Every finding on record at The Enclave

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 #1) of 3 residents reviewed for infection control practices. The facility failed to ensure the wound care nurse, LVN-A, sanitized or washed her hands when changing her gloves while providing wound care to Resident #1. This deficient practice could place residents at risk for cross contamination and infections. The findings included:Record review of Resident #1's face sheet, dated 08/27/2026, revealed the resident was a 64-years-old male and admitted to the facility on [DATE] with diagnosis of orthopedic aftercare following surgical amputation (aftercare following the medical operation to remove all or part of a limb or body part), type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels), and acute osteomyelitis left ankle and foot (sudden, painful bone infection caused by bacteria or other germs). Record review of Resident #1's admission MDS assessment, dated 08/18/2026, revealed the resident's BIMS score was 15 out of 15 which indicated the resident's cognitive was intact, and the resident required Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) to chair-to-bed transfer and Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) to toilet transfer. Further record review of the MDS assessment revealed Resident #1 had diabetic foot ulcer and surgical wound to the left foot in Section M (Skin Conditions). Record review of Resident #1's comprehensive care plan, dated 08/19/2026, revealed that the resident had a care plan of Actual or At Risk for Skin Impairment: Actual: Left foot. For interventions - Apply treatment as ordered and Keep clean & dry and apply skin barrier cream as indicated. Record review of Resident #1's physician's order, dated 08/15/2026, revealed that the resident had the order of Wound Care: Left foot - Cleanse with normal saline, pat dry, apply xeroform, cover with dry dressing. May wrap with kerlix and ace bandage one time a day. Observation on 08/27/2026 at 2:15 p.m. revealed the wound care nurse, LVN-A, washed her hands with water, put on gloves and a gown, and removed Resident #1's old dressing from his left foot. The wound care nurse,, LVN-A changed her gloves without sanitizing or washing her hands, then cleaned the resident's left foot with normal saline, patted dry, and applied a dressing as ordered. Interview on 08/27/2026 at 2:30 p.m. with the wound care nurse, LVN-A said she changed her gloves after removing Resident #1's old dressing from his left foot without sanitizing or washing her hands because she was nervous. LVN-A stated she should have washed or sanitized her hands after taking off her old gloves and before putting on new gloves to prevent possible infection. Interview on 08/27/2026 at 3:15 p.m. the DON stated the wound care nurse LVN-A should have washed or sanitized her hands after taking off her old gloves and before putting new gloves to prevent possible infection. Record review of the facility policy, titled Handwashing/Hand Hygiene, dated 01/2023, revealed This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel should follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 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 after handling used dressings, contaminated equipment, and between glove changes / after removing gloves.

Based on observation, interview, and record review the facility failed to ensure, in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 1 treatment carts (TC #1) reviewed for medication storage. The facility failed to ensure the treatment cart was locked. This failure could place residents at risk of medication misuse and drug diversion. Findings included: During observation on 2/26/26 at 6:59 am, TC #1 was observed to be unlocked and unattended by the state investigator and HR. Further observation revealed a bottle of betadine in the basket affixed to the side of the cart. There were no staff at the nurses' station and there were residents moving about the facility. HR said TC #1 was not supposed to be unlocked. HR further stated he did not know who was responsible for the cart at the time because he was Human Resources, but that the Treatment Nurse had just arrived at the facility. During an interview on 2/26/26 at 7:03 am, the TN said the night nurse was responsible for the treatment cart, as that nurse worked the night shift and would have provided treatments for the residents. An interview was attempted on 2/26/26 at 1:47 pm with LVN A without success. During an interview on 2/26/26 at 2:05 pm, the DON said she expected medication/treatment carts to be locked when not in use and unattended, adding medications/treatments must be secured and not left outside/on top of the cart. The DON said the facility did have mobile residents. The DON said any staff in the facility could pass by a medication/treatment cart and lock it, but the nurse assigned to the cart was responsible for locking it when the cart was not in use/unattended. The DON said it was important to keep medication/treatment carts locked for the safety of the residents/visitors. The DON further stated this was important so that the residents were unable to get into the cart and access medications/treatment that were in the cart. The DON said unlocked medication/treatment carts put residents at risk because they could ingest or take anything in the unlocked cart. The DON further stated a resident, or visitor could pass by a cart and take any medication/treatment left outside the cart if the cart was not being monitored. Record review of the facility's policy titled, Medication Cart Use and Storage revised January 2023, revealed: .Responsible Disciplines Licensed Nurses, C.M.A.'s.The medication cart and its storage bins should be kept closed, secured and/or in the line of sight when not in use.

Based on observation, interview, and record review the facility failed to ensure the residents were free from abuse for 1 of 4 residents (Resident #1) reviewed for freedom from abuse. Resident #1 was kissed and touched by CNA A and it was recorded on the camera in her room.This failure could place residents at risk of abuse, neglect, and exploitation.The findings were:Record review of Resident #1's face sheet dated 2/6/26 revealed the resident was a [AGE] year-old female admitted on [DATE] with readmission on [DATE]. Resident #1's diagnoses included vascular dementia, moderate with anxiety (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain and include anxiety), memory deficit following cerebral infarction (issues with memory following a stroke), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (weakness and loss of strength on one side of the body), and generalized anxiety disorder (excessive, ongoing anxiety and worry that interferes with daily activities).Record review of Resident #1's quarterly MDS dated [DATE] revealed the resident had minimal difficulty hearing, was usually understood and usually understands others and had clear speech. The resident had a BIMS of 11 of 15 indicating the resident was moderately cognitively impaired. The resident did not have any verbal or physical behaviors, had impairment to upper and lower extremities on one side of her body, and used a manual wheelchair. The resident was Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity for toileting transfer and toileting hygiene. The resident was Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. For lying to sitting, transfers, and showers. And the resident was frequently incontinent of bowel and bladder.Record review of Resident #1's Care plan dated 2/6/26 revealed a focus initiated on 3/21/25 and revised on 3/28/25 for memory problems that may affect ability to communicate her needs and wants and forgetfulness with interventions to anticipate her needs, engage in conversations, give time to respond. Another focus initiated on 5/4/25 for problems communicating her needs and wants due to cognitive impairment with the same interventions as previously stated above. Another focus initiated on 3/20/25 and revised on 2/6/26 for being at risk of emotional distress or behaviors and being forgetful, confused, combative and agitated with interventions to reassure the resident she is safe dated 3/20/25, report sadness, crying, wishes to harm self or others dated 12/24/25, risk monitoring on-going. Monitor for any emotional issues and/ or behaviors. Attempt to calm the resident by speaking in a calm tone and reassure the person's safety no date initiated.Record review of the facility investigation regarding CNA A's actions toward Resident #1 dated 12/22/25 revealed an ADHOC was held with the Administrator, DON, and Medical Director for a concern regarding unprofessional conduct. The resident was assessed with no negative findings. The Administrator validated that Resident #1 verbally denied being abused physically or sexually and was monitored following the report of an unprofessional gesture made by a caregiver. CNA A was interviewed and stated he felt compassion for Resident #1 as he did with his own mother and the resident had been crying and was emotional regarding her family member not visiting and he was only trying to console Resident #1 and offer compassion. CNA A stated he needed to go PRN status immediately. The RP was notified on 12/22/25. Resident #1 would continue to be monitored to ensure she continued to have no concerns of abuse and no emotional distress. Resident #1 felt safe and care for by all staff. CNA A was removed from the schedule until interview and retraining completed with administration and reeducation provided regarding 1. Providing compassionate care in a professional manner. 2. Professional conduct and expectations. 3. Identifying, preventing, protecting against and reporting ANE. 4. Resident dignity and rights. 5. Texas HHSC provider letter regarding reportable incidents 6. Updating the plan of care, ensuring that appropriate interventions are in place. 7. Ensure that appropriate interventions are noted on the plan of care as well as the Kardex. 8. Educating staff on intervention such as specific monitoring and interventions and the comprehensive care plan process. All current residents assessed to validate safety and well-being. No negative outcomes identified.Record review of the facility investigation regarding CNA A's actions toward Resident #1 revealed a resident interview dated 12/23/25 with Resident #1. Question #1 - Tell me how you are doing today and handwritten was OK. Question #2 - Tell me how you are being treated here and handwritten was OK. Question #3 - Tell me how care givers speak to you and handwritten was OK. Question #5 - tell me if you have seen anyone treating another resident in a rough manner, in an inappropriate manner or an unkindly manner. Explain, have you ever been treated in a rough manner or unkindly? Handwritten was the resident's response Yes, some man kissed me and touched me. Review of a video provided to the surveyor with file name Ring_Resident#1's first name_20251221_1032 revealed an MP4 video with date and time on the lower right. The video ran from 12/21/25 at 10:32 a.m. to 10:34 a.m. in the resident's room. The video evidence revealed the resident was in bed covered with blankets and a white blanket rolled or bunched up on her chest. CNA A was seated in a chair pulled up next to the left side of Resident #1's bed. CNA A was leaning on his left elbow and arm against the mattress and his right arm from his hand to his elbow appeared to be under the resident's blanket near her chest. The resident's head and face were turned to the right slightly and facing away from CNA A. CNA A was speaking to Resident #1 but the surveyor was unable to hear most of what was being said. The resident was replying as well but the surveyor was unable to understand what was said. The resident's left foot was moving under the blankets during the conversation. CNA A then stood up and leaned over the resident, bending his head, and appeared to kiss the resident near her head but unable to see where on the video as his back was to the camera but a kissing sound could be heard and then CNA A sat back down in the chair and was leaning on his left elbow on the mattress and rested his chin in his left hand and his right hand and arm remained under the resident's blankets at her chest. CNA A began telling the resident that he brought her breakfast and she did not call to be changed or anything so he thought he would check on her. The resident turned her head to face CNA A during that time and Resident #1 asked what was for breakfast and CNA A got up and walked around to the right side of her bed and examined her breakfast, telling her what it was. The resident stated she gets tired of the heavy stuff. CNA A then touched the resident's right upper arm and asked if he could use her bathroom and she said he could. CNA A attempted to close the sliding door to the resident's bathroom but was unable to fully close it and walked to the toilet which could be partially seen in the video and then the video ended.Review of a video with file name Ring_Resident#1's first name_20251221_1037 revealed an MP4 video with a date and time on the lower right. The video ran from 12/21/25 at 10:37 a.m. to 10:38 a.m. in the resident's room. The video evidence revealed the resident remained in bed and was covered with blankets from her waist down. CNA A was standing on the right side of the resident's bed and holding her right hand with his right hand and covering her hand with his left hand. CNA A removed his left hand and leaned down and kissed the resident just to the right side of her mouth and the resident stated, Thank you. CNA A stood back up and was still holding the resident's right hand in his right hand and covered it again with his left hand and looked away from the resident's face and then again released his left hand that was covering their hands and leaned down and kissed the resident on her mouth. The resident smiled and made a pecking kissing sound. CNA A stood back up and covered their hands again with his left and stated, I like you. CNA A then began to cover up the resident while still holding her right hand in his right hand and asked the resident if she wanted him to let her sleep or if she wanted him to visit her and the resident stated she wanted to sleep. CNA A caressed the right side of the resident's face with the back of his left hand and fingers several times and told the resident he would come back and check on her. The resident then apologized and CNA A laughed and stated, It's ok. CNA A finished covering the resident up and moved her call light and bedside table within reach and told the resident he would check on the other residents and make his way back to her probably about lunch time. The resident then stated, And your name is [CNA A's first name]. and he replied it was and the resident stated, And you're a nurse. and CNA A replied that he was and asked the resident Is that okay? and the resident stated it was. CNA A stated he had Resident #1's hall today. CNA A then left the room and shut the door.Record review of CNA A's employee file revealed background checks were completed 9-25-25 and 9-29-25. The competency checklist included privacy, dignity, resident rights, and abuse and neglect were completed on 10/14/25. The competency was met for knowledge of abuse and neglect, and what constituted abuse and neglect and reporting and was signed by the DON. There was a disciplinary action with date of policy violation 12/27/25 by the DON and Administrator. Under summary of violation was typed Rude, disrespectful, or unprofessional behavior to other team members, supervisors, residents, family members or visitors including failure to treat all with kindness, respect, and dignity. Category 1 violation at a level of written coaching to maintain professional boundaries at all times with staff, residents, family members and or visitors. further disciplinary action and or termination. It was signed by CNA A and the DON on 12/22/25. Review of the facility time sheets for December 2025 revealed CNA A worked on 12/21/25 from 6:11 a.m. to 2:26 p.m. and on 12/22/26 7:46 a.m. to 8:53 a.m.; no further shifts were worked at the facility after 12/22/25.In an interview on 2/4/26 at 4:45 p.m. with the Administrator and the DON, the Administrator stated there were previous allegations about inappropriate touching with another resident but it was unsubstantiated . The Administrator further stated there was an incident where CNA A was holding Resident #1's hand but that the resident and her family member both denied any allegation. The Administrator stated CNA A was taking care of his own mother and went PRN and then resigned but it was not related to the current incident. The DON stated the incident was not reported to HHSC as there was no allegation made and the resident felt safe and stated she would still let CNA A care for her. The Administrator stated they had not seen a video where CNA A was sitting next to the resident's bed with his hand covered by blankets. The Administrator and DON stated CNA A was trying to console the resident when he kissed her on her cheek and that it was unprofessional conduct but not reportable. The Administrator and DON stated they were sent one video and the resident and the resident's family member had no concerns or issues. The Administrator stated CNA A did not work at the facility since the incident on 12/21/25. The DON stated the resident's family member was fine with CNA A not working with the resident anymore and had no other concerns. In an observation and interview on 2/4/26 at 5:30 p.m. revealed Resident #1 was resting in bed. The resident stated she did have an incident with a staff member and the facility staff talked to her about it. Resident #1 stated she was told by administration that CNA A was only trying to console her because she was sad. Resident #1 then turned her head towards the surveyor and motioned with her hand pointing to herself and stated, I didn't know I was sad. Resident #1 then stated CNA A was related to someone around here, not sure who but he's someone's nephew I think. Resident #1 then denied CNA A touched her and denied being kissed on the mouth. The resident stated CNA A did kiss her on the forehead. The resident then stated, I didn't feel threatened though. Resident #1 stated it made her feel surprised as she did not think anyone would want to kiss her at her age. In an interview on 2/5/26 at 11:15 a.m. the DON stated there was no allegation made by Resident #1 or her family member and they were sent the video because the family member wanted to know who CNA A was but that there were no concerns or allegations made. The DON stated the video did not show abuse or exploitation of the resident and only showed unprofessional conduct and was not reportable as no allegation was made by the resident or family member and the resident felt safe. In an anonymous interview, and record review, it was stated Resident #1 had stated that CNA A had kissed her and that prompted checking the video camera in her room. The video with CNA A kissing Resident #1 and sitting next to her bed with his hand not viewable under the blankets was sent to the Administrator and the DON via email. Review of the email revealed it was sent to the Administrator and DON on 12/22/25 at 10:30 a.m. The DON had responded that they had received the video and would be addressing the issue. Interview further revealed the facility had terminated CNA A or that was the assumption as they were told CNA A was no longer employed at the facility but not sure on the date , they were told that. In a telephone interview on 2/5/26 at 3:09 p.m. CNA A stated he remembered Resident #1. CNA A stated he had gone in to check on the resident and he asked if he could check her and she said yes, he did and then the resident started to cry and said she just wanted to die. She said her family member forgot about her, she wanted to kill herself and the resident asked if she could get a hug and he hugged her. The next time he sat down with her and she was saying the same things. CNA A stated the resident's statements of wanting to kill herself and being so lonely and her family member forgetting about her were reported to the charge nurse and to the Administrator . CNA A stated that he hugged Resident #1 and kissed her on the cheek but it was kind of mutual. CNA A denied kissing the resident on her lips or being inappropriate .Review of the facility policy for abuse guidance: preventing, identifying, and reporting revised January 2024 indicated Every resident has the right to be free from abuse, neglect. Residents should not be subjected to abuse by anyone, including to but not limited to community team members, other residents, consultants. All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities. as may be required by law and per the current state/federal reporting requirements. sexual abuse is defined at 483.5 as non-consensual sexual contact of any type with a resident. Willful is defined at 483.5 in the definition of abuse and means the individual should have acted deliberately, not that the individual should have intended to inflict injury or harm.

Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for freedom from abuse, neglect, and exploitation.The facility failed to report to HHSC that Resident #1 was kissed and touched by CNA A. This failure could place residents at risk of unidentified and on-going abuse, neglect, and exploitation. The findings were:Record review of Resident #1's face sheet dated 2/6/26 revealed the resident was a [AGE] year-old female admitted on [DATE] with readmission on [DATE]. Resident #1's diagnoses included vascular dementia, moderate with anxiety (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain and include anxiety), memory deficit following cerebral infarction (issues with memory following a stroke), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (weakness and loss of strength on one side of the body), and generalized anxiety disorder (excessive, ongoing anxiety and worry that interferes with daily activities).Record review of Resident #1's quarterly MDS dated [DATE] revealed the resident had minimal difficulty hearing, was usually understood and usually understands others and had clear speech. The resident had a BIMS of 11 of 15 indicating the resident was moderately cognitively impaired. The resident did not have any verbal or physical behaviors, had impairment to upper and lower extremities on one side of her body, and used a manual wheelchair. The resident was Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity for toileting transfer and toileting hygiene. The resident was Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. For lying to sitting, transfers, and showers. And the resident was frequently incontinent of bowel and bladder.Record review of Resident #1's Care plan dated 2/6/26 revealed a focus initiated on 3/21/25 and revised on 3/28/25 for memory problems that may affect ability to communicate her needs and wants and forgetfulness with interventions to anticipate her needs, engage in conversations, give time to respond. Another focus initiated on 5/4/25 for problems communicating her needs and wants due to cognitive impairment with the same interventions as previously stated above. Another focus initiated on 3/20/25 and revised on 2/6/26 for being at risk of emotional distress or behaviors and being forgetful, confused, combative and agitated with interventions to reassure the resident she is safe dated 3/20/25, report sadness, crying, wishes to harm self or others dated 12/24/25, risk monitoring on-going. Monitor for any emotional issues and/ or behaviors. Attempt to calm the resident by speaking in a calm tone and reassure the person's safety no date initiated.Record review of the facility investigation regarding CNA A's actions toward Resident #1 dated 12/22/25 revealed an ADHOC was held with the Administrator, DON, and Medical Director for a concern regarding unprofessional conduct. The resident was assessed with no negative findings. The Administrator validated that Resident #1 verbally denied being abused physically or sexually and was monitored following the report of an unprofessional gesture made by a caregiver. CNA A was interviewed and stated he felt compassion for Resident #1 as he did with his own mother and the resident had been crying and was emotional regarding her family member not visiting and he was only trying to console Resident #1 and offer compassion. CNA A stated he needed to go PRN status immediately. The RP was notified on 12/22/25. Resident #1 would continue to be monitored to ensure she continued to have no concerns of abuse and no emotional distress. Resident #1 felt safe and care for by all staff. CNA A was removed from the schedule until interview and retraining completed with administration and reeducation provided regarding 1. Providing compassionate care in a professional manner. 2. Professional conduct and expectations. 3. Identifying, preventing, protecting against and reporting ANE. 4. Resident dignity and rights. 5. Texas HHSC provider letter regarding reportable incidents 6. Updating the plan of care, ensuring that appropriate interventions are in place. 7. Ensure that appropriate interventions are noted on the plan of care as well as the Kardex. 8. Educating staff on intervention such as specific monitoring and interventions and the comprehensive care plan process. All current residents assessed to validate safety and well-being. No negative outcomes identified.Record review of the facility investigation regarding CNA A's actions toward Resident #1 revealed a resident interview dated 12/23/25 with Resident #1. Question #1 - Tell me how you are doing today and handwritten was OK. Question #2 - Tell me how you are being treated here and handwritten was OK. Question #3 - Tell me how care givers speak to you and handwritten was OK. Question #5 - tell me if you have seen anyone treating another resident in a rough manner, in an inappropriate manner or an unkindly manner. Explain, have you ever been treated in a rough manner or unkindly? Handwritten was the resident's response Yes, some man kissed me and touched me. Review of a video provided to the surveyor with file name Ring_Resident#1's first name_20251221_1032 revealed an MP4 video with date and time on the lower right. The video ran from 12/21/25 at 10:32 a.m. to 10:34 a.m. in the resident's room. The video evidence revealed the resident was in bed covered with blankets and a white blanket rolled or bunched up on her chest. CNA A was seated in a chair pulled up next to the left side of Resident #1's bed. CNA A was leaning on his left elbow and arm against the mattress and his right arm from his hand to his elbow appeared to be under the resident's blanket near her chest. The resident's head and face were turned to the right slightly and facing away from CNA A. CNA A was speaking to Resident #1 but the surveyor was unable to hear most of what was being said. The resident was replying as well but the surveyor was unable to understand what was said. The resident's left foot was moving under the blankets during the conversation. CNA A then stood up and leaned over the resident, bending his head, and appeared to kiss the resident near her head but unable to see where on the video as his back was to the camera but a kissing sound could be heard and then CNA A sat back down in the chair and was leaning on his left elbow on the mattress and rested his chin in his left hand and his right hand and arm remained under the resident's blankets at her chest. CNA A began telling the resident that he brought her breakfast and she did not call to be changed or anything so he thought he would check on her. The resident turned her head to face CNA A during that time and Resident #1 asked what was for breakfast and CNA A got up and walked around to the right side of her bed and examined her breakfast, telling her what it was. The resident stated she gets tired of the heavy stuff. CNA A then touched the resident's right upper arm and asked if he could use her bathroom and she said he could. CNA A attempted to close the sliding door to the resident's bathroom but was unable to fully close it and walked to the toilet which could be partially seen in the video and then the video ended.Review of a video with file name Ring_Resident#1's first name_20251221_1037 revealed an MP4 video with a date and time on the lower right. The video ran from 12/21/25 at 10:37 a.m. to 10:38 a.m. in the resident's room. The video evidence revealed the resident remained in bed and was covered with blankets from her waist down. CNA A was standing on the right side of the resident's bed and holding her right hand with his right hand and covering her hand with his left hand. CNA A removed his left hand and leaned down and kissed the resident just to the right side of her mouth and the resident stated, Thank you. CNA A stood back up and was still holding the resident's right hand in his right hand and covered it again with his left hand and looked away from the resident's face and then again released his left hand that was covering their hands and leaned down and kissed the resident on her mouth. The resident smiled and made a pecking kissing sound. CNA A stood back up and covered their hands again with his left and stated, I like you. CNA A then began to cover up the resident while still holding her right hand in his right hand and asked the resident if she wanted him to let her sleep or if she wanted him to visit her and the resident stated she wanted to sleep. CNA A caressed the right side of the resident's face with the back of his left hand and fingers several times and told the resident he would come back and check on her. The resident then apologized and CNA A laughed and stated, It's ok. CNA A finished covering the resident up and moved her call light and bedside table within reach and told the resident he would check on the other residents and make his way back to her probably about lunch time. The resident then stated, And your name is [CNA A's first name]. and he replied it was and the resident stated, And you're a nurse. and CNA A replied that he was and asked the resident Is that okay? and the resident stated it was. CNA A stated he had Resident #1's hall today. CNA A then left the room and shut the door.Record review of CNA A's employee file revealed background checks were completed 9-25-25 and 9-29-25. The competency checklist included privacy, dignity, resident rights, and abuse and neglect were completed on 10/14/25. The competency was met for knowledge of abuse and neglect, and what constituted abuse and neglect and reporting and was signed by the DON. There was a disciplinary action with date of policy violation 12/27/25 by the DON and Administrator. Under summary of violation was typed Rude, disrespectful, or unprofessional behavior to other team members, supervisors, residents, family members or visitors including failure to treat all with kindness, respect, and dignity. Category 1 violation at a level of written coaching to maintain professional boundaries at all times with staff, residents, family members and or visitors. further disciplinary action and or termination. It was signed by CNA A and the DON on 12/22/25. Review of the facility time sheets for December 2025 revealed CNA A worked on 12/21/25 from 6:11 a.m. to 2:26 p.m. and on 12/22/26 7:46 a.m. to 8:53 a.m.; no further shifts were worked at the facility after 12/22/25.In an interview on 2/4/26 at 4:45 p.m. with the Administrator and the DON, the Administrator stated there were previous allegations about inappropriate touching with another resident but it was unsubstantiated . The Administrator further stated there was an incident where CNA A was holding Resident #1's hand but that the resident and her family member both denied any allegation. The Administrator stated CNA A was taking care of his own mother and went PRN and then resigned but it was not related to the current incident. The DON stated the incident was not reported to HHSC as there was no allegation made and the resident felt safe and stated she would still let CNA A care for her. The Administrator stated they had not seen a video where CNA A was sitting next to the resident's bed with his hand covered by blankets. The Administrator and DON stated CNA A was trying to console the resident when he kissed her on her cheek and that it was unprofessional conduct but not reportable. The Administrator and DON stated they were sent one video and the resident and the resident's family member had no concerns or issues. The Administrator stated CNA A did not work at the facility since the incident on 12/21/25. The DON stated the resident's family member was fine with CNA A not working with the resident anymore and had no other concerns. In an observation and interview on 2/4/26 at 5:30 p.m. revealed Resident #1 was resting in bed. The resident stated she did have an incident with a staff member and the facility staff talked to her about it. Resident #1 stated she was told by administration that CNA A was only trying to console her because she was sad. Resident #1 then turned her head towards the surveyor and motioned with her hand pointing to herself and stated, I didn't know I was sad. Resident #1 then stated CNA A was related to someone around here, not sure who but he's someone's nephew I think. Resident #1 then denied CNA A touched her and denied being kissed on the mouth. The resident stated CNA A did kiss her on the forehead. The resident then stated, I didn't feel threatened though. Resident #1 stated it made her feel surprised as she did not think anyone would want to kiss her at her age. In an interview on 2/5/26 at 11:15 a.m. the DON stated there was no allegation made by Resident #1 or her family member and they were sent the video because the family member wanted to know who CNA A was but that there were no concerns or allegations made. The DON stated the video did not show abuse or exploitation of the resident and only showed unprofessional conduct and was not reportable as no allegation was made by the resident or family member and the resident felt safe. In an anonymous interview, and record review, it was stated Resident #1 had stated that CNA A had kissed her and that prompted checking the video camera in her room. The video with CNA A kissing Resident #1 and sitting next to her bed with his hand not viewable under the blankets was sent to the Administrator and the DON via email. Review of the email revealed it was sent to the Administrator and DON on 12/22/25 at 10:30 a.m. The DON had responded that they had received the video and would be addressing the issue. Interview further revealed the facility had terminated CNA A or that was the assumption as they were told CNA A was no longer employed at the facility but not sure on the date , they were told that. In a telephone interview on 2/5/26 at 3:09 p.m. CNA A stated he remembered Resident #1. CNA A stated he had gone in to check on the resident and he asked if he could check her and she said yes, he did and then the resident started to cry and said she just wanted to die. She said her family member forgot about her, she wanted to kill herself and the resident asked if she could get a hug and he hugged her. The next time he sat down with her and she was saying the same things. CNA A stated the resident's statements of wanting to kill herself and being so lonely and her family member forgetting about her were reported to the charge nurse and to the Administrator . CNA A stated that he hugged Resident #1 and kissed her on the cheek but it was kind of mutual. CNA A denied kissing the resident on her lips or being inappropriate .Review of the facility policy for abuse guidance: preventing, identifying, and reporting revised January 2024 indicated Every resident has the right to be free from abuse, neglect. Residents should not be subjected to abuse by anyone, including to but not limited to community team members, other residents, consultants. All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities. as may be required by law and per the current state/federal reporting requirements. sexual abuse is defined at 483.5 as non-consensual sexual contact of any type with a resident. Willful is defined at 483.5 in the definition of abuse and means the individual should have acted deliberately, not that the individual should have intended to inflict injury or harm.

Based on observations, interviews and record reviews, the facility failed to provide assessments that accurately reflect the resident's status for three (Residents #41, #55 and #34) of 32 residents reviewed for MDS assessment accuracy. 1.Resident #41's MDS assessment did not accurately reflect she had an indwelling urinary catheter. 2. Resident #55's admission MDS assessment did not accurately reflect she had an indwelling urinary catheter. 3.Resident #34's MDS assessment did not accurately reflect she took an opioid medication. This deficient practice affects residents with MDS assessments and could result in missed or inappropriate care. The findings included: 1.Record review of Resident #41's electronic face sheet dated 08/25/2025 reflected she was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: muscle wasting and atrophy (decrease in muscle size and mass, which results in reduced muscle strength and function), pain due to internal orthopedic prosthetic devices (can arise from surgical complications, mechanical issues with the implant), diabetes mellitus (a chronic metabolic disorder characterized by high blood sugar (glucose) levels), osteoporosis (a condition that weakens bones, making them more prone to fractures), post viral fatigue syndrome (debilitating state of physical and mental exhaustion that persists for weeks or months after a viral infection has cleared) and dementia (loss of cognitive functioning-thinking, remembering, and reasoning-to such an extent that it interferes with a person's daily life and activities) Record review of Resident #41's quarterly MDS assessment with an ARD of 07/17/2025 reflected she could usually understand and usually be understood. She was not a candidate for a BIMS which indicated she was severely cognitively impaired. She was dependent on staff for ADLs except for eating where she required set up assistance. She was always incontinent of bowel and bladder. An indwelling urinary catheter was not indicated. Record review of Resident #41's comprehensive care plan revised date 12/27/2023 reflected Focus, I have a Self-Care deficit r/t Poor physical functioning, weakness and debility, incontinent of bladder and incontinent of bowel. Record review of Resident #41's physician order dated 07/15/2025 reflected Collect urine via PVR, urethral catheterization. If residual greater than 250ml leave urethral catheter in place. Record review of Resident #41's Nursing Progress Note dated 07/15/2025 written by LVN D reflected Urine sample collected and sent in hand with lab personnel. Residual greater than 250 cc. Foley catheter remains in place with balloon inflated with 10 cc NS via syringe. Record review of Resident #41's Documentation Survey Reports dated July and August 2025 reflected from 07/15/2025 to 08/04/2025 when the resident went out to the hospital for a change in condition, she had an indwelling urinary catheter. Observation on 08/24/2025 at 10:30 am revealed Resident #41 was on contact isolation and EBP. She had a bin outside of her room which contained PPE. She was lying in bed and had a covered urinary drainage bag hanging on the side of her bed frame. 2. Record review of Resident #55's face sheet, dated 08/27/2025, revealed the resident was 82-years-old female who was admitted to the facility on [DATE] with diagnosis of muscle wasting and atrophy (loss of skeletal muscle mass), emphysema (air-filled enlargement in the body's tissue causes shortness of breath), dementia (loss of memory and thinking ability), acute kidney failure (kidney lose the ability to remove waste and balance fluids), and neuromuscular dysfunction of bladder (nerves that carry messages back and forth between bladder and the spinal cord and brain do not work the way they should). Record review of Resident #55's admission MDS assessment with an ARD of 07/24/2025 reflected the resident's BIMS was 4 out of 15, which indicated her cognition was severely impaired. The resident required substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) from staff for sit to stand, chair to bed, and toilet transfer. Resident #55 was always incontinent of bowel and bladder. Further record review of the MDS revealed Resident #55's indwelling urinary catheter was not coded. Record review of Resident #55's comprehensive care plan, revised date 08/02/2025, reflected I [Resident #55] require a catheter at risk for infection and catheter related injury/issues. Providing indwelling Catheter Care. Record review of Resident #55's physician order, dated 07/18/2025, revealed the resident had the order of Foley Catheter 16 French (indwelling urinary catheter) 10 milliliters, change monthly and as needed. Observation on 08/26/2025 at 2:04 p.m. revealed Resident #55 was on the bed in her room with an indwelling urinary catheter hanging to the bed frame. The resident's indwelling urinary catheter was clean, so the resident refused CNAs provided catheter care at that time. An interview on 08/27/2025 at 11:16 a.m. with the DOCR stated Resident #55 had an indwelling urinary catheter from 07/18/2025 per the physician order, but the resident's admission MDS, dated [DATE], reflected Resident #55 did not have an indwelling urinary catheter, and it was not accurate. Resident #55's admission MDS, dated [DATE], should have reflected the resident had an indwelling urinary catheter. Further interview with the director of clinical reimbursement said not reflecting Resident #55's indwelling urinary catheter was her mistake because she supervised MDS accuracy, and the accuracy of an MDS was very important to reflect the resident's status. However, it did not affect Resident #55's care because the resident already received care related to an indwelling urinary catheter. 3. Record review of Resident #34's electronic face sheet dated 08/25/2025 reflected she was an [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: muscle wasting and atrophy (progressive loss or weakening of muscle tissue, characterized by a reduction in muscle size and mass), chronic obstructive pulmonary disease (group of lung diseases that cause airflow obstruction and breathing difficulties), pain (physical suffering or discomfort caused by illness or injury), and major depressive disorder (mood disorder that causes a persistent feeling of sadness or loss of interest and can interfere in daily activities). Record review of Resident #34's annual MDS assessment with an ARD of 07/25/2025 reflected she could understand and be understood. She scored a 13 of 15 on her BIMS which indicated her cognition was intact She required minimal assistance with ADLs. She had an active diagnosis of pain. She had received, was offered, or declined PRN pain medication within the previous five days. Review of section N0415 High-Risk Drug Classes: Use and Indication reflected she was not taking an opioid medication. Record review of Resident #34's comprehensive care plan revised 04/17/2023 reflected Focus, I am at risk for experiencing discomfort or pan r/t: Hx of fractures, co-morbid medical conditions and joint discomfort, Interventions/Tasks, administer my medications to relieve my pain as recommended by my doctor. Record review of Resident #34's Active Orders As of: 08/25/2025 reflected Tylenol with Codeine #3 Oral Tablet 300-30 MG (Acetaminophen w/ Codeine) Give 1 tablet by mouth every 6 hours as needed for SEVERE PAIN related to PAIN, UNSPECIFIED (R52) ***NOT TO TAKE MORE THAN 4000MG (4GRAMS) OF ACETAMINOPHEN/DAY*** Phone Active 01/02/2025 01/02/2025. Record review of Resident #34's MAR dated 07/01/2025 to 07/31/2025 reflected she took a Tylenol with Codeine tablet for pain on Monday July 21, 2025, at 02:09 am with a pain level of 6 which indicated a moderate amount of pain. During an interview on 08/24/2025 at 10:46 am, Resident #34 stated she sometimes had pain in her back and joints. She stated she took pain medication. During an interview on 08/27/2025 at 08:06 am, LVN F stated she was new at doing MDS assessments. She stated she had done them for about six months. She confirmed Resident #41 had an indwelling urinary catheter the week of 07/15/2025 and her quarterly MDS assessment with an ARD of 07/17/2025 did not accurately reflect the catheter. She stated it was important for the MDS assessment to accurately reflect the resident's status or care might be missed. She stated Resident #34 was on an opioid medication and her annual MDS assessment was inaccurate. During an interview on 08/27/2025 at 3:00 pm, CNA K stated she assisted Resident #41 during the last two weeks of July 2025, and the resident had an indwelling urinary catheter. She stated she provided catheter care for the resident. During an interview on 08/27/2025 at 3:10 pm, CNA L stated she assisted Resident #41 during the last two weeks of July 2025, and she had an indwelling urinary catheter. She stated she provided catheter care for the resident. During an interview on 08/27/2025 at 3:20 pm, the DOCR confirmed that the MDS assessment should reflect a resident's status. She confirmed if Resident #41 had an indwelling urinary catheter it should have been reflected on her quarterly MDS assessment dated [DATE]. She confirmed Resident #34 had opioid medication ordered and had it administered as needed. During an interview on 08/27/25 at 09:36 am, the DON stated the MDS needed to be accurate to reflect a resident's condition and if it were not accurate, could result in missed or inappropriate care. She stated the indwelling urinary catheter for Resident #41 was missed on her quarterly MDS assessment. She stated Resident #34 was taking an opioid medication and it should have been reflected on her MDS. During an interview on 08/27/2025 at 2:55 pm with the ADM who was accountable for the MDS's, stated the accuracy of an MDS was important to reflect the resident's status and to dictate the accurate care needed. She stated care could be provided to the resident that could be inaccurate. Record review of the facility's policy and procedure titled Comprehensive Assessments 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.

Based on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for three ( Residents #17, #41 and #119) of 32 residents reviewed for comprehensive care plans. The facility failed to provide Resident #17 a call bell instead of a call light which was reflected in his comprehensive person-centered care plan. 2. The facility failed to reflect Resident #41 had an indwelling urinary catheter in her comprehensive person-centered care plan. 3. The facility failed to reflect Resident #119 had an oxygen therapy in her comprehensive person-centered care plan. These deficient practices affect residents who require specialized care and could result in inadequate or missed care. The findings included: 1.Record review of Resident #17's electronic face sheet dated 08/24/2025 reflected he was a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: myopathy (muscle disease which results in spasms, stiffness and cramps), acute respiratory failure with hypoxia (life-threatening condition characterized by insufficient oxygen in the blood), epilepsy (neurological condition characterized by recurrent seizures), suicidal ideations (thoughts or feelings about self-harm) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #17's quarterly MDS assessment with an ARD of 06/23/2025 reflected he could usually be understood and could usually understand others. He scored a 06 of 15 on his BIMS which indicated his cognition was severely impaired. He was dependent on his ADL care except for eating where he required set up assistance. He was always incontinent of bowel and bladder. Record review of Resident #17's comprehensive care plan with an initiated date of 06/27/25 reflected Focus, I am at risk for depression: Chronic poor health, Focus, I am at risk for psychosocial or emotional distress, Goal, I will not experience any distress or discomfort that will affect my functional well-being, I have been noted to chew on call light-bell to be used, revised on 08/19/2025, I will be able to utilize my bell without noted decline, Focus, I am at risk for falls, revised on 05/05/2025, Interventions, Anticipated and meet needs and keep call bell within reach. Record review of Resident #17's Psychiatric Subsequent Assessment dated 08/01/2025 reflected he was treated for major depressive disorder, recurrent, severe with psychotic symptoms (a form of severe depression that includes symptoms of psychosis, a break from reality, such as hallucinations (seeing, hearing, or feeling things that are not there) or delusions (false, fixed beliefs), generalized anxiety disorder (a chronic mental health condition characterized by excessive, persistent, and uncontrollable worry about various everyday events or situations) and insomnia (a sleep disorder characterized by difficulty falling or staying asleep, resulting in daytime fatigue and impairment). Observation on 08/24/2025 at 09:40 am, Resident #17 was in his room, lying on a low bed with mat on the floor. The room had an odor of stale urine. Resident #17 was reaching out and acted like he was trying to get someone's attention. When asked by the surveyor if he could reach and use his call light he stated no and moved his hand to illustrate pressing a call light button. His call light cord and button were located approximately three feet from the bed wrapped around the left arm rest of his tall wheelchair. During an interview on 08/26/2025 at 4:40 pm with LVN H who was charge nurse on Resident #17's unit revealed she stated she had checked the resident, and he was dry when they put him to bed at 3:00 pm. She stated she had not noticed his call light was not a call bell as care planned and that it was not within reach since she was on the unit. She stated it was important for him to have a call bell and for it to be within reach in case he needed something. During an interview on 08/27/2025 at 09:36 am with the DON, she stated that Resident #17 should have had a call bell because he chewed on the call light. She did not know why he did not have one, and she stated she would get it fixed immediately. She stated he needed to be able to call staff for assistance and care. 2.Record review of Resident #41's electronic face sheet dated 08/25/2025 reflected she was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: muscle wasting and atrophy (decrease in muscle size and mass, which results in reduced muscle strength and function), pain due to internal orthopedic prosthetic devices (can arise from surgical complications, mechanical issues with the implant), diabetes mellitus (a chronic metabolic disorder characterized by high blood sugar (glucose) levels), osteoporosis (a condition that weakens bones, making them more prone to fractures), post viral fatigue syndrome (debilitating state of physical and mental exhaustion that persists for weeks or months after a viral infection has cleared) and dementia (loss of cognitive functioning-thinking, remembering, and reasoning-to such an extent that it interferes with a person's daily life and activities) Record review of Resident #41's quarterly MDS assessment with an ARD of 07/17/2025 reflected she could usually understand and usually be understood. She was not a candidate for a BIMS which indicated she was severely cognitively impaired. She was dependent on staff for ADLs except for eating where she required set up assistance. She was always incontinent of bowel and bladder. An indwelling urinary catheter was not reflected. Record review of Resident #41's comprehensive care plan revised date 12/27/2023 reflected Focus, I have a Self-Care deficit r/t Poor physical functioning, weakness and debility, incontinent of bladder and incontinent of bowel. Resident #41's comprehensive person-centered care plan did not reflect an indwelling urinary catheter. Record review of Resident #41's physician order dated 07/15/2025 reflected Collect urine via PVR, urethral catheterization. If residual greater than 250ml leave urethral catheter in place. Record review of Resident #41's Nursing Progress Note dated 07/15/2025 written by LVN D reflected Urine sample collected and sent in hand with lab personnel. Residual greater than 250 cc. Foley catheter remains in place with balloon inflated with 10 cc NS via syringe. Record review of Resident #41's Documentation Survey Reports dated July and August 2025 reflected from 07/15/2025 to 08/04/2025 when the resident went out to the hospital for a change in condition, she had an indwelling urinary catheter. Record review of Resident #41's hospital notes dated 08/14/2025 prior to her discharge back to the facility reflected ESBL, E. Coli, Chronic indwelling Foley catheter (replaced in ED on 08/04/2025). Observation on 08/24/2025 at 10:30 am revealed Resident #41 was on contact isolation and EBP. She had a bin outside of her room which contained PPE. She was lying in bed and had a covered urinary drainage bag hanging on the side of her bed frame. During an interview on 08/27/2025 at 08:06 am, LVN F stated she created, reviewed, and updated care plans. She stated Resident #41 had an indwelling urinary catheter the week of 07/15/2025 and the catheter needed to be part of her plan of care. She stated the care plan reflected the care a resident required, and an inaccurate care plan could result in missed care. During an interview on 08/27/25 at 09:36 am, the DON stated Resident #41's indwelling urinary catheter needed to be part of her plan of care. She stated Resident #41's care could be misinterpreted if the plan did not correctly reflect the resident. During an interview on 08/27/2025 at 3:00 pm, CNA K stated she assisted Resident #41 during the last two weeks of July 2025, and the resident had an indwelling urinary catheter. She stated she provided catheter care for the resident. During an interview on 08/27/2025 at 3:10 pm, CNA L stated she assisted Resident #41 during the last two weeks of July 2025, and she had an indwelling urinary catheter. She stated she provided catheter care for the resident. During an interview on 08/27/2025 at 3:20 pm, the DOCR confirmed that Resident #41's indwelling urinary catheter needed to be part of her comprehensive person-centered care plan. 3. Record review of Resident #119's face sheet, dated 08/27/2025, revealed the resident was 102-years-old female who was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis of arthritis (swelling and tenderness on one of more joints, causing joint pain), chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems), muscle wasting and atrophy (loss of skeletal muscle mass), and heart failure (the heart can't pump enough oxygen-rich blood to meet your body's needs). Record review of Resident #119's 5-days Medicare MDS assessment, dated 08/02/2025, revealed the resident's BIMS score was 12 out of 15, which indicated the resident had moderate cognitive impairment, required Substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) to chair to bed and sit to stand and was receiving oxygen therapy. Record review of Resident #119's comprehensive care plan, dated 08/05/2025, revealed there was no care plan regarding Resident #119's oxygen therapy. Record review of Resident #119's physician order, dated 08/05/2025, revealed the resident had the order of Oxygen 3-5 liters per minute and nasal cannular as tolerated for chronic obstructive pulmonary disease. Observation on 08/24/2025 at 10:09 a.m. revealed Resident #119 was on the bed with oxygen 4 liters per minutes via nasal cannula. During an interview on 08/27/2025 at 11:07 a.m. with the DOCR stated Resident #119's care plan did not address the resident's oxygen therapy. The care plan should have addressed Resident #119's oxygen therapy because the resident was taking oxygen therapy as ordered, and it might not affect resident care because nurses followed the physician orders. Review of the facility policy's and procedure titled Care Plans Revised January 2023 reflected The community develops a comprehensive care plan for each resident that includes measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan in conjunction with the plan of care throughout the medical record is developed and or recommended to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan should be prepared, reviewed, and updated in accordance with the RAI guidance on a routine cadence (admission, quarterly, annually and with significant change). Additionally, the care plan should be modified as appropriate and on an as needed basis as per the RAI instructions. Review of the facility policy's and procedure titled Care Plans Revised January 2023 reflected The community develops a comprehensive care plan for each resident that includes measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan in conjunction with the plan of care throughout the medical record is developed and or recommended to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan should be prepared, reviewed, and updated in accordance with the RAI guidance on a routine cadence (admission, quarterly, annually and with significant change). Additionally, the care plan should be modified as appropriate and on an as needed basis as per the RAI instructions.

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 3 (Resident #18, #150, and #1) of 7 residents reviewed for pharmacy services. 1. The facility failed to re-order on time Resident #18's Janumet 50-500 mg medication for diabetes. 2. The facility failed to re-order on time Resident #150's Carboxymethlcellulose sodium 0.5% eye drops for dry eyes. 3. The facility to ensure Resident #1's insulin Lispro KwikPen for diabetes had open date of [DATE], stored inside the 200-unit C-hall nursing cart was not expired. This failure could place residents at risk of not receiving appropriate therapeutic effects of medication.The findings included: 1. Record review of Resident #18's face sheet, dated [DATE], revealed the resident was a 42-years-old male and admitted to the facility on [DATE] with diagnoses of muscle wasting and atrophy (loss of skeletal muscle mass), type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels), hypertension (high blood pressures), and heart failure (your heart can't pump enough oxygen-rich blood to meet your body's needs). Record review of Resident #18's admission MDS assessment, dated [DATE], revealed the resident's BIMS was 15 out of 15, which indicated the resident's cognitive was intact, required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) to sit to stand and chair to bed transfer, and had Diabetes Mellitus in section I (Active Diagnoses). Record review of Resident #18's comprehensive care plan, dated [DATE], revealed I [Resident #18] have diabetes and I am at risk for: Complications associated with diabetes: Frequent Infections, Diabetic wounds, Vision Impairment, Hyper\Hypo-Glycemia, Renal Failure, Cognitive\Physical Impairment. For intervention - Administer my medications as recommended by my doctor. Record review of Resident #18's physician order, dated [DATE], revealed the resident had the order of Janumet oral tablet 50-500 mg - Give one tablet by mouth two times a day related to Diabetes Mellitus. Record review of Resident #18's medication administration record from [DATE] to [DATE] revealed the resident was receiving Janumet oral tablet 50-500 mg - Give one tablet by mouth two times a day related to Diabetes Mellitus at 8:00 am and 5:00 pm. Observation on [DATE] at 4:21 p.m., revealed LVNN prepared Resident #18's medications in front of the resident's room. LVNN could not find Resident #18's Janumet from her cart, so LVNN tried to get this medication from the facility emergency medication cart, but there was no Janumet in the facility emergency medication cart. Further observation revealed LVNN reported it to the DON and primary care physician. During an interview on [DATE] at 4:32 p.m., with LVNN stated she did not give Resident #18's Janumet at this time because the medication was not available. LVNN said she reported it to the DON and primary care physician. The DON said she contacted to the facility pharmacy, and the DON would send the facility staff to pick up this medication, and the primary care physician said facility nurse could administer this medication to Resident #18 when the medication became available. LVNN said she was an agency nurse and worked as needed. However, the facility nurses should have re-ordered this medication on time to give this medication as scheduled. During an interview on [DATE] at 6:00 p.m., the DON stated Resident #18 received his Janumet at 6:00 p.m. because the facility staff picked it up from the pharmacy. The facility nurses should have re-ordered this medication on time to give this medication to the resident as scheduled. The facility did not have specific policy regarding re-ordering medications on time, but if nurses did not re-order medications on time, it might cause the resident to not take their medications as ordered. 2. Record review of Resident #150's face sheet, dated [DATE], revealed the resident was a 91-years old male and admitted to the facility on [DATE] with diagnosis of anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), glaucoma (an eye condition that damages the optic nerve. This damage can lead to vision loss or blindness), and muscle wasting and atrophy (loss of skeletal muscle mass). Record review of Resident #150's admission MDS assessment was in progress because the resident was admitted to the facility on [DATE]. Record review of Resident #150's baseline care plan, dated [DATE], revealed I [Resident #150] am at risk for vision loss/impairment: for intervention - Medications as ordered. Record review of Resident #150's physician order, dated [DATE], revealed Carboxymethylcellulose SodiumOphthalmic Solution 0.5 % (Carboxymethylcellulose Sodium (Ophth) Instill 1 drop in both eyes four times a day for dry eyes. Record review of Resident #150's medication administration record from [DATE] to [DATE] revealed the resident was receiving Carboxymethylcellulose Sodium Ophthalmic Solution 0.5 % (Carboxymethylcellulose Sodium (Ophth) Instill 1 drop in both eyes four times a day for dry eyes at 8:00 am, 12:00 pm, 5:00 pm, and 8:00 pm. Observation on [DATE] at 4:39 p.m., revealed LVNO did not administer Resident #150's Carboxymethylcellulose Sodium Ophthalmic Solution 0.5 % to both his eyes because the medication was not available. Further observation revealed LVNO did not report to the DON and primary care physician. LVNO went to the next resident to give medications. During an interview on [DATE] at 10:34 a.m., LVNO stated she did not administer Resident #150's Carboxymethylcellulose Sodium Ophthalmic Solution 0.5 % to both his eyes because the medication was not available and did not report it to the DON and primary care physician because she was busy passing medication to other residents. LVNO said nurses should have re-ordered this medication on time, but she did not know what reasons nurses did not re-order on time. During an interview on [DATE] at 9:43 a.m., the DON said she reported regarding Resident #150's Carboxymethylcellulose Sodium Ophthalmic Solution 0.5 % was not available to the primary care physician, and the physician said it was fine to administer this medication when this medication was available. The DON stated the facility nurses should have re-ordered this medication on time before nurses run out of the medication to make sure the resident received this mediation as ordered, and Resident #150 did not receive this medication as ordered, so it was a medication error, and the resident might not have therapeutic effect regarding his dry eyes. The facility did not have specific policy regarding re-ordering medications on time. 3. Record review of Resident #1's face sheet, dated [DATE], revealed the resident was 71-years-old female, originally admitted to the facility on [DATE], and re-admitted on [DATE] with diagnosis of lack of coordination (uncoordinated movement is due to a muscle control problem), type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels), Chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), and hypertension (high blood pressures). Record review of Resident #1's quarterly MDS assessment, dated [DATE], revealed the resident's BIMS was 6 out of 15, which indicated the resident had severe cognitive impairment, was dependent (Helper does ALL of the effort) to all activities daily living, and received insulin as ordered. Record review of Resident #1's comprehensive care plan dated [DATE], revealed I [Resident #1] have diabetes and I am at risk for Complications associated with diabetes: For intervention - Administer my medications as recommended by my doctor, monitor labs as indicated. Record review of Resident #1's physician order, dated [DATE], revealed HumaLOG Injection Solution 100UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 150 - 199 = 2; 200 - 249 = 4; 250 - 299 = 6; 300 - 349 = 8; 350 - 999 = 10 For B/S (blood sugar) greater than 400 give 10 units and notify MD (medical doctor), subcutaneously before meals and at bedtime for diabetes. Record review of Resident #1's medication administration record from [DATE] to [DATE] revealed the resident was receiving HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale at 7:00 am, 11:00 am, 4:00 pm, and 8:00 pm. Observation on [DATE] at 2:20 p.m., revealed Resident #1's HumaLOG Injection Solution 100UNIT/ML (Insulin Lispro) Inject Pen in the 200-unit C-hall nursing cart, and it was opened on [DATE]. During an interview on [DATE] at 2:20 p.m., LVNP stated she used Resident #1's HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject Pen around 7:00 am. LVNP said she checked the open date was [DATE] and thought it was fine to use this insulin because LVNP said she was confused regarding the date nurses should discard the insulin pen to 28 days after opened it. During an interview on [DATE] at 2:35 p.m., the DON stated the facility nurses had the responsibility to check their carts and should have discarded Resident #1's HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject Pen on [DATE] because it was opened on [DATE] and should have been discarded 28 days after opened it. The facility did not have a specific policy regarding when to discard an insulin pen, but the facility was following professional guidelines. Resident #1 might have not therapeutic effects regarding blood sugars. Record review of professional guidelines of https://www.healthline.com/health/diabetes/what-to-do-with-expired-insulin#expiration-dates, accessed [DATE], revealed Humalog/insulin lispro vials, pens, cartridges - expiration from the first use - 28 days.

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. The facility failed to ensure: 1. Dietary Aide B failed to wear beard restraints while working in the kitchen.2. Dietary Aide A did not properly wear hair restraints in a way that covered all their hair.3. The facility failed to store wet dishes to allow for air-drying.4. 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 08/24/2025 at 8:26 AM revealed a tray with lettuce, sliced tomato, sliced onion and cheese unlabeled, an open bag of lettuce unlabeled, and three drink dispensers with liquids unlabeled being stored in the walk in refrigerator. Observation of the facility's kitchen on 08/24/2025 at 11:59 AM revealed Dietary Aide A standing at the steam table not wearing facial hair restraint over his facial hair and Dietary Aide B wearing hair restraint in a way that did not cover all the hair on his head. Observation of the facility's kitchen on 08/25/2025 at 11:10 AM revealed Dietary Aide A not wearing facial hair restraint over his facial hair while in the kitchen. 9 trays of wet bowls (approximately 12 bowls on each tray) and 3 trays of wet mugs (approximately 15 mugs on each tray) being stored in a way that did not allow air flow was also observed in the kitchen. An interview with [NAME] C on 08/26/2025 at 1:42 PM revealed she worked at the facility about 8 months. [NAME] C stated all prepared items should be labeled before storing in the refrigerator. [NAME] C stated it was the responsibility of all staff to label items before storing items in the refrigerator. [NAME] C stated hairnets and facial hair restraints were to be worn to cover all hair while in the kitchen. [NAME] C stated it was the responsibility of all staff to ensure their hair nets and facial hair restraints covered all hair. [NAME] C stated dishes should be stored dry or in a way to allow air flow to dry. [NAME] C stated it was the responsibility of the dishwasher to ensure dishes were dried correctly. [NAME] C stated these failures could cause food to be contaminated and could have caused residents to become sick. [NAME] C stated she received training on food storage and labeling, hair restraints and washing and drying dishes from the dietary manager when she started working at the facility. An interview with Dietary Aide B on 08/26/2025 at 1:48 PM revealed he worked at the facility about 4 months. Dietary Aide B stated he was a dishwasher and did not handle food. Dietary Aide B stated all items stored in the walk-in refrigerator were to be labeled with the date opened and used by date. Dietary Aide B stated if he observed items unlabeled, he would report it to the cook or the dietary manager. Dietary Aide B stated it was the responsibility of all staff storing items in the walk-in refrigerator to label items before storing items. Dietary Aide B stated by not labeling food being stored it could cause spoiled foods to be served to residents causing them to get sick. Dietary Aide B stated hair nets were to be worn by all staff while they were in the kitchen. Dietary Aide stated on the date his hair was observed not in the hairnet he had tried to put it all up but because his hair was long it was difficult to get it all in the hairnet. Dietary Aide B stated hairnets prevented hair from falling into food and contaminating foods. Dietary Aide B stated contaminated foods could cause the residents to get sick. Dietary Aide B stated it was the responsibility of all staff to ensure hair restraints were worn correctly. Dietary Aide B stated dishes should be stored so that there is air flow to allow them to dry. Dietary Aide B stated bacteria could grow on dishes if not dried properly and could cause the residents to become ill. Dietary Aide B stated it was the responsibility of all staff to ensure dishes air dry. Dietary Aide B stated he received training on received training on food storage and labeling, hair restraints and washing and drying dishes from the dietary manager when he started working at the facility. Interview with Dietary Aide A on 08/26/2025 at 2:15 PM revealed he had worked for the facility about 9 months. Dietary Aide A stated prepared items stored in the walk-in refrigerator should be labeled before they were stored. Dietary Aide A stated it was the responsibility of everyone in the kitchen to ensure prepared items stored in the walk in were labeled. Dietary Aide A stated by not labeling items, spoiled items could have been served to residents causing them to get sick. Dietary Aide A stated hair restraints were to be worn by everyone while in the kitchen. Dietary Aide A hair restraints were to be worn to prevent hair from contaminating food. Dietary Aide A stated contaminated food could cause illness in the residents. Dietary Aide A stated it was the responsibility of all staff to ensure hair restraints were worn correctly. Dietary Aide A stated dishes should be stored in a way to allow air flow drying. Dietary Aide A stated bacteria could grow on dishes if not dried properly and could cause the residents to become ill. Dietary Aide A stated it was the responsibility of all staff to ensure dishes air dry. Dietary Aide A stated he received training on received training on food storage and labeling, hair restraints and washing and drying dishes from the dietary manager when he started working at the facility. Interview with the Dietary Manager on 08/26/2025 at 2:21 PM revealed prepared items being stored in the walk-in refrigerator were to be labeled and dated. The Dietary Manager stated it was the responsibility of all staff to label and date items before storing them. The Dietary Manager stated by not labeling items stored could result in spoiled items being served to residents causing illness. The Dietary Manager stated hair restraints were to be worn by everyone that entered the kitchen. Dietary Manager stated hair restraints prevent hair from falling into food and contaminating it. The Dietary manager stated contaminated foods had he potential to cause illness in the residents. Dietary Manager stated it was the responsibility of all staff to ensure hair restraint were worn correctly. The Dietary Manager stated dishes were to be stored to allow them to air dry. The Dietary Manager stated the wet dishes could cause bacteria to grow and could cause illness in the residents. The Dietary Manager stated it was the responsibility of all staff to ensure dishes were stored properly. The Dietary Manager stated he provides training to all new staff on labeling items being stored, wearing hairnet/facial hair restraints, and storing dishes when staff start working in the kitchen.Record review of facility policy named Food Storage dated October 1, 2018, revealed 2. Refrigeratorsd. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.Record review of facility policy named Policy: Mechanical Cleaning and Sanitizing of Utensils and Portable Equipment dated October 1, 2018, revealed 9. Air dry all equipment and utensils after sanitizing.Record review of facility policy named Employee Sanitation dated October 1, 2018, revealed 3. Employee Cleanliness Requirements b. Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces 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.Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022 states Except as provided in, (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on observation, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 5 residents (Residents #9, Resident #17 and Resident #105) reviewed for infection control. 1. The facility failed to ensure to utilize proper PPE for direct care of a resident with EBP precautions in place while performing Resident #9's suppository administration. 2. CNA E and CNA J did not clean Resident #17's anal area and rectum and left on his soiled socks when they performed incontinent care.3. LVN-Q measured Resident #105's blood pressure without cleaning the blood pressure cuff. These deficient practices could place residents at-risk for infection due to improper care practices. The findings were: 1.Record review of Resident #9's face sheet, dated 08/25/2025, revealed Resident #9 was admitted on [DATE] with diagnoses which included: infection following a procedure, other surgical site, subsequent encounter, and pressure ulcer of sacral region stage 4. Record review of Resident #9's Quarterly MDS assessment, dated 07/15/2025, revealed the resident's BIMS score 15 indicating intact cognition. The Quarterly MDS assessment further revealed Resident #9 had an ulcer unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar and that was present upon admission/entry. Record review of Resident #9's care plan, last review completed date 07/30/2025, revealed Resident #9 had a focus of At risk for infection or recurrent/chronic infection r/t compromised medical condition: and intervention/tasks Enhanced Barrier Precautions practice as clinically indicated. Record review of Resident #9's physician order summary, dated 08/25/2025, read, EBP (Enhanced Barrier Precautions): Practice EBP as indicated every shift with a start date of 04/08/2025. During observation and interview on 08/24/2025 at 9:30 a.m. it was observed Resident #9's room door had EBP sign on the outside of her room door. Resident #9 was observed lying in her bed and Resident #9 stated she had a wound to her buttock. Resident #9 stated staff did not wear a gown when performing her care. Observation on 08/25/2025 at 2:03 p.m. revealed after knocking on Resident #9's door and opening slightly LVN D standing to the opposite side of the bed elevating Resident #9's left leg and while not wearing a gown. LVN D stated she was performing patient care in which this surveyor closed the door. During an interview on 08/25/2025 at 2:08 p.m. LVN D informed surveyor she was placing a suppository due to Resident #9 had one ordered and then LVN D looked at the signage on the door for EBP. LVN D stated she should have been wearing a gown aside from just her gloves when performing care for Resident #9. LVN D again stated she had used gloves when providing care. LVN D then pushed the room door slightly open to check for the supplies with supplies noted to be by the door as one would enter the room. LVN D stated she should have been wearing gloves and a gown when caring for Resident #9. LVN D stated this was for infection control and to prevent transmissions. LVN D further stated by not wearing the proper PPE it could cause cross contamination to other residents. During an interview on 08/26/2025 at 11:50 a.m. the DNS stated LVN D should have worn a gown while administering the suppository to Resident #9 because she was on EBP to protect the patient and the employee from cross contamination. During an interview on 08/27/2025 at 1:37 p.m. the Administrator stated LVN D should have been wearing a gown while performing the care of Resident #9. The Administrator stated it was to protect and stop spreading infection, and for infection control. The Administrator stated by not wearing the proper PPE it could have spread anything contagious and potentially harm other residents. Record review of facility's Infection Prevention and Control policy, revised date April 2024, read, The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of a quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/oversight, guidance/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. Categories: Types of Isolation Precautions: Transmission-based isolation precautions have been adopted by our community to guide team members to have appropriate isolation techniques when necessary.In addition to isolation practices, Enhanced Barrier Precautions (EBP) maybe implemented as an infection control intervention designed to reduce transmission of resistant organisms. The use of PPE such as gown and glove use during high contact resident care activities. EBP may be indicated as recommendation by the CDC (when Contact Precautions do not otherwise apply) for residents. EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Use of eye protection may be necessary when splash or spray may occur but is not necessary in other situations. Resident/Patients with the following clinical indication should be under EBP: Significant Wounds such as chronic wounds, ulcers, open PUI or complicated/non-healing surgical incisions or wounds, and/or open wounds requiring a dressing.EBP should be utilized during high-contact resident care activities . 2. Record review of Resident #17's electronic face sheet dated 08/24/2025 reflected he was a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: myopathy (muscle disease which results in spasms, stiffness and cramps), acute respiratory failure with hypoxia (life-threatening condition characterized by insufficient oxygen in the blood), epilepsy (neurological condition characterized by recurrent seizures), suicidal ideations (thoughts or feelings about self-harm) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #17's quarterly MDS assessment with an ARD of 06/23/2025 reflected he could usually be understood and could usually understand others. He scored a six out of fifteen on his BIMS which indicated he was severely cognitively impaired. He was dependent on his ADL care except for eating where he required set up assistance. He was always incontinent of bowel and bladder. Record review of Resident #17's comprehensive care plan with an initiated date of 06/27/25 reflected Focus, I am at risk for depression: Chronic poor health, Focus, I am at risk for psychosocial or emotional distress, Goal, I will not experience any distress or discomfort that will affect my functional well-being, I have incontinence, revised on 08/04/25, Interventions, check and change on rounds as needed, Record review of Resident #17's Psychiatric Subsequent Assessment dated 08/01/2025 reflected he was treated for major depressive disorder, recurrent, severe with psychotic symptoms (a form of severe depression that includes symptoms of psychosis, a break from reality, such as hallucinations (seeing, hearing, or feeling things that are not there) or delusions (false, fixed beliefs), generalized anxiety disorder (a chronic mental health condition characterized by excessive, persistent, and uncontrollable worry about various everyday events or situations) and insomnia (a sleep disorder characterized by difficulty falling or staying asleep, resulting in daytime fatigue and impairment). Observation on 08/26/2025 at 4:00 pm of CNA J and CNA E performed incontinent care for Resident #17 revealed he was lying in bed and his pants, and the back of his shirt was wet with urine. The bed sheet he was lying on had a large ring of wet urine which extended to his curled-up legs and anti-skid socks he wore on his feet. CNA E cleaned her hands and put on gloves. CNA E went into his shower room to clean his chair he was sitting on and found a pair of pants covered with feces lying over the shower chair. As CNA E proceeded with CNA J to do a complete bed change. CNA E took off her soiled gloves, sanitized hands and put on clean gloves, she then removed Resident #17's-soaked pants, degloved, washed hands and put clean gloves on. She then had the dirty linen removed, bed sanitized, and applied clean bedding rolled under to complete the bed change. While cleaning and changing the resident's brief, CNA E cleaned the resident's penis, scrotum and wiped the top of his legs which had contact with the resident's soiled pants. CNA J assisted to roll Resident #17 onto his right side and pulled the clean linen through. CNA J wiped the buttocks of Resident #17, and the resident was turned back toward CNA E. They proceeded to change Resident #17's wet shirt and clean any exposed areas of skin. Resident #17 was turned back toward CNA E and the clean brief was slid through. As CNA J was about to pull through the clean brief, the surveyor requested they clean Resident 17's buttocks and anus area. Resident #17 had feces around his anal and rectal area. CNA E and CNA J neglected to remove Resident #17's nonskid socks which were lying on the urine-soaked area of the sheet which were now lying on the clean sheet. During an interview on 08/26/2025 at 4:30 pm CNA E said she was frustrated and she did not remember to take off Resident #17's socks which were lying on the wet sheet. She knew she checked Resident #17's buttocks but did not spread them and clean his rectum and anus. She stated not cleaning the resident, changing his socks and having soiled clothing in his room could cause cross contamination and infection. During an interview on 08/26/2025 at 4:40 pm LVN H who was charge nurse for Resident #17's unit revealed she stated she checked the resident, and he was dry when they put him to bed at 3:00 pm. She stated she had not entered the resident's bathroom during the day and did not see the soiled pants. She stated leaving soiled linen in the room could result in cross contamination and infection. During an interview on 08/26/2025 at 4:45 pm CNA G, stated she did rounds but did not check Resident #17 and took the previous CNA's word that she just changed and did rounds on the residents. During an interview on 08/27/2025 at 09:36 am, the DON, stated that Resident #17 should have been checked to see if he was wet or soiled. She stated Resident # 17 should not have had soiled clothing left in his room, and CNA E and J needed to ensure his anal and rectal area was cleaned as part of incontinent care. She said leaving him in soiled socks could result in infection by cross contamination. Record review of CNA E's Peri Care Audit Tool dated 07/30/2025 reflected Male, buttocks, using incontinent wipe, wash sides, then middle reflected she met the competency skill. Record review of CNA J's Peri Care Audit Tool dated 07/20/2025 reflected Male, buttocks, using incontinent wipe, wash sides, then middle reflected she met the competency skill. Record review of the facility policy and procedure titled Infection Prevention and Control revised April 2024 reflected The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program, includes all staff to include direct and indirect care functions. 3. Record review of Resident #105's face sheet, dated 08/27/2025, revealed the resident was 72-years-old female, originally admitted to the facility on [DATE], and re-admitted on [DATE] with diagnosis of cerebral ischemia (condition that occurs when there is not enough blood flow to the brain), muscle wasting and atrophy (loss of skeletal muscle mass), hypertension (high blood pressures), muscle weakness, and pleura effusion (collection of fluid around your lungs). Record review of Resident #105's quarterly MDS assessment, dated 08/07/2025, revealed the resident's BIMS was 15 out of 15, which indicated the resident's cognitive was intact and required Supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) to sit to stand and toilet transfer. Record review of Resident #105's comprehensive care plan, dated 07/12/2025, revealed I [Resident #105] am at risk for significant infections and/or recurrent infections r/t compromised medical condition. For intervention - Provide education to team members, resident and/or visitors regarding infection prevention practices as indicated. Observation on 08/26/2025 at 8:28 a.m., revealed LVNQ came out from Resident #105's next door with a blood pressure cuff and said she completed measuring blood pressure and giving all medications to this resident and went to Resident #105 to give medications. Further observation on 08/26/2025 at 8:29 a.m., revealed LVNQ entered to Resident #105's room and measured the resident's blood pressure without cleaning the blood pressure cuff. During an interview on 08/26/2025 at 8:42 a.m., LVNQ said she measured Resident #105's blood pressure without cleaning the blood pressure cuff. LVNQ stated she should have cleaned the blood pressure cuff before using it on Resident #105 to prevent possible infection. During an interview on 08/27/2025 at 9:43 a.m., the DON stated LVNQ should have cleaned the blood pressure cuff before using it on Resident #105 to prevent possible infection, she said there was no specific policy for cleaning a blood pressure cuff. Record review of the facility policy and procedure titled Infection Prevention and Control revised April 2024 reflected The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program, includes all staff to include direct and indirect care functions.

Based on observation, interviews and record reviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for two (Resident #17 and Resident #108) of 32 residents observed for dignity and respect. 1. CNA E and J left Resident #17's anti-slip socks which were lying on a urine-soaked sheet on his feet after incontinent care. 2. LVN, I did not knock on Resident #108's door prior to entering his room to administer G-tube medications. These deficient practices could affect residents who require assistance with ADL's and could result in loss of dignity and decreased self-esteem.The findings included: 1. Record review of Resident #17's electronic face sheet dated 08/24/2025 reflected he was a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: myopathy (muscle disease which results in spasms, stiffness and cramps), acute respiratory failure with hypoxia (life-threatening condition characterized by insufficient oxygen in the blood), epilepsy (neurological condition characterized by recurrent seizures), suicidal ideations (thoughts or feelings about self-harm) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #17's quarterly MDS assessment with an ARD of 06/23/2025 reflected he could usually be understood and could usually understand others. He scored a 06 of 15 on his BIMS which indicated his cognition was severely impaired. He was dependent on his ADL care except for eating where he required set up assistance. He was always incontinent of bowel and bladder. Record review of Resident #17's comprehensive care plan with an initiated date of 06/27/25 reflected Focus, I am at risk for depression: Chronic poor health, Focus, I am at risk for psychosocial or emotional distress, Goal, I will not experience any distress or discomfort that will affect my functional well-being, I have incontinence, revised on 08/04/25, Interventions, check and change on rounds as needed, Record review of Resident #17's Psychiatric Subsequent Assessment dated 08/01/2025 reflected he was treated for major depressive disorder, recurrent, severe with psychotic symptoms (a form of severe depression that includes symptoms of psychosis, a break from reality, such as hallucinations (seeing, hearing, or feeling things that are not there) or delusions (false, fixed beliefs), generalized anxiety disorder (a chronic mental health condition characterized by excessive, persistent, and uncontrollable worry about various everyday events or situations) and insomnia (a sleep disorder characterized by difficulty falling or staying asleep, resulting in daytime fatigue and impairment). Observation on 08/26/2025 at 4:00 pm of CNA J and CNA E performing incontinent care for Resident #17 revealed he was lying in bed and his pants, and the back of his shirt were wet with urine. The bed sheet he was lying on had a large ring of wet urine which extended to his curled-up legs and anti-skid socks he wore on his feet. At the completion of the peri-care for Resident #17, CNA E and CNA J appeared to be finished with the peri care and pulled a clean brief up onto the resident and did not remove Resident #17's socks. During an interview on 08/26/2025 at 4:30 pm with CNA E who admitted she was frustrated revealed she did not remember to take off Resident #17's socks which were lying on the wet sheet. She stated it could affect his rights to dignity and to have a clean sanitary area. She stated he could become more depressed or have a loss of self-esteem. During an interview on 08/26/2025 at 4:35 pm with CNA J, she stated she and CNA E forgot to change Resident #17's socks and would change his bed linen again. She stated being in wet socks could affect his self-esteem and he had a right to dignity. During an interview on 08/26/2025 at 4:40 pm with LVN H who was charge nurse on Resident #17's unit revealed she had checked the resident, and he was dry when they put him to bed at 3:00 pm. During an interview on 08/26/2025 at 4:45 pm with CNA G, she stated she did rounds but did not check Resident #17 and took the previous CNA's word that she had just changed and did rounds on the residents. During an interview on 08/27/2025 at 09:36 am with the DON, she stated that Resident #17 should have been checked to see if he was wet or soiled. She stated leaving his soiled socks on, having a soiled pair of socks on him could result in further depression or lack of self-esteem. 2. Record review of Resident #108's electronic face sheet dated 08/24/2025 reflected he was a [AGE] year-old male, originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: Cerebral Palsy (a lifelong movement disorder caused by non-progressive brain damage that occurs before, during or shortly after birth, affecting muscle coordination and tone), malignant neoplasm of rectum (cancer that develops in the rectum, the lower part of the large intestine), moderate intellectual disabilities (slow in the understanding and use of language, basic reading, writing, and counting skills), gastroparesis (stomach muscles do not work properly) and anxiety (common mental health condition characterized by excessive worry, fear, and nervousness). Record review of Resident #108's admission MDS assessment dated [DATE] reflected he could sometimes understand and sometimes be understood. He scored a 00 out of 15 on his BIMS which indicated his cognition was severely impaired. He was dependent on staff for his ADL care and had enteral feedings. Record review of his comprehensive care plan revised date 08/11/2025 reflected Focus, I have a Self-Care deficit, cognitive impairment, poor physical functioning, weakness and debility, Interventions, assist with ADLs. Observation on 08/26/2025 at 4:30 pm of LVN I, revealed she did not knock on Resident #108's door prior to entering his room to administer G-tube medications. During an interview on 08/26/2025, LVN I stated she was trained to respect residents' privacy and knew she needed to knock on Resident #108's door prior to entry. She stated not knocking showed a lack of respect and right to privacy. During an interview on 08/27/2025 at 09:36 am with the DON, she stated LVN I needed to knock on Resident #108's door prior to entry. She stated not knocking could be disrespectful of his rights to privacy. Record review of the facility policy and procedure titled Respect and Dignity revised January 2023 reflected The community promotes care for residents in a manner and environment that enhances each resident's dignity and respect in full recognition of their individuality. Dignity means that the team members conduct activities that assist the resident to maintain and enhance self-esteem and self-worth, team members knock on room doors and request permission to enter.Record review of the facility policy and procedure titled Routine Resident Care date revised January 2023 reflected 7. Incontinence care should be offered and provided timely in accordance with individual needs.

Based on observation, interviews and record reviews, the facility failed to provide the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or residents for one resident (Resident #17) of 32 residents observed for accommodation of needs. Resident #17's call light was located approximately 3 feet from the resident and wrapped around his wheelchair arm rest. This deficient practice could affect residents who require assistance with ADL's and could result in loss of getting needs met. The findings included: Record review of Resident #17's electronic face sheet dated 08/24/2025 reflected he was a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: myopathy (muscle disease which results in spasms, stiffness and cramps), acute respiratory failure with hypoxia (life-threatening condition characterized by insufficient oxygen in the blood), epilepsy (neurological condition characterized by recurrent seizures), suicidal ideations (thoughts or feelings about self-harm) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #17's quarterly MDS assessment with an ARD of 06/23/2025 reflected he could usually be understood and could usually understand others. He scored a 06 of 15 on his BIMS which indicated his cognition was severely impaired. He was dependent on his ADL care except for eating where he required set up assistance. He was always incontinent of bowel and bladder. Record review of Resident #17's comprehensive care plan with an initiated date of 06/27/25 reflected Focus, I am at risk for depression: Chronic poor health, Focus, I am at risk for psychosocial or emotional distress, Goal, I will not experience any distress or discomfort that will affect my functional well-being, I have been noted to chew on call light-bell to be used, revised on 08/19/2025, I will be able to utilize my bell without noted decline, Focus, I am at risk for falls, revised on 05/05/2025, Interventions, Anticipated and meet needs and keep call bell within reach. Record review of Resident #17's Psychiatric Subsequent Assessment dated 08/01/2025 reflected he was treated for major depressive disorder, recurrent, severe with psychotic symptoms (a form of severe depression that includes symptoms of psychosis, a break from reality, such as hallucinations (seeing, hearing, or feeling things that are not there) or delusions (false, fixed beliefs), generalized anxiety disorder (a chronic mental health condition characterized by excessive, persistent, and uncontrollable worry about various everyday events or situations) and insomnia (a sleep disorder characterized by difficulty falling or staying asleep, resulting in daytime fatigue and impairment). Observation on 08/24/2025 at 09:40 am, Resident #17 was in his room, lying on a low bed with mat on the floor. The room had an odor of stale urine. Resident #17 was reaching out and acted like he was trying to get someone's attention. When asked by the surveyor if he could reach and use his call light he stated no and moved his hand to illustrate pressing a call light button. His call light cord and button were located approximately three feet from the bed wrapped around the left arm rest of his tall wheelchair. During an interview on 08/26/2025 at 4:40 pm with LVN H who was charge nurse on Resident #17's unit revealed she had checked the resident, and he was dry when they put him to bed at 3:00 pm. She stated she had not noticed his call light was not a call bell as care planned and that it was not within reach since she was on the unit. She stated it was important for him to have a call bell and for it to be within reach in case he needed something. During an interview on 08/27/2025 at 09:36 am with the DON, she stated that Resident #17 should have had a call bell because he chewed on the call light. She did not know why he did not have one, and she stated she would get it fixed immediately. She stated he needed to be able to call staff for assistance and care. Record review of the Code of Federal Regulations, Title 42 as of 08/28/2025 reflected Resident Rights, the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. Record review of the facility's policy and procedure titled Routine Resident Care, revised date January 2023 reflected 8. Resident call lights should be answered timely and resident requests are addressed. Specific types of call lights, i.e., call light pads, etc. should be added to the resident care plan of care based upon residents' abilities and limitations.

The facility failed to ensure that a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; a resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one resident (#41) out of .three residents reviewed for indwelling urinary catheters. The facility failed to have a diagnosis or physicians order for August 2025 for Resident #41's indwelling urinary catheter. This deficient practice affects residents with indwelling urinary catheters and could result in an inconsistency of care. The findings included: Record review of Resident #41's electronic face sheet dated 08/25/2025 reflected she was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: muscle wasting and atrophy (decrease in muscle size and mass, which results in reduced muscle strength and function), pain due to internal orthopedic prosthetic devices (can arise from surgical complications, mechanical issues with the implant), diabetes mellitus (a chronic metabolic disorder characterized by high blood sugar (glucose) levels), osteoporosis (a condition that weakens bones, making them more prone to fractures), post viral fatigue syndrome (debilitating state of physical and mental exhaustion that persists for weeks or months after a viral infection has cleared) and dementia (loss of cognitive functioning-thinking, remembering, and reasoning-to such an extent that it interferes with a person's daily life and activities). Record review of Resident #41's quarterly MDS assessment with an ARD of 07/17/2025 reflected she could usually understand and usually be understood. She was not a candidate for a BIMS which indicated she was severely cognitively impaired. She was dependent on staff for ADLs except for eating where she required set up assistance. She was always incontinent of bowel and bladder. An indwelling urinary catheter was not reflected. Record review of Resident #41's comprehensive care plan revised date 12/27/2023 reflected Focus, I have a Self-Care deficit r/t Poor physical functioning, weakness and debility, incontinent of bladder and incontinent of bowel. Resident #41's comprehensive person-centered care plan did not reflect an indwelling urinary catheter. Observation on 08/24/2025 at 10:30 am revealed Resident #41 was on contact isolation and EBP. She had a bin outside of her room which contained PPE. She was lying in bed and had a covered urinary drainage bag hanging on the side of her bed frame. Observation on 08/25/2025 at 04:20 pm revealed CNA K and CNA L performed catheter care for Resident #41, CNA K wiped from front to back, cleaned the tip of the catheter and from front out down the tubing. Resident #41's perineal area was cleaned. Aseptic technique was used by both CNA's. Record review of Resident #41's physician order dated 07/15/2025 reflected Collect urine via PVR, urethral catheterization. If residual greater than 250ml leave urethral catheter in place. Record review of Resident #41's Nursing Progress Note dated 07/15/2025 written by LVN D reflected Urine sample collected and sent in hand with lab personnel. Residual greater than 250 cc. Foley catheter remains in place with balloon inflated with 10 cc NS via syringe. Record review of Resident #41's Documentation Survey Reports dated July and August 2025 reflected from 07/15/2025 to 08/04/2025 when the resident went out to the hospital for a change in condition, she had an indwelling urinary catheter. Record review of Resident #41's hospital notes dated 08/14/2025 prior to her discharge back to the facility reflected ESBL, E. Coli, Chronic indwelling Foley catheter (replaced in ED on 08/04/2025). Record review of Resident #41's EMR reflected she had a urinary catheter placed on 07/15/2025 for a change in condition, decreased output, and poor intake. Her physician orders nor diagnoses were updated. She was sent to the hospital on [DATE] with an indwelling urinary catheter which was replaced in the ED. She returned to the facility on [DATE] with an indwelling urinary catheter. She had no active orders, nor diagnosis for the catheter at the time of survey. During an interview on 08/27/25 at 09:36 am, the DON stated Resident #41's had an indwelling urinary catheter related to urinary retention and confirmed the diagnosis, nor the catheter, to include orders for catheter care were in her physician orders for August 2025. She stated Resident #41 was on Hospice. She stated not having the orders or a diagnosis did not meet professional standards for having an indwelling urinary catheter and could affect care and result in urinary tract infections or complications. Record review of the facility policy and procedure titled Incontinence and Catheterization Assessment and Evaluation revised January 2023 reflected: Residents who enter the community without an indwelling catheter are not catheterized unless the resident's clinical condition makes catheterization necessary. The community will assess at risk for urinary catheterization and will provide ongoing assessment for the resident who currently has a catheter. This is followed by implementation of appropriate individualized interventions and monitoring for the effectiveness of the interventions. Recognize and assess factors affecting the resident's urinary function and identified the medical justification for the use of an indwelling urinary catheter. Define and implement pertinent interventions consistent with resident conditions, goals and recognized standards of practice to try and minimize complications from and indwelling urinary catheter.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for one (Resident #174) of six Residents who were reviewed for respiratory care. Resident #174's tubing and mask which were attached to a nebulizer for the resident's breathing treatment were not covered in a plastic bag when not in use. This deficient practice could place residents at risk of respiratory distress, infections, pneumonia and an overall decline in their physical condition.The findings were: Record review of Resident #174's face sheet, dated 08/27/2025, revealed the resident was 70-years-old male who was admitted to the facility on [DATE] with diagnosis of lack of coordination (uncoordinated movement is due to a muscle control problem), type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels), chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems), and acute respiratory failure (difficulty of breathing). Record review of Resident #174's admission MDS revealed the MDS assessment was in progress because the resident was admitted to the facility on [DATE]. Record review of Resident #174's baseline care plan, dated 08/16/2025, revealed the resident had the care for shortness of breath and providing breathing treatment as ordered. Record review of Resident #174's physician order, dated 08/16/2025, revealed Levalbuterol Inhalation Nebulization Solution 0.31 MG/3ML (Levalbuterol HCl) 1 application inhale orally via nebulizer four times a day relatedto CHRONIC OBSTRUCTIVE PULMONARY DISEASE. Observation on 08/24/2025 at 10:32 a.m., revealed Resident #174 was on the bed and sleeping in his room, the was tubing and mask attached to the nebulizer on the nightstand, and the tubing and mask was not covered in a plastic bag. During an interview on 08/24/2025 at 10:39 a.m., LVNM stated Resident #174's tubing and mask which was attached to a nebulizer for the resident's breathing treatment was not covered in a plastic bag when the facility did not use the tubing and mask, and the tubing and mask should have been covered in a plastic bag when they were not used to prevent possible infection. During an interview on 08/27/2025 at 2:49 p.m., the DON said Resident #174's tubing and mask should have been covered in a plastic bag when they were not used to prevent possible infection. Record review of the facility policy, titled Respiratory Tubing/Equipment Management, dated 03/12/2018, revealed To maintain properly functioning equipment and decrease the potential for the spread of infection by maintain clean equipment and tubing bottles and masks.

Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7.41% based on 2 errors out of 27 opportunities, which involved one (Residents #150) of seven residents reviewed for medication errors. a. LVNO did not administer Resident #150's Carboxymethylcellulose Sodium Ophthalmic Solution 0.5 % to both his eyes for dry eyes because the medication was not available on 08/25/2025 at 4:39 p.m. b. LVNO administered Resident #150's Timolol maleate 0.5 % eye drop for glaucoma on 08/25/2025 at 4:39 p.m., but the order and schedule was Administer Timolol maleate 0.5 % eye drop for glaucoma every 12 hours to Resident #150 at 8:00 am and 8:00 pm. These failures could place residents at risk of not receiving the intended therapeutic benefits of their medications or not receiving them as prescribed, per physician orders.Findings include: Record review of Resident #150's face sheet, dated 08/27/2025, revealed the resident was a 91-years old male and admitted to the facility on [DATE] with diagnosis of anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), glaucoma (an eye condition that damages the optic nerve. This damage can lead to vision loss or blindness), and muscle wasting and atrophy (loss of skeletal muscle mass). Record review of Resident #150's admission MDS assessment was in progress because the resident was admitted to the facility on [DATE]. Record review of Resident #150's baseline care plan, dated 08/10/2025, revealed I [Resident #150] am risk for vision loss/impairment: for intervention - Medications as ordered. Record review of Resident #150's physician order, dated 08/15/2025, revealed Carboxymethylcellulose SodiumOphthalmic Solution 0.5 % (Carboxymethylcellulose Sodium (Ophth) Instill 1 drop in both eyes four times a day for dry eyes. Further record review of the resident's physician order, dated 08/11/2025, revealed Timolol Maleate Gel FormingSolution 0.5 % Instill 1 drop in both eyes two times a day for eye pressure (glaucoma). Record review of Resident #150's medication administration record from 08/01/2025 to 08/31/2025 revealed the resident was receiving Carboxymethylcellulose Sodium Ophthalmic Solution 0.5 % (Carboxymethylcellulose Sodium (Ophth) Instill 1 drop in both eyes four times a day for dry eyes at 8:00 am, 12:00 pm, 5:00 pm, and 8:00 pm. Further record review of the medication administration record revealed the resident was receiving Timolol Maleate Gel FormingSolution 0.5 % Instill 1 drop in both eyes two times a day for eye pressure (glaucoma) every 12 hours at 8:00 am and 8:00 pm. Observation of medication pass on 08/25/2025 at 4:39 p.m., revealed LVNO did not administer Resident #150's Carboxymethylcellulose Sodium Ophthalmic Solution 0.5 % to both his eyes because the medication was not available, and LVNO did not report it to the DON and primary care physician. Further observation revealed LVNO administered one drop of Timolol Maleate Gel Forming Solution 0.5 % to both eyes on 08/25/2025 at 4:39 p.m. During an interview on 08/26/2025 at 10:34 a.m., LVNO stated she did not administer Resident #150's Carboxymethylcellulose Sodium Ophthalmic Solution 0.5 % to both his eyes because the medication was not available, and she did not report it to the DON and primary care physician because she was busy passing medication to other residents. LVNO said the nurses should have re-ordered this medication on time, but she did not know what reasons the nurses did not re-order on time. Further interview with LVNO said she administered one drop of Timolol Maleate Gel Forming Solution 0.5 % to both eyes on 08/25/2025 at 4:39 p.m., LVNO said she was a little bit confused regarding the time, and that was why she administered it at 4:39 pm, instead of 8:00 pm, and the nurse said it was medication error because LVNO should have administered this medication one hour before or one hour after, which indicated 7:00 pm or 9:00 pm. During an interview on 08/27/2025 at 9:43 a.m., the DON said she reported regarding Resident #150's Carboxymethylcellulose Sodium Ophthalmic Solution 0.5 % was not available to the primary care physician, and the physician said it was fine to administer this medication when this medication was available. The DON stated the facility nurses should have re-ordered this medication on time to make sure the resident received this mediation as ordered, she said this was a medication error. The DON said LVNO should have administered Resident #150's Timolol Maleate Gel Forming Solution 0.5 % one hour before or one hour after, which indicated 7:00 pm or 9:00 pm and that was a medication error. The DON said Resident #150 might not have therapeutic effects due to these errors, but the physician said there was no adverse effect to the resident. Record review of the facility policy, titled Medication Administration, revised 01/2024, revealed Resident medications are administered in an accurate, safe, timely, and sanitary manner. 6. Administer medications as ordered by the physician. Routine medications shall be administered according to the established medication administration scheduled for the community.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 (treatment cart) of 5 nursing carts and 1 resident (Resident #34) of 32 residents reviewed for storage, in that: 1. The facility failed to ensure the treatment cart was locked when left unattended. 2. The facility failed to notice and remove a jar of medicated chest rub from Resident #34's nightstand. This failure could place residents at risk of misappropriation of medications and not receiving therapeutic benefits of medications. The findings were: 1. During an observation on 08/25/2025 at 10:50 a.m., revealed the treatment cart was found unlocked and unattended on the 300-unit B-hallway. This surveyor was able to open all drawers revealing multiple medications and ointments, scissors, and bottles of medications. During an interview on 08/25/2025 at 10:52 a.m., the wound care nurse stated the treatment cart was unlocked and unattended on the 300-unit B-hallway. The wound care nurse stated she did not realize she left the cart unlocked. The wound care nurse stated it was important the treatment cart was locked at all times due to resident, visitor, and staff safety. The wound care nurse stated by the treatment cart being unlocked, anyone could get into the cart and take medications or scissors from the cart. During an interview on 08/27/2025 at 9:43 a.m., the DON stated the treatment cart should not have been unlocked as it would not be safe for residents and visitors. The DON stated if the treatment cart was not locked someone other than the nurse, like a resident with dementia, could open the cart, take out the medications and take them. The DON said the wound care nurse was responsible for overseeing this and monitored if or not the cart was locked sometimes. 2. Record review of Resident #34's electronic face sheet dated 08/25/2025 reflected she was an [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: muscle wasting and atrophy (progressive loss or weakening of muscle tissue, characterized by a reduction in muscle size and mass), chronic obstructive pulmonary disease (group of lung diseases that cause airflow obstruction and breathing difficulties), pain (physical suffering or discomfort caused by illness or injury), and major depressive disorder (mood disorder that causes a persistent feeling of sadness or loss of interest and can interfere in daily activities). Record review of Resident #34's annual MDS assessment with an ARD of 07/25/2025 reflected she could understand and be understood. She scored 13 of 15 on her BIMS which indicated her cognition was intact. She required minimal assistance with ADLs. She had an active diagnosis of pain. She had received, was offered, or declined PRN pain medication within the previous five days. Review of section N0415 High-Risk Drug Classes: Use and Indication reflected she was not taking an opioid medication. Record review of Resident #34's comprehensive care plan revised 04/17/2023 reflected Focus, I am at risk for experiencing discomfort or pan r/t: Hx of fractures, co-morbid medical conditions and joint discomfort, Interventions/Tasks, administer my medications to relieve my pain as recommended by my doctor. Record review of Resident #34's Active Orders As of: 08/25/2025 reflected no order for medicated chest rub, or for the resident to self-medicate. Observation on 08/24/2025 at 09:40 am revealed Resident #34 was sitting up in her bed the jar of medicated chest rub was sitting on her nightstand. Observation on 08/25/2025 at 2:00 pm of Resident #34 revealed she was talking with a psychotherapist and the medicated chest rub was on her nightstand. Record review of the label on the jar of medicated chest rub reflected ingredients: Camphor 4.8%, Eucalyptus Oil 1.2% and Menthol 2.6 %, the same ingredients in Vicks VapoRub. Safety warning for external use only. DO NOT USE by mouth, in nostrils or wounds or damaged skin. You should not use on lips because active ingredients like menthol and camphor can be drying, irritating, and toxic if ingested or absorbed through mucous membranes and can cause adverse reactions. During an interview on 08/24/2025 at 10:46 am, Resident #34 stated she used the medicated chest rub on her lips at night, and she had it for a while, and could not remember when or how she acquired the rub. During an interview on 08/26/2025 at 4:45 pm with LVN H, who was the charge nurse on the hall for Resident #34, she stated she had not seen the jar of medicated chest rub in the resident's room. She stated she would have removed it because if the resident used it inappropriately, it could cause her harm. During an interview] on 08/27/25 at 09:36 am, the DON stated she would talk to Resident #34 and remove the jar of medicated chest rub immediately. She stated she was unaware the resident had the medication, and she could have ordered it online or had someone bring it in. She stated even though the resident was cognizant having medicinal ointments or creams at bedside could be harmful for her if used inappropriately. Record review of the facility's policy, titled Medication cart use and storage, revised 01/2023, revealed The medication cart and its storage bins should be kept closed, secured and/or in the line of sight when not in use.

Based on interview and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System for 1 of 2 residents (Resident #70) reviewed for MDS transmission. Resident #70's discharge MDS assessment was not transmitted within 14 days of completion. This deficient practice placed residents at risk of not having assessments submitted in a timely manner as required. The findings were: Review of Resident #70's face sheet, dated 08/27/2025, revealed an admission date of 04/09/2025 with diagnoses that included: alcohol dependence with withdrawal, unspecified, cyst of kidney, alcoholic hepatitis without ascites, other specified anemias, fatty (change of) liver, not elsewhere classified, acute metabolic acidosis, anxiety disorder, unspecified, acute and chronic respiratory failure with hypoxia. Review of Resident #70's Discharge MDS Assessment, dated 05/02/2025, revealed the assessment had not been transmitted to CMS. During an interview on 08/27/2025 at 10:00 a.m. the NAS stated she was not responsible for transmitting anything. The NAS further stated typically they had an RN who would come sign the MDS for completion and the RN would be the person who would transmit the MDS. The NAS stated she believed it was within 14 days once the MDS was signed and completed that it must be transmitted to CMS, but she was not sure. The NAS reviewed the Discharge MDS assessment for Resident #70 and revealed MDS SS signed and completed the Discharge MDS assessment 05/02/2025. The NAS further stated the Discharge MDS Assessment for Resident #70 had been sent on 08/25/2025, but she was not the one to send the completed MDS to CMS. During an interview on 08/27/2025 at 10:26 a.m. the DOCR stated the facility had 14 days from the ARD to complete the MDS. The DOCR further stated once the MDS was completed they had 14 days to transmit the MDS. The DOCR stated Resident #70's Discharge MDS assessment was late in being transmitted and further stated she was not sure why it was submitted/transmitted late. The DOCR stated the MDS coordinators (NAS) were responsible for the completion of the MDS assessments and ensuring the submission was done timely. The DOCR further stated typically the MDS SS was the RN who would sign the MDS completion for the community and transmit it. During an interview on 08/27/2025 at 10:50 a.m. MDS SS stated she believed she completed Resident #70's Discharge MDS Assessment on Monday morning which was 08/25/2025. The MDS SS stated the Discharge MDS Assessment would be opened as soon as someone discharged and had 14 days to complete the MDS. The MDS SS stated once the MDS assessment was completed it was added to the next batch to be transmitted to CMS, and it was transmitted through PCC. The MDS SS stated she believed they had 30 days once an MDS was completed to transmit but she was not sure. The MDS SS stated Resident #70 Discharge MDS Assessment got missed and she was asked to complete the MDS. The MDS SS stated they completed it as soon as they realized it. The MDS SS stated she did not feel there would have been a negative outcome because people were not going to look the MDS to care for the resident. During an interview on 08/27/2025 at 12:07 p.m. the DNS stated the NAS was responsible for the completion of the MDS assessments. The DNS further stated a possible negative effect could be it might have delayed the payment of services that were provided. During an interview on 08/27/2025 at 1:41 p.m. the Administrator stated the NAS was responsible for the completion and the transmission of the MDS Assessments. The Administrator stated not transmitting the MDS assessments could have caused an issue with the completion of the assessment and continuity of the care and further stated not transmitting the MDS assessments timely could cause an issue with billing. Record review of facility's policy titled Comprehensive Assessments, revised date March 2023, read The community conducts frequent and different types of assessments, depending on the resident's condition and need.Transmitting Data: Within seven days after completion of a resident's assessment, the community will transmit to the state information for each resident contained in the MDS. Monthly Transmittal Requirements: The community electronically transmits, at least monthly, encoded, accurate, complete MDS data to the state for all assessments conducted during the previous month.

Based on observations, interviews and record reviews, the facility failed to post the following information on a daily basis for one of one facility.The facility failed to post daily staffing and census requirements for 5 days.This deficient practice affects, residents, visitors and staff and could result in a misconception of staff availability for care. The findings included: Observation on 08/24/2025 at 08:50 am, daily staffing dated 08/19/2025 was posted in a hard plastic display frame on the first nurses station counter. Interview on 08/27/2025 at 09:36 am, the DON stated the person who normally posted the staffing was out and it was missed from August 19, 2025, up to August 24, 2025. She stated the importance of having the nursing staff posted was to show how many staff were available in case of emergency and for needed care. Record review of the facility policy and procedure titled Nursing Services revised January 2023 reflected The community maintains and posts continuous time schedules showing the number and classification of nursing personnel, including relief personnel, who are scheduled or who worked in each unit during each tour of duty. The time schedules will be maintained for the period specified by community policy or for at least two years following the last day in the schedule.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Resident #2) reviewed for pharmacy services.LVN A did not administer Resident #2's Famotidine (Pepcid) 10 mg oral one tablet a day for indigestion on 07/20/2025 because she could not find the medication in the medication cart where it was stored. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings were:Record review of Resident #2's admission Record (Face Sheet), dated 07/21/2025, revealed she was [AGE] years old, was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (decline in mental ability which can interfere with daily life) and GERD without esophagitis (a chronic condition when stomach acid flows back into the esophagus causing symptoms such as heartburn, regurgitation, and can cause irritation to the esophagus/throat).Record review of Resident #2's MDS, a Quarterly assessment dated [DATE], revealed a BIMS score of 11 out of 15 indication her cognitive skills for daily decision making were moderately impaired.Record review of Resident #2's Care Plan for I have impaired cognitive function/impaired thought process related to dementia initiated 07/27/2023 and for I am at risk for nutritional deficits and or dehydration risks related to diagnosis.GERD initiated 2/26/25, reflected interventions listed which included Administer medications as ordered.Record review of Resident #2's Physician Order Summary, dated 07/21/2025, revealed an order for Famotidine (Pepcid - a medication to treat GERD, heartburn) oral tablet 10 mg give 1 tablet by mouth one time a day for indigestion.Record review of Resident #2's July 2025 MAR revealed on 07/20/2025 the Pepcid/Famotidine 10 mg was not administered by LVN A, and she had coded 9 other: Nurse Verbally Informed.Observation and interview on 07/20/2025 from 10:33 AM to 10:41 AM of LVN A's medication administration to Resident #2, revealed LVN A did not administer Famotidine 10 mg to Resident #2. LVN A stated Resident #2 was to receive Pepcid (Famotidine) 10 mg one tablet once a day, but she didn't have the medication. LVN A looked through the OTC medication bottles in the top drawer of the medication cart, and stated the medication was there yesterday (07/19/2025) when she gave it to Resident #2, but she could not find it today. LVN A locked the mediation cart, went into the medication room, came out of the medication room and said the medication was not in there. LVN A then logged into her computer, stated she just ordered it from the pharmacy, and it would be delivered to the facility later in the afternoon. LVN A stated the medication was listed as an OTC medication on the order which was why it wasn't refilled. LVN A then administered the other medications she had prepared to Resident #2 and informed Resident #2 the Pepcid/Famotidine 10 mg was not available, but she had ordered it from the pharmacy.Observation and interview on 07/21/2025 at 8:41 AM with LVN B, who was Resident #2's nurse on 07/21/2025, revealed when she looked through the medication cart for the new blister package of Pepcid/Famotidine 10 mg, she stated it was not delivered yesterday (07/20/2025). LVN B stated when she gave Resident #2 the Pepcid/Famotidine 10 mg, she obtained the medication from an OTC box that was kept with the OTC medication bottles in the top drawer of the medication cart; and showed the surveyor the opened box of Pepcid/Famotidine 10 mg stored in the top draw of the medication cart that she removed the medication from.In an interview on 07/21/2025 at 3:53 PM, the DON stated medications would be ordered from the pharmacy in advance so the resident did not run out of medications and the nurses could pull medications from the Pixis machine (a machine with single doses of assorted medications) so they would be available to the resident. The DON stated there would be no harm to a resident if they missed one dose of Pepcid.In an interview on 07/21/2025 from 5:45 PM to 6:10 PM, the Administrator stated the harm to a resident if they didn't receive their medication would depend on the medication and if the medication was an anti-reflux medication it could cause the possibility of acid reflux in the resident.Record review of the facility's Medication Administration policy, revised January 2024, revealed Resident medications are administered in an accurate, safe, timely, and sanitary manner.6. administer medications as ordered by the physician. Routine medications shall be administered according to the established medication administration schedule for the community.

Based on interview and record review the facility failed to ensure medical records were kept in accordance with professional standards and practices and were complete and accurately documented for 4 of 5 residents (Resident #1, #2, #4, and #5) reviewed for accuracy of records. 1. The facility failed to ensure Resident #1's bath or shower was documented as given or as refused 9 times in April and May 2025. 2. The facility failed to ensure Resident #2's bath or shower was documented as given or as refused 6 times in April and May 2025. 3. The facility failed to ensure Resident #4's bath or shower was documented as given or as refused 11 times in April and May 2025. 4. The facility failed to ensure Resident #5's bath or shower was documented as given or as refused 8 times in April and May 2025. These failures could place residents at risk for improper care due to inaccurate records. Findings included: 1. Record review of Resident #1's Admission Record (face sheet) dated 05/04/2025 revealed she was admitted to the facility on [DATE] with diagnoses which included heart failure, stroke, hemiparesis (partial weakness on one side of the body), hemiplegia (partial paralysis on one side of the body), high blood pressure, memory deficit following stroke, and vascular dementia (brain damage caused by decreased blood flow). Record review of Resident #1's MDS, a Quarterly assessment dated [DATE], revealed a BIMS score of 10 out of 15, indication her cognitive skills for daily decision making were moderately impaired; and the resident was dependent on staff to be showered or bathed. Record review of Resident #1's Care Plan for Self-Care deficit related to hemiplegia and hemiparesis, initiated on 09/09/2024 and revised on 03/21/2025, revealed under interventions the resident would be showered 2-3 times weekly by the CNA. Record review of Resident #1's undated Kardex revealed the resident preferred to be bathed 2-3 times a week. Record review of Resident #1's nurses' notes from 04/04/2025 to 05/04/2025 revealed no notation of Resident #1 had refused to be bathed. Record review of the undated Shower Schedule revealed Resident #1 was to be bathed on Monday, Wednesday, and Friday on the 6 am - 2 pm shift. Record review of Resident #1's electronic clinical record for the Bathing Task from 04/03/2025 to 05/03/2025 revealed Resident #1 had only been bathed 5 times on 04/08/2025, 04/15/2025, 04/22/2025, 04/24/2025, and 04/29/2025; there was no documentation the resident had refused to be bathed; and there was no documentation if Resident #1 was bathed or refused on her scheduled shower days on 04/03/2025, 04/05/2025, 04/10/2025, 04/12/2025, 04/17/2025, 04/19/2025, 04/26/2025, 05/01/2025, and 05/03/2025. In an interview on 05/04/2025 at 5:04 PM, the DON stated she spoke with the CNAs who were to have bathed Resident #1 on 04/03/25, 04/05/2025, 04/10/2025, 04/12/2025, 04/17/2025, 04/19/2025, 04/26/2025, 05/01/2025, and 05/03/2025 who reported the resident was bathed on 04/03/2025, 04/05/2025, 04/10/2025, and 04/19/2025 but had refused to be bathed on the other days (04/12/2025, 04/17/2025, 04/26/2025, 05/01/2025, and 05/03/2025). The DON said if a resident refused to be bathed, the CNA should document it in the Point of Contacts Tasks and inform the nurse. In a further interview on 05/04/2025 at 5:23 PM, the DON said the nursing staff should document in the nurses' progress notes if a resident had refused to be bathed. In a further interview on 05/05/2025 from 12:01 PM to 12:25 PM, the DON said after she spoke with the CNAs who worked the days the resident was to have been showered, Resident #1 had refused to be bathed on 04/12/2025, 04/17/2025, 04/26/2025, and 05/01/2025 and confirmed it was not documented in the resident's electronic Point of Care Tasks the resident had refused to be bathed. 2. Record review of Resident #2's Admission Record (face sheet) dated 05/04/2025 revealed he was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses which included morbid obesity (excessive body weight), cognitive communication deficit (difficulty communicating), stroke, hemiparesis (partial weakness on one side of the body caused by the stroke), hemiplegia (partial paralysis on one side of the body caused by the stroke), and high blood pressure. Record review of Resident #2's MDS, a Quarterly assessment dated [DATE], revealed a BIMS score of 10 out of 15, indication his cognitive skills for daily decision making were moderately impaired; and the resident was dependent on staff to be showered or bathed. Record review of Resident #2's Care Plan for Self-Care deficit related to hemiplegia and hemiparesis, initiated on 06/21/2023 and revised on 07/14/2024, revealed under interventions the resident would be showered 2-3 times weekly by the CNA. Record review of Resident #2's undated Kardex revealed the resident preferred to be bathed 2-3 times a week. Record review of Resident #2's nurses' notes from 04/04/2025 to 05/04/2025 revealed no notation of Resident #2 had refused to be bathed. Record review of the undated Shower Schedule revealed Resident #2 was to be bathed on Monday, Wednesday, and Friday on the 6 am - 2 pm shift. Record review of Resident #2's electronic clinical record for Bathing Tasks from 04/03/2025 to 05/03/2025 revealed Resident #2 had only been bathed 6 times on 04/09/2025, 04/14/2025, 04/18/2025, 04/21/2025, 04/23/2025, and 04/25/2025; and it was not documented if Resident #2 was bathed or had refused on his scheduled shower days on 04/11/2025, 04/16/2025, 04/18/2025, 04/28/2025, 04/30/2025, and 05/02/2025. In an interview on 05/04/2025 at 5:02 PM, the DON stated she spoke with the CNA who was to have bathed Resident #2 on 04/30/25 and 05/02/2025 who reported the resident was bathed on those days but not recorded in his electronic clinical record. In a further interview on 05/05/2025 from 12:01 PM to 12:25 PM, the DON said she spoke to the CNAs who were to shower Resident #2, and they had showered him on 04/11/25, 04/16/2025, 04/18/2025 and on 04/28/2025 but it was not documented that he had received the shower. The DON stated Resident #2's family member would reach out to her if he was not showered, and they did not contact the DON about the resident's showers in April. 3. Record review of Resident #4's Admission Record (face sheet) dated 05/04/2025 revealed he was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (irregular heartbeat), heart failure, high blood pressure, morbid obesity (excess body weight) and muscle weakness. Record review of Resident #4's MDS, a Quarterly assessment dated [DATE], revealed a BIMS score of 14 out of 15, indication his cognitive skills for daily decision making were intact; and the resident was dependent on staff to be showered or bathed. Record review of Resident #4's Care Plan for Self-Care deficit related to weakness and debility, initiated on 12/20/2024 and revised on 12/26/2024, revealed under interventions the resident would be showered 2-3 times weekly by the CNA. Record review of Resident #4's undated Kardex revealed the resident preferred to be bathed 2-3 times a week. Record review of Resident #4's nurses' notes from 04/04/2025 to 05/04/2025 revealed no notation of Resident #4 had refused to be bathed. Record review of the undated Shower Schedule revealed Resident #4 was to be bathed on Monday, Wednesday, and Friday on the 6 am - 2 pm shift. Record review of Resident #4's electronic clinical record for Bathing Tasks from 04/03/2025 to 05/03/2025 revealed Resident #4 had only been bathed 2 times on 04/09/2025, and 04/23/2025; refused to be bathed on 04/11/2025; and it was not documented if Resident #4 was bathed or refused on his scheduled shower days on 04/02/2025, 04/04/2025, 04/07/2025, 04/09/2025, 04/16/2025, 04/18/2025, 04/21/2025, 04/25/2025, 04/28/2025, 04/30/2025, and 05/02/2025. In an interview on 05/04/2025 at 5:04 PM, the DON stated she spoke with the CNA who were to bath Resident #4 on 04/04/2025, 04/16/2025, 04/18/2025, 04/21/2025, 04/25/2025, and 04/30/2025 who reported the resident had been bathed. In an interview on 05/05/2025 at 12:45 p.m., the DON stated she spoke with the CNAs who were to shower Resident #4 on 04/02/2025, 04/07/2025, and 04/09/2025 who reported the resident was bathed but it was not documented in the electronic Point of Care Tasks. The DON reported the resident had refused to be bathed on 04/28/2025 and on 05/02/2025 but it was not documented in his clinical record. 4. Record review of Resident #5's Admission Record (face sheet) dated 05/04/2025 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included heart failure, stroke, high blood pressure, kidney failure, lymphedema (swelling caused a lymphatic system blockage) and muscle wasting and atrophy (progressive loss of muscle mass, strength, and power). Record review of Resident #5's MDS, a Quarterly assessment dated [DATE], revealed a BIMS score of 12 out of 15, indication her cognitive skills for daily decision making were moderately impaired; and the resident was dependent on staff to be showered or bathed. Record review of Resident #5's Care Plan for Self-Care deficit related to muscle wasting and atrophy, initiated on 12/01/2023 and revised on 05/03/2025, revealed under interventions the resident would be showered 2-3 times weekly by the CNA. Record review of Resident #5's undated Kardex revealed the resident preferred to be bathed 2-3 times a week. Record review of Resident #5's nurses' notes from 04/04/2025 to 05/04/2025 revealed no notation of Resident #5 had refused to be bathed. Record review of the undated Shower Schedule revealed Resident #5 was to be bathed on Tuesday, Thursday, and Saturday on the 6 am - 2 pm shift. Record review of Resident #5's electronic clinical record for Bathing Tasks from 04/03/2025 to 05/03/2025 revealed Resident #5 had only been bathed 6 times on 04/05/2025, 04/08/2025, 04/12/2025, 04/17/2025, 04/22/2025, and 04/29/2025; had not refused to be bathed; and it was not documented if Resident #5 was bathed or had refused on her scheduled shower days on 04/03/2025, 04/10/2025, 04/15/2025, 04/19/2025, 04/24/2025, 04/26/2025, 05/01/2025, and 05/03/2025. In an interview on 05/04/2025 at 5:04 PM, the DON stated she spoke with the CNAs who were to have bathed Resident #5 on 04/10/2025 and 04/26/2025 and who reported they had bathed the resident. In an interview on 05/05/2025 at 2:43 PM, the DON stated she spoke with the CNAs who were to have bathed Resident #5 on 04/03/2025, 04/15/2025, 04/19/2025 and 04/24/2025 who reported the resident was bathed on those days, but it was not documented. The DON said Resident #5 had refused to be bathed on 05/01/2025 and 05/03/2025 but it was not documented that she had refused. In an interview on 05/05/2025 at 2:08 PM, the Administrator said it should be recorded in the residents' clinical record if they had received a bath or had refused the shower. The Administrator stated if it wasn't recorded in the residents' clinical record the resident was bathed or had refused to be bathed, then it would be inaccurate documentation and he could not think of any harm to the resident. Record review of the Medical Records policy, revised January 2023, revealed A medical record is maintained for every person admitted to a community in accordance with accepted professional standards and practices. The administrator has ultimate responsibility for the maintenance of medical records but may delegate this responsibility to another team member. The medical record consists of but not limited to the following: information to identify the resident, a record of the resident's assessments, the plan of care and services provided, the results of any preadmission screening conducted by the state and progress notes.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The CDM wore a hair restraint that did not cover all his hair. 2. In the freezer, there was frozen raw beef stored over fully cooked frozen pies. 3. In the walk-in cooler, there were: a. Uncovered foods of 3 trays of pie desserts, 2 trays of bowels of fruits, and 1 tray of plates of salad. b. Cheese that was inappropriately stored. c. The CDM revealed he did not label prepare foods with a discard date. 4. In the dish room, the temperature log of the dishwashing machine had the wrong temperature 5. For 06/28/24 lunch, fortified shakes and yogurt temperatures were taken by touching the thermometer outside of the food product and not inside of the food product. 6. The refrigerators' temperature in the kitchen were only checked one time a day. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. During an interview and observation on 06/25/24 at 09:17 AM-09:42 AM (initial tour of the kitchen), the CDM had his hairnet covering only the top half of his hair. When this surveyor pointed out the hairnet was not covering all of his hair, the CDM revealed it was okay because his hair was short. He further revealed it was the long hair that got into foods because the weight of the long hair was more than the weight of short hair. Record review of facility's policy 04.001 Employee Sanitation, approved 10/01/18, reflected 3. Employee Cleanliness Requirements b. Hairnets . or other effective hair restraints must be worn to keep hair from food and food-contact surfaces. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, 2-402.11, revealed, (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles. 2. During an interview and observation of the freezer on 06/25/24 at 09:17 AM-09:42 AM (initial tour of the kitchen), Observation revealed raw beef was placed above boxed of pies. The CDM revealed this was not appropriate and moved the boxes of frozen pies onto another shelf that was no longer under these boxes of raw beef boxed. he moved the boxes of raw beef on the bottom shelf. Record review of facility's policy 03.003 Food Storage, revised 06/01/19, reflected Store raw meats and eggs on the bottom shelf to prevent contamination of other foods. To avoid cross-contamination, store raw or uncooked food and produce away from and below prepared or ready-to-eat food. 3. a. During an interview and observation of the refrigerator on 06/25/24 from 09:17 AM-09:42 AM (initial tour of the kitchen), 2 food carts that contained 06/25/24 lunch had uncovered foods of: 3 trays of pie desserts, 2 trays of bowels of fruits, 1 tray of plates of salad. The CDM revealed this should be covered so it can maintain it's quality and not be contaminated. During an interview on 06/28/24 at 01:43 PM, the RD revealed the foods that were uncovered in the walk-in refrigerator on 06/25/24 were for 06/25/24 lunch and this was okay because they were about to be served. She further revealed if they were not going to be served, uncovered foods could be exposed to air causing their quality to diminish. b. During an interview and observation of the refirgerator on 06/25/24 fro, 09:17 AM-09:42 AM (initial tour of the kitchen), observation revealed cheese was in a bag that was not properly closed all the way. The CDM revealed the bag that the cheese was in clicked to let one know that the bag was fully closed and this specific bag that was found may not have been closed all the way. c. During an interview and observation on 06/25/24 at 09:17 AM-09:42 AM (initial tour of the kitchen), observation of all prepared foods in walk-in refrigerator reflected no discard date. Record review of facility's policy 03.003 Food Storage, revised 06/01/19, reflected Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed, 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. 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. 4. Record review and interviews on 06/28/24 at 11:49 AM, revealed record review of Dish Machine temperatures and sanitizing log, dated June 2024, reflected temperature for AM Wash temp, Noon Wash Temp, and PM Wash temp to be 100 degrees for about 69 out of 82 occurrences. Record Review of this machine's operational requirements reflected this temperature should have been a minimum of 120. The CDM revealed the dishwashers (dishwasher staff spoke Spanish) wrote the temperature before the machine started and did not reflect the appropriate temperature. The CDM revealed he checked the dish machine frequently and it had been reaching appropriate temperatures. The RD revealed contamination could occur if the dish washing machine did not reach the machine's operational requirements. Record review of facility policy 04.006, approved 10/01/2018, revealed: Mechanical Cleaning and Sanitizing of Utensils and Portable Equipment. Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for mechanical cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. 5. Observation and interviews on 06/28/24 at 11:30 AM revealed the temperature for health shakes and yogurt were taken by touching the thermometer to the outside container of these food products. The CDM and RD revealed this was okay. Record review of facility's policy 03.008 Taking Temperatures, revised 06/01/19, reflected Insert the sensing element of the thermometer into the center of the thickest part of the food. 6. Observation and interview on 06/28/24 at 11:00 AM, revealed temperature logs for all of the refrigerators had only one temperature that was being taken per day. The RD and CDM revealed this was okay and they needed to check if more temperatures needed to be taken per day. Interview on 06/28/24 at 01:43 PM, the RD revealed taking temperatures appropriately ensured the refrigerator maintained it's appropriate temperature. She further revealed this was to ensure food would not spoil. Record review of facility's policy 04.035 Cleaning & Sanitation of Refrigerators & Freezers on Units, approved 10/01/18, reflected Temperatures in the refrigerators and freezers will be checked once on the day shift and once on the night shift and recorded on a temperature log by the nutrition and foodservice staff.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident #1) reviewed for accidents, in that: 1. The facility failed to provide adequate supervision of Resident #1 on 02/25/2024 resulting in the resident being found outside of the facility on 02/25/2024 at 4:51 PM. 2. The facility failed to provide adequate supervision of Resident #1 on 04/28/2024 resulting in the resident being found outside of the facility on 04/28/2024 at 9:31 PM. An IJ was identified on 05/02/204. The IJ template was provided to the facility on [DATE] at 4:15 PM. While the IJ was removed on 05/04/2024, the facility remained out of compliance at a scope of Isolated and a severity level of No Actual Harm with Potential for More Than Minimal Harm that is Not Immediate Jeopardy because all staff had not been trained on elopement prevention. This deficient practice could result in a risk to the residents' health and safety and placed the resident at risk of heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. The findings included: Record review of Resident #1's face sheet, dated 05/02/2024, reflected an [AGE] year-old female with an admitted [DATE] and a primary diagnosis of Alzheimer's Disease. Record review of Resident #1's Quarterly MDS, dated [DATE], reflected Resident #1 was severely cognitively impaired with wandering not exhibited during the look-back period of 02/01/2024 to 02/08/2024. Record review of Resident #1's Comprehensive Person-Centered Care Plan, dated 05/02/2024, reflected I am exit seeking, I am at risk for elopement and/or wandering with unsafe boundaries r/t: Alzheimer's Disease initiated on 04/17/2024 with an intervention of Assess my continued need for residing on a memory care/secure unit as indicated. Record review of Resident #1's EHR assessments titled Exit Seeking Risk Tool, dated 02/25/2024 at 4:51 PM, authored by LVN A, reflected Resident was found outside front doors of facility. Resident escorted back to room, resident states I'm ready to leave. With further details that reflected that Resident #1 was assessed to have: wandering behavior, exit seeking behavior, verbalization to leave the facility, a diagnosis associated with confusion, and mobility by wheelchair. Record review of Resident #1's EHR progress notes, dated 04/28/2024 at 9:31 PM, authored by RN C, reflected head to toe assessment completed due to patient being found outside of building with any supervision. no new concerns of skin at this time. Observation on 04/30/2024 at 12:15 PM revealed the outside of the facility to have a large parking lot capacity of at least 80 motor vehicles, adjacent to a forested area, and located approximately .5 miles from a highly trafficked highway. Interview on 04/30/2024 at 2:30 PM, Resident #1's family confirmed they were informed that Resident #1 left the faciity on Sunday (04/28/2024) at 6:30 PM after she walked from her room and left via the front door. She confirmed the only reason the facility knew about it was because a nurse saw her outside. Interview on 04/30/2024 at 3:00 PM, RN B confirmed Resident #1 was one of my wanderers and while doing medication pass RN B was informed by RN C that Resident #1 was found outside on 04/28/2024 in the late evening. RN B confirmed she did a head-to-toe assessment of Resident #1, gave Resident #1 some water and a PRN medication before returned Resident #1 to her room. RN B confirmed she reported this to the DON and Resident #1's RP. Phone interview on 04/30/2024 at 4:01 PM, RN C confirmed on or around 04/28/2024 at 6:30 PM she observed Resident #1 in a wheelchair outside the double doors of the building at the front entrance. RN C confirmed she contacted Resident #1 and called RN B. RN C confirmed RN B responded and took Resident #1 back into the building. RN C confirmed she contacted the DON of this incident. Interview on 05/01/2024 at 2:14 PM, the DON confirmed the front door receptionist leaves at 5:00 PM everyday including weekends and the front doors are magnetically locked at 8:00 PM. The DON confirmed the facility does not have a locked unit or a memory care unit. Interview on 05/01/2024 at 2:45 PM, LVN A confirmed Resident #1 was pleasantly confused, would wander the facility, had dementia, and could self-transfer from bed to wheelchair. He confirmed he remembered the incident on 02/25/2024 when Resident #1 was found outside the front doors wandering. LVN A confirmed during that February instance, he notified the following nurse to continue doing increase supervision checks. Phone interview on 05/02/2024 at 10:34 AM, Receptionist X confirmed she leaves the facility at 5:00 on Saturdays and Sundays but the automatic door locks do not engage until 8:00 PM. Receptionist X denied ever having seen Resident #1 outside the front doors of the facility on any day at any time. Interview on 05/02/2024 at 12:29 PM, the Administrator confirmed he was not familiar with and not notified of the incident on 02/25/2024 involving Resident #1 being found outside of the facility. The Administrator confirmed he was familiar with the incident on 04/28/2024 involving Resident #1 being found outside of the facility. The Administrator confirmed no elopement assessments or incident reports were completed for Resident #1 being found outside on 04/28/2024. The Administrator confirmed there was no incident report for the event on 02/25/2024. Interview on 05/02/2025 at 12:44 PM, the DCO, confirmed she was informed of the incident on 02/25/2024 involving Resident #1 being found outside of the facility but as they had not considered it an elopement, no new interventions took place. The DCO confirmed no elopement assessments or incident reports were completed for Resident #1 being found outside on 04/28/2024. The DCO confirmed there was no incident report for the event on 02/25/2024. Phone interview on 05/02/2024 at 2:07 PM, the MD denied recollection of the 02/25/2025 incident and stated he did not take primary care of hospice residents and deferred them to their hospice physician. The MD stated what medical director would when asked if he was aware of what interventions were in place to prevent residents from wandering out of the facility on the weekend between 5:00 PM and 8:00 PM. Record review of witness statement, undated, received on 05/02/2024, reflected To whom it may concern . I [Former Assistant Administrator] . at the time was manager on duty (MOD) On Sunday 02/25/2024. [Receptionist R] informed me that [Resident #1] wanted to go outside, I told [Resident #1] that was fine and that I am right here. [Resident #1] was sitting outside the front doors and she started wheeling herself to the right on the side walk. I went outside to talk to her as I usually did when I saw [Resident #1] and asked her how she was doing and what she was doing and she started she was looking for her son. I asked [Resident #1] if she wanted help inside and she said sure, what is when I wheeled her inside and [LVN A] wheeled her back to the unit. Record review of facility elopement response policy, titled Elopement Response & Exit Seeking Management, dated revised January 2023, reflected no precise definition of elopement apart from describing an elopement was to have occurred when a resident has been found off the premises without a definition of premises. The policy was reflected to provide protocol when discovering a resident had been found and brought back into the facility such as completing a head-to-toe assessment, reporting the incident to the DON, Administrator, MD, and RP, amongst other internal protocols such as completing an incident report and reflecting the incident in the progress notes. An Immediate Jeopardy (IJ) was identified on 05/02/2024 at 03:57 PM and presented to the Administrator and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 05/03/2024 at 04:31 PM. Plan of Removal: F689 Failure to Provide Adequate Supervision to Prevent Accidents There are 3 out of 124 residents identified who are at risk for Elopement. Staff immediately re-directed resident # 1 from the community's porch, sidewalk area and nursing assessed Resident #1. There were no negative outcomes identified. Date Completed: 4/28/24 Front entrance lock pad system activated by [company name] to continuously require a code to get in or out at all times. Date Completed: 5/3/24 Director of Nursing/Designee initiated in-service training to all licensed nurses and direct care team members on utilizing/accessing the Kardex Plan of Care system to identify residents who are at risk for elopement/wandering. Date Initiated: 5/3/24 Date Completed: Director of Nursing / Designee to conduct retraining for all team members as well as agency staffers (nurses/CNAs) prior to assuming next shift. DNS/Designee will ensure that all newly hired team members receive the training as part of the onboarding. Inservice Topics: o Missing Person Response & Elopement / Exit Seeking Risk and Proper Response to Missing Resident/Resident Elopement Protocol o Identifying and Responding to Triggers to Prevent Elopement and Behaviors o Preventing, Identifying and Reporting Abuse and Neglect. o Education for the nurses and CNA's on the Kardex Plan of Care system to identify residents who are at risk for elopement. o How to identify high risk residents for elopement utilizing the watch like bracelet. Date Initiated 5/3/24 Date Completed: The 3 residents identified to have a high risk for elopement in the community were provided with a watch like bracelet to identify the risk for wandering/elopement. In-service initiated by Director of Nursing/SW/Designee to all team members on the watch like bracelet placed on residents to identify the risk for wandering and elopement. Date Initiated 5/3/24 Date Completed: Resident #1 placed on a one to one monitoring to maintain safety. Resident #2 placed on q15 minute monitoring to maintain safety. Resident #3 placed on q15 minute monitoring to maintain safety. Date initiated: 5/2/24 Date Completed: 5/2/24 Nursing/IDT will continue to monitored resident to ensure resident's safety and wellbeing. Nursing notified MD (PCP) and family representative of incident and resident's status. Date Completed: 5/2/24 VP of Clinical Operations and VP of Operations conducted in-service training to the identified Director of Clinical Operations, Director of Nursing and Administrator regarding identifying and responding to exit seeking and elopement risk or events, implementing appropriate interventions; thus, ensuring the residents' safety and well-being. interventions and updating the plan of care as indicated. Date Completed: 5/2/24 VP of Clinical Operations and VP of Operations conducted in-service training to the identified Director of Clinical Operations, Director of Nursing and Administrator regarding: Missing Person & Elopement / Exit Seeking Response. Additional education provided reviewed the process for reviewing the TXHHSC PL for reporting criteria of missing resident/elopement in order to ensure compliance with state and federal regulations: Preventing, Identifying and Reporting Abuse and Neglect, Facility's process for identifying potential risks of elopement; implementing appropriate interventions and updating the plan of care as indicated. Date Completed: 5/2/24 o Administrator/Social Worker/Director of Nursing/Designee will conduct in-service training to all staff prior to their next shift training regarding: Identifying and responding to missing person, exit seeking and elopement risk and/or incidents, and ensuring that appropriate interventions are implemented to ensure the residents' safety and well-being. Date initiated: 5/2/24 Date completed: o Director of Nursing/Designee will conduct an audit of all recent new admissions and readmission, reviewing the exiting seeking assessment in order to identify any concerns with exiting seeking or elopement risks and the IDT will review the plan of care to ensure it appropriately reflects potential elopement/exit seeking risks and/or will update the plan of care as indicated. Date initiated: 5/2/24 Date completed: 5/2/24 o Administrator/Social Worker/Director of Nursing/Designee will conduct staff and resident interviews to identify any concerns of exiting seeking / elopement behaviors. If identified the IDT will review the plan of care and/or will update the plan of care as indicated in order to ensure it appropriately reflects potential exiting seeking / elopement risk noted. Date initiated: 5/2/24 Date completed: o Director of Nursing / Assistant Director of Nursing conducted re-education to the IDT and all licensed nurses regarding the RAI process to include but not limited to completion of a resident centered comprehensive care plan on each resident regarding services to attain or maintain the resident's highest practical level of physical, mental, and psychosocial well-being. Date initiated: 5/2/24 Date completed: o Director of Nursing / Designee to conduct retraining for all team members as well as agency staffers (nurses/CNAs) prior to assuming next shift. DNS/Designee will ensure that all newly hired team members receive the training as part of the onboarding. Inservice Topics: o Inservice conducted on Missing Person Response & Elopement / Exit Seeking Risk and Proper Response to Missing Resident/Resident Elopement Protocol o Identifying and Responding to Triggers to Prevent Elopement and Behaviors o Preventing, Identifying and Reporting Abuse and Neglect. Date initiated: 5/2/24 Date completed: o Director of Nursing / Designee conducted in-service training to all licensed nurses as well as agency staffers (nurses) prior to assuming next shift. DNS/Designee will ensure that all newly hired nurses receive the training as part of the onboarding. Inservice Topics: o Assessing residents' risk and needs and ensuring appropriate interventions are in place within the plan of care. o Identifying exit seeking / elopement risk for all new admission/re-admissions or any resident that displays s/s of exit seeking/elopement behaviors and ensuring to implement appropriate interventions such as close monitoring safety checks, as indicated to prevent an elopement from occurring. o Process for monitoring and reporting all exit seeking / elopement behaviors or concerns to the licensed nurse in effort to provide needed care, protect the safety and well-being of all residents, to meet the resident's needs, have accurate documentation reflected in clinical record and to ensure appropriate interventions are in place as per facility's expected practices. o What to do or response to a missing/unaccounted for resident/patient as per community's process. Immediately initiating a search of inside and outside of facility to search for resident as per facility's expected practice, Elopement Response Protocol reviewed. o Expectation for reporting elopement events to the DNS, Administrator and MD/NP/PA. Date initiated: 5/2/24 Date completed: o Ad Hoc QAPI held with Administrator, Director of Nursing and Medical Director to review the concerns and plan of removal implemented. Date Completed: 5/2/24 o ADMIN/DNS/SW/ Designee will conduct random daily rounds 3-7 days a week, on various shifts to validate the safety and well-being of our residents. o Director of Nursing/Designee will conduct random weekly audits of 1-3 new admission and/or readmissions' initial care plans and comprehensive care plans in order to validate the accuracy of the care plan by ensuring identified elopement risk are noted in the plan of care and appropriate interventions are in place. o Director of Nursing/Designee will audit and review progress notes, changes in conditions, risk management reports and the nursing 24 hr. report daily 5-7 days per week during the morning clinical meeting in order to validate appropriate follow up and necessary interventions are in place accordingly. o Administrator/Director of Nursing/Designee will conduct Elopement / Missing Person Response Drills on random shifts to identify competency of TMs or to identify additional education needs. Drills will be conducted 2-4 time per month for the next 1-2 months. o This plan will remain in place for the next 2 months and findings will be reported to the QAPI committee during monthly meeting for the next 2 months. The QAPI committee will then determine compliance or identify a need for additional training. Monitoring of the POR was as follows: Observation on 05/03/2024 at 1:38 PM, the front door was revealed to require a passcode to enter or exit the facility. A visitor was observed to exit through the front doors after entering a code provided by the receptionist on a piece of paper. Interview, observation, and record review on 05/03/2024 at 1:44 PM, Resident #1 was revealed to be sitting in a wheelchair holding a stuffed animal while watching television. Resident #1 was observed to be equipped with a small, plastic bracelet. Resident #1 confirmed she was feeling well and smiled during the interview. Resident #1 confirmed she received the bracelet today for unknown reasons. Resident #1 was observed to be sitting next to CNA T who confirmed she was instructed to perform 1:1 supervision with Resident #1 during the entirety of her shift and to document such activity on a provided form. The form provided reflected checks were completed on a fifteen minute basis confirming whether compliance was met or otherwise along with the date and initials by the supervision contact, the most recent of which was completed by CNA T at 1:30 PM. CNA T confirmed she had received an in-service training when she began her shift and had signed her attestation to completing said training. Observation on 05/03/2024 at 1:51 PM, Resident #2 was revealed to be laying in bed, asleep. Upon further inspection, a small, plastic bracelet was revealed on Resident #2's right wrist. Interview on 05/03/2024 at 1:55 PM, CNA U confirmed she was instructed to perform routine fifteen-minute frequent checks on Resident #2 to ensure of potential elopement or endangerment. CNA U confirmed she had received an in-service training earlier that morning and was already aware of Resident #2's proclivity to wandering away for staff to find her. CNA U confirmed she was familiar with the content of the training and felt confident in the material she was in-serviced on. Interview and record review on 05/03/2024 at 1:59 PM, LVN V confirmed being an agency nurse who was instructed to complete fifteen-minute frequent checks on Resident #2 for potential elopement and confirmed the protocol when discovering a resident could not be located was to call a code silver to begin a sweep of the facility to find a lost resident. LVN V confirmed he had received an in-service when he began the shift and denied any confusion or misunderstanding with the course content. LVN V provided the monitoring form he was provided by his administration that LVN V had been inputting his frequent checks affirming his routine monitoring for Resident #2. Observation on 05/03/2024 at 2:06 PM, Resident #3 was revealed to be sitting in the upstairs dining room while being equipped with a plastic bracelet on her right arm. Interview on 05/03/2024 at 2:07 PM, Resident #3 confirmed she felt safe at the facility and denied ever leaving the facility or wandering outside. Resident #3 confirmed she enjoyed going outside of the facility to get fresh air. Resident #3 confirmed she was being supervised by a male staff, who she works with, and felt she was visiting the hospital soon for no known reason. Interview on 05/03/2024 at 2:12 PM, LVN W confirmed she was an agency nurse who was instructed to complete fifteen-minute frequent checks on Resident #3 for potential elopement. LVN W confirmed she received an in-service before starting her shift this morning and confirmed she understood the content and felt confident in maintaining supervision for Resident #3 for a potential elopement. Interview on 05/03/2024 at 2:18 PM, Receptionist X confirmed she had received an in-service earlier at the beginning of her shift that discussed potential elopement risks at the facility and what the protocol was for resident's who appeared confused or wandering out of the facility. Receptionist X confirmed the front door locks were to be indefinitely locked at all times and would have to be exited with a door code that she could provide to visitors upon request. Receptionist X confirmed she was questioned by facility administration during the in-service if she identified any further residents at risk of elopement and denied any further residents who were not already assessed to be genuine risks of elopement based on the resident's verbalization of intent to leave the facility or to be somewhere else. Phone Interview on 05/03/2024 at 2:26 PM, Resident #1's RP answered but no speech heard, contacted again 1 minute later, but same result. Phone interview on 05/03/2024 at 2:28 PM, Resident #1 family member, no answer, VM left. Phone interview on 05/03/2024 at 2:49 PM, Resident #1 family member confirmed she had been communicated by the facility of the policy changes related to the front door and Resident #1's thirty-day discharge from the facility. Resident #1's family member confirmed she felt comfortable with the timeframe provided by the facility with regard to the discharge and confirmed she had already identified further placement as soon as three days from today. Phone interview on 05/03/2024 at 2:59 PM, Resident #1's RP confirmed she had been communicated by the facility of the policy changes related to the front door and Resident #1's thirty-day discharge from the facility. Resident #1's RP confirmed she felt comfortable with the timeframe provided by the facility with regard to the discharge and confirmed she had already identified further placement as soon as three days from today. Interview on 05/03/2024 at 3:33 PM, the Administrator confirmed the ad hoc QAPI meeting took place last night, updating the members of the members, describing to the members the non-compliance, asking the MD if there were any further details needed to add. The Administrator denied any confusion on the deficient practice identified and confirmed the removal was on-going. The Administrator confirmed the committee members have perpetual ability to provide additional changes, recommendations, or concerns to bring to the committee. Interview on 05/04/2024 at 9:44 AM with CNA D, verified in-serviced on ANE, elopement, Resident Rights, POC Identifier. Records reviewed reflected completion of the in-services. Interview on 05/04/2024 at 9:47 AM, with CNA E verified in-serviced on ANE, elopement, Resident Rights, POC Identifier Records reviewed reflected completion of the in-services. Interview on 05/04/2024 at 9:53 AM, LVN F verified in-serviced on ANE, Elopement, POC Identifier, Rights. Records reviewed reflected completion of the in-services. Interview on 05/04/2024 at 10:02 AM, LVN G verified in-serviced on ANE, Elopement, Resident Rights, POC Identifier. Records reviewed reflected completion of the in-services. Interview on 05/04/2024 at 10:15 AM, LVN A verified in-serviced on ANE, Elopement, Resident Rights, POC Identifier. Records reviewed reflected completion of the in-services. Interview on 05/04/2024 at 10:17 AM, RN I verified in-serviced on ANE, Elopement, Resident Rights, POC Identifier. Records reviewed reflected completion of the in-services. Interview on 05/04/2024 at 10:19 AM, CNA J verified in-serviced on ANE, Elopement, Resident Rights, POC Identifier. Records reviewed reflected completion of the in-services. Interview on 05/04/2024 at 10:21 AM, RN K verified in-serviced on ANE, Elopement, Resident Rights, POC Identifier. Records reviewed reflected completion of the in-services. Interview on 05/04/2024 at 10:22 AM, LVN L verified in-serviced on ANE, Elopement, Resident Rights, POC Identifier. Records reviewed reflected completion of the in-services. Interview on 05/04/2024 at 10:24 AM, LVN M verified in-serviced on ANE, Elopement, Resident Rights, POC Identifier. Records reviewed reflected completion of the in-services. Interview on 05/04/2024 at 10:25 AM, LVN H verified in-serviced on ANE, Elopement, Resident Rights, POC Identifier. Records reviewed reflected completion of the in-services. Interview on 05/04/2024 at 10:26 AM, LVN N verified in-serviced on ANE, Elopement, Resident Rights, POC Identifier. Records reviewed reflected completion of the in-services. Interview on 05/04/2024 at 10:28 AM, CNA O verified in-serviced on ANE, Elopement, Resident Rights, POC Identifier. Records reviewed reflected completion of the in-services. Interview on 05/04/2024 at 10:31 AM, Staff P verified in-serviced on ANE, Elopement, Resident Rights, POC Identifier. Records reviewed reflected completion of the in-services. Interview on 05/04/2024 at 10:34 AM, Resident #7 stated she had no concerns regarding safety or care, I like it here. Interview on 05/04/2024 at 10:37 AM, Resident #6 stated she had no concerns regarding safety or care, they take very good care of me. Interview on 05/04/2024 at 10:39 AM, Resident #5 stated she had no concerns regarding safety or care, observed self-propelling in wheelchair. Interview on 05/04/2024 at 10:40 AM, Resident #9 stated she had no concerns regarding safety or care, resident observed playing Loteria with other residents. Interview on 05/04/2024 at 10:43 AM, Resident #8 stated she had no concerns regarding safety or care, observed self-propelling in wheelchair. Interview on 05/04/2024 at 10:45 AM, CNA Q verified in-serviced on ANE, Elopement, Resident Rights, POC Identifier. Records reviewed reflected completion of the in-services. Interview on 05/04/2024 at 10:53 AM, Resident #3 stated she had no concerns regarding safety or care, resident observed playing Loteria with other residents. Interview on 05/04/2024 at 11:00 AM, Resident #10 stated she had no concerns regarding safety or care, resident observed playing Loteria with other residents. Interview on 05/04/2024 at 11:01 AM, Resident #12 stated she had no concerns regarding safety or care, resident observed playing Loteria with other residents. Interview on 05/04/2024 at 11:03 AM, Resident #11 stated she had no concerns regarding safety or care, resident observed playing Loteria with other residents. Interview on 05/04/2024 at 11:10 AM Resident #13, stated she had no concerns regarding safety or care, resident observed playing Loteria with other residents. Record review of Resident #1's elopement evaluation, titled Exit Seeking Risk Tool, dated 05/02/2024, reflected she was identified as an exit-seeking risk due to: Wandering history, wandering behavior, exit seeking behavior, verbalization of intent, associated diagnosis, sundowning syndrome exhibited, and mobility. Record review of Resident #2's elopement evaluation, titled Exit Seeking Risk Tool, dated 05/02/2024, reflected she was identified as an exit-seeking risk due to: Wandering history, exit seeking behavior, associated diagnosis, confusion, and mobility. Record review of Resident #3's elopement evaluation, titled Exit Seeking Risk Tool, dated 05/02/2024, reflected she was identified as an exit-seeking risk due to: wandering history, wandering behavior exhibited, verbalization of intent, associated diagnosis, confusion, and mobility. Record review of staff in-service, titled Elopement Response & Exit Seeking Management, dated 05/02/2024, reflected 125 staff members were in-serviced by the Director of Clinical Operations in a combination of in-person and telephone with signatures of the staff who were in-serviced in person, or a signature of two administrative staff members for the staff who were in-served via telephone. Record review of staff in-service, titled Preventing, Identifying and Reporting Abuse and Neglect, dated 05/02/2024, reflected 124 staff members were in-serviced by the Director of Clinical Operations in a combination of in-person and telephone with signatures of the staff who were in-serviced in person, or a signature of two administrative staff members for the staff who were in-served via telephone. Record review of staff in-service, titled RAI process/Completion of resident centered comprehensive care plan, dated 05/02/2024, reflected 33 total licensed nurses were in-serviced by the Director of Clinical Operations in a combination of in-person and telephone with signatures of the staff who were in-serviced in person, or a signature of two administrative staff members for the staff who were in-served via telephone. Record review of random daily rounds done 3-7 times per week by Administrator/DNS/or SW form, titled Monitoring Tool, dated May 2024, reflected the Administrator completed a round on 05/02/2024 of the 2-10 PM shift with Yes marked under Compliance Met Record review of form Monitoring Tool, dated May 2024, reflected Issue Director of Nursing/Designee will conduct random weekly audits 1-3 new admission and/or readmissions initial care plans and comprehensive care plans in order to validate the accuracy of the care plan by ensuring identified elopement risk are noted in the plan of care and appropriate interventions are in place. Further reflected a notation on 05/02/2024 by the Director of Clinical Operations with Yes for compliance met on a new admission, name provided in the final column. Record review of form Monitoring Tool, dated May 2024, reflected Issue: DON will audit and review progress notes, changes in conditions, risk management reports and the nursing 24 hr report daily 507 days per week during the morning clinical meeting in order to validate appropriate follow up and necessary interventions are in place accordingly, further reflected a notation on 05/02/2024 by the Director of Clinical Operations with yes for compliance met. Record review of form Monitoring Tool, dated May 2024, reflected Issue: Administrator/Director of Nursing/Designee will conduct elopement/Missing Person Response Drills on random shifts to identify competency of TM's or to identify additional education needs. Drill will be conducted 2-4 times per month for the next 1-2 months, further reflected a notation on 05/02/2024 by the Administrator with yes for compliance met. Record review of missing person drills form, titled Emergency Preparedness Drills: Conduct Elopement Drill (Missing Resident Drill), dated 05/02/2024, reflected at 7:25 PM to 8:13 PM, 126 residents were counted, 33 total staff with a response time of 10 seconds and the resident was found. Indications of the precise individual were noted, where they were found, whether emergency medical services or LE were needing to be contacted, or if follow-up corrective action needed to have taken place. Record review of facility ad hoc QAPI meeting, dated 05/02/2024, reflected the MD, Director of Clinical Operations, [NAME] President of Operations, DON, and Administrator were present to discuss the POR. Record review of in-service, titled Elopement Response & Exit Seeking Management. Reporting Abuse and Neglect, dated 05/02/2024, reflected the Director of Clinical Operations and the Administrator were in-serviced by the VP of Clinical Operations and VP of Operations. Training included: Identifying and responding to a missing person, exit seeking and elopement risk, assessing residents risks. The Administrator was informed on 05/04/2024 that the IJ was removed, however the facility remained out of compliance at

Based on interviews and record reviews, the facility failed to provide basic life support, including CPR (Cardiopulmonary Resuscitation), to a resident requiring such emergency care and subject to related physician orders [REDACTED].#1) of 130 residents reviewed for CPR. LVN E failed to immediately start and continuously provide CPR and to activate emergency medical personnel when she determined Resident #1 did not have a pulse or respirations on [DATE]. LVN E did not know the code status of Resident #1 and CPR was not performed. Resident expired at the facility on [DATE]. An Immediate Jeopardy (IJ) was identified to have occurred on [DATE]. This was determined to be a Past Noncompliance IJ due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the investigation. This failure placed residents who requested a full code status at risk of not receiving necessary life-saving measures, which could result in death. Findings included: Record review of Resident #1's electronic record face sheet populated with current date of [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's electronic admission Minimum Data Sets ((MDS) dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 4, which indicated severe impairment. The MDS revealed Resident #1's cognitive skills for daily decision making were severely impaired. Record review of Resident #1's admission physicians orders dated [DATE] indicated Resident #1 had the order for full code. There were no additional orders that indicated Resident #1's code status had changed. Record review of Resident #1's care plan dated [DATE] revealed, I (Resident #1)/Family/RP (Responsible Party) have no DNR (Do Not Resuscitate) documentation; therefore, designating that I am a FULL CODE (CPR) status. Community will follow Full Code Status and review code status quarterly and as needed. Record review of Resident #1's electronic nurses notes revealed the only entries summary by LVN E regarding the incident: documented on [DATE] (6:07 p.m.) revealed, This nurse arrived this morning received report from night shift nurse that resident had a change in condition due to not being easily arousable and unable to take medications stated meds were given but then stated that she was given [MEDICATION NAME] @345 (a.m.)because she was about to be changed by cna {Certified Nurse aide} and bag (Resident #1's [MEDICAL CONDITION] bag) to be replaced and that was usually painful. The{Night shift}Nurse stated she placed a call during the night to hospice and they would be coming out to evaluate. Started rounds cna made aware resident had a bad night. Upon rounds cna stated was having a hard time obtaining a bp.{blood pressure} At this point I went in to the room to attempt to obtain vs {vital signs} resident was non responsive to verbal and tacti stimuli, stern rub (Sternal rub is a commonly used method of assessing response to painful stimuli in assessing the neurological status of an individual) given no response was unable to get a apical pulse. This is done by firmly rubbing the patient's center chest.) Notified hospice through text. Then place call to hospice number and notified resident had another change and that if someone was on the way asked if they had a {DNR} on file due to I heard that there was one at the time she stated let me check and I'll call you back let me find out. Notified DON and management upon arrival. Call was returned by RN (Hospice)on call that she would be in to pronounce and that if it was ok to enter the building. Call then returned ( from hospice) that yes, she spoke with (unknown name) and yes, we had a {DNR}on file. RN arrived asked me if the hospice chaplain was allowed and if any family members had been notified told her no and what had lead up to at this point. She went into the room, pronounced @ 0810. During a phone interview with LVN E on [DATE] at 11:33 a.m. she stated I received report from the off going LVN {D} and she told me that the resident {#1} had a bad night and that she was in pain. The night LVN {D} gave her pain medications. At that time, we did not discuss code status of the resident. {#1}. We did discuss that Hospice had been called and they would be coming this morning to check on the resident {#1}. LVN E further revealed that she called hospice again at beginning of her shift and asked them when they were coming. She stated that they told her soon. LVN E stated she asked the hospice person who answered the phone when she called them if the resident {#1} was a DNR and she was told yes. LVN E stated I saw on the chart a few days ago that the resident {#1} showed full code. But I heard (LVN E could not recall who or when) that hospice had been working on getting her a DNR status. LVN E stated, when I went into her room after the cna ( LVN E could not recall cna's name) had told me that she could not get vital signs on {Resident #1}, After checking resident , I text hospice at that time, I did not get a pulse or respirations, I did not code her because she was 99 pounds and very frail and in pain. LVN E stated, I called hospice again and spoke to the person answering the phone (LVN E could not recall who she spoke with ) and notified resident {#1} had another change and that if someone was on the way, I asked if they had a DNR on file because I had heard that there was one at the time, she stated let me check and I will call you back. LVN E stated, I wasn't sure about her code status and I just did not code her, I assumed because she was on hospice, that she was a DNR. LVN E stated, I tried calling hospice to find out what the status was on the DNR of the resident, but I got mixed messages, I was being told that she was a DNR by someone I can't remember from hospice. LVN E stated, since I found the resident not breathing and no heart rate I don't think doing CPR would have helped her. She stated she left the room along with the cna and waited for hospice to return her calls. LVN E stated that she had been trained in CPR and if someone was a full code she would stay with the resident and call for help while continuing to give CPR. She stated that the code status is in the electronic file and it will say full code or DNR. During an interview on [DATE] at 2:16 p.m. with LVN D she stated she was on the night shift beginning on [DATE] and ending [DATE]. She stated that she recalled the resident {#1}, being restless and having pain in the morning hours on [DATE]. LVN D stated she gave pain medication as physician directed to the resident {#1}. She further revealed that she gave report to LVN E and let her know that hospice would be coming to assess resident that morning. LVN D stated she did not discuss code status during report with LVN E. She stated that she knew that the resident {#1} was a full code as she stated it is on the electronic record on the face sheet. (Surveyor verified this) She stated that she has been trained how to do CPR. She stated that the facility requires the LVNs and RNs to be CPR certified. She stated that she knew that not all Hospice patients are a DNR status and that could change at any time when the patient has a change in their condition. During an interview on [DATE] at 8:45 a.m. with LVN A she stated that Resident #1. She stated that she did not know the code status of the resident but knew to look in the file on the admission orders [REDACTED]. During an interview on [DATE] at 9:00 a.m. with DON B she stated that she remembered resident #1 being admitted . DON B stated that all nurses are to be CPR certified and they are to perform CPR on residents if they are assessed and are not breathing or have no pulse. She stated that the code status is in the residents electronic file on the face sheet. She stated that staff were regularly trained and in-serviced on CPR, codes, and the crash cart. During an interview on [DATE] at 9:30 a.m. with DON C, stated she is in charge of the residents on the first floor of the facility. She stated that she remembered resident #1 being admitted . She does recall that resident #1 was moved to the 1st floor and was more of a palliative care, because her health was deteriorating, but did not know her code status. DON C stated that all nurses are to be CPR certified and they are to perform CPR on residents if they are assessed and are not breathing or have no pulse. She stated that the code status is in the residents electronic file on the face sheet. She stated that staff are regularly trained and in serviced on CPR, codes, and the crash cart. She stated that LVN E had just had an in-service on [DATE] related to AED (Automated external defibrillators) review and abuse and neglect. DON C further revealed that best practice for the nurses would be to give the code status of residents during shift report that have had a change in condition so that it would be clear. DON C further revealed that she had attempted to contact Hospice to identify the status of the Advance Directive on Resident #1. She stated that the Hospice company representative had stated the advanced directive had been mailed to the resident's responsible party and they were waiting on return of this. DON C stated the failure to understand the appropriate code for the resident could cause residents to receive a delay in life sustaining measures and possibly die. During an interview on [DATE] at 3:00 p.m. DON C and DON B acknowledged that after the incident, the facility immediately ensured that all residents in the facility had appropriate code status in their electronic file that was physician ordered. The facility provided in service training regarding the charge nurses to always check code status of resident. DON C further revealed she did an in-service with the nurses to inform them that upon identification of a change in status, vital signs, or absence of vital signs and to initiate CPR and placement of AED if a resident has a Full Code status. They are to immediately notify the Administrator DON/ADON. DON C and DON B also stated that, DON's will validate code status paperwork is completed upon admission and if there is a change to Hospice. During a phone interview on [DATE] at 11:04 a.m. with Resident #1's son (responsible party) he stated his mother was a full code. Record review of facilities policy titled: CPR- Titled Medical Emergency Management dated 2011.-Objective: The community residents receive timely and appropriate interventions in the event of a medical emergency. The staff takes actions to ensure that the resident's Airway, Breathing, and Circulation are maintained until emergency personnel arrive. Staff is aware of each resident's advance directives prior to the administration of cardiopulmonary resuscitation. Guidelines: 1. Licensed nursing staff in the community shall have current CPR certification and keep their certification current during employment .5. Once a medical emergency is identified, qualified staff assesses the resident, initiates the appropriate emergency procedure(s), and calls 911. The staff continues to provide care and monitor the resident until the emergency personnel arrive. Record review of the policy titled Section 30-Advanced Directives dated, ,[DATE] revealed, Paragraph 1 of page 109, Every resident has the right to formulate an advance directive and to refuse treatment. The community will determine the existence of an advance directive at the time of admission. Paragraph 9 of page 109, A copy of the advance directive and subsequent revisions will be included in the resident's medical record. Paragraph 2 under Distribution and notifications of page 109, The community obtains copies of changes to or revocations of an advance directive so that appropriate changes can be made in the resident assessment (MDS) and care plan. Copies of changes to an advance directive are filed in the resident's medical record located at the nurse's station. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation on [DATE]. The Administrator was notified on [DATE] at 6:15 p.m. that a Past Noncompliance Immediate Jeopardy was identified due to the above failures. The facility took the following actions to correct the non-compliance on [DATE]. The facilities actions to address the deficient practice included the following: An immediate audit was performed confirming the presence and accuracy of the code status for all current patients was performed and verified by DON B and DON C checking all resident charts in the facility for resident code status. The facility also suspended the charge nurse (LVN E) in this incident pending an investigation. 100% chart audit of all charts to validate code status of all residents and proper documentation on the resident face sheet of code status by DON's/designee were done. DON's will validate code status paperwork is completed upon admission and if there is a change to Hospice, DON B and DON C will call hospice nurse to identify any changes and will fax any information needed to hospice. The facility provided in-service training records on [DATE]-[DATE] and continuing for nurses on regarding the charge nurses to always check code status of resident. Upon identification of a change in status, vital signs, or absence of vital signs and to initiate CPR and placement of AED if a resident has a Full Code status. They are to immediately notify the Administrator/DON/ADON. Interviews and record reviews of LVN's, CNA's and RN's on duty during time of investigation revealed staff were able to describe change of condition of residents and that code status was found in residents electronic file on the face sheet. Staff were able to describe CPR and to immediately start CPR if they did not know a resident's code status. Interviews on [DATE] between 8:30 a.m. and 6:00 p.m. with staff nurses representing multiple shifts revealed they had received in-services from DON B and DON C in identifying a need for CPR and identification of code status, they were knowledgeable of facility protocol on CPR and knew to stay with resident and to call 911 if resident was full code. Record review of sampled resident electronic records revealed correct advanced directive information on resident face sheets for full code or do not resuscitate. The sampled residents included residents who were receiving hospice services and residents who were not on hospice service. An immediate Jeopardy {IJ} was identified to have occurred on [DATE].This was determined to be a Past Noncompliance IJ due to the facility having implemented actions that corrected the noncompliance prior to the investigation.