Avir at Grand Saline

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident #3) and her representative were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment alternatives or treatment options and to choose the alternative or option he or she prefers. The facility failed to inform Resident #3 and her responsible party in advance about changes made to the physician orders involving insulin dosing and monitoring of blood sugar levels. This failure could place residents at risk of not being informed of changes to their treatment plan and the opportunity to direct his or her own medical treatment. Findings included: Record review of a face sheet dated 10/28/2025 indicated Resident #3 was a [AGE] year-old female who re-admitted to the facility on [DATE] with diagnoses which included a diagnosis of diabetes mellitus (a chronic condition in which the body does not produce enough insulin to regulate blood sugar levels). The face sheet indicated the Resident's family member was her responsible party/representative. Resident #3 discharged from the facility 05/02/2025 Review of the MDS dated [DATE] revealed Resident #3 had a BIMS score of 10 indicating her cognition was moderately impaired. Review of Resident #3's hospital records and physician's orders dated 02/27/2025 indicated Resident #3 was discharged to the facility on [DATE] with physician's orders for blood glucose levels to be checked by glucometer 4 times daily (before meals and at bedtime) and to be given Humulog insulin per sliding scale (insulin dosing based on the patient's blood glucose level at the time of testing). Review of Resident #3's progress notes dated 02/27/2025 indicated the nurse practitioner was notified of Resident #3's admission and hospital discharge orders on 02/27/2025. Further review of the progress notes indicated the nurse practitioner discontinued the sliding scale insulin order and changed the frequency of blood glucose testing from 4 times daily before meals and at bedtime to 2 times daily (before breakfast and at bedtime) with instructions to notify the nurse practitioner if blood glucose levels were greater than 350. Review of Resident #3's progress notes in the medical records dated 02/27/2025 through 03/04/2025 indicated there was no documented evidence that Resident #3 and the responsible party were notified of the changes to the physician orders. During an interview on 10/27/2025 at 11:00 AM, Resident #3's responsible party said she was not notified about the changes made to Resident #3's insulin dosing and blood glucose testing orders that came from the hospital. She said that 4-5 days after Resident #3 was admitted to the facility, Resident #3 told her she had not been getting her insulin shots. She said she questioned the nurse in charge about her mother's insulin orders and blood glucose test results and learned the orders had been changed. She said the facility should have told her about the proposed changes at the time they were made. She said she would not have known about the changes had she not asked about the orders. She said she talked to the Nurse Practitioner and got the sliding scale insulin orders with 4 times a day testing reinstated. She said she would have disagreed with the changes made to the hospital discharge orders if she had been notified of the proposed change. During an interview on 10/28/2025 at 03:05 PM, Charge Nurse C said nurses should notify the resident and his or her responsible party of new physician's orders and changes in physician orders. She said there were times when the resident or responsible party did not agree to orders or changes. Charge Nurse C said it was the resident's right to disagree with the doctor. She said she would let the doctor or nurse practitioner know if a resident or responsible party had a concern or did not agree with any orders. During an interview on 10/29/2025 at 11:30 AM, the DON said the nurses were responsible for notifying residents and responsible parties of changes in care and treatment. She said it was important for the residents and responsible parties to be informed and given the opportunity to participate in the decision-making process. The DON said she and the ADON reviewed new physician's orders daily in the morning meeting. She said they missed seeing that Resident #3 and the responsible party were not notified of the changes to the insulin dosing and blood sugar testing. A record review of the facility's policy titled Change in a Resident's Condition or Status dated Revised April 2025 indicated the following: Policy StatementOur facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition or status (e.g., changes in level of care, billing/payments, resident rights, etc).5.Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.6. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a comprehensive assessment was completed, using the CMS-specified process, within the regulatory time frames for 1 of 3 residents (Resident #4) reviewed for comprehensive assessments. The facility failed to complete a comprehensive MDS assessment for Resident #4 within 14 days of admission to the facility. This failure could place new residents at risk of delays in assessments and the residents' care plans not accurately reflecting their current needs. Findings included: Record review of a face sheet dated 10/28/2025 indicated Resident #4 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included cerebral atherosclerosis (a build-up of plaque in the arteries of and leading to the brain which thickens and hardens the arteries of the brain), major depression, diabetes mellitus, anxiety, sleep apnea, atrial fibrillation (a heart rhythm disorder), dysphagia (difficulty swallowing), arthritis, ataxia (lack of muscle coordination), and repeated falls. Record review of an incomplete admission MDS with an ARD date of 10/20/2005 indicated Resident #4 had a BIMS score of 00 (zero-zero) indicating his cognition was severely impaired. Further review of the MDS indicated sections A (identification Information, F (Preferences for Routine & Activities), GG (Functional Abilities), J (Health Conditions), O (Special Treatments, Procedures, and Programs), Q (Participation in Assessment and Goal Setting) and V (Care Area Assessment Summary) were not completed. Record review of Section Z indicated the MDS had not been signed as completed as of 10/29/2025. Record review of Resident #4's MDS history indicated he was admitted to the facility on [DATE], had an admission assessment in progress and was 2 days overdue. During an interview on 10/29/2025 at 11:10 AM, the MDS Coordinator said she did not know why the MDS had not been completed. She said the facility used the RAI Version 3.0 Manual as the policy for completing MDS assessments. She said she had been the MDS Coordinator for less than a year and was still slow at completing the MDS assessments. She said the Regional MDS Consultant had been helping her, but the Consultant had other buildings to help also. The MDS Coordinator said Resident #4's admission MDS assessment should have been completed by 14 days after admission which was 10/27/2025. Record review of the RAI Version 3.0 Manual: Section 2.2 indicated the following: Policy Interpretation and Implementation1.Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual.2.admission Assessment - The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if:.c. the resident has been admitted to this facility and was discharged return not anticipated and did not return within 30 days of discharge.The admission Assessment (Comprehensive) must be completed by the 14th day of the resident's stay (admission date + 13 = completion date).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 3 of 4 residents (Residents #2, #3, #4) reviewed for baseline care plans. The facility failed to ensure Resident #2's and Resident #4's baseline care plans were implemented and made available to nursing staff within 48 hours of admission. The facility failed to ensure Resident #3's baseline care plan included instructions to address the principal diagnosis of COPD. The facility failed to ensure Resident #3's baseline care plan included instructions to address identified risks for hyperglycemia and hypoglycemia. These failures could affect newly admitted residents and place them at risk of receiving inadequate care and services and not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met. Findings included: 1.Record review of a face sheet dated 10/28/2025 indicated Resident #2 was an [AGE] year-old female who admitted to the facility 10/06/2025 with diagnoses which included Alzheimer's disease, dementia, aortic stenosis (a condition where the aortic valve in the heart becomes narrowed, restricting blood flow from the heart to the rest of the body), and osteoporosis. Review of Resident #2's MDS dated [DATE] noted resident #2 had a BIMS score of 6 indicating her cognition was severely impaired. Record review of Resident #2's medical records for a baseline care plan indicated the electronic care plan for Resident #2 was completed but not signed by the resident, resident's representative, and by the staff who completed the care plan. Section 5. B. Signature of Resident and Representative indicated LVN C had signed the document in the area designated for Resident #2's signature and dated it 10/22/2025. The spaces on the care plan form designated for the signatures of the resident, resident representative, and staff participating in the development of the care plan were blank. During an interview on 10/29/2025 at 11:10 AM, the DON said the nurses usually printed the baseline care plan from the electronic record, completed it manually, and then gave it to the social worker to get signed. She said sometimes, the nurses completed the baseline care plan in the electronic record, printed it, and give it to the social worker to get signed. The DON said it looked like Resident #2's electronic baseline care plan was completed but not signed by the resident, the resident's representative, nor the facility staff. 2.Record review of a face sheet dated 10/28/2025 indicated Resident #3 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included a principal diagnosis of COPD (a condition involving constriction and destruction of the airways in the lungs), a co-existing diagnosis of emphysema (a type of COPD involving the air sacs in the lungs), and pre-existing diagnoses of dementia and diabetes mellitus (a chronic condition in which the body does not produce enough insulin to regulate blood sugar levels). Record review of an MDS dated [DATE] noted Resident #3 had a BIMS score of 10 indicating her cognition was moderately impaired. Further review of the same MDS indicated Resident #3 was ambulatory with a walker and was incontinent at times. Record review of an MDS dated [DATE] indicated Resident #3 discharged from the facility on 05/02/2025. Record review of medical records indicated Resident #3 was initially admitted to the facility on [DATE]. A MDS dated [DATE] indicated Resident #3 was discharged on 09/08/2024 with return not anticipated. Further review of medical records indicated a care plan developed during a facility stay from 08/19/2025 - 09/08/24 was revised for the plan of care for the most current stay from 02/27/2025 - 05/02/2025. The revised care plan included a problem with a start date for 08/20/2024 and identified as a Baseline Care Plan for new admission to skilled nursing facility, edited 02/28/2025. The revised baseline care plan indicated Resident #3's principal diagnosis of COPD and co-existing diagnosis of emphysema were not addressed in the care plan. The revised care plan indicated there were no goals or interventions to address identified risks of hypoglycemia (low blood sugar levels) and hyperglycemia (high blood sugar levels). Record review of scanned documents, progress notes and social worker notes for Resident #3 from 02/27/2025 - 05/02/2025 did not indicate Resident #3 and/or representative had been informed of the development of a care plan. During an interview on 10/27/2025 at 11:25 AM, Resident #3's representative said she had not been consulted about or included in the care planning process for Resident #3. During an interview on 10/28/2025 at 03:10 PM, the DON said she had been at the facility for about 4 months. The DON said she, the MDS Coordinator, and Social Worker shared in the care planning process. She said neither she nor the Social Worker were employed at the facility during Resident #3's stay at the facility and could not explain why Resident #3's revised care plan did not address the principal diagnosis for which Resident #3 was re-admitted to the facility. She said she did not know why Resident #3 and the representative had not been given a copy of Resident #3's care plan. 3. Record review of a face sheet dated 10/28/2025 indicated Resident #4 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included cerebral atherosclerosis (a build-up of plaque in the arteries of and leading to the brain which thickens and hardens the arteries of the brain), major depression, diabetes mellitus, anxiety, sleep apnea, atrial fibrillation (a heart rhythm disorder), dysphagia (difficulty swallowing), arthritis, ataxia (lack of muscle coordination), and repeated falls. Record review of an incomplete admission MDS with an ARD date of 10/20/2005 noted Resident #4 had a BIMS score of 00 (zero-zero) indicating his cognition was severely impaired. Record review of Resident #4's electronic medical records revealed Resident #4's had an undated baseline care plan that was incomplete and had not been signed by Resident #4 or Resident #4's representative. A record review of a paper copy of a baseline care plan dated 10/14/2025 for Resident #4 indicated the blank baseline care plan was printed, manually completed, and signed and reviewed with Resident #4's responsible party on 10/16/2025. The completed and signed baseline care plan was not in the electronic health record. During an interview on 10/29/2025 at 03:15 PM, the DON said she found Resident #2's and Resident #4's manually completed baseline care plans in a stack of papers in medical records. She said it took her a while to find them. She said the care plans had not been scanned into the computer and therefore, were not a part of the electronic health records and were not available or communicated to the nursing staff. The DON said the baseline care plan could not be updated to reflect the residents' changing needs if it was not in the computer to begin with. The DON said it would be better to complete the baseline care plans in the electronic chart to ensure the nursing staff had access to baseline care plans. A record review of the facility's policy titled Care Plans - Baseline Care Plan dated Revised March 2024 indicated the following: A baseline plan of care to meet the residents' immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.1.The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include.but not limited to the following: a.Initial goals based on admission orders and discussion with the resident/representative;, .b.Physician ordersc.Dietary orders,d.Therapy servicese.Social services; andf.PASRR recommendations, if applicable 2.The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission). The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 8 residents reviewed for accidents. (Resident #1).The facility did not prevent Resident #1, who was wearing a Wanderguard bracelet, from leaving the facility unsupervised on 09/07/2025. Resident #1 was found at the intersection of the county road the facility resided on and a state farm to market road approximately 1.3 miles from the facility. The facility was not aware the resident was missing for approximately 1 hour. The noncompliance was identified as PNC. The IJ began on 09/07/2025 and ended on 09/09/2025. The facility had corrected the noncompliance before the survey began.This failure could place residents at risk of potential accidents, injuries, harm, or death. Findings included:Record review of a face sheet on 10/27/2025 indicated Resident #1 was a [AGE] year-old male who admitted on [DATE] with diagnoses including: schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and mood disorders, such as depression or mania), bipolar disorder (a chronic mental health condition characterized by extreme mood swings between mania and depression), psychosis (a mental health condition characterized by a loss of touch with reality), anxiety disorder a mental health condition characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life), depression (a common and serious mental health condition that significantly impacts a person's mood, thoughts, and behavior) and cognitive communication deficit (a difficulty in communication caused by problems with underlying cognitive functions like memory, attention, and executive function, rather than a language or speech impairment).Record review of a quarterly MDS dated [DATE] indicated Resident #1 had clear speech, usually understood others and was usually understood, he had a BIMS score of 07 indicating severe cognitive impairment. He had disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). He exhibited no wandering or other behaviors. He required set-up or clean up assistance with ADLs and he could feed himself. He was occasionally incontinent of bladder and continent of bowel. He was independent with mobility and walking unassisted. Record review of care plans for Resident #1 indicated he had a care plan initiated on 06/21/2025 and revised on 09/08/2025 indicating he was at risk for wandering. Goals included: ensure staff awareness of resident's risk, monitor for expressions of wanting to go home and assess quarterly and as needed for wandering/elopement risk. He had another care plan initiated on 09/08/2025 which indicated he was at risk for elopement and required a secured unit as evidence by impaired safety awareness and at risk for injury from others while residing in secure/ memory unit due to altered cognition and history of elopement. Care plan goals included: Will remain safe within the facility through the next review date. Interventions included: monitor for early warning signs of any behaviors and anticipate behavior(s) and redirect when in close proximity to others that might invoke aggression.Record Review of Resident #1's admission Elopement Risk assessment dated [DATE] indicated the resident had a score of 9. The assessment tool indicated a score of 10 or higher indicated a high risk for elopement. The interdisciplinary team had determined a Wanderguard (a wearable device used in senior living facilities to prevent residents at risk of wandering from leaving a protected area) was not indicated at that time as the resident was not actively exit seeking.Record Review of Resident #1's Elopement Risk assessment dated [DATE] indicated the resident had a score of 4. The interdisciplinary team had determined a Wanderguard was indicated at this time as the resident did leave the facility without notifying anyone.Record Review of Resident #1's Elopement Risk assessment dated [DATE] indicated the resident had a score of 7. The interdisciplinary team had determined the resident needed to be in the secure unit as he had eloped from the facility without staff knowledge and was found by the police approximately 1.3 miles from the facility.Review of Resident #1's Progress Notes in the electronic record indicated on 06/21/2025 he was seen on the driveway of the facility by facility staff. A visitor turning into the facility driveway stopped and gave the resident a ride back to the front door where he was brought inside. He was assessed with no injuries and said he was going to see his brother. A Wanderguard was placed on the resident to alert staff if he left the facility again.Review of Resident #1's Progress Notes in the electronic record indicated the resident did not exhibit any exit seeking behavior from 06/21/2025 until 09/07/2025.A review of the facility investigation report indicated the incident occurred on 09/07/2025 and was reported to the state agency on 09/08/2025 with no times indicated. Resident #1 was last seen at 8:20 AM on 09/07/2025 going towards his room. He was found by the sheriff and police departments about a mile away and the facility was called by the local police at approximately 9:45 AM. Resident #1 returned to facility at 10:00 AM with no injuries noted. Resident #1 was placed on the secure unit for his safety. Review of a handwritten statement dated 09/07/2025 indicated CNA B saw Resident #1 in the dining room at 6:20 AM and he left at the same time as she did and returned to his room. She indicated she gave him his breakfast at 7:45 AM in his room. She said she saw him last at 8:20 AM walking toward his room to go to the bathroom. She said he was acting his normal self and seemed fine. She said she began making her morning rounds getting residents ready for the day.Review of a handwritten statement dated 09/07/2025 indicated CNA Y saw Resident #1 during breakfast and again around 8:00 AM. The statement indicated she and her partner began their morning rounds of getting residents up and ready for the day and did not see the resident elope.During an interview on 10/27/2025 at 9:55 AM, LVN C said she was charge nurse over the secure unit and Hall 100. She said Resident #1 now resided on the secure unit. She said he did not reside on her halls the day he eloped. She said since he had been placed on the unit he had not tried to exit the unit and she said he had no behavior issues. She said all the staff received inservices and training on what actions to take when the alarm sounded indicating a resident with a Wanderguard had walked through an exit door. LVN C produced a purple loose-leaf binder labeled Missing. She said the binder had a list of residents with Wanderguard bracelets and a list of residents residing on the secure unit that included their face sheets with a photo and included their room numbers. She said they were to use the binder to help identify which residents to check immediately when an alarm sounded and they thought someone left the building.During an interview on 10/27/2025 at 10:05 AM LVN X said she was a PRN nurse and she was charge nurse on the 300 and 400 halls. She said they had inservices and training on elopement. She said she did not have any residents that were exit seeking but did have Wanderguard bracelets.During an observation and interview on 10/27/2025 at 10:20 AM Resident #1 was lying on his bed in his room on the secured unit. He appeared clean and well groomed. He said he did leave the building a while back and he heard voices in his head telling him to go see his uncle at his warehouse. He said the police brought him back to the facility. He then told a fantastical story about working for a major satellite and communications company in 1963 (he was born in 1962). He said they could place microchips in animals and people so they could be found by GPS (global positioning system) and he had a microchip in his brain. During an interview on 10/27/2025 at 11:15 AM LVN A said he was the charge nurse on the 500 and 600 halls and he had been on duty when Resident #1 left the facility. He said Resident #1 had been a resident on his hall and he wore a Wanderguard bracelet. He said he heard the front door alarm sound around 9:00 AM on 09/07/2025. He said he went to the front door and looked outside and there were family members and residents sitting outside. He said he did not see any resident not accompanied by a family member. He said he did not see an unaccompanied resident. He said there were residents with Wanderguards outside but were with a family member. He said he assumed they had set off the alarm accidentally. He said he did not do a facility sweep of residents with Wanderguard bracelets to ensure any other residents had exited the facility unaccompanied. He said he did not know Resident #1 was missing from the facility until the police department called and said they had picked up Resident #1 down the road. He said the resident was returned to the facility and assessed for injuries. He said he had no injuries and was placed in the secure unit for his safety. He said the direct care staff received inservices regarding elopement and reporting of elopement. He said they had a purple notebook that contained a list of all residents in the facility fitted with a Wanderguard and all residents currently residing on the secure unit. He said their face sheets along with photos were also in the binder. He said they were to look at the binder and check those residents immediately if the door alarm sounded and they could not see a reason for the alarm to have sounded.During an interview on 10/27/2025 at 11:25 AM the DON said she and her two ADONs were jointly responsible for keeping the purple binder labeled missing accurate and up to date. She said it contained a list of residents currently wearing Wanderguard bracelets and residents residing on the secure unit along with their current face sheets and photos. She said Resident #1 eloped on the weekend but she was notified and aware the resident was returned to the facility by the local police. She said she did not know how far away he was when he was found. She said staff were to check the purple binder if the alarm went off to see who to check on immediately to see if they were missing from the facility. She said sometimes family members take residents outside to sit and visit or to take them to appointments and set off the alarm accidentally. She said Resident #1 had not been exit seeking prior to his leaving the facility on 09/07/2025. She said he would not even go outside until the day he left. She said the resident had been seen by psychological/psychiatric services and he did sometimes get current events confused with daily events. During an interview on 10/27/2025 at 12:105 PM CNA B said she had worked on the hall Resident #1 resided on the day he left the facility. She said she worked mostly the day shift (6AM-6PM). She said on the day he left the facility he had been his normal self. She said she had seen him up early around 6:20 AM and served him his breakfast at 7:45 AM. She said she had last seen him around 8:20 AM walking back to his room to go to the bathroom. She said he had not been exit seeking prior to that day. She said he would walk around the facility but usually around the nurses' station and in the dining room. She said she never saw him going toward the exit doors. She said they received inservices about resident elopement procedures after Resident #1 got out. She said the purple binder at the nurses' station had a list of all the residents with Wanderguard bracelets and if the alarm sounded and no one was immediately seen outside they were to check all the residents inside to make sure everyone was accounted for. If they could not find someone they were to let the charge nurse know. During an interview on 10/27/2025 at 12:07 PM MA E said she had received inservices regarding resident elopement and what facility staff actions should be when the door alarms sounded. She said Resident #1 did not normally exit seek. She said it was out of character for him to leave the building.During an interview on 10/27/2025 at 2:35 PM the local police officer that was called by the sheriff's department to help identify a person they found walking down the county road at the intersection of a state farm to market road. He said Resident #1 could give his name and they called the facility and they said he was a resident at the facility. He said Resident #1 was found about 1.3 miles from the facility and he called the facility at 9:43 AM. He said the resident was okay and did not appear to have any injuries. He said the police department returned the resident to the facility at 10:00 AM. During an interview on 10/28/2025 at 10:00 AM the interim Administrator said he was not officially at the facility when Resident #1 eloped on 09/07/2025. He said his first day was 09/08/2025. He said the previous administrator was no longer at the facility but did not know how long they had been gone. He said the Corporate Director of Operations was in charge of the facility at the time of the elopement. During an interview on 10/28/2025 at 10:10 AM the BOM said she had received a group text from the charge nurse along with the other department heads on 09/07/2025 that Resident #1 had eloped and was at the police department. She said staff did not know he had eloped until the police called them.During an interview on 10/28/2025 at 10:20 AM the DON said LVN A called her and told her Resident #1 was at the police department and was being brought back to the facility. She said she also had received the group text. She said she had talked to an administrator that day but could not recall if it had been the previous administrator or the administrator at the local sister facility regarding the elopement.Review of facility undated Wandering and Elopement Policy indicated If a resident is missing, initiate the elopement/missing resident emergency procedure:.initiate a search of the building(s) and premise(s); and if the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies.Facility took the following actions to correct the noncompliance prior to surveyor entrance:Resident #1 returned to the facility 09/07/2025 at 10:00 AM and was placed on the secured memory unit. Resident #1's care plan was reviewed and updated to reflect current status on memory unit.All residents at risk for wandering/elopement were re-assessed and care plans were reviewed and updated to reflect current interventions being utilized for residents at risk for elopement.Elopement/Wandering Resident Policy was reviewed.All nursing staff on all shifts received education on wandering/elopement and resident safety and included new process of doing census check when wander guard alarms. All Wander Guard systems and door alarms were checked for proper functioning.Actions taken post-investigation were:All Wander Guard systems and door alarms are checked routinely for proper operation.The DON or designee will monitor new admissions for elopement risk and ensure interventions are in place daily for 3 weeks.The DON or designee will audit elopement risk assessment weekly for 3 months to ensure care plans reflect the needs and concerns in the assessments.The ad hoc (when necessary or needed) Quality Assurance and Performance Improvement committee that was completed with the medical director and interdisciplinary team will be discussed at QAA meetings for a minimum of three months or until a pattern of compliance is maintained.During an observation and interview on 10/29/2025 at 11:50 AM the DON provided elopement risk audits in the electronic record being done on residents at risk for elopement. She said she reviewed to see if their scores had changed from the previous scores. She said most residents with high scores were in the secure unit and had been. She said she looked at individual reasons for the increased assessment scores if there were any. She said residents may or may not be placed on the secured unit with high scores. She said the interventions were individualized with talking with family and discussing options. She said if a resident was constantly exit seeking and trying to go out the door they would be placed on the unit. She said Resident #1 had a Wanderguard placed the first time he exited the facility without letting anyone know and she said they considered it a fluke because he had not exhibited that behavior before. She said he would walk around the facility but never went to the doors. She said when he left on 09/07/2025 they decided he would be safer on the unit since it was the second time.Review of the October 2025 MARs for residents with Wanderguard bracelets (Residents #2, #5, #6, #7, #8, #9, #10) indicated placement and functioning every shift.Review of the maintenance weekly logs (07/05/2025-10/25/2025) for accurate operation of door monitors and resident wandering system. During multiple interviews on 10/28/2025 from 4:02 PM-4:30 PM and 10/29/2025 from 8:50 AM-9:45 AM with nurses, CNAs, and MAs from both shifts (6AM-6PM and 6PM-6AM) (CNA F, CNA G, CNA H, CNA J, CNA K, NA L, LVN M, NA N, MA O, NA P, CNA Q, CNA R, CNA S, CNA T, CNA U, NA V, NA W) indicated they said they had been trained on abuse and neglect, residents at risk for elopement, facility staff response if they saw a resident leave unaccompanied, facility staff response to door alarms sounding, the purple binder containing lists of residents at risk for elopement, and doing a census check of all residents listed in the purple binder. They said if they saw a resident exit the facility they should go out and try to get them to come back inside. They said if the door alarms sounded, they should check the panel to identify which door they should check and then go outside and do a perimeter check around the whole facility and if they did not find anyone, they should report it to their charge nurse or DON. They said they should also use the purple binder to identify residents with Wanderguards and go to their rooms or around the facility to make sure they were all present in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 1 of 4 (Resident #1) residents reviewed for pressure injuries. <BR/>The facility failed to ensure Resident #1 did not develop a DTI to her right heel.<BR/>These failures could place residents at risk for development of pressure ulcers, worsening of existing pressure injuries, infection, pain, and decreased quality of life.<BR/>Findings included:<BR/>1. Record review of the face sheet dated 5/9/25 indicated Resident #1 was a [AGE] year-old female, re-admitted to the facility on [DATE] with diagnoses including dementia, diabetes, hypertension (elevated blood pressure), difficulty walking, and muscle weakness. <BR/>Record review of the comprehensive MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS score of 03 and was severely cognitively impaired. The MDS indicated Resident #1 was at risk for developing pressure ulcers/injuries and did not have any skin and ulcer/injury treatments in place.<BR/>Record review of the care plan revised on 2/22/25 indicated Resident #1 was at risk for skin breakdown related to incontinence of bowel and bladder, use of wheelchair, disease process, and food and beverage intake with interventions including skin assessment and inspection every shift with close attention to heels. <BR/>Record review of the physician's orders dated 5/9/25 indicated Resident #1 had an order to cleanse the DTI to the right heel every day shift and to offload heels while in bed every day and night shift starting 5/4/25.<BR/>Record review of a skin assessment dated [DATE] indicated Resident #1had no alterations in skin integrity.<BR/>Record review of a skin assessment dated [DATE] written by RN B indicated Resident #1 had blanchable redness (skin that appear red due to increased blood flow, but becomes paler or white when pressure is applied, returning to its normal color when pressure is release) to her sacrum (the area at the bottom of the spine).<BR/>Record review of the progress note dated 5/3/25 written by RN A indicated Resident #1 had a dark tissue area with surrounding redness to her right heel measuring 2.5cm x 1.5cm. The progress note indicated RN A cleansed the area with normal saline and applied skin prep (skin protectant or barrier film used to protect skin from various irritants and damage) to Resident #1's heel. The progress note indicated RN A notified the NP and Resident #1's responsible party regarding Resident #1's change in skin condition.<BR/>During an interview on 5/8/25 at 11:57 a.m. RN A said she was familiar with Resident #1. RN A said when she came to work on 5/3/25 and she noted Resident #1 was not doing well (no specifics were given) and saw the dark colored area to her heel. RN A said she had not noticed the area to Resident #1's heel prior, but the nurses did not perform skin assessments, the treatment nurse had been responsible for skin assessments. RN A said she contacted the physician regarding the area to Resident #1's heel and obtained an order for skin prep daily. <BR/>During an interview on 5/8/25 at 2:07 p.m. the Hospital Nurse said Resident #1 had redness to her bottom with no open area and a DTI to her right heel.<BR/>During an observation at the hospital on 5/8/25 at 2:10 p.m. Resident #1's right heel indicated there was no open areas or eschar (necrotic, dead tissue that is often black or brown in the wound bed). Resident #1's right heel had a dark purple area with surrounding redness consistent with a DTI.<BR/>During an interview attempt on 5/9/25 at 9:50 a.m. RN B's voicemail was full, and the surveyor was unable to leave a message. <BR/>During an interview on 5/9/25 at 9:56 a.m. LVN C said the week of 5/5/25 was the facility's first week without a treatment nurse in a month. LVN C said she did not remember the last time she had seen Resident #1's feet. LVN C said nurses had not been responsible for skin assessments. LVN C said it had been the treatment nurse's responsibility to complete skin assessments.<BR/>During an interview on 5/9/25 at 10:00 a.m. CNA D said residents received showers 3 times a week on Monday, Wednesday, and Friday or on Tuesday, Thursday, and Saturday. CNA D said Resident #1's scheduled showers were on the 6:00 a.m.-2:00 p.m. shift on Monday, Wednesday, and Friday. CNA D said she was off on 5/2/25 but had worked and given Resident #1 her shower on 4/30/25. CNA D said she did not notice any discoloration or skin issues to Resident #1's heel on 4/30/25 when giving her a shower. <BR/>During an interview on 5/9/25 at 12:19 p.m. the DON said skin assessments should be performed on admission and weekly. The DON said when the facility had a treatment nurse the treatment nurse was responsible for completing skin assessments. The DON said if a resident's care plan said they should have a skin assessment every shift she would expect the resident to have a skin assessment every shift. The DON said she was not aware of any resident with a care plan indicating they should have a skin assessment every shift. The DON said the importance of skin assessments was to monitor the skin and prevent pressure ulcers and major skin issues.<BR/>During an interview on 5/9/25 at 12:47 pm the Administrator said she would have to look at the policy to answer when skin assessments should be performed. The Administrator said the importance of skin assessments was to prevent further skin breakdown, identify areas of concerns, and for infection prevention. <BR/>Record review of the facility's Prevention of Pressure Injuries policy revised 4/2021 indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and intervention for specific risk factors. Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment: 1. Assess the resident on admission (within four hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. 2. Use the standard pressure injury screening tool to determine and document risk factors. 3. Supplement the use of a risk assessment tool with assessment of additional risk factors. Skin Assessment .3. Inspect the skin on a daily basis when performing or assisting with personal care od ADLs. a. Identify any signs of developing pressure injuries. For darkly pigmented skin, inspect for changes to skin tone, temperature, or consistency. b. Inspect pressure points (sacrum, heels, buttocks, coccyx (the last bone at the bottom of the spine), elbows, ischium (a paired bone forming the lower and back parts of the hip), trochanter (a bony prominence found on the femur (though bone) near the hip), etc.) .

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 2 of 5 staff (CNA F and CNA G) viewed for infection control.<BR/>The facility failed to ensure the CNA F performed hand hygiene between glove changes while performing incontinent care on Resident #2.<BR/>The facility failed to ensure CNA G changed gloves and performed hand hygiene after taking a dirty wipe from CNA H and handing her a clean wipe during incontinent care for Resident #3.<BR/>These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. <BR/>Findings Include :<BR/>1. During an observation on 5/8/25 at 9:57 a.m. CNA E and CNA F performed incontinent care on Resident #2. CNA E and CNA F knocked on the door prior to entering the room, explained the procedure, provided privacy, and performed hand hygiene prior to putting on gloves and beginning incontinent care. CNA F opened Resident #2's wet brief then changed her gloves without performing hand hygiene. CNA F wiped Resident #2's vaginal area with disposable wipes, removed the wet brief, changed gloves, and did not perform hand hygiene. CNA E assisted Resident #2 in turning over. CNA F wiped Resident #2's bottom using disposable wipes, changed gloves, and did not perform hand hygiene. CNA F put a clean brief on Resident #2, changed gloves, and did not perform hand hygiene. CNA F retrieved lotion from the bedside table, applied lotion to Resident #2's feet, changed gloves, and did not perform hand hygiene. CNA F put the lotion back on bedside table, covered Resident #2 up, removed her gloves, and washed her hands.<BR/>Record review of the Clinical Competency: Handwashing dated 9/10/24 indicated CNA F had been checked off on proper handwashing techniques.<BR/>During an interview on 5/9/25 at 10:27 a.m. CNA F said hand hygiene should be performed when providing resident care (did not specify what care) . CNA F said hand hygiene should not be performed between glove changes . CNA F said the importance of proper hand hygiene was to prevent the spread of infections. <BR/>2. During an observation on 5/8/25 at 10:07 a.m. CNA G and CNA H performed incontinent care on Resident #3. CNA G and CNA H knocked on the door prior to entering the room, explained the procedure, provided privacy, and performed hand hygiene prior to donning gloves and beginning incontinent care. CNA H opened the wet brief, took a clean wipe from CNA G, and wiped Resident #3's vaginal area. CNA H handed the dirty wipe to CNA G. CNA G threw away the dirty wipe, did not change her gloves or perform hand hygiene, and handed CNA H a clean wipe. Resident #3 rolled to her side and CNA H wiped Resident #3 bottom. CNA G handed CNA H a clean brief. CNA G and CNA H both removed their gloves, performed hand hygiene, and donned clean gloves. CNA H placed clean brief on Resident #3. <BR/>During an interview on 5/8/25 10:07 a.m. CNA G said she should have changed her gloves and performed hand hygiene after she took the dirty wipe from CNA H and before handing her clean wipes or a clean brief. CNA G said she did not change her gloves and perform hand hygiene when she should have because she was nervous. CNA G said the importance of changing gloves and performing hand hygiene was to prevent cross contamination.<BR/>During an interview on 5/9/25 at 12:19 p.m. the DON said she expected staff to perform hand hygiene before providing care, when going from dirty to clean, after providing care, and between glove changes. The DON said the importance of proper hand hygiene was to prevent the spread of infections. <BR/>During an interview on 5/9/25 at 12:47 p.m. the Administrator said she expected staff to perform hand hygiene before putting on gloves, after taking offgloves, and when hands were visibly soiled. The Administrator said the importance of proper hand hygiene was prevention of the spread of infections. <BR/>Record review of the facility's Handwashing/Hand Hygiene policy last revised 1/2025 indicated, The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Administrative practices to Promote Hand Hygiene: 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to prevent the spread of infections to other personnel, residents, and visitors .Indications for Hand Hygiene: 1. Hand hygiene is indicated: a. Immediately before touching a resident .c. After contact with blood, body floods, or contaminated surfaces .f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal .

Bases on observations, interviews and record reviews, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 2 staff (LVN A) reviewed for nursing services. <BR/>LVN A did not don a gown prior to administering Resident #18's medications, who was on enhanced barrier precautions (EBP). <BR/>The facility did not ensure LVN A received initial EBP training upon hire. <BR/>These failures placed could place residents at risk for cross-contamination and the spread of communicable diseases and infections.<BR/>Findings included:<BR/>During observation of medication administration via Resident #18's gastrostomy tube on 11/12/2024 at 11:10 AM, LVN A was observed to prepare a medication for administration, perform hand sanitation, obtain a pair of disposable gloves from her medication cart, and don the gloves. Upon entry into Resident #18's room, a sign indicating the need for EBP was noted on the door and a clear plastic 3-drawer container with PPE in it was noted just inside the door. LVN A did not don a gown prior to admininstering medication. LVN A disconnected Resident #18's gastrostomy tube from the feeding pump, checked the tube for patency, inserted a 30ml syringe barrel into the gastrostomy tube, and then poured the medication and prescribed water flushes into the syringe barrel. LVN A completed the procedure, removed the syringe barrel from the gastrostomy tube, and reconnected the gastrostomy tube to the feeding pump. She then removed and disposed of her gloves, performed hand sanitation, and left the room. <BR/>During an interview with LVN A on 11/12/2024 at 01:15 PM, she said residents who had open wounds or indwelling devices required EBP. She said a gastrostomy tube was considered an indwelling device. LVN A said residents who required EBP had a sign on their doors to communicate the need for EBP. She said Resident #18 had an EBP sign on the door to his room. She said EBP meant Enhanced Barrier Precautions which meant gloves and gowns were to be worn when providing direct care. LVN A said she forgot to don a gown prior to administering medications via the gastrostomy route. LVN A said she should have donned a gown to reduce the risk of cross-contamination and prevent the spread of communicable diseases. LVN A said she had been worked at the facility about a month and had not been trained on EBP at this facility.<BR/>During an interview with LVN B on 11/12/2024 at 01:20 PM, she said the focus of EBP was the use of gloves and a gown when providing direct patient care to residents with wounds and/or indwelling devices. She said administering medications through a gastrostomy tube was considered direct patient care and would require the nurse to sanitize his/her hands and put on gloves and a gown prior to starting the procedure. <BR/>During an interview with the DCO on 11/12/2024 at 02:00 PM, she said LVN A should have donned both gloves and a gown prior to administering medications. The DCO said the facility had no evidence of LVN A being trained on EBP upon hire.<BR/>During an interview with the DON on 11/13/2024 at 09:00 AM, she said she expected nursing staff to follow the facility's policy and EBP protocol when providing care to residents with wounds and/or indwelling devices to reduce the risk of spreading disease.<BR/>During an interview on 11/13/2024 at 11:36 AM, RN DCO stated that there was no evidence of EBP training of employees on hire. She was able to state a potential negative outcome for failure to observe EBP on at-risk residents.<BR/>During an interview on 11/13/2024 at 3:30 PM with the BOM, she said she was responsible for new hire employees and no new hire was trained or checked off on EBP.<BR/>Record review of LVN A's new hire orientation and new associate training indicated reflected she had not received any training on EBP nor the facility's EBP policy.<BR/>During an observation on 11/11/2024 at approximately 10:30 AM, revealed rooms #107, #401, and #609 had EBP signage on the doors with no PPE supplies noted at or near the entrance to the residents' rooms nor was there any PPE set up inside the residents' rooms. <BR/>Record review on 11/13/2024 of a New Associate checklist, dated as revised February 2024, reflected EBP was not addressed upon hire.<BR/>Record review on 11/13/2024 of New Hire Orientation Checklist, dated as revised May 2019, did not address EBP upon hire.<BR/>A record review of the facility's EBP signage (developed by CDC) indicated reflected the following:<BR/>Providers and staff must also wear gloves and a gown for the following High-Contact Resident Care Activities.<BR/> .Device care or use: .feeding tube :<BR/>A record review of the facility's, undated, policy titled Enhanced Barrier Precautions Policy reflected the following:<BR/>Definitions <BR/>EBP are an infection control intervention designed to reduce transmission of MDROs in nursing homes. EBP expands upon Standard Precautions by requiring the use of gowns and gloves during specific high-contact resident care activities for residents known to be colonized or infected with an MDRO as well as those at risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).<BR/>Examples of high-contact resident care activities requiring gown and glove use for residents on EBP include, but not limited to:<BR/> .Device care or use .feeding tubes .<BR/>Indwelling medical device is a device that provided a direct pathway for pathogens in the environment to enter the body and cause infection.<BR/>Staff Awareness and Training:<BR/>1.All staff members will receive initial training on EBP upon hire and refresher training annually thereafter.<BR/>2.Training will include identification of when EBH are needed: Which residents should be placed in EBP, MDRO (Multidrug-resistant Organisms) for which EBP are required, and high contact resident care activities for which EBP should be used.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 facility kitchens.<BR/>1. The facility failed to ensure scoops were not left in the flour in the bulk flour bin.<BR/>2. The facility failed to ensure a box of raw cabbage was not stored on the floor in front of the reach in cooler.<BR/>3. The facility failed to ensure food items were labeled or dated.<BR/>These failures could place residents who ate food from the kitchen at risk of foodborne illness.<BR/>Findings included:<BR/>During observations and interviews on 11/11/24 of the kitchen the following was noted:<BR/>*at 10:10 AM a scoop was left inside the flour in the bulk flour bin in the dry pantry. The DM removed the scoop and placed it in its designated storage hanger. She said new kitchen staff have not learned everything yet and indicated the scoop was labeled flour and the storage hanger indicated flour.<BR/>*at 10:18 AM a box of raw cabbage was stored on the floor in front of the 2 door cooler.<BR/>*at 10:19 AM in the 2 door cooler a resealable bag of breadsticks was not labeled or dated.<BR/>*at 10:25 AM in the single door cooler the following was noted: a large plastic container containing a solid orange-brown substance was not labeled or dated, 1-46 oz. nectar thick cranberry juice had no open date, 1-46 oz. nectar thick apple juice had no open date, 1-46 oz. nectar thick sweetened tea with lemon had no open date, packaging on the nectar thickened liquids indicated After opening may be kept up to 7 days under refrigeration, and 1-2 quart pitcher of tomato juice was not labeled or dated.<BR/>During an interview on 11/11/2024 at 10:38 AM the DM said she had no idea what substance was in the plastic container because that was normally the beverage cooler. She said the thickened liquids were to be dated when opened. She said the dates on the boxes were the truck date indicating when they were delivered to the facility. She said there had been a spill in the cooler that needed to be cleaned before she put the cabbage in the cooler.<BR/>During an observation on 11/12/24 11:02 AM the box of raw cabbage was still stored on the floor in front of the 2 door cooler and in the single door cooler the plastic container containing the solid orange-brown substance was still unlabeled and dated and the pitcher of tomato juice was not labeled and dated.<BR/>Review of a facility policy, dated 12/01/11, on Food Storage indicated .1. e. Scoops are used for items stored in bins, such as sugar, flour, rice, and other items. Scoops are stored covered in protected area near the food containers .i. All items are stored at least 6 inches above the floor .Food is stored on clean racks or shelves .2. e. All refrigerated foods are dated, labeled, and tightly sealed, including leftovers, using clean, nonabsorbent, covered containers that are approved for food storage. All leftovers are used within 48 hours .<BR/>Food and Drug Administration Code, Dated, 2013, indicated: 3-305.11 Food Storage.<BR/>(A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD:<BR/>(1) In a clean, dry location;<BR/>(2) Where it is not exposed to splash, dust, or other<BR/>contamination; and<BR/>(3) At least 15 cm (6 inches) above the floor.

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 2 of 5 staff (CNA F and CNA G) viewed for infection control.<BR/>The facility failed to ensure the CNA F performed hand hygiene between glove changes while performing incontinent care on Resident #2.<BR/>The facility failed to ensure CNA G changed gloves and performed hand hygiene after taking a dirty wipe from CNA H and handing her a clean wipe during incontinent care for Resident #3.<BR/>These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. <BR/>Findings Include :<BR/>1. During an observation on 5/8/25 at 9:57 a.m. CNA E and CNA F performed incontinent care on Resident #2. CNA E and CNA F knocked on the door prior to entering the room, explained the procedure, provided privacy, and performed hand hygiene prior to putting on gloves and beginning incontinent care. CNA F opened Resident #2's wet brief then changed her gloves without performing hand hygiene. CNA F wiped Resident #2's vaginal area with disposable wipes, removed the wet brief, changed gloves, and did not perform hand hygiene. CNA E assisted Resident #2 in turning over. CNA F wiped Resident #2's bottom using disposable wipes, changed gloves, and did not perform hand hygiene. CNA F put a clean brief on Resident #2, changed gloves, and did not perform hand hygiene. CNA F retrieved lotion from the bedside table, applied lotion to Resident #2's feet, changed gloves, and did not perform hand hygiene. CNA F put the lotion back on bedside table, covered Resident #2 up, removed her gloves, and washed her hands.<BR/>Record review of the Clinical Competency: Handwashing dated 9/10/24 indicated CNA F had been checked off on proper handwashing techniques.<BR/>During an interview on 5/9/25 at 10:27 a.m. CNA F said hand hygiene should be performed when providing resident care (did not specify what care) . CNA F said hand hygiene should not be performed between glove changes . CNA F said the importance of proper hand hygiene was to prevent the spread of infections. <BR/>2. During an observation on 5/8/25 at 10:07 a.m. CNA G and CNA H performed incontinent care on Resident #3. CNA G and CNA H knocked on the door prior to entering the room, explained the procedure, provided privacy, and performed hand hygiene prior to donning gloves and beginning incontinent care. CNA H opened the wet brief, took a clean wipe from CNA G, and wiped Resident #3's vaginal area. CNA H handed the dirty wipe to CNA G. CNA G threw away the dirty wipe, did not change her gloves or perform hand hygiene, and handed CNA H a clean wipe. Resident #3 rolled to her side and CNA H wiped Resident #3 bottom. CNA G handed CNA H a clean brief. CNA G and CNA H both removed their gloves, performed hand hygiene, and donned clean gloves. CNA H placed clean brief on Resident #3. <BR/>During an interview on 5/8/25 10:07 a.m. CNA G said she should have changed her gloves and performed hand hygiene after she took the dirty wipe from CNA H and before handing her clean wipes or a clean brief. CNA G said she did not change her gloves and perform hand hygiene when she should have because she was nervous. CNA G said the importance of changing gloves and performing hand hygiene was to prevent cross contamination.<BR/>During an interview on 5/9/25 at 12:19 p.m. the DON said she expected staff to perform hand hygiene before providing care, when going from dirty to clean, after providing care, and between glove changes. The DON said the importance of proper hand hygiene was to prevent the spread of infections. <BR/>During an interview on 5/9/25 at 12:47 p.m. the Administrator said she expected staff to perform hand hygiene before putting on gloves, after taking offgloves, and when hands were visibly soiled. The Administrator said the importance of proper hand hygiene was prevention of the spread of infections. <BR/>Record review of the facility's Handwashing/Hand Hygiene policy last revised 1/2025 indicated, The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Administrative practices to Promote Hand Hygiene: 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to prevent the spread of infections to other personnel, residents, and visitors .Indications for Hand Hygiene: 1. Hand hygiene is indicated: a. Immediately before touching a resident .c. After contact with blood, body floods, or contaminated surfaces .f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal .

Based on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area, for 1 of 6 residents (Resident #38) reviewed, in that:<BR/>Resident #38's call light was inoperative and failed to light and sound at the centralized call light panel, located near the only nurse station in the facility. <BR/>This failure could place residents at risk of not having their needs met .<BR/>Findings included:<BR/>Record review of Resident #38 face sheet revealed an admission date of 04/11/2022 with diagnoses that included: Osteomyelitis (inflammation of the bone or bone marrow, usually due to infection), Difficulty in walking, Chronic pain syndrome, Acquired absence of right toe, Acquired absence of other right toe(s), Other speech and language deficits following unspecified cerebrovascular disease, Pressure-induced deep tissue damage of unspecified site, Pressure ulcer of other side, unstageable, Muscle wasting and atrophy. <BR/>Record review of Resident #38's care plan dated 06/28/2022 revealed he had an amputation to foot, transfer requires mechanical lift, he needs assistance with positioning in bed or chair, he was at risk for choking, required nursing assistance with oral care, staff are to respond to call light promptly. <BR/>Observation and interview on 08/29/22 at 11:53 a.m., Resident #38, stated his call light did not work. Resident #38 said when he needs something, his roommate will press his call light to get someone in the room. Resident #38 attempted activation of his call light revealed no activation at the wall plate connection in his room. Observation of the facility's centralized call light panel, at 11:56 a.m., near facility's only nurse station, indicated no activation of the call light, or sound, for Resident #38's room . <BR/>During interview on 08/31/22 at 9:26 a.m., CNA-A said he was not familiar with the residents on Hall 600. He said he was an agency staff, and this was his first day at the facility. He said if a call light was not working, he would report it to a nurse or the DON. <BR/>During interview on 08/31/22 at 9:28 a.m., LVN-B, said she was familiar with Resident #38 and when he needs something, he uses his call light. LVN-B demonstrated use of Resident #38's call light and said, it's not working. She said, it usually works; I didn't know it wasn't working.<BR/>During observation and interview on 08/31/22 at 9:33 a.m., the DON said the residents use the call lights to communicate their needs. The DON attempted to activate Resident #38's call light and it failed to activate. The DON said, it's not working. Resident #38 said his call light had not been working ever since he was moved to the room, about a month. He said he told 2-3 CNAs, but he could not remember their names, stating you know how they come and go. The DON said she was not aware Resident #38's call light was not working. The DON immediately reported the malfunction to the Maintenance Director.<BR/>Interview on 08/31/22 at 9:38 a.m., the ADM said maintenance checks the call lights on a regular basis and the Fire Alarm Company also check the call light. When asked, she said a log is kept. She said she was not aware of any call lights not working. She said she would provide a log of the call light checks. <BR/>Interview on 08/31/22 at 9:41 a.m., the Maintenance Director said he checked call lights once per month. He said, other than that, he only checks call lights when a new resident moves in or when a resident changes room. He said he checked Resident #38's call light, approximately 1 month ago. The Maintenance Director said the Fire Alarm Company does not check the call lights and he does not keep a record when call lights are checked. <BR/>Record review of facility undated policy, Room Readiness Practice. Facility Practice: Facility staff (maintenance, housekeeping, supervisor, and admission director, others as assigned) check room for admissions and room changes. #10. Does call light work (light on the door and at nurse station).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but , but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 2 of 6 (Resident # 4 and Resident #5) residents reviewed for abuse and neglect.<BR/>The facility staff did not report to the state agency Resident #4's complaint of physical abuse by CNA J and CNA K on 2/17/25.<BR/>The facility staff did not report to the state agency Resident #5's diagnosis of a subdural hematoma (a pool of blood between the brain and its outermost covering) discovered following an unwitnessed fall on 4/11/25.<BR/>This failure could place residents at risk of injuries, abuse, and/or neglect.<BR/>Findings Include:<BR/>1. Record review of the face sheet dated 5/8/25 indicated Resident #4 was a [AGE] year-old male, re-admitted to the facility on [DATE] with diagnoses including contracture (a structural change in the body's soft tissues, like muscles, tendons, ligaments, or skin that causes them to stiffen or shorten), unspecified joint; contracture of muscle, multiple sites; abnormal posture; muscle weakness; and dementia. <BR/>Record review of the MDS dated [DATE] indicated Resident #4 understood others and was understood by others. The MDS indicated Resident #4 had a BIMS of 12 and was moderately cognitively impaired. The MDS indicated Resident #4 was dependent on staff for toileting, showering, personal hygiene, and transfers. The MDS indicated Resident #4 required substantial/maximum assist with rolling left and right, sitting to lying, and lying to sitting on the side of the bed. <BR/>Record review of the care plan last revised 4/1/25 indicated Resident #4 had verbal behavior symptoms directed towards others.<BR/>Record review of a grievance dated 2/17/25 indicated Resident #4 reported to the DON that when CNA J and CNA K were changing him, they were rough with him. The grievance indicated Resident #4 said they pulled his leg when repositioning him. The grievance indicated Resident #4 said the CNAs had been rough with him the morning of 2/17/25. The grievance indicated the DON explained to Resident #4 that CNA J and CNA were not at the facility the morning of 2/17/25. The grievance indicated Resident #4 said CNA K rolled up a rag and slapped him in the testicles with it and knocked a scab off his foot. The grievance indicated the DON explained to Resident #4 that the wound care physician had just seen him and removed a scabbed area to his foot due to it being healed. The grievance indicated the DON notified the Social Worker at this time to assist in interviewing the resident. The grievance indicated the Administrator was notified of the allegation.<BR/>Record review in TULIP (online system for intakes regarding facility reported incidents and complaints in nursing facilities) for 2/17/25 through 5/8/25 indicated the facility had not reported to the state agency the allegation of abuse made on 2/17/25 by Resident #4.<BR/>During an interview on 5/8/25 at 9:13 am Resident #4 said he did not remember the incident from January or February 2025 with 2 CNAs being rough during care and one of them hitting him in the testicles. Resident #4 said staff had been rough with him, but he could not remember any details. Resident #4 said he was not scared of anyone in the facility. <BR/>During an interview on 5/8/25 at 9:36 a.m. the Administrator said she did a full investigation regarding the allegation of abuse made by Resident #4 in February 2025. The Administrator said she did not report the allegation of abuse to the state agency due to the fact the CNAs that were accused of physical abuse by Resident #4 had not worked the day and time he said the incident occurred. The Administrator said she did not think a self-report needed to be done for CNAs who were not in the building for the time of the allegation. <BR/>2. Record review of the face sheet dated 5/9/25 indicated Resident #5 was a [AGE] year-old male re-admitted to the facility on [DATE] with diagnoses including dementia, dizziness, hallucinations, and hypertension (elevated blood pressure). <BR/>Record review of the MDS dated [DATE] indicated Resident #5 usually understood others and was usually understood by others. The MDS indicated Resident #5 had a BIMS of 08 and was moderately cognitively impaired. The MDS indicated Resident #5 did not use a wheelchair and was independent with ambulation.<BR/>Record review of the care plan last revised on 4/15/25 indicated Resident #5 was at risk for falls related to change in environment and admission to the facility. <BR/>Record review of an incident report dated 4/11/25 indicated Resident #5 had an unwitnessed fall. The incident report indicated Resident #5 was found in the floor in front of his bedroom door on his right side with his head lying on the bed handles. The incident report indicated Resident #5 was noted to be bleeding on the top of the head with a hematoma (localized collection of blood often due to injury or trauma). The incident report indicated Resident #5 said he had tripped getting out of bed and hit his head. The incident report indicated Resident #5 was transported to the hospital for evaluation. <BR/>Record review of the hospital discharge paperwork dated 4/12/25 indicated Resident #5's primary diagnosis was subdural hematoma.<BR/>Record review of TULIP (online system for intakes regarding facility reported incidents and complaints in nursing facilities) for dated 4/11/25 through 5/8/25 indicated the facility had not reported to the state agency Resident #5's fall with major injury on 4/11/25.<BR/>During an interview on 5/9/25 at 12:19 p.m. the DON said she had been working as a charge nurse on 4/11/25 when Resident #5 had a fall. The DON said the fall was unwitnessed. The DON said the CNA (name not provided) came to get her regarding Resident #5's fall. The DON said he was lying in the floor by his door. The DON said he had got himself up out of bed and tripped causing the fall. The DON said he was sent to the ER for evaluation. The DON said she had logged on to the hospital records between 11:00 and 11:30 am and saw Resident #5 had a diagnosis of subdural hematoma. The DON said the Administrator was responsible for reporting incidents to the state agency. <BR/>During an interview on 5/9/25 at 12:47 p.m. the Administrator said she was responsible for reporting incidents to the state agency. The Administrator said abuse, neglect, misappropriation, injury of unknown source, and death of unusual circumstances should be reported to the state agency. The Administrator said the importance of reporting incidents to the state agency was to enable complete investigations to be performed and prevention of future incidents. <BR/>Record review of the facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy revised 9/2022 indicated, All reports of resident abuse (including injuries of unknown origin), neglect exploitation, or theft/misappropriation of the resident property are reported to local, state, and federal agencies (as requires by current regulations) and thoroughly investigated by facility management. Findings of all investigation are documented and reported. Reporting Allegations to the Administrator and Authorities: 1. If resident abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines .3. Immediately is defined as: a, within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury .6. Upon receiving any allegation of abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for protection of the resident .

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 2 of 5 staff (CNA F and CNA G) viewed for infection control.<BR/>The facility failed to ensure the CNA F performed hand hygiene between glove changes while performing incontinent care on Resident #2.<BR/>The facility failed to ensure CNA G changed gloves and performed hand hygiene after taking a dirty wipe from CNA H and handing her a clean wipe during incontinent care for Resident #3.<BR/>These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. <BR/>Findings Include :<BR/>1. During an observation on 5/8/25 at 9:57 a.m. CNA E and CNA F performed incontinent care on Resident #2. CNA E and CNA F knocked on the door prior to entering the room, explained the procedure, provided privacy, and performed hand hygiene prior to putting on gloves and beginning incontinent care. CNA F opened Resident #2's wet brief then changed her gloves without performing hand hygiene. CNA F wiped Resident #2's vaginal area with disposable wipes, removed the wet brief, changed gloves, and did not perform hand hygiene. CNA E assisted Resident #2 in turning over. CNA F wiped Resident #2's bottom using disposable wipes, changed gloves, and did not perform hand hygiene. CNA F put a clean brief on Resident #2, changed gloves, and did not perform hand hygiene. CNA F retrieved lotion from the bedside table, applied lotion to Resident #2's feet, changed gloves, and did not perform hand hygiene. CNA F put the lotion back on bedside table, covered Resident #2 up, removed her gloves, and washed her hands.<BR/>Record review of the Clinical Competency: Handwashing dated 9/10/24 indicated CNA F had been checked off on proper handwashing techniques.<BR/>During an interview on 5/9/25 at 10:27 a.m. CNA F said hand hygiene should be performed when providing resident care (did not specify what care) . CNA F said hand hygiene should not be performed between glove changes . CNA F said the importance of proper hand hygiene was to prevent the spread of infections. <BR/>2. During an observation on 5/8/25 at 10:07 a.m. CNA G and CNA H performed incontinent care on Resident #3. CNA G and CNA H knocked on the door prior to entering the room, explained the procedure, provided privacy, and performed hand hygiene prior to donning gloves and beginning incontinent care. CNA H opened the wet brief, took a clean wipe from CNA G, and wiped Resident #3's vaginal area. CNA H handed the dirty wipe to CNA G. CNA G threw away the dirty wipe, did not change her gloves or perform hand hygiene, and handed CNA H a clean wipe. Resident #3 rolled to her side and CNA H wiped Resident #3 bottom. CNA G handed CNA H a clean brief. CNA G and CNA H both removed their gloves, performed hand hygiene, and donned clean gloves. CNA H placed clean brief on Resident #3. <BR/>During an interview on 5/8/25 10:07 a.m. CNA G said she should have changed her gloves and performed hand hygiene after she took the dirty wipe from CNA H and before handing her clean wipes or a clean brief. CNA G said she did not change her gloves and perform hand hygiene when she should have because she was nervous. CNA G said the importance of changing gloves and performing hand hygiene was to prevent cross contamination.<BR/>During an interview on 5/9/25 at 12:19 p.m. the DON said she expected staff to perform hand hygiene before providing care, when going from dirty to clean, after providing care, and between glove changes. The DON said the importance of proper hand hygiene was to prevent the spread of infections. <BR/>During an interview on 5/9/25 at 12:47 p.m. the Administrator said she expected staff to perform hand hygiene before putting on gloves, after taking offgloves, and when hands were visibly soiled. The Administrator said the importance of proper hand hygiene was prevention of the spread of infections. <BR/>Record review of the facility's Handwashing/Hand Hygiene policy last revised 1/2025 indicated, The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Administrative practices to Promote Hand Hygiene: 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to prevent the spread of infections to other personnel, residents, and visitors .Indications for Hand Hygiene: 1. Hand hygiene is indicated: a. Immediately before touching a resident .c. After contact with blood, body floods, or contaminated surfaces .f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan, for each resident, consistent with the resident rights set forth 483.10(c)(3, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (Resident #2) reviewed for comprehensive assessments. The facility failed to ensure a comprehensive person-centered care plan was developed and completed within 21 days of admission to the facility for Resident #2. This failure could place residents at risk of a delay in receiving care and services to meet medical and nursing needs. The findings included: Record review of a face sheet dated 10/28/2025 indicated Resident #2 was an [AGE] year-old female who admitted to the facility 10/06/2025 with diagnoses which included Alzheimer's disease, dementia, aortic stenosis (a condition where the aortic valve in the heart becomes narrowed, restricting blood flow from the heart to the rest of the body), and osteoporosis. Review of an MDS dated [DATE] revealed Resident #2 had a BIMS score of 6 indicating her cognition was severely impaired. Record review of Resident #2's medical records indicated a comprehensive care plan had not been completed. During an interview on 10/29/2025 at 11:10 AM, the MDS Coordinator said she, the DON, and the ADON shared responsibility for developing and implementing the care plans. She said for new admissions, the comprehensive care plan was to be done within 7 days of the completion of the comprehensive assessment and no more than 21 days after admission. She said that since the comprehensive MDS had not been completed, the comprehensive care plan had not been completed. She said Resident #2's comprehensive care plan should have been completed no later than 10/27/2025. The MDS Coordinator said she was working on getting caught up. The MDS Coordinator said the facility used RAI Version 3.0 Manual as the guide for completing MDS assessments and care plans. During an interview on 10/29/2025 at 03:15 PM, the DON said she, the ADON, and the Social Worker were new to the facility and were working on processes to get caught up and organized. She said she was not aware Resident #2's comprehensive care plan had not been completed. Review of CMS's RAI Version 3.0 Manual Section 2.2 indicated the Care Plan Completion Date must be dated by the end of the 7th calendar day following the completion date of the admission Comprehensive Assessment and can be no later than day 21 (admission date +21 = Comprehensive Care Plan due date). A review of the facility's policy titled Care Plans, Comprehensive Person-Centered and dated 2001 with a revision date of March 2022 indicated the following: Policy StatementA comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 1. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in status), and no more than 21 days after admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident #3) and representative was informed of her right to participate in the development and implementation of a person-centered plan of care. The facility failed to facilitate the inclusion of Resident #3 and/or the representative in the care planning process. This failure could prevent residents from incorporating their personal and cultural preferences in developing goals of care. Findings included: Record review of a face sheet dated 10/28/2025 indicated Resident #3 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included a principal diagnosis of COPD (a condition involving constriction and destruction of the airways in the lungs), a co-existing diagnosis of emphysema (a type of COPD involving the air sacs in the lungs), and pre-existing diagnoses of dementia and diabetes mellitus (a chronic condition in which the body does not produce enough insulin to regulate blood sugar levels). Review of the MDS dated [DATE] noted Resident #3 had a BIMS score of 10 indicating her cognition was moderately impaired. She was ambulatory with a walker and was incontinent at times. Review of the MDS dated [DATE] indicated Resident #3 discharged from the facility on 05/02/2025. Record review of Resident #3's medical records indicated a care plan was developed during a previous facility stay from 08/19/2025 - 09/08/24 was revised for the plan of care for the most current stay from 02/27/2025 - 05/02/2025. Record review of scanned documents, progress notes and social worker notes for Resident #3 from 02/27/2025 - 05/02/2025 did not indicate Resident #3 and/or representative had been informed of or invited to participate in the development of a care plan. There was no documentation of a refusal to participate in the care planning process. During an interview on 10/27/2025 at 11:00 AM, Resident #3's representative said she had not been consulted about or included in the care planning process for Resident #3. She said she was never asked to attend a care plan meeting nor was she invited to participate in the development of Resident #3's plan of care during the entire time Resident #3 was at the facility nor was she ever given a copy of a care plan. During an interview on 10/28/2025 at 03:10 PM, the DON said she had been at the facility for about 4 months. She said she could not find any documentation of Resident # 3 or the representative having been invited to a care plan meeting, a care plan meeting being held, or a review of a plan of care for Resident #3. The DON said she, the MDS Coordinator, and Social Worker shared in the care planning process. She said neither she nor the Social Worker were employed at the facility during Resident #3's stay at the facility and could not explain why Resident #3 and the representative had not been invited to a care plan meeting or been given a copy of Resident #3's care plan. A record review of the facility's policy titled Care Plans-Baseline dated Revised March 20244 indicated the following:A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include.but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative;, .4. The resident and/or representative are provided a written summary of the baseline care plan .5. Provision of the summary to the resident and/or resident representative is documented in the medical record. A record review of the facility's policy titled Care Plans, Comprehensive Person-Centered indicated the following: Policy Interpretation and Implementation4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to:a: participate in the planning process.h. see the care plan and sign it after significant changes are made.5. The resident is informed of his or her right to participate in his or her treatment and provided advance notice of care planning conferences.