Every finding on record at Windsor Nursing and Rehabilitation Center of Duval

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for food and nutrition services.1)The facility failed to effectively reseal all food items in the walk-in refrigerator and dry pantry to prevent contamination or spoilage on 05/19/2026.2)The facility failed to label and date all food items located in the reach-in refrigerator, walk-in refrigerator, walk-in freezer, and kitchen shelves on 05/19/2026 and 05/20/2026.3)The facility failed to dispose of expired foods items located in the walk-in refrigerator and dry pantry.4)The facility failed to ensure proper hair restraints were worn by kitchen staff and individuals entering the kitchen. These failures could place residents at risk of cross contamination, loss of nutritional value, and foodborne illness.Findings included:During the initial tour of the kitchen on 05/19/2026 at 09:11 a.m. the following was observed:The reach-in refrigerator contained one tray of cups of liquid, possible juice, that were not labeled nor dated. The dry pantry revealed a pack of hamburger buns, a plastic bag containing several slices of bread, and a plastic bag containing an open bag of flour tortillas, all of which were not properly sealed, nor labeled or dated. Also on the shelf were three bags of corn tortillas with a best by date of 04/27/2026. A tray under the counter contained 10 small containers of dried cereal, none labeled or dated.The walk in refrigerator contained multiple expired and improperly stored items, including: A salad mix dated 05/18/2026 that was open and exposed to air Two trays of sandwiches dated 05/15/2026 with several not sealed Lettuce leaves in a plastic bag dated 05/06/2026 with black spoilage Cilantro in a plastic bag dated 05/07/2026 An unlabeled and undated coleslaw mix in a plastic bag An open gallon of milk with a best by date of 05/17/2026 An unopened heavy cream with a use by date of 05/14/2026The walk-in freezer revealed a previously opened, unlabeled plastic bag of unidentified frozen meat. During an observation on 05/19/2026 at 9:26 a.m. revealed [NAME] A wore a beard cover that did not cover his mustache.During an interview and observation on 05/19/2026 at 9:36 a.m., the DA stated she was trained last month on labeling, storage, and dating food. She said the milk, heavy cream, cilantro, and lettuce were expired and should have been discarded. She stated it was everyone's responsibility to label, store, and date food and did not know why expired food remained. She was observed discarding expired food and unsealed sandwiches.During an interview on 05/19/2026 at 9:45 a.m., [NAME] A stated he was trained last week on labeling, storing, and dating food and that all food should have receive, open, and use by dates. He stated all food should be sealed to avoid cross contamination and spoilage, which could make residents sick. He did not know why expired food remained in the walk-in refrigerator or pantry because it was everyone's responsibility to check.During an observation on 05/19/2026 at 12:09 p.m., revealed [NAME] B wore a hairnet that did not fully cover her hair around the forehead and neck.During an interview and observation on 05/19/2026 at 12:15 p.m., the RD stated she trained staff last week on labeling, dating, and storing food. She stated expired food should be discarded immediately and that all staff entering the kitchen must wear hairnets and beard guards covering all visible hair. She stated [NAME] A should have covered his mustache and provided [NAME] B with a second hairnet. The RD discarded the corn tortillas, bread, and flour tortillas in the dry pantry room. During an interview on 05/19/2026 at 12:36 p.m., [NAME] B stated she had been trained in kitchen hygiene and that hairnets must cover all hair to prevent contamination and choking hazards. She stated she normally wore a cap under her hairnet but overslept and did not have it. She stated she had been trained to label, date, and store food and did not know why expired food had not been discarded.During an observation on 05/20/2026 at 1:51 p.m., revealed the lunch test tray contained fresh apples with a best by date of 05/19/2026. Finished lunch trays on the 600 hall also contained empty apple packs with the same date.During a follow up observation in the kitchen on 05/20/2026 at 2:03 p.m., the reach-in refrigerator revealed meat and cheese sandwiches and peanut butter and jelly sandwiches in plastic bags that were not labeled or dated.During an interview on 05/21/2026 at 9:31 a.m., the DM stated he trained staff last week on labeling, dating, and storing food. He stated food must be sealed and dated to prevent bacteria growth and spoilage. He stated he conducted daily walk throughs but did not see the expired food. He stated everyone entering the kitchen must wear hairnets and beard guards. The DM stated he went by the used by date and the Best Buy date and if it's past that he would throw out the items. The DM stated serving expired food could potentially lead to a foodborne illness and serving food beyond the Best Buy date would not be as fresh.During an interview on 05/21/2026 at 10:00 a.m., [NAME] A stated he had been trained on hair restraints and had not covered his mustache before being corrected by the RD because it was trimmed and kept short. The potential negative outcome of hair getting in food was cross contamination, and the risk of choking on hair.During an observation in the kitchen on 05/21/2026 at 10:03 a.m., the milk delivery driver entered the kitchen several times while wearing a hoodie, with a visible beard and goatee, and no hairnet.During an interview on 05/21/2026 at 10:30 a.m. the ADM stated his expectation was for anyone entering the kitchen to wear proper hairnets and beard guards, including the milk delivery man, because it was not sanitary and hair could fall in the food. During an interview on 05/21/2026 at 1:45 p.m. the DON stated labeling, dating, and storing food were necessary to avoid serving spoiled food, which could cause intestinal problems and foodborne illness.During an interview on 05/21/2026 at 2:25 p.m., the ADM stated he previously identified concerns with food storage and labeling and had provided training. He stated unsealed food might have been due to the type of bags used and that he brought new bags to correct the issue.Reviews of the facility RD monthly quality monitor reports dated 03/10/2026 and 04/22/2026 reflected that all food items were not covered, labeled, and dated. Monthly quality monitor report dated 05/04/2026 reflected that all food items were not covered, labeled, and dated and food was not expired or spoiled. Review of the kitchen's in-service training dated 03/31/2026 titled Kitchen In Service: Labeling, Storage, Sanitation & Tray line Accuracy reflected: Every product in storage must have all required dates: Received By Date - When checking deliveries, pick up each item to verify the date. Open Date - Anything opened or decanted must be labeled right away. Use By Date - All cooked items must have a clear use by date based on policy.If it's missing a date, it cannot be used.Review of the kitchen in-service training dated 05/04/2026 titled In Service: Strengths & Critical Corrections During Survey Window revealed: PurposeTo reinforce safe food handling, sanitation, pest control, and regulatory compliance practices. While the kitchen is doing many things well, several areas must be tightened immediately to avoid F812, F880, F371, F925, and F942 citations.Several storage issues were observed that must be corrected. Tortillas open/unsealed. Chili dated 4/22 still present-expiredAction:Discard expired items.Review of the kitchen in-service training dated 05/19/2026 titled In Service: Labeling, Dating, Sealing, Handwashing & Glove Use revealed:1. Labeling & Dating Expectations - KNOW TODAY'S DATE AND REFERENCE FOOD STORAGE GUIDELINES ATTACHED FOR ACCURATE USE BY DATEA. Received By Dates All items must have a received by date. Manufacturer expiration date must remain visible and must be followed.B. Items Removed From Original PackagingMust be labeled with: Item name Date opened or prepped Manufacturer expiration date if unopened Use by date if opened (per facility guidelines) or manufacturer's expiration date (which ever comes first) Items must be discarded when quality deteriorates, even if not expired.C. Leftovers Must be labeled with item name, date prepared, and use by date(72hrs per facility policy)2. Sealing RequirementsAll food items in dry storage, refrigerators, and freezers must be properly sealed.Acceptable sealing: Bags folded and fully closed Bags or containers covered with saran wrap Ziplock bags fully zipped, If zip cannot close wrap with saran wrap Containers must have tight fitting lidsUnacceptable: Open bread bags Unsealed lettuce bags Containers without lids Loosely folded bags.6. Hair Nets & [NAME] NetsHair Nets Must cover all hair. Staff may need to: oAdjust hairstyleoWear two hair netsoProvide their own bonnet that fully contains hairBeard Nets Must cover the entire beard/mustache, tuck in additional netting to reduce excess netting that may obstruct vision7. Surveyor Findings (Corrective Focus Areas)These items were found during survey and must not recur:Expired or Poor Quality Items Expired corn tortillas mixed with non expired items Expired milk Lettuce dated 5/6 still in use with visible deterioration (discard after 5 days from open) Prepped mixed lettuce unsealed and undated Bread items unsealed and undated Whipped cream/heavy cream expired per manufacturer date Unlabeled/undated bagged item in fridge (appeared to be meat)Labeling/Sealing Failures Items without dates (focus expiration dates) Items without labels Items not sealed properly Items stored in bags that were folded but not securedPPE Failures [NAME] nets not covering full beard/mustache Hair nets not covering all hair.Review of the facility policy titled Employee Sanitation date approved 10/01/2018 reflected, Policy: The Nutrition & Foodservice employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness.Procedure: 3. Employee Cleanliness Requirementsb. Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces.Review of the facility policy titled Food Storage date approved 10/01/2018 reflected: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines.Procedure: 1.Dry Storage roomsd. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 2. Refrigeratorsd. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.e. Use all leftovers within 72 hours. Discard items that are over 72 hours old.3. Freezerse. Store frozen foods in moisture-proof wrap or containers that are labeled and dated.

Based on observation, interview, and record review, the facility failed to establish a system of accurate reconciliation and determine that drug records were in order, and that an account of all controlled drugs were maintained and periodically reconciled for 3 of 11 medication carts (Medication Cart #1, Medication Cart #2, and Medication Cart #3) in the facility effecting 5 of 11 residents (Resident #91, Resident #201, Resident #122, Resident #14, and Resident #73) reviewed for pharmacy services.The facility failed to ensure:1. RN A accurately reconciled Resident #91's narcotic medication log on medication cart #1 when he administered Resident #91's Lorazepam 0.5 mg (controlled medication used for anxiety). 2.MA E accurately reconciled Resident #122's narcotic medication log on Medication Cart #2 when she administered one tablet of Hydrocodone-Acetaminophen 10-325 mg.3. MA E administered Resident #201's 1 tablet of Hydrocodone-Acetaminophen 5-325 MG after signing the controlled medication log. 4.LVN F accurately reconciled Resident #73's narcotic medication log which revealed the controlled medication discrepancy for Resident #73's Lorazepam 1 mg (controlled medication used for agitation) with lesser amount of pills in the blister pack than on the controlled medication log and lesser amount of medication in the one out of 16 syringes for Resident #14's Lorazepam 1 mg/ml gel in each syringe. These failures could place residents at risk for loss of prescribed medications, potential for not receiving their prescribed medications, and risk of drug diversion. Findings included:Record review of Resident #91's face sheet, dated 05/21/2026, reflected [AGE] year-old female, originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included: schizoaffective disorder, bipolar type (a chronic mental health condition combining schizophrenia symptoms like delusions or hallucinations with severe mood swings of mania and depression), epilepsy (a chronic neurological disorder characterized by recurring, unprovoked seizures, which occur when abnormal electrical activity in the brain causes temporary surges), anxiety, and depression disorder.Record review of Resident #91's annual MDS assessment, dated 12/02/2025, reflected unassigned Resident #91's BIMS score with severely impaired cognitive skills for daily decision making. The MDS assessment indicated Resident #91 received scheduled antipsychotic and antianxiety medications.Attempted to interview Resident #91 and not able to receive any comprehensive response due to her cognitive impairment. Record review of Resident #91's comprehensive care plan, revised on 01/13/2025, reflected Resident 91 had anti-anxiety medications related to anxiety disorder with intervention to administer antianxiety medication as ordered by physician. Record review of Resident #91's order summary report indicated she had an order for Ativan Oral Tablet 1 MG (Lorazepam) Give 1 tablet by mouth three times a day related to schizoaffective disorder, bipolar type with an order start date of 04/21/2026 and Ativan Oral tablet 1 MG (Lorazepam) give 1mg for anxiety irritability related to schizoaffective disorder, bipolar type for 30 days as needed with start date of 4/20/2026 and stop date of 05/20/2026.Record review of Resident #91's medication administration record for 05/21/2026 indicated Resident #91 received scheduled Ativan Oral Tablet 1 MG (Lorazepam) at 8 a.m. when medication was not documented in controlled medication administration record. 1. During medication cart #1's reconciliation with RN A on 05/21/2026 at 08:56 a.m., Resident #91's narcotic medication log showed a discrepancy in the count with a blister pack of Resident #91's Lorazepam 0.5 mg. The blister pack had 2 tablets less than what was documented on the controlled medication log, there was no red sticker indicating dosage directions change observed on blister pack and controlled medication log with 35 tablets in the blister pack and 37 tablets in the controlled log. During an interview on 05/21/2026 at 8:48 a.m., RN A stated he administered the two tablets of Ativan (Lorazepam) to Resident #91 but failed to document the administration on Resident #91's narcotic record. RN A stated he was responsible for documenting the administration of controlled medication on the resident's narcotic record immediately when a narcotic medication was administered. He stated that he forgot to sign for Resident #91's controlled medications log since he was very busy all morning. RN A stated that not documenting the narcotic medication could cause a discrepancy or a medication error, since the next nurse would not know the resident had already received the narcotic medication. RN A stated he received training on medication administration and proper documentation of controlled medication administration in the last two months.2. Record review of Resident #201's face sheet, dated 05/21/2026, indicated a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses included: poly osteoarthritis (osteoarthritis affecting five or more joints simultaneously), anxiety disorder, major depressive disorder (a serious mood disorder), and pain in right shoulder.Record review of Resident #201's annual MDS assessment indicate Resident #201 had a BIMS score of 10, which indicated moderate cognitive impairment. The MDS assessment indicated Resident #201 was treated for pain in right shoulder with pain medication.Record review of Resident #201's comprehensive care plan, dated 01/26/2021, indicated Resident #201 had potential for pain related to Diabetic neuropathy (nerve damage caused by long-term high blood sugar and fat levels in people with diabetes), poly osteoarthritis, muscle spasms pain. The care plan interventions included Administer analgesia as per orders. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Record review of Resident #201's order summary report indicated Resident #201 had an order for Hydrocodone-Acetaminophen oral tablet 5-325 mg give 1 tablet by mouth three times a day for Arthritis with a start date of 08/28/2025.Record review of Resident #201's medication administration record, dated 05/21/2026, indicated Resident #201 did not receive 1 tablet of Hydrocodone -APAP 10-325 mg take on 05/21/2026.Record review of Resident #122's face sheet, dated 05/21/2026, indicated a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses included: chronic pain syndrome (a condition where persistent pain lasts beyond the expected healing time [typically 3 to 6 months]), bilateral primary osteoarthritis (degenerative joint disease with no single identifiable cause, primarily driven by aging, genetics, and lifelong joint wear) of first carpometacarpal joints (connect the carpal bones [wrist] to the metacarpal bones [hand]), and general anxiety disorder.Record review of Resident #122's quarterly MDS assessment, dated 03/27/2026, indicate Resident #122 had a BIMS score of 14, which indicated intact cognition. The MDS assessment indicated Resident #122 was treated with scheduled pain medication regiment for chronic pain syndrome.Record review of Resident #122's comprehensive care plan, dated 03/27/2026, indicated Resident #122 had chronic pain. The care plan interventions included anticipating the resident's need for pain relief and respond immediately to any complaint of pain through scheduled pain medication. Record review of Resident #122's order summary report indicated an order for Hydrocodone-Acetaminophen oral tablets 10-325 mg; give 1 tablet by mouth three times a day for pain with a start date of 09/12/2025.During medication cart #2's reconciliation on 05/21/2026 at 09:56 a.m., Resident #201's narcotic medication log showed a discrepancy of count with a blister pack of Resident #201's Hydrocodone -APAP 5-325 mg, there was 1 tablet more in the blister pack than on the controlled medication log count with 43 tablets in the log and 44 tablets in the blister pack. Resident #122's log had one tablet less of Hydrocodone -APAP 5-325 mg in the blister pack than documented on the controlled medication log with 39 tablets in the blister pack and 40 in the controlled log. During an interview with MA E on 05/21/2026 at 10:05 a.m., she stated she had been in-serviced on medication administration annually and periodically throughout the year. She stated that she was supposed to document controlled medication post administration immediately and not before administration. She stated that not documenting the medication administration or documenting and not administering medication could cause confusion and residents could receive more medication or not receive medication due to these medication errors. She stated that she was usually more attentive to details.During an interview with RN B on 05/21/2026 10:04 a.m., she stated that she worked with Resident #201. She stated that she received in-services regularly -annually and monthly - on different issues including medication administration and controlled medication reconciliation. She stated that when nurses or med aides give controlled medication, they should sign immediately on computer and controlled medication log. She stated that not signing administered medication or signing but not giving medication can lead to med error and diversion. If discrepancy is discovered, per policy they should let the ADM and DON know immediately. She stated that if ordered medication was not administered that could lead to increase in pain or worsening of medical conditions. She stated that administering medication and not signing the controlled log could be considered to be the med error.3. Record review of Resident #14's face sheet, dated 05/21/2026, indicated an [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses included: dementia (an umbrella term for a loss of cognitive functions including memory, reasoning, and language that is severe enough to interfere with daily life and independent functioning) and chronic atrial fibrillation. (a continuous, long-lasting irregular heart rhythm).Record review of Resident #14's quarterly MDS assessment, dated 04/23/2026, indicated Resident #14's BIMS score of 6 indicating severe cognitive impairment and received antidepressant medications.Record review of Resident #14's comprehensive care plan, revised 10/03/2025, indicated Resident #14 uses anti-anxiety medications related to adjustment issues and dementia with behavioral disturbances with interventions: administer anti-anxiety medications as ordered by physician. Record review of Resident #73's face sheet dated from 05/21/2026 indicated a [AGE] year-old male who was admitted on [DATE] with diagnoses included: dementia with agitation (distressing behavioral syndrome marked by restlessness, pacing, emotional distress, or aggression). Record review of Resident #73's quarterly MDS assessment, dated 03/11/2026, indicated Resident #73's severely impaired cognitive skills for daily decision making and unassigned BIMS score with administration of antianxiety medication. Record review of Resident #73's comprehensive care plan, revised 03/14/2024, indicated Resident #73 had physical and verbal aggressive behavior related to dementia, poor impulse control with interventions: administer medications as ordered. Record review of Resident #73's order summary report indicated Resident #73 had an order for Ativan oral tablet 1 mg (Lorazepam) Give 1 mg by mouth every 8 hours as needed for anxiety/agitation for 14 days with a start date of 05/21/2026.During medication cart #3's reconciliation on 05/21/2026 at 10:21 a.m., the discrepancy in the count of controlled medication lorazepam 1 mg tablet for Resident #73 with discrepancy in count between blister pack with one tablet less than documented on the controlled medication log and discrepancy in lorazepam 1 mg/ml gel with approximately 0.25 mg/ml left in the syringe which is 1/4 of prefilled dose observed in other syringes for Resident #14 with no documentation indicating the discrepancy in the log. The number of syringes was equal to the number in the count on the log, but each syringe should consist of 1 mg/ml medication in gel form.During an interview on 05/21/2026 at 12:28 a.m., LVN F stated she did not administer lorazepam 1mg/ml to Resident #14, and she counted the controlled medications at the beginning of her shift today, 05/21/2026 at 6:00 a.m., with a night nurse. LVN F stated that she had training on controlled medication storage and administration in the last 3-4 months. She stated that she was responsible for medications on her cart including counting the controlled medications at each shift change to make sure the count was correct. She stated that she was counting the syringes with lorazepam for Resident #14 by the tips of syringes without looking at the content of medication inside the syringes, so she overlooked that one of the syringes was 2/3 empty. She stated if she did not follow the proper medication storage and controlled medication counting policy, it could lead to medication errors and drug diversion. LVN F stated that when a medication discrepancy is found, the DON should be notified immediately. She took the medication to the DON. She stated that she was supposed to document controlled medication administration in the controlled log immediately after administration and she got busy and forgot to do it. During an interview on 05/21/2026 at 4:05 p.m., the DON stated that he worked at the facility for 12 years and had medication administration in service on an annual basis and provides in services to his nursing staff on monthly basis through in person and computer modules. He stated that nursing staff received education on medication error, 10 steps of medication administration: wrong med, time, route, pt, rational for medication administration. He stated that they started the investigation and in services. He stated that he started interviewing nursing staff on different shifts and those who worked with the cart the night prior. He denied any history of suspicious behavior from staff regarding medications or any history of narcotic discrepancies. The DON stated there was no harm or impact on the residents regarding the incorrect counts. He stated that the ADON and himself were doing the random cart audit and MARs. He stated that each nurse or med aides were responsible for their medication carts and counting controlled medication at shift change. He stated that any medication change should be identified during medication administration through and a red sticker identifying medication order change should be placed on medication package. He stated that when medication error was identified the following steps should be taken: the computer form of medication error submitted by ADM, nurse responsible for that cart should complete the reports, DON initiate investigation in order to assess and determine the problem and consequences to residents, and notify family, physician and following with additional training to nursing staff. He stated that they have a strong support from outside sources: 6 nurses, 2 physicians support and pharmacist reviewed medication and medication administration on a regular basis. He stated if PRN medication was not administered correctly for Resident #14 and Resident #91, it did not affect their health status but still could be considered a medication error. During an interview on 05/21/2026 at 4:21 p.m., the ADM said she was not trained in medication administration and storage as she was not medically licensed. She stated that the DON, ADON, charge nurses and medication aides were responsible for counting controlled medications at shift change and monitor for medications' discrepancies especially with controlled medication to prevent drug diversion. She stated that the DON randomly audits the med carts and MARs. She stated if a discrepancy is noted, nurse of med aide was responsible to notify the ADON, DON, or herself. She stated that if not monitored and properly counted, it would potentially harmfully affect residents. Controlled meds should be signed immediately in controlled medication book and computer, medical chart of each resident. The ADM said in services on problem with controlled medication counting was addressed, the nurse practitioner and other health professionals including medical director was notified, it is important to document controlled medication administration immediately as incomplete information was not our intended goal that could cause the confusion and administration of medication to resident incorrect dose. Inservice on Med errors received from DON regarding Resident #14's medication and addressed immediately, self-reported to state, in-services and investigation initiated.Record review of an in-services for last 12 months, May 2025-May 2026, revealed an in-service on passing medications: using the 5 rights during medication pass: 3-right dose and 5-right route. Match the MAR (medication administration record) to the drug label. completed and signed by RN A, MA E and LVN. Record review of the facility's Medication Administration policy, dated 10/01/2019, revealed Medications are administered as prescribed in accordance with good nursing principles and practices.10 Rights of Medication Administration - Whenever you are preparing to give someone medication, it is important to understand the 10 rights of medication administration. Safety should be the first thing on your mind with medications. There is always a risk of giving the wrong pill, the wrong dose, or the wrong person's medication. If this happens, harm to the person can occur and some reactions can be deadly.It is important for everyone to know the safety rules for medications.3. Right Dosage. This is one of the most important in the 10 rights of medication administration. Check the doctor's order/MAR against the medication on hand. Calculate the dosage yourself to make sure it is right. Pay attention to the dosage of the actual medication versus the required dosage the patient is to take. 6. Right Documentation - Nurses need to document medications as they are given. Any medication documentation needs to be initiated. E. Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) are compared with the medication label. If the label and MAR are different and the container is not flagged, indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's order are checked for the correct dosage schedule.2. Administration: B. Medications are administered in accordance with written orders of the prescriber.4. Documentation: The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given.Record review of the facility's Training - Education Charge Nurses and Medication Aides, dated 05/21/1026, revealed Prevention of Medication errors 2. You are responsible for adhering to the facility policy and procedure on medication administration. Follow the 10 Rights of medication Administration. Right dose: in case of dosage change, apply the change in direction sticker. Right documentation: document immediately after administration, NEVER BEFORE NOR LATER.Record review of Documentation of Controlled Medication policy, dated 10/01/2019, revealed the controlled substance record refers to the document(s) utilized to track controlled substances on a shift-to-shift basis from the point of receipt through destruction/discharge. These documents may also be referred to as a controlled substances book or proof of use sheetProcedure: 1. The Director of Nursing Services is responsible for the Controlled Substances Record. It is recommended that the Controlled Substances Record be examined weekly by the Director of Nursing or designee for any tampering, irregularities, or incompleteness. 8. The licensed nurse of medical aide on the shift reporting to duty counts all medications with licensed nurse or medical aide going off duty. The nurse coming on duty should be overseeing both the controlled substances record and each scaled unit dose card. Each card should be checked back and front for tampering and quality control. If there is a discrepancy in the count, do not sign the record. Report the discrepancy to the supervisor of DON. 9. The last signature in the controlled substances record is responsible for the count.

Based on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors and failed to report drug errors to the resident's physician in a timely manner and record them in the resident's record for 1 of 5 residents (Resident #91) reviewed for drug administration. The facility failed to ensure that RN A administered a correct dose of Lorazepam 0.5 mg (controlled medication used for anxiety) to Resident #91 for a week without obtaining a correct dose of medication according to the physician order. This failure could place residents at risk for overdosing, delayed healing, and other adverse consequences. Findings included: Record review of Resident #91's face sheet, dated 05/21/2026, reflected [AGE] year-old female, originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included: schizoaffective disorder, bipolar type (a chronic mental health condition combining schizophrenia symptoms like delusions or hallucinations with severe mood swings of mania and depression), epilepsy (a chronic neurological disorder characterized by recurring, unprovoked seizures, which occur when abnormal electrical activity in the brain causes temporary surges), anxiety, and depression disorder. Record review of Resident #91's annual MDS assessment, dated 12/02/2025, reflected unassigned Resident #91's BIMS score with severely impaired cognitive skills for daily decision making. The MDS assessment indicated Resident #91 received scheduled antipsychotic and antianxiety medications. Record review of Resident #91's comprehensive care plan, revised on 01/13/2025, reflected Resident 91 had anti-anxiety medications related to anxiety disorder with intervention to administer antianxiety medication as ordered by physician. Record review of Resident #91's order summary report indicated she had an order for Ativan Oral Tablet 1 MG (Lorazepam) Give 1 tablet by mouth three times a day related to schizoaffective disorder, bipolar type with an order start date of 04/21/2026 and Ativan Oral tablet 1 MG (Lorazepam) give 1mg for anxiety irritability related to schizoaffective disorder, bipolar type for 30 days as needed with start date of 4/20/2026 and stop date of 05/20/2026. Record review of Resident #91's controlled medication revealed administration of wrong dose of Ativan oral tablets of 0.5 mg instead of 1mg as ordered on following dates: -4/24/2026 at 3 p.m., 5/5/2026 at 9:00 a.m. and 8 p.m., 5/6/2026 at 9 a.m., 5/11/2026 at 9 a.m., 5/14/2026 at 9:00 a.m., 5/15/2026 at 9 a.m., 5/16/2026 at 9:00 a.m. and 5:00 p.m., 5/17/2026 at 11 a.m., which was documented on MAR which totaled to 10 doses of this medication administered to Resident #91. During an observation and attempted interview of Resident #91 on 05/21/2026 at 12:35 p.m., Resident #91 was observed trying to get out of bed. She could not comprehensibly respond to questions regarding medication administration or her condition. During an interview on 05/21/2026 at 8:54 a.m., RN A stated that he worked at this facility for 4 years on 100 hall and took care of 31 residents including Resident #91. He stated that he administered Ativan oral tablet 0.5 mg (Lorazepam) 2 tablet on 05/21/2026 at 7:40 a.m. from the blister pack that included as needed medications and not from the blister pack that contained 1mg of Ativan for Resident #91. He stated that he was not sure when this medication dosage was changed. He stated that he administered a dose of 0.5 mg Ativan instead of 1mg from this blister pack which was indicated by his signatures on the controlled log for Resident #91. He stated that when medication dose changed, nurses were responsible for placing a red sticker of medication change on the blister pack and controlled log to avoid the confusion. He stated that administering wrong dose to Resident #91 could be considered a medication error and not treating the health conditions Resident #91 had. During an interview with PNP on 05/21/2026 2:38 p.m., she stated she saw Resident #91 every other week. She stated that Resident #91 could not communicate and had behaviors like crawling on floor, she puts as needed order of 1 mg oral Ativan every 8 hours as needed with start day on 04/20/2026 and stop day on 05/20/2026. She stated that if nurses gave medication on 05/21/2026, it was a med error, due to giving med without order, she stated that giving incorrect dose of 0.5 mg of Ativan for Resident #91 could be not providing Resident #91 with needed treatment and affect the results of treatment. PNP stated that she put her own orders in the system, but nurses ask her for as needed orders and they did not ask her for new order for Ativan 1mg for Resident #91, that's why she did not put an order in the system. She stated that she will put a new PRN order right now. She stated that overall nurses at this facility were doing good job communicating residents' needs and administering medications according to physicians' orders. She was not aware of med errors at this facility prior to this incident. During interview with ADON on 05/21/2026 1:15 p.m., he stated not administering correct doze could be considered a medication error. ADON stated that he had in-service on medication administration and controlled medication reconciliation on regular basis - annually. He stated that nursing staff (CMAs and charge nurses) are supposed to count controlled meds at beginning and end of their shift. He stated that ff discrepancy in controlled medication count was found, nursing staff was supposed to notify DON, ADONs and ADM immediately to start investigation. He stated that he was not aware of discrepancies for Resident #91 and Resident #14until notified by state. ADON stated that charge nurses and CMAs were responsible for following 5 rights of medication, including correct doze of medication, according to the physician order on MAR. She stated that if correct doze of medication was not available in the facility, charge nurses or CMAs were responsible to notify ADON or DON and they would contact physician to change the order. During an interview on 05/21/2026 at 12:11 p.m., the DON, he stated that regarding the narcotic discrepancies that was found the day prior was submitted to the state for intake. The DON stated that they started the investigation and in services. He stated that interviews with the residents stated that they all received their medications. He denied any history of suspicious behavior from staff regarding medications or any history of narcotic discrepancies. The DON stated there was no harm or impact on the residents regarding the incorrect counts. He stated that ADON and himself were doing the random cart audit and MARs. The DON stated that each nurse or med aids were responsible for their medication carts and counting controlled medication at shift change and following physician orders and if physician orders changed, place a change order red sticker on blister pack to alert regarding the change. DON stated that he had training on medication storage and controlled medication annually and staff get that training through computer modules annually. During an interview on 05/21/2026 at 2:21 p.m. with ADM, he was trained proper medication administration and storage policy. He stated that he was aware of need for signing for controlled medication administration immediately and not signing until medication was administered to residents. ADM stated that DON, ADON, charge nurses and medication aides were responsible for counting controlled medications at shift change and monitor for medication discrepancies especially with controlled medication to prevent drug diversion. He stated that DON randomly audits of med carts and MARs with assistance from pharmacy consultants and he tries to assist them as much as he could due to lack of medical training. He stated if discrepancy is noted, nurse of med aide was responsible to notify ADON, DON or himself. He stated that if not monitored and properly counted, it would potentially harmfully affect residents. During an interview with Psych NP on 05/21/2026 2:38 p.m., she stated she saw Resident #91 every other week, she cannot communicate and has behaviors, crawling on floor, she puts PRN 1mg Ativan q8hrs and the stop day was yesterday. She stated that if nurses gave medication today, it was a med error, due to giving med without order, she stated that under medicating this resident would be not providing her with needed treatment and affect the results of treatment. She puts her own orders in the system, but nurses ask her for PRN and they did not ask her for new PRN order for Resident #91, that's why she did not put an order. She stated that she would put a new PRN order right now. She stated that overall nurses were doing good job communicating residents' needs at this facility and administering medications according to her orders. She was not aware of med errors at this facility prior to this incident. During an interview on 05/21/2026 at 4:05 p.m. with DON, he stated that he worked at the facility for 12 years and had medication administration in service on the annual basis and provides in services to his nursing staff on monthly basis through in person and computer modules. He stated that nursing staff received education on medication error, 10 steps of medication administration: wrong med, time, route, pt, rational for medication administration. He stated that they started the investigation and in services. He stated that he started interviewing nursing staff on different shifts and those who worked with the cart the night prior. He denied any history of suspicious behavior from staff regarding medications or any history of narcotic discrepancies. DON stated there was no harm or impact on the residents regarding the incorrect counts. He stated that ADON and himself were doing the random cart audit and MARs. He stated that each nurse or med aids were responsible for their medication carts and counting controlled medication at shift change. He stated that any medication change should be identified during medication administration through and a red sticker identifying medication order change should be placed on medication package. He stated that when medication error was identified the following steps should be taken: the computer form of medication error submitted by ADM, nurse responsible for that cart should complete the reports, DON initiate investigation in order to assess and determine the problem and consequences to residents, and notify family, physician and following with additional training to nursing staff. He stated that they have a strong support from outside sources: 6 nurses, 2 physicians support and pharmacist reviewed medication and medication administration on a regular basis. He stated if PRN medication was not administered correctly for Resident #14 and Resident #91, it did not affect their health status but still could be considered a medication error. During an interview on 05/21/2026 at 4:21 p.m. with ADM, she was not trained in medication administration and storage as she was not being medically licensed. She stated that DON, ADON, charge nurses and medication aides were responsible for counting controlled medications at shift change and monitor for medications' discrepancies especially with controlled medication to prevent drug diversion. She stated that DON randomly audits of med carts and MARs. She stated if discrepancy is noted, nurse of med aide was responsible to notify ADON, DON or herself. She stated that if not monitored and properly counted, it would potentially harmfully affect residents. He stated that administered controlled medications should be signed immediately in controlled book, computer, and medical chart of each resident. He stated that in-services on problem with controlled medication counting were addressed, nurse practitioner and other health professionals including medical director were notified, It is important to document controlled medication administration immediately as incomplete information is not our goals which could cause confusion and administration of medication to resident an incorrect dose. The in-service on Medication errors was received from DON regarding Resident #14 and Resident 91's medication and addressed immediately, the self-reported to state on Resident #14's controlled medication discrepancy was submitted, and in-services/investigation was initiated. Record review of an in-service Pharmacy recommendations, dated 02/03/2026, revealed 4.When passing medications, you should do your 3 checks! While doing so you will notice any deviance in directions. Place a directions change sticker until new blister arrives signed and completed by LVN.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity, including the right to be free from unnecessary drugs used in excessive dose including duplicated drug therapy, excessive duration, without adequate monitoring, and without adequate indications for it for 1 of 5 residents (Resident #14) reviewed for pharmacy services and unnecessary drugs. The facility did not prevent Resident #14 from receiving 13 doses of unnecessary psychotropic drug, Ativan 1ml/mg, discontinued on [DATE]. This failure could place residents at risk for overdosing, delayed healing, and other adverse consequences. Findings included: Record review of Resident #14's face sheet, dated [DATE], indicated an [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses included: dementia (an umbrella term for a loss of cognitive functions including memory, reasoning, and language that is severe enough to interfere with daily life and independent functioning) and chronic atrial fibrillation. (a continuous, long-lasting irregular heart rhythm). Record review of Resident #14's quarterly MDS assessment, dated [DATE], indicated Resident #14's BIMS score of 6 indicating severe cognitive impairment and received antidepressant medications. Record review of Resident #14's comprehensive care plan, revised [DATE], indicated Resident #14 uses anti-anxiety medications related to adjustment issues and dementia with behavioral disturbances with interventions: administer anti-anxiety medications as ordered by physician. Observation of controlled medication log for Resident #14's Ativan 1ml/mg on [DATE] at 9:12 a.m., revealed this medication was administered to Resident #14 on the following dates: -[DATE] at 2:00 p.m., [DATE] at 10:00, [DATE] at 1:10 p.m., [DATE] at 6:00 p.m., [DATE] at 10:50 p.m., [DATE] at 8:20 a.m., [DATE] at 9:00 a.m., [DATE] at 9:00 a.m., 2/2526 at 9:00 p.m., [DATE] at 9:00 a.m., [DATE] at 9:40 a.m., [DATE] at 4 p.m., and [DATE] at 7 p.m. with 13 doses were administered to Resident #14 without active physician order for this medication. During an observation and attempted interview of Resident #14 on [DATE] at 1:15 p.m., Resident #14 was observed lying in bed. She could not comprehensibly respond to questions regarding medication administration or her condition. Record review of Resident #14's order summary report indicated an order for Ativan oral tablet 0.5 mg (Lorazepam). Give 0.5 mg by mouth every 8 hours needed for anxiety related to unspecified dementia and psychotic disturbance, mood disturbance. with order day [DATE] an no active order listed for topical Ativan (1ml/mg) apply every 8 hours as needed with a start date of [DATE] and discontinued date of [DATE]. During an interview with PNP on [DATE] at 8:15 a.m., she stated Resident #14 did not have an active order for medication Ativan 1ml/mg topical form. She stated that this resident did not require the topical form any longer due to reduced agitation and being able to take oral form of this medication. She stated that topical form of this medication was discontinued on [DATE] and new order of Ativan oral tablet 0.5 mg to take every 8 hours as needed for anxiety was started last year and she renewed it on monthly basis. She stated that if nursing staff contacted her regarding the topical form needed for this resident, she could order it for Resident #14, but she was not contacted and per her assessment of Resident #14, she did not require topical form any longer. She stated that larger dose of topical Ativan (1ml/mg) is normal as it absorbed through skin and not gastrointestinal system, so it is normal practice to order larger dose or the same medication for topical versus oral medication. She stated that she did not see any harm in administering on as needed basis this topical medication to Resident #14, but it should not be administered to Resident #14 without physician order and needed to be removed from the medication cart to avoid the confusion. During an interview with Pharm on [DATE] at 9:03 a.m., he stated that he was a pharmacist for this facility and Resident #14 did not have a current order for Ativan 1ml/mg topical form. He stated that it started on [DATE] and they did not receive a discontinuation order, but the order of topical Ativan for Resident #14 expired and they did not refill this order for Resident #14. He stated that Resident #14 has an active order for oral Ativan 0.5 mg every 8 hours as needed. He stated that if residents received both medications at the same time could potentially cause oversedation and harmful effect would depend on multiple factors. He stated that topical form of any medication was less effective and it was common practice to proscribe larger dose of topical than oral for effectiveness. During an interview on [DATE] at 4:05 p.m. with DON, he stated that he worked at the facility for 12 years and had medication administration in service on the annual basis and provides in services to his nursing staff on monthly basis through in person and computer modules. He stated that nursing staff received education on medication error, 10 steps of medication administration: wrong med, time, route, pt, rational for medication administration. He stated that they started the investigation and in services. He stated that he started interviewing nursing staff on different shifts and those who worked with the cart the night prior. He denied any history of suspicious behavior from staff regarding medications or any history of narcotic discrepancies. DON stated there was no harm or impact on the residents regarding the incorrect counts. He stated that ADON and himself were doing the random cart audit and MARs. He stated that each nurse or med aids were responsible for their medication carts and counting controlled medication at shift change. He stated that any medication change should be identified during medication administration through and a red sticker identifying medication order change should be placed on medication package. He stated that when medication error was identified the following steps should be taken: the computer form of medication error submitted by ADM, nurse responsible for that cart should complete the reports, DON initiate investigation in order to assess and determine the problem and consequences to residents, and notify family, physician and following with additional training to nursing staff. He stated that they have strong support from outside sources: 6 nurses, 2 physicians support and pharmacist reviewed medication and medication administration on a regular basis. He stated if PRN medication was not administered correctly for Resident #14 and it did not affect their health status but still could be considered a medication error. During an interview on [DATE] at 4:21 p.m. with ADM, she was not trained in medication administration and storage as she was not being medically licensed. She stated that DON, ADON, charge nurses and medication aides were responsible for counting controlled medications at shift change and monitor for medications' discrepancies especially with controlled medication to prevent drug diversion. She stated that DON randomly audits of med carts and MARs. She stated if discrepancy is noted, nurse of med aide was responsible to notify ADON, DON or herself. She stated that if not monitored and properly counted, it would potentially harmfully affect residents. He stated that administered controlled medications should be signed immediately in controlled book, computer, and medical chart of each resident. He stated that in-services on problem with controlled medication counting were addressed, nurse practitioner and other health professionals including medical director were notified, It is important to document controlled medication administration immediately as incomplete information is not our goals which could cause confusion and administration of medication to resident an incorrect dose. The in-service on Medication errors was received from DON regarding Resident #14 and Resident 91's medication and addressed immediately, the self-reported to state on Resident #14's controlled medication discrepancy was submitted, and in-services/investigation was initiated. Record review of an in-service Discontinued Medications, dated [DATE], revealed: when medications are discontinued by physician order. The medications marked appropriately and destroyed.If a physician discontinues a medication, the medication container is placed in a location marked for discontinued medications as soon as possible signed and completed by RN A and LVN.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs for 1 of 6 residents (Resident #179) reviewed for accommodation of needs.The facility failed to ensure Resident #179's call light had been placed within reach.This failure had the potential to place dependent residents at risk for injuries and unmet needs.Findings included:Record review of Resident #179's undated admission record reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, muscle wasting, age-related physical disabilities, and cerebrovascular accident (stroke) with paralysis of the left side.Record review of Resident #179's care plan, initiated on 03/05/2022 and revised on 10/19/2022, reflected she was at a high risk for falls related to cerebrovascular accident (stroke) with left-sided paralysis, impaired balance, and impaired coordination. Interventions included, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.Record review of Resident #179's Annual MDS dated [DATE] reflected a BIMS score of 14, indicating she was cognitively intact. The MDS further reflected Resident #179 required substantial/maximal assistance with personal hygiene, upper body dressing, and lower body dressing.During an observation on 05/19/2026 at 10:22 a.m., Resident #179 was sitting upright in her wheelchair with her bedside table positioned in front of her, the call light was located on the bed behind her and out of reach. Resident #179 stated she could not reach the call light and stated she would eventually get help because she could holler if needed.During an observation on 05/19/2026 at 10:50 a.m., Resident #179's remained up in her wheelchair and the call light remained clipped to the bed and out of reach.In an interview and observation on 05/19/2026 at 10:51 a.m., MA D stated Resident #179 could not reach the call light when it was on the far side of the bed. MA D stated the call light was supposed to be attached to the resident's wheelchair and she was not sure why it was out of reach. MA D further stated all staff were responsible for ensuring call lights remained within residents' reach and staff monitored this through rounds and resident observation. MA D stated Resident #179 would not have been able to call for assistance without access to the call light. MA D moved the call light and attached it to Resident #179's wheelchair.In an interview on 05/22/2026 at 12:04 p.m., the DON stated call lights should have remained within reach of all residents. The DON stated all staff were responsible for monitoring and ensuring call lights were accessible. The DON stated staff had been trained through in-services and return demonstrations. The DON further stated the risk to Resident #179 was her needs may not have been met if she was unable to use her call light to request assistance.In an interview on 05/22/2026 at 1:34 p.m., the ADM stated call lights were expected to remain within residents' reach at all times. The ADM stated all staff were responsible for ensuring residents' call lights were accessible. The ADM stated staff had been trained through in-services conducted by the DON and compliance had been monitored through rounds conducted throughout the building. The ADM further stated the potential negative outcomes to Resident #179 for not having the call light within reach could have included falls and unmet needs due to the resident being unable to call for assistance.Record review of the facility policy titled Call Lights: Accessibility and Timely Response, dated 10/13/2022, reflected, Staff will ensure the call light is within reach of resident and secured as needed.

Based on observation, interview, and record review, the facility failed to secure confidential and personal medical records for 1 (Resident #40) of 9 residents reviewed for privacy and confidentiality of records.The facility failed to protect Resident #40's PII on 03/27/2026 when the AMD emailed a PEME request form to an RP of another facility resident. This failure placed residents' PII at risk of exposure to unauthorized parties through electronic communication. Findings included:Review of Resident #40's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old female who admitted to the facility on [DATE]. Resident #40 had the following diagnoses: high blood pressure (the force of blood against the artery walls is consistently too high), non-Alzheimer's dementia (a decline in memory, thinking, and other cognitive abilities that interfere with daily life, not caused by Alzheimer's disease), anxiety (feelings of discomfort, distress, or apprehension often in response to real or perceived threats), lack of coordination, altered mental status, and restlessness and agitation. Resident #40 required supervision or touching assistance with all ADLs. Resident #40 had a BIMS score of 08, indicating moderately impaired cognition. Review of Resident #40's comprehensive care plan dated 05/05/2026 reflected, she was dependent on staff for meeting emotional, intellectual, physical, and social needs. She needed assistance and reminders to activities. Review of Resident #40's progress notes dated 03/21/2026-04/21/2026 revealed no progress note by any staff indicated Resident #40's PII had been shared with an unauthorized party. Review of Resident #40's signed (by the RP) admission agreement revealed: Resident Rights. As a resident of Facility, Resident is entitled to various rights that Facility encourages Resident to exercise. A Statement of Rights is available on the Texas Secretary of State website and is attached hereto. The Facility Manual and Forms to be Completed Upon admission outline additional rights of Resident, including: Rights under the Health Insurance Portability and Accountability Act of 1996 (HIPAA)In an observation and attempted interview on 05/19/2026 at 10:35 AM, Resident #40 was ambulating on her own in the hallway appropriately dressed and in good spirits. Resident #40 was unable to be interviewed due to her cognitive impairments. In a confidential interview on 05/20/2026 at 1:04 PM, it was revealed that Resident #40's PII information had been shared with this interviewee via electronic communication by the facility's AMD. The interviewee stated that the email came from the facility where their FM lived, so they thought it was intended for them, and the body of the email only said, LET ME KNOW IF I DID IT RIGHT so the only way for the interviewee to know what the email was about, was to open the document that was attached, where Resident #40's PII was located. The interviewee volunteered to forward the electronic communication to the state surveyor at this time. Review of a forwarded email from the confidential interviewee revealed an email dated 3/27/20226 at 4:06 PM from the facility AMD, with a document attached to the email, titled PEME Request Form' that included Resident #40's full name, DOB, and SS#, and information about Resident #40's personal income. A typed notice at the bottom of the email reflected, Notice: This e-mail, including any attachments, is the property of [corporate] or its affiliates and is intended for the sole use of the intended recipient(s). It may contain information that is privileged and/or confidential. Any unauthorized review, retention, use, disclosure, or distribution is prohibited. If you are not the intended recipient, please notify the sender regarding the error in a separate email and delete this message. The views expressed in this e-mail do not necessarily represent the views of [corporate] or its affiliates.In an interview on 05/20/2026 at 2:54 PM, Resident #40's RP, he stated that he believed the resident was on Medicaid, and that he could not recall a time where anyone from the facility reached out the him about Resident #40's PII being accidentally shared with anyone, and that if it was, that was concerning to him. In an interview on 05/20/2026 at 2:00 PM with the ADM, he stated they did not have a HIPAA policy, but that they followed HIPAA guidance. In an interview on 05/22/2026 at 11:53 AM with the AMD, she stated that the PEME form was to send to corporate for a current resident to reapply for Medicaid. The form was used when the facility would try to get the residents covered for another month by Medicaid. She stated there were 3 residents in the facility that required the use of that form recently. She verified Resident #40 as being one of those 3. She stated that it was brought to her attention by the confidential interviewee that she had emailed Resident #40's form to that person by mistake. She stated she also made a call to the RP of Resident #40 and notified them of the mistake. She stated that she would normally ensure HIPPA compliance by double checking the email she was sending something to. She stated she could get in big trouble if she did not maintain HIPAA compliance, and that risks to residents included things getting out that should not get out. In a follow-up interview on 05/22/2026 at 1:49 PM with the ADM, he stated that usually when emails went outside of the [facility] network, the email would show the compliance snippet at the bottom of the email notifying the recipient to disregard the email if it was not intended for them. He stated his AMD had not previously reported this mistake to him. He stated that they could try to recall messages, but that he has not seen the facility utilizing encrypted emails. He stated that staff were trained in privacy and confidentiality during their initial onboarding. Review of the manual provided by the facility titled United Stated Department of Health & Human Services Summary of the HIPAA Privacy Rule dated 05/03 (no year written) revealed: Individually identifiable health information is information, including demographic data, that relates to: the individual's past, present or future physical or mental health or condition, the provision of health care to the individual, or the past, present, or future payment for the provision of health care to the individual,and that identifies the individual or for which there is a reasonable basis to believe can be used to identify the individual. Individually identifiable health information includes many common identifiers (e.g., name, address, birth date, Social Security Number).

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #29) of 9 residents reviewed for accidents and hazards.The facility failed to ensure Resident #29 did not keep smoking materials in his room. This failure could place residents at risk of a fire, burning themselves, or ingesting unknown substances.Findings included:Review of Resident #29's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old male who admitted to the facility on [DATE]. Resident #29 had the following diagnoses: high blood pressure (the force of blood against the artery walls is consistently too high), seizure disorder (recurrent, unprovoked seizures caused by abnormal electrical activity in the brain), bipolar disorder (mental health condition characterized by significant mood swings), schizophrenia (chronic mental health condition that manifests in young adulthood, impairing daily function and quality of life, including hallucinations, delusions, disorganized thinking), lack of coordination, and allergic eczema (an allergic reaction to a substance that comes into direct contact with the skin). Resident #29 had a BIMS score of 12, indicating moderately impaired cognition. Review of Resident #29's comprehensive care plan dated 05/13/2026 reflected, Resident #29 had been identified as having PASRR positive status related to a severe mental illness: Schizoaffective Disorder, Bipolar type. He was a smoker of e-cigarettes and would not smoke without supervision. He was to be instructed about smoking risks and hazards and on the facility smoking policy. Staff were to notify the charge nurse immediately if it was suspected the resident had violated facility smoking policy. He required supervision while smoking . Review of Resident #29's smoking/tobacco acknowledgement dated 02/25/25 revealed The facility respects the resident's right to smoke. All tobacco products will be kept by the facility staff. This includes, but is not limited to, smoking tobacco, chewing tobacco, matches, lighters, and all other types of smoking paraphernalia. Under no circumstances will smoking materials (cigarettes, lighters, etc.) be allowed to be kept in the residents' room or on their person. The facility will designate a specific outdoor location and time for smoking. Smoking will be permitted only in the designated area. All residents will be allowed to smoke, with supervision, in the designated areas and times. Smoking inside the facility is expressly prohibited and will result in discharge. Resident #29's signature was observed on the acknowledgement. In an observation and interview on 05/19/2026 at 10:36 AM, Resident #29 was observed standing at his dresser, facing the doorway of his room, blowing a puff of smoke out of his mouth and then quickly putting something in the top drawer of his dresser. The surveyor asked Resident #29 what he was blowing out of his mouth and he stated it was nothing. The surveyor asked Resident #29 if staff had informed him of the facility's smoking policy, and Resident #29 shook his head 'yes', and that the staff said it was okay for him to vape in his room. There was no oxygen tanks or concentrators observed in the room. In an observation and interview on 05/19/2026 at 10:45 AM, the AD stated she facilitated smoking and smoke breaks at the facility. She stated that they had a list of residents who vaped, and that residents were not permitted to keep vapes in their rooms, due to safety and because there was posted smoking times. She stated that Resident #29's vape should be in the secured smoking box. She stated Resident #29 would sign himself out on pass, and when he came back to the facility, the receptionist would ask the resident if he had any vapes, cigarettes, or lighters on him and they would obtain the items and secure them. She stated that she was not sure if they had previously confiscated vapes from Resident #29. The SW approached at this time, and the surveyor advised the staff of their observation, to which the facility staff went outside and brought Resident #29 to his room. Resident #29 retrieved a vape from his top dresser drawer and handed it to the SW. The SW was overheard informing Resident #29 of the facility's smoking rules and informed the resident she would put the vape in his smoking box.In an interview on 05/22/2026 at 12:30 PM, CNA T stated she had been driving the facility van for 6 months, and that Resident #29 frequently went on outings in the facility van. She stated that she gave all residents the whole rundown, meaning that any over the counter items, cigarettes, cigars, vapes, needed to be turned into herself, the receptionist, or the AD upon arrival back to the facility. She stated she told all riders the rules before leaving and upon return to the facility. She stated she was not aware of Resident #29 having not turned in vapes before. She stated that if residents brought those items into the facility and did not turn them in, it could be hazardous to oxygen, it could start fires, residents could potentially choke, or their blood pressure could go up. She stated that this was the first occurrence she had heard about a resident bringing something back into their room that was considered prohibited. In an interview on 05/22/2026 at 12:40 PM, the DON stated that residents were not permitted to keep smoking materials in their rooms and that they turned in those items to a staff member to be secured. He stated the facility encouraged residents to turn those items into staff so they could use them during designated smoking times. He stated that because they cannot search a resident, they remind them to turn prohibited items into staff so they could access those items during the allotted time. If family members brought in cigarettes or lighters, the staff also encouraged them to turn those items into a designated facility staff member. When staff discovered these items in a resident's possession, staff would encourage the resident again to turn the items in. The DON stated that this was the first occurrence for Resident #29 in a long time. He stated that risks to residents, if smoking materials were kept on their person or in their rooms, was that if they had something flammable, they could burn themselves or ingest something that staff did not know what the contents were. In an interview on 05/22/2026 at 1:32 PM, the ADM stated that residents were not permitted to keep smoking materials in their rooms and if residents were found with those items, they were asked to hand them over to facility staff. He stated that to ensure residents turned in those items when brought back from outings, the front desk receptionist was to ask the residents upon coming back into the facility if they obtained those items, and to turn them in for proper storing. He stated the van drivers should also be notifying residents upon reentry. He stated that his expectation was for residents to turn those items into staff. He stated that risks to residents, if smoking materials were kept on their person or in their rooms could be items catching on fire and it could be hazardous to themselves or others. Review of the facility policy titled Resident Smoking dated 10/24/22 reflected, It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. 1.Smoking is prohibited in all areas except the designated smoking area. A Designated Smoking Area sign will be prominently posted. 7.Electronic cigarettes (e-cigarettes/vape/vapor pen) can catch on fire and/or explode if not handled and stored safely. Safety measures for the use of electronic cigarettes by residents will include, but are not limited to:a.Use of e-cigarettes in designated smoking areas only.10.All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan.12.If a resident or family does not abide by the smoking policy or care plan (e.g. smoking materials are provided directly to the resident, smoking in non-smoking areas, does not wear protective gear), the plan of care may be revised to include additional safety measures13.Smoking materials of residents smoking will be maintained by nursing staff.

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 environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 14 residents (Resident #162 and Resident #179) reviewed for infection control.1. CNA C failed to wash or sanitize her hands when going from a dirty surface to a clean surface while performing incontinent care for Resident #179.2.The facility failed on 05/19/2026 to use the CDC recommendations regarding contact isolation for chicken pox for Resident #162.These deficient practices had the potential to place residents at risk for cross contamination and the spread of infection.Findings included:Review of Resident #162's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old female who admitted to the facility on [DATE] with the following diagnoses: non-traumatic brain dysfunction (brain-related problems that occur without and external physical injury), heart failure, arthritis (inflamed or damaged joints), non-Alzheimer's dementia (a decline in memory, thinking, and other cognitive abilities that interfere with daily life, not caused by Alzheimer's disease), and restlessness and agitation. Resident #162 had a BIMS of 00, indicating severe cognitive impairment. Review of Resident #162's comprehensive care plan dated 05/20/2026 reflected Resident #162 was receiving hospice care, she had declined recommended pneumococcal and flu vaccines, which may have increased her risk for preventable communicable respiratory illness and complications. Her care plan indicated she had active chickenpox and was at risk for infection transmission, skin breakdown, discomfort itching, and complications related to viral illness. She was to be administered anti-viral medication as ordered, maintain contact isolation as ordered, obtain labs as ordered by the provider. She was on antibiotic therapy acyclovir r/t suspected chickenpox infection. Review of Resident #162's progress notes dated 05/18/2026 revealed the first documentation of suspected diagnoses, 2:00PM: Upon assessment; noted Itchy rashes of fluid/pus filled blister on abdomen, chest and under the bilateral breast, Possible chicken pox. Resident will be contact precaution until further order.Review of progress note dated 05/18/2026 at 6:45 PM reflected Resident #162, Received Stat BMP results. Notified NP and received orders Acyclovir Oral Tablet 800 MG (Acyclovir) Give 1 tablet by mouth every 8 hours for possible chicken pox for 7 Days.Review of Resident #162's progress note dated 05/18/2026 at 9:33 PM reflected, Resident continues on f/u for suspected chicken pox and remains in contact precautions.Review of a provider communication log for daily rounds dated 05/22/2026 revealed Resident #162 had infectious abscess on her chest/abdomen, identified as pustules, small abscess, the doctor advised the facility to discontinue isolation, ordered Bactrim twice a day, and if there was drainage, to get a culture and sensitivity. In an observation on 05/19/2026 at 10:31 AM, Resident #162's room revealed a closed door with a blue cloth cubby hanging on the door containing different sized gloves, and yellow gowns. A sign on the door said Contact Precautions Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. A stop sign with a Do Not Enter Isolation See Nurse Before Entering was taped to the wall next to the door. Review of the CDC websites www.cdc.gov transmission-based precautions recommendations for chicken pox revealed, Use Airborne Precautions for patients known or suspected to be infected with pathogens transmitted by the airborne route (e.g., tuberculosis, measles, chickenpox, disseminated herpes zoster). Use personal protective equipment (PPE) appropriately, including a fit-tested NIOSH-approved N95 or higher-level respirator for healthcare personnel.Record review of Resident #179's undated admission record reflected she had been a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, muscle wasting, age-related physical disabilities, and paralysis of the left side.Record review of Resident #179's care plan, initiated on 03/05/2022 and revised on 03/07/2022, reflected Resident #179 had bowel and bladder incontinence related to cerebrovascular accident (stroke). Interventions included: Clean peri-area with each incontinence episode. Check frequently and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes.Record review of Resident #179's Annual MDS dated [DATE] reflected a BIMS score of 14, indicating she had been cognitively intact. The MDS further reflected Resident #179 had required substantial/maximal assistance with personal hygiene, upper body dressing, and lower body dressing.In an observation on 05/20/2026 at 11:50 a.m. of peri-care CNA C washed her hands with soap and water prior to the start of care, unfastened the brief, and cleansed Resident #179's perineal area from front to back using one pass with a clean cloth for each pass. CNA C then turned Resident #179 and cleansed the buttocks using the same method. CNA C changed gloves but did not cleanse her hands with alcohol-based hand sanitizer or wash her hands prior to donning a new pair of gloves. CNA C completed care to the back and placed a new clean brief under the resident.In an interview on 05/20/2026 at 1:27 p.m., CNA C stated she had been trained to cleanse her hands after removing gloves and had been instructed to use soap and water or an alcohol-based hand sanitizer. CNA C stated she had just forgot. CNA C further stated the negative effects of failing to wash hands and change gloves when moving from a dirty surface to a clean surface could have resulted in cross contamination leading to infection.The state surveyor notified the IP (DON) on 05/21/2026 at 11:35 a.m., of the current CDC guidelines related to airborne precautions for suspected chickenpox.In an interview on 05/21/2026 at 12:11 PM with the NP, she stated she saw Resident #162 on 5/20/2026 she stated that the resident does not have a lot of spots, but she had a blister like rash to her right breast, right abdomen, and it spread to the left abdomen. She stated the resident had dementia and could not give an accurate history. She reiterated the resident was on hospice. She stated she did not think she could do a test on chicken pox, she stated usually they had to start the antibiotic early for it to be effective. She assumed the facility had started Resident #162 on precautions. She stated that the facility should be using contact and airborne precautions and specified that masks should be worn in this resident's room. In an interview on 05/22/2026 at 9:44 AM, the ADM stated that they had a skin doctor in the building at this time and the doctor ruled out chicken pox, discontinued all orders and isolation precautions and was diagnosed with a bacterial skin infection.In an interview on 05/22/2026 at 12:00 p.m., the DON stated staff should have washed or sanitized their hands when going from dirty surfaces to clean surfaces in between glove changes. The DON stated staff had been trained in handwashing, infection control, and incontinent care through in-services and return demonstrations. The DON further stated failure to wash or sanitize hands when moving from a dirty surface to a clean surface could have caused the spread of infection.In an interview on 05/22/2026 at 12:48 PM, the DON stated that he looked at the CDC and it said if it was confirmed chicken pox they were to use airborne precautions. He stated that they had 2 situations at play, they notified the NP of the situation, and she ordered the facility to place the resident on contact isolation pending her arrival. When the NP came to review the patient, they asked her where they were going with the diagnosis. He stated that he was thinking of droplet vs airborne precautions, and he asked the NP to confirm with the doctor. The NP told them the doctor would be there Friday, and she ordered an antiviral pending the arrival of the doctor. He stated if they suspected chicken pox, they should have followed the proper precautions. He stated his chief nursing officer advised him he should have sent the resident to the hospital to confirm the diagnosis rather than waiting on a doctor to come to the facility. He stated that if he would have had an outbreak, they would have had to report it to the city public health department. The resident was diagnosed with impetiginous dermatitis and was put on droplet precautions 05/22/2026. In an interview on 05/22/2026 at 1:34 PM, the ADM stated staff had been expected to wash their hands and follow facility guidelines for infection control. The ADM stated staff had been educated on infection control and handwashing through in-services and visual checkoffs. The ADM further stated failure to wash hands when needed could have led to the spread of infection.In a follow up interview on 05/22/2026 at 1:40 PM, the ADM stated that he brought the precautions up to the NP, and the ADM stated he would contact the doctor to confirm Resident #162's diagnosis. He told the NP that he wanted to do PCR testing, but the NP said she was not aware of a test for it. He stated that in short, it did not make sense to him that the NP stated it was needing to be treated as chickenpox. He stated the MD stated it would not be chickenpox either, but general wound care came here on 5/22/2026, and if they did not feel it was chickenpox they would follow the right protocol. He stated that the MD was not the resident's doctor so he could not give the diagnosis. He stated that if they did not follow the proper CDC recommendations it could have been spread to other residents and/or staff. Review of the facility's Infection Prevention and Control Program policy dated 5/13/2023 reflected, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases.5.Isolation Protocol (Transmission-Based Precautions):a.A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines.b.Residents will be placed on the least restrictive transmission-based precaution for the shortest duration possible under the circumstances.Record review of the facility's Hand Hygiene policy, dated 10/24/2022, reflected the following: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Additional considerations: The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Based on interview and record review, the facility failed to allow one of one (Resident #1) resident reviewed, or the resident representative to obtain a copy of the resident's medical records upon verbal or written request to the facility. The facility failed to provide medical records for Resident #1 to his RP / family representative within two working days of a request on 03/31/2026. This failure placed residents in the facility at risk by causing a negative health impact due to not having continuity of care. and the right to review their health care.Findings included: A record review of Resident #1's face sheet date 04/07/2026 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included atherosclerosis of native arteries of extremities (a disease involving the buildup of fats, cholesterol, and other substances (plaque) in artery walls, which narrows pathways and restricts blood flow), Severe Protein-Calorie Malnutrition (is a life-threatening, critical lack of nutrients, appearing as marasmus (wasting), kwashiorkor (edema), or a mix of both), Gastrostomy Status (the presence of a surgically created opening (stoma) in the stomach, often using gastrostomy tube (G-tube or PEG tube) for long-term enteral feeding, hydration, or medication deliver), Type 2 Diabetes Mellitus with unspecified complication (patient has a chronic blood sugar management disorder but does not have associated diabetic retinopathy, kidney damage (nephropathy), nerve damage (neuropathy), or major vascular issues), Parkinson's Disease without Dyskinesia (a progressive, incurable neurological disorder caused by the loss of dopamine-producing neurons in the brain, leading to movement issues like tremors, stiffness, and slow movement.), Dementia (a decline in mental ability-such as memory, reasoning, and communication-severe enough to interfere with daily life). Face sheet also reflected Resident #1 had a designated RP, same person that requested medical records. A record review of Resident #1's admission MDS assessment dated [DATE] reflected a BIMS score of 04 indicating severe cognitive impairment. A record review of Resident #1's care plan initiated 02/28/2026 reflected Resident #1 had an ADL self-care performance deficit related to dementia, impaired cognitive function/dementia or impaired thought processes r/t CVA. A record review of Resident #1's RP's request for medical records reflected Resident #1's RP filled out the form on 03/31/2026requesting the following (History and Physical, Medication Administration Records, Chest X-ray Report, Discharge Summary, Transfer Summary, Laboratory Date, PT, OT, ST, any and all record). The medical record request form stated, The patient named above is currently seeking/receiving medical and nursing care in our nursing facility. For optimal continuing care, we require release of the following medical information from the Resident's hospital records. A record review of Medical Record staff communication to the facility's corporate office regarding Resident #1's RP's request for medical records, reflected the Medical Records staff did not reach out to the corporate office until 04/06/2026, six days after the request was made and three days after Resident #1 was discharged from the facility. During an interview on 04/15/2026 at 10:10 am, the Medical Record staff stated Resident #1's RP requested medical records, and she submitted the request form to the corporate office. The Medical Record staff stated that once the request form was filled out by the resident or RP, the form was given to the Administrator to review and then she attached the face sheet and the POA document and sent the document to the corporate office. The Medical Record staff stated sometimes the corporate office would call to request additional documents or tell her which documents to print and give to the resident or the RP. The Medical Record staff stated she submitted the request form from Resident #1's RP to the corporate office on 04/06/2026 because she was still within her 7-day window time frame. The Medical Record staff stated the delay was on her; she was busy. The Medical Record staff stated Resident #1's RP wanted the medical records before Resident #1 was discharged or on the day of discharge. The Medical Records staff stated up to the time of this interview, on 04/15/2026, Resident #1's family had not gotten the medical records as requested because the corporate office did not give her [MR] the go ahead. During an interview on 04/15/2026 at 10:58 am, LVN A stated Resident #1's RP had asked her for medical records request form sometimes at the end of March 2026, but she could not remember the exact date. LVN A stated she collected the medical records request form from the Medical Record staff and gave it to Resident #1's RP. LVN A stated Resident #1's PR had to fill out the request form, and she gave it to the Medical Record staff herself. During an interview on 04/15/2026 at 12:28 pm, the Administrator stated the process for requesting a medical record by residents /RP was to complete a written request form, he verified the request form to understand what the resident or family was requesting. The Administrator stated the Medical Records staff would then send the request to the corporate office for the legal team to review, after revision, communication was sent out to the Medical Records staff to send the records to the resident/ RP. The Administrator stated he spoke with Resident #1's RP the day after she submitted the medical records request and the RP stated she needed a paper copy of the records for a family in the medical field to review. The Administrator stated he offered Resident #1's RP the ability to sit with a staff member and review Resident #1's medication list on the computer, and she refused. The Administrator stated that in order for a medical record to be released to a Resident or their RP, the form had to be sent to the legal department. The Administrator stated the facility usually responded to the resident or the RP within 24 hours and up to 3 days or more for the resident or RP to receive the requested documents depending on the volume of the documents. The Administrator stated Resident #1's RP's request was denied because the RP was not the POA. Attempts to contact Resident #1's RP were made via phone and email on 04/15/2026 at 09:16 am and 9:19 am respectively. There was no response, the call was directed straight to voice mail, and no way to leave a voice message. During a phone interview on 04/17/2026 at 09:56 am, Resident #1's RP stated she spoke with the Administrator regarding wanting medical records and the Administrator stated he had to get with legal before giving the records. Resident #1's RP stated the Administrator did not tell her that she needed to fill out a medical record request form. Resident #1's RP stated, a week later she found out from a nurse that she had to fill out a medical record request form and give it to the Medical Records staff to be able to get the records. Resident #1's RP stated she wanted the medical records for the resident before or on the day of discharge for Resident #1 to use for following up with his PCP. Resident #1's RP stated Resident #1 was discharged from the facility on 4/03/2026 and as of 04/17/2026, she had not gotten the requested medical records. Review of facility's policy titled Release of Medical and [NAME] Records Policy effective February 22, 2016, reflected: In order to ensure compliance with this policy, all requests for medical and billing records must be cleared through the Legal Department prior to the release of any information.The procedure for medical and billing records requests is as follows:A fully completed medical or billing records release authorization form must be submitted either by the Resident, if a Resident is able to complete such a form, or by the appropriate Authorized Party.The medical records release authorization form should be emailed or scanned to the Legal Department listed in the corporate email directory.The Legal Department will authorize the request or respond to what additional documentation may be necessary for the request to proceed. Medical and/or billing records should not be released under any circumstances until such release is authorized by the legal Department.

Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures for two of eight residents (Resident #1 and Resident #2) reviewed for abuse and neglect . The facility failed to report to Health and Human Services alleged abuse that occurred when Resident #1 threw a cold coffee at Resident #2 and Resident #2 hit Resident #1 which resulted in Resident #1 sustaining a bruise beneath her right eye, a scratch on her right arm, anger and pain . This failure could place residents at risk of abuse, neglect, pain, and diminished quality of life. Findings include: 1. Record review of Resident #1's face sheet, dated 06/27/25, reflected a [AGE] year-old female with an original admission date of 07/29/2021 and readmission [DATE]. Resident #1 had diagnoses which included Parkinson's Disease (a progressive neurological [anything related to the nervous system, which includes the brain, spinal cord, and nerves] disorder that primarily affects movement, causing symptoms like tremors, stiffness, and difficulty with balance and coordination) without dyskinesia, without mention of fluctuations (diagnosis of Parkinson's disease where the individual does not experience dyskinesia [involuntary, jerky movements] and there is no indication or mention of the motor fluctuations), schizoaffective disorder, depressive type (a mental health condition characterized by symptoms of both schizophrenia [a chronic brain disorder that significantly affects how a person thinks, feel and behaves]), mood disorder, specifically major depressive disorder (a serious mental illness characterized by persistent feelings of sadness, loss of interest in activities, and significant changes in mood and behavior that interfere with daily life),bipolar disorder (a mental illness characterized by extreme shifts in mood, energy, and activity levels, ranging from periods of elevated mood to periods of depression), current episode manic severe with psychotic features (indicates a serious manifestation of bipolar disorder, involving extreme mood swings, elevated energy levels, and potentially delusional or hallucinatory experiences.) Record review of Resident #1's MDS , dated 04/17/25, reflected a BIMS score of 15, which indicated no cognitive impairment. Record review of Resident #1's care plan, revised dated 08/26/21, reflected Resident #1 was identified as having PASRR positive status related to a severe mental illness: schizoaffective disorder, depressive type. 2. Record review of Resident #2's face sheet dated 06/27/25, reflected a [AGE] year-old male original admission date of 03/06/2021 with diagnoses of unspecified dementia (a general term for a decline in mental ability severe enough to interfere with daily life), unspecified severity, with other behavioral disturbance (exhibits symptoms of dementia where the severity is not specified and also experiences behavioral disturbances beyond agitation and atherosclerotic heart disease of native coronary artery without angina pectoris (the coronary arteries (blood vessels supplying the heart) are narrowed due to atherosclerosis (plaque buildup) but the patient does not experience chest pain). Record review of Resident #2's MDS , dated 05/27/25, reflected a BIMS score of 7, which indicated severe cognitive impairment. Record review of Resident #2's care plan, revised dated 12/10/21, reflected Resident #2 was physically aggressive with staff at times related to dementia. Record review of Resident #1's nursing progress notes by RN A, dated 06/23/2025, reflected staff notified RN A that Resident #1 had a physical altercation with Resident #2 in the smoking area, Resident #2 punched Resident #1 in the face and Resident #1 threw coffee on Resident #2 (coffee was cold). Resident #1 stated, I requested him to move from the way, the other resident got agitated and punched in my face which made me upset that's why I threw coffee on him. Action taken - staff immediately separated the two residents and ensured their safety and residents assessed for immediate medical or psychological needs, skin evaluation completed, bruise noted to below left eye and left cheek and scratch to left arm. Pain assessment done, PRN Tylenol administered, assessed coffee cup, coffee noted cold., neuro checks initiated and were in progress, administrator, NP made aware, called POA to notify, unable to reach and left a message, resident is own RP, observed closely for any change in behaviors, response: Resident #1 alert and responded verbally, she was resting in bed with no s/s of distress/discomfort noted at this time. Record review of nursing progress notes, by LVN A, dated 06/23/25, reflected Resident #2 was assessed from head to toe three different times, no burn noted during assessment. Resident #2 did not sustain any burn in any area of his body, and he denied any pain or discomfort, will continue monitoring . Observation on 06/27/25 at 12:27 PM of Resident #1 revealed swollen a crescent shaped bruise approximately 1 inch wide and 1.5 inches in length approximately .5 inches below Resident #1's left eye and 5 red indentions scattered in a line approximately 4 inches long about 6 inches below the residents left elbow and about 4 inches above the wrist. Interview on 06/27/25 at 12:27 PM with Resident #1 revealed, she remembered the incident and said she was mad when it happened and was mad now and her face still hurt but her arm no longer hurt. Interview on 06/27/25 at 5:10 PM with Resident #2 revealed he remembered the incident with Resident #1, but he was no longer upset with Resident #1, and everything was good . Interview on 06/27/25 at 1:41 PM with RN A revealed she did not witness the altercation between Resident #1 and Resident #2. She assessed Resident #1 after the AD/BOM and HRC reported the incident to her. Her understanding was Resident #1 poured coffee on Resident #2, and Resident #2 punched Resident #1 in the face, but the coffee poured on Resident #2 was not hot. RN A said at the time of her assessment or Resident #1, Resident #1 had a bruise below the left eye and a scratch to her left arm. She said she would consider the bruise to Resident #1's face, an injury because it was in the area of the brain . She said she considered the altercation a resident-to-resident altercation and a form of abuse. She said she was trained in ANE, and the administrator was the abuse and neglect coordinator, and all incidents of abuse and neglect should be reported to the administrator. RN A said she did not find any changes to Resident #1's mental status or vital signs when she conducted her assessment and Resident #1 was at her normal baseline. RN A said she called the NP, and the NP told her to monitor Resident #1 and report if Resident #1 had any change of condition, and Resident #1 did not have a change in condition. Interview on 06/27/25 at 2:04 PM with LVN B revealed she assessed Resident #2 after his altercation with Resident #1. She said she did not witness the altercation between the two residents, but it was reported to her by the AD/BOM who told LVN B Resident #1 poured coffee on Resident #2. LVN B assessed him for burns. She said she assessed him three separate times by the end of her shift and found no injury. She said she was trained in ANE when she was hired at the facility. She said because the residents engaged in a physical altercation, it was abuse and the incident was reported to the administrator directly after it occurred. She felt Resident #1 received minor injury in the altercation and because there was injury to her face, they started neuro checks, because the neuro checks would reveal if there was a major injury. Interview on 06/27/25 at 2:14 PM with the AD/BOM revealed she heard yelling from her office and went outside. She said a resident was yelling at Resident #2 because he was mad Resident #2 hit Resident #1. The AD/BOM said she separated both residents and asked what happened. They reported to her they were lined up waiting to smoke and Resident #2 was standing in front of Resident #1. Resident #1 wanted to get in front of Resident #2. Resident #1 asked to get in front of Resident #2 and Resident #2 told her No so Resident #1 threw coffee on Resident #2. When Resident #1 threw the coffee at him, Resident #2 hit Resident #1. The AD/BOM said neither resident was scared, and Resident #1 wanted to get her cigarettes so she could smoke. She stated she was trained in the different types of abuse when she was hired. She stated when one resident hit another resident it was a form of abuse and staff were to report it to the Administrator regardless of the level of injury. She said residents cussing or yelling at each other was a form of abuse. She said the Administrator was the ANE coordinator and the incident was reported to the Administrator. Interview on 06/27/25 at 4:27 PM with the Administrator revealed he did not report the incident between Resident #1 and Resident #2 to the state survey agency because a lot of their cases were unique. When he spoke with Resident #1 about the incident, she said she was not in pain or hurting. Resident #1 she initiated the contact with Resident #2, and she understood he was a man who had difficulty controlling his impulses. He said he did not report the incident because it did not require first aide. He said when he spoke with Resident #1 about it, she repeatedly said she just wanted to go out and smoke her cigarettes. He said Resident #1 was not crying or upset about the incident when he spoke with her, and he did not feel like she was abused or neglected. The Administrator said the facility followed the Long-Term Care Regulation Provider Letter to guide them for reporting incidents to HHSC. Record review of the Long-Term Care Regulation Provider Letter Title Abuse, Neglect Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility Must Report to the Health and Human Services Commission reflected: Type of Incident to Report Abuse (with or without serious bodily injury) When to report: Immediately, but not later than two hours after the incident occurs or is suspected

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 10 residents (Resident #61, Resident #84, and Resident #131) reviewed for rights. The facility failed to ensure CNA A and LVN B knocked on Resident #61's, Resident #84's, and Resident #131's door when going into the residents' rooms. The deficient practice could place residents at risk of feeling like their privacy was being invaded or the facility was not their home. Findings included: Review of Resident #61's Face Sheet dated 04/02/2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #61's diagnoses included pneumonia (infection in the lungs), type 2 diabetes mellitus with diabetic peripheral angiopathy (damage to the blood vessels in the legs and feet due to diabetes), obstructive pulmonary disease (chronic progressive lung disease), muscle wasting, lack of coordination, dysphagia (difficulty swallowing), cognitive communication deficit (problems with communication), chronic kidney disease, hypertension (high blood pressure), hyperlipidemia (high cholesterol), and end stage renal disease (kidney failure). Record review of Resident #61's Quarterly MDS dated [DATE] revealed Resident #61 had a BIMS score of 11 indicating moderate impairment. Review of Resident #84's Face Sheet dated 04/02/2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #84's diagnoses included type 2 diabetes mellitus without complications (high blood sugar), hypertensive heart disease with heart failure (damage to heart and heart failure due to chronic high blood pressure), low back pain, abnormalities of gait and mobility, muscle wasting, lack of coordination, chronic obstructive pulmonary disease (chronic progressive lung disease), anxiety (feeling of uneasiness or worry), heart failure, unsteadiness on feet, insomnia (difficulty sleeping) and malaise (feeling of general discomfort). Record review of Resident #84's Quarterly MDS dated [DATE] revealed Resident #84 had a BIMS score of 15 indicating intact cognitive response. Review of Resident #131's Face Sheet dated 04/02/2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #131's diagnoses included chronic pain, type 2 diabetes mellitus without complications (high blood sugar), hypertensive heart disease without heart failure (damage to heart due to chronic high blood pressure), lack of coordination, anxiety (feeling of uneasiness or worry), hyperthyroidism (excessive production of thyroid hormones), and epilepsy (seizure disorder). Record review of Resident #131's Quarterly MDS dated [DATE] revealed Resident #131 had a BIMS score of 0 indicating severe impairment. Observation of 700 hall on 03/31/2025 at 08:31 a.m., revealed CNA A did not knock on Resident #61's door before entering. Observation of 100 hall on 04/01/2025 at 8:52 a.m., revealed LVN B walked into Resident #84 and Resident #131's room without knocking. During an interview attempted with Resident #131 on 03/31/2025 at 9:31 a.m., revealed that she would not want to talk to the surveyor. During an interview with Resident #84 on 03/31/2025 at 2:55 p.m., she said that staff do not knock on her door. She said that she would like for staff to knock all the time. She said she gets upset when staff just walk into her room . During an interview with CNA A on 04/02/2025 at 12:37 p.m., she said that she had been trained on resident rights. She said the policy for knocking was that staff were supposed to knock, introduce themselves. She said staff were to knock anytime they wanted to enter a resident's room. She also said that it was important to knock on the resident's door because it was their right to have privacy. She said if staff do not knock it would be bad for the resident. She also said that staff needed to respect the resident and his/her privacy. She said that nurses monitor to ensure staff are knocking on the resident's doors by observation. She said she did not realize she did not knock on Resident #61's door. During an interview with LVN B on 04/02/2025 at 01:29 p.m., she said that she had been trained on resident rights. She said that staff were supposed to knock on all residents' doors before entering. She also said that it was the resident's right to refuse someone entry into their room. She said the only time staff did not need to knock was in an emergency. She said by staff not knocking the resident may not know what the staff want and get upset and think that the staff were not considerate of him or her. She said the whole staff monitored to ensure staff were knocking on the residents doors. She said that the staff would tell someone to make sure and knock if they saw them not knocking. She also said management does observations and remind staff to knock on the resident's door. She said that she did not knock on Resident #84 and Resident 131's door because she forgot, or the door was open. She said even if the door was open, she still should have knocked. During an interview with the DON on 04/02/2025 at 2:44 p.m., he said he and staff had been trained on resident rights. He said the policy was that staff were to knock on the door, introduce themselves, and wait for the resident to answer. He said that all staff were to always knock except in an emergency. He said that if staff did not knock the resident may get the impression that the staff are invading their privacy. He said that all management was responsible for monitoring to ensure staff are knocking. He said that management monitored to ensure staff were knocking by doing rounds. He said that he did not know why staff were not knocking. He said staff were trained and it would have been a shock if they were not knocking. During an interview with the ADM on 04/02/2025 at 03:56 p.m., he said that he and staff had been trained on resident rights and knocking on residents' doors. He said the policy was to knock on the door and wait for a response from the resident. he said all staff were supposed to knock before entering the resident's room. He said that it was important for staff to knock on the resident's door for their privacy. He said the resident may get startled or scare the resident. He said that all managers should be monitoring that staff are knocking on the door. She said management monitors it by observation. He said he did not know why staff were not knocking on resident's doors before entering. Record Review of Promoting/Maintaining Resident Dignity Policy dated 01/13/2023 revealed that All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. Maintain resident privacy.

Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared by methods that conserve nutritive value, flavor, and appearance. The meal test tray's on 03/31/2025, 04/01/2025, and 04/02/2025 were not at appropriate homelike meal temperature, had an unappetizing off-putting appearance (no seasoning observed, and food colliding together), not cooked well (overcooked), and lacked palatable seasoning including flavor. The facility failed to provide palatable food that was attractive or appetizing to residents' who complained the food did not look or taste good. This failure could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life. Findings include: Record review of Resident #130's Face Sheet dated 04/02/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included Schizoaffective Disorder (mental health condition such as, mood disorders, hallucinations, and delusions), Bipolar (mental illness characterized by extreme mood swings), Traumatic Brain Injury With Loss of Consciousness (concussion), Muscle Weakness (lack of muscle strength), Intellectual Disabilities (neurodevelopmental disorder characterized by significantly impaired intellectual and adaptive functioning) , Epilepsy (brain condition that causes recurring seizures), and Heart Disease (conditions that affect the heart). Record review of Resident #130's quarterly Minimum Data Set, dated dated dated [DATE] reflected a Brief Interview for Mental Status Score of 05, which indicated cognitive severe impairment. Record review of Resident #130's Care Plan dated 01/25/2025 reflected Resident #130 requires supervision with eating and with setup assistance at times by 1 staff. Monitor Resident #130's change in eating patterns and habits. Record review of resident #68's Face Sheet dated 04/02/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included Cerebral Infarction (stroke that affects the blood flow to the brain), Muscle Wasting and Atrophy (loss of muscle mass and strength), Lack of Coordination (difficulty controlling voluntary muscle movements), Intellectual Disabilities (neurodevelopmental disorder characterized by significantly impaired intellectual and adaptive functioning), Respiratory Failure (condition that occurs when the lungs cannot remove all of the carbon dioxide the body produces), Anemia (condition in which you do not have enough healthy red blood cells or hemoglobin to carry adequate oxygen), and Depression (mood disorder, the individual experiences persistent symptoms of lower state of mind and mood, sadness, and a loss of interest in daily activities). Record review of resident #68's quarterly Minimum Data Set, dated dated dated [DATE] reflected a Brief Interview for Mental Status Score of 12, which indicated moderate cognitive impairment. Record review of resident #68's Care Plan dated 10/12/2024 reflected Resident #68 requires supervision during eating and with setup assistance. Monitor Resident #68's change in eating patterns. Record review of resident #30's Face Sheet dated 04/02/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included Cerebrovascular Disease (a group of disorders that affect blood flow to the brain), Major Depressive Disorder (individual experiences extensive symptoms of lower state of mind and mood, sadness, and a loss of interest in daily activities), Lack of Coordination (difficulty controlling voluntary muscle movements), Muscle Wasting and Atrophy (loss of muscle mass and strength), Epilepsy (brain condition that causes recurring seizures), and Cerebral Infarction (stroke that affects the blood flow to the brain). Record review of resident #30's quarterly Minimum Data Set, dated dated dated [DATE] reflected a Brief Interview for Mental Status Score of 15, which indicated intact cognitive response. Record review of resident #30's Care Plan dated 01/19/2025 reflected Resident #30 can feed self with supervision to limited assist and setup by staff. In an interview on 03/31/2025 at 7:48 AM conducted with FSS , he stated staff make the sauce and residents do not like the sauce. FSS stated he posted chicken picata on the menu for today and then served chicken tenders. Food Service Supervisor stated anyone who comes to him with a complaint put it on the grievances. Food Service Supervisor stated the plate warmers work and the food goes out hot. FSS stated the plate warmers should hold temperature for 20 minutes, but the kitchen relies on Nursing staff to pass the trays out when leaving the kitchen. In an interview on 03/31/2025 at 9:54 AM conducted with Resident #130, he stated the following: He receives meals and drinks, but the meal at this facility is not what he wants, and it is not good. The food is cold. The food alternatives are all right, but not things he really wants. In an interview on 03/31/2025 at 10:49 AM conducted with Resident #68, he stated he receives meals and drinks, but the staff are stingy on the coffee. Resident #68 stated the food has not been good during each mealtime and dislikes the quality. In an interview on 03/31/2025 at 10:50 AM conducted with Resident #30, he stated the following: he receives his meals and drinks at the facility, but the food is not the best. Resident #30 feels they must eat what they get, and the food is not great overall. Observation on 03/31/25 at 12:15 PM revealed a plate of food with two fried chicken patties, a scoop of orzo that was hardened around the edges, and a tomato slice with melted cheese. The orzo was flavorless and was hard to chew. The tomato with cheese was bland. Additional observation revealed a puree plate with all the items running together. It contained chicken, green beans, bread, and orzo. The chicken was thick and flavorless, and the orzo was tacky and hard to swallow. In an observation on 03/31/2025 at 1:08 PM of Resident #14 during mealtime, it was observed there were snacks and extra food provided that was not on meal ticket. Record review of Resident Council notes/ Grievances were conducted, there were consistent notes of complaints in terms of the food within the last 3 months. January 2025 stated, Too much spaghetti and pasta, dislikes the milk and orange juice being served, no more eggs and want potatoes, and resident is lactose intolerant and still receives dairy products. February 2025 stated, resident requesting Dietary to change the breakfast. March 2025 stated, resident doesn't get the correct diet, resident who don't want pork still gets pork, resident receiving cold cereal and not hot cereal, and resident's not receiving food that's been requested. In a confidential residential meeting on 04/01/2025 at 2:00 PM, the majority of 7 of 7 residents in the meeting stated the following: lunch and dinner are late. The kitchen changes up what is on the menu sometimes if kitchen staff make something from scratch, or it will take them a longer time. The food quality depends on the day and what it is they are serving that will determine if its good or not. Residents think the food brands are not the best and effects the quality of taste. Residents have made recommendations at times, but there have been times staff will say that is not their job if they do not work directly in the kitchen. Residents have issues with food on the menu not matching. The food served is too cold. Sometimes the food will sit out in the halls for 10 to 15 minutes in which the food will be cold or slightly warm, not hot given the facility have 4 different dining rooms and residents who eat in their rooms. The residents stated it makes them feel frustrated or at times they do not want to eat. Residents understand food is expensive, but they have not seen grapes or other fruit and vegetables that are fresh. Observation on 04/01/25 at 5:10 PM revealed a plate of beans, ham, and potatoes with cheese on top. The ham was hardened on the edges, the beans were not served separately and were colliding with the other items on the plate. The potatoes had very little cheese and did not taste of any other seasoning added. Observation on 04/02/25 at 12:45 PM revealed a plate of pulled pork, hot potato salad and broccoli. The vinegar taste from the hot potato salad had transferred to the broccoli and the broccoli was overcooked and mushy. In an interview on 04/02/2025 at 1:00 PM conducted with CNA G, she stated the following: The policy for resident rights when it comes to food is to read the meal ticket, and diet. Residents can have food within their assigned diet and right to refuse food. The hall tray process is, a Nurse checks meal tickets and CNA G double check meal trays and give it to residents while sanitizing in between. Staff are supposed to pass out meal trays to residents as soon as possible, a team of staff helps, so it can be handed out warm to residents. Staff make sure resident's meals are at appropriate temperatures when receiving meals, they do not check with a thermometer and just feel the plate to see if it is warm. If the resident does not like the meal provided, alternative is offered. If residents are served food that is not in their diet or non-preferred, staff make sure that the resident gets the right food and alternative or speak with staff in the kitchen to fix it. If a resident does not like the food and does not eat it, staff will offer milkshakes. The resident could potentially lose weight nor gain nutrients . The Dietician oversees making sure residents are satisfied with their meals. Staff will try to help encourage residents to eat the food, but it can affect the residents quality of life if they are not receiving good food for them to be well fed. In an interview on 04/02/2025 at 1:10 PM conducted with FSS, he stated the following: he was aware of the food arriving cold, and when people complained he would be out in the hallways ensuring the staff was passing out trays in a timely manner. FSS stated that the food will stay warm for 20 minutes when it leaves the kitchen. FSS stated when he gets a grievance, he goes over the grievance with the Nursing staff and the individual. FSS stated that he does not go to the corporate Dietitian to change the menus. The corporate Dietician set the menus for 6 months in advanced. Food Service Supervisor stated that the residents consistently complain about the menu. FSS stated that he does taste test the food but any issues with the food is because the menus are bland. FSS stated he does add cranberry juice to the bread to give it more flavor. FSS stated he posts the big menus and makes the posted daily menu's match the corporate menus. FSS stated he makes substitutions on the daily menu because of resident preferences. FSS stated he does not have proof that there were resident preferences for removing menu items. In an interview on 04/02/2025 at 1:30 PM conducted with RN F, she stated the following: The policy for resident rights when it comes to food, is staff can provide alternatives or residents have the right to say no, but staff try to encourage residents to eat. The hall tray process is, the food comes out of the kitchen and goes to dining room or resident's bedrooms, Nurses check diets and food, when it is ready to serve the Certified Nurse Aide check then serve the food to residents. Staff sanitize in between providing meal trays. Staff are supposed to pass out trays to residents, it is usually quick, and staff try not waste time, so residents can get warm food. Staff make sure resident's meals are at appropriate temperatures when receiving meals, staff can feel if the food is warm by the touch of the hand on meal plate. If a resident does not like the meal provided, alternatives or preferred snacks are offered. The steps made if a resident is served food that is not in their diet or non-preferred is, they take the food to the kitchen and notify the kitchen staff, so it can be corrected. If a resident does not like the food and does not eat it, staff attempt to encourage the resident to eat food or offer shakes, it can affect the resident's weight and they will let the Nurse Practitioner and Dietician know, so that way they can make meal adjustments. The kitchen staff and FSS oversees making sure residents are satisfied with their meals. It can affect the resident's quality of life if the resident does not eat such as, make the resident weaker, have no energy, and lose nutrients. In an interview on 04/02/2025 at 2:45 PM conducted with DON, he stated the following: The policy for resident rights when it comes to food, refers to Dietitian Manager, make sure diet is followed, make sure the food is provided to the resident timely, and right to refuse food. The hall tray process is, released from the kitchen to the dining room and hall, the nursing staff check the diets. If a resident complains about the food, they will provide an alternative and tell the Dietician. If the food does not taste good per the resident, they will inform the Dietary Manager and visit with the resident to meet their needs. Staff sanitize in between providing meal trays. Staff are supposed to pass out trays to residents, he does not have a specific timeframe but as fast as possible. Staff make sure resident's meals are at appropriate temperatures when receiving meals, the residents will let them know and they can warm up the food for the residents in a microwave for whoever may need it warmer, and for a resident who is non-verbal, the staff observe the resident's facial expressions or ask if it's hot or cold to see if a resident gives them behavioral cues to let staff know. If a resident does not like the meal provided, alternatives or preferred food are offered. The facility has a big budget when it comes to food. They try to accommodate resident preferences. They can transport residents to get certain food from a store. What steps are made if a resident is served food that is not in their diet or non-preferred, they make reasonable offers or they will review the diet. If a resident does not like the food and does not eat it, staff attempt to encourage resident to eat food or provide medication from a Physician to see if that will help with food intake and assist with maintaining residents' weights. The Administrator, Director of Nursing, and Food Service Supervisor as well as all staff oversees making sure residents are satisfied with their meals. It can affect the resident's quality of life in term of their weight. In an interview on 4/02/2025 at 4:05 PM conducted with the ADM he stated menus should match what is on the plate. Administrator stated staff should keep track of meals matching the menu. Administrator stated his expectation if staff are not presenting options, is for them to present options, and try to address that situation. Administrator stated the facility make sure the menu meets the nutritional value for residents and they can tweak the menu. Administrator stated he is responsible for the kitchen staff, and everyone has an individual diet including individual palette. Administrator stated negative outcomes is bad food coming out of the kitchen, and flavor of the food is the number one complaint at the facility. Record review of Meal Service and Nursing Responsibilities policy revised on 11/2007 stated: Policy: It is the policy of this facility that Nursing Services will cooperate with the Dietary Department to ensure that each resident is served according to regulations. Purpose: To insure accurate and safe meal service. Procedures: Trays will be passed in a timely manner. Food must remain covered while being distributed through the hallways and tray cards should remain with trays throughout meal service (unless there is a dual card system). Offer substitute food of equal nutritive value to a resident if the resident refuses a menu item. Record review of Meal Services and Between Meal Feedings policy revised on 05/2007 stated: Policy: It is the policy for this facility that the Nursing Department is responsible for ensuring that the residents receive their meals and nourishments. Purpose: To ensure that residents receive meals and nourishments in a timely, courteous, and helpful manner. Procedures: 1. The Nursing Department is responsible for the delivery of food and ensuring that all efforts are made to assist residents during meal and nourishment times. 2. Specific mealtime responsibilities are: The deliver of food/meal trays to the residents in a timely manner. Encourage residents to eat all the food they were served. Order equivalent substitutes for food if less than 75% is accepted (check the daily menu for pre-planned vegetables and entree substitutes). Review tray identification cards for special needs. 51115 Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared by methods that conserve nutritive value, flavor, and appearance. The meal test tray's on 03/31/2025, 04/01/2025, and 04/02/2025 were not at appropriate homelike meal temperature, had an unappetizing off-putting appearance (no seasoning observed, and food colliding together), not cooked well (overcooked), and lacked palatable seasoning including flavor. The facility failed to provide palatable food that was attractive or appetizing to residents' who complained the food did not look or taste good. This failure could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life. Findings include: Record review of Resident #130's Face Sheet dated 04/02/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included Schizoaffective Disorder (mental health condition such as, mood disorders, hallucinations, and delusions), Bipolar (mental illness characterized by extreme mood swings), Traumatic Brain Injury With Loss of Consciousness (concussion), Muscle Weakness (lack of muscle strength), Intellectual Disabilities (neurodevelopmental disorder characterized by significantly impaired intellectual and adaptive functioning) , Epilepsy (brain condition that causes recurring seizures), and Heart Disease (conditions that affect the heart). Record review of Resident #130's quarterly Minimum Data Set, dated dated dated [DATE] reflected a Brief Interview for Mental Status Score of 05, which indicated cognitive severe impairment. Record review of Resident #130's Care Plan dated 01/25/2025 reflected Resident #130 requires supervision with eating and with setup assistance at times by 1 staff. Monitor Resident #130's change in eating patterns and habits. Record review of resident #68's Face Sheet dated 04/02/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included Cerebral Infarction (stroke that affects the blood flow to the brain), Muscle Wasting and Atrophy (loss of muscle mass and strength), Lack of Coordination (difficulty controlling voluntary muscle movements), Intellectual Disabilities (neurodevelopmental disorder characterized by significantly impaired intellectual and adaptive functioning), Respiratory Failure (condition that occurs when the lungs cannot remove all of the carbon dioxide the body produces), Anemia (condition in which you do not have enough healthy red blood cells or hemoglobin to carry adequate oxygen), and Depression (mood disorder, the individual experiences persistent symptoms of lower state of mind and mood, sadness, and a loss of interest in daily activities). Record review of resident #68's quarterly Minimum Data Set, dated dated dated [DATE] reflected a Brief Interview for Mental Status Score of 12, which indicated moderate cognitive impairment. Record review of resident #68's Care Plan dated 10/12/2024 reflected Resident #68 requires supervision during eating and with setup assistance. Monitor Resident #68's change in eating patterns. Record review of resident #30's Face Sheet dated 04/02/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included Cerebrovascular Disease (a group of disorders that affect blood flow to the brain), Major Depressive Disorder (individual experiences extensive symptoms of lower state of mind and mood, sadness, and a loss of interest in daily activities), Lack of Coordination (difficulty controlling voluntary muscle movements), Muscle Wasting and Atrophy (loss of muscle mass and strength), Epilepsy (brain condition that causes recurring seizures), and Cerebral Infarction (stroke that affects the blood flow to the brain). Record review of resident #30's quarterly Minimum Data Set, dated dated dated [DATE] reflected a Brief Interview for Mental Status Score of 15, which indicated intact cognitive response. Record review of resident #30's Care Plan dated 01/19/2025 reflected Resident #30 can feed self with supervision to limited assist and setup by staff. In an interview on 03/31/2025 at 7:48 AM conducted with FSS, he stated staff make the sauce and residents do not like the sauce. FSS stated he posted chicken picata on the menu for today and then served chicken tenders. Food Service Supervisor stated anyone who comes to him with a complaint put it on the grievances. Food Service Supervisor stated the plate warmers work and the food goes out hot. FSS stated the plate warmers should hold temperature for 20 minutes, but the kitchen relies on Nursing staff to pass the trays out when leaving the kitchen. In an interview on 03/31/2025 at 9:54 AM conducted with Resident #130, he stated the following: He receives meals and drinks, but the meal at this facility is not what he wants, and it is not good. The food is cold. The food alternatives are all right, but not things he really wants. In an interview on 03/31/2025 at 10:49 AM conducted with Resident #68, he stated he receives meals and drinks, but the staff are stingy on the coffee. Resident #68 stated the food has not been good during each mealtime and dislikes the quality. In an interview on 03/31/2025 at 10:50 AM conducted with Resident #30, he stated the following: he receives his meals and drinks at the facility, but the food is not the best. Resident #30 feels they must eat what they get, and the food is not great overall. Observation on 03/31/25 at 12:15 PM revealed a plate of food with two fried chicken patties, a scoop of orzo that was hardened around the edges, and a tomato slice with melted cheese. The orzo was flavorless and was hard to chew. The tomato with cheese was bland. Additional observation revealed a puree plate with all the items running together. It contained chicken, green beans, bread, and orzo. The chicken was thick and flavorless, and the orzo was tacky and hard to swallow. In an observation on 03/31/2025 at 1:08 PM of Resident #14 during mealtime, it was observed there were snacks and extra food provided that was not on meal ticket. Record review of Resident Council notes/ Grievances were conducted, there were consistent notes of complaints in terms of the food within the last 3 months. January 2025 stated, Too much spaghetti and pasta, dislikes the milk and orange juice being served, no more eggs and want potatoes, and resident is lactose intolerant and still receives dairy products. February 2025 stated, resident requesting Dietary to change the breakfast. March 2025 stated, resident doesn't get the correct diet, resident who don't want pork still gets pork, resident receiving cold cereal and not hot cereal, and resident's not receiving food that's been requested. In a confidential residential meeting on 04/01/2025 at 2:00 PM, the majority of 7 of 7 residents in the meeting stated the following: lunch and dinner are late. The kitchen changes up what is on the menu sometimes if kitchen staff make something from scratch, or it will take them a longer time. The food quality depends on the day and what it is they are serving that will determine if its good or not. Residents think the food brands are not the best and effects the quality of taste. Residents have made recommendations at times, but there have been times staff will say that is not their job if they do not work directly in the kitchen. Residents have issues with food on the menu not matching. The food served is too cold. Sometimes the food will sit out in the halls for 10 to 15 minutes in which the food will be cold or slightly warm, not hot given the facility have 4 different dining rooms and residents who eat in their rooms. The residents stated it makes them feel frustrated or at times they do not want to eat. Residents understand food is expensive, but they have not seen grapes or other fruit and vegetables that are fresh. Observation on 04/01/25 at 5:10 PM revealed a plate of beans, ham, and potatoes with cheese on top. The ham was hardened on the edges, the beans were not served separately and were colliding with the other items on the plate. The potatoes had very little cheese and did not taste of any other seasoning added. Observation on 04/02/25 at 12:45 PM revealed a plate of pulled pork, hot potato salad and broccoli. The vinegar taste from the hot potato salad had transferred to the broccoli and the broccoli was overcooked and mushy. In an interview on 04/02/2025 at 1:00 PM conducted with CNA G, she stated the following: The policy for resident rights when it comes to food is to read the meal ticket, and diet. Residents can have food within their assigned diet and right to refuse food. The hall tray process is, a Nurse checks meal tickets and CNA G double check meal trays and give it to residents while sanitizing in between. Staff are supposed to pass out meal trays to residents as soon as possible, a team of staff helps, so it can be handed out warm to residents. Staff make sure resident's meals are at appropriate temperatures when receiving meals, they do not check with a thermometer and just feel the plate to see if it is warm. If the resident does not like the meal provided, alternative is offered. If residents are served food that is not in their diet or non-preferred, staff make sure that the resident gets the right food and alternative or speak with staff in the kitchen to fix it. If a resident does not like the food and does not eat it, staff will offer milkshakes. The resident could potentially lose weight nor gain nutrients. The Dietician oversees making sure residents are satisfied with their meals. Staff will try to help encourage residents to eat the food, but it can affect the residents quality of life if they are not receiving good food for them to be well fed. In an interview on 04/02/2025 at 1:10 PM conducted with FSS, he stated the following: he was aware of the food arriving cold, and when people complained he would be out in the hallways ensuring the staff was passing out trays in a timely manner. FSS stated that the food will stay warm for 20 minutes when it leaves the kitchen. FSS stated when he gets a grievance, he goes over the grievance with the Nursing staff and the individual. FSS stated that he does not go to the corporate Dietitian to change the menus. The corporate Dietician set the menus for 6 months in advanced. Food Service Supervisor stated that the residents consistently complain about the menu. FSS stated that he does taste test the food but any issues with the food is because the menus are bland. FSS stated he does add cranberry juice to the bread to give it more flavor. FSS stated he posts the big menus and makes the posted daily menu's match the corporate menus. FSS stated he makes substitutions on the daily menu because of resident preferences. FSS stated he does not have proof that there were resident preferences for removing menu items. In an interview on 04/02/2025 at 1:30 PM conducted with RN F, she stated the following: The policy for resident rights when it comes to food, is staff can provide alternatives or residents have the right to say no, but staff try to encourage residents to eat. The hall tray process is, the food comes out of the kitchen and goes to dining room or resident's bedrooms, Nurses check diets and food, when it is ready to serve the Certified Nurse Aide check then serve the food to residents. Staff sanitize in between providing meal trays. Staff are supposed to pass out trays to residents, it is usually quick, and staff try not waste time, so residents can get warm food. Staff make sure resident's meals are at appropriate temperatures when receiving meals, staff can feel if the food is warm by the touch of the hand on meal plate. If a resident does not like the meal provided, alternatives or preferred snacks are offered. The steps made if a resident is served food that is not in their diet or non-preferred is, they take the food to the kitchen and notify the kitchen staff, so it can be corrected. If a resident does not like the food and does not eat it, staff attempt to encourage the resident to eat food or offer shakes, it can affect the resident's weight and they will let the Nurse Practitioner and Dietician know, so that way they can make meal adjustments. The kitchen staff and FSS oversees making sure residents are satisfied with their meals. It can affect the resident's quality of life if the resident does not eat such as, make the resident weaker, have no energy, and lose nutrients. In an interview on 04/02/2025 at 2:45 PM conducted with DON, he stated the following: The policy for resident rights when it comes to food, refers to Dietitian Manager, make sure diet is followed, make sure the food is provided to the resident timely, and right to refuse food. The hall tray process is, released from the kitchen to the dining room and hall, the nursing staff check the diets. If a resident complains about the food, they will provide an alternative and tell the Dietician. If the food does not taste good per the resident, they will inform the Dietary Manager and visit with the resident to meet their needs. Staff sanitize in between providing meal trays. Staff are supposed to pass out trays to residents, he does not have a specific timeframe but as fast as possible. Staff make sure resident's meals are at appropriate temperatures when receiving meals, the residents will let them know and they can warm up the food for the residents in a microwave for whoever may need it warmer, and for a resident who is non-verbal, the staff observe the resident's facial expressions or ask if it's hot or cold to see if a resident gives them behavioral ques to let staff know. If a resident does not like the meal provided, alternatives or preferred food are offered. The facility has a big budget when it comes to food. They try to accommodate resident preferences. They can transport residents to get certain food from a store. What steps are made if a resident is served food that is not in their diet or non-preferred, they make reasonable offers or they will review the diet. If a resident does not like the food and does not eat it, staff attempt to encourage resident to eat food or provide medication from a Physician to see if that will help with food intake and assist with maintaining residents' weights. The Administrator, Director of Nursing, and Food Service Supervisor as well as all staff oversees making sure residents are satisfied with their meals. It can affect the resident's quality of life in term of their weight. In an interview on 4/02/2025 at 4:05 PM conducted with the ADM he stated menus should match what is on the plate. Administrator stated staff should keep track of meals matching the menu. Administrator stated his expectation if staff are not presenting options, is for them to present options, and try to address that situation. Administrator stated the facility make sure the menu meets the nutritional value for residents and they can tweak the menu. Administrator stated he is responsible for the kitchen staff, and everyone has an individual diet including individual palette. Administrator stated negative outcomes is bad food coming out of the kitchen, and flavor of the food is the number one complaint at the facility. Record r

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to ensure DA I ate food outside of the kitchen production area. 2. The facility failed to ensure the dishwasher's hot water was at the appropriate temperature. 3. The facility failed to ensure areas behind the oven and stove were clean. 4. The facility failed to ensure shelves were functional and did not require additional supports for the shelves to stay upright. 5. The facility failed to ensure the items in the walk-in fridge were free from liquid from other food products. 6. The facility failed to ensure the floors in the kitchen, walk-in fridge, and storage room were swept clean and free of trash. 7. The facility failed to keep the microwave clean. These failures could place residents who were served from the kitchen at risk for consuming hazardous expired food and developing foodborne illnesses. Findings Included: Observation on [DATE] at 7:15 am in the dry storage pantry revealed unknown food items on the ground out of packages. Observation on [DATE] at 7:15 am in the walk-in fridge revealed dust and dirt on the ground along with plastic bags and scraps of cardboard. Observation on [DATE] at 7:15 am revealed a box labeled Butcher Box Pork with a red liquid on top. Observation on [DATE] at 7:18 am revealed the microwave with red splatters on the interior walls. Observation on [DATE] at 7:18 am revealed 3 shelving units in the walk-in fridge with rust over the entire surface and wood blocks supporting the shelves to keep them level. Observation on [DATE] at 7:19 am revealed food and cooking oil debris on the floor, behind the stove and ovens, and on the gas, lines leading to the equipment. Observation on [DATE] at 7:30 am revealed the dishwasher reaching a final temperature of 112 degrees Fahrenheit throughout the entire cycle. During an interview on [DATE] at 7:45 am DA J stated that she was not sure how to do the time and temperature checks on the machine . She stated she does not normally run the dishwasher. She stated she saw the dishes needed to be done so she jumped in a started washing dishes. Observation on [DATE] at 5:15 pm revealed DA I standing in the doorway between the dishwashing room and the production area eating a cucumber while watching the staff serve dinner. During an interview on [DATE] at 11:45 am CK K revealed that the shelves in the pantry had been broken for a while and that she did not know when they were going to be replaced. She stated that the dirty floors should have been cleaned by the dishwasher or night shift from the previous day. She stated she did not see the red liquid, but a cook should have thrown that out. She stated she was trained on kitchen cleaning procedures when she was hired and the FSS has a cleaning schedule for everyone. During an interview on [DATE] at 2:15 pm with the FSS revealed that he was not sure why they did not replace the shelves. He stated it was an old building and old equipment. He stated they have been replacing equipment slowly but had not replaced the shelves yet. He stated his cooks should have removed the contaminated box and labeled and dated the content and put it in a pan. He stated that it was hard to clean behind the ovens because maintenance must help them unplug the machines. He stated he has a cleaning schedule and they deep clean once a month and last time they cleaned behind the machines was when they received the new equipment months ago. The expectation was that staff clean the floors and the workstations after their shift and to adhere to the cleaning schedule even when he is not on shift. He stated his employees were to eat off the clock in the employee breakroom and not in the kitchen. If the food were not prepared properly the residents could get sick. During an interview on [DATE] at 3:05 pm with the DON he stated that he refers to the dietary manager to follow all food regulations and that he expected the FSS to enforce all food safety and sanitation regulations. During an interview on [DATE] at 4:00 pm with the ADM he stated that he expects the FSS to ensure the employees are following all policies and regulations. He stated the FSS is responsible for the kitchen at all times and all shifts. Record review of facility policy entitled Dietary, Sanitation revised ,d+[DATE] revealed. It is the policy of this facility that the food service area shall be maintained in a clean and sanitary manner. 1. All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter. 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas.

Based on observation, interview and record review the facility failed to ensure each resident's bedside, toilet and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 3 of 10 residents (Resident #13, Resident #34, and Resident #124 ) reviewed for resident call system . The facility failed to provide a working communication system, which was easily at reach, which would allow Resident #13, Resident #34, and Resident #124 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living. Findings include: Record review of Resident #13's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #13 had diagnoses which included a cerebral infarction (a stroke), vascular dementia (brain damage caused by multiple strokes), need for assistance with personal care, unsteadiness on feet, major depressive disorder, anxiety (feeling of uneasiness or worry), personal history of benign neoplasm of the brain (brain cancer), and personal history of non-Hodgkin lymphoma (cancer that affects part of the immune system). Record review of Resident #13's Quarterly MDS dated [DATE] reflected Resident #13 had a BIMS Score of 13, which indicated intact cognitive response. The MDS further reflected Resident #13 needed the assistance of two or more helpers for his activities of daily living, bed mobility, and transfers, and he used a wheelchair for mobility. Record review of Resident #13's Care Plan, last revised on 03/07/25, ensure Resident #13's call light was within reach and encourage the resident to use it for assistance as needed. Resident #13 needed prompt response to all requests for assistance. A working and reachable call light. Review of Resident #34's Face Sheet dated 04/02/2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #34's diagnoses included adult failure to thrive, muscle wasting, lack of coordination, muscle weakness, unsteadiness on feet, dementia (memory, thinking, difficulty), Parkinson's disease (a progressive disorder that affects the nervous system), dysarthria, and anarthria (severe speech sound disorder), and dysarthria (speech sound disorder). Record review of Resident #34's Quarterly MDS dated [DATE] reflected Resident #34 had a BIMS Score of 12, which indicated moderate cognitive impairment. The MDS further reflected Resident #34 was dependent on staff for his activities of daily living, bed mobility, and transfers, and he used a wheelchair for mobility. Record review of Resident #34's Care Plan, last revised on 01/27/25, encourage Resident #34 to us bell to call for assistance. Call light was within reach and encourage the resident to use it for assistance as needed. Resident #34 needed prompt response to all requests for assistance. Review of Resident #124's Face Sheet dated 04/02/2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #124's diagnoses included muscle wasting, lack of coordination, muscle weakness, unsteadiness on feet, severe intellectual disability, anxiety (feeling of uneasiness or worry), depressive disorder, seizures, respiratory failure and reflux. Record review of Resident #124's Quarterly MDS dated [DATE] reflected Resident #124 had a BIMS Score of 0, which indicated severe cognitive impairment. The MDS further reflected Resident #124 was dependent on staff for his activities of daily living, bed mobility, and transfers, and he used a wheelchair for mobility. Record review of Resident #124's Care Plan, last revised on 03/06/25, Be sure Resident #124's call light was within reach and encourage the resident to use it for assistance as needed. Resident #124 needed prompt response to all requests for assistance. Observation of Resident #13's call light on 03/31/25 at 07:24 AM revealed the call light was at the foot of Resident #13's bed on the floor. Observation of Resident #124's call light on 03/31/2025 at 9:37am revealed that his call light was not within reach of the resident. Resident #124's call light was on his roommate's bedside table. Observation of Resident #34's call light on 03/31/2025 at 10:04am revealed that his call light was clipped onto the light in the resident's room. The call light was about 40 feet above the resident out of reach as the resident could not get out of bed on his own. During an interview on 03/31/25 07:23AM with Resident #13 revealed earlier in the morning at 06:35 AM he was trying to get help with his call light because it had fallen between the bed and the wall. Resident #13 stated the CNA threw the call light and tossed it across the room when he assisted him up to the wheelchair. Resident #13 stated he had been trying to get someone to help get him changed. During an interview with Resident #124 on 03/31/2025 at 9:37am revealed he would not talk to the surveyor. During an interview with Resident #34 on 03/31/2025 at 10:04am revealed that staff do not answer his call light. He said his call light was not always within his reach and he cannot get help. During an interview with CNA A on 04/02/2025 at 12:32pm revealed she had been trained on resident rights. She said the policy was the call light had to be always within the resident's reach. She said the call light should be within reach any time the resident was in bed or in their room. She said if the call light was not in the resident's reach the resident would not be able to get the help they need. She said that the CNA's were responsible for ensuring the call light was within reach. She said that when the CNA's did their rounds, they were supposed to check the call light and make sure it was in the resident's reach. She said she did not know why the residents' call lights were not in reach. During an interview with LVN B on 04/02/2025 at 1:22pm revealed that she had been trained on resident rights. She said that the call light was supposed to be where the resident could reach it. She also said that if the resident was paralyzed the call light should be placed on the side that was not paralyzed. She said all staff were responsible for ensuring the call light was within reach. She said if the call light was not within the resident's reach that the resident could fall or hurt. She also said that the nurses and CNA's were responsible for ensuring the call lights were within the resident's reach. She said the CNA's and nurses monitor the call lights by doing rounds and will put the call light in the resident's reach if it was not in their reach. She said that the staff did not pay attention to the call lights and that was why the call lights were not in reach. During an interview with the DON on 04/02/2025 at 2:52pm revealed that he and staff had been trained on resident rights. He said that the call light was supposed to be within the resident's reach. He also said that if anyone saw the call light not in reach the staff member was responsible for putting it within the resident's reach. He said if the call light were not within the resident's reach that the resident could not let staff know what they needed or communicate with the staff. He also said that all staff were responsible for ensuring the call lights were within the resident's reach. He said call lights were monitored by doing rounds. He said he did not know why the call light was not in reach. He said it would be magic if he could tell me why the call lights were not in reach. During an interview with the ADM on 04/02/2025 at 3:52pm revealed that he and staff had been trained on resident rights. He said that the call light was supposed to be within the resident's reach. He also said that primarily the care giver was responsible for putting the call light within the resident's reach. He said if the call light were not within the resident's reach that the resident could not call for help when they needed it. He also said that care givers and management were responsible for ensuring the call lights were within the resident's reach. He said call lights were monitored by doing rounds. He said he did not know why the call light was not in reach. Record Review of Call Lights: Accessibility and Timely Response Policy dated 10/12/2022 revealed staff will ensure the call light is within reach of resident and secured, as needed. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Based on observations, interviews, and record review, the facility failed to ensure the meals served reflected the nutritional needs of residents in accordance with established national guidelines for all residents when the facility failed to ensure menus were followed for all residents for 2 of 2 meals observed. The facility failed to follow the posted menus for two meal services served at the facility on Monday, 03/31/25 and Tuesday 04/01/25. These failures could place residents that eat food from the kitchen at risk of poor intake, chemical imbalance, and/or weight loss. Findings included: Observation of posted menus on 03/31/25 at 11:53 AM revealed menu items for lunch meal service to be chicken piccata, orzo, parmesan tomato half, wheat bread, baked peach slices, coffee or tea and garnish parsley sprig. Observation of lunch meal service on 03/31/25 at 12:35 PM revealed resident meal trays being served with two fried chicken patties, orzo, parmesan tomato half and a slice of bread. Observation of posted dinner menus on 04/01/25 at 4:11 pm revealed menu items for dinner to be maple glazed ham, sweet potatoes, season beans, wheat roll and apple cranberry crisp. Observation of dinner meal service on 04/01/25 at 5:35 PM revealed resident meal trays being served with plain ham, white potatoes covered in cheese, seasoned beans, a piece of wheat bread and apple cranberry crisp. In an interview on 04/01/25 at 2:15 pm with the FSS , he stated that he frequently changes the menu from the corporate company to accommodate the resident's needs. He stated he will post a daily menu and then initiate the individual menu item changes without updating the posted daily menu. He did not see the need to change the actual menu that was posted for the residents. He stated the residents do not complain about the changes. He stated he would have heard complaints from the residents because he is present on the floors for most meals. He stated that residents get bored of the meals because they are on a cycle. He stated it could cause potentially confusion to the residents if they read the menus but those who read the menus do not complain. The facility does approve the menu with the corporate company. They do not adjust the menus for the next menu cycle because it is impossible to tell exactly what his residents will like. He stated he goes to the resident council meetings to see what his resident's like but does not keep a record other than what is on their meal tray ticket likes and dislikes section. In an interview on 04/02/25 at 3:00 pm with the DON stated that the menus that are posted should have been accurate for what is served on the plate. It is the facility expectation that he follows the facility policy for substitutions. In an interview on 04/02/25 at 4:00 pm the ADM stated menus being followed was essential, so the resident was aware of the foods being offered. He stated all changes need to be signed off by the dietitian. He stated that flavor of the food is the biggest complaint, so they make changes. He stated that they should be adjusting the menus from the corporate company to the resident's needs and desires . Review of substitution log revealed that only one substitution had been documented on 03/31/25 which was white potatoes with cheese in place of sweet potatoes. Record review of substitution policy dated 05/10/2018 stated, The FSD and the nutrition consultant will ensure that documentation of the meals served, and substitutions made is maintained to ensure compliance with the menus as planned. 1. The nutrition consultant will initial and date the substitution list and ensure that an approved copy is placed with the weekly menu.

Based on observation, interview, and record review the facility failed to revise the care plan for 1 of 10 (Resident #92) residents reviewed for care plans. The facility failed to update the care plan to reflect the use of bed rails as an assistive aid for Resident #92. This failure placed the resident at risk of losing mobility, becoming entrapped, and receiving improper care. Findings include: Resident #92 Record review of Resident # 92's face sheet was a [AGE] year-old female admitted to the facility on [DATE] with pertinent diagnoses of unspecified dementia without behavioral disturbances (a degenerative brain disease that does not cause behavioral issues), Muscle wasting and atrophy (a generalized condition of muscle deterioration), unsteadiness on feet, and cognitive communication deficit (the inability to communicate effectively). Record review of Resident#92's MDS dated [DATE] indicated Resident #92 has a BIMS score of 13 which indicated cognition was intact and limited assistance to only supervision with activities of daily living. Record Review of Resident #92's care plan updated on 03/31/25 reveals, Resident #92 has an ADL self-care performance deficit r/t Confusion, Impaired balance. Interventions include. SIT TO LYING: supervision or touching assistance. LYING TO SITTING ON SIDE OF BED: supervision or touching assistance. SIT TO STAND: supervision or touching assistance. CHAIR/BED-TO-CHAIR TRANSFER: supervision or touching assistance. Care plan has no mention of assistive bed rails. Record Review indicates no bedrail assessment in the medical records. Observation and Interview with Resident #92 lying in bed on 04/01/25 at 01:45 PM with bed rails up. She stated that her bed is old, and the bed rails came with it. She likes the bed rails because they help her adjust her body in the bed. She stated that they do not hinder her ability to get out of bed. She stated that they do not make her feel restricted and that she could put them down if she wanted to. She demonstrated how she utilized the bed rails to get out of bed and walk over the bathroom. In an interview with RN E 04/02/25 at 11:06 AM she stated she was aware that Resident #92 had bedrails but was not aware that it was not on her care plan. She stated that when someone gets bed rails the DON had trained them to do a bedrail assessment. She stated that bed rails should be care planned and have doctor's orders. She stated that someone could use them inappropriately and cause her to lose mobility if they are not used in the proper way. Interview with the DON on 04/02/25 at 03:34 PM he stated that care plans ensure the best delivery of care. That the care plans should have your dietary needs, code status, any behaviors, ADL's and a plan for assistance with ADL's. The care plan was supposed to project the picture on how to provide the best care possible. He stated bedrails should be on there. He stated that they did a bed rail assessment for all resident's last month and he was surprised that Resident #92 was not identified as having a bed rail. He stated that he trained the nurses to do a physical devices assessment. He stated that the nurses, the care managers, or he would do the physical device assessment and update the care plans. He stated the facility would ensure they have proper consents for the side rails. If the side rails were not care planned and were used inappropriately, she could, theoretically, become trapped in her bed. Interview with ADMIN on 04/02/25 4:00 PM he stated that care plans are used to provide feedback to the facility and make sure the facility is meeting the resident's expectation. He stated that the expectation was for bed rails to be care planned if they are used as assistive devices. He stated they did an audit and was unsure why Resident #92 did not show up on the audits. He stated that she was completely ambulatory and was able to pull the bedrails up when she needed. He stated if she is using the bed rails, they should be in the care plan. Record review of Care Plan policy dated 10/24/22 states, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. e. Resident specific interventions that reflect the resident's needs and preferences.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #461) of three residents reviewed for quality of care. The facility failed to respond to and assess Resident #461's malfunctioning beeping oxygen concentrator with a red-light indicating malfunction for approximately 45 minutes. This failure could place residents at risk of an oxygen delivery problem, not receiving necessary medical care, harm, and hospitalization . Findings included: Review of Resident #461's face sheet dated 04/01/24 reflected an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's disease (a progressive neurodegenerative disorder primarily affecting movement, causing symptoms like tremors, slowness of movement, and stiffness, often due to a decline in dopamine-producing brain cells) and dementia. Review of Resident #461's admission MDS assessment, dated 03/26/24, reflected no BIMS score . Resident #461's care plan dated 03/18/25 reflected resident had a diagnosis of Parkinson's disease with an intervention dated 03/18/25 of give medications as ordered by the physician. Resident #461's care plan reflected he was followed by hospice with an intervention dated 03/06/25 keep the environment quiet and calm. Review of Resident #461's order dated 03/31/25 reflected resident may have oxygen for shortness of breath as needed. Observation on 03/31/25 at 8:47 am when walking down facility hallway 900 of hearing a loud beeping noise coming from room [ROOM NUMBER]. After entering the room surveyor observed the noise came from Resident #461's oxygen concentrator. The devise was operating, and surveyor observed Resident #461's nasal cannula (flexible tube with two prongs that are inserted into the nostrils to deliver supplemental oxygen or increased airflow to a patient in need of respiratory support) in place. A red light was lit on the concentrator. The concentrator was wrapped in plastic. Surveyor alerted nurse who was at the central nurses' station located at the end of the 900 hallway . Observation and interview on 03/31/25 with LVN C at 8:49 am revealed when LVN C came into Resident #461's room after being alerted to the noise by the surveyor, LVN C confirmed that the concentrator was beeping, and a red light was on indicating the concentrator was not working. LVN C stated that Resident #461 was getting oxygen, but it was at a concentration level of 1 and the concentration level should have been at 2. LVN C said she was getting him another concentrator because, this one seems not to be working. LVN C removed the plastic that was wrapped around the concentrator and remarked that the concentrator was, superhot and it was overheating because the plastic wrapped around the vents of the concentration had not been removed before the concentrator was activated. LVN C said that when equipment was beeping and a red light was activated, it indicated that there was a problem with the equipment that needed to be addressed. LVN C said she did not hear the beeping and no staff informed her of the beeping sound coming from Resident #461's room LVN C unplugged the concentrator and said she would replace it. Interview on 03/31/25 with MA D at 8:55 am reflected she arrived on the 900 hallway at about 8:15 am but did not notice the beeping coming from Resident #461's room. Interview on 03/31/25 with Resident #27 at 9:00 am reflected the beeping sound from Resident #461's had been going on for about 45 minutes to an hour. Resident #27 said CNAs were walking up and down the hallway serving breakfast and the beeping sound continued from Resident #461's room and she did not hear anyone make any statements about alerting a nurse to figure out the noise in Resident #461's room. Resident #27's room was number 908. She stated she had been in her room and on the 900 hallway all morning. Review of Resident #27's MDS dated [DATE] reflected a BIMS score of 14 indicating intact cognition. Interview on 04/01/25 with the ADON at 7:54 am revealed that when there was a noise or beeping sound coming from a resident's room staff need to check it out quickly because there could be a problem with any equipment that might be in the room. It is not good quality of care to allow a beeping noise from a resident's room to continue and not respond, it should be addressed. When the ADON was told that plastic was observed wrapped about the oxygen concentrator in Resident #461's room, the ADON said the plastic should have been removed prior to the concentrator being operated and even if there was nothing wrong with the equipment, the beeping noise can be annoying to the resident. Interview on 04/02/25 with the DON at 3:22 pm reflected it would be a concern if there was beeping noise coming from a resident's room because it would suggest that something was not functioning with the equipment, and it needed to be looked at. The negative impact of not responding to beeping machinery would be that the resident would not receive the benefit of what the machinery was to provide. The ADM was requested to provide the facility quality of care policy and provided the facility Quality Assessment and Assurance Committee policy, not applicable to this citation. There is no facility policy for this citation.

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 environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 7 residents (Resident #114, Resident #460, and Resident #461) reviewed for infection control. 1. The facility failed to ensure the TN H sanitized her hands and changed gloves prior to applying wound treatment and clean dressing to Resident #114's left heel wound. 2. The facility failed to post Enhanced Barrier Protection signage on Resident #460 and Resident #461's doors when they admitted to the facility with a wound and a suprapubic catheter. 3. The facility failed to ensure Enhanced Barrier Protection was worn when providing resident care for Resident #461's suprapubic catheter. These failures could place residents at risk of transmission of disease and infection. Findings included: Record review of Resident #114's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #114 had diagnoses which included dementia, dysphagia (difficulty swallowing), repeated falls, diabetes mellitus type 2, metabolic encephalopathy, and history of venous thrombosis and embolism (blood clots). Record review of Resident #114's Quarterly MDS dated [DATE] reflected Resident #114 needed the assistance of two or more helpers for her activities of daily living and used a mechanical lift with two people assisting for transfers, and a wheelchair for mobility. She had one unstageable deep tissue pressure injury to her left heel. Record review of Resident #114's Care Plan, last revised on 02/07/25, reflected a focus on an alteration in skin integrity related to the presence of an unstageable pressure ulcer/injury to her left heel. The goals were for Resident #114 to remain free from additional pressure ulcers/injuries and for the current pressure ulcer/injury to show signs of healing as evidenced by a decrease in size/measurements, and to remain free from signs and symptoms of complications such as infections. Interventions included applying treatment as ordered, and assessing for complications, including signs and symptoms of infection. Review of Resident #460's face sheet dated 04/01/25 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including encephalopathy (affects the brain's function, leading to changes in mental state and cognitive abilities), bipolar disorder (treatable mental disorder marked by extreme changes in mood, thought, energy and behavior) and chronic kidney disease, stage 3. Review of Resident #460's admission MDS assessment, dated 03/27/25, reflected no BIMS score . Resident #460's care plan initialed on 03/27/25 and revised on 03/31/25 reflected she had a stage 3 pressure ulcer (involves full-thickness skin loss, exposing subcutaneous fat, but not bone, tendon, or muscle) on her buttocks and an unstageable pressure ulcer (a full-thickness skin and tissue loss where the true depth of the ulcer is obscured by slough (yellow, tan, gray, green, or brown) or eschar (tan, brown, or black) in the wound bed, making it impossible to determine the stage) on her lower extremity. Review of Resident #460's order dated 03/31/25 reflected use gown and gloves for high contact resident care activities for those with known to be colonized or infected with a CDC (Centers for Disease Control) targeted MDRO (multidrug-resistant organism) as well as those with increased risk of MDR (Multidrug-resistant), residents with wounds or indwelling medical devices. Review of Resident #461's face sheet dated 04/01/25 reflected an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's disease (a progressive neurodegenerative disorder primarily affecting movement, causing symptoms like tremors, slowness of movement, and stiffness, often due to a decline in dopamine-producing brain cells) and dementia. Review of Resident #461's admission MDS assessment, dated 03/26/25, reflected no BIMS score . Resident 461#'s care plan dated 03/18/25 reflected resident had a diagnosis of Parkinson's disease with an intervention dated 03/18/25 of give medications as ordered by the physician. Resident #461's care plan reflected he was followed by hospice with an intervention dated 03/06/25 keep the environment quiet and calm. Resident #461 care plan revised on 03/19/25 reflected he had a suprapubic catheter (a thin, flexible tube inserted into the bladder through a small incision in the lower abdomen (pubic area) to drain urine) related to neurogenic bladder (a condition where the nerves that control bladder function are damaged, leading to abnormal bladder control). Review of Resident #461 order dated 03/31/25 reflected use gown and gloves for high contact resident care activities for those with known to be colonized or infected with a CDC (Centers for Disease Control) targeted MDRO (multidrug-resistant organism) as well as those with increased risk of MDR (Multidrug-resistant), residents with wounds or indwelling medical devices. Observation on 03/31/25 at 11:45 AM was conducted of wound care for Resident #114 with the TN H. Resident #114's wound was documented in physicians' orders as pressure wound located the left heel. The TN H did not change gloves or conduct hand hygiene after cleansing Resident #114's left heel wound and before applying wound treatment and clean dressing. Interview on 03/31/25 at 12:15 PM with the TN H revealed she did not change her gloves or conduct hand hygiene after cleansing the wound and before applying wound treatment and clean dressing. The TN H further stated she should have conducted handwashing and glove change after cleaning the wound. She stated not conducting hand hygiene and a glove change after cleaning a wound could lead to cross contamination to the resident. She stated she had received training on hand hygiene during wound care, but do not remember when. Interview on 04/02/25 at 02:43 PM with the DON revealed he had worked in the facility for [AGE] years. He stated the policy for conducting hand hygiene during wound care included preparing the field, hand hygiene, donning gloves and gown, removing the old dressing, and when going from cleaning wound to applying clean dressing do hand hygiene and change gloves. The DON stated he was responsible for ensuring staff are conducting hand hygiene when providing resident care, and their IP program mandated hand hygiene training every month for 10 staff. Not conducting hand hygiene and changing gloves during wound care had the potential of nursing care being provided with unclean hands, and the possibility of spreading microorganisms to the resident. Interview on 04/02/25 at 03:53 PM with the ADM revealed he had been with the facility for [AGE] years. He stated the policy for conducting hand hygiene during wound care was all staff were responsible for conducting hand hygiene before and after providing care to a resident, and to conduct hand hygiene during care when going from contaminated to clean areas. The ADM stated the DON, himself, and all Infection Preventionists were responsible for ensuring all staff were conducting hand hygiene when providing resident care. The ADM further stated all staff were to follow all universal precautions when providing resident care, and not doing so could put the residents at risk of infections and negative outcomes. A review of the CDC Long Term Care Facilities reflected when implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g. gown and gloves) For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. Review of Enhanced Barrier Precautions, signage observed at the facility posted on the doors of other resident rooms, not posted on Residents #460 and #461's doors reflected: Enhanced Barrier Precautions: Providers and staff must: wear gloves and a gown for the following High-Contact Resident Care Activities. Do not wear the same gown and gloves for the care of more than one person. Providers and staff must also: Dressing Bathing/Showering Transferring Changing Linens Providing Hygiene Changing briefs or assisting with toileting Device care or use: central line, urinary catheter, feeding tube, tracheostomy Wound Care: any skin opening requiring a dressing. Observation on 03/31/25 at 9:48 am of the door of Resident #460's room, #806, reflected no EBP signage. Observation and interview on 03/31/25 of LVN C at 10:41 am who exited Resident #461's room with no gown. When asked if the LVN C provided resident care, she said yes, she provided care for resident's suprapubic catheter. LVN C was observed not wearing a PPE (personal protective equipment) gown and there was no enhanced barrier precaution sign on Resident #461's door informing staff providing care for high-contact resident care activities of device care or use of urinary catheter must wear gloves and a gown. Interview on 04/01/25 with LVN C at 8:29 am reflected she performed suprapubic catheter care for Resident #461 on 03/31/25 of at 10:41 am and did not wear a gown and the resident did not have the facility required EBP signage on his door. LVN C stated that the EBP requirements involved wearing a gown when resident care was provided for a suprapubic catheter for infection control reasons. LVN C said that if staff did not wear the barrier controls of the gown required for EBP residents when providing resident care, residents could get an infection and become sick. Interview on 04/01/25 with the ADON at 7:45 am reflected nurses needed to wear a gown when attending to a resident's suprapubic catheter and for wound care. When a resident admits to the facility with a wound or a suprapubic catheter EBP signage should be immediately posted on the resident's door to notify staff of the necessary infection control precautions needed when providing care for that resident. The EBP PPE is necessary to protect the resident from infection. Interview on 04/01/25 with ICS at 3:36 pm revealed if a resident had wounds and if a resident had an indwelling medical device, a suprapubic catheter, EBP would be required when caring for these residents. EBP signage should be posted on every resident's door as soon as they are admitted to the facility if the resident requires EBP. The EBP signage informs the staff of the infection control needs of the resident and that they need to wear PPE when providing resident care. Residents #460 and #461 should both have had EBP signs on their doors as soon as they were admitted to the facility and LVN C should have worn a gown when she provided care to Resident #461 for his suprapubic catheter. LVN C said the negative effect of not having the EBP signage in place as soon as the residents are admitted is that staff are not informed about the infection needs of the resident and they might assist the resident without the proper EBP, and residents could become infected. LVN C said that a possible negative effect of LVN C not wearing a gown when providing care involving Resident #461's suprapubic catheter is that the resident could get an infection because the proper EBP PPE was not worn. Interview on 04/02/25 with the DON at 3:22 pm reflected Residents #460 and #461 should have had EBP signage posted on their doors as soon as they admitted to the facility and the nurse providing suprapubic catheter care for Resident #461 should have worn the proper PPE. If you do not have the EBP signage posted on resident doors for residents who required EBPs staff providing care could expose residents to infection and if staff are not wearing the appropriate PPE, staff could expose residents to infection. The DON said staff was trained in EBP and infection control procedures, including posting proper EBP signage and wearing PPE to reduce the potential for the spread of infection. Review of Policy & Procedure on Hand Hygiene dated January 2018 reflected: This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: h. Before moving from a contaminated body site to a clean body site during resident care. j. After contact with blood or bodily fluids k. After handling used dressings, contaminated equipment. Review of Policy & Procedure on Infection Prevention and Control Program dated 05/13/23 reflected: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 2. All staff are responsible for following all policies and procedures related to the program. 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. Review of facility Enhanced Barrier Precautions policy dated 04/05/24 reflected it is the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines: All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO (multidrug-resistant organisms). Implementation of Enhanced Barrier Precautions: Make gowns and gloves available immediately near or outside of the resident's room. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. High-contact resident care activities include. a. Dressing b. Bathing c. Transferring d. Providing hygiene. e. Changing linens. f. Changing briefs or assisting with toileting. g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes. h. Wound care: any skin opening requiring a dressing .

Based on interviews and record review the facility failed to act upon the pharmacist's drug regimen review irregularity reports for two of (Residents #1 and #2) of seven residents reviewed for medication consents. 1. The facility failed to respond to the pharmacist's notification that Resident #1's Trazodone (an antidepressant and sedative medication used to treat depression and may also be used for other conditions) consent was missing and needed to be obtained and uploaded. The facility had an unsigned written consent from Resident #1's RP before administering Trazodone. 2. The facility failed to respond to the pharmacist's notification that Resident #2's Lorazepam (a medication used to treat anxiety) consent was missing and needed to be obtained and uploaded. The facility had an unsigned written consent from Resident #2's RP before administering Lorazepam. This failure could place residents at risk of not having their preferred RP represent them in medical and care decisions, their preferred RP being unaware of the care, treatment, and treatment alternatives they are being provided, and not having pharmacist's notifications and recommendations for their medications and treatments followed. Findings included: Resident #1 Review of Resident #1's admission record, dated 09/19/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE], had a POA/RP , and with diagnoses including burns involving 20-29% of body surface with 0%-9% third degree burns, bipolar disorder current episode depressed mild or moderate severity unspecified, generalized anxiety disorder, and cognitive communication deficit. Review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 3, indicating she had severe cognitive impairment. Section N (Medications) reflected Resident #1 was receiving an antipsychotic and antidepressant. Review of Resident #1's quarterly care plan, dated 08/19/24, reflected she had a mood problem related to bipolar disorder, anxiety, and history of alcohol abuse with an intervention to monitor, record, and/or report to MD as needed any signs or symptoms of depression, anxiety, or sad mood. Resident #1's care plan also reflected she used antipsychotic medications (Seroquel) related to bipolar disorder with an intervention to monitor/document/report as needed any adverse reactions of antipsychotic medications, such as insomnia. Review of Resident #1's order summary report, dated 09/19/24, reflected an active order started on 06/10/24 for the following: Trazodone HCI Oral Tablet 50 MG (Trazodone HCI) Give 0.5 tablet by mouth at bedtime for insomnia (give 25mg). Review of Resident #1's electronic health records, as of 09/19/24, reflected there was no consent form for her Trazodone HCI Oral Tablet 50 MG (Trazodone HCI) order. Review of Resident #1's MAR schedule for August and September 2024 reflected she received the Trazodone order from 08/01/24 through 09/18/24 . Resident #2 Review of Resident #2's admission record, dated 09/19/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE], had an RP, and with diagnoses including paranoid schizophrenia and unspecified dementia. Review of Resident #2's quarterly MDS, dated [DATE], reflected no BIMS score indicated. Section N (Medications) reflected Resident #1 was receiving an antidepressant. Review of Resident #2's quarterly care plan, dated 08/27/24, reflected she had the potential to be verbally aggressive related to dementia and mental/emotional illness. Review of Resident #2's order summary report, dated 09/19/24, reflected she completed the following order started on 08/22/24 and ended on 09/05/24: Lorazepam (Ativan) 0.5MG/ML GEL 0.5 mg/1ml MG/ML (Lorazepam) Apply 0.5 mg transdermally every 8 hours as needed for anxiety/agitation for 14 Days. Review of Resident #2's Informed Consent for Psychoactive Medications, undated, reflected an order for Lorazepam Gel for acute agitation and anxiety. Resident #2 printed her name on the consent 08/22/24 and did not sign. RP printed their name on 08/22/24 and did not sign. Facility representative who provided information and completed the consent form signed on 08/22/24 . Review of Resident #2's MAR schedule for August and September 2024 reflected she did not receive the Lorazepam order from 08/01/24 through 09/18/24 . Review of the facility's Pharmacist Review from June through August 2024 reflected the Pharmacist initiated a medication regimen review on 06/17/24 and indicated Resident #1's Trazodone consent was unable to be located and recommended staff to obtain and scan consent into the chart. The Pharmacist also initiated a medication regimen review on 08/26/24 and indicated Resident #2's Lorazepam consent was unable to be located and recommended staff to obtain and scan consent into the chart. During an interview on 09/19/24 at 1:23 p.m., the NP stated consents must be signed by residents' POAs . During an interview on 09/19/24 at 2:39 p.m., the ADON stated her expectations for psychological consents were that they were to be signed right away from pen to paper. The ADON stated consents must be signed by the resident or the resident's RP. The ADON stated it was important to have consents signed so staff had consent to treat the resident using medications. The ADON stated the receiving nurse was responsible for getting residents' consents signed. The ADON stated her, and the DON's job were to oversee and make sure residents' consents were completed . Review of the facility's Notification of Changes policy and procedure, implemented 10/24/22, reflected the following: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 3. Circumstances that require a need to alter treatment. This may include: a. New treatment. Additional considerations: 2. Residents incapable of making decisions: a. The representative would make any decisions that have to be made. b. The resident should still be told what is happening go him or her.

Based on interview and record review, the facility failed to keep residents free from abuse for 1 (Resident # 1) of 9 residents reviewed for abuse. The facility failed to ensure Resident # 1 was not physically assaulted by Hospitality Aide A. The noncompliance was identified as PNC. The IJ began on 08/02/2024 and ended on 08/06/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of physical harm, mental anguish, or emotional distress. The findings included: Record review of Resident # 1's admission face sheet dated 9/9/24, revealed Resident # 1 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of schizoaffective disorder bipolar type (A rare mental health condition that combines symptoms of schizophrenia and bipolar disorder), profound intellectual disabilities, epilepsy (Seizure disorder) , age-related physical debility, muscle wasting and atrophy, lack of coordination, adjustment disorder with mixed anxiety and depressed mood, hyperlipidemia (High levels of fat particles in the blood), history of sudden cardiac arrest, chronic pain syndrome, disturbance of salivary secretion, hypothyroidism (Overactive thyroid), type 2 diabetes, hypertensive heart disease without heart failure, atrial fibrillation (An irregular often rapid heart rate), depression, anxiety disorder, elevated white blood cell count, and bipolar disorder current episode hypomanic (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of Resident #1's quarterly MDS assessment dated [DATE], revealed Resident # 1 had unclear speech but was usually understood by staff. The MDS revealed Resident # 1 understood others. The MDS revealed Resident # 1 did not have a BIMS score recorded. The MDS reflected Resident # 1 had no behaviors or refusal of care. Record review of Resident #1's care plan, initiated on 12/29/21 and revised on 7/25/22, revealed Resident # 1 had, an ADL self-care performance deficit related to impaired balance, limited mobility with bilateral extremity contractures. Interventions included Resident # 1 requires extensive to total assistance by 1-2 staff with bathing/showering, bed mobility, toileting, and transfers. Resident # 1 is noncompliant with medical regiment and resistive to care related to adjustment to nursing home. Interventions stated to allow the resident to make decisions about treatment regimen, to provide a sense of control. It also stated to give a clear explanation of all care activities prior to an as they occur during each contact, to provide consistency in care to promote comfort with ADLs, and to maintain consistency in timing of ADLs, caregivers, and routine, as much as possible. Record review of witness statement dated 8/2/24 revealed Scheduler CNA A reflected Scheduler CNA A was at the nurse station when she heard a slapping noise and a resident crying. Scheduler CNA A went to go check where the crying was coming from. Scheduler CNA A found Resident # 1 in room [ROOM NUMBER] A crying and Hospitality Aide A coming from the closet gathering clothes for Resident #1. Scheduler CNA A asked Hospitality Aide A why Resident # 1 was crying. Hospitality Aide A said she did not know. Scheduler CNA A went to check Resident # 1 and found a red mark on Resident #1 right thigh. Hospitality Aide A stated that Resident # 1 hit her very hard. Scheduler CNA A told Hospitality Aide A to remove themselves from Resident # 1's room. Scheduler CNA A told Hospitality Aide A that they could no longer provide care to Resident # 1. Scheduler CNA A made sure Resident # 1 was safe and called the abuse coordinator and reported the incident to him and the charge nurse also. Record review of Resident #1's nursing progress note dated 8/2/24 at 8:17 am revealed staff member reported to charge nurse Resident # 1's increased agitation during incontinence care early that morning; likely the result of being awakened to provide care. Resisting nursing care following an incontinence episode Resident # 1 experienced. The Charge nurse completed observation, skin, and pain assessments of Resident # 1. Her demeanor was evaluated as well. Around 7 am, further assessment was completed by the DON of the incident that occurred during charge nurse shift. Primary physician notified of incident. RP unable to be reached for notification purposes of incident. Resident # 1 in bed excited at her usual demeanor without sign of distress. Record review of Resident #1's nursing progress note dated 8/2/24 at 8:32 am revealed Resident # 1 still declined to be assisted this morning despite encouragement by 2 nursing staff. The staff will revisit her to prevent the occurrence of what happened earlier in the day. Record review of Resident #1's weekly nursing skin evaluation dated 8/2/24 revealed Resident # 1 had resolving dermatitis. No skin tears, bruises, pressure ulcers, or non-pressure wounds. Record review of Resident #1's pain evaluation dated 8/2/24 at 8:36 am revealed no complaint of pain in last 5 days, normal breathing, no negative vocalization, relaxed body language, smiling facial expression, no need to console, pain score of a 2 out of 10. Record review of photo evidence from the Administrator of Resident # 1 revealed Resident # 1 had a red imprint of an entire handprint on her upper right outer thigh. Observation and interview on 9/9/24 at 12:20 pm of Resident # 1 revealed Resident # 1 was in bed. Resident # 1's bed was in lowest position up against the wall with fall mat on floor next to the bed. Resident # 1 shook her head yes when asked if she was ok and shook her head no when asked if she needed anything. Resident # 1 shook her head no when asked if she had any concerns. Resident # 1 appeared clean and well groomed. Resident # 1's room appeared neat, clean, and homelike. An interview on 9/9/24 at 2:00 pm with the DON reflected that he said he had been called by the Administrator to inform him of the incident. DON said when he arrived at the facility he completed a pain evaluation and skin evaluation on Resident # 1. DON said he then performed a counseling with Hospitality Aide A and placed them on suspension pending investigation. An interview on 9/9/24 at 2:50 pm with the Administrator reflected he said, about the incident involving Resident # 1 and Hospitality Aide A, that he received a phone call from Scheduler CNA A about the incident. Administrator said Scheduler CNA A explained the series of events to him and told him that she had also gave the charge nurse the details of the incident. The Administrator said Hospitality Aide A never admitted to him of slapping Resident # 1 on the thigh. The Administrator said the DON arrived at the facility shortly after the incident occurred and went and completed a skin and pain assessment of Resident # 1. An interview was attempted on 9/9/24 at 4:45 pm with Scheduler CNA A. The call was not answered; voicemail left. An interview on 9/9/24 at 5:11 pm with Administrator reflected he said it was their expectation of the staff to report all suspected abuse to him since he was the abuse coordinator. The administrator further said it was his and the DON's responsibility to educate the staff on ANE, watch for techniques for staff to practice prohibiting ANE, and to watch staff for burnout and exhaustion. The administrator said a negative impact of resident abuse would be a sense of hopelessness for the resident and that the resident could become scared to rely on staff to take care of them. Record review of Hospitality Aide A personnel file reflected a hire date of 3/5/24. Employee counseling/ suspension report dated 8/2/24. Employee termination record dated 8/6/24. No record of training was in the employee personnel file. Record review of in-service logs reflected the following Abuse, Neglect, and Exploitation training was completed: undated with 16 staff signatures of attendance, 8/3/24 with 59 staff signatures of attendance, 8/5/24 with 9 staff signatures of attendance, and 9/3/24 with 7 staff signatures of attendance. Record review of Resident behavior training completed 8/1/24 with 11 staff signatures of attendance, 8/3/24 with 60 staff signatures of attendance, and 8/5/24 with 9 staff signatures of attendance. Record review of Resident resisting care training completed 8/2/24 with 24 staff signatures of attendance. Record review of facility's Abuse, Neglect, and Exploitation policy dated 8/15/22 reflected under policy heading It is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Under heading Policy Explanation and Compliance Guidelines 3. The facility will provide ongoing oversight and supervision of staff to assure that its policies are implemented as written. Under heading Employee Training A. New employees will be educated on abuse, neglect, exploitation, and misappropriation of resident property during initial orientation. B. Existing staff will receive annual education through planned in-services as needed. Under heading Prevention of Abuse, Neglect, and Exploitation B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation , and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of individual residents care needs and behavioral symptoms. D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. The noncompliance was identified as PNC. The IJ began on 08/02/2024 and ended on 08/06/2024. The facility had corrected the noncompliance before the survey began.

Based on observations, interviews, and record reviews, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible for 1 of 1 facility reviewed for physical environment, in that: The facility failed to ensure no open flames are near oxygen cylinders, store cylinders in the upright position, and secure the cylinders from residents and the public. An Immediate Jeopardy (IJ) was identified on 01/26/24 at 10:25 AM While the IJ was removed on 01/27/24 at 10:27 AM, the facility remained out of compliance at a scope of widespread and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor their corrective actions. These failures could place residents at risk of injury or death due to improper or unsafe smoking. The findings included: Observation on 01/23/24 at 01:47 PM revealed that 2 of 2 outdoor storage spaces for oxygen cylinders, enclosed with chain link fencing, had unlocked doors. 1 outdoor storage space was located more than 10 feet away from the main dining room and right outside of the kitchen. The other outdoor storage space was located more than 10 feet away from the therapy room. The outdoor storage space near the main dining room and kitchen included about 10 empty oxygen cylinders and about 30 full oxygen cylinders. There was 1 empty oxygen cylinder stored upside down and 1 empty oxygen cylinder laying sideways under other empty oxygen cylinders. There was debris stuck in between cylinders, including 3 pieces of paper and some leaves. During an interview on 01/24/24 at 02:49 PM, the DON stated the extent of what the nursing staff knew was where the oxygen tanks were and to bring the oxygen cylinders when the oxygen ran out. The DON stated the oxygen cylinders should be stored upright. The DON stated the public did technically have access to the oxygen tanks as someone could walk behind the building and even cut the chain linked fence to access the oxygen cylinders. During an interview and observation on 01/24/24 at 01:54 PM, CNA B was smoking a cigarette in the no smoking area that surrounded the outside oxygen storage area, about 9 feet away from the full oxygen cylinders. CNA B stated she was smoking a cigarette and the staff smoked here when the weather was bad. During an interview and observation on 01/24/24 at 01:57 PM, the Floor Tech confirmed there were 2 CNAs who were smoking cigarettes there and they should not be smoking there. The Floor Tech further stated the 2 CNAs may be new and not know that they should not be smoking near the oxygen tanks. Only 1 CNA was observed smoking. The other CNA was not present at this time. During an interview on 01/24/24 at 02:56 PM, the Administrator stated there should be no smoking around the oxygen storage area outside and the staff are trained on this. During an interview and observation on 01/24/24 at 04:13 PM, the FSS confirmed there were 10 cigarette butts on the floor in the no smoking area that was near full oxygen cylinders. One cigarette butt was only 3/4 of the way done and found in a cardboard box that was 9 feet away from full oxygen cylinders. The FSS further stated staff had smoked in this area when the weather was bad but had been told to stop smoking in this area. During an interview and observation on 01/24/24 at 04:18 PM, ADON A revealed there was an oxygen cylinder that was stored upside down and one that was laying on its side on the ground. ADON A stated this was not how the oxygen cylinders should be stored. ADON A confirmed there were cigarette butts on the floor in the no smoking area that was near full oxygen cylinders and should not be here. She revealed she had not seen these cigarette butts before or had seen anyone smoking in this area before. During an interview on 01/25/24 at 10:23 AM, the Administrator stated, no one should be smoking near the oxygen cylinders, if that's what you saw. During an interview on 01/25/24 at 10:28 AM, LSC revealed the following: Oxygen storage can present specific risks in the context of a fire emergency or explosion. If there is an explosion in a facility where oxygen is stored, whether it's a medical facility, industrial site, or any other location, several additional hazards can arise: 1. Increased Fire Intensity: o Oxygen supports combustion, and if stored oxygen is involved in a fire or explosion, it can significantly increase the intensity and spread of the fire. This is because oxygen can act as an oxidizer, accelerating the combustion of other materials. 2. Pressure Vessel Rupture: o Oxygen is often stored under pressure in tanks or cylinders. In the event of an explosion, the pressure vessels containing the stored oxygen may rupture, leading to the release of high-pressure gas. This can cause additional hazards, including flying debris and potential injuries. 3. Oxygen Enrichment: o The release of oxygen can lead to oxygen enrichment in the surrounding air. While oxygen is essential for human respiration, elevated oxygen levels can increase the risk of fires and make materials more combustible. This can create an environment where fires are easier to ignite and more challenging to control. 4. Risk of Flash Fires: o If oxygen is released rapidly in a confined space, it can create conditions for flash fires. A flash fire is a sudden and intense fire that occurs when a flammable substance comes into contact with a source of ignition in the presence of an oxidizer like oxygen. 5. Potential for Explosions: o If there are other flammable materials present, the combination of oxygen and these materials can create explosive mixtures, increasing the risk of secondary explosions. 6. Inhalation Hazards: o In the aftermath of an explosion involving oxygen storage, there may be a risk of inhaling high concentrations of oxygen, which can lead to respiratory issues and other health concerns. 7. Specialized Firefighting Challenges: o Fires involving oxygen storage require specialized firefighting techniques. Traditional water-based firefighting methods may not be effective, and in some cases, they can exacerbate the situation. Firefighters may need to use specialized extinguishing agents to control the fire. Given these risks, it's essential for facilities storing oxygen to adhere to strict safety protocols, including proper storage, handling, and emergency response procedures. Staff should be well-trained in the safe management of oxygen, and facilities should have appropriate safety measures in place, such as fire suppression systems, ventilation, and the use of flame-resistant materials. During an interview with the National Director of Sales for [company who supplied the facility's oxygen storage] on 01/26/24 at 09:25 AM and 09:45AM, he stated empty oxygen cylinders should not be stored upside down because this could damage the valve of the empty oxygen cylinder. He further revealed that the empty oxygen cylinders were refilled and a damaged valve increased the chance of a full oxygen cylinder to, shoot off like a rocket, because it made the full oxygen cylinder unstable. He further stated people had been killed by oxygen cylinders. The National Director of Sales further revealed if a fire started next to full oxygen cylinders, these oxygen cylinders, can turn into missiles, and move in any direction. During an interview on 01/26/24 at 11:30 AM, a confidential staff member stated when staff smoked cigarettes near the storage of oxygen cylinders, they were told to stop. The confidential staff member stated that they had reported this to the Administrator before. They further stated that residents did not have access to the oxygen cylinder storage area. The confidential staff member also revealed that they do fire drills monthly and they were taught to not go through the exit door that is near the oxygen cylinder storage area. They further revealed that if there was a fire in this area that spread to the kitchen, the fire could get bigger due to grease and ovens. Follow up call for further questions for the National Director of Sales for [company who supplied the facility's oxygen storage] was made on 01/26/24 at 04:15 PM with no answer nor response back. Record Review of USA Food Code 2022 revealed, 4-301.14 Ventilation Hood Systems, Adequacy. The accumulation of grease and condensate mat contaminate food and food-contact surfaces as well as present a possible fire hazard. Record Review of Health Care Facilities Code, 2012 Edition, revealed Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20ft of outside storage locations. The Administrator revealed that they used this policy, and the facility did not have their own policy for the outside oxygen storage. Record review of the product label for Oxygen, Compressed USP UN1072, produced by Air Liquefaction, undated, indicated DANGER: MAY CAUSE OR INTENSIFY FIRE: OXIDIZER. CONTAINS GAS UNDER PRESSURE: MAY EXPLODE IF HEATED . Do not smoke . Keep/store away from clothing and other combustible materials. This was determined to be an Immediate Jeopardy (IJ) and the Administrator was notified on 01/26/24 at 10:25 AM, an IJ Template was presented to the Administrator, and a Plan of Removal was requested to lift the immediacy. The following Plan of Removal submitted by the facility was accepted on 01/26/24 at 03:52 PM. January 26, 2024 [Facility] LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Attention Sir or Madam: On January 26, 2024, the facility was notified by the surveyor, that an immediate jeopardy had been called and the facility needed to submit a letter of credible allegation. The Facility respectfully submits this Letter for Plan of Removal pursuant to Federal and State regulatory requirements. Submission of the Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusions set forth in the verbal and written notice of immediate jeopardy and/or any subsequent Statement of Deficiencies. The alleged immediate jeopardy allegations are as follows: Issue: [Citation Number and Title] No residents were identified as smoking in that area. No staff are identified, other than by CNA B. 1) As of 1/26/24, oxygen cylinders are secured with chain link fencing. Full and empty oxygen cylinders are stored upright. Debris and paper have been removed from the oxygen storage area. Oxygen storage areas were cleaned of cigarette butts by Maintenance Director and/ or designee. 2) To identify any other related oxygen storage concerns, the Maintenance Director and/ or designee made rounds to ensure all oxygen cylinders storage areas and oxygen used in resident care areas are properly stored. 3) An Oxygen Safety policy was developed on 1/26/24 and will be used for staff education on the below topics regarding oxygen. 4) On 1/26/24, All staff will be reeducated by the Administrator / designee on the following topics: Abuse and Neglect Oxygen Storage No smoking in oxygen storage area Designated smoking areas Proper method to extinguish and discard smoking paraphernalia 5) The Maintenance Director and/ or designee will observe the oxygen storage areas daily to ensure the oxygen is stored upright and secured daily during rounds. The Director of Nursing and/ or designee will observe oxygen cylinders in resident care areas to ensure that oxygen is stored upright and secured properly daily during rounds. 6) The housekeeper / designee will monitor and clean the outside oxygen storage area daily and as needed. The Administrator / designee will monitor outside oxygen storage areas daily on various shifts and as needed rounding to ensure there are no people smoking in that area. The Administrator and/ or designee will monitor compliance that staff are rounding daily on various shifts to ensure oxygen is stored upright and secured and free of debris. An Ad Hoc QAPI meeting was completed on 1/26/24 to discuss the root cause and plan to correct attended by the Administrator, Director of Nursing, Maintenance Director, and the Medical Director. We respectfully submit this action plan for removal of Immediate Jeopardy. Sincerely, [The Administrator] POR Verification 1) Verified via Observation on 01/26/2024 at 5:18 p.m. Verified via Interview on 01/26/2024 at 5:20 p.m. with the Maintenance Director who stated he personally secured the oxygen cylinder area, added a sign which read Replace Lock After Removing Oxygen, personally ensured oxygen cylinders were in the upright position, removed debris from the cylinder storage area, and removed the cigarette butts. 2) Verified via Interview on 01/26/2024 at 5:20 p.m. with the Maintenance Director who stated he personally performed rounds throughout the facility to ensure all oxygen cylinders storage areas and oxygen used in resident care areas were properly stored. 3) Verified via Record Review of Oxygen Safety Policy Interview with the Administrator on 01/26/2024 at 4:15 p.m. revealed he assisted with the creation of the Oxygen Safety policy. Interview with DON on 01/26/2024 at 4:12 p.m. revealed he assisted with the creation of the Oxygen Safety policy. 4) Completion date of re-education of all staff will be 1/26/24, in person or via telephone. Those that are PRN, Agency and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. Any staff member not re-educated in person or via phone today (1/26/24), will be removed from the schedule until re-education is provided. Verification of 100% of staff re-education will be verified by the Administrator / designee. Interview with Administrator on 01/26/2024 at 4:15 p.m., the Administrator stated staff work a four-days on and 2 days off schedule so that there was no distinction between weekday and weekend staff. The Administrator further stated that he and 5 additional designees divided the list of staff members and educated each staff member present in the building in person. The Administrator further stated that he and his 5 designees called all staff members who were not present to share the Oxygen Safety Policy and documented each conversation on an individual One-on-One In-Service form. The Administrator identified designees as: HR L, HR M, the Admissions Director, and the DON Joint Interview with: HR L, HR M, the Admissions Director, and the DON on 01/26/2024 at 4:20 pm revealed they assisted the Administrator to educate the staff regarding the Oxygen Safety Policy o Verification via in person interviews with 9 staff members from 2 pm to 10 pm shift, telephone interviews with 7 staff members from 6 am to 2 pm shift, and telephone interviews with 6 members of 10 pm to 6 am shift. all staff listed below confirmed they received and understood the Oxygen Safety Policy to include keeping cigarettes and other open flames away from oxygen cylinders, storing cylinder in the upright position, and ensuring the oxygen storage area is locked at all times. o In-Person Interviews (2 pm to 10 pm shift) Activity Aide N 4:22 p.m. RN O 4:26 p.m. Cook P 4:28 p.m. CNA Q 4:30 p.m. CNA R 4:32 p.m. ADON G 4:34 p.m. Medication Aide S 4:36 p.m. CNA T 4:39 p.m. CNA U 4:42 p.m. Telephone Interviews (6 am to 2 pm shift): RN V 4:45 p.m. Receptionist W 5:26 p.m. CNA X 5:09 p.m. LVN Y 5:12 p.m. CNA Z 5:28 p.m. Cook AA 4:43 p.m. LVN BB 5:30 p.m. o Telephone Interviews (10 pm to 6 am shift): Medication Aide CC 5:24 p.m. CNA DD 5:00 p.m. CNA EE 5:16 p.m. LVN FF 5:03 p.m. CNA GG 4:49 p.m. CNA HH 4:53 p.m. Record review of 183 individual One-on-One In-Service forms revealed the in-service included: o Only smoke in designated areas (NOT near oxygen cylinders) o Oxygen cylinders should only be stored in the upright position o Oxygen storage should secure behind locked gate at all times 5) Verified via Interview on 01/26/2024 at 5:20 p.m. with the Maintenance Director. The Maintenance Director revealed that he would check the oxygen storage areas daily. He further revealed that he would check that the fence surrounding the oxygen storage was locked, the Empty and Full signs are posted appropriately, the No Smoking signs are posted, the oxygen cylinders were upright, and that the areas was clean and free from debris. Record review of the Housekeeping/Maintenance Log, dated 01/27/2024, revealed regular checks have been performed. 6) Verified via in person interview with the Housekeeper on 01/26/2024 at 4:37 p.m. who stated she and all the Housekeeping Staff had been instructed to monitor and clean the outside oxygen storage area on a daily basis and more often as needed o Interview on 01/26/2024 at 5:20 p.m., the Maintenance Director revealed that he would make sure that the outside oxygen storage area was clean and free from debris daily. Record review of the Housekeeping/Maintenance Log, dated 01/27/2024, revealed regular checks have been performed. Verified via Interview with the Administrator on 01/26/2024 at 4:15 p.m. who stated he will perform rounds on a daily basis, across all shifts to ensure no one is smoking in the oxygen storage area Additional Interview with the Administrator on 01/27/2024 at 8:39 a.m. revealed he and the MOD during weekends perform rounds to check oxygen storage and record checks in Managers' Log. Record Review of Managers' Log, dated 01/27/2024, revealed regular checks have been performed. Verified via Interview with the Administrator on 01/26/2024 at 4:15 p.m. who stated he will perform rounds on a daily basis, across all shifts to ensure oxygen cylinders are stored in the upright position, the storage area is locked, and free of debris Verified via Interview with the Administrator on 01/26/2024 at 4:15 p.m. who confirmed a meeting was held and that he attended along with the Director of Nursing, the Maintenance Director, and the Medical Director. Verified via Interview on 01/26/2024 at 5:20 p.m. with the Maintenance Director who confirmed a meeting was held and that he attended along with the Director of Nursing, the Administrator, and the Medical Director. Interview with DON on 01/26/2024 at 4:12 p.m. who confirmed a meeting was held and that he attended along with the Administrator, the Maintenance Director, and the Medical Director. Record Review of Ad Hoc QAPI Sign-In Sheet which listed the Administrator, the Director of Nursing, the Maintenance Director, and the Medical Director as attendees An Immediate Jeopardy (IJ) was identified on 01/26/24 at 10:25 AM While the IJ was removed on 01/27/24 at 10:27 AM, the facility remained out of compliance at a scope of widespread and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor their corrective actions.

Based on interview and record review, the facility failed to ensure that residents received proper treatment and care for one (1) of (2) residents (#17) who receive respiratory care when: Resident #17 was admitted to the facility on [DATE] without her bi-level positive airway pressure ([MEDICAL CONDITION]) machine (a method of respiratory ventilation used primarily in the treatment of [REDACTED].#17 to go to the hospital due to respiratory distress and anxiety from not having the appropriate equipment at the facility. This deficient practice could place 14 residents, who require respiratory care at the facility, at risk for diminished quality of care. Findings include: Review of Resident #17's hospital discharge paperwork dated 09/23/13 reflected a [AGE] year old woman with [DIAGNOSES REDACTED]. Review of Resident #17's Physician ' s Discharge Order from the hospital dated 09/23/13 at 2:30 pm reflected to discharge Resident #17 to a skilled nursing facility, Respiratory Oxygen (O2) per nasal canula (nc) at 2 liters/minute (l/m) keep saturation equal to or above 92 percent (sats greater than 92%), [MEDICAL CONDITION] as per current settings. It further reflected that it was a fax to the facility received on 09/23/13 at 15:32. The Director of Nursing (DON) signed the orders as being received. During an interview on 9/26/13 from 10:40 am to 11:20 am, Licensed Vocational Nurse (LVN) G stated that he does not know what time Resident #17 arrived to the facility on [DATE]. He further stated that the facility van driver brought her to the facility from the hospital and took her to her room, but did not notify him (the charge nurse) that she was in the facility. Resident #17 then came to the nurses' station at about 4:00 pm or 4:30 pm on 09/23/13 complaining of shortness of breath. LVN G stated that is when he discovered that she was at the facility. Resident #17 was in a wheelchair, has no hands, and is a bilateral [MEDICAL CONDITION]. LVN G further stated he had no way to get a pulse oximetry reading (a non-invasive method to monitor the oxygenation of a patient's hemoglobin) on her, and had orders to keep her O2 saturations greater than 92%. Resident #17 then told LVN G that she could not lie down without her [MEDICAL CONDITION] because she could not breathe. He then stated that there was no [MEDICAL CONDITION] available for the resident in the facility. He further stated that the DON told him that it had been ordered. LVN G then stated that he told the DON that he had no way to check her pulse oximetry because she had no hands or feet, and her ear lobes were too small. He further stated that the DON then instructed him to just put her to bed because she was just anxious, and there was nothing wrong with her. LVN G then stated that the DON said the resident has a history of being anxious and told him they were working on getting a [MEDICAL CONDITION] for her, but they stopped because it was after 5:00 pm. LVN G then stated he started making phone calls to get the [MEDICAL CONDITION] himself. He further stated that the patient kept telling him "I cannot lie down without my [MEDICAL CONDITION]." LVN G then stated that the DON kept telling him to just to put her to bed. He further stated that the DON finally told him the [MEDICAL CONDITION] would be delivered to the facility sometime after midnight. LVN G then stated that he had instructed the Certified Nurse Aides (CNAs) not to put Resident #17 to bed. He further stated that he was making rounds at about 9:00 pm, and an unidentified CNA reported to him that Resident #17 could not breathe, and that she was in bed because the DON instructed the CNAs to put her to bed. LVN G then stated that he went to her room and assessed Resident #17 and he could not hear any breath sounds with his stethoscope. LVN G then stated that she was very distressed and anxious and could barely speak. He further stated that the resident asked him to please call 911. Resident #17 then stated that she needs to go back to the hospital to get [MEDICAL CONDITION], and that she can come back to the facility when they get the [MEDICAL CONDITION]. LVN G then stated that the resident requested 911, so he called 911. He further stated that the DON and Administrator heard him calling 911, and told him to hang up, but he refused. LVN G then stated Emergency Medical Services (EMS) came and took Resident #17 to the hospital, and LVN G was told to make a quick note in the chart, and after that he had no access to the chart. During an interview on 10/02/13 at 9:57 am, LVN H stated she was assigned to the 500 and 700 halls on 09/23/13 when Resident #17 was admitted to the facility. She further stated that her and LVN G both had admissions that evening so they were helping each other. She further stated that she remembers that LVN G ' s new admission needed [MEDICAL CONDITION] and her new admission needed constant positive airway pressure ([MEDICAL CONDITION], an assistive breathing device that provides nighttime relief for individuals who suffer from sleep apnea). LVN H then stated that at about 4:30 pm that evening, she and LVN G were told that the company they were ordering the [MEDICAL CONDITION] and [MEDICAL CONDITION] from was closed. At about that time, Resident #17 came to the nurses ' station asking about her [MEDICAL CONDITION] and that Resident #17 was worried about not having it. LVN H further stated that sometime after dinner on 09/23/13, three unidentified CNAs came to her and told her that they were going to put Resident #17 to bed, and she stated that she told the CNAs that they needed to let LVN G know because he was Resident #17 ' s nurse, and LVN G said that she cannot go to bed without her [MEDICAL CONDITION]. LVN H further stated that the CNAs said that the DON told them to put her to bed, so they did so. She further stated that after that, she remembers seeing LVN G running into Resident #17 ' s room and she went and grabbed an O2 tank because she knew she was probably in respiratory distress. LVN H further stated that they put O2 on her, and she had rapid respirations, and was very anxious. LVN H further stated that the DON told them to give Resident #17 a [MEDICATION NAME] and told LVN H to leave the room. She further stated that LVN G then called 911 and the DON was at the nurse ' s station when he called 911 and told him to hang up but he would not hang up. LVN H then stated that the first responders arrived very quickly and they could not get a pulse oximetry reading or a blood pressure on Resident #17 either. She further stated that right after EMS took Resident #17, that the DON took Resident #17 ' s chart into her office. Review of Resident #17's Nurse ' s Note dated 09/23/13 9:00 pm reflected that the nurse responded to resident ' s room for report of respiratory distress by CNA, unable to obtain O2 saturation level or blood pressure, but was anxious and complained of shortness of breath. DON notified, patient stated to have full code and everything done and have 911 called and be sent back to the hospital. EMS responded within 10 minutes, DON at bedside for duration, per EMS assessment and patient request, sent to hospital for further evaluation and treatment. Review of Resident #17's Billing Summary from EMS dated 09/23/13 reflected that Resident #17 was found lying in bed inside nursing residence. Nursing staff inform medics that the patient is having shortness of breath after she realized she did not have [MEDICAL CONDITION] ready at the facility. It further reflected that Resident #17 does not feel comfortable being at the facility without her [MEDICAL CONDITION]. It further reflects that the resident is alert and oriented x 4. Review of Resident #17's discharge paperwork from the hospital dated 09/24/13 reflected that Resident #17's chief complaint was shortness of breath and the emergency department [DIAGNOSES REDACTED]. It further reflected that Resident #17 states she just left the hospital and is wondering why she was not sent home with a [MEDICAL CONDITION] machine. Emergency differential Diagnoses: [REDACTED]. Review of Resident #17's Nurse Clinical Report from the hospital dated 09/24/13 reflected that Resident #17 was discharged from the Emergency Department a few hours ago and per the nursing home, she was sent back via EMS because they did not have [MEDICAL CONDITION] the patient needed. Per EMS the patient was complaining of mild respiratory distress. It further reflected that Resident #17 is alert and oriented x 4 and appears anxious. Resident #17 was discharged 3:05 am on 09/24/13 back to the facility Review of Resident #17's Physician's progress note dated 09/24/13 reflected that the resident was quite anxious at the time of his initial visit and the [MEDICAL CONDITION] machine she used the night before at the facility did not function appropriately. It further reflected that Resident #17 was upset because the [MEDICAL CONDITION] she was given did not work the night before. During an interview on 09/26/13 at 8:45 am, the Medical Director stated that Resident #17 was admitted to the facility on [DATE] in the evening, had an anxiety attack, and it was unclear whether her [MEDICAL CONDITION] was set up. When asked if it is normal protocol to accept residents at the facility without their equipment, he stated that he would like to think that all of the equipment a resident needs is at the facility at the time of admission. When asked how the facility could monitor a resident's O2 who does not have hands or lower extremities, the Medical Director stated that that is a good question. He further stated that while on the phone with the DON, another staff member called EMS even though through his conversation with the DON he thought the resident was not having any distress. During an interview on 09/26/13 at 9:15 am, Resident #17 stated that she came into the facility on [DATE] and had bad anxiety. Resident #17 then stated that she needed O2 because she couldn ' t breathe and there was none in the room. She further stated that she told a nurse to call 911 because there was not a complete [MEDICAL CONDITION] there and she cannot breathe without it. She also stated that there was some loud confusion up front and that she went out to the hospital that night and came back around 3:00 am. During an interview on 09/26/13 at 11:30 am, the DON stated that Resident #17 came in on 09/23/13 around 7:30 pm and LVN G should have taken the report and it was his responsibility to make sure that the resident has all of the equipment they need before they arrive at the facility. The DON further stated that the resident was being difficult but was not having any respiratory problems and there was no reason to send Resident #17 back to the hospital. She did not understand why LVN G would call EMS. During an interview on 09/26/13 at 3:50 pm, the DON stated the Assistant Director of Nurse's (ADON's) are responsible for monitoring the charge nurse's to make sure they get the required equipment such as [MEDICAL CONDITION] for new admissions. When told about having discrepancies of the time when the resident arrived the DON stated the Van driver and LVN H would know exactly when the resident was brought to the facility. The Surveyor then asked for the Van driver ' s number and LVN H ' s number. The DON stated she is texting the Van driver right now (from her personal phone) but the Van Driver would most likely not answer her phone if she was driving. When the Surveyor asked the DON a second time for the two phone numbers she changed the topic. When the Surveyor asked for the third time for LVN H and the Van driver ' s numbers the DON stated I do not have them, I have to get those number from Human Resources (HR). At 5:00 PM, the DON stated " I have the van driver ' s phone number for you in my (personal) cell phone " . This was an hour and fifteen minutes after she was asked initially for the phone numbers. The surveyor asked for the names of the CNAs who worked that shift on 09/23/13, and the DON stated they were off and would have to find those numbers as well. During an interview on 09/26/13 at 5:02 PM the Van Driver stated that she brought Resident #17 to the facility around 6:30-7:00 PM. During an interview on 09/26/13 at 3:55 pm, Resident #17's son stated that the resident got to the facility around 3:00 pm on 09/23/13 and that staff members told her that they were going to get the [MEDICAL CONDITION] within 3-4 hours. He further stated that he was at the facility with her and that she was scared because she did not have a complete [MEDICAL CONDITION]. He further stated that he stayed 2-3 hours and left the facility around 6:00 pm that day. Review of the facility's Pulse Oximetry (Assessing Oxygen Saturation) Policy dated 09/2012 reflected that you must place the probe on the finger and turn on the oximeter, and compare oximeter pulse rate with resident's radial pulse. Review of the undated facility's Equipment - General Use for All Residents Policy reflected that the need for special equipment should be referred to the facility Administrator and DON. Review of the facility's Admission Checklist form reflected: "Please complete the following checklist for each new admission and submit to the Director of Nursing. 22. Special supplies or equipment have been ordered." Review of CMS form 672 reflected 14 residents who receive respiratory treatment in the facility.

Based on observation, interview, and record review, the facility failed to provide supervision to prevent falls for 1 of 8 residents reviewed for accidents (Resident #1). Resident #1 was assessed as being at high risk for falls. Resident #1 sustained 5 falls during the months of January, April and May 2013 that resulted in injuries. The facility did not provide adequate interventions to prevent falls, which included the Falling Star Program. This failure could place 114 residents needing assistance with transfers at risk of falls and/or injuries. Findings included: Review of face Sheet for Resident #1 revealed the resident was admitted on [DATE] and discharged on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] reflected Resident #1 had short term memory impairment; mobility was by the use of a wheelchair or a walker. She required minimal assistance and/or cueing for transfers, dressing, hygiene and bathing. The resident was continent of bowel and bladder. The resident had no limitation of Range of Motion. Review of a Fall Risk assessment dated [DATE] indicated Resident #1 scored a 13, which indicated she was at high risk for falls. (reference range- 10 or above was high risk). Subsequent evaluations by the facility staff, on 3/19, 4/18 and 4/20/2013, after each fall sustained or elevated this score. Review of a " Post Fall Care Plan " care plan revised 3/19 and 4/18/2013 indicated the resident had a history of [REDACTED]." Review of Care Plan dated 3/20/2013 for Resident #1 revealed she was not on the Falling Star program, nor was it updated on 4/18 or 4/20/2013 to reflect being placed on the program. During an interview on 8/21/2013 at 2:00 p.m. the complainant stated resident fell multiple times while residing in the facility. Once the resident did strike her head when she fell , the last time she fell she fractured her knee cap. The resident also had extensive bruising of her chest wall and the left side of her face. The complainant stated Resident #1 was taken off Hospice services due to her knee not healing and causing so much pain. Once she was off Hospice, the resident's knee was surgically repaired. Review of Nurse Notes reflected Resident #1 had experienced a fall on 01/11/2013 with an injury to the back of her head. Labs and X-Rays were obtained per physician order. Review of Incident Reports reflected Resident #1 suffered the following falls: - 03/15/2013 at 02:45 p.m. - resident fell with no injuries. The resident was to be rounded on more frequently. - 03/19/2013 at 09:45 a.m. - resident fell with no injuries. Resident stated she felt weak and fell to the ground. The resident was to have cardiac and neurological consults, a medication review and therapy referral. Staff was to monitor resident closely. Post Fall Care Plan listed Assess for Falling Star Program as an intervention. - 04/18/2013 at 07:05 a.m.- resident fell and pulled television onto the floor no injury was documented. The resident was instructed to use the call light for staff to assist when needed. The resident was also to have a medication review, to be oriented to surroundings, and assessed for the Falling Star program. - 04/20/2013 at 02:00 p.m. - resident fell and was found with a hematoma of the scalp. The resident also reported left knee pain. The resident was sent to emergency room and admitted to a local hospital. The Post Fall Care Plan indicated the need for the resident to be assessed for the Falling Star program and encourage the use of proper footwear. Further review of the incident reports above reflected under "recommended inservces" no documentation was included that inservices recommendation were made or conducted. During an interview on 8/22/2013 at 1:30 p.m. Certified Nurse Aide (CNA) A said the placing of the star next to the residents name means they are to remain in bed and not be up in their wheelchair. During an interview on 8/22/2013 at 4:00 p.m., CNA B said when she cared for Resident #1 there was not a star beside her name when she provided care for her. During an interview on 8/22/2013 at 4:00 p.m., CNA C said the star by the door means the resident moves slowly and we need to allow more time to care for the resident. Review of a Physicians Order List identified 15 residents that were on the Falling Star Program. Observations on 8/23/2013 between 1:00 p.m. - 2:00 p.m. reflected that 22 residents had stars beside their names, outside their room, identifying the resident as being on the Falling Star Program. Interview on 8/22/2013 at 2:50 p.m. the Director of Nursing (DON) stated any nurse can initiate the Falling Star Assessment. The policy is for any one experiencing three falls in a ninety day period to be assessed. The determination is based on the fall risk assessment and meeting the criteria of the policy. The charge nurse also has the option of placing a resident on the program without having met all of the criteria. The Care Plan is then to be updated. The results of the assessments and possible interventions are discussed in the morning meetings. This is where the determination is made to place an individual on the Falling Star Program. Residents on the Falling Star program have a star placed next to their name outside the room. The residents on the Falling Star Program are to be visualized every hour and then documented on the SMAR. The DON further stated it is the nurses responsibility to document this monitoring. Review of policy titled Falling Star Program; undated, revealed residents with three or more falls in three months should be placed on the Falling Star Program. This would have involved the placement of a star outside the door of the resident. Residents placed on the program were to be monitored on an hourly basis. Results were to be documented in the clinical record. Review of Policy titled Fall Risk Assessment and Management, undated, revealed the nursing staff was responsible for identifying resident risk factors for falls and documenting the risks. The staff was responsible for determining if falling was related to a change in condition. The nursing staff should review medications that could relate to falls. The staff should consider use of a fall monitoring program or devises to monitor the resident. The CMS 672 dated 08/21/2013 indicated 114 residents required assistance with transfers.