Every finding on record at Stone Oak Care Center

Based on observation, interview, and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for one (1) of six (6) residents (Resident #1) reviewed for medical records. The facility failed to include documentation to show Resident #1 and/or Resident #1's family member agreed to the resident residing in the locked unit. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records. The findings included: Record review of Resident #1's admission Record, dated 06/02/2026, revealed an [AGE] year-old female. She was admitted on [DATE]. Resident #1 had three (3) listed contacts: an Attorney for her Emergency Contact #1, a family member as the Emergency Contact #1 (both contacts designated #1) and Resident Representative, and an APS agent. Record review of Resident #1's Medical Diagnosis tab in Resident #1's electronic medical record, undated and accessed 06/02/2026 at 02:06 p.m., revealed diagnoses included encephalopathy (a disease in which the function or structure of the brain is affected, typically caused by infection, tumor, or stroke), panic disorder (a mental health condition characterized by recurrent, unexpected panic attacks and persistent worry about future attacks), neurocognitive disorder with Lewy bodies (also known as Lewy body dementia, a complex brain disorder characterized by the presence of abnormal deposits of a protein in the brain, called Lewy bodies, that affect chemicals in the brain and result in cognitive decline over time), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Resident #1's Quarterly MDS Assessment, dated 05/05/2026, revealed the resident had a BIMS score of 07, indicating she was severely cognitively impaired. She was documented as having the presence of wandering behavior occurred one (1) to three (3) days. She did not use a mobility device and was independent with walking 10 feet to at least 150 feet. Resident #1 and her Significant Other were documented as having participated in Assessment and Goal Setting. Record review of Resident #1's Order Summary Report, dated 06/06/2026, revealed an order, Admit to Secure unit due to behaviors that may include but not limited to: wandering, exit seeking, rummaging, hoarding and disturbed sleep patterns., noted as Active, with an order date of 01/26/2026 and no end date. Record review of Resident #1's Nrsg: Exit Seeking Risk Tool, dated 01/28/2026, revealed under A. History/Behaviors, number six (6) was checked as appropriate, Verbalization: Resident verbalized the need and/or desire to go home or to another location and has the ability to act on that verbalization . and number twelve (12) was checked, Mobility: Resident is physically able to exit on foot or by wheelchair. The section titled Care Plan Decision, Yes was selected for Based on the above assessment, Does the resident display exit seeking behavior?. Record review of Resident #1's Resident and Community Care Agreement [Facility Name], documented as signed 01/29/2026, revealed, 1. Key Definitions in this Agreement.1.4 Community, we, our, and similar terms mean [Facility name]. 4. Consent to Treatment. You authorize us to provide Services to you that are reasonable and medically necessary for your well-being, health, and safety as we determine in conjunction with you or Your Representative and your Attending Physician and other Authorized Providers., electronically signed by Resident #1 and the Care Navigator on 01/29/2026. The document included Exhibit B Statement of Resident Rights (26 Tex. Admin. Code 554.401 which included the Rights of the Elderly (Tex. Human Resource Code Section 102.003 and was electronically signed by Resident #1 on 01/29/2026 to acknowledge receipt of this Statement of Resident Rights and Rights of the Elderly. Record review of Resident #1's Progress Notes revealed:- dated 01/30/2026 by Psychiatric NP, .Patient seen on locked unit.Patient is .highly confused and anxious, highly repetitive. Was difficult to redirect because she was very forgetful at this visit. and under Assessment and Plan, At this time, patient is not deemed to be safe to join general population for programming due to significant risk for attempt to elope. Confusion levels are too significant for safe community participation.- dated 04/03/2026 by Psychiatric NP, .seen for routine psychiatric reassessment in skilled nursing facility where she resides on locked unit. She continues to need to be placed on locked unit due to severe risk for elopement. Attempt was made to program [trial] patient off of locked unit however she became agitated and did start to exit seek during that episode, so determined that for safety she continues to be needful of locked unit. Record review of Resident #1's IDT: Care Plan Conference & Advanced Care Planning Review, dated effective date and signed on 01/29/2026, revealed the reason for the care plan meeting was for the initial baseline 48-hour care plan. Resident #1's listed contact Attorney was documented as participated and reviewed the updated plan of care. Additional comments were noted to include .currently in memory care. The section titled Acknowledgements- At Risk Areas- Advanced Care Plan: Care Choices .1. Resident/Representative have been educated that, due to advanced age, medical conditions, and/or current medication regimen, the resident is at risk for the following areas: . *At Risk for wandering, elopement, or unsafe exit-seeking behaviors. were checked. Record review of Resident #1's IDT: Care Plan Conference & Advanced Care Planning Review, dated effective date 04/30/2026 and unsigned, revealed the reason for the care plan meeting was a routine care plan review (annual/quarterly/significant change). Resident #1's listed contact family member was documented as participated and reviewed the updated plan of care. The section titled, Acknowledgements- At Risk Areas- Advanced Care Plan: Care Choices . 1. Resident/Representative have been educated that, due to advanced age, medical conditions, and/or current medication regimen, the resident is at risk for the following areas: . *At Risk for wandering, elopement, or unsafe exit-seeking behaviors. were checked. Additional comments were noted to include, He [family member] shared that he still sees significant decline in her cognition and memory at times when he visits and feels she requires the support of memory care for ongoing LTC. Record review of Resident #1's Care Plan, undated and accessed 06/02/2026 at 02:11 p.m., revealed the focus At risk for elopement and/or wandering with unsafe boundaries r/t: cognitive impairment/judgement and safety awareness., date initiated and created on 01/28/2026 with intervention/task, Assess my continued need for residing on the memory care/secure unit as indicated., date initiated and created 02/12/2026. During an observation and interview on 06/02/2026 at 12:06 p.m., Resident #1 was observed in her room, located in the secured unit. During an interview, Resident #1 stated she was not senile (having or showing characteristics of old age, including a loss of mental capacity) but that she had a temper which was what got her here (at the nursing facility in the secured unit). Resident #1 stated she did not belong in the secured unit but also stated she wanted to go home and indicated she would leave the facility if given the opportunity. Resident #1 was observed during the interview to repeat the same stories or facts, which was focused on her family member and stating her family member turned her prior physician and the police against her. Resident #1 stated she was prescribed medication for dementia but would not take it (at home). Resident #1 did not answer when asked about consent for admission or when asked about the admission process and would return to her prior statements about her family member, turning everyone against her. During an attempted interview with Resident #1's APS contact on 06/02/2026 at 02:33 p.m. and on 06/03/2026 at 01:16 p.m., there was no answer, message(s) were left with a return call not received. During an attempted interview with Resident #1's Attorney and Emergency Contact #1 on 06/03/2026 at 05:17 p.m. and 6/04/2026 01:47 p.m., there was no answer, message(s) were left with a return call not received. During an interview on 06/03/2026 at 03:33 p.m., the Care Navigator stated Resident #1 signed her own admission paperwork with Resident #1's attorney present over the phone for confirmation that Resident #1 was able to sign. During an interview on 06/04/2026 at 01:55 p.m., the ADMIN stated the physician's order was the consent for Resident #1 to be in the secured unit. She stated Resident #1 was admitted to the facility from a hospital with the hospital documentation noting that Resident #1 was exiting seeking and Resident #1's family member was unable to care for her. The ADMIN stated for placement in the secure unit, the facility procedure was for the IDT to meet and review the resident's clinical information, specifically exit seeking behaviors with a low BIMS or cognitive status, and the IDT will discuss the information with the resident and family, and then the physician. She stated residents in the secured unit had to meet criteria and in Resident #1's case, Resident #1 immediately went to the secured unit. The ADMIN stated that Resident #1 signed her admission documentation, referring to document Resident and Community Care Agreement [Facility Name], documented as signed 01/29/2026. During an interview on 06/04/2026 at 02:28 p.m., Resident #1's family member stated Resident #1's attorney assisted with Resident #1's admission to the nursing facility due to him having been in the hospital. Resident #1's family member stated the attorney acted with his permission for Resident #1. He stated he did not know if the attorney signed anything, but he was given paperwork today, 06/04/2026 for it (Resident #1's admission). He stated that the facility called him today, 06/04/2026 and asked if he wanted to keep Resident #1 in the secured unit and he replied yes. During an interview on 06/04/2026 at 05:22 p.m., the ADMIN stated Resident #1's baseline care plan, referring to document IDT: Care Plan Conference & Advanced Care Planning Review, dated 01/29/2026, showed Resident #1's secure unit placement was discussed with Resident #1's Attorney and the quarterly care plan, referring to document IDT: Care Plan Conference & Advanced Care Planning Review, dated 04/30/2026, showed Resident #1's secure unit placement was discussed with Resident #1's family member. Record review of facility policy titled, Criteria for Memory Support Unit, dated February 2017 and date revised January 2023, revealed: Guideline:Residing on the Memory Support Unit (MSU) should be the least restrictive course of action in that it allows the resident's free movement in a safe environment. The following criteria will serve as a guide for admission to and discharge from the memory care support unit (MSU).admission .- Family/RP accepts the admission, transfer, and discharge criteria of the community.

Based on interview, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 1 of 1 nurse (LVN A) reviewed for competent nursing care.The facility failed to ensure the LVN A practiced nursing within her scope of practice when she conducted an initial admission assessment, initiated a baseline care plane and initiated the comprehensive care plan for Resident #1. This deficient practice affects residents who depend on nursing care and could place residents at risk for incomplete or inaccurate assessment and care plans. The findings included:Record review of Resident #1's face sheet dated 12/02/2025 revealed an admission date of 11/28/2025 with diagnosis which included: acute on chronic combines systolic congestive and diastolic heart failure (heart failure where both sides of the heart are compromised), type 2 diabetes mellitus without complications and primary open-angle glaucoma bilateral stage unspecified (symptomless vision loss due to elevated eye pressure when then eye drainage system fails). Record review of Resident #1's MDS assessments revealed she did not have a comprehensive assessment due to new admission status. Record review of Resident #1's assessment and baseline care plan dated 11/28/2025 revealed as assessment review all body systems was completed including a physical a head-to-toe assessment, vital signs and completion of the baseline care plan signed by LVN B. There was a black check box at the bottom of the form to indicate an RN had reviewed the document that was not marked off as reviewed. Record review of Resident #1's comprehensive care plan initiated on 11/28/2025 included plans of care for: -diabetes, risk for nutritional deficits and/or dehydration, risk for falls, actual or risk for skin impairment, advanced directives/full code status, risk for oral care issues all initiated by LVN B. An RN reviewed and updated the comprehensive care plan on 12/01/2025. During an interview on 12/02/2025 at 4:02 p.m., LVN B stated she was the admitting nurse and completed a head-to-toe assessment and initiated the baseline care plan. She stated she based her assessment on what she can see and what the residents and the family tell her. She stated she can do the baseline care plan as a LVN, but an RN was required to do the comprehensive care plan. LVN B stated Resident #1 was a new admission on [DATE] at approx. 2:00 p.m. She stated she was not prepared for the admission. She stated she did not receive a report, and the resident did not have any paperwork with her. LVN B stated the admission Coordinator told her she was getting a new admission approximately one hour prior to Resident #1 arriving. LVN B stated she was told Resident #1 was a respite hospice patient. She stated the Admissions Coordinator told her the hospice nurse would come to the facility to do her admission. LVN B stated she was aware of the LVN scope of practice. She stated she was able to complete assessments including an initial baseline assessment base on her five senses.what she can see, smell, hear, etc. LVN B stated she had never been told an initial or baseline assessment and care plan must be reviewed or completed by an RN. She stated it is always done by the admitting nurse, and she was that person. LVN B stated Resident #1's admission occurred during day shift on regular weekdays. She stated there was an RN in the building when the admission occurred. During an interview on 12/03/2025 at 1:11 p.m. the DNS (Director of Nursing Services on facility records) that had been promoted but was still in the process of transitioning. She stated she was still providing oversite to the facility in an interim manner for a few more days. She stated her last day as DON was officially 11/21/2025 however she was remaining in the facility as interim DON until the new DON had completed training. She stated she was not sure when that would be. The DNS stated either a licensed or registered nurse was able to complete a new admission. She stated LVN B did conduct the initial assessment which included the baseline care plan for Resident #1. She stated an RN should go behind the LVN within 48 hours and review the assessment and baseline care plan and document the review. She stated on the last page of the baseline care plan and initial assessment there was a place to document the RN review. The DNS stated she did not consider a complete head-to-toe assessment to be a comprehensive assessment, rather each section was considered a focus assessment. The DNS stated there was a part of the initial baseline assessment/care plan that should only be done by an RN and that the care plan interventions. After reviewing Resident #1 care plan she stated acknowledgement that LVN B had completed the baseline care plan interventions, and the document was not signed as reviewed by an RN. The DNS stated the facility had an interdisciplinary team M-F, with a RN on staff should review it and make sure everything was covered. She stated she was not sure why Resident #1's was missed. She stated there was an RN in the building from 6 am to 10 p.m. She personally was in the building until 8 pm, most nights and many nights there was also an RN available for review. The DNS stated she LVN B was the admitting nurse so her completing the baseline care plan automatically triggered initiation of the comprehensive care plan, also by LVN B. She stated that was how the charge nurses were trained. The DNS stated the DON was responsible for ensuring nursing scope of practice was followed. During an interview on 12/03/2025 at 4:56 p.m., the new DON stated he had been the DON since last week and was not under the direction of DNS. He stated the DNS was still at the facility until he adjusted to the facility and learned the corporate ways. He stated he was the one communicating in morning meetings and the DNS was acting as his support person from the clinical aspect who also happened to be the previous DON/interim Director. The new DON stated he expected the LVN charge nurse to complete a full assessment upon admission, lock it and then he would review it, usually within 48-72 hours. He stated he was aware of all new admission residents, and he knew who is coming in to the facility. He stated in addition; he reviewed PCC daily. He stated it had been corrected (after surveyor intervention). He stated he ensured everything was transferred over from the initial assessment/baseline care plan to the comprehensive care plan. He stated this was important for the care of the resident. Record review of LVN B Licensed Nurse Competencies Checklist dated 6/12/2025 revealed: Admissions/Re-admissions: completion of nursing admission UDA (assessment) and initial plan of care upon admission was a category that was marked as successfully completed. Record review of LVN B nursing license revealed she held a current Licensed Vocational Nursing license in the state of Texas. Record review of the Texas Board of Nursing LVN Scope of Practice revealed: Board Rule 217.11(1)(A): Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. (i) collecting data and performing focuses nursing assessments. Assessment: the LVN collects data and information, recognizes changes in conditions and reports this to the RN supervisor or another appropriate clinical supervisor to assist in the identification of problems and formulation of goals, outcomes and patient centered plans of care that are developed in collaboration with the patients, their families and the interdisciplinary health care team. The LVN cannot perform independent assessments as the LVN has a directed scope of practice under supervision. The RN is responsible for overall coordination of care and performs comprehensive assessments, initiates the nursing care plan and implements and evaluates care of the client or patient.

Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident and determined that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 4 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1's Lantus (insulin glargine- a long-acting insulin) was administered on 11/28/2025. This failure could place the residents at risk of hyperglycemia (elevated blood glucose levels) and poorly controlled diabetes. The findings included: Record review of Resident #1's face sheet dated 12/02/2025 revealed an admission date of 11/28/2025 with diagnosis which included: acute on chronic combines systolic congestive and diastolic heart failure (heart failure where both sides of the heart are compromised), type 2 diabetes mellitus without complications and primary open-angle glaucoma bilateral stage unspecified (symptomless vision loss due to elevated eye pressure when then eye drainage system fails). Record review of Resident #1's MDS assessments revealed she did not have a comprehensive assessment due to new admission status. Record review of Resident #1's baseline care plan dated 11/28/2025 revealed she had diabetes with an intervention to administer medications as recommended by her doctor. Record review of Resident #1's Order Summary Report revealed a physician order dated 11/28/2025 for Lantus Solostar subcutaneous (under skin into fat) solution pen-injector 100 unit/m. (insulin glargine), inject 35 units subcutaneously at bedtime for hyperglycemia (elevated blood sugar), hold if blood sugar under 60. Record review of Resident #1's November 2025 MAR revealed Lantus Solostar subcutaneous solution pen-injector 100/unit/ml (insulin glargine), inject 35 units subcutaneously at bedtime for hyperglycemia was documented as given by LVN A at bedtime on 11/28/2025. During an observation and interview on 12/02/2025 at 3:05 p.m. Resident #1 was observed in her room and was aware, alert and conversational. She stated she had been in the facility a few days. She stated she had a few rough days but things had started to improve. She stated she had diabetes that was controlled with shots she took before bed each night. She stated she did not think she got her insulin the first night she was at the facility although she had gotten it every night sense them. She stated she had no noticeable effects from not receiving her medication and had not felt ill. She stated she did tell staff, but she was not sure who she told or when. During an interview on 12/02/2025 at 4:42 p.m., LVN A stated she did not give Resident #1 Lantus subcutaneous injection on 11/28/2025 because the resident was a new admission and she assumed the medication had not yet arrived from the pharmacy. She stated she did provide an accuchecks that was documented. She stated she documented administration of Lantus inadvertently when she only meant to document that she had completed the accuchecks. LVN A stated Lantus (insulin glargine) was available in the facility emergency medication e-kit. She stated she did not access the e-kit to give the Lantus. She stated she did not know why. During an interview on 12/03/2025 at 1:11 p.m. the DNS (Director of Nursing Services on facility records) that had been promoted but was still in the process of transitioning. She stated she was still providing oversite to the facility in an interim manner for a few more days. She stated her last day as DON was officially 11/21/2025 however she was remaining in the facility as interim DON until the new DON had completed training. She stated she was not sure when that would be. The DNS stated Lantus was available in the facility e-kit. She stated the e-kit was a large metal medication cart with a computerized log in and password. She stated the nurse had to type in the resident's name, choose the medication listed to have access to the medication in the e-kit. She stated this was based on the physician order for the medication that had been entered into PCC based upon admission. The DNS stated Resident #1 was a hospice respite admission from home. She stated the resident brought her home medication but was unsure what had happened. She stated on 12/02/2025 she discovered the Lantus had not been given as ordered on 11/28/2025 and spoke with LVN A who informed her she was not aware the family had brought the Lantus to the facility. The DNS stated LVN A should have accessed the e-kit if the Lantus was missing and administered the insulin to Resident #1. The DNS stated to administer insulin as ordered because the resident could have developed hyperglycemia. Record Review of the facilities policy titled Medication Administration dated January 2024 revealed: Resident medications are administered in an accurate, safe, timely, and sanity manner.6. Administer medication as ordered by the physician.

Based on interview and record review the facility failed to ensure medical records were maintained in accordance with accepted professional standards and practices for each resident, that were complete and accurately documented for 1 of 4 residents (Residents #1) reviewed for accuracy of medical records. The facility failed to ensure Resident #1's progress notes were documented accurately and according to professional standards of practice when LVN A documented she administered Lantus (insulin glargine-a long-acting insulin) on 11/28/2025 when she did not. This deficient practice could place residents at risk for errors in care and treatment and inaccuracies in documentation. The findings include:Record review of Resident #1's face sheet dated 12/02/2025 revealed an admission date of 11/28/2025 with diagnosis which included: acute on chronic combines systolic congestive and diastolic heart failure (heart failure where both sides of the heart are compromised), type 2 diabetes mellitus without complications and primary open-angle glaucoma bilateral stage unspecified (symptomless vision loss due to elevated eye pressure when then eye drainage system fails). Record review of Resident #1's MDS assessments revealed she did not have a comprehensive assessment due to new admission status. Record review of Resident #1's baseline care plan dated 11/28/2025 revealed she had diabetes with an intervention to administer medications as recommended by her doctor. Record review of Resident #1's Order Summary Report revealed a physician order dated 11/28/2025 for Lantus Solostar subcutaneous (under skin into fat) solution pen-injector 100 unit/m. (insulin glargine), inject 35 units subcutaneously at bedtime for hyperglycemia (elevated blood sugar), hold if blood sugar under 60. Record review of Resident #1's November 2025 MAR revealed Lantus Solostar subcutaneous solution pen-injector 100/unit/ml (insulin glargine), inject 35 units subcutaneously at bedtime for hyperglycemia was documented as given by LVN A at bedtime on 11/28/2025. During an observation and interview on 12/02/2025 at 3:05 p.m. Resident #1 was observed in her room and was aware, alert and conversational. She stated she had been in the facility a few days. She stated she had a few rough days, but things had started to improve. She stated she had diabetes that was controlled with shots she took before bed each night. She stated she did not think she got her insulin the first night she was at the facility although she had gotten it every night sense them. She stated she had no noticeable effects from not receiving her medication and had not felt ill. She stated she did tell staff, but she was not sure who she told or when. During an interview on 12/02/2025 at 4:42 p.m., LVN A stated she did not give Resident #1 Lantus subcutaneous injection on 11/28/2025 because the resident was a new admission and she assumed the medication had not yet arrived from the pharmacy. She stated she did provide an accuchecks that was documented. She stated she documented administration of Lantus inadvertently when she only meant to document that she had completed the accuchecks. LVN A stated Lantus (insulin glargine) was available in the facility emergency medication e-kit. She stated she did not access the e-kit to give the Lantus. She stated she did not know why. During an interview on 12/03/2025 at 1:11 p.m., the DNS stated she was interim DON until the new DON finished training and orientation. She stated LVN A had informed her on 12/02/2025 she made an error in documentation and on 11/28/2025. She stated LVN A informed her she did not give Lantus to Resident #1 as documented. The DNS stated she it was important for staff to follow physician orders. She stated inaccurate documentation could lead others to believe that the medication had been administered when it was not. She stated documenting a med was given when it was not, did not meet the facilities expectations. Record review of a handwritten facility document (undated) indicated the facility did not have a policy for documentation or accuracy of documentation. Record Review of the facilities policy titled Medication Administration dated January 2024 revealed: Resident medications are administered in an accurate, safe, timely, and sanity manner. The policy did not address documentation of medication.

Based on interview and record review, the facility failed to collaborate with hospice representatives through effective communication for 1 of 2 residents (Resident #1) reviewed for hospice services.The facility failed to collaborate with hospice upon Resident #1 admission on [DATE] to ensure the resident received three glaucoma medications she was taking at home and were detailed on her preadmission home health pre-admission paperwork.This deficient practice could place residents who receive hospice services at risk of receiving inadequate care due to a lack coordination of care, and communication of resident needs and could lead in complications of eyesight. The Findings included: Record review of Resident #1's face sheet dated 12/02/2025 revealed an admission date of 11/28/2025 with diagnosis which included: acute on chronic combines systolic congestive and diastolic heart failure (heart failure where both sides of the heart are compromised), type 2 diabetes mellitus without complications and primary open-angle glaucoma bilateral stage unspecified (symptomless vision loss due to elevated eye pressure when then eye drainage system fails). Record review of Resident #1's MDS assessments revealed she did not have a comprehensive assessment due to new admission status. Record review of Resident #1's baseline care plan dated 11/28/2025 revealed the resident was a hospice respite patient. The section of the checklist care plan for vision impairment was not marked and was blank. Record review of Resident #1's Home Health Care IDG Meeting Review notes uploaded into the resident's medical record prior to her admission by the Admissions Coordinator and dated 11/18/2025 revealed a medication reconciliation list which included:1.Lantanoprost (PF) o.005% eye drops, I drop both eyes at hour of sleep for glaucoma effective 9/29/20252. brimonidine 0.2% eye drops, one drops both eyes two times daily for glaucoma effective 9/29/2025.3. Cospoft (PF) 2%-0.5% eye drops 2 drops two times daily in both eyes for glaucoma effective 9/29/2025. Record review of Resident #1's handwritten hospice orders dated 11/28/2025 (date of facility admission) did not include any of the three glaucoma eye drops. The order was signed by the hospice RN and an unknown facility staff member. Record review of Resident #1's Order Summary Report dated 12/02/2025 revealed: 1. Cospopt PF ophthalmic solution 2-0.5%, instill one drop in both eyes two times a day for glaucoma had an order and start date of 12/01/2025. 2. Brimonidine Tartrate ophthalmic solution 0.2%, instill one drop in both eyes, two times a day for glaucoma had an order and start date of 12/01/2025. 3. Latanoprost PF ophthalmic solution 0.005%, instill one drop in both eyes at bedtime for glaucoma had an order and start date of 12/01/2025. Record review of Resident #1's November 2025 MAR's revealed she did not receive any of the three-glaucoma eye drop medications on 11/28/2025, 11/29/20205, or 11/30/2025. Record review of Resident #1's December 2025 MAR revealed she received her first dose of all three-glaucoma eye drops on 12/01/2025 in the morning. During an observation and interview on 12/02/2025 at 3:05 p.m., Resident #2 was observed in bed, with her walker nearby. She was awake, alert, and conversational. She stated she had been in the facility for several days. She stated she had a rough start. She stated she had glaucoma and took three different medications to treat it. She stated she had the medications in her purse since arrival at the facility and had told the staff about it. She stated yesterday in the evening, she told a male nurse (unknown) and he took the medications from her and said he needed to talk to her doctor about them. She stated she thought she would get the medications that night, but she did not. She stated she did receive them yesterday. Resident #1 stated she did not notice any change in her vision from not receiving her eye drops. She stated she was able to get up by herself and use her walker to without assistance. During an interview on 12/02/2025 at 4:02 p.m., LVN B stated Resident #1 was a new admission on [DATE] at approx. 2:00 p.m. She stated she was not prepared for the admission. She stated she did not receive a report, and the resident did not have any paperwork with her. She stated Resident #1 came with medications in a little bag, some were over the counter and some were prescriptions. LVN B stated the admission Coordinator told her she was getting a new admission approximately one hour prior to Resident #1 arriving. LVN B stated she was told Resident #1 was a respite hospice patient. She stated the Admissions Coordinator told her the hospice nurse would come to the facility to do her admission. LVN B stated the hospice nurse did not arrive until near the end of the shift at approximately 4 pm. LVN B stated the hospice nurse wrote orders for medications from the hospice physician. LVN B stated she then called the facility NP just to notify them that the patient had arrived but not to reconcile medications. She stated she informed the NP that the hospice nurse wrote orders for medications, and she told her it was okay to accept those orders. LVN B stated she did have access to the medical records including the home health notes under miscellaneous in Resident #1's medical records or use the medication reconciliation against hospice medication orders. She stated she did not look under miscellaneous for them. She just asked the Admissions Coordinator what to do and she was told the hospice nurse would handle it. LVN B stated she was the admitting nurse. She completed an assessment. She stated she asked Resident #1 if she had any vision issues or if she wore glasses and she had said no, that was why she left the care plan blank and she did not consult with family for additional information. During an interview on 12/03/2025 at 11:20 p.m., the Admissions Coordinator stated when she received a referral for care when the resident was coming from home, she would let the people who inquired know she needed medical records from primary care, from home health or from hospice. She stated this information was then sent to the DON for approval. She stated once the approval processes were completed the admitting documents are already uploaded into the medical record. When the admitting nurse admits the resident, the documentation is already there, including the medication list under miscellaneous. The Admissions Coordinator stated she notifies the charge nurse of the admission, she stated she could not say for certain who it was, most likely LVN B. She stated the nurse did not ask any questions or express any concerns when she told them about Resident #1's pending admission. She stated LVN B did not ask for the documentation or medication list from her because she already knew it was in the computer. During an interview on 12/03/2025 at 12:08 p.m., the Hospice RN stated she was the nurse who came to the facility to admit Resident #1. She stated she asked the nurse (LVN B) for any medications the family had brought in. The Hospice Nurse stated she used the medications given to her by LVN B to write orders for the facility for the medications. The Hospice RN stated she did have access to the medication list of the medications Resident #1 used at home but did not review the list when writing the orders. She stated she relied on the charge nurse (LVN B) to provide her with the information. The Hospice RN stated if the family did not provide all the medications in physical form she would have missed those medications when writing orders. She stated she was unable to review the medications or orders written from hospice at the time of the interview. During an interview 12/03/2025 at 12:15 p.m., several members of Resident #1's family stated they were upset Resident #1 did not receive her glaucoma eye medication for several days. They stated the eye drops were given to facility staff upon admission in the bag with the rest of her medication. They stated they were told by the resident and staff (unknown name) that the eye drops were found in the basket of Resident #1's walker. During an interview on 12/03/2025 at 1:11 p.m. the DNS (Director of Nursing Services on facility records) that had been promoted but was still in the process of transitioning. She stated she was still providing oversite to the facility in an interim manner for a few more days. She stated her last day as DON was officially 11/21/2025 however she was remaining in the facility as interim DON until the new DON had completed training. She stated she was not sure when that would be. The DNS stated she learned there was a concern for Resident #1's medication on 12/01/2025. She stated Resident #1 stated she had not gotten her eye drops. The DNS stated she told the resident she needed to check her orders. She stated they did not see any orders for them. She then got the hospice orders, and they were not there. The DNS stated she then went back to Resident #1 for more information. She stated Resident #1 told her there were three medications. She did not know the names of the medications but could remember the first letter of each one. The DNS stated she asked the resident if she had given the medications to the nurse and she said no, they are right here. The DNS stated she opened her walker (basket) and they were sitting right there. She stated she asked Resident #1 if she could take them and call hospice so they could start administering them. The DNS stated she called hospice, got a verbal order and then told Resident #1 they would start administering the eye drops. She stated she also notified the family about the eye drops and they did not express any concerns. The DNS stated the facility did not go by the medication reconciliation list provided by hospice home health because it was uploaded/dated 11/20/2025 and the resident was not a patient here at that time. She stated they go by what orders the hospice company (hospice RN) writes. The DNS stated the hospice RN was responsible for calling and verifying with her hospice company/physician. She stated what the hospice company writes proceeds anything written prior to it. The DNS stated they were coordinating services with the hospice company ensuring the hospice nurses come in and greet the patient, goes over their home meds with them, then comes to our nurse with their orders. She stated the hospice nurses' orders are the ones they follow. The DNS stated her admitting nurse and the facility nurses had no responsibility to review the med reconciliation list. She stated they do not refer to that. She stated their responsibility was what was in front of them. She stated the purpose of the medication reconciliation list was to refer to if they had questions. During an interview on 12/03/2025 at 4:56 p.m., the new DON stated he had been the DON since last week and was not under the direction of DNS. He stated the DNS was still at the facility until he adjusted to the facility and learned the corporate ways. He stated he was the one communicating in morning meetings and the DNS was acting as his support person from the clinical aspect who also happened to be the previous DON/interim Director. He stated the facility coordinated care with hospice ensuring the Admissions Coordinator coordinated the admission. He stated the admission was communicated on PCC dashboard that a patient was coming and what room they were assigned. The new DON stated that after the patient arrived, the nurse should greet them and settling them into their new home. He stated the hospice nurse reconciles medications with the charge nurse. He stated they obtain all the medications with the patient and write out the orders. The hospice nurse reviews them with the facility nurse quickly and the facility nurse was responsible for putting the orders into PCC. The new DON stated the facility nurse did not have any responsibility for review of information provided prior to admission including a list of medications taken at home. He stated this was extra information, in case something was missing and was meant more for the leadership team. He stated members of the IDT team including himself found the missing medication, added it to the orders and she was given her eye drops the same day. The new DON stated he sent the DNS to talk to Resident #1 and address any concerns she had, and she was happy. He stated the facility found Resident #1 had the medications on her walker. The new DON stated no one from the IDT team or management had reviewed Resident #1's medications on the date of her admission. He stated it was hospices responsibility to review the reconciliation list, write an order and give it to the facility charge nurse. He stated it is them the facilities responsibility to assume care. He stated when a resident comes from the hospital the nurses review their paperwork. He stated the difference with an admission when it is hospice is that hospice is doing the admitting, not the facility. Record review of a contract between the hospice company and facility referred to as Center in the contract dated 10/23/2019 revealed: 5.6 Cooperation with Hospice Staff: Center (facility) shall cooperate with Hospice staff members in carrying out each patients POC (plan of care).Section 6 Mutual Rights, Duties, and Obligations of the Parties 8.1 Development and Implementation of Plan of Care. When a Center resident is authorized by Hospice for admission program, or when the Center admits a Hospice patient to the Center. Hospice and Center shall jointly develop and agree upon the patients POC. Hospice shall retain overall professional management of and responsibility for directing the implementation of each patient's plan of care. Center shall be responsible for implementing those portions for the patient's plan of care that qualify as room and board services, inpatient services or respite services. Record review of the facilities policy titled End of Life Care and Coordination-Hospice/Palliative Care dated January 2023 revealed: 1. Physician orders should be obtained to clarify specific treatments, procedures and activity. 2. The resident and family should participate in developing the plan of care, where appropriate.

Based on interviews and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 5 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded on his Quarterly MDS assessment, signed as completed on 11/03/2025, for a fall without injury that occurred on 10/07/2025. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: Record review of Resident #1's admission Record, dated 11/07/2025, reflected a [AGE] year-old male. He was admitted on [DATE]. Resident #1 was noted to be on hospice. Record review of Resident #1's Medical Diagnosis tab on the EMR, undated and accessed 11/07/2025 at 04:02 p.m., revealed diagnoses included malignant neoplasm (cancerous tumor) of unspecified kidney, muscle wasting and atrophy (shrinking of muscle or nerve tissue), and anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder. Record review of facility Risk Management document, titled #5651 Fall, dated 10/07/2025 at 09:00 a.m., revealed LPN A completed the report. Resident #1 was noted to have had a fall in his room. LPN A described the incident as REACHED FOR A BLANKET ON THE FLOOR, AND ROLED OUT OF THE BED. No injuries were observed at the time of the incident. Resident #1's pain was noted at a level of 3, no range noted, and he was noted as alert. No injuries were noted to have been observed post incident. The physician, the DON, and the responsible parting were noted to have been notified on 10/07/2025 between 09:00 a.m. to 09:19 a.m. Under notes, intervention was noted as add bed Bolsters. Record review of Resident #1's Progress Notes, dated 11/07/2025 for date range 10/07/2025 to 10/10/2025, reflected:- a SNF Follow UP note, dated 10/07/2025 at 08:00 a.m. and signed 10/08/2025 at 10:14 a.m. by MD B, ***Chief Complaint*** Pain after fall from bed ***Hospital Course*** Patient experienced a fall from bed earlier this morning without head strike, now with leg and back pain. Nursing staff at bedside confirmed no head injury. Hospice nurse has been consulted and will adjust pain medications. Labs and vitals were reviewed. Plan is to continue current care. ***History of Present Illness*** [Resident #1], [AGE] years old male, was seen lying in bed, complaining of pain in his legs and back after he fell out of his bed earlier this morning. Discussion with the nurse at the bedside confirmed that the resident did not hit his head during the fall.During his last visit on 9/17/2025, he reported uncontrolled pain.***Care Coordination***Discussed fall and current symptoms with bedside nurse. Hospice nurse consulted to adjust pain medications. Labs and vitals reviewed; plan to continue current care.- a Nursing Progress Note, dated 10/07/2025 at 08:56 a.m. by LPN A, CALLED TO PT'S ROOM, HE IS ON THE FLOOR, SAID HE WAS REACHING FOR A BLANKET ON THE FLOOR AND ROLLED OUT OF THE BED ONTO THE FLOOR ON HIS LEFT SIDE, NO OBVIOUS INJUIRES NOTED, .RESIDENT PLACED BACK IN THE BED, RESIDENT HAS CHRONIC MOSTLY UNDETERMINED PAIN, AND ANXIETY. Record review of Resident #1's MDS tab on the EMR, undated and accessed 11/07/2025 at 04:09 p.m., revealed Resident #1's last two MDS assessments were a quarterly MDS assessment on 09/15/2025 and 10/27/2025. Record review of Resident #1's Quarterly MDS Assessment, dated 10/27/2025 and signed as completed on 11/03/2025 by the RNAC, reflected assessment observation end date of 10/27/2025. Resident #1 had a BIMS score of 15 indicating he was cognitively intact. Under Any Falls Since Admission/Entry or Reentry or Prior Assessment, Resident #1 was coded as having not had a fall since admission/entry or reentry or the prior assessment. The section for fall history was noted to have been signed as completed by the RNAC. Record review of Resident #1's comprehensive care plan, dated as last care plan review completed 09/09/2025, reflected I am at risk for falls r/t: .10/7/25, date initiated and created 08/16/2025 and revised on 11/07/2025. Interventions included 10/7/25: Fall Risk: *Bolster / Scoop Mattress for safe boundaries to minimize risk for rolling out of bed., date initiated, created, and revised 10/07/2025. During an observation and interview on 11/07/2025 at 01:21 p.m., Resident #1 was observed lying on bed with an air mattress with bolsters and his call light in reach. Resident #1 stated he had a fall at the facility. He stated he slipped out of bed but did not get hurt. He stated he did not need to be sent out to the hospital. During an interview on 11/10/2025 at 02:59 p.m., the RNAC stated the procedure for her knowing if a resident had a fall was to attend the interdisciplinary team meetings in the morning and to review the risk management reports. She stated a resident having had a miscoded fall history on his MDS assessment would not impact his care if the fall was care-planned with appropriate interventions. She stated for Resident #1, she coded there was no falls, but he did have a fall according to a risk management report. She stated this error would not have impacted Resident #1's care because the staff provide care according to the resident's care plan. During an interview on 11/10/2025 at 04:30 p.m., the DON stated a documentation error on the fall history of a MDS assessment would not impact a resident's care if the interventions for the fall was care-planned. During an interview on 05/16/2025 at 04:46 p.m., the ADMIN stated there would be no impact on a resident's care if the MDS assessment's fall history was incorrect, if the care plan was accurate. She stated if the care plan was accurate, the team providing direct care to the resident would be aware of the interventions enacted following the fall. Record review of the facility's policy, Comprehensive Assessments, dated revised March 2023, reflected: .Accuracy of AssessmentEach resident receives an accurate team member assessment of relevant care areas that provide teammembers [sic] with knowledge of each resident's status, needs, strengths, and areas of decline.CertificationA registered nurse signs and certifies that the assessment is completed. Everyone who completes aportion [sic] of the assessment also signs and certifies the accuracy of that portion of the assessment. MDS information is the clinical basis for each resident's care planning and delivery. Each individual assessor is responsible for certifying the accuracy of responses on the forms relative to the resident'scondition [sic] and discharge or reentry status.

ased on interview and record review, the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 2 of 8 residents (Resident # 2 and Resident # 6) reviewed for abuse and neglect.The facility did not provide evidence of a thorough investigation, including interviews with residents in the unit where Resident #2 resided, following a family member's allegation of neglect to the Admin on 8/7/2025. The facility did not provide evidence of a thorough investigation, including interviews with residents in the unit where Resident #6 resided, following a family member's allegation of abuse to the Admin. on 8/1/2025. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm.The findings included:1. Record review of Resident # 2's face sheet, dated 10/02/25, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: Major depressive disorder ( is a mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities previously enjoyed), Chronic heart failure (a condition in which the heart does not pump blood as well as it should), and Kidney disease (when the kidneys are damaged and cant filter, waste, fluids and toxins from the body). Record review of Resident #2's admission MDS assessment, dated 07/24/2025, revealed the resident's BIMS score was 01, which indicated severe cognitive impairment.Record review of the facility investigation file titled [Resident #2] revealed a document titled Provider Investigation Report (Form 3613-A) dated 8/07/2025. The 3613-A reflected Resident #2's family member alleged Resident #2 had been neglected by the facility because the family member observed the resident wearing a brief soiled with urine when she would visit. The Form 3613-A described the investigation of the allegation did not include a physical assessment of Resident #2 due to discharged status, but included team member and resident interviews, and a record review. The form also reflected the following:After a thorough investigation, findings were unfounded. Resident with no new skin issues noted. Questionnaires revealed no negative findings.Further record review of the facility investigation file reflected 16 questionnaires dated 8/07/2025. The questionnaires included questions regarding abuse and neglect asked of residents performed on the 300 and 400 resident halls. In an interview with the Admin. on 10/3/2025 at 9:50 AM, she stated Resident #2 resided on 500 hall immediately prior to discharge. She said the facility's investigation of the abuse allegation included resident and staff safe surveys. She said that the facility received multiple allegations of abuse/neglect within several days, so the resident surveys on the 300 and 400 halls were used to determine safety of all residents within the facility. She said residents on the 500 hall were not surveyed during the investigation of the allegation of neglect of Resident #2. She said the determination of unit safety was also made through daily, routine angel care rounds performed by staff every morning. 2. Record review of Resident #6's face sheet dated 9/30/2025 revealed an [AGE] year-old male admitted to the facility on [DATE] and discharged on 8/07/2025. Relevant diagnoses included cognitive communication deficit and unspecified dementia (a progressive neurological disorder that affects cognition and memory). Record review of Resident #6's quarterly MDS reflected a BIMS score of 02, which indicated severely impaired cognition. Record review of the facility investigation file titled [Resident #6] revealed a document titled Provider Investigation Report (Form 3613-A) dated 8/1/2025. The 3613-A reflected Resident #6's family member alleged Resident #6 had been physically assaulted by a shoe, resulting in a facial injury. The Form 3613-A described the investigation of the allegation included a physical assessment of Resident #6, resident and team member abuse and neglect questionnaires, and of review of video footage. Further record review of the facility investigation file reflected 16 questionnaires dated 8/07/2025. The questionnaires included questions regarding abuse and neglect asked of residents performed on the 300 and 400 resident halls. In an interview with the Admin. on 10/3/2025 at 9:50 AM, she stated Resident #6 resided on the memory care/600 hall during his admission. She said the facility's investigation of the abuse allegation included a physical assessment of Resident #6, resident and staff safe surveys, and an interview with the resident and his family member. She said the investigation did not include abuse/neglect surveys on residents of the memory care unit because she felt they could not participate in the surveys due to cognitive decline, and the residents would not be able to respond. She said physical assessments in place of verbal surveys were not performed as part of the investigation. She said her interviews of the staff did not reveal findings that any residents on the memory care unit were exhibiting behaviors that deviated from their baseline status, so she felt that was sufficient evidence that all residents on the memory care unit were safe. She said the determination of unit safety was also made through daily, routine angel care rounds performed by staff every morning. In an e-mail dated 10/3/2025 at 2:22 PM, the Admin. sent a message informing the survey team that resident surveys had been located after the survey team exited, and the documents had been secured in the admission Coordinator's office. Record review of the attached file reflected 5 resident interview questionnaires dated 8/8/2025. The resident room numbers were not documented on the questionnaires, and the survey team could not verify the room assignment of the residents 8/8/2025 as the documents were provided after survey exit. Record review of the facility policy titled Abuse Guidance: Preventing, Identifying and Reporting revised 1/2024, revealed the following: Investigation should include, but is not limited to:Conducting observations of the alleged victim, including identification of any injuries as appropriate. Monitoring of the alleged victim and other residents at risk, such as conducting unannounced management visits at different times and shifts .Interactions and relationships between staff and the alleged victim and/or other residents, interactions/relations between resident to other residents.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of 1 of 5 residents (Resident #4) reviewed for pharmacy services. The facility failed to ensure Resident #4's PRN Tramadol (a pain medication) orders included the necessary indications for administration. These failures could lead to mismanagement of a resident's pain or unintended sedation. Findings included:Record review of Resident #4's face sheet dated 9/30/2025 revealed a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included dementia (a progressive disorder affecting memory and cognition) and muscle weakness. Record review of Resident #4's admission MDS submitted 9/12/2025 reflected a BIMS score of 04, indicating severely impaired cognition. Record review of Resident #4's Order Summary Report dated 9/30/2025 revealed the following:Tramadol HCl tablet 50mg, give 1 tablet by mouth every 6 hours as needed for pain (order date 9/05/2025)Tramadol HCl tablet 50mg, give 2 tablet [sic] by mouth every 6 hours as needed for pain (order date 9/05/2025)Record review of Resident #4's Care Plan Report printed 9/30/2025 revealed the following:[Focus] Baseline / Initial Care Plan: I may be at risk for: self-care deficit, falls, skin concerns, pain, infection & nutritional/hydration concerns and emotional distress {sic} [Intervention] PAIN RISK: Monitoring on-going for pain or discomfort. Provide nonpharmacological interventions to relieve pain/discomfort such as repositioning, back rub, relaxation and [etcetera]. Administer pain medications as indicated. Report pain concerns to [the provider] as indicated. (date initiated 9/17/2025)Record review of Resident #4's September 2025 MAR revealed the following:Tramadol HCl tablet 50mg, give 1 tablet by mouth every 6 hours as needed for pain (order date 9/05/2025)10/11/2025 at 6:44 PM for pain level 410/12/2025 at 2:47 PM for pain level 410/17/2025 at 12:01 PM for pain level 410/17/2025 at 7:22 PM, no documented pain level10/20/2025 at 10:35 AM for pain level 610/26/2025 at 7:01 PM for pain level 510/27/2025 at 8:33 PM for pain level 5Tramadol HCl tablet 50mg, give 2 tablet [sic] by mouth every 6 hours as needed for pain (order date 9/05/2025)Not administeredResident #4 was unable to participate in an attempted interview on 9/30/2025 at 2:08 PM due to cognitive decline and confusion. In an interview on 10/1/2025 at 10:00 AM, LVN D said she administered Tramadol 50mg 1 tablet when Resident #4 complained of pain. She said she would then reassess him in an hour and if the pain had not resolved or was worse, she would administer another tablet of Tramadol 50mg after calling the provider to obtain a one-time order. She was unsure under which circumstances she would administer Tramadol 50mg 2 tablets to Resident #4. She said she had seen other residents' PRN pain medications contained specific parameters for administration, but she was not sure why Resident #4's orders did not. LVN D said the potential harm to a resident receiving PRN pain medications without specific parameters was intoxication or sedation. In an interview on 10/1/2025 at 10:00 AM, the DON said that nursing staff were taught by the facility to administer a lower dose of PRN pain medication for mild pain and a higher dose of medication for severe pain. She said the medication order should clarify which dosage of the medication to administer for the level of pain. In an interview on 10/2/2025 at 10:34 AM, the RPh said the inclusion of a pain scale parameter on the two PRN Tramadol orders would be considered best practice and appropriate to ensure management of Resident #4's pain. He said it was unlikely Resident #4 would receive too much Tramadol because nurses are trained to question duplicate administration of medications. He said he had audited Resident #4's medication regimen in September 2025, but he had not focused on the PRN pain medication. In an interview on 10/2/2025 at 10:40 AM, the MD clarified the order should have been transcribed to include pain level of 1-4 out of 10 for 1 tablet of Tramadol 50mg, and pain level of 5-10 for 2 tablets of Tramadol 50mg. He reported no concerns with the care provided to the resident by the facility. Record review of the facility policy titled Pain Management revised 1/2025, revealed the following: The Licensed Nurse, when administering; scheduled, routine, or PRN pain medications, should monitor the effectiveness of the intervention i.e. pain medication, post administration and if not effective follow physician's orders and/or notify the prescriber.

Based on interview and record review, the facility failed to maintain clinical records on each resident, in accordance with accepted professional health information management standards and practices, that are: complete, and accurately documented for 1 (Resident #3) of 15 residents reviewed for clinical records, in that:Resident #3's clinical record contained inaccurate information.This deficient practice could cause miscommunication among the resident's caregivers and result in improper care.The findings were: Record review of Resident #3's facesheet, dated 10/03/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Muscle Wasting and Atrophy, Essential Primary Hypertension, and Cerebral Infarction. Record review of Resident #3's comprehensive MDS, dated [DATE], revealed a BIMS score of 2 which indicated severe cognitive impairment. Record review of Resident #3's clinical progress notes revealed a provider note, dated 08/15/2025, .eyes did appear to be mildly red, no discharge noted. He was started on erythromycin 3 times a day for 5 days. Apply warm compresses as needed. Further review revealed a provider note, dated 08/22/2025, .mild redness in both eyes. Further review revealed a provider note, dated 08/26/2025, . treated for bilateral conjunctivitis with erythromycin showing improvement.Review of Resident #3's list of medical diagnoses, as of 10/03/2025, revealed conjunctivitis was not listed and review of Resident #3's physician orders and medication administration record revealed the medication erythromycin was never ordered nor administered to the resident. During an interview on 10/03/2025 at 10:50 a.m. with the DON and the NP, both stated they did not recall Resident #3 ever experiencing redness in his eyes. The NP stated she recalled the resident very well and that the documentation regarding conjunctivitis was entered into Resident #3 clinical record in error.Record review of the facility policy, Medical Records, revised January 2023, revealed, A medical record is maintained for every person admitted to a community in accordance with accepted professional standards and practices.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #4) reviewed for infection control. The facility failed to properly implement enhanced barrier precautions for Resident #4. This failure could result in the spread of infection or illness.Findings included:Record review of Resident #4's face sheet dated 9/30/2025 revealed a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included dementia (a progressive disorder affecting memory and cognition) and muscle weakness. Record review of Resident #4's admission MDS submitted 9/12/2025 reflected a BIMS score of 04, indicating severely impaired cognition. Record review of Resident #4's Order Summary Report dated 9/30/2025 revealed the following:EBP (Enhanced barrier precautions): Practice EBP as indicated: every shift (order date 9/17/2025)WC: Cleanse with normal saline and pat dry with gauze. Apply Bacitracin ointment to sutures and cover with dry dressing day and prn, as needed for if soiled or missing [sic] (order date 9/17/2025)Record review of Resident #4's Care Plan Report printed 9/30/2025 revealed the following:[Focus] At risk for infection or recurrent/chronic infection r/t compromised medical condition [intervention] Enhanced Barrier Precautions practices as clinically indicated [sic] (date initiated 9/17/2025)Record review of Resident #4's September 2025 TAR revealed the following:EBP (Enhanced Barrier Precautions): Practice EBP as indicated: every shift (start date 9/17/2025 [6:00 PM])Resident #4's September 2025 TAR was signed as completed for all shifts beginning 9/17/2025 night. Record review of Resident #4's October 2025 TAR, printed 10/1/2025, revealed the same order and was signed as completed on 10/1/2025 day by LVN D. No sign indicating EBP status or PPE cart were observed on the following dates/times:9/30/2025 at 2:08 PM10/1/2025 at 9:13 AMResident #4 was unable to participate in an attempted interview on 9/30/2025 at 2:08 PM due to cognitive decline and confusion. He was observed to have a wound on his forehead with multiple sutures. The wound did not have a dressing. In an interview on 9/30/2025 at 2:59 PM, CNA stated Resident #4 was not on any isolation precautions, including EBP. He said he would know if a resident required isolation precautions based on the electronic medical record or the signage on residents' doors. He said he was new to the facility but had training about infection prevention from the facility upon hire. In an interview on 10/1/2025 at 10:00 AM, LVN D said she did not think that Resident #4 required EBP. She said her initials as completed on a TAR order for EBP indicated the EBP precautions were implemented, including sign and PPE cart), and that she understood the resident was on EBP. She did not recall signing Resident #4's TAR for EBP on 10/1/2025. She was unsure why Resident #4 was on EBP. She said the potential harm to a resident of not having ordered isolation precautions implemented was the spread of infection. In an interview on 10/1/2025 at 10:00 AM, the DON said she did not think Resident #4 required EBP, but she would research the issue for clarity. In a subsequent interview on 10/3/2025 at 10:45 AM, the DON said Resident #4 should not have had an order for EBP because the wound did not have a dressing and was not severe enough to require EBP. She was unsure why the nursing staff had signed the TAR indicating Resident #4 was on EBP. She said she was acting as the interim infection preventionist, and she reviewed admission orders frequently to audit the initiation and discontinuation of isolation precautions. She said the potential harm to a resident who did not have proper isolation precautions implemented was infection. Record review of the facility policy titled Infection Prevention and Control revised 4/2024, revealed the following:Residents/patients with the following clinical indication should be under EBP open wounds requiring a dressing; excluding simple skin breaks or tears that are covered with an adhesive bandage (e.g., Band-aid) or similar dressing.

Based on observations, interview and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for three residents (Residents #2, #11 and #14) of thirty-two residents reviewed for MDS assessments. The Facility failed to note on Resident #2's admission MDS dated [DATE] he was taking a hypoglycemic medication. 2. The facility failed to ensure Resident #11's Quarterly MDS assessment was coded Not rated, resident had a catheter instead of Always incontinent for a resident identified to have a suprapubic catheter. 3. The facility failed to ensure Resident #14's quarterly MDS assessment was coded Yes regarding the resident was receiving antidepressant for his depression. These failures could place resident at risk for inadequate care due to inaccurate assessments.The findings included: 1.Record review of Resident #2’s electronic face sheet dated 07/23/2025 reflected he was a [AGE] year-old male who was admitted to the hospital facility on 05/28/2025. His diagnoses included: displaced fracture of the right femur (a broken thighbone where the broken pieces are out of alignment with each other), diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels), post-traumatic stress disorder (a mental health condition that develops after experiencing or witnessing a traumatic event) and alcoholic cirrhosis (scarring) of liver with ascites (fluid) (a severe liver condition where excessive alcohol consumption leads to scarring of the liver, and the accumulation of fluid in the abdominal cavity). Record review of Resident #2’s admission MDS assessment dated [DATE] reflected he could usually understand and usually be understood. He scored a six out of fifteen on his BIMS which indicated he was severely cognitively impaired. Resident #2 was noted on the assessment to have an active diagnosis of diabetes mellitus. He was noted to have received insulin injections for seven days. Under Section N0415 “High-Risk Drug Classes: Use and Indication”, he was not noted to be taking “J. Hypoglycemic (lowers blood sugar) (including insulin)”. Record review of Resident #2’s Comprehensive Care Plan revised date 07/17/2025 reflected “Focus, have diabetes, Interventions/Tasks, administer medications as ordered.” Record review of Resident #2’s “Active Orders as of: 07/24/2025” reflected Lantus Subcutaneous (applied under the skin) Solution (Insulin) inject ten units subcutaneously one time a day for diabetes mellitus start date of 05/25/25. During an interview on 07/25/2025 at 10:12 AM with the DOCR she acknowledged the high-risk medication insulin which was a hypoglycemic should have been noted on Resident #2’s admission MDS assessment. She stated it was important to have an accurate MDS assessment to ensure proper care is provided. During an interview on 07/25/2025 at 12:30 PM with the DON, she stated she did not realize the admission MDS assessment was not accurate for Resident #2. She stated the MDS assessments must accurately reflect the resident’s status to meet their care needs, or they might be missed. During an interview on 07/25/25 at 12:35 PM with the ADM, she stated she needed to audit the MDSs to ensure they are completed, submitted timely and were accurate. She had no explanation as to why Resident #2’s admission MDS assessment must be accurate to show the type of care he required, and he could miss needed care. 2. Record review of Resident #11’s face sheet dated 07/24/2025, revealed Resident #11 was admitted to the facility on [DATE] with a diagnosis that included: flaccid neuropathic bladder, not elsewhere classified (a condition where the bladder muscles are weak and cannot contract effectively to empty urine). Record review of Resident #11’s physician order summary dated 07/24/2025, revealed order dated 06/17/2024, Suprapubic catheter change on the 15th of the month. 18FR/10CC every night shift starting on the 15th and ending on the 16th every month related to FLACCID NEUROPATHIC BLADDER, NOT ELSEWHERE CLASSIFIED. Record review of Resident #11's Quarterly MDS assessment, dated 07/02/2025, revealed a BIMS score of 01 which indicated severely impaired cognition. The Quarterly MDS Assessment further revealed in Section H (Bladder and Bowel), it was coded Resident #11 had a indwelling catheter, however Always incontinent was coded in Section H0300-Urinary Continence. In section H0300 of the Quarterly MDS assessment if the resident had a urinary catheter (indwelling condom), Not rated should have been coded. Record review of Resident #11's care plan, last care plan review completed date of 07/13/2025, revealed Resident #11 had a focus of I require a suprapubic catheter r/t DX of Urinary retention r/t Prostate condition. During an observation and interview on 07/25/2025 at 10:00 a.m. the DOCR after reviewing Resident #11's Quarterly MDS assessment stated the MDS should have been coded not rated and had been coded incorrectly. The DOCR further stated the MDS coordinator was responsible for the accuracy of the MDS assessment and the new MDS coordinator had completed Resident #11's Quarterly MDS assessment dated [DATE]. The DOCR stated inaccurately coding the MDS assessments could affect the overall care of the resident. During an observation and interview on 07/25/2025 at 10:54 a.m. the MDS coordinator stated after reviewing Resident #11's Quarterly MDS assessment it had been miscoded in error and should have been coded not rated. The MDS coordinator further stated miscoding the MDS assessments could cause billing issues and did not feel it could cause any patient care issue with it being incorrectly coded. During an interview on 07/25/2025 at 11:12 a.m. the DON stated MDS assessment accuracy was the responsibility of the MDS coordinator. The DON further stated that by not accurately completing the MDS assessment she would assume it could affect the type of care. During an interview on 07/25/2025 at 2:34 p.m. the Administrator stated the MDS coordinator was responsible for the MDS accuracy. The Administrator stated by the MDS assessment not being accurate it could provide incorrect information. The Administrator further stated he did not feel in Resident #11's case there would be a potentially negative outcome as they relied on the care plan for care. 3. Record review of Resident #14’s face sheet, dated 07/25/2025, revealed the resident was [AGE] years old male and admitted to the facility on [DATE] with the diagnoses of muscle wasting and atrophy (loss of skeletal muscle mass), dementia (loss of memory and thinking ability), hypothyroidism (thyroid gland does not produce enough thyroid hormone), and depression (lowering of a person’s mood). Record review of Resident #14’s quarterly MDS assessment, dated 04/29/2025, revealed the resident’s BIMS score was 1 out of 15 indicating the resident had severe cognitive impairment and the resident required supervision or touching assistance (Helper provides verbal cues and/or touching assistance), such as sit to stand and chair to bed transfer. Further record review of the MDS assessment revealed regarding the question of “the resident was receiving antidepressant,” the answer was coded “No.” Record review of Resident #14’s comprehensive care plan, dated 09/14/2024, revealed “I [Resident #14] require anti-depressant medication targeted behaviors is insomnia, crying, anger, and fatigue. For intervention, administer medication per medical doctor orders.” Record review of Resident #14’s physician orders, dated 03/12/2025, revealed the resident had the order of “Mirtazapine oral tablet 7.5 mg (mirtazapine) Give 0.5 tablet by mouth at bedtime for depression to equal 3.75 mg.” Record review of Resident #14’s medication administration record, from 07/01/2025 to 07/31/2025, revealed the resident was receiving “Mirtazapine oral tablet 7.5 mg (mirtazapine) Give 0.5 tablet by mouth at bedtime for depression to equal 3.75 mg” at bedtime as ordered. During an interview on 07/25/2025 at 9:49 a.m. the MDS coordinator stated after reviewing Resident #14's quarterly MDS assessment it had been miscoded in error and should have been coded “Yes” because Resident #14 was receiving Mirtazapine for depression, and it was an anti-depressant. The MDS coordinator further stated miscoding the MDS assessments could cause billing issues, and it might affect some patient care, and it was the MDS coordinator’s responsibility for MDS accuracy. Record review of the CMS RAI Version MDS 3.0 Manual dated October 2024 revealed in part, .The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part of that assessment process and is required by CMS . CH 3: MDS Items [H] H0300: Urinary Continence: Coding instructions: Code 9, not rated: if during the 7-day look-back period, the resident had an indwelling bladder catheter . Record review of the facility policy and procedure titled “Comprehensive Assessments” date revised March 2023 reflected “Accuracy of Assessment, each resident receives an accurate team member assessment of relevant care areas that provide team members with knowledge of each resident’s status, needs, strengths, and areas of decline.” Record review of the CMS RAI Version MDS 3.0 Manual dated October 2024 revealed in part, .The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part of that assessment process and is required by CMS . CH 3: MDS Items [H] H0300: Urinary Continence: Coding instructions: Code 9, not rated: if during the 7-day look-back period, the resident had an indwelling bladder catheter . 3. Record review of Resident #14’s face sheet, dated 07/25/2025, revealed the resident was [AGE] years old male and admitted to the facility on [DATE] with the diagnoses of muscle wasting and atrophy (loss of skeletal muscle mass), dementia (loss of memory and thinking ability), hypothyroidism (thyroid gland does not produce enough thyroid hormone), and depression (lowering of a person’s mood). Record review of Resident #14’s quarterly MDS assessment, dated 04/29/2025, revealed the resident’s BIMS score was 1 out of 15 indicating the resident had severe cognitive impairment and the resident required supervision or touching assistance (Helper provides verbal cues and/or touching assistance), such as sit to stand and chair to bed transfer. Further record review of the MDS assessment revealed regarding the question of “the resident was receiving antidepressant,” the answer was coded “No.” Record review of Resident #14’s comprehensive care plan, dated 09/14/2024, revealed “I [Resident #14] require anti-depressant medication targeted behaviors is insomnia, crying, anger, and fatigue. For intervention, administer medication per medical doctor orders.” Record review of Resident #14’s physician orders, dated 03/12/2025, revealed the resident had the order of “Mirtazapine oral tablet 7.5 mg (mirtazapine) Give 0.5 tablet by mouth at bedtime for depression to equal 3.75 mg.” Record review of Resident #14’s medication administration record, from 07/01/2025 to 07/31/2025, revealed the resident was receiving “Mirtazapine oral tablet 7.5 mg (mirtazapine) Give 0.5 tablet by mouth at bedtime for depression to equal 3.75 mg” at bedtime as ordered. During an interview on 07/25/2025 at 9:49 a.m. the MDS coordinator stated after reviewing Resident #14's quarterly MDS assessment it had been miscoded in error and should have been coded “Yes” because Resident #14 was receiving Mirtazapine for depression, and it was an anti-depressant. The MDS coordinator further stated miscoding the MDS assessments could cause billing issues, and it might affect some patient care, and it was the MDS coordinator’s responsibility for MDS accuracy. Record review of the CMS RAI Version MDS 3.0 Manual dated October 2024 revealed in part, .The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part of that assessment process and is required by CMS . CH 3: MDS Items [H] H0300: Urinary Continence: Coding instructions: Code 9, not rated: if during the 7-day look-back period, the resident had an indwelling bladder catheter . Record review of the facility policy and procedure titled “Comprehensive Assessments” date revised March 2023 reflected “Accuracy of Assessment, each resident receives an accurate team member assessment of relevant care areas that provide team members with knowledge of each resident’s status, needs, strengths, and areas of decline.” 2. Record review of Resident #11’s face sheet dated 07/24/2025, revealed Resident #11 was admitted to the facility on [DATE] with a diagnosis that included: flaccid neuropathic bladder, not elsewhere classified (a condition where the bladder muscles are weak and cannot contract effectively to empty urine). Record review of Resident #11’s physician order summary dated 07/24/2025, revealed order dated 06/17/2024, Suprapubic catheter change on the 15th of the month. 18FR/10CC every night shift starting on the 15th and ending on the 16th every month related to FLACCID NEUROPATHIC BLADDER, NOT ELSEWHERE CLASSIFIED. Record review of Resident #11's Quarterly MDS assessment, dated 07/02/2025, revealed a BIMS score of 01 which indicated severely impaired cognition. The Quarterly MDS Assessment further revealed in Section H (Bladder and Bowel), it was coded Resident #11 had a indwelling catheter, however Always incontinent was coded in Section H0300-Urinary Continence. In section H0300 of the Quarterly MDS assessment if the resident had a urinary catheter (indwelling condom), Not rated should have been coded. Record review of Resident #11's care plan, last care plan review completed date of 07/13/2025, revealed Resident #11 had a focus of I require a suprapubic catheter r/t DX of Urinary retention r/t Prostate condition. During an observation and interview on 07/25/2025 at 10:00 a.m. the DOCR after reviewing Resident #11's Quarterly MDS assessment stated the MDS should have been coded not rated and had been coded incorrectly. The DOCR further stated the MDS coordinator was responsible for the accuracy of the MDS assessment and the new MDS coordinator had completed Resident #11's Quarterly MDS assessment dated [DATE]. The DOCR stated inaccurately coding the MDS assessments could affect the overall care of the resident. During an observation and interview on 07/25/2025 at 10:54 a.m. the MDS coordinator stated after reviewing Resident #11's Quarterly MDS assessment it had been miscoded in error and should have been coded not rated. The MDS coordinator further stated miscoding the MDS assessments could cause billing issues and did not feel it could cause any patient care issue with it being incorrectly coded. During an interview on 07/25/2025 at 11:12 a.m. the DON stated MDS assessment accuracy was the responsibility of the MDS coordinator. The DON further stated that by not accurately completing the MDS assessment she would assume it could affect the type of care. During an interview on 07/25/2025 at 2:34 p.m. the Administrator stated the MDS coordinator was responsible for the MDS accuracy. The Administrator stated by the MDS assessment not being accurate it could provide incorrect information. The Administrator further stated he did not feel in Resident #11's case there would be a potentially negative outcome as they relied on the care plan for care. Record review of the CMS RAI Version MDS 3.0 Manual dated October 2024 revealed in part, .The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part of that assessment process and is required by CMS . CH 3: MDS Items [H] H0300: Urinary Continence: Coding instructions: Code 9, not rated: if during the 7-day look-back period, the resident had an indwelling bladder catheter .

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 #98) of 28 residents, 1 of 1 medication rooms, and 1 (500-hall nursing cart) of 5 med carts reviewed for pharmacy services. 1. There were three antibiotic solutions (Imipenem and cilastatin) for Resident #98 to be given via intravenous route that expired 07/22/2025 found inside the facility medication room on 07/24/2025. 2. There was one super sani-cloth germicide disposable wipe that expired 05/2025 found inside the facility medication room on 07/24/2025. 3. There was one bottle of Senna-Plus 8.6 mg that expired 06/2025 found inside the 500-hall nurse cart on 07/24/2025. This failure could place residents at risk of not receiving appropriate therapeutic effects of medication. The findings included: Record review of Resident #98's face sheet, dated 07/25/2025, revealed the resident was an [AGE] year old female and admitted to the facility on [DATE] with diagnoses of sepsis (the body's extreme response to an infection), muscle weakness, type 2 diabetes mellitus (the body has trouble controlling blood sugar and using it for energy), urinary tract infection (bladder infection), and hypertension (high blood pressure). Record review of Resident #98's admission MDS assessment, dated 04/03/2025, revealed the resident's BIMS score was two out of fifteen indicating the resident had severe cognitive impairment. Record review of Resident #98's physician order, dated from 07/17/2025 to 07/18/2025, revealed the resident had the order of Imipenem-Cilastatin Intravenous solution reconstituted 500 mg. Use 500 mg intravenously four times a day for ESBL (extended spectrum beta-lactamase) of the urine for 7 days. Record review of Resident #98's medication administration record, from 07/01/2025 to 07/31/2025, revealed the resident was receiving Imipenem-Cilastatin Intravenous solution reconstituted 500 mg via intravenous route from 07/17/2025 as ordered, and it was discontinued on 07/18/2025. Observation on 07/24/2025 at 1:53 p.m. revealed the facility had only one medication room, and inside the medication room there were Resident #98's three Imipenem-Cilastatin Intravenous solutions reconstituted 500 mg, and the three solutions were all expired on 07/22/2025. During an interview on 07/24/2025 at 2:03 p.m. RN-E stated there were Resident #98's three Imipenem-Cilastatin Intravenous solutions reconstituted 500 mg inside the facility medication room, and the three solutions were all expired on 07/22/2025. RN-E said facility nurses did not use this medication because it was discontinued on 07/18/2025, did not know the reason the medication was still in the medication room, and all expired medications should have been removed from the medication room. 2. Observation on 07/24/2025 at 1:53 p.m. revealed there was one Super Sani-Cloth Germicide disposable wipe that expired on 05/2025 inside the medication room. During an interview on 07/24/2025 at 2:03 p.m. RN-E stated there was one Super Sani-Cloth Germicide disposable wipe that expired on 05/2025 inside the medication room. RN-E said facility nurses did not use this wipe, and did not know the reason this one was still in the medication room. 3. Observation on 07/24/2025 at 2:34 p.m. revealed there was one bottle of Senna-Plus 8.6 mg that expired on 06/2025 inside the 500-hall nurse cart. During an interview on 07/24/2025 at 2:34 p.m. LVN-F stated there was one bottle of Senna-Plus 8.6 mg that expired on 06/2025 inside the 500-hall nurse cart. LVN-F said the nurse did not use it, did not know the reason this one was still in the nurse cart, and all expired medications should have been removed from the cart. During an interview on 07/24/2025 at 2:35 p.m. the DON stated all expired medications should have been removed from the medication room and carts, and expired medications might not reach therapeutic effects, and the facility did not have specific policy regarding expired medications and wipes. Record review of the facility policy, titled Medication Administration, revised 03/2019, revealed . two. Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route.

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. 1. The facility failed to store plastic cups and bowls to allow for air-drying in the dish room.2. The facility failed to ensure all prepared items in the walk-in refrigerator was labeled and dated with use by date. These failures could place residents at risk for food borne illness.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. 1. The facility failed to store wet insulated plastic dome plate covers to allow for air-drying by the steam table.2. The facility failed to ensure all prepared items in the walk-in refrigerator were labeled and dated with the use by date. These failures could place residents at risk for food borne illness. The findings included: Observation of the facility's kitchen on 07/22/2025 at 9:03 AM revealed two stacks of wet insulated plastic dome plate covers, approximately fifteen in each stack, next to two stacks of dry insulated plastic dome plate covers by the steam table. The insulated plastic dome plate covers were stacked right side up on top of one another and did not allow airflow circulation. Observation of the facility's walk-in refrigerator on 07/23/2025 at 2 PM revealed three trays, each containing approximately thirty bowls of desserts, and four trays of prepared liquids were unlabeled. Observation of the facility's kitchen on 07/24/2025 at 11:00 AM revealed two stacks of wet insulated plastic dome plate covers, approximately fifteen in each stack, next to two stacks of dry insulated plastic dome plate covers by the steam table. The insulated plastic dome plate covers were stacked right side up on top of one another and did not allow airflow circulation. Interview with the Interim Dietary Manager on 07/25/2025 at 12:51 PM revealed he was filling in as the dietary manager since the previous manager quit and was learning this facility's kitchen and staff. The Interim Dietary Manager stated all open and prepared items being stored in the walk-in refrigerator needed to be labeled prior to being stored. The Interim Dietary manager stated it was the responsibility of all staff to ensure items in the walk-in refrigerator were labeled. The Interim Dietary Manager stated clean dishes were to be stored to allow air flow to allow drying. The Interim Dietary Manager stated all staff were responsible to ensure dishes were stored to allow proper air drying. The Interim Dietary Manager stated not properly drying and storing kitchen equipment and not labeling open or prepared items could cause food borne illness in the residents. During an interview with the Dietary Aide on 07/25/2025 at 1:54 PM she stated opened or prepared items in the walk-in refrigerator were to be labeled prior to being stored. The Dietary Aide stated dishes were to be stored to allow them to air dry. The Dietary Aide stated it was the responsibility of all staff to ensure opened or prepared items were labeled prior to being stored in the walk-in refrigerator. The Dietary Aide stated it was the responsibility of all staff to ensure dishes were stored to allow air flow to air dry. The Dietary Aide stated not labeling items stored in the walk-in refrigerator could cause staff to use old or expired foods and the residents could get sick. The Dietary Aide said if dishes were not dried before they were stored it could cause bacteria to grow causing residents to get sick. During an interview with the facility administrator on 07/25/2025 at 2:46 PM the Administrator stated all items opened or prepared being stored in the walk-in refrigerator were to be labeled with the use by date. The Administrator stated that it was the responsibility of all staff to ensure items were labeled. The Administrator stated by not labeling items in the walk-in refrigerator it could place the residents at risk of food borne illness. The Administrator stated clean dishes should be dried prior to being stored and by not doing so it could cause bacteria to grow on the dishes and potentially make the residents sick. The Administrator stated all staff were responsible to ensure dishes were dry before storing. Record review of facility policy named General Kitchen Sanitation, undated, revealed After cleaning and until use, store and manage all food-contact surfaces of equipment and multi-use utensils in a manner that protects the surfaces from manual contact, splash, dust, dirt, insects and other contaminants. Record review of facility policy named Food Storage, undated, revealed Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles.(B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 (Resident #32) of twenty-eight residents reviewed for environment, in that: Resident #32's room air conditioning vents were visibly soiled. This deficient practice could result in residents living in an unclean and unpleasant environment.The findings were: Record review of Resident #32's face sheet, dated 07/25/2025, revealed the resident was an [AGE] year old male, originally admitted on [DATE], and re-admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease (destroys memory and other important mental functions), heart failure (the heart does not pump blood enough), muscle weakness, muscle wasting and atrophy (loss of skeletal muscle mass), and dementia (loss of memory and thinking ability). Record review of Resident #32's quarterly MDS assessment, dated 07/02/2025, revealed the resident's BIMS score was 00 which indicated the resident was unable to complete the interview. Record review of Resident #32's comprehensive care plan, dated 07/12/2025, revealed the resident was at risk for infection or recurrent; chronic infection related to compromised medical condition. Observation on 07/22/2025 at 10:44 a.m. revealed Resident #32's room had one air conditioning vent in the ceiling. Further observation revealed the vent was soiled with a black substance and with rust. Further observation revealed the return vent was covered with dust. During an interview on 07/22/2025 at 11:39 a.m., the DON stated that Resident #32's room had one air conditioning vent, and it was rusty and soiled covered with dust. The DON said a dirty air conditioning vent might cause respiratory infection. During an interview on 07/22/2025 at 11:46 a.m., the District Manager for environment said Resident #32's room had one air conditioning vent, and it was dirty with dust, and the facility cleaned air vents once a month to prevent infection. Record review of the facility's July 2025 Deep Clean Schedule, dated 07/2025, revealed Resident #32's Room would be scheduled for deep clean on 07/18/2025. Record review of the facility policy, titled Physical Environment, revised 02/2017, revealed The community is designed, constructed, equipped, and maintained to protect the health and safety of resident, personnel, and the public.

Based on interviews and record reviews, the facility failed to encode and transmit required MDS information within 14 days after discharge for 2 of 32 residents reviewed for MDSs.1.Resident #24 was discharged on 01/29/25 and as of 07/24/25 he did not have a discharge MDS assessment. 2.Resident #84 was discharged on 03/14/25 and as of 07/24/25 did not have a discharge MDS assessment. This deficient practice affects residents who receive care at the facility and could result in negative impacts on discharge planning. The findings included: 1.Record review of Resident #24's electronic face sheet dated 07/25/2025 reflected he was an [AGE] year-old male who was admitted to the facility on [DATE] and discharged on 01/25/2025 to the hospital. His diagnoses included: congestive heart failure (a long-term condition that happens when the heart cannot pump blood well enough to give the body a normal supply, resulting in shortness of breath), peripheral vascular disease (refers to any disease or disorder of the circulatory system outside of the brain and heart), and acute respiratory failure with hypoxia (a condition where the body does not get enough oxygen, leading to low blood levels of oxygen). Record review of Resident #24's admission MDS assessment dated [DATE] reflected he scored a nine out of fifteen on his BIMS which indicated he was moderately cognitively impaired. He usually understood and was understood. Record review of Resident #24's comprehensive care plan initiated on 01/23/2025 and cancelled on 07/25/2025 reflected Focus, Discharge Planning, interventions/Tasks included: coordinate safe discharge efforts as indicated by ensuring appropriate referrals have been made, DME has been ordered and home-based services have been arranged prior to discharge. Record review of Resident #24's IDT: Discharge Summary-Planning/Instructions/Recapitulation dated 01/22/2025 reflected Resident #24 was being discharged to home/assisted living/group home with Home Health., anticipated discharge date /actual discharge date was 02/02/2025. He was to be discharged home with family and provider services. 2. Record review of Resident #84's electronic face sheet dated 07/25/2025 reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] and discharged to a private home or apartment with no home health or hospice. His admission diagnoses included: muscle weakness (lack of muscle strength), depression (a mental state of low mood and aversion to activity), and hypertension (high blood pressure). Record review of Resident #84's quarterly MDS assessment dated [DATE] reflected he could be understood, and he could understand. He scored a fifteen out of fifteen on his BIMS which indicated he was cognitively intact. Record review of Resident #84's comprehensive care plan revised 08/12/24 reflected Focus, wish to return home with supportive care and services family support, home health care. Record review of Resident #84's IDT: Discharge Summary-Planning/Instructions/Recapitulation dated 03/19/2025 reflected to return to prior home or community-based living, ALF/group home. During an interview on 07/25/2025 at 10:12 AM with the DOCR she acknowledged there was not a discharge MDS assessment for both Resident #24 and Resident #84 and did not know why and the person who should have completed one was no longer available. She stated that a discharge MDS signifies a resident's completion of a cycle of care and could negatively affect discharge planning. She stated the discharge assessment needed to be completed and sent in within fourteen days of the resident's discharge. During an interview on 07/25/2025 at 12:30 PM with the DON, she stated she did not realize the discharge MDS assessment was not completed for Residents #24 and #84, and it could negatively impact the discharge process, and tracking of care. During an interview on 07/25/25 at 12:35 PM with the ADM, she stated she needed to audit the MDSs to ensure they were completed, submitted timely and were accurate. She had no explanation as to why Resident #24's and #84's discharge MDSs were not completed. She stated the failure to complete and submit a discharge MDS could result in inaccurate quality measure, potential payment issues for the facility, and citations. She stated not completing a discharge MDS could result in inaccurate resident data and could hinder care planning for the residents. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.18.11, October 2023 reflected OBRA-Required Tracking Records and Assessments are Federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes. These assessments are coded on the MDS 3.0 in items A0310A (Federal OBRA Reason for Assessment) and A0310F (Entry/discharge reporting). They include: Tracking records, Discharge (return not anticipated or return anticipated) Record Review of CMS Memorandum Summary dated August 25th, 2014, reflected discharge assessments are required assessments and are critical to ensuring the accuracy of Quality Measures (QMs) and in aiding in resident care planning for discharge from the certified facility.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 (Residents #20 and #64) of ten residents reviewed for incontinence care. 1. When CNA-A and CNA-B were providing peri care to Resident #20, CNA-A cleaned the resident's genital area without separating the labia. 2. When CNA-C and CNA-D were providing peri care to Resident #64, CNA-C did not clean the resident's suprapubic area (below the umbilical region), left groin area, and left buttock area and cleaned the resident's genital area with multiple passes with one wipe. This failure could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included: 1. Record review of Resident #20's face sheet, dated 07/25/2025, revealed the resident was an [AGE] year old female and admitted to the facility on [DATE] with the diagnoses of hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body), muscle weakness, dementia (loss of memory and thinking ability), type 2 diabetes mellitus (the body has trouble controlling blood sugar and using it for energy), hypertension (high blood pressures), and muscle wasting and atrophy (loss of skeletal muscle mass). Record review of Resident #20's quarterly MDS assessment, dated 06/19/2025, revealed the resident's BIMS score was three out of fifteen indicating the resident had severe cognitive impairment, was dependent on the staff for chair to bed and toilet transfer, and was always incontinent of bladder and bowel. Record review of Resident #20's comprehensive care plan, dated 03/14/2025, revealed the resident episodes of bowel and bladder incontinence. For intervention - incontinent care assistance every shift and as needed and check and change on rounds and as needed. Observation on 07/24/2025 at 9:16 a.m. revealed CNA-A and CNA-B removed Resident #20's old and dirty brief, and CNA-A started cleaning the resident's suprapubic area, left groin, and right groin. When CNA-A cleaned the middle area of Resident #20's genitals, CNA-A did not separate the resident's labia. CNA-A cleaned the middle area of the resident's genitals without separating the labia, then rolled the resident to her left side and cleaned the resident's buttock area. During an interview on 07/24/2025 at 9:23 a.m. CNA-A stated when she cleaned the middle area of Resident #20's genitals, she did not separate the resident's labia, and she said she should have separated the resident's labia area when cleaning to prevent infection. CNA-A said she got checked-off regarding female peri care every other month. During an interview on 07/24/2025 at 2:45 p.m. the DON stated the facility did not have a specific policy regarding peri care. The DON said they used a skill check-off sheet for female peri care without catheter, and the sheet did not indicate separating female labia area when providing peri care, but the facility was following general professional guidelines. The surveyor tried to ask more questions, but the DON was unwilling to answer. Record review of professional guidelines (National Library of Medicine - Chapter 5: Provide for Personal Care Needs of Clients - Nursing Assistant - NCBI Bookshelf), titled Provide for Personal Care Needs of Client - perineal care for female, undated, revealed Expose their perineum only, Separate the labia, Use water and a soapy washcloth, Clean one side of the labia from top to bottom, and Using a clean portion of the first washcloth, clean the other side of the labia from top to bottom. 2. Record review of Resident #64's face sheet, dated 07/25/2025, revealed the resident was a [AGE] year old male and admitted to the facility on [DATE] with the diagnoses of cerebral infarction (blood supply to part of the brain is blocked or reduced), muscle weakness, type 2 diabetes mellitus (the body has trouble controlling blood sugar and using it for energy), hypertension (high blood pressures), and hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body). Record review of Resident #64's admission MDS assessment, dated 04/23/2025, revealed the resident's BIMS score was 7 out of 15 indicating the resident had severe cognitive impairment, was dependent on the staff for sit to stand and chair to bed transfer, and was always incontinent of urinary bladder and frequently incontinent of bowel. Record review of Resident #64's comprehensive care plan, dated 04/09/2025, revealed the resident episodes of bowel and bladder incontinence. For intervention - incontinent care assistance every shift and as needed and check and change on rounds and as needed. Observation on 07/24/2025 at 11:47 a.m. revealed CNA-C and CNA-D removed Resident #64's old and dirty brief. CNA-C started cleaning the resident's right groin area, penis, and scrotum with multiple passes with one wipe, then rolled the resident to his left side without cleaning the resident's suprapubic area and left groin area. Further observation revealed CNA-C cleaned Resident #64's right buttock area and rectal area, then repositioned the resident to supine position (lying on the resident's back with the face facing upward) without cleaning the resident's left buttock area. CNA-C changed gloves without sanitizing his hands then put a new and clean brief under Resident #64, then closed it. In an interview on 07/24/2025 at 12:03 p.m. CNA-C stated he did not clean Resident #64's suprapubic area, left groin area, and left buttock area and cleaned the resident's genital area with multiple passes with one wipe because he was so nervous so forgot about cleaning those areas and using one wipe for each stroke. CNA-C said he should have cleaned Resident #64's suprapubic area, left groin area, and left buttock area and used one wipe for each stroke and then discarded it to prevent infection. He said he got a skill check-off last week. In an interview on 07/24/2025 at 2:45 p.m. the DON said CNA-C should have cleaned Resident #64's suprapubic area, left groin area, and left buttock area and used one wipe for each stroke and then discarded it to prevent infection. Monitoring peri care was the DON's responsibility by conducting skill check-offs. Record review of the facility skill check-off sheet, undated, revealed . 8. Use one wipe for each stroke and then discard. 10. Turn resident on side, remaining area including rectum and buttocks without returning to urethra area. Leaving entire area clean and dry (Remember one wipe per each stroke and discard).

Based on observations, interviews, and record reviews, the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 2 of 10 residents (Residents #20 and #64) by 2 of 4 CNAs (CNA-A and CNA-C) reviewed for competent staff, in that: 1. When CNA-A was providing peri care to Resident #20, CNA-A cleaned the resident's genital area without separating the labia. 2. When CNA-C was providing peri care to Resident #64, CNA-C did not clean the resident's suprapubic area (below the umbilical region), left groin area, and left buttock area and cleaned the resident's genital area with multiple passes with one wipe. The failure could place residents at risk for not receiving nursing services by adequately trained staff and could result in a decline in health and infection. Record review of Resident #20's face sheet, dated 07/25/2025, revealed the resident was an [AGE] year old female and admitted to the facility on [DATE] with the diagnoses of hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body), muscle weakness, dementia (loss of memory and thinking ability), type 2 diabetes mellitus (the body has trouble controlling blood sugar and using it for energy), hypertension (high blood pressures), and muscle wasting and atrophy (loss of skeletal muscle mass). Record review of Resident #20's quarterly MDS assessment, dated 06/19/2025, revealed the resident's BIMS score was three out of fifteen indicating the resident had severe cognitive impairment, was dependent on the staff for chair to bed and toilet transfer, and was always incontinent of bladder and bowel. Record review of Resident #20's comprehensive care plan, dated 03/14/2025, revealed the resident episodes of bowel and bladder incontinence. For intervention - incontinent care assistance every shift and as needed and check and change on rounds and as needed. Observation on 07/24/2025 at 9:16 a.m. revealed CNA-A and CNA-B removed Resident #20's old and dirty brief, and CNA-A started cleaning the resident's suprapubic area, left groin, and right groin. When CNA-A cleaned the middle area of Resident #20's genitals, CNA-A did not separate the resident's labia. CNA-A cleaned the middle area of the resident's genitals without separating the labia, then rolled the resident to her left side and cleaned the resident's buttock area. During an interview on 07/24/2025 at 9:23 a.m. CNA-A stated when she cleaned the middle area of Resident #20's genitals, she did not separate the resident's labia, and she said she should have separated the resident's labia area when cleaning to prevent infection. CNA-A said she got checked-off regarding female peri care every other month. During an interview on 07/24/2025 at 2:45 p.m. the DON stated the facility did not have a specific policy regarding peri care. The DON said they used a skill check-off sheet for female peri care without catheter, and the sheet did not indicate separating female labia area when providing peri care, but the facility was following general professional guidelines. The surveyor tried to ask more questions, but the DON was unwilling to answer. Record review of professional guidelines (National Library of Medicine - Chapter 5: Provide for Personal Care Needs of Clients - Nursing Assistant - NCBI Bookshelf), titled Provide for Personal Care Needs of Client - perineal care for female, undated, revealed Expose their perineum only, Separate the labia, Use water and a soapy washcloth, Clean one side of the labia from top to bottom, and Using a clean portion of the first washcloth, clean the other side of the labia from top to bottom. 2. Record review of Resident #64's face sheet, dated 07/25/2025, revealed the resident was a [AGE] year old male and admitted to the facility on [DATE] with the diagnoses of cerebral infarction (blood supply to part of the brain is blocked or reduced), muscle weakness, type 2 diabetes mellitus (the body has trouble controlling blood sugar and using it for energy), hypertension (high blood pressures), and hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body). Record review of Resident #64's admission MDS assessment, dated 04/23/2025, revealed the resident's BIMS score was 7 out of 15 indicating the resident had severe cognitive impairment, was dependent on the staff for sit to stand and chair to bed transfer, and was always incontinent of urinary bladder and frequently incontinent of bowel. Record review of Resident #64's comprehensive care plan, dated 04/09/2025, revealed the resident episodes of bowel and bladder incontinence. For intervention - incontinent care assistance every shift and as needed and check and change on rounds and as needed. Observation on 07/24/2025 at 11:47 a.m. revealed CNA-C and CNA-D removed Resident #64's old and dirty brief. CNA-C started cleaning the resident's right groin area, penis, and scrotum with multiple passes with one wipe, then rolled the resident to his left side without cleaning the resident's suprapubic area and left groin area. Further observation revealed CNA-C cleaned Resident #64's right buttock area and rectal area, then repositioned the resident to supine position (lying on the resident's back with the face facing upward) without cleaning the resident's left buttock area. CNA-C changed gloves without sanitizing his hands then put a new and clean brief under Resident #64, then closed it. In an interview on 07/24/2025 at 12:03 p.m. CNA-C stated he did not clean Resident #64's suprapubic area, left groin area, and left buttock area and cleaned the resident's genital area with multiple passes with one wipe because he was so nervous so forgot about cleaning those areas and using one wipe for each stroke. CNA-C said he should have cleaned Resident #64's suprapubic area, left groin area, and left buttock area and used one wipe for each stroke and then discarded it to prevent infection. He said he got a skill check-off last week. In an interview on 07/24/2025 at 2:45 p.m. the DON said CNA-C should have cleaned Resident #64's suprapubic area, left groin area, and left buttock area and used one wipe for each stroke and then discarded it to prevent infection. Monitoring peri care was the DON's responsibility by conducting skill check-offs. Record review of the facility skill check-off sheet, undated, revealed . 8. Use one wipe for each stroke and then discard. 10. Turn resident on side, remaining area including rectum and buttocks without returning to urethra area. Leaving entire area clean and dry (Remember one wipe per each stroke and discard).

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 (Resident #64) of twenty-eight residents reviewed for infection control practices. When CNA-C was providing peri care to Resident #64, CNA-C changed gloves without sanitizing or washing his hands. This deficient practice could place residents at risk for cross contamination and infections.The findings included: Record review of Resident #64's face sheet, dated 07/25/2025, revealed the resident was a [AGE] year old male and admitted to the facility on [DATE] with the diagnoses of cerebral infarction (blood supply to part of the brain is blocked or reduced), muscle weakness, type 2 diabetes mellitus (the body has trouble controlling blood sugar and using it for energy), hypertension (high blood pressures), and hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body). Record review of Resident #64's admission MDS assessment, dated 04/23/2025, revealed the resident's BIMS score was 7 out of 15 indicating the resident had severe cognitive impairment, was dependent on the staff for sit to stand and chair to bed transfer, and was always incontinent of urinary bladder and frequently incontinent of bowel. Record review of Resident #64's comprehensive care plan, dated 04/09/2025, revealed the resident episodes of bowel and bladder incontinence. For intervention - incontinent care assistance every shift and as needed and check and change on rounds and as needed. Observation on 07/24/2025 at 11:47 a.m. revealed CNA-C and CNA-D removed Resident #64's old and dirty brief. CNA-C started cleaning the resident's right groin area, penis, and scrotum with multiple passes with one wipe, and then CNA-C changed gloves without sanitizing or washing hands. CNA-C rolled the resident to his left side and cleaned Resident #64's right buttock area and rectal area, and then changed gloves again without sanitizing or washing his hands. CNA-C put a new and clean brief under Resident #64 and closed it. In and interview on 07/24/2025 at 12:03 p.m. CNA-C stated he changed gloves without sanitizing or washing his hands. CNA-C said he should have sanitized or washed his hands before wearing new gloves to prevent infection. In an interview on 07/24/2025 at 2:45 p.m. the DON said CNA-C should have sanitized or washed his hands before wearing new gloves to prevent infection. Record review of the facility policy, titled Handwashing/Hand Hygiene, revised 01/2023, revealed . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for situations such as this (including but not limited to): between gloves changes/ removing gloves.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 did not elope from the facility without staff knowing from 05/10/25 at 06:03 PM to 05/11/25 at 12:50 AM (approximately 6 hours and 47 minutes). The noncompliance was identified as PNC. The IJ began on 05/10/25 and ended on 05/11/25. The facility had corrected the noncompliance before the investigation began. This deficient practice could place residents at-risk of harm, serious injury, or death. The findings included: Record review of Resident #1's admission Record, dated 06/24/25, reflected Resident #1 was a [AGE] year-old female admitted [DATE] with diagnoses to include vascular dementia (type of dementia caused by brain damage from impaired blood flow) and Alzheimer's disease (a degenerative brain disorder that primarily affects memory, thinking, and cognitive abilities). Record Review of Nursing Admission/readmission assessment, authored by LVN A on 05/10/25 at 03:19 PM, reflected Resident #1 was alert but some disorientation or forgetfulness, able to verbalize needs & wants. It further reflected Resident #1 was not physically able to leave the building on their own so resident did not need an Exit Seeking care plan. Record Review of Resident #1's MDS assessment, dated 05/15/25, reflected a BIMS score of 1 out of 15, indicating severe cognitive impairment. It reflected Resident #1 had a behavior of wandering in the last 1 to 3 days. It reflected the wandering did not place the resident at significant risk of getting to a potentially dangerous location to include outside of the facility. Record review of the Investigation Timeline, undated, created by the ADM, reflected as follows: On 05/09/25: The Admissions Coordinator gave wander guard device to LVN D who then placed it in 600 med cart. The Admissions Coordinator updated community dashboard with Resident #1 admission needs wander guard in the nurses cart On 05/10/25: *At 02:45 PM Resident #1 admitted to community with family and LVN A completed head to toe assessment *At 04:30 PM: video surveillance revealed LVN A opened up 600 hall med cart and took out the wander guard then placed it back. *At 04:35 PM: LVN A went on break and gave report to LVN B without mention of any supervision for Resident #1 *At 05:55 PM: LVN A came back from break *At 06:03 PM: RN C opened the door and let Resident #1 out of the facility. There was no inclement weather and Resident #1 was dressed appropriately. *At 06:45 PM: The nearby hospital called the facility stating Resident #1 was at the hospital. *At 06:59 PM: Head count was done, and all other residents were in the facility. All doors, windows, and wander guard system was checked. Resident with a wander guard were checked for placement and functionality. On 05/11/25: *At 12:50 AM: Resident #1 returned to the community and placed in the secured unit. MD and RP were notified. Head to toe assessment was completed. Record review of the provider investigation report for this incident, dated 05/11/25, reflected, On 05/10/25 at approximately 06:30 PM [Resident #1] who admitted earlier that day exited the community and walked across the parking lot to the neighboring hospital. The hospital staff notified the community that the resident was there and out of an abundance of caution resident was evaluated and discharged back to the facility. Resident's assigned MD and RP were made aware. Upon resident's return to facility, she was assessed and placed on the secured unit and on-going monitoring is in place. Resident is at usual physical and emotional baseline status, no [signs and symptoms] of emotional or physical trauma. IDT has reviewed/update the plan of care accordingly. Observation on 06/24/25 at 10:50 AM revealed Resident #1 was in the secured unit and was not able to provide answers to questions asked. Interview on 06/24/25 at 11:14 AM, the ADM revealed Resident #1 needed to have a wander guard out of precaution because the facility was told Resident #1 wandered in and out of rooms at her previous facility. She revealed LVN A failed to put a wander guard on Resident #1. She revealed Resident #1 was not put in the secured unit because they were told Resident #1 did not ambulate. She revealed RN C let Resident #1 opened the door and let Resident #1 out of the facility. Interview on 06/24/25 at 12:06 PM, RN C revealed she saw Resident #1 waiting by the front door to the facility, opened the door for her, and let her out of the building. RN C revealed she did not know Resident #1 was a resident. Interview on 06/24/25 at 01:15 PM, LVN A revealed she did not remember Resident #1 or any elopement incident that happened in May 2025. Voicemail was left for LVN B on 06/24/25 at 01:43 PM with no call back from LVN. Interview on 06/24/25 at 02:26 PM, the Admissions Coordinator revealed the DON did as assessment for Resident #1 at Resident #1's previous facility and told her on 05/09/25 that Resident #1 needed a wander guard when Resident #1 was going to be admitted on [DATE]. The Admissions Coordinator revealed she gave the wander guard on 05/09/25 to LVN D to put in her med cart and expected LVN D to pass along the information that Resident #1 needed this wander guard to the oncoming shifts until Resident #1 admitted to the facility. The Admissions Coordinator revealed she also updated the dashboard in the electronic medical record (EMR) and staff knew to look at for updates for resident care. Voicemail was left for LVN D on 06/24/25 at 02:45 PM with no call back from LVN. Interview on 06/24/25 at 03:11 PM, the ADM and DON revealed they had assessed Resident #1 at her previous facility and learned Resident #1 was considered a wanderer but was not exit seeking. They revealed this was why they had a wander guard ready for when Resident #1 was admitted . The ADM revealed LVN A knew she needed to put the wander guard on Resident #1 because it was in her med cart and because this direction was reflected on the EMR Dashboard, which nursing staff knew to review when they logged into the EMR. The ADM further revealed LVN A did not work at the facility anymore. They revealed they did not have hospital records for Resident #1 when she was at the hospital on [DATE]. Record review of the facility's policy Resident Safety: Prevention of Responding to Missing Person, and Exit Seeking, revised January 2025, reflected New Admits/Re-Admits should be assessed/re-assessed as clinically indicated by completing the elopement risk/exit seeking assessment UDA in[EMR]. And If assessment deems resident is at risk for elopement and placement on a special care unit or the use of an alert bracelet may be utilized to maintain the resident's personal safety and promote overall well-being. The Administrator was notified on 06/25/25 at 02:48 PM, a past non-compliance IJ situation had been identified due to the above failure. The facility implemented the following interventions. Record Review of Resident #1's care plan reflected a focus of At risk for elopement and/or wandering with unsafe boundaries r/t cognitive impairment/judgement and safety awareness, initiated 05/11/25, with intervention Safety Risk: Monitor resident regularly throughout shift to prevent wandering into other rooms, exit seeking and elopement. Distract & Assist quickly to prevent accidents/injury. Notify the nurse., initiated 05/11/25. Record Review of Resident #1 doctor's orders reflected as of 05/10/25 Admit to Secure unit due to behaviors that may include but not limited to: wandering, exit seeking ., dated 05/11/25, and Resident #1 was being monitored for wandering behavior. Resident #1 was placed on the secured unit on 05/11/25, when the resident came back to the facility. Record review of in-service training, starting on 05/10/25, reflected licensed nurses (to include LVN A, LVN B, and RN C) were educated on the importance of immediately completing the admission assessment/evaluation and exit seeking tool. Record review reflected all staff (to include LVN A, LVN B, and RN C) were educated on 05/10/25 for Elopement Response & Exit Seeking Management and Resident Safety, exit seeking, abuse and neglect and Identifying and Responding to Triggers to Prevent. Record review reflected all staff (to include LVN A, LVN B, and RN C) were educated on 05/10/25 for Process for monitoring, identifying, and reporting resident with exit seeking behaviors or identified risks. Abuse and Neglect (~25% of staff were interviewed on in-servicing on elopements) Record review of facility Incidents and Accidents report for the last 6 months reflected that no other resident had eloped apart from the incident on 05/10/25. Record review of facility's monitoring tool for Elopement/Missing Person Response Drills, dated May and June 2025 dates, reflected the facility was monitored all shifts initially then random shifts, 2-4 times per month x1-2 months. Record review of 4 residents (to include Resident #1) reflected exit seeking tool was completed on 05/10/25. Interview on 06/24/25 at 03:11 PM, The ADM revealed there was not an official training or policy for letting visitors in and out of the building but she let the staff know how to tell the difference between a visitor and a resident so a resident would not be accidentally let out of the building. Interview on 06/25/25 at 10:48 AM, the DON revealed on 05/10/25 they re-assessed all residents with the exit seeking tool to ensure they were filled out properly. Interview on 06/24/25 at 10:58 AM, CNA K (typically worked 6AM-2PM, but worked other times as well) revealed he was trained on preventing elopements to include what residents were at high risk for elopements, responding to door alarms, checking on residents regularly, doing headcounts, and more. He revealed if a resident were to elope, he would follow the resident out and contact the ADM immediately. Interview on 06/24/25 at 11AM, LVN P (worked 6AM-6PM) revealed she was trained on elopements and would follow a resident who exited the building for safety. She revealed she would respond to any alarm to make sure residents were safe. She revealed they performed resident head count checks to make sure all the residents were in the building. She revealed she would report abuse, neglect, or elopements to ADM right away. Interview on 06/24/25 at 12:06 PM, RN C (worked 6AM-6PM) revealed after this incident she was trained on being able to identify who was a visitor and who was a resident. She revealed she would check in with the front desk, who oversaw letting people in and out of the building. She revealed visitors also had name tags to show they were visitors. She revealed she was trained on elopement to include checking on residents regularly and to respond to the wander guard alert if a resident were to get to the front door. She revealed for new admissions they assessed residents to include seeing how oriented they were in the facility. She revealed if a resident was confused, they would monitor resident to ensure they did not wander. She further revealed they would also have to assess if resident needed to be in the secured unit. Interview on 06/24/25 at 12:25 PM, Receptionist O (worked 8AM-5PM) revealed anyone who leaves the building needed to check out with her. She revealed when anyone enters the building, they also checked in with her. She revealed if she did not know if a resident was supposed to leave for the day, she would check with the nursing staff before letting them out because they needed to sign something first. Interview on 06/24/25 at 02:26 PM, the Admissions Coordinator (worked 8AM-5PM) revealed she was trained on how to tell the difference between a resident and a visitor to include asking specific questions. She revealed she was trained on preventing elopements like redirecting residents who were trying to exit the building. She revealed if a resident were to exit the building, she would follow them. She revealed their wander guard alarm system would alarm if a resident with a wander guard was trying to exit the front door. She revealed she made sure that staff had wander guard as needed if a resident assessment showed a resident needed a wander guard. Interview on 06/25/25 at 08:37 AM, CNA E (worked 10PM-6AM) revealed she was trained on preventing elopements. She revealed for Wander alarms, if the alarm went off, they would run to stop the resident, redirecting them away from the exit. She revealed she would follow the resident if they did happen to exit and kept eyes on her residents. She revealed she would report to ADM immediately. She revealed that PCC had a front page for pertinent alerts. She further revealed she was trained to tell the difference between visitors and residents. She revealed the visitors had visitor badges, so the staff knew to look out for this. Interview on 06/25/25 at 08:52 AM, CNA F (worked 10PM-6AM) revealed she was trained on elopement. She revealed she checked on residents in their rooms frequently. She revealed if a resident was not in their room, she would check their restroom, her hallway, speak to the nurse, and contact ADM immediately. She revealed if the door alarm went off, she would redirect resident to the middle of the building and alert the nurse. She revealed if a resident eloped, she would not leave any resident alone due to resident safety. She revealed she was trained on abuse and neglect and reported this along with elopements to the ADM immediately. She revealed visitors had name tags or she would look at the visitor logbook to verify visitors. She revealed she used the home page in the PCC for alerts to include resident pictures for warnings such as if a resident was a wanderer. Interview on 06/25/25 at 08:58 AM, LVN G (worked 6PM-6AM) revealed she was trained on what to do when a resident eloped. She revealed if a resident had a wander guard, the alarm went off and they would respond immediately to get the resident. She revealed she would call ADM and DON immediately if there was a missing resident, and they would search the building to see if resident were hiding somewhere first. She revealed if the doors alarmed, they would go outside right away to search for resident. She revealed she was trained on how to tell the difference between a visitor and resident. She revealed visitors had name tags and she would ask more questions to the visitor or resident to determine who they were. She revealed if a visitor did not sign in, she would ask questions. She revealed she used the PCC Dashboard for pertinent alerts for residents. Interview on 06/25/25 at 09:10A, Receptionist O revealed if a resident were to exit the building, she would stay with them the whole time and call for help. She revealed if any alarm went off (to include the wander alarm or door alarm), she would go to the direction of the alarm, redirect resident, and contact nursing staff. She revealed if someone were to leave, she would contact ADM. Interview on 06/25/25 at 09:15 AM, Dietary [NAME] Q, Dietary Aide R and Dietary Aide S revealed they were trained on elopement. They revealed if they heard any alarm, they would go towards the alarm and make sure the resident was redirected from exiting. They revealed they knew to help locating a missing resident if the whole building needed to find a resident, but they have not been asked to do so yet. They revealed if they saw abuse, neglect, or an elopement, they would contact the ADM as soon as possible. They revealed they knew visitors should have name tags, but they revealed they knew they had to speak with the nursing staff before letting anyone out of the building to ensure it was a visitor. They revealed if they saw a resident exiting the building, they would make sure to follow them, so the resident remained safe. Interview on 06/25/25 at 09:20 AM, CNA J (worked 6AM-2PM) and LVN U (worked 6AM-2PM) revealed they were trained on elopements and had a quick reference attached to their badges. They revealed if they heard an alarm go off in the building, they would go to it right away and make sure the resident would not elope. They revealed they would count residents and go outside if they were not able to locate the resident inside the building. They revealed they do visual checks on residents frequently and were aware of what residents wandered or were exit seeking. They revealed they knew visitors had name tags to identify themselves, but if they questioned if someone was a visitor, they would ask questions or look in EMR to see if they were a resident. They revealed they could also check with the receptionist to identify visitors before letting them out of the building. They revealed they were trained on abuse, neglect, and elopements and would report to the ADM and DON right away. LVN U revealed he was detailed in his assessments and even documented in progress notes if a resident was a wanderer or elopement risk. He revealed if the resident was not capable of contributing to an interview, he would call family, previous nurses, administration, or the previous facility. They revealed they knew to look at the EMR dashboard for pertinent alerts to include if a resident was a wanderer. Interviews on 06/25/25 at 09:26 AM, CNA V (worked 6AM-2PM), CNA K (worked 6AM-2PM), Agency Nurse T (worked 6AM-6PM) revealed they were trained on abuse, neglect, and elopement and to report to ADM and DON immediately. They revealed they checked on their residents frequently and if they had a missing resident, they would search the building and let all nursing staff know. They revealed they would search outside if they could not find the resident inside. They revealed visitors had name tags and they would double check with the nurses before letting someone out of the building. They revealed they used EMR dashboard for any alerts for their residents. Agency nurse revealed that she was detailed in her assessments of residents to include their physical assessment, physical ability, and if a resident were a wanderer or needed monitoring. Interview on 06/25/25 at 10:08 AM, LVN W (worked 2PM-10PM) revealed he was trained on elopements. He revealed he would respond to alarms right away for wander guards or doors. He revealed if they did not find the resident inside the building, they would have to go outside to find the resident. He revealed he would report to ADM immediately. He revealed if resident exited the building, he would follow the resident out. He revealed the visitors had a badge to identify themselves. He revealed EMR had an alert page to know about anything new going on with the residents. He revealed he checked on his residents regularly and if someone was missing, they would have to search for the resident and alert ADM immediately. He also revealed he contacted the ADM immediately if there was any abuse or neglect. He revealed the number one priority was resident safety. He further revealed he recorded detailed information if resident had incident or history of elopement. He revealed they would document any observations or potential triggers. Interview on 06/25/25 at 11:15 AM, CNA X (worked 10PM to 6AM and 2PM-10PM sometimes) revealed she was trained on abuse, neglect, and elopements. She revealed she would report to nurse and ADM immediately. She revealed if any doors or wander guard alarmed, she would do a head count, check doors, and check wander guards. She revealed she redirected residents from going outside. She revealed if they made it outside, she would stay with the resident. She revealed she used the EMR dashboard for alerts. She revealed visitors had name tags and she knew to not let residents out of the building. She revealed she checked residents frequently. She revealed if she had a missing resident, she would let nurses know, do a head count, search for resident, and report to ADM immediately. Interview on 06/27/25 at 01:03 PM, COTA Y revealed she had been trained on preventing elopements. She revealed she would respond to any door alarms or wander guard alarms. She revealed she would help out with searching for any missing residents or any resident that had eloped. She revealed if she saw a resident elope, she would follow the resident for resident safety. She revealed she knew to report abuse, neglect, and elopements to the ADM immediately. Observation on 06/24/25 at 09:06 AM revealed that upon entrance, this surveyor had to be let into the facility by Receptionist, check in via a computer, and get a name tag to identify as a visitor. This observation continued throughout investigation. Observation on 06/26/25 at 06:45PM revealed the front door was locked and needing a staff member to verify this surveyor was a visitor before opening the front door. The noncompliance was identified as PNC. The IJ began on 05/10/25 and ended on 05/11/25. The facility had corrected the noncompliance before the investigation began.

Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, to the administrator of the facility and to other officials including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities in accordance with State law through established procedures for 2 of 4 residents (Residents #2 and #3), reviewed for freedom from abuse, neglect, and exploitation. The facility failed to report the incident of suspected abuse on 6/5/25 when the visitor was noted pounding hard on the bed of Resident # 2 , yelling WAKE UP! . These failures could put the residents at risk of abuse, allegations of abuse not being reported immediately, and could result in physical and psychosocial harm. The findings were: Record review of Resident # 2's face sheet, dated 6/25/25, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: Alzheimer's disease (a neurodegenerative disease that destroys cells in your brain, causing loss of some brain functions, including memory and language), Anxiety ( a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome) and Hyperlipidemia ( abnormally high levels of fats in the blood) Record review of Resident #2's admission MDS assessment, dated 06/10/2025, revealed the resident's BIMS score was 01, which indicated severe cognitive impairment. The admission MDS assessment further revealed Resident #2 required substantial/maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) for sit to lying, chair/bed to chair transfer, was dependent (helper does all of the effort. Resident does none of the effort to complete the activity) for toileting hygiene, upper body dressing, and lower body dressing. Record review of Texas Unified Licensure Information Portal (TULIP) on 6/25/25 at 9:21 A.M. revealed that no self-reported incidents regarding allegations of neglect were reported. Resident record review of Resident #2's progress notes, dated 06/05/2025, revealed noticed visitor, pounding hard on bed angrily yelling wake up, also noted Resident # 1 asking visitor, why are you always so mean to me. Interview with CNA M on 6/25/25 at 2:20 PM revealed while assisting ,Resident # 2's roommate with activities of daily living on 6/5/25, she heard visitor for Resident # 2 pounding hard on Resident #2's bed, yelling, Wake up, followed by Resident # 1 stating, Why are you always so mean to me? CNA M stated she pulled the curtain and said, Excuse me, to the visitor, and reported the incident to LVN L. CNA M stated she did not report the incident to the Administrator because she was under the impression that LVN L would handle that. She stated that by her not reporting abuse and neglect to the administrator, Resident # 2 risked further abuse from possibly occurring. During an interview with LVN L on 6/25/25 at 3:45 PM, LVN L stated . She documented an incident CNA M reported to her during shift on 6/5/25. CNA M reported that a visitor for Resident #2 had been vigorously pounding on Resident #2's bed and yelling, Wake up, after which Resident #2 said, Why are you always so mean to me? LVN L stated she reported the incident to her ADON N and not her Administrator because of the chain of command. LVN L stated by her not reporting abuse and neglect to the administrator, Resident # 2 could have been abused. The interview with ADON N on 6/26/25 at 1:10 PM stated , she did not remember any specific report of abuse or neglect involving Resident #2 by LVN L. ADON N stated that any reports of abuse or neglect should be directed to the administrator. During an interview on 06/25/2025 at 12:30 PM, Resident #2 stated she did not want to discuss the incident regarding the visitor pounding hard on her bed. During an interview on 06/26/2025 at 4:18 PM, the Administrator confirmed she did not receive a report about Resident #2's incident with a visitor and had not seen the nursing note dated 6/5/25 before the surveyor's intervention. She explained she would have reported and investigated the abuse allegation involving Resident #2 after reviewing the note. The Administrator acknowledged that failing to report the allegation could have resulted in Resident #2 being subjected to abuse. Review of the facility policy, Abuse Guidance effective February 2017, read: It is the responsibility of our team members, consultants, attending physicians, family members, visitors, etc. to promptly report any incident of suspected neglect or resident abuse, Types of abuse; Verbal abuse is the use of oral, written, or gestured language that willfully includes the use of disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability ,should a family member or visitor be accused or suspected of abuse, that individual will be removed from the community; thus, preventing the individual from entering the community. Report alleged or suspected abuse to HHSC by email reporting or via TULIP reporting within the designated time frames under HHSC's PL 19-17 are reported immediately, but not later than 2 hours after the allegation is made.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free from accident hazards as was possible and that each resident received adequate supervision to prevent accidents for 2 of 26 residents (Residents #1 and #2) reviewed for accidents/supervision in that: 1. The facility failed to ensure the safety and prevent serious bodily injury of Resident #1 by failing to provide the adequate supervision necessary to prevent Resident #2 from wandering into Resident #1's room. This failure could place residents at risk of harm or injury and contribute to avoidable accidents. The findings were: 1. Record review of Resident #1's face sheet, dated 02/07/2023, revealed the resident had an initial admitted to the facility of 10/29/2022 and a readmitted [DATE], with diagnoses that included: muscle wasting and atrophy (loss of muscle tissue), cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately or following directions) and anxiety disorder (excessive anxiety and worry that is difficult to control, which may cause impairment in social, occupational, or other areas of functioning). Record review of Resident #1's Discharge MDS, dated [DATE], revealed the resident's cognitive skills for daily decision making were severely impaired. Further review revealed the resident exhibited physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others), and exhibited other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) between one and three days during the seven day period prior to the assessment date. Record review of Resident #1's Care Plan, revised on 01/23/2022, revealed a focus area, I have impaired cognitive function r/t Alzheimer's. Interventions included, Cue, reorient and supervise as needed. Further review revealed a focus area, I am at risk for falls r/t Debility & Weakness, cognitive impairment noted, poor safety awareness, chronic pain. Interventions included, Assess ability and safety for walking with walker device as indicated. Routine rounds to help with safety checks by all team members. 2. Record review of Resident #2's face sheet, dated 02/12/2023, revealed the resident had an initial admitted to the facility of 02/06/2022 and a readmitted [DATE], with diagnoses that included: mild protein-calorie malnutrition (undernutrition results from not getting enough protein, calories or micronutrients), Alzheimer's Disease (type of brain disorder that causes problems with memory, thinking and behavior., gradually progressive condition), muscle wasting and atrophy (loss of muscle tissue), and other abnormalities of gait and mobility. Record review of Resident #2's Significant change MDS, dated [DATE], revealed the resident had clear speech, was able to make self unself understood and understand others, was visually impaired (requiring corrective lenses) and had a BIMS score of 02, which indicated severe cognitive impairment. Further review revealed the resident exhibited physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) daily during the seven-day period prior to the assessment date and exhibited other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) between one and three days during the seven-day period prior to the assessment date. Review revealed resident wandered between 4-6 days during the seven-day period prior to the assessment date. Record review of functional status revealed resident required supervision to limited assistance of one person assist for walking in the corridor and locomotion on the unit. Record review of Resident #2's Care Plan, revised on 02/24/2022, revealed a focus area, I am exit seeking, I am at risk for elopement and/or wandering with unsafe boundaries r/t cognitive impairment. Goal: My safety will be maintained and I will demonstrate a well adjusted and content demeanor with my daily routine through my next date. Interventions: Assess my continued need for residing on the memory care/secure unit as indicated. Distract me from exit seeking by offering pleasant diversions, structured activities, food, conversation, television, book. Provide planned and engaging activities as well as activities to meet my needs .behavior may be related to a need that can not be stated. Further review revealed a focus area, I have impaired cognitive function r/t Alzheimer's. Interventions included, Cue, reorient and supervise as needed. Record review of Resident #1's electronic progress notes, dated 01/28/2023, created by LVN A, revealed pt was trying to push another resident then she slides, and both landed on the floor. The other resident stood up and ambulate without help fell . Two assisted to bed. Record review of Resident #1's incident report, dated 01/28/2023, prepared by LVN A, revealed the nursing description as this nurse was at the nurse station when pt slides and fell . Resident and another patient were trying to go into the same room at the same time and both fell and the resident description as stated that she was trying to go into her room. Further review of incident report reveals a note dated 01/30/2023 by the DON, after investigating the recent fall, it appears resident fell while trying to enter her room at the same time another patient was entering the room. Staff members were present and with another resident and were unable to get to both residents in time. Staff to redirect other residents from going into resident's room. Staff to ensure resident is using assisted devices while ambulating. Record review of Resident #1's post fall review, dated 01/28/2023, created by LVN A, revealed the resident was pushing another resident at the time of the fall, and when the resident was asked, why do you think you fell she responded, trying to push another resident. Record review of Resident #1's post fall review for a second fall, dated 02/05/2023, created by the DON, revealed the resident was getting out of bed at the time of the fall however resident unable to walk without assistance due to previous fall, with fracture and readmission from hospital. Resident was asked, why do you think you fell and responded, I wanted to get out of bed. Record review of an x-ray report, dated 02/06/2023, revealed Findings: there is a fracture involving the right femoral neck with mild displacement. The joint shows no dislocation. Pubic rami are intact. There is prosthetic left femoral head in proper alignment with respect to the acetabulum. New from 1/28/2023. There is no fracture or acute dislocation. The prosthesis is properly situated without any loosening. Pubic rami are normal. Osteopenia is present. CONCLUSION: New right hip fracture as described above. Intact left hip arthroplasty new from 01/28/2023. Record review of Resident #2's electronic progress notes, dated 01/28/2023, created by LVN A, revealed pt was trying to enter another resident's room when she was pushed by another resident then she slides both landed on the floor. she stood up and ambulate without help. no s/s of pain noted. skin intact. Record review of Resident #2's incident report, dated 01/28/2023, prepared by LVN A, revealed the nursing description as resident observed sitting on the floor with another resident and stood right up ambulating without any s/s of pain, skin intact and the resident description as resident unable to give description. Further review of incident report reveals an entry, other info: was trying to enter another resident's room and resident was behind her. Notes at the bottom of the report dated 01/28/2023 by the DON, IDT TEAM MET TODAY REGARDING FALL ON 01/28/2023. Resident was going into another resident's room. Her and another resident were attempting to go into the room together and other resident was making sure [Resident #2] did not enter her room. Other resident fell back and [Resident #2] fell attempting to leave room and got up from the floor on her own. Staff to encourage [Resident #2] to participate in activities of choice and keep her busy. Record review of Resident #2's post fall review, dated 01/28/2023, signed by LVN A, revealed the resident was pacing around at the time of the fall, in the hallway and was trying to go to another resident's room. In an interview with the DON on 02/11/2023 at 2:10 p.m., the DON revealed Resident #1 was no longer a resident of the facility. The DON stated while Resident #1 was in the hospital following her second fall on 02/05/2023, the family made the decision to move Resident #1 closer to family upon discharge. An observation on 02/11/2023 at 2:55 p.m. in the memory care unit revealed 14 residents in the community room, 8 sitting near the television in chairs and on the oversized couch the DON states the facility recently acquired. There were 3 others sitting at a small table near the wall talking and 3 others, which included Resident #2, were pacing through the community room and up and down the hallway. In an interview with LVN A on 02/11/2023 at 3:14 p.m., LVN A revealed Resident #1 was impulsive and always on the move, she like to do for herself and wanted it her way. LVN A revealed she was working the day Resident #1 and Resident #2 fell and witnessed the fall from the nurse's desk. LVN A stated she saw both residents in Resident #1's doorway, but before I could get to them, Resident #1 pushed at Resident #2 and they both fell to the floor. LVN A further shared that Resident #2 got up on her own as LVN A reached them but Resident #1 was having pain that they learned was from a hip fractured hip from the fall. In a phone interview with LVN B on 02/12/23 at 1:00 p.m., LVN B revealed Resident #1 was generally easy going and kind to everyone except there was one resident she was not very nice to, she didn't seem to like her [Resident #2] very much. LVN B further shared that Resident #1 would talk ugly to Resident #2, almost like she was a child, she [Resident #1] would tell her [Resident #2] to sit down when Resident #2 was pacing around them. LVN B revealed, One time from the back of the couch I saw her [Resident #1] sitting sideways on the couch and went to see why she was leaning that way. She [Resident #1 was sort of sitting on her [Resident #2] leg. LVN B was asked how staff addressed Resident #1 and #2 behaviors and she stated, for wanderers we redirect and try to get them focused on something to keep them busy and if we see any of them getting frustrated with another resident we redirect and separate the two residents. LVN B was asked if Resident #1 used a walker or not and LVN B revealed Resident #1 was mostly independent with her walker on the unit and without one in her room. LVN B added, however after the fall she thought she still could do everything for herself and would try to get out of bed, I would always make sure she had her call light and show it to her, but she wouldn't use it, she would just try to get up, so we had her bed in the lowest position possible. An observation and interview with CNA C on 02/12/2023 at 2:38 p.m., revealed several residents in the community room of the memory care unit. Of the 5 watching television one attempted to stand several times without assistance and a staff member would run over to assist her. Three others, including Resident #2 were pacing in and out of the community room down the hallway where the resident rooms are located, and staff was observed following them and redirecting back to the community room. CNA C revealed it is a constant struggle keeping everyone where they need to be with all the wanderers and the ones who need assistance. CNA C further revealed she recalls Resident #1becoming anxious and frustrated by Resident #2's constant pacing. CNA C recalled one day Resident #1 had her hands on Resident #2's shoulders while she was sitting at the table and told her to stay here. CNA C was asked if staff receive training in dementia and behaviors and CNA C revealed they do receive training. In an interview with LVN A on 02/12/23 at 3:43 p.m., LVN A was asked if Resident #1 was using a walker at the time of the fall. LVN A revealed Resident #1 used a walker when out on the unit but at the time of the incident she was in her room where she ambulates without her walker. LVN A stated, When I got to the door, I didn't see the walker anywhere around her [Resident #1]. LVN A stated she only saw Resident #2 walk to Resident #1's doorway where Resident #1 was standing. Resident #1 then told Resident #2 Get out of here, grabbed Resident #2's shirt and pushed at her and they both fell to the floor. An observation and interview on 02/12/2023 at 4:26 p.m., in the memory care unit revealed the nurse at the nurse's desk with the medication cart blocking the entrance into the nurse's station and two CNA's busily interacting and redirecting 16 residents. LVN A moving things from nurse's station countertop to under counter as two residents attempt to take items. LVN A reveals she had to move the medication cart to block the entrance where she is because residents were joining me and trying to take off with things. RN D revealed one of the residents had been at the doors to the unit starting to disrobe when he walked by, so he came in to assist. RN D confirmed there are several very active residents on the memory care unit that wander throughout the day without much of a break. In an interview with the Director of Clinical Operations and the Administrator on 02/12/2023 at 6:25 p.m., the Director of Clinical Operations stated the facility did not have a policy related to resident-to-resident altercations.