Every finding on record at The Madison on Marsh

Based on interview and record review the facility failed to ensure the residents had the right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to the right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care for 4 of 6 residents (Residents #2, #20, #27 and #73) reviewed for Resident Rights.The facility failed to ensure Residents #2, #20, #27 and #73, and/or the resident's representative were invited and given the opportunity to participate in the resident's care plan meetings.This failure could place residents at risk of a decline in physical health, psychosocial health, and quality of care.Findings include:1. In a record review of Resident #2's face sheet, dated 02/25/2026, reflected a [AGE] year-old female who was initially admitted to the facility on [DATE]. Resident #2 had diagnoses which included Acute Gastrojejunal Ulcer with Hemorrhage (a severe, potentially life-threatening complication where an ulcer at the surgical site between the stomach and jejunum [middle section of the small intestine ] erodes into a blood vessel, causing significant bleeding), Nondisplaced Transverse Fracture of Shaft of Left Tibia (a break across the shinbone where the bones remain aligned), Chronic Atrial Fibrillation (irregular heart rhythm where the heart's upper chambers quiver instead of beating effectively), Major Depressive (persistent sadness), Anxiety Disorder (persistent fear or worry), Morbid (Severe) Obesity (very overweight), and Polyneuropathy (the widespread damage of multiple nerves, causing numbness, tingling, burning pain, and muscle weakness).In a record review of Resident #2's Quarterly MDS, dated [DATE], reflected Resident #2's BIMS score was 10/15, which indicated moderate cognitive impairment. Resident #2 required maximum to dependent assistance (which meant staff did all of the effort) with care. During an interview on 02/26/2026 at 11:36 a.m., Resident #2 revealed she had never received a letter or invitation for a care conference, had never attended a care conference meeting with the DON, the Administrator, the DOR, Dietary, or Activities, and had never received a copy of her plan of care.2. In a record review of Resident #20's face sheet, dated 02/25/2026, reflected the a [AGE] year-old male who was initially admitted to the facility on [DATE]. Resident #20 had diagnoses which included Osteomyelitis (a serious bone infection), Type 2 Diabetes (high blood sugar level), Paraplegia (is the impairment or loss of motor and sensory function in the lower extremities), and Obstructive and Reflux Uropathy (urinary tract disorder where urine flow is blocked or flows backward into the kidneys).In a record review of Resident #20's admission MDS, dated [DATE], reflected Resident #20's BIMS score was 15/15, which meant an individual had perfect or fully intact cognitive function. Resident #20 required partial to maximum assistance with care.During an interview on 02/25/2026 at 12:02 p.m., Resident #20 revealed he talked to therapy and nursing when he first got to the facility and there was no meeting with anyone else to discuss his care and had never received a copy of his plan of care.3. In a record review of Resident #27's face sheet, dated 02/25/2026, revealed a [AGE] year-old female who was initially admitted to the facility on [DATE]. Resident #27 had diagnoses which included a fracture of the unspecified part of the neck of the left femur (serious hip injury), Iron Deficiency, Moderate Protein-Calorie Malnutrition, Hyperlipidemia (high levels of lipids in the blood), Essential Hypertension (chronic, high blood pressure), Heart Failure (heart not pumping enough blood), Muscle Weakness (reduced muscle movement), and Chronic Kidney Disease (kidney function loss).In a record review of Resident #27's Quarterly MDS, dated [DATE], reflected Resident #27's BIMS score was 3/15, which meant severely impaired cognitive function. Resident #27 required partial to maximum assistance with care.During an interview on 02/25/2026 at 12:54 p.m., Resident #27's family member revealed she had never received a letter, invitation or phone call for a care conference, had never attended a care conference meeting with the DON, the Administrator, the DOR, Dietary, or Activities, and had never received a copy of Resident #27's plan of care.4. In a record review of Resident #73's face sheet, dated 02/25/2026, revealed an [AGE] year-old female who was initially admitted to the facility on [DATE]. Resident #73 had diagnoses which included Metabolic Encephalopathy (a broad term for acute brain dysfunction), Muscle Weakness, Difficulty in Walking, Dementia (memory loss), Schizoaffective Disorder (hallucination/delusions), Generalized Anxiety Disorder (chronic worrying), and Bipolar Disorder(extreme mood swings).In a record review of Resident #73's Quarterly MDS, dated [DATE], reflected Resident #73's BIMS score was 07/15, which meant significant challenges with recall and orientation. Resident #73 required mostly maximum assistance with care.During an interview on 02/24/2026 at 1:15 p.m. the Administrator stated the interdisciplinary team collectively handled social worker duties, which included conducting care conferences. He explained the DON, the DOR, and himself conducted care conferences with residents and/or their families. He also stated he wrote his notes on paper, as did the rest of the team, and the notes were later entered into the facility's electronic medical record.During an interview on 02/25/2026 at 12:23 p.m., the DON revealed newly admitted residents had a care conference completed immediately, within 24 hours of admission, she spoke directly with the resident or, when applicable, the responsible party. She further stated the dietary and activities departments also met with residents separately to obtain information relevant to their areas and when the resident was receiving therapy services, the DOR participated as well.During an interview on 02/25/2026 at 12:54 p.m. Resident #73's family member revealed she had never received a letter, invitation or phone call for a care conference, had never attended a care conference meeting with the DON, the Administrator, the DOR, Dietary, or Activities, and had never received a copy of Resident #73's plan of care.During an interview on 02/25/2026 at 1:30 p.m. the Administrator stated the DON, the MDS Coordinator, and himself were responsible for the 48-hour care conference. He also reported he was unsure whether the resident or responsible party was given a copy of the care plan.During an interview on 02/25/2026 at 1:46 p.m., the MDS Coordinator revealed the DON spoke with residents but did not provide a written letter to the residents or their responsible party about the time and date the care conference was being held. If a resident was alert, she would remind them of the meeting and its scheduled time; if the resident was not alert, she would contact the responsible party.During an interview on 02/26/2026 at 11:00 a.m., the DOR revealed the facility held care conferences with residents or their responsible party, and she participated in those meetings. She reported the DON and the Administrator also attended. She stated the three of the IDT communicated regularly and discussed these matters during their weekly interdisciplinary team meetings. She further stated written notices were not sent to the residents or their responsible parties and that meetings were held on an impromptu (without advance planning) basis. She said care conferences were essential for care planning, ensuring safe discharges, and meeting residents' needs, and added without them, residents would not have the opportunity to express their expectations.During an interview on 02/26/2026 at 11:08 a.m. the MDS Coordinator revealed care conferences were conducted with the residents and/or their responsible party or family members, along with the DON, the Assistant DON, and at times, representatives from dietary, activities, the Administrator, or the DOR. She reported these conferences were held to establish a baseline understanding of the residents, which included their diet, goals, medications, and code status. She added without these meetings, the interdisciplinary team might not fully understand the residents' needs.During an interview on 02/26/2026 at 11:14 a.m., the DON revealed written letters were not mailed or provided to residents to notify them of the date or time of a care conference. She explained care conferences were conducted to discuss the resident's plan of care, provide updates, and address any concerns raised by the resident or family. She added the only negative consequence she could think of if care conferences did not occur was that families might not receive updates on the residents' condition. During an interview on 02/26/2026 at 3:46 p.m., the Administrator revealed the purpose of the care conference was to update the family on the residents' status and to allow families to inform staff of any changes to the residents' physician or other important updates and explained failing to hold care conferences could result in negative outcomes, such as misinformation, missed or undocumented changes in the resident's condition, failure to update the plan of care, or missed medication changes.In a record review of the form the Administrator stated he had taken notes on during care conferences with residents and/or their responsible parties did not show who attended the conference and date the conference was held.In a record review of Resident #2's, Resident #20's, Resident #27's and Resident #73's progress notes in the facility's electronic medical record revealed there was no documentation of a care conference with the residents or a family member, no documentation of phone calls made to invite the resident's responsible party, and there was no documentation of a letter or invitation for the resident's or family members to attend a care conference.In a record review of the facility's Comprehensive Care Plan policy, dated October 1, 2025, reflected, 4. The comprehensive care plan will be prepared by an interdisciplinary team that includes but is not limited to.c. A nurse aide with responsibility for the resident. d. A member of the food and nutrition services staff. c. The resident and the resident's representative to the extent practicable. f. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by their resident. Examples include but are not limited to:.ii. Activity Director. iii. Social Services. v. Family members or others desired by the resident. 7. The physician other practitioner or professional will inform the resident and or resident representative of the risks and benefits of proposed care of treatment and treatment alternatives options the facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record including discussions with the resident or resident representative. 8. Qualified staff responsible for carrying out interventions certified in the care plan will be notified of their role and responsibilities for carrying out the interventions initially and when changes are made.

Based on interview and record reviews the facility failed to ensure a facility with more than 120 beds employed a qualified social worker on a full-time basis for 1 of 1 (facility) reviewed for social worker qualifications.The facility, licensed for 125 beds, failed to employ a full-time social worker.This failure could place residents at risk of social service and psychosocial needs not being met.Findings include:In a record review of the facility's daily census, dated 02/26/2026, revealed the facility had a total licensed bed capacity of 125. In a record review of the Facility Summary Report from TULIP noted the facility had a total licensed capacity of 125 beds.During an interview on 02/24/2026 at 1:15 p.m., the DON revealed the previous social worker left for better job opportunities, and the interdisciplinary team had been managing the social worker duties, which included sending referrals and conducting care conferences.During an interview on 02/24/2026 at 2:34 p.m., the Administrator revealed the facility did not have a social worker on staff and reported the position had been vacant for approximately three to four weeks. He further explained the interdisciplinary team, which included himself, had been covering the social worker duties.During an interview on 02/25/2026 at 12:23 p.m., the DON revealed the facility was in the process of hiring a social worker. She explained the facility did not have a corporate social worker assigned to the building; however, if needed, a social worker from a sister facility could provide assistance. She further stated there was no established schedule for when a social worker would come to the facility, as the Administrator was responsible for arranging those visits.During an interview on 02/25/2026 at 1:30 p.m., the Administrator revealed he was responsible for hiring a full time social worker but had not been successful in locating a licensed candidate. He added the facility did not have a corporate social worker, though a social worker from a sister facility could provide assistance if available and if he requested it. He further noted he had not sought such assistance since the departure of the full time social worker.During an interview on 02/25/2026 at 3:46 p.m., the Administrator revealed the Social Worker position had been posted on both the company website and on Indeed. In a record review of the facility's job advertisement for a Social Worker was requested for both the company website and other jobsite board. And the facility was able to provide the advertisement from the company website but not from the any jobsite boards. In a record review of the undated Social Worker job announcement reflected a licensed Social Worker was being hired at the facility.In a record review of the undated, staff roster, provided by the facility, revealed there was no Social Worker.

Based on interview and record review the facility failed to ensure before a resident was transferred or discharged , the facility must notify the resident and resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 2 of 6 residents (Residents #2 and #12) reviewed for discharge planning.1. The facility failed to notify Resident #2 and Resident #12, or the residents' representative or POA of the transfer or discharge with the reasons for the move in writing in a language and manner they understood when they were transferred to the hospital.2. The facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State LTC Ombudsman involving Resident #2 and Resident #12, when they were transferred to the hospital.These failures could place residents at risk of being discharged without alternative placement, discharge options, their rights to appeal and access to advocacy services.Findings included:1, A record review of Resident #2's face sheet, dated 02/25/2026, reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and was her own responsible party. Her diagnoses included Acute Gastrojejunal Ulcer with Hemorrhage (a potentially life-threatening complication where an ulcer at the surgical site between the stomach and jejunum (middle section of the small intestine ) erodes into a blood vessel, causing significant bleeding), Nondisplaced Transverse Fracture of Shaft of Left Tibia (a break across the shinbone where the bones remain aligned), Chronic Atrial Fibrillation (irregular heart rhythm where the heart's upper chambers quiver instead of beating effectively), Major Depressive, Anxiety Disorder, Morbid (Severe) Obesity, and Polyneuropathy (the widespread damage of multiple nerves, causing numbness, tingling, burning pain, and muscle weakness).A record review of Resident #2's Quarterly MDS, dated [DATE] reflected Resident #2's BIMS score was 10/15, which indicated moderate cognitive impairment. Resident #2 required maximum to dependent assistance (which means staff does all the effort) with care. A record review of Resident #2's progress note, dated 12/15/2025, reflected the resident was sent to the emergency room on December 15, 2025, for abdominal pains. There was no evidence a transfer or discharge notice was provided to Resident #2 in writing or to the LTC Ombudsman. 2. A record review of Resident #12's face sheet, dated 02/25/2026, revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and was her own responsible party. Her diagnoses included Urinary Tract Infection, Muscle Weakness, Difficulty in Walking, Dysphagia (difficulty swallowing), Hyperlipidemia (is high levels of lipids in the blood), Essential Hypertension (chronic, high blood pressure), and Morbid Obesity.A record review of Resident #12's admission MDS dated [DATE], reflected Resident #12's BIMS score was 14/15, which indicated cognitively intact mental status. Resident #12 required moderate to maximum assistance with her care.A record review of Resident #12's progress notes, dated 01/09/2026, reflected she was sent to the emergency room. There was no evidence a transfer or discharge notice was provided to Resident #2 in writing or to the LTC Ombudsman. During an interview on 02/25/2026 at 11:28 a.m., the DON revealed the only time the Ombudsman was notified about discharges was if a resident left against medical advice or if it was an unsafe discharge to the community.During an interview on 02/26/2026 at 12:23 p.m. with the facility's Ombudsman, she said she received one discharge notice in December 2025 and one in January 2026 and neither one was for Resident #2 nor Resident #12.During an interview on 02/26/2026 at 4:23 p.m., the DON revealed residents never received a transfer or discharge notice in writing.During an interview on 02/26/2026 at 4:23 p.m., the Regional Operations revealed she's never heard of having to provide a written notice to residents when they were discharged to the hospital with the intention of returning to the facility.A record review of the facility's Transfer and Discharge policy, revised 12/01/2025, reflected: Policy Explanation and Compliance Guidelines:3. The facility's transfer/discharge notice will be provided to the resident and the resident's representatives in a language and manner in which they can understand. The notice will include all of the following at the time it is provided:a. The specific reason and basis for transfer or discharge.b. The effective date of transfer or discharge.c. The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged .d. An explanation of the right to appeal the transfer or discharge to the State.e. The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests.f. Information on how to obtain an appeal form.g Information on obtaining assistance in completing and submitting the appeal hearing request.h. The name, web address, and phone number of the representative of the Office of the State Long-Term Care Ombudsman.i. For nursing facility residents with intellectual and developmental disabilities (or related disabilities) or with mental illness (or related disabilities), the notice will include the name, web address and e-mail addresses and phone number of the state agency responsible for the protection and advocacy of these populations.4. Generally, the notice must be provided at least 30 days prior to a facility-initiated transfer or discharge of the resident. Exceptions to the 30-day requirement apply when the transfer or discharge is effected because: a. The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident; b. The resident's health improves sufficiently to allow a more immediate transfer or discharge; c. An immediate transfer or discharge is required by the resident's urgent medical needs; or d. A resident has not resided in the facility for 30 days. e. In these exceptional cases, the notice must be provided to the resident, resident's representative if appropriate, and LTC ombudsman as soon as practicable before the transfer or discharge.7. The facility will maintain evidence that the notice was sent to the Ombudsman.10. Emergency Transfers to Acute Care . f. Document assessment findings and other relevant information regarding the transfer in the medical record.g. Provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated.h. The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices.

Based on interview and record review the facility failed to develop and implement a comprehensive person- centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 6 residents (Resident #1 and Resident #27) reviewed for care plans 1, The facility failed to ensure Resident #1's comprehensive care plan was developed to address the code status was changed from full code to DNR on 01/07/2026.2. The facility failed to ensure the care plan for Resident #11 was developed to address the code status was changed from full code to DNR on 01/12/26.3. The facility failed to ensure Resident #27's comprehensive care plan was developed to address the code status was changed from full code to DNR on 02/11/2026.These failures could place residents at risk of not receiving treatment aligned with their expressed wishes and physician orders.Findings included: 1.In a record review of Resident #1's face sheet, dated 02/25/2026, reflected an [AGE] year-old female who was initially admitted to the facility on [DATE]. Resident #1 had diagnoses which included Mild protein-calorie malnutrition (a decrease intake of protein often appearing as weight loss), Dysphagia (difficulty swallowing), Cognitive Communication deficit (often caused by brain injury [stroke, tumor, TBI] or neurological disease), Schizoaffective disorder (a chronic mental health condition which can include, hallucinations, delusions, disorganized speech with mania or depression), Bipolar disorder (a chronic mental health condition characterized by intense mood swings, ranging from extreme highs to severe lows), and Anxiety disorders (a persistent, excessive fear or worry that interferes with daily life).In a record review of Resident #1's MDS dated [DATE], reflected Resident #1's BIMS score was 07/15, which indicated severe impairment. Resident #1 was dependent on the staff to do all her activities of daily living.In a record review of Resident #1's physician orders, dated 01/07/2026, reflected she had a DNR order signed by her physician.In a record review of Resident #1's care plan, initiated on 01/01/2026, reflected: she had no care plan for her advanced directive. In a record review of the facility's DNR binder, Resident #1 had an OOH-DNR order that was filled out correctly. 2. Record Review of Resident #11's admission MDS assessment, dated 01/17/26, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. The resident's cognitive status was intact with a BIMS score of 15. Her diagnoses included heart failure. Record review of Resident #11's Order Summary Report, dated 01/12/26, reflected: DNR.Record review of Resident #11's Care Plans, dated 01/10/26, reflected: Resident requests code status of full codeFacility interventions included: Inform staff of code status and monitor for decrease in change of condition, report to physician, and responsible party.3. In a record review of Resident #27's face sheet, dated 02/25/2026, reflected a [AGE] year-old female initially admitted to the facility on [DATE]. Resident #27 had diagnoses which included a fracture of the unspecified part of the neck of the left femur (is a serious hip injury), Iron Deficiency, Moderate Protein-Calorie Malnutrition, Hyperlipidemia (high levels of lipids in the blood), Essential Hypertension (chronic, high blood pressure), Heart Failure, Muscle Weakness, and Chronic Kidney Disease.In a record review of Resident #27's MDS, dated [DATE], reflected Resident #27's BIMS score was 3/15, which meant severely impaired cognitive function. Resident #27 required partial to maximum assistance with care.In a record review of Resident #27's physician orders, dated 02/11/2026, reflected she had a DNR order signed by her physician.In a record review of Resident #27's care plan, initiated on 02/10/2026, reflected Resident requests code status of full code. Facility interventions included: Inform staff of code status and monitor for decrease in change of condition, report to physician, and responsible party.In a record review of the facility's DNR binder, reflected Resident #27 had an OOH-DNR order that was filled out correctly.During an interview on 02/25/2026 at 12:54 p.m., Resident #27's family member revealed Resident #27 had a signed DNR order that was given to the facility.During an interview on 02/24/2026 at 2:34 p.m., the Administrator stated the DON, himself, and the therapy staff conducted care conferences with the residents and their families and afterwards they updated the resident's care plan in the facility's EMR.During an interview on 02/25/2026 at 1:46 p.m., the MDS Coordinator said the DON was responsible for completing the baseline care plan. She reported these conferences were held to establish a baseline understanding of the residents, including their diet, goals, medications, and code status. She added that without these meetings, the interdisciplinary team might not fully understand the residents' needs.During an interview on 02/26/2026 at 11:14 a.m., the DON revealed newly admitted residents had a care conference completed immediately, within 24 hours of admission, and she was responsible for those. She explained care conferences were conducted to discuss the residents' plan-of-care, provide updates, and address any concerns raised by the resident or family. When asked what impact, if any, could occur if a resident did not have a code status order. She responded, I don't know.During an interview on 02/26/2026 at 3:46 p.m., the Administrator revealed the purpose of the care conference was to update the family and/or resident on the resident's status and to allow family members to inform staff of any changes to the resident's physician or other important updates. He further explained failing to hold care conferences could result in negative outcomes, such as misinformation, undocumented changes in the resident's condition, failure to update the plan of care, or missed medication changes.In a record review of the facility's Comprehensive Care Plan policy, dated October 1, 2025, revealed: Policy Explanation and Compliance Guidelines 3. The comprehensive care plan will describe at a minimum the following.b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment.5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.7. The physician, other practitioner or professional will inform the resident and/or resident representative of the risks and benefits of proposed care of treatment and treatment alternatives/options the facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record including discussions with the resident and/or resident representative.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of four residents (Resident #94) reviewed for accidents and supervision. The facility failed to ensure CNA A supervised Resident #94 while her bed was elevated in the air. This failure could place residents at risk for accidents and falls.Findings include: Record Review of Resident #94's admission MDS assessment, dated 01/16/26, reflected resident was a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's cognitive skills for decision making were severely impaired. The BIMs score was left blank. The resident required moderate assistance for repositioning. Her diagnoses included stroke, hemiplegia (partial paralysis), and cancer. Record review of Resident #94's Care Plans reflected:01/15/26: The resident had an ADL self-care performance deficit.Facility interventions included: Transfer: The resident required mechanical lift with 2 staff assistance for transfers.02/25/26: The resident had impaired cognitive function/impaired thought processes related to difficulty making decisions and neurological symptoms.Facility interventions included: Cue, reorient, and supervise as needed.01/20/26: Risk for fallsFacility interventions included:Fall identifiers in place. Leaf on door/red band on mobility device. An observation and interview on 02/24/26 at 11:00 AM revealed Resident #94'a bed was highly elevated in the air. The positioning side rail on the right side of the bed was lowered. CNA A was in the room. After the State Surveyor entered, CNA A walked out of the room and said she was going to get the Hoyer lift to transfer the resident. Resident #94 was able to answer some questions and said she was not scared being so high in the air. 2-3 minutes later CNA A returned to the room. She said the Hoyer lift was being used for another resident. CNA A lowered the resident's bed and repositioned the side rail. An interview on 02/24/26 and 11:05 AM with CNA A revealed it was not okay to leave Resident #49's bed high in the air and leave the room. She said she did it because she was going to get the Hoyer lift. CNA A said leaving the resident's bed elevated high in the air could cause her to fall. An interview on 02/24/26 at approximately 12:00 PM with the DON revealed staff were not allowed to leave a resident alone in an elevated bed with the positioning rail down. The DON said leaving the resident in that position placed them at risk for falls. Record Review of the facility's policy, Incidents and Accidents, revised 12/01/25, reflected: Policy Explanation .Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent reoccurrences and improve the management of resident care.

Based on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of three residents (Resident #57) reviewed for Foley catheters.The facility failed to ensure CNA B cleaned the Foley catheter and perineal area for Resident #57 during incontinence care. This failure could place residents at risk for developing urinary tract infections and skin infections.Findings include: Record review of Resident #57's quarterly MDS assessment, dated 11/21/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's cognitive skills were severely impaired, with a BIMs score of 1. The resident required a Foley catheter. Her diagnoses included heart failure and obstructive uropathy (blockage in the urinary system). Record review of Resident #57's Care Plans, dated 10/10/25, reflected:History of urinary tract infection, presence of catheter. Facility interventions included: Clean peri -area (anal/genital openings) with each incontinence episode.An observation and interview on 02/24/26 at 12:00 PM of Resident #57 revealed staff were preparing to do catheter care. CNA A, CNA B and CNA C prepared their supplies. CNA C was translating for the resident. CNA B unfastened the brief and cleaned the peri-area. CNA B washed her hands and put on new gloves. The resident was incontinent of bowel. CNA B cleaned the peri-area and buttocks. The resident was turned to her back and a clean brief was placed. There were no issues with hand hygiene. The resident had visible bowel movement on the catheter tubing and peri-area. CNA B started to close the brief. The HHSC State Surveyor observing asked CNA B was she was going to clean the stool. CNA B said, I did not see it. CNA B recleaned the peri-area, vaginal area, and the Foley catheter tubing. There was a moderate amount of stool cleaned. CNA B placed a clean brief on the resident. An interview on 02/24/26 at 12:30 PM with CNA B revealed she was supposed to clean the catheter tubing and the peri-area during incontinence care. She said in this case she did not do it, because she did not see the stool. She said she was not wearing contacts. CNA B said failure to clean the peri-area and Foley catheter could cause infection. An interview on 02/26/26 at 11:25 AM with the DON revealed staff were supposed to clean the peri-area and catheter tubing during incontinence care and were trained to do so. The DON said she monitored incontinence care weekly. She said CNA B usually did a good job. The DON said Resident #57 did not have frequent urinary tract infections, but failure to clean the peri-area and Foley catheter tubing could cause urinary tract infections. Record review of the facility's policy, Catheter Care, revised 12/01/25, reflected: 1. Female.10. Gently separate the labia to expose the urinary meatus.11. Wipe from front to back with a clean disposable moist wipe or cloth moistened with water andperineal cleaner (soap).12. Use a new disposable moist wipe or a new part of the cloth or different cloth for each side.13. With a new disposable moist wipe or new moistened cloth, starting at the urinary meatus moving out,wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter.14. Dry area with towel if needed.

Based on observation, interview and record review, the facility failed to ensure it provided a safe, functional, sanitary, and comfortable environment for residents, staff and the public for one of four residents (Resident #94) reviewed for environment. The facility failed to ensure Resident #94's environment was clean and sanitary. This failure could place residents at risk for having an unclean and unsanitary environment.Findings included: Record Review of Resident #94's admission MDS assessment, dated 01/16/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's cognitive skills for decision making were severely impaired. Her BIMs score was left blank. The resident required moderate assistance for repositioning. Her diagnoses included stroke, hemiplegia (partial paralysis), and cancer. An observation on 02/24/26 at 11:00 AM revealed Resident #94's bedroom wall next to her headboard had a large, dry, red/tan spill on it. The resident said she did not know how the spill got there. She said it did not bother her. An interview on 02/24/26 at 11:45 am with CNA A revealed she did not know anything about the spill on Resident #94's bedroom wall. CNA A said she was supposed to notify housekeeping for spills on the wall. An interview on 02/25/26 at 5:00 PM with the Administrator revealed the spill on Resident #94's bedroom wall was red juice. He said he thought the spill had been there maybe a day or two. He said if staff saw a spill on the wall they were supposed to get it cleaned. Record review of the facility's policy, Safe and Clean Environment, dated 10/01/25, reflected: Policy .the facility will provide a safe, clean, comfortable, and home-like environment .

Based on record review and interviews, the facility failed to ensure completion of a discharge summary including a recapitulation of the resident's stay, and final status at discharge for 1 of 3 residents (Resident #1) reviewed for discharge summary. The facility failed to complete a recapitulation of stay for Resident #1, who discharged to the community on 10/07/25. This failure could place residents at risk of a recapitulation of their stay being unavailable to help ensure continuity of care once they are discharged from the facility.Findings included: Record review of Resident #1's face sheet dated 10/21/25, indicated a 55yo female who admitted to the facility on [DATE] with diagnoses which included anxiety (excessive worry, fear, and nervousness), chronic kidney disease (kidneys unable to filter waste products from the blood), fibromyalgia (widespread body pain and fatigue), displaced trimalleolar fracture of left lower leg (severe injury to the ankle joint where three of the bones are broken and displaced) and muscle weakness (muscles lose their strength and tone). Resident #1 discharged from the facility on 10/07/25. Record review of Resident #1's discharge MDS assessment dated [DATE], indicated Resident #1's cognition was intact with a BIMS score of 15. Resident #1 was discharged to the community with a discharge assessment-return not anticipated. Record review of Resident #1's comprehensive care plan dated 08/01/25, indicated Resident #1 expressed a desire to return to the community. The care plan interventions included make arrangements with required community resources to support independencepost-discharge. Record review of Resident #1's Discharge Instruction Form, with an effective date of 10/01/2025, reflected it was not complete nor signed. The areas of Follow-up Appointment, Dietary Recommendations, Skin Issues and Patient Instructions/Teaching were all missing required information. Record review of Resident #1's IDT - Recapitulation of Stay, with an effective date of 10/08/2025, revealed the document was not complete nor signed. The areas of Nursing Services, Activities, Dietary Services, and Rehabilitation Services were all missing required information. The only completed section was Social Services. Record review of Resident #1's nursing progress note dated 10/07/25 at 15:21 (3:21 PM) and signed by RN A, revealed . [Resident #1 was discharged today accompanied by his [sic] [family member] with take home meds and discharge instructions. Review of Resident #1's EMR reflected no discharge summary was completed or uploaded. During an interview on 10/21/25 at 2:00 PM, RN A stated when a resident discharged from the facility the discharge summary was completed. RN A said the nurse was responsible for ensuring the nursing summary section was completed. RN A said the discharge summary included the list of medications the resident was taking, home health company, any equipment needed, the summary of their care, and any upcoming doctor appointments. RN A stated the SW informed her on the morning of 10/07/25, that Resident #1 would be discharged the same day. RN A stated she gathered all of Resident #1's medications, recorded her routine vitals and printed the discharge paperwork. RN A stated she completed the recapitulation of the medications and had Resident #1 sign it. RN A stated she failed to make a copy as Resident #1 was in a rush to leave. RN A stated she was supposed to make a copy and place it in the discharge paperwork tray to be scanned into Resident #1's EMR by Medical Records. RN A stated she was supposed to create a Progress Note and enter the details of Resident #1's discharge including when and whom she left with, discharged location, observation, etc. RN A stated she completed discharges before and made copies, except this time Resident #1 was in a hurry. RN A stated she was trained on how to complete discharges by the ADON. RN A stated she never had issues with discharges before. RN A stated she should have copied the discharged paperwork. RN A stated Resident #1's physical and mental health could be jeopardized without the list of medications and details of her stay properly documented. RN A stated it was important for Resident #1 to have a copy of her Discharge Summary completed in case there was an emergency. During an interview on 10/21/25 at 2:35 PM, the ADON stated the SW alerted the nurses which residents were being discharged , the date and time, and the mode of transportation. The ADON stated the nurse gathered all medications and completed the discharge paperwork. The ADON stated the nurse confirmed the discharge with the resident. The ADON stated on the day of discharge, the nurse gathered all medications and informed the resident of the discharge time. The ADON stated the nurse confirmed all medications in the resident's room with the resident and/or family and educated them. The ADON stated the nurse should have printed the discharge form because it included the medication list including the discharged date and had the resident sign it. The ADON stated she instructed the nurses to print two copies to be signed by the resident. The ADON stated you were supposed to enter everything that transpired during the discharge process into the resident's EMR under Progress Notes. The ADON stated RN A knew the discharge process, how to complete the paperwork and to educate the residents on their medications. The ADON said by not completing a discharge properly, residents may not know the time or how to take their medications. The ADON stated if the residents were not alert to understand the medication list, it could lead to the residents taking the incorrect amount. During an interview on 10/21/25 at 3:05 PM, the SW stated she had worked at the facility for six months and she was trained by a peer from one of their sister facilities on Discharges. She stated said they discussed everything required for discharge planning (continuation of care, durable medical equipment, follow-up appointments, referrals, Social Security Income, transportation, etc.). The SW said she was instructed to make sure she initiated all the required paperwork for the discharge so the residents received necessary services. The SW stated as a team it was decided when a resident was medically stable to discharge or if they met their therapy goals. The SW stated a discharge list was sent out to management that included the name of the residents being discharged and it was also discussed during the morning meeting. The SW stated they discussed the confirmed time and day of discharge and communication was shared with the nurses. The SW stated at discharge residents received a discharge form, a list of their medications and any home health information that had been set up. The SW stated she initiated the discharge form and completed her section and nursing was required to complete the rest of the form. During an interview on 10/22/25 at 11:20 AM, the DON stated each department was responsible for completing their section of the discharge summary. The DON reviewed Resident #1's EMR and said there was not a complete discharge summary. The DON said Resident #1's discharge summary should have been completed on 10/07/25, when she discharged from the facility. The DON said not completing a discharge summary in its entirety placed the resident at risk for missing follow up appointments and missed medications. During an interview on 10/22/25 at 2:15 PM, the ADM stated the discharge process was started at admissions during their Circle of Excellence Meetings. The ADM stated they met with the resident and their RP and discussed their expectations, discharge planning and any special services or equipment based on the resident's progress therapeutically. The ADM stated the next steps were to touch base with the resident as needed and once the resident decided, they provided a list of other Nursing Homes, Group Homes, or Homeless Shelters. The ADM stated the SW initiated the discharge summary and then each department had a section they were required to complete. The ADM said failure to complete a discharge summary placed the resident at risk for missed follow-up appointments or not knowing what medications they were taking. The ADM stated he would attempt to establish more concrete discharge plans at admissions. Record review of the facility's policy Discharge Summary and Plan with a revised date of December 2016, indicated . 2. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's:a. Current diagnosis;b. Medical history (including any history of mental disorders and intellectual disabilities); .p. Medication therapy. 3. As part of the discharge summary, the nurse will reconcile all pre-discharge medication with the resident's post-discharge medications. The medication reconciliation will be documented.13. A copy of the following will be . filed in the resident's medical records:a. An evaluation of the resident's discharge needs;b. The post-discharge plan; andc. The discharge summary.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan interventions for each resident consistent with the resident rights that included measurable objectives and time frames to meet the resident's medical needs identified in the comprehensive assessment for 1 (Resident #1) of 6 residents reviewed for care planning. The facility failed to care plan Resident #1's wound care order that reflected the following: Allow Pico dressing to stay 1 week, then remove and let doctor know what underlying wound look like. Text picture to [number] in the morning until 10/08/2025. This failure could affect resident care/services and may cause a delay in treatment and/or complications, infection, and poor wound healing. Record review of Resident #1's admission Record, dated 10/16/25, reflected an [AGE] year old-female initially admitted on [DATE] with diagnoses to include Spontaneous Rupture of Extensor Tendons (unexpected and without apparent cause tear of the tendons that extend the fingers and thumb) Left Lower Leg, Strain of Left Quadriceps Muscle, Fascia and Tendon (tear or overstretching of muscle fibers, fascia (connective tissue that wraps around, supports, and separates muscles, organs, blood vessels, and nerves), or tendons in the thigh), Postprocedural Seroma of a Musculoskeletal Structure Following a Musculoskeletal System Procedure (collection of serous fluid that forms after a musculoskeletal system procedure), Difficulty in Walking, and Lack of Coordination (uncoordinated movement due to a muscle control problem). Record review of Resident #1's admission MDS assessment, dated 09/15/25, revealed the resident had a BIMS score of 15 out of 15, which indicated cognition was intact. The MDS assessment under Section GG-Functional Abilities also revealed resident required assistance with walking. The MDS assessment under Section M-Skin Conditions revealed resident was at risk of developing pressure ulcers/injuries. Record review of Resident #1 Comprehensive Care Plan, dated 09/15/25, revealed the care plan did not include focus, goals, and interventions of wounds. Record review of Resident #1's prescription, signed and dated 10/01/25 by [MD] reflected the following: Please allow PICO dressing to stay on for 1 week. Then remove and let us know what underlying wound looks like. Text picture to [number]. Record review of Resident #1's order summary report, dated 10/17/25, reflected the following: Allow Pico dressing to stay 1 week, then remove and let doctor know what underlying wound look like. Text picture to [number] in the morning until 10/08/2025 11:46. Start date: 10/01/2025 and End date: 10/08/2025. In an interview on 10/16/25 at 4:51 PM with DON, she stated Resident #1 came into the facility post-surgery for her knee. DON stated Resident #1 had sutures on her knee. DON revealed the facility only monitored Resident #1's wound. In an interview on 10/17/25 at 2:00PM, LVN B revealed she did not deal with wounds. She stated if there were any changes, she reported it to the nurse. She stated she looked at the treatment and admission report to find the residents' needs. LVN B stated some care plans were important. She stated if there were any changes with the resident, she had to look at the care plan. She also stated if there were no changes or a resident was a long-term care resident, she did not often look at the care plan. LVN B stated the risk of not looking at resident's care plan was not understanding what the resident's needs were. In an interview on 10/17/25 at 2:49 PM with MDS Coordinator, he stated he had worked at the facility for three months. He stated the ADON or Wound Care Nurse was responsible for adding any wound care to care plans. He also stated he had 21 days for the care plan. MDS Coordinator stated acute care plans were done by the ADON. He stated he would help with updating care plans if the Wound Care Nurse was behind. He also stated he could not update the care plan with wound care if the Wound Care Nurse did not tell him. The MDS Coordinator stated he was told on 10/16/25 by DON to add wound care into Resident #1 care plan. He stated not having wound care in the care plan could affect the resident's care. In an interview on 10/17/25 at 3:29 PM, the ADON revealed the facility monitored Resident #1's wound. She stated Resident #1's care plan should have been revised to include any wound care that was provided by the facility. The ADON also stated it was the MDS nurse's responsibility to update Resident #1's care plan. She stated sometimes MDS Nurse may not be in the facility upon a residents' admission but was still responsible. ADON stated the risk of not including the care plan was staff not knowing proper care for the resident In an interview on 10/17/25 at 5:14 PM, Wound Care Nurse stated her understanding was the MDS Nurse oversaw the care plans. The Wound Care Nurse revealed she had been performing wound care for Resident #1 although it was not in the care plan. She stated wound care goals and interventions were supposed to be included in Resident #1's care plan. She revealed the wound care for Resident #1 was not in the care plan due to an oversight. She stated she was responsible for updating care plans of all resident that she saw for wound care. The Wound Care Nurse stated not revising care plans to include new goals was risk of resident's care being affected. In a follow-up interview on 10/17/25 at 5:31 PM, Administrator and DON stated they identified that Resident #1 did not have wounds care planned. The DON stated the MDS Coordinator was responsible for updating care plans. The DON also stated the Wound Care Nurse was responsible for updating care plans to include wounds. She stated the wound nurse was supposed to add to Resident #1's care plan because she was monitoring the resident's wound. DON revealed she was responsible for overseeing that care plans were updated. DON stated the risk of not updating the care plan was residents not receiving the proper care. Record review of the facility's policy titled, Care Plans-Baseline revised March 2022 reflected in part the following: The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following:a. Initial goals based on admission orders and discussion with the resident/representative;b. Physicians orders;c. Dietary orders;d. Therapy services;e. Social services; andf. PASARR recommendation, if applicable.

Based on interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 (Resident #2) of 4 residents reviewed for elopement. The facility failed to provide adequate supervision to Resident #2 and as a result, the resident eloped from the facility and was found by a passerby between 12:00 pm and 2:00 pm in front of a local store (8.9 miles) away from the facility. Resident # 2 was gone from the facility for over five and a half hours and last seen on 02/22/25 at 1:41 AM. Resident #2 was taken to a hospital on [DATE] at 2:00 PM, and a nurse from the hospital notified the facility. The above noncompliance was determined to be a past non-compliance Immediate Jeopardy that existed from 02/22/25 at 01:41 AM, and the Immediate Jeopardy was determined to have been removed on 03/01/25 due to the facility's implemented actions that corrected the non-compliance of re-educating staff about assessing and identifying wandering residents, elopement risks, and alarm management prior to the beginning of the HHSC investigation on 04/16/25. This failure could place residents at risk for accidents, falls and serious injury resulting in a decreased psycho-social well-being, physical decline, or death. Findings included: Review of Resident #2's Face Sheet dated 04/16/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses: Cirrhosis of liver (chronic liver damage from a variety of causes leading to liver failure), Hepatic encephalopathy ( the loss of brain function when a damaged liver does not remove toxins from the blood) , restlessness, and agitation. Review on Resident #2's Elopement risk assessment dated 01/25/25 revealed 1. No risk. Patient is able to make decisions regarding tasks of daily living e.g. decisions are consistent and reasonable . Review of Resident #2's admission MDS assessment dated [DATE] revealed Resident #1's BIMS score was 10/15 (moderate cognitive impairment), and the resident had no wandering behavior, was independent with locomotion off unit, with setup only, not steady, but able to stabilize without staff assistance with balance during transitions. Review of Resident #2's Care Plan dated 02/17/25 revealed, Problem. Potential for elopement as evidenced by: Exit seeking. Goal. Maintaining the least restrictive environment while providing for Resident #2 safety for 90 days. Intervention. Frequent monitoring. Have activities involved with favorite pastime. Photo in MARS and Elopement risk book. Further review revealed, Problem. Resident #2 demonstrates movement behavior that may be interpreted as wandering, pacing, or roaming r/t the diagnosis (es) of Hepatic Encephalopathy and problem understanding the immediate environment. Goal. Resident #2 will respond to staff direction to redirect attention from a potentially problematic situation (such as elopement or entering a peers' room) when any difficult behavior occurs by the next 90 days. Intervention. Implement preventative intervention strategies: Assess for potential elopement/unauthorized departure risk. Implement preventative intervention strategies: Make rounds/room checks per facility protocol to minimize chance of unauthorized leave. Implement preventative intervention strategies: Provide simple, clear directions to help the resident know what is expected. Review of ADL self-care performance revealed Resident #2 is capable of increased independence in at least some ADLs. Review of Resident #2's Nurse Progress dated 02/17/25 at 2:31 PM written by RN D revealed, [Resident#2] is attempting to exit through back doors &states he needs to go home. Management notified. Upcoming charge nurse notified. [Resident#2] . has been walking around back & forth from his room to dining area & halls. Resident#2 to be monitored for elopement. Review of Resident #2's Nurse Progress Note dated 02/17/25 at 8:46 PM written by RN C revealed, Patient attempting to exit the building. Review of Resident #2's Nurse Progress Note dated 02/23/25 at 7:53 PM, reflected the DON stated on 02/22/25 at 07:20 AM This nurse was notified by CN the [Resident#2] was not present in his room while rounding and that he had left AMA. This writer asked the CN to immediately do a facility door-to-door search with the team. Administrator and MD notified. Son of the resident called and notified that he had left AMA, and a search was initiated to ensure resident safety. Review of NP progress note dated 02/24/25 at 01:32 AM, reflected she saw Resident#2 on 02/20/25 at 01:32 AM .Subject: Patient seen today in room. Patient unable to answer questions clearly, confused. No pain or distress at this time. Spoke to nursing and therapy and they state that patient was exit seeking and with thrive in a memory care unit. Review of the Facility's Provider Investigative Report dated 03/01/25 revealed on 02/22/25 Resident #2 left the facility at 04:00 AM. At some point between 12:00 PM and 2:00 PM, the resident was located at nearby Wal-Mart and taken to a local hospital, where a nurse's note documented his presence shortly after 2:00 pm. The resident was found safe, without injuries, and expressed a desire to return home. notifications to [Resident #2] 's Doctor, Family member and Ombudsman was done. The Facility conducted several Staff and Resident interviews and could not figure out how [Resident #2] opened the door and exited the facility without anyone hearing the alarm, or if the alarm went off at the opening of the door. This incident prompted a comprehensive facility-wide response, staff training, and policy reinforcement to prevent future occurrences. The investigation remains ongoing, with continued audits, training, and elopement drills in place to strengthen security and resident safety. Life satisfaction rounds and interviews with the residents and education with staff about the elopement, elopement risks, alarm system and elopement were conducted, and staff statements were collected. The nurse assigned to Resident#2 on 02/22/25 shift 10 PM to 6 AM terminated. Findings: unconfirmed. Review of Resident #2's Physician medication order Recap Report dated 03/04/25 revealed the following medications orders: -Folic acid tab 1000 mcg given 1 tablet orally one time a day for vitamin deficiency. -Pantoprazole tab 40 mg give 1 tablet orally two times a day for GERD (a digestive disease in which stomach acid or bile irritates the food pipe lining). -Divalproex tab 125 mg given 1 tablet orally two times a day for restlessness and agitation. -Lactulose sol 10 gm/15ml give 60 milliliters orally four times a day for Cirrhosis of liver. Doxycycl HYC cap 100 mg give 1 capsule orally one time a day for bacterial peritonitis (a severe bacterial infection of abnormal accumulation of fluid in the abdomen). -Tamsulosin cap 0.4 mg give 1 capsule orally one time a day for BPH (non-cancerous enlargement of the prostate gland). -Finasteride tab 5 mg give 1 tablet orally one time a day for BPH. -Miralax oral packet 17 gm give 17 gm by mouth one time a day for constipation. -Thiamine HCL oral tablet 100 mg give 1 tablet by mouth one time a day for Thiamine deficiency. -There was no order for a Wander Guard. Review of the facility's Camera footage titled Video for the front door, revealed Resident #2 on 02/22/25 at 04:00 AM from inside pushed the door electric latch retraction, walked steadily via the front door, wearing beige shirt pants, beige long sleeve jacket, and outdoor shoes. Resident #2 was seen leaving the facility. The Camera was facing outside, and there was no camera facing inside the facility. The door had oval glass at the middle. The Video did not have any sound. Interview on 04/16/25 at 2:38 PM, CNA D stated she was working the 300 hall the day of the incident. She stated the staff searched for Resident #2 everywhere in the facility, and they could not find him. She stated she was thinking Resident#2 left sometime during the night shift. She stated she was trained to round every 2 hours or more frequent to check on residents. She stated she did not notice Resident#2 exit seeking behaviors to exit the facility. She stated Resident#2 was independent, used to walk around inside the facility, but she did not see him trying to leave until the incident happened. Interview on 04/16/25 at 3:09 PM, LVN I stated Resident #2 was last on 300 Hall. She stated she used to take care of him when he was in 100 Hall, and at that time, Resident#2 was most of the time, in bed. LVN I stated she rounded every two hours on the residents. LVN I stated the CNAs were in and out of the residents' rooms all the time. She stated when she was working during the night shift, she had some residents that would roam the facility and go to other halls and the staff would bring them back to their rooms. Interview on 04/16/25 at 4:10 PM, the Administrator stated Resident #2 was there for short term. He stated the staff were trained to round on the residents every 2 hours. He stated Resident#2 was in the library when the 10 PM-6 AM shift staff came in for their shift. He stated the CMA for 2 PM-10 PM gave Resident#2 his medications, and the 2 PM-10 PM nurse saw the resident around 7 PM. He stated the nursing progress note from the night shift for RN R was done at 1:41 AM on 02/22/25. The Administrator stated CNA P was sent to the hospital to identify Resident#2. The Administrator stated Resident#2 was found by a passerby in front of Local store door, and the passerby called the paramedics who took Resident#2 to the hospital. The Administrator stated Resident#2 may have the code for the door, because if the person exiting the door had the code, the alarm would not go off. He stated after the incident, the facility changed the code. He stated the alarm sound was louder in the nursing station, and the facility increased the volume by the main facility exit door. The Administrator stated, per the staff at the time of the incident, the alarm did not go off. He stated the Resident#2 did not follow anyone. Interview revealed the Administrator, DON and Maintenance Supervisor reviewed the Video for the front door and saw the resident exiting the front door by himself. He stated Resident#2 may have observed the staff entering in the key code and got the code. The Administrator stated the housekeeping staff did not work at night; they started their shift at 5 AM and went home at 4 PM. He denied any other resident had eloped from the facility before or after the incident. Interview on 04/17/25 at 06:11 AM, Housekeeper Q stated he started his shift at 5 AM all the time, except if he had to shampoo the carpet, then he comes in at 4 AM . He stated whenever he came in to work, the alarm was always on, and when the alarm goes off, he walked around and check if there was someone outside the door. He stated there were no supplies delivery early in the morning. Interview on 04/17/25 at 06:58 AM, the Administrator stated the door alarms engaged automatically, they were doing weekly checks, before the incident, by the Maintenance Supervisor. When the Administrator was asked if there was a power outage the night of the incident that can affect the alarm system, he replied he did not know, and did not know if the alarm system was connected to the generator. The Administrator stated the Maintenance Supervisor would have that information. He stated the facility sent LVN L to the hospital to assess and speak to Resident#2. He stated the Corporate Marketer and the Maintenance supervisor tried also to talk to Resident#2, but the local PD did not allow them to talk to Resident#2 because of the ongoing investigation. He stated he did not get the police report from the local police department. The Administrator stated the facility asked for it, and the local police department wanted $1000 to release the report, and it would take up to 6 months to get the full report. He stated Resident#2 wanted to leave the facility and go home. He stated the Resident lived near the Local store he was found in. When asked about the elopement risk to the residents, the Administrator stated they would contact the family, put the resident on one-to-one monitoring, and start the process of discharge to a safer facility. The Administrator mentioned that the facility did not have a secured unit and did not have wander guards for elopement risk residents. Interview on 04/17/25 at 07:28 AM, LVN D stated she was familiar with Resident #2, and he was not having exit seeking behavior. She stated he wanted to go home, and the family had known about it. LVN D stated the facility was trying to discharge him. Interview on 04/17/25 at 07:33 AM, RN M stated she did not work with Resident #2 and denied seeing him try to go out. Interview on 04/17/25 at 07:47 AM, LVN L stated, she was familiar with Resident#2 and he was not trying to go out of the facility. She stated she did not see him wandering. She stated after the incident, she went to the hospital to identify and assess Resident#2. She stated she went to his room in the hospital and talked to him but did not ask him how he got out of the facility. She stated Resident#2 was not in distress during the hospital visit and he was sitting at the edge of the bed. Interview on 04/17/25 at 07:57 AM, the Maintenance Supervisor stated he went with LVN L to the hospital to talk to Resident#2, but he could not talk to him. He stated Resident#2 was seen in a Video walking out the front door, the Camera was facing outside, and there was no sound. He stated after the incident, he had the local fire department come to the facility and check the alarms. Interview revealed the alarm testing showed all alarms were working. He stated the alarm should go off whenever the door opened from during the time from 6 PM to 6 AM. He stated the camera was situated outside the door, on the keypad side, and he did not know if the camera could capture the resident key in the code from inside. He stated he was not aware of any power outrage at the time, and even if there was a power outage the alarm, would still go off and sound. He stated the alarm was automatically set to engage at 6 PM and disengage at 6 AM. He stated the alarm would go off at the nursing station and by the front door area. He stated the door alarm cannot be disarmed by anyone unless they have the code to disarm it, and no one in the facility had that code. He stated the facility did not get any citation for the door's alarms during the last survey. He stated his guess was that someone entered the code at the nursing station to silence the alarm in the nursing station and did not enter the code at the front door to silence the alarm by the front door. He stated at that time the alarm by the door was not too loud. He stated after the incident, the local fire department came to the facility and tested the alarms. Interview revealed the alarm sound by the front door was set to a louder volume. Interview on 04/17/25 at 08:47 AM, the DON stated at first Resident#2 was ready to go home after he was done with rehabilitation, then his ascites (abnormal accumulation of fluid in the abdomen) was worsening, was sent to hospital. She stated after he came back from the hospital, he was A&O x4, stable, and wanted to go home. She stated the Resident#2 called his family and spoke to them, one or two days before the incident, about going home. Interview revealed the resident would walk around the facility without a walker. She stated a resident family member visited him the day before the incident and the resident told the family member that he wanted to go home but the son wanted him to stay in the facility. She stated the management informed the family that the resident had a desire to leave the facility. She stated the discharge protocol was initiated for his safety. The DON stated the resident had a cell phone, but the phone service was disconnected due to a lack of payment. Interview revealed the resident used the facility land line to call his cousin. When asked about the elopement risk to Resident#2, she stated the resident was not at risk for elopement prior to the incident. She stated it was a resident right to leave the facility and the facility could not hold the resident against his wishes to leave as per the facility policy. She stated the resident was appropriately dressed and had shoes on when he left the facility. She further stated the resident was fine and no alcohol or drugs were found on him when he taken to the hospital. She stated LVN L went to the hospital to see the resident. The DON stated the resident told LVN L that he walked out of the facility main door. The resident walked to Local store. The DON stated she did not speak to him face to face at the hospital and the facility wanted to ensure that he was safe. She stated after the incident the facility conducted elopement prevention drill, and all the staff were in service trained on the residents elopement prevention. She stated the night of the incident the staff denied hearing the alarm going off at any time. An attempt was made on 04/17/25 at 09:55 AM to interview Resident#2, but his Family Member answered the phone call. The family member stated Resident #2 did not have a cell phone and he moved to another facility after he was discharged from the hospital. He stated he did not recall the exact date of the incident, and what he know about the incident was that the resident walked through the facility front door and was found in local store parking lot by the local police and was taken to a hospital. He denied the resident was having any issues from the elopement. Interview over the phone on 04/17/25 at 10:29 AM, CNA S stated she was working the 300 hall the night of the incident. She stated the resident was on her assigned hall. She stated the resident walked around all the time. She said she laid eyes on him before she started her rounds. She stated she doesn't remember the exact time, but she rounds every 2 hours. She said the resident was present up until her last round around 3 AM or 4 AM. She said she didn't hear the door alarm, it's very sensitive, even when the wind blows, it goes off. She said staff ran to the door when the alarm went off to see if a resident tried to elope. She said she could hear the alarm from 300 hall. She said the resident was dressed in street clothes while lying in his bed that night because she changed his roommate. She said the resident may have eloped because he may have been watching staff, because around 3 AM, CNAs conducted rounds and nurses were giving medications. She said the resident was smart and may have been watching staff to see if they were preoccupied. She stated resident never voiced to her he wanted to leave. She said the resident would walk around in the middle of the night, some nights, but he was never go to the door. She stated she believed the nurse, can't remember her name, noticed he was gone. She stated she was contacted once she left and was told the resident eloped. Interview over the phone on 04/17/25 at 10:33 AM, LVN N stated, he worked with Resident#2 another night. He stated Resident#2 had the habit of wearing daytime attire even at night, walking around between his room, nursing station and dining area. He stated Resident#2 sometime would ask to call his wife and wanted his wife here at the facility. He stated, he did not see the Resident#2 wife or family member visiting at night. LVN N stated, he did not hear the door alarm going off during the night of the incident. He stated to enter or exit the facility after 6 PM, someone must key in the code from inside otherwise, the alarm would go off whenever the door opened. LVN N stated the facility was non-smoking and none of the staff went outside to smoke. Interview over the phone on 04/17/25 at 10:45 AM, CNA P stated she was not working on hall 300 the night of the incident. She said the resident was independent. She said she would see him walking around; he would go to the ice machine or come through the dining room. She said she never heard the alarm go off that night. She said when the alarm went off, staff would check at the nursing station to identify which alarm was going off, rush there and check to see if a resident eloped. She said all staff would check which door was alarming and go and check. She said the alarm was working that night because she stood at the door until someone let her in the building to start her shift. Interview over the phone on 04/17/25 at 12:02 PM, RN R stated, she knew Resident#2, and worked with him a couple of times. She stated the Resident spend most of his time up and walking around independently. She stated the day of the incident, she went in to work late at 10:20 PM. She stated, she rung the bill, and nobody came in to open the door for her. She stated when she put the code from outside and open the door, the alarm did not go off. She stated usually at night, the alarm would go off whenever the door was open without keying in the code from the inside, but that did not happen that night. When asked if she notified someone about the alarm not going off, RN R stated she voiced to the staff at the nursing station the door alarm did not go off when she was coming in. She stated she rounded on her residents at 11:30 PM, and went on with her usual shift rounding, assessing residents, giving medication, etc. She said she could not remember the last time she saw Resident#2 that night, and per her documents, she did his physical assessment at 01:41 AM. She stated she was contacted once she left and was told the resident eloped. She stated she was suspended pending the investigation and was let go afterwards. Review of the directions reflected the location the paramedics picked Resident#2 from was 8.9 miles from the nursing facility via the website https://www.mapquest.com. Observation on 04/17/25 at 05:05 AM revealed two surveyors entered the facility at 05:05 AM, using the four-digit code provided by the Administrator the day before (04/17/25), the alarm went off. Observation revealed RN O walked to the front door and saw the surveyors entering the facility. RN O entered the key code and turned off the alarm. Housekeeper Q walked to the lobby area too. The staff left the lobby area. One surveyor stayed in the front lobby and the other surveyor went to the nursing station. The surveyor opened the front door and heard the alarm in the lobby. The surveyor at the nursing station heard the alarm. Observation revealed staff going to the front lobby to see what was happening and saw the surveyor at the front door with the alarm going off. Observation revealed the door alarm would go off when the surveyor pulled or pushed the front door. Observation revealed RN O turning off the door alarm when she determined it was the surveyor who opened the door and set off the alarm. Observation on 04/17/25 at 12:20 PM, revealed the street facing this facility was a busy 2-lane street. Interview on 04/16/25 at 2:38 PM, CNA D stated she was working the 300 hall the day of the incident. She stated she received training on resident elopement prevention. Interview on 04/16/25 at 3:09 PM, LVN I stated Resident #2 was last on 300 Hall. She stated she had training on resident elopement, the steps to take with exit seeking residents, including, immediately informing the management. Interview on 04/17/25 at 05:27 AM, RN O stated he started working in the facility after the incident. He stated he was trained on the resident elopement prevention before starting to work with the residents. He stated when the alarm went off, staff would check at the nursing station which door alarm was going off, where, then go there and check, including outside, and see if a resident had eloped. He said all staff would check which door and go and check. He stated at night the staff round on the residents every hour. He stated at that time there was one resident wandering around and exit seeking, and all the staff had to keep an eye on him. Interview on 04/17/25 at 05:36 AM, CNA K stated she did not remember Resident#2. She stated was in serviced on preventing resident elopement. She stated the door alarm would go off, if the door was open from outside, and there is no code to get into the facility. She stated, then, whoever enter had to punch the code to silence the alarm, or ring the bell for someone to open the door from inside after punching the code in. Interview on 04/17/25 at 05:48 AM, LVN G stated she started working with the facility after the incident. She stated she received training on residents' elopement prevention during orientation. She stated at the start of her shift, she did rounds on the residents and check the residents' presence before she get the report from the outgoing nurses. Interview on 04/17/25 at 06:11 AM, Housekeeper Q stated he was in-serviced on residents' elopement prevention including to check all the rooms, look around the building, and notify the Administrator, and DON immediately. Interview on 04/17/25 at 7:17 AM, CNA F stated her first day working in the facility was last Saturday (04/12/25). She stated before she started working on the floor with the residents, she received training on residents' elopement prevention. She stated she was trained to pay attention to doors alarm and to answer as soon as she heard the alarm going off. She stated she was trained to do rounds on residents at the start of her shift, and at least every 2 hours. Interview on 04/17/25 at 07:22 AM, LVN H stated she returned to work three weeks ago and was not there during the resident elopement incident. She stated was trained on residents' elopement prevention. LVN H stated she was to follow the facility policy, that included doing a head count at change of shift, total facility resident head count if there was a missing resident and alert the Administrator . She stated for the residents with exit seeking behaviors she was to notify the administrator. LVN H stated she was to check the doors and put a plan in place; notify the family, the MD, and constantly do visual check on the resident. She stated the risk to resident, safety issue, and possible injury. LVN H stated there was a busy street by the facility. Interview on 04/17/25 at 07:28 AM, LVN D stated to prevent residents from eloping, the staff must look for the resident, do rounds and count the residents every shift; notify the Administrator, DON, and family if a resident left the facility. Interview on 04/17/25 at 07:33 AM, RN M stated she received an in-service on resident elopement prevention that included for the staff to do a head count, and see all the residents during their shift, and notify the Administrator if any resident was missing. RN M stated the staff must round on residents every two hours. She stated for any resident with exit seeking behavior, she notified the Administrator, the family, and the MD. She stated she would follow physician ordered for lab work to see if something was wrong with the resident. She stated the risks to residents were endanger their life and safety issues. Interview on 04/17/25 at 07:47 AM, LVN L stated she was trained on residents' elopement prevention. LVN L stated when she hears the alarm, she had to check outside, and inside for the resident before turning the alarm off. She stated for the resident with exit seeking behaviors, she would immediately notify the charge nurse, and the Administrator. She stated, she would make sure the resident was away from the front door, notify the MD, and the family. Interview on 04/17/25 at 08:47 AM, the DON stated after the incident the facility conducted elopement prevention drill, and all the staff were in service trained on the residents elopement prevention. Interview over the phone on 04/17/25 at 10:33 AM, LVN N stated he was in-serviced on preventing resident elopements. Review of the facility's Inservice trainings revealed on 02/22/25 the facility conducted the following trainings across all the three-shifts with staff in-person and over the phone: elopement drill; elopement policy; abuse and neglect prevention; Elopement policy a. alarms checks b. if Resident is missing notify within 15 minutes to DON/Administrator; shift to shift report: for all CNAs and nurses. Walking rounds verifying with census. Every 2 hours visually account for each resident; check elopement resident who is high risk. Do elopement assessment on admission; Elopement Drill and information about the electronic monitoring system to ensure the doors worked properly and securely and the staff were provided the door access code. Review of Daily Doors Alarms, Wandering System and Storage Area log Maintenance forms for the month of February 2025 did not reveal any problems with the exit door mechanisms prior to 02/22/25 and after. Review of the facility's Maintenance Front Door daily check log between 02/21/25 and 04/16/25(entrance date) revealed no issue with the front door alarm system. Review of the facility's Provider Investigation Report dated 03/01/25 revealed Elopement Drills initiated on 2/22/25 will be completed on 3 shifts in the next 24 hours. The Administrator and DON were educated by the Regional Director of Clinical Services on abuse prevention policy, resident rights, elopement policy; Timely Reporting/Recognizing Abuse, Neglect: Change in Condition; Documentation; Physician Notification and family and clinical rounds for assistance, supervision, and needs. The facility had a QAPI meeting on 02/22/25 at 2:00 PM , and on 03/19/25 at 11:00 AM to address the facility elopement prevention protocol. Review of the local weather history for the area near the facility, on February 02/22/2025, revealed the temperature at the time was 43 degrees Fahrenheit, and foggy.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. The facility failed to ensure food items in the facility walk-in refrigerator were covered, labeled, and dated. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: Observation on 04/16/25 at 11:40 AM of the facility's walk-in refrigerator revealed: 1. A plastic container had food that looked like sausage was not labeled. 2. A plastic container had some kind of red sauce was not labeled or dated. 3. A gallon sized Ziplock bag had cooked Brownies that were not dated or labeled. 4. A gallon sized Ziplock bag had about 8-10 Bread slices with butter that were not dated or labeled 5. A quart sized Ziplock bag had 4-5 pieces of cooked Corn bread that were not dated or labeled 6. A plastic bag that had about 10-12 pieces of Danish bread were not dated, labeled, or covered. 7. A used block of unknown kind of cheese , wrapped loosely in a plastic wrap was not dated, labeled, or covered. 8. A quart sized Ziplock bag had about 7-8 slices of cooked meat that were not dated or labeled. 9. A bag of Grated Cheese that was not dated or labeled. In an interview on 04/16/25 at 01:33 PM with [NAME] C revealed he was working in the facility kitchen as an morning [NAME] since November 2024. He stated that all food items in the kitchen should be labeled, dated, and covered. He stated that the foods that were cooked should have a use-by date of three days after cooking. Other food items like ready-to-eat/serve items should have an expiry date on them. He stated everyone in the kitchen, including the cooks, dietary aides, and dietary manager, were responsible for dating, labeling, and covering all food items. He stated not covering, labeling, and dating food items could cause cross contamination and potentially cause illness in residents. In an interview on 04/16/25 at 01:45 PM, the Dietary Manager stated everyone, including the cooks and himself, were responsible for covering, dating, and labeling all food items in the kitchen. He stated that he had been working in the facility for last two years and ensured that all staff received multiple in-services about food labeling, dating, and covering appropriately. He stated her expectation was all food items in the kitchen should be marked with a cooked date once the food item was cooked and stored for use later and a use-by date for leftovers and opened food items. He stated it was his expectation that all foods should be properly sealed in Ziplock bags or containers with tight fitting lids. He stated the risk of not dating, labeling, covering food items could cause cross contamination resulting in food borne illness or food contamination. He added that he had thrown away the food items in the refrigerator that were not dated or labeled appropriately. Review of facility's policy titled Food Storage revised 3/2019 reflected, .13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 2-3 days or discarded 15. Refrigeration .e. All foods should be covered, labeled, and dated . Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation, interview, and record review, the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #1) of 5 residents reviewed for ADLs. The facility failed to ensure Resident #1 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings include: A record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes mellitus, muscle weakness, and cerebrovascular accident (CVA). Resident #1 had a BIMS score of 02 out of 15 which indicated Resident #1's cognition was severely impaired. She required extensive assistance of two-persons for physical assistance with personal hygiene. A record review of Resident #1's Comprehensive Care Plan, dated 04/29/21 to present, reflected the following: problem: Resident#1's ADL function are impaired related to Hx CVA .weakness/debility, Hand Contractures, . depends on staff with ADLs. Goal: will maintain a sense of dignity by being clean, dry, odor free, and well-groomed over next 90 days. Interventions: assist, give . nail care schedule and prn .Assist with all ADL's as needed. An observation on 04/16/25 at 09:55 AM revealed Resident #1 was laying in her bed. The nails on both hands were approximately 0.3 centimeter in length extending from the tip of her fingers. The nails were discolored tan and the underside had a dark brown colored residue. Resident #1 was unable to answer questions. Interview on 04/16/25 at 10:08 AM, CNA A stated CNAs were allowed to cut the residents' nails if they were not diabetic. CNA A stated he would talk to the nurse about Resident #1's long nails because she was diabetic. Interview on 04/16/25 at 10:14 PM, RN B stated CNAs were responsible to clean and trim residents' nails as needed. RN B stated only nurses cut residents' nails if they were diabetic. RN B stated no one notified her Resident #1's nails were long and dirty, and she had not noticed the nails himself. RN B stated Resident #1 was diabetic, and he would clean and trim his nails. Interview on 04/16/25 at 2:33 PM, the DON stated nail care should be completed as needed and every time aides washed the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated residents having long and dirty nails could be an infection control issue. Record review of the facility's policy titled, Bath-Bed dated, March 2013, reflected, Purpose. To cleanse, refresh, and soothe the Patient; to stimulate circulation; and to inspect the body. Care for fingernails . is a part of the bath. Be sure nails are clean. Fingernails .of diabetic Patients are cut by the licensed nurses .

Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments for four (treatment cart #1 and medication cart #2, Medication cart #3 and Medication cart 4) of 4 carts reviewed for locked drugs and biologicals. The facility failed to lock treatment Medication Cart #1, Medication Cart #2, Medication Cart #3, and Medication Cart #4 when not in use. This failures could affect residents at risk of drug diversion or misuse of medications. Findings included: Observation on 01/17/2025 at 5:25 AM revealed Medication Cart #1 and Medication Cart #2 unlocked on the hall while LVN A was in a Resident's room. LVN A walked out of the Resident room and down to the nurse's station leaving the Medication Cart #1 and Medication Cart #2 unlocked. Medication Cart #1 and Medication Cart #2 drawers were able to be pulled open and exposed routine medications. Medication Cart #1 and Medication Cart #2 continued to remain unlocked during an observation of LVN A passing medication to four different residents. Observation on 01/17/2025 at 5:30 AM LVN A walked back to the Medication Cart #1 and proceeded to pass medication entering a Resident room without locking the Medication Cart #1 or Medication Cart #2 Observation on 01/17/2025 at 5:53 AM revealed Medication Cart #3 and Medication Cart #4 on the hall with no staff members present or residents were present. The drawers to Medication Cart #3 and Medication Cart #4 were able to be pulled open and exposed routine medications. Medication Cart #3 and Medication Cart # 4 remained unlocked for approximately 10 minutes. Interview and Observation with LVN A on 01/17/2025 at 5:30 AM revealed she was using Medication Cart #1 and Medication Cart #2 because one cart contained routine medication and one cart contained overflow routine medication as well as PRN medication. LVN A stated she was aware that the Medication Cart should have been locked when not in eyesight however she was disorganized due to her being new to working this hall. LVN A stated the risk of leaving the medication carts unlocked would be someone could access the medication. During an observation of medication pass to 4 residents, LVN A continued to leave Medication Cart #1 and Medication Cart #2 unlocked when entering resident rooms. Interview on 01/17/2025 at 6:05 AM with LVN B revealed Medication Cart#3 and Medication Cart #4 should have been locked however she had just begun her shift at 6:00AM and the nurse before her would have been responsible for ensuring the medication cart was locked. Interview on 01/17/025 at 1:45 PM with the Regional Director of Clinical Services and the Director of Nursing revealed medication carts were expected to be locked when not within eyesight of the nursing. The Regional Director of Clinical Services and the Director of Nursing both agreed the risk of leaving the cart unlocked would be someone would be able to access the medication. Review of the facility policy Medication labeling and storage dated revised February 2023 revealed Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Based on observation, interview, and record review the facility failed to ensure residents had a right to personal privacy for one of three residents (Resident #3) reviewed for personal privacy in that: CNA C failed to ensure the door to Resident #3's room was closed while she assisted in dressing Resident #3. This failure could place residents at risk for low self-esteem, loss of dignity, and decreased quality of life due to a lack of privacy during their care. Findings included: Review of Resident #3's face sheet, printed 01/17/2025, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included but not limited to hypokalemia (high levels of potassium). Review of Resident #3's baseline care plan dated 1/10/2025 revealed Resident #3 was a fall risk, required 1 person assist and was incontinent in bladder. Review of Resident #3's electronic file revealed a MDS had not been completed. Observation on 01/17/2025 at 5:05 AM revealed CNA C was assisting with incontinent care of Resident#3 while the curtain was not drawn, and the door was open. Resident #3 was seen undressed from waist down and turned on her side exposed to the hallway. CNA B walked out of the room to get supplies leaving the door open and Resident #3 turned on her side undressed from waist down. Resident #3 did not have a roommate, and no one was observed on the hall. Attempted interview on 01/17/2025 at 2:00 PM with Resident#3 was unsuccessful. Resident #3 was observed laying in bed and would not respond to questions. Interview on 01/17/2025 at 5:54 AM with CNA C revealed when assisting with incontinent care, she should always close the curtains and resident door to ensure privacy. CNA B stated she did not pull the curtain and close the door due to rushing because she had to go get another resident up and ready for dialysis. CNA C stated the risk leaving the door open and not pulling the curtain would be that the resident would not have privacy. Interview on 1/17/2025 at 12:29 PM with the Administrator revealed staff were aware that the privacy curtain and door should be closed when assisting with incontinent care. The Administrator stated she would have a discussion with Caregiver B regarding her leaving the door open. The Administrator stated the risk of leaving the door open would be the resident privacy could be violated. Interview on 1/17/2025 at 2:45 PM with the Director of Nursing revealed staff were aware of closing the door and privacy curtain during incontinent care. The Director of Nursing stated the Surveyor completed observation at a busy time and staff were trying to change residents before the shift change and had a lot of things to do during that time. The Director of Nursing stated she had 5 CNAs scheduled for the night shift and felt there was enough staff to provide proper care to residents. The Director of Nursing did not acknowledge any risk due to not pulling the privacy curtain and closing the door. Review of the facility policy titled Resident rights- abuse, neglect exploitation undated did not address resident rights to privacy.

Based on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive assessment and quarterly review assessments for two (Resident #1 and Resident #2) of four residents were reviewed for comprehensive care plans. The facility failed to ensure the interdisciplinary team revised and reviewed the care plan after each assessment for Resident #1 and Resident #2. This failure could affect residents by placing them at risk for not having their individual needs met. Findings included: Record review of Resident #1's face Sheet printed 01/17/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included but not limited to acute chronic diastolic heart failure (causes a stiff left ventricle that prevents the heart from relaxing between beats),type 2 diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels.) and high blood pressure. Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 15 which indicated Resident#1 was cognitively intact. Review of section GG indicated Resident #1 was independent with eating, oral hygiene, and upper dressing. Review of Resident #1's care plan dated effective 8/8/2024 revealed Resident #1 was at risk for hyper/ hypoglycemic episodes secondary to diabetes. Interventions included: diet as ordered, meds as ordered, lab as ordered. Resident #1 received pain management with intervention to include review medication, frequency, and side effects. Review of Resident #1's care plan conference revealed the last care plan was held 09/18/2024. Review of Resident #2's face sheet printed 07/17/2025, reflected an [AGE] year-old female admitted to the facility 04/27/2022 with diagnoses that included stroke (occurs when the blood supply to part of the brain is blocked or reduced.) and dementia (diseases that affect memory, thinking, and the ability to perform daily activities.) Review of Resident#2's care plan dated effective 4/27/2022 revealed Resident #2 was incontinent with bowel and bladder. Interventions included monitor signs symptoms, document refusals and encourage fluid intake. Review of the quarterly MDS undated revealed a BIMS score of 10 which indicated Resident #2 was mildly cognitively impaired. Review of Resident #2's care plan conference notes revealed the last care plan was 07/16/2024. Interview on 01/17/2025 at 11:39 AM with the Social Worker revealed care plans were completed within 48 hours of admission and quarterly. The Social worker stated she checked the MDS calendar once a month to determine when care plan conferences were due. The Social Worker stated care plans should be updated quarterly however she was not sure of there was a risk if they were not updated quarterly. The Social Worker stated she was not sure why the care plan conferences had not been done timely stating it was likely an oversight due to her being busy with other task. Interview on 01/17/2025 at 12:29 PM with the Administrator revealed the Social Worker was responsible for ensuring care plans were completed timely. The administrator stated she would have to speak with the Social Worker to determine why care plans conference were not completed timely however stated he was sure that staff had been in continuous contact with residents and their responsible parties frequently however may not have documented the conversations. The Administrator did not acknowledge any risk associated with not completing care plan conferences timely. Review of the policy Care Plans, Comprehensive person- Centered revised September 2010 The Interdisciplinary Team must review and update the care plan at least quarterly,

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) for 1(Resident #4) of 5 reviewed for pharmaceutical services The facility failed to ensure Residents #4's medication administration was administered according to the physician order. This failure placed residents at risk of not having accurate clinical records completed to indicate if a medication was administered, resulting in potential medical errors and a decline in health. Findings included: Review of Resident #4's electronic face sheet printed 01/17/2025 revealed a 65- year -old male admitted to the facility on [DATE] with diagnosis that included but not limited to diabetes (body does not make enough insulin) and high blood pressure. Review of Resident #4's care plan effective 11/01/2024 revealed Resident #4 was hypo or hyperglycemic secondary to diabetes with interventions which included diet as ordered and medication as ordered. Review of Resident #4's admission MDS dated [DATE] revealed a BIMS score of 10 which indicated Resident #4 was mildly cognitively impaired. Review of Resident #4's order physician order revealed HumuLIN 70/30 U-100 Insulin 100 unit/mL subcutaneous suspension (40 units) VIAL (ML) Subcutaneous One Time Daily Starting 12/13/2024. Order Date: 12/13/2024 TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS Notes: Do not give insulin if EQUAL/less than (110). Alert MD if Blood Sugar greater than:(400) PR aware Review of the MAR dated 12/01/2024-12/31/2024 revealed on 12/18/2024 Resident #4 was recorded as 86 and documented that insulin was given by LVN C. On 12/19/2024 Resident #4 blood sugar was documented at 96 and insulin given by LVN C. Review of the document titled non prn medication notes for Resident #4 dated 12/01/2024-12/31/2024 revealed no documentation of medication not being given on 12/18/2024 or 12/19/2024. Attempted call on 01/17/2025 at 2: 00PM to LVN C was unsuccessful. Interview on 01/17/2025 11:50 AM with the Director of Nursing revealed she was not sure if LVN C had given Resident #4 the medication or not however nursing staff were aware that orders should have been followed. The Director of Nursing stated staff still had to put their initials on the MAR and she was not sure of how staff indicated that medication was not given. Interview on 01/17/2025 at 12:29PM with the Administrator revealed he was not sure why the MAR would show the medication was given if it should not have been given and stated he would have to speak with the Director of Nursing for clarification. Interview on 01/17/2025 at 1:45PM with the Regional Director of Clinical Services revealed the Director of Nursing was not pulling the correct document which showed when a medication was not given. The Director of Clinical Services revealed the non- prn medication notes would revealed if a medication was not provided. The Director of Clinical Services reviewed the non - prn medication notes along with the surveyor and confirmed that there was no documentation on 12/18/2024 or 12/19/2024 of Humulin not being given. The Regional Director of Clinical services stated the risk of Humulin being given outside of the order would be the residents blood sugar could drop. The Regional Director of Clinical Services stated all nursing staff would be in- serviced today (01/17/2025) regarding administering medication according to physician orders. The Regional Director of Clinical Services stated moving forward the Director of Nursing would be responsible for ensure MAR's were completed correctly and medication was being given as prescribed. The policy dated Medication labeling and storage did not discuss medication administration.

Based on interviews, and record review the facility failed to review and revise the person-centered comprehensive care plan to reflect the resident's current status, for 2 of 6 residents (Resident #37 and Resident #50) reviewed for care plans. The facility did not update Resident #37's care plan to reflect goals and interventions for Hospice. The facility did not update Resident #50's care plan to reflect goals and interventions for Hospice. This failure could place residents at risk for not receiving appropriate care and intervention to meet their current needs. The findings were: Review of Resident #37's MDS significant change assessment dated [DATE], reflected he was a [AGE] year-old female admitted on [DATE]. Her diagnoses included: Dementia (confusion), hypertension (high blood pressure), and diabetes (high blood sugar). She had a BIMS score of 2 which reflected his cognitive status was severely impaired. She required moderate to maximum assist of one staff member for activities of daily living. Section O of the MDS was marked for hospice. Record review of Resident #37's Care Plan initiated on 04/011/23 reflected, it had been edited/updated on 09/30/2024, [resident was on hospice services], further review reflected there was no goals and approaches for hospice. Record review of the consolidated physician orders dated 11/2024 reflected Resident #37 admitted to Hospice services on 09/18/2024. Review of Resident #50's MDS quarterly assessment dated [DATE], reflected she was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Her diagnoses included: Hypertension (high blood pressure), and dementia (confused). Her BIMS score of 3 reflected her cognitive status was severely impaired. She required moderate to maximum assist of one staff member for activities of daily living. Section O of the MDS was marked for hospice. Record review of Resident #50's Care Plan initiated on 06/24/24 reflected, the care plan had been edited/updated on 9/10/2024, [resident was on hospice services], further review reflected there was no goals and approaches for hospice. Record review of the consolidated physician orders dated 11/2024 reflected Resident #50 admitted to Hospice services on 07/24/2024 . In an interview on 12/04/24 at 9:30 a.m. the DON revealed, the MDS/care plan nurse should be aware of any changes with the residents and update the plan of care. The DON stated that they did not have permanent MDS coordinator nurse, the floater MDS nurse for the cooperation was coming when she could and completing the MDS, but not updating any plans of care. The DON stated that she and the ADONs were updating the plan of care. The DON stated that she supposed there had been some of the plan of care's that had not been updated appropriately with the goals and approaches. The DON was aware that Resident #37 and Resident #50 were on Hospice services. The DON stated if the care plans were not follow-up on appropriately then the staff would not know what the goals are. In an interview on 12/04/24 at 12:00 p.m. the Administrator revealed the MDS/care plan nurse position was open at this time and the facility was looking for a new one. The Administrator stated he was aware the MDS was being completed by the floating MDS nurse for the company. He was unclear who was following up on the care plans. Review of the facility's policy titled Care plan Process and Person-Centered Care dated March 2022, reflected the following: 7.The comprehensive, person-centered care plan: a. incudes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the residents' highest particle, physical, mental, and psychosocial well-being .c. incudes the resident's goals .11. Assessments of the residents are ongoing and care plans are revised as information about the residents and the resident's condition change .12. the interdisciplinary team reviews and updates the care plan; a. when there is a significant change in the residents' condition; b. when the desired outcome is not meet.

Based on observation, interview and record review, the facility failed to ensure all assistive devices were maintained and free of hazards for three (Residents #22, #36, and #59) of 6 residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #22, #36, and #59. These failures could place residents at risk for equipment that is in unsafe operating condition, that could cause injury. Findings included: Review of Resident #22's significant change MDS assessment, dated 09/21/24, reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of hypertension (high blood pressure), dementia (confusion), and diabetes (high blood sugar). Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves. Review of the Resident #22's plan of care dated 09/21/2024 with updates reflected goals and approaches to include wheelchair mobility for locomotion. Observation on 12/02/2024 at 12:30 p.m., revealed Resident #22 was sitting in her wheelchair, in the dining room and had no skin problems. The wheelchair's right armrest was cracked with foam exposed. There was dried food substances on the back of the wheelchair and both wheels. Review of Resident #36's quarterly MDS assessment, dated 10/28/2024, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of hypertension (high blood pressure), muscle weakness (muscle deterioration), and age-related physical debility (no balance). Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves. Review of the Resident 36's plan of care dated 09/04/2024 with updates reflected goals and approaches to include wheelchair mobility. Observation on 12/02/24 at 12:45 p.m., revealed Resident #36 was sitting in her wheelchair in the dining room and the wheelchair's left armrest was cracked with exposed foam and the right arm rest was missing. There were no skin tears on arms. The wheels of the wheelchair had dried food substance on both wheels and on wheel rims and there was dried food on the seat and back of the wheelchair. Review of Resident #59's quarterly MDS assessment, dated 11/20/2024, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of atrial Fib (heart rate is irregular) hypertension (high blood pressure), and Alzheimer's dementia (confusion). Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves. Review of the Resident #59's updated plan of care dated 10/21/2024 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 12/02/2024 at 12:47 p.m ., revealed Resident #59 was sitting in her wheelchair in the dining room and the wheelchair's left armrest was cracked with exposed foam. There were no skin tears on the arms. Resident #59 stated she was just fine, and she thought her wheelchair was fine also, she did not need another wheelchair of new arms. In an interview on 12/04/2024 at 10:30 a.m., MA A stated when a resident's wheelchair needed repair the staff were to report it to the maintenance director. MA A stated we report to the maintenance director by writing in the book at the nurse station. MA A was unaware of any wheelchair that required repair, even though she did served lunch in the dining room and saw all the residents. In an interview on 12/04/2024 at 10:59 a.m. with the DON revealed she had no cleaning schedule for wheelchairs. The DON stated if the wheelchairs were dirty the night shift would clean them if they saw them, there was no monitoring system for cleaning the wheelchairs, it was on an as needed basis. The DON stated if there were many dirty wheelchairs, then [we] (administrative staff) would power wash the wheelchair . The DON stated if the wheelchairs were left in bad repair and were not clean, it could affect the quality of life for the residents. In an interview and record review on 12/04/2024 at 11:00 a.m., the with Maintenance Director revealed the staff informs him of equipment repair by logging the needed repair in the maintenance book at the nurse's station . The Maintenance Director verified he was the person who repaired the wheelchairs, but he was unaware of any wheelchairs that required new armrest. Record review at the nurses' station of the maintenance logs reflected no wheelchairs that had been placed in the log for repairs. In an in interview on 12/04/2024 at 12:00 p.m., with the Administrator revealed he was not aware of any wheelchairs that required repair in the facility. The Administrator stated there were plenty of parts and he would see that the wheelchairs were repaired. Review of the Facility's Policy titled Maintenance services dated December 2009 reflected Maintenance service shall be provided to areas of the building, grounds, and equipment . f. establishing proprieties to providing repair services . j. others that may become necessary or appropriate .3. The maintenance director is responsible for developing and maintaining a schedule of maintenance services to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner

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 in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure food items were accurately labeled and dated with the received or expiration date. These failures could place residents at risk for food-borne illness and cross contamination. Findings Include: Observation of the walk-in refrigerator on [DATE] at 9:18 am revealed the following: -1 large zip top bag of lettuce with no received date or expiration date. - 1 large container of unidentified food sauce dated [DATE]. There was no label description. -1 large container of unidentified yellow dessert dated [DATE]. There was no label description. Observation of the dry storage on [DATE] at 9:25 am revealed the following: -1 10lb bag of potatoes opened with no received date or expiration date. Interview with DM on [DATE] at 9:50am, he stated staff is expected to label and date all foods stored in the refrigerator, freezer, or dry storage. He stated the risks of the foods and liquids not being properly labeled and dated could cause food borne illness, and individuals could become sick. Interview with DA B on [DATE] at 11:38am, she stated any items stored in the refrigerator, freezer, or dry storage should be labeled and dated with an open date or expiration date. She stated the risks of foods not being labeled and dated could result in residents being served expired foods. Review of the facility's Food Receiving and Storage Policy, dated [DATE], reflected Policy Statement: Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored , prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. 4. All food items should be dated with the received date, unless labeled with a readable label from the food vendor. 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within ,d+[DATE] days or discarded. Review of the U.S. FDA Food Code 2022 reflected: Chapter 3 . section ,d+[DATE].11 Compliance and Food Law: . C. Packaged Food shall be labeled as specified in LAW, including 21 CFR 101 Food Labeling [* .(b) A food which is subject to the requirements of section 403(k) of the act shall bear labeling, even though such food is not in package form. (c) A statement of artificial flavoring, artificial coloring, or chemical preservative shall be placed on the food or on its container or wrapper, or on any two or all three of these, as may be necessary to render such statement likely to be read by the ordinary person under customary conditions of purchase and use of such food. The specific artificial color used in a food shall be identified on the labeling when so required by regulation in part 74 of this chapter to assure safe conditions of use for the color additive.], 9 CFR 317 Labeling, [*(a) When, in an official establishment, any inspected and passed product is placed in any receptacle or covering constituting an immediate container, there shall be affixed to such container a label .Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S ,d+[DATE].18. Section ,d+[DATE].12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section ,d+[DATE].17 . Commercial processed food: Open and hold cold . B. 1. The day the original container is opened in the food establishment shall be counted as Day 1. 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. C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. eCFR- Code of Federal Regulations are indicating within the text by an *- www.ecfr.gov

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse,establish policies and procedures to investigate any such allegations for 1 (Resident #5) of 24 residents reviewed for abuse in that: LVN D failed to report Resident #5's allegation of physical abuse to the Abuse Coordinator on 10/16/23. This failure could place residents at risk of continued and unrecognized abuse which could result in emotional distress and diminished quality of life. Findings included: Review of facility's policy Abuse Protocol dated April 2019 reflected 1. The Patient has the right to be free from abuse .The Executive Director (Administrator), and in his/her absence, the Director of Nursing, will perform the duties of the Abuse Prevention Coordinator .Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting physical harm or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being .The Charge Nurse will immediately examine the Patient and notify the Abuse Prevention Coordinator upon receiving reports of mental, physical or sexual abuse. Findings of the examination will be record in the patient's medical record. (Protection) 10. The Abuse Prevention Coordinator will: a. Immediately (within 2 hours) report to The Department of Aging and Disability Services (DADS) and other appropriate authorities incident of Patient Abuse as required under applicable regulations and regulatory guidance. Review of Resident #5's face sheet dated 10/18/23 reflected Resident #5 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of cerebral infarction, arthritis, chronic obstructive pulmonary disease, contractures of left and right hand, pain, bipolar disorder, and schizophrenia. She was her own responsible party. Review of Resident #5's Quarterly MDS assessment dated [DATE] reflected Resident #5 had a BIMS of 15 indicating she was cognitively intact. She required substantial to maximal assistance with toileting. Resident #5 was always incontinent of bladder and bowel. Review of Resident #5's comprehensive care plan last updated 10/02/23 reflected Resident #5 has history of refusing basic direct care from staff including incontinent care. Resident #5 has a well-known prior and current history of calling the state with accusations/complaints about staff and nursing facilities. Observation and Interview on 10/17/23 at 11:10 AM with Resident # 5 revealed she was lying in her bed. She stated the night before last (Sunday night) about 1 am or 2 am a female CNA who worked night shift was rough and grabbed on her right arm and leg when providing incontinent care. She reported yesterday to charge nurse who worked yesterday and today (LVN D) about how aide was rough with her. She could not recall the name of the CNA. She stated when female CNA was rough with her it hurt and caused her arthritis to bother her more. She stated she wanted to talk to the DON about it and asked for DON. She stated previous to this incident she did not like the CNA's attitude but denied any previous abuse allegations. She stated when female CNA was in her room to provide incontinent care, she was rude and nasty to her. She stated she told the CNA she did not want to be changed and wanted her to leave. Resident #5 stated she would rather be wet than be changed by her. She stated she fought back to female CNA who was rough with her to defend herself. Interview on 10/17/23 at 11:28 AM LVN D revealed he was aware of Resident #5 telling him yesterday at the end of shift change (2 pm) of an aide over the weekend being rough with her. He stated Resident #5 was not specific about who the aide was and when it occurred specifically. He stated he did not report it since it was around the end of his shift and was on his way out of the facility. He stated he did not report it to anyone even today about Resident #5's allegation of aide being rough. He stated he did not report it since he knew how Resident #5 was and her history of accusations in past. He stated he had not reported the allegation and did not tell his supervisor or the Administrator. Interview on 10/17/23 at 11:35 AM with the Administrator and DON revealed both were unaware of Resident #5's allegation of abuse. Surveyor reported the allegation of physical and verbal abuse to Administrator. The Administrator stated LVN D should have reported Resident #5's allegation of abuse. The Administrator and DON stated they would immediately investigate and look into this allegation of abuse. Interview on 10/17/23 at 11:55 AM with the Regional Director of Operations revealed the facility would self-report the abuse allegation to the state and initiate investigation into the alleged abuse allegation for Resident #5. He stated LVN D had been in-serviced recently on abuse protocol policy and reporting requirements. He stated LVN D would be suspended pending investigation. Surveyor attempted to contact CNA E on 10/19/23 at 10:28 AM but was unable to reach CNA E. Review of CNA E's statement dated 10/17/23 reflected On 10/15/23 I went in [Resident #5's] room and asked was she ready to be changed and she said yes. I gathered my supplies and laid her bed back. She said she can't use wipes so I went to get towels and wet them with warm water. She asked if there was soap on them I told her no. I then asked her to roll on left side so I could clean her and she asked for a towel so I provided her with one. She then rolled back on her left and I started cleaning her and she started kicking and swinging at me and said stop so I stopped and reported to the Charge Nurse. Interview on 10/19/23 at 2:00 PM with Administrator stated she had in-serviced LVN D prior with LVN just a day or two before about reporting any abuse/neglect allegations to Admin. She stated LVN D should have reported the allegation of abuse immediately to her. She stated it was important for her to be informed as the abuse coordinator of any allegations of abuse to ensure residents safety and to prevent any further abuse/neglect. She stated she had initiated an in-service now specifically to report to her as the abuse coordinator and let her decide what was reportable and what needs to be done as the abuse coordinator. She stated LVN D was terminated yesterday for failing to report allegation to Administrator as in-serviced. Review of No Excuse for Resident Abuse facility In-service dated 10/13/23 reflected all staff including LVN D were in-serviced on abuse protocol policy to call Administrator first, then DON immediately and failure to report could end in termination. Review of Tulip reflected facility self-reported intake #458368 to HHSC on 10/17/23 at 12:34 PM for Resident #5's allegation of abuse with alleged perpetrator CNA E.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (Resident #1) of six residents observed for dignity. The facility failed to treat Resident #1 with respect and dignity when staff told him to urinate in his linens instead of assisting him with toileting. Resident #1 suffered a loss of dignity, was depressed, his feelings were hurt, and he was afraid to eat much for fear of having to have a bowel movement in bed. This failure could place the 34 residents, who were continent of bladder, and 57 residents, who were continent of bowel, at risk for loss of dignity, depression, isolation, and decreased self-esteem. Findings included: Resident #1's MDS assessment, dated 09/25/17, reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had moderately impaired cognition, was totally dependent upon two plus persons for assistance with toilet use, and was occasionally incontinent of bladder and bowel. Resident #1's Care Plan, dated 09/18/17, reflected the resident required extensive assistance with toileting, and the resident was to have a urinal at his bedside. One of the goals of the care plan was for the resident to maintain a sense of dignity by being clean, odor free, and well groomed. The care planned interventions included assisting the resident with activities of daily living as needed, maintaining a urinal at the resident's bedside, and emptying the contents as needed. An observation of Resident #1 on 09/26/17 at 9:30 a.m. revealed he was seated in his wheelchair watching television in his room. An isolation sign was posted and an isolation cart with PPE was at the doorway entrance. There was a strong urine odor in the room, and there were soiled linens lying on the unmade bed. The linens looked like they were soiled with dry urine. A urinal was hanging on the side rail of the bed and contained approximately 200 milliliters of urine. An interview with Resident #1 at the time of the observation revealed he was not sure how long the soiled linens had been on his bed. He stated the soiled linens were there because a staff member, name unknown, told him to urinate on his sheets because he could not reach his urinal. He stated the staff, name unknown, was not able to take him to the toilet. The resident stated he did not sleep in his bed the night of 09/25/17, and he spent the night in his wheelchair. An observation and interview with CNA A on 09/26/17 at 9:35 a.m. revealed she entered the room of Resident #1. CNA A stated the soiled linens were on the resident's bed when she came in for work the morning of 09/26/17 because the staff on 10:00 p.m. to 6:00 a.m. shift did not change the resident. CNA A stated she put the soiled linens on the floor and went and told the staff from 10:00 p.m. to 6:00 a.m. shift to clean them up. CNA A stated she guessed the staff just put the soiled linens back on the bed. An interview with Resident #1 on 09/26/17 at 12:30 p.m. revealed the resident felt like a bum when the staff member, name unknown, told him to urinate on his sheets. The resident stated it hurt his feelings and made him depressed. The resident stated it was almost lunch time, but he did not eat a lot in the afternoons to prevent having a bowel movement because staff might not have time to take him to the toilet. Resident #1 stated he did not want to have a bowel movement on his sheets. An interview with CNA E on 09/26/17 at 2:00 p.m. revealed a resident's family complained to him that staff were providing untimely incontinent care so he gave them his telephone number to call if it happened again. A confidential interview revealed he/she did not know who told Resident #1 to toilet in his sheets, but he/she had heard staff tell residents to toilet in their briefs before. An interview with LVN D on 09/26/17 at 3:40 p.m. revealed she worked the 10:00 p.m. to 6:00 a.m. shift and would once in a while find residents soiled when coming on shift. She stated residents would ask for incontinence care, but because they were changed at 8:00 p.m. the CNA would wait to change them until about 10:30 p.m. LVN D reported most of her assigned residents were incontinent. An interview with CNA C on 09/26/17 at 4:05 p.m. revealed she worked the 10:00 p.m. to 6:00 a.m. shift on 09/25/17. CNA C stated Resident #1 wanted to stay in his chair and not go to bed, and she denied seeing any soiled linens on the resident's bed. CNA C revealed she assisted the resident with his urinal, but he did not need to use the toilet. An interview with the DON on 09/26/17 at 5:40 p.m. revealed she would be conducting in-services with staff to address hygiene and dignity. The facility's current Abuse policy and procedure, dated November 2016, reflected the following: .Person-centered-care means to focus on the Patient/Resident as the locus of control and support the Patient/Resident in making their own choices and having control over their daily lives. .The facility will monitor through its Quality Assurance Committee and identify and correct: (C) inappropriate staff behaviors such as directing patient/residents who need toileting assistance to urinate or defecate in their beds . The Resident Census and Conditions of Residents Form CMS-672, signed and dated by the DON on 09/26/17, reflected 34 residents were continent of bladder and 57 residents were continent of bowel.

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (Resident #1) of six residents observed for activities of daily living. The facility failed to treat Resident #1 with respect and dignity when staff told him to urinate in his linens instead of assisting him with toileting. Resident #1 suffered a loss of dignity, was depressed, his feelings were hurt, and he was afraid to eat much for fear of having to have a bowel movement in bed. This failure could place the 34 residents, who were continent of bladder, and 57 residents, who were continent of bowel, at risk for loss of dignity, depression, isolation, and decreased self-esteem. Findings included: Resident #1's MDS assessment, dated 09/25/17, reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had moderately impaired cognition, was totally dependent upon two plus persons for assistance with toilet use, and was occasionally incontinent of bladder and bowel. Resident #1's Care Plan, dated 09/18/17, reflected the resident required extensive assistance with toileting, and the resident was to have a urinal at his bedside. One of the goals of the care plan was for the resident to maintain a sense of dignity by being clean, odor free, and well groomed. The care planned interventions included assisting the resident with activities of daily living as needed, maintaining a urinal at the resident's bedside, and emptying the contents as needed. An observation of Resident #1 on 09/26/17 at 9:30 a.m. revealed he was seated in his wheelchair watching television in his room. An isolation sign was posted and an isolation cart with PPE was at the doorway entrance. There was a strong urine odor in the room, and there were soiled linens lying on the unmade bed. The linens looked like they were soiled with dry urine. A urinal was hanging on the side rail of the bed and contained approximately 200 milliliters of urine. An interview with Resident #1 at the time of the observation revealed he was not sure how long the soiled linens had been on his bed. He stated the soiled linens were there because a staff member, name unknown, told him to urinate on his sheets because he could not reach his urinal. He stated the staff, name unknown, was not able to take him to the toilet. The resident stated he did not sleep in his bed the night of 09/25/17, and he spent the night in his wheelchair. An observation and interview with CNA A on 09/26/17 at 9:35 a.m. revealed she entered the room of Resident #1. CNA A stated the soiled linens were on the resident's bed when she came in for work the morning of 09/26/17 because the staff on 10:00 p.m. to 6:00 a.m. shift did not change the resident. CNA A stated she put the soiled linens on the floor and went and told the staff from 10:00 p.m. to 6:00 a.m. shift to clean them up. CNA A stated she guessed the staff just put the soiled linens back on the bed. An interview with Resident #1 on 09/26/17 at 12:30 p.m. revealed the resident felt like a bum when the staff member, name unknown, told him to urinate on his sheets. The resident stated it hurt his feelings and made him depressed. The resident stated it was almost lunch time, but he did not eat a lot in the afternoons to prevent having a bowel movement because staff might not have time to take him to the toilet. Resident #1 stated he did not want to have a bowel movement on his sheets. An interview with CNA E on 09/26/17 at 2:00 p.m. revealed a resident's family complained to him that staff were providing untimely incontinent care so he gave them his telephone number to call if it happened again. A confidential interview revealed he/she did not know who told Resident #1 to toilet in his sheets, but he/she had heard staff tell residents to toilet in their briefs before. An interview with LVN D on 09/26/17 at 3:40 p.m. revealed she worked the 10:00 p.m. to 6:00 a.m. shift and would once in a while find residents soiled when coming on shift. She stated residents would ask for incontinence care, but because they were changed at 8:00 p.m. the CNA would wait to change them until about 10:30 p.m. LVN D reported most of her assigned residents were incontinent. An interview with CNA C on 09/26/17 at 4:05 p.m. revealed she worked the 10:00 p.m. to 6:00 a.m. shift on 09/25/17. CNA C stated Resident #1 wanted to stay in his chair and not go to bed, and she denied seeing any soiled linens on the resident's bed. CNA C revealed she assisted the resident with his urinal, but he did not need to use the toilet. An interview with the DON on 09/26/17 at 5:40 p.m. revealed she would be conducting in-services with staff to address hygiene and dignity. The facility's current Abuse policy and procedure, dated November 2016, reflected the following: .Person-centered-care means to focus on the Patient/Resident as the locus of control and support the Patient/Resident in making their own choices and having control over their daily lives. .The facility will monitor through its Quality Assurance Committee and identify and correct: (C) inappropriate staff behaviors such as directing patient/residents who need toileting assistance to urinate or defecate in their beds . The Resident Census and Conditions of Residents Form CMS-672, signed and dated by the DON on 09/26/17, reflected 34 residents were continent of bladder and 57 residents were continent of bowel.