Every finding on record at Spanish Meadows

Based on interview and record review the facility failed to incorporate the recommendations from the Preadmission Screening and Resident Review (PASRR) Level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 4 residents (Resident #1) reviewed for PASRR. The facility failed to initiate Resident #1's Nursing Facility Specialized Services (NFSS) within 20 business days following the Interdisciplinary Team (IDT) meeting held on 04/21/2026, during which the need for a customized manual wheelchair was identified and agreed upon by the IDT. This failure could cause residents with mental health disorders and psychiatric conditions to have a delay in services or not receive specialized services or equipment that may be needed. Record review of Resident #1's face sheet, dated 07/23/2026, revealed a [AGE] year-old male originally admitted [DATE], and most recent admission date of 05/18/2024. His diagnoses included muscle wasting and atrophy (gradual wasting away or shrinkage of an organ, tissue or muscle), muscle weakness, unsteady on feet, lack of coordination, reduced mobility, and unspecified intellectual disabilities (an impairment with intellectual and adaptive functioning which may affect intelligence, learning, and everyday life skills). Record review of Resident #1's Quarterly MDS assessment, dated 07/02/2026, revealed a BIMS score of 02, indicating severely impaired cognition. The MDS assessment also revealed Resident #1 had impairment to lower extremities on both sides and utilized a wheelchair, as well as Resident #1 required partial/moderate assistance with lower body dressing, putting on/taking off footwear, personal hygiene, toileting hygiene and shower/bathing self. Record review of Resident #1's care plan dated 07/17/2026 revealed resident was identified as having PASRR positive status related to intellectual disabilities with a goal of maintaining highest level of practicable wellbeing. Interventions included provide service coordination with local authorities and RP to the quarterly care plan meetings to discuss resident's function and report any need to evaluate for habilitative services and/or durable medical equipment to maintain the resident's current level of function. Record review of Resident #1's PASRR NFSS form, revealed a request for a customized manual wheelchair. Date of Assessment 06/25/2026. Record review of Resident #1's intake investigation worksheet complaint intake # 1103594 received 07/09/2026 revealed an email an email correspondence in which it was stated, .These NFs were informed that as per 26 TAC Chapter 554, Subchapter BB S554.2704 (i)(7)they have failed to submit a complete and accurate request for nursing facility specialized services (NFSS) in the LTC Online Portal within 20 business days after the date of the Interdisciplinary Team meeting. The resident has not received a Medicaid service because of the following: The NF was notified and instructed to submit a NFSS Request by a specific deadline but failed to do so. The NFSS Request submittal by the NF was denied and there was not a follow up submittal to ensure the request was approved to provide specialized services for PASRR for the resident. In an interview on 07/23/2026 at 9:38 a.m. DOR stated that he and the DON were responsible for submitting the NFSS requests through the LTC Online Portal. He stated that he does the therapy portion and the DON would review it to ensure the information was accurate before submission. The DOR stated that the process for initiating an NFSS request began with the facility conducting an IDT meeting. He stated that an order would be filed and therapy would go and evaluate the resident. He stated once the evaluation was completed, then we submit the NFSS and request the physician's signature. The DOR stated that he did not know when Resident #1's IDT meeting had been held and directed the surveyor to ask the DON for that information. He stated that he was aware that the facility had 20 business days to submit the NFSS request through the online portal. He stated that there had been a glitch in the system, which was the reason the request had not gone through. He then stated, actually, it went through just now. The DOR stated that he was initially under the impression that it had been submitted but he rechecked it on Tuesday, 07/21/2026, and realized it did not go through. He stated that he checks on the NFSS requests status every other day. He stated that Resident #1 has not received the customized wheelchair, but he was using a regular wheelchair at this time. The DOR stated that it was important to submit the NFSS on time because the residents do not get the services needed. In an interview on 07/23/2026 at 10:18 a.m. the DON stated that the DOR was responsible for submitting the NFSS if it was customized equipment or habilitative service. Therapy would need to evaluate the resident first then submit the NFSS. He stated the IDT meeting for Resident #1 was conducted on 04/21/2026 and a customized manual wheelchair was recommended. He stated that he opens the NFSS form for the assessments to be done. The DON stated that Resident #1's NFSS form was first opened on 04/21/2026. He stated that he was aware that the facility had 20 business days to submit the NFSS online which was equivalent to 30 calendar days. He stated that he was aware that Resident #1's NFSS timeframe had passed. The DON stated that the DOR was having difficulties submitting. He stated that there was a section on the NFSS form that was incomplete and that was why it was not submitted. Then the DOR told him that there was a glitch in the system and that was why it was not going through. He stated that it was important for the NFSS to be submitted within time, so the recommended device or service was received as soon as possible. The DON stated that the negative outcome would be that Resident #1 would not get the customized manual wheelchair on time but that he does have a functional wheelchair to move around at this time. Record review of the facility's admission Criteria policy dated March 2019 reflected: Policy Statement: Our facility admits only residents whose medical and nursing care needs can be met.Policy Interpretation and Implementation: .9. All new admission and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per Medicaid Pre-admission Screening and Resident Review program (PASARR) process.c. Upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation.

Based on interview and record review, the facility failed to review and revise a comprehensive care plan after each assessment, including both the comprehensive and quarterly review assessments for 1 of 3 (Resident #2) residents reviewed for care plan revisions. The facility failed to revise Resident #2's care plan to discontinue the use of floor mats to the bilateral side of the bed. This deficient practice could affect Resident #2, by placing him at risk of not receiving appropriate interventions to meet his specific needs.Record review of Resident #2's face sheet dated 7/23/2026, indicated an [AGE] year-old male who was admitted to the facility on [DATE]. His relevant diagnoses included Unspecified Dementia (decline in memory and thinking skills), Muscle Weakness (generalized), other abnormalities of gait and mobility, and other lack of coordination. Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated Resident #2 usually understood and was usually understood by others. The MDS assessment indicated Resident #2 had a BIMS score of 9, indicating he was moderately cognitively impaired. The MDS indicated that he required assistance with ADLs. Record review of Resident #2's Care Plan dated 7/23/2026 reflected focus: I had a fall on 7/6/2026 with open area to left temporal area related to poor balance. While laying in bed I attempted to roll onto my side when I rolled off the edge of the bed onto floor hitting myself with unknown object. Resident #2's Care Plan Intervention stated floor mats to bilateral side of the bed. Record review of Resident #2's Order Summary report dated 7/23/2026, stated: Floor mats to sides of bed at all times due to poor safety awareness was discontinued on 7/7/2026. Record review of Resident #2's Progress Notes dated 7/23/2026 stated: 7/8/2026 Patient Voicing that he dislikes floor mats, that is harder to get out of bed, this nurse educated patient regarding the need of floor mats and the need to use of call light whenever he needs assistant, patient states understanding. During an observation on 7/23/26 at 7:42 a.m., no floor mats were observed on either side of Resident #2's bed. During interview on 7/23/26 at 7:43 a.m., Resident #2 stated that he had fallen from his bed in the past. He stated that he does not remember if he ever had floor mats. During interview with CNA A on 7/23/26 at 11:19 a.m., CNA A stated she would check Resident #2's care plan on the computer. CNA A stated that some residents use mats that were placed next to their beds. CNA A stated that the mats were used to prevent major injury if a resident were to fall. CNA A stated that if Resident #2's care plan was not updated, he will not receive the proper individualized care he needs. During interview with LVN A on 7/23/2026 at 11:38 a.m., she stated Resident #2 previously had a mat, but it was removed because the order for the mat was discontinued. LVN A stated that the order to remove the mat was given on 7/7/26 because Resident #2 wanted the mats removed. LVN A stated that resident Care Plans were updated by MDS staff. LVN A stated that a negative consequence of not having updated Resident #2's individualized care plan would be that the staff may not be informed on how to properly care for him. During an interview with CPC A on 7/23/2026 at 1:25p.m., CPC A stated she updates resident care plans when new physician orders were provided. Care Plan Coordinator A stated she was not aware she had to update Resident #2's Care Plan immediately. CPC A stated she does her updates when she does her quarterly reviews. CPC A stated it was important that the care plan be revised whenever orders change so that the staff know the status of the residents' daily needs. CPC A stated a negative consequence of not updating the care plan when an order was changed was that Resident #2 would not receive the individualized care he needs. During an interview on 7/23/2026 at 2:30 p.m., the DON said Resident #2's care plan had to be accurate and this way all staff could know what the resident needed. The DON stated it was important to have an up-to-date care plan to ensure they provide the individualized care each resident requires. The DON stated that he knew that the care plans had to be resident specific. DON stated a negative consequence of not updating a care plan promptly was the physician's order and care plan would differ; this could result in a Resident #2 not receiving proper care. Record review of the facility policy titled Care Plans, Comprehensive Person-Centered, revised date December 2016, reflected Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change.

Based on interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need that were identified in the comprehensive assessment for 2 of 3 residents (Resident #1 and Resident #2) reviewed for comprehensive person-centered care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #1 and Resident #2 to address transfers. This deficient practice could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. The Findings include: 1. Record review of Resident #1's face sheet, dated 05/28/2026, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Unspecified Dementia (a medical placeholder used when a patient clearly has symptoms of dementia, but the exact underlying cause has not yet been pinpointed or confirmed), Parkinson's disease without dyskinesia (refers to the condition prior to the development of involuntary, wriggling movements), and muscle weakness. Record review of Resident #1's quarterly MDS assessment, dated 03/04/26, reflected a BIMS score of 4, which indicated Resident #1's cognition was severely impaired. Chair/bed-to-chair transfer was marked on the MDS as 03 which indicated partial/moderate assistance - helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Record review of Resident #1's Care Plan initiated on 11/28/25 reflected focus: he was at risk for falls and required assistance by staff with transfers due to decreased physical mobility, weakness, unsteady gait, cognitive and unsteady gait, interventions: assist with transfers as needed. 2. Record review of Resident #2's face sheet, dated 05/29/2026, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE]. Resident #2 had diagnoses which included: Dementia (a decline in mental abilities such as memory, thinking, and reasoning that is severe enough to interfere with daily life), Parkinson's disease without dyskinesia (refers to the condition prior to the development of involuntary, wriggling movements), and muscle weakness. Record review of Resident #2's quarterly MDS assessment, dated 04/28/26, reflected a BIMS score of 13, which indicated Resident #2's cognition was intact. Chair/bed-to-chair transfer was marked on the MDS as 03 which indicated partial/moderate assistance - helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Record review of Resident #2's Care Plan initiated on 7/26/25 reflected focus: he was at risk for falls and required assistance by staff with transfers and ADL's interventions: assist with transfers as needed. During an interview on 05/28/26 at 11:30 a.m., CNA A stated that Resident #1 needs assistance with transfers because he was not able to transfer by himself because of the resident had Parkinson's. CNA A stated that she knew how to access the Kardex but confirmed that Resident #1's information was not available on the Kardex regarding transfers. During an interview on 5/28/26 at 12:28 p.m., LVN B stated Resident #1 needed assistance with transfers because the resident had an unsteady gait. LVN B stated that a negative outcome of the care plan not being accurate could place Resident#1 and Resident #2 at risk for falls or injury. LVN B stated that the assistance needed for Resident #1 and Resident #2 were not resident centered. During an interview on 05/29/26 at 11:50 p.m., the DON said Resident#1 and Resident#2's care plan had to be accurate and this way all staff could know what the resident needed. The DON said he did not think there was a negative outcome. The DON stated that he knew that the care plans had to be resident specific. Record review of the facility policy titled Care Plans, Comprehensive Person-Centered, revised date December, 2016, reflected A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 1 of 5 residents (Resident #1) reviewed for abuse and neglect, in that: The facility did not implement their abuse policy related to reporting a major injury when Resident #1 had an unwitnessed fall that resulted in multiple rib fractures, T5 vertebral fracture and lumbar transverse fracture. This failure could place residents at risk of abuse and neglect.The findings were: Record review of Resident #1's face sheet, dated 4/17/2026, revealed an [AGE] year-old female with an admission date of 3/07/2026 with diagnoses which included: osteoarthritis (protective cartilage cushioning the ends of bones wears down over time, causing joints to become painful, stiff and swollen), osteoporosis (disease that makes bones weak, brittle, and porous, resembling a sponge), Alzheimer's Disease ( progressive brain disease, which causes a slow decline in memory, thinking, and reasoning skills), hypertension (high blood pressure), stable burst fracture of unspecified thoracic vertebra (a broken back bone in the upper/mid-back where the vertebra collapses under high pressure but stays in alignment), spinal stenosis (narrowing of the spaces within the spine, which puts pressure on the nerves and spinal cord traveling through it). Record review of Resident #1's MDS assessment, dated 3/14/2026 revealed a BIMS score of 3 which indicated Resident # 1 had severe cognitive impairment. Record review of Resident #1's MDS assessment, dated 3/14/2026, revealed Resident #1 required substantial/maximal assistance for toilet transfer. Resident #1 required substantial/maximal assistance for chair/bed-to-chair transfer. Record review of Resident #1's care plan, dated 3/24/2026, revealed Resident #1 required assistance with ADLs R/T decreased mobility, weakness, unsteady gait, unsteady balance with transitions, poor safety awareness, HX of falls, S/P spinal surgery R/T fracture of spine, multiple fractures D/T fall. Goals included will receive assistance as needed and maintain the highest level of independence and interventions included, assist resident as needed with ADLs. Record review of Resident #1's progress notes revealed a progress note written by LVN A, on 3/01/2026 at 1:05 AM stating, .resident was noted sitting up on the floor in the restroom doorway. Resident states she was walking back to bed after using the restroom and fall back onto her bottom and back, denies hitting head. Voices pain to right heel, right hip and lower back. Right heel is noted with redness, no visible discoloration to hips, and red scrape noted to lower back. Resident shows ROM to all extremities and guarding to right hip. Resident was assisted up, was able to bear weight to legs but was unable to ambulate. Resident was assisted to bed, head to toe assessment completed, PRN APAP was given and NP was notified of incident. Record review of Resident #1's progress notes revealed a progress note written by LVN B, on 3/07/2026 at 6:30 p.m. stating, .ribs multiple fx's, T5 vertebral fx, lumbar transverse fx. Record Review of TULIP (HHSC online incident reporting application) on 4/18/2026 at 11:50 a.m. revealed the facility had not made a self-reported incident involving Resident #1. Observation on 4/17/2026 at 10:01 a.m., Resident #1 was seen in the dining area, actively participating in activities. Resident # 1 was observed sitting in her wheelchair eating no facial expressions of discomfort were observed. During an interview on 4/18/2026 at 11:35 a.m., the DON stated Resident #1's unwitnessed fall happened on 3/01/2026. The DON stated the Administrator was made aware. The DON stated an incident report was completed on 3/02/2026 and concluded unfounded ANE.The DON stated the appropriate time frame to report allegations of abuse, neglect, exploitation, or injury of unknown injury was two hours. The DON stated Resident #1's unwitnessed fall was not reported to any state agency because there were no radiology exams done at the facility that indicated fractures. Regarding the facility procedures, the DON stated the facility would self-report any unwitnessed falls with injury, injury of unknown origin or when they suspected abuse, neglect to the state. The DON stated the facility did not report Resident #1's unwitnessed fall. During an interview on 4/18/2026 at 12:03 p.m., the Administrator stated the date of the unwitnessed fall involving Resident #1 was on 3/01/2026 and she was made aware by the DON on 3/01/2026. He stated regarding facility procedures, the facility would report to the state unwitnessed falls with injury, injuries of unknown origin and suspected abuse or neglect. The Administrator stated the facility did not make a self-report to the state regarding Resident #1's unwitnessed fall. The Administrator stated the injuries were made known to the facility when Resident #1 was re-admitted . The administrator stated the reporting time frames for allegations of abuse, neglect, and exploitation and injury of unknown origin was two hours. The Administrator stated Resident #1's unwitnessed fall was not reported to within the two-hour time frame of learning about the injuries. The Administrator stated Resident #1's unwitnessed fall was not reported because the facility did not know of the injuries until the resident was re-admitted back and a report was received from the hospital nurse, which included chronic and acute fractures. Record review of the facility policy titled Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property undated, stated under section Reporting and Response, subtitle Serious Bodily Injury Reporting- 2 hour limit: If the events that cause the reasonable suspicion result in serious bodily injury to a resident, the covered individual shall report the suspicion immediately, but no later than 2 hours after forming the suspicion. External Reporting: Initial reporting of allegations: if an incident or allegation is considered reportable, the administrator or designee will make an initial (immediate or within 24 hours) report to the State Agency.'

Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but no later than 2 hours after the allegation was made, if the alleged violation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 1 of 5 residents (Resident #1) reviewed for reporting injuries of unknown origin.The facility failed to report when Resident #1 was readmitted to the facility from the hospital after having sustained a fall at the facility, of multiple fractures to the ribs, T5 vertebral fracture, and lumbar transverse process fracture. The facility failed report to the State Agency when Resident #1 had an unwitnessed fall on 03/01/2026, and sustained fractures to the ribs, T5 vertebral fracture and lumber traverse process fracture.This failure could place residents at risk for undetected abuse, neglect, and/or decline in feelings of safety and well-being.The findings included:Record review of Resident #1's face sheet, dated 4/17/2026, revealed an [AGE] year-old female with an admission date of 3/07/2026 with diagnoses which included: osteoarthritis (protective cartilage cushioning the ends of bones wears down over time, causing joints to become painful, stiff and swollen), osteoporosis (disease that makes bones weak, brittle, and porous, resembling a sponge), Alzheimer's Disease ( progressive brain disease, which causes a slow decline in memory, thinking, and reasoning skills), hypertension (high blood pressure), stable burst fracture of unspecified thoracic vertebra (a broken back bone in the upper/mid-back where the vertebra collapses under high pressure but stays in alignment), spinal stenosis (narrowing of the spaces within the spine, which puts pressure on the nerves and spinal cord traveling through it). Record review of Resident #1's MDS assessment, dated 3/14/2026 revealed a BIMS score of 3 which indicated Resident # 1 had severe cognitive impairment. Record review of Resident #1's MDS assessment, dated 3/14/2026, revealed Resident #1 required substantial/maximal assistance for toilet transfer. Resident #1 required substantial/maximal assistance for chair/bed-to-chair transfer. Record review of Resident #1's care plan, dated 3/24/2026, revealed Resident #1 required assistance with ADLs R/T decreased mobility, weakness, unsteady gait, unsteady balance with transitions, poor safety awareness, HX of falls, S/P spinal surgery R/T fracture of spine, multiple fractures D/T fall. Goals included will receive assistance as needed and maintain the highest level of independence and interventions included, assist resident as needed with ADLs. Record review of Resident #1's progress notes revealed a progress note written by LVN A, on 3/01/2026 at 1:05 AM stating, .resident was noted sitting up on the floor in the restroom doorway. Resident states she was walking back to bed after using the restroom and fall back onto her bottom and back, denies hitting head. Voices pain to right heel, right hip and lower back. Right heel is noted with redness, no visible discoloration to hips, and red scrape noted to lower back. Resident shows ROM to all extremities and guarding to right hip. Resident was assisted up, was able to bear weight to legs but was unable to ambulate. Resident was assisted to bed, head to toe assessment completed, PRN APAP was given and NP was notified of incident. Record review of Resident #1's progress notes revealed a progress note written by LVN B, on 3/07/2026 at 6:30 p.m. stating, .ribs multiple fx's, T5 vertebral fx, lumbar transverse fx. Record Review of TULIP (HHSC online incident reporting application) on 4/18/2026 at 11:50 a.m. revealed the facility had not made a self-reported incident involving Resident #1. During an interview on 4/18/2026 at 9:01 a.m., LVN A stated the Administrator was the abuse coordinator. LVN A stated Resident #1's unwitnessed fall happened on 3/01/2026. LVN A stated he entered Resident #1's room and saw Resident ##1 sitting on the floor in the bathroom's doorway. He stated Resident #1's heel had redness and she had a red scrape to the lower back. LVN A stated the resident had pain but was able to stand and she was assisted back to bed after an assessment was completed. LVN A stated he notified the NP and Resident #1 was transferred to the hospital. He said he informed the DON and ADON of Resident #1's fall. LVN A stated he asked Resident #1 what happened and she said she was going back to bed after using the bathroom but had fallen back and landed on her bottom. LVN A stated he would report any ANE and injuries to the ADON and DON. LVN A said not reporting allegations of ANE or injury of unknown source could negatively affect the resident because they could have a serious injury. During an interview on 4/18/2026 at 9:55 a.m., LVN B stated the administrator was the abuse coordinator. LVN B stated she was provided with re-education and reminders of ANE during monthly meetings and as needed. She said the Administrator and the IP were the ones that proved training on ANE. LVN B stated she received report from the hospital nurse on 3/07/2026 which included Resident #1 having sustained fractures to her ribs, T5 vertebral fracture and lumbar transverse process fracture. LVN B stated she did not remember if she had notified the administrator or the DON of the hospital report received. LVN B stated it was the responsibility of administration to notify state agency of allegations of ANE, or injuries of unknown source. She said would immediately notify her supervisors of any falls or ANE. LVN B stated a resident could be impacted negatively by not reporting ANE or injuries of unknown source which would create an unsafe environment and the resident would not be protected. During an interview on 4/18/2026 at 11:35 a.m., the DON stated it was the Administrator's responsibility to report allegations of abuse, neglect, exploitation, and injuries of unknown source. The DON said if the Administrator was not available, he would report to state agency allegations of ANE. The DON stated staff were required to complete training on ANE and reporting monthly and as needed. The DON stated Resident #1's unwitnessed fall happened on 3/01/2026. The DON said Resident # 1 was cognitively impaired and when asked what happened by the staff, she said she was heading back to bed after using the bathroom when she lost her balance and fell. The DON said the fall was unwitnessed and the resident was assessed and sent to the emergency room. The DON said the Administrator was made aware of Resident #1's fall and transferred to the hospital by him, on 3/01/2026. The DON stated the appropriate time frame to report allegations of abuse, neglect, exploitation, or injury of unknown source was two hours. The DON stated the incident, which involved Resident #1, was not reported to any state agency because the fractures were not confirmed at the facility. The DON stated the facility's policy on reporting allegations in which bodily injuries occurred was within the allotted time. During an interview on 4/18/2026 at 12:03 p.m., the Administrator stated she was the abuse coordinator and responsible for reporting any allegations of abuse, neglect, exploitation, and injuries of unknown origin which resulted in serious bodily injuries.The Administrator stated staff were trained at least annually in reporting any allegations that resulted in serious bodily injury. The Administrator stated Resident #1 sustained the fall on 3/01/2026 and was notified by the DON later in the day. The Administrator stated the initial injury was a scratch to Resident #1's back and redness to the heel and Resident #1 was able to verbalize she was trying to go back to bed after using the bathroom. The Administrator stated she interviewed LVN A, who found and assessed Resident #1. The Administrator stated Resident # 1 was sent out to the hospital, but no reports of fractures were made until the resident was readmitted on [DATE]. The Administrator stated on 3/06/2026, the hospital referral did make mention of multiple fractures. The Administrator stated the reporting time frames for allegations of abuse, neglect, exploitation, and injuries of unknown origin was two hours. The Administrator stated the incident was not reported within the two-hour time frame. The Administrator stated there would be no negative effect to the resident by not reporting a bodily injury to state agency. The Administrator stated she could not remember what the facility's ANE policy stated in regards to reporting incident of bodily injury to state agency. Record review of the facility policy titled Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property undated, stated under section Reporting and Response, subtitle Serious Bodily Injury Reporting- 2 hour limit: If the events that cause the reasonable suspicion result in serious bodily injury to a resident, the covered individual shall report the suspicion immediately, but no later than 2 hours after forming the suspicion. External Reporting: Initial reporting of allegations: if an incident or allegation is considered reportable, the administrator or designee will make an initial (immediate or within 24 hours) report to the State Agency.'

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for storage, preparation, and sanitation.2.The facility failed to label and date 4 cans of evaporated milk stored in the dry storage area.3.The facility failed to ensure that 4 oz. cups of sherbert stored in the freezer were labeled and dated.These failures could place residents who store food items in resident refrigerators and who receive meal and/or snacks from the kitchen at risk for cross contamination if consumed and food-borne illnesses if consumed.The findings included:2. In an observation on 1/27/2026 at 10:30 AM, the initial tour of the kitchen accompanied by [NAME] G, revealed 4 cans of evaporated milk in the dry storage pantry without an out-of-the box date. The expiration date for the 4 cans was 1/7/27.3. In an observation on 1/27/2026 at 10:30 AM, the initial tour of the kitchen accompanied by [NAME] G revealed 7 4oz. sherbert cups that did not have an expiration date and no out-of-the box label.In an interview on 1/27/2026 at 10:35 AM with [NAME] G, she said it was important to label and date cans. She said if they were not labeled, it could cause harm to the residents. She said there was a designated kitchen staff member that oversees receiving and storing merchandise and labeling cans and foods. She said the designated kitchen staff member had just started one week before and that the dietary manager provides training on topics such as labeling, defrosting raw foods, rotating cans and discarding expired foods. [NAME] G said the box that contained the sherbert ice cream in the freezer was thrown out which contained the expiration date and open date.In an interview on 1/29/2026 at 4:19 PM with the Dietary Manager, said she was constantly observing and checking labeled cans and making sure food was stored properly. She said she provides the kitchen staff daily reminders on labeling, food storage, and food temperatures. The DM said she provides weekly in-services to the kitchen staff as well.In an interview on 1/29/2026 at 4:30 PM with [NAME] H, said she was designated staff for storing all the merchandise brought by in the vendor. She said her duties included rotating the cans in the food pantry by placing the older cans to the front and the newer cans to the back. She checked the expiration dates and placed labels on the items as she placed them on the shelves. [NAME] H said she cleaned out the refrigerators and freezer, disposed of poorly looking produce and changed out boxes that contained produce. She said she had thrown out the box, which was dated, that contained the evaporated milk, to make room for new merchandise. She said she was supposed to label the cans with the date when she removed the cans from the box but did not. [NAME] H said she received daily reminders from the DM about labeling. Record review of the facility policy titled Food Receiving and Storage dated November 2022, indicated Dry Food Storage .3. Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. 4. Dry foods that are stored in bins are removed from original packaging, labeled and dated ( use by dare). Such foods are rotated using a first in - first out system. Refrigerated/Frozen Storage 1. All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date). Record review of In-Service Summary and Attendance dated 12/26/25, Description of Training Session: Label and Restocking, indicated 11 kitchen staff signatures on the attendance record. Record review of In-Service Summary and Attendance dated 1/1/26, Description of Training Session: Labeling and Dating, Temp. Logs, indicated 10 kitchen staff signatures on the attendance record. Record review of In-Service Summary and Attendance dated 1/28/2026, Description of Training Session: Label and Dating Food Items, indicated 10 Kitchen staff signatures on the attendance record.

Based on observations, interviews, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #68) of 8 residents observed for infection control. The facility failed to ensure CNA A changed gloves after touching the bed remote during perineal care for Resident#68 on 01/28/2026. The facility failed to implement the required contact precautions sign on the room entrance doors for Resident #54 and Resident # 70 for Transmission Based Precautions.These failures place residents at risk for healthcare associated with cross contamination and infections. Findings included: 1.Record review of Resident #68's electronic face sheet dated 1/29/2026, reflected an [AGE] year-old male admitted to the facility on [DATE], original admission date of 08/17/2024. His diagnoses included Acute Ischemic Heart Disease (a sudden, dangerous shortage of blood and oxygen reaching the heart muscle), Hypertension (high blood pressure), Unspecified Dementia (group of thinking and social symptoms that interferes with daily functioning), and Benign Prostatic Hyperplasia (an enlargement of prostate). Record review of Resident #68's quarterly MDS assessment dated [DATE] revealed he scored a 04 on his BIMS which indicated he was severely cognitively impaired. During an observation on 01/28/2026 at 3:33 p.m., CNA A donned gloves and touched the bed remote to move the bed up to working height. She then proceeded to unfastened Resident #68's brief and grabbed the clean wipe. CNA A continued with pericare using the same pair of gloves. During an interview on 01/28/2026 at 3:47 p.m., CNA B stated that after touching the bed remote with gloves, she was to remove gloves, sanitize, and put on new gloves. She stated that everybody touches the bed remote, including the resident. CNA B stated that it was important to change gloves after touching the bed remote to protect the resident from cross contamination. During an interview on 01/28/2026 at 3:51 p.m., CNA A stated that she knew that she was supposed to change gloves after touching the bed remote but forgot. She stated that the bed remote could be contaminated with bacteria from the resident and other staff. She stated that she was a recent hire, and she did get infection control training upon hire. CNA A stated that it was important for her to change gloves after touching it to prevent infection. During an interview on 01/28/2026 at 4:05 p.m., ADON C stated that staff was to remove gloves after touching the bed remote due to the remote being contaminated. She stated that they have had infection control training several times. ADON C stated that staff were to change gloves after touching the bed remote to prevent any infection. During an interview on 01/29/2026 at 5:15 p.m., the DON stated that infection control in-services were done frequently depending on the situation. They do them quarterly and as needed. She stated that the staff were to change gloves after touching the bed remote to prevent cross contamination. The DON stated that the negative outcome would be that the resident can get an infection. Record review of the facility's Competency Evaluation Form Perineal Care revealed #7. Raise bed height to your comfort level and lower resident's head. #8. Wash your hands Record review of the facility's Infection Control Policy and Practices revised date October 2018 revealed Policy Statement: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation: 1. This facility's infection control policies and practices apply equally to all personnel, consultants, contractor, residents, visitor, volunteer workers, .) 2. The objectives of our infection control policies and practices are to: a.prevent, detect, investigate, and control infections in the facility; b.maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. 4. All personnel will be trainined on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. 2. Record review of Resident #54's admission record dated 1/28/2026, revealed a [AGE] year-old male with an admission date of 1/15/2026. His diagnoses included Sepsis (body's extreme reaction to an infection causing the immune system to harm tissue and organs) and pneumonia (common lung infection, leading tiny air sacs to fill with fluid or pus). Record review of Resident #54's MDS assessment dated [DATE], indicated a BIMS score of 12 which indicated moderate cognitive impairment. Record review of Resident #54's order summary dated 1/28/2026, indicated Contact Precautions D/T MRSA to Blood: Provide barrels for proper disposal of linen and waste in biohazard bags every shift Date ordered: 1/20/2026. In an observation on 1/27/2026 at 4:26 PM, there was a yellow bag hanging from Resident #54's room which contained gloves and gowns. The bag had an EBP sign affixed to it. There was a second sign located at the side of the door frame that stated, PLEASE SEE NURSE BEFORE ENTERING. In an interview on 1/29/2026 at 10:59 AM with LVN F, she said that contact precautions were discontinued today for Resident #54 and that not having the correct sign placed on the door can cause exposure to whatever organism was present. She said basic infection control training was given to her upon hire. In an interview on 1/29/2026 at 4:44 PM with LVN E, he said Resident #54 was positive for MRSA to the blood and had informed administration and housekeeping. He said housekeeping would bring the barrels and the yellow hanging bags with pockets and, depending on the type of precautions, they would provide the needed supplies. He said the signs were placed on the yellow bags by nursing. LVN E said that Resident #54 had an EBP sign on the yellow bag but did not know who placed it on there. He said, if people were not completely aware of the organism, it could cause cross contamination. In an interview on 1/29/2026 at 5:12 PM with the Housekeeping Supervisor, he said the nurses notify him when a resident is under precautions. He said housekeeping places the yellow bags with pouches and were filled with the supplies needed, according to the type of precautions the resident was under. He said if it's airborne precautions, then there is a special mask that needs to be added to the yellow bags, and they will add the sign or sometimes they get the signs from the nurses. He said the nurses inform housekeeping of the type of precautions the resident was under. He said he did not recall who had informed housekeeping of the type of precautions needed for Resident #54 and Resident #70. In an interview on 1/29/2026 at 5:45 PM with the DON, he said the same yellow bag was used for precautions and what differentiates if the sign on the door that reads SEE NURSE BEFORE ENTERING. He said the EBP signs were laminated and placed in the yellow bag's sleeve which included instructions on which type of PPE was used. He said Resident #53 was under EBP and then changed to contact precautions. The DON said not having the correct sign could have caused the possible spread of any communicable infection that the resident may have had. He said in-services were done and random rounds were done to ensure staff was wearing appropriate PPE. The DON said there was yearly infection control training and as needed. Record review of Resident #70's admission record dated 1/29/2026 indicated at [AGE] year-old male with an admission date of 1/22/2026. His diagnoses included Sepsis (body's extreme reaction to an infection causing the immune system to harm tissue and organs) and Anogenital (Venereal) Warts (bumps on the skin around the genitals and anus, caused by a sexually transmitted infection). Record review of Resident #70's MDS assessment dated [DATE], indicated a BIMS score of 8 which indicated moderate cognitive impairment. Record review of Resident#70's order summary dated 1/29/2026, indicated Contact Precautions D/T HPV (Anogenital warts): Provide barrels for proper disposal of linen and waste in biohazard bags every shift Date Ordered: 1/23/2026. In an observation and interview on 1/27/2026 at 11:35, there was a yellow bag hanging on Resident #70's door that contained gloves and gowns. There was no sign on the bag to indicate which type of precautions were in place. There was a sign on the door frame, facing forward, that stated PLEASE SEE NURSE BEFORE ENTERING. LVN D said Resident #70 was under contact precautions due to genital warts. In an interview on 1/29/2026 at 11:17 AM with the MDS Coordinator, he said he had reviewed Resident #70's history and physical which indicated the resident had anogenital viral warts. He said he had done some research and determined that the resident was to be placed under contact precautions for precautionary measures. He said he received the order from Resident #70's physician for contact precautions and informed LVN I. He said the yellow hanging bag was brought by housekeeping and the nurses placed the sign in the bag. The MDS Coordinator said in-services were held in December. In an interview on 1/29/2026 at 5:53 PM with LVN I said, contact precautions were initiated immediately after he was notified by his supervisor. He said when a resident was under EBP, the staff must wear a gown and gloves when providing care. He said when a resident was under contact precautions, the staff will use gowns and gloves upon entering the resident's room. He said the negative outcome of not knowing the resident was under contact precautions, can cause cross contamination. Record review of the Annual Bloodborne Pathogens & Hazard Communication Awareness Training Employee Attendance Record dated 10/13/2026, indicated training was done on the following: .3. Modes of Transmission . 7. Personal Protective Equipment, 8. Selection of PPE . 13. Signs and Labeling included 48 employee signatures noted. Reviewed U.S. Department of Health and Human Services Centers for Disease Control and Prevention form CS19-306149-A which is an example of a sign for Contact Precautions that can be posted outside a resident's room.

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 resident's goals and preferences for 1 (Resident #23) of 3 residents reviewed for respiratory care.The facility failed to ensure Resident # 23's oxygen was administered at the correct setting of 2 liters per minute on 1/27/2026 as ordered by the physician.These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care.The findings included:Record review of Resident #23's admission record dated 1/29/2026 indicated a [AGE] year-old male with an admission date of 9/13/2025. The resident had diagnoses which included: Chronic Obstructive Pulmonary Disease (a progressive and irreversible lung disease that makes breathing difficult by damaging airways and air sacs, causing inflammation), Chronic Respiratory Failure (long-term condition where the lungs cannot properly exchange gases, leading to low oxygen or high carbon dioxide in the blood), Obstructive Sleep Apnea (common disorder when the airways are repeatedly blocked during sleep, causing brief to briefly stop breathing).Record review of Resident #23's Quarterly MDS assessment, dated 12/21/25, indicated Resident #23 had a BIMS score of 6 (indicated severe cognitive impairment). Section O- Special Treatments, Procedures, and Programs. Respiratory Treatments indicated Oxygen therapy was checked off.Record review of Resident #23's active orders as of 1/26/2026 indicated O2 at 2L/min. Via N/C continuously Via O2 Concentrator every shift. Order date: 9/17/2025.Record review of Resident #23's care plan dated 1/04/2026 indicated FOCUS: I have a BIPAP and am on continuous Oxygen per nasal cannula which I refuse to keep on a lot of the time. GOAL: I will have no shortness of breath daily by next review in 90 days. Interventions: .Give Oxygen as ordered: O2 at 2 LPM via N/C continuously.During an observation of Resident #23 on 1/27/2026 at 11:37 AM revealed the oxygen level on the oxygen concentrator machine was a 1 Liter Per Minute via nasal cannula. Observation of Resident #23 revealed the resident was sitting up in sitting up in his wheelchair. No signs of respiratory distress noted.In an interview on 1/27/2026 at 11:37 AM with Resident #23 said he did not move the setting on the oxygen concentrator and that he only knew that he was supposed to be on 2 liters.In an interview on 1/27/2026 at 11:43 with LVN D, he said he was the nurse for Resident #23. LVN D observed the setting was at 1 Liter Per Minute. He said the Oxygen setting was supposed to be at 2 Liters Per Minute as ordered by the physician. He was not sure who might have moved it. He said he did his round at 6 AM and observed the setting at 2 Liters. LVN B said that not receiving the prescribed dose of Oxygen can cause O2 de-saturation and the resident can go into respiratory distress. LVN D adjusted the Oxygen setting to 2 liters and assessed Resident #23In an interview on 1/29/2026 at 5:45 PM with the DON, said that oxygen settings are checked every shift and documented. He said that random rounds are done by the DON to check for compliance. The DON said RT perform spot checks and document O2 saturation every shift. He said annual skills check-off list includes O2 therapy and nebulizer use. He said a corporate level in-service was scheduled on 1/28/2026 for management related to Respiratory Services and then provide an in-service to the rest of the staff. In an interview on 1/29/2026 at 6:10 PM with the LNFA, she said nursing in-services and a plan of correction were started immediately. The LNFA said clinical meetings were held every morning to discuss each resident and address problems, interventions and solutions. She said QAPI meeting were done monthly to discuss referrals, admissions/discharges, infection control, incidents, and falls.Record review of the facility's policy titled Oxygen Administration dated October 2010 indicated Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation- 1.Review the physician's orders or facility protocol for oxygen administration. Steps in Procedure- .8. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute.

Based on interview and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice for 1 (Resident #54) of 2 residents reviewed for parenteral fluids.The facility failed to ensure that Resident #54's intravenous medication bag was labeled with the resident's name.The facility failed to ensure the dressing on Resident #70's peripheral intravenous line (a short flexible tube inserted into a vein to administer fluids and medications) was dated and initialed.This failure could place residents at risk for medication errors and delay in medication administration.The findings included:Record review of Resident #54's admission record, dated 1/28/2026, indicated the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. The resident had diagnoses which included: Chronic Respiratory Failure (long-term condition where the lungs cannot properly exchange gases, leading to low oxygen or high carbon dioxide in the blood), Heart Failure (the heart cannot pump enough oxygen-rich blood to meet the body's needs), Chronic Obstructive Pulmonary Disease (a progressive and irreversible lung disease that makes breathing difficult by damaging airways and air sacs and causing inflammation).Record review of Resident # 54's MDS assessment, dated 1/25/2026, indicated Resident #54's BIMS score was 12 (indicating moderately impaired cognition). Section I8000 indicated Additional active diagnoses included Pneumonia (common lung infection that causes inflammation) and Sepsis (the body's extreme reaction to an infection causing the immune system to go into overdrive and starts harming tissues and organisms).Record review of Resident #54's Order summary indicated Vancomycin HCl Intravenous Solution 1000 MG/ 200 ML Use one application intravenously at bedtime, start date: 1/20/2026.Record review of resident #54's Care Plan dated 1/20/26 indicated: Receiving ABT TX R/T Dx: Leukocytosis 1/20/2026 Vancomycin HCl IV Dx Elevated [NAME] Blood Count. Goal: Infection will be resolved. Resident will not have any adverse effects. Interventions: Administer medications as ordered.In an observation on 1/27/2026 at 4:35 PM, an empty bag of Vancomycin 1000 MG/200 ML was hanging on an IV pole in resident #54's room. The label on Vancomycin IV revealed another resident's name. The DON and LVN A were made aware of the Vancomycin and was removed from Resident # 54's room by the DON.In an interview on 1/29/2026 at 4:44 PM with LVN A said he had given resident #54 the medication and that there were 3 bags of the same Vancomycin IV medication. He said he accidentally grabbed the medication that belonged to another resident (Resident #78). He said both residents had the exact medication ordered and only saw the first name on the bag and grabbed it. LVN A said the 5 rights of medication administration were the right drug, dose, patient, time and route. He said the importance of following the 5 rights of medication administration is to avoid medication errors. He said the only negative outcome was that it was a mistake for this resident, but he did receive the right medication and the right dosage. We try to avoid errors as much as possible and not commit errors. LVN A said no new orders were given by resident # 54's physician.In an interview on 1/29/2026 at 5:45 PM with the DON, He said medication administration in-services were ongoing which began he began on 1/27/26 and with the emphasis on the 6 rights of medication administration. He said LVN A was suspended until the facility concluded its investigation. The DON said LVN A will need to complete a skills check-off list and a 1:1 in-service/education with the DON and the Executive Director before returning to work.In an interview on 1/29/2026 at 6:10 PM with the LNFA, she said nursing in-services and a plan of correction were started immediately. She said spot checks were being done to ensure interventions were carried out. The LNFA said clinical meetings were held every morning to discuss each resident and address problems, interventions and solutions. She said QAPI meetings were held monthly to discuss referrals, admissions/discharges, infection control, incidents, and falls. 2. Record review of Resident #70's admission record dated 1/29/2026 indicated at [AGE] year-old male with an admission date of 1/22/2026. His diagnoses included Sepsis (body's extreme reaction to an infection causing the immune system to harm tissue and organs) and Anogenital (Venereal) Warts (bumps on the skin around the genitals and anus, caused by a sexually transmitted infection).Record review of Resident #70's MDS assessment dated [DATE], indicated a BIMS score of 8 which indicated moderate cognitive impairment.Record review of Resident #70's order summary with a start date of 1/23/2026 indicated Assess IV site (right back of hand) Q shift for infiltration or S&S of infection every shift.Record review of Resident #70's order summary with a start date of 1/22/2026 indicated Change Hep-Lock (a small, capped-off IV tube inserted into the vein that allows nurses to give medications of fluid) every 72 hours and PRN, may change PRN if hard stick. In an observation on 1/27/2026 at 11:35 AM, Resident #70 had an IV access to his left forearm and covered with a dressing that was not labeled or dated.In an interview on 1/27/2026 at 12:04 PM with LVN D, he said the IV access was only good for 72 hours, unless otherwise ordered by the physician. He said not knowing how long the IV has been inserted can cause possible infection to the site or infiltration (occurs when an IV tube slips out of the vein, causing fluids or medicine to leak into the surrounding tissue instead of the bloodstream).In an interview on 1/29/2026 at 5:23 PM with LVN I, he said he had replaced Resident #70's IV access to the left posterior (back) forearm and used a 22-gauge needle. He said he flushed the IV access, placed tape, and dated it for 1/23/2026. LVN I said not having a label on the IV dressing can cause a risk for phlebitis, infection, and possible sepsis. He said he had an in-service on IV medication and labeling of the IV dressings about 3 months ago.In an interview on 1/29/2026 at 5:45 PM with the DON, he said during each shift, the nurses were to check the IV flush order before and after infusion and at the same time checking that the IV site was secured and checking for S&S of infection. He said the facility policy states to label the IV site. He said standing orders were given to change IV site every 72 hours and for a midline IV site, was every week.Record review of policy titled Policies and Practice-Infection Control dated October 2018, indicated .Contact Precautions can occur: with indirect contact with environmental surfaces or resident-care items in the resident's environment such as door handles, table surfaces, mobile phone or TV remotes. Transmission-Based Precautions include: Contact Precautions.Record review of In-service and Attendance dated 1/27/2026, Topic: The 6 rights to med pass, Trainer: Executive Director, indicated 16 employee signatures.Record review of the facility's policy dated April 2019 titled: Administering Medications indicated Policy Interpretation and Implementation.10. The individual administering the medication checks the label THREE (3) times to verify the right resident, the right medication, right dosage, right time, and right method (route) of administration before giving the medication.Record review of the Annual Bloodborne Pathogens & Hazard Communication Awareness Training Employee Attendance Record dated 10/13/2026, indicated training was done on the following: .3. Modes of Transmission . 7. Personal Protective Equipment, 8. Selection of PPE . 13. Signs and Labeling included 48 employee signatures noted.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #78) of 2 residents reviewed for pharmacy services.The facility failed to ensure discontinued medication prescribed for Resident # 78 were removed from medication storage room [ROOM NUMBER].This failure could place residents at risk of receiving wrong medications.The findings included:Record review of Resident #78's admission record dated 1/29/2026, indicated a [AGE] year-old male with an original admission date of 10/17/2024 and an admission date of 1/15/2026. Resident # 78's admission record included diagnoses of sepsis (body's extreme reaction to an infection, creating tissue and organ damage) and pneumonia (common lung infection that causes inflammation). Record review of Resident #78's order summary, dated 1/15/2026, indicated Vancomycin HCl Intravenous solution 1000 MG/ 200 ML, use one application intravenously every 18 hours related to pneumonia. Start Date:1/15/2026 and Discontinue date: 1/16/2026Record review of Resident # 78's medication administration record indicated Vancomycin was given on 1/15/2026 at and the second and last dose was given on 1/16/2026.In an observation on 1/27/2026 at 4:45 PM, revealed Vancomycin IV medication for Resident #78 was hanging in a clear plastic bag in Medication room [ROOM NUMBER]. Next to Resident # 78's IV medication was Resident #54's medication which was Vancomycin IV, same dose as Resident #78. The DON witnessed the current and discontinued IV medication hanging on the wall for both residents. In an interview on 1/27/2026 at 4:45 PM, the DON said there is a specific location in the medication room for discontinued medications. He said discontinued medications are to be placed in a bin designated for discontinued medication, located at the bottom of the shelf in the medication room. In a second interview on 1/28/2026 at 4:15 with the DON, he said the IV Vancomycin medication had not been inventoried, so it stayed in the medication storage room. He said a facility drug destruction log is filled out by the nursing staff or medication aide and is pulled out of the area and placed in a box designated for discontinued medication. He said the staff informed him of the discontinued medication and he retrieved the discontinued from the medication room and placed them under lock and key. The DON said once a month the pharmacy consultant will come into the facility and verify the discontinued medication and seal the box to prepare for destruction. He said the sealed boxes were picked up by a vendor for destruction. The DON said he was not told that there was Vancomycin in the medication room that had been discontinued.In an interview on 1/29/2026 at 10:59 AM with LVN F, she said she received the order from the NP to discontinue the Vancomycin IV for resident #78 on 1/16/2026. She said she made an entry in the progress notes and discontinued the medication on the MAR. She said she removed the medication from her med cart and placed the Vancomycin IV medication in the medication room in a box designated for discontinued medication. She said she did not remember seeing the Vancomycin hanging on the wall with the rest of the current medication. She said she did not fill out any form indicating the medication was discontinued. She said she did not have to notify the DON of discontinued medication.Record review of the facility's policy titled Discontinued Medication dated November 2020 indicated Policy Interpretation and Implementation .2. The nurse receiving the order to discontinue a medication is responsible for recording the information (e.g., writing discontinued date, dating and initialing MAR) and notifying the dispensing pharmacy of the discontinuation.

Based on observation, interview, and record review, the facility failed to ensure biologicals were stored in locked compartments and accessed by authorized personnel for 2 (Resident #54 and Resident #61) of 6 residents were reviewed for medication storage.The facility failed to ensure Resident #54's and Resident #61's did not have Normal Saline (a sterile mixture of water and 0.9% salt that closely matches the natural fluid balance in human blood) Prefilled syringe on top of the residents' bedside tables on 1/27/2026.This failure could place the residents at risk of having unauthorized access to prescription medications and biologicals and place residents at risk of access to hazards.The findings included:In an observation on 1/27/2026 at 12:27 PM, revealed an unpackaged prefilled 10 cc syringe of Normal Saline on top on Resident #61's bedside table.In an observation on 1/27/2026 at 4:35 PM, revealed an unpackaged, prefilled 10 cc syringe of Normal Saline on top of Resident #54's bedside table.Record review of Resident #61's face sheet, dated 1/29/2026, indicated a [AGE] year-old female with an original admission date of 1/16/2026. Her diagnoses included Sepsis (the body's extreme reaction to an infection which creates tissue and organ damage), Incisional Hernia with Obstruction (a condition where part of the intestine pushes through a weak spot in the abdominal wall and becomes trapped and blocked), Perforation of the Intestine (a hole, tear, or rupture in the wall of the small or large intestine).Record review of Resident #61's physician orders indicated PICC Line to right upper extremity flush with 10 cc of saline Q-shift and with ABT therapy, dated 1/17/2026.In an observation on 1/27/2026 at 12:27 PM, revealed an unpackaged prefilled 10 cc syringe of Normal Saline on top of Resident #61's bedside table.Record review of Resident # 54's face sheet, dated 1/28/2026, indicated a [AGE] year-old male with an original admission date of 7/18/2025. His diagnoses included Sepsis (body's extreme reaction to an infection, creating tissue and organ damage) and Pneumonia.Record review of Resident # 54's physician orders indicated Flush IV line with 10 cc of NS before and after medication administration Q shift, dated 1/15/2026.In an observation on 1/27/2026 at 4:35 PM, revealed an unpackaged, prefilled 10cc syringe of Normal Saline on top of Resident #54's bedside table.In an interview on 1/27/2026 at 12:38 PM with LVN F said she was not sure why the syringe was left on top of Resident # 61's bedside table. She said she disposed the syringes in the medication cart's sharps container or in the trash can. She said she made rounds every 1 to 2 hours and did not see the syringe on the bedside table. LVN F said a negative outcome could be that the resident could pick it up and use it for another purpose.In an interview on 1/29/2026 at 5:45 PM with the DON, he said that nursing administration performed rounds and checked the overall cleanliness of the resident's rooms and looking for objects that are not supposed to be at bedside. He said in-services were given to staff on 1/27/2026 and were ongoing, regarding IV supplies at bedside including NS.Record review of the facility's policy titled Medication Labeling and Storage, dated February 2023 indicated Medication Storage .2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Based on observation, interview and record review the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption for 1 of 2 resident refrigerators reviewed for refrigerator sanitation. The facility failed to ensure resident's personal refrigerators were maintained. Resident #90's refrigerator had 4 small individual cartons of orange juice and an individual container of gelatin that were all expired.This failure could place residents who store food items in resident refrigerators, at risk for cross-contamination and food-borne illnesses if consumed.Findings were:Record review of Resident #90's admission Record dated 01/29/26 revealed [AGE] year-old female with diagnoses of Alzheimer's Disease (brain disorder causing decline in memory, thinking, and daily functioning), Unspecified, Heart Failure, Unspecified, and Essential (Primary) Hypertension (high blood pressure).Record review of Resident #90's MDS dated [DATE] had a BIMS Score of 06 suggesting severe cognitive impairment.In an observation on 01/27/26 at 12:05 pm, surveyor observed 4 small orange juice cartons and an individual cup container of gelatin with expired date 01/21/26 inside Resident # 90's personal refrigerator in her room. In an observation on 01/27/26 at 12:06 pm a Resident Refrigerator Temperature Log had been taped on the top of the resident refrigerator. It had been noted that the refrigerator had last been checked on 01/27/26 in the AM. In an interview on 01/27/26 at 12:06 pm Resident #90 said she has drank orange juice and does eat gelatin but could not recall when it was brought in or who put it in the refrigerator in her room.In an interview on 01/27/26 at 12:24pm LVN D said the managers are the one's in charge of checking refrigerators in resident's rooms. He said they are checked daily to make sure the temperature has been set appropriately and there should be no expired food left in the refrigerator.In an interview on 01/27/26 at 1:28pm the DON said the managers are in charge of checking the refrigerator in the residents room. He said the administrator assigned which resident rooms each manager was in charge of. He said the managers checked resident rooms including their refrigerators every morning. The DON said Manager E was in charge of Resident #90's room.In an interview on 01/27/26 at 6:07 pm Manager E said he checked Resident #90's room including the refrigerator. He said he had not seen any juices or gelatin in the refrigerator. Manager E said he had checked Resident #90's refrigerator in her room some time in the morning, he did not remember what time exactly but had not seen any of those items in there. Manager E said he had been assigned to check Resident #90's room daily. He said he was required to check the refrigerator temperature and if there was any food in there that was expired. Manager E said he did not know what could have happened if any of those foods were consumed by Resident #90 because he was not a doctor.In an interview on 01/29/26 at 5:46 pm the Administrator said the facility has angels or ambassadors who are managers and are required to do rounds on resident rooms daily. She said they were responsible for making sure the residents rooms were clean and if they had a refrigerator in the room, they needed to make sure the temperature was appropriate for the food kept inside and ensure that it was labeled and was not expired. The managers do their rounds before their morning meeting between 8:00 am and 9:00pm. She said Manager E was assigned to Resident #90. The Administrator said Manager E does his rounds in the morning, daily. She said all staff are reminded what to do when they do their rounds. The Administrator said Resident #90 could have gotten an upset stomach had she consumed those expired items.Record review of the facility's policy Foods Brought by Family/Visitors revision date March 2022; Policy Statement: Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. Policy Interpretation and Implementation 6. The nursing staff will discard perishable foods on or before the use by date.

Based on observation, interviews, and record reviews, the facility failed to maintain effective pest control for 1 of 1 facility in that: The facility failed to have an effective pest control effectively treat the facility for roaches. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life. The findings include: During an observation on 10/02/2025 at 8:20 AM, a live roach revealed on the floor behind a freezer in the kitchen. During an interview on 10/02/2025 at 8:24 Am the Dietary Manager stated they used to have a bad infestation about six months ago. She said, It's not that bad now but once in a while we'll see a few, but not that much. The Dietary Manager said they try to get rid of all the boxes when their shipments came in because the boxes attract the roaches. She said during the time of the infestation, the exterminator came in and applied fog and other chemicals in the kitchen area. She said the roaches were seen throughout the facility but mainly in the kitchen. The Dietary Manger said the food trays go through three sets of eyes to make sure there are no insects of pests. Pests can carry diseases and can bring bacteria and cause stomach viruses and are a hazard to residents. During an interview on 10/02/205 at 2:07 PM, [NAME] A said, Every so often a roach may appear, but we try to keep the kitchen clean. She said, One of my responsibilities is to maintain a clean kitchen and if I see a roach I will throw it in the trash can and clean the area with a disinfectant. The cook said roaches carried diseases and could cause bad health. During an interview on 10/02/2025 at 5:10 PM the Maintenance Supervisor said he saw dead roaches and once in a while I'll see a few live ones here and there. He said if pests were seen, the staff notified housekeeping but if they're not available they notified him, and he would call the pest control company. He said the facility had a contract for pest control services provided monthly. The Maintenance Supervisor said he provided some assistance with pest control such as using disinfecting wipes to get rid of sugar ants. He said the pest control company serviced the entire facility. During an interview on 10/02/2025 at 5:17 PM the DON said they had a commercial pest control vendor that provided monthly services and as needed. He said the facility did have a policy on pest control and a designated pest control binder containing monthly invoices of services provided to the facility. Record review of Pest Elimination Services Agreement, dated 8/2003, revealed the following, estat Pest Reporting, Sanitation & Structural Inspection, Service Report. Frequency: Each Service ECO2000 Cockroach Program. Frequency: Monthly Check Point Rodent Program. Frequency: Monthly Stealth Fly Program. Frequency: Monthly Ground Force Ant Program. Frequency: Monthly Record review of Pest Control Invoice Customer Service Report, dated 9/19/2025, revealed the following services, SERVICE: Cockroach/Rodent Program, Large Fly Program, Air Quality Program. TARGET PESTS: Rats, Flies, Cockroaches. CONDITION FOUND / ACTIONS TAKEN Pest activity found during service: (Yes) Exterior Area-Birds noted during service Roof. This area was inspected and serviced. Structural concerns that could cause pest problems: (No) Sanitation issues that could cause pest problems: (No) Record Review of Pest Control Invoice dated 8/23/2025, 7/25/25, 6/27/25, 5/20/25, 4/15/25, 3/21/25, 2/28/25, 1/09/25, 1/10/25 and 1/13/25 revealed the following services, SERVICE: Cockroach/Rodent Program, Large Fly Program, Air Quality Program. Record review of policy dated: May 2008, titled: Pest Control revealed This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. And Maintenance services assist, when appropriate and necessary, in providing pest control services. Record review of policy dated: October 2008, titled: Sanitization revealed All kitchens, kitchen area and dining area shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 3 residents (Resident #2) reviewed for medical records accuracy, in that: The facility failed to document Resident #2's physician ordered weekly skin assessment from 12/26/24 through 02/27/25 for a total of 10 out of 10 skin assessments that were not documented. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment. The findings included: Record review of Resident #2's face sheet, dated 09/16/25, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: psoriasis ( skin cells build up and form scales and itchy, dry patches), unspecified dementia (loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life ), unspecified severity, without behavioral disturbance, psychotic disturbance mood disturbance, and anxiety, contracture, unspecified joint, and essential (primary) hypertension (high blood pressure) Record review of Resident #2's quarterly MDS assessment, dated 08/22/25, revealed Resident #2 had a BIMS score of 01, indicating severe cognitive impairment. Record review of Resident #2's care plan with an initiation date of 05/02/25 reflected a focus of I'M AT RISK FOR SKIN BREAKDOWN AS I HAVE: (1) Anemia (2) Major Depressive Disorder (3) Dementia (4) Bony prominences (5) I require partial/moderate assistance with bed mobility and substantialassistance with transfers (6) I am incontinent of Bowel and Bladder with no initiated date and interventions of, WEEKLY SKIN ASSESSMENT BY LISCENCED [licensed] NURSE with no initiated date. Record review of Resident #2's active physician's orders revealed orders for, WEEKLY ASSESSMENT DUE THURSDAY, with a frequency of every night shift every Thu (Thursday) with an order date of 08/06/20 and an order type of Standard Order Treatment - [TAR] Record review of Resident #2's December 2024, January, February and March 2025 TAR reflected her order for weekly skin assessment was signed by LVN A weekly from 12/26/25 through 02/27/25 as administered. Record review of Resident #2's weekly skin assessment record document that included more details such as a body diagram to indicate location and description of any skin issues reflected Resident #2's last weekly skin assessment record document was completed on 12/19/24. There were no weekly skin assessment record documents identified from 12/26/25 through 02/27/25. During an interview with Resident #2 on 09/09/25 at 10:17am she was unable to answer any related questions coherently. During an interview and record review with the DON on 09/15/25 at 4:32pm he stated skin assessments were completed weekly and stated an assessment should be completed whether a resident had anything new or not. The DON reviewed Resident #2's assessments and confirmed that there was a gap without skin assessments from December 2024 till March 2025 that should not be there. The DON stated he had not noticed they were missing. The DON reviewed Resident #2's TAR and stated LVN A had documented that she done the skin assessment in December 2024 till March 2025 but there were no skin assessments document populated. The DON stated the nursing staff was responsible for completing the weekly skin assessments and stated he did not know why they were not done and stated he had not spoken to LVN A yet and did not know if LVN A completed Resident #2's skin assessment and did not document them or if she had not done them. The DON stated completing weekly skin assessments were important to see if there was any abnormal development of skin issues and to make sure they were attended to properly. The DON stated staff had been trained over completely skin assessments weekly and stated they completed annual competencies that covered skin. The DON stated the wound care nurse was responsible for monitoring and reviewing skin assessments to ensure they were completed. The DON stated LVN B who was the previous wound care nurse was responsible for reviewing the skin assessments during the time of the identified gap. The DON stated LVN B no longer worked at the facility and stated their current wound care nurse had recently started but was still in training and had not yet been on the floor. The DON stated he and the ADON had weekly meetings where they wound go over documentation which included progress on wounds and the completion of their systems. The DON stated their facility policy stated staff should develop a new skin assessment document anytime one was scheduled and stated staff did not follow their policy in this situation. The DON stated he had reviewed Resident #2's chart and did not identify any deterioration of Resident #2's skin from December 2024 through March 2025 when no skin assessments were populated. The DON stated not completing skin assessments as ordered could negatively impact residents because they could develop skin issues that do not get treated on time or appropriately. During a telephone interview on 09/15/25 at 11:00pm with LVN A she stated nurses were responsible for completing skin assessments for residents weekly and stated sometimes the wound care nurse would also complete skin assessments. LVN A stated they had to assess the resident's skin, sign off on the TAR and should document on the body diagram. LVN A stated the body diagram should be completed whether or not there were any changes in skin integrity. LVN A stated she was not aware of Resident #2 not having a skin assessment document populated from 12/26/24- 02/27/25. LVN A stated she recalled assessing Resident #2 during her night shifts with the assistance of a CNA and stated Resident #2 did not have any deterioration from 12/16/24 -03/06/25 during the time she did not populate a skin assessment document. LVN A stated she did not know why she did not document Resident #2's skin assessment and stated she knew how to complete the body diagram and stated she did not know if she was in a hurry or didn't have time to document it on the body diagram. LVN A stated she had previously been trained over completion and documentation of skin assessments every year during their annual competencies. LVN A stated it was important to document residents skin assessment on the body diagram weekly to observe any changes. LVN A stated she thought the ADON was responsible for monitoring and ensuring the nurses skin assessments were completed but was not sure how the ADON did so. LVN A stated their facility policy stated they should document on the body diagram. Although LVN A did not follow the facility policy in this situation LVN A stated in this situation she had followed the facility policy. LVN A stated Resident #2 had no deterioration but stated a negative impact if they did not document skin assessments could be that they would not know if something was new or not. During a telephone interview on 09/16/25 at 3:45pm with LVN B who was the previous wound care nurse she stated she would do the initial skin assessment and skin assessments for residents who had any wound and nurses were responsible for completing skin assessments for resident's weekly who did not have any wounds. LVN B stated she recalled Resident #2 and stated from December 2024 to March 2025 the nurses would have been responsible for completing her weekly skin assessments. LVN B stated they had to sign off on the TAR and populate the body diagram and document anything that was noticed on there. LVN B stated the body diagram had to be populated every time regardless if a resident had any changes or not to their skin integrity. LVN B stated she was not aware of Resident #2 not having a skin assessment document completed from 12/26/24 - 02/27/25 and did not know why that was not documented and was not sure if the skin assessment had been completed and not documented on the body diagram. LVN B stated she was previously the wound care nurse at the time and stated the wound care nurse or DON were responsible for monitoring and ensuring nurses skin assessment were completed by running reports to see if the skin assessments were completed. LVN B stated she never ran any reports and stated the DON would run the report and then show her what was not complete and then she would track down the nurse and tell them. LVN B stated was trained over the completion and documentation of skin assessment when she first got hired in September of 2023. LVN B stated she did not recall the facility skin policy. LVN B stated it was important to document on the body diagram for things to be reported and treated when noticed and stated not documenting a resident skin assessment could negatively impact them because something could go unnoticed or intreated. Record review of LVN A's skills verification checklist dated 05/07/24 indicated she had met the skill for skin assessment sheet. Record review of facility policy titled, Pressure Ulcer Injury/Injury Risk Assessment with a revised date of July 2017 stated, .b. Once inspection of skin is completed document the findings on a facility- approved skin assessment tool.The following information should be recorded in the resident's medical record utilizing facility forms: 1. The type of assessment (s) conducted.5. The condition of the resident's skin (i.e., the size and location of any red or tender areas), if identified.11. Initiation of a (pressure or non-pressure ) form related to the type of altercation in skin if new skin alteration noted.

Based on interview and record review the facility failed to incorporate the recommendations from the PASRR Level II determination and the PASRR evaluation report for 1 of 4 residents (Resident #1) reviewed for PASRR.The facility failed to initiate an NFSS within 20 business days following the date the services were agreed upon in the IDT meeting.This failure could cause residents with mental health disorders and psychiatric conditions to have a delay in services or not receive specialized services or equipment that may be needed.Findings include: Record review of Resident #1's face sheet, dated 09/17/25, revealed a [AGE] year-old male originally admitted [DATE], and most recent admission date of 12/11/23. His diagnoses included dementia (a loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), severe intellectual disabilities (a significant impairment with intellectual and adaptive functioning which may affect intelligence, learning, and everyday life skills), cognitive communication deficit, muscle wasting and atrophy (gradual wasting away or shrinkage of an organ, tissue or muscle), and muscle weakness. Record review of Resident #1's Quarterly MDS assessment, dated 09/06/25, revealed a BIMS score of 02, indicating severely impaired cognition. The MDS assessment also revealed Resident #1 had impairment to lower extremities on both sides and utilized a wheelchair, as well as Resident #1 required partial/moderate assistance with eating, substantial/maximal assistance with oral hygiene, upper and lower body dressing, putting on/taking off footwear, personal hygiene and dependent on toileting hygiene and shower/bathing self. Record review of Resident #1's undated care plan revealed resident was identified as having PASSR positive status related to severe intellectual disabilities with a goal of maintaining highest level of practicable wellbeing. Interventions included provide service coordination with Behavioral Health, invite TTBH and RP to the quarterly care plan meetings to discuss resident's function and report any need to evaluate for habilitative services and/or durable medical equipment to maintain the resident's current level of function, PT/OT/ST as ordered, obtain order to evaluate for physical and occupational therapy, and once the evaluations were complete, submit form 2466 to request habilitative PT and OT services. Record review of Resident #1's Form 1057 - LIDDA Habilitation Service Plan, with plan date of 08/20/24, revealed an annual meeting was held in person. Services agreed upon: . OT and PT. In an interview with Resident #1 on 9/15/25 at 3:40 pm, the resident was unable to answer any questions using words. He was able to nod yes or shake head no. Resident was unable to answer any questions pertaining to receiving PASSR services or attending PASSR meetings. Resident nodded yes when asked if receiving therapy. In an interview via email on 09/09/25 at 9:34 AM with the HHSC PASSR Unit Program Specialist, she said, I call before I send the email and they said they would work on getting the NFSS request submitted. are because they were late or did NOT submit or initiate and get approved for service. In an interview on 9/16/25 at 9:50 am the MDS nurse said he was responsible to complete the PL1 upon a resident's initial admission. The MDS nurse said once it was complete, the DON takes over with any follow-ups. The MDS nurse said he was not responsible for submitting the NFSS in the LTC Online Portal. The MDS nurse said the DON deals with that. In an interview on 9/16/25 at 3:50 pm the DON said he was responsible for PASSR submission in the online portal. He said once the original meeting was done by TTBH, they must notify the MD. Once they received the MD order for services such as PT, PT would then evaluate for habilitation services, then the NFSS would be completed with the recommended services, and he would submit the NFSS in the online portal. The DON said to his understanding, the submission of the NFSS form in the online portal were submitting within 21 business days of the IDT meeting. The DON said he recently took over the task in March of this year. The DON said the previous MDS/RN Coordinator oversaw the NFSS submissions in the online portal in collaboration with the DOR. The DON said they submitted the NFSS for Resident #1 and it was denied. The DON said he talked to someone in March, but he could not remember who, and he was told to submit the NFSS within a certain time frame, but it was denied because it was submitted incorrectly. The DON said the resident did receive the PT and OT services, but not through PASSR. The DON said they had a recent IDT meeting on the 3rd of September. The DON said PT and OT already did their assessments and they were pending MD signature. The DON said he the NFSS would be submitted within the 20 business calendar days. In an interview on 9/16/25 at 4:47 pm with the Administrator, he said it was his understanding that upon approval of services for PASSR, they had 20 business days to update that information onto the online portal. He said he believed the DON was in charge with the assistance of the DOR. He said he knew of the 20-business day requirement because he overheard it said by the DON in a discussion regarding the urgency of the time frame. Record review of the facility's admission Criteria policy revised December 2016 reflected: Policy Statement: Our facility will admit only those residents whose medical nursing care needs can be met. Policy Interpretation and Implementation: .8. Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-admission Screening and Resident Review program (PASARR) to the extent practicable.9. Potential residents with mental disorders or intellectual disabilities will only be admitted if the State mental health agency has determined (through the preadmission screening program) that the individual has a physical or mental condition that requires the level of services provided by the facility.10. The acceptance of resident with certain conditions or needs may require authorization or approval by the Medical Director, Director of Nursing Services, and/or the Administrator.12. The Administrator, through the Admissions Department, shall assure that the resident and the facility follow applicable admission policies.

Based on observation, interview, and record review, the facility failed to ensure residents have a right to a safe, clean, comfortable, and homelike environment for 2 of 85 residents (Resident #1 and Resident #2) reviewed for safe, clean, and comfortable environment. The facility failed to recognize and repair water damage to the ceiling, in two rooms occupied by Resident #1, and Resident #2. This deficient practice failure could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe. The findings included: 1). Record review of Resident #1's Admission Record, dated 03/07/2025, reflected she was a [AGE] year old female, initially admitted on [DATE], with diagnoses of dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Record review of Resident #1's Quarterly MDS dated [DATE], reflected Resident #1 had a BIMS score of 12 which suggests moderate cognitive impairment. Resident #1 was always incontinent of bowel and bladder according to section H in the MDS. Record review of Resident #1's Care Plan, dated 02/15/2025 was up-to-date with interventions in place. Record review revealed on 02/21/2025 at 02:26 pm, a Progress Note was written by the Social Worker documenting Resident #1 had a room change due to inclement weather and roof renovations with the RP being notified. Observation on 03/03/25 at 02:55 pm Resident 1's previous room had slight bubbling to seams on ceiling by light and vent. In an interview on 03/07/2025 at 04:11 pm, the DON stated he did not notice anything wet or damaged in Resident #1's room during his tour of the rooms on Saturday and Sunday (02/22/2025 and 02/23/2025) with the ceiling in Resident #1's original room except being able to see the seams in the drywall, but he could see the seams in the drywall in the ceilings in some of the rooms. The DON stated he had not known it was wet until Life Safety notified them of what they had seen from the attic side on 02/28/2025. DON stated they had moved Resident #1 out of that room as soon as Life Safety told them about the hole in the roof and the ceiling of Resident #1's room being wet. 2). Record review of Resident #2's Admission Record, dated 03/07/2025, reflected she was a [AGE] year old female, initially admitted on [DATE], with diagnoses of dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), osteoporosis (brittle bones), and anxiety disorder. Record review of Resident #2's Quarterly MDS dated [DATE], reflected Resident #2 had a BIMS score of 12 which suggests moderate cognitive impairment. Record review of Resident #2''s Care Plan, dated 12/28/2024, revealed was up-to-date with interventions in place. Record review revealed on 02/21/2025 at 02:38 pm, a Progress Note was written by the Social Worker documenting Resident #2 was moved to a new room due to due to inclement weather and roof renovations with the RP being notified. Observation on 02/28/25 at 01:35 pm Resident #2's previous room had a maintenance worker in the room patching the walls and ceiling. In an interview on 03/03/2025 at 01:15 pm, Resident #2 stated it looked as if the corner in her new room was either leaking or going to leak and when it did leak, she would file a complaint and they would come fix it. In an interview on 03/03/2025 at 03:19 pm, CNA B stated she only saw the barrel catching the water dripping from the ceiling in Resident #2's previous room on 02/21/2025, after Resident #2 had been moved out. In a telephone interview on 03/07/2025 at 01:15 pm, LVN C worked the 6 am - 10 pm shift on the South halls on 02/22/2025 and 02/23/2025. He said he thought only two of his rooms were affected by dripping from the ceiling. One of his rooms was Resident #2's room. LVN C stated he heard about the ceilings falling when he came to work (02/22/2025). He said he would do random room checks all the weekend. LVN C stated he told his CNAs to let him know if they noticed any leaking or water damage. He said when his checks were completed, he had not notice any of the other ceilings leaking. In an interview and observation on 03/07/2025 at 07:15 pm, Resident #2 stated she told the two guys who came around asking if she had problems with her room that there might be damage to the upper corner at the ceiling. She stated she did not know the two guys, but whoever they were, they fixed the water damage to the corner. She said she was very happy about how quickly they fixed her room. The corner of the wall/ceiling area had been patched and no damage was visible. Record review of facility's Resident Rights Policy, Nursing Services Policy and Procedure Manual for Long-Term Care 2001 MED-PASS, Inc. (Revised February 2021), revealed, Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. 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 observations, interviews, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 5 residents (R #1) reviewed for supervision. The facility failed to ensure R #1 received adequate supervision as R #1 eloped from the facility without anyone's knowledge on 11/21/24 between 2:30AM-3:00AM and was found by RT A when R #1 was reentering the facility. R #1 was out of the facility for approximately 8 minutes before RT A saw him reenter the facility. R#1 sustained an unwitnessed fall while out of the facility that resulted in a closed tripod fracture of left zygomaticomaxillary complex, a fracture of lateral orbital wall, left side, initial encounter for closed fracture, a fracture of left orbital floor, and a closed fracture of the left maxillary sinus. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 11/21/24 and ended on 11/22/24. The facility corrected the non-compliance before the investigation began. This failure could lead to residents exiting the facility unattended which could result in injuries, hospitalization , or death. The findings included: Record review of R #1's face sheet dated 11/26/24 reflected a [AGE] year-old male, with an original admitted [DATE]. His diagnoses included cognitive communication deficit (difficulty with communication skills that stem from an underlying cognitive impairment), unspecified dementia (lose of cognitive functioning, a group of thinking, and social symptoms that interferes with daily functioning), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Record review of R #1's admission Minimum Data Set (MDS) assessment dated [DATE] reflected R #1 had a BIMS score of 10 indicating moderate cognitive impairment. R#1's MDS reflected he required supervision or touching assistance for bed mobility, transfers, and when walking 50 feet with two turns. Record review of R #1's wandering risk scale signed on 11/21/24 by the ADON with an effective date of 11/20/24 at 10:46AM reflected R #1 was ambulatory, could communicate, could follow instructions, had no history of wandering, had no reported episodes of wandering in the past 3 months, and had medical diagnoses of dementia/cognitive impairment with a BIMS score of 12 or less. R #1's wandering risk scale score was 9, which indicated R #1 was at risk to wander. Record review of R #1's Care Plan initiated 11/20/24 reflected R #1 was at risk of wandering/elopement and included his 11/20/24 wandering risk scale score of 9 and category of At Risk to Wander, no specific initiation date was noted. Some of the interventions included were, staff to assist with re-orientation to room and facility, routine check every 2 hours and to locate the residents where abouts, providing verbal cues and reminding often, hourly checks, assure that staff/receptionist was aware the resident was at risk for elopement, if the resident was walking in a potentially unsafe area or situation, redirect to safer area, leave safe and reassess regularly, encourage activities to divert attention and meet needs for social, cognitive stimulation, and complete elopement risk, if the resident was missing from the facility, follow elopement protocol, and notify the MD and family immediately and document. Interventions did not have a specific initiation date noted. R #1's care plan reflected a focus of, I had a fall on 11/21/24 with no injuries at [SIC] related to (r/t) cognitive impairment, poor balance, and poor safety awareness. I fell outside while I was walking looking for my cousin. No specific initiation date was noted. R #1's interventions included sensor alarm to bed, transfer to emergency room for evaluation and treatment, bed to the lowest positioning, administration of pain medications, encouraging resident to call for assistance, notifying the MD and responsible party (RP) of any falls and injuries, call light within reach, taking vital signs with neuro checks protocol if head injury occurred, monitoring and reporting to the MD for signs and symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture and agitation, and these interventions did not have a specific initiation date noted. Record review of R #1's progress notes documented on 11/20/24 reflected R #1 seemed confused, disoriented, and unaware of where he was. Record review of R#1's change in condition dated 11/21/24 at 2:59am stated R #1 had an unwitnessed fall with documentation of an abrasion/skin tear discoloration to left elbow, abrasion/skin tear to back of left hand, abrasions to front of left knee, left cheek discoloration/abrasion, left eyebrow contusion (bruise), abrasion, discoloration, and left eye discoloration. Record review of R# 1's progress notes dated 11/21/24 at 3:00am written by LVN B reflected R #1 had an unwitnessed fall and was noted outside in back of the facility next to the dumpster. R #1 was found with abrasions to the left knee, left elbow, left cheek, nodule to left brow, discoloration under left eye with swelling, discoloration noted to left eye and left arm, with resident stating that his foot got caught (dragged) and he lost his balance falling. Progress note stated R #1 was confused and forgetful at times and was looking for his cousin's house. Notifications were made to the MD, the DON, the on call manager, and R #1's family. R #1 was sent to the hospital. Record review of the hospital visit summary for R #1 stated patient arrived to hospital on 11/21/24 and had a diagnosis of, closed tripod fracture of left zygomaticomaxillary complex, fracture of lateral orbital wall, left side, initial encounter for closed fracture, fracture of left orbital floor, and closed fracture of the left maxillary sinus. Record review on 11/22/24 at 1:54pm and 2:31pm of the facility video surveillance footage reflected R #1 exited the double fire door exit at the end of his hall and was noted entering the service hall approximately 8 minutes later when found by RT A. Time stamped date and time on videos reviewed were not accurate. Record review of R #1's progress note dated 11/21/24 at 4:26pm by the Social Worker reflected R #1's photo and face sheet had been added to the elopement binder in anticipation of his return to the facility. Record review of R #1's progress notes dated 11/21/24 at 9:00pm reflected R #1 returned to facility from the hospital and was unaware he had been at the hospital for a fall. Report received from the emergency room to the facility nurse communicated R #1 had a left eye blow out orbital fracture. Record review of R #'1's progress notes dated 11/22/24 at 1:57pm by the Social Worker reflected the facility had a care meeting with R #1's family on 11/22/24. R #1's family was explained 3 options, 1.) R #1 could stay at facility and would continue to be monitored 2.) R #1 can be referred to a facility that has a wander guard system in place or 3.) R #1 could be referred to a facility that had a secured unit. Family for R #1 stated they preferred for R #1 to be referred to another facility. Record review of R# 1's progress noted dated 11/22/24 at 2:24pm by the Social Worker reflected she had reached out to 6 facilities to gather information regarding, VA contracts, wander guard systems, secure units, and male beds. Record Review of TULIP (HHSC online incident reporting application) on 11/22/24 at 12:00pm revealed a self-report was submitted by the facility and received on 11/21/24 at 10:29AM. During an interview with the DON on 11/22/24 at 1:09pm the DON stated R #1 admitted to the facility on [DATE] and had only been in the facility about a day. He stated he was not aware that R #1 was a wanderer until time went on and they noticed R #1 would walk out of his room and wandered the hallway but was not exit seeking. The DON stated R #1's nurse at the time of R #1's exit from the facility on 11/21/24 was LVN B. He stated the last person to round on R #1 was CNA D at around 2am. The DON stated they reviewed surveillance footage and saw that R #1 exited through the 31-40 hallway door and entered the facility through the service door in the back hallway. The DON stated a respiratory therapist was in the service hall and saw R #1 in the service hall at around 2:30am/3:00am. The DON stated staff completed a head to toe and noted skin tears and open areas to his left, arm, forehead, and left side of his face. The DON stated R #1's family was notified and wanted him sent out for evaluation. The DON stated at the hospital he was treated for a facial maxillary fracture. The DON stated prior to R #1 exiting the facility on 11/21/24, the only assessments completed on R #1 were their regular admission packet and nursing assessments. The DON stated a wandering assessment was completed on R #1 the day of the incident, after the incident. The DON stated the doors R #1 exited from had a continuous alarm that went off when the doors were opened. The DON stated through their investigation they gathered the nurses did not hear any alarm go off. The DON stated the following day they checked the doors and stated they were up and running with nothing identified not working. The DON stated he thought the staff followed all the procedures that they needed to at that time and did not think there was any failure by staff. The DON stated in response to the incident when R #1 exited the building they identified 4 other residents at risk for wandering, which were placed on hourly checks along with R #1 who was placed on 15-minute visual checks. The DON stated they had added keypad locks to the service entry doors and were doing hourly monitoring on the fire exits to ensure all fire exits were activated. The DON stated additionally in R #1's hall they had added an additional chime door alarm to both the service hall door and the double fire door exit on that hall. The DON stated they had also added a chime alarm to the front entry door and had added a staff member to be in the service hall between the hours of 7pm and 7am. The DON stated he had provided in services to staff. The DON provided copy of in services and topics covered and resident/door monitoring. During an interview with LVN B on 11/22/24 at 4:32pm, she stated she was R #1's nurse from 10:00pm on 11/20/24 until 6am on 11/21/24. LVN B stated R #1 was a brand-new admission and had been completing his first 24 hours in the building. LVN B stated R #1 was wandering but was not exit seeking. LVN B stated R #1 was confused looking for his cousin and was wandering the halls and rooms and was reoriented by staff to go back to his room. LVN B stated this had been constant since he was admitted . LVN B stated because R #1 was not exit seeking and they did not have any specific timeline/monitoring in place before the incident, when he exited the building, aside from random check ins with him and when they saw him in the hallway. LVN B stated R #1 was last rounded by CNA D when he was asked to take R #1 back to his room to get dressed because R #1 was getting undressed and wandering the hall. LVN B stated R #1 needed to use the restroom and CNA D took him to the toilet and exited the room to give R #1 privacy because he was able to go to the restroom on his own. LVN B stated R #1 went out through the double doors or the loading dock doors and stated she was not sure but knows that one of the respiratory therapists saw R #1 outside. LVN B stated R #1 was taken to his room where she asked what happened, and completed a head-to-toe assessment, took vitals, contacted the DON, the responsible party for R #1, on call manager, and the MD. LVN B stated R #1 stated his foot got caught on something and he tripped and fell and then got up and continued walking looking for his cousin's house. LVN B stated R #1 was not very reliable. LVN B stated when she assessed R #1, he had multiple abrasions to his left knee, elbow, hand, cheek, and eyebrow along with a nodule and contusion to left eyebrow and underneath left eye and left arm. She stated she could not identify if it was new or not because R #1 admitted with some bruising from the hospital admission. LVN B stated she explained injuries, his head injury, and that R #1 was on blood thinners to the MD and he ordered to send R #1 out. LVN B stated when R #1 returned from the hospital he had an orbital fracture. LVN B stated when R #1 was found she and LVN C went to test the door alarm in R #1's hall and noted there was no alarm that sounded. LVN B stated the alarm was deactivated and it was indicated by no alarm sounding and the light being off on the panel at the nurse's station. LVN B stated she was not aware of any issues with the door alarms recently. She stated there was construction going on at the facility and was not familiar with who deactivated the alarm or reactivated it. She stated she was not told that the construction crew had left. LVN B stated when the exit doors needed to be used the nurses had to be notified and had to be told when they were done using the exit doors because they were responsible for activating the door alarm. LVN B stated she did not see any fault on the nurse but stated they were ultimately responsible for the residents. LVN B stated in response to the incident when R #1 exited the building they had added a staff member to be sitting at the back doors to monitor the service hallway. R #1 was placed on 15-minute visual checks, and they were having to check the doors and alarms hourly. LVN B stated they also added chirping alarms to the service hall door and back double doors. LVN B stated not monitoring residents who were at risk for elopement and not monitoring door alarms to ensure they were functioning and activated could negatively impact residents because they could leave the building and get lost, have an accident, or get injured. During an interview with the ADON on 11/22/24 at 7:45pm she stated she completed wandering/elopement assessments on all residents and had identified 4 residents at risks (R #1, R #2, R #3, and R #5). These residents were updated in the wandering/elopement binders located at the nurses stations and the front desk and were being monitored hourly. The ADON stated she added R #4 to the list to be cautious because although he was not a wandering risk, he did enjoy walking around the outside of facility. During an interview with LVN C on 11/25/24 at 10:30pm, she stated she was not R #1's nurse but did work from 10:00pm on 11/20/24 until 6am on 11/21/24. LVN C stated R #1 would wander in the hall and staff would redirect him back to his room but never stated he wanted to leave and never tried to leave. LVN C stated R #1 was last rounded by an aide at around 2:30am who took him to the restroom. LVN C stated at that time, R #1 was just mumbling to himself and talking about Vietnam. LVN C stated after the camera footage was reviewed, they identified that R #1 exited through the back doors in his hall. LVN C stated the respiratory therapist found R #1 between 2:00am-3:00am. LVN C stated R #1 didn't say why he left but did state that he tripped and fell on the cement and that was how he got the scrapes on his knee, elbow, wrist, and around and under his eye. LVN C stated R #1 was assessed, the MD was notified, and R #1 was sent out. LVN C stated she knew they did a CT scan at the hospital and thought everything had been found to be okay. LVN B stated when R #1 was found she and LVN C went to test the door alarm in R #1's hall and noted there was no alarm that sounded. LVN C stated her and LVN B tested the door alarm on R#1's hall and realized that it was not on because no alarm sounded, and the light was off on the panel. LVN C stated they reset the door alarm and activated it. LVN C stated she was not aware of any issues with the door alarms recently. She stated there was construction going on in the back all week at the facility, so the alarms were turned off. LVN C stated the nurses were responsible for making sure the alarms were on and stated the construction workers should have told them when they left, so the nurses could have turned the alarms back on. LVN C stated anyone needing to use the exit doors should notify the nurses and should let them know when they were done. LVN C stated it was miscommunication because the construction crew never told them they left, so the nurses never turned the alarm back on. LVN C stated she did not know who deactivated the door alarm and stated the facility failed to ensure the fire door alarm was activated in the 31-40 hall. LVN C was aware of how to check that the door alarms were activated. LVN C stated this was her first night back since the incident. She stated she had been trained over door alarm activation, both at the start of her shift and previously over the phone by the DON, who also went over added door alarms, a new worker that would be in in the back hall monitoring, and R #1's nurses monitoring him every 15 minutes. LVN C stated not monitoring residents who were at risk for elopement and not monitoring door alarms to ensure they were functioning and activated could negatively impact residents because they could leave or get injured without their knowledge. During an interview with RT A on 11/26/24 at 12:39am, he stated he worked from 10pm on 11/20/22 to 6am on 11/21/24. RT A stated R #1 was last rounded at around 2am and 4am, when an aide and nurse took R #1 to the restroom, and the nurse walked away but the aide stayed in the hallway. RT A stated at that time R #1 was fine. RT A stated about 30 minutes later he went to heat up his coffee in the back hall between 2AM and 4AM when he saw R #1 enter the service hall and appeared dirty and with some blood on the side of his head. RT A stated he asked R #1 who seemed confused what had happened, and R #1 stated he had tried to go down the stairs and he tripped, he fell on his side, he got an abrasion to one side of his temple, and a scrape on one knee and shoulder. RT A stated R #1 was assessed and LVN B took over. RT A stated he was not aware of R #1 wandering. RT A stated he did not hear any alarm between 2:30am and 3:00am. RT A stated there had not been any issues with the door alarm and stated they were good at checking the doors to be locked with activated alarms. RT A stated not monitoring residents who were at risk for elopement and not monitoring door alarms to ensure they were functioning and activated could negatively impact residents because they could leave the facility if the alarm was not activated and could get an injury from a fall or even worse. RT A stated the residents would be placed in jeopardy if they left the facility. During an interview with CNA D on 11/26/24 at 1:54am, he stated he worked from 10:00pm on 11/20/24 until 6am on 11/21/24. CNA D stated he rounded on R #1 at around 2am when R #1 was talking about random things, praying, and walking around his room. CNA D stated R #1 was taken to the restroom and then taken to bed. CNA D exited the room and went to work with another resident. CNA D stated he had not heard R #1 state that he wanted to leave the facility and he had only seen R #1 up in his room. CNA D stated he was not sure how R #1 got outside, and he understood he went through the emergency doors. CNA D stated he did not hear any alarms between 2:30am and 3AM. CNA D stated he did not know if there were any issues with the activation of the door alarms recently. CNA D stated the nurses were responsible for turning the alarm off and on. CNA D stated he did not know who deactivated the alarm the night R #1 exited the building. CNA D stated he did not know if staff failed to ensure the fire door alarm was activated for hall 31-40 on 11/21/24 between 2:30am-3:00am. CNA D stated after the incident the nurses now had to sign off when checking the doors. CNA D stated not monitoring residents who were at risk for elopement and not monitoring door alarms to ensure they were functioning and activated could negatively impact residents because they can get out. During a follow up interview on 11/26/24 at 5:42pm the DON stated the nurses, LVN B and LVN C were responsible for ensuring the door alarms were activated. The DON stated they should have been monitoring/checking if the door alarm was activated on 11/21/24 but was not able to say why they had not. The DON stated both LVN B and LVN C were aware of the procedures for the door alarms and had both been trained prior to the incident with R #1 but was unsure by who or when. The DON stated not monitoring residents who were at risk for elopement and not monitoring door alarms to ensure they were functioning and activated could negatively impact residents by having a similar situation occur with doors left unarmed and unattended and residents could wander out through the exit without staff being aware. During a follow up interview with the ADON on 11/26/24 at 6:50pm, she stated LVN B was R #1's nurse and CNA D was R #1's CNA from 10:00pm on 11/20/24 until 6am on 11/21/24. The ADON stated she was not sure who rounded on R #1 last, as the DON had conducted those interviews. The ADON stated R #1 was a brand-new patient and had not had a history of wandering and had not stated he wanted to leave the facility. The ADON stated she was told R #1 went through the fire exit doors to get outside and she was not aware of any staff hearing an alarm on 11/21/24 between 2:30am and 3:00am. The ADON stated a respiratory therapist found R #1 when he walked back into the facility service hall. The ADON stated that as per staff, R #1 voiced he was looking for his cousin. The ADON stated staff were not aware that R #1 had exited the facility. The ADON stated R #1 was assessed, and the MD was notified and gave orders to send R #1 out to the hospital. The ADON stated R #1 had minor bruising and skin tears. The ADON stated the hospital finding was a facial fracture. The ADON stated she was not aware of any recent issues with the fire door alarm activation. The ADON stated in order to activate the door alarm the light would have to be on and the alarm should sound when the door was opened. The ADON stated to deactivate the alarm you would need to go back physically and press the button on the panel and reset it to turn off the alarm. The ADON stated the nurses were responsible for ensuring the door alarms were activated. The ADON stated the nursing staff, LVN B and LVN C were responsible for monitoring the door alarms to ensure they were activated on 11/21/24 and should have been but she did not know why they did not. The ADON stated prior to the incident with R #1 staff had just been verbally trained on how to monitor the door alarms to ensure they were activated. The ADON stated in response to the incident the facility implemented 15 minutes checks for R #1, 1-hour checks for any at risk residents, hourly door checks, in-services over elopement policy, wander/elopement binder, and assessing 100% of residents for wandering risk. The ADON stated they also added a bed alarm to R #1's bed, in-serviced staff on deactivation and activation of the fire door alarms and who was responsible, added chime alarms on service doors, added keypad lock to service doors, and placed a staff member in the service hall from 7pm -7am. The ADON stated the failure was staff did not make sure the alarm was on. The ADON stated not monitoring residents who were at risk for elopement and not monitoring door alarms to ensure they were functioning and activated could negatively impact residents because they could exit the building without staff being aware and could cause a serious injury. Record review of R #1's physician order dated 11/21/24 at 10:49pm reflected R #1 was placed on hourly checks. Record review of R #1's November medication administration record (MAR) reflected R # 1 was being checked hourly. Record review of additional sampled residents R #2, R #3, R #4, and R #5 reflected wandering assessments had been completed on 01/21/24 with R #2, R #3, and R #5 identified as at risk for wandering and were placed on hourly checks. Record review of R #2, R #3, and R #5's November medication administration record (MAR) reflected they were being checked hourly. Record review of R #1's physician order dated 11/22/24 at 1:53pm reflected R #1 had a sensor pad added to bed due to poor safety awareness and history of falls. Observation on 11/22/24 at 1:32pm confirmed a keypad lock had been added to the service hall door located in R #1's hall in addition to a chime alarm present on both the service hall door and the double fire exit doors. Observation and test of north side doors on 11/22/24 at 3:10pm confirmed 3 of 3 doors had working alarms that sounded when opened and continued when closed until staff pressed button on panel. Observation and test of north side doors on 11/22/24 at 3:15pm confirmed 3 of 3 doors had working alarms that sounded when opened and continued when closed until staff pressed button on panel. Observation of R #1 on 11/22/24 at 5:43pm confirmed he had a bed sensor pad that would trigger sound notification when resident would move off it. Observation and record review on 11/22/24 at 7:35pm of wander/elopement binders located at the nurses' station and front desk reflected they had been updated to include residents identified at risk for wandering/elopement. Face sheets and pictures of at-risk residents were noted in binders. Record review of R #1's 15-minute checks reflected staff started monitoring him at 9:15PM on 11/21/24 and had completed all checks up until current time of 5:15pm on 11/26/24, when copies of 15-minute checks were submitted to Surveyor E. Record review of north and south side hourly door checks reflected staff started hourly checks on 11/22/24 at 7:00AM and had completed all checks up until current time of 5:15pm on 11/26/24 when copies of the hourly door checks were submitted to Surveyor E. Record review of in-service dated 11/21/24 reflected staff from all departments were in-serviced over hourly checks for fire exit doors activation, 15-minute interval checks for R #1 and hourly checks for any resident at risk for wandering, wandering/elopement binder placement, and policy and procedures for elopement and wandering. 18 staff members from various shifts included 5 LVNs, 4 CNAs', 2 respiratory therapists, 1 therapy staff, 1 housekeeping staff, 1 dietary staff, and 4 leadership staff including the Maintenance Director, DON, ADON and Administrator were interviewed between 11/22/24 and 11/26/24 and recalled and understood the recent Inservice/training. During an interview on 11/26/24 at 7:53pm with the Regional Nurse she stated there was only 9 full time staff members that had not been trained and had not yet worked since the incident. The Regional Nurse stated they were going to be working on calling them. Record review of the wandering and elopement policy with a revised date of March 2019 stated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Record review of the exit and means of egress policy dated January 2019 stated under the section, Policy Interpretation and Implementation the following verbiage, 7. Exit doors will remain unlocked at all times. Residents are never denied access to unlocked exits. During an interview with the Administrator on 11/26/24 at 7:33pm he stated the closest policy they had related to door alarms was the Exits or Means of Egress policy that was provided.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: 1. The facility failed to keep the kitchen and dish room walls and floors clean. 2 The facility failed to ensure the juice dispenser nozzles were clean. 3 The facility failed to ensure the ice machine was clean. These failures could place residents at risk of foodborne illnesses. Findings included: An observation of the kitchen on 10/21/2024 at 8:45 a.m., revealed multiple broken floor tiles, the floor grout had a thick black substance adhered to it, the tiles on the corner edges of the floor bed were cracked and had a black substances collected in the corner. The walls in the kitchen and dish room had yellowish stains and, in some areas, there were black spots in the ceiling. The vinyl backsplash strip on the bottom of the walls throughout the kitchen had black spots and, in some areas, separated from the wall and the sheet rock was peeling. In an interview on 10/21/2024 at 9:15 a.m., the DM said the kitchen floors were cleaned daily by the dietary staff. She said the floors were swept and mopped daily with hot water and cleaning chemicals. The DM said the yellowish stains on the walls were water stains. She said whenever it rained the water would leak into the kitchen. The DM said the roof was in the process of being repaired due to the water damage from recent rains. The DM said she did not know what the black spots throughout the ceiling were. The DM said she had a cleaning schedule for her staff to follow and to ensure the kitchen was kept clean. An observation of the kitchen (follow-up) on 10/22/2024 at 2:00 p.m., revealed one juicer that had two nozzle dispensers that were not clean. One nozzle had a reddish and white slimy substance adhered to hit and the second nozzle had a reddish slimy substance adhered to it. In an interview and observation on 10/22/2024 at 2:12 p.m., Dietary [NAME] N said the juicer was cleaned daily. She said the staff member who cleaned the juicer would initial and date the log. Surveyor observed Dietary [NAME] N review a binder with different logs but said she was not able to find the daily cleaning schedule log in the binder. She said she didn't know where the daily cleaning schedule log was. In an interview on 10/22/2024 at 2:16 pm, the DM said staff were supposed to clean the juicer and both dispensers daily. She said she had a log where staff members would sign off after they cleaned the equipment. The DM said she would have to look for the log because she didn't have it readily available. The DM said if the juicer and its dispenser were not cleaned it could cause contamination and it would be an infection control problem. An observation and interview with the DM on 10/22/2024 at 2:30 p.m., of the facility's ice machine reflected a 2 to 2 1/2 inch oblong black spot on the plastic backsplash which could have direct contact with the ice when it fell into the holding area. The DM said her staff were not responsible for cleaning the ice machine. She said the responsibility fell on the Maintenance Director. The DM said she was not sure what the black spot was but said it should not be there as it could contaminate the ice. An interview and observation on 10/22/2024 at 2:45 pm, the Maintenance Director said he was responsible for cleaning the ice machine. He was observed checking the black spot on the ice machine and said, I must have missed that spot two weeks ago when I cleaned the ice machine. He said he cleaned the ice machine every 3 months or earlier if needed, he said he did not keep cleaning logs. He said when he cleaned the ice machine, he would first melt all the ice, then he would use a mixture of water and Clorox to clean it. He said he had never seen any black spots on the ice machine prior to 10/22/2024. He said he would immediately melt the ice and clean the ice machine. He was not able to say if the black spot caused had any negative effects on residents. An interview on 10/22/2024 at 3:00 p.m., the DON said the ice machine was not his responsibility but if the ice machine were not cleaned properly it could cause respiratory issues for residents. An interview on 10/23/2024 at 11:53 a.m., the Dietician said she was not responsible of making sure the dietary staff had their food handler's certification. She said she would visit the facility two times a month or as needed. She said during her visits, she would make sure the kitchen was sanitary. She said she would also inspect the ice machine and had never seen any black spots and the juicer did not have any slimy substance adhered to the nozzles. The Dietician said the facility's kitchen was kept in a sanitary condition. In an interview on 10/24/2024 at 3:00 p.m., the Administrator was asked if he were aware of the kitchen's walls, broken floor tiles, the sanitation of the juicer, and ice machine and he said, he would look into it and was not able to say if there were any negative effects to residents. Record review of the kitchen's daily cleaning schedule (provided on 10/23/2024) for the month of October 2024 (1st to 21st) revealed the floor had been cleaned but they did not include the juicer. The daily cleaning schedule from October 21-27, 2024, revealed the word juices had been added (handwritten) to the cleaning schedule. Record review of the kitchen's daily cleaning schedule for the months of September through October 19, 2024, revealed the juicer was not included in the daily cleaning schedule to be cleaned. The daily cleaning schedule for October 21-27, 2024, revealed the word juices had been added (handwritten) to the cleaning schedule. In an interview on 10/24/2024, the DM said even though the daily cleaning schedule prior to 10/19/2024 did not include the juicer as an item to be cleaned, she would make sure staff cleaned it daily. Record review of the ice machine manufacture's recommendations revealed, recommends cleaning your ice maker every six months to keep it working properly. Record review of FDA Code 2022, chapter 2, Mangement and Personnel reflected (8) Describing the relationship between the prevention of foodborne illness and the management and control of the following: (a) Cross contamination, Pf (b) Hand contact with READY-TO-EAT FOODS, Pf (c) Handwashing, Pf and (d) Maintaining the FOOD ESTABLISHMENT in a clean condition and in good repair; Record review of the kitchen's Sanitation policy dated 2001 and revised on 11/2022 revealed: Policy statement: The food service area is maintained in a clean and sanitary manner. Policy interpretation and implementation: 1. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. 2. All utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners are kept in good repair. 10. Ice machines and ice storage containers are drained, cleaned and sanitized per manufacturer's instructions.

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 5 of 11 dietary staff (Dietary Staff M, N, P, Q, and R) reviewed for food and nutrition services. The facility did not ensure Dietary Staff M, N, P, Q, and R had a current food handlers' certificate while working in the facility's kitchen. This failure could place residents who consumed food prepared from the kitchen at risk of food-borne illness. Findings included: Record review of the 11 Dietary Staff food handler's certificates revealed 5 of them (Dietary Staff M, N, P, Q, and R) did not have a food handler's certificate prior to 10/21/2024. Record review of facility's staff roster revealed Dietary Staff M's hire date was 09/19/2023, Dietary Staff N's hire date was 12/12/2021, Dietary Staff P's hire date was 07/31/2024, Dietary Staff Q's hire date was 10/09/2024, and Dietary Staff R's hire date was 07/21/2023 An interview on 10/23/2024 at 8:45 a.m., the DM said she was hired on 01/03/2024. She said when she first met her staff, she asked them if they all had their food handlers certificate, and all said yes. She said she took their word and didn't bother asking them for a copy of their certificate. She said the person who was responsible for making sure dietary staff had their food handlers certificate was human resources. The DM said she called Dietary Staff M, N, P, R, and Q on 10/21/2024 after the surveyor's initial tour to request their food handlers certificate because she didn't have a copy in her records. She said Dietary Staff M, N, P, R, and Q told her they did not have a current food handlers certificate and she advised them to take the course as soon as possible and to provide her with the certificate. The DM said the residents could be at risk for food borne illness if the staff did complete training on proper food handling requirements as required by regulations. The DM said the facility did not have a policy indicating dietary staff needed a food handlers certificate. An interview on 10/23/2024 at 9:30 a.m., the HR Manager said she was responsible for hiring all staff and making sure all staff had the required credentials. She said she was not aware kitchen staff had to have a food handlers certificate within 30 days of employment. She said her main focus was on making sure CNA's, LVN's, and RN's had their credentials. She said, I'm going to be honest with you, I know for sure there are some kitchen staff that do not have a food handlers certificate. She was not able to say how not having a food handler's certificate could negatively affect the residents. An interview on 10/23/2024 at 3:00 p.m., the Administrator said, he would look into it and was not able to say if there were any negative effects to residents. A copy of the facility's policy indicating the dietary staff needed a food handlers certificate was requested but he did not provide one before exit. Review of the TAC chapter 228.31 .Certified Food Protection Manager and Food Handler Requirements. (d) All food employees, except for the certified food protection manager, shall successfully complete an accredited food handlers training course, within 30 days of employment. (e) The food establishment shall maintain on premises a certificate of completion of the food handler training course for each food employee. The requirement to complete a food handler training course for each employee.

Based on interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made to the State Survey Agency for 1 of 4 residents reviewed for abuse (Resident #1). The facility did not immediately report an incident involving alleged physical abuse to Resident #1 by an unknown staff member to the state agency. This failure placed resident at increased risk for delayed treatment and investigation for abuse and neglect. Findings Included: Record review of Resident #1's face sheet revealed a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including, but not limited to, unspecified dementia without behavioral disturbance, depression, hypertension, hypotension, chronic kidney failure and falls. Record review of the MDS assessment for Resident #1, dated 2/28/24 revealed no BIMS score as Resident #1 was cognitively unable to complete the brief interview for mental status. She was not coded for any behaviors. She required substantial/maximal assistance of one person for toilet use. She was frequently incontinent of bladder and occasionally incontinent of bowel. Record review of a progress note for social services dated 4/1/2024 revealed that a grievance was filed on Resident #1's behalf by the social worker, but record review of the grievance log does not show this grievance was documented in the log. Record review of the Provider Investigation Report revealed the allegation of abuse was reported to HHSC on 4/2/24, and the abuse assessment was completed on 3/31/24, and assessment revealed no injuries or bruising to hands, as well as no change in behavior. The Provider Investigation Report also revealed that the incident was reported to the facility on [DATE], but that it occurred on 3/18/24. Resident #1 was unable to recall the staff or CNA's name. Facility investigation report also revealed that Abuse, Neglect, and Exploitation in-service was conducted with all staff on 4/2/24. In an interview with Resident #2 on 10/23/24 at 9:26 AM, she stated Resident #1 got mad easily whenever anyone spoke to her, and she would sometimes try to hit the staff. Resident #2 stated she had never seen her roommate Resident #1 get abused physically or verbally. Resident #2 stated the staff treated her with dignity and respect. They always knock on her door before they come in her room. Resident #2 denied having any complaints about the facility. In an interview with the Social Worker (SW) on 10/22/24 at 11:40 AM, she stated she did not think a grievance was done since a report was filed with the state, but it should have been so that it would be listed on the grievance log. The SW does not remember Resident #1 ever accusing anyone of abuse prior to this event or after, and the SW denied seeing any bruising or other marks to Resident #1's body. In an interview with the ADON on 10/22/24 at 12:15 PM, she stated Resident #1 accused a CNA, who was trying to pull up her brief, of abuse, and either Resident #1 stopped the CNA and pushed her hand away or the CNA pushed Resident #1's hand away. ADON stated she doesn't remember exactly what occurred or how, but incident was reported. The ADON stated Resident #1's roommate was present and denied seeing the incident occur. ADON denied ever having any complaints on either of the CNAs that were working on that shift. The ADON denied seeing any bruising or any redness to Resident #1's hands or arms around that time. In an interview with the DON on 10/22/24 at 12:35 PM, he stated he would have to look into the investigation for Resident #1 and review it again, but obviously the dates are wrong as the provider investigation and assessment should read 3/31/24 and not 4/31/24. Also, he stated that how and when they reported depended on the allegation or situation, but typically with resident abuse it is reported to the state immediately. In an interview with the Administrator on 10/22/24 at 12:40 PM, he stated that the dates on the facility investigation were wrong because the incident did not occur or happen on 4/31/24, and then get reported on 4/2/24, as that would be impossible. He also stated with physical abuse they typically reported immediately, and he was not sure why they didn't in this case. In an interview with CNA - F on 10/23/24 at 3:11 PM, stated if she remembered correctly, the CNA grabbed Resident #1's diaper to fix it, and Resident #1 reached down to help her, and the CNA playfully swatted her hand telling her don't grab that. CNA - F felt that Resident #1 took it the wrong way, and that Resident #1 had never made complaints such as that before that she was aware of. CNA - F stated if she ever witnessed abuse, she would report it to the charge nurse and Administrator. In an interview with CNA - J on 10/22/24 at 3:21 PM, stated she did not remember Resident #1 ever making any claims of abuse, and never noticed bruising or redness to her hands or arms. CNA - J stated that she checked Resident #1's blood pressure daily, so she always saw her arms and hands. CNA - J denied ever hearing about staff slapping or swatting any residents' hands, but if she ever witnessed abuse, she would report to charge nurse and administrator. Record review of facility's Abuse and Neglect Policy, revised April 2021, revealed the facility would identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property, and investigate and report any allegations within timeframes required by federal requirements.

Based on observtion, interview and record review, the facility failed to provide adequate supervision for one Resident (Resident #1) of 12 residents reviewed for accidents and hazards, in that. Resident #1, who required the assistance of two persons for bed mobility and toileting, sustained a laceration requiring twelve sutures when provided care by only one CNA. This failure could place residents at risk of serious injury. The noncompliance was identified as past non compinace. The noncompliance began on 12/01/22 and ended on 12/05/22. The facility had corrected the noncompliance before the survey began. The findings were: Record review of Resident #1's Admission Record dated 12/19/22 indicated Resident #1 was a [AGE] year-old male admitted to facility on 11/25/19 with the diagnoses of chronic kidney disease, type 2 diabetes mellitus with long-term use of insulin, gastronomy (tube into stomach for feeding and medications), hypertension (high blood pressure), dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), psychotic disturbance (severe mental disorder that cause abnormal thinking and perceptions. People with psychoses lose touch with reality), mood disturbance (feelings of distress, sadness or symptoms of depression, and anxiety), heart failure, cerebral infarction (stroke), and myocardial infarction (heart attack). Record review of Resident #1's quarterly MDS dated [DATE] indicated Resident #1: -had unclear speech, -was rarely/never understood by others, -was sometimes able to understand others, - was severely cognitively impaired, -transfers and locomotion on the unit did not occur, -was totally dependent for bed mobility, dressing, toileting with two or more persons assisting. -was always incontinent of bowel and bladder. Record review of Resident #1's care plan dated 09/27/22 indicated: -Resident #1 required assistance with Activities of Daily Living due to Resident #1 being totally dependent on nutrition/hydration from staff via enteral tube feedings. Resident #1 had limited mobility related to left sided weakness following a stroke. Resident #1 was confused and unable to make his needs known, and staff needed to anticipate all of Resident #1's needs. Resident #1 care plan reflected for bed mobility and toileting: total dependence with 2+ person physical assist. -Resident #1 was a fall risk and dependent on staff for transfers due to decreased physical mobility, weakness, unsteady balance with transitions, cognitive impairment, poor safety awareness, and unstable health condition. Resident #1's status post stroke with left-sided weakness. Staff to encourage and remind resident to call on staff for assistance with all transfers by using the call light when in room, staff to redirect resident as needed when attempting to transfer self, staff to ensure call light was always within reach when in room and answered promptly, bed to the lowest position when in bed, and bedside fall mats. Record review of Resident #1's Fall Risk Assessments revealed: -12/01/22 Fall Risk Assessment, 10 Score, High Risk for falling. -04/04/20 Morse Scale Fall Risk Assessment, 65 Score, High Risk for falling -11/25/19 Morse Scale Fall Risk Assessment, 50 Score, High Risk for Falling Record review of Resident #1's progress notes revealed: -On 12/08/22 at 11:35 AM Nursing Note written by ADON H: Note Text: S/P FALL Patient had a fall on 12/01/2022. Patient unable to communicate how incident occurred due to having a medical diagnosis of vascular dementia, and history of cerebral infarction. Resident was noted with a laceration to left forehead on time of fall and was sent out to VRMC for eval and treat. Patient returned back to our facility the same day with stiches to forehead. Neuro checks initiated by floor nurse. Prn pain medications are being administered. PCP and Family members were notified of time of incident. Patient has been stable s/p fall. Will continue with IV hydration continuous r/t abnormal labs. -On 12/01/22 at 11:20 AM Nursing Note written by LVN B: Note Text: EMS ARRIVED AND PATIENT TRANSFERED TO STRETCHER VIA EMT'S AWAKE AND ALERT. TRANSFERED TO VRMC, CHEST NOTED RISING AND FALLING. REPORT GIVEN TO (Name) RN AT VRMC. -On 12/01/22 at 11:04 AM Nursing Note written by LVN B: Note Text: EMS ACTIVATED PENDING ARRIVAL. -On 12/01/22 at 11:00 AM Nursing Note written by LVN B: Note Text: I WAS NOTIFIED BY STAFF THAT PT HAD FALLEN FROM HIS BED WHILE SHE WAS PROVIDING PERICARE. UPON ENTERING ROOM NOTED PATIENT ON HIS LEFT SIDE WITH LARGE AMOUNT OF BLOOD WHERE HIS HEAD WAS. ASKED PATIENT IF HE WAS OK AND PATIENT RESPONDED, 'SI (yes)'. ASSISTED PATIENT BACK TO BED WITH STAFF AND APPLIED PRESSURE TO LACERATION ON LEFT SIDE OF HEAD TO STOP BLEEDING. AFTER BLEEDING SUBSIDE AREA WAS CLEANED WITH NS, PAT DRIED, APPLIED GAUZE AND COVERED WITH DRY DRESSING. ASSESSED PATIENTS VITALS BP-133/93, P-104, T-97.7, R-22, O2 SAT-100%. NEURO CHECK PERFORMED, PATIENT ALERT AND ABLE TO VOICE NAME, PERRLA, RIGHT AND LEFT PUPIL SIZE 3MM. GTUBE IN PLACE BUT TORN MID TUBE. RP NOTIFIED. [Doctor name] NOTIFIED AND ORDERS TO SENT TO VRMC TO EVALUATE AND TREAT. Record review of the hospital report for Resident #1, dated 12/01/22 revealed: [AGE] year-old male evaluated status post fall from bed with a laceration to left frontal area. Laceration was closed with 12 sutures. CT of head and C-spine for traumatic injury were negative for acute. Resident was discharge back to nursing facility with sutures to be removed in 7 - 10 days. Observation on 12/15/22 at 02:57 PM revealed Resident #1 was sitting up in bed with his knees bent. The bed was at the lowest level and a fall mat was beside the bed. Resident #1 was well-groomed abd the call light was within reach. Resident #1 had a bandage to hi sleft forehead which was clean, dated and initialed. A bandage was noted on his right upper arm which was clean with initials and date. Resident #1 was nonverbal. In an interview on 12/15/22 at 03:40 p.m., the DON stated CNA A was suspended, in-serviced, and written up because she did not follow the plan of care during care for Resident #1. The DON stated Resident #1 was to have 2 people in the room for care and CNA A was by herself. In an interview on 12/15/22 at 04:18 p.m., LVN B stated she was doing her medication rounds and was notified by a CNA A that Resident #1 had fallen. LVN B stated she immediately went to the resident. LVN B stated Resident #1 was on the floor next to the bed, on his left side with blood around head. LVN B said Resident #1 stated he was okay. LVN B stated she applied pressure to Resident #1's forehead to stop bleeding. LVN B said Resident #1's left arm is contracted but he was able to move other extremities. LVN B said vitals were taken and neuro checks completed. LVN B stated she notified the doctor and RP. LVN B stated the doctor gave orders to send the resident out to hospital. LVN B stated LVN J came in and assisted. LVN B stated CNA A was at the side of the bed. LVN B stated CNA A told her she was changing the resident and the resident struck at her so she let go when he struck her and the resident fell on the floor. LVN B stated Resident #1 does make (unintelligible) comments to her but has never struck out at her. LVN B stated CNA A was the only CNA in the room doing care. In an interview on 12/19/22 at 01:06 p.m., CNA A stated she went in to check on Resident #1 (12/01/22 at 11:00 a.m.). He had vomited and was dirty. CNA A stated her partner was with another resident so she started to clean Resident #1. CNA A stated when she was turning him to remove his brief, he hit out with his right arm. She stated she let go from the hit she received on her right hand. CNA A stated de started to roll off the bed. CNA A stated she attempted to stop him from falling off the bed but was unable to. She said her arms ached for two days from the effort of trying to stop him from falling off the bed. CNA A saw somebody, another CNA, passing by and she asked him to get the nurse because she did not want to leave the resident. CNA A stated one of her partners and the nurse, LVN B, came to check the resident. CNA A stated LVN B assessed the resident and they put him back to bed. CNA A stated she did not see any bleeding when the resident fell , but after the nurse came in and was checking him, the nurse said he was bleeding. CNA A stated normally there are two people going in to take care of that resident, but since she saw he had vomited, she started performing care. CNA A stated there are people who only need one person for care, but there are others who are two people for care. CNA A stated it is also on the CNA's computer. CNA A stated Resident #1 is a two person assist. Observation on 12/19/22 at 01:22 p.m., of the CNAs computer in the hallway revealed CNA A demonstrated where to find the information for residents on how many people were needed for assistance. CNA A demonstrated knowledge on how to obtain information for four different residents. In an interview on 12/19/22 at 02:05 p.m., CNA C stated she is CNA A's partner today. CNA C stated the CNAs work on either side of the hall. CNA C stated when there is a two person assist, the two CNAs get together and coordinate a plan to work together for the two-person assist. Observation on 12/19/22 at 02:14 p.m. of CNA C on the CNAs computer in the hallway revealed the aide demonstrated knowledge on the computer finding whether a resident was a one or two person assist. In an interview on 12/19/22 at 02:28 p.m., CNA D stated when she is working on the hallway there are two CNAs on the hall. CNA D stated when she has a resident who is a two person assist, it is her responsibility to get her partner to help. CNA D stated if there is a new resident and she does not know the care, she will ask the nurse or therapy. CNA D stated she had been trained on the CNA computer, but it has been a while. CNA D stated she has been at the facility for [AGE] years working as a CNA. Observation on 12/19/22 at 02:43 p.m. revealed CNA D demonstrated knowledge on the CNA computer on how to find how much assist is needed for residents. In an interview on 12/19/22 at 02:55 p.m., CNA E stated there are two CNAs per hallway. CNA E stated she likes to work as a team and partner up with each other for resident care, both going to each resident's rooms to provide care. Observation on 12/19/22 at 03:10 p.m. of CNA E at the CNA computer revealed the aide demonstrated knowledge of how to find how many person assist is needed for residents. In an interview on 12/19/22 at 03:30 p.m., CNA F stated there are always two CNAs on a hall. CNA F stated, We work together as a team. CNA F stated he had been a CNA for five years. CNA F stated he would check the computer at the beginning of his shift and also round with a CNA from the previous shift. He stated he has a partner on the hall and they both provide care for residents who are a two person assist. In an interview on 12/19/22 at 03:52 p.m., CNA G stated she was working on two hallways with a partner. CNA G stated there were only ten residents she was assigned to. CNA G stated some of the residents are one person assist and some were two person assist. CNA G stated if she needs assistance, she gets her partner. CNA G stated she can find on the CNA computer how much assist a resident is. CNA G stated she had training on the computer about two weeks ago. CNA G stated when performing care, if changes are noted, she reports the changes directly to the nurse. In an interview on 12/19/22 at 05:20 p.m., DON stated she is notified of all falls through the ADONs. DON checks notes every morning to see what has occurred since she was last in the building. The DON stated the Administrator does the reporting to State if necessary (Administrator reported this incident to State). DON stated CNA A should have had another staff with her while performing incontinent care for Resident #1 per their policy. The DON stated the negative outcome was that the resident fell and received a laceration to the head requiring sutures. The DON stated CNA A was suspended, in-serviced before being allowed back on the floor, and written-up. The DON stated all staff were in-serviced after the incident with Resident #1. DON stated she had only been the DON for a couple months and she was trying to make changes to improve the facility and staff for the better. DON stated she had been the MDS nurse at the facility before taking the DON position. DON stated she and the RN ICP are the ones who teach the in-services. DON stated CNA A has not had any other similar incidents. Record review of the facility's policy Nursing Services Policy and Procedure Manual for Long Term Care 2001 MED-PASS, Inc (Revised December 2007) Falls and Fall Risk, Managing revealed: Policy Statement Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation Prioritizing Approaches to Managing Falls and Fall Risk 1.The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once).