Every finding on record at Signature Pointe

Based on observation, interview and record review the facility failed to post in a form and manner accessible and understandable to residents and resident representatives a list of names, addresses (mailing and email, and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit for 1 of 1 buildings reviewed for postings The facility failed to ensure the number to HHS Long Term Care Regulatory (state survey and certification agency) number for filing grievances, or complaints or suspected violations of state or Federal violations was posted. This failure could place residents at risk of lack of knowledge of who to contact should they require advocacy, investigation, and not knowing their rights, how to exercise their rights, or investigations into violations of their rights.Findings include: An observation throughout the facility on 04/14/26 at 10:40,9:15 AM and 04/15/26 at 9:15 AM, revealed there was a single posting on the 1st floor only, and no HHSC complaint number and statement that the residents may file a complaint with the State Survey Agency posted in any other location of the facility. Further observation revealed all public areas of the facility including, and the dining room, the posting for the abuse number was not posted.During an Observation and interview on 04/16/26 at 11:20 AM SW stated she does the update of the ombudsman and abuse coordinator with paper postings. She stated the facility had an interim ombudsman due to the current one being promoted. She stated as a temporary fix they have posted throughout the facility on all floors, provided contact information for both the Ombudsman and ADMIN. SW stated she does not have access to the glass cabinets displaying the postings but added I would think either the ADMIN or Maintenance supervisor would have the key access to the glass cabinets. The SW stated they have had an issue with the one cabinet located in the elevator. During an interview on 04/16/26 at 11:55 AM ADMIN stated it was important to have this signage posted on each floor. ADMIN stated she did not know why there was no HHSC complaint number and statement that the resident may file a complaint with the State Survey Agency posted in the facility. The ADMIN stated it was important to have this signage posted so residents will know how to file a complaint regarding staff. The Administrator said the risk to the residents would be unreported abuse and neglect.Record review of the facility's policy and procedure on Resident Rights, revised February 2021, reflected: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: Communicate with outside agencies (e.g., local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection, or advocacy organizations etc.) regarding any matter.

Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for four of eighteen residents (Residents #19, #52, #67, and #79) reviewed for medication storage. 1. The facility failed to ensure Resident #52 did not have a muscle cramp foam inside her room on 04/14/2026. 2. The facility failed to ensure Resident #67's did not have a nasal spray and adaptogenic mushroom inside his room on 04/14/2026. 3. The facility failed to ensure Resident #79 did not have a pain relieving gel inside her room on 04/15/2026. 4. The facility failed to ensure Resident #19 did not have a pain relief ointment inside her room on 04/15/2026. These failures could place residents at risk of wrong medication administration, accidental overdose, misuse of medications, and possible adverse reactions.Findings included: 1. Record review of Resident #52's Face Sheet, dated 04/16/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle spasm and chronic pain.Record review of Resident #52's Quarterly MDS Assessment, dated 03/12/2026, reflected that the resident was unable to complete the interview to determine the BIMS score. The Staff Assessment for Mental indicated that the resident had memory problem. The Quarterly MDS Assessment showed that the resident had muscle spasm and chronic pain.Record review of Resident #52's Comprehensive Care Plan, dated 04/15/2026, reflected the resident had chronic pain and one of the interventions was administer analgesic medication.Record review on 04/14/2026 of Resident #52's Assessment Notes reflected the resident did not have an assessment for self-administration of medications.Record review on 04/14/2026 of Resident #52's Physician Order reflected no order for muscle cramp foam.During an observation and interview on 04/14/026 at 9:18 a.m. revealed Resident #52 was in her bed, awake. It was observed that a container of muscle cramps foam was on top of the resident's side table and was on plain view. The resident said the medication was hers but she was not using it.During an observation and interview on 04/14/2026 at 9:26 a.m., RN B said he did not notice that there was a medication inside Resident #52's room. He said if the resident did not have an assessment for safe self-administration, then no medications should be inside their room because the staff would not be able to assess if the resident was using it appropriately or how many times the resident was applying it. He went inside the room, talked to the resident and took the muscle cramp foam. He said he would also check if the resident needed the muscle cramp foam so he could request for an order for it. He said if the medication was ordered, the staff should be the one administering it.2. Record review of Resident #67's Face Sheet, dated 04/16/2026, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with age related cataract (lens of the eyes become cloudy leading to blurred vision and difficulty seeing clearly). Record review of Resident #67's Quarterly MDS Assessment, dated 02/01/2026, reflected the resident was cognitively intact with a BIMS score of 15. Record review of Resident #67's Comprehensive Care Plan, dated 02/14/2026, reflected the resident had impaired visual function and one of the interventions was to ensure appropriate visual aids were available.Record review on 04/14/2026 of Resident #67's Assessment Notes reflected the resident did not have an assessment for self-administration of medications.Record review on 04/14/2026 of Resident #67's Physician Order reflected the resident did not have an order for nasal spray and adaptogenic mushroom (fungi that may help the body manage stress).During an observation and interview on 04/14/2026 at 9:46 a.m. revealed Resident #67 was in his wheelchair inside room. It was observed that a nasal spray and a bottle of adaptogenic mushroom were on top of his drawer that was in line with the resident's door. The resident said those were his medications and he took the adaptogenic mushroom to increase his strength.During an interview on 04/14/2026 at 11:18 a.m., ADON A said residents should not have any medications inside their room because the staff would not be able to monitor the effectiveness of the medications and how often the residents were administering them. She said confused resident might apply the medication every thirty minutes and no one would know. She said she would go to Resident #67's room to check if he still have the nasal spray and the adaptogenic mushroom. She said he did not even know what the effect of adaptogenic mushroom to the resident or its potential interactions with the medications he was taking.3. Record review of Resident #79's Face Sheet, dated 04/16/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with dementia (a condition characterized by loss of memory and ability to reason) and osteoarthritis (a type of arthritis that happens when the cartilage that lines your joints is worn down and your bones rub against each other). Record review of Resident #79's Quarterly MDS Assessment, dated 03/09/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident had dementia, osteoarthritis, and was in pain in the last seven days.Record review of Resident #79's Comprehensive Care Plan, dated 02/19/2026, reflected the resident had was taking an anticoagulant (medication used to prevent blood clotting) and one of the interventions was to monitor for muscle joint pain.Record review on 04/15/2026 of Resident #79's Assessment Notes reflected that the resident did not have an assessment for self-administration of medications.Record review on 04/15/2026 of Resident #79's Physician Order reflected that the resident did not have an order for pain relieving gel.During an observation and interview on 04/15/2026 at 9:53 a.m. revealed Resident #79 was in her bed, awake. It was observed that a pain relieving gel was on top of the resident's side table. The resident said the relieving gel had always been in her side table. she said nobody mentioned to her that she cannot have a pain relieving gel inside her room.During an observation and interview on 04/15/2026 at 10:09 a.m., the WCN said there should be no medications inside the room because residents might use them inappropriately, like consuming them or applying their eyes or nose. She said she would talk to Resident #79 about the medication. She went inside the resident's room, talked to the resident, and took the medication. She said she would give it to the charge nurse. During an interview on 04/15/2026 at 12:07 p.m., LVN H said the WCN told him about the medication inside the Resident #79's room. He said he did not notice the medication when he did his morning round. He said, sometimes family members would bring the medications so they also needed to talk to the family members to let them know if they were bringing any medication for the residents. 4. Record review of Resident #19's Face Sheet, dated 04/16/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with fibromyalgia. Record review of Resident #19's Comprehensive MDS Assessment, dated 03/29/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had fibromyalgia and was occasionally in pain. Record review of Resident #19's Comprehensive Care Plan, dated 04/07/2026, reflected the resident had chronic pain and one of the interventions was administer analgesia as ordered.Record review of Resident #19's Physician Order, dated 04/12/2026, reflected Biofreeze External Cream 10 % (Menthol (Topical Analgesic). Apply to AFFECTEDAREAS topically every 6 hours as needed for PAIN.Record review on 04/15/2026 for Resident #19's Assessment Notes reflected the resident did not have an assessment for self-administration of medications.During an observation and interview on 04/15/2026 at 12:35 p.m., Resident #19 was in her wheelchair, awake. it was observed that a full cup of green ointment was on top of the resident's overbed table. The resident said she asked the therapist to give her some biofreeze and the therapist handed it to her.During an observation and interview on 04/15/2026 at 12:46 p.m., the WCN said she did not notice the cup with green ointment on top of Resident #19's table. She went inside Resident #19's room, talked to the resident, and took the cup of biofreeze ointment. She said the resident said the green ointment was biofreeze and she asked the therapist to get her some. She said she would let the DON know that a therapist handed over the biofreeze so he could communicate the issue to the department of therapy.During an interview on 04/16/2026 at 6:46 a.m., ADON A said the therapist should have not given Resident #19 her biofreeze because the therapist was not authorized to dispense medications. She said the therapist should have called the nurse if the resident requested for it. She said medications should not be inside the residents' rooms because confused residents might use them inappropriately. She said the staff should be mindful that when they check on the residents, they check also if the they have any medications inside their room. She said topical medications could cause harm if applied to the skin too much. She said too much topical medication could cause skin damage. She said even supplements could be harmful if there was no order for it and if nobody knew if the supplement had any effect on the medications being taken by the residents. She they already started an inservice about medications inside the rooms of the resident.During an interview on 04/16/2026 at 7:21 a.m., the DON said he already talked to the DOR regarding a therapist giving Resident #19 her biofreeze. He said the DOR already talked to the therapist and provided an one-on-one in-service regarding not dispensing any medication. He said the therapist should have called a nurse when the resident requested for the biofreeze because the therapist was not authorized to hand-over medications. said medications should not be inside the rooms of the residents because it could cause probable harm such as misuse, overmedication, or allergic reactions. He said the staff did not even know how often the residents were applying the topical medications, the nasal spray, and the supplement. He said the expectation was for the staff to make sure there were no medications inside the room. He said if the resident needed the medications, then the staff should request orders for the medications and the staff should be the one giving the medications to them. He said he also talked to the family members to let them know if they bringing any medications to the facility. He said she had already started an in-service about over-the-counter medications. He said the residents should have an assessment that they could safely administer medications before medications could be left with them. During an interview on 04/16/2026 at 7:59 a.m., the Administrator said the expectation was for the staff to make sure there were no medications inside the residents' rooms the residents might consume them or use them on their eyes causing irritation. She said the DOR already talked to the therapist not to give any medication found inside the room. She said residents could not administer any medication with an assessment that it would be safe for the residents to take the medications by themselves. She said the DON already started an in-service about over-the-counter medications but would still closely coordinate with the DON to monitor the adherence of the staff to the policies.During an interview on 04/16/2026 at 8:26 a.m., the DOR said he already talked to the PRN therapist who handed over a cup of medication to a resident. He said he told the therapist to call the nurses when a resident requested any medication from inside their room. Record review of the facility's policy Medication Labeling and Storage Nursing Services Policy and Procedure Manual for Long-Term Care revised 2023 reflected Policy Statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls.Record review of the facility's In-Service OTC Medications and Self-Administration, dated April 15, 2026, reflected Over-the-counter (OTC) medications are not permitted at the bedside unless a self-administration assessment has been completed and the resident has been deemed appropriate . Any unauthorized medications found at bedside must be removed and addressed.

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 the facility's main kitchen and two of two substations, reviewed for food and nutrition services. The [NAME] failed to wear a hair net to properly cover her entire head while food was being prepared.The facility failed to properly seal food stored in the freezer.The facility failed to ensure the ice machine and ice scoop, located in the substation on the 4th floor, was thoroughly cleaned.The facility failed to ensure the microwaves in the dining area of the 3rd and 4th floors were properly cleaned.The facility failed to ensure proper pest control in the dining area of the 4th floorThe facility failed to ensure the trashcan in the main kitchen had a lid on it.The facility failed to ensure the sanitizer bucket (red bucket) in the substation on the 4th floor had the appropriate level of sanitizer fluid in it. These failures placed residents at risk of exposure to food contamination and illness. Findings included:Observations on 04/16/26 from 9:26 a.m. to 9:46 a.m. in the facility's only kitchen revealed: [NAME] M was observed in the kitchen area, while food was being prepared, and she was wearing a ball cap. She had a large ponytail protruding from underneath the ball cap, that was not covered. An ice machine, located in the substation on the 4th floor, had white stains on the inside panel wall and dark stains on the inside metal panel of the ice machine. An ice scoop holder storing an ice scoop, located in the substation on the 4th floor, had a pool of water in it. One large sheet of cake, located in the freezer, was not completely sealed and exposed to air. Two of two microwaves, located in the dining area on the 3rd and 4th floor, had dried food stains along the inside panel walls. A tray of six clean small serving bowls, located in the dining area on the 4th floor, had a German roach crawling between the bowls. A large trashcan in the main kitchen area did not have a lid on it.During an interview and observation on 04/15/26 at 12:30 p.m., revealed [NAME] E was plating food for the residents lunch in the kitchen substation on the 3rd floor. The Dietary Manager stated the sanitizer bucket (red bucket) in the kitchen had the appropriate amount of sanitizer solution in it. The Dietary Manager tested the solution in the container, and the PPM registered at 0, which indicated no sanitizer solution was registered in the mixture. The DM stated he normally tested the buckets throughout the day to ensure it had the appropriate level of sanitizer solution in it. He stated the bucket needed to have the appropriate amount of sanitizer solution in it to effectively clean spills while serving food to residents.During an interview on 04/16/26 at 11:41 a.m., the Plant Operations Supervisor stated when staff observed pests or rodents, they were to chart it into the pest control book and when the pest control came to the facility to treat the facility, they treated the area. He stated the pest control person reviewed the pest control book to determine what area needed to be treated. He stated pest control was scheduled to treat the inside of the facility bi-weekly or if there was an emergency. He stated he was made aware of the roach observed in the dining area on the 4th floor and pest control was notified. He stated pest control was at the facility on 04/15/26 and treated the entire 4th floor. During an interview on 04/16/26 at 12:50 p.m., the Administrator was informed by the Surveyor of the findings in the kitchen area. She stated she expected the Dietary Manager to ensure all kitchen standards were met to avoid any food contamination. She stated she would follow up with the Dietary Manager.During an interview on 04/16/26 at 1:15 p.m., the Dietary Manager was informed by the Surveyor of the concerns observed in the main kitchen and the substations on the 3rd and 4th floor. He stated they had cleaned the ice machine and replaced the dirty microwaves. He stated the ice scoop holder was cleaned. He stated he will ensure the food in the feezer was properly sealed to avoid contanmination. He stated he in-serviced his team on 04/15/26 on wearing the appropriate head coverings. He stated the risk of not addressing the concerns mentioned could result in food contamination. Record Review of the Facility's policy titled Food Storage, dated 2023, revealed, Sufficient storage facilities will be provided to keep food safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Record Review of the Facility's policy titled Employee Hygiene for Food Safety, dated 2023, revealed, All food and nutrition service employees will practice good personal hygiene and safe food handling. Wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food.Record Review of the Facility's policy titled Cleaning and Sanitation of Dining and Food Service Areas, dated 2023, revealed, The food and nutrition staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance written, comprehensive cleaning schedule.Review of TITLE 21--FOOD AND DRUGS CHAPTER I--FOOD AND DRUG ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICESSUBCHAPTER B - FOOD FOR HUMAN CONSUMPTION PART 110 -- CURRENT GOOD MANUFACTURING PRACTICE IN MANUFACTURING, PACKING, OR HOLDING HUMAN FOOD.

Based on observations, interviews, and record review, the facility failed to ensure each bed have ceiling suspended curtains, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains for seven of fifteen residents (Residents #4, #48, 50, #64, #73, #95, and #100) reviewed for privacy and confidentiality.The facility failed to ensure Residents #4, #48, #50, #64, #73, #95, and #100 had privacy curtains for their privacy. This failure could place the residents at risk of not having their personal privacy maintained while care was provided, which could result in the residents feeling uncomfortable during care and having their personal and medical record exposed to unauthorized individuals.Findings included:During an observation on 04/14/2026 at 11:40 a.m., revealed Resident #100's privacy curtain was stuck in the track and could not close.During an observation on 04/14/2026 at 11:53 a.m., revealed Resident #50 had no privacy curtain in a shared room. During an observation on 04/14/2026 at 12:05 p.m., revealed Resident #4 had no privacy curtains and Resident #64 had no privacy curtains for the foot of her bed. During an observation on 04/16/2026 at 8:55 a.m., revealed Resident #95 had no privacy curtains for the foot of her bed in a shared room.During an observation on 04/16/2026 at 8:55 a.m., revealed Resident #73 had no privacy curtains for the foot of her bed in a shared room.During an interview on 04/16/26 at 11:30 a.m., the DON was informed by the Surveyor of Residents #4, #48, #50, #64, #73, #95, and #100 not having the privacy curtains. He stated he and the Administrator had went to the 4th floor and identified the residents' rooms that did not have complete privacy curtains. He stated they corrected some of the rooms but had to order more privacy curtains. He was informed by the Surveyor of CNA S providing incontinent care to Resident #48 and the resident room door was open and the privacy curtain was partially drawn. He stated the resident's door should have been closed and the curtains should have been drawn for the resident's dignity.During an interview on 04/16/26 at 12:00 p.m., ADON S was informed by the Surveyor of Residents #4, #48, #50, #64, #73, #95, and #100 not having the privacy curtains. She stated she was made aware of this by the DON. She stated housekeeping had ordered curtains for the residents. She was informed by the Surveyor of CNA S providing incontinent care to Resident #48 and the resident room door was open and the privacy curtain was partially drawn. She stated the residents needed privacy curtains for their dignity. Record review of the facility's policy, Resident Rights, dated 02/21, reflected Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;

Based on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of twelve (Resident #9, and #74) reviewed for respiratory care. The facility failed to ensure Resident #9 had physician's orders for the use of an oxygen concentrator. The facility failed to ensure Resident #74 had an order for her suction use on 04/14/2026. These failures could place the residents at risk of respiratory infection, respiratory complications, and not having their respiratory needs met.Findings included: Record review of Resident #9's Face Sheet, dated 04/15/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy (hole in neck to allow air to pass).Record review of Resident #9's Comprehensive MDS Assessment, dated 1/01/26, reflected Resident #9 had a BIMS of 99 (unable to complete the interview). Record review on 04/14/2026 of Resident #9's Comprehensive Care Plan, dated 1/07/26, reflected no plan of care for oxygen use. Record review of Resident #9's Physician's Order, dated 04/14/26, reflected no physician's orders for oxygen use.During an observation on 04/14/26 at 11:05 p.m., revealed Resident #9 was lying in bed and she was using an oxygen concentrator by way of a nasal cannula. During an interview and record review on 04/15/26 at 11:13 a.m., RN M was informed by the Surveyor of Resident #9 not having a physician's order for the use of an oxygen concentrator. RN M verified the resident did not have physician orders and he stated it was required because it was a medication for the resident. He stated it was needed for the resident's safety. During an interview and record review on 04/15/26 at 12:52 p.m., ADON S was informed by the Surveyor of Resident #9 not having physician orders for the use of an oxygen concentrator. She stated she was informed of this by one of her nurses. She stated the resident required physician orders for the device. She stated the resident had orders for use of the oxygen device but it may have discontinued. She stated physician orders were needed to ensure the resident received the oxygen.During an interview on 04/16/26 at 12:26 p.m., the DON was made aware of Resident #9 not having physician orders for the oxygen device. He stated physician orders were required for the resident. He stated the admitting nurse should ensure the resident had physician orders for particular care. He stated if the resident did not have orders, their care may not be carried out.Review of Resident #74's Face Sheet, dated 04/16/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hemiplegia (paralysis of one side of the body) and dysphagia (difficulty in swallowing).Review of Resident #74's Quarterly MDS Assessment, dated 03/19/2026, reflected that the resident was unable to complete the interview to determine the BIMS score. The assessment indicated that the resident had memory problem. The Quarterly MDS Assessment did not show that the resident was using a suction machine.Review of Resident #74's Comprehensive Care Plan, dated 02/05/2026, did not reflect that the resident was using a suction machine.Record review of Resident #74's Physician Order on 04/14/2026 reflected that the resident did not have an order for suctioning.During an observation and interview on 04/15/2026 at 7:14 a.m., revealed a suction machine was on top of the Resident #74's side table. Resident #74 did not reply when asked about her suction machine.During an observation and interview on 04/15/2026 at 7:38 a.m., LVN C said that Resident #74 had been using the suction machine for more than four months. She said the suction was used when there was an accumulation of secretions in the resident's mouth. She logged on to her computer and checked if the resident had an order for suctioning. She said she did not see an order for the resident's suctioning and that she did not notice that there was no order for the resident's use of the suction machine. She said there should be an order for the suction machine because the direct staff were using the suction machine to clear the resident's secretions. She said there should be an order for all the treatment being done for the resident. During an interview on 04/16/2026 at 6:56 a.m., ADON A said there should be a physician's order for the suction machine use because it was a medical procedure that was used if there was accumulation of secretions in the airway or if there was any sign of respiratory distress. She said the order should reflect the procedure, it's frequency, and the rationale why it was used. She said it was an oversight on the part of charge nurses taking care of Resident #74 because they did not notice that there was no order for suctioning. She said it was also an oversight on her part because she did not audit the resident's orders. She said they already started an in-service about orders.During an interview on 04/16/2026 at 7:27 a.m., the DON said there should be an order for Resident #74 suction use to ensure that the resident was assessed and it was a medical necessity. He said there should be physicians' orders in everything done for the residents to ensure safety, compliance, and coordinated care. He said the physicians' orders were fundamental and served as instructions on how to ensure the residents were receiving proper care. He said he already started an in-service about making sure there was a physician's order on everything done for the residents.During an interview on 04/16/2026 at 7:59 a.m., the Administrator said if the resident had a suction machine, then there should be an order for it because it was a treatment done by the nurses. She said there should be physicians' orders for medications, treatment, diet, and therapies. She said the DON already started an in-service about physician orders but would still closely coordinate with the DON to monitor the adherence of the staff to the policies.Record review of the facility's policy, Medication and Treatment Orders Nursing Services Policy and Procedure Manual for Long-Term Care revised July 2016 reflected Policy Statement: Orders for medications and treatments will be consistent with principles of safe and effective order writing . Policy Interpretation and Implementation . 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state . 9. Orders for medications must include . a. name and strength of the drug; b. number of doses, start and stop date, and/or specific duration of therapy; c. dosage and frequency of administration; d. route of administration; e. clinical condition or symptoms for which the medication is prescribed.

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for three of five residents (Resident #8, #74, and #125) reviewed for feeding tube management.1. The facility failed to ensure LVN D checked Resident #8's g-tube placement before flushing and administering medications on 04/15/2026. 2. The facility failed to ensure LVN C checked Resident #74's residual before flushing and medication administration on 04/15/2026.3. The facility failed to ensure LVN A checked Resident #125's g-tube placement before flushing and administering medications on 04/15/2026. These failures could place residents with g-tubes at risk for tube displacement, clogging, aspiration, and discomfort.Findings included:1. Record review of Resident #8's Face Sheet, dated 04/16/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with gastrostomy.Record review of Resident #8's Comprehensive MDS Assessment, dated 01/15/2026, reflected that the resident was unable to complete the interview to determine the BIMS score. The Staff Assessment for Mental indicated that the resident had memory problem. The Comprehensive MDS Assessment indicated the resident had a feeding tube (a way of providing nutrition directly to the stomach).Record review of Resident #8's Quarterly Care Plan, dated 04/15/2026, reflected the resident required tube feeding and one of the interventions was to check for tube placement.Record review of Resident #8's Physician Order, dated 09/02/2025, reflected Enteral Feed Order every day shift Check G-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach) placement prior to administration of water/formula/med through the tube.During an observation on 04/15/2026 at 1:25 p.m. revealed LVN D was about to administer Resident #8's medications via g-tube. He sanitized his hands, put on a pair of gloves, and sanitized the resident's overbed table. After sanitizing the overbed table, he took off his gloves, and sanitized his hands, and placed a towel on top of the overbed table. He then started to prepare the resident's medications. He put each medication in small plastic cups, crushed them, returned the crushed medications to the small plastic cups, and dissolved them. He also prepared a cup of water. He sanitized the bell of his stethoscope and hang it on his shoulders. He went inside the resident's room bringing with him the medications and the cup of water and placed them on top of the overbed table. He took 60 ml piston syringe from the IV post and placed it also on top of the overbed table. He washed his hands and put on a gown and a pair of gloves. He raised the resident's bed, elevated the head of the bed, turned off the machine, and disconnected the g-tube from the formula. After disconnecting the g-tube, he took his stethoscope and assessed the resident's abdomen by placing the bell of the stethoscope on the upper and lower quadrants of the abdomen. After assessing the abdomen, he attached the syringe to the g-tube, and checked for the residual (amount of formula, water, and secretions left in the stomach) by pulling the plunger of the syringe. He then disconnected the syringe, pulled the plunger, connected the barrel of the syringe to the g-tube, flush the g-tube, and poured the dissolved medications one by one flushing in between medications. He did not check for the placement of the resident's g-tube before flushing and administering the medication. After he was done administering the medications, he flushed the g-tube, detached the syringe, connected the g-tube to the formula, and cleaned the table and the syringe.During an interview on 04/15/2026 at 1:44 p.m., LVN D said he did auscultate (listening to the sounds inside the body using a stethoscope) the abdomen of Resident #8 by placing the bell of the stethoscope on the four quadrants of the resident's abdomen to listen to the bowel sounds. He said, but to check for the placement of the g-tube, he should have used his stethoscope by listening to the whoosh sound when air was introduced. He said the placement of the g-tube should be checked to make sure that the g-tube was not dislodged. He said the dislodged g-tube could cause aspiration. 2. Review of Resident #74's Face Sheet, dated 04/16/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with gastrostomy status.Review of Resident #74's Quarterly MDS Assessment, dated 03/19/2026, reflected that the resident was unable to complete the interview to determine the BIMS score. The Staff Assessment for Mental indicated that the resident had memory problem. The Quarterly MDS Assessment showed the resident had a feeding tube. Review of Resident #74's Comprehensive Care Plan, dated 02/05/2026, reflected the resident had a g-tube and one of the interventions was for care staff to monitor aspiration.Review of Resident #74's Physician Order, dated 10/24/2026 reflected every day shift Check residual: if < 100 cc return to stomach and continue with med/formula administration. If residual > 100cc hold medications/formula for 1 hour then reassess. Flush with 15-30 cc tap water and clamp tube.During an observation on 04/15/2026 at 7:19 a.m. revealed LVN C was about to administer Resident #74's medication via g-tube. She sanitized her hands, put on a pair of gloves, and sanitized the resident's overbed table. After sanitizing the overbed table, she took off her gloves, and sanitized her hands, and placed a wax paper on top of the overbed table. She then started to prepare the resident's medications. She put the medications in small plastic cups, crushed them, and returned the crushed medications to the small plastic cups. She then went inside the resident's room bringing with her the medications and placed them on top of the overbed table. She went to the sink to get some water, placed it on top of the table, and dissolved the medications. She also placed the syringe on top of the table. She then sanitized the bell of her stethoscope using an alcohol wipe and placed it also on the table. She washed her hands and put on a gown and a pair of gloves. She raised the resident's bed, elevated the head of the bed, turned off the machine, and disconnected the g-tube from the formula. After disconnecting the g-tube, she took the syringe, pulled the plunger halfway, connected it to the gtube, and checked the placement of the g-tube via auscultation. After checking for the placement, she disconnected the syringe, pulled the plunger out of the syringe, connected it again to the g-tube, and flushed the g-tube. After flushing the g-tube, she poured the dissolved medications one by one and flushed in between medications. She did not check for the residual before flushing and medication administration. After she was done administering the medications, she flushed the g-tube, detached the syringe, and cleaned the table and the syringe.During an observation and interview on 04/15/2026 at 7:38 a.m., LVN C said she did not see an order to check the gastric residual before medication administration. She logged on to her computer and checked Resident #74's orders. She said there was an order to check the residual before administering medications and she missed it. She said the residuals should be checked to make sure that the resident's stomach was functioning properly. She said the residual be checked to see if the content of the stomach was not too much because the resident might throw up if the or might aspirate if the stomach was still full. She said even though there was no order for checking the residuals, the best practice was to check it to prevent any adverse reactions.3. Record review of Resident #125's Face Sheet, dated 04/16/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with gastrostomy status.Record review of Resident #125's Comprehensive MDS Assessment, dated 04/10/2026, reflected the resident's full ARD would be on 04/23/2026.Record review on 04/14/2026 of Resident #125's Baseline Care Plan revealed the resident was not care planned for tube feeding.During an observation on 04/15/2026 at 6:16 a.m. revealed RN A was about to administer Resident #125's medication via g-tube. He put the medication in a small plastic cup, crushed them, returned the crushed medication to the small plastic cup, and dissolved it. He went inside the room and brought with him the medication and a cup of water and put them on the overbed table. He took a 60 ml piston syringe from the resident's IV pole and placed it also on the overbed table. He put on a gown and a pair of gloves, raised the bed, elevated the head of the bed, turned off the machine, and disconnected the g-tube from the formula. After disconnecting the g-tube, he attached the syringe to the g-tube, and pulled the plunger of the syringe to check for the residual. After checking for the residual, he disconnected the syringe, pulled the plunger out of the syringe, attached the barrel of the syringe to the g-tube, and flushed it. After flushing the g-tube, he poured the dissolved medication, and flushed it. He did not check for placement of the resident's g-tube before flushing and administering the medication. After he was done administering the medication, he flushed the g-tube, detached the syringe, and cleaned the table and the syringe.During an interview on 04/15/2026 at 6:56 a.m., RN A said every time the g-tube would be used to, like connecting the formula or administering medications, the placement should be checked to make sure the formula and the medication would go to the stomach and that the tube was not displaced. He said he did not know why he forgot to check for placement of the g-tube.During an interview on 04/16/2026 at 6:56 a.m., ADON A said g-tube placement and gastric residual should be checked before introducing water and administering medications. She said g-tube placement should be checked to ensure the g-tube was in the right place and would not cause aspiration. She said even though the residents were on continuous feeding, the placement should still be checked. She said gastric residuals were also checked prior to flushing and medication administration to see if the stomach could accommodate the water and the medications. she said checking for the residual was also one way to assess if the stomach was emptying. She said not checking the residual might cause vomiting and aspiration pneumonia. She said the expectation was for the staff to check for g-tube placement and the gastric residuals before flushing and administering medications. She said they already started an in-service about g-tube placement and residual checks.During an interview on 04/16/2026 at 7:27 a.m., the DON said the placement of the g-tube should be checked before flushing it and before medication administration to ensure the medications and the fluid would enter the stomach. He said checking the placement was a safety step to ensure the tube was not in other parts of the body, like the lungs, esophagus, and cavities inside the body, that could result to aspiration and ineffective feeding because the formula was not delivered to the intended site. He said gastric contents should also be checked to ensure there was no delayed emptying of the stomach. He said another reason the residual should be checked was to make sure the resident was tolerating the amount of formula ordered, and if not, the order could be adjusted. He said the expectation was for the staff to follow the policies and procedures for enteral feeding. He said he already started an in-service for checking g-tube placement and the gastric residuals.During an interview on 04/16/2026 at 7:59 a.m., the Administrator said the expectation was for the staff to check the g-tube placement and the residual content as per orders. She said the DON already started an in-service about g-tube but would still closely coordinate with the DON to monitor the adherence of the staff to the policy about g-tube.Record review of the facility's policy Administering Medications through an Enteral Tube Nursing Services Policy and Procedure Manual for Long-Term Care revised November 2018 reflected Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube . Steps in the Procedure . 6. Verify placement of feeding tube.Record review of the facility's policy Checking Gastric Residual Volume (GRV) Nursing Services Policy and Procedure Manual for Long-Term Care revised November 2018 reflected Purpose: The purpose of this procedure is to assess tolerance of enteral feeding and minimize the potential for aspiration . Preparation 1. Verify that there is a physician's order for this procedure . General Guidelines 1. Do not use gastric residual volume (GRV) as a routine indicator of proper feeding tube location . Steps in the Procedure . 4. Attach sixty (60) mL syringe to end of catheter tube . 6. Aspirate stomach contents.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 4 of 12 residents (Residents #4, #9, #74 and #124) reviewed for care plans. The facility failed to ensure Resident #4, #9 and #124's care plan reflected an intervention which included the bed being in the lowest position and fall mat alongside bed. The facility failed to ensure Resident #74's care plan, dated 02/05/2026, included a care plan for suction use due to the resident was unable to expel any secretion. These failures could place residents at risk of their needs not being met. Findings include:Record review of Resident #4's Face Sheet, dated 04/15/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with lack of coordination and muscle weakness.Record review of Resident #4's Comprehensive MDS Assessment, dated 1/15/26, reflected Resident #4 had a BIMS of 99 (unable to complete the interview). The Comprehensive MDS Assessment indicated the resident had an active diagnosis of muscle wasting.During an observation on 04/14/26 at 12:05 p.m., revealed Resident #4 was lying in bed, which was in its lowest position and a fall mat was placed on the left side of the resident's bed.Record review on 04/14/2026 of Resident #4's Comprehensive Care Plan, dated 4/01/26, for fall prevention reflected no intervention to include the resident's bed being in the lowest position and fall mats being placed on both sides of the bed. Record review of Resident #9's Face Sheet, dated 04/15/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with lack of coordination and muscle weakness.Record review of Resident #9's Comprehensive MDS Assessment, dated 1/01/26, reflected Resident #9 had a BIMS of 99 (unable to complete the interview). The Comprehensive MDS Assessment indicated the resident had an active diagnosis of seizure disorder.During an observation on 04/14/26 at 11:05 p.m., revealed Resident #9 was lying in bed, which was in a low position and fall mats placed on both sides of the resident's bed.Record review on 04/14/2026 of Resident #9's Comprehensive Care Plan, dated 1/07/26, reflected no plan of care for fall prevention nor interventions to include the resident's bed being in the lowest position and fall mats being placed on both sides of the bed. During an interview and record review on 04/15/26 at 11:13 a.m., RN M was informed by the Surveyor of Resident #9 not having a care plan for fall prevention. He stated the resident required her bed to be in a low position and fall mats on both sides of her bed to reduce the chance of her injuring herself if she fell out of bed. He stated he did not update care plans and was not sure who did.Record review of Resident #124's Face Sheet, dated 04/15/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with Alzheimer's disease.Record review of Resident #124's Initial MDS Assessment, dated 4/08/26, reflected no BIMS score for the resident. The MDS Assessment had no active diagnoses indicated on the assessment.During an observation on 04/14/26 at 11:5 p.m., revealed Resident #124 was lying in bed, which was in a low position and fall mats placed on both sides of the resident's bed.Record review on 04/14/2026 of Resident #124's Comprehensive Care Plan reflected no plan of care for fall prevention nor interventions to include the resident's bed being in the lowest position and fall mats being placed on both sides of the bed. During an interview and record review on 04/15/26 at 11:29 a.m., LVN T was informed by the Surveyor of Resident #124 not being care planned for fall prevention. He stated he was not sure if the resident was care planned for fall prevention. He stated the resident should be care planned because she was a fall risk and it was needed to inform staff of the care plan. During an interview and record review on 04/15/26 at 11:29 a.m., MDS D was informed by the Surveyor of Residents #9 and #124 not being care planned for fall prevention. She reviewed the facility's system of record and stated there was no intervention including the residents needing fall mats and the bed being in the lowest position. She stated it should be care planned for staff to know the plan of care for the residents. She stated it was the MDS nurse, ADON, and DON's responsibility to update care plans. She stated Resident #124 had not had his comprehensive assessment completed yet because she was out on vacation and the fall prevention care plan was not triggered.During an interview on 04/15/26 at 12:55 p.m., ADON S was informed by the Surveyor of Residents #4, #9 and #124 not being care planned for fall prevention. She stated Resident #9 was a fall risk because she had fallen before. She stated Resident #124 was a new resident and she was not sure if she had fallen but she leaned in the bed and they were concerned she would fall out, which was why they lowered her bed and placed fall mats on both sides of her bed. She stated it should be care planned for staff to know the plan of care for the residents. She stated it was mainly the MDS nurses' responsibility to update care plans.During an interview on 04/16/26 at 12:45 p.m., the DON was informed by the Surveyor of Residents #4, #9 and #124 not being care planned for fall prevention. He stated leadership completed IDT meetings for the residents and the MDS nurse was responsible for updating their care plans. He stated they were trying to get all care plans updated because it was used to determine the care needed for each resident.Review of Resident #74's Face Sheet, dated 04/16/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hemiplegia (paralysis of one side of the body) and dysphagia (difficulty in swallowing).Review of Resident #74's Quarterly MDS Assessment, dated 03/19/2026, reflected that the resident was unable to complete the interview to determine the BIMS score. The Staff Assessment for Mental indicated that the resident had memory problem. The Quarterly MDS Assessment did not show that the resident was using a suction machine.Review of Resident #74's Comprehensive Care Plan, dated 02/05/2026, did not reflect that the resident was using a suction machine.Record review of Resident #74's Physician's Order on 04/14/2026 reflected that the resident did not have an order for suctioning.During an observation and interview on 04/15/2026 at 7:14 a.m., revealed a suction machine was on top of the Resident #74's side table. Resident #74 did not reply when asked about her suction machine.During an interview on 04/15/2026 at 7:38 a.m., LVN C said that Resident #74 had been using the suction machine for more than four months. She said the suction was used when there was an accumulation of secretions in the resident's mouth. She said the resident was unable to expel any secretion. During an interview on 04/16/2026 at 6:08 a.m., LVN C said she did not see any care plan for Resident #64's suction use. She said the MDS Nurse was the one doing the care plans.During an observation and interview on 04/16/2026 at 6:29 a.m., MDS Nurse G said if the resident was using a suction machine, then there should be a care plan in place for suctioning so that the staff knew the interventions and goals for the resident pertaining to suction use. She said the purpose of the care plan was to ensure that the residents would receive tailored care specific to their needs, preferences , and goals. She said the care plan also facilitated a consistent care because all the healthcare providers would be in sync in terms of the care of the residents. She checked on Resident #74's care plan and saw that the resident did not have a care plan for suctioning. She said she would audit the resident's care plan and would put a care plan for suctioning. She said she would also audit the care plans of the other residents so that there won't be confusion about their care.During an interview on 04/16/2026 at 6:46 a.m., ADON A said care plans were important because care plans served as the contract between the facility and the resident in terms of what care and services would be provided by the facility. ADON A stated care plans would project the problem lists of the residents and the goals and the interventions pertaining to the said problems. She said without the care plans, needed interventions might not be provided and the needs of the residents would not be met. She said the expectation was all the issues of the residents were care planned. She said she would coordinate with the DON and the MDS Nurse to make sure the residents had appropriate care plans. During an interview on 04/16/2026 at 7:27 a.m., the DON said that the care plans would represent the whole picture of the current condition of the resident and how the facility would provide the care needed to meet the needs of the residents. He said if there were no care plans, the staff might miss the care needed by the residents. He said the care plans also served as a communication tool across the providers so that everyone taking care of the residents would be in the same page. He said the expectation was for all residents to have care plans with regards to their medical issues. He said he would coordinate with the MDS Nurses to audit the care plans of the residents. During an interview on 04/16/2026 at 7:59 a.m., the Administrator said that all the residents should have a care plan appropriate to their needs. She said without the care plan, the staff would not know the goals and the interventions needed by the residents. She said the expectation was for all the residents were care planned accordingly to meet their needs. She said she would coordinate with the DON and the MDS Nurses to make sure all the residents were care planned.Record review of facility's policy, Comprehensive Care Plans, dated 2022, reflected It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.

Based on interviews and record review the facility failed to ensure that the transfer or discharge was documented in the resident's medical record for one (Residents #121) of three residents reviewed for transfers and discharges.The facility failed to obtain a signed Against Medical Advice document during Resident #121's discharge on [DATE].This failure could prevent the resident from receiving necessary information about the resident's support needed for further care.Findings included:Review of Resident #121's Face Sheet, dated 04/15/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with joint replacement and seizures. Record review of Resident #121's 's MDS Assessment, dated 02/23/26, did not reflect the resident's BIMS score. The MDS Assessment reflected the resident had active diagnoses of joint replacement and seizures.During a record review on 04/16/26 at 9:40 a.m., revealed Resident #121's progress notes indicated she had discharged from the facility against medical advice. The facility's system of records did not reflect a signed AMA form on file.During an interview on 04/16/26 at 12:45 p.m., the DON was informed by the Surveyor of Resident # 121 not having a signed AMA on file. He stated the discharge nurse on duty should ensure the resident or their RP signed the AMA upon discharge. He stated RN M was the discharge nurse at the time and although the resident had signed a document, she should have signed the AMA form because it educated the resident of the risk of leaving the facility.During an interview on 04/16/26 at 12:55 p.m., RN M stated he had completed the discharge for Resident #121. He stated he was aware the resident had to sign an AMA form but had forgotten and only had her sign the progress notes forms. He stated the AMA had to be signed by the resident because it was making her aware that she was leaving against medical advice.During an interview on 04/16/26 at 12:45 p.m., the Administrator was informed by the Surveyor of Resident # 121 not having a signed AMA on file. She stated the discharge nurse on duty should ensure the resident or their RP signed the AMA upon discharge. She stated RN M should have had Resident #121 sign the AMA form because it educated the resident of the risk of leaving the facility. Record review of facility's policy, Transfer and Discharge, undated, reflected It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility, except in limited circumstances. This policy applies to all residents regardless of their payment source. The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided:a. The specific reason and basis for transfer or discharge.b. The effective date of transfer or discharge.c. The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged .

Based on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for two of ten residents (Resident #92 and Resident #10) reviewed for abuse and neglect.The facility failed to ensure Resident #10 was free from abuse when Resident #92 hit him on 03/23/2026. This failure could place residents at risk of abuse and emotional stress.The findings include:1.Record review of Resident #92's Face Sheet, dated 01/30/2026, reflected the resident was a [AGE] year-old male who admitted on [DATE]. Resident #92 had diagnosis including Unspecified Dementia (diagnosis used when symptoms of cognitive decline - severe memory loss, impaired thinking, and reduced social abilities - are present but underlying cause has not been determined), Unspecified mood [affective] disorder is a clinical ( diagnosis used when mood-related symptoms that cause significant distress but do not fully meet criteria for a specific mood disorder like depression or bipolar disorder.Record review of Resident #92's Quarterly MDS (tool used to assess health status) Assessment, dated 02/23/2026, reflected moderately impaired cognition with a BIMS (screening tool to assess cognitive status) score of 11. Record review of Resident #92's care plan with an initiation date of 03/24/2026 revealed [Resident #92] had a resident to resident and he struck to another resident to the side of his face, with an initiation date of 03/24/26. Resident #92's Comprehensive Care Plan did not indicate behaviors toward staff or other residents. Record review of Resident #92's progress notes dated 03/24/26 revealed Resident #92 was monitored for changes or symptoms. Resident #92 had no emotional distress or changes noted. During an attempted interview on 04/15/26 at 2:40 PM, Resident #92 refused to speak to the surveyor.Record review of Resident #10's Face Sheet dated 02/25/2026, reflected the resident was a [AGE] year-old male who originally admitted on [DATE] and a re-admitted on [DATE]. Had a diagnosis of Acute respiratory failure unspecified whether with hypoxia or hypercapnia, (indicates a critical condition where the lungs cannot adequately exchange gases, leading to insufficient oxygen or excessive carbon dioxide levels). The unspecified nature of the diagnosis means that the specific type of respiratory failure (hypoxemic or hypercapnic) is not clearly defined at the time of diagnosis. Diagnoses of type 2 diabetes mellitus with hyperglycemia ( a person diagnosed with type 2 diabetes has persistently high blood sugar levels)Record review of Resident #10's Quarterly MDS (tool used to assess health status) Assessment, dated 02/25/2026, reflected moderately impaired cognition with a BIMS (screening tool to assess cognitive status) score of 12.Record review of Resident #10's care plan with an initiation date of 03/24/2026 revealed [Resident #10] had a resident to resident where he had been struck by another resident to the side of his face. With an initiation date of 03/24/26. Resident #10's Comprehensive Care Plan did not indicate behaviors toward staff or other residents.Record review of Resident #10's progress notes dated 03/24/26 revealed Resident #10 was monitored for changes or symptoms. Resident #10 had no emotional distress or changes noted.During an interview on 04/15/2026 at 2:30 PM Resident #10, was observed lying in bed. Resident #10 stated that he was doing fine and that this was the best care he had received. Resident #10 stated that he had a roommate, but the roommate was put out of his room due to hitting him. Resident #10 stated that his roommate was getting out of bed, attempting to get into his wheelchair, and having difficulty. Resident #10 stated that he told him to call the nurse to help him get into his wheelchair and go where he needed to go. Resident #10 stated that his roommate became upset, came over to his side of the bed, and attempted to hit him in his head with his fist. Resident #10 stated that he told the resident, I will knock your ass out, you are lucky that I cannot get up as quickly as I used to. Resident #10 stated that the roommate picked up his urinal off the bedside table and hit him in his stomach and head. Resident #10 stated that he began to yell for the nurse, the nurse came in along with the CNA to check on him. Resident #10 stated the nurse completed an assessment on him, and he did not have to go to the emergency room. Resident #10 stated that he was happy nothing was in the urinal and that it was plastic. Resident #10 stated that the roommate was normally aggressive with staff and residents. Resident #10 stated the nurse did come in after the incident and completed a head-to-toe assessment. Resident #10 stated he advised the ADMIN and DON that he did not want to press charges. Resident #10 gave staff a statement, and the resident was moved out of his room. Resident #10 stated he does feel safe at the facility, and his call light was within reach but normally just calls out for someone. Resident #10 further stated staff do respond promptly to his needs. Resident #10 stated he does not have any additional concerns.During an interview on 04/16/2026 at 11:12 AM the SW stated she had been a SW for 5 years. SW stated she was advised from the Nursing staff that the residents were arguing with each other. SW stated Resident #92 stated he got his wheelchair stuck on Resident #10's wheelchair. Resident #10 was making some comments about him. Resident #92 stated that he grabbed the plastic bottle off the table and lightly tapped him with it. She stated Resident #92 stated that he understood that any type of physical behavior was not to be tolerated. Resident #92 stated he understood. Resident #10 was upset and stated Resident #92 got his chair stuck on his. He advised him that he should have used the call light to get it undone. At which point Resident #92 grabbed the bottle and struck him. SW stated there was no documented history of aggression by either one of the residents towards each other or towards any other residents. SW stated she asked Resident #10 if he wanted to relocate and he advised yes. Resident #10 stated he felt safe at the facility. Resident #92 was advised he would be moving to another room. SW stated Resident #92 stated he understood but had one request of staff. Which was if he could stay on the same floor due to him liking the nursing staff that takes care of him. Psych was also advised to follow up with them. Neither resident felt upset or other issues with each other. She stated as of now there are no issues with either one of them. SW stated Resident #92 was currently on psych service case load, she did an initial, them Resident #92 would be re-assigned to one of the 3 psych services personnel SW stated the facility had in-service training about abuse and de-escalation and to report any abuse to the Administrator.During an interview on 04/16/2026 at 11:18 AM CNA G stated she had been a CNA for 12 years. She stated Resident # 92 or Resident #10 had no history of aggression towards other residents. She stated she had no issues while she provided care to both residents when they were in the same room. She stated there had been no issues or concerns from either resident since the incident. She stated when she returned to, she had in service training regarding ANE. During an interview on 04/16/2026 at 11:40 AM LVN K stated she has been a Nurse for 2 and half years. She stated neither resident had a history of aggression towards other residents. She stated they got labs immediately afterward the incident for both residents and they were negative for UTI. During the time they were rooming together they never had issues with each other. They have not said anything about the incident afterwards. She stated if ANE was suspected she would notify the ADMIN immediately of the incident. LVN stated there were no other incidents of resident-to-resident altercation with Resident #92 as the perpetrator had occurred since Resident #92's incident on 03/23/26. Record review of the facility's Statement of Resident Rights Revised February 2021 reflected, You have a right to be free from abuse, neglect, misappropriation of property, and exploitation.Record review of the facility's policy titled Resident to Resident Altercations revealed revised September 2022, revealed All altercations, including those that may represent resident-to-resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator. Policy Interpretation and Implementation. 1. Facility staff monitors residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, and or staff. 2. Behaviors that may provoke a reaction by residents or other include: b. physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects.

Based on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy during personal care and confidentiality of personal and medical records for two of fifteen residents (Residents #48, and #84) reviewed for privacy and confidentiality. The facility failed to ensure Resident #48's door was closed or the privacy curtain was drawn during incontinent care on 04/14/26. The facility failed to ensure that the roommates of residents with AEM had signed consents in the active section of the EHR from Resident #84 or their RP acknowledging the AEM in the shared room since 01/07/2026. These failures could place the residents at risk of not having their personal privacy maintained while care was provided, which could result in the residents feeling uncomfortable during care and having their personal and medical record exposed to unauthorized individuals.Findings included: Record review of Resident #48's Face Sheet, dated 04/14/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle wasting, and lack of coordination.Record review of Resident #48's Comprehensive MDS Assessment, dated 03/19/2026, reflected the resident had an intact cognitive response with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had diagnoses of muscle wasting, and lack of coordination.During an observation on 04/14/2026 at 11:29 a.m., revealed CNA S was providing Resident #48 incontinent care while the resident's room door was open, and the privacy curtain was partially drawn. The resident was missing part of his privacy curtain near the foot of the bed. During an interview on 04/14/26 at 11:32 a.m., CNA S stated she was providing incontinent care to Resident #49 and was not aware the resident's roommate had left the room. She stated she was so focused on the resident, and she did not notice the room door had opened. She stated she pulled the privacy curtain alongside the resident's bed but the resident did not have a privacy curtain near the foot of his bed to completely provide the resident privacy. During an interview on 04/14/26 at 11:39 a.m., LVN T was informed by the Surveyor of CNA S providing incontinent care to Resident #48 and the resident room door was open and the privacy curtain was partially drawn. He was informed the CNA stated the resident's roommate had left the room and failed to close the door. He stated the CNA should have closed the door for the resident's privacy and dignity. Record review of Resident #84's admission Record dated 01/07/2026, revealed a [AGE] year-old female who had original admission date of 01/07/2026. Resident #84 was noted to have diagnosis including Chronic Systolic (Congestive) Heart Failure (condition where the heart's left ventricle weakens, becomes enlarged, and cannot contract properly to pump enough blood), Chronic Obstructive Pulmonary Disease (progressive, incurable, yet treatable lung disease that causes chronic airflow constriction leading to severe breathing difficulties) Unspecified Dementia (diagnosis used when symptoms of cognitive decline- severe memory loss, impaired thinking, and reduced social abilities- are present but underlying cause has not been determined), Anxiety Disorder (persistent, excessive fear or worry that interferes with daily life). Record review of Resident #84's quarterly MDS assessment dated [DATE] reflected a BIMS (standardized assessment tool to evaluate cognitive function, specifically memory and orientation) score of 12 indicating moderate cognitive impairment. Record Review of Resident #84's Care Plan, last updated 03/30/2026, revealed no indication of resident being in a room that currently had ongoing AEM.Record review of Resident #107's admission Record dated 02/02/2021, revealed an 87 -year-old female who had original admission date of 02/21/2021. Resident #107 to have a diagnosis including Unspecified Dementia (diagnosis used when symptoms of cognitive decline - severe memory loss, impaired thinking, and reduced social abilities - are present but underlying cause has not been determined), Anxiety Disorder (persistent, excessive fear or worry that interferes with daily life), with the diagnoses of type 2 diabetes mellitus with hyperglycemia ( a person diagnosed with type 2 diabetes has persistently high blood sugar levels)Record review for Resident #107 revealed a signed consent from the resident/RP dated 02/05/2021; be moved into a room with ongoing AEM for roommate.Record review of Resident #107's quarterly MDS dated [DATE], reflected a BIMS (standardized assessment tool to evaluate cognitive function, specifically memory and orientation) score of 7 indicating severe impairment. Record review of resident #107's Care Plan, last updated on 03/10/2026 revealed no indication of resident being in a room that currently had ongoing AEM. Observation on 04/14/2026 at 9:20 AM of the shared room door for Resident #84 and Resident #107 revealed a sign that reflected, This room is being electronically monitored. Further observation revealed a camera placed on Resident #107 side of their room. Observation on 04/15/2026 at 1:25 PM of the shared room door for Resident #84 and Resident #107 revealed a sign at reflected, This room is being electronically monitored.During an interview on 04/16/2026 at 11:18 AM the SW stated she was familiar with the process with AEM. The SW stated the AEM forms are located outside of the SW office. This is if any staff member has observed, been advised or heard about a resident wanting or having a camera placed in their room. The staff member will fill out the form and submit it. The SW stated if staff observed a camera, in a resident's room they would fill out a form, and then the family or patient would sign most circumstances it would be the family signing the form. The SW stated the forms were readily available whether the SW was there or not. The SW stated when the form was completed, they would turn it into the SW office. It is either given to me or medical records department, to be scanned and added to the resident file. The SW stated the signed consent form should be in the miscellaneous or documents tab of the EHR. The SW stated that the risks of not having the signed consent was that there was no evidence the resident or RP was made aware they could possibly be filmed, and that there may be audio recording capabilities as well; that would be a privacy violation and that ultimately the DON was responsible to ensure all consents were obtained and in the EHR. During an interview on 04/16/2026 at 11:55 AM the ADMIN stated the SW handles the AEM forms, and if residents had an AEM signed the SW would get the sign for the room. The ADMIN stated that the risks of not having the signed consent was that there was no evidence the resident or RP was made aware they could possibly be filmed, and that there may be audio recording capabilities as well. That would be a privacy violation, and that ultimately the DON was responsible to ensure all consents were obtained and in the EHR.Record review of the facility's policy, Resident Rights, dated 02/21, reflected Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;Record review of the facility provided policy, dated 09/01/2025, revealed the statement The facility supports the rights of residents to use electronic monitoring devices in their rooms to promote safety, autonomy, and quality of care, in accordance with federal regulations and applicable state laws.Policy Guidelines Consent RequirementsWritten consent must be obtained from: The resident, or The resident's legal representative if the resident lacks capacity. If the room is shared: Consent must be obtained from the roommate or roommate's representative.If consent is not granted, accommodations (e.g., room change, camera positioning) will be explored.Procedure1. Resident/family submits request for electronic monitoring. 2. Facility provides consent forms and reviews policy. 3. Obtain required consents (resident + roommate if applicable). 4. Post required signage. 5. Document in medical record and care plan. 6. Notify staff of monitoring device. 7. Ongoing review for compliance.Documentation RequirementsConsent forms (resident and roommate) Care plan inclusion Progress notes regarding monitoring Any incidents, complaints, or investigations.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of ten residents (Resident #91 and Resident #82) reviewed for infection control. 1. The facility failed to ensure CNA F performed hand hygiene and changed her gloves during Resident #91's incontinent care on 04/14/2026.2. The facility failed to ensure RN B performed hand hygiene before preparing Resident #125's medication on 04/15/2026.These failures could place residents at risk of cross-contamination and development of infections.Findings included: 1. Record review of Resident #91's Face Sheet, dated 04/16/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body). Record review of Resident #91's Comprehensive MDS Assessment, dated 01/17/2026, reflected the resident had a moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated that the resident was incontinent (unable to control) for bowel and bladder. Record review of Resident #91's Comprehensive Care Plan, dated 02/22/2026, reflected the resident had bowel and bladder incontinence and one of the interventions was to clean peri-area with each incontinent episode.During an observation on 04/14/2026 at 11:24 a.m. revealed CNA F was about to do Resident #91's incontinent care. She went inside the resident's room put on a pair of gloves. She did not wash her hands before putting on her gloves. She took a brief from the resident's drawer, opened it, and placed it at the side of the of the resident. She pulled some wipes and placed it on top of the wipes dispenser. It was observed that some of the wipes fell on the bed. She unfastened the brief and cleaned the resident's perineal area (area between the thighs) using the front to back technique. After cleaning the perineal area, she then assisted the resident to roll to her side, cleaned the resident's bottom, pulled the soiled brief, and threw it in the trash can. After cleaning the bottom, she took the new brief she placed beside the resident and placed it under the resident. She did not change her gloves after cleaning the bottom and before touching the new brief. When she about to roll back the resident, she realized that she did not have the barrier cream she needed to use for the resident's bottom. She removed her gloves, went to the resident's drawer, and looked for some cream. She then went to the bathroom to get a pair of gloves from the wall of the bathroom. She did not do hand hygiene before putting on the new pair of gloves. It was also observed that she used the wipes that fell on the bed.During an interview on 04/14/2026 at 11:41 a.m., CNA F said she was supposed to change her gloves after cleaning Resident #91s' bottom before touching the new brief to prevent using dirty gloves. She said, she did change her gloves at one point but did not sanitize her hands because there was no sanitizer inside the resident's room. she said she had a small one that she used to put in her pocket but maybe it fell because she could not find it. She said she also needed to wash her hands before doing any care, not only before incontinent care. She said it did not occur to her that there was a bathroom inside the resident's room and she could washed her hands if there was no sanitizer in sight. She said she should have thrown the wipes that fell on the bed and did not use them because they were already dirty.2. Record review of Resident #125's Face Sheet, dated 04/16/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with gastrostomy status.Record review of Resident #125's Comprehensive MDS Assessment, dated 04/10/2026, reflected the resident's full ARD would be on 04/23/2026.Record review on 04/14/2026 of Resident #125's Baseline Care Plan revealed the resident was not care planned for tube feeding.During an observation on 04/15/2026 at 6:16 a.m. revealed RN B was about to administer Resident #125's medication via g-tube. He put on a pair of gloves and started to prepare the resident's medication. He did not do hand hygiene before preparing the resident's medication. After preparing the medication, he went inside the room, wore a gown and a pair of gloves, and administered the resident's medication. He did not do hand hygiene before administering the medication.During an interview on 04/15/2026 at 6:49 a.m., RN B said he did not know why he forgot to wash his hands or even sanitize his hands before preparing Resident #125's medication and even before putting on the PPE. He said it was important to do hand hygiene to make sure the hands were clean during medication preparation and administration.During an interview on 04/16/2026 at 6:46 a.m., ADON A said hand hygiene should be done before, during, and after doing any care or treatment. She said the hands should be washed or sanitized to prevent cross contamination and probable infection. She said after cleaning the resident's bottom, the gloves should have been changed before touching the new brief to avoid transfer of microorganisms to the new brief that could eventually cause infection. She said every time the staff change their gloves, the hands should be sanitized for the same reason. She said the wipes that fell from the dispenser should have been discarded because they were already dirty. She said the expectation was for the staff to be mindful to be not the cause of the development of any infection. She said they already started an in-service about handwashing and perineal care.During an interview on 04/16/2026 at 7:21 a.m., the DON said staff should do hand hygiene before, during, and after care and treatment. He said hand hygiene was the most effective way to prevent cross contamination that could possibly lead to infection. He said the gloves should have been changed after touching something soiled like the resident's bottom and the soiled brief to make sure there was no transfer of microorganisms to the new brief. He said it should be clean to dirty and not the other way around. He said he already did a one-on-one in-service about perineal care with CNA F and a facility wide in-service about handwashing.During an interview on 04/16/2026 at 7:59 a.m., the Administrator said the expectation was for the staff to wash their hands before any care and treatment, to change their gloves when needed, and to sanitize their hands before putting on their gloves. She said the DON already started an in-service about handwashing and perineal care but would still closely coordinate with the DON to monitor the adherence of the staff to the policies.Record review of the facility's policy Infection Control Guidelines for All Nursing Procedures Nursing Services Policy and Procedure Manual for Long-[NAME] Care revised August 2012 reflected Purpose: To provide guidelines for general infection control while caring for residents . General Guidelines . 3. Employees must wash their hands . Before and after direct contact with residents . d. After removing gloves . After handling items potentially contaminated with blood, body fluids, or secretions . 4. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub . Before and after direct contact with residents . Before preparing or handling medications . Before moving from a contaminated body site to a clean body site during resident care . After removing gloves.Record review of the facility's In-Service Proper Perineal Care & Infection Control Practices, dated April 14, 2026, reflected Policy and Procedure . pericare must follow clean to dirty technique . gloves must be . removed after contact with contaminated areas, hands must be sanitized.

Based on observation, interview, 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 one of ten residents (Resident #98) reviewed for pharmaceutical services.The facility failed to dispose of Resident #98's expired insulin on 04/15/2026.This failure could place residents at risk of not receiving the medication's full therapeutic benefits and not receiving medications as ordered resulting to adverse effects.Findings included:Record review of Resident #98's Face Sheet, dated 04/16/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus. Record review of Resident #98's Comprehensive MDS Assessment, dated 01/30/2026, reflected the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment indicated the resident had diabetes mellitus. Record review of Resident #98's Comprehensive Care Plan, dated 01/29/2026, reflected the resident had diabetes mellitus and one of the interventions was administer insulin as ordered.Record review of Resident #98's Physician Order, dated 12/14/2025, reflected GLARGIN YFGN INJ 100 U/ML Inject 10 unit subcutaneously (administer under the skin) at bedtime related to Diabetes mellitus due to underlying condition with diabetic nephropathy (nerve damage due to diabetes).During an observation on 04/15/2026 at 11:20 a.m. revealed Resident #98's insulin KwikPen was inside a nurse's cart. It was observed that the insulin had a date opened 03/14/2026 and an instruction to discard after 28 days.During an observation and interview on 04/15/2026 at 11:21 a.m., LVN C said she was not the one administering Resident #98's insulin because the insulin was scheduled at bedtime. She looked at the insulin and said the opening date of the insulin was 03/14/2026. She said the insulin also had an instruction that specified to discard it after 28 days. She said after 28 days, the insulin was already considered expired. She took her cell phone and counted how many days passed from opening date of the insulin. She said the insulin should have been dispose 04/11/2026 and said the insulin was expired for four days. She took the insulin and discarded it. She said expired medications could be less effective or more toxic. During an interview on 04/16/2026 at 6:46 a.m., ADON A said there should not be expired medication inside the carts because expired medications could be less potent and would not be able to provide the full benefit of the medications. She said the nurses were responsible in ensuring there was no expired medications in the carts that they were using. She said she was also responsible in checking and auditing the carts for expired medications. She said the expectation was that the staff would check the carts for expired medications. She said they already started an in-service about insulin storage.During an interview on 04/16/2026 at 7:21 a.m., the DON said the expired insulin should have been disposed of on 04/11/2026 when it was opened 03/14/2026. He said expired medications could be less potent or could cause adverse effects depending on the medication. He said the nurses were responsible in checking their carts for expired medications. He said the ADONs were responsible in going behind the nurses and he was responsible in checking if the ADONs were checking the carts. He said the expectation was the staff would be mindful in checking the expiration dates of the medication. He said he already started an inservice about insulin storage, labeling, and expiration.During an interview on 04/16/2026 at 7:59 a.m., the Administrator said the expectation was for the staff to check for the medications before administering them to prevent any adverse reactions. She said the DON already started an in-service regarding the expired medication but would still closely coordinate with the DON to monitor the adherence of the staff to the policies about expired medication.During an interview on 04/17/2026 at 10:54 a.m., LVN J said it did not occur to her that the insulin for Resident #98 was already expired. She said she saw the date it was opened but thought the expiration date was 04/14/2026. She said expired insulin could lose its effectiveness.Record review of the facility's policy Administering Medications Nursing Services Policy and Procedure Manual for Long-Term Care revised April 2019 reflected Policy Statement: Medications are administered in a safe and timely manner, and as prescribed . 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so . 4. Medications are administered in accordance with prescriber orders, including any required time frame . The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.

Based on observations, interviews, and record reviews, the facility failed to ensure the resident's environment remained free of hazards as was possible for one of six residents (Resident #73) reviewed for accident hazards. The facility failed to ensure Resident #73 had physician orders for a scoop mattress to ensure it was not a hazard for the resident. This failure could prevent the residents from having an environment that was free from accidents, potential injury, and exposure to toxic chemicals.Findings included: Record review of Resident #73's Face Sheet, dated 04/14/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #73 had diagnoses of muscle wasting, and lack of coordination.Record review of Resident #73's Initial MDS Assessment, dated 1/20/26, reflected the resident had a BIMS score of 3 (severe cognitive impairment). The MDS assessment reflected the resident had active diagnoses of age-related physical debility and lack of coordination.During an observation on 04/14/26 at 11:35 a.m., revealed Resident #73 was lying in bed on a scoop mattress (a scoop mattress features raised sides and a concave center). Record review of Resident #73's Comprehensive Care Plan, dated 10/28/25, reflected the resident being a fall risk, but there was no intervention including the use of a scoop mattress. Record review of Resident #73's Physician's Order, dated 04/14/26, reflected no Physician orders for a scoop mattress. During an interview on 04/16/26 at 11:30 a.m., ADON S was informed by the Surveyor of Resident #73 lying on a scoop mattress, but she did not have a physician's orders for the equipment. She stated she was informed of this by the DON on 04/15/26. She stated they completed an assessment and determined the resident did not need the scoop mattress and they replaced it with an air mattress. She stated the risk of the resident having the mattress could be a form of restraint for the resident. During an interview on 04/16/26 at 12:26 p.m., the DON was informed by the Surveyor of Resident #73 not having a physician's order for the use of a scoop mattress. He stated physician's orders were required. He stated the admitting nurse should ensure the resident had physician's orders for particular care. He stated they conducted a sweep of all residents with scoop mattresses, reassessed the residents, determined the residents did not require them, and had them removed. He stated if the resident did not have orders, their care may not be carried out.Record review of the facility's policy, Resident Rights, dated 02/21, reflected Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;c. be free from abuse, neglect, misappropriation of property, and exploitation;d. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms

Based on observation, interview, and record review, the facility failed to ensure that the assessments accurately reflected the resident's status for two (Resident #74 and Resident #110) of ten residents reviewed for accuracy of assessments.1. The facility failed to ensure Resident #74's Quarterly MDS assessment dated [DATE] accurately reflected that the resident had an external catheter and received suctioning.2. The facility failed to ensure Resident #110's Quarterly MDS assessment dated [DATE] accurately reflected that the resident had a nephrostomy.These failures could place the residents at risk for not receiving care and services to meet their needs, diminished functions of health, and regression in their overall health.Findings included:1. Review of Resident #74's Face Sheet, dated 04/16/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with hemiplegia (paralysis of one side of the body) and gastrostomy status (having done a surgical procedure that creates artificial opening into the stomach to provide nutritional support).Review of Resident #74's Quarterly MDS Assessment (assessment used to determine functional capabilities and health needs), dated 03/19/2026, reflected that the resident was unable to complete the interview to determine the BIMS (screening tool used to assess cognitive status) score. The MDS indicated that the resident had memory problem. The Quarterly MDS Assessment did not show that the resident was using an external catheter (non-invasive device used to manage urinary incontinence) and a suction machine (equipment used to mechanically aspirate pulmonary secretions to clear the airway).Review of Resident #74's Comprehensive Care Plan, dated 02/05/2026, reflected the resident used an external catheter and one of the interventions was for care staff to ensure that suction tubing was connected securely and functioning properly. The care plan did not indicate that the resident was using a suction machine.Review of Resident #74's Physician's Order, dated 10/30/2025, reflected Pure wick (a female external catheter positioned externally to absorb the urine): Insert pure wick female catheter per manufacturer's instruction. Maintain catheter device to low continuous suction per protocol. every shift.Record review on 04/14/2026 of Resident #74's Physician's Order reflected that the resident did not have an order for suctioning.During an observation and interview on 04/15/2026 at 7:14 a.m., revealed a suction machine was on top of the Resident #74's side table. Resident #74 did not reply when asked about her suction machine.During an interview on 04/15/2026 at 7:16 a.m., LVN C said that the machine on top of Resident #74's side table was a suction machine. She said the resident also had an external catheter and had been using both had been using both for more than four months. She said the external catheter was not suctioning well so the family member took it home. She said she did not know if the family member would have the external catheter repaired or would bring a new one.2. Record review of Resident #110's Face Sheet, dated 04/16/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with obstructive and reflux uropathy (a blockage in the urinary tract) and displacement of nephrostomy catheter (a thin tube inserted through the skin into the kidney to drain urine).Record review of Resident #110's Comprehensive MDS Assessment, dated 02/10/2026, reflected that the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 13. The Comprehensive MDS Assessment did not indicate that the resident had a nephrostomy (a surgical procedure that inserts a tube to the kidney to drain urine to a bag outside the body).Record review of Resident #110's Comprehensive Care Plan, dated 04/14/2026, reflected the resident had a nephrostomy tube (a thin tube inserted through the skin into the kidney to drain urine) and one of the interventions was for care staff to provide nephrostomy care every shift.Record review of Resident #110's Physician's Order, dated 10/30/2025, reflected dressing change every day shift every Thu related to DISPLACEMENT OF NEPHROSTOMY CATHETER.During an observation and interview on 04/14/2026 at 9:20 a.m. revealed Resident #110 was in his bed, awake. The resident said he a had a nephrostomy tube on the left side of the body that he had for approximately a year. He lifted the side of his hospital gown to expose the nephrostomy bag (an external medical device designed to drain urine from the kidney).During an observation and interview on 04/16/2026 at 6:29 a.m., MDS Nurse G said the purpose of the MDS was to collect and record pertinent data about the resident. She said the MDS was used to do a basic assessment of the resident that could be from the documentation from the nurses or through a face-to-face assessment. She said the data collected would be the basis for the residents' care plans. The data collected were the resident's demographics, cognition, behavior, functional abilities, diagnoses, and if the resident was using any kind of special treatment. She turned on her computer and saw that Resident #74 was not coded for her external catheter and suction use. She said she did not know why the external catheter was not coded since the resident was using it since October 2025 and had an order for it. She said since the suction use did not have an order or any documentation, then it was not captured. She then checked Resident #110's MDS and saw that the resident was not coded for his nephrostomy. She said it was an oversight because if the residents were using an external catheter, a suction machine, and had a nephrostomy, then they should be coded for them respectively. She said she would audit the MDS' of the residents and would make sure that everything was coded appropriately. She said if the residents were not properly assessed, the needs would not be met, and there could be confusion in the provision of care and in doing the care plan. During an interview on 04/16/2026 at 6:56 a.m., ADON A said she was not familiar with MDS assessments but if the residents should be coded for an external catheter, suction, and nephrostomy, then the residents' MDS' should reflect the external catheter, suction, and nephrostomy.During an interview on 04/16/2026 at 7:27 a.m., the DON said the MDS Nurse was responsible in making the MDS assessment of the residents. He said the MDS was done upon admission, discharge, or if there was a change in condition. He said the purpose of the MDS was to capture current and significant quality measures that could be basis of residents' care. He said if the residents were using an external catheter, suction, a nephrostomy, then the residents' MDS' should reflect them. He said if the assessment in the MDS was not accurate, the care needed by the resident might not be met. She said the expectation was for the residents to be accurately assessed and coded in the MDS.During an interview on 04/16/2026 at 7:59 a.m., the Administrator said the MDS was done to reflect the current condition of the resident. She said if there was no accurate assessment, there could be a misunderstanding about the care needed by the residents. She said she would coordinate with the MDS Nurses to evaluate and resolve the issue.Record review of the facility's policy Resident Assessments Nursing Services Policy and Procedure Manual for Long-Term Care revised March 2022 reflected Policy Statement: A comprehensive assessment of every resident's needs is made at intervals designated by OBRA (federal law that required nursing homes for a standardized assessment) and PPS ( payment used by Medicare to reimburse providers) requirements . 1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments . 3. A comprehensive assessment includes . a. completion of the Minimum Data Set (MDS) . 5. The interdisciplinary team uses the MDS form . to conduct the resident assessment . 9. All resident assessments completed . are maintained in the resident's active clinical record.

Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan within 48 hours for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care to one of eight residents (Resident #125) reviewed for baseline care plan.The facility failed to ensure Resident #125 had a baseline care plan after admission to the facility on [DATE]. This failure could place the resident at risk of not receiving necessary care, treatment, and services upon admission that could result to worsen condition.Findings included:Record review of Resident #125's Face Sheet, dated 04/16/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. Upon admission, the resident was diagnosed with malignant (conditions that are dangerous to health) neoplasm (abnormal growth of tissue in the body) of mandible (Jaw bone), diabetes mellitus (high blood sugar), hypertension (high blood pressure), gastro-esophageal reflux (stomach acid repeatedly flows back into the tube connecting your mouth and stomach), acute kidney failure (kidneys stop working), dysphagia (difficulty in swallowing), aphasia (a language disorder), and gastrostomy status (having done a surgical procedure that creates artificial opening into the stomach to provide nutritional support).Record review of Resident #125's Comprehensive MDS Assessment, dated 04/10/2026, reflected the resident's full ARD (Assessment Reference Date: last day of the assessment period) would be on 04/23/2026.Record review on 04/14/2026 of Resident #125's Baseline Care Plan revealed the resident was only care planned for enhanced barrier precautions. The resident's baseline care plan did not include the minimum healthcare information necessary to properly care for the resident immediately upon admission. The plan did not address any resident-specific health issues such as dysphagia, diabetes mellitus, neoplasm, kidney failure, aphasia, and gastrostomy; safety concerns such as elopement risk and fall risk; needs for supervision such as the mode of transfer, shower, and dressing; behavioral intervention such as any PASRR (process to determine if an individual mental illness, intellectual disabilities, and developmental disabilities) recommendation. The plan did not reflect any goals and interventions to address his current needs.During an observation and interview on 04/16/2026 at 6:29 a.m., MDS Nurse G said all the residents admitted should have a baseline care plan within 48 hours to be able to meet the immediate needs of the residents. She said if the resident was admitted on [DATE], then there should be a baseline care plan by 04/12/2026. She checked the Resident #125's care plan and said the resident did not have a base line care plan. She said the only focus on the care plan of the resident was only about enhanced barrier precaution and nothing else. She said the base line care plan should, at least, reflect the resident's medical issues. She said the nursing department, the admitting nurse, the ADON, or the DON, should have done the base line care plan. She said she would make the resident's care plan.During an interview on 04/16/2026 at 6:56 a.m., ADON A said if a resident came after office hours or during the weekend, the admitting nurse should do the baseline care plan. She said she was not able to follow-up and it was an oversight on her part. She said she would do the care plan of Resident #125.During an interview on 04/16/2026 at 7:27 a.m., the DON said baseline care plans were important because it would give the providers the minimum healthcare information about the resident that needed to be addressed immediately or upon admission. He said without the baseline care plan, the immediate needs of the resident would not be met. He said he already started an in-service about baseline care plan.During an interview on 04/16/2026 at 7:59 a.m., the Administrator said all the residents must have a baseline care so that the care staff would know how to take care of the residents. She said the expectation was for the admitting nurse to initiate the baseline care plan. she said the DON already started an in-service about baseline care.During an interview on 04/17/2026 at 8:41 a.m., LVN I said she was the one who admitted Resident #125. She said the resident was admitted past eight in the evening and she had no time to do the baseline care plan. She said she did know that a base line data should be done upon admission of a resident. She said the computer indicated that a base line care plan should be done 04/12/2026 but it did not occur to her that the date mentioned was the deadline for the baseline care plan. She said she should have initiated the initial plan. She said the next shift should have done the base line care plan. She did not reply when asked if she told the next shift to do the baseline care plan.Record review of the facility's policy Care Plans - Baseline Nursing Services Policy and Procedure Manual for Long-Term Care revised March 2022 reflected Policy Statement: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission . Policy Interpretation and Implementation . 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident.

Based on interviews, and record review the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 6 residents (Resident #1 and #2) reviewed for ADL care provided to dependent residents. The facility failed to ensure Resident #1's fingernails were trimmed. The facility failed to ensure Resident #2 received her scheduled bed baths for January 2026 and December 2025. These failures could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem.Findings Included:Record review of Resident #1's Face Sheet, dated 01/14/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses of Hemiplegia affecting left dominant side (paralysis) and contracture of left hand (permanent tightening of tendons). Record review of Resident #1's Quarterly MDS Assessment, dated 10/15/25, reflected the resident had an intact cognitive response. The Quarterly MDS Assessment reflected the resident had active diagnoses of Hemiplegia affecting left dominant side and contracture of left hand (permanent tightening of tendons). The resident required total assistance for ADL care. Record review of Resident #1's Comprehensive Care Plan, dated 12/17/25, reflected the resident had an ADL self-care deficit and the resident was totally dependent on staff to provide ADL care. Record review of the Facility's Grievance log for December 2025 revealed Resident #1 filed a grievance on 12/17/25 about his fingernails not being trimmed. Observation of the pictures dated 01/05/26 provided by Resident #1's RR revealed the resident's fingernails on both hands being at least a half-inch in length and some of the fingernails had thick black substance under them. In an interview on 1/14/26 at 9:12 AM, Resident #1 stated he had been requesting to have his nails trimmed for weeks. He stated the long nails were digging into the palm of his left hand because it was contracted. He stated he had first complained about his nails needing to be trimmed sometime in December to a CNA (unknown) and he was told a nurse would trim them. He stated he told a male nurse (unknown) and was told they would be trimmed. He stated he complained to someone checking on residents and he finally got them trimmed on or about 1/07/26. In an interview on 1/14/26 at 9:15 AM, Resident #1's RR stated she had been attempting to get the resident's fingernails trimmed for weeks and was told by the nursing staff and Administrator it would be done, but they never did. She stated they finally trimmed his fingernails in January 2026. Record review of Resident #2's Face Sheet, dated 01/14/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had a diagnosis of Hemiplegia affecting left dominant side (paralysis) Record review of Resident #2's Quarterly MDS Assessment, dated 12/31/25, reflected the resident had a severe cognitive impairment. The Quarterly MDS Assessment reflected the resident had active diagnoses of Hemiplegia affecting left dominant side (paralysis) and physical debility. The resident required total assistance for ADL care. Record review of Resident #2's Comprehensive Care Plan, dated 10/02/25, reflected the resident was at risk for skin breakdown and the resident was totally dependent on staff to provide ADL care. Record review of Resident #2's clinical records on 01/14/26, revealed 1 shower form dated 10/17/25 uploaded in the facility's system of record for the resident. After this was brought to ADON M and the DON's attention, the facility provided shower forms for December 2025 and January 2026. Bed bath forms were received for 12/05/25, 12/11/25, 12/16/25 (refused because water was cold), 12/20/25, 01/02/26, and 01/10/26. In an interview on 1/14/26 at 12:56 PM, Resident #2 stated she really liked getting bed baths, but she had not been receiving them consistently. She stated she only received one bed bath last week. She stated she also needed her hair to be washed. She stated she needed her bed baths and had not refused any. In an interview on 1/14/26 at 1:07 PM, LVN R stated she was the charge nurse for the hall of Resident #1. She stated she was unaware of the resident's nails not being trimmed. She stated when the resident received his showers, the CNA should also check to ensure his fingernails were trimmed. She stated the resident's showers were completed by the 2PM - 10 PM staff. She stated the resident not having his fingernails trimmed could result in his fingernails digging into his skin on his left contracted hand. She stated Resident #2's showers or bed baths were provided by the evening CNAs. She stated the resident was scheduled for showers on Tuesday, Thursday, and Saturday. She stated it was her and the ADON's responsibility to ensure residents received their showers or bed baths. She stated if the resident did not receive them, she could have skin breakdown. In an interview on 1/14/26 at 1:12 PM, ADON M stated the charge nurse was responsible for ensuring residents received their showers or bed baths and fingernails trimmed. He stated he was not aware of Resident #1's fingernails not being trimmed. He was told by the Surveyor of Resident #2 stating she was not receiving her scheduled bed baths. He stated the CNAs were required to complete showers and bed baths whenever the resident was scheduled for their shower. He stated the charge nurse was responsible for signing the form, and if the resident refused the charge nurse was responsible for encouraging the resident to take a shower and if they still refused, the charge nurse was to contact the RR or emergency contact. He stated all shower forms were to be uploaded in the residents' clinical records. He was told by the Surveyor there was only one shower sheet uploaded for the resident, which was on 10/17/25. He stated he would research where the showers sheets were at for the resident. He stated if the resident did not receive her showers she could have skin breakdown. He stated the residents did not have an assigned CNA for their halls and the CNAs rotated halls daily. He stated LVN R was the charge nurse for the residents and was responsible for ensuring residents received their bed baths or showers. In an interview on 1/14/26 at 1:19 PM, the DON stated the CNAs were to complete shower sheets, the nurses were to sign them, and then they are sent to medical records to be scanned and uploaded into the resident records. She stated if the resident did not receive their scheduled bed baths or showers, they could have infections and skin breakdown. She stated the ADONs should be checking to ensure the residents receive their showers or bed baths. She was told about Resident #2 complaining of not receiving her bed baths as scheduled. She stated she had observed the shower forms for December 2025 and January 2026. She was told about Resident #1's grievance of not getting his fingernails trimmed on 12/17/25, and the length of time between the time the resident had made a grievance to when the resident had stated his nails were finally trimmed on 1/07/26, and she stated she did not know why it took so long because she was out the office. She stated she spoke with the nurses and ADONs about staying on top of ensuring the residents were being groomed when they received their showers or bed baths. Record review of the facility's policy on Activities of Daily Living (ADL), Supporting, dated December 2001, revealed, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, including assistance with hygiene (bathing, dressing, grooming, and oral care).

Based on interviews and record reviews, the facility failed to notify, consistent with his or her authority, the resident representative when there was a need to alter treatment significantly for 1 of 5 residents (Resident #1) reviewed for Resident Representative notification of treatment change. The facility failed to ensure Resident #1's Resident Representative was notified of the medication, Tramadol, prescribed to the resident on on 11/18/25. This deficient practice could place the resident at risk of taking medication that may be harmful to the resident. Findings included: Record review of Resident #1's Face Sheet, dated 01/14/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had a diagnosis of dementia (memory and thinking decline). Record review of Resident #1's Quarterly MDS Assessment, dated 10/15/25, reflected the resident had an intact cognitive response. The Quarterly MDS Assessment reflected the resident had active diagnoses of dementia (memory and thinking decline) and depression. Record review of Resident #1's Physician orders, dated 01/14/26, reflected the Tramadol HCI 50 MG by mouth every 8 hours as needed for pain, prescribed on 11/18/25. Record Review of Resident #1's admission forms signed on 07/14/25, revealed the RR signed as the party consenting to the resident to receive treatment at the facility. In an interview on 1/14/26 at 9:15 AM, Resident #1's RR stated she was not made aware of the resident receiving Tramadol for his pain. She stated as his RR she should have been made aware of the physician orders for the resident. She stated she spoke with the Administrator and was advised they did not have to contact the RR because the resident was of sound mind. The RR stated she thought because this was a narcotic, the RR should have been notified of the medication being administered to the resident. The RR stated she was concerned about the resident being given the pain medication because he was a recovering alcoholic. In an interview on 1/14/26 at 11:00 AM, the Administrator and Chief Nursing Operator were told about Resident #1's RR not being notified of the medication being prescribed to Resident #1. The Administrator stated she was trained if the resident was of sound mind, the resident could make decisions regarding his care and the resident was in pain. She stated the RR would only be notified if the Resident was not coherent. The Administrator and CNO stated the resident had the right to make decisions regarding his care. The Administrator stated the Surveyor wanted the facility not to respect the rights of the resident by not allowing him to make decisions regarding his care. The CNO stated they would change the RR to Resident #1 to prevent having to contact the RR on file for any care regarding the resident because he was coherent. In an interview on 01/14/26 at 11:45 AM the DON, and ADON S stated they were not aware if consent from Resident #1's RR would be required if the resident was of sound mind. They stated they tried to ensure the RR was made aware of the resident's care because she was constantly in communication with the nursing staff. Review of the facility's policy on Resident Representative (02/2021) revealed The term Resident Representative is defined as: An individual chosen by the resident to act on behalf of the resident in order to support the resident in decision -making; access medical, social or other personal information of the resident ; manage financial matters, or receive notifications.

Based on interviews and record reviews, the facility failed to ensure the resident had the right to receive written notice, including the reason for the change, before the resident's room was changed for 1 of 5 residents (Resident #1) reviewed for room change notifications. The facility failed to ensure Resident #1's Resident Representative was notified of the room change prior to Resident #1 being moved from room [ROOM NUMBER]B to room [ROOM NUMBER]B on 11/03/25. This deficient practice could place the resident at risk of experiencing anxiety and depression about moving to a new environment. Findings included: Record review of Resident #1's Face Sheet, dated 01/14/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses of depression and anxiety. Resident #1 was not his own Responsible Party Record review of Resident #1's Quarterly MDS Assessment, dated 10/15/25, reflected the resident had an intact cognitive response. The Quarterly MDS Assessment reflected the resident had active diagnoses of dementia (memory and thinking decline) and depression. Record review of Resident #1's Room Change notification revealed the form was signed by Resident #1 on 10/29/25, who was not his own RP, and not the RR. The notification stated the resident was moved to a Medicaid room on the Medicaid floor. The resident was residing on the 3rd floor and was moved to the 4th floor. Record Review of Resident #1's admission forms signed on 07/14/25, revealed the RR signed as the party consenting to the resident to receive treatment at the facility. In an interview on 1/14/26 at 9:15 AM, Resident #1's RR stated she was not made aware of the resident's room change. She stated she had received a call from the resident advising her the facility was moving him to a different room on a different floor. She stated she was the resident's RR for a reason, and she should have been notified of any changes involving the resident. She stated she had medical power of attorney to make decisions on the resident's care. She did not indicate if the facility or Resident #1 advised her of the reason for the room change. In an interview on 1/14/26 at 12:30 PM, Resident #1 stated he had a form shoved into his face telling him he was going to be moved to the 4th floor. He stated he felt as if he was being coerced into signing the paper because they made it seem as if he did not have a choice. He stated he contacted the RR, and she was frustrated because the facility had him sign the document instead of contacting her. Resident #1 stated he was not sure why he was being moved to another room. In an interview on 1/14/26 at 11:00 AM, the Administrator and Chief Nursing Operator were told about Resident #1's RR not being notified of the room change. The Administrator stated she was trained if the resident was of sound mind, the resident could be informed of the change request, and the Resident could inform the RR. She stated the RR would only be notified if the Resident was not coherent. The Administrator and CNO stated the resident had the right to make decisions regarding his care. The Administrator stated staff went to the resident and notified him of the room change and he stated he would notify the RR. The Administrator stated the Surveyor wanted the facility not to respect the rights of the resident by not allowing him to make decisions regarding his care. The CNO stated they would change the RR to Resident #1 to prevent having to contact the RR on file for any care regarding the resident because he was coherent. The Administrator stated they had moved all Medicaid Residents to the fourth floor. Review of the facility's policy on Resident Representative (02/2021) revealed The facility treats the decisions of the resident representative as the decisions of the resident to the extent delegated by the resident or to the extent required by the court, in accordance with applicable law.

Based on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for three of ten residents (Residents #1, #2, and #3) reviewed for resident rights. The facility failed to ensure the call light system in Residents #1, #2, and #3's rooms were adequately equipped to allow residents to call for staff assistance through a communication system on 11/04/25. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings include: 1. Record review of Resident #1's Face Sheet, dated 11/04/25, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included difficulty walking and muscle weakness. Record review of Resident #1's Quarterly MDS assessment, dated 9/30/25, reflected a BIMS score of 03, which indicated severe cognitive impairment. For ADL care, it reflected the resident was dependent on staff to provide all care. She had active diagnoses of a lack of coordination and muscle weakness. Record review of Resident #1's Comprehensive Care Plan, dated 9/25/25, reflected the resident was a fall risk, and included an intervention of ensuring call light was available to the resident. In an interview and observation on 11/04/25 at 8:19 AM, Resident #1's call light was observed hanging from the side of the bed, on the floor and out of her reach. She was asked if she knew where her call light was located and she stated no. In an interview on 11/04/25 at 10:58 AM, LVN F stated the DON told her about Resident #1 not having her call light within her reach. She stated the call light should be in reach of the resident in case she needed assistance and for her safety. She stated they did rounds every 1-2 hours, and they checked to ensure call lights were in the residents' reach. She stated they were supposed to clip it to ensure that it did not fall on the floor. In an interview on 11/04/25 at 11:22 AM, CNA D stated she was told by one of the nurses that Resident #1 did not have her call light within her reach. She stated she did clip the call light to the resident's gown in the morning prior to breakfast. She stated she checked to ensure call lights were within the residents' reach throughout her shift. She stated there were a lot of risk if the call light was not within reach of the resident. She stated the resident would not be able to contact anyone if help was needed. 2. Record review of Resident #2's Face Sheet, dated 11/04/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included muscle weakness and unsteadiness on feet. Record review of Resident #2's Quarterly MDS assessment, dated 8/29/25, reflected a BIMS score of 0, which indicated severe cognitive impairment. For ADL care, it reflected the resident required total assistance. She had active diagnoses of muscle wasting and age-related physical debility. Record review of Resident #2's Comprehensive Care Plan, dated 6/03/25, reflected the resident was a fall risk. In an interview and observation on 11/04/25 at 8:30 AM, Resident #2's call light was observed hanging from the side of the bed, on the floor and out of her reach. She was asked if she knew where her call light was located and she stated no. 3. Record review of Resident #3's Face Sheet, dated 11/04/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included muscle weakness and muscle wasting. Record review of Resident #3's Quarterly MDS assessment, dated 6/10/25, reflected a BIMS score of 3, which indicated severe cognitive impairment. For ADL care, it reflected the resident required substantial assistance. She had an active diagnosis of chronic pain. Record review of Resident #3's Comprehensive Care Plan, dated 11/04/25, which was updated after surveyor observation, reflected the resident was resistive to care and often removed her call light. None of the interventions referenced ways to keep the resident's call light on the bed. In an observation on 11/04/25 at 8:32 AM, Resident #3's call touch pad was observed on the floor, near the back wall, and out of her reach. In an interview and observation on 11/04/25 at 8:32 AM, the DON was shown the call lights for Resident #2 and Resident #3 on the floor and not within reach of the residents. She stated the call lights should be in reach of the residents so they could contact staff if they need assistance. She stated she had constantly coached her staff to ensure the call lights were clipped near the residents every time they made their rounds. She stated she constantly reminded them to check for this throughout their shift. In an interview on 11/04/25 at 8:55 AM, the Administrator was advised of Residents #1, #2, and #3 not having their call lights within their reach. She stated they had constantly tried to engrain in the nursing staff's brain to check for this every time they provided care to the residents and when they made their rounds. She stated they were trying to change the culture at the facility because they had identified this as a problem when they took over as leadership at the facility. She stated the risk of the call lights not being in reach of the resident could prevent them from contacting staff when they needed help. In an interview on 11/04/25 at 9:11 AM, ADON M stated the DON advised him of Residents #2 and #3 not having their call light within their reach. He stated the call light should be clipped near the patient. He stated if the call light was not within reach, it could delay patient care. He stated staff were to walk the halls and check to ensure call lights were within reach each time they check on the resident. He was shown pictures of the call lights not being within the residents' reach. In an interview on 11/04/25 at 9:30 AM, LVN O stated ADON M had advised her of the call lights not being within reach of Resident #2 and #3. She stated every time she made her rounds, she had checked to ensure the call lights were within reach of the resident. She stated the DON told her the call light should be clipped to the resident's gown or clipped to their pillow, because when the residents move around in bed, the call light could fall to the ground. She stated the call lights should be within their reach so they could call for help if they needed it. In an interview on 11/04/25 at 9:39 AM, CNA K stated she was advised of Resident #2 and #3 not having their call lights within their reach. She stated she checked to ensure call lights were in the residents' reach as soon as she started her shift and when she picked up the trays for breakfast. She stated they had residents who threw their call lights on the floor, so she had to make sure the call light was clipped to them. She stated if the call lights were not within the residents' reach, they could not contact the nursing staff. Record review of the facility's policy on Answering Call Lights dated September 2022, revealed The purpose of this policy is to assure timely responses to the resident's requests and needs. Ensure the call light is assessable to the resident when in bed.

Based on observations, interviews, and record review, the facility failed to ensure the resident had a right to confidentiality of his or her personal and medical records for eight (Residents #1, #5, #6, #7, #8, #9, #10, and #11) of twelve residents reviewed for privacy and confidentiality. The facility failed to ensure LVN A closed, locked, or minimized her laptop's monitor and did not leave Residents #1, #5, #6, #7, #8, #9, #10, and #11's medical information exposed and unattended on top of the nurse's cart on 12/03/2025. This failure could place the residents at risk of their medical information being accessed by unauthorized individuals.Findings included: Resident #1 Record review of Resident #1's Face Sheet, dated 12/03/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with malignant (conditions that are dangerous to health) neoplasm (abnormal growth of tissue in the body) of the colon (part of the large intestine) and hypertension (high blood pressure). Resident #5 Record review of Resident #5's Face Sheet, dated 12/03/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with intracranial hypotension (abnormally low pressure in the skull). Resident #6 Record review of Resident #6's Face Sheet, dated 12/03/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with cardiac arrest (heart attack). Resident #7 Record review of Resident #7's Face Sheet, dated 12/03/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with pneumonitis (swelling of the lung tissue). Resident #8 Record review of Resident #8's Face Sheet, dated 12/03/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with acute respiratory failure (inability of the lungs to provide adequate oxygen). Resident #9 Record review of Resident #9's Face Sheet, dated 12/03/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with heart failure (heart muscle is unable to pump enough blood to the body). Resident #10 Record review of Resident #10's Face Sheet, dated 12/03/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with Parkinson's disease (movement disorder). Resident #11 Record review of Resident #11's Face Sheet, dated 12/03/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with congestive heart failure. Observation on 12/03/2025 at 9:16 AM revealed an untitled piece of paper was left on top of a nurse's cart parked in the hallway. On the piece of paper was Resident #1, #5, #6, #7, #8, #9, #10, and #11's blood pressure, pulse rate, and oxygen saturation. It was also observed that the laptop on top of the same nurse's cart was open. The monitor of the open laptop showed Residents #1, #5, #6, #7, #8, #9, #10, and #11's pictures and that the residents were on skilled nursing. The nurse's cart was unattended and was facing the hallway with several staff walking back and forth. During an interview on 12/03/2025 at 9:18 AM, LVN A stated she left the cart because she went to attend to a resident who needed assistance. She said the best practice was to secure any information about the residents before leaving the cart unattended. She flipped that paper and closed her laptop. She said the piece of paper had some of the residents' vital signs while the laptop showed the names of the residents, their pictures, and that they were on skilled nursing. She said she should have secured the paper and closed the laptop she was using before leaving the cart. She said she would be mindful that no information about the resident would be exposed. In an interview on 12/03/2025 at 11:59 AM, the DON stated personal and medical information about a resident should be secured to avoid a HIPAA violation. She said the information should not be exposed for everybody to see because it was confidential. She said the health information should be protected and could only be shared to the residents, the responsible parties, and the providers. She said the information could not be seen by staff that had nothing to do the residents' care, visitors, and even vendors. She said the staff were expected to provide full privacy and confidentiality of information for all residents. The DON stated she would start an in-service about privacy and confidentiality of the residents' information. In an interview on 12/03/2025 at 1:08 PM, the Administrator stated the staff must make sure the residents' information was not exposed and was protected because it was a violation of the residents' privacy and confidentiality. She said the vital signs, their pictures, and the level of care they were receiving were medical information and should not be seen by unauthorized individuals. She said the expectation was for all the staff to make sure the personal and medical information of a resident were not left unattended. She said she would collaborate with the DON to do an in-service about privacy and confidentiality. In an interview on 12/03/2025 at 3:00 PM, ADON H stated the laptop should have been closed and the paper should have been facing down so that unauthorized individuals would not have any access to the medical information of the residents. She said the vital signs were medical information, a well as knowing that the residents were in skilled nursing. She also said that the pictures of the residents with their names and the level of care was protected health information and should be secured. She stated the residents' information was restricted to unauthorized individuals and it was a HIPAA violation if the information were visible to others that were not providing care to the residents. She said the expectation was for the staff not to leave any personal or medical information about any resident at any time and to always close their laptops before leaving their carts. She said she would coordinate with the DON to do an in-service about privacy and confidentiality. Record review of the facility's policy, Confidentiality of Information and Personal Privacy 2001 MED-PASS revised October 2017 revealed Policy Statement: Our facility will protect and safeguard resident confidentiality and personal privacy . Policy Interpretation and Implementation . 1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records.

Based on observation, record review and interview the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #24) of five residents reviewed for pressure ulcers. The facility failed to appropriately identify Resident #24's skin injury, obtain, and provide appropriate treatment. The facility failed to notify the physician of Resident #24's new facility acquired wound to the left buttock and the deep tissue injury to the left heel. This failures placed residents at risk for skin break down, multiple skin injury, and a decline in quality of life. Findings include: Review of Resident #24's face sheet dated 12/21/2023 revealed a 90-years-old female admitted to the facility 04/05/1922 with a readmission on 12/24/2022. Resident #24's diagnoses included: Parkinson's, (a disorder of the central nervous system that affects movement) dementia (a condition characterized by progressive or persistent loss of intellectual functioning), major depression, dysphagia (difficulty with swallowing), lack of coordination, muscle weakness and chronic kidney disease. Review of Resident #24's care plan dated 12/21/2023 reflected, Problem Start Date: 12/19/2023 Category: Integumentary System (Skin) WOUNDS TREATMENT LEFT BUTTOCK: RESIDENT IS AT RISK FOR COMPLICATIONS AND WORSENING OF EXISTING WOUND(S) (PRESSURE ULCER, SURGICAL WOUND) R/T IMPAIRED MOBILITY, AND BODY SYSTEM DEFICIENCIES IN ABILITY TO HEAL. Goal, RESIDENT'S ULCER WILL DECREASE IN SIZE BY NEXT REVIEW. Intervention, APPLY DRESSINGS AND WOUND CARE PER MD ORDER: DATE, TIME, AND INITIAL WOUND DRESSING. DOCUMENT IN NURSING PROGRESS NOTES AND WOUND ASSESSMENT RESIDENTS TOLERANCE TO THE PROCEDURE. Problem Start Date: 04/21/2022 Category: Integumentary System (Skin) (Resident #24) is at risk for pressure ulcers and other skin related injuries due to incontinence. (Resident #24) will maintain skin integrity without new skin related injuries over the next review period. Approach Start Date: 04/21/2022 Observe skin for redness and breakdown during routine care. Review of the MDS dated [DATE] reflected she had a BIMS score of 9, and required maximum assistance with activities of daily living. Further reflected the resident did not have a skin issue and she was a high risk of developing a pressure ulcer/injury. Skin and ulcer/injury treatments was for pressure reducing device for bed. Review of Physician order with a start date of 12/19/2023 for wound prevention to turn and offload/pad pressure points while in bed 6 times per shift. Cleanse open wound of the left buttock with normal saline, pat dry, apply anasept gel and cover with boarded island dressing daily and PRN. Apply skin prep to left heel daily. Observation and interview on 12/18/23 at 03:45 PM, Resident #24 was in bed, well groomed, and the room was clean. Resident #24 stated she had a wound on her bottom area that the facility did not treat, she stated the staff only applied cream. Resident #24 stated the staff knew of the wound and she had told one of the staff members (CNA A). Resident #24 stated she started feeling like she had a wound on her bottom about 2-3 weeks ago because it stung while she was being provided care. Observation on 12/19/23 at 12:43 PM, during incontinent care for Resident #24 revealed she had a open area to the left buttock. The wound did not have a dressing and the wound bed was red, and no tunneling was noted. In an interview on 12/19/23 at 12:59 PM, CNA C revealed she took care of Resident #24. CNA C stated she had worked in the facility for two weeks and for one week she had taken care of the resident. CNA C stated Resident #24 was alert and oriented, she was incontinent of bowel and bladder. CNA C stated when she started taking care of Resident #24 the resident had the open area to the left buttock and after she cleaned the resident, she applied barrier cream. CNA C stated she had not informed the charge nurse of the open area because when she started working with the resident, the resident already had the open area, and she assumed the charge nurse was aware of the open area. CNA C stated when there were any skin issues, she was supposed to notify the charge nurse immediately. In an interview on 12/19/23 at 01:18 PM, LVN D stated she was the charge nurse for Resident #24. LVN D stated she was not aware Resident #24 had any skin issues and no one had reported the resident having any wounds. LVN D stated Resident #24 had a history of a wound that had resolved about one year ago. Observation and interview on 12/19/23 at 01:21 PM, LVN D assessed Resident #24's bottom area and she stated it was an open area and she was going to inform the wound care nurse to assess the open area. LVN D informed the wound care nurse. LVN D reviewed the clinical records and stated Resident #24's weekly assessments had not been completed since October. LVN D stated the 7pm - 7am charge nurse was to complete Resident #24's weekly skin assessments. LVN D stated the aides were to inform the charge nurse of any skin issues and the charge nurse will assess the resident, then the charge nurse will inform the resident's responsible party and wound care nurse. In an interview on 12/19/23 at 01:38 PM, CNA E stated normally she did not take care of Resident #24. She stated she took care of Resident #24 about two weeks ago and her bottom area was intact, but yesterday when she was taking care of the resident the resident reported burning sensation on her bottom. While CNA E was providing incontinent care to Resident #24, she noted the resident with an open area on her bottom. The open area was not bleeding and did not look like it was a new wound. CNA E cleaned Resident #24 and applied barrier cream. CNA E stated she didn't recall informing the charge nurse directly of the open area because it did not look like it was a new wound, and assumed the nurse was aware of the wound. CNA E stated if the resident had any skin issue the aide was expected to report to the charge nurse immediately. In an interview on 12/19/23 at 04:00 PM, LVN F stated she was the wound care nurse and she had been completing wound care in the facility for more than one year. LVN F stated Resident #24 was alert and oriented and she was able to voice her needs. LVN F stated Resident #24 was at risk for developing pressure ulcers and she had an history of pressure ulcers that had resolved. LVN F stated the charge nurses were the ones to complete weekly skin assessments, and if there was any skin issue, they would inform LVN F (wound care nurse) and she will complete the skin assessment. LVN F said she was not aware Resident #24 had a wound prior to today. LVN F completed Resident #24's head to toe assessment and noted a wound on the left buttock and measured 3cm x1.6cm x 0.2cm, no drainage , no foul odor and the wound bed was red, LVN F stated only the wound care doctor was to stage the wound. LVN F also noted redness to her left heel 2cm x2cm non-bleachable. LVN F then informed the wound care doctor of the skin issues with new orders wound treatment orders. LVN F stated the wound required treatment because it was an open area and without treatment the wound could deteriorate or be infected. LVN F stated the aides were supposed to report any skin issues to the charge nurse or the wound care nurse. In an interview on 12/19/23 at 04:32 PM, CNA G stated she was taking care of Resident #24. CNA G stated Resident #24 was alert and oriented and she was able to voice her needs. Resident #24 was incontinent of bowel and bladder, and she required total assistance with activities of daily living. CNA G stated she noted redness on Resident #24's bottom area on 12/15/23, she was off on 12/16/23 and when she took care of the resident on 12/17/23 the bottom area looked like the skin was peeling off. CNA G stated she did not inform the charge nurse of Resident #24's skin issue because she was too busy. CNA G stated she was expected to report any skin issues to the charge nurse immediately, so that the charge nurse would assess the resident. In an interview on 12/19/23 at 05:21 PM, ADON B stated she was the unit manager for the fourth floor and oversees the care of the residents. ADON B stated Resident #24 required assistance with activities of daily living and she was incontinent of bowel and bladder. Resident #24 was at high at risk for pressure ulcer because she was not ambulatory, and she had a history of pressure ulcers. ADON stated she was not aware of Resident #24 having any skin issues. ADON B stated the aides were to report to the charge nurses of any skin issues and the charge nurses were to complete the skin assessment. ADON B stated the charge nurses were expected to complete weekly skin assessment to be able to notice if the resident had any skin issues. ADON B stated she was responsible to do a follow up and make sure the weekly skin assessments were completed but she did not, she stated I Just missed it, i am not gonna lie to you. ADON B stated when the aides noted redness/open area on Resident #24's bottom they were supposed to report immediately to the charge nurse. ADON B stated the charge nurse failed to complete the weekly skin assessments and the aides failed to report a skin issue. Open wound on the resident without proper treatments could lead to the wound getting worse and or being infected. In an interview on 12/20/23 at 12:28 PM with the DON she stated she was made aware of Resident #24's wound, prior to yesterday she was no aware of the wound. DON stated the facility completed a skin sweep and no new wounds were noted. DON stated she expected the aides to report any skin issues they noted on the resident and document. DON also expected the charge nurses to complete weekly skin assessments to identify the resident skin issues, thus being able to intervene timely. The DON further stated, if the resident had a wound the wound care Dr had to be notified so as treatment could be started to prevent the wound from getting worse or being infected. In an interview on 12/21/23 at 08:24 AM, RN H stated she took care of Resident #24 on the 7p-7a shift. The resident was alert and oriented and she was able to voice her needs. Resident #24 required assistance with activities of daily living, and she was incontinent of bowel and bladder. RN H stated Resident #24's weekly skin assessment was scheduled on the night shift, and the charge nurses were expected to complete the weekly assessments. RN H stated if the charge nurse was not able to complete the scheduled weekly skin assessment, they were to inform the oncoming nurse, but she stated she did not inform the oncoming nurse or management that she was not able to complete the weekly skin assessment. RN H stated the weekly skin assessment was to check and see if the resident had any skin issues so it could be addressed promptly. RN H stated if Resident #24's weekly skin assessment was completed the resident wound could have been identified and treatment initiated. RN H stated open wounds that are not treated could deteriorate or being infected. In an interview on 12/21/23 at 09:42 AM, the ED stated she was not aware Resident #24 having any skin issue. The ED stated if the resident had any wound or skin issues, the staff were to intervene and notify the wound care Dr so treatments could be provided to prevent the wound from deteriorating or being infected. The ED stated the facility expected the aides to report timely of any skin issues and the charge nurses to complete weekly skin assessment per scheduled. The ED stated if the resident had a new wound the treatment nurse had to be made aware so she could assess the skin issue timely. In an interview on 12/21/23 at 01:22 PM, the wound care Dr, stated she was in the facility weekly to assess the progress of the wounds and change treatment orders if need be. She stated she was not aware of Resident #24's wound until Tuesday (12/19/23). After assessing Resident #24 she stated the resident had two skin issues, one was on her left buttock that was a skin trauma, looked fresh and she was not able to determine when it started, she stated it was not a pressure ulcer. The second issue was a deep tissue injury to the left heel, it was not open. She stated she already put orders in place. The Dr stated she expected the staff to report any skin issues to her timely for treatment to be started to prevent wound infections or the wound deteriorating. Review of the facility policy revised April 2018 and titled Pressure ulcer/skin breakdown - clinical protocol reflected, 1. The nursing staff assess skin and notify MD of any skin issues weekly per facility protocol. 2. In addition, the nurse shall describe and document/report the following. a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. Review of an undated policy titled, Skin assessments must be done weekly; No exceptions!! Reflected, Nurse aides must fill shower sheets daily and report any skin issues to the nurse ASAP. The nurse must then follow up, complete a new skin assessment detailing the new skin issue and put in a new wound care consult. Failure to do so will result in disciplinary action.