AVALON PLACE KIRBYVILLE

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for 1 of 7 residents (Resident #50) reviewed for resident abuse. The facility failed to ensure Resident #50's was free from physical abuse when Resident #3 pushed a rolling bedside table into his roommate Resident #50 causing a skin tear and Resident #50 to fall to the ground on 03/25/25. This failure could place residents at risk of physical harm, mental anguish, or emotional distress.The findings include: 1. Record review of Resident #3's face sheet dated 09/09/25 indicated he was a [AGE] year-old-male admitted on [DATE] and readmitted [DATE] with diagnoses of Alzheimer's disease (progressive brain disorder that causes a gradual and irreversible loss of memory, thinking skills and the ability to carry out daily activities), dementia with psychotic disturbance (involves symptoms like hallucinations (seeing hearing or smelling things that are not there) delusion (false, fixed beliefs) such as paranoia) and anxiety disorder (a mental health condition characterized by excessive worry, fear or apprehension that is difficult to control and interferes with daily life). Record review of a skin assessment dated [DATE] for Resident #50 indicated he received a skin tear to his left forearm 8 cm x 5.1 cm in size. Record review of Resident #3's Annual MDS assessment dated [DATE] indicated he had a BIMS of 3 which indicated he was severely impaired of cognition. The assessment indicated Resident #3 behaviors present including inattention that comes and goes, disorganized thinking continuously. The assessment indicated Resident #3 had diagnoses of Alzheimer's disease and dementia with psychotic disturbance and received an antianxiety medication received during the last 7 days. Record review of Resident #3's Care plan updated 08/27/25 indicated he was at risk for delirium and confusion episodes related to Alzheimer's disease and dementia and had a behavior problem on 03/20/25 Resident #3 pushed a bedside table into another male resident causing Resident #50 to fall to the floor. The care plan did not indicate any other behavior problems. Record review of Resident #3's SBAR (a standard communication tool to communicate a resident's status) dated 03/20/25 indicated a behavior change of Resident #3 told his roommate to get out of their room, then pushed resident with a bedside table knocking Resident #50 to the floor. The SBAR indicated orders received to send Resident #3 to in patient hospice. Record review of Resident #3's nursing note dated 03/20/25 indicated a resident-to-resident behavior observed. Resident #3 pushed a bedside table into Resident #50 knocking him down. Resident #3 was redirected away from the area, placed on one-on-one supervision. The nurse's note indicated that Resident #3 stated his roommate stole his belongings. Record review of Q 15 Minute Monitoring dated 03/20/25 indicated Resident #3 was monitored one on one and every 15 minutes documentation until discharged to inpatient hospital. During an observation and interview on 09/08/25 at 12:30 p.m. Resident #3 was sitting in a chair and said he was treated well and denied any residents were rough, hit or pushed him. Resident #3 denied he pushed or hit Resident #50 with a bedside table or any other resident. 2. Record review of Resident #50's face sheet dated 09/09/25 indicated he was a [AGE] year-old-male admitted on [DATE] and readmitted [DATE] with diagnoses of Alzheimer's disease, dementia with psychotic disturbance, hallucinations and anxiety disorder. Record review of Resident #50's quarterly MDS assessment dated [DATE] indicated he had a BIMS of 3 which indicated that he was severely impaired of cognition. The assessment indicated Resident #50 diagnoses of Alzheimer's disease and received an antidepressant and antipsychotic medication received during the last 7 days. Record review of Resident #50's Care plan updated 09/08/25 indicated he had impaired cognition, refused care and had a communication problem, and had difficulty understanding some verbal content related to Alzheimer's disease and dementia. The care plan indicated Resident #50 had a fall on 03/20/25, he was knocked down by a bedside table pushed into him by his roommate. The care plan did not indicate any other behavior problems. Record review of Resident #50's nursing note dated 03/20/25 indicated Resident #50 received a skin tear to left upper arm. During an observation and interview on 09/08/25 at 12:20 pm, Resident #50 was sitting in a chair and denied any residents were rough, hit or pushed him. Resident #3 denied he pushed or hit Resident #50 with a bedside table or anything. Record review of the investigation worksheet for Resident #3's dated 03/20/25 indicated the allegation was made on 03/20/25 at 3:00 p.m. and was reported to state on 03/20/25 at 4:32 p.m. Record review of Resident #3's Provider Investigation Report dated 03/20/25 indicated a resident-to-resident altercation in which Resident #3 pushed a bedside table into Resident #50 causing a skin tear and Resident #50 to fall to the floor. The findings indicated inconclusive for the allegation of abuse. Investigation Summary indicated the intent of Resident #3 was not to hurt Resident #50 by pushing the table out of the way, but pushing the table caused Resident #50 to fall and resulted in a skin tear. Resident #3 was monitored one on one with documentation every 15 minutes until discharged from the facility to inpatient hospice. During an interview on 09/08/25 at 11:45 a.m., LVN A said she was providing care for Resident #3 and #50 today and she witnessed the incident between the residents on 03/20/25. She said on 03/20/35 she was sitting in the nurse's office looking at them. LVN A said Resident #50 was inside the room in her view with a rolling bedside table in front of him and Resident #3 was standing in front of him just talking. She said there was no yelling, arguing or aggression. She said there was no indication anything was wrong. LVN A said Resident #3 told Resident #50 he was looking for his suitcase, I know you took it and pushed the rolling bedside table into Resident #50 causing a skin tear and fall. She said there were no previous or prior incidents. LVN A said she immediately separated them, Resident #3 was immediately placed on one-on-one monitoring with documentation of every 15 minutes but watched constantly. LVN A said she provided wound care to Resident #50 and had him x-rayed with results of no fractures. She said Resident #3 was sent to the behavior hospital the next morning. LVN A said she was educated on abuse and neglect and notified the Administrator immediately. During an interview on 09/10/25 at 10:30 a.m., the DON said her expectation was all residents be free from abuse and neglect. She said all staff had been educated frequently on abuse and neglect and elopement prevention. She said related to the incident with Resident #3 and #50 there was no sign of a problem, no urinary tract infection or lab problems, or no new medication that could have caused behaviors. She said the residents had no prior signs or symptoms that would lead us to suspect an incident and no triggers or suspected behavior that could lead up to an incident. The DON said there was no way we could have predicted an incident would happen between these roommates. She said we addressed the situation, removed Resident #3 and monitored him one on one until he was sent to the hospital. The DON said when Resident #3 returned to the facility he had a different roommate. She said Residents #3 and #50 have not had any incidents since. During an interview on 09/10/25 at 10:45 a.m., the Administrator said her expectation was all residents be free from abuse and neglect and stay safe and secure in the facility. She said all staff were educated frequently on abuse and neglect. She said the incident with Resident #3 and #50 was unable to be predicted. She said there no signs of a problem; the residents had no prior incidents or behaviors. She said there have been no incidents since and the residents were no longer roommates. The Administrator said the residents were immediately separated; Resident #3 was placed on one-on-one monitoring until sent to the hospital and Resident #50 was assessed and x-rayed with no fracture. She said the facility investigated the incident, in-serviced staff, interviewed staff and residents and notifications as required. The Administrator said there was nothing to predict an incident would happen. Record review of and undated facility policy titled, Abuse/ Neglect indicated, The resident has the right to be free from abuse, neglect, . Residents should not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, . 5. Physical Abuse: Includes, hitting, slapping.Resident to Resident The above policy will apply to potential resident-to-resident abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 7 residents (Resident #101) reviewed for accidents and supervision. The facility failed to provide adequate supervision for Resident #101 on 05/12/25 when the resident was removed from the secured unit and brought out to the main dining room for an activity. The resident exited the facility through a door that did not alarm and without staff knowledge and was found walking outside the back of the facility walking down a sidewalk. The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 05/12/2025 and ended on 05/12/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving appropriate supervision and interventions which could lead to residents sustaining serious injury or harm. Findings include: Record review of a face sheet dated 09/09/25 indicated Resident #101 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included catatonic schizophrenia (severe mental condition combined with pronounced psychomotor disturbances) dementia (loss of cognitive functioning), chronic obstructive pulmonary disease (lung disease that causes difficulty breathing by blocking airflow from the lungs), hemiplegia (paralysis of one side of the body associated with varying degrees of abnormal muscle tone, impaired sensation, visual impairment and loss of movement control on the affected side) and anxiety (persistent and excessive worry that interferes with daily activities). Record review of a quarterly MDS, dated [DATE], indicated Resident #101 had a BIMS score of 3 indicated severely impaired cognition and cognitive patterns of inattention and disorganized thinking continuously. Diagnoses were dementia, schizophrenia, anxiety, and chronic obstructive pulmonary disease. The assessment indicated Resident #101 wandered 1 to 3 days of the look back period and was independent of sitting to stand and walking 150 feet in a corridor or similar space. Record review of Resident #101's care plan, with a target date of 12/04/25, indicated Resident #101 was at risk for wandering related to impaired safety awareness and required secure unit placement due to being a wander threat, elopement risk, disorientation and impaired safety awareness. The care plan indicated Resident #101 had an actual elopement attempt; he wandered outside the facility unattended initiated on 05/12/25. Resident #101's care plan interventions included resident will reside in the secure unit. Record review of Resident #101's Elopement Risk assessment dated [DATE], indicated Resident #101 was a high elopement risk and resided on a secure unit. Record review of a progress note dated 05/12/25, LVN G indicated it was reported to the DON that Resident #101 was brought off the secured unit to attend a facility activity in the dining room and when staff were returning residents to the unit Resident #101 was not readily available. The progress note indicated staff immediately made a thorough search of the facility and surrounding premises and noted Resident #101 walking along the sidewalk. Resident was returned to the secure unit with no injury or pain noted. The progress note indicated a family member and physician were notified Resident #101 had wandered outside unsupervised. Record review of an Event Nurses' Note Elope or Attempt dated 05/12/25 indicated Resident #101 was brought off the secured unit to attend a facility activity in the dining room and when staff was returning residents to the secured unit, Resident #101 was not readily available. The note indicated staff immediately made a thorough search of the facility and surrounding premises and noted the resident outside the facility walking along the sidewalk. Resident was returned to the secured unit. The note indicated he exited the left side dining room door, was missing less than 5 minutes, and was discovered on the sidewalk at the left side rear of the building. The note indicated Resident #101 was cognitively impaired, wandered, and required cueing and acquired no injury. Record review of the investigation worksheet for Resident #101's dated 05/12/25 indicated the allegation was made on 05/12/25 at 3:00 p.m. and was reported to state on 05/12/25 at 5:14 p.m. Record review of Resident #101's Provider Investigation Report dated 05/12/25 indicated the nursing facility was hosting a carnival in the dining room. Several residents from the Secured unit were brought out to enjoy the festivities. Resident #101 was sitting on the left side of the dining room with several residents from the secure unit. Resident #101 was not at the table. The facility began a search and called code orange. The DON located Resident #101 as he was walking on the sidewalk. She asked why he was outside and his response was not clear, but the DON walked Resident #101 back inside with no hesitation. Resident #101 was assessed with no injury or pain. The investigation summary indicated Resident #101 was outside for 1-2 minutes at most. Resident 101 was returned to the Secured unit and not noted exit seeking. The facilities findings were inconclusive. Staff were in-serviced on Elopement prevention, Elopement prevention of secured unit resident attending activities away from the secured unit, Resident Rights, Abuse/ Neglect, color code system, no alarms are to be turned off and no doors propped open, demonstration for operation of doors in dining room and secured unit. The facility performed environmental rounds, reviewed Resident #101's care plan and MDS. The facility notified the family, physician, ombudsman and HHSC. A new mag-lock keypad alarm system was installed on exit door on left side of dining room and the Incident was presented during QAPI. Record review of Resident #101's Elopement Risk assessment dated [DATE], indicated Resident #101 was a high elopement risk, resided on a secure unit and had an elopement attempt. During an interview on 09/08/25 at 11:55 a.m., CNA L said on 05/12/25 CNA Y took Resident #101 out to the carnival and left him with a nurse. She said she was unsure which nurse. She said she was taking her dirty laundry barrel out to the end of Hall 200 to laundry and as she passed the dining room, she saw Resident #101 sitting at the table in front of the window in the dining room about 8 to 10 steps from the door to exit the dining area to the outside of building. CNA L said she took her barrel to the laundry at the end of Hall 200 when she came back, Resident #101 was not sitting in his chair and she asked the DON where Resident #101 was. She said she notified the Administrator who called for a Code Orange and she went down Hall 200 and exited to the left. CNA L said Resident #101 was brought back to the secured unit and started on q 15-minute checks for a few days. She said Resident #101 wandered but did not push on the doors. CNA L said the secured unit residents now attend activities on the unit only. During an Interview on 09/08/25 at 1:55 p.m., the AD said it was nursing home week, and the facility was having a carnival in the dining room on 05/12/25. She said she and the ADON went to the secured unit and chose 3 appropriate residents from the unit to enjoy the carnival. She said she was taking pictures of residents when she saw CNA Y bring Resident #101 into the carnival. The AD said she assisted the 3 residents from the secured unit playing games and did not see Resident #101 exit the facility. She said the last time she saw Resident #101 CNA Y was with him. The AD said when she was returning the 3 residents from the secured unit back to the unit, she asked CNA Y if Resident #101 was back there, and CNA Y said she had left him at the carnival. The AD said she immediately notified the Administrator to call a Code Orange, but the DON had already found and returned him into the building. The AD said CNA Y did not ask her to monitor Resident #101 before she left him. The AD said the residents on the secured unit were now enjoying on the unit activities at this time. She said after the incident, she was educated on abuse/ neglect, resident rights, and elopement prevention. She said she was educated on removing secured unit resident off the secured unit to include notifying the charge nurse when staff removed the resident from the unit, stay with them the whole time, and notifying the charge nurse when the resident was returned to the unit. The AD said if a resident eloped, she would notify the charge nurse, the DON, the Administrator and whole team, a Code Orange would be announced, and everyone would start looking for the missing resident inside and outside. The AD said she would start looking where the resident was last seen and spread out including resident rooms, closets, bathrooms in every room, the kitchen, and outside of the facility. During an interview on 9/8/25 at 3:50 p.m., CNA Y said she was educated on abuse/ neglect, resident rights and elopement prevention on hire. She said after the incident she was educated if a resident eloped, she would notify the charge nurse, a Code Orange would be called, and everyone would start looking for the resident inside and outside of the facility. She said she had been there 2 weeks when the incident with Resident #101 happened. She said a carnival was going on in the main dining room off the secured unit and some staff had come to the unit and asked if any residents wanted to go to the carnival. CNA Y said Resident #101 wanted to go, so she told LVN G on the secured unit at the time and she said to take him to the carnival, but she would have to come back to the unit. She said she and Resident #101 stayed in the main dining room for about 15 to 20 minutes and she handed him over to the ADON. CNA Y said, I asked the ADON do you have him I have to go back to the Unit. I had to say do you have him twice before she agreed. She said the ADON took a picture of Resident #101 and then CNA Y said she left Resident #101 sitting at a table by himself. She said after she returned to the secured unit, within a few minutes, she heard a Code Orange called. CNA Y said she believed the alarm was disabled on the door to exit the dining room and Resident #101 walked out the door and was found on the driveway behind the building. CNA Y said she verified with the ADON twice before she left Resident #101. She said when she left the carnival area, the ADON was taking Resident #101 to get popcorn. During an Interview on 09/08/25 at 3:40 p.m. the ADON said it was nursing home week and on 05/12/25, the facility was having a carnival in the main dining room. She said she and the AD went to the secured unit and chose 3 appropriate residents to come off the unit to enjoy the carnival. She said she noticed Resident #101 was in the dining room with CNA Y who was a new CNA to the facility. She said during the event she gave Resident #101 some popcorn while he was at the table at the corner of the main dining room with CNA Y with him. The ADON said when the residents from the secured unit were being taken back to the secured unit, she noticed Resident #101 was not there. The ADON said a Code Orange was called, and Resident #101 was found outside the back of the building. She said she was aware CNA Y said she left Resident #101 with her but she said she did not accept supervision of Resident #101 from CNA Y; she already was monitoring 3 residents from the secured unit that were chosen due to appropriateness to be removed from the secured unit. She said CNA Y did not ask her to monitor Resident #101. The ADON said the DON found Resident #101 and returned him to the unit, but she was not sure how long he was missing. She said the secured unit residents were now only attending activities on the secure unit and not leaving the unit for activities at this time. She was educated on abuse/ neglect, resident rights, elopement prevention, the procedures for removing residents from the secured unit, and on demonstration of operating the doors of secured unit and dining room exit doors, to remain locked and alarmed at all times. She said if a resident eloped, she would notify the charge nurse, the DON, the Administrator, a code orange would be announced, and everyone would start looking for the missing resident inside and outside of the facility. During an Interview on 09/08/25 at 3:35 p.m., the Maintenance Director said on 05/12/25 he was outside of the facility right outside Hall 100 talking to a painter and heard the DON outside. He said he then saw Resident #101 walking down the sidewalk behind the facility at the side of the building and the DON met Resident #101 and walked him back into the facility. He said before and after the incident he was educated on abuse/neglect, resident rights, and elopement prevention. During an interview on 09/08/25 at 5:25 p.m., the DON said she was down Hall 100 and ran out hall 100 exit door and toward the back of the building, she reached the driveway in the back of the building, she could see Resident #101 on the sidewalk and called for the Maintenance Director to get to him. She said the Maintenance Director was standing at the end of Hall 100. She said she ran past the Maintenance Director and met Resident #101 and walked him around the building and entered through the end of Hall 100. The DON said Resident #101 was outside the back of the building about 45 steps from the external exit door of kitchen. She said he walked out the door by the left side of the kitchen. She said a new keypad was installed on 05/12/25 to the dining room and new alarms on both exit doors. The DON said she sat in the kitchen all day on 05/12/25 with her laptop monitoring the exit doors to the dining room until the lock was installed and both door alarms were functioning. The DON said the facility had only on the secured unit activities at this time. She said she in-served staff on elopement prevention and resident rights before and after the incident. She said she in-serviced staff on doors not to be propped open and no alarms to be turned off after the incident. The DON said CNA Y did not come back to the facility after the incident and self-termed. The DON said she was unable to do a one-on-one training with CNA Y. The DON said she in-serviced all staff including ADON on the process of bringing residents off the secured unit, if they remove a resident from the unit they notify the charge nurse before and when they return the resident to the secured unit and to stay with the resident at all times when the resident was off the secured unit. During an interview on 09/08/25 at 3:45 p.m., HR said CNA Y no longer worked at the facility and she self-terminated after the incident on 05/12/25. During an interview on 09/08/25 at 5:00 p.m., the Administrator said on 05/12/25, she was notified Resident #101 was missing and she called a Code Orange. She said the DON ran down Hall 100 and out of Hall 100's exit door toward the back of the building and found Resident #101 on the sidewalk about 45 steps from the door by the kitchen at the back of the building. She said they determined the left side dining room exit door did not alarm when Resident #101 went out of it while at the carnival. She said the resident was found within 1 to 3 minutes and was about 20 feet from the Maintenance Director and a painter who were looking at the building roof. The Administrator said after the incident, they installed a new keypad on the left door to the dining room and new alarms on 05/12/25. She said the facility would do activities directly on the unit with residents who resided on the secured unit. The Administrator said the facility in-served staff on elopement prevention, alarms, doors not to be propped open, resident rights, no alarms to were to be turned off and if they removed a resident from the unit, they were to notify the charge nurse before and upon returning the resident to the unit. While off the unit, staff were instructed to stay with the resident at all times. She said she thought the alarm had malfunctioned. During an observation and interview on 09/08/25 at 12:05 p.m., Resident #101 was in his room on the secured unit lying in bed. He was confused and only able to answer simple questions. Resident #101 said he did not remember going outside on carnival day. During an observation on 09/08/25 at 3:15 p.m., with the Administrator the dining room exit doors were tested. The left side of the dining room exit to the outside door was pressed on the door and held for 15 seconds, the door immediately alarmed and released to open at 15 seconds. The right side of the dining room exit door to the outside of the facility opened with a loud alarm after pushing on the door. During an observation on 09/09/25 at 2:00 p.m., residents in the main area were participating in BINGO. There were no residents from the secured unit participating in BINGO off the secured unit. During an observation on 09/09/25 at 3:45 p.m., the left side of the dining room exit door to the outside was pressed and held for 15 seconds, and the door immediately alarmed and released to open at 15 seconds. The right side of the dining room exit door to the outside opened with a loud alarm on pushing door. During an observation on 09/10/25 at 8:00 a.m., the left side of the dining room exit door to the outside was pressed and held for 15 seconds, the door immediately alarmed and released to open at 15 seconds. The right side of the dining room exit door to the outside opened with a loud alarm on pushing door. During an Interview on 9/10/25 at 8:30 a.m., LVN G said on 05/12/25 she was the charge nurse responsible for the secured unit the day Resident #101 got out. She said CNA Y, a new CNA, took Resident #101 to an activity off the unit. She said she was unaware Resident #101 had left the unit until the facility staff started looking for him, but he was found within minutes. She said a Code Orange was called. LVN G said she was educated on abuse/ neglect, resident rights, elopement prevention and removing secured unit resident off the secured unit before and after the incident. During an interview on 09/10/25 at 10:30 a.m., the DON said her expectation was all residents be free from abuse/ neglect and stay safe and secure in the facility. She said all staff have been educated frequently on abuse/ neglect and elopement prevention. She said they now re-educate monthly on abuse/ neglect and elopement prevention. During an interview on 09/10/25 at 10:45 a.m., the Administrator said her expectation was all residents be free from abuse/ neglect and stay safe and secure in the facility. She said all staff have been educated frequently on abuse/ neglect and elopement prevention. Record review of an undated facility policy, titled Elopement Prevention indicated, .Every effort will be made to prevent elopement episodes while maintaining the lease restrictive environment for residents who are at risk for elopement. 1. The Elopement Risk Assessment will be completed upon admission. The resident's care plan will be modified to indicate that the resident is at risk of elopement episodes.7. If a resident is discovered to be missing, a search shall begin immediately. Intervention Strategies .keypad exit magnetic locks, Keyed Alarms, Secured Unit.Staff will receive training during their orientation process and then annually regarding Elopement prevention. During interviews on 09/08/25 from 11:30 a.m. - 09/09/25 at 4:00 p.m., 7 LVNs (4 days and 3 from nights shift- LVN A, LVN B, LVN C, LVN D, LVN E, LVN F, LVN G), 2 RNS, RN H and RN J were educated on abuse/neglect, resident rights, elopement prevention, removing secured unit residents off the secured unit, and demonstration of operating the doors. They said if a resident eloped, they would notify the charge nurse, DON, Administrator, a code orange would be announced, and everyone would immediately start looking for the missing resident inside and outside the facility. They said during the search all resident rooms, closets, bathrooms and all other rooms were searched, including outside the facility. They said the responsible party, physician, ombudsman and HHSC were notified. If the resident was not found the police would be notified. During interviews on 09/08/25 from 11:30 a.m. - 09/09/25 at 4:00 p.m., 16 CNAs (from each shift- CNA K, CNA L, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, CNA T, CNA U, CNAV, CNA X, CNA Z, CNA HH) were educated on abuse/ neglect, resident rights, elopement prevention, removing secured unit residents off the secured unit, and demonstration of operating the doors. They said if a resident eloped, they would notify the charge nurse, DON and Administrator and a code orange would be announced. They said everyone would immediately start looking for the missing resident inside and outside the facility. They said all resident rooms, closets, bathrooms and all other rooms were searched. They said outside area around the facility would also be searched. During interviews on 09/08/25 from 11:30 a.m. - 09/09/25 at 4:00 p.m., HR, DM, [NAME] AA, Dietary Aid BB, Dietary aid GG, Maintenance director, Laundry CC, HK Supervisor, HK DD, HK DD, HK EE, Floor Tech FF were educated on abuse/ neglect, resident rights, elopement prevention, removing a secured unit resident off the secured unit, and demonstration of operating the doors. They said if a resident eloped, they would notify the charge nurse, DON and Administrator and a code orange would be announced. They said everyone would immediately start looking for the missing resident both inside and outside the facility. They said the search would include all resident rooms, closets, bathrooms and all other rooms were searched. They said the outside the facility would also be searched. Record review of an in-service sign in sheet titled, No Alarms are to be turned off and no doors are to be Propped Open dated 05/12/25 for department Maintenance indicated 1 staff member Maintenance Director signature. Record review of in-service sign in sheet titled, Demonstration for operating the door(s) in the dining room dated 05/12/25, indicated 54 staff members signed the in-service record which included AD, LVN D, CNA W, LVN G, CNA L, ADON, CNA Y CNA X, CNA Z, HK DD, Laundry CC, Rehab Director, RN H, CNA R, CNA N, CNA HH, DM, CNA M, RN J, LVN A, and CNA S. Record review of in-service sign in sheet titled, Demonstration for operating the door(s) on the secure unit dated 05/12/25, indicated 54 staff members signed the in-service record which included AD, LVN D, CNA W, LVN G, CNA L, ADON, CNA Y CNA X, CNA Z, HK DD, Laundry CC, Rehab Director, RN H, CNA R, CNA N, CNA HH, DM, CNA M, RN J, LVN A, and CNA S. Record review of in-service sign in sheet for policy on Color code program dated 05/12/25, indicated it was important to know the color code when an emergency happened, and code orange indicated a resident elopement. 54 staff members signed the in-service record which included AD, LVN D, CNA W, LVN G, CNA L, ADON, CNA Y CNA X, CNA Z, HK DD, Laundry CC, Rehab director, RN H, CNA R, CNA N, CNA HH, DM, CNA M, RN J, LVN A, and CNA S. Record review of in-service sign in sheet for new policy on Elopement Prevention (Secured Unit Residents attending Activities away from the Secured Unit), dated 05/12/25, indicated 54 staff members signed the in-service record which included AD, LVN D, CNA W, LVN G, CNA L, ADON, CNA Y CNA X, CNA Z, HK DD, Laundry CC, Rehab Director, RN H, CNA R, CNA N, CNA HH, DM, CNA M, RN J, LVN A, and CNA S. Record review of an AD Hoc QAPI Contributors form, dated 05/12/25, indicated there was a meeting held on 09/15/25 consisting of the Administrator, the assistant Administrator, the DON, the ADON, the AD, Laundry Worker CC, Rehab Director and BOM. The following interventions were put in place: New Policy: Elopement Response. The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 05/12/2025 and ended on 05/12/2025. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 4 resident personal refrigerators reviewed for food safety (Resident #46). The facility failed to ensure the refrigerator for Resident #46 did not contain a greenish/black substance in the freezer section. This failure could place residents at risk for food borne illnesses.Findings included: Record review of Resident #46's face sheet, dated 12/03/25, reflected he was an [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included Parkinson's disease (a progressive neurodegenerative disorder that primarily affects movement due to the loss of dopamine-producing brain cells, leading to symptoms like tremors, stiffness, and balance problems), and type 2 diabetes mellitus (a chronic condition where the body doesn't use insulin properly, leading to high blood sugar levels). Record review of Resident #46's quarterly MDS assessment, dated 09/04/25, reflected he had a BIMS score of 6, which indicated severe cognitive impairment. During an observation and interview on 12/01/25 at 08:45AM, Resident #46 was lying in bed in his room. He gave this surveyor permission to check his refrigerator and there was a greenish/black substance in the freezer section. The Administrator came into the room and said she would have someone clean the refrigerator. During an interview on 12/03/2025 at 9:49 AM, the ADON said her expectation for the fridges was that family were to maintain and clean the fridges. She said she also expected the housekeeping staff to check the fridges with temperature checks. She said the risk was there could be contamination that could make a resident sick. During an interview on 12/03/25 at 12:06PM, the DON said the resident and responsible party were responsible for cleaning the refrigerator. She said in absence of the responsible party and resident then the housekeeper should clean it. She said the food can develop bacteria and potentially make a resident sick. During an interview on 12/03/25 at 12:08PM, the Administrator said the resident and responsible party were responsible for cleaning the refrigerator. She said if they needed help then they can ask staff for help. Record review of the facility's policy, Personal Refrigerators Policy, dated 2022, stated: .The care and maintenance of any refrigerator is the responsibility of the resident and/or responsible party. It is also the responsibility of the resident and/or resident representative to properly store non-facility supplied foods that require refrigerator in their personal refrigerator. If food is expired or appears spoiled or moldy, the facility reserves the right to discard it. Housekeeping can assist the resident and/or family member by inspecting the refrigerators at least weekly and assist with removal of outdated food items and cleanliness. Care and MaintenanceThe resident and/or resident representative should clean and maintain the refrigerators according to the manufacturer's user manual. If needed you can ask facility housekeeping or maintenance staff for assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the right to formulate an advance directive was provided for 1 of 4 residents reviewed for advanced directives. (Resident #7).<BR/>- The facility did not have a valid OOH-DNR for Resident #7.<BR/>This failure could place residents at risk of lifesaving procedures performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state. <BR/>Findings included:<BR/>1. Record review of a face sheet dated 05/10/23 indicated Resident #7 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included high blood pressure, progressive disease that destroys memory and other important mental functions, and loss of cognitive functioning. She was designated as DNR.<BR/>Record review of the current MDS dated [DATE] indicated Resident #23 was alert to person, place, and time with a BIMS of 99 indicating she was unable to complete the interview. <BR/>Record review of physician orders for May 2023 indicated Resident #23 had an order dated 09/20/22 for DNR.<BR/>Record review of the EMR for Resident #7 indicated a scanned OOH-DNR with physician signature dated 04/01/13 indicated the following:<BR/>-Section B had nothing marked as to who the declarant was signing the OOH-DNR for the resident,<BR/>-Section B had nothing marked as to why they are implementing the OOH-DNR,<BR/>-Section B had no printed name of the Declarant signing the OOH-DNR and no date when they signed it,<BR/>-#3 Witness Section had no date when it was signed by and no printed name for the 1st witness signature, and <BR/>-#3 Witness Section had no date when it was signed by the 2nd witness signature.<BR/>During an interview on 08/22/23 at 02:08 p.m. the DON said the OOH-DNR was incomplete like it was. She said the resident would be a full code because the OOH-DNR was null and void. She said it was hers and nursing responsibility to ensure the OOH-DNR was complete and accurate to be valid. <BR/>Record review of the Out-of-Hospital Do-Not-Resuscitate Order nstructions for Issuing An OOH-DNR <BR/>Implementation: The OOH-DNR Order may be executed as follows:<BR/>Section B - If an adult person is incompetent or otherwise mentally or physically incapable of communication and has either a legal guardian, agent in a medical power of attorney, managing conservator, or a qualified relative, the guardian, agent, a qualified relative, or parent of a minor child may execute the OOH-DNR Order by signing and dating it in Section B .<BR/>In addition, the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in section B.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure individuals identified with MI, DD or ID were evaluated for 1 of 6 residents reviewed for PASRR (Resident #3) <BR/>The facility did not have an accurate PASRR level 1 screening for Resident #3. <BR/>This failure could place residents who have a diagnosis of mental disorder, developmental disability or intellectual disability at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. <BR/>Findings included: <BR/>Record review of a face sheet dated 08/21/23 indicated Resident #3 admitted [DATE], and readmitted [DATE] was an [AGE] year-old female, with diagnoses of major depressive disorder (mental disorder characterized by persistent hopelessness, disinterest in and lack of enjoyment of normal activities, and prolonged sadness that affects people on a daily basis and can be recurring) and anxiety (intense, excessive, and persistent worry and fear about everyday situations) <BR/>Record review of PASRR level 1 screening completed by the transferring facility dated 05/15/22 indicated Resident #3 was negative for mental illness, intellectual disability, and developmental disability. No PASRR Level II (PE) Screening or form 1012 (Mental Illness/Dementia Resident Review) was found in the clinical record from 05/18/22 through 8/21/23. <BR/>Record review of an annual MDS dated [DATE] indicated Resident #3 had a BIMS score of 11 indicating she had moderately impaired cognition, was negative for PASRR, and had a diagnosis of depression and received medication for depression 7 of 7 days. <BR/>Record review of a care plan revised 03/21/23 indicated Resident #3 was currently taking psychotropic medication for depression and anxiety and required monitoring for side effects, behaviors, and mood problems. <BR/>Record Review of physician orders dated August 2023 indicated Resident #3 had a diagnosis of major depressive disorder. The orders indicated Resident #3 was prescribed Remeron (an antidepressant medication) 15 mg daily for major depressive disorder with a start date of 02/26/23; sertraline (a medication to treat depression and anxiety) 100 mg at bedtime for depression related to major depressive disorder with a start dated of 02/26/22; and buspirone (an antianxiety medication) 10 mg three times a day for anxiety with a start date of 07/18/23. <BR/>During an interview on 08/21/23 at 2:06 p.m., the MDS nurse said she was responsible for PASRR forms. She said when the facility had a social worker the social worker would help with PL1s. She said no one double checked the PASRR forms. The MDS nurse said she received education on PASRR including webinars and training with the most recent training in May or June 2023. The MDS nurse said Resident #3's PL1 was negative and should have been corrected. She said it was missed. The MDS nurse said she reviewed the residents' admission documentation and diagnoses to ensure the PL1s were correct. She said the risk of an incorrect PL1 was a resident may not receive needed services. <BR/>During an interview on 08/21/23 at 2:12 p.m., the DON said Resident #3's PL1 was negative and should have been positive. She said it was just missed. The DON said the MDS nurse was responsible for PASRR forms. She said the MDS nurse was educated on completing PASRR forms. The DON said her expectation was PASRR form be completed correctly and timely. She said the risk of an incorrect PL1 was a resident could miss needed services. <BR/>During an interview on 08/22/23 at 12:14 p.m., Corporate Nurse F said the facility did not have a policy on PASRR, they followed best practice and the RAI. <BR/>During an interview on 08/22/23 at 2:30 p.m., the administrator said the MDS nurse was responsible for making sure the PL1 was correct and uploaded into the system. She said her expectation was for all residents to receive the required services. She said Resident #3's PL1 was just missed. The administrator said she expected PASRR forms to be completed timely and correctly. She said the potential risk was a resident might not receive services they deserved. <BR/>Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual titled, A1500: Preadmission Screening and Resident Review (PASRR) Item Rationale Health-related Quality of Life indicated . o All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions o Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 4 errors out of 30 opportunities, resulting in an 13.33% percent medication error involving 2 of 4 residents reviewed for medication pass. (Residents #43 and #18)<BR/>-LVN B failed to administer 2 scheduled medications (Metoprolol and Spironolactone) and 1 prn medication (clonidine) (all to treat high blood pressure) as ordered by the physician for Resident #43 <BR/>-LVN C did not administer 1 scheduled medication (ascorbic acid 500mg) (used to treat wound healing) as ordered by the physician for Resident #18. <BR/>This failure could place residents at risk for inaccurate drug administration resulting in decline in health and decreased quality of life.<BR/>Findings included:<BR/>1. Record review of the face sheet dated indicated Resident #43 was a [AGE] year-old male admitted on [DATE]. His diagnoses included cerebral infarction (disrupted blood flow to the brain (stroke)), hypertension (elevated/high blood pressure), diabetes mellitus type 2 (chronic condition that affects the way the body processes blood sugar), convulsions (burst of uncontrolled electrical activity between brain cells), and atrial fibrillation (a type of irregular heartbeat). <BR/>Record review of an MDS dated [DATE] indicated Resident #43 had moderately impaired cognition with a BIMS score of 08 out of 15 and had diagnoses of hypertension and stroke. <BR/>Record review of a care plan reviewed on 04/29/23 indicated Resident #43 was at risk for complications related to hypertension and included interventions of give medications as ordered and monitor/document/report prn any headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, or difficulty breathing (signs/symptoms of elevated blood pressure). <BR/>During an observation and interview on 08/22/23 (Tuesday) at 07:27 a.m. LVN B administered medications to Resident #43. Prior to administering his medications she obtained vital signs of BP and P. She said his BP was elevated at 231/180 (normal BP level was 120/80). She then obtained his medications and administered hydralazine (medication used to treat high blood pressure) 50mg, Losartan (to treat high blood pressure) as well as his other medications and administered them with a glass of water. She did not ask the resident any questions about how he was feeling or anything else. <BR/>Record review of the August 2023 physician order summary on 08/22/23 at 11:45 a.m. indicated Resident #43 was to also receive medications to help treat high blood pressure to include: Metoprolol 75 mg at 08:00 AM; Spironolactone 25 mg on Tuesdays, Thursdays, and Saturdays on Day; and a prn order for Clonidine 0.1 mg every 8 hours prn for BP 170/90 or greater. <BR/>During a record review and interview on 08/22/23 at 11:55 a.m. with LVN B and the DON the August 2023 MAR for Resident #43 indicated he was to receive Metoprolol 75 mg at 08:00 AM, Spironolactone 25mg was to be administered on 08/22/23 on Day, and Clonidine 0.1 mg every 8 hours as needed for BP 170/90 or greater; there was no indication the medications were administered by LVN B. LVN B said she asked Resident #43 if he wanted his prn medication and he said no. The DON said a resident should not be asked if they want a prn blood pressure medication because the medication should be administered if the parameters warrant it to be given. <BR/>2. Record review of the face sheet dated 08/22/23 indicated Resident #18 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included hypertension (elevated/high blood pressure), vitamin deficiency, and gastroesophageal reflux disease (GERD) stomach contents leak backward from the stomach into the esophagus (food pipe)). <BR/>Record review of an MDS dated [DATE] indicated Resident #18 had moderately impaired cognition with a BIMS score of 08 out of 15 and had diagnosis of vitamin deficiency. <BR/>Record review of a care plan dated 03/08/23 indicated Resident #18 had vitamin deficiency with interventions including to give medications as ordered. <BR/>During an observation and interview on 08/22/23 at 08:10 a.m. LVN C administered medications to Resident #18. Prior to administering her medications she obtained vital signs of BP and P. She said her BP was low at 94/42. She said because Resident #18's BP was below the parameters to administer the blood pressure medications she was to hold them.She then administered aspirin 325mg, Ducolax 5mg, Calcium 600mg + Vitamin D 5mcg, Cetirizine 10mg, Colace 100mg, Vitamin B12 1000mcg, Famotadine 20mg, Magnesium oxide 400mg, Miralax 17 gm with 5 ounces of water, multivitamin with minerals, Protonix 20mg, sodium chloride 1 gm, Vitamin D3 125mcg, zinc 50 mg, and Nitro Bid apply 2 inches to each leg. <BR/>Record review of the August 2023 physician order summary on 08/22/23 at 11:25 a.m. indicated Resident #18 was to receive the medications administered by LVN C. The orders also indicated she was to receive ascorbic acid (Vitamin C) 500mg for wound healing.<BR/>During a record review and interview on 08/22/23 at 11:35 a.m. with LVN C she said there was an order on the August 2023 physician orders dated 07/03/23 for Resident #18 to have ascorbic acid 500mg for wound healing. She said she did not see the ascorbic acid order on the August MAR for Resident #18. Reviewing the EMR MAR LVN C said it listed on the wrong MAR and was missed by the staff including her to administer the medication since the first of August. <BR/>During an interview on 08/22/23 at 02:06 p.m. the DON said she expected all staff to administer medications as ordered by the physician. She said missed doses of the ascorbic acid ordered for wound healing could result in the wound not healing or worsening. <BR/>An Administering Medications policy and procedure revised December 2012 indicated Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed In Accordance with Orders: 3. Medications must be administered in accordance with orders, including any required timeframe

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 2 residents (Resident #43) reviewed for significant medication errors.<BR/>-LVN B failed to administer 2 scheduled medications (Metoprolol and Spironolactone) and 1 prn medication (clonidine) (all to treat high blood pressure) as ordered by the physician for Resident #43 when his blood pressure was elevated at 231/180.<BR/>This failure could place residents at risk of not receiving the therapeutic effect of the mediations and could result in declining health status.<BR/>Findings included:<BR/>Record review of the face sheet dated indicated Resident #43 was a [AGE] year-old male admitted on [DATE]. His diagnoses included cerebral infarction (disrupted blood flow to the brain (stroke)), hypertension (elevated/high blood pressure), diabetes mellitus type 2 (chronic condition that affects the way the body processes blood sugar), convulsions (burst of uncontrolled electrical activity between brain cells), and atrial fibrillation (a type of irregular heartbeat). <BR/>During an observation and interview on 08/22/23 (Tuesday) at 07:27 a.m. LVN B administered medications to Resident #43. Prior to administering his medications, she obtained vital signs of BP and P. She said his BP was elevated at 231/180 (normal BP level was 120/80). She then administered Hydralazine (medication used to treat high blood pressure) 50mg, Jardiance (to treat elevated blood sugar) 25mg, Eliquis (to treat a type of irregular heartbeat) 5 mg, Keppra (to treat seizures (a burst of uncontrolled electrical activity between brain cells)) 750mg, Losartan (to treat high blood pressure) 100mg, Metformin (to treat elevated blood sugar) 1000mg, and Vitamin D3 (to treat vitamin deficiency) 125mcg with a glass of water. She did not ask the resident any questions about how he was feeling or anything else. <BR/>Record review of the August 2023 physician order summary on 08/22/23 at 11:45 a.m. indicated Resident #43 indicated Resident #43 was to receive medications to help treat high blood pressure to include: Metoprolol 75 mg at 08:00 AM; Spironolactone 25 mg on Tuesdays, Thursdays, and Saturdays on Day; and a prn order for Clonidine 0.1 mg every 8 hours prn for BP 170/90 or greater. These medications were not administered to the resident. <BR/>During a record review and interview on 08/22/23 at 11:55 a.m. with LVN B and the DON the August 2023 MAR for Resident #43 indicated there was no indication the Metoprolol, Spironolactone, or Clonidine were administered by LVN B on the eMAR. LVN B said she asked Resident #43 if he wanted his prn Clonidine and he said no. She said she did not realize she missed the Metoprolol and Spironolactone. The DON said a resident should not be asked if they want a prn blood pressure medication when their blood pressure level was elevated and required the medication per orders and parameters. The DON said not administering the blood pressure medications could result in the resident having a stroke or dying.<BR/>An Administering Medications policy and procedure revised December 2012 indicated Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed In Accordance with Orders: 3. Medications must be administered in accordance with orders, including any required timeframe

Based on observation, interview, and record review the facility failed to ensure all drugs were stored in a locked compartment and not left on top of the medication cart for 1 of 3 medication carts (400 hall medication cart); failed to ensure expired medications were not stored with current medications for 1 of 3 medication carts (200 hall) and 1 of 1 medication room (Secured Unit); and medications of different routes were not stored together for 2 of 3 medication carts (400 hall and Secured Unit) observed for medication storage.<BR/>-The facility did not ensure the 400 hall medication cart was secured and unable to be accessed by unauthorized personnel, residents, or visitors. <BR/>-The facility did not ensure medications were not stored on top of the 400 hall medication cart when unattended. <BR/>-The facility did not ensure expired medications were not accessible and available for use on the 200 hall medication cart and the Secured Unit medication room.<BR/>-The facility did not ensure medications of different routes were not stored together on the 400 hall medication cart and the Secured Unit medication cart. <BR/>These failures could place residents at risk for not receiving drugs and biologicals as needed, medications being used past their effective or expiration date, and drug diversion.<BR/>Findings include:<BR/>1. During an observation on 08/22/23 at 7:27 a.m., LVN B performed FSBS and drew up insulin to administer to Resident #43. LVN B left the 400 hall medication cart outside of the resident room with the drawers facing the hallway, the cart was unlocked, and a vial of Lantus insulin was left on top of the cart while she entered the resident room and administered his insulin. LVN B was in the resident's room with her back to the doorway. LVN B then went back to the medication cart and obtained Resident #43's medications. LVN B again she left the medication cart outside of the resident room with the drawers facing the hallway, the cart was unlocked, and a vial of Lantus insulin was left on top of the cart while she entered the resident room and administered his insulin. LVN B was in the resident's room with her back to the doorway. <BR/>During an interview on 08/22/23 07:45 a.m. LVN B said she did not think leaving the insulin on top of the cart unlocked was an issue because the medication cart was within her eyesight, and it was at the end of the hall. She said she forgot to lock the cart before walking away from it. <BR/>During an interview on 08/23/23 at 01:10 p.m., the DON said medications were not to be left on top of medication carts and medication carts were to be locked when staff walked away from them because any confused resident or visitor could access the cart. <BR/>2. During an observation and interview on 08/23/23 at 10:50 a.m. of the 200-hall medication cart, the CN indicated there was a card of Allopurinol 100 mg with an expiration date of 05/23/23. The CN said expired medications should not be on the medication cart. <BR/>During an interview on 08/23/23 at 01:10 p.m. the DON said expired medications were not to be on the medication carts available for use; they were to be pulled to be destroyed. <BR/>3. During an observation and interview on 08/23/23 at 11:15 a.m. of the 400-hall medication cart with the CN indicated there was a box of acetaminophen 650mg rectal suppositories and an enema stored with oral medications. The CN said the rectally administered items should not be stored with oral medications; they should be stored separately. <BR/>During an observation and interview on 08/23/23 at 11:40 a.m. of the Secured Unit medication cart with the CN indicated a bottle of nitroglycerin oral medication, a box of Exelon topical patches, and a vial of Vitamin B-12 injectable medication were stored together in the top drawer of the medication cart. LVN D said she did not know the medications were not supposed to be stored together on the cart. <BR/>During an interview on 08/23/23 at 01:10 p.m. the DON said medications of different routes should not be stored together on the medication carts. <BR/>4. During an observation and interview on 08/23/23 at 01:55 p.m. of the Secured Unit medication room with LVN D indicated a box of prescribed promethegan suppositories expired 11/2022. LVN D said expired medications should be pulled to be destroyed and not available for use. <BR/>An Administering Medications policy and procedure revised December 2012 indicated <BR/> Safety of Medication Cart 16. During administration of medications, the medication cart will be kept closed and locked when out of the sight of the medication nurse of aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to resident or others passing by <BR/>A Storage of Medications policy and procedure revised April 2007 indicated Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: Unusable Drugs or Biologicals 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed Marking Drugs for External Use/Poisons: 4. Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medications Orderly Storage and Dispensing: 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems

Based on observation, interview, and record review the facility failed to maintain infection control prevention and practices for point of care equipment by 3 of 3 LVNs reviewed for infection control. (LVN A, LVN B, and LVN C) <BR/>* The facility failed to ensure LVN A, LVN B, and LVN C cleaned and disinfected glucometers appropriately after resident use. <BR/>This failure could place residents at risk of infections or diseases from blood borne pathogens. <BR/>Findings included: <BR/>1. During an observation and interview on 08/21/23 at 10:55 a.m. LVN A pulled a glucometer out of the top drawer of the medication cart. She cleaned the glucometer with a wipe from a red topped container for less than a minute. She performed a FSBS test on a resident. She then cleaned the glucometer again with the wipe from the red topped container and cleaned the glucometer for less than a minute and placed the glucometer into the top drawer of the medication cart. LVN A said she would not have done anything differently. <BR/>2. During an observation and interview on 08/21/23 at 11:20 a.m., LVN B pulled a glucometer out of the top drawer of the medication cart and did not clean the glucometer. She performed FSBS on a resident. Without cleaning the glucometer, she placed it in the top drawer of the medication cart. LVN B said she would not have done anything different. <BR/>During an observation and interview on 08/22/23 at 07:27 a.m., LVN B pulled a glucometer out of the top drawer of the medication cart and did not clean the glucometer. She performed FSBS on a resident. Without cleaning the glucometer, she placed it in the top drawer of the medication cart. LVN B said she would not have done anything different. <BR/>3. During an observation and interview on 08/22/23 at 11:10 a.m., LVN C pulled a glucometer out of the top drawer of the medication cart and did not clean the glucometer. She performed FSBS on a resident. She then placed the glucometer on top of the medication cart. LVN C said she would not have done anything differently. LVN C said the glucometer was to be cleaned before and after the resident's FSBS was done. LVN C said the glucometer was supposed to be cleaned with an alcohol wipe. LVN C said she had been trained in the proper cleaning/disinfecting of a glucometer but did not remember all the steps to be done or what to clean with. LVN C pulled the red top container (Micro Kill +) on the medication cart out of the bottom drawer. She said the contact time on the container was 2 minutes for most pathogens so the glucometer needed to be cleaned for 2 minutes with the wipe before the next use. <BR/>During an interview on 08/22/23 at 11:50 a.m., the DON said staff were to use the purple top container of wipes to clean the glucometers. She said staff staff were provided with 2 glucometers on each medication cart so that one was wrapped with the wipe while the other one could be used. She said the glucometers were to be cleaned before and after each resident use. <BR/>An Obtaining a Fingerstick Glucose Level Policy and Procedure revised December 2011 indicated Equipment and Supplies: .3. Disinfected blood glucose meter (glucometer) Steps in Procedure: 3. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses 18. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice <BR/>An undated manufacturer guide indicated on page 46 Cleaning and Disinfecting Your Meter and Lancing Device: 4. To clean your meter, clean the meter with one of the validated disinfecting wipes listed below Medline Micro Kill + Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean Allow the surface of the meter or lancing device to remain wet at room temperature for the contact time listed on the wipe's directions for use <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 13 residents reviewed for respiratory care and services. (Resident #29) <BR/>The facility failed to administer the correct dose of oxygen to Resident #29. <BR/>This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. <BR/>Findings included: <BR/>Record review of physician orders dated August 2023 indicated Resident #29, admitted [DATE], was [AGE] years old with a diagnosis of congestive heart failure (a chronic condition in which the heart does not pump blood adequately). The orders indicated the resident received oxygen at 3 liters per minute via nasal cannula continuously effective 05/01/22. <BR/>Record review of the most recent MDS assessment dated [DATE] indicated Resident #29 was alert, oriented with a BIMS of 9 (indicates moderate cognitive impairment) and received oxygen therapy in the last 14 days. <BR/>Record review of a care plan updated 08/02/23 indicated Resident #29 was short of breath with exertion/activity secondary to congestive heart failure. One of the interventions was to administer oxygen at 3L NC continuously. <BR/>During the following observations, Resident #29's oxygen was administered at 4.5L NC. The resident's speech was garbled and was not comprehensible for interview. <BR/>*on 08/21/23 at 9:43 a.m., <BR/>*on 08/21/23 at 11:55 a.m., <BR/>*on 08/22/23 at 9:35 a.m., <BR/>*on 08/22/23 at 3:11 p.m., and <BR/>*on 08/23/23 at 9:42 a.m. <BR/>During observation and interview on 08/23/23 at 9:42 a.m., after observing Resident #29's oxygen setting, LVN C said Resident #29's oxygen was in progress via NC at 4.5 L NC. She said the resident's oxygen should be set at 3L NC and the resident received the incorrect dose of oxygen. She said she was responsible for checking to ensure the resident received the correct dose, but she had not checked it. She said the possible negative outcome of the resident receiving oxygen at 4.5L could be the resident would receive too much oxygen and it would cause increased confusion. <BR/>During an interview on 08/23/23 at 10:00 a.m., the DON said her expectations were for the oxygen to be administered as prescribed. She said administering too high of a dose of oxygen could cause Resident #29 to become dependent on it. She said it was the charge nurses' responsibility to check the resident's oxygen dosage to ensure they received the correct dose, and they should be checking it every shift. <BR/>Record review of an Oxygen Administration policy revised October 2010 indicated: . Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for essential equipment. <BR/>The facility did not ensure the gas stove, and the convection ovens were in safe operating condition. <BR/>This failure could place the residents at risk of a fire and not receiving their meals in a timely manner.<BR/>Findings included:<BR/>During an observation and interview on 09/09/24 at 7:50 a.m., [NAME] A turned on the burners on the stove. 2 of 6 burners did not light using their pilot lights and she picked up a long lighter and lit pilot. She turned the burners on and the burners lit. She said occasionally the pilot lights go out and we must light the pilots . She said the DM knew about the pilot lights going out.<BR/>During an interview on 09/10/24 at 2:00 p.m., the Administrator said the portable AC in the kitchen might have blown out the pilot lights, but she would have the maintenance supervisor to check on the pilot lights.<BR/>During an interview on 09/11/24 at 12:55 p.m. the DM said the pilot lights would have to be lit occasionally for the last month, but her staff knew to watch for the pilot lights and to light if needed. She said the pilot lights going out might have been related to the portable AC units. <BR/>During an interview on 09/11/24 at 1:00 p.m., the Maintenance Supervisor said he would go to the kitchen and clean the pilot lights. He said the staff had not reported the pilot lights not being lit. He said the equipment should be in good working order and if not, the burner might not work as required. The maintenance supervisor said some pilot lights will leak small amounts of gas, and some do not, he said he was new and was unsure what type of pilots were on the stove. He said he would check the burners. <BR/>Record review of the Preventive Maintenance dated March 2003 indicated The facility will ensure that a comprehensive preventive maintenance program is in place for essential operating equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 13 residents reviewed for respiratory care and services. (Resident #29) <BR/>The facility failed to administer the correct dose of oxygen to Resident #29. <BR/>This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. <BR/>Findings included: <BR/>Record review of physician orders dated August 2023 indicated Resident #29, admitted [DATE], was [AGE] years old with a diagnosis of congestive heart failure (a chronic condition in which the heart does not pump blood adequately). The orders indicated the resident received oxygen at 3 liters per minute via nasal cannula continuously effective 05/01/22. <BR/>Record review of the most recent MDS assessment dated [DATE] indicated Resident #29 was alert, oriented with a BIMS of 9 (indicates moderate cognitive impairment) and received oxygen therapy in the last 14 days. <BR/>Record review of a care plan updated 08/02/23 indicated Resident #29 was short of breath with exertion/activity secondary to congestive heart failure. One of the interventions was to administer oxygen at 3L NC continuously. <BR/>During the following observations, Resident #29's oxygen was administered at 4.5L NC. The resident's speech was garbled and was not comprehensible for interview. <BR/>*on 08/21/23 at 9:43 a.m., <BR/>*on 08/21/23 at 11:55 a.m., <BR/>*on 08/22/23 at 9:35 a.m., <BR/>*on 08/22/23 at 3:11 p.m., and <BR/>*on 08/23/23 at 9:42 a.m. <BR/>During observation and interview on 08/23/23 at 9:42 a.m., after observing Resident #29's oxygen setting, LVN C said Resident #29's oxygen was in progress via NC at 4.5 L NC. She said the resident's oxygen should be set at 3L NC and the resident received the incorrect dose of oxygen. She said she was responsible for checking to ensure the resident received the correct dose, but she had not checked it. She said the possible negative outcome of the resident receiving oxygen at 4.5L could be the resident would receive too much oxygen and it would cause increased confusion. <BR/>During an interview on 08/23/23 at 10:00 a.m., the DON said her expectations were for the oxygen to be administered as prescribed. She said administering too high of a dose of oxygen could cause Resident #29 to become dependent on it. She said it was the charge nurses' responsibility to check the resident's oxygen dosage to ensure they received the correct dose, and they should be checking it every shift. <BR/>Record review of an Oxygen Administration policy revised October 2010 indicated: . Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observation, interview, and record review the facility failed to maintain infection control prevention and practices for point of care equipment by 3 of 3 LVNs reviewed for infection control. (LVN A, LVN B, and LVN C) <BR/>* The facility failed to ensure LVN A, LVN B, and LVN C cleaned and disinfected glucometers appropriately after resident use. <BR/>This failure could place residents at risk of infections or diseases from blood borne pathogens. <BR/>Findings included: <BR/>1. During an observation and interview on 08/21/23 at 10:55 a.m. LVN A pulled a glucometer out of the top drawer of the medication cart. She cleaned the glucometer with a wipe from a red topped container for less than a minute. She performed a FSBS test on a resident. She then cleaned the glucometer again with the wipe from the red topped container and cleaned the glucometer for less than a minute and placed the glucometer into the top drawer of the medication cart. LVN A said she would not have done anything differently. <BR/>2. During an observation and interview on 08/21/23 at 11:20 a.m., LVN B pulled a glucometer out of the top drawer of the medication cart and did not clean the glucometer. She performed FSBS on a resident. Without cleaning the glucometer, she placed it in the top drawer of the medication cart. LVN B said she would not have done anything different. <BR/>During an observation and interview on 08/22/23 at 07:27 a.m., LVN B pulled a glucometer out of the top drawer of the medication cart and did not clean the glucometer. She performed FSBS on a resident. Without cleaning the glucometer, she placed it in the top drawer of the medication cart. LVN B said she would not have done anything different. <BR/>3. During an observation and interview on 08/22/23 at 11:10 a.m., LVN C pulled a glucometer out of the top drawer of the medication cart and did not clean the glucometer. She performed FSBS on a resident. She then placed the glucometer on top of the medication cart. LVN C said she would not have done anything differently. LVN C said the glucometer was to be cleaned before and after the resident's FSBS was done. LVN C said the glucometer was supposed to be cleaned with an alcohol wipe. LVN C said she had been trained in the proper cleaning/disinfecting of a glucometer but did not remember all the steps to be done or what to clean with. LVN C pulled the red top container (Micro Kill +) on the medication cart out of the bottom drawer. She said the contact time on the container was 2 minutes for most pathogens so the glucometer needed to be cleaned for 2 minutes with the wipe before the next use. <BR/>During an interview on 08/22/23 at 11:50 a.m., the DON said staff were to use the purple top container of wipes to clean the glucometers. She said staff staff were provided with 2 glucometers on each medication cart so that one was wrapped with the wipe while the other one could be used. She said the glucometers were to be cleaned before and after each resident use. <BR/>An Obtaining a Fingerstick Glucose Level Policy and Procedure revised December 2011 indicated Equipment and Supplies: .3. Disinfected blood glucose meter (glucometer) Steps in Procedure: 3. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses 18. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice <BR/>An undated manufacturer guide indicated on page 46 Cleaning and Disinfecting Your Meter and Lancing Device: 4. To clean your meter, clean the meter with one of the validated disinfecting wipes listed below Medline Micro Kill + Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean Allow the surface of the meter or lancing device to remain wet at room temperature for the contact time listed on the wipe's directions for use <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to have a final summary of the resident's status at the time of the discharge that is available for release to authorized persons for 1 of 3 residents reviewed for discharge summary (Resident #50).<BR/>The facility did not have a physician signed Discharge Summary within 20 business days after Resident #50 discharged from the facility and did not return. <BR/>This failures could place discharged residents at risk for a lack of continued care and services. <BR/>Findings included: <BR/>Record review of the face sheet printed 08/23/23 indicated Resident #50 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. His diagnoses included diabetes mellitus type 2 (chronic condition that affects the way the body processes blood sugar), benign neoplasm of cerebral meninges (non-cancer tumor that arises from the membranes that surround the brain), obstructive hydrocephalus (any condition that blocks the flow of fluid in the brain or spinal cord), hypertension (elevated/high blood pressure), and convulsions (burst of uncontrolled electrical activity between brain cells). The face sheet also indicated he was discharged to the hospital on [DATE]. <BR/> Record review of Nurse Notes indicated on 06/07/23 Resident #50 had with issues of penile swelling and pus drainage; he had an elevated potassium level of 6.9; and the physician ordered the resident to be sent to the hospital for evaluation. The ambulance arrived and the resident was sent to the hospital due to lab values. <BR/>Record review of the EMR indicated Resident #50 had a Discharge Summary with effective date of 06/07/23. The form had no information filled out on it and was not signed by the physician. <BR/>During an interview on 08/23/23 at 12:15 p.m. the DON said she and the MR staff were responsible for filling out the Discharge Summary reports and either sending or taking over to the physician office for him to sign. She said Resident #50 was sent and admitted to the hospital on [DATE]. She said when she reviewed Resident #50's Discharge Summary it was blank and so she filled it out today and it was taken to the physician for him to sign. <BR/>According to the Texas Administration Code &sect;554.1202(4) The physician must: (4)write, sign, and date a physician's discharge summary within 20 working days of being notified by the facility of the discharge, except as specified in &sect;19.1912(e) of this title (relating to Additional Clinical Record Service Requirements), if the resident has been temporarily discharged for 30 days or less, and readmitted to the same facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to have a final summary of the resident's status at the time of the discharge that is available for release to authorized persons for 1 of 3 residents reviewed for discharge summary (Resident #50).<BR/>The facility did not have a physician signed Discharge Summary within 20 business days after Resident #50 discharged from the facility and did not return. <BR/>This failures could place discharged residents at risk for a lack of continued care and services. <BR/>Findings included: <BR/>Record review of the face sheet printed 08/23/23 indicated Resident #50 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. His diagnoses included diabetes mellitus type 2 (chronic condition that affects the way the body processes blood sugar), benign neoplasm of cerebral meninges (non-cancer tumor that arises from the membranes that surround the brain), obstructive hydrocephalus (any condition that blocks the flow of fluid in the brain or spinal cord), hypertension (elevated/high blood pressure), and convulsions (burst of uncontrolled electrical activity between brain cells). The face sheet also indicated he was discharged to the hospital on [DATE]. <BR/> Record review of Nurse Notes indicated on 06/07/23 Resident #50 had with issues of penile swelling and pus drainage; he had an elevated potassium level of 6.9; and the physician ordered the resident to be sent to the hospital for evaluation. The ambulance arrived and the resident was sent to the hospital due to lab values. <BR/>Record review of the EMR indicated Resident #50 had a Discharge Summary with effective date of 06/07/23. The form had no information filled out on it and was not signed by the physician. <BR/>During an interview on 08/23/23 at 12:15 p.m. the DON said she and the MR staff were responsible for filling out the Discharge Summary reports and either sending or taking over to the physician office for him to sign. She said Resident #50 was sent and admitted to the hospital on [DATE]. She said when she reviewed Resident #50's Discharge Summary it was blank and so she filled it out today and it was taken to the physician for him to sign. <BR/>According to the Texas Administration Code &sect;554.1202(4) The physician must: (4)write, sign, and date a physician's discharge summary within 20 working days of being notified by the facility of the discharge, except as specified in &sect;19.1912(e) of this title (relating to Additional Clinical Record Service Requirements), if the resident has been temporarily discharged for 30 days or less, and readmitted to the same facility.

Number of residents sampled:<BR/>Number of residents cited:<BR/>Based on observation, interview and record review the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 2 of 2 days reviewed (12/1/25 and 12/2/25) for nurse staffing posting. The facility failed to post the required current daily staffing information on 12/1/25 and 12/2/25. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts. Findings included: During an observation on 12/1/25 at 8:20 AM, no nurse staffing data was posted in the facility. During an observation on 12/2/25 at 10:25 AM, no nurse staffing data was posted in the facility. During an interview on 12/2/25 at 11:00 AM, the DON said nurse staffing data was not posted. She said it used to be posted near the nurse's station, but it was no longer posted. She said she would run the staffing report and post it now. During an interview and observation on 12/2/25 at 11:25 AM, the DON said staffing was posted behind the nurse's station. This surveyor observed the daily nurse staffing posted behind the nurse's station. During an interview on 12/2/25 at 1:04 PM, the DON said she and the ADON were responsible for making sure staffing was posted. She said there was a miscommunication with her corporate. Corporate told her they did not need to post it. The DON said they use the staffing application for daily staffing and it could be printed out if needed. However, she understood it did not need to be posted. During an interview on 12/2/25 at 2:22 PM, the ADON said she used to post the daily staffing every day. She does not remember when she stopped. She understood from corporate that they did not have to post the daily staffing. She said corporate may have been misinformed or confused as well. She said she believed the last time she posted daily staffing was about 6 months ago. The ADON said the risk of not having daily staffing posted was residents/visitors would not know if there was enough staff to care for the residents. During an interview on 12/2/25 at 3:19 PM, the DON said the risk of not having staffing posting was that the residents would not know if there was an adequate number of staff to care for them for the day. During an interview on 12/2/25 at 3:52 PM the ADM said her Regional Area Director told her staffing had to be posted. She said it had not been posted in months, but she did not know how many. She said the risk of daily staffing not being posted was that personnel would not know what staffing was in the facility. During an interview on 12/2/25 at 12/03/2025 8:32 AM the ADM said they did not have a policy for posting daily staffing.

Based on interview and record review, the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 1 facility kitchen reviewed for food and nutrition services. <BR/>The facility failed to designate a person to serve as the dietary manager who met the required qualifications. The facility designated Dietary Supervisor did not have a dietary manager's certification or any other qualifying credentials. <BR/>This failure could place residents at risk for the spread of foodborne illness and residents not having their nutritional needs met. <BR/>The findings included:<BR/>During an interview on 09/9/24 at 8:30 a.m., the DM said she had taken her food handler test, however had not been sent to classes for certified dietary manager. She said the company had talked about sending her for certification classes but did not send her to classes. She said she had worked as the Dietary Manager for almost a year.<BR/>During an interview on 09/11/24 at 10:00 a.m., the Administrator said she had tried to send the DM to become certified and the class was canceled. She said the next class would be in February 2025. The Administrator said she was trying to help the DM become certified.<BR/>During an interview on 09/11/24 at 12:30 p.m., the HR staff said the DM was not certified and thought she had been hired as the DM about a year ago was rehired by their new managing company. The HR staff said the Administrator had tried to send the DM to class and said the class was canceled.<BR/>Record review of an email addressed to the Administrator dated 09/11/24 indicated the dietary manager class would be February 22, 2025.<BR/>Record review of a list provided by HR staff dated 09/11/24 indicated the DM was hired on 04/22/21, then promoted to DM on 09/15/23. The HR staff said the Administrator had tried to send the DM to class and said the class was canceled.<BR/>Record review of training indicated the dietary manager had completed a food handler for DM and had 8 hours of training dated 09/10/23.<BR/>Record review of the undated job description indicated Clinical Dietary Manager The following is a non-exhaustive criteria that relates to the job of clinical dietary manager, and it is consistent with the business needs of the facility. These are legitimate measure of the qualifications, and are related to the functions that are essential to the job of a Clinical Dietary Manager.<BR/>Base Knowledge: Must obtain and maintain Certified Dietary Manager (CDM), Certified Food Protection Professional (CFPP) credential from ANFP (Association of Nutrition and Foodservice Professionals).