GREENVIEW NURSING AND REHABILITATION

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review that facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is (A) significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment).<BR/>On 5/11/2024 Resident #1 was admitted into the hospital due to a decline in health. Resident #1 was lethargic, unable to stand, skin was pale in color and fingertips were turning purple. Resident #1 was diagnosed with severe dehydration and non-traumatic rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood). <BR/>The facility failed to identify there was a decrease in Resident #1's meal intake and notify the nutritionist, NP, or PCP to address nutritional or hydration concerns for Resident #1<BR/>This failure could place residents at risk of not getting the medical treatment required that could lead to other adverse health consequences. <BR/>Findings included: <BR/>Review of Resident #1's undated face sheet reflected an [AGE] year-old male with an admission date of 5/2/2024. Diagnoses included: UNSPECIFIED DEMENTIA (a group of thinking and social symptoms that interfere with daily functioning), Parkinson's disease (a disorder of central nervous system that affects movement, often including tremors), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and depression (a group of conditions associated with the elevation or lowering of a person's mood).<BR/>Review of Resident #1's admissions MDS assessment dated [DATE] reflected incomplete. Only the identification page of the assessment had been completed no other sections of the assessment were completed. <BR/>Review of Resident #1's care plan dated 5/2/2024 reflected Resident # 1 was an elopement risk and was placed on the secure unit at the facility when he admitted to the facility. Resident # 1 was at risk for falls and had previous falls in the home prior to admitting to the facility. The care plan did not reflect any interventions to address the nutritional or fluid intake needs for Resident #1. <BR/>Review of Resident #1's physician orders for Resident #1 reflected, the facility did not have a physician's order for Resident #1's diet or fluid intake. <BR/>Record review of hospital medical records dated 5/11/2024 reflected Resident #1 was admitted to the hospital on [DATE] from the nursing facility. Resident # 1 was diagnosed with non-traumatic rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood) and severe dehydration. Resident #1 was currently in the hospital receiving fluids and has suffered acute kidney injury. <BR/>In an interview via phone on 5/14/2024 at 7:40 am with Resident #1's RP, revealed when she showed up on 5/11/2024 to take Resident #1 home she stated he was very weak, pale in the face, fingers were turning purple, and he could not get up out of the wheelchair into the car. She stated she had them call 911 and he was taken to the hospital where he was diagnosed as being severely dehydrated and having rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood). The RP stated she was not aware of what could have happened in this short period of time to cause this decline in his health. She stated when he admitted to the facility, he was using his walker to walk, eating, and talking. The RP stated she admitted Resident #1 to the facility on 5/2/2024 because they were having some renovations completed at their home. She stated he was previously at another facility closer to their home but had continued to have elopement issues so that was the reason he was transferred to this facility. The RP stated Resident #1 was on the secure unit at this facility, but stated she just does not understand the decline in his health from the time he admitted to the time he discharged . <BR/>In an interview on 5/14/2024 at 10:00 am with hospital RN staff reported Resident #1 stated that he had not had anything to eat or drink for the past three days. Hospital RN staff reported the resident admitted to the hospital with severe dehydration and rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood) she stated this could cause the dehydration. <BR/>In an interview on 5/14/2024 at 11:15 am with PCP, revealed he never saw Resident #1 while at facility he stated the NP met with the resident. He stated he was never contacted or made aware of any issues related to this resident. The PCP stated there were no additional treatment services for this resident and there were no medication changes ordered for this resident. <BR/>In an interview on 5/14/2024 at 12:38 pm with the DON she reported they did keep fluid intake records for Resident #1 she stated when the resident had some coughing issues when eating and drinking, they contacted the RP on 5/6/2024 who advised that Resident #1 had a swallowing problem. She stated they were advised to cut his food smaller and encourage smaller bites, drink and swallow slowly, and monitor the resident. The DON stated they do not track fluid intake for residents unless there was an order. However, she stated if the resident was eating below 50% of their meals, they were provided with a supplemental shake with each meal. She stated it was standard facility protocol, however reported they do not document if the shake supplement was provided or if the resident consumed the shake. She stated they did not add this intervention to the care plan because it was standard to do and not an order. She stated she did not address the eating or drinking issues with the NP or PCP because they spoke with the RP and were doing what the RP advised them to do for the resident. The DON stated she did send the resident out to the hospital because she stated he did not look right. She stated the resident was assessed at the hospital and returned to the facility the same day. She stated the hospital called and stated the resident was stable and ready to be picked up. The DON stated they never received any discharge paperwork from the hospital from the 5/9/2024 visit due to a breach in their system. The DON stated she did contact the director of OT/PT to have a swallow assessment completed for the resident. The DON stated all staff had been trained on abuse/neglect and the protocol. She stated all CNA staff had been trained to report any changes in condition to their nurse and they would discuss in their morning meeting for steps to take and treatment. The DON stated the facility did not have a hydration policy. <BR/>In an interview on 5/14/2024 at 3:17pm with the NP revealed, Resident #1 admitted to the facility on [DATE] for respite care. She stated she normally did not see the residents if they were at the facility for respite care. She stated she did not know how long Resident #1 was going to be at the facility, so she saw Resident #1 on 5/6/2024. The NP stated Resident #1 was not getting any additional treatment and, stated no medications were changed. She stated the resident was confused and appeared to have already had a cognitive decline requiring to be on a secure unit. She stated she was contacted by the facility indicating that Resident #1 was having some hip pain. She advised the facility to check with the RP about getting some x-rays and stated she was advised that Resident #1 would be discharging on 5/10/2024 to return home. She stated she was not aware of any other issues regarding Resident #1. <BR/>In an interview on 5/15/2024 at 12:15 pm with the hospital treating physician reported that rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood) could be caused from a fall and being left in that spot for a prolonged period of time or it can be caused by not getting the nutrition and hydration needed. She stated the resident reported lying in the bed and not having anything to eat or drink for three days. She stated the cause of rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood) would be consistent with lying in a bed and not having anything to eat or drink for three days. The physician reported there was no other way that the rhabdomyolysis could be caused except for one of these two ways.<BR/>Record review of facility abuse/neglect policy dated March 2018 reflected the following: <BR/>All residents will be free from abuse/neglect. <BR/>Record review of facility Intake, Measuring and Recording policy dated October 2010 reflected the following: <BR/>Review the resident care plan to assess for any special needs of the resident. <BR/>Verify there is a physician's order for this process. <BR/>In an interview with the DON on 5/14/2024, she stated the facility did not have a dehydration/ hydration policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that was not possible or the resident preferences indicated otherwise for 1 of 13 residents (Resident #1) reviewed for nutrition and hydration.<BR/>On 5/11/2024 Resident #1 was admitted into the hospital due to a decline in health. Resident #1 was lethargic, unable to stand, skin was pale in color and fingertips were turning purple. Resident #1 was diagnosed with severe dehydration and non-traumatic rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood). <BR/>The facility failed to identify there was a decrease in Resident #1's meal intake and notify the nutritionist, NP, or PCP to address nutritional or hydration concerns for Resident #1.<BR/>This failure could place residents at risk of nutritional deficit, dehydration, and other adverse health consequences.<BR/>Findings included: <BR/>Review of Resident #1's undated face sheet reflected an [AGE] year-old male with an admission date of 5/2/2024. Diagnoses included: UNSPECIFIED DEMENTIA (a group of thinking and social symptoms that interfere with daily functioning), Parkinson's disease (a disorder of central nervous system that affects movement, often including tremors), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and depression (a group of conditions associated with the elevation or lowering of a person's mood).<BR/>Review of Resident #1's admissions MDS assessment dated [DATE] reflected incomplete. Only the identification page of the assessment had been completed no other sections of the assessment were completed. <BR/>Review of Resident #1's care plan dated 5/2/2024 reflected Resident # 1 was an elopement risk and was placed on the secure unit at the facility when he admitted to the facility. Resident # 1 was at risk for falls and had previous falls in the home prior to admitting to the facility. The care plan did not reflect any interventions to address the nutritional or fluid intake needs for Resident #1. <BR/>Review of Resident #1's physician orders for Resident #1 reflected, the facility did not have a physician's order for Resident #1's diet or fluid intake. <BR/>Record review of meal intake records dated 5/2/2024- 5/11/2024 reflected on 5/6/2024 ,5/7/2024, 5/8/2024, and 5/10/2024 Resident #1 consumed less than 25% of his dinner on the days listed. On 5/2/2024 reflected no record of dinner eaten. <BR/>Record review of progress note dated 5/2/2024 at 5:27 pm by LVN A reflected, Resident #1 refused to eat dinner because he had anxiety and was worried about being at the facility. The note reflected LVN A redirected Resident #1, however does not indicate if he ate his dinner. <BR/>Record review of progress note dated 5/6/2024 at 2:18 pm by LVN A, reflected he contacted the RP regarding Resident #1 observed coughing and after eating and drinking. The RP stated Resident #1 had swallowing problems due to his Parkinson's disease. The RP stated Resident #1 had a swallow study in January 2024, she advised for the resident to take small bites and to encourage to swallow in between bites. <BR/>Record review of hospital medical records dated 5/11/2024 reflected Resident #1 was admitted to the hospital on [DATE] from the nursing facility. Resident # 1 was diagnosed with non-traumatic rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood) and severe dehydration. Resident #1 was currently in the hospital receiving fluids and has suffered acute kidney injury. <BR/>In an interview via phone on 5/14/2024 at 7:40 am with Resident #1's RP, revealed when she showed up on 5/11/2024 to take Resident #1 home she stated he was very weak, pale in the face, fingers were turning purple, and he could not get up out of the wheelchair into the car. She stated she had them call 911 and he was taken to the hospital where he was diagnosed as being severely dehydrated and having rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood). The RP stated she was not aware of what could have happened in this short period of time to cause this decline in his health. She stated when he admitted to the facility, he was using his walker to walk, eating, and talking. The RP stated she admitted Resident #1 to the facility on 5/2/2024 because they were having some renovations completed at their home. She stated he was previously at another facility closer to their home but had continued to have elopement issues so that was the reason he was transferred to this facility. The RP stated Resident #1 was on the secure unit at this facility, but stated she just does not understand the decline in his health from the time he admitted to the time he discharged . <BR/>In an interview on 5/14/2024 at 10:00 am with hospital RN staff reported Resident #1 stated that he had not had anything to eat or drink for the past three days. Hospital RN staff reported the resident admitted to the hospital with severe dehydration and rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood) she stated this could cause the dehydration. <BR/>In an interview on 5/14/2024 at 11:15 am with PCP, revealed he never saw Resident #1 while at facility he stated the NP met with the resident. He stated he was never contacted or made aware of any issues related to this resident. The PCP stated there were no additional treatment services for this resident and there were no medication changes ordered for this resident. <BR/>In an interview on 5/14/2024 at 12:38 pm with the DON she reported they did keep fluid intake records for Resident #1 she stated when the resident had some coughing issues when eating and drinking, they contacted the RP on 5/6/2024 who advised that Resident #1 had a swallowing problem. She stated they were advised to cut his food smaller and encourage smaller bites, drink and swallow slowly, and monitor the resident. The DON stated they do not track fluid intake for residents unless there was an order. However, she stated if the resident was eating below 50% of their meals, they were provided with a supplemental shake with each meal. She stated it was standard facility protocol, however reported they do not document if the shake supplement was provided or if the resident consumed the shake. She stated they did not add this intervention to the care plan because it was standard to do and not an order. She stated she did not address the eating or drinking issues with the NP or PCP because they spoke with the RP and were doing what the RP advised them to do for the resident. The DON stated she did send the resident out to the hospital because she stated he did not look right. She stated the resident was assessed at the hospital and returned to the facility the same day. She stated the hospital called and stated the resident was stable and ready to be picked up. The DON stated they never received any discharge paperwork from the hospital from the 5/9/2024 visit due to a breach in their system. The DON stated she did contact the director of OT/PT to have a swallow assessment completed for the resident. The DON stated all staff had been trained on abuse/neglect and the protocol. She stated all CNA staff had been trained to report any changes in condition to their nurse and they would discuss in their morning meeting for steps to take and treatment. The DON stated the facility did not have a hydration policy. <BR/>In an interview on 5/14/2024 at 3:17pm with the NP revealed, Resident #1 admitted to the facility on [DATE] for respite care. She stated she normally did not see the residents if they were at the facility for respite care. She stated she did not know how long Resident #1 was going to be at the facility, so she saw Resident #1 on 5/6/2024. The NP stated Resident #1 was not getting any additional treatment and, stated no medications were changed. She stated the resident was confused and appeared to have already had a cognitive decline requiring to be on a secure unit. She stated she was contacted by the facility indicating that Resident #1 was having some hip pain. She advised the facility to check with the RP about getting some x-rays and stated she was advised that Resident #1 would be discharging on 5/10/2024 to return home. She stated she was not aware of any other issues regarding Resident #1. <BR/>In an interview on 5/14/2024 at 4:26 pm with LVN A revealed, the CNAs were trained to let their nurse know if there was any change in condition for any resident. LVN A stated the CNA staff are trained to pay attention to the resident's trays if they are not eating or drinking when the get their meals, their urine color, or if they are changing the resident and they are fairly dry they are not getting enough hydration and they would need to push fluids. LVN A stated the resident admitted for respite care and had a decline while at the facility. He stated all staff had been trained on abuse/neglect and the administrator was the abuse/ neglect coordinator he stated he had never seen or suspected abuse/neglect at this facility. <BR/>In an interview on 5/15/2024 at 7:08 am with RN revealed, he worked with Resident #1 on the secure unit. He stated when the resident admitted to the facility he was doing more. He stated he was using his walker to get around and able to feed himself with some assistance as needed. He stated the resident took water and other hydration with meals and stated his appetite continued to decrease. RN stated he contacted the RP on 5/6/2024 and reported swallowing problems but was told he was still on a regular diet and needed to take small bites. He stated the resident was a 2x person assist for the week that he was at the facility. RN stated he contacted the hospital Resident #1 went to on 5/9/2024 to try to obtain those records however, due to the hospital breach in their system they did not have any records available they could provide. RN stated he let the DON know about the issues Resident #1 was having and they contacted the therapy department to try to get another swallow study for the resident. RN stated they helped with eating and drinking for Resident #1 he stated the resident continued to decline. The RN stated the CNAs are trained to report any changes in a resident's condition to the nurse on duty. He stated they would report to the DON or contact the NP for concerns with a resident. <BR/>In an interview on 5/15/2024 at 7:32 am with RP, revealed Resident #1 saw two doctors on yesterday and stated they came up with a plan for him to go home on hospice care. She stated the doctor of the supportive and palliative care department attributed his condition to his current diagnosis and progression of the Parkinson's disease and Dementia. She stated she just did not expect this, and stated she wanted someone to blame. The RP stated she felt the hospital did not do what they needed to do on 5/9/2024 before releasing him back to the facility. She stated she did speak with the hospital staff on 5/9/2024, but stated she could not remember what was said regarding Resident #1's condition. The RP stated she would be taking Resident #1 back home to are for him and that he would not be returning to the facility. The RP stated palliative care has been put into place and they will come into the home and provide these services. <BR/>In an interview on 5/15/2024 at 12:15 pm with the hospital treating physician reported that rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood) could be caused from a fall and being left in that spot for a prolonged period of time or it can be caused by not getting the nutrition and hydration needed. She stated the resident reported lying in the bed and not having anything to eat or drink for three days. She stated the cause of rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood) would be consistent with lying in a bed and not having anything to eat or drink for three days. The physician reported there was no other way that the rhabdomyolysis could be caused except for one of these two ways. <BR/>In an interview on 5/15/2024 at 2:15pm with director of OT/PT revealed, she was advised that Resident #1 was coughing and had problems swallowing during meals. She stated since Resident #1 was a Veteran, and his services were being covered by the Veteran Administrator she contacted the VA to get approval for another swallow study to be completed on Resident #1. She stated she was advised by the VA that this condition was not a new condition for Resident #1 and that a swallow assessment was completed in January 2024 and another one would not be approved at this time. <BR/>In an interview on 5/15/2024 at 2:30 pm with LVN B revealed, she worked through an employment agency. She stated she worked the night of 5/9/2024 when Resident #1 was sent out the hospital. She stated she was advised by other staff that he was sent out due a decline, stated the resident was struggling breathing and his blood pressure was low. LVN B stated she received a call that night from the RP. She stated the RP reported that the hospital advised her to put a DNR in place for Resident #1. She stated the RP blamed herself for his decline and stated he had been declining ever since going to the first facility. She stated the RP reported that she felt the resident was declining to due being in unfamiliar surroundings and places. LVN B stated the administrator was the abuse/neglect coordinator and they needed to report any suspected abuse/neglect to the administrator immediately, she stated she had never seen or suspected abuse/neglect at this facility. <BR/>In an interview on 5/15/2024 at 4:07pm with CNA B, revealed she worked on the MC unit with Resident #1. Stated she was not aware that the resident had any eating issues. She stated she was not aware of why the resident was on the secure unit and thought it was odd. She stated she gave the best care that she could to the resident with the information she was provided. CNA B stated the nurses usually would let them know what was going on with a resident. CNA B stated the RP advised them to cut Resident #1's food up so he could take smaller bites, but stated he should have been on a puree' textured diet. She stated there were a lot of things that the RP stated Resident #1 could do when he admitted but he could not, she stated they had to provide a lot of assistance to Resident #1. CNA B stated she let the nurse on duty LVN A know about the amount of assistance Resident #1 required. She stated when the resident was in the wheelchair, he required two people assist because he was a tall man and required two people to assist him. CNA B stated she had been trained on change in condition, she stated it could be loss of appetite, not participating in activities, or wanting to stay in bed. She stated she was trained to let her nurse know if there were any changes with the residents. She stated if a resident had hydration problems, they were trained to push hydration throughout the day and encourage the resident drink throughout the day. CNA B stated the administrator was the abuse/neglect coordinator and they were required to report immediately if they see or suspected abuse/ neglect to the administrator or their nurse. She stated she had never seen of suspected abuse/neglect at this facility. <BR/>In an interview on 5/15/2024 at 4:18 pm with CNA C, revealed she worked the 6pm to 6am shift with Resident #1 on the secure unit. She stated when she noticed the resident had a change in condition and was in the bed more, she stated she let the nurse know. She stated she did not assist with any meals, she stated when she arrived, she just turned the resident every two hours to prevent skin breakdown. CNA C stated they were trained to let the nurse know if there were any changes with the residents. She stated she had also been trained on abuse/ and stated the administrator was the abuse/neglect coordinator and they needed to report immediately if they seen or suspected abuse/neglect. She stated she had never seen or suspected abuse/neglect at this facility. CNA C stated if a resident hydration concerns, they would push fluids and monitor the intake throughout the day. <BR/>Record review of 10 resident's charts who were identified to have fluid restriction/ monitoring, special diet. Each resident's chart reviewed had a care plan to address nutritional needs, an order to monitor hydration intake, meal intake records to monitor the amount of their meal they consumed throughout each day. The records reflected they were monitored and evaluated by the primary care physician and nutritionist regularly. The charts reflected weekly weight monitoring to track any significant weight loss of the residents. <BR/>Record review of facility in-service on abuse/neglect dated 3/25/2024 reflected staff had been in-serviced on abuse/neglect. <BR/>Record review of facility in-service on Standard of Care dated 1/11/2024 reflected staff had been in-serviced on standards of care. <BR/>Record review of facility abuse/neglect policy dated March 2018 reflected the following: <BR/>All residents will be free from abuse/neglect. <BR/>Record review of facility Intake, Measuring and Recording policy dated October 2010 reflected the following: <BR/>Review the resident care plan to assess for any special needs of the resident. <BR/>Verify there is a physician's order for this process. <BR/>In an interview with the DON on 5/14/2024, she stated the facility did not have a dehydration/ hydration policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation of resident property were reported immediately, but no later than 24 hours after the allegation was made to the State Survey Agency for 2 of 5 residents (Resident #1 Resident #2) reviewed for abuse. <BR/>The facility failed to report within 24 hours to the State Survey Agency (HHSC - Health and Human Services Commission) that there was alleged physical abuse between Resident # 1 and Resident # 2 when staff reported to the ADM on 04/05/2025. Resident #2 pushed/hit Resident # 1 in the chest as they passed each other in the hallway on date 04/05.2025. <BR/>This failure could place residents at risk for further abuse.<BR/>Findings included:<BR/>A record review of Resident #1's face sheet dated 04/19/2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnosis was end stage renal disease(kidneys lose the ability to remove waste and balance fluids), essential primary hypertension(abnormal high blood pressure), and osteoarthritis(flexible tissue at the ends of bones wears down).<BR/>A record review of Resident #1's Quarterly MDS assessment, dated 01/29/2025, reflected the resident had a BIMS score of 15, which indicated cognitive intact. <BR/>A record review of Resident #1's facility investigation report dated 04/08/2025, reflected Resident # 1 notified the charge nurse that Resident #2 had hit her in the breast area.<BR/>A record review of Resident #2's face sheet dated 04/19/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2's diagnosis was cerebral infraction(blood flow to the brain blocked), type 2 diabetes(body having trouble controlling blood sugar and using it for energy), and vascular dementia(memory loss).<BR/>A record review of Resident #2's Quarterly MDS assessment, dated 03/10/2025, reflected the resident had a BIMS score of 9, which indicated moderate cognitive impairment. <BR/>A record review of Resident #2's facility investigation report dated 04/08/2025, reflected Resident # 1 notified the charge nurse that Resident #2 had hit her in the breast area.<BR/>A record review of the facility's provider investigator report dated 04/08/2025 reflected the facility did not report the alleged verbal sexual abuse allegations within 24 hours to the State Survey Agency (HHSC). The Provider investigator report revealed the incident occurred on 04/05/2025 at 2:30 pm. The ADM reported the incident to HHSC on 04/05/2025 at 12:41 pm.<BR/>Attempted interview with ADON on 04/21/2025 at 12:53 pm and 4:00 pm was unsuccessful. Voice message was left for the ADON to return call. The ADON did not return call before or after the facility exit on 04/21/2025.<BR/>During an interview with Resident #2 on 04/21/2025 at 1:05 pm, stated that he was safe and did not have any issues with Resident # 1. Resident # 2 stated that he and Resident # 1 was both in wheelchairs, and Resident # 1 came down the hall, date and time not recalled, and told him to pick which side he was going to be on. Resident # 2 stated he did not mean any harm but he pushed Resident # 1 toward her chest area to move her out of his way so he could get by. <BR/>During an interview with Resident # 1 on 04/21/2025 at 1:30 pm, stated she was safe, and she did not have any issues with Resident #2. Resident # 1 stated she was coming down the hallway, could not recall the date, and she just only told Resident # 2 which side of the hall he was going to be on. Resident # 1 stated Resident # 2 had said something to her (can't recall), and he pushed her chest area. Resident # 1 stated she was not injured or hurt but she did let staff know what had happened. <BR/>During an interview with the DON on 04/21/2025 at 4:03 pm, stated the ADM was responsible for reporting the incident with Resident # 1 and Resident # 2 on 04/04/2025. The DON stated it was expected for the ADM to report timey to prevent any further abuse.<BR/>During an interview with the ADM on 04/21/2025 at 4:11 pm, stated that when the incident had happened on 04/05/2025 at 2:30 pm he immediately started investigating. The ADM stated Resident # 1 and Resident # 2 were both interviewed, and he was getting conflicting stories from each of the residents. The ADM stated that it was first told Resident # 2 had pushed Resident#1 out the way to get by when they were in the hallway. The ADM stated then it was told Resident #2 had hit Resident # 1 in the breast area when they were in the hallway. The ADM stated he did not report to the state as alleged abuse until 04/08/2025 after the stories kept on changing. The ADM stated the report should have been made to HHSC on 04-05-2025 when the incident had occurred. The ADM stated he was responsible for reporting the incident to the state timely. The ADM stated it was expected to report alleged abuse to HHSC within 24 hours to prevent further abuse.<BR/>A record review of the Long-Term Care Regulation Provider Letter dated August 29, 2024 facility's reflected Abuse, Neglect, Exploitation, Misappropriation of Resident Property and other incidents that a Nursing Facility (NF) must report to the Health and Human Services Commission (HHSC).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations were thoroughly investigated and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the allegation was verified appropriate corrective action was taken for one of six residents (Resident #1) reviewed for abuse and neglect .<BR/>The facility failed to report, within five days, the results of an investigation of an allegation of Abuse and Neglect involving Resident #1 when she fell on 4/15/2024.<BR/>This failure could place residents at risk for continued abuse or neglect without appropriate corrective actions being taken. <BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated 4/29/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Chronic Obstructive Pulmonary Disease (a condition involving constriction of the airways and difficulty breathing), Dementia (progressive memory loss), Hypertension (high blood pressure), Congestive Heart Failure (weakness in the heart that leads to a buildup of fluid in the lungs), Mood Disorder, Acute Respiratory Distress and Chronic Pain.<BR/>Record review of Resident #1's MDS, dated [DATE], reflected a BIMS of fourteen (14), which indicated Resident #1 had no cognitive impairments.<BR/>Record review of Resident #1's SBAR form, dated 4/15/2024, reflected RN A entered Resident #1's room and saw Resident #1 on the floor with two EMTs rolling Resident #1 onto a lift blanket. The SBAR form indicated RN A asked the EMTs what happened, and they told her the resident fell.<BR/>During an interview on 4/29/2024 at 12:15 PM, the DON stated RN A went and told her she was sending Resident #1 out to the ER then she went back later on and told her Resident #1 was found on the floor and she thought EMS had dropped Resident #1. The Therapy Director first came to her the next day, 4/16/2024, and stated the ST was in the room and Resident #1 had not fallen, then a couple days later, the Therapy Director went back and said the ST was in the room and heard a noise and then saw Resident #1 on the floor. The DON stated at that point Resident #1 had already passed away in the hospital. The DON stated at that point she informed the AD. She stated it would be the AD's responsibility to investigate. She stated there was no suspicion about Abuse and Neglect and that an investigation was not completed. She further stated, I was missing pieces to the story, and I didn't know I was missing pieces.<BR/>During an interview on 4/29/2024 at 12:58 PM, the AD stated, I did not have any awareness that there was an unwitnessed fall. He stated there was a dispute in regard to the allegation that she was found on the floor and that is the reason why it was not investigated. He stated he was responsible for ensuring an investigation is done . He said these incidents should be reported to him so he can ensure residents are safe.<BR/>Record review of the facility policy Abuse, neglect, Exploitation or Misappropriation - Reporting and Investigating, dated September 2022, reflected: All reports of resident abuse (including in juries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulation) and thoroughly investigated by facility management. Findings of all investigations are documented and reported .Investigating Allegations: 1. All allegations are thoroughly investigated. The administrator initiates investigations. <BR/> <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review the facility failed to ensure each resident receives adequate supervision and assistive devices for one of twenty residents (Resident #1) reviewed for accidents.<BR/>The facility failed to ensure Resident #1's coffee cup was positioned properly at the upper right of his plate which led to him knocking it over. Resident #1 sustained 2nd degree burns to his bilateral inner thighs from the hot coffee.<BR/>An IJ was identified on 01/11/2024 at 4:10 PM. While the IJ was removed on 01/12/2024, the facility remained out of compliance at a severity level of actual harm and a scope of isolated harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. <BR/>These failures placed all residents at risk for injuries, pain, and mental anguish. <BR/>Findings include: <BR/>Record review of Resident #1's face sheet dated 01/11/2024, reflected Resident #1 was a [AGE] year-old man admitted on [DATE] with diagnoses of unspecified glaucoma (build-up of fluid in the eye, which presses on the retina and optic nerve), unspecified cataract (a condition in which the lens of the eye becomes cloudy), muscle weakness (lack of physical or muscle strength), and type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye (central part of the retina, swells from the leaking fluid and causes blurred vision).<BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 09, which indicated moderate cognitive impairment. Section B (Hearing, Speech, and Vision) reflected Resident #1's vision was highly impaired. Section GG (Functional Abilities and Goals) reflected Resident #1 required setup or clean-up assistance for eating. <BR/>Record review of Resident #1's care plan dated 01/11/ 2024 reflected Resident #1 was care planned for impaired visual function related to cataracts, glaucoma, and diabetic retinopathy. Resident #1 was care planned for ADL self-care performance deficit related to confusion, impaired balance, and limited mobility with interventions of eating self-performance (limited assist) support provided (x1 assist). Resident #1 was also care planned for blisters to medial thighs bilaterally related to coffee spillage in his lap. <BR/>Record review of the facility nursing progress note dated 12/29/23 reflected, At approximately. 10:00 am the nurse was called to the dining room; the nurse notified the resident was yelling. Resident reported he had spilled coffee on himself, the nurse returned to his room to assess injury. I wasted coffee in my lap <BR/>Record review of the facility nursing progress note dated 01/02/24 reflected, Nurse practitioner there to see resident today and assess blisters to inner thighs bilaterally. New orders noted by the charged nurse and entered into the computer. Care plan updated to reflect the following: Focus: Resident #1 had blisters to medial thighs bilaterally related to coffee spillage in his lap. Goal: Resident #1's blisters would heal without complications in the next 30 days. Interventions: Administer treatment as ordered by the physician, assist Resident #1 with his coffee and provide Kennedy cup (non-spill cup) as needed while drinking his coffee, for closed blister on left inner thigh: spray with skin prep or betadine and cover with foam dressing daily, for opened blister on inner right thigh: clean with NS, apply Silvadene to red base wound, calcium alginate to the slough are and cover with foam dressing, change daily, monitor blisters to legs bilaterally for signs of infections or swelling, and notify physician with any concerns. <BR/>Record review of the facility nursing progress note dated 01/02/24 reflected, received new order for wound care to change orders for care of burns to residents bilateral thighs, New order to clean open blisters to bilateral thighs with NS/WC, pat dry, apply petrolatum gauze to wound beds, and cover with dry gauze type dressing daily and PRN. Resident advised of new orders to start 01/11/2024.<BR/>Record review of the wound care progress note dated 01/03/24 reflected, Resident #1's wound #1 status was Open. The date acquired was: 1/1/2024. The wound was classified as a Partial Thickness wound with etiology (the cause or cause of a disease) of 2nd degree Burn and was located on the right, Anterior Upper Leg. The wound measured 8cm length x 8.5cm width x 0.1cm depth; 53.407cm2 area and S.341cm3 volume. There was no tunneling or undermining noted. There was a non-present amount of drainage noted. There was no necrotic tissue within the wound bed. The periwound skin appearance did not exhibit: Callus (a region of thickened skin that develops from increased friction), Crepitus (popping, clicking or cracking sound in joints), Excoriation (health condition where you compulsively pick at your skin), Induration (thickening or hardening of soft tissues of the body), Rash (irritated or swollen skin), Scarring (the body's natural way of healing and replacing lost or damage skin), Dry/Scaly (small, hard, dry area that fall of in small pieces), Maceration (skin softening and breaking down due to prolonged contact with moisture that is usually not present on the skin), Atrophie Blanche (a chronic condition that presents as recurrent, painful, ulcers of the lower leg, ankle, or dorsal foot), Cyanosis (bluish color in the skin, lips, and nail beds caused by a shortage of oxygen in the blood), Ecchymosis (bruises), Hemosiderin Staining (areas of discolored skin that usually affect the lower leg, typically on the ankle and the top of the foot), Mottled (marked with spots of different colors), Pallor (skin paleness), Rubor (redness to skin), Erythema (skin rash). Periwound temperature was noted as No Abnormality. Wound #2 status was Open. The date acquired was: 1/1/2024. The wound was classified as a Partial Thickness wound with etiology (the cause or cause of a disease) of 2nd degree Bum and was located on the left,Medial Upper Leg. The wound measures 0.5cm length x 3cm width x 0.1cm depth; 1.178cm2 area and 0.118cm3 volume. There was no tunneling or undermining noted. There was a non-present amount of drainage noted. The wound margin was flat and intact. There was no necrotic tissue within the wound bed. The periwound skin appearance did not exhibit: Callus (a region of thickened skin that develops from increased friction), Crepitus (popping, clicking or cracking sound in joints), Excoriation (health condition where you compulsively pick at your skin), Induration (thickening or hardening of soft tissues of the body), Rash (irritated or swollen skin), Scarring (the body's natural way of healing and replacing lost or damage skin), Dry/Scaly (small, hard, dry area that fall of in small pieces), Maceration (skin softening and breaking down due to prolonged contact with moisture that is usually not present on the skin), Atrophie Blanche (a chronic condition that presents as recurrent, painful, ulcers of the lower leg, ankle, or dorsal foot), Cyanosis (bluish color in the skin, lips, and nail beds caused by a shortage of oxygen in the blood), Ecchymosis (bruises), Hemosiderin Staining (areas of discolored skin that usually affect the lower leg, typically on the ankle and the top of the foot), Mottled (marked with spots of different colors), Pallor (skin paleness), Rubor (redness to skin), Erythema (skin rash). Periwound temperature was noted as No Abnormality.<BR/>A Record Review of Coffee temp log reflected there was no documentation of coffee temperatures before January 2024. There were missing coffee temperatures for the PM shift on 01/07/24, 01/08/24, and 01/09/24. The coffee temperature log only has one AM and one PM column for documentation. <BR/>During an observation on 01/10/24 at 1:15 pm of Resident #1's injuries, it was observed Resident #1 had two bandaged areas on both his right and left inner thighs. Observation of the upper right inner thigh area was observed to be pink in color, skin missing. No observation of Resident's #1 left thigh due to Resident #1 yelling out in pain. <BR/>During an interview on 01/10/24 at 10:30am with Resident #1 stated his plate was placed in front of him and his cup of coffee placed beside the plate (right side), but near the edge of the table. Resident #1 states that his vision was impaired, and he can see objects, shadows, and movement, but not clearly. Resident #1 stated that typically his cup of coffee would have been placed near to the center of the table. Resident #1 stated that his cup was usually at the upper right of his plate with the handle turned out so that he could easily manage his grip on the cup. Resident #1 stated that while he was attempting to take a bite of his food, his hand/arm knocked over his cup of hot coffee directly into his lap. Resident #1 stated he yelled out in pain when he spilled the hot coffee. Resident #1 states that he was wearing sweatpants at the time.<BR/>During an interview on 01/10/24 at 11:45 am with the CNA, he stated that Resident #1 needs his food and drink positioned to his liking, so he doesn't knock it over. CNA stated that Resident #1 liked his coffee positioned near the center of the table so could see it. <BR/>Attempted an interview on 01/10/24 at 1:20 pm with LVN #1. No answer but voicemail was left. No return call was made from LVN #1. <BR/>During an interview on 01/10/24 at 2:45 pm with the DON, she stated she was notified of Resident #1 injuries but there was no redness or blistering at the time. Resident #1 was given a cold towel to place in his lap and the MD was notified. The DON stated LVN #1 and NA #1 gave Resident #1 a shower after the incident and no redness or blistering was observed at that time. DON stated that Resident #1 sustained 2nd degree burns to his left and right thigh because of the incident.<BR/>During an interview with Dietary Supervisor on 01/10/24 at 3:15pm, a request was made for the coffee/hot liquid temperatures for the calendar year of 2023. Dietary Supervisor stated the facility had not taken any coffee/hot liquid temps prior to January 2024.<BR/>During an interview on 01/10/24 at 4:15 pm with the ADM, he stated hot liquid temps should be taken after batch of coffee was made. The ADM stated if no temperatures are taken then there would be potential for the coffee/hot liquid to be too hot for the residents. If the coffee/hot liquid was too hot, then there would be risks for resident to sustain injuries from the coffee/hot liquid. <BR/>During an interview on 01/10/24 at 4:30 pm with the Dietary supervisor, she stated coffee was made 7 times a day. There was a coffee pot for both halls and one for the dining area. The Dietary supervisor stated that the dishwashing staff was responsible for checking the temperature of the coffee. The Dietary supervisor stated she was not aware the temperature of the coffee needed to be checked after each batch was made. <BR/>During an interview on 01/11/24 at 9:45 am with dishwashing staff #1, he stated he checked the temperature of each coffee pot before each meal. Dishwashing staff #1 stated he only checked the temperature for breakfast and before lunch. The dishwashing #1 stated he did not remember when he was in-services on hot liquids.<BR/>Attempted an interview on 01/11/24 at 10:15 am with NA #1. No answer but voicemail was left. No return call was made from NA #1.<BR/>Attempted an interview on 01/11/24 at 2:15 pm with LVN #1. No answer but voicemail was left. No return call was made from LVN #1.<BR/>Attempted an interview on 01/11/24 at 12:55 pm with NA #1. No answer but voicemail was left. No return call was made from NA #1.<BR/>Review of the facility's Safety of Hot Liquids Policy dated 2001 reflected Residents will be evaluated for safety concerns and potential of injury from hot liquids up admission, readmission and on change of condition. Appropriate precautions will be implemented to maximize choice of beverage while minimizing the potential of injury.<BR/>Policy interpretation and implementation <BR/>1. <BR/>The potential for burns from hot liquids is considered an ongoing concern among residents with weakened motor skills, balance issues, impaired cognition, and nerve or musculoskeletal condition.<BR/>2. <BR/>Residents with these or other conditions may suffer from accidental burns and related complications stemming from thinner, more fragile skin that may burn quickly and severely and take longer to heal.<BR/>3. <BR/>Residents who prefer hot beverages with meals (i.e. coffee, tea, soups, etc.) will not be restricted from these options. Instead, staff will conduct regular Hot Liquid Safety Evaluations as indicated, and document the risk factors for scalding and burns in the care plan.<BR/>4. <BR/>Once risk factors for injury from hot liquids are identified, appropriate intervention will be implemented to minimize the risk from buns, such interventions may include: <BR/>A. <BR/>Maintaining a hot liquid serving temperature of not more than 155 degrees Fahrenheit: <BR/>B. <BR/>Serving hot beverages in a cup with a lid:<BR/>C. <BR/>Encouraging residents to sit at the table while drinking or eating hot liquids:<BR/>D. <BR/>Providing protective lap coverage or clothing to protect skin from accidental spills, and <BR/>E. <BR/>Staff supervision or assistance with hot beverages.<BR/>5. <BR/>Food service staff will monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding.<BR/>This was determined to be an Immediate Jeopardy on 01/11/24 at 4:10 pm. The ADM was notified. The ADM was provided with the IJ template on 01/11/24 at 4:10 pm. <BR/>The Plan of Removal was accepted on 01/12/2024 at 10:20 AM and included the following:<BR/>All listed items will be completed by 01/12/24 with continued follow-up:<BR/>1. <BR/>On 1/11/2024, Resident #1 was assessed by the Director of Nursing/Designee to validate that the resident was not exhibiting signs or symptoms of physical or psychosocial distress related to the deficient practice and to ensure that measures were in place to minimize the risk of future burns related to hot liquids. Care Plan was reviewed to validate all current interventions in place. <BR/>On 1/11/2024 The Director of Nursing/Designee notified resident #1's responsible party and physician of the identified deficient practice. <BR/>2. <BR/>On 1/11/2024, dietary log was initiated to monitor and temp all brewed batches of coffee throughout the day. Total of 13 dietary staff, 9 of which have received education, the remaining 4 will be completed on 1/12/2024, prior to start of shift, on the process to monitor and temp all batches and requirement to be 155 degrees or less prior to making available for residents consumption.<BR/>3. <BR/>The Director of Nursing/Designee completed a sweep of all facility residents' hot liquid assessment, validated they were current and applicable for all residents on 1/11/2024. Director of nursing/designee then validated for appropriate interventions to be in place and that care plans are updated as applicable related to risk assessment. 3 residents with visual deficit/legally blind were identified including Rresident #1 All 3 identified were supplied with specialty mugs with handles, non-slip bases and lids on January 4, 2024. 4 residents identified as needing assist with all hot liquids, these care plans were updated to reflect necessary need. 5 residents identified with need to be seated at table to securely place hot liquids while drinking. Those care plans updated to reflect the need for this intervention on 1/11/2024. <BR/>4. <BR/>Director of Nursing completed education with all dietary staff on requirements to monitor and log temperature of all batches of coffee, and requirement that temperature before serving or making available to resident be 155 degrees or less<BR/>5. <BR/>The Director of Nursing/Designee provided education to all facility staff on policy for hot liquids and list of specific residents that require additional interventions for hot liquid safety. This education included the requirement to implement appropriate interventions to prevent burns for residents consuming hot liquids.<BR/>To monitor for compliance: Director of Nursing/Designee will review residents identified with safety concerns from hot liquid assessment daily x 7 days, beginning 1/12/2024, to validate all implemented interventions are in place and any newly identified residents at risk are addressed accordingly with appropriate interventions. Any identified concerns will be corrected with applicable education completed as identified, Director of Nursing/Designee will then continue to monitor daily in clinical meeting ongoing. Monitoring will continue daily in kitchen with temperature log completed on each new batch. Administrator/designee will audit logs daily Monday through Friday to validate hot liquids are temped prior to serving and will review in QAPI for compliance. Any trends or concerns were/will be addressed with the Quality Assurance Performance Committee and continue until a lessor frequency deemed appropriate through QAPI review.<BR/>Plan of Removal completion date is 01/12/2024. <BR/>Monitoring for Plan of Removal was completed on 01/12/2024 as follows:<BR/>The Director of Nursing/Designee provided education to all facility staff on policy for hot liquids and list of specific residents that require additional interventions for hot liquid safety. This education included the requirement to implement appropriate interventions to prevent burns for residents consuming hot liquids.<BR/>In an interview on 01/12/2024 at 9:05 am with Regional RN, stated Resident #1 was assessed and not exhibiting and signs or symptoms of physical or psychological distress related to recent deficient practice in regard to the coffee burn. Measure have been put in in place to prevent further coffee burns including a cup with a lid, the kitchen staff will ensure coffee remains 155 or less prior to serving coffee to the resident. Resident #1 was in a great mood. He stated, I'm getting better every day. Wounds are improving. Noted inner left thigh was healed, and 2 of the wounds to the right inner thigh are pink, and dry, without any scabs. The wound to the top of the right thigh was approximately 1cm x 1cm, skin pink, blister has popped and without any signs of infection. Resident #1 stated, it does itch a bit. Resident #1 denies any pain. Family and physician were notified of the deficient practice. The physician agrees with current wound care orders and interventions. Regional RN also stated that the facility identified Resident #1, Resident #2, and Resident #3 will use a Kennedy cup (non-spill cup). Resident #4, Resident #5, Resident #6, and Resident #7 will need physical assistance at the table during meals. Resident #8 Resident #9 Resident #10, and Resident #11 will need to be sitting at a table when receiving hot liquids. <BR/>During interviews on 01/12/24 from 9:50 am - 10:45 am with six dietary staff members (1 dietary supervisor, 3 dietary aides and 2 dietary cooks), who were able to articulate information from the hot liquid in-service.<BR/>Observation on 01/12/2024 at 9:30am, Kennedy cups for Resident #1, Resident #2, and Resident #3. Each cup had the resident's name on it. <BR/>Record review on 01/12/2024 at 9:45am, reflected a new hot liquid temperature sheet with columns for documentation for date, time, batch, temp, staff name, and correction/retemp. <BR/>Record review of the facility's Procedure for monitoring temperature of Coffee<BR/>1. <BR/>All batches of coffee to have temperature taken prior to being allowed for resident consumption.<BR/>2. <BR/>Log each temperature, date/time, batch number, your initials, and time temperature taken.<BR/>3. <BR/>If temperature too high - above 135 degrees, correction taken and what temperature was on recheck.<BR/>An IJ was identified on 01/11/2024. The IJ template was provided to the facility on [DATE] at 4:10 PM. While the IJ was removed on 01/12/2024, the facility remained out of compliance at a severity level of actual harm and a scope of isolated harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens reviewed for dietary services.<BR/>1. The facility failed to seal food products in airtight containers, labels food products with product name, label food products with the open/discard date, and dispose of food products after discard date.<BR/>2. The facility failed to clean and sanitize the kitchen's only industrial can opener, food prep areas, and the area surrounding the facility's only dishwasher.<BR/>This failure placed the residents at risk of ingesting food-borne pathogens.<BR/>Findings included:<BR/>Observation on 2-12-2024 at 8:45 AM in the facility's dry storage area reflected 1 box of pineapple tidbits stored directly on the floor; and 2 large bags of potato chips, each stored in a 2-gallon plastic bag, without labels which signified the product name, the date they were opened, or the date the product expired.<BR/>Observation on 2-142-2024 beginning at 8:50 AM of the facility's walk-in cooler (32 degrees Fahrenheit) reflected 1package of sliced American cheese in a plastic bag, which was not tightly sealed, without a label which signified the product name, the date it was opened, or the date the product expired; 1 package of grated cheese, which was not tightly sealed, without a label which signified the product name, the date it was opened, or the date the product expired; 1 package of chicken fried patties, which was not tightly sealed, without a label which signified the product name, the date it was opened, or the date the product expired; 1 40 ounce bottle of barbeque sauce without a label which signified the product name, the date it was opened, or the date the product expired; 2 small packages of sliced luncheon meat, which were not tightly sealed, without labels which signified the product name, the date they were opened, or the date the products expired; 1,one, 4 quart plastic contains of tomatoes, which was not tightly sealed, without a label which signified the product name, the date it was opened, or the date the product expired; 1, one, 4 quart plastic contains of green bell peppers, which was not tightly sealed, without a label which signified the product name, the date it was opened, or the date the product expired. <BR/>Observation on 2-12-2024 at 9:00 AM of the facility's freezer (-8 degrees Fahrenheit) reflected 39 assorted boxes and bags of frozen foods stored closely together, thus having limited adequate circulation around food storage containers. Observation reflected 1 bag of fried potatoes, without a label which signified the product name, the date it was opened, or the date the product expired; and, 4 individual bags of frozen waffles, without labels which signified the product name, the date they were opened, or the date the products expired.<BR/>Observation on 2-12-2024 at 9:32 AM of the kitchen's food preparation area and equipment reflected the industrial can-opener its internal working parts, and the plastic mounting bracket, which secured it to the food prep table, were coated with a dark brown substance and food particles. The dark brown substance and food particles were sticky to the touch and thick enough to scrape away with a gloved finger; the facility's only dishwasher had an accumulation of white grit and food particles on the top, and sides, of the machine. The metal vent, above the dishwasher, had an accumulation of grime and a dark brown substance; and, the side walls of a preparation table, next to the facility's flat grill, had an accumulation of grease and food particles.<BR/>Interview on 2-14-24 at 12:35 PM with DA revealed it was important to store foods in airtight containers, label the product with its name, write the date the item was opened, and write the date when the item was expected to expire for foods in the dry storage, refrigerator, and the freezer. The labels were created to know which items were fresh; and which items needed to be thrown away. Food improperly sealed, or not thrown when they expired, risked the growth of bacteria, mold, and food-borne pathogens. Kitchen equipment, and food preparation areas, needed to be cleaned with soapy water and sanitizer, which also reduced the growth of bacteria, mold, and food-borne pathogens having spread through cross-contamination. If a resident ingested bacteria, mold, or food-borne pathogens, they risked becoming ill having resulted in vomiting, stomach pain, and diarrhea.<BR/>Interview on 2-24-2024 at 12:43 with the KM revealed food stored in the dry storage area, the refrigerators, and in the freezers were required to be sealed in airtight containers, labeled with the product name, labeled with the date the item was opened, and labeled with the date the item was expected to expire. The labeling system was in place to know which items were fresh; and which items needed to be discarded. If air got into a food container, or was kept past its expiration date, the item risked the growth of bacteria, mold, and food borne pathogens. Kitchen staff were also instructed to clean, and sanitize, their respective areas after each use. Ineffective cleaning and sanitizing also promoted the growth of bacteria, mold, and food borne pathogens. If a resident consumed bacteria, mold, and food borne pathogens, they were placed at risk for illnesses having resulted in stomach cramps, diarrhea, dehydration, and unintended weight loss. The KM stated the failure of her staff to properly label and date stored food products and sanitize their respective food preparation areas was the result of the kitchen staff having failed to follow instructions and the KM having failed to train her staff. <BR/>Interview on 2-14-2024 at 1:39 PM with the DON revealed she expected the kitchen staff was knowledgeable about the way food was supposed to be stored, how long foods were supposed to be kept, and how kitchen areas, and equipment, were supposed to be cleaned. Periodically, members of the IDT team checked areas throughout the facility and brought areas of concern to the IDT meetings for discussion; however, she was not informed about any short comings in the kitchen, or its failures to adhere to proper food storage and cleanliness. <BR/>Interview on 2-14-2024 at 2:26 PM the ADM revealed there were facility policies in place that covered food safety and sanitization for dietary services. The kitchen was not checked by the IDT team; the ADM relied on the DM's input. The failure for the kitchen's non-compliance of company policy was the DM not having trained her staff and not having held her staff to the facility's standards.<BR/>Record review of the United States Food Code 2022, website: www.fda.gov. Food Contact with Equipment and Utensils: Pathogens can be transferred to food from utensils that have been stored on surfaces which have not been cleaned and sanitized. They may also be passed on by consumers or employees directly, or indirectly from used tableware or food containers. Food Storage: The possibility of product contamination increases whenever food is exposed. Changing the container(s) for machine vended time/temperature control for safety food allows microbes that may be present an opportunity to contaminate the food. Pathogens could be present on the hands of the individual packaging the food, the equipment used, or the exterior of the original packaging. In addition, time/temperature control for safety foods are vended in a hermetically sealed state to ensure product safety. Once the original seal is broken, the food is vulnerable to contamination.<BR/>Record review of the kitchen's staff instructions, undated, indicated the [Cook's Helper] was supposed to check the walk-in (referring to the walk-in refrigerator) and make sure all was dated and anything over 5 days was thrown away. [AM [NAME] Job Flow] indicated staff cleaned and sanitized their area. [Lunch [NAME] Work Flow] indicated staff cleaned and sanitized their area.<BR/>Record review of the facility's policy for [Foods Preparation and Service,] dated November 2022, indicated [General Guidelines] (2) Cross-contamination could occur when harmful substances, chemical or disease-causing microorganisms were transferred to food by hands, food contact surfaces, sponges, cloth towels, or utensils that were not adequately cleaned. [Food Preparation Area] (4d.) Cleaning and sanitizing work surfaces and food contact equipment between uses, following food code guidelines. [Food Distribution and Service] (15) All food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendations. <BR/>Record review of the facility's policy for [Refrigerators and Freezers,] dated November 2022, indicated (7) All food was appropriately dated to ensure proper rotation by expiration dates. Received dates, dates of delivery, were marked on cases and on individual items removed from cases for storage. [Use by] dates were completed with expiration dates on all prepared food and refrigerators. Expiration dates on unopened food were observed and [used by] dates were indicated once food was opened. (9) Supervisors were responsible for ensuring food items in pantry, refrigerators, and freezers were not passed [used by] or expiration dates.<BR/>Record review of the facility's policy for [Food Receiving and Storage,] dated November 2022, indicated [Dry Food Storage] (4) Dry foods that are stored in bins are removed from original packaging, labeled, and dated [use by dates.] Such foods are rotated using a [first-in first-out system. (5) Food in designated dry storage areas were kept at least 6 inches off the floor. [Refrigerated and Frozen Storage] (1) All food stored in the refrigerator or freezer are covered, labeled, and dated [use by dates;] and, (3) Refrigerated foods are stored in such a way that promotes adequate air circulation around food storage containers. <BR/>Record review of the facility's policy for [Sanitization,] dated November 2022, indicated (3) All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions; (8) When cleaning fixed equipment (mixers, slicers, and other equipment that cannot readily be immersed in water), the removable parts are (a) washed and sanitized and non-removable parts were cleaned with the detergent and hot water, rinsed, air dried and sprayed with the sanitizing solution; and (b) the equipment was reassembled and any food contact surface that may have been contaminated during the process were re-sanitized.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to follow regulations and a written policy on permitting residents to return to the facility after they were hospitalized , or placed on therapeutic leave, for 1of 8 residents (RES #6) who were reviewed for discharges.<BR/>On 11/11/2023, the facility did not allow RES #6 to return to the facility after he was sent to the emergency room for acute care. <BR/>This failure placed residents at risk for not receiving care and services to meet their needs upon therapeutic leave and hospitalization.<BR/>Finding include:<BR/>Record review of RES #6's AR, dated 12-5-2023, reflected RES #6 was [AGE] year-old male who was admitted to the facility on [DATE]. RES #6 was diagnosed with Anxiety Disorder, Attention Deficit Hyperactivity Disorder, Intellectual Disabilities, and Type-2 Diabetes. <BR/>Record review of RES #6's Annual MDS, dated [DATE], C- Cognitive Patterns, C0100, indicated that a BIMS, which was a numeric score to designate a level of cognitive function, should have been conducted; however, Section C0500 did not indicate RES #6's BIMS Score. Section E- Behaviors, RES #6 was coded as 0 for (1) physical aggression directed towards others, such as hitting, kicking, pushing, scratching, grabbing, abusing others sexually; (2) verbal behaviors directed towards others, such as threatening others, screaming at others, cursing at others; and (3) other behaviors direction towards others, such as physically hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, growing food or body wastes, or verbal and vocal symptoms like screaming and disruptive sounds. A code of 0 indicated RES #6 did not exhibit the listed behaviors. <BR/>Record review of RES #6's Discharge MDS, dated [DATE], indicated a Staff Assessment for Mental Status, Sections C0700 was coded a 1 for Short-Term Memory, which indicated RES #6's memory was OK. Section C1000 was coded a 2, for Cognitive Skills for Daily Decision Making, which indicated RES #6's decision making was Modified Independence, which meant he had some difficulty in new situations only. Section E- Behaviors reflected RES #6 was coded as 1, for (1) physical aggression directed towards others, such as hitting, kicking, pushing, scratching, grabbing, abusing others sexually; (2) verbal behaviors directed towards others, such as threatening others, screaming at others, cursing at others; and (3) other behaviors direction towards others, such as physically hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, growing food or body wastes, or verbal and vocal symptoms like screaming and disruptive sounds. A code of 1 indicated RES #6 exhibited the listed behaviors 1-3 days.<BR/>Record review of RES #6's CP, revised on 2/3/22, indicated a Focus Area for Needs, demonstrated by RES #6 dependent on staff for emotional intellectual physical and social needs Related to cognitive deficits. RES #6 preferred music, dancing, singing, sports, TV, cooking, and exercise. The Goal, initiated on 12/6/2021, indicated RES #6 would maintain involvement in cognitive stimulation and social activities as desired. Interventions for facility staff were to (1) provide a program of activities that is of interest and empowers the resident by encouraging and allowing choice, self-expression, and responsibility; and (2) provide one-on-one room visits and activities if unable to attend out of room events. <BR/>Record review of RES #6's PN, written on 11/10/2023 at 7:30 AM by RN A, indicated RES #6 was on isolation for Covid-19 and was acting out towards staff. The PN indicated RES #6 had turned up his radio, slammed his door, cursed at staff, threw objects at staff, pulled the call button cord from the wall, swung the call button cord at staff, punched two staff, and kicked at staff. RES #6 was sent to the hospital (the ER) on 11/10/2023 at 8:00 AM for his displayed agitation. Both LAR #6 and LAR #7 were called. <BR/>Record review of RES #6 PN, written on 11/10/2023 at 12:41 PM by RN A, reflected RES #6 returned to the facility on [DATE] at 12:41 PM. RES #6 remained calm and ate his lunch. RES #6 was in a new room, had a music box for entertainment, and watched TV. <BR/>Record review of RES #6 PN, written on 11/10/2023 at 1:45 PM by RN A, reflected RES #6 continued to play his music loudly, which led to the power cord removal. RES #6 attempted to get the power cord back from RN A but was told no. RES #6 grabbed the power cord, along with RN's stethoscope, and threw them both back at the RN A. RES #6 continued to slam his door, curse at staff, and kick at staff, which led to a phone call for police intervention. The local PD arrived on scene. RES #6 assaulted a police officer. The PN indicated the PD Officer stated he could not do anything about RES #6's behavior because RES #6 was not in a right frame of mind. The DON and administration worked with RES #6's PCP to get to try to get him somewhere else for help. <BR/>Record review of RES #6's PN, written on 11/10/2023 at 2:41 PM by RN A, indicated RES #6 received a Haloperidol injection in left upper arm. (Haloperidol, also known as Haldol, was a medication for mood disorders, which helped the recipient think more clearly, feel less nervous, and take part in everyday life.) <BR/>Record review of RES #6's PN, written on 11/10/2023 at 3:30 PM by RN A, indicated the Haldol injection was not affective. RES #6 continued to kick at and throw objects at staff. RES #6 stated he did not want to be at the facility anymore. The facility called a staff member at a local community adult daycare, which RES # 6 attended frequently, to help calm RES #6. The intervention did not work. The facility called EMS and RES #6 was sent to the local hospital ER for his behaviors. <BR/>Record review of RES #6's PN, written on 11/10/2023 at 10:15 PM by RN B, indicated RES #6 returned from the local hospital ER with the ADM at 10:15 PM. RES #6 continued to beat on the secure doors and yelled he did not want to be there. RES #6 was provided a one-to-one staff. RES #6 was observed as he sat in bed and watched TV. <BR/>Record review of RES #6's PN, written on 11/11/2023 at 12:35 AM by RN B, reflected RES #6 threw his shoes, a trash can, and patient supplies down the hall. RES #6 continued to yell, curse, kick at staff, and hit doors. RES #6 continued to verbalize he wanted to leave and wanted to go to jail. Staff were unable to redirect him.<BR/>Record review of RES #6's PN, written on 11/11/2023 at 2:32 AM by the DON, reflected RES #6 assaulted the charge nurse and got through the doors of the secure unit. RES #6 ran to the front of the facility, where he tore things up and threw anything he could get his hands on. Staff could not return RES #6 to the secure unit; staff called 911. the PD removed RES #6 from the facility by 3 PD Officers. RES #6 was outside of the facility with the PD Officers. The facility contacted LAR #6, who requested a medication review for RES #6's behaviors. <BR/>Record review of RES #6's PN, written on 11/11/2023 at 3:30 AM by the DON, indicated the PD brought RES #6 back inside the facility from the parking lot. The PD escorted RES #6 back to his room and decided not to take RES #6 anywhere. The PD stated RES #6 resided at the facility and he had medical care. The PN indicated the PD informed facility staff that the facility would have to manage RES #6. The charge nurse called EMS; EMS transported RES #6 back to the local hospital ER. <BR/>Record review of RES #6's PN, written on 11/11/2023 at 5:05 AM by LPN A, indicated the local hospital ER called the facility and reported RES #6 was calm and was ready to return to the facility. <BR/>Record review of RES #6's PN, written on 11/11/2023 at 5:15 AM by LPN A, indicated nurse reported to DON and left voicemail on administrator's #. (The PN did not contain any more information.)<BR/>Interview on 12-5-2023 at 2:51 PM with the SW at the local hospital ER revealed RES #6 had two visits to the local hospital ER between 11-10-2023 and 11-11-2023. The SW read from their charting system that RES #6 presented to the ER from the facility, by EMS, on 11-10-23 at 3:42 PM and DC back to the facility with the ADM on 11-10-2023 at 9:53 PM. RES #6 returned to the ER by EMS on 11-11-2023 at 4:09 AM and was prepared to DC back to the facility. The SW stated the ER staff called the facility on 11-11-2023 at 5:05 AM to inform the facility that RES #6 was calm and ready to return. The SW stated the ER called the facility again on 11-11-2023 at 6:09 AM, having spoken to RN A, and informed RN A that RES #6 was ready for return to the facility. The SW stated that RN A responded by stating, we are not taking [RES #6] back; we will get in trouble for dumping him, but we will be OK with that. The SW stated the facility did not send RES #6's medications to the hospital and RES #6 stayed in the ER for the next 3 days until DC to LAR #7 on 11-14-2023 at 3:38 PM. The SW at the local hospital ER reviewed the documentation and stated there was no documentation of additional calls between the local hospital ER and the facility.<BR/>Interview on 12-5-2023 at 2:38 PM with LAR #6 revealed the family was upset because LAR #6 and LAR #7 felt like the facility dumped RES #6 at the local hospital ER for his behaviors. LAR #6 stated RES #6 was back at home living with LAR #7, but it was difficult for LAR #7 to provide the level of care RES #6 required. LAR #6 stated that LAR #7 was not used to RES #6's routines or medication requirements. <BR/>Interview on 12-5-2023 at 4:00 PM with RN A revealed he spoke to the ER staff on the phone on 11-11-2023 around 6:09 AM and admitted he told the ER staff that we, the facility, are not taking [RES #6] back; we will get in trouble for dumping him, but we will be OK with that. RN A stated that the information he told the ER about refusing RES #6's return was disseminated from RN B in the morning shift change report on 11-11-2023 between 5:00 AM to 6:00 AM. <BR/>Interview on 12/5/2023 at 5:13 PM with the ADM revealed RES #6 had a lot of behavioral outbursts on 11/10/2023 and 11/11/2023. The ADM stated that RES #6 destroyed property, threatened the safety of other residents, and assaulted his staff. The ADM explained that he never officially told any of the staff that RES #6 was not allowed back at the facility. The ADM stated the official word to DC RES #6 was not given to him until the morning of 11/11/2023, around 6:15 AM, by his corporate offices. He stated he did not know why RN A told the ER that the facility would not accept RES #6 back at the facility at 6:09 AM. The ADM stated he called the local hospital ER on [DATE] at 630 AM and spoke to a man, a man whose name he could not recall, having stated [RES #6] has demonstrated behaviors that make him a danger to other residents and staff, and we will not be able to accept him back. The ADM stated the man who answered the phone simply hung up the phone having said nothing. The ADM did not make any more attempts to check on RES #6 or to locate a different facility to address RES #6's needs. The ADM's conversation with the local hospital ER was not documented in RES #6's chart. Upon request for existing documentation related to RES #6's DC, the ADM did not present any documentation that could support the facility's attempts to seek alternate accommodations for RES #6.<BR/>Interview on 12/5/2023 at 5:15 PM with the DON revealed she had been speaking with the SW at the local hospital ER multiple times on 11/10/2023 and 11/11/2023 to try to get RES #6 some help. The DON stated [RES #6] behaved in a manner, which posed a danger to residents and staff. We, the facility, were not trying to dump [RES #6] at the ER. We tried to get him some help. <BR/>Interview on 12-6-2023 at 4:00 PM with LAR #7 revealed she picked RES #6 up from the local hospital ER on [DATE] at 3:38 PM. RES #6's did not have any medication from the facility. After LAR #7 collected RES #6 from the local hospital ER, LAR #7 and RES #6 went to the facility at 5:30 PM to collect RES #6's things. Record review of RES #6's Order Summary Report indicated on RES #6 was prescribed multiple medications for mood, sleep, cholesterol, and diabetes. LAR #7 stated she was not sure how to provide care for RES #6. She stated that he had a lot of pills, and she was not comfortable giving RES #6 injections.<BR/>Interview on 12/6/2023 at 5:57 PM with RES #6 revealed he was acting out in the facility due to being isolated after having tested positive for Covid-19 (11/9/2023.) RES #6's daily routine was altered, due to isolation, and was not allowed to go to the adult day care, like he had been doing daily. RES #6 said the facility sent him to the hospital, where he stayed until his LAR #7 picked him up and took him home. RES #6 stated he was glad to have left the facility and was glad he was back home with LAR #7. RES #6 stated he was doing OK.<BR/>Record review of the facility's policy regarding Transfer or Discharge, Facility Initiated, dated October 2022, in Section- Notice of Discharge after Transfer, reflected if a discharge is initiated by the facility after an emergency transfer to the hospital, the reason for discharge was based on the resident's status at the time the resident seeks to return to the facility, not at the time the resident was transferred to acute care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure full visual privacy by having ceiling suspended curtains, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains for 2 of 2 residents (Resident #73 and Resident #28) who did not have ceiling suspended curtains in their room. <BR/>The facility failed to provide privacy curtains for Resident's #73 and #28 who shared a room. <BR/>This failure could place all residents who depend on staff for personal care at risk for lack of personal privacy, dignity and self-esteem.<BR/>Findings Included: <BR/>Record review of Resident #73's undated face sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Dysphagia (difficulty swallowing) following non-traumatic intracerebral hemorrhage (brain bleed, stroke), Nutritional Anemia (low red blood cell count due to poor nutritional intake), Senile degeneration of brain (loss of intellectual ability associated with advanced age), Hyperlipidemia (high fats in blood), and anxiety disorder.<BR/>Record review of the annual MDS for Resident #73 dated 10/02/2022 reflected his functional status required extensive assistance of one person for dressing, toileting, and personal hygiene. His BIMS score was 0, indicating severe cognitive function. <BR/>Record review of the care plan for Resident #73 dated 04/16/2021 and revised on 11/23/2022 reflected he was incontinent of bowel and bladder. Clean peri-area with each incontinence episode. <BR/>Record review of the undated face sheet for Resident #28 reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Schizophrenia (severe mental condition resulting in hallucinations and delusions - seeing and hearing things that are not there), Protein-calorie malnutrition (inadequate intake of food resulting in muscle wasting, loss of under the skin fat), Hypothyroidism (condition in which thyroid gland doesn't produce enough hormone can disrupt heart rate, body temperature, and all aspects of metabolism - chemical processes that occur in body in order to maintain life), and unspecified intellectual disabilities. <BR/>Record review of the quarterly MDS for Resident #28 dated 10/21/2022 reflected his functional status required supervision and limited assistance for dressing, toileting, and personal hygiene. His BIMS score was 3, indicating severe cognitive function. <BR/>Observation on 11/30/2022 at 10:00 AM revealed there were no privacy curtains installed in the room assigned to Resident #73 and Resident #28 who were not interviewable. <BR/>Interview on 11/30/2022 at 10:15 AM CNA G stated she didn't know why there were no privacy curtains in the room for Resident #73 and Resident #28. <BR/>Observation and Interview on 11/30/2022 at 10:20 AM with MNT-F who was observed coming down the hall with a ladder. All rooms should have privacy curtains. I'm fixing to put some in there. (Resident #73 and #28's room) <BR/>Interview on 11/30/2022 at 10:30 AM, MNT-E stated, All rooms should have privacy curtains. I have them (curtains) in the back storage, but they haven't been put up yet. The residents need them up if they're being changed or just want some privacy. <BR/>Interview on 11/30/2022 at 2:37 PM, DON stated, We are supposed to have privacy curtains in every room, even private ones. The resident's dignity could be at risk.<BR/>Interview on 11/30/2022 at 3:08 PM, ADMIN stated, The potential issue with not having curtains is privacy, maybe they're getting treatments. Yes, it could be a dignity issue. <BR/>Review of a facility policy Confidentiality of information and personal privacy dated 10/2017 reflected The facility will strive to protect the resident's privacy regarding his or her: accommodations, medical treatment, personal care.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary and comfortable, environment for resident's, staff, and the public for one hall (secure unit) of two halls and one room (Resident #59's) of twenty-five rooms reviewed for environment.<BR/>The facility failed to ensure intake and exhaust air vents were in clean and good repair for the secure unit. <BR/>The facility failed to ensure walls, ceiling tiles, bathroom trim, and sinks were in clean and good repair for Resident #59's room. <BR/>This failure could affect all residents, staff, and the public by placing them at risk for diminished quality of life due to the lack of a well-kept environment.<BR/>Findings included:<BR/>Observation on 11/28/2022 at 9:10 AM in Resident #59's room revealed, peeled off paint on the wall near the bathroom door. The bathroom door had a built-up brown substance near the handle and there was graffiti (writing) on the bathroom door. There was a hole in the bathroom ceiling and paint was peeling off the metal trim around the bathroom walls. Exhaust vents in the bathroom and bedroom had thick dust on them. There was a slimy, black substance around the sink handles in the bedroom and the wall over Resident #59's bed had graffiti written on it. <BR/>Interview on 11/28/2022 at 9:17 AM, Resident #59 stated, I wrote on the walls when I wasn't feeling good, and I can't get it off. They're supposed to paint the walls. <BR/>Interview on 11/29/2022 at 10:39 AM, MTN-E stated, That could be dirt on the (bathroom) door. (Resident #59's room). I haven't had a chance to come back here. CNAs and Nurses can turn in issues on work orders. There is a loose ceiling tile and dust on the vents. I have a company that's supposed to change filters. The bathroom needs to be redone. Vent dust could be unhealthy. I have allergies bad myself. I'll get my assistant to come in here and put a new ceiling tile up. That nasty gunk around sink, it's not mold, it just hasn't been cleaned. When the housekeeping company left, they didn't leave any supplies. I'm reordering all cleaning supplies. <BR/>Observation on 11/29/2022 at 2:50 PM on the secure unit revealed, three intake vents in the hallway coated with dirt and dust. Seven exhaust vents were coated with dirt and dust. A sprinkler head outside Resident #59's room was coated with dirt and dust from the exhaust vent. <BR/>Interview on 11/29/2022 at 3:07 PM, MNT-E stated, The air filter company comes one time a month. They were here yesterday. I'm trying to change companies. They're supposed to change the filters, but they left some filters outside my door. The intakes are dirty, and the sprinkler heads are coated with dirt. It's (cleaning) not being done. I'm fixing to clean that myself. I'm trying to get this done. I've been working 12 hours a day.<BR/>Interview on 11/30/2022 at 2:37 PM, DON stated, It (dirty intake and exhaust vents) could worsen their (residents) allergies or breathing. I would think maintenance should be cleaning them routinely.<BR/>Interview on 11/30/2022 at 3:04 PM, Dr. H. stated There's no doubt that air quality is important. Particulate matter can make things worse. Chronic Rhinitis can be seasonal or perennial. Common sense would tell you if you're not cleaning the vents, it could make allergies worse. <BR/>Interview on 11/30/2022 at 3:08 PM, ADMIN stated, Inhaling all that buildup (dirt, dust) could cause more respiratory issues. I'm responsible for making sure the vents are clean. <BR/>Review of a facility policy Maintenance Service dated 2001 and revised December 2009, reflected, The Maintenance Department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times. Functions of Maintenance personnel include, Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. Maintaining the building in good repair and free from hazards. Providing routinely scheduled maintenance service to all areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 1 of 5 residents (Residents #1) reviewed for food and nutrition services.1. The facility failed to ensure Resident #1's personal refrigerator did not have a brown substance stuck to the bottom of the refrigerator and freezer along with a food encrusted butter knife. 2. The facility failed to ensure Resident #1's personal refrigerator had a temperature log.These deficient practices could place residents at risk of foodborne illness due to consuming foods which might be spoiled. The findings include: Record review of Resident #1's admission Record reflected Resident #1 was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Alzheimer's disease (a progressive brain disorder that affects memory, thinking, and behavior), elevated blood pressure, muscle weakness and chronic pain. Record review of Resident #1's admission MDS, dated [DATE], reflected Resident #1 had a BIMS score of 15, which indicated she was cognitively intact. Resident #1 required Substantial/Maximal assistance with personal hygiene, upper and lower body dressing. During an observation and interview on 09/12/25 at 10:25 a.m. revealed Resident #1 had a personal refrigerator. There was a brown substance stuck to the bottom of the refrigerator and freezer along with a food encrusted butter knife. There was no temperature log for the refrigerator. Resident #1 stated she did not have anything in the refrigerator at this time, but she did occasionally store food in it. Resident #1 stated staff did not clean her refrigerator. In an interview on 09/12/25 at 1:05 p.m., the Maintenance Director stated it was his first week working at the facility. He stated all refrigerators should have a temperature log and be clean. He stated he was not sure why it had not been done in the past. He stated housekeeping and maintenance were responsible for checking the cleanliness of the refrigerators and temperatures. He stated not keeping the residents' room refrigerators clean and within a proper temperature, could lead to mold, antifreeze could be leaking, spoiled food not at the right temperature that could cause residents to become sick. In an interview on 09/12/25 at 1:10 p.m., the ADM stated the facility staff should have been checking the residents' refrigerators in the rooms for cleanliness and temperatures. He stated moving forward the facility would have a temperature log taped to each refrigerator. He stated he was not sure why it was not completed before now. He stated the negative effects could be spoiled food, which could cause illness Record review of the facility's policy titled Resident Refrigerators, dated 06/15/2025, reflected, Maintenance staff shall record refrigerator temperatures weekly on a temperature log attached to the refrigerator. a. A thermometer shall remain in the refrigerator. It shall be calibrated prior to use and periodically thereafter.b. Temperatures will be at or below 41 0 F, and freezers will be cold enough to keep foods frozen solid to the touch (or in accordance with state regulations).c. If temperatures are out of range, maintenance staff shall notify nursing department to discard any foods that require refrigeration and take measures to remedy the problem.d. If problems persist with maintaining proper temperatures, the refrigerator shall be removed from use and the resident/family notified.(Nursing/housekeeping) staff shall clean the refrigerator weekly and discard any foods that are out of compliance. Nursing staff shall clean up spills as needed or refer to housekeeping staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents for 1 of 1 facility reviewed for environment.<BR/>The facility failed to repair cracks and penetrations (holes) in residents' bedroom and bathroom walls, clean residents' toilets and bathroom floors, clean dust particles and dirt from the ceiling and air vents in residents' bedrooms, repair residents' bathroom toilet, clean residents' bedroom and bathroom walls, empty residents' trash in their bedrooms and bathrooms, properly repair residents' bathroom vents, and clean residents bedroom blinds, windows and window sills.<BR/>This deficient practice could place residents at risk of not living in a safe, functional, sanitary and comfortable environment.<BR/>Findings included:<BR/>Observation of Resident #59's shared bedroom and bathroom on 3/17/25 at 10 AM, revealed dust particles and dirt on the residents' ceiling and coming out of the air vents. There were black, furry spots in and around the bedroom air vent that appeared to be mold. Dirt, dust, food, and trash were observed on and in the corners of the room's floors and walls. The bedroom floors were discolored and dingy from past incidents of water leaks and standing water. The bathroom toilet was in disrepair, leaking at the base. A stained and discolored towel was observed around the base of the toilet. Clumps of dirt and other unidentified matter were observed on the bathroom floor. The toilet seat appeared to be stained with feces. The interior toilet rim contained what appeared to be smeared feces. The molding along the bathroom floor was dirty, stained and gapped. The trashcans in the room and bathroom were full. The bathroom wall contained holes. There were stains and splatters observed on the walls of the bathroom. Around the base of the toilet and near a used plunger, wet and soggy pieces of toilet paper were observed. The toilet base was also observed to be stained and the bolts securing it to the floor were rusty or missing.<BR/>Observation of Resident #74's shared bedroom and bathroom on 3/17/25 at 10:37 AM, revealed wet coffee grounds in and around the edge of the sink. The bathroom floor and walls were observed to be dirty, scuffed and stained. The toilet seat and rim were observed to contain dirt, hair and feces smeared on and around them. A hole in the bathroom wall was observed. The bedroom floor appeared to be dirty, dingy and stained from past incidents of water leaks and standing water.<BR/>Observation of Resident #6's shared bedroom and bathroom on 3/17/25 at 10:47 AM, revealed dirty floors containing dirt and dust. The bathroom walls were observed to be splattered and dirty. The trash can in the bathroom was full. The bathroom contained a toilet chair over the commode that was splattered with feces. The toilet rim and bowl also contained splattered, dried feces, and dirty water in the bowel containing urine and toilet paper that had not been flushed. The walls and doors in the bathroom were scuffed, scraped and discolored. The air vent in the bathroom was observed to be in disrepair as it was being held onto the ceiling by one piece of black tape at one corner but pulling away from the ceiling tile elsewhere leaving a gap around the vent. Toilet paper pieces were observed behind and around the toilet bowel. The air conditioning vent appeared to contain black, furry spots believed to be mold around its edges, The vertical window blinds were observed to be broken, dirty and stained. The windows in room were observed to have brown paper towel twisted and pushed into the cracks of the window, presumably to prevent water from leaking in. The bedroom floors were observed to be dusty, dirty and containing trash.<BR/>In an interview on 3/17/25 at 9:52 AM, Resident #59 stated that his room and bathroom had not been cleaned since 3/14/25. He stated that his bedroom and bathroom are often unkept and dirty. He stated that housekeeping at the facility is irregular and inadequate. The Resident stated that he has had past problems with roaches in his room, but none at this time. The Resident stated that the staining and dinginess on the floor was caused by water leaking in at the windows. The Resident stated that the trash in his room and bathroom were emptied whenever housekeeping got around to it. The Resident stated that the toilet in his bathroom leaks. He stated that he has made staff aware of this, but no repairs have been done. The Resident stated that he puts a towel around the base of the toilet to keep the leaking water from standing on the bathroom floor. <BR/>During interview with Resident #59, a member of the housekeeping staff came in the room and asked the Resident if he needed anything. The housekeeping staff then stated that he would come back later. After the housekeeping staff member left, Resident #59 stated that this was part of the problem. He said staff come in and ask if you need anything rather than coming in and completing basic housekeeping services.<BR/>In an interview on 3/17/25, Resident #6 (who is mostly non-verbal) indicated that she would like her room cleaned by nodding her head.<BR/>In an interview on 3/19/25 at 2:10 PM, LVN D stated that she is an agency nurse that had been assigned to the facility approximately 1 week prior. LVN D stated that her expectation regarding resident rooms and bathrooms is that they would be neat, orderly, clean and be free from hazards. LVN D stated that she would expect resident rooms and bathrooms to be cleaned daily. If this did not occur, the risk of danger to the residents and is maximized, including threats of infection or disease. LVN D stated that she had not observed any rooms in need of housekeeping services at the facility.<BR/>In an interview on 3/19/25 at approximately 2:15 PM, HK A stated that he has been employed at the facility in housekeeping services for 3 years. His supervisor is HKS. HK A stated he is familiar with housekeeping duties and their cleaning schedule. He stated that there is at least 2-3 housekeeping staff members present at the facility 7 days a week. HK A stated that he follows a published cleaning schedule that includes disinfectant cleaning of all hard surfaces and floors, daily cleaning of all bathrooms, and emptying trash cans. If an issue regarding housekeeping is brought to his attention, he is to handle that immediately. If there are any issues of disrepair in any part of the facility, he will notify nursing staff and they will create a digital workorder in PCC that is immediately routed to maintenance staff. HK A stated that he has been properly trained to conduct all aspects of his job and that he feels supported by management and other staff members.<BR/>In an interview on 3/19/25 at 2:21 PM, HKS stated that she has been employed with the facility since 2013. She started out as a CNA, but was promoted to supervisor of housekeeping, laundry and floors in 2021. HKS stated that it is her expectation that she and her staff follow their published guidelines or processes as they pertain to their position in order to maintain a safe environment for the residents and others by preventing the spread of infection. HKS said that she actively participates in housekeeping and laundry duties where needed. She stated that her department is fully staffed, but due to the size of the facility and the extent of its needs, there are times when her departments are running behind in their scheduled duties. HKS stated that she typically has 3 staff on duty, including herself. She said she will come in on weekends as well and help if needed as well. HKS stated that she is familiar with the facility's policies and procedures pertaining to housekeeping, floors and laundry and makes she her staff are aware too. HKS said she is aware of the broken toilet in Resident #59's room and elsewhere. She stated that her department will handle minor types of maintenance issues if they can, but typically an electronic work order is input and assigned to the maintenance team to complete. HKS stated that management is very supportive of her department and its needs. <BR/>In an interview on 3/19/25 at approximately 2:30PM, the MT stated that he has been employed with the facility for 1 month. MT said that his department is made aware of maintenance issues throughout the building through an electronic work order system. The work orders are routed to him or his supervisor. Those work orders are then completed based on the seriousness of the issue being reported. MT stated that his priority tasks today have been repairing toilets and plumbing in the 100 hall. MT stated that unresolved maintenance issues and lack of proper housekeeping could lead to hazards to the residents' safety.<BR/>In an interview on 3/19/25 at 2:35 PM, the CRN acknowledged that housekeeping has been an ongoing issue of concern that the facility is addressing. CRN stated that housekeeping staff are invested in remedying the identified problems and try hard. However, CRN said that some of the problems lie with the residents. He stated that housekeeping staff get a lot of push back from residents in that they don't want their space touched or moved around in order to properly clean. CRN stated that this became such an issue that they had to engage the assistance of their ombudsman. According to CRN, the ombudsman was able to get a handful of residents to agree to allow housekeeping to come in and do a deep clean and organization of their rooms. CRN said things have improved since they began doing mock surveys and focusing on housekeeping services. CRN stated that they implemented a new cleaning schedule that staff are still getting familiar with. CRN stated that maintenance issues are handled by that department. He stated that an electronic work order is created and routed to the maintenance team for assessment and completion. CRN said there are only 2 members of the maintenance staff so some work orders are delayed in completion. He said the maintenance supervisor is good at work order prioritization. CRN said if something needs to be done such as cleaning or minor maintenance, he will do the task himself to get things done quickly. CRN said the lack of housekeeping and maintenance could lead to serious hazards and danger to the residents and put them at risk of further illness.<BR/>In an interview on 3/19/25 at 2:35 PM, the DON stated that maintenance and housekeeping staff are on-call or available 24/7. She stated that CRN is always available to her and the rest of the facility staff for support and guidance. DON said she feels housekeeping and maintenance do a good job and work hard. The supervisors in those areas are also knowledgeable and good managers per DON. DON said a lack of proper housekeeping and maintenance could lead to illnesses.<BR/>In an interview on 3/19/25 at approximately 2:45PM, the ADM stated that he is the interim administrator and has been assigned to this facility since February 2025. He stated that he is familiar with the housekeeping and maintenance processes and needs within the facility. He believes all staff follow the policies implemented at the facility. He stated that housekeeping is to follow a daily housekeeping schedule that all have been trained on. This includes the weekends. ADM stated that if this schedule is not followed, residents and others could be put at risk for illness and could lead to infection control issues. ADM stated that the maintenance department utilizes a digital work order system within the PCC system. ADM stated that when a maintenance issue is discovered and a work order input in the system, the maintenance supervisor gets an alert. The supervisor is to prioritize completion of these issues, but is expected to resolve the issues right away. ADM said the negative impact of not resolving maintenance issues timely is that the problem can turn into something bigger that could cause and environmental hazard and lead to a lack of infection control.<BR/>Review of Resident #59's face sheet revealed the resident is a [AGE] year-old male who was originally admitted to the facility on [DATE], with his most recent admission on [DATE]. Resident #59's diagnoses include cerebral infarction (stroke), hypertension (high blood pressure), major depressive disorder (low mood, loss of interest, pleasure, or happiness); blindness of the right eye, and insomnia. Resident #59's quarterly MDS assessment dated [DATE], indicated a BIMS score of 15, suggesting no cognitive impairment.<BR/>Review of resident #74's face sheet revealed resident #74 was admitted to the facility on [DATE]. His diagnoses include Drug or Chemical Induced Diabetes Mellitus (a chronic condition characterized by insulin resistance and elevated blood sugar), acute kidney failure, and personal history of traumatic brain injury. Review of resident #74's quarterly MDS assessment dated [DATE], indicated the resident's BIMS score to be 9, suggesting moderate cognitive impairment.<BR/>Review of Resident #6's face sheet revealed the resident is a [AGE] year-old female who was originally admitted to the facility on [DATE], with her most recent admission on [DATE]. Resident #6's diagnoses include chronic obstructive pulmonary disease (progressive lung condition which causes breathing difficulties), Type 2 Diabetes Mellitus (chronic condition characterized by insulin resistance and elevated blood sugar), unspecified asthma (a breathing disorder), and moderate protein calorie malnutrition (deficiency of energy, protein and micronutrients). Review of Resident #6's quarterly MDS assessment dated [DATE], indicated the resident's BIMS score to be 15, suggesting no cognitive impairment.<BR/>Review of the facility's policy entitled Cleaning and Disinfection of Surfaces revised August 2019, states<BR/>Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard.<BR/>Review of the facility's policy entitled Cleaning and Disinfecting Residents' Rooms revised August 2013, states in part:<BR/>Housekeeping surfaces will be cleaned on a regular basis, when spills occur and when the surfaces are visibly dirty.<BR/>Environmental surfaces will be cleaned on a regular basis, when spills occur and when the surfaces are visibly dirty.<BR/>Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly dirty.<BR/>Clean medical waste containers intended for reuse .daily or when such receptacles become visibly contaminated .<BR/>Review of the facility's policy entitled Maintenance Services revised December 2009, states in part:<BR/>The Maintenance Department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure the residents had the right to be free from physical abuse and neglect for 3 (Resident #1, Resident #2, and Resident #3) of 9 residents reviewed for abuse and neglect. 1. The facility failed to provide continuous one to one monitoring for Resident #1 after repeated targeted aggressive behavior against Resident #2. An Immediate Jeopardy (IJ) situation was identified on 07/01/25 at 6:55 pm for failure #1. While the IJ was removed on 07/02/25 a 6:42 pm the facility remained out of compliance at a scope of isolated that with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. 2. The facility failed to ensure Resident #3 was not physically abused by MA F on 06/25/2025 when MA F grabbed Resident #3's wrist. These failures could affect the residents by placing them in mental anguish or emotional distress, pain, and physical harm. <BR/>Findings included: <BR/>1.Resident #1 <BR/>Review of Resident #1's face sheet dated 07/01/25 reflected an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including other frontotemporal neurocognitive disorder (degeneration of the frontal and temporal lobes of the brain, leading to a range of behavioral, language, and movement difficulties) vascular dementia (a decline in thinking skills caused by conditions that reduce or block blood flow to the brain, leading to brain damage), with other behavioral disturbance, and major depressive disorder (a serious mental illness characterized by persistent sadness, loss of interest in activities, and other symptoms that significantly interfere with daily life). <BR/> Review of Resident #1's quarterly MDS assessment, dated 05/23/25, reflected a BIMS score of 9, indicating moderate cognitive impairment Section E Behavior reflected physical behavior directed towards others (example hitting, kicking, pushing, scratching, grabbing, abusing others sexually) &ndash; behavior of this type occurred every 1 &ndash; 3 days. Verbal behaviors directed towards others (example threatening others, screaming at other, cursing at others) &ndash; behavior of this type occurred every 1 &ndash; 3 days. <BR/> Review of Resident #1's care plan reflected focus &ndash; noted behaviors of physical aggression: <BR/>1. 05/13/15 resident to resident &ndash; Resident #1 was seen holding a fork/spoon like object and was on the verge of trying to stab another resident <BR/>2. 05/19/25 resident to resident - Resident #1 grazed the other resident in the back of head with remote <BR/>3. 05/28/25 resident to resident &ndash; Resident #1 hit another resident with a broom while sitting in the secure dining room <BR/>4. 06/01/25 resident was destroying dining room area by overturning table and chair <BR/>Review of Resident #1's care plan reflected interventions for noted behaviors of physical aggression: <BR/>1. 05/13/25 document behaviors in the clinical record. <BR/>2. 05/13/25 let physician know if behaviors are interfering with daily living. <BR/>3. 05/13/25 refer to psychologist/psychiatrist as needed. <BR/>Review of Resident #1's care plan reflected focus revised on 05/29/25 indicated Resident #1 had potential to demonstrate verbally abusive behaviors related to vascular dementia, with other behavioral disturbance. Review of Resident #1's care plan reflected focus revised on 05/26/25 indicated Resident #1 resided on the facility secured unit related to deemed at risk for elopement. <BR/> Review of Resident #1's care plan reflected focus revised on 06/30/25 indicated Resident #1 demonstrated behavior symptoms/risk at times such as cursing at other residents who are in the way and following other resident (Resident #2) around telling him to get out from his property. <BR/> Review of Resident #1's care plan reflected focus revised on 05/26/25 indicated Resident #1 was at risk for behaviors related to demonstrates physically abusive behaviors 05/26/25 &ndash; resident to resident, Resident #1 ambulating on hallway with staff member when he hit another resident in the face. <BR/> Review of Resident #1's care plan reflected interventions dated 05/26/25 indicated psychiatric referral as needed to evaluate and follow in house or outpatient. <BR/> Observation of the facility secured unit on 07/01/25 at 12:10 p.m., revealed Resident #1 was sitting quietly at a dining table. Residents had finished eating. Two staff members were observed in the dining area performing normal work duties. <BR/>Observation in facility secured unit on 07/01/25 at 2:56 p.m., Resident #1 reflected the door was closed to Resident #1&rsquo;s room. When surveyor entered with the assistance of RN D, Resident #1 was sitting on his bed. His roommate was laying in his own bed sleeping. Observed no 1:1 monitoring of Resident #1. <BR/> Review of Resident #1&rsquo;s Nurses Note dated 05/09/25 written by the ADON reflected Resident #1 was placed on the secure unit due to elopement risk. <BR/> Review of Resident #1&rsquo;s Nurses Note dated 05/13/25 written by LPN A reflected aide (name of aide not stated) reported to LPN A that Resident #1, who was the roommate of Resident #2, was seen holding a fork/spoon like object and was on the verge of trying to [stab] Resident #2. The aide was unable to remove the fork/spoon out of Resident #1&rsquo;s hands. LPN A was called and able to remove the fork/spoon from Resident #1. Both residents were assessed for injury, none at the time will continue to monitor both residents for any complications. <BR/>Review of Resident #1&rsquo;s Nurses Note dated 05/20/25 written by RN C reflected Resident #1 was holding a remote in hand and refused to put remote down. Resident #1 picked up broom in the dining room hallway and attempted to hit another Resident #2. CNA (name of CNA not stated) able to redirect and remove broom from Resident #1. Resident #1 was holding remote that he refused to put down. Resident #1 &ldquo;grazed&rdquo; Resident #2 in the back of the head with remote. Residents separated for safety. Resident #1 closely monitored post incident. <BR/> Review of Resident #1&rsquo;s Progress Note Psychiatric Initial Evaluation dated 05/20/25 by PNP reflected dementia with behavioral disturbances. Patient #1 currently on 1:1 observation, continue current medication regimen. Continue to assess for adverse effects and let medication management associates know. Patient has significant cognitive impairment consistent with Alzheimer&rsquo;s disease (a progressive neurodegenerative disorder that gradually destroys memory and thinking skills, eventually impacting the ability to carry out even the simplest tasks). Patient with history of becoming easily agitated. Staff report patient was physically aggressive towards another resident with difficulty redirecting over the weekend. No aggressive behaviors noted during evaluation. Seen for initial psychiatric evaluation by request of facility. Consider sending to psychiatric hospital or emergency room if patient is a danger to self or others. <BR/> Review of Resident #1&rsquo;s Nurses Note dated 05/20/25 written by RN D reflected PNP saw Resident #1. PNP said she hoped the medications will help calm him down and he will have less behaviors. <BR/>Review of Resident #1&rsquo;s Nurses Note dated 05/26/25 written by LVN E reflected Resident #1 walked down the hallway of the secured unit when he hit Resident #2 on the face. Both Resident #1 and Resident #2 grabbed each other&rsquo;s arms. Residents separated by two staff members (names of staff members no listed). No acute injuries noted. Resident #1 was easily redirected and was calm after being separated from Resident #2. Will continue to monitor. <BR/> Review of Resident #1 Psychiatry Follow Up from PNP dated 05/27/25 reflected Resident #1 was involved in an altercation with another resident over the weekend, where he was the aggressor. Resident #1 with vascular dementia with behavioral disturbances, currently 1:1 (indicates that one staff member is assigned to continuously observe a single patient. This was often necessary for patients with certain behavioral conditions). Consider sending to emergency room or psychiatric hospital. Dementia in other diseases classified elsewhere, moderate with other behavioral disturbance &ndash; Resident #1 with history of becoming easily agitated. Was involved in an altercation with another resident [Resident #2] over the weekend. Resident #1 was the aggressor. Resident #1 continued to be on 1:1, required close monitoring. He appeared to dislike one particular resident (Resident #2). Resident #1 seen in room on 1:1 observation, did not engage much, oriented to self only, significant cognitive impairment consistent with dementia. Resident #1 required 1:1 observation and required close monitoring. Staff were to monitor, redirect, and ensure Resident #1&rsquo;s safety. It was recommended to keep Resident #1 and Resident #2 in separate locations. <BR/>Resident #2 <BR/>Review of Resident #2&rsquo;s face sheet dated 07/01/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including senile degeneration of brain (decline in cognitive abilities, memory, and behavior associated with old age), Major depressive disorder, wandering in diseases (repetitive, aimless movement from place to place, often without a clear purpose or destination, especially in individuals with dementia or other cognitive impairments). <BR/>Review of Resident #2's quarterly MDS assessment, dated 04/18/25, reflected a BIMS score of 3, indicating severe cognitive impairment. <BR/>Review of Resident #2's care plan reflected focus revised on 04/12/25, indicated Resident #2 had a behavior problem related to taking other residents&rsquo; food off their tray during meals. <BR/> Review of Resident #2&rsquo;s Nurses Note dated 05/13/25 written by LPN A reflected Resident #1, who was a roommate with Resident #2, was seen holding a folk/spoon like object and was on the verge of trying to stab Resident #2. The aide (name of aide not stated) tried to get the folk out of Resident #1&rsquo;s hands but Resident #1 was unable to give up the folk. LPN A was called to the scene and was able to remove the folk from Resident #1. Both residents were assessing for any injury, no injuries. <BR/>Review of Resident #2&rsquo;s Nurses Note dated 05/26/25 written by LVN E reflected Resident #2&rsquo;s was walking down the hallway when he was hit on left side of jaw by another resident (Resident #1). Both residents grabbed each other's arms. Resident separated from the other resident by staff x2. No visible injuries noted. Attempted to initiate neurological assessment and vitals, Resident #2 refused at this time. Will continue to monitor. <BR/>Review of Resident #2&rsquo;s Nurses Note dated 05/20/25 written by RN C reflected Resident #2 was sitting in chair in dining room. Another resident (Resident #1) attempted to hit Resident #2 with broom and hit the chair. Resident #2 remained seated in dining room chair. Resident #1 grazed Resident #2&rsquo;s hair on the back of the head with the remote. Resident #2 remained seated, no signs of agitation or aggressive behavior noted. Residents separated for safety. <BR/>Review of Resident #2&rsquo;s Progress Note Psychiatric Follow Up Evaluation dated 05/20/25 by PNP reflected Resident #2 was involved in an altercation where he was hit by another resident (Resident #1). Plan was to redirect and keep him safe. <BR/>Review of Resident #2 Progress Note from PNP dated 05/27/25 reflected Resident #2 was involved in an altercation where another resident (Resident #1) hit him; Resident #2 did not retaliate. Resident #1 required redirection and safety measures. Staff were advised to try to keep Resident #2 and Resident #1 in different locations to prevent further incidents. <BR/>Review of facility complaint incident report dated 06/01/25 revealed Resident #1 had a problem with Resident #2. Resident #1 is fixated on Resident #2. Resident #1 said, &ldquo;he thinks resident two broke his family up.&rdquo; <BR/>Review of Psychiatry Follow Up from PNP dated 06/10/25 reflected Resident #1 with history of becoming easily agitated and continued to be 1:1 observation, required close monitoring. On and off agitation and aggressive behavior towards one particular resident (Resident #2). Social support &ndash; Resident #1 received 1:1 observation and required close monitoring due to aggressive behavior. Follow up &ndash; staff to monitor, re-direct and keep safe, continue 1:1 observation due to behavioral issues. Keep Resident #1 and Resident #1 at different locations was encouraged. Continue secure unit placement. Consider sending to the emergency room if identified harm to self or other. <BR/>Review of Resident #2&rsquo;s Nurses Note dated 06/17/25 written by RN D revealed Resident #2 would take food when he walked by. <BR/>Review of IDT (team is composed of various healthcare professionals who collaborate to provide comprehensive care and support for residents) meeting note dated 06/19/25 and attended by the Administrator, ADON, MDS Coordinator and therapy reflected, &ldquo;Team decided that with information that we reviewed [Resident #1] would be OK off 1:1 monitoring.&rdquo; No MD or PNP listed as attending meeting and no documentation of information reviewed. <BR/>Review of Resident #2&rsquo;s Nurses Note dated 06/20/25 written by RN D revealed Resident #2 seen walking around eating and stealing food from others. Was able to redirect him but he kept walking towards other and grabbing at food or drinks. Other patients are very upset and stating they might hit him if he kept doing it. <BR/>Review of Resident #2&rsquo;s Nurses Note dated 06/21/25 written by RN D revealed was going in other rooms and standing over patients while sleeping. Other patients getting upset. <BR/> Review of Resident #2&rsquo;s Nurses Note dated 06/26/25 written by RN D revealed continues to take other's food at times. <BR/> Review of Resident #2&rsquo;s Progress Note dated 07/02/25 written by MD reflected Resident #2 was the target of another resident&rsquo;s (Resident #1&rsquo;s) erratic behavior on 06/28/25, though staff prevented altercation. <BR/>Interview on 07/01/25 at 2:42 p.m., with the PNP revealed Resident #1 was a safety concern because he was aggressive. She was concerned about his safety and the safety of the other residents if Resident #1 was not provided 1:1 monitoring. She said he was on the correct medications and if he was not given 1:1 monitoring, the facility needed to find alternative placement for Resident #1. <BR/>Interview on 07/01/25 at 12:10 p.m., with RN D revealed Resident #1 &ldquo;targets&rdquo; Resident #2, but Resident #1 instigates things by taking food and items from residents&rsquo; trays (including Resident #1&rsquo;s tray). RN D said he was not concerned Resident #1 would harm other residents and Resident #1 was currently not 1:1. RN D felt they had enough staff and Resident #1 could be watched. He said some incidents between Resident #1 and Resident #2 have occurred in the past even when Resident #1 was on 1:1 monitoring because staff was not watching. An example was when Resident #1 attempted to hit Resident #2 with a broom. <BR/>Interview on 07/01/25 at 2:56 p.m., with RN D revealed Resident #1 said he was taken off 1:1 monitoring last Wednesday (06/25/25) and when RN D came to work on the following Thursday (06/26/25), Resident #1 was off 1:1 monitoring and had been off 1:1 monitoring since. <BR/>Interview on 07/02/25 at 11:29 p.m., CNA G revealed she had not witnessed any physical aggression towards Resident #2 by Resident #1. She said Resident #2 would go around Resident #1&rsquo;s food tray and take things from his tray. CNA G example gave the example of when Resident #2 took Resident #1&rsquo;s food cover. CNA G said this would aggravate Resident #1 and said Resident #1 would say something to the affect that Resident #2 was messing with his wife. Resident #1 thought that Resident #2 was in Resident #1&rsquo;s home. She said Resident #1 would threaten Resident #2 when Resident #2 moved things around and said, &ldquo;I&rsquo;m going to kick your ass.&rdquo; CNA G did not think that 1:1 monitoring was necessary because there were 2 aides in the secured unit she said when staff was there they could re-direct Resident #1. She said that Resident #1 listened to her, but she was not sure if he listened to the staff on other shifts. <BR/> Interview on 07/02 25 at 2:50 p.m., LVN E revealed she had worked in the secured unit and was familiar with the relationship between Resident #1 and Resident #2. She said that Resident #1 seemed like he would get agitated when he saw Resident #2. She said Resident #1 would get upset and start walking towards Resident #2 getting verbally aggressive and cursing. She said there was an altercation between Resident #1 and Resident #2 with a broom when she was on duty, but she did not see what happened. She said a CNA got in between the residents. She said she was not concerned about resident safety because Resident #1 always received 1:1 monitoring when she was working the secured unit. She said as long as Resident #1 was 1:1 she was not concerned about safety. She said it was the responsibility of the DON and Administrator to decide if a resident received 1:1 monitoring. She said the negative effect of a resident who does not have 1:1 monitoring and needs 1:1 monitoring was that a resident could get hurt. <BR/> Interview on 07/02/25 at 2:17 p.m., RN C revealed she used to work in the secured unit at night and was familiar with Resident #1 and Resident #2. She said they are physically independent in that they are not in wheelchairs and are able to walk. She said Resident #1 and Resident #2 do not like each other. Resident #1 would say, &ldquo;it is my house.&rdquo; She said the residents should be separated. She said Resident #1 should definitely be monitored 1:1. She said if Resident #1 was not monitored 1:1, Resident #2 can get close to him and that irritated Resident #1. She said if Resident #1 is monitored 1:1, he can be re-directed quickly. She said when he received 1:1 monitoring, he was fine but as soon as he was taken off his behaviors go back to what they were previously. She thinks that Resident #1&rsquo;s behavior could cause harm to Resident #2 or himself if Resident #1 did not receive 1:1 monitoring. <BR/> Interview on 07/02/25 at 12:46 p.m., with the DON revealed she had not witnessed any disturbances between Resident #1 and Resident #2, but it was reported to her by the overnight nurse (could not remember the name of the nurse) by phone that Resident #1 attempted to hit Resident #2 with a broom. The ADON had heard that Resident #1 thinks that Resident #2 was trying to &ldquo;break up his family.&rdquo; She said that Resident #1 found Resident #2 sitting on Resident #1&rsquo;s bed and Resident #2 had an incontinent episode and Resident #1 had been &ldquo;fixated&rdquo; on Resident #2 since this episode. The ADON said the IDT team decided if a resident was going to come off 1:1 monitoring. She said the IDT team consists of the Administrator, the DON, Social Worker, and psychologist. She said she felt like the PNP should have been included in the decision whether to remove Resident #1 from 1:1 monitoring. <BR/> Interview on 07/01/25 at 5:13 p.m., CNR #1 revealed Resident #1 was fixated on Resident #2 and they were both in the secured unit, so it was not like you could keep them separate. She said the facility held an IDT meeting on 06/19/25 and the team reviewed Resident #1&rsquo;s behaviors and progress note charting and found 1:1 monitoring for Resident #1 was not warranted any longer. She said the facility needed to make sure the provider was consulted and updated. She said if the PNP said Resident #1 needed to have 1:1 monitoring, then Resident #1 needed to be on 1:1 monitoring. She said if you don&rsquo;t get the approval from the provider, the PNP, you run the risk of more resident-to-resident altercations. <BR/> Interview on 07/02/25 at 3:15 p.m., CNR #2 revealed that during the IDT meeting on 06/19/25 that concluded that was okay to end Resident #1&rsquo;s 1:1 a critical component that was missing because the PNP was not included and consulted. He said it was the responsibility of the Administrator make sure that all relevant people are present during an IDT meeting. He said the possible negative outcome of not including the PNP provider at the IDT meeting to provide input regarding the possibility of removing Resident #1 from 1:1 monitoring would be continuing issues with resident-to-resident altercations. <BR/> Interview on 07/02/25 at 3:06 p.m., the Administrator revealed the PNP should have been kept in the loop when the IDT team made the decision on 06/19/25 to removed Resident #1 from 1:1 monitoring. He said he thought Resident #1 was doing better because Resident #1 did not have any incidents of altercations with Resident #1. He said that the IDT meeting participants should have included a mental health provider to discuss Resident #1&rsquo;s 1:1 status. He said that Resident #1&rsquo;s 1:1 monitoring should have remained intact, and he should not have been removed from 1:1 monitoring. He said the negative affect of not having a resident on 1:1 monitoring who should be on 1:1 monitoring would be that it could be unsafe for residents. The Administrator said it was his understanding that Resident #1 only had problems with Resident #2, and Resident #1 was focused on Resident #2. Resident #1 thought that Resident #2 stole his family. He also heard that Resident #2 had an incontinent incident on Resident #1&rsquo;s bed and Resident #1 had not forgotten about the incident and Resident #1 was still upset about it. The Administrator said the facility was working on getting Resident #1 transferred to another facility because of his fixation on Resident #2 and concerns for Resident #1&rsquo;s safety and other safety of the other residents in the secured unit. It is the responsibility of the Administrator and the IDT team to make sure that the physical and mental providers are included in the IDT meeting when making decisions about 1:1 monitoring status. <BR/>Review of facility policy Resident to Resident Altercations dated December 2016 reflected the facility staff will monitor residents for aggressive/inappropriate behavior towards other residents. Occurrences of such incidents shall be promptly reported to the nurse supervisor, director of nursing services, and the administrator. If two residents are involved in an altercation staff will notify each resident's attending physician of the incident, review the events with the nursing supervisor, director of nursing and possible measures to try to prevent additional incidents, make any necessary changes to the care plan approaches to any or all of the involved individuals, document in the resident&rsquo;s clinical record all interventions and their effectiveness, contract psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for interventions and management as necessary or as may be recommended by the attending physician or interdisciplinary care planning team. If after carefully evaluating the situation, it is determined that care cannot be readily given within the facility to transfer the resident. <BR/>This was determined to be an Immediate Jeopardy (IJ) on 07/01/25 at 5:27 pm. The Administrator was notified at 6:55 p.m. The ADM was provided with the IJ template on 07/01/25 at 6:55 p.m. <BR/>The following Plan of Removal submitted by the facility was accepted on 07/02/25 at 1:01 p.m. <BR/> PLAN OF REMOVAL <BR/>On 07/01/2025 an abbreviated survey was initiated at the facility. On 07/01/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. <BR/>The notification of Immediate Jeopardy states as follows: The facility failed to continuously monitor Resident #1 1:1 for multiple altercations of aggressive behavior targeted against Resident #2. <BR/>IMMEDIATE JEOPARDY PLAN OF REMOVAL for F600 &ndash; Failure to Protect Residents from Abuse <BR/>Tag Number: F600 Regulation: The resident has the right to be free from abuse. Deficient Practice: The facility failed to ensure that Resident #1 was continuously monitored as ordered for 1:1 supervision following multiple episodes of physical aggression toward Resident #2, placing Resident #2 at risk for harm. <BR/>1. Corrective action(s) taken for resident(s) found to be affected: <BR/>Who: The Administrator/Designee and Secure Unit Charge Nurse. <BR/>What: Immediately reinstated 1:1 monitoring for Resident #1 to ensure Resident #1 and Resident #2 are separated. 1:1 monitoring to include direct 24-hour eyes on supervision by dedicated/assigned staff member. In-service education provided clarification to staff to ensure Resident #1 is not left alone at any time and the protocol for providing breaks and adequate replacement for assigned staff member. <BR/>When: Initiated on 07/01/2025, following incident review. <BR/>Where: On the secured memory care unit, where both residents reside. <BR/>Additionally: <BR/>Resident #2 was assessed by the ADON/Designee for injury and psychosocial impact&mdash;no acute injury found, no acute psychosocial impact. Referral was made to [MD] on 07/01/25 to conduct follow up visit on 7/2/2025. No other residents identified during review of R-to-R altercations with Resident #1 <BR/>Psychiatric Nurse Practitioner (NP) re-evaluated Resident #1 on 07/01/2025, recommending need to reinstate 1:1 due to continued aggression. <BR/>The interdisciplinary team (IDT) met on 07/01/2025 and updated Resident #1&rsquo;s care plan to reflect behavior management strategies, permanent 1:1 status, and physical separation plan from Resident #2 through direct 1:1 supervision. Finding alternate placement. <BR/> 2. How the facility will identify other residents who could be affected: <BR/>Who: ADON/Designee. <BR/>What: Conducted a review of all residents on the secured unit with active or recent aggressive behavior or R-to-R altercations within the last 30 days. Facility wide incidents were reviewed and are currently ongoing starting on 7/1/25 <BR/>When: Audit began 07/01/2025 and will be completed by 07/02/25. <BR/>Where: Secured unit. <BR/>The audit includes: <BR/>Review of behavior monitoring orders. <BR/>Validation of 1:1 interventions being documented and implemented. Documentation is assigned to the Charge Nurse on the MAR/TAR every shift and paper monitoring, which includes location, behavior/activity and supervising staff initials, is ongoing with 1 hour frequency. <BR/>Confirmation of care plan updates for any additionally identified resident and interdisciplinary review of any behavior incidents in the last 30 days. <BR/> 3. Systemic changes made to ensure the deficient practice does not recur: <BR/>Who: Staff Development Nurse, in coordination with Administrator/Designee and Regional Nurse Consultant. <BR/>What: Regional Nurse provided education to the Assistant Director of Nursing and Administrator on 07/01/2025 by in-service education. Assistant Director of Nursing and Administrator will conduct Facility-wide in-service education and posttest for all licensed nurses, CNAs, agency and direct care staff prior to the start of assigned shift. New staff will receive training during orientation: <BR/>Abuse prevention <BR/>Resident to Resident altercation policy <BR/>Requirements for initiating, documenting, and discontinuing 1:1 supervision. In-service provided clarification to staff outlining the expectations of 1:1 supervision, including, 24-hour eyes on supervision; not leaving Resident unsupervised at any time; providing adequate coverage of assigned staff member. <BR/>Importance of timely IDT reviews and documentation in the MAR/TAR and care plan. <BR/>When: Initiated on 07/01/2025 and completed by 07/02/2025 with all current and oncoming staff/agency prior to start of shift worked; new staff will receive this training during orientation. <BR/>Where: In-person training held in facility and documented with sign-in sheets. <BR/>Additional changes: <BR/>Continue 1:1 Supervision Monitoring Log, to be maintained at the point of care (resident&rsquo;s room or nearby nurse station), requiring hourly initials by assigned staff. Verification of completion of monitoring log will be done by ADON/designee daily. <BR/>1:1 supervision will be reviewed by IDT within 24 hours of initiation and will be reviewed daily for continued appropriateness of 1:1. <BR/> 4. How the facility will monitor to ensure compliance and prevent recurrence: <BR/>Who: Administrator/designee. <BR/>What: <BR/>Weekly audits of 100% of residents with 1:1 orders for compliance with documentation, monitoring logs, and MAR/TAR entries. <BR/>Monthly reviews of incident reports involving R-to-R contact, focusing on behavioral care planning and response follow-through. <BR/>When: Weekly audits for 8 weeks starting 07/02/25, followed by monthly audits for 4 months. <BR/>Where: Monitoring will occur facility wide for any identified R-to-R altercations. <BR/>Audit results will be reported to the QAPI Committee monthly, and immediate corrective action will be taken for any missed 1:1 interventions or breakdowns in IDT communication. <BR/>5. Date of completion: <BR/>All corrective actions and training will be fully implemented by: July 02, 2025 <BR/>Monitoring: <BR/>Review of Resident #1&rsquo;s MAR and TAR reflected 1:1 supervision continuous 24hr monitoring with every hour checks every hour for physical behaviors every shift documented every hour with no behavioral issues reflected. <BR/>Observation 07/02/25 at 11:25 a.m. of Resident #1 with 1:1 monitoring dedicated/assigned staff member. <BR/>Observation 07/02/25 at 1:00 p.m. of Resident #1 with 1:1 monitoring dedicated/assigned staff member. <BR/>Observation on 07/03/25 at 11:40 am of Resident #1 with 1:1 monitoring dedicated/assigned staff member. <BR/> Interview on 07/02/25 with CRN #1 stated she assessed Resident #2 for any psychosocial impact and no acute injury found. <BR/> Review of PNP documentation dated 07/01/25 re-evaluation of Resident #1 recommended need to reinstate 1:1 monitoring due to continued aggression. <BR/>Review of interdisciplinary team (IDT) meeting document dated 07/01/2025 and review of updated Resident #1&rsqu[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #2) of two residents reviewed for medication pass, in that: <BR/>The facility failed to ensure Resident #2 was administered his medications within the one hour before and one hour after timeframe. <BR/>These failures placed residents at risk for not receiving therapeutic effect of their medications as ordered by the physician. <BR/>Findings included: <BR/>Review of Resident #2's face sheet dated 6/1/2025 reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included: Parkinson's Disease (central nervous system disorder), Type 2 Diabetes (blood sugar regulation disorder), Asthma (breathing disorder), Hypertension (high blood pressure), major depressive disorder and Epilepsy (seizure disorder). <BR/>Review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 13 suggesting no cognitive impairment. <BR/>Review of Resident #2's orders dated 6/1/2025 reflected a physician's order for Rytary Oral Capsule Extended Release 48.75-195 MG (Carbidopa-Levodopa) Give 4 capsule by mouth three times a day related to PARKINSON'S DISEASE WITHOUT DYSKINESIA, WITHOUT MENTION OF FLUCTUATIONS. <BR/>Review of Resident #2's MAR audit for the last 14 days reflected the following late administrations: <BR/>Rytary Oral Capsule Extended Release 48.75-195 MG (Carbidopa-Levodopa) <BR/>Scheduled on 05/21/2025 at 06:00 am <BR/>Administered on 05/21/2025 09:49 am (2 hours and 49 minutes late) <BR/>Rytary Oral Capsule Extended Release 48.75-195 MG (Carbidopa-Levodopa): <BR/>Scheduled on 05/23/2025 at 06:00 <BR/>Administered on 05/23/2025 at 09:33 (2 hours 33 minutes late) <BR/>Rytary Oral Capsule Extended Release 48.75-195 MG <BR/>Scheduled on 05/27/2025 at 06:00 am <BR/>Administered on 05/27/2025 at 08:32 am (one hour and 32 minutes late) <BR/>Rytary Oral Capsule Extended Release 48.75-195 MG (Carbidopa-Levodopa) <BR/>Scheduled on 05/20/2025 at 22:00 (10 pm) <BR/>Administered on 05/21/2025 at 02:52 am (3 hours and 52 minutes late) <BR/>Rytary Oral Capsule Extended Release 48.75-195 MG (Carbidopa-Levodopa <BR/>Scheduled on 05/21/2025 at 22:00 (10 pm) <BR/>Administered on 05/22/2025 01:18 am (2 hours and 18 minutes late) <BR/>Rytary Oral Capsule Extended Release 48.75-195 MG (Carbidopa-Levodopa) <BR/>Scheduled on 05/22/2025 at 22:00 (10 pm) <BR/>Administered on 05/23/2025 04:25 am (5 hours and 25 minutes late) <BR/>Review of Resident #2's care plan reflected the following problems: [Resident #2] has the potential for complications r/t Parkinson's with an intervention: Administer [Resident #2's] medications as ordered. <BR/>During an interview on 6/1/2025 at 1:57 pm, Resident #2 stated his medications had often been late. He stated when his Parkinson's medications had been late, it had caused him to have increased tremors in his hand and made it hard for him to hold or grasp things without dropping them or spilling them. He stated it had further affected his speech when they had been late as his speech had started to slur. He stated it had usually been the first dose of the day and the last dose of the day that had been late, and staff had often woken him late after midnight to give him his meds scheduled for 10 pm. Resident #2 stated the doctor had told him his medications for Parkinson's were very time-oriented and needed to be on a schedule to help him with his symptoms. <BR/>During an interview on 5/30/2025 at 5:29 pm, the DON stated medications were to be administered within one hour before or after the scheduled time. She stated they had a lot of agency nurses, and these nurses would not accept shifts if they must pass meds. She stated medications being late had been a problem since she started in March 2025, but they were doing the best that they could. She stated she was aware of medications being late on the north side due to the use of agency nurses who were not familiar with the residents, and it took them longer to pass meds. She stated nurses and medication aides were to chart in the EMR when the med was given so the administration time reflected the time the medication was given. <BR/>During an interview on 6/1/2025 at 2:40 pm, the DON stated it was her expectation that medications be given on time and that staff arrive on time and give meds on time. The DON stated her concerns with Resident #2's late medications for Parkinson's disease were adverse effects which were usually an increase in symptoms including tremors. She stated this could be uncomfortable for the resident. <BR/>During an interview on 6/1/2025 at 3:36 pm, the MD stated she had heard from residents and staff, as well, about late medications. She stated she was aware they had been working on it to improve, but consistent staffing had been a problem. She stated with Parkinson medications they need to be given within a few hours but within the one-hour time frame would be ideal. She stated in general - except in an emergency - within an hour would be ideal for med administration. She said her concerns for Resident #2 were that there was a sufficient gap between doses to help manage symptoms. She stated she was not aware of what the gaps in doses had been for Resident #2 and she would have to look into it. <BR/>Review of facility policy Administering Medications dated Q3 , 2018 reflected the following: <BR/>Medications shall be administered in a safe and timely manner, and as prescribed. <BR/>Medications must be administered in accordance with the orders, including any required time frame. <BR/>Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 3 residents (Resident #3) reviewed for significant medication errors. The facility failed to ensure Resident #3 was administered her Rivaroxaban 20mg tablet (a medication used to prevent blood clot formation to prevent a cerebral infarction, which is a blood clot blockage that impairs blood flow through the brain artery that can lead to permanent disability or even death) scheduled medication on 06/22/2025, 06/23/2025, 06/24/2025 and 06/25/2025. These failures placed residents at risk for complications, as well as jeopardize their health and safety. Findings included: Record review of Resident #3's admission record, dated 07/02/2025, reflected a [AGE] year-old female originally admitted to the facility on [DATE] and last readmitted on [DATE]. Resident #3 had diagnoses that included Type 2 Diabetes Mellitus (a condition that affects how the body uses sugar as a fuel), Senile Degeneration of Brain (a decline in an individual's memory, behavior, and cognitive abilities), Chronic Systolic Heart Failure (an impairment in the heart's ability to fill with and pump blood), Cerebral Infarction (a blood clot blockage that impair blood flow through the brain artery), Chronic Kidney Disease (an impairment in the kidney's ability to filter out toxins), Anxiety Disorder (intense and excessive worry and fear in response to real or perceived threats), Essential Hypertension (high blood pressure), Chronic Obstructive Pulmonary Disease (a chronic lung disease that limits airflow and causes ongoing respiratory symptoms), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Paroxysmal Atrial Fibrillation (an abnormal heart rhythm that is characterized by rapid and irregular beating of the upper portions of the heart). Record review of Resident #3's comprehensive MDS, dated [DATE], reflected a BIMS score of 13 which indicated her cognition was intact. Record review of Resident #3's care plan, dated 10/14/2019 and last revised 04/26/2025, reflected Focus: [Resident #3] receives anticoagulant therapy r/t Disease process of chronic embolisms (a long-term conditions that blocks blood flow), atrial fibrillation, cardiac pacemaker (an implantable device that regulates heart rate when triggered). Interventions included: Administer ANTICOAGULANT medications as ordered by physician. Observe for side effects and effectiveness Q-SHIFT. Record review of Resident #3's care plan, dated 04/13/2021 and last revised 04/26/2025, reflected Focus: [Resident #3] has chronic deep vein thrombosis (a long-term condition characterized by blood clots in the veins) BLE. Interventions included: Give medications as ordered. Observe/document for side effects and effectiveness. Record review of Resident #3's care plan, dated 05/09/2022 and last revised 04/26/2025, reflected Focus: [Resident #3] had a cerebral vascular accident (a condition in which poor blood flow to a part of the brain causes cell death). Interventions included: Give medications as ordered by the physician. Observe/document side effects and effectiveness. Record review of Resident #3's Rivaroxaban order dated 10/10/2022 revealed Rivaroxaban Tablet 20 MG Give 1 tablet by mouth in the evening for Heart valve condition give with the evening meals. Record review of Resident #3's Medication Administration Record (MAR) for Rivaroxaban reflected the medication was scheduled to be given with the evening meal. The MAR reflected that staff did not give the resident the Rivaroxaban on the following dates:06/22/2025 showed not given,06/23/2025 marked as given (Interview with MA H revealed medication was not available and was not given),06/24/2025 marked as given (Interview with MA H revealed medication was not available and was not given), and06/25/2025 showed not given. Record review of Resident #3's Medication Administration Record nurses' notes reflected the following:06/22/2025 19:38 (07:38 PM) Note Text: Rivaroxaban Tablet 20 MG Give 1 tablet by mouth in the evening for Heart valve condition give with the evening meals on oredr [spelling?].06/25/2025 17:23 (05:23 PM) Note Text: Rivaroxaban Tablet 20 MG Give 1 tablet by mouth in the evening for Heart valve condition give with the evening meals reorder. Record review of Drug Record Book, dated 04/03/2025 to 07/03/2025 reflected the following ordered and delivery dates for Resident #3's Rivaroxaban 20MG tablet quantity of 14 with each delivery from the facility pharmacy:Ordered 04/10/2025 Received 04/11/2025,Ordered 05/04/2025 Received 05/04/2025,Ordered 05/18/2025 Received 05/19/2025,Ordered 06/03/2025 Received 06/04/2025, andOrdered 06/23/2025 Received 06/25/2025. During an interview with RN C on 07/02/2025 at 2:17 PM, revealed that she had been trained on medication administration. She said that the policy for medication out of stock was to put a note in awaiting the medication delivery. She said depending on the medication staff could pull it out of the e-kit or call the pharmacy for a stat delivery. She said the effects of a resident not getting medication that is prescribed was that by the resident not having the medication, it was not serving the purpose for what the medication was used for. During an interview with Resident #3 on 07/02/2025 at 3:06 PM, revealed that when MA F gave her medication to her on 06/25/2025. She said was checking her medication and noticed she did not have her Rivaroxaban. She said she described the medication to MA F and the aide told her that she did not see it. Resident #3 said she told MA F that it was her medication to prevent a stroke. She said that then MA F tried to grab the medication cup from her but Resident #3 refused to give it the MA F. Resident #3 said that she kept telling MA F that she would take her medication, but she wanted the nurse to see what medications she had and what medications she did not get. She said that CNA J came into her room and confirmed that Resident #3's Rivaroxaban was not in the pill cup. Resident #3 stated that she missed several doses of her Rivaroxaban that week. During an interview on 07/02/2025 at 5:15 PM, LVN B stated Resident #3's Rivaroxaban was taken off the medication cart and put on the nurses' cart to ensure the Rivaroxaban was being given starting 06/26/2025. She said the policy for medication that was out of stock was to check the e-kit (pharmacy supplied emergency kit to obtain needed medication) to see if it was available. She said staff was also supposed to notify the DON and ADMIN to get approval to have the medication stat delivered. She said then staff was to contact the pharmacy. She stated that no one told her that Resident #3 was out of the medication. She said looking at the EMAR it looked as if it was checked off but not given. The person giving it did not notify her that the medication was not in stock. She stated the negative affect of Resident #3 not getting the medication was she could have a stroke. During an interview on 07/02/2025 at 6:04 PM, MA H stated she told Resident #3 that she was out of the Rivaroxaban. She said the policy was if the medication was out of stock that staff needed to resubmit the medication to the pharmacy. She stated she was not sure when and what time she ordered the medication. MA H stated the medication should have come in while she was scheduled off. She also said she was not sure if she told the nurse that Resident #3 was out of the medication. MA H stated she checked the box on 06/23/2025 and 06/24/2025 which indicated she administered Resident #3 the Rivaroxaban on accident. MA H stated the negative affect of Resident #3 not getting the medication was it could upset Resident #3. During an interview on 07/02/2025 at 6:20 PM, MA F stated she went to Resident #3's room to administer her medication. She stated Resident #3 asked for a medication that was not in the cup. MA F stated she told Resident #3 that the medication was not in the cart or in overflow. She stated all the pills in the cup were all the pills that were in the medication cart for Resident #3. She stated the Rivaroxaban was on the EMAR but not in the medication cart. MA F stated Resident #3's Rivaroxaban was on reorder and should have already been received. She stated she notified LVN K on 06/25/2025 that Resident #3 was out of her Rivaroxaban. During an interview on 07/03/2025 at 09:54 AM, MA G she worked on 06/22/2025 as the medication aide. She stated the resident was out of the medication and it was reordered, though she wasn't sure when. She stated the policy for when a medication was out of stock was to check the overflow area to check if the medication was there. She stated, if not then they were to use the refill button on the EMAR. MA G stated they were then instructed to tell the nurse, and the nurse would contact the pharmacy and possibly pull it from the facility's E-Kit (emergency supply of medication provided by the pharmacy) if the medication was in the E-Kit. She stated she was unsure if Rivaroxaban was one of the medications provided in the E-Kit. MA G stated, in the past there was some difficulty obtaining medication from the pharmacy due to insurance issues, but she was unsure if that was the case with Resident #3's Rivaroxaban. She stated if a resident were to miss their dose of Rivaroxaban, then it could cause the resident to have blood clots that could lead to strokes. She stated it was important to ensure the resident received their anticoagulant medications. During an interview on 07/03/2025 at 11:15 AM, the ADON revealed her, and staff had been trained on medication administration. She stated the policy for medication that was out of stock was the medication aide would tell the nurse so the facility can get an on hold order until the medication could be obtained. She said Resident #3 could have a heart attack or some other medical condition if the medication was not given. She said that Resident #3's Rivaroxaban was placed on the nurse's medication cart for the nurses to administer effective 06/26/2025. The ADON reviewed the Drug Record Book and stated it appeared the resident must have missed some doses based off the quantity received and the order received dates. The ADON stated the negative affect of Resident #3 not getting the medication was she could have a heart attack or another medical condition. During an interview on 07/03/2025 at 11:38 AM, CNR #1 stated it was her expectation for medication aides to notify the nurses. She stated the nurses should then contact the provider to place the medication on hold until it could be obtained. CNR #1 stated she also expected the nurses to contact the pharmacy to find out when the medication would be delivered or place a stat delivery for the order. CNR #1 reviewed the Drug Record Book and stated it appeared the resident must have missed some doses based off the quantity received and the order received dates. She stated the negative affect of Resident #3 not getting the medication was she could have complications from the diagnosis the provider is treating with the medication prescribed, she could have a decline in health status, or even hospitalization. During an interview on 07/03/2025 at 12:03 PM, the ADM stated he and staff was trained on medication administration. He stated the policy for medication that was out of stock was that the medication aide was to let the nurse know. The ADM stated then the nurse should call the provider. The ADM reviewed the Drug Record Book and stated it appeared the resident must have missed some doses based off the quantity received and the order received dates. He stated depending on the medication it could cause the resident to spiral. He also stated it could cause clots. He said he was not sure because he was not medical. Record review of in-services for 04/01/2025-07/01/2025 reflected no in-services related to medication administration, medication reordering, or what to do if a medication was not in stock. Record review of facility policy titled Administering Medications, dated 2001 and revised April 2019, reflected: Policy StatementMedications are administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation.4. Medications are administered in accordance with prescriber orders, including any required time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable, and a resident with pressure ulcers received necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for one 1 (Resident #3) of six residents reviewed for quality of care. <BR/>The facility failed to complete weekly skin assessments, obtain wound care orders and a therapy consult for Resident #3, causing his wound to deteriorate. <BR/>These failures placed the resident at risk of not receiving adequate care and services, pain, and decreased quality of life.<BR/>Findings included:<BR/>Review of Resident #3's face sheet dated 5/29/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: Spastic Quadriplegic Cerebral Palsy (congenital disorder of movement, muscle tone or posture), other mixed anxiety disorders, urine retention, chronic pain, Hypertension (high blood pressure) and cramps and spasm.<BR/>Review of Resident #3's quarterly MDS dated [DATE] reflected a BIMS score of 13 suggesting resident was cognitively intact. Further review of MDS, section M, Skin Conditions reflected a clinical assessment was competed to determine risk of pressure ulcer/injury and that Resident #3 was at risk of developing pressure ulcers/injuries. The MDS , Section M, reflected Resident #3 did not have any pressure ulcers/injuries at that time.<BR/>Review of Resident orders from 4/1/2025 until 5/29/2025 reflected no treatment orders for wound care or medications for wound healing.<BR/>Review of Resident #3's progress notes dated 4/28/2025 at 11:30 pm revealed Resident c/o burning sensation to abrasion on right calf. Redness to abrasion noted on assessment. This nurse cleaned 5x5x0.1cm abrasion to back of right calf with normal saline and applied TAO and a dry dressing.<BR/>Review of Resident #3's progress notes dated 4/29/2025 at 11:55 pm reflected F/U skin injury. This nurse cleaned 5x5x0.1cm abrasion to back of right calf with normal saline and applied TAO and a dry dressing. On assessment this nurse noted slight redness on border of skin injury. No c/o of increased pain/discomfort. <BR/>Review of Resident #3's progress notes dated 5/2/2025 to 5/28/2025 reflected no notes about wound on right rear calf and no notes about therapy consult .<BR/>Review of Resident #3's progress notes dated 5/29/2025 at 1:08 pm by LVN-A reflected Partial thickness wound with etiology of trauma to right posterior superior calf. 80% granulation tissue noted and 20% slough. Dried serous drainage noted to peri wound. Peri wound with no abnormality noted. New wound care order of Partial thickness wound with etiology of trauma to right posterior superior calf. Cleanse with wound cleanser or normal saline. Pat dry. Apply TAO to wound bed. Apply calcium alginate. Cover with silicone border dressing to promote autolytic debridement daily and PRN. RP, [name] notified of area and of new wound treatment. RP also verbalized consent for resident to be seen by [name] Wound care. No concerns or questions voiced at this time.<BR/>Review of Resident #3's weekly skin assessments revealed he received a skin assessment on 4/10/2025 and not again until 5/29/2025.<BR/>During an interview on 5/29/2025 at 11:04 am, Resident #3 stated he had had the wound on the back of his calf for a couple weeks. He stated they were cleaning it and putting some stuff on it but hadn't done that in while. He stated the wound was from the back of his calf rubbing on his wheelchair because of the way his lower leg hangs. He stated one of the staff gave him a towel to sit on to cover the edge of the wheelchair seat but it was still rubbing and hurt. He stated a nurse told him to leave it open so it would heal, but it kept rubbing on his chair and had gotten worse. He stated a staff person also told him they would have therapy look at his chair to see if they could help. He said he supposedly had a custom wheelchair on order but did not know the status on that. Resident #3 stated the wound was burning but the pain medications he was already on helped some.<BR/>During an interview on 5/29/2025 at 11:15 am, LVN A said she had just started as wound care nurse and was not sure how long the facility was without a wound care nurse before she started. She stated she would be reaching out to the wound care doctor for orders and follow up for Resident #3. LVN A stated she checked the EMR and the last weekly skin assessment was competed on 4/10/2025 for Resident #3.<BR/>During an observation conducted with LVN-A present, on 5/29/2025 at 11:04 am, Resident #3 was noted to have a wound approximately (investigator did not have a ruler to measure but wound care nurse took measurements afterwards) 1cm wide by 2cm long on his right rear calf. The wound area was oval, red around the edges, open and not covered. The top layer of the skin had been rubbed away exposing raw skin. Observation also revealed that Resident #3 was sitting on a towel that was draped over the front edge of his wheelchair seat.<BR/>During an interview on 5/29/2025 at 9:43 am, WCMD stated he had taken over wound care of this facility about 5 weeks ago. He stated when he first started coming the facility had 13-14 wounds and now they were down to 5-6. He stated he has observed residents being offloaded using wedges or other cushions and heels being floated and wounds were improving and healing.<BR/>During an interview on 5/30/2025 at 5:12 pm, DON stated skin assessments are supposed to be completed weekly. She stated they had a problem back in April where the skin assessments were not being generated as expected in the electronic medical records, but the nurses still knew to complete the skin assessments and chart in the progress notes. DON stated the prior wound care nurse was responsible for making sure the skin assessments were being done, but she had been terminated. She stated the facility had just hired a new wound care nurse, but the charge nurses were responsible for completing weekly skin assessments in the interim, until the wound care nurse had been replaced. <BR/>Review of undated facility policy skin Assessment reflected:<BR/>It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment.<BR/>1. <BR/>A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury.<BR/>7. <BR/> Documentation of skin assessment:<BR/>a. <BR/>Include date and time of the assessment, your name, and position title.<BR/>b. <BR/>Document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.).<BR/>c. <BR/>Document type of wound.<BR/>d. <BR/>Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain).<BR/>e. <BR/>Document if resident refused assessment and why.<BR/>f. <BR/>Document other information as indicated or appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #2) of two residents reviewed for medication pass, in that: <BR/>The facility failed to ensure Resident #2 was administered his medications within the one hour before and one hour after timeframe. <BR/>These failures placed residents at risk for not receiving therapeutic effect of their medications as ordered by the physician. <BR/>Findings included: <BR/>Review of Resident #2's face sheet dated 6/1/2025 reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included: Parkinson's Disease (central nervous system disorder), Type 2 Diabetes (blood sugar regulation disorder), Asthma (breathing disorder), Hypertension (high blood pressure), major depressive disorder and Epilepsy (seizure disorder). <BR/>Review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 13 suggesting no cognitive impairment. <BR/>Review of Resident #2's orders dated 6/1/2025 reflected a physician's order for Rytary Oral Capsule Extended Release 48.75-195 MG (Carbidopa-Levodopa) Give 4 capsule by mouth three times a day related to PARKINSON'S DISEASE WITHOUT DYSKINESIA, WITHOUT MENTION OF FLUCTUATIONS. <BR/>Review of Resident #2's MAR audit for the last 14 days reflected the following late administrations: <BR/>Rytary Oral Capsule Extended Release 48.75-195 MG (Carbidopa-Levodopa) <BR/>Scheduled on 05/21/2025 at 06:00 am <BR/>Administered on 05/21/2025 09:49 am (2 hours and 49 minutes late) <BR/>Rytary Oral Capsule Extended Release 48.75-195 MG (Carbidopa-Levodopa): <BR/>Scheduled on 05/23/2025 at 06:00 <BR/>Administered on 05/23/2025 at 09:33 (2 hours 33 minutes late) <BR/>Rytary Oral Capsule Extended Release 48.75-195 MG <BR/>Scheduled on 05/27/2025 at 06:00 am <BR/>Administered on 05/27/2025 at 08:32 am (one hour and 32 minutes late) <BR/>Rytary Oral Capsule Extended Release 48.75-195 MG (Carbidopa-Levodopa) <BR/>Scheduled on 05/20/2025 at 22:00 (10 pm) <BR/>Administered on 05/21/2025 at 02:52 am (3 hours and 52 minutes late) <BR/>Rytary Oral Capsule Extended Release 48.75-195 MG (Carbidopa-Levodopa <BR/>Scheduled on 05/21/2025 at 22:00 (10 pm) <BR/>Administered on 05/22/2025 01:18 am (2 hours and 18 minutes late) <BR/>Rytary Oral Capsule Extended Release 48.75-195 MG (Carbidopa-Levodopa) <BR/>Scheduled on 05/22/2025 at 22:00 (10 pm) <BR/>Administered on 05/23/2025 04:25 am (5 hours and 25 minutes late) <BR/>Review of Resident #2's care plan reflected the following problems: [Resident #2] has the potential for complications r/t Parkinson's with an intervention: Administer [Resident #2's] medications as ordered. <BR/>During an interview on 6/1/2025 at 1:57 pm, Resident #2 stated his medications had often been late. He stated when his Parkinson's medications had been late, it had caused him to have increased tremors in his hand and made it hard for him to hold or grasp things without dropping them or spilling them. He stated it had further affected his speech when they had been late as his speech had started to slur. He stated it had usually been the first dose of the day and the last dose of the day that had been late, and staff had often woken him late after midnight to give him his meds scheduled for 10 pm. Resident #2 stated the doctor had told him his medications for Parkinson's were very time-oriented and needed to be on a schedule to help him with his symptoms. <BR/>During an interview on 5/30/2025 at 5:29 pm, the DON stated medications were to be administered within one hour before or after the scheduled time. She stated they had a lot of agency nurses, and these nurses would not accept shifts if they must pass meds. She stated medications being late had been a problem since she started in March 2025, but they were doing the best that they could. She stated she was aware of medications being late on the north side due to the use of agency nurses who were not familiar with the residents, and it took them longer to pass meds. She stated nurses and medication aides were to chart in the EMR when the med was given so the administration time reflected the time the medication was given. <BR/>During an interview on 6/1/2025 at 2:40 pm, the DON stated it was her expectation that medications be given on time and that staff arrive on time and give meds on time. The DON stated her concerns with Resident #2's late medications for Parkinson's disease were adverse effects which were usually an increase in symptoms including tremors. She stated this could be uncomfortable for the resident. <BR/>During an interview on 6/1/2025 at 3:36 pm, the MD stated she had heard from residents and staff, as well, about late medications. She stated she was aware they had been working on it to improve, but consistent staffing had been a problem. She stated with Parkinson medications they need to be given within a few hours but within the one-hour time frame would be ideal. She stated in general - except in an emergency - within an hour would be ideal for med administration. She said her concerns for Resident #2 were that there was a sufficient gap between doses to help manage symptoms. She stated she was not aware of what the gaps in doses had been for Resident #2 and she would have to look into it. <BR/>Review of facility policy Administering Medications dated Q3 , 2018 reflected the following: <BR/>Medications shall be administered in a safe and timely manner, and as prescribed. <BR/>Medications must be administered in accordance with the orders, including any required time frame. <BR/>Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections when 1 of 5 staff (CNA A) observed for infection control failed to perform proper hand hygiene. <BR/>CNA-A failed to perform hand hygiene while serving and assisting residents with their meal in the facility's only dining room on 5/29/2025. <BR/>These deficient practices placed residents at risk for cross contamination and spread of infection. <BR/>Findings included: <BR/>During an observation in the dining room on 5/29/2025 at 12:31 pm CNA-A was observed three separate times, carrying meal trays from the kitchen cart and taking them to the residents. He then placed the tray on the table and assisted residents by setting up their trays - taking utensils and unwrapping them from the napkin and placing them on the tray, and opening drinks. CNA-A carried meal trays to residents without using hand hygiene in between the carrying/passing each tray. <BR/>During an interview on 5/29/2025 at 12:42 pm, CNA-A stated he had passed four trays to residents without using hand hygiene in between. He stated he had received training on performing hand hygiene between each tray passed. CNA-A stated he did not have a reason for passing trays without hand hygiene, that it was not acceptable and that he knew what he was supposed to be doing. CNA-A stated passing trays without performing hand hygiene could lead to cross contamination with bacteria or germs and residents could get sick especially older people. <BR/>During an interview on 5/30/2025 at 4:44 pm, the DON stated she was aware of staff passing trays during lunch in the dining room without performing hand hygiene. She stated her expectation was that staff will sanitize their hands before passing trays and in between passing trays. She stated her concerns would be for cross contamination and infections. She stated they have residents at risk for infection and a worst-case scenario could be a resident gets an infection and becomes septic [[life threatening complication of an infection]. She stated she has done in services on hand hygiene with staff and she expected them to follow training. <BR/>During an interview on 5/29/2025 at 5:01 pm, the ADM stated his expectation was that staff will perform hand hygiene after each time they touch or pass a tray. They can either wash their hands or use hand sanitizer. The ADM stated his concerns for staff not performing hand hygiene would be that germs can be passed easily, the facility had a population that could get sick easily and infection like the common cold, flu or viral or bacterial infections could be spread. <BR/>Review of Facility Policy Handwashing/Hand Hygiene dated Q3 , 2018, reflected: This facility considers hand hygiene the primary means to prevent the spread of infections. <BR/>1. <BR/>All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. <BR/>2. <BR/>All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. <BR/>7. <BR/>Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: <BR/>a. <BR/>Before and after coming on duty. <BR/>b. <BR/>Before and after direct contact with residents. <BR/>o. <BR/>Before and after eating or handling food. <BR/>p. <BR/>Before and after assisting a resident with meals <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 2 of 6 residents (Resident #68 and #55) reviewed for resident rights.<BR/>The facility failed to ensure Resident's #68's call light was within reach on 03/17/25.<BR/>The facility failed to provide Resident #55 with access to the call light when he was sitting in the middle of the room. <BR/>This failure could place residents at risk of needs not being met. <BR/>Findings included: <BR/>Record Review of Resident #68's face sheet dated 03/18/25 reflected the resident was a [AGE] year-old female admitted on [DATE]. Her diagnoses included congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs), anxiety (intense, excessive, and persistent worry and fear about everyday situations), anemia (a condition marked by a deficiency of red blood cells or of hemoglobin in the blood), and cerebral infarction (a pathologic process that results in an area of necrotic tissue in the brain).<BR/>Record Review of Resident #68's 5-Day MDS dated [DATE] reflected Resident #68 required supervision or touching assistance for eating, was dependent on staff for toileting, and required substantial or maximal assistance for bathing. MDS reflected Resident #68 had a BIMS score of 08 which indicated Resident #68 was moderately cognitively impaired. <BR/>Record review of Resident #68's care plan dated 10/26/22, updated on 10/27/22 reflected: Resident was at risk for falls r/t impaired mobility/balance, impaired cognition, psychoactive medication, HTN, CVA with left hemiparesis, CHF, CAD, NSTEMI. <BR/>Goal: Resident #68 would be free of falls through the review date.<BR/>Interventions included: Call Light within reach at all times.<BR/>In an interview and observation on 03/17/25 at 10:57 AM, Resident #68 did not verbally answer the state surveyor but shook her head yes when asked if she was ok and if the staff treat her well. Resident #68 appeared pleasantly confused and was continuously grinding her teeth. Resident appeared clean and groomed. Resident #68's call light was observed out of residents reach and was at the end of Resident #68's bed on the floor. Resident #68 was not able to demonstrate if she could reach the call light.<BR/>In an observation on 03/17/25 at 12:32 PM, Resident #68's call light was observed out of the residents reach and lying on the floor in front of the resident's bed.<BR/>Review of Resident #55's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including mood disorder, diabetes, anxiety, and schizophrenia.<BR/>Review of Resident #55's most recent MDS, dated [DATE], reflected a BIMS of 2, indicating a severe cognitive impairment.<BR/>Observation on 3/17/25 at 2:12 PM, revealed that Resident #55 was sitting in the middle of the room in a geri chair, . Resident #55 did not have the call light was not within the residents reach. close to him when Resident #55 was in the middle of the room. Resident #55 was moaning and wanting help, . Resident #55 was trying to get his sweater off, but he could not get the sweater off. Resident #55 was in the room for almost 10 minutes before staff came to help. resident #55. <BR/>In an interview on 03/17/25 at 12:34 PM, CNA C stated Resident #68 was able to talk and communicate with her and the resident could use the call light to call for help if needed. She stated Resident #68 used the call light frequently when she needed help from staff. She stated Resident #68 would not have been able to reach her call light where it was located at that time. She stated she had been trained on call light placement. She stated if a resident could not reach their call light, they would not be able to call for help or the staff would not know if a resident was in distress.<BR/>In an interview on 03/19/25 at 12:11 PM, the ADM stated the staff had been trained on resident rights and call light placement. He stated it was his expectation that all residents call lights be in reach at all times. He stated if a residents call light was not within the resident's reach, a resident could have possibly fell trying to get to the call light. <BR/>In an interview on 03/19/25 at 12:18 PM, the DON stated the staff had been trained on resident rights and call light placement. She stated it was her expectation that all residents call lights be within their reach at all times. She stated if a residents call light was not within their reach, it could have caused potential falls, a lack of immediate assistance, or their needs may not have been properly met.<BR/>During an interview on 3/19/2025 at 1:30 PM with CNA D, she stated that it is not expected that the resident will be put in the middle of the room where Resident #55 cannot get help and is without stimulation for an extended period. The CNA D said that if Resident #55 is left alone in the middle of the room, Resident #55 could fall and get injured. CNA D said that she had been trained on resident rights and dignity; the last time was around a month ago. <BR/>During an interview on 3/19/2025 at 1:40 PM with CNA E, she stated that it is not expected for Resident #55 to be in the middle of the room without the call light. CNA E said that it is not typical for a resident to be put in the middle of the room without being able to reach the call light. Resident #55 is not typically left in the middle of the room. CNA E said that if resident #55 is left in the middle of the room and out of reach of the call light, Resident #55 could be injured. CNA E said that she had been trained on resident rights and dignity; the last time was a month ago. <BR/>During an interview on 3/19/2025 at 1:50 PM with LVN B, she said the call light needs to be within reach when a resident is in their room alone. LVN B said that residents are not expected to be left in the room with the call light within reach. LVN E said that she has been trained on resident rights and dignity, the last time being a month ago. LVN B said a resident could fall out of the chair or be injured. <BR/>During an interview with DON on 3/19/2025 at 2:35 PM, she stated that leaving a resident in the middle of the room was not expected at the facility. The DON said leaving a resident like this was not acceptable at the facility at any time. The DON said she was trained on residents' rights and dignity when she started at the facility. The DON stated that a resident could fall and be injured if left in the room alone without being in reach of the call light. If the resident chooses to do that, it should be care planned . <BR/>During an interview on 3/19/2025 at 3:10 PM, the ADM stated that leaving a resident in the middle of the room was unacceptable and that the facility does not expect that. The ADM said that he had been trained on resident rights and dignity. <BR/>Record review of the facility policy titled Answering the Call Light and dated 2001 (revised July 2023) reflected Purpose: The purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines: 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor .<BR/>Review of the facility's Resident Rights Policy, dated 2003, reflected the following:<BR/>Resident rights provide and ensure the promotion and protection of dignity and confidentiality, self-determination, and communication. <BR/>Outcome:<BR/>Protection and promotion of resident rights<BR/>Improve resident outcomes by respecting resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation of resident property were reported immediately, but no later than 24 hours after the allegation was made to the State Survey Agency for 2 of 5 residents (Resident #1 Resident #2) reviewed for abuse. <BR/>The facility failed to report within 24 hours to the State Survey Agency (HHSC - Health and Human Services Commission) that there was alleged physical abuse between Resident # 1 and Resident # 2 when staff reported to the ADM on 04/05/2025. Resident #2 pushed/hit Resident # 1 in the chest as they passed each other in the hallway on date 04/05.2025. <BR/>This failure could place residents at risk for further abuse.<BR/>Findings included:<BR/>A record review of Resident #1's face sheet dated 04/19/2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnosis was end stage renal disease(kidneys lose the ability to remove waste and balance fluids), essential primary hypertension(abnormal high blood pressure), and osteoarthritis(flexible tissue at the ends of bones wears down).<BR/>A record review of Resident #1's Quarterly MDS assessment, dated 01/29/2025, reflected the resident had a BIMS score of 15, which indicated cognitive intact. <BR/>A record review of Resident #1's facility investigation report dated 04/08/2025, reflected Resident # 1 notified the charge nurse that Resident #2 had hit her in the breast area.<BR/>A record review of Resident #2's face sheet dated 04/19/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2's diagnosis was cerebral infraction(blood flow to the brain blocked), type 2 diabetes(body having trouble controlling blood sugar and using it for energy), and vascular dementia(memory loss).<BR/>A record review of Resident #2's Quarterly MDS assessment, dated 03/10/2025, reflected the resident had a BIMS score of 9, which indicated moderate cognitive impairment. <BR/>A record review of Resident #2's facility investigation report dated 04/08/2025, reflected Resident # 1 notified the charge nurse that Resident #2 had hit her in the breast area.<BR/>A record review of the facility's provider investigator report dated 04/08/2025 reflected the facility did not report the alleged verbal sexual abuse allegations within 24 hours to the State Survey Agency (HHSC). The Provider investigator report revealed the incident occurred on 04/05/2025 at 2:30 pm. The ADM reported the incident to HHSC on 04/05/2025 at 12:41 pm.<BR/>Attempted interview with ADON on 04/21/2025 at 12:53 pm and 4:00 pm was unsuccessful. Voice message was left for the ADON to return call. The ADON did not return call before or after the facility exit on 04/21/2025.<BR/>During an interview with Resident #2 on 04/21/2025 at 1:05 pm, stated that he was safe and did not have any issues with Resident # 1. Resident # 2 stated that he and Resident # 1 was both in wheelchairs, and Resident # 1 came down the hall, date and time not recalled, and told him to pick which side he was going to be on. Resident # 2 stated he did not mean any harm but he pushed Resident # 1 toward her chest area to move her out of his way so he could get by. <BR/>During an interview with Resident # 1 on 04/21/2025 at 1:30 pm, stated she was safe, and she did not have any issues with Resident #2. Resident # 1 stated she was coming down the hallway, could not recall the date, and she just only told Resident # 2 which side of the hall he was going to be on. Resident # 1 stated Resident # 2 had said something to her (can't recall), and he pushed her chest area. Resident # 1 stated she was not injured or hurt but she did let staff know what had happened. <BR/>During an interview with the DON on 04/21/2025 at 4:03 pm, stated the ADM was responsible for reporting the incident with Resident # 1 and Resident # 2 on 04/04/2025. The DON stated it was expected for the ADM to report timey to prevent any further abuse.<BR/>During an interview with the ADM on 04/21/2025 at 4:11 pm, stated that when the incident had happened on 04/05/2025 at 2:30 pm he immediately started investigating. The ADM stated Resident # 1 and Resident # 2 were both interviewed, and he was getting conflicting stories from each of the residents. The ADM stated that it was first told Resident # 2 had pushed Resident#1 out the way to get by when they were in the hallway. The ADM stated then it was told Resident #2 had hit Resident # 1 in the breast area when they were in the hallway. The ADM stated he did not report to the state as alleged abuse until 04/08/2025 after the stories kept on changing. The ADM stated the report should have been made to HHSC on 04-05-2025 when the incident had occurred. The ADM stated he was responsible for reporting the incident to the state timely. The ADM stated it was expected to report alleged abuse to HHSC within 24 hours to prevent further abuse.<BR/>A record review of the Long-Term Care Regulation Provider Letter dated August 29, 2024 facility's reflected Abuse, Neglect, Exploitation, Misappropriation of Resident Property and other incidents that a Nursing Facility (NF) must report to the Health and Human Services Commission (HHSC).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 2 of 6 residents (Resident #68 and #55) reviewed for resident rights.<BR/>The facility failed to ensure Resident's #68's call light was within reach on 03/17/25.<BR/>The facility failed to provide Resident #55 with access to the call light when he was sitting in the middle of the room. <BR/>This failure could place residents at risk of needs not being met. <BR/>Findings included: <BR/>Record Review of Resident #68's face sheet dated 03/18/25 reflected the resident was a [AGE] year-old female admitted on [DATE]. Her diagnoses included congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs), anxiety (intense, excessive, and persistent worry and fear about everyday situations), anemia (a condition marked by a deficiency of red blood cells or of hemoglobin in the blood), and cerebral infarction (a pathologic process that results in an area of necrotic tissue in the brain).<BR/>Record Review of Resident #68's 5-Day MDS dated [DATE] reflected Resident #68 required supervision or touching assistance for eating, was dependent on staff for toileting, and required substantial or maximal assistance for bathing. MDS reflected Resident #68 had a BIMS score of 08 which indicated Resident #68 was moderately cognitively impaired. <BR/>Record review of Resident #68's care plan dated 10/26/22, updated on 10/27/22 reflected: Resident was at risk for falls r/t impaired mobility/balance, impaired cognition, psychoactive medication, HTN, CVA with left hemiparesis, CHF, CAD, NSTEMI. <BR/>Goal: Resident #68 would be free of falls through the review date.<BR/>Interventions included: Call Light within reach at all times.<BR/>In an interview and observation on 03/17/25 at 10:57 AM, Resident #68 did not verbally answer the state surveyor but shook her head yes when asked if she was ok and if the staff treat her well. Resident #68 appeared pleasantly confused and was continuously grinding her teeth. Resident appeared clean and groomed. Resident #68's call light was observed out of residents reach and was at the end of Resident #68's bed on the floor. Resident #68 was not able to demonstrate if she could reach the call light.<BR/>In an observation on 03/17/25 at 12:32 PM, Resident #68's call light was observed out of the residents reach and lying on the floor in front of the resident's bed.<BR/>Review of Resident #55's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including mood disorder, diabetes, anxiety, and schizophrenia.<BR/>Review of Resident #55's most recent MDS, dated [DATE], reflected a BIMS of 2, indicating a severe cognitive impairment.<BR/>Observation on 3/17/25 at 2:12 PM, revealed that Resident #55 was sitting in the middle of the room in a geri chair, . Resident #55 did not have the call light was not within the residents reach. close to him when Resident #55 was in the middle of the room. Resident #55 was moaning and wanting help, . Resident #55 was trying to get his sweater off, but he could not get the sweater off. Resident #55 was in the room for almost 10 minutes before staff came to help. resident #55. <BR/>In an interview on 03/17/25 at 12:34 PM, CNA C stated Resident #68 was able to talk and communicate with her and the resident could use the call light to call for help if needed. She stated Resident #68 used the call light frequently when she needed help from staff. She stated Resident #68 would not have been able to reach her call light where it was located at that time. She stated she had been trained on call light placement. She stated if a resident could not reach their call light, they would not be able to call for help or the staff would not know if a resident was in distress.<BR/>In an interview on 03/19/25 at 12:11 PM, the ADM stated the staff had been trained on resident rights and call light placement. He stated it was his expectation that all residents call lights be in reach at all times. He stated if a residents call light was not within the resident's reach, a resident could have possibly fell trying to get to the call light. <BR/>In an interview on 03/19/25 at 12:18 PM, the DON stated the staff had been trained on resident rights and call light placement. She stated it was her expectation that all residents call lights be within their reach at all times. She stated if a residents call light was not within their reach, it could have caused potential falls, a lack of immediate assistance, or their needs may not have been properly met.<BR/>During an interview on 3/19/2025 at 1:30 PM with CNA D, she stated that it is not expected that the resident will be put in the middle of the room where Resident #55 cannot get help and is without stimulation for an extended period. The CNA D said that if Resident #55 is left alone in the middle of the room, Resident #55 could fall and get injured. CNA D said that she had been trained on resident rights and dignity; the last time was around a month ago. <BR/>During an interview on 3/19/2025 at 1:40 PM with CNA E, she stated that it is not expected for Resident #55 to be in the middle of the room without the call light. CNA E said that it is not typical for a resident to be put in the middle of the room without being able to reach the call light. Resident #55 is not typically left in the middle of the room. CNA E said that if resident #55 is left in the middle of the room and out of reach of the call light, Resident #55 could be injured. CNA E said that she had been trained on resident rights and dignity; the last time was a month ago. <BR/>During an interview on 3/19/2025 at 1:50 PM with LVN B, she said the call light needs to be within reach when a resident is in their room alone. LVN B said that residents are not expected to be left in the room with the call light within reach. LVN E said that she has been trained on resident rights and dignity, the last time being a month ago. LVN B said a resident could fall out of the chair or be injured. <BR/>During an interview with DON on 3/19/2025 at 2:35 PM, she stated that leaving a resident in the middle of the room was not expected at the facility. The DON said leaving a resident like this was not acceptable at the facility at any time. The DON said she was trained on residents' rights and dignity when she started at the facility. The DON stated that a resident could fall and be injured if left in the room alone without being in reach of the call light. If the resident chooses to do that, it should be care planned . <BR/>During an interview on 3/19/2025 at 3:10 PM, the ADM stated that leaving a resident in the middle of the room was unacceptable and that the facility does not expect that. The ADM said that he had been trained on resident rights and dignity. <BR/>Record review of the facility policy titled Answering the Call Light and dated 2001 (revised July 2023) reflected Purpose: The purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines: 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor .<BR/>Review of the facility's Resident Rights Policy, dated 2003, reflected the following:<BR/>Resident rights provide and ensure the promotion and protection of dignity and confidentiality, self-determination, and communication. <BR/>Outcome:<BR/>Protection and promotion of resident rights<BR/>Improve resident outcomes by respecting resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to provide the residents or family group with a private space; and consider the views of the resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility or to demonstrate their response and rationale for such response for 1 of 1 resident council reviewed. <BR/>The facility failed to provide a private meeting space for residents to conduct monthly resident council meetings.<BR/>The facility failed to follow up on concerns and requests expressed in resident council meetings from January 2025 through March 2025.<BR/>This failure placed residents at risk of not having the privacy needed to openly discuss their needs and preferences and have their preferences honored.<BR/>Findings included:<BR/>During an interview on 3/17/25 at approximately 3 PM, AD stated that the facility does not have a private meeting space for family or resident group meetings. The AD stated the facility's normal practice was to put up fabric curtains at the dining room entrance to prevent access by uninvited persons.<BR/>Observation of the facility's dining room on 3/18/25 at 11 AM, revealed a temporary expandable curtain rod and blackout curtains being used to restrict access to the designated resident council meeting area which was in the open dining room. The curtains did not completely obstruct the view into the area and did not obstruct the sounds of conversation inside and outside of the meeting area, therefore providing no privacy.<BR/>During interviews conducted on 3/18/25 at 11 AM at the resident council meeting, residents expressed the grievance official does not respond to the resident or family groups concerns and no rationales are provided relating to grievances filed. The group stated they do not know who the current grievance official is. The group stated that the process for filing a grievance involves filling out a grievance/concern report and putting it in the [grievance] box. The residents stated resolutions to grievances filed are not shared with them. Leaving the residents to believe that their grievances are not a priority, are not resolved, or that staff members don't care about their preferences or concerns. The resident council stated that their complaints regarding food, menus, and food temperatures continue to be unresolved issues. They stated that lost or missing clothing items that go to laundry continues to be an issue. Resident #29 stated that the facility continues to serve too much pasta and starchy foods that are not good for her health or her preferences. Resident #12 stated that she has continuously expressed her desire to have more fiber in her diet. Resident #12 said the drinks offered lack taste, are watered down, and sometimes are thick and chunky. The residents stated that they go weeks without their sheets being changed. Resident #49 stated that socks and other clothing items are often lost in the laundry or just never returned from laundry.<BR/>Review of Grievances on 3/18/25 at 12:00 PM, reflected in part the following:<BR/>1/17/25 10:45 AM<BR/>Grievance/Concern Report<BR/>Communicated By: Resident Council<BR/>Concern: Socks are missing.<BR/>Resolution: None listed; Only documentation listed is Theft/Loss. No resident follow-up indicated.<BR/>1/17/25 10:45 AM<BR/>Grievance/Concern Report<BR/>Communicated By: Resident Council<BR/>Concern: Food is cold.<BR/>Resolution: There (sic) working on fixing the steam table. It's not staying hot enough. 1/29/25 @ 12:35 PM 1.) took temps of plate warmer-one side was 110 [degrees] another was 115 [degrees]. 2.) steam table temp was 145 [degrees] and all lights were on-meaning they (sic) working. No resident follow-up indicated.<BR/>1/19/25 1:10 PM<BR/>Grievance/Concern Report<BR/>Communicated By: Resident #29<BR/>Concern: .dietary is serving too much pasta.<BR/>Resolution: Resident to be informed when pasta is served so that she can choose something else. No resident follow-up indicated. <BR/>1/29/25 No time listed<BR/>Grievance/Concern Report<BR/>Communicated by: Resident #12<BR/>Concern: No menu for Sunday<BR/>Resolution: They forgot. I told them that's important for the residents to know what there (sic) meal is going to be for that day. No resident follow-up indicated.<BR/>1/31/25 3:45 PM<BR/>Grievance/Concern Report<BR/>Communicated by: Resident #29<BR/>Concern: Food. Last Resident Council meeting it was decided that the a la carte would come down on February 1st. Several residents complained .meat is not cooked well. Meat is greasy. Lemonade & tea are hot and not cold. When the food is supposed to be cold it is hot. When the food is supposed to be hot it is cold.<BR/>Resolution: .cooks take the temps on there food before serving it. No resolution. No resident follow-up indicated.<BR/>2/4/25 2:45 PM<BR/>Grievance/Concern Report<BR/>Concern: Missing sweat pants.<BR/>Resolution: Keep looking. No resolution. No resident follow-up indicated.<BR/>2/17/25 4:55 PM<BR/>Grievance/Concern Report<BR/>Communicated by: Resident #74<BR/>Concern: He has gone all weekend without a TV cause (sic) the plug will not reach. It is almost 5:00 today & still no TV.<BR/>Resolution: None listed. No resident follow-up.<BR/>Review of Resident #12's face sheet dated 3/19/25, revealed resident #12 was originally admitted to the facility on [DATE], with her most recent admission being on 3/24/23. Her diagnoses include chronic kidney disease (gradual loss of kidney function), Type 2 Diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels), Heart Failure, Need for Assistance with Personal Care, and Dementia (a group of symptoms affecting memory, thinking, and social abilities) in other diseases classified elsewhere without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #12's Quarterly MDS assessment dated [DATE], indicated the resident's BIMS score to be 9, suggesting moderate cognitive impairment.<BR/>Review of Resident #29's face sheet dated 3/19/25, revealed Resident #29 was originally admitted to the facility on [DATE], with her most recent admission being on 3/1/25. Her diagnoses include Acute Posthemorrhagic Anemia (a condition in which a person quickly loses a large volume of circulating hemoglobin, Urinary Tract Infection (an infection in any part of the urinary system), and Type 2 Diabetes Mellitus (a chronic condition characterized by insulin resistance and elevated blood sugar). Review of Resident #29's Quarterly MDS assessment dated [DATE], indicated the resident's BIMS score to be 13, suggesting minimal cognitive impairment.<BR/>Review of Resident #49's face sheet on 3/19/25, revealed Resident #49 was originally admitted to the facility on [DATE], with his most recent admission being on 6/20/24. His diagnoses include acute chronic combined systolic and diastolic heart failure (congestive heart failure), Type 2 Diabetes Mellitus (a chronic condition characterized by insulin resistance and elevated blood sugar), and Morbid Obesity (excessive body weight which could lead to death) due to excessive calories. Review of Resident #49's annual MDS assessment dated [DATE], indicated the resident's BIMS score to be 14, suggesting minimal cognitive impairment.<BR/>Review of Resident #74's face sheet on 3/19/25, revealed Resident #74 was admitted to the facility on [DATE]. His diagnoses include Drug or Chemical Induced Diabetes Mellitus (a chronic condition characterized by insulin resistance and elevated blood sugar), acute kidney failure, and personal history of traumatic brain injury. The Resident's code status was full code. Review of Resident #74's quarterly MDS assessment dated [DATE], indicated the resident's BIMS score to be 9, suggesting moderate cognitive impairment.<BR/>During observation of the facility on 3/17/2025 at 10:25 AM, staff were observed searching residents' rooms for socks, and none could be found. Also, staff members were attempting to locate clean sheets for residents' beds that had already been stripped. An unidentified staff member was overheard saying that the sheets were in the dryer and would be ready soon. <BR/>During an observation of the facility on 3/19/25 at approximately 2:30 PM, the ADM and other staff were seen going through piles and bags of clothing items stacked on top of tables in the dining room with residents gathered around in an effort to identify the owner of the clothing items and/or giving the items away to a resident in need. <BR/>In an interview on 3/19/25 at 2:35 PM, the DON stated that she had been employed with the facility for 2 weeks. DON stated that the facility's SW would normally be designated as the facility's grievance official. The DON stated the facility does not currently have a SW on staff. The former SW left her position 2 weeks prior. The DON stated that she and ADM are handling the facility's grievances in the absence of a SW. The DON stated there were no unresolved grievances. The DON stated that she has handled one grievance herself and that she notified the person reporting the grievance of the outcome.<BR/>In an interview on 3/19/25 at 2:35 PM, the CRN stated that he knew the former SW to prioritize grievances and complaints. The CRN stated that the facility SW would typically serve as the facility's grievance official, but the facility does not currently employ a SW. He stated that he has assisted in the resolution of grievances. The CRN stated that the resident's food choices and menu requests as stated on the grievance reports are regarded as a priority and changes have been made according to those requests. The CRN stated the kitchen staff try hard. He stated that it is his belief that all parties to any grievance filed have been notified of its outcome. The CRN stated that the makeshift privacy curtain/partition utilized for family and resident group meetings is sufficient as you can't hear what's being said on either side of the curtain. The CRN stated that AD sits directly on the outside of the curtain/partition to prevent anyone else from entering the area, not to listen to what is being said. He said he feels the grievance process here is a good process.<BR/>In an interview on 3/19/25 at approximately 3 PM, the ADM stated their grievance process involves the completion of a grievance form that is then forwarded to the SW for resolution. The SW is to resolve the grievance within 3-5 days. Currently the facility does not have a SW on staff, but a SW has been hired that will be starting soon. ADM stated that in the absence of a SW, he has been handling grievances filed. He stated that there are no unresolved grievances and residents have been notified of the resolution of grievances filed. He stated the importance of resolving grievances is to ensure residents feel heard and problems or issues are remedied. The ADM acknowledged lost or missing laundry items have been a problem. His expectation is the laundry schedule will be followed as stated in policy. ADM stated that he or other staff will personally search for missing items and go through unclaimed laundry items to identify its owner or give the item to another resident who can use them. Missing socks and clothing items is issue that has to be addressed on an ongoing basis. <BR/>Review of the facility's policy revised on 2/2021 entitled Resident Rights states in part the following:<BR/>1. <BR/>Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:<BR/>t. <BR/>privacy and confidentiality.<BR/>v. <BR/>have the facility respond to his or her grievances.<BR/>Review of facility policy dated 12/23 entitled Grievances reflected the following: It is the policy of this facility to establish a grievance process that allows the residents a way to execute their right to voice concerns or grievances to the facility or other agencies/entity without fear of discrimination or reprisal. General concerns may be voiced at resident and/or family council meetings.<BR/>A review of the action plan implemented by CRN on 3/19/25, in recognition of deficient practice, revealed the following in part:<BR/>1. <BR/>Develop a Comprehensive Grievance Policy<BR/>a. <BR/>Create a clean, written grievance policy that outlines the procedures for resident to voice concerns, the process <BR/>for investigating grievances, and the timeline for resolution. This policy should be easily accessible and provided to all <BR/>residents upon admission.<BR/>2. <BR/>Designate a Grievance Official .<BR/>3. <BR/>Educate Residents and Staff:<BR/>a. <BR/>Inform residents of their right to file grievances .<BR/>b. <BR/>Train staff on the importance of addressing complaints promptly and respectfully, emphasizing the facility's <BR/>commitment to resolving issues.<BR/>4. <BR/>Implement a Reporting System .<BR/>5. <BR/>Timely Investigation and Resolution:<BR/>a. <BR/>Investigate all grievances promptly upon receipt.<BR/>b. <BR/>Provide the resident with a written decision regarding their grievance, including steps taken to resolve the issue.<BR/>6. <BR/>Monitor and Evaluate .<BR/>7. <BR/>Protect Against Retaliation .<BR/>8. <BR/>Provide External Resources .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that each resident has a right to personal privacy and confidentiality of his or her personal medical records for 1 of 6 residents when reviewed for privacy (Resident #246).<BR/>The facility failed to ensure the RN provided privacy by closing the laptop and leaving the laptop unattended in the hallway which displayed Resident #246's information after closing Resident #246's door and while performing wound care on Resident 246's right arm on 03/18/25 at 11:45 AM.<BR/>These failures could place residents at risk of having medical information personal or care instructions exposed to others and misuse of personal information.<BR/>The findings included:<BR/>Record review of Resident #246's face sheet dated 03/18/25 reflected a [AGE] year-old male with an admission date of 02/17/25. His diagnoses included sepsis (a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), pleural effusion (accumulation of excessive fluid in the pleural space, the potential space that surrounds sac lung), dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), and chronic kidney disease (long standing disease of the kidneys leading to renal failure).<BR/>Record Review of Resident #246's 5-Day MDS dated [DATE] reflected Resident #246 required set-up or clean up assistance for eating, was dependent on staff for toileting, and required substantial or maximal assistance for bathing. The MDS reflected Resident #246 had a BIMS score of 03 which indicated Resident #246 was severely cognitively impaired. <BR/>Record review of Resident #246's care plan dated 02/23/25 reflected: Resident had alteration in skin integrity, fragile skin, poor nutrition, Stage 4 Pressure Ulcer of Contiguous Site of Back, Buttock and Hip, Unstageable Pressure Ulcer of Right Elbow. <BR/>In an observation on 03/18/25 at 11:50 AM, Resident #246 was lying in bed with the head of bed elevated. The resident was awake and had his call light in reach. The resident did not appear to be in any pain or distress. The resident appeared pleasantly confused and did not answer questions when asked by the state surveyor. <BR/>In an observation on 03/18/25 at 11:45 AM, RN A prepared her supplies to perform wound care for Resident #246. RN A locked her treatment cart and entered the resident's room, leaving her computer open with Resident #246's information displayed. RN A closed Resident #246's door and prepped Resident #246 for wound care. The State Surveyor stepped out of the resident's room prior to wound care being performed and other residents and staff were present in the hallway. RN A's computer screen was visible to the state surveyor and although facing toward Resident #246's door, it could have been picked up or viewed by other residents or staff. RN A performed wound care for Resident #246 without having closed the computer. RN A finished wound care and left the resident's room. RN A walked down the hallway to dispose of hazardous waste while the monitor remained open displaying Resident #246's information. <BR/>In an interview on 03/18/25 at 11:57 AM, RN A stated she usually closed her computer and turned it over after she looked at her notes. She stated she had not meant to leave it open. She stated she had been trained on resident privacy and HIPPA. She stated if a device was left out in the open with a resident's information displayed, another resident could take a look at the information. <BR/>In an interview on 03/19/25 at 12:11 PM, the ADM stated staff had been trained on resident rights and privacy and protecting resident health information. He stated it was his expectation that residents' records should be preserved and kept confidential by staff. He stated if a resident's information had been left exposed or out in the open, the resident's private information could have potentially been seen by others or gotten into the hands of the wrong person. <BR/>In an interview on 03/19/25 at 12:18 PM, the DON stated staff had been trained on resident rights and privacy and protecting residents' health information. She stated it was her expectation that residents' records should be preserved and kept confidential by staff. She stated if a resident's information had been left exposed or out in the open, it would violate the HIPPA law. <BR/>Record review of the facility policy titled Resident Rights and dated 2001 revised February 2021 reflected Policy statement: Employees shall treat with kindness, respect, and dignity. Policy Statement: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; t. privacy and confidentiality .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents for 1 of 1 facility reviewed for environment.<BR/>The facility failed to repair cracks and penetrations (holes) in residents' bedroom and bathroom walls, clean residents' toilets and bathroom floors, clean dust particles and dirt from the ceiling and air vents in residents' bedrooms, repair residents' bathroom toilet, clean residents' bedroom and bathroom walls, empty residents' trash in their bedrooms and bathrooms, properly repair residents' bathroom vents, and clean residents bedroom blinds, windows and window sills.<BR/>This deficient practice could place residents at risk of not living in a safe, functional, sanitary and comfortable environment.<BR/>Findings included:<BR/>Observation of Resident #59's shared bedroom and bathroom on 3/17/25 at 10 AM, revealed dust particles and dirt on the residents' ceiling and coming out of the air vents. There were black, furry spots in and around the bedroom air vent that appeared to be mold. Dirt, dust, food, and trash were observed on and in the corners of the room's floors and walls. The bedroom floors were discolored and dingy from past incidents of water leaks and standing water. The bathroom toilet was in disrepair, leaking at the base. A stained and discolored towel was observed around the base of the toilet. Clumps of dirt and other unidentified matter were observed on the bathroom floor. The toilet seat appeared to be stained with feces. The interior toilet rim contained what appeared to be smeared feces. The molding along the bathroom floor was dirty, stained and gapped. The trashcans in the room and bathroom were full. The bathroom wall contained holes. There were stains and splatters observed on the walls of the bathroom. Around the base of the toilet and near a used plunger, wet and soggy pieces of toilet paper were observed. The toilet base was also observed to be stained and the bolts securing it to the floor were rusty or missing.<BR/>Observation of Resident #74's shared bedroom and bathroom on 3/17/25 at 10:37 AM, revealed wet coffee grounds in and around the edge of the sink. The bathroom floor and walls were observed to be dirty, scuffed and stained. The toilet seat and rim were observed to contain dirt, hair and feces smeared on and around them. A hole in the bathroom wall was observed. The bedroom floor appeared to be dirty, dingy and stained from past incidents of water leaks and standing water.<BR/>Observation of Resident #6's shared bedroom and bathroom on 3/17/25 at 10:47 AM, revealed dirty floors containing dirt and dust. The bathroom walls were observed to be splattered and dirty. The trash can in the bathroom was full. The bathroom contained a toilet chair over the commode that was splattered with feces. The toilet rim and bowl also contained splattered, dried feces, and dirty water in the bowel containing urine and toilet paper that had not been flushed. The walls and doors in the bathroom were scuffed, scraped and discolored. The air vent in the bathroom was observed to be in disrepair as it was being held onto the ceiling by one piece of black tape at one corner but pulling away from the ceiling tile elsewhere leaving a gap around the vent. Toilet paper pieces were observed behind and around the toilet bowel. The air conditioning vent appeared to contain black, furry spots believed to be mold around its edges, The vertical window blinds were observed to be broken, dirty and stained. The windows in room were observed to have brown paper towel twisted and pushed into the cracks of the window, presumably to prevent water from leaking in. The bedroom floors were observed to be dusty, dirty and containing trash.<BR/>In an interview on 3/17/25 at 9:52 AM, Resident #59 stated that his room and bathroom had not been cleaned since 3/14/25. He stated that his bedroom and bathroom are often unkept and dirty. He stated that housekeeping at the facility is irregular and inadequate. The Resident stated that he has had past problems with roaches in his room, but none at this time. The Resident stated that the staining and dinginess on the floor was caused by water leaking in at the windows. The Resident stated that the trash in his room and bathroom were emptied whenever housekeeping got around to it. The Resident stated that the toilet in his bathroom leaks. He stated that he has made staff aware of this, but no repairs have been done. The Resident stated that he puts a towel around the base of the toilet to keep the leaking water from standing on the bathroom floor. <BR/>During interview with Resident #59, a member of the housekeeping staff came in the room and asked the Resident if he needed anything. The housekeeping staff then stated that he would come back later. After the housekeeping staff member left, Resident #59 stated that this was part of the problem. He said staff come in and ask if you need anything rather than coming in and completing basic housekeeping services.<BR/>In an interview on 3/17/25, Resident #6 (who is mostly non-verbal) indicated that she would like her room cleaned by nodding her head.<BR/>In an interview on 3/19/25 at 2:10 PM, LVN D stated that she is an agency nurse that had been assigned to the facility approximately 1 week prior. LVN D stated that her expectation regarding resident rooms and bathrooms is that they would be neat, orderly, clean and be free from hazards. LVN D stated that she would expect resident rooms and bathrooms to be cleaned daily. If this did not occur, the risk of danger to the residents and is maximized, including threats of infection or disease. LVN D stated that she had not observed any rooms in need of housekeeping services at the facility.<BR/>In an interview on 3/19/25 at approximately 2:15 PM, HK A stated that he has been employed at the facility in housekeeping services for 3 years. His supervisor is HKS. HK A stated he is familiar with housekeeping duties and their cleaning schedule. He stated that there is at least 2-3 housekeeping staff members present at the facility 7 days a week. HK A stated that he follows a published cleaning schedule that includes disinfectant cleaning of all hard surfaces and floors, daily cleaning of all bathrooms, and emptying trash cans. If an issue regarding housekeeping is brought to his attention, he is to handle that immediately. If there are any issues of disrepair in any part of the facility, he will notify nursing staff and they will create a digital workorder in PCC that is immediately routed to maintenance staff. HK A stated that he has been properly trained to conduct all aspects of his job and that he feels supported by management and other staff members.<BR/>In an interview on 3/19/25 at 2:21 PM, HKS stated that she has been employed with the facility since 2013. She started out as a CNA, but was promoted to supervisor of housekeeping, laundry and floors in 2021. HKS stated that it is her expectation that she and her staff follow their published guidelines or processes as they pertain to their position in order to maintain a safe environment for the residents and others by preventing the spread of infection. HKS said that she actively participates in housekeeping and laundry duties where needed. She stated that her department is fully staffed, but due to the size of the facility and the extent of its needs, there are times when her departments are running behind in their scheduled duties. HKS stated that she typically has 3 staff on duty, including herself. She said she will come in on weekends as well and help if needed as well. HKS stated that she is familiar with the facility's policies and procedures pertaining to housekeeping, floors and laundry and makes she her staff are aware too. HKS said she is aware of the broken toilet in Resident #59's room and elsewhere. She stated that her department will handle minor types of maintenance issues if they can, but typically an electronic work order is input and assigned to the maintenance team to complete. HKS stated that management is very supportive of her department and its needs. <BR/>In an interview on 3/19/25 at approximately 2:30PM, the MT stated that he has been employed with the facility for 1 month. MT said that his department is made aware of maintenance issues throughout the building through an electronic work order system. The work orders are routed to him or his supervisor. Those work orders are then completed based on the seriousness of the issue being reported. MT stated that his priority tasks today have been repairing toilets and plumbing in the 100 hall. MT stated that unresolved maintenance issues and lack of proper housekeeping could lead to hazards to the residents' safety.<BR/>In an interview on 3/19/25 at 2:35 PM, the CRN acknowledged that housekeeping has been an ongoing issue of concern that the facility is addressing. CRN stated that housekeeping staff are invested in remedying the identified problems and try hard. However, CRN said that some of the problems lie with the residents. He stated that housekeeping staff get a lot of push back from residents in that they don't want their space touched or moved around in order to properly clean. CRN stated that this became such an issue that they had to engage the assistance of their ombudsman. According to CRN, the ombudsman was able to get a handful of residents to agree to allow housekeeping to come in and do a deep clean and organization of their rooms. CRN said things have improved since they began doing mock surveys and focusing on housekeeping services. CRN stated that they implemented a new cleaning schedule that staff are still getting familiar with. CRN stated that maintenance issues are handled by that department. He stated that an electronic work order is created and routed to the maintenance team for assessment and completion. CRN said there are only 2 members of the maintenance staff so some work orders are delayed in completion. He said the maintenance supervisor is good at work order prioritization. CRN said if something needs to be done such as cleaning or minor maintenance, he will do the task himself to get things done quickly. CRN said the lack of housekeeping and maintenance could lead to serious hazards and danger to the residents and put them at risk of further illness.<BR/>In an interview on 3/19/25 at 2:35 PM, the DON stated that maintenance and housekeeping staff are on-call or available 24/7. She stated that CRN is always available to her and the rest of the facility staff for support and guidance. DON said she feels housekeeping and maintenance do a good job and work hard. The supervisors in those areas are also knowledgeable and good managers per DON. DON said a lack of proper housekeeping and maintenance could lead to illnesses.<BR/>In an interview on 3/19/25 at approximately 2:45PM, the ADM stated that he is the interim administrator and has been assigned to this facility since February 2025. He stated that he is familiar with the housekeeping and maintenance processes and needs within the facility. He believes all staff follow the policies implemented at the facility. He stated that housekeeping is to follow a daily housekeeping schedule that all have been trained on. This includes the weekends. ADM stated that if this schedule is not followed, residents and others could be put at risk for illness and could lead to infection control issues. ADM stated that the maintenance department utilizes a digital work order system within the PCC system. ADM stated that when a maintenance issue is discovered and a work order input in the system, the maintenance supervisor gets an alert. The supervisor is to prioritize completion of these issues, but is expected to resolve the issues right away. ADM said the negative impact of not resolving maintenance issues timely is that the problem can turn into something bigger that could cause and environmental hazard and lead to a lack of infection control.<BR/>Review of Resident #59's face sheet revealed the resident is a [AGE] year-old male who was originally admitted to the facility on [DATE], with his most recent admission on [DATE]. Resident #59's diagnoses include cerebral infarction (stroke), hypertension (high blood pressure), major depressive disorder (low mood, loss of interest, pleasure, or happiness); blindness of the right eye, and insomnia. Resident #59's quarterly MDS assessment dated [DATE], indicated a BIMS score of 15, suggesting no cognitive impairment.<BR/>Review of resident #74's face sheet revealed resident #74 was admitted to the facility on [DATE]. His diagnoses include Drug or Chemical Induced Diabetes Mellitus (a chronic condition characterized by insulin resistance and elevated blood sugar), acute kidney failure, and personal history of traumatic brain injury. Review of resident #74's quarterly MDS assessment dated [DATE], indicated the resident's BIMS score to be 9, suggesting moderate cognitive impairment.<BR/>Review of Resident #6's face sheet revealed the resident is a [AGE] year-old female who was originally admitted to the facility on [DATE], with her most recent admission on [DATE]. Resident #6's diagnoses include chronic obstructive pulmonary disease (progressive lung condition which causes breathing difficulties), Type 2 Diabetes Mellitus (chronic condition characterized by insulin resistance and elevated blood sugar), unspecified asthma (a breathing disorder), and moderate protein calorie malnutrition (deficiency of energy, protein and micronutrients). Review of Resident #6's quarterly MDS assessment dated [DATE], indicated the resident's BIMS score to be 15, suggesting no cognitive impairment.<BR/>Review of the facility's policy entitled Cleaning and Disinfection of Surfaces revised August 2019, states<BR/>Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard.<BR/>Review of the facility's policy entitled Cleaning and Disinfecting Residents' Rooms revised August 2013, states in part:<BR/>Housekeeping surfaces will be cleaned on a regular basis, when spills occur and when the surfaces are visibly dirty.<BR/>Environmental surfaces will be cleaned on a regular basis, when spills occur and when the surfaces are visibly dirty.<BR/>Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly dirty.<BR/>Clean medical waste containers intended for reuse .daily or when such receptacles become visibly contaminated .<BR/>Review of the facility's policy entitled Maintenance Services revised December 2009, states in part:<BR/>The Maintenance Department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens reviewed for dietary services.<BR/>1. The facility failed to seal food products in airtight containers, labels food products with product name, label food products with the open/discard date, and dispose of food products after discard date.<BR/>2. The facility failed to clean and sanitize the kitchen's only industrial can opener, food prep areas, and the area surrounding the facility's only dishwasher.<BR/>This failure placed the residents at risk of ingesting food-borne pathogens.<BR/>Findings included:<BR/>Observation on 2-12-2024 at 8:45 AM in the facility's dry storage area reflected 1 box of pineapple tidbits stored directly on the floor; and 2 large bags of potato chips, each stored in a 2-gallon plastic bag, without labels which signified the product name, the date they were opened, or the date the product expired.<BR/>Observation on 2-142-2024 beginning at 8:50 AM of the facility's walk-in cooler (32 degrees Fahrenheit) reflected 1package of sliced American cheese in a plastic bag, which was not tightly sealed, without a label which signified the product name, the date it was opened, or the date the product expired; 1 package of grated cheese, which was not tightly sealed, without a label which signified the product name, the date it was opened, or the date the product expired; 1 package of chicken fried patties, which was not tightly sealed, without a label which signified the product name, the date it was opened, or the date the product expired; 1 40 ounce bottle of barbeque sauce without a label which signified the product name, the date it was opened, or the date the product expired; 2 small packages of sliced luncheon meat, which were not tightly sealed, without labels which signified the product name, the date they were opened, or the date the products expired; 1,one, 4 quart plastic contains of tomatoes, which was not tightly sealed, without a label which signified the product name, the date it was opened, or the date the product expired; 1, one, 4 quart plastic contains of green bell peppers, which was not tightly sealed, without a label which signified the product name, the date it was opened, or the date the product expired. <BR/>Observation on 2-12-2024 at 9:00 AM of the facility's freezer (-8 degrees Fahrenheit) reflected 39 assorted boxes and bags of frozen foods stored closely together, thus having limited adequate circulation around food storage containers. Observation reflected 1 bag of fried potatoes, without a label which signified the product name, the date it was opened, or the date the product expired; and, 4 individual bags of frozen waffles, without labels which signified the product name, the date they were opened, or the date the products expired.<BR/>Observation on 2-12-2024 at 9:32 AM of the kitchen's food preparation area and equipment reflected the industrial can-opener its internal working parts, and the plastic mounting bracket, which secured it to the food prep table, were coated with a dark brown substance and food particles. The dark brown substance and food particles were sticky to the touch and thick enough to scrape away with a gloved finger; the facility's only dishwasher had an accumulation of white grit and food particles on the top, and sides, of the machine. The metal vent, above the dishwasher, had an accumulation of grime and a dark brown substance; and, the side walls of a preparation table, next to the facility's flat grill, had an accumulation of grease and food particles.<BR/>Interview on 2-14-24 at 12:35 PM with DA revealed it was important to store foods in airtight containers, label the product with its name, write the date the item was opened, and write the date when the item was expected to expire for foods in the dry storage, refrigerator, and the freezer. The labels were created to know which items were fresh; and which items needed to be thrown away. Food improperly sealed, or not thrown when they expired, risked the growth of bacteria, mold, and food-borne pathogens. Kitchen equipment, and food preparation areas, needed to be cleaned with soapy water and sanitizer, which also reduced the growth of bacteria, mold, and food-borne pathogens having spread through cross-contamination. If a resident ingested bacteria, mold, or food-borne pathogens, they risked becoming ill having resulted in vomiting, stomach pain, and diarrhea.<BR/>Interview on 2-24-2024 at 12:43 with the KM revealed food stored in the dry storage area, the refrigerators, and in the freezers were required to be sealed in airtight containers, labeled with the product name, labeled with the date the item was opened, and labeled with the date the item was expected to expire. The labeling system was in place to know which items were fresh; and which items needed to be discarded. If air got into a food container, or was kept past its expiration date, the item risked the growth of bacteria, mold, and food borne pathogens. Kitchen staff were also instructed to clean, and sanitize, their respective areas after each use. Ineffective cleaning and sanitizing also promoted the growth of bacteria, mold, and food borne pathogens. If a resident consumed bacteria, mold, and food borne pathogens, they were placed at risk for illnesses having resulted in stomach cramps, diarrhea, dehydration, and unintended weight loss. The KM stated the failure of her staff to properly label and date stored food products and sanitize their respective food preparation areas was the result of the kitchen staff having failed to follow instructions and the KM having failed to train her staff. <BR/>Interview on 2-14-2024 at 1:39 PM with the DON revealed she expected the kitchen staff was knowledgeable about the way food was supposed to be stored, how long foods were supposed to be kept, and how kitchen areas, and equipment, were supposed to be cleaned. Periodically, members of the IDT team checked areas throughout the facility and brought areas of concern to the IDT meetings for discussion; however, she was not informed about any short comings in the kitchen, or its failures to adhere to proper food storage and cleanliness. <BR/>Interview on 2-14-2024 at 2:26 PM the ADM revealed there were facility policies in place that covered food safety and sanitization for dietary services. The kitchen was not checked by the IDT team; the ADM relied on the DM's input. The failure for the kitchen's non-compliance of company policy was the DM not having trained her staff and not having held her staff to the facility's standards.<BR/>Record review of the United States Food Code 2022, website: www.fda.gov. Food Contact with Equipment and Utensils: Pathogens can be transferred to food from utensils that have been stored on surfaces which have not been cleaned and sanitized. They may also be passed on by consumers or employees directly, or indirectly from used tableware or food containers. Food Storage: The possibility of product contamination increases whenever food is exposed. Changing the container(s) for machine vended time/temperature control for safety food allows microbes that may be present an opportunity to contaminate the food. Pathogens could be present on the hands of the individual packaging the food, the equipment used, or the exterior of the original packaging. In addition, time/temperature control for safety foods are vended in a hermetically sealed state to ensure product safety. Once the original seal is broken, the food is vulnerable to contamination.<BR/>Record review of the kitchen's staff instructions, undated, indicated the [Cook's Helper] was supposed to check the walk-in (referring to the walk-in refrigerator) and make sure all was dated and anything over 5 days was thrown away. [AM [NAME] Job Flow] indicated staff cleaned and sanitized their area. [Lunch [NAME] Work Flow] indicated staff cleaned and sanitized their area.<BR/>Record review of the facility's policy for [Foods Preparation and Service,] dated November 2022, indicated [General Guidelines] (2) Cross-contamination could occur when harmful substances, chemical or disease-causing microorganisms were transferred to food by hands, food contact surfaces, sponges, cloth towels, or utensils that were not adequately cleaned. [Food Preparation Area] (4d.) Cleaning and sanitizing work surfaces and food contact equipment between uses, following food code guidelines. [Food Distribution and Service] (15) All food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendations. <BR/>Record review of the facility's policy for [Refrigerators and Freezers,] dated November 2022, indicated (7) All food was appropriately dated to ensure proper rotation by expiration dates. Received dates, dates of delivery, were marked on cases and on individual items removed from cases for storage. [Use by] dates were completed with expiration dates on all prepared food and refrigerators. Expiration dates on unopened food were observed and [used by] dates were indicated once food was opened. (9) Supervisors were responsible for ensuring food items in pantry, refrigerators, and freezers were not passed [used by] or expiration dates.<BR/>Record review of the facility's policy for [Food Receiving and Storage,] dated November 2022, indicated [Dry Food Storage] (4) Dry foods that are stored in bins are removed from original packaging, labeled, and dated [use by dates.] Such foods are rotated using a [first-in first-out system. (5) Food in designated dry storage areas were kept at least 6 inches off the floor. [Refrigerated and Frozen Storage] (1) All food stored in the refrigerator or freezer are covered, labeled, and dated [use by dates;] and, (3) Refrigerated foods are stored in such a way that promotes adequate air circulation around food storage containers. <BR/>Record review of the facility's policy for [Sanitization,] dated November 2022, indicated (3) All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions; (8) When cleaning fixed equipment (mixers, slicers, and other equipment that cannot readily be immersed in water), the removable parts are (a) washed and sanitized and non-removable parts were cleaned with the detergent and hot water, rinsed, air dried and sprayed with the sanitizing solution; and (b) the equipment was reassembled and any food contact surface that may have been contaminated during the process were re-sanitized.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to obtain the hospice nursing documentation, most recent hospice plan of care specific to each patient, hospice election form, physician certification and recertification of the terminal illness specific to each patient, names and contact information for hospice personnel involved in hospice care of each patient, hospice medications information, hospice physician and attending physician orders for one (Resident #246) of six residents reviewed for hospice services and records.<BR/>The facility failed to obtain the required hospice documentation for Resident #246 when he was admitted to hospice. <BR/>This failure could affect residents by placing them at risk for services and treatments not being coordinated for end-of-life care.<BR/>Findings included:<BR/>Record review of Resident #246's Face Sheet dated 03/18/25 reflected he was a [AGE] year-old male admitted on [DATE] with active diagnoses of sepsis (an infection of the blood), heart failure (a condition in which the heart is unable to pump blood around the body properly), hypertension (elevated blood pressure), and chronic kidney disease. <BR/>Record review of Resident #246's census report dated 03/18/25 reflected his primary payor was Hospice Medicaid Texas as of 03/14/25. <BR/>Review of Resident #246's progress notes type Nurses Notes dated 03/16/25 at 1:02 pm reflected Received report from The hospital on what are the wishes of resident's family. They will continue comfort measures with Hospice. nurse came to drop off orders and this nurse asked if resident may be able to get a bariatric bed to help. She said she would ask and be back later. She dropped off some updated orders to DC and some to add. Resident returned via emergency medical services and was transferred to his bed without further incidents. Per report, there were not any other injuries than existing skin issues. Resident in bed with two family members at bedside. He was medicated with 4 MG of hydromorphone and 1 MG of Ativan. Resident received new orders for antibiotic Cefdinir & Fluconazole for urinary tract infection Orders updated in PCC. Hospice nurse here. Signed by LVN B<BR/>Review of Resident #246's care plan dated 03/16/25 reflected he was receiving anti-anxiety medications related to comfort care. There were no Hospice care plans for Resident #246. <BR/>Review of Resident #246's Nursing Facility follow up exam progress notes dated 03/17/25 at 8:30 am reflected Resident #246 was a [AGE] years old male, is being seen today for a nursing facility follow-up visit. The patient is now on hospice care after recent hospitalization. Discussed with Family Member at bedside desire to keep patient comfortable. Electronically signed by Nurse Practitioner <BR/>Record review of Physician Orders Summary for the month of March 2025 reflected there was no order for hospice services. The physician orders also reflected an order for Hydromorphone (a pain medication) oral tablets for pain hospice, end of life care dated 03/16/25.<BR/>Review of Resident #246's Significant change in status MDS assessment dated [DATE] was in progress and reflected a BIMS score of 03 which indicated severe cognitive impairment. The MDS was incomplete at the time of review. <BR/>In an interview on 03/19/25 at 1:41 PM LVN B stated Resident #246 was on hospice services. She stated there was normally a physician's order for hospice services to evaluate and initiate hospice care. The charge nurses obtain the hospice physicians order and places it into the resident's electronic medical record. She stated Resident #246 had a palliative order from the hospital upon his recent discharge on [DATE]. She stated there was no order to specify what hospice company was to provide care. She stated hospice communicates with the facility staff with any type of changes in the residents' condition or needs when they come into the facility. She stated the hospice aide visits twice a week to assist with bathing and the nurse comes 2 times weekly for Resident #246. LVN B stated Hospice does provide a folder located at the nurses' station with the resident's hospice plan of care in it. LVN B stated Resident #246 did not have a folder yet available from hospice. She stated by not having a folder containing the hospice plan of care, orders, certification, contact information, or appropriate physicians order in the medical record it could cause confusion related to what company the resident was receiving services from leading to not receiving the care that was needed.<BR/>In an interview on 03/19/25 at 1:59 PM the DON stated she has worked at the facility for 2 weeks. She stated she was unsure when Resident #246 was admitted to hospice. She stated the charge nurses were responsible for checking orders upon readmission from the hospital and placing the hospice order into the computer. She stated administration staff were now doing a daily white board meeting where they review orders. She stated the DON and the ADONs were running an order recap report from the electronic medical records to review residents for changes in conditions, new orders received, labs, and 24-hour report information to assist in catching errors. She stated not having a hospice plan of care available, certification, hospice medication list, contact information, or orders to admit to hospice can create confusion. She stated the nurses would not know who to call for Resident #246. The DON stated the hospice medical director was also Resident #246's primary physician so the nurses would still have a contact if a change in residents condition occurred. <BR/>Review of the facility's policy titled, Hospice Program, revised July 2017 reflected, <BR/>Hospice services are available to residents at the end of life.<BR/>In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs. These include:<BR/>Twenty-four-hour room and board care.<BR/>Administering prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care.<BR/>Notifying the hospice about the following:<BR/>(l) A significant change in the resident's physical, mental, social, or emotional status.<BR/>(2) <BR/>Clinical complications that suggest a need to alter the plan of care.<BR/>(3) <BR/>A need to transfer the resident from the facility for any condition.<BR/>(4) <BR/>The resident's death.<BR/>Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day; and<BR/> Our facility has designated (Name) (Title) to coordinate care provided to the resident by our facility staff and the hospice staff. (Note: this individual is a member of the IDT with clinical and assessment skills who is operating within the State scope of practice act). He or she is responsible for the following:<BR/>a. <BR/>Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for residents receiving these services.<BR/>b. <BR/>Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the resident and family.<BR/>c. <BR/>Ensuring that the Long term Care facility communicates with the hospice medical director, the resident's attending physician, and other practitioners participating in the provision of care to the resident as needed to coordinate the hospice care with the medical care provided by other physicians.<BR/>d. <BR/>Obtaining the following information from the hospice:<BR/>(l) The most recent hospice plan of care specific to each resident.<BR/>(2) <BR/>Hospice election form.<BR/>(3) <BR/>Physician certification and recertification of the terminal illness specific to each resident.<BR/>(4) <BR/>Names and contact information for hospice personnel involved in hospice care of each resident.<BR/>(5) <BR/>Instructions on how to access the hospice's 24-hour on-call system.<BR/>(6) <BR/>Hospice medication information specific to each resident; and<BR/>(7) <BR/>Hospice physician and attending physician (if any) orders specific to each resident.<BR/>e. <BR/>Ensuring that our facility staff provides orientation on the policies and procedures of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents.<BR/>13. <BR/>Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental, and psychosocial well-being.<BR/>14. <BR/>The coordinated care plan will reflect the resident's goals and wishes, as stated in his or her advance directives and during ongoing communication with the resident or representative, including:<BR/>a. <BR/>Palliative goals and objectives.<BR/>b. <BR/>Palliative interventions; and<BR/>c. <BR/>Medical treatment and diagnostic tests.<BR/>15. <BR/>The coordinated care plan shall be revised and updated as necessary to reflect the resident's current status including, but not limited to:<BR/>a. <BR/>Diagnosis.<BR/>b. <BR/>Problem list.<BR/>c. <BR/>Symptom management (pain, nausea, vomiting).<BR/>d. <BR/>Bowel and bladder care.<BR/>e. <BR/>Nutrition and hydration needs.<BR/>f. <BR/>Oral health.<BR/>g. <BR/>Skin integrity.<BR/>h. <BR/>Spiritual, activity and psychosocial needs; and<BR/>i. <BR/>Mobility and positioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure the residents had the right to be free from physical abuse and neglect for 3 (Resident #1, Resident #2, and Resident #3) of 9 residents reviewed for abuse and neglect. 1. The facility failed to provide continuous one to one monitoring for Resident #1 after repeated targeted aggressive behavior against Resident #2. An Immediate Jeopardy (IJ) situation was identified on 07/01/25 at 6:55 pm for failure #1. While the IJ was removed on 07/02/25 a 6:42 pm the facility remained out of compliance at a scope of isolated that with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. 2. The facility failed to ensure Resident #3 was not physically abused by MA F on 06/25/2025 when MA F grabbed Resident #3's wrist. These failures could affect the residents by placing them in mental anguish or emotional distress, pain, and physical harm. <BR/>Findings included: <BR/>1.Resident #1 <BR/>Review of Resident #1's face sheet dated 07/01/25 reflected an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including other frontotemporal neurocognitive disorder (degeneration of the frontal and temporal lobes of the brain, leading to a range of behavioral, language, and movement difficulties) vascular dementia (a decline in thinking skills caused by conditions that reduce or block blood flow to the brain, leading to brain damage), with other behavioral disturbance, and major depressive disorder (a serious mental illness characterized by persistent sadness, loss of interest in activities, and other symptoms that significantly interfere with daily life). <BR/> Review of Resident #1's quarterly MDS assessment, dated 05/23/25, reflected a BIMS score of 9, indicating moderate cognitive impairment Section E Behavior reflected physical behavior directed towards others (example hitting, kicking, pushing, scratching, grabbing, abusing others sexually) &ndash; behavior of this type occurred every 1 &ndash; 3 days. Verbal behaviors directed towards others (example threatening others, screaming at other, cursing at others) &ndash; behavior of this type occurred every 1 &ndash; 3 days. <BR/> Review of Resident #1's care plan reflected focus &ndash; noted behaviors of physical aggression: <BR/>1. 05/13/15 resident to resident &ndash; Resident #1 was seen holding a fork/spoon like object and was on the verge of trying to stab another resident <BR/>2. 05/19/25 resident to resident - Resident #1 grazed the other resident in the back of head with remote <BR/>3. 05/28/25 resident to resident &ndash; Resident #1 hit another resident with a broom while sitting in the secure dining room <BR/>4. 06/01/25 resident was destroying dining room area by overturning table and chair <BR/>Review of Resident #1's care plan reflected interventions for noted behaviors of physical aggression: <BR/>1. 05/13/25 document behaviors in the clinical record. <BR/>2. 05/13/25 let physician know if behaviors are interfering with daily living. <BR/>3. 05/13/25 refer to psychologist/psychiatrist as needed. <BR/>Review of Resident #1's care plan reflected focus revised on 05/29/25 indicated Resident #1 had potential to demonstrate verbally abusive behaviors related to vascular dementia, with other behavioral disturbance. Review of Resident #1's care plan reflected focus revised on 05/26/25 indicated Resident #1 resided on the facility secured unit related to deemed at risk for elopement. <BR/> Review of Resident #1's care plan reflected focus revised on 06/30/25 indicated Resident #1 demonstrated behavior symptoms/risk at times such as cursing at other residents who are in the way and following other resident (Resident #2) around telling him to get out from his property. <BR/> Review of Resident #1's care plan reflected focus revised on 05/26/25 indicated Resident #1 was at risk for behaviors related to demonstrates physically abusive behaviors 05/26/25 &ndash; resident to resident, Resident #1 ambulating on hallway with staff member when he hit another resident in the face. <BR/> Review of Resident #1's care plan reflected interventions dated 05/26/25 indicated psychiatric referral as needed to evaluate and follow in house or outpatient. <BR/> Observation of the facility secured unit on 07/01/25 at 12:10 p.m., revealed Resident #1 was sitting quietly at a dining table. Residents had finished eating. Two staff members were observed in the dining area performing normal work duties. <BR/>Observation in facility secured unit on 07/01/25 at 2:56 p.m., Resident #1 reflected the door was closed to Resident #1&rsquo;s room. When surveyor entered with the assistance of RN D, Resident #1 was sitting on his bed. His roommate was laying in his own bed sleeping. Observed no 1:1 monitoring of Resident #1. <BR/> Review of Resident #1&rsquo;s Nurses Note dated 05/09/25 written by the ADON reflected Resident #1 was placed on the secure unit due to elopement risk. <BR/> Review of Resident #1&rsquo;s Nurses Note dated 05/13/25 written by LPN A reflected aide (name of aide not stated) reported to LPN A that Resident #1, who was the roommate of Resident #2, was seen holding a fork/spoon like object and was on the verge of trying to [stab] Resident #2. The aide was unable to remove the fork/spoon out of Resident #1&rsquo;s hands. LPN A was called and able to remove the fork/spoon from Resident #1. Both residents were assessed for injury, none at the time will continue to monitor both residents for any complications. <BR/>Review of Resident #1&rsquo;s Nurses Note dated 05/20/25 written by RN C reflected Resident #1 was holding a remote in hand and refused to put remote down. Resident #1 picked up broom in the dining room hallway and attempted to hit another Resident #2. CNA (name of CNA not stated) able to redirect and remove broom from Resident #1. Resident #1 was holding remote that he refused to put down. Resident #1 &ldquo;grazed&rdquo; Resident #2 in the back of the head with remote. Residents separated for safety. Resident #1 closely monitored post incident. <BR/> Review of Resident #1&rsquo;s Progress Note Psychiatric Initial Evaluation dated 05/20/25 by PNP reflected dementia with behavioral disturbances. Patient #1 currently on 1:1 observation, continue current medication regimen. Continue to assess for adverse effects and let medication management associates know. Patient has significant cognitive impairment consistent with Alzheimer&rsquo;s disease (a progressive neurodegenerative disorder that gradually destroys memory and thinking skills, eventually impacting the ability to carry out even the simplest tasks). Patient with history of becoming easily agitated. Staff report patient was physically aggressive towards another resident with difficulty redirecting over the weekend. No aggressive behaviors noted during evaluation. Seen for initial psychiatric evaluation by request of facility. Consider sending to psychiatric hospital or emergency room if patient is a danger to self or others. <BR/> Review of Resident #1&rsquo;s Nurses Note dated 05/20/25 written by RN D reflected PNP saw Resident #1. PNP said she hoped the medications will help calm him down and he will have less behaviors. <BR/>Review of Resident #1&rsquo;s Nurses Note dated 05/26/25 written by LVN E reflected Resident #1 walked down the hallway of the secured unit when he hit Resident #2 on the face. Both Resident #1 and Resident #2 grabbed each other&rsquo;s arms. Residents separated by two staff members (names of staff members no listed). No acute injuries noted. Resident #1 was easily redirected and was calm after being separated from Resident #2. Will continue to monitor. <BR/> Review of Resident #1 Psychiatry Follow Up from PNP dated 05/27/25 reflected Resident #1 was involved in an altercation with another resident over the weekend, where he was the aggressor. Resident #1 with vascular dementia with behavioral disturbances, currently 1:1 (indicates that one staff member is assigned to continuously observe a single patient. This was often necessary for patients with certain behavioral conditions). Consider sending to emergency room or psychiatric hospital. Dementia in other diseases classified elsewhere, moderate with other behavioral disturbance &ndash; Resident #1 with history of becoming easily agitated. Was involved in an altercation with another resident [Resident #2] over the weekend. Resident #1 was the aggressor. Resident #1 continued to be on 1:1, required close monitoring. He appeared to dislike one particular resident (Resident #2). Resident #1 seen in room on 1:1 observation, did not engage much, oriented to self only, significant cognitive impairment consistent with dementia. Resident #1 required 1:1 observation and required close monitoring. Staff were to monitor, redirect, and ensure Resident #1&rsquo;s safety. It was recommended to keep Resident #1 and Resident #2 in separate locations. <BR/>Resident #2 <BR/>Review of Resident #2&rsquo;s face sheet dated 07/01/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including senile degeneration of brain (decline in cognitive abilities, memory, and behavior associated with old age), Major depressive disorder, wandering in diseases (repetitive, aimless movement from place to place, often without a clear purpose or destination, especially in individuals with dementia or other cognitive impairments). <BR/>Review of Resident #2's quarterly MDS assessment, dated 04/18/25, reflected a BIMS score of 3, indicating severe cognitive impairment. <BR/>Review of Resident #2's care plan reflected focus revised on 04/12/25, indicated Resident #2 had a behavior problem related to taking other residents&rsquo; food off their tray during meals. <BR/> Review of Resident #2&rsquo;s Nurses Note dated 05/13/25 written by LPN A reflected Resident #1, who was a roommate with Resident #2, was seen holding a folk/spoon like object and was on the verge of trying to stab Resident #2. The aide (name of aide not stated) tried to get the folk out of Resident #1&rsquo;s hands but Resident #1 was unable to give up the folk. LPN A was called to the scene and was able to remove the folk from Resident #1. Both residents were assessing for any injury, no injuries. <BR/>Review of Resident #2&rsquo;s Nurses Note dated 05/26/25 written by LVN E reflected Resident #2&rsquo;s was walking down the hallway when he was hit on left side of jaw by another resident (Resident #1). Both residents grabbed each other's arms. Resident separated from the other resident by staff x2. No visible injuries noted. Attempted to initiate neurological assessment and vitals, Resident #2 refused at this time. Will continue to monitor. <BR/>Review of Resident #2&rsquo;s Nurses Note dated 05/20/25 written by RN C reflected Resident #2 was sitting in chair in dining room. Another resident (Resident #1) attempted to hit Resident #2 with broom and hit the chair. Resident #2 remained seated in dining room chair. Resident #1 grazed Resident #2&rsquo;s hair on the back of the head with the remote. Resident #2 remained seated, no signs of agitation or aggressive behavior noted. Residents separated for safety. <BR/>Review of Resident #2&rsquo;s Progress Note Psychiatric Follow Up Evaluation dated 05/20/25 by PNP reflected Resident #2 was involved in an altercation where he was hit by another resident (Resident #1). Plan was to redirect and keep him safe. <BR/>Review of Resident #2 Progress Note from PNP dated 05/27/25 reflected Resident #2 was involved in an altercation where another resident (Resident #1) hit him; Resident #2 did not retaliate. Resident #1 required redirection and safety measures. Staff were advised to try to keep Resident #2 and Resident #1 in different locations to prevent further incidents. <BR/>Review of facility complaint incident report dated 06/01/25 revealed Resident #1 had a problem with Resident #2. Resident #1 is fixated on Resident #2. Resident #1 said, &ldquo;he thinks resident two broke his family up.&rdquo; <BR/>Review of Psychiatry Follow Up from PNP dated 06/10/25 reflected Resident #1 with history of becoming easily agitated and continued to be 1:1 observation, required close monitoring. On and off agitation and aggressive behavior towards one particular resident (Resident #2). Social support &ndash; Resident #1 received 1:1 observation and required close monitoring due to aggressive behavior. Follow up &ndash; staff to monitor, re-direct and keep safe, continue 1:1 observation due to behavioral issues. Keep Resident #1 and Resident #1 at different locations was encouraged. Continue secure unit placement. Consider sending to the emergency room if identified harm to self or other. <BR/>Review of Resident #2&rsquo;s Nurses Note dated 06/17/25 written by RN D revealed Resident #2 would take food when he walked by. <BR/>Review of IDT (team is composed of various healthcare professionals who collaborate to provide comprehensive care and support for residents) meeting note dated 06/19/25 and attended by the Administrator, ADON, MDS Coordinator and therapy reflected, &ldquo;Team decided that with information that we reviewed [Resident #1] would be OK off 1:1 monitoring.&rdquo; No MD or PNP listed as attending meeting and no documentation of information reviewed. <BR/>Review of Resident #2&rsquo;s Nurses Note dated 06/20/25 written by RN D revealed Resident #2 seen walking around eating and stealing food from others. Was able to redirect him but he kept walking towards other and grabbing at food or drinks. Other patients are very upset and stating they might hit him if he kept doing it. <BR/>Review of Resident #2&rsquo;s Nurses Note dated 06/21/25 written by RN D revealed was going in other rooms and standing over patients while sleeping. Other patients getting upset. <BR/> Review of Resident #2&rsquo;s Nurses Note dated 06/26/25 written by RN D revealed continues to take other's food at times. <BR/> Review of Resident #2&rsquo;s Progress Note dated 07/02/25 written by MD reflected Resident #2 was the target of another resident&rsquo;s (Resident #1&rsquo;s) erratic behavior on 06/28/25, though staff prevented altercation. <BR/>Interview on 07/01/25 at 2:42 p.m., with the PNP revealed Resident #1 was a safety concern because he was aggressive. She was concerned about his safety and the safety of the other residents if Resident #1 was not provided 1:1 monitoring. She said he was on the correct medications and if he was not given 1:1 monitoring, the facility needed to find alternative placement for Resident #1. <BR/>Interview on 07/01/25 at 12:10 p.m., with RN D revealed Resident #1 &ldquo;targets&rdquo; Resident #2, but Resident #1 instigates things by taking food and items from residents&rsquo; trays (including Resident #1&rsquo;s tray). RN D said he was not concerned Resident #1 would harm other residents and Resident #1 was currently not 1:1. RN D felt they had enough staff and Resident #1 could be watched. He said some incidents between Resident #1 and Resident #2 have occurred in the past even when Resident #1 was on 1:1 monitoring because staff was not watching. An example was when Resident #1 attempted to hit Resident #2 with a broom. <BR/>Interview on 07/01/25 at 2:56 p.m., with RN D revealed Resident #1 said he was taken off 1:1 monitoring last Wednesday (06/25/25) and when RN D came to work on the following Thursday (06/26/25), Resident #1 was off 1:1 monitoring and had been off 1:1 monitoring since. <BR/>Interview on 07/02/25 at 11:29 p.m., CNA G revealed she had not witnessed any physical aggression towards Resident #2 by Resident #1. She said Resident #2 would go around Resident #1&rsquo;s food tray and take things from his tray. CNA G example gave the example of when Resident #2 took Resident #1&rsquo;s food cover. CNA G said this would aggravate Resident #1 and said Resident #1 would say something to the affect that Resident #2 was messing with his wife. Resident #1 thought that Resident #2 was in Resident #1&rsquo;s home. She said Resident #1 would threaten Resident #2 when Resident #2 moved things around and said, &ldquo;I&rsquo;m going to kick your ass.&rdquo; CNA G did not think that 1:1 monitoring was necessary because there were 2 aides in the secured unit she said when staff was there they could re-direct Resident #1. She said that Resident #1 listened to her, but she was not sure if he listened to the staff on other shifts. <BR/> Interview on 07/02 25 at 2:50 p.m., LVN E revealed she had worked in the secured unit and was familiar with the relationship between Resident #1 and Resident #2. She said that Resident #1 seemed like he would get agitated when he saw Resident #2. She said Resident #1 would get upset and start walking towards Resident #2 getting verbally aggressive and cursing. She said there was an altercation between Resident #1 and Resident #2 with a broom when she was on duty, but she did not see what happened. She said a CNA got in between the residents. She said she was not concerned about resident safety because Resident #1 always received 1:1 monitoring when she was working the secured unit. She said as long as Resident #1 was 1:1 she was not concerned about safety. She said it was the responsibility of the DON and Administrator to decide if a resident received 1:1 monitoring. She said the negative effect of a resident who does not have 1:1 monitoring and needs 1:1 monitoring was that a resident could get hurt. <BR/> Interview on 07/02/25 at 2:17 p.m., RN C revealed she used to work in the secured unit at night and was familiar with Resident #1 and Resident #2. She said they are physically independent in that they are not in wheelchairs and are able to walk. She said Resident #1 and Resident #2 do not like each other. Resident #1 would say, &ldquo;it is my house.&rdquo; She said the residents should be separated. She said Resident #1 should definitely be monitored 1:1. She said if Resident #1 was not monitored 1:1, Resident #2 can get close to him and that irritated Resident #1. She said if Resident #1 is monitored 1:1, he can be re-directed quickly. She said when he received 1:1 monitoring, he was fine but as soon as he was taken off his behaviors go back to what they were previously. She thinks that Resident #1&rsquo;s behavior could cause harm to Resident #2 or himself if Resident #1 did not receive 1:1 monitoring. <BR/> Interview on 07/02/25 at 12:46 p.m., with the DON revealed she had not witnessed any disturbances between Resident #1 and Resident #2, but it was reported to her by the overnight nurse (could not remember the name of the nurse) by phone that Resident #1 attempted to hit Resident #2 with a broom. The ADON had heard that Resident #1 thinks that Resident #2 was trying to &ldquo;break up his family.&rdquo; She said that Resident #1 found Resident #2 sitting on Resident #1&rsquo;s bed and Resident #2 had an incontinent episode and Resident #1 had been &ldquo;fixated&rdquo; on Resident #2 since this episode. The ADON said the IDT team decided if a resident was going to come off 1:1 monitoring. She said the IDT team consists of the Administrator, the DON, Social Worker, and psychologist. She said she felt like the PNP should have been included in the decision whether to remove Resident #1 from 1:1 monitoring. <BR/> Interview on 07/01/25 at 5:13 p.m., CNR #1 revealed Resident #1 was fixated on Resident #2 and they were both in the secured unit, so it was not like you could keep them separate. She said the facility held an IDT meeting on 06/19/25 and the team reviewed Resident #1&rsquo;s behaviors and progress note charting and found 1:1 monitoring for Resident #1 was not warranted any longer. She said the facility needed to make sure the provider was consulted and updated. She said if the PNP said Resident #1 needed to have 1:1 monitoring, then Resident #1 needed to be on 1:1 monitoring. She said if you don&rsquo;t get the approval from the provider, the PNP, you run the risk of more resident-to-resident altercations. <BR/> Interview on 07/02/25 at 3:15 p.m., CNR #2 revealed that during the IDT meeting on 06/19/25 that concluded that was okay to end Resident #1&rsquo;s 1:1 a critical component that was missing because the PNP was not included and consulted. He said it was the responsibility of the Administrator make sure that all relevant people are present during an IDT meeting. He said the possible negative outcome of not including the PNP provider at the IDT meeting to provide input regarding the possibility of removing Resident #1 from 1:1 monitoring would be continuing issues with resident-to-resident altercations. <BR/> Interview on 07/02/25 at 3:06 p.m., the Administrator revealed the PNP should have been kept in the loop when the IDT team made the decision on 06/19/25 to removed Resident #1 from 1:1 monitoring. He said he thought Resident #1 was doing better because Resident #1 did not have any incidents of altercations with Resident #1. He said that the IDT meeting participants should have included a mental health provider to discuss Resident #1&rsquo;s 1:1 status. He said that Resident #1&rsquo;s 1:1 monitoring should have remained intact, and he should not have been removed from 1:1 monitoring. He said the negative affect of not having a resident on 1:1 monitoring who should be on 1:1 monitoring would be that it could be unsafe for residents. The Administrator said it was his understanding that Resident #1 only had problems with Resident #2, and Resident #1 was focused on Resident #2. Resident #1 thought that Resident #2 stole his family. He also heard that Resident #2 had an incontinent incident on Resident #1&rsquo;s bed and Resident #1 had not forgotten about the incident and Resident #1 was still upset about it. The Administrator said the facility was working on getting Resident #1 transferred to another facility because of his fixation on Resident #2 and concerns for Resident #1&rsquo;s safety and other safety of the other residents in the secured unit. It is the responsibility of the Administrator and the IDT team to make sure that the physical and mental providers are included in the IDT meeting when making decisions about 1:1 monitoring status. <BR/>Review of facility policy Resident to Resident Altercations dated December 2016 reflected the facility staff will monitor residents for aggressive/inappropriate behavior towards other residents. Occurrences of such incidents shall be promptly reported to the nurse supervisor, director of nursing services, and the administrator. If two residents are involved in an altercation staff will notify each resident's attending physician of the incident, review the events with the nursing supervisor, director of nursing and possible measures to try to prevent additional incidents, make any necessary changes to the care plan approaches to any or all of the involved individuals, document in the resident&rsquo;s clinical record all interventions and their effectiveness, contract psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for interventions and management as necessary or as may be recommended by the attending physician or interdisciplinary care planning team. If after carefully evaluating the situation, it is determined that care cannot be readily given within the facility to transfer the resident. <BR/>This was determined to be an Immediate Jeopardy (IJ) on 07/01/25 at 5:27 pm. The Administrator was notified at 6:55 p.m. The ADM was provided with the IJ template on 07/01/25 at 6:55 p.m. <BR/>The following Plan of Removal submitted by the facility was accepted on 07/02/25 at 1:01 p.m. <BR/> PLAN OF REMOVAL <BR/>On 07/01/2025 an abbreviated survey was initiated at the facility. On 07/01/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. <BR/>The notification of Immediate Jeopardy states as follows: The facility failed to continuously monitor Resident #1 1:1 for multiple altercations of aggressive behavior targeted against Resident #2. <BR/>IMMEDIATE JEOPARDY PLAN OF REMOVAL for F600 &ndash; Failure to Protect Residents from Abuse <BR/>Tag Number: F600 Regulation: The resident has the right to be free from abuse. Deficient Practice: The facility failed to ensure that Resident #1 was continuously monitored as ordered for 1:1 supervision following multiple episodes of physical aggression toward Resident #2, placing Resident #2 at risk for harm. <BR/>1. Corrective action(s) taken for resident(s) found to be affected: <BR/>Who: The Administrator/Designee and Secure Unit Charge Nurse. <BR/>What: Immediately reinstated 1:1 monitoring for Resident #1 to ensure Resident #1 and Resident #2 are separated. 1:1 monitoring to include direct 24-hour eyes on supervision by dedicated/assigned staff member. In-service education provided clarification to staff to ensure Resident #1 is not left alone at any time and the protocol for providing breaks and adequate replacement for assigned staff member. <BR/>When: Initiated on 07/01/2025, following incident review. <BR/>Where: On the secured memory care unit, where both residents reside. <BR/>Additionally: <BR/>Resident #2 was assessed by the ADON/Designee for injury and psychosocial impact&mdash;no acute injury found, no acute psychosocial impact. Referral was made to [MD] on 07/01/25 to conduct follow up visit on 7/2/2025. No other residents identified during review of R-to-R altercations with Resident #1 <BR/>Psychiatric Nurse Practitioner (NP) re-evaluated Resident #1 on 07/01/2025, recommending need to reinstate 1:1 due to continued aggression. <BR/>The interdisciplinary team (IDT) met on 07/01/2025 and updated Resident #1&rsquo;s care plan to reflect behavior management strategies, permanent 1:1 status, and physical separation plan from Resident #2 through direct 1:1 supervision. Finding alternate placement. <BR/> 2. How the facility will identify other residents who could be affected: <BR/>Who: ADON/Designee. <BR/>What: Conducted a review of all residents on the secured unit with active or recent aggressive behavior or R-to-R altercations within the last 30 days. Facility wide incidents were reviewed and are currently ongoing starting on 7/1/25 <BR/>When: Audit began 07/01/2025 and will be completed by 07/02/25. <BR/>Where: Secured unit. <BR/>The audit includes: <BR/>Review of behavior monitoring orders. <BR/>Validation of 1:1 interventions being documented and implemented. Documentation is assigned to the Charge Nurse on the MAR/TAR every shift and paper monitoring, which includes location, behavior/activity and supervising staff initials, is ongoing with 1 hour frequency. <BR/>Confirmation of care plan updates for any additionally identified resident and interdisciplinary review of any behavior incidents in the last 30 days. <BR/> 3. Systemic changes made to ensure the deficient practice does not recur: <BR/>Who: Staff Development Nurse, in coordination with Administrator/Designee and Regional Nurse Consultant. <BR/>What: Regional Nurse provided education to the Assistant Director of Nursing and Administrator on 07/01/2025 by in-service education. Assistant Director of Nursing and Administrator will conduct Facility-wide in-service education and posttest for all licensed nurses, CNAs, agency and direct care staff prior to the start of assigned shift. New staff will receive training during orientation: <BR/>Abuse prevention <BR/>Resident to Resident altercation policy <BR/>Requirements for initiating, documenting, and discontinuing 1:1 supervision. In-service provided clarification to staff outlining the expectations of 1:1 supervision, including, 24-hour eyes on supervision; not leaving Resident unsupervised at any time; providing adequate coverage of assigned staff member. <BR/>Importance of timely IDT reviews and documentation in the MAR/TAR and care plan. <BR/>When: Initiated on 07/01/2025 and completed by 07/02/2025 with all current and oncoming staff/agency prior to start of shift worked; new staff will receive this training during orientation. <BR/>Where: In-person training held in facility and documented with sign-in sheets. <BR/>Additional changes: <BR/>Continue 1:1 Supervision Monitoring Log, to be maintained at the point of care (resident&rsquo;s room or nearby nurse station), requiring hourly initials by assigned staff. Verification of completion of monitoring log will be done by ADON/designee daily. <BR/>1:1 supervision will be reviewed by IDT within 24 hours of initiation and will be reviewed daily for continued appropriateness of 1:1. <BR/> 4. How the facility will monitor to ensure compliance and prevent recurrence: <BR/>Who: Administrator/designee. <BR/>What: <BR/>Weekly audits of 100% of residents with 1:1 orders for compliance with documentation, monitoring logs, and MAR/TAR entries. <BR/>Monthly reviews of incident reports involving R-to-R contact, focusing on behavioral care planning and response follow-through. <BR/>When: Weekly audits for 8 weeks starting 07/02/25, followed by monthly audits for 4 months. <BR/>Where: Monitoring will occur facility wide for any identified R-to-R altercations. <BR/>Audit results will be reported to the QAPI Committee monthly, and immediate corrective action will be taken for any missed 1:1 interventions or breakdowns in IDT communication. <BR/>5. Date of completion: <BR/>All corrective actions and training will be fully implemented by: July 02, 2025 <BR/>Monitoring: <BR/>Review of Resident #1&rsquo;s MAR and TAR reflected 1:1 supervision continuous 24hr monitoring with every hour checks every hour for physical behaviors every shift documented every hour with no behavioral issues reflected. <BR/>Observation 07/02/25 at 11:25 a.m. of Resident #1 with 1:1 monitoring dedicated/assigned staff member. <BR/>Observation 07/02/25 at 1:00 p.m. of Resident #1 with 1:1 monitoring dedicated/assigned staff member. <BR/>Observation on 07/03/25 at 11:40 am of Resident #1 with 1:1 monitoring dedicated/assigned staff member. <BR/> Interview on 07/02/25 with CRN #1 stated she assessed Resident #2 for any psychosocial impact and no acute injury found. <BR/> Review of PNP documentation dated 07/01/25 re-evaluation of Resident #1 recommended need to reinstate 1:1 monitoring due to continued aggression. <BR/>Review of interdisciplinary team (IDT) meeting document dated 07/01/2025 and review of updated Resident #1&rsqu[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation of resident property were reported immediately, but no later than 24 hours after the allegation was made to the State Survey Agency for 2 of 5 residents (Resident #1 Resident #2) reviewed for abuse. <BR/>The facility failed to report within 24 hours to the State Survey Agency (HHSC - Health and Human Services Commission) that there was alleged physical abuse between Resident # 1 and Resident # 2 when staff reported to the ADM on 04/05/2025. Resident #2 pushed/hit Resident # 1 in the chest as they passed each other in the hallway on date 04/05.2025. <BR/>This failure could place residents at risk for further abuse.<BR/>Findings included:<BR/>A record review of Resident #1's face sheet dated 04/19/2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnosis was end stage renal disease(kidneys lose the ability to remove waste and balance fluids), essential primary hypertension(abnormal high blood pressure), and osteoarthritis(flexible tissue at the ends of bones wears down).<BR/>A record review of Resident #1's Quarterly MDS assessment, dated 01/29/2025, reflected the resident had a BIMS score of 15, which indicated cognitive intact. <BR/>A record review of Resident #1's facility investigation report dated 04/08/2025, reflected Resident # 1 notified the charge nurse that Resident #2 had hit her in the breast area.<BR/>A record review of Resident #2's face sheet dated 04/19/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2's diagnosis was cerebral infraction(blood flow to the brain blocked), type 2 diabetes(body having trouble controlling blood sugar and using it for energy), and vascular dementia(memory loss).<BR/>A record review of Resident #2's Quarterly MDS assessment, dated 03/10/2025, reflected the resident had a BIMS score of 9, which indicated moderate cognitive impairment. <BR/>A record review of Resident #2's facility investigation report dated 04/08/2025, reflected Resident # 1 notified the charge nurse that Resident #2 had hit her in the breast area.<BR/>A record review of the facility's provider investigator report dated 04/08/2025 reflected the facility did not report the alleged verbal sexual abuse allegations within 24 hours to the State Survey Agency (HHSC). The Provider investigator report revealed the incident occurred on 04/05/2025 at 2:30 pm. The ADM reported the incident to HHSC on 04/05/2025 at 12:41 pm.<BR/>Attempted interview with ADON on 04/21/2025 at 12:53 pm and 4:00 pm was unsuccessful. Voice message was left for the ADON to return call. The ADON did not return call before or after the facility exit on 04/21/2025.<BR/>During an interview with Resident #2 on 04/21/2025 at 1:05 pm, stated that he was safe and did not have any issues with Resident # 1. Resident # 2 stated that he and Resident # 1 was both in wheelchairs, and Resident # 1 came down the hall, date and time not recalled, and told him to pick which side he was going to be on. Resident # 2 stated he did not mean any harm but he pushed Resident # 1 toward her chest area to move her out of his way so he could get by. <BR/>During an interview with Resident # 1 on 04/21/2025 at 1:30 pm, stated she was safe, and she did not have any issues with Resident #2. Resident # 1 stated she was coming down the hallway, could not recall the date, and she just only told Resident # 2 which side of the hall he was going to be on. Resident # 1 stated Resident # 2 had said something to her (can't recall), and he pushed her chest area. Resident # 1 stated she was not injured or hurt but she did let staff know what had happened. <BR/>During an interview with the DON on 04/21/2025 at 4:03 pm, stated the ADM was responsible for reporting the incident with Resident # 1 and Resident # 2 on 04/04/2025. The DON stated it was expected for the ADM to report timey to prevent any further abuse.<BR/>During an interview with the ADM on 04/21/2025 at 4:11 pm, stated that when the incident had happened on 04/05/2025 at 2:30 pm he immediately started investigating. The ADM stated Resident # 1 and Resident # 2 were both interviewed, and he was getting conflicting stories from each of the residents. The ADM stated that it was first told Resident # 2 had pushed Resident#1 out the way to get by when they were in the hallway. The ADM stated then it was told Resident #2 had hit Resident # 1 in the breast area when they were in the hallway. The ADM stated he did not report to the state as alleged abuse until 04/08/2025 after the stories kept on changing. The ADM stated the report should have been made to HHSC on 04-05-2025 when the incident had occurred. The ADM stated he was responsible for reporting the incident to the state timely. The ADM stated it was expected to report alleged abuse to HHSC within 24 hours to prevent further abuse.<BR/>A record review of the Long-Term Care Regulation Provider Letter dated August 29, 2024 facility's reflected Abuse, Neglect, Exploitation, Misappropriation of Resident Property and other incidents that a Nursing Facility (NF) must report to the Health and Human Services Commission (HHSC).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 1 (Resident #1) of 1 resident reviewed for care plans in that:<BR/>1. The comprehensive care plan did not reflect Resident #1's behaviors of refusing HD along with interventions. <BR/>2. The facility failed to notify the kidney center on 05/09/24 and 05/11/24 about the resident refusing treatment and not making it to his appointments as reflected in the care plan. <BR/>These failures could result in residents at risk of receiving inadequate interventions not individualized to their care needs.<BR/>Findings include : <BR/>Record review of Resident #1's face sheet dated 06/04/24 revealed a [AGE] year-old male admitted on [DATE] with a diagnoses of type 2 diabetes mellitus (long term medical condition in which the body doesn't use insulin properly, resulting in unusual blood sugar levels) without complications, acute metabolic acidosis (condition in which too much acid accumulates in the body), hyperkalemia (high potassium levels in the blood), end stage renal disease (AKA end stage kidney disease or kidney failure is final, permanent kidney failure that requires a regular course of dialysis or a kidney transplant), fluid overload unspecified, and patients noncompliance with other medical treatment and regimen due to unspecified reason. <BR/>Record review of Resident #1's MDS assessment dated [DATE] reflected Section O titled Special Treatments, Procedures, and Programs marked for dialysis while a resident. Section I reflected active diagnosis of Renal Insufficiency, Renal Failure, or End Stage Renal Disease (kidney failure). MDS assessment reflected a BIMS score of 14 suggesting cognition intact. <BR/>Record review of Resident #1's care plan last revised 06/01/24 reflected identified problem alteration in kidney function with intervention notify physician and dialysis center if [Resident #1] is unable to make appointment. The care plan did not identify any behaviors related to dialysis. <BR/>Record review of Resident #1's nursing progress notes dated 05/07/24 reflected , Resident refused to go to dialysis today due to nausea. PRN administered for the nausea. Resident still refusing to go to dialysis. NP notified. The nursing note reflected the NP was notified but not the KC. <BR/>Record review of Resident #1's nursing progress notes dated 05/10/24 reflected , Resident is non-compliant with HD, resident was sent to the ER yesterday due to refusal to go to dialysis. The nursing note did not reflect that the KC was notified. <BR/>Record review of KC medical records requested for Resident #1's hospitalization reflected an encounter date 05/14/24 and reflected, brought from NH for missing HD for &gt;1 wk. Found to have volume overload and hyperkalemia. Received multiple sessions of HD in hospital. DC back to NH. Nephrology consult notes reflected, [Resident #1] declined to go to dialysis subsequently due to some stomach upset. Finally transported to dialysis but instructed to get ER clearance and found to have potassium 6.1 chronically volume overloaded but not dyspneic (short of breath).<BR/>In an interview on 06/04/24 at 10:27 AM with the KC ADM she stated Resident #1 missed HD treatments on 05/07/24 , 05/09/24, and 05/11/24. The KC ADM stated they attempted to contact the facility and called 05/09/24, 05/10/24, 05/11/24, and 05/14/24 to ask why Resident #1 was missing treatments but received no response and no call back. The KC ADM stated Resident #1 eventually showed up on 05/14/24 for treatment but due to missing so many sessions Resident #1 was sent to the emergency room where he was admitted to the hospital and received his HD there. The KC ADM stated while being transported to the ER for HD clearance, Resident #1's vitals were normal, he denied shortness of breath, weakness, and dizziness. She stated Resident #1 did not appear in any apparent distress based on nursing assessments.<BR/>In an interview on 06/04/24 at 02:22 PM with Resident #1, he stated he knew he was supposed to go to dialysis, but he usually wakes up feeling sick and declines to go. Resident #1 stated both the KC and the NF have educated him on the importance of attending dialysis. <BR/>In an Interview on 06/04/24 at 03:14 PM with the MDS Coordinator, she stated if care plans were not implemented it could affect the resident in a negative way. The MDS Coordinator said that a negative outcome of not receiving dialysis would cause the resident's body to fill with toxins. The MDS Coordinator stated it was the residents right to refuse care and services but if they are frequently refusing care, it should be care planned . The MDS Coordinator stated she was new to the facility and they were still in the process of completing audits for care plans. <BR/>In an interview on 06/04/24 at 03:58 PM with the DON, she stated it was her expectation that the care plans were made to address each residents' unique needs and every aspect of their care. She stated that based on the documentation available the KC was not notified of Resident #1 refusing HD and not making his appointments. She said the expectation has been that the nursing staff contact the dialysis center if a resident isn't able to make it and then document it- she said, they are usually good about documenting these things. The DON stated that the nursing notes did reflect he frequently refused HD, that the NP was notified, and he received HD at the hospital. The DON stated the nursing staff is responsible for notifying the KC when Resident #1 is unable to attend his appointments. The DON added that they were having phone issues at the facility briefly during this time which could be why the KC was not able to get through, however, nothing was documented to show an attempt was made to reach out to them for the two days in question. The DON stated that she was not sure what interventions were in place because she did not see anything in the care plan to reflect Resident #1 refusing HD. She stated both of her MDS Coordinators are new, and they will be receiving training on the expectations because she expects that refusal of care is reflected in the care plan. The DON also stated that they had not completed care plan audits for the last month but have been in discussions in the morning meetings of those that need to be updated and are working on them. <BR/>In an interview on 06/04/24 at 04:15 PM with the ADM he stated it was his expectation that each resident has an individualized care plan. The ADM stated that refusal of care or services should be a part of the care plan. He stated if it were his family member refusing dialysis, he would expect it to be care planned so that he knew there were interventions in place. The ADM stated it was the responsibility of the nursing staff to initialize care plans and the MDS Coordinator's responsibility to keep up with any changes. The ADM stated if the resident is not able to make it to the KC for HD it is his expectation that nursing staff, or the assigned van driver notify the KC. The ADM stated he did not have a clinical answer to a negative outcome that could occur from missing dialysis, but he said, it is not good.<BR/>Record review of the facility policy, Care Plans, Comprehensive Person-Centered last revised March 2022 reflected:<BR/>Policy statement: A comprehensive, person- centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident. <BR/>- <BR/>The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.<BR/>- <BR/>The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.<BR/>- <BR/>The comprehensive, person-centered care plan:<BR/>a. includes measurable objectives and timeframes;<BR/>b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including:<BR/>(1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;<BR/>(2) any specialized services to be provided as a result of PASARR recommendations; and<BR/>(3) which professional services are responsible for each element of care;<BR/>c. includes the resident's stated goals upon admission and desired outcomes;<BR/>d. builds on the resident's strengths; and<BR/>e. reflects currently recognized standards of practice for problem areas and conditions.<BR/>continues<BR/>- <BR/>Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.<BR/>- <BR/>When possible, interventions address the underlying source(s) of the problem areas, not just symptoms or triggers.<BR/>- <BR/>Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 2 of 6 residents (Resident #68 and #55) reviewed for resident rights.<BR/>The facility failed to ensure Resident's #68's call light was within reach on 03/17/25.<BR/>The facility failed to provide Resident #55 with access to the call light when he was sitting in the middle of the room. <BR/>This failure could place residents at risk of needs not being met. <BR/>Findings included: <BR/>Record Review of Resident #68's face sheet dated 03/18/25 reflected the resident was a [AGE] year-old female admitted on [DATE]. Her diagnoses included congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs), anxiety (intense, excessive, and persistent worry and fear about everyday situations), anemia (a condition marked by a deficiency of red blood cells or of hemoglobin in the blood), and cerebral infarction (a pathologic process that results in an area of necrotic tissue in the brain).<BR/>Record Review of Resident #68's 5-Day MDS dated [DATE] reflected Resident #68 required supervision or touching assistance for eating, was dependent on staff for toileting, and required substantial or maximal assistance for bathing. MDS reflected Resident #68 had a BIMS score of 08 which indicated Resident #68 was moderately cognitively impaired. <BR/>Record review of Resident #68's care plan dated 10/26/22, updated on 10/27/22 reflected: Resident was at risk for falls r/t impaired mobility/balance, impaired cognition, psychoactive medication, HTN, CVA with left hemiparesis, CHF, CAD, NSTEMI. <BR/>Goal: Resident #68 would be free of falls through the review date.<BR/>Interventions included: Call Light within reach at all times.<BR/>In an interview and observation on 03/17/25 at 10:57 AM, Resident #68 did not verbally answer the state surveyor but shook her head yes when asked if she was ok and if the staff treat her well. Resident #68 appeared pleasantly confused and was continuously grinding her teeth. Resident appeared clean and groomed. Resident #68's call light was observed out of residents reach and was at the end of Resident #68's bed on the floor. Resident #68 was not able to demonstrate if she could reach the call light.<BR/>In an observation on 03/17/25 at 12:32 PM, Resident #68's call light was observed out of the residents reach and lying on the floor in front of the resident's bed.<BR/>Review of Resident #55's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including mood disorder, diabetes, anxiety, and schizophrenia.<BR/>Review of Resident #55's most recent MDS, dated [DATE], reflected a BIMS of 2, indicating a severe cognitive impairment.<BR/>Observation on 3/17/25 at 2:12 PM, revealed that Resident #55 was sitting in the middle of the room in a geri chair, . Resident #55 did not have the call light was not within the residents reach. close to him when Resident #55 was in the middle of the room. Resident #55 was moaning and wanting help, . Resident #55 was trying to get his sweater off, but he could not get the sweater off. Resident #55 was in the room for almost 10 minutes before staff came to help. resident #55. <BR/>In an interview on 03/17/25 at 12:34 PM, CNA C stated Resident #68 was able to talk and communicate with her and the resident could use the call light to call for help if needed. She stated Resident #68 used the call light frequently when she needed help from staff. She stated Resident #68 would not have been able to reach her call light where it was located at that time. She stated she had been trained on call light placement. She stated if a resident could not reach their call light, they would not be able to call for help or the staff would not know if a resident was in distress.<BR/>In an interview on 03/19/25 at 12:11 PM, the ADM stated the staff had been trained on resident rights and call light placement. He stated it was his expectation that all residents call lights be in reach at all times. He stated if a residents call light was not within the resident's reach, a resident could have possibly fell trying to get to the call light. <BR/>In an interview on 03/19/25 at 12:18 PM, the DON stated the staff had been trained on resident rights and call light placement. She stated it was her expectation that all residents call lights be within their reach at all times. She stated if a residents call light was not within their reach, it could have caused potential falls, a lack of immediate assistance, or their needs may not have been properly met.<BR/>During an interview on 3/19/2025 at 1:30 PM with CNA D, she stated that it is not expected that the resident will be put in the middle of the room where Resident #55 cannot get help and is without stimulation for an extended period. The CNA D said that if Resident #55 is left alone in the middle of the room, Resident #55 could fall and get injured. CNA D said that she had been trained on resident rights and dignity; the last time was around a month ago. <BR/>During an interview on 3/19/2025 at 1:40 PM with CNA E, she stated that it is not expected for Resident #55 to be in the middle of the room without the call light. CNA E said that it is not typical for a resident to be put in the middle of the room without being able to reach the call light. Resident #55 is not typically left in the middle of the room. CNA E said that if resident #55 is left in the middle of the room and out of reach of the call light, Resident #55 could be injured. CNA E said that she had been trained on resident rights and dignity; the last time was a month ago. <BR/>During an interview on 3/19/2025 at 1:50 PM with LVN B, she said the call light needs to be within reach when a resident is in their room alone. LVN B said that residents are not expected to be left in the room with the call light within reach. LVN E said that she has been trained on resident rights and dignity, the last time being a month ago. LVN B said a resident could fall out of the chair or be injured. <BR/>During an interview with DON on 3/19/2025 at 2:35 PM, she stated that leaving a resident in the middle of the room was not expected at the facility. The DON said leaving a resident like this was not acceptable at the facility at any time. The DON said she was trained on residents' rights and dignity when she started at the facility. The DON stated that a resident could fall and be injured if left in the room alone without being in reach of the call light. If the resident chooses to do that, it should be care planned . <BR/>During an interview on 3/19/2025 at 3:10 PM, the ADM stated that leaving a resident in the middle of the room was unacceptable and that the facility does not expect that. The ADM said that he had been trained on resident rights and dignity. <BR/>Record review of the facility policy titled Answering the Call Light and dated 2001 (revised July 2023) reflected Purpose: The purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines: 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor .<BR/>Review of the facility's Resident Rights Policy, dated 2003, reflected the following:<BR/>Resident rights provide and ensure the promotion and protection of dignity and confidentiality, self-determination, and communication. <BR/>Outcome:<BR/>Protection and promotion of resident rights<BR/>Improve resident outcomes by respecting resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of three residents (Resident #1 and Resident #2) reviewed for ADLs.<BR/>The facility failed to ensure Resident #1 and Resident #2 received showers as scheduled.<BR/>This failure could place residents at risk of a decline in hygiene, at risk for skin breakdown, loss of dignity, and decline in quality of life. <BR/>Findings included:<BR/>Review of Resident #1's significant change in status MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old male admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses including hypertension (high blood pressure), Chron's disease (a type of inflammatory bowel disease), type 2 diabetes (a condition that affects the way the body processes blood sugar), epilepsy (a neurological disorder causing seizures), schizoaffective disorder (a mental health disorder that is marked by a combination of symptoms, such as hallucinations or delusions, and depression or mania), muscle weakness, and abnormalities of gait and mobility. Section C (Cognitive Patterns) reflected a BIMS score of 11 indicating moderately impaired cognition. Section GG (Functional Abilities) reflected he required partial/moderate assistance with bathing and transfers.<BR/>Review of Resident #1's comprehensive care plan, a focus, revised on 08/29/24, reflected Resident #1 had impaired physical functioning related to debility, cognitive impairment, and fracture. Interventions reflected he required partial/moderate assistance with bathing. A focus, revised on 07/30/24 reflected Resident #1 had episodes of being resistive to care. Interventions reflected, negotiate a time for ADLs so that the resident participates in the decision-making process. Return at the agreed upon time.<BR/>Review of Resident #1's ADL Bathing Log from 09/15/24 through 10/14/24, reflected he received five showers - 09/16/24, 09/18/24, 09/23/24, 09/27/24, and 10/08/24.<BR/>Review of Resident #1's progress notes from 9/01/24 through 10/13/24, reflected no documentation of bathing offered or refused. The progress notes reflected no documentation of negotiating a time for ADLs.<BR/>During an observation and interview on 10/14/24 at 12:04 PM revealed Resident #1 sitting in a wheelchair in the dining room. His hair was somewhat disheveled. He stated he was going out for an appointment, so he tried to make himself look presentable.<BR/>During an interview on 10/14/24 at 3:46 PM, Resident #1 stated he hardly ever got showers. He stated, If I had to guess, I would say I got three showers in the last 30 days. He stated he was supposed to get showers on Mondays, Wednesdays, and Fridays. He stated the staff hardly ever offered showers. He stated there was one time when he was not feeling good, and he told the CNA he did not want a shower but only that one time. He stated it made him feel like the staff did not care about me.<BR/>Review of Resident #2's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old male admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses including type 2 diabetes (a condition that affects the way the body processes blood sugar), dementia, malnutrition, epilepsy (a neurological disorder causing seizures), and repeated falls. Section C (Cognitive Patterns) reflected a BIMS score of 8 indicating moderately impaired cognition. Section GG (Functional Abilities) reflected he required supervision or touching assistance for bathing.<BR/>Review of Resident #2's comprehensive care plan revised on 10/14/24, reflected a focus of impaired physical functioning related to debility and cognitive impairment. The interventions reflected he required partial/moderate assistance with showering.<BR/>Review of Resident #2's ADL Bathing Log from 09/15/24 through 10/13/24 reflected he received seven showers - 09/18/24, 09/23/24, 09/27/24, 09/29/24, 10/2/24, 10/8/24, and 10/12/24. The log reflected he was not available on two of his scheduled shower days - 10/05/24 and 10/10/24.<BR/>Review of Resident #2's progress notes from 09/13/24 through 10/14/24, reflected no documentation that bathing was refused.<BR/>During an observation and interview on 10/14/24 at 12:16 PM, Resident #2 was sitting on the edge of his bed eating his lunch. His hair and clothes were disheveled. He stated he could not remember how often he showered or if staff offered showers.<BR/>During an interview on 10/14/24 at 2:27 PM, the ADON stated if a resident refused a shower or bed bath, the CNA was expected to tell the nurse. The nurse was expected to talk with the resident and provide education about the benefits of bathing. If the resident continued to refuse, the expectation was the nurse would write a progress not documenting the education provided and the refusal. She stated if a resident was in an even numbered room, bathing was scheduled for Monday, Wednesday, and Friday. If a resident was in an odd numbered room, bathing was scheduled for Tuesday, Thursday, and Saturday . She stated residents had the right to refuse. Not bathing could lead to skin issues or infection.<BR/>During an interview on 10/14/24 at 2:45 PM, LVN A stated she had worked at the facility for just over a year. She stated when a resident refused a shower, she talked with the resident and encouraged them to shower. If the resident continued to refuse, she told the CNAs to document that the nurse had been notified. She stated not bathing routinely could have caused skin breakdown.<BR/>During an interview on 10/14/24 at 3:40 PM, CNA B stated she had worked at the facility for a year. She stated if a resident refused a shower she talked to the resident and tried to influence and encourage them to comply. She stated she notified the charge nurse when a resident refused. CNA B opened an electronic medical record and demonstrated how the CNAs documented bathing. She stated they checked the yes box if the resident was bathed. They checked the no box if bathing was not completed. If bathing was not scheduled for the shift or the day, they could check the n/a box. She stated they just checked the boxes . She stated if bathing was not documented, residents may develop skin problems.<BR/>During an interview on 10/14/24 at 4:20 PM, the DON stated she had worked at the facility for about a month. She stated it was her expectation that bathing was completed as scheduled either Monday, Wednesday, Friday or Tuesday, Thursday, Saturday. She stated if a resident refused bathing, the CNA notified the nurse and the nurse talked with the resident. If the resident continued to refuse, the nurse was expected to write a progress note. She stated she had recently given an in-service that went over this information. She stated not bathing routinely could have caused poor hygiene, odor, or infections. She stated at this time, no-one that she was aware of monitored routine documentation. <BR/>During an interview on 10/14/24 at 4:31 PM, the ADON described the process of how the CNAs documented showers. She stated CNAs checked the appropriate box but did not type any free text because it was not in their scope. She stated the nurses were expected to write a progress note when bathing was refused.<BR/>During an interview on 10/14/24 at 4:38 PM, the AIT stated it was his expectation that documentation was completed timely and accurately. He stated if bathing was not completed routinely, a resident may have experienced infections or wounds.<BR/>During an interview on 10/14/24 at 4:55 PM, the DON stated Resident #2 had been out of the facility for several days recently which may have accounted for some showers not being documented. She stated she did not find any progress notes for either Resident #1 or Resident #2 for refusal of bathing.<BR/>Review of the facility Census Report printed 10/14/24, reflected Resident #1 was staying in a room ending with an even number. The report reflected Resident #2 was staying in a room ending with an odd number.<BR/>Record review of an in-service conducted on 10/02/24 and again on 10/04/24 by the DON, reflected staff were educated on Bed Bath versus Shower, Shower Schedule, and Refusals. 19 staff signed as attending including LVN A and CNA B.<BR/>Review of the policy Activities of Daily Living (ADLs), Supporting, revised 03/2018, reflected in part, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care).<BR/>Review of the policy Bath, Shower/Tub, revised 02/2018, reflected in part, The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. <BR/>Documentation<BR/>1. The date and time the shower/tub bath was performed.<BR/>2. The name and title of the individual(s) who assisted the resident with the shower/tub bath.<BR/>3. All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath.<BR/>4. How the resident tolerated the shower/tub bath.<BR/>5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken.<BR/>6. The signature and title of the person recording the data.<BR/>Reporting<BR/>1. Notify the supervisor if the resident refuses the shower/tub bath.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections when 1 of 5 staff (CNA A) observed for infection control failed to perform proper hand hygiene. <BR/>CNA-A failed to perform hand hygiene while serving and assisting residents with their meal in the facility's only dining room on 5/29/2025. <BR/>These deficient practices placed residents at risk for cross contamination and spread of infection. <BR/>Findings included: <BR/>During an observation in the dining room on 5/29/2025 at 12:31 pm CNA-A was observed three separate times, carrying meal trays from the kitchen cart and taking them to the residents. He then placed the tray on the table and assisted residents by setting up their trays - taking utensils and unwrapping them from the napkin and placing them on the tray, and opening drinks. CNA-A carried meal trays to residents without using hand hygiene in between the carrying/passing each tray. <BR/>During an interview on 5/29/2025 at 12:42 pm, CNA-A stated he had passed four trays to residents without using hand hygiene in between. He stated he had received training on performing hand hygiene between each tray passed. CNA-A stated he did not have a reason for passing trays without hand hygiene, that it was not acceptable and that he knew what he was supposed to be doing. CNA-A stated passing trays without performing hand hygiene could lead to cross contamination with bacteria or germs and residents could get sick especially older people. <BR/>During an interview on 5/30/2025 at 4:44 pm, the DON stated she was aware of staff passing trays during lunch in the dining room without performing hand hygiene. She stated her expectation was that staff will sanitize their hands before passing trays and in between passing trays. She stated her concerns would be for cross contamination and infections. She stated they have residents at risk for infection and a worst-case scenario could be a resident gets an infection and becomes septic [[life threatening complication of an infection]. She stated she has done in services on hand hygiene with staff and she expected them to follow training. <BR/>During an interview on 5/29/2025 at 5:01 pm, the ADM stated his expectation was that staff will perform hand hygiene after each time they touch or pass a tray. They can either wash their hands or use hand sanitizer. The ADM stated his concerns for staff not performing hand hygiene would be that germs can be passed easily, the facility had a population that could get sick easily and infection like the common cold, flu or viral or bacterial infections could be spread. <BR/>Review of Facility Policy Handwashing/Hand Hygiene dated Q3 , 2018, reflected: This facility considers hand hygiene the primary means to prevent the spread of infections. <BR/>1. <BR/>All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. <BR/>2. <BR/>All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. <BR/>7. <BR/>Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: <BR/>a. <BR/>Before and after coming on duty. <BR/>b. <BR/>Before and after direct contact with residents. <BR/>o. <BR/>Before and after eating or handling food. <BR/>p. <BR/>Before and after assisting a resident with meals <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 1 (Resident #1) of 1 resident reviewed for care plans in that:<BR/>1. The comprehensive care plan did not reflect Resident #1's behaviors of refusing HD along with interventions. <BR/>2. The facility failed to notify the kidney center on 05/09/24 and 05/11/24 about the resident refusing treatment and not making it to his appointments as reflected in the care plan. <BR/>These failures could result in residents at risk of receiving inadequate interventions not individualized to their care needs.<BR/>Findings include : <BR/>Record review of Resident #1's face sheet dated 06/04/24 revealed a [AGE] year-old male admitted on [DATE] with a diagnoses of type 2 diabetes mellitus (long term medical condition in which the body doesn't use insulin properly, resulting in unusual blood sugar levels) without complications, acute metabolic acidosis (condition in which too much acid accumulates in the body), hyperkalemia (high potassium levels in the blood), end stage renal disease (AKA end stage kidney disease or kidney failure is final, permanent kidney failure that requires a regular course of dialysis or a kidney transplant), fluid overload unspecified, and patients noncompliance with other medical treatment and regimen due to unspecified reason. <BR/>Record review of Resident #1's MDS assessment dated [DATE] reflected Section O titled Special Treatments, Procedures, and Programs marked for dialysis while a resident. Section I reflected active diagnosis of Renal Insufficiency, Renal Failure, or End Stage Renal Disease (kidney failure). MDS assessment reflected a BIMS score of 14 suggesting cognition intact. <BR/>Record review of Resident #1's care plan last revised 06/01/24 reflected identified problem alteration in kidney function with intervention notify physician and dialysis center if [Resident #1] is unable to make appointment. The care plan did not identify any behaviors related to dialysis. <BR/>Record review of Resident #1's nursing progress notes dated 05/07/24 reflected , Resident refused to go to dialysis today due to nausea. PRN administered for the nausea. Resident still refusing to go to dialysis. NP notified. The nursing note reflected the NP was notified but not the KC. <BR/>Record review of Resident #1's nursing progress notes dated 05/10/24 reflected , Resident is non-compliant with HD, resident was sent to the ER yesterday due to refusal to go to dialysis. The nursing note did not reflect that the KC was notified. <BR/>Record review of KC medical records requested for Resident #1's hospitalization reflected an encounter date 05/14/24 and reflected, brought from NH for missing HD for &gt;1 wk. Found to have volume overload and hyperkalemia. Received multiple sessions of HD in hospital. DC back to NH. Nephrology consult notes reflected, [Resident #1] declined to go to dialysis subsequently due to some stomach upset. Finally transported to dialysis but instructed to get ER clearance and found to have potassium 6.1 chronically volume overloaded but not dyspneic (short of breath).<BR/>In an interview on 06/04/24 at 10:27 AM with the KC ADM she stated Resident #1 missed HD treatments on 05/07/24 , 05/09/24, and 05/11/24. The KC ADM stated they attempted to contact the facility and called 05/09/24, 05/10/24, 05/11/24, and 05/14/24 to ask why Resident #1 was missing treatments but received no response and no call back. The KC ADM stated Resident #1 eventually showed up on 05/14/24 for treatment but due to missing so many sessions Resident #1 was sent to the emergency room where he was admitted to the hospital and received his HD there. The KC ADM stated while being transported to the ER for HD clearance, Resident #1's vitals were normal, he denied shortness of breath, weakness, and dizziness. She stated Resident #1 did not appear in any apparent distress based on nursing assessments.<BR/>In an interview on 06/04/24 at 02:22 PM with Resident #1, he stated he knew he was supposed to go to dialysis, but he usually wakes up feeling sick and declines to go. Resident #1 stated both the KC and the NF have educated him on the importance of attending dialysis. <BR/>In an Interview on 06/04/24 at 03:14 PM with the MDS Coordinator, she stated if care plans were not implemented it could affect the resident in a negative way. The MDS Coordinator said that a negative outcome of not receiving dialysis would cause the resident's body to fill with toxins. The MDS Coordinator stated it was the residents right to refuse care and services but if they are frequently refusing care, it should be care planned . The MDS Coordinator stated she was new to the facility and they were still in the process of completing audits for care plans. <BR/>In an interview on 06/04/24 at 03:58 PM with the DON, she stated it was her expectation that the care plans were made to address each residents' unique needs and every aspect of their care. She stated that based on the documentation available the KC was not notified of Resident #1 refusing HD and not making his appointments. She said the expectation has been that the nursing staff contact the dialysis center if a resident isn't able to make it and then document it- she said, they are usually good about documenting these things. The DON stated that the nursing notes did reflect he frequently refused HD, that the NP was notified, and he received HD at the hospital. The DON stated the nursing staff is responsible for notifying the KC when Resident #1 is unable to attend his appointments. The DON added that they were having phone issues at the facility briefly during this time which could be why the KC was not able to get through, however, nothing was documented to show an attempt was made to reach out to them for the two days in question. The DON stated that she was not sure what interventions were in place because she did not see anything in the care plan to reflect Resident #1 refusing HD. She stated both of her MDS Coordinators are new, and they will be receiving training on the expectations because she expects that refusal of care is reflected in the care plan. The DON also stated that they had not completed care plan audits for the last month but have been in discussions in the morning meetings of those that need to be updated and are working on them. <BR/>In an interview on 06/04/24 at 04:15 PM with the ADM he stated it was his expectation that each resident has an individualized care plan. The ADM stated that refusal of care or services should be a part of the care plan. He stated if it were his family member refusing dialysis, he would expect it to be care planned so that he knew there were interventions in place. The ADM stated it was the responsibility of the nursing staff to initialize care plans and the MDS Coordinator's responsibility to keep up with any changes. The ADM stated if the resident is not able to make it to the KC for HD it is his expectation that nursing staff, or the assigned van driver notify the KC. The ADM stated he did not have a clinical answer to a negative outcome that could occur from missing dialysis, but he said, it is not good.<BR/>Record review of the facility policy, Care Plans, Comprehensive Person-Centered last revised March 2022 reflected:<BR/>Policy statement: A comprehensive, person- centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident. <BR/>- <BR/>The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.<BR/>- <BR/>The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.<BR/>- <BR/>The comprehensive, person-centered care plan:<BR/>a. includes measurable objectives and timeframes;<BR/>b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including:<BR/>(1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;<BR/>(2) any specialized services to be provided as a result of PASARR recommendations; and<BR/>(3) which professional services are responsible for each element of care;<BR/>c. includes the resident's stated goals upon admission and desired outcomes;<BR/>d. builds on the resident's strengths; and<BR/>e. reflects currently recognized standards of practice for problem areas and conditions.<BR/>continues<BR/>- <BR/>Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.<BR/>- <BR/>When possible, interventions address the underlying source(s) of the problem areas, not just symptoms or triggers.<BR/>- <BR/>Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for one (Resident #73) of six residents reviewed for medications.<BR/>The facility failed to indicate adequate diagnosis and monitoring for Seroquel (an atypical antipsychotic medication) for Resident #73. <BR/>The facility failed to have a completed consent with justification of the appropriateness of an atypical antipsychotic medication for Resident #73. <BR/>This failure could place residents on psychoactive medications at risk for adverse consequences such as impairment or decline of an individual's mental or physical condition. <BR/>The findings were: <BR/>Record review of Resident #73's admission Record dated 03/18/25 reflected he was an [AGE] year-old male, admitted to the facility on [DATE]. His diagnosis included: unspecified dementia (a decline in brain function), cognitive communication disorder, depression, and degenerative disease of the nervous system. <BR/>Record review of Resident #73's Psychiatry Progress Notes dated 7/23/2024: Today, we conducted a medication review as requested by the staff for behavioral monitoring and medication review. Present during the review were the Director of Nursing (DON) and Assistant Director of Nursing (ADON)-Pt with a diagnosis of MDD (major Depressive Disorder), Anxiety, and Insomnia.<BR/>Record review of Resident #73's Care Plan revised on 10/06/25 reflected: Focus: Resident #73 is receiving psychotropic medications related to agitation/delirium and depression. Interventions/task: Monitor/record occurrence of for target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Monitor/record/report to MD prn side effects and adverse reactions of psychoactive medications: unsteady gait, tardive dyskinesia, shuffling gait, rigid muscles, shaking, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. <BR/>Record review of Resident #73's consent for Antipsychotic or Neuroleptic Medication Treatment dated 10/10/24 reflected no psychiatric or maladaptive behavior, no diagnosis diagnostic criteria or assessment findings, no need for and benefit of the proposed treatment with antipsychotic medication was indicated. The form was not signed by the persons prescribing the medication, that person's designee, or the facilities medical director. <BR/>Record review of Resident #73's quarterly MDS dated [DATE] revealed a BIMS score of 13, indicating he was cognitively intact. The MDS also reflected Resident #73 was taking an antipsychotic medication daily. <BR/>Record review of Resident #73's Physicians Order Summary dated March 2025 reflected he had an order for Seroquel Oral Tablet 50 MG (Quetiapine Fumarate) Give 1 tablet by mouth two times a day for indication of depression dated 10/05/2024. The order did not have a related diagnosis in place for the use of Seroquel. <BR/>Record review of Resident #73's March 2025 Medication Administration Record reflected Resident #73 was administered Seroquel Oral Tablet 50 MG (Quetiapine Fumarate) Give 1 tablet by mouth two times a day for depression. The MAR reflected there was no monitoring in place for side effects of antipsychotic medications. <BR/>In an interview on 03/19/25 at 1:41 p.m., LVN B stated Resident #73 was currently taking Seroquel for depression. She stated there was no supporting diagnosis in his history and physical. She stated the nurses do enter antipsychotic medication orders upon admission and when received from the doctor. She stated consents for medications should be obtained at the time the order was received. She stated depression was not an appropriate indication of use for Seroquel. She stated the supervisors do check the orders after they were put in. She stated she has been educated on appropriate diagnosis or antipsychotics but not through this facility. She stated this facility did have a learning tree program the nurses used for in-services. She stated not having an appropriate diagnosis, monitoring, or consent could lead to lack of oversight for his mental illness. <BR/>In an interview on 03/19/25 at 1:59 PM the DON stated she has worked at the facility for 2 weeks. She stated she could not explain why the consent for Resident #73's antipsychotic medication was not signed or reviewed by the Doctor. The DON stated depression was not an appropriate diagnosis for Seroquel treatment. She stated Resident #73 had a diagnosis of Major Depressive Disorder noted in his psychiatric notes. She stated administration staff were now doing a daily white board meeting where they reviewed orders. She stated the DON and the ADONs were running an order recap report from the electronic medical records to review residents for changes in conditions, new orders received, labs, and 24-hour report information to assist in catching errors. The DON stated the importance would be that the resident should have the appropriate diagnosis, oversight, and the appropriate medications to treat their psychiatric conditions. <BR/>Record review of the facility's policy Psychotropic Medication Use dated July 2022, reflected:<BR/>Residents will not receive medications that are not clinically indicated to treat a specific condition.<BR/>Policy Interpretation and Implementation<BR/>l. A psychotropic medication is any mediation that affects brain activity associated with mental processes and behavior.<BR/>Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications:<BR/>a. <BR/>Anti-psychotics.<BR/>b. <BR/>Anti-depressants.<BR/>c. <BR/>Anti-anxiety medications; and<BR/>d. <BR/>Hypnotics.<BR/>Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes:<BR/>e. <BR/>indications for use.<BR/>f. <BR/>dose (including duplicate therapy).<BR/>g. <BR/>duration.<BR/>h. <BR/>adequate monitoring for efficacy and adverse consequences; and<BR/>i. <BR/>preventing, identifying, and responding to adverse consequences.<BR/>Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record.<BR/>Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes.<BR/>Residents receiving psychotropic medications are monitored for adverse consequences, including:<BR/>j. <BR/>anticholinergics effects - flushing, blurred vision, dry mouth, altered mental status, difficulty urinating, falls, excessive sedation and constipation.<BR/>k. <BR/>cardiovascular effects - irregular heart rate or pulse, palpitations, lightheadedness, shortness of breath, diaphoresis, chest/arm pain, increased blood pressure, orthostatic hypotension.<BR/>l. <BR/>metabolic effects - increased cholesterol and triglycerides, poorly controlled or unstable blood sugar, weight gain.<BR/>m. <BR/>neurologic effects - agitation, distress, extrapyramidal symptoms, neuroleptic malignant syndrome, Parkinsonism, tardive dyskinesia, cerebrovascular events; and<BR/>n. <BR/>psychosocial effects - inability to perform ADLs or interact with others, withdrawal or decline from usual social patterns, decreased engagement in activities, diminished ability to think or concentrate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents for 1 of 1 facility reviewed for environment.<BR/>The facility failed to repair cracks and penetrations (holes) in residents' bedroom and bathroom walls, clean residents' toilets and bathroom floors, clean dust particles and dirt from the ceiling and air vents in residents' bedrooms, repair residents' bathroom toilet, clean residents' bedroom and bathroom walls, empty residents' trash in their bedrooms and bathrooms, properly repair residents' bathroom vents, and clean residents bedroom blinds, windows and window sills.<BR/>This deficient practice could place residents at risk of not living in a safe, functional, sanitary and comfortable environment.<BR/>Findings included:<BR/>Observation of Resident #59's shared bedroom and bathroom on 3/17/25 at 10 AM, revealed dust particles and dirt on the residents' ceiling and coming out of the air vents. There were black, furry spots in and around the bedroom air vent that appeared to be mold. Dirt, dust, food, and trash were observed on and in the corners of the room's floors and walls. The bedroom floors were discolored and dingy from past incidents of water leaks and standing water. The bathroom toilet was in disrepair, leaking at the base. A stained and discolored towel was observed around the base of the toilet. Clumps of dirt and other unidentified matter were observed on the bathroom floor. The toilet seat appeared to be stained with feces. The interior toilet rim contained what appeared to be smeared feces. The molding along the bathroom floor was dirty, stained and gapped. The trashcans in the room and bathroom were full. The bathroom wall contained holes. There were stains and splatters observed on the walls of the bathroom. Around the base of the toilet and near a used plunger, wet and soggy pieces of toilet paper were observed. The toilet base was also observed to be stained and the bolts securing it to the floor were rusty or missing.<BR/>Observation of Resident #74's shared bedroom and bathroom on 3/17/25 at 10:37 AM, revealed wet coffee grounds in and around the edge of the sink. The bathroom floor and walls were observed to be dirty, scuffed and stained. The toilet seat and rim were observed to contain dirt, hair and feces smeared on and around them. A hole in the bathroom wall was observed. The bedroom floor appeared to be dirty, dingy and stained from past incidents of water leaks and standing water.<BR/>Observation of Resident #6's shared bedroom and bathroom on 3/17/25 at 10:47 AM, revealed dirty floors containing dirt and dust. The bathroom walls were observed to be splattered and dirty. The trash can in the bathroom was full. The bathroom contained a toilet chair over the commode that was splattered with feces. The toilet rim and bowl also contained splattered, dried feces, and dirty water in the bowel containing urine and toilet paper that had not been flushed. The walls and doors in the bathroom were scuffed, scraped and discolored. The air vent in the bathroom was observed to be in disrepair as it was being held onto the ceiling by one piece of black tape at one corner but pulling away from the ceiling tile elsewhere leaving a gap around the vent. Toilet paper pieces were observed behind and around the toilet bowel. The air conditioning vent appeared to contain black, furry spots believed to be mold around its edges, The vertical window blinds were observed to be broken, dirty and stained. The windows in room were observed to have brown paper towel twisted and pushed into the cracks of the window, presumably to prevent water from leaking in. The bedroom floors were observed to be dusty, dirty and containing trash.<BR/>In an interview on 3/17/25 at 9:52 AM, Resident #59 stated that his room and bathroom had not been cleaned since 3/14/25. He stated that his bedroom and bathroom are often unkept and dirty. He stated that housekeeping at the facility is irregular and inadequate. The Resident stated that he has had past problems with roaches in his room, but none at this time. The Resident stated that the staining and dinginess on the floor was caused by water leaking in at the windows. The Resident stated that the trash in his room and bathroom were emptied whenever housekeeping got around to it. The Resident stated that the toilet in his bathroom leaks. He stated that he has made staff aware of this, but no repairs have been done. The Resident stated that he puts a towel around the base of the toilet to keep the leaking water from standing on the bathroom floor. <BR/>During interview with Resident #59, a member of the housekeeping staff came in the room and asked the Resident if he needed anything. The housekeeping staff then stated that he would come back later. After the housekeeping staff member left, Resident #59 stated that this was part of the problem. He said staff come in and ask if you need anything rather than coming in and completing basic housekeeping services.<BR/>In an interview on 3/17/25, Resident #6 (who is mostly non-verbal) indicated that she would like her room cleaned by nodding her head.<BR/>In an interview on 3/19/25 at 2:10 PM, LVN D stated that she is an agency nurse that had been assigned to the facility approximately 1 week prior. LVN D stated that her expectation regarding resident rooms and bathrooms is that they would be neat, orderly, clean and be free from hazards. LVN D stated that she would expect resident rooms and bathrooms to be cleaned daily. If this did not occur, the risk of danger to the residents and is maximized, including threats of infection or disease. LVN D stated that she had not observed any rooms in need of housekeeping services at the facility.<BR/>In an interview on 3/19/25 at approximately 2:15 PM, HK A stated that he has been employed at the facility in housekeeping services for 3 years. His supervisor is HKS. HK A stated he is familiar with housekeeping duties and their cleaning schedule. He stated that there is at least 2-3 housekeeping staff members present at the facility 7 days a week. HK A stated that he follows a published cleaning schedule that includes disinfectant cleaning of all hard surfaces and floors, daily cleaning of all bathrooms, and emptying trash cans. If an issue regarding housekeeping is brought to his attention, he is to handle that immediately. If there are any issues of disrepair in any part of the facility, he will notify nursing staff and they will create a digital workorder in PCC that is immediately routed to maintenance staff. HK A stated that he has been properly trained to conduct all aspects of his job and that he feels supported by management and other staff members.<BR/>In an interview on 3/19/25 at 2:21 PM, HKS stated that she has been employed with the facility since 2013. She started out as a CNA, but was promoted to supervisor of housekeeping, laundry and floors in 2021. HKS stated that it is her expectation that she and her staff follow their published guidelines or processes as they pertain to their position in order to maintain a safe environment for the residents and others by preventing the spread of infection. HKS said that she actively participates in housekeeping and laundry duties where needed. She stated that her department is fully staffed, but due to the size of the facility and the extent of its needs, there are times when her departments are running behind in their scheduled duties. HKS stated that she typically has 3 staff on duty, including herself. She said she will come in on weekends as well and help if needed as well. HKS stated that she is familiar with the facility's policies and procedures pertaining to housekeeping, floors and laundry and makes she her staff are aware too. HKS said she is aware of the broken toilet in Resident #59's room and elsewhere. She stated that her department will handle minor types of maintenance issues if they can, but typically an electronic work order is input and assigned to the maintenance team to complete. HKS stated that management is very supportive of her department and its needs. <BR/>In an interview on 3/19/25 at approximately 2:30PM, the MT stated that he has been employed with the facility for 1 month. MT said that his department is made aware of maintenance issues throughout the building through an electronic work order system. The work orders are routed to him or his supervisor. Those work orders are then completed based on the seriousness of the issue being reported. MT stated that his priority tasks today have been repairing toilets and plumbing in the 100 hall. MT stated that unresolved maintenance issues and lack of proper housekeeping could lead to hazards to the residents' safety.<BR/>In an interview on 3/19/25 at 2:35 PM, the CRN acknowledged that housekeeping has been an ongoing issue of concern that the facility is addressing. CRN stated that housekeeping staff are invested in remedying the identified problems and try hard. However, CRN said that some of the problems lie with the residents. He stated that housekeeping staff get a lot of push back from residents in that they don't want their space touched or moved around in order to properly clean. CRN stated that this became such an issue that they had to engage the assistance of their ombudsman. According to CRN, the ombudsman was able to get a handful of residents to agree to allow housekeeping to come in and do a deep clean and organization of their rooms. CRN said things have improved since they began doing mock surveys and focusing on housekeeping services. CRN stated that they implemented a new cleaning schedule that staff are still getting familiar with. CRN stated that maintenance issues are handled by that department. He stated that an electronic work order is created and routed to the maintenance team for assessment and completion. CRN said there are only 2 members of the maintenance staff so some work orders are delayed in completion. He said the maintenance supervisor is good at work order prioritization. CRN said if something needs to be done such as cleaning or minor maintenance, he will do the task himself to get things done quickly. CRN said the lack of housekeeping and maintenance could lead to serious hazards and danger to the residents and put them at risk of further illness.<BR/>In an interview on 3/19/25 at 2:35 PM, the DON stated that maintenance and housekeeping staff are on-call or available 24/7. She stated that CRN is always available to her and the rest of the facility staff for support and guidance. DON said she feels housekeeping and maintenance do a good job and work hard. The supervisors in those areas are also knowledgeable and good managers per DON. DON said a lack of proper housekeeping and maintenance could lead to illnesses.<BR/>In an interview on 3/19/25 at approximately 2:45PM, the ADM stated that he is the interim administrator and has been assigned to this facility since February 2025. He stated that he is familiar with the housekeeping and maintenance processes and needs within the facility. He believes all staff follow the policies implemented at the facility. He stated that housekeeping is to follow a daily housekeeping schedule that all have been trained on. This includes the weekends. ADM stated that if this schedule is not followed, residents and others could be put at risk for illness and could lead to infection control issues. ADM stated that the maintenance department utilizes a digital work order system within the PCC system. ADM stated that when a maintenance issue is discovered and a work order input in the system, the maintenance supervisor gets an alert. The supervisor is to prioritize completion of these issues, but is expected to resolve the issues right away. ADM said the negative impact of not resolving maintenance issues timely is that the problem can turn into something bigger that could cause and environmental hazard and lead to a lack of infection control.<BR/>Review of Resident #59's face sheet revealed the resident is a [AGE] year-old male who was originally admitted to the facility on [DATE], with his most recent admission on [DATE]. Resident #59's diagnoses include cerebral infarction (stroke), hypertension (high blood pressure), major depressive disorder (low mood, loss of interest, pleasure, or happiness); blindness of the right eye, and insomnia. Resident #59's quarterly MDS assessment dated [DATE], indicated a BIMS score of 15, suggesting no cognitive impairment.<BR/>Review of resident #74's face sheet revealed resident #74 was admitted to the facility on [DATE]. His diagnoses include Drug or Chemical Induced Diabetes Mellitus (a chronic condition characterized by insulin resistance and elevated blood sugar), acute kidney failure, and personal history of traumatic brain injury. Review of resident #74's quarterly MDS assessment dated [DATE], indicated the resident's BIMS score to be 9, suggesting moderate cognitive impairment.<BR/>Review of Resident #6's face sheet revealed the resident is a [AGE] year-old female who was originally admitted to the facility on [DATE], with her most recent admission on [DATE]. Resident #6's diagnoses include chronic obstructive pulmonary disease (progressive lung condition which causes breathing difficulties), Type 2 Diabetes Mellitus (chronic condition characterized by insulin resistance and elevated blood sugar), unspecified asthma (a breathing disorder), and moderate protein calorie malnutrition (deficiency of energy, protein and micronutrients). Review of Resident #6's quarterly MDS assessment dated [DATE], indicated the resident's BIMS score to be 15, suggesting no cognitive impairment.<BR/>Review of the facility's policy entitled Cleaning and Disinfection of Surfaces revised August 2019, states<BR/>Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard.<BR/>Review of the facility's policy entitled Cleaning and Disinfecting Residents' Rooms revised August 2013, states in part:<BR/>Housekeeping surfaces will be cleaned on a regular basis, when spills occur and when the surfaces are visibly dirty.<BR/>Environmental surfaces will be cleaned on a regular basis, when spills occur and when the surfaces are visibly dirty.<BR/>Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly dirty.<BR/>Clean medical waste containers intended for reuse .daily or when such receptacles become visibly contaminated .<BR/>Review of the facility's policy entitled Maintenance Services revised December 2009, states in part:<BR/>The Maintenance Department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens reviewed for dietary services.<BR/>1. The facility failed to seal food products in airtight containers, labels food products with product name, label food products with the open/discard date, and dispose of food products after discard date.<BR/>2. The facility failed to clean and sanitize the kitchen's only industrial can opener, food prep areas, and the area surrounding the facility's only dishwasher.<BR/>This failure placed the residents at risk of ingesting food-borne pathogens.<BR/>Findings included:<BR/>Observation on 2-12-2024 at 8:45 AM in the facility's dry storage area reflected 1 box of pineapple tidbits stored directly on the floor; and 2 large bags of potato chips, each stored in a 2-gallon plastic bag, without labels which signified the product name, the date they were opened, or the date the product expired.<BR/>Observation on 2-142-2024 beginning at 8:50 AM of the facility's walk-in cooler (32 degrees Fahrenheit) reflected 1package of sliced American cheese in a plastic bag, which was not tightly sealed, without a label which signified the product name, the date it was opened, or the date the product expired; 1 package of grated cheese, which was not tightly sealed, without a label which signified the product name, the date it was opened, or the date the product expired; 1 package of chicken fried patties, which was not tightly sealed, without a label which signified the product name, the date it was opened, or the date the product expired; 1 40 ounce bottle of barbeque sauce without a label which signified the product name, the date it was opened, or the date the product expired; 2 small packages of sliced luncheon meat, which were not tightly sealed, without labels which signified the product name, the date they were opened, or the date the products expired; 1,one, 4 quart plastic contains of tomatoes, which was not tightly sealed, without a label which signified the product name, the date it was opened, or the date the product expired; 1, one, 4 quart plastic contains of green bell peppers, which was not tightly sealed, without a label which signified the product name, the date it was opened, or the date the product expired. <BR/>Observation on 2-12-2024 at 9:00 AM of the facility's freezer (-8 degrees Fahrenheit) reflected 39 assorted boxes and bags of frozen foods stored closely together, thus having limited adequate circulation around food storage containers. Observation reflected 1 bag of fried potatoes, without a label which signified the product name, the date it was opened, or the date the product expired; and, 4 individual bags of frozen waffles, without labels which signified the product name, the date they were opened, or the date the products expired.<BR/>Observation on 2-12-2024 at 9:32 AM of the kitchen's food preparation area and equipment reflected the industrial can-opener its internal working parts, and the plastic mounting bracket, which secured it to the food prep table, were coated with a dark brown substance and food particles. The dark brown substance and food particles were sticky to the touch and thick enough to scrape away with a gloved finger; the facility's only dishwasher had an accumulation of white grit and food particles on the top, and sides, of the machine. The metal vent, above the dishwasher, had an accumulation of grime and a dark brown substance; and, the side walls of a preparation table, next to the facility's flat grill, had an accumulation of grease and food particles.<BR/>Interview on 2-14-24 at 12:35 PM with DA revealed it was important to store foods in airtight containers, label the product with its name, write the date the item was opened, and write the date when the item was expected to expire for foods in the dry storage, refrigerator, and the freezer. The labels were created to know which items were fresh; and which items needed to be thrown away. Food improperly sealed, or not thrown when they expired, risked the growth of bacteria, mold, and food-borne pathogens. Kitchen equipment, and food preparation areas, needed to be cleaned with soapy water and sanitizer, which also reduced the growth of bacteria, mold, and food-borne pathogens having spread through cross-contamination. If a resident ingested bacteria, mold, or food-borne pathogens, they risked becoming ill having resulted in vomiting, stomach pain, and diarrhea.<BR/>Interview on 2-24-2024 at 12:43 with the KM revealed food stored in the dry storage area, the refrigerators, and in the freezers were required to be sealed in airtight containers, labeled with the product name, labeled with the date the item was opened, and labeled with the date the item was expected to expire. The labeling system was in place to know which items were fresh; and which items needed to be discarded. If air got into a food container, or was kept past its expiration date, the item risked the growth of bacteria, mold, and food borne pathogens. Kitchen staff were also instructed to clean, and sanitize, their respective areas after each use. Ineffective cleaning and sanitizing also promoted the growth of bacteria, mold, and food borne pathogens. If a resident consumed bacteria, mold, and food borne pathogens, they were placed at risk for illnesses having resulted in stomach cramps, diarrhea, dehydration, and unintended weight loss. The KM stated the failure of her staff to properly label and date stored food products and sanitize their respective food preparation areas was the result of the kitchen staff having failed to follow instructions and the KM having failed to train her staff. <BR/>Interview on 2-14-2024 at 1:39 PM with the DON revealed she expected the kitchen staff was knowledgeable about the way food was supposed to be stored, how long foods were supposed to be kept, and how kitchen areas, and equipment, were supposed to be cleaned. Periodically, members of the IDT team checked areas throughout the facility and brought areas of concern to the IDT meetings for discussion; however, she was not informed about any short comings in the kitchen, or its failures to adhere to proper food storage and cleanliness. <BR/>Interview on 2-14-2024 at 2:26 PM the ADM revealed there were facility policies in place that covered food safety and sanitization for dietary services. The kitchen was not checked by the IDT team; the ADM relied on the DM's input. The failure for the kitchen's non-compliance of company policy was the DM not having trained her staff and not having held her staff to the facility's standards.<BR/>Record review of the United States Food Code 2022, website: www.fda.gov. Food Contact with Equipment and Utensils: Pathogens can be transferred to food from utensils that have been stored on surfaces which have not been cleaned and sanitized. They may also be passed on by consumers or employees directly, or indirectly from used tableware or food containers. Food Storage: The possibility of product contamination increases whenever food is exposed. Changing the container(s) for machine vended time/temperature control for safety food allows microbes that may be present an opportunity to contaminate the food. Pathogens could be present on the hands of the individual packaging the food, the equipment used, or the exterior of the original packaging. In addition, time/temperature control for safety foods are vended in a hermetically sealed state to ensure product safety. Once the original seal is broken, the food is vulnerable to contamination.<BR/>Record review of the kitchen's staff instructions, undated, indicated the [Cook's Helper] was supposed to check the walk-in (referring to the walk-in refrigerator) and make sure all was dated and anything over 5 days was thrown away. [AM [NAME] Job Flow] indicated staff cleaned and sanitized their area. [Lunch [NAME] Work Flow] indicated staff cleaned and sanitized their area.<BR/>Record review of the facility's policy for [Foods Preparation and Service,] dated November 2022, indicated [General Guidelines] (2) Cross-contamination could occur when harmful substances, chemical or disease-causing microorganisms were transferred to food by hands, food contact surfaces, sponges, cloth towels, or utensils that were not adequately cleaned. [Food Preparation Area] (4d.) Cleaning and sanitizing work surfaces and food contact equipment between uses, following food code guidelines. [Food Distribution and Service] (15) All food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendations. <BR/>Record review of the facility's policy for [Refrigerators and Freezers,] dated November 2022, indicated (7) All food was appropriately dated to ensure proper rotation by expiration dates. Received dates, dates of delivery, were marked on cases and on individual items removed from cases for storage. [Use by] dates were completed with expiration dates on all prepared food and refrigerators. Expiration dates on unopened food were observed and [used by] dates were indicated once food was opened. (9) Supervisors were responsible for ensuring food items in pantry, refrigerators, and freezers were not passed [used by] or expiration dates.<BR/>Record review of the facility's policy for [Food Receiving and Storage,] dated November 2022, indicated [Dry Food Storage] (4) Dry foods that are stored in bins are removed from original packaging, labeled, and dated [use by dates.] Such foods are rotated using a [first-in first-out system. (5) Food in designated dry storage areas were kept at least 6 inches off the floor. [Refrigerated and Frozen Storage] (1) All food stored in the refrigerator or freezer are covered, labeled, and dated [use by dates;] and, (3) Refrigerated foods are stored in such a way that promotes adequate air circulation around food storage containers. <BR/>Record review of the facility's policy for [Sanitization,] dated November 2022, indicated (3) All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions; (8) When cleaning fixed equipment (mixers, slicers, and other equipment that cannot readily be immersed in water), the removable parts are (a) washed and sanitized and non-removable parts were cleaned with the detergent and hot water, rinsed, air dried and sprayed with the sanitizing solution; and (b) the equipment was reassembled and any food contact surface that may have been contaminated during the process were re-sanitized.

Based on observation, interview, and record review the facility failed to equip corridors with firmly secured handrails on each side for 3 of 12 residents reviewed for physical environment. <BR/>- 3 Resident bathrooms (Resident # 49's, Resident # 45's, and Resident # 11's bathroom ) were found with loose safety handrails attached to wall. All three resident's toilet themselves.<BR/>This failure could place residents at risk for falls and injuries due to the handrails giving way when pressure was applied.<BR/>Findings Included:<BR/>In an observation on 11/28/2022at 11:00AM, 11/29/2022 at 2:00PM, 11/30/2022 at 10:04AM in Resident # 49's, Resident # 45's, Resident # 11's bathroom , the left-handed shower rail was loose with hole in the wall where handrail was connected. <BR/>In an observation on 11/28/22 revealed Resident#11 had limited range of motion to the right side of her body. <BR/>In an interview on 11/28/22 at 11:00AM Resident #11 stated she did not have use of the right side of her body but was able to toilet herself. She said she was afraid of falling because of the loose safety handrail in her bathroom. <BR/>In an interview on 11/28/22 at 11:10AM Resident #45 stated she had noticed the loose handrail when toileting herself but figured they would fix it when they could.<BR/>In an interview on 11/28/22 at 11:18AM Resident #49 stated she noticed the hand rail was loose when transferring herself to the toilet so she used the other handrail.<BR/>In an interview on 11/30/22 at 10:04 AM with MA-C she said the safety rails were loose in Resident # 49's, Resident # 45's, Resident # 11's bathrooms but had not realized they needed repair until this time. She said this could put residents at risk for falling. She said any staff that was aware of safety issues such as loose handrails should notify maintenance director to fix.<BR/>In an interview on 11/30/22 at 10:16AM with ADM-A, he said the safety rails were loose in Resident # 49's, Resident # 45's, Resident # 11's bathrooms , but was not aware of them needing repair until this time. He said this could put residents at risk for falling. He said any staff that was aware of safety issues such as loose handrails should notify maintenance director to fix.<BR/>In an interview on 11/30/22 at 10:16AM with MNT-E, he said the safety rails were loose in Resident # 49's, Resident # 45's, Resident # 11's bathrooms, and thought old assistant had repaired them already. He said this could put residents at risk for falling. He said any staff that was aware of safety issues such as loose handrails should notify maintenance director to repair immediately. <BR/>In an interview on 11/30/22 at 2:33PM with DON-B, she stated a safety handrail in the bathroom that was not secured to the wall could result in a resident falling and/or injury. She stated the maintenance director should be notified by staff when a loose handrail was noticed. She stated maintenance director should repair loose handrail immediately including any holes in the wall around the handrail. <BR/>Review of a facility's policy Maintenance Service dated 2001 and revised December 2009, reflected, The Maintenance Department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times. Functions of Maintenance personnel include, Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. Maintaining the building in good repair and free from hazards. Providing routinely scheduled maintenance service to all areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review the facility failed to ensure each resident receives adequate supervision and assistive devices for one of twenty residents (Resident #1) reviewed for accidents.<BR/>The facility failed to ensure Resident #1's coffee cup was positioned properly at the upper right of his plate which led to him knocking it over. Resident #1 sustained 2nd degree burns to his bilateral inner thighs from the hot coffee.<BR/>An IJ was identified on 01/11/2024 at 4:10 PM. While the IJ was removed on 01/12/2024, the facility remained out of compliance at a severity level of actual harm and a scope of isolated harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. <BR/>These failures placed all residents at risk for injuries, pain, and mental anguish. <BR/>Findings include: <BR/>Record review of Resident #1's face sheet dated 01/11/2024, reflected Resident #1 was a [AGE] year-old man admitted on [DATE] with diagnoses of unspecified glaucoma (build-up of fluid in the eye, which presses on the retina and optic nerve), unspecified cataract (a condition in which the lens of the eye becomes cloudy), muscle weakness (lack of physical or muscle strength), and type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye (central part of the retina, swells from the leaking fluid and causes blurred vision).<BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 09, which indicated moderate cognitive impairment. Section B (Hearing, Speech, and Vision) reflected Resident #1's vision was highly impaired. Section GG (Functional Abilities and Goals) reflected Resident #1 required setup or clean-up assistance for eating. <BR/>Record review of Resident #1's care plan dated 01/11/ 2024 reflected Resident #1 was care planned for impaired visual function related to cataracts, glaucoma, and diabetic retinopathy. Resident #1 was care planned for ADL self-care performance deficit related to confusion, impaired balance, and limited mobility with interventions of eating self-performance (limited assist) support provided (x1 assist). Resident #1 was also care planned for blisters to medial thighs bilaterally related to coffee spillage in his lap. <BR/>Record review of the facility nursing progress note dated 12/29/23 reflected, At approximately. 10:00 am the nurse was called to the dining room; the nurse notified the resident was yelling. Resident reported he had spilled coffee on himself, the nurse returned to his room to assess injury. I wasted coffee in my lap <BR/>Record review of the facility nursing progress note dated 01/02/24 reflected, Nurse practitioner there to see resident today and assess blisters to inner thighs bilaterally. New orders noted by the charged nurse and entered into the computer. Care plan updated to reflect the following: Focus: Resident #1 had blisters to medial thighs bilaterally related to coffee spillage in his lap. Goal: Resident #1's blisters would heal without complications in the next 30 days. Interventions: Administer treatment as ordered by the physician, assist Resident #1 with his coffee and provide Kennedy cup (non-spill cup) as needed while drinking his coffee, for closed blister on left inner thigh: spray with skin prep or betadine and cover with foam dressing daily, for opened blister on inner right thigh: clean with NS, apply Silvadene to red base wound, calcium alginate to the slough are and cover with foam dressing, change daily, monitor blisters to legs bilaterally for signs of infections or swelling, and notify physician with any concerns. <BR/>Record review of the facility nursing progress note dated 01/02/24 reflected, received new order for wound care to change orders for care of burns to residents bilateral thighs, New order to clean open blisters to bilateral thighs with NS/WC, pat dry, apply petrolatum gauze to wound beds, and cover with dry gauze type dressing daily and PRN. Resident advised of new orders to start 01/11/2024.<BR/>Record review of the wound care progress note dated 01/03/24 reflected, Resident #1's wound #1 status was Open. The date acquired was: 1/1/2024. The wound was classified as a Partial Thickness wound with etiology (the cause or cause of a disease) of 2nd degree Burn and was located on the right, Anterior Upper Leg. The wound measured 8cm length x 8.5cm width x 0.1cm depth; 53.407cm2 area and S.341cm3 volume. There was no tunneling or undermining noted. There was a non-present amount of drainage noted. There was no necrotic tissue within the wound bed. The periwound skin appearance did not exhibit: Callus (a region of thickened skin that develops from increased friction), Crepitus (popping, clicking or cracking sound in joints), Excoriation (health condition where you compulsively pick at your skin), Induration (thickening or hardening of soft tissues of the body), Rash (irritated or swollen skin), Scarring (the body's natural way of healing and replacing lost or damage skin), Dry/Scaly (small, hard, dry area that fall of in small pieces), Maceration (skin softening and breaking down due to prolonged contact with moisture that is usually not present on the skin), Atrophie Blanche (a chronic condition that presents as recurrent, painful, ulcers of the lower leg, ankle, or dorsal foot), Cyanosis (bluish color in the skin, lips, and nail beds caused by a shortage of oxygen in the blood), Ecchymosis (bruises), Hemosiderin Staining (areas of discolored skin that usually affect the lower leg, typically on the ankle and the top of the foot), Mottled (marked with spots of different colors), Pallor (skin paleness), Rubor (redness to skin), Erythema (skin rash). Periwound temperature was noted as No Abnormality. Wound #2 status was Open. The date acquired was: 1/1/2024. The wound was classified as a Partial Thickness wound with etiology (the cause or cause of a disease) of 2nd degree Bum and was located on the left,Medial Upper Leg. The wound measures 0.5cm length x 3cm width x 0.1cm depth; 1.178cm2 area and 0.118cm3 volume. There was no tunneling or undermining noted. There was a non-present amount of drainage noted. The wound margin was flat and intact. There was no necrotic tissue within the wound bed. The periwound skin appearance did not exhibit: Callus (a region of thickened skin that develops from increased friction), Crepitus (popping, clicking or cracking sound in joints), Excoriation (health condition where you compulsively pick at your skin), Induration (thickening or hardening of soft tissues of the body), Rash (irritated or swollen skin), Scarring (the body's natural way of healing and replacing lost or damage skin), Dry/Scaly (small, hard, dry area that fall of in small pieces), Maceration (skin softening and breaking down due to prolonged contact with moisture that is usually not present on the skin), Atrophie Blanche (a chronic condition that presents as recurrent, painful, ulcers of the lower leg, ankle, or dorsal foot), Cyanosis (bluish color in the skin, lips, and nail beds caused by a shortage of oxygen in the blood), Ecchymosis (bruises), Hemosiderin Staining (areas of discolored skin that usually affect the lower leg, typically on the ankle and the top of the foot), Mottled (marked with spots of different colors), Pallor (skin paleness), Rubor (redness to skin), Erythema (skin rash). Periwound temperature was noted as No Abnormality.<BR/>A Record Review of Coffee temp log reflected there was no documentation of coffee temperatures before January 2024. There were missing coffee temperatures for the PM shift on 01/07/24, 01/08/24, and 01/09/24. The coffee temperature log only has one AM and one PM column for documentation. <BR/>During an observation on 01/10/24 at 1:15 pm of Resident #1's injuries, it was observed Resident #1 had two bandaged areas on both his right and left inner thighs. Observation of the upper right inner thigh area was observed to be pink in color, skin missing. No observation of Resident's #1 left thigh due to Resident #1 yelling out in pain. <BR/>During an interview on 01/10/24 at 10:30am with Resident #1 stated his plate was placed in front of him and his cup of coffee placed beside the plate (right side), but near the edge of the table. Resident #1 states that his vision was impaired, and he can see objects, shadows, and movement, but not clearly. Resident #1 stated that typically his cup of coffee would have been placed near to the center of the table. Resident #1 stated that his cup was usually at the upper right of his plate with the handle turned out so that he could easily manage his grip on the cup. Resident #1 stated that while he was attempting to take a bite of his food, his hand/arm knocked over his cup of hot coffee directly into his lap. Resident #1 stated he yelled out in pain when he spilled the hot coffee. Resident #1 states that he was wearing sweatpants at the time.<BR/>During an interview on 01/10/24 at 11:45 am with the CNA, he stated that Resident #1 needs his food and drink positioned to his liking, so he doesn't knock it over. CNA stated that Resident #1 liked his coffee positioned near the center of the table so could see it. <BR/>Attempted an interview on 01/10/24 at 1:20 pm with LVN #1. No answer but voicemail was left. No return call was made from LVN #1. <BR/>During an interview on 01/10/24 at 2:45 pm with the DON, she stated she was notified of Resident #1 injuries but there was no redness or blistering at the time. Resident #1 was given a cold towel to place in his lap and the MD was notified. The DON stated LVN #1 and NA #1 gave Resident #1 a shower after the incident and no redness or blistering was observed at that time. DON stated that Resident #1 sustained 2nd degree burns to his left and right thigh because of the incident.<BR/>During an interview with Dietary Supervisor on 01/10/24 at 3:15pm, a request was made for the coffee/hot liquid temperatures for the calendar year of 2023. Dietary Supervisor stated the facility had not taken any coffee/hot liquid temps prior to January 2024.<BR/>During an interview on 01/10/24 at 4:15 pm with the ADM, he stated hot liquid temps should be taken after batch of coffee was made. The ADM stated if no temperatures are taken then there would be potential for the coffee/hot liquid to be too hot for the residents. If the coffee/hot liquid was too hot, then there would be risks for resident to sustain injuries from the coffee/hot liquid. <BR/>During an interview on 01/10/24 at 4:30 pm with the Dietary supervisor, she stated coffee was made 7 times a day. There was a coffee pot for both halls and one for the dining area. The Dietary supervisor stated that the dishwashing staff was responsible for checking the temperature of the coffee. The Dietary supervisor stated she was not aware the temperature of the coffee needed to be checked after each batch was made. <BR/>During an interview on 01/11/24 at 9:45 am with dishwashing staff #1, he stated he checked the temperature of each coffee pot before each meal. Dishwashing staff #1 stated he only checked the temperature for breakfast and before lunch. The dishwashing #1 stated he did not remember when he was in-services on hot liquids.<BR/>Attempted an interview on 01/11/24 at 10:15 am with NA #1. No answer but voicemail was left. No return call was made from NA #1.<BR/>Attempted an interview on 01/11/24 at 2:15 pm with LVN #1. No answer but voicemail was left. No return call was made from LVN #1.<BR/>Attempted an interview on 01/11/24 at 12:55 pm with NA #1. No answer but voicemail was left. No return call was made from NA #1.<BR/>Review of the facility's Safety of Hot Liquids Policy dated 2001 reflected Residents will be evaluated for safety concerns and potential of injury from hot liquids up admission, readmission and on change of condition. Appropriate precautions will be implemented to maximize choice of beverage while minimizing the potential of injury.<BR/>Policy interpretation and implementation <BR/>1. <BR/>The potential for burns from hot liquids is considered an ongoing concern among residents with weakened motor skills, balance issues, impaired cognition, and nerve or musculoskeletal condition.<BR/>2. <BR/>Residents with these or other conditions may suffer from accidental burns and related complications stemming from thinner, more fragile skin that may burn quickly and severely and take longer to heal.<BR/>3. <BR/>Residents who prefer hot beverages with meals (i.e. coffee, tea, soups, etc.) will not be restricted from these options. Instead, staff will conduct regular Hot Liquid Safety Evaluations as indicated, and document the risk factors for scalding and burns in the care plan.<BR/>4. <BR/>Once risk factors for injury from hot liquids are identified, appropriate intervention will be implemented to minimize the risk from buns, such interventions may include: <BR/>A. <BR/>Maintaining a hot liquid serving temperature of not more than 155 degrees Fahrenheit: <BR/>B. <BR/>Serving hot beverages in a cup with a lid:<BR/>C. <BR/>Encouraging residents to sit at the table while drinking or eating hot liquids:<BR/>D. <BR/>Providing protective lap coverage or clothing to protect skin from accidental spills, and <BR/>E. <BR/>Staff supervision or assistance with hot beverages.<BR/>5. <BR/>Food service staff will monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding.<BR/>This was determined to be an Immediate Jeopardy on 01/11/24 at 4:10 pm. The ADM was notified. The ADM was provided with the IJ template on 01/11/24 at 4:10 pm. <BR/>The Plan of Removal was accepted on 01/12/2024 at 10:20 AM and included the following:<BR/>All listed items will be completed by 01/12/24 with continued follow-up:<BR/>1. <BR/>On 1/11/2024, Resident #1 was assessed by the Director of Nursing/Designee to validate that the resident was not exhibiting signs or symptoms of physical or psychosocial distress related to the deficient practice and to ensure that measures were in place to minimize the risk of future burns related to hot liquids. Care Plan was reviewed to validate all current interventions in place. <BR/>On 1/11/2024 The Director of Nursing/Designee notified resident #1's responsible party and physician of the identified deficient practice. <BR/>2. <BR/>On 1/11/2024, dietary log was initiated to monitor and temp all brewed batches of coffee throughout the day. Total of 13 dietary staff, 9 of which have received education, the remaining 4 will be completed on 1/12/2024, prior to start of shift, on the process to monitor and temp all batches and requirement to be 155 degrees or less prior to making available for residents consumption.<BR/>3. <BR/>The Director of Nursing/Designee completed a sweep of all facility residents' hot liquid assessment, validated they were current and applicable for all residents on 1/11/2024. Director of nursing/designee then validated for appropriate interventions to be in place and that care plans are updated as applicable related to risk assessment. 3 residents with visual deficit/legally blind were identified including Rresident #1 All 3 identified were supplied with specialty mugs with handles, non-slip bases and lids on January 4, 2024. 4 residents identified as needing assist with all hot liquids, these care plans were updated to reflect necessary need. 5 residents identified with need to be seated at table to securely place hot liquids while drinking. Those care plans updated to reflect the need for this intervention on 1/11/2024. <BR/>4. <BR/>Director of Nursing completed education with all dietary staff on requirements to monitor and log temperature of all batches of coffee, and requirement that temperature before serving or making available to resident be 155 degrees or less<BR/>5. <BR/>The Director of Nursing/Designee provided education to all facility staff on policy for hot liquids and list of specific residents that require additional interventions for hot liquid safety. This education included the requirement to implement appropriate interventions to prevent burns for residents consuming hot liquids.<BR/>To monitor for compliance: Director of Nursing/Designee will review residents identified with safety concerns from hot liquid assessment daily x 7 days, beginning 1/12/2024, to validate all implemented interventions are in place and any newly identified residents at risk are addressed accordingly with appropriate interventions. Any identified concerns will be corrected with applicable education completed as identified, Director of Nursing/Designee will then continue to monitor daily in clinical meeting ongoing. Monitoring will continue daily in kitchen with temperature log completed on each new batch. Administrator/designee will audit logs daily Monday through Friday to validate hot liquids are temped prior to serving and will review in QAPI for compliance. Any trends or concerns were/will be addressed with the Quality Assurance Performance Committee and continue until a lessor frequency deemed appropriate through QAPI review.<BR/>Plan of Removal completion date is 01/12/2024. <BR/>Monitoring for Plan of Removal was completed on 01/12/2024 as follows:<BR/>The Director of Nursing/Designee provided education to all facility staff on policy for hot liquids and list of specific residents that require additional interventions for hot liquid safety. This education included the requirement to implement appropriate interventions to prevent burns for residents consuming hot liquids.<BR/>In an interview on 01/12/2024 at 9:05 am with Regional RN, stated Resident #1 was assessed and not exhibiting and signs or symptoms of physical or psychological distress related to recent deficient practice in regard to the coffee burn. Measure have been put in in place to prevent further coffee burns including a cup with a lid, the kitchen staff will ensure coffee remains 155 or less prior to serving coffee to the resident. Resident #1 was in a great mood. He stated, I'm getting better every day. Wounds are improving. Noted inner left thigh was healed, and 2 of the wounds to the right inner thigh are pink, and dry, without any scabs. The wound to the top of the right thigh was approximately 1cm x 1cm, skin pink, blister has popped and without any signs of infection. Resident #1 stated, it does itch a bit. Resident #1 denies any pain. Family and physician were notified of the deficient practice. The physician agrees with current wound care orders and interventions. Regional RN also stated that the facility identified Resident #1, Resident #2, and Resident #3 will use a Kennedy cup (non-spill cup). Resident #4, Resident #5, Resident #6, and Resident #7 will need physical assistance at the table during meals. Resident #8 Resident #9 Resident #10, and Resident #11 will need to be sitting at a table when receiving hot liquids. <BR/>During interviews on 01/12/24 from 9:50 am - 10:45 am with six dietary staff members (1 dietary supervisor, 3 dietary aides and 2 dietary cooks), who were able to articulate information from the hot liquid in-service.<BR/>Observation on 01/12/2024 at 9:30am, Kennedy cups for Resident #1, Resident #2, and Resident #3. Each cup had the resident's name on it. <BR/>Record review on 01/12/2024 at 9:45am, reflected a new hot liquid temperature sheet with columns for documentation for date, time, batch, temp, staff name, and correction/retemp. <BR/>Record review of the facility's Procedure for monitoring temperature of Coffee<BR/>1. <BR/>All batches of coffee to have temperature taken prior to being allowed for resident consumption.<BR/>2. <BR/>Log each temperature, date/time, batch number, your initials, and time temperature taken.<BR/>3. <BR/>If temperature too high - above 135 degrees, correction taken and what temperature was on recheck.<BR/>An IJ was identified on 01/11/2024. The IJ template was provided to the facility on [DATE] at 4:10 PM. While the IJ was removed on 01/12/2024, the facility remained out of compliance at a severity level of actual harm and a scope of isolated harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.