Every finding on record at Avir at Grand Saline

Based on observation, interview, and record review the facility failed to ensure residents were free from physical abuse for 2 of 10 residents reviewed for abuse. (Residents #2 and #3)The facility failed to ensure Resident #3 was free from physical abuse when Resident #2 punched Resident #3 in the left eye, resulting in bruising and a black eye.This failure could place residents at risk for physical abuse, mental abuse, emotional abuse, and harm.Findings included: 1. Record review of an admission record dated 7/25/26 indicated Resident #2 was an [AGE] year-old male who initially admitted to the facility on to the secured unit on 3/11/26 and readmitted on [DATE] with diagnoses including Dementia without behavioral disturbance (a decline in memory and thinking skills without accompanying agitation, aggression, psychosis, or mood changes), depression (a serious mood disorder characterized by persistent sadness, loss of interest in activities, and low energy that interferes with daily life), mood disorder (mental health conditions that affect your everyday emotional state, primarily involving persistent sadness, extreme highs, or intense mood shift to anger), and anxiety disorder (group of mental health conditions involving persistent, excessive fear or worry that interferes with daily life). Record review of quarterly MDS assessment dated [DATE] indicated Resident #2 admitted on [DATE] from an inpatient rehabilitation facility and had clear speech, was able to make him self-understood by expressing ideas and wants; had clear comprehension. He had a BIMS score of 4 out of 15 indicating he had severe cognitive impairment, meaning the person had serious trouble with memory, attention, and knowing the date or year. Section E - Behaviors was marked indicating he had hallucinations and delusions but no physical, no verbal and no other behavioral symptoms directed towards others; He required supervision or touching assist with most ADLs and no DME required. Resident #2 was frequently incontinent of bladder and continent of bowel. The MDS assessment indicated Resident #2 had no fractures and/or other multiple traumas, and no skin condition, no skin injury/wound or treatment, and no recent falls since admission. Record review of Resident #2's undated Care plan initiated on 4/22/26 indicated Resident #2 had the potential to be physically aggressive towards others r/t Dementia, Poor impulse control. Goal: will not harm self or others through the review date. Interventions: The resident's triggers for physical aggression: others using or touching his personal belongings. The resident's behaviors is de-escalated by keeping other residents away from his belongings; Assess and anticipate [Resident #2's] needs: food, thirst. toileting needs, comfort level, body positioning, pain etc.; If physical aggression towards others place on one on one; Monitor/document/report PRN any s/sx of resident posing danger to self and others; When [Resident #2] becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Record review of Resident #2's progress notes indicated the following:-On 7/7/26 at 4:23am; completed by LVN G: CNA informed this writer [LVN G] that [Resident #2 was observed telling roommate [Resident #3] that he is going to beat him up, roommate [Resident #3] was removed from room and assisted to another room.-On 7/10/26 at 6:11am; completed by LVN H: 5:50am went to secured unit after hearing yelling and noted [Resident #2] standing in doorway with staff. Staff stated [Resident #2] pushed and hit his roommate [Resident #3] in the left eye. Both residents [Resident #2 and #3] separated at [that] time. [Resident #2] place on one on one. Administrator notified.-On 7/10/26 at 6:28am; completed by LVN H:[Resident #2] pushed and shoved roommate [Resident #3].-On 7/10/26 at 8:01am; completed by DON: Labs ordered CBC, CMP, A1C, and UA. placed in lab portal.-On 7/10/26 at 10:03am; completed by DON: LATE ENTRY - [Resident #2] continues to be one to one in private room. Referrals sent to behavioral for behavioral admission.-On 7/10/26 at 3:04pm; completed by DON:LATE ENTRY - EDW taken before judge and judge denied, did not say why.[Behavioral Hospital #1 and Behavioral Hospital #2] both stated they need emergency detention unit to admit.-On 7/10/26 at 4:42pm; completed by DON: Staff with [Behavioral Hospital #1] called for update. [Behavioral Hospital #1 Staff] stated that he will help us get EDW come Monday morning as we have to wait for judge to be back in. [Resident #2] remain one-to-one in private room and will remain throughout the weekend until EDW can be obtained. No aggression noted towards staff since separation of him roommate [Resident #3].-On 7/10/26 at 9:13pm; completed by LVN G: [Resident #2] continued on 1:1 monitoring due to aggression towards roommate [Resident #3], has rested well thus far this shift. No aggression noted.-On 7/11/26 at 6:64am; completed by LVN H: [Resident #2] continued one on one care due to aggressive behavior. None reported at that time.-On 7/11/26 at 11:03pm; completed by LVN G: Resident #2 continued to have 1:1 care due to aggressive behavior, no aggression observed.-On 7/12/26 at 7:34am; completed by LVN H: [Resident #2] continued one on one care due to aggressive behavior. None reported since incident.-On 7/13/26 at 11:44am; completed by DON: Multiple calls placed to [Behavioral Hospital #1]. Unable to reach [Behavioral Hospital #1 Staff] with admissions. [Resident #2] remained 1:1 in private room at this time.-On 7/15/26 at 4:19pm; completed by FNP: ASSESSMENT AND PLAN -Male with dementia and mood disorder evaluated after an altercation with another resident, currently calm without reported pain, discomfort,or hallucinations; anxiety and dementia management addressed and observation level reduced given no ongoing agitation or combativenessduring evaluation1. AGITATIONAgitation after altercation with another resident, currently calm without observed ongoing agitation or combativeness during this visit- Discontinue one-on-one observation starting tonight- Continue Depakote 250 mg twice daily2. ANXIETYAnxiety addressed due to concern for becoming easily agitated- Start sertraline25 mg daily. Record review of Resident #2's physical aggression initiated incident report dated 7/10/26 completed by LVN H, indicated the incident happened in [Resident #2's] room. Incident Description: Nursing Description - CNA reported that [Resident #2] pushed and hit roommate [Resident #3] in the face because he used his bathroom. Resident Description: Resident unable to give description. Immediate Action Taken: Resident separated from other resident and placed on one. Labs ordered. Placed in room by himself, referrals sent out to behavioral units for psych stay if indicated. Mental Status: Oriented to Person. Other Info: [Resident #2] possessive over his items. Agencies/People Notified: Administrator and physician. During an observation and attempted interview on 7/25/26 at 5:35 pm, Resident #2 in his room on the secured memory care unit, resting in bed he did not respond to questions asked. Resident #2 was clean, well-groomed with no unpleasant odor and there were no visible bruising, skin tears or marks. 2. Record review of an admission record dated 7/25/26 indicated Resident #3 was an [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on to the secured unit on 4/24/26 and passed away in facility on 7/20/26 unrelated to incident with diagnoses including Schizoaffective disorder bipolar type (is a mental health condition that combines symptoms of schizophrenia (such as hallucinations or delusions) with extreme mood swings, including both high energy mania and low energy depression), Dementia without behavioral disturbance (a decline in memory and thinking skills without accompanying agitation, aggression, psychosis, or mood changes), delusional disorder (is a mental health condition defined by holding one or more false, fixed beliefs for at least one month, while otherwise maintaining normal daily behavior and functioning), anxiety disorder (group of mental health conditions involving persistent, excessive fear or worry that interferes with daily life) and cognitive communication deficit (trouble with talking and listening caused by problems with thinking skills like attention, memory, and problem-solving, rather than a basic physical speech problem). Record review of quarterly MDS assessment dated [DATE] indicated Resident #3 had clear speech, difficulty communicating some words or finishing thoughts but was able if prompted or given time and comprehended most conversations. He had BIMS score of 7 out of 15 indicating he had severe cognitive impairment, meaning the person had serious trouble with memory, attention, and knowing the date or year. Section E - Behaviors was marked indicating he had hallucinations and delusions but no physical, no verbal and no other behavioral symptoms directed towards others; He and required supervision or touching assist with most ADLs and no DME required. Resident #2 was frequently incontinent of bladder and continent of bowel. Record review of Resident #3's physical aggression received incident report dated 7/10/26 completed by LVN H indicated the incident happened in [Resident #3's] room. Incident Description: Nursing Description - [Resident #3] was pushed and hit in the left eye by roommate. Roommate [Resident #2] was being obsessive over shared bathroom. Resident Description- [Resident #3] stated , Roommate hit me in left eye. Immediate Action Taken: Description- [Resident #2 and #3] were separated. Head to toe assessment done. No redness or bruising noted at that tune, Neuros checked. [Resident #3] was offered x-rays by DON and declined stated I'm fine. Injuries Observed at Time of incident: No Injuries observed at time of incident. Level of pain - 0. Predisposing situation/physiological factors: Wanderer and confused. Other information: Roommates; [Resident #3] often pees on floor. Record review of Resident #3's progress note indicated the following:-On 7/7/26 at 4:24am; completed by LVN G: CNA informed this writer [LVN G] that resident's roommate [Resident #2] was observed telling resident [Resident #3] that he is going to beat him up, [Resident #3] was removed from room and assisted to another room.-On 7/10/26 at 5:50am; completed by LVN H: [Resident #3] pushed and hit in left eye by roommate [Resident #2].-On7/10/26 at 6:07am; completed by LVN H: Heard yelling in secured unit, on entering staff standing in hallway with [Resident #3] and stated roommate [Resident #2] this resident in left eye. Separated at that time with assessment done. No redness or swelling at that time. [Resident #3] stated roommate [Resident #2] hit him in left eye.-On 7/10/26 at 7:03am; completed by LVN H: [Resident #3] noted with slight redness and faint bruising below left eye at that time.-On 7/10/26 at 9:17pm; completed by LVN G: Continues to have redness to left lower lid from previous altercation with another resident, denies blurry vision or pain.-On 7/11/26 at 6:32am; completed by LVN H: Continue to monitor for sign and symptoms being hit by roommate. Continue with redness to left eye; continue to deny pain/discomfort.-On 7/11/26 at 11:01pm; completed by LVN G: Continues to have redness to left lower eye lid from physical altercation, no complaints of pain or discomfort or blurred vision.-On 7/12/26 at 7:36am; completed by LVN H: Continue to monitor for sign and symptoms being hit by roommate. Continue with redness to left eye; continue to deny pain/discomfort. Record review of Resident #3's undated care plan indicated the following:-Revised on 3/14/26 indicated Resident #3 resides in the Secure/ Memory unit and am at risk for injury from wandering in an un- safe environment AEB impaired safety awareness. The resident is at risk for injury from others while residing in secure/memory unit D/T altered cognition, history of elopement. Goal: Dignity will be maintained, and [Resident #3] will wander about the unit without the occurrence of any injury through the next review date. Intervention: Anticipate behavior(s) and redirect when in close proximity to others that might invoke aggression; Ensure family/ MD aware of behaviors and/or any increase in behaviors noted; Explain all procedure using terms/ gestures I can understand- repeat as needed; Monitor and chart behaviors qshift and PRN and report to MD; Monitor for early warning signs of any behaviors- approach in calm manner, call by name, remove from unwanted stimuli; Redirect behaviors as [Resident #3] display them.-Revised on 6/9/26 indicated Resident #3 had a behavior problem of urinating on the floor no matter where he is. Goal: will have fewer episodes of urinating on the floor by review date. Interventions: Anticipate and meet [Resident #3's] needs; Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by; If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, people involved, and situations. Document behavior and potential causes. Record review of facility's typed post investigation submission report dated 7/9/26 Incident Type: Other- Resident to Resident Altercation. Agency Immediate Response to prevent recurrence/protect individuals: Agency contacted the local police department and self-reported the incident to HHS. Notified RP, the MD, Ombudsman and Administrator. [Resident #2 and Resident #3] were roommates, they were put in separate rooms;[Resident #2] was on increased monitoring until released by psychiatric services; Neuro checks and x-ray for [Resident #3]; The court denied an emergency detention warrant for [Resident #2]; seeking placement in a psychiatric facility for [Resident #2]. Description of the Allegation: [Resident #2] punched [Resident #3] in the eyes. Injury: Black eye; [Resident #3] reports no pain. Description of Assessment: Initially [Resident #3] left eye looked fine, then about 30 minutes later a bruise started to form underneath his eye. Investigation Summary: [Resident #2] pushed [Resident #3] in the bedroom doorway and had his fists ready to hit [Resident #3]. The CNA asked [Resident #2] what was his reason for all of this and [Resident #2] said he told [Resident #3] where the rest room was, and then he hit [Resident #3]. Both residents were separated and the nurse was notified. Increased supervision for [Resident #2] began immediately. Investigation Findings: Confirmed. Agency Actions Post Investigations: [Resident #2] given a room to himself and increased supervision. Labs were ordered and pain assessment was done. Inservices: abuse and neglect reporting requirements; deescalation tactics and increase supervision expectations and rationale. Record review of a 72-hour. neuro checks report dated effective 7/10/26 indicated Resident #3 had no change in neuro status. Resident #3's neuro remained at baseline, and he voiced no pain complaints. Record review of incident and accident log from 4/1/2026 to 7/25/2026 indicated Resident #2 was the physical aggressor for two previous incidents with other residents on 4/22/26 and on 5/10/26. On 4/22/26: Resident #2 hit a resident in the mouth. On 5/10/26 Resident #2 hit another seated near him and displayed physical aggression toward staff. Record review of handwritten witness statement dated 7/10/26 and completed by CNA J indicated the following: Saw [Resident #2] push [Resident #3] in their bedroom doorway and [Resident #2] had his fist ready to hit [Resident #3]. I [CNA J] asked [Resident #3] and [Resident #2] what was the reason for all of this. [Resident #3] said he just asked [Resident #2] where the restroom was and [Resident #2] went off on him. Both were separated and nurse was notified. During an interview on 7/26/26 at 5:30pm, DON stated that Resident #2 was discharged from Behavioral Hospital #1 on May 27, 2026, following inpatient psychiatric treatment. Upon his return, medication adjustments were implemented, including an increase in divalproex sodium to 250 mg and the addition of metformin. Behavior monitoring was documented on the nurse MAR, and direct-care staff were instructed to report behavioral concerns to the charge nurse. The DON stated that, following Resident #2's 4/22/26 incident with another resident on the secured unit, staff identified that he displayed possessive behavior regarding his belongings. Care-plan interventions were implemented to keep other residents away from his personal items and to redirect or de-escalate him when needed. The psychiatric provider subsequently ordered sertraline 50 mg daily and Depakote sprinkles 125 mg twice daily for mood regulation. Additional medication changes were made after the 5/10/26 and 5/11/26 incidents and during his later inpatient psychiatric treatment. The DON said Resident #3 was selected as a potential roommate after Resident #2 returned from the psychiatric hospital because Resident #3 was considered private and was not known to enter other residents' personal spaces or disturb their belongings. Resident #2 also had an order for one-to-one supervision until cleared by psychiatric services. The DON stated that one-to-one monitoring was initiated after incidents, communicated verbally during shift-to-shift reports, and discontinued after in-house psychiatric evaluation on 7/15/26. She said after Resident #2 threatened to beat up Resident #3 on 7/7/6, Resident #3 was moved to another room. However, he reportedly continued attempting to return to Resident #2's room despite staff redirection. The DON stated that the facility did not intentionally place the residents back together and that the 7/10/26 altercation occurred when Resident #3 entered Resident #2's room to use the restroom. She said following the 7/10/26 incident, the facility reviewed Resident #2's behaviors, laboratory results, and staff interviews. Staff determined that he appeared especially irritable during the morning. Laboratory testing, including an A1C, was ordered to determine whether blood-glucose concerns contributed to the irritability; however, no new medical orders resulted from the findings. Resident #2 was placed in a private room without a roommate. The facility attempted to transfer him to a psychiatric facility, but the emergency detention order was declined. He was later evaluated by the psychiatric provider, who continued Depakote 250 mg twice daily, started sertraline 25 mg daily for anxiety, and prescribed donepezil 10 mg at bedtime for dementia. The DON further stated that Resident #3 received neurological checks and an incident assessment following the injury; however, no photographs were taken. Facility policies regarding abuse prevention, resident-to-resident altercations, behavioral emergencies, and supervision were provided. The facility did not have a specific room-change policy and instead discussed room-placement decisions with department heads during morning meetings. During an interview on 7/26/26 at 6:15pm, Administrator stated he was not informed of the verbal threat that occurred on 7/7/26 until after the resident-to-resident altercation on 7/9/26 had already occurred. The Administrator stated he expected LVN G to have notified him of the verbal threat. The Administrator stated he was aware that Resident #2 had a history of conflicts with previous roommates and other residents. However, because Resident #3 generally did not interfere with other residents, he believed the two residents would be compatible as roommates. The Administrator stated he did not recognize until after the altercation that Resident #2 became agitated when others entered or remained within his personal space, which was identified as a behavioral trigger. He further stated that, based on this information, he believed another resident should not be assigned to Resident #2's room. The Administrator stated Resident #2's previous Resident -to- Resident incidents on 4/22/26 and on 5/10/26 listed on the incident and accident log was called in to the State and had already been investigated. During an interview on 7/26/26 at 6:32pm, LVN G stated she had worked at the facility since November 2025 as a charge nurse on the 6:00 p.m. to 6:00 a.m. shift. LVN G stated she had been assigned to the secured unit approximately two to three weeks earlier and was not yet familiar with all residents residing on the unit. LVN G stated she was not working on the night Resident #2 punched Resident #3. However, she documented in both residents' clinical records that, on 7/7/26, Resident #2 made a verbal threat toward Resident #3. The threat was witnessed and reported to her by CNA K. LVN G stated she did not report the verbal threat to the Administrator, who served as the facility's Abuse Coordinator, because she believed the incident was verbal only. She stated she documented the incident in the residents' clinical records, and the CNAs separated the residents. During an interview on 7/26/26 at 6:45pm CNA K stated she could not recall the exact date of the incident but reported that she and CNA L witnessed Resident #2 make verbal threats toward Resident #3. CNA K stated the incident was reported to LVN G. CNA K stated she heard yelling coming from the residents' room and heard Resident #2 tell Resident #3 that he was going to beat him up. She also heard Resident #2 make statements about using a gun. CNA K stated Resident #2 did not possess a gun or any other weapon. As an immediate intervention, she removed Resident #3 from the room and accompanied him to the common area. CNA K stated she frequently had to separate the two residents because they did not get along; however, she was not aware of any previous physical altercations between them. CNA K further stated Resident #3 reportedly heard voices and would sometimes go into the bathroom to scream or release his frustration, which bothered Resident #2. Telephone interview attempt was made on 7/27/26 at 11:51am to contact CNA J no return call. Telephone interview attempt was made on 7/27/26 at 11:56am to contact LVN H no return call. Telephone interview attempts were made on 7/27/26 at 1:38pm and 1:47pm to contact CNA L no return call. Telephone interview attempt was made on 7/27/26 at 1:47pm to contact LVN C no return call. Record review of secure unit policy dated July 2025 indicated the following: The Secure Unit is designed to provide a safe and structured environment for residents who are at risk of elopement or harm due to cognitive impairment (e.g., dementia, Alzheimer's disease, or other behavioral health concerns). This policy ensures that all residents' rights, safety, and dignity are protected while maintaining compliance with federal and state regulations. 6. Discharge or Transfer from Secure Unit. Reasons for discharge from the unit: a. Resident(s) aggression is unmanageable. Record review of revised resident -to- resident altercation policy dated September 2022 indicated the following: All altercations, including those that may represent resident-to-resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator. Policy Interpretation and Implementation:1. Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, or to the staff .2. Behaviors that may provoke a reaction by residents or others include:a. verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting race or ethnic group, intimidating;b. physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects;c. sexually aggressive behavior such as making sexual comments, inappropriate touching/grabbing;d. taking, touching, or rummaging through other's property; ande. wandering into others' rooms/space.

Based on interview, and record review, the facility failed to ensure residents with dementia received appropriate treatment and services to maintain their highest practicable well-being for 2 of 10 residents reviewed for dementia care. (Resident #'s 2 and 3) The facility failed to identify and address the causes and triggers of Resident #2's behaviors and failed to implement effective, individualized dementia-care interventions, resulting in Resident #2 punching Resident #3 in the eye on July 10, 2026, causing bruising and blackened discoloration. This failure could place residents with dementia at risk for increased behaviors and decreased quality of life.Findings included: 1. Record review of an admission record dated 7/25/26 indicated Resident #2 was an [AGE] year-old male who initially admitted to the facility on to the secured unit on 3/11/26 and readmitted on [DATE] with diagnoses including Dementia without behavioral disturbance (a decline in memory and thinking skills without accompanying agitation, aggression, psychosis, or mood changes), depression (a serious mood disorder characterized by persistent sadness, loss of interest in activities, and low energy that interferes with daily life), mood disorder (mental health conditions that affect your everyday emotional state, primarily involving persistent sadness, extreme highs, or intense mood shift to anger), and anxiety disorder (group of mental health conditions involving persistent, excessive fear or worry that interferes with daily life). Record review of quarterly MDS assessment dated [DATE] indicated Resident #2 admitted on [DATE] from an inpatient rehabilitation facility and had clear speech, was able to make him self-understood by expressing ideas and wants; had clear comprehension. He had BIMS score of 4 out of 15 indicating he had severe cognitive impairment, meaning the person had serious trouble with memory, attention, and knowing the date or year. Section E - Behaviors was marked indicating he had hallucinations and delusions but no physical, no verbal and no other behavioral symptoms directed towards others; He and required supervision or touching assist with most ADLs and no DME required. Resident #2 was frequently incontinent of bladder and continent of bowel. The MDS assessment indicated Resident #2 had no fractures and/or other multiple traumas, and no skin condition, no skin injury/wound or treatment, and no recent falls since admission. Record review of Resident #2's undated Care plan initiated on 4/22/26 indicated Resident #2 had the potential to be physically aggressive towards others r/t Dementia, Poor impulse control. Goal: will not harm self or others through the review date. Interventions: The resident's triggers for physical aggression: others using or touching his personal belongings. The resident's behaviors is de-escalated by keeping other residents away from his belongings; Assess and anticipate [Resident #2's] needs: food, thirst. toileting needs, comfort level, body positioning, pain etc.; If physical aggression towards others place on one on one; Monitor/document/report PRN any s/sx of resident posing danger to self and others; When [Resident #2] becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Record review of Resident #2 progress notes indicated the following:-On 7/7/26 at 4:23am; completed by LVN G: CNA informed this writer [LVN G] that [Resident #2 was observed telling roommate [Resident #3] that he is going to beat him up, roommate [Resident #3] was removed from room and assisted to another room.-On 7/10/26 at 6:11am; completed by LVN H: 5:50am went to secured unit after hearing yelling and noted [Resident #2] standing in doorway with staff. Staff stated [Resident #2] pushed and hit his roommate [Resident #3] in the left eye. Both residents [Resident #2 and #3] separated at [that] time. [Resident #2] place on one on one. Administrator notified. Record review of Resident #2's physical aggression initiated incident report dated 7/10/26 completed by LVN H, indicated the incident happened in [Resident #2's] room. Incident Description: Nursing Description - CNA reported that [Resident #2] pushed and hit roommate [Resident #3]in the face because he used his bathroom. Resident Description: Resident unable to give description. Immediate Action Taken: Resident separated from other resident and placed on one. Labs ordered. Placed in room by himself, referrals sent out to behavioral units for psych stay if indicated. Mental Status: Oriented to Person. Other Info: [Resident #2] possessive over his items. Agencies/People Notified: Administrator and physician. During an observation and attempted interview on 7/25/26 at 5:35 p.m., Resident #2 was in his room on the secured memory care unit, resting in bed he did not respond to questions asked. Resident #2 was clean, well-groomed with no unpleasant odor and there were no visible bruising, skin tears or marks. 2. Record review of an admission record dated 7/25/26 indicated Resident #3 was an [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on to the secured unit on 4/24/26 and passed away in facility on 7/20/26 unrelated to incident with diagnoses including Schizoaffective disorder bipolar type (is a mental health condition that combines symptoms of schizophrenia (such as hallucinations or delusions) with extreme mood swings, including both high energy mania and low energy depression), Dementia without behavioral disturbance (a decline in memory and thinking skills without accompanying agitation, aggression, psychosis, or mood changes), delusional disorder (is a mental health condition defined by holding one or more false, fixed beliefs for at least one month, while otherwise maintaining normal daily behavior and functioning), anxiety disorder (group of mental health conditions involving persistent, excessive fear or worry that interferes with daily life) and cognitive communication deficit (trouble with talking and listening caused by problems with thinking skills like attention, memory, and problem-solving, rather than a basic physical speech problem). Record review of quarterly MDS assessment dated [DATE] indicated Resident #3 had clear speech, difficulty communicating some words or finishing thoughts but was able if prompted or given time and comprehended most conversations. He had BIMS score of 7 out of 15 indicating he had severe cognitive impairment, meaning the person had serious trouble with memory, attention, and knowing the date or year. Section E - Behaviors was marked indicating he had hallucinations and delusions but no physical, no verbal and no other behavioral symptoms directed towards others; He and required supervision or touching assist with most ADLs and no DME required. Resident #2 was frequently incontinent of bladder and continent of bowel. Record review of Resident #3's physical aggression received incident report dated 7/10/26 completed by LVN H indicated the incident happened in [Resident #3's] room. Incident Description: Nursing Description - [Resident #3] was pushed and hit in the left eye by roommate. Roommate [Resident #2] was being obsessive over shared bathroom. Resident Description- [Resident #3] stated , Roommate hit me in left eye. Immediate Action Taken: Description- [Resident #2 and #3] were separated. Head to toe assessment done. No redness or bruising noted at that tune, Neuros checked. [Resident #3] was offered x-rays by DON and declined stated I'm fine. Injuries Observed at Time of incident: No Injuries observed at time of incident. Level of pain - 0. Predisposing situation/physiological factors: Wanderer and confused. Other information: Roommates; [Resident #3] often pees on floor. Record review of Resident #3's progress note indicated the following:-On 7/7/26 at 4:24am; completed by LVN G: CNA informed this writer [LVN G] that resident's roommate [Resident #2] was observed telling resident [Resident #3] that he is going to beat him up, [Resident #3] was removed from room and assisted to another room.-On 7/10/26 at 5:50am; completed by LVN H: [Resident #3] pushed and hit in left eye by roommate [Resident #2].-On7/10/26 at 6:07am; completed by LVN H:Heard yelling in secured unit, on entering staff standing in hallway with [Resident #3] and stated roommate [Resident #2] this resident in left eye. Separated at that time with assessment done. No redness or swelling at that time. [Resident #3] stated roommate [Resident #2] hit him in left eye.-On 7/10/26 at 7:03am; completed by LVN H: [Resident #3] noted with slight redness and faint bruising below left eye at that time. Record review of Resident #3's undated care plan indicated the following:-Revised on 3/14/26 indicated Resident #3 resides in the Secure/ Memory unit and am at risk for injury from wandering in an un- safe environment AEB impaired safety awareness. The resident is at risk for injury from others while residing in secure/memory unit D/T altered cognition, history of elopement. Goal: Dignity will be maintained, and [Resident #3] will wander about the unit without the occurrence of any injury through the next review date. Intervention: Anticipate behavior(s) and redirect when in close proximity to others that might invoke aggression; Ensure family/ MD aware of behaviors and/or any increase in behaviors noted; Explain all procedure using terms/ gestures I can understand- repeat as needed; Monitor and chart behaviors qshift and PRN and report to MD; Monitor for early warning signs of any behaviors- approach in calm manner, call by name, remove from unwanted stimuli; Redirect behaviors as [Resident #3] display them. -Revised on 6/9/26 indicated Resident #3 had a behavior problem of urinating on the floor no matter where he is. Goal: will have fewer episodes of urinating on the floor by review date. Interventions: Anticipate and meet [Resident #3's] needs; Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by; If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, people involved, and situations. Document behavior and potential causes. Record review of facility's typed post investigation submission report dated 7/9/26 Incident Type: Other- Resident to Resident Altercation. Agency Immediate Response to prevent recurrence/protect individuals: Agency contacted the local police department and self-reported the incident to HHS. Notified RP, the MD, Ombudsman and Administrator. [Resident #2 and Resident #3] were roommates, they were put in separate rooms;[Resident #2] was on increased monitoring until released by psychiatric services; Neuro checks and x-ray for [Resident #3]; The court denied an emergency detention warrant for [Resident #2]; seeking placement in a psychiatric facility for [Resident #2]. Description of the Allegation: [Resident #2] punched [Resident #3] in the eyes. Injury: Black eye; [Resident #3] reports no pain. Description of Assessment: Initially [Resident #3] left eye looked fine, then about 30 minutes later a bruise started to form underneath his eye. Investigation Summary: [Resident #2] pushed [Resident #3] in the bedroom doorway and had his fists ready to hit [Resident #3]. The CNA asked [Resident #2] what was his reason for all of this and [Resident #2] said he told [Resident #3] where the rest room was, and then he hit [Resident #3]. Both residents were separated and the nurse was notified. Increased supervision for [Resident #2] began immediately. Investigation Findings: Confirmed. Agency Actions Post Investigations: [Resident #2] given a room to himself and increased supervision. Labs were ordered and pain assessment was done. Inservices: abuse and neglect reporting requirements; deescalation tactics and increase supervision expectations and rationale. Record review of incident and accident log from 4/1/2026 to 7/25/2026 indicated Resident #2 was the physical aggressor for two previous incidents with other residents on 4/22/26 and on 5/10/26. On 4/22/26:Resident #2 hit a resident in the mouth. On 5/10/26 Resident #2 hit another seated near him and displayed physical aggression toward staff. During an interview on 7/26/26 at 5:30pm, DON stated that Resident #2 was discharged from Behavioral Hospital #1 on May 27, 2026, following inpatient psychiatric treatment. Upon his return, medication adjustments were implemented, including an increase in divalproex sodium to 250 mg and the addition of metformin. Behavior monitoring was documented on the nurse MAR, and direct-care staff were instructed to report behavioral concerns to the charge nurse. The DON stated that, following Resident #2's 4/22/26 incident with another resident on the secured unit, staff identified that he displayed possessive behavior regarding his belongings. Care-plan interventions were implemented to keep other residents away from his personal items and to redirect or de-escalate him when needed. The psychiatric provider subsequently ordered sertraline 50 mg daily and Depakote sprinkles 125 mg twice daily for mood regulation. Additional medication changes were made after the 5/10/26 and 5/11/26 incidents and during his later inpatient psychiatric treatment. The DON said Resident #3 was selected as a potential roommate after Resident #2 returned from the psychiatric hospital because Resident #3 was considered private and was not known to enter other residents' personal spaces or disturb their belongings. Resident #2 also had an order for one-to-one supervision until cleared by psychiatric services. The DON stated that one-to-one monitoring was initiated after incidents, communicated verbally during shift-to-shift reports, and discontinued after in-house psychiatric evaluation on 7/15/26. She said after Resident #2 threatened to beat up Resident #3 on 7/7/6, Resident #3 was moved to another room. However, he reportedly continued attempting to return to Resident #2's room despite staff redirection. The DON stated that the facility did not intentionally place the residents back together and that the 7/10/26 altercation occurred when Resident #3 entered Resident #2's room to use the restroom. She said following the 7/10/26 incident, the facility reviewed Resident #2's behaviors, laboratory results, and staff interviews. Staff determined that he appeared especially irritable during the morning. Laboratory testing, including an A1C, was ordered to determine whether blood-glucose concerns contributed to the irritability; however, no new medical orders resulted from the findings. Resident #2 was placed in a private room without a roommate. The facility attempted to transfer him to a psychiatric facility, but the emergency detention order was declined. He was later evaluated by the psychiatric provider, who continued Depakote 250 mg twice daily, started sertraline 25 mg daily for anxiety, and prescribed donepezil 10 mg at bedtime for dementia. The DON further stated that Resident #3 received neurological checks and an incident assessment following the injury; however, no photographs were taken. Facility policies regarding abuse prevention, resident-to-resident altercations, behavioral emergencies, and supervision were provided. The facility did not have a specific room-change policy and instead discussed room-placement decisions with department heads during morning meetings. During an interview on 7/26/26 at 6:15 p.m., the Administrator stated he was not informed of the verbal threat that occurred on 7/7/26 until after the resident-to-resident altercation on 7/9/26 had already occurred. The Administrator stated he expected LVN G to have notified him of the verbal threat. The Administrator stated he was aware that Resident #2 had a history of conflicts with previous roommates and other residents. However, because Resident #3 generally did not interfere with other residents, he believed the two residents would be compatible as roommates. The Administrator stated he did not recognize until after the altercation that Resident #2 became agitated when others entered or remained within his personal space, which was identified as a behavioral trigger. He further stated that, based on this information, he believed another resident should not be assigned to Resident #2's room. The Administrator stated Resident #2's previous Resident -to- Resident incidents on 4/22/26 and on 5/10/26 listed on the incident and accident log was called in to the State and had already been investigated. During an interview on 7/26/26 at 6:32 p.m., LVN G stated she had worked at the facility since November 2025 as a charge nurse on the 6:00 p.m. to 6:00 a.m. shift. LVN G stated she had been assigned to the secured unit approximately two to three weeks earlier and was not yet familiar with all residents residing on the unit. LVN G stated she was not working on the night Resident #2 punched Resident #3. However, she documented in both residents' clinical records that, on 7/7/26, Resident #2 made a verbal threat toward Resident #3. The threat was witnessed and reported to her by CNA K. LVN G stated she did not report the verbal threat to the Administrator, who served as the facility's Abuse Coordinator, because she believed the incident was verbal only. She stated she documented the incident in the residents' clinical records, and the CNAs separated the residents. During an interview on 7/26/26 at 6:45 p.m. CNA K stated she could not recall the exact date of the incident but reported that she and CNA L witnessed Resident #2 make verbal threats toward Resident #3. CNA K stated the incident was reported to LVN G. CNA K stated she heard yelling coming from the residents' room and heard Resident #2 tell Resident #3 that he was going to beat him up. She also heard Resident #2 make statements about using a gun. CNA K stated Resident #2 did not possess a gun or any other weapon. As an immediate intervention, she removed Resident #3 from the room and accompanied him to the common area. CNA K stated she frequently had to separate the two residents because they did not get along; however, she was not aware of any previous physical altercations between them. CNA K further stated Resident #3 reportedly heard voices and would sometimes go into the bathroom to scream or release his frustration, which bothered Resident #2. During an interview on 7/27/26 at 3:33pm CNA M and CNA N stated they worked the 6:00 a.m. to 6:00 p.m. shift on the secured unit. Both CNAs reported that Resident #2 had a history of physical aggression toward other residents and staff and did not tolerate other residents entering his room or personal space. They stated Resident #3 was Resident #2's second roommate and that Resident #2 had physically assaulted both roommates. CNA M and CNA N further stated they did not understand why Resident #2 continued to be assigned roommates despite staff's knowledge of his aggressive behaviors and intolerance of others being in his personal space. Record review of secure unit policy dated July 2025 indicated the following: The Secure Unit is designed to provide a safe and structured environment for residents who are at risk of elopement or harm due to cognitive impairment (e.g., dementia, Alzheimer's disease, or other behavioral health concerns). This policy ensures that all residents' rights, safety, and dignity are protected while maintaining compliance with federal and state regulations. 6. Discharge or Transfer from Secure Unit. Reasons for discharge from the unit: a. Resident(s) aggression is unmanageable. Record review of Dementia - Clinical Protocol dated 2001 indicated the following: .Treatment/Management: .5. The IDT will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise.a. Resident needs will be communicated to direct care staff through care plan conferences, during change of shift communications and through written documentation (nurses' notes and documentation tools).b. Progressive or persistent worsening of symptoms and increased need of staff support will be reported to the IDT. Monitoring and Follow-Up1. The staff will monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician/physician extender.2. The IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors.3. The physician/physician extender and staff will review the effectiveness and complications of medications used to try to enhance cognition and manage behavioral and psychiatric symptoms and will adjust, stop, or change such medications as indicated.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for 1 of 5 residents reviewed for pharmaceutical services. (Resident #1) The facility failed to ensure Resident #1's Lomotil was filled and available for administration from July 10 through July 13, 2026. Resident #1 missed 14 scheduled doses of Lomotil. The facility failed to ensure Resident #1's Lomotil prescription card was noted to have a direction change from scheduled to as needed. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications.Findings included: Record review of Resident #1's face sheet printed on 07/25/26 indicated Resident #1 was an [AGE] year-old female who admitted on [DATE] and with diagnoses including COPD (a term for lung and airway diseases that restrict your breathing), chronic AFib (a continuous irregular heart rhythm where the upper heart chambers quiver instead of beating effectively), Hypothyroidism (underactive thyroid, is a condition where the thyroid gland doesn't release enough thyroid hormone into the bloodstream), Anxiety Disorder (group of mental health conditions involving persistent, excessive fear or worry that interferes with daily life), Alzheimer's disease (is a progressive brain disorder characterized by memory loss, confusion, and personality changes, eventually impairing the ability to carry out the simplest tasks), and Bipolar II (a mental health condition defined by patterns of alternating mood states: major depressive episodes and milder elevated highs called hypomanic episodes. It differs from Bipolar 1 because the up moods never reach full-blown, severe mania). Record review of admission MDS assessment dated [DATE] indicated Resident #1 had clear speech and understood others. She had BIMS score of 6 out of 15 indicating she severe cognitive impairment, reflecting substantial difficulties with memory, orientation, and thinking skills. Resident #1 was continent with bowel and bladder and required supervision or touching assist with all ADLs. During an observation and interview on 77/25/26 at 5:15pm Resident #1 was observed in her room, alert, responsive, and able to communicate her needs. No signs of acute distress were observed. During the interview, Resident #1 stated that she experienced frequent loose stools and was informed that her routinely scheduled antidiarrheal medication was not available at the facility. Resident #1 stated that it took more than three days for the medication to become available. She further stated that the physician later changed the medication order from routine administration to as-needed administration. Resident #1 also stated that her undergarments were missing, which had been sent to the laundry after she soiled herself, were later located and returned. Resident #1 voiced no additional concerns at the time of the interview. Record review of Resident #1's undated revised care plan indicated the following:- initiated on 7/17/26 indicated Resident #1 was verbally aggressive at times r/t Dementia, Ineffective coping skills, Mental / Emotional illness, Poor impulse control. [Resident #1] gets upset and yells and cusses and threatens staff in various ways if she does not get her way on things such as medications. Goal: The resident will demonstrate effective coping skills through the review date. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness; Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document; Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation; Give the resident as many choices as possible about care and activities; and When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.- initiated on 7/9/26, Resident #1 was on anticoagulant therapy r/t Chronic AFib, history of MI, presence of cardiac and vascular implant and graft. Goal: [Resident #1] will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Interventions:. Monitor/document/report PRN adverse reactions of ANTICOAGULANT therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s. Record review revealed a physician's telephone order dated 7/10/26, at 1:59 p.m., for Resident #1 to receive Lomotil 2.5 mg/0.025 mg, two tablets by mouth four times daily for diarrhea. The order was confirmed by LVN B and electronically signed by Resident #1's doctor on 7/13/26, at 5:59 p.m. Record review of Resident #1's physician order dated 7/13/26, at 12:04 p.m., directed staff to administer Lomotil 2.5 mg/0.025 mg, two tablets by mouth every four hours as needed for loose stools. The PRN order was confirmed by the DON and electronically signed by Resident #1's doctor on 7/13/26, at 5:59 p.m. Record review of Resident #1's physician order dated 7/14/26, at 4:12 a.m. listed Lomotil, two tablets by mouth four times daily for diarrhea, but documented the order as discontinued at the same date and time by LVN C. The record did not include a discontinuation reason or a prescriber's signature. The records therefore showed both scheduled and PRN Lomotil orders during the reviewed period and did not clearly establish when the scheduled order was discontinued in relation to the PRN order. Record review of grievance form dated 7/13/26 indicated Resident #1 submitted a verbal grievance to the DON regarding her antidiarrheal medication for not being available and missing undergarments after episodes of loose stools and incontinence. The investigation found that the medication had not been called in by the facility's agent and that the physician changed the medication order to as needed. A stool specimen was obtained for testing, and the medication was subsequently ordered, received, and administered. The resident's missing undergarments were located in the laundry. The grievance was documented as resolved. facility should have obtained medication labeled for the new PRN order and properly discarded the medication associated with the previous scheduled order. She also stated she was unaware that staff were using pink stickers to indicate medication-order changes and would follow up regarding this practice. Record review of Resident #1's MAR for July 2026 showed a scheduled Lomotil 2.5 mg/0.025 mg order for, two tablets by mouth four times daily for diarrhea, with scheduled administration times of 8:00 a.m., 1:00 p.m., 6:00 p.m., and 8:00 p.m. The order began on July 10, 2026, at 6:00 p.m. and was discontinued on July 14, 2026, at 4:12 a.m.On 7/10/26, 6:00pm and 8:00pm Dosage was marked 9.On 7/11/26: 8:00am, 1:00pm, 6:00pm Dosages were marked 9 and 8:00pm marked 2.On 7/12/26: 8:00am, 1:00pm, 6:00pm and 8:00pm Dosages were marked 9.On 7/13/26: 8:00am, 1:00pm, 6:00pm and 8:00pm Dosages were marked 9.Legend on the last page indicated 9 meant other/ refer to progress note, and 2 drug refused. Record review of Resident #1's Progress Notes revealed the following:- On 7/10/26 at 2:20pm; Completed by LVN B: Per [Resident #1's] request n/o received for Lomotil 2 tabs QID r/t diarrhea awaiting med delivery at this time.- On 7/10/26 at 7:02pm; Completed by BOM: Lomotil Oral Tablet 2.5-0.025 MG Give 2 tablet by mouth four times a day for Diarrhea; On order.- On 7/11/26 at 9:00am; Completed by BOM: Lomotil Oral Tablet 2.5-0.025 MG Give 2 tablet by mouth four times a day for Diarrhea; On order.- On 7/11/26 at 12:07pm; Completed by BOM: Lomotil Oral Tablet 2.5-0.025 MG Give 2 tablet by mouth four times a day for Diarrhea; On order.-On 7/11/26 at 7:05pm; Completed by LVN C: [Resident #1] went to the nurse's station saying she was coughing and had an accident on herself d/t having diarrhea. [LVN C] got up to get [Resident #1] Imodium and she started saying, I don't want the Imodium, I want the prescription kind. [LVN C] looked to see if [Resident #1's Lomotil prescription] had come in, even looked in the new red bags from pharmacy that had just came in and it wasn't in yet. [Resident #1] started yelling. [LVN C] got [BOM] because she had passed meds and [LVN C] wanted to see if [BOM] knew anything more.[BOM] said [Resident #1's Lomotil prescription] had not come in yet and [BOM] tried to give [Resident #1] night meds and [Resident #1] refused them. [Resident #1] began to yell and say she wasn't being taken care of, things [took] too long to come in. [LVN C] offered the Imodium again, and [Resident#1] finally took it.- On 7/12/26 at 8:36am; Completed by BOM: Lomotil Oral Tablet 2.5-0.025 MG, Give 2 tablet by mouth four times a day for Diarrhea; On order.- On 7/12/26 at 12:58pm; Completed by BOM: Lomotil Oral Tablet 2.5-0.025 MG, Give 2 tablet by mouth four times a day for Diarrhea; On order.- On 7/12/26 at 5:50pm; Completed by BOM: Lomotil Oral Tablet 2.5-0.025 MG, Give 2 tablet by mouth four times a day for Diarrhea; On order.- On 7/12/26 at 7:06pm; Completed by BOM: Lomotil Oral Tablet 2.5-0.025 MG, Give 2 tablet by mouth four times a day for Diarrhea; On order.- On 7/13/26 at 10:05am; Completed by DON: Late Entry - Lomotil medication clarified, med to be PRN not scheduled per Dr. D. Med called in by Agent. Pharmacy stated will be in today. Not available in e-kit. Imodium given with continues loose stools.- On 7/13/26 at 12:43pm & noted at 12:44pm; Completed by CMA E: Lomotil Oral Tablet 2.5-0.025 MG, Give 2 tablet by mouth four times a day for Diarrhea; med not here.- On 7/13/26 at 5:07pm; Completed by CMA E: Lomotil Oral Tablet 2.5-0.025 MG, Give 2 tablet by mouth four times a day for Diarrhea; med not here.- On 7/13/26 at 7:18pm; Completed by CMA E: Lomotil Oral Tablet 2.5-0.025 MG, Give 2 tablet by mouth four times a day for Diarrhea; med not here.-On 7/14/26 at 3:29am; Completed by LVN C: [Resident #1] went to the nurse station upset because the Lomotil that had been ordered for her diarrhea still had not been delivered. [Resident #1] had been told daily that it should be here on the next delivery. [LVN C] placed a call to [Name of Pharmacy] and spoke to someone in the pharmacy, the situation was explained, and [LVN C] requested a STAT delivery. At 3:46am - [Resident #1] had also reported soiling several pairs of her black leggings/tights and [Resident #1] stated she hasn't gotten them back from laundry. [LVN C] have spoken to laundry personnel, and she stated she will look for them. [LVN C] have also given [Resident #1] a collection hat for her toilet and instructed [Resident #1] to place it backwards in the toilet. [LVN C] also gave [Resident #1] a sample cup and instructed [Resident #1] to bring it to [LVN C] in the biohazard bag, and I [LVN C] will place it on ice. [Resident #1] voiced understanding. [Resident #1] had a male friend in the room as I [LVN C] gave these instructions.-On 7/14/26 at 4:21am; Completed by LVN C: Lomotil received in 4:00am delivery. [Resident #1] made aware. During an interview on 7/26/26 at 3:19 p.m., with DON stated Resident #1's original Lomotil order was written on July 10, 2026. The DON reported that during a clinical meeting held on Monday, July 13, 2026, she clarified the order with Dr. D, who directed that the medication be changed from scheduled administration to PRN use only. The DON stated an authorized agent subsequently called the medication order in to the pharmacy. She explained that Lomotil was not available in the facility's emergency medication kit because it was not classified as an emergency medication. According to the DON, the Lomotil was delivered to the facility on July 14, 2026, at approximately 4:00 a.m. The DON further stated that Imodium was administered to Resident #1 while the facility awaited delivery of the Lomotil because Imodium was available over the counter and was included in Dr. D's standing orders for the treatment of loose stools. During an interview and observation on 7/26/26 at 5:47 p.m., LVN B stated he had worked at the facility for approximately three years and served as the charge nurse for Halls 5 and 6 during the 6:00 a.m. to 6:00 p.m. shift. LVN B stated he was aware that Resident #1 had complained of diarrhea and that he obtained the new Lomotil order. He reported that on July 7, 2026, he received approval from Dr. D for Lomotil 2.5 mg/0.025 mg, two tablets by mouth four times daily for diarrhea. LVN B explained that Dr. D's preferred method of communicating new orders was by text message. Observation of LVN B's cellular phone confirmed text-message communication with Dr. D authorizing Lomotil as a scheduled medication to be administered by mouth four times daily. LVN B stated he believed the order had been forwarded to the pharmacy but did not know why the medication was not delivered sooner. He reported checking the facility's electronic system daily during his shifts for updates regarding the medication's status. LVN B further stated that on July 10, 2026, he instructed the ADON, who was an authorized agent, to place the order with the pharmacy because the medication's controlled-substance classification required an individual with agent privileges to submit the prescription. During an interview on 7/26/26 at 5:58 p.m., the ADON stated she was an authorized agent for Dr. D. She explained that this authorization permitted her and other designated individuals to communicate oral prescriptions by telephone to a pharmacist for Schedule III, IV, and V controlled substances. The ADON stated she was unaware that Resident #1's Lomotil prescription had not previously been called in to the pharmacy and had assumed the medication had already been ordered. She reported that on July 13, 2026, the Director of Nursing instructed her to order Resident #1's Lomotil. The ADON stated that on July 13, 2026, she contacted the pharmacy and provided a verbal prescription for Lomotil 2.5 mg/0.025 mg, two tablets by mouth four times daily for diarrhea. She explained that she submitted the prescription as a scheduled medication because the scheduled order was the only active Lomotil order documented in Resident #1's clinical record at that time. The ADON further stated that the order was apparently changed to PRN administration sometime after the medication was delivered. However, she emphasized that when she contacted the pharmacy, the active order was for scheduled administration, and she followed the order documented in the resident's record. During a telephone interview on 7/26/26 at 6:54 p.m., Dr. D stated that he expected the facility to notify him whenever a resident's prescribed medication was unavailable or delayed. Dr. D stated that he could not recall whether the facility notified him regarding the delay in obtaining Resident #1's Lomotil and would need to review his records. He stated that he was not overly concerned because Lomotil was not considered an emergency medication. Dr. D further stated that the facility had standing orders for Imodium to address residents' episodes of loose stools. During a telephone interview on 7/27/26 at 10:43 a.m., the contracted pharmacy representative stated the pharmacy received Resident #1's scheduled Lomotil order on 7/13/26 and delivered the medication to the facility on July 14, 2026. The representative stated this was the only Lomotil order the pharmacy received. The pharmacy did not receive an order changing Lomotil from scheduled administration to PRN. The representative said the facility needed to send a Lomotil PRN order, for it to reflect active in their system. During an interview on 7/27/26 at 2:12 p.m., CMA E stated she had worked at the facility for approximately five years and served as the CMA for Halls 4, 5, and 6 during the 7:00 a.m. to 7:00 p.m. shift. CMA E stated she worked on 7/13/26 as the CMA assigned to Hall 6, where Resident #1 resided. She reported that she followed the medication directions documented on the MAR. According to Resident #1's MAR, the resident was prescribed Lomotil 2.5 mg/0.025 mg, two tablets by mouth four times daily. CMA E stated the medication was not available in the facility for administration. She reported that she notified the charge nurse on duty and documented the medication's unavailability in Resident #1's clinical record. During an interview on 7/27/26 at 2:23pm, the BOM stated she had worked at the facility for approximately 23 years and, because she was certified as a medication aide, frequently filled in as a CMA when needed. The BOM stated she worked as the CMA for Halls 4, 5, and 6 from Friday, 7/10/26 , through Sunday, 7/12/26 . During that period, Resident #1 had an active order for Lomotil 2.5 mg/0.025 mg, two tablets by mouth four times daily. She stated the medication was not available from 7/10/26 through 7/12/26. According to the BOM, the charge nurses informed her that the Lomotil had been ordered and that the facility was awaiting delivery from the pharmacy. She stated she was instructed to administer Imodium to Resident #1 until the Lomotil was delivered and available for administration. During an observation and interview on 7/27/26 at 2:33 p.m., LVN F stated he had worked at the facility in several positions, including ADON, and most recently served as the charge nurse on the 6:00 a.m. to 6:00 p.m. shift. LVN F stated he worked during the period when Resident #1's Lomotil was awaiting delivery from the pharmacy. He reported that Resident #1 expressed frustration because the medication was unavailable. LVN F stated he personally informed the resident that the medication had been ordered and that the facility was waiting for the pharmacy to deliver it. He said that he did not contact the pharmacy to verify the status of the Lomotil order and explained that the facility's electronic system displayed the order as received, which he understood to mean the pharmacy had received the order. He stated he was unaware at that time that the pharmacy had not actually received it. LVN F reported that the facility administered Imodium to Resident #1 until the Lomotil was delivered. He further stated that the Lomotil order was subsequently changed from scheduled administration to as needed, or PRN, and the medication remained secured on the medication cart after the change. During the observation, LVN F retrieved Resident #1's Lomotil from the narcotic lockbox. Two pharmacy-issued blister cards were observed for diphenoxylate/atropine 2.5 mg, generic for Lomotil. The pharmacy labels were dated July 13, 2026, and directed staff to administer two tablets by mouth four times daily. Each card originally contained 30 tablets. Card 1 of 4 had not been used and contained all 30 tablets. Card 2 of 4 contained eight tablets, indicating that 22 tablets, equivalent to 11 two-tablet doses, had been removed. LVN F stated he was unaware that the pharmacy labels on the two blister cards reflected a scheduled routine order rather than a PRN order. He explained that when the medication order was changed and the medication was secured on the cart, staff should have documented the change by applying the facility's pink Medication Change labels to both blister cards and handwriting the updated directions on the labels. LVN F was observed applying the pink labels to both blister cards to indicate that the medication had been changed to PRN administration. During an interview on 7/27/26 at 3:00 p.m., the DON and Administrator said they discussed the facility's medication-order and pharmacy-notification processes. The DON stated the facility's electronic system was intended to transmit medication orders to the pharmacy and allowed staff to submit orders and verify prescription status electronically. The DON stated that when an ordered medication was not delivered within 24 hours, staff were expected to notify her and the prescribing physician. She explained that medication-delivery concerns were typically identified during the facility's morning clinical meetings. However, the delay involving Resident #1's Lomotil prescription occurred over the weekend, and she was unaware of the issue until she returned to work on Monday, 7/13/26 . The Administrator stated staff were expected to notify the DON by telephone whenever medication had not been delivered within 24 hours, as the DON was available by phone at any time, including weekends. The DON further stated she was unaware that the pharmacy had not been notified of the change in the Lomotil order from scheduled administration to as-needed administration. She believed the ADON had communicated the change to the pharmacy. The DON stated the facility should have obtained medication labeled for the new PRN order and properly discarded the medication associated with the previous scheduled order. She also stated she was unaware that staff were using pink stickers to indicate medication-order changes and would follow up regarding this practice. The DON said Dr. D called back following up on telephone interview and said facility did not notify him regarding Resident #1's medication not available. During attempted interview via phone on 7/27/26 at 1:47pm for LVN C, no answers, no return calls, left a voice message if available. Record review of revised administering medications policy dated April 2019 indicated the following: Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication

Based on observation, interview and record review the facility failed to report to state agency emergency situations that pose a threat to resident health and safety immediately, but not later than 24 hours after the incident occurs or is suspected for 1 of 1 kitchen reviewed for environmental safety.The facility failed to report an emergency situation involving a suspected gas leak/propane odor and fire department intervention to the State Agency within 24 hours of occurrence or discovery on 06/01/26. The fire department responded to the facility, investigated the reported propane odor, and shut off the propane supply to the oven.This failure could affect the health and safety of residents, staff, and visitors due to exposure to a hazardous environmental condition within the facility.Record review of the local fire department's Public Disclosure Report dated 06/01/26 documented a response to a reported propane odor in the kitchen. Fire personnel assessed the area using a carbon monoxide monitor and detected no traces of CO. The report noted a faint propane odor associated with the oven. As an immediate corrective action, the propane supply to the oven was shut off. The report indicated no fire, explosion, injuries, or hazardous material release occurred. The key narrative stated: Smells propane in kitchen very bad [name of fire department] was dispatched [facility's address] in reference to a propane smell in the kitchen. [Unknown personnel] arrived on scene and [name of local fire department] personnel walked the kitchen with a CO monitor. The monitor did not detect any traces of CO. The oven had a faint smell of propane. The propane was shut off to the oven. The worker advised she would have maintenance check it out.Record review of a work order repair invoice dated 6/2/26 indicated the following: Job Details: Oven has a small gas leak on a valve - oven is shut down by the fire department. Completion notes: checked in with maintenance, he showed me the area that the leaks were in. I found one of the connections to the baso valve was very loose. Removed fitting and reapplied sealant. Placed fitting in and tightened it down. No further leaks noted at this time. Relit all pilots and checked functionality. Unit operating properly at this time.During an observation of the kitchen oven and interview with the DM on 6/13/26 at 12:24pm, the DM pointed to the oven area where the leak was coming from and was repaired. No gas smell was observed during the noon meal preparation. The DM said she was notified on the night of 6/1/26 by the DON that she smelled gas and the fire department was notified and came on-site to do a gas test. The DM said the following day on 6/2/26 a repair company came and repaired the oven and turned the gas back on. She said while the oven was temporarily out of use the kitchen staff served sandwiches, chip, and cereal until the oven was repaired.Record review of the Administrator's emailed statement received on 6/13/26 at 12:54pm regarding the incident stated the following: [On June 1st] I [Administrator] was called about 8 PM. I [Administrator] was informed the kitchen smelled like it had gas in it. Facility was unable to get a hold of the maintenance man. I [Administrator] instructed them to call the fire department. The fire department came out and verified the facility had a gas leak. I [Administrator] told the [DM} to not cook anything on the stove or oven. I [Administrator] then asked her what she needed to do for breakfast in the morning because the residents usually have sausage and eggs or bacon. She told me [Administrator] what cereal to purchase and to purchase several gallons of milk as well as bowls for the cereal. The next morning, I [Administrator] went to Walmart and purchased cereal, milk and bowels. As I [Administrator] recall, one plumber came out that day. He verified we had a problem. Because he could not repair the problem, a second plumber was called and he did fix the problem. The maintenance man told me [Administrator] the problem was a fitting or hose that may have been disconnected from the oven/stove while the staff were trying to clean behind it.Record review of the DON emailed statement received on 6/13/26 at 2:22pm, regarding the incident stated the following: On the night of 6/1/26 at approximately 8 pm. I [DON] was up at the facility working late and when the staff and smokers came from outside, they reported to me [DON] that the dining room smelled strong of propane. I [DON] was in my [DON] office at the time. I [DON] went to the kitchen to investigate with a CNA. We both agreed that we smelled it as well when walking into the dining room. It wasn't super strong but warranted investigation. I [DON] was unable to open the kitchen doors as the dietary staff had already left for the evening. I [DON] then called dietary manager to let me [DON] into the kitchen and let her know about smell. She [DM] came up within 5 minutes, and we both went in to investigate. All the knobs were turned off to all appliances we could not tell where anything could've caused the smell other than it was strongest by the oven. I [DON] called [Administrator] and [Maintenance Supervisor]. We all agreed to have fire department come out and investigate to see if they could find cause. I [DON] called 911 about need for clearance of possible gas leak, 3 firemen came out to investigate. They checked all the knobs again and they were all off. No dangerous levels of gas are noted with their device. They also noticed smell from the oven. They opened oven doors and noted that left oven was still hot although dietary had stopped cooking hours before. They stated that kitchen appeared safe now but as a safety measure they wanted to shut off the gas lines. They shut off gas lines behind the stove and suggested not using the stove until maintenance could get someone out to service. I [DON] then called [Administrator, Maintenance Supervisor, and DM] to let them know situation and that breakfast would need to be figured out for the morning.During an interview on 6/13/26 at 5:40 pm, the Maintenance Director stated he had served in that role for approximately one year. He reported that on 6/1/26, the Director of Nursing contacted him after smelling gas in the kitchen. The DON also contacted the fire department. Prior to leaving the facility on 6/1/26, the fire department turned off the oven as a precautionary measure. The Maintenance Director stated that on 6/2/26 he contacted a licensed plumber to conduct a gas pressure test; however, the test could not be completed at that time due to weather conditions, as access to the facility roof was required. He further stated that a repair company responded on 6/2/26 and identified a pilot light line leak (occurs when gas escapes from the piping or fittings that supply the pilot burner in a gas furnace or heater. The pilot light is a small, continuously burning flame that ignites the main burners when the thermostat calls for heat. In many systems, the pilot gas is fed through a dedicated line from the main gas supply to the pilot valve. If this line is damaged, corroded, or has a loose connection, gas can leak even when the pilot is off). The company completed the necessary repairs that same day and restored the gas supply to the oven. According to the Maintenance Director, a gas pressure test was subsequently completed on 6/9/26 to verify that the repairs were effective and that no additional leaks were present. The Maintenance Director stated that a suspected gas leak was considered an emergency due to the potential risk of explosion and the possible health effects associated with gas exposure. He further stated that he was unaware whether the incident had been reported to the State, as reporting responsibilities would fall under the Administrator's authority.During an interview on 6/13/26 at 8:50 pm, the DON stated she had served in that role for approximately one year. The DON stated that a gas leak could be considered an emergency; however, she was unaware that the incident may have been reportable to the State. The DON stated that because the fire department was contacted and the necessary repairs were completed promptly, she believed all appropriate actions had been taken. The DON declined to provide examples of potential outcomes that could result from gas leak exposure.Record review of Disaster and emergency policy dated June 2025 indicated the following: Policy: To maintain and continue staff awareness of the actions to be taken in a disaster situation. Responsible Person: The Administrator will be responsible for the Internal Disaster Plan Policies and Procedures. The DON or Director of Maintenance may serve as backup as assigned by the Administrator. Procedures: To define the proper actions to be taken by the in the event of a disaster situation. Disaster and emergency situations include the following: . Loss of Cooking Capabilities. The Administrator or designated representative will notify the Texas Health and Human Services of the disaster conditions at 800-458-985.Any time in which the disaster plans are implemented HHSC will be notified no later than by the next business day.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and safety.-The facility failed to ensure the required cooking and holding temperatures were known and followed.-The facility failed to ensure food temperatures were consistently monitored and documented for March 2026.-The facility failed to ensure the DM provided oversight and verification of food safety practices.These failures could affect the residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included:Record review of March 2026 food temperature logs revealed the following:Review of available logs dated 03/02/2026, 03/03/2026, 03/04/2026, 03/05/2026, 03/09/2026, 03/10/2026, 03/11/2026, and 03/12/2026 showed the facility failed to document final internal cooking temperatures for breakfast, lunch, and dinner meals. Also, for the meal service holding temperatures for breakfast and lunch meals for the above dates there were multiple entries left blank or marked with slashes (/), indicating required monitoring was not performed or recorded. The facility's temperature log included reference standards for safe food handling (ex: internal cooking temperatures of 145 F-165 F and holding temperatures of 135 F for hot foods and <41 F for cold foods). Additionally, for the following dates in March 2026: on 03/01/2026, 03/06/2026, 03/07/2026, 03/08/2026, 03/13/2026, 03/14/2026, 03/15/2026, 03/16/2026, 03/17/2026, 03/18/2026, 03/19/2026, 03/20/2026, 03/21/2026, and 03/22/2026, the facility did not have any food temperature logs available for review, indicating that required temperature monitoring was not conducted or maintained for those days. Record review of Complaint Investigation worksheet, Intake 1077503 revealed an allegation dietary service. The complaint was reported to HHSC CII on 03/20/2026. Intake 1077503 read in part: The facility's food was atrocious. On 3/7/26, The resident was provided toasted peanut butter and jelly. However, the bread was very hard to eat. On 3/15/26, the resident was served raw chicken. The resident did not eat the chicken. It is unknown if other residents were served raw chicken. During an observation and interview conducted on 3/21/26 at 6:03 p.m., in the dining room during dinner meal service, a resident family member reported that on 3/15/26 kitchen staff served raw chicken that was not fully cooked. During an interview on 3/22/26 at 1:30 p.m., The DM said she had been in her position for approximately one month and previously worked as a cook for approximately one year. The DM reported that cook staff were responsible for obtaining and documenting food temperatures for breakfast, lunch, and dinner meals. The DM indicated that food temperature logs were maintained on a clipboard located above the prep table next to the stacked clean pans. During an interview on 3/22/26 at 2:06 p.m., with [NAME] B he said he began working as a cook during the last week of February 2026 and was trained by [NAME] D. [NAME] B stated he was aware that food temperatures were to be taken; however, he reported he was not instructed to document the temperatures and was unaware the facility maintained a food temperature log. He further stated that no one had shown or reviewed the temperature log with him. [NAME] B said he knew the poultry items were required to reach 165 F but was unable to identify the required temperatures for other food items. He also stated he was not aware of the minimum holding temperature requirements for hot or cold food items. During an interview on 3/22/26 at 2:15 p.m., the DM said that several March 2026 food temperature logs were incomplete or not completed and said she could not confirm whether food temperatures were consistently being taken. DM said the food temperature logs completed on 03/02/2026, 03/03/2026, 03/04/2026, 03/05/2026, 03/09/2026, 03/10/2026, 03/11/2026, and 03/12/2026 were completed by [NAME] C who no longer worked at the facility and his LDW was on 03/12/2026. The DM said [NAME] D had put in his notice and his last day would be 03/26/26. The DM stated she was not aware the cooks were not completing the food temperature logs until this interview on 3/22/26 and said she had not been following up to ensure logs were being completed. The DM said she had not trained or reviewed the food temperature log process with [NAME] B and assumed another cook had done so. The DM stated she should have followed up with [NAME] B regarding completion of the food temperature logs. The DM reported on 3/15/26 she was notified by an unknown person of residents' complaint regarding uncooked chicken served to residents. The DM stated she received a picture of the undercooked chicken and, upon follow-up with [NAME] B (the cook who prepared the meal), he reported taking the temperature; however, the DM said she did not think to check the food temperature log to verify at that time because it did not cross her mind to do so. The DM stated it was evident from the picture she received the chicken was not fully cooked and said it was possible food temperatures were not taken for that day. She said by the time she arrived at the facility on 3/15/26 the residents had already been served different sandwiches such as grilled cheese sandwiches, meat and cheese sandwiches or peanut butter and jelly sandwiches. During an interview on 3/22/26 at 2:30 p.m., [NAME] B initially denied being the cook who served the undercooked chicken on 3/15/26, but later stated he was the cook working that day and prepared the meal. [NAME] B said he took the temperature of the chicken that was served on 3/15/26 but could not recall the internal temperature or the holding temperature at the time of interview. He further stated he did not document the temperature because he was not aware of the food temperature log. [NAME] B said recalled the chicken had bones and he was struggling trying to debone the chicken and it was possible some of the chicken was not properly prepared, but since then the facility no longer ordered that type of meat and he had not had any similar issues since. [NAME] B said he did recall the DM was at the facility on 3/15/26 but did not know it was because of something he did wrong. A phone interview was attempted with [NAME] D on 3/22/26 at 4:17 p.m., regarding food temperature log practices; however, there was no answer, and could not leave a message. During an interview on 3/22/26 at 4:36 p.m., The Administrator said the DM was a new DM and [NAME] B was a new hire. He said the DM was responsible for training dietary staff and ensuring adherence to the facility policies and procedures. During an interview on 03/23/26 at 2:22 p.m.; the HR clerk said Dietary [NAME] B was a weekend cook who worked Fri- Sunday from 5am-8pm. The HR clerk said [NAME] B started around 02/23/26 and said she would get the dates [NAME] B started working by himself as the cook, but a date was not provided. Record review of the DM job description signed on 01/10/2026 indicated the following: Plan, purchase, prepare and ensure delivery of nutritious, high-quality food to residents within the limits of the approved budget, in accordance with the recommended Dietary allowances of the Food and Nutrition Board of the National Academy of Sciences, and in compliance with state/federal regulations and internal policies.Coordinate Dietary activities by performing the following duties personally or through subordinate supervisors.Maintain Rights of Residents as set forth by the Texas Department of Health Laws and Regulations.Essential Functions:- Evaluate and monitor all aspects of Dietary operation, making recommendations forconformance level that will provide nutritionally adequate, quality food.- Maintains high quality food for regular and modified diets.-Plans, organizes, and conducts orientation, training, and in-service educational programs for Dietary personnel.- Investigates and resolves food quality and service complaints.-Prepare routine reports and maintain all Dietary records in accordance with policies and procedures.- Knowledgeable of and implements all safety, universal precautions, and Company policies/procedures for the protection of residents, co-workers, and self.- Other duties as assigned, with or without reasonable accommodations, to assist in maintaining quality standards and maintaining the facility as a viable and successful entity. Record review of a blank cook job description indicated the following Job Summary: Prepare and cook high quality hot and cold foods for regular and modified diets for residents, guests, and employees of the facility in accordance with the State Department of Health Rules and Regulations and the standards set forth by the facility by performing the following duties. Coordinate Dietary activities by performing the following duties personally or through subordinate supervisors. Maintain Rights of Residents as set forth by the Texas Department of Health Laws and Regulations. Essential Functions. Inspects food and food preparation to maintain quality standards, temperature standards, and sanitation regulations. Record review of revised Food Preparation and Service Policy dated November 2022 indicated the following: Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 1. Danger Zone means temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. Potentially Hazardous Foods (PHF) or Time/Temperature Control for Safety (TCS) Foods held in the danger zone for more than 4 hours (if being prepared from ingredients at ambient temperature) or 6 hours (if cooked and cooled) may cause a foodborne illness outbreak if consumed.2. Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food means food that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing a disease or toxin formation). Examples of PHF/TCS foods include ground beef, poultry, chicken, seafood (fish or shellfish), cut melon, unpasteurized eggs, milk, yogurt and cottage cheese.3. Food Preparation means the series of operational processes involved in preparing foods for serving, such as: washing, thawing, mixing ingredients, cutting, slicing, diluting concentrates, cooking, pureeing, blending, cooling, and reheating.4. Food Distribution means the processes involved in getting food to the resident. This may include holding foods hot on the steam table or under refrigeration for cold temperature control, dispensing food portions for individual residents, family style and dining room service, or delivering meals to residents' rooms or dining areas, etc. When meals are assembled in the kitchen and then delivered to residents' rooms or dining areas to be distributed, covering foods is appropriate, either individually or in a mobile food cart. Food Preparation, Cooking and Holding Time/Temperatures1. The danger zone for food temperatures is above 41 F and below 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness.2. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese.3. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, PHF must be maintained at or below 41 F or at or above 135 F.4. Potentially hazardous foods held in the danger zone for more than 4 hours (if being prepared from ingredients at room temperature) or 6 hours (if cooked and then cooled) may cause foodborne illness.5. Food thermometers used to check food temperatures are clean, sanitized and calibrated for accuracy.6. The following internal cooking temperatures/times for specific foods are reached to kill or sufficiently inactivate pathogenic microorganisms:Internal Cooking Temperature 145 F Raw eggs cooked for immediate service Fish (except as listed below) Meat (except as listed below) Commercially raised game animals, rabbits155 F Ground meat (beef, pork) Ground fish Eggs held for service Comminuted meat, fish, or commercially raised game animals Injected or mechanically tenderized meats Ratites (ostrich, [NAME] and emu)165 F Wild game animals Poultry Stuffed fish, meat, pork, pasta, ratites & poultry Stuffing containing fish, meat, ratites & poultry7. Fresh, frozen or canned fruits and vegetables are cooked to a holding temperature of 135 F.8. Raw foods cooked in a microwave reach 165 F in all parts of the food. The items are rotated and stirred during the cooking process so that all parts of the food reached 165 F and allowed to stand covered for at least two (2) minutes after cooking.9. Previously cooked food is reheated to an internal temperature of 165 F for at least 15 seconds before holding for hot service. Reheated foods that are not consumed within 2 hours are discarded.10. Ready to eat foods that require reheating are taken directly from the sealed container or intact package from the food processing source and cooked to at least 135 F for holding for hot service.11. Mechanically altered hot foods prepared for a modified consistency diet remain above 135 F during preparation or they are reheated to 165 F for at least 15 seconds if holding for hot service.Food Distribution and Service1. Proper hot and cold temperatures are maintained during food distribution and service. Foods that are held in the temperature danger zone are discarded after 4 hours.2. The temperatures of foods held in steam tables are monitored throughout the meal service by food and nutrition services staff.3. If time is used in place of temperature as a means of ensuring food safety, the amount of time PHF/TCS foods are held out of temperature control is tracked and foods are discarded accordingly.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 facility kitchens.The facility failed to ensure the reach-in stainless steel freezers and coolers were free from food debris, dried liquid splatters and fingerprints.The facility failed to ensure the bulk bins for sugar, flour and cornmeal were kept clean.The facility failed to ensure the outside of the milk box was clean.The facility failed to ensure the areas above the ovens on the stove were kept clean.The facility failed to ensure the vent hood above the deep fryer was kept clean.These failures could place residents who ate food from the kitchen at risk of foodborne illness.Findings included:During observations and interviews on 02/02/2026 of the kitchen the following was noted:*at 10:00 AM the 2-door stainless steel freezer in the pantry. The indented areas under the handle pulls are filled with food debris, the stainless steel doors had fingerprints and there were splatters on the front vents and door sills, the bottom shelf of the freezer had scattered food debris.*at 10:12 AM the bulk sugar, flour, cornmeal bins in the pantry. The plastic lids had built-up light brown debris in the crevices of the molded plastic, dried food splatters and were generally soiled.*at 10:14 AM the 2-door stainless steel cooler in the pantry had door sills soiled with food debris and dried liquid splatters.*at 10:17 AM the 2-door stainless steel cooler between the pantry and the meat freezer had door sills soiled with food debris, dried liquid splatters and the bottom shelf soiled with dried liquid spills and food debris. *at 10:24 AM the front of the refrigerated milk box had dried liquid drips. *at 10:26 AM the area above the oven doors on the 6-burner stove had a deep golden-brown greasy film that could be scraped with a fingernail. The vent hood above the deep fryer had a light build-up of golden-brown greasy film. The DM said the vent hood had been deep cleaned in December 2025 by a vendor and she knew the maintenance supervisor also deep cleaned it sometimes. She was not aware of routine light cleaning to keep the surfaces free of grease build-up. The DM said she was getting some help from the DM at a local sister facility with setting up cleaning schedules of tasks to be completed. She said she was in the process of breaking down tasks by shift and days to be performed. She said she had purchased stainless steel cleaner to begin cleaning all the stainless steel.Review of a facility policy, revised November 2022, titled Sanitation indicated .1. All kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. 2. All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair. 3. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions.The Texas Food Establishment Rules, dated October 2015, revealed:S228.68. Preventing Contamination From Equipment, Utensils, and Linens. (a) Food shall only contact surfaces of: (1) equipment and utensils that are cleaned as specified under SS228.113, 228.114 and 228.115 of this title and sanitized as specified under SS228.116, 228.117 and 228.118 of this title; . S228.114. Frequency of Cleaning.(c) Nonfood-contact surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues Food and Drug Administration Code, Dated, 2013, indicated the following: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (B)The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations 3-305.11 Food StorageFood shall be protected from contamination by storing the food:(1) In a clean, dry location;(2) Where it is not exposed to slash, dust or other contamination .4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris .

Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 4 medication carts (Cart Hall 2 and Cart Halls 1 & 3) reviewed for pharmacy services. The facility failed to ensure the nursing staff responsible for the safekeeping of narcotics performed and documented change of shift narcotic counts on multiple shifts and days for Medication Cart Hall 2 and Cart Halls 1 & 3. This failure could place residents at risk for loss of medications and possible drug diversion.Findings included: During an observation and interview on 02/03/2026 at 09:01 AM, MA-B was noted standing at Medication Cart Hall 2. The top drawer of the cart was open and a key ring with keys on it was noted lying on top of the cart. When asked if MA-B was available for observation of medication administration, MA-B said she was not the medication aide for the residents. MA-B said she was the staffing coordinator. She said she was also a medication aide and helped in that capacity when needed. She said she was checking the medication cart for needed supplies. MA-B said she obtained the keys to the cart from MA-C who was on another hall at that time. She said the key to the narcotic box in the cart was also on the key ring. MA-B said she counted the narcotics with MA-C when she took control of the keys to the cart that morning (02/03/2026). MA-B said she forgot to sign the narcotic count record. During an interview with MA-C at 09:10 AM on 02/03/2026, she said she counted the narcotics with MA-B prior to giving her the keys to the carts and narcotic boxes for Hall Cart 2 and Hall Cart 1 & 2. She said she did not get to the facility in time to count the narcotics with the off-going night nurse every day. She said she counted the narcotics in the carts she would use every day with whoever had the keys. MA-C said she counted Hall Cart 2 and Hall Cart 1 & 3 with MA-B when she arrived at the facility that morning. During a second interview with MA-B on 02/03/2026 at 09:16 AM, MA-B said she did not count the narcotics with MA-C when she arrived at work that morning. During a second interview with MA-C on 02/03/2026 at 09:18 AM, MA-C said she counted narcotics with LVN-E that morning when she arrived to work. During an interview with LVN-E on 02/03/2026 at 09:20 AM, LVN-E said she had not counted the narcotics with MA-B when she arrived to work. During an interview on 02/03/2026 at 09:21 AM with MA-B, MA-C, and LVN-E, MA-C looked at LVN-E and said, I counted with you this morning. LVN-E shook her head no and said she had not counted with MA-C. When surveyor asked MA-C who she had gotten the keys to Hall cart 2 and Hall Cart 1 & 3 from, she did not reply. When asked a second time, MA-C looked at LVN-E. LVN-E then said, In the book and pointed toward Hall Cart 2. When surveyor asked MA-C if the keys to the cart were left unsecured, inside the narcotic count book lying on top of Hall Cart 2, MA-C replied yes. During an interview on 02/03/2026 at 09:32 AM, MA-C said she did not count the narcotics in Hall Cart 2 and Hall Cart 1 &3 with anyone when she obtained the keys to the carts from the notebook. She said she counted the narcotics by herself. MA-C said it was important to count narcotics every time keys were passed from one person to another to reduce the risk of missing or lost narcotics and other drugs. During an interview with on 02/03/2026 at 10:23 AM, MA-C said she left at 03:00 PM on 02/02/2026. She said counted the narcotics with MA-B and gave her the keys to Cart 2 and Cart 1 & 3. MA-C said she did not work 12-hour shifts. She said she worked from 7AM to 3 PM. She said there was no place on the narcotic count signature sheets to sign for counts done at any time except the beginning and end of the 12-hour shifts. MA-C said she counted the narcotics with MA-B on 02/02/2026 at 3:00 PM and signed that she had performed the count at 6 PM because it was the only spot available to sign. During an interview on 02/03/2026 at 10:26 AM, MA-B said she counted the narcotics on Cart 2 and Cart 1 & 3 with MA-C at 03:00 PM on 02/02/2026. She said she counted the narcotics on the carts with one of the nurses when she left at 5 PM. A review of the Narcotic Count Notebooks for Hall Cart 2 and Hall Carts 1 & 3 noted the first page in the notebooks to have the following instructions in large, bold print: Please count Narcotics and sign the log sheet daily! Record review of the Controlled Substances Count sheet for Hall Cart 2 indicated spaces available for the 6 AM - 6 PM and 6 PM - 6 AM shifts only. There was 1 missing signature for the 6 PM - 6 AM shift on 02/02/2026 which indicated MA-C had not performed a narcotic count with anyone before relinquishing control of the cart. There were no entries for the performance of narcotic counts on 02/03/2026. Record review of the Controlled Substances Count sheet for Hall Cart 1 & 3 indicated an undated entry below the date of 02/02/2026 for an off-going night nurse with no corresponding signature of the on-coming nursing staff. During an interview and record review with the DON on 02/03/2026 at 10:35 AM, she provided a reconstructed accounting of the exchange of control of Hall Cart 2 which indicated Hall Cart 2 and keys were handed off a total of 8 times from 07:00 AM on 02/02/2026 to 07:00 AM on 02/03/2026. The exchange of control of the cart containing narcotics involved 2 Medication Aides, 4 Licensed Vocational Nurses, and 1 Registered Nurse and resulted in 13 missing signatures for narcotic counts from 07:00 AM on 02/02/2026 through 07:00 AM on 02/03/2026. The DON said she expected the nursing staff to count the narcotics at shift change and any time the keys and control of the medication carts were passed from one person to another. She said she expected nursing staff to be honest about their handling of narcotic counts. She said she expected the keys to the medication carts and narcotics to be maintained in a secure manner and not left on top of the cart in the narcotic book. The DON said narcotic counts and the security of the keys to the carts and narcotics were important for minimizing the risk of missing or lost narcotics. A review of the facility's policy dated 2001 and revised November 2022 and titled Controlled Substances indicated the following: Dispensing and Reconciling Controlled Substances1.Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.2.The system of reconciling the receipt, dispensing, and disposition of controlled substances included the following:a.Records of personnel access and usage, .3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count.4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.

Based on interviews and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 4 of 10 residents (Residents #64, #9, #20, and #47) reviewed for resident assessments. 1.The facility failed to ensure the accuracy of the PASRR Level 1 screening dated 9/15/25 for Resident #64. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (Delusional Disorder) was present on 3/22/24. 2. The facility failed to ensure the accuracy of the PASRR Level 1 screening dated 9/11/25 for Resident #9. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (Delusional Disorder) was present at the time.3. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #20. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (Post-Traumatic Stress Disorder) was present upon Resident #20's admission date on 11/01/25.4. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #47. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (Mood Disorder, Schizoaffective disorder, and bipolar disorder) was present upon Resident #47's admission date on 12/11/25. This failure could place residents with positive PASRR at risk of not receiving specialized services which would enhance their highest level of functioning, and could contribute to residents' decline in physical, mental, and psychosocial well-being. Findings included: 1.Record review of the undated face sheet indicated Resident #64 was a [AGE] year-old female that admitted [DATE]. Record review of the physician's orders dated 2/3/26 indicated Resident #64 had diagnoses that included: delusional disorders (a type of serious mental illness characterized by holding one or more firm, false beliefs/delusions, for at least 1 month which are based in reality, often non-bizarre, such as being followed, poisoned, or loved from afar), anxiety (intense, excessive and persistent worry), and mild dementia with agitation (restlessness, anxiety, irritability, and at times verbal or physical aggression). The physician's disorders indicated Resident #64 had orders dated 8/2/25 for Depakote extended release, 250 mg, 1 tab by mouth at bedtime related to delusional disorder. Record review of the annual MDS assessment dated [DATE] indicated Resident #64 had clear speech, understood others, and was understood by others. She had a BIMS score of 11 which indicated moderate cognitive impairment. She rejected care 4-6 days per week. Record review of the undated care plan indicated Resident #64 had forgetfulness/delusional behavior related to dementia, a history of when she got an idea in her head, even if not true, she believed it was true. The care plan indicated she took medication for delusional disorder/behaviors. Record review of a PASRR Level 1 Screening dated 9/15/25 indicated Resident #64 did not have a primary diagnosis of dementia or mental illness. During an interview on 2/03/2026 at 12:50 PM, the MDS nurse said she marked the PASRR Level 1 Screening wrong for Resident #64 on 9/15/25 when the facility had the CHOW. She said she indicated Resident #64 did not have mental illness, but Resident #64 got a diagnosis for delusional disorder on 3/22/25. She said Resident #64 did not have a primary diagnosis of dementia so she should have marked the PL 1 positive for MI. During an interview on 2/03/2026 at 1:36 PM, the MDS nurse said marking a PASRR Level 1 Screening negative, when it should have been positive, could cause residents to miss out on potential services and/or counselling they could receive from PASRR services. During an interview and record review on 02/03/2026 at 2:17 PM, the MDS nurse provided this surveyor a Form 1012 Mental Illness/Dementia Resident Review that she said she would turn into the MD to sign indicating Resident #64 had MI related to delusional disorders. The 1012 form indicated, Complete this form only for nursing facility residents with a current Negative PASRR Level 1 (PL1) Screening for Mental Illness to determine whether to submit a new positive PL 1 screening form on the Long Term Care Portal because further evaluation is needed. During an interview on 2/04/2026 at 2:09 PM, the SW said if a resident had a mental illness diagnosis, she would expect them to be PASRR positive on their PL 1. She said if a resident had MI, ID, or DD, and were marked negative, they could miss out on services that would benefit them. During an interview on 02/04/2026 at 2:21 PM, the DON said anyone with MI, DD, or ID should be marked as positive on their PL 1 so that they could get all the care that they needed. If a resident was marked negative and they were positive, they could miss out on treatments that would provide them needed care. The DON said if a resident had MI it would be beneficial for their overall quality of life and well-being to get extra services through PASRR. During an interview on 2/04/2026, at 2:27 PM, the ADM said anyone with MI, IDD, ID should be marked as positive on the PL 1, so that they could get all the care that they needed and support services for a better quality of life. He said if the PL 1 was marked negative and should have been positive, it could adversely affect their quality of life because the PASRR services gave them more positive things. The ADM said he had seen residents receive PASRR services and they really seemed to enjoy it. 2. Record review of Resident #9's face sheet, dated 02/03/26, reflected he was an [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included delusional disorders The onset date was 04/26/24. Record review of Resident #9's quarterly MDS assessment, dated 11/01/25, reflected he had a BIMS score of 99, which indicated he was unable to complete the BIMS interview. His cognitive skills for daily decision making were moderately impaired. He was usually able to make himself understood, and sometimes able to understand others. He received an antipsychotic medication routinely.Record review of Resident #9's PASRR Level 1 Screening, dated 09/11/25, indicated that in Section C, Mental Illness was marked as no, which indicated Resident #9 did not have a mental illness. 3. Record review of Resident #20's face sheet, dated 02/02/26, reflected he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included Post-Traumatic Stress Disorder (a mental health condition triggered by experiencing or witnessing terrifying events like accidents, abuse, or war, with symptoms lasting over a month). The onset date was 11/02/25.Record review of Resident #20's admission MDS assessment, dated 11/03/25, reflected he had a BIMS score of 05, which indicated severe cognitive impairment. He was sometimes able to make himself understood, and he was sometimes able to understand others.Record review of Resident #20's PASRR Level 1 Screening, dated 11/01/25, indicated that in Section C, Mental Illness was marked as no, which indicated Resident #20 did not have a mental illness.4. Record review of Resident #47's face sheet, dated 02/03/26, reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included Mood disorder , schizoaffective disorder (a mental health problem where you experience psychosis as well as mood symptoms), and Bipolar disorder (This mental health condition causes extreme mood swings that include emotional highs, called mania, and lows, known as depression). The onset date for all three diagnoses was 12/11/25. Further, Resident #47 had a diagnosis of dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), but it was designated as primary. The primary diagnosis was a Mood Disorder.Record review of Resident #47's admission MDS assessment, dated 12/15/25, reflected she had a BIMS score of 00, which indicated severe cognitive impairment. She was sometimes able to make herself understood, and she was sometime able to understand others. She received an antipsychotic medication routinely.Record review of Resident #47's PASRR Level 1 Screening, dated 12/11/25, indicated that in Section C, Mental Illness was marked as no, which indicated Resident #47 did not have a mental illness. The screening further indicated that the resident had a primary diagnosis of dementia. During an interview on 02/03/26 at 01:36PM, the MDS Coordinator said the PASRR Level 1 forms for Resident #9, Resident #20, and Resident #47 were incorrect. She said all three of them should have been marked yes for mental illness. She said Resident #9 and Resident #47 did not have a primary diagnosis of dementia. She said the risk was that these residents could miss out on potential services and counseling they could receive from PASRR.During an interview on 02/04/26 at 01:57PM, the DON said she did not deal with the PASRR Level 1 forms.During an interview on 02/04/26 at 02:01PM, the Interim Administrator said he expected the MDS Coordinator to ensure the PASRR Level 1 forms were filled out correctly. He said the risk was that the residents may not be considered for PASRR services.During an interview on 2/4/26 at 10:05 AM, the VPCO said they did not have a PASRR policy. She said they followed state and federal guidelines for PASRR.

Based on observation, interview, and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being for residents 1 of 2 units (secure unit) reviewed for quality of life, in that: The facility failed to ensure there were organized activities available to secured unit residents on 02/02/26.The facility failed to ensure the activities calendar was initially posted for February, 2026, and once it was posted, was followed. This failure placed residents at risk for a diminished quality of life, behaviors, isolation, and lack of stimulation. Findings included: During an interview on 02/02/26 at 11:45AM, the family member of a resident in the secure unit, Family Member M, said the only time she saw activities conducted in the secured unit was when occupational therapy or hospice would come in and do some kind of activity. During an observation on 02/02/26 at 10:17AM, the residents in the secured unit were sitting in the dining room watching TV. Some residents were asleep in their wheelchairs or couches, and some were wandering around the hall. There was no activity ongoing at this time. There was an activity schedule posted, but it was for the month of January. There was no activity schedule posted for February.During an observation on 02/02/26 at 02:30PM, there was no activity ongoing at this time. The residents had finished lunch, and some were sitting around in the dining room watching tv. Other residents were up and wandering around the unit.During an interview on 02/02/26 at 02:55PM, the Activity Director said that day was her 3rd full day as the activity director. She said her first day was January 28th, but she was required by the facility to continue to administer medications as a medication aide. She said she was about to step away to go administer more medications. She said she did not have access to the computer in the activity director's office yet, and was unable to access activity director materials. She said she did not have a schedule for activities in the secured unit for February yet.During an interview on 02/03/26 at 09:40AM, the Activity Director provided a schedule of activities for the secured unit for February.Record review of the Activities Schedule for February 2026 for the secured unit reflected the following activities for 02/03/26:10AM - Music1PM - Arranging Flowers4PM - Bible Study6PM - TV During an observation on 02/03/26 at 10:18AM, the Activity Director was in the secured unit conducting a coloring activity with the residents.During an observation on 02/03/26 at 01:01PM, there were no activities being conducted in the secured unit at that time. Some residents were still eating lunch.During an interview on 02/03/26 at 1:06PM, CNA N said the Activity Director did not conduct any activities in the secured unit on 02/02/26. She said the aides left out colors for the residents to color. She said there was no specific time when the aides were responsible for doing the activity because they have a lot going on. She said they tried to incorporate activities, but they were doing rounds, smoke breaks, showers, passing trays, and incontinent care. She said the aides had been responsible for activities in the secured unit for the last 2 years. She said the previous activity director only came back to the unit to do activities when state was in the building. She said the risk to the residents was that they could have a decreased quality of life and increased boredom.During an observation on 02/03/26 at 01:13PM, there was no activity being conducted in the secured unit at that time. The CNAs were picking up lunch trays.During an interview on 02/03/26 at 01:15PM, CNA O said the activity in the unit on 02/02/26 was coloring. She said there was no set schedule. She said there was no set schedule because it was hard to fit activities in when the aides are taking care of the residents, including showers, incontinent care, and getting them up for the day. She said the Activity Director did not come to the secured unit to conduct activities on 02/02/26. She said it has been that way for at least 2 years. She said the previous activity director came back to the secured unit for activities a handful of times. She said the risk to the residents was decline and decreased quality of life.During an observation on 02/03/26 at 01:20PM, there was no activity being conducted in the secured unit at that time.During an interview on 02/03/26 at 02:11PM, CNA O said they and the Activity Director did not do the arranging flowers activity that was scheduled at 01:00PM that day.During an interview on 02/04/26 at 01:29PM, the Activity Director said she did not conduct any activities in the secured unit on 02/02/26. She said she did go back to the secured unit on 02/02/26 to ask the residents and aides what they liked and did not like to do. She said after lunch she had to work on the medication cart because the other staff needed her help. She said it was her responsibility to ensure activities were being conducted in the secured unit. She said she started in the Activity Director role on the 26th of January. She said she had not yet been able to work full time as an Activity Director, because she was still required to work as a medication aide. She said she was not certified as an Activity Director yet, but she signed up for the Activity Director course on 02/03/26 after the survey team inquired about her certification. She said she would start the course as soon as she got the materials to work on it. She said the risk to the residents was that they could decline due to not having an outlet in activities. She said she is unsure how long the unit has gone without activities. She said in the past when she had worked on the weekend as a med aide, she had not seen many activities in the unit at all. She said she was sick the past weekend and did not come up to the facility for any activities.During an interview on 02/04/26 at 01:57PM, the DON said the Activity Director and the Administrator were responsible for ensuring that activities were scheduled and that the schedule was followed. She said the risk to the residents was a decreased quality of life due to less interaction and brain stimulation.During an interview on 02/04/26 at 02:01PM, the Administrator said his expectation was that activities should have been scheduled and conducted throughout the day. He said they placed a medication aide in the activity director position. He said the activity director had not yet signed up for the activity course until 02/03/25. He said the risk to the residents not receiving activities could cause decreased quality of life due to the drop in stimulation. He said he expected the Activity Director to keep the activity schedule like it was medication. Record review of the facility's policy, Activity Programs, last revised June 2018, reflected: .Activity programs are designed to meet the interests of and support the physical, mental and psychosocial wellbeing of each resident.2. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident.6. Activities are scheduled 7(seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs.11. Scheduled activities are posted on the resident bulletin board. Activity schedules are also provided individually to residents who cannot access the bulletin board.

Based on observations, interviews, and record reviews, the facility failed to establish and 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 1 of 5 residents (Residents #2) reviewed for infection control and prevention. The facility failed to ensure CNA G and CNA H donned (put on) appropriate PPE (a gown) prior to preparing Resident #2 for a transfer using a Hoyer lift and adjusting his urinary catheter drainage collection bag. This failure could place residents under their care at risk for the transmission of communicable diseases and infections. Findings included: Record review of a face sheet dated 02/02/2026 indicated Resident #2 was an [AGE] year-old male who initially admitted to the facility on [DATE] and re-admitted on [DATE] after a hospital stay. He had diagnoses which included heart disease, chronic kidney failure, influenza A, and sepsis (serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response, potentially leading to the malfunctioning of various organs, shock, and death). Record review of Resident #2's quarterly MDS assessment dated [DATE] noted Resident #2 had a BIMS of 14 which indicated his cognition was intact. Record review of Resident #2's care plan dated 02/01/2026 indicated he required Enhanced Barrier Precautions to prevent spread of multidrug-resistant organisms. During an observation on 02/02/2026 at 01:15 PM, CNA-G and CNA-H were observed preparing Resident #2 for a transfer from his bed to a shower bed using a Hoyer lift. Upon preparing to enter Resident #2's room, a sign indicating the need for EBP was noted posted on the wall to the left of the outer doorway. A plastic 3-drawer container with PPE in it was noted inside and to the left of the doorway. CNA-G and CNA-H were observed to turn Resident #2 from side to side while placing a Hoyer lift sling under him. Resident #2 was noted to have an open wound to his sacrum area. CNA-H was observed to use his right, gloved hand to reposition Resident #2's foley catheter drainage bag from underneath the bed to the foot of the bed. CNA-G and CNA-H were observed not wearing disposable gowns during this time. During an interview on 02/02/2026 at 01:25 PM, CNA-G said she did not see the EBP sign on the wall beside the door leading to Resident #2's room. She said she knew she was supposed to wear gowns and gloves when providing care to residents with wounds, g-tubes, and foley catheters, but forgot. She said EBP was important in protecting residents and staff from the spread of disease. During an interview on 02/02/2026 at 01:28 PM, CNA-H said he did not know what conditions required EBP but knew the EBP sign meant he was to wear gown and gloves when providing direct care to residents in rooms with the EBP sign outside their doors. He said he did not see the EBP sign on the wall beside the door leading to Resident #2's room. He said it was important to follow infection control protocol to keep from spreading infection. During an interview on 02/03/2026 at 01:50 PM, the DON said she expected staff to follow EBP instructions when caring for residents with foley catheters. She said EBP signs were posted on the outside walls beside the doors to resident rooms to remind staff of the need for gowns and gloves to be used when providing direct patient care. She said she was ultimately responsible for ensuring staff adhere to EBP. Record review of the facility's policy dated 2001and titled Enhanced Barrier Precautions indicated the following: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.Policy Interpretation and Implementation3.Examples of high-contact care activities requiring the use of gown and gloves for EBPs include:g. device care or use (.urinary catheter, .h.wound care 5.EBPs are indicated.for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.

Based on interviews and record review, the facility failed to notify the resident's representative when there was a decision to transfer the resident from the facility to the hospital resident for 1 of 6 residents (Resident #95) reviewed for resident rights.The facility failed to notify Resident #95's representative when he was sent to the hospital emergency room for a change in condition.This failure could result in the family or guardian not being aware of conditions that may require them to make medical decisions.Findings included:Record review of a facility face sheet dated 5/15/25 indicated Resident #95 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Parkinsonism, striatonigral degeneration (a rare, rapidly progressive neurodegenerative disorder causing rigidity, slow movement, tremors, blood pressure drops and lack of muscle control and coordination causing awkward or clumsy movements), dementia without behavioral disturbance, mood disorder, vascular dementia, Parkinson's disease, visual hallucinations and high blood pressure. The face sheet indicated Resident #95's responsible party as emergency contact #1 and there was another family member indicated as emergency contact #2.Record review of a comprehensive admission MDS assessment dated [DATE] for Resident #95 indicated he had a BIMS score of 06, indicating he had severely impaired cognition. Resident #95 required partial assistance from one staff with toileting and showering and supervision with dressing and could feed himself. Resident #95 was occasionally incontinent of Bladder and continent of bowel.Record review of a comprehensive care plan initiated 11/12/2025 for Resident #95 indicated he was at risk for falls and had actual falls on 11/14/2025, 11/16/2025, 12/03/2025, 12/21/2025, 12/29/2025, and 01/11/2026. Noted in the care plan with new interventions initiated with each subsequent fall. The record indicated the resident had no major injuries noted from these falls. Record review of a progress notes for Resident #95 indicated the following:On 11/08/2025 at 09:22 AM Skilled Evaluation: No pain, confused and oriented to person, requires cues, severely impaired cognition, speech clean and usually understands others, no difficulty with cardiovascular, respiratory, gastrointestinal, genitourinary systems. He had no issues with swallowing. He had an abscess wound on his right scapula present on admission.On 12/29/2025 at 04:48 AM Nurse's Note: Called to resident room, noted sitting on floor in front of recliner, Resident is alert and oriented to person, neuros initiated, and WNL. 0 c/o pain or discomfort voiced/noted. NP, RP, and DON notified.On 12/31/2025 at 10:56 PM Nurse's Note: 0 delayed injuries post day 2/3 witnessed fall. Neuro checks continue and remain WNL for resident. No complaints of pain or discomfort voiced/noted.On 01/07/2026 at 1:27 PM Nurse's Note: informed by CNA that resident had unwitnessed fall and hit his head, resident does not complain of pain at this time, RP informed, NP and DON notified, new order for Xray placed, neuros initiated.On 01/07/2026 at 10:13 PM Nurse's Note: neuro checks continue after unwitnessed fall with bruising to left eye with knot present. no signs or symptoms of pain or discomfort present. negative findings from xray. resident is resting in bed with eyes closed. easily alert and responsive.On 01/08/2026 at 3:11 PM Nurse's Note: resident changed room and has not been able to settle, he has been agitated and roaming the hallway trying to go back into his old room. Resident has been redirected several times and becomes angry when trying to push him in his wheelchair to his new room.On 01/11/2026 at 01:20 AM Nurse Note: CNA reported to this nurse that resident laying in the floor, went to resident room and noted resident in the middle of his room laying on the floor on his left side, walker is at the end of roommate's bed, able to follow basic commands, denies pain, ROM WNL, assisted up x2 and tolerated well no signs and symptoms of discomfort, noted redness to mid forehead, other injury noted aside from previous bruising to left forehead , eye and spreading to right eye and scab to left eye, no distress, neuros restarted, spoke with RP #2 and verbalized understanding, RP #1 also made aware, DON and NP also made aware. On 01/14/2026 at 8:30 PM Nurse's Note: Called to resident room, noted resident on floor on hands and knees, bed in low position, Resident only responds with moans and groans, resident hair damp, skin is cold and clammy-Blood sugar 135, and vital signs WNL. Bruising noted to face, bilateral upper extremities, back, and chest from previous incidents, no new bruising, or reddened areas noted at this time. Jerking movements to bilateral upper extremities noted. 911 called, Resident trying to get up on bed on his own, resident helped back into bed x2 of staff to minimize risk of further injury NP and DON notified.Review of an unwitnessed fall incident report for Resident #95 dated 01/14/2026 indicated immediate action taken: assessment of resident (indicated above in nurse's note), call 911, called NP and DON notified, attempted to call RP X 3 with no response. The incident report was completed by LVN P.Review of SNF/NF Transfer to Hospital form dated 01/14/2026 for Resident #95 indicated the NP and DON had been notified at the time of transfer. The primary responsible party had not been notified at the time of transfer. There were no documented times the notification attempts were made. LVN P completed the SNF/NF Transfer Form.Review of hospital notes for Resident #95 indicated the resident's responsible party had been contacted by phone on 01/16/2026 and verbally signed the CMS Form 10065-IM explaining Medicare rights as an inpatient and rights to appeal discharge from the hospital on [DATE] at 11:38 AM indicating the RP was aware the resident was in the hospital. Physician hospital notes dated 01/19/2026 indicated Resident #95 had findings of sepsis due to possible UTI and acute enteritis (inflammation of the small intestine) and was started on antibiotics. Physician notes also indicated the resident had a 6 mm stone in the left ureter (tube from kidney to bladder) but was inoperable at that time due to unstable medical condition with urology consult. There was no diagnosis of pneumonia or fractured vertebrae. Resident #95 was nonverbal and unable to follow commands and unable to be redirected easily. Hospital case manager notes for Resident #95 indicated the discharge plan was to discharge back to the nursing facility when stable. During an interview on 02/04/2026 at 9:37 AM Resident #95's responsible party said he was not notified when the resident was sent to the hospital. He said he was usually informed every time something happened, even at 2:00 AM if he had fallen or something. He said he did not know of the resident's transfer until the hospital called him on 02/18/2026.During an interview on 02/04/2025 at 9:25 AM CNA A said she worked on the memory care unit and remembered Resident #95 and said he fell frequently and would not take any assistance from staff. She said he wanted to do everything for himself. She said falls were reported to the charge nurse so they could assess the resident for injuries but Resident #95 usually would not lie there and wait for the nurse to come. She said his short-term memory was really bad, He had to be constantly redirected to not stand during his showers.During an interview on 02/04/2026 at 9:30 AM CNA D said she had worked on the memory care unit. She said Resident #95 fell frequently. She said when he first admitted he was doing pretty well but seemed to go downhill fast. She said he was very stubborn and wanted to do for himself and he was hard to be re-directed because he wanted to do what he wanted to do. She said he had use of a wheelchair but would not use it. She said she was not working the day he was sent to the hospital. During an interview on 02/04/2026 at 9:40 AM LVN F said she was the charge nurse on the memory care unit for the first time on 02/02/2026. She said she was not familiar with Resident #95. She said she was PRN staff and usually worked 2 other halls.During an interview on 02/04/2025 at 9:45 AM the DON said Resident #95 had admitted in November 2025 and had done pretty well for a while but he had started falling a lot. She said he had hit his head a couple of times with no fractures or internal brain bleeding. She said he had bruising on his forehead and a black eye. She said when he fell he would get up before he could be assessed. She said he had a general decline since admission but recently before his discharge he had been declining more rapidly. She said they had therapy try to do some gait training to help build up his strength and increase his steadiness but it was not real successful because his short term memory was so bad he could not remember what he had been taught and carry out the exercise. She said she did not know if the notification to the RP was made when the resident was transferred to the hospital on [DATE].She said he was sent to a small satellite ER on [DATE] and was transferred to the main hospital in a larger city on 01/18/2026. She said that same evening there had been several residents fall and the charge nurse could have been distracted if she did not notify the RP. She said family did not visit often. She said the resident had begun falling more and they had tried many different interventions but they were not successful. She said he was very active and hard to re-direct. The DON reviewed Resident #95's record and said the fall incident report dated 01/14/2026 indicated the charge nurse had attempted to call the RP three (3) times and received no answer. She did not know if there was an inability to leave a message. She said she had tried to call LVN P on 02/04/2026 and she did not answer the phone. She said the employee was difficult to contact. She said that she felt 3 attempts to call was adequate in the facility's attempt at notification of the RP. During an interview on 02/04/2026 at 10:05 AM RN J said she was PRN staff but worked the memory unit frequently. She said she was familiar with Resident #95. She said he was very delusional and hard to re-direct. She said he was unsteady on his feet and his gait was poor. She said he wanted to do things he wanted to do and was stubborn. She said she worked with him the week prior to his transfer to the hospital. She said he had bruising to his face and head from a previous fall the week before. She said x-rays had been done with a mobile unit vendor and were negative for any fractures or internal bleeding. She said he had a wheelchair from the facility available for his use but he refused to use it. She said he cursed at staff when they tried to re-direct him. She said his arms were still strong and he would swat at staff to leave him alone so he could do things independently.A phone interview with LVN P who made the transfer for Resident #95 was attempted and the phone was not answered, and the voice mailbox was full and a message could not be left. Record review of a facility policy titled Change in a Resident's Condition or Status revised November 2022 indicated the following: 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when:.e. it is necessary to transfer the resident to a hospital/treatment center.

Based on interviews and record review, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activity professional for 1 of 1 facility reviewed for quality of life. The facility did not have a qualified Activities Professional to direct their activities program. This deficient practice could affect any resident and could result in residents not receiving activities that were individualized to match the skills, abilities, and interests/preferences of each resident. Findings were: Record review on 02/3/2026 at 10:30 AM, of an audit of the facility's Administrative and other licensed professional staff's credentials revealed the current Activity Director was not certified. Also, during an audit of the staffing roster, there was no one listed as the official activity director In an interview on 02/03/2026 at 12:00 PM, the HR Coordinator said the facility's Activity Director was not certified In an interview on 02/03/2026 at 12:38 PM, the AD said she had been hired as the medication Aide on 05/05/2024. She said when she was offered the position of AD to try but was not sure if she was going to pursue the position, she said, I have not applied for the AD certification course yet. She said, I really don't have any experience as an AD. In an interview on 02/03/2025 at 2:00 PM, the Administrator said the qualifications to be an Activity Director was to have an AD certificate. He said the current AD started working at the facility on 08/1/2024 as a medication aide and did not have the required certification as an AD. He said it was his responsibility to ensure the AD had enrolled in an AD program. The Administrator said the facility did not have a policy on the requirements for AD. The Administrator said the current AD did not have any of the following state requirements: Licensed, certified or registered,Eligible for certification Had 2 years of experience in a social or recreational program with the last 5 years Had completed a training course approved by the state In an interview on 02/03/2026 at 10:26 AM, the Regional Director stated that the facility did not have a policy on Activity Director.

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

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

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

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

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

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

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

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

Based on observation, interview, and record review, the facility failed to ensure the right to be free from abuse was provided for 1 of 4 residents reviewed for abuse. (Resident #1) The facility did not prevent Resident #1 from being physically abused. Resident #1 was pepper sprayed (Pepper spray (also known as capsicum spray) is a lachrymatory agent (a chemical compound that irritates the eyes to cause tears, pain, and temporary [MEDICAL CONDITION]) in the face by CNA A. Resident #1 complained of eye pain, difficulty seeing, and coughing. Resident #1 had increased verbal aggression after being sprayed and was given a one-time dose of [MEDICATION NAME] (antipsychotic). This failure could place residents at risk for physical abuse and fear. Findings included: A face sheet dated 07/11/19 indicated Resident #1 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum (MDS) data set [DATE] indicated Resident #1 had severely impaired cognition, sometimes made his needs known, and sometimes understood others. He exhibited verbal behaviors towards others and rejected care. He required supervision with bed mobility, transfers, and ambulation. He required extensive assistance with dressing and toileting. He was occasionally incontinent of bowel and frequently incontinent of bladder. A care plan dated 06/13/19 indicated Resident #1 was at risk for injury due to wandering behavior and staff should monitor the resident's whereabouts frequently, keep the environment free of hazards, and involve the resident in care as much as possible. Resident #1 was at risk for injury related to antianxiety, antidepressant, and antipsychotic medication use. Interventions included to monitor for increased anxiety and aggression and provide a calm environment. The care plan did not address Resident #1's behaviors. During an observation and interview on 07/11/19 at 10:54 a.m., Resident #1 was sitting in a recliner in his room. He said he did not remember CNA A or the incident that occurred on 06/28/19. He said he knew what pepper spray was but did not recall being sprayed with pepper spray. He said he had no pain to his eyes and had no cough. He said the staff were good to him and treated him well. He said he was not fearful of staff and felt safe at the facility. During an interview on 07/12/19 at 11:14 a.m., CNA A said she worked the night of 06/27/19 and Resident #1 was sleeping when she arrived for her shift but woke up some time later. She said during the morning of 06/28/19, Resident #2 was verbally upset, and it caused Resident #1 to become verbally upset. She said Resident #1 followed her to another resident's room, she said she was in the closet behind the door and he hit the door open, causing the door to hit the other resident in the head and her in the shoulder. CNA A said Resident #1 was being very hostile and demanding towards her and it made her nervous. She said she went to the kiosk to chart about Resident #1 and #2's behaviors when Resident #1 came up to her and started hitting the computer. CNA A said Resident #1 yelled at her to get off the computer because it was not hers. She said she walked off and told CNA B that she was going to pepper spray Resident #1. CNA A said she was not actually going to pepper spray him, she said Resident #1 followed her over to where her personal belongings were, and she told him if he came near her she would pepper spray him. She said Resident #1 continued to get closer and she got her pepper spray and sprayed him in the face. CNA A said Resident #1 began coughing and his face turned red, she said other residents in the common area and CNA B began coughing as well. She said she did not know pepper spray would cause the residents to start coughing. CNA A said if she could do it over, she would not have sprayed the pepper spray on Resident #1, she said she felt terrible for what she did. She said Resident #1 did not touch her, but he made her nervous and she was afraid of him. She said Resident #1 had a history of [REDACTED]. She said she was terminated from the facility. During an interview on 07/11/19 at 3:33 p.m., CNA B said she worked the night of 06/27/19 on the secure unit where Resident #1 resided. CNA B said Resident #1 would cuss at staff, get in their faces, and point at them. She said Resident #1 doubled up his fist at her but did not hit her. CNA B said on the night of 06/27/19, Resident #2 was having behaviors and it caused Resident #1 to have increased behaviors. She said on 06/28/19 around 4:30 a.m., Resident #1 began following CNA A and when CNA A went to chart at the kiosk, he started banging on the computer. CNA B said CNA A left the kiosk and walked towards the common area and said she was going to mace (pepper spray) Resident #1. CNA B said she did not take her seriously and did not think anything of it. She said CNA A paced in the common area a few seconds and walked over to where her personal belongings were located. She said Resident #1 followed CNA A and CNA A turned around and pepper sprayed Resident #1 in the face and said, I done told you to get away from me. She said Resident #1 grabbed at his eyes and began hollering and cussing. She said about that time, LVN C came out of a resident's room and asked what happened. She said CNA A said Resident #1 hit her in the face, but she witnessed the incident and did not see Resident #1 touch her. She said LVN C escorted CNA A out of the secure unit. CNA B said she got a wet cloth for Resident #1's eyes. She said Resident #1 was coughing and his eyes were red and watery. She said Resident #1 said his eyes were burning and he could not see. CNA B said the pepper spray caused several residents to start coughing and she said it was hard to breath in the secure unit. She said she attempted to keep the residents in their rooms and she wore an isolation mask for the rest of the shift. During an interview on 07/11/19 at 3:16 p.m., LVN C said she worked the night of 06/27/19. She said Resident #1 had a history of [REDACTED]. She said Resident #1 raised his hands at staff but did not hit staff. She said Resident #1 had been going in and out of residents' room that night but that was normal for him and he was easily redirected. LVN C said on 06/28/19 around 4:33 a.m., she was coming out of a resident's room and smelled something. She said Resident #1 was standing in the common area cussing and rubbing his eyes. She asked CNA A what happened, and CNA A said she maced him. She said she asked CNA A why and CNA A said Resident #1 hit her in the face twice. She said CNA A had no redness to her face. She said they got a cool cloth for Resident #1's eyes and she escorted CNA A from the secure unit and called the administrator. She said the administrator said to send CNA A home and she did. LVN C said Resident #1's eyes were a little red, his nose was running, and he was coughing. She said Resident #1 did not complain of any pain. She said the incident caused Resident #1 to have increased verbal aggression. She said she called Resident #1's son and he said to give his dad anything that would calm him down. She said she called Resident #1 physician and received an order for [REDACTED].#1 did not remember the incident and was acting normal by the end of the shift. A nursing note dated 06/28/19 at 4:40 a.m. indicated Resident #1 was standing with his hands over his eyes and cussing. CNA A said she maced Resident #1 because he hit her twice in the face. Resident #1 was assessed, and first aid was performed with a cold, wet washcloth. Resident #1 continued to be aggressive and abusive with staff. CNA A was removed from the secure unit and facility. The administrator, responsible party, and Resident #1's physician were notified of the situation. Resident #1's physician gave a one time order for [MEDICATION NAME] 1 mg/5 mg and a new order for [MEDICATION NAME] 0.5 mg twice a day for behaviors. A nursing note dated 06/28/19 at 7:00 a.m. indicated Resident #1 was breathing with no difficulty and eyes were flushed with eye wash. Resident #1 reported normal vision, but eyes were slightly irritated. Resident #1 currently had no behaviors. During an interview on 07/11/19 at 12:13 p.m., LVN G said she came in at 6:00 a.m. on 06/28/19 and assessed Resident #1. She said his eyes were red, but he had no complaints of pain and did not remember the incident. During an interview on 07/17/19 at 8:13 a.m., the local ombudsman returned a phone call that was left on 07/11/19 at 3:27 p.m. She said the facility did not notify her about the incident involving Resident #1. The facility's abuse prevention policy last revised (MONTH) (YEAR) indicated .as part of the resident abuse prevention, the administration will protect our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, and any other individual .develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. The facility's abuse investigation and reporting policy last revised (MONTH) (YEAR) indicated .all alleged violations involving abuse, neglect, exploitation, or mistreatment will be reported by the facility administrator/or designee to . local/state ombudsman . law enforcement officials . During interviews on 07/11/19 from 10:13 a.m. to 4:26 p.m., 9 CNAs (4 from day shift, 3 from evening shift, and 2 from night shift) said they received training on dementia behaviors (anger, fear, boredom, and loneliness) and they should remove themselves from the situation if the situation escalated and notify their charge nurse. They said they were trained on the signs of caregiver burnout and they were rotating shifts off the secure unit. They said they were trained on abuse and they were accountable for their actions. During an interview on 07/11/19 at 4:54 p.m., a local fireman said the administrator came to the fire station on the morning of 06/28/19 and asked if they could come to the facility and blow out the remains of the pepper spray. He said he arrived at the facility on 06/28/19 at 9:47 a.m. and used a positive pressure ventilation fan to remove any pepper spray remains. During an interview on 07/11/19 at 3:05 p.m., a local police officer said the administrator came to the police station and dropped off a report of Resident #1 being pepper sprayed by a CNA. He said the administrator asked him to call Resident #1's son and see if he wanted to press charges. The police officer said he called the son and the son did not want to press charges because his dad should not have hit a female. The police officer said he was not called to the facility and did not go to the facility. He said there was no police report written. The police officer said he was not sure of the date when the administrator came to the police station, but the report the administrator handed him had a fax page on the front dated 07/03/19 with Health and Human Services letterhead. A provider investigation report dated 07/03/19 indicated on 06/28/19 at 4:40 a.m., CNA A got upset with Resident #1 and pepper sprayed him. CNA A was charting when Resident #1 approached her and began cussing, hollering, and shoving her. CNA A left the vicinity and paced in the common area, then retrieved pepper spray from her personal belongings, and pepper sprayed Resident #1. First aide was provided to Resident #1 and CNA A was suspended and removed from the facility. CNA A was terminated, and staff were in-serviced on abuse, neglect, and burnout. Resident #1's responsible party, physician, police, ombudsman, and state agency were notified. Resident #1's responsible party was told that he would have to be the one that pressed charges. Resident #1's responsible party said he did not know if he would press charges because Resident #1 should not have tried to hit a lady. Undated in-service trainings indicated staff were trained on caregiver burnout, dementia behaviors, and abuse. During an interview on 07/11/19 at 2:48 p.m., the DON said the administrator handled the investigation regarding Resident #1. She said staff notified the administrator immediately after the incident on 06/28/19 and removed CNA A. She said she was notified of the incident when she arrived to work on 06/28/19. The DON said CNA A went through the facility's CNA class and was offered a job. She said she did not receive any complaints about CNA A and staff reported CNA A did a good job. She said they completed a back ground check and ensured she was trained on the facility's policies and procedures. She said the facility did everything they were supposed to do to ensure they hired competent staff. The DON said they in-serviced staff on abuse, dementia behaviors, and staff burn out. She said they began rotating staff on the secure unit. She said the administrator told her he was going to the police department and the fire department after the incident, but she was not able to get conformation of when he went to the police station.

Based on observation, interview, and record review, the facility failed to ensure written policies and procedures were implemented to prohibit and prevent abuse for 1 of 4 residents reviewed for abuse. (Resident #1) The facility did not prevent Resident #1 from being physically abused. Resident #1 was pepper sprayed (Pepper spray (also known as capsicum spray) is a lachrymatory agent (a chemical compound that irritates the eyes to cause tears, pain, and temporary [MEDICAL CONDITION]) in the face by CNA A. Resident #1 complained of eye pain, difficulty seeing, and coughing. Resident #1 had increased verbal aggression after being sprayed and was given a one-time dose of [MEDICATION NAME] (antipsychotic). This failure could place residents at risk for abuse, neglect and exploitation. Findings included: The facility's abuse prevention policy last revised (MONTH) (YEAR) indicated .as part of the resident abuse prevention, the administration will protect our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, and any other individual .develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. The facility's abuse investigation and reporting policy last revised (MONTH) (YEAR) indicated .all alleged violations involving abuse, neglect, exploitation, or mistreatment will be reported by the facility administrator/or designee to . local/state ombudsman . law enforcement officials . A face sheet dated 07/11/19 indicated Resident #1 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum (MDS) data set [DATE] indicated Resident #1 had severely impaired cognition, sometimes made his needs known, and sometimes understood others. He exhibited verbal behaviors towards others and rejected care. He required supervision with bed mobility, transfers, and ambulation. He required extensive assistance with dressing and toileting. He was occasionally incontinent of bowel and frequently incontinent of bladder. A care plan dated 06/13/19 indicated Resident #1 was at risk for injury due to wandering behavior and staff should monitor the resident's whereabouts frequently, keep the environment free of hazards, and involve the resident in care as much as possible. Resident #1 was at risk for injury related to antianxiety, antidepressant, and antipsychotic medication use. Interventions included to monitor for increased anxiety and aggression and provide a calm environment. The care plan did not address Resident #1's behaviors. During an observation and interview on 07/11/19 at 10:54 a.m., Resident #1 was sitting in a recliner in his room. He said he did not remember CNA A or the incident that occurred on 06/28/19. He said he knew what pepper spray was but did not recall being sprayed with pepper spray. He said he had no pain to his eyes and had no cough. He said the staff were good to him and treated him well. He said he was not fearful of staff and felt safe at the facility. During an interview on 07/12/19 at 11:14 a.m., CNA A said she worked the night of 06/27/19 and Resident #1 was sleeping when she arrived for her shift but woke up some time later. She said during the morning of 06/28/19, Resident #2 was verbally upset, and it caused Resident #1 to become verbally upset. She said Resident #1 followed her to another resident's room, she said she was in the closet behind the door and he hit the door open, causing the door to hit the other resident in the head and her in the shoulder. CNA A said Resident #1 was being very hostile and demanding towards her and it made her nervous. She said she went to the kiosk to chart about Resident #1 and #2's behaviors when Resident #1 came up to her and started hitting the computer. CNA A said Resident #1 yelled at her to get off the computer because it was not hers. She said she walked off and told CNA B that she was going to pepper spray Resident #1. CNA A said she was not actually going to pepper spray him, she said Resident #1 followed her over to where her personal belongings were, and she told him if he came near her she would pepper spray him. She said Resident #1 continued to get closer and she got her pepper spray and sprayed him in the face. CNA A said Resident #1 began coughing and his face turned red, she said other residents in the common area and CNA B began coughing as well. She said she did not know pepper spray would cause the residents to start coughing. CNA A said if she could do it over, she would not have sprayed the pepper spray on Resident #1, she said she felt terrible for what she did. She said Resident #1 did not touch her, but he made her nervous and she was afraid of him. She said Resident #1 had a history of [REDACTED]. She said she was terminated from the facility. During an interview on 07/11/19 at 3:33 p.m., CNA B said she worked the night of 06/27/19 on the secure unit where Resident #1 resided. CNA B said Resident #1 would cuss at staff, get in their faces, and point at them. She said Resident #1 doubled up his fist at her but did not hit her. CNA B said on the night of 06/27/19, Resident #2 was having behaviors and it caused Resident #1 to have increased behaviors. She said on 06/28/19 around 4:30 a.m., Resident #1 began following CNA A and when CNA A went to chart at the kiosk, he started banging on the computer. CNA B said CNA A left the kiosk and walked towards the common area and said she was going to mace (pepper spray) Resident #1. CNA B said she did not take her seriously and did not think anything of it. She said CNA A paced in the common area a few seconds and walked over to where her personal belongings were located. She said Resident #1 followed CNA A and CNA A turned around and pepper sprayed Resident #1 in the face and said, I done told you to get away from me. She said Resident #1 grabbed at his eyes and began hollering and cussing. She said about that time, LVN C came out of a resident's room and asked what happened. She said CNA A said Resident #1 hit her in the face, but she witnessed the incident and did not see Resident #1 touch her. She said LVN C escorted CNA A out of the secure unit. CNA B said she got a wet cloth for Resident #1's eyes. She said Resident #1 was coughing and his eyes were red and watery. She said Resident #1 said his eyes were burning and he could not see. CNA B said the pepper spray caused several residents to start coughing and she said it was hard to breath in the secure unit. She said she attempted to keep the residents in their rooms and she wore an isolation mask for the rest of the shift. During an interview on 07/11/19 at 3:16 p.m., LVN C said she worked the night of 06/27/19. She said Resident #1 had a history of [REDACTED]. She said Resident #1 raised his hands at staff but did not hit staff. She said Resident #1 had been going in and out of residents' room that night but that was normal for him and he was easily redirected. LVN C said on 06/28/19 around 4:33 a.m., she was coming out of a resident's room and smelled something. She said Resident #1 was standing in the common area cussing and rubbing his eyes. She asked CNA A what happened, and CNA A said she maced him. She said she asked CNA A why and CNA A said Resident #1 hit her in the face twice. She said CNA A had no redness to her face. She said they got a cool cloth for Resident #1's eyes and she escorted CNA A from the secure unit and called the administrator. She said the administrator said to send CNA A home and she did. LVN C said Resident #1's eyes were a little red, his nose was running, and he was coughing. She said Resident #1 did not complain of any pain. She said the incident caused Resident #1 to have increased verbal aggression. She said she called Resident #1's son and he said to give his dad anything that would calm him down. She said she called Resident #1 physician and received an order for [REDACTED].#1 did not remember the incident and was acting normal by the end of the shift. A nursing note dated 06/28/19 at 4:40 a.m. indicated Resident #1 was standing with his hands over his eyes and cussing. CNA A said she maced Resident #1 because he hit her twice in the face. Resident #1 was assessed, and first aid was performed with a cold, wet washcloth. Resident #1 continued to be aggressive and abusive with staff. CNA A was removed from the secure unit and facility. The administrator, responsible party, and Resident #1's physician were notified of the situation. Resident #1's physician gave a one time order for [MEDICATION NAME] 1 mg/5 mg and a new order for [MEDICATION NAME] 0.5 mg twice a day for behaviors. A nursing note dated 06/28/19 at 7:00 a.m. indicated Resident #1 was breathing with no difficulty and eyes were flushed with eye wash. Resident #1 reported normal vision, but eyes were slightly irritated. Resident #1 currently had no behaviors. During an interview on 07/11/19 at 12:13 p.m., LVN G said she came in at 6:00 a.m. on 06/28/19 and assessed Resident #1. She said his eyes were red, but he had no complaints of pain and did not remember the incident. During an interview on 07/17/19 at 8:13 a.m., the local ombudsman returned a phone call that was left on 07/11/19 at 3:27 p.m. She said the facility did not notify her about the incident with Resident #1. During interviews on 07/11/19 from 10:13 a.m. to 4:26 p.m., 9 CNAs (4 from day shift, 3 from evening shift, and 2 from night shift) said they received training on dementia behaviors (anger, fear, boredom, and loneliness) and they should remove themselves from the situation if the situation escalated and notify their charge nurse. They said they were trained on the signs of caregiver burnout and they were rotating shifts off the secure unit. They said they were trained on abuse and they were accountable for their actions. During an interview on 07/11/19 at 4:54 p.m., a local fireman said the administrator came to the fire station on the morning of 06/28/19 and asked if they could come to the facility and blow out the remains of the pepper spray. He said he arrived at the facility on 06/28/19 at 9:47 a.m. and used a positive pressure ventilation fan to remove any pepper spray remains. During an interview on 07/11/19 at 3:05 p.m., a local police officer said the administrator came to the police station and dropped off a report of Resident #1 being pepper sprayed by a CNA. He said the administrator asked him to call Resident #1's son and see if he wanted to press charges. The police officer said he called the son and the son did not want to press charges because his dad should not have hit a female. The police officer said he was not called to the facility and did not go to the facility. He said there was no police report written. The police officer said he was not sure of the date when the administrator came to the police station, but the report the administrator handed him had a fax page on the front dated 07/03/19 with Health and Human Services letterhead. A provider investigation report dated 07/03/19 indicated on 06/28/19 at 4:40 a.m., CNA A got upset with Resident #1 and pepper sprayed him. CNA A was charting when Resident #1 approached her and began cussing, hollering, and shoving her. CNA A left the vicinity and paced in the common area, then retrieved pepper spray from her personal belongings, and pepper sprayed Resident #1. First aide was provided to Resident #1 and CNA A was suspended and removed from the facility. CNA A was terminated, and staff were in-serviced on abuse, neglect, and burnout. Resident #1's responsible party, physician, police, ombudsman, and state agency were notified. Resident #1's responsible party was told that he would have to be the one that pressed charges. Resident #1's responsible party said he did not know if he would press charges because Resident #1 should not have tried to hit a lady. Undated in-service trainings indicated staff were trained on caregiver burnout, dementia behaviors, and abuse. During an interview on 07/11/19 at 2:48 p.m., the DON said the administrator handled the investigation regarding Resident #1. She said staff notified the administrator immediately after the incident on 06/28/19 and removed CNA A. She said she was notified of the incident when she arrived to work on 06/28/19. The DON said CNA A went through the facility's CNA class and was offered a job. She said she did not receive any complaints about CNA A and staff reported CNA A did a good job. She said they completed a back ground check and ensured she was trained on the facility's policies and procedures. She said the facility did everything they were supposed to do to ensure they hired competent staff. The DON said they in-serviced staff on abuse, dementia behaviors, and staff burn out. She said they began rotating staff on the secure unit. She said the administrator told her he was going to the police department and the fire department after the incident, but she was not able to get conformation of when he went to the police station.