 70/30 FlexPen Subcutaneous Suspension Pen-injector (70-30) 100 UNIT/ML (Insulin Aspart Protamine & Aspart (Human)) Inject 36 unit subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9) Hold for blood sugar less than 100 for diabetes at 7:00 am. Observation on 02/18/2026 at 2:18 p.m. revealed Resident #21's insulin Novolog 70/30 Flex Pen for diabetes with no open date was found inside the 200-hall nursing cart. Further observation revealed the insulin pen had label, and the label indicated open and store at room temperature for 14 days. Interview on 02/18/2026 at 2:29 p.m. with DON stated Resident #21's insulin Novolog 70/30 Flex Pen for diabetes with no open date was found inside the 200-hall nursing cart, and the insulin pen should have been discarded 14 days after opening it because the label said, open and store at room temperature for 14 days. If the insulin pen did not have any open date, nurses did not know when they have to discard the insulin pen, and using old insulin might affect Resident #21 to not reach therapeutic effects, and the facility did not have specific policy for insulin but following professional guidelines. Record review of the professional guidelines, titled Mount [NAME] (https://www.mountsinai.org/health-library/special-topic/insulin-and-syringes-storage-and-safety), dated 06/20/2025, revealed Discard insulin after 28 days from the date of opening. 3. Unsecured Medication Cart Observation on 2/19/2026 at 2:26 PM revealed a medication cart unlocked and with no direct observation of authorized staff in the area. The medication cart was parked in the 300 hallways directly in front of the nurse's station. The charge nurses were in the middle of shift change. There were four residents sitting near the nurses' station roughly 6 feet away from the unsecured medication cart. In an interview and observation on 2/19/2026 at 2:45 PM, ADON was notified that the medication cart was left unlocked and has been unsupervised for more than 20 minutes. ADON immediately left the interview and proceeded to the unlocked medication cart to secure it. She notified the charge nurse that the cart was left unlocked. In an interview on 2/20/2026 at 12:51 PM, Medication aide-C said she was certified as a medication aide and certified nursing aide. She said she was provided with in-services on medication administration and securing medications. She said it is important to resident safety to secure medication carts and screens. She said the facility protocol is to make sure medication carts are always locked. She said the impact of leaving a medication cart opened and unsecure could negatively affect a resident as it would be a health concern and they could accidently take medications without knowing it and it could harm them or cause death from these actions. In an interview on 2/20/2026 at 1:07 PM, Medication aide-J said she receives training every 90 days on medication administration and securing medications properly. She said if there was an issue to be addressed, in-services were given immediately. She said securing medication carts was necessary for safety. She said only a handful of staff have access to keys. She said medication aids have access to keys, charge nurse also has access to keys. She said the impact of a medication cart staying unlocked was anyone could get into it, it would be a disaster, they could get wrong medications, can be taken out, and resident could have an allergic reaction or death. In an interview on 2/20/2026 at 1:17 PM LVN-K said medication carts should always be locked and for any reason if it was not locked staff should not be away from it. He said it was the responsibility of the charge nurse to ensure the medication cart is locked for their hallway. He said leaving a medication cart unlocked or unsecured can be dangerous for residents. He said staff were provided with training on medication administration and securing medications properly. He said he was not responsible for the 300-hallway medication cart and he was not aware of it remaining open the prior day. In an interview on 2/20/2026 at 1:47 PM, ADON said medication carts should always be locked unless they are physically taking something out from it. She said the impact of leaving a medication cart unlocked or unsecured could allow for a resident or family member to get into them and take something they shouldn't take. She said a resident could be harmed, have an allergic reaction and all kinds of dangerous outcomes. She said LVN-L was responsible for the medication cart that was left unlocked the prior day. She said LVN-L did not give the medication cart keys to the oncoming charge nurse prior to ending his shift at 2:00 PM. She said he should have switched it out and given it to the next charge nurse. She said it was not his cart and it was a cart that belonged to Medication aide-M, but the key was handed over to him after her count and ending her shift. She said Medication aide-M counted the medications with LVN-L and handed keys over to him. She said regularly medication aides will count with her at the end of their shifts, but she was busy yesterday, and Medication aide-M made the decision to do the count and hand over the medication cart keys to LVN-L, which occurs at times. She said some medication aides will finish their shift early and count out with the charge nurse for their hallway. She said no medications were taken by residents, but she understands there could be harm if this occurs in the future. She said she counseled LVN-L on the importance of securing medication carts. In an interview on 2/20/2026 at 2:01 PM LVN-L said he has been provided training and in-serviced on medication administration and securing medications. He said normally medication aids will count and hand off medication cart keys to the oncoming medication aid. He said if there is an issue with the count he would be notified. He said yesterday's shift he did not have an oncoming medication aide prior to the end of his shift so he was responsible for the end of shift count with Medication aide-M, and he had taken the medication cart keys from her. LVN-L said he was then responsible to hold onto the medication cart key until the next medication aide or charge nurse completes shift change and he hands the key over to them. He said all medication aids and charge nurses are responsible for securing the medication carts, and they should always be locked. He said if medication carts stay open medications could go missing. He said if the medications go missing the residents will not be able to get their medications and residents will have a very bad afternoon and night and be uncomfortable. He said he was made aware that he had left the medication cart open and unlocked the previous day. He said the ADON counseled him on this incident, and he did receive a write up. LVN-L said he will be more diligent with medication carts and ensure they are secure during his shift and at the end of each shift. Record review of the facility policy titled, Medication Storage dated 1/2026, reflected the following: Purpose To establish standards that safeguard residents by preventing unauthorized access to medications and ensuring compliance with applicable federal and state pharmacy regulations. Policy Medication carts must remain locked and always secured unless under direct and continuous supervision of authorized personnel during medication administration. These standards are required to ensure resident safety and regulatory compliance. Procedure Scope This policy applies to all licensed nurses, medication aides (where permitted, pharmacy staff, providers, and facility leadership. Security & Access Medication rooms, carts, and cabinets must remain locked at all times. Access is restricted to, authorized, licensed staff. Carts must be locked whenever they are not actively attended. 1. Locking Requirements The medication cart must be locked: When entering a resident's room (if the cart remains in the hallway) When turning away from the cart. Direct Observation Standard: A cart may remain unlocked only when it is continuously within the authorized staff member's direct, unobstructed line of sight, without requiring significant head turning or repositioning. 2. Key Control Requirements Key Security – Keys must always remain on the authorized staff member's person. – Keys must never be left in the cart lock, placed on the cart, left on surfaces, given to unlicensed personnel, or left unattended.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 2 (Resident #106 and #132) of 24 residents reviewed for infection control practices. 1. Medication Aide-C measured Resident #106's blood pressure without cleaning the blood pressure cuff on 02/19/2026. 2. When CNA-F was providing peri care to Resident #132 on 02/19/2026, CNA-F changed her gloves without washing or sanitizing her hands. This deficient practice could place residents at risk for cross contamination and infections.The findings included: 1. Record review of Resident #106's face sheet, dated 02/20/2026, revealed the resident was a [AGE] year-old male and admitted to the facility on [DATE] with diagnoses of aftercare following amputation (removal of a body part), heart failure (the heart can't pump enough oxygen-rich blood to meet your body's needs), and type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels). Record review of Resident #106's admission MDS assessment, dated 01/08/2026, revealed the resident's BIMS score was 15 out of 15 which indicated the resident's cognitive was intact and was Dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity) to chair to bed and toilet transfer. Record review of Resident #106's physician order, dated 01/05/2026, revealed Metoprolol Succinate Extended-Release Oral Tablet Extended Release 24 Hour 50 MG (Metoprolol Succinate) Give 1 tablet by mouth one time a day for hypertension HOLD MEDICATION FOR Systolic Blood Pressure <110, Diastolic Blood Pressure<60, and/orHeart Rate < 60. NOTFIY MD IF HELD. DO NOT CRUSH OR CHEW.[sic] Observation on 02/19/2026 at 8:40 a.m. revealed Medication Aide-C came out from another resident's room with a blood pressure cuff and machine. Further observation revealed the medication aide opened the computer and entered Resident #106's room and measured the resident's blood pressure without cleaning the blood pressure cuff and machine. During an interview on 02/19/2026 at 8:42 a.m. with Medication Aide-C stated she measured Resident #106's blood pressure without cleaning the blood pressure cuff and machine that she already used on another resident. The medication aide said she should have cleaned the blood pressure cuff and machine before measuring Resident #106's blood pressure to prevent possible infection, and it was her mistake. 2. Record review of Resident #132's face sheet, dated 02/20/2026, revealed the resident was an [AGE] year-old female and admitted to the facility on [DATE] with diagnoses of cerebral infarction (disruption to blood supply that is sever enough and ling enough in duration to result in tissue death), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), and hypertension (high blood pressure). Record review of Resident #132's admission MDS assessment was in progress because the resident was admitted to the facility on [DATE]. Record review of Resident #132's baseline care plan, dated 02/18/2026, revealed Monitor/document resident's abilities for Activity of Daily Livings and assist resident as needed. Encourage resident to do what he/she is capable of doing for self. Observation on 02/19/2026 at 10:30 a.m. revealed that while CNA-F was providing peri care to Resident #132, the CNA cleaned the resident's right and left groin area and genital area and turned the resident to side. Further observation revealed CNA-F changed her gloves without washing or sanitizing her hands and cleaned the resident's buttock and rectum area, then the CNA changed her gloves again without washing or sanitizing her hands. The CNA put the new brief under the resident and closed it. Interview on 02/19/2026 at 10:38 a.m. with CNA-F stated she just changed her gloves without washing or sanitizing her hands while she was providing peri care to Resident #132, and she said she should have washed or sanitized her hands whenever she changed her gloves to prevent infection. Interview on 02/19/2026 at 3:36 p.m. with DON said Medication Aide-C should have cleaned the blood pressure cuff and machine before using it to Resident #106, and CNA-F should have washed or sanitized her hands whenever she changed her gloves to prevent infection. Record review of the facility policy, titled Infection Prevention and Control Program, undated, revealed the ensure the facility establish and maintains an infection control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirement. Further record review of the facility policy, titled Perineal care, undated, revealed XII. Remove gloves. Wash hands or use alcohol-based hand sanitizer. XIII. Put on clean gloves.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (400-500-600-hall medication aide cart) out of 6 medication carts and 1 (Resident #73) out of 3 residents reviewed for pharmacy services. 1. There was one bottle of Nutricia Pro-Stat expired 01/02/2026 found inside 400-500-600-hall medication aide cart on 02/18/2026. 2. Facility nurses opened Resident #73's insulin pen (Glargine-Lantus) on 01/07/2026 and used the insulin on 02/18/2026. However, the label of the insulin indicated Discard 28 days after opening, and 28th day was 02/04/2026. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings included: 1. Observation on 02/18/2026 at 1:40 p.m. revealed there was one bottle of Nutricia Pro-Stat found inside 400-500-600-hall medication aide cart, and the bottle of Nutricia Pro-Stat for increasing protein needs was expired on 01/02/2026. Interview on 02/18/2026 at 1:42 p.m. with Medication Aide-C confirmed there was one bottle of Nutricia Pro-Stat expired 01/02/2026 found inside 400-500-600-hall medication aide cart, and she opened it on 02/16/2026 and used it. The Medication Aide-C said she did not know what reason she did not check the expiration date when opening it, and she stated she usually checked expiration date whenever she passed medications to residents. Interview on 02/18/2026 at 1:43 p.m. with DON stated there was one bottle of Nutricia Pro-Stat expired 01/02/2026 found inside 400-500-600-hall medication aide cart, it was used for increasing protein needs, and medication aides should have discarded all expired medications. Further interview with DON said using expired medications might affect that residents did not have therapeutic effects, such as decreasing protein. 2. Record review of Resident #73's face sheet, dated 02/20/2026, revealed the resident was a [AGE] year-old female and admitted to the facility on [DATE] with diagnoses of muscle wasting and atrophy (loss of skeletal muscle mass), anemia (not enough red blood cells), and type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels). Record review of Resident #73's admission MDS assessment, dated 02/12/2026, revealed the resident's BIMS score was 10 out of 15 which indicated the resident had moderate cognitive impairment and received insulin injection for type 2 diabetes mellitus as ordered. Record review of Resident #73's comprehensive care plan, dated 02/03/2026, revealed the resident had the care plan of The resident has Diabetes Mellitus. For interventions - diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Record review of Resident #73's physician order, dated 02/02/2026, revealed the resident had the order of Insulin Glargine (Lantus) Subcutaneous Solution Pen-injector 100 unit/ml - inject 10 unit subcutaneously at bedtime related to type 2 diabetes mellitus. Record review of Resident #73's medication administration record from 02/01/2026 to 02/28/2026 revealed the resident was receiving Insulin Glargine (Lantus) Subcutaneous Solution Pen-injector 100 unit/ml - inject 10 unit subcutaneously at bedtime related to type 2 diabetes mellitus every night at 08:00 p.m. as ordered. Observation on 02/18/2026 at 2:18 p.m. revealed there was one insulin Glargine (Lantus) Subcutaneous Solution Pen-injector 100 unit/ml inside 200-hall nursing cart, and on the Pen-injector open date was 01/07/2026. Further observation revealed the Pen-injector had label, and the label indicated Discard after 28 days once it was opened. Interview on 02/18/2026 at 2:18 p.m. with LVN-D said there was Resident #73's one insulin Glargine (Lantus) Subcutaneous Solution Pen-injector 100 unit/ml inside 200-hall nursing cart, and on the Pen-injector open date was 01/07/2026, and the label said, Discard after 28 days once it was opened. Further interview with LVN-D said facility nurses used the insulin every night and should have discarded it on 02/04/2026 because the date was 28th days after it was opened. Interview on 02/18/2026 at 2:29 p.m. with DON said facility nurses should have discarded Resident #73's one insulin Glargine (Lantus) Subcutaneous Solution Pen-injector 100 unit/ml on 02/04/2026 because the date was 28th days after it was opened per the label of the insulin Discard after 28 days once it was opened, and it might affect Resident #73 to not reach therapeutic effects. Record review of the facility policy, titled Medication-Administration, undated, revealed . V. Additional considerations include: . c. The Rule of 3 - the licensed nurse administering medications will perform 3 checks comparing the physician's order, pharmacy label, and medication administration record.

Based on observation, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice for 1 (Residents #77) of 4 residents reviewed for respiratory care. Resident #77's CPAP (continuous positive airway pressure) mask was not covered in a plastic bag when it was not used on 02/17/2026. This failure could affect residents with oxygen therapy and could lead them to lack of care including possible infection by not following infection control.The findings included: Record review of Resident #77's face sheet, dated 02/20/2026, revealed the resident was a [AGE] year-old female and originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of cellulitis of left lower limbs (skin infection), chronic pulmonary embolism (sudden blockage in a lung artery), anemia (not enough red blood cells), and sleep apnea (breathing stops and restarts many times while sleeping). Record review of Resident #77's Medicare-5 days MDS assessment, dated 02/13/2026, revealed the resident's BIMS score was 15 out of 15 which indicated the resident's cognition was intact and had non-invasive mechanical ventilator, which was CPAP (continuous positive airway pressure). Record review of Resident #77s physician order, dated 02/10/2026, revealed the resident had the order of apply CPAP (continuous positive airway pressure) at night and as needed at bedtime for sleep apnea. Observation on 02/17/2026 at 10:27 a.m. revealed Resident #77 was on the bed and watching television in her room. Resident #77's CPAP (continuous positive airway pressure) mask connected to a machine was on the nightstand uncovered. Interview on 02/17/2026 at 10:28 a.m. with Resident #77 stated she was using her CPAP (continuous positive airway pressure) every night when she was sleeping. Interview on 02/17/2026 at 11:33 a.m. with LVN-B stated Resident #77's CPAP (continuous positive airway pressure) mask was on the nightstand without a plastic bag. Further interview with LVN-B said the resident's CPAP (continuous positive airway pressure) mask should have been covered in a plastic bag when it was not used to prevent possible infection. Interview on 02/19/2026 at 3:36 p.m. DON stated Resident #77's CPAP (continuous positive airway pressure) mask should have been covered in a plastic bag when it was not used to prevent possible infections. Record review of the facility policy, titled Oxygen Administration, revised 06/2020, revealed . III. Infection control. B. Oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use.

Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards for 1 (Resident #6) of 1 resident reviewed for intravenous fluids. LVN-B flushed the medication port of Resident #6's central line (inserted central catheter: used to deliver medications and other treatments directly to the large central veins near the heart) with 10 ml normal saline when administering antibiotic dose. However, the physician order said, Flush IV (intravenous) line with 5 ml normal saline before and after medication administration. This failure could affect residents by placing them at risk for receiving diluted medication. Findings included: Record review of Resident #6's face sheet, dated 02/20/2026, revealed the resident was a [AGE] year-old female, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnoses of acute hematogenous osteomyelitis (infection that primarily affects the most vascularized regions of the growing skeleton), sepsis (the body's extreme response to an infection), peripheral vascular disease (slow and progressive disorder of the blood vessels), and dysphagia (difficulty in swallowing). Record review of Resident #6's significant change MDS assessment, dated 01/24/2026, revealed the resident's BIMS score was 0 out of 15 which indicated the resident had severe cognitive impairment, and the resident was dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) to chair to bed transfer. Further record review of the MDS assessment revealed the resident had intravenous therapy. Record review of Resident #6's comprehensive care plan, dated 02/26/2025, revealed The resident is on intravenous antibiotic therapy related to osteomyelitis. For intervention - administer medications as ordered. Record review of Resident #6's physician order, dated 01/21/2026, revealed flush intravenous line with 5 ml normal saline before and after medication administration Further record review of the physician order revealed Meropenem intravenous solution reconstituted 500 mg - use 500 mg intravenously every 6 hours for wound infection for 38 days. Observation on 02/19/2026 at 11:11 a.m. revealed Resident #6 had two lumens of central line (one was for medication port, and the other was for blood port) for intravenous therapy. LVN-B hung Resident #6's Meropenem 500 mg intravenous solution to a pole and flushed one lumen for medication port of the resident's central line with 10 ml normal saline, then connected the medication to the lumen for medication port. Interview on 02/19/2026 at 1:25 p.m. with LVN-B she stated she flushed the lumen for medication port of Resident #6's central line with 10 ml normal saline when administering the antibiotic dose. LVN-B said she thought the physician order said to flush 10 ml normal saline before and after medication, but the physician order said, flush intravenous line with 5 ml normal saline before and after medication administration. Further interview with LVN-B said she should have flushed the lumen with 5 ml normal saline as ordered to prevent possible damage of the central line. Interview on 02/19/2026at 3:36 p.m. with DON said LVN-B should have flushed the lumen with 5 ml normal saline before administering the antibiotic to Resident #6 because the physician order said, flush intravenous line with 5 ml normal saline before and after medication administration, flushing central line and following the physician order was nurse's responsibility, and it might cause some damage to the central line. Record review of the facility policy, titled Flushing guidelines for peripheral venous catheter, revised 02/2019, revealed 1. Peripheral intravenous catheter will be flushed prior to each infusion to assess catheter patency and function, and after each infusion to clear the catheter lumen of medication and to prevent contact between incompatible medications

Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Resident #4) reviewed for incontinence care. When LVN-A was providing incontinent care to Resident #4 on 02/19/2026, LVN-A did not clean the resident's left side area of buttock. These failures could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included: Record review of Resident #4's face sheet, dated 02/20/2026, revealed Resident #4 was a [AGE] year old male, admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with the diagnoses of epilepsy (happens as a result of abnormal electrical brain activity also known as a seizure), obstructive and reflux uropathy (a blockage in urinary tract), benign prostatic hyperplasia (prostate to increase in size), and down syndrome (genetic condition caused when an unusual cell division). Record review of Resident #4's Medicare-5 days MDS, dated [DATE], revealed the resident's BIMS score was 0 out of 15, which indicated the resident had severe cognitive impairment, and the resident was dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) to sit to stand, chair to bed transfer, and toilet transfer. Further record review of the MDS indicated Resident #4 had urinary indwelling catheter and was always bowel incontinent. Record review of Resident #4's comprehensive care plan, dated 07/06/2023, revealed the resident had the care plan of Check the resident frequently and as required for incontinence. Wash, rinse, and dry perineum. Change clothing as needed after incontinence episodes and check tubing for kinks and maintain the drainage bag off the floor for urinary indwelling catheter. Observation on 02/19/2026 at 2:27 p.m. revealed LVN-A washed her hands with water, put on gloves and gown, opened the old and dirty brief of Resident #4, then cleaned the resident's penis with a circular motion, right and left groin area, and scrotum area. LVN-A turned Resident #4 to side and cleaned the resident's rectum area because the resident had bowel movement and right buttock area, then put new and clean brief under the resident after changing gloves to new one without cleaning left buttock area of the resident. Interview on 02/19/2026 at 2:36 p.m. with LVN-A she stated she did not clean Resident #4's left buttock area. Further interview with LVN-A she said she was very nervous, so she forgot cleaning Resident #4's left buttock area, and the resident's left buttock was visually clean. LVN-A stated she should have cleaned the resident's left buttock area to prevent possible infection even though the area was visually clean. Interview on 02/19/2026 at 3:36 p.m. with DON stated LVN-A should have cleaned Resident #4's left buttock area even though the area was visually clean per the facility policy to prevent possible infection. Record review of the facility policy, titled Perineal Care, revised 06/2020, revealed . VII. Turn resident to side. VIII. Wash, rinse and dry buttocks and peri-anal area without contaminating perineal area.

Based on interviews and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for accuracy of medical records.LVN N failed to document Resident #1's wound care treatment on Resident #1's medication administration record for December 26, 2025.This deficient practice could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment.Findings included:Record review of Resident #1's undated face sheet revealed Resident #1 was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses that included encephalopathy (a disease in which the function or structure of the brain is affected, typically caused by infection, tumor, or stroke) and dementia (a general term for impaired ability to remember, think, or make decisions).Record review of Resident #1's quarterly MDS assessment dated , 12/07/2025, revealed Resident #1 had short term and long term memory deficits and severely impaired cognitive skills for decision making[KH2] . Section M- Skin revealed Resident #1 had 2 Stage III pressure injuries.Record review of Resident #1's comprehensive care plan revealed a care plan, dated 12/08/2023 and revised 11/14/2025, that revealed Resident #1 had potential for pressure ulcer development and had a Stage III pressure ulcer to the left medial foot and left medial foot superior. An intervention revealed, administer treatments as ordered and monitor for effectiveness.Record review of Resident #1's December 2025 MAR revealed an order, wound care: Left medial foot inferior, pressure injury; Cleanse with NS, pat dry: Apply [NAME] Blue to wound and cover with dry dressing: 3x week and PRN every day shift every Mon, Wed, Fri, order date 12/01/2025 and discontinued date 12/29/2025. The MAR revealed a check mark and staff member initials on 12/03/25, 12/05/2025, 12/08/2025, 12/10/2025, 12/12/2025, 12/15/2025, 12/17/2025, 12/19/2025, 12/22/2025 and 12/24/2025. On 12/26/2025, the MAR was blank. The MAR revealed an order, Wound care: Left medial foot superior, pressure injury: Clean everyday NS/WC, pat dry; Apply [NAME] Blue to wound bed, cover with dry dressing: 3x/week and PRN every day shift Mon, Wed, Fri., order date 12/01/2025 and discontinued date 12/29/2025. The MAR revealed a check mark and staff member initials on 12/03/25, 12/05/2025, 12/08/2025, 12/10/2025, 12/12/2025, 12/15/2025, 12/17/2025, 12/19/2025, 12/22/2025 and 12/24/2025. On 12/26/2025, the MAR was blank. During an interview with LVN A, 01/14/2026 at 1:30 p.m., LVN A stated when a wound care was completed for a resident, the nurse would sign the MAR for the wound care date and stated a blank on the MAR could have indicated that the treatment was not completed. LVN A stated she provided wound care to Resident #1 on 12/22/2025 and stated she was not sure if she was assigned to Resident #1 on 12/26/2025 and stated if she was assigned to Resident #1, she would have completed the wound care treatments by following the orders on the resident MAR.During an interview with Treatment Nurse J, 01/15/2026 at 10:35 a.m., Treatment Nurse J stated she was responsible for overseeing and performing resident wound care. Treatment Nurse J stated she completed Resident #1's wound care on 12/24/2025 and was off on 12/26/2025. Treatment Nurse J stated when she was off, the charge nurses or administrative nurses were responsible for completing resident wound care.During an interview with LVN N, 01/16/2026 at 12:00 p.m., LVN N stated she was the staffing coordinator at the facility and provided wound care to Resident #1 on 12/26/2025. LVN N stated she followed the treatment orders for Resident #1 on the MAR but forgot to document in the medical record. LVN N stated she remembered that she did not document the wound treatment on the MAR after she got home from her shift and tried to log into the medical record system but no longer had remote access. LVN N stated she planned to update Resident #1's MAR the following day but totally forgot.During an interview with the DON, 01/15/2026 at 2:44 p.m., the DON stated if the treatment nurse was not scheduled for the day, the charge nurse was responsible for performing wound care for residents according to their orders on the MAR. The DON stated when treatments were completed, the treating nurse was responsible for signing the MAR to indicate that a treatment was completed. The DON stated staff had received training on documentation and stated it was important to document in the clinical record, so the record indicated the treatment was completed.Record review of a facility policy titled, Documentation-Nursing date revised 01/2025, revealed, Nursing documentation will be concise, clear, pertinent, accurate and evidence based. Procedure 1. Nursing Documentation.H. Medication administration records and treatment administration records are completed with each medication or treatment completed. K. Documentation will be completed by the end of the assigned shift.

Based on interview and record review, the facility failed to ensure residents had the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed for one of one resident (Resident #1) reviewed for room change. The facility did not provide Resident #1 with a written notice prior to a room change or the right to refuse on 06/16/2025. This deficient practice could place residents at risk for being displaced without notice and/or reason to accommodate other individuals.Findings included: Record review of Resident #1's admission Record, dated 09/10/2025, revealed a [AGE] year-old female admitted on [DATE]. Resident #1 was listed as her own responsible party with [family member] listed as financial Power of Attorney and Emergency Contact #1. Record review of Resident #1's Medical Diagnoses, undated and accessed 09/10/2025, revealed diagnoses including acute (present or experienced to a severe or intense degree) on chronic systolic (congestive) heart failure (a long-lasting condition resulting from the gradual decrease in the heart's ability to pump blood out to the rest of the body), senile degeneration of brain (loss of intellectual ability associated with old age), and unspecified dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Census tab on Resident #1's EMR, undated and accessed on 06/10/2025, revealed Resident #1 was moved from room [ROOM NUMBER]-B-A (rehabilitation unit) to 205-B (secure unit) on 06/16/2025. Record review of Resident #1's significant change MDS, dated [DATE], reflected a BIMS score of 05, indicating severe cognitive impairment. Record review of Resident #1's care plan, undated and accessed on 07/11/2025, revealed Resident #1 was an elopement risk related to dementia and impaired safety awareness. Resident #1 was noted to reside in the secure unit. The care plan focus was initiated and revised on 06/16/2025. Record review of Resident #1's progress notes, dated 06/13/2025 (day of admission) to 06/17/2025 (day after transfer to secure unit), indicated no documentation or notification to resident or emergency contact #1 about why a room change was made. Record review of Resident #1's EMR on 06/10/2025 did not reveal documentation of a notification to and/or consent by the resident or emergency contact #1 for a room change. During an interview on 09/10/2025 at 09:00 a.m., Resident #1's family member and emergency contact #1 stated she was never notified about and did not provide authorization for the room change that happened to Resident #1 on 06/17/2025. The family member did not understand why Resident #1 had been moved to a secure unit. The family member recalled she found out about the room change when another family member went to visit Resident #1. She stated she was eventually told (unable to provide who told her or when) that Resident #1 had gone to the front desk and was asking where she (family member) was. The family member stated she got no phone call, letter or verbal explanation as to why Resident #1 was moved. During an interview on 09/10/2025 at 12:10 p.m., Resident #1 stated the facility is very nice and she gets along with almost everyone. She stated she currently had a private room but would like a roommate. She stated her prior roommate was moved after it was discovered the roommate was taking Resident #1's personal items to another room. Resident #1 did not state she wanted to leave the secured unit and did not state why she was on the secured unit. She stated the activities director took the residents outside to do fun activities and the staff were amazing. During an interview on 09/11/2025 at 02:14 p.m., the DON stated Resident #1 was moved to the secure unit due to having been exit seeking and combative. The DON stated the family was informed about the changes and had told her (the DON) to not call them about Resident #1. The DON stated Resident #1's emergency contact had told her that she did not want to be bothered with Resident #1 right then. The DON stated there was no signed consent for the room change. During an interview on 09/11/2025 at 02:14 p.m. (entered room during DON interview), the ADMIN stated there was not a signed consent for Resident #1's room change in her chart. He stated he was unaware if Resident #1's family was notified immediately about Resident #1's move to the secure unit or if they provided room change consent. He stated he was aware that Resident #1's family had told him, the DON, and the ADON not to contact them regarding Resident #1. He stated he did recall Resident #1 exhibited behaviors after admission but could not provide details of Resident #1's move to the secure unit. Attempted interview with MD C on 09/11/2025 at 03:22 p.m. Call back not received. Record review of policy titled, Resident Rights, date revised 08/2020, revealed All residents have a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility including those specified in this policy. The Facility will protect and promote the rights of the resident. A. Be informed about what rights and responsibilities he or she has. C. Choose a physician and treatment and participate in decisions and care planning, including involving representatives and considering personal and cultural preferences;.

Based on interview and record review, the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were complete and accurately documented for two of six residents (Resident #1 and Resident #2) reviewed for medical records accuracy. 1. The facility failed to ensure Resident #1's orders for facility admission and for secure unit admission were reflected in the active orders. 2. The facility failed to ensure Resident #2's orders for facility admission and for secure unit admission were reflected in the active orders. These deficient practices could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment.Findings included: 1. Record review of Resident #1's admission Record, dated 09/10/2025, revealed a [AGE] year-old female admitted on [DATE]. Resident #1 was listed as her own responsible party with [family member] listed as financial Power of Attorney and Emergency Contact #1. Record review of Resident #1's Medical Diagnoses, undated and accessed 09/10/2025, revealed diagnoses including acute (present or experienced to a severe or intense degree) on chronic systolic (congestive) heart failure (a long-lasting condition resulting from the gradual decrease in the heart's ability to pump blood out to the rest of the body), senile degeneration of brain (loss of intellectual ability associated with old age), unspecified dementia (a general term for impaired ability to remember, think, or make decisions), and essential (primary) hypertension (high blood pressure). Record review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 05, indicating severe cognitive impairment. Resident #1 was documented as having not exhibited any behavioral symptoms, including wandering. Record review of Resident #1's significant change MDS, dated [DATE], reflected a BIMS score of 05, indicating severe cognitive impairment. Resident #1 was documented as having not exhibited any behavioral symptoms, including wandering. Record review of Standard Assessment tab on Resident #1's EMR, undated and accessed on 06/10/2025 at 11:02 a.m., revealed one Elopement Risk Evaluation. The Evaluation had a risk score of 1.0, no risk. Record review of Resident #1's Elopement Risk Evaluation, dated and signed 06/13/2025, reflected Resident #1 was able to make decisions regarding daily living tasks and she was able to ambulate or mobilize in wheelchairs. The elopement risk evaluation had a score of 1.0, no risk for elopement. Record review of Resident #1's Elopement Risk Evaluation, dated and signed 06/13/2025, reflected Resident #1 was alert and oriented times 3, did not have a history of falls, was ambulatory, and had adequate vision. Resident #1 was noted to be able to stand but required assistance when standing and was unable to stand independently. She was documented as having taken 1-2 listed medications within the last 7 days. The care plan and interventions were not completed on the evaluation. The elopement risk evaluation had a score of 8.0, moderate risk for elopement. The risk evaluation was not completed or available in Resident #1's EMR until after investigation began, 09/10/2025 at 09:15 a.m. Record review of Resident #1's Order Summary Report, dated 09/11/2025 at 12:01 p.m., reflected no orders for admission to the facility or orders for secure unit placement. Record review of Resident 1's Order Recap Report, dated 09/11/2025 at 04:36 p.m., reflected the following orders:- Admit to [facility name] under the care of [MD C] for skilled services., noted as discontinued with order date of 06/13/2025 and end date of 09/11/2025. Discontinue notation included reason, Admit to secure unit. Order updated.- ***Late entry for 6/13/25***Admit to [facility name] under the care of [MD C] for skilled services for HYPERTENSIVE URGENCY, noted as discontinued with order date of 06/15/2025 and end date of 06/16/2025. Discontinue notation did not include reason.- ***Late entry for 6/13/25***Admit to [facility name] under the care of [MD C] for skilled services for ACUTE ON CHRONIC SYSTOLIC (CONGESTIVE) HEART FAILURE, noted as discontinued with order date of 06/16/2025 and end date of 07/03/2025. Discontinue notation did not include reason.- Admit to [facility name] under the care of [MD C] for long-term care/hospice on secure unit., noted as active with order date of 06/16/2025 and no end date. Order entered after investigation began, 09/10/2025 at 09:15 a.m. Record review of Order Audit Report, dated 09/11/2025 at 04:54 p.m., reflected the order Admit to [facility name] under the care of [MD C] for long-term care/hospice on secure unit., was created by the DON on 09/11/2025 at 04:48 p.m. Record review of Resident #1's care plan, undated and accessed 07/11/2025, revealed Resident #1 was an elopement risk related to dementia and impaired safety awareness. Resident #1 was noted to reside in the secure unit. The care plan focus was initiated and revised on 06/16/2025. During an interview on 09/10/2025 at 09:00 a.m., Resident #1's family member and emergency contact #1 stated she did not understand why Resident #1 had been moved to a secure unit. The family member stated she wanted Resident #1 back on the general population hall and out of the secure unit. The family member stated she voiced this request to the facility during the care planning meeting. During an observation and interview on 09/10/2025 at 12:10 p.m., Resident #1 stated the facility is very nice and she gets along with almost everyone. She stated she currently had a private room but would like a roommate. Stated her prior roommate was moved after it was discovered the roommate was taking Resident #1's personal items and taking them to another room. Resident #1 did not state she wanted to leave the secured unit and did not state why she was on the secured unit. She stated the activities director took the residents outside to do fun activities and the staff were amazing. Resident #1 did not appear upset, stressed, or agitated during the conversation and subsequent observations regarding her placement in the secured unit. During an interview on 09/10/2025 at 04:18 p.m., the ADON stated residents did not have to have an order for placement on the secure unit if there was an elopement attempt. The ADON stated Resident #1 came to the facility for skilled services originally, not long-term care, but she tried to elope from the rehabilitation unit. She stated residents could be moved to the secure unit for their safety. During an interview on 09/11/2025 at 02:14 p.m., the DON stated Resident #1 did not have an order for placement on the secure unit and Resident #1 did not have an active order for admission to the facility. She stated Resident #1's admission order was inactivated on 06/30/2025, when Resident #1 began hospice services. She stated she was not sure why or who inactivated Resident #1's admission order. The DON stated Resident #1's move to the secure unit was care planned from the time of her transfer. During an interview on 09/11/2025 at 02:14 p.m. (entered room during DON interview), the ADMIN stated he could not provide details of why Resident #1's did not have orders for her move to the secure unit and he was just informed by the DON that Resident #1 did not have an admission order. 2. Record review of Resident #2's admission Record, dated 09/11/2025, revealed a [AGE] year-old female initially admitted on [DATE] and re-admitted on [DATE]. Resident #2's family member was listed as Resident #2's responsible party and guardian. Record review of Resident #2's Medical Diagnoses, undated and accessed 09/11/2025, revealed diagnoses including ataxia (impaired balance or coordination), delusional disorders (a type of mental health condition in which a person cannot tell what is real and what is imagined), paranoid (unreasonably or obsessively anxious, suspicious, or mistrustful) schizophrenia (a chronic mental illness characterized by delusions, hallucinations, and disordered thinking), unspecified dementia, and essential hypertension. Record review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS score of 13, indicating mild cognitive impairment. Resident #2 was documented as having not exhibited any behavioral symptoms, including wandering. Record review of Resident #2's Elopement Risk Evaluation, dated and signed 01/21/2025, reflected Resident #2 was not able to make decisions regarding daily tasks and was able to ambulate or mobilize in a wheelchair. She was noted as cognitively impaired and wandered aimlessly. She was noted as having ambulated and propelled self, and/or wanders and had intentionally or unintentionally attempted to leave the community. She was not noted as having verbalized a plan to elope. Interventions were noted for Wander guard and/or secure environment placement. The elopement risk evaluation had a score of 15.0, imminent risk for elopement. Record review of Resident #2's Order Summary Report, dated 09/10/2025 at 04:42 p.m., reflected no orders for admission to the facility or orders for secure unit placement. Record review of Resident 2's Order Recap Report, dated 09/11/2025 at 04:31 p.m., reflected the following orders:- Admit to [facility name] under the care of [MD C] for long-term care in the MCU On hold from 04/27/2025 22:50 [10:50 p.m.] to 05/04/2025 22:49 [10:49 p.m.] On hold from 07/09/2025 07:01 [07:01 a.m.] to 07/10/2025 07:00 [07:00 a.m.], noted as discontinued with order date of 01/21/2025 and end date of 07/10/2025. Discontinue notation did not include reason, but one hold order included reason, sent to ER for evaluation and one resume order included reason, return from ER. -- May admit to secure unit Dx: DELUSIONAL DISORDERS On hold from 04/27/2025 22:50 [10:50 p.m.] to 05/04/2025 22:49 [10:49 p.m.] On hold from 07/09/2025 07:01 [07:01 a.m.] to 07/10/2025 07:00 [07:00 a.m.], noted as discontinued with order date of 01/21/2025 and end date of 07/10/2025. Discontinue notation did not include reason, but one hold order included reason, sent to ER for evaluation and one resume order included reason, return from ER. - Admit to [facility name] under the care of [MD C] for LTC SERVICES., noted as discontinued with order date of 07/13/2025 and end date of 07/14/2025. Discontinue notation did not include reason.- ***Late entry for 7/13/25***Admit to [facility name] under the care of [MD C] for skilled services for HYPERTENSIVE URGENCY, noted as discontinued with order date of 07/14/2025 and end date of 07/15/2025. Discontinue notation did not include reason.- ***Late entry for 7/13/25***Admit to [facility name] under the care of [MD C] for skilled services for ATAXIA, UNSPECIFIED, noted as discontinued with order date of 07/15/2025 and end date of 08/25/2025. Discontinue notation did not include reason. Record review of Resident #2's care plan, undated and accessed 07/11/2025, revealed Resident #2 was admitted to and will reside in the facility's Memory Care Unit for ongoing care and supervision. R/T Diagnosis of: UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY & risk for elopement related to Elopement Evaluation risk score. Resides in MEMORY CARE UNIT. [Resident #2] is an elopement risk/wanderer AEB Disoriented to place, History of attempts to leave facility unattended, Impaired safety awareness, Resident wanders aimlessly, Significantly intrudes on the privacy or activities. The care plan focus was initiated on 01/21/2025 and created and revised on 03/20/2025. During an observation on 09/10/2025 at 11:58 a.m., Resident #2 was noted on the secure unit. Resident #2 was not interviewable. During an interview on 09/11/2025 at 09:15 a.m., Resident #2's resident representative and guardian stated Resident #2's care at the nursing facility had been amazing. She stated Resident #2 was provided the care she required, was aware Resident #2 was on the secure unit, and she and Resident #2 had not had any issues with the staff or other residents on the unit. Attempted interview with MD C on 09/11/2025 at 03:22 p.m. Call back not received. Record review of policy titled, Physician Orders, date revised 06/2020, revealed the purpose, This will ensure that all physician orders are complete and accurate. The policy statement revealed The Medical Records Department will verify that physician orders are complete, accurate and clarified as necessary. The Procedure included, VI. Documentation pertaining to physician orders will be maintained in the resident's medical record.

Based on observation, interview and record review, the facility failed to ensure residents were free from involuntary seclusion and any physical restraint not required to treat the resident's medical symptoms for one of six (Resident #1) residents reviewed for involuntary seclusion.The facility failed to ensure Resident #1 met criteria to remain on the secure unit per secure unit criteria.This failure could place residents who resided on the secure unit at risk for feelings of isolation and anxiety.Findings included:Record review of Resident #1's admission Record, dated 09/10/2025, revealed a [AGE] year-old female admitted on [DATE]. Resident #1 was listed as her own responsible party with [family member] listed as financial Power of Attorney and Emergency Contact #1. Record review of Resident #1's Medical Diagnoses, undated and accessed 09/10/2025, revealed diagnoses including acute (present or experienced to a severe or intense degree) on chronic systolic (congestive) heart failure (a long-lasting condition resulting from the gradual decrease in the heart's ability to pump blood out to the rest of the body), senile degeneration of brain (loss of intellectual ability associated with old age), and unspecified dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 05, indicating severe cognitive impairment. Resident #1 was documented as having not exhibited any behavioral symptoms, including wandering. Record review of Resident #1's significant change MDS, dated [DATE], reflected a BIMS score of 05, indicating severe cognitive impairment. Resident #1 was documented as having not exhibited any behavioral symptoms, including wandering. Record review of Standard Assessment tab on Resident #1's EMR, undated and accessed on 06/10/2025 at 11:02 a.m., revealed one Elopement Risk Evaluation. The Evaluation had a risk score of 1.0, no risk. Record review of Resident #1's Elopement Risk Evaluation, dated and signed 06/13/2025, reflected Resident #1 was able to make decisions regarding daily living tasks and she was able to ambulate or mobilize in wheelchairs. The elopement risk evaluation had a score of 1.0, no risk for elopement. Record review of Resident #1's Elopement Risk Evaluation, dated and signed 06/13/2025, reflected Resident #1 was alert and oriented times 3, did not have a history of falls, was ambulatory, and had adequate vision. Resident #1 was noted to be able to stand but required assistance when standing and was unable to stand independently. She was documented as having taken 1-2 listed medications within the last 7 days. The care plan and interventions were not completed on the evaluation. The elopement risk evaluation had a score of 8.0, moderate risk for elopement. The risk evaluation was not completed or available in Resident #1's EMR until after investigation began, 09/10/2025 at 09:15 a.m. Record review of Resident #1's Order Summary Report, dated 09/11/2025, reflected no orders for secure unit placement. Record review of Resident #1's care plan, undated and accessed 09/11/2025, revealed Resident #1 was an elopement risk related to dementia and impaired safety awareness. Resident #1 was noted to reside in the secure unit. The care plan focus was initiated and revised on 06/16/2025. The care plan also included Resident #1 was at risk for elopement related to Elopement Evaluation risk score, date initiated and created 09/10/2025 (day of investigation entry, 09/10/2025 at 09:15 a.m.). Record review of Resident #1's progress notes, dated 06/13/2025 (day of admission) to 06/17/2025 (day after transfer to secure unit), indicated no documentation or notification to resident or emergency contact #1 about why a room change was made. Record review of Resident #1's Care Plan Conference, dated 08/12/2025 and signed 08/18/2025, revealed Resident #1, Resident #1's emergency contact, and another family member attended the care plan conference. The additional information revealed Family would like for her [Resident #1] to be evaluated to come out of skilled unit. During an interview on 09/10/2025 at 09:00 a.m., Resident #1's family member and emergency contact #1 stated she did not understand why Resident #1 had been moved to a secure unit. She stated she was eventually told (unable to provide who told her or when) that Resident #1 had gone to the front desk and was asking where she (family member) was. The family member stated she wanted Resident #1 back on the general population hall and out of the secure unit. The family member stated she voiced this request to the facility during the care planning meeting. During an observation and interview on 09/10/2025 at 12:10 p.m., Resident #1 stated the facility is very nice and she gets along with almost everyone. She stated she currently had a private room but would like a roommate. She stated her prior roommate was moved after it was discovered the roommate was taking Resident #1's personal items to another room. Resident #1 did not state she wanted to leave the secured unit and did not state why she was on the secured unit. She stated the activities director took the residents outside to do fun activities and the staff were amazing. Resident #1 did not appear upset, stressed, or agitated during the conversation and subsequent observations regarding her placement in the secured unit. During an interview on 09/10/2025 at 03:57 p.m., CNA A, a CNA on the secure unit, stated Resident #1 had not exhibited exit-seeing behaviors and was easily re-directed if she appeared to be wandering aimlessly. CNA A stated Resident #1's wandering happened mostly when Resident #1 had forgotten something and was looking for it. During an interview on 09/10/2025 at 04:00 p.m., LPN B, a nurse on the secure unit, stated she had never seen Resident #1 try to elope or even act as if she wanted to elope. She stated Resident #1 would sometimes wander because she was looking for something she had forgotten. She stated Resident #1 had poor short-term memory but was easily redirected. She stated Resident #1 will sometimes go to the exit door to look through the window and put her hands on the bar, but she knows the door is locked and does not try to exit. LPN B stated she was not aware of Resident #1 having had an elopement attempt and had not been told by other staff of an attempt. She stated Resident #1's only exhibited behavior was being forgetful. During an interview on 09/10/2025 at 04:18 p.m., the ADON stated residents did not have to have an order for placement on the secure unit if there was an elopement attempt. The ADON stated Resident #1 came to the facility for skilled services originally, not long-term care, but she tried to elope from the rehabilitation unit. She stated residents could be moved to the secure unit for their safety. The ADON could not explain why there was not an elopement assessment done for Resident #1 prior to her placement since the initial assessment revealed no risk. The ADON could not explain why the second elopement assessment, with a moderate risk and a created date of 06/16/2025, was entered into Resident #1's today, 09/10/2025. During an interview on 09/11/2025 at 02:14 p.m., the DON stated Resident #1 did not have an order for having been on the secure unit. She stated Resident #1 was moved to the secure unit due to having been exit seeking and combative. The DON stated Resident #1's move to the secure unit was care planned from the time of her transfer. During an interview on 09/11/2025 at 02:14 p.m. (entered room during DON interview), the ADMIN stated he could not provide details of why Resident #1's did not have orders for her move to the secure unit but did recall Resident #1 had exhibited behaviors right after her admission. Attempted interview with MD C on 09/11/2025 at 03:22 p.m. Call back not received. Record review of policy titled, Wandering & Elopement, date revised 08/2020, revealed the purpose of the policy, To enhance the safety of residents of the Facility and a policy statement, The Facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement. The policy procedure did not include a process or indications for residents to be evaluated for the secure unit.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities in accordance with State law through established procedures for 2 of 6 residents (Residents #12, and #18) reviewed for freedom from abuse and misappropriation.1. The facility failed to report the incident of misappropriation on 5.2.25 for Resident # 12 missing a gold diamond necklace. 2. The facility failed to report the incident of alleged abuse on 05/01/2025 for Resident #18.These failures could put the residents at risk of abuse, allegations of abuse not being reported immediately, and could result in physical and psychosocial harm. The findings were:Based on, interview, and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse,or not later than 2 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury , to the administrator of the facility and to other officials including the state Survey Agency where state law provides for jurisdiction in long term care facilities in accordance with State law through established procedures doe 2 of 6 (Residents #12, and #18) reviewed for freedom from abuse, neglect, and misappropriation. 1. The facility failed to report the incident of misappropriation on 5.2.25 for Resident # 12 missing a gold diamond necklace. 2. The facility failed to report the incident of alleged abuse on 05/01/2025 for Resident #18.These failures could put the residents at risk of abuse, allegations of abuse not being reported immediately, and could result in physical and psychosocial harm. The findings were:1. Record review of Resident # 12's face sheet, dated 7/02/25, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: Dementia (is the loss of thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) , hypertension. (happens when the force of your blood pushing against the walls of your blood vessels is too high) and Osteoporosis ( a bone disease that develops when bone mineral density and bone mass decrease. Record review of Resident #12's admission MDS assessment, dated 05/02/2025, revealed the resident's BIMS score was 13, which indicated intact cognition. Record review of the facility's inventory sheet for Resident # 12, dated 4.30.25, did not reveal a gold diamond cross necklace on the inventory sheet . Record review of the facility's grievance's dated 5.13.25 revealed an allegation of a missing gold diamond necklace for Resident # 12 . Further review revealed the Administrator reimbursed the family for Resident # 12 , $1500 , for the missing gold diamond cross necklace. Record review of Texas Unified Licensure Information Portal (TULIP) on 7/02/25 at 8:25 A.M. revealed that no self-reported incidents regarding allegations of misappropriation were reported for Resident #12. An interview with Resident #12's representative party was attempted via phone on 7.2.25 at 9:30 AM and was unsuccessful. Resident # 12 was discharged to another facility on 5.15.25. During an interview on 07/02/2025 at 1:25 PM, the Administrator confirmed he received a report from Resident #12's representative party regarding a missing diamond gold necklace on 5/13/25 . The Administrator stated he did not report the misappropriation to HHSC because of the internal arbitration agreement, and because he reimbursed Resident # 12's family for the gold diamond necklace. After the Administrator familiarized himself with the Long-term care provider letter dated 8/29/25, he acknowledged that incidents that must be reported are exploitation, misappropriation, and failing to report the allegation could have resulted in Resident #12 being subjected to abuse. 2. Record review of Resident #18's Face Sheet, dated 07/02/2025, reflected a [AGE] year-old resident with an initial admission date of 12/16/2023 and diagnosis including Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Depression, and morbid obesity. Record review of Resident #18's Comprehensive Person-Centered Care Plan, dated printed 07/01/2025, reflected Resident #18, consistently denies assistance with care tasks, including hygiene, repositioning, and transfers.Record review of facility grievance written by the LSW and dated 05/01/2025 revealed:This writer spoke with [Resident #18] at her request this morning. She stated she had not had a shower in three weeks, and she would like to have a shower today. When asked what days she has her showers, she stated, 'Monday, Wednesday, and Friday in the morning.'She stated the CNA ([CNA A]) today did not put her brief on correctly, and she went on to show this writer how the brief was placed on her (it was very low in the front and she stated it was up to her shoulder blades in the back.) She stated the CNA was 'rough' with her while providing care. She specifically stated the CNA 'pushes and squeezes' her when she does give her a shower, and [Resident #18] tries to explain to her (even though she knows she does not understand English) how to assist her without hurting her due to her diagnosis of fibromyalgia and arthritis. She stated [CNA A] only 'gives me a deadpan look and goes 'uh' in response.'SW asked [Resident #18] if she feels [CNA A] is rough with her on purpose, and [Resident #18] responded, 'Oh yes. She knows what she is doing. She doesn't listen. Today, when I was asking to have my diaper fixed, I kept saying wait, wait. She just kept doing it. When I said wait over and over and she didn't stop, I finally told her to leave. After telling her to leave three times, I thought maybe she didn't understand what 'please leave' meant, so I said, 'go'. She just stared at me. After I said 'go' a few times, I said go and did this (she made a motion with her hand). [CNA A] then said 'go' and did the same motion with both her hands.She makes fun of me like that.' SW asked [Resident #18] if this has happened before (being made fun of). [Resident #18] stated [CNA A] has done it many times before.[Resident #18] stated she no longer wants [CNA A] to take care of her in any way. She stated today was 'the last straw' and she doesn't want her in her room at all any longer.Interview on 07/02/2025 at 7:46 AM, LSW stated she is not aware of a follow-up to the grievance she wrote on behalf of Resident #18. LSW stated that after she told the Administrator about the incident and handed off the grievance to him, that is where her role in the grievance process stops. The LSW stated when a resident addresses a concern to her, she will generally inform the DON/ADON and write a grievance and from there the Administrator handles it.Interview on 07/02/2025 at 8:18 AM, the Administrator stated they would not ordinarily report a grievance such as the one described with Resident #18 to the state because they did a grievance, the resident has a history of false reporting, and because once he interviewed the resident she was happy with the resolution of CNA A not working with her any longer. The Administrator stated that it was likely that Resident #18 felt as though CNA A was rough because Resident #18 was overweight. The Administrator stated after the resolution with the resident they completed the grievance process and there was no further investigation. Interview attempt on 07/02/2025 at 8:30 AM, Resident #18 did not remember the incident occurring and stated she did not have any concerns for her care.Interview on 07/02/2025 at 2:27 PM, CNA A stated she has never been rough with a resident and would report to the DON and Administrator if she saw another staff member become rough with a resident. Record review of Texas Unified Licensure Information Portal (TULIP) on 07/02/2025 at 8:25 AM revealed that no self-reported incidents regarding allegations of neglect were reported for Resident #18. A review of the facility policy, Abuse Prevention and Prohibition Program, dated October 24, 2024, read: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. The facility has zero tolerance for abuse, neglect, mistreatment, and/or misappropriation of residents' property.

Based on interview and record review, the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment, were thoroughly investigated for 1 of 8 residents (Resident #18) reviewed for abuse and neglect. The facility did not investigate an incident in which Resident #18 made a grievance that a staff member was rough with her and did not stop perineal care when requested. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. The findings included:Record review of Resident #18's Face Sheet, dated 07/02/2025, reflected a [AGE] year-old resident with an initial admission date of 12/16/2023 and diagnoses including Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Depression, and morbid obesity. Record review of Resident #18's Comprehensive Person-Centered Care Plan, dated printed 07/01/2025, reflected Resident #18, consistently denies assistance with care tasks, including hygiene, repositioning, and transfers.Record review of facility's grievance written by the LSW and dated 05/01/2025 revealed:This writer spoke with [Resident #18] at her request this morning. She stated she had not had a shower in three weeks, and she would like to have a shower today. When asked what days she has her showers, she stated, 'Monday, Wednesday, and Friday in the morning.' She stated the CNA ([CNA A]) today did not put her brief on correctly, and she went on to show this writer how the brief was placed on her (it was very low in the front, and she stated it was up to her shoulder blades in the back.) She stated the CNA was 'rough' with her while providing care. She specifically stated the CNA 'pushes and squeezes' her when she does give her a shower, and [Resident #18] tries to explain to her (even though she knows she does not understand English) how to assist her without hurting her due to her diagnosis of fibromyalgia and arthritis. She stated [CNA A] only 'gives me a deadpan look and goes 'uh' in response.' SW asked [Resident #18] if she feels [CNA A] is rough with her on purpose, and [Resident #18] responded, 'Oh yes. She knows what she is doing. She doesn't listen. Today, when I was asking to have my diaper fixed, I kept saying wait, wait. She just kept doing it. When I said wait over and over and she didn't stop, I finally told her to leave. After telling her to leave three times, I thought maybe she didn't understand what 'please leave' meant, so I said, 'go'. She just stared at me. After I said 'go' a few times, I said go and did this (she made a motion with her hand). [CNA A] then said 'go' and did the same motion with both her hands. She makes fun of me like that.' SW asked [Resident #18] if this has happened before (being made fun of). [Resident #18] stated [CNA A] has done it many times before.[Resident #18] stated she no longer wants [CNA A] to take care of her in any way. She stated today was 'the last straw' and she doesn't want her in her room at all any longer.Interview on 07/02/2025 at 7:46 AM, LSW stated she was not aware of a follow-up to the grievance she wrote on behalf of Resident #18. LSW stated that after she told the Administrator about the incident and handed off the grievance to him, that was where her role in the grievance process stops. The LSW stated when a resident addresses a concern to her, she will generally inform the DON/ADON and write a grievance and from there the Administrator handles it.Interview on 07/02/2025 at 8:18 AM, the Administrator stated they would not ordinarily report a grievance such as the one described with Resident #18 to the State because they did a grievance, the Resident has a history of false reporting, and because once he interviewed the Resident she was happy with the resolution of CNA A not working with her any longer. The Administrator stated that it was likely that Resident #18 felt as though CNA A was rough because Resident #18 was overweight. The Administrator stated after the resolution with the Resident they completed the grievance process and there was no further investigation. Interview attempt on 07/02/2025 at 8:30 AM, Resident #18 did not remember the incident occurring and stated she did not have any concerns for her care.Interview on 07/02/2025 at 2:27 PM, CNA A stated she has never been rough with a resident and would report to the DON and Administrator if she saw another staff member become rough with a resident. Record review of Texas Unified Licensure Information Portal (TULIP) on 07/02/2025 at 8:25 AM revealed that no self-reported incidents regarding allegations of neglect were reported for Resident #18.Record review of facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated revised 4/20212, reflected, If the Administrator receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, injuries of an unknown source of crime, the Administrator or designee, may appoint a member of the Facility's management team (the investigator) to investigate the alleged incident.

Based on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments to reflect the current condition for 1 of 6 residents (Resident #15) reviewed for care plan revisions.The facility failed to ensure Resident #15's care plan was comprehensive and updated to reflect Resident #15 had an incident of resident-to-resident aggression. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included:Record review of Resident #15's face sheet dated 07/02/2025 revealed an [AGE] year-old admitted to the facility on [DATE] with diagnoses that included unspecified dementia (group of thinking and social symptoms that interferes with daily functioning), anxiety disorder, and personal history of covid-19. Record review of Resident #15's most recent admission MDS assessment dated [DATE] revealed the resident was severely cognitively impaired. Record review of Resident #15's comprehensive care plan, undated, did not reveal anything related to aggression or altercations with other residents. Record review of Resident #15's progress note, dated 5/6/2025, reflected, While in the dinning [sic] room for dinner, patient was involved in a physical altercation with another patient after an accidental bumping into the other patient wheelchair. In response, this patient wrapped his hands around the other patient's neck. Staff intervened immediately, separating the individuals and redirecting both patients to ensure safety. During the incident, this resident sustained an abrasion to his left cheek, likely resulting from the physical struggle. The area was assessed and cleaned per protocol; no active bleeding was noted. The Administrator, MD, D.O.N and family was notified. Monitoring will continue per protocol. During an interview on 07/02/2025 at 7:18 AM, MDS Coordinator B stated they go through incident reports during their morning meeting. MDS Coordinator B stated she remembers the incident and believes that MDS Coordinator C was in charge of changing Resident #15's comprehensive care plan, as she changed the other resident involved in the resident-to-resident altercation's care plan. During an interview on 07/02/2025 at 7:41 AM, MDS Coordinator C stated because Resident #15 did not have any psychological trauma or physical injuries they did not update his care plan. Record review of the facility document titled Care Planning with revision date 10/24/2022 revealed in part, The IDT will revise the Comprehensive Care Plan as needed at the following intervals: . D. To address changes in behavior and care

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 3 patios reviewed for entrapment and lack of supervision. 1. The secured enclosed patio by the 100-300 hall dining room was accessed by a door that would allow residents, staff, and the public to exit to the secured enclosed patio but would lock behind anyone and would prevent access back into the dining room. 2. The secured enclosed patio by the 400-600 hall dining room was accessed by a door that would allow residents, staff, and the public to exit to the secured enclosed patio but would lock behind anyone and would prevent access back into the dining room. This failure could place residents, staff, and the public at risk for entrapment. The findings included: During an observation of the facility during initial rounds on 11/05/2024 from 09:00 to 06:00 PM revealed 3 secured patios. One enclosed secured patio was located by the 100-300 hall dining room. One enclosed secured patio was located by the 400-600 hall dining room. One secured enclosed patio was located within the memory care secured unit. During an observation on 11/05/24 at 05:30 PM revealed staff and residents gathered at the 100-300 hall dining room. Staff assisted some residents to their tables and other independent residents self-ambulated to the dining room and sat themselves at dining room tables and awaited the dinner meal. Approximately 20 residents were observed in the dining room. Further observation revealed Resident #16 walked in the dining room with his rollator walker and sat down for the dinner meal service. The surveyor observed the door at the end of the dining room which was used to access the adjacent enclosed secured patio. The surveyor exited the door and walked out into the patio. Further observation of the patio revealed a large patio with a concrete patio and walkways around a garden and shrubbery. The walkway led to a fenced in yard secured by a six-foot wooden privacy fence with a secured magnetically locked gate which could not be opened. The surveyor walked back to the door to the facility's 100-300 hall dining room to discover the door had locked behind the surveyor when the surveyor exited the door. Residents and staff could be visualized through the glass locked door. The door presented with a numbered push pin lock. The door presented without any signage to reveal a phone number and or access code. The surveyor had to knock on the glass door to gain the attention of staff. ADON E answered the knock and opened the door. During an interview on 11/05/2024 at 05:40 PM ADON E stated the door was free to exit and would lock behind anyone who would exit. ADON E stated staff would escort residents out to the patio for outdoor activities. ADON E stated there was a code for the door, but it was not posted. ADON E stated Resident #16 could exit to the secured patio and was not aware of the code. ADON E stated Resident #16 had no history of going outside without staff. ADON E stated some residents were aware of the code to enter back into the facility. During an observation on 11/06/2024 at 12:36 pm revealed the enclosed secured patio located by the 300-600 hall dining room. The patio could be accessed by residents, staff, and the public through a glass metal door. The surveyor observed the door needed no code to exit but the door locked behind whoever exited the facility into the garden patio. The patio presented with concrete patios and walkways and features a six-foot privacy wooden fence which was electronically magnetically locked and could not be unlocked. The door back into the facility presented without any signage to advertise an access code and or facility phone number. During an interview on 11/07/2024 at 11:20 AM the Maintenance Director stated the doors to the secured enclosed patios by the 100-300 and 400-600 dining rooms had locks designed to allow anyone out but locked behind anyone who exited and could only be unlocked from the inside or by using a code from the outside. The Maintenance Director stated someone who did not know the code could be locked out of the facility and could not get out of the patio unless someone unlocked the door from the inside. The maintenance director stated he was in the process of removing the locks. The Maintenance Director stated the facility leadership met and decided to remove the locks on 11/07/2024 and provide a handle which would allow free movement in and out. During an interview on 11/8/2024 at 04:00 PM the Administrator stated the doors to the enclosed secured patios by the dining rooms had been locked and were now free to allow exit and entrance to the facility. The locks were changed yesterday 11/07/2024. the administrator stated the decision was made to improve supporting resident's rights of free movement and access to the patios. A record review of the facility's safe environment policy was requested on 11/08/2024 at 09:26 AM via email. A record review of the email dated 11/08/2024 time 09:31 authored by the administrator revealed, the policy was not provided.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed. The facility failed to ensure dietary staff used proper hand hygiene during meal preparation. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 11/07/2024 at 12:08 p.m. revealed the DA carried a bag of hamburger buns from the pantry, placed them on the counter, after she placed the bag down, pulled back plastic wrap from a sandwich on a plate reached up, grabbed a knife by the blade from the magnetic knife holder on the wall, cut the sandwich in half and then placed the plastic wrap back over the sandwich. The DA did not stop to remove gloves and wash her hands or change gloves. Observation on 11/07/2024 at 12:12 p.m. revealed the DA while wearing gloves she went into the pantry, brought back a loaf of bread, opened the bread removed the bread from the bag placed it on a plate, then got a slice of cheese from a zip lock bag, placed the cheese on the bread with her gloved hands and placed the sandwich on the griddle to grill the cheese sandwich. The DA did not stop to remove gloves and wash her hands or change gloves. Observation on 11/07/2024 at 12:16 p.m. revealed the DNS when the DA left kitchen to take items to dish room. The DNS reminded the DA to remove her gloves and wash her hands. The DA then removed her gloves, washed her hands and returned to the kitchen and put on new gloves. During an interview on 11/07/2024 at 1:42 p.m. the DA stated she should have washed her hands once she returned from the pantry and put on new gloves before taking the bread and cheese out to cook the sandwich. The DA stated by not washing her hands and changing her gloves it could cause cross contamination and could cause a resident to get sick. The DA further stated she had been trained on handwashing and cross contamination. During an interview on 11/07/2024 at 1:49 p.m. the DNS stated the DA should have removed her gloves and washed her hands after getting the bread from the pantry before preparing the sandwiches. The DNS further stated the staff had been trained on handwashing, cross contamination and the use of gloves. The DNS stated this practice could cause cross contamination and could cause a resident to get sick. Review of facility's policy Dining Services Standards, revised 12/2022, read Policy: The facility staff will ensure the prevention of infection in the food service department to ensure the residents are provided with a positive meal experience, Procedure: A. Personnel: 4. Nutrition and Food Services personnel in direct contact with food will wear plastic or vinyl disposable gloves. Gloves should be removed upon leaving the work area and hand hygiene performed. Hand hygiene should be performed when returning to the work area and new gloves should be worn. Gloves should be changed, and hands washed with soap and water whenever the gloves are contaminated by touching potentially soiled surfaces such as cashier surfaces, floors, waste cans, cardboard boxes, etc.

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 6 Residents (Resident #48) reviewed for dignity. CNA F walked into Resident #48's room without knocking and while Surveyor and Resident #48 were having a discussion about his medical concerns. This deficient practice could affect any resident and contribute to residents feeling like their feelings, privacy or dignity does not matter. The findings were: Record review of Resident #48's face sheet, dated 11/8/24, revealed he was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus with Diabetic Neuropathy and Major Depressive Disorder, recurrent, moderate, Record Review of Resident #48's annual MDS, dated [DATE] revealed his BIMS was 14 reflecting minimal cognitive impairment, he did not have mood or behavior problems and for activities it reflected Resident #48 found it very important to chose how to spend his days and what activities were important to him. Observation and interview on 11/07/24 at 03:26 PM revealed Resident was sitting in a wheelchair and was talking about the rash on his upper body, hands and legs. Further observation revealed CNA F walked into Resident #48's room without knocking. He had a container of water in his hand. Surveyor and Resident #48 both quit talking. Resident #48 commented, it's like we're not Important and I don't even matter. It's my room. Resident #48 stated he wished staff would knock before they entered his room. Interview on 11/08/24 at 04:42 PM with CNA F revealed he stated he did not knock on Resident #48's room yesterday while he and Surveyor were talking. He stated he stepped out to get Resident #48 water and the Resident knew he was returning. Surveyor proposed CNA F a question: how would you like it if someone walked into your living room without knocking? CNA F stated he would not like it. CNA F apologized and stated he would not do it again. Interview on 11/08/24 at 04:55 PM with the DON revealed CNA F told her about walking into Resident #48's room without knocking. She stated it was a dignity/privacy issue and she expected all staff to knock before entering a Resident's room. The DON stated the charge nurses should be watching out for any incidents. Record review of a facility policy, Resident Rights, revised 8/2020, read in relevant part: The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The Facility will ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the Facility. Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of resident's rights.

Based on observation, interviews, and record reviews the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay for 1 of 8 residents (Resident #4) reviewed for grievances. The facility failed to create a greience for Resident #4 who made a grievance to LVN D, LVN C, CNA A, and The BOM alleging she did not receive medications on Sunday 10/27/2024. This failure could place residents at risk for not having their grievances heard and or resolved. The findings included: A record review of Resident #4's quarterly MDS assessment dated [DATE] revealed Resident #4 was an [AGE] year-old female admitte d on 09/19/2022 for long term care and assessed with a BIMS score of 12 out of a possible 15 which indicated moderate cognitive impairment. Further review revealed Resident #4 was assessed as medically complex with diagnoses which included generalized pain, osteoarthritis, atrophy (weaking) of the eyes complicated by Presbyopia (not able to see close), Hypermetropia (only having the ability to see objects far away) and glaucoma (a condition where the eye's optic nerve, which provides information to the brain, is damaged). Resident #4 was assessed as dependent - helper does ALL of the effort to complete the activity for the following: Toileting and Bathing and was assessed without the ability to stand or walk. A record review of Resident #4's care plan conference dated 07/25/2024 revealed, (Resident #4) is here for LTC (long Term Care). She was discharged from (name of hospice care) hospice in June for stability. She remains on her pain management. She is bed bound and doesn't like to do therapy or get out of bed. (family) visits often. She is able to make her needs known. She prefers in room activities. She remains DNR (do not resuscitate) and regular diet. During an observation and interview on 11/05/24 at 10:39 AM revealed Resident #4 laying in her bed. Resident #4 stated she had not received medications and stated, you could have them give me my meds. Resident #4 continued to explain on 10/27/2024 she had not received her medications and she had complained to (name of family relative) and nurse that day (LVN D). Resident #4 detailed she believed she did not receive her medications and the next morning 10/28/2024 she made the same complaint to her CNA, CNA A, and then again to the BOM. Resident #4 stated no one gave her a report regarding her grievances. Resident #4 stated she did not fill out a grievance report and no one had assisted her in filling out a report. During an interview on 11/06/24 at 01:40 PM CNA A stated she recalled sometime last week - on a Monday Resident #4 made a complaint she had not received her medications that weekend, Sunday (10/27/2024). CNA A stated on Monday 10/28/2024 while she recovered Resident #4's breakfast tray Resident #4's ambassador the BOM entered the room to check in with Resident #4. CNA A stated she then introduced the BOM to Resident #4's complaint. CNA A stated she was a long-term employee of the facility and was not aware of the facility's grievance policy and or procedures. CNA A stated she had not assisted Resident #4 to fill out a grievance form. During an interview on 11/07/24 at 11:45 AM the Administrator stated he had provided the survey team all the grievance forms for the past months of May through November. A record review of the facility's grievance logbook revealed grievances for the time between May 2024 and November 2024 and no grievances were revealed for Resident #4's grievance made on 10/27/ 2024 and 10/28/2024. During an interview on 11/07/24 at 12:00 PM the BOM stated she was the ambassador for Resident #4 and on the Morning of 10/28/2024 she visited with resident #4 who stated she had a suspicion she did not receive her medications Sunday yesterday (10/27/2024). The BOM stated she checked with Resident #4's nurse that day Monday 10/28/2024 LVN C. LVN C reviewed Resident #4's medication administration record for 10/27/2024 and revealed LVN D had documented Resident #4 received her medications. The BOM stated she had not assisted Resident #4 to fill out a grievance form. The BOM stated she had not considered Resident #4's complaint of not receiving her medications as a grievance which needed to be documented since the record revealed she had received her medications. During an Interview on 11/07/2024 at 12:54 PM LVN D stated on 10/27/2024 Resident 4's (family member) called the nurses station and reported her (Resident #4) had alleged she had not received her morning medications. LVN D stated he reported to Resident 4's (family member) he had administered the medications also Resident #4 was a little sleepy that morning and may have not remembered. LVN D stated he did not document the report in any notes and had not generated a grievance report nor reported the allegation of neglect to his superior because he did not recognize the allegation of neglect because he had direct knowledge of the medication administration. During an interview on 11/07/2024 at 4:00 PM the DON stated she expected all the staff to assist residents document grievances made and to submit those grievances to the administrator. The DON stated she was surprised because the staff have been in-serviced on grievances and the facility had many grievances documented and resolved. The DON stated she would follow up with CNA A and LVN D. During an interview on 11/07/2024 at 04:10 PM the administrator stated he was the grievance officer and had not received a grievance report on behalf of Resident #4 regarding her suspicion of not receiving her medications and expected LVN D and the BOM to have generated a grievance report once the administrator received the surveyors report detailing the events on 10/27/2024 and 10/28/2024. A record review of the facility's policy dated August 2020, revealed, Purpose: To ensure that residents, family members, and representatives know about the procedure for filing grievances and complaints. Policy The Facility advises residents and their representatives (including family, legal representatives, and advocates) of their right to file grievances without discrimination or reprisal, and of the process for filing grievances or complaints. and ensures that there is a prompt review, investigation and response to and resolution of grievances and complaints. The disposition of all resident grievances and/or complaints is recorded in the Facility's Resident Grievance/Complaint Log. Grievances and/or complaints may be submitted orally or in writing and can be made anonymously through the Compliance Hotline. Individuals will use Facility complaint forms or may use Resident Grievance/Complaint Form to submit written grievance reports. VI. Duties and Obligations of Staff; A. When a Facility Staff member overhears or receives a complaint from a resident, a resident's representative, another interested family member or visitor of a resident concerning the resident's medical care, treatment, food, clothing, or behavior of other residents, etc., the Facility Staff member is encouraged to advise the resident/concerned party that they may file a complaint or grievance without fear of reprisal or discrimination, and will assist the resident, or person acting on the resident's behalf, in filing a written complaint with the Facility. C. Staff members inform the resident or the person acting on the resident's behalf where to obtain a Resident Grievance/Complaint Form and where to locate the procedures for filing a grievance or complaint (e.g., posted on the consumer bulletin board). D. All alleged abuse, mistreatment, neglect, injuries of unknown source, and misappropriation of property will be reported to the Administrator immediately. See Policy Abuse Prevention Program. F. The Facility will inform the resident or his or her representative or concerned party of the findings of the investigation and any corrective actions recommended in a timely manner. IX. Grievance Complaint Log A. The disposition of all written grievances and/or complaints is recorded on the Resident Grievance/Complaint Log.

Based on observations, interviews, and record reviews the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 1 of 8 residents (Resident #16) reviewed for mechanical soft diet needs. 1. The facility failed to follow the physicians' orders and the Speech Language Pathologist's (SLP) recommendations for Resident #16's mechanical soft diet and served Resident #16 potato chips on 11/05/2024 for lunch. 2. The facility failed to follow the physicians' orders and the Speech Language Pathologist's (SLP) recommendations for Resident #16's mechanical soft diet and served Resident #16 potato chips on 11/05/2024 for dinner. This failure could place residents at risk for harm by aspiration of food into the lungs due to swallowing difficulties. The findings included: A record review of Resident #16's admission record dated 11/05/2024, revealed an admitted [DATE] with diagnoses which included dysphagia oropharyngeal phase (swallowing difficulties), dementia (A group of symptoms that affects memory, thinking and interferes with daily life), and intellectual disabilities. A record review of Resident #16 quarterly MDS assessment dated [DATE] revealed Resident #16 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 10 out of a possible 15 which indicated moderate cognitive impairment. Resident # 16 was assessed with signs and symptoms of possible swallowing disorder coughing or choking during meals or when swallowing medications. And required a mechanically altered diet, require change in texture of foods or liquids. A record review of Resident #16's physicians orders dated 11/06/2024 revealed the physician ordered for Resident #16 to receive a regular diet with a mechanical soft texture, with thin liquids. A record review of Resident #16's care plan dated 11/06/2024 revealed Resident #16 was at risk for falls and had interventions for fall preventions, the resident needs a safe environment with: even floors free from spills and or clutter; adequate glare free light; . (Resident #16) has potential nutritional problem r/t (related to) dementia, dysphagia, GERD (gastroesophageal reflux disease) . provide serve diet as ordered A record review of Resident #16's SLP (Speech Language Pathologist) Recert, Progress, Report & Updated Therapy Plan dated 09/05/2024, revealed a new goal for Resident #16 as Patient will demonstrate ability to safely swallow mechanical safe foods and thin liquids using compensatory strategies in 95% of opportunities to maintain adequate nutrition / hydration. A record review of Resident #16's lunch meal ticket dated 11/05/2024 revealed . Notes: Send only peanut butter and jelly sandwich and chips on plate; cottage cheese, dessert During an observation on 11/05/2024 at 12:16 PM revealed Resident #16 seated in the dining room and was served a lunch plate which included a peanut butter sandwich accompanied by potato chips. Continued observation revealed Resident #16 consumed the meal. During an interview on 11/05/2024 12:20 PM with the facility's SLP and the Dietician, the SLP stated she did not believe potato chips were consistent with a mechanical soft diet. The dietician disagreed and stated Resident #16 was fine with potato chips and bread. A record review of Resident #16's dinner meal ticket dated 11/05/2024 revealed . Notes: Send only egg salad sandwich and chips; cottage cheese, ice cream During an observation on 11/05/2024 at 05:46 PM revealed Resident #16 seated in the dining room and was served a dinner plate which included an egg salad sandwich accompanied by potato chips. Continued observation revealed Resident #16 consumed the meal. During an interview on 11/05/2024 at 05:50 PM the ADON E stated Resident #16 was served [potato chips and was assessed a needing a mechanical soft diet texture. The ADON E stated she needed to confirm if potato chips were consistent with a mechanical soft diet. During an interview on 11/08/2024 at 04:00 PM the DON stated she did not believe potato chips were consistent with a mechanical soft diet and would ask Resident #16's physician for a new SLP evaluation and potential swallow study. The DON stated the risk for a Resident with needs for a mechanical soft diet not receiving mechanical soft foods was aspiration and potential lung infections. A record review of the facility's Dental Soft (Mechanical Soft) Diet policy dated 2022 revealed, Indications for Use: The Dental Soft (Mechanical Soft) Diet is for individuals with limited or difficulty in chewing regular consistency foods. If a Mechanical Soft Diet is ordered, the Dental Soft (Mechanical Soft) Diet would be appropriate if there is a chewing/dentition problem. This diet may also be used by a Speech Language Pathologist (SLP) in the treatment of dysphagia with individualization per recommendations by the SLP. This diet may be used for those experiencing mouth irritation and dentition problems including lack of teeth or poor fitting dentures. Individualization for specific food tolerances is required. For individuals that have any swallowing problems or dysphagia, it is recommended that a SLP be consulted and one of the Dysphagia Level Diets may need to be implemented. General Principles & Guidelines: . 3. The diet consists of food of nearly regular textures but excludes very hard, sticky, crunchy or hard to chew foods. Foods should be moist and fork tender. 10. Hard crisp fried potatoes and potato skins are excluded. Food Guide: . not allowed: . Hard crisp fried potatoes

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 disease and infection for 1 of 1 resident (Resident #1) reviewed for infection control, in that: The facility failed to ensure LVN A changed her gloves when moving from a dirty to clean task and failed to use appropriate hand hygiene between glove changes when she provided incontinent care to Resident #1. This deficient practice could place residents at risk for infection due to improper care practices. The findings included: Record review of Resident #1's face sheet dated 10/15/24 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cognitive communication deficit, profound intellectual disabilities, and benign prostatic hyperplasia without lower urinary tract symptoms. Record review of Resident #1's most recent quarterly MDS assessment, dated 9/27/24 revealed the resident was severely cognitively impaired for daily decision-making skills and was always incontinent of bowel and utilized an indwelling urinary catheter. Observation on 10/16/24 at 9:25 a.m., during incontinent care revealed LVN A removed Resident #1's soiled brief, removed her gloves, did not wash, or sanitize her hands and put on a new pair of gloves. LVN A then obtained a clean brief and placed it on the resident's bed. LVN A continued with incontinent care and wiped the stool from Resident #1's left upper thigh and between the buttocks and anus. LVN A then removed her gloves, washed her hands and left the bedside to obtain a topical medication. LVN A returned with Resident #1's topical medication, went into the bathroom to wash her hands, and used her wet right hand to turn off the faucet. LVN A then put on a new pair of gloves, returned to the resident's bedside and applied the topical medication to the resident's buttocks. LVN A then removed her gloves, did not wash or sanitize her hands and put on a new pair of gloves. LVN A completed incontinent care to Resident #1, took the soiled brief and placed it in a plastic bag, and then with the same gloves took the clean brief and placed it on the resident. During an interview on 10/16/24 at 9:51 a.m., LVN A stated she realized she had missed sanitizing her hands between gloves changes and revealed it was important to do so because it was infection control issue and could result in the resident getting an infection. LVN A further stated she should not have turned off the water faucet with her bare hand because you don't know who else had touched the faucet. LVN A stated she had not realized she did not change her gloves after removing Resident #1's soiled brief and before touching the clean brief, and that it was also considered an infection control issue resulting in the resident vulnerable to infection. LVN A stated she had been in-service and had competency training on infection control almost every week if not once a month. LVN A stated she had been involved in providing training to staff and had been in-serviced by the ADON and DON. During an interview on 10/16/24 at 10:08 a.m., the DON stated, no hand washing between glove changes, going from a dirty area to a clean area during a task, and using your bare hand to turn off the water faucet after washing your hands were all a potential for spread of infection due to improper infection control practices. Record review of LVN A's clinical competency validation document for Hand Hygiene dated 8/15/24 revealed LVN A had satisfied the requirement for proper hand hygiene. Record review of the facility policy and procedure titled Infection Prevention and Control Program, revision date 6/2020 revealed in part, Purpose .ensure the Facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements . Record review of the facility policy and procedure titled, Perineal Care, revision date 6/2020, revealed in part, .Purpose .to maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown .Wash hands .put on gloves .Remove gloves. Wash hands or use alcohol-based hand sanitizer .Note: Do not touch anything with soiled gloves after a procedure .

Based on observation, interview, and record review the facility failed to ensure that residents are free of any significant medication errors for 1 of 12 residents (Resident #1) reviewed for significant medication errors, in that: The facility did not administer Resident #1's recommended doses for dexlansoprazole [a medication used to reduce stomach acidity and prevent stomach ulcers] and sucralfate [a medication used to coat the lining of the stomach and intestinal ulcers by forming a barrier over the ulcers and protecting the ulcer from further injury] from 11/11/2023 to 11/27/2023, resulting in the resident being sent out to the hospital on 11/27/2023. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 12/1/23 at 5:37 p.m. While the IJ was removed on 12/2/23 at 9:48 p.m., the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy because the facility needed to monitor their corrective actions. This deficient practice could affect residents and place them at risk for not receiving a therapeutic effect. The findings were: Record review of Resident #1's face sheet, dated 12/1/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, lamellar ichthyosis [a rare skin condition that causes dark, plate-like scales on the body], gastrointestinal hemorrhage, unspecified, Barrett's esophagus with dysplasia [a condition where damage by acid reflux causes the esophagus to become red and thick and it also causes the cells in the esophagus to become abnormal], unspecified, and congenital hiatus hernia [also known as a hiatal hernia, when the upper part of the stomach bulges through the large muscle separating the abdomen from the chest]. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS of 11, signifying moderate cognitive impairment. Record review of all of Resident #1's active and discontinued physician orders, obtained 12/1/23, revealed the following: - Dexlansoprazole Oral Capsule Delayed Release 30 MG (Dexlansoprazole) Give 1 capsule by mouth in the morning for gerd [also known as GERD, Gastro-Esophageal Reflux Disease, which is acid reflux.] This was ordered on 9/29/23 and there were no other updates or changes to this medication's dosage or schedule since it was ordered on 9/29/23. - Sucralfate 1 GM Tablet Give 1 tablet by mouth two times a day for ESOPHAGITIS [inflammation of the esophagus] GIVE 1 TABLET BY MOUTH TWO TIMES A DAY FOR ESOPHAGITIS***MAY CRUSH AND DISSOLVE IN 10ML OF WATER TO FORM A SLURRY*** This medication was ordered on 9/30/23. Record review of Resident #1's nursing progress notes revealed the following: - Nursing Progress Note, dated 11/8/23 and written by LVN D: pt had coffee ground emesis, no signs of distress noted New order to send Pt to [local hospital emergency room ] for eval and treat. There was no progress note regarding any medication reconciliation when Resident #1 returned from the hospital on 11/11/23. Record review of Resident #1's electronic health records revealed the facility had a copy of Resident #1's hospital records from his admission to the hospital from 11/9/23 to 11/11/23. Record review of Resident #1's hospital records, dated 11/9/23, revealed the following: PRINCIPAL OBSERVATION ADMIT DIAGNOSIS: Coffee ground emesis . ALL PRINCIPAL OBSERVATION DISCHARGE DIAGNOSES: erosive esophagitis [damage to the lining of the esophagus, typically caused by acid reflux]. PERTINENT ADMISSION HISTORY & PHYSICAL EXAM . [Resident #1] is a [AGE] year old MALE patient with [past medical history] of dementia, upper GI bleeding and recurrent episodes of coffee-ground emesis due to LA-D erosive esophagitis [LA is a type of grading system for esophagitis; a grade of a D indicates damage to 75%or more of the esophagus' perimeter], hiatal hernia . sent in . for episode of coffee-ground emesis today. Active Outpatient Medications . Dexlansoprazole 60 mg EC Cap take one capsule by mouth twice a day for stomach . Sucralfate Oral susp 1gm/10mL take 10 mL by mouth four times a day before meals for stomach ulcer. Please make sure that patient takes sucralfate 30 minutes before meals. Record review of Resident #1's electronic Admission/Readmission Evaluation, dated 11/12/23 and signed by LVN A, revealed no documentation of medication reconciliation or review of Resident #1's discharge documentation immediately following his return to the facility on [DATE]. Record review of Resident #1's November 2023 MAR and TAR, dated 12/1/23, revealed Resident #1 received the following medications: - 30 mg of Dexlansoprazole once every morning throughout the month of November 2023 except when he refused the medication on 11/1/23, when he went to the hospital from 11/9/23 to 11/11/23, and when he went to the hospital again from the late morning of 11/27/23 through 11/30/23. - 1 GM tablet of Sucralfate twice a day throughout the month of November 2013 except when he went to the hospital from 11/9/23 to the morning of 11/11/23, when he refused the medication on 11/17/23, when he refused the medication on 11/27/23, and when he went to the hospital from late morning of 11/27/23 through 11/30/23. Record review of Resident #1's nursing progress notes revealed the following: - Nursing Progress Note, dated 11/27/23 and written by LVN E: it was noted that the patient had emesis x2 [two times] during the morning 6 and 7 am, a call was placed to the on call for [Physician B] and gave order to send out to the emergency room . There were no progress notes between 11/11/23 to 11/27/23 indicating any changes to Resident #1's dexlansoprazole and sucralfate. Record review of Resident #1's hospital Gastroenterology Consultation note, dated 11/27/23, revealed the following: This is a [AGE] year-old male with [past medical history] of advanced dementia . erosive esophagitis, hiatal hernia . admitted from . nursing home for coffee ground emesis. [Family member] mentions . [Resident #1] likely is not getting the 'right doses of meds.' .On review of the patient's med rec dated 11/27, he appears to be on Dexlansoprazole 30 mg qAM; however per his . med rec as well as our previous notes, he has been recommended Dexlansoprazole 60 mg PO BID (and would need BID dosing in the setting of high-grade esophagitis.) . Active Problems . 2. Acute upper gastrointestinal hemorrhage, 3. Gastro-esophageal reflux disease [acid reflux] with esophagitis . Likely etiology [cause] of bleed is still likely to be high grade esophagitis demonstrated on repeat EGD [a procedure that visualizes the upper part of the digestive tract to the beginning of the small intestine], especially in the setting of underdosing of his PPI [referring to Dexlansoprazole.] Record review of Resident #1's hospital History and Physical, dated 11/27/23, revealed the following: per records for the facility, patient has been receiving dexlansoprazole 30 mg daily instead of prescribed dose of 60 mg bid, possibly contributing to recurrence of coffee ground emesis and melena [blood in the stool.] During an interview on 12/1/23 at 12:40 p.m., Resident #1's family member stated Resident #1 went to the hospital on 11/9/23 because Resident #1 had bloody emesis. Resident #1's family member stated Resident #1 went to the hospital on 11/27/23 because of the same reason, the bloody emesis. Resident #1's family member stated the cause of the bloody emesis was because of Resident #1's compromised esophagus and the ulcer. Resident #1's family member stated she was not sure if the ulcer was a new or chronic condition. Resident #1's family member stated, I do know that this time in the hospital, in the ER, one of the doctors came in and he was aghast and said, 'they're not giving him the right doses on his medication,' and he lamented that they were only giving a fourth of the dose that they prescribed.That particular medication was that it helps soothe the lining of the esophagus because he has a compromised esophagus and eating sometimes irritates it and he throws up blood emesis. Resident #1's family member stated she did not want Resident #1 to return to the facility. During an interview on 12/1/23 at 1:34 p.m., LVN A stated when a resident was admitted an assessment was done and the medication records were reviewed. LVN A stated, You go over [the records] and see if anything's changed or anything's different. LVN A stated he would review the discharge documentation and the final medication list and if there were any changes he would call the physician and let the physician know a medication had changed. LVN A stated usually a second per son also reviewed the documentation. LVN A stated he recalled Resident #1 went to the hospital on 11/9/23 due to coffee ground emesis, but did not recall if he was the nurse who readmitted Resident #1 back to the facility on [DATE]. LVN A stated he was not working on 11/11/23. LVN A stated he did not know why his name was on Resident #1's electronic readmission form dated 11/12/23. LVN A stated, Maybe I was trying to backdate something. I couldn't remember. During an interview on 12/1/23 at 2:02 p.m., the interim DON stated upon admission an assessment of the resident, a review of the orders, and a medication reconciliation was done. The interim DON stated the discharge summary or clinical packet from the hospital should be reviewed. The interim DON stated, Most of the time [the hospital] fax[ed] over a clinical packet with an order from the doctor that says 'continue orders as per discharge summary' or some randomness that we go through to make sure the orders are correct. Then we can clarify with the physician. The interim DON stated the ADONs reviewed the new admission either the same day or the next business day and if the resident returned to the facility after business hours or during the weekend then the ADONs reviewed the new admission the next business day. The interim DON stated the nurse who admitted Resident #1 back to the facility on [DATE] was LVN A. The interim DON stated, a dose was changed on [Resident #1's] dexlansoprazole that was not-the reconciliation did not happen and his dose continued at his previous dose. The interim DON stated she did not know exactly when the dexlansoprazole dosage was changed. When asked what could have caused Resident #1's medication reconciliation to be missed on 11/11/23, the interim DON stated, the fact that it was a Saturday night, towards the end of the shift, and the process wasn't followed Monday morning. That's my deduction was that they weren't following the in-place policy and procedure. When asked if the facility had a quality assurance process that ensured medication reconciliation was done upon readmission, the interim DON stated, the ADONs reviewed all orders. When asked what sort of negative effect could occur to the resident if medication reconciliation wasn't done after readmission, the interim DON stated, The resident's condition could worsen. When asked what sort of negative affect could occur if a resident was receiving a medication at a lower dose, the interim DON stated, They [the resident] could not be treated effectively. In a follow-up interview on 12/1/23 at 3:15 p.m., the interim DON stated she was not aware there was a change in Resident #1's sucralfate dose. The interim DON stated following Resident #1's admission to the hospital on 11/27/23, the facility had not completed an in-service for ensuring medication reconciliation. During an interview on 12/1/23 at 3:21 p.m., the interim Administrator stated he knew Resident #1's recent admissions to the hospital were related to the gastrointestinal issues and emesis. The interim Administrator stated he was not aware of any medication issues when Resident #1 returned to the facility on [DATE]. The interim Administrator stated, clearly our process didn't work for reviewing the readmitted patients for [Resident #1] because the medication-it was for stomach acid-it was 30 mg when he left, when he came back it had been changed to 60 mg, I think it was. In the morning meeting, in clinical, we should have reviewed that. And we should have caught it at that point. That was the safety net because the nurse, when they readmitted the patient, they failed to put the new orders in. I think the administrative nurses were working the floor and it got overlooked. The interim Administrator stated he was not aware Resident #1's sucralfate dose was also increased. When asked if the facility had completed education on medication reconciliation, the interim Administrator stated he personally didn't conduct any education but he stated the clinical or regional nurse could have conducted the education. During an interview on 12/1/23 at 2:56 p.m., Physician B stated Resident #1 was one of the patients seen by himself as well as the group of physicians he was a part of. Physician B stated he heard Resident #1 was sent out to the hospital. Physician B stated he was not aware of any issues with Resident #1's medications and was not aware of any changes to Resident #1's dexlansoprazole or sucralfate doses. Physician B stated a proton pump inhibitor (like dexlansoprazole) would be necessary if a resident had an ulcer. During an interview on 12/2/23 at 2:10 p.m., ADON F stated the day Resident #1 returned to the hospital on 11/11/23 was a weekend. ADON F stated the admitting nurse must have received the packet and Resident #1 was on 30 mg of dexlansoprazole before. ADON F stated when Resident #1 came back from the hospital the dose was changed to 60 mg. ADON F stated she believed the change was omitted by the nurse, meaning the 60 mg change was not done and Resident #1 continued on the 30 mg dose. During an interview on 12/2/23 at 3:54 p.m., LVN E stated she sent Resident #1 to the hospital because he had black emesis. LVN E stated she was not aware of any concerns about Resident #1's gastrointestinal medication. LVN E stated she did not notice Resident #1's dexlansoprazole and sucralfate medication doses had increased. Record review of the facility's staff roster, dated 12/2/23, revealed the facility had 33 nurses. Record review of an educational in-service, dated 11/28/23, revealed 12 staff members were educated on the medication administration policy and on medication reconciliation. Of the 12 staff members, 8 were nurses. Record review of a facility policy titled, Medication - Administration, not dated, revealed the following: Medications may be administered one hour before or after the scheduled medication administration time. Record review of a facility policy titled, Drug Regimen Review, dated 6/2020, revealed the following: Upon admission, medications will be reviewed with the attending physician to identify clinically significant risks and/or actual potential adverse consequences which may result from or be associated with medications. The Administrator was notified of an IJ on 12/1/23 at 5:30 p.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 12/2/23 at 9:34 a.m. and included the following: Identify residents who could be affected. Residents who are admissions or readmissions have the potential to be affected. Identify responsible staff/ what action taken. 1. Director of Nurses and Assistant Director of Nursing (ADON) re-educated by the Regional Clinical Nurse on the facility policy for reconciliation of medications on admission/readmission on 12/1/2023. 2. All RN and LVN's educated on procedure of reconciliation of medications on all admission/readmission on 12/1/2023 by Regional Clinical Nurse/DON. 3. ADON's were re-educated on medication reconciliation of all admission/readmissions to ensure reconciliation. Education was completed on 12/1/2023. 4. An audit on all admissions/readmissions in past 30 days to ensure accuracy of medication reconciliation was started on 12/1/2023 and will be completed 12/2/23. 5. All new hires will be educated on this process by DON/Designee prior to starting work. This will be ongoing. In-Service conducted. 1. Director of Nurses and ADON's re-educated by the Regional Clinical Nurse on the facility policy for reconciliation of medications on admission/readmission on 12/1/2023. 2. All RN and LVN re-educated on procedure of reconciliation of medications on all admission/readmission on 12/1/2023 by Regional clinical Nurse/ DON. 3. ADON's were re-educated on medication reconciliation of all admission/readmissions to ensure reconciliation. Education was completed on 12/1/2023. Implementation of Changes Director of Nurses and Regional Nurse Consultant were re-educated on the facility policy for reconciliation of medications on admission/readmission on 12/1/2023 by Director of Clinical Education. All RN and LVN re-educated on procedure of reconciliation of medications on all admission/readmission on 12/1/2023 by Regional clinical Nurse/ DON. ADON's were re-educated on review of all new admission/readmissions, medications to be checked to ensure reconciliation is completed on 12/1/2023. All new hires will be educated on this process by DON/Designee prior to starting work. This will be ongoing. An audit on all admissions/readmissions in past 30 days to ensure accuracy of medication reconciliation was started on 12/1/2023 and will be completed on 12/2/23. DON/ADON's will review all admission/readmission orders to ensure accuracy of medication reconciliation within 24 hours of admission/readmission. All re-education and audits were initiated 12/1/2023 by the Regional Nurse Consultant/DON. The changes were implemented effective on 12/1/2023 and re-education is ongoing. Staff will not be allowed to work until they have been fully re-educated. All new hires will be educated on medication reconciliation, prior to working the floor by DON/Designee. The DON/Designee will ensure competency through signing of in service and verbalization of understanding. DON/Designee will complete audit of all admissions/readmissions daily. Monitoring The Administrator/DON/Designee will be responsible for monitoring the implementation and effectiveness of in-service conducted on 12/1/2023 and ongoing. -The Director of Nursing/Assistant Director of Nursing/Regional Nurse Consultant will monitor/review all new admission/readmission daily x4 weeks, then weekly thereafter to be ongoing and report any adverse findings to the QAPI committee. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 12/1/2023 and conducted an Ad HOC QAPI regarding ensuring orders on all new admissions/readmissions are reconciled accurately and in a timely manner. The Medical Director was notified about the immediate Jeopardy on 12/1/2023, the Plan of removal was reviewed and accepted by Medical Director. Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, to review the plan of removal on 12/1/2023. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of New Process. The New Process/ system was started on 12/1/2023. The surveyor verification of the Plan of Removal on 12/2/23 was as follows: During an interview on 12/2/23 at 2:10 p.m., ADON F stated she received education on the medication reconciliation policy. ADON F stated she received education to include the review of all new admission/readmissions to ensure medication reconciliation. ADON F was able to explain the process for medication reconciliation. During an interview on 12/2/23 at 2:20 p.m., the Director of Clinical Education stated she educated the DON, ADON, and the Regional Clinical Nurse on the facility policy for reconciliation of medications on admission/readmission on 12/1/23. During an interview on 12/2/23 at 3:09 p.m., the interim DON stated she received education on the medication reconciliation policy. The interim DON stated she had informed all staff that they were not allowed to work until they received the new education on medication reconciliation. The interim DON stated she planned on being present at the change of shift to ensure all staff members are educated prior to the start of the shift. The interim DON stated the audits would be conducted daily, including the weekends by herself and the ADONs. The interim DON stated an audit of residents who were admitted /readmitted within 30 days was completed by several administrative nurses. The interim DON stated the facility had a new addition to the new hire education to include education for the medication reconciliation. The interim DON stated the admission/readmission audits would be done daily and the resultswouldl be reported to the QAPI meeting. The interim DON stated she would provide oversight over the ADONs to ensure the completion of the admission/readmission audits. These audits will then be presented to the facility's morning meeting. During an interview on 12/2/23 at 2:24 p.m., the interim Administrator stated he was responsible for the implementation of the New Process. The interim Administrator stated the audits would be reviewed in the morning meeting and the nursing staff attending the morning meeting will be reviewing the resident's medical chart at the same time to ensure the medication reconciliation was completed. During an interview on 12/2/23 at 4:05 p.m., the interim Administrator stated an adhoc QAPI meeting was completed on 12/1/23 to discuss the findings of the immediacy and POR. During interviews conducted on 12/2/23 from 12:57 p.m. to 7:53 p.m., a total of 20 LVNs and RNs were interviewed. This included 4 administrative nurses, 3 7am - 3pm nurses, 4 3pm - 11pm nurses, 4 11pm - 7am nurses, and 5 double-shift nurses (7am - 3pm, 3pm - 11pm) were interviewed. All staff interviewed confirmed they received education on medication reconciliation for admissions and readmissions. All staff were able to verbalize understanding of the in-service and the medication reconciliation process. Record review of the facility's educational sign-in sheet, dated 12/2/23, revealed the facility had 33 RNs and LVNs employed. Of the 33 staff, 33 had been educated as of 12/2/23. Record review of educational sign-in sheet, dated 12/1/23, revealed the Regional Clinical Nurse and the DON were re-educated on the Admission and Transfer policy and Medication Drug Regimen Review policy. ADON F was educated the Admission and Transfer policy and Medication Drug Regimen Review policy on 12/2/23. Record review of educational in-services, dated 12/2/23, revealed the facility's ADONs have received the education on admission/readmission and medication reconciliation. Record review of an untitled facility report revealed 60 residents had been admitted within the last 30 days. Record review of an untitled document, dated 12/2/23, revealed the facility completed its audit to ensure medication reconciliation was completed for admissions and readmissions within the last 30 days. Record review of 3 residents who were recently admitted /readmitted within the last 30 days revealed all medications appeared to be current and ordered as prescribed. Record review of untitled document, not dated, revealed the facility had an audit form in place for readmissions and admissions including a column to ensure orders were reconciled by the nurse, completed by the DON, discrepancies were noted, and that the MD and nurse manager were notified. Record review of a facility document, titled [facility name] New Hire Nurse Education, not dated, revealed a new document had been created to accommodate the new education on medication reconciliation for new hires. Record review of QAPI form, dated 12/1/23, revealed a QAPI meeting was conducted regarding the IJ and the plan of removal. Record review of the facility's QAPI agenda, dated for 12/19/23, revealed the facility will discuss the results of their admission/readmission audits int eh QAPI Meeting. On 12/2/23 at 9:48 p.m., the interim Administrator and the interim DON were notified the IJ was removed. While the IJ was removed on 12/02/2023, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy because the facility needed to monitor their corrective actions.