Every finding on record at Tuskegee Airmen Texas State Veterans Home

Based on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 2 Residents (Resident #1) reviewed for essential equipment. The facility failed to ensure Resident #1's WanderGuard device (wander management bracelet) was functioning on all sensors of the four exit doors on the Delta pod. This failure could place residents at risk for elopement and injury. Findings included:Record review of Resident #1's Quarterly MDS, dated [DATE], reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnoses included Non-Alzheimer's Dementia (brain disease that alters brain function and causes a cognitive decline) and aphasia (brain related condition that makes it hard to speak and understand others). Resident #1's BIMS score was blank and staff assessment for Mental Status reflected Resident #1 had a short- and long-term memory problem and cognitive skills for daily decision making were severely impaired. Resident #1 had not exhibited any wandering behaviors. Record review of Resident #1's care plan, dated 02/05/2026, reflected Interdisciplinary team determined the resident to be an Elopement risk due to 7 yes responses from Elopement Eval. and increased wandering behaviors. Wander guard - Apply Security Bracelet (TekTone) for safety. Check placement (back of wheelchair) every shift.Record review of Resident #1's physician orders reflected the following: - Apply Security Bracelet/WanderGuard for safety. Check placement (back of wheelchair) every shift - start date 07/07/2026.- Check WanderGuard device (back of wheelchair) every shift to ensure placement and the red light is visible. If missing or red light is not visible, replace WanderGuard - start date 07/07/2026.Record review of incident and accident log, from 06/23/26 to 07/23/26, reflected no elopements. Observation and interview on 07/23/2026 at 3:00 PM, Resident #1 was sitting up in his wheelchair near the TV. Resident #1 was not able to answer any questions. CNA A showed Resident #1's security bracelet and the blinking red light that indicated it was functioning. CNA A then brought the bracelet by the door to the enclosed patio and stated the keypad should change color, and an alarm would sound if the door opened, however no light came on the keypad, and the alarm did not sound when the door opened. CNA A then went to the other door side door and the keypad lit up and alarm sounded when she opened the door.No residents were observed going into the enclosed patio. Observation on 07/23/26 at 3:31 PM, LVN B took another resident that was wearing a security bracelet near the same patio exit door and the keypad lit up and the door alarm sounded when opened. Interview on 07/23/2026 at 3:18 PM, LVN B stated an alarm would sound any time a resident with a WanderGuard security bracelet would try to go out an exit door on the pod. LVN B stated nurses checked the bracelets every shift to ensure they were functioning, and if they were not, they were to immediately report to their supervisor. Interview on 07/23/2026 at 3:51 PM, Social Worker C stated Nursing was responsible to check placement of the bracelet on residents who wore them. She stated Maintenance, the DON and Administrator received a notification if a bracelet had a low battery. The Social Worker stated if a resident [with a WanderGuard] passed by a door it would trigger the sensor, and if the door opened an alarm would sound and a notification of where it was going off would be sent. Observation and interview on 07/23/26 at 4:11 PM, revealed the Maintenance Director checked the patio door keypad and the alarm with an extra tag (security bracelet). He then tested Resident #1's bracelet on the patio exit door and stated the keypad stayed green and the alarm did not sound when the door opened. He stated he could not give a solid answer to why Resident #1's bracelet was not working. He stated he tested the functioning of the doors weekly and used a different handheld device. He did not answer when asked if there was a risk to residents by not checking the actual security bracelets worn by resident's and the door sensors.Interview on 07/23/2026 at 4:58 PM, the DON stated there had not been any recent elopements and nursing staff checked placement of the WanderGuards. She stated they would make sure the bracelet was not too tight, and if the red light was blinking. The DON stated nursing staff checked it daily and management checked it weekly. She stated it did not keep a log and was not able to provide when the last time Resident #1's bracelet was checked against the door sensors. She stated it was important to ensure the system was functioning for the residents' safety. Interview on 07/23/2026 at 5:29 PM, the Administrator stated they had no elopements since their self-report [in March 2026]. She said doors were tested weekly and the WanderGuards had the ability to tell them when it had a low battery. She stated she was told it was not working properly, so she went and tried it on the patio door, and the keypad did not light up. She tried a second time, and it did light up. She said it was working on the other three doors. The Administrator stated they replaced Resident #1's bracelet and did not know what was wrong with it. She said the bracelets got checked for placement, that the light was on daily and the doors were tested weekly, but they were not checking every single door with each bracelet. She stated it was important to test the WanderGuard system to minimize the risk of elopement.Record review of the facility's Physical Environment: Electrical Equipment policy, dated 2026, reflected in part: The facility will maintain all mechanical, electrical, and patient care equipment in safe operating condition. Policy Explanation and Compliance Guidelines:1. The Maintenance Director shall maintain schedules for routine inspection and maintenance of all mechanical, electrical, and patient care equipment.4. Essential equipment shall be repaired or replaced as soon as practicable.a. Patient care-related electrical equipment.

Based on observation, interview and record review the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident (Resident #109) reviewed for intravenous fluids. The facility failed to change and maintain the integrity of the dressing on Resident #109's Central Venous Catheter (an indwelling device inserted into a large, central vein that sends medicines and other treatments into a large vein in the middle of your chest) per professional standards.These failures could place residents at risk for infections and cross-contamination.Findings include:Record review of Resident #109's quarterly MDS Assessment, dated 06/24/26, revealed an [AGE] year-old male who admitted to the facility on [DATE] and reentry on 06/17/26. Resident #109 had diagnoses which included chronic venous hypertension with ulcer of right lower extremity (damaged vein valves cause blood to pool in the lower leg, forcing fluid into the tissue), lymphedema (chronic condition that causes swelling), polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body), hypertension (high blood pressure), and heart failure. The MDS reflected that the resident's cognition was intact with a BIMS score of 14. The MDS did not address the use of antibiotics or central line.Record review of Resident #109's care plan, revised 07/06/26, revealed Focus: [Resident #109] has potential/actual impairment to skin integrity of the (BLE) r/t lymphedema, not elsewhere classified, cellulitis of unspecified part of limb. Non pressure ulcer right calf to subcutaneous layer, cellulitis of right lower extremity. Goal: He will maintain or develop clean and intact skin by the review date. Intervention: Monitor for side effects of the antibiotics and over-the-counter pain medications: gastric distress, rash, or allergic reactions which could exacerbate skin injury. Care plan did not address the central line. Record review of Resident #109's active physician order, dated 07/08/26, revealed the following orders: CefTRIAXone Sodium Solution Reconstituted 2 GM Use 2 gram intravenously every 24 hours for Wound infection related to Chronic venous hypertension with ulcer of right lower extremity. Order date 07/01/26 - Start Date 07/01/26 - End date 07/16/26. Change dressing to PICC line weekly - Weekly every 7 day(s) for PICC Line - Order date 07/02/26 - Start date 07/02/26. Change dressing to Central Venous Catheter weekly using sterile technique. every day shift every Tue for Central Venous Catheter - Order date: 07/01/26 - Start Date 07/07/26. Record review of Resident #109's July [DATE] revealed the following: Change dressing to PICC line weekly - Weekly every 7 day(s) for PICC Line -Start Date- 07/02/2026 1200. It was documented CVC dressing was changed on 07/02/26 by RN B. Change dressing to Central Venous Catheter weekly using sterile technique. every day shift every Tue for Central Venous Catheter -Start Date- 07/07/2026 0700. It was documented CVC dressing was changed on 07/07/26 by RN B.During an observation and interview on 07/08/26 at 11:26 a.m., revealed Resident #109 was in his room. Resident #109 stated he was doing well. Resident #109 had a central venous catheter on his upper right chest, and the dressing had a date of 06/30/26. Resident #109 stated his catheter was placed on 06/30/26, and his dressing had not been changed since then. The resident denied any pain or discomfort.During an interview on 07/08/26 at 11:30 a.m., LVN A stated she was the nurse assigned to Resident #109. She stated Resident #109 was receiving antibiotics via central line. She stated Resident #109 had orders for antibiotics and flushing. LVN A reviewed Resident #109's orders and stated he had an order for dressing change every 7 days. LVN A reviewed Resident #109's July MAR and stated it was documented the resident's central line dressing was changed on 07/07/26. LVN A entered Resident #109's room, observed the central line dressing and stated the dressing was dated 06/30/26. She stated the nurse assigned to Resident #109 yesterday (07/07/26) failed to change the dressing and documented something that was not done. She stated she was not aware it was not done. LNV A stated the assigned nurses were responsible for changing the dressings. She stated the potential risk of not following physician orders was it could lead to infection.Interview on 07/08/26 at 2:53 p.m. via phone, RN B stated he was the assigned nurse for Resident #109 yesterday (07/07/26) and 07/02/26. He stated Resident #109 was receiving IV antibiotics. He stated the central line dressing had to be changed weekly. He stated he had not changed Resident #109's dressing yesterday (07/07/26) or on 07/02/26, he stated he only flushed the IV. RN B stated when he flushed the IV he did not pay attention to the dressing. He stated he was not aware the dressing had not been changed. RN B stated the night nurse was responsible for administering the IV antibiotics and changing the dressing. RN B stated he did not pay attention when documenting, he stated it was a mistake. He stated he thought the nurse changed the dressing and made the mistake of documenting on the resident's MAR. He stated he does not recall documenting anything. He stated the potential risk of not changing the central line dressing could lead to an infection. Interview on 07/09/26 at 12:16 p.m., the ADON stated the expectation for resident receiving antibiotics the nurses must follow physician orders, check site, flush, and change central line dressing every 7 days. She stated the charge nurse assigned to the resident was responsible for changing the dressings on IVs. The ADON stated if the nurse was unable to change the IV dressings, the nurse must notify the Unit Supervisor, ADON or DON. She stated the potential risk of not changing the IV dressings could lead to an infection. Interview on 07/09/26 at 12:28 p.m., the DON stated the expectation for residents receiving antibiotics the nurses must change the central line dressing weekly, using a sterile technique. If nurse not able to change the central line dressing, the nurse must notify management. The DON stated the nurses were responsible for changing central dressing. She stated the Unit Manager, ADON and herself were responsible for overseeing to ensure central line dressing were being changed. The DON stated they have in-service the nurses and nurses' complete yearly trainings on PICC lines; however, she could not recall when the last time it had been done. She stated the potential risk of not changing the dressing could lead to skin irritation. Record review of facility Mid-line, PICC Catheter Dressing Change dated 09/2012, reflected the following: . The initial dressing change must be done 24 hours post insertion of catheter, dressing changes will then be performed one time per week and as needed whenever the integrity of the dressing is compromised.

Based on observation, interview, and record review, the facility failed to ensure the clinical records were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for 1 of 6 residents (Resident #109) records reviewed for treatment documentation.RN B inaccurately documented that Resident #109's Central Venous Catheter (an indwelling device inserted into a large, central vein that sends medicines and other treatments into a large vein in the middle of your chest) dressing was changed on 07/02/26 and 07/07/26 when it was not.These failures could affect the residents' medical record not being an accurate representation of the resident's medical condition or medical needs. Findings included:Record review of Resident #109's quarterly MDS Assessment, dated 06/24/26, revealed an [AGE] year-old male who admitted to the facility on [DATE] and reentry on 06/17/26. Resident #109 had diagnoses which included chronic venous hypertension with ulcer of right lower extremity (damaged vein valves cause blood to pool in the lower leg, forcing fluid into the tissue), lymphedema (chronic condition that causes swelling), polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body), hypertension (high blood pressure), and heart failure. The MDS reflected that the resident's cognition was intact with a BIMS score of 14. The MDS did not address the use of antibiotics or central line.Record review of Resident #109's care plan, revised 07/06/26, revealed Focus: [Resident #109] has potential/actual impairment to skin integrity of the (BLE) r/t lymphedema, not elsewhere classified, cellulitis of unspecified part of limb. Non pressure ulcer right calf to subcutaneous layer, cellulitis of right lower extremity. Goal: He will maintain or develop clean and intact skin by the review date. Intervention: Monitor for side effects of the antibiotics and over-the-counter pain medications: gastric distress, rash, or allergic reactions which could exacerbate skin injury. Care plan did not address the central line. Record review of Resident #109's active physician order, dated 07/08/26, revealed the following orders: CefTRIAXone Sodium Solution Reconstituted 2 GM Use 2 gram intravenously every 24 hours for Wound infection related to Chronic venous hypertension with ulcer of right lower extremity. Order date 07/01/26 - Start Date 07/01/26 - End date 07/16/26. Change dressing to PICC line weekly - Weekly every 7 day(s) for PICC Line - Order date 07/02/26 - Start date 07/02/26. Change dressing to Central Venous Catheter weekly using sterile technique. every day shift every Tue for Central Venous Catheter - Order date: 07/01/26 - Start Date 07/07/26. Record review of Resident #109's July [DATE] revealed the following: Change dressing to PICC line weekly - Weekly every 7 day(s) for PICC Line -Start Date- 07/02/2026 1200. It was documented CVC dressing was changed on 07/02/26 by RN B. Change dressing to Central Venous Catheter weekly using sterile technique. every day shift every Tue for Central Venous Catheter -Start Date- 07/07/2026 0700. It was documented CVC dressing was changed on 07/07/26 by RN B. During an observation and interview on 07/08/26 at 11:26 a.m., revealed Resident #109 was in his room. Resident #109 stated he was doing well. Resident #109 had a central venous catheter on his upper right chest, and the dressing had a date of 06/30/26. Resident #109 stated his catheter was placed on 06/30/26, and his dressing had not been changed since then. The resident denied any pain or discomfort.During an interview on 07/08/26 at 11:30 a.m., LVN A stated she was the nurse assigned to Resident #109. She stated Resident #109 was receiving antibiotics via central line. She stated Resident #109 had orders for antibiotics and flushing. LVN A reviewed Resident #109 orders and stated Resident #109 had an order for dressing change every 7 days. LVN A reviewed Resident #109's July MAR and stated it was documented resident's central line dressing was changed on 07/07/26. LVN A entered Resident #109 room, observed Resident #109's central line dressing and stated the dressing was dated 06/30/26. She stated the nurse assigned to Resident #109 yesterday (07/07/26) failed to change the dressing and documented something that was not done. She stated she was not aware it was not done. LNV A stated the assigned nurses were responsible for changing the dressings. She stated the potential risk of inaccurate documentation is the inability to know whether the treatment was completed. Interview on 07/08/26 at 2:53 p.m. via phone, RN B stated he was the assigned nurse for Resident #109 yesterday (07/07/26) and 07/02/26. He stated Resident #109 was receiving IV antibiotics. He stated the central line dressing had to be changed weekly. He stated he had not changed Resident #109's dressing yesterday (07/07/26) or on 07/02/26, he stated he only flushed the IV. RN B stated when he flushed the IV he did not pay attention to the dressing. He stated he was not aware the dressing had not been changed. RN B stated the night nurse was responsible for administering the IV antibiotics and changing the dressing. RN B stated he did not pay attention when documenting, he stated it was a mistake. He stated he thought the other nurse changed the dressing and he made the mistake of documenting on the resident's MAR. He stated does not recall documenting anything. RN B stated accurate documentation was important so that other nurses know what treatment had been completed. Interview on 07/09/26 at 12:16 p.m., the ADON stated nurses were responsible for documenting each treatment after completion. If treatment was not completed, nurses were still responsible for documenting that the treatment was not completed. ADON stated the potential risk of inaccurate documentation would be a med error. Interview on 07/09/26 at 12:28 p.m., the DON stated nurses were expected to document accurately, monitor any signs or symptoms. She stated the potential risk of incorrect documentation would be nurses unable to determine whether care was completed in a timely manner. Record review of facility Documentation in Medical Record undated, reflected the following: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of services, but no later than the shift in which the assessment, observation, or care service occurred.

Based on observation, interview, and record review, the facility failed to ensure the resident was not given a psychotropic drug unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #3) reviewed for unnecessary medications, in that: The facility failed to ensure Resident #3 was prescribed a psychotropic drug for anxiety no longer than 14 days PRN. Resident #3 was ordered PRN Lorazepam (a benzodiazepine medication used primarily to treat anxiety disorders and sever agitation) on 06/03/26 without a stop date. This deficient practice could place residents at risk of receiving unnecessary psychotropic medications. Findings included: Review of Resident #3's Quarterly MDS Assessment, dated 04/02/26, reflected he was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had a BIMS score of 14 indicating he had no cognitive impairment. His active diagnoses included Parkinson's Disease (a progressive neurological disorder that primarily affects movement) and anxiety disorder (excessive and persistent fears or worries that interfere with daily life). Review of Resident #3's care plan reflected the following: Focus: [Resident #3] is receiving hospice care services through [Hospice Company]. DX- End Stage Parkinsons.Interventions: coordinate care with Hospice Team. Review of Resident #3's Order Summary Report, dated 07/08/26, reflected the following: Admit to hospice with an order date of 06/03/26 Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for Anxiety with an active date of 06/03/26 Review of Resident #3's June 2026 Medication Administration Record reflected he received the ordered Ativan on the following dates and times: 6/10/26 at 6:40 AM and 6:01 PM, 06/22/26 at 12:42 PM, 06/28/26 at 3:31 AM, and 06/30/26 at 4:42 PM. Review of Resident #3's July 2026 Medication Administration Record reflected he did not receive any Ativan. Observation and interview on 07/09/26 at 9:45 AM, Resident #3 was in his room resting in bed watching TV. Resident #3 said he was not feeling well today and was not doing good. Resident #3 said he had not been anxious in a while and knew to ask for his medication to help him if he needed it. Resident #3 said he had not needed his anxiety medication in a while but was not sure when he last needed the medication. Interview on 07/09/26 at 9:48 AM, LVN D said Resident #3 was placed on hospice services about a month ago or so. LVN D said Resident #3 sometimes hallucinated and showed anxious behaviors and would be given his PRN anti-anxiety medication to help him calm down. LVN D said Resident #3 knew how to ask for his medication if he felt anxious and needed it but he had been doing better lately. LVN D said Resident #3 had not needed his anti-anxiety medication in a while. LVN D said she reviewed Resident #3's orders for his Ativan and it did not have a 14-day stop date for it. LVN D said Resident #3's ordered Ativan should have a 14-day stop date since it had something to do with behaviors. LVN D said the doctor usually gave the order for a 14-day stop date but staff could add it after asking the doctor about it. LVN D said if Resident #3's ordered Ativan did not have 14-day stop date he could have an adverse reaction but she was not sure what that could be. Interview on the phone on 07/09/26 at 9:58 AM, LVN E said she had added Resident #3's as needed Ativan order to his chart. LVN E said the doctor did not give a stop date which normally would have been included with an order like this. LVN E said she was not sure if this situation would apply to a resident on hospice services, which Resident #3 was receiving. LVN E said Resident #3 did get anxious sometimes and would request the ordered Ativan sometimes but he has not recently needed any of this medication. LVN E said the 14-day stop date should have been included with the order and she should have added it to the order but she was not sure what could happen without it. Interview on 07/09/26 at 10:26 AM, the Unit Manager who said Resident #3 should have a 14-day stop date on his ordered Ativan. The Unit Manager said the Pharmacy Nurse who was onsite would have been the one to review Resident #3's orders and make sure the 14-day stop date was included with the order. The Unit Manager said Resident #3 started on hospice services about a month ago and that was where the order came from. The Unit Manager said the nurse who took the order from hospice should have included the 14-day stop date because the resident may not need to be on it for a long time. Interview on 07/09/26 at 10:38 AM, the Pharmacy Nurse said Resident #3 was on hospice services and she understood from hospice that residents on an anti-anxiety medication that was as needed did not require a stop date. The Pharmacy Nurse said normally any anti-anxiety medication that was ordered for as needed required a 14-day stop date for it. The Pharmacy Nurse said she reviewed resident's orders every day and because she thought since the resident was on hospice it was not a requirement for him. The Pharmacy Nurse said ultimately she was responsible for making sure Resident #3's ordered Ativan included a 14-day stop date. The Pharmacy Nurse said if the medication did not include the 14-day stop date he could have adverse reactions but did not specify what they could be. Interview on 07/09/26 at 11:50 AM, the DON said Resident #3 was on hospice services and she understood that meant his ordered Ativan did not need at 14-day stop date. The DON said the Pharmacy Nurse would have been responsible for ensuring the 14-day stop date was included in Resident #3's Ativan order. The DON said there was no risk the 14-day stop date was not included for Resident #3's ordered Ativan because staff were constantly assessing him if he had any sort of effects from his medications. Review of the facility's undated policy titled Use of Psychotropic Medication(s) reflected: 16. Psychotropic medication used on a PRN basis must have a diagnosed specific condition and indication for the PRN use documented in the resident's medical record and is subject to the limitations as noted: a. PRN orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or the prescriber for the rationale for the extended period and indicate a specific duration.

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 2 residents (Resident #1) reviewed for ADL care .The facility failed to provide incontinence care to Residents #1 as needed.This failure could place residents at risk for loss of dignity, infections and a decreased quality of life.Findings include:Record review of Resident #1's quarterly MDS Assessment, dated 03/27/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Parkinsonism (any disorder manifesting symptoms of Parkinson's disease or any such symptom complex occurring secondarily to another disorder), chronic ischemic heart disease (heart damage caused by poor blood flow to the heart), respiratory failure (not enough oxygen travels from the lungs into the blood), anxiety disorder (excessive worry and feelings of fear) and post-traumatic stress disorder (mental health condition triggered by trauma). Resident #1's cognition was severely impaired with a BIMS score of 7, and the resident was dependent upon staff for toileting hygiene. Record review of Resident #1's care plan, dated 01/15/26, reflected [Resident #1] has an ADL self-care performance deficit [related to] Parkinsonism and Impaired balance. Goal: [Resident #1] will maintain current level of function through the review date. Interventions: Toilet use. The resident requires (assistance) by (2) staff for toileting.During an observation and interview on 04/23/26 at 9:55 AM, revealed Resident #1 was in his room in his bed. He stated his brief was changed, but he could not recall when it was last changed. No odor. He was noted wet while performing skin assessment.During an observation on 04/23/26 at 11:18 PM, CNA B and RN C went to Resident #1's room to conduct a skin assessment and to provide the resident with incontinence care. Upon entering the room, they explained the procedure to Resident #1. CNA B and RN C put on PPE and gathered their supplies together. They then went to the resident's bedside. Without performing hand hygiene, CNA B put on gloves and unfastened Resident #1's brief. Resident #1 was wearing two briefs and was heavily soaked in urine with some redness in her perineal area (the area between the genitals and anus).During an interview on 04/23/26 at 11:56 AM, CNA D revealed she was the one assigned to Resident #1. CNA D stated she changed the resident after breakfast. She stated she was the one who applied two briefs on Resident #1. She stated she applied one brief to act as a pad because Resident #1 wet his briefs a lot, and she wanted to prevent him from soiling his clothes. She stated she was aware they were not supposed to double the briefs on residents. She stated the risk of doubling the briefs would be the resident having skin breakdown. She stated she had done training on not putting two briefs on residents and rounding every two hours. She stated she last did her rounds at 9:00 AM and had no reason why she had not changed Resident #1.During an interview on 04/23/26 at 12:18 PM, CNA B revealed she was not assigned to Resident #1. She stated she was just called to help with the skin assessment. She stated she was not the aide who put two briefs on Resident #1. She stated she was aware they were not supposed to double the briefs on residents. She stated the risk of doubling briefs was that it could cause skin breakdown. CNA B stated she had done training on not putting two briefs on residents, but she could not recall when.During an interview on 04/23/26 at 2:55 PM, RN C revealed she was the treatment nurse. She stated she was performing Resident #1's skin assessment, and when CNA B unfastened the resident's brief, she saw Resident #1 had two briefs. She stated she was aware Residnet#1 was not supposed to have double briefs, and she expected the staff to change him more frequently and let the management know. She stated the risk of doubling the briefs was it could cause skin breakdown. She stated she had done training and re-educated staff on incontinence care, but she could not recall when and whether CNA B and CNA D were in attendance. Resident was observed to have some redness on his peri area.During an interview on 04/23/26 at 4:23 PM, the ADON revealed her expectation was the staff performed rounds every two hours and as needed. She stated the nurses were responsible for monitoring the CNAs during their shifts. She stated staff should not double the briefs on residents. She stated the risk of not performing rounds every two hours and doubling briefs was it could lead to skin issues and infections.During an interview on 04/23/26 at 4:43 PM, the DON stated she expected staff to perform rounds every two hours and as needed for residents, who wet heavily.Residnet #1 was not identified as one that wet heavily on his care plan. She stated the nurses were responsible for monitoring the CNAs during their shifts. She stated staff should not double the briefs on residents. She stated the risk of not performing every two hours rounds and doubling the briefs was it could lead to skin issues and infections. The DON stated she had done training with staff on providing incontinence care every two hours and not putting two briefs on the residents. The DON provided these in-service training records. They were not interviewed.Record review of the facility's training records revealed the facility did in-service training on toileting, changing and checking patients every two hours and as needed, and handwashing techniques on 02/25/26. The training record revealed CNA D was not in attendance.Record review of the facility's Incontinent/Perineal Care (Male) policy, revised 09/02/25, reflected the following: . To promote cleanliness and prevent infection and skin irritation. Apply brief/pull-up as indicated.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable and to prevent the development and transmission of communicable diseases and infection for 2 of 2 residents (Residents #1 and #2) reviewed for infection control.1. CNA B and CNA D failed to perform hand hygiene while providing incontinence care to Residents #1 and #2.2. RN C failed to perform hand hygiene and change her gloves when she performed a skin assessment on Resident #2. These failures could place residents at risk for worsening conditions and cross-contamination. Findings include:1. Record review of Resident #1's quarterly MDS Assessment, dated 3/27/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Parkinsonism (any disorder manifesting symptoms of Parkinson's disease or any such symptom complex occurring secondarily to another disorder), chronic ischemic heart disease (heart damage caused by poor blood flow to the heart), respiratory failure (not enough oxygen travels from the lungs into the blood), anxiety disorder (excessive worry and feelings of fear) and post-traumatic stress disorder (mental health condition triggered by trauma). ] Resident #1's cognition was severely impaired with a BIMS score of 7, and the resident was dependent upon staff for toilet hygiene. Record review of Resident #1's care plan, dated 01/15/26, reflected [Resident #1] has an ADL self-care performance deficit [related to] Parkinsonism and Impaired balance. Goal: [Resident #1] will maintain current level of function through the review date. Interventions: Toilet use. The resident requires (assistance) by (2) staff for toileting.During an observation on 04/23/26 at 11:18 AM, CNA B and RN C provided Resident #1 with incontinence care. CNA B and RN C were observed putting on personal protective equipment before they washed their hands. CNA B explained the procedure to Resident #1, she positioned the resident, unfastened the resident's brief, and proceeded to cleanse Resident #1. Resident #1 had two briefs and was heavily soaked in urine with some redness on the resident's perineal area (area between the genitals and anus). She cleansed the resident's abdominal folds and penis in a clockwise direction. RN C performed a skin assessment on the resident, which included assessing the resident's head, face, under arms, abdomen and legs. They then positioned the resident on his side and cleansed his bottom area wiping from the inside to the outside. Without performing hand hygiene or changing her gloves, CNA B put a clean brief on Resident #1. RN C completed the skin assessment and left the resident comfortable with the bed in a low position with his call light within reach. CNA B was observed leaving the room after removing gloves and gown without washing hands and walked down the hall with the trash. RN C was left in the room she removed her gloves and washed her hands.2. Record review of Resident #2's comprehensive MDS Assessment, dated 02/9/26, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included hemiplegia following cerebral infarct affecting the left nondominant side (a severe form of stroke-induced paralysis affecting the entire left side of the body). Resident #2's cognition was severely impaired with a BIMS score of 1, and the resident was dependent upon staff for toilet hygiene. Record review of Resident #2's care plan, dated 03/12/26, reflected [Resident #2] has an ADL self-care performance deficit [related to] dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Goal: [Resident #2] will maintain current level of function through the review date. Interventions: Toilet use. The resident requires (assistance) by (1) staff for toileting.During an observation on 04/23/26 at 11:10 AM, CNA D provided Resident #2 with incontinence care. CNA D put on gloves before washing her hands. After explaining the procedure to Resident #2, CNA D positioned the resident, unfastened the resident's brief, and proceeded to cleanse Resident #2. She cleansed the resident's abdominal folds and penis in a clockwise direction. CNA D turned Resident #1 and positioned the resident on his side and cleansed his bottom area wiping from the inside to the outside. Resident #2's brief soaked with urine. Without performing hand hygiene or changing her gloves, CNA D put a clean brief on the resident and left the resident comfortable with the resident's bed in the low position and the call light within the resident's reach. CNA D then left the resident's room after removing her gloves without washing hands, and she walked down the hall with the trash.During an interview on 04/23/26 at 11:56 AM, CNA D revealed she did not perform hand hygiene before, during, and after Resident #2's incontinence care. CNA D stated she was expected to wash her hands before and in between care, if her gloves were soiled, when moving from dirty to clean, and after care. She stated she forgot. CNA D stated she was supposed to complete hand hygiene and change gloves during incontinence care to prevent cross contamination. She stated failure to wash hands after or before contact with resident, and after removing gloves could lead to cross contamination. She stated she had done training on handwashing, but she could not recall when.During an interview on 04/23/26 at 12:18 PM, CNA B revealed she knew she was supposed to perform hand hygiene before contact with Resident #1, between the care, when gloves were soiled with body fluid, and with each removal of gloves. She stated she forgot. She stated failure to perform hand hygiene before contact, between care, and after removal of gloves could lead to contamination and spread of infection. She stated she did training on hand washing and infection control, but she could not remember when.During an interview on 04/23/26 at 2:55 PM, RN C revealed she was the treatment nurse. She stated she knew she was supposed to perform hand hygiene before contact with Resident #1 and between care. She stated she knew better, but she forgot. She stated failure to perform hand hygiene before contact, between care, and after removal of gloves could lead to contamination and spread of infection. During an interview on 04/23/26 at 4:43 PM, the DON revealed her expectation was for staff to perform hand hygiene before contact with residents, between care, when gloves were soiled, and when they changed gloves. She stated failure to perform hand hygiene before contact, between care, and change of gloves could lead to cross contamination and spread of infection. She stated she had training on infection control with staff.Record review of the facility's Hand Hygiene policy, dated February 2020, reflected, .It is the policy of this facility that staff will perform hand Hygiene and aide in the prevention of the transmission of infections '

Based on observations, interviews and record reviews the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident #1) reviewed for accident and hazards. The facility failed to ensure Resident #1 received adequate supervision to prevent the resident from eloping from the facility through an ancillary door on the service hallway on 03/21/26 at approximately 3:30 PM. An Immediate Jeopardy (IJ) situation was identified on 03/31/26. While the IJ was removed on 04/01/26 the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate effectiveness of their corrective systems. This failure could place residents at risk of serious injury, harm or death. Findings included:Record review of Resident #1's quarterly MDS, dated [DATE], reflected a [AGE] year-old male, who admitted to the facility on [DATE]. The resident's active diagnoses included mild cognitive impairment of uncertain cause, heart failure, high blood pressure, and presence of pacemaker . The resident had severe cognitive impairment with a BIMS score of 4. The resident did not have any behavioral symptoms and had no wandering behavior during the assessment period. Resident #1 was able to walk independently, and he had had two or more falls without injury.Record review of Resident #1's care plan, dated 03/23/26, reflected that he was at risk for falls, and he was determined to be an elopement risk and had a Wander Guard bracelet applied on 12/23/25, with interventions of checking his bracelet every shift. Record review of Resident #1's Elopement Evaluations reflected: On 12/23/25 the resident exited the facility via the front door by following visitors through the door. A Wander Guard bracelet was applied to the resident's ankle. The resident was considered an elopement risk with 8 Yes responses. On 03/23/26 reflected the resident had exited the facility again via a side door. It was determined the resident was still a risk for elopement with 9 Yes answers and the safest option for the resident was to move him to the secured unit. Record review of the facility's incident report, dated 03/23/26, reflected Resident #1 eloped from the facility on 03/21/26 via a side door on the service hallway and was found at a clinic adjacent to the facility. Facility's video footage revealed the resident left the facility at 3:22 PM and was discovered in the parking lot at 3:26 PM. The resident reported to staff that he needed to go into town. The resident and no injury or ill effects, and was placed on 1:1 line of sight observation until the IDT team met on 3/23/26 and determined for the resident's safety he should be moved to the secured unit.Record review of Resident #1's progress notes, dated 03/21/26 at 4:21 PM, written by LVN-A reflected the following: At approximately 1530 [3:30 PM], patient [Resident #1] with a history of dementia left the facility without authorization and was later observed outside in the parking lot of the VA clinic. Patient was alert but confused, stating desire to go to town, with impaired safety awareness. Patient was able to be redirected without difficulty and escorted safely back to the facility. Assessment completed; no injuries noted, and vital signs were within normal range (BP 114/59, HR 80, O 93%). Patient was reoriented and provided reassurance. Staff notified, and elopement precautions reinforced, including increased monitoring. Administrator was contacted and stated patient should be placed on 1:1 observation. Social worker to be contacted regarding possible relocation to a different unit, with follow-up planned for Monday. [Resident #1's Family Member] was contacted and updated on patient status; she expressed that she does not want the patient relocated at this time. Administrator to be updated regarding family's preference. Patient currently resting on unit; will continue close observation and update care plan as needed.Record review of written statement dated 03/27/26, by Housekeeper B reflected she and Housekeeper- C were in the breakroom getting ready to go on break when Housekeeper-C looked out the window and viewed Resident #1 walking across the parking lot. They exited the breakroom, turned off the door alarm, and notified the nurse the resident was outside the facility.During an observation on 03/31/26 at 1:25 PM of the door Resident #1 eloped through revealed it was labeled No Exit, had the Wander Guard system in place, and had a keypad in place. The door was able to be opened without a code, and without setting off an alarm. There was a similar door at the opposite end of the hallway that also did not alarm when opened. During an observation on 03/31/26 at 1:35 PM, the Director of Maintenance activated the WanderGuard alarm for the door Resident #1 used, which was an ancillary door on the service hallway. The alarm from the door was not audible on Alpha Pod, and staff did not appear aware of the alarm. At the nurse call system, a sound of ding dong was heard on the Alpha Pod which was the same sound as the call light activation alerts on the hall at the same call system.An interview attempt on 03/31/26 at 1:30 PM with Resident #1 was unsuccessful, he was not able to answer questions or follow the conversation. In an interview on 03/31/26 at 1:22 PM, LVN-A stated on 03/21/26 she was notified by the housekeeper that one of the residents was outside the facility in the parking lot. She stated when she caught up with the resident, she recognized it was Resident #1 and he was in the parking lot of the clinic adjacent to the facility. She stated Resident #1 walked with a walker and was known to wander between his unit and the front lobby. She assessed him and found no injury and then notified the appropriate people. Resident #1 was placed on 1:1 direct sight observation for the rest of her shift. In an interview on 03/31/26 at 1:40 PM, the Director of Maintenance stated high pitch alarm of the WanderGuard only sounded at the door it was activated at , all external doors have the system in place. On the individual pods the staff would have a ding dong sounding alert on their call light monitor with the location of the door that were activated. If the door activated was on one of the pods the staff of that pod would hear the high pitched alarm as well as the ding dong alert on the monitor. In an interview on 3/31/26 at 3:00 PM, Housekeeper C stated he was in the breakroom changing out a trash bag when he happened to look out the window and saw a resident with a walker in the back parking lot. He stated he did not know who the resident was, but knew he was one of their residents. He alerted Houskeeper- B and they went to Alpha pod to alert the staff. Housekeeper-B stated he did not hear the door alarm while in the breakroom, only when he got out into the hallway. Housekeeper-C put the code in to turn the alarm off, on the way to Alpha pod. During an observation on 3/31/26 from 3:30 - 3:40 PM revealed the Maintenance Worker tested the Wander Guard system at each external door and all alarms were working. The Maintenance Worker stated the alarm was not very loud . In an interview on 3/31/26 at 4:50 PM, the Administrator stated she was notified on a Saturday (3/21/26)that Resident #1 had eloped from the facility, he was spotted by a housekeeper, and returned to the unit with no injury. The resident was placed on 1:1 direct line of sight observation until the IDT team met on Monday (3/23/26) and determined the safest option for Resident #1 was to move him to the secured unit. The resident had not exhibited any exit seeking behaviors since being moved to the secured unit. During observations and interviews on 03/31/26 from 5:40 PM-5:54 PM, the Administrator and State Surveyor stood at the entrance of Alpha pod while the Director of Maintenance activated the Wander Guard alarm in the hallway, and the alarm was audible. While standing at the nurses' station the alarm was not audible but the ding dong alert could be heard on the call light monitor, with the door number displayed in red at the top of the monitor. LVN-A was sitting at the nurses' station documenting; she glanced at the monitor and returned to her computer. The Administrator asked LVN-A about the alert, LVN-A stated, It's not one of our doors, meaning it was not on their unit. Other staff on the unit were also not responding to the alert, were not checking their doors, and not checking their residents with Wander Guard bracelets. The Administrator and the State Surveyor moved to [NAME] pod, on the opposite side of the building, while the Director of Maintenance activated the Wander Guard alarm in the hallway again. The alarm was not audible at the nurses' station but the alert on the monitor was audible, and the door number was displayed on the monitor. Staff on the unit were not responding to the alert. The Administrator asked RN-D what she should do about the alert, RN-D stated, Cancel it. During an observation and interview on 3/31/26 at 6:10 PM on Alpha pod the call light for room [ROOM NUMBER] had been activated. The alert for a call light sounded the same as the alert for a door alarm. RN-E stated the two alarms sounded similar and the only way to know the difference would be to look at the monitor and see if it was a door or a room number displayed . Record review of the facility's policy Elopement, dated 08/26/25, reflected: .4. The facility has an 'eyes on policy' where residents are observed approximately every two hours, or more frequently if deemed necessary. 5. The facility completes a care plan on all residents who are at risk for elopement to communicate to staff the interventions they should attempt to prevent elopement from the facility.6. The facility has an elopement response plan to implement in the event of an elopement. Drills are performed as needed to evaluate and train staff based upon actions/reactions observed during the drill.This was determined to be an Immediate Jeopardy (IJ) on 03/31/26 at 5:30 PM. The Administrator was notified. The Administrator was provided with the IJ template on 03/31/26 at 5:35 PM. The following Plan of Removal submitted by the facility was accepted on 03/31/26 at 8:35 PM: All Veterans identified by IDT for the need of a wander guard bracelet are at risk from this alleged deficient practice. DON immediately in-serviced all staff currently On Shift on door alarm notification on call light system-which states Door Alarm, what it means, what to do when it goes off and to respond immediately; completed by 3/31/2026. Administrator checked all pods and confirmed staff were able to hear door alarm and sound sufficient. Completed on 3/31/2026. All staff not onsite to be in-serviced via electronic communication platform prior to their next scheduled shift by Administrator on 3/31/2026. All veterans that are considered at risk for elopement and wearing wander guard system bracelets are in elopement binder at each nurse's station. Completed by 3/31/2026 by Social Workers . Administrator or designee to do elopement drills utilizing wander guard system 4x per week x4 weeks on all shifts to ensure compliance and response. Ad Hoc QAPI to review plan (DON , Administrator, OSR , and Regional Support) completed by 3/31/2026 and will meet weekly X 4 weeks for effectiveness of plan. Formal QAPI to continue meeting monthly X3 months.Monitoring of the facility's implementation of their Plan of Removal included:During an observation on 04/01/26 from 9:30 AM-10:15 AM, the Director of Maintenance tested the Wander Guard system in the hallways of the facility. Staff from all areas of the facility responded to the door being tested. Staff were able to verbalize their responsibility in the event of an elopement which included searching the immediate area outside the door for a resident, calling a Code [NAME] over their radio, checking their residents on their units and performing a head count on their unit. A Second State Surveyor stood at the nurses' station and observed staff checking the monitor, identified a door in the hallway was alarming, and responded to the door. Observation on 04/01/26 at 3:15 PM revealed the alerts on the computer monitor at the nurses' station for a bed alarm and a door alarm were remarkably different sounding. Staff were aware the new sound was a door alarm that needed immediate attention . Staff were observed responding to the new alert sound. In an interview and observation on 04/01/26 at 10:20 AM, the Director of Maintenance observed the alerts for a call light and a door alarm sounding the same. He stated staff would not know the difference without looking at the monitor. He contacted their vendor via phone who stated he could change the door alert to sound significantly different than the call light alert. The change could be completed remotely and would be completed within a few hours . Interviews on 04/01/26 from 11:00 AM to 3:58 PM in person and via phone with staff (RN-F. RN-G, RN-H, CNA-I, CNA-J, CNA-K, CNA-L, CNA-M, CNA-N, LVN-O, LVN-P, LVN-Q, RN-R, CNA-S, CNA-T, CNA-U, CNA-V, CNA-W, CNA-X, CNA-Y, CNA-Z, RN-AA, Activity Assistant, Laundry Aide. Housekeeper-B, Housekeeper-C, LVN-A) revealed they were able to verbalize elopement procedures, what Code [NAME] meant, and how to differentiate between call light alerts and door alerts. Staff stated if the alert was not on their unit, they were to respond to the door that was alarming and get their assignment from the nurse. Record review of in-services for all facility staff reflected they were educated on elopement procedures, meaning of Code [NAME] announcement, and the Wander Guard alarm responses.The Administrator was informed the Immediate Jeopardy was removed on 04/01/26 at 4:30 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systemically organized in accordance with accepted professional standards for 1 of 6 residents (Resident #1) reviewed for medical records.The facility failed to ensure Resident #1's medical record included documentation reflecting the resident had received showers/baths in February and March of 2026.The failure placed residents at risk of not having continuity of care.Findings included: Record review of Resident #1's admission MDS assessment dated [DATE], reflected the resident was a [AGE] year-old male who was admitted on [DATE]. His diagnoses included Parkinsonism (any disorder manifesting symptoms of Parkinson's disease or any such symptom complex occurring secondarily to another disorder), chronic ischemic heart disease (heart damage caused by poor blood flow to the heart), chronic respiratory failure (not enough oxygen travels from the lungs into the blood), anxiety disorder (excessive worry and feelings of fear), post-traumatic stress disorder (mental health condition triggered by trauma), and heart disease. The MDS reflected Resident #1's cognition was intact with a BIMS score of 13. The MDS Assessment Section GG - Functional Abilities for Shower/Bath Self was coded as Not applicable - (Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury). Further review reflected Resident #1 needed substantial/maximal assistance from staff in regard to personal hygiene. Record review of Resident #1's care plan, dated 01/15/26, reflected [Resident #1] has an ADL self-care performance deficit [related to] Parkinsonism and Impaired balance. Goal: [Resident #1] will maintain current level of function through the review date. Interventions: BATHING/SHOWERING: The resident requires (assistance) by (1) staff with (bathing/showering) and as necessary.Record review of Resident #1's ADL Record for February 2026 and March 2026 in the section titled Shower/Bed Bath reflected the following: Did the resident received a shower?, and No was marked indicating no showers were provided. There was no documentation in the ADL Record or the resident's clinical record reflecting the resident had refused to be bathed. Record review of the facility's shower binder which contained Skin monitoring: Comprehensive CNA Shower Review sheets reflected Resident #1 only had 1 shower sheet for 01/17/26, which indicated he had refused a shower.Observation on 03/18/26 at 9:55 AM revealed Resident #1 asleep while sitting in his wheelchair. Resident #1 appeared clean and well-groomed. Several attempts were made to interview resident, but he continued to sleep. Interview on 03/18/26 at 11:00 AM, Resident #1's family member, Family Member A, revealed concerns about Resident #1's hygiene and showers. Family Member A stated that Resident #1 was last seen on 03/15/26 by family, and the resident had food all over his mouth and face, crust on his eyes, and fingernails were long with a substance built-up underneath the nails. Family Member A stated that they had requested for Resident #1's fingernails to be cut and cleaned on 03/15/26. Family Member A stated that Resident #1 appeared like he had not received a shower in a very long time. Family Member A stated that Resident #1 was unable to say when he had been provided with showers. Interview on 03/18/26 at 12:15 PM, Resident #1 stated he was provided with showers, but he could not recall how often or when the last time he received one. Interview on 03/18/26 at 1:22 PM, LVN A revealed Resident #1's shower days were Mondays, Wednesdays and Fridays during the evening shift. She stated when CNAs showered residents they documented in the resident's the electronic health record and on the shower sheets. LVN A reviewed Resident #1's electronic health record and stated it was documented No which meant that shower/bed bath had not been provided; however, the documentation was during the morning shift. She stated she reviewed the documentation for the evening shift and there was no documentation showing Resident #1 had received any showers/bed baths. She stated in the system it showed that Resident #1's showers were scheduled for Mondays, Wednesdays, and Fridays during the morning shift but whoever put it in the system did it incorrectly. She stated Resident #1 was in a B bed and B bed residents received showers during the evening shift. She stated no one had mentioned or noticed that in the system his showers were inputted incorrectly. LVN A stated there were no shower sheets for Resident # 1, which she was not aware of. LVN A stated due to the lack of documentation they would not know if Resident #1 received any showers/bed baths. She stated the potential risk of not receiving any showers was that it could lead to infections. Interview on 03/18/26 at 1:36 PM, CNA B revealed she was the CNA assigned to Resident #1. She stated she had not provided any showers to Resident #1 during the morning shift due to resident being in a B bed. She stated residents in B beds received their showers during the evening shift. Interview on 03/18/26 at 2:11 PM, LVN C revealed Resident #1 received showers during the evening shift. She stated Resident #1's shower days were Mondays, Wednesdays, and Fridays. She stated she had witnessed CNA D provide Resident #1 with a bed bath about a month or two ago. She stated CNAs documented in the electronic health record and completed shower sheets. She stated she could not recall getting any shower sheets for Resident #1. LVN C stated she was not aware Resident #1's bed baths were not being documented in electronic health record. She stated the expectation was for CNAs to provide showers/bed bath to the residents, document that it was provided, and complete shower sheets. She stated if it was not documented then it was not done. She stated if showers were not provided to residents, it could lead to infection.Interview on 03/18/26 at 3:21 PM, CNA D revealed she had worked with Resident #1 before, but it had been a while since she last worked with him. She stated Resident #1's shower days were Tuesdays, Thursdays, and Saturdays during the evening shift. She stated it had been a couple of months since she had provided him with a shower. She stated showers/bed baths were documented in electronic health record and shower sheets. CNA D reviewed Resident #1's electronic health record and stated in the system his showers were put in on the wrong shift. CNA D stated she would not be able to know when the last time Resident #1 received a shower without any documentation. She stated the potential risk of not receiving any showers was that it could lead to dry skin. Interview on 03/18/26 at 4:22 PM, the ADON revealed Resident #1's shower days were Mondays, Wednesdays and Fridays during the 2:00 PM-10:00 PM shift. She stated Resident #1 received bed baths. The ADON stated that when residents receive a shower or bed bath, the CNAs documented it in electronic health record and completed a shower sheet. She stated she was not aware there were no shower sheets for Resident #1 or documentation of his bed baths. She stated she would have to verify with her staff whether Resident #1 received a shower. She stated the nurses were responsible for following up to ensure showers or bed baths were being provided and had to sign the shower sheets. She stated there was no potential risk to Resident #1 if showers were not being provided, because staff were checking on him daily. Interview on 03/18/26 at 4:44 PM, CNA E revealed he had been providing Resident #1 with his bed baths. He stated he should have been documenting the bed baths in the resident's electronic health record and on the shower sheets. He stated he had not completed the shower sheets because he did not know where they were located. He stated shower sheets needed to be completed because the sheet had the things that needed to be reported, like any skin abnormalities. Interview on 03/18/26 at 5:46 PM, the Interim DON revealed she was notified Resident #1's electronic health record documentation was inputted incorrectly. She stated in the system it indicated Resident #1's showers needed to be provided during the morning shift; however, his showers were supposed to be provided during the second shift. She stated she was not aware shower sheets were not being completed. She stated if it was not documented it did not happen. She stated she expected showers to be completed on the residents' shower days, and staff were supposed to fill out the shower sheets and provide them to the nurses, which the nurses must sign to verify that the shower was completed. She stated the potential risk of not receiving any showers was that it could lead to dry skin.Interview on 03/18/26 at 6:13 PM, the Administrator revealed her expectation was for staff to be documenting showers/bed bath in the resident's electronic health record. She stated from what staff told her, Resident #1's showers were populating on the wrong shift. She stated Resident #1's showers was populating on the 6:00 AM-2:00 PM shift instead of 2:00 PM-10:00 PM shift. She stated Resident #1's shower days were supposed to be Mondays, Wednesdays, and Fridays on the 2:00 PM-10:00 PM shift. She stated staff should be completing shower sheets. She stated she was not aware the shower sheets were not being completed. She stated if it was not documented then it did not happen. Record review of the facility's Bath (Bed) policy, dated 09/2/2025 reflected the following: Bed baths will be provided regularly or as indicated. 21. Complete personal care record.

Based on observation, interview, and record review, the facility failed to ensure that at resident who needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan for 1 of 4 residents (Resident #1) reviewed for physician orders.The facility failed to ensure there were physician orders for Resident #1's use of a CPAP machine, which is non-invasive ventilation machine that involved the administration of air usually through the nose by an external device at a predetermined level of pressure, that was provided by the nursing staff daily. This failure placed residents at risk of not receiving adequate respiratory care. Findings included:Record review of Resident #1's quarterly MDS dated [DATE] reflected he was an [AGE] year-old male admitted on [DATE]. The resident's diagnoses included: Alzheimer's disease (progressive mental deterioration that can occur in middle or old age that affects memory, thinking, and behavior); obstructive sleep apnea (a condition in which breathing stops involuntarily for brief periods of time during sleep), depression (mood disorder); and vertigo (a sensation that the environment is spinning in circles). Section C. cognitive patterns reflected a BIMS score of 02, indicating he was severely impaired cognitively. Section D. Mood indicated he had feelings of being down and depressed, or hopeless for 2 to 6 days. Section GG Functional Status indicated Resident #1 required partial to moderate assistance for lying to sitting on the bed, sit to stand, chair to bed transfer and toilet transfer, supervision and touching for walking, and he used a walker or manual wheelchair for mobility. The MDS reflected that the resident had no falls, but he had a history of falls and used a walker as an adaptive device for mobility. Section N addressed medications prescribed for anxiety, depression, pain, and fluid reduction. Section O Special treatments, procedures and programs did not indicate the resident treatments for Non-invasive Mechanical Ventilator, did not address Resident #1's use of CPAP machine. Record review of Resident #1's care plan dated 02/03/2026 reflected he was cognitively impaired and had impaired thought processes r/t diagnosis of Alzheimer's. Risk for falls, dependent on staff for meeting his needs. r/t cognitive deficits, communication problems r/t hearing. Care plan did not address Resident #1's CPAP treatments per MD orders 08/07/2025 and 02/10/2026.Record review of Resident #1's MD orders dated 08/07/2025 reflected 1. Wipe masks, nasal pillows, daily with damp cloth. 2 empty humidifier chambers, 3. Fill humidifier with warm soapy water, shake well. 4. Rinse, and air dry.Record review of Residents #1 orders (after surveyor intervention) the DON obtained a physician order on 02/10/2026 at 3:35 PM from MD J reflecting Resident #1 utilizes a CPAP at night with settings of 8.0 cm for H2O CPAP at bedtime for sleep apnea- obstructive sleep apnea.During an observation and interview on 02/10/2026 at 1:10 PM his CPAP was on his nightstand. Resident #1 was not interviewed about CPAP treatments and care tasks, due to severe cognitive impairment. During an interview with LVN C on 02/10/2026 at 1:00 PM, she stated that Resident #1 received CPAP treatments for obstructive sleep apnea at night. She reported that residents are provided with an order. During an interview on 02/11/2026 at 3:30 PM with RN-R, she stated that Resident #1 received CPAP treatments for obstructive sleep apnea. She reported no concerns with administration and use daily. LVN-R reviewed the resident orders with the surveyor and stated that he had orders for CPAP cleaning. She could not recall if he had an order for CPAP prior to 02/11/2026. During an interview on 02/11/2026 at 3:40 PM with ADON, she stated that it was the nursing staff responsibility to ensure that MD orders were added to the EMR. She was not aware that Resident #1 did not have an order for CPAP treatments. She stated failing to have an MD order could place the resident at risk of not receiving treatment. The facility did not provide policy for MD orders and respiratory therapies.

Based on observations, interviews, and record reviews, the facility failed to immediately report allegations that involved injuries of unknown source to HHSC for 1 of 4 residents (Resident #1) reviewed for reportable incidents of abuse and neglect.The facility failed to report an injury of unknown origin to HHSC when Resident #1's sustained a bruise of unknown origin to his right eye area on 02/05/2026.This failure could place residents at risk for abuse and neglect. Findings included:Record review of Resident #1's quarterly MDS dated [DATE] reflected he was an [AGE] year-old male admitted on [DATE]. The resident's diagnoses included: Alzheimer's disease (progressive mental deterioration that can occur in middle or old age that affects memory, thinking, and behavior); obstructive sleep apnea (a condition in which breathing stops involuntarily for brief periods of time during sleep), depression (mood disorder); and vertigo (a sensation that the environment is spinning in circles). Section C. cognitive patterns reflected a BIMS score of 02, indicating he was severely impaired cognitively. Section D. Mood indicated he had feelings of being down and depressed, or hopeless for 2 to 6 days. Section GG Functional Status indicated Resident #1 required partial to moderate assistance for lying to sitting on the bed, sit to stand, chair to bed transfer and toilet transfer, supervision and touching for walking, and he used a walker or manual wheelchair for mobility. The MDS reflected that the resident had no falls, but he had a history of falls and used a walker as an adaptive device for mobility. Record review of Resident #1's care plan dated 11/07/2025 reflected the following care areas: * Cognitively impaired and had impaired thought processes r/t diagnosis of Alzheimer's. *An elopement risk and at risk for falls.resident had an actual fall on 11/17/2025 no injury, delayed bruising with noted interventions for no apartment acute injury, determine and address causative factors of the fall. Monitor/document/report PRN X 72 hours to MD for s/sx : pain, bruises, change in mental status, new onset, confusion, sleepiness, abilities to maintain posture agitation.PT consult or strength and mobility, staff to increase monitoring for safety. *Black eye., resident had a fall on 11/12/2025 resulting in bruising to his right eye. Risk for falls, dependent on staff for meeting his needs. r/t cognitive deficits, communication problems r/t hearing.* Moderate risk for falls r/t confusion, gait, and balance problems . follow facility protocol for falls, ensure call light is within reach, educate and encourage residents to call for help. *Impaired visual function r/t impaired vision in right eye d/t macular degeneration (loss of central vision.), Glaucoma (eye disease leading permanent vision loss.), other peripheral vertigo (spinning caused by nerve dysfunction.)Record review of Resident #1's facility incident report dated 02/06/2026 at 5:00 AM by RN-T reflected 2026 a morning nurse called this nurse at the dining table where the resident was sitting and showed a light bruise to right eye, resident is alert and denies pain but said that he can feel it when nurse touching the affected area. BS stable and no signs of change of LOC noted. Assessed for other injury, none noted. Incontinent care provided. Monitored for any changes. RN supervisor, Administrator and POA care notified. POA said to notify her for any changes. Bruise measures 3 cm X 3.5 cm is very faint in color and kin is intact. Resident was unable to give a description. Immediate action take Assessed for injury.unable to give description. was incident witnessed: no.type of injury bruise. Level of pain 0.mental status confused.no injuries observed post incident. Predisposing physiological factors confused. Predisposing situation factors.ambulating without assist and wanderer. Statements were provided. (list in record review). ADON incident note dated 02/06/2026 IDG discussion related to bruise to right eye area. Patient is ambulatory with walker. Head to toe assessment completed. No other injuries noted. He denied pain. Interventions staff educated to monitor patient for safety to avoid skin tears. Facility does not suspect abuse, neglect and exploitation. DON incident note dated 02/09/2026 reflected resident noted to have no pain to eyebrow area, bruising noted to be to eye as a result of gravity and resolving.Record review of Resident #1 photo taken by RN-T and time stamped 02/06/2026 at 5:41 AM. The photo revealed Resident #1 lying on the left side of his face in the bed with his eyes closed. Purple bruising was observed on his upper eyelid and above the eyebrow. eyebrow X2 (purple). Red bruising was observed on crease of eyelid and underneath, lacrimal gland (upper outer part of eye), upper eye lid, meibomian gland (upper and lower eyelid).Record review of Resident #1's Nursing Progress Note dated 02/05/2026 at 6:08 AM written by RN-T reflected on 02/05/2026 a morning nurse called this nurse at the dining table where the resident was sitting and showed a light bruise to right eye, resident is alert and denies pain but said that he can feel it when nurse touching the affected area. BS stable and no signs of change of LOC noted. Assessed for other injury, none noted. Incontinent care provided. Monitored for any changes. RN supervisor, Administrator and POA care notified.Record review of Resident #1's Nursing Progress Note dated 02/06/2026 at 6:12 AM, written by LVN H Resident noted with R eye discoloration. Admin and [family] notified. No distress noted at this time.Record review of Resident #1's Nursing Progress Note dated 02/06/2026 at 7:41 AM written by DON reflected Area to right eye measures 3.0cm x 3.5, light bruise noted, denies pain, when asked what happened, he states that he rolled over and felt it burn, upon assessment, resident's bed side chest was right next to his bed and corner of chest approximates to bed, potentially causing bruising as area appears to have been a [NAME] bump, skin is intact with no open areas, bed pulled away from his bed-side dresser, no changes in condition noted as he remains at baseline, laughing at breakfast table and enjoying breakfast at this time.Record review of Resident #1's Nursing Progress Note dated 2/7/2026 6:28 PM by written LVN P reflected F/u R eye discoloration, healing, no pain or discomfort noted.Record review of Resident #1's Nursing Progress Note dated 02/07/2026 6:30 PM written by LVN-P reflected VSS, and neuros WNL. Record review of Resident #1's Nursing Progress Note dated 02/10/2026 8:20 AM written by DON reflected Resident sitting up in chair with no distress noted, denies pain to right eye, skin warm and intact with healing and resolving of bruising noted, delayed residual bruising from gravity noted to be moving to side of face and eye area, no changes in psychosocial behavior, resident continues to laugh and have great sense of humor noted.Record review of Resident #1's Nursing Progress Note dated 02/10/2026 9:17 AM by written LVN C reflected Discoloration to the right eye remains. [resident #1] continue to deny pain upon palpation or touch. We will continue to monitor.Record review of the facility staff statements dated 02/06/2026 provided by the Administrator via email on 02/11/2026 at 5:48 PM. revealed the following:* CNA-B written statement reflected the incident date 02/06/2026 and date of statement 2/6/2026 at 4:30 PM reflected I noticed R eye bruise this morning on rounds. CNA-B's statement provided no additional information describing the bruise or reporting the bruise. if the nurse was notified of the bruise.* LVN-P's written statement reflected the incident date 02/05/2026 and time of event 6:00 PM morning nurse pointed out possible bruising (discoloration) to [Resident 1's] right eyebrow during staff changes. Area looked pinkish purple this morning.* RN-T's written statement reflected the incident date 02/05/2026 and the time of event 6:00 PM I was called at the dining by morning nurse and showed resident right eye bruising and discoloration. The statement revealed no additional information.* CNA-J's written statement reflected the incident date 02/06/2026 and the time of the event 6:00 PM reflected I recognized that he had a brise on his right eye. CNA-J's statement had no additional information describing the bruise or reporting the bruise. if the nurse was notified of the bruise. During an observation and interview with Resident # 1 on 02/10/2026 at 1:10 PM he was observed with a bruising on the corner and undereye of his right eye with colors (purple, green, blue, and yellow.) Surveyor attempted to interview the resident regarding the injury; he was unable to communicate how he obtained the injury.During an interview on 02/10/2026 at 10:00 AM with the Administrator, she stated that she was notified by LVN-T on 02/06/2026 at 6:30 AM of the fall. She notified the DON, and the resident was assessed upon arrival that morning. Administrator stated that she did not report the incident to HHS because it did not meet criteria. During an interview on 02/11/2026 at 3:55 PM the Administrator stated the provider letter clearly stated that it had to meet all 3 criteria for reporting abuse and neglect to HHS. Administrator said the criteria included Injury of unknown origin, if injury was not witnesses, and if the patient cannot report the incident, and suspicious. During an interview on 02/10/2026 at 10:30 AM with the DON, she was involved in the investigation of Resident #1's fall. She stated he told her that he had fallen . She conducted an observation and incident report regarding the incident. DON stated that the resident was observed with a pink mark on his eye that was consistent with him falling and hitting the corner of the nightstand. The DON said her Investigation findings concluded Resident #1 had his CPAP mask on his face, and as he was falling, he hit his eye on the corner of the nightstand. He was assessed and treated. The Bruising progressed to the side and undereye with increased bruising. She notified the FM and MD. She stated the fall did not warrant an ER visit for treatment. He was monitored, supervised, and assessed by the staff 72 hours and there were not any neurological changes. She stated that all documentation and assessments were in the EMR. During an interview with LVN C on 02/10/2026 at 1:00 PM, she stated that she was on duty from 6:00 AM-6:00 PM 02/06/2026. She was notified by the oncoming nurse LVN T that she observed a bruise to Resident #1's right eye. LVN-C stated that both nurses learned of his injury at that time. She said resident's eye was observed lightly discolored and had transformed to purple with visible marks and bruises thereafter the incident. LVN-C does not know how the injury occurred. LVN-C denied resident falls and altercations during her shift. LVN-C said LVN-T did not report any injuries from the previous shift. LVN-C said the CNA reported no injuries, bruises, or skin issues during incontinent care. LVN-C did not observe injury to right eye during her care rounds, but stated the resident wore a baseball cap all the time and may have covered the injury. During an Interview on 02/11/2026 at 3:30 PM with RN-R, she stated that all staff were notified of the resident's injury to his right eye that has increased in discoloration to a black eye. LVN-R said due to Resident #1's impaired cognition, he would not report how he obtained the injury. She stated interventions included lowering his bed and monitoring for changes neurologically. During an Interview on 02/11/2026 at 3:40 PM with ADON, she stated that she was not notified of the injury by staff. ADON said the resident could not communicate how he obtained the injury to his eye. She stated that interventions were to lower his bed and continue monitoring residents for changes in neurological status and supervision. ADON expected the staff to supervise and monitor residents during their shift to prevent unknown injuries or falls from occurring. ADON expected the nursing staff to report all unwitnessed injuries immediately for leadership and MD notifications, further assessments, and investigations. She does not know how the resident obtained the injury.During an Interview on 02/11/2026 at 3:46 PM with the DON she stated interventions included moving the resident's nightstand away from the bed when the resident was in bed. The DON said that their quality improvement incident note provided information about the incident and staff statements. During an interview on 02/11/2026 at 4:05 PM with LVN T, she stated she observe Resident #1 with a light pink bruise near his eyebrow and undereye. She said that the bruise progressed in color during the day. She then reported the incident to the Administrator, completed the incident report, and sent a text message per the Administrator request of the resident's eye. (She provided surveyor with the photo.) LVN-T notified LVN-S of the injury at 6:00 PM on 02/06/2026. Resident denied pain until the nurse touched the area to investigate and assess. She stated it appeared that he had fallen. She believed the resident may have fallen out of bed overnight injuring his eye, and as the day progressed the injury worsened. Resident was unable to provide details of what occurred. Resident #1 the resident received CPAP treatment every night at bedtime.A phone interview was attempted on 02/17/2026 at 4:51 PM with CNA B, and a voicemail message was left requesting a return call. During a phone interview on 02/17/2026 at 4:53 PM with CNA-E, CNA E stated he was working the 10:00 PM to 6:00 AM shift. He was not working directly with Resident #1. CNA-E said he was assisting another aide (name unknown) with incontinent care, and they observed a mark on Resident #1's undereye. CNA-E said he was unable to identify the mark as a bruise, skin infection, skin tear, or injury. He did not observe a fall during his shift and stated the incident occurred prior to him starting his overnight shift. He stated the nurse RN-T was notified by the other aide (name unknown). He stated LVN-T reported the incident the next day to Administrator before leaving the 6:00 AM shift. CNA-E stated that the Administrator requested staff statements about the resident bruise. The DON provided in-service education to the staff on abuse and neglect procedures.The following information was requested on 02/10/2026 at 10:00 AM from the DON and Administrator to complete the investigation for Resident #1: EMR access, incident and accident reports, abuse and neglect policies, unknown injuries. Staff education and all supporting information and documentation completed by the facility. Record review of the facility's policy dated 10/2022 titled Abuse, reflected in part the following: it was the responsibility of all staff.Purpose to identify, prohibit, and prevent resident abuse. Injury of unknown origin: an injury should be classified as an injury of unknown origin when all of the following criteria are men. The source of the injury was not observed by any person: and the source of the injury could not be explained by the resident.The injury is suspicious because of the extent of the injury or the location of the injury (the injury is located in an area not generally vulnerable to trauma) or the number of injuries at one particular point in time or the incidence of injuries over time.Any allegation of abuse will be immediately reported to the facility Administrator. The facility will designate an Abuse Prevention coordinator who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency, law enforcement, and other officials in accordance with state law.

Based on interviews and reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 3 residents (Resident #1) reviewed for accuracy of assessments. The facility failed to ensure Resident #1's CPAP treatments were coded in his MDS dated [DATE]. This failure could result in Resident missing essential treatment treatments and interventions for care. Findings included: During an observation and interview with Resident # 1 on 02/10/2026 at 1:10 PM his CPAP mask was on his nightstand. Resident #1 was observed in the main resident area of memory care attending activities. Resident # was not interviewed about CPAP treatments and care tasks, due to severe cognitive impairment. Record review of Resident #1's face sheet dated 2/10/2026 reflected he was an [AGE] year-old male admitted on [DATE]. DX: Alzheimer's (severe cognitive decline.) Sleep Apnea (serious sleep disorder), Depression (mood disorder), Obstructive sleep apnea (serious sleep disorder causing changes in blood oxygen levels), and vertigo (motion of spinning). Record review of Resident #1's quarterly MDS dated [DATE] reflected he was an [AGE] year-old male admitted on [DATE]. The resident's diagnoses included: Alzheimer's disease (progressive mental deterioration that can occur in middle or old age that affects memory, thinking, and behavior); obstructive sleep apnea (a condition in which breathing stops involuntarily for brief periods of time during sleep), depression (mood disorder); and vertigo (a sensation that the environment is spinning in circles). Section C. cognitive patterns reflected a BIMS score of 02, indicating he was severely impaired cognitively. Section D. Mood indicated he had feelings of being down and depressed, or hopeless for 2 to 6 days. Section GG Functional Status indicated Resident #1 required partial to moderate assistance for lying to sitting on the bed, sit to stand, chair to bed transfer and toilet transfer, supervision and touching for walking, and he used a walker or manual wheelchair for mobility. The MDS reflected that the resident had no falls, but he had a history of falls and used a walker as an adaptive device for mobility. Section N addressed medications prescribed for anxiety, depression, pain, and fluid reduction. Section O Special treatments, procedures and programs did not indicate the resident treatments for Non-invasive Mechanical Ventilator, did not address Resident #1's use of CPAP machine. Record review of Resident #1's care plan dated 02/03/2026 reflected he was cognitively impaired and had impaired thought processes r/t diagnosis of Alzheimer's. Risk for falls, dependent on staff for meeting his needs. r/t cognitive deficits, communication problems r/t hearing. Record review of Resident #1's MD orders dated 08/07/2025 reflected 1. Wipe masks, nasal pillows, daily with damp cloth. 2 empty humidifier chambers, 3. Fill humidifier with warm soapy water, shake well. 4. Rinse and air dry. During an interview with the MDSC on 02/10/2026 at 2:00 PM, she stated that Section O Special Treatments, Procedures, and Programs would not be coded if the resident had not used the CPAP machine during the 7 days look back period. MDSC said failing to code the resident's treatment could place the resident at risk of missing treatments ordered by the physician. During an interview on 02/10/2026 at 5:00 PM with the FM, she stated that the resident was administered CPAP treatment daily at bedtime since admitting 08/07/2025.During an Interview on 02/11/2026 at 3:30 PM with RN-R, she stated that Resident #1 was administered CPAP at bedtime every night. During an Interview on 02/11/2026 at 3:46 PM with the DON said it was her expectation that the MDS staff address all the residents' care and treatment based on the MD orders of administration and documented. During an interview on 02/11/2026 at 3:55 PM the Administrator revealed it was her expectation for the staff to code resident treatments accurately on the assessments. She stated that she was not aware of the risk to the residents if the treatment was not coded. During an interview on 02/11/2026 at 4:05 PM with LVN T, she stated that the resident received CPAP treatment every night at bedtime.The surveyor requested policies for MDS assessments on 02/10/2026 at 10: 00 AM, 10:15 AM, 1:00 PM, and 4:00 PM from the DON and Administrator via email and verbally. The surveyor requested MDS policies from the DON and Administrator on 02/11/2026 at 1:00 PM, and again at 3:00 PM. The policy was not provided prior to exit.

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included describing the services to be furnished to attain or maintain measurable objectives to meet the resident's highest practicable physical, mental, and psychosocial well-being, for 1 of 6 residents (Resident #1) reviewed for care plans.Resident #1's, care plan dated 02/03/2026 did not address his CPAP treatment for obstructive sleep apnea. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. Findings included:Record review of Resident #1's quarterly MDS dated [DATE] reflected he was an [AGE] year-old male admitted on [DATE]. The resident's diagnoses included: Alzheimer's disease (progressive mental deterioration that can occur in middle or old age that affects memory, thinking, and behavior); obstructive sleep apnea (a condition in which breathing stops involuntarily for brief periods of time during sleep), depression (mood disorder); and vertigo (a sensation that the environment is spinning in circles). Section C. cognitive patterns reflected a BIMS score of 02, indicating he was severely impaired cognitively. Section D. Mood indicated he had feelings of being down and depressed, or hopeless for 2 to 6 days. Section GG Functional Status indicated Resident #1 required partial to moderate assistance for lying to sitting on the bed, sit to stand, chair to bed transfer and toilet transfer, supervision and touching for walking, and he used a walker or manual wheelchair for mobility. The MDS reflected that the resident had no falls, but he had a history of falls and used a walker as an adaptive device for mobility. Record review of Resident #1's care plan dated 02/03/2026 reflected he was cognitively impaired and had impaired thought processes r/t diagnosis of Alzheimer's. Care plan did not address Resident #1's CPAP treatments per MD orders 08/07/2025 and 02/10/2026.During an observation and interview with Resident # 1 on 02/10/2026 at 1:10 PM his CPAP was on his nightstand. Resident #1 was observed in the main resident area of memory care attending activities. Resident #1 was not interviewed about CPAP treatments and care tasks, due to severe cognitive impairment. Record review of Resident #1's MD orders dated 08/07/2025 reflected 1. Wipe masks, nasal pillows, daily with damp cloth. 2 empty humidifier chambers, 3. Fill humidifier with warm soapy water, shake well. 4. Rinse, and air dry. MD order dated 02/10/2026 at 3:35 PM MD J reflected an order Resident utilizes a CPAP at night with settings of 8.0cm for H2O CPAP at bedtime for sleep apnea- obstructive sleep apnea.During an interview with the MDSC on 02/10/.2026 at 2:00 PM, she stated that the MDS would guide the care goals and treatments for the residents' needs. She was unable to answer if Resident #1's care plan addressed his CPAP use at the time of the interview. MDSC said during her assessment she will review the TAR for current treatments during the 7-day look back period and code the MDS. MDSC said if the resident's CPAP was left off the TAR, she would not have addressed the treatment. During an interview with LVN S on 02/10/2026 at 1:00 PM, she stated that Resident #1 received CPAP treatments for obstructive sleep apnea at night. She reported that residents are provided with an order. She stated the care plan addressed resident care and treatment. During an Interview on 02/11/2026 at 3:30 PM with RN-R, she stated that Resident #1 received CPAP treatments for obstructive sleep apnea. LVN-R reviewed the resident orders and care plan during the interview with the surveyor. LVN-R was not aware that Resident #1's CPAP treatments were not addressed in his care plan. LVN-R stated that the resident was at risk of missing care and treatment if it was not documented in the care plan. During an Interview on 02/11/2026 at 3:46 PM with the DON, she stated it was her expectation that the care plans addressed the residents' current treatments of CPAP. She stated it was ADON's responsibility to ensure that all care plans reflected resident care. She stated all the residents' care and treatment based on the MD orders of administration and documented. During an interview on 02/11/2026 at 3:55 PM the Administrator revealed she expected nursing staff to ensure care plans were consistent with residents' care and treatments provided. She stated that she was not aware of the risk to the residents. During an interview on 02/11/2026 at 4:05 PM with LVN T, she stated that Resident #1 received CPAP treatments every night at bedtime for obstructive sleep apnea. She was not aware that the CPAP treatments were not addressed in the care plan. She said the risk to the resident's care plan being inaccurate could result in the resident missing treatment, illness, and other health concerns. Record review of facility policy titled Clinical Services: Care Plans and Case Management dated November 2017 reflected Purpose: to develop an interdisciplinary resident centered comprehensive care plan to meet the individual needs of each resident.An interdisciplinary team develops and maintains a comprehensive care plan for each resident.Designed to identify care needs that include history, risk factors, measurable goals and outcomes, and approaches to meet resident goals.the comprehensive care plan is developed 7 days after the completion of the MDS assessment.care plans are revised as changes are indicated.review of the care plan is made with each comprehensive and quarterly assessment

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to remove previously applied Rivastigmine Patches for Resident #1 as ordered by the physician.This failure could place residents at risk for medication duplication, adverse drug reactions, and potential side effects. Findings included:Record review of Resident #1's Face Sheet, dated 02/05/26, reflected the resident was an [AGE] year-old male admitted on [DATE]. Record review of Resident #1's Quarterly MDS Assessment, dated 01/23/26, reflected the resident had diagnoses of Alzheimer's Disease (progressive brain disorder that causes memory loss and confusion), PTSD (mental health condition caused by experiencing or witnessing a traumatic event), and Gastro-esophageal reflux disease (condition where stomach acid flows back into esophagus). The MDS also reflected a BIMS score of 5, indicating severe cognitive impairment. Record review of Resident #1's Care Plan, undated, reflected the resident was at risk for adverse side effects related to medications with a goal that Resident #1 would be free of side effects related to psychoactive medications. The care plan also reflected Resident #1 had an ADL self-care performance deficit related to Alzheimer's and disease related medications. Further record review reflected Resident #1 had impaired cognitive function or impaired thought processes related to Alzheimer's with an intervention to administer medications as ordered and monitor for/document side effects and effectiveness. Record review of Resident #1's Physician Orders, dated 02/05/26, reflected the following order, Exelon Transdermal Patch 24 hour 9.5MG/24HR (Rivastigmine) Apply 1 patch transdermally [on the skin] one time a day. and remove per schedule. Record review of Resident #1's MAR, dated 02/2026, reflected the Rivastigmine patch (Medication used to help improve memory and thinking in people with dementia) was to be removed daily at 8:59 a.m. and applied daily at 9:00 a.m Record review of Resident #1's MAR further reflected on 02/04/26 the patch was removed at 8:13 a.m. from the right scapula and a new patch was applied at 8:13 a.m. to the left scapula by MA B. This MAR reflected no Rivastigmine patch applications documented to Resident #1's left arm. During an observation on 02/05/26 at 9:29 a.m. LVN A applied Resident #1's Rivastigmine 9.5 mg patch. LVN A performed hand hygiene prior to entering room, applied clean gloves and assisted Resident #1 with removing his jacket. LVN A performed a skin assessment, and a Rivastigmine patch was located on the back of Resident #1's upper left arm. Observation revealed the date on the patch appeared smeared and was illegible. LVN A then located a second Rivastigmine patch on Resident #1's left scapula dated 2/4. LVN A removed both patches and applied a new Rivastigmine patch to Resident #1's right upper arm. LVN A removed gloves and performed hand hygiene prior to exiting the room. During an observation and an attempted interview on 02/05/26 at 9:40 a.m., Resident #1 was in the common area in his wheelchair. Resident #1 was a poor historian and unable to answer questions. The resident did not appear to be in any distress.During an interview on 02/05/26 at 10:07 a.m. LVN A confirmed she found two Rivastigmine patches on Resident #1 at the same time. She stated one patch was located on the back of his shoulder and the other on his upper arm. She stated the patch on the Resident #1's left shoulder was dated 02/04/26, while the date on the patch on his arm was illegible. LVN A stated there was not supposed to be two patches on Resident #1 at the same time and there was an order to remove the old patch prior to applying the new one. LVN A also stated the staff documented where the old patch was removed and where the new patch was placed. LVN A stated she did not routinely administer medications and was unsure why two patches were present or how long the medication was there. She stated she did not apply the patch on 02/04/26 and stated she routinely removed the resident's shirt to ensure any old patch was removed. LVN A stated the risk of not removing old patches could have resulted in excessive medication. During an interview on 02/05/26 at 12:55 p.m., MA B revealed she applied the Rivastigmine patch to Resident #1 on 02/04/26. MA B stated she removed the patch dated 02/03/26, which was located on the resident's right scapula (shoulder blade). MA B stated she recalled applying the new patch to Resident #1's left scapula. MA B stated she did not recall seeing a Rivastigmine patch on his left arm but stated she could have missed it. MA B stated she was unsure how long the Rivastigmine patch was in place. MA B stated the risk of a resident having two patches on at the same time was overmedication. During an interview on 02/05/26 at 4:59 p.m., the ADON revealed she expected staff to remove any old medication patches prior to applying a new patch. The ADON stated all medications were to be administered according to physician orders and pharmacy instructions. She stated with the Rivastigmine patch, there was only supposed to be one patch applied at a time, unless otherwise specified by the orders. The ADON stated the computer orders had a schedule, and staff were expected to document removal time, application time, and patch location with each administration, and she expected staff to follow that system. The ADON stated the facility was going to begin implementing a paper log for all patches to assist staff in tracking patch removal and application. She stated in-services were initiated (02/05/26) on medication patches. The ADON stated the risk of not removing the old patch from a resident was that residents could receive more medication than ordered, but she was unsure of the specific side effects associated with Rivastigmine. During an interview on 02/05/26 at 5:17 p.m., the Medical Director revealed he always expected staff to remove old medication patches prior to applying a new patch. He stated the staff should have known to remove the old patches, unless the order specified two patches. He stated potential side effects of not removing old Rivastigmine patches included headache, upset stomach, and in rare cases, bradycardia (low heart rate), or seizures. During an interview on 02/05/26 at 5:39 p.m., the Interim DON stated she expected staff to check to make sure the old patch was removed prior to applying a new patch. The Interim DON stated there was removal and applying orders in the computer system that she expected staff to follow and document. The Interim DON stated the risk of not removing old patches could cause potential side effects, but was unable to specify the side effects. Record review of the facility's policy titled, Medication Administration, dated revised 07/01/25, reflected the following: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 10. Ensure that the six rights of medication administration are following a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation 11. Review MAR to identify medication to be administered.16. Administer medication as ordered in accordance with manufacturer specifications.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Resident #2) reviewed for supervision. The facility failed to provide adequate supervision to prevent a physical altercation when Resident #1, who was sitting at the dining room table eating and talking with LVN A, got up from the table. LVN A asked him where he was going and to have a seat, Resident #1 stated, I will be right back with you. He then walked up to Resident #2 and punched him in the face causing Resident #2 to fall against the wall and then to the ground, which resulted in Resident #2 sustaining facial bleeding and a fractured hip on 11/27/25. The noncompliance was identified as a past non-compliance. The Immediate Jeopardy (IJ) began on 11/27/25 and ended on 12/02/25 the facility had corrected the noncompliance before the investigation began. This failure placed residents at risk of harm and/or severe injury. Findings included:Record review of Resident #1's most recent Quarterly MDS Assessment, dated 09/25/25, reflected an [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had BIMS of 06 indicating moderate cognitive impairment. Diagnoses included Alzheimer's Disease (neurodegenerative disorder that leads to the gradual decline of cognitive functions), Non-Alzheimer's Dementia (various types of dementia). Resident #1's MDS indicated he had signs of verbal behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing) along with other behavioral symptoms not directed towards others (threatening others, screaming at others, cursing at others). Record review of Resident #1's undated care plan revealed [Resident #1] had Impaired thought processes related to Alzheimer's, Dementia. Goal: He will be able to answer simple questions with a yes/no response. Interventions included Approach calmly and warmly, Ask simple questions that require a yes or no answer, Call resident by name, Do not rush resident, explain all procedures to resident, Introduce yourself when approaching resident, Meds as ordered, Provide choices when possible, Provide consistent routine of care as much as possible. The Care Plan revealed: [Resident #1] was at risk for difficulty in psychosocial adjustment related to admission to facility. Veteran gets easily agitated. Goal: Resident #1 will not exhibit signs and symptoms of difficulties in psychosocial adjustment. Interventions included to encourage resident to read name tags if applicable. Introduce self upon each visit with resident. Introduce others who may have similar interests. Notify physician as needed. Observe for sign and symptoms of difficulties in psychosocial adjustment (decreased socialization, sad mood, verbalizes wants to go home). Orientate to facility. Provide 1:1 assistance with emotional adjustment. The Care plan revealed: [Resident #1] was at risk for exhibiting behavior problems- physical aggression towards peers/staff, agitated with staff/peers, hiding things due to fear of things being taken from him. Risk for self- isolating and paranoid behavior noted behavior refusing meds, agitation. Veteran had resident to resident incident 11/27/25, 11/28/25. Goal: he will accept reassurance and respond to interactions during periods of abnormal behaviors. Interventions included Approach resident warmly and positively at all times, Attempt to keep environment free of stress (loud noise, TV,) Consult with family as needed. Encourage family to limit the number of visitors who come to the facility at one time to decrease stimulation Interventions: redirect, reapproach, provide quiet environment, avoid crowds, noise cancelling headphones, play favorite music, talk to him about his daughters, use do you need to call family? Meds as ordered. [Resident #1] to be sent for eval and treatment at In-patient psychiatric unit if approaches unsuccessful and agitation/aggression continues. Notify MD as needed. Observe and document behavior as needed. Provide 1:1 sessions as needed. Provide for safety of resident during periods of combativeness. Provide quiet spaces when agitated as loud noise can be a trigger. Psych eval as needed. Triggers: echoes, sudden noises, loud noises, paranoia of personal space/items, others entering his space/room. The Care Plan revealed: [Resident #1] was at risk for psychosocial changes related to resident-to-resident incident. Goal: [Resident #1] he will have no psychosocial changes. Interventions included Medication as ordered. Notify physician as needed. Provide diversional activities if behaviors occur. Psychological consult as needed. The Care Plan revealed: [Resident #1] had a history of trauma that affects them negatively related to the military. Triggers include: echoes, sudden noises, loud noises, paranoia of personal space/items, others entering his space/room. He may display: suspicions, hiding items, fears things being taken away, verbal, and physical aggression, agitation, self-isolation, paranoia, refuse care or meds, collects/hides gait belts, makes false claims, throwing items, restlessness. Goal: Triggers that may cause re-traumatization will be minimized daily. Interventions included encourage relationships with family and friends that are supportive. Encourage resident to express feelings, concerns, thoughts in a safe space. Observe for signs and symptoms of depression, anxiety, sleep disturbances. Provide a quiet, non-threatening environment with decreased stimulation as needed. Triggers: echoes, sudden noises, loud noises, paranoia of personal space/items, others entering his space/room, redirect, reapproach, provide quiet environment, avoid crowds, noise cancelling headphones, play favorite music, talk to him about his daughters, use do we need to/can we call family? The Care Plan revealed: [Resident #1] has potential to be physically aggressive behavior r/t Poor impulse control. Goal: [Resident #1] will demonstrate effective coping skills through the review date. Interventions included [Resident #1] triggers for physical aggression. Staff to Monitor signs of aggression like Picking teeth with toothpick. Administer medications as ordered. Monitor/document for side effects and effectiveness. COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Record review of Resident #1's progress notes written by LVN A on 11/27/25 at 10:08 AM revealed [Resident #1] was the aggressor. He was sitting having breakfast and he suddenly got up from the table. I asked him to come back and take meds. He said, I will be back to you in a minute. He walked over to [Resident #2] punch him in the face and he hit the floor and hurt his left hip and leg. We spoke with outside provider; she saw him last week but will re-evaluate and inform us if any changes and will notify the family about the worsening behaviors. Family Member came in the mist of the issue and notified Resident Representative by phone. [Resident #1] is out of the building at this time due to Thanksgiving but will return this evening. Record review of Resident #1's progress note written by Social Worker B on 11/27/25 at 10:23 AM revealed Social Worker observed incident from nurses station that occurred this morning with resident to resident. Social Worker went to observe that matter and nursing staff redirected resident to this room and Social Worker assisted as needed to help redirect resident to room. Social Worker met with resident in room to check status and continue to diffuse his emotional state that caused him to hit another resident, as he was placed 1:1. Resident voiced it was the laughing he heard that made him hit the other resident. Social Worker educated and diffused resident on safety and resident was essentially receptive. Social Worker met with resident's Family Member who came to pick up Resident to go out on pass for Thanksgiving today. Social Worker informed the Family Member as to what occurred today and then the Family Member requested the Social Worker speak with another Family Member; Social Worker informed her what occurred as well. Family Members voiced understanding as to what happened today and will return resident today after Thanksgiving celebration. Care team update and Administrator updated. Record review of Resident #1 progress note written by Social Worker B on 11/27/25 at 10:41 AM revealed ADON contacted outside provider 24/7 on-call number and was able to speak with Nurse Practitioner regarding resident incident. ADON and Nurse Practitioner discussed medications that need reviewed, and Nurse Practitioner will adjust resident's medication and call the resident's family members regarding behaviors today. Care team updated. Record review of Resident #1 progress note written by LVN A on 11/27/25 at 6:24 PM revealed [Resident #1] was out with family all shift Record review of Resident #1 progress note written by RN C on 11/27/25 at 8:00 PM revealed [Resident #1] is 1:1 while sitting in the day room watching tv with. is pleasant and shows no sign of aggression. No Concerns at this time. Record review of Resident #1 progress note written by RN C on 11/27/25 at 9:00 PM revealed [Resident #1] is in room sleeping, with call light in reach, No Concerns at this time. Record review of Resident #1 progress note written by RN C on 11/27/25 at 10:00 PM revealed [Resident #1] sleeping on bed in room with door closed, call light in reach. No concerns at this time. Record review of Resident #1 progress note written by RN C on 11/27/25 at 11:00 PM revealed [Resident #1] sleeping on bed in room with door closed. Call light within reach. No concerns at this time. Record review of Resident #1 progress note written by LVN D on 11/27/25 at 12:37 AM revealed [Resident #1] back from pass with Family. Took meds and stayed in room until 10:30 PM and came out jumped on another Resident verbally in common area. Separated residents. [Resident #1] went back to room and went to bed. Record review of Resident 2#'s most recent Quarterly MDS Assessment, dated 11/17/25, reflected an [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had BIMS of 05 indicating moderate cognitive impairment. Diagnoses included Alzheimer's Disease (neurodegenerative disorder that leads to the gradual decline of cognitive functions), Non-Alzheimer's Dementia (various types of dementia). Resident #2's MDS indicated he had no signs of behavioral symptoms. Record review of Resident #1's undated care plan revealed [Resident #2] had had impaired skin integrity related to 11/27/25- Laceration to right side chin area. Goal: Resident will remain free from skin impairments related to pressure. Interventions include Braden scale risk assessment quarterly and as needed. Encourage adequate hydration and nutrition. Notify responsible party and discuss skin status as needed. Treatment as ordered. The Care plan revealed: Resident #2 has had an actual fall with (minor injury) Poor Balance, Unsteady gait. 11/27/25-fall with injury. Goal: He will resume usual activities without further incident. Interventions included: Staff to monitor more frequently. Check range of motion times daily. Continue interventions on the at-risk plan. Resident #2 sent to ER for eval and treat, pain meds administered. Provide activities that promote exercise and strength building where possible. Provide 1:1 activities if bedbound. Staff to keep Resident #2 in line of site, monitor as needed. Record review of Resident #2's progress note written by RN E on 11/27/25 at 9:02 AM revealed Outcomes of Physical Assessment: Functional Status: Fall. Nursing observations, evaluation and recommendations are: Patient status post fall, Patient noted with cut to the right-side facial area. Pain to the left hip and left rib cage. Patient sent out to the hospital for further evaluation to the left hip. Primary Care Provider Feedback patient sent out to hospital for further evaluation. Record review of Resident #2's progress note written by RN E on 11/27/25 at 9:31 AM revealed [Resident #2] was medicated for pain prior to hospital transfer. Power of Attorney, MD, DON, and Administrator notified of incident. Record review of Resident #2's progress note written by Social Worker B 11/27/25 at 10:24 AM revealed Social Worker met with resident to check status as nursing staff and Director of Rehabilitation was with resident to monitor until Emergency Medical Services to arrive to go to hospital for assessment. Social Worker inquired with resident on his psychosocial well-being after incident to check if he felt safe and comfortable and resident voiced he was okay and was hurting on left side of body as care team was assessing him and assisting him with care. Social Worker contacted resident's Family Member and left voicemail to return call. Social Worker did receive a call back from resident's Family Member and Social Worker informed them of the matter that occurred and that Emergency Medical Services was currently there to pick up resident to take to hospital and they voiced understanding of the matter. Care team updated. Record review of Resident #2's progress note written by LVN A on 11/27/25 at 10:37 AM revealed [Resident #2] was walking through the common area. [Resident #1] got up from eating breakfast and went over to him and punched him in the face. [Resident #2] fell to the ground in shock. [Resident #1] stood over him and told him to say it again. CNA ran over remove [Resident #1] from the area and took him to his room. First aide was rendered immediately. Laceration was cleaned and covered. When Evaluated by Physical Therapy he could not bear weight on the left side and stated, Man, I am hurt. What happened? [Resident #2] remained seated until Emergency Medical Services arrived to transport him to the hospital. Record review of Resident #2's progress note written by LVN A on 11/27/25 at 1:52 PM revealed [LVN A] called hospital to check on [Resident #2]. emergency room Nurse, informed [Resident #2] will be admitted to the surgical floor. RN Supervisor notified. Record review of Resident #2's progress note written by LVN A on 11/27/25 at 6:24 PM revealed Hospital Admit. Record review of Resident #2's hospital record dated 12/01/25 11:16 AM revealed Chief Complaint: Fall. History of present illness: [Resident #2] is an [AGE] year-old male with history of dementia, Alzheimer's disease, alcoholic cirrhosis (advanced form of liver disease related to drinking alcohol), hypertension (high blood pressure), and prostate cancer (cancer that start in the prostate) who presented after an unwitnessed fall at his memory care facility, resulting in left hip pain and inability to ambulate. On arrival, he was noted to have left leg pain, external rotation and shortening of the left lower extremity, and an abrasion to the face, but no evidence of head trauma or loss of consciousness was reported. Imaging, including left femur (thigh bone, longest and strongest bone in the human body) and hip radiographs, confirmed an acute comminuted, displaced transcervical left femoral neck fracture (a type of hip fracture where the bone connecting the ball of the hip joint to the thigh bone breaks), additional trauma imaging showed no acute intracranial (bony part of the skull that holds the brain) or spinal injury, and no acute facial fractures. Record review of the provider investigator report revealed on 11/17/25 at 7:45 AM Resident #1 was eating breakfast talking to staff when he got up from the table, a few feet away and hit Resident #2 on the right side of his face. Resident #2 lost his balance and fell backwards into wall/window seal and then to the ground. Resident #2 had laceration below his right eye, facility cleansed area. Initially denied pain, was able to move extremities. Physical Therapy and Nursing lifted Resident #2 to a chair to finish the assessment, and he then complained of pain, stating something was wrong. Emergency Medical Services was called immediately. The provider response revealed: Residents were separated and assessed. The facility initiated protocol to include: Resident #1 being placed on 1:1 until family arrived to take Resident #1 out on pass for Thanksgiving - Resident #1 remained on 1:1 until the facility sent out to the hospital for evaluation and treatment; and proper notifications completed to family, physician, DON, Administrator, and Regional Support Team. Resident #2 complained of pain to his left side. The facility sent him out via Emergency Medical Services. The facility continued protocol to include: quality of life rounds, in-servicing, staff interviews, as needed Trauma Assessment, Social Service follow-up for psychosocial assessment, and updated the plan of care. The investigation revealed: the Administrator received a phone call at 7:45 AM from the Director of Nursing notifying the Administrator of the incident. It was reported that the nurse was getting ready to give medication and Resident #1 went over and hit Resident #2 in the face, he lost balance and fell into the wall and then to the ground. Resident #2 was assessed and noted to have a laceration to the right side of the face. Nursing cleaned the laceration. Initial assessment of Resident #2 revealed he was able to move his leg. Resident #2 was lifted by staff and placed in a chair. At that time Resident #2 stated something was wrong. The Rehabilitation Director and Nursing assessed his leg and Resident #2 was noted to have pain in his left leg and unable to move. Emergency Medical Services was contacted, and Resident #2 was sent to local hospital for evaluation and treatment. Resident #1 was placed on 1:1 and required redirection multiple times. The Social Worker met with Resident #1 and when asked what happened he mentioned he was hearing laughing and thought it was Resident #2 and was hyper focused on the laughing. Family arrived shortly after the incident and wanted to take Resident #1 out on pass for Thanksgiving. The facility decided to allow Resident #1 go and upon return would be placed 1:1 and then work on an in-patient hospital stay for further evaluation and treatment. The facility did contact psych services to review incident and provider to complete a medication review. Resident #1 had a BIMS of 6, resided in a Memory Care Unit due to poor safety awareness and exit seeking tendencies. He was actively seen by both psychiatry and psychology services. Triggers identified were loud noises, people going into room, and being in his space. Resident #1 currently admitted to hospital for mood stabilization.The facility conducted care plan meeting to discuss re-admission and Resident #1 to be placed on 1:1 to see how new medications were working but facility would like to look at potential alternate placements, with family in agreement. The Administrator completed quality of life rounds, incident review, facility rounds, and staff interviews. No additional concerns identified at this time. In-services were initiated on Behavior in Dementia with de-escalation and dementia. The facility updated Ad Hoc (when necessary or needed) QAPI meeting to include: additional education for memory care unit, updating admission criteria for unit along with admission process, and evaluation of unit staff for compatibility with incident tracking and trending. Investigation Findings revealed: Unsubstantiated willful intent to harm due to Alzheimer's Diagnosis. Resident #1 was placed on 1:1 monitoring starting immediately after the incident on 11/27/25 until he exited the building with family. Resident #1 returned to the facility on [DATE] with continued 1:1 monitoring until he was sent to the hospital for further evaluation. Observation on 12/10/25 at 10:20 AM of Resident #1 in the Memory Care Unit sitting with a staff member putting together a puzzle and listening to music. Resident #1 appeared to enjoy putting the puzzle together, interacting with staff and was without distress. Interview on 12/10/25 at 11:15 AM with CNA F revealed during the time of the incident she was passing breakfast trays when Resident #1 was sitting in a chair in the dining room. CNA F stated she saw Resident #1 smile at Resident #2 as he was walking towards him and said I got something for you so Resident #2 stopped at the table, and within five minutes there was a loud noise and Resident #2 was on the floor. CNA F stated she heard Resident #1 talking to Resident #2 but did not think anything of it because he would joke from time to time. CNA F reported that she was aware of Resident #1's behaviors, therefore when he was around other residents, she often kept an eye on him to de-escalate any potential incidents. CNA F stated Resident #1 was near LVN A and other staff members were in the dining room passing breakfast trays and felt like all residents were adequately supervised. CNA F stated she observed Resident #2 with blood coming from his face, and she and the Rehabilitation Director attempted to help Resident #2 off the floor however he indicated that he was in pain at his hip area. Resident #2 was immediately sent to the hospital and Resident #1 escorted to his room and placed 1:1. Observation on 12/10/25 at 12:45 PM of Resident #2 revealed Resident #1 in bed resting. Resident #2 had just finished lunch, no observations of pain or distress. Resident #2 did not respond to verbal communication at the time. Interview on 12/10/25 at 1:14 PM with the Administrator revealed both Resident #1 and Resident #2 resided in the Memory Care Unit. The Administrator stated she was notified immediately that Resident #1 was sitting at a table next to LVN A while she was talking with him and administering his medication. The Administrator stated she was told Resident #1 got up from the table and hit Resident #2. Resident #2 lost his balance by the window seal and fell. Residents were separated; Resident #1 was placed 1:1 and Resident #2 was sent out to the hospital for further evaluation due to complaints of pain. According to the Administrator she was aware of Resident #1's history of behaviors. The Administrator reported Resident #1 had been working with psych services and had not been physical towards other residents in a while. The Administrator stated while at the time of the incident #1 was not on 1:1 monitoring all staff were responsible for keeping an eye on Resident #1 for any outburst or triggers due to his history. The Administrator stated Resident #1 liked to be in his room alone most of the time, however he enjoyed listening to music and staff led activities. Interview on 12/10/25 at 1:55 PM with CNA G revealed during the incident she was in the kitchen when she heard a bump, and she stepped out and saw Resident #2 on the floor. CNA G stated Resident #1 was close to her, so she separated him by taking him to his room. According to CNA G during the morning hours she, Resident #2 and CNA F were looking at an old picture of Resident #2 and there was laughing during the conversation. CNA G said LVN A reported that Resident #1 hit Resident #2 because he thought Resident #2 was laughing at him. According to CNA G she was aware that Resident #1 had a history of triggers and behaviors. CNA G stated she engaged with Resident #1 a lot when he was out of his room, therefore she had never seen him get physical with other residents. CNA G stated she was responsible for monitoring all residents, CNA G stated residents reacted to triggering things that happened in the past so you have to redirect often while working on the memory care unit. Interview on 12/10/25 at 3:25 PM the Rehabilitation Director revealed he was in the Memory Care Unit at the nursing station speaking with Social Worker B when he heard a disturbance behind him. The Rehabilitation Director stated when he turned around, he saw Resident #2 on the floor and Resident #1 being redirected by staff. The Rehabilitation Director stated he advised to get Resident #2 off the floor due to him being in an awkward position on the wall. The Rehabilitation Director stated once Resident #2 was in the chair he voiced that something didn't feel right. The Rehabilitation Director stated he observed Resident #2 leaning to the right side. The Rehabilitation Director stated at that point emergency services was called. Interview on 12/10/25 at 4:07 PM with Social Worker B revealed she was at the nursing station when the staff were around Resident #1 and Resident #2 in the dining room. Social Worker B stated that she observed staff assisting residents and passing trays, she stated she did not see or hear anything prior to the incident, it was a very calm environment. Social Worker B stated after the incident she went to assist with redirecting Resident #1 in his room. Social Worker B stated while with Resident #1 in his room trying to calm him down, he expressed to her that he heard laughing which got him upset. According to Social Worker B, she did not usually work with Resident #1 but was aware of his behaviors. Interview on 12/10/25 at 4:37 PM with the DON revealed she was notified by the Rehabilitation Director that the team had witnessed Resident #1 punch Resident #2. The DON stated she was told that Resident #2 was approaching the table for medication when he was intercepted with a punch by Resident #1. Resident #2 went backwards and hit his hip on the window sill, then hit the floor. The DON stated upon assessment Resident #2 reported something was wrong with his leg therefore resident #2 was sent out to the hospital. The DON stated Resident #1 was immediately separated and remained 1:1 until family came to take him home for the holiday celebration. The DON stated upon Resident #1's return to the facility he remained 1:1 until he was sent out for evaluation on 11/28/25. The DON stated she was fairly new to the facility however was aware of Resident #1's behaviors. The DON stated at the time of the incident Resident #1 was not on 1:1 monitoring however, staff were aware to keep a close eye on him and to de-escalate any situations where he was involved. According to the DON all staff were responsible for observing residents on the Memory Care Unit, and not doing so placed residents at risk of injury and harm. The DON stated residents on the Memory care Unit had past trauma and were easily triggered, things could happen quickly, making it hard to tell when something was going to occur. The DON stated education was going with staff so they could be aware of resident's triggers and aggressions. Interview on 12/10/25 at 5:40 PM with the Administrator revealed she was aware of Resident #1's behaviors of having aggressions towards others, however there had not been any issues recently that required him to constantly be monitored 1:1. According to the Administrator all staff working on the memory care unit were responsible for all residents' safety, and not doing so placed residents at risk of injury and harm. The Administrator further stated since Resident #1's return to the facility; interventions had been put in place such as 1:1 monitoring, psychiatric evaluation, monitoring his behaviors, identifying his triggers, the [NAME] machine (interactive game table), participating in activities that he liked, coordinating services with family, music, and care plan meetings to identify alternate living arrangements . The Administrator stated there had not been any further incidents between Resident #1 and Resident #2, Resident #2 had been relocated to reside outside of the Memory Care Unit due to his inability to ambulate. The Administrator stated there had been inservices with staff that covered working with residents with diagnosis of dementia, abuse and neglect, along with inservices provided by the social services department educating staff of each resident's triggers and person centered needs, (Resident #1 was in the first group to train on his triggers and behaviors).The Administrator was notified on 12/10/25 at 5:45 PM that a Past Non-Compliance Immediate Jeopardy situation had been identified due to the above failures. The Administrator was provided with the Immediate Jeopardy template for her signature. Record review of facility policy titled Accidents and Incidents dated October 2012 revealed to respond - provide medical attention and investigate an accident or incident. Report Accidents/Incidents the charge nurse must be informed of accidents or incidents in order to provide medical attention. Assisting Accident/Incident Victims: render immediate assistance do not move until he/she has been examined for possible injuries. Medical Attention: Examine and notify the attending physician, and responsible party of the incident and investigate the accident or incident. Record review of facility policy titled Behavioral Health Services dated October 2022 revealed The facility will ensure residents receive necessary behavioral health care and services to assist him or her to reach and maintain the highest level of mental and psychosocial functioning. Behavioral health will encompass the resident's emotional and mental well-being which include, but not limited, the prevention and treatment of mental and substance us disorders, psychosocial adjustment difficulty, and trauma or post-traumatic stress disorders. The facility will utilize the comprehensive assessment process to identify and assess a resident's mental and psychosocial status, response to stressors, trauma triggers, and provide person centered care. The process include: obtain history from medical records, the family, and resident regarding mental, psychological, and emotional health as available, MDS and care area assessments, ongoing monitoring of mood and behavior, care plan development, and implementation. The care plan should have interventions that are person-centered, evidence-based, culturally competent, trauma-informed, and in accordance with professional standards of practice, provide meaningful activities to meet the needs of the resident. Attempt to maximize the resident's dignity, autonomy, privacy, socialization, independence, and safety. Facility staff will receive training during orientation and annually related to behavioral health services. The facility took the following actions to correct the non-compliance prior to the investigation:Record review of an in-service, dated 11/28/25 and 12/01/25, reflected 93 staff including nurses, CNAs, housekeepers, medication aides, activity assistant, activity director, Business Office Manager, medical records, dietary assistant manager, dietary aides and social workers were provided with training on Behavior Management and De-escalation, Abuse, Neglect and Exploitation. Record review of an in-service, dated 11/28/25 and 12/01/25, reflected 93 staff including nurses, CNAs, housekeepers, medication aides, activity assistant, activity director, Business Office Manager, medical records, dietary assistant manager, dietary aides, and social workers: Fundamentals of Dementia Care for Health Facility Personnel. Record review of an in-service, dated 12/02/25, reflected 21 staff that included nurses, nurse's aides, housekeeping, medication aides, activity assistant, dietary aides were in-serviced regarding: Communication book for Staff Documentation of Behaviors or Triggers of Residents and 5 Residents review of Triggers and Intervention. Record review of Resident #1's clinical records revealed Resident #1 was placed one-on-one supervision until he was sent to the hospital for further evaluation on 11/28/25. Record review of Resident #2's clinical records revealed Resident #2 was assessed and transported to the emergency room for further evaluation with findings of a fractured hip. Record review of the Resident observation Surveys conducted on 11/30/25 - 12/10/25 by staff over what signs and symptoms to look for when resident had a change in condition, how to respond when witnessed a resident-to-resident altercation, who do you report abuse/neglect allegations to. All with the understanding to immediately separate residents during resident-to-resident altercation and report to the nurse and the abuse coordinator which was the Administrator. Observation on 12/10/25 from 9:00 AM - 5:00 PM revealed Resident #1 on 1:1 monitoring, staff engaged with residents as they participated in activities, and staff mad

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one of six residents (Resident #2) reviewed for abuse.The facility failed to ensure Resident #2 had the right to be free from abuse on 11/27/25, while on the memory care unit, Resident #1 punched Resident #2 in the face causing him to fall against the wall and then to the ground resulting in facial bleeding and a fractured hip. The noncompliance was identified as a past non-compliance. The Immediate Jeopardy (IJ) began on 11/27/25 and ended on 12/02/25 the facility had corrected the noncompliance before the investigation began. This failure placed residents at risk of harm and/or severe injury. Findings included:Record review of Resident #1's most recent Quarterly MDS Assessment, dated 09/25/25, reflected an [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had BIMS of 06 indicating moderate cognitive impairment. Diagnoses included Alzheimer's Disease (neurodegenerative disorder that leads to the gradual decline of cognitive functions), Non-Alzheimer's Dementia (various types of dementia). Resident #1's MDS indicated he had signs of verbal behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing) along with other behavioral symptoms not directed towards others (threatening others, screaming at others, cursing at others). Record review of Resident #1's undated care plan revealed [Resident #1] had Impaired thought processes related to Alzheimer's, Dementia. Goal: He will be able to answer simple questions with a yes/no response. Interventions included Approach calmly and warmly, Ask simple questions that require a yes or no answer, Call resident by name, Do not rush resident, explain all procedures to resident, introduce yourself when approaching resident, Meds as ordered, Provide choices when possible, Provide consistent routine of care as much as possible.The Care plan revealed: [Resident #1] was at risk for difficulty in psychosocial adjustment related to admission to facility. Veteran gets easily agitated. Goal: Resident #1 will not exhibit signs and symptoms of difficulties in psychosocial adjustment. Interventions included to encourage resident to read name tags if applicable. Introduce self upon each visit with resident. Introduce others who may have similar interests. Notify physician as needed. Observe for sign and symptoms of difficulties in psychosocial adjustment (decreased socialization, sad mood, verbalizes wants to go home). Orientate to facility. Provide 1:1 assistance with emotional adjustment.The Care plan revealed: [Resident #1] was at risk for exhibiting behavior problems- physical aggression towards peers/staff, agitated with staff/peers, hiding things due to fear of things being taken from him. Risk for self- isolating and paranoid behavior noted behavior refusing meds, agitation. Veteran had resident to resident incident 11/27/25, 11/28/25. Goal: he will accept reassurance and respond to interactions during periods of abnormal behaviors. Interventions included Approach resident warmly and positively at all times, Attempt to keep environment free of stress (loud noise, TV,) Consult with family as needed. Encourage family to limit the number of visitors who come to the facility at one time to decrease stimulation Interventions: redirect, reapproach, provide quiet environment, avoid crowds, noise cancelling headphones, play favorite music, talk to him about his daughters, use do you need to call family? Meds as ordered. [Resident #1] to be sent for eval and treatment at In-patient psychiatric unit if approaches unsuccessful and agitation/aggression continues. Notify MD as needed. Observe and document behavior as needed. Provide 1:1 sessions as needed. Provide for safety of resident during periods of combativeness. Provide quiet spaces when agitated as loud noise can be a trigger. Psych eval as needed. Triggers: echoes, sudden noises, loud noises, paranoia of personal space/items, others entering his space/room.The Care Plan revealed: [Resident #1] was at risk for psychosocial changes related to resident-to-resident incident. Goal: [Resident #1] he will have no psychosocial changes. Interventions included Medication as ordered. Notify physician as needed. Provide diversional activities if behaviors occur. Psychological consult as needed.The Care Plan revealed: [Resident #1] had a history of trauma that affects them negatively related to the military. Triggers include: echoes, sudden noises, loud noises, paranoia of personal space/items, others entering his space/room. He may display: suspicions, hiding items, fears things being taken away, verbal, and physical aggression, agitation, self-isolation, paranoia, refuse care or meds, collects/hides gait belts, makes false claims, throwing items, restlessness. Goal: Triggers that may cause re-traumatization will be minimized daily. Interventions included encourage relationships with family and friends that are supportive. Encourage resident to express feelings, concerns, thoughts in a safe space. Observe for signs and symptoms of depression, anxiety, sleep disturbances. Provide a quiet, non-threatening environment with decreased stimulation as needed. Triggers: echoes, sudden noises, loud noises, paranoia of personal space/items, others entering his space/room, redirect, reapproach, provide quiet environment, avoid crowds, noise cancelling headphones, play favorite music, talk to him about his daughters, use do we need to/can we call family?The Care Plan revealed: [Resident #1] has potential to be physically aggressive behavior r/t Poor impulse control. Goal: [Resident #1] will demonstrate effective coping skills through the review date. Interventions included [Resident #1] triggers for physical aggression. Staff to Monitor signs of aggression like Picking teeth with toothpick. Administer medications as ordered. Monitor/document for side effects and effectiveness. COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated.Record review of Resident #1's progress notes written by LVN A on 11/27/25 at 10:08 AM revealed [Resident #1] was the aggressor. He was sitting having breakfast and he suddenly got up from the table. I asked him to come back and take meds. He said, I will be back to you in a minute. He walked over to [Resident #2] punch him in the face and he hit the floor and hurt his left hip and leg. We spoke with outside provider; she saw him last week but will re-evaluate and inform us if any changes and will notify the family about the worsening behaviors. Family Member came in the mist of the issue and notified Resident Representative by phone. [Resident #1] is out of the building at this time due to Thanksgiving but will return this evening.Record review of Resident #1's progress note written by Social Worker B on 11/27/25 at 10:23 AM revealed Social Worker observed incident from nurses station that occurred this morning with resident to resident. Social Worker went to observe that matter and nursing staff redirected resident to this room and Social Worker assisted as needed to help redirect resident to room. Social Worker met with resident in room to check status and continue to diffuse his emotional state that caused him to hit another resident, as he was placed 1:1. Resident voiced it was the laughing he heard that made him hit the other resident. Social Worker educated and diffused resident on safety and resident was essentially receptive. Social Worker met with resident's Family Member who came to pick up Resident to go out on pass for Thanksgiving today. Social Worker informed the Family Member as to what occurred today and then the Family Member requested the Social Worker speak with another Family Member; Social Worker informed her what occurred as well. Family Members voiced understanding as to what happened today and will return resident today after Thanksgiving celebration. Care team update and Administrator updated. Record review of Resident #1 progress note written by Social Worker B on 11/27/25 at 10:41 AM revealed ADON contacted outside provider 24/7 on-call number and was able to speak with Nurse Practitioner regarding resident incident. ADON and Nurse Practitioner discussed medications that need reviewed, and Nurse Practitioner will adjust resident's medication and call the resident's family members regarding behaviors today. Care team updated.Record review of Resident #1 progress note written by LVN A on 11/27/25 at 6:24 PM revealed [Resident #1] was out with family all shiftRecord review of Resident #1 progress note written by RN C on 11/27/25 at 8:00 PM revealed [Resident #1] is 1:1 while sitting in the day room watching tv with. is pleasant and shows no sign of aggression. No Concerns at this time.Record review of Resident #1 progress note written by RN C on 11/27/25 at 9:00 PM revealed [Resident #1] is in room sleeping, with call light in reach, No Concerns at this time.Record review of Resident #1 progress note written by RN C on 11/27/25 at 10:00 PM revealed [Resident #1] sleeping on bed in room with door closed, call light in reach. No concerns at this time.Record review of Resident #1 progress note written by RN C on 11/27/25 at 11:00 PM revealed [Resident #1] sleeping on bed in room with door closed. Call light within reach. No concerns at this time.Record review of Resident #1 progress note written by LVN D on 11/27/25 at 12:37 AM revealed [Resident #1] back from pass with Family. Took meds and stayed in room until 10:30 PM and came out jumped on another Resident verbally in common area. Separated residents. [Resident #1] went back to room and went to bed. Record review of Resident 2#'s most recent Quarterly MDS (Minimum Data Set) Assessment, dated 11/17/25, reflected an [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had BIMS of 05 indicating moderate cognitive impairment. Diagnoses included Alzheimer's Disease (neurodegenerative disorder that leads to the gradual decline of cognitive functions), Non-Alzheimer's Dementia (various types of dementia). Resident #2's MDS indicated he had no signs of behavioral symptoms. Record review of Resident #1's undated care plan revealed [Resident #2] had had impaired skin integrity related to 11/27/25- Laceration to right side chin area. Goal: Resident will remain free from skin impairments related to pressure. Interventions include Braden scale risk assessment quarterly and as needed. Encourage adequate hydration and nutrition. Notify responsible party and discuss skin status as needed. Treatment as ordered.The Care plan revealed: Resident #2 has had an actual fall with (minor injury) Poor Balance, Unsteady gait. 11/27/25-fall with injury. Goal: He will resume usual activities without further incident. Interventions included: Staff to monitor more frequently. Check range of motion times daily. Continue interventions on the at-risk plan. Resident #2 sent to ER for eval and treat, pain meds administered. Provide activities that promote exercise and strength building where possible. Provide 1:1 activities if bedbound. Staff to keep Resident #2 in line of site, monitor as needed.Record review of Resident #2's progress note written by RN E on 11/27/25 at 9:02 AM revealed Outcomes of Physical Assessment: Functional Status: Fall. Nursing observations, evaluation and recommendations are: Patient status post fall, Patient noted with cut to the right-side facial area. Pain to the left hip and left rib cage. Patient sent out to the hospital for further evaluation to the left hip. Primary Care Provider Feedback patient sent out to hospital for further evaluation. Record review of Resident #2's progress note written by RN E on 11/27/25 at 9:31 AM revealed [Resident #2] was medicated for pain prior to hospital transfer. Power of Attorney, MD, DON, and Administrator notified of incident.Record review of Resident #2's progress note written by Social Worker B 11/27/25 at 10:24 AM revealed Social Worker met with resident to check status as nursing staff and Director of Rehabilitation was with resident to monitor until Emergency Medical Services to arrive to go to hospital for assessment. Social Worker inquired with resident on his psychosocial well-being after incident to check if he felt safe and comfortable and resident voiced he was okay and was hurting on left side of body as care team was assessing him and assisting him with care. Social Worker contacted resident's Family Member and left voicemail to return call. Social Worker did receive a call back from resident's Family Member and Social Worker informed them of the matter that occurred and that Emergency Medical Services was currently there to pick up resident to take to hospital and they voiced understanding of the matter. Care team updated.Record review of Resident #2's progress note written by LVN A on 11/27/25 at 10:37 AM revealed [Resident #2] was walking through the common area. [Resident #1] got up from eating breakfast and went over to him and punched him in the face. [Resident #2] fell to the ground in shock. [Resident #1] stood over him and told him to say it again. CNA ran over remove [Resident #1] from the area and took him to his room. First aide was rendered immediately. Laceration was cleaned and covered. When Evaluated by Physical Therapy he could not bear weight on the left side and stated, Man, I am hurt. What happened? [Resident #2] remained seated until Emergency Medical Services arrived to transport him to the hospital.Record review of Resident #2's progress note written by LVN A on 11/27/25 at 1:52 PM revealed [LVN A] called hospital to check on [Resident #2]. emergency room Nurse, informed [Resident #2] will be admitted to the surgical floor. RN Supervisor notified.Record review of Resident #2's progress note written by LVN A on 11/27/25 at 6:24 PM revealed Hospital Admit. Record review of Resident #2's hospital record dated 12/01/25 11:16 AM revealed Chief Complaint: Fall. History of present illness: [Resident #2] is an [AGE] year-old male with history of dementia, Alzheimer's disease, alcoholic cirrhosis (advanced form of liver disease related to drinking alcohol), hypertension (high blood pressure), and prostate cancer (cancer that start in the prostate) who presented after an unwitnessed fall at his memory care facility, resulting in left hip pain and inability to ambulate. On arrival, he was noted to have left leg pain, external rotation and shortening of the left lower extremity, and an abrasion to the face, but no evidence of head trauma or loss of consciousness was reported. Imaging, including left femur (thigh bone, longest and strongest bone in the human body) and hip radiographs, confirmed an acute comminuted, displaced transcervical left femoral neck fracture (a type of hip fracture where the bone connecting the ball of the hip joint to the thigh bone breaks), additional trauma imaging showed no acute intracranial (bony part of the skull that holds the brain) or spinal injury, and no acute facial fractures. Record review of the provider investigator report revealed on 11/17/25 at 7:45 AM Resident #1 was eating breakfast talking to staff when he got up from the table, a few feet away and hit Resident #2 on the right side of his face. Resident #2 lost his balance and fell backwards into wall/window seal and then to the ground. Resident #2 had laceration below his right eye, facility cleansed area. Initially denied pain, was able to move extremities. Physical Therapy and Nursing lifted Resident #2 to a chair to finish the assessment, and he then complained of pain, stating something was wrong. Emergency Medical Services was called immediately. The provider response revealed: Residents were separated and assessed. The facility initiated protocol to include: Resident #1 being placed on 1:1 until family arrived to take Resident #1 out on pass for Thanksgiving - Resident #1 remained on 1:1 until the facility sent out to the hospital for evaluation and treatment; and proper notifications completed to family, physician, DON, Administrator, and Regional Support Team. Resident #2 complained of pain to his left side. The facility sent him out via Emergency Medical Services. The facility continued protocol to include: quality of life rounds, in-servicing, staff interviews, as needed Trauma Assessment, Social Service follow-up for psychosocial assessment, and updated the plan of care. The investigation revealed: the Administrator received a phone call at 7:45 AM from the Director of Nursing notifying the Administrator of the incident. It was reported that the nurse was getting ready to give medication and Resident #1 went over and hit Resident #2 in the face, he lost balance and fell into the wall and then to the ground. Resident #2 was assessed and noted to have a laceration to the right side of the face. Nursing cleaned the laceration. Initial assessment of Resident #2 revealed he was able to move his leg. Resident #2 was lifted by staff and placed in a chair. At that time Resident #2 stated something was wrong. The Rehabilitation Director and Nursing assessed his leg and Resident #2 was noted to have pain in his left leg and unable to move. Emergency Medical Services was contacted, and Resident #2 was sent to local hospital for evaluation and treatment. Resident #1 was placed on 1:1 and required redirection multiple times. The Social Worker met with Resident #1 and when asked what happened he mentioned he was hearing laughing and thought it was Resident #2 and was hyper focused on the laughing. Family arrived shortly after the incident and wanted to take Resident #1 out on pass for Thanksgiving. The facility decided to allow Resident #1 go and upon return would be placed 1:1 and then work on an in-patient hospital stay for further evaluation and treatment. The facility did contact psych services to review incident and provider to complete a medication review. Resident #1 had a BIMS of 6, resided in a Memory Care Unit due to poor safety awareness and exit seeking tendencies. He was actively seen by both psychiatry and psychology services. Triggers identified were loud noises, people going into room, and being in his space. Resident #1 currently admitted to hospital for mood stabilization.The facility conducted care plan meeting to discuss re-admission and Resident #1 to be placed on 1:1 to see how new medications were working but facility would like to look at potential alternate placements, with family in agreement. The Administrator completed quality of life rounds, incident review, facility rounds, and staff interviews. No additional concerns identified at this time. In-services were initiated on Behavior in Dementia with de-escalation and dementia. The facility updated Ad Hoc (when necessary or needed) QAPI meeting to include: additional education for memory care unit, updating admission criteria for unit along with admission process, and evaluation of unit staff for compatibility with incident tracking and trending. Investigation Findings revealed: Unsubstantiated willful intent to harm due to Alzheimer's Diagnosis. Resident #1 was placed on 1:1 monitoring starting immediately after the incident on 11/27/25 until he exited the building with family. Resident #1 returned to the facility on [DATE] with continued 1:1 monitoring until he was sent to the hospital for further evaluation. Observation on 12/10/25 at 10:20 AM of Resident #1 in the Memory Care Unit sitting with a staff member putting together a puzzle and listening to music. Resident #1 appeared to enjoy putting the puzzle together, interacting with staff and was without distress. Interview on 12/10/25 at 11:15 AM with CNA F revealed during the time of the incident she was passing breakfast trays when Resident #1 was sitting in a chair in the dining room. CNA F stated she saw Resident #1 smile at Resident #2 as he was walking towards him and said I got something for you so Resident #2 stopped at the table, and within five minutes there was a loud noise and Resident #2 was on the floor. CNA F stated she heard Resident #1 talking to Resident #2 but did not think anything of it because he would joke from time to time. CNA F reported that she was aware of Resident #1's behaviors, therefore when he was around other residents, she often kept an eye on him to de-escalate any potential incidents. CNA F stated Resident #1 was near LVN A and other staff members were in the dining room passing breakfast trays and felt like all residents were adequately supervised. CNA F stated she observed Resident #2 with blood coming from his face, and she and the Rehabilitation Director attempted to help Resident #2 off the floor however he indicated that he was in pain at his hip area. Resident #2 was immediately sent to the hospital and Resident #1 escorted to his room and placed 1:1. According to CNA F she was inserviced on abuse and neglect, separate and deescalate resident altercations and recognized that residents had the right to be free from abuse and neglect, not being able to do so placed residents at risk of harm. Observation on 12/10/25 at 12:45 PM of Resident #2 revealed Resident #1 in bed resting. Resident #2 had just finished lunch, no observations of pain or distress. Resident #2 did not respond to verbal communication at the time. Interview on 12/10/25 at 1:14 PM with the Administrator revealed both Resident #1 and Resident #2 resided in the Memory Care Unit. The Administrator stated she was notified immediately that Resident #1 was sitting at a table next to LVN A while she was talking with him and administering his medication. The Administrator stated she was told Resident #1 got up from the table and hit Resident #2. Resident #2 lost his balance by the window seal and fell. Residents were separated; Resident #1 was placed 1:1 and Resident #2 was sent out to the hospital for further evaluation due to complaints of pain. According to the Administrator she was aware of Resident #1's history of behaviors. The Administrator reported Resident #1 had been working with psych services and had not been physical towards other residents in a while. The Administrator stated while at the time of the incident #1 was not on 1:1 monitoring all staff were responsible for keeping an eye on Resident #1 for any outburst or triggers due to his history. The Administrator stated Resident #1 liked to be in his room alone most of the time, however he enjoyed listening to music and staff led activities. According to the Administrator all staff were inserviced on abuse and neglect and whom to report to all allegations of abuse. Interview on 12/10/25 at 1:55 PM with CNA G revealed during the incident she was in the kitchen when she heard a bump, and she stepped out and saw Resident #2 on the floor. CNA G stated Resident #1 was close to her, so she separated him by taking him to his room. According to CNA G during the morning hours she, Resident #2 and CNA F were looking at an old picture of Resident #2 and there was laughing during the conversation. CNA G said LVN A reported that Resident #1 hit Resident #2 because he thought Resident #2 was laughing at him. According to CNA G she was aware that Resident #1 had a history of triggers and behaviors. CNA G stated she engaged with Resident #1 a lot when he was out of his room, therefore she had never seen him get physical with other residents. CNA G stated she was responsible for monitoring all residents, CNA G stated residents reacted to triggering things that happened in the past so you have to redirect often while working on the memory care unit. CNA G stated she was inserviced on abuse and neglect, separate residents during an altercation immediately, understood signs and symptoms of abuse and neglect, who to report allegation to and not doing so placed residents at risk of harm. Interview on 12/10/25 at 3:25 PM the Rehabilitation Director revealed he was in the Memory Care Unit at the nursing station speaking with Social Worker B when he heard a disturbance behind him. The Rehabilitation Director stated when he turned around, he saw Resident #2 on the floor and Resident #1 being redirected by staff. The Rehabilitation Director stated he advised to get Resident #2 off the floor due to him being in an awkward position on the wall. The Rehabilitation Director stated once Resident #2 was in the chair he voiced that something didn't feel right. The Rehabilitation Director stated he observed Resident #2 leaning to the right side. The Rehabilitation Director stated at that point emergency services was called. The Rehabilitation Director stated the facility was inserviced on abuse and neglect, he was aware of whom to report allegations to, along with signs and symptoms of abuse. Interview on 12/10/25 at 4:07 PM with Social Worker B revealed she was at the nursing station when the staff were around Resident #1 and Resident #2 in the dining room. Social Worker B stated that she observed staff assisting residents and passing trays, she stated she did not see or hear anything prior to the incident, it was a very calm environment. Social Worker B stated after the incident she went to assist with redirecting Resident #1 in his room. Social Worker B stated while with Resident #1 in his room trying to calm him down, he expressed to her that he heard laughing which got him upset. According to Social Worker B, she did not usually work with Resident #1 but was aware of his behaviors. Social Worker B stated the facility was inserviced on abuse and neglect, she was aware to separate residents during altercations immediately, and to report to the Administrator which was the Abuse Coordinator. Interview on 12/10/25 at 4:37 PM with the DON revealed she was notified by the Rehabilitation Director that the team had witnessed Resident #1 punch Resident #2. The DON stated she was told that Resident #2 was approaching the table for medication when he was intercepted with a punch by Resident #1. Resident #2 went backwards and hit his hip on the window sill, then hit the floor. The DON stated upon assessment Resident #2 reported something was wrong with his leg therefore resident #2 was sent out to the hospital. The DON stated Resident #1 was immediately separated and remained 1:1 until family came to take him home for the holiday celebration. The DON stated upon Resident #1's return to the facility he remained 1:1 until he was sent out for evaluation on 11/28/25. The DON stated she was fairly new to the facility however was aware of Resident #1's behaviors. The DON stated at the time of the incident Resident #1 was not on 1:1 monitoring however, staff were aware to keep a close eye on him and to de-escalate any situations where he was involved. According to the DON all staff were responsible for observing residents on the Memory Care Unit, and not doing so placed residents at risk of injury and harm. The DON stated residents on the Memory care Unit had past trauma and were easily triggered, things could happen quickly, making it hard to tell when something was going to occur. The DON stated education was going with staff so they could be aware of resident's triggers and aggressions. The DON stated staff were inserviced on abuse and neglect and was educated to separate residents during resident to resident conflict immediately and report to the Abuse Coordinator. Interview on 12/10/25 at 5:40 PM with the Administrator revealed she was aware of Resident #1's behaviors of having aggressions towards others, however there had not been any issues recently that required him to constantly be monitored 1:1. According to the Administrator all staff working on the memory care unit were responsible for all residents' safety, and not doing so placed residents at risk of injury and harm. The Administrator further stated since Resident #1's return to the facility; interventions had been put in place such as 1:1 monitoring, psychiatric evaluation, monitoring his behaviors, identifying his triggers, the [NAME] machine (interactive game table), participating in activities that he liked, coordinating services with family, music, and care plan meetings to identify alternate living arrangements . The Administrator stated there had not been any further incidents between Resident #1 and Resident #2, Resident #2 had been relocated to reside outside of the Memory Care Unit due to his inability to ambulate. The Administrator stated there had been inservices with staff that covered working with residents with diagnosis of dementia, abuse and neglect, along with inservices provided by the social services department educating staff of each resident's triggers and person centered needs, (Resident #1 was in the first group to train on his triggers and behaviors).The Administrator was notified on 12/10/25 at 5:45 PM that a Past Non-Compliance Immediate Jeopardy situation had been identified due to the above failures. The Administrator was provided with the Immediate Jeopardy template for her signature.Record review of facility policy titled Abuse dated October 2022 revealed to identity, prohibit, and prevent resident abuse. 1. Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion2. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, resident representatives, friends, and other individuals. The resident(s) will be protected from any identified offender during the course of the investigation by removing the alleged perpetrator from the facility.3. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods or services necessary to attain or maintain physical, mental, and psychosocial well-being. Willful: The individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Mental Abuse: includes but is not limited to: humiliation, harassment, threats of punishment, deprivation, or taking unauthorized pictures or videos of a resident that are demeaningPhysical Abuse: includes but is not limited to: hitting, slapping, pinching, biting and kicking. It also includes controlling behavior through corporal punishment.Serious bodily injury: an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization, or physical rehabilitation; or an injury resulting in criminal sexual abuse.Any allegation of abuse will be immediately reported to the facility Administrator. The facility will designate an Abuse Prevention Coordinator who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency, law enforcement, and other officials in accordance with state law.The facility took the following actions to correct the non-compliance prior to the investigation:Record review of an in-service, dated 11/28/25 and 12/01/25, reflected 93 staff including nurses, CNAs, housekeepers, medication aides, activity assistant, activity director, Business Office Manager, medical records, dietary assistant manager, dietary aides and social workers were provided with training on Behavior Management and De-escalation, Abuse, Neglect and Exploitation. Record review of an in-service, dated 11/28/25 and 12/01/25, reflected 93 staff including nurses, CNAs, housekeepers, medication aides, activity assistant, activity director, Business Office Manager, medical records, dietary assistant manager, dietary aides, and social workers: Fundamentals of Dementia Care for Health Facility Personnel. Record review of an in-service, dated 12/02/25, reflected 21 staff that included nurses, nurse's aides, housekeeping, medication aides, activity assistant, dietary aides were in-serviced regarding: Communication book for Staff Documentation of Behaviors or Triggers of Residents and 5 Residents review of Triggers and Intervention. Record review of Resident #1's clinical records revealed Resident #1 was placed one-on-one supervision until he was sent to the hospital for fu