Avir at Kennedale

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure residents had the right to participate in the development and implementation of their person-centered plan of care for 1 of 6 residents (Resident #32) reviewed for quarterly care plans.The facility failed to invite Resident #32 and responsible parties with 4 quarterly care plan conference meetings for the last 12 months. Resident #32's last care plan meeting was dated 08/07/24. This failure could place residents at risk of not receiving inadequate interventions not individualized to their care needs.Findings included:Record review of Resident #32's face sheet, dated 08/07/25, reflected the resident was a [AGE] year-old female with an admission date of 08/03/23 and returned 03/08/25. Record review of Resident #32's quarterly MDS assessment dated [DATE] reflected her diagnoses included hypertension (high blood pressure), dementia, cognitive communication deficit, and depression. The MDS reflected the resident had severe cognitive impairment with a BIMS score of 4. Record review of Resident #32's care plan, last reviewed/revised date 04/24/25 reflected Category: Return to community referral POA had no desire for [Resident #32] to return to community. Staff will revisit on comprehensive assessments only. Goal: Resident needs will be met by facility staff through the next review period. Approach: 1. Keep POA/[Resident #32] updated on the resident plan of care. 2. Staff will maintain [Resident #32] needs. 3. Follow up with the [Resident #32]/POA annually. Record review of Resident #32's Care Conference Report reflected the last care plan meeting was completed on 08/07/24 for Annual Care Conference. Record review of Resident #32's progress notes reflected no documentation regarding care plan meetings or family being made aware of care plan conference meetings. Interview on 08/05/25 at 1:20 PM, Resident #32's Family Member A/POA revealed he had concerns regarding Resident #32's care and wanted to address it with the facility. Resident #32's Family Member A/POA stated he had not been invited to any care plan meetings to address his concerns. Resident #32's Family Member A/POA stated he was not aware care plan meetings were held quarterly. The last care plan meeting he had been invited and attended was sometime last year 2024, exact date unknown.Interview on 08/05/25 at 1:23 PM, Resident #32 revealed she had no concerns regarding her care. Resident #32 was not a good historian and could not recall if she had attended a care plan meeting or been asked to attend one.An attempt was made on 08/07/25 at 11:25 AM to contact the ADON C/MDS Coordinator by phone; however, there was no answer. Interview on 08/07/25 at 12:52 PM, with the DON revealed the Social Worker and ADON C, who was the MDS Coordinator, were responsible for coordinating the care plan meetings. The DON stated the Social Worker or ADON C would inform her when a care plan meeting was scheduled, and she would attend. She stated care plan meetings should be documented in the residents' charts, and the Social Worker would keep notes of what was discussed during the meeting. The DON stated she had been employed since February 2025, and she could not recall if Resident #32 had had a care plan meeting. She stated care plan meetings should be completed quarterly with family. She stated both the Social Worker and ADON C were no longer employed by the facility. The DON stated she was not aware Resident #32's care plan meetings were not being completed quarterly. She stated the potential risk of not completing care plan meetings would be the team, family, and resident not being informed about changes or areas that needed to be addressed regarding the resident. Interview on 08/07/25 at 1:50 PM, with the Administrator revealed the Social Worker and ADON C were responsible for scheduling care plan meetings. She stated she was not aware Resident #32 had not had a care plan meeting since 2024. She stated the IDT was responsible for conducting the care plan meetings. She stated the potential risk of not having the care plan meetings would be family not being able to communicate their concerns regarding the resident's care or not being able to know the level of care the resident was receiving. She stated Resident #32's family had not mentioned anything to them about a care plan meeting. An attempt was made to contact the Social Worker by phone on 08/07/25 at 2:17 PM; however, there was no answer.Record review of the facility's Statement of Resident Right policy dated 12/01/18 reflected the following: .To participate in developing a plan of care that describes their medical, psychological, and nursing needs and how the needs will be met .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 6 residents (Resident #24) reviewed for abuse and neglect. The facility failed to implement their policy on reporting an incident involving Resident #24, who had a history of exit seeking behaviors and was a high risk for elopement, eloped from the facility on 08/08/25. The resident was found near an apartment complex on a busy street next to the facility by a passerby who brought her back to the facility. This failure could place the residents in the facility at risk of neglect and lack of timely reporting of incidents.Findings included: Record review of the facility's current Abuse/ Reportable Events policy, dated 1/10/17, revealed the following: It is everyone's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Adverse event. An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. Record review of Resident #24's annual MDS assessment, dated 07/10/25, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's Disease (brain disorder caused by damage to nerve cells in the brain), anxiety disorder (a mood disorder characterized by excessive, persistent, and uncontrollable fear and worry about everyday situations), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), diabetes mellitus (a chronic disease characterized by high level of sugar in the blood), muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), unsteadiness on feet and unspecified lack of coordination. The MDS reflected Resident #24 had moderate cognitive impairment with a BIMS score of 11. The MDS further reflected Resident #24 did not exhibit wandering behaviors. Record review of Resident #24's care plan, dated 06/19/25, reflected care plan did not address Resident #24's exit seeking behaviors. Care Plan was updated on 08/08/25, reflected Problem: Resident is at risk of elopement as evidenced by. Goals: Resident will not leave the facility. Approach(s): Notify physician and family of any further concerns. Discuss secure unit placement. Monitor and record behavior with it occurs. 1:1 monitoring within eyesight. Divert residents attention and refocus attention elsewhere, staff to orient and redirect resident as needed if she talks of leaving. Record review of Resident #24's Elopement/Wandering Observation quarterly, dated 06/18/25, reflected Resident #24 was high risk for elopement. The evaluation indicated resident had a medical diagnosis associated with confusion, which may indicate future likelihood of high-risk behavior(s). Mobility: Resident is physically able to exit on foot or by wheelchair. Record review of Resident #24's Elopement Risk Evaluation, dated 08/08/25, reflected Resident #24 was at risk for elopement. The evaluation indicated Resident #24 had a history of attempting to leave the facility one or more times in last week. Statement and/or treats to leave facility. Record review of Resident #24's progress notes dated 08/08/25 at 10:55 AM reflected: This nurse was notified by [NAME] Hall nurse that resident was found next door by a resident of the apartment complex. Vitals and skin assessment normal to resident baseline. MD/DON/RP notified. New orders given via telephone from MD: CBS/CMP/UA/Chest Xray. DON will enter the orders. Resident reports she was going back home attempted to redirect resident and successful. Record review of facility Twenty-Four Hour Report dated 08/08/25 reflected: Resident Name: Resident #24; 6AM-2PM: Eloped @ 1055 [10:55AM]; 1:1 ratio at all times. 2PM-10PM: Elope cont. 1:1, stable, in bed. Record review of facility Event Report for Resident dated 08/08/25, time of event 1055 [10:55AM] reflected: Type of Event: Elopement, Note how long missing: 3-5 mins. Heat to toe assessment: no new injuries noted. Skin warm to touch. MD & RP notified of event. Nurse on St.2 told Administrator resident went out front door behind another resident's family [Initial Name] daughter. 3-5 min later [NAME] as with a lady. Statement of resident obtained: Not able to recall. No injury. List new interventions: Resident on 1:1 supervision. Interview on 09/03/25 at 12:06 PM, LVN A revealed she was the nurse assigned to Resident #24 when she eloped from the facility. She stated she could not recall the exact time, but it was between the times of 10AM - 11AM when Resident #24 eloped. She stated she was getting ready to do blood sugar checks when RN B brought Resident #24 to her and told her someone from the apartment complex saw the resident outside and brought her back to the facility, rang the doorbell and asked if this resident lived here. LVN A stated the Activity Director opened the door and verified Resident #24 was a resident from the facility and brought Resident #24 back to her hall. She stated the last time she observed Resident #24 she was in the dining area. She stated it was about a 5 - 10-minute window from when she last observed Resident #24 to when she was brought back to the facility. She stated she does not know exactly how Resident #24 exited the facility, she stated no alarm doors were heard. LVN A stated after Resident #24 was brought back they checked all the doors to ensure they were all closed and alarms working properly. LVN A stated that morning a visitor had come to visit another resident, and she believes when the visitor left the facility the visitor did not checked behind her and Resident #24 followed her out. LVN A stated Resident #24 saw the opportunity and went for it. She stated Resident #24 had history of exit seeking, she stated she would always say I want the code for the door, if someone was leaving the building resident would say I am going with them, she stated she would try to push the door, and the alarms would go off. LVN A stated Resident #24 would be easily redirected and they would keep her busy with activities. She stated resident would propel in her wheelchair and she was fast moving around. LVN A stated she completed a head-to-toe assessment on Resident #24, and no injuries were noted skin was intact. She stated she notified the doctor, Resident #24 family member/POA, the DON and the Administrator. She stated Resident #24 was placed on 1:1 supervision until she discharged to another facility on [DATE]. Interview on 09/03/25 at 12:19 PM, RN B revealed she was working on 08/08/25 on [NAME] Hall. She stated she was not the nurse assigned to Resident #24; however, she was behind the Activity Director when she opened the door, saw a woman returning Resident #24 and asked if the resident lived here. She stated Resident #24 was in her wheelchair and the woman said she had seen the resident next door in the apartment complex in the middle of the street. RN B stated she asked Resident #24 what she was doing, and Resident #24 told her she was going to go get her car. RN B stated she took Resident #24 back to her hall and told LVN A resident was outside in the street, and someone found her next door and brought her back. RN B stated she could not recall the exact time she had last seen Resident #24, she stated it was after breakfast, before lunch when she was brought back to the facility. She stated when Resident #24 exhibits those behaviors of wanting to leave, they monitor her more frequent and redirect her. RN B stated Resident #24 had a history of exit seeking and trying to open doors. She stated Resident #24 was placed on 1:1 supervision. Interview on 09/03/25 at 12:31 PM, the Activity Director revealed she was working on 08/08/25 when Resident #24 eloped from the facility. She stated the last time she observed Resident #24 she was eating breakfast in the dining room around 8-8:30AM. She stated she could not recall the time, but someone ranged the doorbell, and she opened the door. She stated a women asked if the resident lived here, and she told her yes. She stated she notified the nurse and to take her to her hall. She stated the women stated resident was around the apartment complex next door to the facility. Activity Director stated no alarms were heard that morning. She stated Resident #24 was an elopement risk but she had not seen her open doors. Interview on 09/03/25 at 12:38 PM, the DON revealed she was informed by LVN A Resident #24 was found by a lady coming out of the apartment complex. The lady saw resident, stopped her car and brought the resident back to the facility and asked if the resident lived here. She stated the Activity Director was the one who opened the door and informed the lady that Resident #24 was a resident at the facility. She stated per LVN A last time she observed Resident #24 she was in the dining area and resident was out for about 3-5 minutes. She stated Resident #24 would ambulate in her wheelchair and was known to peddle fast on it. The DON stated Resident #24 was an elopement risk, she stated an elopement assessment was completed on 08/08/25, and resident scored high risk. The DON stated she could not locate any prior elopement assessment completed on Resident #24, then stated she did not look to ensure if any were completed prior to the elopement but she knew resident was a high risk. She stated Resident #24 had history of attempting to leave the facility, she stated one time unknown of date of when if happened, Resident #24 was attempting to leave but was within eyesight of hers and she immediately stopped her and redirected her. The DON stated Resident #24 was placed on 1:1 supervision until she discharged to another facility. She stated LVN A notified the doctor and family member. The DON stated everyone was responsible for reporting any abuse and neglect allegations to the abuse coordinator who was the Administrator. She stated she did not think the incident with Resident #24 was a reportable because resident was brought back quickly to the facility with no injuries. The DON stated after reviewing and discussing the incident pertaining the elopement it should had been reported to the HHSC. Interview on 09/03/25 at 1:03 PM, the Administrator revealed Resident #24 had exited the facility on 08/08/25. She stated till this day they still do not know how resident exited the facility. She stated someone from next door apartment complex found Resident #24 and brought her back to the facility and asked if she lived here. The Administrator stated Resident #24 was only gone for a couple of minutes. She stated she was in her office and could not recall when the last time Resident #24 was last seen. She stated Resident #24 eats her breakfast in her room, once done she is out and about. The Administrator stated Resident #24 was an exit seeker, has tried in the past to exit but was not successful. She stated Resident #24 would always say her car was outside. She stated they would try to redirect resident, keep her busy with activities and watch her within eyesight. She stated after the elopement Resident #24 was placed on 1:1 supervision until they could find an appropriate placement for her. She stated a QAPI meeting was completed with the DON and MD regarding the elopement and suggested Resident #24 required a secure unit. She stated the DON reached out to the family twice on 08/08/25 and LVN B was able to notify the family regarding the incident. The Administrator stated Resident #24 discharged from the facility on [DATE]. The Administrator stated she was the abuse coordinator, and she was responsible for reporting to HHSC. She stated she did not report the incident pertaining Resident #24 to HHSC because she was only gone for a couple of minutes. She stated she reached out to her higher ups and with the DON whether the incident was a reportable and concluded it was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure all alleged violations involving neglect, which included injuries of unknown source, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, which included the State Survey Agency, in accordance with State law through established procedures for 1 of 6 residents (Resident #24) reviewed for abuse and neglect. The facility failed to report an incident to HHSC involving Resident #24, who had a history of exit seeking behaviors and was a high risk for elopement, eloped from the facility on 08/08/25. The resident was found near an apartment complex on a busy street next to the facility by a passerby who brought her back to the facility. This deficient practice could affect any resident and contribute to resident neglect. Findings included: Record review of Resident #24's annual MDS assessment, dated 07/10/25, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's Disease (brain disorder caused by damage to nerve cells in the brain), anxiety disorder (a mood disorder characterized by excessive, persistent, and uncontrollable fear and worry about everyday situations), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), diabetes mellitus (a chronic disease characterized by high level of sugar in the blood), muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), unsteadiness on feet and unspecified lack of coordination. The MDS reflected Resident #24 had moderate cognitive impairment with a BIMS score of 11. The MDS further reflected Resident #24 did not exhibit wandering behaviors. Record review of Resident #24's care plan, dated 06/19/25, reflected care plan did not address Resident #24 exit seeking behaviors. Care Plan was updated on 08/08/25, reflected Problem: Resident is at risk of elopement as evidenced by. Goals: Resident will not leave the facility. Approach(s): Notify physician and family of any further concerns. Discuss secure unit placement. Monitor and record behavior with it occurs. 1:1 monitoring within eyesight. Divert residents attention and refocus attention elsewhere, staff to orient and redirect resident as needed if she talks of leaving. Record review of Resident #24's Elopement/Wandering Observation quarterly, dated 06/18/25, reflected Resident #24 was high risk for elopement. The evaluation indicated resident had a medical diagnosis associated with confusion, which may indicate future likelihood of high-risk behavior(s). Mobility: Resident is physically able to exit on foot or by wheelchair. Record review of Resident #24's Elopement Risk Evaluation, dated 08/08/25, reflected Resident #24 was at risk for elopement. The evaluation indicated Resident #24 had a history of attempting to leave the facility one or more times in last week. Statement and/or treats to leave facility. Record review of Resident #24's progress notes dated 08/08/25 at 10:55 AM reflected: This nurse was notified by [NAME] Hall nurse that resident was found next door by a resident of the apartment complex. Vitals and skin assessment normal to resident baseline. MD/DON/RP notified. New orders given via telephone from MD: CBS/CMP/UA/Chest Xray. DON will enter the orders. Resident reports she was going back home attempted to redirect resident and successful. Record review of facility Twenty-Four Hour Report dated 08/08/25 reflected: Resident Name: Resident #24; 6AM-2PM: Eloped @ 1055 [10:55AM]; 1:1 ratio at all times. 2PM-10PM: Elope cont. 1:1, stable, in bed. Record review of facility Event Report for Resident dated 08/08/25, time of event 1055 [10:55AM] reflected: Type of Event: Elopement, Note how long missing: 3-5 mins. Heat to toe assessment: no new injuries noted. Skin warm to touch. MD & RP notified of event. Nurse on St.2 told Administrator resident went out front door behind another resident's family [Initial Name] daughter. 3-5 min later [NAME] as with a lady. Statement of resident obtained: Not able to recall. No injury. List new interventions: Resident on 1:1 supervision. Interview on 09/03/25 at 12:06 PM, LVN A revealed she was the nurse assigned to Resident #24 when she eloped from the facility. She stated she could not recall the exact time, but it was between the times of 10AM - 11AM when Resident #24 eloped. She stated she was getting ready to do blood sugar checks when RN B brought Resident #24 to her and told her someone from the apartment complex saw the resident outside and brought her back to the facility, rang the doorbell and asked if this resident lived here. LVN A stated the Activity Director opened the door and verified Resident #24 was a resident from the facility and brought Resident #24 back to her hall. She stated the last time she observed Resident #24 she was in the dining area. She stated it was about a 5 - 10-minute window from when she last observed Resident #24 to when she was brought back to the facility. She stated she does not know exactly how Resident #24 exited the facility, she stated no alarm doors were heard. LVN A stated after Resident #24 was brought back they checked all the doors to ensure they were all closed and alarms working properly. LVN A stated that morning a visitor had come to visit another resident, and she believes when the visitor left the facility the visitor did not checked behind her and Resident #24 followed her out. LVN A stated Resident #24 saw the opportunity and went for it. She stated Resident #24 had history of exit seeking, she stated she would always say I want the code for the door, if someone was leaving the building resident would say I am going with them, she stated she would try to push the door, and the alarms would go off. LVN A stated Resident #24 would be easily redirected and they would keep her busy with activities. She stated resident would propel in her wheelchair and she was fast moving around. LVN A stated she completed a head-to-toe assessment on Resident #24, and no injuries were noted skin was intact. She stated she notified the doctor, Resident #24 family member/POA, the DON and the Administrator. She stated Resident #24 was placed on 1:1 supervision until she discharged to another facility on 08/11/25. Interview on 09/03/25 at 12:19 PM, RN B revealed she was working on 08/08/25 on [NAME] Hall. She stated she was not the nurse assigned to Resident #24; however, she was behind the Activity Director when she opened the door, saw a woman returning Resident #24 and asked if the resident lived here. She stated Resident #24 was in her wheelchair and the woman said she had seen the resident next door in the apartment complex in the middle of the street. RN B stated she asked Resident #24 what she was doing, and Resident #24 told her she was going to go get her car. RN B stated she took Resident #24 back to her hall and told LVN A resident was outside in the street, and someone found her next door and brought her back. RN B stated she could not recall the exact time she had last seen Resident #24, she stated it was after breakfast, before lunch when she was brought back to the facility. She stated when Resident #24 exhibits those behaviors of wanting to leave, they monitor her more frequent and redirect her. RN B stated Resident #24 had a history of exit seeking and trying to open doors. She stated Resident #24 was placed on 1:1 supervision. Interview on 09/03/25 at 12:31 PM, the Activity Director revealed she was working on 08/08/25 when Resident #24 eloped from the facility. She stated the last time she observed Resident #24 she was eating breakfast in the dining room around 8-8:30AM. She stated she could not recall the time, but someone ranged the doorbell, and she opened the door. She stated a women asked if the resident lived here, and she told her yes. She stated she notified the nurse and to take her to her hall. She stated the women stated resident was around the apartment complex next door to the facility. Activity Director stated no alarms were heard that morning. She stated Resident #24 was an elopement risk but she had not seen her open doors. Interview on 09/03/25 at 12:38 PM, the DON revealed she was informed by LVN A Resident #24 was found by a lady coming out of the apartment complex. The lady saw resident, stopped her car and brought the resident back to the facility and asked if the resident lived here. She stated the Activity Director was the one who opened the door and informed the lady that Resident #24 was a resident at the facility. She stated per LVN A last time she observed Resident #24 she was in the dining area and resident was out for about 3-5 minutes. She stated Resident #24 would ambulate in her wheelchair and was known to peddle fast on it. The DON stated Resident #24 was an elopement risk, she stated an elopement assessment was completed on 08/08/25, and resident scored high risk. The DON stated she could not locate any prior elopement assessment completed on Resident #24, then stated she did not look to ensure if any were completed prior to the elopement but she knew resident was a high risk. She stated Resident #24 had history of attempting to leave the facility, she stated one time unknown of date of when if happened, Resident #24 was attempting to leave but was within eyesight of hers and she immediately stopped her and redirected her. The DON stated Resident #24 was placed on 1:1 supervision until she discharged to another facility. She stated LVN A notified the doctor and family member. The DON stated everyone was responsible for reporting any abuse and neglect allegations to the abuse coordinator who was the Administrator. She stated she did not think the incident with Resident #24 was a reportable because resident was brought back quickly to the facility with no injuries. The DON stated after reviewing and discussing the incident pertaining the elopement it should had been reported to the State. Interview on 09/03/25 at 1:03 PM, the Administrator revealed Resident #24 had exited the facility on 08/08/25. She stated till this day they still do not know how resident exited the facility. She stated someone from next door apartment complex found Resident #24 and brought her back to the facility and asked if she lived here. The Administrator stated Resident #24 was only gone for a couple of minutes. She stated she was in her office and could not recall when the last time Resident #24 was last seen. She stated Resident #24 eats her breakfast in her room, once done she is out and about. The Administrator stated Resident #24 was an exit seeker, has tried in the past to exit but was not successful. She stated Resident #24 would always say her car was outside. She stated they would try to redirect resident, keep her busy with activities and watch her within eyesight. She stated after the elopement Resident #24 was placed on 1:1 supervision until they could find an appropriate placement for her. She stated a QAPI meeting was completed with the DON and MD regarding the elopement and suggested Resident #24 required a secure unit. She stated the DON reached out to the family twice on 08/08/25 and LVN B was able to notify the family regarding the incident. The Administrator stated Resident #24 discharged from the facility on 08/11/25. The Administrator stated she was the abuse coordinator, and she was responsible for reporting to HHSC. She stated she did not report the incident pertaining Resident #24 to HHSC because she was only gone for a couple of minutes. She stated she reached out to her higher ups and with the DON whether the incident was a reportable and concluded it was not. Record review of the facility's current Abuse/ Reportable Events policy, dated 1/10/17, revealed the following: It is everyone's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Adverse event. An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. Reporting: Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC. -If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. -If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 resident (Resident #24) of 6 residents reviewed for care plans. The facility failed to develop a person-centered comprehensive care plan for Resident #24, who was at high risk for elopement and who had exit-seeking behaviors. Resident #24 eloped from the facility on 08/08/25, she was found near an apartment complex on a busy street next to the facility by a passerby and brought her back to the facility. The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 08/08/25 and ended on 08/12/25. The facility had corrected the noncompliance before the survey began. The failure placed the resident at risk for serious adverse outcomes including serious harm.Findings included: Record review of Resident #24's annual MDS assessment, dated 07/10/25, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's Disease (brain disorder caused by damage to nerve cells in the brain), anxiety disorder (a mood disorder characterized by excessive, persistent, and uncontrollable fear and worry about everyday situations), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), diabetes mellitus (a chronic disease characterized by high level of sugar in the blood), muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), unsteadiness on feet and unspecified lack of coordination. The MDS reflected Resident #24 had moderate cognitive impairment with a BIMS score of 11. The MDS further reflected Resident #24 did not exhibit wandering behaviors. Record review of Resident #24's care plan, dated 06/19/25, reflected care plan did not address Resident #24 exit seeking behaviors. Record review of Resident #24's Elopement/Wandering Observation quarterly, dated 06/18/25, reflected Resident #24 was high risk for elopement. The evaluation indicated resident had a medical diagnosis associated with confusion, which may indicate future likelihood of high-risk behavior(s). Mobility: Resident is physically able to exit on foot or by wheelchair. Record review of Resident #24's Elopement Risk Evaluation, dated 08/08/25, reflected Resident #24 was at risk for elopement. The evaluation indicated Resident #24 had a history of attempting to leave the facility one or more times in last week. Statement and/or treats to leave facility. Record review of Resident #24's progress notes dated 08/08/25 at 10:55 AM reflected: This nurse was notified by [NAME] Hall nurse that resident was found next door by a resident of the apartment complex. Vitals and skin assessment normal to resident baseline. MD/DON/RP notified. New orders given via telephone from MD: CBS/CMP/UA/Chest Xray. DON will enter the orders. Resident reports she was going back home attempted to redirect resident and successful. Record review of facility Twenty-Four Hour Report dated 08/08/25 reflected: Resident Name: Resident #24; 6AM-2PM: Eloped @ 1055 [10:55AM]; 1:1 ratio at all times. 2PM-10PM: Elope cont. 1:1, stable, in bed. Record review of facility Event Report for Resident dated 08/08/25, time of event 1055 [10:55AM] reflected: Type of Event: Elopement, Note how long missing: 3-5 mins. Heat to toe assessment: no new injuries noted. Skin warm to touch. MD & RP notified of event. Nurse on St.2 told Administrator resident went out front door behind another resident's family [Initial Name] daughter. 3-5 min later [NAME] as with a lady. Statement of resident obtained: Not able to recall. No injury. List new interventions: Resident on 1:1 supervision. Interview on 09/03/25 at 12:06 PM, LVN A revealed she was the nurse assigned to Resident #24 when she eloped from the facility. She stated she could not recall the exact time, but it was between the times of 10AM - 11AM when Resident #24 eloped. She stated she was getting ready to do blood sugar checks when RN B brought Resident #24 to her and told her someone from the apartment complex saw the resident outside and brought her back to the facility, rang the doorbell and asked if this resident lived here. LVN A stated the Activity Director opened the door and verified Resident #24 was a resident from the facility and brought Resident #24 back to her hall. She stated the last time she observed Resident #24 she was in the dining area. She stated it was about a 5 - 10-minute window from when she last observed Resident #24 to when she was brought back to the facility. She stated she does not know exactly how Resident #24 exited the facility, she stated no alarm doors were heard. LVN A stated after Resident #24 was brought back they checked all the doors to ensure they were all closed and alarms working properly. LVN A stated that morning a visitor had come to visit another resident, and she believes when the visitor left the facility the visitor did not checked behind her and Resident #24 followed her out. LVN A stated Resident #24 saw the opportunity and went for it. She stated Resident #24 had history of exit seeking, she stated she would always say I want the code for the door, if someone was leaving the building resident would say I am going with them, she stated she would try to push the door, and the alarms would go off. LVN A stated Resident #24 would be easily redirected and they would keep her busy with activities. She stated resident would propel in her wheelchair and she was fast moving around. LVN A stated she completed a head-to-toe assessment on Resident #24, and no injuries were noted skin was intact. She stated she notified the doctor and Resident #24 family member. She stated Resident #24 was placed on 1:1 supervision until she discharged to another facility on 08/11/25. LVN A stated she could not recall if Resident #24's was care planned for being at risk of elopement. She stated the DON was responsible for updating care plans. She stated if Resident #24 was exhibiting exit seeking behaviors it should had been care planned. She stated care plans were needed to keep up with resident's care, safety and have interventions in place. Interview on 09/03/25 at 12:38 PM, the DON revealed she was informed by LVN A Resident #24 was found by a lady coming out of the apartment complex. The lady saw resident, stopped her car and brought the resident back to the facility and asked if the resident lived here. She stated the Activity Director was the one who opened the door and informed the lady that Resident #24 was a resident at the facility. She stated per LVN A last time she observed Resident #24 she was in the dining area and resident was out for about 3-5 minutes. She stated Resident #24 would ambulate in her wheelchair and was known to peddle fast on it. The DON stated Resident #24 was an elopement risk, she stated an elopement assessment was completed on 08/08/25, and resident scored high risk. The DON stated she could not locate any prior elopement assessment completed on Resident #24, then stated she did not look to ensure if any were completed prior to the elopement but she knew resident was a high risk. She stated Resident #24 had history of attempting to leave the facility, she stated one time unknown of date of when it happened, Resident #24 was attempting to leave but was within eyesight of hers and she immediately stopped her and redirected her. The DON stated Resident #24 was placed on 1:1 supervision until she discharged to another facility. She stated she was not sure if Resident #24 was care planned for her exit seeking behaviors prior to being updated on 08/08/25. The DON reviewed Resident #24 and stated resident had not been care planned for her behaviors. She stated the ADON C was responsible for reviewing and updating care plans but since the ADON C left, she was not responsible for care plans. She stated Resident #24 care plan was updated after her elopement and being on 1:1 supervisor. She stated the potential risk of not care planning elopement behaviors would be staff not knowing the interventions in place for high-risk residents for elopements. Interview on 09/03/25 at 1:03 PM, the Administrator revealed Resident #24 had exited the facility on 08/08/25. She stated till this day they still do not know how resident exited the facility. She stated someone from next door apartment complex found Resident #24 and brought her back to the facility and asked if she lived here. The Administrator stated Resident #24 was only gone for a couple of minutes. She stated she was in her office and could not recall when the last time Resident #24 was last seen. She stated Resident #24 eats her breakfast in her room, once done she is out and about. The Administrator stated Resident #24 was an exit seeker, has tried in the past to exit but was not successful. She stated Resident #24 would always say her car was outside. She stated they would try to redirect resident, keep her busy with activities and watch her within eyesight. She stated after the elopement Resident #24 was placed on 1:1 supervision until they could find an appropriate placement for her. She stated a QAPI meeting was completed with the DON and MD regarding the elopement and suggested Resident #24 required a secure unit. She stated the DON reached out to the family twice on 08/08/24 and LVN B was able to notify the family regarding the incident. The Administrator stated Resident #24 discharged from the facility on 08/11/25. She stated she was not aware Resident #24 exit seeking behaviors were not care planned. The Administrator stated at that time the ADON C and Social Worker were responsible for reviewing and updating care plans, but they left after transitioning to the new company. She stated care plans were important so that staff can keep up with the resident's care. She stated the potential risk would be staff not knowing the interventions in place for resident who are high risk of elopement. The Administrator stated all staff were inserviced elopement risk assessments were completed on all residents, care plans were updated on residents identified as being at high risk of elopement. Record review of the facility's policy Care Plan-Resident, dated December 2018, reflected:It is the policy of this home that staff must develop a comprehensive care plan to meet the needs of the resident. 5. Resident Goalsa. List a measurable, reasonable goal for each problem identified.This was determined to be a Past Non-Compliance Immediate Jeopardy on 09/03/25 at 4:15 PM. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 09/03/25 at 4:40 PM. The facility took the following actions to correct the non-compliance prior to the survey: Record review of facility QAPI revealed a meeting was completed on 08/08/25. Record review of Resident #24's care plan, updated on 08/08/25, reflected Problem: Resident is at risk of elopement as evidenced by. Goals: Resident will not leave the facility. Approach(s): Notify physician and family of any further concerns. Discuss secure unit placement. Monitor and record behavior with it occurs. 1:1 monitoring within eyesight. Divert residents attention and refocus attention elsewhere, staff to orient and redirect resident as needed if she talks of leaving. Record review of Resident #8, Resident #9, Resident #14, Resident #30 and Resident #35's Care Plans reflected care plans were reviewed and updated from 08/08/25 through 08/12/25 to reflect them as being high risk for elopements and to monitor for exit seeking behaviors. Record review of in-services with a start date of 08/08/25 reflected all facility staff were in-serviced on Elopement Risk Report, Elopement & Binder, what to do for Elopement, Elopement Risk Assessments. Summary of Meeting: Elopement risk assessments assist staff in knowing what residents are at risk to elope/try to leave facility. High risk residents' pace, wander, pack their items, talk about going home, watches the doors that are exits. Residents who are bed bound, can't push or move their w/cs on their own and can't transfer out of bed are less likely to be high risk. We care completing Elopement Risk assessments, updating care plans, updating elopement binder if any residents are exit seeking nurse, DON, Administrator be told immediately. Elopement Risk Binder will be set up with ALL resident's elopement risk assessment, face sheet, resident at high risk for elopement - (want to be able to walk or use own w/c to push, packs items)- will be at front of binder. Low risk will be next, no risk - (bed bound can't transfer or move w/c independently) -no risk back of binder. Do not provide codes to visitors, during an elopement check inside and outside, complete a head count, make sure visitor check in. Inservices were completed by 08/12/25. Interviews on 09/03/25 from 12:25 PM through 3:30PM with LVN A, RN B, LVN J, LVN K, who worked the shifts of 6:00 AM-2:00 PM and 2:00 PM-10:00 PM revealed the facility staff were able to verify education was provided to them. Nursing staff stated elopement risk assessments were reviewed/competed (an evaluation to determine any resident at risk of elopement), and care plans were updated on residents who were identified as high risk of elopement. Nursing staff stated if any resident exhibits any behaviors, they will report to the DON for care plans to be updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 (Resident #32) of 6 residents for care plan revisions. The facility failed to review and revise Resident #32's comprehensive care plan after the MDS assessment was completed on 06/25/25. Resident #32's last care plan meeting was dated 08/07/24.This failure could affect residents and could result in resident's needs not being met. Record review of Resident #32's face sheet, dated 08/07/25, reflected the resident was a [AGE] year-old female with an admission date of 08/03/23 and returned 03/08/25. Record review of Resident #32's quarterly MDS assessment dated [DATE] reflected her diagnoses included hypertension (high blood pressure), dementia, cognitive communication deficit, and depression. The MDS reflected the resident had severe cognitive impairment with a BIMS score of 4. Record review of Resident #32's care plan, last reviewed/revised date 04/24/25 reflected Category: Return to community referral POA had no desire for [Resident #32] to return to community. Staff will revisit on comprehensive assessments only. Goal: Resident needs will be met by facility staff through the next review period. Approach: 1. Keep POA/[Resident #32] updated on the resident plan of care. 2. Staff will maintain [Resident #32] needs. 3. Follow up with the [Resident #32]/POA annually. Record review of Resident #32's Care Conference Report reflected the last care plan meeting was completed on 08/07/24 for Annual Care Conference. Record review of Resident #32's progress notes reflected no documentation regarding care plan meetings or family being made aware of care plan conference meetings. Interview on 08/05/25 at 1:20 PM, Resident #32's Family Member A/POA revealed he had concerns regarding Resident #32's care and wanted to address it with the facility. Resident #32's Family Member A/POA stated he had not been invited to any care plan meetings to address his concerns. Resident #32's Family Member A/POA stated he was not aware care plan meetings were held quarterly. The last care plan meeting he had been invited to and attended was sometime last year 2024, exact date unknown.Interview on 08/05/25 at 1:23 PM, Resident #32 revealed she had no concerns regarding her care. Resident #32 was not a good historian and could not recall if she had attended a care plan meeting or been asked to attend one.An attempt was made on 08/07/25 at 11:25 AM to contact the ADON C/MDS Coordinator by phone; however, there was no answer. Interview on 08/07/25 at 12:52 PM, with the DON revealed the Social Worker and ADON C, who was the MDS Coordinator, were responsible for coordinating the care plan meetings. The DON stated the Social Worker or ADON C would inform her when a care plan meeting was scheduled, and she would attend. She stated care plan meetings should be documented in the residents' charts, and the Social Worker would keep notes of what was discussed during the meeting. The DON stated she had been employed since February 2025, and she could not recall if Resident #32 had had a care plan meeting. She stated care plan meetings should be completed quarterly with family. She stated both the Social Worker and ADON C were no longer employed by the facility. The DON stated she was not aware Resident #32's care plan meetings were not being completed quarterly. She stated the potential risk of not completing care plan meetings would be the team, family, and resident not being informed about changes or areas that needed to be addressed regarding the resident. Interview on 08/07/25 at 1:50 PM, with the Administrator revealed the Social Worker and ADON C were responsible for scheduling care plan meetings. She stated she was not aware Resident #32 had not had a care plan meeting since 2024. She stated the IDT was responsible for conducting the care plan meetings. She stated the potential risk of not having the care plan meetings would be family not being able to communicate their concerns regarding the resident's care or not being able to know the level of care the resident was receiving. She stated Resident #32's family had not mentioned anything to them about a care plan meeting. An attempt was made to contact the Social Worker by phone on 08/07/25 at 2:17 PM; however, there was no answer.Record review of the facility's Statement of Resident Right policy dated 12/01/18 reflected the following: .To participate in developing a plan of care that describes their medical, psychological, and nursing needs and how the needs will be met .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of six residents reviewed for accidents.<BR/>CNA A failed to safely transfer Resident #1 with a mechanical lift by failing to have another staff member assist with the transfer, which resulted in the mechanical lift tilting over, causing Resident #1 to fall. There was no injury related to the fall. <BR/>This failure could place all residents, who require the use of a mechanical lift for transfers, at risk of injury during transfers.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet revealed the resident was an [AGE] year-old female, initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included: morbid obesity (excessive body fat), atherosclerosis (build-up of cholesterol in arteries), lack of coordination, muscle atrophy (decreased muscle tissue), chronic obstructive pulmonary disease (lung disease), and heart failure. <BR/>Record review of Resident #1's annual MDS assessment, dated 06/14/23, revealed Resident #1:<BR/>- was cognitively intact (BIMS score 13); <BR/>- required extensive assistance with most ADL including bed mobility, dressing, and personal hygiene; and <BR/>- required total assistance and two-person assistance with transfers.<BR/>Record review of Resident #1's care plan, revised 04/25/23, indicated Resident #1 was at risk for falls related to increased weakness and required two-person assistance for transfers.<BR/>Record review of an incident report, dated 06/23/23, indicated Resident #1 was lying on the floor with CNA A present. CNA A reported to DON that she was transferring Resident #1 from a shower chair to her bed using mechanical lift. Resident #1 was alert and denied hitting her head. A physical assessment revealed no visible injuries or swelling. The MD was made aware of the fall. <BR/>Record review of radiology report, dated 06/23/23, revealed the following:<BR/>Right shoulder (2 or more views):<BR/>- A fracture of the right humeral neck. This fracture may be subacute.<BR/>Right humerus-2 view:<BR/>- A fracture of the right humeral neck. This fracture may be subacute.<BR/>Right forearm-2 view:<BR/>- No acute fracture or dislocation of the right forearm.<BR/>Record review of radiology report, dated 06/26/23, revealed the following:<BR/>Right shoulder (2 or more views):<BR/>- No acute fracture or dislocation of the right shoulder.<BR/>Record review of in-service titled Mechanical Lift, dated 06/23/23, revealed staff, including CNA A, were trained on mechanical lift transfer protocol. <BR/>Interview on 06/30/23 at 10:00 AM, the DON stated she was at the facility on 06/23/23 when Resident #1 fell from the mechanical lift. She stated CNA A yelled for her help from Resident #1's room, and when she went in, and she found the resident and CNA A on the floor. The DON stated CNA A reported that she had just given Resident #1 a shower and was transferring her from the shower chair to the bed when the mechanical lift tilted over. The DON stated Resident #1 complained of slight pain to right shoulder but stated she was fine. The DON stated Resident #1 was assessed head-to-toe and there were no visible injuries. The DON stated the medical doctor was immediately notified and an x-ray was ordered for Resident #1. The DON stated the initial x-ray was completed on 06/23/23 and results showed a fracture to the right humeral neck/shoulder, possibly subacute, and the MD was notified of results. The DON stated a sling and follow-up appointment with an orthopedic surgeon was ordered for Resident #1. The DON stated that over the next couple of days, Resident #1 denied being in pain and refused to keep the sling on her arm. The DON stated Resident #1 had full range of motion and was able to move her right arm without pain. Resident #1 informed them she had injured her right arm during a fall several years ago, and it always gave her problems. The DON stated due to Resident #1 denying pain and being able to use her right arm, a second x-ray was ordered and completed on 06/26/23 which revealed negative results for a fracture or dislocation but showed signs of osteopenia. The DON stated the MD came out on 06/27/23 to assess Resident #1 and reviewed the x-ray, and the MD stated there were no apparent issues clinically consistent with a fracture or abnormalities. The DON stated the portable x-ray machines were not always efficient, and the initial x-ray results were inaccurate. The DON stated CNA A knew not to transfer with the mechanical lift without a second qualified staff there to assist based on the training she had received and her experience since CNA A had worked at the facility for several years. The DON stated the risk of using a mechanical lift without assistance could be the resident falling and possibly sustaining serious injuries. <BR/>Interview on 06/30/23 at 11:20 AM, Resident #1 denied being in pain and stated that she was feeling good. Resident #1 recalled having a fall during a mechanical lift transfer on 06/23/23 after receiving a shower. She stated normally two staff would transfer her but on that day CNA A transferred her alone. Resident #1 stated her right arm hurt a little after the fall, but she denied any major injuries. Resident #1 stated she fractured her right arm from a fall years ago and any slight agitation causes it to act up. Resident #1 stated she felt safe during all other transfers in the mechanical lift and denied being abused or neglected. <BR/>Interview on 06/30/23 at 3:15 PM, CNA A revealed she had worked at the facility for five years. She stated she had been trained on using a mechanical lift at least annually and in-serviced as needed. CNA A stated all mechanical lift transfers required two staff; however, Resident #1 wanted a shower very early on the morning of 06/23/23, before all staff had arrived on shift. CNA A stated the shower went well and when it was time to get Resident #1 back in bed, she was unable to find another CNA to assist her. She stated there was a nurse assigned to the hall, but she was administering medications and was not available. CNA A stated she turned on Resident #1's call light and waited several minutes, but no one came to assist her. She stated she heard the housekeeper in the hall and called for her to assist with the transfer. CNA A stated she knew that the housekeeper was not trained to assist, but she did not know what else to do. CNA A stated once she had Resident #1 in the mechanical lift, she felt that she could handle it and told the housekeeper that she could leave. She stated as she was guiding Resident #1 towards the bed from the side of the mechanical lift tilted forward. CNA A stated the weight of the mechanical lift forced her to the floor first, and Resident #1 fell on top of her. CNA A stated she cushioned Resident #1's fall and if anyone was going to be hurt it would have been her. <BR/>Interview on 06/30/23 at 4:00 PM, the Administrator stated her expectation was for all mechanical lift transfers to be conducted by two qualified staff per the facility's policy. She stated the housekeepers were not qualified to assist with the care of residents. The Administrator stated Resident #1 was secure in the shower chair and CNA A should have let her remain there until a second qualified staff was available to assist. She stated CNA A was written up and received re-education on mechanical lift transfers. <BR/>The facility's policy titled Mechanical Lift, dated October 2017, revealed in part the following:<BR/>Policy: It is the policy of this home to utilize the Mechanical (or similar) lift when it is necessary to safely transfer a resident due to body weight or physical condition.<BR/>These are general guidelines only. The specific product utilization by the home may vary per the manufacturer recommendations. Lifting a resident with a mechanical lift is always a two-person procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews 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 demonstrates that this is not possible or resident preferences indicate otherwise for 2 residents (Resident #6 and #7) of 5 residents reviewed for quality of care. 1. The facility failed to ensure Resident #6, who received nutrition via tube feeding and had unavoidable weight loss, was weighed weekly as ordered by the physician. 2. The facility failed to ensure Resident #7, who had unplanned weight gain, was weighed weekly as ordered by the physician. This failure could place the residents at risk of weight changes going unnoticed leading to a worsening of their medical conditions. Findings included:1. Record review of Resident #6's quarterly MDS, dated [DATE], reflected the resident was an [AGE] year-old female, who admitted to the facility on [DATE]. The resident's cognition was intact with a BIMS score of 15. The MDS reflected the resident had a diagnosis of malnutrition (lack of proper nutrition), she required substantial assistance with eating, and she had a feeding tube. The resident also had a diagnosis of a pressure ulcer, which had resolved as of 08/03/25. Record review of Resident #6's care plan, dated 04/10/25, reflected the resident was on a therapeutic diet, had poor nutritional intake, and required a feeding tube. The care plan interventions included monthly weights and reporting to the physician if the resident had a 5% weight loss or weight gain. The resident was also on hospice care. Record review of Resident #6's physician orders reflected there was an order dated 11/12/24 for Resident #6 to be weighed weekly due to the resident weighing less than 100 pounds and have a feeding tube. Record review of Resident #6's weight records reflected she was weighed weekly after the physician order was issued on 11/12/24 until 03/26/25. After 03/26/25, the resident was only weighed twice a month, instead of weekly, until 05/07/25. After 05/07/25, the facility only weighed Resident #6 once a month instead of weekly. The weight records reflected:01/01/25 - 87.2 pounds01/08/25 - 87.8 pounds01/15/25 - 93 pounds01/29/25 - 93 pounds02/05/25 - 94 pounds02/19/25 - 94 pounds02/26/25 - 89.6 pounds03/05/25 - 93 pounds03/12/25 - 92.7 pounds03/26/25 - 89.4 pounds04/09/25 - 90 pounds04/23/25 - 88.5 pounds05/05/25 - 86 pounds05/07/25 - 88.4 pounds06/24/25 - 85.2 pounds07/05/25 - 80.2 poundsRecord review of Dietician notes from January 2025 to June 2025 reflected Resident #6's Dietician notes revealed she was seen once a month until she entered hospice on 6/2/25. The dietician was aware of the resident's weight losses, she made adjustments to the resident's enteral feedings, increasing the hourly amount from 60 ml/hr. to 70 ml/hr. and finally 80 ml.hr. Health shakes were added to her diet, two cans a day and then three cans a day. Fortified foods were added to her menu selections as well.Record review of Resident #6's hospice book records from 6/2/25 to 8/6/25 reflected the resident admitted herself to hospice because she knew she was deteriorating, and a recent chest x-ray revealed a mass in her chest that was assumed to be cancer. The hospice nursing notes revealed the resident complained of pain and anxiety at almost every visit, and her pain and anxiety medications had been increased several times. Interview on 08/22/25 at 12:15 PM with Resident #6 revealed she was aware she was losing weight. She stated she just did not have an appetite. She stated she opted for hospice to spare her spouse from having to take care of her. She stated the last time she was in the hospital (July 2025), a mass was discovered in her chest. She stated she refused any diagnostic testing and assumed it was some form of cancer. Resident #6 stated she received her g-tube feedings at nighttime and during the day she received her meals with a shake. Interview on 08/6/25 at 11:10 AM with LVN A revealed she was unaware of the resident's weight loss. She stated the CNAs were responsible for weighing the residents and reporting the weight back to the nurse for the nurse to enter into the electronic record. She stated she was unaware Resident #6 had an order to be weighed weekly. Interview on 08/06/25 at 11:45 AM via telephone with Resident #6's physician, Physician F, revealed Resident #6 was on hospice for end of life. He stated Resident #6's weight loss would be expected as her condition deteriorated. Interview on 08/06/25 at 12:05 PM with the DON stated she was unaware of Resident #6's weight loss. She stated the nurses were responsible for monitoring the resident's weights and reporting any concerns to her and the physician. In an interview on 08/06/25 at 12:23 PM with CNA E stated she was the CNA assigned to Resident #6. She stated Resident #6 health had been declining. She stated staff assist the resident with eating, but the resident did not eat most of her meals. She stated Resident #6 was given a health shake with her meals. She stated the CNAs were responsible weighing the residents, and they were supposed to report to the nurses if a resident had weight loss or weight gain. Interview on 08/22/25 at 2:10 PM with the Dietitian revealed she visited Resident #6 monthly. She stated Resident #6 struggled to maintain her weight, and adjustments had been made to the resident's diet and tube feeding. Also, health shakes were added to supplement the resident's diet. She stated the resident's caloric needs were met by her tube feedings, and any other intake was just extra calories. The Dietitian stated with the mass in the resident's chest being cancer the calories Resident #6 was taking in most likely were feeding it instead of her. She stated Resident #6's weight loss was unavoidable, but the resident could not afford to lose much moreInterview on 08/22/25 at 2:33 PM with the Dietary Manager revealed she was aware of Resident #6 weight loss. She stated Resident #6 was currently on high calorie foods, health shakes, milk with each meal and extra butter. She stated Resident #6 was also on a g-tube and receiving extra bolus feedings. She stated Resident #6's weight loss was unavoidable, and the resident refused most of her meal. The Dietary Manager stated Resident #6 ate most of her breakfast but when it came to lunch and dinner she refused to eat.2. Record review of Resident #7's quarterly MDS, dated [DATE], reflected the resident was a [AGE] year-old female, who admitted to the facility on [DATE]. The resident had moderate cognitive impairment with a BIMS score of 8. The MDS reflected Resident #7's diagnoses included morbid (severe) obesity due to excess calories and Type 2 diabetes mellitus. The resident required substantial to maximal assistance (helper does more than half the effort; helper lifts or holds trunk or limbs and provides more than half the effort) for transfers and was dependent for bed mobility (helper does all the effort). The resident required only set-up or clean-up assistance with eating.Record review of Resident #7's care plan, dated 06/8/25, indicated she had an unexpected weight gain on 04/14/25 of 48 pounds with interventions of weighing monthly. Record review of Resident #7's physician orders, dated 01/06/25, reflected there was an order for Resident #7 to be weighed every three days. The order reflected the physician was to be notified if Resident #7 gained 3 pounds or more. Review of Resident #7's lab work revealed she had a CBC and a BMP drawn in January 2025, with no abnormal findings. Review of Resident #7's weight records revealed she was weighed every three days from 01/06/25 until 01/25/25. After 01/25/25, Resident #7 was only weighed once a month except for April 2025 where there was no documented weight. From 01/25/25 to 05/05/25, the resident went from 362 pounds to 382.2 pounds, a 20-pound or a 5.58% gain. 01/02/25 - 365 pounds01/07/25 - 365.4 pounds01/10/25 - 366.6 pounds01/15/25 - 367.8 pounds01/25/25 - 362 pounds02/05/25 - 361.4 pounds03/04/25 - 361.2 pounds05/05/25 - 382.2 poundsObservation on 08/06/25 at 11:00 AM revealed Resident #7 was weighed via sling and weighed 371.8 pounds. Interview on 08/06/25 at 11:05 AM with LVN A revealed Resident #7 was weighed every month. LVN A revealed she was unaware Resident #7 had a physician order to be weighed every three days. Interview on 08/06/25 at 11:45 AM with the Physician revealed his physician group had assumed care of the facility in June of 2025. Interview on 08/22/25 at 12:07 PM with Resident #7 stated she was doing well. Resident #7 stated she had been working on losing weight. Interview on 08/06/25 at 12:23 PM with CNA E revealed the CNAs were responsible for weighing the residents. She stated CNAs would report to the nurses if a resident had any weight loss or weight gain. She stated she had not noticed Resident #7 having a significant weight gain, and the resident seemed to be her usual self. She stated she had not noticed the resident being puffier or her clothing being too tight. Interview on 08/22/25 at 1:24 PM with LVN A revealed she obtained Resident #7's weight had been consistent. Interview on 08/22/25 at 1:40 PM with RN B revealed the nurses knew who needed to be weighed by what was on the TAR. The TAR indicated if a resident was supposed to be weighed monthly, weekly, etcetera. She stated there was nothing in the EHR that would alert them to a sudden weight gain or loss. She stated the ADON was responsible for monitoring resident weights.Interview on 08/22/25 at 2:10 PM with the Dietician revealed she evaluated Resident #7 in January 2025 as part of her annual evaluation. She was not aware of any weight issues of Resident #7. Record review of the facility's Weight System policy, dated December 2017, reflected: .Residents will be weighed within a timely manner of admission/Readmission. Residents will be weighed by the 5th of the month. Any Resident with a significant weight loss will be reweighed within 24 hours. The monthly weights will be entered into the computer by the 7th of every month. Weight variances will be reviewed at the weekly (?) The DON/ designee will ensure the physician, Responsible Party, and Dietician will be notified in a timely manner and documented in clinical record software.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments and were labeled in accordance with currently accepted professional principles for 1 (Resident #134) of 9 residents reviewed for pharmacy services.<BR/>LVN D failed to put her initials, date, and time on Resident #134's IV medication bag and tubing when she administered the IV antibiotic, Meropenem. <BR/>These failures could place residents at risk for medication error and delay in medication administration.<BR/>Findings included:<BR/>Review of Resident #134's face sheet, dated 07/16/24, revealed the resident was a [AGE] year-old male admitted on [DATE]. Resident #134's diagnoses which included sepsis without septic shock (a life-threatening medical emergency caused by body's overwhelming response to an infection) and bacteremia (the presence of bacteria in blood).<BR/>Review of Resident #134's physician's orders dated 07/13/24 reflected: (Meropenem Intravenous Solution Reconstituted 1-gram (1000) milligrams /100 milliliters intravenously every 8 hours).<BR/>Observation on 07/15/24 at 8:53 AM revealed LVN D performing morning medication pass for Resident #134. LVN D sanitized and prepared Meropenem 1 g/100 ml, saline syringes and alcohol swabs. She knocked on the door and explained the procedure to Resident #134. She washed her hands, put on gloves and fixed the tubing to the bag. She removed her gloves, sanitized her hands, and put on new gloves. She cleansed the PICC line tip with alcohol, connected the tubing, and adjusted the flow meter. She did not label the bag or the tubing with the date, time, and her initials after administering the IV medication. She removed her gloves, washed her hands, left the resident comfortable, and left the room.<BR/>Observation and interview on 07/16/24 at 9:33 AM revealed Resident #134 was in his room, on his bed. He was observed with the IV medication being administered. The IV bag and the tubing were observed not labeled with date, time, and staff initials.<BR/>Observation and interview on 07/16/24 at 10:15 AM with LVN D revealed Resident #134's IV medication bag and the tubing were missing the time, date, and her initials. LVN D said the intravenous bag was supposed to have the correct resident's name, date, time and initial of the nurse administering the medications. She stated she was aware she was supposed to label the bag and the tubing, but she forgot. She stated failure to label the bag and the tubing could lead to overdose, omission of a dose, and infection control. She stated the bag was changed as scheduled and the tubing could be changed every 24 hours. LVN D stated she had done training on IV administration.<BR/>Interview on 05/16/24 at 01:44 PM with the DON revealed her expectation was that the staff should date and initial IV bags and tubing when administering intravenous medications. She stated putting the dates and initials would show when the bags were hanged and when the tubing was last changed. The DON could not state the risk but stated nothing had happened yet. She stated she had done training and no documentation was provided.<BR/>Review of the facility's IV Administration of drugs policy, revised August 2021, reflected: .1 verify label on intravenous bag with prescriber's order. Attach label (with date ,time, and nurse's initials) to tubing and bag

Based on observation, interview, and record review, the facility failed to ensure the menus met the nutritional needs of residents in accordance with the established national guidelines and were followed for 1 of 3 meals (lunch meal 08/06/25) observed. [NAME] D failed to follow the menu when preparing the pureed lunch meal on 08/06/25. The failure could place residents, who were on a pureed diet, at risk for a decrease in nutritive status, loss of appetite, decreased intake and unwanted weight loss.Findings included:Record review of the facility Week at a Glance menu dated Week 1 Spring/Summer2025, reflected the menu for the lunch service for Wednesday (Day 4) was Cilantro Lime Chicken, [NAME] Pilaf, Squash & Red Peppers, Dinner Roll, Margarine, Fruit Crisp, Beverage.Record review of the Pureed Cilantro Lime Chicken recipe reflected the following: .Add broth, as needed; blend until smooth. 1. If product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency.Record review of Pureed [NAME] Pilaf recipe reflected the following: Place prepared rice in a washed and sanitized food processor. Gradually add broth as needed and blend until smooth. 1. If product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistencyObservation on 08/06/25 at 10:45 AM revealed [NAME] D making pureed lunch. [NAME] D put the lime chicken in the processor, then proceeded to use the processor food pusher to add water twice and added it to the chicken. [NAME] D added the water without measuring, added thickener and blended the mixture. [NAME] D blended the chicken for about 5-10 seconds and then poured it into small food cups. The pureed cilantro lime chicken appeared to have a mashed potato consistency; however, the chicken did not appear to be fully blended. [NAME] D then was observed to put rice pilaf in the processor, then proceed to use the processor food pusher to add water twice and added it to the rice. [NAME] D added the water without measuring, added thickener and blended the mixture. The pureed rice pilaf appeared to have a mashed potato consistency.Interview on 08/06/25 at 12:49 PM with [NAME] D revealed she had been employed for over a month. She stated she reviewed the puree recipe to ensure she had all the ingredients. She stated she was aware the recipe stated not to add water, and she added water to the chicken and rice. [NAME] D stated the chicken and rice were thick and she added water to loosen them up. She stated she could have used chicken stock instead of water, but they did not have any. She stated by adding water it could take away the flavor. Interview on 08/06/25 at 12:53 PM with the Dietary Manager revealed her expectation was for the Cooks to follow the recipes and have the correct food consistency. She stated they had chicken stock in the kitchen, but the [NAME] failed to use it today (08/06/25). She stated it was her responsibility to ensure kitchen staff followed the recipes. The Dietary Manager stated kitchen staff should know not to add water when pureeing food. She stated water could not be added to the pureed foods because it diluted them and took away the nutrients and flavor. Record review of facility's Pureed policy, dated 2022, reflected the following: The Puree Diet is designed for those individuals who have difficulty swallowing or cannot chew foods of the dental soft consistency. Drain liquid from portions needed for pureed preparation. Reserve liquid in case additional liquid is needed when pureeing to the correct consistency. NEVER USE WATER AS THE LIQUID ADDED TO A PUREED ITEM.the following liquids would be acceptable to use when pureeing foods: prepared broth, gravy, sauce, milk, juice and melted margarine/butter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement an effective discharge planning process that is consistent with the discharge rights set forth at 483.15(b) as applicable and involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan for 1 of 3 residents (Resident #24) reviewed for discharges. The facility failed to involve Resident #24's POA in the discharge plan prior to Resident #24 being transferred to a different facility on 08/11/25. This failure could place residents at risk of not having complete records after permanent discharge from the facility. Findings included: Record review of Resident #24's discharged MDS assessment, dated 08/11/25, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE] and discharged on 08/11/25 to Nursing Home. Resident #24 entry/discharge reporting - Discharge assessment -return not anticipated. The resident's diagnoses included Alzheimer's Disease (brain disorder caused by damage to nerve cells in the brain), anxiety disorder (a mood disorder characterized by excessive, persistent, and uncontrollable fear and worry about everyday situations), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), diabetes mellitus (a chronic disease characterized by high level of sugar in the blood), muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), unsteadiness on feet and unspecified lack of coordination. The MDS reflected Resident #24 had moderate cognitive impairment with a BIMS score of 11. Record review of Resident #24's care plan, dated 06/19/25, reflected: Problem: Category: Return to Community Referral POA has no desire for [Resident #24] to return to community. Staff will revisit on comprehensive assessments only. Goal: [Resident #24] needs will be met by facility staff through the next review period. Approach: 1. Keep POA.u pdated on the [Resident #24] residents plan of care. 2. Staff will maintain [Resident #24] needs 3. Follow up with.POA annually. Record review of Resident #24's progress notes on 08/11/25 at 10:30AM by LVN A reflected: Resident is calm and oriented to self. vitals assessed, normal to residents baseline BM reported this morning. Spoke with [family member] facility to give report. Medications reconciled. Meds from med cart, included Lyrica and Norco counted with west side Hall nurse. Majority of residents belongings gathered. Resident in route to [Facility] family in location. Record review of Resident #24's clinical records reflected there was no documented evidence reflecting Resident #24's legal representative or family member was notified of the discharge or involved in the planning of the discharge. Interview on 09/02/25 at 1:23 PM with Resident #24's family member, Family Member C, revealed Resident #24 was transferred to another facility without family consent. Family Member C stated they had two missed calls on Friday 08/08/25 regarding Resident #24's elopement. Family Member C stated they called back and were notified of the elopement, but they were never told about the transfer. They stated they only had a voicemail from the DON stating she wanted to talk to the family member about moving the resident to a secure unit. Family Member C called the facility on Monday 08/11/25 and was told Resident #24 was already moved to another facility Family Member C stated they called the Administrator and expressed their concerns to the Administrator regarding the resident being moved. Family Member C stated the Administrator was under the impression family was aware of the transfer; however, they were not. Family Member C stated the family was aware Resident #24 had exit-seeking behaviors, was at risk of eloping from the facility, and required a secure unit. Family Member C stated the family would have preferred to be given the opportunity to find a more suitable placement for the resident. Interview on 09/03/25 at 12:06 PM with LVN A revealed she was the nurse assigned to Resident #24 when the resident discharged on 08/11/25. She stated Resident #24 eloped from the facility on 08/08/25 and was placed on 1:1 supervision until she discharged on 08/11/25. She stated when she returned to work on 08/11/25, she noticed Resident #24 was scheduled to be discharged . She stated before she released Resident #24, she contacted the DON to ensure this was the plan to transfer the resident. She stated the DON notified her that everything was in place for Resident #24 to discharge to a different facility. LVN A stated she was never told to contact family. She stated the DON was the one who handled the discharge planning for Resident #24. LVN A stated she never contacted the family regarding the discharge, and she only talked to the family on 08/08/25 to notify them of the resident's elopement. On the day of the discharge, LVN A stated she assisted Resident #24 with her belongings. She stated Resident #24 was doing well with the discharge, and the resident was not crying or upset about the transfer. Interview on 09/03/25 at 12:53 PM with the DON revealed she or LVN A had notified Resident #24's family of the resident's discharge on [DATE]. The DON stated she left a voicemail for Family Member C stating she needed to talk to them about moving the resident to a secure unit. The DON stated she was not in the building on 08/11/25 when Resident #24 discharged . She stated it was a mutual decision between herself, the Administrator, and MD to discharge Resident #24 to a more appropriate facility because the resident was no longer safe at the facility. The DON stated she did not have a conversation with Resident #24's family regarding the discharge, but she assumed someone had. She stated she spoke to Family Member C on 08/11/25 around 2:00-3:00 PM and informed Family Member C that Resident #24 had already discharged from the facility. She told the family member she assumed someone had contacted the family prior to the resident's discharge. The DON stated the facility's process for handling discharges involved the facility having a discussion with the family, and this discussion included the Administrator and MD.Interview on 09/03/25 at 1:03 PM with the Administrator revealed when a resident discharged , the facility staff must notify the family and the doctor. Resident #24 discharged from the facility on 08/11/25 due to the facility not being able to meet her needs. She stated Resident #24 was an elopement risk and required a more appropriate placement. She stated on 08/11/25 she assisted Resident #24 with packing her belongings. She stated the resident was pleasant and was okay with the transfer. She stated she was under the impression Resident #24's family was aware of the discharge. She stated she received a call on 08/11/25 around 4:00-5:00 PM from Family Member C asking where the resident was, and she had told Family Member C that Resident #24 had already discharged , and she thought the family member already knew. The Administrator stated she contacted the DON and asked if she had contacted the family prior to the Resident #24's discharge, the DON told her someone from the nursing department had called the family. She stated she spoke to LVN A and LVN A told her she reached out to the DON, and the DON told her to go ahead to discharge Resident #24. The Administrator stated she reached out again to the DON, and the DON told her she was not quite sure if the family was notified. The Administrator stated she reached out to Resident #24's family to apologize, and she provided the family with the location of the facility to which Resident #24 had transferred. She stated the following day she followed-up with the family, and the family informed her the other facility was a better fit for the resident. The Administrator stated she was upset at how Resident #24's transfer was not handled appropriately by the DON. She stated it was a lack of communication. She stated the potential risk would be the family not knowing where the resident had transferred. Interview on 09/03/25 at 3:42 PM with Resident #24's POA revealed she was informed by a family member of Resident #24's discharge. The POA stated prior to Resident #24 discharging she only received a voicemail on Friday 08/08/25 regarding the resident's elopement with consideration to possibly moving the resident to a secure unit. She stated no agreement was made for Resident #24 to be discharged from the facility. Interview on 09/03/25 at 6:08 PM with the MD revealed he was made aware of Resident #24's discharge. He stated Resident #24 eloped from the facility and was at high risk for elopement. The MD stated he approved the resident's transfer to another facility. He stated he expected for the facility to notify the family of the transfer prior to the resident discharging. Record review of the facility's Discharge - Transfer of the Resident, dated 12/2017, reflected the following: It is the policy of this home that residents and/or responsible parties will be notified prior to transfer or discharge. discharged residents will have documentation related to discharge or transfer in clinical software .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident had a discharge summary that included, but not limited to a recapitulation of the resident's stay, that included but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultant results and a final summery of the resident's status to include items, at the time of the discharge that was available to release to authorized persons and agencies, with the consent of the resident or resident's representative for 1 of 3 residents (Resident #24) reviewed for discharge summary. The facility failed to complete a discharge summary for Resident #24. This failure could place residents at risk of not having complete records after permanent discharge from the facility. Findings included: Record review of Resident #24's Discharge MDS assessment, dated 08/11/25, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE] and discharged on 08/11/25 to Nursing Home. Resident #24 entry/discharge reporting - Discharge assessment -return not anticipated. The resident's diagnoses included Alzheimer's Disease (brain disorder caused by damage to nerve cells in the brain), anxiety disorder (a mood disorder characterized by excessive, persistent, and uncontrollable fear and worry about everyday situations), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), diabetes mellitus (a chronic disease characterized by high level of sugar in the blood), muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), unsteadiness on feet and unspecified lack of coordination. The MDS reflected Resident #24 had moderate cognitive impairment with a BIMS score of 11. Record review of Resident #24's care plan, dated 06/19/25, reflected: Problem: Category: Return to Community Referral POA has no desire for [Resident #24] to return to community. Staff will revisit on comprehensive assessments only. Goal: [Resident #24] needs will be met by facility staff through the next review period. Approach: 1. Keep POA.u pdated on the [Resident #24] residents plan of care. 2. Staff will maintain [Resident #24] needs 3. Follow up with.POA annually. Record review of Resident #24's progress notes on 08/11/25 at 10:30 AM by LVN A reflected: Resident is calm and oriented to self. vitals assessed, normal to residents baseline BM reported this morning. Spoke with [family member] facility to give report. Medications reconciled. Meds from med cart, included Lynca and Norco counted with west side Hall nurse. Majority of residents belongings gathered. Resident in route to [Facility] family in location. Record review of Resident #24's clinical record reflected there was no documented evidence showing that a discharge summary had been completed for Resident #24. Interview on 09/02/25 at 1:23 PM, Resident #24 Family Member C revealed Resident #24 was transferred to another facility without family consent. Interview on 09/03/25 at 12:06 PM with LVN A revealed she was the nurse assigned to Resident #24 when she discharged on 08/11/25. LVN A stated she documented a progress note regarding the discharge which was her discharge summary. Interview on 09/03/25 at 12:53 PM with the DON revealed a mutual decision had been made between herself, the Administrator and MD to discharge Resident #24 to a more appropriate facility because resident was no longer safe at the facility. Interview on 09/03/25 at 6:08 PM with the Administrator revealed the Social Worker was responsible for completing discharge summaries. She stated since the Social Worker's employment ended prior to Resident #24's discharge on [DATE], the discharge nurse or DON were responsible for completing the discharge summary. She stated when Resident #24 discharged from the facility, the DON was not in the building. She stated the LVN who discharged Resident #24 should had completed a discharge summary, and the DON should have followed-up on it. She stated the expectation was for discharge summary to be developed and completed. Interview on 09/03/25 at 6:14 PM with the DON revealed the discharge nurse was responsible for completing discharge summaries. She stated if the discharge nurse was unable to complete the discharge summary, the nurse should notify her, and she would complete it. The DON stated due to the change of system they were behind on things, and Resident #24's discharge summary was one of the things that needed to be completed. She stated it was her responsibility to ensure discharge summaries were completed. Record review of the facility's Discharge - Transfer of the Resident policy, dated December 2017, reflected the following: It is the policy of this home that residents and/or responsible parties will be notified prior to transfer or discharge. discharged residents will have documentation related to discharge or transfer in clinical software.9. Discharge Summary completed by DON/designee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments and were labeled in accordance with currently accepted professional principles for 1 (Resident #134) of 9 residents reviewed for pharmacy services.<BR/>LVN D failed to put her initials, date, and time on Resident #134's IV medication bag and tubing when she administered the IV antibiotic, Meropenem. <BR/>These failures could place residents at risk for medication error and delay in medication administration.<BR/>Findings included:<BR/>Review of Resident #134's face sheet, dated 07/16/24, revealed the resident was a [AGE] year-old male admitted on [DATE]. Resident #134's diagnoses which included sepsis without septic shock (a life-threatening medical emergency caused by body's overwhelming response to an infection) and bacteremia (the presence of bacteria in blood).<BR/>Review of Resident #134's physician's orders dated 07/13/24 reflected: (Meropenem Intravenous Solution Reconstituted 1-gram (1000) milligrams /100 milliliters intravenously every 8 hours).<BR/>Observation on 07/15/24 at 8:53 AM revealed LVN D performing morning medication pass for Resident #134. LVN D sanitized and prepared Meropenem 1 g/100 ml, saline syringes and alcohol swabs. She knocked on the door and explained the procedure to Resident #134. She washed her hands, put on gloves and fixed the tubing to the bag. She removed her gloves, sanitized her hands, and put on new gloves. She cleansed the PICC line tip with alcohol, connected the tubing, and adjusted the flow meter. She did not label the bag or the tubing with the date, time, and her initials after administering the IV medication. She removed her gloves, washed her hands, left the resident comfortable, and left the room.<BR/>Observation and interview on 07/16/24 at 9:33 AM revealed Resident #134 was in his room, on his bed. He was observed with the IV medication being administered. The IV bag and the tubing were observed not labeled with date, time, and staff initials.<BR/>Observation and interview on 07/16/24 at 10:15 AM with LVN D revealed Resident #134's IV medication bag and the tubing were missing the time, date, and her initials. LVN D said the intravenous bag was supposed to have the correct resident's name, date, time and initial of the nurse administering the medications. She stated she was aware she was supposed to label the bag and the tubing, but she forgot. She stated failure to label the bag and the tubing could lead to overdose, omission of a dose, and infection control. She stated the bag was changed as scheduled and the tubing could be changed every 24 hours. LVN D stated she had done training on IV administration.<BR/>Interview on 05/16/24 at 01:44 PM with the DON revealed her expectation was that the staff should date and initial IV bags and tubing when administering intravenous medications. She stated putting the dates and initials would show when the bags were hanged and when the tubing was last changed. The DON could not state the risk but stated nothing had happened yet. She stated she had done training and no documentation was provided.<BR/>Review of the facility's IV Administration of drugs policy, revised August 2021, reflected: .1 verify label on intravenous bag with prescriber's order. Attach label (with date ,time, and nurse's initials) to tubing and bag

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable for 1 of 4 residents (Resident #1) reviewed for pressure ulcers. <BR/>The facility failed to ensure Resident #1's off-loading boot, which was used to prevent skin breakdown, was placed on the resident.<BR/>This failure could place residents at risk for the development of pressure injuries. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet, dated 12/07/2023, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included unspecified psychosis (experiencing symptoms of schizophrenia or other psychotic symptoms), acute respiratory disease (affects the lungs, bronchus and respiration), blindness in right eye, pressure induced deep tissue damage on left heal (affects subcutaneous tissue under intact skin), hypothyroidism (underactive thyroid), lack of coordination, and cognitive deficit disorder. <BR/>Record review of Resident #1's initial MDS, dated [DATE], reflected a BIMS score of 4, which indicated severe cognitive impairment. Resident #1 required one-person assist / supervision for transfers and bed mobility, was at risk for pressure ulcers, had an unhealed pressure ulcer, and required a pressure reducing device for the bed. <BR/>Record review of Resident #1's comprehensive care plan, dated 10/20/2023, revealed Problem: skin concerns as evidenced by DTI (Deep Tissue Injury) to heel. Goal: area will heal without complications over the next 90 days. Approach: heel protector on left foot when resident in bed. <BR/>Record review of wound care notes dated 11/29/2023 and signed by the DON, reflected a closed pressure injury on the left heel, 2 cm by 3 cm noting an off-loading required. Wound care notes dated 12/6/2023, signed by the DON, reflected a new of shiny tissue, 2 cm by 2 cm pressure injury on the left heel and an off-loading boot required. <BR/>An observation and interview on 12/07/2023 at 9:39 AM with Resident #1 revealed he was in bed. His off-loading boot was placed on the dresser beside his bed. A sign above Resident #1's bed stated, Please put boot on left foot at all times while in bed. Resident #1 stated he had a wound on his heel but denied any pain. When the off-loading boot, on the dresser, was pointed out to him, he said he did not know what the boot was for. <BR/>In an interview on 12/07/2023 at 9:56 AM, LVN A stated Resident #1 should have an off-loading boot on his left foot any time he was in bed. She said Resident #1 had a deep tissue wound on his left heel and the boot was to prevent skin breakdown. She stated she did not know Resident #1 was back in bed and thought he was at therapy. She said she did not know why the boot was not placed on his foot when he was put back in bed because there was a sign above his bed as a reminder to all staff. She stated the boot may have fallen off but doubted it would fall off and onto the dresser.<BR/>In an interview on 12/07/2023 at 10:01 AM, the Physical Therapist Assistant said she had been working with Resident #1 in the therapy gym and he told her he was tired and wanted to return to his bed. She said she returned Resident #1 to his bed but did not put the off-loading boot on his foot. She said she would normally tell the CNA or nurse that she had put Resident #1 back in bed but did not tell them today. She said she did not know why she did not think to put the boot on the resident or tell the nursing staff she returned him to his bed. She stated Resident #1 required the off-loading boot placed on his left foot any time he was in bed to prevent any skin breakdown. <BR/>In an interview on 12/07/2023 at 11:50 AM, the DON said she did the treatments for all residents in the facility. She stated Resident #1 was admitted with a deep tissue injury on his left heel. She said he required an off-loading boot whenever he was in bed to prevent any skin breakdown. She said all staff were responsible to ensure this was done and she placed a sign above Resident #1's bed as a reminder for them. She said Resident #1 did take the boot off and they would find it on the floor but doubted he placed it on the dresser. She said she verbally educated staff on placing the off-loading boot but did not have a written in-service. She said she included therapy staff in any in-servicing she did, and the Therapy Supervisor also trained therapy staff. <BR/>In an interview on 12/07/2023 at 12:40 PM, the Therapy Supervisor said the Physical Therapy Assistant told her she placed Resident #1 in bed but did not put on the off-loading boot or let the nursing staff know she put him in bed. She said Resident #1 should always have the off-loading boot on when in bed. She said not placing it on him put him at risk of skin breakdown and injury.<BR/>In an interview on 12/07/2023 at 1:30 PM, the Administrator said she expected nursing staff to follow the care plan and ensure Resident #1's off-loading boot was in place when in bed. She said the boot was required to minimize pressure on Resident #1's heel and prevent skin breakdown. <BR/>Record review of the facility's Skin-Preventative Guideline for Resident At Risk for Pressure Injury policy, dated December 2016, reflected, .A care plan will be developed that specified the interventions that will be taken for all pressure injuries. Pressure relief: consider pressure reducing devised for bed .Avoid friction, consider protective devises .use heel protective devises

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (Residents #1, #2, #3, and #4) of six residents and two (CNA B and CNA C) out of five staff in the facility reviewed for infection control practices and transmission-based precautions.<BR/>1. The facility failed to ensure Residents #1 and #2 were separated after Resident #2 tested positive for COVID on 10/19/23, and Resident #1 did not.<BR/>2. The facility failed to ensure Residents #3 and #4 were separated after Resident #4 tested positive for COVID on 10/19/23, and Resident #3 did not. <BR/>3. The facility failed to ensure staff utilized PPE appropriately to prevent cross contamination between residents positive with COVID-19 and residents who were not positive for the virus.<BR/>An Immediate Jeopardy (IJ) was identified on 10/23/23 at 3:45 PM. While the IJ was removed on 10/24/23, the facility remained out of compliance at no actual harm with the potential for more than minimal harm with a scope identified as pattern because the facility needed to complete in-service training and evaluate the effectiveness of the corrective systems.<BR/>These failures could place residents at increased risk for serious complications from a communicable disease that could diminish the resident's quality of life.<BR/>The findings included:<BR/>Review of Resident #1's face sheet, dated 10/24/23, reflected the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included alzheimer's disease (a common and devastating form of dementia that affects memory, thinking, and behavior), chronic obstructive pulmonary disease with acute exacerbation (a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation), and cognitive communication deficit (difficulties with thinking and using language that occur after a neurological damage).<BR/>Review of Resident #1's physician's orders for October 2023 did not reveal an order for isolation related to COVID-19.<BR/>Review of Resident #1's quarterly MDS Assessment, dated 10/11/23, reflected she had a BIMS score of 09 indicating moderate cognitive impairment. <BR/>Review of Resident #1's continuity of care document, dated 10/24/23, reflected under the results category that the resident had tested negative for COVID-19 on 10/16/23, 10/19/23, 10/23/23, and 10/24/23.<BR/>Review of Resident #3's face sheet, dated 10/24/23, reflected the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included acute respiratory failure (a condition where the lungs cannot provide enough oxygen), dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally), and Alzheimer's disease (a common and devastating form of dementia that affects memory, thinking, and behavior).<BR/>Review of Resident #3's physician's orders for October 2023 did not reveal an order for isolation related to COVID-19.<BR/>Review of Resident #3's quarterly MDS Assessment, dated 07/26/23, reflected she had a BIMS score of 11, indicating moderate cognitive impairment. <BR/>Review of Resident #3's continuity of care document, dated 10/24/23, reflected under the results category that the resident had tested negative for COVID-19 on 10/16/23, 10/19/23, 10/23/23, and 10/24/23.<BR/>Review of Resident #2's face sheet, dated 10/24/23, reflected the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included 2019-nCov acute respiratory disease (COVID-19), alzheimer's disease (a common and devastating form of dementia that affects memory, thinking, and behavior), and cerebral infarction (a stroke).<BR/>Review of Resident #2's physician's orders for October 2023 reflected the following: isolation precaution [dx: 2019-nCov acute respiratory disease] which began on 10/19/23. <BR/>Review of Resident #2's quarterly MDS Assessment, dated 08/31/23, reflected she had a BIMS score of 02 indicating severe cognitive impairment. <BR/>Review of Resident #2's continuity of care document, dated 10/24/23, reflected under the results category that the resident had tested positive for COVID-19 on 10/19/23.<BR/>Review of Resident #2's care plan, dated 08/31/23, reflected the following: Problem: Problem Start Date: 10/20/23, [Resident #2] requires isolation r/t: COVID POSITIVE .Approach: Approach Start Date: 1) Follow facility isolation policy <BR/>Review of Resident #4's face sheet, dated 10/24/23, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included transient cerebral ischemic attack (a stroke), 2019-nCov acute respiratory disease (COVID-19), and dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally).<BR/>Review of Resident #4's physician's orders for October 2023 reflected the following: isolation precaution [dx: 2019-nCov acute respiratory disease] which began on 10/19/23.<BR/>Review of Resident #4's significant change in status MDS Assessment, dated 08/30/23, reflected she had a BIMS score of 13, indicating no cognitive impairment.<BR/>Review of Resident #4's continuity of care document, dated 10/24/23, reflected under the results category that the resident had tested positive for COVID-19 on 10/19/23.<BR/>Review of Resident #4's care plan, dated 07/13/23, reflected the following: Problem: Problem Start Date: 10/20/23, [Resident #2] requires isolation r/t: COVID POSITIVE .Approach: Approach Start Date: 1) Follow facility isolation policy .<BR/>Observation on 10/23/23 at 8:15 AM revealed Residents #1 and #2 were in their rooms together. Resident #1 was not wearing a mask and was sitting in her wheelchair next to her bed a few feet from Resident #2 who was in her bed asleep and not wearing a mask. <BR/>Observation on 10/23/23 at 8:16 AM revealed Residents #3 and #4 were in their rooms together. Resident #3 was not wearing a mask and was sitting in her wheelchair with her bedside table in front of her eating breakfast. Resident #4 was not wearing a mask and was sitting on her bed and was a few feet from Resident #3. <BR/>Observation on 10/23/23 at 8:17 AM outside Residents #1, #2, #3, and #4's room revealed two three-drawer bins with PPE in them including gowns, gloves, and face shields. There was also a sign posted that read to see nurse before entering room.<BR/>Observation on 10/23/23 at 8:18 AM revealed CNA B walked into Residents #3 and #4's room wearing only an N95 mask and gloves. CNA B walked into the room and went to Resident #3 to retrieve her breakfast tray, took the tray to the cart on the hall, walked back into the room and went to Resident #4. CNA B tried taking Resident #4's tray and Resident #4 told her she was not finished with her breakfast and did not want her to take it yet. CNA B took her gloves off and walked out of the room without performing hand hygiene.<BR/>Observation on 10/23/23 at 4:10 PM of Resident #1 revealed she was sitting in her wheelchair and had rolled to Resident #2's side of the room. Resident #1 was observed so close to Resident #2 that Resident #1's knees were touching the railing on Resident #2's bed. Neither resident has a mask on.<BR/>Observation on 10/23/23 at 4:20 PM of Resident #4 revealed she was sitting in her wheelchair in the doorframe of her room, making her perpendicular to Resident #3's bed where she was currently lying down. LVN D walked down the hall towards Resident #4 and asked/encouraged her to go back to her side of the room. Neither resident was wearing a mask. <BR/>Observation on 10/23/23 at 4:25 PM of Resident #1 revealed she was sitting in her wheelchair and had rolled to Resident #2's side of the room. Resident #1 was observed so close to Resident #2 that Resident #1's knees were touching the railing on Resident #2's bed. Neither resident has a mask on and Resident #2 was currently yelling for staff to help her and the residents were having a conversation with each other about waiting for the staff to come and help Resident #2. <BR/>In an interview on 10/23/23 at 8:20 AM with CNA B revealed both residents in the room she just left were positive for COVID-19 or had been exposed to it. CNA B said she only went into Residents #3 and #4's room to get their breakfast trays and wore her N95 mask and gloves. CNA B said what she wore in the room was fine so long as she was not changing the residents. CNA B said she did not feel like putting on all the PPE like the gown just to retrieve a breakfast tray from the residents. CNA B said no one told her she should or should not make this choice, she did what she felt like she should do and that was what she did. CNA B said she did not want to continue talking about this and ended the interview. <BR/>In an interview on 10/23/23 at 8:25 AM with the Activity Director revealed she provided a census and indicated a plus sign next to Residents #2 and #4. The Activity Director said that meant those two residents were positive for COVID-19. The Activity Director said since the roommates of those residents did not have a plus sign next to them it meant they were negative for COVID-19. The Activity Director confirmed that Residents #1 and #3 were negative for COVID-19 and each in a room with a positive for COVID-19 resident (Residents #2 and #4).<BR/>In an interview on 10/23/23 at 8:30 AM with LVN D revealed she cared for Residents #1, #2, #3, and #4. LVN D said Residents #2 and #4 were positive for COVID-19 and their roommates Residents #1 and #3 were negative for COVID-19. LVN D said the residents were in the same room because there was no where else to move them without contaminating the new room if they did become positive for COVID-19 later on. LVN D said that was why the choice was made to keep them all in the same room. <BR/>In an interview on 10/23/23 at 8:45 AM with the Administrator revealed the facility hired a new DON last week who was out of the building for a few days so she was acting as the facility's Infection Preventionist for now. The Administrator/IP said Residents #2 and #4 were positive for COVID-19.<BR/>In an interview on 10/23/23 at 10:35 AM with LVN D revealed since she knew Residents #1 and #3 were negative for COVID-19 and were in the same room as Residents #2 and #4 who were positive for COVID-19 she always wore PPE when entering their rooms. LVN D said she already had an N95 mask on so she put on a gown, gloves, and a face shield when caring for the residents. LVN D said she tried to care for the COVID-19 negative residents first, performed hand hygiene, changed her PPE, and then cared for the COVID-19 positive residents next. <BR/>In an interview on 10/23/23 at 10:52 AM with CNA B revealed she knew to wear her N95 mask while in the facility because there were positive residents. CNA B said she knew that when caring for Residents #1, #2, #3, and #4 that she was supposed to wear a gown, gloves, and a face shield. CNA B said she was supposed to care for the COVID-19 negative residents, which were #1 and #3, first and perform hand hygiene and change her PPE before caring for the COVID-19 positive residents, which were #2 and #4. <BR/>In an interview on 10/23/23 at 11:01 AM with CNA C revealed she knew to wear her N95 mask while in the facility because there were positive residents. CNA C said while she was not assigned to Residents #1, #2, #3, and #4 she knew that Residents #2 and #4 were COVID-19 positive and Residents #1 and #3 were COVID-19 negative. CNA C said if she had to care for these residents she would treat them the same and wear full PPE including a gown and gloves.<BR/>Observation on 10/23/23 at 11:25 AM of Residents #3 and #4 revealed there was a family member in their room and they were telling Resident #3 to stay on their side of the room so they did not also catch COVID-19. Resident #3 was observed standing in the middle of the room with her walker and Resident #4 was sitting in her wheelchair a few feet away. Resident #3 began to walk backwards and sat down on her bed. Neither resident was wearing a mask. <BR/>Continuous observation on 10/23/23 at 11:56 AM of CNA B, CNA C, and LVN D passing trays to Residents #1, #2, #3, and #4's rooms revealed the following:<BR/>- <BR/>CNA B was wearing an N95 mask, put on a gown but did not put on gloves or a face shield and walked into Residents #1 and #2's room to take Resident #1 her lunch tray. CNA B asked LVN D if she needed to change her gown before taking Resident #2's tray to her and LVN D told her yes. CNA B took off her gown and washed her hands inside the room. CNA B put on a new gown, face shield, and gloves. CNA B walked into the room and sat down next to Resident #2 to assist her with her lunch meal. <BR/>- <BR/>CNA C was wearing an N95 mask, put on a gown but did not put on gloves or a face shield and walked into Residents #2 and #4's room to take Resident #4 her tray. CNA C took off her gown and gloves, did not wash her hands, and walked out of the room. CNA C put on new gloves, a gown, and a face shield. CNA C walked to Resident #3's bed and sat her lunch tray down. CNA C took off her gown, gloves, and face shield and washed her hands before leaving the room.<BR/>- <BR/>LVN D was attempting to correct CNA B and CNA C in live time ensuring they were wearing the correct PPE and washing their hands but they were not listening. LVN D was visibly frustrated and ended up leaving the area saying she could no longer be a part of the situation. <BR/>In an interview on 10/23/23 at 12:10 PM with CNA C revealed she could not remember what she did or did not do because there was too much going on all at once. CNA C said she thought she did everything right.<BR/>In an interview on 10/23/23 at 1:15 PM with CNA B revealed she knew what she did wrong but did not want to specify. <BR/>In an interview on 10/23/23 at 4:30 PM with LVN D revealed she had a conversation before the lunch meal service with CNA B and CNA C and went through what they needed to do and what PPE they needed to have on. LVN D said there were also signs posted on the outside of the doors to the residents' rooms both inside and outside. LVN D said she was not sure why CNA B and CNA C failed to put on the correct PPE and failed to perform hand hygiene properly. <BR/>In an interview on the phone on 10/23/23 at 5:41 PM with Physician A revealed he was one of the doctor's treating residents at the facility. Physician A said he was aware the facility had experienced a COVID-19 outbreak and had positive residents. Physician A said he was last at the facility on 10/19/23 to check on residents and provide support to the facility. Physician A said he did not know there were both COVID-19 positive and negative residents together in the same room. Physician A said he would not advise the facility to cohort residents unless they were both positive for COVID-19. Physician A said he did not think it would be wise or allowed by CMS or the state of Texas to cohort residents if one was COVID-19 positive and the other COVID-19 negative. <BR/>In an interview on 10/23/23 at 12:18 PM with the Administrator/IP revealed the facility had recently experienced an outbreak of COVID-19 beginning on 10/11/23 when LVN E tested positive. The Administrator/IP said she immediately began testing all residents and staff and found five positive residents on 10/11/23, one positive resident on 10/12/23, and then four positive residents on 10/19/23. The Administrator/IP said Residents #2 and #4 were two of the four residents who tested positive on 10/19/23. The Administrator/IP said both residents #2 and #4 had roommates which were Residents #1 and #3. The Administrator/IP said based on a lot of times previously the roommates of positive residents test positive for COVID-19 the next day after being exposed so she did cohort the positive and negative residents (referring to Residents #1, #2, #3, and #4). The Administrator/IP said she felt it would be upsetting and detrimental to move the residents around especially the specific groups of roommates (referring to Residents #1 and #2, and #3 and #4). The Administrator/IP said she and the staff were trying to keep the residents apart in the rooms and use separate PPE when caring for them. The Administrator/IP said it would also have triggered a lot of other residents to have had to move rooms if they did separate the positive and negative COVID-19 residents since the facility did not currently have any empty rooms. The Administrator/IP said she looked at the CDC's recommendations to see what their isolation guidelines were and informed the local health department the facility had COVID-19 positive residents and staff. The Administrator/IP said she could not find any information from the CDC about cohorting residents and only saw information regarding isolation and quarantine periods. The Administrator/IP said she usually wanted to try and move residents and not cohort them together in the same room if one was COVID-19 positive and the other was COVID-19 negative but was not sure what the facility's policy was and would have to look at it first. The Administrator/IP said the purpose of cohorting residents correctly based on their COVID-19 status was to stop the spread of the infection. The Administrator/IP said the risk of residents not cohorted based on their COVID-19 status put them at risk of getting infected by COVID-19. The Administrator/IP said when caring for these residents staff should be putting on full PPE meaning a gown, gloves, and a face shield. The Administrator/IP said PPE was available outside the residents' rooms and there were signs posted for staff to follow that showed the order to put the PPE on. The Administrator/IP said the purpose of putting on the PPE was to prevent others from getting COVID-19 germs on them and spreading that to other residents. The Administrator/IP said the risk of staff not putting on the correct PPE while caring for COVID-19 positive residents was that they could spread the infection to other residents. The Administrator/IP said she expected staff to also perform hand hygiene when entering/exiting a resident's room or putting on/taking off their PPE. The Administrator/IP said the purpose of performing hand hygiene was to get the germs off their hands to not spread infection. The Administrator/IP said staff had been in-serviced on what PPE to wear when going into rooms and when to wash their hands or use hand sanitizer. The Administrator/IP said the nursing staff and management were monitoring staff to ensure they were following infection control practices and procedures correctly. <BR/>Review of the facility's policy, titled COVID-19 Plan, revised 03/24/21, reflected the following: Suspected case(s) of COVID-19 in the Facility .only patients with the same respiratory pathogen may be housed in the same room. For example, a patient with COVID-19 should not be housed in the same room as a patient with an undiagnosed respiratory infection .For a resident with known or suspected COVID-19: staff wear gloves, isolation gown, eye protection and an N95 or higher-level respirator if available <BR/>Review of the facility's Infection Control- Precautions- Categories and Notices policy, dated August 2020, reflected the following: .3. Standard Precautions will be used in the care of all residents regardless of their diagnosis, or suspected or confirmed infection status .5. In addition to Standard Precautions, Droplet Precautions must be implemented for a resident documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets [larger than 5 microns in size] that can be generated by the resident coughing, sneezing, talking, or the performance of procedures.) .b. Resident placement .place the resident in a private room, when a private room is not available, residents with the same infection with the same microorganism, but with no other infection may be co-horted <BR/>Review of the facility's Hand Washing policy, dated August 2020, reflected: .It is the policy of this home that hand hygiene is the primary means to prevent the spread of infection .1. The use of gloves does not replace proper hand washing .Employees must wash their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: .before and after direct resident contact .before and after entering isolation precaution settings .after removing gloves <BR/>Review of the CDC's website on 10/23/23 (accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html) Reflected the following Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated 05/08/23 .2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection . The IPC recommendations described below (e.g., patient placement, recommended PPE) also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for empiric Transmission-Based Precautions based on close contact with someone with SARS-CoV-2 infection. However, these patients should NOT be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing . Patient Placement .Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room .Personal Protective Equipment .HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).<BR/>The Administrator was notified on 10/23/23 at 3:45 PM that an IJ situation was identified due to the above failures. The Administrator was provided the IJ template on 10/23/23 at 3:49 PM.<BR/>The facility's plan of removal was accepted on 10/24/23 at 9:52 AM and included the following:<BR/> 10/23/2023<BR/>Plan of Removal - F 880<BR/>Immediate Action Taken<BR/>Resident Specific<BR/>All residents tested for Covid 19 by rapid antigen card on 10/23/23 at 4:02 pm. All residents negative. All staff in facility tested on 10/23 and were all negative.<BR/>All nursing staff currently on Staff inserviced regarding PPE usage at 12:00 pm by Administrator.<BR/>Resident #[1] and # [3] (negative residents) moved to room [#] at 10/23/23 at 4:55 pm.<BR/>MD notified of the IJ on 10/23/2023 at 3:53 pm by Administrator, no new orders received. <BR/>Resident #[2] and Resident #[4] (positive residents) moved to room [#] on 10/23/23 at 5:<BR/>All other staff in facility(including housekeeping, laundry, dietary) inserviced on PPE usage by Administrator.<BR/>System Changes<BR/>Facility will ensure that positive and negative residents are not cohorted together in the same room.<BR/>Education<BR/>Administrator providing education to all staff regarding correct PPE usage for Covid Positive staff and and educated on not cohorting positive and negative residents together, and hand washing. All staff present in the facility were educated on 10/23/2023. Return demonstration will be performed on all staff in facility on 10/23. All Staff (including housekeeping, laundry, dietary) not present for the education will receive the education prior to their next shift with return demonstration on proper PPE usage and hand washing.<BR/>Nurse consultant to educate Administrator on proper PPE usage and hand washing.<BR/>Monitoring<BR/>Residents are monitored daily for signs/symptoms of Covid while in outbreak.<BR/>Staff will be monitored for correct PPE usage by Administrator/designee each day and logged on a monitoring tool.<BR/>Staff will be monitored for correct hand washing/hand sanitizer usage by Administrator/designee each day and logged on a monitoring tool.<BR/>On 10/24/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Monitoring observations on 10/24/23 at 12:15 PM revealed Residents #1 and #3 were in a room together and Residents #2 and #4 were in a room together. Positive and negative residents were no longer cohorted together in the same room.<BR/>Monitoring observations on 10/24/23 from 12:20 PM to 1:11 PM revealed staff performing hand hygiene before/after entering/exiting a residents' room and before/after donning/doffing PPE. Staff were observed donning gowns, gloves, and a face shield before entering Residents #1, #2, #3, and #4's rooms to care for them. Staff were observed performing hand hygiene, doffing their PPE, and donning new PPE before interacting with another resident. <BR/>Monitoring interviews were conducted on 10/24/23 starting at 1:11 PM and continued through 2:44 PM with the following staff from various shifts: CNA B, CNA C, CNA F, CNA G, CNA H, LVN D, LVN E, LVN I, LVN J, the Dietary Manager, the Activity Director, the Housekeeping Director, and the Administrator/IP. Staff knew that residents who were positive and negative for COVID-19 could not be in the same room together. Staff knew what PPE to wear when caring for a positive COVID-19 resident, in what order the PPE was to be put on and taken off, and when to perform hand hygiene.<BR/>On 10/24/23, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with the potential for more than minimal harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of six residents reviewed for accidents.<BR/>CNA A failed to safely transfer Resident #1 with a mechanical lift by failing to have another staff member assist with the transfer, which resulted in the mechanical lift tilting over, causing Resident #1 to fall. There was no injury related to the fall. <BR/>This failure could place all residents, who require the use of a mechanical lift for transfers, at risk of injury during transfers.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet revealed the resident was an [AGE] year-old female, initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included: morbid obesity (excessive body fat), atherosclerosis (build-up of cholesterol in arteries), lack of coordination, muscle atrophy (decreased muscle tissue), chronic obstructive pulmonary disease (lung disease), and heart failure. <BR/>Record review of Resident #1's annual MDS assessment, dated 06/14/23, revealed Resident #1:<BR/>- was cognitively intact (BIMS score 13); <BR/>- required extensive assistance with most ADL including bed mobility, dressing, and personal hygiene; and <BR/>- required total assistance and two-person assistance with transfers.<BR/>Record review of Resident #1's care plan, revised 04/25/23, indicated Resident #1 was at risk for falls related to increased weakness and required two-person assistance for transfers.<BR/>Record review of an incident report, dated 06/23/23, indicated Resident #1 was lying on the floor with CNA A present. CNA A reported to DON that she was transferring Resident #1 from a shower chair to her bed using mechanical lift. Resident #1 was alert and denied hitting her head. A physical assessment revealed no visible injuries or swelling. The MD was made aware of the fall. <BR/>Record review of radiology report, dated 06/23/23, revealed the following:<BR/>Right shoulder (2 or more views):<BR/>- A fracture of the right humeral neck. This fracture may be subacute.<BR/>Right humerus-2 view:<BR/>- A fracture of the right humeral neck. This fracture may be subacute.<BR/>Right forearm-2 view:<BR/>- No acute fracture or dislocation of the right forearm.<BR/>Record review of radiology report, dated 06/26/23, revealed the following:<BR/>Right shoulder (2 or more views):<BR/>- No acute fracture or dislocation of the right shoulder.<BR/>Record review of in-service titled Mechanical Lift, dated 06/23/23, revealed staff, including CNA A, were trained on mechanical lift transfer protocol. <BR/>Interview on 06/30/23 at 10:00 AM, the DON stated she was at the facility on 06/23/23 when Resident #1 fell from the mechanical lift. She stated CNA A yelled for her help from Resident #1's room, and when she went in, and she found the resident and CNA A on the floor. The DON stated CNA A reported that she had just given Resident #1 a shower and was transferring her from the shower chair to the bed when the mechanical lift tilted over. The DON stated Resident #1 complained of slight pain to right shoulder but stated she was fine. The DON stated Resident #1 was assessed head-to-toe and there were no visible injuries. The DON stated the medical doctor was immediately notified and an x-ray was ordered for Resident #1. The DON stated the initial x-ray was completed on 06/23/23 and results showed a fracture to the right humeral neck/shoulder, possibly subacute, and the MD was notified of results. The DON stated a sling and follow-up appointment with an orthopedic surgeon was ordered for Resident #1. The DON stated that over the next couple of days, Resident #1 denied being in pain and refused to keep the sling on her arm. The DON stated Resident #1 had full range of motion and was able to move her right arm without pain. Resident #1 informed them she had injured her right arm during a fall several years ago, and it always gave her problems. The DON stated due to Resident #1 denying pain and being able to use her right arm, a second x-ray was ordered and completed on 06/26/23 which revealed negative results for a fracture or dislocation but showed signs of osteopenia. The DON stated the MD came out on 06/27/23 to assess Resident #1 and reviewed the x-ray, and the MD stated there were no apparent issues clinically consistent with a fracture or abnormalities. The DON stated the portable x-ray machines were not always efficient, and the initial x-ray results were inaccurate. The DON stated CNA A knew not to transfer with the mechanical lift without a second qualified staff there to assist based on the training she had received and her experience since CNA A had worked at the facility for several years. The DON stated the risk of using a mechanical lift without assistance could be the resident falling and possibly sustaining serious injuries. <BR/>Interview on 06/30/23 at 11:20 AM, Resident #1 denied being in pain and stated that she was feeling good. Resident #1 recalled having a fall during a mechanical lift transfer on 06/23/23 after receiving a shower. She stated normally two staff would transfer her but on that day CNA A transferred her alone. Resident #1 stated her right arm hurt a little after the fall, but she denied any major injuries. Resident #1 stated she fractured her right arm from a fall years ago and any slight agitation causes it to act up. Resident #1 stated she felt safe during all other transfers in the mechanical lift and denied being abused or neglected. <BR/>Interview on 06/30/23 at 3:15 PM, CNA A revealed she had worked at the facility for five years. She stated she had been trained on using a mechanical lift at least annually and in-serviced as needed. CNA A stated all mechanical lift transfers required two staff; however, Resident #1 wanted a shower very early on the morning of 06/23/23, before all staff had arrived on shift. CNA A stated the shower went well and when it was time to get Resident #1 back in bed, she was unable to find another CNA to assist her. She stated there was a nurse assigned to the hall, but she was administering medications and was not available. CNA A stated she turned on Resident #1's call light and waited several minutes, but no one came to assist her. She stated she heard the housekeeper in the hall and called for her to assist with the transfer. CNA A stated she knew that the housekeeper was not trained to assist, but she did not know what else to do. CNA A stated once she had Resident #1 in the mechanical lift, she felt that she could handle it and told the housekeeper that she could leave. She stated as she was guiding Resident #1 towards the bed from the side of the mechanical lift tilted forward. CNA A stated the weight of the mechanical lift forced her to the floor first, and Resident #1 fell on top of her. CNA A stated she cushioned Resident #1's fall and if anyone was going to be hurt it would have been her. <BR/>Interview on 06/30/23 at 4:00 PM, the Administrator stated her expectation was for all mechanical lift transfers to be conducted by two qualified staff per the facility's policy. She stated the housekeepers were not qualified to assist with the care of residents. The Administrator stated Resident #1 was secure in the shower chair and CNA A should have let her remain there until a second qualified staff was available to assist. She stated CNA A was written up and received re-education on mechanical lift transfers. <BR/>The facility's policy titled Mechanical Lift, dated October 2017, revealed in part the following:<BR/>Policy: It is the policy of this home to utilize the Mechanical (or similar) lift when it is necessary to safely transfer a resident due to body weight or physical condition.<BR/>These are general guidelines only. The specific product utilization by the home may vary per the manufacturer recommendations. Lifting a resident with a mechanical lift is always a two-person procedure.

Based on interview and record review, the facility failed to use the service of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 9 of 30 days (04/13/24, 05/11/24, 05/12/24, 05/19/24, 06/09/24, 06/15/24, 06/23/24, 07/06/24, and 07/07/24) reviewed during a look back period from 04/09/24 to 07/15/24 for weekend coverage. <BR/>The facility failed to have RN coverage in the facility for eight consecutive hours on 04/13/24, 05/11/24, 05/12/24, 05/19/24, 06/09/24, 06/15/24, 06/23/24, 07/06/24, and 07/07/24. <BR/>This failure could place residents at risk for not having their nursing and medical needs met and improper care.<BR/>Findings included: <BR/>Review of the facility's Employee Time Cards, dated 7/14/24, reflected the following:<BR/>- RN Z worked from 8:00 AM to 12:00 PM (4 total hours), took a break for lunch, then resumed work at 12:30 PM to 5:00 PM (4.5 total hours) on 04/13/24.<BR/>- RN Z worked from 7:12 AM to 11:12 AM (4 total hours), took a break for lunch, then resumed work at 11:42 AM to 2:58 PM (3.27 total hours) and the DON worked from 2:00 PM to 4:00 PM (2 total hours) on 05/11/24.<BR/>- RN Z worked from 7:54 AM to 11:54 AM (4 total hours), took a break for lunch, then resumed work at 12:24 PM to 4:38 PM (4.23 total hours) on 05/12/24.<BR/>- RN Z worked from 7:47 AM to 11:47 AM (4 total hours), took a break for lunch, then resumed work at 12:17 PM to 3:54 PM (3.62 total hours) and the DON worked from 3:00 PM to 5:00 PM (2 total hours) on 05/19/24.<BR/>- RN Z worked from 7:55 AM to 11:55 AM (4 total hours), took a break for lunch, then resumed work at 12:25 PM to 4:13 PM (3.8 total hours) and the DON worked from 5:46 PM to 9:12 PM (3.43 total hours) on 06/09/24.<BR/>- RN Z worked from 12:06 AM to 4:06 AM (4 total hours), took a break for lunch, then resumed work at 4:36 AM to 8:10 AM (3.57 total hours) and the DON worked from 7:04 AM to 10:28 AM (3.4 total hours) on 06/15/24.<BR/>- RN Z worked from 8:03 AM to 12:03 PM (4 total hours), took a break for lunch, then resumed work at 12:33 PM to 4:27 PM (3.9 total hours) and the DON worked from 7:57 PM to 12:00 AM (4 total hours) on 06/23/24.<BR/>- RN Z worked from 1:49 AM to 5:49 AM (4 total hours), took a break for lunch, then resumed work at 6:19 AM to 10:06 AM (3.78 total hours) and the DON worked 9:00 AM to 11:00 AM (2 total hours) on 07/06/24.<BR/>- RN Z worked from 8:04 AM to 12:04 PM (4 total hours), took a break for lunch, then resumed work at 12:34 PM to 3:48 PM (3.23 total hours) and the DON worked from 3:00 PM to 5:00 PM (2 total hours) on 07/07/24.<BR/>Interview on 07/16/24 at 12:06 PM with the DON revealed she recently took over staffing from the last few months after the previous ADON left. The DON said she was not aware the facility did not have consecutive RN coverage for the dates listed above. The DON said she was not sure why the RNs were not working for an 8 consecutive hour shift but assumed it was due to them clocking out for a break or a lunch break. <BR/>Interview on 07/16/24 at 3:35 PM with the Administrator revealed the facility did not have a policy for RN coverage and instead followed the CMS guidelines.

Based on interview and record review, the facility failed to use the service of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 9 of 30 days (04/13/24, 05/11/24, 05/12/24, 05/19/24, 06/09/24, 06/15/24, 06/23/24, 07/06/24, and 07/07/24) reviewed during a look back period from 04/09/24 to 07/15/24 for weekend coverage. <BR/>The facility failed to have RN coverage in the facility for eight consecutive hours on 04/13/24, 05/11/24, 05/12/24, 05/19/24, 06/09/24, 06/15/24, 06/23/24, 07/06/24, and 07/07/24. <BR/>This failure could place residents at risk for not having their nursing and medical needs met and improper care.<BR/>Findings included: <BR/>Review of the facility's Employee Time Cards, dated 7/14/24, reflected the following:<BR/>- RN Z worked from 8:00 AM to 12:00 PM (4 total hours), took a break for lunch, then resumed work at 12:30 PM to 5:00 PM (4.5 total hours) on 04/13/24.<BR/>- RN Z worked from 7:12 AM to 11:12 AM (4 total hours), took a break for lunch, then resumed work at 11:42 AM to 2:58 PM (3.27 total hours) and the DON worked from 2:00 PM to 4:00 PM (2 total hours) on 05/11/24.<BR/>- RN Z worked from 7:54 AM to 11:54 AM (4 total hours), took a break for lunch, then resumed work at 12:24 PM to 4:38 PM (4.23 total hours) on 05/12/24.<BR/>- RN Z worked from 7:47 AM to 11:47 AM (4 total hours), took a break for lunch, then resumed work at 12:17 PM to 3:54 PM (3.62 total hours) and the DON worked from 3:00 PM to 5:00 PM (2 total hours) on 05/19/24.<BR/>- RN Z worked from 7:55 AM to 11:55 AM (4 total hours), took a break for lunch, then resumed work at 12:25 PM to 4:13 PM (3.8 total hours) and the DON worked from 5:46 PM to 9:12 PM (3.43 total hours) on 06/09/24.<BR/>- RN Z worked from 12:06 AM to 4:06 AM (4 total hours), took a break for lunch, then resumed work at 4:36 AM to 8:10 AM (3.57 total hours) and the DON worked from 7:04 AM to 10:28 AM (3.4 total hours) on 06/15/24.<BR/>- RN Z worked from 8:03 AM to 12:03 PM (4 total hours), took a break for lunch, then resumed work at 12:33 PM to 4:27 PM (3.9 total hours) and the DON worked from 7:57 PM to 12:00 AM (4 total hours) on 06/23/24.<BR/>- RN Z worked from 1:49 AM to 5:49 AM (4 total hours), took a break for lunch, then resumed work at 6:19 AM to 10:06 AM (3.78 total hours) and the DON worked 9:00 AM to 11:00 AM (2 total hours) on 07/06/24.<BR/>- RN Z worked from 8:04 AM to 12:04 PM (4 total hours), took a break for lunch, then resumed work at 12:34 PM to 3:48 PM (3.23 total hours) and the DON worked from 3:00 PM to 5:00 PM (2 total hours) on 07/07/24.<BR/>Interview on 07/16/24 at 12:06 PM with the DON revealed she recently took over staffing from the last few months after the previous ADON left. The DON said she was not aware the facility did not have consecutive RN coverage for the dates listed above. The DON said she was not sure why the RNs were not working for an 8 consecutive hour shift but assumed it was due to them clocking out for a break or a lunch break. <BR/>Interview on 07/16/24 at 3:35 PM with the Administrator revealed the facility did not have a policy for RN coverage and instead followed the CMS guidelines.

Based on observation and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. <BR/>The facility failed to ensure:<BR/>- the dishmachine was working properly and did not have to been run mulitple times to reach 120 degrees F;<BR/>- the Dietary Manager was aware of the dishmachine was a sanitizing dishmachine and not a high temperature dishmachine; <BR/>- Dishwasher Aide B was documenting actual dishmachine tempteratures; and <BR/>- food stored in the pantry was properly stored, labeled and dated.<BR/>This failure could place residents at risk for food contamination and food borne illness.<BR/>Findings included:<BR/>Observation and interview in the kitchen pantry on 06/04/23 at 9:08 AM revealed a bag of chocolate cake mix was not properly sealed, with a date of 04/20 written on the outside of the manufacturer's bag. The cake mix was open sitting on the top shelf. In the freezer, there was a box labeled fully cooked sausage patties in open plastic, not properly sealed, with a date of 06/03/23. In the refrigerator at the bottom was a gray tub with three bags of yellow liquid. The bags were not labeled or dated. Two bags had dark yellow liquid; the third bag had a lighter yellow liquid with chunks of substances. When asked about the third bag, it was revealed by [NAME] A that the bag contained eggs that she placed in boiling water to cook for breakfast. [NAME] A stated she forgot today was a cold food breakfast day (only serving cereal, milk, toast) and would not be using the eggs. [NAME] A stated she forgot to label and date the eggs so they could be used the following day. [NAME] A stated it was her responsibility to ensure any food that was stored should be properly sealed, labeled and dated to prevent food born illnesses. <BR/>Interview with the Dietary Manager on 06/04/23 at 9:15 AM revealed she monitored the kitchen and staff to ensure facility policies are being followed. The Dietary Manager stated she completed a walk through daily behind staff to make sure food items are labeled, dated, and sealed. The Dietary Manager stated she did not do a walk through today because she was scheduled off. The Dietary Manager stated she was not aware of the opened items in the pantry or the freezer. The Dietary Manager stated she was not aware of the partially cooked eggs in the refrigerator. The Dietary Manager stated [NAME] A was responsible to ensure opened food items were properly stored after used. The Dietary Manager stated the eggs should have been labeled and dated properly so they could have been used the following day. The Dietary Manager stated not having food items properly sealed, labeled, and stored could put residents at risk for illness. <BR/>During observation, interview, and record review on 06/04/23 at 9:30 AM revealed the dishmachine temperature/chemical log was completely filled out for the day. The log reflected:<BR/>- Breakfast: wash 100/rinse 110/ppm 50, initialed by Dishwasher Aide B <BR/>- Lunch: wash 115/rinse 120/ppm 50, initialed by Dishwasher Aide B<BR/>- Dinner: wash 120/rinse 140/ppm 150, initialed by Dishwasher Aide B (which were the exact same numbers from the previous days beginning with 06/01/23). <BR/>When reviewing the dishwasher log, Dishwasher Aide B stated she completed the log for the day by mistake and knew the log should be completed after each meal when cleaning the dishes. Observation of the dishmachine temperature reached between 80 degrees during the dishmachine run. Observation of the dishmachine revealed it ran at least 5 times before reaching manufacturer's minimum of 120 degrees. According to Dishwasher Aide B the dishmachine should reach temperatures of at least 120 degrees to clean dishes. Dishwasher Aide B stated not reaching proper temperatures could result in residents getting sick. <BR/>Interview on 06/04/23 at 9:40 AM with the Dietary Manager revealed the dishmachine machine is a high temperature machine and should reach temperatures of 130 degrees during wash cycle. After pointing out the manufacture template. The Dietary Manager stated she was not aware of the proper wash and rinse temperatures of minimum of 120 degrees. The Dietary Manager stated she expected staff to monitor the machine and to ensure dishes are cleaned by using proper water temperatures and checking sanitation levels. The Dietary Manager stated a couple of weeks ago the facility had water issues and stated the dishmachine had to run several times to reach proper water temperatures. The Dietary Manager stated staff should be monitoring the machine to ensure temperatures are reached before unloading dishes. The Dietary Manager stated the temperature log should be completed after each meal while cleaning dishes. The Dietary Manager stated breakfast dishes should be re-ran to ensure cleanliness and sanitation. <BR/>Observation of the dishwasher on 06/04/23 at 12:30 PM revealed Dishwasher Aide B running the dishmachine, Dishwasher Aide B was not observed monitoring the temperature of the dishmachine to ensure proper temperatures are being reached prior to unloading lunch dishes. Observation of Dishwasher Aide B running the machine several times revealed the dishmachine running at minimum 120 degrees for both wash and rinse cycles. Dishwasher Aide B stated she did have an in-service about the dishmachine, she stated she was aware to keep eyes on the temperature guage for minimum temperatures of 120 degrees. <BR/>Observation and interview of the dishmachine on 06/05/23 at 9:14 AM revealed Dishwasher Aide C running the dishmachine after breakfast, Dishwasher Aide C was observed not monitoring the dishmachine to reach minimum of 120 degrees. Observation of the first run revealed wash 80 degrees rinse at 127, second run revealed wash 105 degrees rinsed at 130, third run revealed was at 125 rinse at 140 with 50 ppm for the sanitizer. According to Dishwasher Aide C she completed in-service to ensure the dishmachine was reaching minimum of 120-degree temperatures. Dishwasher Aide C stated the dishmachine was very sensitive and with any break the temperature will go low, and the machine had to be run several times to get the temperature back to 120 degrees. <BR/>Interview on 06/06/23 at 4:50 PM with the Administrator revealed she was informed by the Dietary Manager that the dishmachine was having issues keeping at minimum of 120-degree temperature and staff was having to run the machine several times to ensure the machine was running properly. The Administrator stated the machine was serviced monthly and there had not been any issues or concerns noted prior to survey. The Administrator stated staff had been in serviced, and the Dietary Manager would be responsible for continued monitoring of both staff and the dishmachine to ensure dishes were being thoroughly cleaned. The Administrator stated not storing food properly in the kitchen could allow staff to used outdated foods. The Administrator stated not ensuring the dish machine was running at correct temperatures could put residents at risk of illnesses.<BR/>Record review of facility policy revised 06/01/19 titled Food Storage reflected: .to ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes .to ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. Store frozen foods in moisture-proof wrap or containers that are labeled and dated. Store raw meets and eggs on the bottom shelf to prevent contamination of other foods. Date, label and tightly seal all refrigerated foods . <BR/>Record review of facility policy dated 10/01/18 titled Mechanical cleaning and Sanitizing of Utensils and Portable Equipment reflected:<BR/> .The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes to ensure thorough cleaning and sanitization to minimize the risk of food hazards. Operate the dish machine as instructed in the manufacturer's directions. <BR/>a. The temperature of the wash water must be at lease 120-degree F

Based on observation, interview, and record review the facility failed to provide a private meeting space for residents' monthly council meetings for 9 of 9 confidential residents reviewed for resident council. <BR/>The facility failed to provide a private space for resident council meetings.<BR/>This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy. <BR/>Findings included:<BR/>Observation and interview, during the confidential group interview with nine residents on 06/05/23 beginning at 10:00 AM, revealed the meeting was held in an open dining room located near the facility's central nurses' station and front entry door. There were no doors that could be closed to ensure the residents' privacy during the meeting. Staff were observed walking through the area while the meeting was in progress. During the confidential group meeting, all nine residents revealed when they had meetings, the meetings were always held in the open dining room area. Residents expressed there were no private areas in the facility that would hold residents, especially if they ambulated with their wheelchairs. The residents stated if they wanted to talk about something private, they would have to whisper or speak very low, which made them uncomfortable expressing their concerns. The residents denied expressing their concern about the location to anyone because they felt it would do no good. The residents stated they would like to have more privacy during the meetings so that they could feel free to speak among themselves. <BR/>Interview on 06/06/23 at 12:54 PM with the Activity Director, she revealed the resident council meetings were scheduled monthly and were held in the open dining room. She stated she would alert staff not to enter the area during resident council meetings. The Activity Director stated in the past she tried to host the meeting in the therapy room; however, the area was too small. The Activity Director stated she was present at all the meetings to help host and took notes. The Activity Director stated she shared any concerns or issues that came up during the meetings with the Administrator. The Activity Director stated she had not received any concerns about the meeting location and felt residents could speak freely during the meetings. She stated she knew that residents had a right to hold meetings in a private area, but the facility did not have any other large private space. The Activity Director stated the risk of holding resident council meetings in an open area was that the residents could not express their concerns out of fear of being overheard by staff which might lead to mistreatment. <BR/>Interview on 06/06/23 at 4:59 PM with the Administrator, she revealed the resident council meetings were held monthly in the dining room. The Administrator stated the Activity Director was present during the meetings because she was the one who hosted the meetings. The Administrator stated usually there were 10-15 residents that attended, and the dining room was the largest space the facility had to hold the meetings. The Administrator stated prior to the meeting, the Activity Director alerted staff not to enter the area unless there was an emergency. The Administrator stated if there were any issues or concerns discussed at the meeting, the Activity Director told her about them, and they were addressed immediately. The Administrator stated it had never been brought to her attention that the location or staff being present was an issue with residents. <BR/>Record review of the resident council minutes for January 2023, February 2023, and March 2023, April 2023, May 2023 revealed no requests for a private area. <BR/>Request for facility policy concerning Resident Council was requested. The Administrator stated the facility did not have a policy.

Based on observation, interview, and record review the facility failed to provide a private meeting space for residents' monthly council meetings for 9 of 9 confidential residents reviewed for resident council. <BR/>The facility failed to provide a private space for resident council meetings.<BR/>This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy. <BR/>Findings included:<BR/>Observation and interview, during the confidential group interview with nine residents on 06/05/23 beginning at 10:00 AM, revealed the meeting was held in an open dining room located near the facility's central nurses' station and front entry door. There were no doors that could be closed to ensure the residents' privacy during the meeting. Staff were observed walking through the area while the meeting was in progress. During the confidential group meeting, all nine residents revealed when they had meetings, the meetings were always held in the open dining room area. Residents expressed there were no private areas in the facility that would hold residents, especially if they ambulated with their wheelchairs. The residents stated if they wanted to talk about something private, they would have to whisper or speak very low, which made them uncomfortable expressing their concerns. The residents denied expressing their concern about the location to anyone because they felt it would do no good. The residents stated they would like to have more privacy during the meetings so that they could feel free to speak among themselves. <BR/>Interview on 06/06/23 at 12:54 PM with the Activity Director, she revealed the resident council meetings were scheduled monthly and were held in the open dining room. She stated she would alert staff not to enter the area during resident council meetings. The Activity Director stated in the past she tried to host the meeting in the therapy room; however, the area was too small. The Activity Director stated she was present at all the meetings to help host and took notes. The Activity Director stated she shared any concerns or issues that came up during the meetings with the Administrator. The Activity Director stated she had not received any concerns about the meeting location and felt residents could speak freely during the meetings. She stated she knew that residents had a right to hold meetings in a private area, but the facility did not have any other large private space. The Activity Director stated the risk of holding resident council meetings in an open area was that the residents could not express their concerns out of fear of being overheard by staff which might lead to mistreatment. <BR/>Interview on 06/06/23 at 4:59 PM with the Administrator, she revealed the resident council meetings were held monthly in the dining room. The Administrator stated the Activity Director was present during the meetings because she was the one who hosted the meetings. The Administrator stated usually there were 10-15 residents that attended, and the dining room was the largest space the facility had to hold the meetings. The Administrator stated prior to the meeting, the Activity Director alerted staff not to enter the area unless there was an emergency. The Administrator stated if there were any issues or concerns discussed at the meeting, the Activity Director told her about them, and they were addressed immediately. The Administrator stated it had never been brought to her attention that the location or staff being present was an issue with residents. <BR/>Record review of the resident council minutes for January 2023, February 2023, and March 2023, April 2023, May 2023 revealed no requests for a private area. <BR/>Request for facility policy concerning Resident Council was requested. The Administrator stated the facility did not have a policy.

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 2 meals (lunch) reviewed for food meeting residents' needs.The facility failed to prepare and serve pureed Cilantro Lime Chicken as a pudding consistency for residents who required pureed diets during the lunch meal on 08/06/25.This deficient practice could affect residents and place them at risk of not receiving meals that meet their needs.Findings included:Record review of the facility Week at a Glance menu dated Week 1 Spring/Summer2025, reflected the menu for the lunch service for Wednesday (Day 4) was Cilantro Lime Chicken, [NAME] Pilaf, Squash & Red Peppers, Dinner Roll, Margarine, Fruit Crisp, Beverage.Observation on 08/06/25 at 10:45 AM revealed [NAME] D making pureed lunch. [NAME] D put the lime chicken in the processor, then proceeded to use the processor food pusher to add water twice and added it to the chicken. [NAME] D added the water without measuring, added thickener and blended the mixture. [NAME] D blended the chicken for about 5-10 seconds and then poured it into small food cups. The pureed cilantro lime chicken appeared to have a mashed potato consistency; however, the chicken did not appear to be fully blended. Neither [NAME] D nor the Dietary Manager checked the consistency or ensured it was all blended to have a pudding smooth consistency.Observation of the test tray on 08/06/25 beginning at 12:42 PM with the Dietary Manager, revealed the test tray included the regular textured menu items and the pureed menu items. The pureed cilantro lime chicken did not have a smooth/pudding consistency. The cilantro lime chicken had bristle in it. The Dietary Manager stated the pureed cilantro lime chicken was not the correct consistency.Interview on 08/06/25 at 12:49 PM, with [NAME] D revealed pureed food needed to have a smooth/mashed potatoes consistency. She stated normally when she blended the food, she could see what kind of consistency it had. She stated she checked the chicken consistency and thought the consistency was correct. She stated the potential harm to residents was the possibility of choking.Interview on 08/06/25 at 12:53 PM, with the Dietary Manager revealed her expectations were for the Cooks to follow the recipe and have the correct food consistency. She stated the pureed meal should be blended thoroughly. The Dietary Manager stated when deboning the chicken, the cooks needed to check thoroughly to ensure there was no bristles or pieces of bones. She stated the potential risk would be residents choking. Record review of the Pureed Cilantro Lime Chicken recipe reflected the following: Remove any skin and bones. Avoid hard, crispy crusts and toppings.2. If the product needs thickening, gradually add a commercial or natural food thickener to achieve a smooth, pudding or soft mashed potato consistency.Record review of the facility's, Pureed policy, dated 2022, reflected the following: The Puree Diet is designed for those individuals who have difficulty swallowing or cannot chew foods of the dental soft consistency.

Based on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format by electronically submitting to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 8 (11/16/24, 11/17/24, 11/21/24, 11/23/24, 11/27/24, 11/28/24, 11/30/24, and 12/31/24) of 8 days reviewed.<BR/>The facility failed to submit accurate licensed nurse hours for 11/16/24, 11/17/24, 11/21/24, 11/23/24, 11/27/24, 11/28/24, 11/30/24, and 12/31/24.<BR/>The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.<BR/>Findings included:<BR/>Review of the CMS PBJ report for CMS for FY Quarter 1 2024 (October 1- December 21) indicated the facility had failed to have Licensed Nursing Coverage 24 hours/day triggered.<BR/>Review of the CMS PBJ report for FY Quarter 1 2024 (October 1- December 31) indicated the facility did not have licensed nursing coverage 24 hours/day for the following dates: 11/16 (TH), 11/17 (FR), 11/21 (TU), 11/23 (TH), 11/27 (MO), 11/28 (TU), 11/30 (TH), and12/31 (SU).<BR/>Review of staff timesheets for 11/16/24, 11/17/24, 11/21/24, 11/23/24, 11/27/24, 11/28/24, 11/30/24, and 12/31/24 indicated there was licensed nursing coverage for 24 hours on those days.<BR/>Interview via phone on 07/16/24 at 2:01 PM with the Corporate Analyst revealed he and another person were responsible for submitting the PBJ staffing information to CMS for the facility. The Corporate Analyst said there was an issue submitting the information where their system was not pulling the LVN worked hours. The Corporate Analyst said this meant that the facility was going to be triggered for not having licensed nursing coverage due to this. The Corporate Analyst said they identified the issue last quarter and corrected it so that going forward it would not happen anymore. <BR/>Interview on 07/16/24 at 2:10 PM with the Administrator revealed he did not know anything about the facility's PBJ Staffing report because corporate was responsible for the reporting.<BR/>Interview on 07/16/24 at 3:35 PM with the Administrator revealed the facility did not have a policy for PBJ Staffing and instead followed the CMS guidelines.