Every finding on record at Amistad Nursing and Rehabilitation Center

Based on observation, interview and record review the facility failed to provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 1 of 1 Resident (Resident #2) reviewed for podiatry care. Resident #2's toenails were long and past the nailbed. On 8/2/26 and on 8/4/26 nursing staff should have known or knew his toenails were long and failed to cut them. This deficient practice could place residents at risk of skin tears, ingrown toenails and infections. The findings were:Review of Resident #2's face sheet, dated 8/6/26, revealed he was admitted to the facility on [DATE] with diagnoses including Type II Diabetes (a chronic condition where the body resists insulin or does not make enough of it, causing sugar to build up in the blood) and unspecified Dementia (a decline in mental ability severe enough to interfere with daily life, affecting memory, communication, and thinking). Review of Resident #2's quarterly MDS assessment, dated 6/2/26, revealed his skills for daily decision making were severely impaired. Resident #1's functional abilities for personal hygiene revealed Not attempted due to medical conditionor safety concerns. Review of Resident #12s Care Plan, dated 3/8/26, revealed he required total assistance by 1 staff for personal hygiene as required. Review of Resident #2's physician orders for August 2026 revealed an order Trim finger and toenails weeklyevery day shift every Sunday. Review of Resident #2's TAR from 8/1/26 to 8/31/26 revealed Resident #1 was scheduled to have his fingernails and toenails trimmed on Sunday, 8/2/26. The charge nurse initialed the task indicating the task was completed. Review of Resident #2's podiatry treatment note, dated 5/8/26, revealed his toenails were cut down and there was evidence of mycosis and more specifically he was diagnosed with onychomycosis (a common fungal infection of the fingernails or toenails that causes the nail to become discolored) and Onychauxis (abnormal thickening of fingernails or toenails) Review of a podiatry reported dated, 7/15/26, revealed Resident #2 was admitted to the list for podiatry care; however, he did not receive treatment. Observation and interview on 8/5/26 at 3:40 PM revealed Resident #2 was lying in bed and awake. He did not engage in conversation. Interview with Resident #2's family member reported his toenails were really long. She drew the covers and sheets back and removed his socks. Observation revealed Resident #2's left and right great toenail were brown with minimal redness around the nailbed. All toenails extended past the nailbed. Interview with Resident #2 family member revealed the foot doctor had cut Resident #2's toenails once since his admission. Interview on 8/6/26 at 6:00 PM with the DON revealed treatment nurse would do weekly skin checks and her would clip a resident's toenails as needed. She stated the nurses were also scheduled to cut the resident's toenails as needed on Sunday's and then the podiatrist would come in periodically. She stated if Resident #2's toenails were past the nail bed, she would say that they needed to get cut. She stated the toenails could become ingrown and cause an infection. Interview on 8/6/26 at 6:15 PM with LVN A/treatment nurse revealed he completed weekly skin checks and stated on 8/4/26 he completed a skin check for Resident #2 and noted Resident #2's toenails were long. He stated he should have cut them, but he did not and could not think of a reason why he did not cut Resident #2's toenails. LVN A stated he trimmed Resident #2's toenails on this date, 8/6/26, and commented they were, a bit long and past the nailbed, He stated it did not look like they were cut on Sunday, 8/2/26 as ordered. He stated Resident #2 had some kind of fungus growing on both great toenails and stated every resident had access to a podiatrist. LVN A stated long toenails could result in them becoming ingrown and could also cause skin tears. He stated either one could result in Resident #2 developing an infection. Interview on 8/7/26 at 5:50 PM with the DON revealed the facility did not have a policy for podiatry care.

Based on observation, interview and record review the facility failed to based on a resident's comprehensive assessment maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance and was offered sufficient fluid intake to maintain proper hydration and health for 1 of 1 Resident (Resident #2) reviewed for gastrostomy tube care. LVN B failed to connect Resident #2's gastrostomy tube per physician orders from 11:00 AM to 3:23 PM on 8/5/26. This deficient practice could place a resident at risk for a lack of sufficient nutritional and fluid intake. The findings were:Review of Resident #2's face sheet, dated 8/6/26, revealed he was admitted to the facility on [DATE] with diagnoses including other diseases of stomach and duodenum (include a range of structural, inflammatory, and motility disorders distinct from standard ulcers and simple gastritis), dysphagia (a person has trouble swallowing, but the exact cause or specific phase of the swallow problem is not yet known )unspecified and gastrostomy status (an opening made through the skin of the belly directly into the stomach. A feeding tube (G-tube) is placed through this opening to give food, liquids, or medicine when a person cannot swallow safely). Review of Resident #2's quarterly MDS assessment, dated 6/2/26, revealed his skills for daily decision making were severely impaired. Resident #2 was on a feeding tube while in the facility. Review of Resident #2's Care Plan, dated 3/8/26, revealed he had a Potential for alteration in nutrition and riskfor malnutrition. Resident with history of failed MBSS while hospitalized resulting in peg tube placement d/t malnutrition anddysphagia. History of significant weight loss. Interventions included Administer enteral feedings/flushes as ordered. Review of Resident #2's physician orders for August 2026 revealed an order NPO diet NPO texture, NPO consistency and Enteral Feed Order two times a day related to Unspecified protein-calorie malnutrition. Diabetisource 70ml/hr X 22 hours. Will provide 1848kcal/day,97g pro, 1230ml free water. Review of Resident #2's TAR for August 2026 revealed an order Enteral Feed Order two times a day related to unspecified protein-calorie malnutrition. Diabetisource 70ml/hr X 22 hours. Will provide 1848kcal/day,97g pro, 1230ml free water. On at 11:00 AM and off at 9AM. Observation and interview on 8/5/26 at 3:23 PM revealed Resident #2 was lying in bed asleep. The G-tube pump was off. Review of the feeding bag revealed Resident #1 was receiving Diabetisource 70ml/hr X 22 hours. Resident #2's family representative was in the room and stated she did not know his feeding tube schedule. She stated she had asked the nurses about it and some staff told her they would connect it every 4 hours and some staff told her it was every 2 hours. The family representative stated Resident #2 lost a lot of weight while at the hospital prior to his admission to the facility. Interview on 8/6/26 at 5:05 PM with the DON revealed Resident #2's family representative reported the nurse did not reconnect Resident #2's G-tube. The DON stated LVN B reported she lost track of time and did not connect Resident #2's G-tube at 11:00 AM because she was testing staff and residents for COVID. The DON stated LVN B had the option to ask another nurse if they could connect his G-tube. The DON stated it was important to follow physician orders because Resident #2's feeding and hydration was calculated specifically for him based on his nutritional needs. The DON stated Resident #2's health could decline if he did not receive the nutrition and hydration he needed which could further complicated his clinical status. Attempted telephone interview on 8/7/26 at 10:48 AM with LVN B. She was not available and left voicemail. LVN B did not return the call. Review if a facility policy, Enteral Tube Medication Administration, dated 3/2025, read The facility assures the safe and effective administration of enteral formulas and medications. Selection of enteral formulas, routes and methods of administration, and the decision to administer medications via enteral tubes are based on nursing assessment of the resident condition, in consultation with the physician, dietician and Consultant Pharmacist. 1. Enteral formulas, equipment, route of administration, and rate of flow are selected based on a nursing assessment of the resident's condition and need with physician, pharmacist, and dietician involvement. 2. Interactions between medications and feeding formulas, and interactions of multiple medications are considered before administering medication through the enteral tube. If necessary, information is obtained from the pharmacy or Consultant Pharmacist.5. Caloric content per milliliter is verified before administration to assure that the correct dosage is given to achieve caloric objectives.

Based on interview and record review the facility failed to notify the resident and the resident's representative of the transfer or discharge in writing and the facility failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 2 Residents (Resident #1) reviewed for the discharge process. The facility failed to provide Resident #1 and her representative with a day discharge notice and the right to appeal. Resident #1 was discharged from the facility on 7/21/26. This deficient practice could affect the resident's or resident's representative from appealing the discharge plan. The findings were: Review of Resident #1's face sheet, dated 8/6/26, revealed she was admitted to the facility on [DATE] with diagnoses including unspecified Dementia (a decline in mental ability severe enough to interfere with daily life, affecting memory, communication, and thinking) , unspecified mood (affective) disorder (clinical diagnosis used when a person has significant emotional or mood symptoms that cause distress or problems in daily life) and other recurrent depressive disorder (a mental health condition defined by repeated episodes of low mood, loss of interest, and low energy, separated by periods of normal mood). Resident #1 was discharged from the facility on 7/21/26. Review of Resident #1's quarterly MDS assessment, dated 5/23/26, revealed her BIMS score was 2 of 15 reflective of severe cognitive impairment. Review of Resident #1's Care Plan, dated 7/28/26, revealed she had impaired cognition due to dementia AEB (as evidenced by) memory deficits, impaired decision-making, decreased safety awareness, and need for supervision/cueing, she was an elopement risk related to wandering and disoriented to place. Some of the interventions included ensure all doors were secured and locked, If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system and monitor location frequently throughout the day. Review of Resident #1's progress notes for July 2026 did not reveal any documentation from the NP to reflect the basis for Resident #1's discharge or how the facility could not meet the resident's needs. Telephone interview on 8/5/26 at 4:30 PM with the facility Ombudsman revealed she became aware the facility discharged and transferred Resident #1 to another facility during her on-site visit on 7/22/26. The Ombudsman stated the facility did not notify her prior to discharging Resident #1. She stated staff reported Resident #1's representative was in agreement with the transfer. Interview on 8/6/26 at 4:03 PM with the SW revealed Resident #1 was transferred to another facility with a memory care unit. She stated during a meeting with the DON and ADM it was decided Resident #1 was too much of a flight risk. She stated it was not a Care Plan meeting or an IDT meeting. The SW stated she was the manager on duty a few weeks back during June 2026. She stated she did not remember the date, but it was on a Sunday. She stated Resident #1 walked out when a staff member entered the facility through the front door. The SW stated she saw Resident #1 walk out but she did not leave the premises. The SW stated she caught up with Resident #1 on the sidewalk and was able to redirect Resident #1 back into the facility. She stated Resident #1 was continuously exit seeking and would push on the front door, try to follow staff and family members in or out when the front door was opened. The SW stated the front door was locked at all times with a keypad and only facility staff had the code to the keypad. Although, she stated family members would somehow get the code and would access the facility on their own. The SW stated during normal business hours the receptionist would disengage the lock for family members and outside providers when entering and leaving the facility. She stated all other exit doors had alarms and would sound if they were pushed open. She stated Resident #1 only attempted exiting the through the front door. She stated Resident #1 had actually never eloped but there were concerns about her heightened exit seeking and increased agitated and aggressive behaviors. The SW stated she did not provide a 30 day discharge notice to the family representative and did not educate the family representative about the appeal process. She stated the reason for discharge was imminent because of Resident #1's exit seeking behaviors. She stated Resident #1's family representative was very upset when she reached out to discuss placement options. The SW further stated she did not contact the Ombudsman about Resident #1's discharge plan. Interview on 8/6/26 at at 5:05 PM with the DON revealed Resident #1 was transferred to another facility due to her exit seeking behaviors. The DON stated they were worried about the resident's safety. She stated she called the family representative to let her know Resident #1 was exit seeking more and the facility planned to discharge Resident #1. The DON stated prior to this the NP completed a medication review and made some medication adjustments and for a short time it seemed to help Resident #1. Resident #1 was less anxious, was calmer and was not exit seeking as much. The DON stated then Resident #1 became aggressive and was refusing medications. The DON stated when she talked to Resident #1's family representative she seemed agreeable. She stated the family representation did not express any concerns to her and if the family representative reported concerns to another staff member, she expected the staff member to let her know about it. The DON stated she did not believe they provided a discharge notice or did not discuss the appeal process with the family representative. Interview on 8/7/26 at 10:00 AM with the DON revealed the ADM was out of the facility related to a medical procedure. State Surveyor requested she contact the ADM and have her call the State Surveyor. The DON agreed to call the ADM. Interview on 8/7/26 at 1:53 PM with Resident #1's family representative revealed the DON called her about discharging Resident #1 from the facility. She stated she did not remember the exact date, but it was a Wednesday and the DON wanted to move Resident #1 by the Friday; within a two-day period. She stated the DON reported Resident #1 was being combative and was trying to elope. The family representative stated Resident #1 eloped shortly after she was Initially admitted to the facility and she found Resident #1 at her home. She stated since then Resident #1 had never attempted to elope. The family representative stated she did not know Resident #1 was acting up because facility staff did not communicate with her about any behavior changes. The representative stated staff did not discuss any safety plan in place. She stated the facility did not follow any protocols; they did not provide her with a 30-day notice and commented you can't discharge a resident from one day to another and expect it to be ok. The family member stated it was heartbreaking. She stated in the 4 years Resident #1 lived in the facility no one said anything to her about any behaviors. The family member stated one time she and another family member visited with Resident #1 and sat up front for an hour and a half. Resident #1 never approached the front door. She stated most recently the ADM reported Resident #1 tried to walk out with a man. She stated she was angry that no one reported anything to her at the time of the incident. The family representative stated she was very upset because the facility never called for a Care Plan meeting, they did not discuss any options with her and did not give us an opportunity to fix the situation before they decided to move Resident #1. She stated she could have hired someone to help with Resident #1. The family representative commented she trusted the facility would do the right by Resident #1 because they were all from the same town. She stated the staff knew Resident #1 from the community. She stated on the day they were packing up and getting Resident #1 for discharge, Resident #1 asked Who is making me move, this is my house, this is bullshit. The family representative stated she understood the NP made a medication adjustment, but staff did not allow time to determine whether or not the changes would help. The family member commented, They did us wrong. Interview on 8/7/26 at 3:38 PM with Resident #1's NP revealed Resident #1 historically had been stable. The NP stated she saw Resident #1 at the end of June 2026 because staff reported an increase in irritability and believed for increased exit seeking behaviors. She stated she reviewed Resident #1's medical records and stated she had titrated Resident #1's physician order for Trileptal [(oxcarbazepine)] is an anti-seizure prescription medication. Doctors also prescribe it off-label for conditions like nerve pain or mood stabilization in bipolar disorder) down to once a day. The NP stated she titrated it back up to be administered twice daily. She stated sometimes it took 4 to 6 weeks for a resident to stabilize. The NP stated she did not recall the staff calling about a discharge plan for Resident #1. She stated she would review her notes and call back with any new information. The NP did not call back. Interview at 4:29 PM with the DON revealed she called the ADM and had not heard from her. The ADM did not contact the State Surveyor. Review of a facility policy, Discharge or Transfer, undated, read The facility will allow the resident to remain in the facility and not transfer or discharge the resident from the facility. In the following limited circumstances, the facility may initiate transfers and discharges: A. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. Documentation: To demonstrate that any of the circumstances permissible for a facility to initiate a transfer or discharge as specified in A - F on the previous page have occurred, the medical record will show documentation for the basis for transfer or discharge. For circumstances A and B the inability to meet the resident's needs, the documentation made by the resident's physician must include: The specific resident needs the facility could not meet; The facility efforts to meet those needs; and the specific services the receiving facility will provide to meet the needs of the resident which cannot be met in the current facility.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, for 1 of 1 kitchen reviewed for food safety. Raisin bread and hamburger buns were stored in the facility's' kitchen pantry without labeled dates to indicate when the food was received and opened.Hamburger buns were stored in the facility's' kitchen pantry unsealed and open to air.The facility's' nutrition room refrigerator had resident foods which were not labeled to indicate when the food was received or when the food should be discarded.Food delivered by the food vendor was stored in cardboard cases upon the floor. These failures could place residents at risk for food borne illness.The findings included: During an observation and interview on 6/23/2026 at 11:00 AM revealed the facility's kitchen pantry stored 5 loaves of Raisin bread, packaged in the manufacturer's clear plastic wrap upon a wire rack. The loaves were all without any labeled date to indicate when the bread was received. A package of hamburger buns was opened and left open to air upon a wire rack. The package did not have any label to indicate when the food was received and when the food was opened. The FSM stated the food should be labeled with the date the food was received and when the food was opened. The FSM stated the dates indicated when the food should be discarded, food which has been opened should be discarded after 7 days. During an observation and interview on 6/23/2026 at 11:18 AM revealed the facility's residents' nutrition room located on the facility's 100-hall, had a refrigerator which stored resident foods. CNA C demonstrated the refrigerator which had a sign affixed to the refrigerator door which reflected, This refrigerator is for resident snacks and resident personal food items: place name of resident on items received. Date each item when received. Check date of best by or expiration each day and discard as needed. Notify resident, Representative, family, when items are discarded. CNA C demonstrated the refrigerator which stored multiple foods without the labels which could have indicated when the food was received and when the food should be discarded. Observations revealed the following foods:A plastic to-go container, which contained an enchilada dinner, with Resident #62's name written upon the container. No date was labeled on the container to indicate when the dinner was received or to indicate when the food should be discarded.A 10.6 ounce opened container of brand name cottage cheese without a label to indicate which resident the food belonged to, when the food was received, when the food was opened, and when to discard the food.CNA C confirmed the food should be labeled with the residents' names and dates to indicate when the food was received and when the food should be discarded. During an observation and interview on 6/26/2026 at 11:30 AM revealed the facility's' kitchen pantry, where foods were stored in cardboard boxes upon the floor. The FSM stated he had just received a food truck delivery from the food vendor and had placed the food, which was stored in cardboard boxes, on the floor. The FSM stated the practice was an oversight and he should not have placed the food on the floor. The FSM stated the failures could potentially place residents at risk for food borne illness. A record review of the facility's undated Food Safety policy revealed, We will insure all food purchased shall be wholesome and manufactured, processed, and prepared in compliance with all State, Federal, and local laws and regulations. Food shall be handled in a safe manner. Procedure: . 2. Food is to be wrapped or sealed and covered in clean containers. Opened food shall be labeled, dated and stored properly. Perishable opened foods shall be used within 7 days or less, in compliance with the Texas Food Establishment rules. Non-perishable foods will be used as long as the quality of the product is maintained. 9. Do not keep potentially hazardous food in refrigerator past the labeled expiration date.

Based on observation, interview, and record review, the facility failed to ensure residents were provided a sanitary and comfortable environment for 1 of 3 shower areas (400-hall shower) reviewed for physical environment. The facility failed to ensure the 400-hall shower area was free from dirt and debris. This failure could result in decreased quality of life. Findings included: In an interview with a confidential resident on an undisclosed date/time, the resident said the shower room in the 400-hall was dirty, and the lack of cleanliness made the resident feel uncomfortable when bathing. In an observation on 6/23/2026 at 2:26 PM, the 400-hall shower was observed to have a wet, black substance between the tiles on the floor. The moveable shower chair had a similar, wet, black substance on the surface of the bottom panel and the fabric straps. In a second observation on 6/24/2026 at 10:45 AM, revealed the condition of the 400-hall shower area was unchanged. In an interview on 6/24/2026 at 10:45 AM, the HSKD said the shower areas were cleaned daily, and the shower chairs were deep cleaned with a pressure washer on the last Wednesday of every month. She said the facility ensured all the chairs were cleaned because they were all cleaned at the same time. She said they did not maintain a log of this activity. She said if the chairs required additional unscheduled cleaning the staff should notify the housekeeping department. She said the shower chair in the 400-hall shower should have received an additional cleaning due to the observed condition. In an interview on 6/24/2026 at 10:45 AM, the DON said the showers and shower chairs were cleaned between each resident by the CNA performing showers, and the expectation was the shower areas and equipment would be cleaned to maintain cleanliness, and the shower area and chair should have received additional cleanings. Record review of the facility policy titled Infection Control Plan: Obserview dated 2016, reflected the following: .3. Non-invasive resident care equipment is cleaned daily or as needed between use by the nursing assistant.

Based on observations, interviews, and record reviews, the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. These grievances included those with respect to care and treatment which had been furnished as well as those which had not been furnished, the behavior of staff and of other residents, and other concerns regarding their long term care (LTC) facility stay, for 3 of 8 residents (Residents #11, #12, and #30) reviewed for grievances. CNA A failed to file a grievance when Resident #11 reported to CNA G that someone stole $31 from her some days prior to 6/24/2026.The facility failed to take immediate action, per their grievance policy, to prevent further potential violations of any resident right while the alleged violations were being investigated when Resident #30's representative complained that LVN D was verbally abusive and neglectful. LVN D was allowed to work in the facility another 3 days after Resident #30's representative made the complaint. The facility failed to issue written grievance decisions to Resident #30, per the facility policy.The Administrator failed to document a grievance made by Resident #12 when he called the Administrators' cell phone on the evening of June 17th, 2026, when he alleged, he was left soiled in his bowel movement for longer than 1-2 hours. These failures could place residents at risk for not having their grievances heard and acted upon for resolution.The findings included. Resident #11A record review of Resident #11's admission record dated 6/26/2026 revealed an admission date of 9/28/2022 with diagnoses which included polyosteoarthritis (a chronic, degenerative joint disease that affects five or more joints simultaneously), chronic pain, and difficulty walking. A record review of Resident #11's quarterly MDS assessment dated [DATE] revealed Resident #11 was a [AGE] year-old female admitted for LTC supports which included assistance with transfers. Resident #11 was assessed with adequate vision, adequate hearing without hearing aid, the ability to understand others and the ability to make herself understood. Resident #11 was assessed with a BIMS score of 9 out of a possible 15 which indicated moderate cognitive impairment. A record review of Resident #11's care plan dated 6/5/2026 revealed a focus of Potential for alteration in mood / behavior due to depression and impaired cognition . Interventions: . monitor, record, report, to MD PN mood patterns signs and symptoms of depression, anxiety, sad mood, as per facility behavior monitoring protocols. A record review of the facility's grievance log for the period January 2026 through June 26, 2026, revealed no grievance recorded for Resident #11's alleged missing $31. During an interview on 6/25/2026 at 1:45 PM Resident #11 stated that, sometime last week, staff had stolen her $31, from her wallet, which she kept at her nightstand. Resident #11 stated she had reported the incident to CNA G. Resident #11 stated she had not received any information regarding the loss of her money and had just resolved to keep her money on her person and not trust any staff at the facility. During an interview on 6/25/2026 at 1:54 PM CNA G stated Resident #11 had reported to her that someone stole $31 from her room. CNA G stated she could not recall the specific day but that the report was some time last week. CNA G stated she had not reported the complaint because she believed the nurses knew about the complaint. Resident #30A record review of Resident #30's admission record dated 6/26/2026 revealed an admission date of 6/2/2026. Resident #30's diagnoses included emphysema (a progressive, irreversible lung disease where the tiny air sacs are gradually destroyed), cerebral infarction (stroke; a medical emergency that occurs when blood flow to an area of the brain is cut off or a blood vessel in the brain bursts), and cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body). A record review of Resident #30's admission MDS assessment dated [DATE] revealed Resident #30 was a [AGE] year-old female admitted for long term care with activities of daily life supports. Resident #30 was assessed with a BIMS score of 13 which indicated intact cognition. A record review of Resident #30's care plan dated 6/26/2026 revealed, potential for ineffective breathing pattern due to but not limited to history of respiratory infections and resident has emphysema with chronic bronchitis, . administer medications / treatments as per medical doctors' orders. A record review of Resident #30's physicians' orders dated 6/26/2026 revealed the physician prescribed for Resident #30 to receive ipratropium albuterol solution, for her emphysema, twice a day in the morning and again in the evening, via a nebulizer (a medical device used to turn liquid medicine into a fine mist). A record review of the facility's grievance dated 6/6/2026 revealed Resident #30's Representative made a grievance against LVN D, (Resident #30's Representative) reported that (Resident #30) stated that she had not received her AM nebulizer medication. (Resident #30's Representative) went to the nurse's station and asked (LVN D) if he could administer the neb treatment and (LVN D) was very rude according to (Resident #30's Representative) and LVN E. (Resident #30's Representative) reported that LVN D stated (Resident #30) could administer the medication herself. (LVN D) did eventually administer the nebulizer treatment after (Resident #30's Representative) asked for it. The nebulizer treatments are scheduled for AM and PM. LVN D administered the medication around 1130-noon. The DON documented, (LVN D) was late administering a neb treatment and was rude to (Resident #30's Representative) after she asked for the neb treatment to be administered. (LVN D) showed poor customer service. LVN D was coached on medication administration and customer service. An employee disciplinary record was requested from corp. the grievance document revealed a meeting was held with Resident #30's Representative and the grievance was confirmed and resolved. The DON documented Resident #30's Representative received a resolution report in a one-to-one discussion. A record review of an email from Resident #30's Representative to the Administrator dated 6/6/2026 at 4:57 PM revealed, Resident #30's Representative made a complaint that LVN D had not administered Resident #30's medications as the prescriber had ordered, that LVN D was rude and verbally abusive, and Resident #30's Representative requested a formal investigation with a written report per the facility's policy; Subject: formal complaint regarding medication and treatment administration. To nursing home administration, I am writing to formally document concerns regarding the care provided to (Resident #30) and specifically the repeated issues involving medication and treatment administration by one of the nursing staff members, (LVN D). I informed (LVN D) that (Resident #30) had not received her morning nebulization treatment. (LVN D's) response was, Okay, I'll do it right now. I then asked for clarification, stating that my understanding was that the treatment was ordered for morning and evening administration. (LVN D) confirmed that was correct. When I asked why it had not been given that morning, (LVN D) stated that (Resident #30) had the nebulizer medication in her room and could administer it herself. I respectfully request: a formal investigation into these incidents; a review of (Resident #30's) medication and treatment administration records to determine whether other prescribed doses or treatments have been missed or administered incorrectly; education or corrective action as appropriate regarding adherence to physician orders; a written response outlining the findings of the investigation and any steps being taken to prevent similar issues in the future. after composing this notification, I learned that (LVN D) went into (Resident #30's) room after I left the building and told (Resident #30) she could administer it herself and that she probably didn't even need it because (LVN D) had not heard (Resident #30) coughing. During an interview on 6/26/2026 at 1:30 PM Resident #30 and Resident #30's Representative stated they were disappointed that they still had not received a written report on the investigative findings of the abuse and neglect claims made on the 6th of June 2026. Resident #30 and Resident #30's Representative stated they had spoken with the DON and learned LVN D had missed Resident #30's albuterol treatments and had not returned to care for Resident #30 since June 6th, 2026. Resident #30 and Resident #30's Representative stated to check with LVN E who was a witness to the incident on 6/6/2026. Resident #30 stated she was intimidated by LVN D's care when on 6//6/2026 in the evening LVN D confronted Resident #30 and accused her of being able to self-administer her own medications and was not even sick because she was not coughing. During an interview on 6/26/2026 at 2:20 PM LVN E stated she was receiving a nurse-to-nurse report from LVN D on 6/6/2026 around 2:00 PM when she witnessed LVN D state to Resident #30's Representative that he had not administered Resident #30's morning nebulizer treatment and Resident #30 could administer her nebulizer herself. LVN E stated she was surprised at LVN D's rude response. LVN E stated she had not reported the complaint to the leadership because she heard Resident #30's Representative state they were going to report LVN D. Resident #12A record review of Resident #12's admission record dated 6/26/2026, revealed an admission date of 5/8/2026. Resident #12 had diagnoses which included neuromuscular dysfunction of the bladder (occurs when damage to the brain, spinal cord, or nerves disrupts the signals required to hold and release urine), a history of falling, and depressive disorders (persistent feelings of sadness, emptiness, and a loss of interest in activities). A record review of Resident #12's admission MDS assessment dated [DATE] revealed Resident #12 was a [AGE] year-old male admitted for LTC supports for activities of daily life. Resident #12 was assessed with adequate vision with eyeglasses, adequate hearing without hearing aids, clear speech, the ability to understand others and the ability to make himself understood. Resident #12 was assessed with a BIMS score of 12 which indicated moderate cognitive impairment. A record review of Resident #12''s care plan dated 6/26/2026 revealed, Resident is incontinent of bowel and requires assistance with toileting tasks due to but not limited to decreased mobility and impaired cognition. Potential for with history of constipation / loose stools. History of colon rectal cancer. check resident frequently throughout the day and as required / requested and assist with toileting as needed. toilet use: requires extensive x1 staff assistance. resident is incontinent of bowel and bladder. potential for skin breakdown due to but not limited to decreased mobility, incontinence and impaired condition, the resident needs assistance to turn, reposition, frequently throughout the day and as requested. During an interview on 6/24/2026 at 9:20 AM Resident #12 stated on June 17th, 2026, he was left in his feces for 2 hours. Resident #12 stated the time was after dinner and he became soiled with feces and ignited his call light. Resident #12 stated he had become frustrated and upset when he was left in that condition with no one responding to his calls when he recalled the Administrator had given him her cell phone number. Resident #12 stated he used his cell phone to call the Administrator. Resident #12 stated the Administrator received his call and within some minutes a CNA entered his room and confronted Resident #12 by stating you got me in trouble! and proceeded to provide rough hurried incontinent care. During an observation and joint interview on 6/24/2026 at 9:40 AM, revealed, the Administrator in Resident #30's room documenting Resident #30's interview. Resident #30 stated he used his cell phone to call the Administrator to notify her when he was left soiled in his feces for 2 hours. The Administrator stated Resident #30 called her on the evening of 6/17/2026 and stated he was left with his call light on for some time. A record review of the facility's grievance log for the period of June 2026 revealed no grievance entry for Resident #12. The log was sent via an email dated 6/24/2026 at 9:47 AM. A record review of the administrators' email dated 6/24/2026 at 1:42 PM to the survey team revealed the Administrator stated she had made a correction to the grievance log. A record review of the corrected log for June 2026 revealed the Administrator had written in a new entry dated 6/17/2026 for Resident #12. A record request was made for the actual grievances listed on the log. A record review of Resident #12's grievance dated 6/24/2026 revealed an incident date of 6/17/2026. The Administrator documented, (Resident #12) was waiting for someone to change him. I quickly thanked him for letting me know and made sure someone went to take care of his needs. During an interview on 6/26/2026 at 3:35 PM the Administrator stated the process for documenting formal grievances when residents or Representatives presented concerns was, if it required an investigation then it was documented into a formal grievance, one of the things that we fail on is giving ourselves credit for things we address and fix, it's very easy to fix things on the spot, but there are those that take a little longer. We have to do in-services and do documentation on because it's serious. so, if it requires an investigation then it's turned into a formal grievance. A record review of the facility's policy titled Grievances dated 11//2/2016 revealed, The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have. The grievance official of this facility is the administrator or their designee.3. The grievance official will: Oversee the grievance process Receive and track grievances to their conclusion Lead any necessary investigations by the facility Maintain the confidentiality of all information associated with grievances Issue written grievance decisions to the resident Coordinate with state and federal agencies as necessary4. As needed, the facility will take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated5. All grievances involving alleged violations of neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the abuse preventionist.6. All written grievances decisions will include: The date the grievance was received A summary statement of the resident's grievance The steps taken to investigate the grievance A summary of the pertinent findings or conclusions regarding the resident's concern(s) A statement as to whether the grievance was confirmed or not confirmed Any corrective action taken or to be taken by the facility as a result of the grievance The date the written decision was issued.

Based on observations, interviews, and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 3 of 8 residents (Residents #11, #12, and #30) reviewed for reporting suspicions of abuse, neglect, exploitation or mistreatment CNA G failed to report an allegation of misappropriation of property to the Administrator, when Resident #11 reported to CNA G that, someone stole $31 from her some days prior to 6/24/2026.The Administrator and the DON failed to report to the State Agency an allegation of neglect and verbal abuse on 6/6/2026, when Resident #30 and her Representative alleged LVN D had neglected to administer medications and was verbally abusive.The Administrator failed to report to the State Agency an allegation made by Resident #12 that he was left soiled in his bowel movement for longer than 1-2 hours. These failures could place residents at risk for not having their allegations and suspicions of abuse, neglect, exploitation and mistreatment reported to the Administration and the State Agency.The findings included: Resident #11A record review of Resident #11's admission record dated 6/26/2026 revealed an admission date of 9/28/2022 with diagnoses which included polyosteoarthritis (a chronic, degenerative joint disease that affects five or more joints simultaneously), chronic pain, and difficulty walking. A record review of Resident #11's quarterly MDS assessment dated [DATE] revealed Resident #11 was a [AGE] year-old female admitted for LTC supports which included assistance with transfers. Resident #11 was assessed with adequate vision, adequate hearing without hearing aid, the ability to understand others and the ability to make herself understood. Resident #11 was assessed with a BIMS score of 9 out of a possible 15 which indicated moderate cognitive impairment. A record review of Resident #11's care plan dated 6/5/2026 revealed a focus of Potential for alteration in mood / behavior due to depression and impaired cognition . Interventions: . monitor, record, report, to MD PRN mood patterns signs and symptoms of depression, anxiety, sad mood, as per facility behavior monitoring protocols. A record review of the state of Texas website, Texas Unified Licensure Information Portal for the facility's account, accessed 6/23/2026 revealed no report of alleged abuse, neglect, exploitation, or mistreatment on behalf of Resident #11 for the period of 6/1/2026 through 6/23/2026. During an interview on 6/25/2026 at 1:45 PM Resident #11 stated that, sometime last week, staff had stolen her $31, from her wallet, which she kept at her nightstand. Resident #11 stated she had reported the incident to CNA G. Resident #11 stated she had not received any information regarding the loss of her money and had just resolved to keep her money on her person and not trust any staff at the facility. During an interview on 6/25/2026 at 1:54 PM CNA G stated Resident #11 had reported to her that someone stole $31 from her room. CNA G stated she could not recall the specific day but that the report was some time last week. CNA G stated she had not reported the complaint because she believed the nurses knew about the complaint. Resident #30A record review of resident #30's admission record dated 6/26/2026 revealed an admission date of 6/2/2026 with diagnoses which included emphysema (a progressive, irreversible lung disease where the tiny air sacs are gradually destroyed), cerebral infarction (stroke; a medical emergency that occurs when blood flow to an area of the brain is cut off or a blood vessel in the brain bursts), and cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body). A record review of Resident #30's admission MDS assessment dated [DATE] revealed Resident #30 was a [AGE] year-old female admitted for long term care with activities of daily life supports. A record review of Resident #30's care plan dated 6/26/2026 revealed, potential for ineffective breathing pattern due to but not limited to history of respiratory infections and resident has emphysema with chronic bronchitis, . administer medications / treatments as per medical doctors' orders. A record review of Resident #30's physicians' orders dated 6/26/2026 revealed the physician prescribed for Resident #30 to receive ipratropium albuterol solution, for her emphysema, twice a day in the morning and again in the evening, via a nebulizer (a medical device used to turn liquid medicine into a fine mist). A record review of the state of Texas website, Texas Unified Licensure Information Portal for the facility's account, accessed 6/23/2026 revealed no report of alleged abuse, neglect, exploitation, or mistreatment on behalf of Resident #30's for the period of 6/1/2026 through 6/23/2026. A record review of the facility's grievance dated 6/6/2026 revealed Resident #30's Representative made a grievance against LVN D, (Resident #30's Representative) reported that (Resident #30) stated that she had not received her AM nebulizer medication. (Resident #30's Representative) went to the nurse's station and asked (LVN D) if he could administer the neb treatment and (LVN D) was very rude according to (Resident #30's Representative) and LVN E. (Resident #30's Representative) reported that LVN D stated (Resident #30) could administer the medication herself. (LVN D) did eventually administer the nebulizer treatment after (Resident #30's Representative) asked for it. The nebulizer treatments are scheduled for AM and PM. LVN D administered the medication around 1130-noon. The DON documented, (LVN D) was late administering a neb treatment and was rude to (Resident #30's Representative) after she asked for the neb treatment to be administered. (LVN D) showed poor customer service. LVN D was coached on medication administration and customer service. An employee disciplinary record was requested from corp. the grievance document revealed a meeting was held with Resident #30's Representative and the grievance was confirmed and resolved. The DON documented Resident #30's Representative received a resolution report in a one-to-one discussion. A record review of an email from Resident #30's Representative to the Administrator dated 6/6/2026 at 4:57 PM revealed, Resident #30's Representative made a complaint that LVN D had not administered Resident #30's medications as the prescriber had ordered, that LVN D was rude and verbally abusive, and Resident #30's Representative requested a formal investigation with a written report per the facility's policy; Subject: formal complaint regarding medication and treatment administration. To nursing home administration, I am writing to formally document concerns regarding the care provided to (Resident #30) and specifically the repeated issues involving medication and treatment administration by one of the nursing staff members, (LVN D). I informed (LVN D) that (Resident #30) had not received her morning nebulization treatment. (LVN D's) response was, Okay, I'll do it right now. I then asked for clarification, stating that my understanding was that the treatment was ordered for morning and evening administration. (LVN D) confirmed that was correct. When I asked why it had not been given that morning, (LVN D) stated that (Resident #30) had the nebulizer medication in her room and could administer it herself. I respectfully request: a formal investigation into these incidents; a review of (Resident #30's) medication and treatment administration records to determine whether other prescribed doses or treatments have been missed or administered incorrectly; education or corrective action as appropriate regarding adherence to physician orders; a written response outlining the findings of the investigation and any steps being taken to prevent similar issues in the future. after composing this notification, I learned that (LVN D) went into (Resident #30's) room after I left the building and told (Resident #30) she could administer it herself and that she probably didn't even need it because (LVN D) had not heard (Resident #30) coughing. During an interview on 6/26/2026 at 1:30 PM Resident #30 and Resident #30's Representative stated they were disappointed that they still had not received a written report on the investigative findings of the abuse and neglect claims made on the 6th of June 2026. Resident #30 and Resident #30's Representative stated they had spoken with the DON and learned LVN D had missed Resident #30's albuterol treatments and had not returned to care for Resident #30 since June 6th, 2026. Resident #30 and Resident #30's Representative stated, check with LVN E who was a witness to the incident on 6/6/2026. Resident #30 stated she was intimidated by LVN D's care when on 6//6/2026 in the evening LVN D confronted Resident #30 and accused her of being able to self-administer her own medications and was not even sick because she was not coughing. During an interview on 6/26/2026 at 2:20 PM LVN E stated she was receiving a nurse-to-nurse report from LVN E on 6/6/2026 around 2:00 PM when she witnessed LVN D state to Resident #30's Representative that he had not administered Resident #30's morning nebulizer treatment and Resident #30 could administer her nebulizer herself. LVN E stated she was surprised at LVN D's rude response. LVN E stated she had not reported the complaint to the leadership because she heard Resident #30's Representative state they were going to report LVN D. Resident #12A record review of Resident #12's admission record dated 6/26/2026, revealed an admission date of 5/8/2026 with diagnoses which included neuromuscular dysfunction of the bladder (occurs when damage to the brain, spinal cord, or nerves disrupts the signals required to hold and release urine), a history of falling, and depressive disorders (persistent feelings of sadness, emptiness, and a loss of interest in activities) A record review of Resident #12's admission MDS assessment dated [DATE] revealed Resident #12 was a [AGE] year-old male admitted for LTC supports for activities of daily life. Resident #12 was assessed with adequate vision with eyeglasses, adequate hearing without hearing aids, clear speech, the ability to understand others and the ability to make himself understood. Resident #30 was assessed with a BIMS score of 12 which indicated moderate cognitive impairment. A record review of Resident #12''s care plan dated 6/26/2026 revealed, Resident is incontinent of bowel and requires assistance with toileting tasks due to but not limited to decreased mobility and impaired cognition. Potential for with history of constipation / loose stools. History of colon rectal cancer. check resident frequently throughout the day and as required / requested and assist with toileting as needed. toilet use: requires extensive x 1 staff assistance. resident is incontinent of bowel and bladder. potential for skin breakdown due to but not limited to decreased mobility, incontinence and impaired condition, the resident needs assistance to turn, reposition, frequently throughout the day and as requested. A record review of the state of Texas website, Texas Unified Licensure Information Portal for the facility's account, accessed 6/23/2026 revealed no report of alleged abuse, neglect, exploitation, or mistreatment on behalf of Resident #12 for the period of 6/1/2026 through 6/23/2026. During an interview on 6/24/2026 at 9:20 AM Resident #12 stated on June 17th, 2026, he was left in his feces for 2 hours, Resident #12 stated the time was after dinner and he became soiled with feces and ignited his call light. Resident #12 stated he had become frustrated and upset when he was left in that condition with no one responding to his calls when he recalled the Administrator had given him her cell phone number. Resident #12 stated he used his cell phone to call the Administrator. Resident #12 stated the Administrator received his call and within some minutes a CNA entered his room and confronted Resident #12 by stating you got me in trouble! and proceeded to provide rough hurried incontinent care. During an observation and joint interview on 6/24/2026 at 9:40 AM, revealed, the Administrator in Resident #30's room documenting Resident #30's interview. Resident #30 stated he used his cell phone to call the Administrator that he was left soiled in his feces for 2 hours. The Administrator stated Resident #30 called her on the evening of 6/17/2026 and stated he was left with his call light on for some time. A record review of Resident #12's grievance dated 6/24/2026 revealed an incident date of 6/17/2026. The Administrator documented, (Resident #12) was waiting for someone to change him. I quickly thanked him for letting me know and made sure someone went to take care of his needs. During a joint interview on 6/26/2026 at 3:35 PM with the DON and the Administrator; the DON responded to the question, what is the policy/process on reporting allegations of abuse/neglect/exploitation? the DON responded, the staff know to report immediately to the abuse coordinator and then the abuse coordinator immediately reports to the state; and the Administrator responded, We follow the state guidelines. The DON responded to the question are there any incidents/grievances/ allegations/ suspicions of abuse, neglect, or exploitation, that have not been reported? The DON responded, No, I think everything that should have been reported has been reported. The Administrator responded, With Resident #11, we weren't aware of her missing money, but we did report it once we knew. Resident #11 will tell everybody, she's very vocal and everybody knows. We find it odd that she didn't tell either of us because we've both spent time with her. The DON added, She spends a lot of time with the ADON and I talked to her on Friday and she didn't say anything about missing money. But it would have been reported, and we did report it yesterday. We interviewed CNA G, and she said in her statement but in her mind she thought it was from way back when, not that it had just happened. So, she thought it was in the past, like a long time ago. A record review of the facility's undated Abuse / Neglect policy revealed, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the residents' medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, . it is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, and situations that may constitute abuse or neglect to any resident in the facility. 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 all incidents that meet the criteria of provider letter 2024-14 dated 8/29/2024. If the allegations involve abuse or result in serious bodily injury, the report is to be made within two hours of the allegation. If the allegation does not involve abuse or serious bombing injury, the report must be made within 24 hours of the allegation.

Based on observations, interviews, and record reviews, the facility failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation were verified appropriate corrective actions must have been taken, for 3 of 8 residents (Residents #11, #12, and #30) reviewed for reporting suspicions of abuse, neglect, exploitation or mistreatment. The facility failed to investigate and provide the State Agency with a report no later than 5 days after the alleged abuse, neglect, exploitation, mistreatment, and misappropriation of property was received for:A reported allegation of misappropriation of property, when Resident #11 reported to CNA G that someone stole $31 from her.A reported allegation of verbal Abuse and neglect when Resident #30 and her Representative alleged LVN D had neglected to administer medications and was verbally abusive.A reported allegation of neglect when Resident #12 alleged he was left soiled in his bowel movement for longer than 1-2 hours. These failures could place residents at risk for not having their allegations and suspicions of abuse, neglect, exploitation and mistreatment investigated and reported to the Administration and the State Agency.The findings included: Resident #11A record review of Resident #11's admission record dated 6/26/2026 revealed an admission date of 9/28/2022 with diagnoses which included polyosteoarthritis (a chronic, degenerative joint disease that affects five or more joints simultaneously), chronic pain, and difficulty walking. A record review of Resident #11's quarterly MDS assessment dated [DATE] revealed Resident #11 was a [AGE] year-old female admitted for LTC supports which included assistance with transfers. Resident #11 was assessed with adequate vision, adequate hearing without hearing aid, the ability to understand others, and the ability to make herself understood. Resident #11 was assessed with a BIMS score of 9 out of a possible 15 which indicated mild cognitive impairment. A record review of Resident #11's care plan dated 6/5/2026 revealed a focus of Potential for alteration in mood / behavior due to depression and impaired cognition . Interventions: . monitor, record, report, to MD PRN mood patterns signs and symptoms of depression, anxiety, sad mood, as per facility behavior monitoring protocols. A record review of the State of Texas' website, the Texas Unified Licensure Information Portal for the facility's account, accessed 6/23/2026 revealed no investigation report for the alleged abuse, neglect, exploitation, or mistreatment on behalf of Resident #11 for the period of 6/1/2026 through 6/23/2026. During an interview on 6/25/2026 at 1:45 PM Resident #11 stated staff had stolen her $31 sometime last week. Resident #11 stated she had reported the incident to CNA G. Resident #11 stated she had not received any information regarding the loss of her money and had just resolved to keep her money on her-person and not trust any staff at the facility. During an interview on 6/25/2026 at 1:54 PM CNA G stated Resident #11 had reported to her that someone stole $31 from her room. CNA G stated she could not recall the specific day but that the report was some time last week. CNA G stated she had not reported the complaint because she believed the nurses knew about the complaint. Resident #30A record review of resident #30's admission record dated 6/26/2026 revealed an admission date of 6/2/2026 with diagnoses which included emphysema (a progressive, irreversible lung disease where the tiny air sacs are gradually destroyed), cerebral infarction (stroke; a medical emergency that occurs when blood flow to an area of the brain is cut off or a blood vessel in the brain bursts), and cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body). A record review of Resident #30's admission MDS assessment dated [DATE] revealed Resident #30 was a [AGE] year-old female admitted for long term care with activities of daily life supports. A record review of Resident #30's care plan dated 6/26/2026 revealed, potential for ineffective breathing pattern due to but not limited to history of respiratory infections and resident has emphysema with chronic bronchitis, . administer medications / treatments as per medical doctors' orders. A record review of Resident #30's physicians' orders dated 6/26/2026 revealed the physician prescribed for Resident #30 to receive ipratropium albuterol solution, for her emphysema, twice a day in the morning and again in the evening, via a nebulizer (a medical device used to turn liquid medicine into a fine mist). A record review of the State of Texas' website, the Texas Unified Licensure Information Portal for the facility's account, accessed 6/23/2026 revealed no investigation report for the alleged abuse, neglect, exploitation, or mistreatment on behalf of Resident #30, for the period of 6/1/2026 through 6/23/2026. A record review of the facility's grievance dated 6/6/2026 revealed Resident #30's Representative made a grievance against LVN D, (Resident #30's Representative) reported that (Resident #30) stated that she had not received her AM nebulizer medication. (Resident #30's Representative) went to the nurse's station and asked (LVN D) if he could administer the neb treatment and (LVN D) was very rude according to (Resident #30's Representative) and LVN E. (Resident #30's Representative) reported that LVN D stated (Resident #30) could administer the medication herself. (LVN D) did eventually administer the nebulizer treatment after (Resident #30's Representative) asked for it. The nebulizer treatments are scheduled for AM and PM. LVN D administered the medication around 1130-noon. The DON documented, (LVN D) was late administering a neb treatment and was rude to (Resident #30's Representative) after she asked for the neb treatment to be administered. (LVN D) showed poor customer service. LVN D was coached on medication administration and customer service. An employee disciplinary record was requested from corp. the grievance document revealed a meeting was held with Resident #30's Representative and the grievance was confirmed and resolved. The DON documented Resident #30's Representative received a resolution report in a one-to-one discussion. A record review of an email from Resident #30's Representative to the Administrator dated 6/6/2026 at 4:57 PM revealed, Resident #30's Representative made a complaint that LVN D had not administered Resident #30's medications as the prescriber had ordered, that LVN D was rude and verbally abusive, and Resident #30's Representative requested a formal investigation with a written report per the facility's policy; Subject: formal complaint regarding medication and treatment administration. To nursing home administration, I am writing to formally document concerns regarding the care provided to (Resident #30) and specifically the repeated issues involving medication and treatment administration by one of the nursing staff members, (LVN D). I informed (LVN D) that (Resident #30) had not received her morning nebulization treatment. (LVN D's) response was, Okay, I'll do it right now. I then asked for clarification, stating that my understanding was that the treatment was ordered for morning and evening administration. (LVN D) confirmed that was correct. When I asked why it had not been given that morning, (LVN D) stated that (Resident #30) had the nebulizer medication in her room and could administer it herself. I respectfully request: a formal investigation into these incidents; a review of (Resident #30's) medication and treatment administration records to determine whether other prescribed doses or treatments have been missed or administered incorrectly; education or corrective action as appropriate regarding adherence to physician orders; a written response outlining the findings of the investigation and any steps being taken to prevent similar issues in the future. after composing this notification, I learned that (LVN D) went into (Resident #30's) room after I left the building and told (Resident #30) she could administer it herself and that she probably didn't even need it because (LVN D) had not heard (Resident #30) coughing. During an interview on 6/26/2026 at 1:30 PM Resident #30 and Resident #30's Representative stated they were disappointed that they still had not received a written report on the investigative findings of the abuse and neglect claims made on the 6th of June 2026. Resident #30 and Resident #30's Representative stated they had spoken with the DON and learned LVN D had missed Resident #30's albuterol treatments and had not returned to care for Resident #30 since June 6th, 2026. Resident #30 and Resident #30's Representative stated, check with LVN E who was a witness to the incident on 6/6/2026. Resident #30 stated she was intimidated by LVN D's care. During an interview on 6/26/2026 at 1:45 PM the facility's Human Resources (HR) Director stated she was asked by her leadership to develop and implement an employee disciplinary record for LVN D related to his misconduct on 6/6/2026 with Resident #30. The HR Director stated a record review of LVN D's employee time records revealed LVN D worked the next 3 days after he was alleged to have been misappropriate with Resident #30, (LVN D) worked 6/7/2026, 6/8/2026, and 6/9/2026 8 hours each day and prior to receiving his employee disciplinary action on 6/9/2026 he left the building and never returned. During an interview on 6/26/2026 at 2:20 PM LVN E stated she was receiving a nurse-to-nurse report from LVN E on 6/6/2026 around 2:00 PM when she witnessed LVN D state to Resident #30's Representative that he had not administered Resident #30's morning nebulizer treatment and Resident #30 could administer her nebulizer herself. LVN E stated she was surprised at LVN D's rude response. LVN E stated she had not reported the complaint to the leadership because she heard Resident #30's Representative state they were going to report LVN D. Resident #12A record review of Resident #12's admission record dated 6/26/2026, revealed an admission date of 5/8/2026 with diagnoses which included neuromuscular dysfunction of the bladder (occurs when damage to the brain, spinal cord, or nerves disrupts the signals required to hold and release urine), a history of falling, and depressive disorders (persistent feelings of sadness, emptiness, and a loss of interest in activities) A record review of Resident #12's admission MDS assessment dated [DATE] revealed Resident #12 was a [AGE] year-old male admitted for LTC supports for activities of daily life. Resident #12 was assessed with adequate vision with eyeglasses, adequate hearing without hearing aids, clear speech, the ability to understand others and the ability to make himself understood. Resident #30 was assessed with a BIMS score of 12 which indicated moderate cognitive impairment. A record review of Resident #12''s care plan dated 6/26/2026 revealed, Resident is incontinent of bowel and requires assistance with toileting tasks due to but not limited to decreased mobility and impaired cognition. Potential for with history of constipation / loose stools. History of colon rectal cancer. check resident frequently throughout the day and as required / requested and assist with toileting as needed. toilet use: requires extensive x 1 staff assistance. resident is incontinent of bowel and bladder. potential for skin breakdown due to but not limited to decreased mobility, incontinence and impaired condition, the resident needs assistance to turn, reposition, frequently throughout the day and as requested. A record review of the State of Texas' website, the Texas Unified Licensure Information Portal for the facility's account, accessed 6/23/2026 revealed no investigation report for the alleged abuse, neglect, exploitation, or mistreatment on behalf of Resident #12 for the period of 6/1/2026 through 6/23/2026. During an interview on 6/24/2026 at 9:20 AM Resident #12 stated on June 17th, 2026, he was left in his feces for 2 hours, Resident #12 stated the time was after dinner and he became soiled with feces and ignited his call light. Resident #12 stated he had become frustrated and upset when he was left in that condition with no one responding to his calls when he recalled the Administrator had given him her cell phone number. Resident #12 stated he used his cell phone to call the Administrator. Resident #12 stated the Administrator received his call and within some minutes a CNA entered his room and confronted Resident #12 by stating you got me in trouble! and proceeded to provide rough hurried incontinent care. During an observation and joint interview on 6/24/2026 at 9:40 AM, revealed, the Administrator in Resident #30's room documenting Resident #30's interview. Resident #30 stated he used his cell phone to call the Administrator that he was left soiled in his feces for 2 hours. The Administrator stated Resident #30 called her on the evening of 6/17/2026 and stated he was left with his call light on for some time. A record review of Resident #12's grievance dated 6/24/2026 revealed an incident date of 6/17/2026. The Administrator documented, (Resident #12) was waiting for someone to change him. I quickly thanked him for letting me know and made sure someone went to take care of his needs. During a joint interview on 6/26/2026 at 3:35 PM with the DON and the Administrator; the DON responded to the question, what is the policy/process on reporting allegations of abuse/neglect/exploitation? the DON responded, the staff know to report immediately to the abuse coordinator and then the abuse coordinator immediately reports to the state; and the Administrator responded, We follow the state guidelines. The DON responded to the question are there any incidents/grievances/ allegations/ suspicions of abuse, neglect, or exploitation, that have not been reported? The DON responded, No, I think everything that should have been reported has been reported. The Administrator responded, With Resident #11, we weren't aware of her missing money, but we did report it once we knew. Resident #11 will tell everybody, she's very vocal and everybody knows. We find it odd that she didn't tell either of us because we've both spent time with her. The DON added, She spends a lot of time with the ADON and I talked to her on Friday and she didn't say anything about missing money. But it would have been reported, and we did report it yesterday. We interviewed CNA G, and she said in her statement but in her mind she thought it was from way back when, not that it had just happened. So, she thought it was in the past, like a long time ago. A record review of the facility's undated Abuse / Neglect policy revealed, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the residents' medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, . it is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property, and situations that may constitute abuse or neglect to any resident in the facility. 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 all incidents that meet the criteria of provider letter 2024-14 dated 8/29/2024. If the allegations involve abuse or result in serious bodily injury, the report is to be made within two hours of the allegation. If the allegation does not involve abuse or serious bombing injury, the report must be made within 24 hours of the allegation.

Based on interviews and record reviews, the facility failed to ensure at the time each resident was admitted , the facility had physician orders for the resident's immediate care, for 1 of 8 residents reviewed (Resident #30) for medications needed upon admission. Resident #30 was discharged from the hospital and admitted to the facility on [DATE] with an immediate need for anticoagulant medication which was not prescribed per the physicians' and manufactures' recommendations and resulted in Resident #30 missing 4 doses. This failure could place residents at risk of not receiving medications upon admission.The findings included: A record review of Resident #30's admission record dated 6/26/2026 revealed an admission date of 6/2/2026. Resident #30 had diagnoses which included emphysema (a progressive, irreversible lung disease where the tiny air sacs are gradually destroyed), cerebral infarction (stroke; a medical emergency that occurs when blood flow to an area of the brain is cut off or a blood vessel in the brain bursts), and cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body). A record review of Resident #30's admission MDS assessment dated [DATE] revealed Resident #30 was a [AGE] year-old female admitted for long term care with activities of daily life supports after a hospitalization for a suspected cardiovascular accident (a stroke). A record review of Resident #30's care plan dated 6/26/2026 revealed, Resident is on anticoagulant therapy . administer medications per medical doctor's orders. A record review of Resident #30's hospital medication discharge orders dated 6/2/2026 revealed the hospital physician prescribed for Resident #30 to receive an apixaban started pack upon admission to the facility. A record review of the medication apixaban's manufacturers website:https://www.eliquis.com/eliquis/hcp/dosing/dvt-peaccessed 6/26/2026, revealed an apixaban started pack was for patients to receive 2, 5mg tablets twice a day for 7 days and then to receive 1, 5mg tablet twice a day for the duration of their anticoagulant therapy. A record review of Resident #30 medication orders and the medication administration record for the period from 6/2/2026 through 6/23/2026 revealed that Resident #30 was not prescribed the apixaban as recommended by the physician and the manufactures' recommendations which resulted in Resident #30 missing 4 doses of apixaban 10mg on the following dates and times:On 6/3/2026 Resident #30 was not administered the morning 10mg dose.On 6/4/2026 Resident #30 was not administered the morning 10mg dose and evening 10mg dose.On 6/5/2026 Resident #30 was not administered the morning 10mg dose. During an interview on 6/26/2026 at 3:35 PM the DON was asked about the admission process to ensure newly admitted residents received their immediate need medications; the DON stated, there was a chart check that was performed by the ADON, and they follow a list of checks, so it covers the diet and things like that. The DON stated the ADON received the documents from the hospital and compared them with the facility physician orders, and if there was anything that needed to be clarified, then it would be clarified. The DON responded to the question How did the apixaban get missed?; the DON Responded, I wasn't involved in that . I wasn't aware that it had been missed. The DON stated the admission nurse was responsible for accurate transcribing of physicians' admission orders and the ADON was the second set of eyes to review the accuracy of physicians' orders. A record review of the facility's undated Resident Rights policy revealed, The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life.

Based on observations, interviews, and record reviews, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, for 1 of 1 facility kitchen reviewed for essential equipment. The facility's 1 of 1 dishwashing machine had a faulty temperature gauge which indicated safe operating temperatures.The facility's 1 of 1 plate warmer was malfunctioning and not operational for longer than a week. This failure could place residents at risk for food borne illness and cold food.The findings included: During an observation and interview on 6/23/2026 at 11:00 AM, revealed the kitchen's 1 of 1 electrical plate warmer was plugged into the electrical outlet but had room temperature plates stored within. DA H and [NAME] G stated the plate warmer was malfunctioning and had not warmed plates since last week or maybe prior. The FSM stated that the plate warmer had been documented in the facility's maintenance care program which alerted the Maintenance Director to the needed repair. During an observation and interview on 6/24/2026 at 11:37 AM, revealed the kitchen's 1 of 1 dishwasher had a temperature gauge which read 110F during operation and after operation. The FSM utilized a temperature gauge and demonstrated that the water temperature during operation was 122F . The FSM stated that the safe operating temperature was for the water to be over 120F . The FSM stated the temperature gauge was faulty, and he would have the Maintenance Director address the faulty gauge. During an interview on 6/24/2026 at 12:55 PM, the Maintenance Director stated he had not been notified of the faulty kitchen equipment. The Maintenance Director stated he reviewed the maintenance care database for the month of June 2026 which revealed no entries for the kitchen's plate warmer or the faulty dishwasher gauge. The Maintenance Director stated the state agency's observations he would take action to address the faulty equipment. The Maintenance Director stated that the potential negative impact to residents was cold plates and a faulty dishwasher temperature gauge. A record review of the facility's undated Preventive Maintenance policy revealed, The facility will ensure that a comprehensive preventive maintenance program is in place for essential operating equipment. Preventive maintenance will completed routinely and according to protocol by the Maintenance Supervisor or qualified designee. The facility will maintain documentation of all preventive maintenance.1. Preventive maintenance will be completed according to protocol outlines.

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 3 of 5 residents (Residents #5, #76, and #77) reviewed for transmission-based precautions. The facility failed to ensure staff wore required PPE when providing assistance for Residents #76 and #77. The facility failed to ensure staff performed proper hand-hygiene when providing personal care for Resident #5. This failure could lead to the spread of infection. Findings included: 1.Record review of Resident #76's admission Record dated 6/24/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included other diseases of stomach and duodenum [digestive tract]. Record review of Resident #76's Order Summary Report dated 6/24/2026 reflected the following physician's order dated 4/17/2026:Currently on transmission-based precautions related to positive test for clostridium difficile [a highly contagious bacterial infection of the digestive tract]. one time a day [sic]The resident is in a room by themselves, remained in their room and all care and services have been performed in the residents [sic] room during the last 24 hours? [sic] Record review of Resident #77's admission Record dated 6/25/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included malignant neoplasm of lateral wall of bladder [cancerous tumor in the bladder]. Record review of Resident #77's Order Summary Report dated 6/25/2026 reflected the following physician's order dated 6/24/2026:Currently on transmission-based precautions related to Diagnoses [sic] of Shingles [an infectious viral illness] every shift The [sic] resident is [NAME] room by themselves, remained in their room and all care and services have been performed in the residents [sic] room during the last 24 hours? [sic] In an observation on 6/25/2026 at 12:26 PM, Residents #76 and #77 were observed to have signage on their respective room doors that indicated both residents were on contact level of isolation. The signage instructed all staff to apple PPE, including a gown and gloves, prior to entering the room. CNA C was seen entering Resident #76 and #77's rooms at this time to deliver the lunch trays without donning PPE. CNA C entered Resident #76's room a second time to deliver a set of disposable silverware and assist Resident #77 with setting up her lunch tray. In an interview on 6/25/2026 at 12:30 PM, CNA C said she had delivered the lunch trays to Residents #76 and #77, and she said both residents required contact level of isolation precautions. She said she did not have to wear a gown or gloves when entering the rooms because contact isolation precautions allowed for staff to enter the room without PPE as long as close contact care was not being provided, such as when delivering a lunch tray. She said she had received training regarding PPE and transmission-based precautions during new hire training. She said the potential risk of not wearing PPE appropriately was the spread of infection. In an interview with the ADON on 6/25/2026 at 12:35 PM, she said all staff should don PPE prior to entering a room on contact level of isolation precautions, including delivering a lunch tray. In an Interview on 6/25/2026 at 1:00 PM with LVN J stated Resident #77 was on contact precautions and staff need to wear PPE to enter the room. Record review of the facility policy titled Transmission-based Precautions dated 2010 reflected the following: . Contact precautions require the use of appropriate PPE, including a gown and gloves upon entering the contact precaution room . 2. Record review of Resident #5's admission Record dated 6/26/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included obstructive and reflux uropathy [difficulty or inability to completely eliminate urine from the body due to physical blockage]. Record review of Resident #5's quarterly MDS dated [DATE] reflected a BIMS score of 07, which indicated moderately impaired cognition. Section H0100A of the MDS indicated Resident #5 had an indwelling catheter at the time of the assessment. Record review of Resident #5's Order Summary Report dated 6/26/2026 reflected a physician's order dated 11/26/2024 that read as follows:Provide catheter care, clean perineal area with soap and water, pat dry every shift. Record review of Resident #5's Care Plan Report undated/printed 6/26/2026 reflected the following focus area initiated 11/07/2024:Resident is on enhanced barrier precautions In an observation on 6/26/2026 at 12:10 PM, LVN B was observed performing indwelling catheter care for Resident #5. After donning PPE, including a disposable gown, disposable face mask, and disposable gloves, LVN B then lowered Resident #5's blankets and under garments to expose Resident #5's pelvis. LVN B did not change gloves or perform hand hygiene before touching Resident #5's genitals and catheter tubing. In an interview on 6/26/2026 at 12:24 PM, LVN B said he should have changed his gloves and sanitized his hands prior to initiating the care of the catheter. He said failing to do so could result in the spread of infection. He said he had received training on transmission-based precautions and hand hygiene but had forgotten to change gloves because he was nervous. In an interview with the DON on 6/26/2026 at 3:35 PM, she said the facility expectation is that staff will perform hand hygiene before beginning care of an indwelling catheter, including touching linens and repositioning a resident. She said the potential harm was the spread of infection. Record review of the facility policy titled Fundamentals of Infection Control Precautions dated 2016 reflected the following: . The following is a list of some situations that require hand hygiene: Before and after assisting a resident with personal care Before and after assisting a resident with toileting After handling soiled or used linens, dressings, bedpans, catheters and urinals .

Based on interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, 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 4 of 8 (Residents #10, #51, #62, #75) residents reviewed for care plans. The facility failed to ensure Resident #10's care plan had discharge plans.The facility failed to ensure Resident #51's care plan had discharge plans.The facility failed to ensure Resident #62's care plan had discharge planThe facility failed to ensure Resident #75's care plan had discharge plans.This could affect residents and could result in residents not being educated on indwelling catheter positioning and residents not having a discharge plan or goal to set. The Findings: 1.Record review of Resident #10's admission Record dated 6/26/2026 revealed the resident was admitted on [DATE]. Resident #10 had diagnoses of paraplegia (paralysis of both lower limbs), lack of coordination, recurrent depressive disorder and moderate protein-calorie malnutrition. Record review of Resident #10's Comprehensive MDS dated [DATE] documented his BIMs score was 12/15 (moderate cognitive impairment). Record review of Resident #10's care plan dated 4/27/2026 did not include a discharge or staying at facility planning. 2.Record review of Resident #51's admission Record dated June 25, 2026, documented she was admitted on [DATE]. Resident #51 had diagnoses of Parkinson's disease, (a progressive neurodegenerative disorder characterized by tremors, muscular rigidity, postural instability, and loss of dopamine-producing neurons in the substantia nigra, often with Lewy bodies present in the brainstem) muscle weakness, lack of coordination, dementia and anxiety. Record review of Resident #51's Quarterly MDS dated [DATE] documented she was usually able to make self- understood, she usually understands others, BIMs score of 9/15 (moderately cognitively impaired). Record review of Resident #51's Care plan dated 4/16/2026 did not include a care plane for discharge or staying at facility planning. 3. Record review of Resident #62's admission Record dated 6/25/2026 documented she was admitted on [DATE] and re-admitted on [DATE]. Resident #62 had medical diagnoses of muscle wasting, dementia, diabetes II, ( a chronic condition where the body does not produce enough insulin or the cells become resistant to insulin,) and chronic kidney disease. Record review of Resident #62's Comprehensive MDS dated [DATE] documented her BIMS score was 7/15 (sever cognitive impairment).Record review of Resident #62's Care Plan dated 6/24/2026 did not include a care plan for discharge or staying at facility planning. 4. Record review of Resident #75's admission Record dated 6/26/2026 documented she was admitted [DATE], re-admitted [DATE]. Her diagnoses included diabetes II, weakness, lack of coordination, and dependence of renal dialysis. Record review of Resident #75's Quarterly MDS dated [DATE] revealed her BIMS score was 8/15 (moderate cognitive impairment).Record review of Resident #75's care plan dated 5/5/2026 did not include a care plan for discharge or staying at facility planning. Interview on 6/25/2026 at 5:58 PM with MDS nurse stated she was not sure why Residents #10, # 51, 62 and #75 did not have care plan for discharge or staying at facility care planning. MDS stated all residents should have documented discharge or staying at facility planning.In an interview on 6/26/2026 at 2:26 PM with the DON stated all residents should have documented for discharge or staying at facility planning. The DON stated could result in staff not knowing resident preference.Record review of policy, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights 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. The comprehensive care plan will describe the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; the resident's goals for admission and desired outcomes, and the resident's preference and potential for future discharge. Discharge plans in the comprehensive care plan, as appropriate.

Based on observations, interviews, and record reviews, the facility failed to ensure the resident has a right to be treated with respect and dignity for 1 of 8 (Resident #51) residents reviewed for personal hygiene in that: Resident #51 had long strands of facial hair on upper lip and chin area, and she did wanted them shaved. This failure could affect all residents that did not want facial hair and could result in low self-esteem. The Findings: Record review of Resident #51's admission Record dated June 25, 2026, documented she was admitted on [DATE]. Her diagnoses included Parkinson's disease, muscle weakness, lack of coordination, dementia and anxiety. Record review of Resident #51's Quarterly MDS dated [DATE] documented she was usually able to make self- understood, she usually understands others and had a BIMs score of 9/15 (meant she was moderately cognitively impaired). She had impairment on one side to her upper extremity, she scored 8/8 for personal hygiene (meant not attempted due to medical condition or safety concerns). Record review of Resident #51's Care plan dated 4/16/2026 documented, The resident has an ADL Self Care Performance Deficit related to but not limited to Dementia, Parkinson's.Intervention, Personal Hygiene: the resident requires extensive assistance x1 assistance with personal hygiene care. The resident had impaired visual function and required eyeglasses. Intervention monitor for/record confounding problems: decline in cognitive status, decline in ADL. In an observation on 6/23/2026 at 11:45 AM, Resident #51's face had long facial hairs on her upper lip and chin area. In an observation on 6/24/2026 at 10:00 AM Resident 51's face had long facial hairs on her upper lip and chin area. In an observation on 6/25/2026 at 10:11 AM Resident #51's face had long facial hairs on her upper lip and chin area. In an interview on 6/25/2026 at 10:12 AM with Resident #51 stated she wanted her upper lip and chin to be shaved. Resident #51 stated she was not aware she had facial hair. Resident #51 stated staff have not offered to shave her upper lip or chin area. Resident #51 stated it made her feel like a man and does not want to have facial hair. She did not recall when the last time her facial hair was shaved by staff. In an interview on 6/26/2026 at 2:26 PM with the DON stated facial hair should be offered to be shaven and hair removed for both men and women by CNA's. The DON stated staff were to provide care and make sure this was in the care plan. The DON stated the harm for residents could be that it affects their self-image, insecurity and feeling clean. The DON was not aware of the facial hair for Resident #51. In an interview 06/25/2026 at 10:14 AM with CNA C confirmed Resident #51 had long strands of hair on her upper lip and chin hairs. CNA C stated she had not worked with Resident #51 for a while. CNA C stated she had offered to shave Resident #51 in the past. In an interview on 6/25/2026 at 5:41 PM with MDS LVN I stated Resident #51 was a 1 person assistance. MDS LVN I, I stated the grooming was making sure residents were clean, put deodorant on them, cleansing skin, clean face, oral care, personal hygiene, brushing hair, brushing teeth, and staff need to offer hair removal, if residents want it. MDS LVN, I stated oral or hygiene was important because residents have right to have their own grooming preferences. Record review of the policy on, Shaving, electrical/Safety Razors, (no date) documented Shape of the male (female) resident can be performed within metric for safety razor depending on the preference and availability of equipment. It is usually done as part of a daily personal hygiene, although every other day is sufficient for some based on the beard (hair) growth period it is done to promote cleanliness and a positive body image. Usually, the resident or staff person staff member performs the procedure, but the nurse can shave the resident illness and disability prevents independence. Goals: 1. the resident will experience cleanliness and comfort. 2.the resident will be free from infection 3. The resident will maintain intact skin integrity. Record review of the policy on, admission packet, dated November 20121, documented, Resident rights, residents of Texas nursing facilities have all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of the state and the United States. They have the right to be free of interference, coercion, discrimination, and reprisal and exercising these rights as citizens of the United States. Dignity and respect, you have the right to; be treated with dignity, courtesy, consideration and respect. Freedom of choice, you have the right to; make your own choices regarding personal affairs, care, high benefits and services., refused to perform services for the person or facility providing services. Participation in your care, you have the right to; refuse treatment, care, or services.

Based on observations, interviews and record reviews, the facility failed to ensure the facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from Each resident's bedside for 1 of 8 (#51) resident with call system in that: Resident #51's call light was not working when she was lying in bed. This failure could affect all residents with call lights at bedside and could result in call light not being answered and causing further harm. The Findings: Record review of Resident #51's admission Record dated 06/25/2026 revealed she was admitted on [DATE], with diagnoses of Parkinson's disease, muscle weakness, lack of coordination, dementia and anxiety. Record review of Resident #51's Quarterly MDS dated [DATE] revealed she was usually able to make herself- understood, she usually understood others and her BIMs score was 9/15 (meant she was moderately cognitively impaired). Resident #51 used a wheelchair to mobilize and she had impairment on one side to her upper extremity. Record review of Resident #51's care plan dated 4/16/2026 revealed, The resident has an ADL Self Care Performance Deficit related to but not limited to Dementia, Parkinson's. The resident had impaired visual function and required eyeglasses. Intervention monitor for/record confounding problems: decline in cognitive status, decline in ADL, deterioration, oral motor function, poor fitting/missing dental appliances, and ensure/provide a safe environment: call light in reach, be sure resident call light within reach and encourage resident to use it for assistance as needed. In an observation on 6/25/2026 at 10:12 AM revealed that Resident #51 pushed the call light, and it did not work when resident pushed it. Further observations, revealed the light on the hall did not light up. In an interview on 6/25/2026 at 10:13 AM Resident #51 stated sometimes staff did not come when she pushed the call light, this did not cause harm. In an interview on 6/25/2026 at 10:14 AM CNA C confirmed when she pushed the call light it was not working. In an interview on 6/25/2026 at 2:45 PM the Maintenance Supervisor stated he was not aware Resident #51's call light was not working. In an interview on 6/26/2026 at 2:26 PM the DON stated she was not aware that Resident #51 call lights did not work. The DON stated because Resident #51's call light did not work that could cause a decrease in care and staff not being aware residents needed assistance. Record review of an email from the ADM, dated 6/26/2026 at 1:10 PM, revealed there was no policy for call lights.

Based on observations, interviews, and record reviews of the facility failed to ensure therapeutic diets must be prescribed by the attending physician for 1 resident of 1 (Resident #62) in that: Resident #62 did not have her ice cream cup with her meal tray. This could affect all residents that get a meal tray and could cause residents to lose weight. The Findings: Record review of Resident #62's admission Record dated 6/25/2026 revealed she was admitted on [DATE] and re-admitted on [DATE]. Resident #62 had medical diagnoses of muscle wasting, dementia, diabetes II, and chronic kidney disease. Record review of Resident #62's Comprehensive MDS dated [DATE] revealed her BIMS score was 7/15 (severe cognitive impairment), and she required supervision or touching assistance with eating; and had no weight loss. Record review of Resident #62's consolidated orders for June 2026 revealed she had a regular diet with mechanical soft, ground texture, and ice cream for lunch and dinner. Record review of Resident #62's Care Plan dated 6/24/2026 revealed, Potential for altercation in nutrition and weight loss due but not limited to resident requires a therapeutic and mechanically altered diet. History of significant weight loss. Interventions serve diet as ordered, and regular diet, Mechanical ground meat texture, regular consistency ice cream with lunch and dinner. In an observation and review on 6/23/2026 at 12:15 PM during lunch, revealed Resident #62's lunch card had typed on it a 4 oz ice cream cup. Resident #62 did not have ice cream on her lunch tray. In an observation on 6/23/2026 at 12:16 PM revealed LVN J helping her cut her steak. The resident did not have an ice cream cup on her plate. Interview on 6/23/2026 at 12:17 PM with LVN J confirmed that Resident #62 did not have an ice cream on her lunch tray as ordered. In an observation on 6/25/2026 at 2:24 PM revealed Resident #62 was not served ice cream with her lunch meal.In an interview on 6/25/2026 at 2:54 PM the FSM stated ice cream should be on the tray for Resident #62 when served her meal. The FSM stated he would talk to staff to make sure Resident #62 gets her ice cream with her meal tray. Interview on 6/26/2026 at 2:26 PM the DON stated Resident #62 should have ice cream on her meal tray and ordered ice cream for weight loss. The DON stated this could cause residents to not get what the physician ordered. Record review of policy, Dietary [NAME] Policy and Procedures [NAME] 2012 revealed to ensure correct understanding our interpretation of therapeutic diets, all diets are ordered as stated in the diet menu. The physician will prescribe diets in accordance with concrete diet meaning. A written order must appear on the medical record before the resident may be served.

Based on observation, interview, and record review, the facility failed to ensure drugs used in the facility were labeled in accordance with currently accepted professional principles for 1 of 4 medication carts (E-Hall medication cart) reviewed for medication storage. The facility failed to ensure 2 insulin pens in the E-Hall medication cart were labeled with the date opened. This failure could result in residents receiving expired insulin, leading to uncontrolled blood sugar levels. Findings included:In an observation and interview on [DATE] at 10:01 AM, 2 insulin pens were observed in the E-Hall medication cart without dates indicating when they were opened. MA A said she thought the pens were removed from the refrigerator storage by the overnight nurse because all of the pens were dated when she worked the day prior. She said the facility policy was to date all insulins at the time they are removed from the fridge, and the potential harm was not knowing if the insulin is expired. In an interview with the DON on [DATE] at 3:35 PM, she said the facility policy is to date all insulins immediately upon removal from the refrigerator. She said the potential harm was administration of expired insulin to residents. Record review of the facility policy titled Medication Labels dated 2025 reflected the following:Medications are labeled in accordance with facility requirements, state, and federal laws.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain grooming, and personal and oral hygiene for 1 of 8 (Resident #51) residents reviewed for personal hygiene in that: 1.Resident #51 had long strands of facial hair on upper lip and chin area, that she wanted staff to shave her.2. Resident #51 had not cleaned her teeth in the last 3 days of surveyor observations. This failure could affect all residents that did not want facial hair, wanted to have clean teeth and could result in low self-esteem. The Findings:Record review of Resident #51's admission Record dated June 25, 2026, documented she was admitted on [DATE]. Resident #51 had diagnoses of Parkinson's disease, (a progressive neurodegenerative disorder characterized by tremors, muscular rigidity, postural instability, and loss of dopamine-producing neurons in the substantia nigra, often with Lewy bodies present in the brainstem) muscle weakness, lack of coordination, dementia and anxiety. Record review of Resident #51's Quarterly MDS dated [DATE] documented she was usually able to make self- understood; she usually understands others and had a BIMs score of 9/15 (meant she was moderately cognitively impaired). She had impairment on one side to her upper extremity; she scored 8/8 for personal hygiene (meant not attempted due to medical condition or safety concerns). Record review of Resident #51's Care plan dated 4/16/2026 documented, The resident has an ADL Self Care Performance Deficit related to but not limited to Dementia, Parkinson's.Intervention, Personal Hygiene: the resident requires extensive assistance x1 assistance with personal hygiene care. The resident had impaired visual function and required eyeglasses. Intervention monitor for/record confounding problems: decline in cognitive status, decline in ADL. In an observation on 6/23/2026 at 11:45 AM, Resident #51's face had long facial hairs on her upper lip and chin area. In an observation on 6/24/2026 at 10:00 AM Resident 51's face had long facial hairs on her upper lip and chin area. In an observation on 6/25/2026 at 10:11 AM Resident #51's face had long facial hairs on her upper lip and chin area. In an interview on 6/25/2026 at 10:12 AM with Resident #51 stated she wanted her upper lip and chin to be shaved. Resident #51 stated she was not aware she had facial hair. Resident #51 stated staff have not offered to shave her upper lip or chin area. Resident #51 stated it made her feel like a man and does not want to have facial hair. She did not recall when the last time her facial hair was shaved by staff. In an interview on 6/26/2026 at 2:26 PM with the DON stated facial hair should be offered to be shaven and hair removed for both men and women by CNA's. The DON stated staff were to provide care and make sure this was in the care plan. The DON stated the harm for residents could be that it affects their self-image, insecurity and feeling clean. The DON was not aware of the facial hair for Resident #51. In an interview 06/25/2026 at 10:14 AM with CNA C confirmed Resident #51 had long strands of hair on her upper lip and chin hairs. CNA C stated she had not worked with Resident #51 for a while. CNA C stated she had offered to shave Resident #51 in the past. In an interview on 6/25/2026 at 5:41 PM with MDS LVN I stated Resident #51 was a 1 person assistance. MDS LVN I, I stated the grooming was making sure residents were clean, put deodorant on them, cleansing skin, clean face, oral care, personal hygiene, brushing hair, brushing teeth, and staff need to offer hair removal, if residents want it. MDS LVN, I stated oral or hygiene was important because residents have right to have their own grooming preferences. Record review of the policy on, Shaving, electrical/Safety Razors, (no date) documented Shape of the male (female) resident can be performed within metric for safety razor depending on the preference and availability of equipment. It is usually done as part of a daily personal hygiene, although every other day is sufficient for some based on the beard (hair) growth period it is done to promote cleanliness and a positive body image. Usually, the resident or staff person staff member performs the procedure, but the nurse can shave the resident illness and disability prevents independence. Goals: 1. the residents will experience cleanliness and comfort. 2.the resident will be free from infection 3. The resident will maintain intact skin integrity. Record review of the policy on, admission packet, dated November 20121, documented, Resident rights, residents of Texas nursing facilities have all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of the state and the United States. They have the right to be free of interference, coercion, discrimination, and reprisal and exercising these rights as citizens of the United States. Dignity and respect, you have the right to; be treated with dignity, courtesy, consideration and respect. Freedom of choice, you have the right to; make your own choices regarding personal affairs, care, high benefits and services., refused to perform services for the person or facility providing services. Participation in your care, you have the right to; refuse treatment, care, or services.

Based on interviews and record review, the facility with more than 120 beds failed to employ a qualified social worker on a full-time basis, for 1 of 1 social services staff reviewed for qualifications of Social Worker. The facility, licensed for 200 beds, did not employ a full-time social worker. This failure could place residents at risk of social service and psychosocial needs not being met. The findings included: Record review of the facility's Daily Census Report, dated 4/6/25, noted the facility had a total licensed bed capacity of 200. Record review of the Facility Summary Report from the Texas Unified Licensure Information Portal (TULIP) noted the facility had a total licensed capacity of 200 beds. Record review of the facility's Contract Binder, showed no contract with a licensed social worker. During an interview on 4/6/25 at 1:14 PM, the DON stated the facility did not have a social worker and had not had a social worker for a while. During an interview on 04/08/25 at 03:53 PM, the Acting Administrator stated it was very difficult to find a social worker in this area, and they have a sign on bonus, and they have made offers to people who back out. The Acting Administrator stated, it has to be over a year, since the facility had a social workder because there was not one here this time last year. The Acting Administrator stated, it is hard because they have to relocate here and after the tragedy they have a bad reputation. The Acting Administrator stated a social worker is needed because the social worker coordinates social services for the residents. The Acting Administrator stated, right now the services are being provided by the nurses, they are just not being done by a licensed social worker. During an interview on 04/09/25 at 11:51 AM, the Compliance Nurse stated, there is no policy on social services.

Based on observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality in his or her personal and medical records for 1 of 1 resident (Resident #52) reviewed for residents' rights. The facility failed to ensure LVN D locked the medication cart computer screen and left Resident #52's information exposed. This failure could place residents at risk of resident-identifiable information being accessed by unauthorized persons. The findings included: Record review of Resident #52's face sheet, dated 4/8/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #52 had diagnoses which included cerebral infarction (type of stroke that occurs when blood flow to a part of the brain is blocked or significantly reduced, leading to tissue death), dementia (a decline in cognitive function that is severe enough to interfere with a person's daily life and activities), dysphagia (language disorder that results from damage to the brain affecting language), and urinary tract infection . Observation on 4/6/25 at 3:05 p.m. revealed the medication cart on Unit E had the computer screen open with Resident #52's information. Approximately a minute later, the DON walked into the unit and observed the medication cart on Unit E with the computer screen open with Resident #52's information. The DON then knocked on a resident room and notified LVN D . During an observation and interview on 4/6/25 at 3:06 p.m., LVN D stated the computer screen on the medication cart in Unit E was left with the computer screen open with Resident #52's information. LVN D stated she got distracted by a resident and forgot to lock the computer screen. LVN D stated, leaving patient information exposed was a HIPAA violation and information could be obtained by unauthorized persons, and it was an invasion of the resident's privacy. During an interview on 4/8/25 at 11:05 a.m., the DON stated it was her expectation that resident information should be private and stated she had seen the computer screen on the medication cart in Unit E open and in full view of the resident's information. The DON stated, the health information from that resident could be talked about and spread through to people who should not have that information. Record review of the facility's, undated, policy and procedure titled, Resident Rights, revealed in part, .The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy .The facility must protect and promote the rights of the resident .Privacy and confidentiality .The resident has a right to personal privacy and confidentiality of his or her personal and medical records

Based on interview and record review, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, package and other materials delivered to the facility or the resident through a means other than a postal service, including the right to privacy of such communications for 1 of 5 residents (confidential resident) reviewed for resident rights. The facility failed to ensure staff distributed mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life. The findings were: During a confidential resident group meeting 1 of 5 members group stated they never received mail on Saturdays because the Front Office Staff didn't work on Saturdays. During an interview on 4/7/25 at 3:16 p.m., the Receptionist stated she worked for the facility for almost 3 years and usually worked from Monday to Friday and sometimes on the weekends. The Receptionist stated she delivered personal mail to the residents daily from Monday to Friday. The Receptionist stated she believed the mailman delivered mail on Saturdays and when the mail was delivered it was placed in a mailbox (large white bin) and stored in the admissions office, which included packages. The Receptionist stated they had a weekend Clerical Staff who was newly hired but stated she knew the mail was not distributed over the weekend because when she returned to the facility on Monday morning, the mailbox had mail and packages stored in the admissions office. The Receptionist further stated, if I lived here and received personal mail on a Saturday and had to wait until Monday, I wouldn't like it because it could be something I have been waiting for and they (the residents) probably don't get personal mail that often and it would be nice to know you are receiving something from somebody. The Receptionist stated she was responsible for delivering personal mail to the residents. During an interview on 4/7/25 at 3:28 p.m., the Admissions Coordinator stated the facility received mail delivery from Monday to Saturday. The Admissions Coordinator stated the Receptionist received the mail and distributed personal mail to the residents from Monday to Friday. The Admissions Coordinator further stated, the Activities Director used to deliver the mail to the residents, but the facility did not have an Activity Director. The Admissions Coordinator stated, on Saturday's mail delivery, they (the staff) put the mail in my office or in the Business Office Managers office. Nobody sorts it on the weekend. The Admissions Coordinator further stated the mail sits in my office or the BOM's office until Monday. The Admissions Coordinator stated mail delivery to the residents was important because it was the resident's connection to the outside since they don't get that many visitors . During an interview on 4/7/25 at 3:41 p.m., the BOM stated he generally worked Monday to Friday and sometimes weekends. The BOM stated he often did not receive any mail unless the Receptionist had delivered it to him. The BOM stated the Receptionist was responsible for sorting the mail, which included the resident's personal mail. The BOM stated, most of the time I come in on Sundays, if I worked on a weekend, I know Sunday there is no mail delivery. I don't really know if the mail is being delivered on Saturday. I don't usually work on Saturday. During an interview on 4/8/25 at 10:51 a.m., the ADM stated mail delivered on a Saturday should be distributed on Saturday. The ADM further stated they had a Receptionist (Clerical Staff) and a manager on duty on the weekends and they should be processing the personal mail to the residents on Saturday instead of holding onto it until Monday. I don't know what the process is right now. The ADM further stated mail delivery to the residents was their right. A telephone interview on 4/9/25 at 10:12 a.m. with the weekend Clerical Staff was attempted but was unsuccessful. The Clerical Staff did not return the State Surveyors call. Record review of the facility's policy and procedure titled Resident Mail Delivery and Distribution, dated 2011, revealed in part, .The health care center will develop a system to deliver and distribute resident mail in accordance with privacy and confidentiality regulations .The Activity Department appoints a specific staff member or volunteers to coordinate mail delivery every day that the facility receives mail or parcels